Venturing Inside Bellevue's Psychiatric ER Weekends at Bellevue is psychiatrist Julie Holland's account of her years treating patients in a New York City psychiatric ER. She says one of the hardest parts of her job was figuring out which patients were manic or schizophrenic and which were high on cocaine or methamphetamines.
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Venturing Inside Bellevue's Psychiatric ER

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Venturing Inside Bellevue's Psychiatric ER

Venturing Inside Bellevue's Psychiatric ER

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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 that 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 the 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 o'clock 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 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 lunge 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 happening 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. If 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, 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 your 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 happen, 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, he 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 a 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. 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 there were 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 all 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 the ER, and we could hold them up to 72 hours. And we'd really have thechance 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, M-I-C-A, which stands for mentally ill, chemically abusing. That really described 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 create 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 started, 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 did 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 this 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 than 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, 3, 5 percent of the population - maybe say, 3 percent - of the population has got bipolar, 1 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 a 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, 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 stayes and who goes and OK, 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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