Drs. Sharfstein and Quaytman Reply

To the Editor: We very much appreciate the comments of Drs. Shapiro and Plakun and endorse their ideas. It is indeed difficult to construct a holding environment that provides meaningful continuity of care for severely ill patients, given the attitudes and constraints of many managed care protocols. What is just as troubling, however, is the impact of the absence of a holding environment on the clinician attempting to do this work. Without this, the clinician cannot find the financial or emotional support to deal with either his own or the patient’s sense of helplessness. The therapist may begin to “identify with the aggressor” in seeing the patient as only manipulative and insatiable. Inevitably, the identity of the therapist is fragmented and diffused so that she can only see herself as a “part object” in the role of “med manager,” or “treatment planner”; the doctor-patient relationship, so central to the treatment of the severely ill patient, is compromised to the extent that it, too, becomes meaningless.

We hope that more clinicians will become advocates for these patients and that enthusiasm to rediscover the importance and utility of treatment algorithms that include interpretative environments and meaning will be rekindled. These environments need not be inpatient settings; however, simply focusing on behavior or measurable goals has proven over and over to leave these patients by the wayside or labeled as chronic. Treatment that looks at these patients in depth can provide valuable research data that will help find new algorithms. As Bockoven reminds us, “It would appear that the way a society treats its mentally ill is but a manifestation or particular instance of the way the members of that society treat each other” (1). Resource allocation, we have learned, is a critical part of the patient’s care and the patient must take responsibility in this arena. However, if the physician does not take responsibility to make sure that the doors to care remain open for these patients, no one else will.