I’m still not sure when it’s time to stop.

He was doing as well as everyone thought he would ever do: Though he insisted that the Ku Klux Klan was stalking him and stealing his thoughts, he was no longer breaking into churches for sanctuary. Though he was still drinking large volumes of alcohol to help mute the taunts of the Grand Dragon, he was drinking less—now just a couple of six-packs of beer most days of the week. Though he rarely experienced moments of subjective peace, he at least looked that way most of the time.

He and I got on well. A kind fellow, he was polite during our conversations. Initially, however, his discomfort was painfully apparent.

“How are things going?” I asked.

“Fine,” he blurted before I had finished saying the word “going”. He looked down, alternatively tapping his feet. Looking back up, he then asked in a stilted voice, “How… are you?”

As the weeks passed, he expressed more of his frustration with the Ku Klux Klan and his own thoughts. Though psychotic, he was clearly bright.

“I try to ignore the Grand Dragon. I know he can’t hurt me,” he bitterly commented. “I think I’ll find peace in the church, but I know it’s not a good idea to go back there. I don’t want to end up in jail again.”

But the moment he acknowledged that his reality may not actually be accurate, he slipped back into the comfortable shoe of fear.

“I hate them! They tried to break into my room last night. I don’t have anything in my room to block the windows except for my table and chairs!” he grumbled. “I can’t stay in Seattle anymore.”

The medication that he was taking was helpful, though perhaps not as helpful as the social connections he was slowly creating in his community. I encouraged this, even when he attributed his improvement to the medication.

“You’re experiencing a notable side effect,” I told him one day. “This could have long-standing effects on your body and I want you to stay healthy for as long as you can. Would you consider changing medications? These are the things that could happen….”

And, after I delivered my soliloquy, he simply commented, “Okay.” He furrowed his brows, perplexed, before adding, “I feel like I’m doing better on this medication, but okay.”

I unwittingly betrayed his trust. He did not do better on the other medication. He disappeared for days on end. Churches routinely called the clinic to report him as as trespasser. He went to jail. He began to wear multiple layers of black clothes in an effort to hide from the Grand Dragon. The tartly sweet aroma of cheap alcohol wafted out of his mouth when he spoke.

He looked terrible. He felt terrible, too.

“The Grand Dragon never leaves me alone and now there are crosses burning in my bones and I can feel the flames crawling along my bones and my muscles are bursting into flames all the time and the showers don’t help not even the cold showers and as much as I pray Jesus does not save me from the Klan and the stations of the cross do not protect me from the stations of the Klan radio that send flames to my body to burn in Hell forever and ever AMEN—”

I worried.

I shared my concerns with him.

“Do you feel like you’re doing better, worse, or the same compared to two months ago?” I asked.

“Worse,” he sullenly replied. “Much worse.”

We agreed to yet another change in medication.

“Fine,” he mumbled, his irritation apparent.

To his credit, he continued to visit me, though he initially made his frustration clear.

“I’m not going to talk to you today,” he said gruffly. “I’m not going to talk about the voices, I’m not going to talk about the Klan, I’m not going to talk about the church. I have nothing to say.”

Surprised and humbled, I nodded. “Okay,” I said quietly. Though I claimed frustration, it was nothing compared to his distress. What else could I say?

We sat in silence.

“The Klan keeps harassing me,” he suddenly said. I could then hardly keep up with what he was reporting: “The fires continue to burn in my bones and I am worried that I am getting shorter because my bones can’t regenerate after the flames eat up the calcium….”

The weeks passed. And his discomfort slowly disappeared.

After greeting me one day, he said, “I’d like to work. Maybe I can do recycling.”

“I think that’s a good idea,” I replied. “What prompted you to think of that?”

“I want to keep my hands busy. I want to work. I want to show the judge that I’m trying to do good,” he said. “If I’m working, I don’t pay as much attention to the Klan. And people then don’t think I’m so weird.”

Inside, I sighed. The agony of realizing that you’re so different from everyone else….

Everyone was telling me that he was doing better. He hadn’t broken into a church in months. He no longer discussed his perceptions of the Klan. He was taking showers on a regular basis, his clothes were cleaner, and he now shaved daily. He was talking more with his peers and drinking a six-pack of beer about every other day.

Objective improvement, right?

“Compared to a few months ago, do you feel like you’re doing better, worse, or the same?” Nothing but the medication had changed.

“Better,” he instantly replied. “Better. But the medication is like a sugar pill. Is it doing anything?”

I shrugged. I wasn’t sure.

But that was subjective improvement, right?

“Do you still experience the Klan harassing you?” I carefully asked later. It’s generally considered ill form to confirm the delusions of others, though I have certainly endorsed them in the past.

“Yes!” he replied without hesitation. “The Grand Dragon sometimes won’t shut up at night; I try to sleep and he continues to preach at me like I am the biggest sinner that ever lived….”

His face contorted with frustration and anger.

“How difficult is it for you to ignore the Grand Dragon?” I asked.

“He tells the Klan to torture me, he does, he does,” he continued. He never answered my question.

So I’m still not sure when it’s time to stop.

Indeed, his condition had improved clinically and he himself suggested that he was feeling better. And yet, there was still so much that could change. He was still tormented, he was still uncomfortable, and he was still psychotic.

When do we decide that this is the best that there is? How do we make that decision? Who makes that decision?

How can we know what is medication-induced and what is not?

A change in medication can result in clinical improvement… or, as he and I had already experienced, worsening of symptoms. How do we decide to take that chance?

How do we assess risk versus benefit?

How do we know if we are overestimating or underestimating the good judgment of others?

What exactly are our goals? What happens if the goals of the patient are unfeasible? What happens if my goals are unfeasible?

Just how do we know that we are providing the best care possible for our patients?

And how do we justify to ourselves and to our patients that the best care we can offer has actually hugely disappointing results?

I shan’t post anything for the next few days. Life will be offering competing interests.