Psychiatric Medication: Where Does a Therapist’s Responsibility End?

More than a prescription

When someone begins taking psychiatric medication, there is often a great deal of attention given to the initial assessment and treatment plan. But I wonder whether we give the same attention to what happens afterwards, when the person returns to their everyday life and begins experiencing what taking that medication actually means for them.

Imagine someone who has recently started medication following a period of significant emotional distress. A few weeks later, they tell their therapist that they are thinking of stopping. They feel exhausted, perhaps emotionally flat, and describe not feeling quite like themselves anymore. At home, their family have also noticed a change. They seem calmer, but less interested in things they previously enjoyed.

When these concerns come up in therapy, a familiar and professionally appropriate response might be: "You need to discuss that with your psychiatrist."

Of course, this is important. Decisions about changing or stopping psychiatric medication require the expertise of an appropriately qualified prescriber. Some changes carry significant risks and need careful medical supervision.

Yet I wonder whether we sometimes allow the conversation to end too quickly.

The prescribing clinician holds responsibility for the medical treatment, but the experience of living with that treatment unfolds in the person's everyday life. A therapist may see them weekly, while their family notices changes in their mood, sleep or behaviour at home. These observations may tell us something that is not immediately visible during a medical appointment.

The risk of rigid boundaries

I think there is a danger in seeing professional boundaries only in terms of what we cannot do. Knowing that a decision falls outside our expertise does not necessarily mean that our responsibility to the person ends there.

A therapist cannot independently change someone's prescription, nor should a family member or community supporter make medical decisions on their behalf. These boundaries exist for good reasons. Psychiatric medication can have significant benefits, side effects and risks, and treatment decisions require appropriate medical knowledge.

However, respecting these boundaries should not prevent us from remaining attentive to the person's wellbeing.

A psychiatrist might review someone periodically, while a therapist may meet them every week. A spouse might notice changes in sleep, appetite or behaviour, and a support worker may see how the person is managing everyday responsibilities. None of these observations independently determines whether the medication is appropriate, but each may contribute something to understanding how the person is coping.

For me, ethical practice involves more than recognising where my professional role ends. It also involves considering what remains within my responsibility when something concerning comes to my attention.

This may mean listening more carefully, helping the person explain their concerns to their prescriber, or, with appropriate consent, sharing relevant observations with the psychiatrist. Where there are concerns about significant deterioration or immediate risk, it may also mean seeking urgent clinical advice or taking appropriate action.

The aim is not to take over the psychiatrist's role, but to ensure that the person does not become isolated with concerns about their treatment simply because another professional holds the prescribing authority.

The limits of a diagnostic label

A psychiatric diagnosis can be enormously valuable. For many people, having a name for experiences that have been frightening or difficult to understand can bring relief. It may help explain patterns of distress, guide treatment and provide access to appropriate services.

Yet I also wonder what happens when a diagnosis begins to shape how we understand everything else about the person.

Someone diagnosed with bipolar disorder, for example, may begin questioning whether an ordinary period of sadness, frustration or excitement is simply part of their emotional life or an emerging symptom. Their family may also become increasingly watchful, interpreting changes in mood or behaviour through the diagnosis.

Sometimes this awareness is essential. Recognising early signs of relapse can be particularly important for someone who has previously experienced mania, psychosis or severe depression. But there is a difference between recognising clinically important patterns and interpreting every ordinary emotional experience through a diagnostic label.

The challenge, I think, is to remain attentive to both.

Exploring someone's trauma, relationships, losses or cultural environment does not invalidate a psychiatric diagnosis. Nor does a diagnosis remove the relevance of these experiences. Psychiatric and psychological understandings can inform one another, helping us consider different aspects of the same person's difficulties.

A psychiatric formulation may help explain symptoms, assess risks and guide treatment, while psychological exploration can bring further attention to the person's experiences and the meanings they attach to them.

Perhaps our responsibility is partly to ensure that these other dimensions of the person's life remain present in conversations about their care.

When someone stops taking medication, what are we hearing?

This becomes particularly important when someone tells us they are no longer taking medication as prescribed. It may be tempting to understand this as a lack of insight, resistance to treatment or a failure to recognise the seriousness of their condition.

Sometimes, particularly where someone has experienced severe mental illness, stopping medication can raise legitimate concerns about relapse. Abruptly stopping certain psychiatric medications may also lead to withdrawal effects or other complications.

When someone tells me they have stopped taking prescribed medication, my first responsibility is to consider their immediate safety and whether medical review is needed. Alongside this, I want to understand their experience. What led them to this decision? What were they struggling with, and did they feel able to discuss their concerns with their prescriber?

Perhaps they are experiencing difficult side effects or feel that the medication has changed something about how they experience themselves. They might be worried about taking it long term, or perhaps they have never felt comfortable raising these concerns during a medical appointment.

There may also be more practical reasons. Someone might misunderstand the instructions, forget doses or struggle to maintain a complicated routine. These differences matter because they may help us understand what kind of support the person actually needs.

NICE guidance on medicines adherence encourages healthcare professionals to explore the reasons people do not take prescribed medication without blame or judgement. This includes recognising the person's concerns, preferences and experiences, rather than assuming that non-adherence is simply a problem of motivation.

I think this has something important to teach us, particularly those of us working therapeutically. We need to remain attentive to clinical risk while also creating space for the person's own account.

Listening in this way does not mean endorsing a decision to stop medication. It means recognising that understanding the person's experience may be an important part of helping them engage with appropriate medical care.

Navigating trust within the community

Within our community, someone experiencing mental health difficulties may turn to several people for support. It might be their spouse, parents, therapist, Rav, teacher, mentor or someone from a local organisation.

These relationships can be enormously valuable, particularly when someone finds it difficult to speak openly about their mental health. But I think we also need to recognise the responsibility that comes with being someone another person trusts.

A person may feel more comfortable discussing their fears about medication with someone familiar than during a relatively short medical appointment. They may describe side effects, express doubts about their diagnosis or ask whether they really need the treatment they have been prescribed.

In these situations, I think it is important to distinguish between being someone whose opinion is trusted and being someone qualified to make a medical decision.

A well-meaning family member may encourage someone to stop taking medication because they appear tired or withdrawn. Another may insist that medication must continue because they are frightened of what happened during an earlier crisis. Both may be acting out of genuine concern, yet neither response necessarily takes account of the full clinical picture.

The same applies to community supporters. Someone may understand psychological distress primarily through personal circumstances, while another may regard medication as the only meaningful solution. Neither perspective should replace an appropriate clinical assessment.

I would see the role of trusted supporters as helping the person remain connected to appropriate care, rather than attempting to determine the medical answer themselves.

This might involve helping someone prepare questions for a medication review, encouraging them to describe side effects or supporting them in communicating concerns they might otherwise hesitate to raise.

Families and trusted supporters can also provide valuable observations, particularly where the person wants them involved. However, we should not assume that family involvement is always wanted or appropriate. Confidentiality, consent and the person's wishes must remain central, and professionals should share information only where consent or another lawful justification permits it.

Keeping the person part of the conversation

There is something that concerns me when several people become involved in someone's care, even when everyone has good intentions.

It is possible for a psychiatrist, therapist, GP and family to be discussing someone's wellbeing while the person themselves feels increasingly excluded from decisions about their own life.

We can become so focused on protecting someone that we overlook their experience of being protected.

Someone may understand why medication has been recommended and still feel uncertain about taking it. They may recognise its benefits while finding some of its effects difficult to live with. These feelings do not necessarily mean that they are rejecting treatment or failing to understand their condition.

They may simply reflect the complexity of living with psychiatric treatment.

Shared decision-making is an important principle of UK healthcare, reflected in NICE guidance and the General Medical Council's professional standards. It involves discussing treatment options, benefits and risks while considering what matters to the individual.

A person with capacity is generally entitled to make an informed decision to refuse treatment, even where professionals disagree. Separate legal provisions may apply in certain circumstances under mental health legislation, but a psychiatric diagnosis does not automatically remove someone's autonomy.

I think this is especially important when we consider the influence that professionals and family members may have over someone who is already feeling vulnerable.

Within our community, meaningful participation may also depend on how information is communicated. This might involve explaining unfamiliar medical terms in ordinary language, providing information in Yiddish or allowing more time for someone to consider their options. A person cannot meaningfully participate in decisions they have not been supported to understand.

Looking beyond whether the medication is working

One of the questions I am left with is how we define successful treatment.

If someone is sleeping better, experiencing fewer symptoms or has avoided another hospital admission, these may be important signs of improvement. But what if they also describe feeling emotionally disconnected, unable to concentrate or less engaged in their family life?

I wonder whether we can consider treatment fully successful without also understanding how it affects the person's everyday life.

Of course, symptom reduction and clinical stability matter. So do physical health, relationships, daily functioning and the person's sense of wellbeing. None of these should automatically be considered more important than the others without understanding the individual's circumstances and clinical needs.

Some psychiatric medications also require specific physical health monitoring, including blood tests or checks for metabolic changes and other adverse effects. These responsibilities must be appropriately allocated to qualified healthcare professionals.

But beyond those medical checks, there is also value in asking how treatment is fitting into the person's life.

Rather than focusing only on whether someone is taking their medication, perhaps we should also be asking how things have been since they started it. What has improved? What feels different? What has become more difficult? And is there something they would like their prescribing clinician to understand?

These conversations do not replace medical assessment. They may, however, contribute to a fuller understanding of the person's experience and help ensure that important concerns are brought to the attention of those responsible for treatment.

A responsibility we cannot simply pass on

I began by questioning where responsibility sits when someone is taking psychiatric medication. I do not think the answer is that everyone should become involved in every clinical decision. That would create confusion and could lead to unsafe advice.

Nor do I think the prescribing clinician's expertise should be questioned simply because another professional or family member understands the person's difficulties differently.

What I am questioning is the assumption that recognising this expertise somehow removes the responsibilities of everyone else.

A therapist who notices concerning changes has a responsibility to consider their significance and respond within their professional role. A support worker who becomes aware of possible deterioration should seek appropriate guidance and take action where necessary. A family member may offer understanding and help someone communicate their concerns without taking over decisions about treatment.

These responsibilities are different, and they should remain different. But I think they also need to be connected.

We will not always know whether a change in someone's behaviour is related to medication, their mental health, their circumstances or some combination of these. Sometimes the answer will be unclear, even when several professionals are involved.

For me, this uncertainty is not a reason to withdraw from the conversation. It is a reason to remain curious, seek consultation where needed and be careful about the conclusions we reach.

Perhaps the question is not simply whether the medication is working, but how the person is living with it.

The prescribing clinician brings medical expertise, while therapists, families and others may notice different aspects of the person's everyday experience. None of these perspectives replaces another, but together they may help us develop a fuller understanding of the person's wellbeing.

And perhaps that is where our shared responsibility lies. Not in everyone having an opinion about what treatment someone should receive, but in recognising that the person receiving it remains more than their symptoms, their diagnosis or their prescription.

Medical decisions must remain with those qualified to make them. But the responsibility to listen, notice and respond appropriately to someone's wellbeing extends beyond the clinical appointment.