Chapter Text
Treatment Plan – Draft
Patient: Holmes, Sherlock
Date: 30.5.2002
Background: SH is a 25yo White male university graduate. He was admitted to dual diagnosis unit at Blakely House for detox on 27.5.2002. BIB brother, Mycroft Holmes, following arrest for intoxication on 26.5.2002. Pt was under the influence of cocaine when he was admitted. Pt began methadone maintenance on 29.5.2002.
Diagnosis:
Axis I: Cocaine Withdrawal, Opioid Withdrawal [292.0]; R/O Bipolar disorder, most recent episode hypomanic [296.40]; R/O Asperger's Disorder [299.80]
Axis II: Diagnosis Deferred
Axis III: Peripheral sensory neuropathy [337.1]; Allergies to shellfish, sulfa medications.
Axis IV: Economic problems, housing problems, problems with primary support group, problems related to interaction with the legal system.
Axis V: Global Assessment of Functioning: 40. Major impairment in multiple areas: social, occupational, family. Some danger of hurting self or others.
4-week Treatment Plan
Goal 1: Pt will reduce dependence on heroin and cocaine.
Objectives:
Pt will adhere to methadone maintenance therapy as directed by his psychiatrist.
Pt will identify triggers for substance use.
Pt will create sobriety plan for after discharge.
Pt will attend scheduled appointments following discharge.
Goal 2: Pt will report fewer mood symptoms.
Objectives:
Pt will use words to describe his mood state.
Pt will use psychotherapy to discuss the impact of his family life on his mood.
Pt will identify activities that bring him pleasure.
Pt will engage in pleasurable activities on a daily basis.
Goal 3: Staff will report improved social functioning of SH at Blakely House.
Objectives:
Pt will attend Social Skills Group and adhere to group rules.
Pt will obey Blakely House rules regarding behaviour towards others.
Pt will use psychotherapy to talk about social and family relationships.
Session Note
Confidential. For training purposes only. Do not circulate.
Date: 30.5.2002 11a.m.
Psychologist: Dr Carola Rivas, PhD
Patient: S.H., 25yo White male, cocaine and heroin user, mood disorder NOS. Session No. 2.
SH: …
CR: …
SH Is this what we're doing? Again?
CR: What are we doing?
SH: You sit there and wait for me to say something.
CR: Yes. Yes, that's part of what we'll do. But today there's something we need to work on together. I've prepared a treatment plan for your stay here. I'd like you to read it so that we can discuss it together. And then we both need to sign it.
SH: …
CR: …
SH: …
CR: ….
SH: Ha!
CR: What's that?
SH: I'm not 'in danger of hurting self or others.' You have got that wrong. Why did you write this? I told you that I wasn't suicidal. And I am not violent.
CR: Perhaps you can tell me what happened in the group yesterday. I was told that you upset another group member.
SH: I deduced the number of suicide attempts that she had made. Turns out I was correct.
CR: And?
SH: She tried to attack me. I didn't hurt her.
CR: Hmm. Why do you think she attacked you?
SH: I said she tried to attack me. They restrained her.
CR: Of course. But, returning to my question, why do you think she wanted to attack you?
SH: Because she has borderline personality disorder. Does there need to be a reason?
CR: Well, frankly, I'm worried about you. I don't like the idea of you being attacked by others while you are at Blakely.
SH: Then don't make me go to group therapy. They don't want me back, anyway.
CR: How convenient.
SH: What are you implying?
CR: That you caused a scene in order to get kicked out of the group. Which I can certainly understand. But I keep coming back to the idea of you being attacked while you're here. That would be very unfortunate.
SH: I am not going to be attacked! And if I were, I can certainly fend for myself. I know martial arts.
CR: And I'm thinking, should we write instead, "Pt in danger of being attacked by other patients"?
SH: Don't write anything. Forget it. Just take out that sentence about me being a danger to self or others.
CR: We could post a security guard outside of your room. Would that help?
SH: There's someone outside of my room all the time anyway. Comes in and checks on me every fifteen minutes. Wants to make sure I don't off myself. Do you know, there are at least five ways that a patient here could kill himself, even with all of the safeguards you have in place?
CR: And why does that interest you?
SH: I'm just saying, for a place that sees a lot of very disturbed individuals—I know what kinds of people are here—you aren't taking the necessary precautions.
CR: I'm listening.
SH: There's a man in 6A who has a belt. His wife brought it in with some clothes, didn't realize it was still in his trousers. He's saving it. You had better look into that.
CR: Thank you. I will. Anything else?
SH: I'll make you a list and bring it tomorrow.
CR: Thank you. But we won't meet again until Friday.
SH: Friday, then. Do you think anyone will do themselves in before then?
CR: Are you suggesting that we meet earlier?
SH: Certainly not. Just that—I wouldn't want—do you have a mailbox? Somewhere to leave the list for you?
CR: You can leave it under my door.
SH: Excellent. Will give me something to do.
CR: Anything else that you'd like to comment on about the treatment plan?
SH: I'm surprised that it took you this long to come up with the Asperger's rule-out. I must be getting better with the social interactions.
CR: I read from Dr Northrup's note that you've been given that diagnosis before. Why didn't you mention it when I asked you what you thought would be the most appropriate diagnosis for you?
SH: And do your job for you?
CR: You were testing me.
SH: Obviously. You're not the only one who is making observations around here, Doctor.
CR: And what do you observe?
SH: Like I said before, you went into this field because of a misguided desire to help others.
CR: Not very specific to me, I'm afraid. Nearly everyone who does what I do—
SH: -has a saviour complex?
CR: Something like that. Again, we're talking about me, not you.
SH: Very observant you are.
CR: …
SH: I'll sign it. Formalities. Paper work. Tedious. Can we move on?
CR: Of course.
SH: Mycroft is bringing my violin tomorrow.
CR: Which one? The Cremona?
SH: Ah, very good. You remembered. The Cremona, yes.
CR: What else should I know about you and music?
SH: Depends on how interested you are in the violin.
CR: …
SH: You won't tell me, but I'd guess that you play. Or you wouldn't remember something like the name of a luthier. And of course you won't tell me one way or another if you play or not. Those are the rules, right? And I'm here to follow the rules. That's what my treatment plan says. So I won't ask you. But I'll tell you, instead. I'd been working on the Sibelius violin concerto. Which, if you don't already know, is a very challenging piece.
CR: Do you like it?
SH: What do you mean?
CR: What do you like about the piece? Why this piece? Why Sibelius? Did you choose it?
SH: I choose all of my pieces. I'm the soloist.
CR: …
SH: I've a bit of thing for Sibelius, those folk melodies here and there, in what is otherwise a pretty standard orchestral tone poem. And the first movement, I like the gradual rise of the semiquavers, almost Bachian in how the bow alternates between the La and Mi strings, until the melody surges to something high and strange. It's difficult to play, even for me. But I was a bit bored with the Mendelssohn. And I'm not feeling particularly keen on Ludwig or Wolfgang at the moment. Wanted something more modern, less tonal. The conductor was game, so we were on.
CR: What is going to happen now?
SH: Now what?
CR: Now that you're here.
SH: That's not the problem.
CR: Is there a problem? Or are you saying that it's fine that you're here? Because I would have thought that a month without the concertino, well, it might put a damper on rehearsal.
SH: If you would let me finish, you would already know how this was going to end.
CR: …
SH: I can't play now.
CR: …
SH: …
CR: …
SH: Go on, ask me. I know you want to know.
CR: What do you mean you can't play? Did something happen?
SH: I don't know. No, that's not true. I'll try to stick to the truth. I think I know what happened. And I just need Dr Franklin to confirm a few things for me. Then I'll know for sure.
CR: I still don't understand.
SH: No, you wouldn't, would you? Peripheral neuropathy. Common side effect of sustained cocaine use. I think even you should know that. Numbness of fingers, loss of sensation, loss of control of fine motor movements. Tell me, doctor, what use is a violinist who can't feel his fingers? Who thinks he's moved into third position but has overshot to fourth? Whose vibrato is scattered and inconsistent? I might as well be last chair of the second violins. My brain knows what to do, but my body won't obey me.
CR: I can't imagine what that must feel like.
SH: Don't bother. I can tell you. It feels – it feels – I suppose you want me to say that it feels like a betrayal? I might say that, if I had ever felt so attached to my body in the first place. But it's transport. It's all transport. These bones, this face, this trick which you see, "es cadáver, es polvo, es sombra, es nada." I knew that. I always knew that. And yet—I wanted a little longer. I thought I'd have more time.
CR: More time for what?
SH: To play. To burn the candle at both ends. It makes a lovely light, my friend. Or are you my foe?
CR: You speak Spanish. You recite poetry.
SH: How observant you are.
CR: May I ask how you learned?
SH: Learned what? Afraid there's no time to discuss castellano or Millay today. Time's up. The 50-minute hour. Am I right?
CR: …
SH: …
CR: You'll tell me more about the poem next time.
SH: Which one?
CR: The Spanish one.
SH: How do you know it's a poem?
CR: Meter, Mr. Holmes.
SH: Very observant, Dr Rivas. And I see you can count.