Academy of Medical Psychology

07/23/2025

Title: What is a Medication? No, I Mean Now

What is a medication? From a strictly medical model a medication is an intervention that is plugged in at a point in an algorithmic process of isolating relevant data, formulating findings and determining "an intervention."

But, Medical Psychologists are not "strictly medical." We also have many years of psychological training and, given the majority of us are advanced-practice, many years of practice experience as psychotherapists. We know nothing that happens between a pt and a therapist is entirely linear (an assumption of "if-then" algorithms) nor can be fully understood, appreciated or utilized as an isolated, unidirectional event

So, from a Medical Psychological perspective medications are chemicals that one puts into the body that interact with extant chemicals and chemical processes in the body. But, they are also part of a shared event between pt. and doctor wherein the pt.'s history of experience with medications (as well as other aspects of treatment and healing) are brought to the therapy relationship where these histories encounter therapist's history of experience with medications. Just as the vocal-verbal communication of the therapeutic dialogue transforms both pt and therapist, the non-vocal representations associated with "medication" and the experience of prescribing are mutually transformative.

Transformation can be for better or worse. Trauma is transformative. But, most people would not want it. Yet, the transformation of the transformation of trauma can be enlightening indeed. So, whatever we have to work with -- vocal-verbal dialogue, medication, trauma -- that "whatever," while potentially perilous, can be a catalyst or the raw material of a process of growth and expanded awareness.

Harry S. Sullivan introduced an essential idea into the collective psychoanalytic-cum-psychotherapeutic repertoire called parataxic distortion (PD) that is the event and process wherein the history and related perceptions and expectations a person brings into a new situation or new relationship not only affects his or her perception of that new situation or relationship but also subtly "molds" the responses of the other who also brings his or her histories, experiences and expectations which are subtly "molding" the responses of the first. Thus not only do the histories, experiences and expectations each is bringing to the other affect each party's perception of the other they also create two new people: the one responding to the other in relationship to the other responding to the one in relationship to the other in what one might call a perpetual reverberating fashion.

WIth much in common with the ways that transference and countertransference interact with each other and awareness of same can contribute to the therapist's understanding of the pt.'s therapeutic need and facilitate attunement processes PD assumes the additional condition that these "reverberating reciprocal effects" are continuous and part of the change process itself (for better or worse) not just "data" or challenges to address to maintain attunement

So, what does this "psychological" PD understanding contribute to our awareness of the pt-doctor-medication triad? (understanding Sullivan was actually a psychiatrist but this was from the day when many psychiatrists also had some degree of psychological knowledge through psychoanalytic training, knowledge which psychologists have inherited even if modern biopsychiatry has abandoned much of this wealth of knowledge). One key potential associated with understanding concepts like PD when prescribing is that it "softens" medications and prescribing and potentially integrates them with the psychotherapeutic process. That is, while a practice that is potentially abrupt, foreclosing and intrusive -- i.e. "I have diagnosed you with X. Take this medication and rid yourself of X" -- prescribing medications can potentially be included as additional vocabulary in a transformative pt-doctor dialogue wherein the pt. brings his or her history, perception and expectations to a potential-healing-event (psychotherapy) the prescriber (in this case a Medical Psychologist) attunes with the pt.'s experiences and in that process of attunement -- that yields that pt.'s struggle and needs -- medication may be one response that emerges as part of the soothing, containment and modulation extension of attunement. Similar to the way a pt. comes in fuming. sputtering and beside him or herself with emotion and "You are angry" emerges as an attuned response that potentially results in soothing, containment and modulation. "Yes. goddamn right I'm angry. Thank you for getting that." Or. the pt. says, ,"Angry? No, I'm heartbroken. I get frustrated when I'm trying to express my feelings and it comes out like this." Or, the pt. comes in, nearly mute, little eye contact, exuding fatigue and the minimal expression the pt does share is she could hardly get out of bed to come to the session. As the attuned therapist you just sit with the pt feeling the heaviness, unable to really "conjure" words to describe the heaviness and burden, at most, maybe "Yeah, it's a burden just to get out of bed and come here." The pt. weeps then -- you are truly with her affectively and thus it's now safe to feel her feelings -- and begins to share and a dialogue begins and therapy is in full swing. Or, the pt. doesn't weep and instead says, in the same fatigued monotone, "Yeah almost impossible to get moving. I wish I had something to help at least pick me up so I could at least get out of bed." Then, perhaps associations to a medication occur to you and you share this and the pt. says, ,"Yeah, I'll try that. I was on medications a long time ago. I think they helped. I think I was taking something that started with an 'S". Or, the pt. says,"Medications? No. I was thinking I wish I had something to go to." You (yourself more fully alert now) say, "Oh. Oh yes. I'm so glad you could make it today. It's so good to meet you." And, again the therapy is in full swing.

Pts and doctors change each other as part of the therapy process. Or, to an extent one could say this mutual change is the therapy happening. Medications don't necessarily have a more special role than any other form of communication -- with intent toward attunement -- than the words shared in the therapeutic dialogue. But, that isn't to say they are less special either. What we, as psychologists have that some other mental health prescribers don't have is the psychological knowledge to know what medications are in the therapeutic dialogue. Without this their potential in healing is relatively random. Medical psychologists aren't limited to algorithmic -- i.e., relatively random -- prescribing where mental health pts are concerned. We have the training and understanding to prescribe in a thoughtful, reflective, responsive, attuned -- and thus therapeutic -- way

Dr. Jeff Cole

06/23/2025

Attached is an essay I posted to our AMP ListServ today 06/22/2025:

When we are faced with momentous events on the global scale we are reminded of how the "body and mind of the collective" parallels and interacts with that of the individual, the dyad, the family and the group

Practical conflicts -- "We only have so much bread (or land, or resources) to share between us. How should we divy these so that each has enough to stay well and function, cooperatively, for the good of all, including, perhaps toward working together to make more bread" -- can be solved directly through gathering data, applying induction and deduction, dialogue, planning, assessing and analyzing

Once emotion enters in, however, the "problem-solving" process becomes much more complicated. "You took more than your share" (and, unspoken: "Now, I'm angry"), "You think you have more rights than I do" (and, unspoken, "Now, I'm incredulous, resentful and indignant"), ,"You are trying to deceive me," (and unspoken, "Now, I'm suspicious, resentful and vengeful"), "You deserve to be deceive -- or controlled, or manipulated, or punished -- in return" (unspoken, "Now, I'm feeling vindictive, seething and hostile")

On the individual level it is at Stage 2 -- "Emotions have now become part of the problem" -- that people enter therapy. People don't generally come to therapy on the basis of "practical problems," e.g., financial, logistic. They may go to an advisor or coach but, unless an emotional barrier, associated defenses, stress, resultant physiological changes and a "mental disorder" emerge they do not generally come for psychotherapy

Why do difficulties handling emotions lead to individuals seeking psychotherapy while practical problems can be addressed by other sorts of experts? Psychotherapists generally understand that emotional experience and the handling and mishandling of emotions are an interpersonal event (developmentally or situationally, usually both) and the interpersonal response necessary for addressing same requires special training in both the dynamics of the interpersonal-affective process and self-awareness (generally, in psychotherapy, revolving around the transference-countertransference dynamic). "I need to have an understanding of what obstructs my pt.'s direct access to his or her emotional experience -- and the defenses he or she puts in place of that access -- and, I also need to be aware of any defenses I might put up reflexively replicating my pt's misattunement experience so that I can attune with -- and thus, sooth, contain and foster my pt.'s modulation of -- his or her own affects.

One barrier that can be particularly resistant to attunement is compulsion. Compulsion, from a psychodynamic perspective, can be understood as "replacing affect with drive." So, instead of, say, feeling my affects: anger, hurt or sadness, I experience drive: aggression, sexual arousal/urgency or acquisitiveness. Neither anger, hurt or sadness nor aggression, sexual arousal or acquisitiveness are necessarily destructive. The former are emotions (not actions) and the latter, while actions can have their protective, procreative and thriving applications. We may need aggression as a component of self-defense, sexual arousal as part of intimacy, bonding and procreation of the species and acquisitiveness for purposes of gathering resources for harder times

However, when a drive is put in place as a defense, i.e., in place of addressing my affective experience -- for example, though there can be many combinations: violent aggression in place of anger and healthy expression of anger, sexual addiction/predation/offending in place of hurt, attachment needs and also anger and greed, usory, gambling addiction in place of sadness, fear, loneliness -- the potential for destruction is very high.

As therapists there are multiple methodological approaches to addressing compulsions but curative processes are generally some combination of limiting the compulsive acting out through behavioral and environmental controls, on the one hand while, simultaneously increasing pt experience of and access to affect attunement, soothing and affect containment on the other. "Put a 'no admittance' block on the casinos and gambling apps; but, also we need to address your loneliness, doubts about self-worth and hurt associated with your losses." One or the other alone will typically not do. E.G., AA/NA and the other self-help organizations require total abstinence. But they also offer unconditional acceptance (a component of attunement), connection, reassurance (soothing) and are affectively containing in this way

Psychophysiologically the cortico-basal-ganglial-thalamocortical circuits (CBGTC) are thought to play a central role in mediation of compulsive behaviors. Neuroscientific, psychiatric and biomedical literature will sometimes infer these circuits are causal determining factors but, we know from observation of the effect of psychotherapeutic, MICA/CAMI group and "12-step" type groups that there are more fundamental interpersonal, psychosocial environmental causal variables afoot. Then again, versus other mental disorders these domains may share more equal weight where compulsions are concerned) Studies have suggested here may be epigenetic prenatal programming in some cases though more research is warranted.

The CBGTC is involved in processes of "reward learning" and timing of behavior-reward relationship. In general pathology, problems of the CBGTC can be associated with Parkinson's Disease and Huntington's. However, with mental disorder, e.g., compulsions, OCD and other action-reward related disorders it is believed that anticipation of delayed reward is reduced such that there is an increase in pursuit of "instant gratification" producing behaviors. This could include "positive reinforcement" producing behaviors such as come from the variable ratio reinforcement (VRR) contingencies of gambling or negative reinforcement such as the relief from anxiety-provoking obsessions when the ameliorating compulsion is performed in OCD.

If we think about how these effects might be related to defensive redirecting from affect processing to drive pursuit we can consider the developmental processes associated with learning frustration tolerance and gratification delay. From the beginning of life the infant learns to tolerate the internal physiological-cum-affective experiences associated with not being able to have what one wants in the moment through the soothing effects of the attachment figures (AF) attunement with the infant's feelings of distress including hurt, resentment, anger and frustration itself while enduring the waiting process until a need is gratified. Without the affective accompaniment of the AF and associated soothing of anxiety associated with these emotions, over time the child may learn to substitute other experiences including psychological defenses. Where the intolerable affective experience is frustration itself the child may learn to substitute other, more immediate gratifications in a cycle that results in both difficulties tolerating painful affects -- again due to the lack of supportive interpersonal processing -- and proneness to cope with the discomfort through more immediately acquirable drive gratifications. "Mommy or Daddy won't help me with my angry feelings. I'll just break my sister's toys. Or, perhaps eat them. {Pica is considered a compulsive eating disorder BTW)."

Awareness of mediating neuroanatomical structures and neurophysiological process variables linking causal interpersonal-affective and interpesonal-affective-developmental event variables and outcome clinical symptom presentation, including symptoms clustering as specific mental disorders can help us better visualize and conceptualize the progression from disease etiology through to the establishment of interpersonal-affective->physiological->clinical presentation pathways, their reciprocality (e.g., the feedback loops of compulsive behaviors), points of intervention and how these can help to ameliorate the disorder and potentially resolve the pathological conditioning replacing it with healthier interpersonal-affective, behavioral and cognitive responses to stressors

On a global scale shifts in emphasis in leadership toward personal power and wealth acquisition (not in any one country; these shifts have been observed across the globe with increased trends toward autocracy and "leader-centered" governments) results in unmodulated responses among the masses who rely on those leaders to foster diplomacy and a sense of international cooperation toward a greater good WIthout a healthy, functioning "CGBCT" leadership to guide populations toward greater international interpersonal dialogue and toward greater understanding and resolution of heightened emotions, the emotions associated with political conflict "get the upper hand" and responses like "aggression", "predation" and "extreme acquisitiveness" become as acceptable to "the people" as they are motivating to the leadership. Individual Medical Psychologists can decide, for themselves, of course the degree and ways in which we might contribute to a more modulated world dialogue. In the meanwhile, in our clinical work understanding the parallels between the collective and individual levels of system disorders like "compulsion" can help us put our individual pt's struggles in perspective including the additional barriers to addressing interpersonal-affective experience in a larger environment that is pulling further and further away from such processes toward more compulsive responses

Dr. Jeff Cole

10/10/2024

Conspiracy oriented MAGA insurectionist party that overthrew GOP and tried to overthrow the government:

Humans, flooded with media, are susceptible to latching on to a "fantasy, or concept" that makes their lives and struggles seem understood and explain the meaning of things they've encountered. That concept (propaganda, feeling one with the herd, or alternate reality) has a defensive/symptom function and becomes dear. They return to the anxiety of not-knowing if that is punctured. Then they can't contain their feelings of anxiety, anger, confusion and look to externalize the affect and attach it to "the other"!

07/05/2024

Here is #2 in a series of posts I’ll be posting in coming days highlighting some of the many Grand Rounds presentations our leaders have provided to membership over the last three years from our “Meet and Greet” and “Grand Rounds” series. These presentations show the extent and depth of AMP specialists’ expertise in Clinical and Medical Psychology.

This one is from my April 2022 presentation on my Relational Psychotherapies and Stress Physiology (RPSP) model

Dr. Cole

07/05/2024

I’ll be posting information from some of the many Grand Rounds presentations our leaders have provided to membership over the last three years from our “Meet and Greet” and “Grand Rounds” series. These presentations show the extent and depth of AMP specialists’ expertise in Clinical and Medical Psychology.

Dr. Cherie Ruben, one of our specialists and her colleague Valerie Nowak, CEO of Harmonia Collaborative Care presented on Collaborative Care in Mental Health

06/29/2024

Last night I presented to the Academy of Medical Psychology(AMP) on the place of Psychology in the evolution of Medicine, from its prehistoric beginnings up through modern medicine — and the medical paradigm based in the body — through to its radical expansion into a psychological container extending beyond the body, into familial and social relationships, and a psychological paradigm based in psychological constructs and relationship with the environment, in particular the interpersonal-affective environment

THE MENTAL HEALTH DOCTORS: EMERGENCE OF THE PSYCHOLOGICAL PARADIGM AS THE "THIRD WAVE"
OF MODERN MEDICINE
Part 11 of the Relational Psychotherapies and Stress Physiology Series (RPSP)
by Jeffrey D Cole, PhD ABMP

From prehistory through approximately 1000 BCE medicine was dominated by an emphasis on basic '"first aid" for injuries and broken bones, phytotherapy (treatment by herbs) for colds and common infections and shamanism or witch doctoring -- direct intervention in the spirit realm -- for more serious illnesses understood as afflictions of the soul. In India and in the West in Greece between the 12th and 5th Centuries BCE -- even while an emphasis on supernatural causes of diseases and intervention continued to hold sway -- exploration of the body and cadavers toward understanding illness increased, culminating in the advent of scientific medicine, Hippocrates and the Aphorismi. Admonitions to focus on physical and natural causes of disease led, ultimately to the emergence of modern medicine in the 19th century the foundational model that has prevailed until today in treatment of diseases of the physical body.

In the late 19th Century physicians across Europe and then in the United States -- including Pierre Janet, Josef Breuer, Sigmund Freud and William James -- studying (presumed) neurological and behavioral conditions identified that forces outside the body (the focal object of medical research until that time) -- especially interpersonal-affective forces within families, between parent and child (and surrogate "parent" figures) and at key developmental junctures -- were primary factors in the development of mental illnesses. Meanwhile, early psychological researchers including Wilhelm Wundt and his students -- including many early founders of tests and measures in psychology (e.g., Francis Galton, James Cattell, Charles Spearman) -- began to establish a structure (based in psychological constructs) to provide a "locus" for this aspect of the human person that could no longer be contained within the limits of the physical body.

Freud's, James's and other medical doctors gradual renunciation of the the body as the primary focus of a medicine of human psychology, together with the early psychologists development of an alternative "structure" around which developed a psychological paradigm, established the beginnings of what could be called the "Third Wave of Modern Medicine," The Psychological Wave. I.e., Wave 1: inception in the progression from Shamanism, first aid and phytotherapy to attention to the body and natural causes in physical illness, to Wave 2) progressing through scientific medicine and biologically-based interventions of modern medicine's treatment of the physical body, to Wave 3) discovering and developing a structure for the genesis, study and treatment of psychological illness.

Each stage of development of medicine produced doctors who were the best of their time and for the function they provided. Today medical doctors of all sorts of specialties (oncology, cardiology, infectious disease doctors, etc) remain at the leading edge for treatments of diseases of the physical body of all sorts (cancer, heart disease, infection, etc). But, psychologists -- trained in the psychological paradigm where the bases of disease lie primarily in this “expanded container” comprised of psychological constructs and relationship -- are the only doctors trained at the highest stage of medical evolution -- this "Third Wave" -- in understanding the bases and treatment of mental illness

Dr. Jeff Cole
President Academy of Medical Psychology and the American Board of Medical Psychology

Thank you to the Board and Membership of AMP for support and the collegial work we do to advance the highest level of integrated care to the public: Doctors Ward Lawson, Jerry Morris, Rory Fleming Richardson, Julie R. Price, Brian Bigelow , Cal Robinson

Very special thanks to my dear and special friend and Research Consultant at Sofia University in Sofia, Bulgaria, Stefani Stefanova Стефани Стефанова

01/13/2024

In a recent conversation on a sister list-serv (NAPPP), I responded to Dr. Jonathan Rich and Dr. John Caccavales' conversation about problems with medication in mental health (Rich did an important study, and they reviewed others.

I thought I'd share my comments with you:

Huckster Prescribing and Marketing: I couldn't agree with John and Jonathan more. Some of you read my ketamine paper of years ago when they first started searching for the next pharm pay day when NAPPP and several of we psychologists and psychiatrists reviewed the literature and reminded them of the Star-D, Kirsh, and pooping out studies about antidepressants (a long-term near hoax cash cow), and later the NICE studies about neuroleptics, and then my review of pooping out and short lived results from amphetamine studies (American College of Lifestyle Medicine). Now they are hyping L*D (and when they ran this one up the flagpole several years ago, John exposed the ruse. They rotate ahead of public knowledge and amassed research on limited, minority of patients prescribed, and short-term effects even for those patients that get some effect. They over rate, over price, and over promise and do "medication only approaches" (We at NAPPP and ABMP got the FDA chief psychiatrist to file a letter years ago saying no well-trained physician believes a medication only approach to mental illness is adequate-see ABMP web site).

People are "prey" to shock and extremist capitalism, marketing psychology (and remember I have an MBA and know how the shock capitalists use psychology to herd masses), poor education (which is constantly under assault by extremist capitalists, to emotion and fear based propaganda, and to halo effects (your physician knows all), and manipulation of junk research (John has written about). See me and John's articles in the next Archives of Medical Psychology (and a book we are working on).

Best,

Jer

01/13/2024

Rep. Greg Murphy, MD, is hoping for action within a week

01/13/2024

Doctors of medicine and psychology on a treadmill can usually get overstressed and burned out. They can become easily frustrated, skeptical, and give up on really healing patience, and just look for short term techniques that satisfy patient’s demands, I can become young disenchanted with their professions self-care, is not emphasized in the training of doctors at all times.

Taking fewer than 3 weeks of vacation each year linked to higher rates of burnout

01/01/2024

https://www.medpagetoday.com/psychiatry/depression/108074?xid=nl_mpt_DHE_2023-12-31&eun=g2232267d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=Daily%20Headlines%20Evening%202023-12-31&utm_term=NL_Daily_DHE_dual-gmail-definition

The medical and pharmaceutical industries will try to sell you a "drug way to tolerate your thinking and life" for profit. Now, we old hippies know you were always temporarily happy when you could "get high". You would have filled out a short questionnaire saying, "I'm happier when I'm high"! But, they will prey upon patients, and get the support of the FDA if the questionnaires show a few points difference when high! Do they really think people are this dumb?

12/22/2023

Thanks to the support of my colleagues at Academy of Medical Psychology (AMP) for another rewarding Grand Rounds presentation this past Thursday (09/14/2023) evening announcing our initiative for a national plan to increase access to integrated treatment. This one was co-presented by myself (Dr Jeff Cole) and Dr Keith Petrosky (who introduced the national plan) while I presented on my relational, mind—>body model version of the bio psychosocial model. Dr Ward Lawson, Dr Jerry Morris, Dr Robert DeFrancisco, Dr Rory Fleming Richardson, Dr Brian Bigelow, Dr Cherie Reuben, Dr Dave Johnson, Стефани Стефанова

09/20/2023