Prescribing Psychiatric Meds: the Dilemma

Hugh:  I’m thinking a lot lately about psychiatric medications – specifically, I’m thinking about HOW to think about them.  It’s not just a theoretical question…one of my new clients says he’s “desperate” for me to prescribe something to “even out” his moods – he gets into states of depression, seemingly “out of nowhere,” and can’t concentrate at work.  At night these moods often interfere with his sleep.  Of course I want to alleviate his distress.  At the same time, I’m concerned that in the long run medications may do him more harm than good.

Ann:  I’m so glad you’ve brought this up, because I’ve been grappling with similar conflicts in my own practice.  I’m seeing someone now who’s been taking medications for years to treat his anxiety.  He’s become dependent on them, believing that he needs them to function in his everyday life.  He recently asked me if I thought he could ever stop – I said I didn’t know, but certainly we could work on it.  Since then he’s brought it up from time to time.  But whenever we talk concretely about stopping he becomes really anxious and tells me he “can’t imagine living without them.”

Hugh:  Interesting how each of them experiences his emotions in a similar way.  My client talks about his moods as things he has no control over, things that “descend” on him at all hours of the day and night.  Your guy talks as if his anxiety exerts an irresistible physical power over him and the meds as the only way to defend himself against it.  Like so many people, they relate to their emotions as if they were unpredictable forces of nature that have no relationship to the actual conditions of their lives.

Ann:  The question of whether to use medications is complicated, isn’t it?  We want to help people who come to us because they’re hurting.  And some people do get quick relief with medications.  The problem is that the very fact of the medications “working” tends to reinforce people’s belief that their emotions are essentially the products of their chemistry, making it harder for them to see their own growth as they find new ways of being in the world.  One “side effect” of meds that’s rarely talked about is that they can often reinforce people’s passivity towards their emotions, obscuring an understanding of themselves as having agency, as being the active creators of their lives – including their emotional lives.

As I see it, what we’re doing in all of our therapy groups is building environments in which people are collectively creating their emotional life together and, in doing so, discovering that they can.  That’s development!

Hugh:  Yes, exactly.

Ann:  All of this has to be on the table in talking with our clients about whether and how they want medications to be part of their development picture.

Hugh:  When I have those discussions, I’ve found it’s helpful to talk about  medications in an ordinary way – by which I mean not in terms of moral categories, but as one of many tools that can be used in particular situations for particular purposes: to support people with depression,  let’s say,  or sleeplessness, enough so that they can give their emotional energy to the strenuous work of development.

Ann:  So how did you respond to the client you talked about at the beginning?

Hugh:  I started by asking him about his history with psychiatric medications.  He’d seen other psychiatrists before coming to me, and he’d been diagnosed with bipolar disorder.  He told me that he was conflicted about taking meds: he didn’t like putting chemicals into his body, they hadn’t worked very well in the past, and he’d had bad side effects from taking them.  But he said he’s exhausted all the time and the mood swings are driving him crazy: “All I want is for them to stop.”  I             said I was also conflicted about prescribing meds for him…Of course, I wanted to do whatever I could to relieve his pain – and I was concerned that “going on” meds might contribute to his idea of himself as helpless and passive.

Ann:  And what happened?

Hugh:  It felt to me like we had opened a door that we could go through together.  As we continued talking, he acknowledged that he wants much more in his life than the absence of pain.  I told him that I wanted much more for him, which brought us to the development question:  What does he need to grow emotionally?  Who does he see himself becoming?  What would it take for him to create the life he wants for himself?

Ann:  What did he say?

Hugh:  He said no one had ever asked him those questions and that he hadn’t ever thought about such things…he’s been preoccupied with how bad he feels right now, which includes blaming himself for being “weak.”  That gave us an opportunity to look at his understanding of himself as “broken” and damaged, rather than as someone who, like all of us, is capable of unlimited development.

Ann:  So what did the two of you decide? Did you end up prescribing medications for him?

Hugh:  We agreed that, to start with, I would write a prescription for medication to help him sleep and that he would use it sparingly because it’s habit forming.  And we also agreed that we would talk regularly about how it’s going and that we’d keep on making these decisions together…I wanted him to know that he’s not alone with this.

Ann:  When it comes to medications, I’ve found that there’s no one-size-fits-all answer.  It’s no secret that there’s a lot of controversy in the mental health field about psych meds – some clinicians swear by them, others swear at them.  And their clients, too, give meds very mixed reviews.  I think for us, as social therapists, we have to ensure that our clients play an active role with us in creating the therapy.  And we have to address the development question very specifically – including whether and how meds fit into the process of their emotional growth and transformation.