Psychodynamic Prescribing

 

 

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.