Brooklyn Zoo Page 20

  So there it was: the proof I needed. Could this finally be the point where I put aside my depressive faith in my own low value? When I achieved a Zen-like comfort with all that I knew, with my orientation in particular and then, as a derivative of my newfound self-assurance, with the absolute value of psychology in general? I told the story of the ash again and again, to anyone who had enough patience to listen, but the answer I found was still no. Somehow, down deep, I was holding hard to my belief that Dr. Levine knew a deeper truth than I, simply because he said it was so. The administrators who failed to hire psychologists. Medical psychiatry. Scott Brent. Dr. Levine. I couldn’t drown out the messages they delivered, and from the deepest place I couldn’t let go of the certain belief that any and all of them were right.

  CHAPTER EIGHT

  I RETURNED TO G-51 AFTER THE WINTER HOLIDAYS TO TWO pieces of news: Gabriel had finally left for Kingsboro, and Hong’s apartment—her last hope for a return to an independent life—had been sold by her legal guardian. I was sorry not to have had the chance to say good-bye to Gabriel and was rendered speechless by the kicker to the real estate proceeding, which was that every last penny of the tens of thousands of dollars Hong profited from the sale was now owed to the hospital for her protracted and involuntary stay. It was poetic injustice.

  As I had learned to expect, no one on the unit knew if Hong had been told. I guessed it was my job to deliver the information, but I wasn’t sure if her English covered such complicated concepts, or even if it was just better for her well-being not to know. After months of her persistent pleas, Dr. Winkler had finally agreed to take her off her meds a few weeks before, and she looked better without them. On the antipsychotics she’d suffered from akathisia, an unfortunate and common side effect that makes users restless, leaving them to pace and rock and march in place, which Hong had done, a constant jittery two-step. I still had no idea what went on in her head, which seemed an insurmountable impediment to therapy, but in her calm state she looked more and more as if she didn’t need inpatient treatment anyway, and the idea that her institutionalization was some kind of horrible mistake haunted me. I both knew this couldn’t be possible (there were just too many people involved in being found legally incompetent) and feared that it was so. My half delusion surely had a lot to do with Hong’s own fantasies but also with the carelessness I had seen play out in my months on inpatient. Things like this happened: Hong, reluctant to let the nurses as much as take her temperature, had finally agreed that her blood could be drawn for the tests that were necessary precursors to transferring to Kingsboro. But then the blood was left to sit around for too long, and it hemolyzed, making its potassium levels appear elevated and too high for the state facility to accept her. The whole trauma of the needle had been for naught and would have to be repeated, which was nothing if not an ironic parallel to Hong’s personal and political history. How could I maintain any faith in a system in which such things were as likely to happen as not?

  Dr. Winkler and I talked and ultimately agreed that treating Hong with dignity meant keeping her fully informed. I went to find her, which took less time than I would’ve liked, given the message I didn’t want to deliver. She sat on her bed in her sweatpants and her pajama top. I summoned her from the doorway, and she followed me to the dayroom, where we sat in plastic chairs and entered what had become, as the days had grown shorter and then longer again, a tentative companionable silence. “Hong,” I finally began, “I have to tell you some bad news. It’s about your apartment. Your guardian has sold your apartment.” She jumped up from her seat.

  “Tell guardian they no sell apat-ment!”

  Her feet were firmly planted. Her arms hung in the air as if in suspended animation while she waited for my reply.

  “I can’t, Hong, it’s already done. They sold it. The apartment is gone.”

  “Tell guardian they no sell apat-ment!” she insisted. Again I tried to explain, and again she failed to understand, or to accept—who knew. I hadn’t even told her the worst part. And to your captors go the spoils.

  “Apartment is sold,” I tried one more time, but again Hong insisted I tell the guardian not to sell. This had been her way with me for months, and it had worked, for whatever that got her. I hadn’t called her brother. I had helped convince Dr. Winkler to take her off the pills. I’d had no certainty about what was best for her then, and I didn’t now either, but worn down, I relented. “Okay,” I said, “I’ll tell them.” Only this time I knew I could make no difference. She went back to her room, and in the weeks that followed, we became partners in denial, avoiding each other and the unpleasantness of our shared knowledge.

  It was easy enough because I was busy. Patients were constantly coming and going, and newer ones than Hong were always presenting me with interesting symptoms. Like Mr. Bernard, the old drunk without a heart. He’d been looking better, but then one morning he told me he’d awoken to an ant attack, to the sight of them and the feel of little legs crawling on his skin. I only had a second to wonder whether there was an insect infestation on the fifth floor when he added, “Then the ant queen called.”

  “You spoke to her on the phone?” I asked.

  “No, I speak to her through my head.”

  “Well, an ant attack sounds just awful,” I said, curious about the visual and the tactile hallucinations, which I’d yet to encounter.

  “If they come back, I’ll jump right out the window to get away from them.”

  “Mr. Bernard, we’re on the fifth floor. That’s a bad idea!” I said to make a point, though the windows did not actually open, so there was little need for worry.

  “It doesn’t matter for me. I can fly,” he said.

  “No, you cannot,” I said.

  “No, I can’t. I’m a human. We can’t fly.”

  “Right,” I said. But then he was off again.

  “But I’m not human! I’m Greek! I don’t have a heart!”

  In the morning meeting I reported that he remained psychotic. “Describe this,” instructed Dr. Begum. I told him about the ant queen and her subjects’ attack. “Yes, formication—tactile hallucinations, they can be a symptom of alcohol withdrawal. So can visual hallucinations. Visual also more common with dementia, less common in schizophrenia,” he said. “We were thinking Korsakoff’s dementia specifically, yes? He will need long-term care.” I started the Kingsboro paperwork. With all of the people we sent there, I imagined it like a clown car, with patients going in and in and in and it never filling up.

  Just as in the ER, on inpatient a steady cadre of admissions asserted they didn’t need to be there. They were often believable. “That’s diagnostic,” Dr. Winkler reminded us. Everything was diagnostic. “Bipolar patients are usually in denial. They come in saying nothing’s wrong. When they’re not manic, they’re very convincing.” Bipolar patients, I’d observed, were also better related than schizophrenics, able to connect. Being with them felt different. Longtime veterans of inpatient wards had other, subtler methods of making the same discrimination. George had recently attended an intake on his own unit, after which a weathered psychiatrist interrupted a discussion about diagnosis to growl, “He’s schizophrenic. I can smell it on him.”

  Differentiating between schizophrenia or mania—which were assumed to be organic diseases—and a psychotic character structure, which resulted more from early trauma than innate disposition, was another thing altogether, especially in the acutely ill states in which we tended to meet people. It would take an outpatient therapist some time to differentiate between the two, but who among our charges would ever have one of those? The medications were all the same anyhow. They worked in varying combinations and with unpredictable degrees of success on different patients. Someday the medicating might be less imprecise, but that was of no help now, to anyone I knew. Maybe to their children. But even then pills would be only a palliative, hardly a cure.

  “I’m here because my stepfather called 911 for no reason,” a twenty-year-old girl name
d Domenica protested to the treatment team. She wasn’t lying. She believed it herself. Until a patient recognizes she has a problem, there can’t be treatment—or so my supervisor had said, back when I’d had one. (Scott had found us a very nice new one, who admitted straightaway that she would not really have the time to see us and then made good on her promise.) While this made sense to me, it also implied a thankless task. If a patient’s defensive structure—her very way of being, as natural to her as the breaths she drew—was built around denial and projection, how was she to begin to take in that she has problems and that they have anything to do with her? Treatment, it seemed to me, had to begin before a patient recognizes she has a problem, but then—the Catch-22—how can it?

  Domenica could tell me little about what had led to her hospitalization, but her mother was more helpful. She reported that her daughter had a violent temper and that others in the home were afraid of her. Her moods swung, and she expressed no interest in doing anything with her life. Her mother was unwilling to take her back into her house, but she hadn’t broken that to Domenica yet. “Maybe,” the older woman kept saying. Domenica told me that she wasn’t really her biological mom anyway.

  “My mother is Beyoncé,” she told me brazenly once we’d spoken a couple times, which made no sense because anyone who read People, as I did, knew the pop star was not ready for children, and she was just barely older than Domenica besides. “Gimme a dollar,” Domenica demanded each time we sat down together. This is what babies would sound like if they could speak, I thought. Her visitors often brought food, which she shoved in her mouth ravenously and with both hands.

  My favorite patient of the new year was aging and opaque, with a wide smile and a charming patter. He came in dressed like a businessman or a child playing dress-up to look like a businessman. He was too confused to give us a coherent picture of even his recent past—in psychiatric lingo, a “poor historian.” He instructed me to call him Buck.

  As reported by the case manager at his state-sponsored apartment program for the mentally ill, Buck’s arrival on G-51 was preordained: fed up with the side effects of his antipsychotic medication—specifically its interference with his erectile functioning—he’d stopped taking it. Then he stopped eating and sleeping at his apartment, spending his nights and early mornings riding the subway instead. His case manager noticed his dramatic weight loss and general griminess and got him to the hospital. Unless he agreed to restart his meds, the program felt it wasn’t safe for him to come back, and so far he was refusing. I was worried that he was consigning himself to a future at Kingsboro. He did not have an apparent care in the world.

  Buck took to waiting for me by the door each morning, in Gabriel’s old seat. “Hey, Doc, I need you to write something down,” he would say. For a couple weeks I obliged, taking pages of notes as we sat across from each other at a dining table, recording the phone numbers of his bank, complaints he wanted to lodge against the city, stories of his time as a “certified peer counselor.” I followed his orders to see where they took us and also because I felt for him. His hyper-cheerfulness and his social isolation made him seem so bereft there. He tried to make friends but with the wrong people—the young tough guys whose sheer numbers and strutting bravado often meant that they dominated the social life of the unit. They gave up only singeing scorn when Buck stuck out his fist to bump theirs.

  “Hey, man,” I’d hear him say as they passed him in the short, wide halls.

  “Don’t talk to me, you crazy old man,” they’d hiss back. For these young men, I guessed, Buck was a cautionary tale, all the more terrifying because no one in the G Building would clearly communicate how they might actually avoid becoming him.

  One morning Dr. Winkler asked how Buck was doing. “He’s less irritable than when he arrived but still pretty disorganized. His residence won’t take him back until he’s stable,” I told him.

  “He won’t go back on the medications that worked for him in the past. None of the other drugs I’ve tried seem to be helping,” he replied.

  “I know,” I said. “He doesn’t like the sexual side effects of the Risperdal.”

  “Who can blame him?” asked Dr. Winkler. But I did not see how the all but complete lack of sexual opportunity inside the G Building beat out impotence on the outside. This was a clear case of six of one, half a dozen of another. For days I’d been thinking of how I might delicately point that out.

  “We’ve developed a good relationship over the last couple weeks. Maybe I can convince him,” I said.

  “It’s worth a try,” said Dr. Winkler, “but we need to start thinking about other long-term care options, just in case.”

  I located Buck in the corner of the dayroom with his back to the other patients, his head down. “Zachary’s at it again,” he whispered to me. Zachary was one of the tough guys, in his early twenties. He dressed like a thug, but he was amiable enough. I’d tried asking him to leave Buck alone, but he denied hassling the older man at all, and I wasn’t sure what to believe. Zachary was sitting quietly on the vinyl couch watching morning television.

  “We need to have a serious talk,” I said, and Buck followed me to the tables and chairs.

  “I’ve got to call Mayor Bloomberg,” he said, agitated, as we sat down.

  “That can wait,” I told him.

  “No it can’t. I’m on parole, and he likes me to check in,” he said.

  “Buck …,” I started.

  “Where’s your pen? I need you to write some things down.”

  I’d left my pen in the chart room, and I told him so.

  “Well, go get it!”

  “Not right now, Buck.”

  “Why not? I’ll walk over there with you.” He got up.

  “Not right now, Buck,” I repeated.

  “Come on!” He waved his hand to set me in motion.

  “Not right now,” I said. He was thwarting my agenda, and my irritation with him poked sharply through my voice.

  Buck froze. I’d satisfied his whims for weeks, never breaking from form, implicitly promising our solicitude would go on and on and never stop, though that could never really be. Buck looked over his shoulder at no one.

  “Damn, Zachary, leave me alone!”

  I looked to make sure, and Zachary was still twenty feet from us, impassively watching Regis and Kelly Ripa and their singsong routine. When I channel surfed past them at home, they sounded only half-grating, but heard amid the anguish of the institution, their merry voices taunted. “What was that?” I asked Buck.

  “Zachary’s picking on me again!” he said.

  “He is?” I asked.

  “You heard him!” said Buck.

  “What did he say?”

  “He said you’re getting irritated with me.”

  Reflexively, I named the defenses in my head: introjection (taking a feared part of a caretaker in, as if to control it) and projection (expelling it onto another because it feels unacceptable in the self). No wonder I’d been so compliant. Buck could no more tolerate evidence of my ambivalence toward him than he could get the mayor on the phone. To know that I could become angry with him was too destabilizing. If it was Zachary who was claiming I was irritated, Buck could simply rail against him—an external enemy—and insist it wasn’t true, which kept our relationship safe. What had he lived through that made such byzantine maneuvers necessary?

  “It’s not fair of me, but I am irritated with you, Buck,” I said. “Maybe that’s difficult for you to know.”

  Buck responded only with stillness, and I wasn’t sure he’d heard me at all. Defenses are deeply ingrained, escaping our notice completely until the moment we’re ready to give them up. Buck wasn’t there—not even close. But if it wasn’t a watershed moment for him, the interaction had an impact on me. Just like outside G, I saw, what transpires in the relationship between patient and therapist offers the best chance at growth. Not just stabilization, but a true getting better. Since my arrival on G-51, I’d wondered how to be
a therapist to my inpatients, as if this were somehow only marginally related to being a therapist elsewhere. The ensuing self-aspersions kept me railing against imaginary external enemies of my own, a million little Zacharys. They drove me mad, but worse: in my need to pay them homage, I risked doing disservice to the people entrusted to my care. Holding on to my own convoluted belief that all that was bad and wrong and unworthy resided in me came at a cost, and it was no longer just to myself.

  Buck sat back down. I told him I’d go get my pen.

  The Justice Department was coming, and the paperwork had to be in order, and that could mean spending as much as triple the amount of time with my charts as with my patients. It was ludicrous, but like so much in the G Building there seemed no way of getting around it. One morning I went in early because it was quietest then and I had a stack of treatment plans that needed finishing. I unlocked the chart room expecting to find it abandoned, but instead it was filled with a group of skinny strangers, fifteen or twenty of them, and young. They were leafing through charts as if they were cheap paperbacks, and a schoolteacher, it seemed, was keeping close watch over them as if to make sure they didn’t trip each other or destroy property. Someone with some authority must have approved whatever this was or they would not have been let inside, but the charts were filled with medical information that was not only legally private but, I thought, morally so. I was only an intern, and so it was not my place to say anything, which had become so frequent a conundrum that by now it made me want to yell. “What’s going on?” I asked their authority figure.

  “Nursing students,” she said. They looked young for college, but maybe that was only because over the course of years I had suddenly become old.