Chapter Thirty-Nine

Progress Note 2

Doctor Virginia East

Progress Note. Session Sixteen.

I have to admit, I am impressed, if not surprised, by Patient X's persistence in ignoring me. While I could happily spend my days doing nothing but reading, writing, and talking about the biochemical workings of the human mind, I am not so enamored of my profession as to imagine that others would naturally feel the same. Even though I have deliberately written my patient's name into my lecture notes so that I am sure to use it often when I am speaking in the hope of forcing his attention, I have no doubt he still spends most of the time thinking of other things during our daily lessons on neurophysiology. Still, after nearly three weeks, I would have hoped he'd make at least a superficial effort to communicate with me, if only from the sheer boredom of listening to the droning of my voice.

Once it was determined that he could safely be removed from his quarters for several hours, I ordered daily outings for additional stimulation, whether he was willing or not. Of course, that complicated things a bit for the commander of the facility who had promised Patient X that he would never be forced into anything against his will. After a heated discussion that included myself, the commanding officer, my patient's physician and his primary caregiver – and the patient himself, for that matter, though he refused to participate – it was determined that he could decline to be removed from his room on any given day, provided he could give a satisfactory reason for wanting to stay put. Apart from a diagnosed physical illness, what constitutes a 'satisfactory reason' was left undecided; however, it was determined by majority vote that the patient's primary caregiver would not be allowed to make that determination without consulting the facility commander, the physician, or myself.

As part of what I am told Patient X refers to as his 'daily airing', I have insisted that he be brought to the office which has been allocated for my use. More than a decade of experience has taught me that reluctant 'psych' patients, like pets and small children, are usually better behaved and more cooperative when they are not on their 'home turf'. Moreover, with the exception of those who are so ill they have suffered a permanent psychotic break and lost all touch with reality, this phenomenon holds true whether the individual is a psychiatry patient requiring medical management of neurochemical imbalances to stabilize mood, normalize affect, and maintain acceptable behavior or a psychology patient requiring only talk therapy, behavioral analysis, and training in various coping mechanisms. It also holds true with Patient X, which, if nothing else, tells me he has an adequate grasp of his reduced circumstances, which may, in the long run prove useful. If he can ever, for even a moment, get past his feelings of anger, mistrust, fear and betrayal, and still realize how very vulnerable he is, he might just be able to accept that there are people here who only want to help him, simply because they have not taken advantage of his condition to hurt him.

At least Patient X has taken my advice about one thing, and though it may not be directly pertinent to his mental health, I am sure, in the long run, it will have a beneficial effect. His primary caregiver informs me that he several days ago requested a meeting with her and his physician to plan a physiotherapy regimen to help him regain his former level of fitness. Most significantly, he set the main goals himself and with the assistance of his caregiver and physician, broke each main goal down into a series of sub-goals and benchmarks to create a workable plan for recovery. If nothing else, getting physically stronger and having a degree of control over how he accomplishes that might help him feel psychologically and emotionally stronger and, eventually, brave enough to open up and participate meaningfully in psychotherapy as well.

In the meantime, though I have years of teaching materials at my disposal, I suspect it may be time to change tack with my neurophysiology lectures. 'Insanity' has not been a medical diagnosis for centuries; however, one popular definition, doing the same thing over and over while expecting different results, seems applicable to the current situation. If Patient X can so thoroughly tune me out that he can sit through daily lectures on neurophysiology, a topic I am sure holds little interest for him, then I must do something to catch his attention, however much it galls me to concede this test of wills. I did secure a copy of the physiotherapy plan and the notes indicate both Patient X and his caregiver are strongly resistant to using any form of hydrotherapy. Perhaps - as a last resort - that would be an effective way to force him out of his comfort zone enough to make him talk to me.

When the tone sounds to indicate my patient is at my door, I put aside his case file. It is my habit to review recent notes before each session to help guide the conversation, but in this case, until my patient is willing to converse, it seems a futile exercise. So I press the button that buzzes him in, and while his caregiver positions him in front of my desk, I pull out my notes for the second half of my lecture on neurotransmitter release. As part of my research on General Reed, I discovered he had collaborated with Doctor Phlox (the same doctor who later turned him into an outrageously unethical fertility experiment) on the Agony Booth, which has become an integral, if barbaric, part of both the civilian and military penal systems. I have determined from his notes that he is more than capable of understanding the material I taught in my Introduction to Neurophysiology course for third year undergraduates in pre-med. Because he is a patient, and not a student, I try to tailor the material to his needs by highlighting information that might help him control his mood, affect, and response to stressors.

As she sets the brakes on his wheelchair, I thank Liz, and while I don't miss the comforting hand on his shoulder as she leaves, I choose not to comment. I still believe, as firmly as on the day I met him, that her compassion and the trust he places in her will be the key to his recovery. No one else can as much as speak to him or, in my case at least, even look at him without his defenses coming up. Liz can wheel him about the facility, lay hands on him, even shoot him full of drugs, and most of the time, he tolerates it.

"So, General, have you decided what you want to work on in counselling yet?" I start off today as I have every session for nearly three weeks.

As he has done every session for nearly three weeks, the general folds his arms across his chest in a patently defensive gesture and locks his gaze on the front edge of my desk.

"All right then, Part Two of Transmitter Release it is." I dim the lights and turn on the projector. My lectures come with a slide show, whether he watches it or not.

=/\=

"In conclusion, I hope you can see how GABA could be very useful in…"

"I'm not always angry, you know."

I'll admit it. His words, spoken so softly I'd have missed them in a crowded lecture hall, take me by surprise. Here I was, just an hour ago thinking I'd have to change my methods to get him to open up, and now he's done it. Not much, but it's not immodest to say I am good at my job, good enough that if I can get just one fingernail into a crack, I can work with a patient; and he may not realize it, but he has given me an entire handhold.

"…controlling your anxiety."

I'm also seasoned enough as both a lecturer and a therapist to not allow him to trip me up. Every moment I've spent with him for the past three weeks has felt like a test, and even though he hasn't said a word to me up to this point, I feel like showing my surprise would be regarded as a failure on my part. I flip to the next slide, which shows the copyright information for the presentation, so that he knows the lecture really was over. Allowing him to interrupt me would be an even worse failure than showing surprise because I assured him early on that I would not be manipulated.

"That doesn't surprise me, Malcolm," I respond as I turn off the projector and turn on the lights.

If he is surprised by my lack of surprise or by my use of his given name, the only evidence of it is how quickly his gaze snaps from the edge of my desk to my face.

"Easily said, harder to prove," he counters smugly, and why not? After all, how does one prove or disprove an emotion, especially an emotion one has made a sincere effort to conceal?

Easily enough, by proving there is no reason for one to experience said emotion.

"Not so difficult to prove, really," I say casually. "Anger triggers the fight or flight response. It releases adrenaline and cortisol which raise the blood pressure, increase heart and respiration rates, elevate body temperature, and stimulate perspiration. Anger requires a tremendous amount of energy to sustain. Energy you don't have.

"Not so long ago, when you were in peak condition, you might have been able to hang on to a really good rage for days, but not now. So, what do you want to do about it?"

"There's not a bloody lot I can do about it, is there?" he mutters.

His arms are folded again, and he is back to staring at the front edge of my desk; and I've had just about enough of that.

"Bullshit!" I snap, and he's looking me in the eye again, his arms are down on the armrests, and his hands have taken a white-knuckle grip on the chair. "Don't think for one minute you can come in here and humor me by just picking at a scab. When there's a festering wound beneath it, we're going to drain it.

"Now, anger is a very useful tool for masking other emotions. Fear, anxiety, depression, loneliness, jealousy, alienation, helplessness, hopelessness, ignorance, inadequacy, frustration, grief, hurt, guilt, embarrassment and shame," a tiny crinkle appears between his brows on 'shame' but I don't comment, "and probably a score or more of other emotions can all easily manifest as anger. So, I ask again, what do you want to do about it?"

"I want to be left alone!" he sulks, and crosses his arms and returns his gaze to the edge of my desk once again.

"That's bullshit too," I confront him, coming around the desk to crouch in front of him, at which point my proximity presents such a threat to him that he grabs the arms of his chair again, probably because he has to grab something and he doesn't have a weapon available. "And I think you know it because you wouldn't have mentioned it if you didn't want to do something about it.

"Being angry about everything used to work for you because you were in a position to punish anyone who pissed you off," I explain. "But circumstances have changed and now you have to actually cope with what you're feeling. So, for the third time, I ask, what do you want to do about it?"

"I don't know!"

We're inches apart, and still, he won't look me in the eye. His grip on the armrests of his chair is so tight the leather is creaking, and his entire body is taut and quivering like a bowstring that's been held at the point of release for too long while the archer tries to aim his shot.

"Yes, you do know, Malcolm," I insist urgently. If he was physically stronger I probably wouldn't risk such close proximity and he won't be this weak for long, so there is no way in fucking hell I'm wasting this opportunity. "Tell me what you're feeling, right now!"

"I'm bloody pissed off at you!" he snarls, and like the archer who has bled away too much of his energy aiming, he misses the mark.

"No you're not!" I contradict him.

"What business have you getting in my face like this?"

"You're using anger, right now, Malcolm, not feeling it!"

"Don't tell me what I'm feeling!"

"I'm telling you what you're not feeling!" This is not splitting hairs. Far from it, I'm pressing him now for the kind of truth he might not have admitted since he was a very small boy, if he even admitted it then. "You tell me what you're feeling! What you're really feeling!"

He draws in a ragged breath, almost a sob, and panting, he tells me, "You're too close! I can't breathe! Get away!"

"Not yet, Malcolm," I say as soothingly as I can manage. Now that I've stirred up the emotional cesspit inside of him, he doesn't need me to keep those waters circulating. "First, I need you to give that feeling a name."

"Please," he gasps, but I stay right there in front of him. I may never have another chance like this, so I have to push him harder now than I might do a more cooperative patient.

"Trapped!" he admits, his voice barely more than a whisper, and I'm out of his space before he can repeat, "I feel trapped!"

As he catches his breath, I pour him a glass of water and drop a straw into it. When he's breathing normally again I hand the drink to him. He eyes the straw suspiciously, but seems to know why it's there as he takes the glass in a trembling hand and clutches it to his chest so he can sip the water rather than wear it.

I wait quietly while he drinks his fill. He doesn't seem the least bit rushed, and I'm in no hurry. I've been paid for three weeks to do basically nothing, for that, if for no other reason, I owe him all the extra time he needs to gather himself now.

When the water is almost gone, he hands the glass back to me with a surprisingly well-mannered 'Thank you.' Then he fixes me with that glare that I've seen so many times on television and growls dangerously, "Don't you ever fucking do that to me again."

I'd be lying to deny that I felt the force of that glare, though in my defense, I suspect it's more of a reaction to who he was and who he may be again one day than to who he is now. The man in front of me right now would find it difficult to muster all at once the speed, strength, and coordination to smash a spider.

"I'm sorry, Malcolm," I begin apologetically, "but I'm going to fucking well do whatever the hell I find fucking necessary to help you."

He's either too tired to hide his surprise at my language or he doesn't even try. If he were another patient, I might even laugh at the wide eyes and downturned mouth that make him look slightly frog-like when he draws back from me, but I am too keenly aware of how hypersensitive he is to any sign of what he might interpret as disrespect to find it amusing on him.

"Look, psychotherapy is hard for trauma patients. Actually, it's fucking brutal. It's frightening. It's frustrating. It's grueling. It's demanding. It's exhausting. Frankly, it's a bitch!"

Normally, I don't curse during a session. Ever. My mother heard me cussing once. She didn't punish me for it. Instead she told me, "Ginny, profanity is the blunt instrument of a feeble mind. I want you to learn to make your point with a scalpel, not a machete. I don't think I've ever heard a thing worth saying that couldn't be said without cursing."

I was young enough at the time that I had to look up the meanings of profanity, blunt, feeble, and scalpel – I knew machete because my father had one he used to clear brush – but once I understood what Mama was saying, I wanted that, too. It wasn't until years later that I realized how very clever she had been to turn that moment into an object lesson on the spot.

But Mama never had to account for the efficacy of the occasional random profane tirade when dealing with a hard man who's lived a hard life and thrived on the sheer, wanton brutality of it, who now has to learn to cope with being vulnerable.

"In fact," I tell Malcolm, "there are only two reasons I know of that trauma patients would ever put themselves through such hell."

"And they are?" The look he gives me is skeptical, but he's actively listening, and that's more than I've got from him in the past three weeks.

It makes me wonder what Mama would say.

"It's their last hope to get better, and it fucking works."

He sits with his lips pressed into a firm line; the only thing he hasn't done is mime zipping them shut. He's clearly not willing to engage again until I convince him.

"I think it can work for you, Malcolm, if you're willing to work with me. But I have to be honest, you're going to have to deal with a lot of shit. I say that because the point of psychotherapy is to get a patient to remember the trauma and deal with it without reliving it, and I suspect you've experienced a lot of trauma in your life."

I don't think he's aware of the slight nod as he scoffs, "I don't see how talking about my feelings is going to make anything any better."

"Oh, unless you bring them up, we probably won't talk about your feelings again for weeks," I say, and get another bemused look from him. "You need to get comfortable talking before we can even think about talking about something as personal as your feelings."

He visibly relaxes a little bit at that.

"Look, I can't make any guarantees about how successful we'll be. A lot of that will depend on how well I can earn your trust and how willing you are to share, but I can make you three promises right now. First, I'll never leave you hanging; whatever emotions we stir up, I will help you process them. I won't let you leave a session feeling agitated and at loose ends. Second, nothing you say to me will ever leave the office. I do keep notes, but they do not leave the office, and they're anonymous. You are Patient X, Commodore Tucker is The Commander of this Facility, Doctor Salazar is The Physician, and Liz is The Caregiver."

He smiles slightly. From him, it's a highly significant indicator and I can't let it go. "The name I chose for Liz seems to please you. Care to tell me why?"

His smile drops away, but he answers directly. "It's more comprehensive than 'Nurse' isn't it?"

"I suppose so. What about it?"

"I think it suits her, that's all."

I don't think he has any idea how much information he's just given me, but I let it go for now. "My final promise is that I won't give up on you as long as you don't give up on me. It's ok to tell me you need to slow down or that you want to change the subject, but you have to keep trying, and when you're stalling, you have to let me poke at you every now and then."

He laughs, softly and with bitterness. "You talk as if I've already agreed to accept your services."

"You have," I point out. "You started this conversation."

He smirks and shakes his head, but it's a gesture of resignation, not denial. "Oh, bloody hell," he mutters under his breath. "All right."

"Now, before you go, I'd like an answer to my original question," I say, applying only gentle pressure. "You can't be angry all the time anymore. So, what do you want to do about it?"

He closes his eyes briefly, and I can tell that the admission, when he makes it, pains him deeply. "I've come to the conclusion that I'm never going to get anywhere without accepting help. I can't afford to alienate the people who are trying to help me. I've told myself more than once that I would co-operate. That I would accept help, maybe even graciously. That I would behave myself. But I can't seem to do it for any length of time."

It's hard not to chuckle at the way he says 'behave myself' with almost the same tone of disgust that a young boy might say 'eat my vegetables', but I daren't laugh. Right now, the only vestige of his old self that he has is his pride, and if he gets even the faintest hint of an idea that I might possibly be mocking him, well, I won't even get the chance to explain myself. He'll shut the door on me forever, though it could very well mean his life. This is a man who truly would sooner die than be humiliated yet again.

"I want to pack in being a bastard to the people who are trying to help me every time something doesn't go the way I want."

"All right, that's a good goal to have," I encourage him. "You're going to start working on it tonight."

"I…what? Our session is almost over!" He glances at the clock. "It's past over."

"I know. I'm giving you homework."

He laughs aloud at this. "Do you have any idea how long it is since I've been in school?"

"It's not that kind of homework," I assure him with a shake of my head. "There's no memorization or computation, and only a very little composition. Do you remember what I said about other emotions masquerading as anger?"

He gives me a nod. "Yes."

I pull out a pen and a paper tablet and say, "I'm going to give these to Liz." I keep talking over his panicked look, hoping to pre-empt any objection. "You can tell her anything you want or nothing at all. I'm just going to tell her you have an assignment for me and it would be good physiotherapy for your fine motor control."

Another nod.

"You're going to write me a list of at least ten of those emotions that you, personally, at some point in your life, have actually experienced and covered with anger, and I want you to be able to name specifically the incident that caused each of the emotions on your list. I might never ask about any of them. I might eventually ask about every single one. If I do ask about any of them, you'll be free to tell me if you're not comfortable talking about it. The important thing I'm looking for is that you're thinking about it. I want you to learn to identify the situations that cause particular emotions. Once you can do that reliably, we'll start working on ways to manage your behavioral responses to those emotions.

"You see, when you say you need to learn to quit being a bastard, what you really mean is you need to learn to cope with unpleasant emotions without covering them with anger and lashing out."

"But you told me we weren't going to talk about my feelings for quite some time," he objects, probably not realizing how much of his anxiety he's giving away.

"I did say that didn't I?" When he nods a third time, I smile back and say, "Well, I guess you're just going to have to trust me on that. Look at it as a small step in the right direction. Once you learn to trust that I won't push you into anything you aren't ready for, you'll be more willing to let me lead you through the painful episodes in your past in such a way that you won't have to experience them all over again every time you remember them.

"Now, are you ready to wrap it up for the day, or was there something else?"

"Bloody hell, woman! Don't you think I've had enough?"

"I think you've had a very good day, today," I tell him. "And I think you know that without anyone having to tell you."

When Liz comes in to collect him and I hand her the tablet and pen, she looks avidly from me to Malcolm and back again. I can see his anxiety from across the room as she asks what the materials are for, but I tell her only what I said I would: that he has something to do for me that would make for good fine motor practice. "If he asks you not to look at it, you should respect his privacy," I add for good measure.

It's clear from his expression that my patient doesn't know what to think. So I crouch down to be in his eye level and tell him, "I know I have to earn your trust. Give me a chance, and I will."

He gives me another unexpectedly polite 'Thank you', and then Liz wheels him away. As soon as the door closes behind them, I literally dance, albeit not very gracefully, for joy.

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