TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. When mentally ill inmates in New York City's Rikers Island jail become too sick, too violent, delusional or suicidal for the jail to handle, they're sent for treatment to Bellevue Hospital. That's where my guest, psychiatrist Elizabeth Ford, treated them. She started working with inmates in 2000 during her internship at Bellevue and continued to treat them as a psychiatrist, eventually becoming director of Bellevue's forensic psychiatric service.
In her new memoir, "Sometimes Amazing Things Happen," she writes about her experiences treating Rikers inmates and how it's affected her to hear their stories of horrible things they've done and the horrible things that have been done to them. She's now trying to improve mental health conditions at Rikers in her position as chief of psychiatry for correctional health services for New York City's public health system.
Rikers encompasses 14 separate jails spread across New York's five boroughs but the hub - nine of those jails - are on a 415-acre island in Flushing Bay, a hundred yards west of LaGuardia Airport. Rikers is a jail, not a prison. Most of the inmates are serving short sentences or waiting to be arraigned. But the court system is so overwhelmed that the wait can be extended over months, even years.
Dr. Elizabeth Ford, welcome to FRESH AIR. So let's talk about some of the typical problems, if there is such a thing as typical problems, that you've seen in the mentally ill inmates at Rikers. I mean, obviously some people there have paranoia and are delusional. I mean, you write about one person who heard voices telling them to amputate a limb to save their souls. Did they succeed in doing that?
ELIZABETH FORD: Thankfully, no. The focus of the book really are on those patients who are so sick that they need to be hospitalized. And so the bulk of the time that I spend with them, at least throughout this time period, is when they're in the hospital at Bellevue. And they are in that hospital because they are the most sick of the men who are incarcerated in this system. And the type of symptoms and pathology that that I saw and took care of during my time there really shocked me.
I have worked in a number of situations but I think for some of these patients, they had never received treatment before. They had never talked to anybody about the things that they were experiencing in their head. And I would say that the jail setting in and of itself can really drive the exacerbation of symptoms.
So people can become quite desperate, whether they're mentally ill or not, in this kind of setting. And I - you mentioned the wanting to cut off a limb. There's a huge range of self-injury, so trying to hurt oneself in various ways that we would not consider - swallowing detergent packets or slicing into your abdomen with a shank. I mean, these are things that are horribly disturbing and certainly to hear about but for the patients enormously disturbing.
GROSS: Some of the inmates who you treated had developmental problems. And so you write about a patient with an IQ of 58 who banged his head against the wall because he didn't know a better way to calm himself.
FORD: Yeah. And...
GROSS: What do you do about that as the psychiatrist?
FORD: Yeah. So increasingly I am noticing in ways that I think I didn't appreciate early in my career the numbers of people who are incarcerated who are neurodevelopmentally delayed and who don't have the education or don't have the cognitive ability to really navigate through this system.
And you're absolutely right, I do write about that particular patient, although he was an amalgam of many patients who will self-soothe in ways that are very harmful, so banging one's head or cutting oneself or punching a wall or sometimes screaming, behaviors that will - if you don't know what's going on can scare the staff members and can scare other patients.
So I - so what do you do about that as a psychiatrist? I mean, I - the first thing I do, which is what I try to do for every patient regardless of what's going on with them, is to sit and be with them and listen. And sometimes for patients, particularly who are neurodevelopmentally delayed, literally just being there for them. Not running away is the best thing that I can do. And then when they settle, we can talk about how best to move forward.
GROSS: Now, some of the patients who you treated were also violent, so they posed difficulties for the guards, for fellow inmates, possibly for you. Was there a separate way of dealing with violent patients?
FORD: Well, I think that that's a good question. There were different approaches to dealing with the violence that happened on those units. Much of the violence was a result of patients feeling like they weren't having their needs met or they weren't being heard. And occasionally, it had to do with their criminal justice case. But there was a wide range of managing it. And we tried as best we could to start with the least forceful intervention, so talking to a patient, trying to understand.
And if that didn't work, offering them medication if that was appropriate to the cause of their violence, if there was a psychiatric reason there. Sometimes patients had to be locked in rooms - it's called seclusion - to keep themselves and others safe. And just like any other psychiatric hospital, for patients who were so extraordinarily violent that there was nothing else we could do, they did have to be restrained, which is not something that any of us ever wanted to do but sometimes happened.
I think over the course of my career, I have definitely found that the first approach, listening to patients and really having patience with them is by far the best approach. They - when patients are scared, they become violent. And if you can listen to them, the fear goes away.
GROSS: Well, I imagine people trusted you with some really awful stories about what they did and what had been done to them. Would you share one of those stories with us that you were told that you found very upsetting about what the person you were trying to help had actually done?
FORD: Yeah, absolutely. That - and that has been for me, I think, the most difficult challenge of this work is to be able to hear stories about my patients, not just about what they may or may not have done but what happened to them and to hold that for them and to be as objective and non-judgmental as I can as a doctor for them.
But so I had - many of the patients I took care of who were accused of sort of high-profile crimes I actually did not include in the book because I wanted to respect their confidentiality. But, I mean, I took care of many patients who had been accused of killing somebody. The most difficult ones for me were those who had been accused of killing a child. And that became particularly hard for me after I became pregnant and had my two children.
But to listen to them talk not necessarily about the crime but about sort of the feelings behind what led up to that, how they felt afterwards and then the whole developmental trajectory that almost made - sometimes it made it seem like it was inevitable what was going to happen. It was very difficult but I think the - so the hardest for me have been accused or charges that relate to child abuse and child murder.
GROSS: Well, you write about one person who is a child pornographer. And you describe how you had to basically count in your mind and, like, disassociate yourself from what you were hearing because it was just, like, too upsetting to listen to. So how do you go about treating somebody whose confession to you was so upsetting, you know, that you had to dissociate? Yeah.
FORD: Yeah. So - it's - and that's - that story that you recount was right in the middle of my own personal development as a psychiatrist in trying to learn how to hear this kind of information and not over empathize and not be disgusted. So I - the story that you describe, the counting and the dissociation, certainly true. I spent several months actually practicing that until I was able to work through in my own therapy and, frankly, also take a break from the work and try to figure out what it was about the - what the patients were telling me and confiding in me that bothered me so much.
And I think the best answer I can tell you is that I got great treatment. And I found some ways to help myself pull back and distance from some of this very intimate and disturbing information and move on. It has also been very helpful for me to always think in the back of my mind, what is going on with this individual that this is the kind of behavior they feel compelled to do or they can't control?
GROSS: Well, you know, there's that conflict that you write about in the book of somebody being in Rikers to be punished, although really mostly they're awaiting trial. So it's like punishment versus treatment. It's like your job is to treat them but they're there because they were alleged to have done something horrible.
FORD: It is true, I have chosen a profession as a doctor in a place where my patients are being punished. Now, many of them...
GROSS: Many of them are being punished because they had a joint or something. And, you know, especially in your earlier years there before the drug laws were liberalized, a lot of people were there - minor possession charges.
FORD: Yes, that's true. And thankfully, those have shifted over time. But yeah, many were in on what I call - well, some minor drug charges but also quality of life charges like sleeping on the subway or sleeping in a - sort of a park that was private. And some of them had a dollar bail, so $1 was keeping them in this - in the jail system.
And I have - I mean, my job is to try to look past that and see these patients as my patients, to care for them, to be curious about them and to be non-judgmental. It is - I will say, it is a daily struggle but one I've found over the years, like, incredibly rewarding. I do think though that's the challenge for being a correctional psychiatrist.
GROSS: So you never feel like you are so - what you've done is so horrible. I don't even want to treat you. I don't want to know you. You should just be, like, locked up behind a closed door and never let out. Do you know what I'm saying?
FORD: I know - of course, I know exactly what you're saying because I've actually felt that about a patient. There was one patient I do - I write about him a little bit in the book for whom I had no empathy, at least I thought I had no empathy. And he had taxed the staff. He was not - he was not stable in either the jail or the hospital. He was very provocative and aggressive with patients who were much younger than him and much more vulnerable and sick.
And there was a point where I just thought, I actually don't really care what happens to you. And it was at that moment, literally that night, I was in tears talking to my husband about sort of what had shifted in me? How could I be feeling this way about someone? And that did end up sending me down a path where I took a break from the work to try to get a sense of it. But yeah, I can understand that feeling.
GROSS: What had that person done?
FORD: He had killed a stranger - allegedly. So he was - he was also not convicted.
GROSS: Well, I wanted to talk to you more about your work. I want to talk to you more about being pregnant while you were working. But first, we have to take a short break. If you're just joining us, my guest is Dr. Elizabeth Ford, a psychiatrist who worked at Bellevue's prison ward where she treated inmates from Rikers Island.
Since 2014, she has been the chief of psychiatry for correctional health services for New York City's public health system. Her new memoir about her work at Bellevue is called "Sometimes Amazing Things Happen." We'll be back after a break. This is FRESH AIR.
(SOUNDBITE OF MUSIC)
GROSS: This is FRESH AIR. Let's get back to my interview with psychiatrist Elizabeth Ford. Her memoir, "Sometimes Amazing Things Happen," is about her work at Bellevue's prison ward treating inmates from Rikers Island. She's now chief of psychiatry for correctional health services for New York City's public health system.
So you talk about being horrified by some of the actions your patients committed but you also write about being horrified at what was done to your patients when they were children. And it seems that most of the time when somebody was mentally ill and had done horrible things, you could pretty well bet that they had been punished in a kind of torturous way when they were kids.
FORD: So of the patients that I took care of, it was almost a universal experience that they had suffered abuse or significant neglect as children. I literally can't remember a patient for whom that didn't apply. And sometimes, yes, they were absolutely awful stories.
A patient talked in a group for the first time, really, about his drinking behavior that started when he was 8 years old because he accidentally learned that if he drank when his father whipped him, it didn't hurt as much. And that's where his alcohol problem started. So stories like that are really heartbreaking and gut-wrenching. And so I - you know, I really - I struggle with hearing those but I have come to almost expect that every patient I take care of has some real abuse history.
GROSS: So that story you just told about the patient who drank when he was their child because the whippings hurt less if he was drinking and he had drunk his father's alcohol because his father was an alcoholic - you learn this at a group therapy session. And it's really hard at that session to get anyone to actually talk. And why would they? Like, why? Group therapy just seems, like, so difficult to me in a prison kind of setting.
And, you know, Bellevue's ward where you work was basically an extension of Rikers Island jail. So, like, you're talking with fellow inmates. Everybody's, of course, like paranoid in prison. You don't know who's going to hurt you when you're in prison. So how did you get people to speak openly in a group therapy session when they're going back to Rikers after leaving Bellevue? Oh, and then you don't want to look weak.
GROSS: Like, if you confess to any kind of weakness and word gets out, like you're done.
FORD: Well, I think that that's a little bit of a misconception. And what I found - part - one of the amazing things really related to the title is that there - patients would come in and expect just, as you describe, that show any weakness and you'll be taken advantage of or share anything about your life and something bad will happen.
And I think what patients found, certainly what I found over the years, is that that was not always the case. And in some instances you could find support where you didn't really expect it. Related to the group therapy, though - because I think that's an extraordinarily important topic to focus on - one of the biggest stressors of being in jail is that you are surrounded by people who you have not chosen to live with. You have officers telling you things that you need to be doing that you may not agree with and you have staff - health staff - who sometimes are asking you to do things you don't want to do.
But you're in a new - an absolutely new community, and group therapy is a perfect petri dish to practice interacting and communicating with people that you don't know and some of whom you might be afraid of or some of whom you don't respect. And so I started that group that you were referring to specifically to address that issue. Like, how can we collectively as a community - that includes the patients and the staff and sometimes even the officers - how can we survive this system and come out the other side hopefully less damaged than when we came in? I have found group therapy to be some of the best treatment in this kind of setting.
GROSS: That's really interesting. So you were dealing often with patients who were - who posed a threat to themselves or to others. How frequently were you threatened by your patients?
FORD: Actually, not very often. There are a handful of times I can remember where I was scared, and it was not necessarily from a threat - a direct threat from the patient, but where I was afraid that something might happen. Their anger or their rage, their paranoia was so overwhelming that I was very scared.
My response to that is typically to let the patients know that I'm afraid. And I sometimes wonder if that's my own style or if that has to do somehow with me being a woman. But when I let the patients know that I am afraid or that their behavior is making me uncomfortable, it almost cuts the scene right at that point. And we reset and start over. And so the handful of times that I have really felt scared, as long as I can stay with the patient and let them know, things have gotten better.
GROSS: How do you tell a patient that they're starting to scare you?
FORD: Very simply. I say I'm starting to get scared right now. Literally that's what I say, sometimes depending on the relationship, I will say I wonder if you're also feeling a little bit scared, but that usually doesn't happen until I've known the patient for enough time that I feel comfortable that won't upset them further.
GROSS: My guest is psychiatrist Elizabeth Ford. Her new memoir "Sometimes Amazing Things Happen" is about her work at Bellevue Hospital in New York treating severely mentally ill patients who were sent to Bellevue from Rikers Island jail. After a break, we'll talk about one of the patients who threatened her when she was pregnant. I'm Terry Gross, and this is FRESH AIR.
(SOUNDBITE OF MUSIC)
GROSS: This is FRESH AIR. I'm Terry Gross. Let's get back to my interview with Elizabeth Ford, a psychiatrist who worked at Bellevue Hospital in New York treating patients who were inmates sent from Rikers Island jail. She became director of Bellevue's forensic psychiatric service. Now she's trying to improve mental health conditions at Rikers in her position as chief of Psychiatry for correctional health services for New York City's public health system. In her new memoir "Sometimes Amazing Things Happen" about her work at Bellevue, she writes that she often had deeply meaningful discussions with her patients, but she felt threatened by some of them.
You tell one story about when you were pregnant and the patient you were talking to said - you were standing, and the patient you were talking to you said you should sit down. Why don't you tell the story, instead of me telling it?
FORD: (Laughter) Yeah. This was a very ill patient who had schizophrenia. And I was very pregnant - that's correct - and was interviewing him to see if we needed to go to the judge to ask him to force medication on this patient because he was not taking his medicine. And we knew from prior hospitalizations that if he took his medicine, he would get well enough that we could actually start talking about some of the deeper issues.
So I was providing what's called a second opinion to see if I agreed with his doctor who wanted to present the case to the judge. So as - and as we were talking, I was standing. It was actually more comfortable for me. I had these - my ankles were very swollen and I was generally uncomfortable. I sort of sat in the back of this room with an attorney and a social worker. And he did very quickly - without much warning, this patient got up and threw a plastic chair in my direction.
It wasn't a particularly heavy chair but he threw it with some force, didn't hit anybody. Everyone scurried out of the room. And I was trying to be brave. There's no question there, I was scared but trying to be the leader, trying to be the person who was going to figure out what to do next and just sort of quietly walked out of the room, went to talk to the patient in his room to find out what was going on.
And he initially didn't say much when we got him back into the room to continue the discussion. He said to me no pregnant lady should stand. I was offering you a chair. And in that moment, I thought how can I be angry at this man who was trying his best to be kind and compassionate to me? Now, it came out in a way that was violent and potentially quite dangerous, but that wasn't the intent.
GROSS: So you were able to put that aside, the fact that he threw a chair at you and then continue to treat him?
FORD: I - well, I wasn't actually his treating doctor, so I was the second opinion doctor. But yes, I think I was - I don't think that I saw him in a different light after that. I was much more cautious about my own pregnancy after that situation, though. I didn't quite realize how much a pregnant woman could inspire all sorts of feelings and behaviors in the patients.
GROSS: Is there another example of somebody behaving totally inappropriately in respect to your pregnancy?
FORD: Well, inappropriately is a tough word for me to define because I do try to, again, understand like what the meaning is behind all the behaviors. I had a number of patients who would talk to me about the fate of my unborn children. I was - I actually was pregnant twice over the course of a couple years on that unit.
And I think probably that would be considered inappropriate if you were talking to a friend and they were describing awful things that might happen to your child when they were born. I think that's probably inappropriate. As they were describing these to me, though, I was getting a window into some of the feelings that they have - that they potentially had about their own childhood, about their own mothers.
There was a lot of discussion about what it meant that I might care for my child more than I care for my patient. What was it going to mean that I was going to be out on maternity leave and abandoning these patients? So there was - the pregnancy brought up a lot of issues.
GROSS: What did they tell you that you should be worried about regarding your forthcoming, you know, baby?
FORD: One patient told me that - well, actually he told me that he knew what the name of the child was going to be and that the child was going to be cursed. And that while I was a good doctor, I was not going to be a good mother.
I had other patients who would tell me you're going to be a great mom and good luck. But I think there was - the primary message was one more of kind of jealousy, maybe fear that I would leave them. It was hard (laughter).
GROSS: A lot of people when they're pregnant try to, like, have soothing music in the background so that the baby in utero will have this kind of, like, warm environment that they're kind of sensing and everything. And you are exposing, like, you know, your baby in utero to people telling you that your baby's going to be cursed.
One person's throwing a chair at you. People are just giving you the most horrible stories about their lives, about acts that they committed, about things that were done to them as as a child. Did you fear that you were exposing your baby in utero to horrible things? I mean, was that ever in the back of your mind? And I'm not saying that that would necessarily be a problem but, you know, people - you worry about things.
FORD: Yeah. Well, I think I can only speak for me as a mother but I suspect that probably most pregnant women worry about what's happening to their baby as it's growing inside of them. And they worry about all sorts of environmental concerns and their own mental health, their physical health and how that's impacting the baby.
So sure, I, of course, worried about that. It wasn't - my work is so much a part of what I do. And taking care of these patients was sort of in my core. I never thought, again, until the very end when that patient threw the chair at me I might be putting my child at risk, so I don't know.
And I - my children now are healthy and happy but I don't know if I'll find out the effects of that kind of work until they're older. And I hope that they can appreciate and understand how passionately their mom feels about the work that she does and how hard she tries to help these patients. And so that's what I hope they've gotten out of the experience.
GROSS: Well, why don't we take a short break here and then we'll talk some more. If you're just joining us, my guest is Dr. Elizabeth Ford. She's a psychiatrist who worked at Bellevue's prison ward where she treated inmates from Rikers Island.
Since 2014, she's been the chief of psychiatry for correctional health services for New York City's public health system. She has a new memoir called "Sometimes Amazing Things Happen." We'll be back after a break. This is FRESH AIR.
(SOUNDBITE OF MUSIC)
GROSS: This is FRESH AIR. Let's get back to my interview with psychiatrist Elizabeth Ford. Her new memoir, "Sometimes Amazing Things Happen," is about her work at Bellevue's prison ward treating inmates from Rikers Island. She's now chief of psychiatry for correctional health services for New York City's public health system.
Earlier in your career, you went through at least one period of just being shaken. You write that you asked your husband to clip things out of the newspaper that might upset you so you wouldn't see them. One night, you woke up screaming in terror. What was happening in that period?
FORD: So as a psychiatrist, looking back on it I think I was developing symptoms of traumatic stress disorder, really. I mean, in the moment, I didn't know what was happening. I was not sleeping. I was so scared for my children's safety, although there was no reason to be. I - my appetite was gone. And I was having a harder and harder time hearing the stories about my patients.
So I think I was developing symptoms. I was fortunate enough that my husband really stayed on me and insisted that I take it seriously. And I got into - I have - as a psychiatrist, I think it's important that you are engaged in your own therapy. So I - and I escalated that treatment a little bit. But it - so it was very hard. That's the darkest period of my career, for sure.
I mean, I do tend to be someone who tries to see things - see the bright side of things. And I have - in some ways I am - I - it's going to sound odd too but maybe grateful for the experience because I have a glimmer into what some of my patients experience now and how they feel. And to know a little bit about that fear and that just out of control helplessness makes me a little bit more understanding, I hope, of some of the things that they're going through.
GROSS: Did you think of giving up your career working with inmates as you were...
FORD: Oh, definitely. Yeah.
GROSS: How come you didn't? How come you stuck with it?
FORD: So I actually didn't stick with it for - I did leave. I left for about 18 months, although my leaving ended up being working in the emergency room for three days a week, where I still ended up seeing these patients.
GROSS: At Bellevue?
FORD: Yeah, at Bellevue. But what I what I found was that in spite of my initial desire to just be gone and not deal with all of these challenges, I was really drawn to these patients. And in the emergency room, I would see patients who had been arrested and were coming in to be evaluated.
And I just was so compelled by the stories they told and the way we were able to interact. And the idea of feeling hopeful about them, God, it was very hard to resist. It was very hard. I missed it. I really missed it. And when I was given - I was very thankful to have been given the opportunity to return to the psychiatric forensic service and be its director in 2009 and...
GROSS: At Bellevue?
FORD: Yeah, at Bellevue. And that also - that helped me to, I think, realize some of the some of the ideas and the vision that I had had earlier in my work that I might not have been able to accomplish had I not been in a leadership role.
GROSS: So stepping back, what do you think are some of the biggest misconceptions that people have about jails in the U.S. and what we need to do in terms of how to keep people in there, the extent that - to which they should be punished while they're in jail, you know, how punitive the system should be?
FORD: Well, I have the benefit of being a doctor in this system, so I really try very hard to think about how can the health of people who happen to be in the jail system be improved? I am not responsible for the why people get into the jail system. And I know there are many strong opinions about that and how jails should operate. I try very hard to focus on the patients and how to treat their mental illness the more I get into this work, also just how to treat the mental health of everybody who works in a jail system.
I think there are some significant misconceptions, though. I think about people who choose to work in jails and also the people who get incarcerated. Jail is a tough place to work. And it can - the setting can really change the way people interact with each other. And officers, health staff, nurses, whomever can behave in ways that they might not if they weren't under the - some of the same kind of pressures as people who are actually incarcerated in those settings.
And so it's - I think it's really important to know how difficult a setting it is to work in. At the same time, it's not hopeless, certainly. And so I think that is also a misconception we have. There are ways for jails and prisons to be more rehabilitative. And I think we can be all starting a conversation about that.
The issue of punishment certainly comes up. Again, from my perspective as a doctor, I have found that positive reinforcement - so that means praising someone or helping someone when they do good things, rather than punishing when they do bad things - is the best way to change behavior. So I think the more that we can try to incorporate that into the mission of the work we do in the jails, the better.
GROSS: So this gets back to something we were talking about earlier when you were asking your husband to clip out new articles from the newspaper that might upset you so that you could read the newspaper without being exposed to these things. What kind of things did he clip out?
FORD: Well, sometimes it seemed like it was most of the newspaper, but he - anything that - so he - there was a - I remember one particular day he clipped out an article about a 2 year old who had been left in the car and had, I think, had to be rescued by an ambulance, a story about genocide in a different country, a story about a murder that had happened in the Bronx. And there was a fourth article that I can't remember now.
But I remember thinking - and he told me these things afterwards - and I just remember thinking if I had read those, I don't know if I would have been able to hold it together enough to get to work. And sometimes he - I asked him to clip things because I did not want to know about people who might be coming to my care at Bellevue. I did not want to be influenced by things that were written about in the press. But mostly it was because I was so fragile at that point that anything that involved human vulnerability or cruelty or abuse was very tough for me.
GROSS: Can you read the newspaper now?
FORD: I can. (Laughter) Yes. I feel like that's a big step for me. But, yes, I can.
GROSS: Well, Elizabeth Ford, thank you so much for talking with us. Thank you.
FORD: Oh, it was my pleasure. Thank you very much.
GROSS: Dr. Elizabeth Ford's new memoir about treating mentally ill patients from Rikers Island jail. It's called "Sometimes Amazing Things Happen." She's now chief of psychiatry for correctional health services for New York City's public health system. After we take a short break, our jazz critic Kevin Whitehead will celebrate Ella Fitzgerald's Centennial. This is FRESH AIR.
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