Several years ago, my esteemed former colleague and supervisor Dr. Sandra Steingard wrote a blog on the website Mad in America titled "Why I Don't Do Med Checks" (which can be found here). In this article, Sandy does a wonderful job describing her philosophy about her approach to psychiatric practice. This philosophy is one that she and I shared over the 15 or so years that I had the pleasure of working with her and one that I continue today. I encourage readers to follow the link above to read her article, and below I outline my particular take on this topic.
When I say, “I don’t do med checks”, what I mean is that I believe good psychiatric care cannot be simplified down to checking in with a person about their medication. While I believe good psychopharmacological care requires a lot of skill, knowledge and thoughtful practice, there is much more to good psychiatric care then reviewing medications and adjusting, adding, stopping or changing them and sending people on their way. Instead, when done well, I believe good psychiatric care is a person-centered approach that involves knowing people well, respecting their whole being and aligning with them to identify a multifaceted approach to mental wellness.
First and foremost, I believe good psychiatric care is built around knowing the person sitting in front of you as well as possible and co-creating a strong, collaborative therapeutic alliance. This involves knowing not only a person’s personal history, but also their values, concerns, goals, dreams, barriers and their personal context including ways in which their gender, sexual preference, racial and socioeconomic situations have affected them continue to affect them. It also involves not only knowing them as individuals but how they are situated in their family and social networks and whenever possible involving these networks in their care because no person is an island. Understanding each person’s multifaceted reality allows someone like me to see potential underlying causes for the challenges they are facing and identify potential remedies. I have never worked with someone in which simply adjusting medication allows that person to flourish in all areas of their life without a number of positive changes also being made.
Even when we narrow our focus to medical concerns during the course of treatment, rarely if ever are medication adjustments considered outside one’s overall life context. By starting with the broadest view possible, we carefully consider all the ways in which a person’s body is affected by everything around them. While we sometimes have the image of the body separated from the outside world, in fact human beings are permeable and the boundaries between what is outside and inside us are more conceptual than real. This is why when I am working with people, I am always interested in and talk about the world around them including their living situation, social connections, family connections, work, play, nutrition, physical activity and any medical concerns that may be impacting them. Untreated nutritional imbalances, medication side effects, metabolic problems, hormonal imbalances, gastrointestinal, respiratory or cardiovascular health and sleep difficulties can have extraordinary impact on one’s mental wellness. And through some combination of good medical care, behavioral changes and increased engagement with healthy activities including social contact, people can see significant improvements above and beyond anything a medication could offer. This is why the majority of most appointments with me are focused on counseling regarding these important issues.
Finally, I believe good psychiatric care involves de-emphasizing medication whenever possible whether its reducing dose or number of medications. There is no medication, supplement or herbal treatment without potential risk of adverse effects. While they can be powerful tools to help reduce the intensity of symptoms such as depression or anxiety or improve healthy functions such as sleep, and while they sometimes may be needed indefinitely to allow some measure of manageability of symptoms and/or improvement of functioning, very often medications can be reduced or discontinued as other wellness practices are initiated and sustained. In this way, sometimes, good psychiatric care means that instead of doing med checks, we “check” meds (in other words, we stop ‘em).