“Mr. Rodgers, I am Dr. Begum. I will be your psychiatrist while you are here. The other people at the table are your treatment team. We will all work together to figure out how to best help you. They will introduce themselves.” We went around the table and told Mr. Rodgers our names and our titles. Nurse. Social worker. Psychologist in training. He nodded through each introduction before Dr. Begum launched into his interview. “Mr. Rodgers, please tell us what brings you here.”
“Sexual problems,” Mr. Rodgers said in a voice that was surprisingly childish given the manly body it came from. He began to cry. Miss Smith handed him a box of tissues and he took a few. His grief was as palpable as his answer was incomplete.
“You are very upset,” said Dr. Begum. “But I’d like you to try to say more so that we can understand and help you.”
“When I was eight, I started to have irresistible urges. I took a nap with my mother, and I touched her inappropriately while she was sleeping.” He continued to cry as he spoke. I did not want him to go on, but he did. “I’ve always had these urges in me. I tried to deal with them. I went to church. I prayed on it. But the urges were bigger than me. I had them toward my stepdaughter, and I couldn’t help myself. She’s twelve. I was alone with her too much, and finally I took her in the back room and I touched her, inappropriately. I did it a few times. I couldn’t help myself. She told her teacher, and my wife kicked me out, and now there are legal proceedings. In Pennsylvania.” He stopped speaking here and wept for his misfortune. I didn’t doubt that he had been very unfortunate in myriad ways that he had not—and could not have—elaborated, but the twelve-year-old girl stuck in my mind. There were silence and something like repulsion around the table. “I came here to get help with my urges,” he said, wiping his face and looking at us.
“Okay, we will try to help you with that,” said Dr. Begum, nodding and taking notes. He went on with the assessment: How was the patient’s appetite, his sleep, his interest in activities he typically found pleasurable? His interview was similar to T.’s but stiffer, hewing closely to what I’d come to understand were the DSM’s main differentials. T. always seemed to be trying to know the patient. Dr. Begum had more quantitative concerns. For how many weeks had the patient’s appetite been poor? For what number of days had he been feeling depressed? The answers would allow us to distinguish among the manual’s different mood disorders—dysthymia and major depression and depressive disorder not otherwise specified.
Adjusting my thinking to this framework had become for me like learning a foreign dialect of a familiar language. It also felt reductive. In whose reality were anyone’s problems so finite and circumscribed? How many times had Mr. Rodgers’s mother sanctioned their incest? How strong was his impulse to abuse his stepdaughter, on a scale from one to ten? For a psychologist the real work began after this kind of checklist conclusion; for modern psychiatry it was more or less where it ended. Dr. Begum seemed like a good doctor, thoughtful and bright and with higher expectations for his staff than they’d been able to maintain for themselves. I both admired his rigor and wondered how he maintained it—how any of them did—given the banality of his task. Arrive at diagnosis; prescribe pill. Repeat, repeat, repeat.
Mr. Rodgers was not suicidal or homicidal, he had been feeling depressed for some months, he was sleeping okay but did not have much of an appetite, he did not take real pleasure in anything lately, he was irritable, he was occasionally hearing a woman’s voice telling him to kill himself, but he was not compelled to obey her. No history of substance abuse, though sometimes he’d have a drink when the woman’s voice became intolerable. No previous psychiatric hospitalizations. No health problems. He had been born at Kings County Hospital, and though he now lived far away, he had last week decided to return here, as if to Mother, for help. When the interview was over, the nurse unlocked the door and let Mr. Rodgers out of our room.
“Depression with psychotic features,” Dr. Begum concluded. “Who would like to follow this case?” He looked at Tamar, Bruce, and me. Were we the only therapists on the unit? I’d gathered that the social workers did discharge planning and not therapy. I wasn’t sure if Dr. Meyer actually saw patients in addition to supervising. The interns who’d been there before us had spoken about the medical students who were often rotating through and also saw patients. But the others had never clarified what happened when no trainees were around at all. Would there actually be no psychotherapy whatsoever if Bruce and Tamar and I weren’t there? This was not out of line with the medical model, which asserted that abnormal behavior results from physical problems and should be treated with medicine, but even at a hospital it seemed like an extreme position.
“I already have five in my caseload,” said Bruce.
“I do, too,” said Tamar.
And so by default I had my fourth patient. The meeting started to break up. I stayed in my seat and wondered how best to be a therapist to someone whose actions repulsed me. Dr. Meyer and Dr. Winkler stayed, too.
Dr. Meyer advised, “You need to explore his legal situation. Is he malingering to avoid his charges, or does he really have a treatable psychiatric problem? Get his permission to call his wife.”
Dr. Winkler offered, “Wilhelm Reich had a similar history.” Reich was one of the early and more controversial psychoanalysts, a contemporary of Freud’s. “He was overstimulated as a young boy—saw some of the servants in his house doing it. Climbed into bed with his nanny when he was just a kid and started touching her. She let him. Anyway, he used his experiences to develop some interesting ideas. Track the voice Mr. Rodgers is hearing. You’ll know he’s getting better as it starts to become more benign.”
Mr. Rumbert was still not talking, but he was no longer wrapped in a sheet, and he was willing to write. On George’s inpatient unit, psychologists had dedicated rooms in which to do therapy. In the G Building, privacy was one more unattainable luxury, and we only had the dayroom with its big public space. Mr. Rumbert and I faced each other across a dining table. Around us other patients sat silently, maybe just staring or watching TV. Mornings were often quiet, before boredom got the better of people and the ruckuses began. Dressed in a crisply ironed pajama set that appeared brand-new and expensive, with erect posture and the smoothest skin, Mr. Rumbert looked regal in the sunlight, the king of Kings County. “Why am I being held here against my will?” he scribbled in my notebook. It felt odd to respond verbally, but writing back didn’t seem quite right either. I wasn’t selectively mute.
“You’ve been confused. You weren’t taking care of yourself. You stopped eating,” I said. Be specific, T. had directed.
“I’m fine,” he wrote. He let me read that and then continued. “In this blessed land of America we have rights none of which have been given to me. You trap me here. I have no name tag. You pump me full of drugs, you and your Dr. T. Where’s my mother?”
“She’s still in New York. She’ll be visiting. I’m not sure when. You can call her,” I said, though of course that would be impractical as long as he refused to speak. “Or I can,” I added.
“I’m still waiting for you to tell me what’s wrong with me, Doctor. What!” he wrote. I felt a moment’s thrill in being called doctor, even on paper, but then became unnerved by Mr. Rumbert’s airs and his assertions. I knew his diagnosis, but what was he to do with the news that what was wrong with him was schizophrenia, catatonic type? And also his paranoia was contagious: How did I really know there was anything wrong with him? Maybe somehow his behavior made sense—his fasting and his silence and his fear that I might zap him with my eyes.
I tried a line of Dr. T.’s. “Your thoughts have gotten all mixed up,” I said.
He became apoplectic, his mouth falling open, his eyes growing wide. He clearly wanted to exclaim, but he had sworn himself to silence. It was a real bind. He finally settled for raising his hands toward the ceiling, shaking them, and looked up as if to ask God to save him from my inanity. He came back down to the paper and scribbled fur
iously: “What? I never said my thoughts were mixed up! Never!” He looked at me imperiously before putting down my pen and padding off in his bright white socks and his pajamas.
I went to find Hong Hanh. She was in her red sweatpants sitting cross-legged on her bed, as rumpled as Mr. Rumbert was pressed.
“Good morning, Miss Hanh,” I said. “Will you come with me to the dayroom to talk?” I wasn’t sure how we would accomplish a conversation, but we were supposed to do at least twenty minutes of therapy a few times a week with our individual patients, and I had resolved to try despite the obvious barrier. She got up and followed me, and we took seats at a table. “I’d like to get to know you,” I said to her. She looked at me.
“You tell Dr. Win-kler I no need be here?” she asked. I nodded. I had. She continued, “And no need medication. I no want medication.” She was on one antipsychotic or another. Everyone there was.
“Okay,” I said. “I’ll tell him that, too.”
We sat looking at each other. Was there nothing else to say? “Dr. Winkler suggested I ask if we could call your brother,” I said. “Maybe he can help us understand—”
Miss Hanh jumped up from her chair. “No call brother. No. No,” she said. She was shaking her head emphatically.
“Okay,” I said, putting out my hand to signal she should sit back down and collect herself. “No call brother. Don’t worry. I won’t call your brother.”
She sat back down. I smiled at her, and she smiled back. “You have some problems with your brother?” I asked gently.
“No call brother,” she said. “No medication. I no need medication. You tell Dr. Win-kler. No medication.” She stood up. Maybe this was a test. If I relayed her messages faithfully to Dr. Winkler, possibly she would begin to trust me, and that would be the beginning of a beautiful relationship. I would just have to become fluent in Vietnamese first. Hong Hanh walked off back toward her room, and I found Gabriel, which was easy because she had not left her spot by the door. I approached her.
“How are you today, Gabriel?” I asked, pulling up a chair to sit down next to her.
She answered too loudly. “I’m good,” she said. “I’m just thinking, thinking and thoughting. Drinking my coffee, my caffeine, my java.” I knew from my time in CPEP that her slightly odd way of talking was evidence of a thought disorder, one of the hallmarks of both schizophrenia and mania. I was relieved to identify a symptom of a genuine psychiatric problem, even if she was mostly in the G Building because she had nowhere else to go.
“You’re waiting to leave for Kingsboro?” I asked.
“I am,” she said, looking down her nose at me with some suspicion.
“You told me that yesterday, that’s how I know,” I explained.
“Well then, why are you asking again?” Her voice was always a decibel too loud.
“Just trying to make conversation,” I said. She looked back toward the door. “How did you sleep last night?”
“I slept fine.”
“How’s your appetite?” When in doubt, I figured, ask questions about symptoms. They were so impersonal they might not scare her off.
“You’re a nosy one, aren’t you?” asked Gabriel.
“I’m doing a not very good job of trying to get to know you,” I said. Maybe she would respond to self-deprecation.
“You can try, but I’m not going to get too close,” she warned, turning her back and ending our talk.
When I met Dr. Meyer in his office for our first individual supervision, he called Gabriel “blissfully psychotic,” by which I figured he meant that if your life sucked as much as hers did, you were better off being a little bit out of it. He contrasted her with Mr. Rumbert. “There are two emotional states underlying schizophrenia: terror and rage. Figure out where Mr. Rumbert is at any given moment, and help him connect those upsetting feelings to what’s going on in his life,” he said. “You’re on his side. Let him feel that. When he asks you to tell him what’s wrong with him, be as concrete as possible. Remind him again, ‘You stopped eating and speaking. Those are signs that something’s not going right.’ See where he takes it from there.” He said that I could communicate my support to Hong Hanh, too, despite the language barrier. “Look, obviously the situation is not ideal, but you can help her to feel better cared for here just by checking in with her every day. Hopefully, she’ll be your first and last non-English-speaking patient, but she won’t be the only one who thinks she doesn’t need to be here. The first thing to work on with someone like Hong is what went wrong that led to the hospitalization. Until a patient can take in the fact that there is a problem, there can’t be any treatment.”
If the Mafia is out to kidnap you, a locked inpatient unit is a great place to hide out, but try convincing a paranoid woman that she’s safe there. “I want my mother contacted when they take me,” the patient, a Ms. Anders, was declaring loudly and angrily to the treatment team as I took a seat in the morning meeting. I was late because, upstairs, Scott Brent had seen Bruce and me laughing in the hallway and had asked us suspiciously what was going on. Nothing was going on. Caitlin watched the whole interaction from her doorjamb, and when Scott had gone into his office and closed the door, she explained that it was his birthday and that he believed the interns were planning something for him. When we told her that we hadn’t known, and further that we had no plans, she told us that we’d better make some. Bruce and I went into our own office, and I shut the door. Bruce declared, “Oh, good Lord!” which I thought summed things up nicely.
As a group, we interns had months ago identified that Scott had a narcissistic character style. If depressives feel guilty and bad, narcissists feel empty and inferior. Their fragile self-esteem requires constant shoring up. They don’t easily let go of perceived snubs like not being allowed to handpick all the interns or not having their every decision applauded, their every birthday marked. I hadn’t spent four years in a doctoral program in psychology not to know how to placate a narcissist, but the very idea of having to do it exhausted me. Besides, it was a cynical task, this avoidance of slighting him, and I preferred to maintain the belief that Scott was better than that, closer to what I needed him to be, even though there was nothing but my wishing to support this. I told Bruce I couldn’t work up the energy to care about Caitlin’s dramatics and didn’t think that he should either. Instead, feeling burdened, he tracked down Alisa, the most sympathetic of our intern group, and the two of them went to troll East Flatbush for a cake. When I arrived late to the morning meeting, the treatment team, save for Dr. Meyer, was assembled, and Dr. Winkler was gently questioning Ms. Anders, all eyes on her.
“Usually, people kidnap for money. Do you have a lot of money?” he asked.
“No,” she replied, hostility in her voice.
“So why do they want to kidnap you?”
“Hate. They hate me.”
“Are you hearing voices?” he asked.
“This is New York City. There are people talking around me all the time. How would I know if they were just voices?”
“You plug your ears,” he told her. “If the voices you’re hearing don’t get quieter, they’re coming from inside your head, and you’ll know you’re hallucinating.”
“You’re not paying attention,” she told Dr. Winkler. “Everyone here knows I’m going to be kidnapped by the Mafia!”
“No, they don’t,” he said matter-of-factly. Dr. Winkler was the only person I’d ever heard speak to the most chronic psychiatric inpatients as if they were fully human, without condescension or pity or something worse. “Is there anything in your life you’re feeling guilty about?”
“No,” she said. “I have no traffic tickets. I haven’t killed anyone.”
“Did you ever want to kill anyone?”
“Are we done here?” she asked haughtily, standing up.
“Sure, for now,” Dr. Winkler said, nodding toward one of the social workers, who unlocked the door to let Ms. Anders return to her room to await her fate.
<
br /> “Paranoid delusions are preceded by a sense of guilt over some long-ago event that’s been obscured over time, and delusions about the Mafia are very common,” Dr. Winkler told Tamar and me and the two medical students, Steve and Jason, who had joined us on the unit that week. “We need to bring the family in to provide a realistic correction to her fear that they’re in danger. They come in and challenge her thinking, unhinge the whole delusional system. Who wants to follow Ms. Anders’s case?” he asked, and Tamar volunteered.
As another new patient was located outside, Dr. Begum told Tamar and me that one of us would lead the next evaluation. Tamar nodded in assent, and I felt relieved. The little old Caribbean man who was brought in answered her questions about his symptoms and his history succinctly. He was as psychotic as any other patient, but he obviously knew his way around a psychiatric screening. When Tamar had finished, Dr. Begum asked if he had any questions for the team. The patient paused and thought and then asked: “Do American women like to have sex in bed?”
Dr. Begum replied, “Yes, I hear that they do,” and then we all got up from the table to leave. I walked down the hallway to Mr. Rumbert’s room. He’d started speaking aloud again the day before, which turned out to be more trying than his silence.
“How do you know that’s my name?” he asked when I addressed him by his name.
“How do you know my mother came to see me yesterday?” he asked when I inquired about the woman’s visit. It was like trying to talk to a freshman philosophy major who’d just watched the entire Matrix trilogy. When I offered him the chance to correct any misinformation I might have, he became indignant and announced that he wasn’t going to speak again until discharge. I told him this would make it difficult for us to let him go, as T. had taught me to say to ER patients who didn’t want to cooperate.
Brooklyn Zoo Page 17