Therapy vs Drugs - October 26, 2007

Dr. Rob,

I've been seeing a therapist for about six months for relationship problems. Sometimes I think I should be on meds but when I ask her, she says "it's up to you." What the fuck?! I'm paying for her help and I never get a straight answer. I'm to the point that I want to stick an ice pick in her spleen. When should I be seeing a therapist, and when should I be taking medication?

Dave

Dave,

We all deserve a spleen, so I'm glad you are seeking a second opinion before taking action. Try not to look at this as an "either or" issue. The reality is that, for most psychological problems, combining both approaches can work extremely well. This position is supported by several research studies. I've worked with many clients who are adamant against medication, believing that talk therapy is a panacea, and that Western medicine has no place in mental health. Unfortunately this causes many people to suffer needlessly:

Client: You think I should take drugs? You suck Dobrenski! Freud said that if we work through the transference reaction, my delusions should subside.

Dr. Dobrenski: You have to understand that while Freud was a pioneer in the field, he was also shockingly ignorant in many ways, and thought that one method of treatment would work for everyone. He also didn't have access to the resources we have now, and the anti-psychotics that the psychiatrist prescribed for you have done amazing things for many people with Schizophrenia. And I don't suck.

Client: If the drugs are so awesome, why don't you take them?!

Dr. Dobrenski: If I had Schizophrenia, I would.

Client: Really?

Dr. Dobrenski: Of course. I wouldn't encourage you to do something if I wouldn't do it myself.

Client: Oh. Well, let's hope you do get Schizophrenia so that we can be pill buddies.

At the same time, it's naïve to think that a pill will resolve all problems. Example:

Client: Who do I have to fuck around here to get some good meds?

Dr. Dobrenski: A psychiatrist. I mean, you don't have to, you know, have relations per se. In fact, that's just a bad idea altogether. Just go for a visit and tell him what is wrong. You're not describing to me any serious symptoms, however. You just seem to hate everyone and everything you come into contact with.

Client: But won't a pill take all that away?

Dr. Dobrenski: A pill that takes away hatred? No.

Client: Oh. So then maybe I should just fuck you instead, since you're the therapist.

Dr. Dobrenski: That probably won't make you less hateful either.

As a Psychologist in New York State, I do not prescribe medication, so people who come to me are often looking for non-medical approaches to psychological problems. If and when the topic of medication does arise, I tell my clients to think of their difficulties in terms of severity and duration. Most practitioners agree that when a problem is both debilitating and has not resolved in a reasonable time frame, a medication evaluation is in order. It's also appropriate when a client isn't responding to talk therapy alone. For example, consider a client whose anxiety is causing her to not sleep, lose 15 pounds, and make it impossible for her to focus on her schoolwork. If this has been going on for three months, causing her grades to suffer, and she hasn't seen any improvement from psychotherapy, it's important she see a medical expert and consider taking medicine.

Therapist Rule: Encourage clients to speak to a medical professional if they have given even the slightest thought to medication. A doctor's visit is simply a consultation, and when you are dealing with one's mental health, another professional opinion only helps. Information is power.

The good news is that there are a number of common problems that can be treated by therapy alone:

1) Panic Disorder: If you've ever had a panic attack, you know the symptoms: extreme anxiety, often accompanied by hyperventilation, sweating, and a feeling that your heart is pounding out of your chest. Unless you have Mitral Valve Prolapse or some other unusual heart difficulty, the odds strongly suggest that this is a psychological condition. This is good news, as some studies report a therapy success rate of over 90%.

2) Generalized Anxiety Disorder (GAD): This typically involves a sort of "free floating" anxiety, sometimes about a variety of life stressors (e.g., finances, relationships, school), or simply a nasty emotional feeling of being jittery and nervous with no obvious cause. Cognitive therapy and other approaches can help with this problem.

3) Mild to moderate depression: Depression is characterized by distorted thinking about oneself, the world, and the future. Therapy helps to correct these faulty ways of perceiving the world, which tends to result in a remittance of symptoms (e.g., loss of pleasure, poor sleep, poor eating habits, low self-esteem). When depression becomes severe, medication usually factors into the discussion of treatment options.

4) Adjustment difficulties: These are basically what they sound like. Any change in functioning brought about by an outside stressor (e.g., a break-up, moving to another city, starting or leaving a job) can be diagnosed as an Adjustment Disorder. Very often, treatment isn't even necessary, as the stressor will either cease to exist or the person will adjust to the new situation. However, people who tend to discuss and process the world around them and their reactions to it, either in therapy or with their friends and family, tend to adjust more quickly and comprehensively. These people generally report greater overall life satisfaction.

In other words, if you are grappling with any of these issues, seeing a therapist alone, without any medication might be enough. More severe problems, such as Bipolar Disorder, any psychotic disorder (e.g., Schizophrenia), and severe Obsessive-Compulsive Disorder almost always require at least a medical consult to see if medication is needed in the treatment.

Feel free to post if you have thoughts regarding certain psychological problems and your experience with therapy and/or medication. Please keep all stabbings to yourself.

Posted by Rob Dobrenski at 12:13 AM

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Comments

I don't know if this should be an e-mail or not, but I have a question. I got a female friend who claims to have Schizophernia, OCD, ADHD, Bipolar Disorder and, if you ask me, nymphomanic. I was wondering if you could have all these disorders and live.... I think that she's bullshiting, 'cause my brain would explode with all those disorders. Little bullshiting help?

Posted by: Captain Canada at October 26, 2007 03:37 AM

You mentioned some symptoms of Panic Disorder. I have Panic Disorder but it affects me differently. Instead of feeling as though I am having a heart attack (as with most cases) my throat feels as though it is being constricted and I feel unable to breathe. Is there any different cognitive responses that are responsible?

ShrinkTalk Note: JB, leave an email and I'll send you some info.

ShrinkTalk Note 2: JB, I tried to respond to your email, but it wouldn't accept it...

Posted by: JB at October 26, 2007 04:20 AM

Rob,

Great post; thanks for the insight. I had a rough year recently - moved almost five times, dropped out of two different grad school programs, changed jobs five times. I'm in that sort of post-college torpor that seems to be affecting a lot of my friends. Last winter I decided to reconnect with my old shrink and he, after two visits, recommended getting on prozac. I was reluctant at first, as I have been on and gotten off antidepressants before and loathed the withdrawal, but things were bad (I wasn't suicidal per se, but I did have suicidal ideation. In other words, I wasn't planning it, but I thought about it sometimes), so I gave it a shot. I took the lowest recommended dose - 20mg - and I felt an immediate, powerful change. In fact, I was almost euphoric the first two days. Then I adjusted and all was normal. Eventually, after a couple months, I tapered down to 5mg per day to negate the slight sexual side-effect, but I still got the anti-D benefits. Finally, a month ago, I got off them completely. The whole experience of 'getting better' was complex. It involved meds, talking a LOT and giving my problems time to heal. Now, things aren't perfect, but I feel like I can handle them. Thanks again for the post - this is an important blog - and good luck to all other strugglers.

Posted by: Drew at October 26, 2007 09:27 AM

I suffered from anxiety and depression, and the problem was that I couldn't get over being anxious or depressed long enough to be able to see what I was doing with my life.

The medication took away a lot of the reinforcing factors of the anxiety and depression. Before, I would be upset about something, start to feel very depressed, and then use that feeling to seek out other upsetting or depressing things.

The medication I took (I won't say the name because all meds work differently for different people, I was on my third med before it started to work for me well) really helped to limit my emotional range, so that I could approach my problems cognitively and resolve them without the constant roller coaster of reinforcing emotions. Without the meds, the therapy wasn't working, and without the therapy the meds would have just left me a zombie.

And the meds were a temporary tool, in addition to dampening my anger/depression, it made me feel less happiness and even what I'd call passion for my fiancee. But once I had the tools to manage my feelings, I slowly came off the meds and have been successful ever since. For me, they wouldn't have been great as a long term tool, because of what they took away, but as a tool to increase the effect of my therapy, the medication was a lifesaver.

Posted by: Surfrock66 at October 26, 2007 09:34 AM

Another gooder. And yes I know that's not really a word.

I love how Client A contradicted his own intelligence by saying "you suck" and quoting Freud in the same statement. I instantly pictured Leo of That 70s Show when I read that.

Client B made me wish there was hope. An anti-hatred pill? The world would be a wonderful place! Although I wouldn't want to take it myself. I quite enjoy hating stupid people. Okay I take that back. The world would be boring without hate. And the idea of people holding hands and singing kumbaya (sp?) truly scares the poo out of me.

Posted by: Amber at October 26, 2007 10:55 AM

Whenever a friend comes to me with any sort of questions on these issues, I don't give them specific advice (in big part because I am, afterall, still just a student.)

But I've found that drawing out a web-node model usually helps them visualize the whole process a lot better and helps them understand it's not an either/or proposition.

(IE - Your Brain Chemistry Affects your behavior, your behavior affects your brain chemistry, , those both affect your thoughts and attitudes, your thoughts affect those all, etc etc. And depending on the specific problem put a few more points/subpoints in, like with depression I include outlook, attribution, exercise level as subpoints.)

Then I just tell them it's up to them (and their therapist) to decide which combination of angles is the best way to get things back on track. It's the gift of control by knowing there are options, and even slight tweaks in a few areas can bring big changes. From there, they can decide (with consultation) if medication is one of those angles they want (or need) to try.

If I were ever inclined to go the therapy route, I'd draw that diagram as soon as the person recognized they had an issue they wanted to treat.

Posted by: Sean at October 26, 2007 01:29 PM

Captain Canada,

i am pretty sure that if you are schizophrenic, you cannot be diagnosed as bipolar. there is an illness called schizoaffective disorder, and to simplify it greatly, it's kind of a combination of the two. again i'm not sure, i'm not a psychologist (yet...), but some categories in the DSM can only be diagnosed in the absence of the other. Bipolar and schizophrenia could, in some cases, look like they overlap therefore making diagnosis hard - so maybe she experienced something like this and became confused. As for the OCD, ADHD, often a mood disorder is co-morbid (occur with) an anxiety disorder of some sort...

but what i would concern myself with is why is your friend telling you that she has all of these things, what was the context?

Posted by: Jackie at October 26, 2007 03:28 PM

I sent you an email on this subject lol. I think this is my favorite post. Because some people really do need medication. But other times some therapists try to just pawn medicine off on you without even getting to know, as I had told you had happened to me. And the medicine they gave me made me feel worse. So I'm really glad that you have some guide lines to help people out.

Posted by: Kiddo at October 27, 2007 12:39 AM