Academic journal article American Journal of Psychotherapy

The Use of Metaphors by the "Ambulatory Inpatients" of the Managed Care Era

Academic journal article American Journal of Psychotherapy

The Use of Metaphors by the "Ambulatory Inpatients" of the Managed Care Era

Article excerpt

An important effect of managed care is keeping partially decompensated patients out of the hospital, for this is the single most decisive factor in cutting the costs of psychiatric services. It is proposed that discharging sicker patients from inpatient units and denying admission to poorly compensated patients poses new challenges to their outpatient therapists. This calls for new, refined psychotherapeutic skills, especially around the development of a therapeutic alliance. Patient communications in the form of metaphors may help the clinician understand the patient's conflicts while avoiding excessive anxiety that might accompany more direct communications. Recognizing the meaning of the metaphor and working with it can keep the patient from regressing and assist in the formation of a therapeutic alliance. This statement is examined in a number of clinical examples. The similarities and differences between metaphors and dreams, symptoms, and the transference are discussed.

INTRODUCTION

In a managed-care environment, patients are discharged from the hospital more rapidly than before. Other patients who could benefit from hospitalization but do not meet "medical necessity" criteria are not hospitalized; instead they are shunted to outpatient care. This is a consistent effect of managed care in the delivery of psychiatric services, as reducing the length of the hospital stay is the single most important factor in cutting costs of psychiatric services ( 1 ). It is well documented that shortened inpatient stays have resulted in patients being significantly more symptomatic at discharge than they were before the days of managed care (2,3 ). The consequences of pressures to discharge patients sooner have received attention from the viewpoint of the psychiatrists working in inpatient units. Both alterations in clinical interventions and legal liability issues have been thoroughly reviewed (2,3). However, not much has been published on how shorter inpatient stays shape the practice of outpatient treaters. This is even more important in settings where low-functioning, seriously disturbed patients are likely to be treated by psychiatric residents without a substantial experience in case management and psychotherapy (4).

These patients have similarities both to inpatients and outpatientshence the expression "ambulatory inpatients." It is important to remember that the classic literature in psychodynamic psychiatry with seriously disturbed patients was written by clinicians working in long-term intensive inpatient settings. In those protective settings, painful psychological material could be explored in patients with shaky ego functioning because the milieu supplied the missing containment. In contrast, most published data on psychotherapy with outpatients refer to more highly functioning patients, those with adequate ego strengths to contain destructive impulses in the face of painful psychological work. Today's reality is radically different; the holding environment provided by the walls of an inpatient ward has virtually disappeared as a scenario for psychotherapy. As an outpatient, the seriously disturbed patient (with a deficit of ego strength) has the option of simply not returning to the office if the material discussed is too painful, or when the transference acquires a negative quality, and so forth. In this context the rapid and safe establishment of a therapeutic alliance is now more important than ever. One of the skills clinicians have to master is how to discuss painful material in a way that keeps the anxiety of the session at a manageable level. Managing to know the patient while at the same time maintaining a safe environment can be very difficult. Although Harry Stack Sullivan understood the importance of this concept more than 50 years ago (5), it is perhaps now even more important than it was in his time.

We have noted that some seriously disturbed patients create allegorical stories that can be used as a neutral middle ground in which to discuss severe anxiety-provoking material. …

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