Learning Objectives

1. Recognize how unconscious psychodynamic factors can contribute to resistance in psychiatric medication adherence
 2. Explain the significance of the therapeutic alliance and its impact on patient response to therapeutic interventions
 3. Understand how the transitional object relates to the patient’s medication adherence.

Introduction

As a psychiatrist working with patients with severe psychosis in two state departments of mental health (New York and Massachusetts), I learned the importance of psychodynamics the old-fashioned way: by frequently bumping up against the patient’s resistance to treatment. I don’t mean pharmacological resistance. I mean the patient’s reluctance or refusal to adhere to the recommended medical regimen, usually grounded in unconscious needs, fears, or wishes. 

“Mr. A.” was a case in point. He had a long history of chronic schizophrenia that was only partially responsive to thiothixene, a commonly used antipsychotic medication in the 1980s. I raised the issue of a clozapine trial with Mr. A, since I had seen some near-miraculous “turnarounds” with this then novel, atypical agent. But Mr. A. adamantly refused. He would take no other medication besides the thiothixene, which at the time was marketed under the brand name, Navane. Why? The clue was Mr. A’s constant and invariable reference to this drug as “Nervine,” which was the brand name of a bromide-based patent medicine he had taken in the 1960s (Buchanan J, The Sylva Herald April 2020).

Owing to the risk of bromine toxicity, the FDA removed this type of medication from the market in 1976. But Mr. A. had very fond memories of this remedy for “nerves”—it had “worked great” for him, “back in the day!” And in his primary process thinking, “Navane” and “Nervine” were inextricably conflated. No amount of secondary process “correction” on my part altered Mr. A’s conviction. And so, treatment proceeded using thiothixene, which I judged to be much better than nothing. 

I’ll say more about Mr. A shortly, but looking back on this case from the perspective of over 30 years, I now wonder if a more interpretive, psychodynamic approach to Mr. A. might have yielded better results—one that might have addressed Mr. A’s underlying fear of changing medication. In this regard, Dr. Mark L. Ruffalo has discussed schizophrenia from the psychodynamic perspective, noting that “At the heart of the psychodynamic approach to schizophrenia is the idea that psychotic symptoms are not random or meaningless phenomena, but rather rich, symbolic expressions of the patient’s inner world” (Ruffalo ML, Psychiatric Times 2023).

Definition of “psychodynamic”

It is useful at this point to unpack the term “psychodynamic,” as I will use it in this article. Historically, the term has almost always been coupled with the word, “psychotherapy.” Leichsenring, F., Abbass, A., Heim, N., Keefe, J. R., Luyten, P., Rabung, S., & Steinert, C. (2022). Empirically supported psychodynamic psychotherapy for common mental disorders–An update applying revised criteria: Systematic review protocol. Frontiers in Psychiatry, 13, 976885. https://doi.org/10.3389/fpsyt.2022.976885. While a comprehensive review of psychodynamic psychotherapy is beyond the scope of this article, psychoanalyst Jonathan Shedler, PhD, has provided a useful synopsis of the “distinctive features” of psychodynamic psychotherapy: 

• Focus on affect and expression of emotion
• Exploration of attempts to avoid distressing thoughts and feelings
• Identification of recurring themes and patterns
• Discussion of past experience (developmental focus)
• Focus on interpersonal relations
• Focus on the therapy relationship
• Exploration of fantasy life

More broadly, Shedler views the focus of psychodynamic psychotherapy as encompassing “. . . how the person views self and others; interprets and makes sense of experience; avoids aspects of experience; or interferes with a potential capacity to find greater enjoyment and meaning in life” (Shedler J, Am Psychol 2010;65(2):98-109). 

It is in this broad sense that I will use the term “psychodynamic.” It should be evident that in the truncated format of a “med check”—typically, lasting 15-25 minutes—the full range of psychodynamic issues motivating the patient cannot be fully investigated or explored. Nevertheless, I will hope to show that a psychodynamic understanding is still useful—and sometimes essential—in psychopharmacologic treatment. Ettore, E., Müller, P., Hinze, J., Riemenschneider, M., Benoit, M., Giordana, B., Postin, D., Hurlemann, R., Lecomte, A., Musiol, M., Lindsay, H., Robert, P., & König, A. (2023). Digital Phenotyping for Differential Diagnosis of Major Depressive Episode: Narrative Review. JMIR Mental Health, 10(1), e12345.

Rationale for integrating pharmacologic and psychodynamic elements of treatment 

As Ruffalo and Morehead have written, “From a psychodynamic perspective, every interaction between doctor and patient, even in the hospital setting, is an opportunity to relate to the patient psychotherapeutically” (Ruffalo ML and Morehead D, Psychiatric Times 2022). This is especially relevant in psychopharmacologic treatment, in which the patient has not responded fully; is deeply ambivalent about medication; or actively resists medical recommendations. As Mintz has observed:

“Psychodynamic psychopharmacology explicitly acknowledges and addresses the central role of meaning and interpersonal factors in pharmacological treatment. This approach recognizes that many of the core discoveries of psychoanalysis (the unconscious, conflict, resistance, transference, defense) are powerful factors in the complex relationships between the patient, the illness, the doctor, and the medications. In many cases, these factors are largely concordant with treatment and do not need to be addressed in order for treatment to be effective. However, in patients who are treatment-resistant, it is likely that psychodynamic factors (that may well be unconscious) are deeply at odds with therapeutic goals” (Mintz, D, Psychiatric Times 2021). 

Unconscious expectations of patient and psychiatrist

Both the patient and the physician bring their respective hopes, fears, and expectations to the medical check-up (“med check). (I am assuming that, prior to the brief, follow-up session, the psychiatrist has carried out a thorough diagnostic process; discussed the risks and benefits of the proposed medication; and insured that the patient or guardian has provided informed consent to treatment). To be clear: some of the patient’s and physician’s expectations are present on a conscious level. For example, some patients may expect the medication to be helpful, whereas others—particularly those who had a poor response to, or many side effects from medication—may bring very low expectations to the treatment process (Jimmy B and Jose J, Oman Med J 2011;26(3):155-159); Seewald, A., & Rief, W. (Year). How to Change Negative Outcome Expectations in Psychotherapy? The Role of the Therapist’s Warmth and Competence. Clinical Psychological Science, 11(1), September 22. DOI: https://doi.org/10.1177/2167702622109433.. 

But the patient’s expectations may also occur on an unconscious level, depending on a variety of developmental and experiential factors. For example, if the patient has had an especially punitive parent, he or she may unconsciously view the prescribing physician as a “punishing” figure—and medication, the instrument of punishment. Conversely, patients who have idealized a parental figure may have the opposite reaction. I will say more on these essentially transference-based issues below. It should be evident that the physician, too, brings his or her unconscious expectations to the table, based on analogous developmental and experiential factors. 

Much has been written regarding the “placebo” effect of psychiatric medication, and this voluminous topic is simply beyond the scope of this article. Yet we can acknowledge, as Mintz observes, that “Placebo does not mean imaginary or untrue. Placebos produce real, clinically significant, and objectively measurable improvements in a wide range of conditions, including psychiatric disorders” (Mintz 2021). Conversely, the obverse of the placebo response, nocebo responses occur when patients expect (either consciously or unconsciously) to be harmed. Many patients who experience intolerable adverse effects to medications are nocebo responders. It comes as no surprise that these patients are likely to become “treatment resistant.”

Medications as transitional objects: implications for the transference

The concept of the “transitional object” originated in the work of Donald Winnicott (Winnicott DW, Int J Psychoanal 1953;34:89-97). Winnicott spoke of transitional objects as things, such as a teddy bear or blanket, that allowed the child to retain some of the security of the mothering figure without always having the mother or father physically present. To oversimplify, a transitional object is a bit like the “security blanket” made famous by the character of Linus, in Charles Schulz’s “Peanuts” comic strip.

Furthermore, as Dr. Adele Tutter has observed:

“People experience and treat medication as though it were a person: in other words, as an object . . . Medication may represent a third person within the framework of an analytic treatment, expanding the analytic dyad into a triad and offering new transference paradigms to explore.” 

Importantly, Tutter alludes to “. . . the utility of understanding the personification of medication even within a “purely” psychopharmacological treatment” (Tutter A, J Am Psychoanal Assoc 2006;54(3):781-804). 

Indeed, in the case of Mr. A, I believe that the prescribed drug (Navane) was a kind of personified, transitional object for the patient, owing to his conflation of the drug with “Nervine.” Though not strictly a “person,” I believe that “Nervine” functioned as a kind of benign and healing parental figure for Mr. A, which he recalled with a certain affection. On the other hand, his unwillingness to consider any other medication suggests that his comforting association with “Nervine” was not transferred to me—at least not fully. Nonetheless, the “Nervine” may have served as a useful transitional object that allowed Mr. A. to accept the Navane. Accordingly, I respected his wish to continue this drug.

Counter-transference issues

Mr. B.—a remarkably intelligent man diagnosed with chronic paranoid schizophrenia—presented a different form of treatment resistance. Having been trained by the Jesuits, Mr. B. was adept at brilliant, if sophistical, argumentation. He insisted that his dose of thioridazine (Mellaril)—a first-generation antipsychotic—be limited to no more than 25 mg per day: a sub-therapeutic dose by any measure (Cunha JP, RxList 2023. Retrieved from https://www.rxlist.com/mellaril-drug.htm). Attempts to persuade Mr. B. otherwise were swatted away like flies, and invariably led to a fruitless power struggle. 

It didn’t help that Mr. B. held strong anti-Semitic views, which I have described in detail elsewhere (Pies R, New York Times 2006). Being Jewish, I had to examine both my conscious and unconscious reactions to Mr. B’s numerous vituperative letters, in which he would say things like, "Jews don't live long" or "The Jews must pay for killing our Lord." Although I didn’t realize it at the time, I think I unconsciously associated Mr. B. with some of the “high school bullies” who used to harass me with anti-Semitic remarks.

In the course of working with Mr. B, it eventually became clear to me that the best I could do for him was to monitor and treat his many general health needs and shore up the therapeutic alliance—such as it was—as best I could. His need to assert control and dominance was the central, driving dynamic in our relationship, and—with the help of a wise supervisor—I gradually learned to avoid struggling with Mr. B. over his medication dosage. Instead, I tied to “connect” with him by discussing some of his favorite topics in theology. 

In some instances, the physician’s countertransference may manifest as inappropriate pharmacotherapy or polypharmacy. As Mintz has observed:

“When patients struggle with overwhelming dysphoric affects, they often evoke corresponding effects in their prescribers. It seems likely that a medication regimen made up of, for example, 3 antidepressants, 4 mood stabilizers, 3 antipsychotics, and 1 or 2 anxiolytics, has in part been shaped by countertransference. Such a regimen is unlikely to be effective and is perhaps aimed at treating the doctor’s anxiety rather than the patient’s; the patient is not the only source of treatment resistance” (Mintz D, 2021). 

The Importance of the Therapeutic Alliance

The therapeutic alliance is usually defined as “the emotional bond established in the therapeutic dyad, and the agreement between patient and therapist as to the goals and tasks of treatment.” 

The therapeutic alliance is important in both medication treatment and psychotherapy. Indeed, in a large, placebo-controlled, multicenter trial of antidepressant treatment, Krupnick et al showed that patients were most likely to respond when they received the active drug and had a strong therapeutic alliance (Krupnick JL et al, J Consult Clin Psychol 1996;64(3)532-539). Consistent with these findings, Zilcha-Mano et al found that an increase in the strength of the alliance throughout treatment predicts a greater reduction in symptoms throughout treatment (Zilcha-Mano S et al, Psychother Psychosom 2015;84(3):177-182).

Conclusion

The notion that there is a strict separation of “biological” and “psychosocial” interventions in psychiatry is unfounded and unhelpful. On the contrary, as Gabbard argued nearly 30 years ago, “Psychological and biological components of psychiatric illness must be integrated to avoid the perils of reductionism in diagnosis and treatment” (Gabbard GO, Bull Menninger Clin 1994;58(4):427–446). Even in the brief interval typically allotted for “med checks,” psychodynamic issues can and often must be addressed. These include the conscious and unconscious attitudes, fears, and phantasies of the patient, as well as countertransference-based issues on the part of the psychiatrist. Together these factors may affect the strength of the therapeutic alliance, which, in turn, may affect response to pharmacological treatment.

CARLAT VERDICT

The much-maligned “med check” can actually be an occasion for the holistic understanding, care, and treatment of the patient.

References as they appeared in this article:

Buchanan, J. (2020, April 15). 'Miracle' cures an old standard in America. The Sylva Herald. Retrieved from https://www.thesylvaherald.com/history/article_8ea9924c-7f23-11ea-b478-6b15b9bf63f1.html.

Ruffalo, M. L. (2023, February 17). Schizophrenia from the psychodynamic perspective. Psychiatric Times. Retrieved from https://www.psychiatrictimes.com/view/schizophrenia-from-the-psychodynamic-perspective.

Shedler J. (2010). The efficacy of psychodynamic psychotherapy. The American psychologist, 65(2), 98–109. https://doi.org/10.1037/a0018378,

Ruffalo, M. L., & Morehead, D. (2022, May 6). Psychotherapy: A Core Psychiatric Treatment. Psychiatric Times. Retrieved from https://www.psychiatrictimes.com/view/psychotherapy-a-core-psychiatric-treatment

Mintz, D. (2021). Psychodynamic Psychopharmacology. Psychiatric Times, 28(9).

Jimmy, B., & Jose, J. (2011). Patient medication adherence: measures in daily practice. Oman medical journal, 26(3), 155–159. https://doi.org/10.5001/omj.2011.38

Cunha JP. Mellaril. RxList. July 19, 2022. Retrieved from https://www.rxlist.com/mellaril-drug.htm

Winnicott, D. W. (1953). Transitional objects and transitional phenomena; a study of the first not-me possession. The International Journal of Psychoanalysis, 34, 89–97

Tutter A. (2006). Medication as object. Journal of the American Psychoanalytic Association, 54(3), 781–804. https://doi.org/10.1177/00030651060540031401

Pies, R. (2006, January 31). After Polite Sessions, Letters Filled With Anti-Semitism. New York Times. Retrieved from https://www.nytimes.com/2006/01/31/health/psychology/after-polite-sessions-letters-filled-with-antisemitism.html

Krupnick, J. L., Sotsky, S. M., Simmens, S., Moyer, J., Elkin, I., Watkins, J., & Pilkonis, P. A. (1996). The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of consulting and clinical psychology, 64(3), 532–539. https://doi.org/10.1037//0022-006x.64.3.532

Zilcha-Mano, S., Roose, S. P., Barber, J. P., & Rutherford, B. R. (2015). Therapeutic alliance in antidepressant treatment: cause or effect of symptomatic levels?. Psychotherapy and psychosomatics, 84(3), 177–182. https://doi.org/10.1159/000379756)

Gabbard GO. (1994). Mind and brain in psychiatric treatment. Bulletin of the Menninger Clinic, 58(4), 427–446