The application of palliative care to intractable psychiatric disorders has been debated at least since 2010, when a journal article reported that a patient with severe anorexia nervosa died in hospice after being referred there by her psychiatrist. The New York Times published a thought-provoking article earlier this year on the same topic: whether we should ever deem severe, treatment-refractory anorexia incurable and terminal.

Are there incurable psychiatric patients?

Proponents argue that only hubris and false hope on the part of psychiatrists stand in the way. They say we should treat such patients as our colleagues treat medically incurable patients: with palliation and hospice.

This question is vexing enough. But eating disorders are an exception in psychiatry: untreated, they can lead to death from medical causes. Other mental disorders are miserable but not terminal in the same way.

Medical aid in dying

For this reason, discussions of “palliative psychiatry” lead directly to medical aid in dying (MAiD). Although MAiD solely for psychiatric conditions is not legal anywhere in the U.S., laws permitting it exist in Belgium and the Netherlands, and are pending in Canada. Accepting the framework of palliative psychiatry for incurable conditions appears to entail MAiD.

However, arguments that advocate for palliative psychiatry are muddled in several ways and do not, in fact, lead to that conclusion.

Psychiatry is already palliative.

First, psychiatry is inherently palliative. All somatic psychiatric treatment (medication, ECT, TMS, and so on) treat signs and symptoms of psychiatric disorders, not their root causes. That’s because we don’t know these root causes nor the mechanisms that connect them to the manifest signs and symptoms we observe. In essence, all such treatments aim to provide symptom relief, comfort, and support — the very definition of palliative care. It makes no sense to speak separately of palliative psychiatry when palliation is virtually the whole field.

The only exception is psychotherapy, which aims to treat the root causes of emotional distress. Of course, this can succeed or fail, and in the case of failure, we and our patients routinely resort to palliation. This is called supportive psychotherapy. It’s hardly a new concept that needs a new name.

Treatment resistance is slippery.

Second, arguments for palliative psychiatry usually invoke “treatment resistance” or refer to “treatment-refractory” disorders. Disorders so named are the putative targets of palliation since we can’t “treat” them.

There are biases hidden in such language. Treatment resistance is a concept from biological psychiatry. It means a particular patient fails to improve despite somatic treatments that help most other patients. However, as David Mintz argues, adding psychotherapeutic elements to a medication treatment can overcome this kind of treatment resistance. From a psychotherapeutic standpoint, treatment resistance may say more about the treatment than the patient.

Psychiatric disorders are not “things.”

Psychiatric disorders sound misleadingly like reified “things” we can treat with concrete interventions. In reality, our moods, thoughts, impulses, and actions result from a complex interplay of biology and psychology. Treatment resistance in that light is vague and abstract—not a sound basis for life-and-death decisions.

Again, in contrast, psychoanalytic psychotherapy is well-acquainted with treatment resistance. In fact, it’s expected. Not only is resistance not a reason to give up, but it can also be a signpost to insight and improvement.

Personality change can take a long time. I saw a highly defended patient in weekly psychotherapy for several years before she allowed herself to be vulnerable and introspective. In the years before the change, I often wondered if we were wasting time and money if she was “treatment refractory.” Now we both see that she isn’t. Conversely, I’ve seen another patient even longer with little to show for it. Is he incurable? There’s no way to know.

Being present and bearing witness

Third, sensitive psychiatrists (and other mental health professionals) stay with our patients whether they improve or not. The original idea behind palliative care was attending to the patient’s “total pain,” which includes the physical, emotional, social, and spiritual dimensions of distress. Not listed but equally important is bearing witness to distress and maintaining a caring therapeutic relationship, come what may. Again, we offer palliation in nearly everything we do.

MAiD is never inevitable in psychiatry.

Last but not least, given all of the above, MAiD cannot follow as a logical next step even after long-term hopelessness or failure to improve psychiatrically. Staying present isn’t hubris, and it isn’t imparting false hope. If a patient chooses to forgo further treatment, whether somatic or psychotherapeutic, we will honor that choice and remain available. If local laws someday allow, and as a matter of personal conscience, some of us may choose to participate in MAiD. But that will be an individual matter quite separate from incurability, treatment resistance, or comparisons with terminal medical conditions.

Steven Reidbord is a psychiatrist who blogs at Reidbord’s Reflections.