Outpatient

by Ian Watts

“I don’t want to talk about it,” Adam mutters, shifting awkwardly as he sits. His suede jacket is folded over crossed arms, clasping it to his chest like a flotation device. He is embarrassed at the words as soon as he speaks them; they make him feel small, like a child petulantly refusing to brush his teeth. I knew this was a mistake, he thinks, and stares down to inspect the potted plant on the coffee table in front of him.
“I understand completely, Mr. Faraday.” The doctor’s tone is sympathetic, reassuring. “We don’t have to discuss anything you’re not ready to discuss. Would you rather reschedule?”
Adam sighs. He had put off booking this session for weeks after initially agreeing to it, and his embarrassment only deepens as he thinks of telling his family and friends. Finally went to see the shrink, he imagines himself saying. Made it about seven minutes and quit. Did you know they expect you to talk in talk therapy? Thanks for thinking of me, though. I’m going back to bed now.
“No,” he says, and shakes his head. “No, that’s fine. I’m sorry.”
“Not at all.” The doctor’s posture in the high-backed leather chair across the room is upright and attentive: shoulders square and head tilted, hands resting upon his knees instead of typing or scribbling. “What would you like to talk about instead?”
Adam’s shoulders rise and fall. “Look, I don’t want to be rude, I just…don’t know if this is for me.”
“That’s a normal way to feel when someone first seeks counseling,” the doctor says. “Common in my experience, and I’ve been treating patients for a very long time. It’s natural. My first and most important concern is that you feel comfortable here – this should be a place your mind can be at ease.”
“I’m comfortable,” Adam lies. The office is indeed designed for the comfort of multiple senses, from the well-stuffed couches to the soft glow cast by shaded lamps onto neutral-colored walls. It is not yet a quarter past six, and a skylight frames the waning December moon in the ceiling above them. Adam could almost picture himself spending the evening in the big chair reading a book, or curled up on the couch with Erin, his fiancée. But Erin had left, and now instead of a fiancée, he has a psychiatrist. The thought makes comfort seem impossible.
“Let’s take a different approach,” the doctor offers. “Some patients find it helpful to identify their motivation for treatment. What made you decide to make an appointment?”
Adam wonders where to begin. The fight and the breakup that followed? The weeks of unanswered calls and frantic messages that pleaded, raged, and pleaded again over a single day? The episode at the office, and his co-workers’ confused, worried faces? The loved ones who watched him struggle through each day, listening to his laments, telling him urgently that –
“I need help.” He feels a small relief, saying it out loud. “I might be depressed, or something. Your office said you take late appointments, and I can’t afford to take any more time off work.”
The doctor nods, obliging. “I keep my evenings open to accommodate patients’ work schedules. Paperwork and the hospital keep me busy enough during the day. So, how can we best use your time? What are you hoping to get out of therapy?”
How about a lobotomy? Adam thinks. Open my head up and scoop out gray matter until I don’t have to think anymore. About her. About anything.
“I don’t know,” he says instead. “You write prescriptions, right? For Prozac, or whatever? Maybe that’s what I need. A hundred milligrams of Whatever.”
The doctor dons a wry grin. “Most insurance providers will only cover the generic form of Whatever, and it’s rarely effective at that dose in any case,” he says, and Adam smiles at the joke in spite of himself. “Seriously though, pharmaceuticals may be one part of your mental health plan. They can help relieve symptoms, and correct some chemical imbalances. The real goal of cognitive-behavioral therapy, however, is to bring about a positive change in how you think and act. It attempts to treat the root causes of depression and anxiety, and requires more sustained effort than just filling a prescription.”
Adam chews his lip and cracks his knuckles absently. “You can’t just give me some pills that make me happy? Or at least numb me up a little?”
“Nothing so simple, I’m afraid,” says the doctor, smiling. He’s clearly much older than his patient’s thirty-five years, but Adam doesn’t find him grandfatherly so much as wise and professional, like a university fellow who knows and loves his discipline. “But the process can have a deeper and more lasting effect than any medication, if you commit to it.”
The process. Adam swallows deeply, turning the phrase over in his head. Since Erin, he had scarcely been able to commit to getting up in the morning, much less something as involved as the doctor was describing. Still, the steadiness in the man’s voice is a welcoming change from the pity and concern he’s become used to from others those recent weeks. Why not give this session a chance, at least? He’s already paid for the hour anyway.
“It’s racing thoughts, mostly, I guess,” he says. “For a month or so now. Like I can’t get my brain to quiet down. Makes it hard to finish projects, or fall asleep… and once I get to sleep, it’s hard to wake up.” His brow furrows. “Stomach always aches, but I never want food. I tried a hot dog and a beer at my brother’s, and I couldn’t keep it down. Nothing in there to soak it up.”
“How about personal hygiene?”
“Not bad.” He frowns. “Not good, either. I took three showers the other day, just because I didn’t know what else to do with myself. And…” He pauses, searching. “People keep telling me to do what makes me happy, but nothing does. Movies, music, sports, going out with friends – it’s like I just don’t enjoy anything anymore.”
“It’s called anhedonia,” the doctor pronounces. His voice is even, knowing, experienced. “Frequently reported by people experiencing a depressive episode, as are loss of appetite and sleep disruptions. You mentioned your brain won’t be quiet – can you describe what that feels like? Any physical symptoms?”
“Sometimes.”
“Elevated heartbeat? Difficulty catching your breath?”
“Both,” says Adam, “and, I don’t know, a kind of frantic energy. Like fight or flight, but I’ll get it when I’m home alone. Or sometimes with other people, which is worse.”
“At work?”
Adam pauses, considering the question. I don’t want to talk about it, he almost says again, but though he’s not excited to relive that particular memory, it seems safer to do so in this controlled environment than with the people outside the doctor’s office, in his real life. “There was an… incident. At my office. I sort of lost my cool in a meeting.” He considers further. In for a penny… “No, it was more of a meltdown, honestly. My manager asked me about a deliverable, and I just unloaded on him. Both barrels.”
“What happened then?”
“They sent me home.” Adam sighs again, deeper than before, but this time the act feels cleansing, like some of the shame and worry left along with the breath from his lungs. “I’ve been off ever since then, around a week ago now. I have to go back in and face my boss and everyone on Monday. I’m scared I can’t handle it.” He rubs his eyes with the heels of his hands. The doctor listens dispassionately to his account, and then responds.
“It sounds like you weren’t responding to what your manager said as much as you were to your own anxiety,” he says. “The amount of stress you’ve described can erode our impulse control, making it challenging to manage emotions in the moment – even with a healthy diet and sleep cycle. I’m sure the people at work understand this is a health issue, otherwise they would have disciplined you rather than giving you time to recover and return.” Adam absorbs this assessment, delivered without judgement, and nods readily along. He starts to think for the first time that he made the right decision in keeping the appointment.
The doctor goes on. “My goal for our sessions – if you decide to continue therapy – is to help you build the cognitive patterns that will help you cope with these symptoms when they appear, and exercise more executive function over how you react to anxiety.” He gives the younger man a studious look. “What about in more personal settings? Have you experienced these attacks with family? Friends?”
“Yes, and yes. It got so bad at my brother’s house that I sat out back for an hour and chain-smoked by myself. It didn’t help.”
“With your partner?”
That last word lands in Adam’s ears like a piano falling from five stories up. “No partner,” he says, too quickly. I don’t want to talk about it. Revisiting the incident with his manager was painful; discussing Erin, unthinkable. I don’t, don’t, don’t. He knows in the pit of his gut that he must eventually talk about how she haunts his days, else any therapy is just performance art. He will have to confront the night she left, and every day since then that have come and gone with silence between them, but to do so is to admit that he is grieving, and to grieve is to admit at last that it’s over. He cannot. He’s not ready, and the doctor seems to sense this. Instead of urging the conversation forward, he nimbly changes routes again.
“There’s a relaxation exercise I think might benefit you, if you’re willing to try it,” he says to his patient. “Nothing complicated, but it could ease these symptoms when they occur.”
Adam is grateful for the reprieve. “Sure,” he says, and then again with more certainty. “Sure. What kind of exercise?”
“A basic mindfulness procedure, designed to keep you in the present, instead of agonizing about the past or future,” the doctor explains. “Have you ever meditated before?”
“You mean like monks in the mountains? Chanting ‘ohm’ and contemplating the universe?”
“Possibly, but that’s painting with a rather broad brush.” The doctor steeples his fingers, eyebrows raised. “‘Meditation’ just means focusing your thoughts on something to reach a state of peace or clarity. The mind can be trained to focus this way, even with a simple exercise like this one. I’m not promising you’ll attain nirvana, but it might help bring some order to the racing thoughts you described. You can even do it at home.”
“On my own?” Adam felt his own eyebrow arch. “Or do you do house calls too?”
The doctor chortles. It is an easy laugh, and Adam joins him in it. “No, no house calls. Kind of a rule I’ve always had, and anyway, I find it helps to keep this room as a dedicated workspace for my patients and myself. We can begin whenever you’re ready.”
Adam smirks. “Should I lie down on the couch and close my eyes?”
The doctor holds his hands out, palms up in an accommodating gesture. “It’s not a requirement, but you’re more than welcome. Like I said, it’s important that you’re comfortable in here.”
Why not? Might as well act the part. Adam gamely shifts position, pivoting in his seat to lay his head against the throw pillow and extend his legs out before him on the cushions. He glimpses the moon through the skylight, clouds gathering at the corners to encircle it, before lowering the curtain of his eyelids. If this works, I could at least get a nap in. “Ready when you are.”
“Very well.” The doctor’s pleasant baritone fills his ears, divorced from visual distraction. “The first step is to be aware of your body, and gradually relax the tension it’s carrying. Start with your breathing: the air you inhale and exhale, the rise and fall of your chest that accompanies it. Most of the time, we let our subconscious handle respiration while our minds are occupied with other things; take control of it now. Breathe with intention – in for four beats, out for four beats.” Adam followed the instruction. Inhale one… two… three… four, exhale one… two… three… four…
“Pay attention to your body and how it occupies the space in the room. Let yourself feel the fabric against your skin, the places where you’re in contact with the couch, the temperature inside you compared to the air around you. Feel the warmth that flows from your heart, all the way out to the end of each finger and toe…” Inhale one… two… three… “Now focus on each part of your body individually, starting from the bottom and moving up.” Exhale one… two… three… “Feel any tightness in your feet, and relax them. Do the same for your legs… your abdomen…”
Am I doing this right? Adam doubts privately as he lets the doctor’s voice guide him (“… your chest…”). His mind still feels so alert, darting every which way until the voice gives it a new focus (“…your shoulders… your neck…”) and then scattering again. Yet he does feel less anxious. (“Feel your body as a whole… how all of it works in concert with your breathing…”) His muscles are already much less tense than they had been only a few moments ago, when he first lay down. Has he really been walking around for the last few weeks wound so tight, his whole body a clenched fist? (“Feel that warmth again, how it reaches every part of you before returning to the heart…”) If so, it was no wonder just getting out of bed has seemed such a chore.
“Turn your attention even further inward now, to your thoughts,” the doctor intones. Inhale one… two… “Monitor them as they arise, acknowledge them, and allow them to dissolve. Allow your mind to wander, without following it or judging where it goes.” Exhale one… two… “Let your thoughts brush past you without overwhelming you. Let them be running water over stones, wind through a willow’s branches.”
Adam’s thoughts – images and sounds, remembered and imagined, figments of his mind’s eye and ear – rise to meet him from mental depth like bubbles breaking the surface. (“Remain in your awareness of the present moment…”) He recognizes each of them, and observes each swell in turn before vanishing with a gentle pop. Anxiety about the future. Words he ought to have said. Erin’s tears, hot and bitter on her cheeks. He feels a pang, but the doctor’s voice (“Note the feelings you experience, observe and acknowledge them, and let them pass…”) guides him back to center. His chest beats calm and steady quarter notes. How long had he been on the couch? He thinks it could have been three minutes or thirty. As he floats from simple repose toward someplace deeper, the cushions seem to evaporate under him, and he gets the sensation of falling that can precede sleep. It is just disruptive enough to make his eyes flutter open.
He gazes upward, groggy, unfocused. The dim, warm lighting of the room swims in the air. He wonders at how composed he feels: his heartbeat and breathing in easy rhythm, arms so at rest he can barely think how to move them. The doctor’s voice (“Allow your mind to follow the cadence of your breathing, thoughts and feelings in and then out…”) is a low, pleasant hum, the sound of gentle rainfall on the roof at night. He hasn’t felt such peace in so long, at least since before the fight with Erin. He remembers how he would lie beside her, the two of them looking at the ceiling and smiling in wordless afterglow until sleep came for them. He had despaired he’d never feel like this again, looking up alone in his empty bed. It’s going to be alright, he thinks, and watches the light play upon the skylight above him. The clouds have gathered to hide the moon, and the pane reflects the room below it like still water under moonlight. (“Gather mind and body together now, attuned to each other, not two parts but one whole…”) His eyes lazily drink in the murky mirror’s image: his outstretched form upon the couch, the plant on the coffee table, the doctor’s desk, the doctor’s empty chair. The lamps’ light seems to play tricks with his vision as it dances across the glass – the doctor has no reflection, though his voice continues to roll richly from across the room.
“Close your eyes,” the voice tells Adam. He does, immediately. Obediently.
Something’s wrong, he thinks, but the idea is incoherent, insubstantial, easily lost in the rising sense of tranquility he feels. (“Let go of your cares, your fears, your resistance…”) His mind casts about for some thought to which it can cling and pull itself back to waking, but they all wash away, so much sand in the current. And the doctor’s voice persists, implacable as the pull of the tide upon the waves. (“Empty the vessel of your mind, of your soul…”) Then the voice is no longer across the room, but above him, around him, on top of him, whispering at his ear. Wind through a willow’s branches. At last he tries to picture (Erin?), but her features are incomplete, even her name is missing, and then she too is submerged. (“Let the sublime dark fill the space within…”)
A sharp pinch below his jaw, breaking the skin, sinking into the carotid. Feel the warmth that flows from your heart. The warmth flows out of him now, wet and slick against his neck, to be guzzled lovingly by eager, waiting lips. Running water over stones. There are still twenty minutes left in the session.

***

Jenna’s right boot clicks against her left as she sits cross-legged in the waiting room, tapping her foot idly. She arrived ahead of schedule for her first appointment, and now regrets it. The extra quarter-hour or so has given her the opportunity to ruminate on the past two weeks: a night of too much drinking, leading to a spectacular display of emotional fireworks, leading to 72 hours inpatient in the psychiatric ward, leading to here. “You think I’m crazy,” she had said when her mother insisted she start therapy after her discharge. Her mom’s response to the accusation was that she needed to talk to someone, and wasn’t that better than going back to the hospital, and that her friend Grace knew the best doctor, a real miracle worker.
Hard to argue there, Jenna thinks. Grace was a loon before she started treatment. These days she floats around like a happy little cloud. So that was that – she made the appointment, got there early, filled out the forms the pretty, cheerful receptionist in the red scarf had given her. Now the waiting room clock ticks its last few moments to seven, she knows it’s almost time as the previous patient emerges from the doctor’s office. He’s about Jenna’s age, wearing a suede jacket and a pacific expression.
The receptionist greets him brightly. “Same time next week, Mr. Faraday?”
“That’s right.” The young man’s voice is light and airy. “Six o’clock, every Tuesday.” Jenna gives him the up and down as he leaves the waiting room. He doesn’t look crazy, Jenna thinks. The smile on his face is serene, if rather vacant. Pills, maybe. They had given her risperidone in the hospital; it helped with the mania, but it also left her clumsy, with a head that felt full of helium. It would explain the faraway eyes and what looked like a shaving cut on the side of his neck.
“Ms. Bloom?” She turns at the sound of her name. The pretty, cheerful receptionist holds out an inviting hand. “The doctor will see you now.”
Jenna pushes herself to her feet and stretches to her tiptoes before crossing the room. “Busy night, huh?”
“Oh yes,” says the receptionist. She strokes her scarf with one hand and steers Jenna toward the office door. “The doctor has a very full schedule tonight. He’ll be seeing patients all evening.”