There were plenty of others like Harry around that time. Not as well-known or as powerful, with their names carved on the hospital’s walls, but all with the same crushed and baffled air of highfliers who’d fallen to earth.
When I’d been a resident, I didn’t know how many cases I’d treat of clinical narcissism, but suddenly it was all around me. We were taught about a condition called narcissistic injury, a blow to the egos of the self-centered and manipulative. Their personalities had been formed by a parent they’d been able to please only with achievement, who’d never given them unconditional love. Wall Street must lure such people because the hospital was full of them-all wanting special treatment, claiming to know more than I did about therapy, and generally being insufferable.
To have their status stripped away was a terrible blow. They came through the ER and the clinic in agony after the crash had triggered their plummet into anxiety or depression. They sat silently by themselves, pale-faced and shaking, their brains whirring to make sense of how it had all gone wrong. One thing was clear: They didn’t want to be treated by a thirty-three-year-old psych a couple of years out of residency. I looked too young, although I was as old as some of them. I wasn’t important enough.
One of them, a man in his thirties who’d run a real estate fund on Madison Avenue, had been there a couple of weeks before Harry. The fund had $2 billion at its height but was down to nothing, being squeezed by the banks that had lent him money. A friend of his brought him in one night after fetching him from a hotel room where he’d holed up, high on Ketel One vodka and cocaine, screaming at the room service waiter. I’d admitted him, but the next day, sobered up, he wouldn’t look at me. He’d demanded to see a real doctor.
Which was why, when I returned on Monday for morning rounds on Twelve South, I didn’t expect to be paged by Jim Whitehead, the York East unit chief and head of inpatient psychiatry. I couldn’t afford to alienate Jim if I wanted to get on in my career, but when I called him back, he sounded irritated.
“I have a patient here who’d like to be seen by you, Doctor,” he said formally. “Mr. Shapiro.”
Jim was tall and solemn and had stiff black hair with a few gray flecks distributed throughout: even those were carefully delineated. His shirt and suit were always clean and pressed, as if dirt and crumbs slid off them. It beats me how he kept pin-sharp creases in his pants despite being seated for most of the day. When not on York East, he had a lucrative private practice into which he gathered quite a few of his Episcopal patients. He probably wants to shift Harry over there, I thought, and doesn’t want me in the way.
Despite Jim’s mood and the difficulties I feared it could cause me, the news that Harry had asked for me gave me a thrill that I tried to keep out of my voice. I’d thought of Harry a few times that weekend and had even let myself fantasize briefly about him becoming my patient-hadn’t Nora hinted she wanted that? Despite his temper, Harry had many attractive qualities. He was wealthy and well known, and having the whole wing named after him made him a trophy asset that other doctors would covet. Besides that, he was intriguing. There was another story there, behind the headlines, which I wanted to hear. Best of all, I was confident that I could help him, since middle-aged depression is highly treatable. My fantasy was coming true.
I left the Twelve South residents to get on with running things and made my way out of the ward, unlocking and relocking the secure double doors with the jangling bunch of keys that hung at my belt. We referred to patients slipping out as “elopement” rather than “escape,” as if it were a romantic adventure, but I felt like a jailer. York East was one floor up, with a view over the river toward a new condominium block in Long Island City topped by a sign that said FOR RENT. I found Jim in his office by the ward, reading notes on the clipboard he always carried with him. I walked in and sat in front of his desk.
“Mr. Shapiro?” I said.
Jim carefully finished what he was doing before looking up, signaling that he wasn’t going to be distracted by the affair. “Mr. Shapiro,” he said before waiting silently, as if his job were to listen and mine were to explain.
“I don’t know very much about the case, I’m afraid. I admitted him from the ER on Friday. Danger to self. It was the first time I’d seen him, so I’m surprised he’s asked for me. Has he been assessed?”
Jim furrowed his brow, which was as close as he got to an open display of annoyance.
“Not for want of trying,” he said. “I was told of his admission on Friday night and I came by on Saturday morning so we could start treatment immediately. It sounded as if he was in distress.”
So Jim came in on a Saturday, I thought. Not many patients got that treatment. Harry had been unhappy, but so were most of those who got admitted to the ER on Friday night-just as the psychs were leaving for the weekend. With the nurses watching them, there was no need to hurry, so they had to sit it out on the wards until Monday with tranquilizers to soothe them. Yet Jim had taken the time to see Harry the morning after his admission. Either Sarah Duncan had made him give our new inpatient the VIP treatment or he’d spotted the potential in Harry himself.
“He wasn’t cooperative?”
“When I arrived, his wife was with him and they wanted privacy. I came back yesterday, but Mrs. Shapiro said he’d wait to see you today. She apologized, but said it was typical. He always puts his trust in a small circle of people, and he’s taken a liking to you, it seems.”
“Interesting,” I said, trying to portray Harry’s rejection of Jim as an insight into his personality we could examine together. But Jim still looked irked. Harry was used to others being at his beck and call, I imagined. He probably hadn’t noticed the significance of Jim’s arrival to see him on the weekend.
“There we are,” Jim said, looking at his watch. “I’m due in Westchester early this afternoon. I’ll leave him in your hands.”
We had a facility in the New York suburbs for the well-off who wanted to recuperate in more bucolic surroundings. I’d wondered on Friday whether to send Harry there, but it had been late.
Jim unlocked the unit and guided me to Harry’s room, which was about the best we had at Episcopal-the medical equivalent of a penthouse suite. It had a wider bed than the cots on Twelve South and a couple of soft chairs in institutional brown next to a window that overlooked the East River. Harry was pacing up and down by them, clenching and unclenching a fist. He was wearing a crisp monogrammed shirt and looked livelier, but his expression wasn’t any more welcoming.
“Dr. Cowper has arrived, Mr. Shapiro. I’ll let you two have a talk,” Jim said, and he slipped back out. I heard the door to the ward click shut as he left.
“Hello, Mr. Shapiro. How are you feeling?” I said.
Harry glowered at me, his eyes burning.
“I want to leave,” he said quietly.
“I see. Well, let’s talk about that,” I said, crossing to his side of the room and taking one of the chairs.
He briefly stood there glaring before sitting opposite me. It was a lovely morning and the sun was casting a square of light on the floor. There were many worse places to get stranded-an airport, a police station-but his reaction was typical of people who woke up in a secure ward after being persuaded to sign in. They found themselves locked up, with sharp objects removed for safety, needing to ask permission for anything, and they went crazy if they weren’t in that condition already. I glanced at Harry’s notes. There was little there but a scrip for Klonopin, a longer-lasting tranquilizer than the Ativan I’d given out in the ER. His mental status had not been fully assessed, and he hadn’t been interviewed about his history or started on antidepressants. The only psych he’d talked to at length remained me, on Friday night.
“How have you been sleeping?” I said.
“I want to leave,” he repeated slowly, as if I hadn’t listened the first time. I found it hard to hold his intense gaze.
I tried to prevaricate. “I know it must be difficult to be here, but I think it’s a good idea to talk so I can get a sense of how you are. Then we can start on treatment and you can leave, maybe in a day or two. We don’t want to keep you in here any longer than you’re comfortable with, believe me.”
Harry flinched with irritation and got up to stare out of the window. “I don’t think you heard what I said,” he growled over his shoulder.
I didn’t like what I was seeing. Harry was just as moody as he’d been in the ER, but more agitated, which was a bad combination. Patients who are very depressed may think of killing themselves, but they lack the energy to do it. The trickiest moment is when they start to feel slightly better and more capable of action. He was also angry, which was worrying. Suicide is an act of hostility, not only to the suicide victim himself, but also to the person he blames for his plight.
All in all, I wasn’t inclined to release Harry before he had stabilized and I had a better sense of what was going on in his head. Legally, I was in a far stronger position than he. Having signed himself in, he could petition to be let out at any time. But the hospital was allowed to hold him for seventy-two hours before his lawyers could spring him. It would be a disaster if things got that far, given that Harry had paid for the wing in which he was incarcerated, but I didn’t imagine that it would. Three days would be plenty as long as he calmed down.
“What worries you about being here?”
“I can’t sleep,” he said, turning to me. “The bed’s uncomfortable, the blankets are thin, I was cold all night. The traffic noise kept me awake. I’m fine, don’t you understand? There’s nothing wrong with me.”
I listened to the buzz of the cars on the FDR Drive. It sounded pretty routine for New York, and fainter than the noise in my own apartment, but that wasn’t the point. Anxiety and wealth had made Harry hypersensitive. The thread count on the grayish sheets was lower than he was used to, and there was no goose-down duvet. He wouldn’t have noticed either if he’d been at ease.
“I’m sorry, Mr. Shapiro. Perhaps we can discuss all this with your wife and make a discharge plan. We’ll try to agree on a way forward.”
Harry gave a cynical grunt, but he at least agreed to wait for Nora. On the way back to Twelve South, I considered my predicament. Jim’s escape to Westchester had put me in charge of Harry, and he was becoming a difficult assignment despite my earlier wish to get hold of him. I couldn’t in good conscience let him out immediately, but he had a lot more power than most patients-and no compunction about using it.
My best hope, I thought, was Nora.
An hour later I was standing in what we generously called the library, a room with a sprinkling of books and a computer on which patients could send email, listening to Lydia Petrovsky, a birdlike patient who had been with us for a week. Unlike Harry, she showed no sign of wanting to leave-quite the opposite-but her insurer was threatening to withdraw coverage and the finance department wanted her out. As I was trying to persuade her to go back to her apartment and attend the day clinic, my pager vibrated with a summons to see the president.
Sarah Duncan’s office was in a corner of the Shapiro Pavilion, with a view toward the Queensboro Bridge that went to waste. Her twin assistants were both pale and pretty, in their mid-twenties, and dressed immaculately in short skirts and chunky jewelry. One gave me a bottle of water from a small refrigerator and a pro forma apology for Duncan keeping me waiting, which seemed to be the normal course of events. Then she returned to clicking through emails. Since no one else was appreciating the view, I looked at the cars rumbling over the bridge from Queens to Manhattan. The Williamsburg Bridge and the far reaches of Brooklyn were visible through its girders as a cable car looped its way to Roosevelt Island.
“Dr. Cowper?” said a low voice from the doorway, making me jump in surprise. “Please come through.”
Duncan had translucent eyes, silver hair shorn into a bob, and a face that was too smooth to be natural. She scared me. I followed her into a cool corner office that was laid out neatly with no stray papers. There was a sofa, two armchairs, and a glass-topped desk with two inch-thick files resting on it, a fountain pen set precisely beside them. None of the furniture was the standard-issue stuff of the kind that cluttered the rest of the place. She stood by her desk, moving a sheet of paper in front of her and examining it minutely.
“Dr. Cowper, I’ve just been reading about your work here.” She tapped the file. “Very impressive, I must say. You are clearly a highly valued member of the team,” she said, as if pinning a minor medal on me.
“Thank you, Mrs. Duncan. That’s kind.”
“I didn’t interrupt you, by the way? You have a few minutes to spare?”
“It sounded as if it was urgent.”
“That’s one thing I like about doctors-always ready for an emergency,” she said with a curt laugh as she gestured for me to sit opposite her on a sofa. There were clearly other things about us that she didn’t like. “This must be one of the trickiest situations I’ve faced in my time here.”
“I take it you mean Mr. Shapiro?”
“I count myself as a friend of Nora Shapiro, whom I recruited to our board, so I’m anxious to do everything we can for them. You did the right thing to admit him, but I’m hearing that he now prefers to be discharged.”
“He told me so this morning.”
“I take it that we can fulfill his wishes,” she said, gazing at me firmly.
There was a pause while I thought about what to say, apart from: Mind your own business. You’re a bureaucrat, not a doctor. I’d taken the Hippocratic oath to heal patients, while she was in charge of keeping the books balanced. We’d always been assured that when the two clashed, Hippocrates won.
“That might not be best immediately. I’m worried about him leaving while in a fragile condition. I’m sure you understand.”
She sighed and tapped her finger on the arm of the sofa. “Dr. Cowper, you’re a young man and you’ve got a long and hopefully distinguished career ahead, so let me explain something to you, between ourselves. The Shapiros are very important to the future of this hospital. I recently discussed with Nora our plans for a new cancer wing, and she’s talked of making a generous donation that might help to save thousands of lives.”
“I see,” I said, shifting in my seat.
I remembered not taking Duncan’s call in the ER, gesturing to Maisie that I wasn’t available. How smart I’d been then and how stupid now to be in the middle of this political mess. How could I balance my duty to help Harry against the lives of others whom his money might help? The trouble with psychiatry was that patients believed they could diagnose their own state of mind pretty well, and the more disturbed they were, the more likely to believe they were fine. It was Harry’s view of himself against mine.
“If we lost her support, that would be a tragedy, not just for us but for many, many patients.”
“I see that, but-”
“So, look. The last thing I want is to interfere in your treatment of Mr. Shapiro, but surely he can be cared for outside these walls?”
“Well …” I paused, trying to think of a way out. “I’ve agreed with Mr. Shapiro that we’ll talk with his wife later and agree on a plan.”
Duncan gave me a frosty smile as she got to her feet. “Good. I’ll leave you to make a decision.” She walked to her desk and, as I got halfway out the door, added in a low voice: “Do ensure it’s the right one.”
I found Harry sitting with Nora in the patients’ lounge in York East, which looked like a hotel lobby. It had halfway decent furnishings and a flat-panel television-an advance on the old cathode-ray sets fixed to the ceiling in Twelve South. There was no one else in the room, just the two of them side by side on a sofa with hands intertwined.
Nora disentangled hers and got to her feet, leaving Harry sitting by himself. “I’m so glad to see you again, Dr. Cowper,” she said.
Seeing her, I had the same feeling as the first time. She wasn’t like Harry or Duncan, with their easy recourse to intimidation. She didn’t behave like a powerful person or someone on a higher social level-her affect was of surprise at being in that position at all. After my encounter with Duncan, I knew the only way I could avoid either doing something I felt unhappy about or making myself unpopular with my employer was to persuade Nora that her husband should stay for a few days. That would require me to be blunt.
“Perhaps you and I should have a chat in private. Would you mind if we used your room for ten minutes, Mr. Shapiro?”
Harry nodded guardedly, as if he were suspicious of my intentions but couldn’t think of a reason to refuse. I closed Harry’s bedroom door behind us and turned to find Nora already sitting on the bed with her legs crossed and one heel on the ground. It felt too intimate to sit next to her on the bed; I thought of staying on my feet, but that didn’t seem right either. I needed to woo her a little to persuade her to keep Harry with us, so I compromised by sitting at the other end of the bed, by the pillows.
“Your husband told me he wants to discharge himself immediately, Mrs. Shapiro. How do you feel about that?” I started cautiously.
“I don’t know what’s best for him, Doctor. He’s very upset, and I think he blames me for forcing him to come here. I only wanted to help.”
She looked fragile, and I saw tiny lines form by her eyes as she frowned. I liked the way that she hadn’t succumbed to the Upper East Side surgeons the way Duncan seemed to have done. It took nerve for someone in her circle to resist the peer pressure to have a blandly perfect face.
“You did the right thing, but I’m worried about your husband’s mood at the moment. I’m sure he’ll recover, but I’d feel happier if you could persuade him to stay a few days, just to get his treatment under way.”
“Are you worried he’d …?”
Her voice trailed away and I looked firmly into her soft eyes, not wanting to miss my best opportunity.
“To be frank, I am still concerned about self-harm. I’m sure he’d listen to you if you advised him not to leave.”
Nora looked down hesitantly. “I don’t know if I can do that. He’s very unhappy, and he’s not listening to me anymore. Can’t he be treated as an outpatient? I’ll make sure he’s safe. I’ve locked that gun away, like you told me.”
I pursed my lips as I thought. I didn’t feel happy about letting Harry leave in that state, but if Nora couldn’t help, then I’d have to defy both Harry and Duncan to keep him there. It was the slim chance of Harry killing himself against my certain career suicide if I stood in his way. Nora looked at me pleadingly and I felt myself weaken. She’d shown that she would look after her husband, I reflected. It wasn’t as if I would be discharging someone who had no one to guard him.
“Well, if you believe that you can’t change his mind … But we need to have a plan in place, and he would have to enter treatment immediately for his own sake. Do you know a psychiatrist he’d agree to see regularly?”
“Harry wants you to be his doctor,” she said. “He likes you.”
That gratified me, I have to admit. Harry did want me to treat him, as I’d hoped. Jim wouldn’t be happy, but I didn’t care. It was also a relief, which is how I justified it to myself. If I had to discharge Harry, I’d at least be able to watch over him. Anyway, there was no alternative: he had both Nora and Duncan on the run. I put him on Lexapro, an antidepressant that wouldn’t make him more agitated, and half a milligram of Klonopin twice a day. I arranged to see him in two days at my office and gave her my number to call if his mood worsened.
Then, signing my name on the release, I let him go.