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Its footfalls muffled, the psychotropic revolution has been stealing up on psychoanalytic clinical practice over the past quarter century. There is now a convincing accumulation of evidence that psychopharmacological agents are regularly deployed in conjunction with psychoanalytic treatment at all levels of experience: from training analyses of candidates to regular therapeutic analyses to the analyses performed by candidates under supervision. If we add to these all of those gray-area cases of psychoanalytic psychotherapies approaching psychoanalysis in their depth and therapeutic reach, it is obvious that the pharmaco-pervasion of our technique is significant.
Although our technique has been profoundly affected, our theories have, in contrast, lagged behind. Even as the addition of medication to psychoanalytic therapy has become a widely accepted practice, our ideas about it have remained curiously undeveloped and one-sided. Mostly we have addressed one dimension of the problem, contributing a profusion of ideas explaining the symbolism of added medication and its choreography (e.g., “split” treatments, the act of prescribing, inquiries about side effects), but we have had little to say about its “direct” effects on mind/ brain functioning. Moreover, when considering medication, analysts have accepted the diagnostic categories of the DSM and been compelled, for want of anything better, to turn to studies based on these as the only ones with sufficient statistical power to rationalize our clinical decisions. (One promise of the Psychodynamic Diagnostic Manual [PDM Task Force 2006] is the ultimate delineation of theoretically and empirically coherent psychodynamic categories against which various therapeutic approaches, including medication, can be tested.)
The paper that follows this introduction, by Stephen D. Purcell, defines a direction away from our exclusive reliance on DSM-based thinking. Purcell argues that even when DSM considerations suggest the use of a par