The effects of medication on the psychoanalytic process. The case of selective serotonin reuptake inhibitors

Psychodynamically Oriented Psychopharmacotherapy: Towards a Necessary Synthesis

The discovery of psychoanalysis and of psychotropic medications represent two radical events in understanding and treatment of mental suffering. The growth of both disciplines together with the awareness of the impracticality of curing mental suffering only through pharmacological molecules-the collapse of the "Great Illusion"-and the experience of psychoanalysts using psychotropic medications along with depth psychotherapeutic treatment, have led to integrated therapies which are arguably more effective than either modality alone. The authors review studies on the role of pharmacotherapy with psychoanalysis, and the role of the analyst as the prescriber. The psychotic disorders have specifically been considered from this perspective.

On the prescribing analyst

The value of medication for some patients in psychoanalysis serves to highlight the potential challenges of the medical analyst and invites exploration into possible motivations for assuming the prescribing role. Prescribing medication is one way in which the medical analyst integrates the dual identities of physician and analyst while dealing with significant cultural influences and intrapsychic tensions. Technical challenges posed by assuming the prescribing role are explored, as are the potential benefits of split treatment. The educational implications of this argument are discussed in relation to identity formation for candidates who are physicians.

Romantic fantasies of madness and objections to psychotropic medication

Many patients object to, and often refuse, psychotropic medications. The exploration-a "defense analysis"-of their objections brings attention to ubiquitous fantasies of madness, which may be feared and concealed as a source of shame, destruction, and loss, and also cherished and revered as a source of power, inspiration, and mystery. They are commonly illuminated when the prospect of taking medication threatens to expose, confirm, and defuse the fantasized hidden or latent madness. Conscious or unconscious, fantasies of madness can be deeply, appealingly romantic in nature, providing valuable narcissistic supplies while defending against their more humiliating and terrifying aspects. Drawing on personal dynamics, experiences, and identifications, they are thus ultimately and intimately linked to representations of the self. Significant romantic texts illustrate how split-off conceptualizations of madness function as an organizing repository for unacceptable and intolerable emotions, wishes, and impulses. Psychoanalysts may also object to the introduction of medication into an analytic treatment. The analyst's own fantasies around madness and medication may in some cases motivate enactments in which the talking cure is privileged and medication excluded from analytic treatment or from analytic process.

Learning about psychoanalysis combined with medication: a nonphysician's perspective

When medication is at play in an analysis, the nonphysician candidate or psychoanalyst faces conceptual and practical challenges, as well as countertransference risks and opportunities. A psychologist psychoanalytic candidate describes the treatment of an analysand who underwent a gradual uncovering and worsening of obsessive-compulsive and anxiety symptoms; at twenty-one months, the analysand introduced the topic of medication. These developments brought to light transference and countertransference themes connected to the analyst's status as a non-physician candidate; conceptual and practical uncertainties about medication in the context of psychoanalysis; the complex meanings of, and indications for, medication in this case; and the ramifications of a nonphysician candidate's referring a patient to a psychiatrist psychoanalyst for medication while being supervised by another psychiatrist psychoanalyst.

Healing psychiatry: a pragmatic approach to bridging the science/humanism divide

Competing urges to think of human mental suffering as comprehensible and susceptible to scientific formulation, or as deeply complex and beyond the reach of scientific analysis, have torn at the fabric of psychiatry for many years and have left the field conceptually divided between science and humanism. Conceptual reparation of psychiatry is now a core mission of a field that is trying to heal itself so that it is equipped to heal the patients it serves. To formulate their cases comprehensively and provide patients with cutting-edge care, psychiatrists must heal the conceptual wounds that have resulted from dividing the human individual into an object of scientific scrutiny and a subject of personal experience. They must synthesize science and humanism in order to generate new understanding of mental disorders and to train future clinicians and researchers. Principles of classical American pragmatism, I argue in this article, can help to transcend the science/humanism divide in psychiatry. Clinical pragmatism focuses on favorable treatment outcomes by respecting the practical, pluralistic, participatory, and provisional aspects of psychiatric care. It demands that psychiatrists have the skill and flexibility to use multiple explanatory concepts in a collaborative, open-ended process with their patients. These themes are explored from the perspectives of contemporary psychiatric treatment, training, and research.