The Footsteps

Patient information

Name: Jacob Wall

Profession: Project Manager

Age: 39

Clinician information

Name: Dr. Andrea Frickman

Type of Treatment: Individual Therapy

Registration number: 0897392-X4

PROGRESS REPORT

Patient report of symptoms/behaviors

Jacob seems unaware of his disconnect from reality and expressed stress and frustration at my reactions in our session today. 

Jacob still expresses sadness over his recent divorce but says he has moments of cautious optimism about the future, which was not the case at our last session. He described walking his dog Moko and enjoying fresh sunshine and the “crisp winter air.” 

Session notes

Today was an interesting one with Jacob, I have to say. He usually presents as very coherent, but this session he displayed signs of aggression, social deregulation, and a disconnect from reality. I’m recommending we put him on 0.5 milligrams of clozapine and monitor him closely for the next 24 to 72 hours. 

The session began normally. Jacob was around five minutes late when he came into my office with Moko. This is routine behavior for Jacob; he has expressed difficulty with motivation and getting out of bed since his divorce. In past sessions, he often credited Moko with being the only reason he went anywhere at all. We have been working on Jacob’s feelings of hopelessness with a combination of cognitive exercises and behavioral therapy. 

Today was different. Jacob’s face was flushed when he entered my office, and his pupils appeared slightly dilated. He looked agitated, but I was able to convince him to sit down. 

“What’s going on?” He didn’t answer me immediately. I gave him a glass of water and handed him the box of tissues I keep on my desk. He wiped his face. 

“None of this is real.” He gestured at the window, with its layer of bright white snow clumped an inch high on the ledge outside, then the sunshine streaming into the office, the couch, the walls, my desk. “None of it,” he repeated. 

What a statement to start our session with, don’t you think? I tried to probe a bit further. “Why don’t we backtrack a bit. What’s wrong?” 

He calmed down a little then, but only slightly. I gestured to the couch, and he sat on the left side furthest from my armchair. It’s funny, the uncomfortable patients always sit on the left side. The relaxed ones sit on the right, straight across from me. I wonder if it’s a conscious decision, or if it’s their fight-flight reflex kicking in? (Note: research recent papers written on spatial positioning in therapy as a possible topic for further study). 

Anyway, Jacob calmed down a bit and sat down on the couch, and Moko sat quietly next to him. The dog, of course, was not agitated. 

“It started out normal, doctor. I got up, fed Moko, took him for a walk, came here, all the usual stuff. The snow outside is very pleasant. I wasn’t thinking about Judy—well, not much, anyway. I was doing my breathing exercise on my way here, like we talked about. In through the nose, hold it in the chest, 2, 3, and out through the mouth. It was helping this time, I really think it was.”

“That’s great Jacob, I’m glad.” He seemed really fidgety and his shoulders were hunched away from me. Classic avoidance posture. 

“Yeah, but that’s when I noticed the snow.” He ran his hand through his dog’s fur and scratched behind his ears. “Moko was lagging behind me, so I turned around to tell him to hurry up. And that’s when I saw it. There were no footsteps in the snow.” He looked up at me very intensely. That’s when I realized this was serious. Disconnect from reality, coupled with possible memory loss. I wanted to get a more complete assessment, so I kept my questions open. 

“No footsteps?” 

“Where we’d been walking, there were no footsteps! It was like we were floating, Doctor.” 

“I see. And what do you think that means?” 

He looked out the window for a while when I said that. He looked so tired, I wanted to ask how he had been sleeping recently. But now was not the time to interrupt him, especially with how fragile he was. 

“I saw my feet sink in. When I was walking, I saw each step I took, I heard that little soft crunch noise under my feet, like the crackle noise that snow makes when it’s kind of icy, you know? But then I looked behind me and the snow was all smooth. It was all gone, like I was never even there. Like I never existed.”

At this point I’ll admit, I was curious, and more than a little concerned. Jacob had displayed standard symptoms of low self-esteem and possible depression in the past few months I’d been seeing him, but I’d never seen him display anything like this level of complete dissociation from reality. Actually, now that I think about it, this is a first for me as a private counselor. It’s textbook, sure, but it’s not exactly common.

“I’m not crazy doctor, I can show you.” 

“You know crazy isn’t a useful word in this office, Jacob. No one is calling you crazy.” He shot up out of the couch and woke Moko. Before I could stop either of them, they were out of the office and through the front door, stepping into the fresh snow outside. 

“See? See?!” I looked down at his feet. 

“I don’t see anything out of the ordinary,” I told him. “Why don’t you come back inside, and we can talk about it some more?”

He shrank then, like a deflated balloon. I felt bad, I really did. But this man needs more help than I can give him now. 

--

After I made sure he was calm and not a danger to himself or others, I let him and Moko walk home and called Dr. Morrison, the nearest reality-dissociation specialist. 

I told him this is the first case I’ve seen in my practice. 

“What are the symptoms?” he asked me. 

“He thinks the snow is supposed to be real.” 

Dr. Morrison gave a little sigh. “Yeah, that’s often how it starts. They’ll see a glitch and not realize it’s part of the program. That’s when we realize they’ve gone reality-blank.”

This made sense, I thought. Jacob’s case really was textbook. 

“Is there anything else I need to do?” 

“Nothing,” Dr. Morrison said. “You can go ahead and disconnect for the day, I’ll send someone to Jacob Wall’s unit to disconnect him manually and begin re-emerging therapy. Poor guy, he’s in for a rough few weeks. But he’ll be fine afterward.” 

“Thanks, doctor. Take care.” 

“You too, thanks for sending the patient my way. Bye now.” 

Once I finish up these notes, I’m going to disconnect from here and begin my regeneration cycle. I do feel bad for Jacob though. Imagine thinking snow is still real, in this day and age! It’s going to be hard. Still, it’s better than letting him failing to disconnect every night, that’ll mess up his brain for sure. 

Moko is a sweet dog, maybe I’ll see if I can get his computer program transferred to my office simulation. Jacob won’t miss it.