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How to Have a Conversation About Medication in Therapy

An open discussion about medications can improve overall success in therapy.

If you are a therapy patient or care for someone who is, the possibility of taking prescribed medications for depression, anxiety, insomnia, mood swings, ADHD, OCD, psychotic symptoms, drug cravings, or any other mental health condition may present an unexpected challenge in treatment. The thought of taking meds may feel so intrusive or unnecessary that you may want to shut it down immediately.

As a psychotherapist specializing in the treatment of bipolar disorder, I routinely discuss issues regarding psychiatric medications with individual patients and family involved in therapy, and I’ve witnessed a number of reactions to the subject. Although I’m not a prescriber, I have found medication issues are frequently present as relevant therapy topics both before and after medications become integral in the overall treatment plan. And since most actual therapeutic contact is performed by therapists—not prescribing psychiatrists—I believe that developing a thoughtful, well-informed medication conversation is often an important part of therapy.

A combination of therapy and medication may be the most effective approach for many people suffering from mental health conditions. However, researchers in 2017 found that people seeking mental health treatment consistently preferred psychotherapy over medication, with stigma and negative attitudes towards people with mental illness reducing the chance of reaching out to prescribing psychiatrists. While attitudes about therapy and medications seem to be improving globally, many mental health patients may believe that there is a “choice” between these two treatments, rather than understanding how both treatments together can improve overall outcomes in well-being, particularly when medications are clinically indicated.

So, if your mental health professional suggests a medication consult or you simply have been wondering about medications on your own, there are some important points to consider in developing a healthy and collaborative medication conversation. First, I have found that therapists can have very different opinions about the role of psychiatric medications in mental health care. I believe a majority of therapists agree that medications are necessary for the most severe forms of psychological disorders, especially when psychosis is present. Yet many are still conflicted about when it’s appropriate to broach the subject of a medication referral, especially if the patient has never taken psychiatric medicines before or has experienced medication failures in the past.

Because of this, you may want to inquire about the therapist’s opinion about medications in general, especially as it pertains to the diagnosis of your presenting condition. If the therapist is not a prescriber, ask who they refer to and what you might expect from a medication consult with one of the known referrals. Also inquire about how the therapist handles medication issues in the context of the therapy session (e.g., unexpected side effects), and how they might handle collaboration with the prescribing physician when those issues are raised.

If an outpatient medication consultation is recommended, understand that it's not a done deal that you’ll be prescribed psychiatric medication. Nothing of the sort is finalized without your input, questions, and ultimately, your consent. So, it’s important to feel that you have been given the time and opportunity to ask questions and receive good medical information.

I’ve found that many of the fears around psychiatric meds come from horror stories people pick up from different sources. These can come from websites, blogs, or other media platforms that don’t adhere to reporting balanced, science-based information. Fears can be made worse with how certain pharmaceutical industry practices may raise suspicions around their products. On the other hand, people also may have had poor experiences in the past with medications, including non-psychiatric ones. Any previous experience should be discussed—the good and the bad—so the prescriber can address concerns and develop a treatment plan that takes those important needs into consideration.

There are frequently multiple medication choices for a single diagnosis, so if one med has not worked well, another option is likely available. And if medications can be held off for a time through therapy, then perhaps that can be a useful trial period to reassess the need for meds later. Also, it’s typically a good idea to ask prescribers what their procedures are in following the course of medication, and what to expect if it doesn’t work. Sometimes this question is looked at as the expectation of a negative outcome and is thus avoided. But I believe it can be a positive way to prepare for potential problems and seek ultimate success, no matter what may happen in the initial treatment phase.

Another piece of the medication conversation involves a thorough understanding and acknowledgment of the stigma against psychiatric medication. This factor should be discussed with the prescriber and the therapist as treatment moves forward. Over the years, I’ve heard patients say, “I don’t want to take pills because it means I’m crazy.” Taking medication does not mean you’re crazy.

Instead, this statement may refer to another, deeper fear beyond medication itself. Here, the term “crazy” actually refers to a sense of profound shame borne of the historical stigma associated with mental illness. Today it’s much easier for most people to go to counseling, but taking medications often remains taboo. Therapy can be thought of as life-enriching; but to many, medication means you’re sick and broken. Thus, the medication conversation can explore the possible feelings of shame in individuals and among their family members, especially when cultural biases may be present. If these are concerns for you, it’s important to share them with your treatment team.

Alongside shame and stigma is the question many people ask: “How will medications change who I am?” Notice that the deep concern embedded in this question isn’t about whether one will get well; but instead, whether there will be a loss of control within the individual. Identity issues very often are revealed through this process, which can be explored to increase overall therapy results. Again, sound information and sensitivity to your fears and concerns can set a productive framework for medication collaboration, as well as advancing treatment for all involved.

If you start a trial of psychiatric medication, know that the medication conversation is not finished. It simply continues into another phase. This is the time necessary to assess initial reactions to medications, especially where side effects are concerned. Having already discussed the possibility of side effects will help you know what to look for, as well as knowing when you should expect some of the main effects you’re hoping to achieve. This phase of care can require lots of patience and perseverance, which can be a great therapy issue in itself, and offer an opportunity for greater emotional growth. The medication conversation proceeds through medication trials and stabilization, with a positive, collaborative approach in place.

Questions beyond this phase often come down to either, “How long do I have to take meds?” or “Do I have to take meds forever?” These questions are inevitable but are too often left unspoken, largely out of fear of what the answers may be. The important thing here is to ask these questions out loud to your treatment team, and openly discuss the future of meds and all aspects of psychological treatment in your life. Working together through these concerns improves all outcomes while minimizing the possibility of treatment failures and symptom relapse.

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Angermeyer, M.C., van der Auwera, S., Carta M.G., Schomerus, G., (2017). Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: a systematic review and meta‐analysis of population surveys. World Psychiatry, 16(1), 50-61.

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