Page numbers printed in boldface type refer to tables and figures.
Abstinence syndrome,198
Acting out, description of,259
Affectcompetence,144
loss of,81
Alexithymia, description of,259
Alliance.
See Therapeutic alliance; Triadic alliance
Ambivalence, description of,259
Antidepressants,209, 230
response rates,20
Anxiety,83–84, 86–87.
See also Psychotic anxiety, description of
treatment-resistant,233
As-if personality, description of,259–260
Attachment styles,39–40,
40definition of,17–18
description of,260
dismissive,42
Austen Riggs Center,x–xi
Authorityconcept of,42–44
therapeutic alliance and,43
Autonomy, description of,260
Balint, Enid,25–26, 58
Balint, Michael,25–26, 58, 242, 266
Beck, Aaron,260
Beecher, Henry Ward,61
Behavior“bad,”79
symbolic meaning of,161–162
Benzodiazepine,133, 233
Biomedical interventions, emphasis on,5–6
Biopsychosocial, description of,260
Bipolar disorder,78
Body ego, description of,260
Bowlby, John,260
Bullying,80
Burnout,243
Caregivingearly models of,191
environment of,104–105
negative expectations of,72
patient experiences with,40–41, 49
Cartesian dualism, description of,260–261
Case vignettesof ambivalence about illness,67–68
of ambivalence about prescribers,205–208
of ambivalence about relinquishing symptoms,209, 210
of ambivalence about treaters,70–72
of biomedically mediated harm,221
of biopsychosocial interplay in response to treatment,102–103
of combined, integrated treatment,229–231
of communication between treaters,233
of countertherapeutic use of medication,142–143, 144–145
of depression,66, 71–72, 102–103
of developmental history,116
of family dynamics and treatment resistance from medications,86–87
of groundwork for good outcomes,194–195
of managing countertransference,244–246
of meaning of treatment,197–199
of medicine and masochism,83–85
of mind-body split,105
of mood symptoms with ambivalence about getting better,125
of the patient’s agency,133–134
of patient’s ambivalence about illness,124
of a person-centered focus,166–168
of pharmacotherapeutic alliance,196–197
of prescriber’s contribution to treatment resistance,93–94
of PTSD,68
of trauma,63–64
of treatment resistance,57
to medications,62–66
of treatment resistance from medications,77–78
of triadic treatment,232
when medications substitute for ego function,219–220
when replacing healthy capacities,80, 81
Chronification, description of,261
Clinical Antipsychotic Trials in Intervention Effectiveness (CATIE),14
Clonazepam,82, 139
Clozapine,210
Cluster B personality pathology,268
Coleridge, Samuel Taylor,159
Collaborative care model, description of,238–240,
239Compliance, versus alliance,136–137.
See also Pharmacotherapeutic alliance
Compromise formation, description of,261
Concordant countertransference, description of,261
Conflict, description of,261–262
Cooper, Arnold,91
Countertransference.
See also Prescribers; Transference
from an impediment to a tool,149
consultation with colleagues,149
description of,262
managing,243–246
overview,147–148
recognition of,148–149
role of psychodynamic formulation and,150
as a tool for understanding patients and developing empathy,151
Culturedepression in Chinese populations,114
influences on illness and treatment seeking,113–114
“Decade of the brain,”237
Defeating process, description of,262
Defense, description of,262
Defense mechanisms,38–39
medications and,77–79
Denial, description of,262
Depression,81–82, 83–84, 86–87, 93–94
antidepressant outcomes,91
case vignettes of,66, 71–72, 102–103
in Chinese populations,114
treatment algorithm for treatment-resistant depression,12–13
13Descartes,260–261
Deutsch, Helen,259
Developmental arrest,87
Disability, with mental illness,116
Dissociation, description of,263
Doctor–patient relationship,4, 7.
See also Patients; Prescriber; Therapeutic alliance; Treaters
alliance,118
communication,25
quality of,23–25
Dynamic unconscious,38
Dysphoria,198
Egobody ego, description of,260
description of,263
medications as substitute for functions of,218–220
Ego-dystonic, description of,263
Ego functions, description of,263
Empathydevelopment of,151
psychological-mindedness and,163
Enactment, description of,263
Erikson, Erik,265
“False-self,” description of,260, 263
Familyambivalence about patient’s illness,125–126
example questions to assess family contributions,86history of mental illness,183
treatment resistance from medications and,85–87
“15-minute med checks,”ix, 92
Freud, Anna,202
Freud, Sigmund,ix, 3, 6, 11, 35–36, 165, 219
GABAergic anticonvulsants,78
Gabapentin,133, 216
Glover, Edward,264
Hippocrates,89
Hope, establishing,134
Hostile dependency,204
description of,264
Identity, adverse effects on,212–213
Illnessambivalence about,66–69, 72
biological theory of,22–23
patients’ ambivalence about,123–124
treatment-resistant medical conditions and psychodynamic psychopharmacology,156–157
“Illness-centered” perspective,ix–x
Immature defenses, description of,264
Implicit social cognitions,38
Inexact interpretation, description of,264
Insel, Thomas,x, 12
Integrated care.
See also Psychodynamic psychopharmacology
description of,238
Interpretation, description of,264
Intrapsychic, description of,264
Jaspers, Karl,11
Jung, Carl,225
Kafka, Franz,129
Kipling, Rudyard,35
Klonopin,232
Krystal, Henry,259
Lamotrigine,78
Lithium,94
Locus of control, description of,18–19, 264–265
Maimonides,111
Main, Tom,147, 237
Manic defense, description of,265
Masochism, medicine and,83–85
McDougall, Joyce,259
Medicalizationadverse effects of biomedical explanations,90–91, 95
stigma,90–91
Medication.
Seealso Treatment resistance
alternatives to discontinuation,145
ambivalence about,122–123
basic psychodynamics impacting responsiveness to,37–42,
37,
40biological effects of,75–76
common dynamics of treatment resistance from medications,76,
76countertherapeutic uses ofaddressing,141–145
framing treatment agreement around health rather than absence of symptoms,141–143
how problems in the alliance may contribute to misuse of medications,143
setting limits,144–145
supporting healthy strategies to replace countertherapeutic uses of medications,144
developmental deficits and,145
identification of uses of pharmacotherapy,140–141,
141prescriber’s recognition of,140
recognition of the signs,140–141,
141overview,139–140
as crutch,79–80
defense mechanisms and,77–79
developing a plan,186, 188–190
as emotional function,41
exploring patients’ ambivalence to medication,122–123
as fetish,220
how to prescribe,48
interference with functioning,87
meaning of,16
negative identity and,76–77
nonpharmacological characteristics of,16–17
outcomes,3–4
overvaluation of benefits of,108
patient ambivalence about treatment with,20–21
patient’s personality and temperament factors affecting outcomes,113personal attachment to,270
physical characteristics of the pill,16–17
potency of,188
psychosocial patient characteristics that affect treatment outcomes,17–21,
18as substitute for ego functions,218–220
treatment as a defense,213–217
treatment resistance to and from,58–59, 60
unconscious dynamics potentially underlying a request to change or discontinue medications,198when medications replace people,217–218
Medicinemasochism and,83–85
science versus art,11
Mental illnessdisability and,116
family history of,183
providers as professionals,140
Mind–body splitavoidance of,195–196
biopsychosocial interplay in response to treatment,102–103
in combined, nonintegrated care,227–228
development of an integrated treatment frame,106–107
familiarity with evidence bases,102
identification of reductionistic pressures,103–108
contributions to a mind–body split in psychiatric thinking,104in split, nonintegrated care,226–227
Models.
See also Mind-body split
biopsychosocial,260
“biopsychosocial model,”11
collaborative care,238–240,
239of early caregiving,191
traditional medical model of treatment,7–8
Narcissistic defenses, description of,265
National Institute of Mental Health (NIMH),x, 12
Negative identitydescription of,265
medication and,76–77
Neuroticism, description of,265
Nietzsche, Friedrich,111, 139
Nocebo effect,19, 266
Object relations, description of,41, 266
Observing ego, description of,266
Orality, description of,266
Osler, William,75, 213–214
Overall diagnosis, description of,266
Patientambivalence about illness,123–124
“built-for-speed” approach to treatment of,122
“designed for comfort” approach to treatment of,122
maintaining neutrality about symptoms when conflicts arise with,124–125
ambivalence about medication treatment,20–21, 121–126,
122with an as-if personality,66
assessing characterological strengths and vulnerabilities of,170–172,
171authorization to address problems in the alliance,178–180
case vignette of developmental history,116
-centeredness,25–27
character disorders,153–154
characteristics of psychodynamic psychopharmacology and,153–157,
154description of,111–112
developmental history,112–115
assessment of character structure,114–115
cultural influences on illness and treatment seeking,113–114
elements of a pharmacotherapy-oriented developmental history,113personality and temperament factors affecting medication outcomes,113development of an “overall diagnosis” of,116–117,
117disturbed and disturbing, in the treatment system,240–241
emotions,45
with a false-self organization,66
family context of ambivalence about patient’s illness,125–126
feelings of disempowerment,19
humility regarding suffering of,103
hyperalertness to being harmed,57
“ideal,”14
important life experiences,112–113
involvement in decision making,24, 189–190
person-centered versus illness-centered focus on,166–168,
167prescriber behaviors that facilitate knowing as a person,112psychoeducation emphasizing role in effective pharmacology,178psychosocial characteristics that affect treatment outcomes,17–21,
18“readiness to change,”21
recovery from pharmacotherapy,38
relationship to treatment,115–116,
115responsibility for treatment outcome,6
role in promoting good outcomes,188–190
sense of self,65
treatment preferences,137
undermining own agency,142
Personality disorder,142–143
Pharmacologist, core tasks of,37–38
Pharmacotherapeutic alliancealliance versus compliance,136–137
elements of effective and empowering healing relationships,130–135
common factors in treatment,131development of the patient’s agency,131–134
establishing hope,134
maintaining a person-centered focus,131
nonverbal aspects of the alliance,130–131
providing a therapeutic rationale,134–135
evidence-based elements of an effective alliance,130fostering,196–197
overview,129–130
working with negative transferences,135–136
Pharmacotherapyhistory of,121
integration between psychotherapy and,228–235
nonpharmacological variables affecting outcomes,18optimization of,163
patients’ recovery from,38
psychological and attitudinal factors influencing response to pharmacotherapy,115Placebo effect,18, 27
Plato,101
Prescribers.
See also Countertransference; Doctor–patient relationship; Treaters
adjusting prescribing strategy based on expectations,202ambivalence about,204–208,
205behaviors that facilitate knowing the patient as a person,112characteristics that may affect outcome,21–23,
22communication between treaters,233–235,
234contribution to treatment resistance,147, 151
adverse effects of biomedical explanations,90–91
confirming negative transferences,92
enactment,92–95
overview,89
unconscious collusion with treatment resistance,89–90
countertherapeutic use of medications and,146
defensive functions that new prescriptions may serve for the provider,199–200,
199evidence-based prescriber variables that support positive outcomes,195maintaining a person-centered focus,131–133
professional pressures and guild tensions,105–106
recognition of countertherapeutic uses of medication,140
skill of,22–23
strategies for dealing with ambivalence,203unilateral prescribing decisions,146
Primitive object relations, description of,266–267
Primum non nocere,139, 197
Projection, description of,267
Projective identification, description of,267
Psychiatry, reductionistic approach to,12
Psychoanalysis, Sigmund Freud’s view of,36
Psychodynamic, description of,37
Psychodynamic formulationcountertransference and,150
developing,190–191
empathy and,151
Psychodynamic psychopharmacologyadaptation of severe impairments in mental functioning,155
basic psychodynamics impacting medication responsiveness,40, 37–42,
37biomedical emphasis on,5–6
biopsychosocial interplay in response to treatment,102–103
characteristics of,49
concept of authority,42–44
concepts relevant to pharmacotherapy,37developing,117, 118
engagement phasedeveloping a medication plan,186, 188–190
inoculating the patient against dynamics that undercut growth,190
involving the patient in medical decision making,189–190
maintaining realistic humility about the potency of medications,188
patient’s role in promoting good outcomes,188–190
developing a psychodynamic formulation,190–191
establishment of a person-centered focus,166–168
eliciting developmental goals,168
psychodiagnostic assessment,167sample developmental goals,167follow-up intake session,180–186
negotiating a shared understanding,185–186,
187negotiating a working alliance,176–177
overview,165–166,
166providing psychoeducation about the psychosocial dimension of psychopharmacology,177–178,
178authorizing the patient to address problems in the alliance,178–180
psychodynamically informed biopsychosocial assessmentassessment of characterological strengths and vulnerabilities,170–172,
171early relational schemas and repeating relational patterns,168–170
exploring secondary gains that may contribute to treatment resistance,176
inquiring specifically about the patient’s experiences with psychiatric caregiving,173–175
inquiring specifically about the patient’s feelings about taking medications,175–176
listening to the meaning and phenomenology of symptoms,172–173
questioning reductionistic assumptions,173
self-assessment checklist,249,
250–
253essentials of treatment,44–48
affect and the expression of patients’ emotions,45
emphasize past experiences,46
emphasize the therapeutic relationship,47
exploration of patients’ attempts to avoid topics or engage in activities that hinder the progress of therapy,45–46
explore patients’ wishes, dreams, and fantasies,47–48
focus on interpersonal experiences,47
identify patterns in patients’ actions, thoughts, feelings, experiences, and relationships,46
overview,44–45
history of,12–13
before initiating treatmentapplication of psychodynamic thinking,160–161
attending to reductionistic pressures,162
development of clinical virtues,161–162
familiarity with evidence bases,159–160
preparatory elements,159,
160integrated care andcollaborative care model,238–240,
239the disturbed and disturbing patient in the treatment system,240–241
integrated perspective on treatment recommendations,241–246
managing countertransference,243–246
teaching ordinary medical psychotherapy,242–243
understanding the dynamics of treatment resistance,241–242
overview,237–238
limitations of,154–155
maintenance phasegroundwork for good outcomes,194–197
avoidance of mind-body split,195–196
evidence-based prescriber variables that support positive outcomes,195fostering the pharmacotherapeutic alliance,196–197
optimize factors that support positive outcomes,194–195
meaning of treatment,197–200
medication changes and requests from the patient,197–199
medication changes and requests from the prescriber,199–200,
199unconscious dynamics potentially underlying request to change or discontinue medications,198overview,193
self-assessment checklist,249,
254–
258sources of treatment resistance,200
treatment resistance from medication,211–221,
212adverse effects on identity and self-concept,212–213
biomedically mediated harm,221
medication as fetish,220
treatment as a defense,213–217
when medications replace people,217–218
when medications substitute for ego functions,218–220
treatment resistance to medications,201–211
ambivalence about medications,201–204,
202,
203ambivalence about relinquishing symptoms,208–211,
209ambivalence about the prescriber,204–208,
205working with transference,221–222
manual,97–99
medication outcomes,3–4
nonpharmacological pharmacotherapy variables affecting outcomes,18ordinary medical psychotherapy and,48–49
patient-centered,8
patient characteristics,153–157,
154practice of,49
principles of,153, 157
psychological and interpersonal factors in,8
risks of,49
as “6-minute psychotherapy,”49
six technical principles of,98–99
split and combined treatmentscombined, integrated treatment,229–231
combined, nonintegrated care,227–228
communication between treaters,233–235,
234integration and nonintegration,226–228,
227integration between pharmacotherapy and psychotherapy,228–235
overview,225–226
split, nonintegrated care,226–227
triadic treatment and the triadic alliance,231–233
training in,161
treatment outcomes,4–5
treatment-resistant medical conditions and,156–157
Psychoeducationabout evidence bases,106–107
in the engagement phase of psychodynamic psychopharmacology,177–178,
178Psychological-mindedness,161–162, 163.
See also Reflective functioning
description of,267
Psychotherapyintegration between pharmacotherapy and,228–235
“ordinary medical,”200
psychodynamic psychopharmacology and,48–49
teaching ordinary medical psychotherapy,242–243
Psychotic anxiety, description of,267
PTSD, case vignette of,68
Racker, Heinrich,261
Rank, Otto,121
Reaction formation, description of,267–268
Reductionistic pressures,103–106,
104Reflective functioning,161–162.
See also Psychological-mindedness
Research Domain Criteria,x, 12
Resistance, description of,268
Rilke, Rainer Maria,193
Schizophrenia,262
Segal, Hanna,269
Selective serotonin reuptake inhibitors (SSRIs),62, 70, 78, 84, 103, 123, 133, 206–207
“emotional deadness,”70
Self-concept, adverse effects on,212–213
Self-harm,124
Semrad, Elvin,55
Sequenced Treatment Alternatives to Relieve Depression (STAR*D),14
Serotonin-norepinephrine reuptake inhibitor,94
Sifneos, Peter,259
Signal function, description of,268
“6-minute psychotherapy,”200, 208, 242
Sociotropy,18–19
description of,269
Somatization,230
description of,269
Splitting, description of,268
SSRIs.
See Selective serotonin reuptake inhibitors
STAR*D.
See Sequenced Treatment Alternatives to Relieve Depression
Suicide, attempts,142–143
Sullivan, Harry Stack,153
Superego, description of,268
Symbolic equation, description of,\269“Talking cure,”35
TDCRP.
See Treatment of Depression Collaborative Research Program
Therapeutic alliance.
Seealso Doctor–patient relationship
authority and,43
authorizing patient to address problems in,178–180
description of,269
emphasis on,47
how problems in may contribute to misuse of medications,143
negotiating a shared understanding,185–186,
187negotiating a working,176–177
Transference.
See also Countertransference
concordant, description of,261
description of,39, 269
negative,143, 206–297, 246
confirming,92
working with,135–136
resistance,69–72
working with,221–222
Transference resistance, description of,269–270
Transitional objects, description of,270
Trauma, case vignette of,63–64
Treaters, ambivalence about,69–72.
See also Prescribers
Treatment of Depression Collaborative Research Program (TDCRP),21–22, 23
Treatment resistance.
See also Medication; Prescriber
case vignette of,57
description of,14–15,
15from a level of meaning,57
from medications,140, 145, 211–221,
212common dynamics of,76,
75defensive functions and,77–79
family dynamics and,85–87
example questions to assess family contributions to,86medicine and masochism,83–85
negative identity and,76–77
occurrence,87
overview,75–76
when medications replace people,82–83
when replacing healthy capacities,79–82
to medications,201–211
ambivalence about illness,66–69,
62ambivalence about medications,61–66,
62ambivalence about treaters,69–72,
62to medications versus from medications,58–59, 60
patients’ ambivalence and,121–126
pharmacological,27
in psychiatric literature,15psychodynamic formulation of pharmacological treatment resistance,58–60,
59psychodynamic sources of resistance,60
sources of,200
understanding,55–57, 241–242,
56Triadic alliance,231–233
Triadic treatment,231–233
Unconscious, description of,270
Well-being,241
Wellbutrin,230
Wellness,231
Winnicott, D.W.,263
Working alliance.
See Therapeutic alliance
Working relationship.
See Therapeutic alliance
Working through, description of,270
Zetzel, Elizabeth,269
