Circe (6 page)

Read files on my desk.

Go to Treatment planning in room A-5.

Go to lunch.

Observe Reality therapy group with Katie so you can take over tomorrow.

Do afternoon room inspections for tomorrow’s reality therapy.

Interview Mr. Benoit, Mr. Eaton, Ms. Aidon, and Mr. Nicca for tomorrow's treatment planning.

Write reports-follow model on your desk – use DSM to code on all 5 axes.

You can go home when you’re done.

Dr. Allen

Her aloofness was preferable to over-involvement, but it was strange on many levels. I think the thing that made it most strange was the fact that she trusted me to do my work without any real supervision from her. It was also strange because I had no idea what she did or if she did anything at all. Finally, it was strange because it was what I had always thought I had wanted from a supervisor. I was wrong. I was uncomfortable with her complete abandonment. I felt slightly helpless, like maybe I wasn’t as completely competent as I thought I was.

I did everything her notes told me to do as thoroughly as I could. I read the files and hauled the stack of six binders down three stories to the conference room, shuffling keys and doors all the way. When I finally made it to treatment planning at 8 a.m., the room was much emptier than I had imagined it. There were only five other staff members present. The social worker, Ms. Gardner, was sitting in a corner making violent gestures and talking vehemently to the nurse who sat beside her. Beside the nurse was Dr. Yoshi. He was wearing a tight, brown windbreaker that looked like it saw its prime around 1982. He sat, huddled up in his chair. It almost looked like he was sleeping, although I couldn’t tell because his glasses were so large and darkly tinted that I couldn’t see his eyes. At the front, sitting away from the table, like guards, were two white clad mental health workers.

Ms. Gardner shook her head when I walked in with the files. "Are you a student or an intern?" she demanded loudly.

"Intern."

"Good. I'm tired of students. The way they treat us over here you would think we were a damned nursery school. I swear that Babcock thinks we’re just here to wipe people's noses and teach them their ABCs, as if we don't have enough to do."

I blinked, slightly blinded by the harshness of her tone. "I’m a doctor," I answered her. I emphasized the word doctor, hoping that my education might shut her up. Of course, it didn’t.

"They come here to learn," she continued. "But they’re always loudmouthed, arrogant, and ignorant."

The nurse, Nurse Brown, leaned towards me. "She had a bad experience with the last student. They had an argument over a patient's diagnosis and it was taken to the supervisors and the student's diagnosis stood. It matched the patient's diagnoses going back over 10 institutionalizations." Nurse Brown grinned triumphantly as she said this.

"Oh, shut up." Ms. Gardner said. Her voice carried the lilt of a joke, but enough emphasis to remind us that she was serious.

"So, what’s your name?" Ms. Gardner asked.

"Dr. Black," I responded.

"Is Dr. Allen going to grace us with her presence this morning?"

"Doubtful, but I've read through all of her reports, so I feel fairly competent in taking her place this morning."

"That'll be a first."

"What?"

"A student who actually reads or does reports and has anything insightful to add."

"I'm not a student. I've completed my doctorate. I'm qualified to act in Allen's place and under her supervision."

"Does she actually give you supervision?"

"Oh, shut up," Nurse Brown said, mocking Ms. Gardner's prior tone. "Don't give the boy a hard time just because you have a grudge against Dr. Allen. I'm sure he's going to have a lot to add."

"Weren't we supposed to start 20 minutes ago?" I asked.

Ms. Gardner rolled her eyes at me. Dr. Yoshi laughed, sinking deeper into his chair. Nurse Brown signaled to the mental health worker who sat in the corner and he left the room. He returned a few minutes later pulling in a man in his sixties with his tongue hanging out. The man sat down next to me at the table and began to fidget. He kept putting his tongue in and out of his mouth and making an annoying slurping noise as he did this.

Dr. Allen's report described Mr. Guiles as a 60-year-old white male who presented with poor grooming and a series of stereotyped behaviors. He had a flat affect and he was disoriented to person, place, and time. He suffered from a number of delusions, which lacked theme and cohesion. He was from Bayou Le Batre, Alabama and had been a resident at C.R.C. off and on for almost 32 years. His condition had worsened with time. He had no family and lacked the ability to groom himself or use the facilities by himself. Dr. Allen had diagnosed him with schizophrenia, disorganized type and given him a global assessment of functioning around 10 out of a possible 100.

Ms. Gardner took the lead with the interview. "So, Mr. Guiles, do you know why we are meeting here today?"

Mr. Guiles shrugged and shifted in his chair again, looking at me. "Who’s dat?" He asked.

"This is Dr. Black and he's going to be your psychologist," Dr. Allen said.

"What you do?" he asked me.

"I try to find ways to help you," I responded.

Guiles stuck his tongue in and out slowly and looked at me. "You know I lived in Africa for fifty years," he said.

"Really," I responded. I took the opening as an opportunity to begin going through the questions of the mental status exam with him. "Do you know where you are now, Mr. Guiles?"

"I'm in the hospital,” he said. Everyone at the table took notes.

Ms. Gardner leaned over, “Do you know why you are at the hospital?"

"I'm sick."

"How?" she asked.

"I reckon 'cause of the war."

"Which war is that?" Nurse Brown asked.

"One of those African wars. You know, in Negaria. I'm one of those albino Africans, you know."

No one could have possibly been whiter than Mr. Guiles. The only African he had in him came from the imported coffee beans they served at the cafeteria.

"Do you know how old you are?" Ms. Gardner asked.

"Twenty-one or 22."

"Do you know who the president is?"

Mr. Guiles flicked his tongue again and looked at me. "I'm thirsty. They never give me any water. Why won't they give me any water?"

I had read Mr. Guiles' file. I knew his history and his diagnosis, but everyone else assumed that I had not. Nurse Brown looked at me and answered his question without even making eye contact with him. "Mr. Guiles has had to be sent to the hospital three times now due to electrolyte imbalance. He sneaks water and drinks so much that his heart can no longer pump. He gets eight glasses a day, but he wants to drink eight gallons."

"They steal my money, too. I got 200 million dollars from those diamond mines."

Dr. Yoshi laughed and leaned over. "Really, can I have some?" His English was almost indecipherable.

"Oh, when they stop stealing it."

"Who do you think is stealing your money?" I asked.

"Them."

"Do you know what year it is?" Gardner asked.

Guiles leaned over and stared at the wall behind her as if searching for some answer to the question there. He stuck his tongue out again and laughed. He put his old, freckled hand on mine. "I want to go home," he said.

"We'd like to see you go home," I responded. "Where is home?"

"Alaska," he said, and grimaced horribly.

"Do you know what this is?" I asked holding up a pencil.

"You know what that is," he responded.

Gardner looked at his file before she asked, "Have you been going to your morning therapy groups?"

"Yes," he said.

"It says here that they haven't seen you in over a month."

"Oh, yeah. Maybe I haven't been going."

"You also haven't been going to vocational groups or afternoon group."

He looked confused and stuck his tongue out again.

"Do you remember what we talked about the last time we met?"

He shook his head.

"You have to go to your groups before we can even talk about you leaving."

"Do you think you can remember to go to your groups this week?" Nurse Brown asked.

"They never tell me about them."

"Yes. They announce every group on the speaker four times before each group. They tell you about them. It says here that Katie has even been coming in to remind you before groups."

He shrugged despondently and began to tap on the back of his neck.

Dr. Yoshi almost moved. He asked him, "Is there anything you need from us? Do you have any questions?"

"I'm thirsty."

"We've already talked about that," Gardner said. "You drink too much water."

His tapping became more intense and more rapid. "Is there anything else that we can help you with?" I asked.

He just began to tap harder and looked at the wall.

"I think Mr. Guiles is done," Nurse Brown said, and with that the mental health worker ushered him out of the room.

"I'm recommending another three months before review. In that time, he must attend reality therapy at least twice a week and see the hygienist at least three times a week. He must also make marked improvement in his ability to care for himself before a group home will be recommended," Ms. Gardner said.

"Current course of medication will be maintained," Dr. Yoshi said.

"I agree," Nurse Brown said.

"Why three months?"

"That’s the longest period we can recommend between reviews. It is also mandatory that we go to court at least every six months to ensure that his institutionalization is legal. We'll have to deal with that in three months. Only doctors can go to court. Psychologists or psychiatrists."

"According to Dr. Allen's report, she indicates that he has been more responsive to working with Katie and her behavioral modeling program than with the reality therapy group. She recommends a change of group and a review in one month." I looked at Dr. Allen's report as I read, purposefully trying to avoid eye contact with Ms. Gardner.

"Mr. Guiles is purposefully resistant to any treatment and we shouldn’t change his treatment until he is at least minimally compliant," Ms. Gardner said.

"Prior testing shows that Mr. Guiles has a borderline IQ and virtually no contact with reality, I think it’s projection to think that he’s purposefully resisting any kind of treatment. Dr. Allen's testing indicates that he’s going to need to be spoon-fed a more basic treatment. His history shows that he has been doing reality therapy for 20 years now and we can see where that has gone."

Dr. Yoshi moved to make eye contact with me, "You have to remember how poor Mr. Guile's prognosis has always been. We don’t expect him to improve. He's been on every antipsychotic we have.” Dr. Yoshi was almost impossible to understand.

"Drugs alone can't be the answer," I responded.

Dr. Yoshi shrugged. "Why not try your way?" he said.

Ms. Gardner turned beet red. "You get to do the paperwork then, Dr. Black," She threw the enormous binder that contained his file at me. "Do you know what you’re doing?"

"I'll figure it out."

For every treatment planning meeting there is a mountain of forms to fill in, and every member of the treatment team has to sign every page. The patient and their family also have to sign every page of the treatment plan. I was to find out later that the better portion of my day would be spent doing paperwork such as this. Mr. Guiles was brought back in and we carefully explained to him about the behavioral modeling program he would be working on with Katie, a Psych Tech. We requested his approval and he grimaced and snorted and put a shaky X on every form we asked him to sign.

This is how my mornings went. We could see three or four patients in a morning. Ms. Gardner and I split up the paperwork. I ate lunch alone, working as I ate. Dr. Allen's office felt oppressive. Its dark walls closed in on me and the flickering neon lights gave me a chronic headache.

Reality therapy seemed like a joke to me. Katie led me through the steps. Apparently, every morning and afternoon she went to all the patients’ rooms and recorded information on how they were keeping up with their hygiene, whether or not they were keeping up with their rooms, whether or not they were waking up, etc. New laws had made it impossible to force the patients to do anything they did not want to do, but everything they did was watched and recorded and noted for later.

Katie told me a story that exemplified this. Legally, every patient had to have access to a phone at all times and allowed to call 911. One patient had a number of paranoid delusions that centered on the persecutory nature of the hospital staff. So, he began calling 911 seven or eight times a day. The  operators called and complained. The police called and complained, but the hospital was helpless to prevent him from dialing. Most of the time, he would call and tell them that Ms. Gardner was trying to plant microscopic bugs in his brain that forced him to steal from other patients, but the story varied and became more eclectic over the years. The phone was a payphone, so the patient could only call toll free numbers and when 911 stopped being interesting, he started calling all of the toll free lawyers he saw on TV. This problem went on until the patient was discharged to a group home, where, as rumor has it, he still calls 911 on a regular basis.

So, when we did reality therapy, our primary goal was to sucker the patients into showing up and staying any way we could. It was also our goal to convince the patients that it was in their best interest to try to learn things like how to bathe, to eat with silverware, and to ignore the voices in their heads.

Katie showed me the files for the patients who were supposed to attend reality therapy before group began. There were 45 files in all.

"Is this one for real?" I asked her as I looked through them.

"Afraid so," Katie answered.

"Mr. Craig Fat?"

"His father was Chinese or something," Katie answered. Katie was a pixie of a creature who couldn’t have been more than 23. She had a Bachelor's degree in Psychology and did most of the grunt work for the first floor chronic ward Psych team. "His name will seem even funnier when you meet him," she said.