The severe mental illness was Mrs. Miller’s. The conspiracy to pretend it didn’t exist, however, was most definitely a family affair. Her husband, Bill, was a nice guy. After five minutes in my office, I realized that he was a relentless cheerleader and a determined advocate for his wife. “Whatever I can do to help, I’ll do,” he said. “Anything.”

It was my unpleasant task to suggest to Mr. and Mrs. Miller that before they focused on issues in their marital relationship-perhaps-Mrs. Miller should seek some individual treatment for the difficulties she was having distinguishing things that were real from things that were not.

“Is it that bad? Really?” Mr. Miller said in mutual self-defense after I’d asked how he felt about what was going on in his marriage. “I love Rachel. In the grand scheme of things this is a small problem, right? I mean, we’re talking weddings. It’s not cancer. There are many, many times when she seems just fine.”

During my internship, while I was spending a rotation in an acute adult psychiatric inpatient unit, I had become extremely frustrated by one of my patients. He was a huge Samoan man, a schizophrenic whose communication abilities had devolved to the point where his speech consisted solely of multiple repetitions of a deeply baritone “hoho,” sometimes singly, more often tendered in multiple repetitions. Despite his severe psychopathology and his immense size-the man outweighed me by at least 200 pounds-he was congenial and cooperative. We would sit for brief one-to-one “psychotherapy” sessions a few times a week. Each meeting lasted five minutes, max. He would listen to me-I doubted at times that he comprehended the intended meaning of a single word I said-gesture in the air with his fat hands, and say, “Hoho, hoho,” occasionally interrupting my otherwise useless intervention, sometimes waiting politely until I was done.

Infrequently he would smile or open his eyes wide in apparent wonder. More often his face would yield no expression at all.

My Samoan patient was already receiving enough Haldol to sedate an elephant, yet his mystifying psychotic process seemed immune to my best, though admittedly inexperienced and ultimately ineffective, attempts to be helpful.

I confessed to my supervisor, who knew the situation well, that I felt incompetent to treat the man. The supervising psychiatrist said two things that have stuck with me ever since. First, he told me that there are some people who are better at being crazy than I will ever be at being therapeutic. The Samoan, he said, was my case in point.

Second, he told me that from a psychopathology perspective, some of our patients have cancer. He was speaking metaphorically, of course, but I still recalled his caution on those days that my clinical skills seemed hopelessly inadequate to contain the sometimes incorrigible forces of my patients’ mental illnesses.

I was tempted to share those pearls of wisdom with Bill Miller the day that he brought his wife into my office for evaluation. But I didn’t. His hope was too inspiring to behold. His desire to lift his wife up was too gratifying to witness. He didn’t want to believe that his wife had the mental health equivalent of cancer. I feared that indeed she might, but I wasn’t ready to believe it either. That’s how powerful his hope was.

Despite the fact that I thought I’d pulled just enough of my punches to allow Mr. Miller’s hope to stay afloat, my ultimate assessment that day, and my verbalized prescription for further care, sucked all the oxygen out of the room.

Every last molecule.

In contrast to bipolar disease, which at its heart is a disorder of mood, schizophrenia is a disorder of thought, of perception. Schizophrenic thinking results in a myriad of cognitive symptoms. Hallucinations, delusions, and paranoia are the most common. In a schizophrenic’s world, what most of us consider orderly thought begins to deteriorate, and cognition becomes subject to interferences from beyond the confines of usual perception. The process that results appears to an outsider to be bizarre, tangential, repetitive, or oddly referential.

An extreme example was my Samoan’s baffling chorus of hohos. But in a schizophrenic’s brain the variety of ways that faulty neuro-chemistry can cause thinking to deteriorate is large. In severe cases the outcomes are almost universally tragic.

The problem that was most apparent to me during my brief appraisal of Mrs. Miller was the extent of her delusional thinking-specifically her irrational belief that she had been a special invitee to all those weddings. Although the nature of the invitations remained her secret during our interview, that was where I focused my attention as I presented my suggestions to the Millers.

Mr. Miller seemed somewhat relieved by my prescription for additional help. For him, it represented an injection of helium that might provide enough lift to keep his airship of hope afloat. But Mrs. Miller resisted my recommendation and argued and bargained and then bargained some more. I couldn’t follow her train of thought as she tried to explain the imperative she felt about attending the weddings. The truth was that her thinking more closely resembled a corral of bumper cars driven by preadolescents than anything like a metaphorical train.

She wept for a good five minutes before she ultimately relented to my suggestion and to her husband’s gentle prodding. She only relented, I was certain, because of her husband’s insistent kindness and his repeated promises that he’d be beside her no matter what, and because I’d managed to make it clear on that day that my resolve was a more than decent match for her thought disorder.

The fear in her eyes when she realized what was about to happen next was as poignant a thing as I had witnessed in my office in a long, long time. She rested her head on her husband’s shoulder and with eyes full of fat tears she said, “Okay, okay. Okay, okay. Okay, okay. Okay, okay.”

He said, “I’m here. I’m here. I’m here.”

I’d been doing clinical work for too long to consider entertaining the clinical delusion that the fact that Mrs. Miller had relented for that moment meant that the road ahead would be smooth.

“No more weddings?” she’d asked me incredulously only a moment after her four pairs of okays had trumped her husband’s three-of-a-kind of I’m here. “Oh Willy, does this mean no more weddings?”

Bill-Willy-looked at me for direction.

I said, “Yes, I’m afraid it does.”

With a despair that I could feel all the way to my toes, she lamented, “What will they do? Oh, what will they do?”

What I saw in her eyes wasn’t concern, it was fear. She hadn’t said, “What will I do?” She had said, “What will they do?” She was worried about “them.”

I wondered, of course, who “they” were. The brides and grooms with whom she hadn’t yet celebrated? Or perhaps-and I knew this was more likely-the speakers of the voices that I suspected were whispering or shouting wicked nuptial imperatives into her ears.

I didn’t know. Nor did I suspect that she would tell me. Not that day.

While the Millers were sitting in my office I’d already acknowledged to myself that I wasn’t the best-equipped mental health professional in town to help Mrs. Miller with her individual treatment. I explained my rationale to the Millers, and with their consent I picked up the phone and called Mary Black-the same psychiatrist who was sharing offices with Hannah Grant before Hannah’s death-and asked if she could do an urgent emergency assessment.

I’d chosen a psychiatrist to assist Mrs. Miller because I knew that the initial phases of Mrs. Miller’s treatment, and likely the long-term progression of her care as well, would involve the shuffling and management of antipsychotic medications, and in Colorado the provision of those pharmaceuticals was the domain of the medical profession. I’d chosen Mary Black as a psychiatrist for Mrs. Miller not only because Mary was good, but also because she was relatively new in town and she was still hungry for fresh patients. I didn’t think it was advisable for the Millers to wait weeks to see a psychiatrist and begin treatment.