Captive patients, captive doctors: Clinical dilemmas and interventions in caring for patients in managed health care

This article explores common clinical dynamics resulting from the denial of choice that many patients experience in managed health care and proposes c linical adaptations for the treating or consulting psychiatrist. Patients w ho feel they have been denied the right to choose their health plan, treatm ent setting, or personal physician commonly go through a subjective experie nce analogous to that of being held captive. This sense of captivity can ex acerbate the feelings of helplessness and hopelessness brought on by seriou s illness. It can also intensify the patient's feelings of alienation and b etrayal when managed care constrains patient-physician decision making by l imiting treatment options. These dynamics can lead to identifiable transfer ence reactions and, in turn, to physician countertransference. Psychiatrist s can do much to ameliorate these potentially destructive dynamics both as treating therapists and as consultants to general physicians. Indications f or consultation or intervention are analyzed and specific clinical strategi es to enhance the patient's decision-making capacity throughout the introdu ctory, ongoing, and termination phases of the treatment alliance are review ed. (C) 1999 Elsevier Science Inc.