The Fantasy of Being “Just” a Psychiatric Prescriber
The job of containment and metabolism
“Therapy is not easy and it’s particularly not easy when the patient is extremely emotionally unstable because they’ve never had a figure in their lives to help them contain their emotions. So, the whole point of therapy (not only for “borderline” patients but for all patients) is for the therapist to act as a container: they need to remain calm enough, and neutral enough in order to gracefully receive the projections, identify with them “just enough” so that they can understand them, contain them, then metabolize them, and then return them back to the patient in a more palatable and thinkable form. And this is a lot to ask of a person but that’s the job…”
In a recent exchange on Miss Apprehension, Zavlis offers a delightfully lucid Bionian picture of psychotherapy. The patient projects onto the therapist, on this reading, to communicate, to regulate, to evacuate an affect they cannot bear on their own. The clinician’s task is to receive it, to identify with it just enough to understand it without being swept into it, to process it, and to return it in a form the patient can tolerate. “This is a lot to ask of a person,” Zavlis writes, “but that’s the job.”
This last bit has been rattling around in my mind. Zavlis is talking about psychotherapists but it applies, in part, to psychiatrists as well since we deal with many of the same problems and the same patients. And yet it seems to me that the psychiatric community has decided that it is not, in fact, our job.1
Many “psychopharmacologists” (as well as nurse practitioners and other advanced practice providers who do a great deal of psychiatric prescribing these days in the US) adopt the attitude that they can be responsible for diagnostic assessments and medication management and do a good job of it while distancing themselves from the emotional lives of their patients. The psychological tangle of ambivalence, frustrations, idealizations, projections, etc., belongs to the therapy hour and to the therapist. The presence of these dynamics in the prescribing room is irksome, met with annoyance and impatience. The prescriber’s remit is narrow and clean. “I’m just here to manage your medications. That sounds like something to bring up with your therapist.”
The trouble is that this is not how prescribing works. (David Mintz’s psychodynamic psychopharmacology is the prime source of wisdom here; see my Q&A with him). The neurochemistry of illness exists in a web of temperament, medications carry meaning and emotional significance, treatment response and resistance are relational as well as pharmacodynamic, and the patient-doctor relationship exists in the graveyard of developmental history.
So affect does not stay politely in the therapist’s office. It shows up wherever it needs to, wherever it must, in whether the patient takes the drug, in how they take the drug, in whether and how they experience its side effects, in the patterns of their exacerbations, in whether they feel heard and seen and how they act out, and in whether they need the treatment to fail. The prescriber who is unable to or refuses to metabolize the emotions finds that the undigested material returns to haunt the therapeutic relationship… as nonadherence, as nocebo, as the slow accretion of polypharmacy, as the “treatment-resistant” patient who is resistant in part because no one in the pharmacological relationship would hold their hesitation and fear and fury long enough to make sense of it.
In some ways, this failure isn’t unique to psychiatry. Under the pressures of time and throughput and an orientation towards disease processes at the cost of the person, medicine has grown steadily less patient with the psychological dimensions of sickness. Patients bring difficult emotions around their illness and treatment to the clinical encounter that, if left unexamined, can corrode their care. When psychiatry is consulted in the hospital, it is at times because the medical and surgical teams are unable to hold and tolerate the affect in the room. They do not have the time, the patience, the attention to deal with it. At some point medicine decided that this is not the job. Or more accurately, the medical bureaucracy decided that clinicians are too highly paid, their time too expensive, for it to be wasted on dealing with this superfluous stuff, and a whole new generation of physicians grew up under the new regime and accepted it as the norm.
Not everyone can do everything, that is true, and specialization is necessary. Most psychiatrists do not need to be psychotherapists (I am not), but they do still need to be attuned to the psychological complexity of the whole person and the relational aspects of psychiatric treatment. Containment is not outsourceable, not fully. The patient ambivalent about a medication needs the prescriber to hold that ambivalence, because the prescriber is the one guiding the pharmacological treatment, and those decisions cannot be made in the therapy room.
Zavlis is right that it is a great deal to ask of anyone. It is a great deal to ask of therapists, who at least have (under ideal circumstances) the training, the supervision and the structure to do the work. Prescribers rarely have anything of the sort. So part of what is needed here is structural. But it begins with relinquishing the fantasy of “pure” medication management. The emotional and relational dynamics are not an intrusion upon the work of prescribing. They are a part of the work itself. Whether you know this or not, whether you accept it or not, that is the job.
See also:
“decided” may be too active a word, perhaps “fallen into the illusion”?
Thanks. I enjoyed Sorbie’s interview and this reflection on it. Here is a short story for you. In 1993 I was prescribed lithium carbonate and haloperidol. Shortly after leaving the hospital I biked to the North Sea and threw them in. A couple weeks later I told the doctor. I don’t honestly know what I was expecting to happen, but I guess I was expecting some sort of discussion. (I was not in good shape and memories of the time are dim.) His response, which was made to nobody in particular, was a single word: “clozapine”.
Thanks for the shout-out, Awais! I agree that lack of containment is a widespread issue in the psy-fields, but wasn't aware it was this pronounced in psychiatry. So, it's interesting to see the intersection of psychoanalysis with prescribing.
Thanks again!