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Part One (#uff4ab4c5-27ea-5def-ad96-4bedfb4e1a9b)
Chapter 1 (#uff4ab4c5-27ea-5def-ad96-4bedfb4e1a9b)
Menaker State Hospital is a curse, a refuge, a place of imprisonment, a necessity, a nightmare, a salvation. Originally funded by a philanthropic endowment, the regional psychiatric facility’s sprawling, oak-studded campus sits atop a bluff on the eastern bank of the Severn River. From the steps of the hospital’s main administration building, the outline of the U.S. Naval Academy can be seen where the river enters the Chesapeake Bay some two and a half miles to the south. There is but one entrance to the facility, and the campus perimeter is demarcated by a wrought-iron fence whose ten-foot spear pickets curve inward at the top. The hospital is not a large central structure as one might imagine, but rather an assortment of redbrick buildings erected at the end of the nineteenth century and disseminated in small clusters across the quiet grounds, as if reflecting the scattered, huddled psyches of the patients themselves. There is a mild sense of neglect to the property. The wooden door frames sag like the spine of an old mare that has been expected to carry too much weight for far too many years. The diligent work of the groundskeeper is no match for the irrepressible thistles that erupt from the earth during the warmer months and lay their barbed tendrils against the base of the edifices, attempting to claim them as their own. The metal railings along the outdoor walkways harbor minute, jagged irregularities on their surfaces that will cut you if you run your fingers along them too quickly.
Twenty-two miles to the north lies the city of Baltimore, its beautiful inner harbor and surrounding crime-ridden streets standing in stark contrast to each other—the ravages of poverty, violence, and drug addiction flowing like a river of human despair into some of the finest medical institutions in the world. Among them is The Johns Hopkins Hospital where I received my medical training. Ironic how, after all these years, the course of my career would take me here, so close to my starting point—as if the distance between those two places was all that was left to show for the totality of so much time, effort, and sacrifice. And why not? At the beginning of our lives the world stretches out before us with infinite possibility—and yet, what is it about the force of nature, or the proclivities within ourselves, that tend to anchor us so steadfastly to our origins? One can travel to the Far East, study particle physics, get married, raise a child, and still … in all that time we’re never too far from where we first started. We belong to our past, each of us serving it in our own way, and to break the tether between that time and the present is to risk shattering ourselves in the process.
Herein lies the crux of my profession as a psychiatrist. Life takes its toll on the mind as well as the body, and just as the body will react and sometimes succumb to forces acting upon it, so too will the mind. There are countless ways in which it can happen: from chemical imbalances to childhood trauma, from genetic predispositions to the ravages of guilt regarding actions past, from fractures of identity to a general dissociation from the outside world. For most patients, treatment can occur in an outpatient setting—in an office or a clinic—and while it is true that short-term hospitalization is sometimes required, with proper medical management and compliance patients can be expected to function in the community and thereby approach some semblance of stability and normality. This is how it is for the majority—the lucky ones, whose illnesses have not claimed them completely—but it is not the case for the patients here. Too ill to be released into the public, or referred by the judicial system after being found either incompetent to stand trial or not responsible by reason of insanity, Menaker houses the intractably psychiatrically impaired. It is not a forgotten place, but it is a place for forgetting—the crimes committed by its patients settling into the dust like the gradual deterioration of the buildings themselves.
The word asylum has long since fallen into disfavor to describe institutions such as this. It conjures up images of patients (there was a time when they were once referred to as lunatics) shackled to concrete slabs in small dingy cells, straining at their chains and cackling madly into the darkness. To admit that we once treated those with mental illness in such a way makes all humanity cringe, and therefore one will no longer find “asylums” for such individuals, but rather “hospitals.” And yet, for places like Menaker, I’ve always preferred the original term. For although we attempt to treat the chronically impaired, much of what we offer here is protection—an asylum from the outside world.
Some of this, perhaps, is too bleak—too fatalistic. It discounts the aspirations and capabilities of modern medicine. But it is important to understand from the beginning what I am trying to say. There are individuals here who will never leave—who will never reside outside of these grounds. Their pathology runs too deep. They will never be restored to sanity, will never return to their former lives. And the danger, I am afraid—and the great tragedy for those who love them—is to cling to the hope that they will.
Chapter 2 (#uff4ab4c5-27ea-5def-ad96-4bedfb4e1a9b)
You’ve got a visitor,” Marjorie said, smiling over at me from the nurses’ station.
I glanced toward the intake room. Through the rectangular glass pane in the door I could see Paul, one of the orderlies, ushering in a new patient. A visitor, I thought. One of Marjorie’s euphemisms.
“Is this going to be one of mine?” I asked, checking the roster board. I hadn’t been advised of any new admissions.
Marjorie nodded. “I think you should see this one.”
“Did he come with any paperwork?”
“Not that I know of.” Marjorie’s eyes were back on the chart in front of her, her attention elsewhere.
I sighed. The protocol was that we were to be advised ahead of time regarding any new transfers to the facility, and that those transfers should arrive with the appropriate paperwork, including a patient history and medical clearance assessment. Patients weren’t supposed to just show up unannounced, and it irritated me when that happened. Still, one had to keep in mind that we were dealing with a state bureaucracy here. Nothing really surprised me anymore. I decided not to be a hardnose and to let the administrative screwup ride for the moment, although I certainly intended to bring it up with Dr. Wagner later.
Paul had stepped through the door and closed it gently behind him. He motioned me over, and I walked across the room to join him.
“What have we got, Paul?”
“Young man to see you,” he said, and we both peered through the glass at the patient seated in the room beyond.
“What’s his story?” I wanted to know, but Paul shook his head.
“You’ll have to ask him.” Apparently, Paul had no more information than Marjorie did.
I pushed through the door. The patient looked up as I entered, smiled tentatively at me. His handsome appearance was the first thing that struck me about him: the eyes pale blue, the face lean but not gaunt. He had the body of a dancer, slight and lithe, and there was a certain gracefulness to his movements that seemed out of place within these walls. A lock of dark black hair fell casually across his face like a shadow. He was, in fact, beautiful in a way that men rarely are, and I felt my breath catch a little as I sat down across from him. I gauged him to be about thirty, although he could’ve been five years in either direction. Mental illness has a way of altering the normal tempo of aging. I’ve seen twenty-two-year-olds who look forty, and sixty-year-olds who appear as if they’re still trapped in adolescence. Medications have something to do with it, of course, although I think there’s more to it than that. In many cases, time simply does not move on for these people, like a skipping record playing the same stanza over and over again. Each year is the same year, and before you know it six decades have gone by.
“I’m Dr. Shields,” I said, smiling warmly, my body bent slightly toward him in what I hoped would be perceived as an empathic posture.
“Hello.” He returned my smile, although it seemed that even my opening introduction pained him in some way.
“What’s your name?” I asked, and again there was that nearly imperceptible flinch in his expression.
“Jason … Jason Edwards.”
“Okay, Jason.” I folded my hands across my lap. “Do you know why you’re here?”
He nodded. “I’m here to see you.”
“Well … me and the rest of your treatment team, yes. But can you tell me a little bit about the events that brought you here?”
His face fell a little at this, as if it were either too taxing or too painful to recount. “I was hoping you’d already know.”
“Your records haven’t arrived yet,” I explained. “But we’ll have time to talk about all this later. For right now, I just wanted to introduce myself. Once again, my name is Dr. Shields and I’ll be your treating psychiatrist. We’ll meet once a day for a session, except on weekends. I’ll review your chart and medication list once they arrive. Paul will show you around the unit and will take you to your room. Meanwhile, if there’s anything you need or if you have any other questions, you can ask Paul or one of the other orderlies. Or let one of the nurses know. They can all get in touch with me if necessary.”
I stood up, but hesitated a moment before leaving. He watched me with an expectant gaze, and despite my better professional judgment, I leaned forward and placed a hand on his shoulder. “It’s going to be okay,” I told him. “You’re in a safe place now.”
He seemed to take my words at face value, trusting without question, and in the weeks and months to come I would often look back upon that statement with deep regret, realizing that nothing could have been further from the truth.
Chapter 3 (#uff4ab4c5-27ea-5def-ad96-4bedfb4e1a9b)
I had to ask him for his name, Charles. I don’t know the first thing about him.” I was in Dr. Wagner’s office, trying not to let my irritation get the best of me. It was two days later and the paperwork for the Edwards patient still hadn’t arrived.
“Don’t worry about the paperwork,” he was telling me. “It’s not important.”
“I don’t see how you can say that,” I responded. I’d declined to take a seat, and now I shifted my weight to the other foot, struggling to maintain my composure. Don’t worry about the paperwork, I thought. He was the administrator, not me. He should be worried enough for the both of us.
Dr. Wagner had been the chief medical officer at Menaker for as long as I’d been here. He’d hired me right out of residency, although he’d actually suggested during my interview that I consider working elsewhere for my first few years of practice. The conversation we’d had didn’t seem that long ago, and standing here today I could picture that younger version of myself sitting in my black skirt and double button jacket—my interview attire, as I’d come to see it.
“The job’s yours if you want it,” he’d told me, “but you should give it some extra thought.”
“Why is that?” I’d asked.
He reached forward and slid an index finger along the top of the nameplate near the front edge of his desk, scowled at the dust gathered on the pad of his finger during that single pass. Then he looked at me. “Right now, you want to go out there and make a difference. You’re ambitious, enthusiastic, full of energy. You want to use the medical knowledge and skills you’ve obtained to change people’s lives.”
“I feel I can do that here,” I replied.
He nodded. “Yes, yes. In small, subtle ways, I’m sure you could. But big changes, the kind you wrote about in your application to medical school, for example—”
“You read that?” I hadn’t included it in my application for this position.
He chuckled and shook his head. “They’re all the same,” he said, throwing up his hands. “Tell me something.” He cocked his right eyebrow and extended his index finger in my direction. The layer of dust still clung to it, displaced from its previous resting place after who knew how many months or even years. “You didn’t use the word ‘journey’ in your essay, did you?”
“Excuse me?”
“Seventy-six percent of medical school application essays have the word ‘journey’ embedded somewhere in their text. Did you know that?”
“I didn’t,” I admitted, although I wasn’t sure what this had to do with—
“I used to be on the admissions committee at Georgetown,” he said, “so I should know. I’ve seen enough essays come across my desk.”
“Seventy-six percent, you say?”
“It’s a mathematical certainty.” He brought the palm of his right hand down on the table with a light smack. “Granted, there’s some slight fluctuation from year to year, but on average it’s seventy-six percent. The word ‘difference’ is in ninety-seven percent of medical school application essays. Ninety-seven percent,” he reiterated. “Can you believe that?” He chuckled again. “We did a study, tracking the most common word usage in application essays over a ten-year period.”
I returned his gaze, not knowing how to respond. The man was eccentric, I had to admit.
“Which means,” he continued, “that almost all prospective physicians want to go on a journey and to make a difference. That’s the prevailing dream.”
“And?” I prodded, still not clear where he was going with this.
“And you won’t do that here at Menaker. There is no journey. Patients are here for the long haul and, for the most part, they’re not going anywhere. And although you might make a small difference in the lives of some of these patients, that difference will be played out slowly over the course of ten or twenty years. It’s not something you’ll notice from month to month, or even from year to year. Young doctors come here because the place has a reputation of housing the sickest of the sick. I get that. I can understand the allure. But within a short time, most of them move on—because this is not what they wanted. Not really.”
“Some of them must want it,” I countered.
He only sighed. “A few, yes. But most don’t. I’ve read enough essays to know.”
I’d gone home that night and managed to unearth my own medical school application essay from eight years before, and goddammit if he wasn’t right. I’d used the word difference twice, and the essay’s last sentence read, I look forward to the journey on which I am about to embark.Pathetic, I thought, standing there in my kitchen. But at the time I’d written it I’d meant every word. The next morning I called him up to accept the position. Maybe my expectations had changed since applying to medical school. Maybe I just wanted to prove Wagner wrong.
“Did you look?” he asked, and we both knew what he was referring to.
“Yes,” I admitted.
“And?”
“And I must be in the minority,” I lied. “When would you like me to start?”
That was five years ago, and despite his predictions at the time, I’ve been relatively happy here. The nursing and support staff at Menaker are dedicated, and the faces of those I work with seldom change. There is a sense of family, and for someone like myself whose real family has been splintered in numerous ways, there is a certain nurturing reassurance in that stability. Wagner had also been right about the patients, who are clearly in it for the long haul. Practicing psychiatry in a place like this is like standing on a glacier and trying to influence the direction it will travel. It’s difficult, to say the least. But sometimes, despite all the forces working against us, we are able to effect a change—subtle, but real—and the victory can be more gratifying than one can possibly imagine. But all jobs entail occasional days when you feel like banging your head against the wall, and for me today seemed to be one of them.
“Am I missing something here, Charles?” I asked. The volume of my voice had ratcheted up a notch. I made myself take a breath and exhale slowly before continuing. “We cannot admit a patient involuntarily to this institution with no court order and no patient records. It’s false imprisonment, tantamount to kidnapping.”
If Wagner was concerned, he didn’t show it. “I think you should leave the legalities to me,” he advised. “Focus on the individual before you, not his paper trail. Talk to him.”
“I’ve been talking to him. For two days now. He doesn’t say much—doesn’t seem to know what to say.”
“It can be difficult.”
“It’s frustrating. I have no patient history or prior assessments to help me here. I don’t even have a list of his current medications.”
Wagner smiled through his goatee. It was a look, I suppose, that was meant to be disarming. “I think you have everything that you need right now. Talking to him is the most important thing. Everything else is secondary.”
I turned and left the office without a retort, deciding that whatever response I might muster wasn’t worth the price of my job.
Chapter 4 (#uff4ab4c5-27ea-5def-ad96-4bedfb4e1a9b)
Why don’t you tell me a little bit about your childhood,” I suggested. We were walking across the hospital grounds, an environment I felt was more conducive to psychotherapy than sitting in a small office as my patient and I stared at each other. Something about the outdoors opens people up—frees them, in a way.
He gave me a pitying, incredulous look—one I’d already become accustomed to receiving from him. I never would figure out where that look came from, but I began to recognize it as his default expression. It was the look I imagined parents of teenagers received with regular frequency. I’m embarrassed for you because of how clueless you really are, it seemed to say, except with teenagers there was usually an added dose of resentment, and I never got that from him. Rather, Jason’s expressions were touched with empathy—something about the depth of those eyes, perhaps—almost as if he were here to help me, instead of the other way around.
“On the surface, I was part of what you might call a traditional family. We lived in a middle-class suburban neighborhood in Columbia.”
“Columbia, Maryland,” I clarified, and he nodded. It was located in Howard County, about a thirty-minute drive to the west of us.
“Dad was a police officer,” he continued. “Mom used to be a teacher, but when the kids were born, she took several years off to run a part-time day care out of our house. It allowed her to stay home with us during those first couple of years.”
“You say ‘us.’ You had siblings?”
“A sister.”
“Where is she now?”
He sighed, as if he’d explained this all a thousand times before. I wondered how many psychiatrists he’d been through before me.
“Your sister,” I prodded, waiting for him to answer my question, but he was silent, looking down at the Severn River below us.
“Is she older or younger?”
“She was three years older,” he said, and his use of the past tense was not lost on me.
“Is she still alive?”
He shook his head. “I don’t know. I haven’t spoken with her in a long time.”
“You had a disagreement? A falling-out?”
“No,” he said. His face struggled for a moment. Beyond the iron pickets, a seagull spread its wings and left the cliff, gliding out into the vacant space some eighty feet above the water.
I put a hand on his shoulder. I wasn’t supposed to do that, I knew. There are rules of engagement to psychiatry, and maintaining appropriate boundaries—physical and otherwise—is one of them. What may seem like a compassionate gesture can be misconstrued. Extending a casual touch, or revealing too much personal information, for example, puts the psychiatrist at risk of being perceived by the patient as someone other than his doctor. The relationship of doctor and patient becomes less clear, and the patient’s sense of safety within that relationship can suffer. And yet, here I was with my hand resting on my patient’s shoulder for the second time this week. I found it unsettling, for I was doing it without thinking, almost as a reflex, and I didn’t understand where it was coming from. Was I attracted to him? I must admit I did feel something personal in his presence, a certain … pull. But it was hard to define, difficult to categorize. But dangerous, yes … I recognized that it had the potential to be dangerous for us both.
“What happened to your sister?” I asked, withdrawing my hand and clasping both behind my back.
“Gone,” he said, following the flight of the gull before it disappeared around the bend. He turned his eyes toward mine, and the hopelessness I saw there nearly broke my heart. “She’s been gone for five years now, and alive or dead, I don’t think she’s ever coming back.”
Chapter 5 (#ulink_c365db79-a765-55cd-999d-048aa745c32e)
The evening group session I ran in the Hinsdale Building on Tuesdays and Thursdays finished on time, but I had paperwork that I’d been putting off, and by the time I finally put that to rest it was almost 8 P.M. Full dark had settled across the campus, and although the hospital does a pretty good job with exterior lighting, the footprint of the place is still over twelve acres and unavoidably prone to large swaths of shadows. It’s for this reason that I don’t like leaving after dark. It’s not the patients I’m afraid of, although we house more murderers per capita at Menaker than they do at the closest prison, Brockbridge Correctional Facility in Jessup. And, yes, we’ve had our share of attacks—something the visitor brochures about this place will never mention. An experienced nurse was once killed here during the night shift, struck by a large television (this was before the days of flat screens) hurled at her by a patient while her back was turned. She’d fallen forward, the TV’s trajectory matching the arc of her fall, and the second impact had crushed her skull between the old Sony and the tiled floor. There are inherent dangers in working with people—many of them with a history of violence—whose self-control is tenuous at best.
But no, it’s not the patients I’m afraid of, but rather the darkitself that I find menacing. It’s been that way for as long as I can remember, and I can’t help but think that it has something to do with him, the way his mind turned the final corner that night when I was eight years old, the way I had to go looking for him, terrified that I was already too late.
The wide brick walkway from the physician offices to the front gate was well lit, but I could hear the April night breeze pushing past the oaks on either side, making their newly budding limbs shift and sway as if finally awakening from a long sleep and realizing they had someplace better to go. I could hear the trees whisper to one another, spiteful old men with malevolence in their hearts, the shadowy expanse of the grounds providing complicit cover for their furtive movements. A finger of one of the branches dipped down to graze my shoulder as I passed, catching on the slick fabric of my windbreaker, and for a moment I felt that it did not want to let go.
“Out for a walk, Lise?” Tony Perkins called out to me from the watchman’s booth near the gate, and the sound of his voice made me jump.
“Goin’ home, Tony,” I replied, but he held up a hand for me to stop a second.
“Let me get someone to escort you. Make sure you get there safe.”
I live in an apartment less than a quarter mile from the hospital, which enables me to commute by foot in all but the most inclement weather. Security here doesn’t like me to walk home at night unattended, and they often have someone accompany me on the trek if I’m leaving after dark. It’s sweet of them and reminds me how Menaker, for all its notoriety, can sometimes feel more like a close-knit community than a hospital for the criminally insane.
Tony spoke into his radio, listened to the response. “Matt will take you,” he advised me.
I only had to wait a minute.
“Headin’ home late, Dr. Shields?” Matt Kavinson emerged from a side path, flashlight in hand.
