Venturing Inside Bellevue's Psychiatric ER

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Venturing Inside Bellevue's Psychiatric ER

TERRY GROSS, host:

Probably the hospital in America most famous for treating psychiatric
patients is Bellevue in Manhattan. My guest, Julie Holland, is a
psychiatrist who spent nine years as the attending physician in
Bellevue’s emergency room on the weekend overnight shift. Her patients
included homeless people who had been acting in a threatening way,
criminal suspects who may have been mentally ill and were brought to
Bellevue by the police, and people from distant places who knew they
needed help and traveled to Bellevue because they knew the name.

Holland is a psychiatrist specializing in psychopharmacology. She now
has a private practice. She’s written a new memoir called “Weekends at
Bellevue.”

Dr. Julie Holland, welcome to FRESH AIR.

Now, when you worked in the Bellevue emergency room, one of your jobs
was to deal with patients that the police brought you, and when an
arrested person is brought to Bellevue, what’s your job as a
psychiatrist in the ER?

Dr. JULIE HOLLAND (Author, “Weekends at Bellevue”): Well, first of all,
it’s not to assess anything like guilt or innocence or whether they are
competent to stand trial. My only job in a pre-arraignment evaluation,
this is after a person’s been arrested but before they’ve been arraigned
by a judge, my job is to make sure that they are safe to be alone in a
cell, that they’re not suicidal or dangerous to any other prisoners who
might be kept in custody.

So if anybody is arrested in New York City and they’re taking any sort
of psychiatric medicines or they seem like they’ve got some sort of
psychiatric symptoms, then the police would bring them into the hospital
to be assessed the psychiatrist. And when I first started working at
Bellevue, it was just Manhattan and Bronx that was going to Bellevue,
and other boroughs - Queens, Brooklyn, Staten Island - they were going
to a Brooklyn hospital called King’s County. But while I was at
Bellevue, things sort of changed, and we started doing pre-arraignment
evaluations from all five boroughs.

So right sort of in the middle of my nine years, all of a sudden I was
seeing more than twice as many prisoners as I had when we started. It
really changed the flavor of the job. I was interacting quite a bit with
police and a lot with criminals, some who were sort of hardened and
sociopathic. But I mean we also got, you know, like the Upper West Side
mom on Prozac who was caught shoplifting.

So anybody who was arrested and had any sort of a psych history was
coming by the hospital for evaluation.

GROSS: Let’s look at one patient who you described in your book and talk
about how you evaluated him. This was a guy who was brought in by the
police, naked, sunburned and screaming. He had taken off his clothes in
Times Square and was parading around, barking like a dog.

So how did you assess what his condition was and whether he was a danger
to himself or others?

Dr. HOLLAND: Well, you know, sometimes just based on the story you can
get a sense that somebody’s really not safe to be out on the streets. I
mean, this was a kid who had come from the Midwest on a bus and had no
money in his pocket basically, knew no one in the city. You know, he had
written this manifesto, basically, that he wanted to be aired on Howard
Stern’s show, and of course, you know, the people at K-Rock had sort
shooed him away.

He ended up sleeping in the park and then ended up in Times Square, and
what he told me was that he was barking and growling like a dog to prove
to the people in Times Square that he wasn’t an animal, he wasn’t a dog.
So I mean, you could see, you know, his thinking was very illogical, his
speech was disorganized. He was talking about the Tower of Babel and
King Arthur. He was really all over the place, and it wasn’t too hard
for me to make an assessment that, you know, being naked in Times Square
puts you in danger and - he was not able to take care of himself.

GROSS: Now, you assumed he was probably bipolar and that you were seeing
him during a period of mania.

Dr. HOLLAND: Exactly.

GROSS: And one of the reasons why you thought that is he was very
preoccupied with religion. He thought that your cells and his cells were
somehow connected. And talk a little bit about the kind of religious
descriptions he was giving you.

Dr. HOLLAND: Well, it’s one of things that can happen when you’re in a
manic episode. You know, bipolar is sort of the newer word for manic
depression, and mania, a lot of things happen in mania. You don’t need
much sleep. You’ve got a lot of energy, and sometimes you can get hyper-
religious. You might think that you’re Jesus or God or that God has
spoken to you, or you’ve had a vision, you’ve had an epiphany.
Epiphanies are very common in mania, in the same way that epiphanies can
be common in somebody taking a psychedelic drug.

You know, things – you can sort of, you can see the big picture. You
pull back and see the macro. Everything’s connected. It all makes sense
to me now. And a lot of times when I would see manic patients at
Bellevue, they would remind me of people who were tripping, who had been
sort of enlightened, and you can also see this, I think, in people who
have had sort of religious epiphanies.

So the idea that everything is interconnected and everything makes
sense, and what he was telling me was that the molecules in his body are
intermingling with the space between our bodies, which are intermingling
with my molecules, and therefore, we are connected and we are one and
there’s no separation between us. That’s true, and that’s something that
you may hear from somebody who is on a psychedelic drug also, sort of
mystical epiphany. It’s pretty common in mania to have these kind of
thoughts, and more importantly to express them.

You know, a lot of people may have thoughts like this, but they don’t
share them, and when you’re manic, sometimes your filter is gone and you
tell everybody what you’re thinking and feeling, and that’s really, you
know, where you can end up at Bellevue.

GROSS: Now, you write in your book that you pride yourself on being able
to tell the difference between a drug-induced mania and a mania that
comes from disease, from bipolar disorder. So in this particular person,
the guy who was naked and barking in Times Square, how could you tell
whether it was a drug-induced mania or a bipolar problem?

Dr. HOLLAND: Well, you know, one thing about drugs is that they come on
quickly, they last for maybe half a day or a day at the most, and then
they go away, and somebody who’s manic is still going to look pretty
manic the next day if they sleep overnight in the ER. But also, I think,
you know, one of the things I got very good at is sort of figuring out
who was a junkie and who was an alcoholic and who was a speed freak just
sort of by the way they dressed and looked and, you know, what kind of
tattoos they had or what kind of T-shirt they were wearing.

It is really hard to tell the difference. When somebody comes in acutely
psychotic, pretty much the hardest thing you have to do in a psych ER is
figure out why they’re psychotic. Are they manic? Are they
schizophrenic? Are they high? You know, if somebody’s been doing cocaine
or methamphetamine for days on end, they can look psychotic. If somebody
is sleep-deprived, they can look psychotic.

So there’s a lot of things that can make somebody look crazy, and some
of them will go away in a day or two and some of them won’t, and what
we’re taught as psychiatrists is that in a cross-sectional analysis,
just seeing somebody when you don’t know the history and you don’t have
a sense of whether they’re ebbing or waxing or waning, in that cross-
section it’s very hard to figure out why they’re psychotic. But I just,
I developed sort of an intuitive sense over the years. I could certainly
tell the difference between schizophrenia and mania.

When someone is schizophrenia and they’re psychotic, they’re much more
paranoid and they’re sort of on the receiving end of everything. People
are out to get them. People can read their minds. When someone’s manic,
it’s more about how they can influence the world. You know, they’ve
written a manifesto they want to share with everybody, or they’ve
figured out an answer that needs to be – you know, they need to
enlighten other people. It’s much more about how they can have an impact
on the people around them as opposed to how the environment is having an
impact on them.

Also in terms of insomnia. When somebody is manic, they don’t need to
sleep. You know, they’ll sleep when they’re dead. Sleep is for chumps.
Whereas if you’re schizophrenic, you want to sleep and you can’t sleep.
So I think that there’s just sort of qualitative differences to the
psychosis in these different states.

GROSS: So let’s get back to the guy who was brought in by the police,
who had been naked in Times Square and barking. You evaluated him as
being bipolar and in a manic phase. So what did you tell the police, and
how did that affect what happened to him next?

Dr. HOLLAND: Well, when the police brought him in, he wasn’t under
arrest. I mean, they clearly understood that he was an EDP, which is
sort of cop talk, emotionally disturbed person. They knew he was an EDP.
They knew that he needed to be at Bellevue. They bring him to us, I sign
the paperwork, and they leave.

If he’s arrested, they have to stay. So I don’t necessarily have to
explain anything to the police, but with this patient, Joshua, what I
really wanted to do was talk to his family. I wanted to talk to somebody
who knew him. I was worried that he’s missing and his family doesn’t
know where he is. You know, he’s taken a bus from the Midwest, he’s in
New York City, he doesn’t know anyone. For all I know, you know, there’s
like a missing persons all points bulletin out on him.

But while he could give me the phone number for K-Rock and Howard Stern,
he wouldn’t give me the number for his family. So I couldn’t call them
to find out if he, in fact, is a bipolar, if he’s off his medicines, is
he allergic to any medicines, you know, what medicines has he responded
to.

It would be great to know, for instance, if he’s one of these patients
who’s had a miraculous response to lithium or depakote. I could put him
back on the medicine that he’s been on.

I didn’t have much to go on, and while he was willing to talk to me
about all sorts of interesting, ephemeral things, he wasn’t willing to
give me any history or any information about his family.

GROSS: So you had him institutionalized at Bellevue?

Dr. HOLLAND: Right, so I had to finally break it to him. You know,
Joshua, dude, I’m sorry, I’ve got to admit you to the hospital. You
know, I’m trying to be his friend. I’m trying not to be confrontational.

I’m not asking him all the standard, boring psychiatry questions that
maybe he’s been asked in other ERs, but I finally had to break it to him
that, you know, I’m going to admit you to the hospital. And he was like,
come on, can’t you just be cool? You know, can’t you just let me go? And
you know, he finally sort of got that I was separating me from him, and
I’m the doctor and you’re the patient, and even though you think we’re
connected, you know, you’re going to be admitted and I’m the one
admitting you. And then he sort of challenged me and said, you know, so
you think you can just decide who’s sane and who’s insane? And I said,
you know, that’s my job, that is exactly what I do here.

And you know, it’s not always easy to figure out who’s sane and who’s
insane. The phraseology I use at one point in the book is there’s a
diaphanous membrane between sanity and insanity, and any of us at any
given time can go crazy.

You know, circumstances can transpire where you will be brought to
Bellevue. Your life can fall apart. You know, you can have a child die,
or you can lose your job and your apartment and become homeless, or
somebody can hand you a cigarette that has PCP in it in a bar, and one
way or another, you may find that you look crazy and you’re brought to
the hospital. And you know, it was sort of my job to pick apart what had
happened to bring somebody to the hospital and what was going to happen
next, you know, and was it safe to send them back on the streets of New
York City or not.

GROSS: If you’re just joining us, my guest is Dr. Julie Holland. She’s a
psychiatrist, and her new memoir, “Weekends at Bellevue,” was based on
her nine years as the overnight doctor at the emergency room in Bellevue
for psychiatric patients, and many of the patients that she saw were
patients who were brought in by the police. Let’s take a short break
here, and then we’ll talk some more. This is FRESH AIR.

(Soundbite of music)

GROSS: If you’re just joining us, my guest is psychologist Julie
Holland, and her new memoir, “Weekends at Bellevue,” is about the nine
years she spent on the night shift in the psychiatric emergency room at
Bellevue on duty there.

You’ve encountered a lot of people who the police brought to you who
were arrested for committing a crime, and you had to determine if they
were a threat to themselves, if they could be alone in a cell. Would you
tell us a story of evaluating one of those people?

Dr. HOLLAND: Well, you know, over my sort of tenure at Bellevue, this
became more and more popular, where I was evaluating prisoners. And you
know, prisoners don’t always want to talk to psychiatrists, and
sometimes they can be pretty hostile, and I definitely had situations
where people would threaten me. I got punched in the face once. I was
called horrible names.

GROSS: Tell us who punched you in the face. How did that happen?

Dr. HOLLAND: Well, that was really a sort of watershed event for me when
I got punched in the face. I was there nine years. I only got punched
once, which, you know, statistically I was in pretty good shape. But I
was – you know, one of things that you will get from reading the book is
that I sort of started out as a hard-ass and a little bit of a bitch,
that I really, I developed this sort of thick skin and hardened shell to
deal with the intensity of everything that was sort of coming at me.

And I got to a place - you know, a lot of the prisoners would pretend to
be mentally ill because they thought it would sort of be an easier ride
to be admitted to the hospital than to be sent out to be arraigned or go
to Rikers.

So I was dealing with a lot of people who were faking being mentally ill
who weren’t. They’re called malingerers, and the term that the hospital
would use sometimes for them was sharks. They pretend to be psychotic,
or they pretend to be suicidal so that they can get admitted to the
hospital because it’s a lot cushier, you know, to have sort of three
hots and a cot at Bellevue than it is to be out on the streets.

So this was one of these situations where I had somebody coming in
saying that they were hearing voices to kill themselves and others, and
they were pretending to be mentally ill, but when you admit somebody
like this to the hospital, they’re very disruptive. They tend to
intimidate the other patients and really make it sort of a dangerous
situation for everybody because sometimes they’re sociopaths and they’re
very aggressive and violent.

So this was one of these situations where I knew that somebody was
lying, and I knew he was pretending to be mentally ill…

GROSS: How did you know? How did you know he was a faker?

Dr. HOLLAND: Well, I like to think that I really have a sixth sense and
know when I’m being lied to, and I think a lot of people like to think
they know, and maybe, maybe I’m wrong. But you know, I just can tell
when somebody’s lying. I can tell by the way they answer questions, the
way they move their eyes, look away, the way their body is, how they’ll
start a sentence looking away and then look right at you when they’re
getting to the biggest lie part of their sentence.

So this was a guy, I knew he was lying, and also he had given an address
that was very close to my apartment on the Upper East Side, and when I
sort of asked him about where he lived, he wasn’t answering the
questions directly. And so I knew that he was lying about where he
lived.

So we knew he was lying, and I went out to confront him and say, you
know, we know you’re lying, basically, and I said, you know, some of the
doctors here think that you’re feigning your symptoms. And he said
feigning? And I said faking, and then he punched me in the face.

And getting punched – I’d never been punched in my life. It was actually
really interesting to me. The force of the blow sort of made me stagger
backwards, and there was like a heat and an electricity to where his
fist and my face met. And you know, I actually pressed charges, and he
ended up spending four months at Rikers, but my biggest fear was that
when he got out of Rikers he was going to come back to find me.

His statement to the police was I wanted to hit the doctor, I hope I got
her good. So clearly, you know, he wasn’t sort of denying that he did it
or, you know, pleading innocent, but I didn’t know if he’d gotten me
good enough, and I got a phone call at about 2:00 in the morning four
months later, informing me that this prisoner was going to be released
from Rikers.

It was a very sort of anxious time for me. But it made me realize that,
you know, I had been acting in a very unprofessional way at times, you
know, just because I’d been in this very intense position and I had been
so defended. I was trying to be a tough guy, and once I got punched in
the face, it really got me to change my demeanor significantly and to be
more therapeutic and less confrontational with the patients.

GROSS: Did you ever hear from him again?

Dr. HOLLAND: I didn’t, no, and I’m hoping that that continues.

GROSS: Right. In what ways were you confrontational with patients?

Dr. HOLLAND: Well, like, if I knew somebody was lying, I could kind of –
I would get up in their face and be like, you know, you suck at lying.
You know, I’m so on to you, and I’m not buying what you’re selling, and
you know, why don’t you try to go try to sell it down at Beth Israel
because, you know, I’ve been doing this too long. You’re not getting
over on me. It was this kind of thing, where it was almost like I would
take it personally if I was being lied to.

GROSS: Why would you do it that way? Had you been around cops so much at
the ER that you started talking like cops do?

Dr. HOLLAND: You know, I don’t – I ended up in therapy for about three
years when – I worked at Bellevue for nine years, and for three of those
years, I was in therapy, and what was interesting is that my therapist
had also had as a patient a co-worker of mine, Lucy, and Lucy and I were
very similar. We both would sort of antagonize the patients, especially
the patients who were handcuffed.

You know, we were just, like, trying to be tough guys. So you know, why
I acted like a tough guy is sort of a complex question to answer, but I
think some of it comes from, you know, my childhood and trying to be
tough as a way of getting my father’s approval, and that that was just
sort of my persona. You know, I was always a tough girl.

When I was growing up, I would, like, you know, swear and smoke
cigarettes and wear leather jackets and, you know, sing in a rock band,
and you know, I was a tough girl. I was a cool girl. I mean, that was
sort of my shtick, and it became even more like of a mask and a sort of
a persona when I got to Bellevue. I had this sort of swagger and
bravado.

But being in therapy got me really to see that for what it was, which
was just, you know, a defense and an act and that I was really very
sensitive and vulnerable and just, you know, sort of covering up. It’s
like French bread. You know, you’re all sort of warm and steamy on the
inside and crusty on the outside. And actually, a lot of people at
Bellevue have a similar demeanor, where they’re really, they’re bleeding
hearts and they’re there because they care and they want to help, but
they end up getting kind of crusty and sealing over just to protect
their hearts, basically.

GROSS: So when you were dealing with criminals in the ER, and you had to
evaluate them, and you knew that they were potentially dangerous, how
did you protect yourself? You describe, like, talking tough and
everything, but in addition to that, was there a certain protocol of how
far away to stand or never to turn your back, that kind of thing?

Dr. HOLLAND: Yeah, well, you know, if I would be in a room with them, I
would certainly have my chair closer to the door, but also, these guys
were always cuffed. They were often cuffed to a wheelchair or cuffed to
a regular chair. So you know, you kind of had a sense of, like, what
their reach was. And I definitely had some people lung at me, and I
really had to sort of scurry backwards quickly. And sometimes the cops
were there, the police were there to sort of make sure things didn’t get
too out of hand. And also, you know, I just learned, I learned to be
nicer to these guys.

I mean, one thing that getting punched really taught me, and my husband,
Jeremy, really taught me this too, is that even people that are faking
mental illness and coming to the hospital, there’s something wrong with
them if that’s where they’re at in their life, and there’s something
wrong in their lives, and so you could at least have a sort of a
therapeutic interaction and say, look, you know, I’m not sure that all
of these symptoms are really happening to you, but clearly something is
happened to you. You’re on the street, you have nowhere to sleep, you
have nowhere to stay, you have no job. You know, what’s going on with
you in your life that you’re at this point? I mean, there’s still a way
to be therapeutic when confronting them with the reality of what’s going
on.

GROSS: Dr. Julie Holland will be back in the second half of the show.
Her new memoir, “Weekends at Bellevue,” is about her nine years as the
attending psychiatrist on the weekend overnight shift at Bellevue’s
psychiatric emergency room. I’m Terry Gross, and this is FRESH AIR.

(Soundbite of music)

GROSS: This is FRESH AIR. I’m Terry Gross, back with Dr. Julie Holland,
the psychiatrist who spent nine years running Bellevue Hospital
psychiatric emergency room on the weekend overnight shift. Many of her
patients were brought in by the police. She's written a new memoir
called "Weekends at Bellevue."

One of the things you had to deal with a lot is the homeless mentally
ill who got brought in by the police. And on the most obvious level, one
of the things you had to confront with some of these people was that
they smelled of urine and feces. And you say that that was even worse in
the winter. So just on that first level, how would you deal with their
hygiene?

Dr. HOLLAND: Well, one of the things that I did was immensely helpful
for me is that when I was in med school I took a clinical hypnosis
class, and we had to hypnotize ourselves and I hypnotized myself to say,
the smell of urine is not offensive to me, and it worked. I mean it's in
my head and when I start to, you know, retch or gag, I would think, the
smell of urine is not offensive to me. It would stay in my head. So that
ended up being a very helpful thing to do.

But it's not just urine. It's, you know, the worst thing actually, if we
can talk about smells, it’s fungus. It’s the sort of athlete's foot,
crotch rot, somebody who’s been on the street for a long time, they're
not bathing. And the smell of fungus is like this acrid stench. It’s
really a problem.

And sometimes when people will come in, especially in the winter where
they would wear layers of clothing, and as you would peel off their
jackets and their sweatshirts, the smell, you know, each layer sort of
trapped its own sort of level of perfume and it would hit you. And you
know, you have to sort of stifle a gagging or retching or, you know,
phew, or turning away.

But they can't help it. I mean there's nowhere to bathe in the city. You
know, the only place they could possibly get a shower are the shelters.
And most homeless mentally ill people avoid the shelters the way a bear
avoids a trap. I mean it’s the last place they want to go. They can't
get any sleep. Their things get stolen. They get abused. They get taken
advantage of. So the smell is a real problem and sometimes the whole
psych ER would just smell like fungus.

GROSS: So what was your job when a homeless disoriented person was
brought in?

Dr. HOLLAND: Well, what was easy is that I always knew they needed to be
admitted. I mean we would always make a space for them. It's somebody
who's genuinely mentally ill and on the street and unable to really make
it out there, then we would admit them. And I would - what I would
always try to do is talk with them really heart-to-heart about what
medicines - if any medicine had ever worked for them or if there's any
medicine they had any sort of good feeling about then that was the
medicine that I would prescribe for them. Because, you know, all the
antipsychotics, to some extent, will work to help quiet the voices and
take the paranoia down a notch.

But what's most important is if they would take it. You know, the pills
don’t work unless you swallow them. So I would always try to figure out
if there's any medicine that they liked or they were willing to take or
else I would try to sell them on the ones that I really like the most.

GROSS: And were they responsive to you’re questions?

Dr. HOLLAND: I think they were for the most part. I mean every once in a
while I'd come across somebody who didn’t want to take anything and
didn’t want to talk and really couldn’t connect. But there's just
something in my heart that connects with people with schizophrenia. I
feel like it's this one illness that I've always really felt some sort
of a kinship to and I don’t know why. It's not like I have anybody who's
schizophrenic in my family.

But just sitting and connecting and talking, somehow I felt like I got
through to a lot of people. And one guy that I got through to who really
kind of touched me somehow was this guy who ended up pushing a girl off
a subway platform.

GROSS: Oh, my god.

Dr. HOLLAND: So, this was one...

GROSS: This is after you had met him did he do that?

Dr. HOLLAND: Yeah. There was this one Sunday night where another
passenger who was on the platform who had seen it happened. She came in
to be evaluated. The ambulance brought her in and the ambulance brought
in the subway conductor who had seen the whole thing - as you can
imagine - who was pretty shaken up. And, you know, we talked to them and
then discharged them. I mean, you know, they were shaken up but they
certainly didn’t need to be admitted.

But then I was wondering where the subway pusher was, because I was
pretty sure that somebody who pushes somebody off a subway platform is
probably a psych patient. But nobody came in that night and what it
turned out actually that he had asked to see a psychiatrist, but they
had sort of ignored his request and gotten a confession out of him.

But he did eventually come to Bellevue after he'd been arraigned to stay
to be admitted to the forensic psych ward and I went up to see him the
next weekend because he was one of mine. You know, he was somebody that
I remembered and I had connected with.

He actually had the same name as a childhood friend of mine, so I really
remembered exactly who he was because he had exactly the same name. And,
you know, granted, it was a horrible thing that happened and my heart
certainly went out to the family of the victim. But my heart also really
went out to the family of him. You know, he had done something life-
changing. He was not going to get out of psych ward or a prison for the
next 25 years.

The good thing that came out of it is that a new mental health law was
created called Kendra's Law, which is instead of involuntarily
committing somebody to an inpatient stay, it’s involuntary commitment
for an outpatient course of therapy. So that means that a judge can sort
of remand you to be seen by a psychiatrist longitudinally and be
followed and make sure that you go to your appointments and that you’re
taking your medicine. And if things start to fall apart and you start to
get sick, you can, by law, be brought to a psych ER to be evaluated
whether you need to be admitted.

And it’s a law that's heart really is in the right place. I mean I, you
know, I mean I am a civil libertarian and I think very, you know, I
think twice before taking away somebody's civil liberties. I take it
very seriously. But, you know, this is a law that's really meant to help
chronically mentally ill people to get well and stay well.

GROSS: So did you feel like you hadn't done the job right when you found
out what happened?

Dr. HOLLAND: Well, I guess what I felt was more of a collective
responsibility that, you know, we had all sort of dropped the ball - all
the hospitals and this was a guy who had been in and out of hospitals
and discharged and readmitted and, you know, gone to clinics and fallen
off taking his medicine. And the last time that he was in a hospital, he
was supposed to go to a state hospital but there weren't any beds, so
they finally just discharged him because he was fine and they didn’t
want him waiting around for a bed.

So, you know, the system is broken basically. There absolutely aren't
enough state beds - chronic beds. You know, what happened back when
medicine started to become effective, back when antipsychotics started
really working in the ‘60s, JFK sort of deinstitutionalized everybody
and shuttered a lot of the state hospitals which was fine, but what was
supposed to happen was they we're supposed to be these halfway houses
and adult houses and community centers where everybody could go and they
never materialized because everybody said, you know, not in my backyard.
I don’t want mental patients in my neighborhood.

So then, you know, it spawned the homeless population. The homeless
mentally ill population was basically spawned because of
deinstitutionalization. And we still have this huge problem where there
are homeless mentally ill people in every major city in the country.
There aren't enough places to put them. There aren't enough adult homes,
group homes, and there aren't enough state hospital beds.

GROSS: If you’re just joining us, my guest is Dr. Julie Holland. She's
written a memoir about her nine years at Bellevue working as a
psychiatrist in the emergency room. It's called "Weekends at Bellevue."

Let's take a short break here and then we'll talk some more. This is
FRESH AIR.

(Soundbite of music)

GROSS: If you’re just joining us, my guest is Dr. Julie Holland. She's
written a memoir about her nine years at Bellevue working as a
psychiatrist in the emergency room. It's called "Weekends at Bellevue."

You write in your book that you pride yourself on intuiting what drugs a
patient took just by looking at them, whether it's meth or crack or
OxyContin. What are the signs that you look for?

Dr. HOLLAND: Well, one of the things that I write about in the book is,
you know, like black T-shirts and tribal tattoos are sort of meth until
proven otherwise.

GROSS: Though, everybody wears that now.

Dr. HOLLAND: Yeah. Well, you know, it’s something that really sort of
took off while I was at Bellevue are piercings and tattoos and it became
sort of harder to figure out who was what as the trend took hold. But,
you know, people tend to be pretty twitchy. When they're high on cocaine
or methamphetamines, you know, these stimulants make people pretty
twitchy and they can have what are called dyskinesias, which are these
sort of twitchy muscle movements or they can just be pacing around.

On the other hand, you know, somebody who is manic or schizophrenic can
sometimes be really sort of what's called psychomotor agitated where
they're - it's hard for them to stay still. But, you know, opiates,
that's easy. You know, the people who are high on methadone or OxyContin
or heroin, their faces are ultra relaxed and they sort of have like a
half Mona Lisa smile and their eyes are at half mast. It’s very hard to
keep your eyes open when you’re opiated even if you’re awake. And
sometimes, you know, their head will dip down and they'll nod it up
which, you know, the expression on the nod really came from that.

So it’s easy to figure out who’s high on opiates and who is high on
stimulants like crack or speed. Some of the other drugs I think are
tricky. PCP is really tricky. It can look like anything. But, you know,
one of the sort of drug crazes that comes and goes is PCP and there's
something called embalming fluid and people will smoke cigarettes dipped
in embalming fluid or marijuana dipped in embalming fluid. And
typically, the embalming fluid is really just a carrier for PCP. So
every once in while we'll have somebody come in who's really grossly
disorganized and agitated and just not making any sense. And sometimes
they're naked and sometimes they're not.

I mean there's a saying in toxicology which is naked running is PCP
until proven otherwise. I mean anybody who throws off their clothes and
starts running around could be high on PCP. Like this guy who was
brought in from Times Square naked, barking like a dog. I did send his
urine and blood off for PCP just to see if that was a possibility.

But the pupils don’t lie and somebody who's high on stimulants will have
dilated pupils. Cocaine and speed and also LSD and mushrooms, they will
dilate your pupils. And then opiates, and sometimes PCP will make your
pupils small. So when I was teaching the residents at the psych ER, I
would always tell them to look at pupils. You know, the pupils don’t
lie. The pupils cannot put one over on you. And if you have a guy saying
that he's in methadone withdrawal and he needs his methadone, look at
his pupils. If they're not dilated he's not in withdrawal. I don’t care
what he's saying.

GROSS: So if you’re diagnosed in the ER at Bellevue that somebody was on
meth or crack or OxyContin and that could explain the behavior that got
them there, what does that mean in terms of what actions you took?

Dr. HOLLAND: Well, what was great about Bellevue, and not every ER has
this at all, but Bellevue has what's called an EOU, which is an extended
observation unit and what it was is that we had a six-bedded unit on the
ER, on the ground floor in the psych ER where we could admit people to
ER and we could hold them up to 72 hours and we’d really have a chance
to observe them longitudinally.

And what happens certainly when somebody comes in and they're high or
they're drunk, they look a lot different the next day. But if somebody
would come in and they were off their meds and they were manic or
schizophrenic, they wouldn’t look very different the next day. So
sometimes just keeping somebody for 72 hours, you can make some phone
calls, try to call their family, people that know them, their co-
workers, their boss, we would get more information and see them sort of
serially, sequentially and get a better sense of what the problems were,
what the real diagnosis was.

Most of the patients really had both. You know, they're called MICA
patients, which stands for mentally ill, chemically abusing. That really
describe the bulk of the patients that we saw at Bellevue. There were
people who had depression or bipolar, but they were also abusing drugs
and alcohol, and it makes the picture very muddy. And sometimes, you
know, people look a lot better when they stop using.

GROSS: You wrote that the most pathetic thing that you dealt with at
Bellevue was botched suicides. Why?

Dr. HOLLAND: Well, you know, what I wrote in the book was you know, you
think your life sucked before. You know, when you get to a place in your
life where everything is so dismal and you’ve sort of run out of options
and you try to kill yourself, there's a tremendous amount of shame
really when you sort of wake up from a failed attempt.

And sometimes you’ve got real physical problems. Just being slumped over
from an overdose you can have nerve damage or you know, I had people
when I was down in Philly at Temple, I had a guy sort of created this
elaborate pulley system and hauled up this very heavy sort of engineered
metal desk to crush him and it did crush him but it didn’t kill him. And
so, he sort of had a lifetime of these horrible crush injuries and
chronic pain to deal with.

I had another schizophrenic who tried to eat ground glass thinking that
would kill him and it didn’t kill him but he had horrible esophageal and
stomach injuries where he had to be fed through a tube for the rest of
his life. So, you know, I never saw the completed suicides. Obviously,
you know, they would go to the trauma slot or to the morgue at Bellevue.
But I did see a lot of failed suicides, you know, what are called
botched suicides. And I also saw sort of people who had start, you know,
like sort of aborted attempts where they'd started to and had been
interrupted. And what was good then, at least, is that I knew they
needed to be admitted. It was very clear that they needed help and that
they were dangerous to themselves. And at least there, there’s no
question that I have to admit them and, you know, I didn’t have to sort
of second guess what I was doing.

GROSS: While you were at Bellevue and seeing a lot of homeless, mentally
ill people and prisoners who, you know, people who had been arrested who
were brought in for your evaluation, there was a period you were
pregnant.

Dr. HOLLAND: Yeah, I was pregnant.

GROSS: You were a mother. Yeah.

Dr. HOLLAND: Yeah.

GROSS: How does that affect your ability to function in that kind of
environment?

Dr. HOLLAND: Well, I’ll tell you one thing that, you know, I was
pregnant twice at Bellevue, four years apart, and I was nursing for two
years, twice. And being pregnant and nursing and being not maternal and
having children makes it a lot harder to be the butch tomboy, tough guy
that I started out being. So, it really changed the way that I related
to patients and the way that I thought about things. I mean, I really -
I became more maternal. You know, I started off as the single gal in her
30s and ended up like a married mother of two by the time I left there.

So, I changed and I softened considerably. And also, you know, being in
therapy for three years and sort of challenging those defenses and
learning, you know, that they’re not really useful and they’re not
therapeutic. It was a lot harder to be one of the guys, you know, after
I’d gone through all that. And I think, in many ways, it made me a
better doctor but it also made it hurt more. You know, if I didn’t have
that layer, that sort of tough layer to protect me, I’m very empathic. I
really feel people’s pain to a large extent.

And, you know, without that mask, I was really feeling everybody’s pain
a lot more and it finally got a little bit unbearable to stay at the
job. And everything just got a lot sadder and everything sort of had
more weight to it then it did when I started. I finally had to leave.

GROSS: You describe, in your book, that, you know, as a mother, one of
the things you really worry about is that one of your children will turn
18 and become schizophrenic or have some other form of mental illness. I
don’t think people – I don’t think most parents worry about mental
illness developing…

Dr. HOLLAND: Right…

GROSS: …as much as you do.

Dr. HOLLAND: Right, they don’t. I mean, you know, most women when
they’re seven months pregnant and they lie awake at night thinking about
the baby, they’re worried that they’re going to be born with some
deformity. That’s very, very rare. What’s not rare is being bipolar or
being schizophrenic or having depression. That’s very common. I mean,
you know, three, five percent of the population - maybe say three
percent - of the population has got bipolar, one percent has got
schizophrenia, 20, maybe 25 percent, depending on who you talk to are
going to have depression. That’s a lot of people.

So it’s much more likely that that’s going to be an issue. And, you
know, the thing about schizophrenia and bipolar - these illnesses don’t
go away, you know. And one of the things that really sets psychiatry
apart from medicine is that medical illness is an endpoint. You get
sicker and sicker and you die. In psychiatry, you just get sicker and
sicker and it doesn’t kill you. These are not fatal illnesses unless you
factor in how many people commit suicide and then schizophrenia really
is a fatal illness. The degree to which someone can lose their mind is
infinite and these are just chronic persistent mental illnesses.

And, you know, I would torture myself thinking that my child was going
to be saddled with something like this.

GROSS: So, now instead of working in the emergency room at Bellevue, you
have a private practice?

Dr. HOLLAND: I do. I mean, all through the time at Bellevue I had a
private practice, but now that is all I do. And it’s, you know,
infinitely easier…

GROSS: But you…

Dr. HOLLAND: …less challenging.

GROSS: You know, at least at Bellevue you see people and you evaluate
them and then you’re on to the next person. I’m not sure that’s a good
thing, but, you know, in the private practice you have a responsibility
for these people’s lives and for their future. And it’s – they’re both
really weighty responsibilities but they’re different from each other.
So, what’s it like for you now, when you come home and you’re bringing
home the continuing pains of your patients, as opposed to…

(Soundbite of laughter)

GROSS: …you know, the horrible stories that you’ve seen in one day and
you’ll never see those people again?

Dr. HOLLAND: Well, the main difference is now, I feel much more equipped
to make a difference. You know, at Bellevue, just the depth of despair
and misery, I could only do so much. I could just kind of, you know,
patch them up and send them back to the front or put a tag on them and
admit them upstairs and move onto the next one.

But there was a lot of recidivism and a revolving door, and the sick
people would just come back over and over. But in my private practice,
for the most part, my patients get better and stay better. I mean, they
may have some problems, they may have some bumps in the road, but
they’re not nearly as sick or hopeless as the Bellevue patients. So, I
don’t have that same, you know, sense of ineptitude, I think. I mean, I
think that I was very good at what I did at Bellevue and I was very good
at triaging and figuring out who stayed and who goes. And okay, this is
what you have, this is the problem, this is what you need and then
moving on. I was very efficient and I think that that’s good.

But now, you know, I spend time getting to know my patients and getting
to know their problems and what they need and their symptoms. And I sort
of fix up just the right cocktail to get them back on their feet. And
for the most part, they get well and they stay well. So, it’s much
easier for me. I feel more competent, I think.

GROSS: Well, Julie Holland, it’s been great to talk with you. Thank you
very much.

Dr. HOLLAND: Well, thanks for having me, Terry.

GROSS: Julie Holland’s new memoir is called “Weekends at Bellevue.” This
is FRESH AIR.
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Capitalism’s Paradoxes, Writ Personal On Film

TERRY GROSS, host:

On September 15th, 2008, Lehman Brothers declared bankruptcy, an act
that prompted widespread recognition that the U.S. was caught in a full
scale financial crisis. Now, a year later, we’re seeing a spate of films
that attempt to grapple with that crisis and the role of the economy in
American life. One of them, Marc Levin’s “Schmatta: Rags to Riches to
Rags,” will be playing for the next several weeks on the various HBO
channels. Another, Leslie and Andrew Cockburn’s “American Casino,” is
currently in theatres but also available on DVD.

Our critic-at-large, John Powers, has seen them and says both have
things to teach us about economic processes we often take for granted.

JOHN POWERS: In good times, most of us don’t give much thought to
capitalism. We simply live within it. All that changes when things go
bad, which is why we’re now seeing a flood of movies about the economy.
The most publicized is Michael Moore’s “Capitalism: a Love Story.” But
frankly, it’s sort of the kind of scattershot tirade I used to hear in
my college dorm. If you actually want to learn something, two other new
documentaries do far more to explain how grand economic forces shape our
daily lives.

“Schmatta: Rags to Riches to Rags,” is an engrossing, elegiac history of
the New York garment industry, largely seen through the eyes of those
who’ve worked there. Starting with the early sweatshops, filmmaker Marc
Levin shows how the notorious Triangle Shirtwaist Factory fire of 1911,
in which 146 female workers died after being locked in their burning
workplace, helped jump-start the entire American labor movement, leading
to widespread prosperity.

By the 1950s, garment workers were buying houses in the suburbs and
sending their kids to college. Four decades ago, 95 percent of our
clothes were made in America. Today, it’s five percent. What happened?
The short answer is the globalized marketplace. Companies began finding
it more profitable to outsource their manufacturing to places like China
or Bangladesh, whose un-unionized workers make a twentieth of American
wages.

Meanwhile, back in New York’s garment district, the unions declined and
American workers lost their jobs, even as the companies that once
employed them prospered and fashion designers became celebrities selling
an image of luxury. Here a former Ralph Lauren designer explains how you
make a really, really expensive pair of jeans.

(Soundbite of movie, “Schmatta: Rags to Riches to Rags”)

Unidentified Woman: When I was at Ralph, I was working on jeans for
$750. How do you make a jean for $750? I mean, even me, I was like, how
do you do that? I mean, my God. You know, unless it had Cher’s
fingerprints on it or something, what could make it worth $750? Well,
you develop the denim using organic yarn – cotton that wasn’t treated
with insecticides, grown under really strict conditions. You cut that
denim in Hong Kong, then you ship it on over to India for hand
embroidery.

Then you add a little purse, also handmade. Then you ship it on back to
Hong Kong because you don’t trust India to close it. And then they close
it and then they ship it on over to us again. And that’s how you make a
jean for $750. Oh yeah, and you also market it correctly.

(Soundbite of music)

POWERS: Those jeans won’t be bought by the people you meet in
“Schmatta,” nearly all of whom love the garment industry but can no
longer find work there. Nor will you see them being worn by the ordinary
homeowners you meet in “American Casino,” Leslie and Andrew Cockburn’s
film about the sub-prime mortgage crisis. Following E.M. Forster’s old
command, only connect, this smart, touching documentary traces the
connections between Wall Street’s high-flying practices and the
countless citizens on Main Street who now face bankruptcy or eviction.

“American Casino” links the crisis to three things - the ideological
belief in unregulated capitalism embraced by the likes of former Fed
Chairman Alan Greenspan; a political class, both Republican and
Democratic, that lifted long-standing restraints on financial
institutions; and brokers who used their new freedom to pioneer risky
financial strategy from the feverish promotion of sub-prime loans to
mathematical models that supposedly made it safe to create a market in
those dodgy loans.

The result was a deeply corrupt system, in which everyone from local
mortgage officers to Wall Street banks made big profits on dangerous
transactions, then passed on the risk like a hot potato. As an in-house
memo at Standard and Poor’s put it, let’s hope we’re all wealthy and
retired by the time this house of cards falls. Of course, the house of
cards did fall, and as the film shows, we now have empty McMansions,
whose untended swimming pools breed West Nile mosquitoes.

“American Casino” introduces us to several people who are losing their
homes, a group that’s disproportionately African-American. Far from
being schemers, they’re likable, heartbreaking figures who teach school
and work for churches. And using interviews with former financial
insiders, the Cockburns reveal how the whole sub-prime loan business
wasn’t just predatory, systematically targeting the poor and preying on
ignorance, but often criminal.

Near the end of “Schmatta,” history comes full circle when a century
after the Triangle Shirt Waist Factory fire, female garment workers
again burned to death, this time in Bangladesh. Looking at their bodies,
we’re reminded of the great paradox we also see revealed in “American
Casino.” Capitalism is the greatest engine for creating growth and
wealth the world has ever known. Even Karl Marx was impressed. But if
you don’t control it, capitalism can be as destructive as it is
creative.

It creates good jobs for American garment workers, then takes them away.
It invents seemingly magical ways of letting people buy homes, then
throws them out. Nothing is immune from its genius for creative
destruction, although one thing does seem to remain constant - the
system is far kinder to bankers and CEOs than to those who cut fabric or
teach in our schools.

GROSS: John Powers is film critic for Vogue and writes the online column
Absolute Powers. You can download podcasts of our show on our Web site,
freshair.npr.org.
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