Meds/ Psychotherapy Debate
June 3. 2006

I would like to respond to the recent discussions on our listserve in regard to the splitting in our field between meds and no-meds, brain and mind, psychiatric and psychosocial, etc. In Madrid, I am going to propose a translational-integrative model of severe mental illness and propose a psychopharmacological approach which is logically coherent, scientifically-based and directly an outgrowth of the proposed etiology, one that centers on neuro-protective processes. There is too much to say about it and it is not appropriate for a posting right now. But the proposed model calls into question our primary psychopharmacological practices and theorizing and points to new directions in psychopharmacological research. The psychosocial interventions, including psychodynamic psychotherapy, in this model, hold a primary and valued place.

I think, to borrow from the valuable work of Martin Buber (for a good discussion building on his "I and Thou," I would recommend his Between Man and Man which today should read "Between Person and Person"). It is important to be aware that the nature of the relationship between the therapeutic partners is crucial in our field (as it is in other branches of the helping professions). 'Dispensing' psychotherapy or medications in an I-It context is equally hurtful. I believe that medications can be administered from an "I-Thou" stance, approaching what psychotherapy entails.

In Buber's framework, an "I-Thou" relation entails openness, directness, mutuality and presence. "I-It" relations entails using or reacting to other persons without allowing them to exist in their uniqueness for oneself. Dialogue, according to Buber, calls for experiencing the other side of the relationship, an act of inclusion not exclusion. It is this inclusion which makes possible for us to meet and know the other in her or his concrete uniqueness and not just as a content of one's experience. Dialogue entails really listening-attaining the "between." Buber remarked that "all real living is meeting. Dialogue is not the mere exchange of words-genuine dialogue can take place in silence (yesterday, one of my patients diagnosed with paranoid schizophrenia told me that he gets more from our sessions when we are silent together than when we speak, argue, etc. He feels that I can then stand his presence more).

Much of our dialogue really is a monlogue. Dialogue is one's whole response of one's being to the otherness of the other, to the mystery, the ineffable, in the other. So much of our discussion is grounded on certainty, projective processes in which we either demonize or idealize others as in psychotic process. In fact, it often reminds me of the everyday delusions we all share and are socially sanctioned. The otherness of the other is comprehended only when I open myself up to her or him in the present moment (I am paying more attention to the present and our capacity to encounter another in the present thanks to an ongoing discussion with Pamela Saunders, Stefanie Glennon and reading Dan Stern and Tibetan Buddhism). For Buber the true teacher (Buber is a great inspiration for me in my graduate teaching and for my teaching at various psychoanalytic institutes) is not the one who pours information into the student's head (I am guilty of this stance. It is a seductive stance to take and I find myself having to continuously resist this seduction) as through a funnel. Rather, it is the one who fosters genuine mutual contact and mutual trust, who experiences the other side of the relationship, and who can help her or his students realize what it is to be a human being in this world. I would add that the good teacher allows for heated disagreement within the context of mutual respect, and importantly, helps the student formulate her or his own insightful questions, challenging the orthodoxy when the latter fails to acknowledge or pay attention to emergent facts which can not be incorporated into current models.

Brian Koehler