Psychodynamic Psychopharmacology: Insights from Dr. David Mintz

In this episode, I engage in a shared-interest conversation with Dr. David Mintz, a psychiatrist with over 30 years of experience at the Austen Riggs Center, about his book Psychodynamic Psychopharmacology: Caring for the Treatment-Resistant Patient. Mintz explores the integration of psychodynamic principles into medication prescribing, emphasizing that psychiatric treatments are not purely biomedical but profoundly shaped by meaning, symbolism, attachment and interpersonal dynamics. Drawing from his work with treatment-resistant patients, often those with histories of early adversity, the discussion distills how psychodynamics influence medication efficacy, adherence, and overall recovery. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. https://www.psychiatrypodcast.com/cme-program Link to blog. https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/episode-244-psychodynamic-psychopharmacology-david-mintz Link to YouTube video. https://youtu.be/kqRlbzU3ukw

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:13David Puder?

  All right, we are going to start. We have David Mintz today. He has written a book, "PsychoDynamics: Psychopharmacology." He's a psychiatrist. He has extensive experience treating patients. Right now, you're at Austin Riggs, is that correct? And you have some private practice as well, I imagine?

• 0:30Speaker 01

  Yes, I do.

• 0:31David Puder?

  Yeah. And so, tell me a little bit about how many years have you been practicing? And what does that look like, most of your career, just to get us started here?

• 0:40Speaker 01

  Yeah, so I came to Riggs in the middle of the 1990s, like, right at the height of the biomedical turn. And so, I came in at a time when I was having a very interesting experience of like, I'm at Riggs doing psychodynamic psychiatry, and the field is going in the completely opposite direction.

• 1:02David Puder?

  Wow, yeah. So 35 years?

• 1:05Speaker 01

  30, 30 years.

• 1:07David Puder?

  30 years, yeah. And so, today, we're going to be talking about psychotherapy. We're going to be talking about how it relates to medication. And hopefully, I will sort of pull from you how medication can evoke some unique things, right, psychodynamically?

• 1:26Speaker 01

  Yes. And the other way around, how psychodynamics really shapes the way medications end up working.

• 1:33David Puder?

  And I think one of my goals for our session today is to really distill how you view your practice, how you view psychiatry, what you do on a regular basis, like, what does this actually look like? Are you prescribing to all of your patients? When do you not prescribe? How do you view that you're different than most prescribers? And how you help your patients view medication, view their identity in the midst of a medical set of issues? And where transference, counter-transference comes in, enactments, the mind-body split,

• 2:14David Puder?

  and how you integrate those? So, kind of give an elevator pitch for where you would like, what are the main things you would like people to take away as we kind of think about starting this?

• 2:26Speaker 01

  Well, I think the evidence, I will start by saying the evidence, I think, is very clear that meaning or meaning effects shapes medication response profoundly across, across drug types and across diagnostic categories. So when we are working in a way that narrowly thinks of our medications as simply biomedical, we are missing something because our medications are, and, you know, not just both biologically active and symbolically active, but for some conditions like depression, predominantly psychol- uh, symbolically active.

• 3:09David Puder?

  Okay, so maybe talk a little bit more about what you mean by meaning and the meaning we ascribe to things, right? The meaning we ascribe to illness, medication?

• 3:19Speaker 01

  Yeah, I, I mean, on some level, I, I think we're talking about the, the worldview that the patient has. So our patients, uh, you know, and again, many of our patients in psychiatry, and certainly the ones that are treatment refractory, which is the population they treat at RIGS, have histories of early adversity, have learned, you know, early on and deep in their bones that caregivers are potentially dangerous. And so they see the world, you know, they come into our offices and, and they come in with a set of expectations. And those expectations shape, uh, the way that they respond. And on the other side, patients who are, have more, um, hopeful, uh, more hopeful orientation towards care.

• 4:04Speaker 01

  We know that the placebo response, you know, ranges from an effect size of something like 1.4 for antidepressants all the way down to like 0.59 for antipsychotics. So the meaning that patients carry, the expectations they, they have of medications really shape, uh, the way that those medications work in the body. And then also, the kinds of things we were just talking about, shape the willingness of the patient even to put our medications into their mouths, right? Because if, if, uh, you know, there's expectations of harm, et cetera, we know that that's affects things like adherence.

• 4:43David Puder?

  Hmm. Yeah. So, okay. So you said because of their childhood early adversity, they may have an expectation of harm, that you will be harming them? We could call this transference. We could call this, what would you, what would you call it? Or how would you like make sense of it?

• 5:03Speaker 01

  I mean, I think, yeah, I would tend to think of it as, as a manifestation of transference, though you could also frame it in terms of the kinds of attachment styles that those early experiences engender in people, which, which really do affect how they relate to care and caregiving figures. But, but in my work, I'm predominantly thinking of that as the kinds of transferences that patients will bring into, into treatment that then undermine, again, for a treatment resistant population undermine how well those medications have worked in the past. And the idea I think that I, I have is that you have to be able to work with those transferences in order to help the patients benefit more

• 5:48Speaker 01

  from the treatments you have to offer as a, as a prescribing psychiatrist.

• 5:53David Puder?

  So let's say they come in with a more avoidant attachment style. What, what tends to be the things that you see? How does that relate to the medication? How does that relate to how they relate to you?

• 6:06Speaker 01

  So, you know, patients with a more avoidant, fearful kind of attachment style, you know, these are people who, who predominantly, who, who, who have had fairly consistent experiences of hurt in, in caregiving contexts. At least that's the, the theory of how that, how that emerges. And so these are people who are likely to be mistrusting and more likely actually to be actually harmed by medications. They're more likely to have nocebo responses. And so these are, these are patients, like in terms of prescribing strategy, these are the kinds of patients that you maybe would start, you know, with a start low and go

• 6:51Speaker 01

  slow approach because they're, when they experience the feeling of the medication in their body, it's much easier for them to interpret that as a harmful experience. But apart from that, I think that maybe in the bigger picture, with patients like that, I am starting a conversation about this with the patient.

• 7:15Speaker 01

  From the first session, probably even before I make any medication change, actually ideally before I would make any medication changes. So it becomes something that we can start to talk about. Like if their body, if they don't like what is happening in their body, we can step back and think, so how much of this is the medication? How much of this is what you carry in? And in a way that, and again, there's research that suggests, for example, when you've talked about nocebo responses before they happen, A, it reduces the likelihood of nocebo responses. And B, patients are able to stick with treatment, even in the context of negative experiences.

• 7:58David Puder?

  Yeah. And what about like within the avoidant attachment styles? Do you see kind of like more of the schizoid personality? For example, I tend to think of more as an avoidant attachment style. Do you also see unique interactions with medications with the different personality styles that someone might present with?

• 8:24Speaker 01

  Yeah, in a sense that, you know, so somebody who is more on the, well, to start with, people with secure attachment styles, you know, we don't, we don't, we often don't see those patients in our practices because they get treated by the primary care doctor. They get better and they take their medications. And so, so our practices are much more likely to be filled with people who have more, you know, fearful or avoidant or dismissive attachment. And yeah, so like we're saying, for people who are more.

• 9:05Speaker 01

  Have more fearful kinds of attachments. There is that expectation of harm. For people who have more dismissive attachments, it's more like there's, there's an expectation of not being helped.

• 9:16David Puder?

  Hmm.

• 9:17Speaker 01

  Which is, which is a slightly different thing. So we know research that suggests that patients are patients with dismissive attachment styles very quickly become non-adherent. They're less likely to do, you know, follow our recommendations. And these are patients, they're kind of, it's the opposite prescribing strategy from somebody with a more fearful attachment, that these are patients you wanna, you wanna, you know, you, you escalate the dose more quickly because they need to see some benefit fairly quickly. Uh, because you only have so much time before they give up. Um, now these patients also, there's research that suggests that particularly with the dismissive attachment patients,

• 10:01Speaker 01

  the negative effect of that dismissive attachment style can be corrected by particularly good communication by the prescriber. So I guess somebody with that attachment style, and you know, you should always be, of course, trying to, um, use your best communication strategies with all of our patients. But with those patients, it's especially important.

• 10:24David Puder?

  So I, I think of like people that move away or people that move towards, you know, like so depressive personality style, they move towards the provider. You know, borderline personality tends to move towards the provider and then away quickly back and forth, right? Whereas like somebody like schizoid, avoidant personality, they move away, dependent moves towards. So are you saying the people who that move, the people that move towards you initially, they want a faster response? The people that move away, it's almost better to have a, a lower dose, start slow, don't cause a side effect? Is that what you're saying or is the opposite?

• 11:03Speaker 01

  No, in fact, the opposite. The patients who, who don't, well, I'm thinking in terms of expectations of harm versus expectations of not being helped, which are two different kinds of expectations. And so it's, it's, yeah, I guess I'm, I frame it differently than those who move, move toward or away as more than, than the kinds of, yeah, the nature of the expectations.

• 11:27David Puder?

  Well, okay, so the people who expect.

• 11:31David Puder?

  The people who are skeptical.

• 11:33Speaker 01

  Yes.

• 11:34David Puder?

  And the people who are sensitive, have a long history, maybe of sensitivities to medication.

• 11:39Speaker 01

  Yes.

• 11:39David Puder?

  Those are the people you would dose slowly.

• 11:42Speaker 01

  Yes.

• 11:43David Puder?

  Okay. And the people who are more.

• 11:46Speaker 01

  With people who are skeptical, you move a little more quickly because they need, they need to see that, that something helps before they give up on it. These are people who, you know, like, if they're not feeling better in two or three weeks, they're like, see, nobody helps.

• 12:01David Puder?

  Right. Right, okay. I'm sorry, we're getting, I'm, I'm trying to get on the same page of, and this is the good aspect of having a conversation here. So, okay, let's, let's say this one more time. So, the people who are doubtful that you're going to be able to help, for you to do something impactful quickly.

• 12:18Speaker 01

  Yes.

• 12:19David Puder?

  Is very beneficial.

• 12:20Speaker 01

  Yes.

• 12:21David Puder?

  And the other group, talk about the other group again.

• 12:24Speaker 01

  The other group, these are the more anxious, fearful types, whose expectation is, is not just that they're not going to be helped, but they're going to be harmed.

• 12:33David Puder?

  They're going to be harmed, okay.

• 12:34Speaker 01

  So, you, so, these are people who, when they feel that medication moving around in their system, it's much easier for them to interpret that malevolently. Right, something's wrong, somebody doesn't feel right, I'm being hurt.

• 12:51David Puder?

  Right, okay.

• 12:52Speaker 01

  And so, these are people that, in addition to just having a conversation about that beforehand, so you have a little wiggle room around whether it's the medication or it's them, you, you would start, start low and go slow, so they have time to adapt to that feeling in their body.

• 13:10David Puder?

  Okay, and so, maybe I was getting off track with, with the way that you've been thinking about this, with talking about personality styles, because it seems like you could have a different personality styles and be in one of these two categories, and it doesn't really, it's not really dependent on the personality style. Is that correct?

• 13:25Speaker 01

  Yeah, I guess so. I mean, if, if we're talking about it in, in the, through the lens of attachment, kind of, and the expectations that go with that, yeah.

• 13:32David Puder?

  Okay. And then what about the more like disorganized attachment style, or in the adult attachment interview, it might be like unintegrated, right?

• 13:42David Puder?

  What do you think?

• 13:44Speaker 01

  You know, well, I think those are people especially who need a lot of information, right, about what's happening in between you and, you know, you're doing everything you can to create a kind of a mentalizing space for them and a space where they feel like they're heard. And I think we're also talking about, you know, I guess the thing we haven't gotten into yet is talking about how we empower the patient. Because so much of this, so much of the negative stuff that happens really comes down to experiences of powerlessness that people bring in. And so, you know, for people like that, and the patient to expect

• 14:28Speaker 01

  harm, you know, it's very important, I think, to to give them a feeling like they have some control over what's happening.

• 14:36David Puder?

  So how do you, like, so if someone comes in and they feel very powerless, and they, how would you help that type of person?

• 14:47Speaker 01

  Well, to start with, maybe just talk about the initial interview, if that's okay, to talk about how we how we get to this. So so one thing, one part of the approach would involve focusing not so much on the illness, but on the patient's developmental goals. Where are you trying to get? So we end up framing the treatment in terms of the patient's, not not a medicalized understanding, but the, you know, but very person centered goals that are that are about, yeah, not so much about illness. And then the next question becomes, right, how do so how do your symptoms get in the way of that? So right away, that starts framing it around what the what the patient as a person wants

• 15:32Speaker 01

  that creates a feeling of, you know, that that this is about them, not about a, you know, a medicalized understanding that they're getting squeezed into. Certainly, there's an element as well of in that initial interview.

• 15:48Speaker 01

  Trying to understand something about their experience of powerlessness. So, you know, as it might go in, in that initial interview, we start with, you know, where are they trying to get, end up talking a little bit about how symptoms get in the way. And then as we talk about symptoms, it would move to a, my, my next question to the patient might be something like, so how far back did these go? And then we end up talking often, and this is again, a patient population of treatment-resistant patients. In my, in the patients I treat, usually their symptoms started somewhere between the age of three and 15, right? So these are longstanding. And as we push it back and understand, ask about like, well, what was going on when your

• 16:30Speaker 01

  symptoms were started? We start to develop the history because they'll tell me of their authoritarian father, or the helplessness they felt in the context of their patient's acrimonious divorce, or whatever it was. And so we're starting to name from early on, something about that experience of powerlessness that contributes to their struggles. So it's, so it's now it's between us in language. And then at some point in there, there's some psychoeducation about how the, the experience, patient's experience of powerlessness may shape their medication response. And so when things start to go awry, like I've tried to start what I would call it, you know, a frontal lobe to frontal lobe communication with the patient.

• 17:17Speaker 01

  Because at some point their limbic system is going to kick in. And if we've already had these conversations, we have a much better chance of going back and having a frontal lobe, frontal lobe conversation about what may be happening that gives the patient a little wiggle room to think about it, to mentalize perhaps about why they might be having an adverse effect, or, or, you know, dealing with a lot of ambivalence about, about taking what I've, you know, what we've decided might be helpful.

• 17:49David Puder?

  Okay, so I hear from you, like, you know, and this kind of aligns with your, I think, work on therapeutic alliance, finding common goals, aspirational goals, right? Not just the negation of depression, or like, I want you to fix my depression, or I want you to change my medication to fix my depression. So you're looking for more-

• 18:11Speaker 01

  Aspirational, person-centered goals.

• 18:14David Puder?

  Person-centered goals. And then, secondly, you're looking for the themes of powerlessness that date back, as far as they know. Now, I imagine you see a lot of patients who have had a lot of treatment.

• 18:28Speaker 01

  Yes.

• 18:29David Puder?

  And with that comes, you know, sometimes they use language that's very, like, medicalized language. Like, you can tell they've been in psychotherapy for years, they're using jargon. How do you deal with that in the midst of this?

• 18:45Speaker 01

  Well, first of all, you're paying attention to it, right? Like, as soon as a patient, I get a patient, we talked about this elsewhere, but, you know, like, in the initial intake, when I get to the, you know, the mental status, and I ask, "Well, what's your mood been like for, you know, the last week or so?" And he says, "Anhedonic."

• 19:05David Puder?

  Yeah, yeah.

• 19:08Speaker 01

  And right away, of course, you know, I'm hearing, like, "So this guy is doing something. For some reason, he wants this, wants me to see him through the lens of the DSM." And I think in my, you know, and I don't know what it is yet, but in my way of working, I think I would just be likely, most likely to just name that, like, just to notice out loud, you know, "I notice you use, you know, you're using this very medicalized language. And, you know, I'm curious about what that means." And, you know, probably in that first session, we don't quite get to it, and I don't expect to. This is something that, especially for people who have a very, very intense attachment

• 19:50Speaker 01

  to a medicalized understanding, this is work you end up doing over time to, you know, help them- In a way, well, you figure out what defenses are in operation around that and work on it. But for starters, just, just, just to name it out loud. And so the patient and I have a way of talking about it.

• 20:13David Puder?

  Hmm. Okay.

• 20:15Speaker 01

  I mean, over, if you want to talk about over time, you know, a couple of things that worth saying. One, if a patient is really sure, like, I'm never sure. The patient gets better. I honestly, I never know why. Right? Because the meaning stuff is so powerful that I really feel like.

• 20:33David Puder?

  But maybe, maybe to talk about what that means for you, that you never know why.

• 20:39Speaker 01

  Well, we'll be starting with a story that a resident told me that I really loved. This was, this was a resident in a, in a military residency. A wife of a serviceman had come in for treatment with depression. The relationship was a very traditional one. So she was home with the three kids, taking care of the house and everything and the kids. And her, her husband, who was a mid-level officer, you know, would come home at, you know, four o'clock or five o'clock, plop down on the living room sofa, put his feet up on the table and say, you know, hon, it's been a long day. Get me a beer. Um, and she's depressed. The resident diagnoses her with depression, starts an antidepressant.

• 21:22Speaker 01

  Her husband and she, you know, husband comes home, she tells him this and his response is, oh, my God, she's depressed enough to need medications. Maybe I ought to do the dishes.

• 21:35David Puder?

  Hmm.

• 21:36Speaker 01

  And two weeks later, she's, she, when she comes in for her next appointment, she's feeling so much better.

• 21:40David Puder?

  Oh, yeah.

• 21:41Speaker 01

  Right? And you know, that's, that's a very pronounced example, but it gets at the ways that I never know.

• 21:50David Puder?

  Yeah.

• 21:51Speaker 01

  How much is placebo? How much is, you know, the patient feels like, oh, my God, somebody's seen how much I'm suffering, that the prescription has served some other end. And I really, and I really feel like I, I never 100% know why my patient is feeling better or feeling worse. Um, you know, and I, and, and I often want to convey that to my patients.

• 22:18Speaker 01

  That that this mind body stuff is so complicated that we can never know for sure. And one of the implications is if a patient knows for sure, that is a hallmark of some kind of defensive operation.

• 22:34Speaker 01

  Because you can't know, you really can't. I mean, given, given the size of the placebo response across conditions, you really can't know.

• 22:42David Puder?

  Right, like some, some people spontaneously remit. But what you're describing is that her new identity with illness gave her positive things.

• 22:52Speaker 01

  Yes.

• 22:53David Puder?

  Which, which can be reinforcing to having an illness itself.

• 22:56Speaker 01

  Oh, absolutely. I mean, this happens all the time, right? That our patients, you know, this is one of the dynamics underlying treatment resistance, right? Is that our patients don't necessarily get sick because of some kind of meaning. Or they probably do, but it's not the meaning that's causing the treatment resistance. But something good happens. And now they're in a dilemma. Right, you know, as, you know, I mean, when, when, that's what people do, right? When you get lemons, you make some lemonade. But then, but then our patients are, end up in an ambivalent place around getting better. You know, so one of the implications of what we're saying now is then, you know, starting to highlight for the patient, because they don't know, they don't even know this, right?

• 23:41Speaker 01

  They're not, they're, they're, they're in many cases, just completely unconscious that they are now ambivalent about getting better. So, you know, I think our task as prescribers is to start to shine a light on that a little bit. So that the patient, you know, so that, in some way, so the patient can become ambivalent about their ambivalence. And it becomes something that they can start working on with you.

• 24:11David Puder?

  Yeah, I like that. It's like, another way of looking at this would be, I'm a fan of reflective function and this kind of idea of like, if you, if you have a definitive answer for the why, but it's a fairly cliche answer, like, why are you like that? I'm bipolar. You know, why do you go off on these rages? I'm bipolar. And, and so having a definitive answer can serve some adaptive purpose early on, like you said, like, this husband is now behaving differently, he's more engaged. But then, it itself becomes a problem, right? If it's so definitive, and if it's not the real issue. Any thoughts on those things? Are we on the same track?

• 24:55Speaker 01

  Yeah, so what you're describing, you know, and again, our patients, I mean, like us, but our, you know, our patients are often really filled with horrible feelings, guilt and shame, and that kind of medicalized understanding often does serve a very defensive function for our patients. Right? And, and in a way, it comes to mean, I'm not responsible for any of the bad things that I do, or that happened to me. As if they're not, at the same time that they have an illness, also a person, right? With their own motivations and their own stuff. And, you know, interestingly, one of the ways that I, that, I mean, that

• 25:38Speaker 01

  I used to see this a lot, a lot more, or the diagnostic categories are changing, what it used to be, all the time, I would see patients who were somewhere in cluster B, right? So they're impulsive, their moods are all over the place, and because of that, somewhere along the way, some doctor told them they were bipolar. Right? And these patients, and you may have had some of these patients, and many of the listeners will have, these patients grab a hold of that diagnosis, right? You can, you can, they grab a hold, and hold on for dear life. They are so attached, right?

• 26:19Speaker 01

  And you know, sometimes, you know, these are the patients who it's not just that I have bipolar, it's my bipolar, right? The kind of the attachment shows up even in the language they use. And the reason that these people get so attached, right, is they are filled with horrible feelings, horrible, horrible feelings, which they manage by splitting, right? They can't stand how bad they feel, so they project it out. Now it's on you, you know, you're the bad one. But then they start to feel guilty about, you know, what they're doing to you and they realize, oh, I'm the bad one. And that badness just flies back and forth in a, in a very painful way. But you give them a diagnosis like bipolar disorder.

• 26:59Speaker 01

  And what that does is that allows them to create a kind of a vertical split right down the middle, right? The good stuff is me. The bad stuff is my bipolar. And that patient, and you watch it, right? That patient feels better immediately, right? Because that diagnosis has relieved them of a sense of guilt and responsibility, right? Which they then lean into defensively. And very often, I think one of the reasons that we did it a lot, that this happened a lot, is we also feel better because this patient rewards us, right? Oh, doctor, you know, you're the first person to really understand me.

• 27:43Speaker 01

  And, you know, and I think what you were getting to in your question is, the problem is, while these patients feel better, they do not get better. And often they get worse, right? Because now they're no longer responsible, feel no longer responsible for their most destructive instincts, right? And, you know, actually, and we become the ones that are responsible. So they, you know, have an affair and blow up their relationship and they're coming back to us. You know, you didn't give me enough lithium or like you need to change my medicines because I just did something really destructive. Yeah. And, and so the diagnosis with that kind of attachment really keeps them from getting a handle on their lives, you know, having authority over themselves in a way.

• 28:29David Puder?

  That's really, that's really good. I had Kernberg on recently, Yeomans, and we were talking about idealization, devaluation, right? So this is a great example of someone who's splitting is idealizing themselves. The true self, you know, the part of them that's, who they are consciously, right, is idealized, and then the devalued self is like, I'm bipolar. And then you get devalued as soon as you're not keeping that devalued side under wraps, right? Interesting. I think, I think the more, like, you know, people with borderline personality disorder, they tend to like treatment. The types of patients

• 29:14David Puder?

  that I'm really thinking about lately are the people that do not like treatment. They're all over Twitter, X, you know, therapy doesn't work, medications don't work. They're, they're on board with like, all the anti-psychiatry stuff. Or they're just like, I don't think this works. I've tried it. You know, I've tried Prozac for two weeks, it doesn't work. You know, and I often see this group of people with the complex PTSD as well. So in factor analysis, complex PTSD tends to have more of the avoidant type of behaviors, whereas people with BPD tend to be more aggressively outwards, you know, so they maybe hold their

• 29:59David Puder?

  aggression in. So with this group of people specifically, I'm curious, what's your approach? Because they tend to, I noticed, devalue me from the get-go. You know, if they're not here to see me because they want to, they're here because they were forced, their parents dragged them here, their parents threatened to take away things. I imagine you see these people at Austin Riggs, like, how do you, how do you win them over? What's your approach? I imagine it's the same stuff, but I just want to hear it again.

• 30:28Speaker 01

  Well, actually, we don't see so many of those people at Austin Riggs, because I think there's a real emphasis, like, if a patient, the patient is here, and, I mean, we'll maybe get off topic for a second, but, you know, if a patient is here at the Austin Riggs Center, and they say, well, I'm just here because my parents dragged me here, the admissions officer is going to say, well, you know, You don't have to be here. You know, we really aren't going to admit you unless you want something out of it. And then they start to come up with, oh, you know, well, actually, and then they find their own reasons.

• 31:01David Puder?

  But what about, what about you? I mean, is that your approach? Are you?

• 31:04Speaker 01

  Well, if I get somebody that, you know, I mean, again, patients are always ambivalent. You know, probably 100% of our patients are ambivalent and some are extremely ambivalent and lean much more on the side of, you know, I don't expect to be helped, I expect to be harmed. And I think part of, part of the, part of the, you know, the trick there, trick is the wrong word, actually, but, but the skill there is, you know, I'm, I'm with them in a sense, you know, like how, where do you join that patient? Our medications, I mean, one way you join a patient like that, right, is by the recognition that our medications are not as good as we

• 31:46Speaker 01

  wish they were. The average patient, you know, who's the average patient is treated with our medications and gets better is still left with a level of symptomology that, that a reasonable person would be seeking treatment for. So to, you know, to not square off in getting overly optimistic.

• 32:04David Puder?

  Right, yeah.

• 32:05Speaker 01

  To, to be, you know, have a kind of a humility about our treatments can and cannot do. And, you know, to really emphasize, I think, the complexity of the patient's role in getting better, to, you know, have conversations about how, you know, how their attitudes shape these things in a way that is attempts to empower them. And, you know, usually joining these patients around the goal where, you know, and again, it's, it may be a little bit different when somebody has like had a very serious, you know, manic episode that it was, you know, dangerous to them or others. But for many of these patients, to join them

• 32:50Speaker 01

  around a, you know, To get to a place of treating them with as few medications as is reasonably possible. You know, so you're joining, you're finding ways to join them that for, for many patients help strengthen the alliance. Now, what we're talking about is not magic, right? It doesn't work for everybody if there really are, I mean, and chances are if there really are, um, have, you know, to their core negative attitudes, these are people that come and then they drop out or they get, you know, they, they don't, they're not going to benefit. You have to have enough ambivalence in a patient like that to work with.

• 33:32David Puder?

  Hmm. Thank you. That's helpful. Okay. Let's, let's talk about your own response, your counter transference to their maybe reaction to you or to them. You talk about this in your book and I'm curious if you can speak to that. How do you, how do you work through your own? I mean, I imagine at this point you don't have any counter transference. Dr. Mintz, you're, you're like a Yoda here with so many years of practice, right?

• 34:00Speaker 01

  I, I, I don't think that takes away counter transference from anybody.

• 34:03David Puder?

  Oh, dang it.

• 34:06Speaker 01

  You know, uh, you know, there's, there's, I think there's layers to that question. Now, I mean, first of all, I think, you know, you just have to recognize like, just like the transference, just like there's always going to be transference, there's always going to be counter transference, you know, and, uh, different patients evoke different counter transferences, but the starting place is to recognize that, um, you know, as, as, as, uh, Elvin Semrad, who was a legendary teacher of psychotherapy in Boston and the generation before me. So he taught the, he taught, he taught the teachers that taught

• 34:47Speaker 01

  me. Uh, he described the doctor-patient encounter as an encounter between a big mess.

• 34:55Speaker 01

  And an even bigger mess, right? We're all messes, we're all unconscious. And I think a starting place is to recognize that I'm vulnerable. Right, so that I have at least a better chance of catching that I'm being caught up in something irrational.

• 35:14David Puder?

  Wait, wait, didn't you say everything has meaning though? Is it really irrational, what you're being caught up in?

• 35:20Speaker 01

  Uh, yeah, I mean, in the sense that, you know, that I'm not fully conscious. Patients are pulling on different motivations in me. And I think, I mean, maybe you're making the point that I was on my way to make, which is one way to manage or deal with this, is to pay attention to that feeling

• 35:42Speaker 01

  and ask, how does this inform my understanding of the patient?

• 35:47Speaker 01

  Right, so to use your countertransference.

• 35:49David Puder?

  Yeah.

• 35:51Speaker 01

  In the service of deepening the work, um, in the service of understanding. And, you know, it's of value because it gives you a little bit of distance. Right, to not just be pushing it away, but by inviting it and, you know, and being curious about it, uh, can help you not get caught up. But that doesn't mean you don't get caught up, you know, like our patients, including, you know, uh, you know, myself who's been doing this with complicated patients. There are patients who pull on your helplessness. They pull on, they pull on all sorts of things. And so, you know, there are some patients, though, though,

• 36:37Speaker 01

  you know, the majority of my patients end up leaving on fewer medications than they come in on. There are patients who evoke a kind of a response to us that give, you know, that ends up giving them very complicated and not particularly rational medication regimens. Right?

• 36:57Speaker 01

  You know, the patients, I may put it another way, you know, our patients are filled with horrible feelings and they fill us with horrible feelings. So we resonate, their helplessness makes us feel helpless, their hopelessness becomes our hopelessness, their rage becomes our rage. And if we're feeling it enough, it starts to shape what we're doing as prescribers and oftentimes, you know, there's a a piece of the prescribing act is an effort to get away from those feelings. Right? We feel helpless with a regimen, you know, we add more and more and more and more because we're trying to get away from a feeling the patient is unconsciously put into us.

• 37:38Speaker 01

  And in fact, I would say, when I, when I see a patient, because we'll get those patients, right, and we're on, you know, 15 psychiatric medications at Rigs and, you know, when I get a patient who comes in with that, and my first thought really is, you know, this patient has made some poor doctor suffer an awful lot to get a medication regimen that looks like this.

• 38:01David Puder?

  That's some, some good empathy, but, but what you're also saying is maybe that helplessness that's more profound and more deep inside of them evoked helplessness in that provider and as providers, we can also be challenged to not join in that.

• 38:18Speaker 01

  Yes.

• 38:19David Puder?

  And then over prescribe out of desperation.

• 38:22Speaker 01

  Yes. Yes. And there's, there's an element of this that I think, you know, maybe you've heard underlying this is to rec, is a kind of recognition of the limits of what our medications can do.

• 38:36David Puder?

  Yeah. Do you, do you, um, do you take home your patients with you? Like, do you think about them while you're reading, while you're watching movies, while you're, you know, going about your weekend?

• 38:47Speaker 01

  Absolutely.

• 38:50Speaker 01

  You know, I mean, I'm seeing them for, you know, well, I shouldn't say that. My therapy patients, certainly I'm seeing, you know, I'm seeing four times a week. So they're really under my skin, but my psychopharm patients who I'm seeing for, you know, 25 minutes a month.

• 39:07Speaker 01

  It's it's a, you know, and it's a small number. So it's a small enough number that they are in my, they're in my head. And it's a kind of a psychotherapeutic, there's a, there's a psychotherapeutic element to it because we are working with meaning in relation to medications. So they are, they, they, they are in my head and things will bring them up and I'm, you know.

• 39:30David Puder?

  Now, you said, under your skin. Is that like a negative feeling? Or is that a?

• 39:35Speaker 01

  It's, yeah, I mean, that when, when they're really under my skin, that is a negative feeling. Um, I've not always, you know, under my skin. And, and, and, you know, it's interesting because we, you know, I think what you're, what you may also be touching on is the, what we learn about what we do with those countertransferences, because, you know, I will often hear from, from people, maybe especially who are not psychodynamically trained, about an effort to compartmentalize.

• 40:07David Puder?

  Hmm.

• 40:07Speaker 01

  Right. You know, you have your, you know, your patient box and your clinical box and then, you know, and they're not supposed to invade your mind or be on, you know, and, and I think of it differently. I don't, I think compartmental, personally, I worry that compartmentalizing is a destructive way to do it.

• 40:28David Puder?

  Okay.

• 40:30Speaker 01

  Where, um, yeah, it's like we end up breaking ourselves into pieces, which is not necessarily good for us. It's more, I think it's, for me, it's more about having a kind of a formulation that gives us some distance.

• 40:46David Puder?

  Yeah. It's, it's like, I've been thinking about my own experience and I, I wrote the other day about how, well, maybe I'll just read it. It was a, kind of articulates this well for myself. Future therapists may ask, how do you not take home emotions and situations from your patients? I used to say, work through your countertransference or personal therapy. Right? Yet patients are often in my mind. I can't read, hear music, watch a movie without thinking of them. And I was thinking about that with like, I mean, I think, yeah, we use our countertransference therapeutically to increase our empathy and all the time that helps. Right? Like, I'll be sitting about a patient, thinking about them, and I'll be like, oh, I feel like

• 41:31David Puder?

  I really miss them and that, and it bothers me, you know? And the next time I'll see them and I'll say, you know, I feel like I really missed you that, and it really is meaningful for them.

• 41:40Speaker 01

  Winnicott would call that a kind of primary maternal preoccupation.

• 41:45David Puder?

  Right? Well, and some patients love to evoke in you a primary maternal preoccupation. Right?

• 41:51Speaker 01

  Yeah. And, yeah, and, and maybe, and most patients, you know, want to know that, that they're on your mind and that there's that kind of caring there.

• 42:02David Puder?

  I've, I've been preparing for an episode on Kafka and schizoid personality. And, and the more, at first, when I was reading about schizoid, I'm like, ah, I'm not like that, you know? I'm not alone, isolated in my room, I'm extroverted. But then the more and more I read about schizoid and this like fear of being consumed, this fear of having your mind overly colonized. Right? Kafka had this one line in his letter to his father, which was like, it's like your body was outstretched over my world and there were no more parts that I could, or it was almost like there was no more meaningful room for myself in it. And so Kafka went internal, didn't talk about his, what's going on. Right?

• 42:48David Puder?

  And then wrote about it beautifully in literature, which is, and in his letters and diaries, which I imagine he would be turning over in his grave if he realized we're all reading this and enjoying it. But I'm reading this and I'm like, yeah, I can resonate with that. Right? And so I think what you said earlier, like, there's parts of us that are broken or parts of us that, like, maybe our experience isn't too far from different people's issues. Right? But then maybe we're just not in touch with it until we're really working deeply with a client that.

• 43:24David Puder?

  Evokes that, struggles with it.

• 43:26Speaker 01

  Yeah, absolutely. And I think to, to, to be comfortable with that. Right to, to, to for it to be okay, right, that, that the, the injured parts of me are resonating with the injured parts of my patients. You know, it, it makes it a very different experience than if you feel like, oh, my God, that shouldn't be happening.

• 43:46David Puder?

  Right, the guilt, the self, yeah, it's, I think a lot of providers have a lot of guilt about not being fully arrived or not being like a Yoda like, uh, idealization that they imagine they should embody, right?

• 44:00Speaker 01

  Yeah. Yeah. And, you know, let's, you know, on this, I think there's some, for me, there's something about recognizing, there's a way of recognizing that, that those, those resonances or those feelings that get stirred up are both real and unreal. You know, because, because, you know, once we get into talking about things like projective identification, like I am feeling, I am feeling anger, right?

• 44:27David Puder?

  Okay.

• 44:28Speaker 01

  Or frustration or whatever. And at some point, and I, and I think more, you know, the, the longer I do this, the quicker this happens, I go, oh, my God. Right. I can barely handle this feeling for an hour. And my patient lives with this.

• 44:48David Puder?

  Oh, yeah.

• 44:49Speaker 01

  Like all the time.

• 44:51David Puder?

  Yeah.

• 44:52Speaker 01

  Right. And in a way it restores me to, uh, to a place of empathy. It gives me some distance. And, you know, when I teach about this, I, I will often show the, the clip from The Matrix where when Neo has, you know, um, has been shot and he's down and, uh, they're watching the screen and saying, get up. And he gets up. And the agents all pull out their guns and they start shooting. But now he sees the code falling.

• 45:21David Puder?

  Oh, wow.

• 45:22Speaker 01

  And he puts up his hand and the bullets stop right before they hit him. And he grabs one and he's able to look at it from all the.

• 45:29David Puder?

  Uh huh.

• 45:31Speaker 01

  And, and for me, the, having a formulation. Provides that distance, which doesn't stop me from engaging with the patient. It's not compartmentalizing. It is a kind of engagement, but that does, that allows me not to kind of be overwhelmed by the emotional experience that is evoked in me.

• 45:54David Puder?

  Okay, so yeah, that's, that's something to aspire towards. I haven't reached that point yet.

• 46:02David Puder?

  If I'm gonna be honest.

• 46:03Speaker 01

  You know, and I mean, I, I, you say that as if I've only reached that point. Like, we're, like, we are all human, right? And so, some patients that, that it's powerful enough that.

• 46:17David Puder?

  Well, I think, I think, okay, so, you know, we're, we're on this path together. I think this is, this is the common thread that we sort of hold, this projective identification. So the patient, like, let's say they, they have this sort of projection that you are a sadist of sorts, right? And so they're projecting that on you. And then the identification is you identify with that, right? And so if this is going on unconsciously in a provider, they may be mean to the patient in some small way, you know, maybe a slight jab, right? It could be very subtle, but it could really harm the therapeutic alliance. And so what you're talking about is like, instead of making that slight jab, you recognize

• 46:59David Puder?

  it and you're being like, huh, why do I feel a little bit more angry or like, I feel like being mean to this person?

• 47:05Speaker 01

  Yeah.

• 47:06David Puder?

  What might be going on inside of me?

• 47:07Speaker 01

  Boundary tighter than it needs to be, or, you know, do something that is injurious.

• 47:15Speaker 01

  Or, or, or to say, or the opposite. I think my tendency.

• 47:20David Puder?

  Okay.

• 47:22Speaker 01

  Was that, you know, I, I was, I was a sadistic older brother to my younger sisters when I was a little kid. And so I got into medicine. You know, with deep, deeply conflicted about my aggression.

• 47:36David Puder?

  Hmm, okay.

• 47:37Speaker 01

  And needing to do no harm. So I think in the situation you described, the valence for me would be reaction formation. So a patient is projecting onto me sadism, and I'd be much more likely to bend over backwards.

• 47:54David Puder?

  Hmm.

• 47:55Speaker 01

  To be accommodated.

• 47:56David Puder?

  Got it, got it, yeah.

• 47:57Speaker 01

  And so we can have all sorts of complicated reactions. And, and these are the, you know, and for me, the problem as a prescriber would be, for example, a patient would say, you know, you're hurting me with this medication. And that would be, you know, distressing enough that it would interrupt my mentalizing capacity. I would be flying into action, de-prescribing before I could think, oh, what is going on here?

• 48:23David Puder?

  Hmm.

• 48:23Speaker 01

  So no C-Bers, like before I could step back and really think and engage with the patient about what might be going on. And so, yeah, so I'm going to get us back to the conversation we were having before about just how, how these, the things that get put into us can, can evoke a kind of irrationality in prescribing.

• 48:46David Puder?

  Yeah, okay. So it's like your, um, your proclivity of reaction formation to deal with your aggression is baked into your personality, right? At this point, it's a higher order defense, some nice, nice reaction formation. And so it's, I think this is where it's, it's good for providers to know, okay, what are my normal defenses? What are the normal ways that I would defend against aggression? For some people, it's being more obsessive, more meticulous. For, for some people, it might be wanting to push away, withdraw, right?

• 49:25Speaker 01

  Yes.

• 49:27David Puder?

  What do you think about?

• 49:28Speaker 01

  You know, it's not my aggression, it's your aggression.

• 49:31David Puder?

  Right, projecting it back onto the person. Yeah, that would be a more probably primitive denial. It's not there at all. I'm not aggressive. I'm not aggressive.

• 49:42Speaker 01

  Exactly. Yeah, and I think that to your point, like, I think,

• 49:47Speaker 01

  you know, it used to be like all psychiatrists were getting their own therapies and

• 49:53Speaker 01

  and we don't, you know, it's not part of our, part of our expectation anymore. But for me, it was, it became extremely important to recognize that that was a proclivity. So that when, when a patient would be pushing on that button, that would be a place where I would take a deep breath, learned to take a deep breath, step back, gather myself before, before I start, you know, reacting or de-prescribing.

• 50:21David Puder?

  Yeah.

• 50:22Speaker 01

  And we, and we just need to recognize as physicians, as, you know, that, that that we can easily become irrational ourselves. Well, I mean, we're all, we're all irrational all the time, but we can, we can really bring it into our work in a way that doesn't help it.

• 50:38David Puder?

  Right. And I would say there's, there's probably a reason developmentally, you would agree with that, right? Like, there's a reason why you have reaction formation. You've, you've shared it, like, there's a reaction against maybe the uncomfortableness of the aggression that you had, that you knew that you had. So there's a, there's a reasonable, and that's where I think the therapy, personal therapy, can be so helpful is to understand why things aren't maybe as irrational as they seem. But I think, I think we should make therapy very normal, you know, as an ongoing process of our work. I mean, I can't imagine not having ongoing therapy.

• 51:18Speaker 01

  Yes, for sure. That's, it's always suspicious to me when someone, we have a psychiatrist who hasn't, hasn't explored themselves that way.

• 51:26David Puder?

  I won't hire them. I have a, I have a small private practice. If someone hasn't done their own work, I will not hire them.

• 51:33Speaker 01

  Yeah.

• 51:34David Puder?

  It's an awkward, it's, you know, it's not something I would ask in an interview question, but it comes out somehow, you know?

• 51:40Speaker 01

  Yeah.

• 51:41David Puder?

  But I think it's like, like, I can't imagine giving psychotherapy without doing your own depth therapy.

• 51:49Speaker 01

  Yeah.

• 51:49David Puder?

  Right? So, okay, speak to that.

• 51:51Speaker 01

  And what we're saying is, as, as we're not even talking about psychotherapy, we're talking about pharmacotherapy.

• 51:57David Puder?

  To do pharmacotherapy? You should, you should do your own therapy so you know your blind spots. Yeah, absolutely.

• 52:07David Puder?

  So it sounds like you, you see some patients four times a week? Is that what you said? Those are your more intensive?

• 52:13Speaker 01

  My therapy patients at Riggs, I am seeing four times a week. I mean, they're here for a definitive psychanalytic.

• 52:18David Puder?

  Wow.

• 52:19Speaker 01

  But I am prescribing for

• 52:22David Puder?

  A lot of other ones.

• 52:23Speaker 01

  Other therapists' patients, and the expectation is that I would see them, you know, for 25 minutes after initial, now, this may be important, what I have that a lot of clinicians don't have is I've got time for that initial evaluation. So I'm seeing patients at least two or three hours.

• 52:40David Puder?

  Wow.

• 52:41Speaker 01

  For evaluation. So, and, and the way I frame it, my first, my, the first session is really focused on who is my patient?

• 52:52Speaker 01

  And the second one is focused on what is my patient, you know, diagnostically and really diving into the medications. But my, all my patients have failed multiple medication trials already. So I don't wanna, I'm not diving into prescribing right away without understanding something about the psychology that is in the way of their, and personally, I feel like, you know, our field, this is a problem in the field, that we don't, we don't take that extra hour.

• 53:28Speaker 01

  When we get a really treatment refractory complicated patient, we don't take that extra hour to, to really think about why, you know, like, what is in the person that might be in the way? And how do you start to form an alliance that you can lean on? And how do you?

• 53:44David Puder?

  I mean, as, as you say that, I'm hearing, because I have tons of listeners who are stuck in some system where they have to see patients, the first patient, 30 minutes, subsequent patients, 15 minutes. That's like very normal to be, like, that's the only job you can get, maybe, as a nurse practitioner, your first year or two, right?

• 54:06David Puder?

  So what, what I, what advice I would have, and then I'd be curious what advice you would have. My advice would be to schedule them weekly for a while. And even weekly, you'll get, you know, if you can go two months of weekly work, you know, it's a luxury too, because they could, you could be booked out for three months, you know, which is another problem. But go ahead.

• 54:27Speaker 01

  Yeah. I mean, in terms of advice for the, for the clinician, I think that that's right. If you can do that, you know, schedule them weekly for a while while you, while you're working on that stuff, that's great. And I think also, there are times, even in the middle of the work, when things are going awry. And, you know, one of the more powerful interventions we have is to increase the dose of the doctor. Right? Where you say, I think we should meet for a little, you know, there's a lot of side effects or whatever. I think we should meet for a little bit, a little, you know, weekly for a while. And it's amazing, in my experience, it's amazing that the number of times that those problems clear up almost immediately. Cause a patient has an experience

• 55:12Speaker 01

  of your investment in them, or an experience of your presence. But on a, you know, I, I think on a bigger level, you know, I, I, I fear that what we're, we're in, in this way of working, where we, we don't give ourselves the time. And we feel like we can't give ourselves the time because there's so many patients.

• 55:32David Puder?

  Right.

• 55:33Speaker 01

  Right? So we can't, we can't afford to do that. But the thing is, because we don't give our patients that time in the beginning to really understand it, they don't get better. Right? We're not dealing with the stuff that's really in the way of they're getting better. We're not, we're not forming the kinds of therapeutic relationships that actually help the medications work better. So we feed into the problem of all these treatment resistant patients, when I think if we did, as a, as a field, did a little bit more of that work upfront, we would end up having less patients to deal with, because a portion of them would really get better.

• 56:14David Puder?

  Yeah.

• 56:17David Puder?

  Yeah, absolutely. And a lot of them would be demedicalized. And then, you know, I think, I think my practice at this point, not everyone gets put on a medication. That's a surprise to people. You know, sometimes when they're seeing a psychiatrist, they want to be put on a medication. Sometimes they get off medication slowly. You know, and I don't know your thoughts are on like de-prescribing. How often do you guys de-prescribe where you're working compared to prescribe?

• 56:50Speaker 01

  You know, we treat complex, complex patients. There's probably only about less than 10% of our patients end up on no medications. Most of our patients, but, but our average patient certainly ends up on fewer medications. And I think part of that is that there's a focus on, you know, the, as we're talking about the irrational elements of prescribing, the ways that prescribers can get caught up in trying to, trying to get rid of their own bad feelings through the prescribing act. And, and so.

• 57:25David Puder?

  What's like, give me an example of irrational prescribing?

• 57:29Speaker 01

  Well, again, you know, a patient who comes in on two antidepressants and two mood stabilizers and two antipsychotics.

• 57:35David Puder?

  Yep.

• 57:36Speaker 01

  And something for sleep and something for anxiety. And you know, by the time they have all that, they probably need a stimulant as well to discuss their, they're so sedated and you know, and why literally we, we, those patients come to us all the time on those kinds of regimens. And so, I mean, that's it. That's, that's, and you know, you know, I, I think as I was implying before, like, we don't do, I don't do that. You know, we don't do that. Other doctors do that. You know, like we, we all have those vulnerabilities. Right. But, you know, you have a formulation, you confer with colleagues, you do things like that. And it does help you kind of get your, get your feet under you.

• 58:18Speaker 01

  And so you can, you can prescribe more rationally for those patients. And oftentimes they end up on, on a lot less medication then. The other thing I'll add is, you know, about this is in the way I talk to my patients, both in terms of having a kind of a humility about what our medications can and can't do, but also emphasizing that the ways that the meanings affect how these medications work. I think there's a consistent effort in the way I work with patients at least, that they feel that there are internal resources they can recruit,

• 59:03Speaker 01

  and that they do recruit in the service of their recovery, and also that they bear some degree of responsibility when treatments don't work, at least some of the time.

• 59:16David Puder?

  Right.

• 59:17Speaker 01

  So when my patients feel more responsible, they can, you know, it makes it easier to lean into things like lifestyle adaptations, to work on the psychology that is in the way that they're getting better. And I want, so I want my patients to feel it's not just a biological problem, and that they should come to me with an attitude of like, fix me. I want them to feel like I'm going to do my part and they got to do their part.

• 59:44David Puder?

  Absolutely.

• 59:45Speaker 01

  And that also allows, allows, I think, to reduce medications, because they are picking up functions.

• 59:53David Puder?

  Absolutely.

• 59:55Speaker 01

  Functions that they've, that they've kind of handed, handed to the doctor that they didn't have to.

• 1:00:00David Puder?

  Yeah, just yesterday I told a patient, if you were to go in the morning and do 30 minutes of cardio, get your heart rate to 135, which for her is not hard, she's young, and do sauna for 20 minutes after, in three days you will feel better.

• 1:00:19David Puder?

  You know, your anxiety would probably go from an eight to a six at least, an eight to a four, maybe, you know? And, you know, I've seen it over and over again. But if they're caught in this mindset, which is what I really am enthusiastic with you about, if they're caught in this mindset that there's nothing that they can do to make themselves better because they are just an automaton diagnosis on medication, right? Then like, yeah, then they're not going to take those efforts potentially.

• 1:00:51Speaker 01

  Yeah. And if you want to, I mean, to make matters worse, we can accidentally lean in to that, to those kinds of processes that promote the patient being a chronic patient by agreeing that it's just medical or that that's the right solution. You know, and as we're talking about, I think about patient.

• 1:01:16David Puder?

  And I would say for a couple of patients like that I have, they need to hear that it is medical and that they will need to be on medication, you know? So it's like, there is, there are patients in my mind that do have schizophrenia that may need to be on meds the rest of their life.

• 1:01:32Speaker 01

  Oh, yeah, for sure. I didn't mean, I didn't mean to lean into a kind of psychological reductionism there. What I meant, you know, what I meant was that there, that for every patient, including a patient with schizophrenia, there is a person and there is a psychology that is affecting whether that patient takes the medication, what they do, what other lifestyle things they, they do, how they work on the psychology. So I didn't mean, I didn't mean to imply.

• 1:02:04David Puder?

  Yeah, I didn't think you did, but I, I didn't think that you meant to imply that. But nevertheless, I think it's worth stating.

• 1:02:12Speaker 01

  Yes, absolutely.

• 1:02:14David Puder?

  That there are patients, especially with the anosognomia, where they have difficulty even knowing or having insight into their illness, right?

• 1:02:24Speaker 01

  Yeah.

• 1:02:25David Puder?

  Those patients are difficult to help sometimes continue to take medication that is very life-saving, keeps them off the street, keeps them.

• 1:02:36Speaker 01

  You know what the single, the single greatest determinant of whether that patient is going to take their medication or not?

• 1:02:47David Puder?

  I would, I would say either illness severity or you're therapeutic alliance.

• 1:02:53Speaker 01

  Yeah, it's not illness severity. Actually, illness severity is leans against, in some ways leans against, at least leans against the alliance, but the alliance is the greatest predictor. So again, I think we're coming back to talking about like, how do you form those kinds of relationships where people feel your presence and your care, your interest, where they feel they're a partner, you know, because across, across, across all diagnostic conditions, it's, you know, it is, it is really one of the biggest determinants. Major depression,

• 1:03:33Speaker 01

  right? With major depression, there was this kind of landmark study years ago. Well, the, the TDCRP study, the Treatment of Depression Collaborative Research Project, which was before STAR-D, right? The, the largest NIMH-funded multi-center placebo-controlled trial that had been done. They were looking at what's the best treatment for depression. Is it, you know, psychodynamic therapy, cognitive behavioral therapy, or medications? And what they found in that study was they're all roughly equivalent with a slight edge to the combination of medications and psychotherapy. But Krupnik, Satsky, and Al went back and looked at that data afterwards in a secondary analysis through the lens of the alliance, because they had

• 1:04:15Speaker 01

  collected alliance data. And it turned out you were, you know, you had the best results if you had a good alliance with your doctor and you got the active drug. The worst results if you got a placebo and you had a poor alliance. But in those other two cells, you were actually better off in terms of reduction in depression, having a good alliance with your prescriber and getting a placebo.

• 1:04:35David Puder?

  Yeah, wild.

• 1:04:36Speaker 01

  And you were having, you know, if you got the active antidepressant and had a poor alliance.

• 1:04:41David Puder?

  Yeah.

• 1:04:42Speaker 01

  So.

• 1:04:43David Puder?

  There's so much psychiatrist effect, and I think this is, this is something I've reiterated in my audience over and over again. And, and, and so pay attention as much as you would to the psychopharm to like, what is it that grows your ability to have an alliance? Right?

• 1:05:01Speaker 01

  Absolutely. Absolutely. In terms of psychiatrists, if you you may know this study, another analysis, another secondary analysis that TDCRP, MCK, ML, et al.

• 1:05:12David Puder?

  Yep.

• 1:05:13Speaker 01

  Looked at, looked at, looked at outcomes also through the lens of the prescribers at those five sites. And it was interesting, it turned out, if a doctor got a good result with a patient, they tended to get good results with all the patients. And if they had a poor result with the patient, they tended to get poor results with all the patients. And then there were, you know, and then some people fell out in the middle. But so they using linear hierarchical modeling as a statistical technique, they could stratify them into highly effective, moderately effective, and relatively ineffective prescribers. And again, the highly effective prescribers got better results with placebo

• 1:05:58Speaker 01

  than the relatively ineffective prescribers got with active antidepressant.

• 1:06:04David Puder?

  Yes.

• 1:06:05Speaker 01

  So who we are, how we sit with the patient matters tremendously.

• 1:06:10David Puder?

  The the connectedness, the therapeutic alliance, the empathy, I would say as well, the provider reflective function.

• 1:06:18Speaker 01

  Yes.

• 1:06:19David Puder?

  I think has a lot to do with their therapist effect. Maybe the most, actually. I don't know if you saw that study. They looked at what created the biggest therapist effect. And they they did reflective function of the therapist. So they did adult attachment interview of the therapist. And then they gauged their reflective function, you know, like the how they answered the why of attachment interview questions. Why was your mother that way? If you if you were a therapist who was very sort of nuanced in your why, you had

• 1:06:56David Puder?

  Better results, and it was something like 70% of therapist's effect could be determined by reflective function.

• 1:07:05Speaker 01

  Yeah.

• 1:07:06David Puder?

  Of the therapist.

• 1:07:07Speaker 01

  I didn't know that story, but yeah, that's, that makes total sense.

• 1:07:11David Puder?

  So I think, I think what we're, what we're talking about today is a lot of deepening of reflective function, by the way, because a lot of mentalizing, staying in the not knowing, right, that's a deepening of the reflective function, not having a concrete answer, that's a kind of a trite or an overly simplified biological determined answer. That would be a lower reflective function statement, actually. Like, so for example, if you're like, well, why did your mother do that? Well, she was bipolar.

• 1:07:38Speaker 01

  Yeah.

• 1:07:39David Puder?

  It's like, case closed, that would give you about a three on 11-point scale from negative one to nine.

• 1:07:45Speaker 01

  Yeah.

• 1:07:45David Puder?

  Which would be a pretty low score, actually.

• 1:07:47Speaker 01

  Yes.

• 1:07:48David Puder?

  And so it's, it's kind of like not, you're not quite reflecting yet, right? Score.

• 1:07:53Speaker 01

  Yes.

• 1:07:54David Puder?

  So I think, uh, working with countertransference, how you've talked about that, it's kind of like moving into a more reflective state, moving into a deepening of the curiosity of like why you're having these reactions, why you're being pulled into these enactments or projective identification, why you're identifying with the emotions, what you're identifying with, how you're reacting to those identifications. That's all a lot of higher reflective function work that you're doing.

• 1:08:21Speaker 01

  Yes, absolutely. Absolutely.

• 1:08:24David Puder?

  So.

• 1:08:25Speaker 01

  You know, and, and, you know, and maybe, I mean, maybe, what you're talking about is nuanced, very, much more nuanced, but, you know, to put it on a, maybe another level, what we're talking about also is just the importance of the psychiatrist, just holding in mind that it is not, you know, like getting away from a kind of reductionism, either biological or psychological, and recognizing that it is always, always complicated. And in fact, in that's, in, in the, the TDCRP, one of the, somebody else did a different analysis and found that, and this is with the whole sample, not just the, the medication

• 1:09:08Speaker 01

  patients, but that the, whether the, whether the psychiatrist thought of illness as biological...

• 1:09:18Speaker 01

  Or psychological had an effect. And the doctors who had more of a psychological frame of mind about psychiatric illness tended to get better results, at least in that NIMH-funded study.

• 1:09:31David Puder?

  Interesting, yeah. Well, it's, yeah, it's an example of they're going to be probably more apt to incorporate therapy in their work, refer to therapists. It blows my mind when I see a patient that's seen a psychiatrist for 10 years and never seen a therapist. It's like, they never referred you to a therapist? I'm confused. Well, we could talk forever. This is really good. I want to kind of wrap up our time here. Dr. Mintz, what kind of like things would you want to reiterate maybe, or like say before we get off? Any kind of final closing reflections?

• 1:10:14Speaker 01

  Well, I think you were really touching on it, that forming a relationship with our patients where there is room, room for us first to think on a couple of levels, but to create a way of speaking to our patients that keeps it complicated, that doesn't just cram things into a biological bucket, but that recognizes there's a biology and a psychology in a way that empowers the patients rather than, you know, because the risk is if it's just biological, the patient just has to wait to be fixed with our medications.

• 1:10:56Speaker 01

  And, you know, which includes things like sharing with the patient about placebo effects. And doctors are often scared to do that because they worry it will take away the placebo boost, though it doesn't, you know, the research suggests that, you know, it doesn't take away much. Open-label placebos are still effective, right? But what it does is empowers the patient to start asking questions about how much of this is me and how much is the medication? And Yeah, I think it just gets to the point about having a very nuanced kind of engagement with our patients, because I think we harm them otherwise. You know, and in fact, we do. There's an interesting study, if I can talk about it for a second, Kemp, Lickle,

• 1:11:41Speaker 01

  and Deacon, that took college students with a history of depression. They enrolled them in a study to determine if their depression was psychological or biological. The white person with a white coat comes in, takes a cheek swab, disappears, comes back, and says, oh, your depression is psychological, or it's a biological, or situational, or it's biological. And of course, that's a sham condition, because we don't have that test. But the patients who were told they had a biological depression, you know, that that was about, you know, their genetics, or whatever, much higher levels of prognostic pessimism, you know, which we know contributes to worse outcomes.

• 1:12:15David Puder?

  Yeah.

• 1:12:16Speaker 01

  And lower levels of self-efficacy against, like, well, what can I do? It's just in my genes. So I think it's just so important for us to talk to our patients about their psychiatric struggles in a nuanced bio-psycho-social kind of way.

• 1:12:34David Puder?

  Yeah, it's like, even if you believe in strict determinism, please act as if you do have free will, right? I've done a couple of episodes on free will, and I'm a big proponent, because I see it so linked to that self-efficacy perspective. And it's like, yeah, we need to have this, feeling biologically determined is like, the hammer has already been nailing the casket shut, right? It's like you're doomed to this, to this thing. And so, yeah, it's not as helpful.

• 1:13:09Speaker 01

  It has real effects on our patients.

• 1:13:10David Puder?

  Yep. Yep. Well, great. Hey, I really appreciate you coming on. I think the audience will find this helpful and illuminating. And I think if they want to get your book, I'd highly recommend it. It's a great book. Psychodynamic, psychopharmacology. Is there any other way to get in touch with you? Or are you on any social medias? Or do you avoid those like the plague?

• 1:13:30Speaker 01

  Uh, I'm not so much on social media anymore. I wouldn't say I avoid them like the plague. But if people want to reach out to me, you know, I'm at the Austin Riggs Center, [email protected]. And

• 1:13:45Speaker 01

  Yeah, that would be the best way for people to reach out.

• 1:13:49David Puder?

  Okay, so if you've heard this, if you've get his book, if you read it, send him one thoughtful gratitude laden email that encourages him to keep going. Okay?

• 1:14:00Speaker 01

  I'm gonna keep going. I like this is, this is, this is, um, the importance of the doctor-patient relationship is probably as close to a religion as I get, so.

• 1:14:10David Puder?

  Okay, yeah, that's good. All right, take care. We'll leave it there for today.

• 1:14:15Speaker 01

  Okay, take care.