The patient with whom I am exchanging pleasantries and sports scores is a second-generation pedophile. It is only a small exaggeration to say that he is on every medication known to man. Brutally and repeatedly sodomized by his stepfather through childhood and adolescence, he is himself a gentle person who experiences his deep aquifers of rage only when they spout forth under pressure in threatening auditory hallucinations. His own brief career as a sex offender followed the same quiet, obsequious, ingratiating style, and he inflicted no physical violence on the boys involved. It ended in a trip to the state prison, a dangerous place for convicted pedophiles, particularly for this slight and timid individual. I can make some fairly safe assumptions about what happened to him there.
Although I have known this patient for a number of years, my formal role with him in the clinic setting where I work part-time is limited to writing his prescriptions. If I really did all the paperwork I am supposed to do in connection with this, we would have no human interaction whatever. As it is, the mental health center's assigned clinician does the frontline work, and each new clinician chooses one of two basic tacks when my patient's name is transferred to their caseload. Some, focusing on his "major mental illness" diagnosis of schizoaffective disorder, concentrate on the management aspect, filling his weekly medication caddies or getting him to the cooking group. Others, usually inexperienced or idealistic or both, take on his posttraumatic stress disorder and his history with varying degrees of skill and intuitive common sense (few have meaningful supervision--their supervisor usually only shows them which forms to fill out and when).
Ontogeny recapitulates phylogeny in the careers of this second group of clinicians, as it did in my own. Regardless of what any of us may have read, each generation of would-be therapists has to make Freud's original mistake of uncovering too much with the wrong patients and making them worse. This is the foremost vulgar error of psychodynamics, and the reason why many clinicians, trying to play it safe, thereafter avoid "content" altogether, or learn to see it only as something to be replaced by more adaptive cognitive schemata.
In this case, with sensitive history-taking and puzzling through recurrent nightmares, my patient's most recent idealist (an unusually gifted one) succeeded in precipitating a florid psychotic episode with command hallucinations both suicidal and homicidal. Perhaps some different, adaptive schema would not have been such a boring idea after all. The newly re-stabilized patient is fresh from the hospital.
Needless to say, with what influence I have, I try to support the management-minded clinicians' efforts and to dampen the idealists, but either way, clinicians only last at most a year or two. I am always left, as now, with my pedophile and his ongoing quest to be as numb as possible.
For the sake of emphasis, I will recite his medication list, with total daily doses (most are divided into fours, as frequent dosing is reassuring to him; the caddy boxes are reliable friends). Clonazepam 5 mg, oxcarbazepine 600 mg, risperidone 12 mg, trifluoperazine 20 mg, valproate 2000 mg, fluoxetine 80 mg and trazodone 200 mg at bedtime. And there may be more. Not to mention his insulin and oral hypoglycemic, his ACE inhibitor, his COX-2 inhibitor, his statin, his triptan, his proton-pump inhibitor, his inhalers. And the occasional zolpidem or oxycodone thrown in by a well-meaning on-call general physician. Altogether, a lot of things are being inhibited here. And God knows what interactions are going on beyond the binary scope of my software.
This man is younger than I am, and he can hardly move. Sometimes after seeing him, I walk up and down the hills across the street as fast as I can until I am sweating and breathless just to prove that movement is possible.