DID I REALLY GET BETTER OR WAS IT THE MEDS? ASSESSING TREATMENT RESPONSE

The question of whether a patient has "really" gotten better — or whether the well-being they feel is merely the effect of the medication — tends to come up in my office just as the fog begins to lift. Symptoms lose their grip, breathing finds its own rhythm again, the world regains its contours, and precisely when the person could simply be celebrating, an uncomfortable doubt sprouts, perhaps fearful of what lies ahead: "How much of this improvement is mine, and how much belongs to the pill you prescribed me?"

It's an understandable doubt, with an understandable anguish behind it. After all, when we talk about mental health, we're not dealing only with symptoms: we're talking about identity, personality, choices, relationships, and the way people recognize themselves. After months of being unable to get out of bed, sleep properly, concentrate, or feel pleasure, improvement can actually feel strange. Sometimes people grow suspicious of their own relief, as if well-being had to show ID to prove it's legitimate — and here to stay.

I usually answer that question with a simple image: the car and the driver.

Some cars are excellent — exceptional, even. They have a supremely efficient and reliable engine, smooth and precise steering, spectacular stability, brakes that seem to anticipate being needed, a flawless gearbox, and they deliver everything and then some on a track in ideal conditions. Sometimes they're the fastest in the world, the very pinnacle of automotive technology.

Now picture a terrible driver — the kind who got a license God only knows how — sitting behind the wheel of a magnificent car like that. Besides underusing everything the machine has to offer, he manages to compromise even its finest features, so badly does he drive. He may stall the engine right at the start, botch a gear change spectacularly, hop the curb on his first maneuver, and even leave the car "broken down" through some basic error at the wheel.

Now imagine the opposite: an excellent driver — experienced, attentive, with a deep knowledge of engines, transmissions, and electrical systems. The kind who catches the faintest noise that shouldn't be there, wrings the most out of the mightiest technology, and could easily work as a test driver. But he's handed an old jalopy: the engine begging for mercy, the tires nearly bald, a gearbox that won't shift even under torture, and the carburetor (yes, the car and I both date back that far) more clogged than a storm drain in a flood. The super-driver, for all his skill, will barely get it moving.

By this logic, a car and a driver in minimally adequate condition make the ideal combination for a safe trip completed in reasonable time. Sometimes a good car even helps the driver learn, sharpening his skills with everything the machine has to give. Other times, a good driver compensates for lower horsepower and coaxes more out of the car than anyone would have thought possible.

See where this is going? Which one is running properly — the car or the driver, the medication or the patient? Or does success lie in the combination of the two?

On the car-as-medication side, it needs to be effective, suited to the demands of the route, tuned to deliver the desired performance, used with the regularity and discipline the owner's manual calls for, taken in for every scheduled service without skipping a single one, protected from light, heat, and anything that could degrade it, and fitted with a factory engine and parts of trustworthy provenance. On the driver-as-patient side: taking the medication as directed, caring for oneself, trying to do better what one now realizes was being done poorly, seeking complementary psychotherapy, managing time, diversifying activities, exercising, seeking out people and situations that inspire something good, steering by a brand-new ethic of living and, where it applies, drawing on one's spirituality.

Every psychiatric treatment requires teamwork. At minimum, it takes this car-and-driver duo working in synergy for as long as necessary to assess whether the combination works well as it is or could be improved. Only in very specific cases can eventual progress be credited to the medication alone or to the driver alone. It does require, admittedly, that the latter show at least good adherence to the medication, taking it at the prescribed dose and times, with all the precautions they were given.

If there has been consistent improvement, as with the hypothetical patient who asks the question in this post's title, it's because the parts are working well together. The medication did its job, and the patient did theirs. Score one for each.

So this isn't a matter of choosing between two competing explanations — "either it was me" or "it was the medication." All the resources involved, pharmacological and otherwise, including the will to get better of the person in treatment, helped restore the conditions for regaining effective control of one's own life.

The medication doesn't replace you

Psychiatric medications can turn down the noise produced by certain symptoms and increase the stability of the nervous system. It's like setting out in a freshly serviced car: starting no longer takes so much effort, acceleration feels safer, and holding a reasonable speed no longer burns through every ounce of available energy.

Depending on the condition, medication can help reduce anxiety, persistent sadness, irritability, impulsivity, repetitive thoughts, sleep disturbances, or intense mood swings. In other words, it can widen the margin between what happens to you and your capacity to respond to what happened.

But the medication doesn't choose the destination. It doesn't decide which relationships deserve to be preserved, which boundaries need to be set, which job suits you, or what kind of person you want to be. Nor can it determine what truly matters to you.

Medication can make driving possible again, but the one holding the wheel is still you. So perhaps it's fairer to think of it this way: the medication doesn't create an artificial version of you. When it works well, it can lower the obstacles that were keeping important parts of you from coming through. It isn't "the medication speaking for me." It's the medication working so that I can be a better version of myself.

The driver needs work, too

This is where authorship comes in. You decide, within the real possibilities of each moment, where to go and how to drive. That involves choices, values, boundaries, relationships, work, rest, leisure, life projects, and a larger sense of meaning for all of it.

Psychotherapy can work as a kind of driving school — happily, without a grumpy examiner clutching a clipboard in the passenger seat. It helps you develop self-knowledge, emotional regulation, communication skills, and resources for handling curves, traffic jams, and unexpected changes of route.

Good driving doesn't mean never making a mistake, never coming undone, never drifting a little off course. It means noticing earlier what's happening, balancing the turn of the wheel against the pressure on the accelerator, and refusing to let every slip be turned into a final verdict on your own worth.

Some people believe that for their improvement to be "truly theirs," they should manage everything on willpower alone — as if withstanding suffering without any help were proof of character. It isn't. Driving with the handbrake on doesn't demonstrate greater skill at the wheel. It just wears out the car and makes the trip needlessly hard.

No one drives in a vacuum

If we want to stretch the metaphor, we might remember that there's also the road. The road is the context: family, work, finances, relationships, losses, violence, prejudice, inequality, illness, the news, and all the circumstances that run through a life.

Sometimes the road is well paved. At other times there are potholes, roadwork, fog, detours, and a sign reading "alternate route" just when you were already running late. Part of healthy driving is taking the actual terrain into account. There's no point in blaming the engine alone — or second-guessing your own abilities — when the road is in terrible shape. By the same token, acknowledging external difficulties doesn't mean giving up your capacity to make choices. Even if that means choosing a different, safer route.

By the way, what's going into the tank?

The fuel stands for factors like sleep, diet, physical movement, exposure to natural light, use of alcohol and other substances, screen time, breaks, leisure, and time spent with people who do you good.

These elements don't cure every mental disorder, and it would be unfair to suggest that someone remains depressed or anxious merely because they didn't exercise enough or failed to organize their routine properly. Mental health is more complex than a checklist of healthy habits.

Even so, habits can boost or hinder any treatment. Asking a car to climb a mountain road on a full tank is quite different from asking it to do so running on fumes. Reasonably regular sleep, whatever healthy eating is within reach, some movement, and supportive relationships won't solve everything, but they help the organism make better use of the resources at hand.

The goal is not to build a perfect routine. Perfect routines tend to last until about next Tuesday. The goal is to build conditions good enough that life doesn't depend on heroic effort alone.

Maintenance is not failure

Every car needs servicing, alignment, and tire checks. In clinical practice, that means appointments, symptom follow-up, monitoring for side effects, dose adjustments, and strategies to prevent relapse.

Maintenance is not failure — much less is it optional. It's care for what is working. It's also important not to change or stop the medication on your own just because you've improved. In many treatments, improvement is precisely a sign that the strategy is working — not that it has become unnecessary.

Any change should be discussed with the professional following your case, taking into account the diagnosis, how long you've been stable, your history of relapses, side effects, and your current life circumstances.

So what belongs to the medication, and what belongs to me?

I don't believe the two can be separated with the precision of someone splitting a restaurant bill. Improvement, as we've seen, comes from a harmonious, well-orchestrated partnership.

The medication can take some of the weight out of the backpack. But you're the one who chooses the trail, takes the steps, senses the limits, and decides when it's time to stop and catch your breath.

Some signs that the improvement bears your signature: your choices begin to align once more with your values; basic tasks stop demanding a colossal effort; a range of emotions manages to show up in ways that fit the situations at hand; relationships become clearer, with a greater capacity for closeness and for setting boundaries; old, healthy interests reappear, or new and equally healthy ones begin to emerge; even on hard days, some capacity remains to care for yourself and correct course; and life goes back to presenting possibilities rather than only obstacles and cliff edges.

Getting better doesn't mean feeling happy all the time. A healthy person still feels sadness in the face of loss, anxiety in the face of threat, and irritation when their boundaries are trampled. The goal is not to anesthetize the emotions. It's to be able to feel them without being completely hijacked by them — to be, like the good driver, in command of the situation rather than surrendered to it.

On the other hand, some signs call for a frank conversation at your next appointment: euphoria out of proportion to the context, a marked drop in the need for sleep, agitation, new impulsivity, the feeling of being too revved up, excessive sedation, apathy, loss of interest, or emotional blunting — that impression that "nothing touches me anymore." If the improvement trades one form of suffering for another, it may be time to recalibrate.

Small tests of authorship

During the first weeks or months of treatment, a few simple exercises can help you notice how your own participation shows up in the overall picture of improvement. At the end of the day, write just three lines: What most influenced my emotional state today, whether from the outside world or from within me? What choice did I make that was in line with what I consider important? And what is the smallest possible goal for tomorrow?

Another exercise is the "two mirrors": ask two people you trust what they've noticed becoming "more like you" again in recent weeks. Sometimes others can see changes we can't yet recognize in ourselves.

Finally, record your energy level from zero to ten when you wake up and before you go to sleep. Don't chase perfect scores; look for trends. It's well worth bringing these notes to your next appointment. They tell a fuller story than the isolated snapshot of a single day.

Getting better doesn't mean becoming someone else

Getting better means fitting inside yourself again — perhaps not exactly the version that existed before the crisis, but one with more resources, more awareness, and more freedom to choose.

Fluctuations will keep happening. There will be sunny days and rainy ones, open roads and unexpected traffic jams. The goal of treatment is not constant happiness, which is impossible (and even a little suspect). The goal is to increase your capacity to travel through different conditions without completely losing your bearings.

In the end, the bottom line remains simple: the medication doesn't reinvent you, doesn't choose your destination, and doesn't rewrite your story.

With time, the question itself may change. Instead of "was it the medication, or was it me?", it may become: "With what I have now, what has become possible to build?"

 

Image credit: AI-generated image from a prompt by the author.