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Psychodynamic Psychopharmacology


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Table of Contents

Part 1. What Is Psychodynamic Psychopharmacology?
Chapter 1. What Is Psychodynamic Psychopharmacology?
Chapter 2. Why Psychodynamic Psychopharmacology?
Chapter 3. What Is Psychodynamic About Psychodynamic Psychopharmacology?
Part 2. Understanding Pharmacological Treatment Resistance
Chapter 4. Psychodynamics of Pharmacological Treatment Resistance
Chapter 5. Treatment Resistance to Medications
Chapter 6. Treatment Resistance From Medications
Chapter 7. The Prescriber's Contribution to Treatment Resistance
Part 3. The Manual of Psychodynamic Psychopharmacology
Chapter 8. Avoid a Mind-Body Split
Chapter 9. Know Who the Patient Is
Chapter 10. Attend to Patients' Ambivalence
Chapter 11. Cultivate the Pharmacotherapeutic Alliance
Chapter 12. Attend to Countertherapeutic Uses of Medications
Chapter 13. Identify, Contain, and Use Countertransference
Chapter 14. Who Is Psychodynamic Psychopharmacology For? Patient Characteristics
Chapter 15. Before Initiating Treatment
Chapter 16. The Engagement Phase
Chapter 17. The Maintenance Phase
Chapter 18. Split and Combined Treatments
Chapter 19. Psychodynamic Psychopharmacology and Integrated Care
Appendix 1. Psychodynamic Psychopharmacology Self-Assessment Checklist
Appendix 2. Glossary of Psychodynamic Concepts Relevant to the Practice of Pharmacotherapy

About the Author

David Mintz, M.D., is Director of Psychiatric Education, Associate Director of Training, and a Team Leader at the Austen Riggs Center in Stockbridge, Massachusetts.


In Psychodynamic Psychopharmacology: Caring for the Treatment-resistant Patient, David Mintz, MD, takes up Sir William Osler's public comment, "The desire to take medicine is perhaps the greatest feature which distinguishes man from animals." Osler's comment seems quaint and dated now. Is taking medicine really the greatest difference between us and animals? How about love sonnets and trigonometry and AI? To be fair, just after the previous quotation, Osler said in the same lecture, "Why this appetite should have developed, how it could have grown to its present dimensions, what it will ultimately reach, are interesting problems in psychology."
This gem of a book is an attempt to address those interesting problems and does so by examining treatment resistance in modern psychiatry. Mintz diagnoses the cause of the treatment resistance as our impersonal and medical focus on medications at the expense of our understanding of the person who is suffering.
While there are many articles and books that start by complaining thatmental health treatment has lost the mind and therefore lost sight of the mission, Psychodynamic Psychopharmacology offers a fresh perspective through a close reading of clinical cases of treatment-resistant depression. The book attempts to sew up the dualistic divide and address the problem of treatment resistance by carefully attending to the person/patient and the person's feelings, needs, goals, fears, and unconscious psychodynamics, while respecting the impressive empirical evidence base for the effectiveness of psychopharmacology.
For Mintz, modern psychiatry needs a sober midcourse correction more than it deserves a victory lap. He is persuasive, thorough, and reminds us that all good treatment is based on the hope and the humility that patient and doctor share. Psychodynamic Psychopharmacology begins with a review of the basics of psychodynamic theory, the
concept of treatment resistance, and the many psychological factors involved-such as ambivalence, meaning of the illness, meaning of the medication, and transference. Mintz makes the interesting distinction between resistance to the medication--why patients do not or cannot let themselves take advantage of what medications have to offer--and resistance from the medication-- when patients use medication for unhealthy ends, such as excessively sedating themselves or avoiding contact with painful feelings they would be better off confronting.
The second half of the book collects and systematizes these conceptual points into a manual of psychodynamic prescribing with detailed case examples and vivid illustrations of Mintz's caring, compassionate, and humane approach. There is a terrific chapter on patients' ambivalence toward medications, illness, family, and treaters. The chapter on the engagement phase in psychodynamic psychopharmacology is especially comprehensive in conveying the depth of understanding needed to prescribe well. The author provides an extended clinical example that illustrates how the psychiatrist speaks with a patient about the psychological context for taking medication, showing how curiosity, openness, psychodynamic insight, and appropriate management result in a harmonious doctor-patient alliance that is likely to optimize the outcome.

David Mintz's book on psychodynamic psychopharmacology invites us to consider how rather than what to prescribe. Echoing Balint, he reminds us that the pharmacotherapeutic alliance and the manner in which the doctor interacts with the patient are instrumental to outcomes. He educates us on factors that affect treatment, such as patient characteristics (attachment style, placebo, treatment preference) and prescriber characteristics (warmth, promoting autonomy, supporting decision-making).The book is well structured, starting with defining psychodynamic psychopharmacology and its large evidence base. It provides a framework for considering treatment resistance at the level of meaning and subsequently breaks down the overarching principles of psychodynamic psychopharmacology. It is suffused with case formulations and transcripts of conversations with patients. We meet a patient whose psychosis was protecting them against the depressing reality of an earlier loss; the prescriber took this into account when deciding to prescribe less aggressively and to allow for grieving to take place. Examples of patients using their medication in countertherapeutic ways or being unhealthily attached to their tablets made me consider my own practice. Prescribing in a truly integrated way can feel like a novelty and sometimes lonely in a predominantly biological psychiatric paradigm. You are not alone. Mintz guides you with a manual on how to approach the engagement and maintenance phase of prescribing. There is a self-assessment toolkit and a glossary, all invaluable tools for clinical practice and teaching purposes.
This book does not antagonise but it complements the science
of psychopharmacology. It should be in the curriculum of psychiatric if not medical training. It is likely to restore faith in psychiatry as a profession and in our roles as doctors of the mind and
the body.

This book is the first of its kind in providing a comprehensive review of psychodynamic psychopharmacology. While a few book chapters or editorials have been powerful, this book offers a potent mix of research reviews, clinical examples, vignettes, practical tips, and effective use of tables and graphs. The author articulates the impact of the therapeutic relationship on psychopharmacologic interventions and how to manage common clinical pitfalls.

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