GRACE | Andrzej Koczapski

Grace loves her hair. It's her most treasured possession. 

Her only other possessions are the layers of clothes she's wearing, and a department store shopping bag. But she's happy. Sitting quietly. Eyes closed. Smiling. Rocking gently back and forth. Humming and mumbling softly to herself. Sometimes cocking her head as if listening. Then nodding and smiling more broadly.

When I introduce myself, she opens her eyes. Notices me. She's friendly and polite. Gracious. Regal, even. As if she's royalty, just visiting briefly from another planet. She doesn't say anything unusual or bizarre, but her sentences don't seem connected to each other. As if she's reaching into a big bucket and just pulling out whichever one is closest to the surface at the time.

I ask if she has any pain or discomfort. She smiles and shakes her head. "I like peonies." Closes her eyes. Opens them again. "Is there any coffee?" It's impossible to find out where she was or what she was doing before coming in to hospital.  

Most of my information comes from the police report. They've seen her several times over the last few years, in response to calls from people who were concerned about her or annoyed by her. Usually, they just give her a warning. Sometimes they keep her in jail overnight. This time was different. She seemed more disorganized than usual, and looked unwell, so they brought her to the emergency department at University Hospital. Now she's been admitted to our psychiatry ward.

She's pleasant and cooperative with the physical examination and blood tests. She doesn't think there's anything wrong with her, but she seems to appreciate having a warm safe place to sleep. Lab results show a urinary tract infection, which can cause confusion and delirium in vulnerable people. I start her on an antibiotic for the infection. And an antipsychotic, for the delirium if she has it, and the schizophrenia, which I'm pretty sure she does have. 

Over the next few days, we get more information. Previous police reports show that she sometimes sleeps in a 24-hour printing shop, in a corner behind one of the photocopy machines. It's a franchise with several locations around town. Common, before the internet and home printers made them obsolete. She also hangs around the Oakridge shopping center. Rummaging through garbage bins for discarded food from restaurants and supermarkets. Wandering through the food court, picking up things people have left on their trays. Mostly she just sits by herself, outside in the sun, eyes closed, smiling, rocking back and forth. In the warm weather she sleeps in a park. I'm not sure what she does in the winter. Maybe she finds a quiet corner in the shopping center after it is closed for the night.

Considering her lifestyle, it is remarkable there are so few police reports. Are the people in Vancouver uniquely tolerant? Or does Canadian politeness prevent them from bothering her? Or are there already so many unusual people living here that nobody particularly notices? Whatever, she has mastered the art of blending in. And surviving in the city with no income or housing. 

After a week, the urinary infection has cleared and she's more alert. What's left is a pleasant vagueness, which, I'm beginning to realize is her usual state. She doesn't know the date, but I don't think it's because she's confused. That kind of information is just not important to her. She lives in the moment. She knows where she is, although her answers vary. "Hospital." "Vancouver." "The Universe." And she knows how to take care of herself. Beneath those many layers of clothing, she's healthy and well-fed.

She politely but firmly refuses our offers to help her apply for social assistance or look for housing. "I live under the sky," she says.

She doesn't trust showers but agrees to have a bath. It takes three baths before the water runs clear. She lets us wash her clothes. Her coat is some kind of cotton. After one washing, it's only slightly cleaner. And the water is filthy. We wash it again. And again. It takes 10 washes before it's completely clean. It wasn't black after all. It's a blue denim jacket.

Which brings us to her hair. It's tangled and matted into a single thick rope, right down to her waist. Impossible to brush or comb. The individual strands have clumped together into a completely new material. Like the felting process, where a knitted wool hat becomes a felt cap when treated with steam. You can't even wash it properly. The water just runs off the surface.   

Grace is proud of her hair. She thinks it's beautiful. It's her security blanket. In the cold weather she wraps it around her neck like a scarf. It's part of her identity. One of the few things she can call her own.  

But it's damaged beyond repair. The only way for her to have a healthy head of hair would be to cut it right down to her scalp. Then let it grow back normally. When I suggest this, Grace flatly refuses. She has never cut her hair in her life, and she doesn't want to start now. She is unimpressed by my argument that when it grows back it could be even more beautiful than before.

The nurses have strong opinions on this. But they don't agree with each other. I've never seen anything like it. We have a couple of tense meetings.  

One group feels that Grace's hair is a serious health hazard. It's dirty, smelly, impossible to comb. She could have a scalp infection underneath and you'd never know. If not now, maybe next week or next month. Untreated scalp infections can spread and cause serious complications. Her judgement is impaired and she doesn't understand the risks. We have an obligation to treat her and keep her safe. When she leaves the hospital, there will be no one to look after her. So, the time to act is now. We should cut her hair, then clean and disinfect her scalp and start her on a program of haircare so it will grow back without tangles. Even if she refuses, we should do it anyway. She's in hospital involuntarily under the Mental Health Act, which means we can treat people whether they agree or not.

The other group says the Act is designed for serious mental illnesses, and Grace's hair doesn't qualify. Her bloodwork and vital signs are normal. She has no physical complaints. There's no current evidence of infection, so the concern about risks is insufficient for us to force treatment. There are many other risks we tolerate in our patients, like obesity and smoking. We may not agree with how she manages her hair, but it's her personal choice and we should respect her wishes. If we cut it against her will, she'll be really upset. Maybe she'll get depressed, which would be us causing a mental illness instead of treating one. She would never trust the hospital again. And it looks like we are one of the few supports she has in her life.

Since I'm Grace's attending physician, they want me to make the final decision. This is tricky. Emotions are running high on both sides.

I listen to everyone's concerns, and say that I, too, worry about infections, but I have to agree with the second group. Cutting her hair is not like washing her clothes. If we cut her hair against her will, we'll be overstepping our boundaries.  

The first group is unconvinced. They argue it's unethical to send her out of hospital with hair like that. It would mean we aren't doing our job properly. The discussion gets increasingly heated. Everyone is passionate and articulate, but it seems to me they're looking mostly at the theoretical aspects. 

I ask them to think about the practicalities. If we did cut her hair, how would we do it? Would we hold her down, kicking and screaming, while trying not to accidentally jab each other with the scissors? Would we need to give her a general anesthetic? How would she react when she woke up? 

I ask them to consider the similarities between doing this and participating in a gang rape. This halts the discussion. They look shocked. When they start talking again, everyone is more subdued.

The verdict is that we will respect Grace's wishes. We all agree we want to help her. But it needs to be in a way that's fair and realistic and doesn't cause a whole new set of problems. And we know that, despite our best intentions, there's only so much we can do. It comes with the territory in this line of work.

Now we've resolved our own problems, it's a little easier to deal with Grace's. We're all trying to do a better job of seeing things from her point of view. She's a very pleasant person when you get to know her. With a warm, distant, regal manner. Appreciative of the hospital staff. No complaints. Off in her own world most of the time. So vague that it's almost impossible to find out anything about her.

She shows me some of the contents of her shopping bag. A scarf. A sweater. Various trinkets she's picked up. Her 'treasures.' A few coins. A little bracelet. A colorful pebble. A twig with an interesting shape. She's like a magpie, collecting shiny objects. A raccoon, rummaging through garbage cans. A seagull, scavenging food from peoples' plates.  

A month later, Grace is about the same. I'd hoped the antipsychotic would make her more accessible, but she's not much different than when she arrived. She has politely and consistently refused all offers of help with finances, housing, medical follow-up or connection with community services. She won't take medications after discharge, and it doesn't look like they were doing anything, anyway. After treating her urinary tract infection, all we've really done for her in hospital is washed her clothes and given her some food and a place to sleep.  

She's ready to leave hospital, she tells me. She has places to go. Things to do. I'm not sure what, exactly. Maybe she has a regular territory she roams through, like a coyote. Shopping center, park, 24-hour print shop. Maybe a place that donates clothing.

Grace hands me something from her shopping bag. It's a little ceramic elephant with a chipped ear. A gift, she says, for helping her. I try to politely refuse, but she insists. "You deserve it." She's vague about where it came from. "I was helping some people move."

Now she's at the door. We say goodbye and wish her well. No taxi. She wants to walk. I have a sudden wave of anxiety. Her shoes! We never checked that they were okay! But on a quick glance they look to be in fairly good shape. Sturdy boots. And they seem to fit. And during her baths we saw that her feet were healthy. No blisters. I breathe a sigh of relief.

I feel privileged to have had a glimpse into the life of this unique person. Frustrated that I couldn't do more to help her. Impressed by her survival skills. And intrigued by her similarities to other creatures that live on the fringes of human society. Magpies, raccoons, seagulls, coyotes.

Then she's gone. Just like that. Striding away in her boots and blue denim jacket. Shopping bag in hand. Uncut waist length hair swinging proudly behind her. On to the next stage of whatever it is she's going to do. Leaving nothing but a memory. And a little ceramic elephant.  

I think about the roles elephants have played in my career over the years. The fable of the six wise blind men and the elephant, and how it might apply to different types of psychotherapy. The exercise of trying to not think of the word 'elephant' as an example of what it's like to have obsessive compulsive disorder. And Ganesha, the Hindu elephant-headed god, symbolizing wisdom, intellect, new beginnings and the removal of obstacles. Relevant to all psychiatric treatment.

Now the elephant with the chipped ear sits on my desk. A symbol of the gap between what we'd like to be able to do in treatment and what we can actually accomplish. And a reminder that something can be damaged but still beautiful.

Andrzej Koczapski is an addiction psychiatrist in Vancouver, BC. During his career, he encountered many situations that could have made good stories but always felt too busy to write them down, telling himself "Maybe someday when I retire." Now mostly retired, he writes memoirs from the perspective of 50 years of clinical practice. In the process, he is constantly reminded of the amazing diversity of human experience, the challenges of working in the mental health field and the courage and resilience of both staff and patients.

PRINT