Weekends at Bellevue

by Julie Holland

  As I fill out the paperwork on the five patients, I am multitasking. Writing and listening, I nod my head to confirm the information is reaching my brain as Nancy tells me about a case that has just come in: a former corrections officer who used to work for D.O.C., who is now a homeless man. He has been arrested for jumping a subway turnstile, which is how we get a good chunk of our homeless patients these days. While in his cell, he defecated on himself and threw his feces at the guards, so NYPD brought him to us.

  It becomes clear, once he has been interviewed, that this man is completely out of his mind. He has some sort of psychosis; whether brought on by drugs or mental illness, I can’t yet say, but what is said is an oft-spoken line by Nancy. “He ain’t goin’ nowhere but up.” Unquestionably, he needs to be admitted to the prison psychiatric ward upstairs. In order for him to go up he needs to undergo a physical exam, a chest X-ray, and an EKG. He also needs his blood drawn for routine testing. All of these tests require the patient to be cooperative and lie still, or else to be sedated.

  Although the former corrections officer acquiesces to the EKG and the chest X-ray, the psych tech informs me that he is refusing to allow his blood to be taken. I leave the relative comfort and safety of the nurses’ station to find the patient.

  I give him my usual shtick. “Here’s the deal, sir,” I begin. “You’re going to have your blood taken. It’s a requirement for the admission. It is up to you whether this happens with you tied up and sedated or freely moving and cooperating.” In psychiatry, this is the oldest trick in the book, the old “choice-no-choice” paradigm. This gives the patient the illusion of control over a situation, offering him a choice that implies freedom, when really there is none. I had used the technique earlier with another man who required a bed upstairs by saying, “You’re going to be admitted to the hospital. Would you like to be a voluntary or an involuntary patient?” You’d be surprised how often this works, especially with toddlers.

  The former C.O., no dummy, is not falling for it. He tells me, “There is no fucking way you are taking my blood. Period.”

  I have seen patients who are hesitant about blood draws. Sometimes it’s a needle phobia, but other times it’s something more delusional. “Are you afraid of needles?” I ask.

  “No.”

  “Do you think there’s something special in your blood that you’ll lose if we take a few teaspoons?” I’ve had psychotic patients who are deathly afraid of losing some sort of vital power if their blood is removed.

  He stares at me blankly, either unable to fathom what I’m trying to get at, or perhaps acutely afraid that I can read his mind. I can’t tell, but if it’s the latter, he’s masking the suspicion well. He doesn’t look very paranoid, but he is dead set against the blood draw.

  The arresting officer is hanging out in the detainable area watching football. He is near the patient and overhears our short exchange. “Can I have some time alone with my prisoner?” he asks me. He rolls the former D.O.C. officer’s wheelchair down the hall and then begins to threaten this patient with various forms of aggression, beating the hell out of him, slamming his face into something, and other things I can’t hear fully. I am alarmed at how quickly the cop goes from zero to sixty. There is no small talk, no chitchat, no cajoling, just immediate threats of violence. The cop isn’t getting anywhere with this tactic; he is, however, getting progressively redder in the face.

  I know how these things go, and I know that we will eventually have to tie our patient down and sedate him in order to obtain his blood. The lab technician is waiting patiently along with a number of CPEP staff and hospital police who are lined up along one wall, assuming we’ll have to do a restraint, while the man from NYPD issues his threats at the man formerly from D.O.C. down the hall.

  I finally intervene, mostly because I know the lab tech waiting to draw his blood is getting antsy. She has other patients to get to in other parts of the hospital.

  As I get closer to the two of them, I can hear the NYPD cop yelling, “I’m gonna pull down your pants and pull on your balls until you howl if you don’t start cooperating with the doctor.”

  I step in and tell the officer as calmly as I can, “That’s all right. We’re just going to restrain him. It’ll be easier for everyone.”

  After the patient is cuffed to the stretcher, the arresting officer makes a big show out of snapping on a pair of gloves, making motions to pull down the man’s pants, licking his lips, saying, “I hope your balls are big and juicy. This is going to hurt and I’m going to enjoy it.”

  Picking my jaw off the floor, I ask the officer in an overly polite manner, “Um, actually, sir, could you please just step away from the patient? We’re going to take over now.”

  Throughout the melee that ensues, which requires eight people to restrain him, a sheet to be placed over his mouth so he cannot spit or bite, and his arms and legs to be tied to the stretcher, the patient yells and curses, threatening to come back one day and kill us all. “I’ll do each one of you. I’ll fuck you all up. I’ll fucking kill you, and I’ll fuck up your cars, too, and then you’ll know it’s me that did it.” Soon after his blood is taken, the man falls asleep from the sedating medication.

  The arresting officer takes off his gloves and retreats from the patient, acting as if he has helped us with the restraint process. He takes me aside and explains to me in a stage whisper, “I hope that I didn’t offend you with my language. These are techniques we use to get criminals to comply.” His language is stilted, formal and rehearsed. He sounds like he’s reading from an official guide to police behavior. He reaches out to shake my hand, implying to me that we are on the same team, the restraining team.

  I am repulsed. I try not to roll my eyes or grimace as I say to him in a complicit tone, “I totally understand. Whatever works,” and shake his sweaty hand. Nice technique, dude. The ol’ pull-your-juicy-balls threat. Worked like a charm. And that last scene about your enjoyment, in front of a standing-room audience? Bravo.

  I cannot look him in the eye. I walk away thinking how he is a power-hungry, maniacal little weakling, and how much I resent his aligning himself with me.

  Not for the first time, I find myself reflecting on the sadomasochism involved in being a cop or a corrections officer. How incredibly homoerotic it all is: the nightsticks with the handles shaped like dildos, the handcuffs, the shiny black leather boots, the men putting other men into cages, the bondage, the discipline, the dungeons. The anal rape between prisoners, or between the cops and the criminals. Which came first: the fetish or the job?

  And how did a corrections officer snap so hard? How did he slide from D.O.C. to homeless psychotic? Was he already flirting with the edge of reality when he took the job? Was he seriously psychiatrically ill and they missed it, or was he snorting mountains of cocaine when he was off duty? And will this city cop, the supposedly sane one, ever become as insane and violent as my patient? He can’t act that sadistic all the time, right? Does he have control over how he turns on and off that homoerotic rage?

  When I can’t get the patients to do what I want, it drives me crazy. I get angry. Sometimes I even get mean. I’ve seen how I act and it’s high time I spoke to Mary about it. Seeing the cop get so nasty, I was embarrassed for him. I don’t ever want to be like that, controlling yet impotent if I don’t get my way with a patient.

  Or am I already like that? Is this why I can’t stop thinking about him?

  I’m counting on Mary to help shed some light on this.

  I Should’ve Known Better

  Mary and I spend several sessions trying to tease apart the sadistic impulses I’m experiencing at CPEP. Some of the analysis is easy: I turn my fear into aggression, my default position is to act like a hard-ass to hide my dismay at the casualties being wheeled to my ER. And then my best defense turns into a good offense.

  “I was rewarded by my father for being a tough guy in my childhood,” I explain. “I remember him standing in his underwear. The garage door was
open, and he was yelling at me. I remember thinking, He’s in his underwear for the whole neighborhood to see, but he doesn’t care about that, because he’s too busy yelling at me. I was in kindergarten, and I had run home from the bus stop before the bus came, because some of the bigger kids there were making fun of me. I came to him crying, begging for his help, and he was very clear with me: I had to go back there and fight my own battles. He was not going to fight them for me. But he was turning me away in a disgusted manner.”

  Mary and I decide that most of the macho behavior, my biggest defense at my job, comes back to my proving myself to my father. Growing up, I did fight my own battles, and I became a bit of a bully in the process. I wound up the winner, more often than not. But there were others who did not fare as well as I, especially my two sisters.

  “You know, the way you paint it, it sounds to me like you have survivor guilt, to some extent, because you figured out how to get your father’s love and attention, which was in short supply in your house, and you ended up in a better position than your sisters.”

  “Not only was my strength and power rewarded, my father admired self-sufficiency. I could win his admiration by being stoic and cheerful, pretending that I didn’t need him or anyone else to do anything for me. It became a huge part of my persona. I’m Julie, the girl who doesn’t need anything from anyone. I can do it all myself. Why do you think it was so hard for me to start therapy?

  “Some of my earliest memories are of him rejecting me when I was acting needy. Like this one time, I remember being in a car with my parents. I’m sitting between them in the front seat, being incredibly thirsty, and making noises with my mouth to imply just how thirsty I am, when my dad screams at me to be quiet. My mom defends me, telling him I’m just thirsty, but he’s upset that I am making so much noise about it. He’d prefer I suffer in silence, which is definitely how he does it.”

  “So, how did that make you feel?” asks Mary.

  I hate that stupid question. It’s the hardest part of psychotherapy for me. I can never quite put myself back there entirely, to feel what the little girl was feeling. “Well, I guess I remember feeling really sad and rejected, that he wasn’t sympathetic, not just that, but that he was disdainful of me in that state of need. I felt his disdain, his revulsion.”

  “And now? Where do you stand?”

  “It’s second nature for me now, to deny that I need anything.”

  “Hmm … I’m just wondering how this might play out at the hospital. You’re surrounded by people in a state of need, but you don’t reject them, do you?” Mary asks.

  “Well, that’s complicated. I think there are times when I do, when I treat them just the way my dad treated me. But I took this job, I went into psychiatry, really, because I wanted to help people in need. I wanted to fix it so they felt better. I respond immediately to people who need something—anything—impulsively. I want to plug the hole. Like, I have to stifle this impulse to help people carry their grocery bags in my apartment building, or if I’m in line at the store and someone is short some money, I’ll always think about volunteering to pay. Even on the street, I’ll hear someone complain about how they can’t get somewhere, I’ll think, I have a car you can borrow. I don’t say it, thank God, but I find myself thinking it. If I see someone shivering on the street, I have an impulse to give them the coat off my back. It’s pathological, right? I have a neurotic impulse to help people?”

  “I’m not sure I’d say it’s pathological. It’s interesting, and as long as you’re thinking it, and not constantly acting on being the Good Samaritan, I’m not sure there’s anything wrong with having that impulse. It’s probably one of the things that makes you a good doctor. You have a genuine desire to make things better for other people.”

  “Well, that’s true enough. It is one of the reasons I went to work at Bellevue. I wanted to help the homeless schizophrenics I saw on the street when I was a kid. It’s almost like I’m trying to make sure no one else ends up needy like I was. I’m trying to avoid the whole situation. It’s all just projection, isn’t it? Me gratifying their needs because I want my own fulfilled?”

  “Right. The flip side of it is, you’re trying to make sure no one else ends up in a state of need, which you find intolerable.”

  Mary, as usual, seems to get exactly what I’m saying. It feels good to be understood, and my mood starts to ease as I keep talking.

  “Luckily, at Bellevue, it works out fine because I have the tools to help, I can plug the holes and give people what they want, to some extent. The problem comes when they’re intensely, dramatically needy, and I can’t fix everything for them. I think I go into ‘reject mode’ then. I want them away from me. I turn into my dad, I guess, disdaining them for making too much noise about being thirsty. But also, I’m uncomfortable. I don’t want to be confronted with my ineptness, with my impotence in the face of their illness.”

  “Do you think this is some form of projected self-hatred?” asks Mary, cutting to the chase. I like that. Other therapists would wait around for the patient to arrive at her own conclusions, but Mary offers it up herself for our discussion.

  “I think it is, yes. It’s pretty much as simple as that, right? Dad hates me needy. I hate myself needy. I hate you needy.”

  Good psychotherapy is like an archaeological dig. We spend our sessions “digging in the dirt,” to quote Peter Gabriel, to find the places in my past where I was wounded and have scarred over. They are tender areas, well-guarded, inhabiting terrain that is difficult to navigate. I feel as though Mary and I are colleagues on an excavation, trying to make sense of a large, puzzling site. We poke around until we find an item, dust it off, study it, and together we learn how it fits into the scheme of what we have already uncovered.

  It has been enlightening, to say the least. I am enjoying our work together and hope that she is too. Mary is trying to help me to be a better person, and I’m desperately hoping that will translate into my becoming a better doctor … or at least less of a tyrant at CPEP.

  Papa Don’t Preach

  Sunday night and I have the opportunity to speak with an eighteen-year-old girl who has just killed her baby. That’s how the cop presents it to me, but later it’s clarified: She’s just been arrested for the death of her baby, which occurred two weeks ago. Being the attending in charge, I can assign the case to a resident, or even a medical student, but I choose to take the case myself. I’ve never talked to anyone who’s done this, and I’m curious. I’ll admit it: Part of the appeal of psychiatry for me is the voyeurism—I am allowed to ask anything. The standard rules of social etiquette do not apply.

  For a pre-arraignment evaluation, I only need assess suicidality or dangerousness secondary to psychosis, whether the prisoner is safe to be in police custody and can behave appropriately in front of the judge. The shrinks at Bellevue set the bar pretty high, though. Whenever we can, we try to turn them around, these prisoners-turned-patients, and send them back with NYPD to be arraigned. This will likely be one of those times.

  Initially, the girl told the police that she’d woken up in the morning and the baby had been facedown in the crib, presumed to be asleep, but actually dead. When they returned to her home for questioning after the autopsy revealed suffocation, she admitted that she smothered her baby with a pillow.

  “What happened?” I ask.

  “He wouldn’t stop crying. I fed him and changed him, but he wouldn’t stop. I finally put a pillow over his face to stop it. When I pulled the pillow away, he was still breathing … but kind of like little breaths. And he wasn’t crying anymore, so I put him in his crib and I went to bed. I needed to sleep. When I got up in the morning, he was dead.”

  “So you didn’t mean to kill him.”

  “No.” She begs me with her eyes to believe her.

  She has no psychiatric history to speak of. She is not currently psychotic, nor has she ever been. She may be eighteen, but she acts and talks like she is much younger—a guileless child.
The main issue is this: Can she handle where she’s at and what’s coming next or will she fall apart and kill herself?

  She is clearly distressed and feeling guilty, yet won’t go so far as to say that she is suicidal, or even depressed.

  “What happens now? What should I do next?” she asks me, reading my mind.

  “I’m not sure how to answer that. If you leave here, you’ll go with the police to get arraigned in front of the judge. Then they’ll either release you on bail, or they’ll keep you in custody, I guess.”

  “In jail? In a cell?” she asks nervously.

  “I guess so, yes,” I answer. “Unless it seems like you’re too sick to go with the police, then I would send you to a hospital psych ward for a while.”

  “But I’m not crazy. I just don’t know what to do now, is all …” her voice trails off before switching gears. “Am I going to be in the newspapers, do you think?” she asks, her voice a different tone.

  “I have no idea. Why?” I ask.

  “Because I’m afraid my baby daddy’s family is going to come down on me and my parents.”

  “You’re worried about what they’ll do?”

  “I should have to pay for what I done,” she explains to me. “Maybe I should be dead too?” She asks me this question as if I would answer it. I wonder if her alluding to her death being an equal retribution for the baby’s death qualifies as suicidality. Can I safely send her out to be arraigned if she’s thinking in these terms? After asking her some more questions, I am assured that she has no real intention of trying to kill herself. She’s just at a loss for what she is meant to do now. She’s like a small child who knows that she’s in trouble, nervously awaiting her punishment. Over time, I bet she’ll probably put herself through worse than anything the DA can dish up.