In a treatment environment in which most patients bring psychiatric complaints to primary care clinicians, psychiatrists increasingly treat patients who have not responded to initial treatment strategies. Hence, such patients make up a substantial proportion of the caseloads of psychiatrists. The dilemmas these patients pose often test the limits of our knowledge and our skills. Equally important, they test our emotional capacities, whether we are offering pharmacotherapy or psychotherapy or leading treatment systems. When characterologic difficulties contribute to treatment resistance, distressed patients may transmit to physicians the same distressing feelings that they are trying to escape. In treatment systems, the patient’s internal tumult may be projected into the larger system, so that psychiatrists are managing both the evoked irrationality in the system and the intense distress of the patient.  

Integrating a psychodynamic perspective into treatment offers a way, first of all, to make sense of treatment-resistance, preserving the treater’s capacity for empathy while also allowing the treater to better adapt to the unique demands of the individual patient. Understanding the underlying dynamics of complex patients also gives the psychiatrist tools to address irrational system dynamics that are potentially countertherapeutic if unidentified and unchecked. Thoughtful attention to the meanings of countertransference is one valuable tool not only for managing unhelpful reactions, but also understanding the patient’s experience. A psychodynamic perspective also provides tools for developing and using a therapeutic alliance, with patients for whom the alliance is often fragile. Understanding the patient’s and therapist’s contribution to impasses in psychotherapy can help such treatments become unstuck, and is an important aspect of the skillset of competent psychiatrist-psychotherapists. Those same skills can also be useful for addressing treatment resistance in relation to psychopharmacotherapy, given how meaning effects often shape pharmacotherapy treatment outcomes. 

This conference, designed for psychiatric residents, is intended to enhance participants’ capacities to work effectively with difficult-to-treat patients through the integration of psychodynamically-informed and patient-centered perspectives into diverse aspects of the patient’s care. The knowledge, skills, and attitudes of psychodynamic psychiatry are not only useful in the psychotherapy of patients, but also foster leadership skills for addressing systems enactments in relation to challenging patients, and can markedly enhance effectiveness of pharmacotherapy. 

Objectives: 

At the Conclusion of this 2-day conference, residents should be able to: 

1. Empathically describe the human struggles and common dynamics underlying treatment-refractoriness, encompassing both the patient’s and the treatment’s contribution to impasse 
2. ​Ameliorate treatment-interfering dynamics in psychotherapy 
3. ​Apply practical psychodynamics to enhance pharmacotherapy outcomes 
4. ​Improve medical leadership skills through the ability to address systems dynamics evoked by complex patients.  

Agenda: 

Friday, April 23