Selective serotonin reuptake inhibitors in the context of an ongoing analysis

When the Analytic Patient has Attention Deficit Hyperactivity Disorder

Most analysts are now treating or can expect to treat adult patients with cognitive deficits such as attention deficit hyperactivity disorder (ADHD), based on the prevalence of this syndrome in children and its continuation into adulthood. ADHD is a cognitive disorder considered by nonanalytic and analytic writers to be a dysfunction of affect regulation and behavioral inhibition. Analysis deals with these issues, and most analytic theories address affect regulation. Manifestations of ADHD can mimic the clinical expression of intrapsychic conflict, in which the cognitive deficits are embedded. If these symptoms are interpreted primarily as transference resistances without acknowledging the cognitive contribution, the patient may experience a resurgence of feeling misunderstood and shamed, helpless and defective. Confusion in the countertransference is a hallmark of analyses in which cognitive deficits are intertwined with psychic conflict, sometimes leading the analyst to compartmentalize the cognitive and the conflictual and to miss aspects of the patient and the process. Appropriate action within the analytic frame may be needed to help the patient seek information, specialists, or coaches to deal with limitations in executive functioning. A variety of technical considerations and confusions in the countertransference are illustrated.

Psychodynamic psychiatrists and psychopharmacology

Over the past 20 years, the previously frowned upon combination of pharmacotherapy and psychoanalytic or psychodynamic therapy has become common practice because of both findings from the neurosciences that demonstrate hardwired brain development from chronic early stress and trauma and from efficacy studies that show the superiority of combined therapy over either psychotherapy or medication alone. With this shift has also come a more focused interest in the psychodynamics of pharmacotherapy itself. This article will review some of the current thinking in this area and then present the personal approaches toward pharmacotherapy of two psychoanalysts, one at an academic hospital (RC) and the other in private practice (JS).

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.

Medication as object

People experience and treat medication as though it were a person: in other words, as an object. Among the many symbolic meanings attributed to medication, this sort of personification, or object representation, is a meaning that medication is uniquely positioned to contain and convey: imbued with intentionality and influence, medication moves beyond the sphere of static, iconic representation and enters the changeable, dynamic object world of action, aim, and agency. Unlike more generic or stereotypic meanings, object representations attributed to medication may reflect the patient's specific dynamics and object relations. These representations are many and mutable, and take on shifting and overlapping forms that evolve with the analytic process. Medication may represent a third person within the framework of an analytic treatment, expanding the analytic dyad into a triad and offering new transference paradigms to explore. The defensive displacement of transferential qualities and attitudes, or split-off parts thereof, from the analyst onto medication can serve as a powerful resistance to the awareness of the transference to the analyst. Clinical examples illustrate the utility and importance of the analysis of medication as object, for both patient and analyst, with particular attention to the transference.

Thoughts on medication and psychoanalysis: a lay analyst's view

The issues involved in split analytic treatments-where a second person manages the patient's medication-are discussed from the point of view of a developmentalist and lay analyst. Case material is presented to illustrate the interplay of medication with other elements of the psychoanalytic situation. Medication and its effects, it is argued, should be accorded no special status apart from other interventions and enactments in an analysis. Some see medication and psychoanalysis as parallel processes, two separate and unintegrated theoretical systems, and recommend shifting back and forth between models of the mind or becoming "bilingual"; against this view, it is argued that anything the analyst does will affect the patient's thoughts, fantasies, and even physiology in individual ways, and only attention to analytic material can reveal what an intervention means in a specific case. Success in split treatment depends on a collaborative therapeutic alliance among patient, analyst, and consultant. Because there is as yet no theory that bridges psychoanalysis and psychopharmacology, analysts must talk of these matters as incompletely synthesized and regard them as part of the challenges that make psychoanalysis the exciting, impossible profession it is.

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.