The Client–Therapist Relationship
The first dynamic to explore is the complex relationship between the client, the therapist and the drug. Whenever a person is either taking psychotropic medication or participating in therapy, there is usually only one relationship to consider, but when the two are being engaged in at the same time a person has a relationship with both the therapist and the drug. There are important psychodynamic implications in this which have to do with issues of power, dependence, ingratiation and seduction, and these are often overlooked. Kaufman (1994) describes therapists who continue to treat someone in psychotherapy, when they are actively dependent on drugs as over-involved and over-enabling, because of the lack of confrontation. Although this comes from a psychodynamic model, whatever the approach used by the therapist ignoring the drug use would need to be questioned.
It is important to remember that in almost all drug treatment settings, abstinence is usually a goal to be achieved before entering psychotherapy to explore the underlying issues. This is often assumed to be because drugs affect cognitive processing and affect resolution. However, Ghodse (1995) from a viewpoint of the addiction literature, reminds us that the client must use the relationship with the therapist to identify and alter intra-psychic processes using techniques of insight, restructuring of belief systems and cognitive reframing and that drugs impair awareness, concentration and memory. He sees the supportive relationship between patients and therapists becoming a substitute for drug dependency just as drug dependency may be a substitute for aspects of important relationships. Psychotropic drugs and psychotherapy therefore both have important psychodynamic and object-relations functions.
Kohut (1977) from an object relations perspective explored the connection further by suggesting that a person uses a drug to cure the central defect in his or her self, and it becomes a substitute for the self-object which failed him or her. In psychotherapy, the client’s transferences to their drugs (that is the unconscious hopes, desires and fears) are replaced by transference to the therapist, and that transference unlike the one to the drug is used to promote growth. The meaning of client’s transferences to their drugs may be contained in the metaphors which clients use to describe them (Montague, 1988). Words such as ‘pacifier’, ‘consoler’, ‘comforter’ or ‘crutch’, ‘band-aid’, ‘support’, ‘life-line’, ‘security’ clearly indicate how people transfer their hopes and expectations onto drugs.
However drugs do not calm people, rather they sedate them; do not promote autonomy, rather they undermine it; do not make people secure, rather they increase their insecurity. The role of the drug is to act as a transitional object which Winnicott saw as representing the ‘maternal imago or part object breast and the mother’s supportive tension-regulating functions’ (1971: 527). Paradoxically drugs replicate the symbiotic relationship which a person had with their mother’s breast, but unlike the dependence on a therapist do not ‘repair’ the damaged object relationship and so do not promote healing. Levy (1993) reminds therapists that whenever drugs are used during therapy, their meaning and usefulness must be constantly scrutinised to prevent the unconscious avoidance of the task.
The Patient–Doctor Relationship
Hausner (1993), like Levy, assumes the therapist is also the prescriber, and identifies three dynamics in the patient’s transference to the drug: the soothing effect, the placebo effect, and compliance. He goes on to explore the doctor/therapist’s counter-transferences such as identifying with the patient’s anxiety and feeling soothed when prescribing, fear of loss of control if the patient is disturbed, regressed or distressed, or emotionally disengaging from the patient, among others. He comments that substituting medication for oneself may mean that the source of well-being and security may become invested in the medication itself with the potential to undermine the therapeutic relationship.
Nevins (1993) explores what he sees as the psychological meaning of medication but focuses also on the medical counter-transference as three types. His first is that the symptom is an invading enemy to be fought off in a battle, a hypothesis which is unquestioningly accepted literally. An example of this is the unquestioning acceptance of the serotonin deficiency myth, or that chemicals make brain connections work better. The second form of counter-transference is of manipulation of the existing emotional system, such as the hypothesis that depression has occurred due to some blocking mechanism which must be removed. The third type of intervention conveys to the patient that biological mechanisms provide the exclusive explanation of symptoms and treatments, and if the doctor does not know what is wrong, how could the patient possibly know either.
Goldhamer (1993) says that the patient may have fantasies of being poisoned, manipulated, coerced or seduced by the omnipotent parent-doctor, while on the other side is a desire for a magical cure. In this dynamic the patient wants to be loved and understood and the medication is a gift signalling concern and understanding of the patient’s suffering. The gift may provoke ambivalent feelings of being dismissed and the pills are an alternative to being listened to. Goldhamer identifies the need for the doctor to be active so that when the doctor cannot make a diagnosis of a physical condition, he still feels he must do something and so prescribes.
The Doctor–Therapist Relationship
The third range of psychodynamic influences is less frequently considered as having an impact on the interface between psychotherapy and psychopharmacology, and that is the dynamic interplay between the doctor and the therapist. However well the therapist may have set the boundaries to prevent external contamination of the therapeutic relationship, what often goes unnoticed is that most clients taking medication will be returning to their prescriber during the course of therapy for a repeat prescription. At one level, if the prescriber was also the referrer, it may seem courteous to enquire how therapy is progressing and to apply outcomes of symptom reduction or ‘progress through feeling better’ to the evaluation of therapy that is implicit in such a question.
In this situation, it is important to discover early on whether such a referral was a ‘referral up’ to a higher authority or a ‘referral down’ to a lesser one. This process of referral often carries within it unconscious issues of power and control, and whose task it is to determine the outcome as successful or not. A medical practitioner who has referred ‘up’ will be more likely to limit himself to prescribing and to defer to the therapist who is a specialist in psychotherapy. One who has referred ‘down’ will be much more likely to comment, change the prescribing or refer elsewhere without reference to the therapist. They should be given short shrift, but some therapists may adopt a dependent position and defer to the doctor who has no knowledge of the process and would not dream of interfering in any medical specialism!
When two practitioners are sharing the treatment, as is the case with a prescribing medical practitioner and a counselling psychologist, there is potential for competition to see who the patient will prefer. This may lead to dynamics of seduction where both may seek to impress the patient or ingratiation where they may compete to gratify the patient. There is also potential for dynamics such as splitting where the doctor is thought to be treating the symptoms while the therapist is focussed only with life issues. Patients may themselves be drawn into such splitting for example by consulting the doctor about sleep difficulties for which the doctor prescribes a sedative without either being aware of the implications for the therapy. This is made worse when the therapist is excluded from the process or worse still when the therapist does not consider it to be any of their business!
Further underlying dynamics of envy may be present where the psychologist envies the doctor’s power to diagnose and prescribe which may lead to mimicking of medical language and behaviour. The opposite may also occur where the doctor envies the therapist’s time with the patient and the ensuing relationship which may lead to attempts on the part of doctors to counsel the patients themselves. The alternative scenario may occur in medical settings where the dominance of the medical paradigm may mean that the therapist feels unable to challenge the doctor’s authority and becomes compliant.
The Case of Ian – Part 3
After the withdrawal experience, Ian decided to gradually withdraw from the antidepressants and I agreed that he would do it at his own pace. I advised him how to do it safely by making a small reduction to minimise withdrawal symptoms and wait until he had recovered fully before he made another. His experience of an abrupt withdrawal was seen as useful because it helped him to see he was physically as well as psychologically dependent on the drug. However when he went to get his repeat prescription, he was told that the doctors were now going to see him every month to monitor how he was, not trusting that the psychologist knew what she was doing because she had not put a withdrawal schedule in place.
British Medical Association and The Royal Pharmaceutical Society (2015) British National Formulary. London: The Pharmaceutical Press.
Ghodse, H. (1995) Drugs and Addictive Behaviour (2nd edn). Oxford: Blackwell Science.
Goldhamer, P.M. (1993) ‘The challenge of integration’, in M. Schachter (ed.), Psychotherapy and Medication. Northvale, NJ: Jason Aronson.
Hausner, R. (1993) ‘Medication and transitional phenomena’, in M. Schachter (ed.), Psychotherapy and Medication. Northvale, NJ: Jason Aronson.
Hayward, P., Wardle, J. and Higgitt, A. (1989) ‘Benzodiazepine research: Current findings and practical consequences’, British Journal of Clinical Psychology, 28: 307–27.
Kahn, D.A. (1993) ‘Medication consultation and split treatment during psychotherapy’, in M. Schachter (ed.), Psychotherapy and Medication. Northvale, NJ: Jason Aronson.
Kaufman, K. (1994) Psychotherapy of Addictive Persons. New York: Guilford Press.
Kohut, H. (1977) The Analysis of the Self. Connecticut: Int.U.P.
Levy, S.T. (1993) ‘Countertransference aspects in the treatment of schizophrenia’, in M. Schachter (ed.), Psychotherapy and Medication. Northvale, NJ: Jason Aronson.
Montague, M. (1988) ‘The metaphorical nature of drugs and drug taking’, Journal of Drug Issues, 26: 417–24.
Nevins, D.B. (1993) ‘Psychoanalytic perspectives on medication for mentaliIllness’, in M. Schachter (ed.), Psychotherapy and Medication. Northvale, NJ: Jason Aronson.
Winnicott, D.W. (1971) Playing and Reality. London: Routledge.