by Samuel Shem
‘Yeah, but the thing is, maybe he’s right. The theory, I mean.’
‘You, gay?’
‘Latent gay? Gay-latent? Like they say – “there’s a kernel of truth, in every Wheaties flake”?’
And yet Blair’s assaults on Solini and me were fairly benign compared to what he did the next week in Case Conference to Hannah Silver.
Hannah was having a terrible time downstairs in BPO with D. Her patients, still devastated by Ike’s suicide and its denial, taken off their antidepressants and put on God knows what, had gotten more depressed. Hannah and the staff were stretched to their limits, trying to keep suicide attempts to a minimum. Hannah was unskilled at drawing bloods for the Department of Defense study, and whenever one of her depressed patients, arms bruised the color of ripe plums, saw her approach, all hell broke loose. She insisted that Win Winthrop draw the bloods. He readily agreed, but the combination of his butcher’s touch with his preacher’s zeal sent Hannah’s patients spinning even more quickly down that ever-constricting spiral through depression toward suicidal despair.
There was one bright spot in Hannah’s world: Mary Megan Scorato. She had mostly recovered from her blast of Placedon. Malik had called in a lawyer and written an ironclad document to prevent her from partaking in the Placedon-Zephyrill drugfest. With Malik’s help, Hannah had formed a strong, empathic bond with Mary. Depression was familiar to both of them. Occasionally I’d see them together walking the grounds, and if I hadn’t known them, I would not have been able to tell which was the doctor and which the patient. Their lively chatter back and forth was warm and friendly. The weekend before the conference, as a trial run before discharge, Mary Megan had gone home on an overnight. Hannah, concerned about her potential for harming herself, had had Mary phone her on Saturday and Sunday to let her know how things were going. Hannah had high hopes that the Case Conference would help Mary plan for discharge.
In the conference, Heiler, trying to mobilize the latent rage in Mary, failed miserably. No attack provoked anger. In fact, his escalating assaults brought an enshrouding silence. She sat there still as a stone. Finally Blair said, ‘Yeah, and I hear you were knocked up when you were seventeen.’
She jumped, and then settled. Picking at the red scar on her wrist, she said, softly, ‘That is a private matter.’
‘Why?’ No answer. ‘Why!’
Mary was silent, but her knuckles were white. She seemed paralyzed, imploded into a psychic hell. The slight smile on her face resembled the illusion of a smile you sometimes see, if the muscles clench right, on the face of a corpse.
Blair said Mary Megan could leave. With the gait of a marionette, she did.
Pissed off, Blair attacked Hannah. ‘Your being “kind” to her,’ he said, ‘isn’t fair to her. Don’t you get it? This is a BPO with USA!’
‘USA?’ the BMS medical student asked in a wheezing voice.
‘Unsuccessful Suicide Attempt. Because of you, Dr Silver, that sweet lady’s about to go down the tubes. You had her call you on the phone?’
Hannah looked down at her own clasped hands and nodded.
‘That’s the worst thing you could have done. Let’s talk phone calls.’
At the blackboard, Heiler wrote BORDERLINE PHONE CALL, with stick figures of patient and therapist – SELF and OBJECT – holding tiny telephones to stick ears. ‘You tell your borderline to feel free to call you at home.’ He wrote:
A) FEEL FREE TO CALL ME AT HOME.
‘When they call you at home,’ he went on, ‘you say’ – and he wrote:
B) WHY ARE YOU CALLING ME AT HOME?
‘When they say “Because you told me to call you,” you say’:
C) YES BUT WHY ARE YOU CALLING ME?
‘When they say “Because I’m upset,” you say’:
D) YES BUT WHY ARE YOU CALLING ME?
‘And continue,’ he said, ‘until they hang up. Not only is this getting them to take responsibility for themselves, but remember – you never know what these borderlines are doing while they’re talking to you on the phone.’
‘What could they be doing?’ the BMS student asked innocently.
‘Masturbating. Talking to you, and masturbating like crazy.’
The med student began wheezing uncontrollably. He reached into his pockets. His face got red. Shit, I thought, we’re gonna have to do mouth-to-mouth. But then he found his inhaler and, pumping it, he left.
‘In short, Dr Silver,’ Blair said, ‘you suck.’ He left.
Solini and I thought Hannah would be devastated, but she was calm. ‘He’s the expert,’ she said. ‘Studies have shown that SELF psychology works. I guess I’m not getting anywhere with her, really.’
‘But that’s crazy,’ I said. ‘If you were his patient, and you were upset, would you call him for support?’
Immediately her eyes rolled up to the recessed lighting. ‘Of course not, Roy, that’s the whole point. Now that I’m in analysis again I understand.’ Hannah had had a consultation with Schlomo Dove, who told her: ‘You are like the sun, giving your warmth away to others, leaving yourself cold and empty,’ and then hooked her right up with the perfect analyst, Dr Ed Slapadek, rumored to be so tough that he made Blair Heiler look like the Easter Bunny. Hannah smoothed out her dress. It was light cotton, and covered with the kinds of tiny and bright flowers that often graced Heiler’s Liberty of London ties. There was new lift in the zone of her breasts, as if one of those postmodern Wonderbras was lifting flesh all the way from those hips.
‘New dress, Hannah-babe?’ She blushed and nodded.
‘Gotta run,’ she said. ‘I’ve got supervision with Blair.’
After a few weeks of the Borderline Theory, our patients were doing their best to act like borderlines. They were all worse, much worse – cutting, slashing, smashing, bashing, and sexualizing with a celestial fury which, turned on the Heiler spindle, meant they were better. It was Borderline City.
My most difficult patient was Zoe. Continuing to binge and purge and jog in the ravaging heat, in therapy she would point out how I’d missed the point and that the real point was that I was too distant, cool, and incompetent. ‘I want a new therapist,’ she’d say to me. ‘I want Dr Heiler.’
The worst was one day, as I was sitting in the living room, she assaulted me in front of the other patients, screaming, ‘Asshole! Hey, everybody, see this guy? He’s my therapist and he’s an asshole!’
I sat there fuming, not knowing how to respond. Then I noticed Blair Heiler, watching from the doorway. He took a first kick-step into the jungle of borderlines, and all hell broke loose. He reached his office door, turned, and said, ‘You poor sonsabitches,’ and closed the door behind him.
Later that day, with Henry and Hannah in supervision with Blair, he smiled at me and reached his elegant, long-fingered hand across his power desk to mine.
‘Glad to see you’re finally getting the hang of this, Roy.’
‘But she hates me,’ I said, surprised at his being so nice to me.
‘Great, just great,’ he said, pointing out that while Zoe had often called me ‘jerk’ and ‘incompetent,’ this was my first ‘asshole.’
‘Easy for you to say. She loves you. Hates me, and loves you.’
‘She’s splitting.’
‘What’s “splitting”?’
‘Krotkey Factor Number Four.’ He went to a blackboard and did stick figures.
Splitting was so complex that I was soon lost in the childlike scribbles. In the center, with bald head and glasses, Blair wrote Dr RENALDO KROTKEY = BORDERLINE GENIUS. On either side were a tiny stick figure with diapers, labeled BORDERLINE BABY = SELF, and a large, strangely imposing stick figure with comically large breasts, who turned out to be BORDERLINE MOM = OBJECT. Blair took the eraser and split MOM vertically into two parts, which he labeled GOOD MOM and BAD MOM. I didn’t understand much of this, except that it was classic KROTKEY and that BABY SELF could not contain all the rage it felt in its stick body at OBJECT MOM, and so,
in order to achieve OBJECT CONSTANCY and keep MOM in one piece, it had to split MOM into two pieces – GOOD MOM and BAD MOM – and love GOOD MOM and hate BAD.
‘I’m the GOOD MOM,’ Heiler said, ‘you’re the BAD, you poor bastard.’
‘Why?’ I asked, using Blair’s favorite confrontational word.
‘Good question. Because the MOMs of borderlines are so screwed up.’
‘Why are these MOMs different?’ Hannah asked.
‘Oh God,’ Blair said, as if this were the dumbest question ever. ‘The sicker the person, the earlier in life the damage was done. The damage done you two guys – your being so “nice”?’ Solini and I looked at each other. ‘You got to about age three before you took the hit. Borderlines are so sick, they take the hit earlier, in the first year of life.’
‘How do you know that?’ I asked.
‘They had to be damaged that early, to be so sick! Whose fault is it?’ He drew a box around MOM. ‘MOM’s fault. MOM won’t let the borderline separate from her, become a SELF-sufficient SELF and treat others like OBJECTS. The borderline tries to suck MOM’s tits dry.’
‘Which is why Zoe treats me as BAD MOM and you as GOOD MOM?’
‘That, and because you’re doing a terrible job with her by being “nice.”’
‘But what do I do about it?’
‘Treat her worse.’
‘And she’ll like me better?’
‘Ahh, women,’ he said, staring at Hannah as if she were a specimen. ‘Treat ’em worse, they love you better. An eternal truth. Stop trying to be a nice guy and she’ll split the other way.’
‘I’ll be GOOD MOM and you’ll be BAD?’
‘Guaranteed.’
‘That’s crazy!’
‘No, that’s Krotkey.’ He sighed in admiration. ‘A man who never took a hit. Totally undamaged. A genius.’
‘But Malik says that—’
‘Malik finishes training in July. Do you know where Malik will be then?’
‘No, where?’
‘Neither does he, and neither does anybody else. But it won’t be here at Misery. Malik’s a pussy.’ An Asian woman came in and placed a ribbon of computer sheets on Blair’s desk. ‘Preliminary data on Placedon and Zephyrill.’
‘Already, man?’ Solini asked.
‘You’ve got to publish the preliminary before they beat you to it. Borderline work is dog-eat-dog. Lotta sonsabitches. You guys’ll want to join my research team, get your names on my papers, start those careers.’
‘But about Zoe,’ I said, ‘I don’t think I can be nasty.’
‘Sure you can. It’s in you, and it’s fun. To think only of your SELF? To get out your anger at OBJECTS? It’s the greatest. Mind you,’ he said, with a wink, ‘healthy narcissism can be hard for some OBJECTS to take.’
‘But won’t my being SELF-centered get in the way of relating to others?’
‘No. Relating to others will get in the way of your SELF. Get a SELF, then get yourSELF a sexy OBJECT.’ On the blackboard he wrote: SELF = SEX. MORE SELF = MORE SEX. He chuckled. ‘Yes, yes, narcissism is what made this country what it is today.’ His eyes shone proudly. For a second it seemed he might cry, with pride. ‘My dad, a major general, taught me that.’
Jesus, I thought, the guy has a heart after all.
‘Healthy narcissism, Renaldo Krotkey. The American Dream.’
It was all I could do to keep from saluting.
‘Now then,’ Blair said, snapping back from pride and glory. ‘Solini?’
‘Sir?’ Henry sat up, expecting to be reamed out as a gay-latent all over again. But Blair reached over and shook his hand. ‘Glad to see that Thorny your dickhead is doing worse.’
‘Thanks, sir. But he thinks he’s doing like better?’
‘Never accept a borderline’s reality as real.’
‘But I’m worried. He’s talking pretty well to OBJECTS like me and Roy.’
‘Maybe he is,’ Blair said, ‘to real OBJECTS. I’m talking internal OBJECTS, people inside his head. We physicians are smarter than that. The more intelligent the person, the higher the graduate degree, the less concerned with reality. Don’t quote me on that, but as a rule of thumb. So don’t be “nice” to him, eh?’
Solini pledged that he would not, and we waited for Heiler to turn to Hannah and her great work down in Depression where all her patients were so terrifically worse – especially her favorite, Mary Megan Scorato, who was on five-minute checks for suicide – that we thought that rather than a handshake she’d get a small medal. To our surprise Blair totally ignored her. Her face fell.
‘Because you guys are getting the hang of this,’ he said, ‘I’m going to teach you the most important and delicate matter in all of psychiatry – harder than borderlines, more intellectually challenging than research.’ He walked to the blackboard and drew a stick building. ‘Pick a city – say Boston. What are the two biggest buildings in Boston?’
‘The Prudential,’ I said, ‘and the John Hancock.’
‘INSURANCE,’ he said, writing it in caps. ‘INSURANCE bastards. Biggest buildings, biggest profit margins on earth. The cocksuckers.’
Heiler proceeded to give his most complex lecture. Stick figures represented DCTORS, PATIENTS, and, in the stick building, stick INSURANCE executives with dollar signs ($ $) where their eyes should have been. Basically it was about how, for each patient, you had to make up multiple DSM diagnoses to dupe INSURANCE and transfer some of the dollars from the INSURANCE executives’ eyes to the DOCTORS’ pockets. He concluded, ‘Every single day, we doctors have to make sure our patients are sick enough to stay in the hospital, but not so sick that INSURANCE says they’re not improving and have to be discharged. Sick, but getting well. Getting well, but still bad. Bad, but getting better.’
‘Which is worse,’ Solini said.
‘Which is,’ I said, ‘in fact better.’ Blair laughed. That charming laugh.
‘So we have to keep them acutely chronic?’ Hannah asked.
‘No, chronically acute,’ Blair said coldly. ‘Welcome to mental health care in America, folks. It sucks, and I want you guys to start doing it.’
‘Doing what, man?’
‘INSURANCE rounds. Stop talking to patients, start talking to INSURANCE.’
‘You want us to not see patients?’ I asked pointedly.
‘Not seeing them is seeing them – part of Borderline Technique. Think I don’t know how infuriating it is for them to try to catch me to talk? Drives ’em nuts. They go ballistic, start acting like they’re guzzling rocket fuel. Which lets ’em stay here longer, long enough to shift from BAD OBJECTS to GOOD.’ He flicked a blond forelock and downshifted to his Huck Finn aw-gosh mode. ‘Look, guys, I know that sometimes I seem uncaring. But it’s because I really care for these borderlines. For them to get better, I have to confront them all the time, and to do that I have to keep them here as long as possible. It’s hard to change a borderline. Most psychiatrists won’t even try. They hear the word “borderline,” they run like hell. There are only a few of us left who are fighting to take the time and energy to do it right. Think I like spending four hours a day on the phone to these high school dipshits in fucked-up places like Omaha and Toledo telling me they’re gonna discharge my borderlines because they’re not sick enough? I do it to give these borderlines the time they need. I do it because I care.’
Oh my God, I thought, underneath all this, he’s nice?
‘I care enough,’ Blair went on, ‘to let these darn borderlines stay here and take all the time they need to get worse.’
‘But most of them don’t want to stay,’ Hannah said. ‘They want out.’
‘Of course they want out,’ Blair said derisively, ‘they’re borderlines.’
He dismissed us. Henry, Hannah, and I stood dazed in the lobby.
‘He’s crazy,’ I said. ‘And cruel.’
‘It seems cruel,’ Hannah said, ‘but he’s an expert in cruelty to this kind of patient. What do we know? I’ve got t
o believe Blair knows what he’s doing. Don’t you have the sense that underneath it all he’s a sweetheart?’
Neither Henry nor I said that we had that sense.
‘Well, I do. He comes on tough in public, but behind the closed doors of an office, no-one knows what goes on. I bet his patients adore him.’
‘No foolin’,’ Solini said, ‘he’s probably fucking ’em all on that desk.’
‘Lucky them,’ Hannah blurted out. Then she blushed and said, ‘Oh gosh.’
Why do men follow leaders?
Without realizing it, trying all the while not to try it, as gradually and inevitably as the turning of summer toward fall where from day to day you can’t really see the changes but one day you wake up chilled, your throat scratchy, the air crisp, chilled, not only almost fall but even containing the seeds of winter, we began to be affected by the Heiler machine.
How could we not be? Given the ferocity of the patients, and the vagueness of psychiatry in dealing with such definite ferocity, we felt constantly under attack, constantly criticized, constantly made to feel we were failing, that compared to Heiler and a lot of other experts we were simply inadequate, as psychiatrists and as human beings. Faced with these violent, raging people, what were we supposed to do? It wasn’t like treating someone with a broken bone, where you took an X ray and saw the crack and followed the manual on how to set it. Here there were no white bones and black cracks. Here there were spectra of color with no edge between one color and another, and if you took an X ray you’d see pitch-black. In the chaotic gray of emotional pain, we needed something definite, something that would show us what to do.
Blair Heiler, in the hell of Emerson that he had created, was strangely comforting.
Especially after Malik, after the vagueness of Malik who gave us no THEORY except to be human and who was always asking us to keep asking questions and telling us that our innocence was our power and our way of empowering our patients who were not OBJECTS to us but much like us, in being, basically, human beings – it was comforting to have some certainty, for the one thing you could say about Blair was that he was certain. There were no shadows in his sun. Follow Heiler, and you knew what to do. You never had to think. Heilerized, we could be certain of ourSELVES. Certain of ourSELVES, what did it matter that our patients, our OBJECTS, seemed so uncertain, so stuck? Given Heiler logic, stuck could be unstuck, could it not? Heiler was marching music, stirring up feelings of high school glory when I, trombonist in the Columbia High Fish Hawk Marching Band, would blast out ‘The Dominator’ and kick my legs out and move swiftly through ‘Semper Fidelis’ up from the river to the cemetery for the Gettysburg. Heiler was Sousa; Malik was all Ravel.