Personality Disorder (Not Otherwise Specified)

My patients called me Dr. Holloway. My friends called me Jason. I won’t tell you what my three ex-wives called me but I’m sure you can guess. I was a psychiatrist (and a damn good one seventy percent of the time).

My adult life had been full of restarts, reinventions, and rehabilitations. This new beginning, though . . . this was supposed to be different. I’d taken a job at Margins Treatment Center in sunny Los Angeles as the Clinical Director. As a top-quality Partial Hospitalization Program in Beverly Hills that took insurance, Margins was like an Ivy League school. The richest of the rich bought their way in and covered the cost for those needing a sliding scale. It was a mixing pot of Los Angeles’s mental health struggles, from those who just needed a break from life to those who tried to permanently break from life. The center helped people deal with life’s margins, the parts that few others saw until the ink bled across the page and demanded attention.

I’d been a Board-Certified psychiatrist for eighteen years and had worked in hospitals, nursing homes, VAs, pill mills, private practices, intensive outpatient programs, rehab facilities, and even did a little bit of under-the-table guided psychedelic trips at the tail end of my last marriage. Any setting that needs a psychiatrist to sign a script, I probably worked it. Some were tolerable, some were good, most were unbearable. Margins promised to be a great gig. My best in years.

As the Clinical Director, I was there to direct, not see patients directly. But how could I run a clinic without contributing to what made it tick?

Complicated Grief

Therapy groups held a special place in my heart. Nothing replaced a good one-on-one but magic happened when you put a bunch of untrained, struggling individuals together and made them talk out their issues. Patients often responded to other patients in ways my license and experience would never have allowed. Those raw moments bore unforeseen therapeutic healing. Margins offered all types of groups, from addiction to psychosis to nail-biters anonymous.

I was a month into my role as Clinical Director when I decided to scratch my itch. I’d quickly mapped out the idiosyncrasies of my new colleagues and Dr. Julius Turner—the long-time Margins psychiatrist who should have gotten my job, to hear him tell it—was always four to five minutes late. It was “therapeutic” to let the patients sit with any discomfort or resentment, he’d muse, but I just saw it as untreated ADHD. Either way, I came to his Suicidal Ideation group on time, sat in the moderator chair, and introduced myself.

Only three patients today. A small, intimate group. I knew each case from the shared one-liners during Morning Report, where the various clinical staff gave daily updates and impressions on Margins’s census. Marcus Walters, thirty-five, was recovering from a serious suicide attempt by unsuccessful hanging after losing his wife in a car crash. While this was his first attempt, Kelly Rosenthal had danced with death many times by the age of twenty-five. Her bright smile and welcoming demeanor did nothing to advertise that she’d just tried to overdose on her mood stabilizing medication a week before. Lyle Blevins, forty-six, had never attempted and likely never would but his bad OCD kept him fantasizing about ending his life every waking moment. That suffering almost excused his sour attitude. Almost.

I started on time. Five minutes later, Dr. Turner waltzed into the therapy room, head down, and paused when he saw me in his seat. Tall and lanky and with thick-rimmed glasses that gave him an AI-generated feel, his expression was always some variant of “I just sniffed something slightly sour.” Clean-shaven, soft-jawed, and clear-skinned, he could have been ten years my junior. I was pretty sure we were the same age. I gave him the “I got this”nod. I’d guessed he was the type who didn’t like to engage in conflict in front of patients and I was right. After he’d reluctantly backed out, I gestured for the interrupted patient to go on.

Marcus: I don’t drink coffee but I still put the water to boil every morning. She always needed that cup to start the day.

Kelly: How long were you married?

Marcus: Too long. That’s what she would say. As a joke; that was her humor. Eleven years. Not long enough.

Dr. Holloway: Such sudden loss is never easy.

Marcus: You get paid to pretend you understand. You don’t.

Dr. Holloway: I don’t. Not like this. But I’ve lost. My first wife left me. Took the kids. The whole nine. It felt like a death.

Kelly: Shit, Dr. H., That sounds hard.

Dr. Holloway: Our marriage was designed to withstand hard. It couldn’t endure me being an alcoholic.

Lyle: Share much?

Marcus: Damn. I’m sorry.

Dr. Holloway: Don’t be. I got a free script of the best medicine in my field: regret.

Marcus: My only regret is I wasn’t successful.

Kelly: I’m glad you’re still here.

Kelly reached across the aisle and squeezed Marcus’s hand.

Lyle: I thought touching wasn’t allowed.

Everyone’s head turned as the door to the group therapy room opened. Instead of Dr. Turner, come to regain his dignity, the program’s director and founding CEO leaned in halfway. Short and commanding, Dr. Kristen Lynch wore a different color suit dress every day. Today was olive green. Even through her always-on smile, I could tell she wasn’t happy.

Dr. Kirsten Lynch: Dr. Holloway, a word . . .

Adjustment Disorder

“You rang?” I said when we were far enough down the hallway.

“If I needed another group leader, I would have hired one,” Dr. Lynch said.

“It’s good to connect with the patients,” I said.

“We have enough connections. What we don’t have is leadership.”

During my brief job interview, Dr. Lynch told me only that she’d applied to medical school once upon a time but soon found she would have more interest in employing doctors than in being one. I’d done my homework, though. She made most of her money writing self-help books and, from the looks of her social media, was just a few thousand subscribers shy of influencer status. Margins had grown into something bigger than her original ambitions and needs. But as long as she kept things afloat—including being efficient about insurance costs—the business would keep her comfortable in between book contracts.

Of course she wouldn’t take well to my unorthodox ways. I was usually good about hiding them until the end of a new job’s honeymoon period, at least. I was off my game. She had hired me quickly. I suspected she’d let me go twice as fast if she saw me as a threat to stability.

We went to Morning Meeting, which had started ten minutes ago. Margins employed two psychiatrists, four therapists, two social workers, and a pharmacologist who came in once a week to consult. As they went through the census, I tried and failed to hide my drifting attention.

I caught the newly hired therapist staring at me halfway through report. New to Margins but not new to me. Her hair wrapped in a neat bun above sharp, kind eyes, a designer scarf snug around her neck, she looked like she’d stepped right out of ten years ago. She sipped her coffee as our gaze connected. Evelyn. What the fuck was she doing here? We had history. The type of history that could truncate my stay in California.

“A therapist follows her former patient all the way across the country to haunt his new life,” I said out the side of my mouth at the coffee pot. She’d gotten up to pour her second cup. “That’s got to be violating some code of ethics.”

“Trust me, I had no clue,” Evelyn said. She really did look the same. Except the unease. That was new. “I’d like to keep this job, if possible.”

“Don’t worry. I’m sure they like you more than they like me.”

“They need you more than they need me,” she said.

“I won’t tell if you don’t.”

Evelyn looked me over. She’d helped me through some tough times. And she had to be thinking about the unorthodox methods I used in treating patients. But things were different now. I was on medication. Besides, Dr. Lynch made it clear that my role here wasn’t to treat.

“How’s your husband?” I said. I couldn’t for the life of me remember his name.

“Same ol’. I don’t know what he’d do without me but don’t tell him that. You seem to be doing well.”

“I am,” I said. For now.

Major Depressive Disorder

I kowtowed to the boss’s request and made sure most of my hours were spent doing Clinical Director things: reviewing notes, lengths of stay, treatment outcomes, and making myself available for any issues that arose among the clinicians.

But something about that patient Marcus . . . I just had to help him. I snuck in personal afternoon therapy sessions. His room was south-facing and far from Dr. Lynch’s office. There wasn’t much that could be done when it came to furnishing living spaces for psychiatric patients but Margins somehow transcended the suffocating feel of locked wards while maintaining safety. During intake, each patient could decorate their room from pre-selected décor. The result was often telling to any mental health provider with a keen enough eye. Marcus had chosen sterile; the walls were bare, the bed unseasoned.

Dr. Holloway: What do you remember about her?

Marcus: She’d always say “you know?” at the end of a sentence and her voice would go real high. She didn’t like the lights on at night. She kissed out the side of her mouth.

Dr. Holloway: What are you feeling right now?

Marcus: Anger.

Dr. Holloway: Towards?

Marcus: Everyone. Her. You. This place. Whoever decided a person couldn’t take their own life. I just want to die. No one will miss me. Shouldn’t I be allowed to?

Dr. Holloway: Some think you should.

Marcus: And you?

Dr. Holloway: I think . . . what would she want?

Anxious Attachment

I left the office late and caught my date walking full stride to her car in Freebird Restaurant’s parking lot. I intercepted.

“Whoa, we just got here,” I said.

“No, you just got here. I’ve been here thirty minutes.”

“You wanted someone ambitious. What’s more ambitious than a busy doctor?”

Amber came back in, but we never fully recovered. I had a list of questions and topics I’d prepared. I’d really only asked her on a second date because I’d gotten side-tracked on the first and my fourteen-year-old son Kayden liked that she wasn’t a doctor. And she’d only answered my text after I promised not to be late this time. Halfway through dinner it was clear we’d never work.

Still, a novel question burned through. “Let’s say we go far,” I said. “Marriage far. If you died, tragically, would you want me to live on or to romantically die?”

Amber mouthed the last two words: romantically die?

“Sorry. Unalive myself.”

Amber took a bite, looked at her phone, then at me, and sat back. “Live on,” she said. “You’re ambitious, right? Be great without me.”

“You didn’t give it much thought,” I said. Amber shrugged and went back to her phone.

When the check came Amber raised her eyebrow. You’re ambitious, right? I paid the bill. Amber muttered her thanks and quickly left, furiously texting, probably about how much of a waste I proved to be. On my own way out a couple minutes later, someone tapped my shoulder. Evelyn. My old therapist turned new colleague.

“Now it’s getting creepy,” I said.

“I thought the same. I was having dinner with my other half and thought I’d say ‘hi.’ It’s good to see you dating again. How’d it go?”

I laughed.

Post Traumatic Stress Disorder

“I brought dinner,” I announced as I walked through the front door of our second-floor apartment. The lease was month to month. I hoped to soon change that.

Kayden rushed over and gave me a full hug. I hesitated a bit before returning the embrace. I mouthed to my father in the background as I pointed to my son: See, you did this. I took after Mom, who had been about as affectionate to us as a rattlesnake. Dad was always the hugging type and now he doted over his only grandson.

My father touched my shoulder as he exited. “He was good. As always. And we already ate. Two hours ago.”

“Thanks, Dad.”

“How was the date?” Kayden said once his grandfather had left. My son, the youngest of three, had decided at the age of ten to give his rehabilitated father a second chance and his mother had decided this was unforgiveable. What was supposed to be joint custody in Washington, D.C. turned into a type of emotional abandonment. Kayden stopped asking about his mother around his thirteenth birthday, didn’t protest when I announced the move from coast to coast, and since landing in Los Angeles had taken attention to my love life like it was his own school project.

“It went great. We hit it off. So much better than our first. We have so much in common.”

Kayden’s smile melted. “You were late again, weren’t you?”

“Late is relative. Reframe it. I was early for our third date.”

Kayden picked up my phone, unlocked it against my protests, and opened up my dating app. “I finished my homework. Time to do yours.”

See?

“Who’s the parent, here? Oh, that’s right, I am.” I snatched the phone, playfully. “Time for bed, matchmaker.”

Disorganized Attachment

Back in my room, I cursed at my phone after swiping until I didn’t know what I was swiping for. I went to my bedside table, dispensed a Xanax, popped one, and then noticed a broken section on my custom-made medication dispenser. I’d consulted with a college friend-turned-engineer on ways to mitigate my issues with taking my meds consistently. Now, the side with my most important medication was jammed. So much for an Ivy League education.

Anger. The feeling is anger.

How the fuck? I’d missed a month’s worth of medication. Not all of it—the antidepressant and the one that helped stave off alcohol cravings had both dispensed fine. But the most important one: the antipsychotic.

It had taken me years to find a regimen with the right combination of efficacy and managed side effects. I’d balanced out the weight gain with a ketogenic diet, had an auto-renewing Biotene delivery for the dry mouth, and took Gabapentin for the restless leg. I’d been so successful that I’d achieved the ultimate patient status: It feels like I’m taking nothing at all.

The stabilizing antipsychotic had hit a variety of my neuroreceptors. Every patient was different and sometimes changes were immediate but mostly the clinical effects came over time, as the saturation levels rose and receptor expression levels adapted and shifted. When the change did come, for some it would be sudden and steep. Hearing voices or gravely delusional one week and insightful and organized the next. I knew from experience that my course was more insidious. The extra dopamine produced in my mesolimbic tract (the highway that delivered the important reward-based neurotransmitter to other parts of my brain) had silently taken residence over the last month and was likely affecting a multitude of my sensorium.

In layman’s terms, this wasn’t good.

Schizophrenia—Empathetic Type

This wasn’t my first rodeo. I was well-aware of my condition as I’d coined it myself: empathetic schizophrenia. Good luck finding it in any textbooks and definitely don’t expect insurance to pay. I had a patient with schizophrenia in residency who ran a Fortune 500 company and was able to keep the voices under wraps as long as she took her meds. It had given me hope during a time when I questioned whether my mental health would force me to drop from the profession. As a disease, schizophrenia manifested on a full spectrum, from hearing voices to fixed false beliefs to crippling paranoia to thoughts that just never organize themselves quite right.

For me, I took on other people’s attributes. Most notably, the symptoms of my patients. If they were depressed, I got depressed. Heard voices? I heard them, too. Manic and grandiose? My credit score remembered. My own psychiatrists didn’t believe me, and I started simply reporting hearing the voice of my dead mother whenever I was symptomatic and needed meds. I privately demoed monikers in those early years. Absorptive schizophrenia? Ugh. Chameleon psychosis? Nice, but too reptilian. And then I had a patient with bad social anxiety who described himself as an “empath”: someone who could feel other people’s emotions as their own.

Voila. Empathetic schizophrenia was born. It proved a great tool to secretly treat patients. A horrible thing to lose control of.

But I was still in control. Right?

Poor insight is a hallmark of psychosis. Meaning, one often doesn’t know when they are psychotic. There were ways of finding out. And I’d been psychotic and delusional enough times to know how to navigate it. Now, could I navigate it well? You could ask my first two wives but that would be cheating. My third wife . . . she understood the dance. And that’s why she left.

I started with patient Marcus. I’d taken on his distress—clear from the ridiculous question I’d posed to Amber—but was he even real? Million-dollar question. I easily found his chart which included notes from other staff.

A good sign, but not enough.

I sat in on his groups. I took note of the mental statuses of the other patients as Marcus spoke, checked for the interactions, recognized my own countertransference. It was like trying to figure out if one were living in a simulation.

I considered consulting with Evelyn. She could tell me quickly and definitively if Marcus existed. And she already knew what my mind was capable of. But she didn’t know I hadn’t been on my medication. What if she took this as a decompensation?

Was this a decompensation?

Cognitive Behavioral Therapy for Psychosis

I found Evelyn in the breakroom, filling up on coffee. She seemed to be expecting me.

“I need you to chart check a patient for me,” I said.

“You’re worried about them?”

“Not him. Me. I think I may be having a hallucination.”

“This place’ll do that to you, you know.”

“I’m serious. The patient’s name is Marcus.”

“Last name?”

“I don’t know, actually. Just tell me I’m not crazy.”

Evelyn adjusted her scarf and slid behind the nearest computer. “I can’t tell you that. But I can tell you if he’s real. Marcus Walters. Here after a suicide attempt. Looks like—shit—lost his wife?”

“Car crash,” I said. “Very sad.”

“Devastating.” Evelyn turned from the computer screen to me. “How are things at home?”

“I’m not here for a session. Thanks for the consult.” I left before I could hear more.

Bipolar Disorder, Type I

As Clinical Director I technically “ran” Morning Report. I thought of it similar to group therapy: Let it run its course and I intervened when it veered off the rails. The impressive Margins team was a large part of what made the job great instead of just good. Evelyn, of course, could do no wrong in my eyes. Though Deidra Foote, PhD didn’t have the pleasure of once being my therapist, she’d been at the treatment center since its inception, and I quickly learned to trust her judgement. Sean Cohen was a resourceful, middle-aged social worker who navigated Los Angeles better than Google Maps when finding services for patients nearing discharge. I listened to their insights and recommendations with respect and weight.

Dr. Turner and me, however . . . we just didn’t see eye to eye.

Dr. Turner: Johnny Clay, forty-one, coming down off a bad manic episode. Fresh face tattoo. Traveled to D.C., believing he was hired as consultant to the president. Some underlying narcissism. How’s he doing in group?

Foote, PhD: Interpersonally reactive. Several redirections. Walked out of . . . two this week.

Sean: Only two?

Foote, PhD: Baby steps.

Dr. Holloway: Getting out of his head will be good for him.

Dr. Turner: Heard reports he’s been making our VIP patient uncomfortable. Talking about all the movies he’s seen in group, acting surprised when someone inevitably points out the VIP sitting beside him was in said movie.

Dr. Holloway: We’re a psych facility. It’s supposed to be uncomfortable.

Dr. Turner: The VIP wants to be moved.

Dr. Holloway: No special treatment.

Dr. Turner: Do you know what VIP means?

Dr. Holloway: Important people are still people. What’re they going to do? Review us on Yelp? No special treatment.

Life In the Margins

Dr. Lynch’s latest book, Life in the Margins: How to Take Control of Your Mental Health While Being Successful, was a hit. She passed around signed copies to the entire staff and often took meetings virtually from the next book tour city. So when insurance started requiring exit interviews for all patient discharges as part of billing, she was both stretched thin and in a particularly receptive mood.

She agreed to let me do them. All of them. In return, I laid off the groups and “extraneous” patient care.

I quickly found these exit interviews to be bullshit. They all felt like Red in The Shawshank Redemption sitting in front of the parole board, putting forward his best.

One, however, threw me off with her honesty.

Annabelle Brown, a thirty-seven-year-old lifelong bachelorette, was going home three months after checking in for a bad case of sex addiction. When most people hear such a diagnosis they think of a man addicted to porn or spending his life’s savings on sex workers. So everyone at Margins scoffed at her one-liner until they actually read her case. Hundreds of thousands on premium matchmaking services, multiple STDs, a few ongoing court cases from exhibitionism, and fired from three jobs for watching porn at work. The most recent termination had prompted her coming to Margins.

Sex addiction was a wary addition to any group setting, but most of the cases that sought this level of treatment were men. I knew from case studies that it presented differently in women and that she wasn’t going to enter any room looking for her next conquest. Still, she surprised me in how insightful she was about relationships, intimacy, and loss—especially towards Marcus. I’d even piggybacked off her comments a few times in group. They’d grown close. Annabelle’s addiction and aim to get better took any sexual tension off the table. Whenever someone brought up at Morning Report a concern of how much time they spent together, I shut it down quick.

As I sat with Annabelle for her exit interview, I made a mental note to check in on Marcus and see how this discharge was hitting. I asked her the routine questions pertaining to why she’d come. If her symptoms had improved. What she’d learned. How life might be different. She looked me in the eye and told me she didn’t plan to change a single behavior. It was the framing. Labeling her actions as an addiction discounted her regaining autonomy for her sexuality.

At some point, I was sure she’d stopped talking about herself and was referencing my whole approach to dating and intimacy. I hadn’t kissed a woman in years, not since becoming a full-time parent again. I had to make sure I found just the right one, that she checked all the right boxes for me and Kayden, before I could even think about physical attraction.

I was floored. Annabelle was right. I was going about this dating business all wrong. I should be approaching it by needs of shared pleasure and autonomy, not logistic compatibility.

Doctor, heal thyself.

Sex Addiction

I arrived at the restaurant five minutes early. I’d matched with Caroline Miller after clearing several filters from my dating app. She was definitely different than the usual women I swiped right on, with their crisp, professional-grade pictures, Ivy League-laden bios, and at least two serious hobbies to show “well-roundedness.” But something about her unpolished profile made me tingle in ways that furthered the anticipation during the drive across town.

The food was good. The conversation was better. I scrolled through my list of questions and put my phone face down. Fuck it. “What’s your fantasy?” I asked.

She nearly choked on her blackened Cajun salmon. “Excuse me?”

“I’m not trying to be freaky, or too forward. Okay, maybe a little forward. But I want to know what does it for you. In any category.”

She picked at her food and then looked at her phone. Shit, I’d lost another one.

“Power off,” she said, placing the phone face down on the table. Her eyes sparkled. “Making sure Siri doesn’t hear.”

“Doesn’t hear what?” I said. I forgot all about that goddamn list.

“Me telling you my fantasy.”

And then, she told me.

Grandiose Ideations

My father leaned in for a whisper when I came in. “It’s well past midnight. You smell like perfume. Did you use protection?”

“What am I, sixteen?”

“Well, did you?”

“No! I mean, I didn’t need to.” And I hadn’t. I’d gotten to second base and was only hitting for first.

Dad patted me on the shoulder and left. Behind him, Kayden was beaming. My dad didn’t shy away from innuendos and he’d requested more than once to give Kayden his version of the “birds and the bees” talk. “You know, in case you missed anything.” What speculations had my father voiced as my date stretched into the night? I didn’t want to know.

We watched a movie. I deflected any and all questions about my date as I hadn’t quite figured it out myself.

I woke up a few hours into the night. Kayden had put a blanket over me and gone to bed. I turned over and began to doze when I remembered I hadn’t yet taken my medication. I thought about it, all that had happened, who I had helped. My dose was one pill a day. One full pill. I cut it in half.

Doctor, heal thyself.

Sometimes healing came from going through, not around.

Delusional Disorder

Margins and I fell in a groove. The center became inundated with referrals due to Dr. Lynch’s literary success, got on another, lucrative insurance panel, and hired two new therapists.

As for me, I felt alive. I felt effective. The small bit of medication did enough to keep me stable while allowing me to tap into my gift. I was well aware that feeling like I could control my psychosis was what led to the crumbling of all my previous lives. Virginia Beach. Atlanta. Miami. Ann Arbor. D.C. But this time was different. This time I was in control.

If I leaned into the schizophrenia just enough, I could connect with my patients on a cosmic level. And maybe help myself a little. The result? We’d both soar.

Very Important Person Disorder

Foote, PhD: First new, just discharged from UCLA. Big name actor back in the ’80s. Meth addiction, on and off, but when it’s on it’s bad. Tried to cut a hidden camera out of his eye this last go round. Surprisingly pleasant on intake.

Dr. Turner: How famous?

Foote, PhD: Household.

Dr. Turner: Regular groups for the Regularly Important Patient, right, Dr. Holloway?

Dr. Hollway: Right. Next.

Foote, PhD: Here’s one you don’t see every day. Delusion she’s dead and her body is rotting from the inside.

Dr. Holloway: Cotard’s. Haven’t seen one of those in a while.

Foote, PhD: This is a thing?

Dr. Holloway: Definitely a thing.

Dr. Turner: I’ll take her. What psychosis groups we have going?

Dr. Holloway: Not a good idea. Put her with a bunch of paranoid patients hearing voices and she’ll feel we’re invalidating her beliefs.

Dr. Turner: But we are invalidating her beliefs.

Dr. Holloway: Do you know for a fact her insides aren’t rotting?

Dr. Turner: What an absurd question. You’re not even going to consider—

Dr. Holloway: I’ve considered it. Regular groups. Assign her to my caseload.

Foote, PhD: You don’t have a caseload.

Dr. Holloway: Semantics. Next patient.

Cotard’s Delusion

Quite the test case. Unlike my empathetic schizophrenia, Cotard’s was defined in the textbooks, in the section of rare psychotic disorders that no one knew what to do with. With it, patients developed the belief that they were either dead or parts of their bodies were dead or rotting.

I dove right in.

The patient—a forty-six-year-old woman, recently divorced, adult children, no psychiatric history—should have been entering the next phase of her life and then, bam! Beliefs of rotting from the inside out. Her delusions were potent; they immediately wrapped around me.

I had four dates lined up in the next week and I didn’t touch my plate at a single one. I feared my insides wouldn’t be able to process the food. Only Caroline stuck around for more. I took a chance and told her I had a patient with a food aversion and I was trying to put myself in their shoes. Like method acting, but with psychiatry. She thought it was cute. Go figure. I stopped sleeping because I feared I wouldn’t wake up. As I suffered (and rotted?) internally I used the insights to guide the patient through her own psychosis and find meaning. I’d lost fifteen pounds by the time she was discharged.

That was horrible. That was amazing. I should have learned my lesson. I should have taken my medication. But with great power comes great responsibility, right?

Hypomania

Here are some of the Margins patients I treated over the course of the next three months:

A thirty-six-year-old woman, married with twin preteen daughters, with delusions that her family members have been replaced with imposters. Capgras Delusion. A spiritual cousin to Cotard’s and found in the same textbook section. I had one night of wondering if Kayden was an imposter. He was so much more wholesome than me, after all. Instead of confronting him (yes, I seriously considered it), I took a whole pill that night alongside a glass of wine.

The insight I gained helped me break the woman’s delusion the next day. She was “in and out”—something the insurance liked to see.

A twenty-four-year-old man, just got into medical school, stuck inside because he was convinced parasites had taken root underneath his skin. I was up all night scratching. Nothing a little Benadryl and long sleeves couldn’t tackle.

Fifty-five-year-old woman with narcolepsy. Bad enough to get into Margins. That was a hard week. Two of my dates left me snoring into my dinner napkin. Caroline drove my car home. I offered my bed and for me to crash on the couch, but she cited my previously stated wishes to have her properly meet Kayden before any sleeping over. She Uber’ed home. Kayden heard the whole thing and the next day asked if I needed the birds and the bees talk. How embarrassing.

These were the mains. There were others that caused only comical shifts in my mental state. There was one “kid” with an intense fear of butterflies (his family had a lot of money and needed a break). Delusions of government spy drones, various manifestations of OCD, and hearing the voice of Pee-wee Herman’s ghost.

All manageable. I was handling it.

Secure Attachment

Or so I thought. I got to work early one morning and decided to check on Annabelle Brown, see if she’d shown up at any other psychiatrist’s office, if her framing shift had been only temporary. But I couldn’t find anything. At all.

An impossible explanation immediately came to me. I went and waited in the breakroom until Evelyn showed up. As soon as she entered, I locked the door.

“I’m going to have to start charging you, you know,” Evelyn said.

I got right to it. “Did you delete a patient’s chart?”

Evelyn saw that I was serious. We both sat. She looked as tired as I felt.

“You deleted my documentation on Annabelle Brown,” I said. “I’m not asking you ‘if.’ I’m asking you why.”

Evelyn told it to me straight. It’s what I’d loved and hated about her as a therapist. “Annabelle wasn’t real. She was a hallucination. You’re surprised by this?”

“For her, yes. Are you sure? Of course you are.” Shit. I thought I was only on the edge of my disorder, adopting just enough of my patients’ issues to facilitate healing. But this? A whole patient, conjured up? That meant auditory and visual hallucinations with widespread altered beliefs. How deep was my psychosis if I hadn’t even suspected?

“You’ve been doing well,” Evelyn said. “The patients love you. The staff respects you. You just need to stay grounded.”

“Thank God for you,” I said.

“I’m your colleague. Hell, damn near employee. I can’t be your therapist.”

“I’m not asking for that. Just a little grounding.”

“Have you been taking your medications?”

I nodded. Evelyn smelled the lie.

“We’ll set up a weekly check-in. Let’s call it ‘Therapy Supervision’—something Dr. Lynch can bill for. It’s just a check-in. Nothing more.”

Paranoid Personality Disorder

While I was worried about my downfall coming from within, I’d silently gained an outward enemy. Dr. Julius Turner wanted my job, and he was secretly finding ways to get it. He only needed to convince one person.

I don’t know what the conversations were like, only the aftermath. Afterwards, Dr. Lynch wouldn’t talk to me about it. No one would. I didn’t learn the full extent of my spiral until years later, after I’d lost everything, including my autonomy.

But I’m a schizophrenic empath (I’m working on that one, fully aware that using the disease as an adjective is problematic). This is how I imagined the conversation went:

Dr. Turner: I’ve found some irregularities in Dr. Holloway’s documentation.

Dr. Lynch: You’re swinging for the fences, I see.

Dr. Turner: A courtesy check. I know you were pressured to hire him. He popped out of nowhere.

Dr. Lynch: And has considerably decreased our average length of stay which puts us in great position to negotiate better rates with insurance.

Dr. Turner: Reimbursement rates aren’t everything.

Dr. Lynch: Our patient satisfaction has also shot through the roof.

Dr. Turner: I’ve gotten a few Google Reviews, too.

Dr. Lynch: Really? Show me one.

Dr. Turner: I have a patient soon and want to make this quick.

Dr. Lynch: Of course.

Dr. Turner, handing over his preloaded tablet: You’ll want to take a look at this. That’s Jason’s—

Dr. Lynch: “Dr. Holloway’s.”

Dr. Turner:  . . . his last several notes on a patient named Annabelle Brown. Even got a lengthy discharge summary. It’s particularly detailed about the patient’s sex addiction.

Dr. Lynch: I never took you for a prude.

Dr. Turner: That’s not what I mean. Here’s last month’s census. Notice anything?

Dr. Lynch: No Annabelle Brown.

Dr. Turner: Nope. What’s more, he deleted the entire chart yesterday.

Dr. Lynch: You got an alert on his EMR activity or something? Fuck. You’re thinking insurance fraud?

Dr. Turner: If only.

Borderline Personality with Recurrent Suicidal Ideations

Patients came and went. Except Marcus. Every time I thought he might be ready for discharge, he proved me wrong.

Dr. Holloway: It can be scary when things are going well. It can make us feel like we’re losing control. Being in here is safer.

Marcus: . . .

Dr. Holloway: Is that why you cut yourself? To take back control?

Marcus: . . .

Dr. Holloway: Your insurance will only cover two more days here. Leadership wants to send you back to the hospital. I want to send you home. You have to give me reasons. You have to tell me you didn’t try to kill yourself in your room last night.

Marcus: I didn’t try to kill myself in my room last night. We done?

Dr. Holloway: Marcus—

Marcus: There’s not a goddamn thing I’m in control of.

Dr. Holloway: You have control over what decisions you make. How you honor your wife’s memory.

Marcus: When I die who will you feed this bullshit to? None of it matters. Are we done or are you sending me back to that hellhole?

Dissociative Identity Disorder

By now, Caroline must have thought I had multiple personalities, she’d seen so many phases of me. But she stuck around. And seemed to like who I was.

Things were going well. And that was scary. I knew my defenses were set to self-sabotage.

But I did it anyway. I picked a fight, right at the start of dinner. A petty one. One of those hypothetical questions that didn’t have a right answer. She tried to de-escalate but I dug in. I blew up. And in the end I told her I wasn’t ready for a relationship and that she should run. She did.

A woman slid into the empty chair opposite me. I was about to tell her I had syphilis when I saw it was my former therapist.

“Since I’m not officially your therapist anymore,” Evelyn said. “I can ask this plainly: What the fuck was that?”

“It wasn’t going to work out anyway,” I said.

“Of course not, with that attitude.” Evelyn frowned and glanced beside her. “What?”

I had been looking off to the side. Another person had joined our table. Annabelle. Annabelle Brown. The fake Annabelle Brown. She was cutting into a ribeye, a judgmental smirk on her face.

“She’s right, you know,” Annabelle said. She took a bite of the ribeye. Blood dripped down her chin. What a detail. Auditory, visual, and was that . . . gustatory?

“When’s the last time you saw your doctor?” Evelyn said.

Good question. “I’m my own doctor,” I said. “You know that.”

“Maybe it’s time for that to change?”

Annabelle popped another bloody forkful in her mouth and nodded emphatically.

Factitious Disorder

I found a provider at Second Changes Psychiatry, a small office in the South Bay, removed from the insular community of Beverly Hills and downtown Los Angeles. The setting was posh, intimate, and quiet.

Dr. Sabrina Lopez was kind and inquisitive. Fuck it: I told her my diagnosis of empathetic schizophrenia. She thought this was bullshit, of course, but was nice about it. When she started talking about alternatives to medications, I turned up the heat.

“I’m a third-grade teacher,” I said, knowing my profession’s weak spot. “This helps me connect with my students.”

Hearing this, Dr. Lopez got real serious, real quick, and wrote a prescription. “Something strong, to stabilize things.”

Now to find a therapist. Maybe I’d tell her the whole story. Probably not.

Avoidant Attachment

As a psychiatrist (and a damn good one seventy-three percent of the time) I knew that any change in my medication would take weeks to work. Still, I was horrified to see Annabelle Brown sitting in the next day’s group. Kendall Lee, a twenty-year-old who’d just spent three months in UCLA’s inpatient eating disorder unit, didn’t seem to notice.

Marcus: I’m going home tomorrow. It’s time to move on. And live. Like she would want me to, you know? This life—including her—was good to me.

Kendall: I know I just met you but I can tell you have a great spirit.

Annabelle: You said it in the past tense. “Was” good to me.

I looked at Marcus, searching for some reaction. His head was low. Of course he didn’t react. Annabelle wasn’t real, for fuck’s sake. And all those times I’d thought Marcus and Annabelle were in sync—Marcus nodding to Annabelle’s insights—was just me, making things up, applying psychotic significance to insignificant things.

Kendall: I can’t imagine going home yet. All my classmates know I’m here, that I can’t figure this shit out. It’s so embarrassing.

Marcus: It’ll get better.

Annabelle: You’re just going to let that slide, Dr. H?

Dr. Holloway: Marcus . . .

Annabelle: He spoke about “life” in the past tense. You heard it.

Dr. Holloway: You’ll do great.

Annabelle: Did you hear me? Dr. Holloway. Ask him what he meant.

Marcus: Thank you, Dr. Holloway. You’ve been amazing.

Annabelle: Dr. Holloway!

Session over. We discharged Marcus that evening.

Event Note

Marcus Walters was a thirty-five-year-old man with no significant past psychiatric or medical history who presented to Margins Treatment Center after a two-week hospitalization due to a serious suicide attempt by hanging.

Shortly after discharge, Mr. Walters died from jumping in front of a moving train. His note said, simply, “Our life was full and good. I couldn’t live without you, Evelyn.”

-Dr. Turner

The driest, saddest thing I ever fucking read.

Aftermath

Dr. Lynch gave me a week off after Marcus’s suicide. I expected to be fired. Wanted to be. I used my vacation to make it a whole month. I took my medications and I saw my new doctor. Annabelle faded away.

The pain remained. But work had to be done.

Narcissistic Personality Disorder

This was a snag, you see. Dr. Lynch was doing well. Margins was doing well. Even I was doing well to anyone not looking hard enough. I imagine Dr. Turner thought the stage was set to throw me under all the busses. I could just see him walking into our boss’s office, face scrunched like he’d just discovered a new level of sour, believing he had me dead to rights.

Dr. Turner: You’ve read the report?

Dr. Lynch: I have.

Dr. Turner: Patient Marcus Walters showed up on March fourteenth and from then on Jason—Dr. Holloway—began referencing a therapist in his notes, Evelyn Walters, LCSW. The patient’s dead wife. According to records, Evelyn and Dr. Holloway lived in Atlanta at the same time five years ago. He thinks his former therapist—dead therapist—now works here with him. He’s unwell.

Dr. Lynch: The report you supplied was very thorough and convincing. I will take care of this.

Dr. Turner: That’s a relief. I read your book, by the way. Very chic.

Family and Medical Leave (FMLA)

The director called me to her office my first day back, a month after Marcus’s suicide.

She gave me the news and sent me on my way.

Psychotic Disorder – Not Otherwise Specified

Evelyn Walters, LCSW waited for me in the hall. We went to lunch. I drove; Evelyn’s car was in the shop.

“Your husband drove you to work,” I said. “That’s cute.”

“So, you going to tell me what happened or . . .?” Evelyn said.

“I was sure she was going to fire me,” I said.

“Well? Did she?”

“No. She fired Dr. Turner. Cited lack of professionalism and team coherence. You think they were screwing?”

“Hell to the hell no,” Evelyn said. Then she thought about it. “God, I hope not.”

“I’ll take his caseload,” I said.

“That’s a lot, you know,” Evelyn said. She upturned her cup of coffee. “Can you handle that?”

“Now I can. I have a date tonight.”

“New swipe?” Evelyn said.

“Old swipe. Caroline. The one I blew up on. I think we can patch things up.”

“Well, look at you,” Evelyn said. “Being stable and shit.”

“Thanks to you.”

Alcohol Use Disorder – Early Relapse

Director Kirsten Lynch, MD and CEO of Margins Treatment Center, NYT Bestselling author of Life on the Margins, budding socialite and dedicated dog Mom, didn’t drink much on the job. It wasn’t professional. But they didn’t teach any of this shit in business school, so fuck professionalism, right?

She made sure her office door was locked and took another swig. She’d just fired Dr. Turner. He’d make a fuss—his type always did—but the lawyers could figure all that out. She was well aware of the rumors about them fucking but he’d made a move on her all those years ago at the Christmas Party. If he wanted to go down that route he’d lose more than his job.

It was Dr. Jason Holloway that made her nervous. If what Dr. Turner claimed was true—and really Kirsten had no reason to discount any of it, even if she wanted to—Dr. Holloway had fully hallucinated a Margins therapist with the same name as a patient’s dead spouse. And had Kirsten heard him talking to someone in the hall as he’d left their meeting? The empty hall?

But whatever Dr. Holloway was, whatever he was going through, it was good for business. Kirsten finished the bottle, turned on her computer, and began to clean up Dr. Holloway’s notes.