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Ms. M is the kind of patient that many psychodynamic psychiatrists might be reluctant to work with based on her presentation. She has a long history of severe alcoholism and substance abuse beginning in adolescence, several suicide attempts, and self-harm in the form of wrist cutting. Her treatment history includes major boundary issues with one therapist and a sadomasochistic engagement with another. However, Ms. M is highly motivated, has benefited from treatment in the past, and demonstrates humor, a sense of hopefulness, and resilience in her initial presentation. She readily engages in a three and then four times per week treatment. Unlike the image of the “worried well” patient who seeks out intensive psychodynamic or psychoanalytic treatment, Ms. M is quite ill and seeks out psychodynamic treatment after multiple other treatment failures. Dr. Tuttle understands that, although Ms. M appears “delightfully engaging” on the surface, she is in a “severely regressed state, in crisis and feeling rejected and lost.” Despite Ms. M having an intellectual understanding of some of her difficulties, this has not translated into a deeper emotional understanding or meaningful change in her presenting problems.
As a psychodynamic psychiatrist, Dr. Tuttle attends to Ms. M's medical needs, including the effects from her alcohol use, and her psychiatric medication. He continues Ms. M on the fluoxetine and quetiapine that had been started on an inpatient admission to maintain stability and to observe her mood. After Ms. M's mood had been stable for a year and she questioned the need for the quetiapine, Dr. Tuttle stopped this medication. Because he was seeing her frequently and knew her baseline, he was able to observe the effect of discontinuing this medication. He noted that Ms. M “became noticeably more labile, with periods of irritability and slightly pressured speech.” Dr. Tuttle then restarted this medication and observed significant benefit. These discussions and