Chapter 1 CHAPTER 1
“I’m not trying to kill myself.” Though his expression was flat, Nigel McGowan’s color—at least how it appeared on my laptop screen—was whiter than the wall behind him.

How many times have I heard those words? Another patient had sworn the same to me only two days before, during my weekend on call for the Anchorage Regional Hospital. That patient had begged me to free him from his involuntary confinement in the ER. But the raw ligature burns around his neck—from where the noose had yanked the hook free from the ceiling at the last moment—were far more persuasive than any of his pleas.

“You’re not suicidal,” I said, focusing back on Nigel. “You just don’t want to extend your life any longer than necessary. That right?”

“Exactly right, Dr. Spears,” he said, as sweat beaded along his receding hairline.

Having seen the worrisome images of Nigel’s swollen, red-and-black blistered foot and shin, I was surprised he was upright at all with such an overwhelming infection snaking up his leg and into his bloodstream. “All right, Nigel,” I said. “Say I dove to the bottom of a swimming pool and decided not to extend my life by resurfacing. Wouldn’t that make me suicidal?”

He crossed his arms and rested them on his bulging belly. “That’s a silly comparison.”

“Is it, though? You’ve had uncontrolled diabetes for years, and you still refuse to take insulin. It gave you a heart attack before your fortieth birthday. And now you’ve got an infection that, according to your own doctor, will cost you your leg—probably your life—unless you agree to go to hospital for intravenous antibiotics.” I pointed at the screen. “Make no mistake, Nigel. You’re killing yourself. You’re just doing it slower than most.”

“I’m of sound mind. And I don’t want medications.” His damp lip quivered. “It’s my choice.”

He was right. I had no legal grounds to certify Nigel and keep him involuntarily in hospital for treatment—unlike my patient who’d tried to hang himself—even though his life was in the same degree of jeopardy. That conundrum made my temples throb. “And in my example, Nigel, it would be within my rights to stay underwater until I drowned.”

Nigel swiped the sweat from his brow with the back of his hand. “This isn’t helping.”

“Help?” I stared intently at his wan face. “Since when do you come to me for help?”

His image froze on the video chat screen momentarily, but his words were still clear. “What kind of psychiatrist talks like that?”

“I’ll give you this, you’re one of my most reliable patients. Over three years, and I don’t think you’ve missed an appointment yet. But in that time, when have you ever taken my advice?”

“You mean your drugs, don’t you?”

“No, Nigel. Advice. For years, I’ve been begging you to come join group therapy. To join any group at all.”

“Group therapy?” He huffed. “For an agoraphobic?”

“You’re not agoraphobic.”

“I have a pathological fear of rejection.”

“As we’ve discussed, that’s not agoraphobia.” Besides, technically, it was a single rejection he kept reliving. Six years after being dumped by his then boyfriend, he was still grieving the breakup of a relationship that had only lasted months. “Let’s say you don’t die, Nigel. How do you feel about living with only one leg?”

“I hardly ever leave my apartment anyway.” But the quick flick of his eyes betrayed his anxiety.

“And then when you lose the other leg? You OK with not leaving your bed, either?”

He eyed me dolefully. “Where’s your compassion, Dr. Spears?”

Nigel had a point. A casual observer might have assumed I was taunting my own patient. But I saw no other choice. Pity was the one card Nigel relied on. It gave him a sense of control. He used it to handcuff the few people in his life who still cared about him, including me. And I knew from previous experiences that sometimes only harsh boundaries—even the threat of abandonment—would motivate him to comply.

“Enough of this manipulative crap,” I said. “I’m calling an ambulance and you’re going to go to the hospital. Right now!”

“I won’t go.”

I held his gaze. “If you don’t, Nigel, I’m firing you as a patient. And you and I will have no further contact. Ever.”

His eyes went a bit wider. “You can’t do that!”

“Yes, I can,” I said. “Don’t worry, though. I’ll find you another psychiatrist. One who will be far more sympathetic to your plight. You can tell him or her all about how Gary abandoned you while the gangrene creeps up your leg.”

His voice faltered. “Please, Dr. Spears…”

I stared back at him, not giving an inch. His life hung in the balance. “It’s your call, Nigel.”

His image froze again, for longer this time. When the screen came back to life, his chin hung low, but he was nodding.

“It’s the right choice, Nigel.” I offered a reassuring smile. “This is what we’re going to do: I’m going to hang up now and call the ambulance. And I’ll see you at the hospital later.”

Before he could reply, I ended the videoconference with a click of the mouse, partly because I wanted to dispatch the ambulance right away but mainly because I didn’t want to leave any wiggle room for him to renege.

I picked up the phone and dialed 9-1-1. The dispatcher confirmed an ambulance would be arriving at Nigel’s apartment within minutes.

As I dictated the note into his electronic medical record, I reflected on the pros and cons of virtual medicine, which had become so prevalent, especially for us psychiatrists, in the post-COVID world. Had Nigel been in my office, he might have had time to tell me he’d changed his mind while waiting for the ambulance. Then again, if we had been sitting face-to-face, connecting with one another’s physical presence, maybe it would’ve been much easier to convince him to go to the hospital in the first place.

It was the paradox of virtual medicine. Psychiatrists needed to see their patients. Visual cues were often more important to us than words. And the widespread availability of videoconferencing made remote consults possible. But while virtual care offered all the convenience in the world, it also lacked the immediacy and intimacy of a one-on-one session, missing all those intangibles that could never transcend the screen. One day, some brilliant neuroscientist was bound to identify the alternate hot spots in the cerebral cortex and various pheromones that respond to human proximity. More than likely, some researcher already had.

But an in-person visit wasn’t an option for my next patient. She lived almost a thousand miles away, beyond the Arctic Circle, in the northernmost town in North America: Utqiagvik—formerly known as Barrow—Alaska. For Brianna O’Brien, like my other patients who lived in a town that was only accessible by air, virtual care was their sole option, apart from my biannual visits. I tried to get up there in the spring and again in late summer, and my trip for later next month was already booked.

I clicked the invitation icon on my laptop, and Brianna’s head appeared, framed by reddish-blonde hair that extended beyond her shoulders. With her makeup-free, heart-shaped face and her grayish doe-eyes, Brianna looked closer to fifteen or sixteen than the twenty-two-year-old she was. She wore the same black T-shirt—emblazoned with the words “Fuck the Police!”—that I had seen at previous sessions, but I didn’t recognize her backdrop, which looked to be the interior of a trailer or an RV. Usually, during our sessions, she sat in her small but always immaculate kitchen.

Brianna nodded her greeting, her mouth set in the ambiguous Mona Lisa smile that I’d come to expect from her.

“Hi, Brianna. Where are you?”

“At a friend’s.”

“Where’s Nevaeh?” Usually by now, her adorable four-year-old daughter would have popped into the frame and peppered me with rapid-fire questions.

“With my aunt.”

Her inquisitive child resembled my Ali, in looks and personality, when my daughter had been about the same age. Nevaeh’s absence only reinforced how I much I was missing Ali this summer. My sixteen-year-old had chosen to stay in Seattle with her mom to attend an intense dance camp instead of spending the month of August with me in Anchorage. Or, at least, that was how my ex-wife had justified it.

“How are you doing today?” I asked.

She ran a hand through her hair, pulling away loose strands. “I’m OK.”

I picked up on the hesitance in her tone. “You sure?”

“I still feel kind of… fuzzy, I guess.”

“Since you started the new medication?”

“Maybe, yeah.”

“That’s normal. The side effects with Ketopram are always worst in the first month. And they’re usually gone by the end of the second.”

Brianna accepted my explanation with a twitch of her shoulders.

“And your appetite?” I asked.

Her screen flickered for a second or two. “It’s OK,” she said.

“And what about your thoughts, Brianna?”

Her gaze drifted away from the camera. “They’re… quiet.”

I found her choice of words curious. “Quiet how? Peaceful?”

“Calm, I guess.”

“How are you sleeping?”

“Not great.” She bit her lip and then added, “But I never really do.”

“Some people get vivid dreams when they start taking Ketopram. Are you experiencing those?”

“Just one. But I keep having it.”

I flashed an encouraging smile. “Can you elaborate?”

“It’s a nightmare, not a dream.”

“Can you describe it to me, Brianna?”

“Me and Nevaeh are in my car,” she said softly. “She’s in her booster seat in the back, playing on my phone. We’re not moving. It’s really gray outside, and I can’t really see through the window. At first, I think I must be parked in a dense fog or something…”

I gave her a few moments to finish, but she only picked at a few more loose hairs. “But it’s not fog?” I prompted.

She sunk lower in her seat. “That’s when I see the drip coming from the corner of the driver’s window. Then the window cracks, and freezing water gushes inside. And just then—when I realize we’re underwater—I wake up.”

“You mean like submerged? Under the sea?”

She nodded.

“How did you end up there?”

“Don’t know.”

“In this nightmare, you didn’t deliberately drive into the water, did you?”

“No.”

“Do you ever fantasize about harming yourself, Brianna?”

“Nevaeh was in the car, too!” Her voice cracked.

“How about without Nevaeh?” I asked softly.

She shook her head. “I’d never leave my daughter alone in the world.”

Brianna had rarely been even this forthcoming with me in the four months since I’d started seeing her. I didn’t want to stretch the bounds of her trust, so I didn’t push further.

Her family doctor had been treating Brianna with various antidepressants on and off since he’d diagnosed her with a delayed postpartum depression. I recognized early on in our therapy that Brianna was still suffering from a major mood disorder. Since the antidepressants she had been taking hadn’t worked, I’d switched her over to Ketopram the month before. The groundbreaking drug, which had only been on the market for the past two years, had proven effective on other patients with refractory depressions that failed to respond to other antidepressants. Including my own.

“How about your overall mood?” I asked. “Are you finding more enjoyment in things?”

“Maybe? I mean, you know, with Nevaeh and all.”

I chuckled. “That kid is something.”

“She’s everything,” Brianna said with a blank nod. “I’m crying a little less, too.”

“So… progress, then?”

“Yeah, maybe.”

Her tone was too unconvincing to leave be. “Is there something else, Brianna?”

She opened her mouth and then stopped, dismissing it with another shrug. “I can’t remember the last time I laughed.”

“Laughed?”

“A belly laugh, you know? Like when you can’t stop giggling with your girlfriends. Used to do it all the time. Before the depression.”

Brianna had a way of describing her depression as a single sudden event, like an earthquake hitting, instead of an evolving medical condition. I had probed before, trying to find a specific precipitant for her despondency beyond the postpartum hormones, but she inevitably would clam up.

There were still so many pieces of Brianna’s life that were missing for me. Areas that remained taboo. I knew hardly anything about the father who abandoned her family when she was young or the oil field worker who’d fathered Nevaeh. In an earlier session, Brianna had blurted something about a man who’d taken advantage of her while she was still in high school. But she backtracked almost immediately, and I wasn’t able to unearth any more details. I hadn’t pushed too hard, aware it would take a lot of time and patience to get her to open up about any trauma.

With some patients, I could establish therapeutic intimacy in a single session—with others, it took years, if ever. Brianna and I were nowhere near that point. And in my experience, each patient required an individual approach to getting there. As much as Nigel often needed a strong hand, Brianna responded best to a softer approach. I’d seen how quickly the wrong line of inquiry or even a single question could shut her down for an entire session.

As we only had thirty minutes booked for this appointment, I used the remainder of our time to emphasize the nonpharmaceutical remedies that we’d discussed before to complement her medication, including exercise and sleep.

As the session was ending, Brianna bit her lip and viewed me with uncharacteristic inquisitiveness. “Will I ever get back to being me again, Dr. Spears?”

“You will. It’ll take time. But you will.”

“Time… Yeah, OK.” She dug her fingers through her hair again as if sifting through sand. “Dr. Spears?”

“Yes?” I surreptitiously glanced at the clock at the bottom of my screen. It was five minutes past the hour, and I could see my next patient had already logged into the virtual waiting room.

“It’s just that… there’s… I don’t know…”

I could see she was struggling to put something into words, but I was distracted by the time-warning light that was now flashing on my screen. So instead of trying to draw what she wanted to say out of her, I said, “Let’s pick this up on Friday, all right, Brianna?”

Not once did I suspect those would be the last words I ever spoke to her.