Twelve Patients: Life and Death at Bellevue Hospital (7 page)

“And trauma, Ingrid? A common denominator?”

“For the kids we see usually it is. But not always. Take Emily, for example. Her doctors have looked high and low for trauma, parental abuse, or sexual abuse, but many times that’s not the case. There are other subtle issues like personality, coping skills, and environmental cues that we don’t know about. Remember your biology: Kids are what their grandmothers ate!” She smiled and got back to business.

Through the window I saw a girl about ten years old accompanied by a young female psych tech approach the two teenagers at the table.
She had been watching them from a seat outside her room where she had sat through a fifteen-minute “time-out” for a mini tantrum when she refused to get dressed for breakfast. The two girls looked at her as she spoke to them. They then made room around the table, and the tech pulled up another chair and brought some paper and crayons. In a few minutes she was hunched over her project. Tanisha lent her some pencils, and Emily started talking to her.

The picture that emerged of Emily was a pre-pubertal girl with a pretty average upper-middle-class life, who developed fluctuating or exaggerated emotional highs and lows in first or second grade. Then over the years she was diagnosed with depression, anxiety, histrionic personality, schizo-affective disorder, eating disorders when she suffered from anorexia and bulimia, conduct disorder, borderline personality disorder, and manic depressive disorder plus a handful of other “disorders” from the
DSM
, or
Diagnostic and Statistical Manual
, psychiatry’s bible for the last thirty years. Equally impressive was the list of medications in another column with dates connected by arrows to the disorders, as well as a list of psychiatrists, psychologists, and psychiatric social workers she had seen in a decade of peripatetic therapy throughout the city of New York. The list of medications included all the SSRIs I was familiar with and a few I had seen on television ads but didn’t know anything about. Ritalin and long-acting stimulants, anti-psychotics from Abilify to Seroquel to clozapine, and a long list of anti-anxiety medications in a broad range of dosages from short to long acting. Emily was also taking a variety of other medications for allergies, mild asthma, abdominal pain, menstrual cramps, and migraine headaches, along with birth control pills.

I watched her through the glass. She was so young. As she sat drawing with Tanisha and the younger child, I found it hard to believe that she’d been medicated for most of her life. In fact, watching them, I was struck once again by how very difficult it is to grow up in our environment. Both of these young women thought actively about dying, about taking their own lives. Money did not cushion all blows.

For Emily, the problem maybe consisted of too much “care” rather than too little. The kinds of therapies she had received were as diverse
as her diagnoses and medication lists. There was a prominent Freudian Manhattan psychoanalyst. There was a Jungian analyst, a psychotherapist, three different psychologists who specialized in personality disorders, one who taught Cognitive Behavioral Therapy (CBT), and another Dialectical Behavioral Therapy (DBT), a third specializing in neurocognitive testing, and a fourth at the bottom of the page involved in investigational work with a new treatment group modality for personality disorders at Columbia. The social workers included therapists from Brooklyn to Queens, Manhattan’s lower reaches, and its northernmost enclaves near the Cloisters. I was totally baffled by Ingrid’s list—and at the same time it gave me a deeper insight into Emily’s problems and her parents’ frustrations, hopes, fears, and feelings of hopelessness and helplessness in the face of the diagnostic and therapeutic overkill. There was another column labeled “misc” for miscellaneous. This column included gynecologists, internists, neurologists, gastroenterologists, pulmonologists, acupuncturists, Chinese herbalists, and some I couldn’t interpret.

I arranged to attend a group meeting on 21 West, the inpatient adolescent unit, a few days later. The floor is for kids only, in the middle of our 350-bed psychiatric hospital within a hospital.

The head nurse, Jane Tyler, unlocked the unit for me and then locked me in when I went through the gray double metal doors. She put her finger to her lips and waved me over to her, whispering, “We are just starting the unit daily meeting. Come in and join us.” She pointed to an empty seat between the art therapist, Julie, and a young skinny Chinese boy whose age I could not guess. Twelve? Fifteen? He sat quietly drowning in the folds of his hospital gown, looking down at his hands in his lap.

We went around the room for introductions. A 21 West unit head nurse ran the meetings. She was firm and established rules of politeness and respect that were repeated in unison. At the same time she was tuned in to every gesture and emotional nuance in the room. Tanisha and Emily sat next to each other opposite me. They each had black speckled notebooks in their laps. They opened them during the meeting. They appeared to be reading from them or taking notes from time to time.

In the middle of the meeting a boy named Tyrone, who appeared to be eighteen from his size, began shouting and stood up in the middle of the room. He felt one of the other boys had looked at him and said something disrespectful. Several behavioral health aides got up at the same time and surrounded him. One RN left the room and came back three minutes later with a psychiatrist, Tom Tregerman. When Tyrone saw the psychiatrist, he looked at him and started to explain what had happened. At the same time he relaxed, put his arms down, and walked with the physician from the room. Tom was the one person who had an immediate calming effect on Tyrone. He was enormous for his age and had caused serious property and bodily damage to another patient and an aide during a flash outburst. As I remembered Tyrone’s “story,” his childhood had been like living in
Apocalypse Now
.

Tyrone talked about his father all the time, asking when was he going to come and visit? When did he call? Did he know the phone number and address of the hospital? Those of us who knew his story understood that the father had abandoned him as a small child. He and his mother lived in poverty, and the father failed to provide child support. His visits, when they happened, were short and unannounced. Tyrone lived for them. He was on the waiting list for the state hospital. There had been too many failures sending him home and to alternative “residential” homes in the archipelago of child and adolescent facilities. What was his future? His life trajectory? Next stop adult psychiatric unit, or Rikers Island, or a mix of both? You didn’t need to be a soothsayer to see into the future.

The part of the brain that processes emotions and perceived inputs like fear into rapid bursts of hormonal outputs is called the amygdala or emotional regulator. It’s the part of the deep ancestral brain that responds directly to environmental signals, premonitions, and threats. The conscious neural connections to protect this part of Tyrone’s emotional brain from being directly activated were poorly developed, perhaps destabilized by childhood trauma or even stress in utero as a developing fetus. The external environment offered no stabilizing or mitigating relief. The hope of his team of therapists was that routines and predictability, rewards for positive behavior, and careful schooling
under reliable supportive supervision could start to rebuild the missing pieces. Create a mini scaffolding to build upon. He desperately needed to be cared for and loved. The moving pieces on our units, the staff rotations and shift changes, vacations, and absences for illnesses, made it all seem confusing and reproduced the most profound emotional activation in him, rejection. The state hospital would be a short-term “solution” in this situation. Drugs would calm his behavior, and he would be looked after in a reasonable environment in central Queens.

I caught up with Tanisha a few days later in PS 37, the inpatient school for kids. This New York City school is at the opposite end of a long corridor from the adolescent psychiatry unit. All of the classroom windows look out onto the East River. She was sitting in a social studies classroom with three other teenagers. The top of her head half covered a notebook. Mr. Vargas waved me in and introduced me to the class. I sat next to Tanisha and asked, “
¿Qué tal, Tani? ¿Cómo va el diario?
How are you doing and what’s up with your diary?” The kids were encouraged to journal and use art to express themselves. They used the large pads and colored pencils and crayons to share something about themselves. We reviewed the art as part of the forensic evidence of the kids’ emotional “temperature” at daily rounds.

The drawings were posted around the units and exhibited in the hospital’s giant atrium. Like outsider art, art from untrained, non-professional artists, some of it was spectacular. It was the amygdala speaking truth to power. And some of the most provocative art came from patients who could not verbalize what was going on in their heads. I had gone to outsider art exhibits in New York where the best work was by hospitalized patients forgotten in long-term facilities. Martín Ramírez drew exquisite and intricate pictures of interiors full of trains on used brown grocery bags. The recluse Henry Darger created erotically charged internal fantasy worlds of a depth and richness and erotic sensibility that gave you pause. Cracks in the wall. How to interpret the subtle signs from the kids’ hidden worlds? What did the newest diagnosis, conduct disorder, mean? An authorization to use Zyprexa?

Tani. That’s what she was called on the unit; her
abuela
had called
her Tani. “I am writing about my life. Besides, I am finding things I had forgotten. Places where I had lived and people who I knew but had been buried someplace. I have seen some strange stuff. You guys think I am making it all up.”

“You know, Tani, we hear and see some unbelievable things that kids cannot make up. I don’t think there is one thing you have shared with us that we don’t believe. Not one. You really amaze us with how well you look after yourself. We know your suffering has been real.”

“Well, maybe sometime I will share this with you. You told me you keep a journal. You always have that little black notebook with you in your pocket. I see you taking it out and writing in it. What do you put in there?”

I took it out and let her thumb through it. “I have a hundred of these notebooks. I have been writing down my thoughts and the odd things, connections that I know I will forget. Like a vivid dream that wakes you in the morning and then vanishes.”

“The stories that
Abuela
told me come back in dreams. Like last night I was riding a horse bareback in the countryside. Going to the next town to get some milk for a baby I helped deliver, and the mother’s milk had dried up. I was terrified the baby would die before I got back.
Abuela
was a midwife. She told me many times there wasn’t enough food for everyone. They pretended to eat. She said in Haiti, just over the border, they were so poor they ate dirt. They made it into patties, cooked it, and ate it. Just to fill their bellies. She said so many babies died over the border they stacked them in the morning like wood and at the end of the day a man would come and put them on a cart and take them away.”

My mind drifted to my time as a medical volunteer in central Haiti, in the Artibonite Valley. The neonates did die, a lot of them. The ones with tetanus were hard like cordwood. Their tiny emaciated cadavers frozen in a death rictus. Their ribs like grinning teeth. They were stacked and taken away by a man with a cart. I didn’t know where they went.

We sat and talked until the bell rang and the class was dismissed. The kids moved to music and art class two doors down at the southern
end of the corridor. “I am drawing my dreams as I write about them,” she said as she packed up her stuff. “I will give you the one I have been working on this week.”

The kids were escorted down the hall by a tall well-groomed black man wearing a suit and a yellow tie with a lovely smile. “Okay, kids, let’s get to it. Music and drawing. Work and fun to be done. Dr. Manheimer, you are welcome to join us. We do some great stuff in here.”

Tani pulled out a large drawing from her personal stack. Chagall would have been proud. “I had a dream I was on the farm in the DR, the Dominican Republic. All of the animals were talking like humans, just like us. Many were half humans and half chickens,” she said, pointing to one peculiar beast that had the head of a chicken and the body of a man but also had wings and was floating through the air. The yellows were mixed with reds, blues, and purples. An enormous moon eclipsed the sun so only a sliver could be seen. Animals and people floated by. A silver-haired woman rode a horse in the center with a man behind her. His arms were wrapped around her. “You can keep this, Dr. M.” It was beautiful and dream-like. There was no anger or rage in the picture. Everything was in harmony. The center was holding. The couple, clearly Tani’s
abuela
and her
marido
or husband, were the force holding everything in orbit as they moved around, floating in the ether. Something clicked at that point. I made a connection and wrote a note in red ink in my black notebook with the picture secured under my arm. I took the elevator down to my office.

Patty buzzed me on my cell phone as I was checking my email on the BlackBerry waiting for an elevator. The Abeloffs, Emily’s parents, were in the office. Of the dozens of emails that had accumulated, a couple stood out.

I apologized to the Abeloff family for my lateness as we settled in the office. Emily had been with us for over two weeks at this point. There had been family meetings and a miscellany of private discussions. I thought they wanted to transfer her to a private hospital in the suburbs, or perhaps a bed had opened at one of the private hospitals in the city, maybe even McLean in Boston or the Hartford Retreat.

“We want to thank you for the care our daughter has received on
21 West.” Ariel Abeloff took the lead this time. Her face was different. It wasn’t frozen with fatigue and resignation.

“Dr. Adrian spends hours with us. She patiently walked us through the entire course of Emily’s illness. The multiple diagnoses, the hundred and one treatments, and the one-inch stack of medications.” She paused for a moment and looked at her husband. “For the first time we have a handle on the issues both for Emily and for us.” I listened.