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Making Combined Therapy Work

Making Combined Therapy Work

Although the focus of some debate, a number of excellent studies comparing psychotherapy or medications alone versus combination therapy have reported two important findings. First, the combination of psychotherapy and medication is better than either treatment alone (primarily in severely ill or chronic patients) and second, biological symptoms (e.g., sleep disturbance, agitation) generally respond better to medications, whereas psychological and interpersonal deficits are more effectively treated by psychotherapy (Barlow et al., 2000; Dewan and Pies, 2001; Keller et al., 2000). This paper addresses several key issues that are important in making combined treatment work effectively. First, medications have powerful psychological meaning for both patients and therapists. Second, when indicated, combined treatment can be provided by a psychiatrist (integrated treatment) or a psychiatrist/psychopharmacologist plus a non-physician psychotherapist (split treatment).

While I present data suggesting that integrated treatment by a psychiatrist is the treatment of choice on both theoretical and economic grounds, split treatment continues to be widely practiced. Psychotherapy by itself is a complex procedure that requires great skill and has the potential for both benefit and harm. Adding another modality (medication) and another partner (a prescribing physician) requires even greater sensitivity and skill on the part of the clinician.

When medications are used in addition to psychotherapy, it is important to emphasize that combined therapy does not mean that only half the usual attention needs to be paid to each modality. Medications (e.g., antidepressants, anxiolytics and sleeping medications) are sometimes prescribed long after they would have been discontinued if the patient had been treated with medication alone. Also reported are cases where primary care physicians (and some psychiatrists who primarily practice psychotherapy) add subtherapeutic amounts of medications to ongoing therapy due to their discomfort with psychopharmacological agents (Dewan, 1992).

Every patient and therapist brings their own unique and personal attitudes toward medication. Therefore, therapists need to carefully assess their own reasons for considering medications and also look for the psychological reactions and meaning, both obvious and covert, that medications have for each patient.

Some patients derive a psychological benefit from being given medications since they consider it a caring, nurturing act that feeds their dependency needs or validates their suffering. Other patients see it as an imposition of external control or as a statement by the therapist that they are not strong enough to solve their problems by themselves, which may contribute to noncompliance. Offering medications to patients in denial of their illness means that they have to confront their worst nightmare and acknowledge that they are very sick. Some patients with bipolar disorder will take antipsychotic medications for a short time but refuse the long-term use of mood stabilizers because it forces them to recognize that they are suffering from a chronic illness (Dewan, 1992).

Not offering medications is also interpreted in different ways. Some patients see it positively, feeling that the therapist "must be interested in me as a person and not just in my symptoms" or "I am competent enough to do it by myself." Angry and dependent patients may regard it negatively, as a withholding of support or prolongation of their agony. This is particularly potent since our culture vigorously promotes the false idea that a pill can fix everything. Other patients feel they are not being taken seriously, or are not considered sick enough, or even that the therapist thinks they are faking their symptoms. Some patients so overvalue their medication that they will carry around the unfilled prescription as a soothing, and often very effective, good luck charm or transitional object.

Psychotic patients may have unusual, idiosyncratic associations to the names of medications. One of my patients vehemently opposed taking Stelazine (trifluoperazine) ("I hate it! It reminds me of my sister Stella"), but graciously agreed to taking an equivalent drug, Mellaril (thioridazine) ("That's fine. It will make me mellow, right doc?") (Dewan, 1992).

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