Front Matter

“Mintz’s Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient turns the problem of treatment resistance on its head—it’s not caused by an inadequate pill; it arises from the complexity of the patient. Master psychopharmacologists are usually master psychotherapists in disguise, and this systematic discussion of the personal, relational, emotional, and symbolic aspects of medication treatment provides both an erudite understanding of these factors and wonderful practical advice about how to handle them.”

—Richard F. Summers, M.D., Clinical Professor of Psychiatry and Senior Residency Advisor, Perelman School of Medicine of the University of Pennsylvania

“David Mintz, an award-winning educator and experienced clinician, creates a road map to help us understand and navigate treatment resistance, inspired by the biopsychosocial model and patient-centered medicine, approaches that optimize care and prevent burnout and moral injury among physicians. This book summarizes evidencebased research addressing the relevance of placebo and nocebo effects in all clinical practice, the meaning of medication, and factors that positively or adversely affect the therapeutic alliance and doctor–patient interactions. Mintz also provides manualized guidelines for the practice of psychopharmacology in challenging clinical situations where multimorbidities, unconscious conflicts, negative attitudes, avoidant attachments, ambivalence, and treatment nonadherence interfere with adequate clinical care. This accessible book will be helpful to all psychiatric trainees and their supervisors, who will invariably face the challenges of treatment resistance in everyday practice.”

—César A. Alfonso, M.D., Clinical Professor of Psychiatry at Columbia University, Editor of Psychodynamic Psychiatry, and Chair of the Section on Psychotherapy of the World Psychiatric Association.

“Dr. David Mintz has done a great service in this excellent book for those who prescribe psychiatric medications: he has provided an important approach to optimizing treatment outcomes by integrating pharmacotherapy with a psychodynamically-informed perspective that enhances therapeutic factors for the patient and the doctor–patient encounter. Through clinical examples and literature review, he has defined what many clinicians have learned through experience but were not taught as part of their psychopharmacology education. The interpersonal context of the prescribing relationship between prescriber and patient may have deep psychodynamic meaning to many patients. Understanding these factors (such as transference to parental figures) can enhance the adherence and effectiveness of treatments. I recommend this book for all psychopharmacology prescribers.”

—Carl Salzman, M.D., Professor of Psychiatry, Harvard Medical School

“David Mintz and colleagues have written an invaluable book for those who prescribe psychotropic medications. With rich theoretical background, vivid case examples, and practical clinical advice, they offer prescribers a way to elicit and address patient concerns that can strengthen the doctor–patient alliance and in this way improve the patient experience with medication use. This is a book for clinicians at all levels of experience and should be assigned reading for psychiatrists in training.”

—Robert J. Waldinger, M.D.

“If you are at an impasse with your patients despite optimal psychopharmacology, in all likelihood the problem is not with the biology but with the powerful psychology of the person and the therapist. Psychodynamic Psychopharmacology provides a road map for overcoming the impasse and achieving positive outcomes. This is a must-read for all psychiatrists in today’s world of managed care and time-limited treatment.”

—Steven S. Sharfstein, M.D., President Emeritus, Sheppard Pratt Health System, and Past President, American Psychiatric Association

“David Mintz’s new book broadens the scope of the current reductionist model in biological psychiatry by introducing prescribers to the relational dimension of psychopharmacology provision, which often spells the difference between successful and failed treatments. Based on his team’s extensive experience with treatment-resistant patients at the Austen Riggs Center, Dr. Mintz’s state-of-the-art manual systematically reviews subjective and intersubjective factors contributing to psychopharmacological treatment outcomes that complement the current biomedical treatment algorithms.

The newly formulated field of psychodynamic psychopharmacology shifts clinical attention from the prevalent symptomatic treatment approach to evidence-based principles of care, which include the person of our patient, the meaning of the treatment, and the relational dimension of the treatment provision. The book chapters systematically review the rationale and evidence for psychodynamic psychopharmacology and address a range of topics, including medication resistance, patient autonomy, the attachment dimension behind transference reenactments in the treatment setting, and the importance of paying attention to the clinician’s countertransference response. Part 3 provides a step-by-step treatment manual with relevant clinical vignettes that would benefit both beginning and seasoned practitioners. I would highly recommend this book as an indispensable resource for every psychiatric residency program and every prescribing clinician.”

— Yakov Shapiro, M.D., Clinical Professor and Psychotherapy Supervisor, Department of Psychiatry, University of Alberta, and Clinical Director, Integrated Psychotherapy/Psychopharmacology Service (IPPS), Edmonton, Canada

“A compelling case for bridging the mind-body divide in psychiatry through a psychodynamic lens. Dr. Mintz outlines a way forward that improves outcomes for patient and practitioner. This is truly patientcentered, affirming care.”

—Kathryn Kieran, PMHNP-BC, Psychiatric Mental Health Nurse Practitioner, McLean Hospital

“Psychodynamic Psychopharmacology is the book and approach we need for appreciating the treatment-resistant patient. Mintz writes with decades of clinical experience and builds upon a century of evidence-based research to understand treatment resistance, and patients experiencing treatment resistance, differently. Mintz teaches us how to seek understanding of the people we meet as patients and allows the unconscious to become conscious: the way forward for psychiatry is to renew the therapeutic alliance.”

—Abraham M. Nussbaum, M.D., MTS, DFAPA, Chief Education Officer, Denver Health, and Associate Professor of Psychiatry, University of Colorado School of Medicine

“Psychodynamic Psychopharmacology is a welcome book with a crucial message. Our patients are more than bundles of molecules and receptors; they come to us with a suitcase full of life experiences that affect their attitudes and their ability to collaborate in treatment of any kind. Illness-driven behavior is not just willful oppositionalism. Read this book to be reminded of the rich, but often torn, fabric of a human life and the need to know all about it. Then get out your prescription pad.”

—John M. Oldham, M.D., Distinguished Emeritus Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine

“Following the dictates of evidence-based prescribing remains problematic in all of medicine. What about the person receiving the treatment, the prescriber, and their relationship? David Mintz beautifully demonstrates the clinical value of integrating each of these and other variables into the treatment process.”

—Bernard D. Beitman, M.D., Visiting Professor, Department of Psychiatry and Behavioral Sciences, University of Virginia, and Founding Director, The Coincidence Project

Preface

Acknowledgments

Part I

What Is Psychodynamic Psychopharmacology?

1 What Is Psychodynamic Psychopharmacology?

2 Why Psychodynamic Psychopharmacology?

3 What Is Psychodynamic About Psychodynamic Psychopharmacology?

Part II

Understanding Pharmacological Treatment Resistance

4 Psychodynamics of Pharmacological Treatment Resistance

5 Treatment Resistance to Medications

6 Treatment Resistance From Medications

7 The Prescriber’s Contribution to Treatment Resistance

Part III

The Manual of Psychodynamic Psychopharmacology

8 Avoid a Mind-Body Split

9 Know Who the Patient Is

10 Attend to Patients’ Ambivalence

11 Cultivate the Pharmacotherapeutic Alliance

12 Attend to Countertherapeutic Uses of Medications

13 Identify, Contain, and Use Countertransference

14 Who Is Psychodynamic Psychopharmacology For? Patient Characteristics

15 Before Initiating Treatment

16 The Engagement Phase

17 The Maintenance Phase

18 Split and Combined Treatments

19 Psychodynamic Psychopharmacology and Integrated Care

Appendixes

1 Psychodynamic Psychopharmacology Self-Assessment Checklist

2 Glossary of Psychodynamic Concepts Relevant to the Practice of Pharmacotherapy

Index

For much of the past century, Western psychiatry was dominated by psychoanalysis. Although Freud himself was optimistic about future biomedical treatments (Freud 1926/1959, 1940[1938]/1964; Simmel 1937), this did not prevent divisions within psychiatry in which somatic treatments were denigrated as addressing patients’ symptoms but failing to achieve a deeper cure. When biomedical psychiatry came into ascendance in the last quarter of the 20th century, psychoanalysis received the same treatment in return. Under the banner of evidence-based medicine, much of the accumulated wisdom of psychoanalysis was disparaged as groundless, especially because psychodynamic psychiatry was late to the game in accumulating an evidence base (McWilliams 2013). Unfortunately, despite our mushrooming understanding of neuroscience and increasing focus on evidence-based treatments, there is little indication that outcomes are substantially improved. Rather, treatment resistance is increasingly recognized as a major issue in psychiatry.

One likely source of the epidemic of psychiatric treatment resistance is the general neglect of psychodynamic and psychosocial factors in psychiatry, beginning with the biomedical tilt in psychiatry at the end of the 20th century (Plakun 2006). The focus on “evidence” in psychiatric research and the psychiatric literature has meant a focus on neuroscientific evidence and a general neglect of psychosocial factors in prescribing. It has also led to a disparagement of viewpoints that draw from the accumulated wisdom of psychoanalysis (Plakun 2012). Consequently, psychosocial evidence bases have, in recent years, been largely neglected by academic psychiatry (Mintz and Flynn 2012), including those that apply to psychopharmacology.

Economic and political factors in medicine have reshaped the doctor–patient relationship in ways that often minimize the impact of potentially mutative psychosocial factors. Models of compensation by third-party payers have favored the development of “15-minute med checks,” in which the focus is more on medications and symptoms and less on the person with the symptoms. The increasing use of symptom checklists to evaluate patients’ response to medications has further promoted an “illness-centered” perspective that fails to capitalize on the potential benefits of a patient-centered perspective. In addition, the introduction of the electronic medical record often has the effect of focusing prescribers on their digital device rather than on their patient, further chipping away at the potential health benefits of a more person-centered doctor–patient relationship. These effects not only occurred at the level of the individual relationship of doctors and patients but also began to tarnish the public perception of psychiatry, so that psychiatrists often began treatments from a position of substantial mistrust. For example, a 2009 Gallup Poll (Jones and Saad 2011) revealed that only 33% of Americans believed psychiatrists adhere to “high” or “very high” ethical standards. Alarmingly, this put them on par with bankers, even after the financial crisis of 2008, and significantly lower than nurses (83%) and medical doctors in general (65%).

Beginning in the early 2000s, the National Institute of Mental Health (NIMH) sought to address the problem of psychiatric treatment resistance by focusing on biological correlates of psychiatric illness while minimizing the focus on psychosocial factors. Although the goal was to identify new targets for biomedical treatment that would yield better outcomes, the effect of this myopic focus was to ignore research that could benefit patients almost immediately (e.g., by optimizing factors in the working relationship) while supporting research that would not likely benefit patients for a generation. As Plakun (2017) noted, “It is our patients who are left to suffer, while clinging to hope that the promised big breakthrough of brain and gene research is just around the corner, when it is still likely decades away” (p. 132). With the development of the Research Domain Criteria focusing on neurobiological mechanisms of psychiatric illness, what little funding was left essentially disappeared for studies examining aspects of the prescribing process, contributions of patient psychology to pharmacological treatment outcomes, or other psychosocial aspects of care directly affecting outcomes (Plakun 2017). Given what we are learning about the role of nonpharmacological factors in shaping pharmacological treatment outcomes, it is perhaps not surprising that, toward the end of his tenure, NIMH Director Thomas Insel concluded that “the unfortunate reality is that current medications help too few people to get better and very few people to get well” (Insel 2009, p. 704).

At the Austen Riggs Center we routinely treat patients who have failed to respond adequately to multiple pharmacological treatments, psychotherapies, and hospitalizations. Austen Riggs is a fully open psychoanalytic hospital with the explicit mission of understanding and treating patients who have been labeled “treatment resistant.” The emphasis is on replacing external controls (e.g., locked doors, privilege systems) with highly engaged therapeutic relationships, a deeply questioning attitude about the meaning of symptoms and symptomatic behaviors, and a focus on patients’ autonomous motivations and capacity to learn from experience (Plakun 2011). Our patients are not the “ideal patients” without comorbidities on whom most pharmacotherapeutic treatments are tested in placebo-controlled trials. Rather, our patients are like everyone else’s patients: both diagnostically and psychologically complicated. On average, our patients carry six diagnoses, almost always with significant character pathology. More than half have histories of early adverse experiences, including physical and sexual trauma, significant losses, neglect, and serious family dysfunction. Approximately one-third of our patients meet criteria for PTSD.

Furthermore, it is quite common for our patients to have disturbed relationships with caregiving and authority that can undermine alliances or promote subtle perversions of the therapeutic task. They are often ambivalent about their illnesses because they have learned to extract covert gratification from the illness or its symptoms. As such, they may work, perhaps unconsciously, to undermine our therapeutic efforts. Frequently, these patients’ early negative experiences with caregiving have been reaffirmed through subsequent engagements with the mental health system, deepening their ambivalence about treatment. Ultimately, these factors complicate, in profound but often covert ways, the healthy and effective use of medications. These are not patients who will typically respond to the algorithm that suggests a particular dosage increase or a change of medication because their resistance originates as much in their psyche as in their disturbed biology.

This book emerges out of two decades of work within the prescribing medical staff at the Austen Riggs Center to grapple with, understand, and address the problem of pharmacological treatment resistance. Our patients have been excellent teachers, revealing the myriad ways they can thwart our therapeutic aspirations, often with little conscious awareness of doing so. They show us, over and over, how we get it wrong and unwittingly become part of the treatment resistance. They have taught us that when treatment resistance is an aspect of the illness, there is usually a good reason for it. We have learned that to address pharmacological treatment resistance, we must understand and respect the patient’s reasons for that resistance.

This book was born of a hope that an empirically testable model integrating an informed understanding of the psychodynamics of pharmacotherapy with evidence of the psychosocial aspects of prescribing would offer a credible antidote to the biological tilt that has developed in psychiatry in recent decades. With a combination of clinical wisdom, scalable techniques, and evidence, we hope to pave a way forward to a model of care that incorporates both biological and psychodynamic perspectives. We hope that the knowledge we have acquired over a century of learning at the Austen Riggs Center will not only benefit the hundred or so patients we treat yearly but also prove useful to prescribers with basic psychotherapeutic skills who work in more resource-limited environments with equally complicated patients.

I acknowledge the contributions of my colleagues at the Austen Riggs Center, especially Barri Belnap, M.D., who sifted with me through everything we had learned at Riggs to distill our learning into the basic principles of psychodynamic psychopharmacology.

I also acknowledge the medical directors at Riggs under whom I served and learned, especially Eric Plakun, M.D., whose editorial eye sharpened my thinking and who supported me in bringing this project to completion.

I also acknowledge all of those who volunteered their time and minds to review and improve initial drafts of this work, in particular Patrick Kelly, who brought his writing skills and layman’s eye to the task and helped me explain myself better; Elizabeth Weinberg, who brought her psychoanalyst’s eye to the task and helped me see where I had not gone far enough; Louis Graff, M.D., and Madeleine Lansky, M.D., who brought the perspective of the clinician in the trenches and helped ensure these ideas were scalable; and Kate Gallagher, Ph.D., who did all of the above.