I often question the role of medications in mental health. The medications we have today were not present a few decades ago. In context of the history of humanity, their presence is merely a blip on the radar. Yet somehow, their use is skyrocketing.
As I have learned and continue learning their use from residency training and in private practice, I notice that they seem to have a place in some situations and are next to or worse than useless in others. So it seems natural to wonder why this is and what their place is.
The public voice seems to carry a mix of strong opinions representing either side of the camp of whether medications are a curse or a blessing. Especially in the context of children and adolescents, where there is an increase in the use of psychiatric medications in the youth despite only a few being FDA approved in this population and the stakes are high, it seems to me that the meanings of medications need consideration.
Here I compile a few of the thoughts I’ve had on the issue. I’m sure I’ll come up with others later, so this is not a comprehensive list.
I strongly encourage people who are considering being on or are on medications and those who care for people on medications to consider their possible meanings for their selves. Each context is unique and the individuals involved are in the best position to understand those particular situations.
Medications do seem to have some place. As a general example, there are times when a person comes to a psychiatrist with symptoms of depression asking for help. The psychosocial reasons for the depression may not be readily apparent. He asks for help in terms of feeling better as well as creating a situation in his life that would help him feel more in control. A medication alongside working with an understanding therapist might be helpful in such a case.
Of course, things are rarely this simple.
Psychology and Biology – Mind and Brain
The complexity that comes into the decisions of prescribing a medication come into play by taking the position that symptoms and medications themselves have meaning for the people involved. By taking this position, we can begin to think of their roles in their contexts and their roles for the persons involved.
The mind and things that affect it, including medication, can be understood in terms of both biology and psychology. The two can be viewed as dimensions of the mind as inextricably linked as the length and width of an object. They both help to define the object. Without one, there is no other.
However, in this day and age, there seems to have been a push towards a biological perspective over a psychological one. Present day research searches for 2 or 3 dimensional physical representations – graphs and chartings – of symptoms and the effects of medications. Research by this method is may best be suited for biological viewpoints and interpretations.
This method, however, can create an inherent bias towards the one side of biology. We must be careful as this bias can rob us of the intent and means to understand something at a more fundamentally human level – a level where individuals can begin to work with the situations that have created problems for their selves.
The state of health care today tends to show an increasing reliance on medication as a method of treatment. In many cases, people consider it the only method. When a person has a cold, he may demand an antibiotic though it would be as useless as using a screwdriver with a nail. Rather some good sleep, fluids, and time would be best. Sometimes, a medication is simply not the answer.
With unending repetition in the research, disease is noted as an entity created by many forces coming together. In Chinese medicine, this may be considered a lack of harmony. In Western medicine, it is called multi-factorial. Psychiatric illnesses such as bipolar disorder, major depressive disorder, and psychotic illnesses all have some elements of biology and environment interfacing to produce the emergent symptoms.
But a predominantly biological view downplays the importance of environment. It reinforces the idea that “there is something I cannot understand that is wrong with me” rather than an empowering, “maybe there is something I can understand that I can work on.”
Placebos may demonstrate meaning
The research community in medicine will often compare a test medication to what is termed a “placebo.” Placebos are something like sugar pills, designed to have no significant effect. In an experiment, both the subjects and the researchers do not know who is taking the placebo and who is taking the real deal.
Somehow, about a third of people seem to respond to placebo – sometimes regardless of the ailment. Research then looks for the test medication to exceed the placebo by certain criteria and state “it works”.
But, something is at work here. What is it that this placebo is doing? Why has it created a response in a third of the patients? Why are we not looking at this response with awe?
Psychological Action of Medication
I think that a major aspect of prescribing and using medications that may explain this placebo response is that the medications have meaning. They send a message and have a psychological action. Specifically, they reinforce and highlight the existing or lacking empathic connections between members close to the individual, including family members and the physician.
This is stressed as important in the psychological therapies, but I think it is just as important in the psychopharmacologic therapies.
This empathic reinforcement is likely at work both in the placebo response group and in the true medication group.
It acts as an amplifier. A good positive connection can yield an improved response and a lacking or detrimental connection can combine with medication to yield a worse and possibly damaging outcome.
One of the reasons for “acting out” or “bad behavior” or even depression and anxiety seems to stem from a break in empathy between parent and child. It is a situation where the parent does not understand the child’s wishes or fears and mistakes his laughter and cries for something else. It is a situation where the child or adolescent’s methods of asking and communicating and the parents’ methods of hearing do not connect adequately.
Sometimes this is because of a harsh reality of a single parent needing to make ends meet and is unable to be there as often as he or she would like. Sometimes, it may be because no one was empathic with the parents as they themselves grew up and they do not know how to do so. There are many possible reasons that reflect individual cases.
What is empathy? There are many attempts to define this term. A simple definition is the ability to share and understand the feelings of another. I would add, however, that there is a variability of empathic investment that can be made.
As an example, we can see someone smile and say they are happy. But, there is something more about understanding the person’s context, wishes and fears and seeing that same person smile. There is a deeper understanding of that person’s happiness. There is a greater ability to communicate with that person and share his experience.
That level of empathic understanding is then communicated to the person, the process of which can have a huge impact. We often talk about listening, and its importance in communication, but the empathic element and the depth to which it can be exercised is often missed in the discussion.
Empathy As It Relates to Concentration
Good empathy requires the resource of concentration. It requires effort on the part of the observer to shift to and maintain focus upon another person. This is a major part of therapy and a major part of parenting. It is an understanding of the root of the person to the level that the observed patient/child may not even understand. Yet somehow, this level of care is communicated to the person. It’s not just “I know what’s best for you,” it’s that the person feels that his interests are trying to be understood. Simply stating or ordering it to a person – child or adult — does not change the feeling as empathy communicates itself when truly genuine.
When an empathic connection is there, it is strongly felt and can be a truly guiding and healing force. When it is lacking, there can be the sense of loneliness. When lacking for extended periods, feelings of worthlessness can arise. In the child, this manifests as anger, resentment, “acting out,” and overt depression, among other “symptoms.”
Empathic Reinforcement and Empathic Erosion
The psychological aspect of the medication, excluding the biological for a moment, acts to amplify the character of the empathy that already exists.
If the person feels there are weak or non-existent connections, meaning that he feels that no one truly understands or cares for him, the medications drive that message home. In such a case, medications can undermine the healing process.
One way in which medications can highlight a poor empathic connection is through its inherent emphasis on biology. When the symptom is ascribed to biological or other such notions – it may be considered “un-understandable.” It is thought to be at a “scientific” level and therefore can only be understood in terms of relatively humanly distant 2 or 3 dimensional graphs, molecules and receptors.
A solely biological view suggests no responsibility on the part of the individual or those in the care-taking roles of the individual for the ailment other than the dispensing of medication. Rather, the symptoms are thought of as the result of forces that are not within his or her control be it God, evolution or whatever.
The biological position may be reinforced for either religious or scientific ideologies when medications are prescribed and the idea that one can do something for oneself is removed.
Therefore, less or no effort is expended towards understanding this person’s sadness at any deeper humanistic level. If a parent, for example, is unable to understand the child’s sadness and has given up rather than sought help from someone who may be able to point out psychological or social mechanisms that could be contributing, then the medication can be erroneously relied upon to “take away” the symptoms and leave the rest of the person intact.
How the symptoms arrived is chalked up to some force that cannot be understood. The individual as well as those around him then do not take responsibility for the understanding and working through of solving the root of the symptoms. The reasons to focus some level of concentration on the person’s situation is diminished, and empathy erodes.
Missed Empathic Connections Reinforced By Medication
Children often do not possess the capabilities to express themselves as well as adults. After all, they are still learning. Similar emotions are there but are often bigger and more intense than the attenuated versions found in adults.
Children who are anxious or depressed often present as irritable and angry. They act destructively and attack those closest to them.
Those around a child must be able to understand that the attacks are not a result of being “bad” or “wrong,” but are some form of expression of pain, and the child is looking for relief. He has not developed the capacities to describe this emotional pain. Statements and actions that say the child is bad or wrong in such situations only worsen the problem. This would be an example of what could be called poor empathic connection or misattunement.
A medication in such situations could be a detriment. Giving a medication is a statement that highlights the negative behaviors and feelings and furthermore states that there is something inherently “wrong” with the child.
When a medication is provided for a child who is seen as “misbehaving” the medication can be viewed by the child as a form of punishment. He may consider himself as bad and that not only do his parents say so, but now an external physician says so, too. The parents may even feel justified in their positions even if it is their own contributions to the family dynamic that might be lending to or creating the symptoms within the child.
In this case, the parents may, at least unconsciously, consider the medication as a form of sanctioned punishment.
With both parent and child viewing the medication as a negative consequence to the child’s unwanted behavior, the child who accepts taking the medication, accepts the view of himself as “bad” and in need of punishment to get better. The view of being bad is reinforced, especially when the medication does not remove the symptoms. His self-esteem is deflated and with this lowered self-esteem, and the effect of the medication is, in fact, opposite that which was consciously intended.
Suicide Risk, Medication, and the Erosion of Empathy
Notice that most medications in child psychiatry carry warnings that state they may cause the recipient to have suicidal thoughts. There are many different biological receptors that are being acted upon by all of these different medications. Can they really all be hitting the right configuration of receptors that say “think of killing yourself”? Does something magical happen at the age of 18 that it no longer occurs? Rather, perhaps the meaning of the medications should be more of concern.
Highlighting and reinforcing poor empathy may be related to these suicidal thoughts. The idea that “there is something wrong with me” “a doctor tells me so,” or “my parents were right,” can be detrimental.
Overall, these feelings of worthlessness can pervade a person who feels misunderstood. If the mechanisms that create or amplify these feelings lie within the very meanings of the medication and not the biological implications of the medication, then what does this do to the discussion of psychiatric medications in context of suicidality?
In other words, perhaps the meaning behind the medication contributes to the suicidal risk factor, and not the targeted biological changes that accompany the use of medication.
Medication as Improving Empathic Connection
Medications can improve as well as diminish an empathic connection. Again, I think it is a highlighting effect that it carries. At times, it can say “someone who understands cares.” The message itself describes the empathic connection already in existence and, as delivered by a perceived caring and understanding authority figure, can be immensely powerful.
If a person feels understood at a deep level, he will hear what is suggested at a deeper level. Taking a medication from someone who is trusted is a daily reminder that there is someone who cares. This is a power that cannot be underestimated as any caring parent, grandparent, teacher, or therapist will tell you.
The important factor here is that the physician prescribing the medication and the parent who dispenses the medication care. When I say care, I mean at a fundamental level. The physician spends the time and effort to get to understand and know the patient. The parent tries to follow and understand the mechanisms that may have contributed to the situation – even if that understanding takes years of therapeutic work and blame upon the self.
When a relatively psychologically healthy person is cared for, there is a strong feeling that arises within him. This feeling in itself can be healing. Alongside the biological effects of the medication, empathy and medications can be synergistic forces of healing.