Brooklyn Zoo (24 page)

If the Mafia is out to kidnap you, a locked inpatient unit is a great place to hide out, but try convincing a paranoid woman that she’s safe there. “I want my mother contacted when they
take me,” the patient, a Ms. Anders, was declaring loudly and angrily to the treatment team as I took a seat in the morning meeting. I was late because, upstairs, Scott Brent had seen Bruce and me laughing in the hallway and had asked us suspiciously what was going on. Nothing was going on. Caitlin watched the whole interaction from her doorjamb, and when Scott had gone into his office and closed the door, she explained that it was his birthday and that he believed the interns were planning something for him. When we told her that we hadn’t known, and further that we had no plans, she told us that we’d better make some. Bruce and I went into our own office, and I shut the door. Bruce declared, “Oh, good Lord!” which I thought summed things up nicely.

As a group, we interns had months ago identified that Scott had a narcissistic character style. If depressives feel guilty and bad, narcissists feel empty and inferior. Their fragile self-esteem requires constant shoring up. They don’t easily let go of perceived snubs like not being allowed to handpick all the interns or not having their every decision applauded, their every birthday marked. I hadn’t spent four years in a doctoral program in psychology not to know how to placate a narcissist, but the very idea of having to do it exhausted me. Besides, it was a cynical task, this avoidance of slighting him, and I preferred to maintain the belief that Scott was better than that, closer to what I needed him to be, even though there was nothing but my wishing to support this. I told Bruce I couldn’t work up the energy to care about Caitlin’s dramatics and didn’t think that he should either. Instead, feeling burdened, he tracked down Alisa, the most sympathetic of our intern group, and the two of them went to troll East Flatbush for a cake. When I arrived late to the morning meeting, the treatment team, save for Dr. Meyer, was assembled,
and Dr. Winkler was gently questioning Ms. Anders, all eyes on her.

“Usually, people kidnap for money. Do you have a lot of money?” he asked.

“No,” she replied, hostility in her voice.

“So why do they want to kidnap you?”

“Hate. They hate me.”

“Are you hearing voices?” he asked.

“This is New York City. There are people talking around me all the time. How would I know if they were just voices?”

“You plug your ears,” he told her. “If the voices you’re hearing don’t get quieter, they’re coming from inside your head, and you’ll know you’re hallucinating.”

“You’re not paying attention,” she told Dr. Winkler. “Everyone here knows I’m going to be kidnapped by the Mafia!”

“No, they don’t,” he said matter-of-factly. Dr. Winkler was the only person I’d ever heard speak to the most chronic psychiatric inpatients as if they were fully human, without condescension or pity or something worse. “Is there anything in your life you’re feeling guilty about?”

“No,” she said. “I have no traffic tickets. I haven’t killed anyone.”

“Did you ever want to kill anyone?”

“Are we done here?” she asked haughtily, standing up.

“Sure, for now,” Dr. Winkler said, nodding toward one of the social workers, who unlocked the door to let Ms. Anders return to her room to await her fate.

“Paranoid delusions are preceded by a sense of guilt over some long-ago event that’s been obscured over time, and delusions about the Mafia are very common,” Dr. Winkler told Tamar and me and the two medical students, Steve and Jason,
who had joined us on the unit that week. “We need to bring the family in to provide a realistic correction to her fear that they’re in danger. They come in and challenge her thinking, unhinge the whole delusional system. Who wants to follow Ms. Anders’s case?” he asked, and Tamar volunteered.

As another new patient was located outside, Dr. Begum told Tamar and me that one of us would lead the next evaluation. Tamar nodded in assent, and I felt relieved. The little old Caribbean man who was brought in answered her questions about his symptoms and his history succinctly. He was as psychotic as any other patient, but he obviously knew his way around a psychiatric screening. When Tamar had finished, Dr. Begum asked if he had any questions for the team. The patient paused and thought and then asked: “Do American women like to have sex in bed?”

Dr. Begum replied, “Yes, I hear that they do,” and then we all got up from the table to leave. I walked down the hallway to Mr. Rumbert’s room. He’d started speaking aloud again the day before, which turned out to be more trying than his silence.

“How do you
know
that’s my name?” he asked when I addressed him by his name.

“How do you
know
my mother came to see me yesterday?” he asked when I inquired about the woman’s visit. It was like trying to talk to a freshman philosophy major who’d just watched the entire
Matrix
trilogy. When I offered him the chance to correct any misinformation I might have, he became indignant and announced that he wasn’t going to speak again until discharge. I told him this would make it difficult for us to let him go, as T. had taught me to say to ER patients who didn’t want to cooperate.

“Are you threatening me?” he asked. I wasn’t quite,
though I could see why he saw it that way. The next day we met with his mother and Dr. Winkler in the dayroom. It was my first family meeting on inpatient. Families could play an important role in recovery—or sabotage it altogether—but so far none of my other patients had relatives interested in showing up. I got Mr. Rumbert from his room, and he followed after me in his socks. When we sat down at a table still jelly stained from breakfast, Dr. Winkler asked how he was doing.

“I’ve been thinking a lot about what I am and how people see me,” he said.

“ ‘Oh would some power the gift to give us, to see ourselves as others see us!’ ” replied Dr. Winkler. “Robert Burns.”

Mr. Rumbert explained that this was especially on his mind because he was having trouble with his vision. He couldn’t see himself clearly, and he couldn’t tell if he was eating the right things, “what the Bible says you should eat.”

“Does the Bible tell you to starve yourself to death?” asked Dr. Winkler. Mr. Rumbert shook his head, and Dr. Winkler went on. “The Bible says many things, lots of them contradictory.” They discussed some of these. Mr. Rumbert’s mother asked when she could take her son home to Barbados. “We have to figure out what medicines work for him and then work out a treatment plan for after discharge,” Dr. Winkler told her.

“How do I know when a medicine is working for me?” asked Mr. Rumbert.

“What works is what helps you eat, sleep, and concentrate,” Dr. Winkler explained.

The next day Mr. Rumbert was as open with me as he’d been. “Am I clean?” he asked when I greeted him. He sounded worried. He explained that his problem with his sight left him unable to tell. I told him he looked quite clean to me and
asked him what it meant to him to be dirty. “That no human would want to get near me,” he replied.

“What would happen then?” I asked and then heard Dr. T. in my head: “Too complicated.”

“Bizarre ideation,” Dr. Winkler labeled Mr. Rumbert’s thinking when we spoke. Psychotic symptoms had delightful names. They rolled off the tongue. Flight of ideas. Phonemic paraphasias. “How’s it going with Mr. Rodgers?” he asked.

The child molester. I was seeing him three times a week, as I was expected to, and tolerating it by learning about his history and avoiding his present. This probably wasn’t the way to go. It was no kind of telescopic lens. He told me he’d married an older woman soon after graduating high school, and then had four children with her. She had an affair and he left. After one year as a single man he’d married again—the woman with the daughter. He tried to solve the problem of his untoward sexual desires in church. It hadn’t worked. He remained pretty depressed, I told Dr. Winkler—though the voice endorsing suicide had faded as the antipsychotic medication took effect and he remained outside the jurisdiction of the Pennsylvania police. We could begin to think about discharging him. Mr. Rodgers’s father had called to say that he would take his son home within a few days to face his legal troubles with his stepdaughter. I would talk to Mr. Rodgers about how he wanted to proceed with his charges. Would he plead out? Go to trial? What were the likely outcomes of each? It wasn’t therapy, but it was all that I could stomach, and maybe it would even be marginally useful to him.

There was a twenty-five-year-old deaf and mute patient on the unit. Her name was Camara. One night she apparently fainted
and fell, and the next morning a roly-poly white man none of us had ever seen before appeared at our meeting, identifying himself as a clinical case manager and suggesting that the chart note indicate that Camara had “placed herself on the floor.” I tried to make eye contact with someone on the team to confirm that this was lunacy, but no one met my gaze. Apparently, the word “fall” did not go lightly into a chart. The fainting had been no one’s fault, and Camara had not hurt herself, but every patient was a legal proceeding waiting to happen, every staff member a potential accused assailant. As if the patients’ paranoia were not enough to leave the fifth floor bursting at its cracking seams, the staff’s almost matched it most weeks. The Justice Department’s impending arrival only inflamed this, and we were reminded of it in one way or another daily. (By the constant painting and repainting of the first floor, for one: Did DOJ prefer teal to aquamarine? The question was obviously keeping somebody up nights.) The atmosphere on the unit was so fraught that I could almost feel sympathy for the somber and silent recreation therapist who locked himself alone in the cavernous group room from nine to five each day. If you didn’t interact with anyone, there was less to worry about. But then there was the fact that there were no groups being run on the unit, and that even the interns’ pleas to use the space—
which did not after all technically belong to this man
—to run therapy groups for a couple of hours a week had gone unanswered. (Actually, he nodded when Bruce and I asked to use the room, but then he disappeared at the agreed-upon time, along with the room’s only key.) Was a “group” one burned-out city employee hiding alone for hours in “the group room”? The answer, it seemed, was yes. In contrast, in casual conversation George would occasionally launch into a story with a line like, “One of my inpatients left knitting group
today to go check her e-mail …,” and my mouth would fall open.
Knitting group? E-mail?
The next day I would report on the bounties of the private hospital to my fellow Kings County interns, who would gather like orphans around Annie just back from Daddy Warbucks’s to hear my dispatches. What puzzled me almost as much as the recreation therapist’s blatant shirking of his sole responsibility was that he went by the title “Doctor,” even though he was not one.

Still, “Dr.” Jacobs’s behavior made other things on G-51 seem less weird in comparison. Like: members of the treatment team sometimes addressed floridly psychotic patients with frustration and cries of “You’re not making any sense!” (Not making any sense was exactly why they were in our company, so yelling at them for it seemed particularly unreasonable.) Like: Dr. Meyer rarely showed his face on the unit after the interns’ first week there, and no one seemed to find his absence even worth mentioning.

The last point got to me. Dr. Meyer was the one psychologist assigned to the unit, and from what I could tell, he almost never actually set foot on the unit. I met with him in his office once a week for forty-five minutes of individual supervision, and when he wasn’t reminding me to carve out a place for my field with my notes—refer to voices as “auditory hallucinations,” to alcohol as “EtOH”—he was helpful and engaging. For example, when I shared with him my strategy for helping a psychotic patient manage his feelings about having been abused as a child—“Try not to think about it,” I told him—Dr. Meyer diplomatically replied, “That’s one way to go.” I explained that while I would never suggest such a thing to an outpatient, on inpatient I was trying to prepare the man for discharge by building his defenses.

“Which defense is that?” he’d asked.

“Repression,” I said.

“Defenses operate unconsciously,” he reminded me. “This is obviously already on his mind. Ask him why he’s thinking about his abuse now.”

What I was thinking about as I sat with Dr. Meyer, as the weeks went by, was this: Did we psychologists matter at all here? In the ER, T. ruled her own little world. Unencumbered by anyone or anything, she made use of her space to be a psychologist, to be always planting seeds. On inpatient, larger forces seemed to have come together to silently assert psychology’s insignificance. All the trainees who came onto G-51 were treated equally, no matter their training or experience. The interns were appreciated as extra bodies who could give the patients attention, but never as if our specific knowledge of psychological functioning was of any particular value. And so Jason, the dentist training to be an oral surgeon and doing his mandatory ten-day psychiatric rotation, had as many patients as I did, but with less supervision (I wasn’t sure he had any, actually). Had he learned, as I had, that paranoia is the externalization of one’s own aggressive impulses? That delusions represent the unconscious wishes of the parents? That auditory hallucinations result from the projection of the pathological introject of the mother? Did he even know what an introject was? Granted, I had little experience in actually treating the sickest people, but I had at least spent many years in school learning how to think about human health and pathology. That seemed of little repute here. Dr. Begum was always making noise about getting the staff in order, but he left Dr. Meyer out of this equation. If he believed that psychology had something to contribute to his unit, wouldn’t he remark upon my recalcitrant supervisor? It wasn’t clear that anyone other than Tamar and Bruce and me took note of Dr. Meyer’s absence, or
even whether the chain of command would entitle anyone to say anything if they did. Maybe it wasn’t Dr. Begum’s place to remind Dr. Meyer to show up. I didn’t know. All I did know was that everyone who worked there seemed to have a sense of his or her own distinct purpose and that my supervisor’s actions communicated that at the very least he himself felt his—and by extension likely ours—not worthy of fulfilling.