The mere mention of prescribing psychiatric meds creates an immediate emotional, reactive war zone, that fuses genuine pain and suffering, drug industry marketing (e.g., “Neurontin for everything”), legal “responsibility” of the physician, minimum scientific fact, advocacy groups (e.g., N.A.M.I.), and T.V. advertising (“ask your doctor”). Is it possible to find a way to think about these issues and make intelligent decisions?
The interactions and interrelationships between the individual and the environment are always at work. How this occurs determines how the organism functions (thinking, behaving, feeling). This applies to the cellular level as well as the organism as a unit. The issue of medication is superimposed on this core fact which in turn triggers assumptions the individual makes about self and responsibility, which will also trigger a fair “dose” of anxiety. These assumptions are communicated to the physician who either accepts them as factual or explores ways to think about and question the assumptions. A reciprocal relationship begins which can spiral into a point of no return. Assumptions become facts, with no way to back down the process. It is rare when a physician asks the patient what he/she wants the medicine to do that he/she cannot or is unable to take care of at the present time, or “what is your plan for decreasing your need for this medicine?” What is the long-term impact of telling a patient that he’ll always have to be on an antidepressant? When do symptoms and symptom amelioration begin to define self? When do the assumptions driving DSM-IV become facts? When one is labeled with a “disorder,” medicine is almost automatic, e.g., “mood disorder.”
The decisions have to be focused on the choices about responsibility one makes in the relationship with one’s environment. What external resources will one use, or not use, in dealing with one’s problems? This question also applies to thinking about one’s relationships, not just medical choices.
Dr. Bowen’s letter of March 1978 is a response to a patient inquiring about the possibility of discontinuing Lithium.
March 16, 1978
Dear
How in the heck are you going to get off lithium if you are dependent on it to maintain your equilibrium and you have to get the environment to approve and assume responsibility for you if the experiment fails?
I think you can develop the ability to maintain full control of yourself without the propensity to respond to environmental stimuli, but the environment does not think so, and you have your own brand of doubts about you. The chances for failure are much greater if you involve the environment in your decision. It probably would be wiser to postpone a decision about the lithium until you can be real sure within yourself and you can accept full responsibility for the outcome. We can talk more about this later.
For now,
Murray Bowen, M.D.