by Evelyn Sharenov
The first time I meet Annie*, she’s in the middle of a handstand push-up against the wall outside her room. Balanced on her palms, her back and legs straight up, she pushes off without a sound. A cropped tee falls to her bra line, exposing the bone marimba of her ribs. Her tangle of auburn hair spills to the floor and she has the translucent skin I associate with redheads; an appealing scatter of freckles dusts her nose. She looks more like a gangly teen than the twenty-five years I know her to be.
“Hey,” she calls as I pass by. She rises on thin sinewy arms without missing a beat, and huffs audibly as she lowers herself.
“Hey yourself.” I bend down and smile at her upside-down face.
“Could you help me? I need to shave my legs but someone has to watch me.” She sniffs toward the clinical desk. “They’re all too busy.”
“I’ll see how my morning looks and get back to you in a few minutes. You must be Annie.” It’s difficult to imagine her near death, but when I bend down to greet her, I note the black sutures that bite into the separated edges of flesh on her left wrist. Her self-inflicted wounds are almost healed, but I walk away with a sense of Annie’s troubled life.
“You heard of me?”
I’ve spent the last hour immersed in her past, familiarizing myself with her case. Of course, I don’t tell her that. I’ve been in this field a year, on 3 East, a thirty-bed, locked psychiatric ward in a hospital in Portland, Oregon. It’s a long road from being a student to forming any sense of competency. Annie’s presence on the ward is daunting; a twinge of stage fright had come over me when I greeted her. She’s challenged far more seasoned professionals than me. Her chart is seven inches thick—the clinical equivalent of hundreds of thousands of frequent flier miles—distilled from dozens of hospitalizations and years of outpatient treatment. It’s hard to believe the upside-down, in-person Annie has burned as many bridges as hospital-chart Annie.
Joanie, a newly minted MSW, watches the monitors at the clinical desk, which illuminate the dark corners and heavy magnetic doors on 3 East and hopefully prevent assaults and elopements. She’s working her way out of the deep hole of college-loan poverty. We’re a subset of a weekend team that includes six therapists, five nurses, and five psychiatrists who rotate in receiving our calls. We have each other’s backs in emergencies.
“Any reason I shouldn’t help Annie shower?”
“Yeah,” Joanie says. She reminds me that Alan, a fellow therapist, is leading a process group. Annie had declined his invitation to attend. But when process group is in session, everything else stops.
In shift report and briefings, we discussed our strategy for working with Annie, particularly the need for consistency. Joanie and I are needed on the floor until Alan’s free. Several patients are still asleep. Others start their day’s journey in a slow drift upward from the strange and frightening dreams that come from psychosis and antipsychotic medication.
I check my watch. Breakfast has come and gone while I’ve gotten caught up on Annie’s history. I work back-to-back, sixteen-hour shifts Saturday and Sunday. It’s Saturday morning, the start of my workweek.
Patients are admitted to 3 East in the acute phase of their illness for assessment, stabilization, and referral. Annie was admitted on Wednesday on a psychiatric hold, a status denoting patients who are a danger to themselves or others, with a diagnosis of borderline personality disorder (BPD). Because her illness has been well documented over its ten-year course, we know what to expect—up to a point. Her overly bright greeting, the strenuous exercise, her mood of the moment could swiftly devolve into something dark and irrational.
She’ll manipulate staff, split us into enemy camps, hate us then love us in the time it takes her heart to beat twice. Her emotional landscape is one of extremes. She’ll rage at those who are supposed to love her, who did love her once until it got too hard. She’ll rage at their abandonment. She’ll rage equally at those who try to hang on to her. We can expect her to try anything to fill the emptiness that—like an organ not visible on a CT scan but with an anatomical location vaguely near the human heart—comes with her disorder.
Beyond genetics, we recognize people by their personality traits—the quirks and behaviors that distinguish us from each other. Our personalities reveal themselves in our earliest years; however, personality disorders—patterns of inflexible and maladaptive behaviors—manifest later when they harden and set. No one knows which plays the larger role: nature or nurture. A parent or husband or sister may recognize something’s wrong then ignore the resulting discomfort and frustration and say ‘it’s just the way she is.’ BPD sometimes forms in response to triggers like abuse or abandonment—real or perceived. Real or perceived: this is the mystery at the core.
Young women with Annie’s diagnosis often act out in the form of suicidal gestures. These days, BPD sufferers can visit websites that cater to self-cutters and teach innovative means of self-destruction. Annie shares these creative, self-destructive tips the way best friends share clothing and secrets.
When process group ends, I find Annie. I turn the hot water on for her shower and bring her a cheap, pink, hospital-issue razor. She comes equipped with a heavy white Turkish towel and her cosmetics kit stuffed with miniature, free-gift-with-purchase samples of expensive toiletries.
Delicate white scars map her flesh; intricate patterns crisscross her arms, legs, and stomach—trails of superficial cuts that end just before reaching the generous blood supplies of her arteries and deep veins. I hand her the disposable razor.
“Not a pretty sight, is it?”
“You look like my grandmother’s lace curtains.”
She giggles. The bathroom fills with steam, and I can’t see her reflection in the mirror. I’m uneasy and move closer to watch her stroke the razor easily up her long legs.
“These razors are the pits. They never get it all.”
Afterwards, when she arrives for lunch, she’s meticulously made-up and neatly dressed in designer jeans and a bulky Aran-knit sweater: just a pretty young woman sitting down to lunch on a sunny afternoon. She drinks a glass of milk; she wolfs down two portions of Salisbury steak and gravy, two portions of mashed potatoes with butter and sour cream—all served on paper plates with plastic utensils—and four Styrofoam cups of ice cream for dessert.
When I walk past her room fifteen minutes later, I hear her throwing up in her bathroom.
“Are you okay?” I interrupt the unmistakable gagging noise she makes as she purges her lunch.
“Yeah. I’ll be out in a minute.”
A stuffed animal rests on her pink pillowcase. She’s taped photos to the wall above her bed. One photo in particular catches my eye. I lean in to study it. Annie stands at the center of a group of people jammed together in tree-dappled sunshine. They pose for the camera, smile, and wave happily. Annie looks healthy and plump.
When she emerges from the bathroom, her lips are raw. She smells of toothpaste and has changed into a hospital gown. She slumps down onto her bed and clutches her shabby teddy bear.
I look from her photo to Annie in her bed.
“Who are these people?” I ask. “How old are you here?”
“Sixteen. My mother, my brother, my uncle, my cousin, and my best friend.”
I search for clues in the photo. Nine years. What the hell happened to her?
“Do I have to act out to get a shot? I just want to sleep now.”
“I’ll bring you something.”
I inject a mild sedative. Now is not the time to discuss coping mechanisms. She skips dinner and sleeps through the evening. Sometimes that’s the best you can do for someone.
When I leave the hospital that night through the sliding glass doors of the emergency room, I inhale deeply. There’s a disconnect between 3 East and the rest of the world. It’s an occupational hazard. Inside, I lose track of time.
It’s the end of February, still dreary and cold, but it is a clear night with a dazzling array of stars and a sliver of a bright, white moon. Plumes of vapor billow from my mouth. I point my car home. Garlands of Christmas lights still grace houses and trees in Portland. I can’t decide whether my neighbors are lazy or crazy or both; maybe they’re depressed by our long gray winters, or they’re eccentrics who love Christmas lights. Whatever their reason, that night I’m grateful as it allows me to focus on something other than my medical profession’s penchant for dehumanizing patients when it defines them by their diagnoses, particularly anyone diagnosed with mental illness. While “Gall Bladder in Room 3” will leave the hospital without gall bladder issues, the “Borderline in Room 7” will likely be discharged with the same issues that brought her to the hospital in the first place.
It’s no surprise then that patients label themselves by their diagnoses as well. I’m more likely to hear “I’m a paranoid schizophrenic” than “I’m a college student and sometimes I hear voices”—the already fragile psyche stigmatized by itself.
From her records, I learn that Annie defiantly embraces her diagnosis. On a limited playing field, she takes pride in being the best at something where few seek a trophy. It has its own perverse logic. She derives her identity from being “a borderline” and sees herself as a teacher to others with BPD.
“I flunked DBT,” she brags during intake. DBT—dialectical behavior therapy, an offshoot of cognitive behavioral therapy—is the most effective treatment for someone as non-committal as Annie is to life’s infinitive: to be. DBT sessions teach basic skills, such as skills needed to stay alive, when to breathe, and how to walk step-by-step past disaster. Annie had arrived on 3 East following several suicidal gestures, a smorgasbord of passive and aggressive attempts at self-annihilation. The serendipitous arrival of a friend usually thwarted her plan. This last time, she upped the ante. She swallowed barbiturates then passed a razor across her left wrist. When she changed her mind, when no one came to save her, to prove their love, she dialed 9-1-1 and left the door unlocked and phone line open as she spiraled down into unconsciousness.
It’s now my second weekend with Annie. She invites me into her room and collapses onto her bed. I pull up a chair. Her features are gaunt and distorted by crying. Her chart indicates she’s down six pounds from a week ago. There’s a cotton ball taped to the antecubital space of her left arm from the morning’s blood draw. Purging destroys fluid and electrolyte balance, which can lead to seizures and cardiac arrest. A phlebotomist arrives daily to collect a tube of Annie’s blood.
Her nightstand is a mess. Sticky remains of last night’s juice smear its surface. Used tissues dry into stiff white clots. An open composition notebook invites snooping.
“How was your week?” I ask her.
“Just awful. If I can’t get out of here, I don’t know what I’ll do.”
Is that a threat? Certainly, she can make the connection between her suicide attempt and her hospitalization. Does she really imagine we’ll open the doors and let her out?
“Sounds like you feel pretty hopeless,” I say. Although I really want to know about her week, she frightens me and my voice gives it away. Annie spots my insecurity and pounces.
“Don’t talk to me like that,” she snaps then starts to sob.
“Like what?” I ask.
“Like a nurse or therapist, whatever.”
“I am a nurse. How do you want me to talk to you?”
“Like a friend.”
“I care about you; I want to know what’s going on; that’s why I asked.”
How easily she walks over my carefully constructed boundaries. “I don’t think you’re ready for discharge if that’s what you’re asking. What would you do if you got out of here tomorrow?”
She stops crying. “They’d find me dead with a needle in my arm.”
“Well, now, that’s kind of dramatic. And not likely to encourage me to advocate for your freedom.”
“I’m nothing if not dramatic.”
“OK, you got me. So short of finding you dead with a needle in your arm, what do you want to do? What happens after here?”
“I want a life. Like everyone else. I deserve it.”
“Of course you deserve it, but we work for the lives we want, and sometimes we don’t get them. And we try again and keep on trying. Swallowing pills and slashing your wrists doesn’t tell me that you want a life,” I point out. “It tells me you’re ambivalent.”
“Yeah, I get that.”
We sit quietly for a few minutes, then I stand to go.
“Do you have to be so neutral?”
“Annie, you know the limits of our relationship. Maybe a shower and some fresh clothes, clean up your mess. You might feel…”
“Go to hell.” There’s something animal in her voice, growling and hungry.
I keep walking. Neutral? When I think of Annie I feel weary and sad. I want to grab her by the shoulders and shake some sense into her; I’m definitely not neutral.
Still, I’m not surprised by Annie’s boldness when she walks into my transitions group in the afternoon. I’ve designed it for patients nearing discharge. It covers the basics—first steps after walking out of the hospital’s sliding doors into daylight, where to go and how to get there, how you fill prescriptions. And more complex issues, like staying out of the hospital, symptom management, access to housing and health care—how to keep from falling through the cracks of bureaucracy. I teach our most vulnerable citizens how to negotiate a draconian system of health care.
Annie comes up to me at the end.
“I liked your group. I learned something from it.”
“That it has nothing to do with me.” She smiles and walks away.
The doctor sees her on rounds, speaks with her briefly, jots some notes, and increases her Ativan for anxiety. He’s not Annie’s psychiatrist, but he’s well versed on her case; everyone who works on 3 East is familiar with Annie’s story.
We tweak her medications. Until new and better medications come along, that’s all we can do. Annie’s been on antidepressants, antipsychotics, mood stabilizers, anti-anxiety medications, and sedatives. They relieve some of her symptoms and temporarily improve her quality of life, but there are no medications to cure BPD. One therapist, in complete frustration, suggests that Annie needs a “personality transplant.”
Later in the evening, Joanie calls me. Her voice carries from Annie’s room down the long hall to the community room. She’s at Annie’s side when I arrive. Annie is tangled in a mess of sheets. Her eyes roll up in her head, her back arches, and she thrashes uncontrollably half off the bed. She’s unresponsive to our queries and white froth turns blood-tinged when she bites her lip. It looks like a classic grand mal seizure.
Annie experiences these after particularly violent episodes of purging. Alan gets there just after me. We catch her before she hits her head and carefully lower her onto the floor.
The seizure is over in an eternity of moments, and then Annie is still. Her blood pressure and pulse are normal, her breathing is unlabored, but she’s pale. I give her low-flow oxygen through nasal prongs for a few minutes and notify the physician. An hour later, she’s awake but sleepy.
“What happens when I have a seizure?” she asks. Do her lips turn blue? Does she froth at the mouth? Do her eyes roll back in her head? Do her arms and legs jerk?
I think about it.
“It’s pretty scary looking,” I answer.
I help her clean up and change into flannel pajamas. I think about neutrality and professional boundaries. Then I sit down with her and describe her seizure in detail.
She sits cross-legged on her bed. A tiny reading lamp clipped to her notebook casts a halo of warm light around her. When I leave for the night, she’s writing it all down.
We’re worn down. I’m worn down. I dread my long weekends locked in 3 East with Annie. The staff meets weekly for debriefings and diagnoses each other with compassion fatigue. We veer between giving up on her and believing that she’s tough and will survive. We’re horrified but not surprised that we share some visceral responses to her—anger, mainly. We are surprised when our collective negative energy evaporates as she charms us with a joke or smile, a token of her affection.
She should be out having fun with friends, going to college, dating, enjoying a loving family. Instead, she spends her time with us—binging, purging, cutting, and committing desperate acts of near self-destructive attention-grabbers. She is both victim and predator. In my better moments, I compare her to Tinkerbell; Annie doesn’t stand a chance unless we believe in her.
One of the staff psychologists obtains permission to take her for a walk on the quiet street in front of the hospital for some fresh air and a smoke. Annie runs toward the busy intersection and darts out into traffic. He runs after her and tackles her down; cars skid and slam on their brakes.
That week, I feel the prickly aftershocks of this incident. The staff is vigilant but gives her space. She’s off “constant” watch. I count the number of times she paces the length of the ward. Seventeen laps equal one mile; she does twice that.
My stomach muscles hurt, braced against threat. The signs are there. We take turns walking past her room. I’m apprehensive but not surprised when I hear the crash in Annie’s room.
She stands on a chair with a fragment of fluorescent light bulb that she’s broken out of its ceiling cage. She slashes at her wrists. Blood drips onto the floor. I grab towels to apply pressure while two others take her down from the chair. When we attempt to pry the glass from her hands, she puts the shards into her mouth and swallows. Annie slithers and writhes across a floor that glitters with fragments of glass. Her mouth oozes blood; she bites at us.
“Code Green” echoes over the hospital speakers and trained staff arrives from all departments. The emergency room nurses are there when Annie loses consciousness and turns blue. We have minor cuts and bruises and other deeper injuries that don’t show.
Closure is overrated, and in our line of work, it’s elusive. Sometimes I read about a former patient in the newspaper—usually bad news. Not knowing is my way of holding out hope.
Annie is referred to the state hospital, but does not meet their criteria for admission. Her problem is behavioral; she isn’t psychotic. She’s lucky; the state hospital is no place to get better. So she stays in 3 East for a few more months.
Annie is discharged early, at the end of May, into a run of good weather. She gets better. She gains weight. She hasn’t cut herself in a month; she discusses her behavior with mature insight. I’m not sure her improvement has anything to do with us.
In the next few months I hear rumors that Annie is or has been in our emergency department after another suicide attempt. I want to see her, but I don’t want her back on 3 East. It’s another hospital’s turn. The tools in our toolbox are failures of science and art.
A year later, I find a note taped to the clinical desk inviting us to Annie’s memorial service. There’s a phone number if we want additional information. I don’t call.
*All names and physical descriptions are changed to protect the identity of both patients and staff. The events are correct and in the order they happened. The locales exist although Woodland Park Hospital in Portland, Oregon, closed in January 2004.
Evelyn Sharenov is a writer and editor whose work has been published in The New York Times, Glimmer Train, Fugue, Mediphors, and numerous anthologies, including Best American Short Stories. Her journalism has also appeared in Bitch Magazine and The Oregonian newspaper. In addition to writing fiction–short and long form–Sharenov writes essays and creative nonfiction. She is a psychiatric nurse practitioner.