When A Patient Requests Xanax: A Doctor’s Unexpected Response

Amy:  One aspect of my family therapy practice includes working with family doctors during their Residency training. These young physicians spend time  with me in my office where they learn about relationship aspects of clinical care.  I also observe and participate in their patient sessions in the clinic.  I have been doing this for many years, during which time  I have observed many changes in medical education. One glaring shift is the emphasis on medications.

Since I am not a medical doctor, I don’t have much opinion on prescribing drugs for the many ailments which bring patients to see their doctors. But I do have an opinion on the rampant, reflexive prescribing of the vast array of psychiatric and tranquilizing/stimulating medications that now dominate the practice of primary care.

Many of these patients present with what I call “problems of living”:  Stress-related problems like moderate anxiety and depression, and many of the  chronic pain syndromes. Ultimately, there are no drugs to treat the human condition, despite the claims of the pharmaceutical industry. But, with some care and understanding,  there is help for this kind of suffering. Here’s an example of a young physician who applied that kind of treatment:

The Case:  One evening in the clinic, Dr. Alyssa, an astute, thoughtful physician asked me to sit in on her patient session: Her young female patient was requesting Xanax, and the doctor wasn’t comfortable with the automatic writing of this  prescription.  What happened in the next fifteen minutes taught us something about how a seemingly straightforward  visit can be transformed into a therapeutic experience.

Dr. Alyssa knew this patient slightly, having seen her once or twice before. The patient, Ivanna,  a twenty-five year old emigre from the Ukraine, had been complaining to Alyssa about her anxiety-generating mother-in-law, with whom she lived. Apparently the household was full of tension, making it difficult for anyone to have “peace of mind”. Ivanna was currently enrolled in nursing school and worried that the upset in the household was sapping her energy, making it difficult for her to concentrate on her studies. She thought Xanax would help “take the edge off”.

When Alyssa and I entered the room together, we asked the patient to expand on her story a bit. . The mother-in-law’s incessant demands, intrusiveness and hyper-criticalness created lots of misery for everyone at home.  During the telling of her saga, Alyssa and I became impressed by this young woman’s  resilience in the face of some rather dramatic household pressures. Ivanna told us that she and her husband had been married a few years and enjoyed a strong, loving relationship. She said, “He knows the way his mother is. She drives him crazy, so he just tries to avoid her.” Ivanna and her husband–needless to say–are strenuously saving money for a place of their own.

As we talked, Alyssa and I freely shared our impressions with this young patient: We told her how we were struck by her intelligence, resourcefulness  and resilience. We continued to listen, an active kind of listening where we openly appreciated the patient’s strengths. Dr. Alyssa and I appreciated the thoughtfulness of this young woman, and Ivanna felt our respect and admiration. Her face assumed a bit of a glow.  She was clearly pleased–and I think a bit surprised–to receive this kind of affirmation from a couple of professionals.

We also noted how Ivanna tended to “go it alone”a bit too much perhaps. She said she “didn’t want to burden” her husband, so she kept most of her stress to herself. We casually commented on how trying to be “tough” can end up feeling pretty heavy. In fact, our stress usually feels much weightier if we don’t get a chance to blow off steam with our loved ones. Using ourselves as examples, we said, “Us care-taking types” often tend to “hold it in ” at our own expense. It’s a hard way to go. Alyssa suggested that Ivanna include her husband in her “bench-sitting sessions”–a spot she retreats to as an escape from her mother-in-law.

The whole conversation lasted about fifteen minutes. I excused myself, and the visit ended with Ivanna getting a refill for an allergy medication. I think she forgot about the Xanax. It didn’t come up again.

On reflection, this visit had a couple of ingredients that often prove useful: First, Alyssa and I treated this young woman as if she were healthy. We looked for health, and found it. When we found it, we commented on it, and magnified it. We also communicated, by our body language and our attitude, that we weren’t afraid of this patient’s suffering. We subtly conveyed through our conversation that her anxiety was not dangerous; we weren’t worried. This approach provides some of the most powerful medicine I know. I could talk for a long time on this theme, but I’ll save it for later posts.

We also wove in a bit of family systems therapy: We knew that Ivanna’s shouldering the tensions on her own increased her stress. It sounded like her marital partnership was both stable and strong.  By encouraging her not to “protect” her spouse, to ask for his help when she’s anxious and feels  the need to escape, we strove to provide a healthier balance, both for the patient and for her relationship. She didn’t resist this suggestion.

I realize that there are many docs who would have prescribed Xanax for this young woman. No big deal. But it would have been a missed opportunity. Both the patient and doctor, I believe, got something from this visit. The patient left the session with a deeper appreciation for herself and her strengths. And she got a few tips on how to include bringing her husband closer to help with her stress-relief. And, though I don’t know for sure, I think Alyssa felt pleased to be able to use her whole self–not just her prescription pad–in a healing capacity. It takes curiosity and courage to make this happen. And Dr. Alyssa demonstrated both.