Implications for Therapeutic Practice
The Meaning of Symptoms
Symptoms mean more to the psychologist than merely a definition of the problem such as anxiety or depression, since they point to what the problem is about. Much therapy is essentially about defining and working through the problems which underlie symptoms. So they are not only the means of access to the underlying problem but also indicators of the resolution of the problem. Sometimes in the early stages of therapeutic work, people experience new symptoms or an increase of existing ones. This can be interpreted in two ways. It may be seen as evidence of an uncovering of what is the underlying problem, or it can be seen as ‘getting worse’. When people have the expectation that symptoms should be eliminated as evidence of progress or ‘getting better’, this may undermine the therapy. Clients who have accepted medication may not expect an increase of symptoms unless this is discussed early on in the process of contracting. It follows that suppression of symptoms with drugs may prevent monitoring of progress.
A second but related factor which needs to be considered is the question of the client’s motivation in seeking therapy. Hayward et al. (1989) who investigated the combination of benzodiazepines and cognitive behavioural therapy suggest that drugs may reduce the motivation for psychological approaches by giving the illusion of improvement and interfere with the development of tolerance to stress. They warn that state-dependent learning may be difficult to generalise, that is what is learned while taking drugs is not applied when people have stopped the drugs. Furthermore, people may attribute their improvement to the drugs rather than their own efforts, and clients may forget what they have learned in sessions.
The Case of Ian – Part 2
Ian had come for therapy to deal with relationship difficulties where he and his partner kept having rows over trivial matters and he finished up devastated for days. He had not discussed the drugs in depth because he did not think they were part of the problem and he was only taking ‘a low dose’. By chance he went away on a business trip and forgot to take the drugs with him and after three days felt nauseous, shaky and dizzy. He rang me and was shocked when I suggested he was having a withdrawal reaction and should restart the drugs immediately which should correct it. Were the drugs connected to the rows and relationship difficulties in any way I wondered?
Kahn (1993) suggests that most research assumes that psychotherapy and drugs work additively on different aspects of illness; psychotherapy for social functioning and medication for abnormal mood and thought content. This is probably a widely held view and would explain how medication and psychotherapy are so frequently combined. However it assumes that thinking and mood are abnormal and not related to the rest of psychological functioning or what is happening in a person’s life.
Kahn refers to the Boston–New Haven Collaborative Study of Depression, which produced four negative hypotheses. Firstly they propose that drugs are a negative placebo, increasing dependency and prolonging psychopathology. Secondly they point out that drug relief of symptoms could reduce motivation for therapy. Thirdly they suggest that drugs could eliminate one symptom but create others by substitution if underlying conflicts remain intact. And fourthly, they propose that drugs decrease self-esteem by suggesting that people are not interesting enough, or suited to, or capable of insight-oriented work.
Hayward, P., Wardle, J. and Higgitt, A. (1989) ‘Benzodiazepine research: Current findings and practical consequences’, British Journal of Clinical Psychology, 28: 307–27.
Kahn, D.A. (1993) ‘Medication consultation and split treatment during psychotherapy’, in M. Schachter (ed.), Psychotherapy and Medication. Northvale, NJ: Jason Aronson.