Roose: Medication in combination with analysis generally involves consultation with a psychopharmacologist and often split treatment. Not surprisingly, this generates a unique set of technical and theoretical problems. Consultations are generally sought either during the initial evaluation for treatment or during the mid-phase of the analysis, and the different timings generally reflect different motivations for the therapist and often different meanings to the patient.
In the first case, the analyst presumably believes neither that illnesses can be separated into those with biological versus psychological etiologies and consequently require biological versus psychological treatments, nor that psychoanalysis is always preferable to medication. In fact, many psychoanalysts have long observed that intense and persistent dysphoric affects or high anxiety levels interfere with psychoanalysis to the degree they limit the patient's cognitive capabilities.
One advantage of consultation at the initial stage of treatment is that in most cases, strong and constant transference paradigms haven't yet developed, so disruptive effects of introducing a third person may be minimized. Also, it allows for consideration of whether treatments should be sequenced before combined, specifically whether in certain circumstances a medication trial should precede the initiation of psychoanalysis. This may also be approached from the other direction, that is, starting with a trial of psychoanalysis to reduce symptoms or establish a therapeutic alliance before committing to medication. One should be mindful of the long-standing principle in therapeutics that in order to evaluate efficacy and side effects, it's preferable to begin only one treatment at a time.
However, most consultations are sought after analysis has been well established, primarily because of persistence of symptoms of anxiety or depression, despite the presence of good therapeutic process. Many of these patients may indeed need medication. However, the major problems encountered are not diagnosis and treatment recommendations, but rather the often unexpressed meaning to both analyst and patient of turning treatment over to medication. If the analyst believes psychological treatment is always preferable to medication, which is only to be considered when psychoanalysis has failed, then the analyst may turn to medication consultation primarily out of frustration, and more importantly, with a tacit sense of defeat. Here, the pharmacologist's recommendation for medication, albeit correct, doesn't sufficiently address the problem, and a medication consultation shouldn't replace a more encompassing treatment consultation.
To the patient, the suggestion of medication may have multiple meanings, prominently one of failing to have worked effectively in analysis. They may think that if only they were good enough or had sufficient strength of character, they wouldn't need medication and could do it on their own. If the patient interprets recommendation for medication as proof the therapist is giving up, then outrage, despair and relief may all be expressed. One way a patient commonly expresses anger is saying, "If you think a medication is indicated, why is it only now being recommended? Why didn't you suggest this previously, especially since my symptoms have been chronic?" Actually, the answer to that can most often be found through analysis of the countertransference.
A variation on the mid-phase consultation occurs when the call to the consultant is initiated by the patient, often prompted by newfound conviction they have a biological illness and that medication will provide them with a faster and more dramatic result than psychoanalysis. Such behavior is invariably considered to be acting out. But whatever the motivation, it shouldn't obscure the fact medication might be indicated.
Furthermore, transference paradigms manifest during consultation represent important material to be brought back into therapy. For example, if a patient instantly feels that the pharmacological consultant is too cold, mechanical, superficial and only interested in symptoms, or alternatively, if the patient experiences the consultant as extraordinarily clear and feels he or she has an instant understanding of the illness, it's a reasonable assumption that these intense feelings represent part of transference that may not have been previously expressed. Therefore, interdicting consultation so as to prohibit acting out may deprive the patient not only of helpful medicine but also of treatment of significant transference material.
It's important to realize that effective administration of medication with psychoanalysis requires establishment of multiple therapeutic alliances, between analyst and patient, between patient and pharmacologist, and perhaps most importantly, between analyst and pharmacologist. Although dynamics are inherent in any consultation setting, a unique feature of this last relationship is that it's often cross-generational. More experienced senior analysts are seeking pharmacological consultations from a younger generation for whom they have often been teachers, supervisors and, not infrequently, significant transference figures. So if combined treatment is faring poorly, then raising dose or interpreting transference may not be the key intervention. Rather, it may be that attention to the relationship between therapist and consultant will correct the course of what is very often effective treatment.Q. What do you see happening in the future?
Roose: Medication is now being used in combination with psychodynamic therapy with sufficient frequency so that it is possible to do prospective studies of medication's impact on therapy and vice versa, and equally important, what is the best way these combined treatments should be administered. The question is not only whether prescribing medication may interfere with an analytic treatment, but also whether the analytic situation interferes with optimal administration of medication. My concern here is that analysts doing excellent analysis may be constricted by the analytic situation, so that it might interfere with the prescription of medication. I don't know if this is so, but we have the opportunity to study these questions. It's no longer sufficient for me or anyone else simply to give their opinions. The issue is that a frequently occurring treatment like medication with analysis should be studied. We need to convert opinions into testable hypotheses and do well-designed studies that will give us data-based answers.
It's striking to me that during my generation the issue of medication with psychoanalysis has significantly changed. When I was training as a candidate, there was almost a don't-ask-don't-tell rule; if you had a patient on medication, you don't tell about it and the supervisor shouldn't ask. Within the past 20 years, there has been a dramatic change in the use of medication and it is probably the most frequently occurring parameter in current psychoanalysis. The issue needs to be studied and taught in the psychoanalytic curriculum and in psychiatric residency.