The Bethesda Group was scheduled to catch a two o'clock flight this afternoon and was more than adamant about not changing plans, reporting that it would put the rest of their hospital visits off-schedule. As it was, they had pushed this meeting to the last minute as Dr. Charles and the other visiting doctors hustled around doing what seemed to be self-generated paperwork and other last minute personal preparations prior to leaving.
The original reason for the meetings between the Denver and Bethesda doctors was to go over the results and conclusions of the Group's analysis of 15 PTSD patients they met with during the past two and a half weeks in Denver. Of those patients, five had a Select Group status with five individual sessions each. These represented Denver VA patients specifically chosen for unique traits or aspects in their treatment and recovery cycle which appeared notable. Ten of the patients had only two sessions each and were being used to develop a base-line profile on the "typical" Denver PTSD patient, to correlate with the findings of a multi-regional VA study.
Both aspects of the study had been touted as progressive yet complementary to past and current work being done on the subject. There had been a recent surge of inquiries regarding Viet Nam era PTSD findings due to the rise in purportedly associated trauma experiences ranging from suppressed childhood molestation to victims of other forms of violence. Cross correlation was now being run on these group similarities.
The original plan involved all four members of the Bethesda team meeting with the Primary Care Physician for each of the 15 veterans in the study, with special attention given to the Select Group patients. Dr. Bondurant had primary charge for one-third of the patients, with two of those in the Select Group. His unique background as an MD (Psychiatry) and Ph.D.(Psychology) accounted for his heavy involvement and personal investment in the Stress Syndrome program and associated studies.
The expectation was to spend at least 30 minutes discussing each of the patients in detail, with meetings to have begun yesterday. The findings of the Bethesda Group, folded into his own treatment, could mean nothing less than improvements for all concerned, Dr. Bondurant reasoned, and he was not likely to let an opportunity like this slip by. He was a little surprised that his colleagues showed such minimal concern for the findings of this study and the last-minute change of meeting schedules, but that was their problem. His interest was in the welfare of his patients.
After nearly an hour of listening to Dr. Charles ramble on, Dr. Bondurant was amazingly unimpressed with the results of the Bethesda Group's findings. They had concluded nothing not already derived by the Denver VA staff and noted in the records. He showed his disappointment by questioning Dr. Charles' statements, interrupting his monologue, asking for further clarification on several points. And he carefully observed the growing frustration and animosity of Dr. Charles, who obviously would rather be off doing other things.
So far, no significant suggestions for changes in treatment or medication had been made. There had been little or no insight into or sharing of methods used successfully in other VA regions. The monologue consisted of patient history reviews that could just as easily have been summarized from the existing records. Dr. Bondurant suspected a sham.
The first four patient reviews had been, in Dr. Bondurant's opinion, shallow and cursory. There was only one more left to be done, and it was just now going on 12:20. That was less than 15 minutes spent on each. He had already moved from strong suspicion to a weak certainty that Dr. Charles either hadn't done a thorough analysis at all or was providing pat diagnoses as a cover to some deeper, hidden agenda. Bondurant's interest now was in testing his new hypothesis, in getting closer to the truth behind the charade that seemed to be unraveling around the activities of the Bethesda Group.
Jason Orr was the last patient on the agenda. He was Bondurant's favorite, personally as well as professionally. Jason had more spunk, more courage, more self determination then all of the other patients combined. Jason seemed to have more to offer the world at large and was worth saving, worth making an extra effort for. But he was also the most resilient. Jason held the deepest secrets, and fought the hardest to maintain his independence from the system. Consequently, he had been the focus of a significant amount of Dr. Bondurant's energy and had provided Bondurant with very fruitful research material. Although he never admitted it to anyone, Jason Orr was the primary source of his fairly well-known paper, "Possible Pre-conditions for Post Traumatic Stress Disorder," published nearly four years ago in The American Journal of Psychiatry and reprinted shortly thereafter in the VA's own internal papers.
What most irritated Dr. Bondurant now, even more than the feeling of being led by the nose, was Dr. Charles' obsessive clock watching. He had rested his arm on the table so his watch was visible just below the cuff. Bondurant thought the maneuver was pathetic and clumsy, but apparently Dr. Charles considered his movement undetectable. Either that, or he just didn't care.
Something's off here, Bondurant thought as he drew little circles in the corner of the first blank page of his note pad. He came prepared to take copious notes, to absorb the wisdom and enlightenment of a team of experts. He had yet to put anything down except the date, a title for the meeting, and a collection of doodlings around the border of the paper. Everything except the restless art had been neatly printed before the meeting even started.
"That leads us to our last subject," said Dr. Charles as he shifted slightly in his chair and glanced nervously at his watch for the third time in the last 60 seconds. "You've also got a patient named Jason Orr." It was stated in such a dogmatic manner that Bondurant felt like he was being told something he wasn't supposed to have known. Or perhaps more in the style of an Inquisition, the statement was meant to be an accusation. In either case, he used it for his cue to challenge the entire proceedings.
"Ah, yes. Orr. An interesting case. I'd like to spend a bit more time discussing Jason Orr. There are some unique aspects here that deserve our attention." Bondurant leaned forward and planted both elbows on the table, smiled broadly and looked directly across into the eyes of Dr. Charles. At that instant, he saw the smoldering that had been growing slowing suddenly burst into flame. This was a direct challenge. It was time to call his bluff. "I'd be very interested in seeing the actual notes from the discussions you and the others had with Jason Orr, if you can share those."
Dr. Bondurant relaxed with his chin in his palms, elbows propped up on the table, and watched the waves of body language sweep over his adversary. For Bondurant, watching the stages of Charles' reaction was like reading a book. Dr. Charles' initial reaction was one of total indignation and silent rage. Immediately following was a definite reining in of control in a defensive withdrawal to formulate response tactics, followed by a firm setting of mental resolve, presumably based on stubborn pride and bruised ego.
Not only is something fishy with this entire project, Bondurant mused, but I think I just caught my friend the Doctor with his pants down. How could such a dinosaur survive in the system for so long? Or is that circular logic? Bondurant's Number One Enemy was gross incompetence and avoidable human error, and he seemed to be in a system that acted like a petrie dish for those specific organisms. He noticed it more lately than ever before.
Dr. Charles was curt and sharp in his next statement. More importantly, it oozed with that sickening gel of mindless authoritism that permeated the VA administration.
"Yes. Jason Orr. I had the pleasure of conducting three sessions with Mr. Orr myself. I think he should be dropped from the program." This was so unexpected it was like a non-sequitur.
Bondurant knew immediately his raised eyebrows and involuntary grin completely gave away the fact that not only was he taken by surprise, but that he couldn't possibly take such a statement seriously. He waited to the count of five, wondering if perhaps Dr. Charles would break into laughter and admit the joke. Dr. Charles sat stone-faced, defiantly accepting the original challenge, staring at the impudent young Denver physician. This was no joke. It was the response of a wounded, cornered animal.
"Uh, yes," Bondurant said before clearing his throat. "That would certainly warrant a full case review, wouldn't it? That would make your notes even more important. When did you intend to schedule the review?" One of the best ways to survive in a system one absolutely loathed was to intimately know its internal workings and be able to turn that system back upon itself whenever necessary. The fixed stare back at Dr. Charles seemed to take the Bethesda physician down a few notches.
"Well, actually, that is nothing more than my personal observation at this time. I've not drawn up a formal position on the matter." Charles shuffled some papers around. "I think it's something you and I ought to talk about when we have a little more time." Another nervous glance at the watch. "Let's get back together on it first thing when I return to the Washington office. At the end of the week after next, say, Friday, early afternoon?" He began gathering up the small pile of papers, giving an obvious signal the meeting was over and Bondurant was dismissed.
Well, I'll be damned, Bondurant thought to himself. The old fart really is pulling my leg. And he thinks he's getting away with it! This whole thing is nothing but a ruse. But for what? Bondurant grinned sheepishly and rubbed his chin as if in deep contemplation.
"Sit tight for a second," Bondurant said softly. "You've just made an accusation we can't just let lay. There could be several serious ramifications. I'd like to get some of the details behind your observations so I can start reviewing my notes and the case history on Jason Orr to see what I can find to validate and support your observations." Play the fool, Bondurant always said, and the fools will play with you.
"Well, again, that isn't my official recommendation as of this instant. But yes, let me share with you a few of the things I observed." Dr. Charles seemed to relax a bit, giving a clear indication he intended to at least discuss the issue. "I'm certain that if you look for them, you'll find they exist in a fairly strong pattern throughout this man's history." Dr. Charles squared himself in his chair, resigned to spend a few minutes in support of his firmly stated and rather rash statement.
"One of my first impressions was that Jason Orr was not being honest with me. I felt very strongly that he was 'faking it' on several occasions. I've seen a lot of these cases in my years, Dr. Bondurant, and one tends to develop a sixth sense about such things. And believe me, they are very subtle. There's absolutely no negative reflection on the case Physician when that happens. It's something that can only be detected after years of experience, like I've had."
"Well, I could certainly benefit from your knowledge. What sort of things do you look for?" Bondurant couldn't have sounded more sincere.
"Well, first, he only half answered my questions, probably to cover up some flaws in his story. I've seen men make up entire histories, entirely independent persona, down to the smallest detail, just to keep on the disability roles.
"He also has a diagnosis, I recall, of agoraphobia. That one might be clearly off-base. He seemed to interact well, communicates well with strangers, by his own admission, and even reported he is performing adequately at his job. In fact, he has one of the most stable employment histories of any of the Denver patients and of most of the PTSD cases that I'm familiar with. He also indicated it had been nearly 6 months since his last episode of acute anxiety, and more than a year since any major panic attack."
"Now, that, I would think, speaks well for his treatment, wouldn't you?" Bondurant asked through his sheepish grin. "I'm sure you made note of the severity of his condition when he first came in here six years ago. I think we've made remarkable progress since then."
"Well, as a matter of fact," came the reply, "his remarkable recovery is one of the things that raises my suspicions."
"Dr. Charles," the calm, smooth voice explained, "the reason he was chosen for this program is , in spite of the progress we've made, Jason continues to experience a significant difficulty in letting go of his guilt feelings. Additionally, he still has a dominating lack of self-worth. I'm sure you're aware that this pattern has been the subject of much research, and has been hypothesized as grounds for a possible susceptibility and pre-condition to PTSD. I understand certain measures are underway to incorporate a well-designed battery of psychological screening for certain covert military assignments based on this research. You are familiar with that work, aren't you?"
"Well, of course," Dr. Charles sputtered, quickly glancing through his notes to find some reference to the research work in question.
Bondurant let him squirm for a minute as if unaware that Charles was groping for the words to fill in the blank of exactly where he had run into that topic, probably one of Bondurant's own papers. He decided it was prudent to ease the tension.
"Quite honestly, Dr. Charles, I had hoped to come away from this meeting with some very specific advice on how to 'get into' patients like Jason Orr. I was counting on your help to identify ways to drain the power away from those hidden anxiety stressors."
Dr. Charles glanced at his watch. "Well, I'm just not fully convinced that's something that can be done. Despite a review of the records, I'm not at all certain this fellow," glancing at the notes for name confirmation, "Jason Orr, is as severe a case as is presented. Now don't misinterpret what I'm saying. Even the best doctors can be misled, especially if good intentions and personal investment are part of the formula. Like I said, I've seen it all before. This certainly wouldn't be the first time and, unfortunately, it won't be the last."
"But I do want to assure you that I'm not officially questioning the care that's been given to date. I think you're doing a marvelous job out here. This is beyond a matter of questioning the handling of the case. It has more to do with having a gut feel for these kinds of things, and a certain emphasis on the big picture. I've had the misfortune to deal with countless individuals who cling to a system for identity and recognition beyond the time when that system can support them any longer. Sometimes I'm almost certain the system itself attracts individuals of that mentality."
My God, thought Bondurant, the man doesn't even own a mirror! This is remarkable.
Dr. Charles looked at his watch again "We need to wrap things up so I can get moving. We'll talk on this further before I take any action, I assure you. You know, my job isn't all that pleasant." There was a deep sigh and what appeared to be a momentary giving in to an overwhelming fatigue. "I'll be taking back with me dozens of cases like this Jason Orr, and they'll no doubt end up in the formal reviews just like you mentioned. We can only carry them so far, Dr. Bondurant. Especially when they are resistant to our efforts."
"Well, excuse me," Dr. Bondurant said softly, "but isn't that our reason for existence....to help people like Jason Orr who have trouble working themselves back into society after having traumatic experiences in war? Or is that too naive an assumption." He took the sharp edge off his question with an innocent smile.
Dr. Charles seemed to bend a little under the weight of Bondurant's rationality. "In a perfect world, my young friend, that would probably be the way things would work best. However, at present, there is an urgent need to trim some of the fat out of our program. Our 'real purpose,' as you call it, is to help vets get back into society, yes. Unfortunately, we can't always lead them by the hand forever. In some cases, it turns out better for the vet to be made to face the problem of final social adjustment on his own. I'm under tremendous pressure from higher up to make drastic changes in our Veteran's Care Units, and to re-focus the entire program, if necessary. That's all being driven by finance, not by medicine. At some point in the near future, when the surgeon starts cutting, it won't be with a scalpel. Those that have any chance of standing on their own will need to be prepared for separation from the system. And my task is to assess just how drastic an impact that will have. So now you know more than I had intended to tell.
"I suggest we plan on talking again in about two weeks, like I said before. Undoubtedly, I'll have many young people like yourself calling me, demanding special consideration for some individual or other. But the end result will be a leaner program, with less options to provide the care you seem to believe we are chartered to. Unfortunately, the charter is drawn up in the committee room, not in the operating room. And when the committee controls the budget, the charter is subject to change. My team will have several specific recommendations to make, after visiting all the hospitals on our schedule. Most of the conclusions we will reach have been pre-defined for us."
Dr. Charles slowly brought himself back to his normal perfunctory manner, neatly tapping the small stack of papers into perfect alignment. He raised up slowly, while explaining that he needed to wrap things up so he and the others could get to their plane on time. Dr. Bondurant made no attempt to move, barely listening, slouching slightly into his chair, looking thoughtfully at the ceiling over Dr. Charles' left shoulder. His attention immediately returned with the next statement.
"Our next stop will be Gulfport, Mississippi. I expect to be overwhelmed with problems you wouldn't even dream of here in Denver. Fortunately, I'm familiar with their operations and we'll only be there for a week. Gulfport seems to be the epitome of a facility that just can't handle all the cases that they've got. And they always seem to get the worst. I'm sure it's a place you would find very unpleasant, no doubt about it. Thank your lucky stars you have the opportunity to work here in a place like Denver.
"Good day, Dr. Bondurant. Remember to call me." A very tired old man moved toward the door and headed out into the quiet hallway.
Robert Bondurant, MD., Ph.D., (a Double-Doc, as he was fond of calling himself), leaned back in one of the colorful little plastic chairs that were scattered around the small cafeteria-style conference room, feeling its injection-molded polyethene contours strain against his weight. He stared at the variety of multi-sized holes in the acoustic tile ceiling, wondering if there really was any way the universe was mirrored in such trivial things as the patterns found on ceiling tiles; a star chart mapping one-for-one a perfect replica of some section of an infinite universe. Is there really a star pattern that exactly matched the layout of that particular tile square, right there just one space ahead of the long florescent light fixture?
He pushed himself away from the table, forcing the chair to noisily overcome the friction that it experienced in its contact with the dull linoleum floor, and slowly picked up his notepad. It was time to reassess his situation. Frustration wasn't something he dealt with well, that much he was certain about, and he had long ago found that the trivial things in life weren't worth worrying about at all. And this one definitely appeared trivial at the moment. After all, it was just the career of one man in an insignificant role among many millions of inhabitants on an obscure planet, possibly identified by a tiny hole in one of the ceiling tiles.
He had no precise measurement of the full ramifications of the shift in perspective he had just undergone. But one had certainly taken place. Therefore, he was in no great hurry to react. Reaction would come when he had a firmer grasp of the details. Then, he'd just set a course he felt comfortable with and go with it. The exact definition of that course would make itself known in the very near future.
Robert Bondurant ambled down the clean but quiet halls of the hospital's administrative wing toward the stairwell that lead to his office. To the casual observer, he appeared to be just wandering aimlessly around the corridors. He always gave the impression of utter detachment, looking conspicuously out of place, as if he were lost.
The walk back to the office was uneventful. He passed only one harried administrative assistant hurrying down the hall with an armful of Xeroxed copies of some erudite verbiage or other. He smiled cordially and nodded, but they hadn't even looked him in the eye as they passed. Bondurant turned the smile inward, in a feeling of pity for those trapped in a web of an administrative bullshit, like this one. Or any administration, for that matter.
As he stepped lightly up two flights of stairs, he tried to read the remnants of occasional graffiti barely visible under the fresh attempt to paint it over; saw the many layers of chipped and peeling paint curling slightly back upon itself at the edges of the oversized wooden frame windows that greeted him on each landing; felt the accumulated heaviness and hollowness of the years this building had stood and absorbed as his shoes echoed a scuffing sound on each iron stair tread.
At each step, he let the bonds of personal attachment to his surroundings loosen, anticipating the need for a coming detachment, reminding himself that this kind of assertion of individuality was a good thing under any circumstances.
It was now time to give some very directed thought to this whole business about Big Brother Bethesda showing up here in Denver, under false pretenses. There was something in the overall concept that was definitely ominous and personally discomforting. An insidious sense of danger gnawed at the corners of Robert Bondurant's mind as he noiselessly unlocked his office door, slid inside, and quietly latched it behind him. He knew he would need to let his feelings come forward so he could deal with them. All in good time. Each at their own pace.
Somewhere in the shadows of his recent conversation was a direct and significant threat. Not only to himself, but to the entire VA PTSD program, to the projection of his role as an independently thinking doctor in a repressive, blindly moving system. And perhaps more importantly, more specifically, to individuals like Jason Orr.
Bondurant thought about what this meant to the future of his own career, and for each of his patients, including Jason. Of course, he wasn't in charge of the program itself, he readily admitted. But he did have a responsibility to each of his patients, each unique manifestation of an out-of-balance individual struggling to find their own place in the larger, sometimes overwhelming scheme of things. They would all certainly be affected by any change whatsoever. Such was the nature of change.
As he settled himself in his padded, high-backed chair and put his feet up on the corner of his desk, his thoughts kept going back to the comments Dr. Charles had offhandedly made about the VA facilities in Gulfport. He was almost certain that Dr. Charles wasn't familiar enough with his own record to have known that he actually had served a short but intense internship there, nearly eleven years ago. Or was he?
He remembered the short time spent in the hot, humid Mississippi town, in the separate facility that served as the psychiatric ward for the main hospital just down the road. It was known throughout the system as the VA's own Black Hole of Calcutta. Inside the Gulfport facilities, such references were never made. At lease, not openly. There was Building #67, sitting inconspicuously beside the oval parking area, where men simply disappeared to a guarded top floor isolation ward. But few people who actually worked at Gulfport ever talked about it. Not nearly as much as the patients themselves. It was like an ever-present but never acknowledged ugly family secret, like incest or child abuse. Every once in a while, in a hushed tone in some quiet corner, and usually spawned by some recent activity involving a new assignee to that ward, there were some quietly conveyed stories about Vets being confined to the top floor of Building #67 since the early and mid-60's. In fact, the rumor was, if you were placed as a patient on any floor above the second, in any of the buildings, your chances of ever leaving the premises again were suspect.
On a few occasions, he had been aware of men assigned to that wing who were a little confused, perhaps mildly paranoid, but otherwise certifiably healthy. Perhaps their paranoia had some foundation. They were quietly shuffled through the administrative process into solitary confinement, never to be heard from again. Sometimes, so it was said, their records would mysteriously disappear from the file room. Some dark inner workings of a more powerful system mandated they be shut away, probably because they knew something that someone else wanted kept secret. In a very real sense, it was just like the darkly woven plot of a spy novel. There were always "government people" hanging around. CIA? He had been told not to ask too many questions.
There were a few other little irritating things he tried to ignore, but just couldn't, like the warehousing of patients. It was a term he had never heard before and had not heard since. But it was almost fictional at the time. It's impact was heavier on him now, as he thought through the memories. Patients were reportedly "shelved", put away in isolation wards under heavy sedation, given little or no care, simply kept around for when the head count was required come funding time. Or for the experimental operations, done without signed consent, or even the awareness, of the patients. Yes, that had been the experience of a lifetime that shook the very foundations of his untainted medical ethics.
A family friend, an acquaintance of his father's, had worked back in the Washington Headquarters, in Bethesda, and was able to pull strings to get him this Denver assignment. He got away from Gulfport as quickly as he could. That friend was no longer with the system, no longer alive. Even at the time, almost eleven years ago, they couldn't or wouldn't discuss specific hospital practices with him regarding activities at Gulfport. There was little reason to suspect his Bethesda contact could have, or would have, helped him get to the bottom of his present observations and assumptions, even if they was still around. That was OK. He would proceed on his own.
Doctor Double-Doc took a deep breath and released his tensions by absorbing the aura of his surroundings. The walls were covered with a mix of soft Monet's, Manet's and Degas', as well as more modern renditions of the Impressionistic themes. Soft colors and hazy objects exuded the gentle energy of comfort and relaxation, somehow reinforcing within him his favorite advice: Quit taking life so seriously!
The casual observer might conclude that the entire arrangement was perfectly designed by an interior decorator to help induce a state of sedation, except he had done it himself without much conscious effort. In fact, it was almost done subconsciously. The display was merely an arrangement of prints he had collected over the years.
Robert Bondurant had a task. He wasn't exactly sure what is was, or how to articulate it, but he had a project which needed his immediate attention. And he felt certain he would find the direction of his efforts as well as the answers to his questions in the files of Jason Orr and a few of the others. There was something he could do for them and for himself. He just had to identify exactly what it was. And the only way to do that was to go to the files.
Jason's file was the largest, taking up nearly half the top drawer. Bondurant carried the file folders to the side of his desk where he set them neatly on the floor, still in chronological order. He was proud of the way his organizational skills made his job easier. With all his patient records, it was possible to find a specific time interval or a specific phase of treatment through his color coding, numbers and alpha character mnemonics.
And so began a journey back in time, back through his early discussions with Jason where he was exploring the inner workings of panic disorder. Bondurant would spend a significant part of today and tomorrow re-reading, re-living, re-thinking those early encounters, so well documented in his meticulous notes. He was able to key right in on the more intense sessions with Jason that had occurred over the past six years. He was especially interested in reviewing the discussions which brought out those strong episodes of paranoia Jason was able to articulate so well, making them real for Dr. Bondurant.
Bondurant thought for a minute about the value of Jason and the things he learned from him. Those vivid insights into Jason's mind provided the core of his understanding which he had applied to many of the other patients.
He started reading the early reports he had written, trying to reconstruct his own frame of mind. In the course of the review, he noticed there had been a slight change in his handwriting over the last 6 years. He was becoming sloppier, producing less precisely defined letters on the page. He briefly wondered what a graphologist would make of that.
** *********************************************
"Explain that to me, Jason. You keep saying 'they'. Who are 'they'?"
Jason shuddered involuntarily, thin sheets of ice breaking on the back of his head like window glass, drenching him with cold, wet shards. "I don't know. They. Feelings. Voices. Not me. Not something I want to have anything to do with. Something that takes over and sucks the real me out of me. They say things that I don't want to hear. They tell me I'm really fucked up. They tell me to give up so they can take over. And I can't shut them up when they get going. That's the scariest part."
This was the first time Jason had ever taken advantage of Dr. Bondurant's suggestion to come in to the clinic whenever the panic condition felt overwhelming. Tonight it had. And Bondurant had met him there, setting aside some his own evening activities. That had immediately cemented the growing bond of trust between them. Now Jason was trying to explain something apparently beyond his ability to communicate.
"Tell me. When you say 'they', do you mean you, or is it really somebody else you're referring to?"
"When I'm thinking clearly, then I know it's really me. But when I'm wrapped up in it, it seems to be coming from outside my realm of control. I guess it's just some twisted, suppressed part of me. But it's not a part of me that I want to give control to."
"Why not? What would happen?" Control is always the key issue, he noted. Bondurant was eager to learn how precisely Jason could define its aspects and inner workings.
"I don't know. I just know that I never want to let that happen. They're big, Doc. They're the biggest things I've ever seen."
"What do you mean 'seen'? Can you actually visualize something?"
"Well, kind of. I mean, it's not like I actually have visual hallucinations of objects. It's just that I know what they'd look like if I could ever see them."
"And what's that? Describe them for me?"
It was obvious that just thinking about this was getting Jason more upset. He could feel the tightening in his chest, the quickening of his pulse, the pressure in the back of his head. Bondurant watched each of the reactions take their toll on him.
"Look, Doc. This is really freaking me out. I'm going to take that other quarter milligram that I talked myself out of before."
"I think that would be a good idea. Here. Here's a glass of water. I think you're going to have to learn that it's alright to take a quarter milligram when you're feeling like this. Or even a half milligram. I trust your judgment. You're probably the last person I'd ever suspect of taking too much of this. I know how much you hate to increase your dosage even a little bit. But at times like this, I think you're better off increasing your dosage until you've calmed down. You can always decrease it back to your normal level when you're feeling stable again. You just have to remember not to drop the levels too fast. I think you've got a pretty good feel for that already."
"I know. It just feels like I'm loosing so much ground, even to give in an eighth milligram. It's just so damn hard to cut back again. But right now, I think you're right. I guess it's worth it for the time being." Jason took the small pill.
"When you're ready, I'd like you to describe what your demons would look like, if you were to confronted them."
****************************
From another folder, Bondurant was able to pull these notes from one of the follow-up sessions.
"Jason, I need to know a little more about these demons, as you call them. What can you tell me? I remember we started talking about them some time ago, and you only got a little ways into it before you became too uncomfortable. Do you think you could tell me a little more about them now?"
"Aw, Doc. I feel like if I tell you, then you'll think I'm certifiably crazy. And if I don't, then I'm stuck with still having to deal with them alone. But I'll give it a try."
"Well, Jason, let's not worry about your being crazy. I wouldn't even know how to fill out the forms to certify you. But right now you look like you're pretty uncomfortable just talking about it. And that tells me something already. So let's start with this: What image do you conjure up in your mind when I mention your demons?" Bondurant watched as the internal fears forced themselves to the surface of an otherwise stoic personality.
"Uh, if you mean visual image, that's a little hard to explain. But that's something I've thought a lot about. It's kind of like this. If I imagine them, then I pretend that they're a bunch of Hell's Angels. You know, like a motorcycle gang. With a bunch of Green Berets and Rangers mixed in with the crowd. And they're all really pissed off. It's an image of some real rowdy dudes. But I never really see that, exactly, projected out into the tangible world. I just have mental images. "
"There have been a couple times when I think I've actually seen something, but it didn't have any specific form. They're just blobs, like floating amoebas. And about the only time I ever visualize them is when I'm caught in that half-asleep-half-awake state. I get stuck there sometimes. Generally, it's not all that great a place to be. Sometimes, at least in the past before all this panic stuff, it was kind of neat, because I could sort of control my dreams from there. But other times, when I'm really trying to wake up but I get stuck there, then I know I'm still asleep and I know I'm half awake. It's just damned scary then. I have a hard time telling which world is more real. It's like they keep shifting, and at times they're both real. It's mixing a dream with reality, like hallucinating on some really nasty acid back in the old days."
"And you've taken LSD before, as I recall. When was the last time?"
"Oh, jeez, it's been almost 15 years. Early 70's. Probably the last time was in 1972 or 73. And I remember the last one was a real bummer, because I started feeling trapped in a hallucination, just like being trapped in a half-dream state. That and the terrible stomach cramps. That's when I swore off the stuff forever."
"So what is it that you hallucinate? Do you actually see things? Hear things?"
"Well, a little of both. Like I can hear my own thoughts as if they were coming from somewhere else. I hear the demons plain as day. Sometimes I'm surprised other people can't hear them. That's the real hallucination part. And what I see are these floating shapes that are just splotches with brown and black spots in them. Like real negative energy."
"And what do these things, these shapes, do?"
"Well, mostly they're just there, and they won't go away. They keep telling me how bad off I am, as if I didn't know that to begin with. They try to get me to believe that I'm losing control to them. They try to cover me up with their negative energy, to engulf me like an amoebae engulfs its food." Tears formed at the corners of Jason's eyes as he took a deep breath. The familiar blanket of panic was settling around his shoulders, making his chest tighten up with the swelling of emotion. "They try to make me think they're real, but I fight them." His voice quivered.
"How do you do that?" Bondurant calmly watched the deep and powerful emotions well up in Jason, yearning to get out. And he watched as Jason fought them with everything he had.
"Well, this is going to sound crazy...but the best way, the only way, I've ever found of getting rid of them is to douse them in white light. I pretend that I have a squirter of pure white light and I spray them till they're gone. Or I picture myself reaching out with a big bucket or a pitcher of cream...pure white liquid that I pour over them. Then they're gone. But it takes a lot of power and concentration for me to do that."
"But you can always do that? You can make them go away? All the time?" Dr. Bondurant leaned back, hand on his chin. His brief notes would allow him to reconstruct this all very precisely.
"Yah. So far. So far, I've been able to make them go away." It was a barely audible whisper, right on the edge of tears.
"Well, let's call it a day, what do you think? You've been doing extremely well in confronting these feelings, Jason. I'm proud of you. You may want to let them out of you even further. Let yourself cry. Let yourself scream. And you've been doing well with your medication, from what you've said. You've been talking about dropping you dosage again a bit. How's that going?"
"Well, I keep trying to back down, but it's like running into a brick wall. Last week I dropped down a half milligram, but it only took less than one day and I had to take the pill again." Jason was always upset by his inability to overcome the affects of his medication. If it were up to him, he'd have done away with all of it immediately.
"Jason, when you feel like challenging the medication, take very small steps. Remember we talked about how it would affect your system to abruptly change your dosage? I think it's great that you're trying to cut back, but let's be a little bit slower in our approach, uh? Like maybe, try taking 1/8 milligram steps. It may take longer, but, believe me, you'll be a lot more comfortable with the results. We'll try talking about these demons again next time. Take care. You're doing well, believe me. I'm very impressed."
*************************************
From a bit later in the records, Bondurant pulled a few more pages of notes from sessions where Jason again attempted to verbalize the shapes and forms of his fears.
"Jason, you mentioned a few sessions ago this motorcycle gang that's always after you. And you also say there are some Army and Marine people with them. Can you talk a little about them? Describe what they look like? What they do?"
"Well, it's kind of like a recurring dream, except it can also be even like a day dream. I'm walking down the road. I'm not really going anyplace in particular. It's just the thing to do. I'm walking down the road, some unspecified highway. It's like 'The Highway Of Life' or some shit like that. And there's a van full of guys out looking for me. The van is painted camouflage green and brown and it's full of a mix of motor cycle gangs and Green Berets. Jolly Greens, we used to call them. And they're out cruisin', looking for me. They want to beat me up. They do it every time they find me."
"Why, Jason? Why do they want to beat you up? What did you do to them?"
"I don't know. They just do. It's not like they're mad at me personally or anything. That's just the thing they do. They drive up and down the road looking for people to beat up. And I'm sort of on the top of their list. I walk down the highway like I'm hitch hiking on the shoulder. They drive around looking for me. Sometimes, when they find me, I can't even make myself move. I can't run or scream or fight back or anything. I just get jumped on by these guys, kicked and punched and beat with sticks and chains and rifle butts. Sometimes one guy will hold me up while somebody else tries out some karate moves on me. I mean, they really fuck me up pretty bad. And since it's right on the shoulder of the highway, other cars are driving by. But if anybody else stops, it's always another couple of guys in jungle fatigues. Or in leather jackets with chains and shit hanging all over them. And they always help the guys beating me up, as if they needed any help. No one ever stops to help me."
"You said 'they do it every time'. What did you mean by that?"
"Well, it's a recurring theme. Like something that happens almost on a regular schedule. They find me and they beat the shit out of me. But part of their game, see, is that they try to beat me up to the point that I'm almost dead, but never quite dead all the way. I mean, if they really killed me, then they wouldn't have me around to beat up any more, and they don't want to loose that privilege, or that special treat they get from kicking the shit out of me, or whatever. Is that making any sense?"
Bondurant quickly sketched a few notes as he nodded. "Yes. Yes it does. But I'm not sure I understand their motive. Why is it they want to beat you up?"
"Oh, there's no reason. Or at least I don't think there is. I don't think it's because of anything I did. They don't even know me personally. It's like when I watched choppers go up in flames. It really hurt, watching those guys burn up like that. I didn't know any of them personally. If I could have helped them, I'd have done it. Not because I knew them, but because it was the thing to do. It's kind of the same with these guys. For them, it's just the thing to do. They don't really know me, but sooner or later, they always find me. I don't know. Maybe it's because of something I didn't do."
"A little while ago you said something about a back door. What exactly is this back door?
"Oh, God, Doc. This is the part where you simply say, 'O.K., pal. You'd better stay here for awhile.' And then you slowly move your hand down to that secret button under your desk and ring the security alarm and the guys with the nets come in and take me away."
"I hope you're just kidding about that." Bondurant smiled, appreciating the depth of Jason's concern for his self image.
"Well, sort of. However it works, you're going to give some serious thought to having my head examined after I tell you this."
"Go ahead. Try me. I promise I'll let you know if you say something I haven't heard before."
"Well, that's not too comforting. All that means is that you've locked a bunch of other guys up before me." The exchange of grins took the edge off the feeling that Jason had about letting his closest held secrets out.
"I've got this image of a porch that's just out the back door of my mind. I picture myself moving back as far as I can in my head, and there's a door there. Outside that door is the back porch. And a whole other world. But it's outside my mind, so it's really in some other dimension or something. Most of the time, 99.9% of the time, I don't even think about the back door. But when I'm having these panic attacks, that's where the feelings of fear and panic and doom and all that come from. That's how those thoughts I can't seem to control get into my mind. It's just an image, you know. It's how I can say they're not my thoughts, that they seem to come from somewhere else. That's the somewhere else. They come in through the back door, from a place outside my mind, like smoke seeping in through the cracks."
"Let me ask you one thing before you go on. You keep mixing metaphors. Tell me honestly: Do you really think thoughts can get into your mind from some source outside your mind?"
"No. I don't. Except.......Shit. The first time I ever thought that was happening was the first time I had a panic attack. There was something happening that I didn't have any control over. It was as if there was something else, overpowering me, taking control. When I'm thinking clearly, like I am now, I know that's a pretty ridiculous idea. But when that panic shit starts, I don't think like I do now. And anything is possible. All those fantasies become reality. That's one of the scariest things about a panic attack. The ordinary, everyday rules of reality stop. And a different set of rules over-rides everything I ever thought was real, like my being in control of my own mind and body."
Jason took a deep breath and laid his head back against the back cushion of the chair. Dr. Bondurant didn't saying anything. He just jotted a few notes and waited. He admired the ability Jason had to describe these things. He also admired the inner strength he seemed to have to deal with them so well.
Jason moved forward with resolve. "Remember I told you about the image I have of the car load of tough guys that beats me up on the road side? Well, all those guys hang out on the back porch. It's just my image of an easy access into my mind. I mean, I literally picture it as a back door, with a big piece of glass and a curtain, separating the house from a back porch, like in an old farm house. Is this making sense?"
"Go on. You're doing all right."
"Well, the ridiculous thing is, anybody could just kick the back door in. Or just punch a hole through the glass and reach in and unlatch the door if it was locked. But, you see, these guys don't have to do that. They're all professional locksmiths anyway. So even if I changed the door to a big steel-plated deal with a real good lock, they'd get in any time they wanted. The point is, they know they can do more damage to me just hanging around on the back porch. Just being there is enough to rattle my cage. One of the things that really pisses me off about that whole image is that they're just showing off. Just stomping around to scare the shit out of me. And it works. When I have a panic attack, it always starts with these guys just pounding and kicking on the door, not necessarily to break in, but just to let me know they're out there, waiting. They know they'll get their chance."
"Now, let me get this clear. These are images that you have where you personify your fears. They take the form of motorcycle gangs and Green Beret soldiers. And the most significant impact they have is just making you aware they exist. Is that a fair summary?"
"Well, yah, pretty good, I guess."
"So, what happens the other times? Do they ever come in? Do you ever go out?"
"There's no way I'd go out onto that back porch. There's no way in hell I'd stand a chance against any one of them, and there's a couple dozen hanging around there at any one time. As far as them getting in.......well, there have been a few times when I've imagined that they kicked the door down and have come in. One time was when I tried to stop taking the medication. You remember, when my girlfriend called the hospital after I passed out and was puking and all? That was really the first time they ever got in and did anything. And I swear it was the most terrifying thing I've ever experienced. The closer I get to a panic attack, the closer they get to breaking the door down. I don't ever want to have to deal with those fuckers again. Ever. They're so much bigger than me, it's not even funny. I wouldn't survive."
"Jason, have you ever considered going out on the back porch and confronting these images? Or of opening the back door and letting them in?" Bondurant wanted to see the limits of control that Jason felt constrained to.
"No. No, I can honestly say I've never in my right mind ever considered doing that."
**************************************
By mid-afternoon on Thursday, Robert Bondurant had completed a review of Jason's records, re-familiarizing himself with most of the details. He hadn't even bothered to pull any of the other patient files. However, he had come to a decision.
His job was to take care of people like Jason Orr. To understand their problems and to help them. If this system wasn't going to support that role, then he was ready to find some place that would. He would do all he could to keep Jason and the others under the care of the VA program. But if they went, so would he.
It was really a simple decision. It was the right thing to do. And he felt
so good about how much he had helped them so far, he considered contacting them
all and keeping closer track of them. Regardless of the existing VA rules for
patient scheduling on 60 day intervals. He just might start doing that next
week. And he'd probably start with Jason.
To be continued...
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