Life of the mind: How do I know I'm helping

There were two minutes left of the session and my patient went quiet and contemplative, her Jackie O look today, bobbing diamond earrings and claret nails.

She had not started the course of anti-depressants she’d been prescribed. When she said she’d changed her mind about wanting them but felt guilty, I said something like: “You feel it’s obligatory to take the drugs in order to please your GP?” She said she didn’t want to disappoint anyone, but that she’d asked for them in a panic.

Therapy and anti-depressants are a confusing area for me. When this lady is in a manic state she does present as quite unwell and I can see why the GP would have given her what she demanded. On the other hand, that was a five minute consultation during which she was at her illest. I see her once a week for 50 minutes and, in fact, she’s very rarely that anxious. It seems to me that she was fobbed off with drugs when really the gap between therapy sessions was feeling long and she just wanted someone to say: “It’s all going to be fine.”

I remember defiantly declaring to my psychoanalyst 16 years ago: “Maybe I’ll just go on anti-depressants or something!” I was needling him and I wanted him to say: “Don’t be ridiculous. Give this treatment time and let’s think together about your need for a non-reflective quick fix.” Instead he said, in a tone that I felt suggested he wished I’d bugger off: “Well, you do seem very anxious.” I felt dropped, evicted from analysis, and I’m sure he will have tried to interpet that and I suppose I ignored him. I took Effexor (unsayable without an American movie-trailer voice) for three months and enjoyed not being frantically anxious, but hated the chemical taste in my mouth and the emotional flatness. I didn’t really see how they were going to help me. The analysis, however, did… tectonically slowly.

I have another patient who keeps crashing off her anti-depressants in the belief that it will please me. Then she gets very unwell and thinks I’ll hate her for going back on them. She refers to them as “the tablets” and they have magical properties in her mind. She attributes all her thoughts and feelings to their side-effects and when she’s crashed off them (dangerous—you are supposed to come off gradually) she attributes all her thoughts and feelings to the withdrawal. So, somehow, her real self doesn’t exist at all. I interpreted this once and she said: “I was put on them when I was 16 and told the doctor about what was happening at home. I can’t remember what I was like before I started taking them.” She’s now 47. In supervision someone called them “the magic beans.”

Another patient finds that, on anti-depressants she feels her husband forced her to take, she has to get a doctor’s certificate to go on a diving holiday because the diving company is worried she might be unstable. “It’s ridiculous. It’s if I wasn’t taking them that I’d be unstable,” she says. “Or would I?” Oof. Honestly, I have no idea. She is entirely different to how she was when I first started seeing her a year ago, a month before she went on the drugs. Then she was silent, surly, aggressive. Now she is communicative, thoughtful, interested. Is it the anti-depressants, the therapy, the combination, a change of job and apartment?

I’m betting on the therapy, but I would, wouldn’t I?