This week’s entry introduces the complex topic of how we approach the use, or non-use, of psychotropic medications. Jeanne Christensen, one of our most senior clinicians, offers a window into the partnership she develops with the client while in the role of Intensive Psychotherapist (IP). Supporting, clarifying, creating as much safety as possible, and always working to develop a collaborative relationship between the client and the psychiatrist, what she’s describing is an aspect of how we attempt to tailor our therapeutic environments to the very specific needs of each of our clients and families.
Underlying the IP-client alliance around medications is a key element of our view, stated succinctly by Ed Podvoll, MD: “The major point of medication usage is to ensure that the integrity of the wakeful mind is protected. The natural and inherent precision that can accurately discriminate dream from reality requires protection.” Of course, in order for us to be of aid in that highly subtle process, developing an open, honest, and trusting relationship with the client is paramount.
As Jeannie emphasizes, this won’t be possible without also protecting the client’s own sense of what works, and doesn’t work, for them. This points to another key element of our view and practice with medications; while being useful for many people, we don’t insist on their use as a condition for being at Windhorse. The path of how that all works will be discussed in our next podcast and in many to come.
Journeys with Clients and Medication
By Jeanne Christensen, MA
Part of my role as a Windhorse clinician is to explore with the client, when indicated, the usefulness of medications and psychiatry visits. Often, before I ever meet the client, I am trying to find a psychiatrist in town who both has an opening, and who I think might be a good match for that person based on what I know of the client’s history. Once the team is established, I accompany the client to their initial and ongoing appointments with their psychiatrist. At times, I may simply be a companion and observer. At other times, I may be an advocate, a moral support, a reporter, a tracker, or a suggestion-maker. I am an extra set of eyes, ears, and brains to join the person on their personal journey, which is sometimes painful and complex. I am often the communicator back to the team and family around medications, changes in medications, side effects and direction of treatment. I am often helping the client both understand and remember what the doctor has said and helping them formulate what to talk about before the next appointment. There are several factors that contribute to how this journey with medications goes. In this post, I will discuss my reflections on how clients view medications, their relationship with me, their relationship with their doctor, and their motivation toward wellness.
Views about medications
Different people view medications very differently. After all, what we put into our bodies, or what we allow to be put into our bodies, is a serious matter. It is common for Windhorse teams to begin with a person who has already been on a long and exhaustive journey with various treatments and medications. So from the start, they may be frightened, discouraged, hopeful, angry, traumatized, defensive, compliant, or have some combination of these feelings. Medications can be seen as a tool toward recovery. However, they can also be seen as a rescuer, an attacker, something to self-harm with, something to numb with, or something to avoid at all costs. Sometimes, there is a need to heal a prior psychological injury that happened from a bad experience with medications. There can also be mixed experiences, where perhaps a medication really helps calm certain horrible symptoms but has the side effect of weight gain or the inability to feel one’s emotions.
I have had a number of clients over the years who have expressed the wish not to have to take medications. To them, it feels horrendous to have a condition that requires medications in order to be of sound mind. They have already learned a lot about themselves—for instance, how they might begin to read too much into situations when things get overly stressful. They believe they should be able to keep this from happening, through self-awareness, self-calming, self-control, etc. It feels like a failure to once again have symptoms flare up. I empathize with this view. It is easy to lay blame on oneself for having any kind of illness. It can especially be devastating to identify as having a mental health diagnosis.
At Windhorse, we tend to talk about “extreme states” rather than mental illness. If I have an “extreme state,” I have an experience. If I have a “mental illness,” that implies a long-term condition, perhaps lifelong. Along with that comes stigma and shifts in outlook about my future. As a professional, I wonder what gives me the right to tell someone they will have such-and-such illness for the rest of their lives and that they will always need some kind of medication. In my experience, and in our collective experiences at Windhorse providing intensive relational and environmental interventions, I see that I do not actually have that right. I know that I cannot possibly predict a client’s future. I know people who were told such a thing in their past who recovered completely, without relapse. My position as I journey with clients is to keep an open mind, to help the client think about medications in the present—not as a life sentence—and to partner with their doctor to take the least amount of medication for the most beneficial effect.
Views about the therapy relationship
As a therapist, I spend anywhere from one to four hours per week with a client through direct contact and in meetings with the team and family. This really puts me in touch with the client’s experience. In his book Recovering Sanity, Ed Podvoll MD said, “Therapeutic exchange is a conscious process and happens because one has gradually developed the full intention of ‘giving up’ and ‘letting in’ . . . With this kind of gentle contact a soft spot in the patient and oneself can become available.” My sense is that through my exchange with the clients, they feel understood, and trust develops. Clients typically allow and welcome my presence with them at their doctor appointments. They also seem to feel okay about letting me know if I’ve said too much. I generally ask ahead of the appointment what they want to discuss. I might remind them of something I’ve noticed in terms of changes in symptoms having to do with mood, energy, quality of sleep and mental clarity. I listen to frustrations around side effects, and I encourage empowerment around sharing those pieces of information with the doctor. Hopefully, the client sees me as a non-judgmental and supportive partner to their recovery process.
Views about doctors
Ideally, the doctor would be seen as a friendly and knowledgeable partner and collaborator. If a person has either a tendency to defer blindly to authority or to fight or mistrust authority, those urges can get in the way of the collaborative spirit. Of course, how the doctor responds to the patient also factors in. There have been times following a doctor’s appointment when a client tells me they think their doctor is “mad” at them. Then I explore and reflect with them, comparing notes on our experiences and process the interaction. I have seen clients relate with their doctors anywhere along the continuum between ‘I don’t need you, everything’s fine’ to ‘everything’s terrible, I need you desperately!’
Some clients have no interest at all in seeing a Psychiatrist. If the use or non-use of medications is a point of disagreement between the client, family, and team, then we must determine whether we have enough common ground in order to enter a recovery path together. Occasionally there are times when we simply can’t all agree on how to proceed, and a team will not begin. At other times, we might all agree to proceed, at least as an exploration, of what might be most helpful between medications, no medications, or alternative therapies in combination with either.
Nowadays, there are known alternative treatments to pharmaceuticals, and many of the psychiatrists we work with are exploring integrative psychiatry as an adjunct to the ways in which they typically prescribe. We are more likely to hear information coming from the psychiatrist about nutritional deficiencies which can be corrected with diet and supplements, for example. Also, ketamine for depression and neurofeedback for a variety of anxiety problems have been highly successful alternative therapies for a number of our clients. Here in Boulder, we have a booming cannabinoid business, and some doctors are beginning to carefully explore the effects of different strains of marijuana as well as CBD benefits. Clients may want to get a massage or acupuncture or consult with an Ayurvedic doctor, all of which are generally supported by the psychiatrist. In this way, I believe, views about doctors are evolving. Rather than exuding an almost godlike authority and expertise, doctors seem to be exploring more with their patients as partners on a quest. This is a welcome evolution! Still, a doctor’s trust must be earned, and I have known clients who have wanted to change doctors. When this happens, I listen, process, and when we agree it’s warranted, I assist in finding a new doctor.
The client’s motivation toward wellness
As I think about a person’s journey with medications, what they are thinking about their overall life journey at any given point in time seems vital to how the experience of exploring medications will be. If someone inadvertently perpetually identifies as “sick,” it might be difficult to move toward a new identity of being well and functional. Being “sick” might deflect quarreling parents from hurting one another, for example. Fears about success and failure can also get in the way. It might feel easier to stay withdrawn because that feels safer in the moment compared to the pressures and risks of making a new friend or getting a job. Another complication is when the appeal to one’s inner world is greater than the desire to have a so called “normal” life. On Windhorse teams, we strive to assist clients in a “shift of allegiance,” moving from preoccupation and allegiance to internal thoughts and patterns to “cultivating one’s own health and sanity.” Even then, it can be a long journey.
Mostly what I have found in my work at Windhorse is that the client really appreciates having another person by their side as they go along their way. Exploring medications is an inexact science. The healing aspect of relationship seems to greatly aid that exploration.
Jeanne Christensen, MA, has been with Windhorse Community Services since 2004. She currently serves as an Intensive Psychotherapist and Team Supervisor, and she has prior experience on Windhorse teams as Basic Attender and Team Leader. She received her MA in Counseling from the University of Northern Colorado in 1985, and her BA in Psychology from Florida State University in 1982. For many years before coming to Windhorse, she worked as a Psychotherapist and Case Manager at the local community mental health center in Boulder. Jeanne combines a deep understanding of traditional approaches in mental health treatment with the Windhorse model.