Chapter Forty-Four
Therapy Note
Doctor Virginia East
It's nothing short of astonishing, the progress Patient X is making in some aspects of his recovery. I'm sure much of it has to do with the confidence he is gaining as his physical condition improves. When a man navigates the world by annihilating everyone and everything that opposes, annoys, or even merely inconveniences him, strength and stamina are of the essence. He practices willingly enough all of the anxiety reducing techniques I have taught him, from any of a half dozen different breathing techniques to progressive muscle relaxation, stretching, the use of pressure points, guided imagery, and even mantras and affirmations. Once a week, we pick an emotion from the list I had him write after our first 'real' session, and he tells me about a time when he felt that emotion, explains how he masked it with anger, and describes how he could have, and might in the future, allow himself to feel the actual emotion and cope with it appropriately.
In other ways, I'm not sure we're getting anywhere at all. For one thing, I'm still not convinced that he's genuinely engaged rather than just going through the motions, but even 'faking it' does require him to think about alternate coping strategies, regardless of whether he has any plans to actually implement them. Many, perhaps a majority, of my patients never intend to use the strategies they learn and discuss in therapy. Then they have an incident, a crisis usually, where they exhaust their customary unhealthy techniques, discover that none of them seem to help, and in a last ditch effort to hold it together, try something we have practiced in therapy and find it works.
He's also still incredibly wary, anxious, and utterly paranoid about being mocked, taunted, disrespected, or humiliated. I still think he'd prefer a physical assault to being shamed, though I'm certainly not going to do either. And for all that he's willing to talk about incidents in his past where he's covered his true emotions with anger, lashed out, and destroyed the source of his emotional discomfiture, he still won't talk about anything that comes close to touching on any of his, what I am sure are multiple, traumas.
The commander of this facility has been content so far with my regular assurances that we are making progress, that Patient X is building a toolbox of strategies to help him handle the distress he will undoubtedly feel when he begins to confront his traumatic past. But with every stride my patient makes in his physical recovery, every meter he walks beyond what he managed the day before, every additional kilo he lifts, he becomes more dangerous to the commander of this facility and all of us who work here; and I worry what will become of my patient should the commander decide that his psychological progress is lagging too far behind his physical recovery and he has become too much of a liability due to his continued mental instability.
disturbingly, the two psychotic episodes I know of and the intermittent canine delusions aren't even the most troubling aspects of this patient's treatment. Bizarre as it may seem, here and now, while he is surrounded by people who seem willing and able to indulge these episodes without judgment, they are coping behaviors that actually work. Of course he'll have to learn to control them before he goes back out into the world again, or he'll be dead the first time he has a break, but for now, it's just an aberrant behavior that lets him escape his reality when it becomes too intense.
The thing that troubles me most about this patient isn't even a tangible matter. It's just a feeling I have, a sense of foreboding, and though I am loath to act without empirical data informing my decisions, it may become necessary in this case. With every small breakthrough, every catharsis, every up, down, and left turn, every psychotic break and minor crisis, I feel like there is something more, something bigger, bubbling just beneath the surface. I constantly feel as though I am waiting for yet another shoe to drop, and I suspect his troubles are legion.
Interestingly, though, a recent event that one would reasonably have expected to cause Patient X a considerable setback, has actually led to significant improvement in his emotional stability and his interactions with others. The patient's Care Team has gained a new de facto member, whom I will call Senior hereafter, and Senior's influence over the past week or so has been arguably greater than even that of the primary caregiver, for whom Patient X has, perhaps unwittingly, begun displaying some vestiges of genuine affection. To the complete frustration of the entire team, Senior refuses to participate in any meetings, refuses to divulge anything about his interactions with the patient, and won't even submit notes for our edification. He insists that he wants only to be the patient's friend, even though I'm quite certain he knows to the precise degree how much easier he could make our work if he'd only provide us with a little information and encourage the patient to try a little harder to cooperate with us.
Bewilderingly, Senior gained his influential status with the patient only after an episode in which he threatened physical violence and frightened him so badly that the patient suffered a complete psychotic break in front of multiple witnesses. After removing the patient to a private area, he managed to talk the patient down, bring him back to reality, and calm him to the point where he was able to face the audience that had witnessed his breakdown, apologize for the inappropriate behavior that had provoked the initial threat of violence, and more than willingly - at his own request, in fact - remain among those who had witnessed his vulnerability throughout the preparation and consumption of the evening meal. I strongly suspect that Senior's methods (which I understand included a kiss on the forehead and a shot of apple jack) would have cost any licensed psychologist his or her livelihood; but when my patient sat before me the next day looking calmer and more confident that I had ever seen him, willingly telling me about the encounter because Senior had suggested it might be a good idea, something about 'ends and means' came to mind and I decided to overlook the unconventional therapy. Of course, Senior wasn't specific about how much he thought my patient should tell me, so an hour long encounter which included a thirty to forty-five minute private conversation was condensed into a two-minute monologue which I suspect, if he had tried a little harder, my patient could have delivered in a single breath.
The first time I approached Senior about his initial encounter with Patient X he would only tell me that I'd have to ask the patient about it, that he had promised he would keep everything about their interaction confidential. The second time I asked, he threatened to take me over his knee if I pestered him again, and having known Senior my entire life, I determined at that moment that I should not ask him a third time. However, the fact that the initial encounter has led to a nightly ritual of drinks and conversation after the evening meal that (as several team members have noticed) gets them out of any clean-up chores, makes me even more curious to know what they discuss. I don't believe my patient has yet recovered the capacity to feign interest so late in the day and with alcohol in his system. If he wasn't genuinely engaged with Senior, his behavior and expressions would reveal his pretense.
With regard to the other witnesses of the initial event, i would ordinarily be concerned that they might divulge even minor details of it outside the family - a development that could have far-reaching and potentially catastrophic consequences. I can guess that were the patient in his previous position of unchallenged power, they would all have been imprisoned or perhaps even killed to prevent even the possibility of their disclosing having witnessed an episode so damaging to his dignity and supposed invincibility. It would be all too easy, on seeing the patient in what was undoubtedly an extremely vulnerable state, to mistakenly think he was therefore less dangerous; the truth is that in the long term he is a greater danger to them than ever, simply because of what they have seen. However, it would seem that the individuals concerned are not only trustworthy in themselves but have been strenuously warned not to discuss the episode even among themselves, and certainly not with anyone else. If they did so and so much as a whisper of it reached his ears, his trust in Senior, in the Commander of the Facility, and probably also in me would be irretrievably damaged. Without doubt, if he ever regained his freedom, one of his first acts would be to take revenge for what he would perceive as a heinous and unforgivable betrayal.
So I have been gently, carefully, and oh, so patiently probing my patient about the incident and their subsequent conversations. I do not delude myself into thinking that he occasionally 'lets something slip' during our encounters. My patient is far too clever for that. When he provides the rare, informative answer to one of my questions, I know it is because he has decided it is either something with which I can be trusted, or nothing of any consequence. Regardless of whether he answers me, though, I continue to ask, because simply hearing the question forces him to consider the answer, whether he shares it or not; and the key to helping this patient who keeps so much so close to the vest will be in making him think, not necessarily in getting him to talk.
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