Therapy and medication: Can we have one without the other?

[brightness]

I've been an undergrad psych major and a psych patient, and I've done therapy and medication for treatment. Until I decided to try medication, I was 100% on the path to becoming a clinical psychologist. However, after some symptoms became worse, and at the recommendation of a trusted psychologist, I decided to try medication. Within 6 months I experienced a strong turnaround and relief that was...well, it seemed miraculous. From that time on, I stopped being sure about being a clinical psychologist and explored a lot of career paths; however, I always stayed interested in mental health.

My biggest question is whether or not I want to be a practitioner in the mental health field that cannot prescribe medication. I want to know what a psychologist has to offer that a psychiatrist trained in therapy doesn't...and furthermore, can a psychologist fully treat the symptoms of mental illness despite the inability to presribe? For years and years I went through psychotherapy, but I needed the combination of medication to help me get "leveled out" (as leveled out as I'll ever be!). I really want to know what a psychologist offers a client that a psychiatrist doesn't.

What do you think?

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[cara susanna]

Usually psychologists work in tandem with someone who can prescribe, either a psychiatrist or the person's HMO.

As for the difference, not all psychiatrists offer talk therapy. Some do, but not all of them.

 

[RayneeDeigh]

Well first it's important to keep in mind that the huge population that uses the mental health field is extremely varied. There are people with different disorders/issues/problems than your own that may need only medication, only therapy, or a combination of both.

A large number of psychologists "share" their client populations with psychiatrists who handle the prescriptions and medication changes. When it works well it's teamwork and when it doesn't, it's a big mess with lots of disagreements. I think the mental health field in general is moving towards an interdisciplinary approach though, I'm sure we'll see more of this as time goes on.

However, it sounds like you're looking for us to talk you into wanting to pursue clinical psychology. We can't really do that. If you believe that medication is a key part of managing mental disorders and you want to be the person doing the prescribing, then you'll probably be unhappy with psychology unless you seek licensure in a state where there are Rx privileges.

I also want to point out that your personal experience is just one instance. Some people make leaps and bounds in psychotherapy and others don't, just like some people respond to medication and others don't

 

[BamaPsych]

This is a very important topic to me. Initially upon exploring careers in mental health, I asked the same questions that you did.

Personally, I feel that some patients may respond better to therapy, some to medication, and some to both equally. I know people first-hand that require antidepressants, indefinitely, to live a happy lifestyle. These people that I'm reffering to do not attend therapy sessions but are happy to have their medication and content that it resolves their problem. I also know someone that was on antidepressants but felt like it altered their personality so much that they hated themselves...and they sought therapy to confront their disorder from that angle. Using depression as an example...I believe some people are depressed because of their interpretation of events (learned helplessnesses) and some have a biological disposition, and some may have both. Science (both medical and psychological) supports both of these notions. Therefore, I believe that each field has their own place in treating such disorders.

This is really cliche, but from personal experience I just believe some people respond better to certain types of treatment (therapy vs. medication vs. therapy + medication).

Ultimately, I decided against Psychiatry not because I thought Psychology was more effective or some other "greater than/less than" rationale. The simple thing that barred me from that career path was Med School - no way could I handle certain rotations (I hate blood, surgery, giving people shots, etc.), so I wouldn't survive.

 

[Mr Violin]

I used to think about this issue a lot when deciding what career I would chase down. Let me first say that my opinions are probably biased towards what I want to believe but at the same time I try to consider the facts I know equally. Also as a disclaimer I am still an undergrad and am still learning and expanding my understanding of psychology and the mind, a process which will probably never stop.

There is a plethora of research indicating that biology and neurology play a roll or have traces in many mental disorders.

The philosophy of the chicken and the egg here (in some disorders) is what fascinates me. We seem to know so little about conscious thought and the influence it has on the body that maybe in some cases/disorders it is the "mind" changing first and in turn altering the body to reflect or make possible that change.

Take for example the link between a dysfunctioning amygdala and antisocial personality disorder. I may be pullin' a lot of this out of a hat, but what happened first? Did the individual think in such a way that removed emotion from his memories, or was he born with a dysfunctional amygdala that molded his personality absent of emotion/regard for others.

Even if we can locate a gene that says a person is "at risk" for developing a mental disorder there are still environmental influences that play a role in whether or not that prophecy is fulfilled.

Or what about when someone consistently smiles versus frowns. I think (please don't be wrong and look like an idiot ) research has shown that when someone consistently smiles they are happier as opposed to someone who frowns. Here the mind is influencing the body (telling it to smile) which in turn influences the mind (affective state). I know this is a vast oversimplification when attempting to compare it to the possibilities of some mental disorders but my (here it is..potentially biased) opinion is that the mind and body are a two way street (although the influence one has on the other is not equal. I.e. those disorders with clearly large biological roots won't just be magically fixed by altering the way the "mind" thinks).

It might help to figure out in what way you want to work with people and where you think your strengths are in such a task. Also, only you can figure out what is most interesting and what you feel the most passionate about.

For me it was the realization that yeah, treatments may be multifaceted/interdisciplinary but I am most interested in the cognitive implications. Don't get me wrong the biological/neurological aspect is also very intriguing but I want to focus on the psychological angle of mental disorders for my research/practice which is why I will be applying to clinical programs.

Wohooo!

 

[brightness]

A part of me does think that I want to be talked into clinical psychology, because thats what my degree was preparing me to do...or, thats what I thought I was doing for a long time. I've been feeling like I have no idea what to do now.
I agree that some people respond to therapy moreso than medication, others to medication moreso than therapy. I always thought I'd be in the first group, and it was a shocking blow to be in the second- it made me feel like I failed in therapy. Of course you have to take every individual as an individual. The reason I brought up my personal experience was because that is what made me second guess clinical psychology as a career- I don't want to transfer my patients care when I know them so well as a therapist!

Maybe thats just the control freak in me. But what happens when a psychologist doesn't see eye to eye with the psychiatrists (or NP, or PAs) prescription and care plan?

 

[WannaBeDrMe]

With my experience, I've seen the flipside. I've seen lots and lots of people flip out from reactions to medications. Not just psychotropics, even benadryl can push someone into an altered state.

Even so, I don't want to do therapy or prescribe. I want to offer and encourage more solid and thorough diagnostics before people rush to establish a plan of care filling people full of meds or letting them sit with a thought record for a few weeks until their next appointment.

There are SO many opportunities within mental health. As the others have said, this is truly a place where there's room for lots of different approaches. You will have clients just as varied as your colleagues. I've had a range from students embarrassed by their financial situation (which I do take seriously) to individuals who bit chunks of flesh out of their own arms... in my presence.

Don't feel like you are settling for whatever route you choose. If medicine is your passion, there are dozens of jobs in psychopharm. Research, testing, development, marketing, sales, you could go to med school to become a psychiatric phyisician, you could go to DO school for more of a mind-body approach. I know DO's get knocked but for my money, if I had a choice, I'd choose a DO physician every time over MD for any ailment.

When the clinicians don't see eye to eye, there are staffings/treatment team meetings. I've stood up to every psychiatrist I've ever worked under at one point or another. Sometimes, he agrees, sometimes, he showed me I was wrong, sometimes, we just walked away pissed.

It's like any other professional relationship, it's a collaborative effort. Nearly every psychdoc I've worked with has really and truly valued me as a clinician and respected my input. They take what I shared and they couple that with their assessment to create medical interventions, if necessary.

BUT... docs come in all colors too... I worked under one dude that I do not respect at all who believed in poly-pharmacy. That can mean (as it did for him) hit them and hit them hard w/as much as possible to limit ANY behaviors. They would come to be wwalking/talking, maybe seeing trees growing out of the walls, but they weren't frightened and they were functional... and they'd leave him peeing their pants and drooling. No lie and no exaggeration. He even put a 2 year old on Risperdal.

So, I mean, then tehre's some p-doc's who don't prescribe at all, they treat meds like in other disciplines. You don't prescribe chemotherapy to everyone with a cold... so why give antid's to everyone who is sad?

Ok, I'm getting off topic, this is a hot button for me. As for what I think... I think more care needs to go into crisis counseling/prevention/assessment/diagnostics and creation of a collaborative treatment plan. I don't think there is one best answer for everything.

Idealistic, no? Good luck w/your decision.

 

[Pterion]

What do you think?

In answer to the thread title: "Yes"

But some people need both. Some need one and not the other. Some enter the health care system interacting with the clinician (physician or psychologist as the case may be) who is best suited to assist them. Some find one clinician type who is partnered with the other, making continuity of care an easier thing to guarantee. Many do not. This is unlikely to change soon. You can dislike it all you want. Or you can enter the system and change it from the inside. (Metaphor, anyone?)

You did not fail "therapy". It was not the right therapy for you. It happens. Many have no response to medications-or a negative response-and flourish under the guidance of the "talk therapist". Do not assume that because you needed medication that psychology as a clinical field is insufficient. It is not a panacea, but it is far from insufficient.

 

[erg923]

I would just like to add not too circumscribe clinical psychology too narrowly. Therapy is just one of things clinical psychologists do. Many psychologist's work outside of strictly clinical settings as consultants, research consultants, test developers, statisticians, professors, court systems, etc. Training in psychometric assessment and in depth cognitive assessment is one of the biggest differences between the training in the 2 professions. I find that clinical psychologists bring important insights into some of the nuances of diagnosis and treatment planning that psychiatrists do not. Clinical psychologists (Ph.Ds) are also trained heavily in statistics and research methodology and often have more knowledge of conducting research than the average psychiatrist who comes out of residency. I often advise people, if you do not have a substantial interest in medicine in general, the 4 years of medical school before the psych residency would be miserable.

In clinical situations, you will largely responsible for the psychosocial treatment plan and the psychiatrist will be in charge of meds. If a patient voices concerns about side effects or an ineffective medication regime, you can express these concerns to the psychiatrist and see if they think a change might be best. Handle this delicately and I would recommend not "advising" the psychiatrist on what medication might be best, as you are not trained for this. Their are many times when psychologists and psychiatrists disagree on clincial questions, sometimes diagnosis as well. In hospitals and academic med centers, the psychiatrists usually carry more influence, and they may get their way despite your reservations or protest. This is just part of the hierarchy that we all deal with. This hierarchy is less pronounced outside hospital situations.

 

[brightness]

I really appreciate all of the insight from all of you. Definitely made me think about whether or not I should clinical psych...but mainly, made me realize that my experiences are 1)Not the only experiences in the world and 2) Should not be the sole factor in guiding what I do in mental health

I also strongly agree that medication should be used as the 2nd line of defense...and that initially therapy, exercise and eating right should be the first plan. As we all know, however, some people are too depressed, anxious, whatever to get themselves on that road, so maybe that is where medication comes in.

In any event, I really do wish that clinical psychology programs had more focus on the neurobiology of mental illness/phenomena. Not necessarily prescribing itself, but knowledge about the biological processes.

 

[Ollie123]

They do if you look at the right programs/labs!

Try and graduate from Wash U's doctoral program without a solid understanding of biological basis for disorders...just try it

Remember, classes are but a tiny portion of the learning you should be doing in grad school, so not having a multitude of classes in biology doesn't mean you won't be adequately trained in it. Furthermore, many departments are perfectly content to let you take classes outside the department if it is deemed sufficiently relevant to your area to be worth your time.

I agree that its still far too common for places to treat biology as something scary and irrelevant compared to things like the social environment, but that doesn't mean the training isn't out there if you want it.

 

[cara susanna]

Yeah, I don't know where the OP is getting the impression that most clinical programs skip over that aspect. Even undergrad programs have at least one class that covers the biological basis of disorders.

 

[PinkSoil]

I think that therapists can offer a great deal in terms of medication, even though they cannot prescribe.

When I was working on my masters degreee, I took a psychopharmacology class. The professor taught us how important it is to know these medications because, ultimately, if a patient is doing medication + talk therapy, the therapist is the one who is going to be talking with the patient a lot more than the psychiatrist.

Common (majorly edited) scenario that happens to me in session with patients:

Patient: I have been socially isolating.
Me: What do you think is causing that?
Patient: I don't know.
Me: How do you think it relates to your depression?
Patient: I guess I'm not going out b/c I'm depressed.
Me: Did you tell the doctor about this?
Patient: No... I'll tell him/her next time.
(enter coversation and possible role playing about being honest with one's psychiatrist)

Another example of how we can play important roles in our client's medication issues/and how important it is for us to be educated:

I had a patient who really misunderstood the psychiatrist, and did not realize that a rash is not a normal side effect of Lamictal. She thought it was like any other side effect, such as nausea or headache. Even though the psych. had explained this to her, she didn't understand. In our session, I provided further education on the side effects of Lamictal, and then collaborated with the psych. to let her know that the patient didn't fully understand.

I have also had family sessions in which half of the family is in favor of a certain med, and half the family isn't. Again, this is where therapy is instrumental in working with people's fears, indecision, and feelings when it comes to taking medications.

Remember-- they speak with us more often, more in depth, and are usually engaged in a deeper relationship with us, rather than with the psychiatrist.

Like the OP, I am no stranger to the use of psychiatric medications. However, I have had the opposite experience-- I seem to be pretty med. resistant, and have found therapy to be the most helpful in my treatment.

It also depends on what you are dealing with. For psychotic disorders, medication is pretty much going to be the main treatment. For some people with anxiety disorders, or certain mood disorders... medication is going to be a tool-- therapy is going to be where the work is done. Medication can be instrumental in helping someone reach a certain place so that they can focus and work hard in therapy. And finally, there are some individuals who are going to respond much better to therapy and should not be rushed off to the psychiatrist.

 

[brightness]

Well, I really don't consider one course in the biological basis of behavior to be adequate. To really understand it, you need biology classes and chemistry in your background, which most psychologists don't have. Still, I do see (after doing some more research) that some schools have a keen focus on the biological aspects of behavior. Perhaps a program such as this would be better for me.
Also, after hearing an example of how a psychologist can help with med compliance/education and communication with the psychiatrist, I realize how true this is. Even in my own experience, my psychologist has done conference calls with the psychiatrist if I was confused, needed help, was uncomfortable, ect.
Now its just a matter of looking into programs, finding ones that are a fit with my GPA and interests, and seeing if I can get in anywhere!
To be perfectly honest, I have lower grades because I took chemistry and biology versus say, psychology and sociology courses, so now I'm not very competitive for PhD programs at all. I've been wondering if schools factor this in when making their admissions decisions at all.

 

[cara susanna]

Eh, I wouldn't say that you need chemistry per se. I hadn't taken chemistry since high school and I had no trouble in biopsych, psychopharm, or neurobio in undergrad. Yes, you would have to know chemistry in order to have a truly expert understanding, but not a fundamental, basic knowledge.

 

[RayneeDeigh]

I'm sure this will sound rude (I apologize) but how do you know that most psychologists don't have adequate training in biology/chemistry? That sounds like an assumption to me. Your training in psychology can be as biologically based as you want it to be. As someone (I think it was Ollie) said, training is NOT just about classes. If you want biological training you can pick a lab or practical training that emphasizes it and be more than happy.

I personally was a chemistry/microbiology double major for a while in undergrad. Another one of my cohort members has a master's degree in psychiatric sciences and an undergraduate degree in biology. A third works in a lab studying dementia which is about as biologically based as they come. You will find MANY psychologists have this kind of background, and if you go around saying that psychologists don't have enough training in biology you may find that a lot of them get offended. You can go through a psychology program without taking much biology stuff at all, or you can jam-pack your experiences with it. That's up to you.

 

[brightness]

The fact that you can go through an entire PhD in psychology without taking any biology means that there are psychologists who have very little background in science. I honestly don't know how many psychologists do or do not, however. I stand by my assertion that psychologists don't have as much training as I'd like in biology and that one class in the undergraduate major is not adequate.'
I didn't say that most psychologists don't have an adequate training in biology. What I meant was that one course in the undergraduate major is not enough prep to learn neurobiology thoroughly. I also said that most psychologists don't have enough chemistry and biology in their courses (like in clinical programs), but I meant for my liking, not that psychologists can't do their jobs.

I'm sure this will sound rude (I apologize) but how do you know that most psychologists don't have adequate training in biology/chemistry? That sounds like an assumption to me. Your training in psychology can be as biologically based as you want it to be. As someone (I think it was Ollie) said, training is NOT just about classes. If you want biological training you can pick a lab or practical training that emphasizes it and be more than happy.

I personally was a chemistry/microbiology double major for a while in undergrad. Another one of my cohort members has a master's degree in psychiatric sciences and an undergraduate degree in biology. A third works in a lab studying dementia which is about as biologically based as they come. You will find MANY psychologists have this kind of background, and if you go around saying that psychologists don't have enough training in biology you may find that a lot of them get offended. You can go through a psychology program without taking much biology stuff at all, or you can jam-pack your experiences with it. That's up to you.

 

[Ollie123]

The fact that you can go through an entire PhD in psychology without taking any biology means that there are psychologists who have very little background in science. I honestly don't know how many psychologists do or do not, however. I stand by my assertion that psychologists don't have as much training as I'd like in biology and that one class in the undergraduate major is not adequate.'
I didn't say that most psychologists don't have an adequate training in biology. What I meant was that one course in the undergraduate major is not enough prep to learn neurobiology thoroughly. I also said that most psychologists don't have enough chemistry and biology in their courses (like in clinical programs), but I meant for my liking, not that psychologists can't do their jobs.

I still think you're placing WAYYYY too much emphasis on coursework. That's just not how grad school works.

I've taken 8 graduate courses at this point. I don't think I've learned as much in those 2 semesters worth of classes as I do in a week or two outside of class on research and other activities. Don't get me wrong, classes are still important and valuable, they're just an adjunct to your education, rather than the primary component of it. I haven't heard you mention faculty/labwork/practicums once in this thread. That should be what you're looking at when you look at grad schools, not how many required courses have the word "biology" in them.

Stop worrying about how many classes people have to take in x or y. If you focus on it that much in grad school, you're not going to do well. Get in a solid lab doing biologically-focused research, make sure they have the clinical opportunities you want available, and you'll be 10x better off than someone who loaded up on bio coursework.

 

[RayneeDeigh]

Alright first of all, CPA requires that all Canadian programs include AT LEAST one course in neurobiological "stuff." I know this because my cohort and I are currently groaning about the course being at 8:00am on Tuesday mornings. Correct me if I'm wrong, but the APA must have some similar requirement.

And actually Brightness, you did say that most psychologists don't have enough training in biology/chemistry.

Why are you worried about what the majority of Psychologists train in, anyway? We've already said that it's very possible to get training that is strongly rooted in neurobiology in a Clinical psych program.

 

[brightness]

Look, I'm not here to mince words with you. I said that psychologists don't have enough training in biology and chemistry, and that one class isn't adequate. I MEANT that they didn't have enough training in biology and chemistry for my liking. I think I already said that. I clearly offended you, then clarified what I said, so good enough, right?

Alright first of all, CPA requires that all Canadian programs include AT LEAST one course in neurobiological "stuff." I know this because my cohort and I are currently groaning about the course being at 8:00am on Tuesday mornings. Correct me if I'm wrong, but the APA must have some similar requirement.

And actually Brightness, you did say that most psychologists don't have enough training in biology/chemistry.

Why are you worried about what the majority of Psychologists train in, anyway? We've already said that it's very possible to get training that is strongly rooted in neurobiology in a Clinical psych program.

 

[brightness]

I appreciate this insight, because I don't generally think of graduate school in terms of all the research experience you get. Sometimes its easy to forget that, since clinical psychology is a little different, than say, nursing or physical therapy or something like that.

I still think you're placing WAYYYY too much emphasis on coursework. That's just not how grad school works.

I've taken 8 graduate courses at this point. I don't think I've learned as much in those 2 semesters worth of classes as I do in a week or two outside of class on research and other activities. Don't get me wrong, classes are still important and valuable, they're just an adjunct to your education, rather than the primary component of it. I haven't heard you mention faculty/labwork/practicums once in this thread. That should be what you're looking at when you look at grad schools, not how many required courses have the word "biology" in them.

Stop worrying about how many classes people have to take in x or y. If you focus on it that much in grad school, you're not going to do well. Get in a solid lab doing biologically-focused research, make sure they have the clinical opportunities you want available, and you'll be 10x better off than someone who loaded up on bio coursework.

 

[Chimed]

I'm sure this will sound rude (I apologize) but how do you know that most psychologists don't have adequate training in biology/chemistry? That sounds like an assumption to me. Your training in psychology can be as biologically based as you want it to be. As someone (I think it was Ollie) said, training is NOT just about classes. If you want biological training you can pick a lab or practical training that emphasizes it and be more than happy.

I personally was a chemistry/microbiology double major for a while in undergrad. Another one of my cohort members has a master's degree in psychiatric sciences and an undergraduate degree in biology. A third works in a lab studying dementia which is about as biologically based as they come. You will find MANY psychologists have this kind of background, and if you go around saying that psychologists don't have enough training in biology you may find that a lot of them get offended. You can go through a psychology program without taking much biology stuff at all, or you can jam-pack your experiences with it. That's up to you.

Well, that's the wrong assumption many people make about psychology--that being a psychology major is equated with straight "talk therapy." At my undergrad, the psychology department was heavily biologically based and the major was basically a science degree requiring chemistry and biology. Also, the majority of faculty members had some sort of science background.

 

[immortalavalamp]

Remember, too, that sometimes the shoe is on the other foot--that some people simply don't respond to medication, and that it isn't until they are under the care of a skilled therapist that they can improve at all.

Although many psychologists don't have "a lot" of science training, this makes sense to some extent. I'm not sure that psychologists NEED to understand how proteins are symthesized in depth. Now, if they're interested in prescription privilges, that's a different conversation...but most of the psychologists I've come in contact with have a pretty solid handle on the biological basis of disorders, etc.

 

[Therapist4Chnge]

If I had my druthers, clinical program would have more req. classses in neuro and health, since the research seems to support a stronger biological basis for some disorders. The problem is that there are already so many required areas, there really isn't room for everything, but I think as we move forward we'll see the need for more training in these areas.

As for the convergence of talk therapy and medication.....I think ultimately this is what is needed. There are issues on either end (those who want 'magic pills'....when talk therapy is more effective, and those who avoid meds and want talk therapy....when meds are more effective), and they can only be resolved with more research into combination therapy. People can still choose what they ultimately want, but at least we'd have better data to 'show' a best practice for each Dx.

 

[HeyJude]

I found this article rather inciteful. It is closely related to the topic of drug therapy. Here are a few interesting tid-bits.​

France, C.M. & Lysaker, P.H. (2007).The "chemical imbalance" explanation for depression:Origins, lay endorsement, and clinical implications. Professional Psychology Research and Practice, 38, 411-420.​

"The monoamine hypothesis has provided the impetus for numerous important research projects seeking the biological causes of depression and efficacious pharmacological treatments for the same. However, this chemical imbalance explanation remains unproven and is potentially invalid. The significant limitations of the imbalance explanation, however, have not prevented U.S. laypersons (as well as some treating professionals and other stakeholders) from being urged (e.g., via DTC advertisements) to accept the explanation as a likely fact."

"Also interfering with response-equals-causation logic are findings that in many clinical trials, antidepressants have exhibited either no or very modest advantages in comparison with placebos (Kirsch, Moore, Scoboria, & Nicholls, 2002; Kirsch, Scoboria, & Moore, 2002). Such findings raise the possibility that antidepressants may often act as active placebos rather than having unique and specific antidepressant properties."​