Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient

by David Mintz MD

Overview

The troubling increase in treatment resistance in psychiatry has many culprits: the rise of biomedical psychiatry and corresponding sidelining of psychodynamic and psychosocial factors; the increased emphasis on treating the symptoms rather than the person; and a greater focus on the electronic medical record rather than the patient, all of which point to a breakdown in the person-centered prescriber–patient relationship.

Psychodynamic Psychopharmacology illuminates a new path forward. It examines the psychological and interpersonal mechanisms of pharmacological treatment resistance, integrating research on evidence-based prescribing processes with psychodynamic insights and skills to enhance treatment outcomes for patients who are difficult to treat.

The first part of the book explores the evidence base that guides how, rather than simply what, to prescribe. It describes precisely what psychodynamic psychopharmacology is and why its emphasis on combining the often-neglected psychosocial aspects of medication with biomedical considerations provides a more optimized approach to addressing treatment resistance.

Part II delves into the psychodynamics that contribute to pharmacological treatment resistance, both when patients' ambivalence about their illness, the medication itself, or their prescriber manifests in nonadherence and when medications support a negative identity or are used as replacements for healthy capacities. Readers will gain basic skills for addressing the psychological and interpersonal dynamics that underpin both scenarios and will be better positioned to ameliorate interferences with the healthy use of medications.

The final section of the book offers detailed technical recommendations for addressing pharmacological treatment resistance. It tackles issues that include countertransference-driven irrational prescribing; primitive dynamics, such as splitting and projective identification; and the overlap between psychopharmacological treatment resistance and the dynamics of treatment nonadherence and nonresponse in integrated and collaborative medical care settings.

By putting the individual patient back at the center of the therapeutic equation, psychodynamic psychopharmacology, as outlined in this book, offers a model that moves beyond compliance and emphasizes instead the alliance between patient and prescriber. In doing so, it empowers patients to become more active contributors in their own recovery.

Product Details

ISBN-13:	9781615371525
Publisher:	American Psychiatric Association Publishing
Publication date:	02/10/2022
Pages:	295
Product dimensions:	6.00(w) x 9.00(h) x (d)
Age Range:	18 Years

About the Author

David Mintz, M.D., is Director of Psychiatric Education, Associate Director of Training, and a Team Leader at the Austen Riggs Center in Stockbridge, Massachusetts.

Table of Contents

PrefacePart 1. What Is Psychodynamic Psychopharmacology? Chapter 1. What Is Psychodynamic Psychopharmacology? Chapter 2. Why Psychodynamic Psychopharmacology? Chapter 3. What Is Psychodynamic About Psychodynamic Psychopharmacology? Part 2. Understanding Pharmacological Treatment ResistanceChapter 4. Psychodynamics of Pharmacological Treatment ResistanceChapter 5. Treatment Resistance to MedicationsChapter 6. Treatment Resistance From MedicationsChapter 7. The Prescriber's Contribution to Treatment ResistancePart 3. The Manual of Psychodynamic PsychopharmacologyChapter 8. Avoid a Mind-Body SplitChapter 9. Know Who the Patient IsChapter 10. Attend to Patients' AmbivalenceChapter 11. Cultivate the Pharmacotherapeutic AllianceChapter 12. Attend to Countertherapeutic Uses of MedicationsChapter 13. Identify, Contain, and Use CountertransferenceChapter 14. Who Is Psychodynamic Psychopharmacology For? Patient CharacteristicsChapter 15. Before Initiating TreatmentChapter 16. The Engagement PhaseChapter 17. The Maintenance PhaseChapter 18. Split and Combined Treatments Chapter 19. Psychodynamic Psychopharmacology and Integrated CareAppendix 1. Psychodynamic Psychopharmacology Self-Assessment ChecklistAppendix 2. Glossary of Psychodynamic Concepts Relevant to the Practice of PharmacotherapyIndex

What People are Saying About This

Abraham M. Nussbaum

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.

Robert J. Waldinger

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.

Steven S. Sharfstein

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.

Katherine G. Kennedy

Psychodynamic Psychopharmacology is the must-read manual for anyone who prescribes medications, to any patient, for any diagnosis. In this thoughtful, extensively-referenced, clearly-written guide, David Mintz brilliantly lays out the compelling case for ending the cycle of mindless prescribing. He introduces readers to a new framework of psychodynamically-informed medication practices, taking into account the complicated interplay between psychological defenses, the symbolic meanings of medications, interpersonal stressors, and the therapeutic alliance. This practical handbook, filled with vivid vignettes and richly detailed examples collected from decades of clinical work, offers a useful roadmap with specific guidelines that will help any practitioner, from the earliest-career to the most seasoned. If you have ever wondered why the medications you prescribe don't work the way you want them to, then this book is the antidote to your anti-integrative practices, the balm for your biomedically-focused prescribing, and the salve for your split mind/body style. If you prescribe medications, then please read this book!

Bernard D. Beitman

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.

Richard F. Summers

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.

César A. Alfonso

With Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient, 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 evidence-based 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.

Carl Salzman M.D.

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 in 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.

John M. Oldham

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.

Kathryn Kieran

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 patient-centered, affirming care.

Dr. Yakov Shapiro is a clinical professor and psychotherapy supervisor

David Mintz' 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 Centre, Dr. Mintz's state-of-the-art manual systematically reviews subjective and intersubjective factors contributing to psychopharmacological treatment outcome 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 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 is an indispensable resource for every psychiatric residency program and every prescribing clinician.

Editorial Reviews

In Psychodynamic Psychopharmacology: Caring for the Treatment-resistant Patient, David Mintz, MD, takes up Sir William Osler's public comment, "The desire to take medicine is perhaps the greatest feature which distinguishes man from animals." Osler's comment seems quaint and dated now. Is taking medicine really the greatest difference between us and animals? How about love sonnets and trigonometry and AI? To be fair, just after the previous quotation, Osler said in the same lecture, "Why this appetite should have developed, how it could have grown to its present dimensions, what it will ultimately reach, are interesting problems in psychology." This gem of a book is an attempt to address those interesting problems and does so by examining treatment resistance in modern psychiatry. Mintz diagnoses the cause of the treatment resistance as our impersonal and medical focus on medications at the expense of our understanding of the person who is suffering. While there are many articles and books that start by complaining thatmental health treatment has lost the mind and therefore lost sight of the mission, Psychodynamic Psychopharmacology offers a fresh perspective through a close reading of clinical cases of treatment-resistant depression. The book attempts to sew up the dualistic divide and address the problem of treatment resistance by carefully attending to the person/patient and the person's feelings, needs, goals, fears, and unconscious psychodynamics, while respecting the impressive empirical evidence base for the effectiveness of psychopharmacology. For Mintz, modern psychiatry needs a sober midcourse correction more than it deserves a victory lap. He is persuasive, thorough, and reminds us that all good treatment is based on the hope and the humility that patient and doctor share. Psychodynamic Psychopharmacology begins with a review of the basics of psychodynamic theory, theconcept of treatment resistance, and the many psychological factors involved—such as ambivalence, meaning of the illness, meaning of the medication, and transference. Mintz makes the interesting distinction between resistance to the medication—why patients do not or cannot let themselves take advantage of what medications have to offer—and resistance from the medication— when patients use medication for unhealthy ends, such as excessively sedating themselves or avoiding contact with painful feelings they would be better off confronting. The second half of the book collects and systematizes these conceptual points into a manual of psychodynamic prescribing with detailed case examples and vivid illustrations of Mintz's caring, compassionate, and humane approach. There is a terrific chapter on patients' ambivalence toward medications, illness, family, and treaters. The chapter on the engagement phase in psychodynamic psychopharmacology is especially comprehensive in conveying the depth of understanding needed to prescribe well. The author provides an extended clinical example that illustrates how the psychiatrist speaks with a patient about the psychological context for taking medication, showing how curiosity, openness, psychodynamic insight, and appropriate management result in a harmonious doctor-patient alliance that is likely to optimize the outcome.

Journal of Psychiatric Practice - Richard Summers

David Mintz's book on psychodynamic psychopharmacology invites us to consider how rather than what to prescribe. Echoing Balint, he reminds us that the pharmacotherapeutic alliance and the manner in which the doctor interacts with the patient are instrumental to outcomes. He educates us on factors that affect treatment, such as patient characteristics (attachment style, placebo, treatment preference) and prescriber characteristics (warmth, promoting autonomy, supporting decision-making).The book is well structured, starting with defining psychodynamic psychopharmacology and its large evidence base. It provides a framework for considering treatment resistance at the level of meaning and subsequently breaks down the overarching principles of psychodynamic psychopharmacology. It is suffused with case formulations and transcripts of conversations with patients. We meet a patient whose psychosis was protecting them against the depressing reality of an earlier loss; the prescriber took this into account when deciding to prescribe less aggressively and to allow for grieving to take place. Examples of patients using their medication in countertherapeutic ways or being unhealthily attached to their tablets made me consider my own practice. Prescribing in a truly integrated way can feel like a novelty and sometimes lonely in a predominantly biological psychiatric paradigm. You are not alone. Mintz guides you with a manual on how to approach the engagement and maintenance phase of prescribing. There is a self-assessment toolkit and a glossary, all invaluable tools for clinical practice and teaching purposes.This book does not antagonise but it complements the scienceof psychopharmacology. It should be in the curriculum of psychiatric if not medical training. It is likely to restore faith in psychiatry as a profession and in our roles as doctors of the mind andthe body.

British Journal of Psychiatry

Reviewer: Daniel M Tuinstra, MD (Holland Hospital)
Description: This book explores the impact of interpersonal relationships and psychological significance of psychopharmacologic interventions in psychiatry, which often leads to treatment adherence challenges. The book provides theoretical consideration and practical advice for managing these complex interactions.
Purpose: The book assists psychiatrists in exploring reasons why optimized psychopharmacologic interventions may not be as effective as expected with special attention to psychodynamic factors including transference and countertransference reenactments. Additionally, the author attempts to improve outcomes for patients and more satisfaction from the psychiatrist through emphasizing the therapeutic relationship in the treatment setting.
Audience: The ideal audience for this book is early career psychiatrists, psychiatrists in training, and academic preceptors. The book meets the needs of any clinician who has encountered treatment-resistant patients. The author is of the utmost credibility on the subject matter.
Features: The author draws from clinical experience to illustrate theoretical concepts and applies them through vignettes. He also systematically summarizes psychopharmacologic research. Tables and graphs are used effectively. Key points summarize and enhance retention of the content and provide a handy reference for clinical situations that arise.
Assessment: This book is the first of its kind in providing a comprehensive review of psychodynamic psychopharmacology. While a few book chapters or editorials have been powerful, this book offers a potent mix of research reviews, clinical examples, vignettes, practical tips, and effective use of tables and graphs. The author articulates the impact of the therapeutic relationship on psychopharmacologic interventions and how to manage common clinical pitfalls.

Doody's Review Service