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Integrative Psychiatry Blog 

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  • Writer's pictureRyan Sheridan, NP

I'm a Washington, DC-Based Psychiatric Provider: We Must Renew Our Commitment to Do No Harm.


Person contemplating the risks of mental health treatment in Washington, DC

I•at•ro•gen•e•sis: Any negative effects or harm caused by a treatment or intervention.


Let’s delve into a controversial topic, one that is sure to raise some eyebrow and perhaps even upset a few folks.  That’s the point – we need to have this conversation. 


Before we do, note this is meant to serve as a thought provoking discussion. The objective here is not to drag therapy or mental health treatments as a whole, but to elicit a much-needed discussion on our goals, purpose, and use in practice.


As an integrative psychiatric nurse practitioner in Washington, DC, I'm keenly aware of the delicate balance between healing and harm in mental health care. The concept of iatrogenesis is a term traditionally associated with unintended harm caused by medical treatment, but certainly applies in mental health.


Mental health is no stranger to such complexities. This post will wade through the nuanced effects of talk therapy and psychiatric medications, the paradox of increased mental health resources alongside rising mental health challenges, and the role of the provider in therapeutic outcomes.


Why aren't therapy and psychiatric providers discussing interventions with the goal of completion or termination in mind? Sure, it can be hard to pinpoint a definitive timeline, but the goal should be improvement and subsequently a retiring of the working relationship, shouldn't it?


Yes, Talk Therapy Has Risks


Talk therapy, often seen as a cornerstone of mental health treatment, promises understanding, catharsis, and a path toward healing. Yet, its efficacy and impact can vary widely, presenting potential risks alongside its benefits.


What if therapy, noble in intent, actually makes things worse?


In a field as complex as mental health, understanding these nuances is crucial for both practitioners and patients. Here are just a few scenarios, but in reality the point I am trying to make is that we should think about these possibilities, and others, when considering therapy.


No good surgeon would be providing quality care if they didn’t discuss the risks of a potential surgery, why should mental health be different?


In fact, there's a growing body of research to suggest that maybe the degree to which we prescribe talk-therapy to young minds, may have a negative impact. Of course countless folks have benefited here, but what about those who haven't or worse - were harmed?


1. Creating Dependency Instead of Promoting Independence


A therapeutic alliance is foundational to effective therapy; however, there's a delicate balance to maintain. Dependency occurs when patients lean too heavily on their therapists for validation, decision-making, and emotional support, at the expense of developing their autonomy and resilience.


  • Example: Consider Jane, who began therapy to navigate her divorce. Over time, she found herself unable to make even minor decisions without her therapist's approval, leading to a stagnation in her personal growth. Her dependency on her therapist's insights meant she was less confident in her ability to handle life's ups and downs independently.

2. Misdiagnosis and the Pathologization of Normal Life Struggles


The therapeutic process involves exploration and interpretation of thoughts, feelings, and behaviors. There's a risk, however, of overpathologizing normal reactions to life's stresses or misinterpreting these reactions as symptoms of more serious mental health conditions.


  • Example: Tom sought therapy during a stressful period at work, hoping to find strategies to manage his stress. Instead, he was quickly labeled with generalized anxiety disorder. This diagnosis led to an unnecessary focus on treatment for an issue that was essentially situational, not pathological.

3. Mismatched Therapeutic Approaches


Each patient is unique, and a one-size-fits-all approach to therapy can lead to mismatches that hinder progress. Therapeutic misalignment can stem from differing expectations, personalities, or disagreement over goals and methods.


  • Example: Lisa, a pragmatic, solution-focused individual, was paired with a therapist specializing in long-term psychoanalytic therapy. The mismatch in expectations left Lisa feeling frustrated and misunderstood, as she sought concrete tools and strategies rather than exploratory sessions about her childhood.

4. Boundary Violations and the Erosion of Trust


Therapy is built on trust and safety, with clear professional boundaries to protect both patient and therapist. When these boundaries are crossed, it can harm the therapeutic relationship and the patient’s well-being.


  • Example: Michael's therapist often shared personal stories and irrelevant problems, blurring the lines between therapist and friend. This not only distracted from Michael's issues but also placed an inappropriate emotional burden on him, complicating his therapeutic journey.

Expanding the Conversation


As we discuss these potential risks, my aim is not to cast doubt on the value of talk therapy but to advocate for a more nuanced understanding of its complexities. By acknowledging and addressing these challenges, therapists can better safeguard their practice against unintended harm, ensuring that therapy remains a beneficial, empowering experience for those seeking help.


In the quest for mental wellness, an informed, critical approach to therapy — one that embraces its potential both to heal and to harm — is essential. As practitioners, our commitment to ongoing learning, ethical practice, and person-centered care will guide us toward more effective, compassionate mental health support.


Iatrogenesis from Psychiatric Medications


Expanding on the complexities of psychiatric medications illuminates the delicate balance between their potential benefits and the risks they carry. This deeper exploration aims to foster a more nuanced understanding of these challenges, emphasizing the importance of informed decision-making in psychiatric treatment.


1. Side Effects: A Balancing Act


Psychiatric medications can cause a wide range of side effects, varying from mild to severe, and affecting patients differently. These can include physical symptoms like weight gain, dizziness, or sexual dysfunction, as well as emotional or cognitive effects such as mood swings or difficulty concentrating.


  • Example: Anna started a new antidepressant to help manage depression. While her mood improved, she experienced significant weight gain and felt constantly fatigued, leading her to question if the trade-off was worth it. This scenario highlights the need for healthcare providers to work closely with patients, monitoring side effects and adjusting treatment plans as necessary to find the most beneficial and least harmful balance.

2. Misuse and Dependency: Navigating the Tightrope


Certain classes of psychiatric medications, especially those with sedative or stimulant properties, have a high potential for misuse and dependency. This risk necessitates careful patient selection, monitoring, and, when appropriate, the exploration of alternative treatments.


  • Example: John was prescribed benzodiazepines for his acute anxiety. Over time, he found himself relying increasingly on the medication to function daily, leading to dependency. His story underscores the importance of considering long-term implications and the potential need for dependency management strategies.

3. Withdrawal Symptoms: The Challenge of Discontinuation


Stopping or reducing psychiatric medications can lead to withdrawal symptoms that range from mildly uncomfortable to severely debilitating. These symptoms can include anxiety, mood swings, sleep disturbances, and physical effects like nausea and headaches.


  • Example: After deciding to taper off her antidepressant, Emily experienced intense withdrawal symptoms, including dizziness, irritability, and a return of her depressive symptoms, illustrating the need for carefully crafted plans that help implement lasting change and allow for the planned discontinuation of medication .

4. Long-Term Unknowns: Venturing into Uncharted Waters


The long-term effects of many psychiatric medications are not fully understood, especially when used over decades. This uncertainty presents a dilemma for both patients and practitioners in weighing the benefits of symptom management against potential unknown risks.


  • Example: Mark has been taking antipsychotic medication for several years to manage his severe depression. While his symptoms are mostly controlled, he worries about the potential long-term effects on his brain health and overall well-being, highlighting the importance of ongoing research and patient education.

5. Overprescription: Seeking Balance in Treatment


The tendency to prioritize medication as a first-line treatment overlooks the potential benefits of alternative therapies and the importance of a holistic approach. This can lead to overprescription, where the underlying causes of mental health issues may not be adequately addressed.


  • Example: Leah was quickly prescribed medication to manage her symptoms of depression without exploring other treatment options like therapy, lifestyle changes, or social support. This approach may provide short-term relief but fails to address the complex interplay of factors contributing to her mental health, suggesting a need for more comprehensive, individualized treatment strategies.

 

Understanding the complexities and risks associated with psychiatric medications is crucial for both healthcare providers and patients. This knowledge empowers informed decision-making, ensuring that the benefits of these medications are maximized while minimizing their potential harms.


It calls for a collaborative approach to treatment, where open dialogue, regular monitoring, and a willingness to adjust plans are central to achieving the best possible outcomes for mental health.


The Paradox of Increased Access vs. Rising Mental Health Challenges


In an era where mental health awareness is at an all-time high, the juxtaposition of increased treatment availability against the backdrop of a growing mental health crisis paints a complex picture of the current landscape. This paradox invites a deeper examination of the nuances underlying accessibility, the quality of care, and the societal perceptions of mental health interventions.


The Paradox Unpacked


As mental health services become more accessible, one might expect a corresponding decrease in the prevalence of mental health issues. Yet, the reality is quite the contrary; the number of individuals reporting mental health challenges continues to rise.


This situation points to a multifaceted dilemma involving the efficacy of treatments, the variability in the quality of care, and the evolving societal challenges that contribute to mental health issues.


Quality of Care and the Role of Providers


The effectiveness of mental health treatment is profoundly influenced by the quality of the therapeutic relationship and the expertise of the provider. Despite the best efforts to standardize care through evidence-based practices, the personal qualities, skill levels, and even the ethical standards of practitioners can vary significantly, impacting treatment outcomes.


While this is more the exception than the norm, bad actors, or those who prioritize profit over patient welfare, exploit vulnerabilities, further complicating the trust and effectiveness of mental health care.


The Misconception of Universal Benefit


The notion that "everyone can benefit from therapy" is worth scrutinizing. While therapy offers tremendous benefits for many, suggesting it as a universal solution overlooks the individuality of mental health needs and can lead to the medicalization of normal life experiences.


The analogy of a healthy person unnecessarily seeking surgical intervention highlights the potential downsides of engaging in therapy without clear needs or objectives, such as fostering dependency or diverting resources from those in critical need.


Therapy as a Substitute for Social Connections


In our increasingly digital and isolated world, therapy's role has expanded, sometimes filling the void left by diminishing social connections. While therapists provide essential support, equating this professional relationship with genuine friendship or community can lead to an unhealthy reliance on therapeutic settings for basic emotional and social needs.


This dynamic not only places undue pressure on the therapeutic relationship but also detracts from the importance of building and maintaining a supportive network outside of therapy.


The Need for a Broader Dialogue


The current discourse on mental health care often champions the expansion of services and destigmatization of therapy, overlooking the critical discussion about the appropriate use, potential risks, and the complex dynamics of therapeutic intervention.


Encouraging a broader conversation can help align expectations, improve treatment outcomes, and ensure that those who can truly benefit from therapy receive the care they need without contributing to the overpathologization of normal life challenges.


Moving Forward


Addressing the paradox of increased mental health treatment availability amidst rising mental health challenges requires a multifaceted approach. This includes improving the quality and accessibility of care, fostering public education about mental health, and promoting community and societal initiatives that support mental well-being.


By acknowledging the complexities of mental health care and advocating for informed, personalized approaches to treatment, we can better navigate the intricate landscape of mental health in our society, ensuring that the expansion of services genuinely translates into improved mental health outcomes for all.


Provoking Thought, Inviting Dialogue


My goal is not to undermine the undeniable value that therapy and medications bring to countless individuals seeking solace and improvement in their mental wellness. These tools, when applied judiciously and thoughtfully, can be life-changing.


However, the essence of our dialogue aims to broaden the perspective on mental health care, pushing beyond the surface to explore the depths of its application, effectiveness, and impact on society at large.


Fostering a Holistic Conversation


The conversation surrounding mental health care often oscillates between two poles: advocating for broader accessibility to therapies and medications, and highlighting the success stories of those who have found their path to recovery through these means.


While these narratives are important, they sometimes overshadow discussions about the challenges, limitations, and potential misapplications of therapeutic interventions. By engaging in open dialogues that encompass the full spectrum of experiences — including those less talked about — we can cultivate a more balanced and comprehensive understanding of mental health care.


Embracing Complexity and Individuality


Each individual's mental health journey is as unique as their fingerprint. What works for one person may not work for another, and the reasons behind this variance are as complex as the human mind itself.


Recognizing this diversity calls for a tailored approach to mental health care, one that considers the person's unique background, circumstances, preferences, and needs. It also underscores the importance of choice and consent in therapy, ensuring that individuals are active participants in their treatment plans rather than passive recipients.


Encouraging Critical Inquiry and Education


To navigate the complexities of mental health care effectively, both practitioners and those seeking care must be equipped with critical thinking skills and a deep understanding of the potential benefits and risks associated with different treatment modalities.


This includes an awareness of how societal, cultural, and personal biases can influence the therapeutic process, as well as an understanding of the ethical considerations inherent in mental health practice.


Education, both formal and informal, plays a crucial role in fostering this understanding, empowering individuals to make informed decisions about their care.


For example, providers should be discussing how termination of care on day one. Patients should note this as well and include it in their decision making process. That’s not to say we have a definitive answer – it’s to say termination of care should be the goal.


Advocating for Integrative and Ethical Practices


In my DC-based practice, I champion an integrative approach that respects and honors the whole person — mind, body, and spirit. This approach combines the best of conventional and complementary therapies, tailored to meet the unique needs of each individual.


Moreover, it demands a commitment to ethical practice, transparency, and continual learning and improvement. By holding these values at the forefront of mental health care, we can ensure that our efforts to support mental wellness are grounded in respect, integrity, and a genuine desire to do good.


Conclusion


The journey toward mental wellness is both personal and communal. As we strive to enhance the quality and accessibility of mental health care, let us also commit to a deeper exploration of its complexities.

 

Through open dialogue, critical inquiry, and an unwavering dedication to ethical and individualized care, we can navigate the challenges of mental health together, building a future where everyone has the support and resources they need to thrive.


Ryan Sheridan, NP

Let’s continue this vital conversation, enriching our understanding and refining the ways we support mental wellness in our community and beyond. Feel free to reach me by email.

 

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