Psychotherapy or Medication?
Rees Chapman, Ph.D.
I am often asked which is the best treatment for mental disorders: psychotropic medication or psychotherapy. Initially, I try to reframe the question as "what are the pros and cons of medication and of therapy?" This is because neither is perfectly suited to intervening in mental disorders, and at times the best outcome results from a combination of the two. I try to help patients understand, and seek more information about, the merits of both approaches.
In fact, certain disorders seem to be resolved better with psychotherapy. These include mild to moderate depression, anxiety disorders, behavioral disorders (in the absence of other psychopathology), substance dependence, and personality disorders. Some seem to respond best to a combination of drugs and therapy; these include ADHD, and developmental disorders. Others can be addressed psychotherapeutically without medication, although they often require a great deal of hard work by the patient and the therapist; bipolar disorder and psychotic disorders are examples. From time to time, researchers (e.g., in Western Lapland, Finland) demonstrate that, on a longterm basis, patients with schizophrenia actually functioned best with therapy alone, without medication, although the therapeutic intervention is apparently highly specialized. I have never worked with schizophrenic patients attempting to go medication-free, although I have provided essential emotional support and help in adapting socially and vocationally to the disorder while they are prescribed antipsychotic drugs. In two decades of practice, I have only helped a handful of patients with bipolar disorder function without psychotropic drugs. The approach is to help the patients be much more self-aware and self-disciplined, with many mechanisms of external support and structure (from significant others, employers, and members of his/her social network) devised and implemented. The cycles of mood are predicted and planned for, and they attempt to construct and organize their lives around the expected depressive and manic episodes. It is very hard work, and only a few were successful.
There is a principle I find useful with regard to medication, as well as therapy. It purports that we function best when we draw more upon our own internal resources to accomplish our goals than when we look outside ourselves for these. To the extent that we rely upon pills or other external devices to solve our problems, we are likely to become dependent upon them - if not chemically/biologically, then psychologically. The same is true of psychotherapy, as well; if we can't function without the advice of a counselor, then we become dependent upon others as sources of direction, and our own capacity for autonomy is compromised. This is why the best therapy is time-limited, with the client and the therapist collaborating to bring the therapy to some closure after accomplishing certain therapeutic goals. I have never told a client that he or she will require therapy for the rest of their lives - unlike some psychiatrists who tell their patients that they should never consider discontinuing their meds.