“He doesn’t have to have any face-to-face contact with people that way,” she said. “His affect was very flat. That’s what stands out to me. He answers questions about emotions with abstractions. I think he’s trying very hard to sound conventional when it comes to talking about feelings.”
“So you think he’s schizoid?” I asked, testing the waters with T. by referring not to a psychiatric disorder but to a character style, a descriptor for someone whose fears about closeness keep him isolated, who doesn’t experience his emotional world the way other people do, who’s interpersonally a bit odd.
“Probably,” she replied. “He generally gets by. Nobody on the street would know anything was off.”
“So what do we do for him?”
“The police thought something was wrong. Taking that into consideration, we’ll keep him and observe. We’ll make sure that his judgment isn’t a threat to his safety. He is likely schizoid, but he may also be headed toward the more psychotic end of that spectrum. He could be having a first break. There’s no family to call for collateral information, though maybe he’ll agree to let us talk to his ex-wife. With a patient like Mr. Cook, you wait a bit and see.”
The next day I was off. I took an “education day,” as opposed to a vacation day, to meet with my dissertation adviser. We went out to the very end of Long Island, where we courted the social psychologist whose data I was hoping to mine. Over lunch in the food court at SUNY Stony Brook we discussed research measures of adult attachment and their relationship to psycholinguistics, and by the time I returned to the psych ER the next day, Mr. Cook was gone, sent upstairs, and I never saw him again. That was CPEP for you. Blink and you’d miss someone, or maybe a patient would be there four weekdays straight, and you’d feel as if you’d lived out her harrowing course alongside her over many months. On my day away, immersed in the minutiae of academia, I relished the conversations of people unalarmed by the exigencies of the emergency loony bin. Was that the real world? Was this? They were so disparate that going back and forth between the two was viscerally unnerving, like jumping from the hot tub to the cold pool at the Russian baths.
Too soon I was back in my morning group, with a young white drug addict brought in by—“BIB” in chart shorthand—his sister. There was a young, pretty black woman who’d asked her husband to bring her in after watching “upsetting events” on the news; one man who wouldn’t say why he was there at all; a tearful young woman with no front teeth to whom I paid less mind than I might’ve because of her appearance and the fact that she lived in a group home; and an oddly dressed thirtysomething whose “affect was not appropriate to content” when he reported, with a grin, that he was there for beating his caseworker. After group I called the purportedly clobbered caseworker. She laughed and said that no, he wasn’t violent, just not med compliant, and I guessed that I must’ve been the biggest believer of nonsense who’d ever crossed the CPEP threshold with her very own skeleton key.
The next morning, the same patients were still there, and we felt like old friends, or I felt as if we were old friends for all of us. This helped me relax, and probably not coincidentally they were the most interactive group I’d led. Mr. Fincher—the white drug addict who lived in an affluent Brooklyn neighborhood not usually inhabited by Kings County patients—explained, as if it were no biggie, that he’d disappeared on a crack binge for a week and his mother and sister had flown in from Phoenix to find him on the streets and bring him to the hospital. Mrs. Kendrick—who’d been upset by the television—told us through her tears that she was responsible for some gang killings of teenagers she’d seen on the news. In actuality, she had nothing to do with gangs, but it is common, in psychosis, to believe oneself at the center of events literally—if not psychologically—unrelated to you. Shirley, the toothless woman I’d considered so uninteresting the day before, had found herself an ornamental headband and a denim miniskirt, and her mood was brighter and her attitude more confident, and she strutted around the group room as if she were one of the Supremes; she interrupted the others as they talked, and I had no patience with her. The man who wouldn’t speak the day before was now talking enough to share that he was waiting for a bed upstairs, and the one who’d claimed to have beaten his caseworker said he was going home later that day. Group lasted twenty-five minutes—a good ten longer than usual—because of Dr. T.’s insistent voice in the back of my head: you can be therapeutic. I waited for something to inspire me, but for all of the interesting content, nothing did, and group ended with its usual whimper.
When I got back to T.’s office, there was a note from her. “Went to meeting. Fincher’s mother and sister will be here at 11:00 to take him home. Talk to him—the hard line—and then to them—limit setting.” The day before, I’d been in T.’s office as she spoke to the young man’s mom on the phone. The mother had asked, “Is he still mad at me for bringing him in?” and T. had almost lost it. I got Fincher from the hallway and brought him into my room. In a Yankees cap and with two days of stubble, he did not look particularly interested in anything I might have to say.
“So your mom and your sister are coming to pick you up.”
“Great,” he said.
“You don’t sound like you mean that.”
“They’re the ones who brought me here. I didn’t belong in the first place. My roommate never should have called them.”
“What do you think would have happened to you?”
“The same thing as always. I wind up back at my apartment, living my life.”
“How long do you think you can go on like this?” I asked. This was not his first crack binge, his first disappearance.
“Until I get tired of it. Then I’ll go back to school. I’m going to be a psychologist.”
“What makes you interested in that?”
“I’m good with people,” he said.
“Psychologists have to spend a lot of time working on themselves. Did you know that?”
“I don’t need any work,” he said.
“You’re in a psychiatric emergency room. As a patient,” I reminded him.
“I didn’t need to be here,” he reiterated.
Dr. T. had instructed me exactly what to say. In a stern voice I managed: “You’ve just lost another semester’s tuition. You’re twenty-six, and you’ve barely finished a year of college. You’re not going anywhere until you stop using drugs. Certainly not into a doctoral program,” I added, sounding harsher than I felt.
He looked at me angrily. “What’s the point of this?”
I cringed. I had asked T. the same thing. She reminded me, “Because someday, when he’s ready, he’ll remember what you said and it may be of use to him.”
I told him, “You’re not ready to truly look at yourself yet. Someday maybe you will be, and you’ll remember what I’ve said.” I was not even convincing myself. I hadn’t said anything particularly profound. He was going to be a burnout, and a corpse waiting to happen, until he stopped using crack: like, duh.
“Are we done here?” he asked.
When I went to get Fincher’s mother and sister from the waiting area at 11:00, they were upper-middle-class and white and so at once felt immediately—wincingly—familiar to me. As we settled into T.’s office, I relaxed in a way that I had not managed in CPEP in all of my days. My unease there was so multifaceted I hadn’t quite connected it to the differences in class and race that were almost constant givens for me in the setting, but now, as I melted into T.’s chair, it was startling in its obviousness.
The room fell silent. Mrs. Fincher looked clueless and out of place. She wore a large diamond ring on her index finger, and her dark hair was blown straight. She had on a brave face, but it didn’t feel like the right one. The sister was another story. Her eyes were bloodshot, and she looked as if she hadn’t slept, and I thought of my own sibling and how I might feel under similar circumstances. I recited the short speech Dr. T. had prepared for me.
“You need to stop coddling hi
m,” I said. “You need to set limits. Trying to be nice and rescuing him is not going to help him get clean.”
“That’s what everyone has told us,” Mrs. Fincher said.
“Right,” I said.
“I don’t understand,” intoned his sister with intensity. “Am I just supposed to sit back quietly and let my brother kill himself?” She was enraged. Mrs. Fincher put a hand on her daughter’s back. I wished I had an answer that could make it even a little better, and I half believed there was one.
Afterward, as I told T. about the brief meeting, I surprised myself by bursting into tears. Though my eyes regularly teared in response to sad stories, the bursting was another matter. It came on like a sneeze, but with less warning. It was notable, and it was the second time in my life it had happened. The first had also been in supervision, during graduate school, and my supervisor back then had hypothesized the tears really belonged to the patient I was discussing, who’d appeared to feel nothing as she detailed a childhood filled with unthinkable neglect. Was this that? The idea suggested a certain emotional contagion addressed by theory—a patient’s split-off feelings are communicated nonverbally to the therapist, who can unconsciously process them and give them back in less potent form, like a mother bird chewing food for her chick. But I also had my very own preexisting despondent feelings about difficulties I was powerless to affect. What of this bursting was about the Finchers, and what of it was about me? That was always the unknowable thing.
T. handed me a tissue and waited. I wasn’t sure what part of my thinking to share. I saw there was little time, in a psychiatric emergency room, to contemplate the esoteric questions of graduate school outpatient treatments. “Things move so fast here you never get a chance to process how you feel. I think it’s been building up. I’m sorry for the tears.”
“Never apologize for having an emotion,” T. said. “Just make sure you give it some thought.”
“My sister lied to the police and told them I pulled a knife on her.”
“My boyfriend called the police for no reason and told them to bring me here.”
“My wife is the one who needs help. I called 911 and asked them to bring me here to set an example for her.”
“I had a couple beers and thought I wanted to kill myself, but now that I have no more drink in me, I’m feeling good, and I have no reason to be here.”
Such were the collection of stories that began my mornings. By week three I had conquered the patient roundup and the television, finally to find myself dealing with actual psychological problems—rampant externalization and denial.
T. instructed: “When the whole group is blaming someone else for why they’re here, say, ‘I find this hard to believe. All these doctors here are so stupid as to admit you for no reason? They want to make you all suffer while the real bad guys are out there going about their lives?’ ”
“I’ve been asking them to think about what’s going on inside of them, rather than what’s going on outside,” I told her.
“No,” she said. “Too sophisticated. Say to them: ‘None of you have any problems?’ ”
“They’ll say they don’t,” I said glumly. That particular day I had run what felt like a pronouncedly stubborn and self-defeating group.
“Then say, ‘Okay, well, I guess we’ll just have to agree to disagree.’ ”
But I was also getting sharper. When a patient I had been indulgent with during group said to me, “You understand me so much better than Dr. T.,” I knew right away that he was a substance abuser and that I had missed this issue and Dr. T. had not. For the rest of that day, each time he saw me in the hall, he told me that I should get a raise. Actually, the opposite was true. The next day, T. and I spoke to him together. T. asked him if he had any thoughts about what they’d talked about the day before. He could not remember the conversation.
“I think it had something to do with your drinking,” I told him. He never mentioned my raise again.
Of course each time I felt satisfied with my growing competence, there was something to remind me of how little I knew, if not about my field per se, then certainly about the world. One morning Rhoda presented me with a Mr. Rain, thirty years old and unwashed. “He was brought in for threatening to shoot someone at his new group home,” she told me.
We went into T.’s office to talk. He was gentle and truly not smart. He told me that he hated his new residence. I asked if he thought he had any alternatives. “I was in foster care once,” he said. “I liked it. Can I go back there?”
After Mr. Rain and I finished, Rhoda came in to ask whether he had access to a weapon. I didn’t know, because despite his presenting problem I hadn’t thought to ask and the very idea that he could have obtained a gun sounded preposterous to me, which I didn’t hesitate to tell her. She didn’t hesitate to look at me as if I were an idiot.
“This is East Flatbush! You can get a gun on any street corner!”
There were other things you could get on Brooklyn street corners that I didn’t know much about either, but I learned about from people like Mr. Tacks, who had been quick, in morning group, to let me know that he didn’t belong in the psych ER. During group, Mr. Tacks’s story concerned calling the police in order to set an example for his wife. It changed when I sat with him one-on-one. “I called them to come take her away, but then I realized she needed to be home to watch our daughter, so I went instead,” he said.
“That doesn’t make any sense, Mr. Tacks.” I liked that line, it was so knowing and world-weary. I’d stolen it from Dr. T.
“What makes no sense is keeping me here. I’ve got multiple businesses to run, and being in here just keeps me from making money for my family. I’ve been away long enough. I just got back from upstate in May. My businesses are suffering.” He spoke quickly and a little too loudly and was having more fun than anyone deserved to have in the psychiatric emergency room. Sure, mania had its downside, but it could also be a hoot.
“What did you go upstate for?” (I felt so satisfied, knowing he meant prison.)
“Assault,” he said. “It was my fourth incarceration. My second or third there was a corrections officer who disrespected me. Me and my boys went and found him. They beat the guy. I waved around a gun, decided not to shoot. We showed him.” He puffed out his considerable chest.
“But you went to jail for …”
“Four years,” he said. “And I’m taking names of people who piss me off here.”
I took a deep breath. A danger to others, possibly. Poor insight and judgment, for sure. “So what you’re saying to me—someone who works here—is that if you get angry at any of the staff members, you will track them down and hurt them? Do you think that assault is a good idea? Do you think that telling me of your intentions is a good idea?”
“What are you talking about? I didn’t say that.”
After we were done, Mrs. Tacks had come to visit, and I brought her in with him to get a clearer sense of why her husband was there in the first place. “The last time he was hospitalized was at Elmhurst ten years ago. They told him to call 911 if he ever needed help. He woke up from a post-beer nap feeling depressed and called EMS. I told him not to do it,” she said. “Now he’s stuck here for a while, right?” I informed her he’d been admitted for seventy-two-hour observation. She continued, “I called the police on him last week for putting his hands on me. He slapped me, and they took him away, but actually I hit him first. It didn’t look too good for him,” she said, pointing to her rounded belly. She was notably pregnant. She continued, “He got back from jail seven months ago, and just like that we’re having another kid. I have two older kids, but our first daughter together is four. I had her while he was away. He didn’t even know about her until he got home.”
Mr. Tacks was quiet for a change. “Why did you hit him?” I asked her.
She gave him a dirty look. He said, “She’s so jealous. I went out to the store, and she thought I was with another woman.”
“How long
was he gone?” I asked her.
He answered before she could: “Five minutes.”
“Has he been unfaithful to you in the past?” I asked her.
“Yes,” she replied.
“We weren’t together then!” he said to her, and then turned to me to explain. “When I got out, I slept with one of my hos.”
My eyes opened wide, and I didn’t bother to try to hide my middle-class surprise. “You’re a pimp?” I asked him.
“Not anymore,” he said.
I took a deep breath. “What goes on between the two of you that things get so heated that you’re hitting each other?”
He brushed me off with his right hand, apparently incensed by the question: “I’m a shooter, not a hitter.”
Mrs. Tacks was no more abashed about her own antisocial tendencies. “I held up a bank once with my asthma inhaler. They gave me money, and I never got caught.” Again I was stumped. My silence unnerved her: “How else was I supposed to feed my kids?”
T. laughed when I recounted the meeting. “Your typical narcissistic-borderline couple,” she said. Narcissists, who have a fragile sense of self that they bolster with grandiosity, often pair with borderlines, who are likely to provide them with the idealization they crave. “Who else did you have in group this morning?”
I listed the names, forgetting the toothless woman and then remembering. “Oh, and Shirley.”
“She’s going home today. We should see her first. Why do you think you almost left her out?”
“She lives in a group home. She doesn’t have any front teeth. I think I see her and assume she’s a hopeless case, so I end up being more focused on the other patients. Also, she was interrupting the others a lot. I felt really annoyed; it’s so hard to get a conversation going in there, and she was making it harder.”
“Don’t be so quick to dismiss her as un-helpable. Teach her something,” she said. “Ask the other group members to talk about what it’s like for them when Shirley interrupts. She may not get it now, but it will stay with her. We know Shirley here. We see her and other people like her over and over. The staff starts to get frustrated. I’m no exception. Just last week I saw Sequoia Diaz and rolled my eyes, thinking, ‘She’s back again!’ She used to come in every month. And I saw her, and it was obvious I was exasperated, and she said to me, ‘But, Dr. T., it’s been almost eight months!’ And it had been. She said, ‘I’ve been trying, but it’s hard!’ So I told the staff to congratulate her on going almost eight months between ER visits.”
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