Beyond Chemistry

The clients referred to me for psychopharmacology consultation often seem to feel a certain relief once they’ve let me know that, when it comes to meds, they’ve tried “everything” and so far “nothing” has worked. After we’ve run down the list of what they’ve taken and how it’s failed to make any difference in their mood or state of agitation or ability to concentrate, they sit back as if to say, “Now it’s your turn.” In fact, this is the kind of ritual that they’re used to: once they’ve told the unhappy tale of their symptoms and the frustrating failure of drugs to do much good, what else is there for them to say?

My answer? Plenty. Here’s where I break from their expected ritual and explain that I work a bit differently than most prescribers. I believe that the chemical effect of pills is only part of their impact. The other part may seem a little weird, I warn clients, but it has to do with their thoughts, feelings, and expectations around the medications they take—in other words, their relationship with their drugs. I emphasize that for some people, more may be riding on this relationship, the source of so much hope and potential disappointment, than on any other in their life. Understandably, this notion gives many people pause; they’re not used to considering the chemical agents in their daily lives to be like a living, breathing psychological presence in their minds, whether conscious or not.

But then I say something that’s often even more startling to them: I don’t prescribe medications to a person unless all the inner parts of that person are on board with the decision to take them. If they have doubts or fears or any sort of ambivalence about meds and their possible impact, I tell them that we need to focus on the root of these feelings, not just go through the motions of a standard med check. With some clients, I can see their eyes narrow as they wonder if they’ve come to see an actual psychiatrist. Thus, to make sure they get what I’m saying, I often give them the example of the different parts of my own inner world that speak up when I go to see my internist for my annual physical exam. Entering his office, the sunny optimist in me hopes my doctor will soon be slapping me on the back to congratulate me: “Keep up the good work, Frank. You’re a pillar of health.” But a more skittish part of me dreads getting my blood drawn and awaits the unsettling news that my cholesterol blood level is suddenly soaring. And, of course, there’s always the part of me that feels ridiculous sitting in that cold exam room in an embarrassingly flimsy paper gown, waiting for the all-powerful doctor to examine me.

After hearing this, most of my clients begin to understand what I’m talking about. I then suggest that we try to get to know the different thoughts and feelings they might be having about taking a medication for anxiety, for instance. This invitation to look at their relationship with their medications is rarely, if ever, part of a dialogue with a prescriber, but it’s often not even brought up by therapists, the people who should be inquiring most about the important relationships in their clients’ lives. Why this huge chasm between psychology and psychopharmacology?

Typically, I find that therapists are reluctant to get involved in the prescribing process and feel intimidated by the medical and scientific aspects of meds, viewing the subject as beyond their scope of knowledge and professional expertise. Others reject medications as a legitimate form of treatment, turned off by the excesses of Big Pharma and disdainful of the idea of a quick fix for the complex psychological issues a client needs to sort out in treatment. Others may feel a sense of failure at the idea that something beyond the treatment they’ve been offering is necessary. For whatever reason, once they’ve referred someone for a medication consultation, many therapists tend to compartmentalize their relationship with that client and tune out to the medical aspects of their care, showing only a perfunctory interest in the ups and downs of their reactions to the medications they may be taking.

On the other side, psychiatrists and primary-care physicians often have just 15 minutes with patients and feel the constant pressure to do something to justify insurance reimbursement for the office visit or for another day in the hospital. For want of other alternatives, the prescriber may just add another medication to the mix, without having the time to consider the psychological impact. Although a therapist typically has a better sense of the patient’s day-to-day state of functioning, communication between prescriber and therapist is often minimal at best.

How can we bridge this gap? One step is for therapists to understand that bringing the same internal curiosity and focus to psychopharmacology with clients that they would when addressing any other clinical issue in therapy encourages compliance, increases the effectiveness of meds, and deepens and strengthens the treatment. Another step is for prescribers to acknowledge that unresolved psychological issues around people’s strong, largely unacknowledged feelings toward the drugs they’re prescribed regularly interfere with the physiological impact of those drugs.

Between Two Worlds

As both a prescriber and a therapist, I do much of my work using the Internal Family Systems (IFS) model of therapy, in which I help my clients clarify the relationships between themselves and their internal parts—the various aspects of them that may hold entirely different emotional positions about the issues in their lives, including taking psychiatric medications. Engaging different parts within the client’s own psyche about meds—their usefulness, desirability, side effects, unintended consequences, and so on—helps them tune into their own mental/physical system in a deeper, more focused way.

Jane, for example, had been referred to me by her primary therapist for increasing depression. After our initial visit, she chose to take Citalopram, a selective serotonin reuptake inhibitor (SSRI). But during her follow-up visits, she kept telling me, “The medication isn’t working.” Curious about what might be interfering with the drug’s effectiveness, I asked her to take a moment to reflect—“go inside”—and see what thoughts or feelings came up about her medications.

Jane said, “I really want to feel better, I’m tired of being depressed.”

“Any other thoughts or feelings?” I asked.

She paused for a moment. “Well, I guess there’s a part of me that never really liked the idea of taking medications in the first place,” she said slowly.

I asked her to focus on that part of her for a moment longer to see if we could learn more about it. “Really take some time with this part. See if you can be curious and open to hearing about it,” I instructed.

She looked up at me with surprise and said, “I think there’s a part of me that honestly doesn’t want to get better.” She then began to talk about the times in her life when feeling good had led to disappointment. The excitement and hope she’d felt with each new romantic relationship, for example, had eventually ended in a breakup and left her feeling rejected, hurt, and even suicidal at times.

“Jane, it totally makes sense to me that a part of you would be reluctant to feel better and even to take medications,” I said. “In my clinical experience, parts that haven’t been heard can block medication responses.” I then asked her if she’d be willing to explore this issue further with her therapist to see what else might come up, and she agreed.

During our next session, Jane told me that the exploration with her therapist had led her to talk about being date-raped in college and the suicidal feelings she’d struggled with afterward, something she’d previously not disclosed. Now, she realized, a fearful part of her inner self would lead her to pull back whenever she’d start to get close to somebody. Together, we discussed how this part was trying to protect her from getting hurt again by blocking the medications—which made sense to her. At her next follow-up appointment, she announced she was feeling much better: the medications seemed to be working more effectively, even with no change in dosage.

Often, I’ve found that simply acknowledging and thereby validating these types of feelings can be enough to alter a physiological response to medications. Indeed, I invite any skeptics to consider the placebo effect. If people can get positive responses from a medication even when they only think they’re taking it, why can’t a part of them block a medication response too? Of course, pills don’t only work by placebo effect, but unless a therapist thoroughly investigates the complex issues a client may have around taking a medication, their usefulness may be severely compromised. After all, it simply makes sense that meds are more effective when clients are in touch with all their thoughts and feelings about them and able to negotiate and collaborate with their different parts to make sure they’re in agreement about whether even to take meds. Doing this work up front, which I think more effectively happens in the therapist’s office, can eliminate a lot of unnecessary failed trials with drugs, as well as unwarranted side effects.

Symptoms vs. Feelings

Another important step in working with clients around medications is to help them differentiate symptoms from feelings. Many people tell me they want to take a medication, but when I ask them how they think a medication can be helpful, they say something like, “I don’t want to feel sad all the time,” or “I’m tired of being so lonely,” or “I want to be less angry with my kids.” I then explain that these are feelings, and medications are intended to treat symptoms, not feelings.

Symptoms include panic, depression, inability to concentrate, irritability, and insomnia, whereas feelings include sadness, loneliness, anger, and distress. (Anxiety can be a symptom or a feeling and needs to be differentiated as such.) Generally, symptoms are biologically based, and feelings are psychologically mediated. Also, symptoms tend to be more global—affecting the whole system—in contrast to feelings, which tend to encompass a specific part of the inner self experiencing a specific emotion for a particular reason.

Of course, symptoms frequently cause uncomfortable feelings, and psychological issues often trigger biological responses. The task at hand, then, is to determine how much of a client’s experience is psychological and needs to be worked out in therapy, and how much is biological and might be appropriately addressed with medication. Usually, it’s not one or the other, but a combination of both. When asked, however, clients can often differentiate how much of each is at play. Sue, for instance, a college freshman who came to see me because she was struggling in school, was able to say after checking inside, “I think 80 percent of my struggling is due to being away from home and missing my family, but 20 percent feels like depression.” Clearly, Sue identified her feelings in missing her family, and her symptoms in describing depression.

Sometimes, the underlying issue is biological, as became evident with Tom, a gay client I’d been seeing in therapy for six years. Although his long-term relationship with his boyfriend had recently ended, he’d been making good progress working through his feelings about the breakup and figuring out what he wanted for his future. Then, therapy seemed to stop in its tracks: it felt flat, undirected, and void of the sense of purpose and flow that characterizes good, forward-moving work. There was a pervasive deadening, a lack of life and emotion, in both his therapy and his personal life. What had happened? Was this a psychological slowdown, or something else?

As I frequently do with clients during difficult moments, I asked Tom to stop and go inside himself for a moment, to see if he could get a deeper felt sense of his own experience. When I first ask this of clients, some pause for a few seconds, then say crisply, “Nothing comes up at all.” So it’s important to get them to slow down, deepen their breathing, and gradually shift into a more relaxed, receptive state. With Tom, I told him that I would time him for 30 seconds to a minute so he could really begin to listen deeply for some quiet voice inside. When he finally looked up, Tom had a puzzled look on his face.

“Quicksand,” he said. “It’s as if there’s quicksand between me and my feelings.”

“Can you tell me more about this?” I asked.

“It’s really thick. I can’t penetrate it at all. I can’t get a sense of what’s going on inside myself at all,” he answered.

“Check in again,” I prompted. “See if this is happening across the board, or if it feels like it’s only affecting certain parts of you.”

Tom went inside again and with a newfound certainty in his voice said, “Yeah, it’s happening everywhere, in all areas of my life, inside and out.”

This was concrete information we could work with. If Tom had said, “There’s just this part of me that’s still really depressed about the relationship, but the rest of me feels okay,” I’d have considered his problem to be more a psychological response related to his recent loss. But this pervasive quicksand sensation suggested a biological state of numbness or shutdown—a kind of global depression, which had numbed his emotional responsiveness across the board and was preventing him from fully engaging with any part of his life.

When I asked Tom if he’d like some help from medications to get him get out of this quicksand, he answered immediately and with more life than I’d seen him exhibit in a while. “Oh, yes!” he exclaimed. I then encouraged him to go inside again and see if his internal world of parts also wanted help, and if any aspect of him was opposed to the idea of taking a medication for any reason at all. He closed his eyes, concentrated, and then said, “No, they all want help. Everybody feels just awful about this!”

At that point, I felt confident not only that his feeling of distance between himself and the world was a mind–body enveloping, biologically based condition, but also that his entire system was in agreement about taking medication. Afterward, we went on to discuss the options available to him, along with the range of possible side effects. Tom chose to take the SSRI Escitalopram because of its fast-acting response. Within two weeks of starting the medication, he reported feeling better, and his work in therapy got back on track. His progress was a clear example of how medications work best as therapy enhancers, not replacers, helping the work progress when overwhelming life situations cause strong biological reactions that might derail it.

Educating, Not Deciding

Just as unrecognized biological issues can undermine psychotherapy, unacknowledged psychological issues can negatively affect biology and ultimately the effect of medications and the therapeutic processes. Take Janet, for example, a 26-year-old woman who had a trauma history that included being raised in a violent family and being subjected to repeated sexual abuse by her older brother. In addition to seeing me for regular therapy sessions, she’d been taking an SSRI to help manage her depression. Over the course of several years, we’d been doing good work, and she’d made steady progress. She’d begun to feel so much better that she asked to decrease our sessions from twice a week to only once. Pleased with her improvement, I agreed. We had what seemed like one more important piece of work to do on a particularly traumatic event in her life, but we set up a plan for working on it after her summer vacation.

Then everything quickly started falling apart. Janet began missing sessions, quit paying her bill, and rapidly put on a considerable amount of weight. She became walled off and inaccessible in a way I hadn’t seen before. So I invited her to go inside to see if she could get a sense of what was happening. After about a minute, she burst into tears.

“I can’t do this,” she sobbed. “It’s too painful, just too scary. I’m afraid, terrified of doing this work. I’m so full of shame, and a part of me is worried that you’re going to hate me for giving up.”

I assured her that I didn’t hate her and, in fact, was glad she’d let me know how she was feeling. She went on to tell me that since we’d decided to focus on this last critical issue, her life had seemed to implode. Her medication had stopped working. She couldn’t concentrate, had trouble sleeping, and had started nighttime eating again, resulting in her weight gain. She’d developed all the symptoms of a major depression while still on an SSRI, which had been working fine until then.

I told her it made perfect sense that she didn’t want to move forward into this frightening terrain. When I asked her to check internally to see what was going on with her parts and the meds, she said, “I actually think it’s two different parts. Both are young. One blocked the meds because it didn’t want us to ‘go there.’ It just wanted to have a good summer.” She went on to explain that the other part blocked the therapy because it felt so much shame and was afraid of my response. Once she connected internally with both parts of herself, it became possible to come up with a therapeutic compromise that addressed each part’s concern. We agreed that she’d come once a week during the summer with no change in her meds, and she’d address the particularly traumatic event in the fall, at which point we’d reevaluate the medication dose and start up twice-a-week sessions again.

My approach with medications rests on one basic principle: I educate clients about meds, but they must decide whether or not to take them. In other words, although I can explain which are most appropriate and their possible side effects, it’s up to my clients to decide within themselves what they want to do—with the full awareness of all their thoughts and feelings about taking the medication. I remind clients that they’re not taking the meds for me; “compliance” isn’t the issue. As I know from experience, when clients leave therapy and view taking medication as “something the doctor told me to do,” the power differential is heightened and the process of recovery often backfires. Even if medication is routinely taken, this attitude can dampen its effects or render it useless.

Too often, when medication is prescribed, therapists assume that the job is done and therapy can proceed. In this way, it’s as if the client had just been vaccinated and doesn’t have to worry about the onset of untoward symptoms. The reality, however, is that beginning meds is just the first step in the ongoing work of psychopharmacology, which also involves helping clients stay attuned to their reactions and assessing the effects of medications so that they’re better able to express what’s going on with them during their follow-up appointments with their prescriber. Helping clients regularly explore their inner experience with medication—their shifting feelings about whether they’re helping or not, whether the side effects are worth it, and whether they still think taking medication at all is an “acceptable” option—should be a regular part of the therapeutic encounter.

Activating the Prescriber’s Parts

Clients are certainly not the only ones who have reactions and feelings about taking medications. When clients come in desperately wanting me to give them something to take away their pain, I can also get emotionally triggered or feel as if I’ve failed when a medication doesn’t work and the client gets frustrated with me. Sure, my inner helper likes it when my clients feel better, but like a lot of therapists, I often struggle with suggesting a medication trial. I worry that I’m inadequate as a therapist and have to resort to meds, or that I’m suggesting a medication too early because I can’t tolerate the intensity of my client’s pain. At times, I’ve agreed too readily with a client’s request for medications for all sorts of reasons that aren’t genuinely therapeutic or in the client’s best interests.

Dan, whom I was seeing for both therapy and medication management, came to our session asking for an antidepressant for what he described as increasing depression over the previous month. The progress we’d made over a few years of therapy was reassuring, and I’d come to look forward to seeing his name on my schedule each week. He had been on medication in the past with good success, so without much hesitation or taking the time to do my own inner 30-second check-in, I quickly agreed, asking him if he wanted to go back on the antidepressant Sertraline, since it had worked before, or if he wanted to try something different. After he decided to go back on Sertraline, I gave him a prescription with instructions on how to increase the dose. Dan left feeling hopeful, but over the next several weeks, he came into sessions complaining of being numb and disconnected. Was the medication not working, did he need a higher dose, or was something else going on? That’s when I got curious.

“Dan, can you check inside to see if you have any feelings or reactions to being on this medication?” I asked.

Used to this sort of question by now, he took a few moments and then said, “All I feel is numb. I feel nothing but numbness—I’ve got no feelings and no thoughts.” Knowing that too much of an SSRI can sometimes cause this sensation, I asked him to check inside again to see if his “gut” told him to increase or stop the medication. He was somewhat surprised by the answer that welled up. “I think it makes more sense to stop the medication,” he said. “I’ve actually been feeling worse ever since I started it.”

It was at that moment that I realized I’d initially reacted too quickly to Dan’s request. I wasn’t sufficiently curious about why he wanted to begin retaking medication, and I didn’t take the time to explore what was going on for him at the time. Instead, the parts of me that liked and wanted to be liked by Dan had colluded with the parts of him that had wanted to take medication. In exploring what had precipitated his desire to start taking meds again, he told me that he’d just learned that his sister’s cancer had come back and that the prognosis was grim. What he’d misinterpreted as depression was really an attempt to numb out and avoid feelings of fear and grief. It turned out that we were medicating a psychologically protective response in him, not a biologically based depression. Dan’s parts that didn’t want to feel and my parts that wanted to be liked got in the way of effective treatment, leading to my prescribing an unwarranted medication.

Bridging the Gap

Too often therapists don’t talk about meds with either clients or prescribers because they fear treading into areas that are beyond their field of expertise. Somehow, they believe having an intelligent conversation about psychopharmacology presupposes a deep grounding in the minutiae of neurotransmitter effects or other heavy-duty neurobiological subject matter. Not at all! Rather, an important part of therapy with clients taking medications is regularly asking them about their responses—both mind and body—to the full impact of medication, before, during, and after the time they’re taking them. Ongoing discussion about clients’ relationships with their meds should be as integral to therapy as other important dimensions of their lives, such as their family situation, troubles with work, personal triumphs or failings, or any other issues that generate intense feelings and shape their day-to-day existence.

Asking and listening are essential to making sure that psychotherapy supports the work of psychopharmacology. Asking means inquiring about clients’ thoughts and feelings around taking medications, and listening means helping them check in with their internal reactions, exploring any conflicts that arise. For the therapist, there’s also listening to your own reactions and feelings about medications. All are part of the all-too-often shadowy world that lies at the interface of psychotherapy and psychopharmacology. By acknowledging this territory, as with other charged issues, psychotherapists can help clients give voice to their complex emotional responses to taking meds, even if they feel the neuroscience and biochemistry of medication lie beyond their expertise. After all, even without a medical degree, therapists know quite a bit about how to handle a troubled relationship when they see one.

Illustration © Ralph Butler