The challenge of psychotherapy-pharmacotherapy integration: psychodynamic aspects

Abstracts

A associação da psicofarmacoterapia à psicoterapia é prática freqüente e muitas vezes indispensável. É essencial a compreensão psicodinâmica da relação da dupla paciente/psicoterapeuta, caracterizando o tratamento combinado, e do trio paciente/psicoterapeuta/psicofarmacoterapeuta, no caso da co-terapia, já que, se negada ou pouco compreendida, pode levar ao fracasso do tratamento. Este estudo revisa os aspectos psicodinâmicos e técnicos relacionados à integração dos tratamentos psicoterápicos e psicofarmacológicos, na tentativa de buscar a maneira mais adequada de lidar com as questões transferenciais e contratransferenciais envolvidas nessas modalidades terapêuticas.

Tratamento combinado; co-terapia; transferência; contratransferência

THEORETICAL-CLINICAL COMMUNICATION

The challenge of psychotherapy-pharmacotherapy integration: psychodynamic aspects

Paula Lubianca Saffer

Physician. Specialist in Psychiatry, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. Specialist in Analytical Psychotherapy, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

^{Correspondência}

ABSTRACT

Association of psychotherapy and psychopharmacotherapy is a frequent and often indispensable practice. Understanding the psychodynamics of the patient-psychotherapist relationship, characterizing the combined treatment, and the triad patient-psychotherapist-psychopharmacotherapist, concerning split treatment, is essential, since it can lead to treatment failure if denied or poorly understood. The present study aims at reviewing the psychodynamic and technical aspects of psychopharmacologic and psychotherapeutic treatment integration, as an attempt to find the most adequate way to deal with the transference and countertransference aspects involved in these therapeutic modalities.

Keywords: Combined treatment, split treatment, transference, countertransference.

"No pill can help me deal with the problem of not wanting to take pills.

Likewise, no amount of psychotherapy alone can prevent my manias and depressions.

I need both."¹

Kay Redfield Jamison

Introduction

The association of psychopharmacotherapy and psychotherapy is a frequent clinical and often indispensable practice. According to Steven Rose, a psychopharmacotherapist and psychoanalyst who frequently provided guidance to analysts who indicate drug therapy to their patients, at the time of his formation, "if you had a medicated patient, you wouldn't talk to your supervisor about it, and he wouldn't ask."² Over the past decades, there have been major changes in psychotherapists' and psychoanalysts' attitude toward the concomitant use of drugs during psychotherapy and psychoanalysis. It has become necessary to have a deeper knowledge by mental health professionals about varied therapeutic modalities, since approaching emotional problems through an exclusively biological and psychological view can prevent the patient from having the most adequate treatment. In addition, it is essential to have a psychodynamic understanding of the patient/psychotherapist and patient/psychotherapist/psychopharmacotherapist relationship, since it can lead to treatment success or failure if denied or little understood.

This review of the literature was motivated by the author's clinical experience, who identified difficulties in the management of patients undergoing analytical psychotherapy who were being submitted to psychopharmacological treatment with the same professional and also in those submitted to a treatment modality in which the patient is undergoing psychotherapy with a professional and clinical-psychiatric care with another.

The term "combined treatment" will be used to refer to patients undergoing psychotherapy and psychopharmacotherapy with the same professional, and split treatment to refer to patients undergoing each of those treatments with different professionals, forming a "therapeutic triangle." In some articles, the term split treatment is used to refer to both the treatment in which psychopharmacotherapists and psychotherapists work together and to the treatment in which both professionals work independently.^3-5 Other articles use the term collaborative treatment when both professionals work together, coordinately.⁴ There is a lack of uniformity when using those terms, which reflects the limited knowledge and the polemic character of this issue.

It should be stressed that, despite all these treatment modalities being common in clinical practice, there are few studies on this subject. In addition, they do not receive much attention during the formation of mental health professionals, with a usual prevalence of a supervision divided into psychotherapy and psychopharmacotherapy. Consequently, when this type of treatment is performed, both psychotherapists and psychopharmacotherapists have greater difficulty understanding the psychodynamic aspects.

This study aims at reviewing the psychodynamic and technical aspects related to the integration of psychotherapeutic and psychopharmacological treatments, as an attempt to search for the most adequate way to deal with transference and countertransference issues involved in such therapeutic modalities.

This review of the literature approaches the main psychodynamic models, the characteristics of combined and split treatment, the role of therapists, psychiatrists and drugs in transference and countertransference relationship and the technical aspects of those therapeutic modalities. To do so, articles in the databases MEDLINE and LILACS were selected using the terms split treatment, combined treatment, psychotherapy and pharmacotherapy and psychopharmacotherapy. All articles found were included.

Main psychodynamic models

Freud developed a revolutionary model of the psyche by discovering the unconscious. He defined the unconscious as "an instance or system comprised of repressed contents that escape other instances, pre-conscious and conscious."⁶ Despite being always present in the doctor-patient relationship, during the treatment dynamics and in results obtained unconscious aspects tend to be ignored by the prescribing psychiatrist.⁷

Melanie Klein later approached the early stages of psychic development. In the Kleinian view, at the psychiatric office, adult patients will develop with the psychiatrist and medication the characteristics of their first bond, their first possession: maternal breast. Along with the milk, the baby ingests and introjects objects and psychic instances, bonds and anxieties that psychically nurture it.⁸

According to Melanie Klein, a patient who predominantly works in the schizoparanoid position will experience the medication in a particularly persecutory form, suspecting the drug and the psychiatrist, instead of perceiving the possibility of being helped. He can end up by attacking the bond, as a re-edition of the early conflict against objects experienced as persecutory. Hostile drives may occur against the psychiatrist, experienced as frustrating, and the patient starts missing appointments and does not follow recommendations as to drug dosage. In these cases, the treatment has risks of failure.^7,9 A patient closer to a depressive position could see the medication as a predominantly repairing act and may accept the care provided by the psychiatrist. If it occurs, better prognosis can be expected.⁷

Winnicott, through his concepts of transitional object, transitional phenomenon and sufficiently good mother,¹⁰ makes us regard the psychiatric treatment as a transitional space, which tends to qualify the subject to use his life creatively. To make that happen, a "sufficiently good" psychiatrist must be found, with enough trust and strength to tolerate the patient's ambivalence and destructiveness, and survive to them.⁷ According to Gabbard, patients with a borderline personality disorder can see the medication as a transitional object or a therapist's replacement, which can help them in situations of intense separation anxiety, such as, for example, when the therapist performing the combined treatment is on vacation.¹¹ The psychopharmacotherapist can be seen as an ideal transitional object that supplies the pills, helping the patient tolerate changes in the psychotherapeutic process, in the sense of developing more stable object relations.¹² Even drug packages or medical prescriptions can serve as transitional objects, as an aid to deal with the anxiety of temporarily losing the object-physician. Swallowing the drug can also partly represent the therapist's "internalization" during the psychotherapeutic process.¹³ Some patients only accept taking drugs that they can grind. They do not admit swallowing, for example, capsules, which can be a representation of the transference relationship with the therapist, as well as of defense mechanisms prevalent at that moment. The need of breaking the pill into several pieces can represent the patient's resistance in receiving and enjoying the psychotherapist's interpretations, for example, at a moment in which paranoid anxieties are predominant.

To Bion,¹⁴ human beings are group beings, and the relationship between two people can be considered a group relationship. There are two superposed planes in a group: the first is the plane of conscious intentionality, which Bion calls "work group," whereas the second is ruled by anxieties, defenses and unconscious desires, which the author calls "groups of basic assumptions," which are "pairing," "dependence" and "fight/flight." The group working with the basic assumption of pairing has an unconscious, messianic hope, of something about to happen that will solve group difficulties. That basic assumption can have productive implications when acting on the establishment of a therapeutic alliance, or can represent a difficulty in case it creates, for example, a utopian hope regarding a third element joining the group. The psychiatrist can also be seen as a leader of messianic characteristics, who will save the patient, defending him against his own feelings of hate, destructiveness or despair, according to the basic assumption of pairing. As to the basic assumption of dependence, Fridlenderis & Levy⁷ stress that the group expects someone or something (ideal external object) to provide satisfaction of all its needs and desires. Under that perspective, the patient can expect medicine to supply him all his needs. The psychiatrist should know that he can be occupying this dynamically established space. The group working with the basic assumption of fight/flight has a fantasy that there is an enemy (persecutory external object) and that it is necessary to attack it or escape from it, experiencing the psychiatrist as someone dangerous.

Combined treatment

It is a therapeutic modality in which the professional prescribing also provides psychotherapy.

According to Gabbard, this type of treatment has many advantages, despite split treatment being currently the standard treatment. Combined treatment implicitly encourages the integration between mind and brain, under the patient's and therapist's perspective. At the same session, the therapist should be able to change between a more or less observational and objective approach and another that is more empathetic and intersubjective, but not less scientific.¹⁵ Listening to patients both from the psychopharmacological and psychodynamic perspective is not an easy task. The prescribing therapist should "change the gears" between the psychodynamic and psychopharmacological when assessing and treating patients. The therapist should try to determine whether interpretative, psychopharmacological, or both interventions are appropriate for the current clinical situation.¹⁶

From the psychodynamic perspective, there is the advantage of facilitating the understanding of transference, i.e., the transference that is developed with the drug and the therapist can be assessed by the same professional, reducing the risk of dissociation.^15-17 Drugs can be seen, for example, as a controlling agent or a poisonous toxin. The psychiatrist who is immersed in psychotherapy with patients can have a better notion of transference aspects involved in the relationship with drugs, since many of them reflect a pattern of internal object relations, which are apparent in transference with the therapist. Similarly, the latter can identify the defense mechanisms used by the patient. The same defenses that seem to be used to deal with suffering during treatment can be used to deal with stress related to prescribed drugs.¹⁵

Pharmacological action can change transference, which can modulate the subjective experience of drug action. According to Brockman, in patients with borderline personality disorder, the introduction of drugs should only occur after a psychodynamic and clinical understanding of each case; thus, it can be known whether specific symptoms and adverse effects are better managed through interpretation or change in medication.¹⁸

Combined treatment allows more time to the development of a psychiatrist/patient relationship, and an intense therapeutic alliance can thus be formed. Such alliance itself can be much more important than the impact of a particular therapeutic modality. Trust in the same professional can facilitate an open talk about embarrassing concerns related to the medication. Sexual adverse effects, for example, may not be revealed if the patient meets the prescribing professional once every 6 months. Therefore, combined treatment can represent a therapeutic modality that provides the greatest adherence potential to the pharmacological treatment.¹⁵

In addition, some patients may prefer a condition of privacy and convenience by only dealing with one professional and resist introduction of a new one, which can bring more expenses and an ambiguous character to the treatment. The patient would then be in doubt as to the responsibility of each professional in providing help to given problematic situations.¹⁹ The same concerns regarding the responsibility of each professional and the legal risks of such treatment can make some psychiatrists choose combined treatment.²⁰

On the other hand, both the patient and the therapist can unconsciously have a combination assuring that some affections should be treated using drugs and others through therapy. The idea of medication can become a container of the negative transference the patient feels and the therapist cannot tolerate.²¹ In this case, indication of a drug treatment can be inadequate, perhaps reflecting a performance by the psychotherapist.

Goldman et al. conducted a study to assess use and costs of both therapeutic modalities in depressed patients and concluded that combined treatment, opposite to what was expected, is less expensive than split treatment, especially due to the need of a larger number of sessions. Furthermore, they stress that the psychiatrist, when performing this type of treatment, can start use of medication earlier in relation to split treatment and does not require many sessions to convince the patient of drug efficacy.²²

In our country, a study carried out at the outpatient clinic of Instituto Cyro Martins used a questionnaire developed by the researchers to assess 34 patients undergoing psychotherapy referred for psychopharmacotherapeutic treatment. They all reported feeling satisfied with split treatment, but 55.9% would rather receive care by the same professional. The patients who preferred split treatment felt safer by having opinions from two professionals, whereas those who preferred a single professional stressed the unique therapeutic bond and economic factors and major factors for their choice.²³

Gabbard highlights some specific situations in which combined treatment seems to be more adequate. They are patients with type I bipolar disorder that deny diagnosis and do not cooperate with the treatment plan; patients with severe or unstable medical conditions, when medical knowledge is important for a general management of the treatment; patients with severe borderline personality disorder that use dissociation in such a way to cause treatment suspension; severe suicidal patients that are too impulsive and may need hospitalization; patients with severe eating disorders that have problems dealing with medical complications; patients without a clear diagnosis, in which continuing a bond with the psychiatrist can provide an assessment of indication for drug use as part of the therapeutic plan.¹⁵

Split treatment

It is a therapeutic modality in which a professional performs psychotherapy and another conducts psychopharmacotherapy, in an integrated and collaborative work, or also totally independent.

The therapist's tolerance degree toward the patient's anxiety can represent a problem in treatment guidance, i.e., in adopted conduct when one realizes the patient's suffering is marked by each professional's anxiety. Excess of tolerance to the patient's pain may lead to a sadistic conduct by professionals. Similarly, intolerance to suffering can lead to excessive use of medication, with greater urgency and intensity of pharmacological intervention. The psychotherapist can only deal with transference if able to take care of his own tolerance to the patient's anxiety. When the psychiatrist and the psychotherapist have similar tolerances to pain, the treatment is more likely to be successful, creating better conditions for the patient to elaborate his suffering.¹⁷

When both professionals are involved in the treatment, it is common that the psychiatrist delegate psychodynamic understanding to the therapist. Thus, medication easily becomes dissociated from psychotherapy. This type of compartmentalization often contributes to the patient's tendency of maintaining both processes totally separated, especially regarding patients with borderline personality disorder. Moreover, lack of contact or inadequate communication between professionals can also contribute to treatment fragmentation. Patients and professionals can be confused as to each one's responsibility, for example, when the patient is in crisis, and such doubt may lead to failure in dealing with those situations. When there is an adequate communication between professionals, the opportunity for exchange can be beneficial for all parts involved.¹⁵

On the other hand, Hunt supports the idea that a professional with psychodynamic formation does not have skills to deal with the relationship between the prescribing professional and the patient. He believes that the psychopharmacotherapist can be as collaborative and able to neutralize paranoid fears as himself, who is a psychoanalyst, as long as he can deal with unconscious meanings of taking a given drug, i.e., is skilled in the psychodynamic field.⁹

The role of psychotherapists, psychiatrists and medication in transference relationship Even when dealing with cases in which drugs are considered necessary, the way patients wish to be medicated or not is very important, and should be observed and understood by psychotherapists and psychopharmacotherapists.^17,20,21,24 Taking medications is not an emotionally neutral action, in which there may be both positive and negative transference.⁷ Alicia Powell suggests considering the "patient's medication lifespan," that is, examining subjective aspects of a drug treatment, like what is performed in dreams, i.e., using not only the manifest content, but also transference and countertransference associations.²¹ Independent of the psychotherapeutic stage in which the drug treatment is being indicated, the therapist should explain the reason for referral, allowing the patient to have time to consider this issue and react according to his real concerns. The patient's associations, including dreams, doubts, feelings and memories in the following sessions will express transference reaction and real concerns related to indication of pharmacological treatment.²⁵

Fantasies and expectations about the medication fall on the physician's figure, from whom a fast relief of suffering is expected. Promise of well being brought by psychotropics reactivates childish desires linked to prohibitions imposed by parents. What the "child" cannot obtain from one, it tries to obtain from the other. The psychotherapist, a rigid and demanding "father," does not relieve and insist in a confrontation with life, and the patient tends to seek medicine, "heartwarming mother," which relieves and satisfies him.^7,17 The patient can create a dissociation between professionals, in such a form that the demand for medication tends to grow, and the ability to support anxieties tends to diminish. It is important for the psychiatrist to be alert and deal with this issue together with the psychotherapist. On the other hand, other patients may feel the physician as cold, rigid and assertive, searching in "mother psychotherapy," more ambiguous and reflexive, resources to stand his anxieties, free from psychiatric drugs, even when he still needs them.¹⁷ Combined treatment is a representation of parenthood relationship, and it works well as long as the "parents" interact with mutual respect and adequate communication, thus preventing the "child" to put one "parent" against the other. Otherwise, the "child" has an opportunity to act her desire and have a special and idealized relationship with one of the "parents."²⁶ Therefore, combined treatment demands more psychotherapeutic skills than split treatment.²⁷

The patient may present a positive transference reaction as he understands referral to a psychiatrist as a care, not different from motherly care of a child. Symbolically, medication represents a form of feeding and a powerful present, orally incorporated. In addition, indication of another professional can represent a second person to nurture him. He may feel special and that he is receiving a superior treatment because there are two professionals involved. There is a fantasy that they often talk about the patient, and this is the status of "special child" transferred for this therapeutic family.¹² The patient's doubts concerning dosage, side effects, need of prescription, schedule to take the medication and other questions can show his level of egoical functioning.²¹ Similarly, if the psychopharmacotherapist encourages the patient's participation in the pharmacological treatment, by informing him about side effects, mechanisms of action and other details, the patient's observing ego is more likely to be activated to analyze the effects of medication and for subsequent investigation, which can be facilitated by introduction of a new drug.²⁸

Negative transference reactions can occur when the patient experiences change in relationship as a narcissistic wound, a threat to autonomy or a lack of therapist's interest or competence.^2,7,12 He can have fantasies of being poisoned, seduced and manipulated.^25,29 Referral is perceived as a sign that the patient is not a good candidate to the insight-oriented treatment, concluding that he is sick, only able to obtain some relief through medication. It becomes idealized and omnipotent, able to solve all problems. He may also feel that the therapist has no interest in proving him care, is afraid of him or dislikes him, that being the reason to refer him to another therapist.^12,25 This dynamics can inhibit the patient to discuss such painful feelings.¹²

Patients with given personality structures may feel threatened to lose control and autonomy, regarding the medication as intrusive and potentially dangerous, which puts the self integrity at risk. Such patients tend not to adhere to the drug therapy or to avoid both treatments to maintain internal integrity. There may also be fantasies that the therapist is incompetent or that he did not work enough to help the patient, which explains the need of medication.^2,7,12,20 Therapist's devaluation or pharmacotherapy idealization creates an ideal field through which the patient can use dissociation as a common defense mechanism against internal conflicts.^7,12 For a depressive patient, for example, medication can symbolize a punishment, a confirmation of self-image of hopelessness and debility and reinforcement of masochistic tendency. The patient can also present a passive and expecting conduct, which limits his participation in psychotherapy while waiting for a pharmacological relief.⁴ On the other hand, for manic patients, it may represent the danger of an undesired interruption in search of satisfaction, a threat to his omnipotence.^7,30 In this last case, a psychodynamic approach can reduce disease denial and establish a therapeutic alliance.³⁰

Imhof et al. stress that, after drug assessment with another professional, the patient can criticize the psychopharmacotherapist, and it may mean an unconscious attempt to reestablish his loyalty to the therapist. Furthermore, the impact of different prices for appointments in the patient's perception should not be ignored.²⁰ As to the communication with the psychopharmacotherapist, complaints of side effects can be replacing painful affections, as well as request for new prescriptions can be expressing a desire for something else from the professional.²⁰

It can be seen that patients usually show resistance against changes and suspect anything new, independent of the treatment to which they are being submitted. According to Brockman, this is particularly true in patients with borderline personality disorder.¹⁸ Indication of a drug in the treatment can be refused by the patient and, from the psychodynamic perspective, refusal can be associated with one of many causes of refusing to follow an expected psychotherapeutic behavior.²⁸

Table 1 summarizes advantages and risks found by surveyed authors in both treatment modalities.

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Psychotherapist's and psychopharmacotherapist's countertransference in split treatment

For the psychotherapist, drug therapy success can be experienced as a narcissistic wound, feeling devalued.^11,12 It can also represent a difficulty in accepting slow evolution, which is a characteristic of the psychotherapeutic process, or in tolerating painful affections, indicating drug therapy to treat his own anxiety.²⁵ He may unconsciously experience the patient's state of anxiety and depression as a threat, indicating drug therapy as an attempt to avoid identification with the patient and to protect himself from that suffering.^3,7 In addition, he can refer the patient to create a distance from negative therapeutic reactions and psychotherapy impasses. A common trap for psychotherapists is idealization of pharmacotherapy, attributing all progress, or its lack, to the medication, which devalues the therapist's work, reflecting self-esteem conflicts in the professional.¹² A reflex of such idealization can be seen when a psychotherapist, when referring the patient for psychiatric evaluation, expects that, in a clinical appointment, the psychopharmacotherapist will be able to diagnose and prescribe a drug and often does not understand the request for more appointments to end the evaluation. This sometimes causes mistrust in the psychotherapist and raises concern of losing the patient to the other professional.

The psychotherapist can also refer the patient on his request, to gratify him, even without clinical conviction of its usefulness, which later may cause a feeling of having been manipulated and devalued.¹²

According to Gabbard, "prescribing a drug has a similar probability to any other therapeutic intervention of being contaminated by transference."¹¹ Psychopharmacotherapists, for being more active and directive than psychotherapists, may act authoritatively and omnipotently, establishing a relationship in which the physician knows everything and the patient should be complacent about everything. This can make the professional label the patient as "bad" if he interrupts the treatment, instead of understanding transference reaction. In patients with chronic diseases, professionals who are much identified with their drugs and omnipotence may feel discouraged due to a lack of treatment progress, and resulting anxiety may lead psychopharmacotherapists to overmedicate the patient.¹² Excessive prescription is a common manifestation of a countertransference that can be a reflex of feelings of impotence and anger evoked by the patient.¹¹

As previously mentioned, patients can idealize the psychopharmacotherapist, and the higher risk occurs when the professional narcissistically incorporates such idealization, instead of understanding the nature of this distortion. When this occurs, he can be part of a conspiracy with the patient, devaluing the psychotherapist and blaming him for treatment failure.^12,26 In this case, psychopharmacotherapists can feel damaged for having to share their power with the psychotherapist and may experience the therapeutic triangle as a competition, with the belief that his approach is superior.²⁶ According to Lejderman et al., the problem arises with competition between professionals by considering their theoretical background as unique or superior to the others, characterizing a resistance to therapeutic progress.³¹ Differences in theoretical backgrounds, as well as feelings of competition and envy are common, and patients with borderline personality functioning can use this gap to create more dissociation and frequently an impasse situation during treatment.³

There can also be countertransference anger, a common response to patients' non-adherence. Some psychopharmacotherapists can be conniving with non-adherence, with the aim of showing patients how sick they will be if they do not follow their guidance, whereas others may threaten them with the possibility of discharge in case they interrupt the treatment. According to Gabbard, professionals who have difficulties controlling their anger may not set limits for patients, hoping that, by gratifying their patients' demands, they will be maintaining aggressiveness outside the therapeutic relationship.¹¹

If the psychopharmacotherapist respects and esteems the psychotherapist, he will be more likely to develop a positive countertransference with the referred patient.²⁰ By prescribing a drug, psychiatrists may be expressing their authority or desire to be loved and admired by the patient. For depressed patients, through projective identification, psychiatrists can experience feelings of hopelessness, shame and guilt, affections that can also be awakened by a real frustration, due to therapeutic failure.⁴

Some aspects of countertransference stressed above, despite not being mentioned in reviewed articles, are also applied to combined treatment.

Both professionals, therefore, should be alert to avoid a defensive use of drugs, and should remain alert when indicating, starting, changing and interrupting a given drug, identifying possible countertransference performances.⁷

Technical aspects of split treatment

Despite split treatment being a very common therapeutic modality in our country, there is no consensus as to how this type of treatment should be conducted.

Imhof et al., in an article called "The relationship between the psychotherapist and the prescribing psychiatrist," describe some basic conditions for the proper development of split treatment. Among them, they stress the need professionals have of knowing the experience, qualification, including area of specialty, theoretical formation and type of patients that each one would rather not treat.^19,20 In a dialogue between professionals, there should be issues concerning the psychotherapist's and psychopharmacotherapist's expectations about the moment in which contacts between both professionals should occur and which responsibility in the treatment each one should have.¹⁹ Communication between professionals is always crucial, and the patient should be informed that this will occur.^19,20,26 Hansen-Grant et al. suggest that the first contact between professionals should occur personally or by telephone before the first appointment.³²

Most patients seem to be satisfied in knowing that the professionals communicate with each other, promptly agreeing with their contact. A patient rarely prohibits communication between psychotherapists and psychopharmacotherapists, which usually indicates the presence of a complex transference with one or both or the existence of a very important secret that was reported to only one of them. Refusal of a contact between professionals makes a proper development of split treatment impossible.¹⁹

Communication between professionals should not be restricted to treatment onset; on the contrary, it should be frequent, each professional informing the other about major issues, such as prolonged absences, changes in therapeutic approach and important changes in the patient's clinical status. Moreover, they should know each one's general impression about the patient's response to the treatment.¹⁹ Responsibility of each professional in special situations, such as emergences, should also be well established.³²

When professionals have previous work experience, treatment tends to be more effective, which also occurs if psychologists have a basic knowledge of medications, and psychiatrists have a psychodynamic understanding.²³

Hansen-Grant et al. carried out a study with the aim of assessing the extension and characteristics of the communication between resident psychiatrists and psychotherapists. They observed that, in 53% of cases, the resident was in contact with the psychotherapist, which was started by the psychiatrist in 47.7% of times, and by the psychotherapist in 43.2% of cases of split therapy. In that study, communication between professionals was irregular and not much frequent and, in almost half of cases, the contact occurred only once for a 5-month period.³²

In our country, in a study developed by a group of psychiatrists working at the outpatient clinic of Instituto Cyro Martins, among psychotherapists part of the therapeutic triangle, 81% felt well when requesting psychiatric assessment, complementing and helping the patient; 57% reported some interference in the transference relationship after referral; and 70% of professionals considered communication with the psychiatrist good or excellent. Out of six psychiatrists who answered the questionnaire, all reported discussing the case with the psychotherapist most of the times, and 66.7% communicated personally or by telephone, besides in writing.²³

Psychopharmacotherapists need to recognize the treatment objective and respect the limits of the type of approach to be used; they should avoid deep interpretations; inadequate investigation related to extremely personal areas, such as history of trauma; excessive availability as an empathetic listener, which can encourage expectation of a continuous gratification, lead to an idealization of the professional and interfere with the alliance between patient and psychotherapist. Likewise, even a psychotherapist familiar with drugs should be alert not to advise the patient as to choice of medication, dosage or side effects.¹⁹

On the other hand, Goin claims that it is not possible to perform psychotherapy without using the natural resources of a support therapy, such as clarifications, confrontations and interpretations given as explanations and proper encouragement. Occasionally, after the psychopharmacotherapist is familiar with the patient and have a collaborative relationship with the psychotherapist, a psychodynamic interpretation of resistance and defenses by the former can be useful. The author stresses that the challenge is to achieve therapeutic success that is beneficial for the treatment as a whole and that supports the other professional's work.²⁶

If the patient is talking about side effects of the drug only with the psychotherapist because he is embarrassed, for example, to talk about his sexual dysfunction, he should be encouraged by the professional to take these complaints to the psychopharmacotherapist. Similarly, if the patient is reporting the psychopharmacotherapist issues that are not shared with the psychotherapist, such as problems with illicit drugs or painful transference feelings, the professional should encourage him to talk about these subjects with the psychotherapist. In addition, the professional should make a brief contact by telephone to clarify the objective of referral, thus preventing his colleague to conclude that there might be a communication problem.¹⁹

Steven Roose stresses that split treatment demands the establishment of multiple therapeutic alliances, including between psychopharmacotherapists and psychotherapists, stating that most of the times there is a relationship between professionals from different generations, and that psychopharmacotherapists are usually younger and psychotherapists are older; the latter is often an ex-professor of the former and not rarely a transference figure.² As to a cross-generational relationship between professionals, it is important to be alert to negative and competitive feelings.²⁶ Therefore, if the treatment is not being successful, increasing drug dosage or a transference interpretation may not be the solution. An evaluation of the relationship between professionals may be needed to correct treatment course.² To Goin, younger professionals seem to be more familiar and comfortable with the idea of being part of a work team, but this does not prevent them from developing a countertransference reaction when the patient is referred to another professional.²⁶

Table 2 brings some suggestions for reducing and controlling the risks of split treatment.

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Final considerations

Psychodynamic knowledge is essential for any professional's work, even for those who are dedicated to the practice of psychopharmacological treatment. It is necessary not only to know what to prescribe, but also how to prescribe it, both in combined and in split treatment. Combined treatment has more advantages compared with split treatment, which exposes psychotherapeutic and psychopharmacotherapeutic treatments to more risks and costs, resulting in lower treatment adherence. At the same time, there is the need of developing strategies aiming at reducing the risks of split treatment, which since academic formation should be known by future professionals, as it is a very common practice in our country. Supervision with a professional experienced in combined treatment can be a strategy that, since the beginning, students are encouraged to mind-brain integration and learn how to deal with the complex psychodynamic aspects of these therapeutic modalities.

ACKNOWLEDGMENTS

Special acknowledgement to Prof. Antonio Marques da Rosa for his valuable encouragement and support.

References

Received January 24, 2006.

Accepted June 20, 2007.

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Publication Dates

• Publication in this collection
  13 Dec 2007
• Date of issue
  Aug 2007

History

• Accepted
  20 June 2007
• Received
  24 Jan 2006