I am generally agreeable to providing cognitive-behavior therapy alone, as it has shown to be effective in the randomized trials. However, when beginning treatment with a client who is reluctant to take medications, I make a point of setting the stage, at the beginning of treatment, for the possibility that if the client does not respond to cognitive-behavior therapy, a drug trial may be indicated. I put the client on notice that if, after 3 months or so, he or she is not making progress in cognitive-behavior therapy alone, I will reopen the question of whether it makes sense to add medications to the treatment. Cognitive restructuring interventions are particularly helpful in this situation.
Clients have many objections to medications.
Often these have some validity, of course, and they all deserve careful attention. Many objections that clients have to medications, however, involve distorted, maladaptive thinking, and here the skills of the cognitive-behavior therapist can be invaluable. I work patiently, taking as much time as needed to carefully get these concerns out on the table and examine them. Sometimes people are afraid medications will significantly alter their personality that they will become different in some way that is disturbing to them and robs them of their individuality. Another concern is that the drugs will make the client feel worse the client fears that side effects will make him or her feel worse, not better.