I am a psychiatrist, and by the very nature of
my work I am given permission to peek into
the dark holes and crevasses of my patients’
lives. I am a fifty-three-year-old man, and I
have been doing this for a long time—decades, in fact—and on the day I introduced myself to my new patient, Lionel Blake, I remember thinking that there were few things in the course of human existence that surprised me any more.
~ ~ ~
Lionel Blake was sitting on the edge of his bed in his room on our psychiatry unit when I entered through the open doorway. He had been admitted to the hospital the night before, first appearing in the Emergency Room where he was seen by the ER doctor on call, and then directed into psychiatry for an evaluation of what was diagnosed as psychosis. The Emergency Room in the city hospital where I worked was almost always very busy at night, and the doctors and social workers usually didn’t have much time to obtain lengthy histories from the patients that they saw.
Tattoos ran up and down Lionel Blake’s arms, the green and red colors mixing in with his dishwater skin, and on his face his mustache curved down over his lower lip, partly covering the gaps in his teeth. As I leaned forward to grip his extended right hand, his odor spread out around me like a musty blanket—worn and ragged and damp from the rain, the smell rising up and encircling me like two unwashed hands. As he took my hand, I could see on the inside of his right arm the skull and crossbones from an old, fading tattoo.
“Good morning, Mr. Blake,” I said. “I’m Doctor Leonard. Doctor Patrick Leonard. It’s nice to meet you.”
His grip was unexpectedly strong, closing down over my hand and pumping one, two, three times. I looked down at his hand, and I saw that he had only three fingers and a thumb. His index finger was gone.
Lionel Blake’s grin grew wider.
“Do you really think it’s nice to meet me?” he asked. “Do you really? I don’t think you do. I think you’d rather be somewhere else right now.”
He tilted his head back and laughed, and I could see his Adam’s apple slide up and down beneath the taut skin of his neck. The skin wrinkled, pressing up around the tattoos of daggers on each side of his neck, until their blades disappeared and all that I could see were the black outlines of their handles.
“I’m here, Mr. Blake,” I said. “I am here to try and help you.”
I paused for a second, as Lionel Blake’s laughter slowed. It slowed and slowed, and then it stopped.
“I don’t want your fucking help!” he said. “Leave me alone. Get the fuck away from me.”
Lionel Blake looked around the room, his head moving back and forth. The muscles in his neck tensed, and he stared at me. Then he did something I didn’t expect. He reached down and pulled off the loafer from his left foot and straightened up with it in his hand. He passed the shoe back and forth in his hands, catching it and tossing it. The shoe made a dull, hollow sound each time it hit the palm of his hand.
I have seen many strange things over the course of my work in an inpatient psychiatry unit. I have seen a man drop a lit cigarette into his boot, the sparks and flames shooting up over the sides of the leather. I have witnessed an older woman, convinced that the daughter who had brought her into the hospital was not really her daughter, try to strangle the younger woman with her shoestring. I have seen odd and terrible things.
But I have never had a patient take his shoe off and toss it back and forth in his hands like this, while glaring at me. There was something in his look, in his eyes, as the sound of the shoe hitting his palm rose up through the room. His eyes flashed silver, like the sun hitting the shiny metal of the barrel of a gun.
My work is focused on helping my patients through crises in their lives, crises that lead to their being hospitalized for their own safety—and, sometimes, for the safety of those around them, their friends and relatives. I like this kind of work very much. It is very different from doing longer-term therapy, working with patients over stretches of months and years. My practice involves a much shorter time frame, usually a period of days, rarely more than a week, in which I try to help people regain their control to the point where they can go back out and function in a world which had become too much for them only recently.
I looked back at Lionel as he passed his shoe back and forth in his hands. Lionel continued to stare directly into my eyes. He was a tall man, much taller than me, and he looked down on me as his shoe passed from one palm to the other. I felt a twinge of anxiety run through my abdomen, and up into my throat. There was something frightening about this man, something more ominous than most of the patients that I encountered. His arms bulged out against his torn T-shirt, the biceps popping out of the short sleeves. His eyes narrowed as he looked at me, until they became two thin slits in his face, and his lips curled up in a scowl. I had always prided myself in my ability to calm my patients, to allow them to feel safe, but with this man I suddenly wasn’t so sure.
“I told you to leave me alone, motherfucker. I told you!” Lionel shouted. “You didn’t listen. Just like every other bitch, you didn’t listen to me.”
The hospital room was spare, empty of everything but the essentials. No TV. No window. Only a bed, a chair, and a sink over against the wall. And Lionel, standing between me and the door, passing his left shoe back and forth between his hands. I tried the only thing that I could think of to do. I tried to apologize.
I have found that my patients appreciate it when I acknowledge that I am wrong. Perhaps more important, I am letting them know that I can see things from their point of view. It doesn’t matter how distorted their vision may be, how confused—or even psychotic—they are. They believe that they have a point. And this is where, I think, the power of me saying I’m wrong comes from. Many of these people have been told that they are “crazy” for years and years, that their view of life has no meaning.
So when a doctor apologizes, when a person in authority tells a patient that he is wrong and, more important, that they are right, it can immediately remove the tension and anxiety from a situation. I have seen angry patients—men and women who were screaming and threatening towards everyone in a room—become calm and relaxed after hearing me tell them that I was wrong. But the apology had to be genuine. It had to reflect my sincere belief that I was wrong in my actions, that I could have done something, or said something, in a way which showed I understood my patient’s position. If there was any dishonesty, any hint that I was being patronizing towards the patient, they would know immediately.
“Sir, I am really sorry if I offended you,” I began. “I didn’t mean—”
These were the last words that I could get out of my mouth. Lionel’s hand flashed across his chest and up toward my eyes, and then I felt—no, heard—a dull sound like an object hitting the hard shell of a melon, and pain spread out through my face and down into my neck. A dark gray color covered everything, and the world in front of me slipped out of focus as I felt myself tipping, tipping, falling over and down and down.
I awoke to a screeching, tearing noise. Slowly, it came into focus. It was the PA system for the hospital.
“Code red. Code red, one east, room one-twelve. Security, please respond. Security, please respond.”
I could hear the words floating out above me, like birds. But I couldn’t see anything at all. Only the dark gray color over everything, as if a burlap bag had been pulled tight over my head. I reached out with my right arm, then my left, grasping at the air. In front of me, maybe above me, I could hear someone laughing.
“Why don’t you try to help me now, you cockroach. Come on, help me out now!”
I felt a sharp pain explode in my right side, spreading out through my ribs, and I couldn’t breathe. I flailed at the air with my arms, harder and harder, and I tried to pull in air through my pursed lips. Another pain hit me, now in my left side, and I heard a crunching, tearing sound. Then Lionel spoke again.
“Don’t touch me. Don’t you dare touch me.”
I managed to open my eyes, and up above me—what seemed like a long way above me—two men in blue uniforms grappled with Lionel. One grabbed each of his arms and pulled him, kicking and screaming, backwards out of the room. His legs splayed out, and he kicked at the men dragging him out of the room with his feet, until his other shoe flew off of his right foot and crashed into the wall. I closed my eyes, and the noise and sounds faded again.
~ ~ ~
When I came to, the ER physician told me that three ribs were fractured on my left side, and two on the right. Amazingly, no damage was done to my lungs, and I didn’t need to be hospitalized.
“You are lucky,” he told me. “Really lucky.”
I didn’t feel very lucky. Why had Lionel attacked me? The simple answer, that he was paranoid and felt threatened, was too easy. I had worked with many paranoid patients over the years, probably hundreds, and I had never been attacked by one of them. I had always been able to calm people, to set them at ease. What had happened this time?
The question kept pressing up into my thoughts. I had a talent—an almost unerring sense of knowing what people wanted to hear. And I used it, in my interactions with my patients, to set them at ease. To let them know that I understood what they were experiencing. In the world of psychiatry, we call this empathy. It was not something that could be taught, at least not completely, but with Lionel it had failed me. Why? I didn’t understand it, not at all. And my lack of understanding was more painful to me than the sharp pains that kept pressing up from the fractured ribs on each side of my chest.
I went back to see Lionel the next day. This was not something a psychiatrist would normally do after being attacked by a patient. In fact, Lionel Blake would be charged with assault for what he had done. I was told that a police report had already been made out. But I had to see this patient—not for his sake but for mine. I had to know what I had done wrong. It wasn’t a matter of trying to help, or to understand—not at all. I needed to know where my instincts had failed me.
My instincts. That was it, really. I had functioned through most of my career on instinct, anticipating what my patients would say or do, putting myself in their position, understanding their pain and anger and even rage. These were not things that I had been taught, that I had learned. They were my way of entering into the human drama of the people that I tried to help.
Lionel was closed away in a small, drab, windowless green room on our unit, lying back on his hospital bed with his arms and legs restrained by leather straps. The attendant unlocked the door and let me into the room.
“Be careful,” he cautioned. “He spits.”
I nodded. Lionel was lying on the bed with his eyes closed, and I wasn’t sure if he was asleep. I cleared my throat.
“Good morning, sir,” I said.
Nothing. I bent forward and gently shook his leg back and forth. Still nothing. I shook his leg again. Lionel groaned, and his eyes opened partially.
Lionel had been given a combination of medications earlier that day, Haldol and Ativan—two mainstays of our defense against agitated, angry, combative patients. The Haldol was an older anti-psychotic medicine—a medicine we used to treat a patient’s break with reality. It had been around for decades, and it could be given through an intravenous line, or even through a needle directly into a patient’s muscle, if they refused to take it in a pill form. The Ativan was a strong sedative, which we used mainly to slow people down, to calm and sedate them, and it could be given in the same forms as the Haldol. Lionel had been restrained and given both of these medications through a needle into his arm.
I looked over Lionel’s chart. He had received both medications, in pretty high doses, in shots through a syringe and needle into the muscles of his upper arm. Doctors had tried to start an intravenous line, but each time it was put into the veins of his forearm, Lionel had thrashed back and forth until he ripped it out, and blood spurted bright red over the white sheets that covered the mattress on which he lay. This happened once, twice, three times through the night in his small, enclosed room, until finally they gave up and decided to give him the intramuscular injections.
The nursing notes showed he had been calling out and screaming--howling, according to one note—and trying to pull loose from his restraints. At one point he had actually pulled one arm free and scratched at his face with his fingernails, until blood had sprung forth from a spot beneath his right eye, dripping down over his face.
My thoughts were interrupted by Lionel, who came suddenly awake below me on his mattress on the floor of the small room. His eyes flipped open, and he sat straight up in bed, his arms and legs straining against the restraints. He looked at me and nodded his head slowly up and down. When he spoke, his words were surprisingly calm and measured.
“I thought you would be back,” he said. “I’ve been waiting for you.”
I didn’t know what to say. Lionel’s paranoia hadn’t surprised me—it was something that I dealt with almost every day in the course of my work. Many of my patients struggled with distortions in their interpretations of the things happening around them, twists and bends like a Picasso painting in which the parts of their reality is pulled apart and then put back together in jarring, frightening ways. And I could usually deal with it by acknowledging their pain and fears, by letting them know that I was trying to understand how they had arrived in front of me.
With Lionel Blake it was different. He had pushed aside all of my efforts to understand him, to listen to what he said, to offer him help. I had encountered many patients over the years with whom I didn’t immediately establish a connection. People with whom I had to work, over minutes and hours and days, to win their confidence. But nothing like Lionel. He had hit me in the head with his shoe, for God’s sake, when I tried to meet him at his level.
I smiled and looked at Lionel. I don’t know why I smiled. Not exactly. Maybe it was the absurdity of the situation. My head ached where I had been hit with the shoe, and every time I took a breath the pain ran up and down both sides of my chest like needles pressing into the skin. The seconds went by, stretching on, as we looked at each other. I tried to look away, but there was something in his eyes that held me, and I couldn’t. And as I looked at him, I felt as if I were falling down into his eyes, tumbling into some vast, wide, gray field of smoke and fog like a teenage boy standing in front of a fire and getting drunk for the first time.
It was then that it hit me again, almost as hard as Lionel Blake had hit me in the head with his shoe. How had my training and instincts gone so wrong with this patient?
He repeated himself.
“I’ve been waiting for you.”
“Why did you assault me?” I finally asked. And then it all came spilling out. “Why did you kick me? You broke my ribs. You asshole, you almost killed me!”
I stopped suddenly and covered my mouth with my hand. It was a reflexive movement. I couldn’t believe it. I had called a patient an asshole. Never in my career had I called a patient a foul, derogatory name.
Now Lionel was the one smiling, grinning at me. He began to laugh out loud.
“That’s right, doctor. That’s exactly what I am. And you, you are talking to me like a real sonofabitch, instead of telling me you’re ‘glad to see me’ when you’re not.”
Lionel turned his head to the side and spit out onto the floor. Then he looked back at me.
“You are the only damn doctor who has ever spoken to me like a real person. What do they teach you fuckers in medical school, anyway? Don’t they teach you to be honest with your patients? Don’t they teach you to tell us the truth? Don’t they?”
A warm sensation started in my chest, growing warmer and warmer until it was almost hot, wrapping around me and spreading up through my neck and over my face like the heat from a fire. Lionel’s questions echoed through the room, from one wall to the other, and then up into my thoughts. What had I been taught in my training? Really, what had I learned?
~ ~ ~
I had learned to accept all of the vagaries of human existence. Nothing I heard was alien to me. Nothing at all. But my response, my reaction to all that I took in, could be false. Like some reveler at a masked ball, I dodged in and out between my patients and their families, never lifting my mask to reveal my true thoughts and feelings.
~ ~ ~
It wasn’t until several weeks later that I realized how much Lionel had helped me to see myself in the course of my work. I was making rounds one morning, seeing patients who had been admitted to our unit the previous night, and I picked up the chart outside of room one-twelve. It described a young woman who had come in to the Emergency Room the night before, after taking an overdose of Tylenol in a suicide attempt. It didn’t tell me much, only that the woman was in her thirties and had struggled with depression most of her adult life.
I walked through the door to the room. It was dark inside, with the light turned off and no window to the outside world. At first I couldn’t see anyone in the darkened space, only shadows from the lights out in the hallway glancing off of the bed and furniture. And then a figure in the corner of the room, crouching down by the wall, came slowly into view.
I squinted and tried to see the figure more clearly. I didn’t want to turn the lights on right away, as the lighting on the psychiatry unit was bright and harsh, and it could be disturbing to patients who were already anxious and frightened when they were admitted to our unit. The outlines of the woman came into view, emerging until I could see her more and more clearly. She was a large woman, very large, and her bulk filled the corner of the room, spreading out over the walls. Her head was bent forward, tucked under a raised arm, and there was a soft shaking sound rising out of her mounds of flesh.
She was crying, and I could see her entire body shaking back and forth in the shadows. I watched her for a little while as I thought about what I would do next. Behind me I heard one of our nurses clear her throat, once, then twice, and then a tugging at my elbow. I turned around to see Michelle, our unit manager, motioning with her hands. I leaned over towards her, and I heard her whisper into my ear.
“Be careful, Doctor. Be careful. She already hit Bridgette right in the face.”
Bridgette was one of our ward nurses here in the city hospital. She had been working on the psychiatry unit for a long time—fifteen years or more. She was one of our most experienced nurses, and I had never heard of her being struck by a patient in all of the time I had worked on this unit. Never.
I nodded and turned back towards the patient crouching in the corner of the room, crying softly. She had raised her head now, and I could just make out her eyes, the light from the hallway reflecting off of them.
The woman’s name was Precious Gibson, and, from across the room, I watched as she stood up to her full height, shaking her head back and forth as she did.
“Turn the damn light on,” she bellowed, and the words rang through the small space.
I reached over to the wall and flipped on the light switch. The fluorescent light flashed through the room, and suddenly I saw the full figure of the patient standing before me in her thin blue hospital gown. Her skin was dark black, almost blue, and folds of fat hung from her arms and abdomen. She raised her right arm to cover her eyes.
“Where am I?” she asked.
Her voice rumbled out into the room, like a growl from a cornered animal. I looked over her, standing in the light. She must have weighed 400 pounds or more, and the weight of her breasts pulled her forward and down towards the floor, leaning over until it was hard for her to stand upright.
“You are in the hospital,” I replied. “You are on our psychiatry unit.”
She nodded her massive head up and down, and then she spoke.
“The psychiatry unit?” She repeated the question. “The psychiatry unit?”
Now her head shook back and forth, from side to side. She smiled, and her lips curled up so that I could see the yellow color of her teeth. She started to laugh, first a snorting sound, a giggle, and then the sound built on itself, louder and louder. It was an infectious sound, like the wind spreading out into the environment, touching on the corners of the room in which we stood as it became louder and louder. It reached up into my thoughts, and before I knew it I was smiling as I listened to her laughter.
Then it stopped, and a scowl suddenly fell over her face. As quickly as the laughter had come, it was gone.
“Why am I here?” she asked. “What am I doing here?”
I looked down at her chart. It said that she had been found walking naked out into traffic on a busy street near the hospital. It said that she had been stepping in front of cars, causing them to swerve away from her, to slam on their brakes to avoid hitting her in the dark, pouring rain. Someone called 911, and the police came and brought her into the hospital’s Emergency Room, where she lay on a gurney and screamed in a loud voice about someone named Bobby.
I looked up from the chart. In front of me now, the woman began to walk towards me from across the room. As she walked, the frown on her face deepened. I took a step back, involuntarily, and thought about what I had read in the chart.
“It says here, Ms. Gibson, that—”
And then I stopped. The words in the chart reflected what had happened, the events that led to Precious Gibson being hauled in to our Emergency Room. But they did not explain what led to her standing naked out in traffic howling at the rain and darkness. The words may have been what had happened, but they did not tell me why it had happened.
In front of me, Precious Gibson came to a halt, like a car lurching forward as the brakes are slammed. As I watched her, her bulk slowly transformed, shifting and mixing like some giant creature rising up out of my subconscious until in my mind I saw the image of Lionel Blake standing before me, and I heard again his questions: What do they teach you in medical school? Don’t they teach you to be honest with your patients?
I did not really need to ask Precious Gibson how she ended up naked in the street. That was not the key to her distress, to her pain. It would not lead me to help her up out of her agony. And so I asked her the question that I really wanted answered—the question I knew she needed to answer.
“Who is Bobby?”
Precious Gibson paused and stared at me. It was a long pause. Then her face came alive, the flesh twitching and jumping again, until she was smiling at me and reaching out towards me with her hands moving back and forth, as if she were trying to wade through deep water.
“Bobby. Yes, Bobby. Is he all right? Please tell me he’s all right. I love my Bobby.”
I took hold of each of her hands with mine, steadying them until they slowed down and stopped moving. She looked up at me and squeezed down on my hands. I could feel the perspiration on her palms, wet and cold.
“Do you know where Bobby is?” she asked. “I have to find him. Please. Please help me to find him.”
Her voice was high-pitched, almost squeaky, and in her eyes I could see the bright shining flash of fear rise up into the room. She began to tremble, her hands shaking at first with fine tremors, then increasing in intensity, until they were jerking up and down like the wings of a bird, pulling my hands along with them.
“Who is Bobby?” I asked. “Can you tell me who he is?”
I looked over at Michelle. She had a puzzled expression on her face. “I don’t know who he is, doctor. This is the first that I’ve heard of him.”
Precious Gibson jerked her hands free from mine, sliding them out of my grasp. “No, no,” she shouted. “Not him. Not him. Her.”
She had turned towards the small bed in her room and was rummaging through the blankets that covered it, tossing them aside. She reached down and grabbed hold of something, and spun back towards me with a photograph clutched in her right hand. She pushed it towards me, up towards my face.
“Look. Look. Bobby,” she shouted again.
I took the photograph from her hand and looked down at the image. The photo was crumpled, with a crease running down the center where it had been folded in half. But I could make out the faded picture—it was that of a baby, holding onto a rattle colored red, white, and blue.
“Is this Bobby? Is this who you mean?” I asked.
Suddenly her eyes focused in on me, and when she spoke her words were sharp and crisp.
“Yes, yes, this is Roberta. I call her Bobby. Everyone calls her Bobby. She’s my baby. Oh my God, my baby.”
Her hand rose to her mouth, covering it as if she could hold in her pain, as if she could catch it in her palm and fingers. Then she shook her head back and forth, from side to side. She was crying again.
“Bobby is only a year and a half old. A year and a half, and I don’t know where she is. I don’t know what happened to her.” She slammed her fists down against her thighs, over and over as she spoke.
“I just don’t remember.”
~ ~ ~
It took our social worker most of the day to track down Precious Gibson’s home address. She lived in the south end of the city, in an apartment building in a very poor part of town. When the police finally found her landlord and got into her apartment, they found baby Roberta sitting in a high chair at the kitchen table.
She was strapped into the chair, and dried baby food covered her tray, crusting over the edges and falling out onto the floor. She was pounding her fists on the tray and crying out. The apartment was empty. No one knew the baby was sitting alone, in the kitchen. No one heard her crying.
It was hard to tell how long baby Bobby had been alone in the apartment, sitting trapped in her high chair. Maybe hours. Maybe days. No one knew. I was able to convince the police to bring the infant into the hospital, to show her to Precious Gibson before we turned the baby over to Child Protective Services.
When the social worker brought the baby into the room, Precious didn’t look up at first. She was sitting on the floor, on the mattress in the middle of the room, staring down at her feet. Her head hung down, and I could hear her crying, the sound rising up towards me in a rhythm tied to her breathing. When she inhaled, the sound softened, and then when she expelled the air from her lungs it came out like the squeaking noise of worn car brakes sliding down a steep hill. I cleared my throat.
“Precious, there’s someone here to see you,” I said.
“Leave me alone!” she barked. “I don’t want to see no one.”
“Oh, I think you do,” I said. “I think this is someone that you do want to see.”
It was then that baby Bobby squealed and kicked her legs out, almost falling from the arms of the social worker who carried her into the room. The baby smiled, and then she began to laugh.
Precious looked up, her head snapping as she looked over at her baby. Her mouth dropped open, and she leapt from the mattress on the floor to her feet—all in one motion. Her arms spread out, one on each side, like great wings, and then a smile appeared on her face, the skin stretching tight across her lips.
“Oh my God!” she screamed. “Oh my God”
Precious Gibson ran across the floor towards her baby. Before anyone could move, she had scooped Baby Bobby out of the social worker’s arms. She turned towards me, standing at the door to her room, and lifted the child up high above her head. The baby wriggled back and forth in her arms and reached with her own arms towards the ceiling while she giggled.
“Thank you, Doctor. Thank you,” Precious stammered. She lowered the baby into her arms and pulled her in close to her face to kiss her on the top of the head. Then she looked directly at me.
“Thanks for listening to me.”