Chapter Forty-One
Coping
Doctor Virginia East
"Very good, Malcolm," I say after he's been breathing properly for about three minutes without interruption. "Now, do you think you have enough gas in the tank to move yourself out of your wheelchair and into a regular one?"
He frowns, but he doesn't open his eyes, which I think is a testament to the effectiveness of the 4-7-8 breathing technique. It had taken me nearly five minutes to convince him simply to close his eyes as part of the exercise. It's no small thing for someone that wary to be able to carry on a conversation without actually seeing the other party, and I'm sure Malcolm is more aware than most people just how much information is conveyed by body language. I wouldn't go so far as to say he trusts me, not even a little bit right now, but I do think the breathing has made him calm enough for his rational brain to decide that the simple act of talking isn't necessarily a threat.
"I suppose I could, why?"
"I just think getting out of the wheelchair as much as possible will help you feel less like an invalid," I tell him, and it's half the truth. He'll learn the other half soon enough. "And feeling less like an invalid will make you feel more confident and better able to cope with whatever comes your way."
He doesn't open his eyes at once, but his thoughtful expression tells me he is actually considering my suggestion. After several moments, he nods and concedes, "That would seem like a reasonable assumption."
"So are you willing to try it?"
"I suppose so," he agrees, however reluctantly. At some point he has opened his eyes, but he doesn't seem particularly suspicious. It's just what you do when you're having a conversation; you look the other party in the eye.
"Do you mind if I push your chair?"
Now his shields come up, his eyes narrow and his mouth gets tight. "Why?"
"Because I have a particular seat in mind for you," I tell him, and he looks rightfully uneasy. The chair I have chosen for him is all chrome and black leather. It looks like something out of a high-end urban design catalog, and sits like something out of Torquemada's parlor. Apart from the deceptively poor design – it looks sleek and elegant and expensive, but the angle at which the seat slopes creates the feeling of one's rear end sliding out the back and forces one to constantly push the upper body against the backrest to avoid getting stuck folded in half like a pocketknife with one's knees against one's chest and one's ass hanging out – I have also enlisted an engineer to bend the frame in such a way that too much pressure on the backrest causes it to rock backward, making one feel the need to lurch forward and scrabble for purchase to avoid toppling over and cracking one's head on the floor. Of course, no one can really get stuck and it won't actually topple (I'd never have a piece of dangerous furniture in my office), but that's impossible to know when one is in freefall.
His eyes roam the room until he spots it, off in the corner, facing the junction of two walls, and his eyebrows climb. "You're going to sit me in the corner like an errant schoolboy?" His tone is scathing, his upper-class English accent so pronounced you could slice bread with it.
"You could choose to see it that way," I admit, "but if you consent to try it, I think you'll find it accomplishes a lot more than just giving you time for a good, long think about the latest naughty thing you've done."
Looking at me suspiciously he asks, "What 'naughty thing' is that?"
He knows as well as I do that if I start making a list we'll never get to move on; but I honestly don't think he's stalling. He's just misunderstood the purpose of the exercise, which isn't surprising as most people have never been sat in the corner for any reason other than discipline.
"There is no 'naughty thing,' Malcolm," I assure him. "I won't judge you for your past behavior, but in time, once you're comfortable talking with me, I will try to help you understand it and use that knowledge to change your future actions, if you want to. I just mentioned it because that's why parents and teachers put children in corners, to contemplate the effects of their misbehavior on the people around them. And honestly, I don't think you'll get that far today. In fact, if you do, I'll have to completely re-evaluate my plans for your treatment. This exercise has an entirely different purpose."
"And what exactly is that?"
He hates giving away his anxiety. When he was in power – and probably for a long, long while before that – any sign of it would have been an indicator of weakness he couldn't afford, so he must have perfected that front of perfect, cold arrogance we saw so often on the television. Even now, when his defences have been brutally broken apart by what he's been put through, he's so good at hiding it that I guess anyone less highly trained and experienced than I am would find it very hard to detect; but I can tell now he is getting anxious, and I'm fine with that for now. I elect not to answer his question directly – he can make his own inferences.
"Look, I told you yesterday that counselling can be brutal," I remind him. "I understand what I'm asking you to do, and I get that you're frightened. That's ok. I know it's a big ask, but I think you can handle it."
I'm not sure he has quite worked out yet exactly what I intend to do, and I have no intention of telling him. I would not consider today's session a complete failure even if he went into a full-blown panic attack, if he crumpled into a sobbing heap, or if he hauled off and tried to slug me, or any combination of the three.
"What makes you think I'm frightened?" he asks, with an edge to his voice – yep, he really does hate to be read that well – and I have to wonder if he really doesn't recognize the signals he's giving off.
"I'm well-trained and good at my job," I respond with a small smile, hoping a little teasing might lighten his mood.
It does not.
Getting a glower from him, I also add, "I can see that you're pale and perspiring, your pupils have dilated, your breathing has accelerated, you're swallowing frequently, probably in response to the bitter taste of adrenaline that's flooding your mouth, and your left foot is bouncing like you have a spring in your leg. I suspect, too, that your heart is pounding and your hands are clammy."
He's more than just a little irked at being so efficiently outed, but now that he knows there's no covering his reactions from me, he takes the opportunity to wipe his sweaty palms on his track pants and makes a conscious effort to still his jittery leg.
"You still haven't told me what you expect to accomplish by having me sit in the corner," he observes sulkily.
"I know," I admit, "because part of the lesson to be learned lies in figuring that out for yourself."
His leg is back to bouncing again, which assures me he is genuinely engaged in our conversation.
"Now, if you don't feel up to it today, Malcolm, all you have to do is say so, but sooner or later we're going to have to do this or something like it. It is a necessary step to your recovery. A fundamental building block, and you're not going to achieve much progress until you do this."
He's looking quite petrified now, and I can't say I blame him. He doesn't know me yet, and I'm asking him to turn his back on me, though I'm still not convinced he's realized yet that will be the net effect of sitting him in the corner. There's no telling what I'm capable of, and I'd guess that even here in the Bunker he has more strangers with potential reason to hurt him than any ten ordinary men.
I could reassure him by pointing out that doing anything to hurt him would, at the very least, cost me a life-long friendship because I'm here at Trip's request and Trip wants him to get better; but I won't. He needs to find some way to let his rational mind override his instinctive fear, and it will be far more effective if he can decide on his own that I can be trusted than if I spoon-feed him reasons why it's better for me not to harm him.
"What happens today if I say no?" he asks, and again the anxiety's peeping out.
I shake my head. "I'm not going to tell you that. In life, we don't always know the consequences of our actions beforehand. I just want you to evaluate this one activity on its potential merits and decide whether you're strong enough to cope with it today."
"You're not giving me much help in making the decision, you know," he complains bitterly.
"That isn't my intent," I admit. "In fact, I think you will come to realize that most of my help will feel like the mental, emotional, and spiritual equivalent of an unanesthetized dental extraction."
"Well, fuck me!" He gives a dark laugh and visibly relaxes, which isn't surprising. I've confirmed for him that what I'm asking him to do will be horrible, which gives him permission to freak out a little and relieves him of the burden of hiding his anxiety.
I consider moving around the desk and sitting in the armchair beside him, but conclude quickly that I think he would prefer the distance. So I just lean forward instead.
"Look, Malcolm, I know I said I think you can handle this, but I could be wrong. That's why it has to be your choice. All I know for sure is that you will either succeed and derive a sense of accomplishment from it, or fail and learn something to help you do better next time."
"And will you let me know if I've succeeded?" he asks.
I shake my head. "I won't have to. You'll know before I do."
"How?"
"Because we've been discussing this long enough now for you to have set some expectations," I tell him. "You already have some idea of what you want to happen, what you want to do and not do. You've set the objectives. You'll know if you meet them."
He sits very still for a long time. I'm not even sure he's breathing, but his eyes move from one side to the other occasionally, as if he's having an internal debate. Finally, he sighs deeply.
"Fuck it all," he says softly. "I'll try it."
I request and receive Malcolm's permission before I move his wheelchair, and again when I offer support to help him move to my chair in the corner; and I'm careful to put my arm out and let him grab on to me rather than putting my hands on him.
He accepts my assistance relatively graciously and complies readily enough when I encourage him to start the 4-7-8 breathing. I stay in his eye-line for a minute or two while he settles in, and then slowly move away.
At first, he manages to maintain his breathing quite well, all things considered. I stand directly behind him for a minute or two, until I am certain that he's firmly focused on whatever he's using to keep control. Finally, I begin to inch away. I've not even completed my first step when I hear a small hitch. He has gone completely still, listening, waiting to see what happens next. Given his history, this has got to be tremendously stressful for him. Eventually, he needs to breathe again, and the first few breaths are a little shaky because he's held it so long; but soon, he resumes the 4-7-8 pattern.
I stay where I am, watching, waiting for him to relax the tiniest bit. It takes all of ten minutes, but eventually, it happens, and the chair shifts. Instantly, his breath catches and he shifts his weight. He takes a few little gasping breaths, stops, and after a few seconds, perhaps half a minute, resumes the breathing pattern.
I could stop the exercise right now and give him an easy win if I wanted, but I don't think the general has ever taken the easy way in his life. I think he'd feel cheated if I stopped him before he hit a wall. I think he's someone who needs to push himself to the limits of his capacity, and I don't think it matters at the moment whether he overcomes his limitations or falls flat. He just needs to find out, to the last millimetre, how far he can push himself, so he can do better next time.
But that doesn't mean I can't help him, just a little.
"You're doing well, Malcolm," I say in a low, encouraging tone, and he visibly starts. "Just focus on your breathing. Meanwhile, I'm just going to potter around a bit."
"P-Potter around?" if he's aware of the anxiety in his voice, I'm sure he hates it.
"Paperwork, correspondence, organize my desk drawer," I say casually. "Perhaps I'll even dust. I'd like you to just sit tight and practice that breathing."
I hear some muttering, which I suspect to be profanity, and return to my desk, to activate my computer. The screen is divided into three sections. The top section is subdivided into three video images. There are a handful of cameras installed around the room, all of them on a hardwired, closed-circuit feed to this monitor. Moreover, the cables running from the cameras to my monitor go through a PVC conduit mounted to the wall at ceiling height. I've made sure Malcolm knows it's my standard practice to record sessions, but I've also made it clear that if anyone wants to hack the feed, they can only do it from inside this room. Since I've insisted that Trip keyed the lock only to my access card, no one can get inside the room without my buzzing them in, unless I hit my panic button.
The middle section is his biometric readout. Two thirds of that section is a pane displaying two squiggly lines, an EKG and an EEG. The other third provides numeric readouts of Malcolm's heart and respiration rates, his blood pressure, temperature, and blood oxygen levels. Trip has warned me not to put too much stock in these metrics right now as they're still experimental improvements on existing equipment already in use in the fleet. He says the most I can count on them reporting accurately is the difference between 'alive' and 'dead', but I suspect they're much better than that. Still, the only data we've been accepting is that which we receive from the monitors that have been attached to Malcolm. They send their telemetry to the nurse's station in the corridor outside Malcolm's room. We know this data is not one hundred percent reliable, either, except when he's in his room attached to the stationary machine. The portable monitor, a device about the dimensions of two PADDs stacked together, is susceptible to data corruption and outages as Malcolm moves about and passes computers, security stations, and other sources of EM radiation throughout the bunker. Nevertheless, I use this information now. All I really need it to show me is whether he is becoming more or less agitated.
The final section is a task pane. Correspondence is something I can work on in fits and starts, giving it only a part of my attention and interrupting myself as necessary to have a word with my patient. This isn't like our first session, though, where he refused to participate and I completed my session notes just to have something to do. This time, he is already working very hard, as I can tell from the monitors, and I will be using the small noises of my working to provide him with additional stimuli, to see how he copes with the – for healthy people – mild anxiety of the sounds of unknown activities occurring behind his back.
Of course, he's about as far off 'healthy' as you can get, mentally speaking, without requiring a strait-jacket. His awareness of danger goes from 0-60 in a split second and doesn't stop to ask questions on the way.
The first tap of my finger on the keyboard opening the correspondence window causes all the biometric readouts to shoot up. On the video feed, Malcolm visibly flinches.
"I'm just going to take care of some of my correspondence, now," I tell him. "Are you doing all right?"
The readouts spike again, but then go back down a bit. I get a mumbled response.
"I'm sorry, Malcolm, I need a clear yes or no."
"Yess," he hisses from across the room. It's a blatant lie, but I let it go. He's in no danger at the moment, and the entire purpose of this exercise is for him to practice coping with being not ok. I watch the monitors for a bit, and he returns to the 4-7-8 breathing. The readings don't return to baseline (in these circumstances, which must be desperately stressful for him, I wouldn't expect that), but so far, he's doing well.
I set the correspondence pane to accept manually entered data. In addition to wanting to avoid dictating my letters with a patient in earshot, I also don't want to give him too much information about what's going on behind his back. The more he knows about what I'm doing, the easier it will be for him, and I have determined at this point that he doesn't want this to be easy.
As expected, all the readouts shoot up again in response to the rapid tap-tap-tapping as I begin typing away. He has a little more trouble recapturing the rhythm of his breathing this time, but he just manages to do it, for a minute or two.
Then the most peculiar thing begins to happen.
=/\=
I am not a general psychologist. I am not one to analyse some office minion's Oedipal dreams and help him determine how to appropriately interact with his attractive female supervisor so that he can avoid losing his job and eventually advance in his career. I'm not going to entertain the inconstant musings of some well-coiffed Cabinet minister's bored wife until she finds something less self-destructive than swilling champagne, popping designer drugs, and fornicating with household servants and tradesmen to help her deal with the realization that her life of privilege will never be what she expected before her liver explodes, her kidneys calcify, and undiagnosed tertiary syphilis Swiss-cheeses her brain. I don't deal with the oversexed, the disaffected, and the disillusioned. I don't train undisciplined minds to master their impulses and behave appropriately.
I am a psychological traumatologist. I take men who are afraid to sleep because of the harm they might do to themselves or others in the throes of a waking nightmare and teach them that they don't have to be afraid of the dark. I take women who can't bear to be touched and help them find comfort in a hug. I take broken minds and broken spirits and mend them the best I can, or, more accurately, help them mend themselves, so that they can function in the world again, be part of a family, join a group of friends.
Still, Commodore Tucker did not hire me solely for my specialty. There are any number of traumatologists in the Empire nowadays. In the past five or ten years it has become a highly sought-after specialty. The Empire has been at war for decades, and the stresses of serving in combat have become so extreme that the Fleet and MACOs alike are now medically discharging veterans who are too dangerous and unpredictable to serve on combat ships, releasing them on an unprepared civilian population like so many rabid dogs. So, my colleagues and I are needed, so much so, that the Empire now pays a stipend sufficient to cover the costs of food and lodging to encourage students to enter the field. Being who he is and knowing who the patient is, the commodore could have, literally, drafted into service any qualified practitioner he wanted.
He did not choose me simply because he knows me, either – or even because he trusts me, though I am sure those reasons had a great deal to do with his final decision to hire me.
Ultimately, he chose me because of my superior qualifications.
In every field of human endeavour, there are those who stand head and shoulders above the rest. They are leaders, trend-setters, teachers, scholars, and experts. They are the inventors of theories, formulas, and equations that help us describe the world; the discoverers of elements, particles, compounds, and materials that help us construct it; the designers of machines and essential tools that help is manipulate it; the developers of practices and protocols that help us organize it; the founding fathers and mothers of subspecialties and entire schools of thought that help us understand it. When you think of genetics, you think of Gregor Mendel, Josef Mengele, Crick and Watson, and Arik Soong. When you think of chemistry, it's Joseph Priestly, Alfred Nobel, Madame Curie, and Fritz Haber. In physics, you think of Archimedes, Newton, Einstein, Bohr, Heisenberg, Schrödinger, Hawking, Cochrane, and now, Tucker. They are the Immortals.
I do not imagine that I might someday stand among the likes of Ivan Pavlov, B.F. Skinner, Maslow, Freud, Jung, and Harry Harlow. Traumatology as a sub-specialty of psychology is in its infancy. We don't yet have a pantheon of great thinkers to venerate and imitate. We must look to one another for the best ideas and try to improve upon them, and for all I know, my name and my work won't even rate a footnote in the texts used to train student traumatologists a hundred years from now. Still, at least for the moment, it is not immodest for me to say that any list of the best practitioners active in my field of study would have to include my name in the top ten.
I am a top-tier specialist within my specialty, and I can count on one hand the colleagues and rivals who can claim experience and achievements on par with my own. For the past fifteen years I have maintained both a clinical practice and a research focus. Throughout my clinical career, I have treated exclusively veterans and, more recently, active duty servicemen and women. As psychological trauma goes, their experiences are unique and distinct from the types of trauma civilians suffer in that military trauma almost always consists of not only things that have happened to the patient, but also things the patient has done to others. They have to deal not only with the shame of a victim who was too weak or afraid to stop an aggressor, and the survivor's guilt that plagues nearly anyone who has survived an event in which others nearby were killed, but also the shame and guilt of an aggressor who looks back on the things he or she has done and realizes the enormity of his or her actions. For many of our veterans, their trauma starts the day they leave home for basic training, and continues right up until they die in the line of duty or are mustered out on medical grounds.
In addition to seeing patients, I have spent the past six years directing a longitudinal study of several hundred men and women serving in the Imperial Fleet and the MACOs. Starting with a survey we sent them at home the month before they left for basic training, we have been collecting data on our subjects, their attitudes and experiences, the traumas they endure, the coping strategies they use, and the trajectories of their career paths and personal lives at quarterly intervals. At any given time, I have from six to twenty undergraduate, graduate, and post-doctoral students collating and analyzing data, testing hypotheses, describing trends and correlations, conducting interviews with our subjects, and making historical comparisons with data gathered in years past. The newest member of my team invariably spends his or her days triaging my correspondence by referring most inquirers to journal articles I have published in the past that address their particular concerns because I simply don't have time to answer the dozen daily requests I receive for information on studies I completed years ago. We submit an annual report to the Imperial Office of Military Personnel, and just last year, presented sufficient evidence supporting the benefits of simply having someone to talk to about a traumatic event for the admiralty to train crew members as counsellors. Of course it's not the same as having a fully qualified traumatologist on board, and all of the newly trained counsellors will have to have a 'real' primary specialty in some other department, but it's a step in the right direction. Within the next four years, every ship in the 'Fleet and every facility will have at least one mental health specialist available to the crew.
I work hard to effect change, which is usually very difficult, and often somewhat dangerous in a system where speaking truth to power can so easily be construed (or wilfully misconstrued when fragile egos are involved) as treason. I strive to think outside the box and to see things from a different point of view. I have no desire to prove somebody else's theories by replicating their results in a repeat of a clinical trial. That kind of work is necessary, but unchallenging. I want to be a leader. I want to set the bar both in research and in the clinical treatment of psychological trauma patients. I don't do what other people are doing. I look forward to reading the results of their work when they publish, but I go out of my way to find something else that interests me. As a result of my tendency to strike out at an odd angle and blaze my own path, I have published observations my colleagues have called 'uncanny', made discoveries they consider 'miraculous', and developed protocols and practices they think are 'inspired'. I might not be a legend in my field a century from now, that is for history to decide; but at the moment, I am a rock star.
So, Commodore Tucker hired me to treat General Reed not just because we're old friends, but also because there aren't five other people in the Empire who are as qualified as I am to help this great and terrible, horribly damaged, sad and tragic figure who sits before me now.
Induction into the military is inevitably a traumatic experience in and of itself as it involves breaking down the individual and reforming him or her as part of a team. Some recruits are more adaptable than others. They may be team players by nature, so with a dent here and a ding there, they mold themselves to fit the space they are required to occupy and get on with their lives in service to the Empire.
Others are not so malleable. Whether they're hard-headed, independent and uncompromising, or just lacking in coping strategies that allow them to adapt to the military lifestyle, they struggle more than their more flexible peers. Far beyond getting battered and bruised, they're often stripped down or shattered and reassembled with elements added in or left out in order to make them suitable to fulfil the needs of their unit, like a piece of flat-pack furniture with parts that don't appear on the assembly diagram or a jigsaw puzzle that is missing some pieces.
However they emerge from induction training, the vast majority of our service men and women start their careers with unresolved trauma, and it only gets worse from there. As newly commissioned soldiers enter active duty, we take their still-fragile, recently damaged minds, batter them relentlessly, and expect them to heal. In military service, punishment even for minor infractions and simple, honest mistakes is arguably unduly harsh. Additionally, the trauma of battle, losses, the occasional in-fighting and so-called 'friendly-fire' 'accidents' are piled haphazardly upon the imperfect psychological foundations laid during basic training. Most of the women and many of the less physically imposing men also face sexual predation from both genders. Those who would be leaders, either through greater strength, superior intelligence, or both, must contend with the ever-present threat of a coup and the occasional betrayal when one of their underlings attempts one.
Those who find support and camaraderie with a like-minded colleague often unwittingly put themselves at greater psychological risk. Some officers, insecure of their capacity to lead, are exceedingly suspicious of any subordinate who might command the loyalty of even one or two fellow underlings and will seek to separate the friends by any means possible. If a transfer seems inconvenient or insufficiently brutal, there are any number of duties on a combat ship to which a popular junior officer can be assigned which can be made to ensure his or her prompt demise. If the loss of a seasoned officer proves some hardship to the crew, at least the captain will have reminded them of where their loyalties had better lie, for their own well-being.
There is no question in my mind that my patient is intimately familiar with both sides of the Human equation. On the one hand, he is slight of stature, polite, and surprisingly soft-spoken (when he isn't spewing invective), which leads me to believe he was raised to be a gentleman. His interactions with Liz are sometimes unexpectedly indulgent of her doting, which suggests that at some time in his past, he was acquainted with genuine tenderness. All indications point to him having been a target of aggression well before he became an aggressor.
On the other hand, by the time he'd discovered his own capacity for aggression, his time as a victim had taught him extremely well how to use pain or threat of pain, shame, fear, and humiliation, to make others do what he wanted. He would have had to become ruthless, brutal, and cruel to acquire the power he held in the MACOs and later as a member of the Triad. And then there was that alleged traitor he cut to ribbons on live television, mandatory viewing for the entire Empire. I was on duty at the VA hospital when that happened. We were herded like cattle into the common rooms and lounges, any place in the hospital that had a TV screen, attendance was taken, and government security forces monitored us to ensure we remained attentive until the victim's dying gasp. The episode set some of my patients back months or even years in their recovery. One of them who was already on suicide watch still managed to find a way to end his life despite our vigilance. The number of psychiatric admissions to both veterans' hospitals and civilian facilities skyrocketed in the following week and then climbed steadily for more than a month after that. I wondered at the time if the great and terrible General Reed had any clue the damage he was doing, and if he had, did he care. Now, I'm convinced that, not only did he know to the precise degree the harm he was causing, but that it was his specific intent to do so.
I'm also more than certain that he couldn't have done otherwise if he had wished to.
Though only a fool or someone with a death wish would ever have said so aloud, I don't think there was a person in the Empire who couldn't have recognized General Reed as a broken man. For all his power and authority and despite the physical skills he must have possessed to reach the high position he attained, something inside of him must have been broken for him to be able to carry out such an inhuman act with no display of regret, compassion, or even disgust. I'm not saying everyone would have recognized the damage as trauma; I'm sure most people believed he was just born cruel and bloodthirsty by nature, like certain dogs, born with defective regions of their brains which cause them to be hyper-aggressive, that are incapable of seeing any situation as something other than a threat and are therefore untrainable, prone to biting the hand that feeds them, and, regrettably, sadly desirable for fighting. Such animals, in my opinion, should be put down or utilized for medical research to develop medications that will allow future generations to live normal lives. It is cruel to maintain these animals in a heightened state of rage just for the amusement of wagering on which one is most likely to kill another when they're thrown into a pit together.
General Reed, however, is not untrainable, and I'm sure at least a half dozen of my colleagues would have recognized this, if only because it would have been impossible for him to attain the status he held if he walked around in a red-hot rage all the time. More than likely, if such had been the case, he would have died, either in an accident or at the hands of his colleagues, before he had advanced out of the ranks of junior officers; for while a certain degree of aggression is desirable and even encouraged in fighting men and women, and even though The Powers That Be don't seem to mind individuals picking one another off from time to time over petty squabbles and old grudges, the kind of blind fury that leads to carelessness and mission failure is generally discouraged.
The general's rage, his fury and aggression, are fuelled by trauma. His intimate understanding of trauma, in turn, allows him to wield his rage, fury, and aggression like a scalpel, dissecting and ultimately destroying anyone he turns on. His years in power enabled him to avoid his fears and use his trauma, turning it into a weapon, but that power also eroded – or better said, supplanted – his coping skills. The past year of ongoing trauma, with no real strategy for how to deal with it, save perhaps plotting revenge, has left him physically and psychologically vulnerable. Now, finding himself physically helpless to carry out the punitive and vengeful acts he might have previously employed to cope with his anxieties and concerns has pushed him beyond vulnerable to the point of being fragile. So it's no surprise that he now finds even the small anxiety of being asked to sit with his back to someone almost more than he can bear.
I know this, I understand it. I understand trauma. I was ready for a shattered patient, a man whose sense of self had been demolished, a man who views every movement as a potential threat and every word as a possible lie or a taunt. I was ready for a patient who was simply incapable of coping with any psychological stressors, but for all my excellent training, my cutting-edge research, my 'uncanny' observations, 'miraculous' discoveries, and 'inspired' practices, I am utterly unprepared for what happens over the next few minutes as I compose a message containing instructions to my research team at the VA hospital in Georgia.
First, his breathing falters. This is perfectly acceptable. In fact, as I have already determined to push my patient to his limit today, it's virtually a requirement of the exercise. Next, he falls into deep, rapid breathing, which makes it necessary for me to watch more closely his blood gasses and brain activity. In strictly medical terms, there would be no harm in allowing him to hyperventilate to the point of fainting. Psychologically speaking, it would be an absolute betrayal. My patient is already fragile. In agreeing to participate in this exercise, he has opened himself up to all manner of judgements and assumptions from me. He has allowed me to see his weakness and his struggle to overcome it; he is letting me watch him fight his fear. I cannot allow him to fail. A stalemate is acceptable; a loss is not. Moreover, an unconscious person is subject to an incalculable degree of vulnerability, exposed to innumerable harms and humiliations from having a moustache drawn on his face with a permanent marker to, quite simply, being murdered.
So I monitor his oxygen and CO2 levels, his EEG (which is showing some unusual activity), and his coloring on the video feed.
And then he whimpers quietly, a soft little animal sound. Unexpected from such a man as this, but not unheard-of in my practice. Touch-typing has become a lost art with the refinement of speech-to-text in the past century or so, but it is a skill I have cultivated, specifically for circumstances such as this, when I need to enter information at the same time that I am monitoring or engaging with a patient. So as I watch the video feed and the biometric data I am able to continue typing faster and louder, giving Malcolm the stimulus needed to further heighten his anxiety.
There is much lip-licking, a little more whimpering, and some yawning. Then his breathing shifts again, and he begins to pant. With his tongue out, and his lips drawn back, he is panting like a dog.
I stop typing now, and take a long, critical look at my readouts. Malcolm's EEG has gone completely haywire; it looks almost as if I'm monitoring two minds at once, one superimposed over the other. But he isn't seizing despite the bizarre brain activity; his vitals are steady, his blood gasses are levelling out, and he's in no apparent medical distress.
I decide to let the episode continue and resume my typing. He whimpers again at the clacking of the keys and brings one hand up to his mouth to lick it. He holds his fingers strangely, as if the digits are joined and he no longer possesses an opposable thumb, but otherwise, I recognize this as a self-soothing gesture along the lines of nail-biting or rocking.
I whack the return key considerably harder than necessary, and he snarls and resumes panting. The chair shifts; he growls, corrects his posture, whines a bit in his throat, and returns to licking his…paw?
Behaviorally, it appears that Malcolm is experiencing a psychotic break, but otherwise, he seems all right. His BP is actually coming down a bit, and his heart rate is slowing, too. I don't know what the hell his brain waves are telling me, but physiologically, he seems to be coping.
He resumes panting and…yeah. No. I've seen enough. It's time to bring the general back. I need to think – hard – about what I've seen; what, consciously or unconsciously, he's allowed me to see. It may well be a coping behavior, and it appears to be a very effective one, at that, but not a good one. It may have stabilized his vital signs, but I'd wager every last credit I have to my name, hock everything I own and bet that, too, that he isn't mentally or emotionally capable of ordering a cup of coffee right now, let alone performing the functions of his office.
I approach carefully, speaking quietly to him as I move in his direction, and I realize I am already dealing with him in the same way I would a frightened dog.
He starts growling. Aggressively.
"Malcolm?" I say wheedlingly. "It's all right. You've done well."
"Rowrowrowrowrow." It's a grumbling warning sound.
He doesn't turn to look at me, but he tilts his head, clearly listening.
It isn't often that I genuinely don't know what to do. Patients often have unexpected reactions, but training and experience have taught me the right actions to take in most situations. This time, though, well, nothing I've encountered has prepared me for anything like this, and who the patient is has as much to do with things as what he's doing.
"Malcolm, stop it," I say firmly.
The growl he gives me raises goose flesh on my arms and the back of my neck. I don't want to try the conventional commands one uses for dogs, such as heel and hush. That dual EEG gives me pause. If General Reed is mentally present right now, barking orders at him could be taken as an attempt to humiliate him, and, if he recovers, that could be dangerous for me.
"Malcolm, the session is over," I say as calmly as I can manage.
He growls again.
"Let's get you back in your chair," I continue, ignoring the threat. I'm close enough now to reach out and touch him. "Let me help you."
I reach out to put my hand around his left bicep. He cries out, an inhuman sound like that of a dog that's been kicked, rises and turns on me with a speed he should not be able to manage in his condition. Before I know it he has struck me three times and lunged into my arms. I feel a sharp pressure on my neck, and then he goes limp.
He's breathing rapidly and mumbling incoherently against my chest now. I pull him around the chair and out of the corner, and then let the two of us sink gently to the floor.
=/\=
Half an hour later, I nudge my dozing patient.
"Hmm?"
"Malcolm?"
I feel him tense, but he doesn't panic. I suspect he's all out of adrenaline for the moment.
"Do you want to talk about that?"
"No."
There's no hesitation, but he's interestingly not emphatic.
"You know we'll have to, eventually."
"Yes, but not now."
"Are you ready to go back to your room?"
"Absolutely."
"Do you mind if I lift you into your chair?"
On this, he hesitates.
"I suppose not," he finally decides.
The wheelchair is nearby.
I work out. I'm more than strong enough to just embrace him under his arms, lift, pivot, and lower him into the seat. I help him get situated, sitting upright, his feet on the footrests, his clothing more or less in order, and then I wheel him over to the couch and sit facing him.
"Malcolm, can you look at me?"
His head is slightly bowed, but he rolls his eyes up to meet mine. His shields are at maximum. He knows I've seen something he keeps very well hidden, and that letting me see it is going to have consequences.
"I…don't know what that was," I admit. "For the moment, I'm going to call it a psychotic episode brought on by stress, but I think we both know it was something…different."
He nods.
"Has this happened before?"
Another nod.
"Recently?"
"Not to this degree."
"Ok."
There's a brief silence, and then, almost timidly, he asks, "What are you going to tell Commodore Tucker?"
He's actually asking two questions here, and I think he knows it. I decide to answer only the obvious one.
"I'm not going to tell him anything," I say. "Everything that happens in here is covered under Doctor-Patient confidentiality."
He nods again, processing that answer, then, in a voice that reveals more bitterness and grief than I think he would if he had any control over it, he asks, "Do you still think you can … fix … me?"
That was the other question, and I answer with perhaps a bit more confidence than I feel, "I told you before, I wouldn't give up on you as long as you didn't give up on me. It will take time, – How much? I don't know. – but I think, as long as we work together, we can, eventually, get you fighting fit again."
He shifts his posture slightly, then, and raises his head to look directly at me. He takes a deep breath, holds it for a moment and releases it, then licks his lips (to moisten them, not in that strange, animal way he was doing earlier) and says, "Thank you."
I smile and acknowledge with a nod. Neither of us has anything else to say right now. I return to my desk and page Liz. When she arrives, I buzz her in, and I can tell by her face that she knows something has happened; she looks at me and pales slightly. She catches herself just as she's about to ask, and addresses Malcolm instead, asking if he is ready to go back to his room. He acquiesces with a nod, and they are gone.
I pull a mirror out of my desk drawer to assess the damage. I have a black eye, a busted lip, and…teeth marks on my neck.
It's a good thing I have a couple of turtle necks in my wardrobe. If Trip asks, I'll tell him I walked into a door.
He may not believe me, but then treating General Malcolm Reed was never going to be without its dangers.