Attend to ambivalence about loss of symptoms. Identify potential sources of ambivalence about symptoms, such as secondary gains, and communicative or defensive value of symptoms. It may be helpful at the point of intake to ask the patient what he would stand to lose if treatment was successful. (The same question posed in the middle of a treatment may be colored by the doctor’s frustration and is more likely to produce a negative response.)
Address negative transferences and resistance to medications. Once potential sources of resistance to the medication or the doctor are understood, they must be addressed. If they are clear at the outset, they must be addressed preemptively. In this way, an alliance is made with the patient before massive resistance is sparked. Negative transferences must be identified and worked through. Empathic interpretation of nocebo responses can resolve adverse effects.21
Be aware of countertherapeutic uses of medications (resistance from medications). Countertherapeutic uses of medications should also be interpreted. As a prescriber, you might tolerate some irrational use of medications if the patient is working through an issue that interferes with a healthier use of those medications. There comes a time, however, when discontinuation of a countertherapeutic medication may become a condition of continued pharmacological treatment.
Identify and contain countertransference in prescribing. When patients struggle with overwhelming dysphoric affects, they often evoke corresponding effects in their prescribers.2 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. A psychodynamic psychopharmacologist recognizes that the psychiatric relationship is an encounter between a big mess and an even bigger mess. An attitude of humility along with periodic consultation about difficult cases helps manage irrational prescribing.
There are many sources of pharmacological treatment resistance. When treatment resistance arises from the level of meaning, interventions are not likely to be successful unless they address problems at the level of meaning. Psychiatric care providers who operate from either a dogmatic psychotherapeutic paradigm or a psychopharmacological paradigm are hobbled by having access to only half the patient. Psychodynamic psychopharmacology combines rational prescribing with tools to identify and address irrational interferences with healthy and effective use of medications. We should not neglect psychodynamic contributions that enhance the integration of meaning and biology. It is the capacity to integrate and understand complex situations that more than anything else lends its particular power to our discipline and gives us skills for working with particularly troubled patients.