Page 31 of Enter if you Dare: Part Three

“He was always like this,” Kelly says. “Even as a boy. I used to worry about him until I realized he’d finally found a place that accepts him for who he is.”

“That’s the best thing about the island—everyone fits in here,” Valli says.

My father announces he wants to take Mom back to the house, as it’s getting cold outside, so everyone heads back. The biggest mistake is us all returning at the same time. Noa finds some old board games in the closest, and our quiet night turns into an all-out competition. I’m not sure how we are going to survive the holidays if this is any indication of how it’s going to go. When my parents turn in for the night, Valli and I walk back to the shed. Noa tells us he will be back after he kicks his brother’s ass in some “guess the celebrity” game.

The stroll back to the shed is quiet, and I’m grateful, since it gives me plenty of time to process the fact that Valli loves me. For the first time since Cave was taken away, I feel like everything is going to be okay and that my heart can mend.

GREENBANK PSYCHIATRIC FACILITY

CLINICAL PROGRESS NOTES - CONFIDENTIAL

Patient: Cavan Saint-James

Admitting Physician: Dr. Evan Malcolm

Reviewing Clinician: Dr. Seth Fairchild

Review Period: Admission to day twenty-two

Document type: Multi-session progress summary

Purpose: Clinical record

PRESENTING HISTORY AND ADMISSION NOTES:

The patient was admitted involuntarily following an incident involving self-endangerment and property destruction. Burns to the forearms and hands were assessed on admission as superficial through to partial thickness and have been managed with twice-daily dressing changes. Patient tolerated wound care without incident from day three onward, having required physical management during initial dressing changes on days one and two.

Patient is referred to throughout this document by patient’s chosen name, Cave, provided by his emergency contact, rather than his legal name.

With a history of prior admission to Greenbank Psychiatric Facility, the patient has a good understanding of the daily expectations and the layout of the building. Patient demonstrated knowledge of restraint release techniques on day one not consistent with first admission.

COMMUNICATION AND BEHAVIORAL PROFILE:

Patient is selectively mute. I do not assess this as an inability to communicate, but rather a deliberate and consistent choice. The patient demonstrates clear comprehension of spoken language. He follows instructions, tracks conversations, and responds to direct questions with non-verbal cues such as nodding, shaking his head, shrugging, or redirecting his gaze when he chooses to engage.

Patient has been observed to speak on two confirmed occasions during the review period. Both instances involved single words. The first, “home,” was recorded during the first day while under sedation, and the second, “Valli,” was observed before visitation from his girlfriend.

It is this clinician’s professional opinion that the patient’s selective mutism is not a symptom of a psychotic disorder or cognitive impairment. Rather, it has become a long-established coping mechanism that has served as a protective function for this individual over an extended period. Attempts to pathologize this communication style are likely to be counterproductive and may constitute a barrier to therapeutic progress.

Patient communicates with notable sophistication throughout non-verbal means. He is observant of his environment and the people in it. He notices details that most patients and some staff overlook. This is not hypervigilance in the clinical sense, and there is no evidence of paranoid ideation. It is more accurately described as a heightened attention style, likely developed and refined over many years as an adaptive response to environments in which reading people had survival value.

SESSION PROGRESS - WEEKS ONE AND TWO:

Initial sessions were unproductive. Patient attended all scheduled appointments without resistance, which this clinician notes as significant given his general reluctance to cooperate with facility routines in the early admission period. He sat in the chair, did not speak, and made no aggressive gestures. He looked at the wall.

This clinician decided after session three to discontinue standard intake questioning and simply be present with the patient, which was more productive. Patient began brief eye contact by session four.

By session five, the patient responded to yes and no questions with head movements approximately sixty percent of the time. The remaining questions he chose not to answer, which this clinician respected without comment.

SESSION PROGRESS - WEEKS THREE AND FOUR:

A significant shift occurred at the start of the third week when this clinician asked about the topic of riddles as a mode of communication, following information shared by the admitting physician regarding the patient’s known communication patterns. The patient’s response was a controlled smirk, the first spontaneous facial expression observed across any session, and sustained eye contact. He did not offer a riddle. He did not need to, as the acknowledgment that his language was known and respected appeared sufficient. Patient engagement increased from this session onward. Non-verbal responses became more consistent and more nuanced. Patient began volunteering non-verbal information without being directly asked. During the same session, he pointed, gestured, and placed his hand flat on his chest in response to a question about what he returned to mentally when not in session.

When asked whether that was something or someone, the patient shook his head at something and nodded at someone. This clinician noted that was good, and it was something worth holding on to. Patient held eye contact for an extended period before returning his gaze to the wall. This clinician recorded this as a meaningful moment of connection.

While consistently flat in presentation, the patient shows evidence of internal emotional range. He responds to mentions of his home environment with subtle but observable physiological changes: a slight softening around the eyes, and a change in tension held in the jaw and shoulders.

Patient participated in session nine for the full duration without disengagement behaviors present. He responded to eleven of fourteen questions posed, a notable increase from zero responses in session one. He terminated the engagement once when asked about the specifics of his childhood admission. This clinician did not pursue the line of questioning. The patient’s right to decline was noted and respected.