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Psychotherapy? Medication? Both? Neither?

On paper, two individuals may appear to be suffering from seemingly identical problems. But as I hope to demonstrate, decisions about treatment recommendations can only competently emerge from a careful assessment of the very particular individual, beyond how problems may appear on the surface.
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There is widespread and often strident controversy -- both in the general public and an alarming percentage of physicians, psychologists, psychiatrists, clinical social workers, counselors, coaches, etc., -- regarding the need for psychotherapy vs. medication vs. both vs. neither. Studies of questionable validity tend to be ham-fisted and poorly designed, simply because answering the question globally is like trying to capture smoke with a butterfly net. In contrast to statistical studies, there is a different kind of evidence based on boots-on-the-ground clinical experience over the course of one's career working all day, every day practicing psychotherapy. My own professional opinion is both crystal clear and decidedly equivocal -- It depends! On paper, two individuals may appear to be suffering from seemingly identical problems. But as I hope to demonstrate, decisions about treatment recommendations can only competently emerge from a careful assessment of the very particular individual, beyond how problems may appear on the surface.

To illustrate, I will discuss a hypothetical, 34-year-old individual who describes himself as "depressed and unable to get past my girlfriend breaking up with me after four years." Since the breakup the prior weekend, he has had great difficulty getting himself out of bed and functioning as a promising young physician. He shows up for an initial session looking visibly depressed, anxious, disheveled and exhausted.

-- The case for psychotherapy alone. In hearing the person's narrative, we learn that the breakup is but the latest in a recurrent pattern, invariably triggered by his girlfriends' perception that he is unable to match their level of commitment. In all instances, he has secretly wondered, "maybe I could do better." Whereas in his 20s, his non-commitment seemed to make sense, he is beginning to recognize that the problem may have less to do with unwillingness and more to do with an inability to commit, despite his avowed desire to have a family. We also learn that his parents were divorced when he was 5, that the impact was "devastating," and that as an only child, he perceived his mother needing extreme emotional support from him. Aside from this most recent breakup, in which marriage had been seriously discussed, he has never experienced overt depression. His many friends view him as humorous, engaging and very hard-working. He clearly has a naturally sunny, resilient disposition.

Given his psychological-mindedness, his recognition that he is caught in a repetitive pattern of avoiding intimacy, his strong motivation to change based on his feelings of devastation and fear that he would never be able to marry and have children, and his awareness that his family history may in some way fuel his problems with commitment, he is an excellent candidate for developing insight and awareness into his clearly defined pattern of relational self-sabotage. Medication is out of the question.

-- The case for medication and psychotherapy. Now let us conceive, in many respects, of the same individual. The glaring difference is he never remembers a time in his life when he felt a sense of joy or unrestrained pleasure, even following achievements or events that might typically be cause for happiness. Always driven, he has the same promising career ahead of him. But with each rejection, his devastation lasts for months, threatening his academic and professional success. His pervasive aura of gloom and negativity puts people off, resulting in few friendships, a loner mentality, and accompanied by a sense of clinginess and suffocating dependence on girlfriends that they all described as driving them away. Following his parents' divorce, he described his mother as never bouncing back to life, retreating frequently to her bedroom, unable to show warmth or even interest in her son beyond his accomplishments.

This gentleman is clearly in need of sorting out his emotions and attitudes which interfere with all relationships and threaten his professional success. But unlike the person described above, his pervasive history of isolation, joylessness, alienating dependence on girlfriends and inability to recover from rejection, it is highly unlikely that psychotherapy will be able to get very far in the absence of antidepressant medication. I speak with him about not getting a "fair shake" from his own biochemistry and he warily agrees to consider medication.

-- The case for medication alone. Let us now consider the person above, identical in his initial presentation, but lacking in psychological-mindedness: a sense that there is more going on here than meets the eye. He views his pattern with "fickle and unreliable women" as bad luck in not yet having found the right one. Once that happens, he believes everything will fall into place. He is disdainful of shrinks, thinks they're only for crazy people, and states, "No offense, but I came here looking for medication that I thought you could prescribe. Can you refer me to someone who can?"

For obvious reasons, this is not someone who can earnestly engage in psychotherapy given his conviction that all of his problems are simply bad luck, his sense of stigma associated with psychotherapy, and his complete absence of psychological-mindedness. Nevertheless, it is clear that his problems, like the gentleman above, also have a strong biological component. As such, he could potentially feel better if he were to see an expert in psychopharmacology who could regularly monitor benefits vis-à-vis side effects and adjust accordingly. Were he simply to receive a quick prescription from his internist with no consistent follow-up, there is a strong likelihood of failure to benefit, following which his disdain for psychotherapy would infiltrate medication as well: "Yeah, I tried medication and it only made me feel worse."

-- The case for neither. Consider the prior person having already failed in his attempt to try medication without expert prescription, monitoring and follow-up. He scorns psychotherapy and continues to view his problems as bad luck with fickle women. His solution is simply to suck it up and try harder to find "the right one."

As I have tried to illustrate, in offices of physicians, college counselors and psychotherapists who are overrun with patients due to the impossible demands of insurance companies, Medicaid, and Medicare, a quick prescription or piece of advice often does more harm than good. Similarly, given the dictates of insurance companies and the dearth of out-patient clinics due to draconian budget cuts, there is often no place to refer someone for competent psychotherapy. But when adequate resources are available, it is essential to carefully assess the unique individual's need for psychotherapy and/or medication beyond initial impressions.