Brooklyn Zoo Page 11

  I told her about Marcus, who had said during group that the police had brought him to CPEP the night before for play fighting on the corner with a friend. “Do you think the police in New York City have time to give a lick about innocent fighting on a corner?” she asked me. I said that seemed unlikely. “It doesn’t make any sense,” she said with a sigh, forever troubled by my naïveté. “Go get him.”

  Marcus was still in his pajamas, clutching a pair of jeans. His outfit hadn’t seemed strange in the disarray of the early morning, but it was now way past breakfast, and the pajamas felt embarrassing.

  “I was just messing around on the corner,” he told T. once he was seated in her office.

  “That doesn’t make any sense,” she said, shaking her head.

  “There was some alcohol involved,” he said.

  “How much?” she asked.

  “A couple beers,” he said.

  “That still doesn’t make any sense. But we’ll come back to it. I want you to tell us about your life.”

  “My life?”

  “Yes. What do you do every day? Do you have a job? Go to school? Do you have friends? A girlfriend? How’s your relationship with your family?”

  Marcus was twenty-six and did not have a job, had not worked in five years. He had finished high school but did not do any college. His best friend was killed—“in 1997, no wait, it must’ve been 2007”—by a rapper he seemed to expect us to have heard of. He did not have a girlfriend. He lived with his sister in the same housing project as his mother and stepfather, whom he used to have a good relationship with, “but now there’s this thing they won’t help me with.”

  T. asked: “This thing they won’t help you with?”

  Marcus looked at her. I thought I saw a flash of suspicion, but then his face went blank. “It’s nothing. They’re very helpful.”

  “I’m confused. You just said they aren’t.”

  “What do you mean?”

  T. tried a different tack. “Why aren’t you working, Marcus?”

  “I want to work. I haven’t been able to find anything. I don’t want a minimum-wage job.”

  “Everyone has to start somewhere,” she said. “You’re drinking too much to hold down a job.”

  “No,” he said.

  She raised her eyebrow. “I want you to go out there for a while and think about all this. Think about why you’re here. Be as honest with yourself as you can. And then you’re going to come back in, and we’re going to have another conversation.”

  When Marcus went back to the hallway, T. said: “He’s not just your run-of-the-mill alcoholic. He’s paranoid. He’s vacuous. We’re not going to learn enough from him about what’s going on. Call the family.” She flipped open the chart, found a number for Marcus’s mom, and set it down in front of me. Graduate school had not required such phone calls, and not for the first time Dr. T.’s full attention left me acutely aware of my unpreparedness. Had my classmates done things like this on their externships? Had the other interns? I imagined they had each performed a hundred brilliant inquiries with families of psychiatric patients and that I would simply never catch up.

  I called Marcus’s home number and reached his stepfather, who sighed heavily after I identified myself. “Please don’t let him out. He’ll wind up right back there. He was at Interfaith a couple weeks ago. They said he doesn’t have any mental problems, but they’re wrong. He’s a wild man when he drinks, and he’s not right when he’s sober either. His mother’s terrified he’s going to get himself killed, and I don’t blame her. We live in a housing project, and he threatens the other young men when he’s drunk. He’s gotten himself shot at twice. He tried to punch out a cop. His brother just went to jail. My wife can’t take losing another boy.” The stepfather told me he would bring Marcus’s mother in when she returned from her errands later that afternoon, around three o’clock, he guessed. I hung up the phone and conveyed the information to T.

  “So what do you think?” she asked me.

  I thought in my head. Then I thought out loud. “There are some things in talking to Marcus that don’t make a lot of sense.”

  “Right,” she said.

  “How he wound up here, for one. Why he’s not working, for another. He’s only got a high school degree and no work history to speak of but seems to think he’s above working for minimum wage. He seems suspicious of his family, and then he got suspicious of you for asking about them. He got the year his friend was killed confused by an entire decade, and then, I guess his friend could have been killed by a famous rapper, but it doesn’t seem entirely likely. And his stepfather, the things he said about Marcus picking fights, oh, and that he hasn’t managed to get dressed yet this morning.”

  “What does that all add up to?”

  I was stumped. I spoke slowly. “Any one of those things on its own could be explained away.”

  She shook her head. “No. No, no. We don’t explain things away here. We do exactly the opposite. When something doesn’t make sense to you, that’s the thing to zero in on. Use a telescopic lens. If it doesn’t make sense, it doesn’t make sense for a reason. Something is not right. I imagine the police picked up on it, or they wouldn’t have brought him here. And this is not his first hospitalization besides. Anyway, we’re going to keep him for a couple days. I think there’s some kind of psychotic process, maybe schizophrenia. We’ll have to observe and talk to his mother. Can you come back later this afternoon?”

  When I arrived at three, T. was waiting. “Mrs. Stevens’s husband dropped her off. She and Marcus have been talking for a few minutes. Go get them and bring them in,” she directed.

  Like all of the mothers and other visitors I’d seen that week, Mrs. Stevens looked overwrought. She was all but wringing her hands as she sat in the waiting area, looking tiny next to her sturdy son. I led them around the bend and back to Dr. T.’s office. I felt like T.’s lackey and I liked it, absolving me, as I felt it did, of any real responsibility. Marcus and Mrs. Stevens took the chairs. I returned to my perch on the desk.

  Dr. T. looked at them. Mrs. Stevens extracted an envelope from her purse and handed it to my supervisor. “I wrote this,” she said, nodding. T. took a typed letter out of the envelope and put it down on the desk so she and I could read it together. It was addressed to a judge, and it implored him to commit Marcus to rehab. The letter was heartfelt. In it Mrs. Stevens struggled with formality, as if enough multisyllabic words could convince this magistrate of justice and thereby save her child. But Marcus had committed no crime, and so there could be no sentence, and all the best grammar would not fix whatever was going awry in this young man’s mind.

  “One problem, though,” said T., “is that he’s not functioning even when he’s sober.”

  His mother began to cry. “That’s true,” she said.

  “Alexandra!” exclaimed Marcus, addressing his mother by her first name, his frustration palpable. “I haven’t done anything! I haven’t even done anything!”

  “Exactly! You don’t do anything!” she exclaimed. “You sit around your sister’s house. You drink. You get the people around you angry. This is not a life!” His mother took a tissue from T.’s desk and wiped her eyes.

  “How do you process what your mother is saying to you?” Dr. T. asked him.

  “She hates me. She’s always so critical of me,” he said, sounding enraged, looking at the floor.

  “Did he tell you about his friend who was shot this year? Did he tell you about his brother? Did he tell you about all the times he’s almost gotten himself killed?”

  “It’s nothing! You’re making a big deal out of nothing! Everyone makes such a big deal about nothing!”

  Mrs. Stevens was crying harder now: “How can you call your life nothing?”

  Marcus jumped out of his chair, towering over her. “Alexandra!” he implored. T. was up, too, in a flash, her hand gently on his chest.

  “Marcus, enough.” She was firm. “Out in the hall! You need to cool d
own. Out.” She opened her door and Marcus followed her orders, tense as he crossed the threshold. T. watched him walk away and begin to collect himself before she closed the door.

  “How long has he been like this?” T. asked Mrs. Stevens.

  “He started drinking about five years ago. But like my husband told you, he’s not right even when he’s sober. He’s suspicious of us. Won’t let anybody help him. Then his friend was shot to death on the street, and his brother—he worshipped his older brother, and now he’s gone, too. Prison. Twenty-five years.” She looked up at us, not crying anymore, just relating facts and challenging us to accept them as she’d had to.

  “He’s had a lot of trauma,” T. told her. “Trauma impacts different people differently depending on how they’re wired. How it’s affected your son is that he’s become withdrawn, he’s retreated into himself, he’s severed his connection to reality somewhat, though that might have happened even without these difficult circumstances, we can’t really know. I’m going to admit him upstairs as soon as there’s a bed. He’ll stay for a few days or maybe longer, until they can get him stable on an antipsychotic medication. He’ll be encouraged to come for outpatient treatment after he gets out, and you can support him in that. But it has to fail before it can work. For people with the kinds of problems I suspect Marcus has, it generally takes between three and five years between diagnosis and actually sticking with treatment.”

  “He doesn’t have between three and five years,” said Mrs. Stevens, still matter-of-fact: angry young man plus bad neighborhood plus psychosis equals short life expectancy. It was heart wrenching, and I was barely holding back tears—not for the patient, who had not taken in the gravity of his situation, but for the mother, who had. T. sighed.

  “We can’t know, yet, how this will play out,” she said.

  Mrs. Stevens went out the front door, and it was time for me to go too. But I left and I didn’t. All weekend long I dreamed about the ER. Fragments, not narratives, and when I tried, I could not even convey anything coherent about the dreams. Still I knew, when I awoke unrested, that I had been in CPEP as I slept, among the unquiet minds.

  CHAPTER FIVE

  WHILE MY MORNINGS WERE SPENT IN THE PSYCH ER, MY afternoons were filled with other pursuits, or in pursuit of having other pursuits. If I lived in a world where people who weren’t in therapy were suspect (beyond just my classmates, most of my New York City friends saw therapists, it was just what one did, like going to the gym), in East Flatbush the opposite was true, and getting anyone who wasn’t locked up to come see a psychologist required at the very least a handful of phone calls, and then another handful after that. This aversion to treatment had a lot to do with shame. Somehow coming to see a therapist was the worst thing. Perhaps as a corrective, and also because this was the fashionable attitude, Kings County’s Behavioral Health department had taken the stance that difficulties in living were “illnesses” that developed in the body, without having much to do with context: if you were “sick,” it wasn’t your “fault.” That life was more complicated than that nobody bothered to get into.

  Upon discharge from the G Building, former inpatients were often referred for treatment to the outpatient clinic, the N Building. Once registered there, they were assigned to Phase One, psychoeducation. In rooms with desks and chalkboards, they were then educated in groups about their so-called medical conditions. Divorced as these supposed illnesses became from any possibility of non-medicinal assistance, was it any wonder that afterward patients with profound difficulties relating to others saw little point in beginning Phase Two, group psychotherapy? This was clearly the first obstacle for the women in my depression group, only one of whom was showing up regularly. When the other women did come, they called what we were doing “class.” I was also seeing a family headed by a mother who’d been similarly undereducated about her teen daughter’s problems, and they were failing to appear more often than not. It was certainly my responsibility to engage my patients in treatment, and I was trying, but the cards were stacked against me at the outset by the very institution that was supposed to share my goals.

  The frustrations of the N Building quickly revealed themselves to be stymieing. The chart room there was a Stone Age quagmire staffed by a cranky matron. It was her job to retrieve patients’ charts from the high shelves—indeed, getting them oneself was prohibited—but she acted as if she were doing an enormous favor when she took a request and then was as likely to fulfill it as not. The psychiatry residents who worked in the clinic, prescribing medication to the outpatients who managed to show up, were as unenthusiastic as the chart room lady about working with the psychology interns. We’d been paired up with these residents early in the year, the idea being that we would collaborate on the same case—the interns doing the talk therapy, the residents doing the medicating. “Collaboration” was the operative word, as Scott presented this as a peer relationship, a chance to learn from each other. We were all, as it were, trainees. The residents—who had their own director of training, and God only knows what he’d said to them—didn’t see it that way.

  “She needs some cognitive-behavioral therapy,” my resident instructed me sternly as I sat down in his office for the first time. He was talking about Carmen Thompson, my paltry single individual outpatient. Neither of us had met her yet, though we’d both read her chart.

  “She needs 37.5 milligrams of ProzacXanaxWellbutrin!” I wanted to exclaim, but instead I just asked him what made him say that.

  “She has cognitive distortions,” he said, getting up to dismiss me. This resident was very busy, and giving vague orders was all he had time for. It was our first meeting, and then, too, it was our last.

  The other interns had longer encounters with their residents, but with similar outcomes. In the quiet of our own office, Leora related a conversation that actually went like this:

  Resident: You need to set an agenda for your patient in each session.

  Leora: That’s not how I work.

  Resident: Well, you should.

  Leora: Listen, why don’t we stick to our own areas of expertise?

  Resident: And what are those?

  Leora: I know more about therapy. You know more about medication.

  Resident: No. I know as much as you about therapy. I know more about medication.

  What else was there to be said?

  All of these cognitive distortions aside, once I finally met Carmen Thompson, I found her effervescent and flirtatious (character style: hysterical). She liked a rapt audience for her stories. But early traumas suffered at the hands of a withdrawn mother and an abusive father had left her terrified of intimacy, which might have developed with any of the four intern therapists before me had she ever managed to show up consistently. She’d been coming to the N Building for five years, since before the advent of this phase model, which had been put in place only recently to solve the problem of understaffing—it took fewer therapists to treat people in groups. Carmen had been grandfathered into individual therapy, which I gleaned was only still an offering in N to give us interns the opportunity to conduct it. It was as if these patients were to be our playthings in this anachronistic endeavor we called psychological treatment. Carmen was as casual about coming to her therapy as the N Building was about providing it.

  Just as my supervisor the neuropsychologist Caitlin Downs had warned, Carmen had been hard to pin down from the beginning. When she didn’t show up for our first scheduled appointment, I went directly to Caitlin’s office to suggest delaying our first official supervision, which was supposed to take place the following morning. “I figure since I haven’t seen her yet, we won’t have anything to talk about,” I said. I had never opted out of a supervision before: there was always something to talk about with a well-schooled therapist. But after our initial frustrating discussion, I was already uninterested in Caitlin’s thought process, and the idea of spending forty-five minutes with her at a stretch, even with a session to present, was taxing. W
ithout one I didn’t think I could bear it. Caitlin granted my request but looked dubious and put off.

  “Should I not have done that?” I asked the other interns later.

  “Well, you haven’t seen the patient yet, so it doesn’t seem so bad,” said Alisa, who was always putting a kind spin on things. But I would keep doing it, every time Carmen canceled thereafter.

  When Carmen and I finally met for our first session, I described it to Caitlin unenthusiastically the next day, not out of lack of engagement with Carmen, who like all patients was plenty interesting, but out of the hopelessness inherent in the supervisory situation. I’d concluded that Caitlin had nothing to offer me. It wasn’t her fault. She was a neuropsychologist. I might have gotten over this and tried simply to enjoy her company, but I was cranky in the wake of what felt like multiple disappointments, and also Caitlin, taking umbrage at my obvious indifference, was refusing to make herself enjoyable. Soon Carmen had called once more to cancel.

  “I told you so,” said Caitlin the next time I saw her. “If you had brought cancellations up like I told you to the first time we met, this wouldn’t have happened.”

  But of course it would have. Patients don’t stop acting out just because they’re instructed to. If it were that easy, no one would need therapy. I explained this to Caitlin tolerantly, but she didn’t seem to appreciate the lesson, or the others I delivered later and with less forbearance after her pronouncements of points I deemed similarly misinformed, until we were barely talking about Carmen at all. Forced into a corner by the unfortunate combination of our respective personalities, Caitlin made it clear that she was to be the supervisor here—there was no room for my two cents. I took the hint but chewed it up and spit it out at her, and then I did it again. By the end of a handful of meetings her frustration with me was as clear as my impotent rage. We would go on like that for some time.