Psychotherapy and Medication

The Challenge of Integration

Fredric N. Busch, Larry S. Sandberg

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781136648335
• Edition: 1
• Topic: Psicología
• Subtopic: Psicopatología

Over the past two decades, the use of medication combined with psychotherapy or psychoanalysis has shifted from an infrequent occurrence to common practice. Concurrently, attitudes toward medication have changed from viewing this intervention as disruptive or as a last resort to a welcome aid in the psychotherapeutic or psychoanalytic process. However, this relatively rapid change has created difficulty in the integration of medication use into the psychotherapeutic setting. Psychotherapy and Medication is an exceptionally valuable and timely volume that provides psychoanalysts, psychotherapists, and other mental health professionalswith information on how to work with medication theoretically, clinically, and technically in the context of a psychotherapeutic or psychoanalytic treatment.

Important areas of discussion include evidence that a change in the use of medication has taken place, an examination of the factors that have led to this shift, as well as a review of the issues and questions about combining treatments. Psychotherapy and Medication also serves as a framework in how to best answer the many questions that have arisen as the willingness of analysts to use medication increases. Such significant questions include: How should analysts introduce patients to medication? What are the clinical advantages of combined treatment? What is the impact of medication discussions and prescribing on the analyst's role and how is this best handled?

1 Introduction

DOI: 10.4324/9780203805473-1

Over the last 20 years the use of medication in combination with psychodynamic psychotherapy or psychoanalysis has shifted from an infrequent occurrence to common practice (Roose, 1995). Paralleling this shift, attitudes toward medication have changed from viewing this intervention as disruptive or an addition of last resort to a welcome aid to the analytic process. This rapid change, however, has created difficulty, both theoretically and technically, in the integration of medication use into the analytic setting (Busch, 1998; Roose & Johannet, 1998). Although these treatments can work well together, there are potential pitfalls that can disrupt the effectiveness of combining treatments. The intent of this book is to provide information on how to work with medication theoretically, clinically, and technically in the context of a psychodynamic or psychoanalytic treatment. Toward this goal, we will describe the evidence that this change has taken place, examine the factors that have led to this shift, and review the issues and questions about combining these treatments.

Psychoanalysts' Shifting Views of Medications

Early concerns about the use of medication in a psychoanalytic treatment focused on several issues (Roose, 1995). Psychoanalysts feared that medication would reduce motivation for change by easing negative feelings that led patients to pursue treatment. In addition, anxiety was believed to be of particular value because it indicated the presence of psychic conflict, thus aiding the analyst in pursuing the unconscious sources of the patient’s symptoms. In this sense, the presence or onset of anxiety could be looked at as a positive sign rather than a detriment because it suggested that conflicts were being addressed. Since anxiety was an indicator of conflict rather than a cause of the patient’s problems, it was not necessary to treat it with medication. In addition to potentially derailing valuable negative affects, medications were seen as possibly undermining the patient’s sense of autonomy and self-esteem (Sarwer-Foner, 1983).

Because medications were viewed as containing significant risks for treatment, they were typically relegated to a secondary role, even by pioneers in introducing medication to psychoanalysis. Ostow (1962) saw medication only as a support for psychoanalysis, warning that “drugs should not be used in psychoanalysis or psychotherapy unless they are essential to protect the patient or to protect the treatment” (p. 147). As late as 1983 Sarwer-Foner stated,

It is clear that one will not give pharmacotherapy to a patient unless one believes that the symptoms the patient presents and the disease process producing the symptoms cannot be mastered or dealt with by the patient in psychotherapy at that moment in time or space. If this assumption is not correct—if the patient can, in fact, with the help of the physician, correct and master the intrapsychic problems causing the symptoms and the suffering—then the psychotropic medication … is not really needed … (p. 167). The patient may perceive the act of taking the medicine as proof that he cannot handle his symptoms or problems without it. (p. 168)

By the mid 1980s, however, psychoanalysts began to talk increasingly about potential benefits of medications (Cooper, 1985; Esman, 1989; Lipton, 1983). Recent studies (Donovan & Roose, 1995; Roose & Stern, 1995; Yang et al., 2004) highlight a shift in both frequency of and attitude toward medication use. In a study at Columbia University Center for Psychoanalytic Training and Research with a return rate of 89% (Roose & Stern, 1995), candidates were given an anonymous questionnaire to evaluate their level of medication use. The study found that 29% of the candidates’ cases in analysis were also on medication (16/56) and that 11 of 24 of the candidates (46%) had at least one patient in analysis who was also on medication.

To test the theory that this was just a trend in the younger generation of analysts, the researchers then assessed training and supervising analysts (Donovan & Roose, 1995). Of those surveyed, 76% returned the questionnaire regarding patients they had had in analysis in the preceding 5 years. The analysts reported on 277 patients: 18% (51/277) had been on medication during psychoanalysis, and 62% (21/34) of analysts had at least one patient who received medication. In 84% of cases (36/43) in which patients had been given medication for a mood disorder, the psychoanalysts noted that the mood disorder as well as the psychoanalytic process improved. Indicating that Columbia is not the only institute demonstrating this trend, graduate analysts at the Cincinnati Psychoanalytic Institute were found to have 36% of their patients in analysis on medication (Cabaniss & Roose, 2005).

Factors Leading to Increased Medication Use

Several factors have combined to bring about this attitudinal shift in psychoanalysts regarding medication use. The availability of safer, better tolerated medications has reduced the adverse impact that medications may have in treatment. In addition, systematic studies have repeatedly confirmed the effectiveness of medication for a variety of syndromes, providing a strong evidentiary basis regarding their use (Janicek et al., 2006). Third, multiple external pressures have affected psychiatrists and psychoanalysts in ways that call for more medication use, such as insurance company oversight, pharmaceutical company marketing, and direct-to-consumer advertising. Finally, the boundaries between the biological and psychological bases of syndromes have become increasingly unclear. For example, syndromes previously viewed as psychologically based or as personality disorders have been redefined as primarily biological illnesses found to be responsive to medication. Important examples include dysthymic disorder (Kocsis et al., 1988, 1996), formerly characterized as depressive personality, and attention deficit disorder (Wender, 1995), in which the individual exhibits difficulties with procrastination, concentration, and attention previously seen as passive-aggressive or as derived from psychic conflict.

Another factor that has played a role has been the shift to evidence-based medicine, which expounds the view that treatments should be prescribed according to whether they have demonstrated efficacy in treatment of specific disorders. The gold standard for these determinations is randomized, controlled clinical trials in which the treatment, delivered in a form in which adherence can be assessed, is compared to a placebo. Medication and certain psychotherapies have been extensively studied using these approaches, but psychoanalytic treatments have not.

In the late 1980s the stakes were raised in the lawsuit of Osheroff v. Chestnut Lodge, in which a patient sued Chestnut Lodge Hospital for treating his depressive disorder with an intense inpatient psychoanalytically oriented psychotherapy instead of medication. Klerman, a consultant to the plaintiff in this case, stated that “this case goes a long way to establishing the patient’s right to effective treatment” (1990, p. 416), by which he meant treatment found to be effective through controlled clinical trials. In addition, Klerman warned that “the courts may be an appropriate arena for litigation when a small minority of the profession persist in practices that scientific evidence and professional judgment have deemed obsolete” (p. 417).

Stone (1990) wrote a strong rebuttal to Klerman’s comments, noting that Klerman (1988) had stated in his writing that “individual psychotherapy based on psychodynamic principles remains the most widely used form of psychotherapy. Although systematic, controlled, clinical studies do not exist, clinical experience supports the value of this form of treatment” (p. 330). In spite of this response, some psychoanalysts interpreted the Osheroff debate as creating legal pressure to consider and employ medication. As Stone averred, “Klerman’s recommendations may have considerable legal consequences, even if his ideas have no basis in law and are intended only as clinical recommendations” (p. 420).

Studies showing an advantage in combined treatment of many disorders compared to medication or psychotherapy given alone (Barlow, Gorman, Shear, & Woods, 2000; Keller et al., 2000; Thase, 2000) have also influenced prescribing trends among psychoanalysts—despite the primary use of interpersonal psychotherapy or cognitive–behavioral therapy rather than psychoanalytic treatment in these studies. In depressive disorders, combination treatment has been found to be particularly valuable for more severe episodes, whereas milder symptoms often respond to psychotherapy or pharmacotherapy alone (Thase et al., 1997). A more recent study of chronic depression demonstrated a significant additional benefit for combined treatment over medication (nefazodone) or psychotherapy (a form of cognitive behavior therapy) alone (Keller et al., 2000).

Recommendations for providing psychotherapy plus medication in at least some cases have been made for a variety of disorders (American Psychiatric Association, 1998, 2000). For example, the practice guideline for the treatment of patients with panic disorder refers to a study in which the addition of psychodynamic psychotherapy to a medication treatment reduced the risk of relapse. The guideline avers that “psychodynamic psychotherapy is commonly used in conjunction with medication on the basis of a clinical consensus that it is effective for some patients” (American Psychiatric Association, 1998, p. 21). Based on studies and clinical experience, recommendations for combined treatment are frequently made for patients with more severe depression or anxiety disorders, patients who are unresponsive to psychotherapy or pharmacotherapy alone, or patients who have problems complying with treatment. The revised practice guideline for the treatment of patients with major depressive disorder states:

The combination of a specific effective psychotherapy and medication may be a useful initial treatment choice for patients with psychosocial issues, interpersonal problems, or a comorbid axis II disorder together with moderate to severe major depressive disorder. In addition, patients who have had a history of only partial response to adequate trials of single-treatment modalities may benefit from combined treatment. Poor adherence with treatments may also warrant combined treatment with pharmacotherapy and psychotherapeutic approaches that focus on treatment adherence. (American Psychiatric Association, 2000, p. 9)

Positives and Pitfalls for Psychoanalysts in the Use of Medication

There are many benefits for psychoanalysts and their patients in bringing medication into their therapeutic armamentarium (addressed in greater depth in chapter 5). Chief among these is the potential to relieve patients more rapidly of distressing and impairing symptoms. Medication treatment can often aid patients in engaging in psychotherapy—for example, by reducing disruptions in concentration and motivation. Rather than erasing anxiety that can be useful for psychoanalytic exploration, medication can help to reduce the anxiety to tolerable levels that can allow more effective engagement of the patient’s observing ego. Exploration of the meanings of medication and being medicated can provide an additional window into a patient’s intrapsychic life, conflicts, and transference reactions and help patients comply with their medication. When a therapist is working with another practitioner who is prescribing medication, a positive collaborative relationship can provide additional support and perspective for treatment.

However, potential pitfalls in medicating patients also exist. Psychoanalysts can experience a disruption in their analytic stance as they attempt to assess the patient systematically with regard to indications for and reactions and response to medications. Preexisting negative attitudes toward medication, conscious or unconscious, may affect the analysts’ abilities to think about medication psychodynamically. A recent review of the charts of candidates in analytic training indicated little or no documentation of medication assessment or monitoring, as well as minimal or no comment about the impact of the medication on the status of the transference and countertransference (Cabaniss & Roose, 2005). When an analyst is working with another practitioner who is prescribing medication, conflicts can develop that can disrupt or adversely affect the treatment (see chapter 7).

In addition to problems for the analyst, medication can create difficulties for patients in analysis or psychodynamic psychotherapy. They may experience discussions about medication as intrusive or have concerns that the analyst sees them as too “sick” for analysis alone. Symptom relief through medication can reduce some patients’ interest in addressing broader intrapsychic and interpersonal problems and lead them to discontinue the analytic treatment.

Psychodynamic Psychotherapy Versus Psychoanalysis and the Use of Medication

Conducting inquiry and treatment of patients with medication is more complex for patients in psychoanalysis than for those in psychodynamic psychotherapy. Psychoanalysis will typically include fewer directive interventions, less give and take between analyst and patient, and a lower frequency of nonanalytic interventions than psychodynamic psychotherapy, and therefore the interventions required for psychopharmacological evaluation and monitoring will be more discontinuous and potentially disruptive.

In conducting psychoanalysis then, a psychoanalyst will more strongly consider employing a split treatment to minimize disruption to the analysis and will be very alert to the impact of medicating on the analytic process and the transference. In this book, there will not be a specific chapter on combining treatments in psychoanalysis versus psychodynamic psychotherapy, but in certain instances we will point out special factors involved in employing medication during psychoanalysis.

Questions About Combined Treatment Addressed in this Book

As this overview suggests, in spite of the increasing willingness of psychoanalysts to combine medication and psychoanalysis or psychodynamic ps...