I offer this story in part to try to explain why it can be hard to not offer neuroleptics and why I think they are helpful in some instances. I use this as a demonstration of how a physician who prescribes drugs can also value and respect other contributions to an individual's recovery. Most importantly, this anecdote is offered as a story in praise of families and a recognition of their importance to the process of recovery.
I met Ronan as he was leaving his teen age years. He had abused a number of substances in his adolescence and he struggled to maintain sobriety. In his late teens, he experienced psychosis. He had spells during which he was violent. He was admitted to a psychiatric hospital and started on antipsychotic medications.
I met him after he had been hospitalized. At my initial meeting, his parents accompanied him. They were both initially uncomfortable with their son taking psychiatric drugs but at the time I met him his mother was more supportive than his father of this component of his treatment. His father, a deeply spiritual man, struggled then and struggles today with the notion that neuroleptics might be of benefit for his son and he and I have spent many hours over the years discussing the pros and cons of this type of treatment. However, his son's episodes of violence had frightened everyone in the family and his father reluctantly accepted this part of his son's treatment.
For many years, Ronan was a man of few words but also of few complaints. Over the years, his self reports were fairly consistent; he would tell me he was doing well and working regularly. In the early years, the family reported that he would come to work sporadically and only stay for brief periods of time. He sometimes had problems with hygiene and he could be overtly hostile towards his family and others. However, his parents were never critical and they never wavered in their support of their son; Ronan was always welcome at work and home and treated as a respected and valued member of his family.
Ronan's father is a tradesman and Ronan had been his father's work partner since he was a teen. Ronan was welcome to come to the work site whenever he was able and his father was always welcoming and encouraging. Ronan's mother has also been an important and consistent person in his life. She is the family organizer. She made sure that he had food and that he got to his appointments. She helped him find an apartment and when he had problems with his landlord, she ran interference and tried to help him be successful in keeping the apartment. She also welcomed him into the family home. When his hostility rose to levels that left his siblings frightened to be with him, she set limits on his visits but did so in a loving and respectful way. Some of these discussions happened in my office and I observed the firm but caring way in which she interacted with her son.
Ronan and his family had worked with a family therapist before I had met him and this clinician remained involved in Ronan's life for many years. Ronan did not, however, find it easy to express himself with words. It was hard to know to what extent this form of therapy helped him but his therapist was another supportive and constant person in his and his family's life.
About 5 years ago, Ronan was violent again. His spells seemed to come out of nowhere and afterwards he had trouble explaining what had happened to him. At that time, I recommended that he try clozapine, a drug that is often helpful when others have not been effective. Since then, his recovery has been gradual but striking. He is now an active participant at the job site. He is not only welcomed at his mother's home but he is fully engaged with his family. When I met with them recently, she told me about the lovely and personalized holiday cards he made for each member of his family.
The use of clozapine has come with some serious costs. He gained over 80 lbs. But on this front, he is also changing. After years of talking with me and others about ways that he can change his diet, he has begun to loose weight and he has now lost 30 lbs in the past eight months. In addition, he recently stopped smoking. He has been clean and sober for over a decade.
I could not have not offered him medications. His violence was so severe and at the time I knew of no safe place where he could have gotten treatment in a medication free environment. I do believe clozapine has been beneficial to him but I also know that I can not be sure of this; perhaps it is a coincidence that he is doing better in recent years. There is no way of knowing. We have talked about slowly reducing his dose of clozapine but thus far, this is not something that he wants to do. I will be honest; in his case, I am not strongly advocating this although I would support him if that is what he choose to do. As I have done with so many of my patients, I have had a frank discussion with Ronan and his parents about Anatomy of an Epidemic and the implications of the research discussed in that book. I do not know what leads to his violent episodes. Neither does he. Beyond the risk his outbursts poses to others, including those who love and care about him most; these outbursts are traumatic for him as well.
The thing I feel most certain of with Ronan is that he has a remarkably loving and supportive family who have been his biggest advocates and important partners in helping him have a life full of meaning and value. I believe medications have played a role in his recovery but I feel even more sure that it has been his parents' consistency and love that have been most critical to his recovery.
Note: I have Ronan's permission to share this story although to protect his privacy, his name has been changed and I have tried to avoid using identifying information. Anecdote has its limitations. I have learned to respect each person's experience of the world and, at the same time, remember that my own version of the story is just that - my version.
Anatomy of a Psychiatrist: Dr. Steingard chronicles how she is integrating information from Anatomy of an Epidemic into her community mental health practice. She also discusses changes in Vermont's mental health system and the influence of pharmaceutical advertising on clinical practice.