Why does the same psychiatric drug help one person – but harm another? Do psychiatric medications “work” by chemistry alone – or through expectation, placebo, and social factors?
Clinical research and outcome studies, as discussed in-depth by Robert Whitaker in Anatomy of an Epidemic, don’t support the current widespread use of psychiatric medications. Medication risks often outweigh any benefits, not only in studies that downplay or ignore long-term use issues, but even over the short term. Clinical trials results are manipulated and hidden to promote medications for marketing purposes.
Moving from aggregate research data to individual experience and choice has been a challenge for people concerned about these startling facts about psychiatric drugs. How do we engage a single unique individual from a framework of statistical assessment of medications, when that single individual may very well be the outlier exception found in statistical data – or even represent new data with no precedent in existing studies?
In this edition of Madness Radio, David Cohen, social work professor at Florida International University and co-author of Your Drug May Be Your Problem, discusses the role of social context in constructing how we experience psychiatric medications and all drugs. In my work with people around medications and withdrawal, I’ve noticed a parallel between worse side effects and lower empowerment and control. It turns out animal studies on drug addiction show the same importance of the social factor of control and choice in drug effects. I’ve met people in my counseling practice who are physiologically devastated by regular lithium use, and then talked with other people on the same dosage for the same time period who are thriving in their life with the assistance of lithium. David’s work begins to address this paradox: how medication effects are not simply chemical impacts on a biological brain, but rather the complex interactions of social factors, expectation, placebo, “nocebo,” and learning. As a harm reduction approach to withdrawal emphasizes, empowerment may be the most important consideration for supporting people’s wellness.
David asks us to consider medications from a standpoint of substances that alter consciousness. We know for example that alcohol has “objective” chemical risks — and that alcohol can be of perceived practical benefit to many people nervous in social interactions — but the impact of alcohol use is radically diverse depending on the person. Alcohol is a very, very dangerous drug that causes brain injury and carries extraordinary social harms alongside it — and is also tolerated without problems by many people.
In challenging the biological model of mental illness, it may also be important to go beyond the biological model of medication effects. Can we acknowledge drug risks and toxicities while also acknowledging the variability of response based on the social experience of medication? Is the meaning of medications for each individual more than just a biological question, just as the meaning of “mental illness” for each person is more than just a biological question? Do we need a recovery model of medications instead of a biomedical model of medications?
After all, the key ingredient to the success of the Soteria Project and Open Dialogue – innovative low-medication treatments with high recovery rates – seems to be the expectation of recovery offered by caring clinicians. Sounds a lot like the placebo effect to me.