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COMMENTARY

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.

You unfold a story, and that’s the beginning 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.

Next year he entered with a quicker step and talked more rapidly.

Job going well.

He went to the urologist who checked him out. The doctor said he was fine.

"It's not the erection, I told him, it's the ejaculation. It doesn't 'spurt out' as well as it did in the past. The urologist said, 'Can you run as fast as you did at 16?' I had to admit I got the point."

Last summer, his whole family went out to Connecticut to visit a cousin. His parents went, and he carefully named 6 or 7 aunts and uncles. The nieces and nephews were swarming all over the place. It was obvious he enjoyed them immensely, and I realized I hadn't known much about his family before.

I could tell he was starting to unfold a story, and that’s the beginning of psychiatry.

Thanksgiving he went to visit his parents in Indiana, and his father was in a nursing home. He had a minor stroke, couldn't move his left arm, there were gaps in his memory, but he could still speak and have a good talk.

"I looked around that place and there were all these old people sitting and staring at the floor. They weren't looking at the TV and they weren't talking to each other. They were just staring at the floor."

"Then I came back to my job and home in Wisconsin," he went on. "You see, I usually get my meals at a diner near my house, 3 or 4 nights a week. Everybody knows me, calls me by name, and there's a good deal of joking and horsing around. There's a strip club nearby and the girls come in for dinner too. The girls are joking and the waitresses and cooks join in, too. After I saw that nursing home, I just didn't feel like it. For several days, I didn't care about food, no appetite at all. If an attractive woman came in, I hardly noticed. I didn't care about girls and I didn't care about the Green Bay Packers. It was like I stood outside everything and nothing was important. That lasted 3 or 4 days and then it all went back to normal. I could enjoy the diner again and my sexual feelings came back."

"Very interesting," said I, drawing on years of clinical experience (and the back-swing is getting easier now), "What do you think was happening?"

"I was scared," he said, "I was scared I'd wind up in that nursing home. Scared the hell out of me."

"You bet," I said, "You were face to face with the Grim Reaper, something we'd all like to forget."

In the 5 minutes left, I mentioned as casually as I could estate planning (if that's your thing), the comfort of religion (ditto), the carpe diem option, and what St. Francis said if he knew he was dying next morning: he'd tend his garden and feed the animals. Also, Montaigne's: "I want death to find me planting the cabbages."

I thought that fit the location and his thinking pattern. Some crops take years to reach their peak.

Rising to go, he said it was good to talk with someone who knew the territory-he'd see me again next year. He gave me a long look and a quick solid hug like the players do.