THE EFFECTS OF MEDICATING OR NOT MEDICATING ON THE TREATMENT PROCESS
Bertram P. Karon, Ph.D.
Michigan State University and the Michigan Psychoanalytic Council
As Johanna Tabin (2003) pointed out, medicating or not medicating has meanings for psychoanalysts and patients, including transferences and countertransferences. Helpful are the facts: Breggin & Cohen (2000) describe known side effects and how to optimally wean a patient from psychiatric medications, most of which have severe withdrawal effects.
I have never medicated a patient who was not on medication when they came to see me. It has never been necessary. I tell patients that I will never ask you to give up anything you need, but the odds are that you will eventually be off medication if you continue to work with me. For new or unmedicated patients, I say that if you want medication, see Dr. A, who will give you the right medication at the right dosage. If you want someone who will give you the right medication and also talks to his patients, see Dr. B. If you want to work, stay here. “Won’t you see me with medication?”
“No. But I will be here after you’ve tried it.” They get mad, but never leave. Physicians and nurses are most likely to use this as resistance, raising it whenever there is something else they should be talking about. I always summarize the scientific literature once. After that, ask what they might be avoiding. If you are concerned about being sued, let them know at the outset that medication is an option.
The Michigan State Psychotherapy Research Project (Karon & VandenBos, 1981) compared psychoanalytic therapy, with and without medication, vs. medication for severely disturbed center city schizophrenics. An average of 70 sessions of psychoanalytic therapy, with or without medication, was far better than medication, most markedly with respect to the thought disorder, but also led to a more human way of life and approximately half the probability of readmission within two years. Patients improved most if therapist did not use medication at all, or used it initially but withdrew it as quickly as the patient could tolerate.
Most, if not all, neuroleptic medications are neurotoxic. (Breggin, 1997; Breggin & Cohen, 2000. Recent MRI studies show intracellular damage from neuroleptic medication (e.g., Gur et al., 1998). The reported differences in the brains of monozygotic twins discordant for schizophrenia (Suddath, Christison, Torrey, Casanova, & Weinberger, 1990) disappear if the data are statistically corrected for lifetime medication dosage.
Courtney Harding’s (1988) long term follow-up study found that 50% of schizophrenics stopped taking their medication. Every schizophrenic who completely recovered (30%, as in most long term follow-ups) was among the 50% who had stopped. Three out of four patients in Gunderson’s study of insight vs. supportive therapy dropped out, because all therapists insisted that the patients stay on medication (Karon, 1984). Ann-Louise Silver (Silver, 2000) reported that when she first worked at Chestnut Lodge, her schizophrenic patients were not medicated. Later, all of her patients were medicated as a matter of policy. In the premedication days, she had patients who got romantically involved, got married, had children, and related to their spouses and children. None of her medicated patients ever formed a new relationship.
In the NIH collaborative study of depression, medication or two types of brief therapy were equally helpful during the first year. At 18 months they were still equally helpful but no better than placebo. In other words, medication or brief therapy help in the short run; but it takes work to change long term vulnerability. Of patients on maintenance medication for bipolar disorders who take their medication, 73% relapse within 5 years and 50% of those who do not relapse reported significant symptoms short of rehospitalization (Gitlin et al., 1995).
Recent meta-analyses find SSRI’s are only slightly better than placebos. They habituate and nearly two-thirds of depressed patients are medication resistant. The older anti-depressants, MAO inhibitors and tricyclics made patients fat. SSRI’s do not make patients fat, but they do increase suicide and homicide. The manufacturers have been successful in getting the newspapers not to mention the drug the patient is on when they go on a rampage.
Deikman and Whitaker (1979) demonstrated that you could take all patients off medications in an inpatient ward at the University of Colorado and the patients did better than on an expert psychopharmacology ward, including less suicides and re-hospitalization.
Anti-anxiety medications habituate within a year. As the British psychiatrist Isaac Marks said, if you cure an anxiety reaction with medication, you cure it for a year. If you cure it with a psychological treatment, you cure it.
Valium and Xanax are well known to be addictive, and many patients have had serious problems. Because of the danger of addiction, Kernberg has warned that they are especially contra-indicated for borderline patients. A less publicized problem with benzodiazepines is they interfere with the transcription of short term memory into long term memory, a serious side effect if the patient is going to have a normally complex life, which patients are rarely told about.
But if we are not going to use medications, then we need to talk about what you do with difficult patients. There is general advice, not specific to schizophrenia, in my book (Karon & VandenBos, 1981) on treating homicide, suicide, patients who won’t eat, patients who can’t sleep, catatonic stupor, and delusions.
There is no such thing as a spontaneous anxiety or an endogenous depression. If a patient is anxious, there is something to be scared of. If a patient is depressed, there is something to be depressed about. If it is not in consciousness, then it is unconscious. If it is not in the present, then it is in the past and something in the present symbolizes it.
The defense mechanism of isolation is typical of severely depressed patients. They typically make no connection between their feelings and obvious experiences that would depress anyone. It is always important to ask what happened before they started feeling depressed and keep asking when they say “Nothing” or “Nothing important.” The “unimportant” will turn out to make good sense of their symptoms.
I allow patients to call me. Rarely do patients abuse that privilege, but they can frequently weather a crisis, a panic, a suicidal impulse, a terrifying hallucination, even a psychotic break, if their therapist is a phone call away. Further, patients often get through difficult situations without calling you when they know they can reach you.
There are very few patients who will abuse this. Usually, they are depressive patients who use the phone call to torture you, to seduce you into treating them worse than their parents did.
Hallucinations are simply waking dreams. Get associations if you can, and use them in the therapeutic process.
If you think the patient is delusional, ask him or her to tell you about it in as great detail as possible. Do not attack or humiliate the patient or call it delusional. You never know that something is delusional just because it is improbable. If you investigate a delusion from the patient’s point of view, he or she will discover its inconsistencies or even that it is delusional. Then your interpretations solve a problem for the patient.
All that we have to offer our patients is understanding, but that is far more powerful than any medication.
[Footnote citations available upon request. ACW]