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The Concept-Laden Prescription

The Concept-Laden Prescription

Compared with the many recent articles addressing medications' multiple meanings for the patients who take them and the psychiatrist-therapists who prescribe them, there has persisted in the literature and in clinical practice a curious literal conception of the prescription itself. This article challenges the idea that the only medication that can be prescribed comes in the form of pills or tablets; on the contrary, ideas constitute some of the most potent "medication" known. The prescription has always been a powerful symbol for the achievement of health, and when employed as a conveyor of ideas mined in the therapy, it has untapped synergistic, therapeutic potential.

The concept-laden prescription (CLRx) combines the time-honored therapeutic significance of the prescription with ideas written on the prescription that are central to the patient's needs, conflicts, deficits, or feelings that are currently evolving in the psychotherapeutic work. CLRxs complement, rather than substitute for, traditional prescriptions.

The CLRx is an actual prescription on which the psychodynamically oriented psychiatrist (who also writes traditional prescriptions) writes messages that have already been distilled from the psychotherapeutic work. The patient has already "suffered" the truth of these observations and is in agreement with them. Capturing their essence on a prescription keeps them on the "radar screen of psychotherapy" for further inquiry and consolidation.

Usually dispensed during the working-through phase of therapy, the CLRx helps to solidify insights when the therapeutic alliance is strong and resistance is low. A major aim in writing CLRxs
is to relocate and expand therapy to a different space that allows for greater spontaneity, playfulness, and creativity. Here are a few sample CLRxs:

You have my permission, and blessing, to take at least one thing for yourself every day. Sig: one bid refill × 1000 No substitution—written for a patient who was an expert in self-denial.

Remember, I am not abandoning you. I just need a vacation. Sig: one qid refill × 500 No substitution—written for a patient who experienced absence as abandonment.

You need to let me have limitations without vilifying me. My limitations are no reflection on your worth as a person. Sig: one qd refill × 10,000 No substitution—written for a patient who could not tolerate anything less than perfection in her therapist.
This technique is one that I have developed in my clinical practice; it has not been the object of scientific study, but my experience suggests that the judicious use of the CLRx engenders trust, introduces humane playfulness, and promotes honesty in the psychotherapeutic enterprise.

The origin of this idea
A clinical experience early in my career stimulated the ideas put forth in this report. As a liaison psychiatrist on a cardiac unit, I was interviewing a disgruntled senior nursing supervisor from another hospital who, as a patient in the unit, was recovering uneventfully from a myocardial infarction. Feeling wronged and embittered about recently being passed over for promotion, she began telling me about her plans to hand in her resignation shortly after her scheduled return to work. It suddenly dawned on me how tempting it was to think of her resignation as only a short, signed letter rather than a constellation of strong feelings prompting her to envision and plan a certain action. With this realization in mind, I proceeded to explore the many elements of her resignation—problems with authority, envy of her co-workers, resentment over life-long financial constraints, and most important, never feeling appreciated by her mother.

This experience led me to appreciate how narrowly I had been conceiving one aspect of my psychodynamically oriented psychotherapy practice, namely, prescription writing. Just as with the nurse's letter of resignation, could there be more to a prescription than writing the name, amount, and dosage of the drug, along with instructions for taking it, the number of refills, and whether the brand name or a generic was indicated?

The inquiry led to a fascinating possibility: I could, as a psychiatrist doing therapy and prescribing medication in the traditional fashion (for the same patient), also write "prescriptions" that consisted only of ideas, suggestions, questions, or recommendations that were germane to and evolving from our psychotherapeutic work. I could write these CLRxs for patients taking medication as well as for patients who were not.

What is medication?
We have all been conditioned to think of medication only as pills or tablets prescribed by a physician. A more complex and inclusive definition of medication includes the prescription of both psychological and biologic interventions. Writing CLRxs makes use of the fact that strongly held ideas constitute some of the most potent medication known. Some ideas are so powerful that people are willing to die in their defense. These beliefs seem to be as integral a part of our existence as are our cardiovascular or neurologic systems. Other ideas provide psychological equilibrium.

For example, some men who act unconscionably are "medicated" by the idea they are "nice guys" and, as a result, suffer little or no distress following such behaviors. Other ideas have disturbing "side effects": some people believe that perfection is an attainable state and suffer greatly in its pursuit. In addition, referring to ideas as medication is not simply a figure of speech; recent studies show that psychotherapy actually changes neural pathways and chemistry in the brain—
just as psychopharmacologic agents do.1

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