Mintz

Recovery from Childhood Psychiatric Treatment

Recovery from Childhood Psychiatric Treatment:

Addressing the Meaning of Medications

David Mintz
“We physicians cannot discard psychotherapy, if only because another
person intimately concerned in the process of recovery—the patient—has
no intention of discarding it…All physicians, therefore, yourselves in-
cluded, are continually practicing psychotherapy, even when you have no
intention of doing so and are not aware of it; it is a disadvantage, however,
to leave the mental factor in your treatment so completely in the patient’s
hands. Thus it is impossible to keep a check on it, to administer it in doses
or to intensify it. Is it not then a justifiable endeavor on the part of a physi-
cian to seek to obtain command of this factor, to use it with a purpose, and
to direct and strengthen it?” (Freud, 1905)

Abstract: Medications exert effects not only through biological mechanisms

but also through the meanings that they carry. While positive effects (e.g., the
placebo effect) are broadly recognized, psychiatry is often less attuned to the
negative effects that are mediated through the meaning of medications. These
negative effects may be especially pronounced when noxious meanings and
countertherapeutic aspects of medications are incorporated into the unfolding
development of a child and not countered by psychotherapeutic experiences
that allow iatrogenic meanings to be placed in context. In this paper, psychoso-
cial mechanisms, by which medications may cause harm, are explored. These
include adverse effects on identity, impaired agency, impaired affective compe-
tence, and negative effects on the patient’s relationship with care. When such
harm has occurred at the level of meaning, it is best addressed at the level of
meaning. Examples of psychotherapeutic work with young adults is offered
to demonstrate the process of reworking developmental harm related to the
meaning of medications.

Keywords: psychotherapy, psychopharmacology, adverse effects, child

development

David Mintz, M.D., Director of Psychiatric Education/Associate Director of Training/

Team Leader, Austen Riggs Center

Psychodynamic Psychiatry, 47(3), 235–256, 2019

© 2019 The American Academy of Psychodynamic Psychiatry and Psychoanalysis
236 Mintz

INTRODUCTION

At this point, it is widely accepted that psychiatric medications ex-

ert their effects through a broad range of mechanisms, some mediated
biologically through their actions at various receptor sites and others
mediated symbolically, through the meanings they carry. In the fa-
miliar case of the placebo, positive expectations are transformed into
beneficial physiological and psychological changes. Placebos reduce
pain neurotransmission and produce measurable and medically mean-
ingful reductions in a range of illnesses (Finniss, Kaptchuk, Miller, &
Benedetti, 2010). The placebo effect also contributes substantially to
the action of psychiatric medications. The effects are so substantial in
the treatment of depression (Kirsch & Sapirstein, 1998; Khan, Warner,
& Brown, 2000; Kirsch, Moore, & Scoboria, 2002) that antidepressants
may arguably be seen primarily as psychological treatments (Ankar-
berg & Falkenström, 2008).
While most clinicians are aware of the potential benefits of meaning-
based effects, the field of psychiatry is considerably less focused on
their harmful counterparts. It is only in the last decade that the phe-
nomenon of the nocebo response (Hahn, 1997; Mintz, 2002) has begun
to enter into the psychiatric literature. As the mirror image of the place-
bo response, nocebo responses occur when expectations of harm result
in physical or psychiatric symptoms. In contrast to the placebo effect,
which is generally based in conscious and shared expectations of heal-
ing, nocebogenic expectations are generally not shared between patient
and treater, are often quite idiosyncratic (Mintz, 2002), and may even
be unconscious (Jensen et al., 2012). As social disadvantage appears to
be a major factor in nocebo responsiveness (Hahn, 1997), it is likely that
psychiatric patients are a population particularly vulnerable to harm
by nocebo effects.
The nocebo response is only one of many ways that medications
cause meaning-based harm. Other forms of harm may not be as
straightforward as nocebo side-effects and may not be limited to the
period of time that is contemporaneous with the administration of the
medication. Medications, for example, may become a concrete symbol
of defect that is incorporated into a patient’s personal identity in ways
that prove harmful. The prescription of a medication can be assigned
a range of destructive interpersonal meanings (e.g., “I am intolerable”)
that may prove developmentally problematic. Medications and asso-
ciated diagnoses can be used defensively in a range of ways that can
interfere with self-knowledge, agency, or growth. Medications can also
 Recovery from Childhood Psychiatric Treatment 237

substitute for the development of important affect management skills

and other ego functions in ways that leave lasting deficits.
These meaning-based effects are amplified in a culture in which med-
ical solutions are sought for increasingly varied forms of human suffer-
ing and where great faith is placed in neurobiology (Conrad, 2008; Wil-
liams, Martin, & Gabe, 2011). Indeed, one of the greatest challenges cur-
rently faced by the psychopharmaceutical industry in the United States
is the growing potency of placebo expectations, making it increasingly
difficult to demonstrate superiority of active drugs over placebo (Tuttle
et al., 2015; Walsh, Seidman, Sysko, & Gould, 2002).
While all people who take medications may attach pathogenic mean-
ings to them, children and adolescents may be particularly vulnerable,
because such effects can be amplified when incorporated into unfold-
ing developmental processes. If an adult, for example, is stuck with
a needle, there will be a small lesion that will quickly heal without
consequence. If that same lesion, however, is inflicted on an embryo, it
is much harder to predict whether and how that injury will be devel-
opmentally incorporated, greatly amplifying its effects. For many chil-
dren, pathogenic meanings associated with medications will become
part of their struggles as adults, sometimes to devastating effect.
This is not to say that medications should be avoided in children.
Rather, it is crucial that the meaning of medications be addressed as
an aspect of the treatment of children and adolescents, as well as in the
treatment of adults, especially those who have been medicated since
childhood. Typically, when harm develops and occurs at the level of
meaning, the problem will be most usefully addressed at the level of
meaning. Far too often, however, medicated children receive little or no
psychological treatment (Olfson, Crystal, Huang, & Gerhard, 2010) that
could help to identify and reverse such pharmaceutically-related de-
velopmental injuries. Even when children who are prescribed medica-
tions are provided with concurrent psychotherapy, guild tensions and
processes promoting mind-body splits in conceptualizing treatment
may lead to a neglect of medications as a focus of psychotherapeutic
exploration.

TRENDS IN PSYCHIATRIC TREATMENT

Presidential Proclamation 6158 officially declared the 1990s “The

Decade of the Brain.” In the two decades that followed, tremendous
optimism about developments in neurobiology, together with changes
238 Mintz

in medical economics that often prioritized efficiency above effective-

ness, led to significant shifts in the practice of psychiatry and in the role
of the psychiatrist. Just as psychiatrists began to relinquish the role of
therapist (Mojtabai & Olfson, 2008) and redefine themselves as “psy-
chopharmacologists,” there were changing expectations in the culture
at large. Pharmacologic treatment came to be seen as a normative re-
sponse to an increasingly broad range of social and emotional distress,
such that by the early 21st century, as many as a quarter of adult women
and a fifth of adult men were prescribed antidepressants (MedCo, 2011).
These developments had similar effects on the care delivered to chil-
dren and adolescents. The early 1990s saw the beginning of a prolifera-
tion of psychotropic prescriptions to children. From 1987 to 1996 pre-
scription rates of psychotropics to children under 18 increased almost
threefold, from 1.4% to 3.9% (Olfson, Marcus, Weissman, & Jensen,
2002). In 1994, 3.4% of medical office visits by children resulted in the
prescription of a psychotropic; by 2001, 8.3% of office visits (and 10%
of all office visits by adolescent males) resulted in psychiatric prescrip-
tions (Thomas, Conrad, Casler, & Goodman, 2006).
All classes of psychiatric medications saw increasing use with chil-
dren and adolescents. Stimulant use increased from 0.6% to 2.4% of
children between 1987 and 1996. Antidepressant use escalated rapidly,
then fell somewhat after they were implicated in increased suicidal-
ity in adolescents. Only about 0.3% of children were prescribed anti-
depressants in 1987; however, by 1996, the antidepressant prescription
rate to children had increased to 1% (Olfson et al., 2002). Further, by
1997, 1.3% of children were prescribed antidepressants, and by 2002
that number had increased to 1.8% (Vitiello, Zuvekas, & Norquist,
2006), representing a six-fold increase. Antipsychotic use also increased
six-fold between 1993 and 2003, with 18.3% of all visits by children to
psychiatrists resulting in an antipsychotic prescription (Olfson, Blanco,
Liu, Moreno, & Laje, 2006). For many children these regimens became
complicated with increases in polypharmacy mirroring general increas-
es in prescription rates. For those children with psychiatric diagnoses,
nearly a quarter (22.2%) were prescribed medications from multiple
classes in the years 1996–1999. Within a decade, nearly a third (32.2%)
of psychiatrically diagnosed children were prescribed multiple classes
of medications (Comer, Olfson, & Mojtabai, 2010). Children most likely
to receive antipsychotic medication were those experiencing social ad-
versity (e.g., poverty, foster care), suggesting ways that medications be-
come solutions to psychosocial problems (Zito et al., 2008; Zito, Burcu,
Ibe, Safer, & Magder, 2013).
Even very young children have not been immune to these increases.
2.3% of preschoolers aged 2 to 4 were prescribed a psychotropic medi-
 Recovery from Childhood Psychiatric Treatment 239

cation in 2001, double the rate of 1995 (Zito et al., 2007). Antipsychotic
prescription rates for children five and under doubled between 1999
and 2007 from 0.078% to 0.16% (Olfson et al., 2010). In the dominant
biomedical treatment paradigm, most of these children appear to have
been offered little other than a prescription, with less than half receiv-
ing psychosocial treatment or even a mental health assessment (Olfson
et al., 2010). This is despite the fact that there is convincing evidence
that the incidence of childhood psychiatric conditions is significantly
influenced by a range of psychosocial factors, including such early
adverse experiences as maladaptive family functioning (Green et al.,
2010), impaired family structure, and parental mental health (Visser,
Lesesne, & Perou, 2007).

MEANING AND MEDICATION

One implication of these findings is that treaters of both adults and

children will increasingly encounter patients who have known life
primarily in a medicated state. These medications will have had both
intended and unintended effects on the patient’s neurobiology. More
profoundly, these medications may have developed symbolic value
with far-reaching consequences, as these medicated children struggle
to make sense of their symptoms, the meanings attached to their medi-
cations, the cultural constructions of illness, and a host of other factors.
Medications are often prescribed in the context of an implicit (or even
explicit) theory of mind, motivation, and perhaps even personality.
Dysfunctional thoughts, feelings, and behaviors are seen as deriving
from defects in neurobiology that can be ameliorated by the rational
use of medications. One feels bad or acts out because of a “chemical
imbalance,” the prescription implies. The growing child is likely incor-
porating these neurobiologic metaphors attached to the pills that he
or she is ingesting. To the extent that these children have been provid-
ed psychiatric treatment that targeted primarily the patient’s biology
(without any significant psychotherapeutic treatment or effort to bal-
ance biological understandings with psychological ones), they may be
especially likely to understand themselves in reductionist, mechanistic,
and deterministic terms. The evidence for this in our culture is clear.
Processes of medicalization (Collin, 2016) have reached a point where
identities are increasingly mediated and defined by diagnoses.
The emphasis in our culture on biogenic theories of psychiatric ill-
ness is not only driven by the pharmaceutical industry but has also
been driven by well-intentioned social policy aimed at reducing stigma
240 Mintz

(U.S. Department of Health and Human Services, 1999; National Al-

liance on Mental Illness, 2012). According to the rule of unanticipat-
ed consequences, however, an increasing acceptance of the chemical
imbalance theory has often had the opposite effect (Kvaale, Haslam,
& Gottdiener, 2013). While these efforts do appear to lessen blaming
dynamics (Deacon & Baird, 2009; Kvaale et al., 2013), they promote a
sense of biological otherness that actually reduces the social acceptance
of people of mental illness and increases overall stigma and perceived
dangerousness (Kvaale et al., 2013; Pescosolido et al., 2010), burdening
rather than relieving children and adults with psychiatric diagnoses.
Children and adults in this environment face not only social stigma,
but also self-stigma in relation to the biogenic theory of illness. Stu-
dents with a history of depression, for example, were enrolled in an ex-
periment that was manifestly intended to determine, based on genetic
testing, the basic nature of their depression (Kemp, Lickel, & Deacon,
2014). Based on a mock cheek swab, study participants were randomly
informed that their depression was either biological or psychological in
nature. While in this case, failing to relieve participants of self-blame,
biogenic explanations of illness profoundly mediated the participants’
sense of self and self-efficacy, worsening prognostic pessimism and
mood regulation expectancies, both factors which are well known to
worsen treatment outcomes.
Holding an important place in the patient’s life and the life of their
family, these medications can also come to function as important in-
ternal objects in their own right (Tutter, 2006). Medications may be as-
cribed personalities and intentions (Gutheil, 1982), or they may even
take on important parental functions, such as soothing, containing, or
supporting. The emotional attachment to medications may be so pow-
erful that it easily eclipses attachments to people.
At the same time, medications may be given or taken in ways that
suffuse them with malevolence. They can represent forms of punish-
ment and can be experienced as overbearing, controlling, or even colo-
nizing. Like a narcissistic parent, they can usurp credit for the child’s
accomplishments. In addressing one aspect of the child (neurobiology),
medications can feel neglectful of the whole child, with all of his or her
complexity. Virtually any characteristic that can be ascribed to the im-
portant attachments in a child’s life can also be ascribed to medications.
These object relations are then ingested on a daily basis in a concrete act
of incorporation.
 Recovery from Childhood Psychiatric Treatment 241

MEDICATIONS AND DEVELOPMENTAL INJURY

Vignette 1*

Justin was an 18-year-old male who sought residential treatment af-

ter an altercation with his father in which both sustained injuries. Say-
ing, “I want to be able to control myself better,” Justin had a long his-
tory of psychiatric treatment that began at the age of 3 when he was
diagnosed with ADHD. Both stimulants and antidepressants tended
to help him initially, but he seemed subsequently to become more agi-
tated. By age 7, after a consultation with a national expert on childhood
bipolar disorder, his diagnosis was revised to bipolar disorder, which
he still carried at admission. On a combination of mood stabilizers and
antipsychotics, he was still prone to mood lability and anger that re-
quired very high doses of medications to suppress.
Justin had significant learning disabilities in a number of domains
that necessitated academic accommodations. Emotionally, he func-
tioned much like a child half his age. There were also significant dif-
ficulties in social adjustment: he both was targeted by his peers and
provoked them. Verbal altercations commonly erupted into physical
aggression both at school and at home.
He and his family ascribed his difficulties primarily to bipolar dis-
order. While he did not like his medication regimen of two sedating
antipsychotics, two mood stabilizers, and an α2-adrenergic agonist, he
very much felt that he needed them to prevent himself from becoming
dangerously manic and out of control.
Biomedically Mediated Harm. Though the most lasting harm is most of-
ten mediated by the meanings that medications hold, lasting harm can
also be caused by long-term exposure to medications whose physiolog-
ic effects interfere with developmental processes. Such was the case for
Justin, who presented not only as sedated, but as cognitively impaired
on high doses of multiple psychiatric medications. While it was diffi-
cult to sort out which of his deficits were endogenous and which were
the result of highly sedating and cognitively impairing treatments, it
was clear that there was evidence of progressive cognitive impairment
with a drop in full scale IQ of nearly 50 points between the ages of 5
and 18.
Defensive Use of Medications. On an intrapsychic level, medications
can exert negative developmental effects in myriad ways. Medical ex-

*All names and details have been changed to protect patient privacy.
242 Mintz

planations may serve as “inexact interpretations” (Glover, 1931), pro-

viding an explanation of motivation and behavior that can be used de-
fensively to obscure self-awareness. A common example of this is the
bipolar patient who does not want to acknowledge or feel responsibil-
ity for some kind of destructive action, thus attributing that action to
“my bipolar,” as if their subjectivity or desire were irrelevant. By this
mechanism, patients who defensively rely on biomedical understand-
ings as inexact interpretations will likely suffer from marked deficits
in self-understanding and experience impairments in agency, even
though they experience their medications as helpful and feel quite at-
tached to them.
Medications may also be used defensively in an attempt to replace
people. This is especially likely for those patients with early experi-
ences of unreliable caregiving and pronounced defenses against depen-
dency. Such patients prefer to turn to medications to manage dyspho-
ria, as turning to people carries a much greater risk of disappointment.
Quickly resorting to medications allows such patients to remain un-
aware of dependent longings. Secondary developmental harm occurs,
however, when these patients fail to develop adequate social support
systems or the emotional skills necessary to tolerate the ambiguity and
ambivalence inherent in human relationships. Increasingly isolated,
their distress mounts, which increases reliance on medications, leading
to further depopulation of their social world, and so on.
For children and adolescents (as well as for adults who are deeply em-
bedded in a family context), medications and their associated meanings
are just as likely to serve defensive functions at the family level. When
mothers, for example, experience their child’s emotional struggles as
offering a dichotomous choice between “sick child” and “poor moth-
er,” mothers will defensively choose to understand the child’s struggles
as illness (Singh, 2004). In Justin’s case, there were powerful family dy-
namics that contributed to a defensive medicalization of his issues. His
father, Dr. X, was a physician of national prominence and the eldest of
two children whose parents (Justin’s grandparents) were described as
having “a perfect marriage,” promoted by the fact that “my mother
always agreed with my father and did what he wanted.” In the family
kitchen hung a plaque that said, “Love me the most when I deserve it
the least, because that’s when I need it the most.” Accordingly, Dr. X’s
emotionally troubled older brother took the majority of the parents’ at-
tention, much to the resentment of Dr. X. Though he strove to gain his
parents’ praise, his successes were continually downplayed in an effort
to shield his brother from narcissistic injury. As an adult, Dr. X was
hyper-competent and intolerant of imperfection in himself and others,
and certainly did not wish to repeat the injustices that he felt were done
 Recovery from Childhood Psychiatric Treatment 243

to him. Consequently he identified with Justin’s younger sister, con-

tinually holding her up as an example of how Justin should be, just as
he appeared to avenge himself on his older brother, now represented
by Justin. Justin’s mother sometimes wished to shield Justin from his
father’s resentment but was stymied by the family culture in which it
was necessary that the parents present as a united front.
A defensive family organization emerged wherein Justin became the
“identified patient” (Jackson & Satir, 1961), driven by the father’s dif-
ficulty tolerating a view of himself as anything less than perfect and
subsequent inability to recognize his role in any conflict with Justin.
The family seemed to agree to protect this vulnerability in the father
so that he could remain competent and came increasingly to blame all
problems in the family on Justin’s illness. Indeed, Justin’s sister’s anxi-
ety disorder was thought by the family to be a reaction to the stress
of having Justin as a brother, and both parents independently main-
tained that their struggles with alcohol abuse were directly caused by
the strain of raising Justin.
Though Justin manifestly joined the family narrative, it became ap-
parent that on some level he was aware of his unjust situation and
frustrated by the ways that he was held accountable for troubles that
were not primarily his. This contributed to his baseline anger, making
it more likely that his temper would flare when frustrated. This, in turn,
served as support for the narrative of his illness. Typically, as he was be-
coming agitated, the family response would be to inquire whether Jus-
tin had taken his medications. In this way, his father and others could
defensively avoid awareness of their contribution to a problematic fam-
ily dynamic by labeling Justin’s anger as a meaningless expression of
his aberrant biology. When this happened, Justin faced a dilemma. He
could protest that his anger was, in fact, legitimate and press his point.
Ultimately, however, the dynamic would further anger him, only sup-
porting the point of his pathology. Alternatively, he could choose to
keep the peace and accept that his anger was merely an expression of
illness, leading to a de-escalation of tensions. In either case, the result
was a validation of the illness narrative.
Medication and Identity. It is perhaps not hard to see how such de-
fenses can not only impair self-knowledge, but also promote the devel-
opment of a negative identity (Erikson, 1968). Patients, and children in
particular, incorporate the meanings assigned to their illness. Pills can
become a concrete symbol of defect, serving to localize that defect in
the one taking the pill. It is as if children ingest the meaning with the
pill. If not provided opportunities to process what medications actually
mean, it is not uncommon for that child’s identity to include significant
244 Mintz

elements of sickness, badness, or incapability, among other things. This

was certainly the case for Justin, who was hopeless about making a
meaningful life for himself as he reached adulthood, seeing himself as
profoundly impaired, dangerous, and unlovable.
Medications can also introduce a significant degree of identity confu-
sion (Erikson, 1968), where the child (or former child) is fundamentally
unclear about the difference between the “real me” and the “medicated
me.” This is particularly the case when children have been medicated
from an early age. To the extent that the child’s developing capacities
are potentially attributable to medications, they are likely to be left with
serious questions about which capacities are theirs and which capaci-
ties are attributable to the medications. Such a child may, for example,
not have any clear idea whether their ability to inhibit impulsive action
is a now an intrinsic ego function that has emerged though a normal
maturational process or if “self-control” is really control by the medica-
tion.
Effects on Affect Competence. Justin did not struggle much with iden-
tity confusion, as he took it as a foregone conclusion that any capac-
ity for containment belonged to the medication and not to him. The
family’s reframing of any conflict as a “problem of illness,” rather than
a “problem of living,” truncated Justin’s development in a number of
related ways. One was in his sense of agency and personal responsibil-
ity. In a normal maturational process, the child comes gradually to feel
responsible for his or her actions and thus begins to develop ways of
managing behavior and controlling impulses. When problematic be-
haviors are singularly understood through a biomedical lens, however,
it removes the agency from the patient. It is now the doctor who is
responsible (Belnap, personal communication). Consequently, Justin
was generally not encouraged by others to develop self-control. Rather,
when he became upset, the immediate response was to take a dose of a
sedating medication and sleep it off. In this way, medications actually
substituted for development and Justin was truly left with impaired
skills for self-management.
In such situations, emotions may lose their functions as signals and
cease to provide guidance to the patient. In healthy development, emo-
tions are essentially another sense organ that help the individual nav-
igate the world and register aspects of their experience (particularly
interpersonal situations) as good or bad for the self. Someone who has
successfully navigated Erikson’s developmental stage (Erikson, 1950)
of initiative vs. guilt, for example, takes the feeling of guilt to mean
that he or she should likely make efforts to curtail the guilt-promoting
behavior. There are patients, however, who take the experience of guilt
 Recovery from Childhood Psychiatric Treatment 245

or dysphoria to mean that they should go to their psychopharmacolo-

gist and reassess their medications. For such patients, including Justin,
it is almost as if they have ceased to have feelings which can usefully
be explored, understood, and recruited in the service of development.
Instead, they have only symptoms to be reduced and ignored.
For Justin, the failure to develop affect competence fed his negative
self-image as one who was bad, sick, and irreversibly broken. The bi-
ologization of his troubles also contributed to the sense that improve-
ments were attributable to medical intervention and not to Justin’s own
efforts at self-control. He was thus deprived by any sense of emerg-
ing competence that might have encouraged further efforts to develop
these capacities in himself.
Effects on Relationship to Care. Especially when powerful family forces
are at play, the child seeking treatment is in need of an outside perspec-
tive to allow him or her to differentiate from toxic projections from the
family. The prescriber attending primarily to “symptoms” may lack the
necessary perspective to develop an “overall diagnosis” (Balint, 1969;
Weinberg & Mintz, 2018) that grasps the complex interplay between
meaning and biology, committing the error that Erikson cautioned
against in Childhood and Society when he wrote, “do not mistake a child
for his symptom” (Erikson, 1950). Without such perspective, the doc-
tor is prone to collude with family defenses. As Ferenczi noted, when
children have experienced harm at the hands of caregivers, “Probably
the worst way of dealing with such situations is to deny their existence,
to assert that nothing has happened and nothing is hurting the child...
These are the kinds of treatments which make the trauma pathogenic”
(Ferenczi, 1931).
When the child experiences the treater as betraying the position of
the Third (Muller, 2007), representing a reality perspective outside the
dyad, deep-seated mistrust of caregiving may be reaffirmed. Especially
if a treater has been induced to re-enact some aspect of previous trauma,
there are likely to be marked effects on future therapeutic relationships
with “built-in transference” (Volkan, 2010), eclipsing any “as-if” qual-
ity of the patient’s transference expectations. Such patients are likely to
have particular difficulty orienting themselves helpfully to treatment.
The harmful effects of this dynamic might emerge in the form of the
patient adopting a passive stance of learned helplessness or a rebellious
stance that interferes with engagement.
This seemed to be the case for Justin. While in all likelihood, he did
have some neurocognitive deficits that increased his impulsivity and
lability, there was little or no attention given to dynamics in the fam-
ily that exacerbated his problems. When conflict erupted in the fam-
246 Mintz

ily, they would immediately contact the psychopharmacologist to get

Justin’s illness under control. Because the prescriber unquestioningly
accepted the medicalized family narrative, his response was limited to
increasingly heroic efforts to suppress Justin’s bipolar illness, effective-
ly abandoning Justin to serve as a container for the family’s toxic pro-
jections. This dynamic was likely amplified by Dr. X’s powerful pres-
ence. When requesting medication adjustments for his son, he spoke
with clarity and force and with intolerance for other perspectives that
typically made people acquiesce. Rather than being able to provide an
outside perspective to Justin and his family about the complex nature
of Justin’s troubles, the prescriber was enveloped by a powerful family
neurosis, becoming, in a sense, one with the parents. This only wors-
ened Justin’s treatment resistance, as he was left with little hope that
anyone could really help him and felt already doomed to an utterly
unsatisfying life. Even upon entering a program that aimed at facili-
tating significant character change, Justin’s main aspiration was to be
suppressed just a little more.

ADDRESSING DEVELOPMENTAL HARM FROM

MEDICATIONS

When a patient’s developmental trajectory has been disturbed by the

direct action of a medication (e.g., negative effects on cognition), it is
likely that deprescribing (Gupta & Cahill, 2016; Mintz, Seery, & Cahill,
2018) will be a helpful component of effective treatment. Meaning-based
factors should, however, still be taken into account. Deprescribing can
remove direct biological effects while having no effect on residual iatro-
genic effects associated with adverse meanings. Further, deprescribing
medications to which a patient has an important emotional attachment
or that have served as a substitute for emotional development typi-
cally requires thoughtful timing and a sound therapeutic alliance if one
wishes to avoid further adverse consequences. In cases where harm is
mediated by meaning, deprescribing is generally not indicated unless
countertransference pressures have led to irrational prescribing.
In Justin’s case, it was important to simplify his regimen and reduce
the sedative burden of his medications, as he was sufficiently cognitive-
ly impaired that it adversely affected his ability to use psychotherapy.
At the same time, he was deeply attached to his medications. There
was a clear sense that every decrease in dosage required increased con-
tainment by the therapist. Immediately after each decrease, he would
complain of becoming manic. In the course of psychotherapy, Justin
 Recovery from Childhood Psychiatric Treatment 247

was able to explore this feeling of agitation and came to differentiate

“mania” from intense anxiety related to fear of loss of control and fur-
ther to differentiate this from a normal, unmedicated level of energy,
such as he had not experienced in the previous 13 years.
Gradually Justin was also able to better understand the defensive
role that medications played in his family dynamic. On periodic visits
home from the residential program, Justin would experience escala-
tion of agitation, and staff would frequently get calls from his parents
stating that he was becoming manic. This was curious, as there was
no evidence of mania at any point during his residential treatment. In
his therapy, it became clear that he was not manic, but enraged, and
that the family had agreed to call it mania in an effort to sap Justin’s
anger of meaning. This understanding allowed Justin to begin to ques-
tion his basic sense of himself as fundamentally flawed, to transform
symptoms back into feelings, and to work at understanding and gain-
ing some mastery over his affective life.
As previously noted, this kind of developmental harm from the di-
rect, long-term effects of medications is relatively rare. It is much more
common that developmental consequences stem primarily from mean-
ings that adhere to those medications. In these cases, it is generally use-
ful to help the patient understand how the meanings and uses of those
medications have become pathogenic. The ability to do so is based on
the ability for the treaters to hold an integrated bio-psycho-social per-
spective and to resist pressures to experience the patient in dualistic or
reductionist terms.

Vignette 2

At the age of 20, Ryan was admitted to a psychiatric hospital with

frightening, ego-dystonic homicidal impulses. His decompensation be-
gan after moving away to college, where he began isolating and failed
all his classes. He returned home, but escalating conflicts with his par-
ents overwhelmed them to the point they asked him to move out. After
disturbing thoughts about a girl evolved into homicidal impulses, he
moved back home but soon became terrified when homicidal thoughts
towards his parents emerged. He asked to be hospitalized, unsure if he
could restrain himself.
At the hospital, he denied hallucinations and delusions but did brief-
ly think that he was being fed a pizza with human flesh on it. His pre-
occupation with concerns that his brain had been damaged by previ-
ous psychiatric treatments was taken as further evidence of a psychotic
process. He was diagnosed with schizoaffective disorder and started
248 Mintz

on a mood stabilizing antipsychotic, a serotonergic antidepressant, and

anxiolytic. He was referred to a psychoanalytic residential treatment
center for more comprehensive treatment in a contained setting.
Like Justin, Ryan was diagnosed at age 3 with ADHD. Ryan, howev-
er, had a more complex and conflicted understanding of his problems.
He had an idea that “I haven’t honored my anger,” and he thought that
this might contribute to his problems, particularly his homicidal im-
pulses. He also had a much more consciously complicated relationship
with medications. Ryan had been a highly energetic and curious child
who was prone to breaking things and who often proved overwhelm-
ing to his parents. From toddlerhood through his latency years, he tried
various stimulants without much benefit. In adolescence he was started
on Wellbutrin, which offered real benefits for his mood and function-
ing. However, he was convinced that Wellbutrin had also caused irre-
versible brain damage. In his current desperate state, he felt he needed
medications to contain violent impulses. At the same time, he bore tre-
mendous resentments toward his doctors and parents for permitting
him harmfully to be medicated.
Ryan was in therapy throughout much of his childhood. While he
had experienced his relationship with his therapist to be helpful and
supportive, his therapist approached medications from the position of
a mind-body split and had therefore treated questions about medica-
tions as falling within the purview of the prescribing psychiatrist. The
meanings that medications held for Ryan went largely unexplored.
In Ryan’s case, the leading edge of treatment after transitioning from
acute inpatient hospitalization to a psychoanalytic therapeutic com-
munity was his conviction that his brain had been damaged by medi-
cations. This was crucial to address from the outset, as his profound
distrust of doctors and his intense need-fear dilemma regarding medi-
cations was utterly paralyzing. As Volkan has noted in such cases, “At-
tending to indications of a built-in transference is critically important
in the establishment of a solid therapeutic relationship. When patients
relate to their present analyst as an extension of one from their past, it
is important to acknowledge and elicit curiosity about this and mark a
clear boundary between the two” (Volkan, 2010, p. 14).
The first task for the prescriber-therapist, however, was to resist the
many pulls into reductionist thinking and to preserve a place for curi-
osity about this aspect of Ryan’s life. The pressures were considerable.
There was an insurer who appeared to measure the value of treatment
according to the pace at which medications were being adjusted, requir-
ing the therapist-prescriber to actively resist this reframing of the prob-
lem in biomedical terms. There was also unconscious pressure from the
patient to view his problems largely through the lens of biology, as he
 Recovery from Childhood Psychiatric Treatment 249

presented a view of himself as neurologically damaged by prior treat-

ments. Having felt that his parents and previous doctors entered into
some kind of unholy alliance that devastated him, he demanded that
the new therapist accept his view and become his ally against them.
Efforts to question his certitude initially placed the therapeutic alliance
on precarious ground. The therapist-prescriber was aided in holding
an integrated perspective by the routine practice of writing a brief psy-
chodynamic formulation of the meanings and psychological functions
of medications.
Over several months of exploration of Ryan’s history with and feel-
ings about medications, a picture gradually emerged that offered al-
ternative explanations of how medications had harmed him. For ex-
ample, Ryan angrily related how, when he was put on Wellbutrin and
his angry outburst towards his parents had begun to decrease, all of the
credit was given to the Wellbutrin. It was his experience, though, that
he was already in the process of a developmental shift where he was
beginning to become more effective at calming and containing him-
self. Ultimately, the medications (or, he later came to understand, the
meanings attributed to them by his parents) had deprived him of much
needed recognition of his competence. This deprivation was one way
that medications had harmed him.
At the same time, Ryan was conscious of identity confusion in rela-
tion to medications, with questions about what belonged to him and
what was attributable to medications. When he made gains while on
medications, he was left with the question, “Is this the medicated me or
the natural me?” These concerns went far beyond questions of whether
he or the medications deserved credit but went to the core of his being.
He wondered if a false-self had been created by medications, and he
had developed an identity that was essentially unreal. The problem,
for Ryan, was so extensive that he wondered, “Am I doing therapy
on a person who does not really exist?” In this sense, Ryan might say
that “Medications confuse me or erase me.” This was another way that
medications had harmed him.
Later Ryan recounted another narrative from adolescence. After be-
ing put on Wellbutrin and experiencing a reduction in depression and
a boost in self-confidence, he had persisted in trying to kiss a girl who
did not want to be kissed. His public shame amplified feelings that he
was bad, unworthy, and unlovable, and he defensively concluded that
medications had made him this way. In the exploration of how medica-
tions had made him bad, another story began to emerge, which was a
story of how bad he already felt, and how he had come to use anxiety
and fear of consequences to help him inhibit his impulses. When his
250 Mintz

depression lifted, and with it, his anxiety, he was temporarily deprived
of a familiar strategy for self-containment.
Over time, Ryan’s overdetermined preoccupation with the idea of
being brain damaged loosened. While Ryan continued to believe that
Wellbutrin had harmed him, he no longer experienced this in a biomed-
ical sense that left him feeling doomed. Rather, he saw himself as hav-
ing experienced developmental injuries (in which he had also partici-
pated) that had been mediated by non-biologic aspects of medications.
From this vantage point, he could feel his agency, and his conviction
of being harmed was replaced by a belief that the harm that was done
could be ameliorated by psychotherapeutic work and a decision to take
up, again, the task of development.
This is, of course, just a small subset of the work that Ryan did in his
therapy, much of which did not involve a focus on medications. Issues
related to medications that were intellectually grasped were remem-
bered and repeated in the transference over and over, allowing oppor-
tunities to work this through at deeper and deeper levels. For example,
as he began to develop and express a greater sense of agency, very con-
crete castration fears emerged in relation to the therapist-prescriber. In
his therapy, he became aware of a need to sit in such a way as to literally
protect his genitals. While some of this derived from a transference ex-
pectation that his psychiatrist-therapist, like his parents, would not be
able to tolerate his aliveness, the therapist-prescriber was experienced
as particularly dangerous by virtue of the concrete power to medically
disempower, subdue, and control Ryan’s emerging capacity for initia-
tive. These fears, emerging in the transference, shed further light on the
ways that Ryan, as a child and adolescent, had experienced medication.

CONCLUSION

In an era of polarization in mental health and with protesters gather-

ing at psychiatric meetings to decry the abuse of children by organized
psychiatry, it is important to reiterate that the possibility of develop-
mental harm from medications is not an argument against using psy-
chiatric medications to treat childhood mental disorders. Children can
just as easily be harmed when denied appropriate medications. When
there is some lasting harm done by medications, it is often not the ac-
tive drug that is the source of the iatrogenic effect, but rather it is patho-
genic meanings that are taken in, along with the pill, that interfere in
some way with healthy development.
This becomes more likely when the prescriber is operating from a
biomedically reductionist paradigm. In such cases, treaters are more
 Recovery from Childhood Psychiatric Treatment 251

likely to misdiagnose psychiatric conditions, because the role and im-

pact of psychological and social factors (e.g., early adversity) in symp-
tom production will not be fully considered. The medical model con-
ceives of illnesses as residing in the disturbed biology of individuals.
Sometimes, though, illnesses are interpersonal. A biopsychosocial per-
spective allows prescribers to make a broader, more complex and more
nuanced “overall diagnosis” (Balint, 1969; Weinberg & Mintz, 2018),
that could include, for example, symptoms as adaptations to pathologi-
cal family dynamics as means of communicating things that cannot yet
be put into words (Mintz & Belnap, 2006) or as the result of dynamics
that render the identified patient as a container for family pathology.
A more accurate diagnoses then allows for a more precisely targeted
treatment.
Whatever the source of the symptoms that medications are targeting,
those medications will likely have effects that are mediated by mean-
ing. Often, those effects will be positive, and skilled prescribers will
typically strive to foster, exploit, and ignore placebo aspects of medi-
cations in the prescribing process. When medications carry something
symbolically noxious to the child, however, this must not be ignored.
Psychotherapeutic attention to the meanings and psychological uses
of medicines is required both to illuminate symbolic aspects of medi-
cations and also to begin to address, at the level of meaning, harmful
developmental effects.
Less than half of all children who are prescribed psychiatric medica-
tions receive any kind of concurrent psychotherapy (or even an assess-
ment by a mental health professional) (Olfson et al., 2010). Given the
potential for meaning-based harm, most children receiving psychiat-
ric medications should have some opportunity for psychotherapeutic
work to explore the meanings that medications have for them and to
put medications into a healthy perspective that will promote better
long-term outcomes. Children who do receive concurrent psychother-
apy are most likely to be those for whom repeated medication trials
have failed to produce the desired outcome. Paradoxically, however,
those children for whom medications are most helpful may be most
at risk for meaning-based iatrogenic effects. Because the medications
seem to work, they are likely to be seen as potent with a corresponding
increase in the potency of the meanings associated with them. Further,
the meanings of these medications are also more likely to go unques-
tioned. It may not be until adulthood that developmental deficits be-
come apparent.
When patients are first introduced to medications and negative ef-
fects have not been incorporated into unfolding developmental pro-
cesses, it may not be necessary for psychotherapeutic exploration to
252 Mintz

have great depth or intensity (as in the case of Ryan above). Ordinary
“medical psychotherapy” conducted by a prescribing psychiatrist dur-
ing the course of a medication-focused psychiatric visit may suffice. If
the prescribing psychiatrist takes the time to inquire about the child’s
feelings, beliefs, and fantasies about medications (and those of the fam-
ily as well), this may be sufficient to identify pathogenic meanings and
patterns. Depending on the extent of external pressures to internalize
pathogenic meanings, psychoeducational strategies may be adequate
to ameliorate the most noxious effects. This might include recognizing,
with appropriate humility, what medications can and cannot do, active
questioning of pathogenic assumptions, and encouragement to recruit
and develop internal resources to supplement (or eventually replace)
medications.
Especially when medications serve defensive functions, when aspects
of a negative identity have begun to develop, and/or when medica-
tions have already begun to supplant internal controls, more intensive
psychotherapy is likely to be warranted. Psychodynamic techniques,
as illustrated above, offer one possible strategy. Cognitive-behavioral
techniques countering dysfunctional cognitions about medications
may also prove useful. When medications appear to serve a family lev-
el defense, adjunctive family therapy may be warranted.
Non-medical therapists are not immune from dualistic assumptions
that can interfere with an exploration of the meanings that medications
hold. Dualistic pressures embedded in the medical system at large,
guild tensions, defensive operations on the part of the patient and fam-
ily, and competing priorities for psychotherapeutic focus can all lead
therapists to neglect medications as a legitimate focus of psychother-
apy. Psychotherapists (non-medical as well as prescribing) can play a
crucial role in optimizing medication outcomes. Therapists should be
aware that even when the patient is not showing obvious evidence of
symbolically-mediated harm from medications, the psychotherapeutic
exploration of the patient’s “medication life” (Powell, 2001) still pro-
vides a unique perspective into the patient’s object world, sense of self
and personal agency, and relation to care, among other things.
The alarming incidence of psychiatric treatment resistance may stem
in part from a dominant biomedical paradigm that has undercut the
provision of integrative biopsychosocial treatment and deprived pro-
viders of some of their most powerful tools (Mintz, 2002; Mintz & Bel-
nap, 2006; Mintz & Flynn, 2012). Fortunately, the focus on evidence-
based practice has illuminated the limitations of this model and begun
to temper the false confidence of biomedically reductionist psychiatry.
As the director of the National Institute of Mental Health has recently
noted, “The unfortunate reality is that current medications help too few
 Recovery from Childhood Psychiatric Treatment 253

people to get better and very few people to get well” (Insel, 2009, p.
714).
With renewed humility, the field of psychiatry appears poised to
recognize the value of our psychotherapeutic heritage, reaffirm a com-
mitment to patient-centered biopsychosocial practice, and re-introduce
psychodynamic understanding into the psychiatric toolkit. One im-
portant aspect of integrative care is the recognition that medications
exert profound, and sometimes harmful, effects that are mediated by
meaning. The more this recognition is held in the mental health field,
the better psychiatry can observe the first rule of medicine: primum non
nocere. In attending to the meanings of medications, mental health pro-
fessionals are positioned, as Freud suggested, “to obtain command of
this factor, to use it with a purpose, and to direct and strengthen it” in
the service of optimal developmental outcomes (1905, p. 259).

REFERENCES
Ankarberg, P., & Falkenström, F. (2008). Treatment of depression with antidepres-
sants is primarily a psychological treatment. Psychotherapy: Theory, Research,
Practice, Training, 45(3), 329-339.
Balint, E. (1969). The possibilities of patient-centered medicine. Journal of the College
of General Practitioners, 17(82), 269-276.
Collin, J. (2016). On social plasticity: the transformative power of pharmaceuticals
on health, nature and identity. Sociology of Health & Illness, 38(1), 73-89.
Comer, J. S., Olfson, M., & Mojtabai, R. (2010). National trends in child and adoles-
cent psychotropic polypharmacy in office-based practice, 1996-2007. Journal of
the American Academy of Child & Adolescent Psychiatry, 49(10), 1001-1010.
Conrad, P. (2008). The medicalization of society: On the transformation of human conditi-
ons into treatable disorders. Baltimore: Johns Hopkins University Press.
Deacon, B. J., & Baird, G. L. (2009). The chemical imbalance explanation of depres-
sion: reducing blame at what cost? Journal of Social and Clinical Psychology,
28(4), 415-435.
Erikson, E. H. (1950). Childhood and society. New York: WW Norton & Company.
Erikson, E. H. (1968). Identity: Youth and crisis (Austen Riggs Monograph No. 7). New
York: WW Norton & Company.
Ferenczi, S. (1931). Child-analysis in the analysis of adults. International Journal of
Psycho-Analysis, 12, 468-482.
Finniss, D. G., Kaptchuk, T. J., Miller, F., & Benedetti, F. (2010). Biological, clinical,
and ethical advances of placebo effects. The Lancet, 375(9715), 686-695.
Freud, S. (1905). On psychotherapy. In J. Strachey (Ed. & Trans.), The standard edition
of the complete psychological works of Sigmund Freud (Vol. 7, pp. 64-145). London:
Hogarth Press.
Glover, E. (1931). The therapeutic effect of inexact interpretation. The International
Journal of Psycho-Analysis, 12, 397-411.
254 Mintz

Green, J. G., McLaughlin, K. A., Berglund, P. A., Gruber, M. J., Sampson, N. A.,
Zaslavsky, A. M., & Kessler, R. C. (2010). Childhood adversities and adult
psychiatric disorders in the national comorbidity survey replication I: Asso-
ciations with first onset of DSM-IV disorders. Archives of General Psychiatry,
67(2), 113-123.
Gupta, S., & Cahill, J. D. (2016). A Prescription for “deprescribing” in psychiatry.
Psychiatric Services, 67(8), 904-907.
Gutheil, T. G. (1982). The psychology of psychopharmacology. Bulletin of the Mennin-
ger Clinic, 46(4), 321-330.
Hahn, R. A. (1997). The nocebo phenomenon: Concept, evidence, and implications
for public health. Preventative Medicine, 26, 607-611.
Insel, T. R. (2009). Disruptive insights in psychiatry: Transforming a clinical disci-
pline. Journal of Clinical Investigation, 119(4), 700-705.
Jackson, D. D., & Satir, V. (1961). A review of psychiatric developments in family
diagnosis and family therapy. In N. W. Ackerman (Ed.), Exploring the base for
family therapy (pp. 29-51). New York: Family Service Association.
Jensen, K. B., Kaptchuk, T. J., Kirsch, I., Raicek, J., Lindstrom, K. M., Berna, C., ...
Kong, J. (2012). Nonconscious activation of placebo and nocebo pain respons-
es. Proceedings of the National Academy of Sciences, 109(39), 15959-15964.
Kemp, J. J., Lickel, J. J., & Deacon, B. J. (2014). Effects of a chemical imbalance causal
explanation on individuals’ perceptions of their depressive symptoms. Beha-
viour Research and Therapy, 56, 47-52.
Khan, A., Warner, H.A., & Brown, W.A. (2000). Symptom reduction and suicide risk
in patients treated with placebo in antidepressant clinical trials: An analysis
of the Food and Drug Administration database. Archives of General Psychiatry,
57, 311-317.
Kirsch I., & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A meta–
analysis of antidepressant medication. Prevention and Treatment, 1(2), 2a
Kirsch, I., Moore, T.J., Scoboria, A., & Nicholls, S. (2002). The emperor’s new drugs:
an analysis of antidepressant medication data submitted to the U.S. Food and
Drug Administration. Prevention & Treatment. 5, Article ID 23.
Kvaale, E. P., Haslam, N., & Gottdiener, W. H. (2013). The ‘side effects’ of medical-
ization: A meta-analytic review of how biogenetic explanations affect stigma.
Clinical Psychology Review, 33(6), 782-794.
Medco (2011). America’s state of mind: A report by Medco. Retrieved from http://apps.
who.int/medicinedocs/documents/s19032en/s19032en.pdf.
Mintz, D. (2002). Meaning and medication in the care of treatment-resistant patients.
American Journal of Psychotherapy, 56(3), 322-337.
Mintz, D., & Belnap, B. (2006). A view from Riggs: Treatment resistance and patient
authority—III. What is psychodynamic psychopharmacology? An approach
to pharmacologic treatment resistance. Journal of the American Academy of Psy-
choanalysis and Dynamic Psychiatry, 34(4), 581-601.
Mintz, D. L., & Flynn, D. F. (2012). How (not what) to prescribe: Nonpharmacologic
aspects of psychopharmacology. Psychiatric Clinics of North America, 35(1),
143-163.
Mintz, D., Seery, E., & Cahill, J. (2018). Deprescribing: A Psychodynamically-In-
formed, Patient-Centered Perspective. Current Psychiatry Reviews, 14(1), 19-25.
Mojtabai, R., & Olfson, M. (2008). National trends in psychotherapy by office-based
psychiatrists. Archives of General Psychiatry, 65(8), 962-970.
 Recovery from Childhood Psychiatric Treatment 255

Muller, J. P. (2007). A view from Riggs: Treatment resistance and patient authority–
IV: Why the pair needs the third. Journal of the American Academy of Psychoana-
lysis and Dynamic Psychiatry, 35(2), 221-241.
National Alliance on Mental Illness. (2012). Major depression fact sheet. Retrieved
from http://nami.org/Template.cfm?Section¼Depression&Template¼/
ContentManagement/ContentDisplay.cfm&ContentID¼88956
Olfson, M., Marcus, S. C., Weissman, M. M., & Jensen, P. S. (2002). National trends
in the use of psychotropic medications by children. Journal of the American
Academy of Child & Adolescent Psychiatry, 41(5), 514-521.
Olfson, M., Blanco, C., Liu, L., Moreno, C., & Laje, G. (2006). National trends in the
outpatient treatment of children and adolescents with antipsychotic drugs.
Archives of General Psychiatry, 63(6), 679-685.
Olfson, M., Crystal, S., Huang, C., & Gerhard, T. (2010). Trends in antipsychotic drug
use by very young, privately insured children. Journal of the American Academy
of Child & Adolescent Psychiatry, 49(1), 13-23.
Pescosolido, B. A., Martin, J. K., Long, J. S., Medina, T. R., Phelan, J. C., & Link, B.
G. (2010). “A disease like any other”? A decade of change in public reactions
to schizophrenia, depression, and alcohol dependence. American Journal of
Psychiatry, 167(11), 1321-1330.
Powell, A. D. (2001). The medication life. The Journal of Psychotherapy Practice and
Research, 10(4), 217-222.
Singh, I. (2004). Doing their jobs: Mothering with Ritalin in a culture of mother-
blame. Social Science & Medicine, 59(6), 1193-1205.
Thomas, C. P., Conrad, P., Casler, R., & Goodman, E. (2006). Trends in the use of psy-
chotropic medications among adolescents, 1994 to 2001. Psychiatric Services,
57(1), 63-69.
Tutter, A. (2006). Medication as object. Journal of the American Psychoanalytic Associa-
tion, 54(3), 781-804.
Tuttle, A. H., Tohyama, S., Ramsay, T., Kimmelman, J., Schweinhardt, P., Bennett, G.
J., & Mogil, J. S. (2015). Increasing placebo responses over time in US clinical
trials of neuropathic pain. Pain, 156(12), 2616-2626.
U.S. Department of Health and Human Services (1999). Mental health: A report of
the Surgeon General. Retrieved from https://profiles.nlm.nih.gov/ps/access/
NNBBHS.pdf.
Visser, S. N., Lesesne, C. A., & Perou, R. (2007). National estimates and factors asso-
ciated with medication treatment for childhood attention-deficit/hyperactiv-
ity disorder. Pediatrics, 119(Suppl. 1), S99-S106.
Vitiello, B., Zuvekas, S. H., & Norquist, G. S. (2006). National estimates of antide-
pressant medication use among US children, 1997-2002. Journal of the Ameri-
can Academy of Child & Adolescent Psychiatry, 45(3), 271-279
Volkan, V. D. (2010). Psychoanalytic technique expanded: A textbook of psychoanalytic
treatment. Netherlands: Open Access Scholarly Publishers’ Association.
Walsh, B. T., Seidman, S. N., Sysko, R., & Gould, M. (2002). Placebo response in
studies of major depression: Variable, substantial, and growing. Jama, 287(14),
1840-1847.
Weinberg, E., & Mintz, D. (2018). The overall diagnosis: Psychodynamic psychia-
try, six-minute psychotherapy, and patient-centered care. Psychiatric Clinics,
41(2), 263-275.
256 Mintz

Williams, S. J., Martin, P., & Gabe, J. (2011). The pharmaceuticalisation of society? A
framework for analysis. Sociology of Health & Illness, 33(5), 710-725.
Zito, J. M., Safer, D. J., Valluri, S., Gardner, J. F., Korelitz, J. J., & Mattison, D. R.
(2007). Psychotherapeutic medication prevalence in Medicaid-insured pre-
schoolers. Journal of Child and Adolescent Psychopharmacology, 17(2), 195-204.
Zito, J. M., Safer, D. J., Sai, D., Gardner, J. F., Thomas, D., Coombes, P., ... & Mendez-
Lewis, M. (2008). Psychotropic medication patterns among youth in foster
care. Pediatrics, 121(1), e157-e163.
Zito, J. M., Burcu, M., Ibe, A., Safer, D. J., & Magder, L. S. (2013). Antipsychotic use
by Medicaid-insured youths: Impact of eligibility and psychiatric diagnosis
across a decade. Psychiatric Services, 64(3), 223-229.

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