Dr Houghton is a retired psychiatrist. He resides in Milwaukee, Wisconsin.
Things happen slowly in psychiatry, but if you’re not in a hurry yourself, the patient opens a window and shows you the world.
This patient motors 50 miles to my office once a year, picks up his script of Prozac (20 mg), and drives back to the small town where he lives.
He is a short fellow, straight as an arrow, wears a tie, has the formal manner of a small-town businessman. He wrote tech manuals in a small engine company for 30 years until he retired. That was 5 years and a couple of jobs ago when he first started to see me.
I figured he comes this far because he wants the anonymity which is hard to find in a small town.
The half hour sessions once a year were rather stiff and formal at first. He talked of his work and barely touched on any social life. He found a job selling cars for the largest American franchise, a big dealer right off the freeway. He was very serious about the vehicle, telling me the dimensions, horsepower, gas mileage, the deals they were offering. The first year he was dedicated and enthusiastic for the job.
Naturally I asked myself: is this half-hour conversation a worthwhile form of psychotherapy, a medical necessity? But the fee was heavily discounted by the HMO, of course, and I am a slow learner, not highly goal-directed out of the starting blocks. Real insight—if it ever comes—makes a long slow dawning for me. And that might not be a bad principle for the whole field of psychiatry.
The next year he was less enthusiastic about the job. He looked somewhat discouraged but not clinically depressed. Oh no, he still put his heart into talking up the product. This make of American car was just not selling as well as the imports.
Next year he cut back on auto sales and was looking for other work.
Next year he was building up hours as a teller in a bank, drawing a regular salary, and he was pleased to tell me the people there liked him very much.
One weekend, I happened to drive on other business through the town where he lived, one of those wind-swept conglomerations of buildings under a big sky, with at least 6 square blocks of downtown and a population of 5000. The streets spread out on the grid from there, all lined with tall trees, oak and elm, two blocks of Victorian mansions and then some ranches and bungalows, till the houses thinned out and the farms moved in. It was an old and successful Wisconsin town, and change came slow.
Next year my patient spoke of the bank job as a settled routine, quite satisfying, secure in his finances. With 10 minutes left, he said one thing he wondered about was that sometimes he did not get as sexually aroused. He could still "do it" and all the equipment worked; it just wasn't as ready and regular as before. Could it be the drug?
I asked the usual questions about morning erections, stress, and his physical health.
"All okay," he said.
"It could be the medication," I said, "though you're using a low dose and it's been a while. I'm not sure it's that, but it would probably be a good idea to talk with a urologist."
I wondered if we were moving toward something psychiatric, but it was too early to tell.