Friday, June 13, 2008

One pill makes you taller and one pill makes you small

There are a slew of cliches anyone becoming a psychologist is subject to...

Are you psychoanalyzing me right now?
So do you diagnose all your friends?
What can you tell about me from the drink I just chose?
What do you think about Dr. Phil?

... and so forth.

One in particular seems to be embedded in our culture.

So, you're a shrink, hey?
Or, alternatively, So, you're becoming a psychiatrist, hey?

Let's be honest, now. How many of you are aware of the differences between a psychologist and a psychiatrist (both linked together under that infamous shrink term)?

In a nutshell, psychiatrists go to med school and have an MD. Psychologists go to graduate school and have a PhD. Psychiatrists can prescribe drugs. Psychologists can't. Psychologists (clinical psychologists, specifically) generally have more training in psychotherapy than do psychiatrists, and also have a much greater specialization in assessment.

But there also seems to be to be a deeper undercurrent than that...

I have no intention of bashing the entire field of psychiatry, a la Scientology. Some of the clinicians I admire most (e.g., Yalom) are psychiatrists, and I've worked with some amazing ones in clinical settings. I also don't want to trash the entire notion of psychopharmacological treatment of mental illnesses. I know a lot of people have benefitted a lot from medication for their depression and anxiety.


There's are aspects of the discipline that bothers me. I think that a lot of this comes out of the deterministic perspective that *some* psychiatrists endorse.... the whole chemical imbalance story. While brain chemistry does clearly play a role in depression and anxiety, it is not so nearly as simple a story as client's are frequently told. EVERYTHING is affected by brain chemistry. A glass of wine technically causes a chemical imbalance, as do eating and sleeping habits. Therapy has been found to cause changes in brain chemistry similar to antidepressants. But people are made to believe that this chemical imbalance is somehow qualitatively different, and, more unfortunately, unchangeable-- as though they will be required to take medication for the rest of their lives as the only way to alter it. 

Again, I don't want to give off the impression that I think these medications are completely useless. They very often give people the boost they very much need, which hopefully gives them the resources needed to make other life changes. But after, in depression groups, you hear people argue against the most basic life changes, such as healthier eating, sleeping, and exercises, let alone in social interactions and ways of thinking, because their depression is "chemical" and thus isn't influenced by external forces, you become frustrated.

This fatalistic view on the part of *some* psychiatrists also results in unfortunate conflicts of interest between our two disciplines. Even in my limited professional experience, I've had client's psychiatrists tell them things that completely contradict our therapeutic goals (and are even utterly factually untrue). Other psychologists have told me tales of psychiatrists telling clients that they have no hope of ever working again or of shaking their symptoms, while, on the other end, their psychologists are trying increase their sense of self-efficacy and belief in recovery.

In all truth, actually, this probably has less to do with the discipline of psychiatry, and more to do with the pharmaceutical industry. A lot of psychiatrists do amazing therapy and well thought out prescriptions. Others, however, have figured out that 15 minute appointments to check in on client's medication, along with the nice financial incentives provided by pharmaceutical companies wooing them, is a lot more financially profitable (and reimbursable by HMOs) than an hour of therapy with medication consultation. 

A lot of these sentiments are coming from the fact that I just finished reading Mad in America, about the history of psychiatric treatment of schizophrenics in North America. It was eye-opening, at the very least, although horrendous would probably be a more appropriate term. I can't begin to explain the horrors medical professionals have committed against the mentally ill-- ripping out teeth, blistering their skin, refrigeration, near drowning, lobotomies with ice picks, induction of seizures, to name a few. And I'm not saying that psychology's name is clear in all of this. I certainly feel my fair share of collective guilt over these atrocities. 

However, the author makes a strong point about the current medical norms regarding psychiatric treatment of schizophrenia. The simple fact that a World Health Organization study showed that schizophrenics in the third world have better outcomes than those in North America should be telling enough. However, he paints a picture of fraudulent motivations and unethical research and marketing practices, all in the name of financial gain-- still taking place today. He tells tales of psychiatric researchers ignoring ethical standards in order to get the best results, and thus the best payouts from the pharmaceutical companies... schizophrenics being yanked off their medication immediately, which is know to result in huge symptom increases, aggression, and frequently suicide, all to provide a placebo group that the medications look admirable against. Of shady tactics to get participants in studies without informing them of the huge risks. Of massive cover-ups of the side effects of antipsychotic medications (which include painful muscle spasms and Parkison's symptoms, as well as a recent link to toxic blood diseases). All in the name of money.

It's hard to accept this in a field you want desperately to believe is about helping. 


And please don't take this to believe that psychology is the noblest of fields. We are certainly guilty of our fare share of transgressions, from our involvement in some of these horrific early treatments, to cruel research, to even the extreme mistreatment of clients. However, at the very least, by virtue of our training, we have our hand out of the pharmaceutical cookie jar. Although there is a whole 'nother story about how some are trying to gain access to that cookie jar, but that is for another time.


tmamone said...

So you can't hook me up with any drugs, I take it. Darn!

Just kidding!

But seriously, I agree with you that often the issue goes much deeper than just a chemical imballance. As some one who has been in and out of therapy for over ten years, I find that while medication does help (I'm currently on Effexor, which has definitely helped with some of my anxiety symptoms, especially the nausea), it's not the miracle cure that many commericials would lead one to believe. It also takes work, like learning how to challenge those ANTs (yes, I am speaking your lingo!).

Princess of the Universe said...

I remember always being told (in my Undergrad Psych classes) that the most effective therapy is behavioural combined with drugs (if needed).
Of course drugs take no time or effort, and therapy does.

This is the first time I've been on drugs, and I must confess they have been helpful with my anxiety symptoms. But I know that I won't solve any of the internal issues without talk therapy.

Sometimes looking at those old movies that show asylums gives me the chills. Hosing people down, lobotomies, shock therapy (which still happens).


Your Ill-fitting Overcoat said...

This is a fascinating post and one I definitely agree with. There was an interesting AdBusters issue a few years ago on the same topic. Thanks for posting this.

jenn said...

Interesting observations. I've never been a big believer in pharmaceuticals, and you've hit on some of the reasons why!

Anyway, I've tagged you for a meme over on my blog! Enjoy...

gingatao said...

As someone who has been under the care of both types of practioners, although many years ago, I feel I should point out that many studies have shown that the cure rates for people who receive treatment are almost identical to those who receive no treatment which raises an interesting question concerning effectiveness. Also people should be aware that the definitions of what constitutes 'illness' are constantly being expanded to make more work for the same professionals who create the definitions. What was once sadness is now depression, what was once eccentricity is now social abnormality. I must admit that if the world around me in all its hypocrisy, mediocrity and superficiality is 'sane' then I gladly choose glorious madness.

Princess Pointful said...

Thanks for all the feedback so far, everyone! I know these type of posts are often not what people want to be reading about on a blog....
I especially appreciate people's honesty about their own experiences.

However, I feel the need to do a little defense of my field, Gingatao :). I certainly agree with you that we have a tendency of overpathologizing things-- a simple comparison of the page count of the 1st DSM to the current edition will tell you that one. But I will disagree with the statement about research showing equivocal rates across placebo and treatment groups, as that is not the current state of the research as I know it, though there had been some debate in the past. Also, in current training practices, most treatments that we are taught have to have shown solid empirical support.

Bayjb said...

This might be embarrassing but I did not really know the difference between those two fields. Interesting. Very thoughtful post.

I'm looking forward to the blogger meet up in Chicago! It is funny that we started reading each others blogs just as we're about to meet, at least we'll know each other a little bit!

thegoodnamesaretaken said...

I found your blog through a different one and I've gotta say, I found this post very interesting as someone who has been treated by both types of doctor. Personally, I felt like pills were being shoved at me but sometimes I miss the dual therapies. For now though, I just see a psychologist.

benjibopper said...

do i get points if i did know the difference? i took an abnormal behaviour class in first year, really enjoyed it but yeah, it was pretty deterministic and med focused, even at that rudimentary multiple choice level. i later learned that the best approach (available in this part of the world and in this culture anyway) for a lot of the illnesses we study is a very careful combo of behavioural therapy and meds, which themselves are very touch and go, very trial and error in finding the right one and the right dose. with one illness i studied a fair bit it seems a lot of patients are able to successfully wean themselves off the drugs in time and still control symptoms. what i also learned is that these disorders manifest themselves differently in different cultures, with symptoms unique to cultural context. isn't that amazing?!

Half-Past Kissin' Time said...

I think that one of the most difficult things about mental health problems is getting the person to embrace the fact that lifestyle changes can change his/her condition. Too often, people are just too willing to pop a pill. For example, the brain chemicals endorphins (?) affected by nicotine/smoking can be achieved through exercise and other healthy activities. My husband had tried to quit smoking but hasn't been successful. I try to tell him, "Honey, if nothing changes, then nothing changes." In addition, a little work on the issues that cause one's depression could go a long way towards fixing the problem. I hate that General Practioners prescribe anti-depressants but don't press the therapy/counseling issue enough. Medication in and of itself is great, but not in isolation of other relevant factors. Preaching to the choir, I know...

Ant said...

This is one of the key points that I find very frustrating when dealing with people with depression.

My own surgically logical argument goes: if the problem is chemical, then take the appropriate remedy to sort out the problem and you will no longer be depressed. If the problem isn't chemical then take the appropriate therapy to try and remedy it. If the patient refuses either of these courses then I smell a big fucking rat and conclude that they actually want to be depressed and I absolutely won't indulge that.

(I have quite strong feelings about this because a good female friend of mine is essentially having to raise a child on her own as her husband has been diagnosed with some kind of autism or "selfish bastard disease" as I like to call this particular strain...)

And I agree with the over-pathologizing point too. Suddenly everything is a disease which plays into the hand of this type of patient - they are allowed to "suffer" because they have this thing, handily allowing them to shirk responsibility and fail to live up to their full potential ("I couldn't be the greatest rock star ever living because I had this syndrome. Such ashame, otherwise I would have been brilliant...")

deutlich said...

I can't even begin to explain how much I wholeheartedly appreciate this post.

It is EXACTLY for this reason that I have such a problem with being prescribed pills right off the bat when I KNOW that just speaking with a counselor or therapist makes A WORLD of difference.. As does exercise and putting REAL food in my body - as opposed to snack packs and hamburger helper.

Sleep? Sleep is absolutely the most important part of the whole thing. And it sickens me to the core that so many folks are under the impression that drugs are the only way.


I could rant and rave about this all day... but I won't.

Heart Of Darkness said...

It's stunning people still mistake psychiatrists for psychologist and vice versa - it's as you say, quite significant differences.

What bothers me even more, though, is those people that go on a theraphy course and then call themselves "doctors". Unless you've got a Ph.D. or MD, you're not a doctor!


lissa said...

really interesting piece. i didn't realize how many things could change your brain chemistry. i've never been a fan of the idea of having to take anti-depressants because of how little is known about their long term effects.

Rachel said...

I always held both of those professions to be above and beyond in regard to difficulty. I give them so much credit.

Jocelyn said...

I have to read that book now--and be properly horrified. I so much agree with the points you make here; it still surprises me how many folks I know are on some sort of meds without also using other kinds of therapy (such as talk!).

Sheila said...

As someone with OCD, I have never used any pharmaceutical treatments. I read a book by Marc Summers titled "Everything In Its Place" that helped me to recognize and control my symptoms (to a degree) with behavior modification - something he learned in therapy.

I too believe that there are those who do benefit from the drugs, but I think that Americans are also being over-medicated.

The Little Student... said...

gingatao: As someone who researches behavioral intervention techniques I can tell you that your reference to the literature is wrong. I'm not going to cite a bunch of research because this is a blog comment, but I do want to say a few things. First off, an infamous meta-analysis conducted by Smith & Glass (1983) suggests psychotherapy in general is superior to placebo. Additionally, my own research has suggested certain psychotherapy interventions for certain ailments (both medical ailments and mental ailments) are actually better than state of the art medication. Anyway, my point is you shouldn't talk about what you don't know.

toughtrigger said...

Speaking from a medical field, I'd just like to throw out there that doctors are not these puppets of the pharma companies that you make them out to be. Many states, mine included, prevent taking any sort of freebie from pharmaceutical companies - even down to little notepads, pens, or free lunches. Let alone larger kickbacks. These physicians are not gaining anything personally by prescribing drugs.

I think that many people go into an appointment (in whatever form that might be) for depression wanting to be prescribed something because we have a culture that believes in "magic pills" that will fix things, fast and easily. Clearly this is not true for everyone - as the above comments indicate, and also from my personal experience with some situational depression. But I know a lot of people would rather just feel better, fast, than have to put in the sometimes grueling work of therapy.

Another thing to consider is that many many people are being treated & supervised medically for their depression by primary care providers (family medicine doctors, internists), not by psychiatrists. Obviously they have very different training surrounding the topic of depression and other things.

I don't know, I don't mean to be argumentative here - but I just get a really big sense of "us vs them" here in your post, and I don't really think that's helpful for the field in the long run. Perhaps I'm misreading what you are getting at, though.

Princess Pointful said...

Tough Trigger- I'm sorry if you got an us vs. them mentality out of the post. That wasn't what I was trying to go for, which was why I tried to make a really strong point that it was only *some* psychiatrists who had that mentality. I'm a strong believer in mental health teams, as a general rule, because collaborative treatment really does appear to be the best. However, I guess based on personal experience, it is hard to be collaborative when one member of the team is contradicting another-- which I, and other professional colleagues, have had. Yes, it isn't the majority of psychiatrists, but it's not uncommon. (this is where the problem comes in... any personal anecdotes are too far across the confidentiality line for my liking!)

I'm from Canada, so I can't speak to a lot of American laws. I'm glad to hear there are actions being taken against it. However, the book makes a pretty strong case about how drastically practices changed once drug companies began marketing directly to physicians-- and it is pretty shocking (comments section and all, I'm trying not to go overboard on examples). Also, even if psychiatrists aren't influenced by such propaganda (which I do believe a number aren't), the research underlying a number of these drugs is hugely, hugely unethical. Also, that doesn't change the fact that four 15 minute sessions an hour for drug maintenance is a hell of a lot more profitable and reimbursable than one hour of therapy.

I do agree with you about the GP's prescribing such medication-- I'm sure any of us have a had a friend who was offered anti-depressants for the most banal of problems. I would prefer a psychiatrist prescribe these drugs over a GP any day. I would also prefer that mental health was better prioritized by the medical system, which would solve a lot of these problems. I also wish that people were willing to take greater steps for the own well-being, but for some people, a pill is all they are willing to do at the present time. I definitely agree this is better than nothing... but I think we should be striving for more than that. That's why I have tremendous respect for those psychiatrists who take more than the 15 minutes, even if they aren't doing full-blown therapy, to check in on other life issues... rather than just shuttle them in and out and pretend that it is so simple as a pill in its entirety, rather than a piece of the puzzle.

Thanks for stopping by though. I do appreciate any conversation that this can generate!

poodlegoose said...

I completely agree with much of this post. I started out studying psychology in college, and had to quit because I was in a few classes that focused almost solely on diagnosing and prescribing. Too much unnecessary medication for me.

Tin Ma'am said...

I'm a psych major too.... i totally get the same reactions!

When there's a group of psych majors in a table sitting together, EVERYONE gets sooo self concious. Cos, apparently, we have jedi-like powers of mind-reading.

Yoda said...


Psychiatrists and Psychologists.

Both sound psycho to me :-p

Rachael said...

WOW! great blog post. I agree, I agree, I agree. What a wonderful and messed up field mental health is. I am an LCSW at a prison, and talk about medication issues. In this environment it becomes all too clear just how screwed up the system and mental heatlh care in this country are. Thanks for the post.