by Francis McGivern
Although medication is sometimes necessary, it is rarely sufficient; a therapeutic relationship is always necessary and sometimes sufficient
Engaging in therapeutic work with clients for over ten years now has afforded me an opportunity to witness the journey that each client has had with psychotropic medication. Some have welcomed the prescription of an antidepressant, anxiolytic, tranquillizer, mood stabilizer, or anti-psychotic with open arms perceiving it as a kind of panacea for their ‘psyche-ache’, delivered by a trusted and highly qualified general practitioner or psychiatrist that has brought almost instantaneous relief within days, hours, or even minutes. Others have received their prescription with great weariness, viewing it in terms of knowingly adding a pollutant to their body thereby challenging their long-held image of themselves as ‘not being one for taking tablets’. Others still, whilst having an established relationship with medication to address solely physical illness, perceive themselves to be ‘weak’, to have ‘given in’, or to have failed in some way if they begin a course of medication to address solely psychological issues that they can no longer abide on a daily basis due to their disabling impact emotionally, and socially. Experience has taught me that one thing that unites a significant majority of these individuals is the ambiguous relationship they have with psychopharmacology. Whether or not they welcome this medication, few if any appear to even vaguely understand the drug’s intended action.
As a trainee counselling psychologist, the emphasis of our training was less about clinical assessment and measurement of symptoms and more about establishing the ‘helping relationship’ and witnessing the client’s story. On reflection, however, it would be fair to say that the subtle presence of psychometric tools such as the Beck Anxiety or Depression Inventory and classes on psychobiology, pharmacology, and diagnostic criteria lay the foundations for a ‘way of thinking’ that inevitably encompassed the medical model. In fact, when our student body was informed that the future of psychology could possibly entail the ability to prescribe psychotropic medication, it was received incredibly favourably, presumably without having fully comprehended the implications of such a development for client work. Grandin and Blackmore (2006) conducted an exploratory survey of clinical psychology doctoral students’ level of interest in achieving prescriptive authority and found that the vast majority of students surveyed would be interested in further training, so much so that they would be willing to add six to twelve months and three to four graduate courses to their training. Human beings, almost by definition, function better in a structured, routined, quantifiable environment. An axiom I regularly offer clients, ‘a black or white thinker in a shades of gray world is setting himself up for difficulties’, reflects the degree to which vulnerable individuals find uncertainty and confusion taxing. Modern medicine and psychiatry, however, have offered the vulnerable patient a haven from this uncertainty. Diagnosis, labelling, and medication imply that human experience can be somehow quantified. Current literature is increasingly claiming the view of mental illness as a disease requiring large-scale usage of psychoactive drugs, to be an illusion. Keith (2003) describes psychiatric diagnosis and prescription as the ‘quantification illusion’ as it reduces the human being and all his complexities into a singularly measurable disorder of genes or chemistry. It also serves to maintain the long-established doctor-patient dynamic in which the professional is seen to provide a solution and the patient experiences a relief from ambiguity.
Medications provide an apparent solution to the inevitable distress that comes from the deep loneliness of being human, from the struggles with loving; they provide protection against the ever-present, almost-invisible haunt of madness.
Indeed, Ivor Browne recently (2010) described the phenomenon as “the great illusion” in which science has concerned itself with identifying the parts of an individual that may be causing disturbance within the system, consequently overlooking the person as a whole. The origins of this methodology, Browne argues, can be traced as far back as Galileo who posited that in order for scientific progress to take place, one must only pay attention to things that can be measured. Galileo may not have meant to apply this thesis to complex living beings such as ourselves, who Browne believes have the requisite skills to take control of our behaviour and biochemistry, or at least can learn to do so. Interestingly, in my own psychotherapy practice when a session or two of therapy is dedicated entirely to exploring the personal responsibility a client can take in influencing her mental wellbeing, and psychoeducation is provided on the interplay between thoughts, behaviours, and feelings, I have found a marked improvement in the client’s reported symptom presentation whether or not they are on a course of psychoactive medication. Clients have very regularly communicated to me their assumption that the only significant agent of change was their general practitioner or myself as a therapist, thereby minimising the potential within themselves to effect change. One problem, therefore, appears to be the message that accompanies the prescribed medication. GPs regularly advise their patients that they will need to remain on the drug for anywhere between six to twenty-four months in order for it to have any ‘lasting’ effect. Patients can consequently interpret this to mean that they have very little, if any, agency in effecting improvement in their symptomatology and thus, it is a case of ‘playing the waiting game’. Frankly, I believe this to be grossly irresponsible of the medical profession and it further leaves other professionals such as therapists in the difficult position of attempting to alleviate some of the individual’s concerns whilst trying simultaneously not to contradict the information their GP has given them. There are of course occasions in which psychopharmacology can be the best way to facilitate engagement in therapy for an individual who is anxious or depressed. However, what will likely dictate the long- term mental health of an individual is their perception about whether the medication has been prescribed to them as a treatment or as a means of developing a healthy therapeutic relationship that they will be in part responsible for.
Having engaged in protracted dialogue with both clients and medical professionals about the mechanism of action of particular drugs, their varying side-effects, tolerance, dependence, and optimal prescription length, my sense is that there is far less known about the physiological impact and efficacy of psychopharmacology amongst the medical profession than they would care to admit or have their patients uncover. As regards the efficacy of certain medications it would appear that doctors can rely only upon the results of clinical trials performed by the pharmaceutical industry. Furthermore, GPs tend to prescribe particular medications as a result of exposure to them by medical representatives. Most progressive family practitioners in response to promoted empirical data tend to advocate combination therapy, that is, psychoactive drugs concurrently with psychotherapy. Duncan et al. (2003) highlight outstanding problems even with this progressive stance. They purport that there is diminutive scientific evidence in support of the assertion that:
1. Mental illness is a response to a biochemical imbalance in the brain; 2. Psychopharmacology has shown a better response than psychotherapy, even for severe mental illness; and 3. Superior outcomes occur when psychoactive drugs are prescribed in combination to psychotherapy.
In fact, the aforementioned authors cite a review of ninety-one studies from as far back as 1974 which concluded that tricyclic antidepressants were no more effective than a sugar pill in almost one third of the reports published. It is of interest that the ‘placebo responders’ (those showing rapid benefits from the sugar pill) were eliminated from these studies but were also likely to have been grossly underrepresented in this review, consequently producing biased results in favour of the antidepressant. They argue that not much has changed in almost forty years other than the pharmaceutical industry achieving a greater foothold within the medical infrastructure. In 2004 alone, for example, $4.5 billion was spent by pharmaceutical companies in the United States on direct-to-consumer television advertising following a relaxation by the Food and Drug Administration for the requirement to detail all risk information pertaining to medications. What is perhaps even more alarming is that changes in the law have now empowered drug companies to market ‘diseases’ or ‘disorders’ rather than pharmaceuticals alone, in the guise of ‘educational’ advertisements (Conrad, 2007). A case in point is a well-known SSRI which was approved for market in 1996, a time when Prozac and several other antidepressant medications had the market sewn up. The manufacturer consequently gained approval to‘re-launch’ it as a drug specialising in the treatment of anxiety. Panic disorder (PD) and obsessive compulsive disorder (OCD) were targeted at first and later social anxiety disorder (SAD) and generalised anxiety disorder (GAD). What is unsettling about this event is the company’s direct targeting of potentially vulnerable individuals who were being persuaded that their tendency toward shyness or worry was ‘disordered’ and in need of immediate pharmaceutical intervention. It, therefore, begs the question, how frequently do drug companies knowingly manipulate the function of medication in order to fit market trends, that is, the latest mental illness in fashion? It appears that mental illness serves a positive function for the many purveyors of psychotropic medication, so much so, that it is no longer a condition but a ‘strategy’ (Szasz, 2007).
It surely is bad medicine to alter the brains of those who suffer from the usual problems of living… The more pills we dispense for normal distress, the more we… potentially undermine personal responsibility, and perhaps even threaten the sort of diversity necessary for a flourishing democracy.
Neuroscientist Valenstein (1998) has remarked that the existing evidence in support of a biochemical imbalance explanation for mental illness is flawed and undeveloped. What’s more, he turns the intended action of psychotropic medication on its head, arguing that it in fact creates rather than remedies chemical imbalances due to the brain’s level of plasticity and speedy adjustment to pharmacological intervention.
In my practice as a counselling psychologist I meet with a significant number of individuals who have consulted with their GP and been prescribed a psychoactive drug prior to our first session. On exploration of their presenting issue(s) many clients will describe a collection of symptoms such as feeling overwhelmed, on edge, low, overeating, or perhaps loss of appetite, sleep disruption, loss of interest in sex, agitation, restlessness, and reduced pleasure in things. These same individuals may report that during their seven minute consultation with their GP or ten to fifteen minute consultation with a psychiatrist, they have been diagnosed with clinical depression and have been put on an antidepressant or anxiolytic medication that they are ambivalent about taking. Within the first or second session it becomes quite clear that these individuals are not necessarily clinically depressed but suffering from stress. It is a privileged position to be able to invest time with an individual to help them discover and make sense of their ‘lived experience’ from all its many dimensions. Prosky (2003) reminds us that there are countless choices as regards an explanation for the etiology of a psychological event, most notably mind, body, and context. My experience has been that emphasis tends to be placed firmly upon formulations of a problem without due attention to the context in which a psychological event occurs. Thus, my client with the diagnosis of clinical depression and a prescription for the latest antidepressant in fashion unfurls their story to me… feeling overworked, worried about a sick child, tension with their spouse, and falling behind on their credit card payments. When symptoms are grounded within a context it affords both the client and practitioner, in my view, an opportunity to get a fuller perspective. The client suffering from supposed clinical depression suddenly sees that their experience is a normal response to a number of stressors that is, an event or events that cause an adverse reaction in the person. It is at this point that they realise they can take personal responsibility for helping themselves. They give themselves permission to reflect upon their lifestyle, evaluating what is working for them and what is not, rather than relying solely on the ‘hit-and-miss’ action of psychopharmacology.
I work in a medical centre that I believe is progressive insofar as all disciplines regularly consult with each other centring on best practice for the service user. A client recently remarked to me that the GP within the centre advised that the choices open to her within the centre were either to commence a course of psychotropic medication or to engage in talk therapy and dialogue with me regarding the value of taking medication, making the decision a more supported collaborative one. Based on my experience of working in various centres within primary care this is the exception rather than the rule. Most clients referred to me in the past would have already been five to six weeks into a course of medication. Consequently the initial counselling sessions could possibly be devoted to exploring the individual’s reluctance to be taking such medications, not only because of the many side-effects they are experiencing, but because their intuition is telling them that there has to be another way. Unfortunately, despite the apparent evolution toward a more multidisciplinary approach within our health care system, there still appears to remain only ‘one way’ that proliferates within this system, the ‘bioscientific approach’. Regardless of our professional training, we have all been conditioned to perceive the ‘biological’ as the ultimate source of all our ailments both physiological and psychological. This sets up a scenario whereby multidisciplinary treatment looks ‘as if’ collaboration is taking place but in reality is being dominated by the etiology of a single dimension – biological psychiatry (Prosky, 2003). Sharfstein (2006) laments that the biopsychosocial model has given way to the bio-bio-bio model.
There is a substantial body of evidence in circulation that is contradicting much of the accepted orthodoxy regarding the efficacy of drug interventions (Szasz, 2007). It is thought for instance, that one of the most commonly prescribed medications for bipolar disorder has only a minor effect over and above a placebo in reducing manic and depressive episodes. Once discontinued, however, the risk of a manic episode is greater than prior to its consumption (Moncrieff, 1997). Similar results have been found following a review of the use of antipsychotic drugs over a fifty year period, concluding that there were greater costs than benefits associated with their use, including dependency, withdrawal, and relapse (Whitaker, 2004). Anecdotal reports from both GPs and my clients would suggest that a very popular anxiolytic which has been found to facilitate symptom relief in the very short-term creates a whole host of problems in particular dependency and adverse reactions. These reactions include anterograde amnesia, drowsiness, depression, and paradoxical reactions such as restlessness, agitation, irritability, aggressiveness, delusion, rages, and nightmares (MIMS, 2009). For professionals from all disciplines to not fully engage in a collaborative relationship and provide ongoing monitoring, an individual can rapidly move along the continuum from experiencing temporary biopsychosystemic stress (Keith, 2003) whilst remaining stable and psychologically healthy, to becoming psychologically/physically dependent, fearful of withdrawal, and more prone to relapse.
It occurs to me that whilst I make every effort to maintain as therapeutic an atmosphere as possible in my counselling room, convenience causes me to accept offers from medical centre staff of surplus tissues, mugs, and pens advertising various medications to treat what would appear to be solely ‘physical’ ailments, including depression and anxiety. We are continuously surrounded by product placement and subliminal messages about the pervasive influence our biological make-up has on our lives. ‘Biochemical imbalance’ is as much a part of [our] vernacular as ‘Did somebody say McDonalds?’ (Duncan et al. 2003:173). What isn’t so much part of our vernacular for example, is the growing support for evidence suggesting that many individuals who experience psychosis are survivors of childhood abuse or trauma (Read et al. 2005) which cannot be healed with a drug. Evidence of this nature tends to be largely ignored. In the spirit of objectivity, however, if we are to truly concede that at present there exists no certainty regarding the etiology of mental health problems, then a biological cause is not more or less plausible than any other cause (Lakeman et al. 2009). The conclusion at present, therefore, must be to champion as much as possible a multidimensional approach to understanding the lived experience of individuals. This may require all professionals participating in their care to avoid the desire to provide the expectant patient with a hastily determined solution in order to pacify them temporarily. In addition, by giving due consideration to the context in which an individual’s problems unfold, health professionals may consider alternative forms of intervention rather than taking the sometimes convenient route of psychopharmacology. Ultimately, any decision to commence a course of psychotropic medication should be a joint one (Deegan and Drake, 2006), requiring collaboration between the two experts in the room: the practitioner and the client. This serves to maintain the client’s sense of personal responsibility, participation, autonomy, and self respect, and will ensure optimal use of medication within healthy boundaries.
Francis McGivern is a Counselling Psychologist registered with the Psychological Society of Ireland. He has a private practice in a multi- disciplinary medical centre and is a student counsellor at the Dundalk Institute of Technology in Co. Louth. Francis is a Doctoral Candidate in psychotherapy at Dublin City University. He sits on the Board of Directors of the Rape Crisis Centre North East.
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