Maxwell will be my fourth director in only eight years at CPEP. Meet the new boss, same as the old boss. But I am sorry Daniel and I were never able to resolve our differences. We just couldn’t make it work with Lucy gone. We should have forged a friendship in her honor, but the time for that has passed. I’m staying. He’s going. And here comes my new supervisor. Maxwell will be a cinch compared to Daniel, and I won’t be reminded of Lucy’s absence quite so acutely.
All the Rage
Every Friday, I take the 6 train downtown to see my private patients. I am in my Greenwich Village office with a thirtysomething working gal. My practice is packed with them: Single and dating but not finding “the one,” they get more anxious and depressed as they round the corner to forty. Manhattan is full of pharmacies distributing oral contraceptives and antidepressants with my name on the bottle.
We are twenty minutes into our half-hour session; she has her prescriptions and we’re making small talk before I prepare her bill. Her cell phone rings and I motion for her to take it. It’s fine with me, I have paperwork to do.
“Hello?” she asks, tentatively. “No, I can’t talk. I’m with my psychopharmacologist,” she sings, the seven-syllable word trilling from her mouth. There is no secrecy or hesitation in her voice, but rather a sense of entitlement, of gloating: I have one, don’t you have one too? I have become the equivalent of a Prada handbag. A psychopharm is not a therapist, but rather someone who specializes in psychiatric medications. There is no lying down on my couch and talking about your traumatic childhood or what you dreamed last night. I ask you about specific symptoms, and then fix up just the right cocktail to get you back on your feet. One of the reasons I believe so strongly in psychopharmacology is that it works. And it is fast. Good psychotherapy takes years: Personal growth comes slowly; there is no straight trajectory, and it’s not always obvious whether the therapy is working or not. Antidepressants and mood stabilizers help to eradicate many symptoms of psychiatric syndromes. People feel better and their lives become less chaotic when a good combination of medications are chosen and adhered to.
“Don’t ask the barber if you need a haircut.”
This quote was on the wall at Mount Sinai, next to the X-ray light boxes. If asked for an opinion, the radiologist would often recommend another study to follow up the first. A barber makes his money cutting hair. Could you use a trim? Sure! If you have a condition that can be managed medically or surgically, what kind of advice do you think the surgeon will give you?
People who come to me are stressed-out and anxious or depressed. They have concerns about their sleep, their mood, their level of energy and motivation. These things can be ameliorated with medication, and I tell them so. Every once in a while I will still get a patient who is unsure if he should take medication or not. I take a thorough history and an inventory of family diagnoses of mood disorders. I ask for details about any chemical manipulations that have already been experienced (coffee, cigarettes, pot, psychedelic mushrooms, Ecstasy, various prescription medications borrowed from friends) to help me get a sense of what will feel most comfortable.
People have this idea that they have a “chemical imbalance.” That may well be true, but there is no simple test to determine exactly where your balance may be off. I learn about a patient’s symptoms, gene pool, self-medication preferences, and then I synthesize that into a best guess—a medication to start with.
Sometimes I’ll compare what I do to the job of an optometrist who asks, “Better like this? Better like that?” as he takes two minutes to pick out the perfect lens. I do the same thing, but sometimes it takes months as I try different combinations of medications.
I try to assure my patients, “I have a good feel for this, for whatever reason. My intuition helps out, and I usually get it right on the first try. Sometimes we’ll have to try a second medication, or a combination of two medicines, but I’ll aim for happy and relaxed, with a minimum of side effects. It could happen in a few weeks, or a few months, but we’ll get you back to your old self again.”
A patient who believes in me will believe in my ability to heal. That translates into faith in whatever I prescribe, and when this happens, we’re more than halfway there. The placebo effect looms large in all of medicine, but it probably matters most in psychiatry. When I pick a medication, I really try to sell it. It helps that I mostly prescribe the meds I really like, the ones that I’ve seen work like magic.
Typically, a few months down the road, the next talk we have occurs when the patient is feeling better. “How long can I take this for?” The unspoken belief: It’s not okay to take these pills forever. It’s not normal to feel this good. There must be a catch.
It takes some getting used to, the idea that a little pill, swallowed daily, can provide such substantial relief. Some people adjust to this new fact of life, and others fight it. I encourage my patients to stay on their medications for at least six months, to get comfortable with being comfortable. Many people feel better than they’ve ever felt, and that feels awkward. Whether it’s okay to stay medicated or not is a thorny issue. Most people will feel better on meds than off, but there are some instances where prescriptions should provide only short-term relief. I usually offer two different analogies, and let the patients pick the most appropriate one.
“Say you have unequal-length legs. If I give you a shoe with a higher heel, you can walk normally, barely noticing the discrepancy. But when you remove the shoe, you’ll have trouble walking again. If you have a predisposition toward anxiety or depression, medications will relieve your symptoms, but they won’t change your natural tendency. If we stop the medicines, you’ll most likely go back to feeling the way you did before.”
The contrasting analogy I like to use is the “pillow under the butt” scenario: “Say you’re going down a bumpy road in an old jalopy. You feel every rock; you’re practically thrown from the car. The medicine is like a cushion for your seat. You won’t get so derailed by the stressors in your life. Maybe over time your path will become smoother, or maybe through psychotherapy your jalopy will turn into a luxury car with better shock absorbers. Then you won’t need the pillow anymore.”
I have seen over time that the shoe analogy is more apt. My patients stay with me for years, trying various combinations of medications to defend them from their own misfiring chemistry, exacerbated by the pressures of city living. Their paths rarely become smoother, and even if the psychotherapy is terribly successful, they still find that they feel better when they have that extra cushion that medication provides.
So what do we talk about once they’re stable on their regimens and we aren’t making many changes? As a psychopharmacologist, I don’t officially do psychotherapy per se, but there are always important things to talk about even when the medications don’t need to be adjusted. I establish what could be called a “holding environment,” in which to care for my patients. Basically, I try to preach what I practice. I share with my patients what I’ve figured out so far. I urge them to exercise; consistent cardio does wonders for depression and anxiety, I tell them. I remind them to breathe deeply when they’re tense. “Never underestimate the power of oxygen,” I say.
I focus on harm reduction, as opposed to abstinence. People are going to use substances to alter their consciousness—that is simply a fact of life. And life in the Big Apple is fast-paced and overwhelming. My patients work hard, long hours. With cell phones and BlackBerrys, the scarcity of downtime is a common theme. They use food, alcohol, and other drugs to help them relax. Adding shame to their burden is counterproductive. I’m not judgmental when they admit their vices to me, but I will remind them about running and yoga, the Power of Now, and “just doing nothing” as healthier alternatives. I encourage integration of relaxation and contentment into their jam-packed schedules, and I remind them to have fun, lighten up, and stay in the moment.
Our culture, more than most others, has a hard time incorporating pleasure into the daily routine. Indulging our
selves makes us nervous. There is an element of guilt that accompanies fulfilling our own needs, so we binge secretly, quickly. We women, especially, seem uncomfortable nourishing ourselves, and self-neglect is common. We give to others readily, but to ourselves rarely.
Mostly, I’m starting to realize that psychiatry is primarily projected self-care. I give my patients what I can’t seem to fully give myself: attentive nurturing, compassion, gentle understanding. I’m still struggling with many of the basic issues that my patients are, though it’s easier for me and for them to think that I have it all down pat. I don’t let on that I am a wounded healer, as fragile and fallible as anyone else.
The ultimate goal of psychotherapy is self-love and self-acceptance. It is elusive, but I try to model the desired behavior. My own psychotherapist, Mary, taught me to be loving and gentle with myself, mostly by setting an example for me to emulate. She helped me tame my own self-destruction, and now I am carrying her torch, helping others to trade in their masochism in favor of self-preservation. If I can show my patients enough love and acceptance, maybe they can join me in feeling good about themselves. If they think I’m happy and relaxed, it might make it easier for them to try it.
Making healthy choices is an awkward behavior that takes years to master. Not beating yourself up when you slow down is a good first step. Most of my patients are unmercifully hard on themselves. Happy and relaxed feels unearned and undeserved, foreign and frightening. What is more comfortable and familiar is shame, humiliation, and guilt. These are ingrained by family and society. We binge and purge on cycles of indulgence and regret. Gratify yourself, punish yourself.
We dance on the borderline, the shifting boundary of grandiosity and inadequacy. After hubris comes humiliation, when the idealized version of ourselves doesn’t jibe with reality, and those internalized, derisive voices sure can kick us when we’re down. This sets off a rebellious anger that is directed nowhere but inward. Too often, there is no effective defense from the bullying. It simply triggers more self-destructive behavior.
We don’t see what’s clean; we only see what’s dirty, what is contemptible in the eyes of our inner critic. We can focus on improvements yet to be made, yes, but we should also give ourselves credit for our achievements. There is a lot to be said for gratitude, and for accentuating the positive. I remind my patients to appreciate all they have and all they’ve accomplished, to embrace their largesse and abundance instead of focusing on what they fear is missing or imperfect.
My private practice patients are aware of my Bellevue patients. Sometimes I will hear an embarrassing confession, followed by, “Does that sound crazy?”
I’m able to say, “You want crazy? Let me tell you a little story,” before launching into a Bellevue tale to help put things in perspective. I think it helps them to know that I see people who are substantially sicker than they are.
Bellevue is the perfect yang to my Greenwich Village office yin. At CPEP, I am faced with sequential catastrophes as I put out fires. I triage red, yellow, or green and move on to the next disaster. In my office, it’s more about preventative care, like seeing the dentist regularly and being reminded to brush and floss. Waiting until symptoms and problems have reached epic proportions is hardly the optimal time for intervention. At Bellevue, the patients are nearly toothless, to extend the metaphor. I can only do so much in a twenty-minute CPEP interview, and the dysfunctionality of “the system” itself gets in my way. The patients bounce from hospital to shelter to jail to hospital.
In my office, without my cowboy chaps, I am softer, less protected, and more connected. I can inch forward, opening myself up, and have more hope that I can make a difference. And I don’t get burnt out. On the contrary, I get back as much as I give.
At CPEP, I can’t tolerate getting close because the stories are just too intense. The hardships that my patients endure are like an abyss, threatening to engulf me. But I do need to be touching people’s lives more. I am learning that now. I used to think I could never do full-time private practice without CPEP to balance it out. I thought I would get bored.
Now I’m not so sure.
Whatever Gets You Through the Night
I walk into the CPEP to start yet another shift. It is the fall of 2003, my eighth year. The waiting area looks like a precinct: An assortment of irritated, swearing, drunken arrestees are flanked by two uniformed cops each.
The resident has other patients to see and the police cases are rarely educational. All of these guys are mine as far as I’m concerned. This could take most of my night.
When I started in 1996, we were doing pre-arraignment evaluations for Manhattan and the Bronx only. Now we’ve opened up our catchment area to all five boroughs. Anyone arrested in New York City who seems a little off, or happens to be taking any psychotropic medication, has to pass though our doors. These days, nearly half of all the patients coming through CPEP are under arrest. I’m plenty interested in forensics, but there’s just so much cops and robbers a gal can take.
And then there’s the paperwork. Recently, in the name of efficiency, the forms we fill out on each patient have changed. But, like any form made by committee, it’s got even more boxes to check off than before, and it is insufferably long. I’m spending more time writing than I am interviewing, by far. Anyway, enough bellyaching. I gotta get to work.
The loudest patients are always my number one priority. A very large transgender male to female patient, her eyebrows shaped and nails painted, has been brought in screaming and crying. Three pre-arraignments? Make that four.
“Are you ready for this one, Doc?” the cop asks me.
“I was born ready, Sarge,” I volley back. (I like to talk like I’m on television whenever I can.)
“This guy, this lady, whatever. He threw a container of piss at a bus driver!”
I stare at the cop, not sure I heard him right. “Urine?” I ask. “In a container?”
The patient is crying dramatically, “I’m sorry! I’m sorry! Don’t hurt me! Don’t hurt me!”
“Ma’am,” I begin softly. “Miss? Can you tell me what happened?” It is always most polite to address transgender patients in their preferred gender. Clearly this man has gone through a lot of trouble to be appreciated as a woman. It is an easy way for me to convey to him that I get it, I respect his mission.
“Don’t hurt me! Please, don’t hurt me!”
“I’m not going to hurt you. No one here is going to hurt you. We just want you to calm down so we can help you. Can you answer some questions for us?”
“I’m sorry! I’m sorry!”
“Do you know where you are? Can you tell me your name?”
“I’m sorry! Don’t hurt me! I’m sorry!”
Is she psychotic? The cop’s story sounds like she could have been. Or, it could have been more drama than insanity. The way she’s acting now, she seems like she’s stuck inside some sort of dramatic episode, just crying and crying. Maybe something that’s happening now is resonating with a past traumatic event? She’s not obviously hallucinating or paranoid, but she is unable to focus on anything but her misery and so can’t attend to any other stimuli. In that way, you could say that she is broken from reality, and in effect psychotic.
Nancy is the head nurse on with me tonight. She stands before me with her hands on her wide hips, all business. “What you wanna do with this one, Julie?”
“Can we give her Ativan four IM?” I ask, undecided. I’m open to suggestions, as usual, which is why I don’t state it as a command. Nancy takes my request as if it is an order, stated more definitively, which is how we prefer to play it most nights. If she has a problem with my medication order, she won’t shy away from letting me know, though it probably won’t be spoken. Usually, we do a lot of talking in CPEP with our eyebrows, not our mouths.
The patient lets Nancy give her the injection, amazingly. “Good thing she didn’t fight it, cause that is one humongous she-male!” I exclaim, relieved, when we are on the other side of
the glass.
After the Ativan starts to kick in, the patient quiets down, looking around the nondetainable area like a little kid, lost in Wonderland. I assign her to the resident after all, who goes out to get the full story.
“So, what’s her deal?” I ask, putting my feet up on the desk, waiting for the resident to present the case to me.
“Okay, so she was on this bus, right? A ninety-minute bus ride from Rockland down to the city.”
“State hospital Rockland?” I ask, my eyebrows at attention.
“Yeah, but she says she doesn’t go there for treatment. I asked.”
“Good thinking, asking.”
“So, she’s on this long bus ride and she needs to go to the bathroom. But there is no bathroom on the bus, so she asks the bus driver to let her off somewhere, but he won’t. So she went to the back of the bus and urinated into some sort of plastic bottle and then threw it at him ‘cause she was mad at him for not stopping.”
“Okay, well, our job is just to make sure she’s not psychotic, suicidal, or homicidal. So far she’s just assaultive and showing poor judgment, poor impulse control, et cetera.”
“Right. But now, her main concern is that the police are going to abuse her, and she’s afraid of the other prisoners doing the same. The cops are going to take her to central booking, right?”
“I guess so. But they must have a separate area for the transgender prisoners. I know they do at Rikers.” I throw my feet down, and get up from my chair. “Let’s go ask the cops.”
I am amazed at how calm the patient is now. “You see this? This is great!” I open my arms wide toward the becalmed Babe in Toyland. I am trying to teach the resident something. “Ativan four is my favorite first-line med for sedating a triage. The more I use it, the more I like it better than Haldol five and Ativan two. Look at how calm she is! You give five and two, you incapacitate the patient and it makes further interviews and interactions impossible for at least eight hours. I thought for sure we’d have to eat this admission because the cops wouldn’t be able to deal with the screaming and the drama. And I was afraid it’d take a mess of meds to get her quiet, and then she’d sleep for days. The Ativan four really allows her to calm down and get herself together, but not turn her into a zombie. So now, she can leave!” I say this last part excitedly as we are getting closer to the patient’s stretcher.
Weekends at Bellevue Page 26