There’s No Place Like Gnome

Psychiatric TimesVol 33 No 11
Volume 33
Issue 11

Being an outpatient psychiatrist is a lot like being married. Things go along, the same-old, for long periods. But then there's a moment. Today, with Leslie, I remember why I love my work.


“Doc, am I a gnome?” asks my patient Leslie.

What! It’s Monday afternoon. We’re sitting in my office: sage walls, cream trim, potted plants, upholstered couch, matched chair stuffed with Leslie, bookcase, window shades translucent with sun, tissue boxes as far as the eye can see.

Silly makes a nice change. It’s been hours of patients who are desperately sick, chronically suicidal, refractory to treatment, or just plain miserable.

I want to laugh. But I don’t. He’s serious. “Uhh . . . No.”

“How do you know?”

“Well . . . Gnomes are fictional characters.”

Leslie nods. I wait.

“So, why does my family say I’m a gnome?”

I look over his unfortunate jug handle ears, bald dome, glowing eyes, goofy grin, and 70-year-old, pear-shaped body sagging into the upholstery. It’s hard not to giggle. He is a little old gnome. There’s always a kernel of truth in every delusion (and in every slur or nickname).

This is today’s kink in Leslie’s kookiness. Social reassurance-“Your family wouldn’t say that!”-won’t console him. What’s the tactful (yet, not a lie) thing to say? Tact, timing, dosage: that’s the challenge for any words that leave my lips. I lean forward.

“Maybe . . . because you’re bald?”

His hands jump up to his hairless head. “I shaved it myself! But, it’s not too good in the back.” He turns his head so I can see.

He is the sweetest thing on the planet. (When he’s stable.) An innocent, radiant with wonder, always looking to tell a joke. Leslie was a popular high school history teacher before schizophrenia stole that life. He shifts to face me.

“Doc, do gnomes get erections?”

Here we go. All aboard the train of Leslie’s sexual delusions. Grayness settles over me, like fog. First stop: Erections.

I say, “I wouldn’t know. I deal only with real creatures.” Next stop: Celibacy.

“Doc, how do you define celibate?”

“Well, a celibate person is someone who gives up sexual relations for spiritual reasons.” Next stop: Homosexuality.

“OK. If I’m queer in thought, am I queer in deed?”

Here be dragons. Not going there. “You’re celibate. So, no.” Next stop: VD.

“The nurse at the doctor’s office told me I have a rare form of syphilis. What do you think?”

“I think you don’t. Your last blood test was negative.” As were the gazillion before. “You’re celibate. No sex, no VD.”

Etcetera. More of the same. Can we stop now? The urge to thump my head against a handy wall overcomes me.

Instead, I assess the data. Psych meds don’t get rid of delusions. They help by softening delusions’ hard unreasonableness. Maybe. Better meds can’t come soon enough. Meanwhile, if Leslie accepts my reality-based responses and-fingers crossed-suffers less, I’ll take it.

Leslie nods, “OK. I believe you Doc.” I nod back, and smile. Hey, this is going well. I lift his chart off the stack on the ottoman, and lean back.

“I was afraid to ask,” he says. “I didn’t want you to think I was

A grin escapes me. I look at him, and out pops, “Come on, Leslie, we both know you’re crazy. That’s why you’re here.” I grip the chart instead of clapping a hand over my mouth. I cannot believe I said that!

Our eyes lock. His head sinks into his rounded shoulders. He shrinks back into the chair, just like a scared turtle. The atmosphere in the room darkens, becomes charged and still, the calm before the storm. How do I regain his trust?

My body tingles. My mind sizzles, snaps, and pops in lightning-bolt analysis: I missed the point, and with a heavy hand. I had spoken to the surface question, not to what he’s really asking. Which is: Am I OK, as a person? Do you like me, crazy and all?

The clouds part. The sun comes out. I see the way. I twinkle like mad, maintaining eye contact: I’m so sorry! I didn’t mean to hurt you. You are adorable. I love working with you. He stares, frozen. Will he forgive me? I ground myself in the quality of the session before this awful moment, the strength of our many-years’ bond, and his sense of humor. I beam warmth, ramping it up.

He gives me a long, searching look, and melts. He drops his shoulders, lifts his head and smiles. “Good one, Doc.”

O! Happy day! I grin back: Thank YOU!

Leslie grins a goofy grin: “Wanna hear a joke?” Wow. He’s reaching out. We’re good. I am totally engaged. Fascinated. I LOVE this.

“Sure. Nothing off-color, please.”

“OK. When Cookie Monster was sick, what did he say to his mother?”

“Um . . . Don’t know.”

“I feel crumb-y!” I laugh freely, and so does he.

The session in review: His eye contact is good, mood jovial, and affect broad. Delusional content aside, we’ve kept the conversational ball in play continuously for 20 minutes. He let me confront him with reality. He let me console him. He accepted my apology. Amazing. A triumph of relatedness.

Given that he’s required 2 hospital admissions for terror-loaded paranoia in the past 10 years of treatment, he’s solidly in the maintenance sweet spot. My cup runneth over.

I write the progress note. Does he need scripts? No. I close the chart, and shift forward in my seat. “Leslie, I’m not changing any of your meds today. You’re doing great. I’ll see you next month.”

He beams, and struggles out of the chair. I escort him to the checkout window, where he asks my office manager, “Why should everybody buy a good pair of shoes?”

“Why?” she asks.

“To save their soul!”

It’s so simple, really. What do we all want? To be accepted for our whole selves, from soup to nuts. Especially the nuts.

Leslie didn’t choose his illness. He’s disabled, despite treatment. We both have to live with that. I’m competent and full of good will. Still, I screw up. We both have to live with that too.

One mistake, and time stopped. We sized each other up. Leslie’s craziness; my heavy-handedness; those fell away. We connected as human beings, and found it good. So good, we laughed.

I flashed back 30 years, to my interview for the psych residency at Beth Israel in Manhattan. The attending had asked, “Why do you want to become a psychiatrist?” The question took me by surprise. What to answer? Maybe something fancy about the science of mind and brain? But he’d only ask me to elaborate, and I’d make an ass of myself. “I like psych patients. Getting the story. Helping out. Sometimes, we laugh.”

“You like psych patients,” the attending said. “How refreshing! Usually, I get some fancy patter about the mind and brain. You’re in.”

Being an outpatient psychiatrist is a lot like being married. (34 years. Thank you.) Things go along, the same-old, for long periods. Until Hubby and I have a moment. Everything stops, and I fall for him, just like that. I remember why I love him. Today, with Leslie, I remember why I love my work.

Gnome is where the heart is.


Gitlin is a psychiatrist in private practice in Plattsburgh, NY.

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