I did a presentation to residents and co-teaching faculty on
psychodynamic prescribing last week and decided to post something while it was
on my mind. I also read several book
chapters in the process and have recommended reading that readers might find
useful. My introduction to the lecture
highlighted the longstanding rhetoric within the field that when sufficiently
polarized leads to absurd conclusions.
I used the relative periods of the history of psychiatry and
composites from several authors to look at the main intellectual focus of the
field. In the asylum era up to about
1910 – the focus was gross neuropathology, classification, and
psychopathology. There were also clear
improvements in asylum care. From 1910
to 1960, the focus shifted to psychoanalysis and various theoretical
schools. Starting in 1960, the focus
shifted to biological psychiatry that is commonly characterized as the study of
neurobiology, genetics, and psychopharmacology. The figure below from the
presentation was an attempt to name prominent psychiatrists during each epoch
who were thought leaders. The problem
that should be evident is that these periods were not homogeneous. During the
most recent era for example, there are many biological psychiatrists and at the
same time some of the most significant psychotherapy theorists in Kernberg,
Kohut, Beck, Klerman, Gunderson, and Yalom.
How is it that these divisions seem to exist in the
field? In my experience it comes down to
competitive environments and the associated politics. As an example, I did my psychiatric training
at two different programs. The quality
of both programs and clinical experience was excellent. One department was headed by a psychiatrist
from the Washington University (St. Louis) school of psychiatry. That school was known as the neo-Kraepelinians
and they favored biological explanations for psychiatric disorders but by no
means ignored the psychosocial. The
other school was headed by a psychiatrist who was eclectic and interested in
both the biological and social origins of severe anxiety. He was also surrounded by a staff of
biological psychiatrists, psychotherapists of various origins, and medical
psychiatrists. Both programs had plenty
of faculty on both the psychotherapy and biological psychiatry sides.
Both of those training settings were essentially projective
tests for psychiatric residents and medical students. Some identified with the psychotherapy staff
and some with the biological staff, but everyone trained in both areas and a
wide array of settings. The real
strength of psychiatry is knowing what to do about diagnoses and problems
across a wide variety of settings and presentations. As an example, I could be doing hospital
consults and making aphasia diagnoses one afternoon and the next day seeing
several long-term psychotherapy patients.
From there I could be doing a shift in a crisis unit and doing
appropriate interventions – both therapy and medications.
The broad training that psychiatrists get is rarely
mentioned. What is mentioned are
stereotypes like psychiatrists prescribe medication and financial incentives
drive this process. They do not do
“therapy”. The caricatured biological
psychiatrist states: “I am a biological psychiatrist and I don’t do
therapy. If you have a problem discuss
that with your therapist.” Why is that
not possible? And why are things just as
difficult on the other side of the equation – the psychotherapist that doesn’t
do medications. There was a time when
medically trained psychoanalysts only practiced psychoanalysis. Over the past 40 years, I have seen many
psychiatrists with psychoanalytical training who practice general and even hospital
psychiatry.
In terms of either not prescribing medication or providing psychotherapy,
the first problem is that it is not how psychiatrists are trained. The training is focused on the necessary
treatment techniques to help people who have the most severe problems. The large markers are evidence-based
treatments these days and there are plenty of them, but all fields of
medicine extend into treatments that have little to no evidence. In psychiatry that zone is broader because we
are necessarily focused on subjectivity – it is not a bad thing. It is harder to measure. According to consciousness theorists –
everyone’s conscious state is different and the same external experiences are
experienced differently at the mental level. Meaning to the individual we are
seeing is important. Second, even stable
people end up in crisis whether they are stabilized on medications or improved
in psychotherapy. The ups and downs of
life can trigger a crisis and everything that involves. That generally does not require a change in
medications or psychotherapy plan – but it does involve being able to verbally intervene
in a crisis. That is typically talking
and environmental interventions. Third,
there have been rigid expectations for what constitutes psychotherapy that are
not realistic. For example, hour long
sessions for a new patient on a weekly basis for weeks or months. Most psychiatrists these days see 2 to 3 new
people per day. In just a few weeks of
practice that type of psychotherapy schedule would be filled. Garret (1) has
detailed estimates of how many patients can be seen in a month using 30- and
45-minute visits and they vary from 15 (seen weekly) to 98 (seen less
frequently). In the CMHC settings where
I have worked 30-minute appointments at varying frequencies are the norm. Fourth,
in an average clinical encounter how long does it take to assess the patient’s
state related to medications and make the related decisions. All of that takes about 10-15 minutes. Then what?
You can either have 10–15-minute appointments or discuss other areas of
that person’s life that are relevant to treatment.
How does this happen across settings where in many cases
psychiatrists are expected to prescribe medications in limited periods of time
and have an onerous documentation burden.
The Garrett reference (1) has some clear ideas and specific diagnostic
codes. I have previously written about it on this blog as supportive
psychotherapy being the language
of psychiatry and how pattern
matching in psychotherapy is not much different than pattern matching in
general medicine. In this post I will discuss some additional points in how
this occurs across many appointments and within the same appointment.
In the diagram below, I will discuss several dimensions that
are operating during every appointment but are most apparent in the initial
assessment. The obvious overview is that
there is a psychotherapeutic context for very encounter. This is evident in any treatment literature
that you might read. Different authors
use different terms. For example, prescriptive
therapies can include lifestyle changes (diet, exercise, smoking/alcohol
cessation), medications, behavior therapy, and brief manualized psychotherapies. They all assume that the psychiatrist can see
a problem that responds to a specific intervention and no deeper level of
understanding is necessary. When I use
the term top down, it means approaching problems at the surface. To use a mechanical analogy – it is like
using stop-leak for a blown engine gasket rather than taking the engine apart
and fixing the gasket. Like all
analogies that breaks down at some point.
You could consider behavioral activation a prescriptive therapy but it
also addresses deeper processes and patterns.
Most prescriptive therapies probably lie in a more intermediate position
between purely prescriptive interventions and deeper explorative therapies.
The beauty of psychodynamics is that it operates at the
level of individual human consciousness and that cuts across every domain. The typical descriptive and classificatory
levels of psychiatry give the illusion that all human mental suffering can be
classified into neat categories. Contrary
to antipsychiatry rhetoric that same illusion exists in ordinary medical and
surgical classifications as well. In
psychiatry, there is probably no better example than a paper last week (2)
illustrating how a common DSM based depression checklist is
misinterpreted. This same scale is used
on a large-scale basis and used for genomics studies suggesting a degree of
phenotypic certainty that does not exist.
Psychodynamics and some other forms of psychotherapy address conscious
states that are highly individualized and determine unique pathways to
problems. Psychodynamics also cuts
across all treatment interventions. If
you are a consultant it also includes how other physicians are reacting to your
patient.
The interface between medication response and psychotherapy
is also not typically considered. It is
known that environmental, interpersonal, and psychotherapeutic interventions
can alter both the placebo and nocebo response to medications. These responses
can be powerful and they are not limited to psychiatric medication or
interventions. In some cases, the
physician patient relationship alone is enough to alter response patterns to
illnesses and medications. It is good
practice to use psychotherapeutic interventions that affect both in the desired
directions of increased placebo response and decreased nocebo response.
Beyond the placebo-nocebo effects there are also conditioning effects and the environment of the clinic may be a factor. Staff interaction and the overall quality of the environment can be important. This is thought to be a factor in many clinical trials when patients are seen and treated in clinical settings that seem much more intensive and friendly than their usual clinical settings.
At the psychodynamic level exploring the patient’s expectations,
fears, and fantasies about the medication is an important first step before prescribing. Was the idea to try a medication their idea
or did it come from somebody else? What
does taking a medication mean to them? Is there a fear or wish for dependence? Is there a change in the dynamics of the relationship
based on allowing the physician to make decisions for the patient? Does that occur after an adequate informed
consent discussion? Some writers describe
this regression as the sick role and suggest it may be appropriate if
the patient is very ill, but there always needs to be a plan to restore baseline
autonomy.
Prescribing can be seen as a hostile of caring act depending
on the meaning of the medication. Medication can be seen as soothing, calming, a
way to restore baseline wellbeing, and eventually regain autonomy. It can also be seen as a punishment,
confirmation of a dreaded diagnosis, or a sign of personal weakness. At the fantasy level – it can be seen as a
magical potion that will cure everything that ails the patient. In some cases,
the medicine functions as a talisman warding off symptoms if it is in the possession
of the patient – even when it is not taken.
In the intersubjective field, the prescribing physician can
also develop countertransference thoughts and fantasies about the medication
and because of emotions that occur in the relationship. Common among them is the healer fantasy of
omnipotence that all problems can be treated into remission with
medications. That can lead to over-prescribing,
premature prescribing, and other boundary violations. Various clinical scenarios (errors, treatment
resistance, projective identification) can lead to anxiety and dread in the
countertransference that may affect prescribing. There is also the practical scenario that
when things are not improving any physician’s anxiety will be going up. In a
prescribing scenario that can lead to dose escalation, polypharmacy, inadequate
attention to side effects, and inadequate attention to discontinuing
ineffective therapies. Based on my
conversations with people – they are often skeptical that a rumored combination
of medications will work better than what they have tried in the past. Prescribing can also be a defense against
other factors that are difficult to address.
In the most basic case, prescribing can be seen as a form of
intellectualization (these symptoms – this medication) rather than addressing
the complexity of all the emotions and conflicts in the room.
Another form of prescriber anxiety in the
countertransference is the fear of harm or lability. That is often discussed as a medico-legal
problem. I have never found this a useful
dimension for analysis in clinical practice, but for many years there was the suggestion
that psychotherapy alone without medical treatment may be a risk. That came from the case of Osheroff v.
Chestnut Lodge that was eventually settled and therefore is not established
case law. In this case the plaintiff was
an established professional diagnosed with narcissistic personality disorder
and treated with psychoanalysis at the Chestnut Lodge – a psychiatric hospital.
When he started to get worsening
depression and severe agitation at the 6 month mark a consultant recommended a trial
of medication – but the treatment staff decided to continue psychoanalysis. After another month of marked decline, he was
transferred to another hospital where he was treated with an antidepressant and
a phenothiazine where he improved and was eventually discharged and resumed
working. This case is frequently cited as evidence of the superiority of
medical treatment – but from the description it seems that psychodynamic
prescribing just needs to adhere to a general rule in medicine – if the
treatment is not working try something else. I have not seen any countertransference
related factors described that could have led to this inertia – but it is easy
to speculate.
Adherence is often discussed in very basic terms from a
prescriber standpoint. For example,
fewer doses per day, long-acting injectable medications, and sustained release
medications all improve adherence. From
a psychodynamic standpoint – adherence is a meaningful communication. Does it suggest ambivalence, resentment, or a
challenge to the prescriber’s authority, interpersonal style, or
diagnosis? That can all be openly discussed.
Although I have listed several psychodynamic factors relevant
to prescribing, they are by no means exhaustive. I am certain that in any practice out there
psychiatrists could create a list based on the patients they see every
day. Of those factors the most significant
one in practice has been countertransference.
Every psychiatrist needs to be aware of that dynamic more than the rest
because it is most likely to affect your judgment and the judgment of your
coworkers. If you do team meetings like I did every day for 22 years, it is
most likely to disrupt your team and the environment and in the worst case
affect the safety of patients and staff.
In that scenario you need to figure it out and figure how to keep a lid
on the place. The same thing is true for
consult-liaison docs who are seeing disruptive patients in medical and surgical
settings.
I seem to be stating what is obvious to most psychiatrists. That
is probably because most people still do not know what we do and we don't seem to talk about it much. After all Paul Dewald (1) wrote very well about
this over 70 years ago. Everything in
that chapter still applies today.
George Dawson, MD, DFAPA
References:
1: Dewald PA. Psychotherapy a dynamic approach. 2nd ed. New York: Basic Books, 1971.
2: Mintz D, Azer
J. Integrating psychoanalysis and
pharmacotherapy. In: Gabbard GO, Litowitz BE, Williams P, eds. APPI Textbook of psychoanalysis, 3rd ed. Washington DC: American Psychiatric
Association Publishing, 2025: 291-305.
3: Mintz D. Psychodynamic psychopharmacology. Washington
DC: American Psychiatric Association Publishing, 2022
4: Garret M. Psychotherapy for psychosis. New York:
The Guilford Press, 2019.
5: Novalis PN, Singer
V, Peele, R. Medication-therapy
interactions and medication adherence. In:
Clinical Manual of Supportive Psychotherapy, 2nd ed. Washington DC:
American Psychiatric Association Publishing, 2020: 377-391.
6: Wright JH,
Turkington D, Kingdon DG, Basco MR.
Cognitive-behavior therapy for severe mental illness. 2nd ed. Washington
DC: American Psychiatric Association Publishing, 2020.
