Medication consultation and split treatment during psychotherapy

Clinical barriers to effective pharmacotherapy in co-occurring psychiatric and substance use disorders

Prescribing medications to patients with cooccurring psychiatric and substance use disorders often evokes distressing emotional responses from both clinician and patient that affect the delivery of appropriate pharmacological treatment. One important polarization revolves around the clinician under-prescribing to avoid feeling like he or she is overmedicating the patient versus over-prescribing when risk levels are minimized. A case report illustrates some common, rapidly shifting responses to both medication and clinician. These reactions include 1) an idealized, passive relation to the medication followed by disappointment in its weakness, 2) minimizing the danger of medication through idiosyncratic and potentially dangerous overuse to replicate effects of the addictive substance, or 3) experiencing the medication as harmful, leading to phobic avoidance and underutilization. The recommended clinical response is to avoid these polarizations and to engage with the patient's suffering and dangerous behavior by 1) taking reasonable pharmacological risks, 2) establishing provisions for safe use and frequent monitoring, 3) conveying tolerance for idiosyncratic use within safe limits, 4) regular exploration of the meaning of the medication with links to both the addiction history and the treatment relationship, and 5) frequent psychoeducation.

A View from Riggs: Treatment Resistance and Patient Authority—III. What is Psychodynamic Psychopharmacology? An Approach to Pharmacologic Treatment Resistance

The authors explore the phenomenon of treatment resistance in relation to medications. They also propose and define a discipline of "psychodynamic psychopharmacology," describe its philosophical underpinnings and make technical recommendations for the psychodynamic treatment of pharmacologic treatment resistance. The authors review the recent literature suggesting a major role for interpersonal and meaning effects in positive pharmacologic treatment outcomes, and suggest that many patients are "treatment-resistant" to medications because an appreciation of the patient's dynamics is not incorporated into an understanding of repeated treatment failures. Common resistances to the effects of medications are considered, as well as ways that patients may become entrenched in treatment resistant illness from counter-therapeutic uses of medications. The authors propose that psychodynamic psychopharmacology advances the overall clinical effectiveness of medications with treatment-resistant patients by integrating a psychodynamic appreciation of the patient with a psychopharmacologic understanding.

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.

Psychodynamic Trojan Horses: Using Psychopharmacology to Teach Psychodynamics

Concurrences of scientific, cultural, and economic developments in the past decade have changed psychiatric practice and psychiatric training. The explosion in neurobiological sciences has left residents with an overwhelming amount of neurobiology to master at the same time that managed care has led to a de-emphasis on psychiatrists providing psychotherapy. Consequently, many residents are left questioning the relevance of psychodynamics for psychiatry, given that the majority will function primarily as prescribers. However, the illusion, increasingly common in our culture, that medications are a simple fix leaves residents unprepared to make sense of the complex and irrational processes that happen in the acts of prescribing and taking medications (or not taking medications). Consequently, residents may feel confused, angry, hopeless, and/or abandoned in their role. These residents are often hungry for a context to explain why they feel hopeless, confused, or defeated in carrying out the "simple" task of prescribing. A psychodynamic understanding can provide such a holding context, just as it can give residents tools for backing out of futile and/or destructive enactments and turning conflicts around medications to some therapeutic good. Many psychodynamic concepts that initially may have seemed to residents part of some arcane and outmoded pseudoscience suddenly become relevant when they provide both a context for understanding the resident's distress and useful clinical tools. Those psychodynamic psychiatrists wishing to promulgate a psychodynamic understanding may need to meet psychiatric trainees at their developmental level and take seriously the current emphasis on providing effective somatic treatments. By engaging trainees at the junction of psychodynamics and psychopharmacology, psychodynamic psychiatrists may find a more receptive audience and open the door for greater interest in developing psychodynamic understanding and technical skills.

Psychodynamic perspectives of collaborative treatment

In contemporary psychiatric practice, collaborative treatment between a psychiatrist and psychotherapist is very common. Much attention has been devoted to the fiscal, ethical, and legal issues relevant to this treatment modality. However, such collaboration had been proposed long before the advent of managed care, which has accelerated the trend to separate the dynamic and the biologic. While fiscal considerations have been highlighted of late, the underlying tension between the dynamic and biologic remains and with it the complexity and potential pitfalls that directly and indirectly affect patient care. These issues are often neglected or kept in the realm of the unconscious. The key issues of transference, countertransference, and dynamic issues related to medication are discussed from the perspectives of the psychiatrist, the therapist, and the patient. In this article, the authors review the literature in order to revisit and reframe psychodynamic issues, as a timely reminder for clinicians to look at patients in different frameworks, and as a means of enhancing the effectiveness of collaborative treatment.

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

This paper deals with two analysands who developed serious symptoms of anxiety and depression during the middle phase of their analysis. The symptoms were severe enough to disrupt the previously established analytic process. After a consultation, both patients were put on a selective serotonin reuptake inhibitor (SSRI). Both responded well to the medication, not only in terms of symptom reduction but also in re-establishing the analytic process. Both patients made very little reference to medication after an initially negative reaction to the suggestion of a psychopharmacology consultation. The process of seeking a consultation, the prescription and monitoring of the medication, the concept of medications as parameters, and the possible reasons for the virtual absence of references to medication are discussed.

Beyond dualism: psychoanalysis and medication in the 21st century

Dualistic thinking continues to pervade psychoanalytic views of psychopathology. The author points out the shortcomings of this perspective as represented in Mark Swoiskin's article, "Psychoanalysis and Medication: Is Real Integration Possible?" She contends instead that the latest scientific evidence does not support a dichotomy between organic (biological) and psychodynamic (nonbiological) factors in psychopathology. She presents two cases to illustrate both the challenge and the importance of reformulating psychoanalytic views in an integrated, holistic way.

Concurrent psychotherapy and pharmacotherapy in the treatment of depression and anxiety in cancer patients

Over the past 30 years, numerous studies have compared the relative effectiveness of psychotherapy, pharmacotherapy, and concurrent therapeutic approaches in treatment of common psychiatric disorders, such as depression and anxiety. Generally, these studies have demonstrated that the combined approach is somewhat more effective in treating the disorder in question, as well as in preventing relapse. A number of theories regarding the reasons for this finding have been proposed. The application of this therapeutic approach to the specific population of cancer patients has not been studied in systematic research. This paper briefly reviews the studies comparing the efficacies of various treatment approaches for depression, discusses reasons for the efficacy of such an approach, and outlines a series of reasons why this may be the preferred model for intervening with cancer patients.

Collaboration with the nonphysician therapist : a seminar for postgraduate third-year psychiatry residents

The integration of psychotherapy and pharmacotherapy becomes more complex when two clinicians collaborate in providing patient treatment. A course for postgraduate third-year psychiatry residents was developed to review the literature, discuss various treatment models, and delineate the technical skills and treatment issues involved in the collaborative model. This article describes the course content, design, and evaluation at one institution.