Dedicated to the Game

“Look at all this shit!”
He waved the stack of envelopes at me.
“Look at this one.”
He held up the letter on top. It was from another hospital and marked, ‘Important: Do Not Discard’.
“These are the ones you have to be careful to discard.”
He threw it in the wastebasket, and followed it with the rest of the unexamined mail. I was far enough into my training not to be shocked by this sort of thing. I’d weathered surgeon’s tirades and soaked up jaded, callous humor in the emergency room. Still, my experience with this psychiatrist had me believing for years afterwards that, in his specialty, like sought like.
“This kind of clutter is the enemy,” he continued, opening the top drawer in his desk.
He scooped out a handful of keys.
“Look at these! I don’t know what this is for,” he said, holding up a sturdy door key. Into the bin it went.
He tossed a few more, then dumped the remainder back in the drawer with an expression of disgust.
“We’ve wasted enough time,” he declared, “better show me the case.”
I handed him the chart, with my history on top. He lingered on the assessment at the bottom of the page. Residents sometimes began to sweat when attending physicians paused too long in their documentation review. I did not in this case, because the assessment was not mine in the first place; the patient brought her diagnosis with her from the last admission. He grunted and moved on to the ancillary notes, containing the comments from psychiatric nurses who had evaluated the patient.
“Jesus Christ! Did you read this?”
Now I began to sweat. I hadn’t read the nurse’s notes. He handed me the chart with a shake of his head. I’d gotten lucky; the question was rhetorical. Curiosity displaced my anxiety and I began to read with interest. Immediately, I realized what he was on about.
At the bottom of the page, several of the nurses (a cabal?) postulated that dark forces were at work in the patient’s life. The assessment dwelt upon the young lady’s practice of witchcraft, not as an expression of alienation in a personality dangerously adrift, but as an activity with sinister efficacy. I looked up at him as I finished reading.
“How can we hope to do anything for the patients when we’re up against this kind of stupidity from the staff? Borderline,” he stated, returning to my assessment, “Do you really believe that?”
I shrugged. She had the black nail-polish sign, which every trainee knew was pathognomonic for borderline personality disorder.
“There are some people that fit the bill, but mostly the term is an epithet applied to people who we don’t like because they are frustrating. It’s the DSM used as a cudgel, and it justifies our bringing these people into the institution when their community becomes too frustrated with their behaviors. They come in for a few days or a few weeks until they’ve cooled off, then they go back out with the same problems, to the same problems. So this kind of inpatient treatment is like firing into the tree line: it’s good for keeping the enemy’s head down, but it’s not good for hitting anything.”
His words were familiar in structure and reference. At home that evening, I poured through my memory and my boxes of books, and I eventually placed them. They recalled an image from Heart of Darkness.

Once, I remember, we came upon a man-of-war anchored off the coast. There wasn’t even a shed there, and she was shelling the bush. It appears the French had one of their wars going on thereabouts. Her ensign dropped limp like a rag; the muzzles of the long six-inch guns stuck out all over the low hull; the greasy, slimy swell swung her up lazily and let her down, swaying her thin masts. In the empty immensity of earth, sky and water, there she was, incomprehensible, firing into a continent. Pop, would go one of the six-inch guns; a small flame would dart and vanish, a little white smoke would disappear, a tiny projectile would give a feeble screech – and nothing happened. Nothing could happen. There was a touch of insanity in the proceeding, a sense of lugubrious drollery in the sight; and it was not dissipated by somebody on board assuring me earnestly there was a camp of natives – he called them enemies! – hidden out of sight somewhere.

The image stuck and grew stronger over the years until I ceased to see my preceptor as chief among madmen and came to see him as Marlow on the boat. He was the lone relativist in a wilderness of absolutists who considered borderline personality more than a label on a charge sheet (it is that at least, for the Diagnostic and Statistical Manual which codified the term is a tool intended to itemize mental illness for billing). For his fellow wardens of the institution, there existed a borderline personality fact about certain people, caused by borderline personality pathologies and amenable, potentially, to borderline personality treatments. He saw them firing into a continent. He did not, of course, live in the land of absolute relativism, where everything is an onion made of layer upon layer of motives and relations with no pertinent core. He believed in borderline personality as a country over yonder. It recognized certain commonalities, but those commonalities arose in the villages. They accrued; they did not come down from on high.
He cared about how seriously the nurses, psychologists and patients took diagnoses, not because relativism was true. He cared because absolutes did not obtain. Worse, absolutes destroyed. On occasion, bullets fired into the tree line did hit something, and that something was an enemy by definition. Over his career, he’d seen victory declared over schizophrenia and the state institutions emptied onto the street. He’d seen the profession take a pass on intractable diagnoses, like personality disorders. He’d heard from his predecessors about neurosurgical solutions considered quite successful in their time. It wasn’t that relativism was true, it was just that truth didn’t work that way. It wasn’t diagnosis-friendly, and the truth about psychology all the less so.