The Madness of Mixing Medications and Therapy, a Mess Unique To Psychiatry

She came in wanting several sessions to discuss the death of her dear pet. She took care of him until the end and struggled with how the decision to put her dog down was made and the procedure itself. She was rattled to the point of needing to take time off work.
"I don't think what you are going through needs any medication intervention", I told her, and she agreed. Our 6 sessions would be for therapy only.

When a clear distinction in treatment is made, that I would follow a patient only for medication or only for therapy, what follows is so much more straight forward. I had not known this would be the case. When I first started out and decided to offer both treatment modalities, I was certain that the two complimented each other, that my outcomes would be EVEN BETTER, because of the synergy that would be created by combining both medications and therapy. But I am now much less sure. More and more, I am experiencing the two in conflict and how I, as the administrator of both, embody this conflict for patients such that it undermines my ability to do either thing well.

Because when you think about it, medication and therapy communicate very different things to the patient. Medication communicates a helplessness, that I as the psychiatrist believe you need a medication to feel better. It is to take the power of recovery out of the patient's hands and to make it an expectation that it can be a passive process.
Therapy on the other hand demands engagement and motivation from the person. It is communicating that a problem is worth time, understanding, and takes work to sort out.

This case, I will call the patient Daphne, is a good illustration of this.
The first 3 sessions were spent discussing the changes in her life and sacrifices she had made to look after her dog and see to it that he was comfortable and loved. We discussed what she missed most about him and some of her fondest memories. We were starting to discuss what her life would look like now that he is gone and she began to plan some regular activities to help her fill the void. She started volunteering at an animal shelter and was spending more time with friends.

In the 4th session, I remember feeling optimistic and looking forward to seeing how Daphne was doing. I remember thinking we were right on schedule, that in 6 sessions, the goals of therapy would be met and we would have a "tidy" end to therapy. But this was not the case.

Daphne came in and the moment she slumped in the chair, I could tell something was different. She told me how exhausted she was all the time, that she could not continue living like this. She presented contradictory information saying she was depressed, but she still had the energy to volunteer and she just went to a party with friends last night and had fun. I voiced a curiosity to her low energy and I asked her more about it.
"I don't know", she would answer to just about every question I asked. That or "It is hard to explain".

She started crying and told me she did not know why she was crying. When I asked her what she hoped I could do for her, she did not know the answer to this either. She tells me how she has been feeling this way even before her dog had died.

"Maybe I am depressed", she says.

It is right here, this moment where I could feel my brain scramble. I thought we were doing therapy…but does she want medication?? And here is the conflict.

With therapy, it is unhelpful, even irresponsible to pathologize and medicate what might be a difficult psychological issue that can be resolved through therapy. Therapy is difficult, but it is the act of talking it through, in a trusted and safe space with a trusted and neutral person, that is the treatment. This process can bring about not only resolution of symptoms but an increased sense of self-understanding and lasting change.

With medication, it is very unhelpful, even irresponsible to withhold medication management of a mental disorder when it might be needed. I have had the experience of doing therapy with a patient for months and not getting anywhere. Until out of desperation, I prescribed a new medication, and the symptoms improved within 2 weeks. By withholding medication when it is needed, patients internalize that they are not doing enough to get better and that their suffering is their fault. This is harmful too.

How to tell who will benefit from medications and/or therapy is impossible. And though evidence supports the use of both in conjunction, the reality of this kind of holistic practice is far more complicated. In Daphne's case, I ask myself, do I explore why she is more shut down today? What do I do with the invisible pressure she exerts on me to act (i.e. prescribe), communicated to me through her resistance to therapy today? Resistance is a normal part of therapy, and yet medication is a normal part of psychiatry. I might also add, sessions are typically 50 minutes long, and so I do not have enough time to do both in one day.

In the end, with her in tears, and I in a therapeutic paralysis, I leaned back on the muscle memory from my psychiatric training. I re-examined her medications and did find there was room for improvement. She had been stabilized years before on a medication that is also sedating and so certainly this medication could be draining her energy. We started titrating her onto another antidepressant with better side effects.

After this session, I myself felt very drained, like the right side of my brain was in a boxing match with the left side. It is impossible to know from this vantage point what the "right" thing to do is in these cases. And these kinds of cases are arising more and more frequently because of the myth that medications can work magic, combined with the entitlement of patients to certain medications (stimulants most of all) after they self-diagnose on TikTok. So managing expectations is another part of this job that is often unpleasant and can even be confrontational. Bleeding into my interactions with Daphne are the many other conversations I have had with patients who demand something from me I do not feel comfortable, capable, or safe to provide. I admit that in the back of my mind, I feared Daphne was asking for a stimulant when she clearly did not have a diagnosis to justify its use.

I often get questions about burn-out in psychiatry, and why it is so hard to find a psychiatrist these days. I can't help but see these two questions as related in some way. There is an impossibility to the job of being a psychiatrist in how mental health care is currently being delivered...and how it can not possibly meet the need as it stands. This can be for patients and care providers alike, for lack of a better word…crazy-making.