Antidepressants can be examined in therapy just as we examine everything else in our lives
Many people seek both therapy and medication when in emotional distress. However, they both exist in completely different systems. Few psychiatrists do therapy. Conversely, psychotherapists who aren’t physicians (and the vast majority of us aren’t) aren’t allowed to provide medication (the American Psychological Association pushed hard for this years ago but failed). In fact, many therapists remain in the dark about psychiatric medications.
Antidepressants are especially tricky in this regard. They’re confusing to understand and controversial. Serious studies indicate they don’t work while others insist that they largely do. Some suggest much (perhaps as high as 50%) of the effect of antidepressants is a placebo. Certain psychiatrists believe that’s just fine—that’s part of how the medications work.
Even with these complications, therapists need to reorient their relationship with antidepressants, familiarizing themselves with their uses, side effects, mechanisms of action, and cultural significance, including, importantly, how that varies across communities and groups. By doing so, therapists can help patients examine antidepressants using the same tools we use in therapy to examine everything in our lives that relates to our suffering.
Therapy and psychiatry have largely separated into two sets of labor, but it didn’t used to be that way
Early psychotherapy was developed and practiced nearly entirely by physicians, largely psychiatrists. In fact, the earliest psychoanalytic institutes were open for training and membership exclusively to psychiatrists, with psychologists (and later social workers and other mental health professionals) cast out. There were a number of reasons for this. Primarily, there was a belief that training in the workings of the physical body was essential to treating problems of the mind.
As psychotherapy grew in demand, this changed. Therapy and psychiatry have separated into two sets of labor. The vast majority of psychotherapy is now done by non-medical doctors. Psychiatrists mainly focus their practice on psychopharmacology or working in inpatient settings.
Economics is a significant factor here: The number of physicians has remained fixed even as the population of the United States has grown; the number of medical and residency spots has remained steady; and the demand for psychiatry has grown as mental health struggles have increased and more and more increasingly popular and profitable psychiatric medications have come onto the market. Psychiatrists, usually much more expensive than therapists, prescribe medications to an increasing number of patients whom they see less frequently for shorter periods of time. Patients are evaluated for medications and those medications are monitored by separate, often parallel providers.
Even though they don’t prescribe, therapists should understand how antidepressants (and their side effects) affect their patients’ emotional lives
While not for the purposes of prescribing, therapists would do well to understand psychiatric medications like antidepressants. This understanding, then, helps patients understand their experiences, decide what’s working (and what isn’t), and grapple with their feelings about the decision to take medication, their resistance, and their side effects.
In particular, psychiatric medications can cause serious side effects: difficulty sleeping, difficulty staying awake, lack of interest in sex, inability to have an orgasm or sustain an erection, premature ejaculation, feeling separate from one’s body, mania, agitation, feeling empty, suicidality. All of these experiences should be the very stuff of therapy. Instead, these are usually related to as between a patient and their psychiatrist, understood as purely medical issues. The concern, then, becomes about informing the question of whether a patient is open to or compliant with their medication rather than exploring these experiences as related to the patient’s emotional life writ large.
How can therapy make meaning from the experience of antidepressants?
By sufficiently learning about the practical aspects of antidepressants, therapists can help patients make meaning out of their experiences with these medications. Ideally, this would include regular collaboration between psychotherapists and psychiatrists, including a foundation of mutual respect for one another’s work. This is not the norm.
How can therapy help make meaning? SSRIs and SNRIs, for example, quite commonly cause sexual side effects. Knowing that and inviting discussion of those effects—or fears of those effects—in therapy can help patients make decisions about whether or not to take such a medication or discontinue one they’re already on. Additionally, therapy provides an opportunity to ask larger emotional questions: What is the role of sexuality in someone’s relationship with power? How does a fear of losing sexual potency relate to having been a late bloomer sexually? Or how does this fear affect identifying a same-sex attraction that has been latent? How does it relate to conflicts about sex in a marriage? Rather than separating them from the rest of our lives, inviting antidepressants to be seen as objects of meaning allows for them to be considered in tandem with everything else we take on in therapy.
