Patient requested an impromptu emergency session, arrived at the office very distraught, more so than I've ever seen him. Exuding sheer panic. We were very careful to go over the story of his day in detail to deconstruct what led him to this state:
Despite his fear of heights, patient volunteered to bungee jump at a carnival, in hopes of encouraging his son to participate. During the fall, he blacked out. His anxiety level ticked up when, rather than reawaken at this dream carnival, he awakened in his bed with his wife. Up until now, patient's worlds regularly alternate days upon waking in the morning, in his words "like clockwork." But after two days, patient still had yet to wake up in the world where his son is alive and his wife is not - i.e. the dream world. Although patient claims there were no irregular events over the course of these past few days, he seems to neglect the impact of his daily stressors: his job as a homicide detective, the pending birth of a grandchild, a pregnant teenager living in his home.
Of course, patient initially refused to regard this as a sign of positive progress, of beginning to accept the death of his son. I explained that the image of falling is indicative of the most common of ways to transition out of a subconscious state. Finally, patient has allowed himself a tiny window of opportunity to acknowledge the reality of his son's death.
Much as I'm excited by this development, progress will have to remain cautious, slow. Unfortunately, patient stubbornly clings to his elaborate coping mechanism, refusing to believe that his son is dead and demanding that I help him "figure out how to get back to my son." Baby steps - but nonetheless, a breakthrough.