The fallacy of the Quick Fix for Psychiatric Medication and Crisis Management
The above title may have you agreeing that there is no such thing as a quick fix when it comes to psychiatric medication for psychiatric disorders such as anxiety, depression, and bipolar disorder. Yet, for all the education and advice that is doled out in sessions, clinicians we will inevitably get called by our patient who is in an emotional crisis. How then do we “fix” that?
As a physician, my aim is to relieve suffering and not to see my patients in either physical or emotional pain. I readily admit that I do prescribe pills to relieve anxiety in such moments. However, from a psychological vantage point, the patient’s crisis is also a window for me into their world: what they are thinking, feeling, and expecting, and how they are coping. This is valuable because inevitably I will uncover distorted, habitually unhealthy thinking, beliefs, expectations, and ensuing behaviors.
Therein for me lies the gold, so to speak: the likely reason for the crisis in the first place and how my patient’s current way of coping with it may even be perpetuating it. At such times, it is understandable that my patient may become the victim of their own deep-seated core dysfunctional thinking. The unfortunate consequence is that such thinking ultimately disempowers patients, and makes them see medication, hospitalization, or other service as the rescuer that they believe they need in order not to drown.
My approach to crises has always been one of being empathic but practical. If someone feels like they are drowning, they deserve to feel like a lifeline is available to them. For me, that means my making myself accessible to my patient and them knowing when I will be at the end of the phone if needed. I know such symbolism goes a long way with my patients, and just their knowing that has actually meant that my phone does not actually ring off the hook. However, as I also explain to my patients, they will need to prepare themselves for those times when both their therapist and/or psychiatrist are not available. Is that when the quick fix, anxiety-relieving medications can come in handy? Yes, but with caveats as detailed below.
As I often explain, while medication can calm nerves and take the painful edge off the intensity of angst or even the rush of thoughts in the midst of a crisis, it can never change thinking patterns or dysfunctional beliefs that give rise to anxiety, panic, or depressive moods. That is why I have always viewed medication as a top-down approach, whereas greater and more lasting relief comes from the bottom-up approach of addressing distorted beliefs so that they no longer have the power to create depressed mood, anxiety, or panic. This would typically occur before or after a crisis has been managed, so the patient has time to reflect upon and challenge their own thinking in the interim. Thus, they are better prepared to manage next time.
During a crisis, clinicians commonly do crisis intervention: an intervention designed to help the patient mobilize their own inner resources in order to deescalate anxiety, anger, panic, substance use, or out control eating, for example. That may something as simple as deep breathing, stepping out for air, or going for a walk. Whatever it is, it can only be effective if practiced, otherwise, all the talk in the world is of no use if it is not implemented when it matters.
As part of crisis intervention, I advise my own patients not to feed the crisis, in what they do, or what they think.
For example, if my otherwise healthy patient has an established anxiety /panic disorder, I would tend to discourage them from feeding panic by going to the emergency room every time they have a panic attack, convinced they are having a heart attack. Instead, I would first recommend distracting themselves from such self-fulfilling thoughts. Otherwise, they might needlessly dramatize the crisis because of adrenaline and other stress hormones kicking in to complicate the picture. This can ratchet up such unhealthy thinking, given how powerfully emotions drive thoughts and vice versa. Sometimes such thinking will even create the very symptoms the patient is fearful of. This can make it particularly hard to tell the difference between a heart attack and a panic attack. All the more reason to re-evaluate once anxiety is soothed, and not simply assume the worst.
A non-addictive/non-dependency forming medication like Vistaril® can certainly be of particular value here in calming things, However, imagine if that was the default answer to any upticks in anxiety? That begs the question of whether physicians should keep prescribing these types of medication, lest they convey a quick-fix mentality, leaving the patient beholden to a medication for life, bereft of any self-soothing skills in the long term.
Could such chronic, as needed, prescriptions also mean that some patients continue to live in crisis or merely leap from one crisis to another? The short answer is yes. The interesting reason typically lies in the origins of their way of thinking and coping, usually dating back to a traumatic upbringing and what they themselves may have been modeled by adults in their family of origin. There often has been dramatic and unhealthy ways of coping with high intensity of emotions and few problem-solving skills. In part, it can also be attributed to our quick fix and prescription advertising culture, whereby instant results are all too regularly promised. When it comes to psychiatric and psychological disorders, nothing could be further from the truth, as such messages tend to set patients up for unhealthy expectations for their own recovery.
As a practicing psychiatrist, I have always believed in equipping my patient with the appropriate long-term knowledge and tools to manage their chronic anxiety, eating disorder, substance use disorder, or mood disorder. One of the most important things I try to do is set realistic expectations for recovery: how recovery will look (not fast like a flip of a switch), the usual course/pattern of their disorder (up’s and downs), and how they can empower themselves on the way to recovery, with the help of appropriate, long-term medications (to make the bumps less bumpy along the way). That way they know my role, their therapist’s role, and most importantly, their own role in the process.
Of the many ways I try to help my patients meaningfully, I try to communicate regularly with my patient, and to encourage regular communication between myself, my patient, and their therapist. I have found this goes a long way in preventing crises, resolving issues before they escalate to crisis point, and conveying the importance of reaching out to others, as well as the regular work that is required on the part of all in properly managing psychiatric disorders in the long term.
After de-escalating the crisis, my aim would be to say goodbye to the quick fix, and hello to the real work of recovery.