Okay, so welcome. I'm gonna do the psychoanalyst thing and start exactly on time. I'm David Mintz. I'm a psychiatrist at the Austin Riggs Center, which is a last-of-its-kind psychoanalytic hospital focusing on work with complex comorbid and treatment refractory patients. These are patients who have, you know, been on countless, countless medications and they come to us and then we have to figure out what to do about their treatment. I'm also the recent past chair of the Psychotherapy Caucus of the APA. I am not going to introduce Carl because I would feel compelled to recount all of his accomplishments and that would take up all the time for this talk, so I will let him introduce himself. I will start by saying neither Carl nor I have any disclosures. And I'm going to start with the topic of the science of the art of psychopharmacotherapy. And there's a lot, you know, I think when we talk about wanting to practice evidence-based practice, typically we mean the evidence base that connects symptoms to DSM disorders to medications. But there's a whole other evidence base that is, I think, really unfortunately neglected, and you'll hear why in my talk, that gives us guidance not about what to prescribe but about how to prescribe in order to achieve good effects with our patients. And this ranges from, as we have up here, prescriber effects, which we'll talk about, characteristics of the pill, non-clinical patient characteristics, and by non-clinical patient characteristics I mean these are characteristics of the person rather than the illness itself and that interacts with how the patient is able to make use of medications and the therapeutic alliance. So I'm going to go over some of the evidence base for this, although probably only about a third of what I could talk about given the breadth of information we have about this. So, and I want to start with a study by a secondary analysis of the TDCRP study. The TDCRP study, Treatment Depression Collaborative Research Project, was, before STAR-D, the largest NIMH-funded, multi-center, placebo-controlled trial of the treatment of depression. They were trying to figure out what's the best treatment for depression. Is it medications? Is it psychodynamic treatment? Is it cognitive behavioral treatment? And what they found in the original study was kind of the Dodo verdict, which is all have won and all must get prizes, and basically they were all equivalent with the combination of medications and psychotherapy, slightly better results. Decades, a decade and a half, two decades later, McKay, Amell, and Wampold went back and looked at that data through the lens of the prescribers. So they knew who the prescribers were and it turned out that a physician's physician effects accounted for greater variability in outcomes than did medication condition. So they were able basically through this, so if a psychiatrist got a good result with one patient, that psychiatrist tended to get good results with all their patients. And if a psychiatrist got bad results with a patient, they tended to get bad results with all the patients, right? And so using the statistical technique of linear hierarchical modeling, they were able to stratify the psychiatrists into those who got very good results, those who got moderate results, and those who tended to not get good results with patients. And the effects were additive. So if a patient had a doctor in the high-functioning group and got the active drug, those are the patients that have the best results. The patients who had doctors in the relatively ineffective group and got the placebo had the worst results. But, and I just want you to think about what I'm about to say, the top one-third of psychiatrists got better outcomes with placebo than the bottom third got with active drug. So just, just think about that for a second, what that means for how we sit with our patients. And you know what those top one-third of psychiatrists were doing? Neither do I, right? Because process research is hard, nobody's getting rich doing it. Now there's another branch of the study, and so this is an inference, but another branch of that study suggested that the doctors that had a psychological frame of reference instead of a biological frame of reference tended to get better results. So that may be it, but we don't know for sure because that wasn't specifically tested in just this group. Now one way that how we sit with our patients can either promote or interfere with their treatment is the ways we talk to them about their illnesses. And medical, our medical explanations are very complicated. So in a study by Kemp, Lickle, and Deacon in 2014, they took college students with a history of depression and they enrolled them in a study to determine if their depression was a psychological or biological depression. So some, you know, somebody shows up in a white coat, does a cheek swab, disappears for 15 minutes, and then comes back and tells you if your depression is a psychological one or a biological one. And then they did a bunch of testing to determine how the patients experienced their illness, and a number of important findings came out of this. One was that the biogenic theory, the patients who thought their depression was was genetic or biological, it did not in this group reduce self-blame, which is one reason I think we are pulled to do that is to make the patients feel better. Now there are some other studies that do suggest it can reduce self-blame, so it's complicated, but in addition it found that it increased prognostic pessimism. So these students felt just less hopeful about the outcome of their illness, and we know that prognostic expectancies are directly correlated with outcomes. So if you have hope, you have a better outcome. If you don't have hope, you have a worse outcome. So when we give a biomedical, really reductively biomedical, explanation to our patients, we're actually probably harming their treatments. These patients also had worsened mood regulation expectancies, so they just felt much less like, well, what kind of, there's nothing I can do, I just have to wait for the doctor to make this better, and we also know that negative or poor mood regulation expectancies affect how individuals cope and directly influences depressive outcomes. And they had decreased self-efficacy in managing depression. So again, when we give an overly biomedical explanation, it puts the patient in a passive helpless position, and then they just have to wait for us to fix them, and it is the worst place from which to be trying to get better. Now, moving on to the pill. The characteristics of the pill influence outcome, and there's a lot of different research. I'm just going to talk about two pieces of this, but the color of the pill makes a difference, believe it or not. So red pills tend to be energizing. Blue pills make good anxiolytics and antidepressants, because they tend to be calming in Western cultures. So these are obviously culturally constructed things in Western cultures, except there was a study that found that this finding does not hold in Italy, at least not among Italian men. Any idea why this would not hold among Italian men? Football, yes, exactly. In Italy, which is a soccer-mad country, the Italian team is the blues. So for Italians, for us, blue is a color of tranquil skies and tranquil seas, but in Italy, blue is a color of power and masculine vitality. And so that tends to have the effect that red pills have in the United States of being energizing. Expensive pills work better than inexpensive pills. If, you know, you let slip in a placebo-controlled trial, this is 25 cents versus $85. The $85 pill works a lot better. And this is not just academic, right? This is not just academic, because our patients routinely go to the pharmacy and they've been getting a yellow pill for the last two years, and now suddenly there's a little, the size of the pill matters too. Now there's a tiny white pill, right? And we know that most, the majority of patients who experience generic substitutions report decreased intention to continue medications. It doesn't necessarily mean they'll stop, but they will tell you they're more likely to stop, and certainly if there's problems, you know, and we've all had this, and this is important enough that in Germany, they have stopped transitioning patients from brand-name antipsychotic, schizophrenic patients from brand-name antipsychotics to generics, because it actually costs the system more to do that, because then those patients aren't taking their medications, they're ending up in the hospital, they're spending tens of thousands of dollars, right? And 34% of patients experience new adverse events when there's a generic substitution. You know, either it doesn't work as well, or they have new side effects they didn't have before, and chances are most of that is not because there's major differences in bioavailability, you know, because of the binding agents in those pills. I think so much of that, and you'll hear this throughout the talk, comes from an experience of disempowerment. It is such a fertile breeding ground for problems in pharmacotherapy. Placebos. So the placebo effect accounts for a large proportion of antidepressant response. We know this. In a lot of published literature, it's, you know, 35 to 50, but those studies were based on published published studies, and of course we know there's a huge publication bias. Study shows a response, it goes in a journal, it shows no response, it languishes on the researcher's desk, you know, and eventually falls off into the garbage can and never sees the light of day. But there are unbiased samples. The unbiased sample is the FDA database, right? Because when you are proposing a new medication, you tell the FDA, these are the studies I'm going to do, and the FDA gets those studies, positive or negative. So when researchers have looked at the FDA database, it turns out that somewhere between 75 and 81 percent of antidepressant effect is due to placebo. And said in another way, we know that meta-analyses estimate placebo effect sizes to be about 1.05, whereas antidepressant effect sizes are often in the 0.3s somewhere. So the placebo effect is about three times more powerful than our antidepressants. Now in research, you know, they're trying to get rid of the placebo effect, but I think what that means for us is we should be experts in trying to amplify the placebo effect. Because placebo obviously does not mean imaginary, right? These placebo effects are real effects. There's research that shows that they're persisting for at least a year in many cases. And you can measure, like, you can look in the brains of people that are having a placebo response. It looks pretty much like the brain of somebody who's having an active medication response, except for some differences at the brainstem level. So these are real things. So we need to be thoughtful and mindful about how to amplify these effects. While, of course, having some integrity and not disempowering our patients, which we'll talk about. Now here are some non-clinical patient variables that affect medication outcomes. And I'm going to talk about some of these, but this slide is, you know, as this cartoon says. I'll pause for a moment so you can let this information sink in, right? This is mostly just to kind of overwhelm you with just a portion of what we know about how the person of the patient and their social situation and their beliefs and character can affect medication outcomes. And there's a lot of this. We'll talk about a few things. I think especially ambivalence is a big one. We know that ambivalence leads to pharmacologic treatment resistance in various ways. And, you know, patients can be ambivalent about a number of things. They can be ambivalent about medications. Anybody have patients that are ambivalent about medications? Is anybody in this room not ambivalent about medications, right? I don't want to take medications. I presume most of you don't, although Osler, Sir William Osler, did say that man is the only animal that wants to take medicines. So, although from, I think, from my perspective, the patients that really want to take medications, they are often the sickest of our patients. And in terms of ambivalence, we know from a study by Piguet, who was a sociologist who interviewed 140-ish patients with a history of antidepressant treatment about their treatment with antidepressants. It was very open-ended. Basically, just tell me about your experience of antidepressants. And then they did a factor analysis and identified 15 themes that tended to come up as people discussed their antidepressants. And of those 15 themes, the top four were all about being harmed. You had to get to the fifth theme for patients to start to talk about the way they felt helped by their medications. So, our patients are carrying around a lot of ambivalence about the treatments we offer. And other research suggests that if we don't ask specifically about that, they don't tell us and we don't know. Ambivalence is directly correlated with non-compliance. Patients with early ambivalence are two times more likely to stop their medications and three times more likely to stop if there's any kind of side effect at all. And so, I think as psychiatrists, we want to know something about their ambivalence so that we can deal with it directly as opposed to just letting it, you know, do what it's going to do. And, of course, also patients who perceive medications to be stigmatizing also are much more likely to have poor adherence. Now, patients can also be ambivalent about illness, right? Does anybody have patients that seem to be ambivalent about getting better, right? Yeah, right. Because, you know, when life gives you a bunch of lemons, what do you do? You know, you make lemonade and our patients do that. They find the hidden gratifications in illness. You know, maybe, you know, and I can tell you from my work with my patients, so many of my patients are far more powerful as sick people than they ever were as well people, right? Anybody have that experience? And then how do you give that up? Now, they lose a lot in being ill and I think part of our job is also how do you highlight those, you know, those struggles so the patient can grapple with them consciously as opposed to letting it unconsciously play out again. And this is where, you know, psychodynamic psychopharmacology or motivational interviewing are these kinds of things we can use to highlight the ambivalence and then help the patient work through it. And as we know, the patients who then, with secondary gains, are less likely to recover. Along these same lines, the patient's readiness to change makes a huge difference. So, you know, how many psychiatrists does it take to change a light bulb, right? One, but the light bulb has to want to change, you know, that joke. But it's true, right? The research suggests, like Bightman did a study of a benzodiazepine for panic disorder, but before the patients were enrolled in the study, this randomized study, they were given Protestca and D-Clemente's readiness to change battery and it turned out that the patients who were ready to change and got the active benzo had the greatest reductions in anxiety. The patients who are not ready to change and got the placebo had the lowest reductions in anxiety, but in the two other cells, patients who were ready to change and got the placebo had greater reductions in anxiety than the patients who are not ready to change and got the benzo, right? And this is so, you know, and we tend to think of benzos as pretty straightforward, but even there, the patient's psychology is more powerful than the medication. And this has been replicated for depression as well in adolescent depression. And then there are patients who have side effects from everything, right? It's another way we get, you know, we have trouble with our patients. And I think that very often that stems from experiences of powerlessness. So we know, for example, that people from marginalized groups, racial and ethnic minority groups, women, people from lower socioeconomic statuses are all more likely to experience nocebo responses. And in case anybody doesn't know what that is, it's just the evil twin of the placebo response, where there are expectations of harm that turn into concrete real medical harm. The difference, one difference between placebos and nocebos is placebo effects tend to be conscious and shared, whereas nocebo expectations are often unconscious and idiosyncratic. So we don't know about them until they start showing up in lots of side effects. And this, of course, contributes to health inequity, right? Because our, you know, a patient coming to see an old white guy who comes from a marginalized group is just more likely to have a negative response to medication. So there's an, you know, this is kind of a way that those patients are then subjected to, or they experience worse results than a patient from a more empowered group. And it's not just social disempowerment. Patients who disempower themselves also have more nocebo responses. So patients who are characterologically acquiescent, those patients who basically have to say yes, they cannot say no to an authority figure. They have to say yes, even if their alarm bells are going off, right? So they take the pill, they actually do tend to have early nocebo responses, but as soon as they start to feel it moving around in their system and things, something starts to feel different, they interpret that in a way that turns it into a nocebo response. So powerlessness is a real problem in that regard. In terms of the pharmacotherapy alliance, first of all, alliance is not the same thing as compliance, as I was just suggesting. We also know that alliance is directly correlated with treatment response. So again, another secondary analysis of the TDCRP data showed that alliance was an equally powerful factor in pharmacotherapies and psychotherapy. They had hypothesized that the alliance would be really important in psychodynamic treatment, a little bit less important in CBT, and probably negligibly important for psychopharm, but it is as important in psychopharm as in any of those other modes of treatment. And it was a stronger determinant of treatment outcome than drug condition. So again, in this study, the patients who had a good alliance with their doctor and got the active antidepressant had the best results. The patients who had a poor alliance with their doctor and got the placebo had the worst results. And again, you know where I'm going, right? In those two other cells, the patients who had a good alliance with their doctor and got a placebo had greater reductions in depression than the patients who had a poor alliance with their doctor and got the active drug. And this mediates, in this study, they were, you know, tracking adherence and patients were taking their medications. So the alliance mediates outcomes directly, but it also mediates outcomes through increased medication adherence. So the better our alliance, the more likely the patient is to do as we recommend. Some elements of an effective pharmacotherapeutic alliance, which I'll talk about pretty much most of these, warmth and presence, autonomy, support, agreement about targets, respect for treatment preferences, shared decision-making, good communication. So in terms of the value of warm human engagement, an interesting study by Cruz, where they put a recording device into a psychiatry intake clinic and they just asked the raters to rate the warmth of the tone of voice of the clinician. And apparently this is something that's, there's pretty good inter-rater reliability. People know when somebody has a warm tone of voice or not. And for every standard deviation interval above the mean, there was a corresponding 162% increase in appointment adherence, right? So if you had a warm tone of voice, your patients were almost three times more likely to show up for a second appointment, right? Now, you know, again, I don't know, there's not any research that I know of that teaches people how to have a warm tone of voice, but it is something for us to think about as we engage with our patients. Similarly, a study by Rosen, Nakash, and Allegria in 2015 put a recording device, a camera, in a psychiatry intake clinic and they just looked at how did the clinician, the intake clinician, interact with the computer or not. If they interacted with the computer once, that was coded as a session with technology interaction. If they didn't touch the computer at all, no technology interaction. And in that study, and you know, I don't quite know how to wrap my mind around this in a field where we're all interacting with computers, but in that study there, first of all, if you interact with the computer, there was a significantly lower rating of therapeutic alliance, but it resulted in a significant, like really significant, reduction in treatment continuation. So if you didn't touch the computer, 77% of patients came back for a second appointment. If you interacted with the computer, only about a quarter of patients came back. Now I don't, I imagine that doesn't match up with the experience of most people in here, but I figure some of that is we have ways of apologizing for the computer or doing something to try to let, you know, not let that computer interaction interfere as much as it might, but probably it is having a negative effect in some way or other with our patients. We want, and again this gets to the, you know, to the empowerment of the patient, we want to explore our patients' treatment preferences. Turns out that patients receiving their preferred treatment modality do better. So Coxas did a study where they took patients, determined do you want psychotherapy or pharmacotherapy, and then they randomized them. So maybe you got what you wanted, maybe you didn't. For the patients who were randomized into their preferred treatment, about half of those patients got better. Patients who wanted medications but were randomized into pharmacotherapy, only about a quarter of those patients got better. And if patients wanted psychotherapy and were given medications, 7.7% of those patients had a therapeutic response, right? So it's really important for us to be assessing what our patients want, you know, what kinds of treatments. And even, you know, when I have a patient who comes in and they've seen a commercial or their cousin's friend had a great response to, you know, Lexapro or something, I will generally say to the patient, you know what, that's exactly the right medication for you. But let me tell you why. I'll tell the patient, it's not because Lexapro is any better than other antidepressants, probably, but the research shows us that the treatment you want tends to work better than the one you don't. Now, you know, whatever medication you pick, it's not generic yet, so it's going to cost you. And, you know, now what do you want to do? You know, but again, you'll hear that I think I have a way of working that is constantly trying to hand as much power back to the patient as possible. And patients who get the treatment that they want respond more rapidly, and it turns out in a study, in a primary care office, where doctors were trained to elicit patient preferences, it doesn't increase the time for an appointment. So if we're asking the patient what you want, you know, one anxiety is, well, it's going to feel like mess with my efficiency, but it doesn't seem like it does in terms of the research. Now, another, we know also patients given a non-preferred treatment are a lot more likely to discontinue treatment and misfollow appointments. And another anxiety we have, I think, is that, well, if I ask the patient what they want, we're going to end up with all sorts of crazy regimens. But actually, the research shows, other research shows, that actually when we involve patients in decision-making, they get treatment, they get medications that are more concordant with guidelines, not less. Now, importantly, of course, patients from marginalized groups are statistically more likely to prefer counseling, but they're given less information about treatment options, and we, there's a communication pattern that perpetuates patient passivity. So it's another way that, of course, we worsen the outcomes through, you know, our systemic biases that are just built into, built into our culture and our practice of medicine. If we involve patients in decision-making, it turns out that involved patients are 2.3 times more likely to continue treatment. And in this study by Woolley, the way they were involved, these are patients who are inpatient for depression, suicidal depression, they're put on Lexapro, and they are then discharged. The choice these patients were given was, do you want to take this medication once a day or three times a day? Just that choice increased the likelihood they would continue their medication two and a half fold, right? That's a medically meaningless choice. So again, it speaks to why we, you know, tell our patients, you know, these are, these are the antidepressants, which one do you want? Because it just increases the chances that they will make use of it. And these patients were 7.3 times more likely to take their medications if they also agreed about the diagnosis with the doctor. And it improved outcomes, not just immediately, but 18 months out if we involve patients in decision-making. And as I said, it promotes treatment consistent with guidelines. So thank you very much. If you want to take a picture, here's some, here's some more. So I guess this is also in the packet, but if you want to follow up with some, some more readings about that, that's there. Well, good morning, everybody. I'm Carl Salzman. I come from Boston, where the Celtics have lost two in a row. I'm at Harvard Medical School at Beth Israel Hospital in the Massachusetts Mental Health Center, where I've been for most of my career. I have no, nothing to report. I'm a clean old man. I assume everybody here cares about their patients, would like to be helpful, is sensitive. And so in a way, what this lecture is all about is beside the point, because you already know all of this. But in fact, we all need to think about some of these issues as we go along, because as David has just mentioned, it's more than just the pills. And if you want to take away something from the meeting, that's really very good, buy his book, which is a terrific review and an exposition of a lot of these topics. It's really good, with a great bibliography. Now, over the years, what I think many of us have learned is that prescribing psychotropic drugs is more than just knowing about the pharmacology, because some patients get better with a drug, and at the same doses, some patients don't get better. And those of us who pay attention to such things notice, as David has mentioned, that the interaction between prescriber and patient may actually have some impact upon the pharmacology. It doesn't change the number of molecules that they're taking in, but it changes the way they experience it and feel it. And that leads us to the sort of obvious comment about knowing the patient, not just the symptoms. And I'm concerned that psychiatry has moved more and more in this DSM-driven way of prescribing by just getting the symptoms, as opposed to knowing the human being who's got the symptoms. Now, that then leads to the notion that the doctor and the patient are in this together. The prescriber and the patient are now in a relationship. One of them, the patient, is obviously needy and dependent and maybe scared. The prescriber is in the position of trying to figure out what to do. And sometimes it's obvious, you know, if the patient's bleeding, you stop the bleeding. Sometimes it's equally obvious the patient is, you know, severely depressed, you give them an antidepressant. But it's usually more subtle than that. At least it has been in my experience. And so the concept of a compassionate therapeutic alliance, a relationship between the prescriber and the patient, to me, is as essential as knowing the DSM list of symptoms and being able to understand what the patient's experience is. Now, in order to do that, you have to care. You have to actually care about what the patient is. You just don't want to give them the drug and get them out of there. You want to understand the patient. This is where compassion comes in. And this is when we are honestly interested in what the patient is telling us. And we can convey this through the way we are. And again, this sounds like I'm telling you something that everybody automatically does, but actually it's not true. Many prescribers just listen for the symptoms and actually may not even like the patients or feel that the patient is just trying to manipulate them. And it boils down to us. We have to really know our patients and believe them as they tell us what is going on. The old psychoanalytic notion was unconditional positive regard. What the patient says is important. And what you say back is also important. And as David has indicated, there's clear evidence from research studies that when the patient feels understood, they have a better outcome than when they don't feel understood. And there's double blind data for that in quite a number of studies. Now, here's the list of things not to do. This will guarantee that it won't work. When the patient comes in, you'll look stern and angry or distracted and you're checking your watch. Don't smile. Smiling is very bad. Patients, you want to be the boss, right? And as the patient comes into your room, you're looking around, checking, make sure the lighting is okay, no real eye contact. The patient sits down and starts to talk and you start typing into your computer. There's studies to show that the dropout rate in prescribing is twice as high or higher when the prescriber is typing as opposed to looking at the patient. And I don't know if any of you have had that experience of going to the doctor and having the doctor typing away at looking at the screen while you're trying to tell them how badly you feel. Now, obviously, if the telephone rings, you must pick it up because it might be your investment counselor and you want to know what to do or your car has been fixed and the muffler is there and so come pick it up and thank you very much. A lot of prescribers will do that. A lot of doctors do that. It's outrageous, but it happens. Now, of course, as the hour is coming to close, you're going to check your date book or something, make sure who's coming next, something, you know, look at your watch. Patient is, hey, what about me? And then, of course, you remember you have to call your spouse or a friend to check on the lunch date. Excuse me for a minute and you take a call. This is all humorous, but it's actually real. And patients have told me over and over again when they come in, you know, that doctor, that doctor didn't pay any attention to me. That doctor didn't really care, didn't really know who I was. Most of you in the audience are probably not old enough to remember the TV show Dragnet. Anybody remember Dragnet? It's a cop show set in Los Angeles and the cop is Joe Friday and Joe Friday had never smiled and when he was interrogating the patient, he would, the criminal or the suspect, he would say, just the facts, ma'am. That was the tagline of the whole show, just the facts, ma'am. And I'm concerned that we do the same thing sometimes. I don't want to know all that stuff, just tell me how you're feeling, you know, how's your sleep, how's your appetite, how's your energy, you know, do you feel like killing yourself, that sort of thing. Patients try to tell us what's going on and we're not listening to that. Back in the days when I was a resident, we were taught, don't make it sound like an interrogation, like a police interrogation. Don't just, you know, look for the facts, find out what's going on with the patient and what their experiences. Obviously, you do need some facts, but there are ways of getting them as opposed to just the facts, ma'am. Tell me how you are, tell me what's going on in your life, you know, and then you could ask specific questions. So how's that sleep going, how's your energy, etc. Okay, so instead of the negative interrogatory way, how do we be? And now I assume everybody likes to be this way, but it's worth mentioning. Obviously, you want to smile at the patient, come right in, please have a seat. How are you feeling? Now, you're watching the patient do this, you're already learning diagnostic information from watching the patient walk from the door to the chair. You're looking at body language, you're looking at gait, you're looking at possible physical evidence, but you're also looking at facial expression. Is this patient scared, terrified, shaky, looking around? I like to think about how I feel when I'm sick and I have to go to the doctor. Usually, I'm scared and I'm scared about several things. One, I'm scared that I've got something really bad and I'm going to get some really bad news, but I'm also going to get scared that I'm not going to be liked by the doctor. I want the doctor to like me because I need his help or her help, usually. And the doctor, I hope, is going to be able to give me something that'll make me feel better, but I'm not exactly sure that that's what I really want. What I want is to be understood. I want to feel that when I have left the office, somebody else understands what my experience is. Because sometimes the doctor will say, I don't think you need any medication. Now, that may be a relief or it may not be a relief, but at least I understand that. So, now if the doctor says, okay, I think they will give you some pills. Psychiatrist again. Now, we sort of assume that that's what the patient came for. We're a psychiatrist and psychopharmacologist. And so, we assume that the patient wants the medication. But as David has eloquently pointed out, that isn't always the case. They may say they want medication, but there may be another whole side to their set of feelings that are worth trying to explore. How? Simple question. So, I'm going to give you some medication. How do you think? Is that okay? What do you think about that? Are you already taking medication? Tell me about the other medications. We obviously always ask a list of medications, but you never ask, what are they like? How do they make you feel? Patient may not want to admit or tell you all of this because it may drive you. They're afraid it may drive you away. But at least you ask how the medications, how you feel about taking medications, and how you feel about taking the medications you're currently taking. Most of the patients that I see when they come in are taking at least three psychiatric medications at a time. And we have patients who are chronically ill who take you four or five psychiatric medications simultaneously. Now, what does the patient think about us when they come in? We assume they're coming in because they want our help and that we're the good good folk. But they worry about what we think about them, the way I worry about what my doctor thinks about me. And what do they worry about? Am I crazy? If I take, if you're giving me a pill, does this mean I'm crazy? Does it mean I'm hopeless? Does it mean that I'm not likable because there's something really bad about me? Or because I feel so guilty about something that I actually really deserve not to be liked? And then, and here we need to be a little bit more psychoanalytic in our thinking. The doctor represents an authority figure. Society imbues upon us the ability to tell people what to do. We can even call in the law if we had to, to make them take the pill. Very powerful people. And when you, you know, you think about a description of jobs, doctor is always a head of lawyer and Indian chief. We are powerful people. That means there's going to be the possibility of transference. What is transference? The patient puts feelings from an earlier time of their life onto this figure. And the figure is usually a figure who has power or importance or control. Doctors, obviously, police, and teachers, and coaches, and parents. And we may be perceived as a parent figure. And if we had trouble with our parents, or we had parents who were abusive, or angry, or dismissive, or critical, or made us feel inadequate, we could expect that the doctor might feel the same way. And somehow that would come out in the way I was being treated. So it's important to keep in mind the possibility of transference. Now, on the other side of it, patients may be coming for medication, but then they don't take it. As David has indicated, not everybody does what you would think they do in this logical situation of coming to the doctor to get something, and then you go home and you don't take it. Why? Well, sometimes the patient says, you know, if I take this medication I really must be sick, and I'd rather not think of myself that way. Why? Because in my life it's important for me to feel in control of myself, able to take care of myself, and I don't want to be dependent on a pill or anything else. Or my parents taught me stiff upper lip, don't be a sissy, don't take pills, or I might lose control. If I take that pill, am I going to act strange? Am I going to be in danger? Am I going to be dangerous to anybody else? Now the sensitive prescriber should be aware of this and maybe ask a little bit about it. You might say, you know, I understand you're unhappy, but tell me a little bit more about it and how you feel, and how you feel about taking pills and psychiatric medications. Now why don't patients take their medications also? Because sometimes it's important for them to be sick, because in the world that they live, which is usually the family, the identity and cohesion of the family requires that one person be labeled as the trouble, the problem. Yesterday morning, Dr. Eric Clayton gave a fantastic lecture in which he emphasized this point, particularly about suicidal patients of personality disorders, that sometimes they have to be that way in order for the family to stay together, which means if they take the medication and get better, they may be thrown out of the family or worse could happen. Clinical example, and I'll bet this has happened to all of you, at least in your training. I remember a young man who was very psychotic and responded to anti-psychotic medication and his parents, who were part of the treatment, said, doctor we will do anything that you ask us to do to help our son. So what did they do? As he was getting better, they threw the patient the pills in the toilet. Patient relapsed, got psychotic, and they took him away from us because they couldn't tolerate that he would not be the designated bad person. We need to think about those kinds of things. So you ask gently, so how do you feel about taking medication? How has it been in the past that you took medication? Is this okay? Will it be okay with your family? Sometimes of course it's useful to ask the family member to come in, or the spouse, or the friend, or the lover, or the roommate. Not only to get more information, but to enhance this alliance. Now when we prescribe, we prescribe obviously with the hope that the pill, the medication, is going to help the patient. We want to say that, but we can't promise what we can't deliver. The truth is, psychiatric medications are relatively lousy. If you really think about it, we don't have any medications that cure anything. We have medications that are helpful and are necessary, but they're not very good. If you look at the best clinical data, you get about a 60% response at about a 30 to 40% remission rate at best. So we can't say, well, you know, the patient says, well, are we going to be all better? You say, well, you know, and you have to figure out a gentle way of saying, well, I can't promise you that. Now the other part of this is, we know that patients with chronic psychiatric disorders often will require medication for the remainder of their lives. There's data all over this building talking about relapse and recurrence, and it's true. So if we're treating a patient who's having their third episode of depression or bipolar mania or a panic attack or a psychosis, they're going to need to stay on their medication more or less indefinitely, and that's a terrible thing for some people to experience. That does indicate defect, weakness, disappointment, failure, and correspondingly anger. You can't tell me that, you know, I'm not going to do what you're going to do because you're telling me, because that would only confirm what you, I don't want to hear, that I am defective. So we need to understand that some patients need to be told this in a compassionate, gentle way. It's not that you're a bad person, it's kind of like diabetes, you know, this, you know, it's not a moral issue that you have this disorder, and together we can do this. We can work together. I will prescribe it, you tell me how you're feeling, and together we will go through life trying to manage the medication and to do the best we can together. This isn't about me doing something to you, this is about us doing something together. It's a partnership. This is what David's talk indicated, the Pharmacotherapeutic Alliance. This is a true partnership, and sometimes I use those words when somebody looks at, I'm getting the sense that they're feeling a little bit jittery about my being in control of them, and I, and this is often true of patients who've been psychotic and who are very sensitive to being in control. This is a partnership. I know about drugs, but you know how you're feeling. I'll suggest this drug, and then if you take it, you do your best to tell me how it's making you feel, and if it's not good, tell me, and together we'll try to figure it out. We'll either change doses, or we'll change medications, etc. Okay, so the compassionate psychopharmacologist needs to know something more than just the list of symptoms, because what may actually happen is that the patient has come to you saying they're here for their symptoms, but they're looking for something else. For example, a nice young woman comes to see me to regulate her lithium. She knows she has bipolar illness. The lithium has been helpful, but she didn't like the previous doctor, and so would I take over her lithium, and so I said, well, tell me about yourself, and we talked, and I asked questions more or less about what her life was like and how she felt, not just the symptoms. The diagnosis was pretty clear. At the end of the session, she says, can I ask you a question? Of course. Would you be my therapist, because you understand me the way the other doctor didn't, and I need to have a therapist, because my bipolar illness gets me into trouble. She had actually come to interview me, rather than the other way around. I hadn't realized it. Some patients are concerned about insurance companies knowing they're taking medication, or other people knowing that might negatively impact upon their life, so they want to know about confidentiality. That's an easy one. Everything is confidential. What happens in the office stays in the office, like Las Vegas. Okay, now, some patients are feeling bad about themselves, and they use their diagnosis as an excuse for why things are not working out very well. Again, you have to sniff that out, because they may not be reliable in taking the medication, and the kind of questions that one asks is, or general, well, tell me about your life a little bit. Will you work, and what's going on in the family? It's not just, again, as I've said, not just the symptoms. It's trying to get to understand the patient, and then the compassionate prescribers sensitive to these issues, and also alert to the fact that the patient may not actually be reliable in taking the pill, or in reporting faithfully how it makes you feel. So, in order to establish the alliance, be a compassionate prescriber, it's really sort of obvious, but it does need to be say. We don't just limit the interview to just the facts, just the symptoms, just the DSM criteria. Tell me, tell me about yourself. Tell me about your life. What's going on now? Well, can you tell me a little bit about growing up, what that was like? And suddenly, the patient becomes a full human being, and we have a sense of what we're doing in addition to just the diagnostic criteria. Okay, I'm going to move along a little bit. I talked about these. Just to review, medications might mean failure to the patient. Medications might mean they're giving up control, which all of us don't want to give up. Try giving medication to somebody who's got obsessive-compulsive disorder, in which control is the name of the issue, and they will take medication, but it's very hard for them to really give up control. Medications might mean disobeying the family traditions. You know, up in the northwest of this part of the country, stiff upper lip country, you don't give in, you don't show weakness, and you don't take medications if you don't have to. You grit it and bear it. It's all wrong, but that's the way it is. And medications might mean surrendering personal control of your life. So we work together as a team. It's not that I'm going to tell you what to do, it's that we're going to discuss together what could be done and try to work as a team. Lastly, we need to talk about side effects. Now we can scare the willies out of our patients by telling them the side effects of our drugs, but of course we have to. There is such a thing as informed consent. So the question is, how do you do it, and how much do you tell the patient? I mean, if you tell a patient who's acutely psychotic that these pills might kill you, that's not a very good idea. So you have to make a judgment about whether the patient is capable of using the information and understanding it, and also helping you build the alliance. I, as the prescriber, understand that you, the patient, may experience some effects of this pill that aren't so great, and what I would like for you to do is to tell me if you're having side effects. Call me up, text me, make an appointment. I don't want you to feel alone with these side effects. Now, some of the side effects you have to tell patients about, so you have to do it as gently as possible. You can't lie about it, but you can find a way to say, you know, some people have these kinds of side effects, and sometimes they're troublesome, but if you call me, you're not alone with these side effects. This is a partnership, a pharmacotherapeutic alliance, and your job as part of this alliance is to just let me know what's going on and how you feel. Now, in this alliance, there are some things that are hard to talk about. One of them is money, but the other one is sex, and how you talk about sex or the sexual side effects of medications, of which we know is a real problem for SSRIs in particular, dual acting, antidepressants in particular. We may be giving a young person a pill that's going to ruin their sex life, or at least make it difficult, and we can't do that because this is part of normal life and growing up, but we want to use these drugs, so we have to alert the patient, and maybe as gently as possible, without insulting or scaring, that you may have some of these side effects. Would you call me if you do? And together, we'll see if we can figure out what to do, whether we're going to change the dose, change the pill, change the timing of the pill, look for other ways of helping you out. That builds the alliance. That makes this a relationship, and then what I've discovered is that I really like my patients after being able to establish this. It's fun to talk to them because they are enjoying talking to me, even though we're talking about bad stuff and serious stuff. In older people, there's a concern about cognition, because older people, like me, already have cognitive problems. Forgetfulness is common, and the question is, is the medication going to make the forgetfulness worse? Will it cause Alzheimer's disease? Well, there's no, none of our drugs are going to cause Alzheimer's disease. Believe me, that's true, but they might impair memory, particularly in the elderly. Sedative hypnotic drugs can do that. So the question is, if you really feel the patient needs the medication, how to give it, how to prescribe it, and you may need somebody to help the older person, depending on the degree of their ability to conform, but again, it requires a sort of a gentleness. Now, older people, you say, how can older people have a transference and treat you like that you're a parent, because they're older than you are? It happens. It's true, and older people will, you know, react to you both positively and negatively, depending on how you are, and one last thing about that, and then I'll be pretty well ready to stop. In our business, you must not touch patients. That's the rule, not in geriatrics. Sometimes the way to build the alliance is to put a hand on the shoulder, speak gently, make sure they understand. This is what I'd like you to take. I'd like you to take it in this schedule. Maybe I'll write it down for you, and what you're doing is you're building the relationship. It isn't so much the pill. Now you have some trust that the patient can work with you. So, just to conclude, it's sort of a sermon here. Prescribing is an art, as well as a science. The science is actually fairly straightforward. I mean, we all come to hear about the latest new drugs and all the stuff that we need to know, but it's how we use the science, and that means the humanistic aspect, the compassionate aspect of prescribing, and so my message to myself and to everybody else is know the patient, not just the symptoms. Thank you. Okay, so, I think, actually, I'm probably going to do a lot of just reiterating some of the things that Carl just said in our last 15 minutes, where I talk about the pharmacotherapeutic alliance, and I want to start with a quote by the poet Rainer Maria 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, right? And so this is, I think, a part of the point that we're talking about is it's not just the pill. So much else has to happen, and I'm going to focus, before I focused on the evidence around the alliance, I'm just going to focus more on the theory and ways of thinking about how to develop an alliance. So, to start with, we can think of the alliance as consisting of three pieces, the task, the goal, and the bond. This is Borden's trans-theoretical tripartite model of alliance. So we want to ask ourselves, I think, and ask our patients, what is the task? As long as we, you know, one piece is if we and the patient have the same task in mind, or the same ways of formulating the task, that helps the alliance. What are the goals? You know, what is, where are we trying to get? Because, of course, we may be trying to get one place and the patient is trying to get someplace else, so we want to figure that out. And how does one nurture the bond? Because, you know, certainly you can have problems around, you know, disagreeing about the task, but if you have a bond, the relationship survives and you work it through. So, you know, from a biomedical perspective, of course, you know, the task might be to accurately assess and diagnose and then provide medications. I think from a more biopsychosocial perspective, we might want to develop not just a DSM diagnosis, but what Michael Bolland, who gave us the idea of patient-centeredness, called the overall diagnosis, where you're, partly your sense is, how is the patient trying to use the treatment that I have to offer? And I'll talk a little bit more about how that relates then to goals. But, you know, what are the goals that we have? Because our goals and the patients might be different. Are we treating disorders? Right? That's the medical model, right? The illness-focused, illness-centered approach is really what we're treating, is DSM diagnoses. Evidence suggests very few of us actually work that way, right? We are treating something else, although that's the model that is pushed on us everywhere. But it's not, it doesn't make sense, so we don't do it, except around Korsakoff's syndrome. That's the place where we operate from a biomedical model. We give somebody thiamine and we treat the illness. Are we reducing symptoms? Is that the goal? Are we decreasing suffering? Is that the goal? Are we enhancing functioning? Promoting recovery? Are we promoting development? And, you know, we can be we can be working at any of these levels or some combinations, but, you know, a patient or we may be operating at the curing disorders level and somebody else is working at the enhancing functioning level, and if we're not on the same page, those treatments go awry. So to think about the task, first of all, how many of you are psychopharmacologists? Okay, good. And the rest of you, I assume, are psychiatrists. And, you know, I make that point because, of course, like, well, does anybody know what the derivation of the word psychiatrist is? It comes from the Greek, Psyche Iatros, doctor of the soul, right? And what's a psychopharmacologist? One who studies psychiatric medications. The patient has just dropped out in that formulation, right? And, of course, you have to forgive me, this is a bit of, of course, a false dichotomy, but to make a point, as somebody with an illness-centered approach, we're focusing on the actions of medications on symptoms as opposed to I think from a more biopsychosocial approach, really a focus is more on functioning. You know, psychopharmacologists would be a more illness-centered approach as opposed to a more patient-centered approach. I think that as a psychiatrist who has a more of a developmental model, we're mental health professionals, but increasingly we're pressured into becoming mental illness professionals, really, to the extent that our primary focus is just on diagnosis and not on functioning, on healthy functioning, except for healthy functioning as the absence of symptoms. But few of us would be content with just that in our own personal lives, right? A psychopharmacologist might ask, what is this patient, right? As opposed to, who is this patient? You would ask as a psychopharmacologist, what do I prescribe? But from a more biopsychosocial perspective, you're also asking, how do I prescribe, right, to get the best results with this patient? From a psychopharmacologist perspective, the doctor is the expert, but from a psychiatrist perspective, there's distributed expertise and authority. The patient knows what their goals are, they know where they're trying to get, there's things we know, there's things they know, and we're trying to figure out where's the middle ground between those things. And if there's a shared assumption about the task, it tends to go better, but a lack of understanding may create misalignment. So we can have different goals or different approaches, and if it doesn't match up with what the patient is looking for, you know, that is a relationship that easily gets in trouble. In terms of goals, you know, symptomatic, symptom goals or disorder goals versus developmental goals, as I said, if we're focused on one and the patient is focused on the other, there's problems. And that can go either way. Very often, right, we get patients who are just like, fix me, and we're like, you know, it doesn't work that way. You know, I can do this much, or you can do, the medications can do this much, but you've got to do this much if you really want this treatment to work well. And goals for patients, of course, can be unconscious, like the patient comes in, they want a medication because they want to feel better. But perhaps underneath that, they've had a lot of early adverse experiences and a huge chip on their shoulder about caregivers. They like need to prove to themselves, see, you can't count on anybody, nobody's ever there for you. You've got to be there just for yourself, right. And so their more unconscious goal is actually for you to fail. And then maybe under that, under all of that, their deepest goal is to be loved. They want to be sick so they can get care. And so the patient may have layers and layers of goals which are more or less unconscious, which leads, as I suggested, to ambivalence. And we want to be listening for that, right. And as I said, ambivalence is, you know, a driver of all sorts of problems. And there's simple things we can do. When there's, you know, to get at, as I said, patients won't tell you they're ambivalent. So I always ask in that, usually, almost always, or always in that first session, what's it like for you to take medications? Right, or if they're younger, or really embedded in a family context, I might want to know about how it is for in their family. And patients may right there tell you, I hate taking medications, I hate being dependent on anything, you know. And then right there you know where some of the sources are, and you can start to make it conscious, and then you can work on it as opposed to it just doing what it's going to do. Or about care providers, right. So many of our patients have come into the office already knowing who we are, right. Because they've had early adverse experiences with caregivers, they have real negative expectations of what, you know, people are like, especially caregivers. And they've had also real experiences with psychiatrists. And, you know, usually if you ask, you know, what's your experience with psychiatrists been? They'll tell you how many of their psychiatrists didn't really listen, didn't really care, just gave them a pill and got them out the door. And so you know. Or, you know, it's other things as well. But the patient is telling you what their transference to you is, walking in the door. And then you can work on that. And often once I've asked that question, and I've gotten a developmental history about their early life experiences, I will ask, so how does the, you know, I had an authoritarian father. So how does that color the way you experience caregivers now? And it now suddenly becomes conscious. Oh yeah, I have real problems with authority. And we can work on that, right? That we can engage that consciously as part of our relationship. And as I said, patients are ambivalent about health. So and I will often ask, is there anything you might stand to lose if treatment works? Now this is a question I will tell you. You have to ask in the first session, if you're going to ask it. If you wait six months down the road till you're frustrated and thwarted, it's, the patient hears it in a totally different way. And rightly so, because now your question is an accusation, right? But when you ask it in the first session, you're just curious. And the patient may tell you. I had a patient, you know, very therapy naive, who said, who was the mother of a young child and had been under depression since, for two years, since her child was a toddler or a little bit younger. She said, I'll lose the attention of my husband. You know, she was, she had collapsed because that was the only way she knew she would get the attention in the family. She was, you know, as treatment played out, it turned out she was in a massive struggle with her, with her toddler child for this, for the attention of her husband. And that was the issue that had to be dealt with in the therapy. But she, on some level, she knew it, not fully, but knew it enough to tell me. In terms of bond, you know, partly we're talking about how do you take a patient-centered perspective. So as I said, in the first couple, in the first session or so, I will try to get a developmental history, which has several benefits. One, it alerts the patient that you're interested in more than just symptoms. It also highlights, as I suggested, the transferences and relational patterns that may affect the patient's healthy use of medications. And it will tell you, the patients, if they, if a patient is the kind of patient who is really conflicted about dependency, and every time they get in a relationship and somebody starts to feel dependent, they find a way to blow that relationship up, that will happen with medications too. This is a patient who has, is fine taking a medication that doesn't work, but if the medication works, it makes them anxious because it makes them feel they need it. And then these are the ones that, as soon as they feel better, like for four days, they've stopped, I don't need it anymore, I'm good. And they stop their medication and then they're, you know, relapsed a month later. And if you've identified this, you can talk to the patient about it before it comes, you know, before their defenses are sparked and their resistances and their fears, and then you can work on it. And so we want to establish a treatment agreement with the patient that recognizes the psychosocial dimension. So I will, I will, in that first session, also, you know, we've talked, you know, obviously we do psychoeducation, but I will do psychoeducation about the, you know, the power of the placebo effect. If it's a patient who's had a lot of nocebo responses, probably some of the data around the psychosocial dimension of nocebo responses, I'll emphasize the patient's role in recovery, and I will always emphasize that the alliance has a major impact on treatment outcome. And part of what I will say, one of the implications of that, then, is I'll say to the patient, so if I'm doing something you don't like, not only do I want you to tell me, but I need you to tell me. Because otherwise, things will be happening that are going to under, ultimately, my goal is to help you. And if you're not telling me, chances are I'm not giving you the treatment that is most helpful. And, and often I will then say, and how good are you at telling authority figures that you're unhappy with them? And that, you know, and they'll tell me, oh, I'm not so good. So I say, you know, I'll probably ask every, every couple of times we meet just to, just to double-check then. I was on a, I was on a panel with somebody with lived experience some years ago, and they said they'd been through eight psychiatrists before they felt like somebody had given them, authorized them, let them say anything critical at all, you know. In terms of empowering the patient, we want to maintain realistic humility about medications, as Carl was talking about. Medications can do this much, but you have to do this much. I would tend to put the patient's learning and growth and agency first. So I frame medications as supporting the patient's ability to grow, learn, and use treatment. Symptom reduction may not be the primary goal. The patient's functioning is a primary goal. You know, certainly in a place like Riggs, where people come to learn about themselves and use their therapy. If it takes, you know, six or eight milligrams of Klonopin to get rid of your anxiety, now you have no anxiety, but of course you're not going to remember shit about what you talked about in your psychotherapy. So that's obviously not the right medication. It also means making choices in a very deliberate manner, one thing at a time, so the patient comes out of that experience knowing what their medications do and don't do. So many patients get started on three things at once, and then they don't, and they feel better, and do they need to take all three, or is it just one? And so I really want my patients to know as much as possible, although it's always impossible, right, to know what your medications are doing, because these psychosocial stuff is influencing it so much that I, you know, I will sometimes say to my patients who've seen the psychopharm gurus in Boston, and New York, and LA, and whatever, you know, I'm an expert too, but my expertise is in not knowing, right, because this stuff is so complicated. It's always impossible to know for sure what's psychological and what's biological, but our struggle together to figure that out puts you more in charge of your treatment. It may mean keeping questionable medications for a while, while the patient is sorting things out so they know, they get clear on knowing what's what. I had a patient who had lost a lot of weight, wasn't eating, she was on Wellbutrin, and I wanted to stop it, but she also had a false self, and she felt like, well, if you put me on Remeron, and I start gaining weight, I'm not going to know, is that me doing that, or is that the medication? And so I said, okay, let's keep the Wellbutrin for a while and see if you can gain weight on your own, which she did, and as I said, it may mean discontinuing medications to help patients learn who they are, or to develop mature coping, because, of course, we have patients who also use medications to substitute for all sorts of ego functions. Every time they get anxious or upset, they take, you know, 100 milligrams of Seroquel, they never learn how to manage their feelings, and so in cases like that, sometimes you have to stop things. How are we with time, Carl? Okay. Lastly, I just want to say, you know, interpatients bring in negative transferences to the work of, you know, we've done nothing, and they already distrust us, or we do something little, and it just explodes, because now that maps directly on to their deepest fears of who we might be. So, you know, we want to, I think, consider how alliance problems may repeat relational patterns, and I will interpret these things. I get a little bit of a developmental history, you know, five, ten minutes worth, just so I have in mind, like, what the transferences are likely to be, and then I can say, oh, do you think that this could be this thing that we talked about in our first hour, and it gives us a little bit of room when that happens, and I will also make misuse or adherence issues relational, instead of just like, oh, you need to take, they don't work if you don't take them, or the question would be more like, you know, you stopped the medications without calling me or telling me, or you didn't tell me in our last session, how does this reflect a problem in our relationship that you didn't feel like you could tell me you wanted to stop this medicine? So the next time they want to stop it, they know, like, you know, the expectation is they'll call me and we'll talk it through, and you know, and I'm involved in that, and it slows things down, or you know, maybe we can talk about this when we meet next, and it's a simple thing, but we have to have that relational perspective, and sometimes you also want to increase the dose, right, of the doctor. If things are going awry, sometimes I will say to the patient, let's meet a little bit more often while we figure this out, and right, you know, it's sometimes that is absolute magic, right, suddenly medications that don't work are now working, or, and it's, you know, if you're in a system where you're in your own private practice, where you have some control over your schedule, it's an extremely powerful intervention, and we have time for a few questions. Good afternoon. Thank you so much for the talk. For context, I'm an Army psychiatrist, and I care for many middle-aged men who identify as gender-stereotypical males, and my question is, when I'm doing shared decision-making and providing options, sometimes I get a response of, well, I don't know, you're the doctor, so one, how do I kind of increase the confidence when I'm giving options, and two, do you think there's a gender relationship between, like, therapeutic alliance and relationships? Well, first of all, I want to, one of my teachers years and years ago said, you know, the most hostile thing a patient can say to you is you're the doctor, right, so there's, so right away I would be thinking about negative transferences and that kind of thing, and, you know, I think in terms of that question, we don't want to force the patient to decide if they don't want to, but create a relationship where we're drawing attention to that, maybe repeating to them that the evidence really does suggest that the treatment you want, or that, you know, but in the end, you know, if the patient's need is for you to be in the position of authority, you know, you roll with it and then work on it. And obviously there's all sorts of complicated, you know, I gendered stuff around authority that, you know, as a female, you probably know way more about it than I do. I think about it a lot, yeah, for sure. Thanks for a great talk. Can you say something about the slides you showed on Alliance? How was Alliance measured in those studies? Which study? Just the impact of Alliance on outcome. The one from the Krupnik-Satzky study, there were, I think, both Alliance measures. They had the patient and the doctor and raters. All three, I think, were rating the Alliance. I forget what the Alliance instrument was. Okay. Excellent talk. My question was, there are surveys showing when Europeans come to the US, one of the things which strikes them most is the direct to patient advertising. Is the direct to patient advertising. So I have a lot of patients who read all these new, or see all these ads and come to me, and I, my approach with them was, you know, I wish the medicine would do all what they are saying, but listening to your talk, it kind of put me in a little conflict about asking the patient what you prefer, because I typically tell them, come two notches down from what you think this medicine is going to do to you. So any thoughts on that? Okay. Oh, in terms of direct, so I think it's like I said, that you would want to, from the beginning, at least in the way I think of it, I'm inviting the patient into an alliance where we are thinking about the relationship, we're thinking about meaning, we're thinking about the role the patient's psychology has in promoting positive outcomes. So, you know, if a patient has experienced something like some direct to consumer advertising is coming in, I would do like you did, which is, A, to have some realistic humility about what medications really can do, like I wish they could do everything that, you know, that, you know, three weeks later you'll have a big smile, it doesn't work that way, but, you know, that may be the best one to start with, because the evidence says it's the one you want, and then there's the struggle around, you know, well, but, but given that they're all actually equal, you know, how much do you want to pay, how much more do you want to pay? And, you know, it's part of a larger project of really trying to put the patient, let the patient feel how responsible they are for the outcome of treatment. I doubt it. You know, again, to the extent that if there's, if the patient gets what they want, it probably gives, you know, helps, but, but, you know, I would think that probably the opposite, because patients are end up, may end up wanting things that are maybe not the optimal thing for them, or, you know, they want to have that diagnosis now, because then they can get that medicine, or obviously complicated things. We have time for one more question. Yeah, you mentioned the interference of technology in patient alliance, and my question is relative to the generations. So I've read something recently that the Gen Z population reacts to technology differently than the millennial and other generations, and the question is, if you feel, or if you have any data that suggests that they respond differently, and, or are they're more likely to be more in a improved alliance, say, with technology or not? Just a question out there, because there is a difference, I think. So, you know, I'm actually, if you have some, I'd be interested in what evidence you have. I actually don't know anything about that. I know I've read little things about it that Gen Z, you know, they might rather test, text, and call, or talk in person, and, you know, but I think Carl and I operate from a position, there's something about, you know, being in the room with somebody, feeling, you know, like they're feeling something, and you're feeling something of what they're feeling, because they're anxious, you know, there's projective identification happening that isn't going to, you know, come across on text. So I, so, you know, I personally operate from a place of, I want to meet, I want to be in the room with a patient and not use too much technology, but, you know, it's certainly believable that some Gen Z patients would prefer, would prefer a more technologically mediated interaction and feel more comfortable with it, but I don't know about any data. There is a little bit of experience now suggesting that some women who have experienced severe trauma are more comfortable talking about their experience through the media, through virtual interactions with their prescriber, but this principles of compassion don't stop because you're using an electronic media. In fact, it might even be easier to be sympathetic or empathic or understanding because there's less danger, and I have one patient who is an example of that, and just the other day she was saying that compared to before COVID, she now finds it easier to talk about some childhood abuse that she experienced, although we both knew that she had it before COVID, but she didn't really feel comfortable talking about it, and now she felt comfortable talking about it, and I said, is that because we're not in the room together? And she said, yes, and she said, I trust you. I'm sure nothing would happen, but somehow it's easier. This doesn't get to the question, but I think you're also highlighting a way that it's really helpful for us to, the way you do as a psychotherapist, talk about the relationship. That question, is this because of the setup, you know, as part of the kind of alliance-building things we can do, is to pay attention with the patient to how we're working together. You know, we're over time, but I think Carl has to run. I'm happy to grab, you know, if people want to talk to me up front.

psychopharmacology

therapeutic alliance

evidence-based practice

prescriber effects

placebo effect

psychological frame

treatment outcomes

compassionate relationships

transference

medication stigma

patient-centered approach

shared decision-making

treatment compliance