There was a typical October drizzle drifting across the car park as I pulled in for the morning, a mist which steadily increased as I pulled my bag from the boot and hurried across to the gate lodge, hunting for my security pass as I did so. Inside, there was the usual Monday morning queue, the process of clearing staff and issuing their keys always taking longer at the start of the week. I'd often wondered if this was due to the guys behind the glass having accrued monumental hangovers in the course of the weekend but finally concluded that it was just yet another example of their bloody mindedness. Believe it or not this is a hospital- albeit a highly secure one- but you'd never guess it from dealing with the security staff.
Still. No keys, no access. No access, no job. So grin and bear it.
I'd just reached this zen-like conclusion- as I did, perforce, most days- when I noticed my boss a few places ahead of me in the queue and managed to attract her attention with a well timed wave. I was obviously among the blessed this morning, though, because she promptly dropped back for a chat. Albeit not a friendly social one- Linda was just as focused as you might expect a consultant forensic psychiatrist to be. Especially one who'd been on call all weekend and now, I belatedly realised, had a convenient minion on whom to offload any inconvenient issues that had emerged the while.
Which suspicion appeared to be all too accurate, given that her opening gambit was to enquire about my caseload.
"Well, you know how it is- you could always do with more time, fewer problems, but generally, I'm coping. I assume that I'm about to get a little extra something, though?"
She had the good grace to laugh, slightly.
"Nothing too onerous, I hope," she explained. "In fact, I think this one might interest you. A prison transfer we took as an emergency on Saturday afternoon. Good nursing observations from the prison 'hospital', for a change, and I saw him briefly yesterday, but ... I don't know. There's something odd about this one. Not your normal paedophile, I mean- or at least in his opinion. Come over to my office, though ... I'll show you the notes."
She paused as we finally got to the head of the queue, turning to me as she started for the exit.
"You're a bloody good senior reg, Dave. But if you want to make it to consultant ... well, it'll be interesting to see what you make of Dr M..."
Once through the lodge, keys clipped firmly onto strap, placed securely in belt pouch- all as per regulations- Linda set a rapid pace across the 'campus'. Unlike most clinicians of her status, L's office was within the secure area- behind the four metre concrete wall, in other words- which, as she put it, saved time and got her a higher quality of administrative staff ... many, if not most, of the hospital's clerical types being far too scared of our- umm- challenging patient group to come so close to them on a daily basis.
It was one of the reasons I liked her- that and the fact that she kept a stock of excellent coffee and was even prepared to share it with underlings. This morning she gave me a cup as we got into her room, as well as a voluminous file- or, strictly, several files, loosely tied together with prison service tape. Which, taking the hint, I began to read as she turned away to make some phone calls, check through messages and generally prepare for her day.
So. Dr Pieter M. I knew the name, of course, his trial and conviction having filled a fair few column inches in my morning newspaper. But I'd never expected to see him here...
Not that the case notes were all that informative- most of the bulk consisted of legal documents, most interestingly witness statements from his trial and copies of the material that had led to his conviction in the first place. I scanned that, of course- its a necessary if distinctly unpleasant part of the job- but I put most of my initial effort into reading the clinical entries. Such as they were- a couple of reports prepared for the Court, the nursing notes Linda had mentioned from the prison hospital wing and, finally, the written referral to us. All of which gave me more questions than answers- not least quite how he'd been thought worthy of a bed here- and as an emergency, to boot- on such scanty evidence.
I was still pondering it all when Linda finished her calls and turned to me expectantly.
"So- what do you think?", she asked.
"I think I probably ought to go and see him. There's not a huge amount to go on, here."
I pointedly didn't mention the fact that she didn't seem to have written up any notes from her meeting with him, nor was she sharing her own thoughts and observations. Far be it from me to question, though...
In any case, I seemed to have given her the answer she wanted, as she replied brightly,
"Good, Darwin ward have got him on 1:1 obs as you might expect"- Darwin had nurses individually assigned to "observe" virtually all of their patients- "but I'm sure they'll find you a room to talk to him. Oh, and I've checked- they've got nothing in the way of transfers or admissions scheduled for this morning, so why don't you toodle off over there now?"
I can take a hint, me. So sod my schedule for the morning- I picked up my stuff and headed over to Darwin.
This place is laid out like a giant clockface, single storey wards arranged in pairs around a slightly squashed circle. For some reason they're all named after scientists- in alphabetical order from Angstrom to Wilkins, since you ask- but in any case Linda's office was round the back of the Perutz/Rutherford block, which made it about as far from Darwin as it was possible to get. And the rain was now coming down with a vengeance.
So I was a bit wet when I got to my destination, my mood not further improved when I let myself through the outer door of the 'airlock' and discovered the vestibule to be full of clinical supplies- for which, read 'drugs'- which it shouldn't have been. But it was, and that meant that I couldn't proceed through the inner door- and onto the ward itself- until all the patients had been safely corralled out of the way. Absurd, I know- the chances of a patient actually wanting to steal the sort of medication we used was minimal, the chances of them getting through the innumerable layers of packaging the pharmaceutical industry went in for before the riot squad- sorry, Special Intervention Team- arrived non-existent. But then, on another level, it was sensible. Darwin was a dedicated special care unit, after all, dealing with newly admitted patients considered unsuitable for Angstrom and Bohr, - the formal admission wards- and for others who'd experienced problems on their 'home' areas. So: Better safe than sorry and all that.
Only, just at the moment, I was dripping wet and they'd switched off the heating in the vestibule- must be something temperature sensitive in one of those boxes, I guessed- so I was also freezing and it took bloody ages to clear the area and let me in. As a result, I wasn't brilliantly happy when Joe, the ward manager, finally waved me through- and, perversely, my temper didn't improve when he immediately showed me into an interview room, presumable having been warned in advance of the purpose of my visit. In any case, I had no chance to express any sort of vexation- however pathetic- and instead found myself face to face with my patient.
Who was, on first impressions, a slightly shabby looking, fifty-something male. Medium height, rimless glasses, still dressed in prison issue clothing. Definite incipient bald spot, slight paunch. Body language constrained but seemingly confident, hesitating to make eye contact but maintaining appropriately thereafter. Did not offer any sort of greeting, remained sitting in the plastic chair he'd been given as I formally took responsibility from the nurse who'd been with him on my arrival, set my bag down on the table and found a note pad to begin the interview proper. Overall- nondescript sort of bloke, someone you'd have walked past in the street without a second glance. Didn't look like a PhD, for sure. And, yes, that really is how clinical observations are made- whatever the text books might say.
I introduced myself, explained that I was here to do the formal admission- which includes taking blood pressures and a family history and all that stuff, though I have no idea why the nursing staff can't bloody do it- and also to have an initial chat, given that I was part of the team that would be caring for him.
He let me get through pretty much the entire spiel without interrupting- which was novel- and thereafter the interview, I thought, went pretty well. I mean, working as a forensic psychiatrist means that most of my first 'chats' with my punters- sorry, patients- tend to involve either long, complicated explanations of quite why they had to chop a sibling or whoever's head off with mum's best carving knife ... or a simple refusal to talk to me, me obviously being- from their perspective, at least- the living incarnation of Beelzebub ... or their particular demon of choice.
Dr M wasn't like that. Once he'd got used to being in a room with just me- realised that he was no longer being 'shadowed' by one of the ward's typically rather physically impressive nurses- he opened up completely. Admitted it all. Agreed that all the legal documents were correct, that all the files recovered from his computer were his, that he'd known about them, had deliberately obtained them, that...
Well, he was pretty co-operative. Except that that was all slightly moot- he'd been convicted, after all, so what he thought about it all was hardly the issue- and there was one glaring issue that I felt might complicate our future treatment options.
He didn't think that he'd done anything remotely wrong.
Linda, when I caught up with her late in the afternoon, wasn't all that impressed. Nor was she remotely surprised, or, to be fair, even slightly critical of me. In fact, as she listened to the recordings- we don't generally publicise the fact that we tape interviews, but we often do- she actually congratulated me on my interview technique, even as she was pointing out a couple of things I might have chosen to follow up on.
Which all, I realised, meant that this- he- was now my case. And I'd done the PSE, ABC and SPA- present state examination, aberrant behaviour check-list and sexual preference analysis, to the uninitiated- and, of course, talked to the bloke on a human to human basis. And it had got me nowhere. I still wasn't sure what he was doing here in the first place, didn't actually have a clue what I was supposed to be treating him for, let alone what sort of treatment to offer ... and Linda was being distinctly cagey about offering me any sort of advice. Which made me think that maybe- just maybe- there was Politics involved.
Which was probably not brilliant news, at least if I wanted my career to continue on its so far moderately stellar course. I went home with a distinctly uneasy feeling about the whole business.
Next morning, I got into my own office- well, cubbyhole, and that shared with a couple of Linda's even more junior doctors- and found a note from Linda on my desk. Which informed me that she was away for a couple of days, dealing with some bureaucratic shit or other- no surprises there- but which signed off on a slightly odder note.
'Re Dr M', it said, 'Keep up the good work.'
Dr M was still on Darwin, given that we- I- had, as yet, no idea where a more appropriate placement might be, but it wasn't raining and they'd shifted the junk, so this time I got onto the ward without any hassle. Problem was they had a couple of transfers in progress and no interview room for me to use. I ended up seeing him in a corridor, which was hardly best clinical practice. It also meant that I had no objective record of proceedings.
Which was a shame, given that he immediately took me by surprise by the effusiveness of his greeting. Actually, I thought he might even try to hug me- no staff around to intervene, I noted, side stepping neatly- but he limited himself to a very warm, "Doctor!" before continuing,
"You're a reasonable man," he said, generously, "and you must know that I've done nothing to warrant being in a place like this ... so please ... why am I locked up with all these cretins and imbeciles?"
Well, two black marks to Dr M, I thought, bristling. Firstly, its always a mistake to tell a psychiatrist that he/she is 'reasonable'- of course we're reasonable, its our job. And that job tends to involve us talking to people who are more or less away with the fairies, so ... we don't tend to value their personal judgements on our sanity all that highly.
Secondly, we don't tend to work with 'cretins and imbeciles'. Sure, both started out as diagnostic terms with more or less precise definitions, but no more. Not only have we expunged the words from our professional vocabulary but we've also removed the need to detain people with learning difficulties in bloody great asylums. And even if that involved transferring them to the tender mercies of social care, the previous history was still something of a professional sore spot. So I bridled, a bit.
"Cretins and imbeciles, Dr M?", I said, pointedly. "Actually, most of your fellow residents on the ward- and in the wider hospital- have really rather high intelligence. In fact, if life had gone just ever so slightly differently for them most of them could easily have PhDs just as shiny as your own."
Which was a bit below the belt, if not actually provocative, but I quickly covered my tracks by getting in a couple of direct questions. Its called seizing the therapeutic opportunity, I think, or, at least, it is when you come to write up the notes afterwards. In any event, I continued without giving him the opportunity to reply.
"One thing I am curious about, though," I said, "is how come the courts convicted you, and convicted you on, what, fifteen counts?- and sentenced you to a pretty lengthy prison term, of course- if you'd not done anything at all amiss? Why do you think that might be?"
Which was, of course, the professional equivalent of lugging a 10kg sledgehammer at a peanut- certainly not the preferred course of action this early in the process- but it still didn't get a reaction, let alone provoke a sudden outpouring of delusional ideation, paranoid conspiracies or even the slightest hint of Ideas of Reference. Bloke seemed quite sane, really- if you ignored the inconvenient fact that he was also guilty as hell. Nonetheless, I listened to what he was saying as well as how he was saying it- sometimes a useful technique, I've found- and filed it away for future consideration.
And, having listened, terminated the conversation and left the ward. A sadder but no wiser man, as someone once put it.
Linda was interested. I got to see her pretty much first thing on her return to the coalface- a most unusual thing- and she was, yup, interested.
"So", she said, magisterially, "You're saying, basically, that he's in some sort of denial? That he's aware of his position- well, how could he not be, really- and of everything stacked up against him, but he's just not, as they say, 'having any of it'?"
"Well, no," I said, just slightly hesitantly. "Problem is, I don't think he is in denial- or not as we usually mean the term, anyway. I mean, its not that his subconscious is aware of stuff that his conscious mind would prefer to ignore. To date, I've seen nothing to indicate that sort of inner psychic conflict."
"I know it sounds ridiculous, but I think he's genuine. He really, truly can't see what he's done wrong."