The Skeleton Cupboard (18 page)

To begin with, Paul rejected all foods, but he'd drink water. Occasionally other young people in the unit would come past his room and say hello, and we left his door open so he could hear their music and the sound of laughter in the recreation room as they played pool, chatted and watched television.

One day a song was playing loudly from across the unit—I can't remember which one—and Paul started humming in his sleeping bag. The nurse who was sitting quietly and patiently by his side joined in. In time Paul asked what the song was. He was told, and then, after a few moments, he asked if he could be helped to have a shower. Without fuss the nurse called for a colleague and they took him into the shower room. The rest of us, who had studiously pretended not to react when they took him out, stood in the nurses' office and silently cheered and high-fived.

After a week Paul was beginning to join the unit and become a member of our community. While he spoke little and made no eye contact, it was possible to see him smile occasionally, a wonky, reluctant half upturn of his mouth, as he listened to the chatter of the young patients and the staff team around him.

He was a good-looking boy, with thick chestnut-brown hair and deep dark eyes. I found it very difficult to meet his gaze. Having read his history in the many files compiled by social services and other agencies over his twelve years, I knew that behind those eyes was a past I couldn't bear to think about: mother with mental health problems, alcoholic father, domestic violence, physical abuse and abject neglect to the degree that he would often be seen rummaging for food in dustbins near his flat.

Eventually Paul moved out of his sleeping bag. He would allow himself to be washed. In time he began to wash and feed himself, but he struggled to engage any further. So one day we, as a staff team, decided we needed to give him a nudge.

The day had started normally with breakfast, and then Paul was told that he would, after breakfast, brush his teeth and go into the unit school—just to sit and take the community roll call, with no expectation that he would engage in the school day, although he was welcome to sit in the main area and listen to the lessons going on in the rooms around him. I was to accompany Paul to school, sit next to him and be near him until he felt he needed to return to the safety and containment of the locked unit.

Paul and I joined the group of young people and stepped into the sunshine. It was a bright late-spring day and the air smelled of cut grass and roses; I was happy. Paul walked next to me, his head down as we made our way across the courtyard to the school building. He said nothing.

In the school, Paul and I sat next to each other in the large circle of chairs and listened as the head teacher, an ex-professional rugby player, reassured the young people with his structured roll call and his large but calming presence. Everything felt right.

Each young person acknowledged their name and spoke about their goal for the day. The bright, perfectionist, eating-disordered, self-harming girls and one boy were easily able to set out their coursework goals, and the teaching staff quickly jumped in to encourage them to reduce their overelevated expectations.

The angry pupil-referral-unit kids, those who had been kicked out of school, sat back and laughed at the thought of a “goal.” One was excluded back to the unit for a lack of respect, and the others quickly fell into line and managed to find something that they were interested in accomplishing that day.

The sweet and talented psychotic girl with an autistic-spectrum diagnosis rocked and bit the back of her hand while the staff showed her yesterday's drawing and asked her if she would like to complete it. She had sketched most of London in perspective and to scale, but she had still to finish each carefully outlined turret of the Tower of London. She grimaced, shrieked and nodded.

Then it was Paul's turn and we all paused, but only briefly, ready to pass on by him. He spoke.

“I want to do English—to read stories.”

It was a good moment, a great moment. The teacher smiled. I teared up and had to look away. This was what I was training for.

Roll call ended and all dispersed to their classrooms. Paul and I sat together. He looked at me and gave a wonky smile.

We sat in silence as I wrestled with my next move. Other team members passed me, smiling and nodding encouragement, because they knew that this brittle, broken boy was only ever going to make the next step forward toward them if I was there to facilitate that. I was the person he trusted, maybe the first person he'd trusted in his whole life, and I knew I could and would bring him on to the next stage of his recovery. I felt so high.

He was looking at me questioningly.

“Paul, let's think about the next move.”

No response, just that smile.

A considered, therapeutic pause and then: “Paul, you have made a big step. Let's make it bigger.”

The classroom was quiet. I had the odd sensation that everyone was waiting for me to do my stuff.

And so I did.

“Paul, you are a beautiful, bright boy. You are better than you think you are. You came into the unit in a sleeping bag, wanting to die, and we were worried about you. We thought you were going to die and we would have to do drastic things to you to help you live. But you proved us wrong.”

Paul stared at me, unblinking. My heart was racing. This is why I did this job.

“Paul, now is the time to make the next step, and I will make it with you…”

I had to reach out to him, to hold his hand and help him learn to take his first few steps back into life.

Time stopped. I went to place my hand on his …

*   *   *

Half an hour later I was sitting in the critical incident debriefing. My eyes were bruised and my nose was bleeding. I felt broken.

“Why did you encourage him to go into the classroom?” the now rather scary head teacher asked me.

“I thought he wanted to. The time felt right.”

“Right for whom?” The head looked really unimpressed with me.

“For Paul.”

“So you weren't aware that the care plan had specifically laid out the first step in his systematic desensitization program to school—sit, do roll call, come back to the unit?”

“Yes, I was aware.”

“Why didn't you follow it?”

“We all knew he was ready to join in.”

“Who is ‘we'?”

“Me, the staff, the other kids.”

“No one saw this. No one understood why you did what you did. What did you see?”

What did I see? I saw a boy who needed me. I saw a boy who had never been understood, and I knew I understood him. I thought that he was telling me, with his smile, that he was ready to take the next step.

But maybe that had all been wishful thinking. The reality was different. What I had played out in my head was not what was going on in the school: There was no anticipatory silence. I had dreamed it all up and had seen what I wanted to see as I sat in my reverie of salvation, my rescue fantasy.

“Paul has known nothing but physical abuse. You made a physical move. You touched him without warning and without his permission.” The teacher told me off sternly.

I got it: Paul had only responded to my physical gesture of compassion in a manner that he understood. When anyone approached him physically, they beat him.

Paul punched me hard between my eyes and almost broke my nose; this was the physical language he understood. I had expected him to understand mine because I needed him to validate my desire to rescue him.

Paul taught me that my rescue fantasies were my problem. He was my professional salvation. Some people you can't save. Rescue fantasies are just that; they're fantasies.

*   *   *

As with Paul, it seemed that with Harold I had encountered another person I wouldn't be able to save.

Harold's reading test score—the test of premorbid IQ—had indicated that he was intensely bright.

His verbal IQ score, a measure of crystallized “hold” abilities, was provided by two types of measures: the vocabulary subtest for measuring word knowledge, verbal concept formation and fund of knowledge; and the similarities subtest for measuring verbal reasoning and concept formation.

The performance IQ score was provided by two different types of performance measures: object assembly for measuring spatial reasoning and visual-motor coordination; and block design for measuring the ability to analyze and synthesize abstract visual stimuli, nonverbal concept formation, visual perception and organization, simultaneous processing and learning.

Harold's verbal IQ was good, but his performance IQ was very poor.

But it was his memory that really troubled me. Harold's immediate memory, working memory and delayed memory scores were all significantly lower than I had predicted. To add to this, his visuospatial memory was shot.

I met with Chris, who was on time but all out of any kind of compassion. In fact, she seemed short with me, irritated. Had she glimpsed me at Heaven?

“The results speak for themselves. So why the urgent meeting?”

“I just wanted to double-check. It's big news to give and I don't want to get it wrong.”

Chris put on her spectacles and ran her fingers down Harold's raw scores, checking them against the scaled scores, which indicated where his results sat among the “normal population” of his age.

“Come on, it's pretty obvious. There is a significant difference between premorbid and current functioning, and the most impaired capacities sit around those we'd expect in an early but established Alzheimer's-type dementia—visuospatial, short-term recall … Do I have to carry on? Haven't you had your neuropsychometric testing lectures?”

“Yes, but…”

“But what?”

I knew I was wrong to like her at the beginning of this God-awful placement. She defended me against that ghastly bloody woman only because it turned her on—and I had evidence to back that up.

“OK. I'm sorry for wasting your time. I'll leave.”

I started to pull the testing papers together.

Chris lit a cigarette. “Stop the tantrum. I'm here, so let's get on with it. Just tell me what your problem really is.”

“Look, there's no problem—I'll go. Sorry to bother you.”

Chris started smiling as she continued to drag on her cigarette. I wanted to punch her in the face.

After an interminable silence I felt like I was going to explode. “What? What do you want from me?”

She took another heavy drag on her cigarette. “Don't bullshit me with the ‘I think I've got my scoring wrong' malarkey.”

Malarkey? Who says that? This woman was from another age.

“‘Malarkey'?” I couldn't help myself.

Chris smiled again. “Yes, malarkey. Nonsense. Drivel. Rubbish.”

“OK, Chris, my malarkey, as you call it, is that I don't want to tell him what the results show.”

“Why not? That's your job. That's what you are paid to do.”

“It's not as cut and dried as that.”

A pause. “Well, I disagree. It is ‘as cut and dried as that' because if you don't tell Harold, who will?”

“Why does he have to know?”

“Know?” Chris was getting angry and I began to feel like a naughty little child. “Know? It is his right to know. He consented to the test because he wanted to know. In fact, given what you have already told me about this man and what his results show, he is way too intelligent to not already know.”

I couldn't speak and just sat there feeling red in the face and uncomfortably vulnerable.

Chris seemed to soften. “Look, breaking bad news is never easy, but it's part of the job, and the skill is in doing it well.”

“Are you serious? How can this kind of news be broken well?”

“It can be done with compassion, with respect and with care.”

“I don't think that I am the girl for that job.”

“Well, I think that you bloody well are.” Chris mashed her cigarette into the ashtray and stood up. “And next time you want to tell me that you are afraid of what the job is asking you to do, tell me straight. No pretending not to know how to do the scoring. OK?” She picked up her bags.

“No malarkey, you mean?”

“No more malarkey, thanks. You can't pull it off.”

Leaving the room, Chris squeezed my shoulder.

*   *   *

Harold was screwed. I had to tell him. I poured us both a cup of strong, thick, fresh black coffee, sweetened as I knew Harold liked it; my grandmother drank it the same way.

He took a sip and blew on the hot liquid. “OK,
mein Schatz, gib mir die schlechte Nachricht.
” He asked me for the bad news.
“Wann wird sich mein Zustand verschlectern? Wie schnell?”

When will my decline happen, and how quickly?

“How about you tell me how you think you did, Harold?”

Harold just smiled warmly; I sensed he knew I was delaying the difficult conversation.

“Well, Harold,” I said eventually, “your lifelong abilities are well above average, and your verbal test scores indicate that they are still well preserved. But you did have greater than expected difficulties with tests of memory and nonverbal reasoning.”

Harold continued to wait patiently.

“Harold, it seems that you have signs of dementia.”

“I knew,
mein Schatz
.”

I felt awful. “Look, Harold, of course I can't say definitively that you have Alzheimer's because this is a diagnosis of exclusion and we need to continue to be vigilant that there aren't other explanations. However, your bloods are normal, you don't drink heavily, your thyroid is functioning well, and so the most likely explanation is that what you are experiencing is because of dementia.”

“I'm sorry you had to tell me.”

“I didn't want to. I'm so sorry.”

I felt like crying.