16 - Treatment framework

Treatment framework

Prescribing psychotropics CHAPTER 14 Relational aspects of prescribing practice This section provides clinicians with practically useful advice in the relational aspects of prescribing. Evidence exists for the importance of the doctor–patient relationship in improving treatment outcomes.1–3 The key factors that help develop, maintain and deepen the relationship include instilling trust and regard.4 Three concepts are important here: object relations, memory and the treatment framework. Object relations This means how the individual views themselves and others around them. This view then influences how they process incoming data (e.g. what is happening in an interaction). This view of themselves has been determined from early experience. In essence it means that the present interaction may be experienced inaccurately through the prism of the past (another way to think of this experience is that this is the transference). This has implications for both the patient and the clinician. For example, if the patient has had early experience of uncaring parents, they will have greater difficulty in trusting the clinician. In turn, if the clinician’s early experience is of demanding parents who expected them to always get it right, a treatment-­resistant patient may be a particular challenge for them. This object relations approach allows one to be aware of factors regarding the patient, the clinician and the clinician– patient relationship. Memory Up to 95% of our goal-­directed activities are executed unconsciously.5 Thus, the clinician’s prescribing may be more influenced by procedural memory than their subjective view that they are using working memory (i.e. there is an illusion of the application of active thinking to solve the specificity of the present problem). By definition, procedural memory and the action flowing from this may not be best suited for a particular clinical situation. Acknowledging the unconscious influence on the present may help bring the conscious mind into play. Treatment framework This is using knowledge of the clinician’s usual way of working (e.g. following this edition of The Maudsley Prescribing Guidelines), and a knowledge of how they tend to personally apply these guidelines. Straying from the guidelines may be based on good clinical judgement but also it may indicate that there is some psychological factor influencing decision-­making. Given this psychological factor may be unconscious, the ability to review ‘what one usually does’ is then a useful check on what may be happening in prescribing. For example, if the prescriber is able to think ‘I do not usually prescribe such a high dose of antipsychotic as a starting dose’ they may then be able to pose the question ‘Am I feeling very anxious to satisfy the demands of this patient?’ In effect they may then be able to catch themselves acting out (i.e. replacing thinking with behaviour) in the countertransference (in this case their great anxiety to satisfy the patient).