If one were to interview a cross-section of analysts today, there would be a spectrum of positions taken regarding the use of psychotropic medication in psychoanalytic treatments. There still remain those who adhere to the theoretical and clinical position that any patient who requires medication is unanalyzable. However, the availability of more effective, user-friendly psychotropic agents such as SSRIs, and research showing that the combination of psychotherapy and medication is more effective than either treatment alone in treating depression has led to many patients on the couch being medicated. This change reflects the view of many analysts that the alleviation of symptomatology or treatment of biological disorders is compatible with a psychoanalytic treatment.
The decision to use medication results from different processes in different consulting rooms. These different processes are related to, but not totally predicted by, the discipline of the clinician and his or her theories regarding treatment and pathogenesis. Some treatments are spirt between analyst and psychopharmacologist by necessity, as when the analyst is not a medical doctor Some treatments are split because of the theoretical stance of the analyst, whether M.D. or not, that what gets analyzed is not what gets medicated or that the activity of medicating interferes with the analytic process. Many other analytic clinicians do their own prescribing. Within each subcategory the individual practitioner's view of pathogenesis, the degree to which one believes in descriptive psychiatry, and the efficacy of psychotropic agents can affect the timing and vigor with which one approaches the use of medication.
When considering the patient's need to get well, is there really room for such variability in approach? Even while the field has moved to incorporate the legitimate use of psychotropic agents into our work, many old controversies persist regarding which symptoms get treated with medication and which get analyzed. The dominant role of the analyst's theory of pathogenesis and therefore of treatment plays a central role in whether, when, and how medication is used. Has this trend made psychoanalysis a more effective treatment modality?
My own clinical work has gradually come to involve a more rigorous use of psychotropic agents. What has become more apparent to me is the variability in presentation of affective symptomatology and disorders in patients and the dramatic transformation of character organization that occurs in relationship to symptom resolution resulting from the use of psychotropic medication. This occurs in treatments that take a vigorous, persistent, sometimes long-term approach to the use of medication in the context of a psychotherapeutic relationship with a practitioner who truly believes in the clinical effectiveness of medication.
The clinician must be willing to allow a theoretical paradox to exist in his or her mind and influence his or her approach to treating symptoms. The paradox is that symptoms may or may not have meaning that is usable in an analytic sense. For example, panic anxiety is often amenable to treatment with anxiolytics and, following a positive response, is of no further source of distress or interest to the patient. One cannot permit the patient their own experience of the positive response to medication if the analyst is not willing to believe in the validity and therapeutic effectiveness of such a response, particularly if one views symptomatology as predominately dynamically determined (the result of conflict or a breakdown product of the self, etc.).
The therapist who shares the patient's wish to be symptom-free and feel better as soon as possible need not be viewed as “avoiding self understanding.”
The therapist who shares the patient's wish to be symptom-free and feel better as soon as possible need not be viewed as “avoiding self understanding.” Rather, this therapist makes use of a process that over time allows the patient to feel his or her best self without conceptualizing the experience of feeling badly as a by-product of their disabled character or conflict. Such an approach can allow the patient to recover from the burden of biology—whether it is syndromic in nature, as more easily recognized in Axis I disorders, or less organized states characterized by a preponderance of less severe, often chronic symptoms of anxiety and depression. The individual participates more actively in determining what is meaningful in his or her life and what needs exploring. Affective illness is notorious for disrupting a person's capacity for experiencing meaning.
Affective illnesses are often difficult to diagnose. Even when symptoms present more “classically,” they are not always straightforward to treat. Depressions often require several trials of medication and involve additions of mood stabilizers, traditional anxiolytics, and anti-psychotics for some forms of disorganizing anxiety states. This is particularly truly in the diagnosis of Bipolar II Disorder, which often presents as depression partially responsive to initial treatment with an anti-depressant and often requires a mood stabilizer to deal with persistent symptoms of anxiety, irritability, and impulsivity. This diagnosis is often made over time.
One of the most substantial risks we expose our patients to is the under-diagnosis or partial treatment of affective disorders, which can result in what I refer to as treatment-induced or iatrogenic character disorders. I have seen this during the course of treatment of several individuals who presented with affective symptomatology
Jamie Feldman, M.D., is in private practice of psychiatry in Cambridge, Mass.
and what could be viewed as concomitant character pathology. I have treated several patients with various depressive and bipolar disorders in which sub-therapeutic doses of medication have resulted in affective lability and cognitive difficulties, which make the diagnosis of borderline personality a very tenable diagnostic formulation. Persistence in the use of medication, with adequate doses and proper choices resulted in the emergence of a much more organized, less disturbed personality. Our patients rely on us to use our best judgment and clinical skills to help them. They want us to be respectful of the meaning their symptoms play in their ability to live as organized and comfortable a life as possible. They often fear to acknowledge the presence of a biological illness and have difficulty tolerating the kinds of clinical trials of medication required for effective treatment.
The use of psychotropic medication has become more prevalent for good reason. It helps particularly when prescribed in the context of treatment by analysts who feel confident in their diagnostic skills and believe in the potential efficacy of medication, and who appreciate the potential difficulties involved in achieving successful results. This holds true for patients whose lives and characters span the entire spectrum of pathology. A theoretically open mind allows treatments focused on patient recovery that are defined differently for each individual. We often need to suspend what we know, what we are looking for or what we believe in, in order to give patients a chance to become who they can be.