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  Generally, psychologists do two kinds of testing, cognitive and personality, and I’d done a fair amount of both in graduate school. Cognitive tests measure IQ and educational achievement. They’re used to diagnose learning disabilities, including ADHD, and to quantify other intellectual abilities, most often when they seem on the decline, say after a head injury, or if some kind of dementia is settling in. Personality tests look at different aspects of a person’s cognitive, emotional, and interpersonal functioning. Some of them involve self-reports, where the participant answers a series of questions about himself. Others are projective, which means the subject is presented with an ambiguous stimulus like an ink blot and asked to make meaning of it, offering clues to his emotional preoccupations. Cognitive and personality tests are ideally given in conjunction, as the two areas are inextricably intertwined, our intellect shaped or constrained by our character.

  The first time I met with Grant Carson, it was not to administer any test but simply to hear about his life. I went into the basement on my own for the first time, down the very long staircase, and found him sitting, lanky limbed and bent, on the metal bench that lined the back wall of the holding cell. He was staring at the gray cement floor beneath his laceless boots. He did not look up when I introduced myself and explained why I was there, though he did stick out his cuffed hands meekly to shake mine. His long neck craned downward, his eyes hidden in shame, he was the most pitiful being I’d ever seen, like a woodland creature awaiting transformation in a fairy tale. Though he was almost fifty, he looked like a little boy, something in his face and the way he was folded. I sat down at the table in front of him and put down my notebook and pen. “How are you doing today?”

  “I’m tired,” he said, still looking at the floor. His tone and prosody did nothing to lend credence to the idea that he was a grown man. “I don’t sleep much at Rikers.”

  “How come?” I asked.

  “My mother comes to see me in the middle of the night. She sits next to me and we talk. She died of cancer a few years ago, so the only time I get to see her is when she shows up real late.”

  I nodded and thought. “What do you talk about?”

  “About when I was a child. I tell her if she’d loved me, she wouldn’t have let my stepfather rape me. She tells me I’m worthless and that I should shut up.”

  “What’s that like for you?”

  “She’s a real comfort,” he said, nodding his head and rocking back and forth.

  “How long has she been coming to see you like that?”

  “She started when I was in Attica.”

  Grant Carson went on to describe his life, more than a third of it spent in one type of prison or another. His longest stint had been ten years at Attica Correctional Facility in upstate New York, not too long before our meeting. The charges had always been similar: robberies he could not recall, criminal possession of weapons, drugs. He told me he started using marijuana at age seven, the year after his stepfather began sodomizing him in his closet on an almost daily basis. When he wasn’t being raped himself, he could hear the man in the next room with his sister. “I used to see her crying in her room, and I knew.”

  His stepfather threatened to kill the children’s mother if they told, and Grant kept quiet. He began responding to a voice that no one else could hear around age nine, was disruptive in class, and got suspended or expelled multiple times. His family doctor labeled him hyperactive. His stepfather died when Grant was fifteen, but the man continued to haunt him in his dreams, where his appearance was enough to make Grant get up and run in his sleep. He began drinking at eleven and using crack at sixteen and angel dust at twenty. He got what passed for help—that is, antipsychotic medication—for the first time in jail at age twenty-five. He’d never had any kind of talk therapy. During his time away from jail, he’d fathered a child every few years—none of the five now wanted much to do with him. His acting out was like Russian roulette: he’d tried to hang himself dozens of times while at Attica, where the guards would always arrive in time to save him, in time but also much too late.

  “Your stepfather never comes to visit like your mother?” I asked.

  “No, just in my dreams,” he said, shaking his head. “But sometimes Ken comes.”

  “Ken?”

  “He’s this white guy.” Grant was black. “He’s been coming around since I was a kid.”

  “Do other people know Ken?”

  “I’m not really sure,” he told me. “When Ken comes, Grant leaves.”

  I paused at the last part. I’d quickly assumed Ken was just another auditory hallucination, a voice in Grant’s head. But if he really experienced himself as leaving upon Ken’s arrival, he might be describing an alter, another personality. Dissociative identity disorder (DID), or multiple personalities, is theoretically an outgrowth of early and chronic traumatic experience, so it fit with Grant’s history, but there was debate in the field about the disorder’s actual existence. Some clinicians identify DID in a large number of their traumatized patients, while others claim it’s iatrogenic, or brought on by the treatment itself, by practitioners who want to find it working with patients who are eager to please. I’d taken an entire class on the defense called dissociation, the process that underpins DID. Like all defenses, dissociation is a normal function of the mind, widely experienced, for instance, in the benign form of daydreaming—the daydreamer “leaves” a situation mentally while remaining physically present and physiologically awake. Dissociation also offers protection from overwhelming experiences of terror, as an unbearable event is processed as if not quite happening to the self. Trauma victims commonly describe watching themselves as if from the outside as the very bad thing goes on, and therapy with this population is necessarily focused on integrating the disturbing experiences—making them part of their conscious and continuous life story. Like other defenses, dissociation is only pathological when it becomes a person’s go-to way of dealing with even objectively minor life stressors, and this is what theoretically happens in dissociative identity disorder. DID always made sense to me: it just seemed like dissociation reaching its inevitable potential. But I’d never before been seated at a metal table across from someone who had it, and I found it perversely exciting.

  “What do you mean Grant leaves?” I asked. There were specific questions designed to clarify whether someone was prone to dissociation, but damn it I couldn’t remember them just then.

  “Sometimes Ken takes over,” he replied.

  When I finished my interview with Grant, I went back upstairs and straight to Dr. Wolfe’s cubicle—he had been assigned to oversee the case—and he was thoughtful.

  “It might explain why he can’t remember the robberies,” he said. “Or he could be malingering.”

  It was hard for me to believe that the fragile man who’d sat before me could fake a toothache, let alone anything as elaborate as a white man named Ken, but I agreed the matter warranted more attention. Dr. Wolfe suggested I add a self-report measure that helped flesh out dissociative experiences to the list of tests I’d administer to Grant, and he told me he’d want to speak to Grant himself before the testing was through. We told Dr. Ruben, the psychiatrist who’d made the referral, that I suspected DID, and he expressed faux annoyance: he’d had high hopes that this one might be treated with a quick dose of Ritalin and then sent off to trial. “Multiple personalities!” he exclaimed under his breath and walked off, shaking his head.

  The next week Grant was returned to the courthouse twice to take hour upon hour of tests. Given that our mutual efforts would likely culminate in the conclusion that he, like all the others, was unfit to stand trial, it seemed like overkill, but who was I to say? First thing in the morning, he was waiting for me in the basement holding cell, his head held low. We started with the WAIS—the Wechsler Adult Intelligence Scale. David Wechsler, the American psychologist who developed the test, defined intelligence as “the global capacity of the individual to act purposefully, to think
rationally, and to deal effectively with his environment.” The test measures verbal and nonverbal abilities, and it’s how you arrive at someone’s IQ. Some parts of the test involve learning a new skill, and these measure what is called fluid intelligence, while others look at fund of knowledge, or crystallized intelligence. Generally speaking, intelligence is impacted by a lot of things. Like every aspect of being, some of it has to do with innate capacity, and some of it has to do with environment. Grant had only gone as far as the ninth grade, and given all the abuse he was enduring at home, it wasn’t likely he was able to focus on what was going on in the classroom, whether or not he had ADHD. As Grant and I moved through the different parts of the test, it was obvious he wasn’t doing well. We’d been carrying on for a while when he couldn’t define one of the vocabulary words I presented to him, and he looked as if he might break down. I stopped to ask why he thought he was getting so upset.

  “I want to do well because then I’ll feel happy,” he answered, and I couldn’t say which I thought was less likely.

  After Grant and I had spent two days and many hours engaged in the Rorschach, the Thematic Apperception Test, the Delis-Kaplan Executive Function System, and the Test of Memory Malingering, among others, on yet another morning Dr. Wolfe came down with me to meet Grant and to administer the Multidimensional Inventory of Dissociation (MID), to determine once and for all if our guy had multiple personalities. Grant spoke a little differently of the white man named Ken this time around, and it was hard to say whether he was a hallucination or an alter. The MID wasn’t a huge help because while Grant agreed that yes, he had trancelike episodes where he stared off into space and lost awareness of what was going on around him, felt uncertain about who he really was, and relived traumatic events so vividly that he totally lost contact with his surroundings, he didn’t always seem to completely comprehend the statements he was endorsing. Dr. Wolfe was not convinced, and I didn’t know what to think. With so much trauma in his history and so many symptoms in his present, it was difficult to parse the whole thing out. This was almost always the case with our defendants, though Grant was an extreme example. Dr. Wolfe and I settled on a diagnosis of chronic post-traumatic stress disorder, among others.

  Every testing report ends with recommendations, and beyond suggesting that Grant be found unfit to stand trial, ours came down to this: get this guy some serious psychological help. I had never before so vehemently hoped that my recommendations would be implemented, but given that Grant still stood accused of holding up honorable citizens at gunpoint on the subway, and that the justice system had limited resources when it came to mental health care, I doubted he would ever get the therapy he’d need to have any relief. Grant Carson was probably the first person I’d ever met who made me question whether significant relief was always even a possibility. Maybe a person could only take so much. Maybe there was a point of psychological no return.

  As one month passed at forensics and then another, I began to be acutely discomfited by the fact that I had yet to actually conduct a fitness-to-stand-trial evaluation. The students were allowed, if never outright encouraged, to do this—to go through the standard interview protocol with a defendant while the doctors looked on. Given that these evaluations were more or less all that went down in the court clinic, I felt conspicuous about my reluctance, my self-appointed status as the wallflower at the orgy. I’d grown up with a critical father. I’d gone on to choose first one and then another career where I could make others the explicit focus of attention—perhaps no one need notice me—but now there was this live audience. At forensics I’d looked on as the master’s students led the assessments, and I knew I couldn’t do much worse. One particularly shiny-haired girl had giggled most of the way through, to the point where I cringed mightily for the defendant, whose business there was not a laughing matter. In the laid-back court clinic, where responsibility for teaching was after all so diffuse, no one was going to suggest that I do anything. It was all up to me, which made my reticence feel all the more like a personal failure.

  Dr. Wolfe walked back to collect a couple students. I had stopped waiting a beat to volunteer to go downstairs to watch, and so I stood up right away. The mood that day was jovial. Dr. Wolfe and Dr. Laytner were excited about this case, a young man who had tried to kill his family with a samurai sword. It had dramatic overtones and a potentially compelling narrative, at least relative to the heavy rotation of disturbers of the peace who so often filled our days.

  It was actually starting to feel monotonous, all that craziness I was not there to learn to treat, and so I had decided—with Scott’s approval—that I would leave the court clinic for good that week, a month early. All the commuting back and forth midday had proven a disappointing way to spend my time, and also I guessed, having gotten a feel for what profound mental illness looked like, I’d learned as much as I was going to there. One rotation or another had to be cut short by a compulsory month in the psychiatric emergency room anyway. Beginning the next week I would be at the hospital full-time.

  From the other interns’ experiences—shared in fitful bursts before our seminars and during our weekly intern support group—I understood this would be a mixed bag. My sense that psychologists might be dismissed by the psychiatrists who ruled the G Building had been correct, to the extent that the M.D. in charge of the inpatient unit that Jen, Leora, Zeke, and Alisa had been assigned to had refused to give them patients at all. Instead, this psychiatrist distributed therapy duties among the third-year medical students, who, while they had passed gross anatomy, had likely never as much as taken Psych 101. Scott had tried to intervene to no avail, and our director finally settled on moving the interns to a different unit altogether, but not before we’d all learned a pointed lesson about the dismissive arrogance of psychiatry. Until then it had been for us mostly a myth.

  On our trek down the long courthouse staircase, Dr. Wolfe told me Scott had asked him to supervise the women’s depression group I had recently begun co-leading in the outpatient clinic. Each of the five forensic psychologists spent one day a week at the hospital proper, so many of them supervised non-forensic goings-on. Dr. Wolfe’s news was especially welcome because with forensics coming to a sudden close, I had regretted cutting ties with him, the only psychologist I’d so far found to look up to. It was proving hard, at this institution under siege, to locate someone willing to take on that role. If there was an every-man-for-himself ethos in Behavioral Health that year, I could hardly blame the staff, who from the junior psychologists on up seemed themselves without solid leadership. Still, I felt a lack. I had started co-leading a support group for cancer patients as they waited for their chemo, and my warm but impossibly overstretched oncology group supervisor canceled about half the time. I had signed up for a seminar on family therapy, which included taking on a family case, and my supervisor for that was equal parts helpful and scatterbrained—“I got held up at the bank” was the best he could do after forgetting to show up for what would have been our third-time-rescheduled second meeting. (“At gunpoint?” Jen asked, not altogether kidding, when I repeated his words to her later.) We’d started an interesting psychopharmacology class, but the psychiatrist teaching it only managed to make it once in a while. While Caitlin Downs never canceled a supervision, our time together was so unsatisfying I wished she would. Dr. Wolfe was available and knowledgeable about psychology, and after all these weeks seemed fond of me. As small a bright spot as that was in the larger picture of my training, it was sustaining.

  Joseph de la Paz sat waiting in the basement holding cell. He was small, in his mid-twenties, and with the by-now-familiar history—his education cut short when his thoughts began to feel scrambled, his sporadic drinking and drug use becoming heavier as his psychotic symptoms intensified. He was obsessed with homosexuality and homicide. Mr. de la Paz traced the origin of his problems to his aunt, with whom he lived. She’d put something in his soup, something she had gotten from a “homosexual” who also happened to
be a witch doctor. He feared that people were out to destroy him. He’d purchased the sword at a mall in order to protect himself from his aunt and her gay witch doctor friend and anyone else who might be involved in conspiring against him.

  “Why would they want to hurt you?” asked Dr. Laytner.

  “Because now women don’t respect men,” replied Mr. de la Paz.

  “But why hurt you in particular?” he followed up.

  “Because in America there are a lot of homosexuals,” replied Mr. de la Paz.

  “But why you?” persisted Dr. Laytner.

  “Only God knows,” he concluded.

  The guard led him out of the cell while we remained. During the interview he had become suspicious of the lawyer Jim Danziger, who he feared might be under the control of the witch doctor. He would not talk to Jim, and so he would be found unfit. As we waited for the next defendant, I gathered my determination and requested to lead the 7:30. Dr. Laytner and Dr. Wolfe said sure. To be polite, I thought, they changed the subject and looked away, allowing me and my nerves some time alone. But my trepidation was for nothing. The guard came in to report the defendant was refusing to see us. The morning was over, I had to go back to the hospital, and telling myself that at least I’d tried, I would not volunteer again.

  On my last day at the court clinic, Dr. Young called me into her office for the first time. Because my days at forensics were ending, she needed to formally evaluate me. She had a form for this on her desk, and I could see the Likert scale on which she was supposed to rate me, one through five—five being the best—on various dimensions. She read the first item aloud to me. “ ‘Student was able to incorporate new material effectively.’ How do you think you rate on that?” she asked.