Significant differences exist between psychodynamic and psychopharmacological clinical techniques due to the different methods of gathering information and the types of interventions being made. An analyst or dynamic psychotherapist may thus have difficulty or feel awkward when shifting between one approach and the other, and the patient may find these changes confusing.
While many therapists believe that such maneuvers can be done effectively, others believe that the active intervention of prescribing medication, either by the therapist or a consulting psychopharmacologist, can lessen the intensity of the transference and thus blunt and impair the most powerful psychodynamic tool for producing clinical improvement. The prescribing state of mind may also covertly heighten directive, authoritarian, and omnipotent countertransference responses on the part of the physician psychotherapist and psychopharmacologist, adversely affecting the treatment and transference as well.
Managing these technical difficulties may be either facilitated or worsened by having a consulting psychopharmacologist prescribe the medication. Some physician analysts believe that referring the patient to a colleague for medication actually clarifies the transference, improving and preserving the analytic process as a result.
Other physician analysts feel that prescribing the medication themselves will enhance the total treatment because of the ability to know the patient more completely, to monitor the physiological impact of the medication more closely, and to assess more completely the patient's psychological reactions to these impacts as well as side effects. The presence of a "third party" in the treatment introduces a complicating array of transference and countertransference responses between the members of this therapeutic triangle (Busch and Gould, 1995).
The working relationship between a psychopharmacologist and a dynamic psychotherapist or analyst may be structured in various ways and therefore requires examination. While most practitioners argue for close communication and contact between the two (Gould and Busch, in press), others believe that as little contact as possible preserves the analyst's neutrality more effectively, which aides the therapeutic process.
According to Kelly (in press), an "abstinent" model calls for the physician analyst to refrain from prescribing medications because it would interfere with the analytic function in this specific dimension. Within this model, the analyst limits communication with the consulting psychopharmacologist as much as possible and examines the psycho-pharmacological treatments as a development in the patient's life just like any other.
Listening to a patient for both psychopharmacological and psychoanalytic data is not an easy task. The clinician tends to get involved in a certain mode of listening and a certain pattern of data gathering. The clinician in the fourth year with a patient in analysis is going to be far less likely to ask about vegetative symptoms than he or she would in the initial evaluation.
Cabaniss (in press) proposes that, from a clinical standpoint, the prescribing psychoanalyst must "shift gears" between psychodynamic and psychopharmacological frames of reference when assessing and treating patients. The therapist can shift the conceptual framework for evaluating the clinical data between the dialectical poles of psychopharmacological and psychodynamic perspectives. Considering the weight of the evidence in both dimensions concurrently, the therapist attempts to determine if interpretive, psychopharmacological or simultaneous interventions are appropriate to the immediate clinical situation.
For instance, the patient who suffers from guilt when improving on medication may associate a sense of increased potency with damaging, hurtful behavior or fantasies toward others, or the persistent guilt may be evidence of a partially resolved depression. Considering the weight of the evidence, the therapist can interpret the patient's conflicts, increase the dose of medication or both.
In order to effectively shift gears, the clinician needs to pose a number of questions:
1) Is the symptom the patient is describing part of a medical psychiatric syndrome that may improve with medication?
2) What do the symptoms represent psychologically, considering genetic, transferential and free-associative data?
3) What degree of interference or disruption in the patient's life and treatment is created by the symptoms? Greater severity of such disruptions would prompt the clinician to lean toward medication use.
4) Is the symptom responding to psychological intervention or interpretation?
5) Would adding, changing or withholding medication create adverse or beneficial effects on the psychotherapeutic process?
6) What are the countertransference issues that the clinician is experiencing with regard to the symptoms? Is he or she feeling frustrated, despairing, hopeful, disdainful, etc. about the therapeutic process? Could the clinician be reacting to the discomfort of deepening material or more intense affect states?
7) How does the patient feel about a medication addition or change? What does he or she believe it means about the condition and himself or herself as a person? How may the options be presented to or discussed with the patient in order to facilitate participant prescribing?
In summary, medication use becomes a major event in psychodynamic treatments. Combined treatments benefit from appreciating the dialectic relationship between psychodynamic and psychopharmacological frameworks, both in general and in specific instances in individual treatments. Assessing a patient's clinical response to the medication always involves monitoring its physiological effects. It also includes understanding the meanings to the patient and assessing the psychological impact of:
a) taking medication in and of itself,
b) experiencing somatic, emotional and psychological changes produced by the lessening or elimination of target symptoms or the emergence of side effects, and the changing dynamics of the patient's relationships with the analyst and, if present, the psycho-pharmacologist.
Psychoanalysts and psychodynamic therapists must continue expanding their individual awareness and expertise about medication, and psychopharmacologists must expand theirs regarding dynamic approaches to perception, experience and interpersonal relatedness. When is medication helpful and when does it interfere? What technical interventions may ease the shift from psychopharmacological to psychoanalytic roles? By doing so we may continue to develop new clinical and theoretical models of combining such dissimilar treatments toward a shared goal of improved clinical efficacy.