“Excuse me, but I was talking to the lady, putting together words, phrases, sentences, but not the kind they give out in court,” said gray dress.
“I’m sorry, but I can’t help either of you.” This was true, but it sounded so wrong. I tried to come up with something more therapeutic. “Someone else will help you soon. I have to go find the patients on my list,” I explained, holding up the census. They looked at me as if I were crazy, and I reinforced that idea by suggesting they have a nice day.
In the men’s EOB room next door—identical down to its white peeling paint—I discovered two more patients. One was lying on a vinyl mattress, wrapped from head to toe in a gray flannel blanket. The other was asleep on the hard floor, despite the two empty beds. I saw Kelvin in the hallway and motioned him over. He smiled and walked toward me. I appreciated his good humor. “Should I wake them?” I asked. He approached the man on the floor and nudged him gently with his sneaker.
“You don’t ever want to bend over a patient here to wake him up,” he explained as he nudged. “You can’t be sure what shape he’s in. If he’s psychotic, or even just startled, he might lash out in response. You don’t need to get punched in the face, and he doesn’t need to suffer the consequences of hitting you.” I nodded. The patient just grumbled and rolled over, his arm slung to his side. Kelvin bent down, keeping as much distance as he could, and read the patient’s plastic admission bracelet. He recited the name to me: not on my list. Apparently, anyone could wander into the EOB rooms to get some rest.
Kelvin walked over to the man in the bed. He nudged him as well, with his hand this time, still keeping his distance. The patient pulled the blanket off his face to look at us. I explained who I was and asked his name. Bingo. On the list. “We’re going to have a group in the dayroom in a few minutes. Would you like to join us?” I asked. He returned the blanket to his face. It hadn’t occurred to me that a patient might refuse, and so I had not asked Dr. T. if group was mandatory. Even if it was, I couldn’t imagine how I would enforce attendance. I thanked Kelvin and went to explore the rest of the ER. One down, two to go.
With an aide’s help, I found my second patient, an old and sickly looking man, standing in the doorway of the bathroom in his pajamas with urine running down one leg. “I’m going to have to get him cleaned up. Can you talk to him later?” asked the aide. I was still not breathing through my nose but knew instinctively that he stank worse than even the room around him. I wasn’t supposed to feel this way—and there was the rub. The first lesson of graduate school in clinical psychology is that “supposed to feel” is a distinctly un-clinical concept, and what you actually feel provides important information about a patient’s interpersonal world. But I wanted nothing to do with this man. (“Neither did his mother,” said the voice of one of my professors in my head.)
“Please,” I said, motioning the aide forward. She led him off, holding his arm.
I called my third patient’s name out in the small, bleak waiting area at the farthest point from the EOB rooms. No one responded. I walked back to the center of the Y and found a nicer, air-conditioned room with five vinyl reclining chairs next to the nursing station. There was a man sprawled on each chair. I spoke my patient’s name once again. This time someone responded. “That’s me,” he said, opening his eyes. He was dressed and clean enough. I approached him.
“I’m Darcy,” I said. “I work in the Extended Observation Bed unit, which you’ve been admitted to.”
He nodded. “I know. Been here before.”
“Normally, there’s a morning group for EOB patients to help get you oriented, but this morning it’ll just be you and I,” I said, making the decision not to have a proper group, as if it were not a choice made for me. “Do you have any questions?” I asked. He did not.
I explained that he would be in EOB for a maximum of seventy-two hours and that Dr. T. and I would be speaking with him later to see how he was doing. He seemed content and thanked me for the information. “Just one question,” I said to him. “Why are you sleeping in here when you have a bed down the hall?”
He pointed toward a small window air-conditioning unit. “The AC,” he said. “It’s cooler in here.”
It was 10:15 by the time I let myself back into Dr. T.’s office to wait for her. It had taken me forty-five minutes simply to locate three patients and not have a group. “You’ll do better tomorrow,” Dr. T. assured me when she came in at 11:00 and I told her about my morning.
“Was the census right? Are there only three patients today?” I asked.
“Yes, unfortunately,” she said. “I have to talk to admissions. We get a thousand dollars from the state for each bed, but only when they’re filled. Sometimes the psychiatry residents forget about us, admit people right upstairs, where there are rarely enough beds. If they can’t be transferred to another hospital, which most of them can’t be, because they don’t have insurance, they end up sitting around the ER for several days waiting for a bed to open up, while they could be in EOB actually getting treatment.”
“And what if someone doesn’t want to come to group? What do I do?” I asked, telling her about the man in the blanket.
“Once in a while, if someone is new to a medication, he might be too tired to come, but we can’t know how a patient’s doing if he’s in bed all day. Group is a critical part of this experience. You need to be getting across the point that treatment is not just sleeping. We expect them to function here.
“Also, you have to think about the way you say things. Don’t ask ‘Would you like to come to group?’ But rather ‘Get up. It’s time for group now.’ My son is grown, but when I was learning to do all of this, he was in preschool. I learned how to be good with the patients by watching his preschool teachers. Structure is the trick, with little kids and with psychotic patients. The more things escalate, the tighter the structure you need. But always empathic,” she concluded. “So let’s go talk to the man in the blanket—Mr. Bonture.” She had his chart on her desk and glanced at the admission note before we left her office.
Mr. Bonture was right where I’d left him, asleep, or at least wrapped head to toe in his blanket despite the heat. “Wake up, Mr. Bonture,” directed T., standing near but not within arm’s reach of the bed. “Mr. Bonture, sit up please,” she said. He peered up from his blanket, unwrapped it, and sat up. “Good morning,” she said.
“Morning,” he replied, groggily. He was wearing a hospital gown.
“How are you doing today?” she asked in a tone one might use with a small child.
“I want to sleep,” he said, still groggy.
“This is not a hotel,” she said firmly, her voice still up a pitch. “You have to get out of bed and get dressed. You’ll feel more awake then. You’ll get some food.”
“Okay,” he said, but turned away from us, lying back down, pulling the blanket only up to his chin this time.
“Have you gotten your medicine today?”
“No,” he said, back still turned.
She sighed and explained to me that the hospital’s computer program for drugs was not all that efficient. “The private hospitals have a much better one. It costs a million dollars. We probably lose more than that each year because ours is so subpar.”
She turned back to Mr. Bonture. “I want to see you dressed and in my office in half an hour,” T. said.
“Okay,” he replied.
I followed Dr. T. back into her office, relieved because I figured that she hadn’t had much more luck with him than I had. I didn’t want to look bad, or at least not any worse.
She continued our lesson. “The ER is not like long-term therapy. In long-term therapy you work with a wide-angle lens. Here we use a telescopic lens. We only talk about the most immediate issues.”
She opened Mr. Bonture’s chart and showed me the admission note. He lived in a group home for the mentally ill and had been brought to the ER after threatening to kill his roommate. “We’ll call his caseworker at some point an
d ask if he has any history of violence. The note doesn’t mention any, but we always need to confirm with collateral sources. When we talk to Mr. Bonture, we’ll ask him, ‘Do you want to kill your roommate? Do you want to kill yourself?’
“I don’t care about his words really. I want to see his emotional reactions. Anyone can tell us they’re not homicidal. But is he guarded when he responds? Is he sincere? Affect is such a rich language. To be of use here, you need to learn to read it perfectly. You want to know how deep the psychosis goes. How bad is it. Lean on the sore spot and see how the patient reacts. Become progressively more challenging. You want to see how he responds while he’s in here—in this safe environment. You’ll see when we interview him.”
When Mr. Bonture was up and dressed, he knocked on the door of T.’s office. He was still a little groggy but said he wanted to sit down and talk. He’d been to G-ER before and was presumably well enough to know that release required some cooperation. This was a good sign.
“Are you feeling a little better?” T. asked.
“Yes, a little better.”
“Less angry?”
“I’m not angry,” he said, shaking his head.
“What happened with your roommate?”
“He disrespected me. He insulted me.”
“So what did you do?”
“I told him not to disrespect me.”
“What else?” she asked.
“I threatened him.” He was sheepish now.
“Threatened what?”
“To kill him. I didn’t mean it, ma’am. It was just that he insulted me.”
“You can’t go around threatening everyone who insults you. What was your plan?”
“I hoped to hurt him,” he said emphatically.
“Do you have a weapon?”
He nodded. “My fists,” he said. “I’m a boxer.”
“You don’t look very strong.” It was true. He did not.
“I am, ma’am. He’s strong, too, though. It would’ve been a fair fight.”
“People on the streets of the city can be insulting. Do you plan to go around beating up everyone who insults you?”
“No, ma’am.” Mr. Bonture sounded sincere.
“What are your other options?”
“I’ll ignore them. I’m better than that.”
When he left, Dr. T. asked if I understood the point of the brief interview.
“You pressed the issue, saw how he reacted. You questioned his judgment and also insulted him, saying he didn’t look strong,” I said.
She nodded. “The ‘insult’ was sincere. It was what I was thinking. It’s important that you are honest here all of the time. Patients sense when you’re disingenuous.” She went on, “Maybe he just needed to cool off. His insight and judgment certainly seem to have gotten a little better. I’ll talk to the psychiatrist about adjusting his medication. We’ll keep him another night and make sure he still looks okay tomorrow. You’ll see how he does in group.”
Upon arrival on the third day at my new rotation, Dr. T.’s words from the previous morning replayed in my head like a strophic melody. “You’ll do better tomorrow.” I tried not to dwell on the fact that doing better simply meant successfully gathering a small handful of confused people into one room. To think about the six years I’d spent in graduate school to arrive at this moment was self-defeating. I was becoming a better psychologist.
I put my things down in T.’s room and found Rhoda in the office she shared with another of the social workers. I introduced myself and asked for the census. She gave it to me. She was compact, with short hair and a square jaw. She wore jeans and a flannel shirt. She told me that she worked with EOB patients, too, mostly on discharge planning. It seemed no one left CPEP without a post-emergency treatment plan. “I’m sure I’ll be seeing you around,” she said as I left to gather my patients.
There were five patients on the EOB census, including Mr. Bonture and the man from yesterday who’d needed cleaning off. The EOB rooms were empty, so I headed straight back to the hallway with the nursing station. Patients were lined up in front of a room opposite, from which nurses dispensed pills into tiny paper cups, watching their charges down them with small servings of juice. I called the name of the first woman on my list. “She’s with me,” one of the nurses told me, looking up from taking a patient’s blood pressure. “Right here, but she’s deaf. Do you sign?”
“No,” I told her. My deficiencies were apparently endless.
I called the names of the two other new patients. One young man responded. He was maybe twenty-one and handsome, with taut but not oversized muscles and in a clean T-shirt and jeans. Relieved because he looked like someone I might encounter outside the psych ER, I explained who I was and told him I’d like to take him down to the group room. He was lucid and agreed, and we walked around the corner and down the hall to the dayroom, across from the EOB beds. The dayroom was lined with plastic chairs attached to one another, and there was a round table in the center. The sickly old man, Mr. Younger, sat in the room eating his breakfast. He was clean today, but pieces of muffin fell from between his few teeth as he ate, the crumbs emerging from his too-thin face like maggots from a corpse. The flies buzzed around. The sun shone in too brightly for comfort. I asked Mr. Younger and the handsome man, Mr. Payne, to stay there while I located the other two. A third woman, not on the EOB list, was sitting at the table. “I don’t belong here,” she announced to me. “I’m Jewish!” She was the first white patient I’d seen in the ER in three days.
I left the dayroom and went back into the hallway. Uncertain how long the two men I’d corralled would wait, I made haste to find the other two patients, keeping my eye on the dayroom door in case anyone decided to leave. Mr. Bonture was outside T.’s office. “Remember me?” I asked. He nodded. “I’d like you to go to the dayroom to participate in a group.” I waved him down the hallway, watching as he headed for his destination while I walked the other way. So close now, I got past my self-consciousness and began calling the name of my fourth and final EOB member, Martina, as I walked. She appeared in front of me groggy and in a hospital gown and rubber-soled socks. Triumphant, I invited her to come with me to the dayroom. When we arrived, the other three were still there, as well as the Jewish woman who didn’t belong. I felt some relief in my accomplishment, but then I realized the television was on, which meant my task was not complete. Dr. T. had said the boxy set needed to be quieted for group and turning it off required unlocking the mounted plastic case in which it sat, which meant getting the key to the case from an office down the hall. “I’ll be right back!” I said.
“Television key?” I asked unceremoniously, poking my head into a room that Dr. T. had pointed out the day before. Someone handed me a key on a long wooden stick. I grabbed it like a relay racer and was back in the group room within seconds, but even standing on a chair, I could not quite reach the lock. The patients sat waiting. It occurred to me to ask the handsome young man for help, but I thought that if he fell off the chair and was hurt, I would be responsible. Instead, I pulled the table over and climbed onto it in my platform heels. The key did not fit easily into the lock, but I jimmied it until it opened, pushing the power button on the set with a flourish. The room went quiet. My patients looked unimpressed. I climbed off the table.
I introduced myself again and explained to my four charges plus the Jewish woman that this morning’s group would be a chance for EOB patients to get oriented and ask any questions they might have. The Jewish woman got up and left. Martina had fallen asleep, her head nodding to one side, her hospital gown falling half-open to display dark stretch marks on her breasts.
“I’d like everyone to introduce themselves and tell the group why you’re here,” I said. I remembered a truism passed down from a supervisor in grad school: a group is only as strong as its highest-functioning member. I turned to the young, good-looking man and asked him to start.
“I’m Glover Payne. I got upset with my girlfriend and
took some pills.” He frowned and then nodded at me.
I turned toward Mr. Younger, who was sitting across the small room from me, masticated food still coming out from between his teeth. He did not respond. “Mr. Younger?” I asked. Nothing. I continued around the room. “Mr. Bonture?” I asked.
“When am I going to go home?” he wanted to know.
“I’m not sure. Yesterday, Dr. T. thought you were doing okay. Maybe today?”
Glover Payne spoke again. “How about me?”
“I’m sorry, but I don’t know. This isn’t a discharge group.” I looked at the woman in the hospital gown, hoping she could introduce herself and change the subject. She dozed. I didn’t have it in me to wake her.
“Well, can you tell me when the discharge group takes place? I’d like to go to that one,” said Glover.
“There is no discharge group,” I said, though I was uncertain. “There’s only this one. You’ll have a chance to talk about discharge later today with Dr. T. Mr. Bonture, Glover told us why he’s here. Can you let him know how you ended up here?”
“My social worker brought me,” he said.
Glover nodded again. They both looked at me. I wanted to know more about Glover and his girlfriend and the pills but wasn’t sure if this group was too public a setting for such questions. “Are you both getting everything you need?” I asked them. If I couldn’t quite be a psychologist, at least I could be a good hostess.
“The food’s not too good. I’m going to go for a nice meal when I leave,” said Glover.
“I might be leaving today,” Mr. Bonture told him.
“So who was it you said we should talk to about getting discharged?” Glover wanted to know.
“Dr. T. will be here later. She’ll be able to tell you more.” I might as well have been wearing a sign that said “Useless,” but anyway there was nothing to be done about it. “Dr. T. and I will be talking to you all one-on-one later,” I told them, ending our meeting.
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