Installment #11
iii
On the first day of the summer session, Fugue will find he has five
children assigned to his class, three boys and two girls.
Lance is a lanky 14-year-old boy with sandy hair, hooded brown eyes and a
perpetual scowl on his face. Lance finally managed to burn down his school
after repeatedly setting fires in wastebaskets. He has been in ASP since
January, when---in a reading class where Fugue just happened to be
substituting for the day---he jumped up and, without warning, punched
another child at the base of the skull. Lance refuses to carry a PEM sheet,
but if he did it would be blue; Lance is unable to accept negative points
without flying into an explosive rage. He is invariably on "Special
Precautions," which means a male Therapy Aide accompanies him
throughout the school day and is always close by.
Lance has three Axis I, or primary, diagnoses: Attention Deficit
Hyperactive Disorder; Disthymic Disorder---chronic depressive or irritable
mood; Conduct Disorder.
He has an Axis II, or underlying, diagnosis of Expressive Language
Disorder---an inability to express feelings and function academically.
There are no medical complications noted on Axis III.
Psychosocial Stressors noted on Axis IV include the recent death of his
stepfather, his mother's injury in a car accident, and an impending court
hearing at which the judge, after studying a report written by Little Ark
psychiatrists, will determine whether Lance will be transferred to a DFY
cell or remain at the hospital.
His Axis V Global Assessment indicates that his ability to function in any
social setting is severely impaired, and has been for the past year.
Lance's contract states that he was placed in ASP because he was assaulting
others, frequently had to be restrained, and refused to follow
instructions.
Lance has four clinical options---excusing himself from the classroom to
avoid conflict; drawing, at which he is quite talented; playing a game;
asking permission to talk to a therapist.
In order to reenter the regular program, Lance must learn to avoid
conflict, be able to "take time out" before losing control,
express his feelings calmly, and follow directions without losing his
temper. He must get off Special Precautions, require no more than four CIT
interventions in the space of two weeks, be able to carry a PEM sheet, and
achieve a B level.
Helma is 17 years old, short and pudgy, extremely bright, and suicidal.
Although both her wrists are heavily scarred from past, self-inflicted
slashings, she is primarily an "eater," compulsively consuming
pens, paper clips, pins and even batteries in a habitual pattern of
self-abuse. As a child she was repeatedly sexually abused by her father,
who subsequently abandoned the family. She has been in and out of mental
hospitals all her life, and this is her third hospitalization at Little
Ark. Helma is generally disliked by teachers and Therapy Aides, who
consider her a manipulator and instigator of her peers, and despised by the
other children, who likewise label her a troublemaker. In the past her
mother has been supportive, calling Helma frequently and visiting her once
a week during all her hospitalizations. However, of late her mother has
shown signs of drawing away, and this has been extremely disturbing to
Helma.
Helma will turn 18 in three months, and will then have to leave Little Ark.
She knows her mother will not allow her to live at home, and she
desperately hopes to qualify for placement in a "halfway house"
or lightly supervised adult residential center where she can live
semi-independently. The alternative, if she is unable to bring her
self-destructive urges under control, will be involuntary hospitalization
in an adult psychiatric facility, most likely Big Ark. Helma finds this
prospect extremely troubling, for she is aware that her life in Big Ark
would be considerably different---sparer, constantly adrift in a sour mist
created by heavy doses of psychotropic drugs to control her---from what she
has experienced in any of the children's hospitals she has been in.
Helma's Axis I diagnosis is Disthymia with Major Depression.
Her Axis II diagnosis is Borderline Personality Traits, which may include a
pattern of unstable interpersonal relationships, impulsiveness, depression,
irritability, anxiety, suicidal gestures, and self-mutilation.
It is noted on Axis III that Helma is subject to epileptic seizures and is
allergic to bee stings.
The major Psychosocial Stressor noted on Axis IV is the continued
distancing of the mother, who now refuses to see Helma at all, or even talk
to her on the telephone.
Helma's Global Assessment on Axis V indicates that she is more functional
than she has been in the past, and her therapists believe there is at least
an even chance that she can be successfully placed in a halfway house.
Helma's contract states that she has been transferred to ASP because of
continual self-abuse.
Her clinical options include talking to the staff, writing down her
feelings, and asking for extra medication.
In order to return to the regular program, Helma must express her feelings,
follow instructions, and maintain an A level for two weeks with no
self-abusive behavior.
Roy is a 14-year-old boy who looks 10 years old and acts like 7. Roy is
experiencing his third hospitalization, and this time the precipitating
event was his attempt to strangle a classmate on the school bus. Badly
abused by his father, who abandoned the family, and repeatedly raped by his
uncle, Roy is considered homicidal. His ongoing fantasy, one of the few
feelings he freely expresses, is to get out of the hospital so that he can
find and kill both his father and uncle. He has a desperate, unquenchable
need for attention, and he cannot abide a teacher spending time with
another child unless he is being attended to by a second teacher or Therapy
Aide. He is very attached to John Marsden, and Fugue is curious as to how
Roy will react to Marsden's absence over the summer.
Roy has an Axis I diagnosis of Asperger's Disorder, a freshly coded mental
malady vaguely linked to autism and characterized by an almost total,
sociopathic insensitivity to the feelings and needs of others as well as an
inability to form peer relationships. He has a second Axis I diagnosis of
Attention Deficit Hyperactivity Disorder, or ADHD.
He has no Axis II entries.
On Axis III it is noted that Roy is prone to seizures.
Psychosocial Stressors listed on Axis IV are Roy's homicidal
"ideations," the fact that he has no friends, and the recent
awakening of fierce sexual desire that frightens and confuses him, since he
has no idea how to cope with these feelings.
His Global Assessment is very poor, reflecting his almost total inability
to function except with the attention and help of an adult working with him
on a one to one level.
Roy's contract states that he has been transferred to ASP because of
assaultive behavior and inability to follow directions.
His clinical options include taking time out, expressing his feelings in
writing, and requesting additional medication---but pointedly not talking
to staff or asking that his therapist be called, because Roy will attempt
to exercise these options constantly if afforded the opportunity.
In order to return to the regular program, Roy must learn to accept
"no" for an answer, follow directions, and go for one week
without the need for CIT intervention.
Adam is 15 years old, stocky, darkly handsome, and very dangerous. As with
Lance, Fugue has met Adam before, during the regular school year when Fugue
was substituting for a social studies teacher. At that time Adam taught
Fugue what Fugue considers a valuable lesson.
With barely fifteen minutes left in the school day, Adam had raised his
hand and politely told Fugue that he "wasn't feeling good." Fugue
had asked him if he wanted to go to the crisis room, and Adam had declined.
Fugue had suggested that Adam go to the back of the room and "take
time out," but Adam had also declined this clinical option. After
trying and failing to reach the boy's therapist on the telephone, Fugue had
pointed out to Adam that there were now only five minutes remaining before
he went back to the cottage, and surely he could hold out that long. Adam's
response had been to abruptly leap to his feet, pick up a desk and send it
sailing across the room, narrowly missing the heads of three students, to
bounce off the reinforced Plexiglas of one of the classroom windows. Then
he picked up another desk and did the same thing. Fugue had immediately
called a "five-second-drill," allowing each of the other students
to earn two hundred points for clearing out of the room as quickly as
possible and going to the closest room or office. Adam had just finished
trashing the entire room when the CIT, alerted by one of the students who
had fled, arrived, took Adam down, administered a shot of Thorazine and
carried him back to his cottage strapped to a stretcher and screaming.
Now Fugue listens very carefully when Adam tells him he "isn't feeling
good."
Adam has Axis I diagnoses of Explosive Disorder and Conduct Disorder,
Solitary Aggressive Type.
His Axis II diagnosis is Borderline Personality Disorder.
There are no medical conditions listed on Axis III.
The Axis IV Psychosocial Stressors include the fact that Adam is an orphan
who has been put up for adoption on a number of occasions, but his frequent
hospitalizations have always interfered with the adoption process.
Currently there is a stable, and by all accounts loving, family that has
expressed interest in adopting Adam, but that is now having serious second
thoughts due to his continued violent behavior and their understandable
concern that Adam could pose a threat to their two younger children. Adam
desperately wants to be able to leave the hospital and join the family, but
he simply cannot control his violent outbursts. Thus far his psychiatrists
have not been able to find the proper mix and dosage of drugs to help him;
if he is given enough Thorazine or other tranquilizer to keep him from
exploding, he becomes almost comatose, unable to stay awake for any length
of time. The search for an effective medication protocol for Adam
continues.
His Axis V global assessment is ambiguous, indicating that he can and does
function at an acceptable level when his medication is working.
Adam's contract stipulates simply that he has been placed in ASP because he
cannot control his explosive behavior.
His clinical options are taking time out and asking for additional
medication. Also, he may walk in the corridor outside the classrooms for as
long as he feels he needs to in order to bring himself under control.
He may return to the regular program when he has maintained a Level A or B
for two weeks with no violent outbursts.
Jessica is a 13-year-old, attractive Hispanic girl who has been transferred
to ASP because of her explosive behavior and her unfortunate and highly
annoying habit of sleeping all day, and then wandering through her cottage
at night screaming obscenities and slamming doors until she has to be taken
down and heavily sedated, the result being that she sleeps all the next
day, and then spends the next night wandering the cottage, screaming
obscenities and slamming doors.
Jessica and Helma reportedly cannot stand the sight of each other. Along
with Helma, Jessica is the bane of the Therapy Aides' existence. Jessica
has a serious language disorder, and her speech is virtually unintelligible
except when she clearly articulates the words "shit," "fuck
you," "cocksucker," and "asshole," expressions
which easily and frequently trip off her otherwise thick tongue.
Jessica is diagnosed on Axis I as suffering from Schizophrenic Affective
Disorder, meaning that she frequently hears voices and is out of touch with
reality, but not for sufficient durations of time to warrant a diagnosis of
full-blown schizophrenia. She is also diagnosed on this axis as suffering
the more common Oppositional Defiant Disorder.
Her Axis II diagnosis is Borderline IQ, or mental retardation.
There are no medical conditions cited on Axis III.
Axis IV Psychosocial Stressors include the recent death of her sister.
Her Axis V global assessment indicates that Jessica barely functions at
all.
Jessica has no contract; her therapists assume that she will be in ASP for
as long as she is in Little Ark.
Then there is Pedro. Pedro is not on Fugue's, or any other teacher's,
roster, but Fugue is very interested in the boy. Pedro does not attend
school, and he requires the ultimate in Special Precautions; sleeping most
of the time because of heavy medication, he spends his days on the ICU
cottage in almost perpetual four-point-restraint, his wrists and ankles
strapped to a bed, a male aide sitting in a chair at his side keeping an
eye on him.
In layman's terms, Pedro is simply a raging lunatic, with Axis I diagnoses
of Psychotic Disorder and Conduct Disorder. It is not anticipated that
Pedro can ever attend classes, not even in ASP, for he is simply too
dangerous. He will remain at Little Ark until such time as the doctors find
a suitable mixture and dosage of psychotropic drugs that will leave him
with a modicum of awareness and consciousness but which will also allow him
to be controlled without restraints. He was transferred to Little Ark for
observation and treatment from a DFY facility, where he was serving time
for carrying a concealed weapon, after sneaking up behind a physician and
punching him at the base of the skull. At Little Ark he almost killed a
male aide, again sneaking up behind the man, this time attempting to
strangle his intended victim with a towel. The aide survived only because
he kicked over a table as he was being pulled backward and this alerted
other aides in another part of the cottage who subsequently came to his
rescue. The aide spent two weeks in a hospital suffering from a severely
bruised larynx.
During the regular school year, while checking records on ICU, Fugue has
caught glimpses of Pedro. A tall, emaciated-looking Hispanic, Pedro's
appearance, at least to Fugue, seemed to belie his fearsome reputation and
obvious capacity for deadly violence. Fugue had wanted to try to work with
Pedro after school hours, on the cottage, but when he'd approached
psychiatrists and Therapy Aides with this suggestion they'd thought he was
joking.
Damaged himself, Fugue related well with other wounded people. Dorothy
Evers, now his boss, one of the many wounded women who had fallen into his
life, knew this about him. Indeed, he believed that Dorothy knew him better
than anyone. She understood his dark engine, the pain, stress, compulsion
and obsessions that were the fountainhead of his art. She considered him
quite mad, and he suspected she was right.
Fugue often tells his students, only half-joking, that he is as crazy as
they are, and probably crazier than most. The reason that he has keys to
the hospital's locked doors and they don't is that he doesn't let his
craziness interfere with his taking care of the business of everyday life.
Fugue tells them that there is nothing wrong in itself with craziness---as
long as the crazy person takes care of business. There are areas in every
major city that are stocked with a high percentage of "crazy"
people---artists, eccentrics, those who reject a "normal"
lifestyle. But these people go about their business, paying their bills,
fighting their pain and confusion, sometimes even creating something out of
their turmoil. When they learn to take care of business, Fugue tells his
students, when they learn not to harm themselves or others, when they learn
not to break the law and when they learn to consistently get up in the
morning and go off to school or work, then it won't matter if they're
crazy; they will lose their coded diagnoses when they find their lives. If
they learn to take care of business, they can be as crazy as they please
while pursuing their dreams, whatever they may be. You eat life, he says,
or life eats you.
Fugue does not want to be at Little Ark. He would much rather be home,
commuting from his bedroom to his kitchen to make coffee, and then to his
office across the hall to write his novels and short stories, the work that
has provided his living for the past eleven years, for four years before he
went to work at Little Ark for the first time, and for two years after he
had abandoned his teaching career to write full time and before he had gone
to work as a night security guard. But if he has to take a regular job to
earn money, and he does, then Little Ark is where he wants to be. Besides
relating well with broken children, even the sickest and most dangerous of
them, he knows he is a very good teacher. Dorothy also knows this about
him, which is why she asked him to take charge of ASP during the summer in
the first place.
