Some clinical anecdotes are irresistible.
A 55-year-old gentleman with a vague history of schizophrenia was brought in by a community support worker for a new evaluation, apparently at the behest of a family member, although there was no report of specific symptoms or dangerous behavior. But he had recently moved back to the area, so maybe the family just assumed he ought to get an evaluation for regular treatment.
He presented as somewhat disheveled, with a glazed look in his eyes; he was calm and pleasant enough, albeit quite flat and concrete, answering questions minimally. He couldn't or wouldn't say much about his psychiatric history other than to acknowledge the diagnosis of schizophrenia, multiple previous hospitalizations, and the experience of monthly injections at some point in the past. "What brought you back here from Texas?" "Greyhound bus." For a fleeting moment I thought he was wryly joking (for which his manner otherwise certainly would not have prepared me), but no such luck. So I settled myself uncomfortably into the plane of the literal for the duration.
When I asked him how much alcohol he drank, though (I long ago stopped asking people whether they drink, and now go straight to how much), he answered, "As much as I can." For a second again I wondered about some sly humor on his part, but he was deadpan. Yet his response had the kind of upbeat, slightly dutiful tone one might use to answer a question like "Do you get regular exercise?" But he wouldn't quantify.
So I moved on to marijuana (for which I have also recently moved directly to asking how much)--the complacent yet somewhat eager reply was, "As often as I can get it." "How often is that?" He just shrugged. On to cocaine, for which I still ask whether rather than how much. "Crack," he assented, nodding with an attitude somewhere between satisfaction and gusto. "Do you think any of those drugs could be a problem?" Incomprehension. "Has anyone told you these substances could be bad for you?" "No, nobody ever told me that!" he countered, baffled yet dismissive.
The interview unwound from there. As we returned to his diagnosis, I learned that he had actually "gotten over" his schizophrenia. "Would you consider taking medication again?" "No." (There was more to it, but this was the gist).
In a world of duplicity and innuendo, particularly surrounding substance use and treatment compliance, this was actually refreshing. There was no need to dance around the facts, as it was abundantly clear that he had no use for me, and our relationship at this point could blissfully and neatly come to an end. No hard feelings.
The community support worker, driving him home with a couple of other patients from the same area, stopped at a store to pick up something. The fellow went in and emerged with a beer; upon being told that he couldn't bring the beer in the car, he proceeded to chug it in the parking lot.
One more thing: he does receive Social Security disability payments monthly. Tax dollars hard at work.