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The Use of Pharmacotherapy in Psychoanalytic Treatment

THIS PAPER CONSIDERS THE USE of pharmacotherapy in treatment as a


special case of the general proposition that current psychoanalytic practice is
characterie! "y mo#ement a$ay from the %classical% to$ar! a more fle&i"le
psychoanalytic therapy' This fle&i"ility consists of mo!ifications in analytic
proce!ure per se( an! of a!!ing to analytic proce!ures #arying non)analytic
mo!alities* such as "eha#ioral metho!s an! !rug therapy' Short term !ynamic
psychotherapy is increasingly important as a mo!ifie! psychoanalytic
proce!ure'
None of these mo!ifications is ne$' It has "een pointe! out often* for e&ample*
"y +u!! ,armor -./0.1* that 2reu! an! many of the early 2reu!ians carrie! out
short term analyses' Effecti#e psychotropic me!ication $as not a#aila"le in the
early years* "ut it is $ell 3no$n that 2reu! "elie#e! that "iological* constitutional
factors $ere an essential aspect of the person( an! anticipate! the future
!isco#eries of chemical su"stances $hich $oul! alter these "iological factors'
2or e&ample* in his %Outline% -./451* he state! clearly6
The future may teach us ho$ to e&ercise a !irect influence* "y means of
particular chemical su"stances* upon the amounts of energy an! their
!istri"ution in the apparatus of the min!' It may "e that there are other
un!reame!)of possi"ilities of therapy' 7ut for the moment $e ha#e nothing
"etter at our !isposal than the techni8ue of psychoanalysis* an! for that reason*
in spite of its limitations* it is not to "e !espise! -p' .091'
Since the a!#ent of effecti#e !rugs in the ./:5;s pharmacotherapy has "een an
important ingre!ient of the treatment of schiophrenia* "ipolar affecti#e
!isor!ers* an! se#ere unipolar !epressions' Use in the non)psychotic !isor!ers
is much less commonly appro#e!'
In this paper $e propose that mo!ification of analytic proce!ure is the $a#e of
the future' In!ee!* there are some in!ications that it may "e the psychoanalysis
of the present' In ./04* one of us -H'7'1 chaire! a committee $hich polle! the
mem"ership of the American Aca!emy of Psychoanalysis regar!ing use of
psychotropic me!ication' 2ifty percent of the mem"ers replie!<a surprisingly
high rate<an! of the respon!ers /5= sai! they use pharmaceutical agents'
The sur#ey !i! not !etermine in $hat circumstances !rugs are "eing use!' It
appears that long term psychoanalytic therapy is less popular no$ than in the
past an! that psychoanalysis is "ecoming less central to the theory an! practice
of psychiatry* an! in the teaching of resi!ents an! me!ical stu!ents' In the :5;s
an! >5;s many resi!ents sought psychoanalytic training' In the ?5;s an! 05;s*
although analysis is still #alue! as part of the curriculum* it seems much less
common for resi!ents to o"tain specialie! training in a psychoanalytic institute'
There appear to "e fe$er patients $illing to un!erta3e the years of intensi#e
analytic $or3* three<fi#e times a $ee3* or financially a"le to !o so' Social*
cultural* economic tren!s in society are among the causes' Those social factors
e&emplifie! in the concept of %the me generation% ha#e increasingly emphasie!
imme!iate results $ith minimal effort<fast foo!* fast therapy' @uic3 relief from
symptomatic !istress is more popular than the long term maAor effort re8uire!
for personality change "y psychoanalytic means' Ho$e#er* $hether unmo!ifie!
psychoanalsis is the optimal means of o"taining such personality change in
most patients is still open to 8uestion'
One economic factor $hich appears ominous for psychoanalysis is the current
tren! in $hich thir! party payers !iscriminate against psychoanalysis' Non),'D'
therapists of many !isciplines are !oing treatment of many types* inclu!ing full
scale psychoanalysis* an! they generally charge less than psychiatrists' Short
term !ynamic psychotherapy* $hich claims in some cases to achie#e results
similar to those of long term psychoanalytic therapy -Da#anloo* ./?01* is of
increasing significance'
In a!!ition to these social)cultural an! economic factors* ethical an! legal
issues ha#e ta3en on great importance' Be call your attention to an article "y
Dr' Alan Stone in the Ne$ Englan! +ournal of ,e!icine entitle! The Ne$
Para!o& of Psychiatric ,alpractice-./041' Dr' Stone is a former presi!ent of the
American Psychiatric Association an! a reno$ne! e&pert on psychiatry an! the
la$' In this article he !escri"es a case $hich has #ast an! alarming implications
for psychoanalysts' A patient* $ho himself is a physician* sue! a pri#ate
psychiatric hospital for negligence* on the groun!s that it faile! to pro#i!e anti)
!epressant !rugs for him' %Treate! "y a psycho!ynamic approach in a
specialie! pri#ate hospital $ith an e&cellent psycho!ynamically traine! staff*
the patient !i! not reco#er* % Stone reports' The patient then $as transferre! to
another hospital* recei#e! pharmacologic agents* an! reco#ere! in a fe$
$ee3s' He sue! the first hospital for malpractice' @uestions of !iagnosis*
efficiency of treatment* an! the natural history of his !isor!er* among others*
$ere raise! "y the !istinguishe! psychiatrists testifying' The patient $as
a$ar!e! C9:5* 555 "y the malpractice tri"unal an! the case $as e&pecte! to go
to trial' Dr' Stone comments that %the tri"unal;s a$ar! shoul! gi#e serious pause
to psychiatrists an! others $ho rely e&clusi#ely on the psycho!ynamic
treatment mo!el' Psychoanalysts an! other psycho!ynamic therapists ha#e
"een almost totally immune from malpractice suits heretofore "ecause of
#irtually insurmounta"le technical an! legal reasons' Patients !issatisfie! $ith
their lac3 of impro#ement after prolonge! psycho!ynamic treatment may ha#e
foun! a $ay aroun! these o"stacles<a $ay pro#i!e! "y "iological
psychiatrists' Di3e the patient in this case* they may "e a"le to sue for
malpractice "ecause "iological treatments $ere not a!ministere! or they may
argue that informe! consent to treatment re8uire! that they "e tol! a"out the
alternati#e "iological treatments that $ere a#aila"le% -p' .E0>1'
If a psychoanalyst* after !iscussing alternati#e treatment $ith his patient
conclu!es that a psychoanalytic<psychopharmacological approach is re8uire!
or highly !esira"le* 8uestions are raise! a"out $ho shoul! a!minister this
treatment' There are therapeutic* ethical* an! legal issues to "e consi!ere!' If
the me!ical psychoanalyst<a license! physician<prescri"es the me!ication*
!oes his 3no$le!ge an! e&perience ma3e him 8ualifie! to !o so e#en though
his me!ical license clearly ma3es it legal for him to !o soF If the
pharmacological treatment is pro#i!e! "y another psychiatrist ho$ is the tria!ic
relationship in contrast to the !ya!ic relationship han!le!
psychotherapeuticallyF Bhat are the transference an! counter)transference
implications of these issuesF Bhat are the ethical issues in#ol#e!F Does the
prescri"ing physician actually e&amine the patient an! ma3e an in!epen!ent
Au!gement* or !oes he act as a scri"e for someone elseF Bho might "e sue! if
there is a poor result or a !issatisfie! patientF E&perience $oul! in!icate
strongly that "oth psychiatrists might emerge as !efen!ents' The situation can
"e more complicate!* or complicate! in a !ifferent $ay* if the psychoanalyst
$ere not an ,'D' an! the prescri"er a general psychiatrist or a general
practitioner' All of these situations are in fact e&tant' As $e contemplate treating
patients in the most efficacious $ay these issues an! their implications must
"ecome our concerns' 2or e&ample* ho$ coul! a psychoanalyst o"tain a
genuine informe! consent from an an&ious patient for analytic treatmentF Is it
reasona"le to e&pect that he can e&plain analysis an! compare its proce!ures
an! results $ith all the other possi"le therapiesF
Clearly* closely associate! $ith legal issues are ethical issues* $hich are
ine&trica"ly com"ine! $ith technical 8uestions regar!ing the efficiency of the
treatment' Bhat is our o"ligation as analytic physicians to relie#e pain*
malfunction* an! other serious !istressF If an analytic patient;s pho"ia for flying
is slo$ to respon! to the analytic therapy an! is seriously !amaging his
"usiness career* an! there"y his income* an! perhaps also his family
relationships( an! if "eha#ior mo!ification therapy or !rug therapy $oul! relie#e
the symptoms -$hose psycho!ynamic !eterminants are clear to the analyst1*
$hat is ethically in!icate!F A similar e&ample is the patient $hose fear of
!entists is pre#enting him from getting essential !ental care' The ethically
correct ans$er seems o"#ious* yet it is also o"#ious that the technical 8uestions
re8uire serious consi!eration' If me!ication is successful the patient may
terminate analysis* to his ultimate !etriment* $ith the #ie$ that analysis is an
ineffectual treatment* compare! to me!ication or "eha#ior mo!ification' Or* he
may continue* "ut the analysis may "e more !ifficult' It is possi"le* on the other
han!* that the analysis may "e facilitate! "y the symptom relief since this may
help rein#igorate a stalle! treatment' The theoretical implications are legion' In
each case the !ecision $hether to use !rugs shoul! "e "ase! on the analyst;s
3no$le!ge of his patient an! of the situation at the time' Of course* he also
nee!s an a!e8uate 3no$le!ge of psychopharmacology* or a proce!ure for
referring for !rug therapy "y another !octor'
I!eology is unfortunately "ut perhaps ine#ita"ly a maAor factor in the !ecision
ma3ing process' 7elief in the primacy of organic or psycho!ynamic etiology has
alternate! throughout the history of psychiatry -Garasu* ./091* e#en "efore the
./th century' In 2reu!;s time !uring the late ./th century* "rain pathology hel!
s$ay* an! 2reu! $as !enounce! as %unscientific* % as $ell as immoral' In the
./:5;s mo!ern psychopharmacology "egan $ith the !emonstration that
chlorpromaine ha! a profoun! "eneficial effect on pathological "eha#ior' ,ost
analysts fought the pharmacology tren! -,armor* ./0.1' Ho$e#er* some
intrepi! analysts at that time sa$ the logic of a com"ine! approach' 2or
e&ample a conference $as hel! at ,cHill Uni#ersity in ./:/ on the
physiological an! psychological aspects of psychiatric !rug therapy' The
procee!ings $ere pu"lishe! in ./>5 as a "oo3* The Dynamics of Psychiatric
Drug Therapy-Sar$er)2oner* ./>51' Among the presentations $as a paper
entitle! %The Use of Drugs to O#ercome Technical Difficulties in
Psychoanalysis* % "y Dr' ,ortimer Osto$' Osto$ has "een spea3ing out for the
use of !rugs in this $ay for the past 9: years'
The HAP report of ./?: points out that ol!er psychiatrists* $hose training !i!
not inclu!e psychopharmacology* are li3ely not to use !rugs* $hereas those
$hose training has not stresse! psycho)!ynamics are li3ely not to use clearly
in!icate! psycho!ynamic therapy' Of importance to us are o"Aections of
analysts to the use of !rugs "ase! on psychoanalytic principles' Analysts
concerne! seriously an! legitimately a"out possi"le !ilution or !estruction of the
analytic process "y !irect chemical effects of me!ication an! "y $hat has "een
calle! negati#e place"o effects* that is* harmful effects $hich result from the
meanings to patient an! analyst of the use of the !rug' 7efore $e consi!er
some of these factors $e $ill !iscuss ho$ pharmacotherapy is com"ine! $ith
psychoanalytic therapy* in the #arious !isor!ers'
Schizophrenia and Depression
At this time acute schiophrenia an! psychotic !epression are rarely treate!
$ith psychoanalytic therapy solely' ,any $oul! agree that me!ication is primary
is such cases* $ith psychotherapy an! milieu therapy secon!ary* at least $hen
the psychotic "eha#ior is flam"oyant' Bhen the patient is not grossly psychotic
the matter is consi!era"ly more comple&' It is not uncommon for analysts to
treat schiophrenics an! !epresse! patients $ith analytic therapy* solely or
com"ine! $ith !rugs -Osto$* ./0E1' Bill is 3no$n to fa#or the essentially
psychotherapeutic treatment of se#ere mental !isor!ers* especially
schiophrenia' He $rites6
There is great pressure to use me!ications more for the control of "eha#ior
rather than as an important a!Aunct to more comprehensi#e treatment' I thin3
that it is proper to control "eha#ior $ith me!ication* for e&ample* $hen the
$elfare of the patient an! his surroun!ings are seriously threatene! "y $hat he
!oes' I !o not fa#or the su"stitution of me!ication* or other restraint* for the
human relationships $hich are of fun!amental importance in "uil!ing a trusting
an! healing attitu!e to$ar! oneself an! other people (1983* p' .501'
Another lea!er in the treatment of schiophrenia an! !epression $as Sil#ano
Arieti' He state! his position in these $or!s6
,y o$n mar3e! preference in the a#erage case is in!i#i!ual psychotherapy*
although $ith numerous patients I use! a mi&e! psychotherapy an! !rug
therapy' ,y %"ias% is "ase! on the "elief that physical therapies* as far as $e
3no$ or can infer* pro!uce only a symptomatic impro#ement* $hereas
psychotherapy ten!s to -.1 remo#e the "asic conflicts $hich are important an!
necessary causati#e elements of the !isor!er( -91 correct the psychopathologic
patterns( -E1 change the self)image of the patient an! therefore ma3e him less
#ulnera"le( an! -41 permit the regenerati#e psychological po$ers of the
organism to regain the lost groun!'
Arieti a!!s that in a consi!era"le num"er of cases %the a!!ition of !rug therapy
may help "y !ecreasing an&iety* thus facilitating interpersonal contact -./:/* p'
4/E* 4/41'%
Depression is not a homogeneous entity* there are !ifferent !epressions for
$hich !ifferent therapies are use! commonly' The usual practice ma3es the use
of me!ication !epen! on clinical !iagnosis an! se#erity of symptoms* although
at times psychoanalytic theory may "e an important factor -HAP Report* ./?:1((
-Garasu* ./091' The classical psychoanalytic formulations account for the
clinical manifestations of !epression on the "asis of unconscious conflicts in the
pre!ispose! psychic apparatus* $hich result from a loss of an am"i#alently
regar!e! o"Aect* $hich precipitates an oral regression an! rage turne! against
the introAecte! o"Aect' Ho$e#er* if one e&plains the symptoms of !epression as
the result of a relati#e !ecrease in the catecholamines in the synaptic cleft then
logically treatment shoul! "e chemical* to increase the functional a#aila"ility of
these su"stances' These theoretical positions are not mutually e&clusi#e' It
nee! not "e either ) or* "ut can "e "oth* to #arying !egrees in #arying
circumstances -HAP Report* ./?:1'
Drugs an! psychoterapy of #arious types are com"ine! commonly' In a recent
article Beissman -./0E1 reporte! on a num"er of stu!ies of the efficacy of
se#eral psychotherapies* alone an! in com"ination $ith !ri#e therapy* in the
outpatient treatment of am"ulatory unipolar !epresse! patients' There $as
unfortunately insufficient !ata to inclu!e psychoanalytic therapy in the stu!y'
The e#i!ence in!icate! that the com"ine! treatment* !rugs plus psychotherapy*
is prefera"le to either alone' Desse has reporte! goo! results in the treatment of
se#ere !epressions an! mas3e! !epressions "y com"ining !rug therapy $ith
psychoanalytically oriente! psychotherapy -./?>1* -./?01'
Borderline Disorder
The "or!erline category !oes not !elineate a homogeneous group for the
purpose of treatment* an! the literature contains a $i!e range of statements
a"out $hether to use !rugs* an! if so $hat !rugs in $hat $ay' 7rin3ley et al
!escri"e! %a particular group of !rug)responsi#e "or!erline patients* % an! the
efficacy of the a!Auncti#e use of neurolopetics in lo$ !osage* $hich pro#i!es
%an impro#ement of reality testing an! other functions that ena"les such a
patient to utilie psychotherapy more effecti#ely -./?/* p' 9E:1'% 2or intensi#e*
long term therapy of the "or!erline* Gern"erg recommen!s tran8uilliers only
%$hen the !egree of an&iety is such that it interferes $ith the esta"lishment an!
preser#ation of a meaningful patient)therapist communication -./?:* p' .E.1'%
Cohen -./051 $rote that lo$ !oses of neuroleptics may ser#e as part of the
%support system% in the analytic treatment of such patients* "y pre#enting
transference psychosis an! loss of reality* an! strengthening the therapeutic
alliance'
One generaliation $hich can "e ma!e is that me!ication may ma3e the
"enefits of analytic therapy a#aila"le to some "or!erline patients $ho other$ise
coul! not "e treate! analytically' It shoul! "e mentione! that the !rugs $hich
ma3e therapy possi"le might pre#ent the strengthening of the ego $hich can
result from confronting an! mastering the painful affects' In each in!i#i!ual*
careful appraisal of the clinical an! psycho!ynamic features can lea! to the
most promising treatment !ecisions'
Anxiety Disorder
An&iety !isor!ers can "e treate! "y analytic* supporti#e* "eha#ioral* an!
pharmacologic therapies* an! "y #arious com"inations of the a"o#e( an! all
ha#e their a!#ocates' Current 3no$le!ge suggests that all of the a"o#e may "e
therapeutic* particularly in com"inations* for #arious patients in #arious
circumstances' Since the early ./>5;s Donal! Glein an! others ha#e presente!
!ata in!icating that panic an&iety is 8ualitati#ely !ifferent from generalie!
an&iety* an! that agorapho"ia results from anticipation of panic attac3s -./>41*
-./0E1'
The panic attac3s $hich !etermine the a#oi!ance response are !escri"e! as
occurring spontaneously* $ithout apparent precipitants' Glein -./>41 refers to a
"iological #ulnera"ility to an&iety* $hich $oul! account for the failure of some
patients to utilie analytic insight to o#ercome a pho"ia'
It is note$orthy that in the same article Glein reports precipitating factors
rele#ent to the first panic in a su"stantial percentage' One such factor $as
%threatene! or actual separation from or loss of a lo#e! person* % especially in
$omen( in a large percentage of this group there $as a history of chil!hoo!
separation an&iety' Other factors $hich precipitate! the !isor!er in other
patients $ere %a traumatic life e#ent or alteration of en!ocrine status -pp' .:5I
.:.1'%
Nemiah has presente! a #ie$ of an&iety $hich ta3es account of "oth the
"iological an! the psycho!ynamic -./04a1* -./04"1' He points out that
psycho!ynamic !eterminants of panic attac3s an! an&iety may "e hi!!en from
any "ut analytic in#estigation' Theoriing from the syn!rome of ale&ythymia an!
psychosomatic illness* as $ell as the psychoanalytic #ie$* he suggests that the
panic attac3 may "e %the final common pro!uct of !i#erse un!erlying
mechanisms' In some* it may "e the result of comple& psychological processes(
in others* it may represent the !irect !ischarges of arousal o#er autonomic
channels $ithout any higher psychic ela"orations -./04* p' 4E/1'%
In regar! to treatment* Glein -./0E1 recommen!s %a hierarchy of inter#entions%
"eginning $ith imipramine' If this is ina!e8uate* !epen!ing on the symptoms
an! more comple& pro"lems $hich remain* group or family therapy may "e
trie!( an! patients $ho %!emonstrate the classic psycho!ynamic conflicts<
coul! logically "e treate! $ith an insight)oriente! approach -./0E* p' .>.1'%
Nemiah proposes a psycho!ynamic assessment of e#ery patient $ith an&iety*
an! insight as the preferre! treatment for patients $ho 8ualify' Ho$e#er* he
a!!s me!ication in cases $ith %!isa"ling panic attac3s or stu""orn pho"ic
symptoms'% Nemiah states* %to polarie our clinical an! scientific thin3ing an! to
restrict oursel#es to either a "iological or a psycho!ynamic #ie$ of an&iety or of
the an&ious patient is to limit our #ision an! to compromise the patient;s
opportunity for reco#ery -./04a* p'4451'%
Theory of Combining Drug and Analytic Therapy
In principle* the "iopsychosocial conception of "eha#ior is commonly accepte!'
In practice the "iological has "een relati#ely ignore! "y psychoanalysts' In a
recent article title!* %Bill neuro"iology influence psychoanalysisF% Cooper
-./0:1 presents a carefully reasone! !iscussion of the implications for
psychoanalysis of the recent research in the "iology of an&iety an! of se&ual
"eha#ior' He reaches conclusions similar to those of Nemiah* that some an&iety
is relati#ely non)psychological in origin* "ut some is the result of psychosocial
process* as !escri"e! "y psychoanalysis' He $rites6
This theory suggests that the psychoanalyst is no$ confronte! $ith a
!iagnostic !ecision in his an&ious patient' Bhat portions of the an&iety are* in
their origins* relati#ely nonpsychological* an! $hat portions are the clues to
psychic conflicts that are the originators of the an&ietyF The neuro"iologic
theory !oes not suggest that all an&iety is a nonmental content "ut rather that a
!istinction must "e ma!e "et$een psychological coping an! a!apti#e efforts to
regulate miscarrie! "rain functions $hich create an&iety $ith no or little
en#ironmental input an! psychological coping an! a!apti#e efforts to regulate
!istur"ances of the intrapsychic $orl! that lea! to an&iety an! are en#ironment
sensiti#e' Clearly* $e ha#e not yet arri#e! at the point $here $e can easily
ma3e that !istinction* "ut there is goo! reason to attempt it' In instances in
$hich an un!erlying "iologic malfunction is suspecte!* there is po$erful $arrant
to attempt a "iologic inter#ention that may then facilitate psychological
inter#entions -p' .E/01'
The clinical Austification can "e put in a simple statement' If the com"ination is
e&pecte! to "e "etter for the patient than either alone the com"ination shoul!
"e use!' It is not as easy ho$e#er to !elineate the !ata in the e#aluation $hich
lea! to the !ecision( nor* if the me!ication is Au!ge! in!icate!* ho$ to !o it* nor
ho$ to e#aluate the results' Be no$ ta3e up the in!ications an!
contrain!ications* a!#antages an! !isa!#antages* an! some of the clinical an!
psycho!ynamic factors $hich must "e consi!ere!* in regar! to using me!icines
in psychoanalytic treatment'
The Possible Advantages
The #alue of e&pan!ing the scope of psychoanalysis "y mo!ifying the process
has "een note! "y for many years an! the 8uestion* ho$ much can analysis "e
mo!ifie! an! still "e analysis has "een hotly !e"ate!' 2or some* the issue has
"een resol#e! "y maintaining a strict !iscontinuity "et$een psychoanalysis an!
other psychotherapy' Be consi!er as analytic* follo$ing Ale&an!er -./:41*
treatments $hich use the "asic psychoanalytic concepts in a $ay $hich ma3es
unconscious material conscious an! lea!s to insight' In this regar!* Osto$ in
./0E put the matter in this $ay6
Can one a!minister me!ication $ithin a psychoanalytic treatment regimen
$ithout there"y compromising the analytic 8uality of the patient;s treatmentF ,y
o$n #ie$ is that the com"ine! treatment satisfies all the criteria for authentic
analysis e&cept for the re8uirement that the analyst play no ;real; role in the
patient;s life* that is* that his role "e restricte! to analying' It is generally
un!erstoo!* ho$e#er* that this nonin#ol#ement is a goal* to$ar! $hich one
stri#es* rather than an actuality' The analyst cannot help playing a ;real; role in
the patient;s life in many aspects of the treatment( for e&ample* $hen he
re8uires a firm time commitment -p' 0E1'
A num"er of $or3ers ha#e state! that a maAor a!#antage of a!!ing
pharmacotherapy to psychoanalytic therapy is to ma3e the uni8ue "enefits of
analysis a#aila"le to a large num"er for $hom it is other$ise impossi"le' 2or
e&ample* in ./>5* Bin3elman $rote* %<$ith psychoanalytic therapy as the
primary metho! of treatment* an! $ith the Au!icious use of the phenothiaine
compoun!s* the therapist $ill "e a"le to effecti#ely treat patients that $ere
formerly consi!ere! inaccessi"le -p' :4?1'% In ./0.* ,armor state!* %The issue
is no longer $hether or not !rugs must "e totally a"Aure! in !ynamic
psychotherapy "ut rather* un!er $hat circumstances they can "e facilitators of
therapy -p' E.E1'% Patients $ho are relati#ely more #ulnera"le to stress* $ith
$ea3er egos than the usual goo! can!i!ate for analysis* can "e treate!
analytically "y using me!ication to pre#ent serious !epression* psychotic
!ecompensation* or !estructi#e acting out'
,e!ication may not only pre#ent serious !angers to the analysis an! to the
patient* "ut also may "enefit the analytic process "y influencing the intensity of
!ri#es -Osto$* ./>>1 an! "y impro#ing ego function* as reporte! "y 7ella3
-./?E1* -./0E1' In ./>9 Osto$ $rote that his teacher* Herman Nun"erg*
informe! him that %2reu! spo3e of anticipating a time $hen it $oul! "e possi"le
to use chemical su"stances !uring a therapeutic analysis in or!er to !irect the
analysis into the most fruitful channels -p'91'% It is theoretically possi"le that the
s3illful use of !rugs can ma3e psychoanalysis more rapi!* less painful* an!
more successful' In the HAP report is the remar3* %Presuma"ly $hen
appropriately utilie! -psychotropic !rugs1 shoul! alter response an! prepare
the organism for optimal psychoanalytic therapy -p' E>:1'%
Indications and Contraindications
In!ications for the use of !rugs can "e thought of in regar! to "eginning an!
en!ing an analytic treatment* an! to ameliorating !ifficulties in the course of the
analysis' It is common practice to mo!ify stan!ar! techni8ue in or!er to get
starte!* an! it is not uncommon for patients to resist termination* although the
analyst 3no$s that the analytic $or3 has "een !one' Though not a panacea* in
some cases me!ication can help o#ercome the an&ieties in#ol#e! in "oth'
At any point in the therapy symptoms may !e#elop $hich !o not respon! rea!ily
to the analytic effort' It goes $ithout saying that not all such situations in!icate
a!Auncti#e inter#entions' Drugs shoul! not "e use! for tri#ial or realistic $orries
-,armor* ./0.1' Ho$e#er* if the symptom presents a serious threat to the
patient* e'g' !epression* !ecompensation* !estructi#e acting out* or if the
treatment has "ogge! !o$n an! no purely analytic effort is effecti#e* the use of
!rugs shoul! "e consi!ere!' In e&treme cases the !ecision is not !ifficult'
7efore the situation has "ecome e&treme* the matter is relati#e* an! the "est
gui!e is the inAunction* %3no$ your patient'% 2reu! note! that pho"ic patients
nee! a push to o#ercome the !ysfunction* after the unconscious !eterminants
ha#e "een analye!' Analytic therapy in general !oes not aim primarily at
elimination of symptoms* "ut at impro#ement of unconscious conflicts $hich
pro!uce unsatisfactory "eha#ior* inclu!ing symptoms' ,ost $ho use !rugs !o
so only if the symptoms are so se#ere that they threaten the patient or the
analysis* an! !o not respon! to analysis' In short* !rugs are not a su"stitute for
"ut an a!Aunct to the analytic process'
Possible Disadvantages
,any analysts "elie#e that the analytic process $ill "e sa"otage! "y the use of
psychotropic !rugs* regar!less of $hether the treatment is calle!
psychoanalytic' A !ecrease in emotional pain "rought a"out "y me!ication
rather than "y $or3ing through unconscious conflict may !ecrease moti#ation
for the analytic $or3* $hich $oul! in the long run impe!e rather than impro#e
the treatment' It $oul! lea! to premature termination or to a pseu!osuccessful
outcome in $hich the resolution of unconscious conflict is less than optimal' The
psychopathology is then li3ely to recur'
2or some patients* use of !rugs may signify %unsuita"le for psychoanalysis* %
$ith negati#e effects on self)esteem an! on transference an!Jor resistance' 2or
some* the meaning may "e an organic illness* for $hich analysis $oul! "e
inappropriate' Si!e effects coul! support such a #ie$* as $ell as "eing
un!esira"le* per se' Symptom su"stitution is of course a possi"ility' ,armor has
state!6
The tra!itional psychoanalytic assumption that alle#iating symptoms results
in symptom su"stitution has not "een "orn out "y e#i!ence from hypnosis*
"eha#ioral therapies or !rug therapies' It is clear that the premise $as "ase! on
a close! system theory $hich pre!icate! that suppression of a symptom $ithout
resol#ing the causati#e un!erlying conflicts an! pressures in the system $oul!
result in a su"stitute symptom in another part of the system' Such a
conse8uence is not ine#ita"le' On the contrary* remo#al of an ego)!ystonic
symptom can ma3e the system more accessi"le to constructi#e fee!"ac3s that
may alter the entire un!erlying conflictual pattern (1981* p' E.E1'
Another theoretical o"Aection is the possi"ility that %artificially% remo#ing
symptoms $hich are ser#ing a !efensi#e purpose may precipitate more se#ere
pathology* such as panic states or !ecompensation* !epression* or !estructi#e
acting out'
It may "e that the aforementione! results are theoretically possi"le "ut
theoretically not ine#ita"le' Bhether they occur may !epen! on ho$ $ell the
analyst un!erstan!s his patient' A similar logic applies to the issue of
transference an! countertransference* $hich may "e a!#ersely affecte! "y
psychotropic me!ication' Ho$e#er* as Osto$ has pointe! out* there is no
reason $hy such transference an! countertransference phenomena cannot "e
analye! %as rea!ily as the unconscious meanings of all the other contri#e! an!
fortuitous features of the therapeutic contact* such as !isposition of the office
furniture* <payment of fees* an illness* an! so forth -./>9* p' E1'%
Transference and Countertransference
The meaning to the patient of the use of !rugs* the place"o effect* is intimately
associate! $ith transference an! countertransference' These $ill ine#ita"ly "e
affecte! "y this maneu#er( in $hat $ay* an! ho$ to interpret* $ill !epen! on the
in!i#i!ual case* although some generaliations can "e ma!e' In ./>5* Osto$
state! that* fee!ing* poisoning* manipulation* an! impregnation fantasies are
common' Another possi"le reaction is that !escri"e! "y Sar$er)2oner referring
to possi"le harmful transference effects in %male patients $ith profoun! !ou"ts
a"out their masculinity $ho use social ;outgoingness* ; intellectual an! motor
acti#ity as the maAor !efence against un!erlying unconscious feminine
i!entifications an! passi#ity stri#ings' A !rug that !rastically remo#es this motor
acti#ity is consi!ere! threatening* since it can "e interprete! as a
!emasculiniing action -./>5* p' E/>1'%
In some* me!ication $hich alle#iates pain can signify an! augment hope an!
confi!ence in the !octor -Hol!hammer* ./0E1' It may "e unconsciously a
$elcome gift* or an assault or se!uction -hetero) or homose&ual1' In
o"sessional patients* issues of control $ill "e arouse!' Si!e effects can "e
interprete! as signs of impen!ing !eath or physical !amage in those persons
pre)occupie! $ith "o!y image or "o!y integrity -Sar$er)2oner* ./>5* p' E/?1'
Countertransferences must "e recognie!' 2or e&ample the analyst may !ou"t
his psychoanalytic a"ilities( or he may nee! unconsciously to a#oi! emotional
interaction* e'g' !ue to fear of or attraction to the patient' The !octor may
prescri"e to a#oi! conflicts a"out passi#ity* an! to pro#e his po$er to himself
an! his patient( or to $in the patient;s lo#e an! a!miration' This is "y no means
a comprehensi#e list' In each case the analyst must carefully appraise the
pro"a"le transference an! countertransference effects of gi#ing or not gi#ing a
!rug'
Case Illustration
In this case psychotropic me!icines $ere use! perio!ically in the course of an
analytic therapy' The patient $as a 94)year)ol! music stu!ent* $ho $as referre!
"y her !octor "ecause of an&iety an! !epression' She $as an attracti#e*
intelligent* talente! young $oman $ho $as prone to !epression* characterie!
"y rumination a"out her o$n inferiority* hostility* an! unaccepta"ility to others'
An&iety interfere! $ith her a"ility to perform* sometimes se#erely' Her tolerance
for an&iety $as on the lo$ si!e* an! she $as su"Aect to attac3s of
!epersonaliation* an! relati#ely minor episo!es of paranoi! thin3ing' Culturally
an! intellectually she $as committe! to a psychoanalytic form of therapy* "ut
her ego strength $as less than optimal for analysis' A maAor feature of the
psycho!ynamic picture $as her lo#e* fear* an! anger to$ar! her !ominating*
o#er)protecti#e* aggressi#e mother* $ho !i! e#erything for her* $hich inclu!e!
pro#i!ing the patient $ith plenty of things* such as clothes an! money' Success
in her career or in relationships $ith men pro#o3e! se#ere an&iety relate! to her
conflicts a"out surpassing her mother* $ho ha! not follo$e! her o$n career
am"itions an! ha! an unhappy marriage $ith the patient;s father( an! to her
fear of losing her in!ulge!* protecte! status as her mother;s little girl' On se#eral
occasions me!ication $as use!* $hen an&iety $hich resulte! from for$ar!
steps in her life threatene! her compensation an! her a"ility to continue the
treatment' She respon!e! $ell to lo$ !oses of thiori!aine gi#en for EI4 $ee3
perio!s' Her ego strength impro#e!* an! she "ecame a"le to !eal $ith her
conflicts $ithout the help of me!icine' Her analyst $as con#ince! that $ithout
the !rug she $oul! not ha#e "een a"le to continue the analytic treatment'
Discussion
Bhat are the results of a!!ing pharmacotherapy to psychoanalysisF
Unfortunately there is no har! !ata to pro#i!e an une8ui#ocal ans$er' Se#eral
authorities ha#e asserte! that there is no e#i!ence that !rug use interferes $ith
analytic therapy -HAP Report* ./?:1' There is also no e#i!ence that it facilitates
analysis' The !ifficulties of stu!ying this matter are $ell 3no$n' The comple&ity
of the factors relating to patients* !octors* an! !rugs an! their interaction
creates a large num"er of uncontrolla"le #aria"les'
Ho$e#er* it is reasona"le to speculate that pharmacotherapy may $or3
synergistically $ith analytic therapy to ma3e the treatment more rapi! an! more
efficient* i'e' more cost effecti#e' Osto$ mentione! in ./>9 his "elief that
%ultimately $e shall "e a"le to use -!rugs1 to facilitate the in!olent analysis -p'
:1'% This $oul! of course* "e "eneficial to patients( an! might help mo!erate the
climate of hostility to$ar! psychoanalysis $hich currently pre#ails' Cooper
!escri"es a case in $hich Dithium $as use! to control "ipolar symptoms in the
course of a psychoanalysis' He $rites* %I cannot thin3 of a significant analytic
a!#antage gaine! "y $ithhol!ing the me!ication<there seeme! to "e no great
impe!iment to his continuing a genuine analysis $hile ta3ing me!ication -./0:*
p' .45.1'%
The notion that psychoanalytic therapy coul! "e impro#e! "y the right amount
of the right me!icine* gi#en in the right $ay at the right time cannot "e pro#e! or
!ispro#e!* "ut it is of heuristic #alue' Hi#en the great surge of 3no$le!ge
pro#i!e! "y psycho)pharmacology an! neuro"iology an! the current negati#e
social an! economic attitu!es to$ar! analysis* further stu!y of this matter may
"e of great importance for the future of psychoanalysis'
ootnotes
.
This paper $as presente! at the Annual ,eeting of the American Aca!emy of
Psychoanalysis Ne$ Orleans* Decem"er ./0:'
!""!"#C"S
.
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Assoc' 9 6?99)?EE -APA'559'5?99A1
9
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Han!"oo3 of Psychiatry 9n! E!ition* Kol' III E!s' S' Arieti an! E' 7ro!y' Ne$
Lor36 7asic 7oo3s* Inc'
E
7ella3* D' ./?E Ego function assessment of analytic com"ine! $ith !rug
therapy +ournal of Ner#ous an! ,ental Disease .:?64>:)4>/
4
7ella3* D' ./0E Psychoanalysis in the ./05;s American +ournal of
Psychotherapy E?64?>)4/9
:
7rin3ley* +' ./?/ Do$ !ose neuroleptic regimen in the treatment of "or!erline
patients Archi#es of Heneral Psychiatry E>6E./)E9>
>
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