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  And if “better” meant “more comfortable,” I did, just a few days later with a patient named Garrett Miller who had checked himself in for homicidal thinking. He was a few years sober, depressed, and hearing voices. Major depressive disorder, severe, with psychotic features. When I told Dr. Meyer about him in supervision, he wasn’t buying it. “In the winter one in four psychiatric patients are malingering,” he told me. It was December.

  I liked working with Garrett, though. He was a talker, coherent, and with the typically tragic story. His father had been killed when he was two, shot to death through an apartment door he was pounding on, by an elderly neighbor who’d asked him to bring her some groceries. Garrett’s own homicidal fantasies had been directed toward the wife of his closest cousin. “She was annoying me,” he said, which seemed like a thin motive for murderous thoughts. Garrett’s cousin had just gotten out of jail, and the wife was being possessive of his time. “I was there for him for four years while he was locked up. Where was she?” he wanted to know.

  I said he seemed to have a lot of anger toward women.

  “I was raised by women,” he protested, as if that would invalidate my observation. “Everyone here is so fucked up,” he complained to me. “I feel like I have to take care of them all.” That was something to note.

  “You’re always taking care of people, but you never feel you get any care in return,” I observed. For the first time he agreed with me, but he did not want to say more. “My life is half over anyway.” He was only thirty-six. “What does it matter?” he asked. Often, on inpatient, there was a certain and predictable shutting down. Even when cognitively capable of it, no one on G-51 wanted to think too closely about himself. This was a large part of the problem.

  Garrett was one more patient who couldn’t leave because he didn’t have anywhere else to go. The G Building was not supposed to discharge people to the homeless shelters, as this was either inhumane or a surefire route to a quick readmission. The social workers were kept incredibly busy finding state-sponsored housing programs for those who were functionally homeless, but both Oswald and Miss Smith had disappeared, so no one was working toward Garrett’s departure. He was a voluntary patient and was perfectly happy to stay, which made me think that perhaps Dr. Meyer had been right to suspect that he’d been malingering the voices and the homicidal thoughts. You could choose to see this as sociopathic or incredibly resourceful: once a patient was admitted to G, a team of people went to work on the case, in the end providing a reasonable place to live if nothing more. Most days I admired Garrett’s ingenuity, though I was being at least tacitly lied to in the process, which also made me resentful. Still, in the wake of the mysterious disappearance of the social workers (why did no one on the unit bother to tell anyone else when they were planning lengthy absences?), I took it upon myself, with a martyr’s attitude, to get a name of a housing program for recovering drug addicts and to start the process of applying to it for him. That wasn’t my job, but I didn’t want him to end up like Gabriel or Hong Hanh or the patient who had been the talk of the building days earlier when she finally left for Kingsboro after an entire decade on the fourth floor of G.

  Garrett and I had been working together for a few weeks when I came in one morning to find him enraged. Camara, the deaf and mute patient, had accused a few of the men on the unit of sexually assaulting her late in the night, and Garrett was one of them. He couldn’t tolerate that anyone would think he was capable of such a thing. I took in his indignation and felt apologetic on behalf of the staff. Later I spoke to Dr. Winkler about the whole thing. “She went to one of the night nurses right after,” he told me. “The doctor on call came up and did a sniff test of all the men’s hands. Garrett tested positive.” Camara was transferred to another unit. Maybe her family was going to press charges.

  I was so pissed off at Garrett that I didn’t want to work with him anymore, which was probably understandable and definitely unacceptable. He was assigned to me no matter what, and it was my job to understand and work through my feelings in order to function as his therapist. This was an absolute. “Whoever walks into your office is your patient,” Dr. Aronoff had once said to me pointedly. She meant: no matter what, you can’t act on your feelings with people who have come to see you in good faith. Acting on feelings was what people did outside the consulting room, and it was what made the therapeutic relationship different from all others. It involved the therapist thinking in place of reacting, maybe the most crucial part of a treatment. I needed to be curious about what Garrett was up to: What kind of reaction was he unconsciously intent upon stimulating with his behavior? How could the treatment team use this information to help him know himself better? If I abandoned him in rage and disgust, that was hardly of any use to him, and being of use to him was why I was there, even if no one else managed to see it that way.

  But two months on G-51 had worn me down. I was cranky. No one else on the unit bothered to rein in the feelings patients evoked in them—or even probably to consider them—so why should I? I certainly wasn’t getting much encouragement. Dr. Meyer had recently gone completely MIA along with the social workers. Helpful as Dr. Begum and Dr. Winkler were on the fly, they were too busy to sit down for a discussion of any length. Dr. Begum at least—contemporary, symptom-focused psychiatrist that he was—was unlikely to be able to provide the kind of teaching I was looking for anyway, not that he didn’t wish it were otherwise. (He had recently gleefully announced to me that he was a patient in psychoanalysis himself and that “this depth psychology is so much more interesting than the pills!”) The unit was clearly lacking in psychological mindedness—an appreciation of the value of reflecting on one’s own psychology. This was its weak point.

  As Marvin Mavin and patients like him had continued to terrorize the fifth floor, no one talked about what they were acting out or how the treatment team was failing to help them contain their aggression; they just restrained them and shot them full of Haldol. This was not done malevolently; it seemed to someone the best way to keep them from harming themselves and others. But it only worked until the next time, which without any psychological treatment was sure to come, and it left the other patients feeling unsafe besides. “If I had a grenade, there’d be no people like that left on earth,” Gabriel had said to me, with clenched fists, one morning after Marvin had lurched threateningly around the dayroom while she and I sat together. Her hands and voice shook as she spoke. She was increasingly disorganized for the rest of that day.

  It was an imperfect unit in an imperfect system, and sometimes the clamoring hopelessness made it hard to hear yourself think. For too many reasons to count, this thing had developed in the G Building, this culture of offhand neglect. No one inside quite escaped it: certainly not the patients, and then, too, not the interns. But I had the resources to surmount it, if only for myself. “Graduate school teaches you how to teach yourself,” a professor of mine had said toward the end. I left Gabriel that day to go home and order a book on psychological treatment in inpatient settings. I paid extra for expedited shipping. The text arrived with the first snowfall just as I officially lost my supervisor. Dr. Meyer, who’d apparently been out of town interviewing and otherwise using his sick time to stay as far from G as he possibly could, finally gave his two weeks’ notice, suburban outpatient clinic bound. “This is no place to spend ten years,” he cautioned Tamar and Bruce and me as we clustered in his office to watch him pack his books. I didn’t aspire to any kind of drawn-out stay, but I wanted to get something out of the two months I had left on G-51. I went home and started reading.

  CHAPTER SEVEN

  MY NEW BOOK KEPT ME GOOD COMPANY, LIKE THE VOLLEYBALL Wilson to Tom Hanks’s castaway. Of course psychological treatment is important for psychological problems, it told me. Here is how psychologists have an impact on inpatient wards, it went on. This had much to do with what I suspected: conveying that “symptoms” were more than just arbitrary neurological events; encouraging the team to be thoug
htful about their own emotional reactions; talking to patients individually and in groups to help them make sense of their experiences and concerns. I carried the scholarly tome with me each morning to read on the subway. That it did not prove a corrective to the low professional self-esteem that I had been blaming on my environment was my first clue—well, maybe not my first—that my actual problem was more of an internally generated one. It covered familiar ground, this heightened attention I paid to voices I heard as disparaging. But I could know this for only a moment before I’d forget it again and do the whole thing over.

  The irritable mood that grew out of this conundrum was not winning me any popularity contests on the sixth floor, as I shuffled between Caitlin’s office and Scott’s. The two of them were always around up on six. They were the white noise of our days. For months I’d been enraged, if unfairly, with Caitlin, for offering what I knew passed as therapy supervision at a hospital, but was nowhere near as good as what I had gotten used to in grad school. I retaliated most weeks during our time together by using all the theoretical language I could muster (and I’d learned quite a bit of it) to make Caitlin feel dumb—her Achilles’ heel, even though she had a Ph.D. and the title of neuropsychologist. I might have felt too guilty to keep it up had she not been giving the meanness back to me in equal measure. She was a real hard-ass and a misanthrope. We went back and forth in our mutual aggression until the relationship felt like a tennis match. Sometimes I thought we were just having fun.

  As for Scott, he was steadily indifferent to the charms I peacocked before him, and he bristled toward me only further when I went to him with things worth complaining about, like that my supervisors were evading me. I knew that he didn’t want to hear what as our director he needed to know, but I persisted in trying to tell him, to bolster his self-esteem in this back-channel way, by demonstrating my clear expectation that he was capable of his new job—as if this might eventually both make him better at it and win me his love. In this I wasn’t alone, as he had finally come to occupy a curious and similar place for all of us interns: we found ourselves trying to maintain fondness for him despite his oftentimes egregious unlikability. We would joke about it tenderly among ourselves when he was unresponsive to our concerns, or checked his e-mail multiple times during supervision sessions, or let us know in no uncertain terms that our careers going forward would ever be dependent on his good graces. The latter seemed to tragically illuminate his fragility. He yearned for us to feel his import and power. Us. The interns.

  Most weeks, though, Caitlin and Scott were just low-level annoyances, and my resentment and self-doubt might have been milder had the inpatient unit been the only place I was encountering strong ambivalence about psychology. Instead, it seemed to come up everywhere I went across the hospital campus. In the face of what felt like an onslaught against my field, I had considerable difficulty holding firmly to all that I vehemently believed to be true. The more I struggled to maintain a sense of my own value, the more I wanted to lash out against an amorphous enemy.

  One adversary took form in a seminar on cognitive-behavioral therapy, or CBT, where I found insult heaped not on my profession in general but on my particular psychological orientation. The main premise of CBT is that problems in living originate in cognitive and behavioral factors, which can be changed via skills learned in psychotherapy. The guiding principle of psychoanalytic therapy is that problems in living originate in the unconscious, which needs to be better understood in order to wield less influence. CBT therapists often write psychoanalytic therapy off as fantastical and impractical. Psychoanalytic clinicians tend to find CBT superficial and transiently helpful at best. CBT trainees learn how to follow treatment manuals: each session is sketched out in advance in workbooks that address particular symptoms. Psychoanalytic clinicians are trained by reading theory and case studies and seeing and discussing patients in order to learn how to think about how people function. We are also expected to be in our own therapy, not least so we can understand our emotional responses to our patients in order to use those for the good of treatment rather than for its ill. In my graduate program, if you weren’t yourself in therapy, it was a fierce and unwieldy secret. In contrast, Bruce had actually been told by the director of his CBT-oriented graduate program at a respected university in Massachusetts that anyone who needed psychotherapy had no business being a doctoral student in clinical psychology.

  Like many of the internships in New York City, Kings County’s was psychoanalytically oriented, but because this way of thinking had been coming under fire, training programs were attempting to become “integrative.” And so the interns were offered an ongoing seminar on CBT, taught by the hospital’s CBT expert, Dr. Edward Levine. I tried to go in with an open mind. Dr. Levine—himself, as he told us, once the patient in a psychoanalytic therapy gone awry—had no such intention. In the first seminar, during which we were ostensibly learning about how to teach patients to relax, it was clear that we were also being indoctrinated against our preferred way of working. “A psychoanalytic stance means being quiet and listening because you don’t know what else to do,” Dr. Levine scoffed by way of introduction—as if this were a bad thing. He knew that most of us in the class had invested the last four years of our lives in just that sort of training, and I wasn’t sure how he imagined demeaning our efforts fit in with helping us to consider alternate methods. To help myself decompress during the ninety-minute seminar that followed, I came up with the behavioral technique of making a hash mark in my notebook every time Dr. Levine insulted my orientation. By the end of the first hour, I had drawn eleven sharp vertical lines, but I didn’t feel relaxed at all.

  As the course wore on, Dr. Levine eventually told us more about himself, including that he was the son of Holocaust survivors. The context of this was confessional, as he went on to say that he sometimes felt undercurrents of resentment toward his traumatized patients, whenever he deemed their ordeals less horrifying than Auschwitz. This sharing of his difficulties actually softened me toward Dr. Levine, though I continued to keep a running tally each week of his derisions of my theoretical orientation. I’d counted as many as fourteen in a single ninety-minute class. Philosophical differences about what makes therapy effective aside, I also found his material as flat as the midwestern plains. If a patient was depressed, he told us, she needed to be participating in more rewarding behaviors. What kinds of things does she enjoy doing? Suggest that she do these things. Had I shown up at Dr. Aronoff’s office and found this the best she had to offer, I would have given up all hope in psychotherapy forever.

  As certain as I was of this, something nagged at me in CBT class, something I couldn’t let go of. Dr. Levine was smart and experienced, and if he believed so resolutely that something was so, well, couldn’t it be? On one hand I valued what I knew and believed, but then I would come up against this wall, the bulwark of his omniscience, his insistence that psychoanalytic treatment was bad. I couldn’t quite manage to hold on to my own sense of myself in the face of this older man’s certitude. It was at the heart of why I left his conference room riled up each week, rather than simply bemused by his pronounced obsession with my psychoanalytic camp, his nominal enemy.

  After 9/11, Dr. Levine had worked with a handful of New York City first responders. One of his patients in particular—a fireman who’d been tasked with getting people out of the towers—had wound up especially forlorn, paralyzed by his memories, withdrawing from family and friends, and rarely leaving his house for fear that a horrible fate would befall him. With Dr. Levine’s help, over a number of months the man had become much less symptomatic. When the therapy ended, Dr. Levine asked the grateful man to come in to be filmed talking about his treatment, for teaching purposes. Dr. Levine would show us the tape to illustrate a patient’s take on CBT for post-traumatic stress disorder.

  The burly and upset former firefighter was painful to watch. Almost all of the interns had been in the city on that astonishing day, and the man’s palpable di
stress took us back some years. My fellow intern Zeke left the room halfway through and didn’t want to talk about it later. When the tape ended, Dr. Levine mentioned this as an aside: the patient had been wearing scrubs in the video, and this was because he had shown up on the day of its recording in his street clothes but covered in soot. “He forgot our appointment until the last minute, and he’d been doing some construction on his house. So he rushed over here like that. I had to give him something else to put on, and the scrubs were all I could get my hands on!” Dr. Levine obviously found this mildly amusing.

  Not for the first time in that class, I felt discombobulated by what I was hearing, or rather by what was missing from what I was hearing. The patient, who had needed therapy in the aftermath of a trauma that resulted in becoming covered in ash, had shown up to memorialize this treatment covered in ash. How stubbornly attached to the denial of a dynamic unconscious did one need to be to write such an episode off as mere comical coincidence? Whether it was a focus of one’s therapeutic efforts or not, its significance could not seriously be called into question, could it? And so I raised my hand. I didn’t usually ask anything in that class. In the midst of all the breathing techniques and muscle relaxation exercises there seemed little worth my inquiry. “Dr. Levine,” my voice wavered, “don’t you find it interesting that on the day he was to be videotaped he came in looking like he did at the end of 9/11?”

  Hadn’t he been waiting for one of us to ask? He looked surprised by the idea. “No,” he said, shrugging it off. “He just forgot.”

  I knew with a certainty that made the nerves at the back of my neck constrict that the ash had meaning, that the fireman had unconsciously been using it to communicate something of his experience—that despite his progress some work remained to be done. I wondered about the patient’s intuitive sense of Dr. Levine’s secret resentment, and about my teacher’s own intolerable associations to ash. To find none of this meaningful, I guess I could understand as so much defensiveness, but I could also hardly fathom it at the same time.