We’re worn down.  I’m worn down.  I dread my long weekends locked onto 3 East with A.  The staff meets weekly for debriefings and diagnose each other with compassion fatigue.  We veer between giving up on her and belief that she’s tough and will survive.  We’re horrified at our visceral responses to her – anger mainly – and surprised when our collective negative energy evaporates as she charms us with a joke or smile, some token of affection. 

She should be out having fun with friends, attending college, enjoying a loving family.  Instead she spends her time with us, binging, purging, cutting, committing desperate acts of near self-destruction, attention-grabbers.  Both victim and predator. 

In my better moments, I compare her to Tinkerbell; A. doesn’t stand a chance unless we believe in her.

She has a bad week.  She’s handcuffed and escorted by a Multnomah County sheriff’s deputy to court, where she’s civilly committed to 3 East for a period of six months.  An older man who fills the role of lover, who’s accustomed to their reciprocal use of each other, disappoints her by taking up with someone else, someone who isn’t hospitalized.  Her uncle doesn’t visit; her mother doesn’t call.  She’s been with us a month.  A commitment buys her – and us – some time.                  

One of the staff psychologists takes her for a walk on the quiet street in front of the hospital, for some fresh air and a smoke.  A. runs toward the busy intersection and darts out into traffic.  He runs after her and tackles her down; cars skid and slam on their brakes. 

That week I feel the prickly aftershocks of this incident.  The staff is vigilant but gives her space.  She’s off "constant."  I count the number of times she paces the length of the ward.  Seventeen laps equal one mile; she does twice that. 

My stomach muscles hurt, braced against threat.  The signs are there.  We take turns walking past her room.  I feel apprehension but not surprise when I hear the crash in A.’s room.    

She stands on a chair with a fragment of fluorescent light bulb that she’s broken out of its ceiling cage.  She slashes at her wrists.  Blood drips onto the floor.  I grab towels to apply pressure while two others take her down from the chair.  When we attempt to pry the glass from her hands, she puts the shards into her mouth and swallows.  A. slithers and writhes across a floor that glitters with fragments of glass.  Her mouth oozes blood; she bites at us.

"Code Green" echoes over the hospital speakers and trained staff arrives from all departments.  The emergency room nurses are there when A. loses consciousness and turns blue.  We have minor cuts and bruises and other deeper injuries that don’t show.

Closure is overrated, and in our line of work it’s elusive.  Sometimes I read about a former patient in the newspaper – usually bad news.  Or I see a photo of someone vaguely familiar poised on the Burnside Bridge.  Not knowing is my way of holding out hope.

A. is referred to the state hospital, but does not meet their criteria for admission. Her problem is behavioral; she isn’t psychotic.  She’s lucky; the state hospital is no place to get better.    

A. is discharged early at the end of May into a run of good weather.  She gets better. She gains weight; she hasn’t cut herself in a month; she discusses her behavior with seemingly mature insight.  I’m not sure her improvement has anything to do with us.  

In the next few months I hear rumors that A. is or has been in our emergency department after another suicide attempt.  I want to see her, but I don’t want her back on 3 East.  It’s another hospital’s turn.      

A year later I find a note taped to the clinical desk inviting us to A.’s memorial service.  There’s a phone number if we want additional information.  I don’t call.

Evelyn Sharenov

Although it’s common, the medical profession does a dehumanizing disservice to patients when it defines them by diagnosis, particularly anyone diagnosed with a mental illness. 

Of course, the “Gall Bladder in Room 3” will probably be just fine, whereas the “Borderline in Room 7” is likely to be discharged with the same issues that brought her to the hospital in the first place.  And it’s like a virus: patients often define themselves by their diagnoses as well.  You’re more likely to hear "I’m a paranoid schizophrenic" than "I’m a college student and sometimes I hear voices" – the already fragile psyche stigmatized by itself.

From her records I learn that A. defiantly embraces her diagnosis.  On a limited playing field, she takes pride in being the best at something where few seek a trophy.  It has its own perverse logic.  She derives her identity from being "a borderline" and sees herself as a teacher of other borderlines.

BPD effects approximately two percent of the general population; 10 percent of outpatient and 20 percent of inpatient clients meet the diagnostic criteria.  Of those diagnosed with BPD, 75 percent are female and A. is one of them.

“I flunked DBT,” she brags during intake.  DBT – Dialectical Behavior Therapy, an offshoot of cognitive behavioral therapy – is the most effective treatment for someone as non-committal as A. is to life’s infinitive, "to be."  It teaches basic skills, skills needed to stay alive, like how and when to breathe, how to walk step by step past disaster.  

A. arrives on 3 East following several suicidal gestures, a smorgasbord of passive and aggressive attempts at self-annihilation.  The serendipitous arrival of a friend usually thwarts her plan.  This last time she upped the ante.  She swallowed barbiturates, then passed a razor across her left wrist.  When she changed her mind, when no one came, she called 9-1-1 and left the phone line open as she spiraled down into unconsciousness.   

It's my second weekend with A.  She invites me into her room and collapses onto her bed.  I pull up a chair.  Her features are gaunt and distorted by crying.  Her chart indicates she’s down six pounds from a week ago.  There’s a cotton ball taped to the antecubital space of her left arm, from the morning’s blood draw.  Purging destroys fluid and electrolyte balance.  It can lead to seizures and cardiac arrest.  A phlebotomist arrives daily to collect a tube of A.'s blood. 

Her nightstand is a mess.  Sticky remains of last night’s juice smear its surface.  Used tissues dry into stiff white clots.  An open composition notebook invites snooping. 

“How was your week?” I ask her.  She wants me to ask her.

“Just awful.  If I can’t get out of here, I don’t know what I’ll do.”

Is that a threat?  Certainly she can make the connection between her suicide attempt and her hospitalization.  Does she really imagine we’ll open the doors and let her out?

“Sounds like you feel pretty hopeless,” I say.  Although I really want to know about her week, I have stage fright; my voice sounds thin and practiced.  A. spots my insecurity and pounces.

“Don’t talk to me like that,” she snaps, then starts to sob.   

I had it coming.  “Like what, A.?”

“Like a nurse or therapist, whatever.”

“I am a nurse.  How do you want me to talk to you?”

“Like a friend.”

“I care about you; I want to know what’s going on; that’s why I asked.”  How easily she walks over my carefully constructed boundaries.  “I don’t think you’re ready for discharge, if that’s what you’re asking.  What would you do if you got out of here tomorrow?”

She stops crying.  “They’d find me dead with a needle in my arm.”

“Well, now, that’s kind of dramatic.  And not likely to encourage me to advocate for your freedom.”

“I’m nothing if not dramatic.”

“OK, you got me.  So short of finding you dead with a needle in your arm, what do you want to do?  What happens after here?”

“I want a life.  Like everyone else.  I deserve it.”

“Of course you deserve it, but we work for the lives we want, and sometimes we don't get them.  Swallowing pills and slashing your wrists doesn’t tell me that you want a life,” I point out.  “It tells me you’re ambivalent.”

“Yeah, I get that.” 

We sit quietly for a few minutes, then I stand to go. 

“Evelyn…” 

“Yes?”

“Do you have to be so neutral?”

“A., you know the limits of our relationship.  Maybe a shower and some fresh clothes, clean up your mess.  You might feel…”

“Go to hell.”  There was something animal in her voice, growling, cold, and hungry.

I keep walking.  Neutral?  When I think of A. I feet weary and sad.  I want to grab her by the shoulders and shake some sense into her; definitely not neutral.         

I’m surprised when A. makes it to my transitions group in the afternoon.  I designed it for patients nearing discharge.  It covers basics – your first steps after you walk out of the hospital into the daylight, where you’re going and how you’ll get there, how you fill your prescriptions.  And more complex issues, like staying out of the hospital, and access to housing and health care – how to keep from falling through the cracks of the bureaucracy.  I teach our most vulnerable citizens how to negotiate a draconian system.  

A. comes up to me at the end. 

“I liked your group.  I learned something from it.”

“Tell me.”    

“That it has nothing to do with me.”  She smiles and walks away. 

The doctor sees her on rounds, speaks with her briefly, jots some notes, increases her Ativan, an anti-anxiety medication.  Although his gaze holds you long after you admit you hate your mother, his approach is pleasantly straightforward.  Many patients find this combination abrasive.  He’s not A.’s psychiatrist, but he’s well versed on her case – everyone who works on 3 East is familiar with A.’s story. 

We tweak her medications.  Until new and better medications come along, that’s all we can do.  A.’s been on anti-depressants, atypical antipsychotics, mood stabilizers, anti-anxiety medications, and sedatives.  They relieve some of her symptoms and temporarily improve her quality of life.  But there are no medications for the personality like there are for germs.  One therapist, in complete frustration, suggests that A. needs a "personality transplant."    

Later in the evening, Joanie calls me.  Her voice carries from A.’s room down the long hall to the community room.  She’s at A.’s side when I arrive.  A. is tangled in a mess of sheets and hospital gown.  Her eyes roll up in her head, her back arches and she thrashes uncontrollably, half off the bed.  She’s unresponsive and white froth turns blood-tinged when she bites her lip.  It looks like a classic grand mal seizure. 

A. experiences these after particularly violent episodes of purging.  Alan gets there just after me.  We catch her before she hits her head and carefully lower her onto the floor. 

It’s over in an eternity of moments, and then A. is still.  Her blood pressure and pulse are normal; her breathing is unlabored, but she’s pale.  I give her low-flow oxygen through nasal prongs for a few minutes and notify the physician.  An hour later, she’s awake but sleepy.   

“What happens when I have a seizure?” she asks.  Do her lips turn blue?  Does she froth at the mouth?  Do her eyes roll back in her head?  Do her arms and legs jerk? 

I think about it. 

“It’s pretty scary looking,” I answer.

I help her clean up and change into flannel pajamas.  I think about neutrality and professional boundaries.  Then I sit down with her and describe her seizure in detail.

She sits cross-legged on her bed.  A tiny reading lamp clipped to her notebook cast a halo of warm light around her.  When I leave for the night, she’s writing it all down.

Evelyn Sharenov

The first time I meet A. she’s in the middle of a handstand push-up against the wall outside her room.  Balanced on her palms, her back and legs straight up, she pushes off without a sound.  A cropped tee falls to her bra line, exposing the bone marimba of her ribs.  Her tangle of auburn hair spills to the floor and she has the translucent skin I associate with redheads; an appealing scatter of freckles dusts her nose.  She looks more like a gangly teen than the twenty-five years I know her to be.  

“Hey,” she calls as I pass by.  She rises on thin sinewy arms without missing a beat.

“Hey yourself.”  I bend and smile at her upside-down face. 

“Could you help me?  I need to shave my legs but someone has to watch me.”     She sniffs toward the clinical desk.  “They’re all too busy.”      

“I’ll see how my morning looks and get back to you in a few minutes.  You must be A.”  It’s difficult to imagine her near death, but when I bend down to greet her I note the black sutures that bite into the separated edges of flesh on her left wrist.  Her self-inflicted wounds are almost healed, but I walk away with a sense of A.’s troubled life. 

“You heard of me?” 

I’ve just spent an hour reading about her past.  

I’ve been in this field a couple of years, on 3 East, a thirty-bed locked psychiatric ward in a hospital in Portland, Oregon.  A.’s presence on the ward is daunting; she’s challenged far more seasoned professionals than I.  Her chart is seven inches thick – the clinical equivalent of hundreds of thousands of frequent flier miles – distilled from dozens of hospitalizations and years of outpatient treatment.  It’s hard to believe the upside-down, in-person A. has burned as many bridges as hospital-chart A.   

Joanie, a newly minted MSW, watches the monitors at the clinical desk; they illuminate all the dark corners and doors on 3 East and hopefully prevent assaults and elopements.  She’s working her way out of the deep hole of college-loan poverty.  We’re a subset of a weekend team that includes six therapists, five nurses, and five psychiatrists who rotate call.  We have each other’s backs in emergencies.   

“Any reason I shouldn’t help A. shower?”

“Yeah,” Joanie says.  Alan’s leading process group.  A. declined his invitation to attend.  When process group is in session, everything else stops.

In report we discussed our strategy for working with A., particularly the need for consistency.  Joanie and I are needed on the floor until Alan’s free.  Several patients are still asleep.  Others start their day's journey, the slow drift upward from strange and frightening dreams.   

I check my watch.  Breakfast has come and gone while I’ve gotten caught up on A.’s history.  I work back-to-back sixteen-hour shifts Saturday and Sunday.  It’s Saturday morning, the start of my workweek.   

Patients are admitted to 3 East in the acute phase of their illness, for assessment, stabilization, and referral.  A. was admitted on Wednesday on a psychiatric hold for patients who are a danger to themselves or others – with a diagnosis of borderline personality disorder.  Because her illness has been well documented over its ten-year course, we know what to expect – up to a point.  Her overly bright greeting, the strenuous exercise, her mood of the moment could swiftly devolve into something dark and irrational.  

She’ll manipulate staff, split us into enemy camps, hate us then love us – go from zero to sixty – in the time it takes her heart to beat twice.  Her landscape is one of emotional extremes.  She’ll rage at those who are supposed to love her, who did love her once, until it got too hard.  She’ll rage at their abandonment.  She’ll rage equally at those who try to hang onto her.  We can expect her to try anything to fill the emptiness that – like an organ not visible on a CT scan but with an anatomical location vaguely near the human heart – comes with her disorder.

Beyond genetics, we recognize people by their personality traits – the quirks and behaviors that distinguish us from each other.  Our personalities form in our earliest years.  Personality disorders – patterns of inflexible and maladaptive behaviors – typically manifest in adolescence, then harden and set; they form in response to triggers like abuse or abandonment – real or perceived – and continue into adulthood if untreated. 

Young women with A.’s diagnosis often act out in the form of suicidal gestures.  These days, BPD comes with websites that cater to self-cutters and teach innovative means of self-destruction.  A. shares creative nihilism the way best friends share clothing and secrets.     

When group ends, I find A.  I turn up the hot water for her shower and bring her a cheap, pink, hospital-issue razor.  She came equipped with a heavy white Turkish towel and her cosmetics kit, stuffed with miniature, free-gift-with-purchase samples of expensive toiletries. 

Delicate white scars road-map her flesh; intricate patterns crisscross her arms, legs, stomach, trails of superficial cuts that dead-end before reaching the generous blood supplies of her arteries and deep veins.  I hand her the disposable razor.

“Not a pretty sight, is it?”

“You look like my grandmother’s lace curtains.”

She giggles.  The bathroom fills with steam, and I can’t see her reflection in the mirror.  I’m uneasy and move closer to watch her stroke the razor easily up her long legs. 

“These razors are the pits.  I never get it all.”

When she arrives for lunch, she’s meticulously made-up and neatly dressed in designer jeans and a bulky Aran-knit sweater, just a pretty young woman sitting down to lunch on a sunny afternoon.  She wolfs down two portions of Salisbury steak and gravy, mashed potatoes with butter and sour cream – all served on paper plates with plastic utensils – and four styrofoam cups of ice cream for dessert.

When I walk past her room fifteen minutes later, I hear her throwing up in her bathroom. 

“Are you okay?” I interrupt the unmistakable gagging noise she makes as she purges her lunch.

Yeah,” she calls.  “I’ll be out in a minute.” 

A stuffed animal rests on her pink pillowcase.  She’s taped photos to the wall above her bed.  One photo in particular catches my eye.  I lean in to study it.  A. stands at the center of a group of people jammed together in tree-dappled sunshine.  They pose for the camera, smile and wave happily to an unseen audience.  A. looks healthy and plump.    

When she emerges from the bathroom her lips are raw.  She smells of toothpaste and has changed into a hospital gown.  She slumps down on her bed and clutches her shabby teddy bear. 

I look from her image to A. in her bed.

“Who are these people?” I ask.  “How old are you here?”  

“Sixteen.  My mother, my brother, my uncle, my cousin, and my best friend.”

I search for clues in the photo.  Nine years.  What the hell happened to her?

“Do I have to act out to get a shot?  I just want to sleep now.”

“I’ll bring you something.”       

I inject a mild sedative.  Now is not the time to discuss coping mechanisms.  She skips dinner and sleeps through the evening.  Sometimes that’s the best you can do for someone.

When I leave the hospital that night through the sliding glass doors of the emergency room, I inhale deeply.  There’s a disconnect between 3 East and the rest of the world.  It’s  an occupational hazard.  Inside, I lose track of time.  I’m reminded it’s Christmas when cards and an artificial flame-retardant tree decorated with soft ornaments appears on 3 East. 

Now it’s the end of February, still dreary and cold, a clear night with a dazzling array of stars and a sliver of bright white moon.  Plumes of vapor billow from my mouth.  I point my car home.  Garlands of Christmas lights still grace houses and trees in Portland.  I can’t decide whether my neighbors are lazy or crazy; maybe they’re depressed by our long gray winters or eccentrics who love Christmas lights.  Whatever their reason, that night I'm grateful.

Evelyn Sharenov

"How do we know the attacks are over?" a woman asks.

Her hospital stay was preceded by an overdose of opiates.  A double mastectomy, chemo, and radiation knocked out that part of her reptilian brain devoted to survival.  She’s in her fifties, with disheveled gray hair.  A bright purple blouse flutters to her waist like a deflated foil birthday balloon. Residual glue from electroconvulsive therapy electrodes sticks to her temples; tufts of hair stick to the glue.  This lends an unfortunate comic air to her otherwise forlorn appearance.  She huddles into a chair.  We’re supposed to help her feel safe. 

“What if they bomb us here?”

“How do we know this is real?”

“Yeah, what if they staged it?”

They look to us for answers.  While it seems unlikely that terrorists have much interest in Portland, Oregon, none of us feel safe.  We do, however, know it’s real and we have nothing to offer except words, soothing and hollow, words that don’t reflect our internal landscapes, our churning dread and apprehension.    

The attacks resonate with my own terror of being trapped on an airliner going down; my fears go back to my childhood.  In third grade we train to "take cover" during air raid drills.  It’s cold down there on the floor under our small desks, but not as cold as the Cold War.  The desks are barely wide enough to contain our length, scalp to feet.  We cover our heads with our arms and tuck our legs up under our bodies.  I’m young, but not so young as to believe that this will help if an atom bomb falls on us.  Depending on what we’re made of – brick, glass, flesh – and how far we are from ground zero, we’ll incinerate, liquefy, or vaporize.

Sometime that afternoon, my father calls.  I keep him in a nursing home in Portland, as if I own him and have that right.  In the twilight of our relationship, he’s hobbled by dementia and doesn’t remember how to use the remote control or how to end a phone conversation.  He’s a captive audience.  We weep about the city we know so well we can walk its streets in our dreams and never get lost.  I call the nursing station and ask them to hang up my father’s phone and turn off his television.  Other than that morning, he’s been doing well, the charge nurse informs me.

When I leave the ward that afternoon, a hunger overwhelms me.  I want to hold tight to something innocent, a void so young and pure it’s untouched by breath or fingertip; it has no history, no double helix, no DNA.  I visit my father.    

The next morning everyone is haggard.  The emergency room has filled and emptied and filled again during the night.  We have no empty beds.  Disturbed sleep and dark dreams prevail.  The hospital ramps up staffing as aftershocks shift our roots from shared foundations – the common expectation of safety on our own soil.  The first group on the first morning after 9-11 tallies nightmares – a Ground-Zero litany for the mentally ill:     

“My house crumbled with me in it.”

“I was burned alive.”

“A baby floated through the air toward me.  It had no arms or legs.”

“I jumped out of a window, but I woke up before I hit the ground.”  

In the big picture, I’m a bit player, an editor in the narrative version of their lives.  I enter in the middle of the story, do a brief cut-and-paste, and move on.  My tools are limited: medication and conversation, as much art as science.  I’m a conduit: the scalpel, the IV bag, the splint that holds the fractured psyche together until the crisis passes and the patient can stand on his own. 

There’s always the question: what separates us from them, staff from patients?  Any answer anchored in hard science is a long way off.  Other than that, there are different answers on different days.  On some days what separates us is a matter of degree.  Anyone who experiences an emotional toll – the loss of a child, a life-threatening illness, the turmoil of divorce – knows how fragile sanity seems at times, and rests well when the chill of danger passes.  One morning you wake up and understand you’ve averted disaster. 

I know it’s unlikely I’ll experience the horrors that bring men and women to the ward because whatever trigger, genetic marker, or errant DNA, whatever neurotransmitter in whatever area of the brain has done this to them has not done it to me.  Whether by luck or design, I remain upright.  

The emotional and physical boundaries that are essential on September 10th mean less on September 11th.  On September 10th, the physicians, nurses, and therapists on the ward have the power to say who’s mad.  It’s easy – anyone who sleeps on this thirty-bed ship of fools is mad.  What separates us on September 11th is just this: precious little.  For a brief period of time, shared disaster obliterates the biological and cultural contexts of mental illness.  What we have in common is greater than what distinguishes us from each other.  Jets crash into the familiar landscape of my childhood and carefully established roles change, patients and staff coalesce, one superimposed on the other.     

On September 10th sanity is a worldview, a consensus.  Madness requires witnesses. On September 11th we are all witnesses, sane or mad.

*

At this writing, seven September 11ths have come and gone.  Life moves on and away for those of us who shun the political drama and morally confused pageantry of what is now a more private sorrow.

On another brilliantly clear, splendidly warm day in Portland, in another clinical setting, it’s September 11th again.  A young man enters my office.  There are outward signs that he takes antipsychotic medication: tremors, fatigue, a broad abdomen, but vestiges of the handsome boy remain.  Although he’s making progress toward his goals, this morning he sweats profusely and he’s hypervigilant.  He startles when my phone rings.  He requests a prn – a medication dispensed as needed to treat transient symptoms of anxiety or agitation.

“It’s September 11th,” he says.  On the television in the day room, another group of patients watch the towers fall.    

Evelyn Sharenov

The cool quiet of my car is blessed solitude before my workday.  The drive to Portland begins in darkness and silence.  I don't turn on the radio — just listen to the roads and freeways.  Although it's still warm, day and night move toward the balance of September's equinox.  By the time I walk onto the ward, bright sunlight filters through the Lexan windows onto worn hospital carpet.

Which is to say that that September 11^th starts pretty much like any other September 11th.

Most of my patients are just coming to life.  By the time they venture from their beds and are marginally awake and dressed, I know the rudimentary facts.  In a series of coordinated suicide attacks, two jets have pierced the World Trade Center's Twin Towers in New York City, a third has crashed into the Pentagon, and a fourth is down in rural Pennsylvania.

I obey the human imperative and call family in New York, but the lines are down or busy or there's no one there to pick up.  A flat electronic voice politely tells me all lines are busy and suggests I place my call again later.  The ward manager wants to pray with me.  I'm not a believer, but this morning I need a binding ritual.    

In the usual scheme of things, a disheveled shuffling line of patients stops by the clinical desk to pick up their medications on their way to the community room; then breakfast and a morning news program, followed by the first group session of the day.  There's an eerie inevitability to what happens next.  In a moment someone will turn on the large-screen television.

In the course of eight hours, we — two nurses and three therapists — watch together as an endless loop of video crazily replays itself and the Twin Towers collapse and rise again and again in a bizarre demonstration of death and rebirth.  We're mesmerized by the spectacle, the upturned faces of New Yorkers, mouths open to receive burnt offerings — the ashes of family and friends.

The most delusional of our patients incorporate the television images into their illness; they smell burned flesh and hear screams that we refuse to imagine.  They watch without the filters we take for granted.         

A young man sits up close to the television, close enough to distort any coherent image.  "There, watch that body explode," he yells.  He's somewhere between terrified and excited.

The young man's hair winds into a dozen or so thick blond Rasta plaits.  Dark stubble sprouts like newly mown lawn on his drawn cheeks, and his arms and legs are dotted with old or healing needle marks. 

He's a literature and philosophy major at a small private college in Portland, the domain of the scions of educated well-to-do parents or talent large enough to earn a free pass.  His heroin use masks the paranoid delusions and auditory hallucinations of his psychosis.  He's on 3East in the middle of his first relapse — a month after he stops his medications. 

He'd felt fine.  He had a new girlfriend and wanted to lose the weight he gained from his meds.  He wanted to devour her, fuck her dusk to dawn.  Normal desires.  And the meds interfere with all of it, disrupt everything, not just his delusions. 

Now he's up all night and can't study.  He's restless and his approach has an edge — sometimes mean and off-putting.  His interpretation of reality differs from mine.  He's twenty and has embarked on what will probably be a lifelong struggle with schizoaffective disorder — a combined thought and mood disorder.

Another man, this one middle-aged, puts his arm around his college-aged peer.  His face falls into easy creases and jowls.  He's protective, coming through a vegetative depression — the kind of smothering mood disorder that holds you to your bed.  With the help of ECT — electroconvulsive therapy — and medication, he's fully awake.  His hairline retreats, the remainder grays, ambivalent on how to grow old, but he's clear eyed and animated.  His relentless depression, now lifted, provides new insight.  The two men share a room and are fast friends.  They sit together at meals and in groups.  The older man attempts to impart wisdom that's eluded him in his own life: you have to take your meds. 

Both men — in fact, most of the male patients — wear athletic shoes without shoelaces, ward policy.  During groups, a row of shoe tongues loll to the side like panting dogs.  This morning, no one leaves the community room to wash or dress; pajamas and bad breath are the order of the day.  Schizophrenia and major depression are untidy illnesses, and more so on September 11^th.

Part two next week.

Evelyn Sharenov

“Is that one of yours?” my friend’s daughter asks.  She’s eight.  We’re headed toward Pioneer Place in downtown Portland, OR to catch a movie. 

Her use of ‘that’ as the subject of a sentence, when ‘that’ is a man, unnerves me.  She doesn’t seem nervous at the approach of this seemingly odd fellow, but her mother closes ranks.

“What?” he shouts.  He vehemently challenges an internal voice, an unseen someone.  “Wha-at?” he repeats, angry now.  His way of saying, “Quit messing with my head.”

“Is he one of yours?” my friend’s daughter self-corrects.

“No, but he could be.”

I believe he’s harmless, noisy maybe, this side of shabby, obviously mad, but ultimately harmless.  A scruffy black beard and hair that stands straight up around his head define his appearance.  Black brows meet in the middle of his nose bridge.  His gaze is intense, dark and glaring.  He quiets as we near each other, nods politely, then moves aside to allow us to pass.  He’s close enough for me notice crumbs of meals past in his beard.

Once past us, his quarrel begins anew.

I lead two lives.  On 3East, a locked psychiatric ward in a Portland, Oregon hospital, I stabilize men and women in crisis, move them toward discharge, back into their lives, back into the community.  As a freelancer at Willamette Week and the Oregonian newspaper, I’m out and about in town.

I routinely bump into my patients.  They wander and Portland is a small city, compact, laid out on a grid.  It’s an easy walk from north to south and east to west.  What I’ve noticed is a clear distinction between patients who acknowledge me and those who do not.  The line is drawn along socio-economic divides, as well as the severity of the illness.  There are rules of engagement for such encounters.  I never greet a patient unless he makes the first move.  The initial overture must always be made by the consumer.  Being in treatment – even for depression, which afflicts one in five Americans in any given year – is a sensitive matter.

I know one of the staff at Willamette Week from a weekend he spent on 3East.  He was new in town, depressed and lonely.  He felt – for a fleeting moment – as if not living might be preferable to living, so he checked into the hospital.  He was discharged two days later, armed with a prescription for antidepressants and a referral for outpatient counseling.  He told me he felt ‘normal’ in comparison to some of the other patients on 3East.  During his time on the ward, I don’t mention my connection to WW.  That would be a breach of ethical boundaries.  When I stop by WW to drop off a book review and chat with my editor, he’s the first person I see.  He turns away from me.  Then I pass him as I leave the building.  He’s outside smoking a cigarette.  I don’t attempt to make eye contact. 

Many of my patients are involved in the sex trade, to support their drug habits, pimps, kids.  A visit to 3East is often prompted by an arrest or the need to detox down to a more affordable habit.  “Hey,” “How you doin’,” “There’s my nurse,” they call if they see me on the street.

Over Thai food one evening, my husband notices a young woman at a nearby table.  She looks at me, the briefest eye contact, a flicker of recognition, then nothing.  I never take it personally, that someone is embarrassed to know me in that other context.  “Is she one of yours?” my husband asks.  She’s an attorney and will die of complications of alcoholism in the not-too-distant future.  “Yes,” I nod, and continue chopsticking my Pad Thai.

I literally bump into a young man who I know from two stays on 3East.  “Hey, mom,” he yells out to his mother in another aisle of the one-stop-shopping market.  We’re both trying on shoes.  “See, she’s buying Sketchers too.”  He shows me his new runners, proud to have something in common with me, to share a moment of health, not illness.  But something’s off; his eyes are too bright, his voice too loud, speech too rapid, words tumbling over each other.  His mother approaches.  I know her.  “Is he taking his meds,” I ask.  She shakes her head.  The following week he’s back on 3East, dark and brooding, pacing the ward in his new Sketchers.  Seventeen laps equal one mile.  He doesn’t recognize me or know my name.

Last spring as I walk past a dumpster, on my way somewhere that isn’t the hospital, two heads pop up from dumpster-diving.  “Daddy, look, it’s our nurse.”  She shares what little she has, a broad smile and a generous nature.  Daddy, her boyfriend, waves.  He can’t talk unless he adjusts his tracheostomy tube.  I know them from the local methadone clinic where I occasionally dispense.

I know how it feels to be welcomed.  I’ve learned how it feels to be too visible.  Half visible.  Invisible.  

Evelyn Sharenov

By the time you see me in the hospital, you have no place else to go.  The system has failed you: you’ve alienated family and burned through your support systems.  Perhaps you’re in your first all-out psychotic break or stopped the meds that stabilize your moods, thoughts and behavior.  You could be dangerous – to yourself or someone you once knew and loved, or to a total stranger on the street.

Layers of symptoms interfere with negotiating the basics of daily living – shopping, cooking, paying bills, doing laundry, washing your face and brushing your teeth.

Juggling a job, partner, kids – all things being equal, this is hard enough when everything is great, let alone when you’re battling depression or voices that tell you to hurt someone, voices no one else hears.

It’s a major undertaking just to get out of bed and feed yourself.  Going to the pharmacy or market, making a phone call, knocking on a neighbor’s door, reaching out – these are impossible if you have to fend off menacing and terrifying command hallucinations. or believe the CIA is following you.  In full blown mania, patients may be so euphoric that food and clothing are unnecessary accouterments to life.

You’re beset by bizarre and mysterious somatic complaints for which no medical text can account.  Doctors don’t believe you.  You tell them you’re feet are on fire or that you have electrodes in your brain, that there are fingernails in your scrotum.  You believe the CIA is following you, that cameras are hidden in your walls, that the television is giving you orders.  You leave a trail of chaos in your wake for family and friends to clean up.  They don’t fully comprehend your ailment.  They believe that you have some control over your symptoms and that you’ve chosen to behave in ways that deliberately undermine their best intentions and efforts to save you.  They will doubt and deny and when they finally understand you, they’ll understand you’re a stranger with a familiar face.  

It’s shameful – you know that with what’s left of your ability to reason.  It’s shameful that the weakest and most confused among us are left to negotiate a labyrinth that leads inevitably to the emergency room, where you enter the maze, only to learn there isn’t a psychiatric bed for you.  There aren’t enough beds to start with, and you don’t have the right insurance.  

I apologize.  Society’s failings are compounded by our own.  I can name the agencies involved in educating us, but their programs fly in the face of how we feel when we encounter someone like you.  You’re different and we’re afraid.  You frighten us.  The reptilian brain still cowers in the cave or whispers aggressive thoughts.  There isn’t much to it, the oldest smallest region of our most mysterious organ.  Fight or flight is hard-wired into it.  Stigma lives there.  “Not in my backyard,” stigma whispers.

As self-congratulatory as Portland, Oregon may be, homeless schizophrenics are as common as Starbucks’ franchises.  You give off fumes acquired sleeping in doorways, huddled against the rain in clear plastic dry-cleaner bags, picked up from the exhaust of a million cars, from urinating wherever you can.  Your hobo skin is the product of time and layers of grime.  Your wear all that you own, shabby raiments layered on in no particular order. 

Walking down a tony street in Portland, I feel that same moment of panic and indecision as anyone else.  When you approach me yelling at someone I can’t see, do I cross the street?  Would that hurt your feelings?  Would you understand that I avoided you, recognize my rejection?

Our fears are not baseless.  Statistics in the May 19, 2009 issue of JAMA indicate that 28% of schizophrenics who also abuse alcohol and drugs are convicted of violent crimes, compared to 8% of those who do not have substance abuse problems and 5% of the general population. 

There are other statistics: 25% of the mentally ill population benefit substantially from medication; there are another 25% for whom medication does nothing; medication helps the remaining 50%, more or less.

This is mental illness and you are one of my patients.  Faces and names change; your symptoms do not.  I pull you up from the ground or down from the sky, I stand by as your newborn is removed from the delivery room by a social worker from the Department of Human Services.  I try to help you manage your demons.  You know how that goes.  Sometimes the magic works.  Sometimes it doesn’t.  And in any case, this probably won’t be your last visit here.  The ward, 3East, where you come to stay for a night or a fortnight, is shelter from the storm, a bed and a meal – three hots and a cot, an E-ticket ride at Disneyland, the card that fills the inside straight.  You’re with me as long as your insurance lasts and no longer.  Your oddly worded letters of thanks, your strangely drawn sketches take up a wall of my office. 

Rest now. 

I’ll  tell your story.

Evelyn Sharenov

Women are easy marks for drug companies.  They’re more likely to do their health care homework, correctly fill out insurance paperwork and pay attention to television commercials that feature medications.  They’re more comfortable advocates for their own well being as well as that of family members (a man has to be standing on a bridge ready to jump before he’ll admit he’s depressed) – and more easily turn her healthy behaviors into sales.  Women also pay close attention when an ad features beautiful young models, ads that pitch lifestyles as well as birth control.

So how does big pharma market a new birth control pill?  Several years ago, Bayer started a campaign to push Yaz to the top of the birth control pill charts; it was incredibly successful, until the FDA forced Bayer to pull the ads featuring women kicking balloons labeled "irritability," "headaches," and "increased appetite."  When a pill implies, to the background pulse of a popular rock tune, that it will end pimples and monthly bloat, who wouldn’t pay attention?  Who cares if it can kill you?  

I’ve followed the advertising campaign since it started.  Less obvious and more insidious than the original ads are the ones that feature a beautiful woman lecturing her friends at a high-end party where you just know everyone will go home and fuck.  Yaz is selling something beyond contraception; pregnancy prevention is just the start of the message in these commercials.   

The party pooper, as she’s come to be known in my household, states, “I didn’t go to medical school for nothing,” when her friends express surprise at her vast font of knowledge regarding Yaz.  This is not exactly the same as saying, “I’m not a real doctor, I just play one on TV.”  Ask a viewer whether she thinks that woman is a physician.  She just said she was, didn’t she?

The FDA has been all over this advertising campaign.  Given the politicization of the FDA during the Bush administration, it’s difficult not to read into their maneuvers; however, it does feel right that they are coming down on Bayer in this case.  The pill addresses a majority of menstruating women with its promise to cure pimples and PMS.  It does not deliver.  You don’t have to shoot headaches and cramps with an elephant gun; Midol, acetaminophen, or ibuprofen all work well.  Yaz is helpful for the minority of women who experience an actual psychiatric disorder, PMDD.  PMDD (premenstrual dysphoric disorder) actually interferes with quality of life and the ability to function during the premenstrual phase.  Yaz was also approved for prevention of moderate acne.

Yaz’s formulation includes a synthetic hormone that causes an increase in serum potassium — the level of potassium in the blood.  This is risky business; excess potassium can lead to serious heart problems, as well as involvement of other major organ systems.  As the corrective television advertisement states, "check with your doctor" to make sure your heart and kidney function are normal before starting Yaz.  And unless you’re intent is to purchase a lifestyle in addition to oral contraception, a more traditional birth control pill would work as well.  In 2008, Yaz was the best-selling birth control pill on the market.  And the corrective ad campaign only skimmed the top of Bayer's deep pockets.

Evelyn Sharenov