Daniel Lehrman, MA, NCPsyA, LP
Body & Soul: Reflections on Medications & Psychotherapy
NOTE: This article expands on some of the ideas in my brief statement on the use of medications on the Home page under the Questions About Psychotherapy section. I do not wish to persuade a reader in one direction or another regarding psychoactive medications. Instead, I offer these reflections as a help in thinking through some of the many questions that should be considered. Each person’s needs are unique, and they change over time. If you are considering taking medications or are currently taking them, it is important to work with practitioners with whom you can communicate openly and with trust.
Anyone considering getting help for psychological difficulties is probably aware that medications are one option available for addressing a wide range of problems. The idea of taking medications that will affect us psychologically (psychoactive medications) elicits strong feelings and opinions from many people. Some are very eager for a pill that may help them; others reject the idea with vehemence; many are confused and uncertain about the whole issue. Few are indifferent.
Nowadays, the dominant view in our culture toward psychoactive medications tends to be favorable, as shown by the tremendous increase over the past two decades in the numbers of people taking them. In fact for some people, medications are seen as the first resort for coping with periods of emotional stress and hardship. Very commonly, a person in psychological distress goes to his or her physician and requests a prescription for one of the much-advertised psychoactive medications. After a few minutes of discussion, the doctor—often not a psychiatrist, and therefore lacking specialized training in psychopathology and its medications—writes a prescription.
This way of addressing emotional difficulties, spurred on in part by the rapid developments in brain science and by the availability of ever more psychoactive drugs, deserves careful thought. It certainly is true that medications can be a great help for some people. Particularly for those suffering from conditions that are severely impairing their lives, medications can sometimes facilitate more rewarding functioning, including the process of psychotherapy, and can lead to greater happiness. They can be true lifesavers. However, psychoactive drugs are vastly over-prescribed.
Why is it so important to be cautious and thoughtful when considering psychoactive drugs?
One reason is that medications carry risks of many kinds. As is the nature of risk, many of the potential problems are simply not understood. Risks can vary widely among different populations, from adults, to children, to adolescents, to pregnant women, to the elderly, for instance. The long-term effects of many medications are impossible to know because they have only been available for a short term. Our overall knowledge of brain science, while stunning in its recent progress, is nonetheless in its infancy. As is so often the case, our ability to use technology is far ahead of our understanding of its mechanisms and ramifications.
For extreme psychological disturbance such as major depression, which can cripple a person for years or even a lifetime, the risks of medications can be well worth the benefits. But many people who are taking medications are not suffering severely, and many are not aware of even some of the known risks, let alone the possibility of unknown ones. Neither are many aware of the full range of options such as various kinds of psychotherapy and holistic remedies that are available for treating their presenting problems.
Furthermore, there are frequent side effects of the various psychoactive medications, such as: agitation, disorientation, tremors, irregular heartbeat, headache, insomnia, stomach distress, sexual side effects, weight gain and loss, and menstrual irregularity, among others.
Why, then, given such downsides of psychoactive medications for many people, are they so commonly prescribed?
There are two main reasons. One is financial: Drugs make very good business. It is a distressing but not a new story. The business of medications—money—is often in conflict with the goal of medications—health. And the business is winning. While it would be nice for the pharmaceutical companies to hold the public’s best interest at heart, we continue to learn how deeply naïve it is to assume they do. When one researches the aggressive, greed-driven tactics the pharmaceutical industry uses to increase profits, the situation is truly an appalling betrayal of trust. (See below for sources.) It is worse than in other industries, such as oil companies, because the pharmaceuticals are able to use as leverage the mantle of trust worn by the medical establishment of which they are a part. We have little expectation that the oil companies will operate according to high ethical standards, but we do still expect, even in this greed-driven age, that the medical establishment can be trusted. The pharmaceuticals exploit this relationship and thereby undermine it.
So the reason we are inundated with advertisements for psychoactive drugs is that there are billions of dollars to be made from them. But the reason these advertisementssucceed points us in another, and very important, direction. As with any successful business, something is being sold that the public desires. Let us face it squarely: Many people want psychoactive drugs. And if they are ignorant of their risks, it as much because they wishto remain ignorant as because no one is making a special effort to inform them. The Roman author Petronius astutely observed, the world wants to be deceived (mundus vult decipi). We want to believe in what is being sold.
Drugs, after all, hold the promise of a quick fix to some of our deepest troubles. Facing our difficulties, our vulnerabilities, our unhappiness, and the parts of ourselves we are ashamed of, is not an undertaking many of us invite with open arms. But psychotherapy often involves this kind of work. Most people only undertake psychotherapy under duress of some kind, when they face boulders in the road that they cannot get around without help. While some people realize to their surprise that they find psychotherapy deeply rewarding once they get over their initial natural reluctance toward it, it is usually a very scary prospect at first. Therefore, if faced with a choice between a pill that may take care of our difficulties on the one hand, and the process of baring our soul on the other, the pill appears as a very attractive option! We live in a culture of the quick fix; we put our trust in science, medicine laboratories; we can’t afford to miss a day of work; sadness, pain, and inward struggle have little place in many of our lives.
The implication of this thought often goes unspoken: Psychoactive medications frequently are turned to as an escape. Consider an example. A middle-aged man’s wife dies of cancer. Grief sets in. The man, Gary, is eating and sleeping poorly; he can’t focus at work; he feels awful that he is not taking care of his kids and helping them with their own feelings, but he can’t bear to talk about their mother with them. He starts having fears he never had before, such as a fear of driving. So he goes to his doctor and says he’s got to have something to take—an antidepressant, “just until I get leveled out a bit.” The doctor prescribes one and adds, as Gary is on his way out, “Maybe you should find someone to talk to.”
After some months on medication, Gary feels somewhat better able to focus at work, but other problems have worsened. At home he is even more irritable and short-tempered, as are his children, and the conflicts there have become unbearable. Further, his body “feels like it has aged 10 or 15 years.” At this point he is sick of the drugs. They have not helped as he had hoped, and he thinks some of his physical ailments are from side effects. In desperation he comes for psychotherapy.
This is an example of an escapist use of psychoactive medication. As Gary later said, he went to his doctor hoping to “just get back on track and not to deal with all the pain and craziness.” He wanted his life to be “business as usual” despite the volcanic upheaval that had erupted in it. Note that I am not saying medication should be categorically excluded in such a case. It may have a role to play at some point. But it should not be the first resort. The medication itself was not good or bad. The problem was in the attitude with which Gary sought out and took it. His attitude was, “Go away feelings!” Therefore his relationship to the medication was reinforcing many of his problems rather than helping them. Turning to pills was not helping him to change and to grow, as his life required; they were helping him (though only minimally) to stay the same.
Within a few weeks of psychotherapy Gary decided to stop his medication. He started to speak of his guilt over not having “been a better husband.” For many years he buried his feelings away, and he was hoping he could continue to do so. On another level, though, he knew that style couldn’t last forever, and he occasionally admitted what a relief it was to “not keep everything hidden from myself and everyone else.” After about a year’s work he felt “solid enough to take a break from therapy.” He saw no need to resume the medication despite some rocky periods, though he realized that medication was one potential form of help that might be used now with a far healthier attitude than previously.
People take medications with very different intentions. One seeks healing and a heightening of life; another seeks to forget, to flee, to deaden a troubled life in the spirit of having several martinis each day after work. The difference is by no means always so easy to discern. There is often a fluctuating mixture of motives involved.
The very words “medication” and “drug” point us toward this problem. Note how slippery the term “drug” is. Sometimes it is interchangeable with “medication,” as I have used it in this article, while sometimes it is strictly pejorative, as in the “War on Drugs” or “drug addict.” The slipperiness of the word reflects the slipperiness of the issue. Sometimes medications are agents of healing; sometimes they are drugs—chemical means of escape. Often they are both. Likewise, sometimes the pharmaceutical companies are purveyors of medicines, sometimes they are drug pushers. Perhaps they are both.
Out of our discomfort with the blurry line between the good and the bad, the healthy and the unhealthy in the taking of psychoactive medications, we tend to draw artificially clear lines. So we say some are always bad, and we call them drugs and declare them illegal. We say others are always good, so we call them medications and put them in the hands of doctors. Sometimes we get reminded that neither such absolute is true. We may encounter a case of the genuine medical benefits of marijuana, or we learn that a friend is dangerously addicted to her prescription pain killers. In a day or so, however, we tend to slip back into the old patterns of thinking: Medications are fine, so long as they come with a doctor’s prescription. Countless advertisements per day seek to reinforce this positive association.
Two more points should be made. 1) Not only medications get used as an escape. 2) Not all escapes are bad. Let’s consider each of these.
By “escape” I mean running from realities we don’t want to face, often in an unconscious way. Gary, for instance, did not want to face and feel his guilt, his pain, his fears, his helplessness, and a host of other vulnerable, difficult feelings. Escape can be achieved in many ways, and here we could use the term “defense” or “defense mechanism” almost interchangeably with “escape.” One of the insights of psychodynamic therapy is that anything can be used defensively—not just overt behaviors such as drinking alcohol, and not just “intrapsychic mechanisms” such as repression or projection, but also humor, intellectualization, workaholism, video games, music, religion, meditation, and psychotherapy itself. Sometimes a person uses psychotherapy, for instance, to talk endlessly about his difficulties, but the very talking can be a way of keeping feeling at bay. Instead of experiencing, suffering, and therefore working through his problems, words are used to spin thoughts about them endlessly. The therapist needs to find ways of helping the person to get through this defense.
The second point is that defenses are not necessarily bad. Some—doing crack, for instance—are of course intrinsically damaging. But most of us have since childhood developed ways of protecting ourselves from pain that can be very adaptive and appropriate in many settings. Funny people, for instance, often developed their humor as a way to win over people they feared as children, or to bring people together who were in conflict, or to deflect criticism, or the like. Problems arise when a defensive style becomes “hard-wired,” so that we no longer use it at will, but it comes to define us. Its presence in our life has become tyrannical; we feel less free because of it. The defensive style masters us, instead of the other way around. The funny person can’t seem to be taken seriously; perhaps he doesn’t know how to take himself seriously. His place in the world has been carved out by a single character trait. What started as adaptive defense has become a cage—or sometimes a wall that separates oneself from oneself, and from the world and other people. Note the many famously miserable comedians.
So anything can be used as a drug. But medications have a special susceptibility to being used as drugs! This should be obvious. Yet the attitude is often held—thanks to aggressive advertising and to our desire to believe it—that psychoactive medications are inherently benign tools. They are not. They are extremely powerful substances that work on our very faculties of feeling and thinking, on our sense of our selves. They can be used for good and for ill. They can be growth-enhancing and they can be growth-stunting. They are very often a mixed bag, like most things in life.
For some people, medications can help to open the door to a sense of their own agency, efficacy, and autonomy. For others, medications can close the same door; they become mere drugs. Medications are sometimes sought as a shortcut to contentment, and in this way they can rob a person of her own life’s journey; in the effort to be rid of the pain, one also gets rid of the gain. But for other people, and especially some in severe distress, medications can help clear the way for truly encountering life and oneself. The most reliable way to navigate between the healthy and the unhealthy uses of medications is for a person to be in a therapeutic relationship that will facilitate ongoing exploration and evaluation of his or her experience.
Sources for Further Reading on the Business and Science of Psychoactive Medications
The business and the science of psychoactive medications are deeply intertwined. The business is worth many billions of dollars annually. With such colossal sums at stake, it is no surprise that the pharmaceutical industry works diligently to promote the science that serves their interests. Their reach is wide-ranging. Studies, research facilities, and academic faculty are funded by them; scientists are hired and fired according to their research results; data are skewed and misrepresented.
To take one example: A recent study whose results made their way to national media attention and published in the New England Journal of Medicine, found that some pharmaceutical companies simply have not reported the negative findings on the efficacy of some antidepressants. Specifically, when all findings are reported, only 51% are positive. But after the companies’ selection process, a remarkable 94% appear to be positive! The real results indicate that some antidepressants were found to be no more effective than placebo. But presenting the truth would not be good for business. (The article is aptly titled, “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy” by Erick H. Turner et al., January 17, 2008 and is available online: content.nejm.org.)
The following sources explore the science and the business aspects of this topic from a variety of angles. A very useful brief article, and perfectly accessible to the layperson, is by Frederick Crews, called “Talking Back to Prozac.” It is a review of three of the titles listed below (Healy, Horwitz and Wakefield, and Lane) and appeared in the New York Review of Books, December 6, 2007. It can be found online at: nybooks.com.
A fine overview of the territory is Blaming the Brain by Elliot Valenstein, PhD., Professor Emeritus of Psychology and Neuroscience, University of Michigan.
Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression, David Healy, New York University Press, 2004.
The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder, Allan V. Horwitz and Jerome C. Wakefield, Oxford University Press, 2007.
Shyness: How Normal Behavior Became a Sickness, Christopher Lane, Yale University Press, 2007.
Toxic Psychiatry, Peter R. Breggin, M.D., St. Martin’s Press, 1991.
Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All into Patients, Ray Moynihan and Alan Cassels, Nation Books, 2005.
Blaming the Brain: The Truth About Drugs and Mental Health, Elliot S. Valenstein, Free Press, 1998.
Prozac Backlash: Overcoming the Dangers of Prozac, Zoloft, Paxil, and Other Antidepressants with Safe, Effective Alternatives, Joseph Glenmullen, Simon and Schuster, 2000.
The PBS Frontline program, “The Medicated Child.” This explores the controversial surge in diagnosis of bipolar disorder among children and the resultant use of medications untested for children. One father notes that over years of exploring options for his son, “No one ever mentioned psychotherapy. No one ever said, ‘This is something we can try to work with.”’