Book Review

Less Time to Do More: Psychotherapy on the Short-Term Inpatient Unit

N Engl J Med 1994; 330:1245April 28, 1994

Article

Less Time to Do More: Psychotherapy on the Short-Term Inpatient Unit
Edited by Ellen Leibenluft, Allan Tasman, and Stephen A. Green. 321 pp. $42.50. ISBN: 0-88048-512-4

In the United States today, when a person's behavior deviates sufficiently from the accepted norm to frighten or threaten others and it is determined that the behavior stems from a mental disorder, that person will most likely be placed in an inpatient psychiatry unit, a ward in or a section of a general hospital.

Ellen Leibenluft, senior editor of Less Time to Do More, claims that a revolution in the management of these units has taken place within the past 10 years. It has been manifested, she says, by a drastic shortening of the length of hospitalization, the occurrence of a greater variety of problems, and the extensive use of psychotherapeutic drugs. She has recruited 18 U.S. clinicians who operate such units to address this theme and present their methods of responding to the revolution.

Leibenluft's claim that the book is about psychotherapy requires her to redefine this term. She explains in the preface that today's “hapless inpatient clinicians” are required by economic factors so to blur the boundary between psychotherapy (which she refers to as “regressive”) and management that “the patient will often be discharged with significant symptoms, and will certainly be discharged with his or her underlying conflicts unresolved.” She redefines psychotherapy broadly “as any interaction between staff and patients [aimed at] accomplishing specific therapeutic goals . . . such as to help patients understand their resistance to compliance.” The majority of her coauthors seem to agree with this definition.

Experienced psychotherapists of my generation cannot accept such a redefinition. We see authoritarian controls aimed at producing simple conformity as the opposite of psychotherapy; that is, each is mutually exclusive of the other, with compromise or blurring of the boundaries between the two quite impossible.

The authors seem to agree that pressure from insurance providers has reduced hospital stays to a matter of days or weeks. Working within this constraint, these clinicians have enthusiastically come up with sometimes brilliant, sometimes very sophisticated methods of maximizing the educational aspects of the inpatient milieu, particularly with respect to long-term patients, those with alcoholism or eating disorders, adolescents, and elderly patients. Management consists of controlling patients by means of instruction and physical and medicinal restraints, so that they are protected from society's reactions and their own. Drugs -- their side effects hardly mentioned -- are used to control and manipulate behavior, with no expectation that they will cure anything or resolve underlying conflicts. I think that such an approach would foster resentment of and disrespect for psychiatrists.

If there is to be anything curative in inpatient psychiatry, I should expect it to come from carefully administered psychotherapy in a setting in which there is a specific physician assigned to administer controls in such a fashion as to allow another physician, who is not an agent of the control system, to provide the skill, objectivity, and nonauthoritarian neutrality necessary for effective psychotherapy. Roles would be sharply defined, and the treatment would be time consuming, expensive, and strenuously opposed by third-party payers.

This multiauthored book contains so many redundancies that reading the entire work is a struggle. Less Time to Do More is a telling review of current approaches to inpatient psychiatry; one in which insurers ask us to treat patients as objects to be cleverly and quickly maneuvered into conforming behavior and to overlook the possibility that they may be interesting persons overwhelmed by futile attempts to deal with conflicts beyond their abilities to manage.

Kenneth L. Artiss, M.D.
Rockville, MD 20850