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

This article explores common clinical dynamics resulting from the denial of choice that many patients experience in managed health care and proposes clinical adaptations for the treating or consulting psychiatrist. Patients who feel they have been denied the right to choose their health plan, treatment setting, or personal physician commonly go through a subjective experience analogous to that of being held captive. This sense of captivity can exacerbate the feelings of helplessness and hopelessness brought on by serious illness. It can also intensify the patient's feelings of alienation and betrayal when managed care constrains patient-physician decision making by limiting treatment options. These dynamics can lead to identifiable transference reactions and, in turn, to physician countertransference. Psychiatrists can do much to ameliorate these potentially destructive dynamics both as treating therapists and as consultants to general physicians. Indications for consultation or intervention are analyzed and specific clinical strategies to enhance the patient's decision-making capacity throughout the introductory, ongoing, and termination phases of the treatment alliance are reviewed.