The Use of Pharmacotherapy in Psychoanalytic Treatment

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 characterized by movement away from the "classical" toward a more flexible psychoanalytic therapy. This flexibility consists of modifications in analytic procedure per se; and of adding to analytic procedures varying non-analytic modalities, such as behavioral methods and drug therapy. Short term dynamic psychotherapy is increasingly important as a modified psychoanalytic procedure. None of these modifications is new. It has been pointed out often, for example, by Judd Marmor (1981), that Freud and many of the early Freudians carried out short term analyses. Effective psychotropic medication was not available in the early years, but it is well known that Freud believed that biological, constitutional factors were an essential aspect of the person; and anticipated the future discoveries of chemical substances which would alter these biological factors. For example, in his "Outline" (1940), he stated clearly: The future may teach us how to exercise a direct influence, by means of particular chemical substances, upon the amounts of energy and their distribution in the apparatus of the mind. It may be that there are other undreamed-of possibilities of therapy. But for the moment we have nothing better at our disposal than the technique of psychoanalysis, and for that reason, in spite of its limitations, it is not to be despised (p. 182). Since the advent of effective drugs in the 1950's pharmacotherapy has been an important ingredient of the treatment of schizophrenia, bipolar affective disorders, and severe unipolar depressions. Use in the non-psychotic disorders is much less commonly approved. In this paper we propose that modification of analytic procedure is the wave of the future. Indeed, there are some indications that it may be the psychoanalysis of the present. In 1984, one of us (H.B.) chaired a committee which polled the membership of the American Academy of Psychoanalysis regarding use of psychotropic medication. Fifty percent of the members replied—a surprisingly high rate—and of the responders 90% said they use pharmaceutical agents. The survey did not determine in what circumstances drugs are being used. It appears that long term psychoanalytic therapy is less popular now than in the past and that psychoanalysis is becoming less central to the theory and practice of psychiatry, and in the teaching of residents and medical students. In the 50's and 60's many residents sought psychoanalytic training. In the 70's and 80's, although analysis is still valued as part of the curriculum, it seems much less common for residents to obtain specialized training in a psychoanalytic institute. There appear to be fewer patients willing to undertake the years of intensive analytic work, three—five times a week, or financially able to do so. Social, cultural, economic trends in society are among the causes. Those social factors exemplified in the concept of "the me generation" have increasingly emphasized immediate results with minimal effort—fast food, fast therapy. Quick relief from symptomatic distress is more popular than the long term major effort required for personality change by psychoanalytic means. However, whether unmodified psychoanalsis is the optimal means of obtaining such personality change in most patients is still open to question. One economic factor which appears ominous for psychoanalysis is the current trend in which third party payers discriminate against psychoanalysis. Non-M.D.

therapists of many disciplines are doing treatment of many types, including full scale psychoanalysis, and they generally charge less than psychiatrists. Short term dynamic psychotherapy, which claims in some cases to achieve results similar to those of long term psychoanalytic therapy (Davanloo, 1978), is of increasing significance. In addition to these social-cultural and economic factors, ethical and legal issues have taken on great importance. We call your attention to an article by Dr. Alan Stone in the New England Journal of Medicine entitled The New Paradox of Psychiatric Malpractice(1984). Dr. Stone is a former president of the American Psychiatric Association and a renowned expert on psychiatry and the law. In this article he describes a case which has vast and alarming implications for psychoanalysts. A patient, who himself is a physician, sued a private psychiatric hospital for negligence, on the grounds that it failed to provide antidepressant drugs for him. "Treated by a psychodynamic approach in a specialized private hospital with an excellent psychodynamically trained staff, the patient did not recover, " Stone reports. The patient then was transferred to another hospital, received pharmacologic agents, and recovered in a few weeks. He sued the first hospital for malpractice. Questions of diagnosis, efficiency of treatment, and the natural history of his disorder, among others, were raised by the distinguished psychiatrists testifying. The patient was awarded $250, 000 by the malpractice tribunal and the case was expected to go to trial. Dr. Stone comments that "the tribunal's award should give serious pause to psychiatrists and others who rely exclusively on the psychodynamic treatment model. Psychoanalysts and other psychodynamic therapists have been almost totally immune from malpractice suits heretofore because of virtually insurmountable technical and legal reasons. Patients dissatisfied with their lack of improvement after prolonged psychodynamic treatment may have found a way around these obstacles—a way provided by biological psychiatrists. Like the patient in this case, they may be able to sue for malpractice because biological treatments were not administered or they may argue that informed consent to treatment required that they be told about the alternative biological treatments that were available" (p. 1386). If a psychoanalyst, after discussing alternative treatment with his patient concludes that a psychoanalytic—psychopharmacological approach is required or highly desirable, questions are raised about who should administer this treatment. There are therapeutic, ethical, and legal issues to be considered. If the medical psychoanalyst—a licensed physician—prescribes the medication, does his knowledge and experience make him qualified to do so even though his medical license clearly makes it legal for him to do so? If the pharmacological treatment is provided by another psychiatrist how is the triadic relationship in contrast to the dyadic relationship handled psychotherapeutically? What are the transference and counter-transference implications of these issues? What are the ethical issues involved? Does the prescribing physician actually examine the patient and make an independent judgement, or does he act as a scribe for someone else? Who might be sued if there is a poor result or a dissatisfied patient? Experience would indicate strongly that both psychiatrists might emerge as defendents. The situation can be more complicated, or complicated in a different way, if the psychoanalyst were not an M.D. and the prescriber a general psychiatrist or a general practitioner. All of these situations are in fact extant. As we contemplate treating

patients in the most efficacious way these issues and their implications must become our concerns. For example, how could a psychoanalyst obtain a genuine informed consent from an anxious patient for analytic treatment? Is it reasonable to expect that he can explain analysis and compare its procedures and results with all the other possible therapies? Clearly, closely associated with legal issues are ethical issues, which are inextricably combined with technical questions regarding the efficiency of the treatment. What is our obligation as analytic physicians to relieve pain, malfunction, and other serious distress? If an analytic patient's phobia for flying is slow to respond to the analytic therapy and is seriously damaging his business career, and thereby his income, and perhaps also his family relationships; and if behavior modification therapy or drug therapy would relieve the symptoms (whose psychodynamic determinants are clear to the analyst), what is ethically indicated? A similar example is the patient whose fear of dentists is preventing him from getting essential dental care. The ethically correct answer seems obvious, yet it is also obvious that the technical questions require serious consideration. If medication is successful the patient may terminate analysis, to his ultimate detriment, with the view that analysis is an ineffectual treatment, compared to medication or behavior modification. Or, he may continue, but the analysis may be more difficult. It is possible, on the other hand, that the analysis may be facilitated by the symptom relief since this may help reinvigorate a stalled treatment. The theoretical implications are legion. In each case the decision whether to use drugs should be based on the analyst's knowledge of his patient and of the situation at the time. Of course, he also needs an adequate knowledge of psychopharmacology, or a procedure for referring for drug therapy by another doctor. Ideology is unfortunately but perhaps inevitably a major factor in the decision making process. Belief in the primacy of organic or psychodynamic etiology has alternated throughout the history of psychiatry (Karasu, 1982), even before the 19th century. In Freud's time during the late 19th century, brain pathology held sway, and Freud was denounced as "unscientific, " as well as immoral. In the 1950's modern psychopharmacology began with the demonstration that chlorpromazine had a profound beneficial effect on pathological behavior. Most analysts fought the pharmacology trend (Marmor, 1981). However, some intrepid analysts at that time saw the logic of a combined approach. For example a conference was held at McGill University in 1959 on the physiological and psychological aspects of psychiatric drug therapy. The proceedings were published in 1960 as a book, The Dynamics of Psychiatric Drug Therapy(Sarwer-Foner, 1960). Among the presentations was a paper entitled "The Use of Drugs to Overcome Technical Difficulties in Psychoanalysis, " by Dr. Mortimer Ostow. Ostow has been speaking out for the use of drugs in this way for the past 25 years. The GAP report of 1975 points out that older psychiatrists, whose training did not include psychopharmacology, are likely not to use drugs, whereas those whose training has not stressed psycho-dynamics are likely not to use clearly indicated psychodynamic therapy. Of importance to us are objections of analysts to the use of drugs based on psychoanalytic principles. Analysts concerned seriously and legitimately about possible dilution or destruction of the analytic process by direct chemical effects of medication and by what has been called negative placebo effects, that is, harmful effects which result from the

meanings to patient and analyst of the use of the drug. Before we consider some of these factors we will discuss how pharmacotherapy is combined with psychoanalytic therapy, in the various disorders. Schizophrenia and Depression

At this time acute schizophrenia and psychotic depression are rarely treated with psychoanalytic therapy solely. Many would agree that medication is primary is such cases, with psychotherapy and milieu therapy secondary, at least when the psychotic behavior is flamboyant. When the patient is not grossly psychotic the matter is considerably more complex. It is not uncommon for analysts to treat schizophrenics and depressed patients with analytic therapy, solely or combined with drugs (Ostow, 1983). Will is known to favor the essentially psychotherapeutic treatment of severe mental disorders, especially schizophrenia. He writes: There is great pressure to use medications more for the control of behavior rather than as an important adjunct to more comprehensive treatment. I think that it is proper to control behavior with medication, for example, when the welfare of the patient and his surroundings are seriously threatened by what he does. I do not favor the substitution of medication, or other restraint, for the human relationships which are of fundamental importance in building a trusting and healing attitude toward oneself and other people (1983, p. 108). Another leader in the treatment of schizophrenia and depression was Silvano Arieti. He stated his position in these words: My own marked preference in the average case is individual psychotherapy, although with numerous patients I used a mixed psychotherapy and drug therapy. My "bias" is based on the belief that physical therapies, as far as we know or can infer, produce only a symptomatic improvement, whereas psychotherapy tends to (1) remove the basic conflicts which are important and necessary causative elements of the disorder; (2) correct the psychopathologic patterns; (3) change the self-image of the patient and therefore make him less vulnerable; and (4) permit the regenerative psychological powers of the organism to regain the lost ground. Arieti adds that in a considerable number of cases "the addition of drug therapy may help by decreasing anxiety, thus facilitating interpersonal contact (1959, p. 493, 494)." Depression is not a homogeneous entity, there are different depressions for which different therapies are used commonly. The usual practice makes the use of medication depend on clinical diagnosis and severity of symptoms, although at times psychoanalytic theory may be an important factor (GAP Report, 1975);; (Karasu, 1982). The classical psychoanalytic formulations account for the clinical manifestations of depression on the basis of unconscious conflicts in the predisposed psychic apparatus, which result from a loss of an ambivalently regarded object, which precipitates an oral regression and rage turned against the introjected object. However, if one explains the symptoms of depression as the result of a relative decrease in the catecholamines in the synaptic cleft then logically treatment should be chemical, to increase the functional availability of these substances. These theoretical positions are not mutually exclusive. It need not be either - or, but can be both, to varying degrees in varying circumstances (GAP Report, 1975). Drugs and psychoterapy of various types are combined commonly. In a recent article Weissman (1983) reported on a number of studies of the efficacy of

several psychotherapies, alone and in combination with drive therapy, in the outpatient treatment of ambulatory unipolar depressed patients. There was unfortunately insufficient data to include psychoanalytic therapy in the study. The evidence indicated that the combined treatment, drugs plus psychotherapy, is preferable to either alone. Lesse has reported good results in the treatment of severe depressions and masked depressions by combining drug therapy with psychoanalytically oriented psychotherapy (1976), (1978). Borderline Disorder

The borderline category does not delineate a homogeneous group for the purpose of treatment, and the literature contains a wide range of statements about whether to use drugs, and if so what drugs in what way. Brinkley et al described "a particular group of drug-responsive borderline patients, " and the efficacy of the adjunctive use of neurolopetics in low dosage, which provides "an improvement of reality testing and other functions that enables such a patient to utilize psychotherapy more effectively (1979, p. 235)." For intensive, long term therapy of the borderline, Kernberg recommends tranquillizers only "when the degree of anxiety is such that it interferes with the establishment and preservation of a meaningful patient-therapist communication (1975, p. 131)." Cohen (1980) wrote that low doses of neuroleptics may serve as part of the "support system" in the analytic treatment of such patients, by preventing transference psychosis and loss of reality, and strengthening the therapeutic alliance. One generalization which can be made is that medication may make the benefits of analytic therapy available to some borderline patients who otherwise could not be treated analytically. It should be mentioned that the drugs which make therapy possible might prevent the strengthening of the ego which can result from confronting and mastering the painful affects. In each individual, careful appraisal of the clinical and psychodynamic features can lead to the most promising treatment decisions. Anxiety Disorder

Anxiety disorders can be treated by analytic, supportive, behavioral, and pharmacologic therapies, and by various combinations of the above; and all have their advocates. Current knowledge suggests that all of the above may be therapeutic, particularly in combinations, for various patients in various circumstances. Since the early 1960's Donald Klein and others have presented data indicating that panic anxiety is qualitatively different from generalized anxiety, and that agoraphobia results from anticipation of panic attacks (1964), (1983). The panic attacks which determine the avoidance response are described as occurring spontaneously, without apparent precipitants. Klein (1964) refers to a biological vulnerability to anxiety, which would account for the failure of some patients to utilize analytic insight to overcome a phobia. It is noteworthy that in the same article Klein reports precipitating factors relevent to the first panic in a substantial percentage. One such factor was "threatened or actual separation from or loss of a loved person, " especially in women; in a large percentage of this group there was a history of childhood separation anxiety. Other factors which precipitated the disorder in other patients were "a traumatic life event or alteration of endocrine status (pp. 150– 151)." Nemiah has presented a view of anxiety which takes account of both the biological and the psychodynamic (1984a), (1984b). He points out that

psychodynamic determinants of panic attacks and anxiety may be hidden from any but analytic investigation. Theorizing from the syndrome of alexythymia and psychosomatic illness, as well as the psychoanalytic view, he suggests that the panic attack may be "the final common product of diverse underlying mechanisms. In some, it may be the result of complex psychological processes; in others, it may represent the direct discharges of arousal over autonomic channels without any higher psychic elaborations (1984, p. 439)." In regard to treatment, Klein (1983) recommends "a hierarchy of interventions" beginning with imipramine. If this is inadequate, depending on the symptoms and more complex problems which remain, group or family therapy may be tried; and patients who "demonstrate the classic psychodynamic conflicts— could logically be treated with an insight-oriented approach (1983, p. 161)." Nemiah proposes a psychodynamic assessment of every patient with anxiety, and insight as the preferred treatment for patients who qualify. However, he adds medication in cases with "disabling panic attacks or stubborn phobic symptoms." Nemiah states, "to polarize our clinical and scientific thinking and to restrict ourselves to either a biological or a psychodynamic view of anxiety or of the anxious patient is to limit our vision and to compromise the patient's opportunity for recovery (1984a, p.440)." Theory of Combining Drug and Analytic Therapy

In principle, the biopsychosocial conception of behavior is commonly accepted. In practice the biological has been relatively ignored by psychoanalysts. In a recent article titled, "Will neurobiology influence psychoanalysis?" Cooper (1985) presents a carefully reasoned discussion of the implications for psychoanalysis of the recent research in the biology of anxiety and of sexual behavior. He reaches conclusions similar to those of Nemiah, that some anxiety is relatively non-psychological in origin, but some is the result of psychosocial process, as described by psychoanalysis. He writes: This theory suggests that the psychoanalyst is now confronted with a diagnostic decision in his anxious patient. What portions of the anxiety are, in their origins, relatively nonpsychological, and what portions are the clues to psychic conflicts that are the originators of the anxiety? The neurobiologic theory does not suggest that all anxiety is a nonmental content but rather that a distinction must be made between psychological coping and adaptive efforts to regulate miscarried brain functions which create anxiety with no or little environmental input and psychological coping and adaptive efforts to regulate disturbances of the intrapsychic world that lead to anxiety and are environment sensitive. Clearly, we have not yet arrived at the point where we can easily make that distinction, but there is good reason to attempt it. In instances in which an underlying biologic malfunction is suspected, there is powerful warrant to attempt a biologic intervention that may then facilitate psychological interventions (p. 1398). The clinical justification can be put in a simple statement. If the combination is expected to be better for the patient than either alone the combination should be used. It is not as easy however to delineate the data in the evaluation which lead to the decision; nor, if the medication is judged indicated, how to do it, nor how to evaluate the results. We now take up the indications and contraindications, advantages and disadvantages, and some of the clinical and psychodynamic factors which must be considered, in regard to using medicines in psychoanalytic treatment. The Possible Advantages

The value of expanding the scope of psychoanalysis by modifying the process has been noted by for many years and the question, how much can analysis be modified and still be analysis has been hotly debated. For some, the issue has been resolved by maintaining a strict discontinuity between psychoanalysis and other psychotherapy. We consider as analytic, following Alexander (1954), treatments which use the basic psychoanalytic concepts in a way which makes unconscious material conscious and leads to insight. In this regard, Ostow in 1983 put the matter in this way: Can one administer medication within a psychoanalytic treatment regimen without thereby compromising the analytic quality of the patient's treatment? My own view is that the combined treatment satisfies all the criteria for authentic analysis except for the requirement that the analyst play no 'real' role in the patient's life, that is, that his role be restricted to analyzing. It is generally understood, however, that this noninvolvement is a goal, toward which one strives, rather than an actuality. The analyst cannot help playing a 'real' role in the patient's life in many aspects of the treatment; for example, when he requires a firm time commitment (p. 83). A number of workers have stated that a major advantage of adding pharmacotherapy to psychoanalytic therapy is to make the unique benefits of analysis available to a large number for whom it is otherwise impossible. For example, in 1960, Winkelman wrote, "—with psychoanalytic therapy as the primary method of treatment, and with the judicious use of the phenothiazine compounds, the therapist will be able to effectively treat patients that were formerly considered inaccessible (p. 547)." In 1981, Marmor stated, "The issue is no longer whether or not drugs must be totally abjured in dynamic psychotherapy but rather, under what circumstances they can be facilitators of therapy (p. 313)." Patients who are relatively more vulnerable to stress, with weaker egos than the usual good candidate for analysis, can be treated analytically by using medication to prevent serious depression, psychotic decompensation, or destructive acting out. Medication may not only prevent serious dangers to the analysis and to the patient, but also may benefit the analytic process by influencing the intensity of drives (Ostow, 1966) and by improving ego function, as reported by Bellak (1973), (1983). In 1962 Ostow wrote that his teacher, Herman Nunberg, informed him that "Freud spoke of anticipating a time when it would be possible to use chemical substances during a therapeutic analysis in order to direct the analysis into the most fruitful channels (p.2)." It is theoretically possible that the skillful use of drugs can make psychoanalysis more rapid, less painful, and more successful. In the GAP report is the remark, "Presumably when appropriately utilized (psychotropic drugs) should alter response and prepare the organism for optimal psychoanalytic therapy (p. 365)." Indications and Contraindications

Indications for the use of drugs can be thought of in regard to beginning and ending an analytic treatment, and to ameliorating difficulties in the course of the analysis. It is common practice to modify standard technique in order to get started, and it is not uncommon for patients to resist termination, although the analyst knows that the analytic work has been done. Though not a panacea, in some cases medication can help overcome the anxieties involved in both. At any point in the therapy symptoms may develop which do not respond readily to the analytic effort. It goes without saying that not all such situations indicate

adjunctive interventions. Drugs should not be used for trivial or realistic worries (Marmor, 1981). However, if the symptom presents a serious threat to the patient, e.g. depression, decompensation, destructive acting out, or if the treatment has bogged down and no purely analytic effort is effective, the use of drugs should be considered. In extreme cases the decision is not difficult. Before the situation has become extreme, the matter is relative, and the best guide is the injunction, "know your patient." Freud noted that phobic patients need a push to overcome the dysfunction, after the unconscious determinants have been analyzed. Analytic therapy in general does not aim primarily at elimination of symptoms, but at improvement of unconscious conflicts which produce unsatisfactory behavior, including symptoms. Most who use drugs do so only if the symptoms are so severe that they threaten the patient or the analysis, and do not respond to analysis. In short, drugs are not a substitute for but an adjunct to the analytic process. Possible Disadvantages

Many analysts believe that the analytic process will be sabotaged by the use of psychotropic drugs, regardless of whether the treatment is called psychoanalytic. A decrease in emotional pain brought about by medication rather than by working through unconscious conflict may decrease motivation for the analytic work, which would in the long run impede rather than improve the treatment. It would lead to premature termination or to a pseudosuccessful outcome in which the resolution of unconscious conflict is less than optimal. The psychopathology is then likely to recur. For some patients, use of drugs may signify "unsuitable for psychoanalysis, " with negative effects on self-esteem and on transference and/or resistance. For some, the meaning may be an organic illness, for which analysis would be inappropriate. Side effects could support such a view, as well as being undesirable, per se. Symptom substitution is of course a possibility. Marmor has stated: The traditional psychoanalytic assumption that alleviating symptoms results in symptom substitution has not been born out by evidence from hypnosis, behavioral therapies or drug therapies. It is clear that the premise was based on a closed system theory which predicated that suppression of a symptom without resolving the causative underlying conflicts and pressures in the system would result in a substitute symptom in another part of the system. Such a consequence is not inevitable. On the contrary, removal of an ego-dystonic symptom can make the system more accessible to constructive feedbacks that may alter the entire underlying conflictual pattern (1981, p. 313). Another theoretical objection is the possibility that "artificially" removing symptoms which are serving a defensive purpose may precipitate more severe pathology, such as panic states or decompensation, depression, or destructive acting out. It may be that the aforementioned results are theoretically possible but theoretically not inevitable. Whether they occur may depend on how well the analyst understands his patient. A similar logic applies to the issue of transference and countertransference, which may be adversely affected by psychotropic medication. However, as Ostow has pointed out, there is no reason why such transference and countertransference phenomena cannot be analyzed "as readily as the unconscious meanings of all the other contrived and

fortuitous features of the therapeutic contact, such as disposition of the office furniture, —payment of fees, an illness, and so forth (1962, p. 3)." Transference and Countertransference

The meaning to the patient of the use of drugs, the placebo effect, is intimately associated with transference and countertransference. These will inevitably be affected by this maneuver; in what way, and how to interpret, will depend on the individual case, although some generalizations can be made. In 1960, Ostow stated that, feeding, poisoning, manipulation, and impregnation fantasies are common. Another possible reaction is that described by Sarwer-Foner referring to possible harmful transference effects in "male patients with profound doubts about their masculinity who use social 'outgoingness, ' intellectual and motor activity as the major defence against underlying unconscious feminine identifications and passivity strivings. A drug that drastically removes this motor activity is considered threatening, since it can be interpreted as a demasculinizing action (1960, p. 396)." In some, medication which alleviates pain can signify and augment hope and confidence in the doctor (Goldhammer, 1983). It may be unconsciously a welcome gift, or an assault or seduction (hetero- or homosexual). In obsessional patients, issues of control will be aroused. Side effects can be interpreted as signs of impending death or physical damage in those persons pre-occupied with body image or body integrity (Sarwer-Foner, 1960, p. 397). Countertransferences must be recognized. For example the analyst may doubt his psychoanalytic abilities; or he may need unconsciously to avoid emotional interaction, e.g. due to fear of or attraction to the patient. The doctor may prescribe to avoid conflicts about passivity, and to prove his power to himself and his patient; or to win the patient's love and admiration. This is by no means a comprehensive list. In each case the analyst must carefully appraise the probable transference and countertransference effects of giving or not giving a drug. Case Illustration

In this case psychotropic medicines were used periodically in the course of an analytic therapy. The patient was a 24-year-old music student, who was referred by her doctor because of anxiety and depression. She was an attractive, intelligent, talented young woman who was prone to depression, characterized by rumination about her own inferiority, hostility, and unacceptability to others. Anxiety interfered with her ability to perform, sometimes severely. Her tolerance for anxiety was on the low side, and she was subject to attacks of depersonalization, and relatively minor episodes of paranoid thinking. Culturally and intellectually she was committed to a psychoanalytic form of therapy, but her ego strength was less than optimal for analysis. A major feature of the psychodynamic picture was her love, fear, and anger toward her dominating, over-protective, aggressive mother, who did everything for her, which included providing the patient with plenty of things, such as clothes and money. Success in her career or in relationships with men provoked severe anxiety related to her conflicts about surpassing her mother, who had not followed her own career ambitions and had an unhappy marriage with the patient's father; and to her fear of losing her indulged, protected status as her mother's little girl. On several occasions medication was used, when anxiety which resulted from forward steps in her life threatened her compensation and her ability to continue the treatment. She responded well to low doses of thioridazine given for 3–4 week periods. Her ego strength improved, and she became able to deal with her

conflicts without the help of medicine. Her analyst was convinced that without the drug she would not have been able to continue the analytic treatment. Discussion

What are the results of adding pharmacotherapy to psychoanalysis? Unfortunately there is no hard data to provide an unequivocal answer. Several authorities have asserted that there is no evidence that drug use interferes with analytic therapy (GAP Report, 1975). There is also no evidence that it facilitates analysis. The difficulties of studying this matter are well known. The complexity of the factors relating to patients, doctors, and drugs and their interaction creates a large number of uncontrollable variables. However, it is reasonable to speculate that pharmacotherapy may work synergistically with analytic therapy to make the treatment more rapid and more efficient, i.e. more cost effective. Ostow mentioned in 1962 his belief that "ultimately we shall be able to use (drugs) to facilitate the indolent analysis (p. 5)." This would of course, be beneficial to patients; and might help moderate the climate of hostility toward psychoanalysis which currently prevails. Cooper describes a case in which Lithium was used to control bipolar symptoms in the course of a psychoanalysis. He writes, "I cannot think of a significant analytic advantage gained by withholding the medication—there seemed to be no great impediment to his continuing a genuine analysis while taking medication (1985, p. 1401)." The notion that psychoanalytic therapy could be improved by the right amount of the right medicine, given in the right way at the right time cannot be proved or disproved, but it is of heuristic value. Given the great surge of knowledge provided by psycho-pharmacology and neurobiology and the current negative social and economic attitudes toward analysis, further study of this matter may be of great importance for the future of psychoanalysis. Footnotes 1

This paper was presented at the Annual Meeting of the American Academy of Psychoanalysis New Orleans, December 1985. REFERENCES 1

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