Overmedication as a manifestation of countertransference.
Q. What exactly do you mean by the title of this article? Are you suggesting that the overmedication of persons with intellectual disabilities might have a nonrational explanation?
A. Not in all cases, surely, but some of the most troubling examples simply cannot be rationalized, and these extreme cases might have something to teach us about an ingredient in the explanation of this all too common phenomenon.
Q. Could you please define your terms? Start with "countertransference."
A. Countertransference is a term from psychoanalytic theory and practice. The aim of the psychoanalytic process was to produce a therapeutic relationship between the patient and therapist which mirrored the patient's relationships in the world outside the therapist's office. The events within this relationship could then be analyzed, with the results enriching the patient's life in the world. This would happen when the patient "transferred" his or her emotions and neurotic styles of relating from important figures in his or her life to the therapist; the resulting relationship is called the transference relationship. The therapist, also being human, reacted to the patient's neurotic style of relating with neurotic feelings; these, the therapist's neurotic response to the patient's neurotic input, is the countertransference. A good therapist examines his or her own countertransference as the best clues to the patient's transference, feeds this back in therapeutic ways, and helps the patient examine his or her neurotic responses. This was considered the essence of the psychoanalytic method; the analyst's famed reticence was a technique to foster the transference response and the resulting countertransference.
Inevitably, some of what the patient reacts to is not neurotic; a therapist's lateness, office decor, manner of dress, etc. are all real events and perceptions, to which a patient can have a reaction. A patient's flamboyant style, accent, celebrity, broken glasses, bruises, or responses to the therapist's lateness, office decor and manner of dress are things to which the therapist might have a counterreaction.
Properly speaking, a therapist's response to a patient, in psychoanalytic terms, can be a mix of counterreaction (to real aspects of the patient's functioning) and countertransference (to neurotic aspects of the patient's functioning). But time and the tendency to intellectual shorthand wore this down to the point where all reaction to the patient and what he or she is doing or has done came to be casually referred to as "countertransference."
Q. What do you mean by "overmedication"?
A. This is in fact harder to define. The most rigorous way to try to define it would seem to be single medication dosage or multiple medication types in excess of rational usage guidelines. There are manufacturer's dosage guidelines. There are manufacturer's dosage guidelines, which are certainly not a gold standard but are often pretty good benchmarks when they are research based, for most new antidepressants. Specific serotonergic reuptake inhibitors (SSRI's) cannot be used in doses that cause QTc prolongations beyond 450 msec. There are known therapeutic serum levels for most mood stabilizing medications, and toxic levels for these and anxiolytics. There are practice guidelines promulgated by professional associations and by CMS (and its predecessor HCFA) giving (for once) pretty good ideas for maximum doses of antipsychotics (e.g., haloperidol 20mg/day), and advising against multiple antipsychotics; however, there are no known toxic doses for antipsychotic medications, so these are the most likely to be used at doses that exceed the guidelines. In the most troubling cases, the doses used cause obvious movement disorders, QTc prolongation, (4) or dangerous metabolic effects. (2)
Perhaps the best definition, better than trying to set an arguable milligram limit, is to put it in clinical terms: There seem to be numbers or doses of medication, most often antipsychotic medication but not always, out of all proportion to therapeutic effects achieved, and/or side effects beyond any perceived benefit to the patient.
Q. How does such a situation arise?
A. That is exactly what I am trying to account for, and a long-running case may be instructive, or at least illustrate why I think countertransference, in the loose definition given above, could be part of an explanation.
Mr. V was 33 when we first met, testing in the moderate range of intellectual disability. He resided on a locked living unit at a state facility jointly managed by developmental disabilities and correctional agencies and personnel. The unit housed individuals who had committed criminal acts (arson, pedophilia) and had been adjudicated. Mr V had not been, and his status was an anomaly. He was housed there because of a history of unpredictable violence, some thought to be related to delusional thinking, some to obsessive, even ritualistic questioning; there was other ritualism, hypermnesia, preoccupation with smelling things and obsessive drawing. Some violent episodes were accompanied by signs of autonomic arousal. He had unpredictable outbursts of what caregivers described as "maniacal" laughter. Gaze avoidance and echolalia were denied.
At interview he demonstrated severe bradykinesia, stiffness to the point of suppression of normal lithium tremor, and cogwheel rigidity; oral-buccal dystonia caused speech to be slow and labored. Content was obsessive repetition of several ritual concerns. He denied hallucinations.
He was at that point on lithium 1500mg/day (serum levels between 0.9-1.1 mEq/L), carbamazepine 2400mg/day (serum level 9.0 mcg/ml), and haloperidol 80 (eighty!) mg/day.
The past history was unfortunately sparse. Family history and history of pregnancy and delivery were noncontributory as far as was known. Birth weight was 7 lbs. 2 oz. Developmental and motor milestones were recorded as normal through age 2 years, including speech, but he "jumped in his sleep." However, when he started school at age 5 he was soon referred to the Child Study Team because of "lack of comprehensible communication, temper tantrums, inability to be contained in a group or one area, slobbering, grunting and crying in class, and hitting the school nurse." The Team's diagnosis was "childhood schizophrenia," and when he did well in a therapeutic day program, he was tried in a special education setting, where he again assaulted peers and exhibited "maniacal laughter." He was returned to the day program, but was admitted at age 8 to a state hospital children's unit due to threatening behavior toward siblings. Here he remained until age 13, on thioridazine and trifluoperazine (doses unknown) when PPVT IQ of 55 led to transfer to a developmental center. Formal testing here showed an IQ in the moderate range (instrument unstated), thought to be an underestimate. By age 14 his assaults on staff led to his being referred to as "dangerous and violent" and he was diagnosed with schizophrenia. Doses of both thioridazine and trifluoperazine were increased. He became obsessed with collecting insects (later the subject of his obsessive drawings), leading to "defiance" and fights with caregivers. This led to his transfer to the joint DD/Corrections unit.
At age 25 he was re-evaluated by court order, and this time the diagnosis was: Axis I: childhood onset pervasive developmental disorder; Axis II: no diagnosis; Axis III: organic brain syndrome (sic). Despite a recommendation for retention in a "highly structured mental health facility," he was returned to the developmental center, where he was again assaultive; he was soon returned to the joint DD/Corrections unit. Numerous psychiatric re-evaluations came to different diagnoses; some pointed to his acknowledgment of auditory hallucinations (a complaint he never spontaneously reported) and deterioration when thiothixene was substituted for haloperidol (doses not given), for a diagnosis of schizophrenia; others to insufficient information for a diagnosis of an autism spectrum disorder, others to the possibility of bipolar disorder based on improvement in his violence on mood stabilizers. It could not be determined when or how the dose of haloperidol of 80mg/day had been reached; available notes pointed to relatively recent use of mood stabilizers.
At age 33 the case for an autism spectrum disorder was felt to be compelling, based on his poor social communication, rituals and compulsions, early extreme hyperactivity, rejection of peer relations and loss of speech (assuming the accuracy of the early history). "Childhood schizophrenia" was a term frequently misapplied to children with autism spectrum disorders before DSM-III put forward consensus diagnostic criteria. In addition, there was apparent onset of bipolar disorder (a common comorbidity of autism spectrum disorders beginning to be recognized at that time) partly suppressed by high doses of antipsychotics. It was thought likely the remaining unexplained violent episodes were manifestations of panic disorder, another comorbidity of autism spectrum disorders, but partial seizure disorder could not be ruled out (perhaps explaining a response to carbamazepine). The side effects of the extremely high haloperidol dose were pointed out.
This evaluation took place very early in the availability of fluoxetine, the first of the SSRIs; it was already known that it could not be used together with high doses of antipsychotics because of akathisia (the QTc prolongation issue was not widely known at that time). Trial gradual reduction of haloperidol to permit a trial of fluoxetine was rejected, as was replacement of haloperidol with clozapine (since this would mean discontinuing carbamazepine). Caregivers were completely unwilling even to consider either course of action, and this in a highly regimented, locked unit. One can only ask why.
Q. Why do you think?
A. I think because of what was not on the chart, and not in the above material. The patient was over 6 feet tall and weighed over 250 lbs, and despite his not having had a serious assaultive incident in years, in fact not in the memory of any current caregivers, they were not reluctant to say they were terrified of him. The stories of his assaults--all undocumented and in fact undocumentable when attempts were made to verify them--can only be called legends. He was said to be able to avoid any restraints, assault any number of caregivers at once, to have been retained extralegally on the DD/Corrections unit despite never having been adjudicated due to employee union pressure on powers as high as the state capitol (this at least could be discredited, but not in the minds of caregivers). No amount of debunking or of reassurance could budge caregiver opinion (lending some truth to the local effect of employee pressure, if nothing else).
Nor was an explanation of his assaults--that is, that they were panic episodes not responsive to antipsychotics or mood stabilizers, except perhaps to slow them down. Nor would anyone entertain the theory that haloperidol at these doses was in fact a cause of the problem via akathisia, or recognize the current bradykinesia as a side effect, not a therapeutic effect.
One could only conclude we were dealing with what I loosely called countertransference, really a mix of countertransference and counterreaction to his real assaults. Mr. V was being medicated in proportion to his caregivers' fear of him, not in a way related to his diagnosis or to known mechanisms of drug action. The consequences to him in terms of movement disorders is recounted above.
Q. Is that the end of the story?
A. Fortunately, no. The unit in which he lived was relocated as part of the closure of the larger facility of which it was a part; as a result, the status of all its residents was reviewed, and no legal reason could be found to exclude him from the possibility of community placement. Remarkably (in view of his legendary assaultiveness) a community facility with a firm behavioral structure and known to be equipped to assaultiveness) a community facility with a firm behavioral structure and known to be equipped to take on "difficult cases," found the proposed diagnosis and treatment plan reasonable, and at the age of 39 he was moved to this facility. Over the course of 11 years lithium and carbamazepine were replaced with more effective valproate (now 875mg/day, with serum levels in the 75 to 85 mcg/ml range) and haloperidol was very gradually reduced to 30mg/day. When he did not tolerate further reductions (reacting with severe akathisia), olanzapine was added and gradually titrated up as haloperidol was further reduced to the current 20mg/day. Prozac 10mg/day reduced panic episodes to a rare occurrence; all along a very active behavioral program had kept assaultive responses to unwanted demand to a minimum. The plan is to continue a very slow reduction of the last 20mg of haloperidol; whether this, and perhaps reduction of olanzapine will eventually be possible remains to be seen.
Q. Do you come to your opinion about overmedication as a manifestation of countertransference on the basis of this one case?
A. No, unfortunately. This was the case I could best document. There are at least five others I have encountered. All have in common the patient's imposing size or the degree of intimidation and threat perceived by caregivers, the legendary and mostly undocumentable accounts of past violence, and, interestingly, a missed diagnosis of an autism spectrum disorder with misdiagnosis of schizophrenia (with resulting attribution of violence to hallucinations or delusions, even in the absence of any credible evidence for thought disorder; caregivers often said something along the lines of, "Well, he MUST be hallucinating"), and severe fear of any change or reduction in medication even where there was caregiver acceptance of the new diagnosis and rationale for change, and even when these same caregivers had seen good results from similar changes in the diagnosis and treatment of similar but less intimidating patients. (3)
One exception to this picture is a sixth case, in which both aggression and self-injury were the subjects of legend, but the perceived intimidation on the part of caregivers came not from the patient, who almost always had injured himself rather than others, but from fear of his self-injury causing a reaction from his politically powerful family, and this case returns us to a more complex view of the countertransference/ counterreaction issue.
Q. It does appear that this sixth case raises other issues. How does it fit the rubric of "countertransference"?
A. We have to come back to the terms defined above, and separate neurotic response to the patient's violence and real issues presented by the patient's violence. Unless both are addressed there is, exactly as in a psychotherapeutic relationship, no chance for change.
Direct caregivers in large public facilities are very aware they are under scrutiny, and their jobs, which for the most part offer better pay and benefits than private sector jobs with comparable qualification requirements, depend upon successful management of very difficult people. This means preventing injury to the patient, to other patients, and to themselves and fellow caregivers, in environments frequently, in the current word, "under-resourced." Professional staff must depend upon direct caregivers, and inevitably sympathize and empathize with them when dealing with a patient who poses a threat either because of intimidating violence or threats of job loss. It is very difficult to maintain empathy for a patient who poses a perceived continuous threat, especially when one lacks the resources to treat or even minimize the threat.
This, then, is counterreaction, reaction to very real elements of the patient and his/her situation and behavior. I emphasize that these perceived threats are very real in the world of large public (and often private) facilities for persons with intellectual disabilities. Caregivers feel truly faced with threats to their lives, health and jobs and there is a large element of reality to this sense of threat.
Where this shades into countertransference is where the threat can be seen to be proceeding from events far in the past, and the sense of threat cannot be relieved by rational review of updated knowledge of diagnosis and available therapeutic interventions, even where similar or identical interventions have been successful for other patients in the caregivers' experience.
Q. Can this impasse be resolved?
A. Yes it can, when it is approached as an issue in group process.
Q. What is the first step in approaching this problem?
A. The first step is to examine one's own countertransference and counterreaction. My usual countertransference fantasy is "rescue": these evil people are mistreating this poor patient, and I must contact the authorities and the press. This is a nice movie, but poor reality testing. These situations usually began with well-intentioned efforts to treat an intimidating patient, at a time when there was little to offer, either behaviorally or medically. What was done was what could be done. The "evil people" of the countertransference fantasy are the ones who are requesting the consultation; they in fact are requesting rescue from a difficult situation.
"Authorities" will not help; HCFA and its successor, CMS, have been auditing large congregate living facilities for 25 years, and these patients can still be found. As for the press, Geraldo has moved on. Intimidating people into acting is exactly what the patient or family has done. When one examines the counterransference fantasy, one finds a mirror of the neurotic situation. Acting on it would be like doing family therapy and then calling the police when the arguments don't stop.
In short, the countertransference fantasy contains elements that are a clue to how the caregivers are feeling, and can inform a true therapeutic response.
The next step is to realize that, as in child psychotherapy where the patient's better functioning will mean better functioning for the whole family, the therapeutic alliance is with both the patient and caregivers, at once. (1) Caregivers must be helped to see that what is good for the patient is also good for them--in the long run. Like psychotherapy, pharmacotherapy can yield periods of more difficulty in the short run, and only a strong therapeutic alliance, a shared commitment to the process of undoing the years of mismedication, can keep everyone involved.
This inevitably means addressing the real consequences of any increase in unwanted behaviors, not only with the immediate caregivers but with levels of administration they perceive as threatening. Administrators may have to be brought into the discussions of the treatment plan, to undo the caregivers' real fears, to begin to undo the countertransference fears, and because administrators are in fact responsible and have to answer to even higher levels of administration for any consequences.
When one has a therapeutic alliance with all the caregivers, from direct care to the highest levels of administration, counterreaction is undone.
A. The hard part--undoing the countertransference trap. One must acknowledge that the direct caregivers will bear the brunt of any withdrawal symptoms, and these should be anticipated and planned for. It can help to explain two things: (1) flexible withdrawal of psychoactive drugs and (2) the fact that the therapeutic doses of psychoactive drugs are not proportional to the size of the patient; one medicates the brain producing the behavior, not the seriousness of the behavior. A person with explosive panic episodes may respond to quite small doses of an SSRI, for example.
And one must be prepared to explain this, and to refresh and renew the therapeutic alliance over the years it can take to withdraw people from heroic doses of antipsychotics.
(1.) Joshi SV. Teamwork: The therapeutic alliance in pediatric pharmacotherapy. Child Adolesc Psychiatr Clin N Am 2006;15:239-62.
(2.) Levitas A, Hurley A. The history behind the use of antipsychotic medications in persons with intellectual disability: Part II. Ment Health Aspects Dev Disabil 2006;9:93-101.
(3.) Schwartz RC, Wendling HM. Countertransference reactions toward specific client populations: A review of empirical literature. Psychol Rep 2003; 92:651-654.
(4.) Silka VR, Levitas A, Hurley A. The recent alert on cardiac effects of psychotropic medications. Ment Health Aspects Dev Disabil 2001;4:125-128.
CORRESPONDENCE: Andrew S. Levitas, M.D., Dept. of Psychiatry, UMDNJ/SOM, 40 East Laurel Road, Suite 200, Stratford, NJ 07084-1504; email: firstname.lastname@example.org.
ANDREW S. LEVITAS, M.D. (1) ANNE DESNOYERS HURLEY, PH.D. (2)
(1) University of Medicine & Dentistry of New Jersey/School of Osteopathic Medicine, Stratford, NJ
(2) Harvard Vanguard Medical Associates and Tufts University School of Medicine, Boston, MA
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|Title Annotation:||Ask The Doctor|
|Author:||Levitas, Andrew S.; Hurley, Anne DesNoyers|
|Publication:||Mental Health Aspects of Developmental Disabilities|
|Date:||Apr 1, 2007|
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