Listening to Pain

Early in my practice, a client said something that has stuck with me for the last 30 years. A trained dancer, she told me she avoided taking pain relievers because, in her view, pain was her body’s way of providing important information to her and she needed to “listen”. Although you’ll sometimes hear medical and body-work experts echo this view today, when you move from physical to psychological pain, it’s rarely mentioned. The idea that one needs to “listen” to one’s emotional pain gets short shrift, especially if that pain has been labeled depression, anxiety or an eating disorder. In the current mental health profession, dominated by cognitive-behavioral therapy and psychiatric medication, pain is something to be removed or eliminated. Take this drug. Try this CBT technique.

This perspective has been gaining in power since I started practice, long before the dawn of the Prozac era. In the “good old days,” most clients didn’t expect me to remove their pain. They wanted relief, but they seemed to accept that it would take time to understand their pain and then do something to make it better. I speak in generalities, of course; even then, I had the occasional new client who demanded instantaneous relief. But today, few new clients come into my practice with the idea that pain is something to be listened to — that is, that pain has a value and meaning to be understood. Helping people to accept that their pain contains relevant information and to try bearing with it is one of the earliest tasks of my work. Sometimes I fail.

In an earlier post about some bad reasons to take an antidepressant, I gave several examples of people using psychiatric drugs because they didn’t want to confront certain painful realities about themselves and their lives. I believe they are not unusual. The constant message from the medical establishment that mental illness is caused by a chemical imbalance insists that the pain of depression and anxiety have no meaning to be understood. We are told that eating disorders are maladaptive behaviors that need to be unlearned, rather than desperate efforts to cope with pain by people who have little mental ability to do so.

These are familiar observations to me, but I thought of them again in reading this article about I’ll Have Another, the racehorse that won both the Kentucky Derby and the Preakness Stakes before being retired by his owners. Apparently, his trainers had given him major painkillers prior to these Triple Crown races, and the practice is neither illegal nor unusual in thoroughbred horse racing. Many serious injuries are masked in this way and contribute to the catastrophic breakdown on the track of an alarming number of horses. This past Winter, 30 horses died at Aqueduct alone. In other words, instead of paying attention to their horses’ pain and viewing it as important information, the owners and trainers administer a drug to mask it. Millions of dollars in prize money are at stake, of course. In quest of those riches, they ignore the possible consequences of using painkillers — critical injuries on the track that often result in the horse being put down.

The widespread use of psychiatric medication today strikes me as analogous. By trying to mask or remove their patients’ pain with medication, psychiatrists and other medicating physicans ignore the long-term risks associated with using these drugs. Only now are we beginning to pay attention. Peter Breggin, Robert Whitaker, Joanna Moncrieff and Irving Kirsch are among those researchers who have not only exposed the false claims for cure but also revealed the disastrous consequences of long-term usage of these drugs: irreparable damage to the nervous system, permanent brain damage and reduced life expectancy. In pursuit of the short-term goal of relieving pain — understandable, if misguided — the medical profession does long-term damage to its patients.

I have one relatively new client, deeply depressed and anxiety-ridden, who has been hospitalized twice and tried innumerable psychiatric medications to alleviate his pain. He readily admits that all those drugs have done little to help and that the hospitalizations did nothing. Although he knows the short-term “answers” don’t work, he is suffering deeply and wants relief. When I talk about needing to bear with his pain long enough to understand it, he may grasp what I mean on an intellectual level, but on an emotional level, he just wants me to make it go away. One of the obstacles to our work is his belief and expectation that such a “cure” is possible, based in part on the cultural messages he has received for most of his life. My approach of bearing with and listening to pain is not at all what he expected.

It doesn’t help that modern psychiatry and the media have supposedly “discredited” long-term, intensive psychotherapy. If I suggest to someone that meaningful relief of a lasting nature might take years, he may view me as trying to foster dependency to my financial benefit. She may believe she’ll waste those years, a lot of money and have nothing to show for it at the end. Compared to the promise of a medical cure or 6-week behavioral course to unlearn those maladaptive behaviors, what I have to offer seems far too time-consuming and expensive. Unfortunately, I don’t know of anything else that can make a meaningful difference.

Long-term, intensive psychotherapy is expensive and it does take a long time, no doubt about it. I suppose that’s part of the reason I’m starting this new project with some of the visitors to my site. The goal is learning to hone our attention skills over time and to focus on our pain and the ways we try to escape from it. Taking part won’t provide immediate relief, but it might help participants to develop the habit of listening to and bearing with their pain … long enough to understand what it means and what they might be able to do about it.

Joe is the author and the owner of AfterPsychotherapy.com, one of the leading online mental health resources on the internet. Be sure to connect with him on Google+ and Linkedin.

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87 comments

    I am someone who won’t take Advil for a headache unless I’ve had the headache for hours on end, so I understand where the dancer you’ve written about is coming from. In my case, though, my resistance to drugs is not just from wanting to listen to what the pain is telling me but also the fact that I don’t want anything chemical in my body. I’m always fascinated by people who pop a pill at the first sign of anything… discomfort, pain, fear, sadness etc. I’m not judging anyone who does (it seems natural to want pain to stop, and if you can stop it quickly, why wouldn’t you?) but it’s just a bit foreign to me. It’s interesting that clients would come into therapy thinking there’s an instant cure. That wouldn’t have occurred to me either. It seems by its inherent nature that it would take a good deal of time, just like any method of “problem solving” does.

    I think the “take a pill” mentality is part of modern culture. Throughout the media, we’re bombarded with messages that encourage this way of thinking. Are you old enough to remember that Toyota (I believe) commercial with the tagline — “You need this car.” As if buying a car will make it all better! Buying a car or buying some other object (retail therapy) is just another type of drug to be used as the antidote to pain.

    I think of anti-depressants as chemical dissociation. All the effects and some of the side effects seem very similar to dissociation really, the numbing, the distancing from the pain… Actually, I think natural dissociation can be far more effective at numbing the pain than ADs, and with fewer side effects, not that I’m recommending dissociation but sheesh!!!

    That’s a very interesting perspective. I think I’d agree but I’d be interested in hearing if anyone else has a similar view.

    I would agree that “natural” disassociation is more effective or at least similarly effective as taking psychiatric medication. I don’t know if it is “safer.” I tend to agree that medication does numb the pain. I tend to do better at therapy if I’m on no meds or a very low dose. I assume I’m doing better because I tend to “come out of my shell more,” as well as remembering things. However, without my medication, I’m quite unbalanced-flashbacks, disassociation that lasts days and weeks, severe anxiety, etc. Life is painful either way. Meds or no meds. Some of us, by the time our pain reveals itself, we have jobs and families- responsibilities. I can’t be unstable at work, I would lose my job- then my therapist would lose me as a client. I don’t see medication as a quick relief, it isn’t quick, and it’s expensive as well. I would say my desire to not take any meds is actually much higher than my desire to stop therapy. Sure there are times I wonder if my therapist keeps me coming back for her financial benefit, but I wonder the same thing about my psychiatrist.

    Thank you for this post. I’m learning gradually that it is less helpful to have my pain short-circuited, dismissed, stiff-armed, “addressed,” than to listen to it, let it be heard, give it the respect it needs of having my recognition. I grew up in and embraced a tradition of resolving problems, rising above them, being strong. It always seemed so noble, but now I resent it for dismissing important parts of me. Those parts are still with me, demanding recognition, but are so obliterated it is a very difficult process.

    Fortunately, there are many strands of modern culture that are coming to embrace and foster acceptance of humanity’s weaknesses as well as strengths. My bias is to think this is truer in urban areas with yoga centers, human rights organizations, and, yes, psychoanalysts. But look at the popularity of the book Eat, Pray, Love, which I read recently after years of resisting because I thought it would be trite. Millions and millions of people are in fact receptive to the idea of listening to, getting to know, embracing themselves in full, negative as well as positive.

    So – I hear your pain, but think there’s room for optimism here too :)

    Point taken. I see what you’re saying but in the mental health profession, it’s not a strong voice yet. Spiritual endeavors embrace that point of view more than psychiatry.

    Yes, I guess that might be so. Thank goodness for life outside the profession, then…!

    But I’m not certain “the profession” is the monolith you make it out to be. Do you mean your colleagues? The industry? Insurance? Policy / regulations? Yes, pill-pushing is pervasive. But my CBT treated friends talk about many of the same things I hear from my psychoanalytic therapist (when I can get him to talk :) , about being in better touch with oneself, acknowledging, making room for, coming to terms with, integrating the painful, unpleasant, unwelcome parts of ourselves.

    I’ve been very fortunate, probably exceptionally so, in my insurance coverage of long-term psychotherapy, and my general curiosity brings me in closer touch with its precepts through my own research and extracurricular reading. My immersion in it is of my own engineering, of course; perhaps I have created my own fairyland where long-term psychotherapy seems quite broadly influential and accepted.

    But taking this into consideration, I’m still not convinced long-term, intensive psychotherapy is as discredited as you say. I think it’s firmly out there, in the mix with other therapy options. I wonder if your lament goes to a more subtle issue of what is meant by “the profession”?

    Quick fixes are increasingly available in many arenas of life; no wonder that we hope for them in our emotional distress also. And if a pill stabilizes me for a while, so I don’t kill myself, tiding me over until long-term psychotherapy kicks in, was it not helpful?

    I’m also frustrated by the objections to anti-depressants on the basis that they cause other physical harm. I know they are often not prescribed responsibly, but all medications carry risks. (I’m a young woman with osteoporosis, from taking steroids that supplement insufficient adrenal hormones. Better than dropping dead from shock at the drop of a hat, so they think.) I’m especially frustrated by the insinuation that my body is more important to protect than my emotional state. A significant percentage of self-injurers do it because the physical display of their anguish is societally more acceptable. People understand and accommodate a broken arm much more readily than a broken heart. It’s major, major progress that emotional distress has begun to given the same medical, professional legitimacy that physical ailments have.

    I think psychiatry has actually made significant strides in recent decades towards further acknowledging the depth and meaning of individuals’ anguish. Mental illness has become something society has begun to grapple with, thanks largely to psychiatric professionals and medicinal approaches to treatment. Yes, we want quick fixes; we definitely try them first. Often they work, or work well enough. And we can make them available to people who don’t have access to – or aren’t interested in – deeper resolution.

    Of course the important thing is to preserve more substantive psychotherapeutic treatment for those who need and will avail themselves of it. But CBT helps many, and so do pills. So let’s keep them too!

    But — after this lengthy devil’s advocate opposition, I do also think your underlying premise about pain needing to be acknowledged and owned, not anesthetized and dismissed, is the most important thing. Just not the only thing.

    You definitely have had a different experience from my own. Over thirty years, I’ve watched as intensive psychotherapy has been pushed aside by drugs and CBT. This is not to say it has no place in “the profession” but it certainly is treated with skepticism and suspicion.

    Well, all medical treatment, all expert opinions, should be treated with at least skepticism. Perhaps not suspicion. People should have to grapple with what they think about the options, and hopefully can know what those options are.

    I love this post for fostering this. Look at all this response – this really is something people are grappling with. Thanks for facilitating this discussion.

    I’ve been following your website for some time now, I find it to be a really helpful adjunct to the work I am doing in therapy. I thank you for what you do here and appreciate the opportunity to tell you that you have helped me. I am someone who is in long term psychotherapy (10+ years with the same therapist, a few short breaks here and there- mostly around having babies) I agree with much of what you say about there being no other way to achieve the kind of healing that I am working towards. I am someone who has struggled with depression and anxiety lifelong. Much of what you write about infant attachment gone wrong, the psychotherapy relationship and attachment, shame, hits dead center home with me. I am also a physician… not a psychiatrist, but a primary care physician, and in that role I do a fair amount of prescribing of antidepressant medications. I myself also take antidepressant medication. While I agree with much of what you have written here, and have personal experience with it from my own work in therapy, I think you come down a bit too harshly against the use of medication. I think there is benefit to be had from both pharmacology and psychotherapy… certainly for myself I have reluctantly come to accept that this is the case with regards to the medication.

    For years I would start and then eventually stop my antidepressant med… wanting to not need it essentially. A couple of years ago I finally accepted the fact that I shouldnt do that anymore. (Well honestly it still is sometimes a bit of a struggle, but much less than it used to be). I have a very strong family history of depression… both parents (which undoubtedly contributed to what went awry with my early childhood attachment- which does play a large part in the roots of my depression and anxiety)… but I do also believe there is a biological basis for depression and other psychiatric illnesses (the data for such is there), and I wholeheartedly believe there is a role for treating the disease with medication in some cases, in addition to lifestyle (exercise, meditation, proper nutrition) as well as long term psychotherapy.

    I think it is somewhat like diabetes… we all start out with a genetic predisposition to glucose intolerance, insulin resistance and type 2 Diabetes. For those with a strong family history, certain ethinic groups… it doesnt take much to develop the disease… you might do “everything right” (exercise, eat right, be at ideal body weight) but you still get the disease. Bad luck, bad genetics… it is what it is. Then there are others.. I have morbidly obese patients over 300lbs, one over 400lbs, who somehow are not diabetic… it amazes me. Most people are somewhere in between. Alot of type 2 Dabetics are overweight and could return to normal glucose levels with weight loss, proper diet and exercise, but not all. Those unlucky genetically loaded skinny ones cant… they need medication. Not medication alone… I tell all my patients… doesnt matter what medication or how many medications you take for diabetes, if you dont eat the proper diet, if you dont avoid gaining weight… your sugar will never be controlled. But not everyone can be controlled without medication.

    I think depression and other psychiatric disease are similar. We have a genetic loading and for some people the chemistry is just going to be off… whether its the serotonin equivalent of insulin resistance, or dopamine equivalent, etc we dont really know.. thats the fact. We dont know why the meds work- we know what they do chemically, but we dont know why that makes symptoms better. But the brain is an organ, why wouldnt it have inherent diseases or malfunctions, or states of less than optimal function, just like any other organ in the body? For some people I believe medication is necessary to treat the disease. I reluctantly have come to accept I appear to be one such person.

    Is the medication alone enough? obviously not for me… 10 + years in therapy and I’m not finished with my work yet.. (Your post “it takes time” echos in my head here) Does the medication take away my pain?… honestly no (I wish it were that simple). The angst that you so well describe in so many of your posts is well known to me. So what does it do? It helps. When i take it I tend to get better sleep, I concentrate better, I function better… its less of a struggle to get out of bed. I actually feel that taking my medication helps me to be able to work at a deeper level in therapy, and I’m pretty sure my therapist would agree. When it is difficult to get out of bed in the morning, when taking a shower takes a mental pep talk, its awfully hard to do much other than talk about those things. Therapy becomes a lot about supporting my daily basic function and a sounding place for my dispair. When I am on my medication is when I begin to be able to step back and think about my attachment to my therapist (you might imagine a very powerful one after so long… ) and from there begin to think about how that relates to my relationships with my family of origin, my current relationships, and how that relates to my depression and anxiety, as one example. When I am taking the medications is when I have felt well enough to disclose some of my most traumatic childhood experiences, and allow those experiences of pain, fear, panic to surface enough to work with it.

    It would be a wonderful magical thing if my medication could “poof” make all this anguish go away and be unfelt…. but simply put, the medication is just not that good. Not for me, and not for most of my patients. But it does help, and that is what concerns me about the onesidedness of your post. I function better – in all spheres of my life if I stay on my medication, than if I dont… it has taken me years (literally) to accept this as true, but it is true. I do not believe the medication masks my pain limiting my ability to work in therapy. On the contrary, I believe the medication helps me with my ability to work in therapy, a view I believe is shared by my therapist, who played a big role in working with me on my acceptance of taking it/ needing it.

    I have concern about your post in this regard, bc while yes I agree that there are many people out there looking to a pill for a quick fix which it cannot provide, there are also people out there like me… people who really do benefit from the medication in addition to psychotherapy, who really have a hard time coming to terms with accepting that, and your extreme position here could be harmful… a barrier in getting to that acceptance and ultimately to getting treatment that they need.

    Jenny, while I respect your opinion as a physician, I wonder if you’re aware of the permanent neurological damage that results from the long-term use of these medications, even after a few years. As the data is becoming available, it’s truly alarming, with side-effects similar to those for neuroleptics, even though the public was assured that SSRIs were “safe”.

    There’s no point in arguing with someone’s individual experience of having benefited from ADs, but I’m sure you’re also aware of the various NIH studies showing only marginal benefit from psychiatric medication vis-a-vis placebos. I believe these studies also show no statistically significant benefit after the first 6 weeks.

    I totally agree with Jenny. I am pretty much in the same boat. I have been with the same therapist for 11 years. I have complex ptsd and have many other life stressors. The medication helps me function, have a job, do normal day to day activites that I would not be able to do without it. I also struggled for a long time in accepting that I needed medication. I felt ashamed and weak because I needed it. I still feel a lot of pain, and like Jenny I have her same experience of being able to go deeper into therapy because my pain is not so overwhelming that I can’t function as a mother, at work, as a patrner. I still feel pain. I know what pain is, medication doesn’t take it away nor do I think it is a quick fix, but for some people it is indeed a lifesaver because at least we can function enough to look at our pain and be able to deal with it. Jenny, you sound like me.

    As I said in reply to an earlier comment, I do believe ADs can have a value for some people, as long as it’s short-term. I also suggest you find out as much as you can about the side-effects of using them long-term.

    It is true that without physical pain you are more likely to go beyond your limit and injure yourself further. I don’t often take meds for my pain unless it wakes me up in the middle of the night or is bringing tears to my eyes.
    Emotional pain, my depression – even at it’s worst, is here to teach me something. It is a sign that something about myself or my life needs to change. Knowing this does not make the experience any less difficult, however. I wouldn’t wish the experience on anyone because there are moments when it comes down to a fight for my life and that is frightening and in those moments of agonizing pain one cannot see the purpose of their suffering. It is only, it seems, in the moments of returned health that we are able to see the value of the experience – IF one is open to seeing the value – not everyone is.

    Yes — it’s very hard to see the value of suffering when you’re in the midst of a deep depression. And it’s not surprising that physicians want to do anything they can to alleviate that suffering for their patients. I wonder how we can help people be more open to seeing the value of listening to their pain.

    I can say from my own experience that I have spent almost my entire life trying to find different ways to avoid emotional pain. Food, religion, cutting, smoking, drinking etc. (none of these were practiced in moderation). Interestingly, many of these (like gorging on food until my stomach felt like it would explode, or cutting), involved physical pain. I have used physical pain in the past to dampen emotional pain which I find much harder to bear. Thankfully, I have managed to overcome all of these unhealthy addictions for the most part. I stopped drinking and engaging in bulimia, over 15 years ago. However, I only stopped taking antidepressants 2 1/2 years ago. It was a conscious decision made for many of the reasons you shared on your blog Dr. Burgo. There is a deep part of me that believes that there is great value, possibly some emotional growth or learning, that is only achieved by humans really looking at emotional pain. Kind of like muscles get stronger when you put them through physical stress which involves some pain. Unfortunately right now, our whole culture seems to be fixed to the surface of things. God forbid anyone should be sad or depressed or angry or feel anything perceived as negative. It seems to me so horrible to constantly deny ourselves our own human experience. I think we may be denying ourselves of something very meaningful, like actually living our lives fully and not like we are all on some TV sitcom where everything turns out great at the end of the show.
    Only one last comment. I have heard of the articles in the NYT about this horrible horse scandal, masking the pain of horses so they can race. The implication is how terrible it is to mask the pain of these poor animals (because the pain is there for a reason). But I have also noticed the Times in the last couple of years has put out many articles basically discrediting and really questioning the value of long term in depth psychotherapy and psychoanalysis. Apparently they feel like the pain of horses is worth looking at, but not the pain of humans! Maybe I’m reaching a little to far, but frankly it pisses me off that they don’t balance their reporting. Like how about a story about the total lack of good data on the effectiveness of antidepressants?

    I agree with your observation about the bias in coverage. Psychotherapy and psychoanalysis are definitely out of favor right now, while short-term fixes are in.

    Two comments –
    1. Talking about the complexity of getting to the heart of psychological pain and “dysfunctional”
    behaviors, I’m wondering what is your take on the expert panels that Charlie Rose has been
    offering up in his Brain Series broadcasts (chaired by Eric Kandel)? More often than not, the
    panels seem to be quite enamored with its view that most “illnesses” can be understood, their
    etiologies discovered, and “treatments” developed (primarily with drugs)…..with their models of
    the brain as a beehive of synapses bathed in a cocktail of neurotransmitters. I’m not so sanguine…
    my feeling – our understanding is still only skin deep (excuse the pun) and I don’t know how we
    will ever be able to peel away and understand all the layers of consciousness and behavior.
    2. Where does schizophrenia fit in with your (legitimate) concerns about the “over medicalization”
    of dysfunctional behavior and treating those who seem to display schizophrenic features? I know
    that this this is a complicated question – I am not trying to promote one mode of treatment over
    another. Is there room for Torrey on your bookshelf together with Angel’s NYRB article and the
    books she recommends? Are you familiar with the International Society for the Psychological
    Treatments of the Schizophrenias? http://www.isps-us.org/index.html
    Thank you – Herbert Peress

    Hi Herbert,

    I’ll put those resources on my reading list. But to answer your questions, like you, I’m not sanguine about the possibility of treating emotional illness with drugs. Highly skeptical, actually. Personally, I hate the idea because it removes the meaning from our suffering, as if there’s no reason for it of a psychological or emotional nature, just a chemical irregularity.

    As for schizophrenia, my views are guided by Robert Whitaker’s reporting on the outcome research (Anatomy of an Epidemic). It demonstrates fairly convincingly that the outcomes for those who do NOT take anti-psychotic medication are far better than those who do. I have only worked with one person who was diagnostically schizophrenic — many years ago, as a young therapist — so my experience is limited. However, a number of psychoanalysts I respect — including W.R. Bion and Harold Searles — worked psychoanalytically with schizophrenics with some success.

    I agree that ‘listening to your pain’ is the only solution that actually addresses the problem. Most people understand this intuitively. As a therapy client, though, I also understand the skepticism regarding this path. Long-term therapy is not only long and expensive, it’s also not certain. It’s entirely possible that a client will ‘have nothing to show for it at the end’. For me personally, this is its biggest drawback. Uncertainty.

    On a side note, I always wondered why long-term therapy is called ‘intensive’. Does it feel intensive to a client? Is there a non-intensive kind?

    Good question. I wonder if it’s in comparison to short-term treatments, which don’t go into such depth.

    What has helped me in thinking about emotional pain is the idea that my pain is not personal, in the sense that pain is part of being alive and everyone who lives will experience physical and emotional pain. Pain can be a messenger and needs to be listened to. Emotional pain also has some “gifts” which includes the ability to have compassion for others who are suffering (we understand their pain because we share in it to some degree).

    I like what you say about empathy. I believe that people who have little ability to bear their own pain can’t have much genuine empathy for others who suffer. Maybe sympathy of the “poor you” kind, but not true empathy.

    Do you ever incorporate any kind of somatic body-work into your practice for folks like your new client, as another way of listening to their pain if they’re feeling too depressed and hopeless to experience any kind of meaning in your conversations or in the pain itself? A lot of therapist in my area seem to be doing this these days, even those with a psychodynamic approach, which I find interesting.

    Very recently I decided to listen to my emotional pain and not try to logic myself out of the bad feelings. My mistake was trying to force my emotion to match my actions, if I’m acting kindly towards the person I don’t like, then I should like that person since he’s done nothing wrong to earn my dislike. I believe this misguided method was a rebellious reaction against my narcissistic parents who are ruled by emotion and throw temper tantrums at a drop of a mood swing, there were no rational explanations and no rules to follow to prevent their earth-shattering domestic violence. Undoubtedly my parents are deeply troubled people with alot of pain and they want relief from their emotional pain. So they take it out of us and it’s a mental relief, like a burp, there now I feel better and so should you, never mind you’re the recipient of my abuse and projections. But it’s just a temporary fix. Now that we’re adults and we don’t allow are parents to use us as emotional punching bags and chew toys, it’s almost funny to watch them not get their fix because they actually get the shakes, like an addict denied a hit of drug.

    I think of it as vomiting, more than burping. Or shitting, using you as the toilet for all their emotional pain. As you learned, it’s very important to set firm limits with people like that.

    I agree entirely and want to add a couple of qualifications.

    Pain killers can help if you don’t know the reason for it – to think clearly about cause and so on isn’t helped when just struggling not to kill yourself.

    Once the cause is known the pain killers can help make it easier to take the required action.

    By pain killers I mean not only drugs (one of god’s good gifts in my view) but also psychological techniques, relationships we live and so on.

    During the last Winter Olympics I watched as an ice skater/dancer badly injured her leg, received pain medication and continued to skate. At the time my mind began reeling at the possibilities of the damage she was doing because her leg wasn’t fixed it just she was rendered unable to know there was a problem (I know this is true of all pain meds but this one had a powerful impact). A few days after this experience I felt my own severe pain, chose not to medicate and after spending hours waiting for treatment at the hospital emergency (thanks to a triage nurse who decided that NOT taking medication meant i was NOT in pain) was able to tell the doctors exactly what was going on in my body. This knowledge (unimpaired by pain medication) was able to lead them to do the tests that were needed instead of the tests they would have done had I been medicated (the dr confirmed this) and they picked up what was a critical and very nearly fatal problem and I was able to get the treatment I needed; instead of being sent home to die.

    Emotional pain, I continue to learn a lot from and about. I definitely relate to the client (and anyone else) who wants relief … so do I. I do NOT want it through medications though. I hate the thought of something having control of my mind and changing who I am based on chemicals; of the side effects they produce of … all of it really. I also don’t get the taking them; all it does is mask what is going on and changes nothing – underneath all the problems will still be there!

    I’ve found it frustrating in talking to different therapists in the past that so many have basically said that unless I take antidepressants it means I don’t want to get better and they can’t help; or that unless I take them it means I’m not depressed enough. Actually I suppose part of that is true; if they really can only work with someone medicated they probably truly don’t have the ability to provide the help I need (only just thought of that). Suggestions also that taking medication to stop thoughts of self injury or to head off panic attacks is also frustrating because again I don’t see that it does anything as far as changing what’s underneath or addressing the basic shame that you write about that and that is so real to me. How could taking medication change the fundamental parts of who we are? or touch the deepest places (in my mind it can’t)

    I’m slowly learning more about listening to my pain and what it means. I notice that often there is a strong link between emotional pain and physical pain that is easy to mistake for just physical. I can see where my mouth tends to go numb on one side when I’m stressed as an example; where my blood pressure rises and where my shoulders ache from trying to hold everything together inside my mind. Yesterday I tried listening to some of the pain and noticed how what I thought was extreme anger held so much sadness underneath, and I’m sure there is more beneath that and beneath that and beneath that.

    My therapist has taught me in part about how listening to the pain lets us see what we really need. My problem with that is what do we do when we listen to our pain, hear what it is telling us but don’t have the answers or ability to do anything about what we are learning? I also wonder how long do we bear with it? as in, I can’t sit forever trying to bear with the pain, eventually (and quite soon at times) it becomes unbearable when I don’t distract from the emotional pain because the physical pain kicks in overtime, my heart rate increases, blood pressure rises, head starts spinning and I know if I don’t get out of that state of mind I’ll end up back in that hospital. So I either disocciate or find something to distract with. Lot’s to think about and learn always …

    This is all very interesting, and of course I agree with your approach. In response to your last paragraph, I find that over time, little by little, one gets better at bearing the pain — like building muscle. It’s very hard, though, when you can’t figure out what to do about it, or when there’s nothing to be done about it. I’m thinking of a client about my age who has spent most of his life on drugs, recreational and psychiatric, and feels he has wasted his life. How do you bear the pain of mourning for time you can never get back?

    That’s what I wonder also, how do you bear with such pain … when you’ve wasted your life and ruined everything, it seems never ending

    I have never even thought of trying to live without my anti-depressants and/or psychotropic drugs. I did not realize it was an option. Due to a 4-year lapse in having transportation during which I was hit by and then run over by a vehicle; yes, the lady had insurance, but then shortly thereafter died… long story, outlook still okay.
    But, the thought of trying to relive the pain that I went through when I ‘lost my 2 and 6 year old to the state’… another long painful journey for me. Still get tears in my eyes just bringing it up.
    I do not ‘get’ how life could be possible with the the level of depression I was once at…
    I am actually petrified at the thought of following through with psychotherapy.
    Thank you for your website and allowing me to respond,
    Vicki

    Maybe there is some pain that is just too much to face. I can be too optimistic sometimes about what the human spirit can endure, and the growth that can come from it.

    I think your response was quite accurate and it seemed well though out… I believe this is where it can be aptly applied that, “Time can eventually heal all wounds”. Some painful events, such as those involving my children, are those that I have to sometimes ‘put off for awhile’, because it will be at a time when their questions and concerns can be age-appropriately brought to me, at which time maybe the most painful of all feelings to me, ‘guilt’, can be assuaged by my being able to let them know that none of it was done intentionally and most important of all, nothing that happened was ‘their fault’. Having other people take over and limit you on what they feel are ‘appropriate’ ways to speak, react, act, or behave around your own kids, even when you “know them better than that”, expands the time which I feel will help the painful hurts finally begin to heal. Not just my own, but the hurts I know that my children feel. Unanswered questions I know that are there but they cannot ask, will all have to still wait. Lost forever to me is the ability to try and fix anything ‘overnite’ or at the push of a button. My life revolves around ‘hurry up and wait’. Yet on the positive side, I do not let my kids think they have to worry about me and I do see my psychiatrist every three and a half weeks without fail, because it is his impact on me and continual positive input on how proud he is of me and how unselfish of a person I am that keeps me able to hold my head up and still be able to say to anyone listening that ‘I am a Good Mother.’ He has been my doctor for twelve years now and one of the most spiritually inspiring people in my life, at least since my father passed.
    I just don’t want you to think I feel as if I am a lost cause, just bound by time. Sorry to be so long-winded, and truly appreciative of your time. Sincerely, Vicki Lauterburg

    I worked in pharma R&D for 30 years. I used to work on the data for those trials and for the preclinical safety research. I know the clinical evidence for antidepressant medications is unconvincing and side effect profile is fairly extensive.

    That being said, I’ve been on an antidepressant (in my case, an SNRI) for several months. I was in psychodynamic therapy prior to that and continue to be. I fully expect to be in therapy for years to come. The main reason I’m able to work on therapy, though, is because the AD helped me to have enough energy to do the hard work. I feel pain, fear, sadness, happiness, and a whole range of emotions. The only time I have felt numb was the period shortly after my mother died, when everything was overwhelming and I shut down.

    I don’t expect to be taking an AD forever. My physician isn’t a big fan of long-term AD use and neither am I. Nor am I a fan of some of the side effects I’ve experienced.

    Before I started the AD, I could physically get to therapy with a lot of effort, but I couldn’t put the emotional work into it. I just couldn’t. If my ability to do that is from a placebo effect, well, I’m okay with that. Dumbo needed his feather at first, too. Eventually he could give it up and I expect that for my AD use as well. In the meantime, though, I’m finally making some progress in therapy and am able to get more out of my life outside of therapy and whatever tools I need to use to continue that, I’ll use for now.

    I often sound as if I’m completely against ADs but I’m not. I do think they have their uses as long as it’s not “like insulin for diabetes,” the way they’re usually sold, as if you’ll need to be on them for life.

    I’m always glad to be reminded of your nuanced stance — i know for myself, loved ones & many clients, various carefully prescribed & monitored psychoactive meds have brought both accessibility to psychotherapy and relief of real, leftover unpleasance after many years of good psychotherapy had allowed Big but insufficient changes & reached the asymptote of utility. Your blog is a fine service to public mental health. bd

    I just did a 10 day meditation retreat, and one of the experiences is of one’s relationship to pain. It’s 10 days of observing. You can’t avoid pain when you’re sitting on a bench or cushion for many hours a day. But the focus is to be present with it, and notice how it changes. Some pain you do something about, and some is more “psychological” which it’s best to learn to look deeper into and welcome, because it changes.

    Theoretical knowledge is nowhere near the usefulness of having the experience. There were very uncomfortable emotions from deep down that came up too, but the commitment to just sit with them led me to very different, non-avoidance responses. It’s only been a couple days and I’m still processing it.

    This sounds like a retreat a friend of mind went to … Vipassana? I think there is a huge value/meaning to be found in simply bearing with one’s pain, but not everyone agrees.

    I did it in Thailand, so it wasn’t Goenka. I’ve done that one, but I wouldn’t recommend it as it’s a bit too controlling – often they chase you down and yell at you if you’re not sitting when you’re supposed to, even if you’re crying. Little compassion when I was there.

    Peter Levine wrote some interesting pieces on what mindfulness does on a brain chemistry level to heal trauma. It’s hard to learn to make different choices inside when the defensive habits are so strong and often largely unconscious. Slowing things down to extreme can be very good to see things clearly.

    acclimatisation to and normalising of (the pain and then it lessens) like training a muscle a bit (only alot harder id say)

    thats what im trying to do at present, practicing sitting with it,

    i do believe its the hardest thing ive ever done in my life so i wouldnt say to someone that i would recommend it, cos it takes over and has made functioning difficult as i learn to face the emotional pain,

    but it is a choice i would choose again and again for myself time after time, cos at least i will die trying!! and i may get further with it than i ever thought,

    and i just wasnt going to sit at the bottom of the pit any more, and run in the same circles,

    I think Freud said it best in STUDIES IN HYSTERIA:

    “[M]uch will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health, you will be better armed against that unhappiness.”

    Life is blood, sweat, and tears, and patently unfair. Hence, common unhappiness. It does seem to me that a goal of psychotherapy, whether brief or long-term, should be the alleviation of psychological misery. I’ve seen too many suffer for too long with chronic pain, whether physical or emotional. It crushes and stresses so much that the real person within can be lost.

    Freud understood so much, so early on. I agree that the goal of psychotherapy should be to alleviate psychological misery, but I’m confused by your last sentence. It almost sounds as if you feel it’s better to take drugs to alleviate the pain than to face it.

    Sometimes yes, sometimes no. It depends on the situation, the duration of the pain, the intensity of the pain, the prognosis for the patient, the patient’s particular circumstances, etc. One size definitely does not fit all, nor does one treatment protocol or approach fit all. This is as true for psychological pain as for physical pain.

    I love your website, and have found many of your insights valuable, but I think you are a bit dismissive of CBT and therapists who practice it. I do agree with your points about medication in this post. I suffered from a very deep depression and tried, quite literally, every antidepressant on the market with no relief for more than a few weeks at a time. When the psychiatrist started trying combinations of the drugs and my monthly bill for drugs was more than $500, I just gave up on feeling better until a friend found out about my depression and just kept after me to try seeing a psychologist she knew.

    I eventually agreed to see this therapist, and am so glad I did. My therapist is a cognitive behaviorist. Within two months, using CBT techniques, I was feeling dramatically better. However, the therapist encouraged, and continues to encourage me to actually address the underlying issues that have caused me to struggle with depression periodically over the years. So therapist who use CBT techniques are often not ‘just’ cognitive behaviorists. We do discuss cognitive distortions, but we also explore the reasons for them. I think that CBT techniques can be useful tools for quick relief of extremely serious symptoms (like those of the depressive patient of yours that you mentioned) that more psychoanalytic therapists are too disdainful of.

    Fair enough. I do think that some CBT techniques have value and I use them in my practice. But I don’t subscribe to the idea that we are simply programmed in the wrong way and need to rectify faulty modes of thinking. I believe in internal objects, and parts of the self that interact with one another. I believe that negative self-thoughts usually involve a lot of unconscious rage. CBT techniques can help as long as you use them in conjunction with deeper exploration.

    i agree with you regarding listening and experiencing ones pain. for a great many years i took psych meds which changed everytime a new one was released on the market. none of them worked and some of the side effects were dangerous: seizures & fainting for example. i was diagnosed with bipolar II a number of years ago but only last year did my new therapist through my request looked at my mental health chart. that’s when we both discovered the bp diagnosis. since then i’ve done a great deal of research. along with other diagnoses, i determined that antidepressants and anti-psychotics and mood stabilizers were just worthless. i’ve been in psychotherapy since i was 19 yrs old. many therapists have passed through my life. i do believe in the “talking cure” and not any of these cure me immediately. there aren’t any sure fixes. i am a totally different person from the one who walked into therapy those many years ago. just this past year i told my psychiatrist that i didn’t want to take any more psych meds. i wanted to work on other methods of treatment like meditation and my psychotherapy. plus i am a writer who is quite addicted to creating with words and other means of expression. these help to work through the depressions and the suicidal feelings. mostly i am hypomanic or just okay with my mood level but depression sneaks up on me all the time when i least expect it. the moods unfortunately change when i least expect them to do. this i am working on also, recognizing the triggers that cause a mood to come on. gaining control is difficult but presently i am reading the book “bipolar in order” by tom wootten. and another book which deals with other aspects of the psychological condition titled: “the coming of the feminine christ.” this book is filled with insights that are unimaginable. it is such a profound book which has opened my eyes to things about my childhood that i never thought about before now. it helps me greatly to combine the knowledge of both of these books and the work i am doing with my therapist. the combination of all of these and what i do with the rest of my life keep me alive and living an exhilarating and imaginative life with its bumps and fears. the hardest thing to deal with is the pain, physical and emotional and psychological. but i am a fighter and a believer in psychotherapy. it has brought me this far. thank you for once again writing an insightful and thoughtful post. pain is part of life and you are right, it exists to feed us messages about our selves. recently i wrote a blog post specifically about the pain of bipolar depression and the creativity that can evolve out of those intense emotions that surface during those long moments of depression and thinking seriously about committing suicide. i was told recently that a hormone is released in the brain before a person is about to die in order to prepare them for a more accepting death. this same hormone is supposed to be released when you are in a state of a bipolar depression and that when you feel suicidal the hormone makes you think of death and it also takes away the fear that death usually brings under other circumstances. for me when i am not depressed and the thought o death enters my mind, i feel fear and become frightened by the thought of my own mortality ut during depression no fear of suicide. it’s an interesting dichotomy and quite perplexing. let me know what you think about all of this. jennifer

    This is all very interesting. Of course I’m on the same page — I value all of my emotional experience, including the pain, and rely upon it as a source of meaning and creativity. But as you can see from other comments, some people have found themselves in so much pain that they could not function; they feel that ADs have been a life-saver. I respect your decision to take yourself off meds but it seems that a great many people don’t feel able to follow your example.

    I’m thinking about all the studies that suggest that a combination of both medication and psychotherapy yield better results than either medication or psychotherapy alone. I have had to have antidepressants prescribed in the past as a “band-aid to prevent me from committing suicide before I moved on to working on the issues that caused me to become so depressed. I do believe, however, that because I suffered from 20 years of childhood and young adult trauma, long term therapy has been absolutely necessary for me. I don’t believe short term therapy can undo 20 years of damage caused by daily trauma. The trauma caused PTSD, anxiety, depression, agoraphobia and issues I may have yet to uncover. At times the anxiety has been so paralyzing that I have been unable to progress in therapy without medication, so think I have benefited from both therapy and medication as part of my recovery. I believe I have still have a long road ahead of me, but not to travel it would be to live a life without discovering my full potential. I am sober alcoholic for almost 20 years and I know have a deep strength that will get me through this recovery process.

    When suicide is a risk, or depression so debilitating that the person can’t function, then ADs are definitely of value. As long as it’s not forever, and as long as it’s combined with psychotherapy. Just be careful about the long-term side effects.

    Thanks, Heather. I was unaware the Xanax was under fire in Australia but I read up a little. The addictive and potentially life-threatening nature of these drugs is finally getting the attention it deserves, but the same can be said of so many psychiatric meds commonly prescribed. Rather than correcting a chemical imbalance, SSRIs actually cause one; the body comes to depend upon the drug to maintain an adequate level of serotonin in the neural synapse, and when it is discontinued, the body goes into withdrawal.

    “When different places within us are in pain, we should extend the care of deep friendship towards them. We should not leave them isolated under siege in pain. When a part of your body is ill, it must be a lonely experience for it. If we integrate its experience and embrace it in the circle of recognition and care, it alters the presence of the illness and pain”.

    p.249-250, “Eternal Echoes” John O’Donohue, 1998.

    love your post, actually the opposite of what alot of people do, especially with cancer, they hate it and fight it,

    whereas if they loved those cells and meditated on those parts and loving them better, it might be an act of alchemy on the body physically,

    this sort of stuff really helps inspire me to keep embracing the pain that comes up and have the courage to love it and believe that it can change from pain into healing,

    thanks for the positive post,

    I appreciated reading everyone’s comments. Although I struggle with depression and anxiety I am not taking medication mostly because of the potential long-term side effects and because I have not found them that helpful in the past. A couple of years ago, I went to see a psychiatrist and after answering some questions, (I think my appointment lasted for 20 minutes) he prescribed me an antipsychotic-I did not take it. Anyways, he said that this particular antipsychotic would help me with my mood swings-I do not have a bipolar disorder but struggle with emotional dysregulation and BPD traits.
    When I am struggling with anxiety and depression (especially the anxiety), I wonder how much this almost constant state of unease is hurting my health. Meaning, maybe not taking the meds will be detrimental to my health—like not taking a cholesterol medication. Just a thought, I know, does not seem like a good argument.
    I also wonder if I would be a better parent if I masked my emotional pain-(although my past was quite traumatic) how I understand and express my emotional pain seems to be anxiety and depression (I have been able to stop abusing substances so I am left with the anxiety…).
    Additionally, if I am aware of the controversy surrounding the use of long-term use of psychiatric meds—their harmful effects and so on, why are so many Drs. seemingly ignorant about this? …and they are very intelligent people so I am a bit confused about this.

    I think there’s a large amount of dis-information by pharmaceutical companies, to begin with, and then physicians these days are over-worked and seeing so many patients that they just want to prescribe something to alleviate their pain. It’s understandable if misguided.

    I think you make a good point that I haven’t given enough weight to — there is also lasting damage of a kind that occurs from debilitating and lifelong depression or anxiety.

    interesting the point on the meds long term damage, i had a psych nurse who saw this, he said the old anti psychotics used long term gave people outward tics and involuntary movement problems, but that all the new drugs are doing is slowly invisibly damaging peoples inner organs and bringing premature deaths,

    he did wonder with some clients if they would be any worse off drinking or taking street drugs (cannibus)cos at least it would be there drug of choice,

    i think there is some truth in that, especially for the high doses of these sorts of meds.

    i totally believe that the psychs make “whats the least worst for this patient, and whats affordable” and so give meds,

    and its true that depression can kill so i suppose for some people meds might help prolong a life that could have been ended much sooner at the persons own hands,

    so much grey area in life!

    It surprises me, how little public information there is about the damage done by the long-term use of these drugs. The professionals with first-hand knowledge know just how destructive they can be.

    Hello, I’m just new to this page.

    I would be very interested to know more about the lasting damage that can occur from debilitating and lifelong depression and anxiety.

    I have just recently visited a consultant psychiatrist to get her opinion on my mental health. She diagnosed dysthymia, depression episodes, anxiety and general anxiety disorder.

    I have never liked the idea of seeing a shrink, with all its stigmas, but l actually ‘clicked’ with this one. And l would be interested to know more on the lifelong effects or depression and anxiety. I know it is debilitating, its a constant struggle living a normal life.

    Suffering is a universal condition relieved only by enlightenment and made tolerable only by knowing there are available paths to enlightenment, the kingdom of God, nirvana. And of course taking up one of these pathways, talking the talk, walking the walk. Then whatever else you do, and whatever happens to you, can be used as part of your spiritual practice. Pain can be pretty distracting and prolonged suffering can make us shut down, but let’s not forget what our goals are.

    I’m never entirely sure what enlightenment means, but I largely agree with what you say. While I don’t consider myself to be on a “spiritual path” in the way that term is usually meant, I most definitely view my pain and my suffering as meaningful parts of this journey I’m on.

    Hello Dr. Burgo,

    What would you tell to someone who have been diagnosed as “mild social phobic”. Since I read Bradshaw book I am much better.

    Thanks and I love your blog. (sorry if my english is not very good.)

    Hi, I don’t have enough information here to answer. I’d need to know more about this mild social phobia.

    Hi.
    I have had a similar experience to Jenny (the physician) and despite my initial resistance to medication,I have found it extremely beneficial to treat complex PTSD arising from multiple traumas, including an extremely dysfunctional relationship with a narcissistic mother. It has enabled me to function on a daily basis in order to care for myself and those I care about – primarily 2 young children (and husband) I have been in therapy and on and off medication for over 7 years. I am interested to know whether you believe in any genetic component for depression/anxiety and what you mean by “long term” use of antidepressants. Are you talking years, decades, what? Also, I thought the studies regarding antidepressants versus placebos related to minor to moderate depression not severe, major depression but perhaps I am mistaken.
    Personally I have tried to take a wholistic approach to the whole thing – that has meant exercising more, seeing a naturopath at times, seeing a psychologist at times, taking medication and seeing a psychiatrist regularly, seeking out practical and emotional support from others, setting boundaries with my family of origin, writing about my experiences etc etc.

    I support that holistic approach — sounds just right.

    As for a genetic component, it doesn’t really matter to me. Yes, there may be a predisposition in certain families, but that doesn’t mean the expression of that tendency can’t be coped with on a psychological level. As Schore and others have shown, genes don’t unfold in some automatic, pre-determined way but express themselves in response to the emotional environment after birth.

    Pain killers are very very useful. Just go to the dentist and you’ll see what I mean. Without anesthetic you’d twist and squirm and the dentist could not do their job well.

    Similarly in psychotheraphy, I think that when pain becomes too painful the mind “twists and squirms” or rather denies and rationalizes through defence mechanisms and makes the job of the psychotherapist much harder.
    In psychotheraphy current medication acts like a dangerous anesthetic. Doing theraphy without them is posible but it’s like a dentist doing an extraction with only a selective muscle paralizer (don’t want to stop the heart) , which in psychotheraphy would be the deactivation of the bad defence mechanisms.

    Psychotheraphy needs safe medication just as much as a dentist needs a safe anesthetic. I believe you don’t have to focus on the pain but rather on what is causing it.

    In my opinion, this medication would probably disable pleasure as a by-product of disabling pain. Just like anesthetic disables bodily pain and pleasure.

    i like this post, i have taken myself off anti psychotics which i found just made me like the living dead, ” the drugs do work” and i see acquaintances still on them and that kind of know they are numbed out but seem to have crossed a line in having the courage or ability to do anything about it,

    i feel there is a difference between the stronger antipsychotics and the less strong (in my opinion) anti depressants

    i would say the diff for me has been one is like going to bed when you break your leg, thus not being able to do anything at all, whereas the latter have been more like whereing a plaster cast on a broken leg to support you AS you heal, and just as you have several different leg casts until you leave off one altoghether, so you can reduce meds accordingly (my experience)

    also a point to be made that of course we can have in built defence “medicating actions” like over exercising, over working that can numb us out, or over thinking, which do similar things to medication sometimes,

    therapy and deeper more visualisation work is helping me with all this,

    i like a saying ” keep looking at the bandaged place, as that is where the light enters”

    that saying helps give me courage to keep bearing the pain so i can learn listen and process it and hopefully heal as best i can, (heaps more than if i had continued on strong meds)

    thanks again for raising these issues and bringin like minded folks together on this

    cheers

    This is an interesting post. Sadly it also touches on a personal issue for me.
    A therapist I’m going to suggested to test me for depression after I told her I have lost all interest in pretty much everything I used to like and that I feel lonely. I asked her if she would send me to a psychiatrist if she were to diagnose me with depression. She said it would be a good idea to use medication if the test were to reveal that I’m depressed.
    I told her that there is no risk of me suiciding and that I don’t want to take medication due to it’s side effects (sterility, depression, increased risk of suicide, etc) but she still held on to her view that medication could help me in the case that I were depressed.
    Are antidepressants helpful to patients who are depressed but are not scared of the pain and are cooperative in theraphy? Is a test for depression really necesary when there is no insurance involved? I feel like she doesn’t believe my emotions are trustworthy enough.

    No, antidepressants aren’t very helpful for people like you who are willing to face their pain. Unfortunately, the view expressed by this therapist is standard dogma. My advice is to trust your own instincts/emotions and ignore her.

    bearing with their pain

    Maybe it’s just me being overly sensitive to the judgmental language but, why would you want to teach people how to put up with their pain like an unwelcome guest that has to be tolerate regardless of consequence? It is here is where I think this is at the core of it all: we want all pain to go away, but what would happen if we learned these emotions we’re desperately trying to get away from in some form or another are merely feelings not to be tolerated, but accepted as part of the whole? Why do we willing accept the good bits of us, but try to desperately hide/banish the bad?

    Dr. Burgo,
    I have been in twice-per-week therapy for a year and a half now. Though my therapist has never labeled me, my best guess is complex PTSD as a result from childhood neglect, physical and sexual abuse, and inappropriate exposure to people with mental disorders as well as death/dying. I’ve had nightmares my whole life until recently, and hallucinations and night terrors during my childhood which are now reoccurring since being in therapy. I’ve had some panic attacks since being in therapy and dissociate sometimes when talking about the past. I own a small business and have a lot of responsibilities, so it’s very difficult for me to manage these overwhelming feelings and also keep it together enough to not ruin the stability (not to mention thousands of dollars I put into my mental health that) I get from gainful employment.

    For the past year my therapist has recommended I see a shrink to get medications to help, as well as continuing our talk therapy. I have grown to trust that she is doing her very best for me, but I am not one to ever trust medications/big pharma/etc. so have been resisting seeking this kind of help. However, my latest episode of depression and feeling suicidal has made me finally give into the idea. I see a shrink next month, one that my therapist knows and respects. I’ve discussed my concerns with my therapist, but she insists she’s seen medications help many people–and it’s the ideal to combine medications with talk therapy for best results (my paraphrase of what she’s said). I could be wrong, but I believe she feels that reducing the anxiety will help me dig into the past more, unlock more traumatic memories, and help go deeper into the pain without as many barriers and spiraling side effects as I experience now.

    My question is for you… and one I’ll be asking my therapist and anyone who may have an informed opinion… is how can I at this stage in the process make the best decision possible for myself and my health? I know that if the shrink prescribes a medication, I don’t have to take it. I can do my research on side effects. I can trust my gut. But do you think I should get a second opinion from a psychologist or psychiatrist? I’m a fairly well informed person in general, but in this area I have no idea what’s best for me.

    I have your book (I’m on chapter 2) and I thoroughly enjoy your blog. I’m a first-time poster, but this topic is so timely for me now and I’d be lying if I said I wasn’t afraid of either option — taking drugs and not taking drugs.

    The proposition that taking drugs helps you to delve deeper into the past is now accepted dogma but I have not found that to be true in my own experience. By all means get a second opinion. Make sure it’s someone who has a skeptical view of psychiatric meds.

    I wanted to say thank you for this forum. This post and discussion helped me form my own thinking in two ways: 1) I went to the psych and was prescribed Abilify. I decided, for now, not to take the medication. But still, it’s comforting to know this psyche’s opinion and treatment plan (versus having no feedback/diagnosis for my issues) — I can always return to him/a 2nd opinion/and/or the meds if I feel I must. And 2) I (for the first time) entrusted the help of a friend who has extensive experience in similar areas, and most importantly, has navigated the psych department of our mutual health care provider for many, many years. She’s painfully shy, but in this area, she has had to become a firm and strong advocate for herself to get good care. She’s going to hold my hand through the process and help me do the same for myself, whenever I need that. For now, I’ll double down on my self-care, healthy living and my psychotherapy work. Should I need more help beyond that (and I may), I’ll have a plan, and that in itself is a tremendously powerful (less desperate/at the mercy of) feeling.

    Recently I had an episode where I felt I hit rock bottom, again. I find it hard to cry and I was crying to exhaustion. I was scrambling to think of ways to suicide but without pain to myself and my loved ones. Obviously nothing came to mind! ( I am also fortunate to feel connected to others which protects me somewhat) I’ve experienced these periods intermittently my whole life so I know that they will pass and I will feel better again soon but I have to take control of my self. As Dr JB says I have to bear the pain. The difference this time is that Iacknowledged the bleeding obvious. I am responsible for what I put in my body. Too much alcohol, sugar, processed or fatty food or having little nutritious food at all affects my thoughts and feelings. I am at a healthy weight but I have found that if I stop regularly exercising, being outdoors and become careless with nutrition my mental health gradually slides down that slippery slope towards oblivion. Last year my doctor suggested I take AD, I was severely depressed with many physical ailments. She gave me a sample pack that sits unopened in my drawer to this day. Of course I have not taken them but arrogantly and erroneously I think it is ok for me to indulge in too much wine if my mood needs dampening or bolstering. Yes I recognised my hypocrisy. Now three days later I feel fabulous again. I’m popping sunflower seeds, herbal teas, walking in the beautiful autumn sun and noticing all that makes me feel happy to be alive. I still have and feel all the same sorrows but I can bear it better when I take responsibility for my healthy being. Nature abhors a vacuum, so last night when I desperately wanted that drink to banish my demons I ate fruit, seeds and vegetables then listened to music. The feelings eventually went. Do, observe then correct.
    However I have seen medication work for a child of mine who was suffering from psychotic episodes and conversion disorder.
    I also know that depression will start to hit sometimes when I visit this site, I need to be mindful of that also.
    One size does not fit all. As you Dr JB say we all need to find our own way.

    Thank you for your blog.

    Dr. Burgo, how do you explain recurring debilitating seasonal affective disorder, depression that recurs like clockwork when the days shorten? Is that a merely a psychodynamic phenomenon in your view?

    Similarly, how do you explain, three children, all raised by the same parents (specifically by a mother who has been diagnosed with bipolar disorder and has experienced rapid cycling bipolar depressions and, in the past four years, crippling six-month-long depressions sometimes accompanied by suicide ideation), who exhibit these signs:

    One, no psychiatric diagnosis, a fairly “normal” adolescent boy and a, typically, straight A student;

    Two, an adolescent girl (the youngest) who was caught cutting and has been diagnosed as having depression, is now on Prozac, and through all this has been, typically, a straight A student;

    and Three, an adolescent girl (the oldest) diagnosed, two years ago, with bipolar, OCD, and oppositional defiant disorders who has exhibited signs of all three disorders since early childhood, even though her parents were clueless as to why she behaved so badly.

    As the bipolar mom, diagnosed two years ago, I’ve lived my life since I was a kid feeling that something was “wrong” with me. Suicide attempts marked my adolescence. In that, I share a history with my oldest, and two a lesser extent, with my youngest.

    But, from the time my oldest daughter was little, like I was in my own childhood family, she was significantly different than her siblings. Only, unlike me, she was worse. But, the again, I reacted to her outbursts in a way in which my parents never reacted to mine.

    Which brings me to all the feelings of “what did I do wrong as a mom?” that I can have at times. But when I get bogged thinking like this, I remind myself that my other two kids exhibit none of the mean and spiteful behavior of their sibling. So it’s not just that I parented her differently. She behaved differently than the other two. Way differently. (In her defense, however, she can be a very insightful person, even loving. But, when she’s bad…)

    So, in a family like ours, given the little you know about us, would you say our dysfunction has all been about psychodynamics, with psychiatric factors playing no part? If so, I’d have to say I disagree. I think we represent a combo of genetics, biology, and family dynamics.

    I’ve got too much evidence that there is a genetic and biological component at play in my family to simply ignore it. That being my own psychiatric make up (genetics that have, I think, affected my daughters). In addition, there is the fact that one kid raised by the same mom is vastly different than her siblings are in ways that are destructive because, I think, her brain is radically off and has been since birth (biology).

    I’m not saying that the only solution is for my daughters and I to take medications. I know for certain medication is not doing anything to help my seasonal depression. So, I am seriously considering moving to a sunny climate during fall and winter. Which only underscores the fact that, irrespective of whatever psychological issues I’v got going on, and I know I’ve got them, without adequate sunlight, I will get depressed–sometimes depressed enough to consider suicide (biology)

    P.S. I want to mention that my youngest daughter’s cutting incidences occurred in response to stressors. She is normally pretty even-tempered and pleasant. However, as she has gotten older, she is standing up to her older sister’s bullying more than she ever did in the past. The final cutting incident, out of a reported four, occurred after a shouting and match between the two. That was when I first learned of the cutting. And that was when I told my oldest (age 17) she had to go live with my elderly parents–which has worked out well for them and for my, now much quieter, family.

    Bottom line, though, is my original question: Is it your view that illnesses like bipolar and clinical depression, OCD and ODD, have no psychiatric component. As I said, I’ve experienced evidence to the contrary–and I haven’t even touched on the behaviors I or my daughters have exhibited when hypomanic (a state I didn’t know I could get in until two years ago. But one that, in hindsight, I can definitely see that lived through).

    This does seem like necroposting, but I am burningly curious as to your response to Clarissa’s comment (the one directly above mine), which encapsulates everything that bothers me about the “psych illnesses have little to do with biology” claim.
    I am a young M.D. (not yet licensed, however, as I am currently battling my own strain of bipolar / depression / dysthymia / mood disorder NOS / what have you) aspiring to a residency program in psychiatry. Having been both, I can say with certainty that the pills-only approach is deeply unsatisfying for both patient and physician, and psychotherapy has helped me a great deal (but not as much as, as you say, learning to recognize my pain and pay attention to the things it is telling me). I also find it telling that, of all the cases I reviewed in the psych ward as a student, not a single one had what you’d call a “normal” childhood and upbringing, or even a tolerable one.
    I can also say that I feel I would probably not be here to write this comment without the help of medications. Proof of that, I find in the fact that whenever I go off meds for a couple days (always unintentionally, I am a forgetful and flaky person), I find it impossible to function. Of course, it could be withdrawal, as you and others (like Whitaker, who I find sensationalist though he does make valid points) say. Which came first, the neurological deficiency or the drug? I don’t think anyone is qualified to say just yet.
    What I am qualified to say is that my childhood, though not easy, was not terribly traumatic, while what is notable about my history is the extreme proneness to volatility in my father’s family, and a history of suicides, institutionalization, and impulsive and poorly-thought-through actions that I think are suggestive of mania. Any influence I have from them would more likely be biological than environmental, as I barely ever met them growing up, and my father’s only sign of being “abnormal” was a badly-handled mid-life crisis, which I would put down purely to poor decision-making. One of our psych professor’s lectures comes to mind, where he expressed genetic loading in literal terms, as loading a gun. Yes, you need to pull the trigger (environmental factors) to fire the gun, but the bullet also needs to be there in the first place (biological factors).
    I have also seen the study results comparing psychotherapy*ONLY* regimens to medication*ONLY* regimens. Which I find a bit akin to comparing diabetics making only lifestyle changes and taking no insulin to diabetics taking insulin and retaining all their old bad habits. Of course you’re not going to see a significant difference between the two, and if you’re looking at milder cases of diabetes or even pre-diabetes of course the lifestyle changes are going to have a better outcome. That’s selection bias, as I’m sure you’ll know. Similarly, I suspect the cases where schizophrenia was cured with no or minimal use of neuroleptics were milder, gentler cases in the first place, as no responsible psychiatrist would withhold medical treatment from a full-blown case of psychosis where the potential for self-harm / harming others is present, and the only clinical trials such patients would be allowed to participate in is to compare one neuroleptic to another, not to compare neuroleptics to no neuroleptics.
    You have already said that you are not categorically against ADs. That’s cool. I’m no great fan of ADs either: the evidence for them is too weak to quite satisfy the scientist inside. Not all cases of “depression” have a biological basis, some are simply cases of unsucessful coping, as you say, and medication should not be the first line of therapy for such cases (and never the sole or lifelong treatment, at any stage of treatment). And lastly, whether you are a psychotherapist or psychiatrist, coming to a “conclusion” on the patient’s condition without gathering as much information as you possibly can is criminal laziness. What I am worried about is that there is enough misinformation / stigma / fear surrounding the topic of mental illness to scare away people who actually do need the treatment. I am also worried that the harm caused by irresponsibility on the part of psychiatrists is incorrectly ascribed to the medication, which in itself is only a tool. I trust my physician that I have been seeing for five years, who has also treated and successfully “cured” a number of my friends and my current boyfriend. (I, however, am supposedly a refractory case.) I trust my old therapist (whom I have stopped seeing, sadly, for financial reasons) and you, insofar as I can trust anyone I meet online. There are plenty of mental health care professionals both MD and not that I decidedly do not trust.

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