Beyond dualism: psychoanalysis and medication in the 21st century

A Theory of Everything: Overlapping Neurobiological Mechanisms of Psychotherapies of Fear and Anxiety Related Disorders

Similarities within the phenomenology, neurobiology, psychotherapeutic, and pharmacological treatments of distinctly categorized anxiety and fear related disorders suggest the involvement of common neurobiological mechanisms in their formation. This theory of integration is the focus of the Research Domain Criteria (RDoC) approach initiated by the NIH. The current article explores potential facets of overlap among mainstream methods of psychotherapy for anxiety, fear, and trauma related disorders. These overlaps include associative learning of safety, cognitive reappraisal and emotion regulation, therapist as a social safety cue, and contextualization. Temporal contextualization and placing memories in their time and place will be suggested as a potentially important, and less explored aspect of psychotherapy.

Castration Depression: Affect, Signal Affect, and/or Depressive Illness?

The value of Charles Brenner's ideas regarding depression is assessed, focusing on the significance of castration depressive affect. His discussion of whether depression is an affect, a signal affect, or an illness is examined, with special emphasis on his failure to sufficiently address depression as an illness or disorder as defined by psychiatry. Clinical material from the analysis of a man who suffers from severe depression suggests that incorporating psychiatric concepts (biological and pharmacological) with modern conflict theory can be a useful way to understand and treat some patients with depression. Theoretical and clinical controversies associated with combining psychiatric/biological and psychoanalytic views of depression are examined.

Contributions of a relational psychoanalytic approach to dealing with the nonadherent psychiatric patient

Nonadherence to medication is one of the great challenges facing any psychiatrist today. The main focus of this article is to illustrate the contributions of a relational psychoanalytic approach to dealing with the nonadherent psychiatric patient. Special emphasis is given to the importance of recognizing the therapist as an active subject and taking responsibility over the negative aspects of the therapist. A clinical vignette is presented, by which these points are illustrated and defined.

The analyst's attitude toward pharmacotherapy

The increased acceptance of medication in psychoanalysis has occurred with too little consideration of possible complications. The potentially adverse psychological effects and disintegrative aspects of this important technical modification require further examination. While the use of phenomenologically defined diagnostic criteria provides valuable guidance to the clinician, the decision to include pharmacotherapy in a psychoanalysis must be understood also as a transference-countertransference enactment. The analyst's attitude toward pharmacotherapy is an essential element in some defensive and gratifying enactments, resistances that can interfere with psychoanalytic processes. Clinical material is presented illustrating narcissistic and perverse resistances that might be facilitated by analysts' attitudes toward pharmacotherapy, attitudes often tacitly communicated in decisions to use combined treatment.

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.

Further thoughts on dualism, science, and the use of medication in psychoanalysis

In response to Deborah Cabaniss's article, "Beyond Dualism: Psychoanalysis and Medication in the 21st Century," the author further considers the differences between the aims of symptom reduction and psychic integration, the concept of mind-body dualism, and the nature of scientific inquiry as they pertain to the use of medication in psychoanalytic therapies. He warns against the collapsing of concepts, aided by a misapplication of science, with respect to how we listen to, organize, and respond to clinical material. He argues that only when such scrutiny occurs can the important and challenging questions pertaining to the use of medication in psychoanalytic therapies be meaningfully considered.