The old idea that therapists should support use of medications, versus the new idea that therapists should support empowerment and informed choice:
Many of us were educated to believe that psychiatric medications are well-tested, relatively benign, non-habit forming substances which act to correct “chemical imbalances” that cannot be corrected by psychotherapy alone, and which can be trusted to aid rather than interfere with therapy and with recovery from the problem. Unfortunately, even while more and more people are being given psychiatric medications, often now many medications at the same time (polypharmacy), it turns out that none of the above beliefs can be considered accurate. Below is a one by one review of these beliefs, followed by a rationale for a new way of viewing the role of therapists in relationship to medications.
Are psychiatric medications “well tested?” It turns out that most of them are only tested against placebo for effectiveness over a period of a few weeks. Drug companies sponsor the research, and when a research study shows that a drug is ineffective, they commonly hide the study, while publicizing the studies that do show effectiveness. When dangerous “side” effects are discovered, data about them is often suppressed (for example, the SSRI’s and suicidality in adolescents, or massive contributions to weight gain and diabetes by Zyprexa, are some dangerous effects known to have been deliberately hidden.)
Are psychiatric medications “relatively benign?” While the neuroleptics (often misleadingly called “antipsychotics”) are the worst offenders, shown to directly contribute in a number of ways to high death rates as well as neurological disorders and brain shrinkage, other psychiatric medications are not so innocent either. Anti-anxiety medications like Xanax may reduce anxiety in the short run, but appear to make it worse down the road. SSRI’s are associated with a host of possible problems, including frequently contributing to mania (which is then at risk of being seen not as an SSRI side effect but as “bipolar disorder” which can then be treated with more medications.)
Are psychiatric medications “non-habit forming?” Actually, all of the classes of psychiatric medications have been shown to be habit forming. That is, people who attempt to quit them suddenly are likely to fare much worse than people who quit them gradually, and people who withdraw from them may experience worse symptoms than before starting the medications, or even completely new symptoms. Since most people are uninformed about these withdrawal effects, symptoms that emerge during withdrawal are often seen as indicating an ongoing need for the medication, rather than being seen as the withdrawal problem that they are.
Do psychiatric medications “correct chemical imbalances which could not be corrected by psychotherapy alone?” Only in the commercials. In truth, humans have not been found to have particular “balances” of neurotransmitters, and the only thing that can be said about psychiatric medications is that they create abnormalities in neurotransmitter conditions. That is, neuroelptics block dopamine transmission to an abnormal extent, SSRI’s lead to abnormal availability of serotonin, etc. On the other hand, for any mental disorder, there are people who recover without ever taking medications, or who eventually stop taking medications and stay well, which undermines the argument that these mental disorders involve ongoing “chemical imbalances” which require medications.
Can psychiatric medications be trusted to aid, rather than interfere with, therapy and with recovery from the problem? Certainly, there are times when medications can aid therapy, But medication can also interfere dramatically with therapy. Medications typically aim to eliminate troublesome feelings, rather than help a person learn how to relate to them and process them. It is difficult to help a client process feelings which are numbed out. Methods learned in therapy pale in effectiveness compared to a few Xanax. The paranoid client taking large doses of a neuroleptic may have fewer paranoid thoughts and less spontaneous interest in them as a result of the medication, but also may have little ability to take an interest in therapy or to reflect about the paranoid thoughts, due to that same medication. Much data shows medications associated with quicker symptom reduction, but also more frequent relapses compared with people who never take medication, which makes sense if one understands the way they can interfere with learning how to handle emotions and thoughts. (Curiously, many clients are currently warned that reliance on street drugs to handle emotional problems will result in emotional immaturity, but are almost never led to even consider the possibility that the same emotional immaturity problem might result from reliance on psychiatric medication to handle emotional problems.) Studies of longer term recovery show it to be more common in those who get off medications: for example, a recent study of 15 year outcomes for people diagnosed with schizophrenia found those showing recovery were 8 times more likely to be off medications. (You can access this study at http://psychrights.org/Research/Digest/NLPs/OutcomeFactors.pdf
A further complication is that reactions to psychiatric medications are highly variable, so much so that studies of “average” responses in studies cannot predict the reactions of individuals. A drug proven to be on average successful for a given disorder may not be helpful to a given individual with that disorder, and may even make it worse. And for clients taking multiple medications, even less is known, since there are very few systematic studies of polypharmacy. (One danger to watch out for is the infamous “prescription cascade” where a second medication is prescribed to deal with the side effects of the first, followed by a third medication to deal with the side effects of the second, etc.)
When therapists believed that medications were well tested, benign, non-habit forming corrections to chemical imbalances that could be trusted to assist in therapy and in recovery, it made sense to take a generally encouraging role in relationship to medications. Therapists typically saw their role as that of recognizing when clients had disorders which likely required medications (those with “chemical imbalances”) and then to encourage those clients to see prescribers for medications and to “comply” with their prescriptions for however long they were written, often a lifetime for many disorders. However, new knowledge requires that therapists take new roles.
Some of the characteristics of the new role for therapists:
- Be cautious about encouraging clients to get on medications.
- Be knowledgeable about alternatives to medication
- Support clients in becoming informed about hazards as well as advantages of medications
- Be aware of how medications may be interfering with therapy and with recovery, as well as aware of any positive contributions from them
- Support clients in making informed & empowered choices about reducing or getting off medications as well as getting on them in the first place
- Once clients have decided to reduce or get off medications, help them do that safely and successfully if possible
One person’s experience:
“It was very difficult for me as an 18-year old man to do all the learning one needs to do about social skills, emotions, about career skills and about ones sense of identity and drive, on medium doses of neuroleptics. Six months after my third psychiatric admission I was at Art College trying to not let hand tremors effect my painting, always feeling half a second out of time with the other students. People observed how when I came off medication, how much more in touch with myself I seemed, both emotionally and intellectually. I was suddenly able to express more complex thought processes again. My decision to cease taking medication received no support from the psychiatrists. My actions were seen as non-compliance and no supportive services were offered to me. I was left to cope with the withdrawal effects alone. This was risky – the first two attempts to withdraw resulted in re-admissions, which were at least partly contributed to by mania-like withdrawal effects. Withdrawal syndromes often produce psychotic experiences and are often mistakenly assumed to be the ‘illness’ returning ( Thomas, 1997; Warner, 1997). This misattribution can increase helplessness in the person concerned.”
– The above quote is by Rufus May, from his article “Understanding Psychotic Experience and Working Toward Recovery” Rufus, despite having been told he was schizophrenic and would always have to take medications, withdrew on his own and then went on to a successful career as a clinical psychologist.