The Concept-Laden Prescription

December 1, 2006
Jerome S. Gans, MD

Volume 23, Issue 14

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.

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

The practice of writing CLRxs
A review of my cases indicates that I tend to write CLRxs for patients who have been in therapy with me for more than 2 years and with whom I have established a meaningful therapeutic alliance. These patients, who make up about 5% to10% of my patient roster, have serious pre-oedipal difficulties involving such basic matters as their right to exist, profound distrust, conviction of their badness, invalidation of their feelings, compulsive need to perform good deeds to obtain love, and a precarious sense of self. The dispensing of CLRxs usually occurs during the phase of therapy that "works through" the insights gained in the analysis of transference. Since no 2 clinical situations are the same, the therapist's introduction of the CLRx should be dictated by the needs of the patient, the phase of the therapy, and the state of the transference, countertransference, and therapeutic alliance. Occasionally, the CLRx simply suggests a book, usually a novel, the discussion of which I believe will illuminate a current issue in therapy.

Therapeutic components of the CLRx
The CLRx can help patients take greater responsibility for their therapy, circumvent oppositionalism, put insights into practice, and promote internalization of lessons learned in therapy. A traditional prescription conjures up the vision of the patient being acted upon by the recommendation of the physician. The CLRx suggests collaboration between physician and patient: "Here is an idea that has evolved from the work between us-let us see what more we can learn and consolidate about it."

Because the CLRx is both like and unlike a traditional prescription, it takes on a metaphorical quality. Just as medication is a reminder of the therapist's existence, knowledge, and caring, the written prescription denotes that something beneficial for the patient is to be ingested. Unlike pills that are ingested, the CLRx is permanent, a kind of transitional object. While the message contained in the CLRx is often concrete and behavioral, the transaction itself is metaphorical. Metaphors provide a play space in which notions of right or wrong have no currency and in which spontaneity and creativity are more possible.2,3 Through the metaphorical mode of the CLRx, the therapist is in a favorable position to make suggestions that can help the patient actualize insight. Consider the following example.

Case vignette
A woman in her 40s with many admirable qualities reported that after telephone calls with her highly critical mother, she would feel defenseless and would go into a free fall that would last for days. Although a sustained inquiry into the dynamics of this interaction resulted in the patient's awareness that she had become an unwitting receptacle for her mother's projected low self-esteem, she continued to be devastated by these conversations.

Her therapist wrote her the following CLRx with the instruction that she keep it by her phone: Mother, what do you think it is about YOU that makes it so difficult for YOU to appreciate me?

The CLRx provided the patient with an opportunity to speak the seemingly unspeakable, to think about why doing so was so difficult, and appreciate what it felt like to risk such a behavior. As in this case, the CLRx may also result in revisiting the transference to see whether, presently, there are things the patient is finding it difficult to say to her therapist.

While the CLRx may appear to be an overly behavioral technique to be employed in psychodynamic treatment, Ablon4 has shown that psychodynamically oriented therapists draw on cognitive-behavioral approaches more than they realize or acknowledge. Conceptual pluralism in the service of helping a patient should trump theoretical purity.

The CLRx promotes integration of important insights gained in therapy by countering the many factors that oppose such assimilation: resistance, excessive anxiety, hostile compliance (in which the lesson is seemingly taken in but never actually learned), a need to defeat perceived authority, the overpowering effects of shame on the learning process, and a profound sense of being undeserving, including being undeserving of the insights of one's own psychotherapy.

It has been my impression that the effectiveness of the well-timed CLRx derives from both the writing of the message and the medium on which it is written. The therapist takes the time and effort to put into writing an important idea that the therapy has yielded. This unexpected and unusual activity can reflect a caring that the patient has come to unconsciously expect without actually appreciating. As Benjamin5 has pointed out in her writings on intersubjectivity, therapy involves the recognition as well as the internalization of the (m)other and, in this instance, the therapist. The message, furthermore, is contained in a transaction that conjures up the patient's ingestion of something from the therapist. One of my patients has been carrying several CLRxs in her purse for more than 10 years!

Writing CLRxs for patients also taking medication
More than prescribing psychiatrists may realize, their patients may be reluctant to be fully honest about their negative thoughts and feelings about medication. Why is this so, and can the CLRx neutralize or reverse this tendency? Patients tend to believe, especially in this era of biologic psychiatry, that psychiatrists are highly invested in the effectiveness of the drugs they prescribe. Psychiatrists, who are paid preferentially by HMOs for prescribing medication but not for seeing patients in psychotherapy, are also very invested in the effectiveness of the medications they prescribe. Training in most residency programs has already predisposed us to such an orientation.6 Sensing this attitude, patients may be more reluctant than they realize to tell the psychiatrist that the drugs are not helping. Certain patients may be more concerned about disappointing their psychiatrist-prescribers than about pursuing their own welfare. In the process, many questions-often shared by psychiatrist and patient alike-never get broached and discussed: "What is actually helping me in this therapy, if anything at all? Is it the medicine? Is it the knowledge, comments, and caring of my therapist? Is it our hard work together? Or would I have made progress or be the same without the medication or the therapy?"

It is my impression that the CLRx provides an opportunity to explore the complexities involved in taking medication as well as to overcome what many patients imagine to be their therapist's overinvestment in the effectiveness of medication. Why might this be so? The therapist's decision to take a time-honored symbol to suggest the potency of words rather than pills has a way of dethroning the majesty of medication. It is unlikely that a true believer in medication's effectiveness would behave in such a manner.

Writing ideas pertinent to the therapy on a prescription pad, in addition to writing traditional prescriptions, has an indirect way of indicating to the patient that the prescribing therapist is not overly captivated by one therapeutic persuasion. What the patient finds therapeutic is the therapist's dedication to pursuing the truth as opposed to promoting his or her "product," be it medication or therapy or both. The sum of these various meta-communications may be that the patient is subliminally invited to think, "My therapist is someone who is open to discussing medication not simply as a substance but as a complex phenomenon to be explored and understood."

I have found that CLRxs can play a role in illuminating the sometimes hidden views of various types of patients toward the medication they are taking. For example, patients with little sense of personal agency who are prone to experience themselves as victims are often more than willing to cede credit to forces outside themselves. In a similar vein, but for different reasons, patients who need to impugn the importance of personal relationships in the healing process often ascribe all progress in the therapy to the medication. Other patients who experience taking medication as a sign of personal weakness may feel the need to deny any beneficial medication effects. The effect of discussing the CLRx with these patients is to accord medication its rightful rather than undue or insufficient credit-a calculation that is never easy and always imprecise.

Of course, patients sometimes experience our interventions in ways other than those we intended; thus, the psychiatrist must be prepared for patients who either interpret the writing of a CLRx as an expression of their therapist's lack of confidence in the effectiveness of traditional medication or as an endorsement of it. And finally, as with any other therapeutic intervention, the CLRx can be misused and constitute an enactment, wherein the patient (or the therapist) experiences the behavior of the other as defensive and intended to strongly influence, persuade, or force the other to react.7

Summary
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 CLRx can contribute to the realization of the following therapeutic aims: replacement of oppositionalism and passivity with the opportunity for more active collaboration in, and responsibility for, the therapeutic process; relocation of therapy to a different space that allows for greater spontaneity, playfulness, and creativity; and a receptivity to an authentic exploration of the value of medication, be it molecular or ideational, in the therapeutic process. When thoughtfully employed with regard for the state of the transference and therapeutic alliance and vigilant attention to countertransference, it can take its appropriate place in the tradition of innovative therapeutic techniques.

Dr Gans is associate clinical professor of psychiatry at Harvard Medical School and clinical associate in psychiatry at Massachusetts General Hospital in Boston. He also has a private practice in Wellesley and Cambridge, Mass. He reports no conflicts of interest concerning the subject matter of this article.

References:

References1. Linden DEJ. How psychotherapy changes the brain. Mol Biol. 2006;11,528-538.
2. Gans JS. The leader's use of metaphor in group therapy. Internat J Group Psychother. 1991;41:127-143.
3. Lakoff G, Johnson M. Metaphors We Live By. Chicago: The University of Chicago Press; 1980.
4. Ablon JS. How expert clinicians' prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive-behavioral therapy. Psychother Res. 1998; 8:71-83.
5. Benjamin J. Like Subjects, Love Objects. New Haven, Conn: Yale University Press; 1995.
6. Lewis JM. Swimming Upstream: Teaching and Learning Psychotherapy in a Biological Era. New York: Brunner/Mazel; 1991.
7. McLaughlin JT, Johan M. Enactments in psychoanalysis. J Am Psychoan Assoc. 1992;40:827-841.