Psychotherapy and psychiatric medication:

Partners, not enemies

Before I went to graduate school to become a psychiatric nurse practitioner, I was a registered nurse for more than twenty years. In that time I gained tremendous respect for the power of medical science and pharmaceutical interventions to save lives, and make lives worth living. I also developed a deep understanding of the limits of a health care approach that only considers medication and physical interventions. When I earned my master’s degree at Seattle University, I was able to supplement this complex view of traditional, physical medicine with the ideas and techniques that continue to inform my practice today. Seattle University’s program is an existential-phenomenological one, and our therapeutic training focuses on helping patients to understand their own place in the universe, and especially its finitude. Existential psychotherapy asks, What does it mean to be alive? Why am I here, now, at this moment? Rollo May, one of the founders of the existential psychotherapy movement, considers a patient’s general sense of unease and dissatisfaction: “Living, thus, becomes equated with ‘becoming’ or ‘doing’; time not spent in ‘becoming’ is not ‘living’ but waiting for life to commence”. Existentialists are not concerned with a kind of hyperkinetic self improvement. While of course I want to help my patients become their best selves, my first goal in therapy is to help my patient center themselves in the world they live in now. We are all given a very small amount of time on this earth, and we often spend that time anguishing and bargaining for more, rather than appreciating that the essential brevity of our lives means what we do have is that much more precious. As Irvin Yalom writes, “Recognition of death contributes a sense of poignancy to life, provides a radical shift of life perspective, and can transport one from a mode of living characterized by diversions, tranquilization, and petty anxieties to a more authentic mode.” Realizing that our lives are but drops of water in a great ocean does not make them less real, less valid. It simply means that we have to find out what we are meant to do in order to make the most of what we have.

Despite my belief in the power of the existential thought process to help re-center people, I also know that one should treat illness of any kind with the most effective medicine, not merely the kind that one believes in most fervidly. Is psychotherapy alone enough to provide patients suffering from mental illnesses like major depression, bipolar disorder, post-traumatic stress disorder, or schizophrenia with relief and stability? A shrinking number of therapists do maintain that even the most acute psychotic states can be treated with talk therapy alone. I am not among them. What I have described so far is applicable to any patient I work with, however many of my patients also require pharmaceutical interventions. In this section of the website I hope to offer useful information about the medicines I use in my practice, and about psychotropic drugs in general. For those people who are unfamiliar with these drugs entirely, it is important to note that they are not all “created equal.” That is, a selective serotonin reuptake inihbitor (SSRI) antidepressant like escitalopram has a relatively mild side effect profile and a decades-long track record, so prescribing it as the first pharmaceutical treatment for a patient’s depression makes sense. On the other hand, there are many second- or third-line options for depression and more serious conditions that I would only consider prescribing if the safest and most tolerable therapies had failed. Certain conditions, like bipolar disorder, must be managed with psychotropic medicines for the patient’s own safety. I treat many patients with bipolar disorder who, unmedicated, are profoundly susceptible to dangerous delusions and to the false certitude of mania. Once they are stable on medication, however, these patients can go on to thrive and live authentic and satisfying lives.

For decades it has been medical consensus that the most effective psychiatric interventions combine psychotherapy and medication. While there is still a lively discussion ongoing in the academic psychiatric community about this conclusion, I can say with the certainty of more than thirty-years’ practice that my patients who benefit most from our work together are those who take medication (if indicated) and commit to psychotherapy. The existentialist approach rejects binaries in favor of the reality of lived experience and knowledge gained through peaceful acceptance of our role in this world. The so-called “therapeutic alliance” [PDF] is an invaluable component of any productive psychotherapy, with or without medication. Building this alliance with my patients is critical to our work, and it can also be quite challenging at times. Given the immense trauma and other hardships some of them have endured, this is understandable. But once we begin to establish a solid foundation of truth and mutual respect, we can collaboratively develop a successful treatment plan.

On this portion of our website you will find information on a selection of the most common mental illnesses and their treatments. This is by no means an exhaustive list of the types of mental illness I treat, nor of the medicines I use.