Issues this post seeks to address:
- What role does medication have in treating mental illness?
- Why does combining medication and therapy produce the best outcomes?
Posts related to this post:
Therapy vs. Medication
I’ve mentioned in one of my other posts that I’ve never taken psychotropic medication. I’ve considered it from time to time to help with my anxiety, but I’ve always ended up coming to the conclusion that my anxiety isn’t that bad – I probably don’t “need it.”
I count myself privileged to have never had to take these types of medications in order to function. I’ve worked with dozens, if not hundreds of people who have, and while most have had positive experiences, it’s been a journey to find the right medication and right dose in almost every case. Some people find that they experience debilitating side effects when they try medication; others don’t end up feeling less depressed or anxious at first. Finding a prescription that works well often takes patience, endurance, and trust in a sometimes too-long process.
When I was a new clinician, I had some difficulty figuring out how and when to refer my clients to their physician for a medication evaluation. I knew about research that showed that therapy could effectively treat mental illness. I also knew that psychotropic medication was about equally as effective. A recent review of existing studies suggested that a combination of therapy and medication was the most effective treatment, at least for depression.
I wasn’t totally sure what to make of these different treatments. Was treatment just a matter of personal choice? Should I encourage my therapy clients to try therapy first, and then try medication if therapy didn’t work? And why did combining these two very different treatments seem to produce the best results?
The Farmer’s Field
I later heard an analogy that helped me answer these questions in a way that works for me. This analogy was presented by a psychiatrist, and I often use it to help my clients think about how they want to treat their depression or anxiety. Here’s the analogy:
A farmer has a field that she needs to plow. Right now, the lines are plowed in all different shapes and directions, and they need to be re-done. She wants to plow the field in straight lines, since it will make sowing and harvesting easier. Unfortunately, when the farmer sets the plow and tries to move, she finds that the ground is extremely hard. It’s frozen and rocky and just generally a mess to try to plow. Any progress she does make is hard-earned; as she looks at the size of the field and sees how slowly she’s moving, she wonders whether it’s worth it to try to plow this field at all. She eventually tires and decides to give up, and the field stays the way it’s always been.
The rows in this analogy represent patterns of thinking, relationships, and behavior that determine how a person lives their life. I’d call them dynamics. Haphazard rows are dynamics that make life more difficult, and might contribute to depression or anxiety. Straight rows represent dynamics that promote healthy, sustainable functioning – they make life easier. Examples of straight rows include having a sense of meaning or purpose in life, engaging in meaningful relationships, practicing moderately healthy diet and exercise habits, and getting adequate sleep.
When the ground is hard, plowing new rows is very difficult. It’s easy to get stuck with the rows you already have, even if they’re sort of wonky. The ground is hard when we struggle with mental illness – depression, anxiety, OCD, addiction, eating disorders, or others. These problems inhibit our ability to change because of the strain they place on our internal resources – our motivation, energy, or ability to cope with stress become diminished and movement becomes difficult. Even when a therapist is there to help guide and push the plow along, sometimes the ground is just too hard.
Softening the Ground
This is where medication can be so helpful. Medication can “soften the ground,” allowing the plow to move again. By augmenting the neurotransmitters in the brain that are associated with mood, anxiety, or other functional categories, psychotropic medications reduce the strain of mental illness on our resources. We become more able to get out of bed in the morning; to exercise or eat healthier; to reach out to a friend or develop a hobby. And as we do so, we plow the straight lines in our field that will continue to yield the benefits of sustainable personal functioning, even if we no longer take the medication.
I always encourage my clients to plow the field when they take medication. They often start feeling a lot better pretty quickly, because life does get easier when we’ve got the resources to cope. Unfortunately, if these quick improvements in functioning aren’t accompanied by an investment in the self, through conscious, personal change, the end result is often an eventual return to the status quo, even with continued medication.
To me, this is what it means to “make hay while the sun is shining.” It’s to take advantage of the improvements brought on by taking a psychotropic medication to work hard. To return a portion of the renewed energy, motivation, or peace of mind we experience toward ourselves, to produce long-term benefits in our functioning.
Cuijpers, P., Berking, M., Andersson, G., Quigley, L., Kleiboer, A., & Dobson, K. S. (2013). A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. The Canadian Journal of Psychiatry, 58(7), 376-385.
DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD. Medications versus cognitive behavioral therapy for severely depressed outpatients: Mega-analysis of four randomized comparisons. Am J Psychiatry. 1999;156:1007–1013.
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32(9), 752-760.