The Difficult-to-Treat Psychiatric Patient

Every patient is either easy to treat or difficult to treat, depending on the clinician's perspective. This perspective is the result of the clinician's formulation of the case and the negotiated goals of the treatment. In recent years, psychiatric treatments, pharmacologic and otherwise, have so proliferated that therapeutic impasse may be regarded simply as an opportunity to try the next treatment. Stepping back to reevaluate, reformulate, and renegotiate is less common than it once was. It is difficult to resist the temptation to try a different medication, add a booster, replace this psychotherapy with that one, and so on until finally, perhaps as a result of exhaustion on the part of the clinician, the patient is labeled "treatment refractory."

The Difficult-to-Treat Psychiatric Patient is an accurate reflection of our times. On the one hand, it is a thorough and eminently readable account of the many ways a clinician can treat the patient who is not getting better. On the other hand, it assumes that the difficult-to-treat patient either must be very ill or hasn't yet received the right treatment. This book thus approaches therapeutic impasse with an idea of treatment that is mostly unidirectional and without particular context—the physician applying treatments to the patient, in an office setting.

A few of the book's two dozen contributors have a broader view of treatment, however. In a chapter on eating disorders, Harris and colleagues remind us of the importance of building an alliance, exploring motivation, considering the potential function of psychiatric symptoms, and remembering the uniqueness of the individual. Zanarini and Silk are similarly thorough in a masterly summary of the treatment of borderline personality disorder, and Hembree and associates acknowledge that treatment goals for posttraumatic stress disorder should be negotiated and that all interventions occur in a particular treatment context.

Most of the book's 14 chapters cover a specific disorder and have titles on the model of "The Difficult-to-Treat Patient With Schizophrenia" or "The Difficult-to-Treat Patient With Dissociative Disorder." One chapter presents a review of specialized somatic maneuvers, such as electroconvulsive therapy and vagus nerve stimulation. The chapters all have reference sections, which include material published as recently as 2001. The index is excellent.

The editors' summary chapter discusses clinical wisdom and concludes the book on a hopeful note. Here the art and poetry of psychiatry are offered as what remains after we have run through the available evidence-based treatments. This seems a curious reversal from the book's introduction, which emphasizes biological factors—and indeed, emphasizes the potential harm in psychosocial interventions more than it does their potential benefits or underutilization.

At the start of the book the editors ask why some patients undermine their own treatment—for example, by "cheeking" medication. They list side effects, unconscious fantasies about medication, financial costs, and limited access as possible reasons, but they do not mention the possibility that the patient didn't "own" the treatment to begin with—something that can happen only if the clinician and the patient begin and ride out the journey together. The editors do address this possibility in the concluding chapter, however. Here again, perhaps, the book is an accurate reflection of the field—after celebrating the many wonderful interventions now available to us, is it time we revisit the art and poetry of the dyad, where treatment is driven as much by the patient as it is by the clinician?