I am a Japanese psychiatrist who has worked in psychiatry for more than 30 years. In this series, I share some of what I have learned about medicine, mental health, life, and people through my experiences in Japan and the United States.
When I was training in psychiatry in the United States, I often found myself thinking about the way addiction was treated.
Patients who were dependent on drugs were sometimes given medications with longer half-lives, which were easier for medical professionals to manage.
Every day, the patients would come to a designated place.
A nurse would give them their medication and watch them take it.
After confirming that they had taken it, the nurse would even collect the container.
In other words, the addictive drug was not simply eliminated.
Instead, it was replaced with something that could be more easily controlled and managed by the medical staff.
At the same time, I saw a very different approach being used for benzodiazepines, such as certain sleeping pills and anti-anxiety medications, which can also lead to dependence.
In those cases, the medication was gradually reduced.
"Let's reduce your usual dose to two-thirds."
Then it would be reduced again.
Eventually, the goal was to stop the medication altogether.
I found myself feeling a certain contradiction.
Of course, I understood that there were medical reasons for using different approaches for different substances.
But as a psychiatrist, I could not help wondering:
Is it really enough to simply adjust the amount of medication?
What is the real purpose of psychiatric treatment?
Perhaps treatment should not be limited to reducing one medication or replacing one drug with another.
A person's way of thinking matters.
So do their daily habits, their relationships with other people, and the way they interpret what happens to them.
Perhaps psychiatric treatment should also help people gradually change these things.
Ideally, the goal would be for a person to eventually live without having to depend on medication.
That was how I thought about psychiatric treatment at the time.
But when I actually faced people with addiction, I realized that things were not nearly that simple.
You cannot simply tell someone,
"Stop taking the drug."
and expect them to stop.
You cannot simply say,
"Change the way you think."
and expect their thinking to change.
When a habit or dependence has become deeply rooted in someone's life over many years, it can be extremely difficult to change through willpower alone.
That is why medical professionals sometimes need to manage medications very carefully.
And this is where I began to see the large gap between ideals and reality.
The psychiatry I saw in America was highly rational in many ways.
At the same time, it contained contradictions.
To treat addiction, another medication may be used.
For another kind of dependence, medication may instead be gradually reduced.
And yet, perhaps what ultimately needs to change is not the medication itself, but the person's life, habits, and way of thinking.
This made me think about something beyond the American system.
Perhaps this is not simply a problem with American psychiatry.
Perhaps it is one of the fundamental difficulties of psychiatry itself.
How should we balance three things?
Using medication to control symptoms.
Gradually reducing medication when possible.
And helping patients change their own lives.
These three things are not always easy to bring together.
There is no simple answer.
Even after many years as a psychiatrist, I do not think I have found one.
Perhaps that is one of the things I learned most strongly during my time in America:
In psychiatry, what seems contradictory at first may actually reflect the difficulty of dealing with human beings.
We want medicine to be rational.
We want treatment to have clear answers.
But human beings are not always rational.
And recovery does not always follow a straight line.
That may be why psychiatry remains both difficult and fascinating.