Staff Perspective: Psychotherapy Outcomes - Improving Perspectives on Psychotropic Medication Use

Staff Perspective: Psychotherapy Outcomes - Improving Perspectives on Psychotropic Medication Use

In previous blog entries, I have focused on presenting anecdotal clinical perspectives gained in my psychotherapeutic interactions with Service members (active duty and Veterans) who have deployed (OEF, OIF, etc.).  I continue that precedent by sharing recent insights into helping deployed Service members improve their perspectives on psychotropic medication use; consequently, improving compliance with psychotropic medication regimens as established by their prescriber(s). 

Whether in individual sessions or in group sessions, Service members who have deployed and are taking psychotropic medications to relieve symptoms of anxiety and depression, will ask candid questions (or make stark statements) about their less than compliant intent regarding use of prescribed psychotropic medications.  I believe this candor is a result of the therapeutic relationship (i.e., feelings of trust and security) and the client’s belief that he or she “will get an honest answer” (i.e., “what do you think, doc.?”) as to the validity of using psychotropic medications.  Two “discussions” in particular seem to occur more frequently than others.  One, a Service member generally asks, “Will I have to take pills for the rest of my life?”  In the other situation, the Service member is frustratingly stating that “the pills don’t work.  I still can’t get to sleep” (or, “I still feel anxious.”).   As stated before, my responses are “intuitive” with the belief that a simple understanding of the clinical process will enable the patient to embrace these concepts and apply them readily in their efforts to reduce emotional and psychological distress. 

With regard to the question of “Will I have to take pills for the rest of my life?” I offer patients the following illustration/analogy.  I generally draw out a stick figure (or describe the scenario when no pencil and paper are available) and place a “cast” on the leg while stating that the individual (in the analogy) has broken his/her leg and it has been placed in a cast.  I then ask, “What else will the doctor give this person?”  Generally, they respond, “pain pills” to which I reply, “what else?”  Eventually, the answer that I am looking for emerges… “crutches.”  From there, I (we) go on to discuss the purpose of providing crutches… “So that the individual might remain active (can still be mobile) while the leg heals.”  “So that you are not putting weight (stress) on the leg while it heals.”  “…to provide support while the leg heals.”  Once I am certain the patient understands the analogy, I state, “your psychotropic meds are like crutches” and go on to explain that the psychotropic medications for deployment-related… (anxiety, for example) should help to reduce anxiety related distress to the point where the individual can be comfortable engaging in anxiety provoking activities.  The hope it that at some point in the future, the activity no longer illicit an anxiety response and the psychotropic medication is no longer needed.  In other words, the psychotropic medication(s) decreases feelings of anxiety and/or depression; the individual is able to engage the environment consistently; and their level of confidence with feeling secure in otherwise anxiety provoking situations strengthens to the point that they are able to engage in these activities without the use of psychotropic medications.  Service members quickly understand the analogy and see that the need for psychotropic medications may not be “forever” and they also understand that they have a measure of control as to how long they might be using psychotropic medications.  That is, they understand this connection to the physiological self and are able to acknowledge their responsibility in determining how long they will need to “take pills” for relief of reported symptoms.

In the other situation, Service members have consistently come in to see me stating that “my medications don’t work.  I still feel anxious.  I still can’t sleep.”  In general, my response relates to redirecting them back to their prescriber; however, a more recent discussion with a patient has led me in an additional direction.  Some months ago, I was seeing a patient who had deployed a number of times.  He stated that “the Ambien doesn’t work.”  Understanding his general habits as well as having a good understanding of his deployed trauma history, I had him explain his use of the psychotropic and its impact on his sleep.  He reported that although the medication helped him fall asleep initially, it would not help him stay asleep or fall back to sleep when he was awakened several times across the course of the night.  I asked what it was that he generally did while awake.  He stated that he did “security checks” around the house (i.e., check doors, check on the kids, listen to see if anything was out of order).  I then asked how comfortable he would feel if he slept through the night foregoing any of his usual “security checks.”  He reported that he would feel “very uncomfortable” and be “really anxious” the next morning.  With this determination, I had a frank conversation with the patient describing and discussing how he undermines the intended purpose of the psychotropic medication.  That is, the Service member was able to see that the Ambien would most likely work as intended; however, he “needed” to be awake throughout the night or he would feel like he “missed something” (a threat) and consequently, feel very anxious about his failure to be alert.  He was “working against” the medication throughout the night, yet unhappy with the fact that it did not put him right back to sleep each time the security checks were accomplished.

The point here is that providers should be aware that when Service members complain that their psychotropic medications do not work, the underlying issue may be that Service members (and Veterans) are undermining the intended use and this (versus the effectiveness of the medication) may be the real problem.  Another example comes to mind.  A number of deployed individuals have stated that they will not take their anxiety decreasing medications when they know they are going out because “I want to be alert” and the psychotropic medications “makes me too calm.”  It is apparent from this example, that deployed Service members are likely decreasing the effectiveness of their psychotropic medications in an effort to feel more secure post-deployment. 

In summary, those of us who provide psychological care as non-prescribers can help to improve deployed individuals compliance with psychotropic medication regimens by pointing out instances and/or patterns of behaviors in which there is a tendency to undermine the effectiveness or intended use of their psychotropics.

Dr. Anthony McCormick is a Deployment Behavioral Health Psychologist with the CDP at Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA.