Session Spotlight: Psychiatric Chronofication

Medication is a cornerstone of treating mental illness, but there are times when a patient’s continued use does not promote mental health. In such cases, the treat ment may unintentionally perpetuate the mental illness and make it chronic, according to experts presenting at the Annual Meeting.

David Mintz, M.D., director of psychiatric education at the Austen Riggs Center in Stockbridge, Massachusetts, referred to this phenomenon as treatment resistance from medications. “These are the situations where patients desire medications, tell you they’re effective, and want more,” said Mintz, who serves as Psychotherapy editor for Psychiatric News. “You may even see their symptom scores improve, but while they may feel better, they get worse in terms of their adaptability and functioning. In these cases, medications have turned to serve counter-therapeutic ends.”

Mintz described several ways that treatment resistance from medications promotes psychiatric chronification. First, they can be disempowering, giving all authority to the doctor.

“I’m not saying [the patient] doesn’t have a biological illness,” he said. “I’m saying they have a complex illness with lots of biological and psychological factors and [in these cases] the patient just hands everything to the doctor, waiting to be healed. That undermines the patient’s capacity to get better.”

Mintz added that medications can suppress normal and healthy but unpleasant feelings. “Feelings are there for a reason, but [some of] our patients have so medicalized and pathologized their feelings that they are chasing away every bad feeling,” he said. “Medications can also interfere with affect competence in that the extent to which somebody pathologizes their feelings and uses medications to control them, they’re surrendering their capacity for self-management.”

Mintz cautioned that psychiatrists should be careful of biomedical reductionism—the idea that all aspects of a mental illness can be explained and understood through biological, physical, and chemical processes. “The more biomedically reductionist your perspective, the more you’re likely to miss the forest for the trees. The symptoms may be better, but you can miss that the function is worse,” he said.

He added that biologically reductionist approaches oversell medications in ways that can undercut patients’ agency and dismiss the internal resources patients may have for promoting their own recovery.

Samar Habl, M.D., director of admissions and associate medical director at Austen Riggs, cautioned psychiatrists to be aware of sources of irrational prescribing, including the patient, the patient’s family, and the psychiatrist’s own motivations. “We can be under enormous pressure from the patient and the family, … and at times we may want to quiet an angry family or angry patient,” Habl said.

Habl encouraged psychiatrists to be aware of countertransference and use it to inform treatment. “A lot of our learning about the patient comes through projective identification,” he said. “Sometimes we may feel their rage, helplessness, or desperation, which can affect how we prescribe.”

Habl suggested talking to the patient about what is transpiring in the patient-psychiatrist relationship. “I might say something like, ‘I feel how desperate you are. I feel it too, and I recognize how I could prescribe in a way that addresses your desperation and gets me to feel like I am doing something, but [in prescribing these medications] we may be missing something [that is] in the way of your development.’” ■

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