Answering Reader Questions About Psychiatry

Including: Psychopharmacology, Projection, "Bipolar Eyes", and more...

The other day I posted a note soliciting reader questions about psychiatry. Thank you to everyone who submitted their questions—I tried to touch on all of them. I was aiming for a reasonable turnaround time on this, so expect more of my slightly-edited free associations on these topics, and less a thoroughly researched thinkpiece with tons of pretty charts. Further questions are welcome in the comments.

(1) How do you feel about the fact that psychiatrists aren’t that much into talk therapy anymore and focus mainly on psychopharmacology nowadays?

I think the shift has been lamentable but also understandable. Psychotherapy achieved its prominence in psychiatry early on in part because there were no other effective treatments available. Ever since the discovery of various psychiatric medications starting in the mid 20th-century, most psychiatrists have steadily been shifting away from psychotherapy. One of the most important, although not the only, influences in this move has been insurance companies’ reimbursement rates, which dramatically favor a “medication management” psychiatric practice instead of one focusing on psychotherapy. It is also important to note that the introduction of the first generation of effective psychiatric medications, specifically lithium and antipsychotics such as chlorpromazine (Thorazine), really did revolutionize the field, and showed the limits of what psychotherapy can accomplish. To put it plainly: take your schizophrenic patient and give them 12 weeks of psychoanalysis vs. 12 weeks of haloperidol and let’s compare results.

Why do I think the shift is lamentable? For one thing, learning the principles of psychotherapy is valuable for any psychiatrist in clinical practice, even ones who do no therapy at all (see #17 below). But I’m also a psychiatrist who’s into psychotherapy. I find it interesting because I find people interesting. And there are still many psychiatrists who practice psychotherapy, despite the shrinking numbers. It enriches my practice: psychotherapeutic principles can be applied to all aspects of psychiatry, not just the “45-minute hour” of talk therapy.

(2) Do you think psychologists should be given prescription authority or not? If so what would that look like?

I do not support prescription authority for psychologists. The training that clinical psychologists and psychiatrists receive is quite different, and psychologists currently don’t receive the necessary instruction in basic sciences, psychopharmacology, or supervised clinical training to prescribe safely. Personally, I have issues with nurse practitioners (NPs or APNs, Advanced Practice Nurses) prescribing, which is now commonplace and isn’t going away. While it can seem like prescribing psychiatric medications is relatively simple—a little touch of Zoloft for your mood and maybe some Trazodone for sleep and you’ll be right as rain—this seeming simplicity is one of the reasons we are overprescribing all kinds of drugs, from SSRIs to amphetamines to antipsychotics.

That said, I understand that as medicine advances we will of necessity change how our therapies are prescribed and who can prescribe them. But—and this is a big but—as it is now there are plenty of psychiatrists who have trouble prescribing responsibly, to say nothing of psychologists or other non-M.D. clinicians. We should treat these medicines with care and respect; expanding the ability to dispense them should be done cautiously.

(3) Do you think that psychiatry should branch off from medicine kinda of like dentistry? Basically do you think it would be a good idea to have a direct entry into a hypothetical shrink school with its own curriculum and training rather than going through medical school and then specializing in psychiatry?

To your question I raise another, namely: what particular need would be served by such a separation? Psychiatry has been a part of the larger medical establishment for well over a century, and with good reason. Human illness is discrete enough that physicians can specialize and devote their lives to studying only a handful, or even one, illness. However, every physician also knows that human dysfunction is never as discrete as we would want it to be, and treating a patient competently requires a broad working knowledge of human illness. This is one of the reasons every medical student in the United States needs to complete a (roughly) standardized set of clinical clerkships during their third and fourth years in order to graduate and continue on to residency training. At my medical school the “core clerkships” when I was a student were: internal medicine (12 weeks), general surgery (10 weeks + 2 weeks of anesthesiology), pediatrics (6 weeks), obstetrics & gynecology (6 weeks), psychiatry (4 weeks), neurology (4 weeks), family medicine (4 weeks), and emergency medicine (4 weeks).

If psychiatry were to have separate training, would we still acquire the broad range of medical knowledge we once got from medical school, and if so, how? Or would we become more like clinical psychologists, social workers, or revert to being psychoanalysts? Would we still speak the same “common language” of medicine as internists and surgeons? What additional skills and knowledge would we acquire from segregating ourselves?

Psychoanalytic institutes took the route of self-ghettoization in the 20th century and have been slowly dying for decades. I see no reason for the rest of psychiatry to follow their path.

(4) Joke question, but do you find the word shrink offensive?

No. I think it’s pretty funny, and I sometimes call myself a shrink. I don’t think many psychiatrists are offended by it, or at least none I know. It wouldn’t be like calling a cop a pig, or a lawyer a shyster.

(5) How do you view yourself compared to other physicians? You’re not really doing the same thing as a normal physician or surgeon (not suggesting you’re not a physician since you have the training to diagnose diseases, but you have the added difficulty of trying to tackle mental disorders and not just physical ones).

Lots of people don’t realize psychiatrists are “normal doctors” or even doctors at all, so I’m used to the question. I don’t really compare myself to other physicians too much, but when I do I’m usually thanking my lucky stars that I became a psychiatrist. What could be cooler than a job where you get to explore the mysteries of the brain and how it goes wrong, meet some really interesting characters along the way, and get to help people? But on a day to day basis, a lot of ways what I do is quite similar to other physicians. For example, both an internist and I spend most of our day talking to people, thinking through diagnosis and treatment plans, making phone calls, ironing out the annoying contingencies of life that get in the way of our brilliant plans, and procrastinating on writing our clinic notes.

The demands on psychiatrists are different from other physicians, but all specialties have their own peculiarities. Many non-psychiatrist have the view of “you deal with it” when it comes to mental illness, which is fair because when my patient has lymphoma I call his oncologist and say, “you deal with it.”

(6) This is a psychopharmacological question, do you think there might a correlation between the decline of smoking and the increase in use of ADHD meds and anti-depressants, considering tobacco has properties of both?

Interesting idea. I’ve seen it floated around before but haven’t looked into it deeply (yet!). On a very high level of generality it strikes me as quite plausible, however given that we’re talking about decades-long trends in decreasing tobacco use and increasing use of other drugs, establishing any clear inverse correlation between the two may be difficult just from a methodological perspective. But sure, substitution is a real thing, and people tend to like having stimulants around that they can use without feeling totally tweaked out all day. The problem, as usual, is that the dose makes the poison (and yes, the Adderall doses people are on are completely out of control).

(7) How would you change training for psychiatrists? And what would you wish you had known or learned before becoming one?

I can’t actually think of much I would change about psychiatric training in the US. In my experience, training programs do a reasonably good job of staying current with new developments in the field. My residency program emphasized psychotherapy more than most, and I’m tempted to say I’d want everyone to have more of it, but I may be speaking more to my own style and preferences than what is really best. I would probably make training in electroconvulsive therapy mandatory given its efficacy, but this is one of those points that psychiatrists would care about more than the general public I think. As long as the culture of the field stays current and interested in innovation, I’m fairly hopeful.

Rather than changes to psychiatric training, I think other specialties could actually take a page or two from our playbook. One example that comes to mind is mentorship and clinical supervision. In my third year of residency, which focused on outpatient work and psychotherapy, I met with four different senior clinicians each for one hour every week to comb through my cases, discuss problems, review mistakes, and help guide my learning. This wasn’t remediation for a struggling resident; it was expected. I can’t recall meeting a non-psychiatry resident who said they received that level of attention and mentorship in their training.

Ultimately, I can’t think of anything I wish I had known before becoming a psychiatrist. Being a psychiatrist seems to run in my family, so I was exposed to it throughout my life in a way that didn’t seem to screw me up in whatever ways people imagine the children of psychiatrists must be screwed up. Thankfully I seem to have been well-informed when making my career choices, as least thus far.

(8) Where do you draw the line and involuntarily commit someone to an inpatient ward?

In order to involuntarily commit someone, you need to be able to justify the need for admission based on factors that are determined at the state level. In the state where I practice, for example, one of the following four criteria must be met. Numbers (1) and (2) are by far the most common reasons.

(1) A person with mental illness who, because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed;

(2) A person with mental illness who, because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm, without the assistance of family or others, unless treated on an inpatient basis;

(3) A person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or paragraph two above;

(4) An individual who is developmentally disabled and unless treated on an in-patient basis is reasonably expected to inflict serious physical harm upon himself or herself or others in the near future…

Usually it’s pretty clear when someone meets criteria for involuntary admission and the decision is not a difficult one. One example among many: the man who is brought to the ER in the middle of a snowstorm after being found wandering barefoot outside, both feet on the verge of frostbite, all the while screaming that he is the bastard son of Jesus Christ and Denise Richards. Easy call.

For me, often most of the difficult cases are ones in which someone is voluntarily seeking psychiatric admission but it isn’t clear they meet criteria to be hospitalized for one reason or another (consider the patient who is suspected of malingering, or who falsely claims to be suicidal in order to have a comfortable place to come down from drugs, or someone in genuine distress but who would be better served with outpatient treatment). This is an issue because psychiatric hospital beds are always in short supply, and while you want to make sure that the beds are reserved for the people who really need them, we also treat people on a first come, first serve basis, and decisions about admission can’t wait to see if a more acute case comes in later.

(9) Medication constantly gets bad press, yet it can be life-saving. What do Psychiatrists really think about meds?

What we call “psychiatric medications” consists of many different classes of drugs that are used for very different purposes. Psychiatrists’ opinions on medications therefore vary widely and it is hard to make general statements. My own view in a nutshell is that our current treatments, despite being relatively primitive and highly imperfect, are nonetheless truly life-saving for the small but enduring number of severely mentally ill people. For some others, medications can be useful for brief periods of time, or in limited circumstances.

There are plenty of good reasons to dislike psychiatric medication. They often have significant side effects and may work only partially if at all. But in my experience there is also a large amount of the very-human and very-understandable “I was hoping this pill would fix the unhappiness in my life and make me a better person, but it didn’t, and I’m angry about that.”

(10) Why are psychiatrists so over-represented in blogging compared to other medical specialties?

Are psychiatrists over-represented? I’m not sure I have a good answer to this. Perhaps we are, but I’m not sure how I would confirm that. My gut instinct is that it has less to do with the number of blogs and more to do with the fact that psychiatry has a more interesting subject matter than, I don’t know, pulmonology? My sense is that psychiatry is also appealing to medical students with backgrounds in the humanities, arts, philosophy, and the like, so perhaps we attract this sort who then go on to blog about creative things.

(11) Is it really possible to separate moral philosophy from an engaged practice of psychiatry? Especially at the limits, many questions of behavior (for example, in relationships) seem to involve theories of what “should” be the case that can conflict obviously with religious norms, but also with other moral claims. Do docs wrestle with this? How do different people deal with it?

You’d think that as a guy who’s interested in both moral philosophy and psychiatry, I’d wrestle with this all the time, but I actually don’t. It isn’t that I haven’t thought about it; rather it just doesn’t come up all that often. For one thing, when evaluating a patient’s mental state, I pay attention to form as much as, if not more than, content. In other words I care about how someone is thinking, the flow and process of their thoughts, not just what they’re thinking (for example, the particular content of your OCD obsessions may not be as important as the fact that you are obsessing all the time). To that extent I’m more interested in helping them think better, as opposed to helping them think “the right things”. The times when I do talk in “should” language, I’m ethically unconflicted. I’m telling people why they shouldn’t kill themselves, to stay away from life-destroying drugs, and similar common sense prescriptions. I try to do this in a Socratic way, allowing them to reach the conclusions themselves if they can, but they know what I’m getting at.

The religion piece is interesting. I don’t think it’s terribly common in psychiatry for someone’s religious beliefs to seriously hamper treatment in the same way that, say, a Jehovah’s Witness poses problems for a surgeon by refusing blood transfusions. Typically it is cultural differences which can pose a problem in psychiatry. The classic example is the patient or family of a patient who come from a culture that doesn’t believe mental illness exists, or explains it away with a superstition. In these cases, even if the illness is very severe, it can take a fair bit of explaining to get them on board with treatment.

The most difficult situations are, as you allude to, those involving relationships. To pick one example, I once treated a woman who had immigrated to the US with her family and whose husband was physically abusing her at home. I arranged a meeting with her, her husband, and their Imam, who translated for her husband and served as their unofficial marriage counselor. I explained to her husband that my foremost concern was the welfare of his wife and, per her wishes, the preservation of their family if possible. I first asked him why he hit his wife, and he gave a long answer that basically amounted to “she wont do what I say, and there is religious backing for what I’m telling her to do and that includes punishing her for disobedience.” I told him that it wasn’t my business to contradict his religion, and that what I was going to tell him was meant with respect, but that the laws of our country would prioritize his wife’s and children’s safety above his religious beliefs. And, since one of their neighbors had already called DCFS out of concern for their children, he may not know that he is skating on thin ice should the neighbor’s concerns continue (turns out he wasn’t aware the government can take your kids away). I asked him to consider his wife’s happiness and what things were like from her perspective, but this got us nowhere, and he was unable to comprehend that she might want to be able to have a female friend come over to the house without first having to ask his permission. Ultimately it was only practical considerations like his fear of the law, along with their Imam’s humane and sensible prodding, that got him to agree to keep his hands to himself.

(12) How often do y’all feel like “I have no idea what to tell this person,” or relatedly like “this is a tough one because this person just sucks, that’s what’s up, I can help them get some symptoms settled but the big issue here is just: not a good person” or whatever?

Usually if I feel like “I have no idea what to tell this person,” it is a good sign I am about to open my big mouth too soon and need to do more listening. If I think that the central issue is one of “not being a good person”, I do a few things. First, I usually consult with someone else to make sure this feeling isn’t just my countertransference getting in the way. This is important because, while I’m pretty good at finding most of my patients likable and interesting enough, I’m only human, and there are some people who just make me want to tear my damn eyeballs out. Knowing who you can and can’t work with is very important, and many physicians don’t allow themselves to acknowledge that they may not like, or even harbor a hateful feeling or two toward, some of their patients. If it turns out that I just don’t like the cut of their jib, I can do one of a few things. If this is on an inpatient unit, I suck it up and deal with it until they are discharged. If I find myself not liking a patient in therapy then things get more complicated and, assuming I’m not bringing in too much of my own personal mishegoss into the treatment, it can indicate an area ripe for exploration since I’m probably not the only person in their lives finding them unlikable right now.

If I think someone is truly a “bad person”, i.e the patient is, say, sadistic or psychopathic, or otherwise characterologically disturbed in thus-far incurable ways, then there may not be much I can do for them beyond “symptom control” and harm reduction.

(13) Any hot pharmacological takes?

Off the top of my head:

(1) Ketamine is overhyped and wont be the great treatment for depression (and whatever else) we’re hoping for.

(2) Some substantial part of the controversy surrounding SSRI efficacy for depression is that we call way too many things “depression”. There are plenty of ways to be sad, unhappy, unmotivated, and feel that life sucks, all while not being depressed, and in my experience SSRIs tend not to help with that kind of misery very much.

(3) The amount of amphetamines we’re currently prescribing is unsustainable and at some point we’re going to figure out how to get millions of people off this stuff. We will also have to realize that not having the attention, concentration, and energy that you want isn’t “having ADHD”; it is to some significant extent a function of living in a world we were not evolved to live in.

(14) Do you think there’s anything even preponderantly true about bipolar people’s eyes (lmfao but for real, this is a meme that comes up a lot)?

I don’t think I had ever heard of “bipolar eyes”, but then again I’m always the last guy to learn about a meme. I would bet that there are all kinds of subtle signs for bipolar disorder we haven’t quite figured out yet, as there are for many illnesses, e.g. differences in handwriting between patients with schizophrenia and normal controls. There may be interesting work to do with electroretinography but that isn’t my wheelhouse.

Thinking back on my experience, I don’t think I’ve ever seen anything that makes me think “bipolar eyes!” other than maybe someone who is manic having a really intense stare. And even then, those in states of mania can have all kinds of facial expressions—sometimes “intense”, but other times fearful, vacant, elated, etc. And I haven’t seen anything in the eyes of bipolar patients when they aren’t manic that distinguishes them from anyone else.

(15) Do psychiatrists ever grapple with the question: if our brains wanted us to know what they’re doing, why don’t they just tell us?

I’m not sure I really understand the question, but I suppose the ultimate reason that they can’t tell us more than they do is that there was no evolutionary pressure for the ability to have a more transparent understanding of our neural mechanics than we in fact have. We can’t even feel pain in our brains! And by the way, what would it even look like for our brains to “tell us what they’re doing”? In what form would this information come, and what purpose would it serve?

On the other hand, our brains are sort of telling us what they’re doing all the time. Isn’t all purposeful human behavior an outward manifestation of something going on in the brain? And what about the massive work brains do in regulating hormone balance and other physiologic parameters? At some point this becomes a measurement problem of what brain activity we are able to measure with whatever technology we have at the time. But sometimes it is obvious: sweaty palms, racing heart, fast breathing, tunnel vision, tingling in your fingers, nausea, a feeling of heat: that’s your brain saying “panic!”

(16) What advancements in the field are you most excited about?

Depends on your time horizon, but there are three things off the top of my head that all deserve much more extended treatment:

I’d say genomic medicine has the highest chance for totally revolutionizing the field possibly within my lifetime. It can be somewhat controversial because the question arises: to what extent will it yield new treatments and cures to once debilitating conditions, or will advances in embryo selection and other prenatal genetic technology mean that those with higher risk for severe mental illness will someday be selected-out before implantation? Will we be able to cure schizophrenia as we will likely be able to cure many other heritable genetic diseases, or is it too polygenic of a disorder to be amenable to a true cure?

Along with advances in genetics, artificial intelligence has to be the most significant potential technology if for no other reason than that it will be likely be one of the most significant innovations in the history of our species. This isn’t the place to get into a long thing about AI; the short version is that I think those who are deeply skeptical of AI’s abilities are fundamentally confused about what intelligence actually is. As for psychiatry, I don’t see AI replacing psychiatrists or therapists anytime soon. A chatbot may be able to mimic what a therapist says, but anyone who has been in therapy knows that what your therapist says often isn’t the most important thing. Here is one situation where having another fallible flesh-and-blood human being sitting across from you is integral to the treatment itself.

Like many I am interested to see what the next few years hold for the mainstreaming of psychedelics, although my hopes for their efficacy are more modest than some. I’m a believer that for the right people they can yield profound and transformative effects (I’ve done a lot of thinking on this topic so I’ll probably write more on this later), although whether this is scalable to be useful as a common medicine is unclear. It will be irritating dealing with the deluge of marketing around psychedelics, and it’ll be odd when every therapist suddenly becomes an expert in in the subject, but I think our culture will adapt pretty quickly as long as we avoid a moral panic.

(17) How do psychiatrists think about projection these days? And concepts like projection? It seems to me like a central thing in nearly all interactions and reflections, but is that even a relevant sort of idea in contemporary practice?!

Good psychiatrists, especially ones with a psychotherapeutic orientation, do think about projection and other psychological defenses like regression, reaction formation, splitting, projective identification, and so on. For my part, I consider understanding them to be essential, and it is worth noting that questions on defense mechanisms such as projection are on medical school and board exams, so they are considered important enough that not just every psychiatrist but every medical student is expected to learn about them at some point. There are all kinds of in-the-weeds theoretical discussions one could have about defenses, exactly how they work and how we should conceptualize them, but all that is of secondary importance. What matters is noticing certain reliably recurring patterns in how people cope, or fail to cope, with the world they find themselves in.

There are lots of ways to think about projection, but the essential idea is that someone disavows unwanted or intolerable aspect of themselves (e.g certain thoughts or feelings) and instead experiences other people as embodying these aspects. We’ve all seen this kind of thing before; children do it all the time as they are learning that they have their own perspective on the world which isn’t simply shared by everyone else. The ability to project is part and parcel of having theory of mind. Projection occurs to varying degrees in normal life, although in its immature/pathological form it can be highly maladaptive. Those with paranoid personalities, for example, tend to project a lot.

Here are just a few ways I think about defenses on a daily basis:

1. Understanding the patient’s level of psychological functioning. The kinds of psychological defenses people use are a good gauge of their ability to perceive reality and cope with what they see. Defenses are typically classified on a continuum of “mature-immature”, or “adaptive-pathological”. Common mature defenses include altruism, sublimation, and humor, while projection, denial, and splitting are examples of immature or pathological defenses. While everyone is liable to utilize immature defenses from time to time, especially under intense stress, it is the pervasive inability to utilize mature defenses that may indicate the presence of psychopathology, such as a personality disorder or psychotic state. Immature defenses typically involve distorting reality to meet one’s needs (eg. denial) or manipulating others (projective identification), whereas mature defenses signal a person’s ability to channel unpleasant affect in a non-destructive way.

2. “Managing the patient”. I put this in quotes because of the somewhat unsavory idea of having to “manage” other people. In this context I mean both being able to understand and respond deftly when confronted with a particular patient’s defenses (it can be quite unsettling to be on the receiving end of a paranoid psychotic fantasy), as well as keeping an inpatient psychiatry unit safe and well-functioning by having a close read on the group dynamics of the various patients and staff.

3. As a “lever” for change. In psychotherapy, especially the psychodynamic flavor, the real-time interpretation of defenses can take on a central role in treatment. Think of defenses like friction: both resist your progress but without them you can’t make any forward movement either. This is another one of those topics on which many volumes have been written.

4. Psychopharmacology. Most people think of defenses solely as the province of psychotherapy, but this is a mistake. The mindful psychiatrist understands that patients also have all kinds of psychological reactions to, and relationships with, their medications. Some use medications as form of resistance to treatment itself. It isn’t uncommon to see someone project parts of themselves that they can’t tolerate onto their medicines just as readily as they project onto other people.

Thank you again to everyone who submitted questions. Other questions welcome in the comments and if there are enough I’ll do this again.