Cover image for Risk factor
Risk factor
Atkins, Charles.
Personal Author:
First edition.
Publication Information:
New York : St. Martin's Press, 1999.
Physical Description:
244 pages ; 22 cm
Format :


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X Adult Fiction Central Closed Stacks

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José Zorrilla (Valladolid, 1817-Madrid, 1893). España. Tras estudiar en el Seminario de Nobles de Madrid, fue a las universidades de Toledo y Valladolid a estudiar leyes y poco después abandonó los estudios y se fue a Madrid. Las penurias económicas le hicieron a vender a perpetuidad los derechos de Don Juan Tenorio (1844), la más célebre de sus obras. En 1846, viajó a París y conoció a Alejandro Dumas, padre, George Sand y Teophile Gautier que influyeron en su obra. Tras una breve estancia en Madrid, regresó a Francia y de ahí, en 1855, marchó a México donde el emperador Maximiliano lo nombró director del teatro Nacional. Publicó un libro de memorias a su regreso a España.

Reviews 2

Publisher's Weekly Review

Following his assured debut in The Portrait, Atkins presents another gripping psychological thriller, this one dealing with a subject common in newspaper headlines: adolescent killers. If crimes committed by teens are on the rise, how do authorities account for the increase and identify the risk factors? Dr. Molly Katz, 39-year-old single mother of two and resident physician on the psychiatric ward of Boston Commonwealth Hospital, is at her wits' end with her caseload and unanswered questions. When a nurse is found stabbed to death on the adolescent ward, Katz has few answers and plenty of guilt. Garret Jacobs, the 15-year-old suspect, is one of her patients, although he'd shown no violent tendencies. The mystery darkens when another nurse is murdered while Garret is in a catatonic state. Katz and her colleagues and superiors discuss issues concerning kids and violence: when does "uncontrolled emotion" become "evil," and how do children grow up to be killers? Meanwhile, Katz is grateful for her two successful, well-adjusted teen children, Josh and Megan, who are soon imperiled as the killer remains on the loose. Atkins, a practicing psychiatrist and Yale faculty member, writes like the authority he is, and handles his female protagonist's "mom" voice with casual ease. He also slows down his plot considerably with long, if fascinating, explanations of psychiatric procedure, diagnostic prophesy and laments over the ineffective health insurance system. Provocative theories abound, including a particularly disturbing suggestion of a new evolutionary strain. But the chilling ending provides a shock that's more visceral than theoretical, which should satiate those who like their social psychology lesson laced with a measure of sinister suspense. (Oct.) (c) Copyright PWxyz, LLC. All rights reserved

School Library Journal Review

YA-Just what causes one child to develop into a remorseless killer while another grows to normal adulthood? Is it a matter of nurturance, or something gone awry in the genetic makeup, or a combination of both factors? These questions are at the core of this compelling story. Dr. Molly Katz is a third-year psychiatric resident at a large Boston hospital. The news that one of her teen patients, Garrett, admitted with full-blown psychosis less than a week earlier, has butchered one of the staff nurses causes her to question her own and her profession's competencies. Readers follow her as she meets with her patients: an obsessive-compulsive who finds coming in for treatment a trial by fire; angry Jennifer, who lashes out at her mother with her fists; and threatening Billy, who assaults his mother in the emergency room and may have been sexually abusing his younger sisters. Then another nurse from the ward is murdered. Already hospitalized, Garrett could not have been responsible, so who is stalking the staff nurses? The surprise identification of the killer brings about Molly's own trial by fire. As she recovers, the original nature versus nurture question returns to her, leading her to pursue her career along a different path. Young adults should find this a fast-paced, interesting read and they're sure to be fascinated by the symptomatology and care of the teenaged psychiatric patients.-Carol DeAngelo, Kings Park Library, Burke, VA (c) Copyright 2010. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.



Chapter One The psychiatric emergency room of Boston's Commonwealth Hospital buzzed around me. It was 11:00 P.M. and I was wondering, not for the first time, why in God's name I had done this to myself. You would think that by now I would have learned to resist my more grandiose urges--guess I hadn't. So there I was, slogging through the paperwork for my fifth admission that evening. I briefly calculated the time that remained on my shift--nine hours, and then set up a fraction in my head to see how much was over and how much remained. It was a mental game that I played when I was on call. I don't know why, but knowing that I was two-fifths done with the night's entertainment was comforting.     A knock came at the door, followed by a head that popped in unbidden. "Dr. Katz." Billy the aide's tone was apologetic.     "You don't have to tell me," I answered, "another evaluation waiting to be seen?"     "You got it."     "Give me three minutes to finish this and I'll be out."     I reapplied myself to the task of completing the four-page preprinted admission form, and then I booted up the computer to enter the patient's orders. In some ways it was probably best that it was busy. Nights on call go much faster if you're seeing patients.     I signed my name to the triplicate form, left the relative calm of the tiny physician's office, and headed into the open area of the psychiatric assessment and triage unit, or PATU.     The PATU consisted of seven small observation rooms that faced out onto a common area. The staff, a psychiatric nurse and aide, lived behind a Plexiglas nursing station that included a split-screen monitor so that we could watch the activity in each of the rooms. Before me lay the efforts of my evening's work.     In cubicle one, huddled under her sheet, was Marisa Thomas, a frequent flyer who was crashing from her most recent crack cocaine and heroin binge. She had come to the emergency room threatening to kill herself and pleading to be admitted to a rehabilitation program. Unfortunately the state had limited drug rehabilitation beds and the few that existed were reserved for high-risk cases, such as pregnant women. At present, Marisa was fast asleep curled up in a ball beneath the flimsy breakaway sheets. In the morning she would be told there were no beds, but by then she would have had a chance to sleep, would no longer feel suicidal and would begin to feel the seering pangs of heroin withdrawal. She would be given a phone number for the methadone clinic and maybe a brief round of "We know you can do it." Then she would leave, get back out to the street, and hunt down her next fix.     Cubicle two contained Eddie Wauslausky, a forty-three-year-old man with a long history of chronic schizophrenia. He had been brought in by his caseworker and the police after they tracked him down. Eddie had stopped his antipsychotic medication two weeks ago and had been drinking steadily since. He became paranoid and barricaded himself inside his room at the residential motel where he had lived for the past twelve years. When they broke the door down, they found Eddie with no weapons surrounded by empty liquor bottles and ravaged boxes of Girl Scout cookies. All the lights had been turned off and the sockets had been ripped from the walls. A point of concern was his single kerosene lantern and five gallons of fuel.     When I asked him why he had the lantern he told me, "I was camping. Is that a crime?"     "Why did you tear out the sockets?" I had persisted.     "They were leaking."     "Leaking what?"     "God, don't they teach you anything? Electricity, they leak all over the place. It pours out of the wires and into my brain. I don't want to be electrocuted. I didn't kill anybody."     Nestled in bed three was a bearded man the police had picked up walking on the highway in his bare feet. He had no identification, refused to give us a name, and sat on his bed mouthing words and gently rocking. His clothes were filthy and reeked of stale sweat and cigarettes, his blood alcohol level and urine drug screen had both come back negative. Whatever craziness he experienced was organic. When I had reviewed his case by telephone with my supervisor, Dr. Adams, he had said, "Sounds like a wanderer."     "Which is?" I had asked.     "There's a breed of schizophrenic who seems to wander from town to town. Although sometimes they stay in one place for years and you see them along the road walking and walking for hours on end. They resist treatment, and the minute they're out of the hospital they stop medication and get back to walking. A lot of them have religious or quasi-religious delusions."     "Like they're Jesus?"     "Exactly. There's a lot of John the Baptists running around too."     "So what should I do?"     "He's not talking about killing anyone or himself?"     "No, but his feet are in pretty bad shape. He's got an infected toe that should be treated before he loses it," I added.     "Think he's gravely disabled?" he asked, intoning one of the three catchphrases that can get you admitted against your will.     "He is."     "Then go ahead and admit him."     "I don't even know his name."     "Do it as a John Doe, and in the morning we can call around to see if anyone at the mental health center knows him."     Bed four was Colleen Finch, a platinum blonde who had a profound urge to hurt herself as a way of psychic release. She came in after having overdosed on her antidepressant. She carried a diagnosis of borderline personality disorder--which basically meant that she was trapped between overwhelming emotions and a profound sense of emptiness. I had seen her before in the emergency room. The last time it had been after she had cut herself too deeply in the stomach with a kitchen knife. I remembered how she had argued with me, saying that she didn't want to be admitted to the hospital. "I do it all the time, what's the big deal? If you make me go into the hospital it will only make things worse."     She was probably right, but at the time I didn't see what choice I had. She had been in and out of the emergency room with an increasing frequency and an increasing severity of self-mutilatory acts. Something was brewing within her, and I didn't want to be the one to send her home to kill herself.     My fifth evaluation, Fred Granger, had already come and gone. Fred was a longtime patient at the local mental health center who frequently visited the emergency room when he needed somebody to talk to and couldn't get in touch with his therapist. He came in, spoke to the nurse for five minutes, had her fill out his paperwork to get his telephone reconnected and then he went on his way.     From the relative sanity of the nursing station I watched as my next evaluation was brought through the outer locked door. My heart sank as the triage nurse led a young girl back to the locked unit.     "Face of an angel," Carla Williams the psychiatric nurse stated, breaking into my reverie.     "What did she do?" I asked.     "Let me look." She ferreted through the triage paperwork. "Here it is. Jennifer Ryan, age thirteen brought by police to E.D. after she attacked her mother. Mother stated, `She's out of control.'"     I let out a sigh. This was no place for a child.     I went over to introduce myself. "Hi, Jennifer, I'm Molly Katz, Dr. Katz."     Her clear blue eyes sized me up. Her face was free of blemishes, but not of makeup. I tried to remember what my own daughter had looked like at thirteen. This girl should have been frightened, yet she appeared poised and out of place. Her clothes were clean and her red hair was tied back into a shiny ponytail. "I shouldn't be here," she stated simply.     "Let's see what we can do about that." And I led her back into the small interview office.     She looked around, taking in the avalanche of paperwork that spilled over the desk and the half-dissected Styrofoam cup that I had shredded while on the phone with an insurance reviewer earlier in the evening.     "So why are you here?" I started.     "My mother thinks I'm crazy or something."     "Why would she think that?"     "I have no idea." She made direct eye contact.     "Did the two of you fight?"     "All the time."     It was like pulling teeth. "What do you fight about?"     "Everything."     I tried to let a silence build, hoping that she would fill the space. Apparently she was fine with quiet and if I wanted the details I was going to have to dig for them. "Give me a for-instance of a fight."     "She doesn't want me to do anything. I can't go out with my friends, she gets mad with what I wear, who I see, she doesn't like my boyfriend. I can't do anything."     "Did something happen tonight?"     "What do you mean?"     "Why would she bring you into an emergency room? Has she done that before?"     "She sent me to Riverton last year."     My ears perked up at the name of the private psychiatric hospital. "How long were you there?"     "Four, five days."     "Why did you go?"     "It's my mom, she thinks I'm this horrible person. She just wants me out of the way so she can ..." She shook her head. "I don't know."     "What about your dad?"     "Long gone."     "Dead?"     "No, he's in Jersey. I tried to stay with him, but it didn't work out."     I tried to reconcile the normalcy of Jennifer's baggy jeans façade with the story that emerged in bits and starts. She looked older than thirteen, almost as if her sexuality had developed before her body had reached its full height. Her breasts were those of a woman, and I could imagine the effect that would have on the boys her age and older.     "Have there been other times in the hospital?" I continued, trying to flesh out any past psychiatric history.     "Just the one time. I was supposed to go to a day program, but it was a joke."     "Where was that?"     "Same place."     "Have you ever been on medication?"     Before she could answer, the phone rang. I picked up.     "Molly, it's Carla. I've got your evaluation's mother out here wanting to talk with you."     "Tell here I'll see her in another five minutes. Anything else out there?"     "Not yet, but the night's still young."     "Yes, and I'm getting older by the minute." I turned back to Jennifer, trying to regain my train of thought.     "That was my mom, wasn't it?" she broke in.     "Yes."     "I don't want to go into a hospital. You have no idea what those places are like."     "We'll see how things go. So what grade are you in?"     "Seventh."     "You like school?"     "It's okay."     "How are your grades?"     "Don't ask."     "That bad?"     She winced. "Not good. They're going to make me repeat."     "Has that ever happened before?"     "No, they came close last year. All that time in the hospital really set me back. That's just what's going to happen now if you send me to a hospital. You'll just make it worse. You should see what it's like at school. Everyone goes to those places and they come back more screwed up than when they left."     "You have friends who've gone into psychiatric hospitals?"     "Yeah, it's weird; they, like, brag about it."     "Why do they go?"     "Stupid stuff, like, one girl tried to cut her wrists and they sent her away for two days, like that's supposed to make her better or something?"     "Doesn't seem like much, does it? What about you, do you ever feel so bad that you wished you weren't alive?"     "Sometimes."     "Have you ever tried to kill yourself?"     "Not serious. I tried to take some pills once, but nothing happened."     "How long ago was that?"     "Before I went to Riverton; that's why they sent me there."     "What kind of pills did you take?"     "Like, my mother's stuff. It was, like, Valiums or something."     "Did they pump your stomach?"     "Yeah, and there was that gross black stuff."     "It sounds serious," I commented, realizing that someone had thought her overdose dangerous enough to warrant gastric lavage followed by charcoal.     "I don't know."     "What about now? Do you sometimes think about killing yourself?"     "Sometimes."     "Do you think about ways of doing it?"     "Like taking pills or something?"     "How often do you think about stuff like that?"     "I don't know, every day maybe."     "Does it get worse when you and your mom fight?"     "Yeah, I just wish she'd mind her own business. I know she's going to try and send me away. It's like she just holds that over my head."     "I'm going to need to talk to her," I admitted, wondering how that would sit with Jennifer.     "Yeah, whatever."     "What I'd like to do is meet with her alone, just as we did and then the three of us will sit down and try to figure out what comes next."     She gave me a look that seemed resigned and too old for her face. "She's going to tell you that I do all sorts of stuff; none of it's true. She lies about me all the time."     "I'll keep that in mind." And I led her out to the row of bolted chairs in the common area. Her mother, who I judged to be around the same age as myself, was sitting tightly clutching her pocketbook.     "Are you the doctor?" she asked, getting to her feet and avoiding her daughter's gaze.     "Yes, I'm Dr. Katz, Molly Katz."     "I need to talk to you." Her eyes were red-rimmed and I noted that a crumpled bit of tissue was caught in the latch of her worn black handbag. Most striking was an angry red bruise that had blossomed on her right cheek.     "What are you going to tell her?" Jennifer asked, an accusatory edge coloring her words.     Mrs. Ryan looked straight at me. "I need to talk to you."     "Let's go into the office."     "I have a right to know what you're going to say. It's not fair. You can't believe--"     "Jennifer," I said, not wanting her to escalate in the emergency room, "it's like I said, I have to talk with your mother and then the three of us will sit down. I need to get all sides of the story."     "It's not fair." She gently stamped her sneaker-clad foot. "I want to hear what she says."     I shot the nurse, who watched the interaction from behind the Plexiglas wall, a warning look. "Carla, maybe you could sit with Jennifer and fill out the paperwork. At least we could get that out of the way."     "What kind of paperwork?" the teen demanded. "Is that to put me away?"     "No, we do it with everyone, it's just a bunch of forms."     Before she could argue or get more upset, I ushered her mother back into the interview office.     "She seems pretty angry," I offered, taking the chair opposite Mrs. Ryan.     "That's nothing, wait till she gets going ..." She looked at me, sizing me up. "Do you have children?" she asked.     "Two."     She thought that over, was about to say something, and then changed her mind.     "So what's been going on?" I prompted.     She laughed; it sounded forced and a bit too hard. "What hasn't been going on?"     "What happened tonight? It must have been something serious to call the police."     "It's just too much. I can't handle her. Everything I say is wrong and she won't listen. She swears at me all the time, but that's nothing. It's when she starts throwing things and hitting ... I can't handle her."     "Did something happen tonight?" I persisted.     "Yeah, I came home from work to find her and her seventeen-year-old boyfriend in my bed." She put her hand to her bruised cheek and pushed a stray lock of brittle blond hair back behind her ear. "She's thirteen; she refuses to use birth control. I know she's using drugs. When she went into the hospital last year, they said she had been smoking pot, and God only knows what else she's using. I get calls from her teachers every week. They call me at work and tell me I have to go in for conferences, but how am I supposed to do that? I work as a teller; it's all I can do to hold on to my job and then I come home to that . They were naked in my bed. I couldn't believe what I was seeing. When I told him to leave she started to yell at me, like I was the one who was doing something wrong."     "How long has this been going on?"     "She hasn't done a thing I've said since she was ten, and God only knows how long she's been sleeping around. It just keeps getting worse. I'm scared to go to work in the morning because I have no idea what I'll find when I come home. She sneaks out at night; I have no idea where she is. I think she's at school and then I get a call to tell me that she never showed. Department of Social Services has been to the house, and they threaten to take away custody. Frankly, I wish they would. I'm sorry if this makes me a horrible person, but I wish someone else would take over. I can't handle her ..." She looked down at her hands now twisted in the strap of her bag. "I can't take her home."     "Why did you call the police?" I asked, knowing that there had to be more.     "I didn't know what else to do. She wouldn't let the boy leave, she kept pulling him back, so I had to threaten statutory rape to get him out of there. At least I think he's her boyfriend. She's only thirteen; I don't know how many boys she's slept with. When she was eleven she had gonorrhea. I had taken her to see my gynecologist because she had just started to get her period and he told me that she had gonorrhea. When I asked her how she got it, she lied. `I don't know how I got it. No, I've never had sex. He must be mistaken.' So like an idiot I believed her. That's the other thing, she lies constantly, to me, to her teachers, to her father. You never know what to believe. I can't trust a single thing out of her mouth. She even accused one of my boy friends of touching her. He wasn't even around when she said it happened. If she makes a promise, she won't keep it. What am I supposed to do? Someone has to be with her twenty-four hours a day. And I have to work."     "So the boyfriend left and then you called the police?"     "She was out of control. I admit that I wasn't in the calmest of states. I told her to go to her room and she wouldn't. It's like she becomes an animal when she doesn't get her way. She started to come after me with a lamp and I got that away from her and then she just started hitting me. If she could have killed me, she would have. I dialed 911. I couldn't think what else to do."     "That was the right thing to do."     "I can't take her home." She pleaded, "You've got to admit her somewhere. I just can't do this anymore."     A vein throbbed on her forehead, and the lines in her face were taut and underlined with harsh dark shadows. For a brief moment I caught the image of her skeleton trying to leap out from under her skin. I wanted to tell her that it was going to be okay, but in my heart I knew that was a difficult statement to make. "Do you feel ready for me to get your daughter?"     "If we have to, but I won't take her back."     On one level I wanted to shake her and say, "You can't just abandon your child in the emergency room." On the other hand, if this had been my daughter and she had done these things ... "I'll be right back."     Jennifer looked up as I came out of the interview room. "Can I go?" she asked.     "I'd like you to come in so that the three of us can talk."     "You're not going to let me go home, are you?"     "I think we should sit down and come to some decisions about what the plan will be."     I watched as the teen struggled to maintain self-control. "What did she tell you?" Her voice crept up in pitch and tone. The crack- and heroin-addicted woman in bed number one responded by closing her door.     I said nothing and held the door to the interview room. As I waited for Jennifer to enter I looked around at the too-small space. Mother and daughter would be sitting almost touching each other. I felt the tension rise and rethought the strategy. "You know what," I said, "why don't we sit in one of the holding rooms." And I motioned for Beth Ryan and her daughter to follow me into cubicle number six.     The two of them sat at opposite ends of the cot while I stood against the wall by the door. Jennifer looked at the floor and her mother stared straight at me. None of us wanted to be there.     "We need to pull together some sort of plan," I started. "It's clear that things have gotten out of hand at home."     "What are you talking about?" Jennifer shot back. "What did she tell you?"     "The truth," her mother stated. "I just told her the truth."     "Like you even know what that is. You're just mad because I can get a boyfriend and you can't."     "You see," Beth said, looking at me for confirmation. "This is how a thirteen-year-old talks to her mother. Beautiful, isn't it?"     I felt myself sinking into quicksand. "Look, it's clear that the two of you have a lot of things to work out, but right now we have to figure out a plan that will be safe."     "Let me go home," Jennifer stated. "That's the only plan I want."     "How would you be able to keep yourself in control?" I asked.     "What are you talking about?" the teen shot back.     I looked at the growing bruise on her mother's cheek and I chose my words carefully. "The police report said that you were pretty upset and hit your mother."     "I never touched her. I told you she lies."     "Then how did I get this?" Beth Ryan asked, turning to look at her daughter. "Care to tell the doctor how this happened?"     "How should I know? Maybe you fell, maybe you hit yourself. Don't go blaming your problems on me."     "That's it," Beth Ryan stated, getting her to feet. "I just can't take this right now."     "What are you saying?" I asked.     "You have to put her somewhere."     "You bitch!" Jennifer erupted and lunged for her mother.     Beth Ryan, apparently used to such a reaction, was on her feet and out the door.     Jennifer followed her into the waiting area. "You fucking bitch!" she shrieked, and hurled curses after her mother.     I looked across the nursing station at Carla, who had already pushed the panic button under the desk. Through the small glass window in the reinforced door that led out to the main emergency room I saw three security officers as they raced to our assistance. Jennifer had cornered her mother and appeared ready to strike. I tried to calm her down, but was prepared to grab her right arm, which was raised in a clenched fist.     "Jennifer, you've got to get under control," I said, as the guards pulled her away from her mother. The minute they touched her she began to thrash and to scream. My heart pounded in my chest as I helped the guards get her onto the restraint bed.     "What are you doing?" she yelled. "Noooo!" She kicked and spit at us as we held onto our assigned limb and proceeded to tie her down. "Help! Mommy, help!"     Once she was secured I turned to Carla. "Get her two milligrams of Ativan, ASAP."     "Coming up."     I turned away from the cursing girl and tried to find her mother. I couldn't imagine what the effect of watching her daughter placed into restraints would have. "Where did the mother go?" I asked one of the security officers.     "I don't know."     I quickly checked the cubicles, thinking that maybe she had gone into one of them to get out of the way. But she was gone.     As Carla returned with the syringe full of tranquilizer, I told her, "I think the mother left."     Jennifer strained against the restraints and screamed as Carla injected her with the medication. "You bitch! You fucking bitch!"     Carla turned to me once she had given the shot, and in a voice that only I could hear, she whispered, "And who can blame her?"