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“There is only so much you can say about Prozac,” one of my students says and makes me chuckle. “Yes, but there is a lot to talk about the meaning that Prozac has to that person.” I say, highlighting that themes in a person’s life come alive when you ask them what the medication means for them. Without this discussion, the physician is at a loss as to how the patient integrates psychiatric medication into their schema of their world. This issue of what the diagnosis and/or the treatment means to that individual patient is what drew me into the world of medicine. Yes, diagnosing can be fun, and watching people get better by using your intervention is fulfilling, but for me, the excitement comes from understanding how the person is thinking about their circumstance, in this case the agreement to begin a psychotropic medication.
Clarissa, sixty-one, comes to mind. She feels that she needs medication “to function”. Sometimes this “medication” is Xanax, and sometimes it is alcohol, and sometimes she takes Zoloft. In her mind, each of these mind-altering agents serve the same purpose. They make her feel rewarded and worthy of enjoying her life. Without these substances, Clarissa feels lost, anxious, and unloveable. Yes, these medications help her feel loveable because they shut off the voice which speaks to her and tells her what a bad person she is. Her superego is very mean and loud, I say, explaining that the medications turn down the volume of her superego, thereby allowing her pleasure. “Wouldn’t it be nice if you could tame your superego without medication?” I propose, hoping that she will work with me to taper her Zoloft. “I am just not sure I can do that. I am an old lady and I have been this way for a long time,” she says, giving me hope that although we both agree that things get harder with age, slowly, change can happen.
Clarissa illustrates the weaving together of medication and psychotherapy which can only be done with time and focus. A “med check” visit could not explore these meanings. A therapist visit could explore these meanings but they would not likely tie the exploration to the discontinuation of the medication. Being able to use medications to launch into a discovery of the internal mind is what I call “integrative care,” as distinct from that term which is now used to suggest that psychiatrists can do chart review while another clinician implements the treatment. Psychiatrists, as prescribers of medication, need to understand how these prescriptions are integrated into the mental interior, through Freud’s famous adage of “free association”. To do this, psychiatrists need to reflect on our history of understanding that meaning is derived from the past, influenced by the present.
Shirah Vollmer MD 