Delusion

by G. H. Ephron

  He didn’t answer.

  “Look, I run the Neuropsych Unit at the Pearce,” I told him. “I’m well aware of the stress that taking care of a person with dementia can cause both to a relationship and to an individual.”

  Teitlebaum seemed to come to terms with his conscience. “No. I wasn’t surprised. She’d started somatizing. Headaches, chronic colds, insomnia. Her husband had become even more distant, withholding. The more upset she got, the more he tightened the screws.

  “The only thing that surprised me was that he let her come.” He looked me in the eye. “I’m even more surprised that he signed a release allowing me to talk to you. He didn’t trust me.” He closed his eyes and rubbed the back of his neck. “On the other hand, he’s a guy who covers his bases.”

  Teitlebaum kept rubbing the back of his neck. I had the impression he was deciding what to do next.

  “Let me show you something,” he said. He put the file on the desk and opened the top drawer and rummaged through it. If the contents of a man’s desk mirror his own consciousness, then Teitlebaum had an exceptionally orderly mind. Little plastic boxes corralled his paper clips and rubber bands, his calculator was placed into the drawer so it fit perfectly alongside a checkbook and a stack of zip disks.

  “Where the hell,” he muttered. “I know I put it somewhere.” He pulled open the next equally tidy drawer, reached his hand in back, and felt around. He drew out a small, black, rectangular object and handed it to me. It was made of metal and heavier than it looked. On one side was bolted a faceplate with a sort of bull’s-eye with a hole in the center. It was attached to a small metal stand.

  Nick’s words came back to me. They’ve got security cameras the size of a quarter these days. “Surveillance camera?” I asked.

  “How’d you know?”

  “Just a guess. Where’d you find it?”

  He paused. I wondered if he was about to cross that invisible line again. “When Lisa called me, she was frantic. They’d just had a break-in at the office, and she found out that her husband had security cameras all over the place, tiny ones, like this. She’d had no idea.”

  He went on. “She’s actually the one who spotted this thing. It was up there”—he indicated the top of the bookcase—“and it may have been there awhile.”

  I stared at a spot on the top shelf where Nick Babikian might have tucked the little black box alongside the vase, or perhaps between the books. I felt the shadow of the profound sense of violation that Teitlebaum must have felt when he realized he was being watched. The privacy of the therapy room is nearly sacred, and here it had been deliberately and systematically profaned.

  “It had a pack of about a dozen batteries wired to it. Apparently, he had gizmos like this all over the place at his company, hardwired into the electrical system. That’s one of the things that pushed Lisa over the edge. She found out he could watch her while she worked. He could watch everyone. With those surveillance cameras, he went a step too far. At first she was frightened. Then angry. And from that anger she drew strength.”

  He took the little camera from me and dropped it back in the drawer.

  “Did she know he had surveillance cameras all over their home as well?” I asked.

  He didn’t seem surprised. “That’s really sick. Well, I don’t need to tell you that.”

  “Did you see any changes in Lisa Babikian before her murder?” I asked.

  “The changes were all for the good,” Teitlebaum said, kneading his hands together. “When I first saw them together, she was pale, listless. Her clothes hung on her. She was the kind of person you looked right through. Over the last few months, she’d become much less transparent. She wore pinks, bright blues, much less of the olive drab. She was taking care of herself, wearing a little makeup. Wearing her hair down. She might even have gained some weight.

  “Of course that was just a reflection of what was going on inside. When she married him, she’d shut herself down. But she wasn’t going to any longer. I encouraged her, of course. She was trying to disentangle her identity from his, to become fully her own person. It was heroic.

  “For him to cut her down, just when …” His voice broke. “Just when …” He shuddered and sat back. “I should have protected her.” His voice turned derisive. “I was a fool. It was pure hubris on my part. I wanted to save her. She came to me, and I failed her.”

  I wanted to save her. His words jumped out at me. Here was emotion more intense than the kind of countertransference I would have expected from a relationship that had lasted six months, even if he had been seeing her twice a week. It made me wonder. It had been awfully easy for Teitlebaum to skate over the border of patient-therapist confidentiality. Why not skate over the intimacy boundary as well? Or was Nick Babikian’s paranoia rubbing off on me?

  Despite the sympathy I felt for Teitlebaum, for his apparently sincere concern and anguish over what had happened, I pulled away. I wanted to come right out and ask, Were you having an affair with your patient?

  Instead I asked, “Did you think she was going to leave her husband?”

  “She didn’t say so,” he said, looking away. It felt like an evasion.

  “Did you think she was having an affair?” I asked, pressing the point.

  The look he gave me said I’d crossed the line. “I can’t answer that,” he said and closed up. This line of questioning had come to a dead end, but why? He’d readily violated other boundaries.

  “She liked nursing?” I asked, moving to safer ground.

  He answered this readily. “Loved it. The first time I saw her get truly animated about anything was when she talked about delivering babies.”

  I remembered the rows of just-born snapshots on Lisa Babikian’s refrigerator. “And yet they had no children of their own?”

  “His choice.”

  “Nick says Lisa didn’t want children either.”

  He gave me a look that said, and you swallowed that? “She went along with it. Just like she went along with pretty much whatever he wanted. She was afraid to argue, to express herself.”

  “You think Nick Babikian was capable of killing his wife?” I asked.

  Teitlebaum’s face collapsed. “God help me.” He stared down at his clenched fists. “His progressive preoccupation with his wife’s whereabouts, the loosening links between his thoughts and reality—I didn’t admit it to myself, but I knew.”

  7

  THE NEXT day was a gorgeous New England spring day, a blip between the freeze-dry of winter and the hot-steam of summer. If you blinked, you’d miss it.

  The grass on the rolling grounds of the Pearce Psychiatric Institute was threadbare. The road through was still gritty with sand as it wound past the brick buildings, some with Dutch gables, others with ornate French flourishes, still others encrusted with Victorian gingerbread. Even back at the turn of the century, design must have been by committee. A splash of red and yellow tulips at the back of the Neuropsychiatric Unit was a reassuring sign that months of drear had indeed ended.

  I let myself in and hurried down the hall past our conference room. No one was there yet. I had time to pour myself coffee and check my mail.

  My colleague and best friend, Dr. Kwan Liu, was blocking the entrance to the tiny room behind the nurses’ station. Gloria Alspag, the nurse who really runs the place, was inside peering at a clipping someone had tacked up on the bulletin board. I should have expected it. Someone, probably Kwan, had pinned up the article and picture of me from the newspaper.

  As she read, Gloria pulled a few dead leaves from Audrey, the philodendron she’d nurtured from a sprout. It had wound its way around the bulletin board and was reaching for the window.

  Gloria was one of those people who look unimposing—not too tall, glasses, short straight hair that she’s always running her fingers through but never tossing. But unimposing she was not. She had the persistence of a terrier and the power of a pit bull.

  “Good morning,” I said.

  “G
reat picture,” Kwan said. It was his cologne that was competing with the coffee smell in the small space. Gloria wasn’t a perfume person. “Especially if what you were striving for is the Johnny Cochrane, just-rolled-out-of-bed look.”

  The rumpled look was anathema to Kwan. He had a standing appointment to get his dark hair trimmed every two weeks, and the cut of his three-piece suit was impeccable.

  “You do look a bit scruffy,” Gloria said, standing on tiptoe. “Probably hadn’t had time for coffee. No, wait, look there.” She pointed to the Dunkin’ Donuts cup I was holding in the photograph. “It’s our Peter.”

  “Give me a break,” I said. “And clear the way. I haven’t had my morning quota.”

  Gloria squinted at me and stepped aside. “You sure you’re ready for this?”

  I poured myself some coffee and kept my head down. I should have been grateful. Gloria was worried about my getting involved in another murder. But instead I felt a flicker of annoyance. I had a mother who did that. I didn’t need it from friends.

  I checked my watch. “Shouldn’t we get going?”

  As we walked down the corridor, I asked Kwan, “You ever heard of a psychiatrist, Dr. Richard Teitlebaum?”

  “I can’t say the name rings a bell. Why?”

  “This case I’m working on. He was the victim’s therapist. I’m just curious to know if he’s got any kind of a reputation, one way or another. He did his residency here about eight years ago. Then moved to Rhode Island. Moved back about a year ago.”

  “Richard Teitlebaum,” Kwan said, turning over the name.

  “Sounds like he’s well connected.” I mentioned a few of the doctors at the Pearce that Teitlebaum said he knew.

  “I’ll ask around,” Kwan offered.

  By the time we got to the conference room for rounds, the others were waiting. Our social worker, physical therapist, and lead mental health worker were at the table. A young psych postdoc, Roger Burnaby, was sitting in a chair against the wall, writing in a notebook. He looked up and nodded when we arrived. Then he pulled his chair up to the table.

  The tall, narrow room, with its glorious but now defunct marble fireplace, was looking a bit spiffier than usual. The holes in the plaster had been repaired, and the formerly pink walls were now a tasteful eggshell. It had been only a month or so since the hospital’s chief financial officer had departed rather than face an investigation of his personal financial ties to pharmaceutical companies. The place was becoming more humane with him gone. One thing hadn’t changed. Spring or no spring, the all-or-nothing heating system was going full-blast.

  Kwan went over to open the window. He pulled and strained, but it wouldn’t budge. Apparently it was painted shut. “Move over, Schwarzenegger,” I said.

  I took a crack at it with no results beyond a spasm in my lower back.

  “Men,” Gloria snorted as she sized up the problem. She systematically whacked the window frame all the way around with the heel of her hand, gave a yank on each of the window ropes, blew into each of her open palms, and effortlessly raised the window.

  “I guess it takes brains and beauty,” Kwan said.

  “Finesse,” Gloria said as she took a little bow. “Always works better than brute force.” The message wasn’t lost on either of us: Women do heavy lifting better than men. I didn’t disagree.

  We turned our attention to the white board and the list of eighteen patients we had on the unit. There was only one new admission. Elizabeth Smetz.

  Kwan said, “She thinks she’s the Virgin Mary, and she’s here to give birth to the Messiah.”

  Gloria took up the tale. “She was trying to build a manger in her garage, screaming at her husband that the innkeeper wouldn’t give them a room. Mr. Smetz was frantic. Brought her in to the emergency room at the Carney. They shipped her to us.”

  I took the file from the rack and opened it. “Seventy-five years old.” I scanned the admitting report. “No psych history,” I said, noting that she’d never been treated for mental illness.

  “Gradual decline?” Kwan asked. That’s what you’d expect if it were dementia.

  “Not that I can see.” I offered him the file.

  He flipped through it. “Odd, the sudden onset. The admitting doc put her on an antipsychotic, Zyprexa. That may make a difference. Has it?” He looked to Gloria.

  “No. She’s driving staff crazy—asking where the manger is. She’s not redirectable or cooperative.”

  Roger, the postdoc, spoke up. “We just sent off her labs.”

  “An intriguing puzzle,” Kwan said.

  After the meeting, we visited Mrs. Smetz during walk-rounds. She was a stout woman with a plain face the color of a burlap bag. Her hair was dyed red. We found her pacing up and back in her room, leading with her right shoulder and muttering to herself.

  “Mrs. Smetz?” I said as we entered the room. “I’m Dr … .”

  She lurched to a halt. Her face lit up. “At last!” She clasped her hands together. “The wise men are here. And one of you is a woman!” She beamed at Gloria. “How delightful.”

  I went along. “We’re here to see how you’re doing.” She smiled at me. “I hope it’s all right if I ask you a few questions.”

  “But you’re the ones who have all the answers,” she said.

  “Even the wise can learn. You’re not at the inn?” I asked.

  “No. I’m in a hospital.” That was unexpected.

  “Do you know why?”

  “The innkeeper won’t give us a room. So we had to come here. My husband …” She glanced about the room, momentarily confused. “Oh, yes, he went to get me some apple juice.” She lowered her voice, “You mustn’t tell him”—she patted her stomach—“about this.”

  A tired-looking older man in a blue plaid shirt and a zippered jacket came into the room carrying a paper cup. He smelled faintly of tobacco. “Joseph!” Mrs. Smetz said.

  He handed her the cup and gave us a weary look. “Bill,” he told us. “My name’s Bill Smetz. Been married fifty-three years, and all of a sudden she can’t remember my name.” He harrumphed. “Thinks she’s Mary, mother of God.” He seemed to be making light of it, but his eyes told another story as he searched us for an explanation, looking for words that could make it all go away.

  I explained that we were there to give his wife a mental status exam, and that he could stay if he wanted. He took a seat. I invited our postdoc to take over.

  Roger began by talking to her informally, putting her at ease. That was good. A mental status exam needn’t feel like an interrogation. Then he asked her if she knew the date.

  “May”—she thought for a moment—“eleventh.” Close enough. It was actually the twelfth. Then she gave the correct year.

  He asked her to repeat numbers. She had no problem. Then words and phrases. Again, no difficulty. She was able to spell words forward and backward. And she remembered three items after five minutes. Attention, concentration, immediate and short-term memory—all seemed unimpaired.

  When he got to, “Do you feel safe here?” a guarded look dropped over her face. She gave an anxious glance toward her husband. “Oh, no,” she said. “The innkeeper doesn’t like us, and the soldiers are looking for us.”

  “Mrs. Smetz …” Roger began.

  “You can call me Mary,” she said.

  “Mary?” Roger looked at me.

  Mrs. Smetz scratched her forearm.

  Roger said, “You’re in a hospital. We’re doctors and nurses who will be helping you get well.”

  The information did nothing to ruffle her surface calm. “Of course, my dear. But you know,” she lowered her voice and confided, “being with child is perfectly normal.”

  When we were out in the hallway, Roger said, “She seems so lucid. Knows the date, where she is. Then she goes down the rabbit hole. Wouldn’t it be possible to talk her out of it, to sort of reeducate her?”

  “You could try,” I said.

  “Until the cows come home,” Kwa
n added. “She’s delusional.”

  “Generally speaking,” I said, “delusions are immune to reality. We could show her on her own birth certificate that her name isn’t Mary. And she might humor us. But she’d come up with an explanation. All the logical arguments you can make won’t yield anything, because the delusional logic makes complete sense to her. And furthermore, the truth of the delusion is felt, it’s not just cerebral. That’s its power.”

  “Not quite the same thing as hallucinations, then, is it?” Roger asked.

  “Not at all the same,” Kwan said. “With hallucinations you can often appeal to a person’s observing sense of self. In essence you sometimes can talk them out of it.”

  “With delusions, there is no observing sense of self,” I added. “For example, you see it in someone who’s anorexic. No amount of logic can convince that person that she’s already bone thin. Or someone who’s paranoid—you can’t make the fear go away by pointing out that it’s irrational.”

  Building a manger was relatively innocuous. What worried us were the potentially destructive behaviors that made complete sense to a delusional mind. Anorexics could starve themselves to death. And paranoids could become hermits, their fear and anger building until they exploded, like the Unabomber.

  “But why is this happening to Mrs. Smetz,” Kwan said, “and why now? No history of mental illness. No prior symptoms. Normal neuro exam so no stroke. All of a sudden, bam, she wakes up Mary, mother of God. For now, all we can do is keep an eye on her and continue with the Zyprexa.”

  That afternoon, Annie beeped me while I was working with a patient.

  “Why is it so hard to talk men into doing the logical thing?” she asked when I finally got back to her.

  “Me?” I asked. “I’m easy. And for you? Anything.”

  “I know you will,” Annie said. “I’m talking about Al Boley, the detective in charge of the Babikian case. I don’t know about that guy. I told him about the video surveillance setup, and it was like he didn’t want to know. Said they already had all the evidence they needed. I felt like reminding him that it wasn’t his job to find enough evidence to incriminate the obvious suspect, his job was to find all the evidence there was to find.”