Goodbye -- a blessing and a curse

She was moving on, but not her patients. Who could blame them for reacting so emotionally?

By Elissa Ely

In my hospital lobby, there was a round man in a misbuttoned cardigan who sat on the bench outside the men's room. His hands were folded in his abundant lap. Helloooooo my friend, he said as I came in each morning. Gooooodbye my friend, he said, when I left each night. His face was a Zen garden, pleasantly blank.

His name was Jim. He had alcoholic dementia. The long-term-care hospital was his home. He will die there. For years, he was too paranoid and belligerent to leave his floor, but with medication, he had evolved into an ambassador of welcome. I was his psychiatrist, though he never recognized me. I was just one of many people he suspected he meant something to. His greeting was meant equally for the consultant who came once a year and the security guard he saw every day. We were all strangers to him.

Recently, after 13 years, I left Jim's hospital. This required many farewells: to colleagues, cafeteria workers, medical records staff, security guards, lab technicians, pharmacists, maintenance men. Most of all, it required farewells to patients who, like Jim, had lived there for years.

In psychiatric theory, the process of termination is therapeutically useful. A patient experiences various stages of grief in a safe and accepting relationship, and it becomes a rehearsal for griefs ahead. In reality, unless the patient is Jim, termination is always hard and not always helpful.

Demented and psychotic patients have had more practice saying goodbye than most of us. "It's too heartbreaking to dig up bones," said one woman, who had no interest in rehashing our years together. She was sick of therapeutic rehearsals.

Another man listened quietly when I explained that I was leaving. He had always been preoccupied with deliberate forms of mistreatment against him: pills that were the wrong color, ominous looks from staff, covert threats from the nightly news anchor.

He nodded understandingly, then went to his room and wrote a long complaint to the human rights officer. He claimed that this termination was part of a deliberate plan to inflict harm on him. I saw his point. We had been together a long time. Separation, however unavoidable, was a form of mistreatment. He took it personally.

Other patients said goodbye in different ways. One had sat in the foyer near the nursing station for years, arranging cups of milk and ginger ale on the rug, or else disrobing, or else picking invisible strands he thought were pieces of Satan off his shirt and dispersing them to the universe. Catastrophic reactions to all antipsychotic medications had made his treatment almost impossible. He enjoyed reading the Bible with me, though, and liked to thumb through the New Testament while I did paperwork in a chair next to him. He was a devout Christian and valued peace. But preoccupations with the presence of Satan on the unit often caused him to fly into war against whoever sat next to him. Afterward, he would weep in apology.

Past and present were confusing to him, dates irrelevant, and the children he once had, now adults, were still infants in his mind. His psychosis existed outside of time. In his case, I hoped saying goodbye might not even be necessary. He might never know I was gone.

Nonetheless, I told him I was leaving a few days beforehand. At first he appeared to absorb the idea. Tenderly, protectively, he picked a strand of Satan off my shoulder and dropped it onto the floor. "Maybe we'll meet in heaven and tell the truth," he said. It was a lovely thought. We enjoyed it for a moment.

A day later, his violence reached new heights. He attacked staff and patients indiscriminately. He screamed at walls. It lasted until the moment I left. He was in restraints when I walked out the door. Patients accustomed to his rage passed his door to shake my hand. They had seen his moon in many phases and knew the rising would wane eventually. His logic, like his behavior, was random and insensible. But this time, it was not random, and made perfect sense.

An administrative termination was required on my last day. It was a peremptory set of steps, and a relief from the personal. I handed over keys, logged off the computer, peeled my name off the label on the lab order book. These were pointed reminders that the business of the patients was officially no longer mine.

I was saturated with farewell, which had come to seem the opposite of care-taking, and did not want to meet anyone else. But I passed one last patient as I was leaving the hospital. The ambassador called from the lobby bench in his friendly way. It was a kind of benediction.

Goooodbye my friend, he said cheerfully. Gooooooodbye.

He waved once, twice. Then, because he was cursed and blessed without memory, he forgot immediately.

Elissa Ely is a psychiatrist for the Massachusetts Department of Mental Health.