A psychiatric hospital is an unsettling place. Each morning, I unlock the door to my assigned ward and move with a quickened pace toward the staff conference room, not comfortable until I hear the click of the door closing and locking behind me. As much as I hate to admit it, the landscape frightens me. I feel totally robbed of my sense of comfort. Social cues are meaningless here. The patients shuffle around, staring blankly ahead or glaring suspiciously from side to side. Sometimes they pass by, uncomfortably close, and I feel my muscles tense, ready to spring away or defend myself. The nurses and mental health workers are more at ease. They know the patients. They know their tendencies, dispositions, triggers, and warning signs. All I know is that I can’t read the faces. I can’t tell what’s going on inside, and I’ve seen enough already in my first week to know that for many, deep turmoil lurks just beneath the tranquil surface.

From the safety of the conference room I read the charts filled with entries like:

“Extensive assault history, especially to females”

“Known to bite and strike at faces unprovoked”

“History of throwing feces and urine”

“Assaulted his mother as well as a police officer”

“Unprovoked assault”

“Sexually inappropriate behaviors”

“Risk of assault (woman over 60 with a knife)”

“Statutory rape”

 “Indecent assault on a child under the age of 14”

“Outstanding murder charges”

“Armed robbery”  

“Armed assault and murder”

These are just from the patients assigned to my team. I can see that many of them have been here for months, if not years. Most of them are forensic patients; 70% are here on a court order because they are either not competent to stand trial or they are not guilty by reason of insanity. These are truly the sickest of the State’s mentally ill. They are the patients who have not responded to standard treatment algorithms. They have nowhere else to go, there are no more capable programs for handling their needs and their challenges. These are the patients I will be working with as a third-year student, fresh out of the classroom.

 After several days, I realize that what gets to me the most are the sounds. I can find reprieve from almost everything else, but the sounds follow me everywhere. Down one hallway a patient bangs his open hand against a pillar again and again, grunting and howling at nobody in particular. Across the corridor in the community common area, a young woman looks at me and bursts out laughing, loudly and uncontrollably as she cries. It’s the character of the laugh that sticks with me. It’s unlike any sound I’ve ever heard before. It’s deeply unsettling, like something from a horror movie. It is uncontrolled, unbridled… unwanted even. Around the corner I can hear a man cry out in rage. The angry shouts appear out of thin air. There is no escalation, no lead-up. There is just quiet, and suddenly, an eruption, disappearing as quickly as it surfaced. There is the clanging of dishware and silverware hitting the floor as a meal cart is upturned, and the howls of pain from the food service worker whose nose was just broken by a swift, well-timed blow to the face. The sounds persist no matter where I go. I can hear them in the bathroom, in the lunchroom, and even in the forgotten room down a secluded hallway, which I found on my third day and appropriated as my sanctuary. It houses an unused computer, which I use to conduct chart reviews and to escape from the chaos when it gets to be too much. Even there, however, I can’t escape the sounds.

  Sometimes, the unsettling noises are much more subtle. It’s the click of a lock whenever someone moves through a door. It’s a mental health worker telling a patient to calm down and take a deep breath. It’s the overheard conversations about poisoned food and FBI surveillance. It’s a woman calmly expressing that she’s going to kill herself. It’s a man speaking softly about stabbing you with a knife. And even in the absence of all these things, there are the unnatural periods of silence. There is the silence of a woman lying wrapped up in her sheets for days at a time, lost in her own world of despair, unable to even acknowledge another human being. There is the silence of the patient who roams the halls, and stares, and watches. I wonder what he’s waiting for. I wonder what he’s watching for. There are some who watch the doors, waiting for careless staff members to leave them ajar, sprinting to catch them before they shut, and then repositioning themselves to try again. This is how they spend their days.   

I try to talk to them, I try to understand like the nurses do, like the psychiatrists do, but I can’t. I can’t understand the shattered minds, the broken spirits, the mix of fantasy and reality. I don’t know what to say, how to react. I ask questions, probing for rationality and so often find none. I struggle to find the humanity here. I want so badly to connect with these patients, to know their worlds and navigate through them. Although I’m ashamed to admit it, most days I just see animals… restless, prowling, lurking, and sulking. I fail again and again to relate. I sympathize, but I cannot find empathy. I wonder if this rotation is bound to be a failure for me. If I memorize the side effect profiles of antipsychotics but cannot find the humanity in those taking them, what will I have accomplished?

Bill Fyfe is a fourth year medical student at the University of Massachusetts. He graduated from the U.S. Coast Guard Academy in 2009 with a degree in government and subsequently served as a deck watch officer aboard the U.S. Coast Guard Cutter MIDGETT in Seattle. He plans to pursue a career in emergency medicine.