THE MATRESS AND THE LADDER

 

A remedy for sadness and loneliness. To be less anxious and reduce worries. A pill to improve sleep. Or one to “turn it on” and another to “turn it off.” Medication for mental exhaustion, to cool down tempers, to control impulsiveness and irritability. A medication to help deal with a difficult spouse or with children who just won’t listen. Something to boost motivation. To eat less and exercise more. A drug to be happy.

There’s hardly a day in my practice when I don’t come across a patient longing for some kind of “magic” that could handle so many emotional and behavioral demands. I understand this infantile fantasy, because it’s very primitive—the idea that modern medicine holds the power to provide instant solutions. The illusion that a few milligrams of a certain substance and an even greater dose of hope can solve all our life’s problems.

But the truth is, that simply doesn’t exist. I’m sorry to say that there’s no miracle molecule, no easy solution to be swallowed with a glass of water that can completely resolve the issues that lead us to seek psychological help. It’s worth remembering that those issues—whether related to work, marriage, relationships, school, grief, challenges, self-image, and so many other aspects—depend on deliberate action. They hinge on a shift in motivation from the individual facing problems and, more importantly, how they face themselves. This change is something medication cannot achieve. But change is essential, and one of the most effective ways to bring it about is through psychotherapy.

I often use the metaphor that, in times of crisis, medication acts like a mattress, carefully placed at the bottom of the hole into which the crisis has dragged us. It cushions the likely “fall” we suffer during those tough times. With different thicknesses and densities, some with more springs or foam, these chemical mattresses, with their controlled prescriptions, are there to counterbalance the emotional gravity weighing down on our psyche. They ensure that we hurt ourselves as little as possible, restoring control over our movements and allowing us to start taking deliberate steps to face the crisis head-on.

From there, we need the help of a ladder to climb out of the hole we’ve fallen into and return to the surface where we once stood. A sturdy ladder, firmly propped against the wall, so that the patient can, by their own efforts, climb it and safely return to life. In a crisis, this escape ladder that pulls us out of the pit represents psychotherapy. Each component of our psychic survival toolkit—the mattress and the ladder—has its importance and value, as well as its unique way of helping us. And each has its specific technique for use, along with a proper time for application.

Medication can be useful both in times of “crisis” and as part of the “maintenance” of treatment, and it should be prescribed and monitored by a medical professional, ideally one with mental health training. Psychotherapy, on the other hand, should be conducted by a professional trained in that field. In my country, recognized professionals include psychologists (those with a bachelor's degree in Psychology and a supplementary year of supervised clinical practice) and doctors specializing in psychotherapy. There are also “alternative” therapies, but they do not equate to conventional psychotherapy, which is made up of clear and specific theoretical and clinical techniques as well as satisfactory levels of scientific evidence. Coaching and life coaching are other types of services that differ from psychotherapy and do not serve as a replacement for it.

Psychotherapy is aimed at providing a process of self-knowledge and transformation. It helps identify the patterns of thought, behavior, and emotions that keep us trapped in cycles of suffering. More than that, psychotherapy offers practical tools for dealing with life’s challenges more effectively.

Unlike medication, which acts at the biochemical level (or more specifically, the neurobiological level), psychotherapy operates in the realm of consciousness. It helps us understand the roots of our problems, often connected to limiting beliefs and the ways we relate to others and the world. It brings us face-to-face with the motivations that make us who we are and drive the way we act. While medication cushions the fall, psychotherapy strengthens us to climb, step by step, toward resolving the conflicts we face.

This is not an easy task. The psychotherapeutic process requires courage, commitment, and patience. Just as we can’t expect medication to make us “wake up happy” overnight, we also shouldn’t expect psychotherapy to spark quick or involuntary changes. Each step is a small but important advance toward self-acceptance and building a more integrated life.

There are times when patients may feel they’re climbing more slowly than they’d like, or that they’re stuck on a certain step. It’s easy to get frustrated during those moments and feel like therapy simply “isn’t working.” But it’s precisely in those moments that persistence is key. Often, we sabotage ourselves because of the fear of becoming so healthy that we no longer have anything or anyone to blame for our failures.

Climbing the ladder involves a movement from “inside out,” a deliberate shift that begins within the patient and is expressed through new behaviors, as well as new forms of emotional regulation that are visible to others. In turn, medication should be seen as an external resource, acting from “outside in.” Both are important and necessary. It’s vital to recognize that there are times—whether in acute crises or chronic conditions—when medication is essential. Medication stabilizes the patient, giving them the ability to participate in therapy. Without this support, many patients wouldn’t be ready to climb the steps of psychotherapy.

In this way, the metaphor illustrates the complementarity between pharmacological and non-pharmacological treatment. Medication can be essential to relieve immediate suffering and give us the breath we need to start therapy. But it’s psychotherapy that helps us transform that initial relief into lasting progress. It invites us to look within, to ask the hard questions, and to work on finding the answers. Psychotherapy is an investment in ourselves and the quality of our future.

It’s worth noting that climbing the ladder of therapy isn’t entirely a solo adventure. While the psychotherapeutic process is deeply personal and individual, it involves a relationship of trust with the therapist, who acts as a guide on this journey. The therapist doesn’t climb the ladder for the patient but accompanies them from wherever they are, helping them recognize their internal resources and find the strength to move forward, even when it seems difficult or unlikely.

Over time, this helps us build a set of emotional and cognitive tools that enable us to handle future crises—and the “normal” challenges of everyday life—more resiliently. The ultimate goal isn’t just to escape an acute situation, but to learn to navigate life more calmly, securely, and naturally, knowing we have within us the tools to face it.

At the end of the process, the patient not only recovers from the crisis but becomes stronger than before. They don’t just return to where they started but advance, with a new perspective on themselves and life, with all its vulnerabilities and strengths. With or without the reinforcement of medication, the great promise is to surpass unimaginable limits.

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