This special section of TAP takes an unapologetic, unabashed stand: that it is sometimes—maybe even frequently—in the patient's best interest to combine psychoanalytic treatment with other treatment modalities. There are many treatments other than psychoanalysis for psychic ills—hypnosis, body work, twelve-step programs, men's work, women's work, all kinds of psychotherapies, nutritional supplements, and many more. Some have been thoroughly researched and have been well documented in their ability to help people change or feel better Others are adhered to because, anecdotally, practitioners and patients feel they help. Where does psychoanalysis stand between these two poles? Somewhere in the middle.
Some of my colleagues were alarmed when I discussed this special section in its planning stages. They wanted to make sure that I communicated that not all analysts “believe in” medication. They wanted me to avoid mentioning that some analysts may be interested in exploring even more far-out, less widely accepted kinds of treatment, such as EMDR (Eye Movement Desensitization and Reprocessing). I've heard about a (depressed) friend's analyst who is “against medication.” Someone on the Open Line list recently said, “Cognitive behavior therapy, ugh!” as if the very topic were repulsive.
I majored in psychology as an undergraduate in a university department that was strongly behavioral in orientation. I was taught about the folly of psychoanalysts who believe behavior change doesn't count (basically, “Psychoanalysis, ugh!”). I learned about the basic premises of behaviorism and its derivative techniques: systematic desensitization, assertiveness training, etc.
Anyone who has ever owned a dog or raised a child will find it hard to dispute the solidity of the basic behavioral premises, for example that positive reinforcement increases behavior and negative reinforcement decreases it. Anxiety and behavior can be conditioned responses, and they can therefore be de-conditioned.
The question is not whether the principles of learning theory are true. Rather what relevance do they have to our work? Is there any need for analysts to learn about cognitive behavior therapy—not necessarily to be able to do it, but to be able to prescribe it?
I believe that it is our job first, last, and in between to relieve suffering. Relief of suffering is likely to be a more complex process, on many occasions, than simply applying the treatment process we most love and admire, psychoanalysis. Sometimes that's enough by itself. Sometimes it's not at all appropriate. Sometimes it's most able to relieve suffering when responsibly and intelligently combined with one or more other types of treatment.
I hope this special section opens up a dialogue on the still controversial issue of combining psychoanalysis with other treatment theories and systems, both within our own profession and between us and colleagues outside psychoanalysis.
I thought over my own practice while preparing this introduction. I have a patient with severe obsessive-compulsive disorder who made tremendous strides in analysis but didn't regain a normal life until behavior therapy and medication were included in her sessions. Another patient had great success with work and relationships after a long analysis, but he retained a sense of dysphoria and disequilibrium and an obsessive fear of becoming immobilized, all of which disappeared on 225 mg of Effexor. A traumatized and depressed patient seemed to me to be “carrying” the depression for her husband as well as herself, as she had for her mother, and I referred them for couples' therapy. A fourth patient developed phobias decades before I met her She had had much psychoanalytic psychotherapy, but neither behavior therapy nor medication had ever been suggested for her phobias, which had become unnecessarily entrenched. The great majority of my patients, like these mentioned briefly, need psychoanalysis or psychoanalytic therapy and one or more other kinds of treatment to feel better and to get better.
I hope this special section opens up a dialogue on the still controversial issue of combining psychoanalysis with other treatment theories and systems, both within our own profession and between us and colleagues outside psychoanalysis.
I invited three analysts to write about their clinical experiences combining psychoanalysis with three other treatment modalities. Art Myerson, who has been interested for many years in cognitive behavior therapy, writes about integrating behavioral therapy with his psychoanalytic perspective. Jamie Feldman, like some psychiatrist-psychoanalysts, uses psychiatric diagnosis and pharmacotherapy as well as an analytic perspective in her practice. She discusses her theory that many patients who present with characterological problems are really suffering from occult affective disorders and may be greatly relieved by medication. Art Nielsen is trained in family therapy and Tavistock Institute group process as well as in psychoanalysis. He practices marital and family therapy using an amalgam of systems theory and psychoanalytic theory. He keeps a social systems approach in mind while conducting individual psychoanalytic work.
Showing respect for and interest in other kinds of treatment, and keeping our patients' well-being in the forefront, may require joining the pure gold of psychoanalysis with various other useful metals. An open and eclectic, patient-centered, not theory- or technique-centered approach will also improve how other mental health professionals perceive us.
Prudy Gourguechon, M.D., is editor of TAP.