AFTERCARE--- FROM HOSPITALIZATION TO OUTPATIENT PSYCHOTHERAPY

(Abstract)

The author reports two longterm cases in which previous psychiatrists treated patients in once a week supportive psychotherapy plus psychotropic medication for many years, in which the patients regressed and deteriorated, resulting in inpatient hospitalization, each one for severe, incapacitating depression and suicidal risk.

After stabilization with inpatient care,www.jamespaice.net referral was made for intensive, outpatient psychoanalytic psychotherapy. In these cases, the more intensive, psychodynamic approach proved beneficial. The intensive psychotherapy also took many years, but they were years of re-integration, maturational development and high level functioning.

Analysis of the previous treatment failures revealed that with superficial supportive treatment with medication and advice, the patients developed a hostile-dependent transference which was not recognized, managed or worked through. In one case the patient and psychiatrist would spend the weekly session discussing symptoms and side effects of medication, and and actually reviewed the PDR together to discuss changes in dosage or medication.

In the other case, the patient was transferred to a series of psychiatrists, as the patient was considered "too difficult." This 'hot potato' patient was scary to a succession of psychiatrists because she told of a powerfully erotic transference toward a previous psychiatrist. He did not manage this 'love transference,' but instead insisted that the patient was 'inappropriate.' The patient felt terribly rejected and developed an incapacitating major depression. When a consultant suggested the patient behave herself and go home and 'live with it,' she made a serious suicide attempt.

These cases reveal not only the lack of effectiveness of some superficial supportive psychotherapies and merely symptomatic treatment with psychotropic medications, but near catastrophic consequences. The trend toward this kind of therapy is unfortunately growing because of the restrictions of managed care, the tendency to reduce insurance coverage of psychiatric treatment and the blitz of drug company advertising.

Making the situation worse is the growing tendency for psychiatric residency training programs to omit training in psychodynamic principles and psychotherapy, while concentrating on the latest psychopharmacological research and neurochemical mechanisms. It is also well known that clinical research in the efficacy of psychiatric medications is often biassed by drug company funding, and that much of the research is poorly designed and poorly controlled, while questionable statistics are touted as giving ample evidence of efficacy. The latest crop of psychiatric residents do not get sufficient expertise to critically question and evaluate drug research studies. Studies have also shown that despite their denials, young physicians are influenced by drug company dinners, lectures, gifts and other perks.

The longterm, intensive psychotherapy must analyze the previous dynamics of unresolved transference-countertransference issues, plus the unresolved dependency conflicts which inclined the patient previously to accept a superficial approach which avoided the analysis and working through of key unconscious conflicts.

The author will illustrate with clinical case histories.