The shock overwhelmed me. The deafening roar still rang in my ears, I looked in stunned amazement and silence at the scene before me. The corpse of a former human, my patient, slumped sideways in the chair before me. With head bloodied and half missing, canted onto it's shoulder, the eyes were still closed in a squint as they had been just a second before he had pulled the trigger of the chromed magnum which now lay on the floor beside the chair. Crimson spattered the wall beside the chair and above my desk. I recognized the red I saw as blood but, I had trouble focusing and realizing that the pinkish pieces and blackish strands throughout were bits of bone and brain and hair. My desk still neatly arranged, had the patient's folder placed squarely in the middle of the blotter. A small clock, placed discretely on the far corner of the desk near the patient, read 3:58:27 PM and continued to tick off the seconds. Interesting how I remember that. Blood and bits were even spattered over these.
Time continued slowly. I remember shaking my head to clear it, thinking what I was experiencing was not real. An hour passed or maybe it was only a minute or a second. The surreal scene did not change. A tentative knock at the door roused me. The secretary called through the door asking if every thing was all right. I turned my head toward the door. The scene changed. The world started to become more believable again. I answered, "Yes." and turned toward the body. Reality struck a home run and I changed it, "No. You better call the police. And, please, don't come in until they arrive.
This man had been my patient for the past year and had been progressing well, I thought. And now this. Certainly a most tragic waste. Maybe if I had had more experience, or been more alert, or not been lulled into complacency, or not been so sure of myself, or something, anything; surely I could have recognized the signs of impending disaster and done something to prevent this abrupt termination of our doctor-patient relationship.
As I waited for the police, my mind wandered back to an hour ago, the start of this dramatic conclusion to a man's life. I distinctly remember catching a glimpse of my name plate, Dr. Van Dern, Psychiatrist, on the door as Corey entered my office today. In the past I've had a stirring of pride at my accomplishment every time I saw it. I wonder if that can continue.
Corey had walked into my office with a nuance of change from his normal pattern, although this isn't saying much. He usually plodded in rather stiffly with head down, eyes looking apprehensively from under his dark brows. Today his head was a little higher, his step a little springier, and there didn't seem to be the apprehension in the eyes, more like a hopefulness. He was dressed in a dark suit, matching patterned tie, and nicely polished although slightly scuffed and dusty shoes; usual attire for him, as he came from his college classroom directly to my office. He was carrying his brief case, as usual, which almost assuredly contained lesson plans and tests and today had transported something more deadly, by far, than a bad grade.
"Hi, Doc." He always called me doc, even from day one. He had a PhD and certainly deserved to be called Doc himself. I guess this was his way of pleasantly telling me I was in charge. As I said, he had been my patient for the past year. He had come to me with a "little problem". His words, not mine. He, I'm sure, realized his "little problem" was actually quite big and complicated but, wanting to spare my feelings and decrease chances of rejection, as a lot of patients do, he opted for the adjective, "little". Few people willingly seek out a psychiatrist for big problems and none for a truly "little problem", although I didn't tell him this.
It had taken him a few sessions to become comfortable with the role of patient and of having to bare his soul to me, a total stranger. There is a large element of trust which must be given to the doctor to do this. Trust is not something that can be given lightly or immediately. It takes time to build trust. As Corey gained trust, more of his story, his history, his dark secrets became revealed to me. One of my mentors, while I was a resident, once told me that patients give a doctor the greatest gift that can be bestowed on another when they trust a doctor enough to give to the doctor a piece of themselves; when they tell the doctor something about themselves.
This process of revelation did not occur as a flowing story. It first started as a vignette of life events, a brief happening here, a fleeting snatch of a memory there. Later, as one memory brought back others and as trust grew, the story fleshed out. Although not told as a coherent time line of events; as it evolved, it eventually could be logically tacked together into a life history. It was a story full of misgivings, mistrust, misery, self doubt, self loathing, rejection, secrets, and hiding. It was a story of guilt and shame, pain and sorrow. There were happiness and successes along the way, but these were not the "little problem". And, most of all, this was a man who was finally freeing himself of his heavy life story. This had taken the better part of nine months, at one session a week.
Rarely do people come to a doctor just to tell a story. They usually want help with solving a problem, although just unburdening the soul often times provides enough insight into themselves and is all the relief and solution they need. This was not the case with Corey. Being the academician that he was, he wanted more. He wanted closure. He wanted an ending. And, he wanted a new beginning. So, for the last three months I attempted guidance and support, encouragement and criticism, feedback and comfort while he tried to unravel an old life and reravel it into one with new meaning. And, he did struggle mightily. He worked not only to see the old in a new light but fought to plan a future based on his new understandings of himself.
So, he came in today. Who could have guessed. After a few pleasantries and small talk about the weather, his job, and his family, that took about ten minutes, we proceeded to the business at hand.
"What can you tell me about how things have been progressing in your life since last week?", I asked.
"Well, I think I have things worked out as well as they are going to be for now.", he replied." When he had gotten to know me a little better he would sometimes play these little mind games with me. Although not spoken, only implied, they went something like this, "I'm thinking of something and I'm not going to tell you and unless you guess that I'm thinking of something and then you guess what it is, then I won't even tell you that I'm thinking of something." Pretty convoluted logic and even more convoluted to try to figure out. I did succeed sometimes.
"Can you be more specific?"
"Well, you know, Doc, you have told me many times that no one can make me do something I don't want to do or keep me from doing something I really want to do, right?" A rhetorical question that needed no response. Even if it had, I've often found it is best to just sit and listen, to not provide comments or answer questions. Patients respect this, I think, because I don't intrude into their story, allowing them to tell it as they see fit. "I think I now have a new approach for handling my life. I've thought about it a lot in the last few days. I think it's best for me. Later today I'll share it with you."
Hindsight is always 20/20, they say. Today I couldn't have agreed more. I would have delved more deeply at that point if I had known what would eventually transpire. I didn't. I have a rule that says, let a patient tell his story in his own time and in his own way. The story usually turns out better. So I didn't probe. But, if I had, would that have changed the outcome of this hour significantly? Another rhetorical question.
"Is there anything else you want to bring out today that concerns you or you just feel the need to talk about?" Not a sterling next question on my part, I admit, but a way to keep things rolling.
"I want to thank you for helping me to come to this point in my life, Doc." I could feel it coming. When a patient gets to the point of saying, "Good-bye. I don't need you to lean on any more." they start by thanking me for my help. In Corey's case, I knew this had been in the works for a time now. We had talked about it lightly in the past few weeks as he had been exploring future options. I knew also, that the next topics of conversation, in some order, would be a rehash of how his life had been before seeing me, his turmoil during his time with me, and his confidence in moving on with his life. And so it went for the better part of the rest of the hour. All except moving on with his life. I figured that would come also. He told me it would.
The patient uses these, I'll call them summary sessions, to say "Good-bye." They resolve the final conflicts of parting. At these times of breaking with a patient I resolve my own issues in saying, "Good-bye" as well. I have mixed emotions. One of these is happiness in closure; a patient's problems are resolving, a life can go forward, a new balance has been struck. There is also sadness due to loss; for even though a patient can not be my friend, I get to know them, in some aspects better than their friends and sometimes better than their families, and I attempt to help with their problems as a friend or family member would.
As the end of the hour drew near, although I wasn't anxious to see him gone, I did want to give him a chance to tell me what he saw in the future. I said, "Well, Doc," giving him back control, "as you leave today, the ball will be in your court. You told me earlier you would share with me. What do you see in the future?" He leaned over, opened his brief case and pulled out the pistol. That's when the shock started and time seemed to slow. I wasn't sure what would happen next.
"Are you going to kill me?", I asked. I think I may have shown calm on the outside but, I know I had agitation in-extremis on the inside.
"No. There is only one bullet in here. It's for me."
I wanted to ask, "Why?", but old habits die hard. Let him tell his story. I probably couldn't have asked anyway as my mouth was very dry.
"Listen, Doc, I'm a big boy. This is my decision, I'm comfortable with it, and I'm willing to accept the consequences. I can tell you don't agree with it. I suspect you would try to talk me out of what I am about to do if I gave you the chance. You need to know I didn't come to this decision lightly, or in haste. In fact when I first decided I would pull the trigger, about a month ago, I knew I couldn't tell you about it because you would try. I have thought about what I am about to do many times every day since then. I've weighed the pros and cons. Some may say I'm depressed. I assure you, I'm not. Some may say I'm crazy. I don't think so. I know what I'm about to do will not make your day and will certainly not please others, but its what I have to do. You may not understand. You may never understand. Know the following and it might help you to understand. Everyone must choose a destiny. You taught me that. Everyone must make choices and then take the consequences of those choices. You taught me that also. I have lived a full life, although it wasn't the one I would have selected for myself had I realized long ago that I could make choices. I accept that. Because I asked for it, my life has changed. I thank you for that. And thanks to you I have made the decision which I was subconsciously struggling with when I first came to you. And now I choose to die. Its been preordained and inevitable. You and I just didn't know it. Now we can't stop it So, good-bye, Doc, and thanks."
At that, he placed the gun to his right temple and pulled the trigger while I sat frozen and in stunned silence. He was right. I don't understand. I may never understand. But, I'm sure going to try.