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'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 really loved this piece! I often encounter this ambivalence around medication in my own work as a pediatric neuropsychologist: clients and families come to me for an assessment because they want to know whether their medication is “working,” whether a child should be on it, whether they’ll always need to be on it, etc... as if there were some objective truth available above and beyond their own lived experience.
What I notice, though, is that for many children and young adults, medication doesn’t feel like a choice among different ways of understanding and responding to their struggles. It feels like a fixed reality. As in, they think some people "need" medication the way diabetics need insulin, and the only task is to figure out if they are one of those people, with a parallel understanding that if that's the case, the medication is something they will always be on, with only minor adjustments possible. This is true even when the medication isn’t clearly helping (or is making things worse), or when only one party believes it’s working, or when it used to help and no longer does -- essentially, "some people are the kind of people who must take medication" is the background assumption. The frame for treatment questions has become “yes medication/no medication,” rather than “how might medication fit (or not fit) into a broader set of ways to help this person tolerate suffering, build capacity, make meaning out of the blooming buzzing confusion of life, be of service and share their gifts with the world, and thrive despite discomfort.”
Part of the dilemma, I think, is that clinicians often sincerely believe medication is the scientifically “right” choice and present it that way, so questions of meaning, ambiguity, and personal values get flattened. And while I certainly understand the impulse not to overwhelm patients who are actively suffering — it can feel the wrong time to launch into complexity! — the result is that our broader conversations about medication often underrepresent nuance, overrepresent certainty, and sidestep meaning-making altogether.
That’s why I especially appreciated your analogy to other big life decisions, like marriage, religion, whether to have children. These are choices that are deeply personal, inherently uncertain, entangled with meaning and ambivalence. It seems to me we need more public conversations that frame medication decisions in this same way, so patients and families aren’t left to navigate these existential questions only in the privacy of a clinician’s office, and only at moments of acute suffering.
Thanks for the many references to add to my reading list. <3
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 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'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 really loved this piece! I often encounter this ambivalence around medication in my own work as a pediatric neuropsychologist: clients and families come to me for an assessment because they want to know whether their medication is “working,” whether a child should be on it, whether they’ll always need to be on it, etc... as if there were some objective truth available above and beyond their own lived experience.
What I notice, though, is that for many children and young adults, medication doesn’t feel like a choice among different ways of understanding and responding to their struggles. It feels like a fixed reality. As in, they think some people "need" medication the way diabetics need insulin, and the only task is to figure out if they are one of those people, with a parallel understanding that if that's the case, the medication is something they will always be on, with only minor adjustments possible. This is true even when the medication isn’t clearly helping (or is making things worse), or when only one party believes it’s working, or when it used to help and no longer does -- essentially, "some people are the kind of people who must take medication" is the background assumption. The frame for treatment questions has become “yes medication/no medication,” rather than “how might medication fit (or not fit) into a broader set of ways to help this person tolerate suffering, build capacity, make meaning out of the blooming buzzing confusion of life, be of service and share their gifts with the world, and thrive despite discomfort.”
Part of the dilemma, I think, is that clinicians often sincerely believe medication is the scientifically “right” choice and present it that way, so questions of meaning, ambiguity, and personal values get flattened. And while I certainly understand the impulse not to overwhelm patients who are actively suffering — it can feel the wrong time to launch into complexity! — the result is that our broader conversations about medication often underrepresent nuance, overrepresent certainty, and sidestep meaning-making altogether.
That’s why I especially appreciated your analogy to other big life decisions, like marriage, religion, whether to have children. These are choices that are deeply personal, inherently uncertain, entangled with meaning and ambivalence. It seems to me we need more public conversations that frame medication decisions in this same way, so patients and families aren’t left to navigate these existential questions only in the privacy of a clinician’s office, and only at moments of acute suffering.
Thanks for the many references to add to my reading list. <3
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