Page 32 of Enter if you Dare: Part Three

BEHAVIORAL OBSERVATIONS - GENERAL WARD:

Patient has maintained consistent compliance without medication from day five onward, following initial refusal. No incidents of physical aggression have been recorded since week one, and patient requires minimal staff intervention during daily routines.

Patient selects the same chair in the common room each session, positioned with his back to the wall and maximum sightlines to all exits. This is noted not as a cause for concern but as information about how this individual organizes his sense of safety in an unfamiliar environment. He is not a threat to other patients; rather, he is managing himself.

Patient eats selectively. He consistently accepts bread-based items and protein. He consistently refuses oatmeal. This clinician does not consider this clinically significant.

Patient was observed smiling once during the review period. He was watching television in the common room—the program was a sitcom of older vintage. The smile was brief, and he appeared unaware of the observation.

Staff member Shawn Reed reports that the patient has become more cooperative with wound dressing changes over the review period and no longer requires physical management. Reed notes that the patient makes eye contact with him now at the start of each interaction, which he did not do during the first week. This clinician considers this a meaningful indication of trust developing within the facility environment.

RISK ASSESSMENT:

Risk to self: low to moderate. The incident that precipitated admission involved self-endangerment in the context of acute emotional distress. Patient does not present as actively suicidal. The behavior appears to have been situational rather than ideological. In this clinician’s assessment, the patient’s primary relationship to self-harm is historical and contextual rather than ongoing.

Risk to others: Low. Two incidents of physical aggression were recorded in the first forty-eight hours of admission, both occurred during restraint application. No subsequent incidents have been recorded. The patient has the capacity for significant physical violence, and this is not in question, but there is no clinical evidence of predatory or unprovoked aggression toward others in the current environment.

CLINICAL IMPRESSIONS:

This clinician wishes to note for the record that the standard diagnostic frameworks available to us for assessment are imperfect instruments when applied to a person of this particular profile.

What this clinician observes with this patient is a man who developed an extraordinarily effective set of adaptive behaviors. Selective mutism, hyper-attentiveness, comfort of silence, and territorial responses have served him and continue to serve him; they are not, in this clinician’s view, symptoms to be eliminated. They are the architecture of a person who has survived things that would have broken many others.

He is not without personal insight, nor without feeling, and despite the circumstances of his admission, he is not without hope. He is simply a man who does not use words unless he must.

This clinician has found, during the course of twenty-two days and nine sessions, that this patient’s adaptations are not as significant a barrier to communication as they may appear.

RECOMMENDATION:

This clinician does not support an extension of the current involuntary hold beyond the original authorized period. The patient presents no credible ongoing risk to himself or others that would meet the clinical threshold required for extended detention. Continuing the involuntary hold beyond the original period is likely to be actively counterproductive to the therapeutic goals identified and may cause measurable harm to a patient whose primary clinical need is the restoration of trust in his environment and the people within it.

Discharge planning should commence immediately. Community support structures should be assessed and documented. In this clinician’s view, those structures are already in place.

The patient is ready to be discharged.

Dr. Seth Fairchild

Consulting Psychiatrist

Greenbank Psychiatric Facility

Valli

Leni and I are at Ares’s Bar catching up. I have been so busy entertaining Noa and Cipher’s families I feel like I have been neglecting her. She says it’s fine, that she likes seeing me happy, and Khodi has been occupying a lot of her time anyway. Her face goes pink every time she talks about him, which I find cute. I only hope she doesn’t get her heart broken when she goes back to school.

The door to the bar opens, and Nixie pops her head in and scans the room, stopping when she spots me. She walks in, but there is no smile. Something is wrong.

“I need you,” she says. “Bring Noa and Cipher to the shed as well, alone.”

“What’s wrong?” I ask, panic washing through me.

“Just hurry. Twenty minutes.”

She walks away before I can ask anything else, and I stand there frozen.

“Hey,” Leni says, snapping me out of my trance. “Whatever it is, you can handle it. I will find something for Noa’s and Cipher’s families to do to keep them busy.”

I nod silently, not trusting myself to speak right now. Tears well in my eyes as I leave the bar to get Noa, who is at the cornfield decorating the outer trees with his brother. When I approach them, Noa takes one look at my face and runs over.