The patient, Clifford, appeared at the hospital on the night of December 26 between 10:00 and 10:30 PM. I use “appeared” advisedly due to the ambiguous circumstances of his arrival. Though he was left outside the admissions building, he was not brought in and instead wandered the premises. A fresh snowfall from the afternoon allowed him to leave a footprint trail that a groundskeeper, thinking a patient had gotten out, followed to the nurse residence hall, where an off-duty orderly was already engaging him. It is still not known how he was brought to the hospital. The groundskeeper said he saw what looked like a black limousine speeding away from the building, while the security guard described a red station wagon with a black cross on the passenger door.

Upon entering the admissions building, he was wearing a Mets cap and what appeared to be a woman’s fur coat. His build was slight. His initial weigh-in was 143 lbs. His vitals were normal while his complexion suggested Vitamin D deficiency. Among his possessions were a suitcase with two additional sets of clothes, hardbound books, formal shoes, shower sandals, and boat shoes. His wallet had $472 in cash, a library card issued simply to a “Clifford,” and a country club membership card issued to a “Rudolph Grattan.” He answered to the former and could not or would not identify the latter. He eventually told us that he was 23 years old.

The patient declared no illnesses or allergies. He divulged no medical history for physical or psychological disorders. And there were no referrals from other physicians. He was docile, almost catatonic, but aware and compliant. He was taken to the low-risk A wing without resistance. This demeanor was consistent throughout the winter. Clifford rose promptly around 8:00 in the morning. He was considerate with the staff and cordial with other patients. He undertook group sessions and therapeutic activities agreeably, though I would not say eagerly. He did not require assistance in life skills, whether eating, bathing, or dressing. He cleaned up after himself.

Clifford gained the admiration, even the fascination, of other patients. The more lucid among them felt an uplift in his presence; as if, as one patient put it, they were passengers on a luxury ocean liner bound for Europe. Clifford was not initially forthcoming about the evidence of his class status. Though it was difficult to overlook for everyone else. Patients of such wealth—and who can read Cervantes in the original without being Spanish—are a rarity, to say the least. And while it was a source of wonder for most, it was a source of uneasiness for some—or at least for me.

His effect upon the staff was more questionable. His low-maintenance behavior enabled orderlies and even some doctors to let their guards down. Some treated him in a manner that was dangerously close to friendship. This was not discouraged because nothing notably inappropriate was witnessed and because it lifted morale among the staff. But not so much that the soft treatment was extended to the typical patient population. After a time, some of the staff had taken to referring to him as “Clifford the friendly ghost.”

My private sessions with Clifford have shown that the staff cannot be blamed entirely for this situation. The lethargic condition of his first appearance proved temporary, and shed itself as a snake sheds old skin. It revealed an amiable, even charismatic comportment. How easily Clifford could speak of his time on the rowing team of his boarding school, his studies of classic texts at Haverford, his summers in Montauk, and his winters in Boulder. I took it as my task to discern where the authentic voice ended and the deflecting of deeper pain began. As if to anticipate this, he offered only the most generic, surface-level disclosures. His parents divorced and remarried, a source of melancholy, to be sure, but nothing of greater profundity. My attempts to probe deeper into his psyche were defended by flashes of tension.

In a voice ever soft and diplomatic but slightly assertive he asked me, “Do you know what if feels like to have a mom on an endless honeymoon in Vienna with a man I never met and whose last name I don’t even remember?”

“I’m sorry, Clifford,” I said, “but my feelings aren’t relevant.”

I made inquiries as to his possible discharge. I told the Head Psychiatrist that, in my opinion, it went against our mission to accommodate privileged patients with little to no apparent mental anguish at the public expense, depriving someone with greater turmoil but fewer resources.

The Head Psychiatrist looked at me as if I had spoken in a thousand-year dead language. “The patient is lost,” he began. “He is in a labyrinth, and it is our task to help him find his way out.”

I told him that I needed more to go on.

“I’m only telling you what I had been told,” was his indifferent reply. It seemed to me that Clifford felt fine where he was. The feeling seemed entirely mutual on the part of the institution.

I worked my way though a surprising multitude of “Rudolph Grattans” in the phone listings. I found what seemed to be the correct one on my fourth attempt. Our conversation was brief and unhappy. In the span of the first two minutes, he denied knowing any Clifford, he denied that his country club membership card was missing. Then he claimed Clifford was his cousin, that he was his guardian and had “power of attorney” over his “general welfare.” He did not care very much for my view but was insistent on the process of procuring a lobotomy “or something related,” he said. “Not for me, mind you, but for Clifford.” I told him that contrary to popular lore you cannot simply wish psychosurgery on just anyone. “I have tennis,” Grattan said as if dismissing an incompetent servant, and hung up.

For much of the winter, Clifford’s treatment routine did not extend beyond our sessions, which were careening at full-speed toward a dead end themselves. I had resigned myself to the comfortable pattern to which everyone else—staff and patients alike—had happily acquiesced. Clifford was the exception to every rule—a kind of inverse of a scapegoat. By spring, however, he’d run out of rules from which to except himself.

I was not present at the incident in April in the recreation area. I’m only going by witness accounts. Clifford was seated at a table by himself shuffling a deck of cards to no apparent purpose. Annabel, a patient of about 50 but with a maturity of about 13, approached Clifford and asked if she could use the cards. Clifford, unusually, did not respond. Slightly agitated, Annabel asked if he wanted to play Uno with her (though they were not Uno cards); again no response. Possibly desiring any acknowledgment at this point, Annabel motioned towards the cards as if to take them from Clifford. Clifford shot up with such force as to launch his chair six feet from the table. Under a hail of playing cards and carrying what looked like the strength of someone double his body mass, Clifford struck Annabel in the face, sending her straight onto the floor tiles, giving her a swollen eye and a concussion.

This incident, called the “eruption,” exposed a marked shift in character, and not merely in Clifford. The slack response of the staff, due to a lax attitude toward the patient, was the dereliction of a policy enforced with greater enthusiasm elsewhere. Clifford practically escorted himself to seclusion.

I proposed a moderate round of ECT to the Head Psychiatrist. He relayed my proposal to the Director, who sent it back to my office with “edits.” Clifford was to be doused with lukewarm water every three-to-four hours and I was to monitor any shift in demeanor. Yet he never wavered from his rigid, fidgety posture and absent, glassy-eyed expression, like a doll’s head that was aware of and indifferent to having been attached to the wrong body. Quite unlike the orderly tasked with the dousing who left each cycle with a fresh stream of tears down his cheeks. When he was returned to the general population a week later, he left behind a Clifford-shaped outline of mold.

The new situation was one of reversal rather than restoration. Clifford was now an object of apprehension. Patients avoided him; staff stopped fraternizing with him as warmly. Not that this registered in any distinct way upon Clifford himself. There was no display of conscious recognition of his outburst. Subsequent outbursts were sporadic, and some, especially where physical harm was likely, were prevented. But not always. Chairs were still thrown, yells resounded through the corridors, and twice Clifford tried to pull the bars off windows. I felt it was my obligation to inform Mr. Grattan of these developments, but his numbers were disconnected.

Clifford now seemed entirely untreatable. He was truly a ghost—a static, and no longer friendly, presence. I found a strange comfort in the shift in mood. Clifford had narrowed the gulf between the staff and the patients. The staff had even begun to see the patients as the patients saw them. It was a blessing to have happen, but regrettable that it hinged on a single individual, whose discharge I was no longer seeking but was now trying to prevent.

I am the first to admit when I am in an ethical gray area. Less because I am technically imprisoning someone than because this patient’s condition is moral and ours is pathological. The line between illness and cure was now ambiguous, if not upended. I consulted the Head Psychiatrist.

“In my experience there are patients who have become detached from all sentiment,” he said. “And then there are patients who need to be detached from their sentiment through every possible measure.”

“Did the Director tell you that too?” I asked a little too facetiously.

“No,” he said with a sigh, “I’ve been telling myself that for years.”

“Does it help?”

“Not in any way you’d think or as much as you’d hope.”

Clifford spent the majority of our most recent session staring longingly at a stuffed blackbird.

“Where did you get that?” I asked.

“I would appreciate it if you relayed your questions through Wendell,” he replied holding up the blackbird by its talons. “And in the proper voice: ‘Like this,’” he said in a squeaky, cartoonish register.

“I’m not going to do that, Clifford.”

Clifford held the blackbird up to his face, “‘Then fuck you, Doctor.’”

In October a groundskeeper came to me to tell me that he saw Clifford standing stock-still in the area by the nurses’ hall where he was originally found and at the same time.

“I’ll tell the Director myself,” I said in a huff.

“I already did. He just nodded at me.”

“Nodded how?”

“Not sure. Kind of in a knowing way, I guess?”

An early snow came later that month, exposing an urgent need for repairs in the A wing heating system. A month would pass before the necessary funds would be available for that to happen. The cold did not relent, as if autumn acquired clinical depression. We went about our days in our winter coats for the duration. Around Thanksgiving I passed Annabel, her eye fully healed and her demeanor more or less back to what it was. She seemed snug in a Mets cap and a fur coat. I felt that the look suited her. I turned my attention to the remainder of my case load.