Psychiatric Medications: Who Decides?


Welcome to a conversation between two social therapists who meet regularly to share and advance our therapeutic work. We hope these dialogues can support and stimulate others who are integrating developmental conversations into their therapeutic practices and personal growth.

But first, a brief explanation of what social therapy is and the perspectives we’re coming from in our dialogues. Social therapy is a radically humanistic approach among the family of postmodern, socio-cultural, critical psychology alternatives to the medical model understanding of human emotionality and cognition. Among these approaches are social constructionism, cultural historical activity theory, and narrative therapies.

Social therapy is a psychology of becoming. It is a non-diagnostic, relational, improvisational, non-manualized approach. The primary modality is group therapy in which heterogeneous groups of people from all backgrounds and ages come together each week to collectively create a new environment for emotional growth. Founded in the late 1960s by philosopher and psychotherapist Fred Newman, its primary influences are the work of Soviet psychologist Lev Vygotsky, the philosopher Ludwig Wittgenstein and methodologist Karl Marx. Together they provide an understanding that human beings are fundamentally social; that people can develop emotionally and socially throughout life; that play and performance are critical to human development; and that language is a continuous, creative and relational activity. The home of social therapeutics is the East Side Institute, the international training center for social therapeutics.

We welcome your responses and comments. Enjoy!

Psychiatric Medications: Who Decides?

Hugh: I’m thinking a lot lately about psychiatric medications — specifically, I’m thinking about HOW to think about them. It’s not just a theoretical question… one of my new clients says he’s “desperate” for me to prescribe something to “even out” his moods — he gets into states of depression, seemingly “out of nowhere,” and can’t concentrate at work. At night these moods often interfere with his sleep. Of course I want to alleviate his distress. At the same time, I’m concerned that in the long run medications may do him more harm than good.

Ann: I’m so glad you’ve brought this up, because I’ve been grappling with similar conflicts in my own practice. I’m seeing someone now who’s been taking medications for years to treat his anxiety. He’s become dependent on them, believing that he needs them to function in his everyday life. He recently asked me if I thought he could ever stop — I said I didn’t know, but certainly we could work on it. Since then he’s brought it up from time to time. But whenever we talk concretely about stopping he becomes really anxious and tells me he “can’t imagine living without them.”

Hugh: Interesting how each of them experiences his emotions in a similar way. My client talks about his moods as things he has no control over, things that “descend” on him at all hours of the day and night. Your guy talks as if his anxiety exerts an irresistible physical power over him and the meds are the only way to defend himself against it. Like so many people, they relate to their emotions as if they were unpredictable forces of nature that have no relationship to the actual conditions of their lives.

Ann: The question of whether to use medications is complicated, isn’t it? We want to help people who come to us because they’re hurting. And some people do get quick relief with medications. The problem is that the very fact of the medications “working” tends to reinforce people’s belief that their emotions are essentially the products of their chemistry, making it harder for them to see their own growth as they find new ways of being in the world. One “side effect” of meds that’s rarely talked about is that they can often reinforce people’s passivity towards their emotions, obscuring an understanding of themselves as having agency, as being the active creators of their lives — including their emotional lives.

As I see it, what we’re doing in all of our therapy groups is building environments in which people are collectively creating their emotional life together and, in doing so, discovering that they can. That’s development!

Hugh: Yes, exactly.

Ann: All of this has to be on the table in talking with our clients about whether and how they want medications to be part of their development picture.

Hugh: When I have those discussions, I’ve found it’s helpful to talk about medications in an ordinary way — by which I mean not in terms of moral categories, but as one of many tools that can be used in particular situations for particular purposes: to support people with depression, let’s say, or sleeplessness, enough so that they can give their emotional energy to the strenuous work of development.

Ann: So how did you respond to the client you talked about at the beginning?

Hugh: I started by asking him about his history with psychiatric medications. He’d seen other psychiatrists before coming to me, and he’d been diagnosed with bipolar disorder. He told me that he was conflicted about taking meds: he didn’t like putting chemicals into his body, they hadn’t worked very well in the past, and he’d had bad side effects from taking them. But he said he’s exhausted all the time and the mood swings are driving him crazy: “All I want is for them to stop.” I said I was also conflicted about prescribing meds for him… Of course, I wanted to do whatever I could to relieve his pain — and I was concerned that “going on” meds might contribute to his idea of himself as helpless and passive.

Ann: And what happened?

Hugh: It felt to me like we had opened a door that we could go through together. As we continued talking, he acknowledged that he wants much more in his life than the absence of pain. I told him that I wanted much more for him, which brought us to the development question: What does he need to grow emotionally? Who does he see himself becoming? What would it take for him to create the life he wants for himself?

Ann: What did he say?

Hugh: He said no one had ever asked him those questions and that he hadn’t ever thought about such things… he’s been preoccupied with how bad he feels right now, which includes blaming himself for being “weak.” That gave us an opportunity to look at his understanding of himself as “broken” and damaged, rather than as someone who, like all of us, is capable of unlimited development.

Ann: So what did the two of you decide? Did you end up prescribing medications for him?

Hugh: We agreed that, to start with, I would write a prescription for medication to help him sleep and that he would use it sparingly because it’s habit forming. And we also agreed that we would talk regularly about how it’s going and that we’d keep on making these decisions together… I wanted him to know that he’s not alone with this.

Ann: When it comes to medications, I’ve found that there’s no one-size-fits-all answer. It’s no secret that there’s a lot of controversy in the mental health field about psych meds — some clinicians swear by them, others swear at them. And their clients, too, give meds very mixed reviews. I think for us, as social therapists, we have to ensure that our clients play an active role with us in creating the therapy. And we have to address the development question very specifically — including whether and how meds fit into the process of their emotional growth and transformation.


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. You can only prescribe if either there is a clinical benefit in the functioning of the person that outweighs harm.
    I think that rules out antidepressants.
    For antipsychotics, you have to consider whether sedation and listlessness is a pro or a con.
    For either, you must have a clear plan, competence, experience and commitment for tapering off.
    You can’t really justify either on the basis of averting suicide, the data just isn’t there except, rather oddly, for clozapine.
    You must communicate all potential harms.

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    • Start with something simple, like magnesium. You also want to find out about his morning routine and things he does or eats. Does he do or eat the same thing(s) on the mornings he has these episodes? I’d try to get him to take an HOD test eventually, but I’m beginning to sound too much like I know what I’m talking about, and the further things to do might be too manifold for a blog.

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    • I prefer the term “emotional pain killers” for these drugs. A tiny amount of Stelazine helped me short term.

      Unfortunately it deadened my ability to experience joy or feel affection. It also made me think psychiatry had all the answers. This led to an anafranil-inspired bout with psychotic mania and 3 weeks with no sleep. 😛

      Down the rabbit hole for 25 years. Doing okay without any drugs now. Grieving over my wasted life though.

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    • When I showed (a friend) a psychiatric social worker a complaint* I had made concerning a medication that had nearly killed me he told me that I could easily be killed for making the connection.

      “..Arriving at Charing Cross Hospital he told hospital staff “I sincerely believe that there is an organisation of people out to discredit and humiliate me and to induce me to kill myself. I know that this sounds like the content of a paranoid schizophrenic delusion but nevertheless I believe it to be true…” Author Peter Chadwick


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  2. That’s the opposite of how my therapist approached forcing me onto drugs. She defamed me to my husband with a bunch of lies she got from child rapists, according to her medical records and my child’s medical records, then threatened me that “if you don’t take all the drugs as prescribed, all the doctors will call you paranoid.”

    Any approach is better than that of my child rape covering up therapist’s approach, I’m sure. It’s a shame our country doesn’t arrest the child rapists and child rape covering up and profiteering “mental health professionals,” however. Especially since covering up child abuse and rape has apparently been the primary function of our “mental health professionals” for over a century.

    And all the “mental health professionals” are required to misdiagnose all who have distress cause by potential child abuse, with the “invalid” DSM disorders, since you can’t bill any insurance company for ever helping any child abuse survivors ever.

    I wish I had known the primary function of our “mental health professionals,” historically and still today, is covering up child abuse and rape, prior to talking to that psychologist. Perhaps the “mental health professionals” should fix that problem in the DSM since over 90% of those labeled as “borderline” are misdiagnosed child abuse survivors. And over 80% of those labeled with the “psychotic and affective disorders” (“depression,” “anxiety,” “bipolar,” and “schizophrenia”) today are misdiagnosed child abuse survivors.

    I hope you do properly inform your clients about the adverse effects of the psychiatric drugs. Like the fact the ADHD drugs and antidepressants can create the “bipolar” symptoms. And the fact that the antipsychotics can create both the negative and positive symptoms of “schizophrenia,” via neuroleptic induced deficit syndrome and antipsychotic and/or antidepressant induced anticholinergic toxidrome. Those two medically known psychiatric drug induced syndrome/toxidrome should be added to the DSM as well.

    I do agree, coercing people to take the psych drugs with outright lies that they are “safe…meds,” or lies about “chemical imbalances” is appalling, extremely widespread, disingenuous, and very unprofessional behavior. And force treating people with the psych drugs should be made illegal, since all the psych drugs are neurotoxins.

    I agree, it should be the clients’ informed choice, and “mental health professionals” force and coercion with lies and threats should be made illegal. The problem is the “mental health professionals” seem to know almost nothing about the actual adverse and withdrawal effects of the psych drugs that they prescribe, so they can’t give their clients enough information to make an informed choice. And if they did give truthful information, no client would agree to take the psych drugs. I’m not certain why people who deny and misdiagnose the adverse and withdrawal effects of the psych drugs with “invalid” DSM disorders call themselves “experts” however.

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  3. We need to cure psychiatry first. Like I have said before, psychiatry is a form of imaginal sickness, and psychiatric jargon is a form of linguistics sickness. We need human/ pro psychological language that will describe psychological reality in human/PROPER way. We need that language to heal our perception of the psyche, because medical jargon is a psychopatic form of demonization of the psychological reality.

    We need to cure imagination and the language, first. Like Hillman did. Our imagination is full of psychiatric lies.

    We need to cure from PSYCHIATRY itself.

    Psyche does not need healing, it needs our courage to face death and suffering which are beyond medical control.

    We do not need healing, we need to learn to face the reality full of non theological suffering, kids. This is psychology not a theology, we cannot cure anything, psyche can do it itself. And psyche or depression is not our property.
    Yes, depression can kill you.
    GROW UP.

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    • Depression is not about the cure, not anymore. It is about facing death in reality of theological negation or apollonian blindness. Ok? And apollonians are people for whom death exists only in the grave, only in material meaning. They are beyond death in psychological meaning. So they do not give a s. about the fact that there are people who must or have enough of dealing with death in reality that does not even exists for their empty strongly apollonian (the least psychological)perception.

      We are talking about war between theological/material negation of death and the brutal realism of death in psychological reality. Because death is the essence of depression. And psychiatry is using theology.


      Bahahaha. Yeah.

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  4. I agree danzig666, prescribing is based on an ideology that the brain is causing the ‘issues’. But it is mind, our thoughts, our stories that we habitually run and re run and create our suffering. You cannot drug that away. Working from a psycho/spiritual, or existential position we understand that as social animals human behaviours, feelings and thoughts come out of psychosocial and spiritual interactions with ‘the group dynamic’, we do not operate as isolated individuals. I refuse to accept the ideology of assuming it is our responsibility to relieve another’s ‘suffering’ through ‘interventions’ and ‘doing to’ such as prescribing drugs, since we know this paradigm is founded on a theory without substance and manipulates the client into a powerless role, (eg, ‘you don’t have the capacity to work this out or live with this within yourself’). Throw that out the window. Start first from the basis of mind sovereignty or mana (Maori word) , that is, do not assume the right to impose your views and strategies on another.
    I like Peter Breggin’s approach, if a client comes to him and wants drugs he tells them to find someone prepared to prescribe. He fully understands the implications of facilitating his clients down that black hole, for himself as well as for his client. It becomes a choice between professional integrity and full responsibility to your client or to collude with a harmful ideology.

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    • Yes, Breggin is wise. I do not believe that psyche is something that can be improved. It’s a myth because people have decided that the psyche is something that needs to be improved to create a kind of control over those who are unlucky, because unhappiness is something that psyche needs, even though on rational level it is something wrong. Psyche creates pathology. That pathology is needed.

      Depression, psychosis is a psychological function. I do not care that theology reject unhapines or death. Psyche is more important than spiritual utopia. Because psyche is true, and spiritualism is a fiction, ego control is a myth of those who residue on that shallow empty level. All they want is to reject sufferring and punish death for what it is. This is highly theological attitude, non human attitude.
      To control psychological reality means to reject its true meaning.

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  5. As a retired LISW with over twenty years working in urban and other areas and well acquainted with treatment from both sides of the desk, this seems like a conversation from eh ? 1990?
    It is good to see a dialogue format but have you been reading what is out there and are you into empowerment, social justice of all tropes, and trauma?
    An overview of past pdych meds? Really?
    What about family history and culture?
    If one’s so called client has a Jewish background wish in terms of intergenerstional trauma , same and even more so for African Americans, Hispanics, and First Nation folks and one cannot forget the Armenian Genocide.
    Then there is the conflagration of layers of complex trauma when intergenerstional trauma is overlaid with victims turning into aggressors. Read “ To Kill a Mocking Bird” Ella May was taped by her “ white trash” father who MADE her accuse an innocent black man. Alice Walker’s “ The Color Purple” showed in fine detail a father’s rape of his daughter. Both men tragically affected by cultural history and using the only power they felt they had sex to enforce control.
    Add to this , so many folks go to their graves without being able to tell about abuse episodes.
    Then there is the why some folks endure and become assets to the world and others like these male fictional characters become part of the great morass.
    Psych meds are ways to control and if you want we all here could share ways of coping without loads of meds or none at all.
    I will be hoping for some interactive feedback. A true dialogue is multi sided.

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  6. Perhaps I was lucky; I went into medical school from postgrad physics and math,which I’d found dehumanizing, and discovered Freud’s scientific attempt to understand psychiatric disorders, as well as very humane descriptions of people suffering from anxiety, depression, etc, etc.
    It was a relief to have a knowledgeable European gentleman, Dr Heinz Lehman, at McGill, not only put a name to the conditions that bothered me but also point out a direction I could go for help, and perhaps even a career.
    When I eventually began psychiatric residency it seemed entirely natural to take a personal history, to get to know my patients, and together we seemed to find the causes of their distress, and this relieved their symptoms.
    Like me they had struggled to keep their feelings bottled up inside.
    This worked fine for over a year, although I recall some of my supervisors skipping sessions with me, until one of them told me to drug a recovering depressed patient. When I declined, and then refused to do so, he attempted to have me thrown out of the residency.
    I realized I was in the wrong profession: psychiatry aimed to treat symptoms with physical agents, while I had what seemed to me to be the scientific approach of searching for the cause of the problem.
    This led to fleeing McGill and Canada for psychoanalytic help in Britain, where by total accident my second training case suddenly became psychotic, and my supervisor, Dr Donald Winnicott, helped me to shut up and listen, and helped penetrate his thought disorder.
    I worked for years in crisis intervention and adolescent psychiatry at Fort Logan, Denver’s mental hospital, but these units were closed because we weren’t drugging people, so I spent the last 20 years of my career in Ottawa, where I could get paid by OHIP to do psychotherapy until patients became well. The most interesting and challenging patients were psychotic or had failed to be helped by repeated biological agents, and we often had to track the trauma to infancy.
    The professional groups to which I belonged didn’t want to hear this. My wife, who had been a top therapeutic community nurse in Britain when we married, and had helped me with psychotic patients, said that I was 50 years ahead of my time, but I fervently hope that humane help is offered to people before then.
    Perhaps I should write more detailed descriptions of how my patients and I did this, but there has been so little interest in my efforts that it’s discouraging.

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  7. Ann and Hugh, this is a respectful and helpful dialogue and should be mandatory for those seeking help for problems and distress. People need to be thoroughly informed about psych drugs, sleeping pills etc, and allowed to make decisions for themselves – unlike what happens in psychiatry.
    “Like so many people, they relate to their emotions as if they were unpredictable forces of nature that have no relationship to the actual conditions of their lives”.

    This is precisely what psychiatry does.

    “That gave us an opportunity to look at his understanding of himself as “broken” and damaged, rather than as someone who, like all of us, is capable of unlimited development”.

    Again psychiatry does this to people who are dealing with difficult life experiences – paint them as broken and damaged – then give them harmful drugs they can never get off of.

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  8. Thank you for your article. I had a few thoughts on what it means to truly have a choice in regards to coming of psychiatric drugs. An important consideration is that a person who is experiencing “depression”, “anxiety”, general “moodiness” or insomnia while taking psychiatric drugs may in part actually be experiencing drug “side effects”, like the effects of any other psychoactive substance. Also, when people are given psychiatric labels, it is extremely powerful. A lot of people’s fears and misconceptions around coming off of psychiatric drugs are largely due to years of highly sophisticated and intense brain washing. The way I see it, people aren’t even able to make a choice to come off of psychiatric drugs in the first place when mitigating factors such as these aren’t being addressed in a direct and honest way. They aren’t being given true informed consent in other words. It sounds like your therapy touches on that a bit, which is great. I will outline a few other factors that should be addressed head on in order for a person to have a more active role in their therapy but before I do, have you or your clients seen this video from Laura Delano?

    Think about what true informed consent would actually look like. Are your clients aware of Robert Whitaker’s books? What if you summarized some of his work in your sessions or a class for example? Are you and your clients familiar with Psychiatric Drug Withdrawal: A Guide for Prescribers, Therapists, Patients and Their Families by Peter Breggin or more of his work? Contrary to popular belief, the withdrawal symptoms can be extremely intense, long lasting and are often conflated with the “diagnosis” itself.

    I strongly suggest making alternatives highly accessible and incorporating them into your work. For example, you could offer a menu of alternative services, educational pamphlets, resource guides, and general tips and tricks around psychiatric drug withdrawal. Have you thought about referring clients to this website or the others below:

    There are also alternative, safe and highly effective sleep aids, such as Herbal Medicine’s “Deep Sleep” or Benadryl. There are a variety of alternatives to dealing with intense anxiety and depression in the moment such as deep breathing, simple mindfulness techniques, taking a walk, etc. Self care such as physical activity, meditation, and “sleeping it off”, can be really useful during psychiatric drug withdrawal, just as much as the catharsis of grieving, letting yourself have a bad day, and knowing that it is okay to feel—allowing yourself to feel without labeling and judging it as anything other than part of the spectrum of human emotion and experience. Just being gentle with yourself and giving yourself a break. I imagine most of these holistic approaches are already incorporated into your practice. This video is really great by the way:

    I also want to bring your attention to something you said when a client questioned you about coming off of psychiatric drugs:

    “He’s become dependent on them, believing that he needs them to function in his everyday life. He recently asked me if I thought he could ever stop — I said I didn’t know but certainly we could work on it.”

    Saying “you don’t know” can be really disempowering for a client as it is almost synonymous with “no” in this context. This is because you are in a position of authority in the mental health field and that statement could reinforce their dependence on the drugs and the brain washing they have had around their “diagnosis”. I think more empowering statements might be, “It can be challenging, but it can be done and I fully support you. We can take it one day a time.” I mean this with all due respect, and I know your heart is in the right place. I just thought it was vitally important that you consider that moving forward.

    Anyway what I have written is not at all exhaustive of my thoughts on this, or the resources available. I typed this out as quickly as I don’t have a lot of time at the moment. Hopefully what I said is helpful though and good luck!

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    • Good post.
      Which makes me wonder if the writers of the dialogue, Anne and Hugh, have read the responses? Perhaps they did not receive them?

      It might be okay for people to feel miserable a great part of their lives.
      I hate the pressure of feeling as if I have to be somehow, or something.
      Belief systems can run pretty deep and I realize people preach that we can change them. However, they have thousands of triggers perhaps, so to actually change them is easier said than done.
      But it’s good to try, and certainly there are lots of ways to do the trying that do not involve medication.
      One really important part to ourselves is finding what we like, where and how we like to live. Not always doable for the majority on limited incomes. It is a luxury.

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  9. As a critic of psychiatry I have to write the drugs are not medications. It is self fulfilling to write “Who decides?” when it has already been decided the drugs are medicines by the authority.
    The doctors are issuing legal drugs not medicines, as there is no physical disease in the patient for the drug-chemical to affect.

    The prescribing doctor does not go through physical withdrawal, or the ups and downs as the drugs are absorbed into the patients body. There is no WE in the legal drug dealing.
    “He recently asked me if I thought he could ever stop — I said I didn’t know, but certainly we could work on it.”
    we’d keep on making these decisions together”

    The drug dealer does not want to see pain in their client so will continue to prescribe drugs.

    “My biggest fear is that people who need the drugs will stop taking them.” Dr. Andreasen

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    • To clarify, a drug only becomes a medicine when it is prescribed by a (mortal) doctor. You the doctor are preforming the magical transformation of drug to medicine. You must bear the responsibility, if you can not, find another profession.
      What responsibility you ask? The actions of your patient that they take while under the influence of mind altering drugs, like a person who voluntarily drinks alcohol and drives home. Did he drink too much?

      So the default is obvious , drug your patient so much that they can take NO action, and then call the lack of action a successful treatment.

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  10. Thank you Ann and Hugh. The title of this article made me smack my head. (It’s the shrink who decides of course.)

    But it offered insight for those of us who are not therapists about the frustration you may feel when “consumers” insist drugs and more drugs are the answer. I even read an article by a “bipolar” woman bad mouthing her “evil psychiatrist” because he was holding out on her and not giving her the “good stuff.” She hunted till she found one who gave her massive quantities of what she insisted she needs to feel good. This is one of those (rare) cases I feel more sympathy for the shrink than the “consumer.”

    In her defense she has received a miseducation through TV commercials and NAMI that psych drugs will cure all your problems and save your soul.

    As far as psychiatrists who oppose these drugs or “swear at them” yes, they exist. (Most write for this site!) But they are few and far between–greatly outnumbered by the pill pushers. Only the pill pushing kind work at centers, serve on the APA boards, or are asked to speak at NAMI conventions. During my years in the System I never met a single one who criticized the pill magic or offered to take me off or inform me of alternatives to drugs and shocks.

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  11. Rachel777
    There were anti drug docs but they kept with the status quote because NO ONE knew how to stop them once they were taken as a regime.
    Behind closed doors one of the docs challenged the staff to take a Haldo or whatever chemical and NO ONE DID.
    The “ story” was two years with compliance and no hospitalizations. And when it did happen there were excuses hiding their ignorance.
    When I was given medication, part of me thought fine Show Me, Show Me Know and after years lost and awful experiences yeah my instinct was right not any type of panacea at best nightmare at worst.
    However people do seek these chemicals. No one has addressed the word of mouth part of this I tried it and it worked white suburban folks and then the kids stole the meds and some bad things happened.
    I think there are some folks who knows why that it is helpful but I don’t understand why and no one knows.
    There are no longitudinal studies at all.
    But it is clear big Pharma and the FDA were actively in greed mode. They didn’t care at all.
    If we are ever to truly have a round table there has to be all encompassing dialogue and truth in lending – really some of the blogs I don’t know.
    I am trying hard to withdraw and rest for awhile from thinking on all of this.
    Hopefully , I wouldn’t be triggered and I can just focus on now not the past. Tincture of Time the best script written after TLC.

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  12. Interesting discussion – clients are certainly going to do better with such an approach than “treatment as usual” (and I use the term “treatment” very loosely).

    Unfortunately, the discussion doesn’t go deep enough to get to the core of what is really going on here. The two client examples are people who were TOLD that their “moods” and “anxiety” were, indeed, things that descended upon them for no reason, and they were TOLD this by the “mental health professionals” they were seeing. The fact that the client had “never been asked” these questions before tells us enough to know that the people dealing with him either were completely incompetent or were corrupt and didn’t care about the outcome. It’s time to move beyond the question of “what to do when people ask for ‘medication,'” and start informing them of the misinformation they have been fed, and the actual hope that they can go way beyond “not feeling bad” in their lives.

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  13. Thank you for the article. Good work.
    Yes moods, symptoms, feelings, they indeed can control. But it can’t be named something, only the person experiencing can name it, or not.
    Often we try to ‘help’ people (maybe always) from the point we are at. From the experiences we had, our wonderful childhood, our minor issues, and so we suggest everyone has control, or can learn acceptance, change and what have you.
    I think it is simplistic to ever assume.
    I also think we can become consumed with wanting to be “normal” or “mentally healthy”
    Because the search for it might never get us there. Wherever “there” is.
    Psychiatry enforces and encourages the feeling that you are “sick”. It seems emotions or reactions are sick and need a label and meds.

    In fact, many lay people believe that the other persons feelings are a sickness.

    We learn as we grow older, which can be helpful for people to know.

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