The Relationship Between Psychiatrist and Patient Also Matters When Prescribing Medication

A visual artist arrived at my office with a mixture of urgency and mistrust. Her physician had recommended medication, but she wanted a second opinion. She wanted relief from insomnia, anxiety, and intrusive thoughts, yet feared that the drug would extinguish the spark that fueled her work. “I’m afraid of losing my creative edge,” she said. In another consultation, a patient confessed to me: “I don’t want to take antidepressants because I feel they’ll change me, that I won’t recognize myself anymore.” He was not afraid of side effects, but of something deeper: the suspicion that medication also acts upon identity. Ultimately, every treatment is an intervention in which body, mind, and personal history converge. It requires listening, respect, and time. What heals is not only the drug, but the possibility of saying: “This helps me, but I am still myself.”

From the Austen Riggs Center in Massachusetts, psychiatrist David Mintz proposes a broader approach he calls psychodynamic psychopharmacology, according to which medications do not act in a biological vacuum, but within a psychological, relational, and symbolic framework. The patient’s interpretation can amplify or interfere with their effect. It is not merely a chemical matter, but also a message. For some patients, medication represents capitulation, an admission of fragility, or a violation of self‑sufficiency; for others, an emblem of external control or an echo of childhood, when they felt unable to express resistance.

Mintz recalls the enthusiasm of the 1990s, when U.S. President George H. W. Bush declared the “Decade of the Brain” and predicted that mental illnesses would be eradicated within ten years. That simplistic optimism, rooted in biomedicine, ultimately stripped many psychiatric patients of their sense of agency and relegated them to a passive position, waiting to be “fixed.” For Mintz, this is the greatest drawback when improvement is the goal. Just as children stop clinging to their teddy bears—once imbued with calming powers—when they internalize the qualities they had attributed to them, the power invested in medication must be returned to the person. If medication is expected to solve everything, there is a risk of transferring all responsibility for change onto the drug and condemning the individual to chronicity.

Evidence supports this integrative view: between 50% and 80% of the response to medication is attributable to psychological factors. Expectations, previous experiences, unexpressed ambivalence, and above all the quality of the doctor‑patient relationship all play a role. A Swiss study involving more than 130 participants showed that mental representations strongly influence adherence: fear of harm, loss of control, or feelings of alienation were the most common themes, while the idea of benefit appeared only in fifth place. For many, medication is not merely a therapeutic tool, but an object laden with symbolic ambivalence. The metaphors used to describe it—crutches, poison, emotional patches—reveal a tension between the desire for relief and the fear of transformation. This ambivalence is even present in its etymology: pharmakon means both remedy and poison, and pharmakos referred to the scapegoat sacrificed in a ritual to purify the community.

The most surprising finding of a recent meta‑analysis on placebo effects in patients with depression was that up to 80% of the benefits associated with antidepressants can be explained by the placebo effect—placebos are not sugar pills; they activate real physiological processes. Another unsettling finding is that they can also generate adverse effects, or a “nocebo effect,” such as anxiety, insomnia, or somatic symptoms, when the person receiving treatment anticipates harm or distrusts it. This supports Mintz’s idea that patient expectations may exert more influence than the drug’s active ingredient. In patients who have a strong relationship with their doctor, placebo can be more effective than antidepressants in patients who do not trust their physician. And, incidentally, studies have shown that when the doctor explains this from the outset, the placebo effect is not diminished.

“When the doctor‑patient relationship is undermined by cuts to national health systems, the most powerful part of treatment is lost,” Mintz reiterates. He adds that under pressure, physicians also tend to simplify and prescribe medications to cope with their own sense of helplessness, even when they might have preferred a more comprehensive approach. Ultimately, it is not only what is prescribed that matters, but how it is prescribed: what may seem like a detail often condenses the very conflicts that run through a person’s life. Perhaps that is why Kipling warned as early as 1923: “Words are, of course, the most powerful drug used by humankind.”