How does a clinician deal with those patients for whom they can ultimately do nothing but help them stay numb for the majority of their days?
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.
Academics, chief residents, inpatient docs, scoff all you want. I defy anyone with a serious public outpatient practice to tell me you do not have at least one, usually several, patients like this. They are one of psychiatry's ill-kept secrets, and I recall discovering them among my attendings' clientele when I was an on-call resident years ago. Luckily, my attendings were of a philosophical generation. Their explanations went straight to the big picture and skipped any attempt to make pharmacological sense or to apologize. These are broken people, they told me. Their lives are unbearable if experienced with any clarity. We help them to stay numb as an alternative to having them, or someone else nearby, get physically hurt or die. And then, over the years, we find something in them to appreciate or to make contact with, some little bit of life left within them. Such appreciation, such contact, must be seen as having value in itself and not as a means to an end.
While dampening the idealism of the clinicians, I have myself practiced a sort of psychopharmacologic idealism. Every single psychotropic on the previous list has been tested with a taper since I inherited this patient several years ago. I have had small victories: buspirone is gone, oxcarbazepine has replaced carbamazepine. But any attempt at the big ones--fluoxetine, valproate, clonazepam, the antipsychotics--inevitably results in emergency department visits, phone calls from a frightened wife, broken windows, punctured walls.
At first I thought we were having a symbolic dialogue about dependency and autonomy through his drastic reactions to any change I would make. I spent lots of phone time reassuring him and getting him to try and hang on, to wait some medically respectable interval before reinstating his former dosage. But after I stopped questioning his regime, there were no further problems until the latest therapist rocked the boat. The patient has taught me, and now he trusts me completely. Our contract is that I will keep him numb. He watches the sports channel and dozes periodically; sports is our topic today. His face is flat, his speech a bit slurred; his half-smiles, though, are still worth the wait.
On my desk beyond him is the latest issue of Neuropsychiatry Reviews in which Elio Frattaroli, M.D., speaks from his new book Healing the Soul in the Age of the Brain (Viking, 2001). His words are an eloquent compensation for today's symptom-driven, mindless psychiatry. He speaks of unconscious conflicts and symptoms as an opportunity for spontaneous growth. True believer in psychotherapy that I am, I still find myself playing with ironic titles of my own. Numbing the Brain While Losing the Soul? Or maybe While Grieving the Soul? While Glimpsing the Soul?
No, there is nothing mysterious here, no hidden conflict to reflect upon in the situation of my pedophile patient. The horror is mostly above board, and if we go looking for more, he lands in the hospital.
Reflection, growth, awareness: such noble statements of value are necessarily one-sided; they always leave something important out. I still hide the newspaper's morning headlines from my 9-year-old, the suicide bombings, child abductions and rapes. From my 17-year-old, I do not. I suppose the difference is that I expect him by now to have developed his capacity for numbness. I must have been teaching him right all along.
Perhaps the Enron and WorldCom executives learned that lesson too well, oblivious to the future pain of the people from whom they stole even as these same people typed their memos and brought them their coffee. But clearly, we all learn adaptive numbness. It is a universal and essential complement to awareness. They must exist in some shifting equilibrium for us to survive in this sometimes hostile and overwhelming, sometimes hospitable and nurturing world.
The "psychic numbing" (DSM-IV language) we are considering here parallels physical processes like hibernation and dormancy. Each seems to allow the organism to await better conditions (why else would my patient brighten while discussing sports scores?); each may end either in death or in a reawakening. I do not delude myself that even with all the time in the world I could "facilitate the maturational process" (Frattaroli, paraphrasing Winnicott) in some idealized psychotherapy with my patient. If his soul is healed, it will be by a Power greater than myself--by a change in the conditions within which he lies dormant. Both forms of psychiatry, biological and psychodynamic, may function as vast defense mechanisms against the recognition of just how bad life can be, and how helpless we are before that fact.
Today I paddle out onto my little lake at sunrise. It is as good a place for awareness as any. The loons are much tamer than they were when I was a boy: numb to the traffic noise from Route 302 that is already beginning to build, numb to me as I approach. Withdrawing to rocky coves, they will retain their numbness even as the noisy jet-skis invade, long after I go to work. Yet these indifferent-appearing loons are acutely aware of fish down deep in the cooler water, diving for them periodically. When I add my noise to the inbound traffic, I will be trying in the midst of my numbness to stay aware of the possibilities in my patient's gentle half-smile and his soul under the numbed-out surface.