Projections, page 12
The most socially adept among us do this all the time—those beyond my own capability, who without effort or training or delay can see through the vast avalanche of social data at just the right angle to find unerringly the meaning of the moment. But every part of us contains our whole, if reflected upon. Even with little carrying capacity, connection still comes, with time.
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•
“I feel like I want to tell you more,” Aynur said as we stood in the doorway of my office. The hallway was quiet, and the carpet looked drab and dim. “It would be nice to talk again, but I guess I know we won’t ever. I am sorry. I know there is no time, but one more thing: I had a final moment you should know about, the morning I was to leave Europe. Not looking at a man, but looking at a girl.
“It was six in the morning, and I was gazing out from my small loft window, drinking the last of my tea, preparing to leave for the airport, and taking a minute to pause and reflect—to pay my respects, in a manner of speaking. There was not really a view of the city, just the gray apartments across the alley, but I still felt this was a goodbye to Paris, a quiet moment of homage. I had learned and changed a great deal, and the French doctors might have saved my life. As I looked out into the light mist of morning, toward the tenement across the way, a ten- or eleven-year-old girl in a hijab emerged alone onto the narrow balcony.
“I had seen her and her family before, in passing, in occasional glimpses, the snapshots one gets. She seemed to have a little sister, and they lived with their mother and father, who wore traditional dress, not typical French style, though I did not know the country. But this was much earlier in the day than I had ever seen her before, and she was alone. She looked out toward the east, followed by a quick glance back to the darkened apartment. Her face was set and serious; she was not there to enjoy the sunrise.
“Then she moved to the balcony, to the edge, and turned her back to the sun, facing west. I held my breath—for her. I had envisaged myself jumping, like this, so many times—while looking out this very same window.
“She took out a phone, and hunched over for a moment, then straightened up and held it out in front of her. In a moment her whole demeanor had changed; she had become a movie star, her face shining with fierce glamour. It was just a selfie.
“She then returned to her position hunched over the phone, looking at the image. She remained this way for almost a minute, and then quickly looked at the sliding glass door back to the house, which she had left partly open; all seemed well for her, remaining dark within.
“For the next ten minutes I watched, enthralled, as she flipped back and forth between the two positions. Her next selfie was another joyful one, then one with a silly duck face, followed by one with her tongue stuck way out, peace-sign fingers forming a horizontal V wagging just below her chin. After each one, she bent abruptly into an intense state of frozen scrutiny. Her focus, her intensity, was impressive. This seemed a rare stolen opportunity—perhaps her mother was in the shower and would emerge any moment. Back and forth she went, on and on, almost puppetlike in the stereotypy of her transitions. I had always seen her, interpreted her, as a small child with her doll, but here she was being jerked back and forth by something else, a new drive—whipped by an unchildlike need.
“Eventually she was satisfied. She slipped back inside, and was gone.
“I felt profound sadness, and joy, and jealousy, all together. Is there a word in English for that? I’ve felt that before, those three things together. There should be a word. All three basic layers of emotion, down and up and sideways, all wrapped up in a tight and disorganized little ball.
“The jealousy—though we shared faith, gender, youth…our cultures were still so different. She was still blessed, gifted, able to begin a journey I could never take. I was bound too firmly to my own, to my trapped and now tortured people.
“My joy came from knowing this was the outset of her journey, that she was setting off from her family’s homeland, preparing to weave a new fabric of her culture, traveling down her own road to autonomy.
“Though moments like this, of course, must occur thousands of times a day, every day, around the world, my sadness might have come from realizing her parents would never know what had happened on the balcony, in the way I did, as a complete stranger; this was a poignant hidden moment of a girl separating from her mother’s hand that would never be shared. The sadness also, I guess, came from my own selfishness—from feeling connected to this girl in many ways, but realizing I would never get to know her deeply. I was still feeling vulnerable, or empty—from my teratoma. From everything.
“She was found and lost to me almost at the same moment. I never existed for her, and never would, and she ended up only a sort of cross-thread in my life—marking a moment—though with a thread that is strong, and durable, like in that rough ribbon you have here with ridges and gaps alternating, called grosgrain, where the weft is even thicker than the warp.
“It is strange to say, but the thickness of her one thread formed a gap around which nothing else can come close. I came to know her deeply, though it took only a few minutes, and now she feels lost to me. I don’t know how, but I might need to find my way back to her.”
CHAPTER 4
BROKEN SKIN
As willing to feel pain as to give pain, to feel pleasure as to give pleasure, hers was an experimental life—ever since her mother’s remarks sent her flying up those stairs, ever since her one major feeling of responsibility had been exorcised on the bank of a river with a closed place in the middle. The first experience taught her there was no other that you could count on; the second that there was no self to count on either. She had no center, no speck around which to grow.
—Toni Morrison, Sula
Henry, nineteen years old, had been found rolling naked on the aisle of a county bus. When the paramedics arrived, he told them that he was imagining eating people, and saw visions of himself consuming flesh and bathing in blood. But after his swift transport to our emergency department by police, Henry gave me, the on-call psychiatrist summoned to evaluate him, a more relatable story instead, with more universal themes. He described a lost love that had brought him to despair, to the aisle of the bus, to suicidal thoughts, and to me.
Not even guessing at his diagnosis yet—there were still too many possibilities—I let my mind work freely, picturing the scene as Henry described his magical first moment of romantic connection from three months ago. In her short fur-lined coat, Shelley had knelt on the torn vinyl seat of the church field-trip bus, leaned close, and kissed him—just as a sunbeam unexpectedly broke through the canopy of trees and fog. More used to the pervasive chill of early spring among the coastal redwood groves, he was surprised and enthralled by the sudden dense warmth on his skin through the window glass. Shelley’s own warmth, the excited heat from her hungry red lips, brought her together with the sun in him. She was connecting him to everything, and connecting to everything in him.
But now, not three months later, everything was lost again—and the midsummer sun had somehow turned freezing. Henry gestured, showed me how he had covered his eyes—hands together, fingers interlocking—to block the sight of her driving away from the parking lot of the diner, where she had met to break up with him, just two days ago. He had been shielding himself from the image of her bright red rear taillights, as she left him to find another. Nothing remained for Henry—he had no connection to her, nor to anyone else, it seemed.
Henry’s blockade of the scene of her departure seemed an oddly immature defense, I thought, more suited to a toddler than a grown man. He was midperformance, reenacting here in Room Eight—and watching me instead of his hands, closely tracking my reaction. As I looked on, and as he lifted his arms higher, the sleeves of his loose sweatshirt fell back to his elbows, exposing forearms crisscrossed in fresh razor slashes—crimson, crude, brutal parallelograms. A big reveal, an intended one it seemed, of agony and emptiness. His barren core was now visible, through his own shredded skin.
At that moment an image came together in my mind, labeled with a short diagnostic phrase. All the cryptic threads of his symptoms, each mysterious on its own, made sense because of their mutual intersection in that instant: the bloody violence of his thoughts about others, the cutting of his own flesh, his bizarre behavior on the county bus—and even the covering of his eyes to not see Shelley go.
The phrase was borderline personality disorder (a label of the moment in psychiatry that may change in time to something more reflecting symptoms, like emotional dysregulation syndrome—but which, regardless of label, describes something constant and universal, a fundamental part of the human heart). These three deceptively simple words clarified Henry’s chaos for me, made some sense of his bewildering complexity, and in particular explained the positioning of his mind on the border between unreal and real, between unstable and stable. He was blocking the light’s path to deflect the harshness of the knowledge it carried, protecting his raw and damaged depths, asserting crude control of what could flow into his body across the border of his skin.
Though each case is different, and I had never seen a person with a combination of symptoms quite like Henry’s, new details began to fit the pattern as I asked more questions. He eventually disgorged again the fantasies of eating people with which he had shocked the paramedics—never actually harming others, but hating strangers on the street simply for being human. When he saw people he saw their insides, and their insides inside him.
The sun hurt, was cold and strong—and so to re-create the original feeling when Shelley had kissed him on the church shuttle, Henry had disrobed on a county bus, seemingly trying to find some patch of skin where the sun would feel the same. He was seeing blood everywhere, was swimming, diving, drowning. Good enough for police transport, state code 5150, to the nearest emergency room, to me.
Some of the people arriving on a 5150 hope to avoid an inpatient stay in the hospital, while others seek admission. My role was to make the border of the hospital real, by finding out who needed help to stay alive. My forced decision as the inpatient psychiatrist was binary: discharge Henry back into the evening or admit him on a legal hold—to our locked unit—for up to three days with no right to leave, an involuntary patient.
With the diagnosis now in mind, it was time to think about writing the note, completing my assessment, and settling on a plan—and that meant beginning with his first words. I looked down at my notes and returned to the moment I had walked into Henry’s life.
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•
Before money from our latest tech boom had flooded the region and brought about the emergency department’s modernization, tiny Room Eight had served for more than twenty years in the valley as a major portal for incoming acute psychiatric patients. Many of the individuals who designed and created our densely connected silicon world had passed through this isolated latrine-sized room at one time or another. The valley was their home, and this their hospital, and windowless Room Eight served as the portal to acute mental health care—and thus as a sort of window into the valley’s most human, most vulnerable heart. Room Eight was important; in a home it matters what can be seen from the window.
But Room Eight was dim and cramped, just big enough for the patient’s gurney. Outside, an amiable, blazered guard stood by. Inside, a single chair for the psychiatrist was positioned as close to the door as possible; the ER setting can be unpredictable, and emergency psychiatrists (like other acute-care medical specialists) are taught to identify flight paths for themselves, and to position themselves close to escape routes, in case the interaction goes awry.
On my first contact with Henry, planning a flight path had seemed relevant. In a baseball cap and jeans, Henry was taller and heavier than me, unathletic but muscular—and his face seemed to twist loathingly at the sight of me. I tried to keep my face impassive, but my abdomen felt knotted and drawn tight in response. I had left the door cracked open, and as I introduced myself, sat down, and asked what had brought him in, the familiar cacophony of the ER filtered through: accompaniment for the first words of his monologue, which as my medical training dictated, would have to constitute the opening line of my note.
Psychiatrists begin as doctors of the whole body, in emergency rooms and on general medicine units, diagnosing diseases of all the organ systems, treating illnesses from pancreatitis to heart attacks to cancer, before specializing in the brain. In this yearlong all-purpose phase of internship after conferral of the MD degree, medical rituals are consolidated—including the rhythms of how to pass along all the information about a patient, in exactly the order expected by the attending physician (the senior doctor to whom the case is presented). This canonical sequence begins with the trinity of age, sex, and of course chief complaint, or chief concern—the reason given by the patient, in the patient’s own words, for showing up in the emergency room that day. The formulation of seventy-eight-year-old woman, chief complaint of worsening cough for two weeks, is stated before anything else, before medical history, physical examination, or lab tests. This ritual makes sense in medicine, establishing focus on the active issue in a way that is helpful—especially for patients with many chronic conditions that would together otherwise be a distraction.
But medical custom is not always translated easily to the reality of psychiatry, especially in the next year of specialty training following medical internship. It takes a little time for the newly fledged residents, now in a phase of resetting and relearning, to transpose this medical rhythm into the new space, since the first thing the psychiatric patient says, when asked, can be awkward to restate as the first line of a medical note: twenty-two-year-old man, chief complaint: “I can feel your energies in me”; sixty-two-year-old woman, chief complaint: “I need Xanax to cry in therapy”; forty-four-year-old man, chief complaint: “These fucks trying to control me. You can’t follow me in death now, can you. Fuck you.” We write it down anyway.
I had elicited Henry’s chief complaint with my stock opener, asking what had brought him here to the emergency room—and conscientiously recorded his response, the first line of my note:
Nineteen-year-old man brought in by police, chief complaint: “My father said, ‘If you kill yourself, don’t do it here at home. Your mother would blame me.’ ”
I recalled having so many immediate questions at that moment, but no pause had been given by Henry—he was only getting going, opening the veins. The words had flowed quickly, in a fluid and organized way—and everything, in retrospect, fit the borderline diagnosis. He implicated that broken relationship as the root cause of his suicidal despair, the lost perfect love that had begun just a few months ago with a kiss on a church field trip, and ended two days ago with their breakup at the diner in Santa Rosa. He had recounted from there the rest of the abbreviated, tortured odyssey occupying his past two days—learning to cut himself in secret, going to his father’s house to show him the results, and after his father’s stunning statement, running out the door and down the street, desperately searching for a bus, in a frenzy to feel what he had felt first with Shelley. Along the way, Henry included the story of his parents divorcing when he was three, complete with memories of climbing up on his mother’s lap, crying don’t want to get that new dad—but her face had been composed and set, impassive, comfortable with her son’s tears. He had described the chaos of the divided home that resulted, when those who most loved each other became overnight those who most hated each other. How all human values, positive and negative, had been inverted, inexplicably, inescapably. How he learned to live with two separate worlds in two houses that could never interact, how he could not speak of one to the other, how he was forced to create and maintain two distinct and incompatible realities to survive.
And finally before he fell silent, he entrusted me with the visions he had described to the paramedics and the ER staff—the images of blood and cannibalism, and his revulsion for other people. Not just a desire for distance, but a disgust with all humanity.
Earlier as a medical student, I might have misdiagnosed him with schizophrenia or psychotic depression—dislodged from the real world either way. But Henry was lucid, and his thoughts were organized; he had not quite broken away. Only the person with borderline can travel from reality to distortion and back, speaking both tongues with dual citizenship—not quite delusional, but with an alternative framework—to help manage a hostile, unpredictable reality.
Sometimes it can seem that both the self and what lies outside the self are not yet fully defined within the minds of borderline patients—not well resolved as entities with constant properties and worth. The relative values of different situations in the world, and of the different levels of human interaction, seem not smoothly compared—leading to reactions without subtlety, such as catastrophic thinking about unlikely possibilities, or extreme reactions to the natural give-and-take of human relationships. It is as if they are still in an early stage of developing a kind of currency exchange that allows human values in different categories to be fairly compared—and so to guide feelings, and actions, in measured ways.
But this pattern of extreme and seemingly unwarranted reactions (which can also be present in other conditions, and occasionally appear in anyone) also seems to constitute a practical strategy for surviving the early-life trauma that so many borderline patients have suffered, a reflection of their reality that there is not a single or consistent value system that makes sense in the world. And other aspects of personal development can seem frozen in early states as well, such as the use well into adulthood of transitional objects like blankets or stuffed animals, items that soothe a child when they are held tight, allowing the security of one environment to be made portable into an insecure space. Henry’s shielding himself from the sight of Shelley’s departure—this was the defense of a child, in blocking rather than addressing an unbearable, unacceptable reality. All of these behaviors can be unsettling to friends and family and caregivers—but with reflection, and with experience, also can stir compassion.
