Brooklyn Zoo (33 page)

“About what?” he wanted to know. Speech seemed effortful. He looked as if he was in some agony and that he knew it well.

“Your doctors are worried that you’re depressed,” Amari said.

“I’m not depressed,” he said. He shifted in his chair, and his tubes moved along with him and he winced.

“It doesn’t look like now is a good time. Can we come back later to talk?” she asked. She looked uncomfortable but in a different way from the patient.

“Not if it’s about depression,” he said.

We left in a flash, as if the room were underwater and we required air. I wasn’t sure if Amari was supposed to try harder to establish some connection or get more information from this poor kid, or to what purpose any of it was. I asked her.

“His mother says he hasn’t been taking his medication. Is he passively suicidal or just hopeless?” she proposed. I reflected on the meager difference between the two.

Camille went off to call the boy’s mother for more information. Raymond and Amari and I found one of the boy’s doctors and asked him for his impressions. “He’s really dependent on his mom,” the doctor said with some disdain, though it only made sense. While other kids were out navigating psychological separation, this one had been on an operating table getting a kidney transplant, or in a hospital room having his blood cleaned by machine. I felt angry toward the doctor then. If we were all angry and critical enough, maybe none of us would have to think about this boy and his horribly raw deal.

Back at the nursing station, Raymond and I sat down. Amari turned to me: “Present the case.”

I had spent the last five months learning this model, but applying it to psychiatric patients exclusively. Of what relevance
was it to this kid, and what was I even supposed to know based on our very brief interaction? “Uh, he’s oriented in all spheres?” Was he? He knew his name, certainly, but Amari had not asked him the date or where we were. These questions would only have irked him more.
I’m not crazy
.

“Start with appearance,” she said.

“He’s adequately groomed?”

She shrugged. “Looks much younger than stated age,” she said.

“Right,” I agreed. “Speech: low volume, normal rate. Mood: depressed.”

Raymond interrupted. “No. Mood is subjective. He said he’s not depressed.”

One-upped by the med student and his meticulous memorizations.

“Affect is appropriate to content,” I continued. “Speech is goal directed, indicating an organized thought process.”

Camille came back and interrupted our exercise. “His mother says he’s been sad for two weeks,” she said triumphantly.

Camille, too, was a conscientious learner. When one is differentiating among the depressive diagnoses—our immediate goal here after all—duration of illness was defining. A diagnosis of “major depressive disorder, single episode” (
DSM
code 296.2) required two weeks of sadness. Dr. Malou weighed in. “We can’t rule out mood disorder due to a general medical condition,” she said sagely. (
DSM
code 293.83.) “We can’t really know.”

But even if we could, what then? Amari spoke as if these distinctions were meaningful here, rather than just bureaucratic, and I began to feel the familiar agitation that psychiatrists engendered in me, with their unspoken insistence on the
primacy of their truths. Who was this kid, and why did we all need to flee him so quickly? If that was happening with everyone in his life, his isolation must have been unbearable. We could conclude that this boy had an adjustment disorder with depressed mood (309.0) or dysthymic disorder (300.4) or depressive disorder not otherwise specified (311), and maybe based on the symptom checklists of the
DSM-IV-TR
, one or the other of these would be more technically correct. This was medical psychiatry at its worst, treating people like math problems, adding up symptoms and their duration and pretending it meant much.

We finished writing a chart note and tromped down the stairs to report to Dr. Kapoor. He said that maybe this was my first CL therapy case. He must’ve thought there was something I could offer this boy. I wondered what that was. The next day I returned to pediatrics alone to find that he had already been discharged.

The psychiatrists knew scintillating facts. Like: IQ predicts the idiosyncratic success of antipsychotic medication (the lower, the better Depakote and Haldol; the higher, the better Seroquel and Clozaril). Or: cocaine can cause a psychotic depression up to two years after the drug’s last use. And: people in the midst of delirium tremens are at risk for stabbing themselves. (“Bipolars stab themselves in the stomach, schizophrenics in the genitals!” declared Dr. Cherkesov.) I was so impressed with what the doctors had learned that the things they did not think about tended to befuddle me. The very fact of my befuddlement, time and time again, stood out in my head. These people were authority figures, and yet I seemed to have picked up some things that they had not. Here it was again,
this ridiculous fact. If it did not bolster my self-denigrating tendencies, at least it supported a multidisciplinary approach.

Two mornings a week Dr. Kapoor worked in Downstate’s outpatient HIV clinic, seeing patients whose doctors thought they might have psych issues. His job was of course to diagnose them and then to prescribe medication based on the diagnosis or to refer them out for therapy. The HIV clinic had different policies from the rest of the hospital. Whereas the medical students and I generally traipsed around seeing inpatient consults as casually as if they were traveling museum exhibits, the clinic patients had to consent to our presence before we were allowed into the room. Most often, quite reasonably, they said no, and so I had already spent more than one morning just sitting in the clinic’s comfortable waiting room with my laptop and my dissertation data while Dr. Kapoor worked alone.

That morning, though, Dr. Kapoor called me into his clinic office when I arrived. He was seated with a bulky white man in his early thirties with close-cropped brown hair. The man introduced himself as John. John was dressed in black jeans and a black T-shirt, with two prominent tattoos keeping company on his bicep, a colorful crucifix and a black-as-night shotgun. John had just arrived and didn’t mind if I listened in. I took a seat in the small consulting room. John explained that his doctor had referred him to Dr. Kapoor because he’d been experiencing panic attacks. He’d been having them for about a year actually, ever since he’d gotten clean after fifteen years of heroin use. He’d tolerated the attacks for many months, but the more comfortable he got with his sobriety, the less willing he was to put up with whatever his body doled out, and so he’d finally mentioned them to his primary care physician. Could Dr. Kapoor prescribe him something to stop the attacks?

Panic attacks, by definition, have no discernible precursor. They come on suddenly and apparently apropos of nothing, and so it’s easy for people who suffer panic to feel as if it’s simply a random physiological event. I wasn’t certain that psychiatry disagreed with this, though I knew that psychology did. The psychoanalytic take on “apropos of nothing” is that it is not “nothing” at all but rather some unacknowledged meaningful stressor that triggers rage. Intense anger is not something that many people, and panic sufferers in particular, are comfortable feeling, and the overwhelming need to keep it out of consciousness necessitates a physiological response: the shortness of breath, the sweaty palms, and the fear of death itself are potent distractions. Panic symptoms are a compromise, as unsatisfying as any. Their occurrence suggests specific unconscious conflicts that serve an important psychological purpose, and bringing these conflicts to awareness is the specific goal of psychological treatment. The panic attacks go away, and the patient has access to a necessary depth of human experience as well.

I wasn’t sure what Dr. Kapoor’s personal take on panic attacks was—if he thought they were meaningful beyond the physiological symptoms. Dr. Kapoor was obviously smart and also thoughtful and had tried to get me going on a “therapy case,” but I had seen too many competent minds dismiss psychological underpinnings to maintain any faith that such an approach was always beneath him. While I began to think about John’s problem in the context of what little information I had about him—his history of heroin addiction, the dueling symbols on his arm—Dr. Kapoor’s questions for John did not imply that his symptoms warranted any further exploration. They were simply to be counted. Did he meet the criteria for panic disorder (300.21) or generalized anxiety disorder (300.2)
or panic disorder with agoraphobia (300.22)? Whatever else Dr. Kapoor might have been thinking was not communicated to John, which would only reinforce the patient’s sense that such a problem could only be treated with pills. The attacks themselves would likely become less incapacitating as long as he stayed on the meds, but the medication would do nothing else to help him live a fuller life. For the momentary comfort the pills offered, their limitations precluded so much that was worthwhile and less ephemeral. Dr. Kapoor would see John to follow up on the meds but at least for the time being did not recommend psychotherapy. I sat there on my hands.

I’d come to CL hoping for a certain effortlessness, a temporary engagement followed by a complete and permanent lack of involvement. I could already tell that there would be times when this would be enough, when all there was to say was “Patient did not have a panic attack” or “Despite tears, patient is not depressed.” But I also already felt that familiar resentment, the insult to my self-esteem as I watched people who had more experience than I—whose very job I’d presumed it was to know more than a mere trainee—address something psychologically treatable as if it were not so. In this way, CL offered me anything but ease, at least for as long as I chose to maintain my lesser-than position. Student. The moniker had worn so thin, my last and sorriest excuse.

That afternoon I went to Scott to ask whether he might dig up a psychologist to provide some extra supervision during my time on CL. I craved my own discipline’s perspective, which was the implicit promise of this internship and one that had been only minimally fulfilled. He acknowledged the soundness of the idea halfheartedly, and we both knew we’d never speak of it again. Later in the week I asked him for a letter of recommendation. It was March and time to think about
what would come next, and there was a job I was applying for. Scott hedged in a similar way, and I knew it was one more thing he wouldn’t give me. I left his office unsettled.

Dr. Winslow was the youngest CL attending, and the best looking. He might have been a catalog model for J.Crew or the Gap, and he was yet another CL brainiac besides. He’d been on CL at Bellevue before coming to Downstate, and he sang the praises of the interdisciplinary team there, but he never sent me alone on calls like Dr. Kapoor did, and Tamar said he never would. One morning I walked into the consult office toward the end of a conversation he was having with a resident. They were discussing a patient in obstetrics we’d be following up with that morning. “She has an outpatient therapist who she’s been with for a while, but she’s no good. She’s a social worker,” he said to the resident. His last sentence dripped contempt. He looked at me and smiled handsomely. He was really very handsome. “I don’t know about you, but I don’t think much of social workers as clinicians,” he said with a conspiratorial glinting smile.

Well, the damnable truth be told, I didn’t either. We all needed somebody to buttress our professional worth. Physicians had psychiatrists, who I’d come to learn were the scourge of the medical profession. Psychiatrists had psychologists. Whom did we have but social workers? One of my professors told this old joke, and George liked to repeat it: social workers want to be psychologists, and psychologists want to be psychiatrists, and psychiatrists want to be psychoanalysts, and psychoanalysts want to be tall. I suspected Dr. Winslow had no more regard for psychologists than he did for social workers.

“When you see the patient, tell her she should really be in therapy with a resident,” Dr. Winslow continued, addressing the underling doctor again. Dr. Winslow was my own age and easier to challenge than the others, and I was starting to feel I’d earned the right to speak up, or that maybe I’d had it all along.