To medicate or not to medicate? That is the question.
(Continuing in my response to the Twitter adversary who apparently believes that everyone in the mental health business wants to diagnose everyone in the world and medicate them and who is willing to take us back to the Stone Age to kill the ancestor of the first diagnosers and medicaters.)
I do diagnose. I don’t medicate. I thought to train to get prescription privileges years ago, before my State changed the law, allowing psychologists to prescribe. When the change was made, however, I found too many reasons not to, not the least of which was that my brain doesn’t work that way. Another reason was that I believe that the problems of existence can only be partially relieved with the use of a pill because the biggest problems come out of our encounters with the world, a world that seems to be hell-bent on tripping us up as we wander carelessly down the halls of life. Unfortunately, some of these problems appear at too early an age for many.
Which brings us to the story of Henry.
I worked in two different state hospitals in two different states at the beginning of my career. The first got me to the place where I got my degree and made me license eligible. This is also where I found I could work in adversity even though I hadn’t the least clue what I was doing or what should or could be done. Perhaps it is unfair to say, but it does seem true in retrospect, that no one else knew what to do either. No one knew what to expect from medication or therapy. What was the need for psychotherapy with the severely mentally ill anyway? And meds were just used to contain those otherwise out of control. As the head nurse waxed in recalling, “One shot in each cheek and you had no problem with them, however crazy they were.” He spoke in the past tense because, at the time, this approach at patient management was discontinued in preference to treatment, which has more recently been discontinued in preference to releasing patients to the street for the police to pick up for corrections therapy, which is to say, just throw them in jail and let God sort them out.
(We used to say, “I can’t believe this is happening now in the 20th Century.” Well, now it is the 21st and we do even less. What seemed like a real shot at civilization proved to be such a fragile thing. That’s because no one wants to pay for treatment, in preference to paying even more to deal with the detritus, as if money is being saved in our pennywise, pound foolish mode of government.)
And then there was Henry. Henry was the first person who, by coincidence certainly, answered questions in treatment, questions I did not know I even had at the time. When I started work at this particular hospital, I was replacing another psychologist and inherited his caseload. I remember unlocking the door to the ward that day and encountering Henry who was waiting for me or for someone. As soon as I closed the door behind me, I was forced to approach him because of the way he positioned himself near the door. He had a warm, friendly face and a round body. He looked at me expectantly as I approached him. When he opened his mouth to speak, out tumbled word-salad. Word-salad is what happens when the words are comprehensible but come out scrambled, lacking any underlying sense or meaning. My first impression was that this guy was nice, but very nuts.
As one might expect in the chaos of a psych ward, Henry quickly faded into the background, except I would greet him every morning when I saw him. He would respond appropriately to my greeting, but what would eagerly follow was another incomprehensible jumble. Until one day, a psychologist from another part of the hospital and with more experience with Henry took me aside to tell me that he did better with less antipsychotic medication. This psych encouraged me to bring the information to the treating psychiatrist, which I did. In a manner that I soon learned was typical, the psychiatrist became defensive despite my efforts to inform and be as non-confrontive as possible, sarcastically demanding whether I or my colleague was trying to tell him how to medicate. To which I replied that I had little direct experience with the patient and was merely bringing him information to be helpful. The outcome was that the psychiatrist did what so many do and have done in the past, he raised rather than lowered the medication and Henry got worse. What resulted was that Henry began to show side effects from the med increase, including excessive drooling and facial twitches. This apparently raised concerns for the psychiatrist who then lowered the medication as originally suggested.
Then, one day an unexpected thing happened. When I entered the ward and encountered Henry, he smiled at me warmly and eagerly opened his mouth to speak. And again, word-salad. For some reason, I took a moment to hear what he had to say, however confused. And suddenly, to my surprise, I could find a bit of sense in it. “Henry,” I said, “Are you telling me that there are people who want to hurt you?” “Yes.” “Now, Henry, are they real people, people on the ward?” “Yes.” “Here’s what I want you to do. If anyone does anything to try to hurt you, even if you suspect someone is trying to hurt you, I want you to tell me. OK?” “OK.”
It might have been another month before Henry was released from the hospital because his thinking cleared up with the medication reduction (not elimination). I later found that he had many contacts in our community, people whom he would visit and who looked forward to his visits. I last ran into him back in the hospital where he recognized me immediately. “Don’t tell me your back in,” I said. “No. I came to visit.” Then, I found myself privileged to have a conversation with someone whom I discovered that I liked. Sad to say but he didn’t include me in his round of places to stop, but then as is so often the case you have to catch me on the run. If I had had a little shop in town, I have no doubt he would have included me in his rounds.
If it needs to be said, this taught me that there is such a thing as successful medication treatment. Also, that there is a role for psychology and psychotherapy in treatment. Who else is to point at reality for patients and make sure that their personhood is not lost? Henry taught me this and more from the experience of working with him and keeping an open mind. This is the peak of inpatient experience. What came next taught me what is wrong with the notion of chemical imbalance. This is an area that I will cover but cannot fully explore in a blog due to its complexity. I will start here by saying that, except for cases like Henry, I don’t believe in it.