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

> 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.

rustcharm 8y ago
And also, if and when medications are very effective, why not use them?
mindgam3 8y ago
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.
- phren0logy 8y ago
  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.
  - mindgam3 8y ago
    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.
    - phren0logy 8y ago
      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.
      - loceng 8y ago
        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.
    - deleted 8y ago
      [deleted]
    - 8y ago
- _carl_jung 8y ago
  > 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.
  - mindgam3 8y ago
    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?
    - docbrown 8y ago
      >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.
      - dang 8y ago
        > 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 https://news.ycombinator.com/newsguidelines.html
vanderZwan 8y ago
> 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.
- Nasrudith 8y ago
  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.
  - camtarn 8y ago
S-E-P 8y ago
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.
- akiselev 8y ago
  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.
  - S-E-P 8y ago
    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.
XXnotrealXX 8y ago
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.

rustcharm 8y ago

And also, if and when medications are very effective, why not use them?

mindgam3 8y ago

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.

phren0logy 8y ago
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.
- mindgam3 8y ago
  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.
  - phren0logy 8y ago
    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.
    - loceng 8y ago
      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.
  - deleted 8y ago
    [deleted]
  - 8y ago
_carl_jung 8y ago
> 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.
- mindgam3 8y ago
  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?
  - docbrown 8y ago
    >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.
    - dang 8y ago
      > 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 https://news.ycombinator.com/newsguidelines.html

vanderZwan 8y ago

> 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.

Nasrudith 8y ago
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.
- camtarn 8y ago

S-E-P 8y ago

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.

akiselev 8y ago
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.
- S-E-P 8y ago
  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.

XXnotrealXX 8y ago

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.