Austen Riggs is Hiring a Medical or Clinical Director/CEO
News
Understanding Treatment Resistance in Pharmacotherapy: A Psychodynamic Approach
Estimated Read Time: 10 -12 minutes
What You Will Learn From This Article
- How psychodynamic factors influence medication adherence and treatment resistance.
- The impact of transference, identity struggles, and dependency fears on pharmacotherapy.
- Strategies for cultivating a psychodynamically-informed therapeutic alliance.
- The role of ambivalence and unconscious resistance in medication nonadherence.
- Practical techniques to integrate psychodynamic insights into pharmacotherapy for better patient outcomes.
As a psychiatrist working with complex cases at the Austen Riggs Center and the author of Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient, I have often found that understanding treatment resistance in pharmacotherapy requires more than just prescribing the right medication. It necessitates a nuanced appreciation of the patient’s psychodynamics, relational patterns, and internal conflicts that undermine the patient’s healthy use of pharmacotherapy. This article is based on a course I presented for the Erikson Institute of the Austen Riggs Center. In that presentation, I explore a case study to illustrate the complexities of pharmacotherapy and to provide insights into an integrated psychodynamic psychopharmacology approach. If you wish to see the course in its entirety and receive free CE/CME, you can access it easily via our online educational system.
Case Study: A Complex Pharmacotherapy Challenge
The patient in focus is a 23-year-old, single, trans woman, an art history graduate student of Lebanese Christian descent. She initially presented with a manic episode five months before her admission to Riggs, where she was prescribed olanzapine and lithium. However, as soon as she became euthymic, she stopped the olanzapine and reduced her lithium dose, prompting a second manic episode. This second episode was marked by religious delusions, culminating in a suicide attempt intended to redeem the world.
Her psychiatric history included gender dysphoria, social anxiety, self-harm, anorexia, chronic depression, and perfectionism. A pattern of nonadherence to medications was evident, reflecting deeper psychological resistance rather than straightforward pharmacological failure.
Determining the Most Pressing Intervention
From a narrowly biomedical perspective, approaches to treatment-non-response often focus on dose-optimization, ensuring trials are of adequate dose and duration, and trying treatments with different neurobiological mechanisms, as well as diagnostic re-evaluation, to ensure that medications are used for the correct psychiatric condition. In this case, however, the diagnostic evaluation that seemed most relevant was developing an overall diagnosis, a patient-centered evaluation which attempted to understand empathically those life-historical factors that made it difficult for her to use both medications and her doctors.
Social and Developmental History: Shaping Pharmacotherapy Approaches
The patient’s background revealed significant psychosocial stressors. She grew up in a high-achieving family with a critical, controlling father and an emotionally absent mother. Her struggles with identity, social alienation, and bullying in a conservative city in the US South contributed to her emotional and psychological distress and distrust of authority.
Understanding her relational patterns provided critical insights into her pharmacotherapy resistance. She exhibited sensitivity to authority figures and systems, often experiencing power struggles and oppositional behavior. These factors influenced her ability to trust medical recommendations, including medication adherence.
Psychodynamic Challenges in Pharmacotherapy
The case highlighted several key psychodynamic challenges:
- Transference to Authority: Her experience with paternalistic authority figures shaped her mistrust of treatment recommendations.
- Medication as a Threat to Identity: She feared that taking medication would alter her sense of self, exacerbating her identity diffusion.
- Resistance to Dependency: She expressed aversion to feeling “tied to something,” leading to counter-dependent behavior against both people and medications.
- The Allure of Mania: Given her baseline dysphoria, manic episodes provided temporary relief, making her less inclined to adhere to mood-stabilizing treatments.
A Psychodynamic Approach to Addressing Treatment Resistance
Understanding and addressing treatment resistance requires a framework that goes beyond prescribing medications. The Psychodynamic Psychopharmacology model developed at Riggs offers a structured approach:
1. Avoiding a Mind-Body Split
- Understanding that response to medications is always complexly determined by biological and psychological/interpersonal factors.
- Attempting to link pharmacotherapy to the patient’s developmental goals.
2. Knowing Who the Patient Is, Not Just What They Have
- Beyond diagnosis, understanding the patient’s internalized models of caregiving and relational patterns is crucial.
- Exploring fears, fantasies, and experiences regarding pharmacotherapy in order to illuminate underlying sources of ambivalence about treatment.
3. Cultivating a Psychodynamically Informed Therapeutic Alliance
- Recognize and address negative transference, helping the patient to differentiate past and present caregiving figures.
- Actively involve patients in treatment decisions to enhance their agency.
4. Attending to Ambivalence
- Very early in the treatment, directly explore patient concerns by asking exploring questions such as, “What is it like for you to take medications?” and "What might you stand to lose if treatment works?”
- Address fears that medications may undermine their identity, autonomy, or coping mechanisms.
5. Recognizing Counter-Therapeutic Uses of Medications
- Identify instances where patients use medications to suppress emotions or avoid developmental challenges.
- Differentiate between treating symptoms and enabling maladaptive coping strategies.
6. Managing Countertransference in Prescribing
- Recognize that clinicians, as much as patients, are under the sway of the unconscious, and grappling with irrationality. Avoid reacting to challenging countertransferences to complex patients with impulsive or irrational medication changes.
Clinical Implications and Best Practices
- By integrating psychodynamic insights into pharmacotherapy, clinicians can improve adherence and treatment outcomes. Key strategies include:
- Establishing a shared understanding with the patient about the purpose and limitations of medications.
- Recognizing when nonadherence is a meaningful expression of deeper psychological concerns rather than simple forgetfulness or negligence.
- Using psychotherapy to address transferential concerns (e.g., fears of dependency, loss of control, and identity disturbances related to medication use).
- Collaborating with therapists to create an integrated treatment plan that aligns pharmacotherapy with the patient’s psychological needs.
Some Parting Thoughts
In my experience, effective pharmacotherapy is not just about prescribing the right drug; it is about understanding the meaning of medication in the patient’s life and how it interacts with their psychological landscape. A psychodynamic approach helps clinicians navigate complex cases where resistance is deeply rooted in identity, relational dynamics, and unconscious conflicts. By addressing these underlying factors, behavioral health professionals can foster better treatment engagement, enhance therapeutic alliances, and ultimately, improve patient outcomes.
I hope you found this article helpful. If so, feel free to check out the entire course. You can earn CE/CME credit after you view the presentation and successfully complete a short quiz derived from the content.
Related Resources
Course
The Art of Pharmacotherapy: Enhancing Outcomes by Integrating Patient-Centered, Psychodynamically-Informed Perspectives
August 10, 2023
Free CE/CME Five-Part Course Series with David Mintz, MD
Resource
Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient
February 24, 2022
Psychodynamic psychopharmacology, as outlined in this book authored by David Mintz, MD, offers a model that moves beyond compliance and emphasizes instead the alliance between patient and prescriber.
Resource