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  “Are you threatening me?” he asked. I wasn’t quite, though I could see why he saw it that way. The next day we met with his mother and Dr. Winkler in the dayroom. It was my first family meeting on inpatient. Families could play an important role in recovery—or sabotage it altogether—but so far none of my other patients had relatives interested in showing up. I got Mr. Rumbert from his room, and he followed after me in his socks. When we sat down at a table still jelly stained from breakfast, Dr. Winkler asked how he was doing.

  “I’ve been thinking a lot about what I am and how people see me,” he said.

  “ ‘Oh would some power the gift to give us, to see ourselves as others see us!’ ” replied Dr. Winkler. “Robert Burns.”

  Mr. Rumbert explained that this was especially on his mind because he was having trouble with his vision. He couldn’t see himself clearly, and he couldn’t tell if he was eating the right things, “what the Bible says you should eat.”

  “Does the Bible tell you to starve yourself to death?” asked Dr. Winkler. Mr. Rumbert shook his head, and Dr. Winkler went on. “The Bible says many things, lots of them contradictory.” They discussed some of these. Mr. Rumbert’s mother asked when she could take her son home to Barbados. “We have to figure out what medicines work for him and then work out a treatment plan for after discharge,” Dr. Winkler told her.

  “How do I know when a medicine is working for me?” asked Mr. Rumbert.

  “What works is what helps you eat, sleep, and concentrate,” Dr. Winkler explained.

  The next day Mr. Rumbert was as open with me as he’d been. “Am I clean?” he asked when I greeted him. He sounded worried. He explained that his problem with his sight left him unable to tell. I told him he looked quite clean to me and asked him what it meant to him to be dirty. “That no human would want to get near me,” he replied.

  “What would happen then?” I asked and then heard Dr. T. in my head: “Too complicated.”

  “Bizarre ideation,” Dr. Winkler labeled Mr. Rumbert’s thinking when we spoke. Psychotic symptoms had delightful names. They rolled off the tongue. Flight of ideas. Phonemic paraphasias. “How’s it going with Mr. Rodgers?” he asked.

  The child molester. I was seeing him three times a week, as I was expected to, and tolerating it by learning about his history and avoiding his present. This probably wasn’t the way to go. It was no kind of telescopic lens. He told me he’d married an older woman soon after graduating high school, and then had four children with her. She had an affair and he left. After one year as a single man he’d married again—the woman with the daughter. He tried to solve the problem of his untoward sexual desires in church. It hadn’t worked. He remained pretty depressed, I told Dr. Winkler—though the voice endorsing suicide had faded as the antipsychotic medication took effect and he remained outside the jurisdiction of the Pennsylvania police. We could begin to think about discharging him. Mr. Rodgers’s father had called to say that he would take his son home within a few days to face his legal troubles with his stepdaughter. I would talk to Mr. Rodgers about how he wanted to proceed with his charges. Would he plead out? Go to trial? What were the likely outcomes of each? It wasn’t therapy, but it was all that I could stomach, and maybe it would even be marginally useful to him.

  There was a twenty-five-year-old deaf and mute patient on the unit. Her name was Camara. One night she apparently fainted and fell, and the next morning a roly-poly white man none of us had ever seen before appeared at our meeting, identifying himself as a clinical case manager and suggesting that the chart note indicate that Camara had “placed herself on the floor.” I tried to make eye contact with someone on the team to confirm that this was lunacy, but no one met my gaze. Apparently, the word “fall” did not go lightly into a chart. The fainting had been no one’s fault, and Camara had not hurt herself, but every patient was a legal proceeding waiting to happen, every staff member a potential accused assailant. As if the patients’ paranoia were not enough to leave the fifth floor bursting at its cracking seams, the staff’s almost matched it most weeks. The Justice Department’s impending arrival only inflamed this, and we were reminded of it in one way or another daily. (By the constant painting and repainting of the first floor, for one: Did DOJ prefer teal to aquamarine? The question was obviously keeping somebody up nights.) The atmosphere on the unit was so fraught that I could almost feel sympathy for the somber and silent recreation therapist who locked himself alone in the cavernous group room from nine to five each day. If you didn’t interact with anyone, there was less to worry about. But then there was the fact that there were no groups being run on the unit, and that even the interns’ pleas to use the space—which did not after all technically belong to this man—to run therapy groups for a couple of hours a week had gone unanswered. (Actually, he nodded when Bruce and I asked to use the room, but then he disappeared at the agreed-upon time, along with the room’s only key.) Was a “group” one burned-out city employee hiding alone for hours in “the group room”? The answer, it seemed, was yes. In contrast, in casual conversation George would occasionally launch into a story with a line like, “One of my inpatients left knitting group today to go check her e-mail …,” and my mouth would fall open. Knitting group? E-mail? The next day I would report on the bounties of the private hospital to my fellow Kings County interns, who would gather like orphans around Annie just back from Daddy Warbucks’s to hear my dispatches. What puzzled me almost as much as the recreation therapist’s blatant shirking of his sole responsibility was that he went by the title “Doctor,” even though he was not one.

  Still, “Dr.” Jacobs’s behavior made other things on G-51 seem less weird in comparison. Like: members of the treatment team sometimes addressed floridly psychotic patients with frustration and cries of “You’re not making any sense!” (Not making any sense was exactly why they were in our company, so yelling at them for it seemed particularly unreasonable.) Like: Dr. Meyer rarely showed his face on the unit after the interns’ first week there, and no one seemed to find his absence even worth mentioning.

  The last point got to me. Dr. Meyer was the one psychologist assigned to the unit, and from what I could tell, he almost never actually set foot on the unit. I met with him in his office once a week for forty-five minutes of individual supervision, and when he wasn’t reminding me to carve out a place for my field with my notes—refer to voices as “auditory hallucinations,” to alcohol as “EtOH”—he was helpful and engaging. For example, when I shared with him my strategy for helping a psychotic patient manage his feelings about having been abused as a child—“Try not to think about it,” I told him—Dr. Meyer diplomatically replied, “That’s one way to go.” I explained that while I would never suggest such a thing to an outpatient, on inpatient I was trying to prepare the man for discharge by building his defenses.

  “Which defense is that?” he’d asked.

  “Repression,” I said.

  “Defenses operate unconsciously,” he reminded me. “This is obviously already on his mind. Ask him why he’s thinking about his abuse now.”

  What I was thinking about as I sat with Dr. Meyer, as the weeks went by, was this: Did we psychologists matter at all here? In the ER, T. ruled her own little world. Unencumbered by anyone or anything, she made use of her space to be a psychologist, to be always planting seeds. On inpatient, larger forces seemed to have come together to silently assert psychology’s insignificance. All the trainees who came onto G-51 were treated equally, no matter their training or experience. The interns were appreciated as extra bodies who could give the patients attention, but never as if our specific knowledge of psychological functioning was of any particular value. And so Jason, the dentist training to be an oral surgeon and doing his mandatory ten-day psychiatric rotation, had as many patients as I did, but with less supervision (I wasn’t sure he had any, actually). Had he learned, as I had, that paranoia is the externalization of one’s own aggressive impulses? That delusions represent the unconscious w
ishes of the parents? That auditory hallucinations result from the projection of the pathological introject of the mother? Did he even know what an introject was? Granted, I had little experience in actually treating the sickest people, but I had at least spent many years in school learning how to think about human health and pathology. That seemed of little repute here. Dr. Begum was always making noise about getting the staff in order, but he left Dr. Meyer out of this equation. If he believed that psychology had something to contribute to his unit, wouldn’t he remark upon my recalcitrant supervisor? It wasn’t clear that anyone other than Tamar and Bruce and me took note of Dr. Meyer’s absence, or even whether the chain of command would entitle anyone to say anything if they did. Maybe it wasn’t Dr. Begum’s place to remind Dr. Meyer to show up. I didn’t know. All I did know was that everyone who worked there seemed to have a sense of his or her own distinct purpose and that my supervisor’s actions communicated that at the very least he himself felt his—and by extension likely ours—not worthy of fulfilling.

  Dr. Begum went away on vacation, and Dr. Winkler was left to manage everyone on his own, but having been around forever, he was either less concerned about getting the staff to behave themselves or less self-defeating. Attendance at the morning meeting became sparse—none of the nurses, none of the social workers. Tamar left to do her month with Dr. T. in CPEP, and Bruce—whose already thin patience with the hospital had dissolved completely after a few weeks of morning meetings—avoided the fifth floor as much as possible. So much for my longed-for camaraderie. I sat in the chart room with Jason and Steve, the medical students. The two had settled in comfortably and quickly. Jason was the dentist. Steve was young, skinny, eager—the first medical student I’d met to date who actually wanted to become a psychiatrist. They were likable enough, but I found their self-assurance abrasive, so certain did they seem that completing any kind of medical training somehow qualified them to be working with crazy people. That I’d studied the human mind all those years and still imagined myself grossly unprepared stood out against their contented certitude, and I briefly wondered whose distortion was more problematic.

  “Who wants a new patient, a Mr. Bernard?” asked Dr. Winkler, beginning the meeting.

  “I do,” I said. “The ones I have are mostly disposition problems at this point.” Which meant that they were only on the unit because they had nowhere else to go, and also that I had given up on them, just like everyone else before me. I was talking about Hong Hanh and Gabriel. Mr. Rumbert—stabilized, I guessed, by an antipsychotic medication—had started talking and eating regularly, and so had gone home with his mother. Mr. Rodgers had taken as much of a break as he could from his miserable family/legal situation and was about to leave as well. The day before, I’d said good-bye to a Mr. Mower, who had emerged from the deepest ebb of his depression nicely with meds or time or conversation and whose departure I’d figured out how to expedite myself when no one else was willing to go downstairs to the pharmacy to fill his prescription in time for him to leave that day.

  Steve turned to Jason: “Do you want Mr. Bernard?”

  Jason to Steve: “Do you?”

  “I’ll take him,” said Steve, making his announcement to Dr. Winkler. It was as if I had not spoken at all.

  “Sure, never mind me,” I said with more resentment than I cared to show, but still considerably less than I felt. They seemed to consider me, a mere psychologist, no more than a planet—a moon—to their sun.

  Steve and Jason were all apologies, and I had a new patient.

  Dr. Winkler went to retrieve Mr. Bernard from the hallway. He was in his seventies, African American with drooping eyelids and age spots, too thin, and barely able to walk in a straight line. Dr. Winkler helped him into a chair. Could he possibly be drunk or high after having spent at least the last twenty-four hours in G-ER?

  “Do you know where you are, Mr. Bernard?” asked Dr. Winkler, skimming the chart as he began the interview. If he couldn’t answer that first crucial question, our assessment would be brief, and I would resort to calling his family to learn about him, if there was any family to call.

  “Is this the projects?” guessed Mr. Bernard, his pink tongue and globules of spittle entering the space in his mouth where his bottom teeth were once rooted in better times.

  “Do you know how you’ve spent the last couple of days?” Dr. Winkler asked, reframing his first question.

  Mr. Bernard paused to reflect. “I’ve been in meetings and consultations with the governor.”

  Jason and Steve tried to hide their smirks. Mr. Bernard’s psychosis, whether substance induced or otherwise, did not make him a good therapy case. My indignation had won me no prize.

  “Do you have any medical problems?” asked Dr. Winkler.

  Mr. Bernard thought and then told us, “I don’t have a heart.”

  “What was that?” asked Dr. Winkler. His hearing wasn’t great.

  “He doesn’t have a heart,” I said loudly.

  “Oh. How is that?” asked Dr. Winkler.

  “My old lady ate it!” replied my new patient, outraged.

  Steve and Jason could barely hold their laughter until Mr. Bernard was out of the room. “You guys want to thank me for taking this one?” I asked, and they nodded and continued to chuckle.

  Dr. Winkler looked at us with a serious face: “ ‘An insane man forsakes reason and often speaks the truth. A sane man holds his tongue.’ Henry Miller. Just because someone’s psychotic doesn’t mean he isn’t telling the truth.” Steve and Jason stopped their laughing.

  Dr. Winkler looked back in Mr. Bernard’s chart and found his daughter’s number. “Call her,” he instructed me. “Find out how many years he’s been drinking. Could be Korsakoff’s dementia. Alcoholics get it from chronic thiamine deficiency. This is a good case. Interesting,” he said, nodding to me on his way out of the chart room. I reached for the chart and the phone.

  Mr. Bernard’s daughter was exasperated but helpful. “He’s been a drunk his whole adult life,” she told me. “He finished a two-year inpatient rehab about six months ago and had been sober as far as I could tell since. But a couple of weeks ago he started complaining that one of his neighbors was bothering him, and he had that irritable tone. I figured he’d started with the drinking again. I gave up on trying to save him a long time ago and haven’t talked to him since the complaining started. I’m self-protective at this point. Did his neighbor bring him in?”

  Consulting the chart, I affirmed this. She asked with a sigh, “When are visiting hours?”

  With so many people from so many different nations both working and residing on the unit, the details of conversations were sometimes lost, and sometimes hard-won. For example, when an obese manic woman spoke, during her initial interview, of the dildo her son had recently purchased for her, Dr. Begum had to stop the proceedings to clarify what that was. The morning meeting was hardly a delicate environment, but still no one rushed to offer an explanation.

  Sometimes it was less vocabulary and more pronunciation that was a stumbling block. When Dr. Begum returned to New York from what felt to me like a very long vacation, I sat in as he interviewed an immigrant from Africa. Her answers to his questions were just vague enough to be bizarre, which was of course diagnostic. “Tell us why you are here?” he began in his Bangladeshi clip.

  “I came here to rest,” the young woman, whose name was Mpenzi, said. She wore a colorful turban around her hair. Her Kenyan accent was melodious to my ear.

  “How old are you?” he asked.

  “Twentysomething,” she replied, smiling beatifically. “You’d have to ask my mother.”

  “How is your mother doing?” he inquired, because family history, and especially of mental illness, which runs in families, was always important.

  “She’s fine. Doing well,” said Mpenzi.

  “Where does she live?” asked Dr. Begum, who would want us to get the woman in, or at least on the phone, ASAP.

  “She’s in he
aven,” replied the patient.

  Dr. Begum turned to me, his de facto American sidekick: “Is that in New Jersey?”

  Mpenzi became my patient. It turned out that she was a permanent resident of Kingsboro, sent to us after a manic episode for stabilization, though she must have mostly achieved as much in the ER because she was placid for the week that I knew her, her most pronounced symptom a long-standing and exciting delusion that Kanye West was on his way to New York to marry her. She hoped to be back at Kingsboro before the Christmas holiday for a party that was apparently not to be missed.

  I could not avoid doing inpatient interviews in front of the team forever, and finally Dr. Begum instructed me to lead one. Dr. Winkler was sensitive and encouraging. “This is like dentistry,” he said to me as we waited for our new charge to be brought in. “You have to get the patient to open up.”

  Her name was Ivory. She was pregnant and addicted to crack. She stared into the distance instead of looking at me and complained that she was not getting any good snacks. I ran through the points of focus I’d written in my notebook—presenting problem, history of the presenting problem, psychiatric history, family history, health problems, drug use, forensic history. She answered me but was so depressed that I quickly began feeling hopeless myself and missed some things. It wasn’t the end of the world. Dr. Begum stepped in to fill in the blanks, and I took in what I’d missed, the information that would help us arrive at the diagnosis. (Substance-induced depression—you couldn’t diagnose anything but substance-induced fill-in-the-blank as long as the patient had recently used.) “Good job,” Dr. Begum said after, smiling as he always did. “Each time you’ll get a little better.”