On G8-East, an inpatient psychiatry unit at the West Haven VA hospital, it was time for team meeting. I scribbled the last of my therapy notes, tucked the pen and notebook under my arm, grabbed my sweater, and slipped a loaded key ring over my wrist. With a well-practiced, one-handed move I lifted a square, chrome-colored key from the bunch and twisted it into the lock to secure my office. In the hall, I used the brass key to let myself onto the ward.
“Good morning!” I said, smiling at an unshaven young man shuffling by. I listened for the lock-click behind me before moving on.
In the conference room I settled in with my team. Dr. Balkan, our ward chief, and Dr. Brett, our psychologist sat at one end of an imposing rectangular table. The rest of us — nurses along with psychologists and psychiatrists in training — found seats among the remaining chairs. Someone had written the date on a blackboard covering the wall behind Dr. Balkan. On the wall across from where I sat, large windows looked into a blue winter sky. Morning sun shining on yellow-beige paint made the room bright and a little too hot.
Hiding my past proved a full-time job in itself.
We were discussing Paul, a new admission. Unlike most of the young veterans on 8-East, Paul hadn’t served in Vietnam. He’d been too disturbed to complete Army basic training. Before his admission he’d been seeing a private therapist, which was also uncommon in this setting.
Paul’s mother had brought him to the Emergency Room after he’d told her that voices in his head were ordering him to kill himself. Our task was to evaluate his condition, then come up with a diagnosis and a treatment plan — a combination of psychotherapy, medication, and things like occupational therapy and groups, even family therapy — that would reduce his symptoms and help him develop better skills for managing his life. The fact that he had a private therapist meant we would try even harder than usual to prove we could do a good job.
I was a clinical psychology intern, part of the staff. With my own set of keys I could come and go from the ward whenever I pleased. I met with all but the most uncontrollable of my patients in my office, one of four just outside the ward’s locked metal door. This reflected quite a turnaround for a woman who had spent more than five years of her life locked behind the same sort of door.
Hiding my past proved a full-time job in itself. I loved being called “Dr. Sawyer,” but discussing restrictions, passes, and medications — or inhaling the antiseptic smell of alcohol when I passed the treatment room — reminded me of my own locked-ward days, and for an instant I’d feel terrified, thinking I was a patient again. I worried I was a fraud. Debating philosophy or Freud’s theories with other trainees, in our nice suits, skirts, and slacks, was like riding a toboggan down a steep hill — the sweet joy of flying, coupled always with fear of a crash. When I hung out in the day-room playing pool with scruffy veterans, I felt much more at home.
Ironically, my secret knowledge also made me feel superior. Transparent jerks, I thought when I heard insecure psychiatry residents make snide comments about patients. Those were often the same doctors who wanted to make sure I knew that their status ranked higher than mine. They tried to show me how smart they were by using Latin terms for situations or procedures with ordinary names, or by correcting me in a condescending way if I mispronounced a particular term or drug. Some told mental-hospital jokes or mimicked weird things their patients had said. As if having contempt for disturbed thinking somehow proved they were sane.
I’d just turned seventeen when I was first admitted to a mental hospital. Shy, frightened, and suicidal, I was diagnosed with schizophrenia, a popular diagnosis in 1960, and given shock treatment, also common at the time. But I grew worse, not better. Three years later, after several more series of shock treatments, I was transferred to a second hospital, “unimproved.” By then I’d lost almost all memory of my first twenty years.
At the new hospital they used psychotherapy, not shock treatment, which to me was a godsend, but I was sure my psychiatrist didn’t like me. I couldn’t think of anything to say when I was with him. Therapy went nowhere.
Stout, stodgy Dr. Martin always looked tense, his shoulders hunched, his eyes scanning the scene as if on high alert — maybe in a jungle anticipating attacks by natives lurking in the bushes. He rarely smiled. If I asked him a personal question — “Are you married?” for instance — he’d flip it and criticize me for putting him on the spot: “Why are you asking me this?” He never stayed around patients if he didn’t have to.
He was apprehensive for a reason. Often, when Dr. Martin walked onto the ward, his teenage patients would scatter out of sight, then call in stage whispers “Chubs! Oh, Chubs. We love you, Chubs.” I would never have taunted him myself, but I admit I enjoyed watching him react. Dr. Martin would look all around, his face flushed and shiny with sweat. Then, as if he’d remembered that his mother told him to ignore bullies, he’d pretend nothing had happened. He might flash me a fake smile before he hurried into the nurses’ station and shut the door.
We weren’t always mean; doctors who liked us earned our respect. But patients made trouble for the ones who turned their anxiety into disdain.
On 8-East most of the young doctors treated me as an equal. We exchanged ideas and advice and helped one another. If rolled eyes or loud sighs from the arrogant ones sparked my anger, it passed quickly. Feeling respected made me more tolerant.
I’d watched even earnest trainees become frightened by patients who reeked, who stood too close, or asked bizarre questions while speaking too loud. I was proud that I wasn’t afraid of craziness. Interacting with patients was easy for me. My problems showed more with the senior staff, where extreme shyness often made me act tongue-tied and feel stupid.
I was playing the reluctant student with skill born of much pretending. They had no idea what this opportunity meant to me.
I sat quietly, at the conference table with my team, but my ears were ringing. Everything I looked at appeared exceptionally vivid and crisp. George, a smart, sensitive resident everyone looked up to, was reading aloud a preliminary report Paul’s doctor had sent. “He claims to be unreal,” George quoted, “to inhabit a world of cardboard representations, absent any living creatures. And he wants to die. He believes his death will bring the world freedom and peace.”
“That’s not the end of it,” Jenine, our head nurse, continued, almost interrupting George. She smiled as if she had salacious gossip to share. “Nursing reports that he hasn’t spoken — hasn’t answered questions, hasn’t asked questions, hasn’t said a word, nada, nothing — since he arrived in the ER Saturday morning.” She raised her eyebrows while she stared at the stack of papers in her hands. Assorted “Wows” filled the room. Trainees groaned and exchanged nervous, whispered jokes. Senior staff sat composed in professorial silence.
“Who would like to interview this challenging young man?” Dr. Balkan asked, after a pause.
No one raised a hand, or moved, or made eye contact with Dr. Balkan. Why would anyone want to interview someone who refused to talk? Especially since our interviewing skills would later be judged and commented on, both in and outside of our meeting.
Yet barely contained energy roiled inside me. I know about this. Let me do it! I struggled to keep my face placid and hold my twiddly fingers still. When no one volunteered for the interview — which would take place before the entire team — I waited briefly, then raised my hand. I enjoyed the silent gratitude I imagined from the others in training, Thank God it’s you and not me who’ll be critiqued and skewered. I was playing the reluctant student with skill born of much pretending. They had no idea what this opportunity meant to me.
Jenine left the conference room to get Paul. Dr. Balkan and Dr. Brett moved to seats at the other end of the table. I slid their vacated chairs closer to the blackboard so they’d be easier to see. A few people rearranged themselves to improve their view. Flushed with pride, I surveyed the room. Can you believe I’m doing this? I said to myself.
Idiot, what were you thinking? came my response, as the reality of the situation began to register. Still, eagerness to give voice to this stranger whose language I spoke overrode my fear. Seating myself in the first chair, I clasped my hands together as tightly as I could, while I waited for Paul.
Because the hospital I’d been transferred to, where I’d met Dr. Martin, was a teaching hospital, we patients became accustomed to all sorts of visitors. Educators and researchers from around the world toured the wards. Famous psychiatrists came to speak in the hospital’s auditorium, their names posted on a sign in the hall like stars on a theatre marquee. Patients were sometimes “borrowed” for clinical presentations. Two or three times a tall, friendly doctor in a white coat approached me on the ward and asked if I were willing to be interviewed by medical students in one of her classes. It was part of their psychiatry clerkship, she’d explained.
Bright red hair, bobbed with short bangs, distinguished this psychiatrist, a woman in her forties. Her plump lips shone with lipstick in the same carmine shade. I didn’t know her name — I ‘d probably been too nervous to pay attention when she first introduced herself. But her calm confidence and easy-going manner made me eager to agree to anything she wanted.
“Here goes Exhibit A,” I called with a big smile on my face to any friends hanging out in the hall whenever I followed the red-haired doctor off the ward to another class. I hoped they’d focus on my joke and not see how much I relished her attention.
Sometimes at night I lay in my bed in the dorm and pictured her talking to me. I wished she could be my doctor.
When I tried to recall details of those interviews, their content eluded me. I remembered only the smile on the doctor’s face, the earnest way her students addressed me, and how easy it had been to talk. They’d listened with care, as if what I had to say was important.
At the door’s opening whoosh I snapped to attention. Jenine escorted a disheveled and dazed, lanky, blond nineteen-year-old into the room. “This is Paul,” she announced.
I stood and extended my hand. “Hi, Paul,” I said. “I’m Dr. Sawyer. I’m going to talk with you here so we can get to know you and figure out how we might help.” Paul’s trembling fingers barely touched mine. Unsteadily he lowered himself onto the empty chair. He turned his pale face toward me and stared as if I were a ghost. Don’t be afraid. I’m one of you, I implored in eye language, aching to soften the brittle edges of his fear.
This performance, one of the ordinary chores of a professional medical education, embodied the extremes of my thirty-one-year-old life. No one present knew about all the times I’d sat in the other chair. For my audience I became an aware, caring doctor about to interview a frightened patient who believed he needed to die. I was a former mental patient who had just volunteered to demonstrate for her peers — the psychologists and psychiatrists of tomorrow — an initial clinical interview.
When I considered my transformation from “unimproved schizophrenic” to clinical psychology intern with an Ivy League degree, I couldn’t explain it technically. Nevertheless, I knew that one significant factor was an interview with Harold Searles. This took place several months after Dr. Martin had been replaced by another psychiatry resident.
Dr. Searles was an internationally acclaimed psychiatrist who wrote about the psychoanalytic treatment of schizophrenia. Famous for his unconventional style and his success with unusually difficult patients, he was my new psychiatrist’s supervisor.
I liked my new doctor, but I hadn’t yet gained control over my self-destructive behavior — only weeks earlier I’d been restricted, because I’d burned myself again, despite having been warned of the consequences. The stakes were high: patients who failed to improve at this hospital were shipped to giant state institutions. My best friend had been shipped to Rockland. I was twenty-one years old by then, and I’d been hospitalized for over four years.
The room smelled of stale, dirty bodies. I shuddered…
The consultation took place in a small room with no windows. I was so anxious I didn’t know what floor I was on, or exactly how I’d arrived there. Three men, each wearing a white coat over his shirt and tie, occupied wooden chairs near mine. One was Dr. Heller, my new psychiatrist, one was Dr. Mesnikoff, the chief doctor of my section, the third one was Dr. Searles. Dr. Mesnikoff’s presence startled me: I wasn’t expecting him. They’re going to decide if I should be shipped, I thought. They want to know if I’m hopeless.
Dr. Searles moved his chair closer to mine. With doughy pale skin, white hair, and a deliberate way of moving, he seemed old and puffy around the edges. I stared at his round face, struggling to pay attention; my future rested in his hands. The whole scene appeared unreal. I watched myself move without volition, as if I were someone else’s marionette.
“Well, hello. I believe I met you once before,” Dr. Searles said, referring to a preliminary meeting some weeks earlier, one I’d dismissed as completely useless. “Aren’t you the girl who wants to be a saint?”
That crazy idea. I cringed at his mischaracterization of my effort to compensate for an evil soul by acting especially good. He doesn’t know anything. How could this man possibly help me?
“When you’re a foul, shameful person you don’t think you could ever be a saint,” I said, after a long pause, not looking at him. The room smelled of stale, dirty bodies. I shuddered.
Dr. Searles stared at me with a placid look I couldn’t translate. I pressed into the back of my chair.
“You look like a frightened young fawn sitting there in front of me,” he said.
Through cottony, gray air more words followed out of his mouth toward me and into my head. His voice sounded kind.
“The way you look at me makes me feel like a dirty old man,” Dr. Searles said, leaning toward me as he spoke. “If talking to me makes an innocent girl like you afraid, I must be an evil person. I feel desperate. I feel so bad I might have to kill myself.”
Air vanished; my ears popped. I make a famous doctor desperate? Me? Words that had gently floated in, turned to hammers in my head.
My stomach churned as I replayed what I had heard: a frightened young fawn . . . dirty old man . . . innocent girl . . . You make me feel bad . . . kill myself.
I’d showed too much fear. My reaction had really upset him.
The conversation stopped. Dr. Searles brought his hands together, then moved to stand, signaling the interview’s end. Although the doctors had talked for a while, I didn’t register anything else they might have said. My noisy brain had drowned out everything beyond myself.
Back on the ward, I headed straight for my bed and lay down. Gradually the hammers softened. Day turned into night, but I hardly noticed. All I cared about was the phenomenal possibility that I’d had an effect on Dr. Searles. I’d made him feel awful; he understood my fear. The power of that connection dazzled me.
The next evening, in the informal group that regularly gathered for coffee and discussion at the end of the hall, I described my conference with Dr. Searles. “I’m still amazed,” I told them. “The first time I talked to him he said I acted like a saint. Now he says I look so frightened I make him feel dirty. Can you imagine?”
“Hell, yes,” said one of the younger ones, Rita, an overweight teenager whose major pathology, as far as I could tell, was extreme defiance and swearing all the time. “You’re always doing shit for other people.”
“Yeah,” chimed in Cheryl. “When someone sneezes, who’s the first to run for a tissue? It’s sickening.”
“You didn’t know it makes us feel rotten?” Judy’s face was flushed; she waved her hands for emphasis, raising her voice. “Like I’m nothing? Like you have to be better?”
One after another, my friends, and even some patients I hardly knew, gave examples of my oppressive helpfulness. My head whirled with the painful news. Yet I could see how annoying I might have been, running around gung-ho trying to fix everything, crowding out others’ efforts to feel useful and worthwhile.
Instead of sinking into guilt and shame, my usual response, it dawned on me that I’d been handed a prize. From their reactions — first Dr. Searles’ and then my friends’ — I grasped the idea that my behavior affected the people I dealt with. I influenced how they saw themselves, not just what they thought about me.
Suddenly I understood the inter in interaction. I had a place in a process, in a relationship. For someone who had felt invisible and unreal, floating alone in the universe without any power or influence, this was an amazing discovery. I started to observe myself and how I worked; it was the beginning of insight. For the first time, I considered the possibility that I might have control of my own fate.
I didn’t question Dr. Searles’ sincerity, because the effect had been so profound. On the surface he made little sense, yet, somehow, he had reached me. I was filled with gratitude.
I glanced at my team seated around the conference table, waiting. You have power. Don’t screw up. I straightened my shoulders and turned to the young man at my side. “How are you doing this morning, Paul?”
Silence . . . He sighed . . . A long pause followed.
Paul’s body exuded a musty, cheesy smell that floated on the draft around our chairs. I recognized the odors of dirt, grease, and sweat accumulated in his hair and on his unwashed skin. I wondered how much time to give him to gather thoughts for his response to my question. I didn’t want to rush him and turn him off, but neither did I want to appear foolish by waiting too long, if he was determined not to speak.
“You don’t seem to be in a mood to talk.”
He shifted in his seat, rubbed his hand through his hair, ignored me.
“You seem pretty nervous. I guess I’d feel nervous, too, in your position. It could feel quite intimidating to sit in front of a group of strangers and talk about yourself.”
Still silent, he perked up slightly, sitting taller in his chair.
“Is that what’s making you nervous — the audience? . . . Is it something else?”
Paul blinked and cleared his throat, his eyes on the floor. “You can’t help. I’m gone.”
“Gone how, Paul?”
Without looking at me he raised his head. Slowly, in phrases reminiscent of obscure poetry, Paul spoke, and in my own way, I translated. “I look for my parents. It’s only cardboard.” He sees others outside himself as unreal. Like me! My heart jumped. Here was a kindred soul who shared my experience. I saw myself in the hospital, a skinny, terrified girl, unable to talk. Struggling to push that image aside, I focused on the clinical. De-realization makes the object world around him seem fake, flat like cardboard. Nothing that happens seems to matter, because nothing is real.
“They’re gone,” Paul continued. “I look for a place to rest, but I don’t exist.” And he’s depersonalized; his own existence doesn’t make sense, either. I know how each kind of unreal feels — profoundly, unbearably weird; it’s awful.
“You and your parents don’t seem real, is that it? I can imagine that’s difficult to experience.”
Paul frowned. “Dark sky hides the snake. Kill it. Kill it dead. They don’t want me here.” Does he feel guilty about sex? Is he worried about rejection?
“You don’t feel wanted?”
“Nothing to believe.” He sounded despondent. Then there’s meaninglessness. Thank God I’m not still there.
“A world where no one means anything to you and nothing is real sounds very lonely, Paul”
“Uh huh.” His face looked blank, but his eyelids twitched. I wished I could comfort him.
“How do you manage that?”
“Listen to music. Don’t talk. I think poison.”
“Kill you? Why?”
“Hell. Dudes find justice in Hell.”
“Are you thinking killing you is connected with justice?”
From staring past me, Paul turned to look me in the eye. He nodded. “Yeah, yeah, that’s it.” His energy picked up. “Voices say gotta go. Evil this boy. No supper for him.”
“Do voices tell you to kill yourself?”
Again he nodded his head vigorously, wrestling with a sticky tongue to form words, forcing them through crusty, white lips dry from anxiety and medication. “They give orders: ‘eliminate yourself.’ ‘Death is peace,’ they say. ‘Die, Bastard,’ they say.”
His eyes expanded, but they focused somewhere beyond the room, shining. Paul looked crazy, caught up in a world we couldn’t see. He’s psychotic. Could I ever have looked like that? I caught a whiff of sour sweat. I hoped it was Paul, not me.
“Do you have a plan? Is there a particular way your voices want you to do this?”
Paul slumped into his chair, and with a large sigh bowed his head.
“What just happened, Paul? You look upset.”
“Bad drama. No one believes me,” he said in a small voice.
“I do believe you!” I blurted out. Then I caught myself.
Paul didn’t respond. After a while he sighed again.
“What is it no one believes?” I asked, deliberately calm.
He sat up. He leaned forward in his chair, facing me. “Plan is right. Life is nothing. Time to go.”
This disclosure seemed to take the last of Paul’s energy. He shrank into his chair, deflated, and covered his face with a large, boney hand. Shit. Did I go too far? I was worried for him.
Our twenty minutes were up. I had to bring the interview to a close.
“Those are pretty serious concerns, Paul,” I said to him, now thinking more of the spectators beyond. “Poisoning, no value in life, nothing real, wanting to die. You sound very unhappy. Our job right now is to make sure you don’t kill yourself and to give you time to figure out how to cope with these things. Do you think you could work with us on that?”
Paul uncovered his face. He hesitated. Then he nodded.
“Thank you for talking with me, Paul,” I said.
Rising to my feet, I reached to shake his hand. He appeared confused, robotic from medication and his abstracted reality, but he pushed himself off his chair to stand. Then, for a moment he came alive. His eyes reached into mine; he smiled at me and gripped my hand. He held on tight, even after I let my hand relax. I heard him mumble something — Is he thanking me? — before Jenine guided him out of the room.
“This is a very disturbed young man.” The chief turned to address all the staff assembled in the room.
Happiness spread through my chest like warm tea. I felt profoundly touched by Paul, and, in a parallel space — as if time had been transmuted — I felt I’d encountered that lost girl from long ago and had reached out to heal myself. I thought of Harold Searles. I did it! How cool am I?
In the next second, I reversed. Who are you kidding? He didn’t say anything real, for goodness’ sake. You looked like a fool, pretending you understood what he was talking about.
Dr. Balkan cleared his throat as Jenine slipped back into her seat. “Thank you, Dr. Sawyer. You stuck with Paul, even though at first he didn’t appear to make sense.” He paused to take a sip from his water glass. “I liked your easy attitude; it seemed as if you’d known him from the start. Your ability to be direct enabled him to trust you enough to speak.”
“This is a very disturbed young man.” The chief turned to address all the staff assembled in the room. “Her questioning allowed us to see his paranoid ideation. His delusion regarding his being evil leaves him vulnerable to suicide. What’s the diagnosis?” He looked around the table.
“Clearly, he’s psychotic,” said one resident.
“Schizophrenic, most likely,” another added after a pause. I recoiled. Reluctantly I wondered if, in Paul’s case, schizophrenia could be correct.
The criticism followed. “She asked too many leading questions,” the first resident said. “How do we know this is what he really thought or if he was just agreeing with her?”
I winced — he had a point.
“And don’t you think some of your interpretations require a real stretch of the imagination?” he continued, looking directly at me.
“A fair question,” I conceded. I thought of Searles again.
“I think the proof of an interpretation is in the patient’s reaction,” George asserted, defending me. “Hers obviously had some merit or he wouldn’t have connected with her the way he did.”
Jenine raised her arm with a dramatic gesture and peered at her watch. “Time’s up,” she declared. She grabbed her stack of folders and left the room.
Amidst the sound of scraping chairs and the murmur of half-whispered comments, we gathered our assorted pens, jackets, sweaters, candy bars, clipboards, notebooks, and keys to head toward the door and the hallway beyond. I was grateful for George’s support, although by then I wasn’t really listening. As I walked out of the room, nodding and saying, “Thank you” in response to several “Good jobs,” I was focused only on myself.
In a small, quiet space, deep within my mind, I was thinking about the young woman I’d pictured for so long as a psychiatric patient, wondering if I was ready to leave that image behind. Could I call myself a psychologist now? Had I indeed become a psychiatric doctor?
I felt a hand on my arm. “. . . make time for it?” George and Dr. Brett were walking beside me.
“I’m sorry,” I said. “Could you repeat that?”
“Lunch,” George said. “Would you join us for lunch?”
I tripped and barely caught myself. Blushing, I picked up my sweater and notebook from where they’d landed on the floor.
Who are they seeing? I wondered.
“Sure,” I said.