Sudhakar Madakasira, MD, DLFAPA

Medical noncompliance and patient resistance to treatment are frequent problems in medical practice. According to an older report by the US Office of Inspector General, approximately 125,000 people die each year in the United States because they do not take their medication properly.¹ The World Health Organization reported that 10% to 25% of hospital and nursing home admissions are a result of patient noncompliance.² In addition, approximately 50% of prescriptions filled for chronic diseases in developed nations are not taken correctly, and up to 40% of patients do not adhere to their treatment regimens.² Among psychiatric patients, noncompliance with medications and other treatments ranges from 25% to 75%.³

In recent years, combining pharmacotherapy with psychodynamic psychotherapy has become a fairly common form of psychiatric practice. A main reason for combining these treatments is that a patient with severe psychiatric symptoms may be unable to engage in self-reflective insightful therapy until those symptoms are substantially relieved with pharmacotherapy. The efficacy of combined pharmacotherapy/psychotherapy may also be more than additive and result in a therapeutic alliance that is greater than the sum of the 2 individual treatments.⁴ Establishing a therapeutic alliance is critical to successful treatment, but this alliance can be distorted by the needs and expectations of both the patient and the clinician.

A psychodynamic understanding of the patient and the therapeutic alliance can facilitate combined treatment in several ways. It can lead to better communication, which in turn can lead to a realistic discussion of a patient’s fears and worries about any medications they have been prescribed. A dynamically aware clinician may better understand what the symptoms mean to the patient. Such clinicians will not only be able to explain the value of a medication, its target symptoms, and the rationale for taking it, but will also be able to discuss the psychological significance of the medication, along with its medical and biological significance.⁵

This article briefly reviews the therapeutic alliance and the influence of transference (the emotional reactions of the patient towards the clinician),⁶ countertransference (the emotional reactions of the clinician towards the patient),⁶ and patient resistance/nonadherence to treatment on the failure or success of pharmacotherapy. We provide case examples to illustrate how these psychodynamic factors can be at play in prescribing.

The therapeutic alliance

The therapeutic alliance is a rational agreement or contract between a patient and the clinician; it is a cornerstone of treatment in medicine.⁶ Its basic premise is that the patient’s rational expectation that their physician is appropriately qualified, will perform a suitable evaluation, and will prescribe relevant treatment is matched by the physician’s expectation that the patient will do their best to comply with treatment recommendations. For this to succeed, the contract needs to be straightforward, and there needs to be no covert agenda. A covert agenda may be in the form of unrealistic expectations and wishes rooted in insecure experiences in childhood by either party. A patient under stress may react to the physician with mistrust, excessive demands, and noncompliance. A physician under stress may react to a patient by becoming authoritative or indecisive, or by overmedicating or underprescribing.

Transference

Transference is a phenomenon whereby a patient’s feelings and attitudes are unconsciously transferred from a person or situation in the past to the clinician or treatment in the present.⁶ For example, a patient who is scared of a serious illness may adopt a helpless, childlike role and project an omnipotent, parentlike quality on the clinician (positive transference) that may be unrealistic. Positive transference may underlie a placebo response to medication in which a patient’s response is too quick or too complete, and it may be a way of unconsciously pleasing an authoritative parent figure from childhood. On the other hand, a patient may unconsciously view their physician as a controlling parent (negative transference) and react angrily or rebelliously. A patient’s flirtatious behavior toward their physician may be a form of transference from unresolved sexual trauma during childhood. However, not all patient reactions should be considered transference; a patient may be appropriately thankful and deferential, or irritated and questioning, depending on the clinician’s demeanor and treatment approach.

Countertransference

Countertransference is the response elicited in the physician by a patient’s appearance and behaviors, or by a patient’s transference projections.⁶ This response can be positive or negative and includes both feelings and associated thoughts related to the physician’s past experiences. For example, a physician in the emergency department may get angry with a patient with an alcohol use disorder because of the physician’s negative experiences with an alcoholic parent during childhood. On the other hand, a physician raised by a compulsive mother may order unnecessary tests on a demanding older female patient. Or, a clinician raised by a sheltering parent may react to a hapless and dependent patient by spending excessive time with them or providing additional medication samples. However, not all clinician reactions are countertransference. For example, a physician’s empathic or stoic demeanor may be an appropriate emotional response to a patient’s diagnosis such as cancer.

Continue to: Patient resistance/nonadherence

In 1920, Freud conceptualized the psychodynamic factors in patient resistance to treatment and theorized that many patients were unconsciously reluctant to give up their symptoms or were driven, for transference reasons, to resist the physician.⁷ This same concept may underlie patient resistance to pharmacotherapy. When symptoms constitute an important defense mechanism, patients are likely to resist medication effects until they have developed more mature defenses or more effective ways of coping.⁸ Even when patients do not resist symptom relief, they may still resist the physician’s choice of treatment due to negative transference. Such patients often negotiate the type of medication, dose, timing of the dose, and start date as a way of trying to “keep control” of a “doctor they don’t quite trust.”⁸ They may manage their own medication regimen by taking more or less than the prescribed dose. This resistance might lead to a “nocebo” effect in which a medication trial fails not because of its ineffectiveness but instead from the unconscious mind influencing the patient’s body to resist. Nonadherence to treatment may occur in patients who have attachment difficulties that make it difficult for them to trust anyone as a result of negative childhood experiences.⁹ Clinicians need to recognize the dynamics of power struggles, control, and trust. A warm, collaborative and cooperative stance is likely to be more beneficial than an authoritative and detached approach.¹⁰

The following 3 case examples illustrate how psychodynamic factors such as transference and countertransference can influence the therapeutic alliance, treatment decisions, and the outcomes of pharmacotherapy.

CASE 1

Mr. A, age 63, has posttraumatic stress disorder originating from his father’s death by a self-inflicted gunshot wound when Mr. A was 19, and later from the symbolic loss of his mother when she remarried. He reported vivid memories of his father sexually assaulting his mother when he was 6. This fostered a protective nature in him for his mother, as well as for his 3 younger siblings. After his father’s suicide, Mr. A had to take on a paternal role for his 3 siblings. He often feels he grew up too quickly, and resents this. He feels his mother betrayed him when she got remarried. Mr. A attempts suicide, is admitted to a local hospital, and then follows up at a university hospital outpatient psychiatry clinic.

At the clinic, Mr. A begins psychodynamic psychotherapy with a female resident physician. They establish a good rapport. Mr. A begins working through his past traumas and looks forward to his therapy sessions. The physician views this as positive transference, perhaps because her personality style and appearance are similar to that of Mr. A’s mother. She also often notes a positive counter­transference during sessions; Mr. A seemingly reminds her of her father in personality and appearance. Perhaps due to this positive transference/positive countertransference dynamic, Mr. A feels comfortable with having his medication regimen simplified after years of unsuccessful medication trials and a course of electroconvulsive therapy. His regimen soon consists of only a selective serotonin reuptake inhibitor and a glutamate modulator as an adjunct for anxiety. Psychotherapy sessions remain the mainstay of his treatment plan. Mr. A’s mood and anxiety improve significantly over a short time.

CASE 2

Ms. G, age 24, is admitted to a partial hospitalization program (PHP). Her diagnoses include seasonal affective disorder, anxiety, and attention-deficit/hyperactivity disorder (ADHD); she might have a genetic disposition to bipolar disorder. Ms. G recently had attempted suicide and was discharged from an inpatient unit. She is a middle child and was raised by emotionally and verbally abusive parents in a tumultuous household. Her father rarely kept a job for more than a few months, displayed rage, and lacked empathy. Ms. G feels unloved by her mother and says that her mother is emotionally unstable. Upon admission to the PHP, Ms. G is quick to question the credentials of every staff member she meets, and suggests the abuse and lack of trust she had experienced during her formative years have made her aggressive and paranoid.

Continue to: Since her teens...

Since her teens, Ms. G had received treatment for ADHD with various stimulant and nonstimulant medications that were prescribed by an outpatient psychiatrist. During her sophomore year of college, she was also prescribed medications for depression and anxiety. Ms. G speaks very highly of and praises the skill of her previous psychiatrist while voicing concerns about having to see new clinicians in the PHP. She had recently seen a therapist who moved out of state after a few sessions. Ms. G has abandonment fears and appears to react with anger toward new clinicians.

A negative transference towards Ms. G’s treatment team and the PHP as a whole are evident during the first week. She skips most group therapy sessions and criticizes the clinicians’ skills and training as ineffective. When her psychiatrist recommends changes in medication, she initially argues. She eventually agrees to take a new medication but soon reports intolerable adverse effects, which suggests negative transference toward the psychiatrist as an authority figure, and toward the medication as an extension of the psychiatrist. The treatment team also interprets this as nocebo effect. Ms. G engages in “splitting” by complaining about her psychiatrist to her therapist. The psychiatrist resents having been belittled. Ms. G demands to see a different psychiatrist, and when her demands are not met, she discharges herself from the PHP against medical advice. The treatment team interprets Ms. G’s resistance to treatment to have resulted from poor attachment during childhood and subsequent negative transference.

CASE 3

Ms. U, age 60, is seen at a local mental health center and diagnosed with major depressive disorder, likely resulting from grief and loss from her husband’s recent death. She was raised by her single mother and mostly absent father. Ms. U is a homemaker and had been married for more than 30 years. She participates in weekly psychotherapy with a young male psychiatrist, who prescribes an antidepressant. Ms. U is eager to please and makes every effort to be the perfect patient: she is always early for her appointments, takes her medications as prescribed, and frequently expresses her respect and appreciation for her psychiatrist. Within a few weeks, Ms. U’s depressive symptoms rapidly improve.

Ms. U is a talented and avid knit and crochet expert. At an appointment soon before Christmas, she gives her psychiatrist a pair of socks she knitted. While the gift is of little monetary value, the psychiatrist interprets this as part of transference, but the intimate nature of the gift makes him uncomfortable. He and Ms. U discuss this at length, which reveals definite transference as Ms. U says the psychiatrist perhaps reminds her of her husband, who also had brown skin. It is also apparent that Ms. U’s tendency to please perhaps comes from the lack of having a father figure, which her husband had fulfilled. The psychiatrist believes that Ms. U’s rapid response may be a placebo effect from positive transference. Upon further reflection, the psychiatrist realizes that Ms. U is a motherly figure to him, and that positive countertransference is at play in that he could not turn down the gift and had looked forward to the therapy sessions with her.

Bottom Line

Even clinicians who do not provide psychodynamic psychotherapy can use an awareness of psychodynamic factors to improve treatment. Psychodynamic factors such as transference and countertransference can influence the therapeutic alliance, treatment decisions, and patient outcomes. Patients’ experiences and difficulties with attachment during childhood should be recognized and addressed as part of pharmacotherapy.

Related Resources

• Neumann M, Silva N, Opler DJ. ARISE to supportive psychotherapy. Current Psychiatry. 2021;20(5):48-49. doi:10.12788/cp.0123
• Mintz D. Psychodynamic psychopharmacology. Psychiatric Times. 2011;28(9). https://www.psychiatrictimes.com/view/psychodynamic-psychopharmacology

Medical noncompliance and patient resistance to treatment are frequent problems in medical practice. According to an older report by the US Office of Inspector General, approximately 125,000 people die each year in the United States because they do not take their medication properly.¹ The World Health Organization reported that 10% to 25% of hospital and nursing home admissions are a result of patient noncompliance.² In addition, approximately 50% of prescriptions filled for chronic diseases in developed nations are not taken correctly, and up to 40% of patients do not adhere to their treatment regimens.² Among psychiatric patients, noncompliance with medications and other treatments ranges from 25% to 75%.³

In recent years, combining pharmacotherapy with psychodynamic psychotherapy has become a fairly common form of psychiatric practice. A main reason for combining these treatments is that a patient with severe psychiatric symptoms may be unable to engage in self-reflective insightful therapy until those symptoms are substantially relieved with pharmacotherapy. The efficacy of combined pharmacotherapy/psychotherapy may also be more than additive and result in a therapeutic alliance that is greater than the sum of the 2 individual treatments.⁴ Establishing a therapeutic alliance is critical to successful treatment, but this alliance can be distorted by the needs and expectations of both the patient and the clinician.

A psychodynamic understanding of the patient and the therapeutic alliance can facilitate combined treatment in several ways. It can lead to better communication, which in turn can lead to a realistic discussion of a patient’s fears and worries about any medications they have been prescribed. A dynamically aware clinician may better understand what the symptoms mean to the patient. Such clinicians will not only be able to explain the value of a medication, its target symptoms, and the rationale for taking it, but will also be able to discuss the psychological significance of the medication, along with its medical and biological significance.⁵

This article briefly reviews the therapeutic alliance and the influence of transference (the emotional reactions of the patient towards the clinician),⁶ countertransference (the emotional reactions of the clinician towards the patient),⁶ and patient resistance/nonadherence to treatment on the failure or success of pharmacotherapy. We provide case examples to illustrate how these psychodynamic factors can be at play in prescribing.

The therapeutic alliance

The therapeutic alliance is a rational agreement or contract between a patient and the clinician; it is a cornerstone of treatment in medicine.⁶ Its basic premise is that the patient’s rational expectation that their physician is appropriately qualified, will perform a suitable evaluation, and will prescribe relevant treatment is matched by the physician’s expectation that the patient will do their best to comply with treatment recommendations. For this to succeed, the contract needs to be straightforward, and there needs to be no covert agenda. A covert agenda may be in the form of unrealistic expectations and wishes rooted in insecure experiences in childhood by either party. A patient under stress may react to the physician with mistrust, excessive demands, and noncompliance. A physician under stress may react to a patient by becoming authoritative or indecisive, or by overmedicating or underprescribing.

Transference

Transference is a phenomenon whereby a patient’s feelings and attitudes are unconsciously transferred from a person or situation in the past to the clinician or treatment in the present.⁶ For example, a patient who is scared of a serious illness may adopt a helpless, childlike role and project an omnipotent, parentlike quality on the clinician (positive transference) that may be unrealistic. Positive transference may underlie a placebo response to medication in which a patient’s response is too quick or too complete, and it may be a way of unconsciously pleasing an authoritative parent figure from childhood. On the other hand, a patient may unconsciously view their physician as a controlling parent (negative transference) and react angrily or rebelliously. A patient’s flirtatious behavior toward their physician may be a form of transference from unresolved sexual trauma during childhood. However, not all patient reactions should be considered transference; a patient may be appropriately thankful and deferential, or irritated and questioning, depending on the clinician’s demeanor and treatment approach.

Countertransference

Countertransference is the response elicited in the physician by a patient’s appearance and behaviors, or by a patient’s transference projections.⁶ This response can be positive or negative and includes both feelings and associated thoughts related to the physician’s past experiences. For example, a physician in the emergency department may get angry with a patient with an alcohol use disorder because of the physician’s negative experiences with an alcoholic parent during childhood. On the other hand, a physician raised by a compulsive mother may order unnecessary tests on a demanding older female patient. Or, a clinician raised by a sheltering parent may react to a hapless and dependent patient by spending excessive time with them or providing additional medication samples. However, not all clinician reactions are countertransference. For example, a physician’s empathic or stoic demeanor may be an appropriate emotional response to a patient’s diagnosis such as cancer.

Continue to: Patient resistance/nonadherence

In 1920, Freud conceptualized the psychodynamic factors in patient resistance to treatment and theorized that many patients were unconsciously reluctant to give up their symptoms or were driven, for transference reasons, to resist the physician.⁷ This same concept may underlie patient resistance to pharmacotherapy. When symptoms constitute an important defense mechanism, patients are likely to resist medication effects until they have developed more mature defenses or more effective ways of coping.⁸ Even when patients do not resist symptom relief, they may still resist the physician’s choice of treatment due to negative transference. Such patients often negotiate the type of medication, dose, timing of the dose, and start date as a way of trying to “keep control” of a “doctor they don’t quite trust.”⁸ They may manage their own medication regimen by taking more or less than the prescribed dose. This resistance might lead to a “nocebo” effect in which a medication trial fails not because of its ineffectiveness but instead from the unconscious mind influencing the patient’s body to resist. Nonadherence to treatment may occur in patients who have attachment difficulties that make it difficult for them to trust anyone as a result of negative childhood experiences.⁹ Clinicians need to recognize the dynamics of power struggles, control, and trust. A warm, collaborative and cooperative stance is likely to be more beneficial than an authoritative and detached approach.¹⁰

The following 3 case examples illustrate how psychodynamic factors such as transference and countertransference can influence the therapeutic alliance, treatment decisions, and the outcomes of pharmacotherapy.

CASE 1

Mr. A, age 63, has posttraumatic stress disorder originating from his father’s death by a self-inflicted gunshot wound when Mr. A was 19, and later from the symbolic loss of his mother when she remarried. He reported vivid memories of his father sexually assaulting his mother when he was 6. This fostered a protective nature in him for his mother, as well as for his 3 younger siblings. After his father’s suicide, Mr. A had to take on a paternal role for his 3 siblings. He often feels he grew up too quickly, and resents this. He feels his mother betrayed him when she got remarried. Mr. A attempts suicide, is admitted to a local hospital, and then follows up at a university hospital outpatient psychiatry clinic.

At the clinic, Mr. A begins psychodynamic psychotherapy with a female resident physician. They establish a good rapport. Mr. A begins working through his past traumas and looks forward to his therapy sessions. The physician views this as positive transference, perhaps because her personality style and appearance are similar to that of Mr. A’s mother. She also often notes a positive counter­transference during sessions; Mr. A seemingly reminds her of her father in personality and appearance. Perhaps due to this positive transference/positive countertransference dynamic, Mr. A feels comfortable with having his medication regimen simplified after years of unsuccessful medication trials and a course of electroconvulsive therapy. His regimen soon consists of only a selective serotonin reuptake inhibitor and a glutamate modulator as an adjunct for anxiety. Psychotherapy sessions remain the mainstay of his treatment plan. Mr. A’s mood and anxiety improve significantly over a short time.

CASE 2

Ms. G, age 24, is admitted to a partial hospitalization program (PHP). Her diagnoses include seasonal affective disorder, anxiety, and attention-deficit/hyperactivity disorder (ADHD); she might have a genetic disposition to bipolar disorder. Ms. G recently had attempted suicide and was discharged from an inpatient unit. She is a middle child and was raised by emotionally and verbally abusive parents in a tumultuous household. Her father rarely kept a job for more than a few months, displayed rage, and lacked empathy. Ms. G feels unloved by her mother and says that her mother is emotionally unstable. Upon admission to the PHP, Ms. G is quick to question the credentials of every staff member she meets, and suggests the abuse and lack of trust she had experienced during her formative years have made her aggressive and paranoid.

Continue to: Since her teens...

Since her teens, Ms. G had received treatment for ADHD with various stimulant and nonstimulant medications that were prescribed by an outpatient psychiatrist. During her sophomore year of college, she was also prescribed medications for depression and anxiety. Ms. G speaks very highly of and praises the skill of her previous psychiatrist while voicing concerns about having to see new clinicians in the PHP. She had recently seen a therapist who moved out of state after a few sessions. Ms. G has abandonment fears and appears to react with anger toward new clinicians.

A negative transference towards Ms. G’s treatment team and the PHP as a whole are evident during the first week. She skips most group therapy sessions and criticizes the clinicians’ skills and training as ineffective. When her psychiatrist recommends changes in medication, she initially argues. She eventually agrees to take a new medication but soon reports intolerable adverse effects, which suggests negative transference toward the psychiatrist as an authority figure, and toward the medication as an extension of the psychiatrist. The treatment team also interprets this as nocebo effect. Ms. G engages in “splitting” by complaining about her psychiatrist to her therapist. The psychiatrist resents having been belittled. Ms. G demands to see a different psychiatrist, and when her demands are not met, she discharges herself from the PHP against medical advice. The treatment team interprets Ms. G’s resistance to treatment to have resulted from poor attachment during childhood and subsequent negative transference.

CASE 3

Ms. U, age 60, is seen at a local mental health center and diagnosed with major depressive disorder, likely resulting from grief and loss from her husband’s recent death. She was raised by her single mother and mostly absent father. Ms. U is a homemaker and had been married for more than 30 years. She participates in weekly psychotherapy with a young male psychiatrist, who prescribes an antidepressant. Ms. U is eager to please and makes every effort to be the perfect patient: she is always early for her appointments, takes her medications as prescribed, and frequently expresses her respect and appreciation for her psychiatrist. Within a few weeks, Ms. U’s depressive symptoms rapidly improve.

Ms. U is a talented and avid knit and crochet expert. At an appointment soon before Christmas, she gives her psychiatrist a pair of socks she knitted. While the gift is of little monetary value, the psychiatrist interprets this as part of transference, but the intimate nature of the gift makes him uncomfortable. He and Ms. U discuss this at length, which reveals definite transference as Ms. U says the psychiatrist perhaps reminds her of her husband, who also had brown skin. It is also apparent that Ms. U’s tendency to please perhaps comes from the lack of having a father figure, which her husband had fulfilled. The psychiatrist believes that Ms. U’s rapid response may be a placebo effect from positive transference. Upon further reflection, the psychiatrist realizes that Ms. U is a motherly figure to him, and that positive countertransference is at play in that he could not turn down the gift and had looked forward to the therapy sessions with her.

Bottom Line

Even clinicians who do not provide psychodynamic psychotherapy can use an awareness of psychodynamic factors to improve treatment. Psychodynamic factors such as transference and countertransference can influence the therapeutic alliance, treatment decisions, and patient outcomes. Patients’ experiences and difficulties with attachment during childhood should be recognized and addressed as part of pharmacotherapy.

Related Resources

• Neumann M, Silva N, Opler DJ. ARISE to supportive psychotherapy. Current Psychiatry. 2021;20(5):48-49. doi:10.12788/cp.0123
• Mintz D. Psychodynamic psychopharmacology. Psychiatric Times. 2011;28(9). https://www.psychiatrictimes.com/view/psychodynamic-psychopharmacology

Medical noncompliance and patient resistance to treatment are frequent problems in medical practice. According to an older report by the US Office of Inspector General, approximately 125,000 people die each year in the United States because they do not take their medication properly.¹ The World Health Organization reported that 10% to 25% of hospital and nursing home admissions are a result of patient noncompliance.² In addition, approximately 50% of prescriptions filled for chronic diseases in developed nations are not taken correctly, and up to 40% of patients do not adhere to their treatment regimens.² Among psychiatric patients, noncompliance with medications and other treatments ranges from 25% to 75%.³

In recent years, combining pharmacotherapy with psychodynamic psychotherapy has become a fairly common form of psychiatric practice. A main reason for combining these treatments is that a patient with severe psychiatric symptoms may be unable to engage in self-reflective insightful therapy until those symptoms are substantially relieved with pharmacotherapy. The efficacy of combined pharmacotherapy/psychotherapy may also be more than additive and result in a therapeutic alliance that is greater than the sum of the 2 individual treatments.⁴ Establishing a therapeutic alliance is critical to successful treatment, but this alliance can be distorted by the needs and expectations of both the patient and the clinician.

A psychodynamic understanding of the patient and the therapeutic alliance can facilitate combined treatment in several ways. It can lead to better communication, which in turn can lead to a realistic discussion of a patient’s fears and worries about any medications they have been prescribed. A dynamically aware clinician may better understand what the symptoms mean to the patient. Such clinicians will not only be able to explain the value of a medication, its target symptoms, and the rationale for taking it, but will also be able to discuss the psychological significance of the medication, along with its medical and biological significance.⁵

This article briefly reviews the therapeutic alliance and the influence of transference (the emotional reactions of the patient towards the clinician),⁶ countertransference (the emotional reactions of the clinician towards the patient),⁶ and patient resistance/nonadherence to treatment on the failure or success of pharmacotherapy. We provide case examples to illustrate how these psychodynamic factors can be at play in prescribing.

The therapeutic alliance

The therapeutic alliance is a rational agreement or contract between a patient and the clinician; it is a cornerstone of treatment in medicine.⁶ Its basic premise is that the patient’s rational expectation that their physician is appropriately qualified, will perform a suitable evaluation, and will prescribe relevant treatment is matched by the physician’s expectation that the patient will do their best to comply with treatment recommendations. For this to succeed, the contract needs to be straightforward, and there needs to be no covert agenda. A covert agenda may be in the form of unrealistic expectations and wishes rooted in insecure experiences in childhood by either party. A patient under stress may react to the physician with mistrust, excessive demands, and noncompliance. A physician under stress may react to a patient by becoming authoritative or indecisive, or by overmedicating or underprescribing.

Transference

Transference is a phenomenon whereby a patient’s feelings and attitudes are unconsciously transferred from a person or situation in the past to the clinician or treatment in the present.⁶ For example, a patient who is scared of a serious illness may adopt a helpless, childlike role and project an omnipotent, parentlike quality on the clinician (positive transference) that may be unrealistic. Positive transference may underlie a placebo response to medication in which a patient’s response is too quick or too complete, and it may be a way of unconsciously pleasing an authoritative parent figure from childhood. On the other hand, a patient may unconsciously view their physician as a controlling parent (negative transference) and react angrily or rebelliously. A patient’s flirtatious behavior toward their physician may be a form of transference from unresolved sexual trauma during childhood. However, not all patient reactions should be considered transference; a patient may be appropriately thankful and deferential, or irritated and questioning, depending on the clinician’s demeanor and treatment approach.

Countertransference

Countertransference is the response elicited in the physician by a patient’s appearance and behaviors, or by a patient’s transference projections.⁶ This response can be positive or negative and includes both feelings and associated thoughts related to the physician’s past experiences. For example, a physician in the emergency department may get angry with a patient with an alcohol use disorder because of the physician’s negative experiences with an alcoholic parent during childhood. On the other hand, a physician raised by a compulsive mother may order unnecessary tests on a demanding older female patient. Or, a clinician raised by a sheltering parent may react to a hapless and dependent patient by spending excessive time with them or providing additional medication samples. However, not all clinician reactions are countertransference. For example, a physician’s empathic or stoic demeanor may be an appropriate emotional response to a patient’s diagnosis such as cancer.

Continue to: Patient resistance/nonadherence

In 1920, Freud conceptualized the psychodynamic factors in patient resistance to treatment and theorized that many patients were unconsciously reluctant to give up their symptoms or were driven, for transference reasons, to resist the physician.⁷ This same concept may underlie patient resistance to pharmacotherapy. When symptoms constitute an important defense mechanism, patients are likely to resist medication effects until they have developed more mature defenses or more effective ways of coping.⁸ Even when patients do not resist symptom relief, they may still resist the physician’s choice of treatment due to negative transference. Such patients often negotiate the type of medication, dose, timing of the dose, and start date as a way of trying to “keep control” of a “doctor they don’t quite trust.”⁸ They may manage their own medication regimen by taking more or less than the prescribed dose. This resistance might lead to a “nocebo” effect in which a medication trial fails not because of its ineffectiveness but instead from the unconscious mind influencing the patient’s body to resist. Nonadherence to treatment may occur in patients who have attachment difficulties that make it difficult for them to trust anyone as a result of negative childhood experiences.⁹ Clinicians need to recognize the dynamics of power struggles, control, and trust. A warm, collaborative and cooperative stance is likely to be more beneficial than an authoritative and detached approach.¹⁰

The following 3 case examples illustrate how psychodynamic factors such as transference and countertransference can influence the therapeutic alliance, treatment decisions, and the outcomes of pharmacotherapy.

CASE 1

Mr. A, age 63, has posttraumatic stress disorder originating from his father’s death by a self-inflicted gunshot wound when Mr. A was 19, and later from the symbolic loss of his mother when she remarried. He reported vivid memories of his father sexually assaulting his mother when he was 6. This fostered a protective nature in him for his mother, as well as for his 3 younger siblings. After his father’s suicide, Mr. A had to take on a paternal role for his 3 siblings. He often feels he grew up too quickly, and resents this. He feels his mother betrayed him when she got remarried. Mr. A attempts suicide, is admitted to a local hospital, and then follows up at a university hospital outpatient psychiatry clinic.

At the clinic, Mr. A begins psychodynamic psychotherapy with a female resident physician. They establish a good rapport. Mr. A begins working through his past traumas and looks forward to his therapy sessions. The physician views this as positive transference, perhaps because her personality style and appearance are similar to that of Mr. A’s mother. She also often notes a positive counter­transference during sessions; Mr. A seemingly reminds her of her father in personality and appearance. Perhaps due to this positive transference/positive countertransference dynamic, Mr. A feels comfortable with having his medication regimen simplified after years of unsuccessful medication trials and a course of electroconvulsive therapy. His regimen soon consists of only a selective serotonin reuptake inhibitor and a glutamate modulator as an adjunct for anxiety. Psychotherapy sessions remain the mainstay of his treatment plan. Mr. A’s mood and anxiety improve significantly over a short time.

CASE 2

Ms. G, age 24, is admitted to a partial hospitalization program (PHP). Her diagnoses include seasonal affective disorder, anxiety, and attention-deficit/hyperactivity disorder (ADHD); she might have a genetic disposition to bipolar disorder. Ms. G recently had attempted suicide and was discharged from an inpatient unit. She is a middle child and was raised by emotionally and verbally abusive parents in a tumultuous household. Her father rarely kept a job for more than a few months, displayed rage, and lacked empathy. Ms. G feels unloved by her mother and says that her mother is emotionally unstable. Upon admission to the PHP, Ms. G is quick to question the credentials of every staff member she meets, and suggests the abuse and lack of trust she had experienced during her formative years have made her aggressive and paranoid.

Continue to: Since her teens...

Since her teens, Ms. G had received treatment for ADHD with various stimulant and nonstimulant medications that were prescribed by an outpatient psychiatrist. During her sophomore year of college, she was also prescribed medications for depression and anxiety. Ms. G speaks very highly of and praises the skill of her previous psychiatrist while voicing concerns about having to see new clinicians in the PHP. She had recently seen a therapist who moved out of state after a few sessions. Ms. G has abandonment fears and appears to react with anger toward new clinicians.

A negative transference towards Ms. G’s treatment team and the PHP as a whole are evident during the first week. She skips most group therapy sessions and criticizes the clinicians’ skills and training as ineffective. When her psychiatrist recommends changes in medication, she initially argues. She eventually agrees to take a new medication but soon reports intolerable adverse effects, which suggests negative transference toward the psychiatrist as an authority figure, and toward the medication as an extension of the psychiatrist. The treatment team also interprets this as nocebo effect. Ms. G engages in “splitting” by complaining about her psychiatrist to her therapist. The psychiatrist resents having been belittled. Ms. G demands to see a different psychiatrist, and when her demands are not met, she discharges herself from the PHP against medical advice. The treatment team interprets Ms. G’s resistance to treatment to have resulted from poor attachment during childhood and subsequent negative transference.

CASE 3

Ms. U, age 60, is seen at a local mental health center and diagnosed with major depressive disorder, likely resulting from grief and loss from her husband’s recent death. She was raised by her single mother and mostly absent father. Ms. U is a homemaker and had been married for more than 30 years. She participates in weekly psychotherapy with a young male psychiatrist, who prescribes an antidepressant. Ms. U is eager to please and makes every effort to be the perfect patient: she is always early for her appointments, takes her medications as prescribed, and frequently expresses her respect and appreciation for her psychiatrist. Within a few weeks, Ms. U’s depressive symptoms rapidly improve.

Ms. U is a talented and avid knit and crochet expert. At an appointment soon before Christmas, she gives her psychiatrist a pair of socks she knitted. While the gift is of little monetary value, the psychiatrist interprets this as part of transference, but the intimate nature of the gift makes him uncomfortable. He and Ms. U discuss this at length, which reveals definite transference as Ms. U says the psychiatrist perhaps reminds her of her husband, who also had brown skin. It is also apparent that Ms. U’s tendency to please perhaps comes from the lack of having a father figure, which her husband had fulfilled. The psychiatrist believes that Ms. U’s rapid response may be a placebo effect from positive transference. Upon further reflection, the psychiatrist realizes that Ms. U is a motherly figure to him, and that positive countertransference is at play in that he could not turn down the gift and had looked forward to the therapy sessions with her.

Bottom Line

Even clinicians who do not provide psychodynamic psychotherapy can use an awareness of psychodynamic factors to improve treatment. Psychodynamic factors such as transference and countertransference can influence the therapeutic alliance, treatment decisions, and patient outcomes. Patients’ experiences and difficulties with attachment during childhood should be recognized and addressed as part of pharmacotherapy.

Related Resources

• Neumann M, Silva N, Opler DJ. ARISE to supportive psychotherapy. Current Psychiatry. 2021;20(5):48-49. doi:10.12788/cp.0123
• Mintz D. Psychodynamic psychopharmacology. Psychiatric Times. 2011;28(9). https://www.psychiatrictimes.com/view/psychodynamic-psychopharmacology

Psychiatric partial hospitalization programs (PHPs), previously known as “day hospitals,” serve to bridge the gap between inpatient and outpatient facilities by providing intensive, highly structured outpatient behavioral health services (typically several hours of psychotherapy each weekday for most days of the week). The concept of PHPs has existed since at least the 1950s, but such programs started to become more common in the United States as the result of legislation passed in 1963 (Box^1-3). In this article, I provide a brief introductory review of PHPs, while acknowledging that most research on PHPs was conducted years ago and is rather limited.

Box

PHPs: What they are, and how they work

The term “partial hospitalization” is fraught with confusion because initially it was used to contrast such services from full hospitalization. Historically, it was used to describe services for patients who had been discharged home from a state hospital and attended a program on the hospital grounds during the day as outpatients. In reality, today’s PHPs are “day treatment” programs, but the terminology has stuck.

PHPs are neither an inpatient service nor a strict outpatient service, but rather a midground along the continuum of treatment intensity between the 2 traditional types of psychiatric services for patients with a range of mental illness of varying severity. The Association for Ambulatory Behavioral Healthcare, which has set standards and guidelines for PHPs, defines a PHP as “an ambulatory treatment program that includes the major diagnostic, medical, psychiatric, psychosocial, and prevocational treatment modalities designed for patients with serious mental disorders who require coordinated intensive, comprehensive, and multidisciplinary treatment not provided in an outpatient clinical setting.”⁴ PHPs can render acute care as an alternative to inpatient treatment, provide transitional stabilization treatment between an inpatient stay and traditional outpatient treatment (once a week or less frequent), and function as a supplement to traditional outpatient treatment.

Medicare has established criteria that PHPs must meet to qualify for reimbursement⁵; these criteria are now widely accepted as standards of care by the insurance industry. To meet the Medicare criteria, PHP treatment must be active and structured to provide an individualized treatment plan that incorporates coordination of services to meet the particular needs of the patient.⁵ It must include a multidisciplinary team approach to patient care under the direction of a physician, and the treatment goals must be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.⁵ The physician must certify the medical necessity for admission by documenting that the patient has a diagnosis of an acute Axis I mental disorder, a level of functioning that includes severe impairments in multiple areas of daily life, and a “reasonable expectation” that the disorder and level of functioning will improve as a result of the treatment.⁵

The Joint Commission (formerly JCAHO) lumps day treatment, intensive outpatient, partial hospitalization, and adult day care services into a single category of an ambulatory health care environment offering an organized day or night program of assessment, treatment, care, services, habilitation, or rehabilitation for individuals who do not require 24-hour care.⁶ For behavioral health, this may be a structured, ongoing program that typically meets 2 to 5 times a week for 2 to 5 hours per day.⁶

Most PHPs for adult patients provide services during the day 5 days per week and average 5 to 6 hours of programming per day. Night or evening programming may be a good option for patients who work during the day. Typically, treatment is provided in a group therapy format, with individual therapy at least once a week. Group therapy may include cognitive-behavioral therapy, coping with grief and loss, trauma recovery, conflict resolution, stress management, anger control, and behavioral modification. Family therapy is provided as needed, but usually is mandatory for children and adolescents. Many PHPs offer intensive outpatient programs (IOPs) as a step down to further facilitate a patient’s adjustment to psychosocial and family functioning while returning to work on a part-time basis. IOPs typically provide 3 to 4 hours of service per day 3 days per week. While not evidence-based, the typical duration of PHP treatment is 4 to 6 weeks, followed by an additional 2 to 4 weeks of IOP.

Continue to: Advantages and disadvantages...

Based on a qualitative literature review, Neffinger¹ outlined potential advantages and disadvantages of PHPs vs inpatient hospitalization (Table¹). While these have not been empirically studied, they may be useful to consider when determining if a PHP would be beneficial for a specific patient.

Which factors are most therapeutic?

Research on which factors of PHPs are of therapeutic value is quite limited and primarily consists of surveys of small numbers of participants. Hoge et al⁷ explored the active therapeutic factors responsible for change in the Connecticut Mental Health Center PHP by comparing responses of 20 patients with those of their clinicians. Ninety-five percent of patients rated structure as the top therapeutic factor, followed by interpersonal contact, medication, and altruism. Other factors that were rated as important by 40% or fewer participants were catharsis, learning, mobilization of family support, connection to community, universality, patient autonomy, successful completion, security, feedback on behavior, and practice at home. In a British study⁸ that used a similar method, patients reported that counseling was the most helpful aspect of treatment, followed by medical treatment, while staff picked groups followed by a planned approach.

Evidence supports PHPs’ effectiveness

Some research has suggested that PHPs can be effective, both clinically and in terms of cost. Marshall et al⁹ conducted a systematic review of the effectiveness of an acute day hospital vs inpatient admission vs outpatient care that included 9 trials. They concluded that psychiatric inpatient admissions could be reduced by at least 23% if patients were diverted to an acute day hospital. They also found some evidence that day treatment programs may be superior to outpatient care in improving symptoms in nonpsychotic patients who are refractory to outpatient treatment. In a systematic review of 18 studies, high rates of satisfaction with PHP services suggested PHPs have an advantage over inpatient treatment within 1 year of discharge; patients and families were more satisfied with PHPs.¹⁰ In a study of 197 urban, socioeconomically disadvantaged, severely ill patients, Sledge et al¹¹ compared the clinical outcomes of those who participated in day hospital programs with those of patients who received inpatient care. They found that while overall the 2 approaches produced similar outcomes, there were slightly more positive effects for day hospital programs in measures of symptoms, overall functioning, and social functioning. In terms of cost effectiveness, a 1978 study found that even after correcting for differences in treatment days between inpatient and PHP services, there was a significant financial advantage with PHP (costs were one-third less), primarily because of lower costs per day.¹² In another study, PHP cost savings were 20%, and potential savings were higher for nonpsychotic patients.¹³

Are PHPs appropriate for children and adolescents?

Studies of PHPs for adolescents found that patients made gains in peer relationships, behavioral and academic performance, and control of their emotions.^14,15 A review of PHPs’ effectiveness for children suggested that 66% to 99% of treated patients demonstrated improvement and successful return to community-based schools, and family functioning was a major factor in improvement.¹⁴ In a follow-up study that surveyed patients via telephone >1 year after discharge from a PHP, almost 80% of the children and adolescents were either “doing OK” or were “well-adjusted.”¹⁴ Only 22.5% required inpatient or residential treatment; the majority were doing well in school, with only 7% failing.¹⁴ In addition, 60% of parents reported satisfaction with treatment, and 85% reported functional improvement in their children.¹⁴

Factors that predict PHP success or failure

In an analysis of a day treatment program that provided 4 months of intensive psychodynamic, group-oriented milieu treatment for patients with long-standing personality disorders, Rosie et al¹⁶ found 3 factors that contributed to the success of the PHP:

• optimal treatment-patient matching
• judicious use of authority in milieu therapy
• maintaining close relationships with referral sources.

In a study that compared 58 patients who completed an Ottawa hospital PHP and 44 who did not complete the program, psychological mindedness and chronicity of psychiatric illness were found to predict completion.¹⁷ However, a study of 59 females with anorexia nervosa who were transferred from inpatient care to an eating disorder day hospital program found that a longer duration of illness, amenorrhea, and a lower body mass index were associated with PHP treatment failure and inpatient rehospitalization.¹⁸ One study found that for individuals who were referred to a PHP from inpatient care, suicidal ideation and greater psychotic symptoms were associated with acute inpatient rehospitalization.¹⁹ Other factors associated with PHP nonattendance and treatment failure include limited personal and economic resources, high rates of substance abuse disorders, multiple admissions, and disability.²⁰ In a study of 103 alcohol-dependent patients who completed IOP treatment, 64% were abstinent at 6 months follow-up; relapse was associated with a longer duration of alcohol dependence and a higher number of prior treatments, while favorable outcomes were associated with a lower degree of depression, anxiety, and craving.²¹ Patients with cocaine dependence who completed an IOP showed significant improvements in addiction scores and had more favorable outcomes in employment status and psychological problems if they stayed longer in treatment.²²

Bottom Line

Psychiatric partial hospitalization programs (PHPs) provide a transition from inpatient hospitalization to outpatient treatment for patients who need further stabilization, or serve as an alternative to inpatient treatment for patients who don’t need or want inpatient hospitalization. PHPs can be as effective as inpatient treatment for all but the most seriously ill patients, and are more cost-effective than inpatient treatment.

Psychiatric partial hospitalization programs (PHPs), previously known as “day hospitals,” serve to bridge the gap between inpatient and outpatient facilities by providing intensive, highly structured outpatient behavioral health services (typically several hours of psychotherapy each weekday for most days of the week). The concept of PHPs has existed since at least the 1950s, but such programs started to become more common in the United States as the result of legislation passed in 1963 (Box^1-3). In this article, I provide a brief introductory review of PHPs, while acknowledging that most research on PHPs was conducted years ago and is rather limited.

Box

PHPs: What they are, and how they work

The term “partial hospitalization” is fraught with confusion because initially it was used to contrast such services from full hospitalization. Historically, it was used to describe services for patients who had been discharged home from a state hospital and attended a program on the hospital grounds during the day as outpatients. In reality, today’s PHPs are “day treatment” programs, but the terminology has stuck.

PHPs are neither an inpatient service nor a strict outpatient service, but rather a midground along the continuum of treatment intensity between the 2 traditional types of psychiatric services for patients with a range of mental illness of varying severity. The Association for Ambulatory Behavioral Healthcare, which has set standards and guidelines for PHPs, defines a PHP as “an ambulatory treatment program that includes the major diagnostic, medical, psychiatric, psychosocial, and prevocational treatment modalities designed for patients with serious mental disorders who require coordinated intensive, comprehensive, and multidisciplinary treatment not provided in an outpatient clinical setting.”⁴ PHPs can render acute care as an alternative to inpatient treatment, provide transitional stabilization treatment between an inpatient stay and traditional outpatient treatment (once a week or less frequent), and function as a supplement to traditional outpatient treatment.

Medicare has established criteria that PHPs must meet to qualify for reimbursement⁵; these criteria are now widely accepted as standards of care by the insurance industry. To meet the Medicare criteria, PHP treatment must be active and structured to provide an individualized treatment plan that incorporates coordination of services to meet the particular needs of the patient.⁵ It must include a multidisciplinary team approach to patient care under the direction of a physician, and the treatment goals must be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.⁵ The physician must certify the medical necessity for admission by documenting that the patient has a diagnosis of an acute Axis I mental disorder, a level of functioning that includes severe impairments in multiple areas of daily life, and a “reasonable expectation” that the disorder and level of functioning will improve as a result of the treatment.⁵

The Joint Commission (formerly JCAHO) lumps day treatment, intensive outpatient, partial hospitalization, and adult day care services into a single category of an ambulatory health care environment offering an organized day or night program of assessment, treatment, care, services, habilitation, or rehabilitation for individuals who do not require 24-hour care.⁶ For behavioral health, this may be a structured, ongoing program that typically meets 2 to 5 times a week for 2 to 5 hours per day.⁶

Most PHPs for adult patients provide services during the day 5 days per week and average 5 to 6 hours of programming per day. Night or evening programming may be a good option for patients who work during the day. Typically, treatment is provided in a group therapy format, with individual therapy at least once a week. Group therapy may include cognitive-behavioral therapy, coping with grief and loss, trauma recovery, conflict resolution, stress management, anger control, and behavioral modification. Family therapy is provided as needed, but usually is mandatory for children and adolescents. Many PHPs offer intensive outpatient programs (IOPs) as a step down to further facilitate a patient’s adjustment to psychosocial and family functioning while returning to work on a part-time basis. IOPs typically provide 3 to 4 hours of service per day 3 days per week. While not evidence-based, the typical duration of PHP treatment is 4 to 6 weeks, followed by an additional 2 to 4 weeks of IOP.

Continue to: Advantages and disadvantages...

Based on a qualitative literature review, Neffinger¹ outlined potential advantages and disadvantages of PHPs vs inpatient hospitalization (Table¹). While these have not been empirically studied, they may be useful to consider when determining if a PHP would be beneficial for a specific patient.

Which factors are most therapeutic?

Research on which factors of PHPs are of therapeutic value is quite limited and primarily consists of surveys of small numbers of participants. Hoge et al⁷ explored the active therapeutic factors responsible for change in the Connecticut Mental Health Center PHP by comparing responses of 20 patients with those of their clinicians. Ninety-five percent of patients rated structure as the top therapeutic factor, followed by interpersonal contact, medication, and altruism. Other factors that were rated as important by 40% or fewer participants were catharsis, learning, mobilization of family support, connection to community, universality, patient autonomy, successful completion, security, feedback on behavior, and practice at home. In a British study⁸ that used a similar method, patients reported that counseling was the most helpful aspect of treatment, followed by medical treatment, while staff picked groups followed by a planned approach.

Evidence supports PHPs’ effectiveness

Some research has suggested that PHPs can be effective, both clinically and in terms of cost. Marshall et al⁹ conducted a systematic review of the effectiveness of an acute day hospital vs inpatient admission vs outpatient care that included 9 trials. They concluded that psychiatric inpatient admissions could be reduced by at least 23% if patients were diverted to an acute day hospital. They also found some evidence that day treatment programs may be superior to outpatient care in improving symptoms in nonpsychotic patients who are refractory to outpatient treatment. In a systematic review of 18 studies, high rates of satisfaction with PHP services suggested PHPs have an advantage over inpatient treatment within 1 year of discharge; patients and families were more satisfied with PHPs.¹⁰ In a study of 197 urban, socioeconomically disadvantaged, severely ill patients, Sledge et al¹¹ compared the clinical outcomes of those who participated in day hospital programs with those of patients who received inpatient care. They found that while overall the 2 approaches produced similar outcomes, there were slightly more positive effects for day hospital programs in measures of symptoms, overall functioning, and social functioning. In terms of cost effectiveness, a 1978 study found that even after correcting for differences in treatment days between inpatient and PHP services, there was a significant financial advantage with PHP (costs were one-third less), primarily because of lower costs per day.¹² In another study, PHP cost savings were 20%, and potential savings were higher for nonpsychotic patients.¹³

Are PHPs appropriate for children and adolescents?

Studies of PHPs for adolescents found that patients made gains in peer relationships, behavioral and academic performance, and control of their emotions.^14,15 A review of PHPs’ effectiveness for children suggested that 66% to 99% of treated patients demonstrated improvement and successful return to community-based schools, and family functioning was a major factor in improvement.¹⁴ In a follow-up study that surveyed patients via telephone >1 year after discharge from a PHP, almost 80% of the children and adolescents were either “doing OK” or were “well-adjusted.”¹⁴ Only 22.5% required inpatient or residential treatment; the majority were doing well in school, with only 7% failing.¹⁴ In addition, 60% of parents reported satisfaction with treatment, and 85% reported functional improvement in their children.¹⁴

Factors that predict PHP success or failure

In an analysis of a day treatment program that provided 4 months of intensive psychodynamic, group-oriented milieu treatment for patients with long-standing personality disorders, Rosie et al¹⁶ found 3 factors that contributed to the success of the PHP:

• optimal treatment-patient matching
• judicious use of authority in milieu therapy
• maintaining close relationships with referral sources.

In a study that compared 58 patients who completed an Ottawa hospital PHP and 44 who did not complete the program, psychological mindedness and chronicity of psychiatric illness were found to predict completion.¹⁷ However, a study of 59 females with anorexia nervosa who were transferred from inpatient care to an eating disorder day hospital program found that a longer duration of illness, amenorrhea, and a lower body mass index were associated with PHP treatment failure and inpatient rehospitalization.¹⁸ One study found that for individuals who were referred to a PHP from inpatient care, suicidal ideation and greater psychotic symptoms were associated with acute inpatient rehospitalization.¹⁹ Other factors associated with PHP nonattendance and treatment failure include limited personal and economic resources, high rates of substance abuse disorders, multiple admissions, and disability.²⁰ In a study of 103 alcohol-dependent patients who completed IOP treatment, 64% were abstinent at 6 months follow-up; relapse was associated with a longer duration of alcohol dependence and a higher number of prior treatments, while favorable outcomes were associated with a lower degree of depression, anxiety, and craving.²¹ Patients with cocaine dependence who completed an IOP showed significant improvements in addiction scores and had more favorable outcomes in employment status and psychological problems if they stayed longer in treatment.²²

Bottom Line

Psychiatric partial hospitalization programs (PHPs) provide a transition from inpatient hospitalization to outpatient treatment for patients who need further stabilization, or serve as an alternative to inpatient treatment for patients who don’t need or want inpatient hospitalization. PHPs can be as effective as inpatient treatment for all but the most seriously ill patients, and are more cost-effective than inpatient treatment.

Psychiatric partial hospitalization programs (PHPs), previously known as “day hospitals,” serve to bridge the gap between inpatient and outpatient facilities by providing intensive, highly structured outpatient behavioral health services (typically several hours of psychotherapy each weekday for most days of the week). The concept of PHPs has existed since at least the 1950s, but such programs started to become more common in the United States as the result of legislation passed in 1963 (Box^1-3). In this article, I provide a brief introductory review of PHPs, while acknowledging that most research on PHPs was conducted years ago and is rather limited.

Box

PHPs: What they are, and how they work

The term “partial hospitalization” is fraught with confusion because initially it was used to contrast such services from full hospitalization. Historically, it was used to describe services for patients who had been discharged home from a state hospital and attended a program on the hospital grounds during the day as outpatients. In reality, today’s PHPs are “day treatment” programs, but the terminology has stuck.

PHPs are neither an inpatient service nor a strict outpatient service, but rather a midground along the continuum of treatment intensity between the 2 traditional types of psychiatric services for patients with a range of mental illness of varying severity. The Association for Ambulatory Behavioral Healthcare, which has set standards and guidelines for PHPs, defines a PHP as “an ambulatory treatment program that includes the major diagnostic, medical, psychiatric, psychosocial, and prevocational treatment modalities designed for patients with serious mental disorders who require coordinated intensive, comprehensive, and multidisciplinary treatment not provided in an outpatient clinical setting.”⁴ PHPs can render acute care as an alternative to inpatient treatment, provide transitional stabilization treatment between an inpatient stay and traditional outpatient treatment (once a week or less frequent), and function as a supplement to traditional outpatient treatment.

Medicare has established criteria that PHPs must meet to qualify for reimbursement⁵; these criteria are now widely accepted as standards of care by the insurance industry. To meet the Medicare criteria, PHP treatment must be active and structured to provide an individualized treatment plan that incorporates coordination of services to meet the particular needs of the patient.⁵ It must include a multidisciplinary team approach to patient care under the direction of a physician, and the treatment goals must be measurable, functional, time-framed, medically necessary, and directly related to the reason for admission.⁵ The physician must certify the medical necessity for admission by documenting that the patient has a diagnosis of an acute Axis I mental disorder, a level of functioning that includes severe impairments in multiple areas of daily life, and a “reasonable expectation” that the disorder and level of functioning will improve as a result of the treatment.⁵

The Joint Commission (formerly JCAHO) lumps day treatment, intensive outpatient, partial hospitalization, and adult day care services into a single category of an ambulatory health care environment offering an organized day or night program of assessment, treatment, care, services, habilitation, or rehabilitation for individuals who do not require 24-hour care.⁶ For behavioral health, this may be a structured, ongoing program that typically meets 2 to 5 times a week for 2 to 5 hours per day.⁶

Most PHPs for adult patients provide services during the day 5 days per week and average 5 to 6 hours of programming per day. Night or evening programming may be a good option for patients who work during the day. Typically, treatment is provided in a group therapy format, with individual therapy at least once a week. Group therapy may include cognitive-behavioral therapy, coping with grief and loss, trauma recovery, conflict resolution, stress management, anger control, and behavioral modification. Family therapy is provided as needed, but usually is mandatory for children and adolescents. Many PHPs offer intensive outpatient programs (IOPs) as a step down to further facilitate a patient’s adjustment to psychosocial and family functioning while returning to work on a part-time basis. IOPs typically provide 3 to 4 hours of service per day 3 days per week. While not evidence-based, the typical duration of PHP treatment is 4 to 6 weeks, followed by an additional 2 to 4 weeks of IOP.

Continue to: Advantages and disadvantages...

Based on a qualitative literature review, Neffinger¹ outlined potential advantages and disadvantages of PHPs vs inpatient hospitalization (Table¹). While these have not been empirically studied, they may be useful to consider when determining if a PHP would be beneficial for a specific patient.

Which factors are most therapeutic?

Research on which factors of PHPs are of therapeutic value is quite limited and primarily consists of surveys of small numbers of participants. Hoge et al⁷ explored the active therapeutic factors responsible for change in the Connecticut Mental Health Center PHP by comparing responses of 20 patients with those of their clinicians. Ninety-five percent of patients rated structure as the top therapeutic factor, followed by interpersonal contact, medication, and altruism. Other factors that were rated as important by 40% or fewer participants were catharsis, learning, mobilization of family support, connection to community, universality, patient autonomy, successful completion, security, feedback on behavior, and practice at home. In a British study⁸ that used a similar method, patients reported that counseling was the most helpful aspect of treatment, followed by medical treatment, while staff picked groups followed by a planned approach.

Evidence supports PHPs’ effectiveness

Some research has suggested that PHPs can be effective, both clinically and in terms of cost. Marshall et al⁹ conducted a systematic review of the effectiveness of an acute day hospital vs inpatient admission vs outpatient care that included 9 trials. They concluded that psychiatric inpatient admissions could be reduced by at least 23% if patients were diverted to an acute day hospital. They also found some evidence that day treatment programs may be superior to outpatient care in improving symptoms in nonpsychotic patients who are refractory to outpatient treatment. In a systematic review of 18 studies, high rates of satisfaction with PHP services suggested PHPs have an advantage over inpatient treatment within 1 year of discharge; patients and families were more satisfied with PHPs.¹⁰ In a study of 197 urban, socioeconomically disadvantaged, severely ill patients, Sledge et al¹¹ compared the clinical outcomes of those who participated in day hospital programs with those of patients who received inpatient care. They found that while overall the 2 approaches produced similar outcomes, there were slightly more positive effects for day hospital programs in measures of symptoms, overall functioning, and social functioning. In terms of cost effectiveness, a 1978 study found that even after correcting for differences in treatment days between inpatient and PHP services, there was a significant financial advantage with PHP (costs were one-third less), primarily because of lower costs per day.¹² In another study, PHP cost savings were 20%, and potential savings were higher for nonpsychotic patients.¹³

Are PHPs appropriate for children and adolescents?

Studies of PHPs for adolescents found that patients made gains in peer relationships, behavioral and academic performance, and control of their emotions.^14,15 A review of PHPs’ effectiveness for children suggested that 66% to 99% of treated patients demonstrated improvement and successful return to community-based schools, and family functioning was a major factor in improvement.¹⁴ In a follow-up study that surveyed patients via telephone >1 year after discharge from a PHP, almost 80% of the children and adolescents were either “doing OK” or were “well-adjusted.”¹⁴ Only 22.5% required inpatient or residential treatment; the majority were doing well in school, with only 7% failing.¹⁴ In addition, 60% of parents reported satisfaction with treatment, and 85% reported functional improvement in their children.¹⁴

Factors that predict PHP success or failure

In an analysis of a day treatment program that provided 4 months of intensive psychodynamic, group-oriented milieu treatment for patients with long-standing personality disorders, Rosie et al¹⁶ found 3 factors that contributed to the success of the PHP:

• optimal treatment-patient matching
• judicious use of authority in milieu therapy
• maintaining close relationships with referral sources.

In a study that compared 58 patients who completed an Ottawa hospital PHP and 44 who did not complete the program, psychological mindedness and chronicity of psychiatric illness were found to predict completion.¹⁷ However, a study of 59 females with anorexia nervosa who were transferred from inpatient care to an eating disorder day hospital program found that a longer duration of illness, amenorrhea, and a lower body mass index were associated with PHP treatment failure and inpatient rehospitalization.¹⁸ One study found that for individuals who were referred to a PHP from inpatient care, suicidal ideation and greater psychotic symptoms were associated with acute inpatient rehospitalization.¹⁹ Other factors associated with PHP nonattendance and treatment failure include limited personal and economic resources, high rates of substance abuse disorders, multiple admissions, and disability.²⁰ In a study of 103 alcohol-dependent patients who completed IOP treatment, 64% were abstinent at 6 months follow-up; relapse was associated with a longer duration of alcohol dependence and a higher number of prior treatments, while favorable outcomes were associated with a lower degree of depression, anxiety, and craving.²¹ Patients with cocaine dependence who completed an IOP showed significant improvements in addiction scores and had more favorable outcomes in employment status and psychological problems if they stayed longer in treatment.²²

Bottom Line

Psychiatric partial hospitalization programs (PHPs) provide a transition from inpatient hospitalization to outpatient treatment for patients who need further stabilization, or serve as an alternative to inpatient treatment for patients who don’t need or want inpatient hospitalization. PHPs can be as effective as inpatient treatment for all but the most seriously ill patients, and are more cost-effective than inpatient treatment.