April 2016
Combined Psychotherapy and Pharmacotherapy

General Principles: 

Opening phase or engaging patient in treatment 

  • Physician forms a therapeutic alliance

  • Engage patient in treatment process

  • Formulate Discrete Psychotherapy and Pharmacotherapy Goals

  • Physician helps patient align himself with goals and become an active participant in therapeutic process. 

Middle Phase 

  • Explore and work through patient’s negative or unrealistic attitudes towards pharmacotherapy

  • Work on goals

  • Explore transference and work through transference resistances 

Termination phase 

  • Solidify gains

  • Explore separation issues 

Therapeutic Alliance: 

Know yourself,

  • Be aware of countertransference

  • Be aware of your attitudes towards psychotherapy and pharmacotherapy

  • Avoid using medications to distance self from patients 

Physician’s attitude and behavior, 

  • Consistent

  • Present

  • Caring

  • Objective

  • Knowledgeable

Know your patient, 

  • Obtain complete history

  • Psychodynamic formulation

    • Pre morbid adjustment

      • Object relations

      • Strengths

      • Highest level of adjustment

      • Vulnerabilities

      • Characteristic defense mechanisms

    • Precipitating factors

    • Understand meaning of illness and symptoms

    • Formulate predictions about how patient will react to.

      • Psychotherapy

      • Medications 


Formulating Treatment Goals: 

  • Use target symptom approach to pharmacotherapy

  • Select target symptoms that bear most symbolic meaning and are seen by patient as being central to their illness 

Helping patient take an active role in treatment 

  • Maintain the attitude that patient is capable of actively participating in treatment

  • Set realistic expectations

  • Set boundaries

  • Safeguard patient’s independence

  • Explore initial attitudes towards psychotherapy and pharmacotherapy 

Patient reaction to pharmacotherapy 

  • Some patients whose symptoms respond to medications improve and sustain this improvement.

  • Other patient improves initially and are able to sustain improvement only it they are validated by significant others.

  • Patient may accept side effects as the cost of improvement.

  • Patient may view side effect as a hostile or brutal attack leading to paradoxical response to the medication.

The Psychotic Patient 

  • Antipsychotic medications help control symptoms

  • These symptoms express for this particular patient his inability to face himself and his most feared impulses, the core inner conflict that can not be solved without regression into psychosis

  • The control of this symptom is seen by patient as beneficial

  • Patient seeks to validate improvement which helps interpret changes as “good”. Psychotherapy at this level is essential in helping patient deal with interpersonal relations.

  • Patient attempts to invest in outside objects.

  • Control of symptoms lays foundation for ego growth and the establishment of neurotic and normal defenses.

  • Poor therapeutic response may be related to patients’ interpretation of medication effects as threatening, as an assault by physician or family to manipulate or control or lack of validation 

The Depressed Patient 

  • Patient and physician attitudes towards psychotherapy and pharmacotherapy may influence outcome.

  • Some depressed patients may see use of medication as failure or weakness.

  • Conversely others may overvalue medications and perceive therapy as a waste of time.

  • Select target symptoms for pharmacotherapy

  • Establish psychotherapy goals

  • Formulate psychotherapy goals passed on your therapeutic frame of reference (psychodynamic, cognitive-behavioral interpersonal )

  • Be aware of the severity of patient’s symptoms early in treatment and be careful not to place demands that patient can not meet since that may lead to further deterioration of self esteem.

  • Monitor progress and increase patient expectations as appropriate

  • Explore symbolic meaning of illness symptoms medications.

  • Explore how patient’s improvement effects interpersonal relationships and how these support or hinder recovery


Daniel Nahum MD

Supported by Unrestricted Educational Grant by SUN Pharma SUN LOGO

>> Please click here the pdf version of this document




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