Just as positive transferences to the doctor or drug lead to positive responses, negative transferences are likely to lead to negative responses. Patients who have been abused or neglected by caregivers in the past or those who otherwise feel vulnerable to authority figures (either because of social disadvantage or a propensity to acquiesce) are prone to nocebo responses.14,15 The obverse of the placebo response, nocebo responses occur when patients expect (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.
Pharmacological treatment resistance
From a psychodynamic perspective, patients may be seen as resistant to medication or resistant from medication. These 2 broad categories of pharmacological treatment resistance tend to have different underlying dynamics and may require different kinds of interventions.
Patients who are resistant to medications have conscious or unconscious factors that interfere with the desired effect of medications. Often, resistance in this category takes the form of nonadherence but also includes patients who repeatedly experience adverse responses to medications (ie, nocebo responders).
In contrast, patients who are resistant from medications more typically are eager to receive the medication or some benefit that the patient ascribes to the medication. For such patients, pills may appear to relieve symptoms, but they do not contribute to an improvement in the patient’s quality of life. Resistance to medications and resistance from medications are not mutually exclusive, and some patients present with both dynamics.
In 1905, Freud16 described the psychodynamic concept of resistance and concluded that many patients were unconsciously reluctant to relinquish their symptoms or were unwittingly driven, for transference reasons, to resist the doctor. These same dynamics may apply in pharmacotherapy. Although suffering greatly, patients may find good uses for their symptoms. Patients who derive significant secondary gains from their symptoms (eg, they are relieved from various burdens, or they receive care rather than neglect as a result of their illness) can be deeply conflicted about getting better, which may manifest as treatment resistance.
Patients who need their symptoms to communicate something that they cannot put into words will be similarly ambivalent.2 When symptoms constitute an important defense mechanism, patients are also likely to resist medication effects until they have developed more mature defenses or more effective ways of coping.3
Patients who are not resistant to symptom reduction may nonetheless be motivated to resist the doctor on the basis of a transference experience of the doctor as untrustworthy or even dangerous. Such patients often painstakingly negotiate the medication, dosing, and timing of medications (so as not to feel under the control of the malevolently experienced doctor) or surreptitiously manage their own regimen (by taking more or less than the prescribed dose). Needless to say, if they are not taking a therapeutic dose, they lessen their chances of a therapeutic response. As noted, if these patients cannot resist the doctor’s orders, then their bodies may unconsciously do the resisting for them, which leads to nocebo effects.
Patients who are treatment-resistant typically present as hungry for medications. Although they take the medications and may report symptom reduction, these patients do not function better with pharmacotherapy; in fact, some seem to get worse. A psychodynamic psychopharmacologist is mindful that there are countless ways these medications may serve countertherapeutic and/or defensive aims.
Patients may use pills defensively to disavow responsibility for their feelings and actions.17 This commonly occurs in the case of primitively organized and character-disordered patients who rely on splitting and projective dynamics. Such patients tend to see things strictly in black and white and often defend against feeling intolerably and completely bad by displacing all of the “badness” onto the “other” in a relationship. After receiving a prescription of 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. They no longer feel personally responsible for symptomatic behavior; therefore, 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 though ill, they remain responsible for their choices.