Should I Take Therapy or Pills

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18 Aug 2012

Should I take therapy or use the pills the psychiatrist gave me? Which should it be. Which is obviously better? I can't seem to get an clear answer from anyone.

I don't want to be on medications because then that would be an admission that I need a crutch to go about my life. Certainly I'm stronger than that.

On the other hand, therapy makes it sound as if this is all in my mind. That I'm faking it or seeking attention. Better to take pills and tell everyone that the problem is physical - or else the pills wouldn't be working. Right?

But I don't like how the pills make me feel and I don't like taking pills anyway. And the last therapist I went to, well, I didn't like how they treated me.

How about if I just ignore it all - maybe it will all go away. After all, I'm feeling fine now.

Does any of the above sound like you? Confused on what to do?

Well, the first thing is that you can't just ignore what has happened in the past, even if you feel fine now. The mood swings and your crazy actions will happen again. You have to take action.

Ok, so we're back to the therapy / medication issue again.

My experience is that both medication (pills, meds) and psychotherapy (therapy, counselling) are useful but for quite different reasons.

Although I like therapy and I have learned to control my hypomania episodes relatively well without medication most of the time, I have found therapy alone cannot prevent me from getting depressed or even lift my mood somewhat. Antidepressant pills have been the only things that work in lightening my depression or delaying the onset of a depression episode.

So the meds have it, right?

The meds do help with depression, but they do not do a particularly good job. When I am taking them, I still get depressed, although the episodes can take longer to happen and can be less intense (check out my experiences with specific drugs). The meds that do work against mania are very effective for me though.

Annoyingly, I've found out that I can get resistant to drugs so they stop working at all.

So for me, taking the pills provides a partial benefit, not a full one. Good for mania, kinda good for depression, and not good at all when taken in the long term. But still the only thing that works against depression, even if it is just short term.

In addition, I've found out that psychiatrists - the ones who can prescribe drugs - tend to spend the time discussing the drugs with you, and less time talking about the general problems you are having. And trust me, if you have reached by a psychiatrist, your life is already more than a bit crazy and it really helps to have someone you can talk with about your problems.

That's where therapists come in. While they may not offer you anything to prevent you from becoming depressed or manic, they are useful in working with you so that you can come to terms with being bipolar and the crazy things that you have done in the past. I have spent the time with my therapist:

Working out whether I am actually manic depressive or just looking for attention

Trying to define who the real me is given my contradictory actions over the years

Working to increase my acceptance of being bipolar and learning to like who I am

Working to create goals and daily habits such that the effects of the mood swings and depression are minimised

Working to increase my self confidence and the belief that I am a good person

Working to ways to reduce the anxiety and guilt that I get when I am depressed and also from when I do stupid things while depressed or manic

Working to control my mania, irritability, and tendency to anger

Working out coping systems for when I am depressed and for dealing with the aftermath of a depressive episode.

So overall, the meds are more effective in relieving the symptoms of depression and mania, but therapy is more effective in the larger sense of helping me to restructure my life so that I am more relaxed and more productive. Happier too.

Neither therapy or medication work alone - but I would argue that the all medications are a subset of therapy - simply one of the many actions you might take for dealing with depression or mania or being bipolar.

By the way, therapy isn't a sign of failure and therapists don't tell you what to do. Therapy is a quiet space where you can think about and talk with someone about the things you won't usually think about. You do the work and you make the gains. The therapist merely acts as a sounding board and a guide.

If you have the capability, have both a therapist and a psychiatrist. Use the psychiatrist to handle the exploration of which medications work best to handle your mood swings. Use the therapist to discuss the wider problems, to help you cope with the existing problems that being bipolar may have caused, and to help you develop coping strategies for now and the future.

You may need to go the the psychiatrist only once every few weeks, but you'll be going to the therapist more often. At the beginning, sessions twice a week would be nice, but therapy should be at least once a week until you feel that you have a handle on the disruption that being bipolar or depressed causes. Sorting out your life is not a quick process, so expect the time you will spend in therapy to be measured in many months (and it will be worth it). For therapy, a twenty minute session is not sufficient. A session should last 45 minutes to 1 hour at least. Don't settle for less.

Because being bipolar affects everyone around you, it will be very handy if there can be therapy sessions involving not just you, but the people you live with. While I haven't taken part in this family approach to bipolar treatment since it is not offered where I live, it seems to me to be the right way to go about it. Consider checking if any of the clinics, therapists, hospitals or medical centres near you offer such treatments - the key terms you are looking for are "family focused" or "family inclusive". An example would be one like The Family Center for Bipolar in New York (not endorsed, merely provided as an example).

If you consider joining family oriented therapy, I would recommend that for a month or two before you start it, or in parallel with the family therapy, that you have one on one sessions with a therapist. There will be stuff that you need to work out on your own and you will need the time and space to do it. And I expect that your personal therapy will continue for much longer than the family therapy, because that's the way it is.

I'm of mixed minds about group therapy. I like the support that having people in similar situations provides, but group therapy may not provide enough focused attention on you and your problems and the methods you need to develop to cope with them. I'd support group therapy only if it is helping you solve your problems and teaching you to manage your life.

If you can only afford to go to a psychiatrist, life gets a bit more complicated. You can see if the psychiatrist will spend enough time with you to discuss your wider problems, i.e. the 45 min to hour long sessions. If that isn't working out, you can check out your church / mosque / temple / synagogue to see if they offer counseling, or local health clinics or hospitals, or any type of support groups in your area. What you will be looking for is someone supportive who is willing to sit with you for an hour, twice a week, while you try organise your life - so the counseling doesn't have to be about being bipolar. If the place you check doesn't offer counseling, ask who they might refer you to.

Unless they have counseling experience, friends are not a good idea to provide counseling. You can use them occasionally to lean on, but dong that over the long term will be tiring for them. And close family are a terrible idea since their expectations of you tend to get entwined in the counseling and muck up the process.

Do not try to sort out your life with just drugs. You will need to take the time to learn to cope with living with bipolar disorder, or mood swings, or mania, or depression. Taking the medications alone will not necessarily resolve your problems.

So get therapy, but, by the way, if you have been prescribed pills, don't forget to take them too. Regularly and on time because they can help and are part of the overall process of helping you manage your mood swings.

addendum: On 1 June 2010, Consumer Reports issued a useful press release on antidepressant medications and therapy. Check the second half of the article for information on therapy, but note that they cheat when discussing therapy by merging "helped a lot" and "helped somewhat" categories to get 91%. It would have been better if they had separated out both categories as they did for medications.

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