It is an abhorrent notion that economic considerations determine treatment, whether we are discussing relieving unnecessary discomfort or saving lives. Excluding a modality of treatment for patients who need but cannot afford that treatment is antithetic to our way of life and to our medical traditions.1
While such an idealistic view appeals to us, the harsh facts of reality, frequently measured in dollars and cents, may preclude such idealism. The economics of psychiatric hospitalization are no exception: few hospitalization programs insure patients for hospital stays longer than 90 days,2 and most cover only 30 days of psychiatric hospitalization.3
In our state hospital, which is also a university teaching facility, we have encountered a number of patients who have experienced ruptures in the continuity of their hospitalization and psychotherapeutic management for economic, rather than clinical or administrative, reasons. In this report, 10 patients are presented who, upon expiration of the insurance policies covering their psychiatric care at private hospitals, were transferred to a state facility (our institution). This transfer was itself a major stress within the stress of a major illness, worthy of examination for its meaning to both patients and families.
We hypothesized that the transfer might have important emotional consequences for patients and families in the course of a psychiatric illness; we felt, therefore, that it was an event important for each therapist to explore and to help the patient integrate. In addition, since there is little or no discussion in the literature of this very common event, we felt that a study and review of such patients might have important implications for understanding the clinical effects of the fiscal arrangements that govern psychiatric hospitalization and that our conclusions might suggest changing these economic provisions.
Ten successive patients were interviewed who were transferred to our state hospital from private hospitals because of lapsed insurance. These interviews were performed by a psychiatrist (T.M.R.) who was not the patient's therapist and was not engaged in the patient's direct care. The interviewer cannot be called a "blind" observer, however, because the interviews had a specific intent: examining the impact and meaning of transfer for the patient. These interviews were tape-recorded with the written consent of the patient. The interviewer also reviewed the course of therapy and the circumstances of transfer with the patient's psychotherapist. Furthermore, the social workers involved with the various families were interviewed for evidence of the meaning and impact of the transfer for the patient's family.
CHARACTERISTICS OF THE PATIENTS
Table 1 summarizes the data on the 10 patients: sex, age at time of transfer, social class,4 educational level, psychiatric diagnosis, and length of private hospitalization before transfer. The average age of the group was 26. All were unmarried. All 10 of the patients were transferred ostensibly for lapsed coverage only, and in all cases the insurance coverage had indeed run out. However, it was also clear that the diagnosis, management, and treatment of these · cases posed significant problems to the private psychiatrist(s) responsible for the patients before transfer.*
A further phenomenon of interest was that six of the 10 patients were transferred to our state hospital by special arrangement. This arrangement was necessary because the six lived "outside the catchment area"; i.e., these patients would not ordinarily have been eligible for admission to our state hospital. The six transfers were based either on agreements between the private hospital and our own or on a temporary address established by family or friends within the catchment area.
All these young, middle-class, well-educated patients were considered to have encouraging prognoses and to be "good psychotherapy cases." For many reasons, therefore, the term "special patient" applies to each member of this group.3
DICHOTOMY OF PATIENTS' ATTITUDES TOWARDS TRANSFER
RESULTS OF THE INTERVIEWS
All patients interviewed expressed keen interest in talking about the experience of transfer. All acknowledged a sense of personal abandonment by their families upon transfer, even though the ostensible reason for transfer was simply that insurance money was no longer available for private hospitalization. All patients had a profound sense of social change from a higher to a lower level in losing private-hospital status. The patients, their therapists, and their families agreed that transfer was a major event and one that represented significant loss. All patients expressed positive feelings towards the physical plant of the private hospitals and negative feelings towards that of the state hospital. Yet all patients felt that the transfer somehow put them in touch with themselves, their illnesses, their expectations of themselves, and a "sense of reality" apparently unavailable to them before the transfer. This "real"/ "unreal"dichotomy is presented in Table 2.
ILLUSTRATIVE QUOTATIONS FROM THE PATIENT INTERVIEWS
The 10 patients reviewed agreed unanimously that at the private hospital they felt "special." In some cases this feeling presented as manic energy and confidence; for others, it was a delusional grandiosity. Upon reflection, the patients indicated that the private-hospital setting fostered this sense of specialness and that on coming to the state hospital, they realized that they would be required to give up this special position.
The following exchange took place with patient #8, a 21 -year-old man diagnosed as having paranoid schizophrenia:
Q. How do you feel about being transferred [from private to state hospital]?
A. I was still hallucinating very heavily. I felt I was being transferred because I was Jesus Christ. I felt I was being treated very special. When I was transferred here [to the state hospital! I started to come down, because at [the private hospital] there were less people and you got more specialized attention.
Q. And this helped you feel less special?
A. Yes, I came down off this Iesus Christ bit and began to feel down - a bit more like myself.
Patient #10, a 32-year-old man with borderline personality organization, when asked to compare the private hospital with the state hospital, remarked:
[The private hospital] was a country club. I really didn't want to leave. I think if I was at [the private hospital], I would coast for a few more weeks or do my body building. You know, I even proposed to a lady there who was 20 years older than me, that's how out of touch I was.
When the same patient was asked how he felt about the transfer, he replied:
It hurts my ego. I find it demeaning. I remember the days when I had more than I even knew what to do with, and now I find myself a "have not."* When I look at this place I say, "My God, I'd better get out of here, this place is doing a number on my head"; and from that perspective - from the feeling that I've been put into a hell hole - it's very conducive to getting well.
Part of the feeling of specialness at the private hospitals seemed to be the pressure to get well; patient #6, a 19-year-old boy with paranoid schizophrenia, remarked:
[The private hospital] is set up so that there's more intensity, sort of like you're on a stage a lot of the time. A lot more is being written down about how you are, how you're acting during the day.
Upon transfer to the state hospital, the same patient noted a sense of abandonment, aloneness, and time to put his problems into perspective at his own pace - a characteristic of the state hospital noted by all patients.
Q. What do you think the feelings of your family were at the time of transfer?
A. My father was in [a city 300 miles away], you see, my parents are divorced, and I sort of felt my mother sent me to [the state hospital] to get rid of me [patient weeps]. I felt abandoned by my family . . . abandoned and alone . . . alone with my problems.
Q. How do you think that affected you?
A. 1 knew how alone I felt as soon as I got transferred to [the state hospital]. That was helpful in some ways. I knew then that I had to think about myself. And when the psychosis was over, and that happened at [the state hospital], I had the feeling that I had done the work pretty much by myself because I was left alone and wasn't put on a stage and expected to do something for the doctors and staff, who were always pushing me at [the private hospital]. At [the state hospital] they gave me time, and my doctor gave me time, to think, which was most useful.
Most patients concurred that with less pressure they had more time to feel depressed and then to make decisions about themselves. Patient #8 remarked:
At [the private hospital] there was always somebody to talk to - I was talked to constantly - whereas here [at the state hospital] there wasn't as much attention. I wasn't ever lonely at [the private hospital] whereas here I was very lonely, very lonely, and that was depressing and after a while it brought me into reality.
All patients interviewed expressed ambivalence about the fiscal arrangements that had precipitated the transfer. All said they had not been informed that their insurance was running out; most patients in this group continued in private hospitals for some time after the insurance had actually run out, incurring further debt for their families. In all cases the financial arrangements touched on issues of anger and dependency apparent to the patients only when the "unreal" atmosphere of the private hospital was behind them. Patient #3, a 26-year-old woman with unipolar manic illness, described it this way:
I feel very bitter because my parents - well, the insurance company I don't so much care about - but my parents' debt was building up at an uncontrollable rate.
Q. Were you aware that the debt was building up?
A. I wasn't so much aware of it then. You see, the thing about [the private hospital] is that you can really enjoy it if you are not really very sick. That's the catch 22 of the place - it's really a playground if you really feel good. Well, my parents didn't really break it to me, and I just became aware of it by thinking about it now. I was in a kind of world of my own. [The private hospital] is very unreal - you become uninvolved in the real world - and as part of my excitement of feeling so well there, I really didn't think about money. But other times I knew the money was going to run out. I used to talk to people there [the private hospital] about what's going to happen when the insurance money runs out - "I'll be here a year and then I'll have to go to a state hospital" - and that was just the worst thing in the world. It made me feel terrible that I never could get acclimated to [the private hospital], but luckily that never happened here. I have had some bad experiences here, but, in general, I feel more my own woman here. I knew I'd have to go to a place that didn't cost money.
As this woman describes it, she felt a sense of liberation from a financial and - by extension - emotional dependence on her parents when transferred. This was a theme recurrent in the patient interviews - namely, that a working through of unresolved family issues for the patient took place at the time of, and because of, the transfer. To examine this phenomenon further, the social workers doing case work with the parents and families of these patients were interviewed.
RESULTS OF INTERVIEWS WITH THE FAMILIES' SOCIAL WORKERS
All 10 patients' families either were in treatment with or had had extensive interviews with a social worker. In all cases the transfer had been a painful, stressful, major transition for the family. For six families, as noted earlier, the insurance coverage had expired sometime before the transfer; these families incurred a considerable debt by continuing to support private hospitalization. They did this because they felt, reasonably, that a rupture in the ongoing psychiatric care of their children might be detrimental.
All families shared a feeling of hopelessness and despair at the transfer. They all expressed the feeling that as long as private hospitalization continued there seemed to be hope - a hope given up at the time of transfer. Therefore, transfer entailed not only an economic strain but also an emotional "giving up."
All these families had high academic and vocational expectations for their children. Each patient was a "special" child for his or her family in terms of aspirations and hopes. Each hospitalization represented an interrupted education and, therefore, shattered, suspended, or altered parental ideals. For the parents, in sum, the transfer represented a loss and a beginning of a mourning process - the loss of the "idealized child." Some of the families were available geographically and emotionally to share this mourning with the case worker; others were not.
This review confirmed the starting hypothesis that hospital transfer would represent an important emotional event for the patient and the family. Understanding the personal meaning of such experiences requires a therapeutic commitment to careful exploration of the feelings associated with life events, including those that appear to be "merely administrative" or "merely a question of economics."
Surprisingly, the impact was not, as we had expected, entirely negative (i.e., discouraging and demoralizing). Understanding this result requires examination of the manner in which certain kinds of losses can further therapeutic growth.
The "special" position. The "specialness" that patients felt while at the private hospital appeared to recapitulate the special position the patient had within the family before the illness; this specialness was further perpetuated at the time of transfer inasmuch as six of the patients were transferred by "special arrangement." Our state hospital, as a university-based teaching hospital within the state system, has long been a "special" institution in its own right; nevertheless, for the patients interviewed, transfer to a state hospital represented a significant social change with both intrapersonal and intra - familial dimensions.
"Giving up." Specifically, transfer first meant giving up certain granthose notions - notions in part arising from the illness itself - that mirrored the family's high expectations of the patient and the patient's high expectations of himor herself. Contributing to these pressures were the implicit expectations of the private psychiatrist that the patient would "improve enough" to allow for discharge before hospital insurance ran out. The patients sensed, then, that the transfer entailed symbolically giving up the "special" family position.
In addition, a family "giving up" process had to occur - giving up economically, giving up their child to his or her fate, and giving up certain aspirations and hopes. This, oddly, appeared to free both patients and families to mourn a loss and experience appropriate depression; the lapse of insurance heralded this new phase.
The giving up of the "specialness" experienced at the private hospital appeared to allow the patient to experience a feeling of a new and separate identity. This is reminiscent of the experience of Deborah's transfer to Ward D in the novel I Never Promised You a Rose Garden:
She was terrified of the Disturbed Ward, from which all pretenses to comfort and normalcy had been removed. ... It was somehow terrifying and somehow comforting in a way that was more than the comfort of the finality of being there. . . . And Deborah suddenly knew what was good about Ward D: no more lying gentility Or need to live according to the incomprehensible rules of Earth. . . .
She was, after all, at home on D Ward, more than she had been anywhere, and for the first time as a recognizable and defined thing - one of the nuts. She would have a banner under which to stand."
This "individuation" allowed the patients to experience a feeling of loneliness and depression. For the patient the transfer in many ways signaled the beginning of the "depressive" phase of psychosis and the beginning of mourning of the loss of former (family-related) aspirations and hopes. This has been hypothesized to be an important stage in the "healing process" of psychotic illness. 7
Reality versus unreality. In addition to the element of "giving up," the element of "reality" played a central role in the experience of transfer. Halpert has noted the tendency for thirdparty payment plans to obscure features of the patient's reality concerning affects and childhood experiences:
When a parent or spouse pays for an adult patient the conflicts, fantasies and stirrings of childhood memories surrounding the feelings of greed, deprivation, guilt and dependency are real and immediate. They come aüve in the transference. When an anonymous, amorphous third party (an insurance company) pays a major part of, or the entire fee for an adult patient, these feelings and conflicts are removed from both reality and immediacy, and resist tance is fostered.8
The patients interviewed experienced at the private hospital not only a "pressure to get well" but also a pressure to seem well, experienced as the quality of "being on a stage." They described a remarkably pervasive atmosphere of unreality, a sense of remoteness from the real world (Table 2). This, too, is reminiscent of Deborah's feelings about Ward D:
They looked at one another and smiled, knowing that "D" was not "the worst" ward at all, only the most honest. The other wards had "status" to keep up and a semblance of form to maintain.6
Like Deborah, our patients expressed a certain relief and sense of freedom upon transfer to the state hospital. They were free most literally from the pressures of the private hospital, the pressures to get well and be discharged within a certain time and of being dependent on their family's insurance policy or "out of pocket" financing.
All the patients here presented, in sum, experienced a shift from the old "reality" of unfulfilled family and personal ideals to the new reality of illness, aloneness, and depression upon transfer. It appears that a new phase of their treatment could then begin - namely, a confrontation with reality with much of the "special" resistance stripped away.
Motivation. Powerful voices urge that state hospitals be phased out;9·10 it has long been known, however, that the threat of state hospital transfer can be an important motivating factor for many patients in private hospital settings.* As expressed by many of the patients interviewed here, transfer to state hospitals was, indeed, an important motivating factor for change. For example, patient #5 described giving up the relaxed "country club" atmosphere of the private hospital and developing a keen desire to get out of the "hell hole" that the state hospital represented for him.
Regression. Another unexpected result of this survey was the paradoxical regressive effect of the more attractive private hospital. Ordinarily, the "noise and dirt" of the state hospital exert for some patients a regressive pull, as if patients felt: Why make an effort toward self-care, cleanliness, and self-discipline when the surroundings seem not to value these traits? In contrast to this state of affairs, posher surroundings are usually considered to exert a counterregressive force by appealing to higher levels of functioning.
Many of the patients in our survey, however, appeared to experience the reverse of these trends. They describe the drifting, "coasting," uninvolved state of mind, conducive to neither self-observation nor change, that the private setting tended to induce. After transfer, though depressed, the patients felt spurred to exert the efforts required to get well.
We would recommend caution in interpretation of this result, since it may indicate more about this selected population of patients than it demonstrates about transfer or state hospitals per se. In any case, generalizations about "milieu effects" must be regarded in the light of individual experience.
The experience of these patients suggests that a fresh look at the terms of insurance policies is needed; clearly, simply increasing the length of coverage may not be the answer. It may be that the present system as it stands is essential for some patients; namely, that there be a time limit on insurance and that - when the time limit is exceeded - state hospitalization be considered. Arkema has commented on the effects of time limits:
The idea is to let time in and of itself ("an und für sich") be the administrator. It is impersonal, not sadistic, and clarifies certain realities. For example, it defies evasion of responsibility through placing blame, plausible rationalizations, and so on.12
Our results suggest that for certain patients, time as an ingrethent in healing - time "at their own pace" - may have been essential in integrating the losses experienced.
The considerable debt that some of the families incurred while paying out of pocket after the policy lapse raises serious questions. Should clinicians allow families to run into debt over the care of one of their own members? It has been suggested that Freud himself would not have allowed it. Mack-Brunswick presents this sentiment in her discussion of the immortal "Wolf-man" case:
At the beginning of 1922 an acquaintance of the patient came to Vienna from Russia, bringing what was left of the patient's family jewels. . . . If he were forced to sell them and live on the money, he would have nothing to fall back on. He therefore told no one that the jewels were in his possession. In his fear of losing Freud's help, it evidently did not occur to him that Freud would never have considered permitting the patient to use up his little capital.13
We believe that therapists in both private and public sectors not only must be alert to individual economics of care, and be ready to explore its dynamic meaning for patients and families, but also should help discourage patients and families from going into avoidable debt.
Let us now reconsider the ideal expressed in the quotation with which we began this article: "It is an abhorrent notion that economic considerations determine treatment. . . ."'
The fact is that economic considerations do affect treatment. We would all wish the "best" treatment for any of our patients or family members. Ironically, what is "best" may be experienced as "worst" by some clinicians and most families; certainly, the transfer was initially felt to be the "worst" result. Yet the patients interviewed here all expressed relief from pressure, a "descent" into realistic depression, a sense of independence from their parents, and a new "reality" upon transfer from private to state hospital. The psychotherapeutic working through of the experience of transfer revealed a repetition of patterns reflecting the patient's interactions with family and patterns developed in earlier life. This "working through" was essential to the recovery phase of the illness described.
It may be necessary, with the future advent of national health insurance, for an individual or committee with knowledge of the intrapersonal dynamics of a case to make the judgment of whether a patient should be transferred from an acute-care to a chronic-care facility. This decision, as has been noted, might first be used as an important motivating factor for the acutely hospitalized patient. If transfer is in fact necessary, it should be considered an important emotional event requiring management as we have outlined. Our recommendation might be that in all such cases psychotherapy be available to both patients and their families before, during, and after transfer and that this psychotherapy be addressed to the meaning of the transfer to the patient in dynamic terms.
The authors gratefully acknowledge the assistance of the following in preparation of this article: Or. Stuart Hauser; Elizabeth Irwin, M.S.W.; the social workers and resident staff of Service II, Massachusetts Mental Health Center; and those patients who kindly agreed to be interviewed and who continued to teach us how to help themselves and others.
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DICHOTOMY OF PATIENTS' ATTITUDES TOWARDS TRANSFER