Meaning and Medication: Addressing Ambivalence in Pharmacotherapy

From a psychodynamic perspective, ambivalence and conflict are fundamental traits of mental life. Patients and doctors alike are always managing competing priorities and conflicting desires and fears. Pharmacotherapy is no exception. Patients are almost always ambivalent about taking psychiatric medications. The ubiquity of ambivalence poses a problem for the prescribing psychiatrist, as ambivalence is one source of pharmacologic treatment resistance. Not only is ambivalence a major contributor to treatment nonadherence, but low expectations can contribute to treatment nonresponse, and ambivalence fueled by fears of being harmed by treatment can promote nocebo responsiveness, leading to treatment discontinuation.

The harried psychiatrist and ambivalent patient may seek to deal with ambivalence by ignoring it. Research suggests that, unless asked directly, patients will signal their ambivalence only 2% to 3% of the time, leaving that ambivalence often to work in the background against the treatment. When asked, however, somewhere between a quarter and a third of patients will indicate their ambivalence. Even when ambivalence is unconscious (or maybe especially when it is unconscious), it can have adverse effects on treatment outcome.

The Nature of Ambivalence in Pharmacotherapy

Patients receiving pharmacotherapy can be ambivalent not just about medications, but also about treaters, and even about health itself.

Ambivalence about medication: It is no wonder that patients are ambivalent about medications, if one considers the etymology of pharmacotherapy (phármakon, φάρμακον) carries the dual meanings of “cure” and “poison.” Patients are often highly attuned to the ways that medications may harm them. For example, in a study of antidepressant users, a factor analysis of those patients’ descriptions of antidepressant use revealed 15 common themes that ran across those unstructured narratives. Of those 15 themes, the four most common were all related to experience of harm! Despite the general safety of most psychiatric medications, they often generate forms of ambivalence not associated with other medications, as they raise disquieting questions about agency, autonomy, dependency, identity, and other conflictual topics central to the human experience.

Ambivalence about treaters: Perhaps a preponderance of our most complex and treatment-refractory patients will have histories of early adversity, often in which they have learned that caregivers can be more harmful than helpful. Still others have had subjectively adverse interactions with the health care system. These early, and subsequent, experiences establish relational schemas (or transferences) that complicate our patients’ abilities to trust our best intentions, which, in turn, can undermine treatment adherence or contribute to nocebo responsiveness. Even the kindest, most patient-centered psychiatrist may be experienced malevolently, through an archaic lens. Transgenerational histories of systemic oppression may have a similar effect, perpetuating the problem of health inequities, as historically marginalized patients are harmed more, and benefit less, from treatment through mechanisms that are mediated, at least in part, through ambivalence about treaters and medical systems.

Ambivalence about illness: When life gives them lemons, people make lemonade. Not uncommonly, the treatment-refractory patient will have discovered, consciously or unconsciously, secondary benefits of illness, which then have the potential to complicate recovery. For example, the patient who has sacrificed to care for others her whole life falls into depression and now is relieved of onerous responsibilities and is receiving the care of which she is typically deprived. It may not come as a surprise when she forgets to take her antidepressants. Patients may also develop complex attachments to symptoms when they serve as a means of communication (for example, expressing anger), or are gratifying in other ways (for example, mania or forms of psychotic denial). When this happens, the patient cannot be expected to be only an ally in the treatment, but perhaps also an adversary.

Powerlessness and ambivalence: Feelings of powerlessness are fertile breeding grounds for ambivalence. Not only does a lack of self-efficacy undermine motivation to take on the work of change, but it also increases the likelihood that the patient will experience harm from treatment, deepening ambivalence. When we behave in ways that disempower patients (for example, through biomedically reductive approaches or through failure to involve patients in decision-making), we risk amplifying ambivalence, including ambivalence about us, sparking efforts, often unconscious, to oppose treatment.

Working With Ambivalence

Basic psychotherapeutic skills are an important part of the psychiatrist’s ability to identify and address the patient’s ambivalence.

Identifying ambivalence: The first step in working with ambivalence is to identify it. Assessing ambivalence should be a cornerstone of assessment with patients who have proven treatment resistant. To assess ambivalence about medications, it may be as simple as inquiring “What is it like for you to take medications?” Sources of ambivalence about treaters can be assessed by getting a developmental history that illuminates the patient’s internalized models of caregiving authority, as well as asking about prior experience of psychiatric caregivers. Ambivalence about illness may be illuminated by inquiring if there is anything the patient may stand to lose if treatment works. Psychotherapeutic sensitivities may help identify less conscious evidence of ambivalence (for example, nonadherence, nocebo responsiveness, other treatment-interfering behaviors). Similarly, psychotherapeutic skills for attending to affect and body language may help identify ambivalence, as when a patient’s foot starts shaking after agreeing to a new medication change.

Addressing ambivalence: From a psychodynamic perspective (and from the vantage point of Motivational Interviewing), perhaps the first and most important point when addressing ambivalence is to understand it empathically. Patients generally come by their ambivalence about psychiatric treatment honestly. Failing to respect the ambivalence risks causing the patient to feel judged and/or misunderstood, deepening resistance.

Making the unconscious conscious is one way that we empower patients, increasing their sense of being able to control something that previously had controlled them. While bringing ambivalence more into conscious awareness and integrating it into the evolving therapeutic alliance, it is helpful to highlight the discrepancy between the patient’s developmental goals and other conflicting (and often less conscious) priorities (for example, to not be controlled by a potentially dangerous authority figure).

The pharmacotherapeutic alliance (to be addressed further in a future article) is often a fulcrum of effective work with ambivalence. To the extent that the pharmacotherapeutic relationship is one in which the patient feels respected, the patient is also more likely to value the psychiatric recommendations. A solid bond creates a space for patient and doctor to work on discrepant goals (not just in the patient, but between patient and doctor), helping the patient tilt toward healthier choices. Fostering the patient’s autonomy and involving the patient in decision-making between medically reasonable options can lessen ambivalence. Patients are typically more committed to treatments for which they have a role in choosing, even in the presence of ambivalence.

A biopsychosocial framework and application of basic psychotherapeutic skills and sensibilities can position the psychiatrist to most effectively address treatment resistance stemming, at least in part, from ambivalence about pharmacotherapy. ■

David Mintz, M.D. is director of psychiatric education and associate director of training at the Austen Riggs Center, a psychodynamic therapeutic community in Stockbridge, Mass. He is also the recent past leader of APA’s Psychotherapy Caucus.

This is part of a series of articles on the psychosocial dimensions of pharmacotherapy.