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  “At least you guys will finally have some exposure to how a functional unit looks,” said our nominal supervisor, who’d eked out some time to meet with Bruce, Tamar, and me as a group, now that the preparations for the DOJ visit had culminated. She apologized too, said she felt bad for us that our inpatient experience had been in the G Building in this time of a real mess. She herself had interned on a different coast, in a functional place. She’d gotten a lot out of it, she said. Our time on G-51 was winding down by then, and I thought that maybe I’d learned just as much or even more from seeing what happened when things didn’t go well, when psychology as a discipline was practically as marginalized as the lunatics themselves. It was starting to sink in, the reality of it, that I might matter after all in this place, if others would let me—no, if I would let myself.

  There was a morning meeting, and it was the usual. A patient was acting out, but we did not discuss it as if it were a treatment matter to be understood and articulated and shared with him to some therapeutic end. “I can’t take him anymore. We’re letting him go,” a nurse declared, enraged, as if this were sound punishment. I’d heard threats like this before—not so different from my outburst with Vera, none of us were immune to these—though usually the line went, “If he doesn’t stop being so intrusive, we’re not letting him leave!” At home later I asked George if he thought all this was normal. He declared, “No!” but then reflected and said that even at his private hospital, where patients and psychology trainees were both better attended to, respect for our discipline was hardly consistently maintained. A psychiatry resident had recently admonished him not to speak to his patients about their lives “because sometimes it upsets them.”

  On my own I thought about why I’d gotten nasty with Vera in that particular moment. Something about her entitlement annoyed me. It was a trait I disavowed in myself, perhaps, but I wished I had supervision to dig a little deeper into the scenario. After some thinking, I went back to her. I asked how what I’d said had felt, and she said she’d been hurt. She recalled a time on the streets when a transvestite had spit in her face, and I knew then that my passive vitriol had hit her like that shower of saliva. With the transvestite she’d gotten so angry she blacked out, which she told me she tended to do when enraged. That morning a nurse had offered her new clothing, but she felt she couldn’t accept it. We talked about her need to see herself as someone who got nothing, and how that got in the way of ever having a different experience. I thought again how much we were alike, just me without the psychopath father, a not inconsequential difference in our respective developmental trajectories, despite the overlapping defenses.

  My last week came, and I said good-bye to Dr. Begum and Dr. Winkler, whose kindness I felt especially grateful for because it had not really been their job to provide that. I thought they’d be at a loss without us, but they didn’t seem too concerned. There weren’t always psychology interns, and certainly things went along. Around the same time George said good-bye to his inpatients over games of foosball and Ping-Pong, I had final sessions across sticky dayroom tables with Domenica and Hong and Buck—each of whom was finally Kingsboro-bound—and one with Vera, who cried and said she would miss seeing me. When I asked her what she’d valued about our time together, because really I wanted to know, she thought and then said that I had made her feel like a person again. The residents of G-51 had gotten so little from others historically that maybe it did not take much more than a little talking to help them regain a feel for their humanity. With Vera, I still regretted that I’d never figured out how to share my messy experience of being with her—that might have meant some growth for both of us. It was a hard thing to know how to do, and after all this time I got that it was the only thing that would make one that rare being: a therapeutic inpatient psychologist.

  And then it was post-midyear, time for Caitlin Downs to share my midyear evaluation. She gritted her teeth as she greeted me. I could tell she was nervous as she shut the door to her office. I’d seen so little but bluster and nastiness from my supervisor it immediately made me tense as well. In a wavering voice she began with her anger about my disrespectful attitude, of which she gave examples—as if she’d been keeping a list and as if I’d argue the point. I had canceled supervisions; I’d addressed her as Caitlin rather than as Dr. Downs in front of a group of internship applicants; I didn’t seem to carry out her instructions; I never appreciated the things she had to say. When she got to the last part, her voice broke. Her eyes teared. She said I’d been making her feel so bad that she’d been complaining about me each week in the junior supervisors’ meeting (that such a thing existed was news to me) and also regularly to Scott. From their conversations, she’d come to the following conclusion: “You remind me of my father.”

  As Caitlin finally began to cry, I felt embarrassed for her, and I felt guilty. I’d seen myself as so powerless in the situation that it hardly occurred to me I was having any impact on her at all. I cringed at the personal information, which she seemed to want to be congratulated for revealing. It occurred to me, since we were sharing, that I might register my own complaints about the way supervision was going—if I’d been no fun, she’d been none either—but I felt so bad about upsetting her that I just vowed to be nicer to Caitlin going forward, to try to find something of value in our time together. Once during graduate school, I’d worked with a patient I really couldn’t stand. “You have to find one thing to like in her,” my supervisor at the time emphasized. All I could come up with was that she had pretty hair. “So focus on that,” he told me. “Eventually, something else will come along.” But it never did, and the woman finally left. She was the only patient I lost during grad school. Caitlin was not the psychologist I needed her to be, but she did show up for every single meeting. It was the one thing I could give her credit for. That would be my point of focus.

  The next week when I arrived for supervision with my new attitude, Caitlin announced she had a surprise for me. She’d gotten me a new patient. “You can finally get rid of Carmen,” she said, smiling. Carmen had continued to miss sessions, and I’d been frustrated by her absences for some time. Still, over six or seven months we’d established a relationship, and I knew she counted on me, even if she wasn’t always able, for complicated psychological reasons we’d been trying to flesh out, to bear coming in. Caitlin was acting like this was a gift, but for me it felt like the opposite: an un-gift without a receipt. I tried to match Caitlin’s enthusiasm to throw her off the scent of my horrified dismay.

  “That’s great news about an additional patient. Thank you. But I’d actually like to keep seeing Carmen as well. Cutting her off doesn’t feel right to me,” I said. I left out what I knew very well she already knew very well: this goes against every fiber of my being.

  “No,” replied Caitlin flatly. “She goes.”

  It was spoken like a challenge. Would I continue to question her authority even after she’d finally told me, through tears and no small amount of returned dislike, that she did not welcome such affronts? I had used up any slack I had with Caitlin a long time ago through ire and self-indulgent quibbling. This was to be my payback, a straitjacket of my own making.

  If I could not continue individually with Carmen, maybe I could see her in group. Dr. Wolfe agreed that was a fine idea, but I knew it was also an impossible sell. Carmen came only once and looked down her nose at the women around her. She stayed the entire ninety minutes, and when it was over, she gave me a piece of stale birthday cake—leftovers—she’d brought in a napkin from home. I left her phone messages for some weeks after. Each went unreturned, and I never saw her again.

  CHAPTER NINE

  I BEGAN MY CONSULTATION-LIAISON PSYCHIATRY ROTATION in A Building on the first Monday in March. After twenty straight weeks of mornings in G—oh, how had I endured?—I climbed the subway steps at Winthrop against the backdrop of the singing alarms and turned right instead of left at the A Building. I cut through the littered parking lot of the BP
station and crossed at the light onto Clarkson Avenue as I dug through my bag for my hospital ID. Since CPEP, I’d worn the card clipped to my shirt because no one can try to choke you with an ID that’s clipped to your shirt. Now two buildings away, in another force field, I hung it back on its metal ball chain, the kind they put dog tags on, and draped it over my head like a tree ornament.

  Consultation liaison was one more thing I’d never heard of during school, far away from the broader applications of my field. Apparently, it was the interface between behavioral health and the other medical disciplines. When hospital doctors have concerns about their patients’ mental health, they call for a psych consult, and the consultant sees the patient and makes recommendations. Most teaching hospitals have CL departments, and they’re often composed of interdisciplinary teams of psychologists, psychiatrists, nurses, and social workers. Kings County’s CL team worked alongside that of SUNY Downstate—Downstate was the private hospital across the street, where patients with insurance tended to go—and was composed solely of psychiatrists. Still, because CL was an arena psychologists routinely worked in elsewhere, we’d been invited to rotate through, to get a taste for what it was like. Tamar had done CL back when I was at the court clinic, and she assured me that the psychiatrists there were friendly to us and to our way of thinking.

  As if being far away from the morass of G weren’t alluring enough, Tamar’s stories of medical patients with discrete and transient psychological problems had gotten me excited about the four months I would spend at CL, traversing the hospital campus with great urgency. “Call for a psych consult!” a medical professional would yell with alarm, and I would appear to attend to the problem, to diagnose, and then to leave, never to return. I had gotten into psychology because I relished the complications of long-term relationships, but what I needed now was a break. Tamar had spoken of foreign (to me) and therefore exciting (to me) conditions: specific phobias, delirium, psychosomatic illnesses. And equally compelling, at this point in my year, was the fact that I would not generally have even one iota of responsibility when it came to helping any of these people develop further understanding of themselves.

  “Good morning,” I greeted the slouching security guard as I entered the lobby, lifting my ID to demonstrate I belonged, and he nodded his head to show I could pass, as if anyone might be turned away. The A Building was more modern than G, with an actual snack shop up front, as opposed to just a window. I weighed my desire for coffee against the possibility of being late to my first CL meeting and then made my way toward the elevator, which I summoned with a button. Already things were simpler. On the fifth floor to the left I found the CL office, a large and dingy space occupied primarily by a wide, old table and a mismatched collection of plastic chairs. A long windowsill overflowed with unwieldy potted plants, and a woman in her late fifties wearing too-large, plastic bifocals and peach lipstick was watering them from a proper plastic watering pot with a very long spout.

  “Good morning,” I said. She looked up. “I’m Darcy—the psychology intern starting here today.”

  “Welcome,” she said. “I’m Dr. Cherkesov. Not too many psychology interns choose to rotate through here. We’ll be happy to have you.” Her accent was thickly Russian, and her attitude was exuberant. “Have a seat!”

  As I chose a chair, the medical students began to wander in. I could tell from their short white coats and their attitude of deference. They were always bright faced and shiny with anticipation. The phone on a table in the corner rang, and one of them asked me if she should answer it. It was her group’s first day, too. Dr. Singer—whom I’d met back in July, that long-ago time, when my intern cohort toured the different rotations—arrived and took a seat next to Dr. Cherkesov, who had finished with the plants. The two of them made an oddly concordant pair. He was very late middle-aged and too thin by half, with military-issue glasses, boils on his gaunt face and neck, and multiple wool sweaters under a frayed tweed jacket. She wore her graying black hair pulled back into a severe bun, with upside-down glasses and Soviet-era lipstick that complemented her polyester dress, Dr. Cherkesov from the bloc. Seated side by side, they were a pair straight out of a graphic novel: the kindly, old-world, adoptive parents who are soon left behind as the boy they raised goes off to confront his past on his way to a singular future.

  Dr. Cherkesov welcomed us all to CL. I could read her ID card now, hanging around her neck, and it attested to her dual degrees: M.D., Ph.D. (Medical doctors could do an extra research year after med school, which earned them a Ph.D. “Mud Phuds,” I’d heard them called, though I’d never met one before.) She asked us to go around the table to introduce ourselves. After we did, she explained that we would gather every morning at 9:00 to review cases that had been seen the previous day or in the middle of the night by the psychiatry resident on call. She turned then to the resident, identifiable by her longer white coat and her fatigue. “How was the night, Dr. Malou?” she asked.

  “Only one call,” said the resident. She was African, with a lovely lilting voice. “Twenty-three-year-old Hispanic female with no significant medical or psychiatric history presented in the ER after a suicide attempt in which she ingested Clorox bleach. She was oriented in all spheres. She was adequately groomed, slim, appeared her chronological age. Her speech was fluent and articulate, normal rate and volume. Her mood was neutral, and her affect was appropriate to content. Her thought process was organized. She denied auditory and visual hallucinations. She reported that she regretted swallowing the bleach.”

  “So you admitted her to the G-ER after she was medically cleared?” asked Dr. Cherkesov.

  “No,” replied the young doctor. “It was her first attempt. She realized what she’d done was foolish, that she didn’t want to die. She had family to go home to, and that was what she wanted, so I cleared her psychiatrically for discharge. She left this morning.”

  Dr. Cherkesov looked at the resident with exaggerated dismay. She began to lecture, and her listeners offered their rapt attention. “When someone presents after a suicide attempt in the medical ER, they call us in to determine whether the patient can go home once she is medically cleared, or whether she needs to go to the psychiatric emergency room in the G Building for further assessment.

  “When we are making this decision, we must ask: How dangerous and irreversible was the attempt? How painful is her chosen method? People think that Tylenol overdose is a painless way to go—it is not, by the way, it’s really a torturous death. But someone who drinks bleach? She knows she is going to suffer before she dies, and she is more than willing to do it.”

  The resident looked pained and offered, “She said she got angry at her mother and did it on impulse.”

  “Even worse!” said Dr. Cherkesov. “Who is to say what she will do next time there is an impulse? Until you and the patient get to the bottom of how this happened, it can happen again. If she is sent to the G-ER, she will be pushed to process her experience. Again and again people will ask her about the attempt, and she will be forced out of her denial, her assertion that this is no big deal. Discharging her only reinforces that what she did is almost irrelevant.” She paused. “Dr. Malou, you took this too lightly. The crime did not fit its punishment.”

  Dr. Cherkesov returned to addressing the rest of us: “A study was done of patients presenting to the medical ER after a suicide attempt. Those who were sent from the medical ER to the G-ER after their attempt were less likely to attempt a second time.”

  Dr. Malou was fighting off tears. I felt for her and with delicious dread anticipated the day when I might be on the receiving end of such a grave teaching point, one that I was never likely to forget. Dr. Cherkesov seemed to take pity on the young doctor and smiled gently. Her tone, if not her message, lightened as her smile broadened, and I found her so acutely and charmingly Russian: “Anyway, you discharged her. I hope nothing will happen. I hope it won’t affect your life in horrible ways!”

  Dr. Malou got up and gathered her not
es and her worry and her shame. Dr. Singer began to fill Dr. Cherkesov in on a case from the day before. The rest of us stopped rubbernecking and turned our attention toward him. He had seen a woman admitted for pregnancy complications. Her obstetrician was worried that the baby was at high risk for cerebral palsy if the mother delivered naturally, but the woman would not agree to a planned C-section. Dr. Singer was called in to determine whether she had decisional capacity: Was she in her right mind to make such a choice? He’d gone to see her and determined that she was confused, in and out of consciousness, and unable to understand the consequences of her decision—apparently, the CL equivalent of unfit to stand trial. I thought about the baby and asked, “What if she had been able to understand the consequences of her decision? She would have been allowed to put the baby at risk like that?” Dr. Singer said no, that if she’d been able to reason and understand and had still refused the operation, the hospital would have gone to court to ask a judge to declare her incompetent for the sake of the baby. CL was more serious business than I’d realized.

  After the meeting I approached Dr. Singer. He was the head of the department and so—in the absence of any psychologist, the same old song—would oversee my tasks there. Tamar had loved working with him. Like Dr. Cherkesov, he welcomed me warmly. His ID card attested to his M.D. and Ph.D., too. He explained that I would spend some days at Downstate and others at Kings County. Each morning after the meeting I would report to whichever attending or resident was “on the pager” and go with him or her on consults in one hospital or the other. He explained that consults were requested by medical doctors, who were supposed to fill out paperwork where they detailed their rationale for the request: for example, “Patient is not eating and is having difficulty sleeping. He reports feeling sad. Please evaluate for a mood disorder.” Often, though, the details were sketchy. A doctor might just write “not eating” or even nothing other than “psych consult.” Sometimes you could reach the doctor to ask for more information, sometimes not, but the consult had to be done within twenty-four hours either way. Dr. Singer summoned a graying Indian man who’d arrived halfway into Dr. Cherkesov’s lesson. “This is Dr. Kapoor. He’s one of the attendings here. You’ll be working with him today, at Downstate,” he told me, introducing us. I read his ID card: another Mud Phud. Rarely did I have this opportunity to feel so undereducated.