Caring for the Treatment-Resistant Patient
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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.
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
About the Authors
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.
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.—Steven S. Sharfstein, M.D., President Emeritus, Sheppard Pratt Health System, Past President, American Psychiatric Association
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.—Robert J. Waldinger, 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.—Carl Salzman M.D., Professor of Psychiatry Harvard Medical School
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.—Abraham M. Nussbaum, M.D., MTS, DFAPA, Chief Education Officer, Denver Health, Associate Professor of Psychiatry, University of Colorado School of Medicine
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.—Dr. Yakov Shapiro is a clinical professor and psychotherapy supervisor, Department of Psychiatry, University of Alberta, Edmonton, Canada, and clinical director, Integrated Psychotherapy/Psychopharmacology Service (IPPS)
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.—John M. Oldham, M.D.,Distinguished Emeritus ProfessorMenninger Department of Psychiatry and Behavioral SciencesBaylor College of Medicine
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.—Bernard D. Beitman, M.D., Visiting Professor, Department of Psychiatry and Behavioral Sciences and Founding Director of The Coincidence Project
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.—Kathryn Kieran, Psychiatric Mental Health Nurse Practitioner, McLean Hospital
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!—Katherine G. Kennedy, M.D., Yale University
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.—Cesar A. Alfonso, M.D., Clinical Professor of Psychiatry at Columbia University, Editor of Psychodynamic Psychiatry, and Chair of the Section on Psychotherapy of the World Psychiatric Association.
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.—Richard F. Summers, M.D., Clinical Professor of Psychiatry and Senior Residency Advisor, Perelman School of Medicine of the University of Pennsylvania
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