The patient was a tall, young black man who slouched in the chair before me, his sinewy arms folded in defense. He narrowed his eyes and waited for me to speak.
I took a deep breath and eyed the chart in front of me, bracing myself for what could be a difficult interview. I scanned his history: 23-year old male with severe, longstanding paranoia, anxiety, and polysubstance abuse, who had done time in jail for armed robbery and was now on probation. I was new to this clinic, but he had been in treatment here for almost a year since he had been released. I saw that he had been on high dosages of antipsychotic medication for almost the entire time, but his symptoms of paranoia had not abated. Notably, the patient had been labeled as "hostile and uncooperative," and multiple doctors had documented that "his paranoia seems to extend to healthcare staff."
I shifted uncomfortably, unsure of what to make of the previous doctors' notes. I had worked with felons before and knew that they were sometimes distant and quietly aggressive, like venomous snakes that could strike without warning. But as a man of color myself, I knew how much prejudice plays a role in perception. Given that the patient's past encounters with doctors were probably contentious, it wasn't surprising that he might be defensive.
"Thanks for coming in," I began agreeably. I watched as he flinched away at the sound of my voice. "I see you've been taking Zyprexa for awhile with no benefit?" I raised my eyebrows questioningly. I hoped that I could disarm him by getting down to business quickly.
"Yeah, whatever," he muttered. "I see you been readin' my chart," he said in an accusatory tone. His lips twisted in disdain.
"Mmhm," I affirmed, nodding matter-of-factly. "Well, I noticed that you've been taking that medication for some time, but it doesn't seem like your symptoms have gotten better," I offered. "And I know it can have some pretty bad side effects."
"Yeah, true..." he said quietly. His body seemed to loosen a bit.
I started to connect the dots. I could see that the patient exhibited none of the more alarming or disabling symptoms of psychosis that might warrant treatment with an antipsychotic medication, such as "disorganized thought," in which a person's thinking breaks down and they are unable to communicate logically, or "internal preoccupation," in which a person seems to be responding to internal stimuli, as if he were hearing voices. Rather, this patient seemed present and acutely attuned to the tension between us.
I also knew that statistically, black men were overdiagnosed with psychosis and put on higher dosages of antipsychotic medication. "You know," I began gently, "lots of times black folks get put on these strong meds even though they don't need them."
The patient perked up and inclined towards me with hands grasped, his face now inquisitive. "Whatchu mean?" he frowned.
"Well, do you ever hear voices when no one is talking?"
He shook his head.
"Do you ever think people are trying to send you special messages, like through the radio or TV?"
He smirked and shook his head again.
"Do you ever think people are following you, or that the police are after you, or that they might be recording your conversations?"
His nostrils flared in response. "You gotta be kidding me," he whispered angrily. I watched as he leaned back, his muscles writhing beneath his baggy black t-shirt. He stared at me grimly. "Do you know what it's like in Richmond?"
I winced internally, immediately realizing my misstep. Richmond was a poor, violent city east of San Francisco. I had treated a number of patients, including inmates, who had grown up there in the mid-2000s, when it was considered one of the most dangerous cities in the U.S. What might look like paranoia elsewhere was basic survival instinct in Richmond. I nodded and looked at my patient intently.
"The way I came up was crazy, feel me?" he averred, waving his hands in dismay. "Shootings every day. My granddaddy..." he began, his voice starting to crack. "I saw my granddaddy get shot when I was ten! He died in the upstairs bedroom. Blood everywhere," he said, covering his face with his calloused hands. "There was blood everywhere." His voice raised, strangled and anguished. "So when you ask if I look over my shoulder!? You better believe I look over my shoulder in Richmond!" He removed his hands and stared at me in proud defiance as tears streamed down his cheeks.
I was struck by his words and felt my hands raise in half-apology. What do you say when someone tells you something truly beyond the pale? How do you console the unconsolable? My innards squirmed as I tried to suppress my overwhelm. I had to bear witness to this man's suffering without looking away.
"It's a tragedy," I said softly. "A terrible tragedy that shouldn't happen to anyone. I'm so sorry." I bent towards him warmly. "And I'm sorry that you've been put on these meds. I'm not sure they've been helpful to you, and they may even have been harmful. We should get you off of them," I said, watching his expression closely as he nodded along, blinking back tears and softening his stance.
"Ok Doc," he agreed quietly. "I'd like that."
Our session ended on a positive note, and I was relieved and appreciative that I could reach him. Of course, psychiatry is an inexact science, and questions lingered. What if I had erred in questioning the judgment of the doctors who came before me, and the patient became psychotic when he was off his meds? And if I was right, what did it say about our healthcare system that doctors were so quick to throw strong medications at young men who looked like my patient?
Four weeks later, we met again. I looked up from behind my desk to see him stroll into the clinic and make his way to my office. He smiled and sat down.
"What's good, Doc?" he grinned.
"How're you doing?" I said, smiling back. "You look fit."
"Yeah, lost some weight since I been off the meds. Still got some anxiety, but I feel much better. Those meds slowed me down," he said, his head bobbing earnestly.
"Any problems with paranoia? Voices? Anything strange like that?"
"Nope. I mean I can't completely relax where I live, but I'm good with that. Just how it is, you know?"
I nodded seriously. "Yeah, I understand." I was glad that he hadn't become psychotic, but I still felt a well of discomfort at the bad news that I had to deliver. The organization that I worked for no longer accepted this patient's insurance, and this would be the last time I would be able to see him. I felt frustrated to be at the whims of a system I couldn't control, but I reminded myself that this was often the nature of the world.
"Well..." I began. My heart beat faster as he continued to beam in my direction. "Unfortunately, we're going to have to transfer your care to another clinic," I said, my face downcast. "The organization that runs this one doesn't take your insurance anymore."
The patient sat back suddenly. "What?" I saw his fists tighten. "We was...we was just gettin started," he said in quiet exasperation.
"I know, I know," I said, shaking my head in chagrin. I glanced at his frowning face and felt a twinge of guilt at having to abandon him so prematurely. This would be yet another hurdle that he had to overcome. "I'm sorry," I reiterated softly, my head bent in acknowledgement of his plight.
There was silence, and then he spoke. "Doc, it's ok," he assured me. "You know, I been thinkin on it, and you know what it is? It's a blessing. It's a blessing that I got to meet you. I'mma stick with that," he said, looking at me steadily, his dark eyes shining with gratitude.
My gaze lifted and we locked eyes. "That's...that's really nice of you to say that. I appreciate it, I do. I enjoyed working with you, even if it was just a short time," I said, smiling in return.
"It's cool, Doc," he said. "Sometimes that's just how it is." He shrugged. "And you know, I been making changes since we last met. Gotta real job, you know? Doesn't pay like the game, but I'm done with that other stuff. Tryin to do the right thing for my family, feel me?" He sat upright and looked at me with determination.
"That's good, that's good. I'm really glad you're making things work for yourself," I said sincerely. "I know we have to stop, but I wish you the best going forward. Truly," I emphasized.
"Thank you," he said simply, and then as he got up to leave he reached out suddenly and offered me a dap. I was taken aback but couldn't resist the gesture. I leaned towards him, and our knuckled fists met momentarily.
"Alright, Doc," he said conclusively, walking towards the exit. "By the way, you watch The Wire?" he asked, grinning my way.
"Oh yeah," I said, breaking into a broad smile despite myself. The Wire had changed my life. "I know all about The Wire. One of the best shows," I affirmed eagerly.
"Ok then," he said, nodding again. "You aight Doc. You aight."
He closed the door to my office behind him, and I sat and stared at the empty chair across from me. I hunched over my desk, my hands clasped as I tried to savor what was left of our interaction. We had connected, albeit fleetingly. I sat still for a few seconds, then picked up another chart before I beckoned the next patient.