By Behdad Bozorgnia, MD
Dr. Bozorgnia is an adult psychiatrist and a psychoanalytic psychotherapist in private practice in Philadelphia, Pennsylvania, USA. He also teaches at the University of Pennsylvania and at the Psychoanalytic Center of Philadelphia. His private practice website is https://bozorgniamd.com
This article was published on February 28, 2022, and last updated/ edited on March 20, 2022.
Patients’ reactions—both positive and negative—to biologically inert substances (placebos) show that patients’ beliefs and expectations contribute to how they respond to medications. This has been well documented in both the placebo and nocebo effects (Colloca and Miller, 2011).
In this article, I will discuss three key points that we need to understand about what has been called “psychodynamic psychopharmacology” and then, I’ll make some clinical recommendations about how to apply them in clinical practice.
Unconscious beliefs and expectations affect response to medications
Here is a key point:
Patients don’t have to be consciously aware of their beliefs and expectations for them to determine patients’ reactions to medications.
Some unconscious beliefs about medications are easily accessible and potentially alterable by conscious thought. For example, a patient may mistakenly assume that selective serotonin reuptake inhibitors are “heavy drugs” and “unsafe”. Such beliefs are potentially amenable to reassurance and psychoeducation.
But, other pertinent mental states—especially those that provoke strong emotional reactions—-are not easily brought to conscious awareness or changed by conscious thought about them. These mental states we can call repressed.
Repressed mental states are often “enacted” in clinical situations
Here is a second key point:
Since repressed mental states cannot be communicated and processed verbally, they are often “enacted” or lived out in experiences and actions in the relationship with medications and, by extension, with the prescribing clinician (Johan, 1992)
When such enactments of repressed mental states undermine psychopharmacological treatment, they can leave both the physician and the patient feeling stuck, frustrated, and helpless (Mintz and Belnap, 2006).
We can identify relevant unconscious factors—-but only indirectly
The third key point that underlies the practice of psychodynamic psychopharmacology is that:
Repressed mental states often cannot be directly observed but must be inferred from the pattern of the patient’s reactions and an empathic understanding of the patient’s emotional life in general.
For example, a patient of mine reacted to almost all psychoactive medications with idiosyncratic side effects that rendered them intolerable. Working with her psychotherapist, I learned that the patient’s mother slipped her a sedative at the age of 8 during the family’s sudden move to a different country. Knowing this, I was able to empathize with her experience and we were able to speak about her understandable mistrust of medications. The doctor-patient relationship was strengthened and by, emphasizing her agency over medications, she tolerated them better.
While prescribing psychiatric medications:
1) We should know emotionally salient features of the patient’s life story, for example, key points in the plot, important characters, and repeated themes (Hamkins, 2013). There are two ways to approach this.
– One is a more general approach that involves asking patients to tell us about their lives from the time they were a child onwards. We can encourage them to talk about their childhood, their experience in school, their experience with work and adulthood. This approach can be very revealing but it can also be quite time-consuming.
– Another more targeted approach is asking about the times in life when symptoms emerged and then getting a sense of the context within which those symptoms occurred. Questions might include: When did you first experience anxiety? What was going on in your life then, even if it does not seem related? When was another time when anxiety got bad? What was going on in your life then? For example, a patient of mine whose anxiety had not responded to SSRIs, SNRIs, and gabapentin, revealed that his anxiety first appeared in response to going to a funeral at the age of 5. Since then he had been terrified of death and often experiencing anxiety coupled with multiple somatic symptoms stemming from this fear. Along with prescribing medications, it was important to discuss the patient’s fears in order to help with the anxiety.
2) We should look for emotionally meaningful connections between the patient’s experience of medications and their experiences in life.
– Are there any parallels (similarities) between major life events or major life figures (parents, siblings, loved ones) and the way the patient experiences medications?
– Is there a significant relationship pattern that’s being repeated in the interaction with medications? For example, a patient of mine wanted to discontinue aripiprazole even though it was helping with her mood because she felt that she could not drink and travel freely while being on it. With some inquiry, we discovered that she had overprotective parents who in their attempts to provide safety for her also made her feel controlled. Similarly, the aripiprazole was protective but also undermined her independence. This concern had to be discussed in order to make progress in her treatment.
3) We should introduce these connections in a gentle and open-minded manner into discussions with the patient, allowing for an exploratory conversation with the patient.
The key to understanding the patient’s unconscious reactions to medication is to approach the topic with curiosity and humility. If a patient is not aware of some emotion or experience that is determining their response to medications, it is likely because being aware of it evokes other painful feelings. So, being insistent or forceful in pointing out these connections will be unlikely to help them take a different perspective and may only make things worse. It is best to simply raise questions and evoke a discussion to help patients to make the connections themselves.
For example, when I get the sense that a patient may have a psychological resistance to a medication response, I generally begin by talking to the patient about the importance of our psychology to our experience of medications—normalizing such reactions. Then, I simply ask open-ended questions and try to see if the patient can explore the topic with me.
For more on psychodynamic psychopharmacology, please see the videos of Raj Mago’s interview with David Mintz, MD, a leading expert on the topic, and our notes from that interview, at the following link:
“Psychodynamic psychopharmacology”: The art of dealing with treatment-resistance (Interview with David Mintz, MD)
Colloca L, Miller FG. The nocebo effect and its relevance for clinical practice. Psychosom Med. 2011 Sep;73(7):598-603. doi: 10.1097/PSY.0b013e3182294a50. Epub 2011 Aug 23. PMID: 21862825; PMCID: PMC3167012.
Hamkins S. The art of narrative psychiatry: Stories of strength and meaning. Oxford University Press; 2013.
Johan M. Enactments in psychoanalysis. Panel report. J Am Psychoanal Assoc. 1992;40(3):827-41. doi: 10.1177/000306519204000307. PMID: 1401722.
Mintz D, Belnap B. A view from Riggs: treatment resistance and patient authority – III. What is psychodynamic psychopharmacology? An approach to pharmacologic treatment resistance. J Am Acad Psychoanal Dyn Psychiatry. 2006 Winter;34(4):581-601. doi: 10.1521/jaap.2006.34.4.581. PMID: 17274730.
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