Dismaying Story #68: When Meds Are Not Enough

Dear Andrew,

I got married twenty-four years ago when I was sixteen. I married someone so totally opposite to me so that I could be provided with stability and taken away from an incredibly dysfunctional home. I have gone through much in my life and that is an understatement. I have been abused in every way from my father, mother, brother, and older sister.

I married an abusive man, who eventually changed his ways when he found God. He has not hit me in years. He has become more gentle but can still be passively controlling. He has changed dramatically but I am still so afraid of him and I have no reason to be. I find myself living for his approval in EVERYTHING! I want to shake this off but don't know how. I am tired of living in fear all the time and walking on egg shells. I have become severely depressed and I am on antidepressants. I have been hospitalized once for a suicide attempt but I am far better now. I am on meds but I am still always afraid. What can I do?

Signed, Walking on Eggshells

Dear Walking,

I am glad you wrote to me because it gives me a chance to talk about an issue that affects many people, namely the use of medication to modify behavior. Drugs can be incredibly beneficial in certain circumstances; they can even save lives when the threat of suicide enters the picture, but they also have limitations.

You have been traumatized by the abuse in your life and you describe many of the classic symptoms that follow from such trauma. Your self-esteem is close to non-existent and your ability to cope with normal day-to-day stresses has been severely compromised. You fear negative consequences constantly (such as the disapproval of others) even in the absence of any immediate external reason to expect such consequences.

This type of fear reaction has two components, physical and behavioral. These two sides feed off each other and make the reaction difficult to modify. We all have physical reactions when faced with traumatic events. You know the symptoms -- your mouth goes dry, you feel a surge of adrenaline course through your body, you get that sinking feeling in the pit of your stomach, you tremble, your hair stands up, and so on. This is your body going into an alert status to prepare you to either fight or flee.

An abusive event also teaches you that such trauma is possible and you should watch out for it in the future. Repeated abuse can cause people to go further and come to several unfortunate conclusions. Chronic victims often believe the pain is inevitable and unavoidable, that the abuse is somehow their fault, that they deserve it or invite it because they are unworthy, and so on.

You were abused by your husband, so his very presence can serve as a stimulus to remind you of the trauma. This invokes a behavioral reaction (for example, walking on eggshells, fear, seeking approval, etc.) and a physiological reaction. When you feel the fear, do you get a little spurt of adrenaline or a dry mouth? I bet you do.

So you went to your physician, who is trained to respond to medical emergencies. The primary methods of intervention are pharmaceutical and surgical. (And yes, I know many physicians go beyond this, but many also tend not to.) At the time you were in the midst of a medical emergency, namely acute depression with suicidal tendencies, so you received a predictable response -- you were hospitalized and prescribed anti-depressants. This was almost certainly the appropriate treatment to get you through the immediate crisis, the period of greatest risk. As you can attest, however, this is not sufficient to address your ongoing issues.

The pharmaceutical solution offers attractive benefits for both the physician and the patient. Our North American medical system places great time demands on doctors. They are typically challenged to care for a flood of patients in a finite amount of time. Writing a prescription is time efficient and is one of the main things physicians are trained to do. Physicians simply do not have time to sit and talk for hours with each of their patients. The medical system is not set up to handle that, and doctors are not rewarded financially for doing so.

Patients also tend to be comforted by the medical model. The underlying message is, "This is not your fault. This is a medical condition to be treated with pills. You don't have to do any hard work or accept any responsibility. Simply take this pill and all will be well." Happily, I can tell from your letter that you don't subscribe to this view. You are asking, "What else can I do?" You are ready to take ownership of the solution and move forward, which is a healthy sign.

The fundamental problem is that pills can only change the physiological aspects of your reactions. They do little or nothing to address the behavioral side. You have never come to terms with the severe damage to your self-image. I would bet good money you have not forgiven yourself for "allowing" the abuse to happen. In your mind, it is still partly your fault. You still expect bad things to happen in your life, even though you say they have essentially stopped. You have been conditioned to expect them, so you now need to reverse that process, to condition yourself to expect them not to occur. This type of behavior modification is difficult to achieve by yourself. I recommend you see a psychologist, whose job it is to spend the time with you that a physician simply cannot. Psychologists are also trained differently and can offer the type of help you need to address your behavioral challenges.

Medication can sometimes be beneficial while you are taking part in behavior modification therapy. In certain cases, pills can help quell the undesirable physical reactions and make it easier for you to isolate and address the behavioral reactions. It wouldn't surprise me, though, if you find you no longer need the anti-depressants once you learn to let go of the fear. For your sake, I hope that is where you are headed.

Finally, you mentioned that your husband can still be passively controlling. Since you "walk on eggshells," I can only assume you have trouble sticking up for yourself in your marriage. Hopefully once you come to terms with your own individual challenges, you will be in a better position to begin working out more equitable ways of interacting with your husband.

All the best,
Andrew