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In psychodynamic psychotherapy the therapist strives to be empathic and human

while maintaining a stance of technical neutrality rather than being directive or self-
disclosing. Patients who meet with a therapist, whether psychodynamic or from
another school of therapy, but particularly one operating from a stance of technical
neutrality, will react to the therapist in a way shaped substantially by important past
relationships that have influenced their experience of others. The psychodynamic
therapist strives to accept whatever the patient brings to the sessions, including
distorted perceptions of the therapist based on past relationships, that is, the
transference, while renouncing ambition and desire about how the patient's life
should be or what choices the patient should make. The psychodynamic therapist
knows central experiences from the patient's life history will inevitably be recreated
in the relationship with the therapist. For example, it is likely a patient with a history
of early sexual trauma perpetrated by her uncle will come to experience the therapist
at different times as like the abusive uncle or like her parents who did not know
about and hence failed to stop the abuse. Psychodynamic therapists try to accept the
transferences that are offered, including distasteful negative transferences, without
refusing them or trying to talk the patient out of them because they recognize that
this is the way a patient's problems come to life in the therapeutic relationship.
Because therapists are also human beings, they will have a range of reactions to a
patient. Some of these will be the kind of reactions anyone would have to a patient
acting in that particular way, whereas others may be more uniquely related to the
therapist's character as shaped by his or her life history. For example, a therapist
who was unable to protect his younger sibling from sexual abuse may respond to
the aforementioned patient's transference to him as an abusive uncle with guilt and
a wish to talk the patient out of the transference through reassurance about how
professional and competent he is. This kind of situation, in which a patient's
transference engages the therapist's character and life history in a way that creates
a reciprocal countertransference that the therapist cannot endure, leading to
unwitting action that pushes the transference away, is called an enactment. It is
partly because of the inevitability that therapists will have these kinds of
countertransference responses that it is so valuable for psychodynamic therapists to
undergo psychoanalysis or psychodynamic therapy themselves so that they become
aware of their blind spots, character styles, and countertransference vulnerabilities.
Generalized Anxiety Disorder
For a psychodynamic therapist even a generalized anxiety disorder, in which
(signal) anxiety seems to be ubiquitous and without specific content, would be
approached with curiosity about and a search for whatever pieces of context may
emerge in the course of exploration of a patient's fantasies, fleeting thoughts, and
other clues from the unconscious that may emerge as associations to the affect of
anxiety are followed. Treatment is oriented toward discovering the unconscious
fantasies that illuminate the conflicts associated with anxiety, some of which may
involve fears of separation from loved ones, fears of loss, fears of castration, or
fears of homosexual impulses. The therapist approaches the patient with no
preconceived notion about what these conflicts are, although with a knowledge of
potentially conflictual issues in human development. The following case example
illustrates psychodynamic therapy with a patient with a generalized anxiety
disorder.
B, a 28-year-old man with a history of a generalized anxiety disorder, was a former
adolescent alcohol abuser now involved in Alcoholics Anonymous (AA). Because
of sexual side effects, he was unwilling to take selective serotonin reuptake inhibitor
(SSRI) antidepressants, buspirone (BuSpar) had been ineffective, and gabapentin
(Neurontin) was too sedating. Clonazepam (Klonopin) was effective, but B's
continued participation in AA led to pressures from AA peers to give up
benzodiazepines. Partly because of these pressures, B sought psychodynamic
therapy with a psychiatrist. When the psychiatrist suggested that they begin tapering
clonazepam, B balked, worried that he would become more anxious. The therapist
suggested that it might be useful to bring his anxiety to sessions if their task really
was going to be to learn more about his anxiety.
On a tapering dose of clonazepam B's anxiety increased. He complained that his
male therapist was unempathic, making B suffer with anxiety while the therapist
watched and did nothing. As the treatment unfolded, the therapist learned B had
been especially close to his mother, who, with B, had been the target of criticism
from his often absent, short-tempered, mean-spirited alcoholic father. B's mother
had surgery and chemotherapy for breast cancer when B was 10 years old. It was
shortly after this that B's anxiety symptoms began.
When clonazepam was discontinued there was an outburst of anger at the therapist
for making B suffer so much. The therapist quietly accepted B's anger at him, noting
that he had asked B to endure more anxiety, while leaving him alone and on his
own most of the week. When he suggested that B had found in the therapist his
absent and sadistic father, B thought this made sense, and began to trust the therapist
more. B said he realized that the therapist could endure and understand his anger
without needing to retaliate and that he was sticking to a treatment plan they had
agreed to from the outset. As the alliance deepened, B struggled to put words to his
experience of anxiety. B spoke more of his attachment to his mother and to the way
he would cling to her to support her, pressing himself against her ample bosom,
while his father would rage at them both while drunk, sometimes suggesting that
B's clinging to her was unnatural and inspired by lust.
B reported a dream in one session in which he watched passively, frozen with fear
and guilt and unable to move, as a man murdered and dismembered a naked woman.
B's associations to the dream led to painful memories of his mother's disfiguring
surgery and to his guilt about not having been able to stop his father from angrily
criticizing her both before and after the surgery. B then added there was another
part of the dream he had left out because of shame. He had been sexually aroused
during the dream. B suddenly reported an intrusive thought that upset him—a
thought that the breast cancer had come because he had been unable to protect his
mother—and because he had been aroused by her breasts. B wept for the first time
in the therapy. Over time therapist and patient explored the dream and his intrusive
thoughts, learning that B felt guilty about having caused his mother's illness and
disfiguring surgery not only because he could not protect her from father's rages,
but also because he felt guilty and ashamed about his attraction to his mother's
breasts. He spoke of the way his father's drunken accusation of lust toward his
mother was right. He feared, too, that he would be disfigured because of a disease
or accident, perhaps by castration, for what he had done to his mother. It was not
easy for B to explore these feelings, but as he did his anxiety diminished.
By the end of B's treatment it was evident that what had appeared initially to be a
generalized anxiety disorder without context had actually been the surface
presentation of unconscious psychological
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conflicts around attraction to his mother, guilt about her disfiguring illness, and fear
of his father. These conflicts were revealed in the course of B's therapy, with
resolution of his symptoms.
Panic Disorder
Psychodynamic therapists view panic attacks as a form of signal anxiety triggered
by unconscious, unresolved past conflicts often involving aggression, anger,
separation, and dependency. By following affects, by listening to the patient's
wishes dreams and fantasies, and carefully exploring the patient's life history, as
well as by attending carefully to the triggering context of panic attacks, a
psychodynamic therapist joins the patient in a search for unconscious past conflicts
related to panic. These conflicts are brought into awareness and under the patient's
conscious control by engaging these issues as they arise in the transference
relationship.
Rather than offer a case example of such treatment, a specific form of
psychodynamic therapy will be described that has been studied for panic disorder.
A randomized, controlled trial compared a manualized, twice-weekly, 24-session
therapy called panic-focused psychoanalytic psychotherapy (PFPP) to twice-
weekly, manualized, applied relaxation training and was found to be efficacious in
patients with panic disorder.
PFPP is conducted in three phases. Phase 1 focuses on acute panic. The therapist
works with the patient to uncover unconscious meanings of panic to achieve relief
from panic attacks. PFPP therapists explore the circumstances and feelings
surrounding the onset of panic, the personal meaning the patient assigns to panic
symptoms, and the feelings and mental content of panic attacks. Conflicts involving
separation, autonomy, and suppressed anger frequently are discovered. Within
phase 1 some panic relief is typical, together with a reduction in any associated
agoraphobia.
Phase 2 of PFPP focuses on lessening vulnerability to panic through the
understanding and alteration of core unconscious conflicts. These are addressed as
they arise in the transference and are shown to be ubiquitous in the patient's life.
Responses expected in phase 2 include improved relationships, less conflicted and
anxious experiences of separation, anger, and sexuality, and reduced recurrences of
panic.
Phase 3 of PFPP occurs during the last third of the sessions and focuses on
termination. Conflicts—for example, those about separation or anger about losing
the relationship with the therapist—are re-experienced directly within the
transference. Although there may be a temporary recrudescence of symptoms
during termination, as if the patient were saying, “If you let the treatment end and
abandon me, then all my symptoms will return,” this allows consolidation of gains
in the termination phase through transference work on the central separation, anger,
and autonomy issues associated with panic. Patients generally emerge with a new
ability to manage separation and anger and to function autonomously.
Posttraumatic Stress Disorder
In PTSD a patient has experienced something horrifying that is out of the range of
ordinary human experience. The experience of anxiety during the traumatic event
may approach that of primary anxiety. As noted earlier, although classified as an
anxiety disorder, the clinical presentation of PTSD includes more than anxiety, with
a range of symptoms that carry discoverable meaning.
Freud's early theoretical formulations dealt with the horror of actual but repressed
sexual trauma as the cause of neurosis as he came across patient after patient whose
unfolding unconscious conflicts described experiences of childhood sexual
seduction. Freud later moved away from theoretical formulations based on the
notion of actual seduction of children by adults to formulations based on the notion
that such seductions were wished for and feared fantasies of patients. There is no
simple equation explaining such matters. Some patients may have actually
experienced early seduction, whereas many others struggle with seduction within
the realm of fantasy.
Patients with PTSD have experienced actual sexual or other kinds of trauma.
Psychodynamic therapists do not generally focus on the symptom of anxiety with
these patients. They recognize that patients with PTSD are likely to struggle with
difficulty trusting authority figures, given that past abusers may well have been
authority figures. Psychodynamic therapists negotiate an alliance within which
patients are encouraged to explore the details of their experience of abuse and the
associated affects as they are able to bear them. Psychodynamic therapists also
anticipate that patients with PTSD will likely mobilize in their transference
relationships with therapists aspects of the past abusive relationship. Thus,
psychodynamic therapists understand they may be experienced within the
transference as the abuser, as the helpless victim of abuse in response to the patient's
sadism, or as the passive witness or bystander, like the other parent in an abusive
family who seems to the child like someone who ought to know about and put a
stop to the abuse—unless he or she is sanctioning it. These are often particularly
difficult transferences for clinicians to endure because they are motivated primarily
by the wish to be healers and helpers. Such transferences may evoke powerful
countertransference reactions in the therapist.
The following case illustrates psychodynamic therapy with a patient with PTSD.
M, a 33-year-old woman, was employed by a domineering male boss who singled
her out at work as the target of his anger, publicly humiliating her over the slightest
failures. Her efforts to report him to his superiors were ignored. After a sexual
approach by him that she rebuffed, she became symptomatic, with re-experiencing
phenomena, hyperarousal, and intrusive memories of the abuse by him. She quit
her job, felt unable to follow advice from friends to take legal action against her
boss, and sought outpatient treatment. M was initially treated by a psychiatrist who
prescribed medications for her symptoms and urged her to file a complaint against
her boss. M felt unable to file a complaint because of her unhelpful past experience
with her boss' supervisor, leading to numerous discussions in which the psychiatrist
urged her to do so. When she experienced significant side effects she stopped the
SSRI he had prescribed. Her psychiatrist pressured her to try another medication,
but this one, too, was associated with intolerable side effects. She ended her
treatment, but, when symptoms persisted, began work with a new psychiatrist,
although with considerable trepidation that she would have another bad treatment
experience.
M began psychodynamic therapy with the new psychiatrist. She quickly felt
comfortable with her new psychiatrist when he could help her to see that her
previous treatment experience had unwittingly recreated the experience of abuse by
a domineering authority figure because the well-meaning first psychiatrist had
badgered her about making a formal complaint she did not feel ready to file and
pressured her to take pills associated with intolerable side effects. The alliance was
off to a good start, with a strong positive transference attachment.
Soon, though, M started to miss or come late to sessions. Although still
symptomatic, she came to a session with a decision to end the therapy. Taken aback,
the therapist pressured her to continue the therapy, and M reacted with intense
anxiety and a flashback to the experience of abuse by her boss. Therapist and patient
were able to notice that the abusive relationship had once again been recreated
between them. This time it was the new psychiatrist who was experienced as
domineering and pressuring her to do something she did not want to do but had
trouble resisting. The psychiatrist suggested that they take stock of what was
happening between them that would lead to another repetition of a now-familiar
pattern. The therapist noted that a choice to end the work was hers to make, but he
thought that they were in the midst of important work and wondered whether there
was more to understand about her wish to flee. The patient agreed to continue the
work. With difficulty M revealed that she had been troubled by somatic sensations
she had avoided revealing. For some weeks, about as long as the lateness and missed
sessions had been occurring, she had been having strange and sometimes arousing
genital sensations before and during the sessions. She realized with fear and disgust
that she was feeling attracted to him. In further work it became apparent that
becoming sexual with the therapist was not just something she feared, but also
something she guiltily desired. This led to the patient's revelation of an experience
of date rape by an 18-year-old man when she was 14 years old. Although she had
never really forgotten this incident, it was an “unthought known” in her mind,
something she tried not to think about or tried to make unimportant on the rare
occasions when she did acknowledge it to herself.
As this experience of date rape was explored, it emerged that it was not her first
terrifying experience of being forced to do something that she did not fully want to
do by a domineering man. Her father, too, had been frightening when angry,
although usually loving and never sexually inappropriate. As the exploration
continued, M reported discomfort and a feeling that bringing the memory of the
date rape to the therapy felt like being invited to reveal more than she wanted to.
When she complained that the therapist was pressing her to reveal things that made
her uncomfortable, he realized that this was true and that he was again in an
enactment. He apologized for pressuring her, noting he could see he was pressing
her to keep going beyond the point that felt safe in a way that replicated her
traumatic experiences with men. After the apology M was able to reveal her
realization that she was also encouraging him to press her to reveal more. She then
guiltily revealed that the experience of date rape, as terrifying as it genuinely was,
was also associated with an intense orgasm. She wondered what was wrong with
her that this was the case. Over the remainder of the therapy much work was done
about her conflicted and guilty sexuality as her PTSD symptoms subsided, and she
decided on her own to file a complaint against her former boss.
M presented with symptoms of PTSD in response to a recent experience at work
that had important connections with earlier instance of sexual abuse and with her
relationship with her father. The first abuse experience was recreated in her work
life and then, repeatedly, in enactments in therapeutic relationships, until the
underlying fears and wishes were brought to consciousness, explored in the
transference, and worked through over the course of several repetitions. Both
therapist and patient recognized their own roles in recreating the problem.
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Specific Phobia and Other Phobic Disorders
In phobic disorders the affect of signal anxiety is evoked in response to a particular
stimulus. Avoiding the stimulus often eliminates anxiety, but the price paid to be
free of anxiety may be high, seriously compromising social or role functioning.
Psychodynamic therapists approach phobias by exploring the meaning of the
phobic stimulus to the individual in terms of its unconscious meaning as revealed
by associated feelings, memories, dreams, and fantasies. As these are recreated
within the transference relationship there is an opportunity to engage and interpret
resistances and defenses and to work through the issues and conflicts that emerge.
D, a woman in her 40s, had a long history of a specific phobia about driving over
bridges. She first sought treatment when the phobia exacerbated after the sudden
death of her father, making it difficult to commute to work. D's psychodynamic
therapist worked with her to explore and elaborate the details of her phobia, which
was most anxiety producing when it involved bridges with open sides. Associated
with her anxiety was a sense of dread that she would be swept off the side of the
bridge and fall to her death. She could sometimes force herself to cross them, but
there was a horrible knot in the pit of her stomach the entire way across. Having
someone else in the car helped, but only if they agreed to hold her hand while they
drove across.
The therapist also explored D's relationship with her father, given that his death
seemed to have made the phobia worse. D had been very attached to her father, who
seemed more loving and tender toward her than her aloof mother, but, despite his
warmth, her father was often absent. She had not really grieved his death because
of how much her widowed mother needed D to be her solid support.
At one point in a session, when the therapist asked if she had ever previously felt
the kind of knot in the pit of her stomach that was associated with driving over
bridges, D suddenly recalled a memory from a family vacation when she was 13
years old. With her father she had climbed a steep and exposed fire tower. Going
up had been exciting and the view was exhilarating, but when she tried to climb
down D became terrified by the steep pitch and small steps and felt the same
horrible knot in the pit of her stomach that was now associated with crossing
bridges. D asked her father to hold her hand during the descent, but he declined,
saying she had to make it down on her own, then turned away from her and
descended. He did not stop when she called him. Alone at the top, D was terrified,
but she had no choice but to make her way down alone. She sat on the steps and
slid down one at a time, all the while terrified she would slip off a step and fall to
the bottom, where her family was gathered waiting and laughing at her timidity.
When she got down her father laughingly commented that he knew she could get
down on her own one way or another.
In the next phase of her therapy driving over bridges became easier while
therapeutic work was being done around the earlier experience at the tower that
caused the same knot in her stomach, the same fear of being swept into space and
falling, and the same sense of shame and humiliation for being laughed at for not
being able to do what others could do easily. These feelings were also associated
with a painful sense of abandonment and ridicule from the father she needed and
loved. She had never spoken to him again about the incident. A great deal emerged
in the therapy about her longing for her father and the way his absence in her life
and tendency to ridicule and tease her had hurt her. She felt that there was something
about her that made her less interesting to him than her older brother, with whom
he spent more time. As these feelings emerged, with them came intense grief over
father's death. Now she would never have him with her again, and the hope of
understanding why he had acted so uncaringly on the tower, or that he would
apologize for it, was gone forever. As she grieved in the sessions and in the rest of
her life, D's bridge phobia diminished further.
In the termination phase of their work, D began to have more trouble commuting
over bridges again. This led to an opportunity to address the ways in which the loss
of her therapist was presenting D with another abandonment. Termination was
another occasion she would feel all alone and in danger of being swept into the
void. During the termination phase abandonment issues were explored in the
transference. D's symptoms subsided again by the time of termination. At 2-year
follow-up she was free of the bridge phobia.
D's phobia about bridges was revealed to be a translation of a humiliating memory
of an abandonment by her beloved but belittling father, whose death could not be
fully grieved until she gained access to issues in their relationship that had been
frozen in time in her symptom. In this instance the “anxiety disorder,” that is, D's
phobia, and the signal anxiety associated with driving over bridges turned out to be
covering over issues having more to do with grief and mourning than with anxiety.
Obsessive-Compulsive Disorder
Although OCD is an anxiety disorder in the nosology of general psychiatry, from a
psychoanalytic perspective it represents a developmental fixation around issues
related to the anal phase of development and to toilet training. It is a disorder in
which signal anxiety may be present (as when intrusive obsessions are associated
with anxiety), although many patients with OCD ward off anxiety through
compulsive rituals,
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expending huge amounts of energy through their symptoms to control and contain
anxiety about unacceptable impulses.
Obsessive-compulsive disorder is thought to have its origins in an individual's
earliest struggles to achieve a capacity for autonomous functioning in the period of
toilet training. During this period a child is encouraged, lovingly and otherwise, to
give up a form of dependence on parents and to take charge of his or her own
excretory functions. This sets into motion the potential for a complicated struggle
about control in the form of complying with or defying parental expectations.
Although defiance is a way of refusing to grow up, whereas complying and
accepting change, although a kind of defeat, is ultimately in the service of achieving
greater autonomy. A psychodynamic therapist approaches a patient with OCD by
searching for the hidden meaning encoded in the obsessions and compulsions, with
anxiety often emerging as the meaning of the symptoms becomes clear.
P, a passive, emotionally vacant, exceedingly polite and quiet man in his 30s, had
obsessive-compulsive disorder and sought psychodynamic psychotherapy because
he was having difficulty functioning at work or in relationships. P had counting
rituals and a compulsion to keep checking that there were no sharp knives left with
their blades exposed and no shoes not properly hung on shoetrees or aligned in
closets. In sessions he often spoke endlessly about seemingly empty details of his
work life. The therapist became drowsy at one point as he listened to P, who noticed
this and, with uncharacteristic affect in his voice, asked, “Doctor, excuse me, but
are you listening?” To this the therapist replied, “No, I guess not. Are you?” P
apologized for having been boring.
This incident led to a direct discussion between them about the way P's obsessive,
circumstantial, and emotionally empty recounting of details was a form of
resistance and one in which his therapist had joined him by becoming drowsy in the
session. Were they going to do the work of therapy together or not?
In subsequent sessions P made efforts to speak more about the origin of his
symptoms, which began with a ritual of kissing his parents each goodnight nine
times lest he be unable to sleep. On one occasion, while explaining this, P made a
slip of speech about having to kiss his father nine times, instead substituting the
word “kick” for “kiss.” When he heard this, the therapist asked P if he had noticed
the slip. P insisted he could not have made such a mistake, escalated his protests
about this for a minute or two as he became sadder, then burst into sobs. While
weeping P accused the therapist of pretending there had been a slip of speech to
make him look bad, and then, with an outburst of anger, recalled the hurt and injury
he had felt when the therapist had become drowsy in the session.
Surprised at the intensity of his feelings, P recalled when his need to kiss his parents
goodnight in a ritualized way had begun. It was after he had gotten a new puppy.
His controlling and intrusive father had kicked P's beloved new puppy after the
latter had a series of toileting accidents in the house. P wept as he recalled his
revulsion and rage at his father and the way he had later comforted his dog when
alone. P recalled having repeatedly unfolded and refolded the blade of his jack knife
to show his dog his weapon and swore to his dog that he would use it on father if
the latter ever tried to hurt him again. Soon after the kicking incident P's father
decided he had had enough of this messy puppy and sent the dog away while P was
at school. P was bereft for a while, but soon settled into an affectless, timid, and
passive way of being.
P responded to what he had learned about his compulsions by actively trying to
suppress them and became more anxious. As his anxiety was explored, memories
emerged of P's earlier struggle with his parents around toileting before the puppy
came into his life, when he had received regular enemas from his father to control
the frequency of bowel movements. Despite loving his father, P was also enraged
at him for taking his dog away without a chance to say goodbye and for the intrusive
and terrifying experience of the enemas, while he was also furious at his mother for
not stopping father. P also felt humiliated that he had experienced this kind of
intrusion into his body and that he had let his dog be given away by his father after
swearing that he would protect the puppy from his father.
The meaning of P's specific rituals about knives and shoes became apparent in the
course of his therapy as a result of his reaction to his therapist's lapse in becoming
drowsy and a slip of speech that revealed aggression hidden beneath passivity and
compliance. P needed to be sure that no knife blades were exposed because such
blades represented the threat of a terrifying assault on his father or an equally
terrifying failure to protect the puppy that he loved but lost. Similarly, P's
compulsive need to put shoes properly and safely on shoetrees was linked to an
effort to put away the memory of and prevent any recurrence of his beloved puppy
being kicked and injured by a shod foot. After these were clarified and P tried to
control his rituals, signal anxiety emerged, and with it the recovery of memories of
an earlier struggle with his parents about intrusive control of his toileting behavior.
Psychodynamic Psychopharmacology in the Treatment of Anxiety Disorders
In addition to psychodynamic therapy as a treatment for anxiety disorders, a
psychodynamic perspective informs psychopharmacologic treatment for anxiety
disorders, as well as for other disorders. If anxiety is a signal, then a psychodynamic
psychiatrist will wonder what the advantage is of medicating it away rather than
bringing the relevant conflicts into consciousness. The psychodynamic
psychopharmacologist will hold this point of view in mind while formulating a
treatment plan and selecting a drug and dosages.
Psychodynamic psychiatrists attend carefully to the meaning of medications when
they treat patients with anxiety and other disorders, recognizing that the way in
which medications are prescribed and their intended and unintended effects will
have important meaning for patients whether or not there is concurrent therapy and
whether or not any such therapy is provided by the psychodynamic psychiatrist or
another clinician. One example of this was part of the case of B, who presented with
a generalized anxiety disorder. His therapist's stance about reducing
benzodiazepines so that B could bring his anxiety to the sessions led to the
emergence of feelings that opened up an understanding of hidden issues in B's life.
The meaning of medications to a patient and to a therapist may not be the same.
Psychiatrists who practice psychodynamic psychopharmacology recognize that the
wish to help patients with medications may not be perceived simply as help by a
patient. The prescription of an SSRI to reduce anxiety may be perceived by a patient
who develops sexual side effects as an intentional interference with his or her sexual
functioning. Prescription of medications, then, becomes an area in which
psychiatrists may step into countertransference enactments. This was illustrated in
the case of M, the woman with PTSD, whose first psychiatrist's well-intended
efforts to prescribe for her PTSD symptoms was experienced by her as a replication
of her abuse by an intrusive and controlling boss. Her new psychiatrist's recognition
of this meaning helped to strengthen their alliance and created a precedent for
examining and learning from other enactments as her treatment unfolded.
There is evidence of the power of meaning effects of medication. One study
suggests a that patient's readiness to change is more predictive of response of panic
disorder to a benzodiazepine than whether the patient is receiving active drug or a
placebo. Similarly, there is evidence the doctor–patient alliance may be more
important for psychopharmacologic treatment outcome than medication. A large,
multicenter, National Institutes of Mental Health–supported study found that in
psychopharmacologic treatment, patients had the greatest
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reduction in symptoms when a strong alliance was paired with an active drug.
Patients receiving placebo who had good alliances with their doctors had greater
symptom reduction than patients with poor therapeutic alliances receiving the
active drug. These studies support a basic premise of psychodynamic
psychopharmacology that symbolic aspects of medications, that is, their meaning,
are as potent as the biologically active ingredients and should not be neglected in
the care of patients.
Suggested Cross-References
The reader is referred to Section 6.1 on classic psychoanalysis and Section 30.1 on
psychoanalysis and psychoanalytic psychotherapy.

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