The doctor was standing behind the curtains.

Doctor Falsh parted the thick blue drapes with a flourish, then slid them closed ceremonially. His interview room was small and windowless – not much more than a glorified closet – but it was placed conveniently, especially for a locked unit, located just next to the row of patient dorm rooms and just across from the nursing station.

Two chairs in the room rested at right angles to one another. Dr. Flash preferred the interpersonal model in which this chair positioning minimized the stress of direct eye contact. The two chairs were also intentionally identical, each with heavy hardwood frames, thick arm rests, and upholstered with blue olefin cushions, which, despite the staff’s best efforts, always whiffed of hospital antiseptic.

Dr. Falsh sat down upon the least stained of the two seats, then took out his pen, pad and papers. It was time to round on the last patient in his roster, the most interesting, but also the most challenging.

“Welcome, welcome, sir, do come in.”

A disheveled middle-aged man shuffled in with two young orderlies in long white coats following behind him. Dr. Falsh noticed today that the patient wore a knitted tie beneath a wool sweater vest. This was perplexing – how was a patient allowed access to a tie – he would need to chat with his nurses after this meeting. We run a locked unit and though Mr. Ams may not be suicidal, universal precautions must be enforced, and ties are dangerous attire. Dr. Falsh himself never wore one when he worked on the unit. He preferred his crisp green scrubs and comfortable sandals.

“Have a seat Dr. Ams, or, I’m sorry, do you prefer Mr. Ams?”

The question was a test. Doctor Falsh was not a timid man, nor paranoid, but of necessity he had to speak, act and react very carefully in his many interactions with Mr. Ams. Delusional disorders were challenging to diagnose and even more difficult to treat. If it was a delusional disorder? They are exceedingly rare, found in less than two out of a thousand people, with monothematic delusions being even rarer. Mr. Ams suffered from a fixed false belief with a single theme: he believed he was a physician, specifically, a psychiatrist.

The differential diagnosis was sparse: (1) a monothematic delusional misidentification syndrome on the psychotic spectrum (Dr. Falsh’s working diagnosis), (2) a delusion of grandeur on the bipolar I spectrum (but nothing has been grandiose about being a doctor for many many decades, particularly a psychiatrist. Still there was a case in Florida last year.), and (3) a dissociative fugue on the amnestic spectrum, presumptively secondary to a series of major traumas (but this typically lifted after several weeks and Mr. Am’s had discharge summaries spanning the last decade.)

Mr. Ams had seen so many psychiatrists and had undergone so many treatments. In an ultimate expression of the identification defense, his delusion evolved from his being a general doctor in his early 20’s to his being specifically a psychiatrist by his early 30’s. Dr. Ams completed his fictional residency, surviving the rigors of training, only to face HIPAA, managed care, EPIC, malpractice lawsuits, medicare opt outs, prior authorizations, dwindling reimbursements, and the agony of chart audits. After his imaginary private practice soon failed, he settled for an unassuming inpatient position. He and his wife soon divorced, she was granted full custody and his children disowned him. He lost the house, then lived in a nearby apartment, finally in a shelter and intermittently in a tent under the interstate overpass. His life presently was a bounce between locked units, shelters and tents. Mr. Ams appeared compliant with medication during his hospital stays – though Dr. Falsh had his suspicions – but in any case, he discarded his medication bottles promptly after each discharge.

As usual, his medical work-up continued to be within normal limits. A physical exam – with a detailed neurological exam – found no abnormalities. His baseline laboratory studies were normal. A new MRI again showed no visible organic changes. His mood was euthymic, his affect was pleasant, his sleep was normal length with no difficulties falling asleep or mid-cycle awakenings. He was eating well. He had no suicidal or homicidal ideations. He evinced no neurovegetative symptoms. His self care was intact. He was well-behaved and pleasantly social with staff and fellow patients.

The hope is that he will respond to milieu therapy (several weeks of calm in the locked unit), individual therapy, support group meetings, and yet another restart of his usual medication.

“Dr. Ams, Mr. Ams, either is fine. Whatever you’re most comfortable with Dr. Falsh.”

There was a moment of calm silence, then they both spoke at once, one stopped, the other continued “It must feel so disorienting for you…”, the other stopped and the one finished, “…to be a psychiatrist but also to be in a locked unit?” Each chuckled awkwardly. After seating themselves, they always asked this question of one another, almost as a matter of greeting.

Reflecting feeling and affect works exceedingly well in connecting psychiatrists with their psychotic patients. Though you may disagree on a shared external reality – for example, the FBI is chasing me versus the FBI is not chasing you – you can still agree and reinforce a person’s emotional response to their perceived reality – for example, it must be so terrifying for you to feel that you are being chased by the FBI.

“Yes it is a great joy to be working with my colleagues again”

“Yes indeed.”

One of the trainee doctors – or was it an orderly – rolled out a chess mat upon the coffee table adjacent to both men’s chairs. He placed a chess timer and a set of chess pieces as well. The two opponents placed their pieces to begin a game.

“Shall we play for the usual stakes?”

“If I win, you swallow the medicine. If you win, I swallow the medicine. If we stalemate, then we both take the medication.”

One reason for seeing this patient last was the fun of playing chess with him. Both men were expert players and their games typically stalemated. Each day at the end of their meeting, they would play a round of timed rapid chess. The doctor had discovered this as an entertainingly efficient way to get this patient to swallow his medication. It also helped to connect the two and to evaluate executive function. And finally, a great deal of subversive glee was enjoyed afterwards when authorizing a HCFA billing form to the insurance company with a CPT code that was essentially for playing a game of chess.

The orderlies – or were they interns – looked on in disbelief at the celerity of the game. White and black pieces clanked symmetrically across the board. Both player’s executive function clearly was highly intact. Each began with a Sicilian defense and tight pawn structure, development followed in midgame with double attacks, skewers, pins, and trapped pieces. After queens were traded, the endgame was apparent and an obvious stalemate arose by nine minutes, with the match ending in a draw by nine minutes and forty-seven seconds.

The chess set was put away and in its place were placed two glasses of water and two small cups each with a single pill inside.

“Remember to gargle and swallow afterwards.”

“On three – one, two, three -” They each placed a pill in their mouths, then gargled their waters, then swallowed.

The doctor had done this often with patients. It was surprisingly easy to “cheek” a medication. “Cheeking” was ward slang for when a patient pretended to swallow a medication but actually hid the pill in their “cheek”, or elsewhere. For the doctor, however, it was always elsewhere. Since his residency, he had perfected the technique of backwashing the pill behind the palate of his mouth and then suctioning it up into his nasal cavity from behind, to sneeze out of his nostril much later in private.

It worked most of the time, but not all of the time. When it failed, the side-effects were horrible – sedation, weight gain, bloating, a feeling of wanting to jump out of your skin, brain fog. It once even made his brain so foggy that he forgot who he was for a while – a successful psychiatrist – and believed to his horror that he was some sort of homeless man.

“Hang in there, it gets better and we’re all rooting for you.”

“I am rooting for you too.”

The team left the room, then the patient rose and shuffled toward the draped wall opposite the door. He rolled the curtains open to reveal the mirrored wall behind them. He stared long into the reflection. Others might see an image of a disheveled middle-aged man wearing green hospital pajamas and plastic sandals. Dr. Falsh, however, saw only himself, the doctor, standing behind the curtains.

Adam Strassberg is a retired psychiatrist living in Portland, Oregon. He uses the intersection of psychology, religion, mythology and magical realism to explore the human condition through fiction. When he’s not writing or napping, he often can be found updating his website at www.doctorstrassberg.com/fiction.