We must also acknowledge that psychiatric medications are just one of many tools people use to modulate their mood, identity, and sense of self. People turn to their smartphones, scrolling through curated feeds; they reorganize their homes; adopt rigid fitness routines; spend hours immersed in work or caretaking; meticulously track habits and sleep; or build identities around aesthetic lifestyles or spiritual practices. These are not chemical substances, but they serve a similar purpose: to regulate experience, to feel a certain way, to exert control over inner life. And people often have ambivalent relationships with these as well. They provide relief and also create dependence. They offer stability and provoke self-questioning.
To isolate psychotropic medication as something categorically different—rather than a formalized, studied version of something humans are always doing—risks reinforcing the false belief that emotional self-regulation through medication is unnatural or illegitimate.
Of course, medications have distinct considerations: withdrawal syndromes, side effects, pharmacological impact on brain function. But they do not exist outside the web of self-shaping choices and tools that people reach for in modern life.
It’s also worth remembering that the impulse to regulate one’s inner life—moods, thoughts, energies, identities—is not a modern invention, nor is it unique to psychiatry. Long before SSRIs or diagnostic manuals, human beings turned to ritual, prayer, movement, storytelling, community roles, aesthetic expression, and environmental attunement to navigate psychological pain and existential confusion. To set psychiatry apart as the sole or primary discipline capable of holding these complexities privileges the field in a way that distorts history and dismisses millennia of human effort to grapple with the same questions: What does it mean to suffer? How do we endure? What helps? When we act as if psychiatric frameworks uniquely accommodate ambivalence and meaning-making, we inflate the importance of psychiatry and obscure the broader, older, and often more culturally rooted repertoire of tools that people have long drawn upon. The question is not whether someone should or should not take medication; it is whether we are expanding the conversation beyond it—asking what else might be possible, what other sources of coherence, connection, or relief could be available, particularly in an era when psychiatry has grown over-important as a primary methodology for self-betterment. We need a wider lens, not a narrower one.
My concern may be an artifact of the fact that you have been on this theme of "to medicate or not to medicate” but I'm beginning to wonder if you don't demand ambivalence of your patients. If there was a standard questionnaire regarding satisfaction with medication that would depersonalize the question. However, patients may be tempted to please you by the wrestling with this issue when it is actually not that big a deal for them.
A fair concern. I myself (try to) approach the issue in a pretty open-ended manner. It's not a big deal for most of my patients, and thank heavens for that!
I suspect you are quite practically-minded about these issues and I suppose that approach works well enough for the patients you see. It is obvious to me as a clinician that some patients struggle with these aspects and other psychiatrists who have paid attention to this phenomenon also find that it is a common occurrence. In specialized settings (such as Austin Riggs, where David Mintz), considerations around meaning attributed to medications can even be the primary reason for “treatment resistance”
I'm not sure if we're making the question of what drugs do needlessly convoluted. Humans have had no difficulty explaining the effects of alcohol with simple clarity for millennia, yet when it comes to prescription medication it seems we get very contrived about it. It seems to me we run to either of two extremes: biobabble straight from the manufacturer’s handbook, or we start talking about philosophy. The doors of perception type stuff was big in the 60s, now it's usually postmodern babbling about the intersection between the drug and us and our social context, blah blah blah. The point is, whatever form the babbling takes, be it biobabble, psychobabble, philobabble, we can't seem to stop ourselves from babbling about prescription psychotropics. I think it's because speaking with clarity about psychotropics is taboo. The social expectation is that you either speak in the strictest establishment terms or you speak in terms so abstract they can be excused as religious freedom of expression. What you can't do is say in plain terms what the drugs do to Tom or Sally.
Think about alcohol again for a moment. Most of us were at some point introduced to it, hopefully not by a minor, but regardless, the person who introduced you to it, what did they tell you about it? Did they say, "When you drink it, you'll find that it raises the amount of GABA in your brain and you'll feel calm"? Did they say, "You'll need to drink alcohol for roughly six weeks before you'll start noticing changes. Come and see me next week to see how it's going"? Did they say, "Everybody responds differently to alcohol. When I drink it I can't pee for a week and everything smells like fish"? Or did they say, "You'll feel relaxed and then if you drink more you'll get tipsy"? I'm willing to bet it was something close to the last, which is a clear, straightforward description of what happens when humans drink alcohol. You'll notice I don't think you would have been told "everybody responds differently," because while some personal variation is normal, and while the mood you're in before you drink may have an effect, and while your social or contextual motivations for drinking may also affect your experience, broadly speaking, most people just get drunk.
Anyway. I think it was in Max Fink's book on melancholia. He was discussing treatment, and he said something to the effect that, based on the clinical picture, he only liked to prescribe a tricyclic if he was confident of achieving at least an 80% remission. So then, are we just philosophising as a way of rationalising piss-weak responses? Should we be shooting for less ambiguous results?
On another aspect, about a year ago I joined a withdrawal support forum for the drug lamotrigine. At first I went there for help and understanding, but very quickly I became fascinated by the nature of drug reactions. The question of what it is about a drug that makes someone markedly worse, to me, may be more fertile ground than what is happening when it makes someone better. I was always taken with Koukopoulos’s equal focus on improvement and worsening under treatment, the way he spent just as much time studying those the drug made more ill. This is a fascinating group, and the cases to be found cut right at the heart of some of the greatest riddles of psychiatry: mixity, borderline, rapid cycling, akathisia. And women... there is something in there that is about women.
I'm a psychiatrist.
We must also acknowledge that psychiatric medications are just one of many tools people use to modulate their mood, identity, and sense of self. People turn to their smartphones, scrolling through curated feeds; they reorganize their homes; adopt rigid fitness routines; spend hours immersed in work or caretaking; meticulously track habits and sleep; or build identities around aesthetic lifestyles or spiritual practices. These are not chemical substances, but they serve a similar purpose: to regulate experience, to feel a certain way, to exert control over inner life. And people often have ambivalent relationships with these as well. They provide relief and also create dependence. They offer stability and provoke self-questioning.
To isolate psychotropic medication as something categorically different—rather than a formalized, studied version of something humans are always doing—risks reinforcing the false belief that emotional self-regulation through medication is unnatural or illegitimate.
Of course, medications have distinct considerations: withdrawal syndromes, side effects, pharmacological impact on brain function. But they do not exist outside the web of self-shaping choices and tools that people reach for in modern life.
It’s also worth remembering that the impulse to regulate one’s inner life—moods, thoughts, energies, identities—is not a modern invention, nor is it unique to psychiatry. Long before SSRIs or diagnostic manuals, human beings turned to ritual, prayer, movement, storytelling, community roles, aesthetic expression, and environmental attunement to navigate psychological pain and existential confusion. To set psychiatry apart as the sole or primary discipline capable of holding these complexities privileges the field in a way that distorts history and dismisses millennia of human effort to grapple with the same questions: What does it mean to suffer? How do we endure? What helps? When we act as if psychiatric frameworks uniquely accommodate ambivalence and meaning-making, we inflate the importance of psychiatry and obscure the broader, older, and often more culturally rooted repertoire of tools that people have long drawn upon. The question is not whether someone should or should not take medication; it is whether we are expanding the conversation beyond it—asking what else might be possible, what other sources of coherence, connection, or relief could be available, particularly in an era when psychiatry has grown over-important as a primary methodology for self-betterment. We need a wider lens, not a narrower one.
Thanks Amit! I completely agree (and I hope the post didn't come across as implying otherwise). I appreciate that you stated it so well.
My concern may be an artifact of the fact that you have been on this theme of "to medicate or not to medicate” but I'm beginning to wonder if you don't demand ambivalence of your patients. If there was a standard questionnaire regarding satisfaction with medication that would depersonalize the question. However, patients may be tempted to please you by the wrestling with this issue when it is actually not that big a deal for them.
A fair concern. I myself (try to) approach the issue in a pretty open-ended manner. It's not a big deal for most of my patients, and thank heavens for that!
I just don't get it honestly
Asking patients if they think the drug help, and if they want to continue taking it takes 30 seconds
What are you talking about during the 30th interview anyway
There are loads of issues with psychotropic drugs, low efficacy, some terrible side effects, diagnosis uncertainty, the list goes on
But the issue of "patients take drugs buy they're not sure if its worth it" can be solved with a simple try of lowering or removing the offending drug
I don't mean to come of as asaulting you Awais as those issues are indeed ever present in psychiatric talks on medias nowadays;
I just don't encounter that issue much in my practice (I *think* I don't at least)
I suspect you are quite practically-minded about these issues and I suppose that approach works well enough for the patients you see. It is obvious to me as a clinician that some patients struggle with these aspects and other psychiatrists who have paid attention to this phenomenon also find that it is a common occurrence. In specialized settings (such as Austin Riggs, where David Mintz), considerations around meaning attributed to medications can even be the primary reason for “treatment resistance”
most likely the pratice (more so than the setting) is very different
I just want to emphasize it's not that I find those matter irrelevant, I actually read Mintz's book a while ago when it went out
I just find myself handling different issues before that comes into play
I'm not sure if we're making the question of what drugs do needlessly convoluted. Humans have had no difficulty explaining the effects of alcohol with simple clarity for millennia, yet when it comes to prescription medication it seems we get very contrived about it. It seems to me we run to either of two extremes: biobabble straight from the manufacturer’s handbook, or we start talking about philosophy. The doors of perception type stuff was big in the 60s, now it's usually postmodern babbling about the intersection between the drug and us and our social context, blah blah blah. The point is, whatever form the babbling takes, be it biobabble, psychobabble, philobabble, we can't seem to stop ourselves from babbling about prescription psychotropics. I think it's because speaking with clarity about psychotropics is taboo. The social expectation is that you either speak in the strictest establishment terms or you speak in terms so abstract they can be excused as religious freedom of expression. What you can't do is say in plain terms what the drugs do to Tom or Sally.
Think about alcohol again for a moment. Most of us were at some point introduced to it, hopefully not by a minor, but regardless, the person who introduced you to it, what did they tell you about it? Did they say, "When you drink it, you'll find that it raises the amount of GABA in your brain and you'll feel calm"? Did they say, "You'll need to drink alcohol for roughly six weeks before you'll start noticing changes. Come and see me next week to see how it's going"? Did they say, "Everybody responds differently to alcohol. When I drink it I can't pee for a week and everything smells like fish"? Or did they say, "You'll feel relaxed and then if you drink more you'll get tipsy"? I'm willing to bet it was something close to the last, which is a clear, straightforward description of what happens when humans drink alcohol. You'll notice I don't think you would have been told "everybody responds differently," because while some personal variation is normal, and while the mood you're in before you drink may have an effect, and while your social or contextual motivations for drinking may also affect your experience, broadly speaking, most people just get drunk.
Anyway. I think it was in Max Fink's book on melancholia. He was discussing treatment, and he said something to the effect that, based on the clinical picture, he only liked to prescribe a tricyclic if he was confident of achieving at least an 80% remission. So then, are we just philosophising as a way of rationalising piss-weak responses? Should we be shooting for less ambiguous results?
On another aspect, about a year ago I joined a withdrawal support forum for the drug lamotrigine. At first I went there for help and understanding, but very quickly I became fascinated by the nature of drug reactions. The question of what it is about a drug that makes someone markedly worse, to me, may be more fertile ground than what is happening when it makes someone better. I was always taken with Koukopoulos’s equal focus on improvement and worsening under treatment, the way he spent just as much time studying those the drug made more ill. This is a fascinating group, and the cases to be found cut right at the heart of some of the greatest riddles of psychiatry: mixity, borderline, rapid cycling, akathisia. And women... there is something in there that is about women.