Psychotherapeutische Beziehung und Psychopharmakotherapie

Abstract

How to effectively combine psychotherapeutic and psychopharmacological treatment in psychiatry remains an important clinical and scientific issue. In the present paper, a threefold perspective is chosen: 1) The prescription of psychopharmacological drugs affects and changes the therapeutic relationship, including phantasmatic or unconscious factors. A dynamic psychopharmacotherapy is needed that allows to correlate interactional and neuro-biological factors. Any prescription of drugs is situated in an interpersonal context which itself represents a therapeutic agent. The biological and interactional effects can best be combined when properly coordinated. 2) Psychodynamic therapies could be suitable instruments to assess subtle effects of medication on the patient's emotional and cognitive attitudes, below the level of clinical symptomatology. Psychotherapy helps to improve psychopharmacological therapies not only by enhancing compliance. It can be used - on principle - to assess the immediate and long-term effects of drugs in the patient's subjective experience (concerning personal identity, vitality, intentionality, etc.). 3) Once it has been admitted that psychotherapy and psychopharmacology do not contradict but complement each other, an overarching model is necessary that does not only combine both additively, but allows to truly integrate them. In the last couple of years, such models have been promoted mainly on a neuro-biological basis. There are hardly any contemporary models relying on psychopathology and psychodynamic theory. Two new perspectives are suggested: A structural perspective: It does not represent a fully developed integrative model, but allows to describe complex interactions. The basic idea is: if in a given structure one element is changed, this change will influence any other element of the structure. So any therapy has an impact on the patient. What is important here is to be able to consider not only the immediate but also the more remote and indirect effects. A psychodynamic perspective: A clinical theory on the integrative use of psychopharmacology and psychotherapy could be based on the most advanced and empirically based psychodynamic diagnostic instrument, the OPD system. A psychodynamic perspective on medication could be systematised according to its four main axes (coping, relationship patterns, psychic conflicts, organisation of personality structure). The present paper deals with an issue that can be situated within a wider perspective; asking for the links between psychopharmacology and psychotherapy confronts with just one example of the necessity to give a solid theoretical background to the much cited bio-psycho-social model and to take its implementation serious.