This man exhausts me. I see him nearly every week. His thoughts are like the ping pong balls that bounce around in a Lotto jar, fast, erratic. It goes on an on. The number never coming up. The balls forever jumping.

I find him first sitting in a chair hunched over in the hallway, a wadded up brown paper towel clutched in his hands. He has been crying, angry, bitter tears. The world is against him. People hate him. I know this from prior conversations. But, he looks different. Defeated? This is someone who faked a seizure in front of me. With him, the truth and a lie are a hairsbreadth apart.

I ask him what is wrong. I ask him would he like to see me. He jumps up and follows me back to the clinic. His speech is even more pressured than usual. His mind is jumping from a height, a body splattering me with blood and bone. He leaves himself everywhere, a carnage of minute details of perceived injustices. My own mind follows one then another then collapses. “Stop, I say, I need to bring you back to here and now.” He quiets for a moment, then is off again.

The officer comes and stands patiently just outside the opening to the concrete cubicle. “Do you want him to see mental health?” she asks. I realize that it is Friday and that mental health is still here since it is not yet the weekend. “Yes, of course, ” I say. First, I must get him to take his medication.He is on treatment for Hepatitis C. I lead his thoughts to the here and now, a mother taking hold of her child’s hand. He swallows the pill dutifully even as he is telling me he wants to die–he spits the threat out like a child screaming that he will show everyone at his party–he will eat the cake but he will not enjoy it.

The officer leads him off. A few hours later he is back. I suspected he would be. They have done nothing for him. They hate him. They are fucking idiots. And, so he has decided to take sixteen naprosyn and ten capsules of gabapentin. He does not seem at all worried by this and I realize that it is possible he is making it up. I check the pharmacy records. I calculate that if he saved all his meds from a week ago, what he says might be true. I ask him if this was a plan, he admits, no, it was impulsive. He asks me what will happen to him. I call poison control and urgent care. The former advises I send him to the hospital, the doctor at the urgent care guffaws, “get a fingerstick and an EKG– he doesn’t need to go out.” I think this is true. I suspect he hasn’t taken much. The scratches on his neck and abdomen are superficial, too. Thin red lines that stand out dramatically against his sallow white skin. He broke up a radio to do it. No, it was not sharp enough to do him in, but yes, he wanted to do himself in. I ask him at one point if he has ever had a pet– the point I am trying to make is about concrete reality, about the effort required to really care for another creature or oneself. It is not an abstraction, it is not some distant philosophy. It is the concreteness of food and water and cleaning out the kitty litter box. This slows him. But, in the end, he lives epic narratives and can not escape. Still, his thoughts rarely go to the egotistically grandiose–the music career, the movie career he was just this close to becoming a star but his mother that fucking bitch who stole his money and thinks she is perfect she thinks she is perfect and she thinks I am trash but that is what it was like she always wanted to hurt me as a child they would hurt me it was Munchausen’s syndrome!

I am trying to read the mental health clinician’s note and listen to him at the same time. Pristine attention is wasted here. It only adds energy to his ranting. My gaze alone is fuel for the fire. I stare at the computer screen. “It’s Munchausen’s by proxy,” I say, not expecting him to stop. “What?” he says. I look up. “It’s Muchausen’s if you do it to yourself. It’s Munchausen’s by proxy if someone else does it to you.” This revelation stuns him. For a few seconds, he does not talk. He is processing something. Something has changed. He says gravely, “I have to write that down, I don’t like seeming stupid in front of people.” For a few seconds, he searches for a non existent pen, dropping the pile of papers of different colors and sizes and states of folding and crumpledness that he holds in his lap, then forgets. And, we are off to the races again.

He signs the refusal to drink activated charcoal. On the paper I note that by not doing what is recommended, he risks “injury, disability, and death” That seems to cover it. We are making deals. He does not want to go on suicide watch. That will only provoke him. He wants to go to C71 to see the psychiatrist. I sigh. They will not take him. I know this. He is clearly suffering, but also insufferable. He is a great sucking mouth that belches insults. He will be right back here. I tell him I will try to reach the psychiatrist. I tell him in my experience it is tough to do at 11 at night. I do try. Now, he asks for Klonopin. I tell him, no, I cant do it since he says he took ten gabapentin which can cause central nervous system depression. This logic makes sense to him, he drops the subject. As he waits for the fingerstick and EKG, he begins insulting a C.O. I walk out and tells him. “Sh. Just be quiet. Just for a little. Just for tonight. You can do this. You don’t not have to be mad, just put it off until morning.”

On the way out, he is grateful. We look at each other for a moment, maybe five seconds, which in his world is a long time. I want to say I feel for you, you are so incredibly fucked up. But, I don’t. This is not a movie though, certainly to look at it, nothing has changed, but maybe in some small way, it has. At least, I have to hope this.

Before, he leaves, he stops by my cubicle. He has no thought that maybe he has spent too much time, or that I have other things to do. He is forever a neglected child. There will never be enough time, love, reassurance, and he will try to eat the world, shoving it like that birthday cake he never got. He will vomit it and feel guilty and then angry for being made to feel guilty and the whole thing will start again.

He has a final request, of course, he does. There is always another and another. Another thought, another word, another solution. He asks me to write down the Munchausen’s “thing”. I scribble it on a piece of computer paper. He looks at it quietly as if trying to memorize it. Then satisfied, he adds it to his pile.