Hacker News Reader

Comment by phren0logy | Hacker News Reader

> The question is, why is mainstream psychiatry still so obsessed with "curing" addiction via chemical means, as opposed to through psychology/trauma recovery?

I'm a psychiatrist, and at the risk of sounding defensive, I'm not sure where you are getting this from. I have never worked at any addiction program where psychological and behavioral interventions weren't the primary mode of treatment. There are medications that can help with diagnoses related to trauma or other contributors to addiction (PTSD, depression, etc), and a handful of medications that can address some limited facets of chemical addiction, but the bulk of treatment is non-pharamcologic.

The same is true when I got to national and international addiction conferences: medications are a side-dish, not the main course.

View on HN

That is great, I don't exactly know where you are located. But as someone in California I can tell you that the amount of (at risk) kids that I've worked with throughout the years tells me over half of them were strung out on a solely medication based treatment. We were the first exposure to actual "therapy" that they've ever had, and it is by far the most effective thing many of them have ever been exposed to. Maybe it's a regional thing, probably a Californian thing.

I think you're conflating multiple factors here, mainly psychiatry and parenting. Child psychiatry is an extreme because the patient is most often not the one making decisions (which they're often not capable of anyway). Much of the time, the patient hasn't even really figured out what their "normal" is before their parents stick them with a professional.

Many parents, especially when looking at-risk demographics, look to psychiatry as an easy fix so that's what the doctors give them. The parents often can't afford to take time to drive their child to a psychiatrist twice a month let alone pay for the sessions. The end result is that psychiatry stuck in a terrible ethical spot, where their duty to treat not just symptoms but causes clashes with the realities where the parents are at the end of their rope. Are doctors stewards of health, responsible for the patient? Or are they professionals that have to meet their clients half way? I don't think there is an easy answer to that question.

Obviously there are many unethical and incompetent psychiatrists but my experience in California (as an adult) stands in stark contrast to all the horror stories I hear about child psychiatry from school administrators. As usual, there is a massive wealth gap and your mileage will vary.

A lot of the kids we've dealt with parents are typically incarcerated, dead, or no longer have custody of their children.

In our area sexual abuse is one of the main issues, usually these kids live with relatives(after the conviction) who are usually the most well off in the family. They still by in large get the short end of the stick even though the relatives/guardians try to work with psychiatrists, but we've heard how that goes. That's often how they end up with us, they (the relatives/guardians) bring their troubled kids to us for actual help, not just medication.

But hey I don't mind, we do better work (at least in our area), bring 'em all. Gets more kids off of substance abuse, gets them connected to people who care about them, and more times than not equips them to help their families and community by in large. And we don't even get paid (all voluntary), and that's how I prefer it.

Is your org more of a last resort for these guardians so they go to psychiatrists first or is it a discoverability problem in general?

Since you're all volunteering, I'm curious if the simple removal of the profit motive is enough to change the way all parties involved approach treatment or if its a matter of just having more time to devote per person (because the limit becomes your time and patience instead of their checkbook).

No, it's for any at risk kid, and many do come first. Most likely discovery since that would take a lot more energy and money.

Since there isn't really any motive to reach a solution, and no harm no foul if it doesn't work out. No one's going to really hold us to anything since it doesn't cost them anything more (sometimes less since we will pay for what they need when they are with us, none of that gets reimbursed).

The other thing is that the parents are often part of the problem.

I’ve seen a couple of “monster” children in my kids school who are highly disruptive and have some obvious issues that will be very difficult as they get older.

It’s pretty obvious why when you see the parents in action.

That's very common. Why would they act any differently, they've seen how their parents treat others, that's their model, even if it's a terrible one.

And interestingly enough, even those that despise their parents will still emulate their behavior, that's something I just don't get

The cynic in me is prone to blame it on the capitalistic nature of our modern society.

You've got to get your numbers up.

It takes way more time to properly deal with psychological issues through therapy than it does to just prescribe a pill. They've got their pill, feel slightly better, so now you get to put them in the "done" pile. So your hospital gets to say it treats 1000 patients per quarter instead of just 100, so they are more attractive to pharmaceutical companies which pay them oodles of money.

The less cynical way to look at it is that the health care system is overloaded and underfunded, they don't have enough resources to properly treat people so they "have" to take the quick and easy route.

Either way, it doesn't sound that great.

Of course this isn't analogous of the entire system, but I do see that a lot at least around here. But we never had very good hospitals or clinics for miles around. Just due to how much money is actually made, and how much they can spare.

Here we don't have too many options, which is why I think it goes to drugs so quickly. Though I personally believe that just about any issue I've seen can be fixed free from the use of drugs. Not a single one in the last few years have stayed on meds after working with us, and none of those have had any severe drawbacks (like suicide, self-harm, etc.) so that's a pretty decent track record. (in fact most are much better off after)

I have some personal experience with this in Mountain View CA. I was having trouble sleeping, to the point of losing the ability to think clearly. The physiatrist I saw only talked to me for about 5-10 min before getting me on some drugs (I've forgotten the names of). Now granted I needed sleep, and they did give me something for that, but at the same time they put me on antidepressants. It took almost a year to get off them. Each time I'd go in for an appointment it'd be a new person talking to me... it was useless, and frankly did a LOT more harm than good.

Something is seriously fucked up with some of these places.

With respect, most psychiatrists I know generally pay lip service to the idea of psychological counseling, but when the rubber meets the road end up relying on meds. I mean think about it. If you actually believed the root cause was psychological, you would become a clinical psychologist instead of going to med school just so you could have the title of Doctor and prescribe meds.

If you are one of the “other” kinds of psychiatrists, who deeply believe in psychological trauma recovery and are trying to fix the system from the inside, then I sincerely commend you for your work.

I probably know more psychiatrists than you do, so I'll offer a counterpoint: Outside of starting your own practice, nobody will pay psychiatrists to do talk therapy when they can pay somebody who didn't go to medical school to do it. For this reason, we end up doing mostly medication management, but at a good clinic this is as part of a team of social workers, psychologists, occupational therapists, etc.

Ironically, most US readers of HN will never have seen such a clinic, as the only places actually staffed this way are things like county mental health departments in states where they can get funded.

So, anyway, psychiatry training REQUIRES that each of us provide many hours of supervised psychotherapy. Some training programs are better than others, but we all graduate with a working knowledge of psychotherapy. Many of us have less opportunity to use it than we would like.

Which brings me to my final point: it's not either / or. That's a false dichotomy. It's about the right tool (or combination of tools) for the job. There are plenty of problems that there is no pill for, and a few problems that no amount of talking about it is going to fix. Horses for courses, and all that.

edit: I'm sorry to see you are getting downvoted. I think many people arrive at the same conclusion you have, based on their experiences. I can totally understand how you arrived at that opinion.

I don’t mind the downvotes. What concerns me more is the obvious logical circles you are spinning in order to make a weak argument in defense of psychiatry.

Your parent comment:

“I have never worked at any addiction program where psychological and behavioral interventions weren't the primary mode of treatment.“

Your latest comment: “Nobody will pay psychiatrists to do talk therapy... for this reason we end up doing mostly medication management...”

So let me get this straight. You are currently doing mostly meds, and you’re presumably working at “one of the good places” where psychological methods are the primary mode of treatment. So either you are completely okay with being relegated to a secondary role in treatment (unlikely, given how psychiatrists tend to dominate the conversation thanks to that Dr. title), or, more likely, you are not being sincere when you state your belief that psychological methods are primary. Which is exactly my point. Psychiatrists by their nature and training don’t believe non-pharma methods are the primary solution. Most really try to pretend that they care, but end up prescribing meds in the end. Which was my original point.

You've crossed into incivility in multiple places here. That's not ok on HN. Please review https://news.ycombinator.com/newsguidelines.html and refrain from posting like this, even when you feel strongly.

I've spent years working with past trauma and many hours in therapeutic circles with traumatized people, so I completely get where you're coming from and our views are probably sympatico. But there's a risk, when one's opinions come from the same intense experiences as one's feelings do, of not leaving enough space for other people. On HN, other people means other commenters, especially ones who are coming from an opposite position. Forum comments tell us very little about who we each are, and inevitably we sketch in the gaps from material of our own past experience. This leaves exchanges fraught with misunderstanding, especially when feelings are strong. We're all responsible for guarding against that.

dang, I appreciate your efforts to maintain civility and I sincerely apologize if my tone came across as disrespectful towards any member of the HN community. I also appreciate you mentioning your experience with past trauma.

Looking back on this comment, I agree that I could have worded this more respectfully. I will strive to do so better moving forward.

I would hope that HN is a space where you can call out illogical ideas, which is what I was trying to do. I reacted emotionally because I felt like I was being trolled, which is extremely common for anyone who exposes themselves by speaking about trauma. I can see now that the intent may not have been to troll me.

However, I do feel like I’m being singled out a bit unfairly here. Again, not excusing the tone of my own comment, but I’ve received a few replies that feel at least as aggressive as my own. There’s one in particular referring to the “stench” of my comment that felt a bit harsh. All I would ask is for the same standards of civility to be applied to all members.

If you see that comment and legitimately believe that mine was noticeably more over the line, please let me know.

"Patronizing stench" is not a fair phrase to direct at someone on HN, and I've replied to it. But there's still a difference, it seems to me. Your comments have been the ones sort of inducting this thread in a generally flamewarrish direction. That's understandable when strong views meet strong feelings meet strong experiences, and easy to fall into without fully realizing. This is provocative territory for a lot of us. But HN is lucky to have a user like phren0logy show up to offer his obviously relevant experience on the topic, and if other users respond by somehow questioning his choice of profession, that's a move that's unlikely to lead to better discussion.

The best ways I know of to avoid this are to stick to describing one's own experience and to look over one's comment several times for anything unduly personal. It can sneak in in a lot of ways.

I have friends who are in orthopedics, and they work with lots of physical therapists. They don't do the physical therapy themselves. Similarly, I'm the medical part of a team, and I'm cool with that. I do the parts that other people can't. It's a pretty standard arrangement and most psychiatrists who treat addiction work this way without much issue.

I think we understand those comparisons. The comparison that is missing, and where experience seems to be lacking with practitioners due to its how it has become structured, is doing therapies without harmful medications - that for many people have extremely negative side-effects, withdrawal symptoms - that some would argue cause more permanent problems/changes.

Would you also say that complex jobs require a whole toolbox, rather than just a hammer, wrench, or driver of some sort?

> going to med school just so you could have the title of Doctor and prescribe meds

Your comment really isn't with respect when you make this assumption about someone's profession based off no knowledge of that person's chosen career path.

I'm not sure what kind of a person knows many psychiatrists but doesn't understand that the boundary between psychiatry and psychology isn't some high garden wall whereby a psychologist tosses the ball over when they can't figure out the case.

Undoubtedly there are some psychiatrists who pursue the title for reasons other than the fact that psychiatrists have the vast majority of the power and funding in western medicine as compared to psychologists. Surely there are some who are genuinely motivated to solve the problem of human psychological suffering.

To those I have a serious question: why did you choose psychiatry over for example a PsyD degree? And: what are the key data points that make you believe that the pharma-centric approach is the one worth devoting your career to?

>why did you choose psychiatry over for example a PsyD degree? And: what are the key data points that make you believe that the pharma-centric approach is the one worth devoting your career to?

The patronizing stench of this comment aside, you’re attempting to wedge these two careers into the same hole when they are apples to oranges. At their foundation, the curriculums between the two are nowhere comparable.

My psychologist has been taught to conduct _psychotherapy_ at an expert level. My psychiatrist is trained to be a _medical doctor_ on all bases with additional expert knowledge in their sub field.

While you may have a certain disdain for the field of psychiatry, attempting to devalue the importance of the balance they maintain for a patient stems from ignorance of what they do.

> patronizing stench

That falls under what the site guidelines refer to as name-calling and ask you not to do.

https://news.ycombinator.com/newsguidelines.html

> I'm not sure where you are getting this from.

Not GP, but the prozac shrimp story probably didn't help the reputation of psychiatry in the United States at least. And to clarify: I do mean "reputation" - I don't know if it actually says anything about the state of medication - could very well be sanitation.

That is completely and utterly peripheral to if the medication works for humans. It is a sanitation and environmental issue period until someone can come up with an alternative that can be absorbed fully or pass into a degraded non-effective state which is a tall order given that even penicillin couldn't. That is also an issue for birth control medication but it is accepted as generally 'environmentally worth it' compared to the costs of increased r-strategy population growth.

Although there are certain parties interested in badmouthing psychiatry at every turn out of dogma and self interest - from the obvious of Scientology and their means of control to the fundamentalist and homophobe contingent angry over their role in destigmatization and having to look for new targets. They're pissed off that gay marriage is widely accepted - saying someone was for gay marriage in the 80's doesn't make them look wacko fringe like it did then but visionary from how utterly vindicated they were. They are angry that science "didn't stay in its lane". And psychiatry is science. Even in its bad old days of abuse of electroshock and lobotomies considered a valid treatment and despite qualitative aspects keeping it from hard equations and laws the fact that they let the evidence speak and draw the conclusions - 'no society is clearly wrong here - homosexuality is not a mental illness' is profoundly science in a 'and yet it moves' way.

So the next target for their otherphobic garbage of strawmen that I sadly am not making up is that psychiatrists and liberal parents want to reassign gender and provide hormone treatments and surgical treatments at will and everyone trans is a bathroom sexual predator.

Meanwhile back in the /bad old days/ of the past when gay-bashing was relatively accepted a trans Bond girl was treated as mere trivia with perhaps a few tasteless jokes that were still better than the horrific 80's AIDS 'jokes' instead of a 'franchise ruined forever' reaction.

This wasn't meant as snapping at you but at a clear frustrating trend that I have noticed.

Hm. According to her, Caroline Cossey (the Bond girl) was more or less hounded into giving up her modelling, TV and acting career due to the backlash. Not sure it's as simple as mere trivia.

https://www.mirror.co.uk/3am/celebrity-news/transgender-bond...

Huh I didn't know that - just that it wasn't of concern. I guess it might have been a case of tolerance bubble striking.

Reply on news.ycombinator.com