Shampoo, soap, and psychiatry

Feigning Sanity at Bellevue, my second article in the Medicine Mensch series.

And here it is in full:

MEDICINE MENSCH: Feigning Sanity at Bellevue
By Zackary Sholem Berger
February 4, 2005

My first rotation as a medical student is psychiatry, that branch of medicine that patrols the border between sane and insane. But as is well known to any observer of human behavior, the sane are sane up until the point when you start looking at them with an analytic eye. Then everyone seems to need treatment, doctors and students included.

At 9:15 every morning, our psychiatry ward has a "community meeting," a chance for everyone — patients, doctors and staff (the "community") — to thrash out problems that are relevant to life on our unit. A sociologist would have a wonderful time here. Everyone sits in large, colorful, uncomfortable plastic chairs, like booster seats for grownups. We're reminded daily that at the meeting, personal issues are out of bounds. But without fail, one of the patients always starts with the question, "When do I get out of here?" Or, "Quiero irme ya." ("I want to leave right now.") (The meetings are translated into Spanish.) "That's a personal issue," a staff member always answers, "but we can try to discuss it generally. We're only talking about community issues now."

(On the other hand, our staff meeting is a freewheeling chance to bitch and moan in the most personal of terms. Without coming to blows and, miraculously, without psychotropic medication, the issues are somehow solved, helped by the powerful motivation of getting enough work done by lunchtime.)

But let's get back to the first meeting. What does the "community" complain about? Someone gets tea instead of coffee at lunch, or vice versa. The meeting room (normally the patient lounge) hasn't had its floor washed in days. One of the patients won't take showers. "Hey, where's the shampoo?" Men are using women's bathrooms. And so on. If this list of problems sounds familiar, it's because they show up at all stages of life whenever people stay in close proximity: in the suburban home, summer camp, resort, homeless shelter or Elderhostel. We all have the same problems when staying three to a room.

Even in an emergency, the sickest mental patients have more in common with us than we might like to admit. A couple of weeks ago, I spent midnight to7 a.m. at Bellevue Hospital's Comprehensive Psychiatry Emergency Program — the psychiatric emergency room. The orientation packet emphasizes a number of safety precautions: Never be alone in a room with a patient; always have an exit route in mind; don't promise a patient, even in the name of politeness, anything that you can't deliver. From these caveats, I imagined a cross between a cellblock at Alcatraz and a chaotic thrill ride of the insane. (Never mind the prime rule of medical-student safety, on any ward, psychiatric or not: Get out of the way as fast as you can; someone larger than you knows exactly what to do in this situation.)

I saw five or six patients, and of those, only one needed urgent psychiatric care. Why did the others come to CPEP that night? It was rough outside, rainy and cold, with a brisk wind off the East River — not a good time to be kicked out by your mother because you've had a fight with her new husband. It also wasn't the best night (from another patient's point of view) to have taken a bus to New York from Michigan to "hang out with some friends" who turned out not to be so hospitable.

The attending physician on call that night decided that none of these other cases could be admitted. There were those who didn't have psychiatric problems at all, and just wanted a warm bed for the night. Others were indeed mentally ill, but not sick enough to stay in the hospital. Some fell into both categories. It's not trivializing the plight of the mentally ill to say that the daily lives of the sane are also ruled by institutions that cannot admit just anyone; the problem of limited resources is a general one. (Have you ever tried to find an apartment in the city, or get your kid into school, or find a job?) Even so, I kept asking myself the question: Shouldn't there be an institution that is ready to help these people, no matter what the cost? And here's the answer: Yes, and you're working in it. But you still can't do everything.

The next morning at 9:15 I did my little bit, filling in as a Spanish translator because a couple of people were out sick. Among other things, I helped make sure everyone understood an important fact: how packets of sweetener are distributed at lunch and why. Life on the wards, like life outside, is measured in shampoo and sugar.