into her illness, meaning she does not believe she is ill. Yet Katie is sick, whether she knows it or not, and she sees me once a month for both medication and therapy to keep her well. Thanks to this routine, she has been stable for nearly 30 years. She is often wary of people, but she has not tried to harm others or herself. It has taken me two years to chip away at her gruff exterior. The first chip was accidental.
I was rewarded with her laughter, a warm sound for the typically cranky woman. “No. No such thing as pixies. And we did all right—my mother cleaned houses … But we couldn’t be wasting expensive milk.” Our relationship stuttered along after that, often wordlessly. I read her body language and recognized her weighty pauses. We sat in silence, appreciating speech instead of expecting it. Sometimes she smelled terrible, which told me she was having a bad month. People with schizophrenia often have poor hygiene. When we began meeting, I silently promised her I would heed these signals, that I would respect her communication style.
For many outpatients, psychiatrists have switched to remote visits. Like many psychiatrists, I resisted this change at first. I enjoy face-to-face therapy visits. Without a good alternative, I have settled into the new normal over the last few months and started seeing patients from my kitchen table. Both psychiatrists and patients reportthe flexibility and newfound freedom. For many of my patients, it works even better than our usual model.
This trajectory is common for people with schizophrenia. I can pick up on early subtleties like poor hygiene in person. Suspicion and paranoid tendencies often reveal themselves even in brief conversation. I can see a patient respond to internal voices in the office. Without face-to-face appointments, it is more difficult to know if the warning signs are there.
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