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Daughter: Daddy, what is an instinct?
Father: An instinct, my dear, is an explanatory principle.
D: But what does it explain?
F: Anything—almost anything at all. Anything you want it to explain.
Why is studying the relationship between psychoanalysis and psychopharmacology so difficult? Several decades ago, the explanatory principles of psychoanalytic ego psychology structured the issue relatively clearly: psychotropic medications interfere with the psychoanalytic process because they alter symptoms that, as the products of neurotic defenses against drive derivatives, serve as motivation for transference and treatment. This point of view generated fantasies of all sorts that still haunt the shadows of our literature on the subject. Using psychotropic medications in an analysis can feel like committing a dirty, secret act evoking mixtures of shame and hope. Prescribing medications may seem to be the “Hail Mary” play of psychoanalytic work: when transference fails, try Tofranil. Medications can seem like a plague of insects: they're here; we don't want them; they are ruthlessly efficient, impossible to get rid of, unstoppable; and they are wrecking our way of life. Medications threaten our omnipotent beliefs in our powers as analysts. Perhaps at the heart of these collective fantasies is our fear that psychopharmacology and those who practice it will put us out of business. It is no wonder that this “presence in the room” has frequently been welcomed with closed arms.