Brooklyn Zoo: The Education of a Psychotherapist

Editor's Note: Following is an excerpt from Brooklyn Zoo: The Education of a Psychotherapist, by Darcy Lockman. © 2012 by Darcy Lockman.

 

I woke a woman named Ophelia for morning group, and she was not pleased. “You woke me from my sunder,” she kept repeating in an angry voice. She followed me into the dayroom anyway. A man named Juan was dancing in the hallways, and I corralled him, too. There was a third patient, a woman, she looked a little slow. And Mr. Rumbert again. I asked them to speak about why they were in CPEP [Comprehensive Psychiatric Emergency Program].

“I came for a bed, but I was double-crossed,” said Ophelia.

“My fiancée called 911 after Shabbos dinner,” Juan said, which sounded funny because he was clearly Mexican.

“Why did she call?” I inquired.

“You’d have to ask her,” he replied.

The woman who looked slow said she’d done crack for the first time and was full of regret.

She began to cry.

Rhoda [a nurse] walked in to get Ophelia. She needed her help with some paperwork.

“You can come back when you’re finished,” I told the patient as she left. She turned and gave me the finger. Juan told those of us who remained that he wanted to read to us from a book called Recreating Your Self. As we listened, Ophelia returned, and she was worked up. She marched up right close to me.

“You double-crossed me,” she yelled. Her body looked tense, poised for a fight. For the first time in the ER, my fear of being physically threatened was being realized. I made my way toward the door, encouraging Ophelia to come with me, not wanting to leave her alone with the other patients. She was taller than I was, and wiry. I imagined her rage would give her fists great force. I had never learned how to protect myself from a punch, and cowering seemed like my best defense. I remembered what T. [a supervisor] had told me weeks earlier about being soothing.

“It’s okay. Come with me. We’ll find you some juice, something to eat,” I said. She followed me as I walked backward into the hallway, which for once was deserted, the guard having abandoned her post. Ophelia remained too close, still menacing, insisting on my alleged crime, taunting me. I continued walking slowly, my body facing toward her as I backed away sideways.

“Hello, hello,” I said loudly, turning my head toward the adjacent halls, trying to get the staff ’s attention without alarming anyone, but someone was always yelling, if not screaming, in the ER, and no one was likely to heed my cautious cries. Calling for help seemed overly dramatic, and I thought it might set Ophelia off besides. Shit.

But Rhoda came out of her office and saw us. She rushed over, inserting her solid body between Ophelia’s and mine. She managed to calm her down while also explaining to me that Ophelia had slammed out of her office two minutes before. “I’ll take care of you,” Rhoda said firmly to Ophelia, shepherding her off to another hallway. I went back to the group room, concerned that the patients might have gotten spooked. Juan and the other woman were now seated side by side. She was choosing passages from his book, and he was reading these aloud. Mr. Rumbert sat across the room, silent but calm. I entered and closed the door and sat to listen and get myself back together. Ophelia was back soon, standing outside the windows of the group room looking in. I saw the guard was back at her post, and I opened the door. “Would you like to rejoin us?” I asked Ophelia, because wasn’t that my job?

“Don’t talk to me,” she said. “You look like a canker sore.”

Afterward, I did not have much left in me, but still I brought Juan into T.’s office for an interview. His chart said he had a long history of bipolar disorder. He told me he was an attorney and a converted Jew and there was no reason for him to be in a psychiatric emergency room.

“Have you been hearing voices?” I asked.

“Yes,” pause, “Guided by Voices,” pause. “Get it? The band?” Guffaw.

“Are you worried that someone is watching you?”

“Yes,” pause, “the Police,” pause. “Every breath I take, every step I make.”

He kept insisting there was no reason for him to be there, and when T. came in, she’d quickly had enough and told him we were done. He got up and walked out, turning off the light as he made his exit.

“That’s so symbolic,” T. said. “Lights out.” I told her about what happened with Ophelia because I thought the staff might want to assign her an assault level. T. asked if I was okay. I was still shaken, but I said yes. Then it was time to go, and as I left, I saw Juan the converted Jew lying on his stomach on one of the reclining chairs. I waved, and he thrust his hands back to catch his ankles in a resplendent yoga bow pose.

All the way to work the next morning I debated whether to bring Ophelia to group. I hadn’t thought to ask T. about that. With a higher-functioning patient—someone who was not psychotic—I thought it would have been important to bring her in, to demonstrate implicitly that her aggressive impulses were not as destructive as she likely feared. I was not sure that the same thinking applied to a psychotic patient, especially a paranoid one, since paranoia reflects a projection of aggression—that is, Ophelia experienced the hostility not as her own but as directed toward her by those around her (in this case, me). I decided I would invite her if she was up but that I would not wake her from her “sunder” if she was still asleep. It turned out not to matter, because when I got the census she was no longer on it—moved to the list of people waiting for a bed upstairs. I was relieved. I found Juan and Mr. Rumbert—who was continuing to speak—and a new woman who was attractive and looked with-it. But then she told me she did “sortation” for a living, which made me suspect she had a thought disorder because I knew, thanks to my month in the psych ER, that use of neologisms was often a symptom of schizophrenia or mania. T. called in sick, and Dr. Brink was my official supervisor for the day.

I spoke to the sortater, who had a long history of psychiatric hospitalizations, for some time and then went to report to Dr. Brink. She seemed distracted, and I felt as if I was bothering her; EOB patients were not her problem, after all, and I didn’t imagine her relationship with T. made her inclined to fill in with her caseload. The hospital police were called to the ER while I sat in Brink’s office, but I paid that little mind. When I got up to go back across the hall, she put her hand out to stop me. “Didn’t you hear that page? You never leave after hearing the hospital police called. You need to pay attention.” It had been a month, and there were many things I had learned there, but others that I had not. I sat to wait while the police broke up a fight in the hallway.

The next day was a Friday, and my last in the psychiatric emergency room; on Monday, I would report to inpatient unit G-51. I gathered the EOB patients for my final group with ease. A moment of interpersonal conflict between two group members got me engaged. The drug addict told another patient he didn’t like being asked about his methadone in the hallway in front of everyone the previous day. The offender replied he’d noticed the drug addict had not eaten breakfast and was testing a theory that methadone users in general didn’t like to eat. I tried to facilitate further discussion, which would have been the meat of an outpatient group, but neither man was as interested as I was.

After group Rhoda told me there was an EOB patient pending. A psychiatrist I recognized by face but not by name told me I should see him to try to make something of his story. Darren looked like a handful of the others I’d seen that month: early twenties and handsome and robust, nicely dressed in jeans and a sweater. His presence in the G-ER didn’t bode well, but I was still maintaining my manic hope that somehow nothing was seriously wrong this time. T. came in as I was beginning my interview with Darren and quietly sat down to observe. I felt my usual self-consciousness and also a determination to do better this time, to prove to us both that my four weeks of immersion in her EOB had taught me something. Darren made eye contact and answered my questions in the right amount of detail, without hesitation or mistrust. To make matters murkier, his reason for admission puzzled me, and I didn’t know where to go with it. “A week of really bad headaches,” he said. If there was one thing I’d learned, it was that you didn’t get brought to a psychiatric emergency room for a headache.

“Did the headaches start because you’d been drinking too much or using drugs?” I asked.

“No, I’m not into any of that,” he said.

“Did your headache come from voices you were hearing that no one else could hear?”

He shook his head.

“Was it because someone was stealing your thoughts or trying to put ideas into your head?”

He gave me a wry smile. Still no.

“Did the headache make you agitated? Did you get very angry at anyone, maybe yell at them on the street or shove them?”

Negative. We sat there together, equally perplexed.

“Where was the pain?” I asked, grasping at straws. If he told me it was in his face, maybe I could diagnose him with a sinus infection. He said that it was in his entire head. I turned to T., defeated. “Do you have any questions?” I half mumbled.

She took over with her usual omniscience. It was not grandiosity, she just really was all knowing. I tried to calculate the difference between my four weeks and her twenty years. Even allowing for fifteen vacation days annually, it was considerable. “Your thoughts were all jumbled up last week, and it really made your head hurt,” she said to Darren. He nodded, and it was as if a light had turned on in his brain.

“They were mad bundled!” he said.

“And that happened in school, too, right? It got hard to pay attention, hard not to get confused?” Darren had told us that he’d flunked out of college four months earlier.

He nodded, starting to look upset. T. had his chart open in front of her and was looking at the doctor’s orders. “Has the medicine we’ve been giving you helped with the headache?” she asked.

“Yes,” he replied. “It’s gone now.”

“You’re lucky,” she told him. “Years ago we didn’t have these pills, and people who got headaches and confusion like yours had much more trouble going about their lives.”

After Darren had left us for the hallway, T. said, “Most likely schizophreniform, though it could be a psychotic depression.” She explained that schizophreniform disorder was diagnosed in patients with less than six months of symptoms of schizophrenia; only some of them would go on to exhibit the full-blown disorder. “His prognosis is good. He relates pretty normally, and his affect isn’t flat. If he stays on the medication, he can probably go back to school, next semester even. He should see a therapist, too, of course, to monitor how he’s doing over time, to help him understand his preoccupations better. He’s far from a hopeless case.”

“How about me?” I asked, aware that my minutes there were dwindling, wanting to remind T. that today it was me who was timing out.

“Not hopeless,” she said. “Frankly, I was surprised by how little you knew when you got here. But you’ve been doing a good job trying to take everything in. It’s a lot of information, and it’s a difficult environment. I wasn’t sure you’d come back after what happened the other day with Ophelia.”

This floored me. It never crossed my mind not to return. What kind of wimp did she take me for? “No. I mean, I was shaken, but this is my internship. I signed up for this,” I reminded her. She pulled out the same evaluation sheet that Dr. Young had filled out the month before. T. had not given me high marks, but at least they were scores that actually reflected her own ideas about my work. As she reviewed them with me, I thought again about what Dr. Wolfe had said the month before, and how after so long in the carpeted classrooms of my graduate school it was actually quite hard to pull off, this task of becoming a better psychologist. But also I felt on my way.

© 2012 by Darcy Lockman. Published by arrangement with Doubldeday, an imprint of the Knopf Doubleday Publishing Group, a division of Penguin Random House, LLC.