Thanks to everyone who responded to our October Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
October Quandary: I’m a new therapist and my client Sandra has been struggling with depression for many years. A psychiatrist has prescribed her an antidepressant, but she’s told me she doesn’t like the “idea” of meds and doesn’t take them regularly. In my opinion, the medication could help, but I’m not sure how best to explore the issue with her—or if I should bring it up at all. The problem is that the psychiatrist only checks in her briefly every couple of months, and doesn’t seem all that engaged in her treatment. What should I do?
1) Have a Practical, Down-to-Earth Conversation
If I was Sandra’s therapist, I might start with having an open discussion about why she fears medication that might prove helpful. Often, clients think that medication is addictive or harmful. Maybe she had a bad experience in the past with meds. Or maybe she thinks that taking pills means she can’t get better on her own. We can help clients who feel this way understand that depression isn’t like a common cold that will clear up in a couple of weeks, but more like pneumonia—long term.
I’d tell Sandra that some medications for depression can be phased in two weeks before treatment begins, and then phased out at the end of treatment, and that meds can do the “heavy lifting” for her, helping her sleep better, change negative habits, and return to doing the daily activities that gave her a sense of mastery and pleasure. Having a friendly, open discussion helps clients feel normal, and that’s especially important when clients’ ambivalence about taking meds is due to fears about being labeled or stigmatized. We therapists need to communicate that taking responsibility for our mental health is a good thing. Helping clients find resilience and hope is a big part of our work.
Gillian Solomon, HCPC UK accredited BABCP member and CBTSA member
2) Ask Questions That Go Deeper
Ambivalence about medication is an incredibly common issue. Sandra’s resistance to taking medication is a great opportunity to explore her underlying feelings and beliefs about her struggles. Sometimes, resistance to medication is rooted in stigma or a misunderstanding about mental illness. Is it possible that Sandra believes she should be able to “snap out of” her depression? Or that taking medication means she’s “weak”? These are questions I’d ask.
Resistance to medication can also be way of expressing that change is hard and getting better sometimes feels scary. I’d want to ask Sandra other questions like, “What does it mean to you to get better?” When someone has been living with depression for many years, it can become fused with their identity, and the thought of living without it can feel threatening, so I might ask, “Who might you be if depression no longer defined you?” If Sandra’s therapist helped her explore some of these questions, it might help clarify exactly what “not liking the idea of medication” means. In the end, Sandra might still decide against taking medication, but at least she’ll be coming from a place of clarity rather than reactivity.
Another important point: the lack of engagement from Sandra’s psychiatrist is obviously not helping her ambivalence. Again, there’s a clinical opportunity here. In this instance, it’s to help her realize what she needs and advocate for herself. Does she want to talk to her psychiatrist about her level of involvement in recovery? What would that look like? Or maybe she wants a new psychiatrist? Encouraging her to feel worthy of proper care can be an antidote to the messages depression often sends about being “not good enough.”
Ashley Anechiarico, LICSW
3) Sit in the Gray Area of Uncertainty
As an occupational therapist, I start with an exploration of what a client is motivated to do, rather than what they aren’t. What lights them up? My scope of practice is different from that of a psychotherapist, although the same principles apply: I work to understand a client’s everyday environment and explore it with them, engaging in what we call co-occupations. I’m on the lookout for glimmers of joy that are expressed in the client’s body, often in the absence of words. When clients show or tell me what they aren’t keen on, I celebrate because they’re expressing agency—the opposite of depression.
I’ve learned to look for solutions coming from the client’s body and being, rather than from what I think could help. If Sandra told me she wasn’t keen on taking medication, I’m not sure I’d want to immediately react by saying that it could help. Perhaps what she’s telling her therapist is that she wants a different kind of relationship with him or her than the one she has with her psychiatrist, one where she gets to have more agency. Could the quandary contain the answer? For me, the mark of great therapists is their ability to sit in the gray area of uncertainty—the sea of uncomfortable emotions—and get curious not only about the client, but about what might be blocking them from really hearing with all of their senses what the client is expressing.
Anne Clarkin, MSc in Occupational Therapy
4) Make Sure You Can Contact the Psychiatrist
First, it’s important to note that Sandra, like all clients, has autonomy and can choose whether or not to comply with treatment recommendations. If I was her therapist, I’d find it appropriate to have a specific discussion with Sandra about my concerns, keeping her autonomy in mind. Beyond this, I’d continue using the usual therapeutic interventions to treat Sandra’s depression.
One thing that sticks out, however, is the fact that Sandra’s psychiatrist isn’t engaged. I wouldn’t imagine there’s anything that precludes the therapist from contacting him or her to share that Sandra is hesitant to take medication, but I’d want to make sure I have a release form signed by the client that would help facilitate this contact. With such an arrangement, I could advise Sandra that I’m obligated to communicate her indifference about taking meds to her psychiatrist, even if she disagrees, due to liability concerns. To not do so and hold this information back would be irresponsible.
Sherwood Schrenk MA, LPC-MH, NCC, QMHP
5) Have the Client Keep a Daily Mood Log
If Sandra was my client, I’d try to convey an appreciation of her ambivalence and help her explore it. Specifically, what doesn’t she like about “the idea of meds”? Where did this idea come from? What might it mean for her if she was on antidepressants? Does she have any family members who’ve taken meds? Is there a part of her that likes the idea of medication? These are all questions I’d ask.
I’d also do a little psychoeducation about how antidepressants work, in the event she doesn’t know. I’d tell her that sometimes it can take weeks to find out if one is effective, and that irregular use may cause side effects that she wouldn’t normally experience if she took the medication regularly. I’d also ask Sandra to sign a release so that I could collaborate with her psychiatrist.
I often liken taking antidepressants to my first experience wearing glasses. My vision was good enough; I wasn’t walking into walls, people, or moving vehicles, but I had no idea how much better it could be, or of the “cost” of compromised vision, like eye strain and headaches. I tell clients that after the slightly uncomfortable adjustment period with glasses, I was amazed at how sharp and clear my vision was. It was a subtle but profound difference.
Finally, in an effort to increase Sandra’s awareness of how medication might help, and help her make an informed decision, I might suggest she keep a daily mood log. Since often those close to us are better judges of our mood, I’d also invite her to consider getting feedback from someone close to her.
In the end, I believe it’s the client’s choice to take medication or not. My role is to help them access as many parts of themselves as they’ll need to make an informed, final decision.
Tish Miller, LCSW
We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.
November Quandary: My client sees his perfectionism as an advantage, a positive in his life—but I can see how it ramps up his anxiety, exacerbates his sense of shame, and keeps in him living a very rigid life. He brushes me off every time I’ve brought up examples of this. Last time I said something about it, he grew visibly angry and told me to I was unfairly judging him. How do I point this out to him in a way he might accept? Or do I keep this observation to myself?
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