This volume, reporting on the experience of the Austin Riggs Center, is a significant addition to the literature on “treatment-resistant” patients. Austin Riggs treats complex, previously treatment resistant patients with a combination of intensive individual psychodynamic psychotherapy, pharmacotherapy, and exploration of family issues and dynamics in an integrated therapeutic milieu setting. This treatment is usually long-term, fully voluntary, and unrestrictive and ranges from inpatient to residential to outpatient care. In this era of limited benefits for psychiatric care, in which locked inpatient units with short lengths of stay and “managed” short-term outpatient treatment have become the norm, Riggs has been able to maintain a philosophy of long-term treatment that is psychodynamically based and focused on the meaning of symptoms, the importance of relationships, and the centrality of the patient’s authority in bringing about change.
One of the many lessons we learn from this wonderful volume is that treatment resistance is a reflection of not only the complexity and severity of patients’ illnesses but also, often, our inadequate, disjointed uncoordinated system of psychiatric care.
This book consists of 14 well-written chapters by Austin Riggs clinicians covering, in a comprehensive and engaging way, the many facets of treatment of these difficult patients. Space limitations do not allow me to review each chapter—I will therefore pick and choose a couple to help the reader get a taste of the richness and clarity of the entire work.
In the chapter titled The Boundaries Are Shifting: Renegotiating the Therapeutic Frame, Edward Shapiro articulates the significance of establishing and maintaining a therapeutic framework that clearly defines the tasks and the role boundaries in therapy. The successful therapist is the one who understands that the optimal treatment framework needs to simultaneously have one foothold in reality and one in the therapeutic relationship. In Shapiro’s words: “Interpretation and management are two tasks of a therapist … There can be no interpretation without competent management and no useful management without interpretation” (p. 164). This is particularly true when starting psychotherapy with a patient who needs treatment but has limited financial resources. The therapist, to establish a lasting therapeutic frame, needs to engage the patient from the beginning in the process of managing these limitations and integrating them (as opposed to ignoring them) into a comprehensive treatment plan. This is an aspect of a therapist’s management task that, if done appropriately, can strengthen the therapeutic framework and, subsequently, allow the interpretive phase of treatment to proceed.
Shapiro finds that many therapists are unable to balance the two tasks of interpretation and management and choose to focus on one or the other—in his words, they become either “managers” or “interpreters.” The managers, passively yielding to the reality of financial limitations, offer patients only “coping strategies, frequent short-term admissions and cognitive schema.” Interpretations are irrelevant in this approach. Long-term work is out of the question. Patients engaged in this therapeutic framework frequently end up feeling powerless, trapped and despairing, and often become treatment resistant.
In contrast, the interpreters choose to focus their efforts exclusively on the work of interpretation in the treatment of these patients. The “real” world of financial resources is seen as external to and potentially threatening the sanctity of the patient-therapist therapeutic dyad. This world is to be shut out of the therapeutic relationship. Neither approach, the author concludes, is successful—only the integration of these two tasks in a cohesive, stable therapeutic frame can be effective. Shapiro, using many examples, eloquently brings to light a variety of other societal pressures that attempt to erode the structure of our work.
Mintz and Belnap’s chapter deals with the concept of pharmacological treatment resistance, often encountered when therapists neglect to consider the significance of meaning in their patients’ symptoms and treatment.The authors describe a new approach, psychodynamic psychopharmacology, which they define as a discipline that “explicitly acknowledges and addresses the central role of meaning and interpersonal factors in psychopharmacological treatment” (p. 42). According to the authors, traditional psychopharmacology primarily considers the ways that patients are similar. Psychodynamic psychopharmacology, in contrast, focuses on what is unique about an individual patient.
This chapter addresses two broad categories of pharmacological treatment resistance: treatment resistance to medications or treatment resistance from medications. Using excellent clinical examples, the authors are able to discuss a variety of unconscious factors that will affect medication resistance such as the meaning and significance of symptoms, the nocebo effect—in which “expectations of harm lead to experience of harm” (p. 48), and meanings patients ascribe to medication. The chapter concludes with the introduction of six technical principles for an effective psychopharmacological approach to the treatment-resistant patient. These principles include having a thorough knowledge of the patient (including a detailed developmental history), addressing the negative transference and resistance to medications, being aware of countertransference feelings when prescribing, and maintaining a solid therapeutic alliance.
In the chapter Working With the Negative Transference,” Plakun eloquently illustrates how patients frequently fail treatments because of their therapists’ inability or reluctance to engage and tolerate negative transference especially when it takes the form of hate. Therapists who cannot tolerate their patients’ rage or aggression end up emotionally withdrawn and removed—thus recreating significant past relationships that left these patients, early on, feeling misunderstood, confused, alone, and abandoned. This unconscious intolerance of negative affects can lead to treatment stalemate and subsequent resistance.
Plakun further addresses the therapist’s work with the negative transference in his chapter on treating chronically suicidal patients. The author describes an approach that he developed in collaboration with the Riggs staff, called “an alliance-based intervention for suicide” (ABIS). This approach focuses on the centrality of a strong therapeutic alliance, defined by Plakun as “the intentionally and explicitly negotiated agreement between the patient and the therapist to collaborate in the treatment task, to which they are both committed.” The establishment of a solid therapeutic alliance allows both therapist and patient to redefine suicide from a symptom to an interpersonal communication within the treatment dyad. Plakun goes on to describe the principles of ABIS. These principles include asking the patient to take responsibility for staying alive as part of the therapeutic alliance. When suicidal thoughts and feelings inevitably emerge, the therapist’s approach is to interpret, in a nonpunitive way, the patient’s aggression in considering ending therapy through suicide. The therapist, while engaging the patient’s affect, needs to identify and contain his/her own countertransference while searching for any perceived injury (real or imagined) that may have triggered the patient’s suicidal wishes. This approach, while holding the patient responsible for the preservation of treatment, also presents the opportunity and hope for future repair. This chapter also provides a good comparison between ABIS and Linehan’s dialectical behavioral therapy as well as Kernberg’s transference-focused psychotherapy—two well-studied and established psychotherapeutic approaches to treating suicidal patients.
Other excellent chapters deal with a variety of topics such as the transmission of trauma, reenactments in therapy, the need for a stabilizing “third” in any dyadic therapeutic relationship, and family and milieu treatment approaches.
Special kudos to Eric Plakun for the superb job of editing this invaluable volume—a must-read for all clinicians treating a growing population of patients who find themselves drifting from one treatment to another and slowly spiraling down into personal and professional chaos.
Radu V. Saveanu, MD
Professor and Vice Chairman
for Educational Affairs
Director of Residency Training
Department of Psychiatry
and Behavioral Sciences
University of Miami Leonard M. Miller
School of Medicine Miami, FL
The author declares no conflict of interest.