Smallville

“No, I cannot forget where it is that I come from

I cannot forget the people who love me

Yeah, I can be myself here in this small town…”

Kenny Chesney, John Mellencamp
When I began my psychiatric training in earnest thirty three years ago, after a challenging rotating internship, the indoctrination that began was regimented, sanctioned, scripted and complete. I knew from a very young age, training-wise, that my job was to ask a few very open ended questions, listen, formulate my thoughts about my patient and his reason for coming to see me, and then to discuss this with my supervisors in order to come up with a treatment plan. A plan that sometimes was, oddly enough, kept a secret from the very person it was supposed to help. The name of the game in those days was to figure the patient out before he did it himself, and then to guide him with judicious rigor and well-timed and brilliant interpretations toward increased insight and mental health. Yes, I was trained in a predominantly psychoanalytic program that was only beginning to bring in the psychopharmacologists, who would later dominate the agenda. 

I was taught to be the proverbial blank screen. I was to show little emotion, offer little to no spontaneous conversation or banter, and to never divulge anything of note or merit about myself except under the direst of circumstances. I embraced the psychiatrist persona that was the norm for that time. This therapeutic stance was just that, but it was not real or fun to me to practice that way. I will never forget how shocked, and yes, maybe a little hurt, I was when one of my long term psychotherapy patients (a lady who had a panic disorder that would be quickly and fairly easily treated today) blurted out, ” I might as well be talking to that doorknob over there as to be talking to you. You never say anything!” When I took this to my supervisor, a prominent psychiatrist who had literally written the book on these kinds of interactions, he praised me for maintaining my therapeutic distance and stance through this obvious transference-based outburst by my patient. He gave me pointers on how to proceed from there, mapping out a strategy for the next several months. I dutifully went back to work. The patient came to see me one more time and never came back. She was not getting what she needed to get better, and she quit. 

Today, I am working in a small South Carolina town. One of my duties this morning was to go over to the probate court at the courthouse building, five minutes away from my office by car, and testify about an evaluation I did a week ago. On arriving at the probate court office, I encountered the judge sitting at her secretary’s desk, taking  phone call. 

“Aren’t you in the wrong place?” I teased her. “Your office is in there.” 

“I know! One of my staff had a death in the family and the other one had already planned a vacation, so I’m doing it all today.” 

Soon afterward, we entered the hearing room, which is just that, a room with one long wooden conference table, a dozen mismatched chairs, a wall full of musty bound county record ledgers, and us. The judge was joined by me, a clinician, the patient, her appointed attorney, and an unsmiling bailiff. 

The format, unlike the proceedings one county up in another courthouse, was informal. Information was shared, the usual legal wrangling was dispensed with, and we all made it clear to the patient and each other that we cared about her, wanted her to get treatment and supported her in doing this. Even in her pre-psychotic state she seemed to grasp the feeling in the room, the common sense of purpose, and the unification of all involved. We even joked and laughed together a few times, which felt wonderfully good and real to me. I realized, mid-hearing, that I was doing something in this sunny small town courthouse that was going to make a real difference in someone’s life. 

I will always be grateful for my training, my supervisors, my colleagues and the experiences and baseline knowledge and skill set they imparted to me. I use those skills every single day. 

However, that can never hide the fact that “I can be myself in this small town”, and it feels good when I am. I’m proud of what I can do to help people here,  and that’s exactly the way it should be. 

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“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.)

“Oh.”

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.