The Riggs Difference: Where Understanding Leads to Recovery
Estimated Reading Time: 9 minutes
Key Takeaways
- Meaning matters: Medications carry symbolic weight that can heal or harm depending on context.
- Nocebo effects are real: Expectations of harm can cause measurable physiological and psychological distress.
- Empowerment protects: Shared decision-making reduces side effects and builds resilience.
- Ethics require balance: Harms from full transparency are balanced by benefits
- Relationship heals: The clinician’s presence and empathy are themselves therapeutic agents.
In a compelling virtual presentation from the Austen Riggs Center’s Erikson Institute, David Mintz, MD, Associate Director of Training and Director of Psychiatric Education at Riggs, examined an often-overlooked dimension of psychiatric care—how the meanings patients attach to medications can profoundly shape their experience of treatment and become a source of harm.
His talk, Meaning-Based Harm from Medications: Clinical and Ethical Implications, challenged clinicians to reconsider the hidden psychological, ethical, and relational forces that accompany every prescription. You can view the presentation and receive free CE/CME credit here. (In addition, this ethics course is approved for AMA PRA Credit™ risk management study.)
Understanding “Meaning-Based Harm”
Mintz opened by noting that placebo and nocebo effects—the positive and negative expectations surrounding treatment—can be as powerful as the pharmacologic properties of medications themselves.
“Who the doctor is,” he said, “often matters more than whether the patient is getting an active drug or a placebo.”
While placebo effects can promote healing, their counterpart, nocebo effects, can produce real suffering. These are harmful responses driven not by biology but by meaning—by expectations of harm, fear, mistrust, or disempowerment in the therapeutic relationship.
How Meaning Produces Harm
Mintz outlined three major pathways through which, the evidence tells us, medications can cause meaning-based harm:
1. Physician Effects:
The way clinicians explain illness or treatment can inadvertently worsen outcomes. For example, telling a patient that their depression is genetically determined can lead to hopelessness, lower self-efficacy that could be mobilized in the service of recovery.
The way clinicians explain illness or treatment can inadvertently worsen outcomes. For example, telling a patient that their depression is genetically determined can lead to hopelessness, lower self-efficacy that could be mobilized in the service of recovery.
2. Nocebo Effects:
When patients expect harm, they are statistically more likely to experience side effects—even when taking inert substances. In clinical trials, as many as 25% of placebo-treated patients report side effects from placebo medications.
When patients expect harm, they are statistically more likely to experience side effects—even when taking inert substances. In clinical trials, as many as 25% of placebo-treated patients report side effects from placebo medications.
3. Treatment Resistance from Meaning:
Patients may unconsciously use medications, or the meanings attached to pharmacotherapy, countertherapeutically (e.g. to avoid emotions, or externalize responsibility. Over time, this can entrench the patient in a patient role or leave them unnecessarily dependent on medications.
Patients may unconsciously use medications, or the meanings attached to pharmacotherapy, countertherapeutically (e.g. to avoid emotions, or externalize responsibility. Over time, this can entrench the patient in a patient role or leave them unnecessarily dependent on medications.
Power, Meaning, and Inequality in Psychiatric Treatment
Mintz emphasized that meaning-based harm is not distributed equally. Patients with fewer social resources—those marginalized by race, class, or trauma—are more vulnerable to feeling powerless in treatment, which heightens susceptibility to nocebo responses.
Even when the patient adopts a self-disempowering stance, these patients are more likely to experience harm from medications. He urged clinicians to consider how power dynamics and cultural context shape medication outcomes, and to approach prescribing as a relational and ethical act, not merely a technical one.
Case in Point: The Generic Substitution Phenomenon
In a striking example, Mintz described a New Zealand study where patients taking a thyroid medication reported large spikes in reported side effects after the drug’s color and packaging changed—even though the formula remained identical. Media coverage amplified fear, triggering a surge of symptom reporting across the country.
This case, he noted, illustrates how societal meanings and narratives—from media to online misinformation—can drive widespread physiological and emotional reactions, independent of pharmacology.
The Ethics of Disclosure: Between Help and Harm
A recurring theme of Mintz’s talk was the ethical tension between truth-telling and harm reduction. Clinicians face a paradox:
- Informing patients about side effects can cause those side effects to appear (a nocebo effect).
- Withholding information may reduce harm—but violates autonomy and informed consent.
Mintz proposed a range of strategies for supporting patient autonomy, while reducing negative effects on treatment of full disclosure of limitations of medications and potential harms.
These included:
- Offer patients a choice about how much detail they want regarding side effects.
- Use positive framing (“95% of patients tolerate this medication well”) to promote optimism.
- Educate patients about placebo and nocebo mechanisms early, normalizing these effects as embodied responses, not “imaginary” ones, and ones that might be addressed at the level of meaning.
Empowerment and Shared Decision-Making
Empowerment, Mintz argued, is the antidote to meaning-based harm. When patients feel they have agency in the treatment process, outcomes improve.
He cited studies showing that simply offering patients a choice between two medications—even if both are placebos—reduces side effects and increases long-term adherence.
“The more we empower our patients,” he said, “the more we reduce the harms we do.”
Practical strategies include:
- Inviting collaboration and reflection on medication meaning.
- Allowing patients to set the pace for change or de-prescribing.
- Framing pharmacotherapy as one tool among many for emotional and relational growth.
“The Doctor Is the Drug”: Relational Factors in Healing
Referencing psychiatrist Michael Balint’s concept that “the doctor is the drug,” Mintz emphasized the transformative power of relationship itself in pharmacotherapy.
A clinician’s warmth, curiosity, and empathy can modulate neurobiological response, while cold or dismissive communication can increase distress and side-effect sensitivity.
Simply “increasing the dose of the doctor”—spending more time, listening more carefully, and fostering trust through openness—can boost response to treatment and reduce harms.
Addressing Split Treatment and Integration
During the Q&A, Mintz and host Kyle Shepherd, DO, discussed the challenges of “split treatment,” where psychiatrists, therapists, and staff work separately. Such divisions, Mintz warned, can leave the meanings of medications unexplored, falling into the “gap between the specialties.”
He advocated for integrated, team-based reflection—where therapists attend to the emotional and relational meanings of medication, and psychiatrists remain open to the psychological dimensions of prescribing.
To hear the full presentation and receive CE/CME credits, please visit the Meaning-Based Harm from Medications: Clinical and Ethical Implications course page.
To learn more about the Austen Riggs Center’s unique approach to psychopharmacology, please visit our psychodynamic psychopharmacology page.
Related Resources
Resource
Psychodynamic Psychopharmacology with Dr. David Mintz (Parts 1 & 2)
January 12, 2023
Matthew Yung, MD, interviews David Mintz, MD, on treatment resistance and psychodynamic psychopharmacology (part 1) and applying psychodynamic psychopharmacology into clinical practice (part 2).
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Meaning-Based Harm from Medications: Clinical and Ethical Implications
August 7, 2025
Free CE/CME course with David Mintz, MD
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