Cut to the Bone

by Ellison Cooper

  Though she’d known that Great Falls was a wealthy area, the understated grace of this place reeked of money.

  As she parked her bike, a whip-thin, overtan man with curly blond hair hurried out the front door. His loose blue tunic and gray linen pants flowed around his body as he held a hand aloft as though Sayer were an old friend.

  “Dr. Altair. Dr. Lilenhammer at your service.” He bowed slightly. “I can’t tell you how much I appreciate you coming all the way up here.” His faint British accent didn’t quite match his vague surfer cult-leader vibe. “I know you must be busy, but, as I’m sure you understand, I hesitate to break patient confidentiality. I have strict rules about where and when I can share patient information and I will only do so if I deem it necessary to prevent harm.” He flashed a blinding smile that made Sayer wonder how much he spent to keep his teeth quite so white.

  “Of course.” Sayer pulled off her helmet. “I appreciate you contacting us. And please, call me Sayer.”

  “Sayer it is.”

  She noticed that he didn’t return the courtesy of providing his first name.

  “Follow me to my office,” he said as he led her through a glossy wooden front door into what looked very much like an expensive Santa Fe spa. A fire roared in the oversized beehive fireplace in the corner. She followed across the terra-cotta tiles and up a narrow, curving staircase.

  Dr. Lilenhammer smiled back at her again as they made their way through a small labyrinth of halls carpeted in soothing earth tones. They finally stopped at an intricately carved doorway and he pulled a single key off the leather necklace he wore.

  “As you can see, we spare no expense making our clients comfortable during their stay.” He unlocked the door and led Sayer into one of the most beautiful rooms she had ever seen.

  The coffered ceiling was clearly transported from an old Spanish mission church. An azure blue tiled fireplace dominated the back wall. The rest of the walls were windows and Sayer realized that the entire room was cantilevered out over the river. Through French doors, a rounded balcony off the end of the room looked like it was floating above the water. She could hear the faint roar of rapids far below.

  “So this is a residential facility?” Sayer asked.

  “It is. Though, at the moment, we only have two residents and they’re on a field trip with my staff to the zoo today. Which means we have the whole place to ourselves.” He held his hand open like he had wings. “We only admit patients that meet specific criteria…”

  Sayer didn’t say anything, but she imagined that the criteria must be having a lot of money.

  As though reading her mind, the doctor smiled again. “I know what you must be thinking. That this facility must cost our residents a pretty penny.”

  Sayer bowed her head slightly with acknowledgment, but kept her face neutral, still not sure what to make of this man.

  “Our research is privately funded, which means that our residents pay nothing. You see, we’re challenging traditional approaches to the treatment of psychosis and there are many people who would like evidence-based alternatives to what we’ve got now.”

  “So the drawing you sent us is from one of your residents?” Sayer dove right in, not wanting to waste any more time on this trip than necessary.

  The doctor steepled his fingertips together and assessed Sayer. “Before I discuss my patient, let me ask, what do you know about psychosis, Dr. Altair?”

  Sayer suppressed the urge to demand that they get to the point. Now was the time to do the annoyingly familiar academic dance to gain this man’s trust and convince him that she was his intellectual equal. “Well, I know it is characterized by hallucinations, delusions, disturbed thought, and lack of self-awareness. Psychosis often manifests as the belief that an individual can see hidden connections, karmic cycles, or magical cause-and-effect connections between unrelated things. It is usually triggered by some combination of genetics, brain damage, and physical or emotional trauma. Neurologically, I know that the brain of an individual experiencing psychosis is sending legitimate sensory signals that are experienced by that individual as very real. For example, when a person is having an auditory hallucination, such as hearing voices, the auditory regions of their brain light up. In other words, their brains are genuinely hearing the voices just like any other sound.”

  “Exactly right.” He remained standing, hands still steepled. “This is why I wanted to speak with you directly. My treatment methods here are seen by many as … unorthodox, despite the research supporting it. I want you to understand that before I discuss my patient.”

  “Your patient? Did you not know his real name?”

  “Correct. I only briefly treated him while he was being held in jail and then briefly again at the hospital. I never confirmed his real identity.”

  Sayer brought up the photo of Luke Windsor on her phone. “Is this the man you treated?”

  He flashed a megawatt smile. “Yes. He’s aged significantly, but that looks like him. You say his real name is Luke Windsor?”

  “That’s right. You treated him but didn’t even know his real name?” This entire place just felt far too woo-woo for her tastes.

  “Let me give you the two-minute spiel about our institute.” He looked to Sayer for permission.

  She gave a small nod.

  “As I’m sure you know, I was a professor at Harvard working on developing new treatments for psychosis. My entire background and training made me believe that our primary goal as doctors treating the mentally ill was to use medication and therapy to reduce symptoms as much as possible in order to help the mentally ill counteract their illness. For example, you brought up auditory hallucinations. One of the most difficult things for many diagnosed with psychosis is ignoring or suppressing the voices in their heads because, as you so accurately pointed out, they sound perfectly real. How are they supposed to be able to tell which are false?”

  Dr. Lilenhammer’s eyes shone with zeal. “I spent the first twenty years of my career looking for medication that could suppress those voices and help patients live a more ‘normal’ life.” He made scare quotes around the word “normal.” “Now, don’t get me wrong, I am a firm supporter of the right medication for the right reason … but everything changed when I went on a trip to Africa.”

  Sayer managed not to roll her eyes as she hoped very much that he wasn’t about to tell her all about some shaman he met somewhere in Africa.

  “While there, I traveled to a village in Burkina Faso where a prominent shaman lived and worked.”

  Sayer sighed under her breath.

  “People traveled for hundreds of miles seeking his guidance and I was quite eager to meet this shaman,” Lilenhammer continued. “When I did, I quickly realized that, were he in the States or Western Europe, he would be diagnosed with psychosis. He had intense, ongoing hallucinations, both auditory and visual. He had no less than twelve different voices in his head, which he interpreted as spirits from the beyond.” He wiggled his fingers in the air.

  “Despite his extensive hallucinatory experiences, this man was living a happy, productive, highly respected life. And I realized”—Dr. Lilenhammer paused dramatically—“that much of our understanding of mental illness is culturally bounded. Right now, the Western medical model focuses on convincing psychotics that their hallucinations are not real. We give them medication to suppress those hallucinations. This works very well in some cases, but not always. In other parts of the world, psychosis is seen as a holy gift. And it’s important to note that I’m not just talking about shamans. Religious practitioners around the world, including modern Christians, believe in prophets that have extra-real perception, able to communicate with God or gods. In one context, a man claiming to speak to God is heralded as a sign of the divinity, whereas in another context that same man with the same exact claim is treated as mentally ill. I simply seek ways to help patients mold their hallucinations into something manageable without forcing them to acknowledge that they aren’t real
as a way to dramatically improve their quality of life while also encouraging a return to functional behavior.”

  He wrapped up what was clearly a well-practiced speech. “In conclusion, I learned in Africa that the goal I had been working toward all those years was wrong.”

  “So, you don’t try to treat hallucinations here?” Sayer asked.

  “It depends what you mean by treat.” He cocked his head to the side and smiled. “For example, one of the institute’s first patients was obsessed with tearing buttons off of clothing, believed them to be receivers for monitoring equipment. He had been institutionalized for years on a dozen different suppressive medications to stop his urges. When he got here, we simply provided him with a whole stack of clothing with buttons he could remove.”

  “You let him obsessively tear off buttons?”

  “Exactly. And we simply resewed the buttons on every night. When we stopped trying to suppress the behavior, he flourished. Did you know that people who make a living as mediums often hear voices in the exact same way that people diagnosed with psychosis do?”

  Sayer frowned, but shook her head. This was going way too far afield from what she wanted to know.

  “It’s true!” He practically jumped back and forth with excitement.

  Sayer could see why people were willing to give this man their money. He was articulate and passionate despite his slightly unusual demeanor.

  “Many mediums hear voices as loud and as often as people with clinical psychosis, so why aren’t they considered mentally ill? Why aren’t they in institutions? The answer is that they found ways to work with their voices. Rather than constantly try to determine reality from hallucination, they accepted the voices as somehow part of their individual experience of the world. And when they met those hallucinations with acceptance, the tone of the voices almost always changed from aggressive and scary to helpful and supportive. So, our treatment focuses on directly confronting hallucinatory input. We examine it together as a therapeutic team, talking about ways to accept and even alter hallucinatory content.”

  “Okay,” Sayer said. “So Luke Windsor was here confronting hallucinatory experiences with you?”

  “No.”

  “No?” Sayer asked, confused.

  “No, Luke Windsor was never here. I’m sorry I wasn’t clear. My colleagues at local hospitals and police stations are aware of my interests. When they arrest or treat someone they believe to be experiencing psychosis, they often call me in. I like to treat such people pro bono and often travel to their location. A few months ago, a police officer friend of mine arrested a man who was clearly experiencing intensive hallucinations. He was frightening people on the street, so they brought him in. After realizing how confused the man was, my friend called me in.”

  “Where was this?” Sayer asked.

  “Not too far from here in McLean.”

  “So, you went to the police station?”

  “Correct. And there I realized that he was indeed experiencing a psychotic episode.”

  “Could you share the nature of your … treatment?”

  “Of course. I asked him to draw me an image of what he was seeing. That’s the drawing I sent to you. I then encouraged him to talk to me about what he was experiencing.” Dr. Lilenhammer fell silent.

  “And?” Sayer finally asked.

  “And he described vivid and terrifying hallucinations of having his brains removed through his nose. Of being cut open, his organs removed, then linen and salt packed into his now empty body.” The doctor paused to watch Sayer’s reaction.

  “He thought he was being mummified?” she asked.

  “More precisely, he believed he was already mummified. You see, he was utterly convinced that he was already dead. Luke Windsor appears to be experiencing one of the most rare forms of psychosis—Cotard’s syndrome.” Dr. Lilenhammer smiled so widely Sayer wondered if his face might eventually split in half.

  “Cotard’s, I’ve heard of that.” Sayer tried to remember that lecture from abnormal psychology. “Isn’t that when a person is convinced they’re dead, even though they’re still walking and talking?”

  “Yes. Psychosis often involves some form of alteration of self-awareness, but Cotard’s is one of the most extreme forms. For some people, they become convinced that part of their body has died or no longer belongs to them. But Luke was convinced that he was most sincerely dead.”

  “He thought he was dead, as in no heartbeat, not breathing?” Sayer asked. “No matter that he had a pulse and could feel his lungs working?”

  “That’s right. It’s a powerful delusion. Those experiencing Cotard’s often die because they simply stop eating.”

  “Because they don’t need food anymore if they’re dead,” Sayer said.

  Dr. Lilenhammer nodded solemnly.

  Sayer thought about Declan’s description of the unsub as zombielike. He must have stopped eating and probably also bathing. “I need to know more about his delusion surrounding death,” she said. “How did he think he died? Where did he believe he was?”

  Dr. Lilenhammer strode over to his desk. “Of course. After talking with you for just a few moments, I feel comfortable sharing everything. Luke believed that he died in a car accident, which I suspect had some basis in reality.”

  “You think he was really in an accident?” That could give them a promising lead if she could find out where and when the accident occurred.

  “I do. See for yourself.” Dr. Lilenhammer riffled through a slender file and pulled out a brain scan that he passed to Sayer.

  “You have an MRI?” Her heart beat more quickly. No matter how much she loved her work as an FBI field agent, her true love would always be neuroscience, and this image would give her a new window into Luke Windsor’s mind.

  “Of course! After I spoke with him at the police station, I saw extensive scarring on his forehead and worried that his delusions might be the result of a medical emergency. It’s always important to rule that out, so I requested a transfer to the nearest hospital for evaluation. He consented to an MRI and, as you can see, it does show evidence of a brain injury consistent with a relatively severe car accident.”

  Sayer held the MRI up to the light. “This is massive damage to the temporoparietal fascia of the right cerebral hemisphere.”

  “A kind of brain damage known to trigger depersonalization and derealization hallucinations such as Cotard’s syndrome,” Dr. Lilenhammer added.

  “This is a serious traumatic brain injury that easily could have triggered a psychotic episode. No wonder he’s suffering from such extreme delusions.”

  “I prefer to say experiencing rather than suffering. Much of the suffering of those with mental illness is caused by a world that does not accommodate their needs,” the doctor said firmly.

  “Can I keep these for now? I promise to return them when the case is concluded,” Sayer asked.

  “Of course. I have copies of my notes here. This file is for you.”

  “So, Luke believed he was killed in an accident. Did you find out anything else about his delusions that might give us insight into why he’s killing these people now?”

  “Well, upon finding himself dead, instead of being at peace, he apparently found himself in the Egyptian afterlife.”

  “Why the Egyptian afterlife?” Sayer asked.

  “I’m unsure, though his hallucinations were elaborate and specific. He saw the sky goddess, Nut, holding up the stars. He believed he could communicate with the sun god through esoteric rituals. He thought that the cycles of the heavens were inextricably linked to our actions here on earth.”

  “‘As above, so below,’” Sayer said under her breath, connecting the dots.

  “What?”

  “I’m sorry. Windsor wrote, ‘as above, so below,’ at one of the crime scenes.”

  “That’s certainly in line with his delusion. Almost all of his hallucinations were related to ancient Egypt somehow. And I will say that he had elaborate knowledge of Eg
yptian mythology. After I spoke with him, I looked up everything he said to me and it was all accurate. He also explained that, because he was dead, he had to make it through afterlife. He spoke of a journey of trials necessary to achieve his place among the gods.”

  Sayer nodded. If Luke Windsor thought he was dead and genuinely trapped in the afterlife, perhaps he believed he had to re-create the twelve chambers to finally pass on.

  “In addition to his Egypt-specific delusions,” Dr. Lilenhammer continued, “Luke also had more traditional delusions about shadowy government agents spying on his every move, out to kill him. It’s why he refused to tell me his real name or background. He claimed that the second I entered his information into my computer, they would come for him. It’s a surprisingly common delusion.”

  “What did you discover about his background?” Sayer asked.

  “Well, our conversations were brief, but I would guess that he is ex-military and that he grew up in this area. That’s about all I could glean from our interactions. I’ll give him credit, despite his intensive delusions, he was shockingly good at keeping background details from me.”

  “And then what happened? Was he arrested?”

  “No, not at all. After the hospital said that they weren’t able to do much for him, and I felt that he wasn’t a threat to himself or others, they simply released him. As you well know, mentally ill individuals are far more likely to be victims of crime than perpetrators. I felt as though this poor man was experiencing delusions brought on by some kind of grievous accident. My only concern was that his Cotard’s would prevent him from appropriate self-care. But beyond my concern, I would never have expected him to be violent or dangerous.”

  Sayer stared at the doctor.

  “I actually offered to let him come stay here,” he continued. “I would have loved to treat him. But he wasn’t interested.” For the first time, the sunny crinkle of the doctor’s face fell. “Though now I’m to understand that I misjudged him horribly. If he has killed a number of people…”

  “Seventeen people, to be exact. Four adults and thirteen children. Plus, he’s still holding an additional ten girls somewhere. One of which we believe he will very likely murder at nine tonight.” Sayer didn’t hold back.