Photo by Sally Huang
-A story adapted from a de-identified Electronic Medical Record
‘One half of mankind does not know how the other half lives’
-A Madman from History
Man and Woman
At first there were two young adults – Man and Woman. They met in the middle, crossing paths as it were, going in opposite directions. Man, pure of heart who’d preserved the respect of his peers and superiors, was traveling the Right direction, learning the tips and tricks of a trade that matched and furthered his own sense of self-importance: medicine. Well, psychiatric ‘medicine,’ to be specific. Woman, swarthy of soul and liked by no one outside of her bewildered family, was traveling the Wrong way. Hers was a life steeped in foible and folly, and before she met Man her disrepute was no fault but her own. Or so She was always told. And so She’d always believed.
The man had a Christian name. Similar to Adam, but not Adam. The woman, too, had a Christian name. Like Eve, but not Eve. To us, it suffices to know that when the man met the woman, he was Man and she was Woman and they were traveling in opposite directions. Of course, there was nothing Biblical or preordained about the meeting of Man and Woman. No lush Garden of Eden backdropped their encounter; they were not bare of body or unblemished of soul, and no literal serpent was handy to set Man and Woman on their paths. As I’ve said, very clearly – Man was already on his path, and Woman on hers.
Instead, Man and Women met by chance in room A4 of the Emergency Department. Of course, the only ‘serpents’ adorning a medical setting like this are symbolic, entwined as a double helix about the staff of Caduceus (for the understandably misinformed) or as a single helix about the Rod of Asclepius (for the pompously informed). We all know this Emergency Department and we also know that room A4 is not for the “usual” cases. You don’t put the persistent cough, or the broken bone, or the hemiparetic limb in A4. No, A4 is where the “crazies” go. But we don’t say what we are all thinking – “A4 is the Crazy room. I’m glad I’m not there. I’m glad Woman is there, and not I.” That would be callous and inhumane. How dare we.
We don’t dare; instead we watch as the medical relationship unfolds. Man’s pager vibrates: “A4 – needs psych eval. Cb# 1234.” From his dusty office, Man uses the staff telephone to dial “1-1234,” and so connects with the doctor in the ER.
“Hello, this is Man, from psychiatry.”
“Hey Man, this is Spencer from the ED. I’ve got a patient for you.”
“Shoot,” Man said, his tone somewhere between encouraging and wary.
“Ok, I’ve got Woman in A4. She’s a 27-year-old with no prior psychiatric history as far as I can tell.” Spencer sounded harried, as if he’d rather not deal with Woman. This was because he didn’t want to deal with Woman; Spencer went into Emergency medicine to sacrifice his talents to the sick, not to surrender them to the crazy. “Woman was brought in by EMS from her parents’ home. EMS say that the parents say that Woman has been acting weird, talking out of her head.”
Man is used to this presentation: ‘he says that she says that they say that the patient has been acting abnormally.’ He effects his most officious tone, trying not to be condescending (but probably being just that) – “how is Woman acting in the ED?”
Spencer sighs, and Man can hear it over the speaker. “Raving mad, speaking rapidly about sin, God, and the devil. She started hitting security personnel so we gave her a B-52.” Spencer chuckled derisively. “She’s calm now.”
To this, Man sighed, louder than Spencer had. “Substances?”
“Urine and blood in the lab.”
“I’ll be down shortly.”
“Thanks,” Spencer responded, with an air of utter finality. His hands were washed of the case, having sentenced Woman to the peculiar justice of Man as Pilate had Jesus to the justice of the Crucifix. Spencer didn’t think like this, though. By the time Man had extricated himself from his fleece armchair in the psychiatry office, ambled down the hallway past the neurology ward (where he was decidedly unwelcome), and tread down the stairs to the Emergency Department where Woman was somnolently waiting for justice Woman didn’t know she needed, Spencer was in room C4, heroically resuscitating the bloody victim of a motor vehicle collision. Rooms C1 through C4 were for the real cases, the ones that actually tested the procedural mettle of emergency trainees like Spencer. A4 was reserved for the non-emergent emergencies, the non-infirm infirm, the healthy unhealthy, the mentally ill.
Man didn’t see the difference between the mentally and physically ill. Doctors like Spencer manufactured these categories, he thought, he knew. Doctors like Spencer ascribed to a different truth, that it was the psychiatrist like Man who manufactured the similarities between aberrations mental and aberrations physical so as to legitimize his profession. And Man knew Spencer’s truth, and Spencer knew Man’s truth, but these truths were irreconcilable so Man and Spencer left them unspoken.
So Man went on knowing himself to be Doctor and Spencer went on knowing Man to be “Doctor” and they went about their business with a mutual disrespect that career speciation would only deepen, making their known differences no less irreconcilable. But this story isn’t about Spencer, or his truths. Spencer’s job was done, his hands proverbially washed, ready to be literally dirtied by the blood, bile and phlegm of C4.
Doctor and Patient
As was said, this is a story about a Man and Woman – in the beginning, at least.
For when Man crossed the threshold of A4 and saw Woman, he became Doctor. And when Woman regarded Man crossing the threshold, she became Patient. And so Man and Woman never knew each other to be Woman and Man, only Patient and Doctor. Their relationship unfolded not as relationships do between women and men but rather as relationships do between patients and doctors.
Doctor reveled in this arrangement but Patient did not. She did not see things as the Doctor did; in fact, she saw little as any others did because she was intoxicated on synthetic marijuana, which she’d learned to smoke because her part-time job regularly drug-tested her and Patient knew how to cheat standard urine drug screens. Patient was troubled, not stupid. Nonetheless, as Doctor advanced she didn’t perceive Doctor as “man” but rather as “beast.” His beady eyes glowed with reddish ember and his pointy teeth gnashed with ill-intent, and she knew that this beast was hellbent on devouring her with the same conviction with which Spencer believed Man was a fraud.
Patient screamed, “Devil be gone!” and reached for the nearest weapon – a grenade! She lofted it towards the beast but he barely flinched as it detonated with resonance that shattered the white-washed tiles. Immune to grenades, this beast! Patient was doomed, and she huddled ever closer to the tiles.
Doctor puzzled at Patient when she lamely tossed her balled-up feces in his general direction. “Devil be gone?” he repeated in his mind. Another hyperreligious delusion, he thought with a contrived air of expertise.
“Hi Miss [he spoke her Christian surname here], my name is Doctor [he spoke his Christian surname here].” She cowered further and shuttered her eyes with her soiled hands. “How did you end up in the hospital?”
Start open-ended, then narrow the questioning. Textbook, nicely done, Doctor reflected.
Demon-beast opened his mouth and fire poured out in myriad tongues, flicking out to maim Patient. Patient reached for water but there was none for her to reach. Thinking her life was at its end, Patient steeled herself and faced her demon for a final reckoning. Hell take me, Patient thought. She closed her eyes and opened her arms, welcoming whatever hell hath wrought.
Doctor took a step back, wary of Patient’s posturing. She’d faced him head on, no doubt in an act of aggression. “Hell take me!” she shrieked – a blood-curdling rally cry if there ever was one. Throwing caution to the wind, are we? Alarm bells rang clarion-clear in Doctor’s head. He nodded, slowly retreated back across the threshold where he’d safely disappear behand a phalanx of beefy security guards armed with guns and brawny nurses armed with syringes.
“Go ahead with the B-52,” Doctor dispassionately ordered the nurse-in-charge. She nodded. Doctor disregarded the vindictive glint in her eye because he felt it, too. Patient needs to be “rapidly tranquilised.” It was a term he’d come across in a British textbook, under the chapter for ‘psychotic agitation.’ That’s why they used the ‘s’ instead of the American ‘z.’ And that was also why Doctor didn’t hesitate to put Patient down, for the time being; it isn’t inhumane – even the staid Brits say so!
Patient didn’t burn in the demon-beast’s hellfire. Her eyes closed and arms splayed, she felt the heat retreating and she cautiously opened her eyes to find herself alone once more, with nothing but the whitewashed tiles to keep her company. But Patient’s solitude was short-lived, because the demon-beast’s squadron of hellhounds bounded into the room and pinned her down. Not like this – please – not like this! Patient’s pitiful bleats drowned in the torrent of bestial howls, powerless against might to state her case for dignified death. The demon-beast is preferable to this! She fought. Let him take me. Let me burn… But instead she drowned. Noxious, hellish, toxic teeth punctured her left shoulder and she descended into blackness. Let me burn like the witch I am…
A company of two nurses and three orderlies made eye contact as they struggled to restrain the Patient. Many eyes rolled. One orderly, a religious man on Sundays, even smiled, amused by the futility of this Patient’s protest. “Let him take me! Let me burn!” she yelled as they plucked her from her corner and tied her limb by limb onto the bed board so that the charge nurse and her two underlings could rapidly tranquilise her with three injections – Benadryl 50mg plus Haldol 5mg plus Ativan 2mg – the dreaded B-52. The orderly smiled knowingly – Patient will sleep soon enough. “Let me burn like the witch I am!” she screamed as the final injection was administered into her left shoulder. It wasn’t the witching Patient but rather the pious orderly who cackled as Patient drifted into sopor.
Back in the comfortable embrace of his tattered armchair, Doctor began laying out the case for Patient to be confined in a psychiatric ward.
Firstly, Doctor pored over Patient’s chart. Aside from a few visits to the emergency room for sundry complaints – once Patient thought she’d contracted an STI, and another time she’d suffered whiplash from a garden variety fender-bender – Patient was psychiatrically unmarked. Until now, Doctor grimly thought.
Second was her Diagnosis– her list was bereft of chronicity. Only the acute, and easily remediable, even more easily abbreviated, had been listed and tidily crossed out –
STI, MVC. This Patient had no active diagnoses, her bill of health having been balanced by precise, pathology-based antidotes.
Doctor squinted. Spencer in fact was the doctor who’d cleared Patient’s STI only a year prior. Spencer’s antidote had been a double-therapy – one pill of antibiotic with an injection of a different antibiotic – et voila, the patient’s physical health had been reconstituted. Doctor feared that his stronger triple-therapy (the B-52) marked nothing more than the beginning of Patient’s path to mental reconstitution.
Third, Doctor reviewed Patient’s Labs. Her pregnancy test – negative. Her complete blood count – unremarkable. Complete metabolic panel – unremarkable. Urinalysis – unremarkable. And, finally, her urine toxicology screen – unremarkable. This was starting to resemble a primary psychosis – inexplicable according to Patient’s fluids, nerves, or sinews – but comfortably familiar to the ever-expanding Wörterbuch der Psychiatrie.
Doctor documented diligently – his findings next to Patient’s history – until there was little left to believe except that Patient was afflicted with one of many Primary psychiatric psychoses, unless…He picked up the staff telephone again, this time to call Patient’s mother, listed as her ‘emergency contact.’ Collateral information was a psychiatric essential.
The phone rang twice before Patient’s mother responded.
“Hello?” the voice was weary and emphysemic.
“Er, hi, this is Doctor [Christian surname], from the department of psychiatry. I’m calling on behalf of Patient; are you aware that she is in the ER right now?” For Doctor, this was a more-or-less automated overture, patterned by experience.
“Yes, this is Mrs. [Patient’s Christian surname], I’m aware,” a time-worn weariness now coated her emphysema. She also spoke with a lazy Southern accent, which Doctor almost always mistook for imbecility. “Is she ok?”
It always irked Doctor when they asked this, for the same reasons left unsaid between Doctor and Spencer. Yes, to her question – Patient wasn’t going to die. But from Doctor’s standpoint, No – emphatically no, Patient wasn’t ok, she needed the sort of help only Doctor could provide. Doctor explained, “Patient is safe. Just acting odd,” his favorite euphemism. Careful to put on his best vernacular, Doctor asked, “has she been ‘talkin’ out of her head’ at home?”
As Doctor predicted, that resonated with Patient’s-mother. She launched into a long, circumstantial, and at times annoying monologue about how Patient has been under a lot of stress – what with Patient’s criminal baby-daddy harassing her for custody of Patient’s three-year-old son; what with Patient trying to balance two jobs to support herself and her son; and what with Patient starting night school to get a graduate business degree.
Or was it law school? Doctor only tuned into Patient’s-mother’s ramblings in spurts, feeling inconvenienced by her rambling medical illiteracy and in himself finding little sympathy for Patient’s tribulations. What mattered to him was the here-and-now, or at least the recent-history-and-now, and it seemed from the mother’s report that Patient snapped eight months before, with intermittent episodes whereby she would start talking to herself, neglecting her child, and refraining from night school altogether. No amount of exhortation by Patient’s-mother herself could get Patient to the ER for evaluation. Finally, Patient’s-mother phoned 911 as a last resort and authorities were dispatched to take Patient from her home and into the hospital.
Now, don’t get me wrong – Doctor was neither evil nor exceptional. He’d worked gargantuan hospital shifts that would make Patient’s night school seem like a breezy Kauaian resort. And between Patient’s baby daddy, bastard son, and imbecilic mother, she was tidily completing a checklist of every Southern stereotype Doctor had encountered during said gargantuan shifts. These sordid tales once moved Doctor. Now they bored him.
Doctor cut Patient’s-mother off, doing his best to retain his affected Southern gentility.
“I see, I see, Patient’s been through quite a bit.” He paused, bracing himself for matronly backlash, “I must ask as I do with every patient like Patient – has she been coping with drugs or alcohol?”
“What!?? My [Patient’s Christian forename]? Never. See, her good-for-nothing son-of-a-bitch Father was an alcoholic – he used to beat me, you know – anyhow, Patient would never touch drugs or alcohol of any sort. She’s a good Christian girl, can’t you see that?”
“Of course, of course, had to ask,” Doctor agreed, more so impressed by Patient’s recent fire-and-brimstone-and-wrath histrionics than by Mother extolling her virtues. He chose, wisely, not to share details of Patient’s rapid tranquilisation, instead focusing on his Assessment and Plan. While he’d been formulating these in his mind, Patient’s-mother had begun railing against the abuses of her ex-husband but Doctor wasn’t listening so he interjected as he pleased,
“Ok, here is my impression,” Doctor paused to let Patient’s-mother mercifully trail off, before delivering his well-practiced coup de grace, a delightful combination of humility, validation, and normalization – the bedside trifecta over which his attendings had once fawned.
“Given I’ve only met Patient this once, I can’t for certain know why she is acting this way.” A humility that was counterfeited even more so than his Southern gentility. “I agree with you that her stressors are contributing to Patient’s present state.” Validation, check. “I will also reassure you that we [the Psychiatric profession] see many cases like Patient’s” – now normalization, check – “but it is still very difficult to predict what sort of care Patient will need in the long term” – a nice closing flourish of humility.
A long pause, mercifully impregnated by Patient’s-mother’s silence. Then,
“Ok, Doctor…what’s your name again?”
“Doctor [Christian surname], miss.”
“Ok, I appreciate everything you are doing for Patient. She needs help.”
“Of that there is no doubt.”
“So what is next?” Patient’s-mother asked, her raspy cough barely concealing her trepidation.
“Ok, so here’s what we’ll do. In her present state, Patient is in no fit state to take care of herself, much less anyone else. Which reminds me – where is Patient’s child?”
“With me, safe and sound.”
“Good. Right, so as I was saying, Patient is in no fit state to live outside the hospital right now -”
“Agreed,” Patient’s-mother interposed, with enthusiasm.
“She needs a higher level of care, which in Patient’s case means a stint at an inpatient psychiatric facility.”
“O..k…” Patient’s-mother replied, with decidedly less enthusiasm. “I’m not sure if I want Patient in some looney-bin. She isn’t crazy like those people…” she said.
For this too, Doctor had a well-practiced riposte, this one relying on psychoeducation and reassurance –
“Worry not, Miss. Psychiatric hospitals aren’t like they used to be. Average length of stay is 3-5 days. We’re not looking at some sort of long-term commitment situation. These hospitals are more for acute crisis stabilization.”
“Oh, I see.” Patient’s-mother sounded placated. “So where would Patient end up?”
“Ah, so there’s the rub,” Doctor said with actual sincerity. “Our inpatient psychiatric unit here closed two years ago. So, for patients like Patient who require inpatient treatment – er, acute crisis stabilization – we transfer them out to in-state psychiatric facilities.”
“Ok,” Patient’s-mother croaked, resigned but clearly not convinced. “Please do your best to send her somewhere local, near the River?”
“Absolutely,” Doctor responded. “But – not wanting to get your hopes up – do know that we refer out on the basis of two factors – insurance compatibility and bed availability. Our goal is to get Patient the promptest, most affordable care.” Expectation-management, check.
“I understand, Doctor [Christian surname]. Thank you so much for all of your help. Please call me anytime with updates.”
“Will do.” And Doctor hung up, ready at last to go about his real business.
Doctor first placed his Orders – 1 mg Risperdal BID, urgent/first dose Now. Haldol 5mg+ Benadryl 50mg+Ativan 2mg IM, q8hr prn Psychotic agitation. Involuntary hold – on the basis of grave self-care deficit, with expectant referral to inpatient psychiatry.
Then, Doctor phoned Spencer, repeating his orders and plan to refer Patient to an inpatient psychiatric hospital. Spencer’s irritation was thinly veiled, even over the phone – his patient length-of-stay just multiplied.
Finally, Doctor consulted the Diagnosis tab of Patient’s chart. He scrolled down until he saw what he wanted.
Doctor selected Schizophrenia F20.9. He signed the note and quickly forgot about Patient. She was sent across the state, by the Sea, and not close by, near the River.
It mattered little. Doctor was going up. Patient was going down.
Professor and Schizophrenic
Many years passed before Man and Woman, Doctor and Patient, crossed paths again. During this time, Doctor grew into his role – the Professor – as facilely as Patient grew into hers – the Schizophrenic.
Ever since that fateful meeting in tiled, crazy A4 – when Patient was shipped off to the sea for rapid psychiatric stabilization and Doctor forgot about Patient as a necessary expedient to process many other patients like her – they’d learned much of the ways in their antipodal arts.
Professor, on the one hand, learned how to evaluate patients much more efficiently, much more expertly; he’d mastered the ruthless art of distilling the patients’ colorful, mostly meaningless words into mostly actionable Diagnostic categories: A raving lunatic was likely psychotic – for that there was an antipsychotic. A perniciously melancholic was likely depressive – for that was an antidepressant. And a patient with fits of both melancholy and euphoric lunacy was likely manic-depressive – for that there was a mood stabilizer. So simple, yet so elegant. Through this, Professor developed the gift of tuning out the rambling annoyances – the sob stories about abusive baby daddies, alcoholic fathers, and imbecilic mothers – that once plagued his training. Of course, he never relinquished that essential artifice of gentility that made all of it possible in the first place.
Above all else, Professor became so ruthlessly efficient at diagnosing and treating mental illness that he became impossible to manipulate – which, to his pride, set him apart from his trainees.
It took no small amount of expertise to turn psychiatry into a purely objective, no-nonsense enterprise.
And around those more complicated patients who presented with combinations of those unquestionable categories the Professor built the nuances of his formidable practice, titrating and cross-titrating every conceivable psychotropic until there was no chemical for which he lacked confidence to brine a patient’s brain. Professor believed that the mind is nothing more than the product of electrochemical communications in the brain. Melancholy, thought Professor, was no less rooted in neural substrate than is multiple sclerosis, or hemiparesis. To regard the mind as distinct from the brain, to sequester room A4 from room C4, was utmost folly.
Granted, Professor would be the first to acknowledge that many of these neural substrates are yet to be discovered. But the effectiveness of his treatments – his antipsychotics, mood-stabilizers, antidepressants with the occasional controlled electroconvulsion for those peculiar cases where chemicals failed – offered definitive proof-of-principle. Almost always, Professor’s manic depressives became less unstable, his psychotics less raving, and his melancholics less depressed. By changing the electrochemistry of their brains, he changed their minds. Someday, Professor knew, science would catch up to him.
While Professor placidly bided his time, Schizophrenic endured a much more tempestuous coming-of-age.
First was her ignominious stop at the psychiatric asylum by-the-Sea. There, Schizophrenic was berated, demeaned, and subdued. Schizophrenic soon realized that defeat was her own paradoxical escape. She ceased her protestations and surrendered herself to the ministrations of more hellhounds, until day broke one morning and she found herself not in hell but in the psychiatric asylum by-the-Sea. The gentle cacophony of seagulls stirred her awake while even gentler voices outside the door jingled,
“Miss [Christian surname], breakfast is ready with your morning medications!”
Schizophrenic cautiously tiptoed outside her room into the open space, a spacious common room dotted with sturdy floor-affixed armchairs, chess tables, and a central hub where nursing staff doled out pancakes with per os medications. From this hub a small nursing staff could survey the entire therapeutic milieu, radiating outward in every degree to encircling rooms, from one of which Schizophrenic had just emerged.
The asylum. A perfect panopticon for madness.
Schizophrenic graciously accepted her pancakes and her medicine – “here’s your Risperdal, Miss [Christian surname]. Might I add you look a lot better today!”
Risperdal? Schizophrenic had not a clue what they meant. She hastily said “Thank you,” cheeking her Risperdal before retreating with her pancakes to the edge of the panopticon. Making sure no one was eyeing her, she carefully spat out the Risperdal while forking in a large chunk of pancake. Schizophrenic couldn’t explain how she ended up in asylum by-the-Sea, nor could she account for her brush with hell. What Schizophrenic did know were these two inalienable facts – one, she was not crazy, and two, she was very hungry.
She ravenously devoured her pancakes and had little time to yearn for more before another sing-songy nurse called out to her.
“Miss [Christian surname], the doctor would like to speak with you now.”
Schizophrenic stood up slowly and began walking across the panopticon toward a slender, kind-appearing man with soft brown eyes and a thick beard flecked with grey. She paused by the trash bin on the way, taking subtle pains to conceal the Risperdal beneath her food scraps and styrofoam plate. As she approached this man, the doctor, his finer features came into view and she appreciated a well-healed scar atop his left eyebrow – an unfortunate asylum-by-the-Sea battle scar, perhaps? – and pastry crumbs scattered across his smart-looking vest. Schizophrenic was a good head taller than the doctor.
“In here, if you please, Miss [Christian surname],” he spoke with a surprising baritone, gesturing into a room no larger than a broom-closet. It was plainly designed for this sort of scenario – diminutive doctor sits on one end of a short wooden desk, facing Schizophrenic. There were no windows, no pictures, nothing outside of the wooden desk and the chairs. Schizophrenic squirmed uncomfortably as the doctor amusedly scrutinized her, fully aware that this design gave Schizophrenic no other choice than to focus on the interview, on him. Just as the panopticon was designed to surveil the patients, the broom-closet was designed to focus the patients’ attentions like a lens bending scattered light back to a focal point.
But the doctor wasn’t cruel. He shattered the silence like brittle glass. “How are you feeling today, Miss [Christian surname]?”
“Er, good, actually. Really hungry.”
“I saw that. Happy to see you’re eating again.”
“I’ll ask you the same question today as I did yesterday, and the day before – she’d been there for at least three days? – “Do you remember what was going on before you ended up in the hospital?”
“To be honest, Doctor, I only remember being very anxious and very scared.” Schizophrenic chose not to rehash her harrowing misadventures with demons and hellhounds, figuring (correctly) that the Doctor had observed her fighting these unseen entities the prior two days. “Wait, is my child okay?”
Doctor smiled with a hint of genuine solemnity. “Yes, he’s safe, with your mother. As for you…I could see you were fighting some inner demons.” His word choice was not coincidental.
Schizophrenic nodded again. They didn’t seem inner at the time.
“And – pardon me for my bluntness – you’re sure you don’t remember using any drugs before you got here?”
Schizophrenic shook her head. “No Doctor, I’ve been clean my entire life.” That’s false; the last thing she remembers, now that doctor asked, was smoking synthetic marijuana at home. But what did that have to do with anything? Cannabis was basically legal; and in Schizophrenic’s experience, it had never reified her so-called ‘inner demons.’
“Well, that being the case…” the doctor started lecturing Schizophrenic on the antecedents and treatments of her condition, the importance of taking her medications, that sort of thing. His words rang hollow in her head, because Schizophrenic’s mind was elsewhere – her child, her life which had been put on standby for three days as she vainly fought her ‘inner demons.’ A spotless audition of her insanity before a gullible audience, she thought with a sickening lurch in her stomach; the pancakes suddenly became insalubrious. The doctor, gullible as the rest, seemed fairly convinced that she had ‘Schizophrenia’ and that the key to her ‘mental health’ was ‘taking the Risperdal’ and ‘going diligently to her outpatient psychiatrist.’
“Outpatient…so you’re saying I can go home today?”
He smiled, stupidly, insanely. “Yes, I believe so. Just a few more questions…” He asked Schizophrenic if she was considering harming herself or anyone else – “No.” And if I were, why would I tell you?? He asked her if she could do a brief cognitive exam – “Sure why not.” He asked Schizophrenic to remember three simple words – tree, ball, flag – then he bid her to draw a clock indicating “ten past eleven” – she did so with aplomb – then he asked her to repeat those three simple words – tree, ball, flag.
“Wonderful,” he proclaimed, putting his hands together in muted triumph. “Our social worker will meet with you briefly to arrange your transportation home and to schedule your outpatient appointment.” He extended his right hand, which Schizophrenic grasped in a handshake, and said “pleasure working with you. I’m glad you’re feeling better.”
Doctor stood up first, opening the door back to the therapeutic milieu and gesturing that Schizophrenic was free to escape the confines of the broom-closet. As she walked back to her room, she turned briefly to see the doctor closing and locking the broom-closet before washing his hands with an ample aliquot of hand sanitizer. He hummed to himself absentmindedly.
Schizophrenic felt dirty.
And that feeling didn’t go away, not when she returned home and held her child in her arms, not when she cleansed herself in the shower of three days of accumulated filth, and not when she threw her discharge paperwork and medications in the trash, trying vainly to forget the unforgettable.
Meanwhile, those ‘inner-demons,’ those stressors which Professor had long ago learned to dismiss as moth-eaten artifacts of Southern melodrama, went nowhere. Her voicemail brimmed with threatening messages from her baby-daddy. She ignored these. Her mailbox overflowed with unpaid bills, notices of employment termination, and – worst of all – a tidy bill from asylum by-the-Sea. Schizophrenic couldn’t pay it, of course, because she had no job and her baby daddy wouldn’t help because he was a good-for-nothin’ son-of-a-bitch, just like her father.
Take your Risperdal, keep your appointments.
Tearfully, she gathered her belongings to the soundtrack of her child’s blissfully ignorant babbles. It didn’t take long. She then picked up the phone and called her mother.
Yes, of course my angel. Never you mind. You and child can stay with me while you get back on your feet.
Death and Life
You may have already guessed how this saga ends. Man’s rises to grace as surely as Woman falls from it.
But forget not that this story is not Biblical. There is no pious scribe to account for these events, or higher power to divine their trajectories. Only me, here, adapting the medical record to tell a story we all know to be true. Is it tragedy? Comedy? Tragicomedy? I don’t think so, because I am neither funny nor emotional; I am neither omniscient nor objective; I am neither mad nor sane. To categorize this saga may be folly akin to diagnosis.
Perhaps, given this skepticism, I am indeed a madman. Perhaps you’ve wasted your time with this saga because nothing that I have written can be trusted. Or perhaps I’m the opposite of mad; perhaps I too am a proud psychiatrist, just like Professor. We have contrarian views but we are cut from the same cloth. We’ve seen the same patients – there are many like Schizophrenic – and we’ve helped them with all the hubris we could muster. Tragicomedy. Or perhaps, even, you are just like Schizophrenic. You’ve gone to war with demons but it is the insane Professors of the world who presume them to be delusions just because they cannot see the battle scars. They cannot even see the scars they inflict.
Point is, I am who I am. You are who you are. Nothing I write here in these pages will change that, just as nothing could stop Man from becoming Professor or Woman from becoming Schizophrenic.
So, like clockwork, the story unfolded.
Back home with her mother, Schizophrenic couldn’t get back on her feet. The harder she tried, the more failure she encountered.
“I’m sorry, but we cannot give you this job without a reference…”
“We regret to inform you that your re-application to Business school has been denied…”
Schizophrenic crumbled again. And again. And again. Each time she was fast-tracked to A4 in the ER, then shipped off to asylum by-the-Sea. She grew accustomed to the short, baritone-voiced doctor and even grew to like the care they bestowed upon her at asylum by-the-Sea.
“Your insurance has lapsed.”
“You no longer have custody of your child.”
“I’ve done everything I can for you, get out of my home.”
Unburdened by expectations, Schizophrenic became less scrupulous with her choices. She reconnected with baby-daddy on the streets. It was a simple commerce: Schizophrenic gave baby-daddy her body, and baby-daddy gave Schizophrenic any drug he came by – synthetic marijuana, heroin, crack cocaine, you name it. The more Schizophrenic used the madder she became, until she lived side by side with her so-called ‘inner demons’ in a manner the rest of the world could not understand. Still, Schizophrenic had yet to cross paths again with that fearful demon-beast that still haunted her dreams, and for this she was thankful.
Good people who saw schizophrenic in the streets gave her nothing but a wide berth. She’s clearly high. They all judged her, and she could sense it. Drug addict. Some Good Samaritans would give her money, others food, but most would give Schizophrenic this reproach-from-a-distance.
Back to A4, but she could no longer go to asylum by-the-Sea because her insurance no longer existed. She went to the state asylum by-the-River this time, maybe a bit mustier and drab, but little else was different. The inpatient psychiatrist by-the-River treated Schizophrenic with dignity. He spent time with her. He taught her things about her Schizophrenia just as psychiatrist by-the-Sea did. Schizophrenic learned that she suffered just as much from her Schizophrenia as she did from her decisions. Substance use disorder is often comorbid with mental illness.
The more time Schizophrenic spent in asylum by-the-River the more she learned about herself. Schizophrenic came to understand her illness as a thing that happened to her. Her brain simply worked differently. The good people who gave her wide berths on the street couldn’t see this, but the good doctors did. They saw it in Schizophrenic’s medical record, in her delusions, her hallucinations, her disorganized thought process. They saw it in her stellar response to antipsychotic medications.
Take your Risperdal, attend your follow up appointments.
Armed with this burgeoning insight, Schizophrenic finally tried to give this thing a go. The state asylum by-the-River’s social workers beneficently set her up with transitional housing, taught her how to live off of disability checks, and gave her a fortnight’s supply of Risperdal, which would tide her over until the day of her first outpatient appointment.
She took her medications every day. She avoided trouble. She blocked baby-daddy from her phone. She felt optimistic, in-control for the first time she could remember.
The morning of her appointment, however, her cell phone rang. It was her mother. Schizophrenic’s Mother would call from time to time, mostly out of guilt, Schizophrenic knew. She normally let it go to voicemail because talking to her mother reminded her of her child, and that just depressed her. But today, feeling protected by this foreign optimism, she picked up.
Oh, you’re going to an appointment? I’m so proud of you, honey. Child is doing wonderfully, by the way. He’s just started kindergarten, and his teachers tell me he is just so smart! Just like you were.
Patient hung up, choking back tears, starkly reminded why she should never again speak to mother. Mother was just like the good people – she didn’t, couldn’t, understand what is was like to be a schizophrenic, to have succumbed to illness that took everything from her. In mother’s eyes, Schizophrenic was just a smart child who, somewhere along the way, got lost. Like the good people, mother believed that Schizophrenic could find her way back with good choices.
Take your Risperdal, attend your appointments.
What Schizophrenic wanted for mom, and all the good people, to understand, was this: she was now Schizophrenic – nothing more, nothing less, and never to be anything else. She knew this before speaking to her mother, but then this knowledge had been a source of hope.
Now all Schizophrenic felt was loss. She was out of medications, so she relapsed instead – on something she’d stashed away in her knapsack for an occasion just like this.
Substance use disorder is comorbid with schizophrenia.
But she kept her appointment. Transitional housing was only a few blocks away from the prestigious university. Feeling a surge of adrenaline and confidence, she made her way to clinic and introduced herself using her Christian surname.
Right this way, Miss [Christian surname]. Professor will be right in to see you.
The clerk led her to a drafty room in the back of the clinic, littered with papers and stacked to the ceiling with esoteric texts. Schizophrenic sat, fidgeting and nervous in her chair, looking apprehensively across Professor’s busy desk to his now-empty chair. She wondered if he would realize she was high. If so, would he judge her? Surely not; the doctors understood her as the good people could not.
As Schizophrenic fidgeted, Professor made his way distractedly down the hallway to his office. He was slightly annoyed because his secretary had neglected to notify him that this clinic slot was taken and he’d planned on using this time for research.
He’d discovered an exciting association between schizophrenia and limbic system dysfunction, now if he could just have some damned free time to write it up…
Schizophrenic heard footsteps echoing down the hall. They grew louder and louder, and she grew more and more anxious. She began sweating, and her heart pounded ever faster. Wasn’t the room drafty a second ago? The room began spinning. No, please no, Schizophrenic thought.
She closed her eyes, begging her senses to stop betraying her. Were they? She began to hear a fiery crackle of flames from outside the room, a low menacing growl.
Professor paused midway down the hall, listening intently to a whimpering voice coming from his room, where Schizophrenic waited for him. The words were unmistakable, and supplicating – “No, please no!” He strode confidently down to his room and opened the door.
A blast of hot wind. Flames like forked tongues lashed out at Schizophrenic, and she cowered in the corner of the room. He was here. She opened her eyes and there he was, in the flesh: Demon-beast. Its eyes were cold and black, its body amorphous and shrouded in hellfire. It didn’t move but Schizophrenic knew it was only a matter of time before demon-beast claimed her. I’m not afraid to burn! Demon-beast momentarily looked away – is he calling his hellhounds? – and she pounced like an animal cornered.
There Professor stood at the doorway, surveying the scene with expert dispassion, not a flicker of recognition in his eyes. “I’m not afraid to burn!” this poor, frail young Schizophrenic shouted. He sighed deeply, and briefly turned his head to summon the nursing staff from the clinic lobby – Schizophrenic is too ill for this setting, he knew.
He turned back to try to calm Schizophrenic down, but it was too late. She’d grabbed a sharpened pencil from his cluttered desk and she set upon him, tackling him to the ground and stabbing him repeatedly – in the neck, the chest, the abdomen, the arms. She gouged bits of flesh from his face and managed to break his nose for good measure before the nursing staff could wrestle her away from Professor. It was too late. Schizophrenic was soaked in blood – Professor’s blood. She’d found the carotid.
Professor felt his face sink into a moist, warm pillow and his senses dulled as if dampened by one of those sedatives he liked to prescribe so much. Feet stampeded around him and terrified voices rang, but even those stimuli faded away until all Professor was left with was his sense of self and his sense of vision. Vision too began to fade, a dark shroud growing from the corners in, until all he could see was Schizophrenic battling unseen forces beyond the shroud.
And at this last sensate moment before death, Professor could only sense who he was, and see who Schizophrenic was.
At this moment, in the very end, Man recognized Woman from A4. He spoke, “Oh…” but the effort stole away Man’s final senses and dead he lay.
Briefest of Epilogues
Woman was judged to be not guilty by reason of insanity. She was Schizophrenic.
Don’t ask me how Man was judged, or if he was judged at all. I don’t know.