Notes:
This is the final chapter of 'In Confidence.' Not surprisingly, it took me longer to write the last two chapters than the others; endings are hard for me, too, especially when I'm working on a story that is as satisfying as this one has been.
Thank you to everyone who has commented on this work. I have been astounded by the interest in Sherlock and psychopathology and have enjoyed every question you have posed to me and comment that you have left. It has been so, so meanginful to write a story that is based on topics so close to my heart - psychopathology and healing - and to engage in so many interesting conversations as a result of it!
In particular, thank you to roane and shimi for your beta work. And thank you to SherlockScarf for your cover art - I am honored that you would choose my story to create a cover.
~Emma
Chapter Text
From: Carola Rivas rivas .uk
Date: Fri, 28 June 2002 at 12:02
Subject: SH discharge summary
To: Dr Mariah Franklin director .uk
Mariah:
I've finished the treatment summary for SH and am sending you the draft so you can add your parts to it.
I'll be interested to hear how the final meeting with him goes.
When can you send me your additions?
~Carola
From: Dr Mariah Franklin director .uk
Date: Monday, 1 July 2002 at 9:33
Subject: Re: SH discharge summary
To: Carola Rivas rivas .uk
Carola:
Just met with SH.
I'll send you my edits later this afternoon.
Interesting meeting. He agrees to continue with methadone but said that he doesn't want to take antidepressants because of sexual SEs. Possible secondary gain from methadone? We should make note of this when we make his London referral. I told him he could choose from Bethlem, Barts, or Maudsley; one of those is sure to meet his exacting standards. Will send out referral notice before the end of the day.
~MF
From: Carola Rivas rivas .uk
Date: Monday, 1 July 2002 at 11:16
Subject: Re: Re: SH discharge summary
To: Dr Mariah Franklin director .uk
Mariah:
According to self-report, his 'drug of choice' is cocaine. I am more concerned about him returning to cocaine than about the therapeutic use of opioids. He has told me that he doesn't want to 'depend on drugs' anymore and his compliance to methadone has been appropriate to do. But – he is moving to Edinburgh for the next few months, so we should find a psych hospital to make a referral to there. Do you still have contacts at the Royal Edinburgh?
~Carola
From: Dr Mariah Franklin director .uk
Date: Monday, 1 July 2002 at 15:33
Subject: SH discharge summary attached
To: Carola Rivas rivas .uk
Carola:
I know a trauma specialist at Royal E. He might be a good choice for SH. Will add that to the list.
Attached you will find the discharge summary with my additions. Please review, sign, and leave in my mailbox.
SH signed consent for his treatment records to be used for training purposes. Please send the therapy tapes to Hugh for transcription.
Thanks,
Mariah
Discharge Summary
Patient: Sherlock Holmes
Individual psychotherapist: Carola Rivas, PhD
Psychiatrist: Mariah Franklin, MB BChir, MRCP
DOB: 19.7.1976
Age: 25
Date of admission: 27.5.2002
Date of discharge: 1.7.2002
Reason for Referral
Mr Holmes was admitted to dual diagnosis unit 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. Mr Holmes had a history of cocaine and opioid dependence and presented with symptoms of a mood disorder, including insomnia, lack of appetite, anhedonia, diminished interest in hobbies and interests, agitation, Global Assessment of Functioning (GAF) 40 at admission. Major impairment in multiple areas: social, occupational, family. Some danger of hurting self or others.
Treatment Received
Mr Holmes to be discharged Monday, 1 July 2002, following 36 days of residential treatment for cocaine and opioid dependence. Patient attended 14 sessions of individual psychotherapy with Carola Rivas, PhD. He attended 15 sessions of the Social Skills Building Group with Shavani Gupta, PhD. Mr Holmes met with psychiatrist Mariah Franklin on 8 occasions for psychopharmacological management. Methadone therapy began on 30.5.2002 at 30mg/day and was well tolerated by the patient. Methadone was titrated up to 100mg/day by 10.6.2002 without adverse effects. Patient was prescribed continued methadone treatment after discharge and agreed to attend follow-up appointments in London. Referrals were made to methadone clinics at Bethlem, Maudsley, and St Barts in London, and the Royal Edinburgh Hospital in Edinburgh. The psychiatrist discussed with the patient the advantages and disadvantages of prescribing an antidepressant for his symptoms of depression. The patient expressed a concern about the sexual side effects of SSRIs and opted to not begin antidepressants at present.
Treatment Goals and Objectives: Summary
1. Goal 1: Pt will reduce dependence on heroin and cocaine.
Pt will adhere to methadone maintenance therapy as directed by his psychiatrist. Patient has achieved this goal. Blood tests and urinanalysis confirm that patient is not using illicit substances and patient is adherent to methadone maintenance therapy.Pt will identify triggers for substance use. Patient is working towards this goal. SH acknowledged that he began to use substances (nicotine) after his mother's death. Patient acknowledged a relationship between his cocaine use and the initiation of sexual relationships.Pt will create sobriety plan for after discharge. Patient has achieved this goal. Patient has expressed the intention to continue receiving methadone treatment in London and has been provided with the appropriate referrals. Patient acknowledges the importance of not returning immediately to environments that he associates with drugs and has arranged to stay with a cousin in Edinburgh for a few months following discharge.Pt will attend scheduled appointments following discharge. Patient has not yet achieved this goal. Patient has not been discharged.
2. Goal 2: Pt will report fewer mood symptoms.
Pt will use words to describe his mood state. Patient is making progress towards goal. Patient has shown improvement in being able to name and discuss his emotions.Pt will identify activities that bring him pleasure. Patient has achieved this goal. Patient reported enjoying the following activities: reading scientific journals (esp. chemistry, forensics, and psychology); playing the violin; solving crimes; and taking strolls through London.Pt will engage in pleasurable activities on a daily basis. Patient achieved this goal. SH reports playing his violin and reading books and articles on a daily basis, activities which he appears to enjoy.
3. Goal 3: Staff will report improved social functioning of SH at Blakely House.
Pt will attend Social Skills Group and adhere to group rules. Partial achievement of goal. Pt has shown moderate improvement in behaviour in the Social Skills group. He has participated willingly in group activities such as: letter-writing, sharing of personal histories, and giving compliments to others. After an early altercation with another group member, SH has demonstrated some improvement in his relationships with others. For example, he is able to engage in reciprocal, appropriate conversations with others. However, the pt continues to make inappropriate facial gestures when listening to certain members of the group. He has also been vocal about his dislike of the group and his resentment at having to participate. [Signed Shavani Gupta]Pt will obey Blakely House rules regarding behaviour towards others. Partial achievement of goal. Patient entered areas that were forbidden to him (ex.: other patients' rooms, the clinic waiting room) despite repeated admonitions to keep within certain bounds. However, patient followed other clinic rules without incident.Pt will use psychotherapy to talk about social and family relationships. Patient achieved this goal. Patient is well-related to the therapist and showed an increasing willingness to discuss personal issues in therapy, including relationships with his parents, brother, cousin, and romantic partners.
Narrative Summary of Progress and Recommendation
A witty and combative conversationalist, Mr Holmes showed initial reluctance to participate in psychotherapy but later appeared to enjoy the therapist's attention and regard. Over the five weeks that he was in treatment, he made considerable progress in his ability to tolerate painful affective states. He used psychotherapy to talk about incidents of childhood trauma, such as the death of his mother when he was 12yo and being discovered in a sexual act with another boy when he was 11yo. Mr Holmes described the events surrounding his mother's death in detail, including the reactions from his father and brother, and was able to accept that he had not received the support that he should have received to deal with his grief as a child. Pt harbours resentment towards his older brother for his perceived abandonment of SH following their mother's death, but appears willing to resume communication with him following discharge. Mr Holmes was able to identify figures who had modelled loving acceptance in his childhood, such as his Spanish grandmother and his female cousin, Georgina, with whom he will be staying once he is discharged. There was mild improvement in the patient's peripheral neuropathy; however, the patient understands that improvement in symptoms may take several years. He recognizes that further drug use will likely worsen his neuropathy and may lead to permanent impairment in fine motor skills. Mood symptoms continue to affect the patient's quality-of-life. Mr Holmes meets the following criteria for dysthymia: depressed mood most of the day, for more days than not, for at least two years; and presence of poor appetite, insomnia, low self-esteem, and feelings of hopelessness, not due to the direct physiological effects of a substance, and causing clinically significant distress in social and occupational functioning. It was recommended that Mr Holmes commence antidepressant therapy following discharge; the patient has expressed a preference to not 'depend on drugs' once his methadone therapy is terminated. Mr Holmes described his vocational goal of becoming a 'consulting detective' and stated an intention to contact the Metropolitan Police of London following discharge in order to apply for a position.
Diagnostic Impressions at Termination
Axis I: Cocaine Withdrawal, Opioid Withdrawal [292.0]; Dysthymic Disorder [300.4]; 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: 55. Moderate difficulty in social and occupational functioning. Moderate mood symptoms.
Signature of Psychologist
Carola Rivas, PhD
1 July 02
Signature of Psychiatrist
Mariah Franklin, MB BChir, MRCP
1.7.02