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 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.

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.

JulyAugust 2014 Issue Available Now
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