There is a diaphanous membrane between sane and insane. It is the flimsiest of barriers, and because any one of us can break through at any given time, it scares all of us. We all lie somewhere on the spectrum, and our position can shift gradually or suddenly. There is no predicting which of us will be afflicted with dementia or schizophrenia, who will become incapacitated with depression or panic attacks, or become suicidal, manic, or addicted. None of these states of mind are uncommon, and all of us have friends and family who are suffering with some degree of psychiatric illness. Many of us should be grateful for our relative mental health.
The reality is this: All of us, to some degree, are mentally ill. We get paranoid, anxious, depressed, and insomniac. We alternate between delusions of grandeur and crippling self-doubt, we suffer from paralyzing fears and embarrassing neuroses. We all have compulsions to do things we know we shouldn’t, and there are millions of us with addictions, whether to gambling, drinking, dieting, or playing Second Life. Every one of us has psychiatric symptoms, many of them serious enough to warrant attention, even if they are not incapacitating. But few of us are willing to let on that we are suffering. This secrecy and shame compounds our avoidance of those who have been officially diagnosed as mentally ill. (In family therapy, where the whole family is considered dysfunctional, there is typically one member considered the “identified patient,” who may have a diagnosis or be taking medication, but everyone else in the family is seen as a participant in the dysfunction, too. As in family therapy, so too in the world. Some people may be the “identified patients,” but we should understand that we are all dysfunctional, to some extent, individually and collectively.)
We avoid dealing with psychiatric patients because we hate to see things in others that we don’t want to see in ourselves: weakness, need, despair, aggression. Our experiences with the psychiatrically ill often fill us with dread; they confront us with our own terror of reaching a catastrophically altered state from which there is no return. We should be compassionate to those who stumble out of our lockstep. Yet in our culture, the mentally ill are demonized and shunned. They are ostracized and marginalized as a by-product of our primal fear of going crazy ourselves. It is the nightmare of our own “shadow self,” as Jung called it, that allows us to treat others so harshly.
Families who would typically care for their own turn their backs on children or siblings who have lost their grip on reality. It is too frightening and emotionally draining to tend to their needs. These persistently, chronically ill patients are then left to fend for themselves, relying on the shelters, hospitals, and soup kitchens to become their caretakers—their new makeshift families. This is how America does it. The hospitals and outpatient clinics substitute for the parents, who are unable or unwilling to tend to their own psychiatric casualties. And it is painful, first and foremost for the patients. I learned this simple fact in my first year of residency at Mount Sinai. Rounding on our patients in the ward, we asked a man with schizophrenia if anything was hurting him.
“Yes,” he replied. “My family doesn’t come to see me.”
Not all countries treat their disabled in this way. Jeremy and I took our first trip together to Vietnam in 1996. I could see how differently the Asian people dealt with the mentally ill. The “patients” were kept with their families, absorbed within the community, their impact diluted among its healthier members. I would discover them in the villages, where they were assigned menial jobs and managed and attended to by their peers. It is a better system than ours, which lumps all the mentally ill together and concentrates them in state hospitals, nursing homes, and adult homes, where they feed off the insanity of their neighbors.
Instead of integrating them among us, we shutter our psychiatric patients away so that we will not have to be reminded of all that can go wrong with our own minds and brains. It is unfair, not just to those who are in some way mentally “defective,” but to us all. I have learned a tremendous amount about myself and the world, about what is important in life and in love, by spending time talking to people with broader worldviews than my own, and that certainly includes the patients I have met at Bellevue. Too quickly, we take away the civil liberties of others due to our collective phobia about insanity, and about altered states in general. This is the basic fear that also fuels our war on drugs, and it is shortsighted and impractical.
We are shortchanging ourselves as a culture by not taking better care of our own psyches, and of the psychiatrically wounded among us. But it’s not an easy job, obviously, to fix their wounds. Nearly every shift, I’m asking myself, What do I do with this patient now that he has shown up here in my ER? What does he need from us right now? Unfortunately, the most common answer is: He needs a childhood transplant, he needs to start over—with loving parents this time, in a caring, nurturing environment.
Most psychiatric patients, especially addicts, alcoholics, and criminals, have horrendous histories of neglect and physical and sexual abuse.
Since there’s no way to fix that after the fact, it’s a lot harder to fix them. Many of the addicts and alcoholics that I triage don’t seem all that interested in getting into treatment, or sticking with a program long enough to make real changes in their lives. Letting them sleep in the ER for a night or two rarely works miracles, and one thing I got used to early in the game at Bellevue was seeing some patients over and over: the drunks who’d show up regularly, the crack addicts who’d come in like clockwork when their checks ran out. I learned to regard the revolving door of my workplace with equanimity. I was not going to be able to change a damn thing, more often than not.
“I’m a cog in the machine; I am a spoke in the wheel.” I chant my mantra in front of the nurses as I twirl in a circle, waving my arms like Shiva. Between the bureaucracy of working in a huge city hospital and the recidivism of the patients, I develop my own version of the serenity prayer: Help me learn to accept that I cannot alter the machine, and I will try my hardest to make sure that the machine does not alter me.
Treated and Released
It is June 27, 2005, my last Monday morning sign-out. July first is next week, but just as I planned last winter, I have not re-upped for another year in Bedlam. I am O.T.D.
I often joked that I’d be working at Bellevue until I was a stooped-over, osteoporotic old woman, and when I said it, I usually believed it, but I’ve finally worked my last weekend. I’ve decided to trade in the psychotics for neurotics: I’m going to do full-time private practice. I always assumed I’d stay hospital-based, mired in academia, teaching and performing clinical research, but my path is pulling me in a different direction. I feel as though I’m heading out to pasture, and I’m not even forty.
I tell people that the reason I am leaving is because of Molly; I need to alter my schedule to accommodate hers. She’ll be starting kindergarten in the fall, and we have decided that we’d prefer her to go to school in New York City, which means reversing our schedule and spending our weekdays in the city and our weekends upstate. That in turn means I can’t keep working my weekend shifts at Bellevue, but working weekdays at Bellevue doesn’t make any sense financially. I can work in my private practice three days a week and still spend plenty of time with my family. And I’m starting to feel that I can be a better doctor in my office than I can in the ER, with a chance of effecting real and lasting change in people’s lives.
I’m looking forward to luxuriating in long-term care instead of triage. I see now that I need the follow-up. I need my people to get better and stay better. I’ve done enough triaging and crisis intervention to last a lifetime, and I’m done passing the patient along to another doctor once I’ve arrived at a diagnosis. I want to do the whole job now. In my private practice, once I settle on the right medication to manage symptoms, there are still years of sessions, getting to understand the patient’s situation, unique stresses, struggles with weight, libido, and balancing work and family. Their prescription regimen is often tailored to help weather particular storms, and I
want to be with them, helping them to navigate through the choppy waters, instead of fishing them out of the stormy sea, letting them sleep on the deck, and then dropping them off at the marina to await another boat.
These past few months, knowing I would be leaving CPEP soon, I was constantly on the lookout for reminders about why I was going. Like waiting until after the holidays to break up with a boyfriend, once I knew I was going to end it, it got harder to stick around and easier to rationalize my impending departure. There are countless things I’ve put up with year after year that I won’t miss: more prisoners, more paperwork, more complicated computer maneuvers. They’ve been snowballing over time, getting worse, conveniently, in the few months leading up to my planned escape.
But here’s the thing that is tipping the scales the most: I’ve transformed significantly, and I’m afraid permanently. It’s not you, Bellevue, it’s me; I’ve changed. The combination of motherhood and psychotherapy has brought down a one-two punch that is making me incompatible with emergency psychiatric work. My hormone-fueled maternal instinct blossomed during my stay at the hospital, and I now can’t shrug things off the way I used to.
When I started my job at CPEP, I made a conscious decision to alter my exterior. I inured myself to the tragedy that walked through the doors. That hard-ass persona allowed me to go about my business weekend after weekend. But my three years of psychotherapy with Mary allowed me to see this act for what it was—a defense. And she taught me, through each of my undignified transgressions, that acting this way does not help my patients.
Oscar Wilde says, “Experience is the name everyone gives to their mistakes.” With every mistake, we must surely be learning, right? Maybe I took longer than others, but eventually I did grow from my experiences, and over time, I softened up my rough edges. But those years of therapy left me with some tender patches that were painfully unprotected. My suit of armor didn’t seem to fit like it did before.
And then motherhood came along, further dilating those soft spots. Something about the physical act of giving birth and nurturing two infants had turbocharged my capacity for empathy. My carefully constructed cynicism and distance started to crack. By 2005, I was simply not the same person I was in 1996. I went from being the prison warden to being the den mother. After two pregnancies and four years of nursing, it was a lot harder to pretend I was one of the guys; being butch just didn’t fly anymore. I couldn’t strut around like I used to, keys jangling, invincible. I had adopted a more caring and approachable bedside manner in my private practice, and I couldn’t shift gears gracefully between my two offices, even if I did have two different bags to take there, accessories to my two different personas.
And then, of course, there was September 11. I remember soon after, sitting in a bathtub with Molly. I pictured a huge jet engine roaring through our high-rise apartment building. I could imagine the cockpit crashing into our bathroom, killing us instantly, or worse, killing only her, and it took my breath away. I sat in that tub, clutching her to my chest, breathless and panicked. I could not bear to lose her.
Motherhood taught me about love, and 9/11 taught me about loss. The terrorists showed us all how quickly life could be taken, and how much it could hurt. After that Tuesday, it seemed, I could no longer look at the lives ruined at Bellevue with my usual casual glance. Every one of those patients had a family somewhere, and a mother, which made it exponentially harder to dampen my heartstrings. I couldn’t deliver my news over the telephone to the concerned parents with the same degree of remove, the clinician’s professional level of indifference. Because I was now a parent too, I couldn’t detach like I needed to. I would hang up from a phone call completely drained, full of sorrow for what they’d have to go through in the years to come.
I hated coming home to my kids emotionally wrung out, trying to blot out the memories of the patients I had treated. We’d be at the playground and my kids would be in the sandbox, but I’d be in the hospital—I couldn’t stop reliving what I had seen or done at work. I was having too much bleed-through between my work and home life, regardless of how organized my closet was. No matter which backpack I was carrying, insanity intruded into my life, as it impinges on us all, like it or not.
I have to admit, I never quite found that middle ground between hard and hypersensitive. I know there is a compassionate place well beyond sadism, an expanse of territory way past empathic failure and just short of giving till it hurts, but for the life of me, I can’t find that place when I am at CPEP. Despite Mary’s best efforts, it has remained elusive. I have to simply accept that I can’t manage caring for the patients, for myself, and for my family the way I need to.
It’s time to let someone else take over.
And so, using my family as an excuse, I make my gracious exit.
I try to make my last sign-out memorable, pulling out all the stops, squeezing in jokes wherever I can. When I’m done, there’s an awkward silence. One of the attendings, a woman of course, clears her throat to say a few words.
“As you all know, it’s Doctor Holland’s last day today. She’s been here nine years.”
“Longer than any other CPEP attending,” I chime in. It is an accomplishment I am proud of, and I have joked with the head nurse for months about wanting a plaque to prove it.
“Well, we want to wish you well, of course,” she says, “and also, I feel like someone should say something about Lucy. You’re the last doctor here who actually worked with her, and you were her good friend. You’re our last tie to Lucy, and with you going, it really is the end of an era.”
I did not expect this. No one warned me there would be Lucy talk. I immediately get misty-eyed, which is the last thing I want right now. I want to leave with my head held high, strong, dignified. I swallow hard and think about something, anything, other than my dead friend.
“We’ll really miss your Monday morning sign-outs. It’s not going to be the same around here without you.”
“I’m counting on it,” I choke out.
I leave the nurses’ station and head for the locker room where there are bagels and coffee to celebrate my last day. There are many hugs, and some good stories about my greatest hits, but there is no plaque.
Castles Made of Sand
We arrive at Cape Cod ahead of the Fourth of July traffic—not that I could see any of the cars behind me. Our station wagon is loaded to the brim with clothes, sand toys, and bicycles; the windsurfer is attached to the roof by a tangle of bungee cords.
We’ve been telling Jojo about the beach for days, and even though he is only fifteen months old, he seems to remember this place, somehow. He makes the sign for water as we get out of the car.
The four of us walk around the house to the porch and say hello to the ocean. There is a strong breeze, and there are plenty of sailboats on the bay.
“How about if you set up the windsurfer and I’ll make up the beds?” I offer to Jeremy.
Molly entertains Jojo on the lawn while Jeremy and I unpack the car and start to set up house.
It is early evening by the time the kids are fed, the bags are unpacked, and the beds are made. Jojo is taking a nap, and Molly and Jeremy are changing into their swimsuits. It is time for me to do the thing that I love most at the Cape.
I lug the board down to the beach and attach the sail. My water shoes and gloves, from the shelf above the washing machine in the garage, just where I left them last Labor Day, are dry and crackly, caked with salt and sand, but they soften immediately as I dunk my hands and feet in the shallow water. I nervously scan the ocean floor for critters as I walk the sailboard out into the deeper water. With my back to the wind, I climb onto the board and stand there for a minute, savoring the moment before the sail is pulled up. I can see the house with its wraparound porch, the beach peppered with children digging in the sand. All around me is air and water, sea and sky. I remember to breathe.
I squat down to untangle the rope, composing a sea chantey as I prepare to pull up the sail, ima
gining pirates on a ship singing, “What shall we do with the drunken sailor?” as they hoist the main. Hand over hand I pull on the rope, my weight back, guiding the mast from horizontal to vertical, until I swap the rope for mast and boom. I reposition my feet as I slowly pull the boom toward me, catching the breeze in the sail.
Steering the board with my feet, tilting the mast to assist in the navigation, I snake the windsurfer between the boats still moored in the bay.
As the bay opens up onto the ocean, there are no more sailboats and motorboats to squeeze by. My obstacles are all behind me. It is just the open sea, the breeze, and I.
I tilt my head so my hair blows away from my face. The wind is misty, salty. I inhale the brine deep into my lungs, thinking how the Bellevue AES docs would administer saline intravenously as the first order of business. There is salt in our blood, in our sweat, and in our tears. Even when we are babies inside the womb, we are cushioned in an oceanic haven.
Here, riding on top of the water, harnessing the breeze, the zephyrs stroking my hair, I have found my asylum, my shelter. Whether on a broad reach or a close haul, as long as I stay out at sea, I am alee, safe from the storm. I will not be rained on by debris from explosions; I will not be required to clean up the psychic fallout from the traumas. I have left the land of four-point restraints and medications, of poverty and despair. I am responsible for no one, for none of it. I have no decisions to make that will alter the course of anyone’s life, only the course of my small craft, upwind or down.
Weekends at Bellevue Page 32