Psychotherapy and Psychiatric Drugs

Both talk and chemical agents can have profound influence over human experience and behavior.  Witness the effects of a charismatic politician or of a few martinis.  It is no surprise that both talk and chemicals have been turned to by those who would help the distress of others.  Both can be powerful, and both have impressive new technologies, on the one hand delivered by words and meanings, and on the other via the blood stream and brain.

Is one any “better” than the other?

Reflect for a moment:  Why do I have any experience, for example a cheerful mood on a particular morning?  Is it because of how I am thinking and feeling and relating to others, or is it because of biochemical events in my nervous system?   The answer is Yes and Yes.  Obviously, both are true, and we can intervene in our own experience and in the experience of others at either level.    To know if any intervention of either kind is preferable it is necessary to know what our objectives are, how well the interventions work, and what their unintended consequences may be. 

Is either kind of intervention more “real” or “basic” than the other?

It is in tune with American culture at this moment in time to assume that a physical, biological level of understanding is more “real” and “basic” than more experiential or interpersonal kinds of understanding.  We associate physical processes with science, and assume that science is the source of “real” understanding of everything.  Philosophers may point out that this sort of thinking is naïve, and may mislead us, but it is deeply imbedded in our culture and we scarcely question it.  I may attribute my good mood to just having gotten good news about someone I love, or I may attribute it to the levels of certain proteins in my blood stream, and in both cases I would be right.  But we would generally tend to assume that the protein explanation is somehow more basic.  Could I call up similar good feelings on days with no good news by manipulating the appropriate proteins?  Possibly so.  Is it also possible that I could jack up the protein levels by getting more good news?  Very possibly so again.  Really, we are beings composed of both  meanings and chemicals, and there is no way around either fact.

Because of our great respect for physical science, it is very common to take a small logical step that appears innocent and obvious:  we may assume that if something can be altered by chemicals (such as psychiatric medications) the really real cause of the whole process is chemical in nature, and only chemical in nature.  It is the last clause about only that causes mischief.  This leads Dr. X to say to Patient Y:  “your gloomy moods and bad behavior are hard-wired.  You were born with them, and will always have them.  You have a biochemical disease and it can only be treated with biochemical agents.”  There is no mention of the fact that the moods and behavior can also be changed by good news – or by the many approaches of psychotherapy.  Dr. X has leapt from having a useful solution (Zoloft or Xanax  or Adderol) to declaring that  he owns a problem, and has the only solution.  This is good marketing (as pharmaceutical companies have discovered) but terrible science.

Actually, science is truly our best guide for finding out a factual answer about anything – or at least about questions that we know how to study scientifically.  But scientific research can be carried out on psychological questions, like the effectiveness of psychotherapy, as well as on questions having to do with chemicals and biological processes.

When we look at the scientific findings regarding the effectiveness of psychotherapy and psychiatric medications, we find that actually both are helpful – and for many situations both are helpful to about the same extent and for about the same proportion of people treated.  At the same time, it is worth noting that the contemporary presumption that "psychiatric conditions are biological so only meds should help" actually runs counter to a lot of evidence to the contrary. Recent studies, for example show that depression is actually treated more effectively with psychotherapy than with medications (Antonuccio, 1995). A meta-analysis of several outcome studies showed that almost twice as many people in any given group would be likely to receive substantial benefit from psychotherapy as compared to those receiving medication alone, and almost twice as many treated with medication alone would be expected to have negative outcomes (Wexler & Cicchetti, 1992). Still, in many cases, medication does seem to be a useful alternative as well.

Then what would lead us to prefer one mode of treatment over another?  Perhaps the main advantages of medications are that they may act more quickly, and they may be less expensive, at least in the short run.  However, when treatment with medication must be kept up over many years (as is often urged) this price advantage can disappear fairly quickly considering the high costs of many medications.  The main advantages of psychotherapy are that it does not carry a demoralizing message that one is biologically defective, and the benefits of treatment persist after the treatment has ended.  The benefits of medication, on the other hand, end as soon as an active level of the agent is out of the system.  Furthermore, it has become increasingly clear that the withdrawal syndromes connected with terminating many psychiatric medications can be very severe (Whitaker, 2011).

There are matters of taste and preference, too.  Some people dislike the idea of manipulating their moods and thoughts by chemicals, and see it as artificial and inauthentic; or they may find that side-effects are unacceptable.  On the other hand, some people find it very difficult to speak frankly or even think clearly about things that have hurt them, or to open up to another person about their deepest assumptions, and they may prefer a form of treatment that is impersonal and purely medical.  Or people may simply find that, for them, one option is more helpful than the other.

To some extent, all of these distinctions are academic nowadays.  Many people who are suffering psychologically will try both forms of treatment, as they simply look for ways to be happier.  According to our Bill of Rights, we all are entitled to pursue happiness.  An intelligent consumer of treatment should explore all the options that our human ingenuity has provided for us, and most will do just that.

References.

Antonuccio, D.O. (1995, 1996). Psychotherapy for depression: No stronger medicine. American Psychologist, 50, 450-452.

Wexler, B.E., & Cicchetti, D.V. (1992). The outpatient treatment of depression: Implications of outcome research for clinical practice.  The Journal of Nervous and Mental Disease, 180(5), 277-286.

Whitaker, R. (2010).  Anatomy of an Epidemic.  New York:  Broadway Books.