Most people expect psychiatrists to be pill-pushers. That is what we are experts at. However, not all of us emphasize medications.
Before medical school and psychiatric residency, I earned a B.S. in Psychology at the University of Michigan, where I was actively involved with Behavior Modification and Transactional Analysis. After medical school, my residency training program taught a rich variety of techniques, including CBT and Intensive Psychodynamic psychotherapies. Since then, I worked for several years as Adjunct Professor of Psychiatry at Stanford, learning, then teaching Dialectical Behavior Therapy (DBT) to psychology residents. My approach has evolved more and more into behavior change, and utilizing medications to facilitate behavior and lifestyle changes.
Medications are not good or bad— each one has pros and cons. Most people worry about becoming addicted, or complacent, if they take psychiatric medications. Fears include:
The stigma of what it “means” to take such medication
Meds will not deal with what they are stressed/depressed about
They are just a crutch
Might feel better and not want to work on self-improvement
General fear of side effects, most often weight gain
Being overmedicated, drowsy, emotionally numb, not caring
Being unable to get off medications
These are all real concerns, and should be discussed with clients. However, they are often overblown and distorted, becoming false facts. These fears can all be addressed as part of a comprehensive treatment strategy. Usually we can find medications that don’t cause weight gain or other serious side effects. Many clients who benefit from medications can eventually come off them if the psychotherapy and medications are managed corroboratively. We can also learn to look at psychiatric medications, and people who take them, non-judgmentally.
A major part of learning mindfulness is to rid ourselves of judging; ourselves, others, and getting away from seeing things as “good or bad.” We must apply the same perspective to medications, and understand that they are not good or bad. Instead, we can see medications as having pros and cons. I often add that not taking medications has pros and cons. Remember we are in 2017. The psychiatric medications we use nowadays have far, far less side effects than the older ones.
We are not faced with a black or white choice, talk therapy or pills. The best option is often both. Medication can be used to facilitate psychotherapy. The right psychotherapy can help many people get off psychotropic medications. I feel so strongly about this I will usually only prescribe medication for patients doing psychotherapy.
A synergistic approach aims to incorporate and coordinate psychotherapy, behavior/lifestyle change, and medications when appropriate. We are not trying to “fix” the client, or the diagnosis. Instead, our goal is to move the client from Illness, to Health, and all the way on to Wellness.
| ILLNESS | HEALTH | WELLNESS |
Symptoms |
| Neither good nor bad | Routines and behaviors designed to:
|
Feelings & Attitudes |
| Getting by |
|
Result | Low energy: Car sputtering | Medium energy: Car runs but not all cylinders are firing! | Energetic, motivated: All cylinders firing! |
We help the client understand what Wellness looks like, what the role of therapy would be, and their own role and work. Think about medications as reducing symptoms that interfere with goals of therapy and lifestyle changes. These symptoms can include:
Anxiety
Insomnia
Emotion dysregulation
Concentration impairment
Lack of energy/drive
Persistent negative beliefs
Critical/shaming self-talk
As a psychopharmacologist and psychotherapist I see how these symptoms can become hurdles to psychotherapy and behavior change, and how addressing them chemically can reduce the hurdles as we move down the field toward Health and Wellness. When we all do our jobs right, the client becomes Well and learns to maintain Wellness. Then, and only then would we start reducing medications. It is important that that time is chosen corroboratively, and that therapy continue (with modifications) while medications are titrating down. Some clients will be found to do best long term with medications.
Where does mindfulness fit in? Mindfulness practices have been translated from eastern beliefs and traditions for our “American” minds, by psychologists Jon Kabat-Zinn, Marsha Linehan, and others. In DBT, people learn a variety of coping tools for behavior change, grounding, emotion regulation, and self-care. The prime tool is Mindfulness Practice, which teaches:
Being in the present, observing/aware of what’s happening, externally and internally, and
Non-judging, because if we get distracted with judging, blaming or criticizing we lose our focus, cause suffering, and block learning.
Most of what throws us into the past, into the future, or into self-criticism, is that voice in our head. That voice, sometimes called “the critic” or “monkey mind” (and many other names) is basically the voice of our childhood programming: our black or white beliefs, judgments, assumptions that get programmed by parents, teachers, clergy, bullies, etc. when we are young. This stream of consciousness becomes our “Default Neural Network” (DNN) which most of us confuse for our self. When we practice Mindfulness, we begin to separate our self from this stream of thinking, beliefs, interpretations and judgments, thereby seeing ourselves and events more objectively.
Our DNN is constantly judging, that’s its job. With anxiety, depression, and trauma, this system is hyper-active. The more we listen to it, the more it is fueled. Conversely, the less we listen to it (by re-directing focus elsewhere) the weaker it gets. Brain imaging studies have shown that over 6 months Mindfulness practice reduces the activity of the DNN. It changes the brain! Mindfulness training helps to separate our self from this system. By practicing mindfulness exercises regularly, we train part of our brain to track what is happening inside and outside, moment to moment. We develop a “higher part” of our mind, which in DBT is referred to as “Wise Mind.” This is an alternative brain network that is often underdeveloped, and like a muscle it can be exercised and strengthened.
However, most people we are trying to help have obstacles to learning. They may have negative beliefs (coming from their DNN) that nothing will change. Lack of energy and motivation are common. They may have trouble concentrating, and/or too much anxiety to do the exercises. They may be too disorganized to prioritize. Medications may help reduce these obstacles.
Since we can now “see” the DNN in imaging studies, we can see what reduces its activity. Meditation reduces the activity of DNN, and so can antidepressants. I frequently see that negative, critical voice quieting with meds. Psychotherapeutic response is accelerated.
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When I grew up, we used terms like “upset” to describe, in a very vague way, that we were emotionally off-kilter. Nowadays DBT has a better term, “dysregulated.” This also implies that we can feel “regulated.”
Consider different levels of dysregulation, beginning with zero, no dysregulation. Grounded. On a scale from 0 to 5, 5 would be off-the-wall, for me, at 5 I’m yelling at people and out-of-control.
Paying attention to our emotional state is important if we want to be fully effective. The earlier we realize that we’re dysregulated, the easier to re-regulate. Often, we don’t realize how dysregulated we are before it slaps us in the face. Often, we start the day dysregulated, only to get more and more dysregulated as the day goes on.
The solution is to begin the day with meditation, yoga, T’ai chi, or something similar so that you start off grounded, ideally close to “0”. Mindfulness practice develops the part of the brain that can actively monitor your level of regulation/dysregulation, as well as many other factors through the day. Coping tools such as breathing exercises, thought stopping, redirection and many others are useful each time you find yourself getting a little dysregulated.
In the graph above, the lower levels of dysregulation, 1,2, maybe level 3 can usually be managed with active use of coping tools. If we miss the opportunity and don’t realize we’re dysregulated until we reach higher levels of dysregulation, then it may be too late for coping tools alone. You may need to take a chill pill.
But that’s ok! Use the incident as a learning opportunity! At this point people will often get down on themselves, that they failed because they had to take the pill. Anticipate the judging, and practice non-judgmentalness toward self and medications. Taking medication isn’t good or bad.
I tell my patients they can do both, the pill and the tools. The medication makes the tools work better; the tools help the medication. Once re-regulated, look back and try to identify earlier opportunities you may have missed to apply the coping tools for next time.
It can go this way:
You’re at level “0”. Calm and regulated. Someone gives you a weird look. You think:
“Why did she look at me like that?” (level 1 dysregulation)
“Maybe I’ve got something on my face, or my hair is messed up” (level 2 dysregulation)
“What if she thinks I’m a slob?” (level 3 dysregulation)
“Why didn’t I check the mirror? (level 4)
“What’s wrong with me?” (level 5)
Another way to describe this is at level 1 you are asking the question. If you start to answer the question it escalates you to level 2. If you get caught up in this stream of thought, you get more and more dysregulated.
Learning Mindfulness and developing Wise Mind requires active intention, prioritization and practice sessions. Over time, Wise Mind is running in the background, like a spell-checker, ready to pop out when necessary. In this case, “You just asked why that lady looked at you like that. Do you really wanna go there?” More and more automatically you will catch the initial thought, which could lead to dysregulation. It’s like the train starting up at the station.
If you automatically begin to answer the thought, you’re getting on the dysregulation train. However, if you tell yourself you just had a dysregulating thought (the train is about to take off, do I really want to get on it?) you now have a choice. Answer the thought, jump on the train, or redirect your mind in another direction. The dysregulating thought goes away in a puff.
Each time we recognize the DNN trying to hijack our brain, and we ground, re-center or re-direct our focus, we are weakening that DNN over time.
Clients need to get this! By intentionally giving less and less attention to our DNN, those judging networks become weaker and weaker. Most of the hard work is up front, learning to separate our consciousness from our DNN. In the beginning it can be like trying to train a wild horse. Many clients give up trying meditation and say “I tried it, it didn’t work for me.” Many or our medications can reduce the agitation of that wild horse, making it easier to train.
Some psychiatric medications can be used on an as-needed (“PRN”) basis, as in the earlier examples, while others are best used on a routine basis, usually once/day. Many, but not all medications which are only used PRN can be habit-forming, while most used routinely are not. Consider a daily medication for clients who are more depressed, having more trouble with activities of daily function such as concentration or self-regulation, as well as those struggling with psychotherapy (which includes ability to do homework).
Psychotherapy is treatment of choice for most emotional problems. Some people, with more biological disorders such as Schizophrenia or Bipolar, may need meds for life. The answers we receive depend on the questions we ask. Most people ask, “Do I need medications?” usually the answer is no, you don’t “need” them. For example, you can choose to continue to struggle or suffer. The better question is “Could I benefit from medications?” which can hopefully lead to a non-judgmental, objective discussion about potential benefits versus side effects, and how medication may fit in with the overall treatment strategy.