by Robert J. Lanz LCSW
Richard probably didn’t name himself Big Dick and he was so schizophrenic most of the time that I was never really sure if he got the joke or not. Maybe he really did have a big dick. I wasn’t about to try to find out that useless piece of information, even if I did work in a real health care facility. Besides, it had taken years to find out anything about Richard’s life despite his frequent intrusions into mine.
One of the things about schizophrenics is that in their long list of symptoms, they often have changes in their affect that makes their illness a little more obvious. Affect, in psychiatric evaluations, is a term for an observable expression of emotion, usually the facial expression of the patient’s feeling state. In the case of the most severely
disturbed, it can be difficult to tell from a patient’s affect exactly what the feeling state may be or what might have precipitated that state. Educated guesses are often part of the evaluation. Sometimes we see something profound, especially if a sudden onset in involved, but for each patient, there is what we call their “baseline”. And if a patient
isn’t feeling anything obvious or his medicine has him so addled that his face is unable to connect to his emotional state, he might not have an affect at all. That expressionless stare even has its own name: a flat affect. That was Richard, the master of the flat affect. A flat affect was Richard’s baseline.
Sometimes when he visited the ER, I tried to get personal with him. Nothing but flat affect. Sometimes I told great jokes and got nothing, flat affect. I watched him with other staff and he had no affect with them either. When there is a flat affect, one can make some assumptions like he doesn’t feel anything. Or maybe he feels things but his medications restrict his ability to show them with an affect. Maybe he’s just a dull guy and never had an affect. The interesting thing is, despite the total absence of any facial gestures, I knew that he liked me and enjoyed our time together.
Many patients, especially pathological ones, and sometimes even outright psychotic ones come to the hospital with other than the best of intentions. They may want to get in out of the rain. They may have smoked up all their government money and want to get into the psychiatric ward and watch TV until their next SSI payday arrives. Maybe they need a meal or a change of clothes. Given that we are an emergency room, patients are expected to have some sort of medical problem in order to get in to see a doctor, so they often fake chest pain or suicidal behavior to access the system, a pretty costly way to get a sandwich and a change of underwear. That’s where the social worker comes in. Over time we come to know who’s faking and who isn’t. We come to know which patients will endure hours of waiting, blood tests, maybe even injections and IV lines just to spend some time with us. Some folks will even act impaired enough to end up sedated and in restraints, all for a warm bed and some juice and crackers.
If you get to know your patients over time and multiple visits and they get to know you, sometimes you can put to end to this expensive charade. Part of my job, although it probably isn’t actually written down in the Human Resources Policy and Procedures Manual, is to use my skill to protect the hospital from unnecessary intrusions and expenses. Richard was a master of expensive intrusions and that’s how we came to know each other better. I’m not sure exactly when it took place, but I do have an idea. I think it was one really busy night in which I hadn’t had time to even eat my dinner and there were a lot of patients waiting to be evaluated. I’m not the kind of guy that puts my needs before those of my patients—taking a break when I’m supposed to regardless of the situation. On the other hand I can only starve for so long and hold my urine for so long and well, some nights it’s just a matter of time before I find some creative way to meet my own needs, too.
That busy night when Richard and I became friends called for some creative thinking. My blood sugar was dropping precipitously and my bladder was bursting to the point that had I been clipped in the kidney by one of the gurneys flying around the ER I probably would have needed to dip into the stash of homeless clothes to get myself presentable again. Nevertheless, I went in to see my next patient, and there was Richard giving me that dead stare as he looked up from the bed. At better than six feet tall, dressed in all camo clothes, his pants neatly tucked into his spit-shined boots, he cut quite an impressive figure—an intimidating one, even. He didn’t have that effect on me, because I was used to him, and if he were going to get weird with me he probably would have done so already. Still,everyone else, including most of the staff, was afraid of him. Maybe the 12-inch Bowie/survival knife he wore strapped to his leg contributed to the intimidation factor.
“Hey Richard, how’s it going?” I asked, as always.
“OK Bob. How about you?” No affect.
“I’m OK. Getting hammered in here tonight.”
“Oh. Do you want me to leave?”
“No, Richard. I just want you to tell me what you need.”
“Remember you told me to come by if I was ever hungry? I’m hungry.”
“Nothing else? No medical problems? It said on your triage note you felt faint.”
“No, just hungry. I had to tell the nurse something. I asked if you were here.”
“Well, I’m here.”
I thought for a moment, listening to my own stomach growling.
“Look, let’s make a deal. You’re hungry and I’m hungry. No way am I going to get any free time to go eat, but if I take you to dinner and you’re my patient, then I can eat too. Cool?”
“OK, let’s go up to the cafeteria. We can leave the knife in my office.”
Big Dick and I were a big hit in the cafeteria. Even without the knife, Richard was the center of attention, but for the most part, the late night diners just did a drive-by stare and went about the business of eating. Most of the staff knew me and some of them probably figured out what I was up to. Asymmetrical psychiatry, I guess you could call it. Anyway, that night we sort of bonded. Richard told me part of the reason he came by was to let me
know he was leaving town and he didn’t want me to worry about him.
“Me and some of the other guys are headed for Desert Hot Springs for the winter. We’re renting a house out there.”
For most of the year, Richard and several other guys like him had a seasonal camp in the arroyo down behind the hospital. They were tidy and didn’t have fires and kept their behavior within some agreed upon limits, just sort of crazy camping. All of the men in the group had some psychological defect to the point where the state had determined they were too goofy to work so they received SSI, supplemental security income. It worked out to about $800 a month and was designed to give them enough money to live in a licensed board and care facility, where they could live safely, three hots and a cot they say, with enough left over for smokes and cokes. Except there was no rule that said they actually had to spend it on a licensed board and care facility. There was no rule that said they couldn’t spend the whole $800 on drugs and alcohol and hookers, and my experience has been that many of my regulars do exactly that. It seems crazy to me. These guys are too mentally impaired to take care of themselves or hold down a job, so the state gives them money to spend however they want with no regard to the effect it might have on their mental health. So, with some pretty big government intervention, this group, was organized enough to camp out in the warm months, save up their SSI money and head out to Desert Hot Springs for the winter where they rented a large house, drank beer, smoked pot and snorted big lines of methamphetamines all day and night according to Richard.
I couldn’t help but laugh.
“Wow, Richard. Sounds like I’m missing the party.”
“Oh. I’ll send you the address Bob. You can come and visit. It’s really nice out there in the desert. And we have a pool.”
A pool. A desert home for the winter. Free health care. Cheap drugs. I wish I could afford that lifestyle myself. I guess I could if I didn’t have to pay so many taxes. I often think about those guys out in the desert. Does Richard smile or get the giggles when he smokes pot?
Does he become a chatter box after a couple of lines of meth? Does he scare the crap out of everyone with that knife? What a life. But hey, on the personal side, I got to eat dinner sitting down and made a friend. As a social worker, I did my job. Richard didn’t need a
blood draw or an EKG or any of that other stuff the law says we have to give anyone who asks. Just by springing for a cafeteria dinner I saved the system enough to pay my weekly salary.
Now if we could just do something bigger about that government funded pool party I missed out on. Might save some real cash on that one.
I’m not holding my breath.