One of the crazy things that will happen to you when you seek treatment for being crazy, is doctors will ask you what treatment you want. Usually your psychiatrist/doctor will give you two options: Would you like to try psych med A or psych med B? This provides the mirage of control over your mental illness and your mental illness treatment.
Frustration, thy name is bipolar.
Patients Choosing Psych Meds Has an Air of Hilarity to It
This choice, of course, is ridiculous.* How should you know which medication to pick? They’re the doctor, the fancy psychiatrist, aren’t they supposed to know?[push]Do you pick the one that’s your favorite colour or matches your hair?[/push]
What criterion could you possibly use to pick a psychotropic medication that would conceivably compare to an actual doctor? Most patients, bipolar or otherwise, don’t even know the chemical name of their psychotropic medication. And why should they? All the di’s, tri’s, methyl’s and dride’s don’t really come in handy on a day to day basis.
The Doctor Is Fighting Learned Helplessness
What the doctor is doing here, is using basic psychology similar to the type parents use on their children.
Your child won’t go to bed. You say to little Billy, “which pajamas would you like to wear, the Spiderman or the Superman ones?” The child then focuses on the fact they get to make a decision, they feel empowered and are less likely to refuse to go to bed. The adult, of course, has given the child a choice the parent doesn’t care about. Superman or Spiderman, the kid is still getting into bed.
This is what doctors are doing. They are giving the person with a mental illness a choice that doesn’t matter. Sure, it seems like it matters because they’re drugs, and your life is on the line, but either way, you’re agreeing to a treatment, and that is all the doctor cares about. (It is why you are there, after all.)
Psychiatrists are Trained to Prevent Learned Helplessness
Doctors have been trained to do this because of the concept of learned helplessness. Learned helplessness is seen in lots of areas of life, but the basic principle is: the person comes to believe they are helpless, whether or not they truly are. A common example of this would be a battered spouse. Because they have been repeatedly abused and controlled, they start to think they don’t have control over anything in their life, even when they do. (Abusing people programs them this way and is one of the reasons an abused person doesn’t leave an abusive relationship.)
As Wikipedia puts it:
[a person] has learned to behave helplessly, even when the opportunity is restored for it to help itself . . . Learned helplessness theory is the view that clinical depression and related mental illnesses may result from a perceived absence of control over the outcome of a situation.
Learned Helplessness is Dangerous in Mental Illness
And this is a very real concern for the mentally ill because not only are you controlled by your disease, but then you’re controlled by the drugs put on top of that. If you then add the layer whereby you doctor is in complete control over your care, the patient begins to feel helpless in increasing areas of their life. This is problematic, particularly for the crazy, because that kind of helplessness, leads to hopelessness, which leads to suicide. When you can’t control anything, there is just no reason to stick around.
Choice of Psychotropic Medication Treatment Feels like a Game Show
But choosing between psychotropic pill A and pill B is akin to choosing to be hit on the head by a baseball bat or a two-by-four. I’m pretty sure there is no good option there. But it gets worse. Choosing a psych med is really more like choosing the blunt object behind curtain A or the blunt object between curtain B. You don’t know the ramifications of the decision. You don’t even have a shaded outline of what to expect. It’s like choosing a car based on how far apart the headlights are. It’s ridiculous. It’s laughable.
Control of Mental Illness, Control Over Treatment
[push]You can choose whether to get treatment or which pill to take, whatever that’s worth, but often these things feel surprisingly similar. Even a person who doesn’t exhibit learned helplessness can reasonably feel completely out of control.[/push]
And you can feel as empowered as you like, but the truth is, you really don’t have control. You didn’t have control over your brain when you got sick, you don’t have control over getting worse and you don’t have control over how your treatment goes, no matter the window dressing provided by the doctor.
You can pick doctors, therapists and pills, but feel helpless in all the ways that matter. It feels like you can’t get better, can’t have a normal life and can’t even figure out why you should want to be on this planet. It feels like picking Spiderman or Superman pjs, but either way, it’s bed time.^
Mine only gave me a choice of antipsychotics after I had bad reaction to the first one she tried.
Wow, surprised that the doctor gave you a choice in the meds–hadn’t been my experience. Often people in managed care situations don’t get the chance to pick doctors but it’s good to see some positive stories about treatment.
Hi MMC,
Obviously, I can’t speak for treatment at large, but personally, I always get options. And if they don’t give them, I might ask for them. I think (if I remember correctly) it didn’t start out that way, but that’s not surprising as I didn’t know much back then.
I’m not quite sure what you mean by “managed care” but I’ve been in care in Canada and the US and found the “choice” aspect fairly similar.
I do think, though, you have to have a rapport with your psychiatrist. If it’s the first time he’s ever seen you and (for whatever reason) you (generically) don’t impress him as being able to decide, it might be different. I don’t know. And, of course, some doctors are going to do whatever they want regardless.
– Natasha Tracy
Hi Natasha,
Love your blog, it’s really insightful to read about other people’s experiences with doctors. A lot of my dealings with my doctors leads me stumped: they always ask if I’m going to commit suicide or if I’ve ‘made any plans’ which I understand they need to ask to cover their backs, but really, if I were serious about killing myself and had made a plan, why on earth would I tell them? It sometimes seems as if they are operating on a level of trust, and to be honest, anyone with bipolar or any other severe mental illness can’t be trusted with big choices because life is too goddamn disorientating as is…Anyway, I’ve started my own blog batsinthebelljar.com about my experiences too. Hope you swing by sometime.
Minkax
Hi Minka,
Thanks for dropping by. I love first-time commenters. Especially ones that don’t hate me.
I think I’m going to answer your question in a whole blog post. It’s a good point.
I think I’ll do it today. I’ll add a comment here when I do, if you’re interested.
Good luck with your blog. I’ll stop by if I can, but in all honesty, I’m a pretty busy gal, so I can’t make any promises.
– Natasha Tracy
Hi Minka,
I wrote a post on Breaking Bipolar about this. To be clear, I think your question is completely reasonable. It spawned an article on my head.
(Some people think this is me belittling them in some way. It isn’t. You asked a good question that I’m sure many people have wondered about over and over.)
http://www.healthyplace.com/blogs/breakingbipolar/2011/05/why-do-doctors-ask-dumb-questions-about-suicide/
– Natasha Tracy
Great article.
I have gone from being on 8 different meds to 1. I ditched them all in January and yes I had a very hairy couple of weeks, followed by a very scary couple of months- but I stayed out of hospital and I didn’t kill myself so it’s all good!
I feel so much better off all the “mood-stabilisers”, anti-psychotics and I especially feel good off the Lithium. My psych would love love love to have me back on meds- but I’ve tried so many and they just don’t work. I need to find my own balance and cope with bipolarity in other ways- that’s just the way it is for some of us.
It was a scary ride coming off meds and I am lucky as I have a very solid support team that kept me going through the darkest hours- but I’m so glad I did it.
The pyjamas analogy is brilliant- that’s exactly what it’s like- and they wait until you’re completely mental and unhinged to pounce, I can’t belive all the meds I “consented” to taking at a time when I barely knew my own name.
Zoe,
Thanks.
8 to 1 sounds pretty good if it’s working for you.
(For anyone reading this, _never_ go off meds without medical supervision. Meds should be tapered. Going cold turkey can go _very_ wrong. Sorry, I had to say that.)
I was never a fan of lithium myself. Found it very fog-inducing. But I tend to be overreactive to meds. Especially the fogginess.
We all do the best we can with consent. It’s very hard for a sick person to think straight, that’s the thing about being sick. And while, certainly, being overmedicated is clearly not a good thing thinking with depression or mania is no picnic either. Everything is a pro/con list. And then muddling through.
I don’t think “they wait until your completely mental and unhinged to pounce.” I think that’s where many people find themselves because that’s how bad it had to be to _get_ treatment. It’s not the doctors doing that, it’s the disease.
I wrote about risk tolerance in treatment and basically, when you start treatment everyone takes the least risky option – obviously, but as options are crossed off, and you get worse, the only things left are untidy, unfortunate options. That’s not the patient’s or the doctor’s fault, it’s just the way it is.
It’s good that going off most of your meds worked for you, but for many people that could send them into a place in their disease when terrible things can happen. Going off a bunch of meds is risky, but you did it. Non-risky choices weren’t available so you made a risky one. Luckily for you the risk paid off. But when you made that gamble, you had no idea of the outcome.
Thanks for your comment.
– Natasha Tracy
(The piece on risk tolerance is here if you curious: http://www.healthyplace.com/blogs/breakingbipolar/2011/03/bipolar-treatment-and-risk-tolerance/ )
Natasha,
Thank you for this entry! When I first started, my doctor gave me the option of depakote, lithium, and tegretol (I think). So I spent a few days researching and figured out I should do depakote because it helped with rapid cycling, which was definitely what I was doing. However, my parents thought lithium would be good first and so he agreed. His rank order was lithium, depakote, tegretol. Interestingly, I had an allergic reaction to lithium and then proceeded to do well on Depakote for two years. Now I’m on lamictal and it seems to be going well.
Take care,
Jess
Hi Jess,
I’m surprised you even were given the option at that point. Doctors generally like lithium so much it’s the first thing they always try. (I gather for those whom it works, do quite well.)
Good to hear that lamictal is working out for you.
– Natasha Tracy
Natasha,
Yes, I was grateful for it, though. Lithium does seem to help most people that do not have rashes and so on. It used to be the cure-all drug for BP, that’s for sure! I’m glad they’ve been able to branch out enough to demonstrate how some drugs affect different areas and may work better for those rapid cycling vs really manic vs mainly depressed etc.
Take care,
Jess
Natasha,
I LOVE this post! I have been struggling with this very issue since receiving my recent and “official” diagnosis of of “The Bipolar Disorder which is a mood disorder, that can be managed with medication, much like diabetes.” That video cracks me up.
http://youtu.be/Bn6orT2jKN0
Seeing my first ever prescribing psychiatrist just this last week, I experienced the absurdity you described and it’s illusion of control. I felt very much “part” of the process in choosing my medications. Me, who wanted the one-hit-wonder pill (and not be on a cocktail), actually found myself asking for MORE, an anti-depressant as well as upping mu dosage of Lamictal.
I was in my car driving to my local pharmacy when it hit me: How did THAT happen? I laughed out loud at the absurdity of what had just occurred. Had I done that? Had he?
Again, thanks for posting this post. You hit it. To quote Cheney, “BIG TIME.” I don’t mis an entry of your blog. You are wring a perspective that everyone SHOULD be reading in the MI blogosphere. Your POV is certainly tough and unyielding. I like that.
Mr.Burns voice: “Exsssellent…”
jt
ps- do you know that i have had people actually comment that they won’t put me on their blog roll because you are on mine? such a “polarizing” figure… lol… now, i know i’m on that right track. cheers.
Hi jt, thanks. Glad you like it.
” I don’t mis an entry of your blog. You are wring a perspective that everyone SHOULD be reading in the MI blogosphere. Your POV is certainly tough and unyielding. I like that.”
Thank-you. That’s quite a compliment.
I know my point of view runs against the grain for many, but I think it’s something many people think variations of but are too scared to say. I’ve always been too opinionated and honest for my own good.
“Do you know that i have had people actually comment that they won’t put me on their blog roll because you are on mine? such a “polarizing” figure… lol… now, i know i’m on that right track.”
This is the first time I’m hearing that but I suppose it’s not surprising. It’s simultaneously one of the most flattering/ridiculous things I heard in a while. It’s rather amazing that someone hates me so much that they don’t wish to have their name sullied by being on the same _screen_ as me. Extraordinary.
– Natasha Tracy
Hi Bec,
You are too kind.
That sounds like a pretty good doctor. I can’t tell you the number of times I wish someone would just say that to me – this is the med I would pick for my daughter. They could still be wrong, naturally, but it has some weight to it.
I’m extremely educated on bipolar and meds and I still think it’s a crap shoot. There are actually a couple of recognized algorithms for selecting treatment in bipolar and they make all the big decisions but it still comes down to med a or med b and no one really knows the answer to that question. And when you’re on multiple meds? Heaven help you.
Recently I’ve been trying to decide between adding NAC, adding a TCA (and attempting to get off Pristiq), adding a dopamine agonist, or something else I haven’t thought of yet. And the doctor has left it completely up to me, which kind of makes me want to strangle him. How, precisely, should I choose between those things? I mean, really. There is _no_ right answer there. Just wrong ones lined up in a row.
(Don’t worry if you don’t know what the stuff is, it’s one of those sketchy-researchy areas.)
I find it all infinitely frustrating, not so much empowering. But then, I don’t see any good alternative.
But that’s me. Most people aren’t in the muck quite so much as I am. And sometimes in the muck I see things more clearly as they’re more accented. And perhaps more thought-nutritious.
Glad you liked it. I’m a believer in thought.
– Natasha Tracy
This has stopped me in my tracks. I’ve never actually thought about it in this way. I was given the choice between lithium and lamotrigine (to be made at the next appointment) and although I was leaning to lamotrigine, my psychiatrist said at the deciding appointment that if it came down to it and he was choosing for his daughter, he would try the lamotrigine first. So that’s what I went with. It’s been by far, the best med I’ve ever taken, but I guess that’s not entirely the point. Although as a former health professional with some training in pharmacology I was able to go and make what I believe was a fairly informed decision by reading professional information, journal articles and the like, at the end of the day, I probably would of chosen whatever the psychiatrist said he would try with his daughter anyway. So really, I didn’t make the choice myself at all, even though I felt that I did.
I usually consider myself to be somewhat of a critical thinker but time and again your articles take it that one (or more) steps further. I wholeheartedly believe that I have a very good psychiatrist but thanks for the food for thought.
Bec