CHAPTER NINE
Life Itself Is Reason Enough To Be Living
March, 1979
The morning after dinner with Julia, I called the Ob clinic at Harvard Community Health Plan, intending to ask for a pregnancy test and initial appointment.
“When was your last period?” asked an impersonal voice on the other end.
I double-checked my date book, although I had it memorized already – January 17th, ten days before Howard had invaded my apartment and violated my tranquility. “The 17th. January,” I heard myself say in hollow tones.
“You were regular? Hadn’t missed any?”
I thought, this might be what the orals were going to feel like? “Mum-hum,” I agreed.
“Any bleeding, spotting, cramps?”
“No.”
“Morning sickness, breast tenderness?”
“A little, I guess.”
“OK, we can set you up for an appointment on March 15th, Thursday. With the nurse. She’ll do a history, send off some labs, a pregnancy test and the other prenatals.”
A flicker of dread flashed through me – the Ides of March. I shivered almost imperceptibly, and asked, “Can I get one before that, a pregnancy test? Today, tomorrow?”
“We can do that, honey, but it won’t be ready for a couple of days, not till after the weekend. And besides, this early, it might not be positive yet, even if you are. No need to come in, unless…”
“No, nothing’s wrong, I just thought…isn’t there a blood test, or something?”
“Yes, but the doctors, they say we’re not supposed to offer it unless a women’s bleeding, or high risk. Any medical problems, like diabetes? How old are you, again?”
“I’m …I’ll be 30 in May. No, I don’t have any problems like that.”
“Why don’t you wait until you come in. It’s not like you’re going to do anything different before then, are you?”
I didn’t have the strength, after days at the clinic, evenings in the library, and nights of fitful sleep, to say anything other than, “OK, Thursday, March 15. Got it.”
At our first meeting in March, Julia and I started preparing for my upcoming orals.
“I’ll be the First Reader, of course, and the department chief will be the committee chair. Don’t worry about him, he’s there to make sure the rest of us treat you fairly.” Dr. Klein smiled. “Fairly – that means we ask you tough questions, but don’t try to score points off of you. We’re not there to show how smart we are, but to make sure you understand your own work. When you do get the doctorate, no one should doubt your ability to review someone else’s study. Our reputations are on the line here, as much as yours. We’re not going to play ‘Gotcha’, Sarah. Stay poised, be yourself, and everything will go smoothly.”
I spent the next two weeks re-reading all my sources, along with those evenings in the library scouring the guides to periodical literature, looking for anything new which had come out that might be even tangentially related to adolescent mothers and their newborns. Totally immersed, I was able to forget for hours, even days, at a time, that my body was changing. Sometimes, when I woke up, the thought of coffee didn’t sit well, and my breasts did seem a little boggy, but most of the time, I could ignore whatever might be happening in my uterus.
At my prenatal appointment, the nurse led me to the scale, and announced, “58 kilograms, 162 centimeters.” What is that in real money? I wondered. I’d never paid much attention to my weight, so I had no clue if I had gained any or not.
She started the interview with that horrid question, “When was your last period?” I knew after all my time in Ob clinics, following my research subjects, why that was so important, but I still wished I didn’t have to remember. We went briskly through my medical history, finishing with, “Do you have any questions, Sarah?”
I hesitated. That morning, I’d notice the faintest pink swirl in the toilet. “I’ve heard sometimes you can spot at 2, or 3 months?”
“Why, did you…?”
I nodded my head, and she went on. “We could have you examined, take a look, get the pap smear and culture out of the way. Maybe it would reassure you?”
“Um…I don’t know – a doctor does the exam?”
“Oh, you’ll like her, she’s one of our senior residents. Gentle, knows her stuff.”
A female gynecologist, Dr. Stephanie Seacrist, walked in, stethoscope slung casually over the shoulders of her starched white coat. With her blond hair pulled back tightly into a no-nonsense bun, and large-framed glasses enhancing her smiling eyes, I immediately relaxed.
Explaining everything I should expect, before she did it, she quickly finished the exam by feeling for my uterus and ovaries with her left hand, while pushing up from inside with two fingers of her right. Then, she took my hand, guided it down to my pubic bone, and said, “Here, feel that? Your uterus?” I nodded as she withdrew her hand, looking briefly at her fingers as she turned the glove inside out.
After she helped me sit up, she asked “Is it OK to talk now, or do you want to get dressed first?”
“Go ahead, it’s OK.”
“I do see a spot or two of blood in there, but there are no lesions, and your cervix is long and closed. So it’s probably nothing. Sometimes as the placenta grows into new parts of the endometrium, that lining can shed a tiny bit.” She dropped her smile as she looked straight at me. “Your uterus seems a little small, for your dates, though. Feels seven weeks-size, and you’re close to eight.”
“What’s that mean?”
“Oh, probably nothing, we never know for sure when conception happens…”
“Even if you know the date when…”
“Yes, you see, sperm can linger in the uterus, or the egg in the tubes, and we don’t know when ovulation happened, how long it takes for the egg to travel down.”
I looked away, frowning, and started to say, “I…”
She quickly went on. “We’ve got a new test now, called ultrasound. It’s not x-rays, no radiation, uses sound waves. At this stage, we should be able to see a baby in there, if it’s at least 7 weeks along. We call it ‘real-time’, because the computer turns the reflected sound waves into a black and white moving image of what’s inside. We could might even see a heartbeat. Sound good?”
I nodded, getting more and more anxious. “When?”
“This is not an emergency, so next Monday is probably the earliest we can squeeze you in, OK?”
I dropped my head, hoping my hair would hide the wetness welling in my eyes.
“Sarah, is everything OK?” Real concern flowed through Dr. Seacrist’s quiet question. “I saw the notes, from the nurse, the baby’s father’s not involved?”
I shook my head, felt the tears now flowing past my nose. I sniffed, saying nothing.
She took my hand. “You don’t have to go through this alone, you know.” She reached into her lab coat pocket and handed me a card after scribbling on it. “Here. You can call me, anytime. That’s my home number. We’re going to get through this, you and me.” Then, in a more business-like tone, she said, “My team’s on call this weekend. If anything – anything at all – happens, call the L&D number on there, ask for me, we’ll make sure everything is OK. All right?”
Biting the inside of my lower lip, I nodded. I wanted to say, thank you, but couldn’t get it past the lump in my throat. She patted my hand once, twice, then said, “Well, I’ll let you get dressed now. Remember, anything. Anytime.”
ii
“Anytime” came sooner than I’d imagined. Friday evening as I rode home, I started feeling some cramps. By the time I got to the bathroom, a little blood with a small clot plopped out. I called the health plan consulting nurse, hoping she’d tell me to “lie down and check with us in the morning.” Instead, she said, “You can stay home if you like, but there’s no way to know for sure what is happening or what might be going on without an exam.”
“If I stay here, how would I know if I have to come in?”
“If the cramps or bleeding get worse, then you really should,” was the answer.
“Is there anything I can do to stop this?”
“I’m sorry, that’s a question you’d have to ask the doctor.”
After hanging up, I pulled out a book I’d bought that week to support my anticipated journey. On impulse I’d purchased Spiritual Midwifery, hoping to gain an alternate perspective to the medicalized obstetrics I’d encountered throughout my career. It offered stories of women living on “The Farm”, a post-hippie commune in Tennessee. Attempting independence and self-sufficiency, the author, Ina May Gaskin, had taught herself and others about pregnancy and childbirth. They became midwives to their community’s burgeoning population. Starting with mostly joyful stories of births, Ina May then detailed what happens during pregnancy, how to keep yourself safe, what can go wrong, and what to do if it does. I flipped to the short section on “miscarriage”, and learned that “…two out of every ten women will have some spotting in the early months, but only one of them will have a miscarriage.”
Somewhat reassured, I was able to fall asleep, but was awakened by a gooey wet feeling between my legs. Just a smear this time, on the insides of both thighs, but enough to send me searching for Stephanie Seacrist’s business card.
“Sarah, you should come in. Now. I’ll see you here, take a look, we’ll talk.”
I headed back to Women’s Hospital, the cramps increasing all the way. By the time I limped through the ER doors, I knew more blood was coming out. Stephenie was there to catch me as I staggered towards a gurney, helping me lie down while she said to the nurse at her side, “Set her up in the gyn room, with a sterile speculum and some ring forceps, please.” Looking at me through eyes enlarged by her glasses, she asked, “Cramping?”
I moaned affirmatively.
“It’s OK, you’ll be all right…”
“The baby?”
“Let me look, then we can talk, all right?” She gave my hand a squeeze, then helped lift me onto the exam table. After the nurse had removed my pajama bottoms, Stephanie said, “Sarah, you’ll have to put your heels into the stirrups now. I’m going to drop the foot of the bed, then tilt you back a bit.”
She talked me through putting in the speculum, adjusted the light above her shoulder, and asked, “Can you get me some four-by-fours?” The nurse ripped open a package of gauze wipes, and then I heard the “click” of an instrument, while Dr. Seacrist said, “Just cleaning things off here…” and then, a “Plop” as something fell into the stainless steel bucket below the table.
“What was that?” I asked fearfully.
“Oh, some blood, a clot…OK, I see it now,” she said, as I felt a sudden, short cramp which reverberated several times, then passed. “Nurse?” Dr. Seacrist asked as I heard her metal stool swivel while a jar cap was unscrewed, then screwed back on. “OK, Sarah. The bleeding’s all stopped now. Let me take this out…” And then I was lying with my legs straight again, looking pleadingly at Stephanie Seacrist.
“I’m sorry. I’m so sorry, Sarah.” She took my hand in both of hers, and said, “There was nothing we, nothing you could do.”
My chest tightened, first with a deep sadness, then a sudden resolve, awareness that, whatever had happened in my womb, my life, my future would go on. “Was it…” I managed, gripping her hands firmly.
“There’s not much there, just the placenta and some unformed tissue. What we call a ‘blighted ovum’.”
“Blighted…” I tried.
“Yes, a lot of conceptions, things don’t go right from the start. The baby never really forms, probably a misfire, the chromosomes coming together improperly. Would you like to see?”
The practical, clinical side of me took over, and nodded. She handed me a small plastic jar, two inches or so in diameter, in which a thumb-sized clump of white feathery material rested beside a small translucent bag, bulging with fluid, whitish flecks floating inside. I turned it round and round, looking up through the bottom, hoping I could sense a soul. My gaze lingered a minute more, then I handed it back to her, asking, “What happens next?”
With a half smile, she answered, “Well, in the old days – meaning when I was an intern – we would have done a D&C, scrap off the inside of your uterus, make sure everything is out and the bleeding’s stopped. But now, as long as you don’t bleed any more – and I don’t think you will – we’ll watch you here in the ER, and you can go home in a few hours.”
I wondered, Why don’t I feel sadder? Out loud, I said, “Thanks. Thank you.” Brusquely, I added, “Can I get dressed now?”
“Of course. The nurse will get you a pad. I’ll come back in a few minutes, OK?” I nodded, trying not to look as she took the jar from my hand, and carried it out with her.
On her return, she sat down heavily on the round, backless stool, and swiveled to look straight at me. “How are you feeling?”
Firmly, I said, “No cramps, all gone. Thanks.” Almost impishly, I continued, “I guess now, I’ll have all my energy available for my orals. So that’s a good thing?”
“Sarah, I sense you’re like me, you’ve always been on top of everything in your life, your direction…but there are some things we can’t, we shouldn’t control.” She paused, “Given you’re a psychologist, a scientist, I shouldn’t need to tell you this, but, listen: Deep inside your heart and mind, I know, you’ve lost someone very close and dear to you. You know, better than most, I suspect, that grieving is healthy, something you have to do. Don’t let the name ‘blighted’, or the size fool you. This pregnancy, this baby was – is – very real to you, someone you’ll never get back, who you’ll always carry with you inside. When it comes – and it will come – when the sadness comes knocking, please, please let it in.”
iii
In the first three weeks after my miscarriage, I threw myself into a job search and continued preparations for my orals. I knew I was suppressing my feelings about losing the pregnancy, but I couldn’t put my life on hold while I dwelt on that.
One evening, I dug Stephanie Seacrist’s card out of my desk drawer.
“Dr. Seacrist, it’s Sarah Stein.”
“Oh, Sarah, how are you? I didn’t see you at your two-week check.”
“Things have been so busy, I never even made that appointment. Everything’s fine, no cramps, no bleeding.”
“Well that’s great. What’s on your mind, then?”
A little awkwardly, I asked, “I know this might not be right, maybe it violates professional ethics, but…can I see you? Outside of the clinic I mean. Not about the miscarriage, more as a…I feel we’re kindred spirits.”
“Uh, sure. I’d love to get together, and chat. In the evening sometime, after work? The best time for me is always the clinic day, before I go on call. Say, this Friday?”
“Great. You know, our offices are so close, we can go somewhere along Francis, near Brigham Circle?”
“Sure, about seven, all right? Oh, and Sarah…you can call me Steph, OK?”
Friday evening, we talked for hours, and discovered the usual strange convergences in our lives. She’d grown up in Columbus, but headed west to Stanford, then UCLA for medical school before deciding the east coast was the place for her.
She allowed, “I’ll never know why Harvard took me, it wasn’t like I was the top of my class.”
“How many women in the residency, Steph?” I asked.
“I’m the only one, my year. And there was only one other, when I got here three years ago.” A bit sheepishly, she wondered, “Why, you think that’s the reason they took me?”
“They took you because you’re good, Stephanie”
“What about you? How are you treated?”
“There have been women in clinical psych for a while now,” I began. “But I still find that, every time I’m looking for work, for a position somewhere, it’s always a man I have to convince.” I told her about the Child Development Unit, with Drs. Wernick and Brazelton in charge, Lauren, Heidi and I doing all the work.
“And now, I’m meeting with David Goldman…”
“The med-ed guy?”
“Yes, he’s trying to integrate the Psychiatry department into the hospital consultation system, and needs someone to direct the research they’re doing on how well it works, this consultation liaison program.”
“Consultation liaison? I’ve never heard of that.”
“Say a lady shows up in labor, full term, but she won’t cooperate? You quickly discover that she’s, as we say in my business, ‘crazy’, schizophrenic, maybe. And hasn’t been taking her meds. You’ve got no clue what to do, but you have to get her to settle down even if only a little, so she doesn’t destroy herself in labor or having the baby. And then what about taking care of the baby after? So you call the psychiatric consultant…”
“Like a cardiologist, if she had heart disease? What’s so special about that, we ask for consults all the time.”
“Right, but for some reason, shrinks have been shunted aside over the years. It’s like they’re not speaking the same language as the other MDs anymore. Anyway, he wants to study ways to help that communication happen better, faster, and more effectively. He thinks he needs a psychologist for that.” I smiled in anticipation. “I’m jazzed about it, hope I get it.”
“Sounds intriguing. Good luck!” She turned serious. “Did you think about what I said, the night of your miscarriage? About grieving?”
“You’re right, of course. I know all about the five stages of grief, that’s really become psych 101 by now.”
“Knowing about it and doing it are two different things, Sarah,” she countered.
“For me at least, it’s not an orderly, step-wise process. I was angry at first, at the very first with…him, then I denied the spotting was important, then I bargained with the nurse, and you. And of course, I was very depressed the night it happened.”
“Acceptance?” she ventured.
“I’m not sure I’ll ever get there, at least I don’t see it yet. I do know I handle things like this not so much as feelings, but by thinking them through, and getting on with my life. Which for now means, getting ready for that oral exam.”
The next day, Marcia called from New York, where she was finishing up her psych residency at Albert Einstein. “Sarah! Good news!”
“Did you get it?” She’d been looking for work back in Boston, and had narrowed the search down to the HMO where I’d been getting my care, HCHP.
“Yep. I start July 1st. I’m coming up this weekend, to fill out forms, talk to the admin people, that sort of stuff. You want to get together tomorrow?”
“Perfect. I’ve got a few things to unload on you.”
“Like what?”
“For starters, my orals are next week…”
That weekend at dinner, it took over an hour to tell her the whole sordid Howard story, my pregnancy and miscarriage. By the end, I felt better than I had since it all started, three months earlier. Crying with a friend I’d known for over ten years was literally what the Doctor, Stephanie Seacrist, had ordered.
As we gathered our coats and purses, Marcia pulled up short before I could reach out for another hug, this time to say goodbye until July. “Oh! Almost forgot! I meant to ask, you still looking at the Boston Institute, looking into psychoanalysis?”
“They’re hesitant, about taking on a psychologist. I’m close to wearing them down, though.”
“Their loss if they don’t. I meant to tell you, this prof, my favorite attending, Petyr Cohen, he’s starting there this month. I bet you’d like him. He’s very smart, so cosmopolitan. He’s already an analyst. You ought to meet him, hear how he survived the war.”
I looked at her suspiciously. “Are you trying to set me up?”
“No, no. He’s married, two kids. OK, separated, but still in the middle of all that. Ugly.” She shivered. “It’s why he’s moving, leaving so he doesn’t have to be in the same city as his wife. Anyway, if you cross paths, tell him I told you about him.”
Intrigued, I pressed her. “During the war? How old is he?”
“Around forty. Very interesting story. He grew up in Switzerland. His parents were Jewish, Greek Jews, but they lived in Hungary. Somehow, when he was very little, they got him out, to stay with another family, hoping he’d be safe, while they waited out the war. The family in Geneva were American, a doctor and his wife. They sent him to an international school, so he speaks perfect Brit-tinged midwestern. Anyway, like I said, he’s a charmer. Ask him anything, then sit back and be entertained.”
iv
Dr. Klein was right, my orals proved anti-climatic. From the first question, it was obvious I knew more about adolescent mothers’ relationships with their infants than anyone else in the room. The conversation quickly devolved to a relaxed exploration of my comportment and ability to remain poised while the committee grilled me with mock seriousness.
The psychology Board exam demanded even less. Billed as a rigorous test of my general knowledge in all clinical psych fields, others had remarked on how 4 hours, 15 minutes was not nearly enough time to finish all the questions, much less review answers. All my life, though, standardized tests had come embarrassingly easy. With only four choices per question, and what seemed like a lifetime of immersion in the field behind me, I breezed through in a little over three hours, checked each answer twice more, and still finished before the proctor called “Time!” A month later, I learned my score of 787 had been the highest in the state that year.
As I methodically added to my supervised clinical hours during a post-doc year at Beth Israel, I divided time between the Consultation Liaison program there, and seeing clients in a state-run clinic in Wellesley. I approached the Boston Institute, hoping I could convince them a Ph.D. could be as effective a psychoanalyst as an M.D. Juggling all these balls at once left little time to wallow in the past or worry about the future.
Dr. Goldman, as the Director of Medical Education for all the psychiatric residencies associated with Harvard Medical school, was far too busy to respond when the National Institute of Mental Health sent out a request in June of 1979 for information about the measures and methods used to evaluate the effectiveness of C-L education in the programs. So naturally, as the newest member of the staff, I got the job. I dutifully canvassed all the program directors, and discovered no one had any systematic way of instructing the residents, much less evaluating them.
“This is worse than embarrassing, Sarah,” Dr. Goldman told me when I shared the news with him. “We’re Harvard, for crying out loud! See if you can put together something I can use to move the program directors on this. Go to that conference in San Antonio, learn all you can, and we’ll fix it. We’re supposed to be national leaders, not followers…”
Pursuing what I regarded as busy work, I daydreamed as I wrote the proposals. Here I was, ready to finally practice independently, and now part of a national effort to advance how psychiatrists are taught. I imagined I’d return from the conference, recognized for my skill in educating residents to work effectively with obstetrician-gynecologists, going on to become an expert in teen-age pregnancy. As my dreams became more baroque, by age 50 I’d become an advisor to the government, testifying before Congress, with a teen-ager – a chaste teen-ager – of my own.
The conference proved to be much less exciting that my fantasy. For two days, medical education directors and their staff analysts droned on while displaying endless variations of evaluation forms on transparencies, nearly unreadable when projected on a screen 100 feet away.
On my return to Dr. Goldman, I told him, “I’ll try to pull something together from all this, and help you get the programs to develop a standardized training module, with follow-up evaluation, but…”
“There’s always a ‘but’ with you, isn’t there, Sarah,” he joked.
“In this case, it will be my final ‘but’,” I replied.
“Oh?”
I told him about one evening, in the unnatural warmth of south Texas. While walking along the Guadalupe River, wondering why it reminded me of the Seine with cruise boatsslowly gliding under arched bridges, I had a sudden realization about my life. I’d been hiding out in the cocooning safety of academic castles like Harvard and B.U., searching for research topics, then gathering data and reporting it. All that felt stifling now that I had my doctorate in hand. At my core, I knew that improving the world through policies, papers, and politics was not what had drawn me into psychology. I needed to leave that world. I needed to help people one at a time, on a personal level.
After explaining all that, I told him I would stay through the follow-up conference, set for February, 1981, in Burlington, Vermont – “New England, somewhere I understand, where it actually snows in winter” – and then set up my own clinical practice.
He beamed when he heard that. “You are so ready, Sarah. It’s time, it’s surely time, for you to fly on your own. Anything I can do to help, let me know.”
I rented a small office in Brookline, ordered a telephone, and began calling insurance companies, to make sure I was on all their lists, the HMOs, the PPOs, the entire alphabet soup that was taking over mental health care as it had medicine. I sent announcements to every psychiatrist, pediatrician, family doctor, and psychologist in Suffolk County. With my job in Wellesley, and the C-L work at Beth Israel, I had one day a week free to see clients. I was on my way.