“Good morning Justin, I’m Dr. Bitonti. How did you sleep?”

“Uh, fine, thank you.”

“Justin, I’m not asking to make polite conversation. You told Dr. Lin last night that you’ve been having trouble sleeping. You were given Trazadone to help with that and I wanted to know if you found it helpful.”

“Oh. Okay, I guess.”

“I know you have a number of drug allergies…any reaction to the Trazadone?”

“No.”

I guess I had slept fine, all things considered. It’s not easy to sleep in a hospital. At least on the psychiatric unit, vitals are done less frequently and bed checks are less intrusive. This morning Brian was there at 7 AM. I guess I was a little surprised. I was half sure he was not going to return. He was beautifully dressed in his suit and without a hair out of place. But he looked like shit, exhausted. His eyes were red and puffy. I didn’t say anything since if there’s anything Brian hates it’s being caught having feelings and being told anything about his appearance is slightly less than perfect. He brought me Starbucks coffee and some pastries, knowing from too many experiences that hospital food is inedible. He also brought me some clothes, my sketchbooks and some pencils, and other necessities. I went and brushed my teeth immediately and gargled with some virgin mouthwash before returning and kissing him. His kiss back was reassuring - he still wanted me even though I was on this psych unit and clearly had lost my shit. When we pulled apart we were both breathless. Some things never change. We sat together in the little visiting area, and Brian took my hand and looked at me so seriously, and I got a little nervous.

“Sunshine?”

“Yes.”

“Listen, are you listening?”

“Yes, I’m listening.” I held back a sigh.

“Would you rather find a finger floating in your can of soda - after you’ve drank half of it - or a bloody bandage under your steak at your favorite restaurant?” This guy.

“Brian…”

“Yes?”

“I can’t believe you watched Friends!”

“What? I have not!”

“You have! The finger in the drink comes straight from Friends!”

“Nope, never seen it.”

“And wait, that bloody bandage one comes from that Mike Myers movie!”*

“Justin, I’m sure I don’t know what you’re talking about. Your bad taste is showing. Answer the damn question.”

So we spent our time like that, and I was grateful to Brian for making it just like we were spending time at home. Well, with considerably more clothes on. Also, obviously finger in the soda, Phoebe got a huge settlement in that one.

“Justin,” Dr. Bitonti said. “I would like to ask you a number of questions. I want to understand your history as well as assess your current symptoms and functioning. Some of the questions I ask may seem repetitive from last night, but I find it’s best if I ask them to you directly rather than rely on Dr. Lin’s notes.”

“Okay.”

“Let’s see, how would you describe your mood most days during the past few weeks or month?”

“My mood? Yeah pretty shitty, I guess.”

“And for how long would you say you’ve been feeling…ah, crappy?”

“I don’t know. I guess since I got back from LA. I was living there for work for a few months. So, I guess about six months.”

“And when you say,” he made big production of looking down at his notes, “‘shitty’ can you tell me more about that?”

“Well I guess I don’t feel much of anything. Like empty, blank.”

“Any periods of time when you feel elated? On top of the world?”

“No, not really.”

“And the things you used to enjoy?”

“I’m an artist and I can’t remember the last time I painted. I’ve always enjoyed going out with Brian and our friends, to bars or a club, but now I’m too tired to go out at night.”

“Brian’s your…”

“My boyfriend,” I smiled a bit remembering how he had used that term last night. For Brian, being out and proud will always trump not putting a label on our unconventional, undefined, non-relationship, which is totally a relationship.

“Boyfriend. And how long have the two of you been together?”

“Uhhh...” Good question. “Off and on since I’ve been 17.”

“I see in your chart that you were attacked at your prom. Brian was the partner who was there and accompanied you in the ambulance then? Or was that during one of those off times?”

“No, it was Brian.”

“Okay, I’m going to return to that experience in a bit. I’m going ask you a bit more about your depressive symptoms.”

“Okay.”

“Have you noticed any changes in your appetite?”

“Yeah, I’m not as hungry as I usually am. I can go the whole day without eating and not notice.”

“It looks like you’ve lost weight according to your chart.”

“Yeah.”

“And you mentioned difficulty sleeping. Is that falling asleep, staying asleep, waking earlier than usual, or a combination?”

“Um, falling asleep. And staying asleep. I get nightmares.”

“And when did the nightmares start?”

“After the…uh…after my prom.”

“Any changes to the frequency or intensity in the last…six months?”

“They’re more frequent. Usually when I’m home they’re pretty rare. But now they’re nearly every night. And I guess I’m not having trouble falling asleep; I’m trying to stay awake to avoid having another one.”

“So if you were to allow yourself to sleep, do you think you would be able to fall asleep?”

“I don’t know. I’m pretty tired all the time so maybe. I sleep a lot during the day, when I’m not working. Or just lay in bed.”

“Do you have nightmares during the day when you sleep?”

“Yeah.”

“Do you ever have periods when you feel a decreased need for sleep? You may not have gotten any more sleep than you have recently but you don’t feel tired, you feel full of energy?”

“No.”

“How is your concentration? Not just for work tasks, but other tasks like reading or watching a movie?”

“Pretty bad, I guess.”

“Any periods when you feel very focused, very driven to work towards a goal?”

“Not recently.”

“In the past?”

“Yeah, when I was working on the movie. I was pretty driven and focused.”

“Did others notice and comment that you were maybe hyper-focused or you could stand to take a break?”

“No, my hand makes me take breaks.”

“That’s from your injury?”

“The brain injury, yes.”

“And how about your patience? Do you find you’re more easily irritated with others?”

“Oh yeah, definitely.”

“How about your sex drive?”

“Um.” I could feel the blush taking over my face.

“Any changes?”

“Uh, I guess. Like I said, I’ve not been going out as much so that’s a change.”

“Going out is a part of your sex life?”

“Yeah. Um, that’s where I meet um…sexual partners. And also Brian and I…sometimes at the club…”

“You and Brian have sex at the club?”

“Yeah and at home too of course.”

“And the other sexual partners?”

“Yeah. That’s mostly at the club but at home too.”

“During the times you and Brian are off in your on-and-off relationship?”

“No…we’re open. We both, ah, trick? But I haven’t, as much recently.”

“I see. And your sex life with Brian aside from not having sex at the club as much now, has that changed?”

“Um, kind of? I, um, don’t initiate sex as much any more. But when he does, it’s the same. I mean, I feel the same.”

“And you are the more…the less dominant partner?”

“I bottom more if that’s what you’re asking.”

“So do you usually initiate sex?”

“Uh, yeah. We both do. Like 50-50 or at least it used to be.”

“Have you found yourself engaging in any impulsive or reckless behaviors such as overspending, driving recklessly, increased or reckless use of drugs or alcohol, or, um, more promiscuous sex?”

“No, none of those.”

“Can you tell me about your drug and alcohol use?”

“Sure. Um, I guess I have a drink most nights at home. More if I’m out.”

“Drinking to intoxication?”

“Yeah…”

“So 7 to…how many drinks per week?”

“Um, to, uh 21 or so. Rarely that many. I might have 3 or 4 if I’m out but I’m never out every night in a week.”

“Do you ever drive drunk?”

“No, never.”

“Have you ever behaved in ways you regret when you’re sober?”

“Not in years.”

“Years? How old were you when you started drinking?”

“16.”

“Have you ever blacked out?”

“Maybe once or twice, not recently.”

“Tell me about your drug use.”

“Uhh the only drugs I use regularly are pot, E, and poppers.”

“Poppers?”

“Amyl nitrite.”

“Ok. And how frequently do you use E or poppers?”

“When I’m out, so not recently. But I guess maybe a couple times a week, sometimes less.”

“And other drugs?”

“I’ve done coke a few times but not often. I’ve tried GHB. Nothing else.”

“Have you ever been hospitalized for alcohol or drug use?”

“No.”

“Have you ever made an attempt to cut back your alcohol or drug use but been unable?”

“No.”

“Have others ever expressed concern about your alcohol or drug use?”

“No.”

“Has alcohol or drug use ever interfered with your functioning at work?”

“I’ve called out from work due to a hangover, but not recently.”

“I want to ask you how you feel about yourself. Would you say you have good self-confidence?”

“Um, I guess not recently.”

“But you did?”

“Uh, I guess I’m a bit more hesitant than I was when I was younger. It was worse after the…after my prom, but it’s been a bit better. And I don’t know that anyone else noticed. I’m pretty good socially even if I don’t feel great or very sure of myself.”

“How about your sense of self-worth?”

“I’ve not been doing very much with myself. Just laying around doing nothing much. So yeah I would say I’m not worth very much.”

“Have you felt guilty for things that others have assured you you don’t need to feel guilty about?”

I flashed on Brian from the night before, “Yeah, I guess.”

“How do you feel about the future?”

“Not great. Unless something changes. I can’t imagine anyone will want to be around me like this, including Brian. And I haven’t been able to paint, it feels like my career is over before it even started. Fuck, I can’t even hold down my job at the diner.”

“Ok and the suicidal thoughts? Did these also start in the last six months?”

“Yeah.”

“And I see here that you have thought about stabbing yourself with a butcher knife? One that you own?”

“Yeah. I guess Brian owns it technically, but yes it’s in the loft where we live.”

“And you feel like you might act on these thoughts?”

“I don’t want to. I want to not want to act on them.”

“Good, that motivation for treatment will be helpful to you, Justin. Any idea what triggers these thoughts?”

“No. They just come to mind and I can’t get rid of them.”

“How frequently do you have them? Every day? Every hour? Every minute?”

“Not every hour but more than once a day…like a few hours a day, I’d guess?”

“And how long do they last fleeting seconds, minutes, hours?”

“Minutes to a hour?”

“And how intense are they? How difficult is it to think about something else?”

“Difficult, they’re pretty intense.”

“And how likely do you think you would be to act on them?”

“I don’t want to act on them. But I’m scared I will and that I won’t be able to stop myself.”

“Have you ever attempted suicide before?”

“No.”

“Have you ever hurt yourself on purpose but without suicidal intent?”

“Like cutting? No.”

“Dr. Lin indicated that you’ve also been having thoughts of harming others.”

“Kind of, I guess.”

“What do you mean?”

“I have these violent images of…of people I love, of them being hurt.”

“Of who being hurt?”

“…Brian…and Gus,” I whispered.

“Who’s Gus?”

“Brian’s son.”

“His son? How old is he?”

“Four.”

“Can you describe these images?”

“They’re…they’re stabbed, or…decapitated…just really bloody.”

“Stabbed or decapitated…with the same butcher’s knife?”

“Yeah…I guess so.”

“Why do you want to hurt them?”

“I don’t!”

…

“I mean, I think I don’t. I don’t know. Why would I be thinking about these things if I didn’t, on some level want them to occur. That’s how the subconscious works, right?”

“To a certain extent…yes. Do you feel threatened by Brian’s love for Gus?”

“What? No! I love Gus, I named him. I’ve always encouraged Brian to have a relationship with him. He only intended to be a sperm donor, a cameo appearance in Gus’s life. But I pushed him to be more involved. I can’t think of anyone I love more than Brian and Gus…they’re…they’re my family.”

“Does that love scare you?”

“Scare me? I…I don’t know. I guess sometimes I’m surprised when Brian shows that he does care about me. He’s…not great with expressing his feelings, has all these walls up, you know?”

“You’re afraid he might feel overwhelmed by your relationship?”

“Yeah, I guess so. He could push me out, if he thought it was best for me. Whether or not I agreed.”

“And what about your biological family?”

“Well, my dad kicked me out when I was 17. When he found out I’m gay.”

“Right around the time you met Brian?”

“Right after, yes. He hated Brian. Tried to kill him, hurt him.”

“Kill him?”

“He rear-ended Brian’s Jeep, on purpose. He punched him on another occasion. He made me choose between being gay, being with Brian, and living at home.”

“So he forced you to leave your family home. Where did you go?”

“I lived with Brian and then Debbie - she’s the mother of Brian’s best friend and kind of a mother to all the gay boys - and then after I was bashed, with my mom for a bit. She and my dad divorced after he kicked me out. And then Brian again.”

“So your dad essentially disowned you and you left to be with a much older lover…someone who looks out for your best interest, even when that means upsetting you. Much like a parent. You’re afraid of losing his love, just like you lost your father’s love. Afraid of losing his love over something you can’t predict, all of a sudden, just like your dad reacted to your coming out. You feel vulnerable to losing this incredibly significant relationship. To losing one of the only stable homes you’ve known since you were 17. Anger, violence can be a way of protecting ourselves from vulnerable emotions such as fear.”

“Huh. Uh, I guess.”

“And your mother? What’s your relationship like with her?”

“It took her a little while but she’s supportive. She tries to help as much as she can - my dad cut me off financially, he refused to pay for PIFA. She wanted to help but she doesn’t have enough, she still has my younger sister to consider.”

“Any violent ideations about your mother or any women in your life?”

“No.”

“Have you ever been physically violent before?”

“I tried to fight back when I was being attacked in high school…”

“Any time that wasn’t in self-defense.”

“No…”

…

“Oh, wait. Yeah…”

“When was that?”

“Um, a year…maybe more…ago?”

“What happened?”

“Well there was a bashing - a drag queen I know was beat up. And there were a bunch of queers who wanted to fight back, not just lobby politicians hoping they will change things. Uh, so they formed this group to fight back. And then some of them decided it was a good idea to, uh, bait straight people.”

“Bait them?”

“To make out in front of them and then fight when they made homophobic comments.”

“So you fought homophobes?”

“Yes…and…”

“And…”

“I confronted my attacker. The kid who bashed me. He struck a deal and got off with community service. He was never punished!”

“That must have been enraging. You suffered permanent injury, and his life was hardly disrupted. So how did you confront him?”

“One of the guys in the Pink Posse, uh, that’s what we called ourselves. He had a gun. And we went to Chris’s house when he was coming home from work. And, uh…I stuck the gun in his mouth. To scare him only! I just wanted him to feel what I felt.”

“So you threatened him with a gun?”

“Yeah…yeah.”

“And was that satisfying?”

“A little…not much.”

“Do you have any other history of violence or violent threats?”

“No…no, that’s it. That’s enough, I guess, huh?” I huffed a bitter laugh. I’ve obviously proven myself capable of the type of violence that’s invading my thoughts. God, I’m a monster.

“Mmm. If you don’t mind, I would like to shift now and talk a bit more about being attacked and the symptoms that have followed this trauma.”

“Okay.”

“The nightmares…they’re about your…prom?”

“Well, the bashing, yes. I can’t remember the other parts.”

“But you remember the attack?”

“Some of it.”

“In addition to the nightmares, do you ever have flashbacks?”

“I have. I first remembered the attack in a flashback.”

“Did anything trigger it?”

“Yeah, seeing Gus play with a plastic baseball bat at his first birthday.”

“Hmmm. Any other flashbacks?”

“Very rarely. I try to avoid baseball bats or anything that might trigger one.”

“Were you around baseball bats a lot? Has avoiding them had a significant impact on your life?”

“Well no, I haven’t been to a baseball game since I was little and I went with my dad.”

“What else do you avoid?”

“Sometimes crowds make me anxious. It took me a while to feel comfortable walking down the sidewalk, even.”

“How do you feel when you’re anxious?”

“Uh, jumpy?”

“More easily startled?”

“Yes.”

“Do you notice that you are particularly observant of your surroundings? More so than others? We called this ‘hypervigilance.’”

“Yes…I feel on guard a lot.”

“Any panic attacks?”

“Yes.”

“Any difficulty trusting others? Trusting the world to be a safe place?”

“Yeah…I guess I don’t see the world as safe as before I was bashed. But I think that’s realistic. I think I was a naive, idealistic kid before. And sure, I’m cautious about opening up to people now. But it’s not just the bashing. People lie to get what they want. They’ll pretend to care and then betray you.”

“Is that something that happened?”

“Yeah…a guy I dated when Brian and I were broken up for a bit cheated on me.” If that’s not the most simplified version of what happened, I don’t know what is.

“Where did you live when you were broken up? With this Debbie?”

“No, I lived with Eth- the guy I was dating. When we broke up, I lived with my best friend. Brian asked me to move back in just before I left for LA. I moved in with him again when I got back.”

“You’ve really bounced around, huh? Does any place really feel like home?”

“The loft - Brian’s place. I guess. But it’s definitely his place. Debbie’s is homey…but not home. Huh. I guess not.”

“It must be hard to feel settled and secure, then. Especially given what you’ve said about feeling fearful that Brian could decide that being apart is what’s best for you.”

“Yeah.”

…

“Although…”

“Yes?”

“He did ask me to move in. He shows he cares about me. The freedom he gives me - like to go to LA to pursue working on the movie. That’s how he shows me. It used to be easier, you know? Before the bashing. It took us a while, to realize that, that I used to be better at understanding how he communicated, that I needed words more than I did.”

“So one of the difficulties you’ve had since the bashing is finding non-verbal communication more challenging to understand?”

“Yes.”

“It makes sense that the world seems like a scarier and more unpredictable place. What have been other negative consequences?”

“My hand.”

“Your hand? Oh right, you mentioned it forces you to take breaks from your art.”

“The brain injury - it damaged my motor cortex. My hand cramps up, it’s weaker than it was. It makes drawing harder.”

“And you’re an artist.”

“Yes…there’s something almost poetic about that huh?”

“Hmmm. The motor cortex is close to the prefrontal cortex. That’s where our executive functioning, our abstract thought, takes place. It makes sense that some non-verbal communication, social cues, may be more difficult if there’s also been some damage to the pre-frontal cortex. It may also feel like your personality has changed since the trauma. Some of that may be PTSD symptoms, but some may be due to your brain injury.”

“Oh…huh. Fuck.”

“Any other experiences that you’ve had that you would describe as traumatic?”

…

“I, um, I was almost raped once…is that what you mean by traumatic?”

“Yes, yes it is. Can you tell me what happened?”

“I was working as a dancer at a club…”

“A gay club?”

“Yes. I was trying to earn money to pay for my tuition. But I was falling behind in my classes. And the owner of the club promised to let me have the weekend off if I came to his party to be ‘decoration.’ He was this gross older guy but I figured it was worth it - I had a project due. So I went. He gave me drugs. I took them willingly. Although I think my drink was drugged too. Then he tried to get me into a, um, sex swing? All these guys at the party were commenting about how they couldn’t wait to have me. But I got away. I kicked the guy - my boss - in the teeth and took off.”

“I’m glad you were able to get away. That’s an incredibly scary situation. Are there any changes in your life that you track back to this experience? Like how you might avoid crowds since the bashing?”

“Um…I avoid parties hosted by creepy old guys?”

…

“No, not really. I guess I have just tried to not think about it since then.”

“Justin, I’m going to ask you some questions to rule out other conditions. Do you feel bothered by obsessions or compulsive behaviors?”

“I’m not obsessed with anything. Can you explain what you mean by compulsive behaviors?”

“Like washing your hands repeatedly or longer necessary. Or like checking locks or making sure the stove is turned off.”

“Well, I check the door to the loft and the alarm all the time. But that’s because I might have forgotten to set the alarm one time and Brian was robbed.”

“Might have?”

“Yeah I couldn’t remember if I had or not. I just never want to be responsible for something like that again.”

“So other than checking the loft door and alarm, any other checking behaviors?”

“No, not that I can think of.”

“Okay, any experiences of seeing or hearing things that others do not?”

“What? No.”

“Okay…is there anything I haven’t asked you about that you think would be helpful for me to know?”

“Um, no. You’ve been pretty thorough.”

“After meeting with you, I concur with Dr. Lin’s diagnosis of PTSD and Major Depressive Disorder, recurrent, severe. Do you have any questions about those diagnoses?"

“Yeah - why severe?”

“Well that’s determined by a number of things. For you, not only the presence of the suicidal and violent thoughts, but also their frequency, intensity, and duration. Further, the level of impact on your daily functioning - you are having difficulty with attendance at work and with engaging with your typical activities with your friends.”

“Oh. Okay. So how do I fix it?”

“Good question, good segue. I would like to discuss the treatment plan I recommend. We know many emotional concerns, severe depression especially, respond well to a combination of medication and psychotherapy. I would like to start you on an antidepressant - Lexapro, which is a daily medication. Lexapro often benefits anxiety as well. One of the side effects can be fatigue, so I’m hoping it will help with your disrupted sleep, and I recommend you take it at night. It can take up to a month to see how you respond to Lexapro. I will keep you on the Trazadone, since you responded well to it, until your sleep schedule is regulated. This is a fairly safe medication but one side effect can be nightmares. Please let me know if your nightmares worsen, and we’ll try something else. I am also going to prescribe an anti-anxiety medication. This is a PRN or take as needed medication - to be taken when you are feeling panicked. Much like you would take aspirin for a headache. The class of medications - benzodiazepines - does come with risk for addiction. I am prescribing Ativan, the medication with the least risk for addiction. I know you drink, Justin, which is fine. But do not take Ativan if you have been drinking and do not drink if you have taken Ativan. The combination can be lethal. Overall, I am not concerned with your level of substance use, however I advise against taking ecstasy since it interferes with the serotonin in your brain and withdrawal from the drug can cause or worsen depression.”

“So together, you think these medications will help me?”

“Together with psychotherapy, yes.”

“Will I have to take them for the rest of my life?”

“Let’s not get ahead of ourselves. Let’s first see if this is a combination of medications that work for you. It can take some time, some experimenting, to determine the best medications for each person. It’s an art as much as a science. Once you find medications that work and have achieved some stability, then you and your doctor can discuss whether it makes sense to taper off of them. I would recommend, once you find a combination of meds that work, you remain on them for at least a year.”

“Huh. Ok. Um, you mentioned therapy?”

“Yes. Medications can be useful, but therapy is where you can learn new ways of coping and gain valuable insight. You will begin with at least group therapy while you’re here at the hospital. We can also begin to explore your options for meeting with an individual therapist.”

“How long am I going to be here? At the hospital?”

“Until we determine you are no longer a risk to yourself or others. Also, given your many allergies, I’m glad we will have you start on medications under medical supervision.”

…

“Justin, does Brian know about the content of your violent ideations? Dr. Lin got the impression he hadn’t been aware you were having violent ideations at all.”

“No! God no. You won’t tell him, will you? You can’t, right?”

“Everything we discuss is confidential, Justin, but there are some exceptions. One of those is that if you are at risk of hurting or killing someone else, we have an obligation to warn that person and the police. While you’re here in the hospital, you are not a risk to yourself or anyone else. We want to be sure that you aren’t a risk when you are released either.”

“But I don’t want to want to hurt them! I don’t!”

“I know Justin, I know you care for them both. But with your history of violence, we want to be especially careful. I hope through some of the therapy you will receive during your time here, you can begin to understand these urges and learn other ways of coping.”

“But if I…if I weren’t here, in the hospital, you would have to tell Brian…and Gus’s moms?”

“Yes, that’s why you’re here….But Justin? Something we may want to talk about is whether it makes sense to talk to Brian. To tell him about your violent thoughts - in an environment and a way that you can control it.”

…