As medications were started, the nursing staff entered a trial-and-error period of attempting to identify a pattern in Donald’s explosions and see what, if anything, we might do to keep our workplace safe. “Show empathy and open-heartedness,” they tell you in nursing school. But this wasn’t going to come readily, and our first step was decidedly inauspicious: we asked permission to remove Donald’s weapons of mass destruction – his heavy shoes – and force him into bare feet.

Unlike many of our more acutely ill patients, Donald had the capacity for apologizing. Within hours of his mayhem, he’d look sad, his head hanging puppy-like. “I’m sorry,” he’d say. But even still, he’d remain maddeningly out of contact with himself, unable to articulate a reflective response even to simple questions about his behavior. When we asked him why he’d demolished four nice chairs, for example, or why he’d kicked a bathroom door off its hinges, “I don’t know” was all he could muster, in what became an oft-repeated refrain. “I shouldn’t have done it. I just want to get out of here.”

On the other hand, we could see that Donald cared passionately, in certain perhaps autistic ways, about a wide range of subjects. He not only cared, in fact – he relished. The more we talked to him, the more we learned: he’d read books about astronomy, literature, Greek mythology, the history of world religions. He could recite the Latin names of obscure dinosaurs and describe in detail the principles of air flight, the distances between subway stations, and the workings of the inner ear. Food inspired special passions: he chattered with gusto about grilling, steaming, roasting, and balsamic glaze, about what Turks do with lemons and eggplants and what Italians do with fish. Much of his knowledge came from cookbooks rather than from direct experience. But relating the piney scent of rosemary potatoes and the tangy pop of blueberries on vanilla ice cream, he sparkled. Some of us among the nursing staff were avid home cooks: we delighted in his good moods.

One day, months into his stay and still on strict lock-down, Donald ambled to the nursing station to grab an apple from the counter. “I’m hungry for something to read,” he announced, mostly to the air. “And by the way, when’s lunch?” The staff at the desk shook their heads and chuckled. “He is such a confused teenager,” said an elderly nursing assistant who, in the course of her many decades of work, had raised four children and, now, more than a dozen grandchildren. “He’s hungry for everything – books, snacks, knowledge. And then suddenly he remembers he wants to smash us all and break out of here.”

For those of us who had raised teenagers, the observation rang instantly true. We glanced around the room, eye contact registering a flash of collective amazement. Donald’s erratic behavioral swings indeed seemed to epitomize the characteristic paradox of teenagers: the yearning, on one hand, to take in the wide world, to absorb it and digest it, to make all of it their own – and the craving, on the other hand, to crack everything apart and break free from familiar confines. The furious kicking at walls, the refusal of therapeutic programs, the appetite for food and facts which could be absorbed, digested, and ruminated upon – all these could be “read,” in a way, as a gestural communiqué: we had on our hands a pimple-faced teenager in full-throttle contradiction. Most of us have had moments of epiphany at some point in our lives, when some image or idea suddenly emerges to give coherence to what previously had been a jumble. So it was that morning: Donald’s pattern of struggle was itself, we decided among ourselves, a clue for some kind of intervention approach. The mothers among us were sure of it.

In the week following this decision, Donald smashed all the ward fire-exit signs and hurled trays across the dining area. But then a few days passed without incident, and despite a prevailing cloud of worry and doubt, I led him out to the garden, watching carefully for pacing, body postures, or facial expressions which might signal impending danger or emotional escalation. Immediately on contact with the breeze and the air, Donald stretched his arms like a lazy cat and stood, blinking and still, in the sunlight.

The first day, we strolled along the walkway and lingered over an area planted with herbs. I plucked a few leaves and offered them. Donald lifted them to his nostrils and inhaled deeply, taking in sage and lavender and lemon-scented geranium. When the horticulturist came out to say hello, Donald cheerfully rattled off the Latin names of at least half a dozen of the ornamentals.

Donald and I strolled in the garden for almost three months, intermittently. We had a pattern: he kicked holes in walls, cracked apart chairs, missed a few days or a week or two of our sessions, depending on the extent of the damage. And then we’d start over, the cycle repeating itself. He listened attentively to the hum of bees and the whistle of breezes; he stroked the soft petals of hibiscus and gingerly traced his fingers along the heart-shaped outlines of Colocasia leaves. Parsley and basil and oregano ripened. I snipped fragments for him to taste, triggering lengthy discourses on pasta and soup stock. He identified butterfly species and listed the medicinal uses of Echinacea. He sniffed everything with his wide nostrils – the soil, the park bench, a brick wall, his fingernails. Donald did a lot of talking in the garden, and I, mostly, did a lot of standing around. But something began to change.

Occasionally at first, and then more frequently, Donald started pausing. Suspended over a bloom or leaf, turning his ear intently to some object I could not identify, he would stand, almost immobile. Then, after a minute or more, he would launch into a description of someone or something as if it had been called up, that moment, to memory. Increasingly, over time, these were personal stories rather than recitations of fact. He told me about a grandmother born in the Greek Isles, a social worker he once knew, a book his mother used to read to him, a fairy tale he remembered. Without probing for information about context or implications, I could not identify the meanings of the associations the garden was conjuring, the thoughts which might be linked to whatever stream of images it had released. But I could see that Donald was beginning to make contact with a narrator inside himself.

Gradually, with setbacks which became less frequent as the weeks passed, Donald’s violent outbursts tapered. Then one day, a fight broke out among some other patients. Instead of entering the fray, as he might have done earlier, Donald stepped back and removed himself, reminding himself out loud, “I should stay out of this.” It was a benchmark moment – our first explicit signal that he had begun to show a capacity for regulatory self-talk.

It was a long time before anyone felt Donald was safe enough even to be considered for transfer to a less restrictive setting. There was no magic in his progress. But a year of intensive interdisciplinary work passed, during which a charming, vibrant, and often funny young man emerged, a young man who had allowed many new people into his circle. And finally the day came when he waved at the door, dragging a rather hilariously heavy bag of books and clothing to the next, hopefully better, chapter of his life.

What might be said, looking back, about the nursing intervention described here? As with the activities described in previous chapters, it embodied many of the traditional nursing values and competencies – patience, perseverance, caring, consistency, reliability, confidence, generosity, optimism. We gave these in abundance – and over a great span of time. Equally importantly, however, is that the nursing team took seriously, particularly in the beginning, the communicative content of Donald’s violent gestures; we looked and listened before dismissing his bizarre, frightening behaviors merely as symptoms needing to be contained or managed. We engaged the details of Donald presentations as ideas which might be thought about and transformed to productive use.

It is worth noting that we made no particularly dramatic show of attentiveness and compassionate care. Nobody talked to Donald about his feelings. Nobody tried to support him to achieve formal or conventional conscious insight. Nobody praised him for participating in a therapeutic activity or offered words of comfort or support for his obvious suffering. The opposite, in fact, was true, since Donald had come to us uniquely unable to tolerate traditional therapeutic “talk” and was intensely hostile to any interactional format which triggered even slight feelings of being boxed in.