“And, by the way…”

He came in for his routine yearly visit with me, stable for the most part in that he was living with his chronic psychotic illness and moving through the world in a fairly normal, logical way most days. He was in his mid-twenties, neat, clean. He was attending to his personal hygiene and wearing rumpled but passable casual clothes. His hair was combed, but it had not been cut or even trimmed in quite a while.

“I don’t think my antidepressant is working,” he announced matter-of-factly.

Like many of my patients, he was and has been subject to that best of all psychiatric interventions, polypharmacy (Yes, I AM being sarcastic), whereby if a patient tells you they are having an exacerbation of symptoms on their current regimen of drugs you simply add another one and hope that augmentation is a real phenomenon. (The drug companies assure me that it is.)


I waited.

He waited.

“Tell me more.”

He did.

His change in symptoms was both vague and intriguing, troublesome and irksome. We’d been down this road before, he and I, several times.

He thought it was the medicine.

I did not.

Ninety-nine per cent of the time it was not.

Medicine is just an easy target. There it sits, on the nightstand, on the window sill above the kitchen sink, in a purse, under the bed. In a brown bottle, with a white childproof cap, neatly labeled,  it is the best absorber of causation ever devised by modern medicine. If something is not right, if something is difficult to figure out, if something is not working or responding the way we all think it should be at week one, week four, or week eight, then it must be the medicine. What else could it possibly be?

“I’m more depressed. I don’t want to do anything. I don’t leave the house. I have no interests. I don’t sleep. I don’t eat.”

We chatted. He weaved and bobbed. I confronted and clarified.

“Maybe it’s the medicine,” I offered, not wholeheartedly but with some degree of inevitable resignation.

“I told you it was the medicine,” he said, triumphant.

We talked about a dosage change. A small increase. A homeopathic sacrifice to the gods of common sense and exasperation.

“There,” I said. “Anything else you think  I should know before we stop?”

He was silent.

I typed in the new dose of the medicine and sent it on its way to the pharmacy in electronic form.

I got up, proffering my hand.

“And by the way,” he said, a calculated afterthought. “I’m very lonely, you know. I’m very lonely. Do you think I’ll ever have a girlfriend?”

I sat back down.

My next patient had already canceled.

I had not been able to do psychotherapy, even rudimentary, time-limited, short-term psychotherapy, in such a long, long time.

I laced my fingers in my best Freudian way, stroked my white goatee, and crossed one leg over the other.

“I’m listening,” I said.


8 thoughts on ““And, by the way…”

  1. Polypharmacy responses are fast becoming the most annoying and (at times) terrifying part of my job. But what do I know? I’m “just a case worker” — using the word “just” with me usually does not end with the result the speaker is expecting it to.

    I wish there was a magic wand, time machine, something to take us back to the day that drugs were not the first go to — and it was prudent to change, rather than add – to give the medication time — or try other options (therapy comes to mind — but I may be a bit biased in that) before we went the heavy duty med route.

    I wish more psychiatrists in my state had your point of view — or at least read your blog.


  2. Ironically — the ones who will discuss it with me are not using the word “just” and are not the ones who I worry about. It’s the ones who won’t even return a phone call and pass messages through the therapist that worry me.


  3. I wish you could practice more in the world of therapy. I think so many people who are desperate would benefit from your wisdom, kindness and expertise. Not to mention your compassion. You write with a heart no found in many these days, and a love for your work that is exceptional. ()


  4. Therapy is a lost art. I’m glad you have the sensitivity, the time and the expertise to keep doing it. I miss that part of my former work. But the opportunities were much too far and few between…
    Keep up the good work, my friend,,,


  5. Susan, I wish I did have the time, but I agree that we’ve moved away from that modality of treatment in large part.
    I’m please that you are still able to connect with people and provide desperately needed services through your new position and calling. Thanks for doing that.


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