A Fatal Debt

by John Gapper

  “Mrs. Shapiro? I’m Dr. Cowper. I’ve just seen your husband and I’ve come to have a chat, if that’s all right.”

  “Thank you, Doctor.”

  Nora twisted her hands together nervously as I sat down by her. She wore an antique silver ring on one finger with an intricate pattern etched on it. It looked as though she’d found it herself in an out-of-the-way shop, not just snapped it up automatically at Tiffany’s. She gazed at me plaintively, as if we were old friends and she trusted my counsel.

  “I thought I should bring Harry in, just in case,” she said. “Was I right?”

  “I’m sure that was best. Can you tell me what worried you?”

  “I don’t know how to describe it. He lost his job, you know. It was so unfair what they did to him. That was last fall. After that, he seemed to deteriorate, to drift out of reach. He got much quieter than he’d been before, and he looked as if he was in pain all the time. He kept on waking up in the night. I sometimes found him pacing around our apartment at three in the morning. He couldn’t stand what had happened.”

  “What made you come here?”

  “We went to East Hampton for the weekend. We’ve got a place out there. I went out for a walk on the beach this afternoon, and when I came back into the house, I heard music from his study. I went through and he was sitting there staring out of the window. He was holding a cocktail glass and …” She rummaged in her handbag. “This was on the table.”

  As she said it, she pulled a shiny object out of her bag and passed it to me. I looked down to find a nickel pistol with a walnut grip lying in my hand. It had a stubby barrel with a notched sight at the end of the barrel. I noticed that it said MADE IN ITALY on the side. It felt cold and heavy, and I almost let it fall to the floor in shock.

  “Pete?” I called, getting up from the waiting room chair with the gun still in my hand and taking a step backward. I rapped on the locked door. Pete opened it and I held the gun out grip first, not aiming it at him. I didn’t know gun etiquette, but I sensed that wouldn’t be the right thing to do.

  “Is this safe?” I asked.

  Pete took the gun and examined it, then slipped a catch and slid the magazine out of the stock. He handed the two parts back to me separately.

  “That’s fine. The safety’s on,” he said. “Beretta Cheetah. Nice weapon.”

  I couldn’t think of a reply to that, so I just nodded and he stepped back inside the ward. I sat next to Nora again and tried to carry on with our conversation as if nothing abnormal had just happened. It was common for Pete to find knives on patients as they came in, but I’d never been handed a gun before.

  “Whose weapon is this, Mrs. Shapiro?”

  “It’s supposed to be mine. I mean, I’ve never used it. I wouldn’t know what to do with it. The permit’s in Harry’s name. There were some break-ins nearby and he said we needed one in case I was alone. He kept it in his study, locked in a drawer-”

  Nora gasped, unable to complete her sentence, and her eyes filled with tears as her pent-up distress overwhelmed her. I felt sorry for her, having to carry this responsibility for a man who’d never needed to be protected before.

  “I need you to store this somewhere safe,” I said. “It’s important that your husband can’t get at it for now.”

  She nodded, still gulping. “I can do that. I’ve got a safe for my jewelry. Harry doesn’t know the combination.”

  “Please put it there right away,” I said, handing her the gun and the magazine and watching her put them back in her bag alongside her makeup and her ordinary things. “You were absolutely right to bring him here.”

  An understatement, of course. A middle-aged white male with several symptoms of major depression including suicidal ideation who’d been drinking and had a gun? Never mind his importance to the hospital and Duncan’s involvement: if that was not a slam-dunk admission for danger to self, nothing was. The women who talked about suicide weren’t generally the ones to be worried about-it was the lone man who never said anything but walked into the woods one day and ended it all. The only issue was whether it would be voluntary or if I would have to commit Harry against his will.

  “You’ve been very understanding, Doctor. I’m so grateful to you,” she said.

  She reached forward and placed her hand on the back of mine. Her palm was warm, and as she rested it there briefly, I could see tears in her eyes. I wished that I could cure her husband for her then and there, but I believed we could bring him back to decent health within a month or two. After excusing myself, I went to check with Maisie. Good news: there was a bed in York East. I dreaded to think of Duncan’s reaction if I’d had to force Harry to bunk in a shared room on Twelve South with a psychotic.

  Some people, however, are hard to please.

  “No fucking way,” Harry responded to my suggestion that he sign himself in. He was still in room four, now standing in his gown. It trailed halfway down his legs, leaving his calves bare, and his shiver had gotten worse.

  “Mr. Shapiro, I do understand your feelings, but I’m in no doubt that it’s best for you to be admitted so we can help you immediately.”

  “What if I refuse?” he said, glaring truculently at me.

  It was a tough question, to which the true answer was: I’ll have to lock you up. I tried to phrase it more gently. “To be honest, I’m very concerned about your state of health, and it’s my duty to protect you. We do have powers to admit you involuntarily.”

  “That sounds like a threat,” he said, his nostrils flaring.

  “I wouldn’t put it that way,” I said soothingly. “I really do think it is best, for all sorts of reasons, for you to be with us. Your wife told me that she found you with a gun this afternoon, and that concerns me greatly.”

  I hoped that my mention of the weapon might extract the truth about what he’d been thinking in that room, but he didn’t respond directly. His head dipped until it hung limply between his shoulders. He sighed, the fight leaving him.

  “I need to talk to Nora,” he said.

  Ten minutes later, the deal was done and I was on the phone to the charge nurse in York East. We didn’t send ER patients up with a full report, just a summary of the initial diagnosis and a mental status exam. Danger to self, danger to others, unable to care for self-whatever was our reason to admit them to a closed ward, rather than just send them away with some pills and an outpatient appointment. When they were assigned to an attending and a team resident, they would be examined again. My job was almost done.

  “I’m admitting a fifty-eight-year-old male with a differential diagnosis of adjustment disorder with anxiety and depressed mood, or major depression,” I said, running briefly through Harry’s symptoms and affect. “His spouse is supportive and will visit tomorrow.”

  Stepping outside, I saw Pete pushing Harry in a wheelchair toward the elevators as Nora watched their retreat. Everyone we signed in was wheeled up to the wards with their notes on their laps to make it harder for them to escape on the way. It was the last I thought I’d see of him.

  3

  There were plenty of others like Harry around that time. Not as well-known or as powerful, with their names carved on the hospital’s walls, but all with the same crushed and baffled air of highfliers who’d fallen to earth.

  When I’d been a resident, I didn’t know how many cases I’d treat of clinical narcissism, but suddenly it was all around me. We were taught about a condition called narcissistic injury, a blow to the egos of the self-centered and manipulative. Their personalities had been formed by a parent they’d been able to please only with achievement, who’d never given them unconditional love. Wall Street must lure such people because the hospital was full of them-all wanting special treatment, claiming to know more than I did about therapy, and generally being insufferable.

  To have their status stripped away was a terrible blow. They came through the ER and the clinic in agony after the crash had triggered their plummet into anxiety or depression. Th
ey sat silently by themselves, pale-faced and shaking, their brains whirring to make sense of how it had all gone wrong. One thing was clear: They didn’t want to be treated by a thirty-three-year-old psych a couple of years out of residency. I looked too young, although I was as old as some of them. I wasn’t important enough.

  One of them, a man in his thirties who’d run a real estate fund on Madison Avenue, had been there a couple of weeks before Harry. The fund had $2 billion at its height but was down to nothing, being squeezed by the banks that had lent him money. A friend of his brought him in one night after fetching him from a hotel room where he’d holed up, high on Ketel One vodka and cocaine, screaming at the room service waiter. I’d admitted him, but the next day, sobered up, he wouldn’t look at me. He’d demanded to see a real doctor.

  Which was why, when I returned on Monday for morning rounds on Twelve South, I didn’t expect to be paged by Jim Whitehead, the York East unit chief and head of inpatient psychiatry. I couldn’t afford to alienate Jim if I wanted to get on in my career, but when I called him back, he sounded irritated.

  “I have a patient here who’d like to be seen by you, Doctor,” he said formally. “Mr. Shapiro.”

  Jim was tall and solemn and had stiff black hair with a few gray flecks distributed throughout: even those were carefully delineated. His shirt and suit were always clean and pressed, as if dirt and crumbs slid off them. It beats me how he kept pin-sharp creases in his pants despite being seated for most of the day. When not on York East, he had a lucrative private practice into which he gathered quite a few of his Episcopal patients. He probably wants to shift Harry over there, I thought, and doesn’t want me in the way.

  Despite Jim’s mood and the difficulties I feared it could cause me, the news that Harry had asked for me gave me a thrill that I tried to keep out of my voice. I’d thought of Harry a few times that weekend and had even let myself fantasize briefly about him becoming my patient-hadn’t Nora hinted she wanted that? Despite his temper, Harry had many attractive qualities. He was wealthy and well known, and having the whole wing named after him made him a trophy asset that other doctors would covet. Besides that, he was intriguing. There was another story there, behind the headlines, which I wanted to hear. Best of all, I was confident that I could help him, since middle-aged depression is highly treatable. My fantasy was coming true.

  I left the Twelve South residents to get on with running things and made my way out of the ward, unlocking and relocking the secure double doors with the jangling bunch of keys that hung at my belt. We referred to patients slipping out as “elopement” rather than “escape,” as if it were a romantic adventure, but I felt like a jailer. York East was one floor up, with a view over the river toward a new condominium block in Long Island City topped by a sign that said FOR RENT. I found Jim in his office by the ward, reading notes on the clipboard he always carried with him. I walked in and sat in front of his desk.

  “Mr. Shapiro?” I said.

  Jim carefully finished what he was doing before looking up, signaling that he wasn’t going to be distracted by the affair. “Mr. Shapiro,” he said before waiting silently, as if his job were to listen and mine were to explain.

  “I don’t know very much about the case, I’m afraid. I admitted him from the ER on Friday. Danger to self. It was the first time I’d seen him, so I’m surprised he’s asked for me. Has he been assessed?”

  Jim furrowed his brow, which was as close as he got to an open display of annoyance.

  “Not for want of trying,” he said. “I was told of his admission on Friday night and I came by on Saturday morning so we could start treatment immediately. It sounded as if he was in distress.”

  So Jim came in on a Saturday, I thought. Not many patients got that treatment. Harry had been unhappy, but so were most of those who got admitted to the ER on Friday night-just as the psychs were leaving for the weekend. With the nurses watching them, there was no need to hurry, so they had to sit it out on the wards until Monday with tranquilizers to soothe them. Yet Jim had taken the time to see Harry the morning after his admission. Either Sarah Duncan had made him give our new inpatient the VIP treatment or he’d spotted the potential in Harry himself.

  “He wasn’t cooperative?”

  “When I arrived, his wife was with him and they wanted privacy. I came back yesterday, but Mrs. Shapiro said he’d wait to see you today. She apologized, but said it was typical. He always puts his trust in a small circle of people, and he’s taken a liking to you, it seems.”

  “Interesting,” I said, trying to portray Harry’s rejection of Jim as an insight into his personality we could examine together. But Jim still looked irked. Harry was used to others being at his beck and call, I imagined. He probably hadn’t noticed the significance of Jim’s arrival to see him on the weekend.

  “There we are,” Jim said, looking at his watch. “I’m due in Westchester early this afternoon. I’ll leave him in your hands.”

  We had a facility in the New York suburbs for the well-off who wanted to recuperate in more bucolic surroundings. I’d wondered on Friday whether to send Harry there, but it had been late.

  Jim unlocked the unit and guided me to Harry’s room, which was about the best we had at Episcopal-the medical equivalent of a penthouse suite. It had a wider bed than the cots on Twelve South and a couple of soft chairs in institutional brown next to a window that overlooked the East River. Harry was pacing up and down by them, clenching and unclenching a fist. He was wearing a crisp monogrammed shirt and looked livelier, but his expression wasn’t any more welcoming.

  “Dr. Cowper has arrived, Mr. Shapiro. I’ll let you two have a talk,” Jim said, and he slipped back out. I heard the door to the ward click shut as he left.

  “Hello, Mr. Shapiro. How are you feeling?” I said.

  Harry glowered at me, his eyes burning.

  “I want to leave,” he said quietly.

  “I see. Well, let’s talk about that,” I said, crossing to his side of the room and taking one of the chairs.

  He briefly stood there glaring before sitting opposite me. It was a lovely morning and the sun was casting a square of light on the floor. There were many worse places to get stranded-an airport, a police station-but his reaction was typical of people who woke up in a secure ward after being persuaded to sign in. They found themselves locked up, with sharp objects removed for safety, needing to ask permission for anything, and they went crazy if they weren’t in that condition already. I glanced at Harry’s notes. There was little there but a scrip for Klonopin, a longer-lasting tranquilizer than the Ativan I’d given out in the ER. His mental status had not been fully assessed, and he hadn’t been interviewed about his history or started on antidepressants. The only psych he’d talked to at length remained me, on Friday night.

  “How have you been sleeping?” I said.

  “I want to leave,” he repeated slowly, as if I hadn’t listened the first time. I found it hard to hold his intense gaze.

  I tried to prevaricate. “I know it must be difficult to be here, but I think it’s a good idea to talk so I can get a sense of how you are. Then we can start on treatment and you can leave, maybe in a day or two. We don’t want to keep you in here any longer than you’re comfortable with, believe me.”

  Harry flinched with irritation and got up to stare out of the window. “I don’t think you heard what I said,” he growled over his shoulder.

  I didn’t like what I was seeing. Harry was just as moody as he’d been in the ER, but more agitated, which was a bad combination. Patients who are very depressed may think of killing themselves, but they lack the energy to do it. The trickiest moment is when they start to feel slightly better and more capable of action. He was also angry, which was worrying. Suicide is an act of hostility, not only to the suicide victim himself, but also to the person he blames for his plight.

  All in all, I wasn’t inclined to release Harry before he had stabilized and I had a better sense of what was going on in
his head. Legally, I was in a far stronger position than he. Having signed himself in, he could petition to be let out at any time. But the hospital was allowed to hold him for seventy-two hours before his lawyers could spring him. It would be a disaster if things got that far, given that Harry had paid for the wing in which he was incarcerated, but I didn’t imagine that it would. Three days would be plenty as long as he calmed down.

  “What worries you about being here?”

  “I can’t sleep,” he said, turning to me. “The bed’s uncomfortable, the blankets are thin, I was cold all night. The traffic noise kept me awake. I’m fine, don’t you understand? There’s nothing wrong with me.”

  I listened to the buzz of the cars on the FDR Drive. It sounded pretty routine for New York, and fainter than the noise in my own apartment, but that wasn’t the point. Anxiety and wealth had made Harry hypersensitive. The thread count on the grayish sheets was lower than he was used to, and there was no goose-down duvet. He wouldn’t have noticed either if he’d been at ease.

  “I’m sorry, Mr. Shapiro. Perhaps we can discuss all this with your wife and make a discharge plan. We’ll try to agree on a way forward.”

  Harry gave a cynical grunt, but he at least agreed to wait for Nora. On the way back to Twelve South, I considered my predicament. Jim’s escape to Westchester had put me in charge of Harry, and he was becoming a difficult assignment despite my earlier wish to get hold of him. I couldn’t in good conscience let him out immediately, but he had a lot more power than most patients-and no compunction about using it.

  My best hope, I thought, was Nora.

  An hour later I was standing in what we generously called the library, a room with a sprinkling of books and a computer on which patients could send email, listening to Lydia Petrovsky, a birdlike patient who had been with us for a week. Unlike Harry, she showed no sign of wanting to leave-quite the opposite-but her insurer was threatening to withdraw coverage and the finance department wanted her out. As I was trying to persuade her to go back to her apartment and attend the day clinic, my pager vibrated with a summons to see the president.