Just take it

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The most common complaint I have heard on my psychiatry rotation is that of stress. Their job stresses them out, their husband stresses them out, the mountain of housework stresses them out, their to-do list stresses them out, their kids with ADHD stress them out. “Just something, just anything, doctor, to take the stress off.”

After the first week I could hear these complaints and realize that I did not have to have an opinion of the patient – I did not have to think they were whiny, or weak, as so many physicians not in psychiatry seem to do (or psychiatrists think and do not verbalize). I also did not have to judge that they were actually strong people who had had horrible things done to them in childhood and throughout life. I could just listen and evaluate dispassionately because, in the end, I was not responsible for figuring out the cause of their problems, nor, really, with their success in treatment. I could accept that this was the way this particular patient experienced the world. They saw stress everywhere, the world was overwhelming, and they believed that upon seeing the psychiatrist they would be presented with a pill, much like Morpheus (such a carefully chosen name) presented a choice of pill to his patient in The Matrix. In psychiatry, however, the patient cares not whether the pill is Red or Blue.

Note that, up until this point, I have not said anything judgmental of any patient I have seen, and that if you are feeling a rise of resentment in your chest at this uppity jerk who is posting some inconsequential reflection on his time in psychiatry…well, what does that say about you? I am going for introspection, not for judgment or valuation.

I have had multiple psychiatrists talk with me philosophically about the role of drugs in their field. One felt like prescribing medications just reinforced the belief of the patient that a drug would solve their problems. The medicines, in a sense, were preventing the patient from developing the coping skills they had never been raised to have by their parents, who usually were not around. He was an addiction specialist, and his argument frequently pertained to prescribing benzodiazepines. More interesting, however, is the discussion I had with another physician about anti-depressants.

There are times, I think, when physicians take a step back and realize how little they know. We prescribe these drugs that have been “evaluated” in randomized controlled clinical trials, which tell the public that a drug is legitimate, but just raise more questions to more than a few people. Not everything can be evaluated in numerical form. The fact that you answered the right questions on a depression screening does not necessarily mean that you have depression. The same goes for ADHD – “yeah, I suppose I do have times of distractibility,” the patient said yesterday, while playing angry birds on her iPhone.

Anti-depressants, as we know from the almighty trials, help in depression, and help to a degree that is directly proportional to how severe the depression presents. But what, really, are the long term effects? I am not talking about symptoms – sure you can have headache, or sexual dysfunction, or you pick your side effect as you read the package insert, but what about qualitative life outcomes?

You see, in our discussion we talked about how the Prozac you take may make you able to handle the stress in your life a little better. Your job is more manageable, your relationship more tolerable, your kids less ADHD-ish, but what if this outcome is not good? What if you just stay in a dead end job or an abusive relationship because you are better able to tolerate it? Is that successful treatment? I don’t think so. Or what if the reason why you have all your stress is not because of external circumstances but because of You? You, as a person, unconsciously desire a certain amount of stress and find ways to seek it out. Prozac lessens your stress, so you seek out circumstances that send it back to where your actual “set point” is. Scary. You take a bad situation and make it objectively worse, even if your subjective experience is the same.

The psychiatrist said that he didn’t believe that the case was as I described above, but he did say that some psychiatrists feel like it is, that medication may not actually help. What if the problem is not the red or blue pill, but the choice itself? Maybe the right choice is the hand you do not see and holds in its palm a mirror. 

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20 Responses to Just take it

  1. sdenheyer says:

    So, I have no qualifications in psychiatry, so what I say may come off as naive or ignorant, but I’m going to say it anyway because I feel that strongly about it…

    I’ve known a handful of people diagnosed with depression, every one of them was close to me, and every one of them was helped by antidepressants and CBT. I’m reasonably sure (to the extent that I can be sure about counterfactuals), that they would have had to grind through life being unbearably sad for no discernible reason if it weren’t for drugs and therapy.

    I know – the folks I’m talking about aren’t a representative sample, so I’ll try to talk about specifics. Your central concern is that people are drugging themselves into acceptance of poor external circumstances. Here’s where my ignorance may show – I thought this was what CBT was for. CBT (from was I’ve seen) is the recalibration of your interpretation of your emotional states based on evaluating external evidence which show you whether your reaction to them is appropriate or not. If it works, you should come out the other end better able to tell whether something in your life needs to change – so goes my admittedly basic understanding.

    Of course, I only see drugs mentioned in your post – not therapy. Maybe that’s the problem?

    To your claim that we don’t really know what we’re doing – this is true, but it is also true that there has never been a time in history when humans have not had to make Important Decisions under conditions of uncertainty.

  2. Joe says:

    Here’s a mirror in a hand you didn’t see:

    “I have heard” “I could hear” “I did not have an opinion” “I did not have to think” “I also did not have to judge” “I could just listen” “I was not responsible” “I could accept” ” I have not said” “I have seen,” “I am going for introspection” “I have had multiple psychiatrists talk with me” “the discussion I had with another” “I think,” “I am not talking about” “I don’t think so.” ” I described above,”

    • claudius says:

      This is a 1st person narrative, of course there are going to be a lot of “I’s.” The key is that the doc is using nearly all action verbs. Saying “I went for a walk” is not narcissism, it describes action. It’s not quantifying the self in relative or unquantifiable terms.

      • Joe says:

        While qubitman more directly implied that andon was a narcissist, my complaint was more about the writing style itself. It could be an indication of narcissism or it could be an indication of any number of other things, like that the author is insecure about the scope of his (her?) argument and wants to establish his perspective. Regardless, it’s a jarring way of writing that detracts from the argument being made.

        What is the subject of the post supposed to be? The “qualitative life outcomes” of people who are given psychiatric drugs. It’s hard to pick up on that because for the first half of the post the subject is “I.” Even when the subject of the sentence isn’t “I” the other people are all described almost solely by how they relate to the author. We’re not really allowed to imagine any of them, besides the girl/woman playing Angry Birds, and she’s only there to make a statement about how useless quantitative measurement can be.

  3. qubitman says:

    Congratulations on completing med school, doctor. You’re on the right track, but you’re too self absorbed to produce any actual analysis. Now, learn to get out of your own way. As the old saying goes “physician, heal thyself!”

  4. disorient says:

    To a patient my doctor would recommend a therapist for your concerns about the effectiveness of medication. Therapists are inconsistently trained and, unlike medication, overwhelmingly useless beyond the placebo effect.

  5. chomskyftw says:

    Admittedly, my own understanding of the issues at stake in this post comes from a graduate psychology degree, experience on Zoloft and Lexapro for anxiety and self-directed online reading, plus some CBT. I’m not a doctor.

    But I am struck by the slightly naive tone of this piece. Are these supposed to be revelations? They just seem like basic issues that a cursory reading of a Wikipedia page would provoke in the most remotely curious reader. This stuff isn’t covered in like, Psychiatry 101? If not, why not?

    Honest question, I’m curious.

  6. Guy Fox says:

    Despite the good intentions I’m sure qubitman and Joe think they have, they’re wrong. Sorry, fellas.

    What is the good doctor doing with this text? What does he express? He is not expressing anxiety about being exposed as a fraud, that his identity as a psychiatrician is in jeopardy of being revealed as sham, that he’s afraid reality will win when it inevitably conflicts with his preferred image of himself. That would be shame, and it would indicate narcissism, as I understand it, but it ain’t here.

    andon is worried that he, his peers, and the pharma-industrial complex are just patching their patients up well enough to send them back into their private phony wars. It’s just triage in the support trench so they’ll be good for another round in the front trench, or that’s what he’s worried about at least. Remember the scene in “28 Days Later” when Selena (a pharmacist) and Hannah (an adolescent virgin) are about to be gang raped by a bunch of crazed soldiers and Selena gives Hannah some pills? Hannah asks Selena “Are you you trying to kill me?” and Selena replies “No, sweetheart, I’m making you not care. Alright?” Well, andon feels something like Selena, and it must suck. A bunch. It’s the guilt of being/feeling powerless to relieve others’ suffering when you’re the Guy who’s supposed to be able to help. Maybe you Guys can help him a little.

    About the only thing I can tell you, andon, is to focus on your patients and to help them as best you know how. Don’t forget why you became a psychiatrist (or at least what motivated you to write this). Beyond that, I have an acquaintance who might be able to do more, but I imagine you’re already acquainted too.

    (P.S. andon, sorry if I reassigned one of your chromosomes with gendered pronouns. Force of habit. It’s a Guy thing. No offense meant.)

  7. Forsooth says:

    Some criticisms and objections on your writing.

    First: You do not sound like a doctor. Whether you are or not is irrelevant, but on an internet where you are made of nothing but words, your credibility (read: identity) is going to be judged based on your writing. The constant “I” that Joe pointed out may or may not be Alone’s narcissism, but the inadvertent repetition makes your sentences stiff and lazy.

    Second: You do not need a disclaimer, especially not one that betrays your insecurities (as an “uppity jerk”). It makes you sound defensive, like you secretly want us to criticize the patient, that you claim not to, and then abuse us for it. Intended or not, it’s dishonest.

    And no more Matrix references. Please. This goes for anyone who is not alone.

    Enough of that though, I’m starting to sound vitriolic. But phrases like “playing angry birds on her iPhone” scald me like liquid nitrogen. I’ll have none of your indoctrinated (-ing) idiosyncrasies.

    Anyone who is in the position to complain to relative strangers about stress caused from “the trenches,” as the Guy above me terms it, does not want to truly leave the trenches. It is the little man who says: “But are you, you who fight in the trenches, fighting for something worthwhile?”

    And Western nihilism retorts, fatly, as it rolls around to war: “Who are we to question the desire not to leave the trenches? One does not do such things, except the Church.” And lo, it justly smote the little man thus.

    Friendly advice: Take all my words with a dash of bitters and lemon peel. Remember, I’m just a dog on the internet, and I welcome both responses and ripostes.

    • Guy Fox says:

      I’ve said my piece about the piece, but this demands a reply:

      And no more Matrix references. Please. This goes for anyone who is not alone.

      Why? Because nobody is allowed to play with that idea? Alone has perpetual copyright? As if his concept wasn’t derived from Baudrillard, the Wachowski siblings, who knows how many studio staff writers, and who knows what else? Because riffing on it is derivative? As if there were anything purely original and derived ex nihilo?

      Do you think anyone can understand the phrase “I’m just a dog on the internet” who hasn’t seen the source from which you derived it dozens of times already? Forgive the pointed allusion, but do you think that’s air you’re breathing now?

      If you’re going to try to discipline your peers, please give us a little more info about your reasons than a tone of exasperation, advertising your own ennui.

    • Forsooth says:

      The problem (or my problem, if you prefer) with the Matrix analogy is that it is so ubiquitous that it is used now as little more than a shortcut. A quick signifier that paraphrases “I know how things really work here, and if you follow me, we’ll see a good rabbit hole” as a nonchalant but weaseling appeal for credibility.

      Think of it. What is it doing in the original piece? A springboard at the start, on which we ready ourselves to jump from for the duration of the essay, to then finally leap off of with the conclusion that we have “maybe” seen through the illusion of the pill choice in general.

      But I thought seeing through “illusions” was the red pill? The analogy just jumbled in on itself. It’s not a criticism of “originality;” this happens often enough I think to justify dissuading others from using it. I’ll admit, the “alone” bit was wordplay that sounds better than “unless you are really sure you know what you are doing;” which is frivolous as all always assume “of course!” I’ll abstain in the future; our pirate has enough parrots.

      It’s dandy to encourage, but one cannot just say “good job, keep going” while translating for other readers. I’m fine with bad-copping it, as long as we see better writing from andon and others in the future.

  8. Comus says:

    Medicine and psychiatry are lodged deep into the market surrounding them. Therefore the aim is not to better the subjective well-being of individuals, but to keep them consuming and working. We have chosen to only keep the former part of Freud’s definition [Actually qua Erikson, unattributed] of mental health being the ability to work and love. Not unnoteworthy is that we do this by prescribing drugs (you have to consume something).

    I rarely meet psychiatrists who agree that drugs are the best sole possible treatment for nearly any mental disorder, yet when they are face-to-face with the grim realities of the health care system, the neverending queues of patients, the unbearable need and misery, the helplessness, the productivity evaluations etc etc the cognitive dissonance kicks in. It does not mean they don’t care or want proper care for their patients, they just are stuck in a system that has little place for humanism and caring. These are not productive views. I think this helplessness qua projected saviourism is why there are so many suicides in the mental health professionals. Easy way out, which can be explained as decent care by some proper randomized controlled studies [after all, who can assume you have the time to critically go through the debate of desk drawer studies, of pharma-funding, of ghost-writing etc of the industry (yet there being that gnawing feeling of that maybe something as bit off)] is to prescribe the drugs, explain it away in bio-reductionist views, make sure the patient’ll somewhat live and move on. You’ve done your deed to the better of your knowledge [you know you can explain this away if need be].

    There are for example studies in scandinavia (somewhere in mainland Finland) where they trained all willing mental health staff (150+) who work at a psychosis ward as psychotherapists, and made remarkable progress in drug-use, in-patient days, delays of retirement, subjective well being and recurrence rates when compared to standard care (in Stockholm, I think). This however was not cost-effective enough to prolong or generalize the standard.

    A quick last thought on the self-rating questionnaires (BDI etc.) used in studies (or physician-rated like MÅDRS, HAM-D). Do you really believe this gives objective information? That the patient or physician can not see through the “aim”? That it does not care to whom the test is filled out for (do you for example think that people will answer the same way when applying for an early retirement or insurance benefits or when going through an pre-job examination?) That the placebo-effect/optimism bias does not transport itself to the questionnaire?

  9. andon says:

    Thanks for your criticisms. I am not yet a physician; I will not be a psychiatrist. I write short things like this about twice a rotation, and this is the first time I have posted one, kind of on a whim. I know a lot of the shortcomings of the medical field, which seem to exist largely because of the sword hovering over doctors heads (I’ll stop using tired analogies, last one I promise).

    The heart of my musings is that I want what I do to matter, which may be narcissistic, naive, or both. You can judge from your armchair as an internet scholar who countertransfers through comments.

    Alone talks a lot about narcissism, but never discusses the solution because, God forbid, he might not know it. He ends with the mirror in the hand frequently, but a diagnosis is not the treatment. He’s busy with his bottle of rum, anyway.

    • Tim says:

      I’d be really interested to read your thoughts on other specialisms, either as you do the rotations, or from your old notebooks. Psychiatry is a bit of an aberation, in that the diseases it treats are in many cases obvius, but the cause and effective treatment not so much. So no matter what you do, you will never know if you did the right thing.

      Regarding medication, I think the problem is that people have trouble thinking in terms of big numbers. Even according to The Trials, many patients will show no positive effect, and those who do improve will probably only do so a little more than they would have anyway.
      But over a large number, that is important. To assess in cold economic (and, as you say, perhaps fundamentally the wrong) terms, if hypothetically 1 in 10 patients ‘recover’, and each patient costs a large amount in lifetime economic impact, then it is most certainly worth spending the drug money. But for the hypothetical 9 in 10 who don’t, it’s hard math to understand. They heard there are drugs that make them better. It was on adverts.
      I think the same sum is true in more human terms too.

      If anything, psyciatry reminds me of palliative care. You probably won’t fix these people. You might make them a little better for a little while, and that is valuable. Or you can drug them so it hurts less, but at what cost. But patients don’t expect paliative care to make them better, because they have been told not to.

    • qubitman says:

      It’s impossible to cure narcissism because the intent spoils the attempt. You want to be free from your self absorption so you can become the false ideal of yourself you’ve created. It should be clear why this is impossible, and very silly. If you weren’t a narcissist you wouldn’t have a false ideal that you would want to achieve, but then trying to abandon that false ideal is just a more insidious version of that same narcissism, because you’re trying not to care about that false ideal so that you can win at the game of “I’m not a narcissist”, which is itself a narcissistic game.

      If you’re watching it, it’s for you. You are here because you’ve been going along thinking there is a problem to be solved, and thankfully TLP and pastabagel have given us a space to play our game of “I’ve got a problem that can’t be fixed”, but you will eventually realize this is all a big hoax. You’re playing a trick on yourself pretending that you have a problem, that your life matters, and that something needs fixing. If this doesn’t satisfy you, try exercise and meditation. 10 minutes of either a day should be plenty. Both if you’re ambitious.

  10. Klosterheim says:

    Thanks, I enjoyed it a lot ! I honestly think you would have other interesting things to write and I’m kinda waiting for them.
    Wondering how you think it relates to psychiatry and to the way people try to do good things in general, around this particular issue : what if making people happier individually wasn’t necessarily the best way to help humanity as a whole in the long run ? I don’t have an established opinion on the matter but it might be interesting to think about. What if helping starving african kids or depressed businessmen was just like that, except on another level ?

    Also, to people accusing him of being a narcissist : you guys know nothing. You’re just looking for someone you can direct your righteous knowledge towards. Read the blog again.

    • Guy Fox says:

      ‘Humanity as a whole’ is kind of a scary idea. You might be able to help people, but ‘humanity’ is more of an idea, which means that any proposal will be an ideology, which, to paraphrase Einstein, would be just another idiotic fiction in the name of which we’ll hate one another. It’s absolutely sensible and admirable to want to help suffering people in East Africa, but who really gives a $hit about helping ‘Somalia’? ‘Humanity’ sounds like one of those ideas that could be used justify trampling on a lot of people. To make it sound less scary, you’d have to give me an idea what you think ‘humanity’ is for, what’s the goal to be pursued, what it’s supposed to mean, and why you think everybody will get behind it without being herded. Individuals can find meaning in their existence and choose sensible goals to pursue, but humanity? yikes.

      It might also be that psychiatry can’t and shouldn’t make people happy. Showing them why and how they’re making themselves miserable and leaving the happiness up to them might be as good as it gets.

      • Klosterheim says:

        Yeah sorry, didn’t make myself very clear. I didn’t mean “humanity” to be beyond individuals. It’s supposed to convey the idea of “all the individuals”, including the ones around the ones you help and the ones who aren’t born yet.
        For example, if as a psychiatrist you treat a dude and end up making him happier, good. But if the dude has a daughter who will have a son who etc, isn’t it infinitely more important to make him a better father ? What if this doesn’t make him happy ?

        Another angle : I sometimes feel like any real political change is impossible because people got far too good at maintaining the status quo. If the system (individuals who form governments and corporations etc) decides to do something good (doesn’t matter what “good” is for the purpose of this argument) once in a while, people are satisfied that it did. But you can’t make the system care, so what we’re doing is waiting for the time when we can be manipulated into whatever decision it wants to make, without ever changing the way it all works / without ever leaving our boyfriend.
        Very simple example : economy wants oil, war is a bad thing, eventually plane crashes into tower, people want to stop the war, future president makes promises, people are satisfied.
        You don’t have to agree but I’m pretty sure it’s comparable.

        It’s still not very clear and I’m sorry about that, kinda trying to find ways to make this point. Anyway, see what I mean ?

        • Guy Fox says:

          As to your first point, if you mean that what people want isn’t always what they need and vice versa, I agree, but you gotta be careful about telling them what they really need or should want.

          As for your second point, I fear the same. Don’t try to bend the spoon. You’ll drive yourself crazy.

  11. dan says:

    First time commenting… not a psychiatrist… but I very much resonate with this line of questioning:

    “What if you just stay in a dead end job or an abusive relationship because you are better able to tolerate it? Is that successful treatment? I don’t think so.”

    I have spent the last twelve years working with various homeless and street-involved populations. For seven years, I worked within a residential program for “youth” (16-24 years old) who were street-involved and either at risk of experiencing homelessness or who were already experiencing homelessness. During that time, I noticed a significant increase of psychiatric involvement with our clients and an equally significant concomitant increase of diagnoses and and prescriptions given to the clients (every one of our clients who saw a psychiatrist received a diagnosis and a script). When I began, a minority of residents were medicated. When I left, the vast majority were medicated. Are you a seventeen year old female who was sexually abused by your mom, bullied at school, and now you have trouble being motivated to get out of bed in the morning? Obviously you’re bipolar! Get out the Quetiapine!

    Of course, some would say that this is a sign that the agency was simply getting better at identifying and addressing health problems and barriers experienced by our residents… but I really do wonder about what seems to be an increasing pathologization of people who are experiencing homelessness or poverty (which is going hand-in-hand with an increasing criminalization of the same population…). I then got to thinking about the various movements that were struggling for change at the beginning of last century — labour groups, immigrants, anarchists, feminists… all working hard, risking their own lives and the well-being of their families, in order to try and produce some “big picture” change. I can’t help but wonder how much of the limited successes they achieved (which are now being scaled back more and more) would have been attained if they could simply be medicated and made to feel at peace with their shitty situations. I mean, if things are fucked, isn’t it healthy to be depressed about that? If we are happy in that situation, isn’t that a sign that we’re fucked?

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