As a psychiatric Fellow in the late 1990s, I found myself torn. I had come to Riggs to learn a psychodynamic perspective on treatment that focused on meaning making, on the value of relationships, and on supporting patient authority. Meanwhile, mainstream psychiatry was moving in a completely different direction. In the 90s, declared by Presidential proclamation to be the “Decade of the Brain,” excitement about our burgeoning neuroscientific knowledge combined with the impact of managed care to produce a model of psychiatric practice that was largely the antithesis of what I was learning in my Fellowship. It felt as if my identity as a psychiatrist was being ripped in two.
My solution was to try to find ways to take my learning at Riggs and apply it to the practice of pharmacotherapy, in the hopes of bridging the opening gulf between these two aspects of psychiatric identity. Having learned from our “treatment-resistant” patients that the failure of pharmacotherapy was, as often as not, connected to problems in the doctor-patient relationship or to the patient’s unengaged conflicts about medications or treatment, I began, with my colleagues at Riggs, to study and write about the impact of meaning on pharmacotherapy outcomes. We identified six core technical principles to provide integrated, psychodynamically informed, patient-centered pharmacotherapy. These were:
- Avoid a mind-body split in approaching the patient
- Know who (not just what) the patient is
- Attend to the patient’s ambivalences about illness, medications, and caregiving
- Foster the doctor-patient alliance and address negative transferences
- Address covert countertherapeutic uses of medications
- Contain irrational prescribing driven by countertransference
Our hope was that we could offer some kind of antidote to the objectifying pharmacomania trending in mainstream psychiatry. Our more modest hopes seemed to be achieved when our publications were incorporated into the curricula of a majority of psychiatric residencies. To have a broader impact in promoting a psychodynamically informed patient-centered perspective, in this age of “evidence-based practice,” however, would require establishing a firm empirical footing for psychodynamic psychopharmacology. In this spirit, the Psychodynamic Psychopharmacology Strategic Initiative at Riggs was born.
With Dr. Gerber’s encouragement and research expertise, what has emerged is a plan to explore potential benefits of psychodynamic psychopharmacology in randomized clinical trials, and to see if pharmacotherapy patients receiving this treatment have better outcomes than patients receiving treatment as usual. If this turns out to be the case, we can then offer an evidence-based argument that a psychodynamic, patient-centered perspective on prescribing is a key element of expert pharmacotherapy.
Such research is new territory for us at Riggs, as this methodology is not an easy fit for a small treatment center with a prevailing commitment to a particular model of care. Indeed, the bulk of this research will have to be carried out at other sites, as it would be inconceivable for us to create a comparison group where we prescribe for some patients as if the meanings of their medications were of no import.
The first step in developing such a research program will be to operationalize the technical recommendations of psychodynamic psychopharmacology into measurable prescribing behaviors (e.g., inquiring about the patient’s feelings about taking medications or exploring covert benefits that patients may derive from their illness). The result of this process will be a treatment manual that is able both to guide a research program and offer guidance for the practicing clinician. When completed, we hope to test the usability of the manual at Riggs. This “fidelity testing” will allow us to assess whether the manual offers recommendations that are user friendly. If adherence to some aspects of the model, as laid out in the manual, is difficult, then those recommendations will be modified or excluded until the manual offers recommendations that prescribers can follow without significant difficulty.
Once we have determined that the manual can work for prescribers, the next, and crucial, step will be to see if the model also works for patients. We anticipate that conducting randomized, controlled trials will be a lengthy and complicated undertaking, requiring us to partner with major academic centers where large scale trials can be undertaken. Our initial efforts are likely to focus on patients who have failed already to benefit from a number of medication trials, though we anticipate that, if psychodynamic psychopharmacology leads to better outcomes for treatment-resistant patients, further research will demonstrate that it produces better outcomes in treatment-naïve patients as well.
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