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  I found Shirley in her miniskirt and her headband and asked her to come to T.’s office. She was so friendly toward me, and I felt guilty for my indifference toward her over the past three mornings. As Dr. T. and I spoke to her, Dr. Amony came in to wish her well, which I had never seen him do with any of the other patients. In his suit and his accent he was as dignified as a head of state, and I thought that Shirley was a valued customer, and I saw that it made her feel good. “Be calm at your residence,” he told her, serene but stern.

  I walked Shirley toward the front to meet her caseworker, who would take her home. Shirley was so excited she tried to hug me with a toothless smile. “No touching!” I said reflexively, feeling like an insensitive jerk but also not wanting her fleshy bosom pressed against mine. I stuck out my hand to shake hers instead, which of course involved touching and might have been confusing. She asked for my card. I hoped her request meant that she hadn’t noticed my coldness, though it would have been better, for her own good in the world, were she able to pick up on others’ signals, no matter how rejecting. At any rate, I didn’t have a card. I apologized.

  When there were only two EOB patients and one refused to get out of bed, I did not have a group. I asked a Miss Williams, who was standing in the hallway peering over her shoulder, to come into T.’s office alone. She was my size but with a psychotic stare intense enough that it left me cold inside. I kept the door to the office open as we sat down because one of the few things I’d learned in grad school about working with psychotic patients was that their delicate sense of safety was predicated on being able to flee. I also made sure her chair was closest to the door. She was fragile looking and rather beautiful, if not so well-groomed, like a television actress made up as a crazy person for a role. She had light brown skin and haunted amber eyes.

  I began with simple questions to see how disoriented she might be. She knew the date, the day of the week, the name of the hospital, and even that we were in the G Building.

  “How old are you?”

  “Twenty-three,” she responded. Her chart said thirty-nine, and she looked it.

  “What year were you born?”

  “Nineteen thirty-one.” Which would have put her in her mid-seventies.

  “How far did you go in school?”

  “I finished seventh grade and then got a scholarship to the college Parsons School of Design.”

  “Sometimes when people are having problems like the kind you’re having, they hear voices that other people can’t hear. Is that happening with you?”

  She glanced at me furtively and did not respond. I tried again.

  “A lot of people who come here tell us that they feel down. They have trouble eating and sleeping. Is any of that bothering you?”

  She didn’t answer in words but drew away from me a little, staring straight ahead and beginning to rock back and forth.

  “Are you feeling afraid of me?” I asked, again rather scared myself.

  She nodded, and I told her the door was open and that she could leave if she needed to. She got up and tiptoed out and then from outside the office asked me for some water. I told her I’d walk with her to the nursing station, where we could get a cup. We moved slowly down the hall next to each other, and she asked quietly if I could also get her some crack. “I do crack every day,” she said.

  “That’s very sad, to do crack every day,” I said, because it was the first thing that came to my mind.

  “What are you talking about? I don’t do crack,” she replied.

  After I’d gotten her some water and we parted, the frightened feeling stayed in my body for quite a while.

  Sometimes when I did not feel fear, I felt loathing. Laverne: I even hated her name. She was all baby fat and at twenty-six had just given birth to her fourth crack-addicted infant, whom the Administration for Children’s Services had quickly relieved her of. The intensity of my feelings toward her tipped me off that her developmental level was not psychotic but borderline, meaning that while she’d achieved the tasks of the first year of life (basic trust, and faith in the fact of her existence), she’d had some trouble with those of the second (separation and individuation, or knowing that one is a separate person from one’s mother and beginning to establish a distinct identity). Borderlines rely on the same primitive defenses as psychotics, but their reality testing is better. They see the world in more conventional ways. While psychotic patients tend to stimulate benignly parental and empathetic feelings in their caregivers, borderlines are famous for enraging those around them. Hence my loathing, though it was of course not solely her doing, as nothing can be aroused in you that doesn’t already reside there.

  “Are you going to help me get my check?” Laverne asked T. She was dressed in a hospital gown and no bra, and her postpartum breasts were pouring out the sides. Often there were too many exposed body parts in the psych ER.

  “That’s not my job here,” T. responded, managing to maintain a sympathetic tone. “I’m here to help us figure out what’s going on with you.”

  “What’s going on is that I need my check.”

  “Why did the ambulance bring you here, Laverne?”

  “I called them,” she said.

  “How come?” asked T.

  “I didn’t have carfare,” she replied.

  “You told the admitting psychiatrist that you felt depressed,” T. began.

  “That’s irrelevant,” Laverne declared.

  “I don’t think so,” said T.

  “Why would I care what you think? Last time I was here they helped me get my check. That’s what I want.”

  “There are social workers here who will help you with the life issues you need help with, but our job right now is to try to get to know you a little, to learn about your life.”

  “That’s irrelevant,” Laverne said again.

  T. persisted, but Laverne was not interested in doing any reflecting. My supervisor finally gave up and sent her out in the hallway.

  “You’re so patient,” I said when Laverne was gone. “I could barely stand to be in the same room with her.” (“Neither could her mother,” my professor’s voice repeated in my ear.)

  T. said: “Developmentally, she’s a baby. You wouldn’t get angry with a baby. With a patient like this you need to find some leverage. She wants child services to let her see her newborn. We’ll let her know that they’re going to read her records and that she needs to cooperate with us if they’re going to give her what she wants.”

  The next morning Laverne was on me the moment I raised my illicit key to Dr. T.’s lock. “Are you the one that’s doing my discharge?” she asked. She was dressed in jeans and a tight pink sweatshirt under a fitted denim blazer, and for a moment I didn’t recognize her. I hated her less when she was clothed, all of her parts contained. “Laverne? I barely recognized you. You look great!” I said to her, remembering T.’s directive to help patients begin to recognize their own improvements. I told her that I didn’t think she was being discharged but that we could talk more in group. For the second day in a row there were only two EOB patients, but they both agreed to attend, and the three of us—Laverne, Mr. Roy, and I—made ourselves cozy in the TV room. Mr. Roy was around Laverne’s age. I asked them to talk about why they were there. Laverne said that she’d been depressed but was better now, and Mr. Roy said he was schizoaffective, which Laverne didn’t know about.

  He explained: “It means I get depressed and also hear voices. Mostly God’s voice, but I’ve learned to live with it.”

  After group I got their charts to make entries. I read over Mr. Roy’s, my attention caught by a nursing note from earlier that morning. It seemed Mr. Roy had complained that he was awoken at 6:00 a.m. by Miss Williams—the woman with the chilling stare. She was bent down over his pelvis, her mouth clutching him. When T. arrived, I told her what I’d read. She said she’d just come from talking to Nurse Higgins about the whole thing. “Probably true. Whatever happened, she went and hid in the restroom afterw
ard, in the tall garbage pail. A patient went in there to pee and saw her intense little eyes peering over the top of it. He ran from the bathroom screaming.” In the aftermath, Miss Williams had been admitted upstairs. T. was on her way to try to smooth things over with Mr. Roy’s mother, who was threatening to sue the hospital. Between the patients and their families, someone was always threatening to sue the hospital, the understandable fallback position of the irate and disenfranchised, who then didn’t always bother once the anger had receded. I brought Laverne in to talk.

  “I need to know a bit about your life and your background,” I told her. She told me that she’d moved in with her most recent baby daddy the day they’d met one year earlier, but that there’d been “infidelity.”

  “He cheated on you?”

  “No. I needed money for drugs.”

  “So you prostituted yourself?”

  “No. I had male friends I knew would give me money.”

  “For sex?”

  “Yes,” she said.

  She told me she’d been raised by both of her parents until her mother died of AIDS when she was fourteen, at which point she was on her own.

  “What about your father?” I asked.

  “I never knew my father!” she yelled. Everything that came out of her mouth had an angry lilt. She went on to talk about wanting to get off drugs, about getting her baby back. I asked how she planned to do this.

  “I’ll wear an S on my chest like Superwoman,” she told me, full of bluster.

  T. came back as we were talking. “When am I going to get my discharge?” Laverne wanted to know from her.

  “You have to show me that you can think. That you can plan,” said T.

  Laverne picked at her fingernails. T. told her to leave. “Come back when you’ve thought about what I said,” she said.

  Some time later T.’s door was open, and Laverne wandered in eating a sausage and cheese biscuit that someone must have brought her. She addressed us only by burping loudly. “Can you say excuse me?” asked T.

  “Excuse you,” Laverne replied sassily.

  After she’d wandered back out, T. said: “Her sarcasm is a sign of intelligence. It’s obnoxious, obviously, but it’s also encouraging.”

  The next morning Laverne refused to come to group, but there were three new patients in the EOB, plus Mr. Roy, who remained. One of the new patients, an older man, was wearing a lot of layers, shirt on top of shirt on top of vest on top of robe. I called his residence—a nursing home—after group. These calls had become a regular part of my morning. What was the patient’s history? What was his baseline functioning? I spoke with the social worker there, who asked, “Is he wearing lots of tops? If he is, he’s still out of his mind and not ready to come back.”

  None of that morning’s patients were ready to leave. Mr. Roy was still psychotic, or at least I guessed as much from his report during group. “The hospital police woke me in the middle of the night and got in my face and called me a bitch,” he said.

  “Why did they do that?” I asked, imagining that they had done nothing of the sort.

  “I don’t know,” he said, looking confused.

  “Do you think you were dreaming or hallucinating?” I asked.

  “Maybe,” he agreed, nodding. I took his ability to consider my suggestion as a sign that he was emerging from his psychosis and noted the entire exchange in the chart, as Dr. T. had been encouraging me to do.

  The two remaining patients were the most interesting to me: Mr. Rumbert, because he was selectively mute, which I hadn’t yet encountered, and Mr. Jean, who was lucid and sad, which meant we could have a good conversation. I brought Mr. Jean into T.’s office first. He was nineteen and in the ER after making a suicidal gesture.

  “What did you do?” I asked him. The admission note had been hard to read, which wasn’t unusual.

  “Pills,” he said. He was in a football jersey, tall with light skin, cornrows, and acne. “Adderall, Tylenol, Zyprexa.” I knew by now that the latter was for serious psychiatric problems—bipolar disorder, schizophrenia. His age made me guess he’d been recently diagnosed.

  “How come?” I asked.

  “My mother. I live with her. She’s crazy. She calls me a piece of shit. She said she wished I was dead, so I ran into the bathroom and started shoving pills in my face.” He began to cry. I handed him the box of tissues on T.’s desk, and he took one, blowing his nose loudly.

  “She really gets to you.”

  He nodded, continuing to cry. I sat quietly, feeling bad for the guy, saddled as he was with such a horrible mother. T. walked in on the middle of our tears and sympathy.

  “What was going on that your mother got so angry with you?” she wanted to know.

  “I don’t know,” he said.

  “You don’t know?”

  “She’s just like that,” he said. T. suggested he spend some time in the hallway reflecting on how he had contributed to his troubles with his mother. The hallway: our version of a think tank. When he was gone, T. had me call the errant mom.

  “He goes wild in the house when he gets upset, and he’s set off really easily,” she told me calmly. “He throws things at me. Breaks things. I had to retire last year because of my health. I can’t take his behavior anymore. It’s too much.”

  When we hung up, I repeated the information to Dr. T., who nodded. She’d heard the same story a hundred times, if not a hundred thousand.

  “I just felt so bad for him,” I told her. “My feelings distracted me. I didn’t challenge him, because it didn’t occur to me that his mother could be anything but crazy.” (An unfortunate artifact—there were so many—of my treatment-resistant desire to condemn my own mother, to exonerate myself.)

  She looked at me hard. “You react strongly to the patients.” She didn’t seem to mean this as a compliment.

  “I know,” I said. “Is that unusual?” The overpowering resonance of others’ sadness in my soul was as automatic to my being as the heavy way I walked, and I usually forgot it was particular to me, or to others with similar psychological structures. But besides that, the ER was such a raw environment, I’d assumed it roused strong feelings in everyone, T. included. For weeks I’d been chalking up her exaggerated sharpness to the emotional stresses of her job, to the constant burden of digesting the unprocessed madness that surrounded her on her own personal western front. I couldn’t believe that in some gentler reality, my teacher would remain so resolutely shrill.

  “People respond differently. But you should always look at it,” T. said. “Have you tried therapy?”

  The ER was crowded, the line for meds twenty people deep, and I waited for my morning patients with impatience. “Fifty-four total on the census today. It’s too much to handle,” Rhoda said to me when she saw me waiting. “Bellevue’s psych ER never takes more than twenty, even though they have five times the physical space as us and twice the staff.” I asked her about the discrepancy. “Because it’s in Manhattan and because they get white patients,” she said.

  Rhoda wandered off, and a rare and manic white guy in his forties came and stood beside me, talking as fast as one of those fast talkers on a TV commercial, but he was not limited by thirty seconds of airtime, and it was truly impressive, his ability to go on and on and on at that speed and not stop. With fifty-four patients, no one was getting enough attention. After the distribution of caplets and capsules and liquids, I ushered my six into the dayroom. Mr. Jean was still there and still stewing about his mother. Mr. Rumbert remained selectively mute. A pretty Indian girl who was new to me had a now familiar psychotic stare and was also choosing not to speak. Despite the fellatio incident, Mr. Roy lingered. When group ended, I returned to T.’s office to record our proceedings faithfully in the charts. T. came in and shut the door behind her. She did not sit down. She was short of breath.

  “What mistake do you think you made when you wrote in Mr. Roy’s chart the other day?” she asked me, her backside pressed against the door as if
to prevent me from leaving. Her tone made me nervous, and I couldn’t for the life of me remember what I’d written. I didn’t have it in front of me, because Mr. Roy’s chart had been missing from the nursing station when I’d collected the others.

  “Refresh my memory?” I asked reluctantly.

  “Hospital police, getting in his face, calling him a bitch.”

  “Oh.” I began to sense where this was going, and I felt a little dizzy. I explained, “But obviously that didn’t happen. I wrote it down because he agreed it was a hallucination. I thought that showed he was making progress, like you’ve been teaching me.” My voice tapered off.

  T. moved away from the door and sat down in the chair next to her desk. “Dr. Amony just read what you wrote. He was reviewing the chart because it’s on its way to administration because Mr. Roy’s mother is threatening to sue over the blow job. Do you see what the problem is?”

  I did not want to, but I did. She continued.

  “A lawyer reading that chart does not understand psychosis. He does not understand delusions and hallucinations and paranoia. He only understands that his client made a serious allegation against the hospital police and that the staff dismissed that allegation without even bothering to ask anyone who’d been on duty the night before what might have happened.”

  “Oh,” I said. I was an imbecile. There was no way around it. My contributions to CPEP were meager, especially compared with the price the hospital might ultimately pay for inviting me to complete my training there.