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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.
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.
— Daniel M Tuinstra, MD
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 science
of 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 and
the body.
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, the
concept
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.
— Richard Summers, MD
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.
Preface
Part 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 Resistance
Chapter 4. Psychodynamics of
Pharmacological Treatment Resistance
Chapter 5. Treatment Resistance to
Medications
Chapter 6. Treatment Resistance From Medications
Chapter
7. The Prescriber's Contribution to Treatment Resistance
Part 3. The
Manual of Psychodynamic Psychopharmacology
Chapter 8. Avoid a
Mind-Body Split
Chapter 9. Know Who the Patient Is
Chapter 10.
Attend to Patients' Ambivalence
Chapter 11. Cultivate the
Pharmacotherapeutic Alliance
Chapter 12. Attend to Countertherapeutic
Uses of Medications
Chapter 13. Identify, Contain, and Use
Countertransference
Chapter 14. Who Is Psychodynamic Psychopharmacology
For? Patient Characteristics
Chapter 15. Before Initiating
Treatment
Chapter 16. The Engagement Phase
Chapter 17. The
Maintenance Phase
Chapter 18. Split and Combined Treatments
Chapter
19. Psychodynamic Psychopharmacology and Integrated Care
Appendix 1.
Psychodynamic Psychopharmacology Self-Assessment Checklist
Appendix 2.
Glossary of Psychodynamic Concepts Relevant to the Practice of
Pharmacotherapy
Index