Combining Psychopharmacology, Psychotherapy and Psychoanalysis
Combining Psychopharmacology, Psychotherapy and Psychoanalysis
The advent of safer psychopharmacological agents with less troublesome side effects, along with increasing knowledge of the broad array of syndromes treatable with medication, have led to a vast expansion in treatment options available to the psychiatrist. Studies and clinical experience demonstrate that employing psychotropic medication in combination with psychoanalysis or psychodynamic psychotherapy now occurs with increasing frequency.
Two recent studies at the Columbia University Center for Psychoanalytic Training and Research indicate the degree of this trend. A survey of training analysts revealed that they had prescribed medication to 20% of their analytic patients in the preceding five years (Donovan and Roose, 1995), while a survey of candidate training cases showed that 30% of their patients were taking medication (Roose and Stern, 1995).
The process of integrating psychoanalytic and psychodynamic treatments with psycho-pharmacology therefore deserves continued study. In many instances, the combination can function synergistically, with psycho-pharmacological interventions aiding the patient's ability to pursue psychoanalytic investigation; these investigations in turn articulate the meaning and impact of taking medication to the patient and therapist (Busch and Auchincloss, 1995).
However, medication and psychodynamic approaches can be in conflict, both clinically and theoretically. The process of learning to work with such different listening frameworks, data sets and technical approaches is therefore quite challenging. The journal Psychoanalytic Inquiry has devoted an upcoming issue to the exploration of these topics, and many of the following ideas are from that issue.
Analytic Bias Against Medication
Controversies about combining psychoanalysis and medication have been present for many years. They arose, in part, from the way in which psychoanalysts employed metapsychological theories to explain both character pathology and major psychiatric conditions. Although the substance of these theories varies between psychoanalytic schools of thought, they all examine psychiatric illness in terms of psychodynamic factors. Conflict arises when a psychodynamically based explanation of a medical condition is construed as its etiology (Roose, 1997; Roose and Johannet, in press; Malin, in press). This leads to an unjustified view of medication as affecting only secondary or peripheral symptoms.
This line of thinking has prompted some psychoanalysts, particularly in past decades, to eschew the use of psychotropic medication altogether. Historically, psychoanalysts have viewed medication as an interference in the development of the transference in psychoanalysis, although sometimes necessary to control symptoms adequately to permit the psychoanalytic treatment to continue. Additionally, medication was felt to reduce anxious and depressive affects that were important motivators for treatment.
Yet this view of physiology as secondary is curious in many respects. Constitutional and biological contributions to psychiatric illness are acknowledged throughout the psychoanalytic literature. In fact, Freud (1914) believed that "all our provisional ideas in psychology will presumably some day be based on an organic substructure" and that his metapsychological theories were only speculative concepts meant to be replaced by the emergence of newer, better explanations.
From this point of view, psychoanalysts who explain psychiatric illness by metapsychological theories alone make the epistemological error of transforming this one perspective into a complete system of theory and technique that then cannot admit of any alternative or adjunctive viewpoints. The same may be said of psychiatrists who employ biological theories exclusively to explain all of their patients' positive and negative responses to medication treatment, or who believe that concepts such as neural Darwinism will eventually explain character type and pathology, obviating the need for psychodynamic treatments.
There has been some shift in the above analytic perspectives. Nonetheless, psychoanalysts continue to struggle with them. Psychoanalysts sometimes have the reflexive concern that when medication is prescribed, the treatment they are performing is no longer psychoanalysis. This may consciously or unconsciously cause an avoidance of medication in situations in which there is a clear indication to consider a trial of medication. Another potential pitfall for analysts is giving too much weight to the meaning of symptoms rather than phenomenology in making medication decisions (Roose and Johannet, in press).
Once it has been determined that medication and psychodynamic treatments should be combined as clinically indicated, a number of questions arise. Which treatments should be used under what particular circumstances? How should varying technical stances with these treatments be managed? Who should prescribe the medication?
With regard to choice of treatments, Roose (1997) emphasized the importance of making medication decisions based on phenomenology, since that is the source of data that studies of medication effectiveness employ. However, case reports of psychodynamic psychotherapy and psychoanalysis, as well as systematic studies of other psychotherapies indicate that biologically based syndromes can respond to psychotherapy.
The clinician that states that medication was used because the symptoms did not respond to interpretation may leave out the possibility that the symptoms may have responded to interpretation in the hands of another psychoanalyst, or that the directive stance adopted for the use of medication prevented the intensification of the transference necessary for symptom relief.
In addition, psychopharmacological treatment may interfere with the patient's motivation to address more long-term characterological issues. Most clinicians have had cases in which the patient's improvement on medication has led to the patient's wish to reduce the frequency of visits or terminate treatment. Whether this is a "good" or "bad" outcome depends on the particular features of the case. In some instances, adequate or significant improvement in the patient's symptomatology may obviate the need for intensive psychotherapy or psychoanalysis. For other patients, it may be difficult to achieve further gains via insight-oriented psychotherapy because the patient is not well suited for it. In other instances, however, the loss of motivation can represent a flight from struggling with maladaptive traits that can lead to ongoing disruptions in psychological functioning and vulnerability to recurrence of symptoms on or off medications.