When a prescription is written and a pill is taken, the effects of the medication are almost always influenced by a number of psychological factors. Some of these factors have to do with the commonly held beliefs regarding “drugs” and “illness” that are etched into the experience of most people in our culture. Other factors spring from highly personal, idiosyncratic sources, either in conscious awareness or buried deeply in the unconscious mind.
The astute clinician should continually ask the questions:
“If medications are suggested or prescribed, how will this be perceived by my patient?”
“What personal meaning might be attached to this form of intervention?”
“Will this damage the collaborative nature of our relationship?”
Prescribing and recommending medication always occurs in an interpersonal context. It is not like a landscaper recommending and applying a particular fertilizer to your lawn. Rather, it can be a highly personalized communication between therapist and client, a communication ripe for all sorts of transference distortions and a type of interaction that may alter the nature of the therapeutic relationship.
Unfortunately, relatively few clinicians engaged in pharmacologic treatment truly appreciate this reality.
Language Links Medicine with Punishment
In our culture, certain themes are evident in our clichés and language that link the taking of medicine with badness and punishment. The saying “Give him a taste of his own medicine” is but one example.
One of the classic scenes from the Our Gang movie shorts has the wicked stepmother punishing Spanky and Alfalfa by making them swallow castor oil. Hearing bad news or carrying out unpleasant tasks is sometimes referred to as having to “swallow a bitter pill.” Even in mature adults, these connections between “taking your medicine” and punishment may echo at unconscious levels.
Probably more common are notions regarding medication and “being sick.” Many psychiatric patients may be able to view their difficulties honorably, as “problems in living,” and yet feel shamed and humiliated by a suggestion that they take psychotropic medications.
The unspoken meaning they perceive may be, “You need medications, thus you are sick.” And being sick, in psychological terms, often carries its own assortment of negative connotations: weak, inadequate, crazy, deranged, and so on. The degree that these beliefs are present are influenced by a number of factors to include age, race, ethnicity, gender, socioeconomic status, and geographical location (e.g. living in Mississippi vs. California).
A common underlying concern sparked by the recommendation for psychotropics is, “The therapist must think I can’t handle things on my own—thinks I need a crutch.” This cannot only be wounding to the client’s self-image, but may undermine the client’s belief that the therapist is hopeful regarding his or her capacity for growth and healing.
Consider that most people who experience a traumatic event do not develop posttraumatic stress disorder. In fact, the normal trajectory for the vast majority of trauma survivors is recovery over time by relying on internal psychological resources and social support.
Natural Trajectory Could Be Impeded
Prescribing a medication too early (or at all) following a traumatic event may impede or derail the natural trajectory of healing and the possibility of psychological, relational, and/or spiritual growth that can follow trauma.
Morality pervades many beliefs about the taking of drugs for emotional problems. Some people erroneously assume that all psychiatric drugs are alike. They conclude that all psychotropics are “tranquilizers,” that all can lead to drug addiction, and that such dependence on drugs is little different than alcoholism. Thus, if you take drugs, you are bad or, at the very least, weak willed.
This view of drugs as evil, or at least as dangerously addictive, is adopted by some 12-step chemical dependency programs. The lay leaders of some 12-step groups are understandably skeptical and afraid of drugs that can lead to abuse but may be ignorant of the fact that most psychotropic medications are not addictive at all.
It is all too common for someone who has received a dual diagnosis of, for example, alcohol abuse and major depression to encounter tremendous pressure in his or her 12-step recovery program to discontinue antidepressant medication.
Fortunately, many recovery programs are learning about the appropriate use of some psychiatric medications and understand their role in treating dual-diagnosis clients.
Finally, psychiatric drugs are seen by some as an assault on free will and autonomy. Certainly this idea has been brought to our attention by media reports of instances in which psychotropic drugs have been used solely to achieve behavioral control.
“Chemical straitjackets” and other forms of biological restraint, such as lobotomies, have been the subject of popular film and television productions (for example, One Flew over the Cuckoo’s Nest, Girl Interrupted, and A Beautiful Mind). And clearly these abuses have and do occur. However, appropriately used medical interventions oftentimes work to free people from debilitating psychiatric symptoms and promote autonomy.
*This article is based on Dr. Moore’s latest book “Handbook of Clinical Psychopharmacology for Therapists” published by New Harbinger Press and coauthored by John Preston, John O’Neal, and Mary Talaga.
Preston, J., O’Neal, J., Talaga, M., & Moore, B. A. (in press). Handbook of Clinical Psychopharmacology for Therapists-Ninth Edition. Oakland, CA: New Harbinger Press.