Adding medications to ongoing psychotherapy: indications and pitfalls

Research suggests that psychotherapy and psychopharmacology together have benefits beyond those when either is used alone. However, since many patients benefit from psychotherapy alone, medications are not always necessary. Medications should be added when patients are unable to deal with their problems in psychotherapy and their symptoms become troublesome. Drastic clinical deterioration, or increased anxiety or acting out that disrupts ongoing psychotherapy, are other indications. Patients' transference color their attitude towards prescribing, or not prescribing, medications and should be dealt with openly. Some patients equate their being given medications with caring, nurturance, or validation of their suffering. Others see it as an imposition of external controls, or a comment on their psychological weakness. Not being given medications benefits patients who think that the therapist "must be interested in me and not just in my symptoms" or that "I can do it myself." Angry, dependent patients may perceive it as withholding of support, prolongation of agony, not being taken seriously, or not being seen as sick enough. Therapists' countertransference may dictate the addition of medications as a distancing or even punishing maneuver. When prescribing, clinicians should choose specific agents with the least side effects, foster "psychopharmacotherapeutic alliances" to enhance compliance, and educate patients regarding common and serious--but not all possible--side effects to decrease complaints. Psychotherapy requires substantial skill to perform competently; psychotherapy and medication requires even greater sensitivity and does not mean that only half the usual attention can be paid to each modality.