LOOKS ARE DECEIVING

Two individuals, street corner philosophers, had one of their afternoon casual conversations when, out of the blue, the first one said.

“You know, there are places that a person should not visit: a jail cell, a psychiatric hospital, and, of course, a cemetery. But jails and hospitals are heartbreaking.”

“What do you mean?” asked the second one.  

“Well, if you visit a jail, you have failed to abide by the rules, you found yourself in the wrong place at the wrong time, or possibly an injustice has been done against you,” he answered.

“Hum?  Or it may be some kind of moral failure or poor impulse control,” the second one said, caressing his goatee.

It was evident that he was trying to set the stage to tell a story. The first one was known for such preludes.

“The thing is that a mental hospital is an especially tough place.  I think it is the saddest of all places. You only make it there when you have lost yourself or the will to continue being yourself. You see, all things that make you human, your memories, private thoughts, and your ability to make sense of your surroundings, get lost when you’re sick. Your mind sinks into dark places, loses touch with reality, or misinterprets others’ intentions.  Your mind gets trapped in a web of fear and persecution”, concluded the first one.

The second one, a skeptical individual, still needed to see the point.

“I don’t get it, so what are you driving at?” asked the second one. “Knowing you, I know that coming up with something… why don’t you just cut through the chase?”.

“Okay… It’s something I just saw a few weeks ago”, replied the first one.

“There’s this young fellow, my next-door neighbor; he’s been sick for a while, you know,” he said, pointing at his head, “mentally sick.”  

He stopped and looked down as if getting into deep thought.

“It was quite a shock… I’ve seen him around, you know. Just another young punk. But this time, when I saw him in the corner by Houston, he was like a different guy. His eyes, like a dead fish, looked glassy, with a confused and cloudy stare. His speech was jumbled, babbling nonsense. Even the way he walked changed. He was a totally different guy… I tell you, like night and day. If you saw him when he’s not sick, you would not recognize him.”

“Really?”…He must have been on something…there’s a new dope going around”, said the incredulous second one.

The first one, as if defending his honor, replied, “Trust me, I know the guy… I’ve bought weed from him before”.

“Oh…Okay. I guess it must be tough getting sick like that,” said the second one. Then, he switched to a different topic.                                              

                                                                                     I

Across town, at a local hospital, a known psychiatrist, Dr. Elaine King, was surprised after she also witnessed the transformation of a very sick individual into his normal self.

This is the patient’s story.

                                                                                     …

Empire State General Hospital pulsated at the rate of the city. Like New York City, it was busy, rushed, and chaotic at times; a reinforced concrete box-.  Two massive, ten-story towers made of concrete, steel, and glass, filled with anonymous souls and sad stories. “Beautiful losers,” Dr. Braum liked to say. The tiled walls, faded like subway tiles, were exact replicas of the city’s coldness and indifference.

It was 8:30 am, the time for morning rounds.

The psychiatric resident, Dr. Patel, paying his dues for the privilege of writing prescriptions independently, was on call the night before. He had been up for the previous thirty-six hours when he admitted Steven Belisario. He tried, like a good Indian person, despite his obvious fatigue, to be courteous and deferent.  While making his English survive the thickness of his Indian accent, he presented the case to his half-asleep Attending, Dr. Brawm:

“Patient’s ID: Steven Belisario.

The patient is 23 years old, single, white, male, of Italian descent. He was brought to the ER by ambulance and escorted by the police. His older brother Christopher Belisario accompanied them and was a collateral informant.

Upon arrival, the patient was disheveled, with a strong stench of urine and feces. He refused to answer questions or to make eye contact. He was babbling incoherently about people trying to kill him.  Suddenly, he became agitated, flipped a tray with his meal, and yelled, “You’re trying to kill me.” He started throwing punches. He had to be subdued by the hospital police and staff. They put him on a four-point restraints.

He was administered a stat dose of Lorazepam 2 mg and Haldol 5 mg, as he kept on fighting his restraints, risking grave medical problems, such as “Rhado.” I could not interview him. He was too psychotic. So, his brother gave the accounts of his erratic behaviors for the past two weeks before his admission.

Christopher Belisario, the patient’s brother, informed us that his brother was isolated at home and appeared to be talking to himself. He started looking at his family members with increased suspicion, looking at others from the corner of his eyes.

He also had a peculiar look in his eyes; he seemed gone. His family  knew when he was getting sick. The neighbors had also seen him around acting strangely, hiding from others. It was not his first time.

When the patient locked himself in his room for two days, they knew that they had to act. It was obvious that he was not taking his medications. 

His brother informed that after he called 911, once the police arrived, he almost broke the door but finally convinced Steven to let him in.”

He finished his assessment by diagnosing the patient as Schizophrenia Paranoid. Plan: Admit to the psychiatric ward C-8.  Dr. Brawm agreed with his assessment. He co-signed Dr. Patel’s report and went back to “read.”

Evidently, the poor soul lost himself. He was trapped in a jungle of distorted thoughts, screaming noises, and threatening voices. The process of piecing him back together started.

                                                                                II

The Attending doctor in charge of his care, once in the ward C-8, evaluated the patient and made her observations:  

“At first, upon arrival at C-8, the patient, Steven Belisario, was disengaged, isolated, and talking to himself. He paced the hallways incessantly, babbling incoherent words. He was then seen throughout the day in a corner of the dayroom, rocking back and forth with his face between his knees.

When I first attempted to interview him, he had already been in the Hospital for a few days. He squatted in what was later recognized as ‘his’ corner. He dressed in the typical light blue hospital gown, following the suicide protocol. He was on one-on-one observation, at arm’s length, with a nursing staff. His hair was messy, still disheveled. He also had cotton balls stuck in both ears in futile attempts at calming the voices inside his head.  

‘Hello, Steven,’ I called his attention, ‘I am Doctor Elaine King. I will be your doctor…I would like to chat with you.’  

He ignored my first contact, but surprisingly, despite looking at me with suspicion and hostility, perhaps because he was familiar with the hospital routine or maybe because he heard a female voice, he agreed to my interview.  

He confirmed, between long pauses and suspicious glances, what was reported during his admission, which made me feel optimistic.

Despite his appearance and behavior, he was not acting out or grossly disorganized; thus, his prognosis would be better. 

After our first few encounters, he still appeared slightly hunched, with long hair covering his face. He was a very fragile, polite, and timid young man. He made no eye contact and seemed a lost little boy, often needing reassurance. He latched on to his one-on-one staff, seeking protection. I felt an instinctive maternal impulse toward him. He was a vulnerable child on the verge of a complete, irreversible mental collapse.

He sat for long hours in the dayroom, staring at the walls, twirling his long hair. A long veil of sadness and loss accompanied him like a shadow. He still had some difficulties articulating his thoughts, but clearly, the medications started to work. His rocking almost subsided.

A week later, I wrote of his improvement in my progress notes. ‘Steven was approachable, no longer hiding in the corner and interacting with other patients, albeit with a touch of suspicions and wariness.’

As I became more familiar with him, his demeanor took me aback. In my more than twenty years of psychiatric practice in New York City, given the neighborhood we served, I have never encountered such a polite young man.  He was in his very early twenties but seemed an adolescent.

His behavior and appearance of a gentle soul were not consistent with his place of residence. He lived in the lower east side of Manhattan, to the east of Broadway Avenue and north of Houston Street, a drug-infested neighborhood, ill-reputed by its criminal activities. 

                                                                                 III

Despite his improvement, I still did not have a first-hand account of his descent into madness. I needed to hear his side of the story. I kept on evaluating daily until, on week three, we had a breakthrough session:

‘Doctor, before I got sick, I did not see things around me. I took things for granted. They were around me, but I paid no mind to them. The walls in my room, my furniture, my TV, my clothing, my face….’ 

The patient explained how he was getting sick but did not know it. His voice was soft, like a whisper.  I had a hard time hearing him.

‘But,’ he continued, ‘gradually, my room started to appear smaller and darker…The TV was talking to me… I no longer felt safe in it. I had to shut the windows and close the drapes. I moved some of the furniture in front of the door….’

He paused, perhaps trying to understand what had happened. A few moments later, he spoke again.

‘My head did not feel like mine; my thoughts were jumbled and cloudy. I had a hard time getting my thoughts together. My thoughts were like running, like when you’re flipping channels or jumping like a playful bunny. I tried getting hold of them, but it was impossible.

The voices in my head were louder. They were talking about me, putting me down, and bossing me around. ‘You’re a loser,’ they said. ‘Close that window; there are some guys to get you!’ I could not sleep; my brain would not shut up. ‘If you fall asleep, they’re gonna get you… you must protect yourself,’ the voices insisted.  My brain hurt.

I obeyed the voices; I had to… I figure they would then leave alone. I barricaded myself, but my room was small, and it did not have much furniture to block the door. I put my small dresser in front of the door and kept the chair near me. If they broke the door, I said to myself, I would hit them with the chair. I had no choice; it was me or them. It was too much, the fear, the voices, the people trying to get me.

I interrupted him to assess the extent of his delusions further. ‘Who was after you?’ I asked. He did not answer.

I decided to stay in my room. For days, I had already stopped taking showers; I was not eating. The water was hurting my skin. I was too busy protecting myself to concentrate on eating or sleeping.’

He seemed to have found his rhythm. His eyes were fixed on the wall as if he were reading a script that was going through his mind.

‘A day or two, I don’t know, I think I heard a loud knock on my door. ‘Stevie, Stevie, open the door!’. It was my brother’s voice.

My brother Chris was angry. My heart was pounding; I was afraid. I did not know what to think. I did not dare to open the door, but because it was my brother’s voice, and he kept banging on it, I opened it. He was standing there.

I heard his angry voice again. ‘What’s wrong with you? … stinks here!’.  I remember my brother saying that my room smelled of dead animals, pee, and shit. I must have been there for a while. I knew it was my brother, but I did not dare to look him in the eyes. The voices told me not to, ‘Don’t look…he might hurt you’.  

Other voices came from the door. ‘Are you okay? You need to come with us.’ I did not recognize them, but my curiosity was stronger than the voices in my head. I dared to look. They were cops! I was convinced that it was a trap. The voices were right. I needed to protect myself.

‘Get out!  Hurry up. They’re gonna kill you!’ said one of the voices. ‘Run!’

I tried pushing my way through the door, but my brother tried grabbing me. I punched his face. I punched him twice. The cops then jumped on me and put me in handcuffs.  I was screaming. No one came to help me.

I woke up in an ambulance.  My head was heavy…I was sleepy, but I saw more people in uniform. I started panicking again, and a uniformed woman with a nice voice told me, ‘You’re going to be okay.’ She said that they were gonna take care of me. I was too drugged up anyway.  I believed her.‘He stopped and looked at me.

I was satisfied with his progress. The medications were working, which reflected his increased insight into his illness. His story also corroborated what his brother said during his admission. He was improving. Vive la science!

During our morning round the next day, I reported his progress.  It was clear to all the team members that the polite young man responded very well to his treatment. The Social Worker, due to administrative pressures and the need for an empty bed, planned for his purported discharge within three or four days. She started setting up his follow-up appointments.

We all agreed that the well-mannered, slightly shy, polite young man responded very well to the treatment provided. He was ready for discharge. 

It was Friday, and I was looking forward to the weekend. I planned to accompany my friend Dr. Braum to his Hamptons vacation home. He was celebrating his eighty-seventh birthday.  It was the closest I was ever going to get to the life ‘of the rich and famous.’  

Dr. Braum lived up to his Jewish stereotype. He got mad money, not from his professional practice but from being the heir to his industrialist, Holocaust survivor father.

                                                                                     IV

I made it to Empire State General after sitting on the Long Island Express for a couple of hours. His discharge was planned for Monday morning. But on Mondays, life in Ward C-8 was a replica of the city’s traffic—a busy hive. I had to meet Steven one last time to document his mental status before his discharge.

I went to the day room looking for him.  

I looked around but did not see him. The day room was shaped like a rectangle with two large doors on one side of the long axis and two large windows on the opposite side facing outside. It was a socialization area where patients spent most of the daytime hours. But more than that, it was an observational arena of psychotic behaviors. We were able to see live the manifestations of very sick brains and the miraculous effects of treatment.

I was about to turn my back and walk to the hallway when a guy approached me. He was tall, with his hair in a ponytail. He wore baggy pants, which were fashionable in hip-hop culture, with construction workers’ boots and an oversized New York Knicks jersey.  

He got near me, still a few feet away. ‘What rup yo?’ he said.  ‘Who’s this guy?’ I thought. 

I did not have time to identify him fully. He startled me. I thought that he was a new patient ready to attack me. You never know; Monday mornings at Empire State General were rough. New blood was coming to the ward after a busy weekend at the ER.   

He swaggered his way closer toward me, displaying the bursting confidence and defiance that I had seen Ricker’s Island inmates show.

‘Yo, Doc, you don’t dig me?’ he said casually. All my antennas were up; I was on guard.

I blinked twice, collected myself, and looked again.  His voice was a deep base that he projected strongly. The guy reeked of Testosterone.  His skin looked terse. He stood with a superbly confident wide stance, ‘ready for whatever,’ as they say on the street.

‘Hi’, I said. I was now on guard. ‘How are you?’.

I was still unsure who the hell this guy was, but I did not want to look impolite or, worse yet, rude and risk a whipping.  His eyes were glued to my face. He explained, while pointing at the nurse’s station that the Filipino nurse had told him that he was being discharged and that I had to write the order for his discharge.

‘This is some kind of bullshit, yo; I’m ready to bounce!’ he said.

Finally, when he spoke again, as he played with his hair in a way I thought peculiar, I took a second look intensely into his eyes. And there he was.

The guy in front of me was my patient, Steven Belisario. 

For a few seconds that felt like an eternity, I tried to reconcile the guy in front of me, this street guy, gang banger, aka ‘cash money,’ with the vulnerable kid that still, a few days ago, I wanted to rescue and felt ready to adopt. Where was the patient that I left Friday afternoon?

Still in shock, I told him that, indeed, he was being discharged within the hour. I took the opportunity to give him the typical speech about the need to keep his appointments, take his medications, and refrain from drugs, alcohol, or nicotine.  I emphasized the need to continue his medications.  ‘Ah aay, doc’, he replied.

In what I later interpreted as his token of gratitude, he first gave me a fist bump, quickly followed by a superficial hug. He then thumped his chest twice and said, ‘I see ya around, doc’ while waving at me the V sign. He swaggered his way to the nurse’s station to settle his final discharge.

I walked to my office to write his discharge summary. That was the last time I saw my patient, Steven Belisario.

Almost a couple of decades later, I remembered his Kafkaesque transformation. Steven Belisario went from a Chrysalis that did not birth a butterfly to a Bengal tiger.

Dr. Brawm had been gone for more than two decades, but I still heard his voice: “Dr. King, things are never what they seem.”  

I no longer have doubts that “looks are deceiving.” 

 

 

P.R. Thompson. 

June 2024