An essential mission of psychotherapy is to guide a patient toward feeling. A central purpose of psychotropic medications is to relieve patients of feeling.
This presents a major clinical challenge.
Prozac, Wellbutrin, Lexapro, Effexor, Ativan… There’s an endless list of drugs designed to change one’s biochemistry, to alleviate mental suffering.
But as a clinician who’s worked with patients from the mildly neurotic to the certifiably psychotic I have found that the major problem afflicting them is not their suffering per se but their relationship to their suffering.
What harms the patient is a habit of avoiding suffering at all costs.
Anticipating our own pain
In the same way our culture has indulged creating societal safe spaces, we’ve done something similar for our minds. We’ve created several safety latches with which to escape painful experiences.
On the surface this might seem like a boon. After all, who really wants to suffer?
And yet we are culturally, and therefore personally, mired in an epidemic of escapism. Consider legal weed and binge-worthy tv, porn and dating apps, social media and, perhaps worst of all, our phones themselves.
Our marketplace is now ready to go beyond alleviating our pain. It’s in the business of aiding us in anticipating our pain, heading it off at the pass, keeping it a safe distance from ourselves at all times.
Nothing does this more incessantly, and therefore more effectively, than psychotropics. And we’d do well to ask: Is that a good thing?
Meds and stuckness
While I don’t advocate needless suffering (I am in a profession of healing after all) I can say we have forgotten how to suffer. We have little to no tolerance for it.
And whatever temporary comfort we may gain from our escapism, we at the same time feel another current of life that runs counter to this: Deep down we know that somehow, some way some form of suffering will find us.[1]This state of largely unconscious vigilance is both exhausting and terrifying. Routinely escaping anxiety also seems to breed it.
And what then?
While I think meds can be effective in short-term use (to treat, say, a debilitating depressive episode, chronic panic attacks, or bipolar disorder that has become dangerous) I have frequently witnessed patients stuck on psychotropics long-term.[2]The vast majority of my patients who use them have been on them long-term, which I would define as six months or more. When I inquire about their last visit to a psychiatrist they often have … Continue reading
Recently a patient of mine, initially medicated with Ritalin in second grade, revealed she’d been on Wellbutrin for over 20 years. Another whom I’ve seen for over five years, has been on antidepressants for over 10 years and is now dependent on them.
These patients are cut off from their emotions, the very ones the drugs are designed to block. They’re neither suffering (even if their sex lives, exacerbated by the side effects, often are) nor are they improving.
They are, we could say, tolerably stuck.
Meds don’t cure
Simply put drugs don’t cure patients. They cover up symptoms and in the process prevent access to them. It’s hard to solve something you (not to mention your collaborator in the therapy process) can’t experience.
Psychotherapy offers something different. It offers the chance—often for the first time—to truly get to know oneself through the process of (re)connecting to all of one’s feelings.
In my clinical experience this process of reintegration, of allowing the patient access to her entire self, cannot be achieved to full effect with psychotropics performing their work. In fact, I have found that the most effective treatment with patients on meds often occurs once they go off their meds.[3]Tapering off meds can be a delicate and even dangerous matter and should be done in full consult with a psychiatrist and also with careful observation from one’s psychotherapist.
When patients come to me I learn about their history with meds through the intake process. While only a psychiatrist can prescribe medication, a competent therapist should still be willing to analyze the potential efficacy and interference of medication in the treatment process.[4]The therapist should not go beyond his scope of competence and play the role of a psychiatrist. Nor should the therapist try to influence the patient re the use of psychotropics. A discussion about … Continue reading
To the extent that meds have a place in the treatment of mental illness, they should not be relied upon for genuine psychic change. That should be the work of the therapeutic dyad.
Emotional suffering after all is woven into the fabric of our lives, often with its roots in relational patterns, internal ambivalence and a buried self. Isn’t it time we learned to stop hiding from that?
Notes, etc.
| ↑1 | This state of largely unconscious vigilance is both exhausting and terrifying. Routinely escaping anxiety also seems to breed it. |
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| ↑2 | The vast majority of my patients who use them have been on them long-term, which I would define as six months or more. When I inquire about their last visit to a psychiatrist they often have difficulty recalling its approximate date. When I inquire about details of their session, there’s little to no sense that an effort was made by the clinician to relate to them as people, to understand the particulars of their condition. In other words, patients are typically given a brief consult to assess their need for medication, prescribed something and then all too commonly not seen for prolonged stretches—all while continuing to be prescribed. The implications of this approach on a patient’s prognosis are obviously massive, and in my estimation this approach falls below the ethical standard of care. |
| ↑3 | Tapering off meds can be a delicate and even dangerous matter and should be done in full consult with a psychiatrist and also with careful observation from one’s psychotherapist. |
| ↑4 | The therapist should not go beyond his scope of competence and play the role of a psychiatrist. Nor should the therapist try to influence the patient re the use of psychotropics. A discussion about them, however, is desirable. This can be initiated by the therapist but should be done in collaboration with the patient. And the patient’s preferences on this should hold considerable sway. |