I had the same experience with my Les Havens interview: he beckoned me in with such warmth and then said, "so...what do you WANT?" He pulled you in and put you off your guard in the same breath.
He told us to fire our supervisors, and I also saw him interview a patient, with his "counter-paranoid position." Using his office to see patients (he told us not to borrow his books, but keep them) was like channeling some higher power.
The most memorable thing he said to me, among many memorable things, was when I asked what to do in therapy when I didn't know what to say.
I’ve been thinking about this discussion all day, particularly in regards to patients I see for substance use disorders. I often struggle to know how to work with clients who don’t take prescribed medications (even non-psychopharmacological medications) due to concerns that they are unnatural and harmful, but don’t apply the same logic to illicit substances to use. Arguments over who is right or who is wrong are never helpful here - but it always feels like such a sticking point for us to be able to get on the same page regarding treatment goals. I like what Dr Mintz says about what matters most is the meaning that the medication has in the patients life; “Medications exert their effects via multiple pathways. Some are mediated biologically via their actions at various receptor sites, whereas others are mediated symbolically through the meanings they have for patients and the doctor-patient relationship,”. I’m reflecting on my current cases now, and trying to shift from working out the ‘truth’ of the patient’s response to certain substances and instead think about why the patient needs it to be true. It sounds so obvious as I write it now, but it really did feel like an ‘aha!’ moment this morning as I was trying to work out how to respond to a particular complex referral today!
I'm very pleased that you interviewed Dr. Mintz, Awais, as David--along with Dr. Glen Gabbard--has been very influential in my own writing and thinking about "psychodynamic psychopharmacology." Indeed, I cite and quote Dr. Mintz's work in an article on this topic, available at:
I also empathize with the tricky issue of addressing "treatment resistance", which (as you point out, Awais) can sometimes come across as "blaming the patient." When Dr. Mantosh Dewan and I wrote a book titled, "The Difficult-to-treat Psychiatric Patient" (American Psychiatric Press,2001), we struggled with the title and possible alternatives for quite a while. Not every colleague was happy with that title; and yet, all of them acknowledged that there are, indeed, patients who are, well--difficult to treat!
I would like to add to the discussion a few points that seem important to me, as a proponent of the "biopsychosocial" paradigm (yes, I know--that, too, is a fraught and controversial term!):
1. With regard to the placebo response, it's important not to generalize this too broadly to all psychiatric disorders or disease states. For example, recent research has shown that whereas there is a substantial placebo response in major depressive and anxiety disorders, the magnitude is significantly lower in, e.g., schizophrenia and obsessive-compulsive disorder. [1,2] Dr. Walter Brown has also pointed out that major depressive illness with strong melancholic features does not respond well to either psychotherapy or placebo; i.e., "the presence of melancholia predicts a poor response to psychotherapy and placebo and a relatively good response to antidepressants and ECT." [https://pubmed.ncbi.nlm.nih.gov/17280578/]
2. The issue of "reductionism" extends beyond "biological" reductionism; indeed, any ideology or paradigm can become reductionistic, including, for example, a rigidly psychoanalytic approach--one that "explains everything" in psychoanalytic terms. Glen Gabbard himself pointed this out in a classic article [3], noting, "Both analysts and their patients secretly are drawn to simple formulations that eschew complexity. The need to remain open to the "infinite space" of meaning, motive, and causation should be a hallmark of clinical psychoanalytic practice." [3] (It is to the credit of both Dr. Mintz and Dr. Aftab that both avoid reductionism in their approach to psychiatric illness).
Finally, as a way of emphasizing the importance of psychodynamics when working with psychotic patients, I offer the following brief vignette regarding a psychotic patient I treated many years ago. [1] Mr. A. had a long history of chronic schizophrenia that was only partially responsive to thiothixene, a commonly used antipsychotic medication in the 1980s. I raised the issue of a clozapine trial with Mr. A, since I had seen some near-miraculous “turnarounds” with this then novel, atypical agent. But Mr. A. adamantly refused. He would take no other medication besides the thiothixene, which at the time was marketed under the brand name, Navane. Why?
The clue was Mr. A’s constant and invariable reference to this drug as “Nervine,” which was the brand name of a bromide-based patent medicine he had taken in the 1960s... I believe that the prescribed drug (Navane) was a kind of personified, transitional object for the patient, owing to his conflation of the drug with “Nervine.” Though not strictly a “person,” I believe that “Nervine” functioned as a kind of benign and healing parental figure for Mr. A, which he recalled with a certain affection. The “Nervine” may have served as a useful transitional object that allowed Mr. A. to accept the Navane. Accordingly, I respected his wish to continue this drug.
Thanks again to you, Awais, and to David for this excellent discussion!
2. Bschor T, Nagel L, Unger J, et al. Differential outcomes of placebo treatment across 9 psychiatric disorders: a systematic review and meta-analysis. JAMA Psychiatry. 2024;81(8):757-768.
3. Gabbard GO. "Bound in a nutshell": thoughts on complexity, reductionism, and "infinite space". Int J Psychoanal. 2007 Jun;88(Pt 3):559-74. doi: 10.1516/e8u0-g516-98g4-11p7. PMID: 17537692.
Fortunately, my transition from Before Mintz Thinking of Psychopharmacology to After Mintz Thinking of Psychopharmacology occurred at the start of my career. Having language for something I noticed, but previously couldn't describe, is priceless.
I think it's really tough for psychiatrists who were not trained and grounded in psychodynamic concepts to add them on later in a way that doesn't feel awkward or forced, even with the best of intentions. The stated or implied ideas that there either really isn't time for that kind of conversation, or that the 'payoff' is not there, leads to more problems are subtle forms of bad treatment. I am so grateful that I was trained at a time (late 70's) when integration of meds with therapy (or just the MD-patient relationship) was developing.
The import of the meaning of meds ( and everything else) is truly at the center of this topic, and I can recall reading or hearing from Havens, Arieti, Yalom, Searles, Frankl, and many others who drilled into me that this matters so much.
Also, the idea that resistance is not only normal, but to be expected by both prescriber and pill-taker is one I've gotten a lot of mileage from. Telling patients that they should PLAN to have mixed feelings about the pills ( and me and therapy) normalizes it and cuts down on guilt or shame. it's gratifying to hear a patient being 'resistant' and then my saying, "good, of course, let's talk" - and it makes the process curiously fun.
I think the psychiatry profession has little awareness of how such things feed into the anger and vitriol of the anti psychiatry voices. The intensity of their feelings should not keep us from hearing their messages and looking in the mirror. It'd be wrong to dismiss those voices as being...resistant
Fantastic discussion! Dr. Mintz made so many excellent points — far too many to comment on individually.
He articulated, with precision, thoughts I’ve recently been having regarding mind–body integration in treatment. The inverse, is that I’m increasingly unable to participate in the old split. I’m seeing more patients anchored in a biological framework (one that can feel predestined or fixed), and yet have a meaningful process when windows are gently opened into the psychological, social, and spiritual dimensions of their lives — noticing how they interweave and shape experience.
I do have concerns that as technology accelerates, the cultural pull may invite people toward a disembodiment, making AI-driven prescribing more appealing and psychodynamic psychopharmacology less so.
"Second, I don't want to depend on pills. And this is where some people really prick their ears and go "did I hear someone voice their internalized stigma?" In particular, I've seen a few different people, as far as I can tell wholly independent of each other, make a comparison with food here. If you don't feel bad about depending on food, but you do feel bad about depending on pills, this goes to show that you're guilty of internalized stigma! You should get over it already and take your pills just like you eat your food.
First a word of why I would depend on the pills if I went back on them: In theory, it might seem like I'd be maximally protected against any looming psychotic breakdown if I were to combine pills with all my self-invented coping mechanisms that I've talked and published about. In practice, that's unlikely. I could retain all the epistemological frameworks I've developed to prop up this flimsy world of mine and make it feel sturdier, but lots of mental actions I perform - like deliberately dissociating in quite specific ways, or conversing with helpful voices - would likely be rendered hard or impossible when on pills. Moreover, in psych treatment, the pills tend to be framed as your number one crutch and anything else as just a complement. Hard not to fall into that way of thinking, if that's how clinicians constantly frame things.
So, I would depend on the pills if I got back on them."
I think this is rarely talked about. How getting help from pills often makes it HARDER to help yourself in other ways. So thanks for bringing this up.
But also ... regarding "treatment resistance". I suspect that SOMETIMES, "treatment resistance" is just people being differently wired. I'm not saying all these other concerns brought up in the interview are invalid. But SOMETIMES, people might not respond to the pills for purely physiological reasons.
In 2016-17, I would sometimes get a racing pulse and constricted breathing. It would go on for literal hours before subsiding, at which point I was exhausted.
I told my psychiatrist I had a stupid psychosomatic problem that was getting increasingly impairing. (I was certain, from the get-go, that it was a "stupid psychosomatic problem" rather than something actually having to do with my hearts and lungs.) My psychiatrist said these were panic attacks. I said panic is an emotion, I would know if I felt it; this is a stupid psychosomatic problem and terribly ANNOYING, but it's not me panicking. He insisted it was a panic attack. I said sure, whatever, guess I might have some sort of subconscious panic then that I'm not aware of AS panic.
And then I got betablockers.
Everyone I knew who had themselves taken betablockers said these are GREAT. So I had HIGH expectations taking them. My psychiatrist had said take 10 mg or maybe 20, no more. And watch out for side effects like low blood pressure and dizziness.
The betablockers did NOTHING. I tried progressively higher dosages. Looked up online how much they prescribe to people for actual heart problems and took the same amount. NOTHING. Then I looked up online at which point you risk overdosing. If I remember correctly, that was supposed to be a risk at 130 mg, so I took 120. NOTHING.
They had absolutely ZERO effect on me. I could pop them with a racing heart and constricted breathing and they did absolutely NOTHING to change that.
I'm thinking surely, this can only be explained by me, IDK, missing some crucial receptors or something. Me being a betablock resistant mutant.
I had the same experience with my Les Havens interview: he beckoned me in with such warmth and then said, "so...what do you WANT?" He pulled you in and put you off your guard in the same breath.
He told us to fire our supervisors, and I also saw him interview a patient, with his "counter-paranoid position." Using his office to see patients (he told us not to borrow his books, but keep them) was like channeling some higher power.
The most memorable thing he said to me, among many memorable things, was when I asked what to do in therapy when I didn't know what to say.
"Wait."
I’ve been thinking about this discussion all day, particularly in regards to patients I see for substance use disorders. I often struggle to know how to work with clients who don’t take prescribed medications (even non-psychopharmacological medications) due to concerns that they are unnatural and harmful, but don’t apply the same logic to illicit substances to use. Arguments over who is right or who is wrong are never helpful here - but it always feels like such a sticking point for us to be able to get on the same page regarding treatment goals. I like what Dr Mintz says about what matters most is the meaning that the medication has in the patients life; “Medications exert their effects via multiple pathways. Some are mediated biologically via their actions at various receptor sites, whereas others are mediated symbolically through the meanings they have for patients and the doctor-patient relationship,”. I’m reflecting on my current cases now, and trying to shift from working out the ‘truth’ of the patient’s response to certain substances and instead think about why the patient needs it to be true. It sounds so obvious as I write it now, but it really did feel like an ‘aha!’ moment this morning as I was trying to work out how to respond to a particular complex referral today!
I'm very pleased that you interviewed Dr. Mintz, Awais, as David--along with Dr. Glen Gabbard--has been very influential in my own writing and thinking about "psychodynamic psychopharmacology." Indeed, I cite and quote Dr. Mintz's work in an article on this topic, available at:
https://www.thecarlatreport.com/articles/4489-the-psychodynamics-of-psychopharmacology-reimagining-the-med-check
I also empathize with the tricky issue of addressing "treatment resistance", which (as you point out, Awais) can sometimes come across as "blaming the patient." When Dr. Mantosh Dewan and I wrote a book titled, "The Difficult-to-treat Psychiatric Patient" (American Psychiatric Press,2001), we struggled with the title and possible alternatives for quite a while. Not every colleague was happy with that title; and yet, all of them acknowledged that there are, indeed, patients who are, well--difficult to treat!
I would like to add to the discussion a few points that seem important to me, as a proponent of the "biopsychosocial" paradigm (yes, I know--that, too, is a fraught and controversial term!):
1. With regard to the placebo response, it's important not to generalize this too broadly to all psychiatric disorders or disease states. For example, recent research has shown that whereas there is a substantial placebo response in major depressive and anxiety disorders, the magnitude is significantly lower in, e.g., schizophrenia and obsessive-compulsive disorder. [1,2] Dr. Walter Brown has also pointed out that major depressive illness with strong melancholic features does not respond well to either psychotherapy or placebo; i.e., "the presence of melancholia predicts a poor response to psychotherapy and placebo and a relatively good response to antidepressants and ECT." [https://pubmed.ncbi.nlm.nih.gov/17280578/]
2. The issue of "reductionism" extends beyond "biological" reductionism; indeed, any ideology or paradigm can become reductionistic, including, for example, a rigidly psychoanalytic approach--one that "explains everything" in psychoanalytic terms. Glen Gabbard himself pointed this out in a classic article [3], noting, "Both analysts and their patients secretly are drawn to simple formulations that eschew complexity. The need to remain open to the "infinite space" of meaning, motive, and causation should be a hallmark of clinical psychoanalytic practice." [3] (It is to the credit of both Dr. Mintz and Dr. Aftab that both avoid reductionism in their approach to psychiatric illness).
Finally, as a way of emphasizing the importance of psychodynamics when working with psychotic patients, I offer the following brief vignette regarding a psychotic patient I treated many years ago. [1] Mr. A. had a long history of chronic schizophrenia that was only partially responsive to thiothixene, a commonly used antipsychotic medication in the 1980s. I raised the issue of a clozapine trial with Mr. A, since I had seen some near-miraculous “turnarounds” with this then novel, atypical agent. But Mr. A. adamantly refused. He would take no other medication besides the thiothixene, which at the time was marketed under the brand name, Navane. Why?
The clue was Mr. A’s constant and invariable reference to this drug as “Nervine,” which was the brand name of a bromide-based patent medicine he had taken in the 1960s... I believe that the prescribed drug (Navane) was a kind of personified, transitional object for the patient, owing to his conflation of the drug with “Nervine.” Though not strictly a “person,” I believe that “Nervine” functioned as a kind of benign and healing parental figure for Mr. A, which he recalled with a certain affection. The “Nervine” may have served as a useful transitional object that allowed Mr. A. to accept the Navane. Accordingly, I respected his wish to continue this drug.
Thanks again to you, Awais, and to David for this excellent discussion!
Regards,
Ron
Ronald W. Pies, MD
1. https://www.psychiatrictimes.com/view/placebo-response-rates-vary-across-psychiatric-disorders
2. Bschor T, Nagel L, Unger J, et al. Differential outcomes of placebo treatment across 9 psychiatric disorders: a systematic review and meta-analysis. JAMA Psychiatry. 2024;81(8):757-768.
3. Gabbard GO. "Bound in a nutshell": thoughts on complexity, reductionism, and "infinite space". Int J Psychoanal. 2007 Jun;88(Pt 3):559-74. doi: 10.1516/e8u0-g516-98g4-11p7. PMID: 17537692.
Fortunately, my transition from Before Mintz Thinking of Psychopharmacology to After Mintz Thinking of Psychopharmacology occurred at the start of my career. Having language for something I noticed, but previously couldn't describe, is priceless.
I think it's really tough for psychiatrists who were not trained and grounded in psychodynamic concepts to add them on later in a way that doesn't feel awkward or forced, even with the best of intentions. The stated or implied ideas that there either really isn't time for that kind of conversation, or that the 'payoff' is not there, leads to more problems are subtle forms of bad treatment. I am so grateful that I was trained at a time (late 70's) when integration of meds with therapy (or just the MD-patient relationship) was developing.
The import of the meaning of meds ( and everything else) is truly at the center of this topic, and I can recall reading or hearing from Havens, Arieti, Yalom, Searles, Frankl, and many others who drilled into me that this matters so much.
Also, the idea that resistance is not only normal, but to be expected by both prescriber and pill-taker is one I've gotten a lot of mileage from. Telling patients that they should PLAN to have mixed feelings about the pills ( and me and therapy) normalizes it and cuts down on guilt or shame. it's gratifying to hear a patient being 'resistant' and then my saying, "good, of course, let's talk" - and it makes the process curiously fun.
I think the psychiatry profession has little awareness of how such things feed into the anger and vitriol of the anti psychiatry voices. The intensity of their feelings should not keep us from hearing their messages and looking in the mirror. It'd be wrong to dismiss those voices as being...resistant
Thank you Dr Moldawsky! It’s good to hear your perspective on this.
Fantastic discussion! Dr. Mintz made so many excellent points — far too many to comment on individually.
He articulated, with precision, thoughts I’ve recently been having regarding mind–body integration in treatment. The inverse, is that I’m increasingly unable to participate in the old split. I’m seeing more patients anchored in a biological framework (one that can feel predestined or fixed), and yet have a meaningful process when windows are gently opened into the psychological, social, and spiritual dimensions of their lives — noticing how they interweave and shape experience.
I do have concerns that as technology accelerates, the cultural pull may invite people toward a disembodiment, making AI-driven prescribing more appealing and psychodynamic psychopharmacology less so.
Thank you so much for posting this.
Thanks, this was a really interesting read. It echoes some concerns I tried to put into words in this blog post, when I thought that perhaps I'd have to get back on the Haldol: https://jeppssonphilosopherauthor.blogspot.com/2024/12/psych-drugs-food-and-internalized-stigma.html
"Second, I don't want to depend on pills. And this is where some people really prick their ears and go "did I hear someone voice their internalized stigma?" In particular, I've seen a few different people, as far as I can tell wholly independent of each other, make a comparison with food here. If you don't feel bad about depending on food, but you do feel bad about depending on pills, this goes to show that you're guilty of internalized stigma! You should get over it already and take your pills just like you eat your food.
First a word of why I would depend on the pills if I went back on them: In theory, it might seem like I'd be maximally protected against any looming psychotic breakdown if I were to combine pills with all my self-invented coping mechanisms that I've talked and published about. In practice, that's unlikely. I could retain all the epistemological frameworks I've developed to prop up this flimsy world of mine and make it feel sturdier, but lots of mental actions I perform - like deliberately dissociating in quite specific ways, or conversing with helpful voices - would likely be rendered hard or impossible when on pills. Moreover, in psych treatment, the pills tend to be framed as your number one crutch and anything else as just a complement. Hard not to fall into that way of thinking, if that's how clinicians constantly frame things.
So, I would depend on the pills if I got back on them."
I think this is rarely talked about. How getting help from pills often makes it HARDER to help yourself in other ways. So thanks for bringing this up.
But also ... regarding "treatment resistance". I suspect that SOMETIMES, "treatment resistance" is just people being differently wired. I'm not saying all these other concerns brought up in the interview are invalid. But SOMETIMES, people might not respond to the pills for purely physiological reasons.
In 2016-17, I would sometimes get a racing pulse and constricted breathing. It would go on for literal hours before subsiding, at which point I was exhausted.
I told my psychiatrist I had a stupid psychosomatic problem that was getting increasingly impairing. (I was certain, from the get-go, that it was a "stupid psychosomatic problem" rather than something actually having to do with my hearts and lungs.) My psychiatrist said these were panic attacks. I said panic is an emotion, I would know if I felt it; this is a stupid psychosomatic problem and terribly ANNOYING, but it's not me panicking. He insisted it was a panic attack. I said sure, whatever, guess I might have some sort of subconscious panic then that I'm not aware of AS panic.
And then I got betablockers.
Everyone I knew who had themselves taken betablockers said these are GREAT. So I had HIGH expectations taking them. My psychiatrist had said take 10 mg or maybe 20, no more. And watch out for side effects like low blood pressure and dizziness.
The betablockers did NOTHING. I tried progressively higher dosages. Looked up online how much they prescribe to people for actual heart problems and took the same amount. NOTHING. Then I looked up online at which point you risk overdosing. If I remember correctly, that was supposed to be a risk at 130 mg, so I took 120. NOTHING.
They had absolutely ZERO effect on me. I could pop them with a racing heart and constricted breathing and they did absolutely NOTHING to change that.
I'm thinking surely, this can only be explained by me, IDK, missing some crucial receptors or something. Me being a betablock resistant mutant.
But maybe someone has a better explanation?