Cottonwood

The first change I noticed was the direction--I was driving away from downtown and my usual route to the hospital. Into the foothills of the west, on a road called Sweetwater, I drove. Wishing I was biking instead of driving to the Cottonwood clinic, I was otherwise stress-free this morning. I listened to NPR on the radio recapping last night's Oscar Awards ceremony. After an eight mile drive on a route Anna and I frequently road bike, I saw a sign indicating Cottonwood's entrance. I turned right and after a few small curves and turns I arrived at a gate with a keypad and speaker. I pushed the "push to talk" button and waited a couple seconds before a pleasant-sounding lady asked my business. I told her my business, a medical student on a rotation assigned to follow Dr. Onate. She opened the gate, instructing me to park and walk into the first building on the left.

I parked, gathered my pencils and notebook, clipped my ID onto my shirt, checked for outstanding nose hairs in the rear-view mirror and got out of the car. It was a breezy morning and every tree in the clinic was dancing. I love that. I walked into the first building on the left and announced who I was. I was given another ID by the receptionist and also told where to find Dr. Onate's office.

"Follow the path past the Lodge, the tennis courts, the pool on the right, and the garden. Onate's clinic is the last long building on the far end of the campus."

"Great," I said.

I walked outside and headed east down the path. The grounds are well-kept at Cottonwood. The walkways are straight-edged and cut through gravel landscape. Every five feet is a tree of some variety. After fifty feet of walking I passed saguaro, rosewood, texas rangers, pine, queen palms, ocotillo, oak, mesquite, and mountain laurels--which happened to be in bloom with their intoxicating grape-smelling flowers. It was the kind of landscape you find at a Sedona or Scottsdale resort.

The campus buildings are constructed of rough-hewn stone, the color of sand. The windows, doors and rooftops are a light blue. The buildings blend with the background mountains and sky. Walking east I passed various staff, starting their day. There was no rush in their walk, at least not the rush you see in the hospital halls of University Medical Center.

I passed the Lodge, tennis courts, pool, and gardens and found the last building on the lot. I walked into the middle door into the reception area. Inside I saw three teenagers sitting--or rather laying sideways across plush armchairs--reading magazines and chatting.

I walked up to the reception desk and introduced myself. The receptionist was the first person I saw on campus who looked really busy. Normal busy for a Monday she told me. She said Dr. Onate was waiting for a medical student and that I must be the one. I was. She led me to his office. Inside Onate was sitting, chatting with a fellow psychiatrist. He smiled and extended his hand, which I shook.

Onate was wearing a dark, Quick-silver button down, untucked, with dark corduroys and black shoes. His skin was bronze and he had a badger-streaked goatee. He was short and well-built. He did not look like a physician. Then again, most psychiatrists don't look like physicians in my book. But Onate had something western about him. I later found out he grew up in Clifton, Eastern Arizona. That explained his mannerisms and look. You can tell if someone is from the copper country.

Onate, like most psychiatrists, enjoys his work. He walked me around the campus, showing me the various buildings and their purpose. We passed through some in-patient units and he stopped occasionally to speak with counselors or nurses about specific patients. Evidently it was a busy weekend. Patients were sneaking benzodiazepines, "cheeking" pills, pretending to use the bathroom to put on hairspray, staying out late at night at the lodge, and upsetting roommates. Nothing unteenager-like there, I supposed.

After the tour we returned to Onate's office. He gave me a seat and I sat. I looked out his window at the blowing queen palms and pines with the clouds passing quickly by under the blue sky. I mentioned he had a better view than any I had seen during medical school. He agreed his location was prime. I wanted to tell him I'd wager his job was probably better than any I'd seen also, but I held that comment in my head and told it to go away. Maybe at the end of my rotation I'd tell him my thoughts on his job.

He showed me his schedule of the day. We were to see three patients and then he had a meeting after lunch. "I'm usually out of here by two," Onate said. That thought I held in my head about his job being the best in medicine almost slipped down to my tongue and out my mouth, but I again held it back. I'd wait and see patients with him first.

We walked out the office together, down the hall to the reception area. We passed your typical office pictures on the wall: An eagle with the word "Dignity" on the top, mountains with the word "Respect" on top, and two ducks necking with the word "Love" on top (they were doing some sort of hugging with their necks, I never really knew what "necking" referred to so I'll just think that's what it means). Onate called for patient 1 and a skinny, young blond guy popped out of the chair he was lounging in. We three walked back to Onate's office.

After introducing patient 1 to me and asking his permission for me to sit in, we all sat down and began the session. Patient 1 wore a blue hoodie, skinny jeans, and converses. He hair was gelled mildly, teepee style. He had aviator sunglasses hanging from the neck of his hoodie. He sat back in the chair and clasped his hands together.

Onate asked how he was doing.

Every day is a struggle, patient 1 said.

Onate: You have the past, the present and the future.

Patient 1: My life is shit, all I do is remember my past. It haunts me, you know what I mean, and all the debt, and survivor's guilt, and pain. It comes back to haunt me and my head does a three-sixty, you know what I mean? Then I think about the future and what's going to happen and my anxiety goes up and I feel like I'm surrounded. He says this while drawing an imaginary circle around himself. And I'm trying to get out, he says, imitating the breast stroke in the air.

Onate: Well, that's why here we are just trying to get you to focus on the present.

Patient 1's story came together a little for me. He's from New York. At his rocky bottom he was living on the street, trying to find a way to his next Heroin fix. His last one was July 4. Out with a bang, he said, smiling at me. I smiled back and looked down at my shoes. Onate said he looked a lot better this week. He was able to talk more--provide more insight into his "present." He was leaving Sunday and wanted to get things ready before his discharge. I wanted to ask patient 1 his plans once out of here. Would he go back to New York? What would he do after his next relapse? Would he end up on the street again? After this session I didn't feel much hope for patient 1. He seemed fragile and unsure. And he was leaving Sunday. After a discussion about his medications, Onate told him thanks and patient 1 got up and left. Onate charted. I looked out the window in wonder of what it would be like to be a patient here.

We gathered patient 2 from the reception area just like patient 1.

Onate: How are you doing?

Patient 2: I've been having more paranoia and acid flashbacks, I presume. I would say flashbacks because it's quite natural to have, coming off drugs.

Onate: Have you tried Seroquel?

Patient 2: It causes me to go crazy, and I'm not exaggerating, it actually makes me crazy. I don't think I'm psychotic, to be honest, and I think that comes from the Seroquel.

Patient 2 is a skinny 17-year-old who has already suffered a heart attack from cocaine use at 15. He's from London. His chart says he studies Fundamental Art. Reviewing his chart before we met patient 2, Onate asked if I knew what Fundamental Art was. Who knows, I said. I wondered if patient 2 knew.

I learned from patient 2 Cottonwood has a liaison set up in London where it's "well-represented." He was targeting two treatment centers: Cottonwood and one in South Africa. Mode of therapy won him over to Cottonwood. Tell me how this sounds to a struggling kid:

Adapted from the Cottonwood brochure:
Cottonwood's compassionate team created an individual plan in which the patient always comes first...a plan that includes these treatment modalities:
Group Therapy
Individual Therapy
Trauma Therapy
EMDR
12-Step Meetings
Equine Assisted Counseling
Expressive Arts Groups
Yoga
Challenge Course
Rocks and Ropes
Psychoeducational Lectures
recreation Therapy
Tai Chi

Sounds like Sedona or Scottsdale for a couple's weekend get-away. And why not? Wouldn't the patient benefit that much more from equine therapy than a stable couple looking for some fun on their stability like a cherry on top?

Patient 2's issue today, other than paranoia, is depression

Patient 2: I don't know, I might be depressed, actually, when does depression start? I might be but I should just give it time. Can I not have something for emergencies, like a benzo--it calms my body.

Now that's Fundamental Art

Onate: You're in a drug treatment facility.

Patient 2: I'm aware of that, he says without sounding britishly snobby (which I didn't think was possible)

Onate: We try and stay away from addictive drugs. Are you open to something else?

Patient 2: Yeah, it won't help, but I'm open to it.

Onate and him agree to start an anti-depressant, a selective serotonin re uptake inhibitor. These are good drugs. Serotonin helps with sleep and a sense of feeling rested and focused. It helps to recognize thoughts for what they are, rational or irrational. I like the choice for patient 2.

I felt some anxiety when patient 2 was complaining about not getting benzos. I imagine he put down a few ten thousand dollars for his month here. As his physician I would feel tempted to make sure he was pleased with his stay--to ensure a good "customer feedback" form was in order. To make sure patient 2 returned home to London and had nothing but good things to say about Tucson. I told Onate after this visit with 2 my thoughts about treating to please and he said no, it wasn't a challenge. Onate asked if I found 2 depressed. I thought not--too talkative, too forward-looking, too engaging. I knew depression to be a black hole for everyone around and 2 didn't leave me feeling drained as some deep depressive patients have.

Patient 3 was talkative. She had long, blond California hair and she wore tight sweats and a hoodie. She could have come straight out of your typical high school pep rally.

Patient 3: I still feel out of body doctor. I feel like my dreams are very, very...I don't feel like I'm sleeping. I dream I'm on a horse with Hulk Hulgan. What is that? I want to change my dosage from night to morning.

Onate: Okay, we don't like to make many changes to your drug regimen. You're very talkative today so let's slow down. We have time.

After some discussion it was agreed to increase 3's Lamictal from 25mg to 50mg. The max dose is 200.

Patient 3: And can I have my razor back?

Onate: You're switching subjects, again.

Patient 3: It's my birthday coming up on the 10th.

Onate: Oh, that's good, he says, smiling

Patient 3: Maybe I'll get a tofu cake, with some recyclable candles. When she says this she smiles, and I think her side profile looks like Joaquim Phoenix, stoned, in Walk the Line. That lazy smile thing going on where the eyes kind of drift aimlessly.

Cottonwood probably hosts many birthdays. The average length-of-stay is 30 days. Some stay 45. And adolescents stay 90. Patients see a psychiatrist once a week and a personal counselor daily. The days are filled up with therapy from the list above. And the final week is "family week." This is what it sounds like, therapy with the family. Another expensive proposition. But Cottonwood, as I'm learning, spares no expense.

After seeing three patients, it was noon. Onate walked me to the cafeteria and we stood in line for food. The cafeteria looked like it belonged in a nice Marriott. The head chef served us--the menu today was top sirloin or fish stir fry. A hot meal, gourmet, cost five dollars. The salad-bar was 4 dollars. The cafeteria served patient and practitioner alike. The patients never sat at the same tables as the staff. But bread was broken together under the same roof. I liked that. I liked the top sirloin.

I spent lunch sitting at a corner table with 5 physicians. Two windows behind me poured the sunlight onto my table. I struck up a conversation with a physician who came out here to work from New York. He is here to stay. We talked a little about religion. He mentioned how one needs to break his heart to find happiness. I couldn't help but ask if he had read The Book of Mormon. He had not. But we both agreed our path to happiness involves focusing less on self and more on others. Any religion that can do this is a good one. I agreed, to a point only. I hope to talk to him about authority next time we share lunch at the same table. He is a good man. And like most staff at Cottonwood, he smiles a lot.

After lunch I was released. I strolled through the campus thinking how nice it would be to bring Anna on a date here. If every treatment center possessed these resources up in the hills where the dove sings every morning, the world would not be so telestial. But we are by design in a telestial world so the stay for patients at Cottonwood is, appropriately, temporary. Pretty soon every patient has to step back out into the unknown future and start that breaststroke, blindly, through the air, trying to find safety.