Psychotherapy and Medication: The Challenge of Integration

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Busch, Frederic N, and Sandberg, Larry S. (2007) New York: The Analytic Press (Taylor & Francis Group). ISBN 13-978-0-88163-451-8. xi + 177 pp.In an era in which combined psychotherapy and medication is seen as the gold standard for many patients, there is little written about how to provide this care optimally. This highly readable and thought provoking book sets out to provide information on how to work with medication theoretically, clinically, and technically in the context of psychodynamic or analytic treatment. The authors present a synthesis of current evidence along with clinical vignettes that range from the simple to the complex. Particularly interesting discussions are devoted to the meaning of medication, the combined treatment of patients with depression, split treatment and suicide. Although this book explores many key concepts, it never oversimplifies or attempts to provide definitive answers. Rather, it challenges the reader to grasp the complexity of these issues and find an appropriate path for each patient and situation.In looking at the meaning of medication, the focus of chapter 4, the authors look at common examples, such as when a patient is noncompliant. In such a situation, what does the prescribing of the drug mean to the patient, the psychotherapist, and the prescribing psychiatrist? The authors point out how the introduction of medication during an analysis or psychotherapy will be experienced by the patient through the predominant transference operating at the time. One must also look at common transferences based on common cultural meanings, placebo effects, and the dynamics of the patient's pathology. Medication can be a threat to the transference, serve as a transitional object, or shift in meaning over time. The authors also discuss the role of countertransference in the therapist when medications are considered or prescribed. Even in formal psychoanalysis, countertransference interference in the optimal use of medication is evident. With thirty percent of analytic patients on medication, it is surprising that the topic of the meaning of medication to analytic patients is not written about more frequently. Analytic training may unconsciously inculcate attitudes that devalue medications, or when they are necessary, then devalue the patients that need them or the analysts that prescribe them. The authors take an important step in opening up that discussion and expanding the field of open analytic inquiry to these countertransference attitudes, which clearly are impediments to optimal treatment.In chapter 8, the discussion of the treatment of depressed patients with both medications and psychotherapy is particularly useful, since this is the best documented and most common area for using combined treatment. The common dynamics of depression lend themselves to various meanings of medication use, which may have helpful or harmful effects on the therapy if not worked with effectively. For example, the patient may feel the therapist is giving up on him by prescribing an antidepressant, which may play into the patient's devalued sense of self. Conversely, a patient may feel understood and responded to with some tangible help with a medication and this may start a positive spiral; however, this may lead to the patient's over-idealizing the therapist. Other common responses are described by the authors, who point out that the therapist must be attuned to the meaning of the interaction to be most helpful in these common but deeply meaningful exchanges. If they are ignored or misread, the therapy may be derailed and the patient may not respond to treatment at all.Split treatments, prescribing therapists, and the issues surrounding these ways of working with patients are discussed in chapters 6 and 7.

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