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The Psychology of Psychopharmacology

Medication is not a substitute for psychotherapy.

After reading psychiatrist Peter Kramer's recent post, "The (modest) Future of Psychopharmacology," I'd like to add a few of my own thoughts on this subject as a practicing clinical and forensic psychologist. Dr. Kramer makes an important point: Psychopharmacology involves far more than simply prescribing pills. Psychiatric medications occupy a predominant place in contemporary psychotherapy. Too predominant, as Kramer himself concedes. Which is why I agree we must take psychopharmacology down from its pedestal, and recognize it as more of an adjunctive than primary treatment modality. Or as he puts it, reduce psychopharmacology to a "constituent of psychotherapy."

As Dr. Kramer indicates, there is a complex, subtle psychology of psychopharmacology. Even for those of us not directly prescribing psychotropic drugs to our patients, the psychological and philosophical implications, ramifications, and consequences of using them (or not) can clearly be seen in the psychotherapy process. To begin with, there are these basic questions: Who is ultimately responsible for our behavior, our choices, our impulses, our selves? Is it us or is it our brain chemistry? Does aberrant neurobiology affect psychology or does aberrant psychology affect neurobiology? Can biochemistry be separated from the self or psyche? I believe Peter Kramer tackles at least this latter topic in his popular book Listening to Prozac.

Many patients reflexively resist taking psychiatric medication because they believe they should be able to manage their lives without it. Needing biochemical support is seen as weakness. Is this simply what Ellis or Beck call a "cognitive distortion" or "irrational belief'? Or what psychoanalysts might term a negativistic "resistance" to treatment? Or flat out denial? Or is it sometimes a healthy, natural reticence? Patients often fear dependence on psychiatric medications. The problem of anxiety is a good example. How do we deal clinically with anxiety? Is all anxiety pathological? How much anxiety must one tolerate before seeking pharmaceutical relief? At what point does "normal," existential anxiety become destructive, debilitating and pathological--as, for example, in panic disorder--necessitating pharmaceutical suppression? Once we do introduce antidepressant and/or anxiolytic drugs to subdue anxiety, where will it end? Will patients become physiologically and/or psychologically dependent on these substances--and, therefore, on those who prescribe them? Might it be more beneficial, for instance, to educate patients about anxiety and its existential inevitability, teaching them to tolerate, move through, and manage it non-pharmacologically whenever possible?

How about anger? Are we too eager to suppress anger with sedating anti-psychotic, mood stabilizing or antidepressant drugs? Anger is a natural human emotion, and, at times, an appropriate and necessary response to life's inescapable challenges and obstacles. Sometimes we need to be angry or outraged, and it is the inability to react angrily, assertively or aggressively when required that is pathological. At what point do we tone down anger pharmaceutically? And at what price? Clearly, when anger or rage become uncontrollable, resulting in destructive behavior, biochemical intervention may be required. But once suppressed, where has the patient's anger gone? Could this pharmacological quelling of anger later result in an even more violent eruption of rage? Has the irritable, resentful or angry patient learned to deal more constructively with frustration and aggression, or merely to depend on drugs to dampen and control such impulses? And what effect does suppressing anger biochemically have on motivation, vitality and creativity?

Pharmacotherapy of psychotic and bipolar disorders is essential and often life-saving. Symptoms can be controlled and stable functioning restored in many cases. But even in these severely devastating and dangerous states of mind stemming, still quite debatably, from a presumed "biochemical imbalance" (see Kramer) or "broken brain," specialized psychotherapy can and must become a central part of treatment. Over-reliance on medication alone is insufficient. In treating such intractable disorders, including addictions, the proper combination of psychopharmacology and psychotherapy can be pivotal in recovery: a delicate balance between encouraging patients to face rather than flee from their demons--anger, anxiety, sadness, loneliness--while not being destructively possessed or overtaken by them.

What of the pervasive use of SSRI's and other drugs to treat depression? Yes, antidepressants do work (see Kramer)--more or less, though not for everyone. They can ameliorate depressive symptoms such as sleep and appetite disturbance, anxiety, avolition, anhedonia or suicidality, and can elevate or stabilize mood. They can provide patients with more energy to deal with their problems. These are invaluable benefits. But antidepressants are not a panacea. Sometimes, as with all medicines, there are unwelcome side-effects. Drugs can't change the patient's stressful circumstances. Nor can neurochemistry exorcise his or her inner demons. Which is why depressed patients also need supportive psychotherapy to help them move forward in life, despite their discouragement, self-doubts, insecurities and fears. When patients instead are perceived and treated as helpless, passive victims of their own biology--whether by psychiatry or other medical doctoring--how does this affect their sense of personal responsibility for bettering themselves and the empowerment to do so? What messages are consciously or unconsciously communicated to patients regarding the nature of psychopathology and psychopharmacology, and what is the psychological impact?

These days, psychiatrists seem to be abandoning the practice of psychotherapy, focusing exclusively instead on psychopharmacology. This is regrettable, since, generally speaking, psychopharmacology is most efficacious when employed in the service of psychotherapy. Yes, taking medication at some point may be a crucial part of the patient's responsibility for getting better; but it is no substitute for real psychotherapy. How psychopharmacology and its implicit psychology is understood and employed in psychotherapy is key: Is medication used merely to deaden metaphorical demons? Or to support confronting and coming to terms with them? When today's primarily biological and cognitive therapies correct course and start asking the right questions (see my previous posting), psychopharmacology can fulfill (as Kramer recommends) its "proper role" as a collaborative, complementary component of psychotherapy rather than its replacement.

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