Sometimes psychoactive medication can work wonders with agitated young clients in the throes of a psychological emergency. But psychiatrist Robert Hedaya, an expert in alternative psychotherapy and founder of the Whole Psychiatry methodology, is concerned with how little we know about the effects of meds on the brains of children and teens.

Have you ever had a new client come to a first session and announce—with a formality that seems right out of the DSM—exactly what his diagnosis is? Perhaps this client is also certain about what symptoms are the result of a “chemical imbalance” and thus can be immediately treated with medication, not therapy. He may be willing to talk about some things in therapy, like his job or his marriage—but in terms of his anxiety, that’s what the pills are for.

When it comes to treating depression, neuropsychologist John Preston, author of Clinical Psychopharmacology Made Ridiculously Simple, says that psychoactive medication is only one alternative and often not the most effective. In addition to his integrative approach—which includes exercise, combating social withdrawal, family involvement, and possibly meds—he’s always on the lookout for toxic relationship issues in the client’s life.

Amid the many controversies surrounding the influence of the drug companies on the quality of mental health care, one important fact about the medications brought to market over the past 25 years has received little attention—few represented any real advance in the science of psychopharmacology or any real expansion of our understanding of how to regulate the nervous system with chemicals.

The clients referred to me for psychopharmacology consultation often seem to feel a certain relief once they’ve let me know that, when it comes to meds, they’ve tried “everything” and so far “nothing” has worked. After we’ve run down the list of what they’ve taken and how it’s failed to make any difference in their mood or state of agitation or ability to concentrate, they sit back as if to say, “Now it’s your turn.” In fact, this is the kind of ritual that they’re used to: once they’ve told the unhappy tale of their symptoms and the frustrating failure of drugs to do much good, what else is there for them to say? My answer? Plenty.

Over the last 150 years or so, we’ve seen successive waves of mass infatuations with psychotropic drugs—morphine, heroin, cocaine, amphetamines, barbiturates, tranquilizers, and antidepressants. While all these drugs are different, the story arc they follow—their rise, triumph, ascendancy, and gradual decline or sudden collapse—does follow a roughly predictable course.

However much we all might like to discuss and debate DSM-5, the field of psychotherapy continues to move forward.