The past 10 years has seen a marked increase in the use of psychotropic medications to treat children and adolescents. Although there is considerable controversy about this trend, it seems inevitable that multimodal treatments including psychopharmacological interventions will need to be better understood and integrated if we are to provide effective treatment to the largest range of patients. In this article, we offer some observations from our clinical experience regarding the effects of medications on the alliance, transference, and family system. In particular, we examine some of the complex psychodynamic meanings of medication that can dramatically affect response to both medication and psychotherapy.