The social worker and a patient’s homicidal thoughts

“Howard wants to go to the hospital. He knows he isn’t doing that great. He says he is having homicidal thoughts.” This from my supervisor, Linda.

Homicidal thoughts on the part of any client get our attention, especially so with Howard, because years before, he killed a man with a gun. I believe it was in a fight.

“He wants you to take him to the hospital, Ray.”

“Sure,” I say. “You think you can go with us?” The hospital is only about two miles away, but I want Linda with me because she is much more experienced in the process of getting a client admitted to the psych unit.

She goes off to gather up the necessary background information. Soon she is back and tells me.

“Howard wants only you to go.”

I find this odd.

I know Howard likes me, he’s known me a while. I get on well with him, but just me? I wonder why. I can do it, of course, but I know it will be so much quicker and trouble-free if Linda is along. Howard comes into my office.

“The hospital admission will go much quicker if Linda comes along,” I tell him. Linda is standing nearby.

“Works for me,” he says. That has to be Howard’s all-time favorite expression.

He seems at baseline.

Howard is a big teddy bear of a man. He usually is good-natured. He is in his late 40s and has abundant gray hair. He is generous to a fault. He is easily separated from his money and frequently taken advantage of. I can see that he is upset, but not psychotic.

“I haven’t slept in days,” he tells me, “and I am convinced my landlord has killed my girlfriend. So I feel the need to kill him,” His exact words.

Howard lives in a rooming house, a flophouse, and the landlord often takes advantage of him. He uses him to do work around the place, making repairs but pays him nothing. Howard says he doesn’t mind, he stays busy, and he likes to be busy. But on some level, I sense Howard feels used. Surely he would not refuse a few bucks thrown his way for the help he gives his landlord.

Our agency handles Howard’s money, and every Monday, he gets $80, and then $20 more on Friday. From this, he is expected to buy his food and take care of personal needs. Other expenses, like rent, are paid directly to the vendor.

Howard is a cutter, uses a knife on himself, often cutting in his midsection. He takes medication for this problem, and without looking at his chart, I cannot tell you what the condition is called. It has a name — everything does.

He mentions his landlord killing his girlfriend, and I gently explore this delusion with him.

“I didn’t know about this relationship, this girlfriend you mentioned. What’s her name?”

“Oh, I don’t know,” he says, as if everyone has a girlfriend whose name they don’t know. I remember Howard coming to me three months earlier telling me he had met the woman of his dreams, the woman he was going to marry. He didn’t know her name, either. He said he would soon be giving up his room and moving in with her. Of course, that didn’t happen.

“Her car is in front of her building,” he says next. “It hasn’t moved in days. Roger killed her, I am sure of it, and I will have to kill him.”

By now, we are in my car headed for the hospital. Howard is next to me in the front seat, and Linda is in the back, taking notes on Howard’s behavior, I see her in the mirror. It is Information to be presented to the doctor at admissions.

As if Linda were not in the car, Howard says, “I didn’t want to go with Linda because I was afraid I would harm her.” He doesn’t explain why.

I feign surprise at what he has said, after a bit of a silence. “Linda? Harm her? You wouldn’t do that, Howard!”

He doesn’t argue the point, and I don’t pursue the topic.

“Ray, please don’t tell Roger I want to kill him.”

“I know you don’t mean that either, Howard. It’s your illness talking, not you. No, I won’t say anything to Roger.”

I must under law warn Roger, or anyone else Howard threatens.

Next, he speaks of moving, as if he knows Roger will have to be told eventually, and he won’t like what he hears, and won’t want to have Howard around anymore.

“Will you help me pack when I get out?” he asks me.

“Sure, Howard. No problem.”

We are now at the emergency psychiatric section of University Hospital. Howard is more settled, less menacing, and he enters the facility with Linda. I very quickly found a parking place. I don’t like leaving him alone with Linda, except they are not really alone now. Security people abound at the entrance to the hospital. I know she will be all right as I go to park, and she is.

Once inside, I sit in the waiting room with Howard. Linda is off to facilitate the admission.

Howard talks more about wishing to kill Roger.

“Is it my illness talking, as you said before?” he asks.

“It is,” I tell him. “Roger didn’t do anything to you, and nobody killed your girlfriend.” I don’t say what I am thinking, your imaginary girlfriend.

A guard escorts Howard to the psychiatric wing. This is not a new experience for Howard; he shows no fear. Soon Linda and I get to leave, go back to our offices. She reminds me, as I knew she would, that Roger needs to be warned about Howard’s threats. Then she offers to do this for me, to call Roger.

“Works for me,” I say with a grin.

Raymond Abbott is a social worker and novelist.

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