A few proposed principles for a balanced psychiatrist

Psychiatrists working within our current mental health system often complain they have no choice other than to practice as they do, which usually involves, for example, prescribing neuroleptics, otherwise called “antipsychotics” for everyone who seems to be having symptoms of “psychosis.”

I recently wrote down some principles I believe a psychiatrist could follow even while working within our current system, that would achieve a better balance between the possible benefits and risks of this kind of medication. In my practice as a non-prescribing therapist I haven’t had a chance to work with any psychiatrist who follows such principles, but I would like to be able to!

For people who come in with emerging problems with psychosis, I would want the psychiatrist to:

• Not assume that people were coming to him or her for medication. They might be coming just because the psychiatrist is seen as the highest authority in mental health care, and the person doesn’t want to mess around going to less than the highest authority when facing a serious problem. Instead, check in with people, what did they come seeking?

• Make sure the person knows that the medication will not do something like correct a known “biochemical imbalance.” People are likely to be coming in having heard this from various sources, and this may be motivating any requests for medications. People should end up on medication due to having believed misinformation, even if the psychiatrist was not the source of that misinformation.

o An alternative, shorthand explanation for what neuroleptics will do is, create a drugged or medicated state that relieves stress. By increasing indifference, the stress that is creating symptoms may be relieved enough that they fade, at least partially.

• Let the person know that there is a lot the psychiatrist doesn’t know about that person, and so the psychiatrist can’t say anything for sure about how the person will do if they try the medications or if they don’t, each case is highly individual.

o That is, some people recover without ever taking medications even at the level of psychosocial treatment currently available. Recovery at times is even very swift once a person feels understood, so it is even possible that waiting a few days or weeks could provide a chance for recovery to happen without medications. Some seem to need the medications more than others, at least for awhile. Some take the medications but get little or no help from them.

o Since there is uncertainty, decisions could best be made jointly, with the understanding that they are based on guesses or estimates that may not be accurate. The psychiatrist could protect him or herself from liability in a legal system that is more likely to acknowledge harm from lack of medication than it is to acknowledge harm from medication, by letting the person know that medications are an available choice for the person as the psychiatrist is willing to prescribe them if the person wants them (unless the problem seems too minor for there to be even a significant chance that the medications might be a reasonable choice.)

• Make sure people are aware that relying on medications may make the problem worse in the long run. So the person should be told that if they do start on medication, the goal should always be to get back off of it as soon as this can reasonably be done.

• Therapy should be suggested. If the psychiatrist does not do therapy or can’t do it in a way the person can afford, then refer whenever possible to a therapist who does work well with psychosis. Explain that therapy over time, if successful, can help the person get off the medication, though this is not easy.

o The psychiatrist, or the therapist that the psychiatrist refers the person to, should be able to educate the person about how there are many factors in addition to therapy that can also make a difference. This includes lifestyle issues, various sorts of interpersonal connections and supports, taking an experimental attitude and paying attention to what works for that individual, self help like hearing voices groups, and getting informed about alternative perspectives on psychosis by reading books, reading recovery stories, and going online to websites like intervoiceonline.org, etc.

• Make sure the person knows that while being psychotic can play a hugely destructive role in one’s life, and so there is lots of reason to try a neuroleptic, there is also a large list of problems, many of them extremely serious, that can be caused by the neuroleptics.

o Make sure the person has access to a good written explanation of all the possible “side effects” and long term consequences of neuroleptic use, that covers all the stuff the psychiatrist doesn’t have time to mention in the session.

o The existence of all these “side effects” could be explained as being another reason to work to make sure any use of neuroleptics is temporary, if at all possible.

• Also, the severity of the psychosis and its likely impact on the person’s life given their situation should be weighed into the decision of if or how much medication to use. The psychiatrist should be able to explain how the experiences and behavior we call psychosis exist on a continuum with other reactions to life, that voices can be considered a variation on automatic thoughts which we all have and that many people hear voices and don’t need help, that many (or perhaps even the majority) of people have at least a belief or two that the mental health system sees as delusional, etc. This helps reduce “fear of madness” that may be making things worse, and makes it less likely that a person who is only mildly psychotic or who is fortunate enough to live in a forgiving setting will feel forced to immediately try neuroleptics.

• Make sure the person knows that once on the medications for weeks or months, withdrawal can be problematic and is best done slowly. Problems that emerge during the withdrawal process may be from doing it too fast, and should not be taken as proof that adjustment without medications is impossible.

This may seem like a lot for a psychiatrist to accomplish with a person, but I think these are all pretty important things to address.

I’m curious to hear comments about these principles from my readers. Do any of the above seem like they are wrong, or “too much?” Did I miss anything that would be important to include?

Some might see these principles as “anti-medication” but I think they could instead be interpreted simply as involving a careful weighing of benefits versus risk, and allowing the person who might be taking the medication to participate in that decision from an informed position.

I know it is tricky with people who are in disorganized states of mind to involve them in decision making. In cases where people don’t seem able to absorb much, the psychiatrist has to be careful not to “throw” the decision by, for example, talking up the risks of medication too much with a person who hasn’t yet had insight into the risks of being in a psychotic state. So in those cases, the trick would be to stay balanced about both possible benefits and risks, avoiding going into too much detail on one side before balancing it with information on the other side, all the while attempting to expand the dialog to include more information.

Often debates about medications break down into whether they are “good” or “bad.” I think more helpful discussions might focus more on how to support the wisest possible decisions about when to use them and when to not use them.

Anyway, your comments?