What’s the Goal of Medication?
Go on a thought experiment with me. What’s “normal” in psychiatry? Are we always supposed to be happy? Is life always supposed to be smooth? Only in the world of advertising and on TV is life easy and all problems are resolved in 27 minutes – plus commercials. (In fact, those products and services in those commercials are placed there to imply using/buying them are your way to get and always be happy.)
So: “Normal” Doesn’t Equal “Always Happy”
We might hypothesize that life is, instead, always in motion – and emotional states are impermanent. It isn’t always a beautiful day. The job doesn’t always go well. We don’t always get the girl (or boy, or non-binary person) at the end of the story. To meet life’s challenges, we have a range of emotions. If there’s a danger, we’re supposed to be frightened. When things are unknown, anxiety is there to give us the extra energy to illuminate the situation and to solve the problem. When things are unfair, anger adds what we need to confront the injustice and move the needle toward fairness. Pain gets us out of situations that are harmful.
What’s Not “Normal” is When Distress Causes Functional Impairment
In fact, the definition of a psychiatric disorder can be summarized as an expression of distress, in the realms of emotions, cognitions or behavior, that causes significant functional impairment in the domains of home, work and play. It is not better explained by a common cultural belief or behavior, or a conflict between the individual and the society. It is not better explained by another medical condition.
Now, expressions of distress are not psychiatric disorders by themselves. How much distress? How much impairment is caused? And is it caused by something that would cause anyone distress (e.g., bereavement)? Is it something that if the stressor were removed, the distress would resolve (e.g., chronic pain)? Is the response something that is so magnified and sustained as to be crushing? How does it harm your relationships or your ability to work, to be a partner or spouse, or to be a parent?
Working Toward the “Reasonable” Response
In psychiatry, we have the awe-inspiring and terrifying work of helping a patient figure out how a patient in this polyglot society figures out the normal that works for them, their families, and the community they want to inhabit.
Part of that task is to figure out: what are reasonable responses to life inputs? Then, we help patients develop the skills to meet those inputs with reasonable responses. Reasonable is a key word here, and it’s about balance. For example, touch a stove and you’ll burn. However, if you spend your life terrified of stoves, you’ll miss the joy of cooking. Another example: go on a date with someone you love, the kiss should be joyful. But if you are (as I was) depressed and anxiety-ridden, I felt nothing but worry. (Don’t worry, today, the kisses are splendid!)
The Role of Medication: Easing the Hyperactive Response
Medication softens and loosens up those hyperactive responses. It makes the stories we tell much more interesting and nuanced. For example:
“Ow, accidentally touched that hot pot, but boy you should see the pasta sauce I made!”
“Wow, went out in that group of strangers… it wasn’t so bad and I had a great conversation with someone.”
“Those voices that usually tell me that everyone hates me and I should fear them were actually much nicer to me today. Maybe I’m okay after all.”
“Got on the plane, I didn’t panic… wonder why I was panicking in the first place?”
It's not going to make a breakup happy – it shouldn’t, breakups should hurt. It’s not going to make that dog trying to bite you less scary. But it can help us differentiate the one dangerous dog from all of the ones that are friendly or neutral.
Medication + Therapy: Crafting New Stories, Enabling New Responses
Therapy more effectively helps us craft new stories about the world that are better and more resilient. Combined with medication, the ideal result is that we can tolerate more distress and tolerate more joy. Mostly, we just feel better. And that is a very good result indeed.