To Medicate or Not to Medicate? A Very Good Question!

Patients who are experiencing strong emotional distress will often ask about taking medication.  Questions about depression or anxiety medications are often accompanied by strong ambivalence:  patients recognize that something is wrong and want to feel better, and at the same time express doubt that a pill will be effective.  Others would rather take a pill and be done with it; they believe that talking about their problems is ineffective, that therapy is a waste of time.

Medications can help.  But there are a number of questions that need to be explored before making decisions about trying a psychotropic medication.

·         How long have you felt the distress? 

·         How intense is the distress? How is the distress impacting your ability to function?

·         If the distress is arising in response to a life situation, how have you managed similar situations in the past? 

·         How well are you sleeping? How well are you eating? 

·         Are you using alcohol or other substances to cope?  If so, what, how much, and how often are you using them?  (Please be honest with yourself and your therapist!)

·         Will medication facilitate the deeper work of psychotherapy? 

It’s important to talk through these questions and share any concerns you have about medications and their possible side-effects with your doctor or therapist.  A good assessment is essential before any medication is considered.   How these questions and others are answered are all part of a good evaluation—an important first step toward making an informed decision.

That said, here are a few thoughts: 

Acute distress clouds thinking.  When you’re in distress, your attention narrows and focuses on those factors that either create or contribute to your distress.  When you’re acutely uncomfortable, it’s harder to see the bigger picture.  Decision-making can become impaired by acute distress: it’s harder to clearly see the issues and all the factors impacting those issues. It's harder to discern the consequences of the decisions you might have to make.  Everything is experienced through the fog of distress.  Depressed clients often report that their thinking slows down when their depression is acute, and one of the hallmarks of depression is the inability to make decisions.  Anxious clients report that they feel unsettled, distractible, hyper-vigilant, and afraid to act. 

Anti-depressant or anti-anxiety medications can take the edge off of acute emotional distress.  Anti-psychotic medications are essential for managing schizophrenias or other psychotic disorders.   The right medication(s), prescribed and monitored by a psychiatrist who has evaluated and understands your distress, can be very helpful.  But medication alone is rarely the sole answer to psychological problems.  However, medication used in conjunction with psychotherapy, especially Cognitive Therapies, has been shown to be very effective.  (Indeed, there is a great deal of research literature in support of combining medications with psychotherapies.)

As a therapist, I want you to have your feelings, but I don’t want to you become flooded, overwhelmed or disabled by them.   Emotional distress signals problems that need to be addressed.  Therapy is about working with your thoughts and feelings.  And meaningful psychotherapy asks that you be willing to experience enough of your distress (without being overwhelmed by it) so that you can work through it.  Finding a medication at an effective dosage that allows you to have your feelings and think clearly can certainly support our work together. 

The idea is not to avoid distress but to work through it.

The Wisdom of Feelings

“I really don‘t like feeling this way.”

This is a comment that therapists hear fairly often.  You may have said this to yourself.  Anger, anxiety, pain, depression, despair, sadness—these feelings can indeed be very difficult and at times can seem acutely unbearable.  Moreover, the statement “I don’t like feeling this way” often signals that you may have a particular relationship with those feelings, a relationship that is built upon deeply held unconscious beliefs about those feelings.  In my experience, those beliefs are embedded in the questions clients ask me when they are having strong uncomfortable feelings:  “Is there a pill I can take for this?”  Or “can’t you do something to help me feel better?”  Many people believe that aversive feelings should be pushed away or resolved as quickly as possible. 

Of course, the therapist can help.  And the process will take time.

 “I really don’t like feeling this way” may signal that there is a story related to the feelings.  The story can often be distilled:  “feelings are bad and are to be gotten rid of as soon as possible.”  Too often, the story about feelings becomes the problem.  If this is what you tell yourself, you may be responding more to the story than the actual situation that gave rise to the feeling.  If the story is negative (which it usually is), attention may be misdirected:  you focus on the story about the feelings and are unable to clearly see the conditions that gave rise to them.  You try to create an ending to the story, but may miss resolving the actual problem. 

Trying to push your feelings away complicates the situation.  When you react to your feelings by pushing them away, those feelings are likely to grow in strength.  While you may temporarily feel better,  you're more likely to end up prolonging and intensifying the pain.  Moreover, the negative story you tell yourself about your feelings will inevitably feed and strengthen the aversion.  You can start to feel overwhelmed, and the impulse to flee or otherwise escape starts to take hold.  There are many escape routes: some people turn to alcohol or pills to feel better while others seek escape in compulsive work, sex or eating.

As counter-intuitive as it seems, it is usually better to lean into your feelings, to accept them as signals that something unsettling has happened.  There is wisdom to be found in your feelings, and strong feelings lead to the deepest insights—when you are able to tolerate and learn from feelings.  And learning from them may mean letting go of the stories you tell yourself about them. 

Instead of impulsively pushing feelings away, it is better to notice that they’ve simply arisen in response to a situation.  And instead of telling yourself a story about your feelings, it is better to ask yourself a few questions: 

·         What is the feeling?  Does the feeling seem to be out of proportion to the situation which gave rise to it?  Sometimes when feelings are especially intense, the intensity may be a signal that the situation is triggering an unconscious memory of an event similar to what you're experiencing now.  Feelings that are out-of-proportion often contain elements of displaced feelings and stories that belong to the past.   

·         What thoughts are associated with the feeling? Paying attention to the thoughts that arise with the feelings may give you a clue about how your beliefs may be contributing to the story.

·         Where in your body do you experience the feeling?  Is there a story about those body sensations?  Memories of old, unhealed traumas are often “stored” in the body.  Those stories must be attended to and processed so that healing can occur. Trauma is best addressed in psychotherapy.

·         What do you believe about your feelings?  Strong, aversive feelings are often associated with negative beliefs:  “I can’t handle this,” “I’m helpless,”  “I’m flawed”  are commonly held beliefs.  Negative beliefs about yourself and your feelings are likely to cloud your perceptions and intensify the impulse to escape.  Negative beliefs may impede effective problem-solving.

Accepting that painful feelings will occasionally arise is a good first step to better managing them.  No one is exempt from emotional discomfort.  However, it is also important to recognize that uncomfortable feelings rise and ebb over time.  This is actually an important point:  Feelings are not permanent.  Although the intensity of your feelings may evoke an unconscious belief that you will have the feeling forever, the reality is that feelings change over time--even from moment to moment.  This is good news.  Knowing that feelings rise and fall can provide the basis for changing your relationship with your feelings and strengthening your ability to cope.

Just noticing your feelings without telling yourself a story about them is not so simple.  Mindfulness and deep self-awareness takes practice.  Becoming aware of the stories you tell yourself takes practice.  Psychotherapy is a very effective process by which to develop awareness and practice those skills. 

A skilled therapist will also help you get to the roots of your suffering in such a way as to help you differentiate past from present and evaluate what is actually happening in the present moment.  A skilled therapist will help you move away from trauma or the negative beliefs about yourself so that you have power to constructively manage your vulnerabilities.  Again, the process takes time. 

Ultimately, psychotherapy will help you change your relationship with your feelings.  In addition to helping you develop strategies for managing your feelings, therapy helps you develop the ability to become aware of the origins of your feelings and the stories you tell yourself about those feelings.  Therapy can help you better evaluate the situations that elicit strong feelings, develop greater clarity about them, and make better choices in response to the situations that evoke intense feelings. 

No one likes feeling aversive feelings.  But your relationship with your feelings need not be averse.