Read here for Part I.
"I hear you want a new therapist," I say to 15-year-old Brittany, who sits at the round table in front of me. I sit in my desk chair, swiveling.
"No," she says, smiling.
"So you haven't been telling Staff you hate me?"
That's a lie. She's been telling people right and left that I'm horrible.
"So who's been telling people you hate me? Your twin?'
"I like you now," she says, with that coquettish smile she gives, the one that may or may not be masking her true feelings.
After a moment of studying that smile, I ask her what's up.
"I wish I was dead," she says. She's still smiling, just not as much.
"Are you fantasizing about the idea of death, or do you really want to kill yourself?" I ask.
"I want to kill myself. People want me to."
"What people?" I ask.
She shrugs. "Just people."
I sigh. I know from reading her chart that she has a history of hearing voices. So I ask.
"Are these real people, or are you hearing voices?"
She pauses. One of those long pauses she gives, while narrowing her cat eyes into ominous slits. Sometimes, when she does this, I think she's going to pounce on me, and scream at me to take away the pain.
"I'm hearing voices."
"What do the voices say?"
Silence. This is what Brittany does, dangle a snippet of disturbing information in front of you, and make you chase after her for the rest.
"Brittany...what do the voices say? Do they tell you how to kill yourself?"
"They say, 'die, die, die...'"
She stares at me with her cat eyes and I stare right back at her with my tired ones. Brittany is tiring me out. She's tiring the treatment team out.
Brittany has Borderline Personality Disorder, a mood disturbance that most therapists in private practice won't touch because borderlines are so volatile, with constant threats of suicide and cutting, and after-hours emergency phone calls that are not emergencies, and "I hate you," one day, then "you're the best therapist I've ever had," the next, so that you, the therapist, end up wanting to kill yourself.
I am suspicious of the "die, die, die" comment. This seems a bit vague to me, as if she were making it up. Brittany, I have learned over the course of the past few weeks, will create all kinds of chaos to get attention.
She tells the Staff how much she hates me, then comes into my office telling me she loves me.
She says she wants to change all her new teachers, and the school counselor tells me they're the best teachers the school has.
She tells you she can't make it through the day without cutting, then smiles like a Cheshire Cat when you ask her if there's anything in her room she could cut with.
If the Staff tells her she can't have a second dessert, she yells at them, and storms into her room. The room that may or may not have a blade, or a shard of glass, stashed in the bed sheets.
The intensity and frequency of Brittany's behaviors are the reason borderlines need to be seen in an inpatient treatment facility: they are simply too much for one person to handle. Members of a treatment team can compare notes and find out that she appeared happy as a clam moments after she told someone else she wanted to kill herself, or that her threat of suicide happened directly after she was told to go to bed. The "splitting" is also more evident when diffused through a team: one person is devalued, while another is idealized.
"That's what the voices say? Die, die, die? They don't tell you how?"
She shrugs. I cross my arms and stare at her. I'm not sure I buy this business about voices, but I have to take her seriously.
"Well, I guess I'll have to put you on Observation then."
"You mean I have to sleep in the living room?"
"Yes. And Staff has to stand outside the bathroom door when you pee."
"That will just make me mad." she glares at me. "And I'll cut."
"You won't be able to. You'll be on Observation."
"I'll find a way. I'm sneaky," she smiles. I want to slug her.
"Then you have to promise me. No cutting, no killing yourself, until tomorrow."
She pauses, considering her options. She holds out her hand.
"I did this with Leslie. I promised her I wouldn't cut for two days, until she got back. And I don't break my pinky swears."
Leslie is Brittany's Primary Stuff. Leslie is caring and earnest and incredibly codependent. Leslie will spend an hour holding Brittany's psyche in her lap, which just encourages Brittany to act crazy.
I hold out my hand. We clasp pinkies, then touch thumbs.
"You better not kill yourself after I go home."
"I won't," she says, smiling beatifically.
She shuts the door to my office and I call the Psychiatrist, run the whole scene by her.
"You have to put her on Observation," she says.
"But I just have a feeling she's not serious...and I don't want to feed the beast."
"How many hospitalizations has she had?"
"You have to put her on Observation."
"All right," I say, "but I'm going to tell Staff not to tell her she's on Observation."
The Psychiatrist and I decide this is the way to go. On my way out, I pull a Staff aside and tell her the plan. The Staff rolls her eyes.
"Oh, yeah, she's hearing "voices'" she snorts. "After she got told she couldn't have a second piece of chicken, she went into your office and told you about voices."
The Staff and I laugh in exhaustion. Brittany has achieved her goal: she has seized control, gotten everyone's attention, and deposited her internal agitation on to the entire team.
* * *
That night, I lean against the kitchen counter while Atticus sets his dirty dinner dishes on the island. Atticus, who has worked with emotionally disturbed adolescents for years, is the Clint Eastwood of therapists. Few words, straight to the point, calling out crap.
"With cutters, you have to give their symptoms back to them."
"What do you mean?"
"Tell her cutters cut, and if that's what she's going to do, she's going to mark up her arms, and she'll look so weird that no one will want to give her a job or marry her."
"I can't tell her that!"
"You have to make her confront what she's doing."
"But what do I do about the voices? I don't think she's really hearing them, but I don't want to not believe her...It's just that the way she talks about the voices is so vague..."
"Tell her to go to her room until she figures out what the voices are saying."
"But what if she goes back to her room and hangs herself?"
"What if she goes back to her room and gets bored because a bunch of people weren't fluttering around her giving her attention? What if she decides her MO isn't working anymore so she stops hearing voices?"
* * *
I am worn out the next day. I didn't sleep well. One of my client's mothers died recently, so I'd spent the morning on the phone with her guardian, and the guardian's mother, and Medi-Cal, trying to figure out who was going to fund her treatment now that her mother was dead. I had four reports to finish, clients to meet with, and I had to sneak out early to pick up Franny from day camp because I had no sitter that day.
And then there was the news from Brittany's social worker. Brittany's mother -- the one who had lost all her kids to the system because she let her boyfriend molest Brittany for six years -- had just had a baby. No one knew she was pregnant. She was a large woman and she didn't tell anyone. So after she had the baby, the social worker arrived at the hospital to "detain" the newborn boy.
Brittany got the news at 5 pm. I could hear her sobbing on the phone outside my door. And then there was a knock. I opened my door. Tears were flowing from her cat eyes, down her cheeks.
She came in and stood in front of me.
"It's my fault they took the baby!"
"It's not your fault."
"But if I hadn't said anything about my stepfather, my family would be together. They wouldn't have taken the baby."
"What happened for CPS to take you and your siblings out of the house?"
"You told about what?"
"And whose fault was it that your stepfather was molesting you? Who made that choice?"
"And who let him?"
"So maybe your mother shouldn't be having more kids," I said. "Your social worker will give the baby to someone who can make better choices for him."
"I can't do this," she says. "I can't make it through the day."
"Yes, you can," I say.
I say this in part because the wall clock tells me it's 5:20 and I have to leave in ten minutes.
She narrows her eyes.
"Do you want to hear the Cutter's Lullabye?"
"No," I say, rather curtly. "I have no interest in hearing the Cutter's Lullabye."
She cocks her head. This was not the answer she was expecting.
"In fact, it sounds like a really dumb song."
She takes this in, then gives me a half-smile. I think she looks relieved.
She holds our hand to me.
"I won't cut myself until tomorrow."
"You won't kill yourself either."
"Okay," she says.
We clasp pinkies, then touch thumbs.
"Can I give you a hug?" she asks.
"I feel better," she says, as we both walk out the door.
"Good," I say, well aware that "better" could only last for five more minutes.
On my way out of the unit, I take Leslie, the sweet, but codependent Staff, aside and tell her to keep an eye on Brittany. I tell her to refuse to listen to Cutter's Lullabyes, or Suicide Lullabyes, and to tell Brittany she's only got five minutes to listen to whatever it is.
Then I cross the parking lot and get in my Prius, drive too fast out the gate, and up through the hilly, high-end neighborhood that lies just outside the treatment facility that houses kids who have grown up in poverty.
I wonder about the kids living in the million dollar homes that I zoom past. I wonder which homes have teens who cut themselves, who deposit their dinners in the toilet, whose suicide threats land them in a swanky treatment center for rich borderline kids.
I drive into the recreation center where Franny's day camp is. I race into the gym and she bounds towards me. She gives a giant goodbye hug to her best camp friend, the one who wears the same starter bra from Target, the one who also lives in two houses.
Franny grabs my hand and pulls me out the door.
"I'm hungry! What's for dinner?"
I sink into the fluffy cloud of innocence and ebullience that follows Franny wherever she goes. And I hope that it stays with her forever.