I was looking through shatterproof glass at a psychotic man flailing violently against the restraints shackling his ankles and wrists to a flimsy bed when I got good news. The next patient just wanted “school clearance.” Piece of cake.
“What’s the story?” I asked the nurse assigned to triage him.
“He’s creepy,” she said. Coming from a black woman half a foot taller and 150 pounds heavier than me, I took this quite seriously.
“The psychotic guy?” I asked. His screams were muffled behind the glass, like a horror movie soundtrack turned low.
“He’s okay. The kid’s creepy,” she said.
“What’s the school clearance for?” I asked.
“Don’t know,” she shrugged. I clenched my teeth, outraged. Her job was to take his medical history and report back. I had no power to make her do her job, which she’d had for decades, so I just stared at her.
“You know…” she finally started. I clicked my pen, ready to jot down information. “He could be one of them school shooters.”
“Thanks,” I said, yanking up my oversized scrub pants and pushing through the locked door that protected us from the patients. “That’s helpful.”
I walked into the room knowing nothing. He was sitting still and waiting silently, staring at a blank white wall. He was 18 but looked 16. He was pale with intense icy blue eyes and terrible acne, slouched in a faded, hooded sweatshirt.
“What brings you in tonight?” I asked.
“I told the other woman,” he said. His face was expressionless.
“I’m sure you did,” I said, and sighed.
We sat in silence. Using silence is one of the best skills psychiatry taught me. Wait it out and people volunteer great information.
“I need a note,” he said. “Or school won’t let me back.”
“Do you want to go back?” I asked.
“No,” he grunted.
“Why does school suck?” I asked.
“The people. The teachers. Everything,” he said. He shrugged. The corners of his lips were frowning but otherwise his face was blank. “I hate it.”
“Anything good in your life?” I asked.
“Nope,” he said with a certainty I wasn’t expecting. “That’s why I want to end it.”
“End your life?” I asked. Another suicidal teen, I thought. This is why he needs clearance.
“Not my life. End their lives,” he said. I wasn’t expecting that.
“Whose?” I asked.
He stared me down with his blank, blue eyes, smiling a bit now. He was using my silence against me and I could tell he was enjoying it. It was working. I started sweating.
“Killwho?” I asked, more forcefully. I was getting nervous as I glanced through the window to the nurse who was supposed to be watching us on camera for safety. She was on the phone, distracted. The tech was on a break. There was no security around. I looked at the broken red plastic panic button hanging flaccidly on the wall. Other than the psychotic guy, we were the only people in a maze of locked doors. I started inching my chair backwards.
“Anyone. Doesn’t matter,” he said. He sounded bored. “I just think I could kill. Maybe a bunch of people.” His lackadaisical tone and nature relaxed me in spite of the content. He was vague and childish. He didn’t have a plan or target. He’d been fantasizing about killing “forever.”
“I said something stupid,” he finally volunteered. “That they’ll all be sorry. I shouldn’t have said it. Can I just have the letter?”
I did a full psychiatric assessment and came up empty. He wasn’t depressed or psychotic or addicted. He was just creepy. I felt uncomfortable around him. Probably, everyone did.
He played video games and didn’t have friends. He fantasized about doing bad things to the world because the world seemed bad to him – not just school, all of it.
“The world is so fucked up,” he said.
I couldn’t help but nod in agreement.
I met his parents in the waiting room. They looked wholesome and tired. His dad had a thick moustache and his mom had frizzy hair and a gold cross. They confirmed his story. They had little to add. He’d been “like this” for years. They wanted to take him home.
“He’s an angry teen. Boys are like that,” his mom said. “We have others.”
“I don’t see how him not going to school will help,” his dad said.
I went back behind the glass, scanning the facts in my head. He had never doneanything violent. His thoughts weren’t crimes. He didn’t meet diagnostic criteria for anything medications would treat and had no interest in therapy.
“You’re right,” I told the nurse. It pained me to admit that though she missed all of the clinical data she was supposed to gather, she was spot-on. “He could be a school shooter.”
“Uh-huh,” she said, not even looking up. “Looks like one, too.”
“What am I supposed to do about it?” I asked.
“Nothing you can do,” she said. “Send his ass home.”
She was right. He didn’t meet criteria for an involuntary hold. There was no “imminent threat” – his dangerousness was chronic and not the result of psychiatric illness. Even if I could admit him to a psych unit, it wouldn’t matter: he’d be back home in a few days even angrier. I did the only thing I could do: I wrote the letter.
One implicit lie of medicine is, “We can help you.” Often, we can’t. It’s a crushing realization to trainees who take on debt, danger, and debilitating exhaustion in an effort to “help people.” As we amass skills and knowledge to become healers, we often find ourselves helpless.
In medicine, we don’t advertise the limits of our system or ourselves, but maybe we should. A resident I trained with suggested we post a sign on our psych ER door reading, “We want to help you. We’re here to help you. But we probably can’t. We hope you understand. We’re sorry.”
If he is the next school shooter, I won’t feel guilty, even if I’m the last psychiatrist on record. I did what I could, which was nothing. There were no tools in my doctor’s kit to help. I’ve come to accept that happens a lot. We’ll just have to wait and see.
Lisa Jacobs is a Child & Adolescent Psychiatry Fellow at Stanford University and the founding editor of The Penndulum.
“Barrel of a Gun” by Danielle Couture, MD