So I want to start, I suppose, with a couple apologies. First, my co-presenter, Carl Salzman, is not here today. He recorded something for the APA, but I've been told in the last 10 minutes that they have no idea where that is. So in the last 10 minutes, I had to update the slides a bit so that I can fill in that half hour of his. So I apologize for that. I also apologize because I predict that for the next hour and a half, hour and a quarter, you're not going to learn anything. And it's not because what I'm saying is not important. It's that the things I'm telling you, you already know. And the complicated thing, I think, for us as psychiatrists is that we are often operating in systems that are trying to get us not to know what we know about working with human beings. So the evidence, I suppose, will be helpful to back you up in knowing that you really do know what you know. But probably much of what I'm going to say today are things you already know in your bones as a human being. I'll just start with a supposed disclosure that I do have some conflicts. None of them, however, are financial. Just the usual ones, intimacy, aggression, et cetera. Oh, thank you. So I want to start. So the first dozen slides just got added in the last 10 minutes. But I want to start just with a case to get us thinking about what it is that we do and how we do it. So M is a 23-year-old single trans woman. She's an art history graduate student. She's of Lebanese Christian descent. The presenting problem, and so these slides are not properly formatted because I just threw them in. Presenting problem is that she had her first manic episode about five months prior to my meeting her. And she's admitted when I meet her to residential treatment at the Austin Riggs Center where I work, which is in many ways a last of its kind psychodynamic hospital focusing on work with patients who are complex and treatment refractory, patients who have failed multiple treatments. And there's something in them that is in the way of their being able to use the mainstream treatments we have to offer. So M had her first manic episode about five months before I met her. At the time, she was started on quetiapine and lithium and very quickly stopped the quetiapine. And as soon as she became euthymic, started lowering the lithium. Familiar story, right? Six weeks later, she had her second manic episode. The second one was terrifying. She had gotten the belief. So she's of Lebanese Christian descent. Things are flaring up in the Middle East. And she gets the idea that she can be the burning bush that is not consumed, and she can deliver a divine message that will bring peace to the world. And she's preparing to self-immolate. She's going to light herself on fire thinking she will not perish. She will not be consumed. And her psychiatrist catches wind of this and basically says, you have to start the quetiapine again, which she does. And then, filled with a profound guilt that she has now betrayed God, kind of like Noah, has avoided the task that she has been given. She's filled with guilt, and she takes all of her quetiapine and ends up in the hospital again. I meet her two and a half months later when she's admitted for residential treatment, now in a depressive phase of her illness. Now, her past psychiatric history is one that she has a history of gender dysphoria, social anxiety, cutting, anorexia, which is in remission when I meet her, depression with low-grade suicidality, imperfectionism, which had begun in high school. And she'd been treated intermittently with SSRIs for five years or so in adolescence, but had never really taken them the way she was supposed to, so never had a positive or never got to a place where she became manic either. Medical history is non-contributory. Now, when I meet her, she's on 600 milligrams of lithium with a blood level of 0.5 milliequivalents and on no quetiapine. She's stopped that. Now, what's the most pressing intervention from a biomedical standpoint? Anybody? Any medical students who want to answer this question? Because it's a medical student-level question. Right? This is a woman who needs an adequate dose of a mood stabilizer and probably an adjunctive antipsychotic. And I think the point I wanted to make, if a medical student had answered that, I would have said, so what we're talking about is a way that oftentimes knowing what to prescribe is the easy part of our job. The hard part is knowing how to prescribe in a way that we get the patient on board with a treatment that we think is the one that's going to help them. That's the hard part. And it certainly was with them. Right? Now, I want to say a few other things about her social history. She grew up in a high-achieving family with an overbearing, critical, controlling father and an emotionally absent, withdrawn mother. And she felt chronically socially alienated, I think especially in relation to her gender dysphoria. So she used a lot of mimicry to try to fit in, which undercut a solid sense of self for her. And despite those efforts, she really felt quite alienated and really didn't have friends until she got into college. And in college, she found her tribe. She was also often also subjected to bullying growing up in a culturally conservative, mid-sized southern city, which targeted both her ethnicity and also implicit gender issues. And she also felt the system really neglected the bullying feeling with administrators saying, well, boys will be boys kind of thing. So knowing this starts to, I think, shape a little bit more how we think about this patient is going to be thinking about systems of care and how useful they are. Now, I'll say a little bit more about her dynamics. So she has characterologic deficits around identity, affect regulation, and ability to form healthy relationships. Her faith in others is easily shaken, plunging her into devaluation. So you disappoint her, which happens easily. And you're kind of nothing. She's highly sensitive to power dynamics and easily becomes oppositional. The world is her father. And so she's got to preserve herself by when there's an authority trying to say no. And further, the transference to authority complicates the task of forming a solid alliance because she really can't trust an authority figure's recommendations because her immediate assumption is, you're not really interested in what I want and need. You are trying to figure out how to bend me to your will. Anybody have this patient so far? You know? And so she expects caregivers to substitute their own agenda for hers. In addition, taking medications is scary for her in the context of her identity diffusion because then she's left with questions. Is what I'm feeling me? Or is this the drug? So she's already confused about who she is, and that makes it even worse. And experiences of dependency are alarming for her, and she defensively moves in a counter-dependent direction. She tells me she's averse to the feeling of being tied to something, and that's people or medications. And so when medications work, and this happens with some of our patients, when medications, our counter-dependent patients, when medications don't work, they can take them forever, right? But when medications work, they get scared. Oh, that means I need this. And these are the patients who stop their medications as soon as they work, and M is one of these patients. And lastly, of course, her baseline is dysphoria. And so manias offer her a seductive temporary relief. And it's clear that at least in the beginning of a manic episode, she's really tempted to lean into it instead of trying to lean out of it. So maybe a show of hands, how many of you have treated a patient like this? Right? These are our patients, the easy patients we never see, right? Because they get treated by their primary care physician. So our caseloads are filled with complex patients, both complex comorbid, but also with complex psychology that is in the way of their using the treatments that we're trying to help them use, right? So part of our task as psychiatrists, I think, involves sussing out what are, not just, you know, what's the biology here, but what's the psychology that is, you know, and especially given that we're treating a lot of treatment-resistant patients, what's the psychology that's in the way of our patients responding to medications? And I tend to think of treatment-resistance as falling into a number of buckets myself. There's treatment-resistance to medications, treatment-resistance from medications, and then there's our contribution to the patient's treatment-resistance. Treatment-resistance to medications typically involves ambivalence, right? Our patients are ambivalent about the treatment we're offering, and they're ambivalent on perhaps multiple levels. How many have patients that are ambivalent about taking medications? Right, I would guess it's 100%, right? And of course, right, because I suspect there's very few people in this room that want to take medications, right? Even though Osler said man is the only animal that wants to take medications, but we also, very few people want to take them, and they're burdensome in, you know, many, many ways. How about anybody here have a patient who seems to be ambivalent about getting better? No, no, nobody. One person, okay. Right, our patients are ambivalent about getting better, and then our patients, as M, I think, very clearly shows, are also ambivalent about treaters. And so these are the patients who don't respond, they don't adhere. Oftentimes, when they do adhere, they have side effects, and we'll talk more about this. Then there are those patients who I think of as treatment-resistant from medications. This is a much more complicated concept. These are kind of the opposite. These are patients who like medications, who want medications, who want more medications, and there's something about that, though, that rubs us the wrong way. You know, these are the patients who ask, and even if you can watch their symptom scales lowering, you're like, you know, I don't want to do this. I want to take things away. I don't want to add things. I want to say no, but, you know, maybe the symptom scales are showing they're benefiting. And I think this countertransference reaction is a sign that there is treatment-resistance from medications. These are patients who are becoming chronic patients because of the way they are attached to their illness, their diagnosis, or something about the medications. And we kind of unintentionally contribute to that. And so we get chronification. And then there's, you know, our own contributions, where the way we approach the patients makes it reasonable that they might want to fight us, where we don't integrate the patient into a whole person. We're just treating their biology, and so we're missing important things, or where medications are used defensively by us. And we'll touch on that as well. So treat-resistance to medications. As I said, one of the things that Freud said was that the ego is first and foremost a body ego. And so for our patients, especially like our psychotic patients, they may know everything is up in the air except for one thing. They know what it feels like to be in their body, right? And then you put a substance into their body, and it feels different to be in their body. And now everything is up in the air. So medications, in that sense, pose a threat to identity. They're incorporated. There's a kind of confusing and penetrating merger. And this is also true, I think, of our patients with what you call false self dynamics, who are so compulsively focused on pleasing the other person that they don't have much of a sense of self. And this is kind of the dynamic with Em, where she's been so busy getting caught up in mimicry that she doesn't know who she is, and then the medication makes her more confused. And medications are also a narcissistic injury for many of our patients. So there's an injury to the self that way. Many of our patients experience secondary gains from illness, the benefits of the sick role. And I will say, actually I will say, and be curious about people's experience of this, but I would say so many of my patients are far more powerful as sick people than they ever were as well people, right? And that's not why they get sick. But once they're sick, and of course, you know, when you get a bunch of lemons, what do you do? Right, you make some lemonade. And our patients very naturally do this, but now they're in a dilemma, like, because they stand to lose something by getting better. Symptoms can be communication for patients. They can be express the, I need you, I don't want to lose you, I need to stay sick, because like, you're the one person in my month or my three months that treats me with respect and compassion, right? Or conversely, you know, we have those patients who have a real chip on their shoulder about failed caregiving. Failed caregiving as a child, and they just need to prove to themselves, see, you can't count on anyone, you can only count on yourself. So we have patients who also resist our medications and want to stay sick to show, see, nobody helps, right? Nobody can help, you know, F you, doctor, you know, like, you're just as bad as everybody else. Medications can undercut defensive activities. Like, I'll tell you another story. So a patient of mine, this is many, many, many years ago when I was a trainee in the fellowship at the Austin Riggs Center. One of my patients was somebody who was in her mid-40s, mid to late 40s, had about a 20-year history of unremitting psychosis. She came in, and now this is the late 90s, we had a bunch of second-generation antipsychotics, but she came in on an old first-generation that was not working, so she was on prolixin, flufenazine. She was hallucinating, delusional, disorganized, and I mean, obviously, I wanted to get her over onto SGA, but she had this idea that if she took this medication, she would become depressed and kill herself. And it was, you know, very deeply held, this idea. And so you can imagine what would happen when I would cajole and cajole, and eventually she'd agree to start, you know, Zyprexa or Risperdal or whatever it was. And basically, as soon as she put it into her mouth, she was so wildly anxious, because she thought she was gonna kill herself, that her anxiety was ramping up, and with it, her psychosis was ramping up. And within days, I had to stop it, because clearly, what I was doing was doing more harm than good. And we went through this cycle a number of times. And then eventually, it took a while, but eventually, we get the psychotic logic of this, because this is a woman who, probably in the prodrome of her illness, becomes pregnant. Father's really nowhere. She has a really loving, supportive family. She moves in with them, has her child, raises her child with a ton of support from loving parents. And, you know, was a loving mother, despite her evolving psychosis. And then when her child is five, he develops a glioblastoma, and dies. Unremitting psychosis from this moment on. Does anybody wanna guess what the most common hallucination is? Pseudo-psychosis? Pseudo-psychosis? That's a good thought, pseudo-psychosis. No, the hallucination is, she hears the voice of her son. He's there. And of her delusions, among the top two or three delusions, are the idea that she can cure AIDS and various deadly diseases. And that she holds the secret for raising the dead. Okay? So you see what we're up against, right? And so we have these dynamics going on in our patients all the time. And if we don't have a way of thinking about it, an openness to it, you're stuck with that cajoling, the patient, take this, and then it doesn't work, because they can't, because there's some psychology there. Now, in her case, this interpretation was not one that I was giving to her, although I will often work interpretively with my pharmacotherapy patients. There's not a patient that was for. What this did was it put me into an empathic position where I didn't feel so frustrated. And I actually got off her back while she did some grief work. And in about six months, she was ready for a trial of clozapine and had what may have been a best possible outcome because she became more organized and able to have developed adult friendships which she hadn't had in her whole life, basically. Her delusions resolved, but she never did lose the hallucinated voice of her son. And again, that may have been a best possible outcome. Who knows? Our patients, how many of you have patients with histories of early adversity? Right? How many of you have patient, how many of you have caseloads the majority of whom have histories of early adversity? Right? That's most of us, again, even though people are getting tired of raising their hands now. But, right, so our patients are coming in to the relationship with us with all sorts of deeply held anxieties about what caregiving authority means, right? They're on some level predisposed to want to fight us, many of them. Others, of course, to totally abdicate any personal responsibility at all and deal with the problem that way. But for many of our patients, medications can reactivate profoundly negative relationship schemas, toxic experiences of rejection. It's like, you're giving me this pill to get rid of me. Sexual intrusion, right? Something that's, you know, somebody that's had been really bodily intruded on and they're putting something in their mouth from you. Other forms of physical or psychological control, you know, most of us have probably had patients who say, you know, I don't want to be turned into a zombie. Now what I hold in mind when I hear that is not just, you know, that I don't want to become a lifeless automaton, but part of the zombie mythology is also falling under the control of the zombie master. So when I hear that, I'm also thinking, like, how are issues of control involved in this moment? And so these are patients who, you know, they have power struggles with us. These are the ones who, they know way more about the possible side effects than we do. Anybody have that patient? Right? And so they struggle with us around the dosing and the timing and, you know, want things often that are not quite rational. Either that or they try to control us. You know, there's this story, but they give us this slice of the story because they're trying to maneuver us into doing their bidding as opposed to trusting us as somebody who's really trying to help them. Or they supplant us, right? We prescribe a hundred and they take fifty. Or they take, you know, we say, well, you know, it's not going to work if you don't take a hundred, so they take two hundred, but they are not going to be controlled by us. Or, for some of our sickest patients, they cannot say no. They're equity, they have to do, they just have to do it. And these are patients, then, who often will, instead of saying no with their mouths, will say no with their bodies, and they will develop side effects. Treatment resistance from medications. There's a number of ways that this happens. Patients submitting to medical authority, right? Because they become a good patient, but they adopt a passive position, right? Fix me, doctor. Fix me. Which is the worst place from which to be trying to get better. We need our patients to be active participants in the task of recovery. There's adverse developmental effects, effects on identity, where medications symbolize I'm bad, I'm helpless. Medications can affect our patients, the way they use their emotions, right? Because we've developed our emotions over hundreds of millions of years for a reason, right? Those, that's our, it's like a sixth sense organ. That's the thing that helps us navigate the social world, and know when we're in a good situation or a bad situation. But I treat people, it's almost like they don't even have feelings anymore, they just have symptoms. You know, we need our feelings, including our bad ones to some extent. Of course, I'm not saying our patients aren't, their calibration isn't way off, but I think they can relate to their symptoms as a way that it's just signs of illness, in a way that deprives them of really important internal information. You know, if I do something and it makes me feel guilty, that feeling has a meaning, right? And that meaning is, you know, I probably shouldn't do that again. But if we, you know, we treat people, I treat people for whom that means I got to go see my psychiatrist, because I'm feeling bad, right? They can't tell anymore what's, what's, what's useful information and what's a sign of illness. And they can substitute, medications can substitute for ego development. I had treated a young woman, 22 years old, at the age of 13, tempestuous young woman from a tempestuous family, but she became the identified patient. At the age of 13, she was, started taking Seroquel for the times that she got dysregulated. By the time I meet her in their early 20s, she's in college, but she's getting dysregulated, often suicidally, three or four times a week. And the Seroquel works great. You know, she takes it, she sleeps it off, she wakes up the next day, she feels better, she's not suicidal. The problem is, you know, we were all kind of tempestuous, most of us, in adolescence, and what we did was we learned how to manage that. We learned effective coping skills. This patient has one coping skill, which is, she takes a Seroquel, right? What is the chance that this person is going to become a non-patient, right? Almost zero, until she can, she can figure out a different way of managing her feelings. So there's lots of different ways like this, that medications can be used counter therapeutically. And our patients can use medications in ways that prevent them, or help them not face healthy developmental steps. You know, you get the patient who, you know, is depressed and anxious and is in an abusive relationship. She's prescribed an SSRI and benzo twice a day, but she doesn't take the benzo twice a day, she takes a double dose at four o'clock, right, just before her boyfriend comes home, so she can just endure whatever's coming her way. And again, what chance does that patient have of becoming a non-patient? Pretty low, probably zero. And patients can use medications in ways that, you know, like our narcissistic patients who just need to squeeze every tiny last bit of bit of efficiency out of themselves, but they're running on fumes and they're depressed and they're exhausted. And medications can serve as in what Glover called an inexact interpretation. So basically, you know, which means, well like, like this used to happen all the time, especially early in my training, and mercifully it happens less now, but you get the patient who's somewhere in cluster B, they're impulsive, their moods are all over the place, and somewhere along the way some, some doctor gave them the diagnosis of bipolar disorder because they're impulsive and have mood instability. And what does that patient do with that diagnosis? Anybody have the patient grab a hold of that diagnosis and hold on for dear life? My bipolar, right? And that's because these patients survive psychically by splitting. They are filled with horrible feelings, they need to get rid of them, they put them on you, when they can't handle being in your care because they're all on you, now it's not back on them. But a diagnosis like that allows them to do a vertical split. It's perfect. The good stuff is me, the bad stuff is my bipolar. The problem is they feel, and they feel better, and we often feel better too, right? Because sitting with the suffering of a patient like that is not easy. And, oh doctor, oh no doctor has ever understood me the way you do, right? And we feel good, and the patient feels good. The problem is they feel better, they get worse, right? Because now they are no longer responsible for their worst instincts. They blow up a relationship. Who's responsible now? You are. You didn't give me enough medicine, you didn't give me the right medicine, right? So, and then there's our contribution, which is just to say failures of tact and empathy and respect, you know, sets the patients against us in some way. Biomedically reductionist approaches, which I'm going to talk about in a few minutes. And, of course, as you know, as Elvin Semrad met some of you who trained in Boston, you know, decades ago, we'll know him, but he was a legendary Boston teacher of psychotherapy. And he talked, as he said of the doctor-patient encounter, that it's an encounter between a big mess and an even bigger mess, right? Because we're all irrational, and our patients bring in horrible feelings, and then they fill us with those feelings. Their helplessness becomes our helplessness, their rage becomes our rage, and then suddenly we're prescribing to lessen our distress as opposed to the patients. And there's a decent chance when that happens that it's not actually targeting the patient's troubles. And so, maybe just questions or comments for a minute, and then I'll move into the talk that I was supposed to give today. I want you to think about what I'm about to say in a minute. The top one-third of psychiatrists got better results with placebo than the bottom third got with active drug. And you know what those top third of psychiatrists were doing? Neither do I. There's maybe some suggestion from another branch of the study that didn't break out the medication arm that suggests that the doctors who had a psychological perspective on depression as opposed to a biological depression were the ones who got the best results but it wasn't applied specifically just to the pharmacotherapy arm so it's hard to know. We don't do this research because process research is hard and nobody's going to get rich from this study. Now some things we know that can get in the way of our patients getting better. One of them is overly biomedical explanations. Explanations that are reductionistically biomedical. You have a chemical imbalance. A study done by Kemp, Lickle, and Deakin in 2014 took college students with a history of depression and enrolled them in a study to determine whether the depression was a psychological or genetic biological depression. So somebody comes in in a white coat, does a cheek swab, disappears for 15 minutes and comes back and informs the students whether their depression was a psychological or biological one. And of course this is a sham condition because we don't have that test. But when students were informed that their depression was a biological depression, first of all in this study it failed to reduce self-blame. Though there are a number of other studies that suggest that is one benefit of an overly biomedical explanation is people feel like, well, I'm not responsible. That didn't happen in this study. More importantly, what they found was increased prognostic pessimism, which we know is a meaningful factor contributing to outcome, how hopeful you are about it. And if you feel like, well, what can I do, you know, it's just in my genes. I'm not going to get better, right? So if we present our patients with too narrowly biomedical an explanation, we actually undermine their hope, which undermines their outcomes. It worsens mood regulation expectancies, and we know that mood regulation expectancies affect individual coping, which then affects outcomes. And it decreases, similarly, self-efficacy in managing depression. So I think one of the things we want to do is present our patients with a realistically complex understanding of how psychology and biology are interacting in their illness. And I especially want my patients to understand that they, I need them to be an active agent in their own recovery if we really want to get the most out of the medications that I'm offering them. The pill, sorry, pill effects, pill characteristics also shape outcome. So the characteristics of the pill, the color of the pill makes a difference. Red pills are energizing. Blue pills are calming in most cases in the Western world, but not in Italy, at least not among Italian men. Do we have an idea why? I'm Italian, I know. Yes, why? Because of the color of our football team. Yes. Blues. So for us in the West, blue is a color of clear skies and tranquil seas, but in Italy, it is a color representing power and masculine vitality. So there it's energizing. Expensive pills work better, right? You let it drop that this is 25 cents or $65, which pill is going to work better, right? And this is not just an academic thing, right? Because every day our patients show up at the pharmacy and they've been taking a large yellow pill and now it's a small white one, right? And we know that the data suggests that the majority of patients will report a decreased intention to continue medications when they've experienced a generic substitution. It doesn't mean they'll stop, but they'll tell you they're more likely to stop. And about 34% of our patients will report new adverse events. So either it doesn't work as well or suddenly they have side effects. And I suspect very little of that has to do with the actual different small differences in bioavailability, right? This is about the experience of powerlessness, which is a fertile breeding ground for all sorts of troubles in psychiatry. We know that placebo effects account for a large portion of treatment responses, especially with antidepressants and anxiolytics. Like with antidepressants, you know, we always have this problem in our meta-analyses of a publication bias, right? Study shows something, it goes in a journal, then when a meta-analysis is done, that goes into the meta-analysis. When a study shows nothing, there's a much bigger chance it's going to languish on the researcher's desk, eventually fall off into a garbage can, and never see the light of day. So we have a real publication bias that skews our meta-analytic results. But a number of people looked at the FDA database, right? And the FDA database, when you're trying to get a new drug, you say, these are the studies I'm going to do. And the FDA is going to get them whether there's positive or negative. So people who are looking at a relatively unbiased sample, now it's still by, you know, they're still really smart people designing those studies to try to get the result they want. But it's a relatively unbiased. And looking at that database, a number of different research groups have found that somewhere between 75 and 81% of drug, antidepressant drug response is attributable to placebo. This is huge. Now, and now, super important to make the point, placebo does not mean imaginary. Like these are real effects. These are real changes in mood. They're real changes in brain scans of these people. These are real effects. So while researchers are trying to get rid of the placebo effect, we should be doing everything we can to try to maximize it. And put another way, meta-analyses also estimate placebo effect sizes to be about 1.05, whereas antidepressant effect sizes are often around 0.3, 0.4, sometimes 0.5. So again, just another way to say placebo effect sizes are, placebo effects are a really important part of our work. There are non-clinical patient variables that affect medication outcomes. So these are characteristics of the person. So as the cartoon says, I'll pause for a moment so you can let this information sink in, right. So this slide was really just to overwhelm you a bit with like all the data we have about the person of our patients and how that shapes medication outcomes. And I'll talk about some of this. So we know, for example, about, we already touched on ambivalence, that ambivalence is related to pharmacologic treatment resistance, patients that can be ambivalent about medications. And a study by Piguet, who's a sociologist, who interviewed something like 140 people with a history of depression, open-ended interview, just tell me about your experience taking medications, and then they did a factor analysis and identified 15 themes that ran across those 140 or so narratives. And of those 15 themes, the top four were all about being harmed. It took to the fifth theme for patients to be talking about ways that medications help them. So our patients are ambivalent, and research suggests that they will tell us this two or three percent of the time. If we ask, they'll tell us about 30% of the time. So we should be asking, trying to get a sense of where are the potential problems with your taking this medication. And we know that patients with early ambivalence are twice as likely to stop medications, and three times as likely if there's any side effect at all. And patients who perceive medications as stigmatizing are, of course, also much more likely not to adhere. And then, as we've talked about, patients can be ambivalent about illness, and we know that patients with secondary gains are less likely to recover. And, right, how many psychiatrists does it take to change a light bulb? Right? Only one. But the light bulb has to want to change. And this is true, right? Because, like, even as, even, even with benzodiazepines, Bernie Bightman did a study where he enrolled patients in a study of panic disorder with a benzo, but they did the Prochaska and DiClemente readiness to change battery. And it turns out that, of course, when patients were in the action phase and they got the active benzo, they had the greatest reductions in panic. When they were pre-contemplative and they got the placebo, they had the greatest reduction, the least reductions in panic. But in those two other cells, patients who were ready to change and got the benzo, got the placebo, had greater reductions in panic than patients who are not ready to change and got the active benzo. So it's that, you know, we think antidepressants is one thing, but this is, this is true, holds true even with benzodiazepines. And we know this also with the research with depression, that readiness to change is a key factor. And so again, part of our job as psychiatrists may be using our psychotherapeutic skills, motivational interviewing, psychodynamic, psychopharmacology, whatever your tools are, to move the patients towards readiness to change. And disempowerment, as I said, is powerlessness, is such a fertile breeding ground for all sorts of problems. And we know that people from marginalized groups, so these are racial ethnic minority groups, women, people from lower socioeconomic status, are all more likely to experience nocebo responses to medications. And again, because I think in the face of the systems they're in, they feel powerless and so are more likely to feel harmed. And this contributes to health inequity, you know, our patients through, because of the systems they've been in, they're just more likely to be harmed because of the position of powerlessness. And it doesn't even have to be the system. Patients who disempower themselves are also more prone to side effects or nocebo responses. So patients who are characterologically acquiescent, those patients who can't say no, as I said, these are the ones who can't say no with their mouths, they say no with their bodies, right? They develop side effects and you're the one who has to stop it because they can't say no to you. The alliance, it's huge, it's key, central, right? First of all, as Havens and Goodtile wrote a paper, you know, decades and decades ago, where they suggested that there's different ways we think about the alliance, but medically we think about the alliance as compliance, the patient is doing what I told them, and so we have an alliance, but that's not an alliance. An alliance is a meeting. And we know that alliance is directly correlated with treatment response. So again, this is another secondary analysis of the TDCRP data, where fortunately they collected some alliance measures. And you know where I'm headed, right? The patient's had a strong alliance with their doctor, got the active drug, had the greatest reductions in depression, patients had a poor alliance with their doctor, got the placebo, had the least reductions in depression, but in the two other cells, you were better off, you had greater reductions in depression, if you had a good alliance with your doctor getting a placebo, than you did having a poor alliance with your doctor and getting the active antidepressant. So to what extent are we attending to the quality of the doctor-patient alliance? And of course we're in systems which, you know, are trying to trim as much fat as possible, and so for the bean counters and bureaucrats at the top, the fat that they're trimming is the relationship. It's the magic ingredient that makes our treatments work. And this is, and there's several ways. A good alliance increases the response to medications directly, but also indirectly through improved adherence. So our patients who trust us are just more likely to take the medications we're prescribing. Now what do we mean when we talk about an alliance? And we'll come back, we'll circle back to alliance in depth in the next part of this. But warmth and presence, autonomy support, agreement about targets, respect for treatment preferences, shared decision making, good communication. So just to say something about the value of warm human engagement. Just the positive, the warmth in our voice makes a huge difference. So a study by Cruz et al., they put a recorder in a psychiatry intake clinic, and apparently it's a pretty easy, you know when somebody has a warm, has a warm approach, a warm tone of voice, and when you don't, so it's pretty easy to get iterator reliability on this. And for every standard deviation interval above the mean, there was a corresponding a hundred and sixty two percent increase in appointment adherence. So if you're one standard deviation above the mean in the warmth of your voice, almost double the number of patients would show up the next time. Now I don't know how you teach warmth in somebody's tone of voice, but something that, you know, we should be conscious of, like just how how we speak to our patients. And this one, I don't know what to do with this study. Similarly, they put a camera in a psychiatry intake clinic, and some of the clinicians were writing stuff down, and others were like interacting with the computer. If you touch the computer, they coded that as a session with technology interaction, even if you touched it once. And in this study, if you touch the computer, it significantly lowered the therapeutic alliance. But second, if you touch the computer, if you did not touch the computer, 77% of those patients came back for a second appointment. And if you did, 27% of those patients came back for a second time. Now I imagine that's not our, because the whole field has moved in this direction, with I think, as far as I know, this is the only study that's been done on this, which really shows it's a bad idea for us to be interacting with our computers. But nonetheless, the whole field has moved in this direction, because again, they've trimmed the fat, so you've got to be, you know, working on three channels at every second. I imagine most of us have found ways to apologize for the computer, or talk about it, or you know, try to engage with our patient in some way that makes up for that, because I suspect most of us do not have that experience of it having this large of a negative effect. But there is almost certainly some negative effect of it. And we want to explore treatment preferences. So patients receiving their preferred treatment do better. In this study by Coxus et al., they took patients, asked, do you want psychotherapy or do you want medications, and then they randomized them. Patients who were randomized into their preferred treatment, about half of those patients got better. When patients who wanted medications were randomized to receive psychotherapy, about about a quarter of those patients got better. But when patients who wanted psychotherapy were given medications, 7.7% of those patients had a therapeutic response. Right? So we have to be mindful of the treatments that our patients are looking for. And when we give patients the treatments they want, and of course that doesn't mean like, well I know my body and I need benzos, and so I'm going to give you benzos. But we're reasonable. It's a really important figure. For me, if a patient comes in and they've seen the commercial, and there's a dark cloud, and now it's a white puffy cloud, and you know, I want that one, and I will say to that patient, you know what, that's exactly the right medication for you. But then I will add, and let me tell you why. It's not because this medication is better than another medication, but we do know that the medication you want works better than the one you don't. Because in my work, I'm trying not to put too much power on the medications. I want the patient to feel that half that power is in them, and so I want them to know. And then I might say, you know, and of course this will cost you 50 bucks at the pharmacy, as opposed to five, and you know, given that it's roughly equivalent, you know, you have to decide what you really want. Patients who get the treatment they want are going to respond more rapidly, and in at least a primary care setting, eliciting patient preference doesn't increase time required for consultation. Patients who get their non-preferred treatment, of course, are less likely to show up, and less likely to keep taking the treatment you've given them. And we know that patients from marginalized groups are statistically more likely, at least in the United States, statistically more likely to prefer counseling, but what we do is we give them less information about treatment options, and we communicate with them in a pattern that perpetuates patient passivity. We put them in the passive role, do what I say, rather than, and so I mean, we need to be doing this with all of our patients, but especially our patients from historically disempowered groups, we need to be working in whatever ways we can to empower them. And in terms of involving patients in decision-making, we know that involved patients, in this study by Woolley, these were patients who were admitted to the hospital with suicidal depression. They were put on an SSRI, I believe in this study it was escitalopram, and they were given a choice. The choice was, do you want to take this medication once a day or three times a day? Completely meaningless, medically meaningless choice, but just that choice increased the likelihood 2.3 fold that they were still going to be taking that medication six months later. And if the patient also agreed with their diagnosis, increased the likelihood the patient was going to be taking that medication six months later, 7.3 fold. And we are constantly making treatment decisions where, you know, one SSRI versus another one, you know, like we should always be offering our patients choices, because it's, there's a, it really is likely to increase the benefits the patients have from that. And when patients are given a choice, they also show improved outcome, now a year and a half later. And, you know, some one objection is, well, I can't let patients decide, because we'll end up with all sorts of crazy regimens. But again, in a primary care setting, what they found was involving patients in medical decision-making actually, you ended up with treatments that were more concordant with published guidelines, not less. So, just, here's some resources, but I'm going to get on to the rest of the talk. Now, we're gonna, we're gonna, I guess, zero in a bit on alliance. And, yeah, maybe just, just start with a quote by, by Rilke, the poet Rilke, who said that ultimately, and precisely, in the deepest and most important matters, we are unspeakably alone. And many things must happen. Many things must go right. A whole constellation of events must be fulfilled for one human being to successfully advise or help another. And, you know, you've already heard me talking about this. There's a, it's, it's not enough to just get an accurate diagnosis and say, here's the pill. There's a whole host of other things that we need to be doing to really, really help our patients as much as possible. Now, I'm gonna have to zoom through these, because, again, I put this together, like, ten minutes before the start, and so I've doubled up here somewhere. Okay, so we're going to talk a little bit about the pharmacotherapy alliance. And we can think of the alliance in the most, in the most, I think, common definition, Borden's tripartite, trans-theoretical model. We can think of the alliance as being a combination of three factors, task, goal, and bond. So, you know, there are different ways we can think of the task. There are different ways we can think of the goal of pharmacotherapy. What's our task, right? From a more narrowly biomedical perspective, we want to get an accurate DSM diagnosis. But what I think I'm arguing for today is we also should have what Michael Boland called an overall diagnosis, an understanding of the patient's relationship to their illness, their relationship to their medications, a sense of how their illness fits into their life. And then it's our task to prescribe, though increasingly I think our task, we're realizing our task is not to prescribe, you know, because we have so many patients who are, you know, as I suggested, you know, quantified in some way by the ways that we, you know, previous generations have used medications with them. And what are the goals of treatment, right? And, you know, I think, you know, oftentimes it's kind of a mishmash in our heads. You know, we may be treating diseases or disorders with our medications, or we may be trying to reduce symptoms, or we may be trying to decrease suffering or enhance function, promote development. And I think it's useful for us to have some clarity in our minds about what we're trying to do with medications or else we end up bouncing all over the place. For me, it's the last one. I think of medications as really being in the service of my patient's development. But that's not the only way to think of it. And then, of course, one has to think about how one nurtures the bond, as we've been touching on. How do we define the task? How many of you are psychopharmacologists? Okay, a few. I'm so glad to see, when I asked this question maybe ten years ago, half the room raised their hands, because then I said, and the rest of you, I guess, are psychiatrists. Right. And, you know, on the East Coast, in the Northeast especially, a lot of psychiatrists rebranded themselves as psychopharmacologists. And that has real implications, right? Because does anybody know the derivation of the word psychiatry? Does our Greek doctor know? I'm gonna say this wrong. I got in trouble for saying this before in front of a Greek psychiatrist. But it comes from the Greek, Psyche, Iatros, doctor of the soul, right? And what's a psychopharmacologist? One who studies psychiatric medications. The person has dropped out, right? And, of course, I'm setting up a false dichotomy to make a point that, you know, from a pharmacologic perspective, biomedically reductionist perspective, our focus is on the actions of medications on symptoms. Whereas, I think, you know, my focus is more on what's the patient's functioning. Again, with our treatment resistance from patients, they may get symptomatically better and functionally worse. And is that, you know, that's certainly not what I'm going for. Illness-centered versus patient or person-centered. And I think when we focus on the whole person, you know, we're functioning as mental health professionals. But increasingly, we are functioning in systems that are pushing us to function as mental illness professionals. As if the absence of symptoms is health. From a medical perspective, we're asking, what is this patient? Depression, bipolar. But I think we also want to ask, who is this patient? You know, medically, you want to ask what to prescribe. But in addition, I think for a psychiatrist, we also want to ask how to prescribe to optimize the benefit. In a more medically reductionist position, the doctor is the expert. I'm the expert in medications. But I think we're going for a kind of distributed expertise or authority. The patient knows something about their developmental goals, their aims. And how do we figure out how to join that? Or where to fight that? And, you know, there can be disagreements about tasks that then become a problem in the alliance. And it can go either way, right? Because it's not just the doctor that's medically reductionist. Very often, we have patients who are in that position of, fix me. And they want things that we think are not really actually going to be healthy for them. They're not going to promote their development. So, you know, we have to tussle and negotiate around what are the goals. So they can be symptom goals versus developmental goals. And I think it's really important to recognize that for our patients, there can be conscious and unconscious goals, right? So you can imagine the patient who, she's been self-sacrificing, taking care of everybody her whole life, never taking care of herself. Nobody takes care of her either. She gets depressed. Now suddenly she's relieved of that and people are taking care of her, right? Her goal, her conscious goal, may be to get non-depressed. But her unconscious goal may be to get taken care of. And as, again, Michael Bolland said, every illness is, how do you put it? Every illness is a vehicle of some plea for love and attention, right? So our patients, of course, that's, you know, one of those levels. Maybe they want to avenge themselves on, you know, failed caregiving. But maybe underneath it all, they just want love. And there's all these levels that are going on in the patient's goals, and the goals can be in conflict. So to get better means they lose your love and attention, for example. So we want to pay attention to this. Now, how do we address this? I think, you know, in our initial intake, these are questions that I think we should all be asking. What's it like for you to take medications? The patients will sometimes lay out the whole problem, and it's taken you like 40 seconds, right? I don't want to be dependent. I don't want to need anything. If the medications do it, it means I can't do it. My family, my family hates medicines. My uncle was, they didn't help my uncle, you know? So we should ask. It takes a minute, and the patient lays out the trouble. Also, we probably want to know, what's your experience of psychiatrists been? Has anybody asked this routinely? Like, what do you hear? Terrible, usually. I mean, 75% of the time. And how? And so the patient will, again, lay out for you, what are the transference, you know, maybe it really was a terrible psychiatrist, but much of the time, that's, you know, the patient is seeing that psychiatrist through the lens of their transference, and so you're prepared already for how is this patient, what are the buttons, what are the ways they're gonna see you, and gives you ways to talk about it. And what I will do is when I ask, you know, about this, and also when I ask, get an early developmental history, we'll talk about, actually I'm gonna save this point for next, but another question. Is there anything you might stand to lose if treatment works? This question, I will tell you, if you're gonna ask this question, you have to ask it in the first session, maybe the second. If you wait till five months down the road when you're feeling frustrated, and you ask this patient this question, they get defensive, and with good reason, because now it's a question that's full of blame, and not just curiosity, right? So again, and I'm treating a population of pretty much exclusively treatment-resistant patients at the Austin Riggs Center, so I am asking this question in the first session to pretty much everyone. And you know, 60% of the time, they won't have an idea, but 30, 40% of the time, they will have some ideas about what's, patient recently, trans woman who felt really harmed by systems she was in, and it's just like, if I get better now, it means all the shit that people did to me didn't matter. Right? The bond. So as I said, I think we should be getting a developmental history on our patients, which is more than, you know, are you married, and do you drink, and do you smoke? But less than, you know, tell me your whole life story. And I think that there's two things I wanna know. And a couple reasons, but well, A, we wanna do this because I think it helps the alliance just because the patient feels like, oh, you're interested in me as a person, and not just as a bag of symptoms. But also, if I'm asking about a person's early relationships, it starts to highlight for me, what are the potential transferences? Like with Em, you know, authoritarian father, it'd be super easy to fall into that role. I wanna know that. And we know that relational patterns can be repeated not just with doctors, but also with medications. So the patient who's, you know, and again, most of us have had this patient, deeply dependent on one level, deeply counter-dependent on another. They're really scared of dependency. So this is the kind of patient, when they get into a relationship and somebody starts to feel dependent, they find a way to blow this relationship up. Do you have that patient or that friend? This will happen with medications, too. These are the patients, again, like Em, who will stop a medication because it works. And we wanna know that. And what I will do, when we've talked about the patient's authoritarian father in that first session, I will ask, so how does this affect how you relate to caregiving authority? Another question takes a minute. And again, the patient will lay out for you how they are predisposed to wanna fight you and why. And you've got them to name it. And you've started like a frontal lobe to frontal lobe conversation about this, so that later on when the limbic system kicks in, you can, you have a much better chance of reestablishing a frontal lobe to frontal lobe, oh, isn't this the thing we talked about in the first session? And you can sometimes write a problem that is developing in the alliance because you've got that frontal lobe, rational kind of recognition, oh, this is something we were expecting. Maybe this isn't me, maybe this is, or maybe some of this is me, but a lot of this is how you are predisposed to experience the world. So we wanna establish, I think, a treatment agreement that recognizes the psychosocial dimension so that we have a way of toggling back and forth between biology and psychology. So for my patients, part of that initial, most of us are doing psycho-ed in that first appointment at some point or other, but part of my psycho-ed is also about, oh, well, you probably heard about the placebo response, and I may give them the data that I gave you about how powerful it is. You know, if somebody's had a lot of side effects, I may give them some of the data about nocebo responses or some of the other data that's in the study. And I will almost always, if not always, give them some psycho-ed about the alliance in a way that what I've done in that first session is I've emphasized the patient's role in their recovery, I've emphasized the importance of their relationships, and I've said to this patient, and if I'm doing something, what this means is if I'm doing something you don't like, not only do I want you to tell me, I need you to tell me, because otherwise, probably, you are having a suboptimal response to the treatment I'm offering. And I think we don't do this enough. I was on a panel with somebody a couple years ago with lived experience who said, I think he said he'd been in the system for something like 13 years before he felt like a doctor had specifically authorized him to protest. And, you know, and we're busy, and we don't always want those headaches, but I think if we do, we end up being able to clear out a lot of potential trouble. Now, some other things I think probably important to maintain realistic humility about medications. You know, I think we want to be careful about over-promising. How are we with time? Oh, oh, wow, okay, this got away from me. I probably didn't need to put in those slides after all. We want to maintain realistic humility about medications. Put the patient's growth and agency first, which means supporting, using medications in a way that support the patient's ability to grow, learn, and use treatment. Symptom reduction may not be the primary goal. It may be functioning, it may be growth. It means making changes in a deliberate manner, because I want my patients to come out of what we've done knowing what works and what doesn't. You know, so many of the patients I get who are coming out of inpatient, they started four things at once, right? And they're better, but they don't, you know, maybe they only need one of those things, and they're, you know, and I want my patients, a way of authorizing them is to do things in a way that they come out of this experiment with you with a clear idea about what works and what doesn't. Sometimes it may even mean keeping questionable medications when changes might interfere with self-understanding. So I had a patient depressed, had lost a ton of weight, couldn't eat, had lost like a quarter, quarter to a third of her body weight. She was on Wellbutrin, which of course, everything in me said, stop the Wellbutrin. You know, it's decreasing her appetite, it's probably doing all sorts of things. But this was one of these false self-patients, that we talked about, who had such a tenable sense of her identity, that she was worried if we changed the medication and she started gaining weight, she wouldn't know, was she doing it, or was the medication doing it? And so with that, we negotiated to continue the Wellbutrin. She started gaining weight, her depression got much better. And so, you know, there's complicated things that we're grappling with. And at other times, it may, when patients have really defensive attachments to medications, it may mean discontinuing medications to help the patients learn who they are, or to develop mature coping. So like this tempestuous young woman who was prescribed Seroquel, and this was her one coping. You know, what happened with her was, just as a throwaway, I wasn't even thinking of this, but in that first session, I looked at her regimen, which had not just Seroquel, but like four sedating medications in it, a GABAergic antidepressant, something for sleep, and some other things, and I just said, I said, wow, it really looks like somebody wanted to keep you under wraps. And it bugged her that I said that, but very quickly, it started bugging her in a different way. And like in a month or so, she was coming and saying, I wanna get off of this if I can. But in this case, I couldn't just stop this, right? Because this person, again, had one coping skill. So for her, what we negotiated was, we're gonna do a long taper, and you're gonna get used to coping at this level, and then you're gonna get used to coping at this level, and eventually, you know, so, and it took, you know, maybe four months, five months for her to get off of it. So sometimes we stop medications to help patients learn and grow. And as we said, patients have, patients come in with negative transferences to authority. So we can be the nicest, most thoughtful, most respectful, caring doctor. That's not who they see, right? And so, I think part of our work is actually being able to recognize and work with negative transferences, right? So consider, as I said, how alliance problems, you know, are showing up. And one of the, you know, to a patient who stops medications, we've already talked about their counter-dependency or their mistrust in the beginning. And so when that happens, we can return to say, well, you know, is this the kind of alliance problem we were talking about? I will also often try to make misuse or adherence issues relational. Instead of just, you know, like, well, the medication isn't gonna work if you don't take it, I may say, the patient, you know, stops the medication since I saw them last. You know, is there, I wonder what the problem is with us. Did I do something that made you feel like you couldn't tell me you had a problem with taking this medication? And what I'm doing is I'm emphasizing the alliance really matters. And what this does is, A, it emphasizes for the patient it matters, but B, the next time they're thinking of stopping their medications, they're more likely to think, well, I should, maybe I'll wait and talk to Dr. Mintz about this. Right, so make it relational. And oftentimes, one of the more powerful interventions we have is increasing the dose of the doctor. Right? I think we should meet a little more often for the next couple weeks. And it is, it really is amazing how a non-response will become a response when what you offer is more of yourself. So that has left us with about 10 or 15 minutes for discussion. Hopefully there are some questions or reactions or protests, things we can sink our teeth into. Thank you. So, there's a question up front about, yeah, actually, there's mics, so if you use the mics. But I'll repeat the question. So, the patient was actually pre-identified as trans, but had not yet taken the step towards estrogen, gender-affirming treatment. So I don't know how, so I don't really know how the estrogen piece fit in. Thank you. This was a phenomenal presentation. Thank you. I learned a lot. A question about SSI. Patients are sometimes... Actually, you know what? I wonder if we can bring the mic a little closer, because the way the speakers are, I think the audience can hear, and I can't. Is there a way... Oh, it's taped down? Okay. Maybe I'll yell. Yes. That was a phenomenal presentation. Thank you. I learned a lot. My question is about SSI. Patients don't want to be off it, and if I start to try to empower them, you'll work, you'll be independent. It's like, what's the point? I'm going to make the same amount of money. So is there a way, a task force that you're aware of to control some of this? Or how do you individually approach these patients? So I think this is an enormously... It's not just... We're in a system right now that, on so many levels, is pushing our patients towards quantification. And I think often when our patients are settling for SSI, it's for good reasons, because the world is not giving them a lot of great options. And like you do, I struggle with this, because you harm the patient if you get them better, you harm the patient if you don't, you harm the patient if you get them off of SSRI, you harm the patient if you help them stay on SSDI. But I think when I've run into that, where my focus is, is helping the patient think about what they lose in being, in their illness identity, and hopefully helping move them towards more ambivalence. So kind of motivational interviewing, like getting a sense of... I didn't so much touch on this, but when I said I work with a developmental focus. So initially, I will start out trying to figure out, what's the patient's ideal for themselves? What would they like to be? Now very often, what you get is where they would like to be, and what they're doing, are very much in conflict. And so it's in a bit... This is the model of psychodynamic psychopharmacology, but it's a bit like motivational interviewing, where you're helping the patient actually recognize that they are doing something to move them away from their larger goals, and you put them into some conflict around that. And sometimes that helps. And there are other times when just what life has to offer somebody is just so miserable that you really are... You're banging your head on a wall, I think. Yes? Hello. My name is Asad Kunai. I will be starting residency this year, and I can say that this talk might have been helping me with the residency, but you're a warm approach when you're talking, rather than the topic itself, maybe. And so seeing all the research that's emphasized on making empathy and motivational interviews, I was wondering if there were any fundings towards these kinds of educations and trainings to the psychiatrist, because there's millions of dollars that are funded to a medication that could increase maybe 50% efficiency to 51%, whereas we could get maybe 10% with educating the psychiatrist. And the second thing would be, this is another topic, the AI that you just press and then just don't take any notes, would that help in terms of having a good communication and just not worry about the note at all? Thank you. Yeah. So, I mean, on the first question, again, I hate to sound pessimistic, or I am not. I'm not actually pessimistic or nihilistic about this. But the system that we're in is one where, right, what, 15, 20 years ago, RDoC criteria were instituted by the NIMH, where the NIMH is only putting money into things with identifiable biomedical targets. And as Tom Insel, who was the director at the time, and instituted this, said after his tenure, you know, that he doesn't think we moved the needle one bit after putting billions of dollars into this, $20 billion or $40 billion, didn't move the needle one bit towards reducing suicides or improving the lives of our patients. Now, 20, 30, 40 years down the road, hopefully that research will end up helping our patients. But if they were putting some bit of that money into the things we're talking about, like how to prescribe, as opposed to what to prescribe, we would have been finding things that would be helping our patients not 30 years from now, but helping our patients tomorrow. And so, and the reason for optimism is, I think, psychiatry gave up for, you know, for the 25 years of pharmacomania that we were in, we basically gave up on psychosocial research. And it is coming back in. I think the field, I think the field reaches biomedical apex at the end of 2009, and has been starting to swing back towards a more integrative place ever since. So I think we are headed in that direction. And on your point about AI, if AI gets to the place where it can take our notes, so we can focus on the patient, that will probably help. Yes. All right. So I, thank you for, again, for this talk. I have a question. When you have a patient that understands that therapy and lifestyle modifications are necessary, very helpful, and they want to be able to engage in them, all right, Dr. Minson, no white vibes right now. It's wonderful. So you have that patient who understands and wants to engage in these modifications in therapy, but they are also a patient who has had many traumatic experiences, childhood adverse experiences, and are almost afraid that there has been too much harm done. So even if they engage with these things for 10 years, 20 years, however long, that they will get to a point where there's too much harm done and the body will just reject it almost. And so, on one hand, they want this magic pill, but at the same time, they understand fully that it doesn't exist, right? That they need to be putting in the work, but are almost afraid to. So they're like perpetually stuck in like a sunken cost fallacy almost. How do you engage with those patients? How do you earn their trust and want them to continue to get better? So, I mean, I think, well, buy my book. The way I approach that patient is I'm very open with my thinking, as you hear. So I would be naming the transferences from the beginning. I would be saying out loud that the patient, the way their early adversity had happened had really left them struggling to hope, left them with deep fears that any effort to help was gonna cause more harm than good. And this would just become a conversation that would, so as this came up, we would name it, we would link it back to something else, try to help the patient differentiate what's here and now from what's there and then. But in a spirit where I am not, trying not to be too invested in any particular outcome so the patient can use me as opposed to feeling that they're being used by me for my own needs to help them or something. Thank you so much. This is wonderful. I have, a patient called me last week. He's a new patient. He asked me about PSSD, post-SSRI, sexual dysfunction, which I had never heard of. And so he asked me what can be done about it. He said he was asking for a friend. Yeah, so, I mean, I think, I mean, this is something that certainly touches on the meaning of medication stuff. I think with a patient like this, I mean, there are ways that patients, obviously, have current sexual side effects or our patients probably have some longstanding side effects but it's so complicated because, of course, it's, how do I say this without getting myself in trouble? There's so much concern about potency in men and so much reason to say, oh, it's not me. It's the medication, right? And so it's really hard to know when you get something like that. As a patient, is there a real medical problem or is this a psychological defense that they're attaching to this medication? And you wanna take it seriously but if you started a conversation early on about meaning a medication that lets you start to open that up over time so that, because I think it's almost always the case when a patient gets better or gets worse when I've started a medication, I literally feel like I never know, is it the medicine or is it some meaning that's attached to the medicine? And I want the patients to share in that ambiguity with me in a way that we can open up questions and then begin to wonder about them as opposed to getting trapped into a narrowly biomedical understanding of what's happened and maybe that would help. So what I, I always do tell, you know, prepare people, you know, saying that sexual dysfunction is a possibility and I talk to them about it. Is there such a thing as really long acting after they stop? I mean, there's a literature on that and again, I think what I'm saying is it's, you know, it's documented but the extent to which that is psychological or biological I think is a question for me. Okay. Thank you. Thank you for enlightening us on the non-pharmacological aspects of psychopharmacology. My question is how often or if you engage families in your work with patients and dealing with all these issues that you described or are there times that families want to get involved and I'd like your thoughts on that. Yeah, so, I mean, in my private practice, which is predominantly people that have been at Riggs and weren't done with, were done with Riggs but not done with treatment and so I'm seeing them for medications or therapy. I won't do that that often but when patients are at Riggs, there are times when I will ask to or the patient will ask or the family will ask for me to get invited to a family meeting and very often that there's, you know, that's a very helpful thing because there are fears in the family, there are fantasies in the family, there are, you know, again, we have our younger patients who are the identified patient and the pill becomes like almost like a funnel through which the family, oh, you're the one taking the pill, right? So almost like a funnel into which all the family pathology is poured, the patient gets pissed off and, you know, what does mom or dad say? Did you take your medicine? Right, as if the fact that they're on medicine means the family didn't do anything to be, you know, to be hurtful and so in times like that, I think for younger patients in that developmental place, it can be very helpful and I'm talking not minors but, you know, young adults who are trying to launch from the family into some kind of independence. Now, I think it's 5.15 so I want to turn you guys loose but I'm happy to stay for a few more minutes and answer some questions. Do people do people want to stay and listen to the questions or. OK. Yes so you can use the mic. Thank you for your presentation. I'm sure people have told you you have a very psychoanalytic kind of appearance and demeanor which is so my wife has been was complaining about that today. This could be the American Academy of psychoanalysis but I wanted to ask you this. Do you see patients in split treatment and the reason I'm asking you that because I do all the time and I'll ask them what when they're not doing well what's going on in therapy. And if let's say it's a CBT focused therapy and you realize that the patient is talking about things from the past that are important and the person's not the therapist really maybe isn't getting it. How do you deal with that. What do you do. So the question is whether I do split treatment I do predominantly split treatment. I have some therapy patients but mostly split treatment in the model that we that we developed at Riggs. I really do think of my medications as supporting the patient's development which means in many ways supporting the patient's therapy. So in that initial meeting I will say to and of course it helps to have some relationship with the with the therapist and some trust. And I do. But in that situation to say like I am prescribing not necessarily to get rid of your symptoms. I mean I may but the primary goal is to put you in the best place possible to do your treatment which means of course you know if it takes if it takes eight milligrams of Klonopin to get rid of your anxiety. Now I've gotten rid of your anxiety but of course you're not going to remember shit about what you talked about in your psychotherapy. So you know so we're not going to do that. And what happens when you do that is it puts the therapist in in a position where if the patient is mucking around with their medications they feel that as a treatment interfering behavior and attack a problem in the transference and they can say the patient what are you doing. Those medications are supposed to help us. So why aren't you taking them. And so I think there are ways especially if you have treatment teams or established relationships that you can work kind of the triadic alliance in a way that really boosts the patient's growth and their ability to use medications helpfully. Hopefully that helps. I think that I think my question is pretty similar to his actually. So my name is Bridget Chavarria I'm early career psychiatrist so I'm my first year of attending hood and I run a partial hospitalization program. And so our whole team consists of me as the prescriber and we have social workers and we have group counselors. And my question is how could I involve our whole team in this approach because oftentimes when there is resistance to treatment everyone is getting involved. So the social worker is doing individual therapy they're addressing these sort of impasses in process group and in regular groups during their group therapy. And so how do you think that I could get my whole team involved. They're eager and they're willing to. So I think there's an interesting question about the role of the psychiatrist in all of this. And I think this this this what you're saying also applies probably to collaborative care where you know in oftentimes I think we may be at a choice point for the field where like in collaborative care or in a partial hospitalization setting the psychiatrist can be the prescriber or of course as psychiatrists we all have had extensive training in psychotherapy. We have all learned how to formulate. We have all learned how to do at least basic psychotherapeutic interventions. And so we can be one of two things we can be the person who comes in and says OK you know give that guy lithium you can boost the Sarah. Well we can add you know some other adjunctive thing or we can also be the person who comes in and says you know like this young kid with an authoritarian dad you've got to give him choices because if you don't he's not going to take the medication. And so I think we can we have to think about how do we reposition ourselves. You know as I just said something come out in psychiatric times we're basically you know we're supposed to practice at the top of our license the top of the psychologist social work license would be doing therapy. The top the top of the license for us is not prescribing right. That's the top of the PA license the NP license the top of our license is our ability to integrate our psychotherapeutic skill sets with our pharmacologic skill sets. And so I so you know I hope you can find a way to be that person who puts things for the team in that kind of context and you can do it by formulating by saying you know by offering an understanding of the psychosocial context of the treatment resistance by doing psycho education with a team about the kinds of factors that we talked about today. And you know and I think this is a plea for psychiatrists in general to you know to really practice seriously practice at the real top of our license. Hi. I work in an acute inpatient setting and so I was wondering how you might advise you know incorporating some of these themes and techniques into that setting where we're really with the patients for such a you know short snapshot and there's so much pressure for like length of stay and as soon as they're stabilized to get them you know out of the hospital. You know I will say this is not my area of expertise because I don't work with that population but I've actually heard just in the last several days from three or four inpatient doctors who are using the psychodynamic psychopharmacology model in short stays and you know in inpatient settings. And I think you know a couple of things I can say a the importance of a formulation that puts us gets us out of the trap of just thinking biomedically. So for us to be doing some kind of formulation with every patient including inpatients and you know some benefits when one benefit I didn't talk about Trello or did a study where they took frontline workers working with really hard to treat chronic self mutilators and they taught a psychodynamic formulation or a cognitive behavioral formulation of self mutilation and that what that did was that restored the clinicians to a position of empathy and we know empathy is one of those factors so a formulation a helps guide treatment but also helps people work more effectively with patients. So that's one thing I would say you know like I said giving patients choices very powerful intervention that makes a big difference down the road you know and until what to the extent that you can really working at developing an alliance which can be challenging you know a setting where somebody doesn't want what you have to offer. But you know we should be trying. Thank you. Well thank you for your talk. I was kind of really inspired by the you know the approach of being so open so early on with the patient. I'm just wondering if you like are there situations you encounter where you know naming the placebo effect or the no stable effect in like backfire ways of avoiding this like for it's like if the patient's getting better but you think it's a placebo effect. Well I think that I mean I think I learned about this a long time ago so I don't name the placebo effect. I teach about the placebo effect I raise questions about the placebo effect but I don't want to be in the position as if I'm the one who knows because I don't know I want to be in the position of somebody who's raising questions and trying to learn together with a patient. I think if you if you name it as if oh well that's just a no CBO response I mean the patient has good reason that it's probably going to backfire because you actually don't know and you're presuming authority that you don't really have. I'm also curious about I guess the idea of not over medicalizing things and I mean if the patient's like really attached to this this kind of biological model of how the medications working for them how do you kind of strike a balance or is it just kind of bringing it to attention other things that could be a role or. Yeah well I think as you heard like I'm I'm raising questions about how complicated mind body stuff is. I'm starting to raise questions about patients complex motivations and I'm starting to raise questions about patients complex motivations and you know defenses and things like that that lets us start to then raise questions you know especially if you can develop a real alliance where the patient takes you seriously then you can start to raise questions about much more cherished defenses to really you know important defensive attachments to diagnoses and things like that but that you know you start raising questions more broadly early and then you get to the heartfelt stuff you know once the patient has some trust. You asked one. Good evening sir. There was a wonderful presentation and the thing I was that in my practice I've seen that people on generic medications is not as effective or not work as well and may need a much higher dose than what we had them when they were on brand name prescriptions. Do you have any idea of what percentage decrease in an activity in generics if you've heard of any. I don't know the specifics of that I will say about the generics you know I mean I said like the majority of 34 percent of patients will do worse on generics in Germany. They have stopped transitioning patients from brand name medication psychotic patients patients with schizophrenia. They have stopped transitioning them from brand name to generic because it turns out it's more expensive to switch somebody to a generic because you know a quarter of those patients or a third or a half end up rehab stop their medications end up rehospitalized and it costs twenty thousand dollars and they save themselves you know three thousand or five thousand dollars by doing the switch. So it's you know we don't think that way and I think it's harder to think that way in a system that you know there's they have a single payer system so the government pays for everything whereas in our system you watch the insurance companies trying to figure out who else can they get to pay for this. So there's a lot less motivation in our system for long term savings and a lot more motivation for short term savings you know in terms of just working with patients like again part of that is the conversation and the record you know raising questions about when there's troubles you know it's naming that that a lot of the problems with generics is actually the experience of powerlessness and for some of those patients I will go to bat and I will get a get a get the brand name but very often by the time we've been through that process they're like oh no no it's OK. I actually I think the generic is fine but they need to be they need to be heard and feel like they have some power in the in the process. There's another comment on you know like how to make a patient take the medication. Now there was a drug called sephiris. If you remember it tasted horrible. Yeah. And so the question was you need an antipsychotic and there was one you could give the patient but it tastes so bad. You start out with the comment that this is really tastes horrible. You want to try it. And a patient will the next time you ask them say doc there was no problem at all. Yeah. And there and you know you you stress how bad it tastes and they come back to say that's not too bad. And you have 100 patients sephiris without a problem. Yeah. And I didn't I didn't go over that data but there's data that suggests that if we tell patients about side effects they are more likely to keep taking the medication if they have those side effects. It's a little complicated because we're also they're also more likely to have side effects if we tell them about them. And then that puts us a little bit in the territory of premium no no Sarah. But I think in the long run it's better obviously to inform our patients as much as we can about you know bad things to expect. One thing when I say when I'm seeing them on a follow up I would the patient want to come and see you unless they specifically get something out of that visit and what are you giving them in a visit that makes it worthwhile for them to come and pay you a hundred dollars to come and see you. So then I incorporate other things that are a physical health you know we talk about weight but losing weight is for everybody's exercise two important things that we should all stress. Then of course the importance of medications because it's known that if you see them every month they get they follow you better and they feel better the moment you stretch them out to three months it's not as good. Is that something you would agree. Yes. Yeah. I mean the like I said like Michael Bolland said who was an intellectual hero of mine you could probably guess because I've mentioned several times the doctor is the drug right. The stretching thing you know if I heard if I heard right you know that that's one of one of our we don't want to search people out especially really troubled patients you know the patients the patients who really give us a hard time. We want to avoid those are the ones actually we should be making the appointment with more often and then make it a point to go. I actually I think I also have to get back to my family. So thank you. I appreciate it.

psychological understanding

psychiatric practice

patient-psychiatrist alliance

human interactions

complex systems

trans woman case

manic episodes

medication adherence

psychological challenges

power dynamics

treatment outcomes

patient empowerment

integrative practitioners

symptom suppression