I am a psychiatrist working in a health maintenance organization (HMO). I live in a world where Internet has replaced aboriginal mental telepathy, Tonya Harding news supersedes news of suffering in Sarajevo, jokes about the Bobbitts surpass the wisdom of true humor, the Dow Jones Average matters more than dreams, and Prozac threatens to surpass aspirin in popularity.
I feel troubled by the indiscriminate use of medications in psychiatry, but also recognize that clients benefit when they take them. This challenges me to find new ways to integrate medications and to make their use more meaningful, rather than just swallowing a pill each day. For some clients “swallowing the pill” is enough, but for others it is not. Establishing a relationship with the medication or actually “becoming” it, as the following examples will demonstrate, provides one way to integrate medication and the individuals’ desire for increased awareness about themselves.
Fortunately, after my psychiatric training, I had the opportunity to study Process Work. Both my professional and personal life were impacted and deeply changed by this study. As a result, I now look at medication prescription with a different perspective. Putting together Process Work and traditional psychiatric training has challenged me. The process work approach offers a way to enrich psychiatric practice with a respect for exploring individual processes in a psychiatric setting.
Outside of private practice, much of mental health treatment is now governed by cost and not necessarily by quality. Insurance companies pay for the shortest possible route to improvement. Medications can bring improvement in several weeks; consequently, some insurance companies pay for only two to five sessions to treat such problems as major depression. Life situations, intrapsychic conflicts, spiritual crises, etc., that may lie at the root of a client’s difficulties are subsequently not explored. This turns much of our current mental health practice into an “antiawareness” system. Many clients worry about “just taking a medicine,” feeling like “passive recipients” while the medicine contains all the healing power. Hearing from my clients about this conflict led me to think about and explore possible ways of “relating” to medicines. Since time with clients is so limited, I needed to find a method that interested clients could also do on their own each time they had contact with their medication.
In this article I will share with you some of the ways that seem helpful for individuals who wish to increase their awareness. These methods are applicable in a psychiatric setting that challenges awareness to the limits and which frequently provides only a few opportunities to be with a client.
The tools of psychiatry no longer seem built on human relationships, but are related to psychopharmacology: Buspar, Zoloft, Effexor, Wellbutrin, Haldol, Clozaril, Risperidone, Prozac, Lorazepam, Lithium, Tegretol, Nortriptyline, and many more. Most of the clients I see come specifically with a referral or request for medication evaluation. Some come asking especially for Prozac since it has achieved such popularity in the media. Others arrive from the hospital where they have been treated with Haldol for their psychoses. Still others are referred by their therapists because they wonder if medications would help. Many come because they suffer from drug or alcohol dependency.
Depression has become an epidemic in our society. Therefore Prozac, a newer antidepressant with fewer side effects, has gained immense popularity. The following examples will focus on how, in a brief period of time, the use of Prozac can provide a key to explore the deeper aspects of a person’s life. It is interesting to note that the clients in the following examples all had different experiences of Prozac in their bodies. Some details have been altered to protect confidentiality.
Client A is a professional woman, married and the mother of a four year-old child. She is an attractive, athletic woman who is troubled by the amount of time her profession takes when she really wants to spend more time with her son. She adamantly asks for Prozac, which a friend had recommended because it helped the friend with a similar conflict.
This woman and I went together on a “Prozac journey.” Initially we explored her feelings and fantasies about what an antidepressant might act like in her body and what it might do for her. She was curious and courageously responded positively to the suggestion that she actually pretend to be Prozac inside her body. As Prozac, she pushed against a big heavy weight. I pushed against her, standing in for the big heavy weight. She responded by pushing against me with a strength surprising to her. She spontaneously made a shift in awareness and saw that her profession was like the weight she pushed against. She realized that she really disliked her profession and that she experienced it as very oppressive. Previously, she had been aware that she wanted to spend more time with her son. Through this experience, she contacted the thing that oppressed her. She also contacted her strength, a previously unknown resource.
She returned three weeks later having made a job change, one in which she had much more time to spend with her family. She continues to use Prozac, which she now identifies as a powerful ally.
Client B is a 39 year-old woman referred by her therapist for assessment of depression. She has had a long history of deprivation and neglect. In her family of origin, she was the youngest sibling, with five brothers and a sister at least ten years older. Her father died when she was five years old. In order to remove her from the abuse of her alcoholic mother, an older brother invited her to live with him, but he also abused her emotionally and physically. A later placement with foster care did not prove significantly more supportive. Thus, the client remembers being depressed for most of her life. This depression had worsened for three to four months prior to the evaluation. She came to the interview saying, “I feel like I want to die.”
I suggested to the client that perhaps something wanted to happen in her, something motivated by her thoughts of wanting to die. Also, I suggested that going into a deeply internal state might have great benefit to her. I invited her to “die” right now by acting out her death. She immediately leaned back and closed her eyes. I supported her by suggesting that she trust what was happening. She suddenly opened her eyes with a surprised look, saying that she heard a “voice” telling her she was okay and that she could live. This was a new and exciting experience for her. During our discussion of what it meant for her, a “critic” began to reveal itself. Getting to know the critic helped because she saw how much the critic resembled the early abusive relationships in her life. A next step in working with this client would be to help her identify with the power of the critic, something that she was unable to do at that time.
This experience was mirrored later, when she asked for Prozac and I invited her to become the drug. When she imagined into what it would be like to be Prozac, she described herself as a collection of atoms like that found in any aspect of creation. Within this experience she found a transcendent element, similar to her earlier experience of “dying.” This made her feel content and happy. As Prozac she found herself doing battle with obstacles that stood in the way of her feeling happy. At this point I had a strong urge to arm wrestle with her and thus represent the obstacles in her way. She seemed not to have had much opportunity to realize her strength. She won with dancing eyes. I prescribed Prozac.
At follow-up she had continued to develop a relationship with the drug which minimized the feeling of powerlessness that so often accompanies the use of medications. She had also increased her own ability to do “combat” with obstacles.
Client C is a single woman who had already been placed on Prozac by her family physician and now wanted to work on problems and “stop fooling around.” She gave a history of having a very abusive father. He told her numerous times that he hated her and would try to break her spirit. Her early adolescence was spent defying him, which provoked physical beatings. To escape, she eventually started drinking. She considers herself alcoholic, but stopped the use of alcohol several years ago. However, she now felt addicted to caffeine and wondered if she might be addicted to Prozac, since she felt her mood had improved since being on it.
I also invited this client to become her experience of Prozac, the “mood elevator,” as she put it. She made a spontaneous arm movement. When we amplified the movement, she flew bird-like through a forest filled with tall trees, wild animals and beautiful streams. A huge contentment filled her being.
This woman’s worries about addiction diminished as she grew aware of her own ability to embody the “mood elevator.” Prozac seemed to help her contact the mood elevator inside of her. This state is already a part of her that, partially due to her abusive past, isn’t easily accessible.
These case studies exemplify a way in which I feel more satisfied about prescribing medications, especially with clients who are seeking to understand more completely the relationship of medication to the difficulties which have prompted a referral for pharmacologic evaluation. This method offers clients two new opportunities. First, it provides an active relationship with not only the medical system and caregivers but also with the pharmacological interventions themselves. Second, it offers a way to use the crisis that brings people into psychiatric care. They gain an opportunity for growth and development instead of just receiving a pill to help them cope. This approach is a beginning in exploring medication intervention in a mental health culture driven more and more to brief solutions and the use of psychopharmacologic interventions.
Jan Loeken, MD, who learned to love nature in her growing up years in Montana, currently lives on a houseboat and works as a psychiatrist at an HMO in Seattle. She will soon return to work at a women’s prison. Through her work, she hopes to help others touch the wondrous spirit shared by us all.