As a psychotherapist, I often confront the debate about using medication to treat depression and anxiety in my NYC therapy practice. It is a big question.
There’s a perception at times that because we practice a non-diagnostic approach, are critical of the medical model and express concern about how antidepressants and other psychiatric medications are marketed that we’re anti-medication. Not only is that just not true–it concerns me. Many people who come to see us are struggling with serious pain–and even when it’s not so serious, they need all the help they can get. For many, many people who seek therapy for depression and anxiety (it should be noted that antidepressants treat anxiety as much as–if not sometimes better than–depression), these medications can be terribly helpful.
Are they for everyone? No. Can they be dangerous? Of course. And they don’t make everything better. I want people to hurt less. Perhaps not as the “good enough” end goal, but if someone is in pain and medication can help, they ought to consider that. At times, they can help someone who is depressed or anxious be able to tolerate some of the painful work of therapy.
However, more than the medications themselves, the marketing of antidepressants by drug companies have changed the way we view therapy and how to “fix” emotional pain. And this deserves to be looked at seriously.
Therapy vs. Medication
Prozac and other antidepressants came on the scene very much marketed as the alternative to therapy or, even better, easier than therapy. The media loved this–it is a juicy story. What this did was cast the conversation as one versus the other: therapy or medication. The presumption is that each treatment is competitive with the other for treating depression and anxiety. Therapy and antidepressants are seen as two treatments designed to reduce the symptoms of these issues. It’s like two competing protocols for high cholesterol or migraines.
The medication/therapy dichotomy has hardly been questioned. And it couldn’t be a more perfect position for drug makers. If we cast antidepressants as competing with psychotherapy, we frame the objective of psychotherapy in a very narrow way: reduce depression and anxiety.
Therapy as Dark Age medicine
There is a notion that the understanding and treatment of mental illness will “catch up” with medical treatments of other sorts of illnesses. Therapy, here, is cast as some sort of witchcraft or alchemy–the last vestige of some Dark Age medicine. Advances in brain science–largely represented as a function of increasingly sophisticated brain imaging technology (MRIs, CAT scans)–are seen as emerging to rid the science and treatment of mental health of its dependence on such an unreliable, subjective phenomena as psychotherapy.
This is much, much more of a statement on therapy than about antidepressants. The drug makers weren’t suggesting that antidepressants did more than they could do, but rather, that therapy intended to do much less than it could do. They had to, quite literally, change our conception–both within the community of people who study and treat depression and anxiety and in the public more broadly–of what depression and anxiety are (a disease) and of what psychotherapy intends to do.
This led directly to the rise of Cognitive Behavioral Therapy (CBT) and other so-called empirically-based practices. Now, I don’t think all of this is bad. We needed more kinds of treatment. We got a new class of medication that helps people with anxiety and depression feel better. That needs to be celebrated for the amazing achievement and tool that it is.
Unfortunately, it also came at the cost of medicalizing how ordinary people see their emotional experiences. In a sense, drug companies and the therapy industry have convinced us that there are only a handful of different kinds of suffering and a correlating handful of different kinds of cures for that suffering. Drug companies essentially said, “No, this has nothing to do with your childhood and all those complicated, Freudian notions. Your suffering is a disease and we sell the cure.”
Fixing emotional pain
The question for the individual patient, in the most basic sense, is how do I get help for this particular sort of pain I’m experiencing? What does it mean to feel better? How do we measure it? Or can we measure it?
The marketing of antidepressants has framed emotional pain as being felt very much like how physical pain is felt. Physical pain is a thing that is treated in and of itself, alienated from its cause. Pain is related to as something that can be made to go away. But what about what’s producing that pain? If my back hurts, there are a number of conditions that can cause that. If there are tools to manage that pain, that’s good, but of course, we want to be sure we’re addressing what’s causing that pain.
Depression has become what the experience feels like rather than understood as a product of painful life experiences. We’ve come to understand that there’s this thing–depression–that exists independent of what we are creating in our lives and our life circumstances. It’s pain without cause or context.
The presumption is that the cause of sadness doesn’t exist or doesn’t matter. The medication treats the affective experience and so it is the affective experience that gets defined as “real.” It is inevitably decontextualized. People are sad for a reason. People are in pain for a reason. People are suffering for a reason. Of course the pain is real. Are antidepressants and other psychiatric medications on offer able to give meaningful help with the affective component of these experiences? Absolutely. But it isn’t–and is never–ALL that is real. This has been forgotten.
The conversation needs to be bigger
What I do in my NYC therapy practice with the debate of antidepressants versus therapy is break away from the either/or of the question. In a sense, the question needs to be bigger–something like, “As we look at the totality of your life, what resources are you open to trying to feel better and grow your life?” Antidepressants (prescribed by a primary care doctor or a psychiatrist) are often on the list. So is, perhaps, church, yoga, spirituality or exercise. At times, therapy may not even have a place in that but then, in a sense, the therapy should be about discovering that.
What concerns me about the presumption that we, as non-diagnostic therapists, may be against medication is that it can feed into a broader conception that taking medication is weak, cheating or somehow not doing the real work. Some people struggle with the idea that they deserve to feel better. You’d be surprised how many people struggle with that notion. If we, as therapists, help them examine these positions–identify them and better understand where they come from (both in the patient’s history and the world) we can help make more choices available.
It’s a decision that’s radically particular to each person asking and it isn’t just based on what approach “treats” what symptom. Antidepressants may be a great tool for managing pain, supporting growth and helping bring stability–helping a patient feel better. How could we not include that in the conversation? But the conversation needs to be about pain and emotional growth and it needs to be wholly contextual (i.e. not just limited to a medical understanding of the experience). There are many frames through which we can understand pain and suffering. The conversation needs to be bigger.
