There is nothing more emblematic of the split within psychiatry than the debate over that deceptively simple piece of paper—the prescription. To some psychiatrists who are uncomfortable with assuming the historical role of the physician, the prescription has come to symbolize the worst elements of psychiatry: “pushing pills,” selling out to “Big Pharma,” and—worst of all—refusing to deal with the complexities of the patient’s inner life. Of course, no group is homogeneous, and it is a mistake to assume that all psychiatrists in this camp think alike. Some, for example, will acknowledge the need for medication in certain “extreme” cases, such as florid psychosis or severe bipolar disorder. Most will acknowledge that on occasion, medication can be helpful in the short run, even if it merely “covers over” the “problems of living” that the patient must ultimately confront. Even so, one finds among these psychiatrists a kind of patronizing tolerance of pharmacotherapy—as if it were some slovenly, ne’er-do-well in-law sacked out uninvited on the living room couch.
Of course, there is more than a grain of truth in their complaints. Unfortunately, many prescriptions for psychotropics are written in haste—often after the infamous “15-minute med check”—and without any real understanding of the patient’s inner life or psychopathology. But this is only one side of that piece of paper—which proves to have moral, symbolic, and psychological layers usually ignored by critics.
Those who see the prescription as merely an exercise in biological psychiatry do not understand the complexity and strength of what I call the prescriptive bond. To understand this bond, we first need to acknowledge the multilayered meanings and symbolism patients attach to psychotropic medications themselves. In a seminal article, Metzl and Riba2 observe that:
Symbolically speaking, medications convey a host of connotative implications that are difficult to recognize, let alone to quantify. These range from preconceived beliefs about drugs that patients carry with them into the examination room, to unspoken messages of nurturance at play when doctors prescribe (or choose not to prescribe) psychotropic medications. . . . Understanding the symbolic functions of the medications is as important as knowing their elimination half-lives or suggested dosing regimens.
For some patients, being handed a prescription may convey, on an unconscious level, the therapist’s role as “nurturing figure,” whereas for others, that same prescription may represent the overbearing authority of the punitive parent. Patients may also have idiosyncratic associations with specific drugs. I recall treating a very psychotic patient who would take only one antipsychotic—thiothixene (Navane). This drug was no more effective than other antipsychotics he had taken, but in his psychotically concrete thinking, Navane had been symbolically fused with an over-the-counter, bromide-based sedative he had taken in the 1940s, called “Dr Miles’ Nervine.” Nervine was nurturance for him—and thus, he would consent to Navane.
In addition to the symbolism and meanings of psychotropic medications, there is the meaning of that piece of paper itself. The prescription embodies more than a drug name and dosage. It is something that bears the physician’s name and signature. It is, in a sense, a tiny part of the physician that the patient takes home—in short, a kind of transitional object, with all the powers and valences associated with these objects. Following Donald Winnicott and other object relations theorists, Metzl and Riba2 describe transitional objects as “imbued with meaning because they symbolize a transition from dependency to autonomy.”
And, of course, there are counter-transference implications to the prescription: for some psychiatrists, writing a prescription may unconsciously reflect anxiety over the patient’s prognosis, or the psychiatrist’s grasp of the case; for others, the prescription may represent the physician’s hope for the patient’s recovery. As Metzl and Riba2 observe, “the act of prescription involves a merging of the expectations of the patient and of the doctor and thus shapes the clinical dialogue of both parties.”
There is also an important ethical dimension to placing one’s signature on that piece of paper we call the prescription. I may not see Hippocrates looking over my shoulder when I sign that prescription, but I am keenly aware of a host of physician forebears scrutinizing my decision. In my mind’s eye, there is Dr Gerace, his fingers still warm on my neck; and there are Uncle Morris and Uncle Elmer asking, “Are you sure about that? Have you double-checked the dose? Will your medicine do more good than harm?” The perverse notion—once voiced by a well-known psychologist but echoed recently by some psychiatrists—that “prescribing is no big deal” reflects ignorance not only of psychopharmacology but also of the moral dimensions of the prescribing act. When I put my signature on that piece of paper, I am putting my name and that of my family behind an implicit oath. That oath is a critical part of the prescriptive bond. That oath says to the patient,
I accept medical responsibility for your life and health. I affirm that I understand not only the nature of the medication I am giving you but also the medication’s interaction with your medical and psychiatric diagnoses, physiology, and biochemistry. I affirm that I know the risks of this medication, which, in good faith, I have discussed with you. I also affirm that I know how to manage these risks safely; and that, to the best of my knowledge, these risks are outweighed by this medication’s benefits. I accept that you have placed your faith in me; and your life, in my hands. I am honored by your trust, and, in turn, I trust you to take this medication responsibly.
Any clinician who cannot inwardly utter this oath, with confidence and conviction, has no business picking up a prescription pad—whatever the clinician’s profession.
Biology versus psychology; brain versus mind; pills versus skills; molecules versus motives—I say, enough of this Manichean mindset, and enough balkanizing of human personhood! Somehow, we need to bridge these widely separated islands of oversimplification. Perhaps such a bridge will follow the contours of the approach used by psychiatrist-philosopher Karl Jaspers, which S. Nassir Ghaemi, MD,3 has called, “biological existentialism.” For Jaspers, there was no contradiction between explaining the patient’s problem at the level of neurobiology and also understanding it at the level of existential meanings. As Dr Ghaemi3 observes of Jaspers, “His approach to spiritual and existential notions . . . built on, rather than negated, an appreciation for science.”
Such integration is a daunting task for psychiatrists, who are hard-pressed even to find time to see patients—much less to achieve what the poet John Keats called “negative capability”: in essence, the ability to entertain two seemingly contradictory or competing concepts at once.
So here I stand, alongside Dr Gerace; my physician uncles; and my crazed residents, Frank and Dave. Whatever and wherever I may be 20 years from now, I know I will always remain a physician. And for all the uncertainties in American psychiatry, I am certain of one thing: if psychiatry is to survive as a profession, we need to become physicians of the body who are also ready to plumb the depths of the soul.