Meaning-Based Harm from Medications: Clinical and Ethical Implications

It is widely accepted that psychiatric medications exert their effects through a broad range of mechanisms, some mediated biologically through their actions at various receptor sites, and others mediated symbolically, through the meanings they carry. While most clinicians are aware of the potential benefits of meaning-based placebo effects, the field of psychiatry is considerably less focused on its harmful counterparts. It is only recently that the phenomenon of the nocebo response has begun to enter into the psychiatric literature. As the mirror image of the placebo response, nocebo responses occur when expectations of harm result in physical or psychiatric symptoms.

The nocebo response is only one of many ways that medications cause meaning-based harm. Other forms of harm may not be as straightforward as nocebo side-effects and may not be limited to the period of time that is contemporaneous with the administration of the medication. Medications, for example, may become a concrete symbol of defect that is incorporated into a patient’s personal identity in ways that prove harmful. The prescription of a medication can be assigned a range of destructive interpersonal meanings (e.g., “I am intolerable”) that may prove developmentally problematic. Medications and associated diagnoses can be used defensively in a range of ways that can interfere with self-knowledge, agency, or growth. Medications can also substitute for the development of important affect management skills and other ego functions in ways that leave lasting deficits.

This presentation will review the evidence base for harmful meaning effects in psychiatry and some of the common dynamics by which the meanings of medication cause harm. We will explore some of the ethical dilemmas posed by mechanisms of harm and efforts to avoid harm. We will also consider the role of an empowering, patient-centered alliance and of basic psychotherapeutic skills in ameliorating harm that is mediated by meanings assigned to medications.