“The unconscious doesn’t know who is abandoning whom,” one supervisor said to me, explaining that my patient was likely feeling left by me, even though she was the one who was not showing up.
“If she had come regularly and had experienced you as a consistent part of her life, she would have had to grieve all that she didn’t have as a child,” one of my professors commented in my final weeks of school when I presented the case—which had by that time spanned three years.
I saw many clinic patients during my four years in graduate school. They arrived with their problems and their stories, and because I was being educated in the psychoanalytic tradition, I learned to begin by asking myself two questions. First, what was their developmental level? At what point in their emotional development had things begun to go awry—the earlier it had been, the worse off they were. Second, what was their character organization? In what ways did they tend to distort reality in an attempt to feel less pain? Together these answers provided an important if gross starting point for every treatment. A patient’s developmental level was psychotic, borderline, or neurotic; his character organization within that level masochistic or obsessive or narcissistic or depressive—the list goes on some—depending on the constellation of defenses he tended to favor. (Myself, I was neurotic, and my own character style a tinge masochistic with stronger undercurrents of depressive: having felt from quite a young age that painful experiences with my parents were my fault, I believed I was so bad. I was not unlike other psychotherapists in that regard. What better way to alleviate a constant and nebulous sense of guilt than to devote one’s life to helping others?)
These two dimensions shed light on the patient’s internal experience, on how he organized and perceived his life. What had become more popular in the world at large, under the rubric of cognitive-behavioral therapy, or CBT, was an emphasis on discrete symptoms, say social phobia or panic attacks, that could supposedly be alleviated in short, rote bursts of ten sessions or fewer. At my school patients came to us for long-term work and character change, to alleviate troubling thoughts and behaviors and then some, as true well-being is more than just the absence of symptoms.
In class, semester after semester, we worked our way through a hundred years of psychoanalytic theory in the order it was written. Outside class I sat with patients and supervisors and tried to figure out how to apply my book learning to my clinical work—the most difficult part of becoming a therapist. As I relaxed through those years into the reassurance of my teachers’ formulations about the people who arrived to see me weekly, I came to grasp why I had finally chosen to study psychology. Having early on found myself in a world where the attitudes of others confused and pained me, I needed badly to make sense of people, to order them, like my patient with her dolls.
But it was not an auspicious moment for nuanced thought, and while I did not fully realize it yet in those first years of graduate school, neither was it a good time for psychology as a field. As if the pernicious hostility toward the psychoanalytic way of working were not enough to threaten the best chance people had for richer lives, the confluence of cultural forces, the advent of pharmaceutical commercials, and a general human aversion to deep consideration of complication had over the course of many decades swayed the conventional wisdom: psychological problems were nothing more than chemical occurrences in the brain, something one caught, like a cold, or was born with, like color blindness. If Descartes’s four-hundred-year-old error had been the separation of mind and body, of rationality and emotion, the modern equivalent, at least in the popular consciousness, seemed to be a separation between brain and mind, in some cases leading to the disappearance of the mind altogether. The medical establishment did not dismiss talk therapy completely, but it seemed to have come to believe that its primary utility was not to make meaning but rather to convince people to take their pills. (“You do the hard work of getting people to be medication compliant,” a psychiatry resident said to me once, in the patronizing tone I would become accustomed to hearing from young psychiatrists, as if this were a skill that one might reasonably spend many years in school acquiring.) The sensible idea that the sum total of one’s biology and life experiences contributed to emotional strengths and vulnerabilities seemed to vanish into air, and along with it esteem for the actual hard work done by psychologists. And so it came to pass that my discipline was slowly being phased out of medical centers—the treatment site of choice for the most disturbed and outcast patients. By the time I completed my four years of doctoral course work and accepted the internship offered me at Kings County Hospital, there were fourteen psychiatrists running and medicating the seven adult inpatient units. There were four psychologists in total covering those wards. Even in the place where I had been invited to complete my training, there was this suggestion of how little what I had to offer might be valued. For my own part, I couldn’t quite get that message out of my mind.
On the first morning of my internship at Kings County Hospital my stomach felt raw. My new professional clothes, so chic in Macy’s dressing room just one month before, looked now only dowdy and overly beige. I met my friend Jen on the corner of Joralemon and Court Streets, halfway between our Brooklyn apartments—mine in tree-lined Brooklyn Heights, where I was renting a small fifth-floor walk-up with my classmate turned fiancé, George; Jen’s in a grittier, hipper neighborhood just the other side of the Brooklyn-Queens Expressway. We met near the Court Street station to ride the Number 2 train out to the far end of our borough, to East Flatbush, where our Jewish immigrant relatives might have settled just two or three generations prior, but which was now home to other, darker-skinned newcomers: Haitians, Jamaicans, Trinidadians, Guyanese. It was less than five miles from where I’d lived for years, but until I interviewed at the hospital, I’d never as much as passed through the neighborhood. In a city of destinations, East Flatbush was not one at all.
Jen, as of that day my fellow intern, had been my friend for six years, since we’d met in a group therapy class when beginning the master’s degrees that we hoped would make us competitive doctoral applicants. We worked in the same research lab, and though she thought of herself as painfully shy, we’d slipped straightaway into an effortless friendship. I grew so attached to her during the two years of our M.A. work that I cried when we didn’t get into the same Ph.D. program. “Maybe we’ll go on internship together,” she said at the time, trying to cheer me. But internship was far off enough then to be only an abstraction, and winding up with Jen seemed unlikely besides. With so many different sites in New York City alone, it was doubtful we would pick the same one, let alone that one would agree upon us. But as we had discussed our respective preference lists just before Match Day that past February, it turned out that both of us—ready for a gritty challenge—had put Kings County in slot number two. Both of us had been certain we wouldn’t get the other public hospitals that had been our first picks.
Jen’s clothing that morning matched mine, in broad sweeps, and looked equally as labored. We had to appear professional now, business casual. Even the moniker was unattractive. “How are you feeling?” she asked.
“Ambivalent,” I answered as we chose seats on the near-empty subway car of our reverse commute. Jen smiled, which I’d known she would do because it was a psych-grad-student inside half joke, the obligatorily measured response of one under constant press to demonstrate how in touch she is with her mixed feelings. In actuality, I was more rueful than anything. While we were still technically students, I knew we’d never be returning to campus again. I was thirty-four years old, and certainly it was time, but I’d loved almost everything about graduate school and could think of little benefit to its end. I enjoyed dividing my time between reading and seeing patients, and discussing the readings and the patients with people who were just as interested in it all as I was. I was living on student loans, which, supplemented by the occasional writing assignment, provided for the basics. And then there was the security inherent in the student positi
on, the absence of any pressure to be the final word.
“Was George excited this morning?” she asked.
Yes, I nodded, he was. As Jen and I traveled farther out into Brooklyn, George, whom I would marry in the spring, was on his way into Manhattan to begin his own internship at Columbia-Presbyterian, the most coveted of placements—a private hospital affiliated with an Ivy League university—and one that hadn’t even seen fit to grant me a second interview last winter when the whole matching process was in bloody swing. George had been a social worker in the navy before he’d gone back to school, and he’d struggled over whether to rank Columbia over one of the three local VA hospitals, but in the end he couldn’t resist the siren call of the world-class medical institution. Geographically, Columbia was about as far as you could get from Kings County within the borders of New York City. It seemed like an apt metaphor.
The train rumbled down the tracks. Speaking over its clatter, Jen told me she was already wishing the year away. Like many of her classmates, she’d worked at Beth Israel for three years during grad school (we called these placements externships), and she’d had enough of hospitals. Most of my own classmates had also done hospital externships during school, but I’d purposely avoided that, choosing to train at a psychoanalytic institute instead, with healthier patients and different objectives. I’d been halfheartedly cautioned against this by my school’s externship adviser—he spoke vaguely about the value of having hospital experience pre-internship—but all of my professors were psychoanalysts in private practice, grooming us for much of the same. I wanted to get right into it. This other work seemed like a lesser option, a booby prize. During my master’s program I had briefly volunteered on an inpatient psychiatric unit in order to build my CV, and I believed I’d learned nothing. I’d helped the handlebar-mustachioed recreation therapist run groups, which meant sitting with him and the patients as we put together a unit newsletter (he eventually left me alone to run that group, thanks—but no thanks—to my magazine background) or played hangman, cautiously renamed Wheel of Fortune by the staff. In my semester there I never once encountered a psychologist. Now, some years of training later, I still had no idea what therapists like me, schooled in long-term recovery with higher-functioning patients, were supposed to do in places aimed at short-term stabilization of the chronically and acutely mentally ill. I felt too embarrassed to ask, half-certain that after six years in school I should know that already and half-afraid that the answer would simply validate the fear that I was superfluous.
The alarm bells of the subway station’s emergency exit gate blared as Jen and I disembarked at the front of the train. I’d exited subway stations throughout the sprawling city over many years but never to the sound of sirens. I assumed they were meant to summon the police, but nobody came. There didn’t seem to be an emergency anyway. Jen and I climbed the stairs into a sunny July morning. We walked straight toward the BP station, left as the road dead-ended at the hospital’s A Building, and right down Winthrop Street a good long way.
In 1831, the population of Flatbush hovered around a thousand, and Brooklyn was a city in its own right. That year the medical facility that would grow into Kings County Hospital opened as a one-room infirmary. Over a century, it became the third-largest medical center in the United States, its collection of buildings in ugly juxtaposition, their unseemly mix of architectural styles spread over twenty-four acres of flat city land. The G Building arrived with World War II. Its Gothic architecture suited its label: insane asylum. Of course no one called it that anymore—now it was Behavioral Health—but it was still an asylum in the popular imagination. My intern class would be the last to both begin and end its tenure in G. A new, $120 million facility for psychiatric patients was scheduled to open a year and a half after my start date.
When I arrived there in the summer of 2007, the decaying G Building’s seven floors housed 230 psychiatric inpatients when filled to capacity, which was more or less always. Its first floor held administrative offices, a small deli window where staff or visitors could buy coffee and sandwiches, and CPEP—the Comprehensive Psychiatric Emergency Program, more commonly known as the psych ER. The second floor was home to a pharmacy and, without irony intended, a unit dedicated to “dual diagnosis” patients, those with co-occurring substance abuse problems and mental illness. The third, fourth, and fifth floors were each home to two locked general wards. The sixth floor had once been for forensic inpatients—men and women convicted of crimes and also in need of treatment for psychiatric problems. The serial killer Son of Sam had been incarcerated there for a time in the late 1970s. No patients had resided there, though, since Kings County’s forensic unit had merged with Bellevue’s in Manhattan some years back, and now the cavernous sixth floor was almost deserted, a dimly lit ghost town with a big empty space for meetings, a handful of offices for staff, and one dank room for the seven adult interns to share. On the seventh floor was a bare-bones gym where patients who were well enough could supposedly get some exercise. Though the building was cleaned regularly and thoroughly, it appeared almost filthy, the years of grime and bad feeling having finally worked their way into the linoleum and the concrete.
Jen and I walked through the back door of G to wait for the elevator that would take us to the sixth floor. The elevator system—which we had been introduced to when we came for our internship interviews six months prior—was arcane. The call buttons didn’t work, and like so many problems in G they must have been deemed unfixable because the hospital had hired elevator operators to run each lift. To let the operator know you needed to go up or down, you had to pound on the metal door, shouting “one,” or whatever floor number you happened to be calling from. If the elevator operator—usually perched on a stool inside the shaft reading the Post or texting or selling knockoff designer handbags, depending on who was working that shift—happened to hear you, you would be granted your ride, as long as the operator could get his or her car to actually stop at your floor. (Sometimes the buttons inside the elevators didn’t work either, and the operator would yell “I’ll be back” as he glided past.) The inpatient units and the stairwells were locked and unlocked with old-fashioned skeleton keys—five inches of nickel-plated steel and heavy in the hand—and the staff took advantage of their cartoonish bulk to make the necessary ruckus on the elevator doors. By six weeks into the year, all of us interns were quite fond of the elevator operators, who greeted our trainee eagerness with almost equal enthusiasm each morning. I asked someone on staff what would happen to the operators once Behavioral Health moved to the $120 million building. “They’ll still run the elevators,” said the person quizzically. Had anyone ever been so new to Kings County Hospital as I?
Jen and I arrived on the sixth floor and walked toward its rotting main space. Streamers hung limply from the ceiling tiles over bagels and tubs of whipped butter and plastic cutlery. An air-conditioning unit—suspended in one of the room’s wall of Gothic-looking windows with their grids of rusting panes—cooled the large room. A sign on the wall, left over from the previous week, bade the outgoing intern class farewell. I envied that group, so far ahead of me in their training. I didn’t know any of them personally, though Jen had received and shared what felt like a carefully worded e-mail from one a couple months prior, a response to some questions Jen had sent her about the internship. The e-mail warned about the lack of amenities like toilet paper in the sixth-floor bathrooms, department politics, and the new director of training, who had started midway through the previous interns’ time there: “I think Dr. Brent will come into his own during your year, so you’ll get to watch him develop, but don’t be afraid to stand up for what you want and demand changes, especially when things get out of control.”
The place was filled with Behavioral Health staff who’d been summoned to greet us. For morning, the mood was festive. Staff introduced themselves sleepily to us as they ate. The interns gathered in a circle, ten of us, seven adult track and three child. We were demographically
representative of our discipline: eight women and two men. All in our early to mid-thirties. Five of the women were Jewish, and two of those Israeli. One of the women was black and one a native Spanish speaker. Intern classes all over the city looked just like us, though most sites did not have quite as many trainees.
Of the six other adult interns, I had known two for years, Jen and Leora, who had been my classmate in graduate school. Friendly if never quite friends, we were the only two of our class of sixteen to be on internship together, the others spread throughout the city and up the East Coast. We hugged in greeting, not having seen each other since classes ended in May. The others introduced themselves in turn: Zeke in an odd corduroy suit with elbow patches, Tamar with a terrible cold, Alisa bubbly and pretty, Bruce curly-haired and wry. The child-track interns said hello, too, though with slightly less interest, as we weren’t sure how much to invest in each other, how much our time there might intersect.
As we all exchanged information, our director of training appeared in our circle, though I hadn’t seen him approach. Scott, as he would instruct us to call him, would never seem to walk into a room, but rather simply to manifest, a desultory rabbit from a long-battered hat. “Welcome,” he said, spreading his arms in front of him. He was average height and slender, boyish, though certainly well past forty, with thinning blond hair and a sallow complexion. There was warmth in his voice, but it was tinged with an irony that negated it, the armor of a man eager to convey that he didn’t want us to imagine that he took himself—this role—too seriously. “I’ve met all of you except … well, you must be Darcy, and you must be Zeke. Glad to finally lay my own eyes on you two.”
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