Who to believe....

I have just had some feedback on an assignment (a research proposal).

Nowadays, I no longer care what they say about my assignment, just whether I passed. I passed, so they can say what they like and I shall believe what I like and be amused by the rest. We get two markers and their comments are often somewhat conflicting. Today's feedback was the best so far.

Marker A: I do not think the proposed study is based on theory, nor do I see the clinical relevance of it. It is also not original and would not contribute to the field. (Aside: why did you pass it then? You clearly didn't read it as I clearly stated I was replicating a previous study in a different population than has been studied in the past. I personally think you rather missed the point.)

Marker B: The propsed study has a clear theoretical basis and has evident clinical implications. It is novel and innovative. You could take this further if you wanted to.

Obviously marker B made the more accurate assessment of my work, but the differences between my markers' comments often amuses me. This one was probably the starkest yet.

It also pisses me off - I have worked in research so I am well used to critical feedback. In fact, I thrive on it - but I thrive on it when I'm able to answer back and have a proper debate. The first marker clearly hadn't read what I'd written, and I seriously doubt I am as wonderful as B suggests. I actually feel quite peeved at their tatty comments scribbled on the feedback form. (Actually, I should be grateful, at least the feedback was legible this time). I passed - who cares, but if they wanted to develop me academically, they'd have to do better than this.

I can't help but feel that the academic work on my course puts me firmly in the role of the ignorant child learning from the all-knowledgeable tutors. So while I shall jump through the hoops and do what I need to do to pass the academic assignments, I can't help but think there must be a better way that actually makes trainees think and engage with their academic work.

Rufus May online

If I know anything about Rufus May from articles he has written and seeing him on 'The doctor who hears voices", his blog is going to make for very thought provoking reading.

The drugs don't work....or is it all in your head.

I'm interested in the psychological (as opposed to the pharmacological) effects of psychotropic drugs. Many moons ago in a past life I was employed as a researcher by a pharmaceutical company. Amongst other things and much number-crunching, I spent a lot of time talking to participants about their experiences of psychotropic meds. They said, imho, very interesting things. People told me that drugs I knew to be stimulants made them dopey. This is highly unlikely from a pharmacological perspective, but they clearly hadn't been told or hadn't understood the pharmacological properties of the drugs. Interestingly, people told me that one brand name drug was totally different from another brand name drug and that one had given them horrendous side effects and the other had completely transformed their lives. (What they clearly didn't know was that it may have been a different brand name, but it was the same drug.) So I got interested in the nocebo effect.

Now, when I talk to people about the drugs they're taking and how awful they're making them feel, I often tell them about the nocebo effect. Usually the psychiatrists will tell them what side effects to look for - and if not, they'll have found worse on the internet anyway. The problem is that some people then immediately start to experience all the side effects they've read about. So I talk to them about the nocebo effect and how our expectations and beliefs effect how we feel and act and how our bodies respond. I've had more than one person say they're more willing to give the drugs a try once they know some of the "side-effects" might stem from their own anxieties. On the other hand, I know that I often struggle with people whose psychiatrist, family and friends are all telling to take a benzodiazepine every time they start to feel panicky. It just reinforces their belief that panic and anxiety is dangerous and that they can't cope with it.

But I'm also interested how drugs effect people's broader sense of themselves and how people interpret taking medication within their broader beliefs about their mental health. I really like Leventhal's self-regulation theory, otherwise known as the common sense model of health behaviour. Basically, people do what makes sense to them (which is often contrary to what makes sense to the doctor). We know that people avoid taking meds for medical conditions like diabetes and HIV because of the stigma and the drugs being a reminder of a condition they'd rather not have. In fact, I would go so far as to say that Conrad's paper on the meaning of medication in epilepsy is one of the most influential papers for all my clinical work - even though I have worked very little with people with epilepsy.

How much more relevant is this in mental health, which is much harder to understand, the drugs much less clean in their effects (and much nastier in their pharmacological side effects, never mind the nocebo effect)? How much do we understand people's experiences of drugs, what they believe about drugs and what they believe about their mental health?

Are drugs the way to a more "normal", more fulfilling life in line with my priorities? Or, are they a sign that I am a total mental-case who can't cope with life? Or, are they highly addictive and really dangerous? Will they let the "real me" shine through instead of my psychosis/parnoia/mania'/depression/anxiety, or will they alter my personality? So, I was very interested in this NY Times article that considers the effect of long-term psychotropic medication on adolescent identity development.

It is an interesting issue. I am currently working in a very drug happy service, but they're also psychology-friendly too so that's fine. I'm not against the use of medication to treat mental health. Sensible and thoughtful use of medication can really help lots of people with mental health difficulties. But I think we must think more broadly about the effects of medications and what they mean to those who are given them.