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Reflections on the American Psychiaatric Association's annual meeting

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What is sad, is the expectation that we have created for patients that a pill should instantly put them to sleep. Of course, they have the same expectations about all their symptoms. When they feel sad, a pill should pick them up. When they feel angry, a pill should calm them down. When they feel hyper, a pill should make them mellow. Pills should exist for every unpleasant feelings. Pills don't appear to work this way. I think medications do have long-term effects, but these effects are seen over weeks and not hours. Perhaps there is no escape from the hour to hour fluctuations of our moods and feelings. I suspect we just have to learn to cope, which is not the message psychiatry has been giving people.

Sleep is a good example. The best evidence for helping people sleep goes to cognitive behavior therapy. CBT helps people learn how to manage their thoughts at bedtime. Here are some examples. I ask people to write down all their fears, worries, and anxieties before attempting to go to sleep. I ask them to write until they can think of nothing more to write. Then put that writing in a special place where they can review it in the morning. "Now," I say, "you have no reason to think any more about your problems. You can do or solve nothing more until the morning." Then I teach them to use mindfulness meditation techniques to still their minds. In addition, basic sleep hygience is important. The bed should be used only for sleep or sex. All other activities should take place outside the bedroom. If one cannot get to sleep in 15 minutes, one should get up and do something and then try to sleep again. Reading exciting novels or watching exciting television programs in the hour before attempting to sleep is also a mistake. Reading a textbook is a much better idea for that hour before sleep. Perhaps a cell phone instruction manual would work just as well or a software use manual. People have to learn how to do these practices. Our contemporary society does not teach this kind of common sense.

In psychiatry, I believe we need to emphasize much more what people can learn to do for themselves and with each other than what drugs can do for them. Most of the people I see in my conventional practice come because the drugs aren't making them happy. They believe that they just aren't on the right medications. Their desire is to find the right combination of drugs that will make them feel "normal". Of course, defining normal usually highlights an expectation for emotional life that is unattainable. We in psychiatry have also fostered this expectation in people.

How does this work in practice. Commonly in a community mental health center, patients come to see the intake worker, then have a psychosocial assessment with a social worker or another type of counselor, and then see the psychiatrist for medication assessment. Since the psychiatrists only job is to prescribe medication, everyone gets a medication. Larger, my sense is that these drugs are functioning as placeboes except for the more severe patients for whom the drugs appear to have some effect, as in reducing paralyzing fear. The psychiatrist then sees people for medication management and a psychotherapist sees them for everything else. This configuration arose because it maximizes income in both the U.S. and Canada. One study showed that it was more cost effective for the same person to have one hour sessions and manage both medication and psychotherapy, that that study had no impact on contemporary practice. Year ago, this was how all psychiatry was done. It fits my model for the use of medication, which comes from a book entitled Unbearable Affect. Drugs are best used to manage unbearable affect in the service of psychotherapy and other healing. People (human contact and support) are also effective for managing unbearable affect, and probably work better than drugs. People, however, are in short supply today. We don't have communities as much as we once did or as much as Third World countries have (this is why their outcomes for schizophrenia are better than ours, as found by the World Health Organization). Withoutdoing both psychotherapy and managing medication, it's impossible to steer this course. People do need some uncomfortable feelings in order to learn new skills. If the goal of perfection through medication could work, no change or transformation would ever occur. We would never address the contexts that produce the emotions and the instability that we feel.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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