The Big Roundtable

Something More Wrong

July 25, 2013

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1.

A kind of laziness brings me back to normal life. I am like a prisoner who is enjoying an imaginary freedom while asleep; as he begins to suspect that he is asleep, he dreads being woke up, and goes along with the pleasant illusion as long as he can. – René Descartes, Meditations on First Philosophy

In the mornings, Creedmoor Psychiatric Center’s Ward 3B resonates with a brand of white noise unique to a psychiatric hospital. It is loud with tinkling and crashing pumped in from television speakers: the metallic rush of the Price is Right wheel pulled by the show’s spinning, smiling winners. Loud with the snores of still, slumped bodies in sticky vinyl chairs, with the shuffling of the 40 slippered and sneakered feet that pace between the two dayrooms, that wander around the nurses’ station. Loud with the rollicking cackles of Caribbean therapy aides. With occasional outbursts over thefts real or perceived—“I wanna see her fit in a size 18! Let me see her breasts fit in my size 18 shirt. I wanna fucking see that right now, hippo!” Fights flame up and flicker out, undulating with moods, obscuring but never quite eclipsing the television and the miniature people who live so noisily inside it. The floor echoes with the game show announcer introducing his grand prize, a state-of-the-art home entertainment system. “If you’re anything like us,” he booms, “you watch a lot of TV!”

Alice Trovato watches a lot of TV. Sitting here, she looks like any other 52-year-old Queens housewife idling the occasional lazy morning in her living room to the soundtrack of soap operas and sitcoms. But Alice, clad in a navy institution-issued sweatsuit that stretches at the belly and tennis shoes that squeak across the linoleum, can be found here every morning dispensing wisdom to fellow inpatients, her surrogate daughters, from a chair she calls her “therapist couch.”

Though Alice’s skin is pallid and her cheeks sunken, her brown eyes are comparatively lucid in a room filled with women alternately sedated or enraged. She comforts Shania, who believes a bulldozer is parked inside her forehead, and Sabrina, who thinks an ex-boyfriend has taken custody of their nonexistent septuplet babies, whose names she cannot always remember but each of whom is called a different diminutive form of “Angel.” She chides the woman called simply Rodriguez—who scratches and spits during fights and has an unnamed communicable disease the ward psychologist says “you don’t want”—for disrupting therapy groups, and counsels Cynthia, an obese 20-something who hears voices, against her meal of Snickers bars—a meat patty, pastries, and Pepsi—even as chunks of cream cheese dangle from the girl’s lips and bits of bagel fall to the floor.

The dayroom is not a living room and these women are not Alice’s family—her own grown son and daughter live, as does Alice’s husband, on their own on the outside. Alice’s “daughters”—the three or four young women who call her Mama, waist-deep in depressions and psychoses similar to those Alice herself has battled, for a comparably shorter period, over the last five years—stroke Alice’s scalp, tie her hair up for her in a tight bun, and unleash to her their problems, actual and imagined, comprehensibly or unintelligibly. She is the ward’s elected president, a self-described advocate for those here contending with disorders she believes are more incapacitating than hers. Most days, she’s feeling better.

Sometimes, though, angry voices and strange images emerge from the tightly folded recesses of her mind. Remnants of an abusive childhood, embedded in her memory the way accustomed-to house mice are in the walls of her old apartment, their presence, though once infuriating, forgotten until one scurries out from a hiding place, irrepressible, and she is forced to admit: “You’re here for your own self, too.”

Alice arrived at Creedmoor Psychiatric Center in September 2010 after spending eight months in Elmhurst Hospital Center following her latest suicide attempt. By the time she arrived on Creedmoor’s 3B, a ward historically known within the hospital as “one of the wildest” wards for its “out of control female patients,” she had been living full-time in psychiatric wards for over a year, had tried to kill herself in five separate, violent suicide attempts, and had been admitted to 14 different hospitals. For Alice, Creedmoor is both the latest stop and the last resort on a five-year-long involuntary journey into the depths of her illness.

 2.

“The general effects of fine air upon the animal spirits would induce us to expect especial benefit from it, in cases of mental depression Several instances have occurred, in which melancholy patients have been much improved by their journey to the Retreat.” From Description of the Retreat: An Institution Near York, for Insane Persons of The Society of Friends, by Samuel Tuke, 1813

Creedmoor Psychiatric Center sits on 200 acres in Queens Village, a residential neighborhood spliced by the Grand Central Parkway and Union Turnpike, and bordered by the leafy wetlands of Alley Pond Park in eastern Queens. The land it sits on remains largely unchanged from its depiction in “Creedmoor—Bird’s Eye View of the Crowds,” a painting reproduced in an 1877 issue of Harper’s Weekly: sprawling blond grass, clusters of trees, and flattened acres stretch across a landscape then, as now, as vast and bare as muslin pulled taut over a loom.

The land where Creedmoor’s campus now scatters, some of its 50-plus buildings long abandoned, was first a plot of farmland owned by the Creed family before its conversion into a National Rifle Association shooting range and National Guard barracks. A psychiatric hospital opened in 1912 with 32 patients; by 1933, its maximum capacity had exploded to 3,319. In September of 1958, when Alice was born, Creedmoor was in the midst of its busiest and most overcrowded period, serving between 6,000 and 7,000 patients, who paced the sprawling grounds and performed in choral groups, an orchestra, and minstrel shows.

Beginning in the 1960s, however, newly developed antipsychotic drugs and changing social policy led to the rapid deinstitutionalization of psychiatric patients here and throughout the country, shifting the burden of their care as much as legally and medically possible from the shoulders of the state to the backs of their communities. By the end of 1985, Creedmoor’s population was down to 1,258. Ten years later, it had dropped to 924, and by 2005, when Alice began having “breakdowns,” the population had shrunk to 449. The year she checked in, 2010, Creedmoor’s average daily population had dwindled to 393, with 386 admissions and 390 discharges accounted for that year—a statistical success, in the view of the New York State Office of Mental Health, whose goal, according to one staff member and echoed by others, is to “get them in, so we can get them out.”

Creedmoor continues to serve its designated district, the 2.3 million-person, 112 square-mile borough of Queens, with 16 wards and 395 beds for longer-term inpatients, in addition to outpatient services, the predominant treatment for the mentally ill in the years following deinstitutionalization. The majority of the patients here are on Medicaid; as a state hospital, Creedmoor cannot turn anyone away, including illegal immigrants and the uninsured. Many suffer from chronic schizophrenia’s fixed delusions (“They wouldn’t know to come in from the cold,” explains Kevin Lynch, the hospital’s director of quality management and a licensed social worker), from schizoaffective disorder, or from other thought disorders. Before arriving here, they believe “‘this life’s not working out for me,’” says Lynch. “Everybody’s here because things weren’t going well out there.”

For employees and visitors, there are a few ways to get here: Exits 23 off the Grand Central or 28A off the Cross Island Parkway, or a combination of subway routes and a handful of buses. Creedmoor evokes for longtime Queens drivers a peculiar curiosity: Framed by the pristine, lonely edges of Alley Pond Park, the two-winged main building cuts a silhouette evocative of the Lincoln Memorial’s statue of the seated president, but bereft of any elegance, its color that of sun-blanched sandstone. Dropped, seemingly, into the only remaining area of Queens uncluttered enough to hold both its campus and the expansive grassy radius that seems to protect it, Creedmoor could not be mistaken for anything other than a hospital or a housing project; it remains an unsettling, 17-story question looming high above the low-slung homes that hedge it and that look as though they want to keep their distance.

To come to Creedmoor as an inpatient is to travel a very different route. The institution accepts only adults who are classified as “severely ill” and at high risk of hurting themselves or, less frequently, those around them. Patients must be referred by another hospital; there are no walk-ins accepted. Sometimes they are transferred voluntarily; other times, with only the consent of their caretakers. While policy may have made the route more labyrinthine, Creedmoor remains for those who find their way here—for Alice and others chronically suicidal like her—the only remaining defense against themselves.

Alice arrived on the admissions ward in September 2010, referred by Elmhurst Hospital Center, a public hospital in Queens. Upon admission, she was, as all new patients here are, analyzed according to Creedmoor’s Psychiatric Assessment, a standard 11-page questionnaire that details every aspect of her medical and personal background: Illness onset (early 2005); symptoms and diagnoses (auditory/visual hallucinations, severe depression, suicide attempts; a bipolar disorder misdiagnosis that was recently changed to schizoaffective disorder); marital status (married to her childhood sweetheart, “the only man I ever had,” Alice calls him); medication regimen (18 pills, administered throughout the day); hobbies (crochet, reading).  Less quantifiable aspects are recorded as well. Question 10 asks, “Does the patient seem motivated for education/treatment?” Alice, says social worker Jacquelyn Smith, a young woman with an eyebrow ring and mousy ponytail, is very motivated.

In October 2010, Alice was transferred to ward 3B, an all-female inpatient unit on the third floor of the main building known for dialectical behavior therapy, a Zen-based cognitive therapy instituted here in 1995 that has since proven effective for reducing suicide attempts and other forms of self-harm. The windows of the activity room on 3B frame a skeletal bustle of leafless trees that separates the parkway from the houses beyond, which are invisible from this vantage point.  Muted cars speed across the asphalt in the distance. Before her admission, Alice drove down that parkway often. “I used to live on Long Island,” she says. “Whenever my husband and I would drive by Creedmoor, I’d say, ‘I wonder what it’s like in there?’” Today, in her fourth month living at Creedmoor, she says, “Well… I know.”

 3.

I been working, mister, since the day I was born
/ Now I worry all the time like I never did before ‘Cause I ain’t got no home in this world anymore / Now as I look around, it’s mighty plain to see
/ This world is such a great and a funny place to be
 / Oh, the gamblin’ man is rich an’ the workin’ man is poor, And I ain’t got no home in this world anymore —I Ain’t Got No Home by Woody Guthrie, who died at Creedmoor in 1967 after suffering from Huntington’s Disease

Despite the ever-present jangling of keys, the cool air noisily pumping through the vents, the back and forth of the aides and the running faucets in the bathrooms whose doors fly open and slam shut, 3B has an odd sort of peace this weekday morning in mid-January. Some patients sleep, others read. Snow piles up outside, gently. Alice sits in her chair, breaking from a Danielle Steele novel to chide a young Middle Eastern patient for leaving the bathroom without washing her hands. “That’s not hygiene!” she calls after her. She takes another break to whisper comfortingly to Sabrina, who bemoans her lost newborns.

 

The ward’s psychologist, Dr. Yakini Etheridge, a woman in her early 30s with eyes that bulge behind glasses that slip down her nose, and Smith, the ward’s social worker, sweep into the dayroom and jostle some patients from their sleep. It’s 10 am and time for the day’s first group. Inpatients in 3B, and most of the Creedmoor population, are required to attend therapy groups; whether oriented toward fitness, health, or psychology, all are known simply as “group.” The therapy used on this ward, dialectical behavior therapy (DBT), commonly referred to as ”East meets West” by the staff and by program materials, is a blend of cognitive-behavior therapy and Zen meditative practice. Over 10-week periods, Etheridge, Smith, and two Columbia University social-work interns teach skills related to two of DBT’s four core principles at a time. This morning’s principle, “Interpersonal Effectiveness,” emphasizes the connection between self-respect and certain skills: How to say ‘no,’ how to ask for what you want, and how to resolve conflict.

Etheridge begins the group by ringing a bell three times, a hallmark of DBT meant to increase “mindfulness of the present moment.” Mindfulness is a core theme of this therapy: Before groups start, the leaders ask each patient to rate her mindfulness on a scale of one to 10, and most groups close with an exercise, such as standing on one foot, to direct their attention to the present moment. Jackie announces today’s topic: Friendship. What do the patients have to offer a new friend?

“I have a very good heart,” declares Alice.

“Mind your business,” another responds.

The staff sometimes overlooks or corrects back talk. Otherwise, they try to decipher a provoking remark: “OK,” Etheridge translates. “So, you respect their space.” She skips over some sleeping patients, shakes others’ knees lightly to rouse them. Many patients sleep in these dayrooms all afternoon, exhausted by the side effects of certain medications, and rarely pose enough of a physical threat to themselves or others as to require medical restraint. Sixty years ago, the dayroom would not have been this sedate: Creedmoor’s population was more than 12 times what it is now, and none of the patients then were yet taking the sort of anti-aggression, antipsychotic drugs that today’s comparably calm patients are prescribed. Chlorpromazine, an antipsychotic with sedative effects widely distributed beginning in 1952, was a precursor to today’s antipsychotics: Chlorpromazine revolutionized psychopharmacology, indelibly altered mental healthcare, and, made Creedmoor’s most aggressive patients so docile that the hospital experienced a 50 percent decrease in use of restraint by 1956.

 

Making friends, starting conversations, understanding body language—these are skills most begin to learn in kindergarten. But the typical 3B patient was abused between the ages of five and eight, was raised in foster care, and has a history of emotional instability and impulsivity. She is usually diagnosed with borderline personality disorder, schizoaffective disorder, or drug abuse. (Borderline is an emotional disorder characterized by rapid, dramatic changes in mood, erratic behavior, and an inability to regulate emotion. Though Alice is formally diagnosed with schizoaffective disorder and depression, her social worker and psychologist agree she has borderline features, too.)

“Bah, humbug,” mumbles Rodriquez, a 37-year-old grandmother with rotting teeth and the communicable disease.

“Are we alive today? Are we here?” Smith asks.

“We’re all present,” says Rodriguez, her short bushy hair in three randomly placed pigtails. “But we’re not present.”
DBT encourages these women—who “go from zero to 60 [MPH],” says Smith, and genuinely believe hurting or killing themselves are legitimate solutions—to abandon the traumas of their past for the present. Having led lives filled early on with dramatic pain, most were never taught how to endure the small disappointments of daily life without disproportionate reactions: cutting, overdoses, suicide attempts. Alice’s own childhood was marked by trauma that returned as psychosis in 2005, triggered by an empty nest, a stressful Wall Street job, and deepening depression. As a young girl, she was abused by her grandfather, whom she lived with during the schoolweek. “I started feeling depressed at the age of ten years old, already,” she remembers. Her grandfather would lock her in the closet and prohibited her from speaking. She remembers using the roller skates her parents bought her, though her grandfather had warned her, “Young ladies don’t roller skate.” He lit a fire and burned the soles of Alice’s feet in punishment. Decades after his death, Alice would begin hearing his voice, telling her to hurt and kill herself.

Antipsychotic drugs combat hallucinations like Alice’s, while the staff teach the women strategies for coping with the past and developing healthy relationships. Smith sits below a laminated sign reading “I HAVE HOPE,” in block letters. She asks, rhetorically, “Do people ever just knock on your door, asking to be friends?” But the ward is essentially organized like a dorm, where people do knock on doors asking to be friends.

“Avon calling!” shouts Rodriguez.

“Yes,” says a patient. “Alice comes by.”

“Well, this [Creedmoor] is a different situation,” Etheridge trails off. “Outside, people won’t be knocking on your door.”

A patient volunteers to read from the DBT handout, her tone flat and pronunciation choppy: “‘Make eye contact and smile. If you have an unfriendly countenance, people are less likely to be receptive to your friendship. Be approachable by not squinting.”

Etheridge asks: “What does it look like if you’re squinting at someone?”
“Like you’re mentally ill,” offers Rodriguez.

 

Carla, an enormous young black woman, slumps in the corner, her head fully covered by a winter coat. Cynthia dozes off, drool collecting at her chin. Alice prods her knee to no avail. Friday is coming up, and Alice doesn’t want Cynthia to lose the day’s privileges: a trip to the Big Nosh, a food shop on the second floor that sells $2 pizza and, blessedly for Alice, caffeinated coffee.

Some, even those with psychosis, are able to have rational conversations. Able, that is, as Lynch says, “to tell you the time of day.”  Alice, and a few others, wouldn’t draw a second glance on the bus or at the market, her illnesses almost as deeply concealed as they were throughout the first 45 years of her life: “Pieces of this were there, but it took building up,” Etheridge explains. These pieces are easy for Alice to explain, harder for her to accept: Daily early-morning deadlines at work meant that she often spent just six hours at home each day. The children she had built her life around, her son and daughter (who, at 26, suffers from multiple sclerosis), had recently moved from home. Poor financial planning left Alice and her husband, an electrician, reliant on a state housing program. And ever-present though invisible, her abusive childhood, her physical ailments, and her as-yet undiagnosed mental illnesses hovered, amassing just out of sight.

“Why not practice half-smiling while listening to music?” suggests Etheridge.

“Everyone tells me that my smile is cute,” says Sabrina. Alice agrees and smiles back as she always does, with her mouth closed. Alice’s jowls droop when she talks, as though she doesn’t have teeth.

Etheridge says, “It’s nice to have a pleasant expression, even if you’re not a smiler.”

Carla wakes up, emerging from her makeshift sleeping bag to volunteer the group’s closing mindfulness exercise: “We can go around and say how our weekend was.”

Etheridge agrees—”My weekend was good,” she says.

“I caught up on some reading,” says the older white woman who is usually angry.

“I think you should skip me,” says the other older white woman who is usually sad.

“I listened to Spanish music,” says the girl who resembles a latter-day Michael Jackson. The next patient just giggles.

“I got a lot of work done,” says Alice.

She reads, and writes dutifully in a journal she’s kept since her early hospitalizations, which started after, at age 46, she tried to kill herself by jumping onto a subway track. (“My husband left for work. I didn’t have the kids home. I just got up and took myself to the train station in Astoria and jumped on the tracks. It was weird,” she says. Two men rescued her and she was taken to Bellevue.)

“And,” Alice adds, “I visited with my husband.”

He comes to Creedmoor because she won’t, even on short visits, return to their home—a roach-and vermin-infested apartment they rent with government help. Social Security did not consider Alice’s bipolar diagnosis a disability that would entitle her to financial support, but, with the schizoaffective designation, Alice’s lawyer hopes she will soon receive disability, plus five years of back-owed support; she plans to use the money toward rent on an apartment in Middle Village, a predominantly Italian-American, working-class neighborhood. If there’s any extra, she and her husband will put it toward a house upstate; for now, though, “we’ll just need a one-bedroom; it’s just us two, me and my husband. I’ll buy a Jennifer Convertibles [pull-out sofa] for the kids, when they come over.”

Alice’s girls on the ward call her husband Dad, and give him candy orders. “Last weekend they ordered eight bags! He picked up chocolates, a People magazine one of the girls couldn’t get her hands on, a crossword, a Sudoku, and a find-a-word. My husband’s like, ‘I’m not rich! But just tell them to give me a dollar-fifty and I’ll pay the rest.’” He visits every weekend, and their children come every other weekend.

Etheridge finishes the mindfulness exercise with Sabrina:  ”I got to see two of my newborn babies, three and four months,” Sabrina says. Alice looks down at her lap. Sabrina’s delusion is persistent: She asked the treatment team about meeting with the chaplains. She wants to attend Protestant, Catholic, and Muslim services, because, a staff member explains, the clergy “are the only ones who believe she has children.”

This is not a bad place, not the hell it had been, historically, or the caricature constructed in horror films. Etheridge goes as far as to call it a “positive place, a place of rehabilitation, arts and music, beautiful and bright,” and, in one sense, she is right. There are places to go to pass the time: There is 102, the newly-renovated annex attached to the main building that houses a weight room, basketball court, and bowling alley; and the Big Nosh, the food shop on the second floor run by mentally-disabled workers. There is natural light here, almost wherever the patients go, except for the nurses’ stations, which somehow seem to always have the dim, artificial lighting of a Holiday Inn corridor.

The main building’s industrial-sized elevators—six in all, though all six rarely work simultaneously—are packed with patients Friday mornings. For most women on 3B, “Funky Fridays,” as they are known here, mean the freedom to leave the ward unchaperoned, to visit the vending machines, the Nosh, and the Everything One Dollar Sundry Store, all located within the main building. Alice usually gets a bagel at the Nosh, eating one half at a table across from the store and saving the rest for later. Cynthia buys a king-size candy bar, two cans of soda and a pastry, and eats everything at once before they head to the dollar store on the 13th floor, where gray steel lockers hold rows of teetering antiperspirant, shampoo, baskets of gloves, Vaseline, headphones, batteries, body wash, and styling gel.

“I want the one that isn’t made in China. ‘Silky Smooth,’ is this made in China?” demands the angry older white 3B patient, leaning over the table, supervising the cashier as he rattles around in the precarious lockers for her.

Alice hasn’t yet received her weekly $8 allowance from the state, but Shania got to the store early and bought her a gift, a bottle of shampoo, though Shania doesn’t have much money either—no one does. The women on 3B elected Alice their president, a responsibility that means weekly patient-government meetings, check-ins with her friends and fellow inpatients, and presenting 3B’s concerns to hospital administrators. It’s an accomplishment Alice regards with considerable pride, because it was a challenge, she says, “to overcome the black-white thing, the old-young thing, the bi thing.” (Alice says most of the women—many of whom are minority group members in their 20s—identify as bisexual, though only hints are dropped. One patient talks about her crush: “Michael Jackson, he’s my husband. I know I said I’d never get married to a man, but I’d get married to Michael Jackson,” and later, in a smoking-cessation group, says, “When I see cigarettes it’s attractive, like a girl in a bathing suit.”) Etheridge says there were other challenges as well: At first, Alice made passive-aggressive remarks, and was “judgmental and condescending” due to being “very smart.” Alice had spent 32 years working on Wall Street, including 21 at Standard & Poor’s, where she worked 12- to 15-hour days supervising a five-person team that analyzed companies seeking the S&P 500 rating. She earned her MBA at Baruch College while pregnant and worked, consistently, until, as Etheridge describes, the “frustrations of her life had built a big mud ball inside,” resulting in a breakdown, and in Alice quitting her job. Most of her friends on 3B have not earned high school diplomas.

Alice says the girls are always buying little tokens in appreciation for her listening to them. They often tell her, not the staff, she says, if they’re hearing voices or want to hurt themselves. (A week earlier, when Shania vomited during dinner, Alice reached out to rub the girl’s back and an aide loudly condemned her, “saying I’m ‘not staff,’” recalls Alice. Alice filed a complaint against the aide with the help of the ward’s treatment team manager.)  ”Sometimes I feel they’re Raggedy-Ann. Maybe I’m meant to be here,” she says. “To listen and talk to the girls—I love them all—that’s really where ‘patient’ comes in.”

The windows of the dollar shop reveal a view of the neighborhood below in miniature that lower-floor patients rarely see: white snow melting into gray grass, the Alley Pond tennis bubble delicate upon an icy expanse, rows upon rows of normal-seeming homes; the recently built public school campus below and twin luxury condos in the distance. The sun is so unrelentingly bright it renders everything in grayscale.

4.

Dying is an art, like everything else / I do it exceptionally well / I do it so it feels like hell / I do it so it feels real / I guess you could say I’ve a call

From Lady Lazarus, by Sylvia Plath

 

Alice has been talking about becoming a peer advocate since she learned about Living & Learning, a Creedmoor program that provides peer-advocacy training, just a short hospital van ride away on another part of the campus. Some programs are housed off-ward, on other floors or in other campus buildings, and inpatients earn—through improved symptoms, good behavior, compliance with meds, participation in group—the highest levels of permission in order to attend particular programs. (Certain programs have certain perks. “What’s the name of that place on the outside?” Sabrina asks about an off-ward program. “Sunshine Group, it’s fun,” Alice answers, seeming to read the girl’s mind. “You get lots of coffee.”)

On a bitterly cold afternoon, Jacquelyn Smith coaches the 3B patients in a group on passing the interviews required for off-ward programs and outpatient housing. “One of the hard things is when they ask you, ‘How’d you get to Creedmoor?’ Being a state hospital, there’s a lot of ‘They are ins-tit-ut-ion-ah-liiiized!’” Smith draws out the word for dramatic effect. “‘There are crazy people in there, talking about ghosts and wandering the ward at night!’”

Alice received the second-highest level of permission in early February. She sits in on Smith’s group, listening intently, yet also, like the polite but brilliant kid in high school, seemingly for the benefit of whoever might be looking to her as an example.

Smith asks: “Does everyone know their diagnoses?”

“Too many,” says Shania, the girl with the bulldozer. “Why do I have so many?”

“It could be that you’re managing many things,” says Smith.

 

Alice has long managed many things. She was classified bipolar in 2005, but felt, “it’s not just the bipolar. Yes, I’ve had the manics, I’ve had the good times, and the bad. But I was looking for a diagnosis that was true to what was happening with me.” She likens this struggle to a similar battle to properly diagnose a kidney problem: After four years of futile medical consultation she learned that she has thin basement membrane disease, a rare kidney condition that causes a depth of pain that, she says, “you’d have to have a baby to understand.”

“They keep changing my medicine,” says the Hispanic woman in a newsboy cap, “and I feel nothing’s working.”

“Well…” Smith trails off, flexes her toes. “The goal is to have the least amount of meds with the best results. You need to know your list of meds. Ask the nurse.”

Dissatisfied with her bipolar meds and battling suicidal thoughts, Alice told her husband and her parents, “There’s more wrong with me than what they’re saying. There’s something more wrong with me.” In 2010, a psychiatrist at Elmhurst “finally got it right,” Alice says, diagnosing her with schizoaffective disorder, depressive type. “I wasn’t just having bipolar symptoms, I was having schizo symptoms.” It had taken five years, five suicide attempts, and more than 14 hospitalizations.

In a September 14, 2010 letter, the psychiatrist described her illness as “chronic, severe, persistent and debilitating,” rendering her “unable to work in any capacity.” Alice initially regarded the letter as “a relief. I finally knew what was wrong.” Days later, however, she admitted it was also “depressing. I’ve been through a lot, haven’t I?” “Her prognosis,” concluded the letter, “is quite guarded.”

“I had a million” meds, says Shania, head rolling back against her chair.

Alice has 18. Her disorder is a twofold condition: schizoaffective, depressive type includes both psychosis and a mood disorder (in her case, severe depression), and it means she takes more prescriptions than she did when she was considered bipolar. There’s Seroquel for controlling hallucinations, and Efexxor, the mood stabilizer; Lexapro, for depression and anxiety, and Haldol, a well-known antipsychotic, which she receives in small doses. Plus iron for her anemia; Synthroid, for a thyroid condition, and fish oil. Then there’s Percocet and Ambien; she has an uneasy relationship with both drugs: She overdosed on Percocet in 2005, downing 175 pills in a suicide attempt that landed her in Mt. Sinai Hospital for two weeks. A month after her release, she swallowed 75 Ambien pills and spent a month recovering at Bellevue.

“You’ll need to know your list of meds and your diagnosis, for any interview,” concludes Jackie. Alice knows both by heart.

Ninety percent of the time, says Dr. Robin Hamilton, a psychiatrist and associate clinical director who played a large role in instituting DBT here in 1995, the ward is calm, and there are few incidents. Sometimes, though, palpable tension creeps through these halls. One morning in early February, a new sign appears on the small dayroom door: “Spitting is the worst thing you can do to someone. It’s nasty and germs. INSTEAD USE YOUR WORDS.” Someone has drawn a mouth with a tongue sticking out. The sign is likely a part of Rodriguez’s therapy; she spat on another patient the day before and was required to fill out a behavioral chain analysis, a worksheet that asks aggravated patients to describe what initial emotional conflict led to their “solution” of fighting or hurting themselves.

 

The patients meet in the room with the spitting poster for medication group with 3B’s psychiatrist, Dr. Antoinette Valbrune, who discusses the relationship between patients and their treatment team: the psychologist, psychiatrist, social worker, therapists and aides. Alice sits on one of the blond wooden chairs against the windowed wall; her dark brown hair, usually wrapped in a shiny bun tight against the crown of her head, is frizzy today. She’s trying to pass kidney stones and received permission to remain in her room (patient rooms are locked during the day to minimize opportunities for suicide), but she missed the girls. Sabrina sleeps under a sweater beside her, her hand resting on Alice’s. Shania walks in, stopping to pet the top of Alice’s head: “How you feeling, Mama?” she asks.

Alice looks pained; she’s wearing a faded nightshirt instead of her usual sweatshirt, but sits upright. She still needs to see the doctor, but the Percocet is helping.

“The thing we have in common is, we all humans. We all experience fear, pain, anxiety,” Valbrune begins, her thick Caribbean accent obscuring some words and mangling others. “Someone comes to the hospital, the goal is to get better and— it’s better for you and the staff if you get out.”

Alice’s eyes close briefly, but she never sleeps in group. The treatment team agrees she’s a “star pupil,” though they’re concerned she may get too comfortable here, as de facto adoptive mother and the ward’s recently elected president. But Alice is comfortable here. “Creedmoor is safety,” she says. “‘Honey, that is not home,’ my husband says. But I need to stay here until I see it as a hospital, not as home.” Alice looks down as Sabrina shifts in her sleep.

Through the open door, Carla can be heard shouting at a male aide at the nurses’ station.

 

“We are humans, we belong to the human race,” Valbrune says, raising her voice over the commotion outside. Carla bursts into the room, pacing, her dirty white basketball shorts swishing. Valbrune continues, “You’re all human and I treat you with respect and I expect you to treat each other with respect. Stop the fight. Let’s see if we can do something and get you out of here.”

Carla stops mid-lap; she seems too big to pace for very long in this small room, “I ain’t getting out of here,” she says.

“You don’t want to leave?” asks Valbrune.

“I said, ‘I ain’t getting out of here.’”

“Everyone’s on the discharge list,” says Valbrune.

“I been on the discharge list since last year,” says Carla.

Ward 3B has, according to Lynch, “anecdotally, a very successful discharge rate, a fairly low rate of readmissions. If they’ve been here for a year, get discharged, and then stay out 35 months, even with bumps and bruises along the way, it is considered a success. We build up on those successes.” Hamilton holds to a theory proven—empirically—that long-term treatment will minimize the number of future hospital stays for these women, even if it costs more at the outset. The state spends between $600 and $1,000 daily per Creedmoor patient; the current 3B inpatients have all lived here for at least three months and, at most, five years. (Nine of 20 3B patients volunteered the length of their current stay: The average was 2.27 years.) The timeline of the treatment demands a patience from the state that is at odds with its mandate to “push out” patients, says Hamilton. But there remain a “core group of patients who might never get out without DBT. They never had the skills to function outside.”

  There is a pause as Valbrune shifts in her chair and changes gears. Carla slinks out of the room. “Relationships between the individual and the healthcare provider is important,” Valbrune says. “If you need something, approach the counter [nurses’ station]. Tell them, ‘I’m hearing voices.’ The way you approach the counter will determine what you get. You can catch more flies with honey than… How do you say?”
“Than with vinegar,” a patient supplies the idiom.

“Yes,” says Valbrune, smiling. The group appears to have concluded.

It’s Thursday, the one weekday 3B inpatients receive afternoon snacks, and the brusque male aide Carla shouted at earlier begins shouting patients’ last names, a roll call for potato chips and coffee. A patient goes up to claim her coffee. “You want powder?” he asks, referring to powdered coffee creamer. She doesn’t respond. “Tell me what you want,” he barks. “This isn’t Dunkin’ Donuts.”

 

5.

Shaketa McKoy , a young therapist wearing tight jeans, prepares the small dayroom for bingo. She sets out bright red fruit punch in little plastic barrels, lines up the prizes: travel-size toothpaste, bottles of carnation-pink shampoo and conditioner, Caucasian liquid makeup, a donated sweater embroidered with flowers, and a selection of faux-designer handbags and wallets. She shouts for the patients to come in, group’s about to start. She takes attendance and passes around weathered bingo cards, the kind seen throughout co-op pool clubs and Catholic church basements, and starts turning the metal bingo ball cage.

Alice wins the first round—”Bingo!”—and gets up to show McKoy her card. “No, sit down, I’m not gonna check. You just read ‘em to me,” McKoy says.

“B14, G54,” Alice begins, seated beneath a poster that reads, Follow Through Separates Big Achievers from Big Talkers.

“Pick your prize,” McKoy interrupts. Alice studies the wallets and picks out a maroon, fake Louis Vuitton purse.

“O61…  G51… N45…O63…O71.” The balls roll within the squeaking cage. The young Middle Eastern woman wins the next round. Outside, Carla starts screaming. An aide plays two cards on her own in the back of the room. The Serbian patient sitting across from Alice doesn’t seem to understand the concept of the game. McKoy shouts—”I explained it already!”—but there’s the rolling and grating of the metal cage, like hundreds of nails on a chalkboard, and the raucous laughter coming from the nurses’ station, and the rattling of the keys that are needed to get anywhere, and it’s possible she missed the explanation.

“I got four-corners bingo!” announces Cynthia, who is wearing a long khaki skirt and khaki-colored T-shirt, her pink plastic rosary, and no fewer than three colorful bracelets on each ankle and wrist.

McKoy calls in an aide and asks her to go out and buy her lunch. Aside from the Big Nosh—which serves mostly patients and only has a few tables and chairs—there are few dining options within walking distance of Creedmoor. One of the closest, a deli on Hillside Avenue, is a 20-minute walk through the snow away. An older patient, clad in a salmon-colored polo shirt and burgundy sweats and known for hurting herself, wins the next round—full-card bingo—and picks out a small teddy bear from the prize table. “That’s good,” says McKoy. “You won’t hurt yourself with that.”

McKoy’s lunch is delivered and the room is filled with the smell of fried chicken. The inpatients eat breakfast at 7 and lunch at noon each day on the ward, just steps down the hallway from the dayrooms, which are just steps down from their bedrooms and bathrooms. McKoy calls the next numbers with her mouth full, “N31,” and Alice wins again.

“You cheating!” the aide in the back says with a smirk, getting up to return her two cards.

“I’m sorry,” apologizes Alice, though she wasn’t, distracted by the prize table. She picks out a matching maroon wallet for her bag.

“I’m looking for another bingo, so everyone could win,” says McKoy. She calls numbers until the ward’s youngest patient cries out “Full card!” McKoy directs her to the prize table: “Go!” Though there are prizes left, the game’s over and patients start to amble out.

“Thank you, Shaketa,” says one, filing by.

“Thank you,” echoes another.

 

6.

Death is one moment, and life is so many of them.

—From The Milk Train Doesn’t Stop Here Anymore, by Tennessee Williams

 

Alice is feeling more uncomfortable in her own skin these days. Petite, with elegant, though chafed, slim hands, she had been hospitalized in 2005 for anorexia and bulimia; at about 5-foot-3, she had weighed 97 pounds at the time. (Metropolitan Hospital classified her drastic weight loss as a suicide attempt. When she threw herself in the Astoria subway tracks that same year, she was, she recalls, 105 pounds.) Today she is over 200 pounds, combating the meds’ side effects—sedation, weight gain, increased appetite—with Creedmoor’s reduced-calorie meal plan, fitness groups, and exercise at the gym downstairs.

Smith and McKoy play a Prevention Magazine walking exercise DVD one bright, cold morning. Patients marvel, whenever the tan blonde host smiles, at how many teeth fit in her mouth. Only Smith and McKoy walk in place for the full mile and a half: Shania is on one-to-one in the corner, Sabrina leaves abruptly and later joins back in, and Alice, who never lets anyone see her winded, takes breaks to catch her breath. Cynthia marches half-heartedly in front, the rosary bouncing up and down against her chest, and McKoy encourages her: “Go on, Cynthia. Walk away those voices!” The sharp winter sunlight illuminates the dayroom’s pale-green walls and sticky white linoleum floors, and Alice pretends that they are walking outside. On Fitness days, they visit the gym, where two radios blast hip-hop on the basketball court and Top 40 in the weight room. Men from other wards lift weights or play basketball, shoulders sloped inward, with shaking pinky-finger tics, their shirts either untucked and unbuttoned or shoved tight into their waistbands. “Amazing, just the way you are,” a pop star croons from within one of the radios, while the 3B women use exercise machines, sit on the sidelines, or, like the Serbian patient whose copper-colored hair matches her suede blazer, pace the perimeter of the basketball court to beats unheard. Alice always mounts the treadmill, walking endlessly toward the bright-white wall ahead, for the full length of Fitness. At a meeting with her treatment team later that week, she will humbly announce a small but hard-earned victory: “From 234 to 218 pounds. It’s moving.”

If things go the way they should Alice will move to Polaris House, the ward upstairs, where she’ll live for six or 12 months while training to become an advocate; where she’ll come and go without asking an aide for a key to get anywhere, where she’ll have afternoon snack more than once a week. If she gets Social Security, if she stays on the meds, if she keeps seeing the doctors and stops hearing the voices; if she stops “wanting suicide,” as she says, and can make it to 55 for her S&P pension, she and her husband will move into the one-bedroom in Middle Village with the pullout for the kids and a savings account for the someday-home upstate. And when she’s settled she’ll return to Creedmoor, a volunteer now, and have another day, the kind she’s had so many of before: She’ll look on as the women paint plastic suncatchers and color in felt coin purses in the activity room, where the parkway will snake just out of sight as it always has and the snow will pile up gently on the metal picnic tables outside as it did her first winter here. In the afternoon Shaketa will bring out the karaoke machine, as she did recently, and the new transfer from Admissions will sing “Unchained Melody” and the Hispanic patient who wears the newsboy cap will gush and fall in love on the spot and sing Madonna to impress her: “Borderline, feels like I’m goin’ to lose my mind.” Alice will understand now the irony of the song, of the scene, but she’ll look on admiringly anyway; and soon enough it will be time to go and if any of the girls who used to call her Mama are still there—Shania with the idling bulldozer, Cynthia with the voices, Sabrina with the imagined babies—Alice will say goodbye, see you soon, and she’ll likely conclude they all feel abandoned, though indeed they probably feel nothing at all. And this, she’ll realize, is how it has to be.

She’ll ride the elevator with the sign that cautions staff against speaking about patient matters in public and at the second floor an aide will board wearing a lab coat that has drawn across the back a wide-open eye and the admonition: “I got my eye on you.” If Alice remembers The Great Gatsby maybe it’ll call to mind Dr. T.J. Eckleburg, the doctor who gazed out from a sun-washed billboard high above this very borough, Queens, Fitzgerald’s “solemn dumping ground,” and she’ll wonder if she ever felt this watched when she lived here. She’ll walk through the lobby that smells so faintly of industrial cleaner, where a single plant on the sill of one of the few, dirty windows still contorts itself reaching for the little light that passes through, and she’ll realize for a moment how dark it is down here and how bright it was on 3B.  And then Alice will leave the hospital to return to the place she now calls home.

This is how it could be.

*Names and identifying details of certain individuals have been changed.

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