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, 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.
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.
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 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.
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.
Often, I’ve found that simply acknowledging and thereby validating these types of feelings can be enough to alter a physiological response to medications. 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.
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.
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. Even without a medical degree, therapists know quite a bit about how to handle a troubled relationship when they see one.
This blog is excerpted from “Beyond Chemistry." Want to read more articles like this? Subscribe to Psychotherapy Networker Today!
internal family systems
mind and body