As I was reading Ezra Klein and Derek Thompson’s Abundance last year, I couldn’t help but think back to a powerful line from the book Health Communism (2022) by Beatrice Adler-Bolton and Artie Vierkant:
“We call for a radical abundance of care that functionally casts off centuries of ideologies of austerity, subjection, and extraction.”
The logic of scarcity, the separation of the “deserving” from the “undeserving” when it comes to clinical care, is deeply problematic. One doesn’t have to be of any particular political orientation to hear the force of that claim.
The answer to the crisis of care, I believe, is more and better care. I do not want to take away the imperfect tools we have to help people. I want us to give people more of what they need. I am of course in favor of curbing inappropriate psychiatric prescribing, unnecessary psychotherapy, waste of community resources, etc. etc., but in my heart, what I really want for all of us is a radical abundance of care.
The problem with medical and psychiatric care is not necessarily that we do too much but that we do too much of some things because we have constrained the supply of all the other things. This is, in effect, the Abundance argument applied to the clinic: the problem is not excess but artificial scarcity.
The more I practice, the more I believe that attention is the rarest and purest form of clinical generosity. The system is organized around scarcity of attention and time. It is relatively easy to ask for and be prescribed medications, but quite difficult to see a physician who actually cares and listens and thoughtfully attends to diagnostic work-up and treatment risks and patient concerns. The default attitude in medicine today is one of impatience.
In a system of scarcity, of course we get inappropriate prescribing and superficial therapy, because we are over-relying on what is easily available. I find it odd that so many smart colleagues in prior decades have focused on expanding access to psychiatric medications as the primary issue, as if the mental health crises we face can be addressed by something akin to putting SSRIs in the water supply. An abundance of good clinical care also means an abundance of support and guidance for deprescribing. Careful, case-by-case deprescribing is good care, and I want more of it.
I have spent my psychiatric career thinking about what it means to help people in states of distress, impairment, and vulnerability, and thinking, too, about the ways our systems of care go wrong. I am genuinely sympathetic to concerns such as over-medicalization and practices such as deprescribing (make deprescribing boring, as I’ve said). These are important issues, I do not think we should neglect them, but they are far from the organizing principles for me.
There are many critics of psychiatry, psychology, and medicine who act as if they hate the treatments we have to offer more than they care about the suffering humans. Or rather, the suffering they truly seem to care about is iatrogenic suffering. Of course, the actual motivations of critics are much more complicated and defensible than that.
Concerns about over-diagnosis and over-medicalization are also driven by a crisis of trust. Conceptualizations and treatments are forms of power, and there are many today who are wary of the power of the healthcare system. And they resist expansion of diagnoses not necessarily because they are blind to the suffering involved and the need for assistance, but because their overarching concern is to limit and oppose the institutional power of medicine. My relationship with medicine and clinical care doesn’t start from mistrust; it starts with the assumption that medicine is deserving of public trust and capable of honoring it, even when it has fallen short of it in practice. Which is one reason why I feel ill-at-home with the overdiagnosis and deprescribing crowd. I am wary of movements that focus on a subtractive agenda, one whose primary ambition is to take things away from people. Too many critics want to take away clinical care they believe to be unnecessary and harmful, and doing so is a bigger priority for them than actually relieving human suffering in effective ways.
In 2023, James Davies, John Read, Joanna Moncrieff, and other co-signatories (over thirty in total) published a letter in the BMJ calling on the UK government to “reverse the rate of antidepressant prescribing.” The priority—reflected in the title of the letter—was not to call on the British government to ensure that people get the right care and supports, whether in the clinic or in the community. The priority was to have fewer people on antidepressants. I do not think I can support a cause that cares more about fewer antidepressant prescriptions than about facilitating access to help that people need.
Most real-world people I’ve met who’ve been unhappy with psychiatric and psychological treatment don’t want less treatment. They want better treatment and more of it. Most real-world patients I’ve met who are worried about medication adverse effects want a prescriber who cares, who is attentive and thoughtful, and willing to inform them accurately and address their concerns, and troubleshoot the tangle of symptoms-comorbidities-iatrogenesis-stressors with them, and discuss trade-offs between symptom improvement and adverse effects, and facilitate their decision-making.
When a patient has ready access to a full range of options, then medication becomes one tool among many, chosen deliberately, not defaulted to out of desperation. Under conditions of an abundance of relational care, the reliance on prescribing becomes easier to remedy. Under such conditions, whether one in six or one in twelve individuals are on psychiatric medications matters far less; it is not a source of alarm, because the people who are on medications are on them because of their informed choice amidst a variety of treatment options available to them and because they believe the ongoing use of medications is a net positive for them and they have the resources and support available to them to safely come off them when they so choose.
For those unaware of the reference, I’m riffing on a famous quote by Simone Weil: “Attention is the rarest and purest form of generosity.”
In 1927, the Harvard professor Francis Peabody famously noted that, "The secret to the care of the patient is caring for the patient." In mental health, caring means much more than a prescription or a therapy hour. Radical abundance -- in line with Ezra Klein and Derek Thompson's approach to socio-political issues -- reminds us that we have a lot to offer to people struggling with a serious mental illness. There are clubhouses and ACT teams and supported employment and a world of other psychosocial supports that are keys to recovery but lack a CPT code and therefore belong to the kingdom of scarcity. Coordinated Specialty Care is still tough to cover with Medicaid reimbursement in most states. Physical rehab for 6 months following a femur break - no problem. Psychosocial rehab after a psychotic break - not so much. Imagine what we could do for people with serious mental illness if we focus less on restrictions and more on "caring" even when that moves outside the bounds of what today a prior auth review deems as "medical necessity."