Antidepressants: a psychotherapist's view
I have decided to reflect on this issue for two reasons, the first reason being the recent news report (BBC, Guardian) that has shown that more than half of all those taking antidepressants experience withdrawal problems - which for millions of people are severe. Secondly, I want to try and inspire people to engage in a psychological process instead of - or combined - with taking antidepressants.
Generally, from my experience, the people who take antidepressants have ultimately found their state of mind, or how they feel, too unbearable - hence they turn to a GP to seek relief. In one such case, I was told that the GP had passed a remark saying that “you wouldn’t think twice about taking a paracetamol for a headache, so you shouldn’t think twice about taking antidepressants if you feel depressed”.
In some circumstances, taking antidepressants may be the correct clinical intervention, especially if symptoms are too debilitating or therapeutic/family support and psychological insight is lacking. However, I fear that the above GP view may not only undermine the premise of therapy (the talking cure) but, ultimately, it can lead the person to doubt their own innate capacity to understand their own mind. Consequently, a golden opportunity may be missed to grow their psychological muscle - or, in Carl Jung’s words, to ‘individuate’.
People are complex systems, with both a conscious and an unconscious mind. I quite like using the metaphor of an iceberg to describe this internal state of affairs. Think of the small mass of ice sticking out of the water as our conscious mind, and the huge mass under the water as our unconscious. As you can imagine the small mass out of the water is very tiny compared to the huge mass underneath; and so, ultimately, much of our waking life is influenced by the huge unconscious mass lurking beneath the water.
Unfortunately, I fear some GPs rooted in their medical model are only aware of and concerned with the conscious aspects of a person’s personality. For instance, a patient may present as depressed and, accordingly, the GP may prescribe an antidepressant. However, this does not necessarily mean that other underlying dynamics or states of mind have been resolved. If anything, it can complicate the picture and lead to a dependency on antidepressants or other medications resulting in a reluctance to withdrawal. A good illustration of this is if a person has an addictive feature to their personality, or has an unconscious investment in being a victim; in both scenarios, we can imagine how withdrawing from antidepressants - or any medication - would be very difficult for more reasons than we might imagine.
So why do some people prefer antidepressants compared to therapy? Apart from the obvious reason of there being a lack of therapeutic services (for instance most psychotherapy services have been cut to near extinction), I think one of the main reasons is the fear of having a depression spiralling out of control, in which a person fears that they will not cope. For some, they opt for the following solution which is: swallowing tablets equals swallowing emotions.
Where appropriate, I try and encourage patients to embrace chaos (emotional breakthrough not down!) so that a new order (state of mind) will emerge. For some people, the thought of working through chaos is too scary and frightening, hence they keep to the old order of life which is familiar, safe, but inevitably miserable. Secondly, trust and control seems to be relevant here in which it is easier to control and depend on a tablet than to be in an emotional relationship with another person, who might let you down. A tablet can be easily picked up when needed and will not let you down. (Well as long as it can be taken regularly as prescribed). In comparison, when engaged in therapy a person has to wait until the next encounter with the therapist. To simplify this matter we might describe the aim as trying to transfer a dependency from a tablet to a dependency onto a person (therapist).
The transference of dependency from tablet to a therapist is a creative response because it provides a process where both the presenting and underlying issues can be discussed, explored and analysed. During this process, the aim is to connect with feelings and emotions that may have been blotted out by the medication that a person has been taking. These emotions and feelings generally relate to various painful issues that our conscious mind has found too unbearable to integrate and as a result has redirected to our unconscious mind. To begin with, this can feel like one big mass of despair or depression which is difficult to explain. Analytical psychotherapy offers an opportunity to disentangle this mass into tangible pieces of insight. It is these tangible pieces of insight combined with the release of emotions that eventually enable the person to understand there own mind. The aim being that the person can use their own mind to manage there internal situation rather than a tablet. Finally, an important element in this process and journey is to encourage the patient to discuss a plan of withdrawal with their GP. I think this is important as it provides a safe passage /procedure for correctly reducing their medication at the right time.
It is my view that being dependent on a therapist is healthier than being dependent on a tablet. The main reason being that therapy offers hope, insight, integration and growth while the tablet offers some people a safe but miserable option.
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