After receiving a prescription for mood stabilizers for bipolar disorder, a patient prone to splitting as a defense will often experience an immediate reduction in dysphoria. A psychopharmacologist who is inclined to think both psychodynamically and biologically will recognize that the reduction in dysphoria may be occurring not because of the medication but because it allows the patient to create a stable split within which he can remain good while all badness is located in “my bipolar.”
While patients may feel better, they actually do worse. No longer feeling personally responsible for symptomatic behavior, they give their worst instincts free rein, exacerbating personal and interpersonal chaos. It is important not to collude unwittingly with these legally competent patients whose treatment resistance relates to defensive use of medications. Rather, it is crucial to empathically help them understand that although they are ill, they remain responsible for their choices.
Medications can be used defensively in myriad ways. Patients who experience people as dangerous and unreliable may attempt to replace people with pills. Still other patients may feel that any “negative” feeling is pathological and should be extinguished. If accepted at face value, this can lead a well-meaning psychiatrist toward an ever more complex and burdensome medication regimen that actually contravenes healthy developmental aims.
When pills are used to manage developmentally appropriate feelings, such as loneliness, disappointment, sadness, frustration, or anger, patients lose important opportunities that might lead to improved internal controls and increased affective or interpersonal competence. Patienthood may be reinforced.
Elements of psychodynamic psychopharmacology
Psychodynamic psychopharmacology represents an integration of biological psychiatry and psychodynamic insights and techniques. Psychodynamic psychopharmacology provides little guidance about what to prescribe; instead, it helps prescribers know how to prescribe to improve outcomes.
There are 6 principles for psychodynamically informed pharmacological practice with treatment-resistant patients3:
• Avoid a mind-body split
• Know your patient
• Attend to the patient’s ambivalence about the loss of symptoms
• Address negative transferences and resistance to medications
• Be aware of countertherapeutic uses of medications (resistance from medications)
• Identify and contain countertransference involving prescribing19
Avoid a mind-body split. A psychodynamic psychopharmacologist recognizes that a rigid mind-body dualism is a fantasy. Experiences, feelings, ideas, and relationships change the structure and function of the brain just as the state of the brain influences experience. A psychodynamic psychopharmacologist considers that a positive or negative medication response may be a direct action of the pill or may be mediated by the meanings the patient attaches to the pill.
Mind-body integration also means that psychotherapy and psychopharmacology will need to be well-integrated so that psychopharmacological interventions facilitate the psychotherapy and so that the therapy helps the patient become conscious of psychological sources of pharmacological treatment resistance. Effective psychopharmacological interventions to treatment nonresponse might include an increase in frequency of appointments rather than an increase in medication dosage.20
Know your patient. Sir William Osler, the father of modern medicine, remarked that “it is much more important to know what sort of patient has a disease than to know what sort of disease a patient has.” This is a central tenet of psychodynamic psychopharmacology. Practically, this means that the pharmacologist should get a thorough developmental and social history to make reasonable hypotheses about the psychosocial origins of the patient’s treatment resistance. The prescriber should also directly assess the patient’s attitudes about medications (fears of dependency, worries about being “turned into a zombie,” and so on). This not only helps assess potential sources of resistance, but it also lets the patient know the prescriber is interested in him as a person, which may enhance the alliance.
