Active Ingredients – The Mechanisms that Matter

Issues this post seeks to address:

  • Why do problems seem to affect some people more than others?
  • How does identifying the dynamics responsible for maintaining our problems lead to more effective long-term change?

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Active and inactive ingredients in medication

I work with quite a few people who take daily medications. Many of them take these medications to treat anxiety or depression. Some take medication for help with attention, to manage their Bipolar disorder, or to treat a variety of chronic health conditions. I consider it a privileged position not to have to take medication on a daily basis in order to manage a chronic concern.

When I worked with youth in a residential treatment program, I was surprised at how many different medications some of the residents were prescribed. I’d help with the disbursements of these medications when the residents got up in the morning and when they went to bed. Some of them took a pill or two once or twice a day to help them manage a specific problem. Others, however, would take a cup of 4 or more medications at a time, sometimes twice a day.

It takes a lot of knowledge and skill for a psychiatrist to effectively manage a prescribed cocktail of medications that target specific problems without causing too many side effects or harmful medication interactions. Each medication has one or more active ingredients that give that medication it’s particular therapeutic properties. Interactions between the active ingredients of different medications can stifle the intended main effect of the medications, or lead to problematic side effects.

Since active ingredients in a medication can’t be administered by themselves, they are often combined with a set of inert, or inactive ingredients (also called excipients). These ingredients are typically used to bind and preserve the medication, dye it, or flavor it, and have very little bearing on the therapeutic effect of the drug. As a result, it’s possible to have a dozen different pills, each containing 200 mg of the active ingredient Ibuprofen, of varying sizes, colors, flavors, and consistencies. No matter which pill you take, however, you should end up with a very similar pain-relieving effect, since the active ingredient is the same. In theory, you could put 200 mg of Ibuprofen into any edible substance and get the same effect, as long as the other ingredients don’t interfere with the Ibuprofen’s effect.

Application to personal problems

I find in my clinical work that personal problems often have “active” and “inactive” ingredients. “Active ingredients” refer to processes or situations that produce a particular effect consistently. It doesn’t matter what the “inactive ingredients” involved in the situation are, the effect – or problem in this case – occurs as a result of the “active ingredients.”

A problem arises when someone has difficulty identifying the “active ingredients” that perpetuate problems in their life, and instead targets one of the “inactive ingredients” for change. Here’s a simple example that I commonly see in my clinical practice:

I frequently meet with individuals or couples where there’s an identified problem with pornography use. Pornography use is particularly problematic among the predominantly-religious clients I work with in therapy, as significant stigma and shame exist for those who deal with this issue. The contexts of the problem vary, but the end results are usually similar: In couples, the partner who isn’t using pornography often feels betrayed, inadequate, and mistrustful, while the partner who views pornography often feels guilty, out-of-control, and insecure.

Prolonged pornography use in these situations can lead to mistrust, blaming, breakdowns in communication, impaired intimacy, and, ultimately, dissolution of the relationship. These are the problems that cause couples to come to therapy in the first place. The simple, most commonly-identified solution to these problem is to get the partner who is viewing pornography to just stop doing it. The narrative makes sense – pornography use inhibits emotional intimacy and leads to partner objectification. The problem is an individual one – it “belongs” to the person who is using pornography, and their partner is in the victim role.

The question I ask myself in these situations is, Is pornography the “active ingredient” in the relationship problems this couple is experiencing?

To answer this, we have to consider whether this “active ingredient” produces a similar effect when combined with different sets of “inactive ingredients.” In other words, does a partner’s pornography use always lead to problems with shame, intimacy, trust and communication in their relationship?

Of course, the answer here is no. It’s possible for couples to exist where, based on the shared values of both partners, viewing pornography does not necessarily indicate problems with trust, communication, or intimacy. I’ve worked with such couples in my clinical practice, which has been an eye-opening experience for me. In such cases, the identified problem of pornography use seems to affect the couple much less than it might a different couple.

If the “active ingredient” in a couple’s relationship issues isn’t the pornography use itself, then what else could it be? To answer this, we need to look at the mechanisms, or dynamics, of the relationship that predict different outcomes among different couples with pornography issues. The actual processes that serve as the “active ingredients” will vary from situation to situation. The following are examples of some of these processes that actually are active ingredients, where combining them with all kinds of inactive ingredients will still produce the same kind of effect:

  • Shame that inhibits open communication
  • Fear of hurting the partner, such that difficult emotions or conversations are avoided
  • Insecurity about how attracted the partner is to them
  • Use of avoidant methods of coping with stress generally
  • Anxiety about the partner’s “spiritual welfare”
  • Difficulty dealing with “mixed signals” from the partner, or an inability to communicate about these “mixed signals” effectively
  • Evaluation of the self or the partner as “less than” the other person, leading to a power differential
  • Objectification of the partner

There are certainly many other dynamics that can be associated with pornography use and that can lead to problems in relationships. In many of the above examples, particularly the last example, it’s very easy to draw a correlation between pornography use and the problematic process. However, it’s important to remember what the “active ingredient” actually is – it’s not the pornography use, it’s the tendency to objectify the partner. While these two frequently go hand-in-hand, it is possible to objectify others without using pornography, and the same relationship problems that occur with the pornography use would occur without it if there was still partner objectification. Thus, the objectification is the “active ingredient” here, and not the pornography use.

Conditional resolution

This isn’t intended to be a defense of pornography use. There’s no evidence that I’ve seen that using pornography is particularly healthy for a relationship, and I use this just as an example of how the “inactive ingredients” are frequently targeted for change. To be fair, many of the problems associated with pornography use that I see in the couples I work with could be “fixed” if the partner who viewed pornography simply stopped. However, this kind of “fix” creates a conditional resolution of the problem – the “active ingredient” is still present, and can easily be activated in the future in a different context (i.e. weight gain, loss of income, crisis of faith, etc.).

I’ve said this in several of my previous posts, and I’ll say it again here: People are complex, and it’s often difficult to see what the actual contributing factors to a problem are. It’s important to seek to understand the “active ingredients” that produce the problems we experience. These active ingredients are the “mechanisms that matter,” the processes that sustain the status quo. When we move beyond the simplest and most obvious explanations for our problems and examine the relevant dynamics, we become much more likely to implement change that successfully and sustainably improves the problems we face.