My name is David Mintz. I'm a psychiatrist at the Austin Riggs Center in Stockbridge, Massachusetts, which, for those of you that don't know, is a last-of-its-kind psychoanalytic hospital specializing in work with complex treatment refractory patients. So, you know, my patients typically would have six or more diagnoses by research criteria, usually with one or two personality disorders thrown in. And so that's how I got interested in this topic is these patients have such complex relationships with medications, with treaters or treatment or treating authority, or with health itself. In addition to working at the Austin Riggs Center, I guess the other most relevant thing is I'm also the former past leader of the Psychotherapy Caucus of the APA. My co-presenter, Carl Salzman, is joining us today by USB. He was wisely trying to avoid this experience here of people being so crowded in together. Carl Salzman, MD, is a professor of psychiatry at Harvard Medical School. He has served as chairman of the American Psychiatric Association Benzodiazepine Task Force. He's been awarded the Elvin V. Semrad Award for Outstanding Teaching in Psychiatry at the Massachusetts Mental Health Center. The Vestermark Award from the American Psychiatric Association for Outstanding Contribution to Psychiatric Education. Heinz E. Lehman Award from the New York State Department of Mental Hygiene for his contribution to psychiatric research. Professor of the Year Award from CME and Outstanding Psychiatrist Award for Education by the Massachusetts Psychiatric Society. He's also been on numerous editorial boards, including the American Journal of Psychiatry. Dr. Salzman is the author of over 300 publications and seven books. I will say that when I was a resident now, just a little over a quarter of a century ago, Carl was the psycho-pharm guru of Boston, and he still is. He's written what he didn't mention here. He's also written papers such as Treat the Patient, Not the Rule Book. I think he's going to be talking about that today. Carl discloses no relevant financial relationships. When I submitted this, I had none either. In the last month or two months, I had a book come out which is relevant to the topic of this, which is thinking about how to use practical dynamics in order to enhance work with treatment refractory patients. For starters, I think we're just going to start with talking about the science of the art of psychopharmacology or pharmacotherapy, because there's a really established evidence base that is not the one that we usually pay attention to. The one we pay attention to, of course, is the one where we're looking at DSM diagnoses and how they compare with medications, but there's an established evidence base that guides us not necessarily in what to prescribe, but how to prescribe with our patients so as to get the best results. I'm going to talk about a number of domains in which this is true. Again, this is just a small slice of what we know, what I can squeeze into half an hour. We're going to talk about how medication outcomes are shaped by a range of factors including prescriber effects, characteristics of the pill, non-clinical patient characteristics by which I mean they're not a characteristic necessarily of the illness itself, but something that's much more part of who the patient is, and then alliance factors. For starters, I'm going to propose that oftentimes, and this is particularly true in the treatment of depression, this is where the evidence is strongest, how we prescribe can actually be more important than what we prescribe. McKay, M.L. and Wampold, who you may have heard of some of these people, they're primarily known for psychotherapy research, but they looked at the TDCRP data. The TDCRP was before STAR-D the largest NIMH-funded placebo-controlled multi-center trial that had been done. The study was meant to look at which were the best treatments for depression. Was it psychotherapy? Was it psychodynamic treatment? Was it cognitive variable treatment? What they found was that they're all roughly similar and the addition of medications to one of the psychotherapies was probably a little bit superior. Now the interesting thing was McKay, M.L. and Wampold went back years later and looked at that data through the lens of the prescriber. It turns out that when you look at it through the lens of the prescriber, so they looked at who the prescriber was and what results did they get. It turns out that if physician effects accounted for greater variability in outcome than did the medication condition, placebo versus active drug. What they were able to do, it turns out, if you were a psychiatrist in this study and you got a good result with one patient, you tended to get a good result with all your patients. If you got a poor result with one patient, you tended to get a poor result with all your patients. Using linear hierarchical modeling, they were able to stratify the psychiatrist into highly effective, moderately effective and relatively ineffective prescribers. The effects were additive. The most highly effective prescribers prescribing the active drug got the best results. The least effective prescribers prescribing placebo got the worst results in the TDCRP study. I want you to think about this. The top one-third of psychiatrists got better outcomes with placebo than the bottom third got with active drug. Just think about what this means for a second for how we sit with our patients. You know what those highest performing psychiatrists were doing? Neither do I. Because we don't study this. If there was any antidepressant that was 30% better than another one, we would know in five seconds. But we don't really know. There's another branch of the study that suggests that it is that, because in the overall study, it looked like the clinicians who had a psychological frame of mind got better results than clinicians with a biological frame of mind, but it wasn't looking particularly at this arm, so we don't know for sure. But in terms of the ways we sit with patients, there's lots of things that we do that make a difference. I just want to talk about one of them, which is the way we talk to our patients about what they're struggling with. It turns out that medical explanations, biogenic explanations that are focused just on the patient's biology are very complicated, because on the one hand, it can help with medication acceptance, but there are unintended consequences. So in one study by Kemp, Leckl, and Deacon in 2014, they took college students that had a history of depression, and they enrolled them in a study to determine whether their depression was psychological or biological. And of course, this was a sham study, because we don't have that technology. But somebody came in in a white coat, took a cheek swab, disappeared for 15 minutes, and came back and told the person whether their depression was psychological or biological. For those college students who were informed that their depression was biological, a couple of things happened. They assumed that it would reduce self-blame, but it did not. The other things, and more important in terms of outcome, is that the people who now believed their depression was biological had increased prognostic pessimism. They just felt less hopeful about how things were going to go. And this is a known factor, of course, in outcome. The more hopeful you are, the better your outcomes. And it also worsened mood regulation expectancies. So they felt like, well, what can I do? I can't do anything. You've got to do it. You're the doctor. And of course, that's a terrible place from which to be trying to get better. And it similarly decreased self-efficacy in managing depression. So how we sit with our patients can make a big difference. And I'll go through lots of stuff like this. And not just how we sit with, all sorts of other things. The characteristics of the pill, right? The color of the pill makes a difference. In the Western world, red pills are energizing. And blue pills are calming. In most places, but not in Italy for Italian men. Anybody have any ideas why that would not, that general rule? Yes, but what about it? Yes. Yes, right. The blue is the color of tranquil skies and tranquil seas. But in Italy, of course, the soccer, the Italian national soccer team is the blues, right? So in Italy, blue is not a color of tranquility. It's a color of representing masculine vitality. And so it has an opposite effect in Italian men, apparently, at least according to a study done by Cataneo in 1970. And we know that expensive pills work better. And this is not just academic, right? Because our patients go to the pharmacy and they've been, for the last year, they've been getting a yellow pill. And now suddenly they're getting a white pill. And this creates real problems because it turns out that most patients will report a decreased intention to continue their medications when they have experienced a generic substitution. It doesn't mean they'll stop, but they'll tell you they're more likely to stop, especially if there's any problems. And actually 34% of patients experience new adverse events, which is either side effects or worsening of functioning when they're given a generic substitution, at least according to Weissenfeld. And I don't think that this is because the bioavailability is always worse in our generics. It's because the patients have an experience of powerlessness that then has all sorts of psychological effects that worsen the effectiveness of their medications or cause side effects. And again, they're not really side effects. They're nocebo effects, but from the patient's point of view, they're just being harmed. And in the placebo literature, what is the size of placebo effects? It turns out they do, I mean, we know they account for a large proportion of medication response, especially with antidepressants, right? And if you look at meta-analyses of published studies, it's somewhere around 50%. The people that have looked at, and of course, those are already biased samples, right? Because if the study finds something that is interesting, it gets published and if it finds there's no difference, languishes on somebody's desk and falls off into the garbage can and never gets published. So a couple of researchers have looked at the FDA database for this stuff, because when you are trying to get a new drug, you say, these are the studies I'm doing and those go to the FDA, whether you get a positive or negative result. So that's a relatively unbiased sample, although obviously there's still smart people designing those studies, trying to get the results that they want. And when you look at that, that data set, it looks like as much as 75 to 81% of drug response could be attributed to the placebo effect. And I want to make this point, and this is a very important point, placebo does not mean imaginary, right? These are real effects, they're real changes in mood. When you look in somebody's brain, the brain looks almost exactly the same, whether somebody's had a placebo response or has responded to fluoxetine, there's some differences at the brainstem level between medicated and placebo responders, but otherwise the brain changes look fairly similar. And of course, you can lower blood pressure with placebos, you can stick a needle, a myograph needle in a nerve and measure a decrease in pain transmission. These are real effects. And so we should, I think as clinicians, working with patients who are suffering, we need every tool we can get. So we should be mindful of the things we can do that can maximize that. Yes, we have a question? Is it lasting effect? What? Is it lasting effect? There's a study by Warner which suggests that it lasts at least a year. He looked at placebo responders a year out. So it looks like it can be a lasting effect. Of course, our medications are also often not that lasting either. So it's not that different. And then patients. Patients bring all sorts of meaningful differences to us. Things that are not necessarily a feature of their depression, for example, but are a feature of their history, a feature of their temperament, a characteristic of how they exist in the world. You probably can't see what this says here, but it says, I will, I'll pause for a moment to let this information sink in. So there's a lot of data here. It's really meant, you know, this is not to be memorable. This is just meant to kind of overwhelm you with what we know about, you know, the, how the person of the patient affects what's going to happen with medication. So the more neurotic patients, the more, you know, primitively organized patients will respond worse. Patients actually who are high in autonomy do better. Patients who are high in sociotropy, which are these are the patients who are more, they turn to you, they're dependent, they're worried. They want to please you. They actually do worse. I'll go through some of these things. Patients who have history of early trauma do worse. Patients with high expectations do well. Patients with low expectations do not. Ambivalence, of course, undermines treatment effectiveness, et cetera. Theory of illness. Patients, at least with, maybe this doesn't apply for patients with very severe depressions, but patients with mild to moderate depression, for example, they have better outcomes if they have a psychological theory of their depression. And they respond better to medications. Why would that be? You know, we don't know for sure, but my hypothesis is those patients have a sense of self-efficacy. I, there are things I can do to make myself better. I don't have to just wait to be cured by the doctor. Now, among those slides, I touched on ambivalence. Patients who are ambivalent are more likely to experience pharmacologic treatment resistance. Does anybody here work with patients that are ambivalent? Right. It's a, I mean, from a psychoanalytic point of view, of course, it's just a characteristic of the human mind to be ambivalent. And I don't want to take medications, and I suspect you don't want to take medications. And actually, the patients that really do want to take medications, they're probably among our sickest patients. So, but our patients are ambivalent, and that has all sorts of effects. And they're ambivalent about a lot of things. They could be ambivalent about medications. How many of you have patients that are ambivalent about their illness? One person. A couple people who are shy about it. Yeah, you know, like, you know, our patients don't get sick because of this, but, you know, when life gives you lemons, what do you do? You make lemonade. Patients find uses. You know, now suddenly, you know, now they get care that they never got. You know, like, I mean, my experience with my patients is so many of my patients, turns out, are far more powerful as sick people than they ever were as well people. Does anybody have that experience? Right? And then when that happens, now the patient is in a bind. And so much of that is unconscious, right? They don't know that's what's going on. That just plays out. And so part of our task is actually to help them understand what's going on so they can then make a conscious choice instead of an unconscious one. But patients are, they're ambivalent about their medications. And it turns out Piguet, who's a sociologist, interviewed something like 140 patients who were on antidepressants and just asked them to talk about the experience of taking medications. And they did a factor analysis and they found 15 themes that came out as people talked about their antidepressants. Themes one through four were all about being harmed. You had to get to the fifth most common theme that they discussed for them to start talking about ways that they were helped by their antidepressants. So our patients are intensely mindful of the ways that we can harm them. And that affects how they use their medications. And we know that ambivalence is directly correlated with noncompliance. Patients who are ambivalent at the start are two times more likely to discontinue medications and three times more likely to discontinue them if there's any kind of side effect at all. And also if they think of medications as stigmatizing, they're also more likely to stop their medications and end up having relapse and that kind of thing. And as I said, patients are also ambivalent about their illness. And we know that patients with secondary gains are less likely to recover. Along these lines in terms of just patient ambivalence, the readiness to change. So how many psychiatrists does it take? Only one, but the light bulb has to want to change. The patient has to want to change. It turns out Bightman, for example, measured readiness to change in a randomized controlled trial of benzodiazepines for panic disorder and found that the greatest determinant of positive outcome was readiness to change. So they gave them the Protrauska and DiClemente battery assessing, you know, are they pre-contemplation, contemplation, action. And the patients that were ready to change, of course, the patients who did the best, again, were the patients who were ready to change and got the benzo. The patients who did the worst were the ones who were not ready to change and got the placebo. But again, you probably know where I'm going. In those two other cells, the patients who were ready to change and got the placebo had greater reductions in anxiety than the patients who were not ready to change and got the active drug. And similar things have been found by Lewis looking in the treatment of adolescent depression, that readiness to change is the kind of the biggest determinant of whether somebody's going to have a positive outcome or not. So this speaks again to the importance of our working with patients to move them, you know, using motivational interviewing or psychodynamic techniques or whatever, you know, techniques are in your toolbox towards readiness to change. Disempowerment is a big part of this too. And people who are socially disempowered are much more likely to experience nocebo responses. So a study by Hahn in 97 that historically oppressed groups, racial and ethnic minorities, women, people of low socioeconomic status were all more likely to experience nocebo responses. So, you know, they get a side effect and they stop it because of a side effect, but it really is a manifestation of their experience of powerlessness. Similarly, patients that are acquiescent, the kinds of patients that just have to do what we say, but they have to please us, they go along. They actually have initial placebo responses because we want them to. But as soon as they start feeling that thing moving around in their body, it makes them feel powerless. And to me, it's almost as if, because they can't say no with their mouths, they say no with their bodies, they get side effects and then they stop them. So again, it speaks I think to the importance of our figuring out how to be empowering to our patients, at least our treatment-resistant ones. And there's the pharmacotherapy alliance, which, you know, I think you probably know where I'm headed. First of all, alliance is not compliance. From I think Havens and Gutile, and Gutile wrote a paper a long time ago, where they notice that for, in the medical world, we often confuse those things. We think there's an alliance if the patient does what we want. But they don't necessarily, you know, that may not be an alliance, that may just be them complying to us. And again, it's not a bad, good place to be working from. And alliance, similarly, is correlated with treatment response. So Krupnik, Sotsky, and et al, looked at, again, they looked at the TDCRP data through the lens of alliance, because they took some alliance measures in that study. And it turned out that the patients who got the active antidepressant and had a good alliance with their doctor got the best results. Poor alliance, placebo, worse results. And again, in those two middle cells, the patients were better off having a good alliance with their prescribing psychiatrist and getting placebo than they were having a bad alliance and getting the active drug in terms of the amount of symptom reduction. So just, yeah, again, let this all sink in, what this means about the way we work and the systems in which we work, which increasingly are trying to get us not to know what we know about human beings and working with people. Now, what are some elements of an effective pharmacotherapeutic alliance? There's warmth and presence, autonomy, support, agreement about targets, respect for treatment preferences, shared decision-making, and good communication, and I will talk about most of these. So for starters, the value of warm human engagement. So it turns out, just generally, you can tell if somebody has a warm voice or not. Like, it's very easy to get inter-rater reliability. So they did a study where they just recorded an intake into a psychotherapy clinic, and they had raters rating the voice, the tone of voice of the person doing the intake. And for every standard deviation above the mean, there was a corresponding 162% increase in appointment adherence. So if you have a really warm voice, your patient is almost three times more likely to show up at their next appointment, at least right after intake. So there's all these little factors that are going on that we don't necessarily think about. And similarly, there's another study by Rosen, Akash, and Allegria in 2015 looked at technology use during intake assessment. They had a camera there, and they just looked, do you touch your computer? If you don't touch your computer, that was coded as a session in which there was no technology interaction. If you touch your computer once, that was coded as a session in which there was interaction with technology. And at least in that study, and I gather this probably won't quite match your experience, but at least in that study, A, it lowered alliance, which we probably know, but it resulted in a huge reduction in treatment continuation. So if you didn't touch the computer, 77% of patients came back for their next appointment. And if you did touch your computer, at least in this study, almost 75% of the patients did not come back. So again, think about what that means for the systems in which we're working, the pressures that we're under. And I don't know why this was so high, because I would guess probably this room is filled with people who are using technology and aren't having this experience. But it is bound to have some real experience. And probably a lot of it is that we're also, like, we're getting better at talking to the patient, apologizing, recognizing that it's there, and you know, those kinds of things. So you know, we have to- Is that true? Because there's constant note-taking, I think we had a similar response, right? Apparently not. I think there's something about the technology that people react to differently. It draws our attention, I think, in a different way. And you know, I don't understand that, but it seems not to be that way. Really important to explore treatment preferences, because it turns out that, obviously, that makes a big difference. So in one study, COCSIS, they asked people whether they wanted psychotherapy or pharmacotherapy. And then they randomized them. And it turned out the people who got their preferred modality, about half of them had a positive response to treatment. They got better. When patients who wanted antidepressants were given psychotherapy, only about a quarter of them got better. And when patients who wanted psychotherapy, but were given medications, 7.7% of those patients had a positive treatment response. So I think it speaks to, you know, the problem of if all you have is a hammer, right? We have to be mindful of the treatments that our patients want. Because it will make the difference between a positive outcome or not. And patients that get the treatment they want also get better more quickly. And it turns out one of the objections as well, you know, if you let patients decide, you'll get all sorts of, you know, it'll take so long. But it doesn't, at least in a primary care setting. It does not add any time to just find out from the patient what treatment they want. And you know, patients given non-preferred treatment are more likely to discontinue treatment and miss follow-up appointments. And also important for to have in mind, attending to patient preferences is really important everywhere. But people from minority groups, oppressed groups, are more likely statistically to prefer counseling, but we give them less information about treatment options. And we have a communication pattern which perpetuates patient passivity. And I think you hear what I'm saying is that the empowerment of the patient is one powerful factor in their being able to make better use of the pharmacologic treatments that we have to offer. And we should have, so we have to involve them in decision-making. And it turns out if you involve patients, and this is really quite amazing actually. This study, if you involve patients in decision-making, they're 2.3 times more likely to continue treatment. These are patients who are leaving an inpatient hospitalization. And the way these patients were involved in decision-making was they were given a choice. Do you want to take this medication once a day or three times a day? Just that choice, you know, more than doubles the likelihood the patient is going to keep taking their medication. And that's, you know, obviously that's a clinically insignificant choice. And then there are more, you know, and similarly, you know, like our antidepressants are basically similar so, you know, it's good to give people choices and that kind of thing. And those patients are 7.3 times more likely to discontinue treatment or to continue treatment. They also agree with your diagnosis. And they get improved outcomes, not just in the short term, but at 18 months if you include, you know, if you involve them in decision-making. And treatments are not, you don't end up with crazy treatments because you're involving patients. It turns out treatments that involve patients in decision-making end up being more consistent with treatment guidelines, not less. And that's it. Here's some resources for people if you want to do further reading. And I am going to try to queue up Carl's talk now. Good afternoon and thank you for attending this great session. I am Carl Salzman. I'm a professor of psychiatry at Harvard Medical School and a psychopharmacologist. And this talk is entitled Treat the Patient, Not the Rulebook. And I've added to that title and the Therapeutic Alliance, which is part of this general topic. Psychopharmacological treatment is at a critical time period. Many useful medications are now available for the clinician to choose from. And there seems to be an increased willingness of patients to accept psychiatric medications. There are now many treatment guidelines, algorithms, and expert consensus suggestions, as well as DSM symptom guidelines for selecting a medication. I would like to suggest that while these guidelines can be very helpful for drug treatment selection, they do not constitute a rulebook for any particular patient. There is also an art to psychopharmacology, as well as a science. And this art is a sensitivity to what the patient may need more than just treatment of the presenting psychiatric symptoms. I am going to further suggest that establishing a therapeutic alliance in which the prescriber and the patient together work to provide optimum care, that this may then extend or enlarge the pharmacologic treatment itself. Modern psychiatrists, like other physicians, are being encouraged to practice evidence-based psychiatry by prescribing psychotropic drugs based on available research and clinical data. Unfortunately, some of the data upon which to base prescribing information, such as treatment algorithms and expert guidelines, are not always reliable and reproducible. Office clinicians are aware that the results from clinical trials do not always translate to office practice and that average drug effects may not apply to any individual patient. Reasons why patients don't always respond the way they do in research studies, research patients may differ in many ways from a clinical sample, doses that are studied and FDA approved may not always be the clinically useful doses. Outcome criteria for a research study are based often on rating scales and they may not be clinically applicable or reliable. And statistical significance in a research study is not the same thing as clinical significance in a clinical practice. Because there may not be a correspondence between published treatment suggestions and an individual patient's response, it is worth considering that the clinical art of evaluating a patient, first for his or her suitability for drug treatment, and second, which drug to choose from among the many options, constitutes a major function of the prescriber. But experience tells us that clinicians must not only rely on the symptom profile of a patient to guide their ultimate prescribing decisions. General diagnostic guidelines are important, but they are not the final word in deciding if and what to prescribe. There are many factors that may suggest problems that are not appropriate targets for drug treatment. The sensitive prescriber will be attuned to the life circumstances of any patient's symptoms in order to distinguish between a drug treatable disorder as opposed to a different problem that requires a different approach. Consider this patient, a depressed businessman, healthy, seemingly happy until recently, not a substance abuser, no prior psychiatric history, married with a family. He decided to retire and sell his business, but could not sell his business. There was an economic turndown, and no matter how hard he tried and how he adjusted the selling price, he could not sell. And gradually, he became depressed, suicidal, had trouble sleeping, weeping, with reduced motivation. An antidepressant was started. Coincidentally, within one week, he did sell his business, exactly as he had hoped, and all of his symptoms vanished. This was the psychopharmacology warranted. If he had gotten better and sold his business at around the same time he got better, would it have been the drug that helped him or the selling of the business or both? So not all problems need drug treatment or drug treatment alone. It is worth keeping in mind, for example, that not all unhappiness is depression. Not all happiness or elation is mania. Not all worry is generalized anxiety. Not all distraction is attention deficit disorder. Not all habits are OCD. Not all sleep problems are a disorder. Not all unpleasant patients have a personality disorder. And not all odd or unrealistic thinking is evidence of latent or emerging psychosis. Clinicians must recognize normal variations in mood, behavior, and cognition, as well as the life circumstances that may be affecting the patient, and not assume that every complaint is a symptom that requires drug treatment. Sometimes a patient who comes for pharmacologic treatment is actually interested in another form of treatment, but is asking for medication in order to feel out the clinician for further treatment. The prescriber should be alert to this possibility after discussing the medications and consider further evaluations and discussion. Consider this patient, an anxious student, a very anxious student, sought psychiatric treatment and was prescribed appropriately an SSRI, and the patient was very appreciative and grateful. But as he was getting ready to leave the office, he said the following words, and this is an actual quote, Doc, do you have a few extra minutes? I want to run something by you. The doctor said, sure, come on back into the office, and the patient then described a very long-standing, complicated, difficult family situation and indicated that it would be helpful to him to discuss this further. He readily agreed to another interview and became ultimately an excellent psychotherapy patient, which is what he was really looking for in the beginning. Now all patients have a biographical story behind or associated with their symptoms, and the art of psychopharmacology prescribing is to get to know the patient's current and past life experiences, as well as the present symptom profile. For some patients, it is not even their problem that needs to be treated, but someone else's. This is illustrated in the next clinical example. The patient was an elderly, demented woman strapped in a jerry chair in a nursing home. The jerry chair was positioned facing the elevator. The patient had a daughter who was constantly calling the nursing home staff, complaining that her mother was screaming all the time and needed medication. I was called in to see this patient, and she was sitting quietly and was a very nice, demented older woman. The elevator door opened, and the daughter stepped out, and the woman started screaming, and she wouldn't stop, and she could not be understood. She was just screaming. The daughter said, see, I told you, she's screaming all the time, give her medication. And she got back on the elevator, the door closed, and the patient stopped screaming. Is this a case for psychopharmacology? Was it a family problem? Is there something going on between mother and daughter, even though both were kind of old? Not all symptoms need medication. What does a patient want from the doctor? What do we all want from our doctor? We want to be understood. We all need to feel understood, but not just by going down a list of symptoms. The best prescribers get to know their patients' life stories, what is upsetting to them, and what are the contexts for the development of their symptoms. I suggest that when a patient feels that the clinician understands the context of their symptoms as well as the symptoms themselves, they are able to be more open and compliant with treatment. Prescribing psychiatric medications is a cooperative undertaking between patient and prescriber and works best when each appreciates being understood. This is the basis for a good therapeutic alliance. Patients do best when they feel understood by their prescriber and when they like their prescriber and when they feel that the prescriber likes them. The concept of a psychological therapeutic alliance is basic to psychiatric practice and applies to the use of psychotropic medication as well as to psychotherapy. Now it's true that for some acutely disturbed patients it may be difficult or even impossible to immediately establish an alliance, but it is not unusual for such a patient to comment many months or years after initial treatment that the most important part of their first meeting was the helpful and compassionate attitude of their treating clinician. So here's a four-wheeled psychotic patient who's speaking after many years of treatment and stability. Quote, and this is a direct quote, the most important thing you said to me in the beginning that this was a partnership and that I had some say in what you were doing. That was because I was scared of the drug and I was afraid to trust you and this made a very big difference. It is also not unusual for such patients to wish to continue to be treated by the same clinician who helped them during their most disordered state, suggesting that a useful therapeutic alliance can begin even when a patient is severely disordered and non-functional. We humans will attach ourselves to those who care for us and who try to understand the basis for our suffering. This attachment is essential for good clinical care. It is especially critical for the use of psychotropic medications, since non-adherence rates are high for many disorders, such as schizophrenia, bipolar disorder, addictive disorders, and even depressive disorders. Clinical experience, as well as published data, indicate that psychotropic drug adherence rates improve when there is a positive, caring, therapeutic alliance that includes the patient and clinician trusting each other. The patient trusts the clinician not to abandon them, not to criticize or judge them. The clinician trusts the patient to take their drugs as prescribed and faithfully report the results. Some patients may even inform their prescriber of a need to alter the drug or dose when changes are needed. It's illustrated in this case of a patient with documented bipolar illness who was well-treated with lithium. She understood that her mood changed and that at times the dose had to be changed. And she said, again, a direct quote, I trust you to trust me to adjust my lithium dose. I have a harder time thinking at the higher dose, but I get more manic at the lower dose. Being able to change doses and knowing you will support me is helpful. And she's been stable for a very long time. The ability of a patient to do this with their prescriber is a sign of a good therapeutic alliance. Developing a trusting alliance leads to what is often called, quote, shared decision making, unquote, and requires a trusting interaction between patient and prescriber. A recent publication even suggests that patients are more likely to return for a second appointment, which is often necessary for adequate psychotropic drug treatment, if the prescriber is looking at them during their meeting rather than typing at a desk computer. Coming for a second appointment may also signal the beginning of a trusting and therapeutic alliance. And think how you might have felt when you were visiting a doctor who was typing away and not paying any attention to you and how you were feeling at that moment. Busy clinicians may not have time to obtain lengthy biographical history or other information in the first or second interview regarding all past and current illnesses. But those who can take the time to ask about previous experiences and symptoms are often rewarded with a more comprehensive understanding of the patient's symptom profile. This is a sign of a good alliance. But when time is as tight as it often is, an alliance can begin with just a few words from the prescriber. Now, here are some words that I use from time to time and I suggest might be helpful to you. I would say to the patient in the beginning, you and I are a team trying to help you feel better. I am a prescriber because I know about medications. But you are the patient because you know how you feel. My job is to prescribe, but your job, equally important, is to faithfully tell me how you are feeling as you are taking this medication. Together, we will monitor your course and make any changes that we both agree to. In conclusion, modern neuroscience and the resulting developments of newer psychotropic drugs have led to great improvements in mental health care. We are considerably better at treating psychotic, mood, and anxiety disorders than we were several decades ago. However, our current treatments are still only modestly effective and remission rates are embarrassingly low. And diagnostic criteria are sometimes variable and not specific. We need to be reminded that our clinical approach to patients is not just the administration of psychotropic drugs. We should not just be drug pushers or, as somebody once referred to me, a mechanic. We should be well-trained, comprehensive clinicians who understand the complexity of human experience beyond the symptom checklist and the treatment algorithm. Treating patients with psychiatric disorders requires more than just a prescription pad. Try to establish a therapeutic alliance and, above all, treat the patient and not necessarily the rule book. The rule book. Thank you very much for your attention. And I will be available to answer questions in the session at the end of the presentations. Thank you. OK. So I am going to talk as well about the pharmacotherapeutic alliance. But really, I think more specifically through the lens of thinking about when you have a patient who's treatment resistant. And I'm going to present a model for working with patients where, when they come in, it's already clear that they've been through a lot and things aren't working. So just to start with a little poetry. So this is a quote by Rainer Maria Rilke, the German poet, 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 I think you know you hear that this is kind of running through this whole presentation today, is the importance of a lot of things besides just finding the right medication. So in terms of the pharmacotherapeutic alliance, I'm going to start with the framework proposed by Borden, which is one of the more commonly used ways of talking about the alliance as something that consists of three elements, task, goal, and bond. And I'm going to look at each of these and think about the ways that we approach them. And it is worth asking ourselves, what is the task that we're taking on? What is the task? What are we trying? When we are a prescriber, what is that? When we're a psychiatrist, what does that mean? Obviously, part of that task is to assess and diagnose. But what are we assessing and diagnosing? Is it just the DSM? Or is it, as Carl was suggesting, something more along the lines of what Michael Ballant, who gave us the concept of patient-centeredness, called the overall diagnosis, which is the understanding the patient, understanding the symptom in the context of the patient's broader life. And I think, actually, I'll argue that that may be the task, is to get the overall diagnosis. And then, is it to prescribe? Is it to not prescribe? I think we think our job is prescribing. But I certainly find myself, in my population of treatment-resistant patients, I do probably more de-prescribing than prescribing. Almost all my patients, 85% of my patients, are on medications. But part of our task is actually to figure out, what can we also take away? And what are our goals when we're doing this? Are we treating symptoms? Are we trying to decrease suffering? Are we trying to enhance functioning? Are we trying to promote the patient's development? It's worth our thinking, when we are prescribing, what it is that we actually are doing. And when we're in a system, which I think pushes us towards, obviously, thinking that we're just reducing symptoms. But I think it's more complicated than that. And then, what do we do to nurture the bond? So I want to just start with, how is the task of pharmacotherapy defined? How many of you are psychopharmacologists? OK. And the rest of you are psychiatrists, I presume. And I say that to highlight, I think, that the way we think of ourselves makes a big difference, right? Because what is, just the derivation of the word, does anybody know the derivation of the word psychiatrist? Must be, it comes from the Greek, psyche, eatros, doctor of the soul, right? And what is a psychopharmacologist, right? One who studies psychiatric medications. The patient is just left out of that formulation right there. And that leads to a kind of a, and again, I'm setting up a kind of a straw man difference, because we all are somewhat caught in the middle of this tension. But the pharmacologist pulls for the focus of actions of medications on symptoms, as opposed to, I tend to think of myself as, the main goal is not symptoms. The main goal is function. The main goal is helping the patient get where they're trying to get, right? And rather than an illness-centered perspective, I think our patients are better off, at least in terms of reliance, if we have a patient-centered perspective. And in this sense, that we aspire to be mental health professionals, but increasingly, we are under pressure to be mental illness professionals, focusing really just on symptoms and the treatment of illnesses. From that perspective, you ask, what is this patient? Are they depressed? Are they bipolar? But we might also ask, who is this patient, as Carl was suggesting, and use that as part of our building the alliance that makes the treatment work. And then, so similarly, you would then ask what to prescribe. But I am going to argue that just as much you need to be thinking how to prescribe in order to help the patient get the greatest use of the things that you then choose to prescribe to them. And in a pharmacologist model, the doctor is the expert, whereas I think that we can have, as Carl suggested, distributed expertise and authority. And I think an implication of this in terms of task is that it's not just my task to help the patient get better. Then it becomes the patient's task, as well, to help themselves get better. And so I think, optimally, we negotiate the kind of relationship where that expectation is clear, that I'll do my part, and the patient has to do their part. And usually, my part is smaller, the way I think of it. Now, we may end up in deep disagreements with our patients about what the task is. And if there is not a shared assumption of task, the patient is pulling one way, we're pulling another, and then the alliance is really hard to forge. So working on that early on is probably really important. And then there's our goals. What are we trying to do, ultimately? And again, this is a place where we may end up at odds with our patients. And is the goal a symptom goal, getting rid of symptoms? Is the goal trying to help the patient get someplace where they're trying to get? And if we're focused on one and the patient is focused on another, we may end up, obviously, at odds with each other. And this goes, actually, both ways. We also all have sat with patients thinking, I wish they would take less medication. And they're hell-bent on trying to get even more and more and more, just like in this cartoon, where we really do feel like if you would just do X, Y, and Z, your life would be better. So these are things we need to negotiate with our patients. And in terms of goals, at least from a psychodynamic perspective, I hold in mind that the patient doesn't have a goal. They have a goal, and then under that, they have another goal. And under that, they have another goal. And those goals don't necessarily line up with each other, right? So the patient may come into you wanting to get rid of symptoms. But they are so enraged by their experiences of adverse caregiving that they're even more motivated to show what a useless piece of what you are, and that you really can't trust anybody. They may be actually more motivated to prove that to themselves than they are to get better. And then underneath that, they may be, at the very bottom, their biggest motivation is just to be loved. And then you get that patient, and they finally get that with you, and then they're scared. If I get better, what happens? Do I lose the one person who listens to me? And almost all of that is going to be unconscious for the patient, right? So part of our task is to kind of suss that out and figure out what are the layers of goals, and try to shine some light on it, again, so the patient is able to address that consciously instead of having it just unconsciously play out. And when the patient has that kind of inner conflict between their goals, they end up with it being ambivalent. And as I said, ambivalence in pharmacotherapy is a big deal. And so when patients are ambivalent, so I want to talk about the kind of alliance I try to form. So for starters, I start with, at least with patients that are treatment resistant. So I already know it's a long slog. Their history is they start something, it doesn't work. They start something else, it doesn't work. I'm not in a rush to start something on day one. I want to know who this person is. So I will actually lead with, where are you trying to get in your life? And try to nudge somebody away from the symptom focus. Because then when problems come up, kind of like in motivational interviewing, you're saying, well, what you're doing now doesn't fit with your larger goal. So what's going on? In terms of sorting out something about the ambivalence, it's really important, really easy in the first session to ask the patient, what's it like for you to take medication? The patient will lay it all out for you, what their conflict is. Oh, I don't want to be weak. I don't want to need anything. My family hates medications. They'll tell you what the problem is if you only ask. And in another study, there's another study. But only 20% of patients will tell you about their ambivalence if you don't ask. So ask. And also, patients are not just obviously ambivalent about medications. They're ambivalent about us. Many of them have had really adverse experiences at the hands of caregivers, parents, coaches, babysitters, other doctors. So they come in with very negative expectations of caregiving. And you want to know that. So again, in that first session, I want to find out, well, what's your experience of psychiatrists been? And patients will, again, they'll tell you, they'll lay it all out, what the resistances are going to be and what the obstacles to a good alliance are going to be. And also, I will start out, as I said, in that first session, I will try to get a very basic developmental history. And from that, which I'll talk about in the next slide. But then I go from, oh, so that happened to you. How has that colored your experience of caregivers? So like I'm asking about the transference that the patient is bringing into treatment. And again, the patient may tell you where the problems are going to be. And patients are ambivalent about health, about getting better, as we talked about. Another question I'll ask in the first session, and this one you have to ask in the first session, is there anything that you might stand to lose if you got better? If you ask this question in the 10th session after you're feeling thwarted and frustrated, it's a totally different question. And the patient hears it defensively, rightly so, because it's, but if you ask it in the first session, you're just curious. And the patient could hear that without getting defensive. Now, a lot of the time, they have no idea. But sometimes, again, they'll lay it all out for you, what their dilemma is in giving up their, like a woman I treated, relatively therapy naive. She says, I'll lose the attention of my husband. She was in a battle with her infant child for her husband's attention, and so she got sick. So patients may tell you. And then there's bond, and Carl was talking a lot about that, the feeling of a connection between two people, the sense that this doctor cares, the sense that we're working together. So like I said, taking a patient-centered perspective, I recommend for the treatment-resistant patient, you can already predict there's going to be trouble, get a developmental history in the beginning. And that's not, does a patient drink and smoke and are they married? And it's not like spending an hour either. It's like five minutes, six, seven, eight minutes at most. Just asking, really, a couple of things. What are the patient's early relational models? So basically, you're trying to figure out, how did they experience caregiving authority? And what are the repeating relational patterns in their life? Because if there's a repeating relational pattern, there's a pretty good chance that's going to show up with medications. So like the kind of patient who is dependent and also deeply counter-dependent, terrified of their dependency. So when they get in a relationship and they start to feel dependent, they blow that relationship up. Anybody have patients like that? Same thing will happen with medication. This is the kind of patient who will take your antidepressant. As soon as they feel better, they're like, I feel better. I have to stop this. Because they're terrified that they're going to get dependent. Because it's useful. It's easier for these patients to take medications that don't work. Because they don't have that fear of dependency. And if they've laid that out for you, that there is issues around dependency. You're then able to start to talk to them about, oh, if you start to have that feeling, let's talk about that. And you want to establish a treatment agreement that recognizes the psychosocial dimension that says to the patient, all the stuff I said in the first talk, that all sorts of psychological stuff matters. Which means your mindset makes a difference. You have a lot of responsibility for the outcome of this treatment. So I would educate. So obviously, so I would always talk about CBOE effect, because everybody knows that. If somebody has a lot of side effects, I would probably educate them something about the evidence base about no CBOE effects. And almost always, or always, I will emphasize the importance of the alliance. And along with that will come something about. And so if I'm doing something that you don't like, not only do I want you to tell me, I need you to tell me. Or else, treatment isn't going to work as well. And you'll have patients, you know, I was on a panel with somebody with lived experience who'd been in the system for 17 years before a doctor said to them, it's OK if you criticize me. You know, I want that. I want to hear that. And you know, you do that, and that's the beginning of building trust for people that are distrustful. You know, I want to emphasize the patient's role in recovery, as I said, as well, so that they feel responsible and not just me. Also, so we're talking also about then empowering the patient to be a partner. Some of the things that this involves is maintaining some realistic humility about medications. You know, if you're like, I can promise you the sun and the moon, you're empowered. The patient is disempowered. And it's not really real, right, because our medications unfortunately are, you know, for most people, don't work as well as we wish they did. And if we overpromise, that's disempowering to the patient. And I will tend to put learning, the patient's learning and growth and agency first. So you know, at a place like the Austin Riggs Center, I say to the patient, you know, my task, my primary goal is not necessarily to get rid of your symptoms, unless that's something that's really important to you. My primary goal is putting you in the best place possible to do your psychotherapy, right, which may mean, you know, if it takes 12 milligrams of Klonopin, and now we've gotten rid of your anxiety, but you're not, you know, obviously, you're not going to remember a thing about what you talked about in your psychotherapy. So the focus is on function, right, and growth. And one of the implications of that is I'm going to make changes in a very deliberate manner, because I want you to come out of this experience knowing what works and what doesn't, which puts you in charge of your treatment. If we start three things at once, nobody knows, right? I want you to be, you know, I want to help you be in charge of this. It may mean keeping questionable medications for a while, when changes might interfere with self-understanding or self-possession. So I had a woman that had lost a lot of weight, could not eat, had terrible pain in her stomach, a quarter of her body weight. And she was on Welbutrin, and she came in, and I wanted to stop the Welbutrin because I thought it was contributing. But this was a woman who had a false self-adaptation, a real pleaser, and in relation to the broader goal, she felt like, well, if we switch this now to something that causes her to gain weight, she won't know, is she doing that? Or is the medication doing that? And her larger goal was to actually become more self-possessed. So I slowed that down, and she, you know, she ended up being able to work through all that without a change in medications. And it could also mean discontinuing medications if they're in the way of the patient's learning. So, you know, obviously we have patients who you know, every time they get upset, they take a Seroquel. And then every time they get upset, they take a Seroquel. And the whole time, you know, one of the things that they're doing is they're undermining their own capacity for self-regulation. They are not learning. And so we might highlight that. One young woman, just as an offhand comment, I said in the first session, wow. I looked at her regimen, which had four sedating medications, and I said, wow, it really looks like somebody wanted to keep you under wraps. And like, you know, and then she was talking about that to her therapist for two or three months, and she came in and was like, I really have to get off of this. Because she didn't like that idea. So, and you know, and I was also talking to her about the ways that it was in the way of her learning. And then, so we're talking in a way about some of the positive things we do to promote alliance. But the other thing is where patients come in with negative transferences. They're, you know, they've got that filter on, that's all they can see, right? And so we also sometimes have to address those. So among other things, like a patient comes in and they say that, you know, this is their experience. You highlight in the first session before the transference has become active. Oh, so this is likely to pop up with us, right? So you're lying with their ego before like affect takes over everything. And then when it starts to, you have that connection to their ego. And you say, oh, this is the thing we talked about, like in the first two sessions, you know, now you're experiencing me this way. And it helps give them some distance and for you and them to work through it. And it's sometimes you can interpret those negative transferences. So I had one patient who, you know, I put her on, this is a way, I don't probably need the whole detail, but somebody who had every anxiety disorder, really anxious, obsessional, narcissistic personality disorder, Borrelian personality disorder, really a wreck. And I put her on Lexapro and she told me she had not slept a night in her adult life due to nocturnal panic, which turned out to be true. This was happening, the nurses were seeing it. Started her on Lexapro and it calmed that down. She was also somebody who would really expect a judgment. So she would say something and then she would think, what are the five things that Dr. Mintz might say that are critical of the thing I said? And now she's put five things out there and then she'd think, well, what are the five things that he might say about each of those five things? And so her thinking did these like horrible, futile loops. You probably have seen patients like that. Put her on Lexapro, that calmed down, she calmed down. She was miserable, she felt so deadened. I'm so cut off from my feelings, how could I possibly do psychotherapy? And I said, well, stick with it, we just started, I cajoled her, and eventually she stopped it. And almost as soon as she stopped it, I got it. Because she was saying things to me all the time when I hurt her feelings, which was very often because she was very sensitive. Like, oh, can't you put me in a cage and throw a blanket over me? Like you do when you have a bird and you don't wanna shut him up. Or, oh, can't you take the top of my head off and scoop my brains out? Or, oh, can't you turn me into a zombie? And just clicked him, oh, oh, she feels like I was trying to shut her up with this pill. And so I offered this to her as an idea, maybe you experienced, of course, that is an actual effect of SSRIs is people feel deadened. But I suggested maybe this has to do with that expectation. And bingo, in her family, the word was hush. And to her, when I gave her that pill and it calmed her down, she felt like it was hush. And so turns out that that was actually a nocebo response in response to the experience that I was trying to shut her up. I said, oh, well, maybe that's why you had that side effect. Let's restart it and see what happens. And that experience of feeling shut down was gone. She became panic-free and able to sleep for the first time in her adult life. It didn't so much help her depression, but it helped with a lot of other things. And so we can use our psychotherapist skills like that to try to get at some of the problems that are there. And also in terms of the alliance, when there's negative, the patient stops the medication. You could point your finger at them, but very often I will take the relational tack, which is, oh, you decided to stop these medications without asking me. How does this reflect a problem in our relationship? Have I done something to make you feel like you couldn't bring this to me? And then something starts to happen. This is part of the long game, too, because now you're building like, oh, the relationship matters to me, and maybe it matters to you. And over time, the patient gets in a place where they're not gonna do this kind of acting out anymore because you've emphasized the partnership piece of it. And another thing you can do sometimes is increase the dose of the doctor. So sometimes when there's real problems, I'll say to the patient, you know what, I wanna meet you a little bit more often for a while. You know, we gotta work on this relationship. And you know, it's shocking the number of times that a treatment non-response will turn into a response if you just do something like that and the patient feels like, oh, this guy cares. So I think that that's it, and time for discussion. Thank you. Thank you very much, Dr. Thank you very much. How about treatment adherence with adults with schizophrenia who have been in the system for a while or are new with psychosis? So you go for the hard ones. The relationship is the most important thing in the beginning, I agree. And I will say the relationship I think is the most important thing because of course probably the most horrible thing about a psychotic illness is not the psychotic symptoms, it's the alienation, the loneliness. And sometimes, I guess I have two different stories in my head. One of a patient who came to realize that when she didn't take her medications, she ended up in a different reality from me. And when she took her medications, we could engage with each other. And eventually that became a reason for her. Another patient, and I think this speaks to the not necessarily treating symptoms, a woman I treated early on in my fellowship at Riggs, so 25 years ago, close to it, who came to Riggs psychotic, 20 years of non-remitting psychosis. And she was on an old, she was on prolixin, which wasn't working because she was hallucinating, she was delusional and disconnected from people. And wanted to start an atypical, but she had this conviction that if she started an atypical, she would become depressed and kill herself. So you can imagine, eventually I pushed enough and she agreed to try it, but the moment that pill went in her mouth, she was so wildly anxious that her psychosis ramped up, and it wasn't ramping up because the quetiapine or whatever was making her psychotic, it was the level of her anxiety. And within three days I was like, okay, primum non nocere, I got to stop this because I'm hurting this person now. And again, it was one of those sorts where eventually I got the hidden meaning. Which was, this was a woman who, in her early 20s, around the time she was having some schizophrenia prodrome, had gotten pregnant, had had a child, moved in with her family, raised her son with a lot of help from her parents. And then when her son was five, he got a glioblastoma and died. And non-remitting psychosis from that point on. Anybody want to guess what her most common hallucination was? Louder? Him? Yes. The hallucinated voice of her son. And among her delusions was the idea that she could cure AIDS and various deadly diseases and that she held the secret for raising the dead. Okay? And you see what I'm up against, right? Like what I have to offer is so puny in relation to what her psychosis was offering her. Now in this case, now that wasn't an interpretation I was giving to this psychotic patient. The value in that case was that it allowed me to maintain my empathy with her and to be there as a steady presence without pushing, without cajoling, creating space. During that time, she actually did grief work in her therapy. And six months, eight months later, she went on Clozarel and it was fine. And she became, her delusions went away. She became more relatable, started developing friends, and in maybe a best possible outcome, she never did lose the hallucinated voice of her son. He was always there with her. And I think that speaks also to the fact that we're not all, you know, getting rid of symptoms is not always the highest goal. So that's some thoughts on those kinds of patients. Hi, Dr. Mintz. I'm Akash. Thank you for the presentation. It was very interesting on many points. I was just curious about one thing about considering what you mentioned about how much the placebo response really plays a role in our patient's response. And then also you mentioned not like over-promising when it comes to meds. So I felt this to be like kind of a tough issue to balance. And many times in my own experience where you're trying to encourage a patient to switch a med, like say if it's like Clozarel, where they're going to have to do lab monitoring weekly or even if it's less like more benign or you want to switch someone to a TCA and you kind of have to persuade in some way. But like how do you manage not to be like over-promising, but at the same time get them into a treatment that's probably going to get them a lot better. So I was just curious if you could elaborate on that. Well, you know, there's promising and there's over-promising, you know, so you don't also want to undersell, right? You don't want to promise a sun and the moon. But, you know, with Clozarel, I would, you know, clearly I would be telling people there's evidence that this is more effective for your condition than a lot of the other things we have. There's a lot better chance that it will work. Again, so you, and you do it in a way, so there's that. And I think some of that is also having a developmental perspective. You know, you're keeping in mind where they're trying to get and working with them around this and emphasizing that, you know, everybody has their piece in this. It's not, you know, none of the pills we have are magic, right? Hello. Thank you for the great presentation. I'm a second year psychiatric resident and I had a patient and still have a patient in resident-run clinic. And like some of the patients that I had before, this lady has been on Xanax for years and then she definitely doesn't want to decrease the dose. I understand. She's been on what for years? She has been on Xanax for years and she doesn't want to taper off. I had previous patients and then, you know, some of the clinics that I work with didn't really feel comfortable decreasing the dose both because patients were basically very, very reluctant to decrease the dose and they were stable overall. But given that in 30 years they're going to be maybe 70, there's going to be an increased chance of delirium. There's going to be increased risk of falls. Given that, how do you approach the patients with benzodiazepine dependence? There is an issue with dependency and there is an actual physical dependency going on at certain levels. So how do you manage that? You know, I mean, part of the answer to that question is so dependent, right, on the psychology of the patient, right? One patient you do one thing, one patient you do something totally opposite as you're trying to get there, you know, for some people. And there's also the difference between, I think, the short game and the long game, right? The long game, you know, which really is harder to play when you're a resident and you're only going to see somebody for a year or two, is to really work on developing a trusting alliance where the patient takes seriously what you have to say. If you come in and, you know, next month you're saying we have to get rid of that, you're going to get resistance. Now I will also say, you know, you have to pay attention to your conscience, right? If I get to a place, like I have a fair amount of room in me for patients to use medications irrationally while we're working something out, but if I get to a place where my conscience is acting up, that's like a bottom line where I say, you know, I can no longer, I cannot in good conscience prescribe this and, you know, we have to figure out what to do about that. If you want to work with me, we have to get you off of this. But, you know, there's, if you also have started with the development thing, where are you trying to get? You know, that's one of the fulcrums is like, oh, this, you know, if you see ways that their attachment to benzodiazepines is in conflict with their broader developmental goals, then you have a fulcrum around which you can start to do those things. Yeah, and so again, so much of it depends on the individual dynamics of the patient, at least in my perspective. Yes. Danielle Lowe, UNC Chapel Hill. I'm a child adolescent fellow, and so I deal a lot with the family dynamics. What data is there, especially about the alliance and trying to get the engagement for successful treatments in that kind of parent-child dynamic? You know what? I haven't really looked into the data in children. I mean, I know, like, everybody I treat is a former child, so, you know, and at Riggs we do a lot of family work because they carry all that stuff in with them. So it's very clear, obviously, that the family dynamic, family feelings about medications, all that stuff plays, you know, influences outcome of medications in a massive way. And sometimes patients are in a, you know, there's something in the family that is in the way enough that you have to treat not just the individual, but figure out a way to treat the family as well. There's been a lot of folks taking pictures. I was wondering if you would be willing to put some of your slides up onto the app for us so that we can. Yes, I have to figure out what the, I just forgot to send them in. This is the problem. So I will figure out how to get them up on the app. Awesome. Thank you. They had meant to distribute them. Okay, thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. I was going to ask a question. Oh. It was just that the, you said that there was a big effect for patients that had a willingness to change. And I'm wondering how that was, like, measured and if that's, like, something that you should be trying to foster without. Yeah. Yeah, so absolutely. So the question is a question about, you know, when I, this study I mentioned about the readiness to change, it was measured using the Procheska and DiClemente readiness to change battery, which is used, you know, primarily comes out of the substance abuse world, but it has applications for depression and all sorts of other things. And I think the implication is, you know, that, for example, motivational interviewing is a technique that you could use to move somebody from pre-contemplation towards contemplation or action. But also, I mean, that's not my, my modality is psychodynamic. So I am doing a lot of work with patients about recognizing their ambivalence, helping shine a light on it so they understand what they're caught in, and giving them a chance then to consciously make a different choice than the one that they've been unconsciously making all along. So I mean, I think there's lots of psychotherapeutic techniques that we can bring to bear to help patients, to help move patients from being not ready to change to being much more ready to change. So again, thank you. Thank you.

video

psychiatrists

therapeutic alliance

patient-centered care

psychopharmacology treatment

medications

pill characteristics

non-clinical patient characteristics

patient outcomes

trust

communication

collaboration