I went back to Dr. Cherkesov with the same question as Alisha’s (could I be of any help?). “She is your classic difficult patient,” said Dr. Cherkesov. “You need to talk to her doctors and nurses to help them understand the angry feelings a patient like this brings about. In psychology and psychiatry, we know our hateful feelings toward patients are only human, and we can usually stop ourselves from acting on them. These other doctors are different: they think they’re supposed to be above that, and so patients like Alisha leave them feeling ashamed, which only intensifies their hatred. Normalize it for them and they will be able to better help her medically.”
“So just talk to them? Tell them to try to be patient with her?”
“And then go back to her and listen. She’s enraged because she feels helpless. Encourage her to reframe her helplessness. She does not have problems—she has challenges! With challenges she also has choices.”
“But does she?” I asked. She was basically a kid. She had a chronic disease. She was in the country illegally. She maybe had no health insurance. She didn’t have a home.
“You have to emphasize the possibility of options. Someone with a shovel has two choices—dig or don’t dig. If you don’t have a shovel, you only have one choice.”
The next day, at Dr. Cherkesov’s instruction, I went to the morning meeting on Alisha’s ward. “She doesn’t seem to have an eating disorder,” I said first, addressing the consult question. I explained my understanding of her to her young doctors, of her frightened desperation and her paralyzing helplessness. I explained that anger was a natural response that they could use empathetically. “Whatever frustration you’re feeling, she’s feeling it ten times over,” I told them. They said they’d read about “the difficult patient” in medical school and took deep breaths and vowed to be kind despite her provocations. They thanked me for coming and requested that I see her again. “Maybe she’ll be less difficult if she feels like someone who works here is really taking the time to listen,” one of them remarked. I almost looked over my shoulder. Worked there? He thought I worked there?
I went to see the gunshot victim. Dr. Singer had told me his name, Nicholas, and that he had a history of bipolar disorder. He was only eighteen, so the diagnosis suggested he’d had some kind of pronounced early problems, but what they were was anybody’s guess. It was so hard to trust the clinical thinking of the doctors who came before you, and when your own judgment was still forming, things sometimes felt hopelessly mysterious. Not that any psychiatric diagnosis mattered all that much for my purposes: I would see him only briefly to help him through a difficult time. In Nicholas’s room I found him with his mother and brother, clustered together tightly. She looked too young to have a son his age, and they were striking, all of them, with dark skin and darker eyes. Nicholas rasped that his throat hurt too much to talk; they’d just removed the breathing tube the day before.
“So what happened?” I asked his mother.
“He was an innocent bystander,” she said.
Bad neighborhoods, I thought, such minefields. Did his mother know—resent?—that I’d never had to walk them? I felt apologetic. Life was so unfair.
“His brother was with him,” she added. I turned to the boy. He was younger than Nicholas probably, but just.
“We were at the playground playing basketball. There were some guys we didn’t know, and one of them left, but he forgot this crazy ring he’d taken off to play. Nicholas picked it up and put it in his pocket—to give the guy later. The guy came back looking for it and thought Nicholas was trying to steal it. He took it, then left again. When he came back, he had a gun. He shot my brother in the chest and walked away.” The brother spoke matter-of-factly. He must’ve told the story so many times by then, and probably it was a familiar one even before his brother became its protagonist.
“He seems more depressed today than yesterday,” his mom said. The shooting had happened just over a week earlier. The doctors weren’t certain he’d regain the use of his legs, but his mother assured me he would. I asked about his psych history.
“He’s never been right,” she told me. “He used to say weird things.”
“Like what?”
“Like that he wanted to die.”
“When?”
“When he was twelve or thirteen. And before that he used to see things, ghosts.”
“When did that start?”
“When he was two or three.”
“What was going on leading up to that?”
“His father was murdered in front of him.”
It had happened down south. It was drug or gang related or both, the mother was vague. The family had gone into witness protection, where they’d stayed for more than a decade before moving to New York to be near family.
“He got into the wrong crowd,” the mother said, as though he hadn’t been born into it. She told me he’d been convicted of arson a few years ago and then diagnosed bipolar by a psychiatrist who’d helped with his charges. Nicholas was in and out of sleep as we talked. I asked the mother and brother how they were holding up, and they reported on the business of that week: getting updates from doctors, trying to convince the boys who’d been witnesses to testify before the grand jury. “They don’t want to be snitches,” the mother said. “I told them this isn’t snitching. Snitching is working for the police. This is different.”
The next time Nicholas opened his eyes I explained that I thought he might want someone to talk to after all he’d been through and that I would come back to see him again soon. He said okay but added that he was fine and didn’t think he’d have much to say. Could this all be so inconsequential—a shooting, a paralysis—in the life of a kid who’d seen what he had? He spoke as if his circumstances were about what he expected for himself, which in itself seemed like something to talk about.
When I returned two days later, Nicholas was restless and alone. I’d been expecting to find his brood, to work with the family in the wake of his indifference. But away from the company of his mother and brother, Nicholas looked desperate, like a caged animal in his eyes. I didn’t want to get too close, but he was paralyzed, so I moved next to the bed.
“I’m trapped,” he declared, scratching mercilessly at his thighs through the white sheet.
“Can you feel that?” I asked, watching his hands. He shook his head. He had a furry boot on each foot. He asked for some water. I went into the hall, where there was a drinking fountain and small plastic cups. I filled two and brought them to him, and he grabbed them and guzzled. A Jamaican nurse came in looking full of all that might comfort a boy. She gave him a shot in the leg that he also couldn’t feel, and he was irritable with her.
“Baby, don’t get frustrated,” she cooed. “Everything happens for a reason. Trust in God.” She put a pillow behind his head, and he asked her to stretch his legs. “Your brother should do this for you,” she said, standing at the foot of his bed, bending his knees while holding his flaccid calves. The television had been turned—by whom?—to FitTV. A muscular Israeli jumped up and down on a step, exhorting morning viewers to follow along at home. From under Nicholas’s bedclothes a tube poked out, yellow with urine. The nurse left, and I turned off the hateful set. Nicholas started right in talking.
“I had three nightmares,” he told me, staring at me intently. “In the first one, I got out of a car with a friend. He gave me a gun, and then I got shot. In the second one, I got shot, too. But in the third, I was at my grandmother’s house, and there was no gun. I fell backward and hit my head and was bleeding all over the place. Once I woke up, I was afraid to go back to sleep.” He stopped talking and waited. I often felt dreams were presented by patients like challenges, material for me to sculpt something out of, buttery maple cookies or Disney figurines.
“What do you make of all that?” I asked. We are the authors of our own dreams, our associations to them as valuable as any therapist’s.
He answered, “That I shouldn’t be alive. I’ve done a lot o
f very bad things in my life. I don’t want to tell you about them. Yet.”
The “yet” chilled me. But how many very bad things could a boy of eighteen actually have done? And what happened to the kid who didn’t particularly want to talk?
“I never let my guard down,” he said.
“Makes sense,” I said. He’d entered witness protection around the time he’d learned to talk.
“My family expects too much of me. They think I should be up and running around already. I’m going to let them down. People keep saying, ‘Don’t worry. It will be fine.’ But I’m not okay. It’s not fine.”
With that he immediately fell to sleep. It was strange actually. I felt weighed down by his vulnerability and all that he’d intimated so quickly, rapid-fire. I went to Dr. Singer.
“Eventually, you want to be future oriented with him,” he instructed. “What are his plans, and how can he actualize them? Acknowledge what he’s struggling with, and help him to envision a better future. I’ll go see him, give him some Seroquel to help with the nightmares.”
The next day Dr. Singer reported to me on his meeting with Nicholas. “He’s still delirious,” he told me. “What he said to you yesterday may or may not be true. No point doing therapy with someone in a delirium.” He gave a little laugh, not at me, but with me, and I joined him, only a little abashed. I’d learned what addiction looked like, schizophrenia and mania. Here was delirium now, feverish and abrupt.
When I returned to Nicholas’s bedside, he greeted me in a friendly way. His mother and brother were back. I asked if he remembered our talk.
“Not really,” he admitted sheepishly. “Well, maybe a couple things.”
I could tell he was embarrassed, and so was I, and I didn’t press the issue. I listened as his mother and brother plotted strategies to get the witnesses to talk. The brother would testify the next day. “Good luck,” I told him before I left.
“I like her,” I heard the mother say as I hit the hallway, which made me feel guilty because what was I really doing for her son?
At my request Dr. Singer and I started spending more time together. Tamar had really raved about him, and doctors and nurses from A Building to C obviously shared her regard. He was the Bruce Springsteen of Kings County Hospital, and walking the long, dreary corridors with him was slow going and magnificent. Everyone wanted a minute with the man, to ask a question or to shake his hand, and I basked in his limelight, important by association. In whatever misguided ways the physicians tended to use psych, they obviously valued it, or at least him. It seemed he had helped everyone, at one recent point or another, with a difficult case. One morning we headed toward 7D North. Between exchanging metaphorical high fives with passing physicians, he briefed and then quizzed me.
“Eighty-one-year-old woman. Cancer all over her body. She was in the hospital for two months, very confused. She was discharged to a nursing home, but now she’s back after just one week with pneumonia. She’s not eating. What was the consult called for?”
I thought: not eating.
I said: “Depression.”
“And what are we actually most concerned about?”
I thought: confusion.
I said: “Delirium.”
Dr. Singer nodded. “Good,” he said. “Now, how’s your French?” Our patient was Haitian and spoke Creole, which I’d learned was similar to the Romance language I’d chosen to take up in high school. We entered the hospital room, and in my twelfth-grade French I introduced Dr. Singer and myself to the elderly woman there. Then I translated his English instructions for her. Lift your left hand. Lift your right. Show me one finger. Show me two. She did as I asked, so we moved on to questions. Are you at a museum? Are you at a school? When she answered both affirmatively, Dr. Singer said we really needed a Creole interpreter and went into the hallway to find one. (In all of the United States, perhaps only at Kings County Hospital could one find such a person simply by popping one’s head into the corridor.) He was back in a flash with a janitor. Still, our patient had already fallen asleep. Dr. Singer roused her. The janitor introduced himself.
“Ask her if she’s in a museum,” Dr. Singer instructed.
The janitor looked at him dubiously. “She’s not in a museum. Why would I ask her that?”
The two of them tried to reach a mutual understanding, but the janitor’s English was not as good as his Creole, and explaining proved cumbersome. Never mind, Dr. Singer finally told him.
“I think she’s been delirious for a couple months,” Dr. Singer said to me. “Her son reported she’s been in and out. We’ll do an EEG to determine for certain.”
“Why do the doctors order a consult for depression with a case like this?” I asked.
“They feel helpless, so they call us. If it’s depression, we give her meds; she eats; they feel better. We’re who they call before they call in the priests.”
He went on: “Do you know this old psychiatry joke? A psychiatrist is called to see a patient. He gets there and the patient is dead. The psychiatrist goes to the physician and says, ‘The patient is dead.’ The doctor looks horrified and replies, ‘What did you say to him?’ ”
If Alisha’s doctors began treating her better, she seemed only to be working harder to come up with reasons to be livid with them. I couldn’t blame her. The real things she had to be enraged about—an incurable disease, so many impossible systems—were for her purposes insurmountable. But the doctors, available and now inclined to help, them she could take on, fists at the ready. And also, there was me, another passerby she could lash out at. Reframe her problems as challenges, give her choices, Dr. Cherkesov had counseled. But so far I’d only managed to become one more in a series of nameless, faceless receptacles for her hate. She barely looked at me as she seethed, in forty-five-minute stretches.
“My doctors are lying to me. They say my bones are still growing and so they can’t do the hip replacement,” she said for the third time in as many visits. I asked what I thought was an innocuous factual question in response, trying to remain engaged, only to have her spit at me, “That’s a dumb question. I’ve told you this story three times!”
“I’m glad you’re bringing that up,” I said, speaking slowly to give her rage time to work its way out of me. “I must admit I’ve been wondering why you tell me the same thing every time I come to see you, all these times in a row.” If she moved past her paranoia, what awaited her was worse. I knew that and she knew that, but we had different ideas about what to do with that knowing, with her preferring to stay stuck like a needle in a scratched record, and my hoping to keep her company as she acclimated to reality and its tragic limitations. I hated that this was the best I could do for her—anything short of a cure and a winning lottery ticket felt insufficient—but at least one of us had to move past our infantile grandiosity, our certain hope that we could conjure all we needed from the magic of our minds.
“Right. Fine. Well, I’ll never tell it to you again. Obviously, I should be keeping it to myself,” she huffed.
“It’s not that,” I said. “I’m here to listen to whatever you need to tell me. But our time together is limited, and I was just thinking we could use it more productively.”
“Well, I’m sorry I spoke to you at all. To any of you! I came to this country when I was twelve because my mom said I could get better medical help here, and look how I end up!”
“Uncured and insufficiently cared for,” I said.
Alisha’s anger broke like a felled horse, and she cried then. I sat quietly until she asked me to go. Too spent now to hiss, she said it almost gently.
In between talking cases I was still going around with the doctor on the pager. On the irritable Dr. Jonas’s days this was trying, as she was in a perpetual rush and three months in she was still acting as if I didn’t exist. One morning I arrived on the fifth floor early only to find her already dashing out with her resident, Alvin Wang. Alvin smiled and waved toward me as he tried to keep up with his mentor’s d
riven march toward the stairwell. Though by then she must’ve known it was my assignment to follow her, she did not slow when she saw me. A psychology trainee wasn’t worth acknowledging, let alone waiting for. I went into the meeting, and after it ended, I decided to stay in the cool of the Kings County room rather than track her down across the street, but then I felt as if I were playing hooky, and also there was the nagging disappointment of possibly missing out on one valuable lesson or another. I crossed over to Downstate and found her and Alvin leaving their sunny suite of CL offices. They were on their way somewhere, and I fell into step alongside.
“Seventeen-year-old Hispanic female,” Alvin told me as we moved along the shiny corridors. Downstate was as sparkling as Kings County was dull. “Raised in the projects. History of multiple rapes. Her doctors can’t find a reason for her headaches, and they want us to determine if they’re psychosomatic.”
“If the psychology intern had been here earlier, she would have known that,” Dr. Jonas said to Alvin, not looking at me still. I was taken aback, mostly surprised that she’d noticed both my current presence and my earlier absence.
“Well, thanks for filling me in,” I said to Alvin with forced cheer. He grinned at me behind his instructor’s back.
The three of us arrived at the chart room off the nursing station on the pediatric ward. Dr. Jonas took the girl’s chart and scanned it. “She’s got meningitis,” she said. “Explains the headaches.” So much for the consult question. She kept reading, and when she spoke again, she sounded contemptuous. “She says that she’s had eleven sexual partners in the last month. She’s lying.”
With a history of multiple rapes, eleven men in one month fit. It wasn’t unusual for sexual assault victims to become promiscuous in the aftermath—a valiant attempt to mitigate the trauma, to better understand or control it this time around. This was hardly an esoteric principle. Was Dr. Jonas really so unfamiliar with it?
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