Weekends At Bellevue: A Memoir

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• Introductory Note
• Mother Nature's Son
• Leaving the Note

Introductory Note

Julie Holland’s memoir, from which these two chapters are excerpted, chronicles the days in the life of a psychiatrist working in the psychiatric emergency room of Bellevue Hospital in New York City. Admittedly cynical and at times unfeeling towards her patients in the beginning, Holland discovers this attitude helped her cope with the day-to-day chaos, and comes through the experience a very different person.

Mother Nature's Son

On a warm day in early spring, two New York City cops and two EMS workers roll a gurney down the hallway, escorting a man to the entrance of Bellevue's psychiatric emergency room, where I work. Lying on the stretcher underneath a white sheet, with a head of dirty blond hair beaded and dreadlocked, he is naked, sunburned, and screaming. I walk out to greet my new patient as the drivers hand me his paperwork to sign.

"What'd you bring me?" I ask eagerly. I can see he's a live one. I love the live ones.

Over the shrieking, one of the EMS guys gives me "the bullet," the few pieces of relevant information when introducing a patient to a doctor: age, chief complaint, pertinent history. "This is Joshua Silver. Twenty-three. No significant medical history, no allergies, no meds. Also, he denies a psych history," he says archly, shooting me a look.

"And how'd he get to you guys? Who called 911?"

"NYPD called in an EDP." This is cop-talk for a psychiatric patient: emotionally disturbed person. "He'd taken off his clothes in Times Square and was parading around, barking like a dog. And growling," he adds.

This gets the patient's attention, and he interrupts the driver to clarify, "It was my way of showing them that I was not an animal. I am not a dog!"

Barking and growling to prove he is not a dog? His logic is lost on me, but at least he's stopped yelling and started communicating.

"You can talk to me," I say, turning my full attention toward him.

"See, there were some guys from Nation of Islam preaching on the corner, and they told a woman who was arguing with them that she was just a dog—God spelled backwards—to which I took offense." He then explains to me, as he did to them, that all people are art. "'Thou art art,' I told them. 'Once you accept that all people, all objects, are art, you will live in heaven as I do.'"

"You know what, Joshua?" I ask, having decided it is time to move out of the triage area and into the locked area. "I think you and I should go talk about this inside." I want us to sit in an interview room so I can try to get some more history, and I don't feel like standing over him while he lies on a stretcher. I can already tell he's an admission and will need to be in the detainable area for patients awaiting beds upstairs.

I let EMS and NYPD know that they are free to leave, and I grab my new patient some hospital pajamas. I help him off the stretcher, wrapping his sheet around him, and walk him into the larger, locked part of the ER. As I escort him through the entrance, the door clicks definitively behind us, and I hope he doesn't notice that he is now locked in. Because he is naked, we can dispense with the contraband search, which is good. The search is often the point where people become uncooperative and agitated, ending up restrained and medicated.

Prior to entering the detainable area, a patient must remove his belt, shoelaces, rosary beads—anything that can be used to hang himself or choke a fellow patient. Inevitably, the patient will insist that he is not suicidal or dangerous, but it doesn't matter; these items are not allowed in the detainable area. Neither are cell phones, crack pipes, backpacks, knives, pens, wallets, and the list goes on. The patient has to give up just about everything along with his freedom.

Luckily, Joshua is oblivious. I show him to the bathroom where he puts on the pajamas quickly. I alternate between keeping an eye on him and setting up the interview room. There are several windowed rooms within the detainable area, each with a desk and two chairs. I put my chair closer to the door. As we settle into our talk, the first thing I notice is that although he is disheveled, he seems well educated with an impressive vocabulary.
He tells me he has written a twenty-eight-page manuscript, which he calls a prose-poem, based on his newly embraced credo that everything is art. He is hoping to reach millions of people by delivering his manifesto on the Howard Stern show on K-ROCK, a radio station in the city.

"I am a holy man," he tells me, explaining how his writing has elevated him to this level. "I feel like King Arthur in a tower of Babel." He is hyper-verbal, spewing non sequiturs. I try to keep up with him, playing follow the leader, as if we are hopping from rock to rock in a rushing stream, but he is pulling far ahead of me. Eventually, I have to tell him he's not making a lot of sense.

"Joshua, you need to slow down. I want to understand what you're saying, but it's difficult for me. I'm focusing on the illogical connections that you're making . . . "

It sounds like "theological connections" to him, and his smile beams; he's pleased that I've grasped his religious message. I don't bother to correct him.

Being preoccupied with religion is a classic manic symptom, and mania is the better-known half of manic depression, now called bipolar disorder. In a manic state, people have less desire for sleep; they will talk more, create more, do more. Commonly, bipolar patients get hyper-religious in their newfound frenzy and sometimes end up on a street corner and then a psych ER explaining that they are Jesus or the Messiah, or that they've discovered a new religion. They've been touched by the Lord who spoke to them. They've had a vision, an epiphany, and they want to share it with the world. Their grandiosity can be charismatic and alluring. Religions and cults are formed around this kind of energy, and I'm happy to warm myself by Joshua's fire during the interview.

In March and April, our ER becomes crowded with manic patients. For many bipolars, there is a seasonality to their symptoms. Just as more people get depressed in the winter months, increased exposure to bright sunlight can elevate moods. Also, the air is heady with religious themes during spring, when Easter and Passover coincide. The resurrection is reenacted in the budding trees and sprouting flowers, miraculously coming to life where once lay a blanket of snow. We get multiple Jesuses in the ER this time of year.

Joshua's pressured speech is another sign of his mania. It rambles hither and yon, like a butterfly dancing merrily among the flowers, setting down briefly on the themes of religion and art as if they were particularly colorful blossoms. I try to join him in his wordplay, to engage him gently in the hopes of learning more about him: where he's from, where his parents are, and whether he's stopped his medication, which is a good bet. Most of the manic patients who come through our doors have gone off their meds. The mood stabilizers have significant side effects, and people are often resentful about having to use them. Also, mania usually feels better than being medicated, at least for a while. It's a bit like surfing, knowing it has to end with the inevitable wipeout, but loving the balancing act required to keep it going.

Most of our patients battle with their need for medications. When they start to feel better, they abandon their treatment plan, thinking they're cured. Even if they know they'll get sick again, they hate taking the pills so much that they stop anyway. Coming through our doors is a painful and humbling lesson in how to manage their illness.

"Joshua," I begin yet again.

"I fought the battle of Jericho."

"I've heard that about you, yes." I smile. "Are you from Jericho?" I ask earnestly.

"No, I don't think so."

"Or maybe a town near there? You took a bus to New York City from where?" I ask. "Can you tell me where your parents live? Is there anyone who might be worried about you, who doesn't know where you are?"

A town near Jericho? What the hell am I thinking? I'll tell you: I am trying to meet him where he is, to work within his delusions and focus on what's important to him, and then gently lead him out to where I am, in reality. This is one definition of psychotic—broken with reality. He lives in a dream, but his hallucinations and delusions are as real to him as the movies we star in while we sleep.

Despite my coaxing, I can't get anything useful out of him. I want to find his parents because I need to talk to someone who knows him to learn whether he's been sick like this before. And I want to let them know that he's been found. I've made dozens of phone calls to parents of the bipolar kids who end up on our doorstep. We get plenty of "first breaks" at Bellevue, the first episodes of psychosis that often herald the arrival of bipolar disorder or schizophrenia. They tend to occur in the late teens or early twenties. This is when the brain is pruning back and reorganizing connections made throughout adolescence, and also when everything is getting more challenging: starting college, joining the army, traveling. Sometimes, during these phone calls, I hear about how bright and promising their children were before they got sick. Other times, when it's not the first break, but the latest in a long series of them, the parent on the phone is terse and angry, burned out, tired of being woken up in the middle of the night to answer the same questions from yet another psychiatrist. In many ways, that's easier for me to deal with than the heartbreak of talking to the "new" parents, giving the first diagnosis, gingerly explaining the illness and its treatment, knowing as I do that they may be in for decades of calls from ER docs.

But tonight there is no phone conversation with the Silvers. Joshua won't even acknowledge that they exist, and I have nothing to go on but his manic ramblings. He tells me he's come to New York City with three dollars in his pocket and nowhere to stay. Knowing no one in the city, he made his way from the Port Authority bus terminal to the K-ROCK radio station at five a.m. in order to spread his message. When I first started my job at Bellevue, I heard the Port Authority referred to as The Port of Atrocities, because EMS brought us such sick people from there. That name stuck with me throughout my tenure at the hospital.

Joshua continues, chronicling the events of his day. After K-ROCK turned him away, he spent the rest of the morning sleeping in Central Park. Later in the afternoon, the police in the park told him to move on, and gave him a tip: Try hanging out around Forty-Second and Broadway. Wandering around Times Square, he happened upon some teens entertaining the tourists by playing drums on overturned white plastic buckets. He danced for them, and the tourists threw him money and took his picture.

"You know how there's cops there on horses? They let me pet the horses; they seemed cool about me touching the animals, and the tourists took my picture again!" He seems impressed that he'd become a tourist attraction himself.

"Well, weren't you naked by then?" I remind him.

He admits that he must have been by this point, but then begins to digress into a tirade against photographers, who, instead of living life and immersing themselves in their surroundings, only interact superficially by documenting the scene.

"You may have a point there," I offer. I think of my boyfriend the photographer whom I confronted with exactly this accusation not so long ago.

My patient perceives me as a friend and ally because I am aligning with him, chatting agreeably rather than asking the standard annoying psychiatrist questions. There's no need for those as far as I'm concerned—he's a definite admission. The only is whether I can get him to sign in voluntarily or will have to fill out the 9.39 paperwork for commitment.

The criterion for a 9.39 is danger to self or others, or an inability to care for self. If a patient doesn't fit this narrow definition, he needs to sign in voluntarily. A frustrating situation often develops in a family when a patient clearly needs psychiatric help but is unwilling to agree to a hospitalization. In Joshua's case, I can probably justify the danger-to-self scenario. He can't fend for himself while he's psychotic like this: He's on the street with three dollars in his pocket—that is, when he's got his pants on—eating and drinking nearly nothing.

Could severe dehydration and low blood sugar be affecting his behavior? Is he high from LSD or PCP? My money is on mania, the "working diagnosis," but it's my job to second-guess myself. If it's drug-induced, he'll come down in a day or so, but the mania won't de-escalate that rapidly. I can ask the nurses to obtain a urine sample to be tested for PCP—phencyclidine—a tranquilizer called Sernyl, once FDA-approved but now illegal. When people are high on PCP, they frequently disrobe and run amok. There is a saying among toxicologists that "naked running is PCP until proven otherwise." Since Joshua presented to the ER naked and disorganized, I figure I should at least send for the test.

If I could just talk to his parents, I'd get a sense of his history—whether he's been depressed or manic before, and what meds work best for him. Of course, he won't offer me any telephone numbers for his family, only for K-ROCK, a number he knows by heart. He still wants Howard Stern to broadcast his manifesto.

I push forward on my chosen tack: schmooze-fest. I tell him I admire his theory that people are art. I share his appreciation for the perfection of all he surveys, of the complexities and magic in the world around us. Like being high on hallucinogens, mania can provide a sense of wonder and awe at the realization of how the universe works. It's easier to access the macro, to pull back and see the big picture. Often there is a feeling that "everything is connected," a realization in common with experiences on psychedelics and with mystical religious epiphanies. There are likely neurochemical similarities between the mystical, psychedelic, and manic states.

At Bellevue, I am repeatedly shown the big picture, taught that there is more than one way to look at just about everything. When I open my ears and mind to the "ravings of a madman," I'm reminded to pay more attention, to Be Here Now. Everywhere we choose to see it, the world is full of splendor and wonderment. I'll never forget the manic teenage boy who tapped my shoulder in the detainable area, excited to explain to me that, "We're part of this huge experiment. All of us are under one microscope, being observed and studied. You know where the eyepiece of the microscope is?" he asked me, his pupils dilated with enlightenment. He pointed to the ceiling, "It's what you call the sun."

Leaving the Note

I have a manila folder full of suicide notes. For a while at Bellevue, if I came across one at my job, I would Xerox it and add it to my file. Eventually, I stopped doing this. It became overstuffed and sadly redundant and meaningless. There are few things as demoralizing as a stack of suicide notes—all that hopelessness, so much sorrow and regret concentrated in one place. It's unnatural. Some of the notes are apologetic: "Tell Ilana I'm sorry." "I know I'm hurting you by what I'm about to do, but I see no other way out of this." "I am so sad and so sorry. Please forgive me."

But there are plenty of notes full of anger, not apologies. One note, addressed to an ex- boyfriend, says succinctly, "This is all your fault."

At least the notes make it easy for me to make a decision about how to handle the case. They are tangible proof that a patient wants to die, which allows me to fill out the paperwork for the admission. The problem is, not everyone leaves a note, and even if they've written one, it doesn't always signify seriousness or intention. Plenty of completed suicides leave no note. And plenty of staged suicidal gestures are accompanied by long letters.

Sometimes a patient will make a veiled or outright threat of suicide on the phone. The person on the other end of the call, not knowing what else to do, dials 911. Then I get a new angry patient showing up in CPEP, dragged out of his home by EMS, forced against his will to undergo a psychiatric evaluation.

One of the rules of thumb that I've developed over the years is to base my treatment plan not on what someone says, but on what he does. People threaten suicide for all sorts of dramatic reasons. I try not to take away their civil liberties and force them into a Bellevue stay unless I have proof of actual harmful intent. Dramatic phone calls don't count.
I've had countless situations where the ex- boyfriend calls 911 after the girl he dumped threatens to kill herself. She was hoping he'd come rescue her, but what she gets instead are a couple of ambulance drivers escorting her to a night with me. Now she has to convince me that she has things to live for. Lucky for her, I'm not hard to convince. I let most people leave the CPEP as soon as we've had a quick chat, once I get the feeling that they have "future thinking." I write up a T & R, documenting that a patient has no suicidal intent, is not hopeless, and has future plans and future thinking. These are key components in the decision to release a patient.

It's tough to decide who's really serious about suicide, whom to detain. Anyone who's recently made an attempt is an automatic keeper; that's easy. Talking about it is one thing—threatening, writing notes, those are things that will make me consider an admission—but if they went through with any sort of dangerous activity, they're in, end of story. It is standard practice when evaluating a recent suicide attempt to do a "walk- through." I ask the patient to take me through that whole day, step by step, to get a sense of how much thought and planning went into the attempt, if any. What were the thoughts and hopes while carrying it out? Many attempts are impulsive and barely thought out. Other times, people will admit that they were hoping to be thwarted, that a loved one would finally understand just how desperate things had become.

Another situation that comes up every once in a while is "suicide by cop." Patients, usually psychotic or high on cocaine or both, will try to get the police to kill them with their guns. Sometimes they will do this by trying to provoke aggression. Other times, they'll reach for the cop's gun, trying to get it out of the holster, which is trickier than it looks—I've tried it (with permission, of course).

Obviously, patients who successfully commit suicide don't cross my path. They go to the medical ER to be resuscitated, or they go to the morgue. The patients that I do see are the failed suicide attempts. The note has been found in time, or the patient is discovered in the bathroom with a noose around his neck, or in the tub with his wrists cut and bleeding. These are the most pathetic things that I deal with, bar none—the botched suicides. It's not that easy to successfully kill yourself. Sometimes the plan is too elaborate, and then there is bound to be a gaffe. When I was a medical student, I had a patient who ate ground glass. He ended up with a lot of severe problems with his stomach and esophagus, but he survived. Then there was the patient who set up an intricate pulley system, hauling a heavy metal engineer's desk up onto the ceiling and sitting underneath it. It didn't kill him, but it did leave him with a lifetime of chronic pain due to the crush injuries. Then there are those brain-injured patients who survive shooting themselves in the head.

It's tougher than you think to end it all, take my word. And after a failed attempt? You thought your life sucked before, just wait. What is always infinitely hard to predict is the future, when there hasn't yet been an attempt, but there are hints. I can't always tell just how desperate a person is, or how far he'll go to escape his painful life. Most of us have had friends, family members, or colleagues die at their own hands. How many of us knew it was going to happen? How many of us missed the warning signs, so easy to see in hindsight? It's easy to blame yourself endlessly when someone you know ends his life. I should've known he was in pain. I should've offered more of my time and my heart. And when it's someone who is assigned to be under your care, it's even easier to beat yourself up.

My first suicide happened when I was a fourth-year resident at the Bronx VA—my last year of training. I was thirty. A thirty-four-year old guy with a heart of gold—nice guy, but a very sick man with intense mood swings and intermittent psychosis—was assigned to me. This illness is called schizoaffective disorder, and it carries a prognosis more dire than bipolar disorder due to its deteriorating course. When I inherited this patient from the outgoing resident in July, she let me know he was in trouble. I had a talk with him, man to man, my desk in between us. He never took off his dark sunglasses during our discussion. (One of the things I fixated on later, in my own interminable postmortem.)

"You're my most dangerous patient," I began. I assumed he'd like to think of himself in those terms. I could tell by the sunglasses, or so I thought. "You just got out of the hospital after attempting suicide. Statistically, you're at risk to try it again." He nodded wordlessly. I was hoping he'd start to open up and tell me why, so we could begin to make a connection, but no, just the nodding.

"What can you and I do to keep you alive, I wonder?" I asked. Let him know he's part of the treatment team. We're in this together. "Search me," he said, shrugging his shoulders.

"Can you please promise me you'll contact me to talk about it if you're feeling suicidal? Can we at least agree on that much?" "Sure thing, Doc," he promised. He sounded genuine. Patient contracts for safety, I wrote in his chart.

He seemed to do okay for most of my outpatient year, which goes from July to June, but at some point in the winter, he missed two appointments with me, one for a group session and another for an individual session. After the second missed appointment, I called his wife to see what was up. She told me bluntly that he had checked himself into a hotel, drunk a bottle of vodka, and taken a few months' worth of hoarded prescriptions that I had written for him.

At first I blamed myself, and was nervous that others would blame me as well. If he had hoarded my prescriptions, this meant he was off his meds while I was still seeing him. I was specifically worried about the peer-review process, the morbidity and mortality conference where I would have to present his case to the other doctors and defend my choice of his medications. But then I felt guilty that I was focusing on me, how this reflected badly on my skills as a psychiatrist. I needed to do something to shoulder more of the responsibility, even if the other doctors didn't bear down on me.

I called his widow again, to commiserate. It was a very emotional phone call; I allowed myself to really open up to her loss and grief, and also, most important, to her anger. I needed to feel guilty because I had let both of us down, and she helped me with that, as she had a right to. She told me how she had known him for eighteen years, and how they'd finally gotten married six months ago. She described how their eight-year-old son kept leaving his seat and going up to the coffin to kiss him good-bye during the open- casket funeral. She shared with me how she felt like his soul had entered her body, and how she spent all day with his ashes, feeling like her heart had been ripped out of her chest and torn apart.

She was full of questions. Why did he leave her so soon after they were finally married? How could he abandon his son? And how could I, his doctor, let this happen? It was tempting for both of us to blame each other. She asked why I had prescribed certain medications instead of others, and why I couldn't see him more frequently. Wasn't there more I could have done? I wanted to know why no one thought to call me for help when he stopped talking for a week at home. He began sitting alone in dark rooms, sleeping more and more. Why didn't she let me know what was going on with him? Why didn't he call me?

I didn't realize anything different was happening with him. I fixated on the signs I should've picked up on. He wore his dark sunglasses one day in group therapy. Maybe that meant something. He seemed irritable with the other patients, which was unusual for him. Maybe that should've tipped me off. And why the hell didn't I call him immediately when he missed his first appointment for group therapy? My patient did not want to be found. He didn't try to hang himself down the hallway while his family ate dinner. He didn't call an ambulance five minutes after he swallowed some pills because he changed his mind. (These are common occurrences in a staged suicidal gesture.) This man checked himself into a hotel room, telling no one where he was going. He left no note, and he took multiple full bottles of multiple medications, chasing the pills down with nearly a quart of vodka. Clearly, he wanted to die and took precautions so that he would not be stopped.

But couldn't I have stopped him anyway? Mostly, what I heard from other doctors at the VA was how some patients are absolutely intent upon ending their life and we can't always prevent them. That this is a rite of passage. It's a fundamental part of residency training in psychiatry; every doctor loses patients. You learn and grow from it, and you go on to the next patient, trying not to let it happen again.

When I'm at the CPEP deciding whether someone should be kept in the hospital or released, I need to choose the path of least mortality: Will this person go out and kill himself or someone else? Dance in the middle of the FDR and cause an accident? Jump from the Brooklyn Bridge?

My answer, more often than not, is, Who the hell knows? Does anyone see a freakin' crystal ball on my desk? I don't have all the answers. I'm doing the best I can with what I have, which sometimes is not much information at all. I'm always pressured to send the patients out, because we only have so much room at the hospital. The busier we are, the higher my threshold for what gets caught in the safety net, and thus pulled into the safe harbor of the psych ward, such as it is. There is an element of uncertainty with every T & R. I have to be okay with that ambiguity if I'm going to work weekend after weekend. I trust my gut and try not to gamble too much on any given case, and usually the house wins.

Before I became a psychiatrist, I rationalized that people had a right to commit suicide. If you're at a lousy party, you should be allowed to leave if you 're not having a good time. But after talking to that man's widow, I got to experience a fraction of the pain that a suicide causes, and my first time sharing that grief made me see things differently, made me understand more fully my own obligation as a physician. Suicide is not just about wanting to leave the party. Depression changes the experience, coloring the perception, which makes it impossible to enjoy the party. As a physician, I must combat the illnesses that cause suicidal thoughts and behaviors. I have an obligation to eradicate the depression that poisons the mind, just as surgeons need to defend their patients from the cancers that hijack the body.

Doctors are supposed to alleviate pain. Psychiatrists are meant not only to soothe the despair and hopelessness that a depressed person experiences, but also, I have come to realize, to prevent the pain of the ones who would be left behind. This means I must do all I can to prevent the leaving.

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Copyright © 2009 Julie Holland. Reprinted by Permission from Bantam Books.