APPTextbook of Hospital Psychiatry

Textbook of
HOSPITAL PSYCHIATRY
EDITORIAL BOARD
David G. Fassler, M.D. Clinical Professor of Psychiatry, University of Vermont College of Medicine, Burlington,
Vermont
Ira D. Glick, M.D. Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of
Medicine, Stanford, California
Patricia R. Recupero, J.D., M.D. President/CEO, Butler Hospital, Providence, Rhode Island
Robert P. Roca, M.D., M.P.H. Vice President and Medical Director, Sheppard Pratt Health System; Medical
Director, General Hospital Contract Management Services, Sheppard Pratt Health System, Baltimore, Maryland
Neil B. Sandson, M.D. Director, Residency Training, Sheppard Pratt Health System, Baltimore, Maryland
Harold I. Schwartz, M.D. Psychiatrist-in-Chief and Vice President Behavioral Health, Institute of Living/Hart-
ford Hospital, Hartford, Connecticut
Philip J. Wilner, M.D. Vice President and Medical Director for Behavioral Health at Weill Cornell Medical Cen-
ter of NewYorkPresbyterian Hospital
Textbook of
HOSPITAL PSYCHIATRY
Edited by
Steven S. Sharfstein, M.D., M.P.A.
With Deputy Editors

Faith B. Dickerson, Ph.D., M.P.H.
and
John M. Oldham, M.D., M.S.
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accurate at the time of publica-
tion and consistent with general psychiatric and medical standards, and that information concerning drug dos-
ages, schedules, and routes of administration is accurate at the time of publication and consistent with standards
set by the U.S. Food and Drug Administration and the general medical community. As medical research and
practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may re-
quire a specific therapeutic response not included in this book. For these reasons and because human and me-
chanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in
their care or the care of a member of their family.
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ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
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Library of Congress Cataloging-in-Publication Data
Textbook of hospital psychiatry / edited by Steven S. Sharfstein, Faith B. Dickerson, John M. Oldham. 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-322-8 (alk. paper)
1. Psychiatric hospital careUnited States. 2. Psychiatric hospitalsUnited StatesAdministration.
I. Sharfstein, Steven S. (Steven Samuel), 1942 II. Dickerson, Faith B. III. Oldham, John M.
[DNLM: 1. Psychiatric Department, Hospitalorganization & administration. 2. Hospitals, Psychiatric
organization & administration. 3. Mental Disorderstherapy. 4. Psychology, Medicalorganization & admin-
istration. WM 27.1 T355 2009]
RC443.T49 2009
362.21dc22
2008016936
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Dedication
To
Moses Sheppard
and
C.F. Menninger and his sons Karl and Will

Founders and Visionaries
This page intentionally left blank
CONTENTS
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Anthony F. Lehman, M.D., M.S.P.H.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xix
1 History of Hospital Psychiatry and Lessons Learned . . . . . . . .1

Jeffrey L. Geller, M.D., M.P.H.
Part I
Inpatient Practice
2 The Acute Crisis Stabilization Unit for Adults . . . . . . . . . . . . .23

Ira D. Glick, M.D.
Rajiv Tandon, M.D.
3 The Child Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Joseph C. Blader, Ph.D.
Andrs Martin, M.D., M.P.H.
A. Bela Sood, M.D., M.S.H.A.
Carmel A. Foley, M.D., M.H.A.
4 The Adolescent Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Gary J. Gosselin, M.D.
David Ray DeMaso, M.D.
5 The Geriatric Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Sibel A. Klimstra, M.D.
Vassilios Latoussakis, M.D.
Dimitris N. Kiosses, Ph.D.
George S. Alexopoulos, M.D.
6 The Eating Disorders Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Harry A. Brandt, M.D.
Katherine A. Halmi, M.D.
Appendices
Example of an Eating Disorder Unit Milieu Manual for Patients . . . . . . . . . 98
Example of an Eating Disorder Unit Schedule and Daily Activity . . . . . . . 101
7 The Trauma Disorders Unit . . . . . . . . . . . . . . . . . . . . . . . . . 103

Richard J. Loewenstein, M.D.
Susan B. Wait, M.D.
8 The Psychotic Disorders Unit . . . . . . . . . . . . . . . . . . . . . . . 119

John J. Boronow, M.D.
9 The Co-Occurring (Substance Abuse/Mental Illness)

Disorders Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Patricia R. Recupero, J.D., M.D.
Michael C. Fiori, M.D.
Mary Ella Dubreuil, R.N., L.C.D.P.
10 The Adolescent Neuropsychiatric Unit:
Developmental Disabilities and Mental Illness . . . . . . . . . . 159
Margaret E. Hertzig, M.D.
11 The Ethnic/Minority Psychiatric Inpatient Unit . . . . . . . . . . . 175

Francis G. Lu, M.D.
12 The Forensic Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Michael A. Norko, M.D.
Charles C. Dike, M.D., M.P.H., M.R.C.Psych.
13 The State Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

Brian M. Hepburn, M.D.
Lloyd I. Sederer, M.D.
14 The Veterans Hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Anne M. Stoline, M.D.
Appendix: Online Resources for Veterans . . . . . . . . . . . . . . . . . . . . 221
15 ConsultationLiaison Psychiatry . . . . . . . . . . . . . . . . . . . . . 223

Lucy A. Epstein, M.D.
Philip R. Muskin, M.D.
Part II
Special Clinical Issues
16 From Within: A Consumer Perspective on

Psychiatric Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Lisa J. Halpern, M.P.P.
Howard D. Trachtman, B.S., C.P.S.
Kenneth S. Duckworth, M.D.
17 Working With Families. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Lisa B. Dixon, M.D., M.P.H.
Aaron B. Murray-Swank, Ph.D.
Bette M. Stewart, B.S.
18 Improving Safety in Mental Health Treatment Settings:

Preventing Conflict, Violence, and Use of
Seclusion and Restraint . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Kevin Ann Huckshorn, R.N., M.S.N., C.A.P., I.C.A.D.C.
Janice L. LeBel, Ph.D.
19 Inpatient Suicide: Risk Assessment and Prevention . . . . . . 267

Robert P. Roca, M.D., M.P.H., M.B.A.
Laurie Hurson
20 Discharge Dilemmas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

John R. Lion, M.D.
Part III
The Continuum of Care
21 Residential Psychotherapeutic Treatment:

An Intensive Psychodynamic Approach for
Patients With Treatment-Resistant Disorders. . . . . . . . . . . . 285
Edward R. Shapiro, M.D.
Eric M. Plakun, M.D.
22 Residential Treatment for Children and Adolescents . . . . . 299

Michael A. Rater, M.D.
Alex Hirshberg, B.A.
Cynthia Kaplan, Ph.D.
23 Hospital-Based Psychiatric Emergency Services . . . . . . . . . 311
Glenn W. Currier, M.D., M.P.H.
Appendix: Sample Comprehensive Psychiatric Emergency

Program Evaluation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
24 Outpatient Community Mental Health Services . . . . . . . . . . 327

Francine Cournos, M.D.
Stephanie LeMelle, M.D.
25 Day Hospitalization and Intensive Outpatient Care. . . . . . . 339

Donna T. Anthony, M.D., Ph.D.
Joan K. Feder, M.A., O.T.R./L., C.P.R.P.
Part IV
Structure and Infrastructure
26 Administration and Leadership. . . . . . . . . . . . . . . . . . . . . . 357

Harold I. Schwartz, M.D.
27 Psychiatrists and Psychologists . . . . . . . . . . . . . . . . . . . . . 371

Barbara Roberts Magid, M.B.A.
28 Social Work and Rehabilitation Therapies . . . . . . . . . . . . . . 377

Diana L. Ramsay, M.P.P., O.T.R., F.A.O.T.A.
Judith S. Gonyea, O.T.D., M.S.Ed., O.T.R./L.
Marlene I. Shapiro, M.S.W., L.C.S.W.C.
29 Psychiatric Nursing: Creating and Maintaining

a Therapeutic Inpatient Environment . . . . . . . . . . . . . . . . . 389
Kathleen R. Delaney, Ph.D., R.N., P.M.H.N.P.
Suzanne Perraud, Ph.D., R.N.
Mary E. Johnson, Ph.D., R.N.
30 Financing of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403
Benjamin Liptzin, M.D.
Paul Summergrad, M.D.
31 Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

Marilyn Price, M.D.
32 Quality Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429

Marlin R. Mattson, M.D.
Appendix: Online Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
33 The Electronic Medical Record . . . . . . . . . . . . . . . . . . . . . . 439

34 Design and Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . 453

Richard C. Lippincott, M.D.
Eugene J. Kuc, M.D.
Todd Hanson, A.I.A.
Part V
The Future of Hospital Psychiatry
35 Hospital Psychiatry for the Future. . . . . . . . . . . . . . . . . . . . 467

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473
CONTRIBUTORS
George S. Alexopoulos, M.D. Faith B. Dickerson, Ph.D., M.P.H.
Professor of Psychiatry, Cornell Institute of Geriatric Director of Psychology, Sheppard Pratt Health System,
Psychiatry, White Plains, New York Baltimore, Maryland; Clinical Associate Professor of
Psychiatry, University of Maryland School of Medi-
cine, Baltimore; Head, Stanley Research Program at
Associate Professor of Clinical Psychiatry, Weill Cor-
Sheppard Pratt
nell Medical Center; Program Director, Psychotic Dis-
orders Continuum at Payne Whitney Westchester, Charles C. Dike, M.D., M.P.H., M.R.C.Psych.
NewYorkPresbyterian HospitalWeill Cornell Med- Assistant Clinical Professor of Psychiatry, Yale Uni-
ical Center, White Plains, New York versity School of Medicine, New Haven, Connecticut;
Medical Director, Whiting Forensic Division of Con-
necticut Valley Hospital, Middletown, Connecticut
Assistant Professor of Psychiatry, Department of Psy-
chiatry and Behavioral Science, Stony Brook Univer- Lisa B. Dixon, M.D., M.P.H.
sity School of Medicine, Stony Brook, New York VA Capitol Network (VISN 5) Mental Illness Re-
search, Education, and Clinical Center (MIRECC),
VA Maryland Healthcare System; Department of Psy-
Medical Director, Adult Services, Sheppard Pratt Hos-
chiatry, Division of Services Research, University of
pital; Associate Clinical Professor of Psychiatry, Uni-
Maryland School of Medicine, Baltimore, Maryland
versity of Maryland School of Medicine, Towson,
Maryland Mary Ella Dubreuil, R.N., L.C.D.P.
Director of Alcohol and Drug Treatment Services,
Butler Hospital, Providence, Rhode Island
Director, Center for Eating Disorders, Sheppard Pratt
Health System, Towson, Maryland Kenneth S. Duckworth, M.D.
Assistant Professor of Psychiatry, Harvard Medical
School, Cambridge, Massachusetts; Medical Director,
Professor of Clinical Psychiatry, Columbia University,
National Alliance on Mental Illness, Arlington, VA;
New York State Psychiatric Institute, New York, New
Medical Director, Vinfen Corporation, Dorchester,
York
Massachusetts
Associate Professor of Psychiatry and Emergency
Postdoctoral Clinical Fellow in Psychiatry, Columbia
Medicine, University of Rochester Medical Center,
University College of Physicians and Surgeons, New
Rochester, New York
York, New York
Professor of Nursing, Department of Community and
Manager of Outpatient Psychosocial Rehabilitation
Mental Health Nursing, Rush College of Nursing; and
Services, Payne Whitney Manhattan, NewYorkPres-
Clinical Nurse Coordinator, Childrens Inpatient Unit,
byterian HospitalWeill Cornell Medical Center,
Rush University Medical Center, Chicago, Illinois
New York, New York
Psychiatrist-in-Chief, Childrens Hospital Boston;
and Professor of Psychiatry and Pediatrics, Harvard
Medical School, Boston, Massachusetts
xiii
xiv TEXTBOOK OF HOSPITAL PSYCHIATRY
Michael C. Fiori, M.D. Kevin Ann Huckshorn, R.N., M.S.N., C.A.P.,

Clinical Assistant Professor of Psychiatry, Depart- I.C.A.D.C.
ment of Psychiatry and Human Behavior, Warren Alp- Director, Office of Technical Assistance, National As-
ert Medical School of Brown University; and Director, sociation for State Mental Health Program Directors,
Alcohol and Drug Inpatient Unit, Butler Hospital, Alexandria, Virginia
Providence, Rhode Island
Laurie Hurson
Carmel A. Foley, M.D., M.H.A. St. Josephs University, Philadelphia, Pennsylvania
Assistant Professor of Psychiatry, Albert Einstein Col-
lege of Medicine of Yeshiva University, Bronx, New
Associate Professor of Nursing, Department of Com-
York
munity and Mental Health Nursing, Rush College of
Jeffrey L. Geller, M.D., M.P.H. Nursing, Evanston, Illinois
Professor of Psychiatry, Department of Psychiatry,
University of Massachusetts Medical School, Worces-
Clinical Instructor of Psychiatry, Harvard Medical
ter, Massachusetts
School, Boston, Massachusetts; Administrative Di-
Ira D. Glick, M.D. rector, Child and Adolescent Services, McLean Hospi-
Professor, Psychiatry and Behavioral Sciences, Stan- tal, Belmont, Massachusetts
ford University School of Medicine, Stanford, Califor-
nia
Assistant Professor of Psychology in Psychiatry, Cor-
Judith S. Gonyea, O.T.D., M.S.Ed., O.T.R./L. nell Institute of Geriatric Psychiatry, White Plains,
Assistant Professor, Occupational Therapy Program, New York
Ithaca College, Ithaca, New York
Gary J. Gosselin, M.D. Associate Professor of Clinical Psychiatry, Cornell In-
Associate in Psychiatry, Childrens Hospital Boston; stitute of Geriatric Psychiatry, White Plains, New
and Instructor in Psychiatry, Harvard Medical School, York
Boston, Massachusetts
Eugene J. Kuc, M.D.
Katherine A. Halmi, M.D. Associate Professor, Department of Psychiatry and Be-
Director, Eating Disorders Program, NewYorkPresby- havioral Sciences, University of Arkansas for Medical
terian HospitalWestchester Division, White Plains, Sciences, Little Rock, Arkansas
New York
Lisa J. Halpern, M.P.P. Research Fellow, Cornell Institute of Geriatric Psychi-
Director, Dorchester Bay Recovery Center, Vinfen atry, White Plains, New York
Corporation, Dorchester, Massachusetts
Todd Hanson, A.I.A. Director of Program Management, Commonwealth of
Director of Health Services Design, JSA, Portsmouth, Massachusetts, Department of Mental Health, Boston,
New Hampshire Massachusetts
Brian M. Hepburn, M.D. Anthony F. Lehman, M.D., M.S.P.H.
Executive Director, Mental Hygiene Administration, Professor and Chair, Department of Psychiatry, Uni-
Maryland Department of Health and Mental Hygiene, versity of Maryland School of Medicine, Baltimore,
Catonsville, Maryland Maryland
Margaret E. Hertzig, M.D. Stephanie LeMelle, M.D.
Professor of Psychiatry, Interim Vice Chair, Child and Associate Clinical Professor of Psychiatry, Depart-
Adolescent Psychiatry, Weill Medical College of Cor- ment of Psychiatry, Columbia University College of
nell University, New York, New York Physicians and Surgeons, New York, New York
Alex Hirshberg, B.A. John R. Lion, M.D.
Clinical Educator, Adolescent Residential and Partial Private Practice and Clinical Professor of Psychiatry,
Hospital Program, McLean Hospital, Belmont, Mas- University of Maryland School of Medicine, Baltimore,
sachusetts Maryland
Contributors xv
Richard C. Lippincott, M.D. John M. Oldham, M.D., M.S.

Professor, Department of Psychiatry and Behavioral Professor and Executive Vice Chair for Clinical Affairs
Sciences, University of Arkansas for Medical Sciences, and Development, Menninger Department of Psychi-
Little Rock, Arkansas atry and Behavioral Sciences, Baylor College of Medi-
cine, Houston, Texas; Senior Vice President and Chief
of Staff, The Menninger Clinic, Houston, Texas
Professor and Deputy Chair, Department of Psychia-
try, Tufts University School of Medicine, Boston, Mas- Suzanne Perraud, Ph.D., R.N.
sachusetts; and Chairman, Department of Psychiatry, Assistant Professor and Director of Specialty Educa-
Baystate Health, Springfield, Massachusetts tion, Rush College of Nursing, Chicago, Illinois
Richard J. Loewenstein, M.D. Eric M. Plakun, M.D.
Medical Director, Trauma Disorders Services, Shep- Director of Admissions and Professional Relations,
pard Pratt Health System, Baltimore, Maryland; Asso- The Austen Riggs Center, Stockbridge, Massachu-
ciate Clinical Professor, Department of Psychiatry, setts; Chair, American Psychiatric Association Com-
University of Maryland School of Medicine, Balti- mittee on Psychotherapy by Psychiatrists
more, Maryland
Marilyn Price, M.D.
Francis G. Lu, M.D. Clinical Assistant Professor of Psychiatry, Warren Alp-
Professor of Clinical Psychiatry, University of Califor- ert Medical School of Brown University, Providence,
nia at San Francisco, San Francisco, California Rhode Island
Barbara Roberts Magid, M.B.A. Diana L. Ramsay, M.P.P., O.T.R., F.A.O.T.A.
Director, Division of Professional Services, Sheppard Executive Vice President and Chief Operating Officer,
Pratt Health System, Baltimore, Maryland Sheppard Pratt Health System, Baltimore, Maryland;
and past President, National Association of Psychiat-
ric Health Systems (NAPHS), Washington, D.C.
Professor of Child Psychiatry and Psychiatry, Child
Study Center, Yale University School of Medicine, Michael A. Rater, M.D.
New Haven, Connecticut Clinical Instructor, Harvard Medical School, McLean
Hospital, Belmont, Massachusetts
Professor of Clinical Psychiatry, Weill Medical College Patricia R. Recupero, J.D., M.D.
of Cornell University, New York, New York Clinical Professor of Psychiatry, Warren Alpert Medi-
cal School of Brown University; and President/CEO,
Butler Hospital, Providence, Rhode Island
VA Capitol Network (VISN 5) Mental Illness Re-
search, Education, and Clinical Center (MIRECC), Robert P. Roca, M.D., M.P.H., M.B.A.
VA Maryland Healthcare System; Department of Psy- Vice President of Medical Affairs, Sheppard Pratt
chiatry, Division of Services Research, University of Health System; Associate Professor of Psychiatry,
Maryland School of Medicine, Baltimore, Maryland Johns Hopkins University School of Medicine; Clini-
cal Associate Professor of Psychiatry, University of
Maryland School of Medicine, Baltimore, Maryland
Professor of Clinical Psychiatry, Department of Psy-
chiatry, Columbia University College of Physicians Lloyd I. Sederer, M.D.
and Surgeons; Chief, Consultation-Liaison Psychia- Medical Director, New York State Office of Mental
try, Columbia University Medical Center, NewYork Health (OMH), New York, New York
Presbyterian Hospital, New York, New York
Michael A. Norko, M.D. Psychiatrist-in-Chief and Vice President Behavioral
Associate Professor of Psychiatry, Yale University Health, Institute of Living/Hartford Hospital, Hart-
School of Medicine, New Haven, Connecticut; Direc- ford, Connecticut; Professor of Psychiatry, University
tor of Forensic Services, Connecticut Department of of Connecticut School of Medicine, Farmington, Con-
Mental Health and Addiction Services, Hartford, necticut
Connecticut
xvi TEXTBOOK OF HOSPITAL PSYCHIATRY
Edward R. Shapiro, M.D. Joseph C. Blader, Ph.D. Grant Support: Abbot Laborato-
Medical Director and Chief Executive Officer, The ries
John J. Boronow, M.D. Speakers Bureau: Pfizer, Astra-
Austen Riggs Center, Stockbridge, Massachusetts; As-
Zeneca, Bristol-Myers Squibb
sociate Clinical Professor of Psychiatry, Harvard Med- Glenn W. Currier, M.D., M.P.H. Grant Support: Pfizer;
ical School, Boston, Massachusetts Speakers Bureau: Bristol-Myers Squibb, Pfizer
Michael C. Fiori, M.D. Speakers Bureau: Reckitt Benck-
iser
Program Director, Harry Stack Sullivan Day Hospital, Ira D. Glick, M.D. Advisory Board: Janssen, Pfizer, Bris-
Sheppard Pratt Health System, Baltimore, Maryland tol-Myers Squibb, Solvay; Speakers Bureau: Janssen,
AstraZeneca, Pfizer, Bristol-Myers Squibb; Research
Steven S. Sharfstein, M.D., M.P.A. Support: Bristol-Myers Squibb, Shire, Solvay
President and Chief Executive Officer, Sheppard Pratt Janice L. LeBel, Ph.D. Consultant: Sheppard Pratt Health
Health System, Baltimore, Maryland; Clinical Professor System, Hogg Foundation for Mental Health, National
and Vice Chair, Department of Psychiatry, University of Association of State Mental Health Program Directors
Maryland School of Medicine, Baltimore, Maryland Office of Technical Assistance, New Zealand govern-
ment, Australian government
A. Bela Sood, M.D., M.S.H.A. Benjamin Liptzin, M.D. Associate Medical Director,
Professor of Psychiatry, Virginia Commonwealth Uni- Health New England
Paul Summergrad, M.D. Honoraria: Pfizer, MC Commu-
versity School of Medicine, Richmond, Virginia
nications
Bette M. Stewart, B.S. Howard D. Trachtman, B.S., C.P.S. Grant Support: Astra-
Department of Psychiatry, Division of Services Re- Zeneca
search, University of Maryland School of Medicine, The following authors have no competing interests to report:
Baltimore, Maryland Donna T. Anthony, M.D., Ph.D.; Harry A. Brandt,
M.D.; Francine Cournos, M.D.; Kathleen R. Delaney,
Anne M. Stoline, M.D. Ph.D., R.N., P.M.H.-N.P.; David Ray DeMaso, M.D.;
Staff Psychiatrist, Perry Point VA Medical Center, Faith B. Dickerson, Ph.D., M.P.H.; Charles C. Dike,
Perry Point, Maryland M.D., M.P.H., M.R.C.Psych.; Lisa B. Dixon, M.D.,
M.P.H.; Mary Ella Dubreuil, R.N., L.C.D.P.; Kenneth S.
Paul Summergrad, M.D. Duckworth, M.D.; Lucy A. Epstein, M.D.; Joan K.
Psychiatrist-in-Chief, TuftsNew England Medical Feder, M.A., O.T.R./L., C.P.R.P.; Carmel A. Foley, M.D.,
Center; and Dr. Frances Arkin Professor and Chair- M.H.A.; Jeffrey L. Geller, M.D., M.P.H.; Judith S. Gon-
man, Department of Psychiatry, Tufts University yea, O.T.D., M.S.Ed., O.T.R./L.; Gary J. Gosselin, M.D.;
Katherine A. Halmi, M.D.; Lisa J. Halpern, M.P.P.; Todd
School of Medicine, Boston, Massachusetts
Hanson, A.I.A.; Brian M. Hepburn, M.D.; Margaret E.
Rajiv Tandon, M.D. Hertzig, M.D.; Alex Hirshberg, B.A.; Kevin Ann Huck-
shorn, R.N., M.S.N., C.A.P., I.C.A.D.C.; Laurie Hur-
Chief of Psychiatry, Mental Health Program Office,
son; Mary E. Johnson, Ph.D., R.N.; Cynthia Kaplan,
State of Florida, Tallahassee, Florida Ph.D.; Dimitris N. Kiosses, Ph.D.; Sibel A. Klimstra,
Howard D. Trachtman, B.S., C.P.S. M.D.; Eugene J. Kuc, M.D.; Vassilios Latoussakis,
M.D.; Anthony F. Lehman, M.D., M.S.P.H.; Stephanie
Executive Director, Boston Resource Center, Boston,
LeMelle, M.D.; John R. Lion, M.D.; Richard C. Lippin-
Massachusetts cott, M.D.; Richard J. Loewenstein, M.D.; Francis G.
Lu, M.D.; Barbara Roberts Magid, M.B.A.; Andrs Mar-
Susan B. Wait, M.D.
tin, M.D., M.P.H.; Marlin R. Mattson, M.D.; Aaron B.
Service Chief, Trauma Disorders Services, Sheppard Mur ray-Swank, Ph.D.; Philip R. Muskin, M.D.;
Pratt Health System, Baltimore, Maryland Michael A. Norko, M.D.; John M. Oldham, M.D., M.S.;
Suzanne Perraud, Ph.D., R.N.; Eric M. Plakun, M.D.;
Marilyn Price, M.D.; Diana L. Ramsay, M.P.P., O.T.R.,
F.A.O.T.A.; Michael A. Rater, M.D.; Patricia R. Recu-
Disclosure of Competing Interests pero, J.D., M.D.; Robert P. Roca, M.D., M.P.H., M.B.A.;
Harold I. Schwartz, M.D.; Lloyd I. Sederer, M.D.; Ed-
ward R. Shapiro, M.D.; Marlene I. Shapiro, M.S.W.,
The following authors have competing interests to declare: L.C.S.W.-C.; Steven S. Sharfstein, M.D., M.P.A.; A. Bela
Sood, M.D., M.S.H.A.; Bette M. Stewart, B.S.; Anne M.
George S. Alexopolous, M.D. Consultant: Forest; Grant Stoline, M.D.; Rajiv Tandon, M.D.; Susan B. Wait,
Support: Forest, Cephalon; Speakers Bureau: Bristol- M.D.
Myers Squibb, Cephalon, Forest, GlaxoSmithKline,
Janssen, Eli Lilly, Pfizer
PREFACE
The psychiatric hospital has played essential roles in proceed to hospitalization now is often viewed as a last
American psychiatry for more than two centuries. Yet resort, triggered by significant risk to self or others, the
during this time, and especially over the past several acuity of patients problems is probably greater than it
decades, hospital psychiatry has seen radical changes. has ever been. Many patients enter the psychiatric
The large rural asylums of the nineteenth century hospital with significant comorbidities, including sub-
where persons with mental illnesses went for shelter stance abuse and serious medical problems, that need
and stayed for years have yielded to the acute psychi- to be addressed. The array of available effective treat-
atric hospitals of the twenty-first century with lengths ments that can be brought to bear has grown tremen-
of stay measured in days. The stakes have always been dously, but then so have the expectations for quick
high for patients and their families when hospitaliza- results. The most effective approaches are interdisci-
tion occurs, but the pace of activity during hospitaliza- plinary, but these require close coordination among
tion and, indeed, the goals of hospitalization have professionals. Critical shortages of mental health pro-
changed profoundly. Todays busy psychiatric inpa- fessionals from various disciplines abound in many lo-
tient units face extraordinary pressures and complex- cales. Shortages in community-based services for con-
ities, and the stakes are high for all involved. An apt tinued care complicate discharge planning. Further
metaphor from Flow Theory is what has been called pressures arise from court systems seeking forensic
being in the zone, which occurs in a wide range of services. Demands for documentation and account-
human activities. A person in the zone experiences ability are rampant. The payers begin to press for rapid
everything coming together under extreme pressure discharge as soon as the patient enters the hospital.
to produce a high level of performance. Baseball play- With all of these pressures, compressed into but a few
ers in the zone describe seeing the stitches on a fast- days, it is no wonder that we hear so many complaints
ball pitch before they hit a home run; jazz musicians that lengths of stay have become too short to accom-
in the zone navigate complex chord changes with plish much more than provision of basic safety during
ease to produce beautiful solos. In the zone experi- a crisis.
ences require a high degree of preparation and techni- Thus, the launch of this new textbook on hospital
cal skill combined with the capacity to relax and focus psychiatry, with contributions from many leading ex-
in real time in order to maximize performance. Mod- perts, is timely, occurring when realistic hope and ex-
ern hospital psychiatry works best in the zone. pectations can set a fruitful course for hospital psychi-
It is difficult to overstate the complexities faced by atry in the twenty-first century. Part I of the textbook
modern psychiatric hospitals. Because the decision to immediately reveals the many roles of current hospital
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xviii TEXTBOOK OF HOSPITAL PSYCHIATRY
psychiatry. These hospital programs serve persons services. More than ever, hospital psychiatry services
across the life span. We see the emergence of units that must be tightly embedded in a comprehensive contin-
focus on specific diagnoses, providing specialized care uum of care that does not permit patients to fall
for highly complex subgroups. We see as well the ex- through the cracks.
plicit acknowledgment of co-occurring problems, sub- Finally, Part II reflects the newest emerging issues
stance abuse, developmental disabilities, and legal en- of twenty-first-century hospital psychiatry. The chap-
tanglements. We see discussion of units focused on ters on preventing suicide and improving safety again
ethnic/minority groups, reflecting the ever-growing di- emphasize the acuity of patients entering the hospital,
versity of our communities. The continuing major the pressures created at the convergence of medical ne-
roles of public hospitals, both state and federal (De- cessity and third-party mandates for the shortest pos-
partment of Veterans Affairs), reflect the fact that our sible lengths of stay, accountability, and the critical
systems of mental health care still rely heavily on gov- need to interface with postdischarge community ser-
ernment support, especially with continuing dispari- vices. Much is at stake. Here we also see the emergence
ties in insurance coverage for mental disorders. The of an age of mental health consumerism and a new
chapters in Part IV (Ill get back to Parts II and III in a spirit of recovery and hope. While chapters on families
moment) underscore the current infrastructure chal- are not new, the maturing movement toward genuine
lenges of hospital psychiatry. While many of the topics alliances between families and treatment teams, re-
addressed in these chaptersinterdisciplinary staff- flected in this volume, is new. Even newer is the focus
ing, finance, legal and regulatory requirements, dis- on patients viewpoints and the emerging theme of
charge and safety, quality indicators, information tech- true collaboration between patients and practitioners
nology, architecturewould have received coverage in in promoting recovery and creating care that is patient
texts on hospital psychiatry 50 years ago, the fact that centered. We see in Part II a new emphasis on partner-
each now warrants an entire book chapter is telling. shipsbetween patients and practitioners, families
Parts II and III of the book address the broader con- and practitioners, and hospitals and communities.
text of twenty-first-century hospital psychiatry. The In sum, the very brief hospitalizations that charac-
chapters in Part III, The Continuum of Care, high- terize twenty-first-century psychiatry can appear as
light the fact that, especially with today s very brief blips in time when viewed across the course of pa-
lengths of inpatient stay, hospital-based treatment tients lives. Yet much critical business occurs during
must be understood within the broader perspective of these inpatient episodes. Skilled, well-informed inpa-
patients lives outside the hospital and the services tient treatment teams must have keen eyes for the sig-
that they need in the community, including mental nificance of the unfolding events, for the opportunities
health clinics, emergency rooms, day hospitals, inten- to make critical interventions, and for the connections
sive outpatient treatment, rehabilitation programs, needed with families and the community-based con-
and residential services. The connection of treatment tinuum of care. When such teams are supported by the
in the hospital with what precedes and follows hospi- right system structures, real therapeutic differences
talization has always been critical, but it is especially can be achieved. For twenty-first-century hospital psy-
so when lengths of stay are so short and the stakes for chiatry, being in the zone can change and save lives.
patients are so high. We know that there are many dis-
continuities in care. Such discontinuities can be par- Anthony F. Lehman, M.D., M.S.P.H.
ticularly unfortunate, even tragic, when they occur at Professor and Chair, Department of Psychiatry,
the interfaces of the hospital and community-based University of Maryland School of Medicine
INTRODUCTION
In the past quarter-century, major changes have oc- or part of the criminal justice system. The scarcity of
curred in psychiatric treatment. Some of these acute psychiatric beds in this country has reached cri-
changes are the result of real progress in the scientific sis proportions. Emergency rooms are often in gridlock
understanding of mental disorders and the develop- with acutely ill psychiatric patients stuck with no-
ment of effective biological and psychosocial treat- where to go.
ments. The evidence base for psychiatric treatment This good news/bad news scenario has never
continues to grow. In addition to scientific progress, been more evident than in inpatient care for psychiat-
there has been a decrease in stigma about receiving ric patients, whether in private psychiatric hospitals,
psychiatric care. This welcome change has occurred in in general hospitals, or in the public sector. Acute psy-
large part due to the fact that psychiatric treatments chiatric care is focused on crisis stabilization and rapid
work. In addition, consumers and families have in- discharge. Readmissions are common. Intermediate
creasingly given voice to their experiences and have and longer-term care take place primarily in the public
assumed a stronger role in making decisions about the sector, often as a result of concerns about public safety.
provision of psychiatric care. More and more seriously and persistently mentally ill
At the same time, there has been some real regres- individuals are in jails and prisons.
sion in the care and treatment of persons with mental These unwelcome trends have occurred even as we
illness in this country. Cost-driven cutbacks in care as know more about how to effectively treat and care for
well as faulty and misguided public policies have re- people with severe mental illness using a combination
sulted in the deinstitutionalization of many seriously of pharmacological and psychosocial treatments in a
ill people, with inadequate community services to continuum of care. Psychiatric treatment, especially
treat them. These unfortunate trends have resulted in in the hospital, has become increasingly specialized.
many persons with mental illness becoming homeless Considerable expertise is available for the care of chil-
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xx TEXTBOOK OF HOSPITAL PSYCHIATRY
dren and adolescents, the very old, and individuals (Salinsky and Loftis 2007). Partial hospitalization dur-
with specific conditions such as eating disorders, posting this time period fluctuated largely due to shifts in
traumatic stress disorders, psychotic disorders, and payment policies through the Medicare program.
brain injuries. Other potential substitutes for inpatient care have
This textbook is all about the good news of psy- grown some, but these community-based alternatives
chiatric treatment, especially in the delivery of inten- have been insufficient to truly offset the declines in
sive (often lifesaving) care in hospitals. Our hope is inpatient psychiatric beds during this time period. A
that this book will have an impact not only in im- 2006 survey of state mental health authorities revealed
proving care in hospitals that already provide needed that more than 80% of states reported a shortage of
treatment but also in expanding opportunities in new psychiatric beds. Among these states, 34 states re-
settings, both hospital and nonhospital, to provide ported a shortage of acute beds; 16 states, a shortage of
available and effective treatments, to do what we can long-term-care beds; and 24 states, a shortage of foren-
and should do in the context of todays medical mar- sic beds. Many states reported longer waiting lists for
ketplace. psychiatric beds. As a result, there is an increased reli-
Inpatient psychiatric services have declined drasti- ance on jails and prisons to address the needs of per-
cally over the past four decades, and beds have been sons with serious mental illness (National Association
reduced across public and private settings in a process of State Mental Health Program Directors 2006).
that has been mainly driven by economics, not clinical A recent report on expenditure trends reinforces
science. The downsizing of state- and county-operated the findings on the decrease in psychiatric beds. From
mental hospitals has been the most dramatic reason 1986 to 2003, the proportion of total expenditures for
for the large decrease in the total number of inpatient mental health that was spent on inpatient psychiatric
psychiatric beds. In 1970, there were approximately treatment fell from 41% to 24%. At the same time, the
525,000 psychiatric beds in the United States, with proportion of total mental health expenditures spent
80% of these beds provided by state or county mental on psychiatric medication grew from 7% to 23% (Mark
hospitals. By 2002, the total number of psychiatric et al. 2007).
beds had declined to fewer than 212,000, with 27% of Has the pendulum swung too far from the provi-
inpatient beds provided by state or county hospitals sion of inpatient care and the financing of that treat-
(Foley et al. 2007). By contrast, in the private sector, ment? We hope that this book will be part of a sincere
growth was most dramatic in the 1970s in general hos- and serious reassessment of the current need for hos-
pitals and in the 1980s in private psychiatric hospitals, pital-based level of care and of funding priorities.
which partially offset the decreases in the public sector. Twenty years ago, a textbook entitled Modern Hos-
However, since the mid-1990s, private-sector downsiz- pital Psychiatry was published to describe the various
ing has occurred, adding to the continuing decline in aspects of inpatient care from admission to discharge
the overall number of inpatient psychiatric beds. and to comment upon various types of hospitals and the
Demand for acute inpatient services was largely role of staff within these institutions (Lion et al. 1988,
stimulated by the needs of patients who were deinsti- p. v). Rereading this textbook underscores the dramatic
tutionalized from state and county hospitals. Insur- changes that have occurred in the last two decades. At
ance coverage through Medicare and Medicaid allowed the time, average lengths of stay in many private psy-
for the growth of psychiatric beds in the private sector. chiatric hospitals as well as inpatient units were three to
Prospective payment under Medicare, implemented in four times what they are today. The concept of a contin-
1983, excluded psychiatric hospitals and dedicated in- uum of care was very rudimentary, and hospital treat-
patient units in general hospitals, fueling the increase ment was considered to be a definitive effort to manage
in the number of these beds. A peak was hit in 1990 the consequences of both acute and chronic mental ill-
with more than 50,000 beds provided through psychi- ness. There was only one chapter on the follow-up to
atric units in general hospitals and 45,000 beds in pri- hospitalization. The concept of recovery from serious
vate psychiatric hospitals. Since that time, however, mental illnesses had not yet been conceived. This vol-
primarily due to managed care utilization review, these ume will hopefully better stand the test of time, but we
beds have declined in number so that private psychiat- are sure significant changes will continue to occur in the
ric hospital beds today number approximately 25,000 ever-evolving dynamic of better understanding the basic
and general hospital beds around 40,000 (Foley et al. causes of mental illness and addictions, revisions in
2007). At the same time, emergency department visits diagnostic assessment, even stronger partnerships with
for mental disorders have increased from about consumers and families, and the development of better
1.4 million visits in 1992 to nearly 2.5 million in 2003 treatment technologies based on scientific discovery.
Introduction xxi
Rockville, MD, U.S. Department of Health and Human

Acknowledgments Services, 2002, pp 200236. Available at: http://down-
l o a d . nc a d i . s a m h s a . g ov / k en / p d f / S M A 0 6 -4 1 9 5 /
The editors would like to express their appreciation for CMHS_MHUS_2004.pdf. Accessed March 2007.
Lion JR, Adler WN, Webb WL (eds): Modern Hospital Psy-
the contributions of the editorial board as well as the
chiatry. New York, WW Norton, 1988
help of Stephanie Provenza at Sheppard Pratt and Liz Mark TL, Levit KR, Buck JA, et al: Mental health treatment
Bednarowicz from the Menninger Clinic in the prepa- exp endi tur e tr ends , 1 986 200 3. Ps ych ia tr S er v
ration of this manuscript. 58:10411048, 2007
National Association of State Mental Health Program Direc-
tors Medical Directors Council: Parks J, Svendsen D,
References Singer P, et al. (eds): Morbidity and Mortality in People
With Serious Mental Illness, 13th Technical Report.
Alexandria, VA, 2006
Foley DJ, Manderscheid RW, Atay JE, et al: Highlights of or- Salinsky E, Loftis C: Shrinking inpatient psychiatric capac-
ganized mental health services in 2002 and major na- ity: cause for celebration or concern? NHPF 823:121,
tional and state trends, in Mental Health, United 2007
States, 2004. Edited by Manderscheid RW, Berry JT.
CHAPTER 1
HISTORY OF HOSPITAL PSYCHIATRY

AND LESSONS LEARNED
Jeffrey L. Geller, M.D., M.P.H.
T he history of American psychiatry, through at least day. This chapter reviews the history of American psy-
the nineteenth century and early years of the twentieth chiatric hospitals and serves as a reference for the
century, is fundamentally the history of inpatient psy- other chapters in this book.
chiatry. The founders of the American Psychiatric Asso-
ciation (APA) were founders of an association of medical
superintendents, some from state hospitals, others
The Early Years
from private psychiatric hospitals. Nine of the original (The Beginning Through 1920)
13 members of the Association of Medical Superinten-
dents of American Institutions for the Insane (AMSAII)
had connections with private psychiatric hospitals.
Origins of Public Facilities
Kirkbride had trained at Friends Asylum and was Super- Public care of persons with insanity began concur-
intendent of the Pennsylvania Hospital for the Insane. rently at multiple levels of government. Prior to the
Woodward, Brigham, and Butler had all been associated nineteenth century, the care of insane persons was
with the Hartford Retreat; Ray was connected with But- predominantly a local endeavor, took place largely in
ler Hospital; and Earle had associations with both almshouses, and was generally custodial in nature
Friends and Bloomingdale Asylums. Two members, (Hurd 1916). When states took responsibility for in-
Cutter (Pepperell Private Asylum) and White (Hudson sane paupers in this era, the state would auction these
Lunatic Asylum) were founders and ran proprietary psy- confessedly undesirable persons to the lowest bid-
chiatric facilities, whereas Bell headed McLean Asylum. der, because the state had to pay the private family to
These founders of American psychiatry, and the provide for the basic needs. If no family could be
hospitals with which each was associated, set the found, jails or strong pens under a relatives supervi-
course for hospital-based care and treatment to this sion were used (Deutsch 1949; Hurd 1916).
1
2 TEXTBOOK OF HOSPITAL PSYCHIATRY
In some states, care for the insane poor became or- 6. Hospitals should have enough wards to treat differ-
ganized at the county level. States created state boards ent classes of insane persons on different wards.
of charity to inspect the county establishments that 7. Hospitals could have up to 600 patients and prop-
housed insane persons. This system was criticized be- erly care for the insane.
cause local variation was extreme and medical and
nursing interventions generally poor (Hurd 1916). In 1868, AMSAII drafted suggested legislation
At the outset, state care meant a state institution concerning the admittance of patients (Hurd 1916):
that was established, built, and managed by the state 1. Insane persons may be placed in a hospital for the
but whose operation was funded by taxpayers and in- insane by their relatives, friends, or legal guardian,
dividuals. These were really state-aided facilities. If but never without the certificate of one or more rep-
the patient or family had resources, they paid for care; utable physicians, after a personal examination,
paupers were the responsibility of the county. Thus, made within 1 week.
the earliest public facilitiesin Williamsburg, Vir- 2. Insane persons may be placed in a hospital by order
ginia, and Columbia, South Carolinawere estab- of a magistrate, who, after proper inquisition, finds
lished pursuant to this model (Hurd 1916). that such persons are at large and dangerous to
State care in which the state was responsible for all themselves or others or require hospital care and
insane persons and executed its responsibility through treatment; the fact of their insanity shall be certi-
state-managed and -funded hospitals began with Wor- fied as specified in the preceding section.
cester State Hospital in 1833 (Hurd 1916). The devel- 3. Insane persons may be placed in a hospital, by or-
opment of state care progressed at quite different rates. der of any high judicial officer, if, on statement in
New Hampshire, for example, did not have an act le- writing of any respectable individual that a certain
galizing state care until 1913 (Hurd 1916). person is insane, and that the welfare of himself or
It was three decades after states began to take re- others requires his restraint, a duly appointed com-
sponsibility for their insane populations before states mission finds the person is a suitable case for con-
began to specifically consider the incurably insane. In finement.
1865, New York State established the first asylum for
persons with chronic insanity, the Willard Asylum
(Deutsch 1949; Hurd 1916). Not everyone was in fa- Origins of Private
vor of such institutions. Amariah Brigham, first super- Psychiatric Hospitals
intendent of Utica State Hospital, in a letter to Dor- Three facilities began as parts of general medical hospi-
othea Dix in 1866, indicated that he opposed the tals. The Institute of the Pennsylvania Hospital started
establishment of hospitals solely for the incurable in- in the general hospital proposed by Benjamin Franklin,
sane. They would, in my opinion, soon become ob- with insane persons scattered throughout the hospital,
jects of but little interest to any one, and where mis- mostly in cellars. A separate wing of the general hospital
rule, neglect, and all kinds of abuse would exist and was then completed, followed finally by a separate struc-
exist without detection (Deutsch 1949, p. 239). ture built in west Philadelphia, some distance from the
At this same time, the members of the AMSAII ar- general hospital, and funded by a colonial grant and sub-
ticulated, at their annual meeting, what they believed scriptions (Deutsch 1949; Kirkbride 1845).
the states responsibilities were (Hurd 1916): The Bloomingdale Hospital in New York began as a
wing of a general hospital, funded by subscriptions
1. The state should make ample and suitable provi- from philanthropic public spirited citizens. The lo-
sions for all its insane. cus of care of the insane moved to a separate structure
2. No insane person should be treated in any county with a grant from the state (Deutsch 1949; Earle 1845).
poorhouse or almshouse. McLean Hospital in Massachusetts started as part
3. Proper classification is an indispensable element of a general hospital, but services for insane persons
and can only be achieved in facilities specifically were provided in a separate facility from the outset.
constructed for treatment. Initial funding was from bequests, subscriptions, and
4. Curable and incurable persons should not be in donations; 3 years after it opened, John McLean of
separate establishments. Boston willed $100,000 to the asylum, and the asy-
5. States should have asylums placed so that individ- lum was renamed in his honor (Deutsch 1949; Mas-
uals can get treatment near where they reside. sachusetts 1845).
History of Hospital Psychiatry and Lessons Learned 3
Three private psychiatric hospitals began as free- ity in Massachusetts, stated in 1860 what he thought
standing institutions funded through different meth- was the role of the private facility:
ods. Butler Hospital in Rhode Island resulted from the
not to compete with the public institutions in mat-
legacy of a philanthropist, Nicholas Brown, and from a
ters of cheapness; but to provide liberally for all the
subscription campaign with the major contributions proper wants of their inmates, and charge all for ma-
coming from Cyrus Butler at the urging of Dorothea terial, time, attention and responsibility, and receive
Dix (Deutsch 1949; Ray 1848). The Brattleboro Re- a corresponding reward. Not to receive and treat the
treat, which began as the Vermont Asylum for the In- violent, the maniacal, the suicidal; but the mild,
quiet, and manageable by personal influence. And
sane, was funded through a bequest by the wife of a
principally to provide and offer to such patients as
physician, with additional funds provided by the state can properly enjoy and profit by them, an opportu-
(Deutsch 1949). The Hartford Retreat in Connecticut nity of using more of their faculties that are sane, a
(subsequently named the Institute of Living) resulted freer range of occupation and action, more of domes-
from a study by the Connecticut Medical Society that tic and social life, more intercourse with the world,
recommended the construction of a freestanding men- and a condition resembling more nearly that of their
own homes that can be offered and enjoyed in the
tal institution. The retreat was funded by a state grant,
public hospitals. (Jarvis 1860, p. 31)
funds from the state medical society, private subscrip-
tions, and a lottery (Connecticut 1845; Deutsch 1949).
Two private hospitals were begun by religious orga- PrivatePublic Interface
nizations. The Friends Asylum in Pennsylvania was Of the larger private facilities, all but one preceded the
initiated by the Society of Friends. Modeled after the states first public hospital, sometimes by more than
English Quakers York Retreat, the Friends Asylum 50 years. The private hospitals met a states need for
was funded by a subscription campaign and in-kind care of indigent insane persons by admitting public
donations. The hospital was established to serve only patients with varying methods of payment. This ar-
members of the Society of Friends, but from 1834 to rangement generally continued until the state deter-
1845 others were admitted. In 1845, admissions were mined it could provide for those insane who required
limited to those connected with the Society of Friends public support more cost-effectively in state hospitals.
and any others who were former patients (Deutsch Bloomingdale Asylum was aided by legislative ap-
1949; Pennsylvania 1845). propriations for its first 30 years; this ended in 1849,
Whereas all of these hospitals were formed under a and the facility then devoted itself to private patients
for-profit model, the Mount Hope Institution in Mary- only (New York 1872). William Rockwell, superinten-
land, which began as Mount Saint Vincent, was based dent of the Vermont Asylum for the Insane (Brattle-
on religious benevolence. Although a Catholic-affiliated boro Retreat), proclaimed in 1867 that his hospital
institution, it accepted patients of all denominations. could accommodate all insane persons of Vermont
The origins of many of the smaller facilities are who require hospital treatment (Vermont Asylum for
much more obscure; many appear to have been set up the Insane 1868). The Hartford Retreat ended its rela-
as a form of private practice. Some that began in the tionship with the state of Connecticut after 30 years of
early twentieth century, such as Chestnut Lodge and receiving such insane patients as were a public
Austen Riggs, were established as venues to practice charge (Connecticut 1871). Butler Hospital received
certain types of psychiatry (Geller 2006). An interesting an annual appropriation from the state that could be
thesis for the founding of many nineteenth-century fa- apportioned to specific patients at a fixed annual cap
cilities is that physicians who had worked in the public per patient (Butler Hospital for the Insane 1878). This
sector needed income-producing ventures later in their continued even after Butler Hospital sent a large num-
careers because there was no public pension or retire- ber of the indigent insane patients to the state facility
ment system (Gerald Grob, personal communication, at its opening. Pennsylvania Hospital provided care to
November 2000). A few additional hospitals were cre- a limited number from the state, doing so without
ated in a fashion similar to the earliest asylums. Moses charge of any kind (Kirkbride 1845).
Sheppard planned for the establishment of a mental in- A social policy evolved in virtually every state that
stitution in Maryland and built a hospital that opened care of its insane citizens would predominantly be a
as the Sheppard Asylum. With a subsequent bequest public function. Despite the operation of many private
from Enoch Pratt, the facility was renamed Sheppard facilities, these accounted for a small percentage of
and Enoch Pratt Hospital (Forbush 1971). those persons institutionalized by the early twentieth
Edward Jarvis, himself an operator of a private facil- century. On January 1, 1920, there were 232,680 per-
sons in institutions for mental disorders in the United most congenial and desirable (Private Asylums
States: 200,109 in state hospitals, 21,584 in county or 1879, p. 243). Patients were such that when you en-
city facilities, 1,040 in institutions for temporary care, counter persons variously occupiedyou find yourself
709 in Public Health Service Hospitals, and 9,238 in not infrequently quite at a loss to determine whether
private hospitals (Pollock and Forbush 1921). Thus, the persons met with are really the insane, or whether
private facilities accounted for only 4% of persons in they may be visitors or officials in the establishment
psychiatric facilities. (Wood 1853, p. 212). Private facilities allowed more
judicious social intercourse with the sane, greater per-
Comparison of Private sonal freedom, more individuation of treatment, closer
approximation to family life, greater ratios of physi-
and Public Facilities cians and attendants, and less use of locked and bolted
It should come as no surprise that public and private doors, and of barred windows (Parsons 1881, p. 575).
facilities had some common features, because the es- Public hospitals were entities of state, county, or
tablishment of many public asylums was directly in- municipal governments, and by mid-nineteenth cen-
fluenced by the early private asylums. The Friends tury states moved to centralize control and to decrease
Asylum and Hartford Retreat influenced the erection asylum superintendents autonomy (Grob 1983).
and organization of Utica State Hospital; the Hartford States oversight over private facilities was extremely
Retreat affected the establishment of asylums in Wor- variable. By 1910, private facilities came under the over-
cester and Boston, Massachusetts; and the Brattleboro sight of some form of a state board in 16 states. Three
Retreat influenced the construction of the state asy- other states had alternative methods of oversight. In 11
lum in New Hampshire (Hurd 1913). states, private facilities were required to be licensed (Bu-
At the turn of the twentieth century, the president reau of the Census 1914), but many were not.
of the New York State Commission in Lunacy argued Public institutions sought to lower their censuses
that both public and private facilities should be able to even as state hospital populations grew and patients
admit patients for 4872 hours on an emergency paper had progressively longer lengths of stay (Grob 1983);
signed by a family physician. Regular lunacy certifi- private facilities sought patients to maximize their oc-
cation would follow and thus the use of jails and pris- cupancy rates. A fundamental criticism of private fa-
ons for the reception of persons ill of brain disease cilities was the inherent conflict of interest of the pro-
could be avoided (Peterson 1902). During the first two prietor: It is not for the interest of the proprietor of a
decades of the twentieth century, both public and pri- private asylum to cure his patients, and hence they
vate hospitals had open, unlocked wards, and both may not make an honest effort to promote their cure
were striving to treat patients without the use of seclu- (Parsons 1881, pp. 578579). Private facilities adver-
sion or restraint (Hurd 1916; Page 1904). tised and were not infrequently endorsed in profes-
Private facilities, like public ones, had issues with sional journal editorials (Two Homes for the Nervous
overcrowding (Vermont 1890), psychiatrists violent and Insane 1880). Advertising by private facilities and
deaths at the facility (Death of Dr. George Cook by physicians was frequent enough that a code for pro-
1876), unwarranted admissions (From the Report of fessional advertising was proposed in 1894 (Provision
the McLean Asylum 1864), allegations of abuse for Professional Advertising in the Code 1894).
(Stewart 1874), and stigma (Parsons 1881). Accounts By the 1880s, some states (e.g., Connecticut, Indi-
decrying inappropriate admissions and ill treatment ana, Maryland, Massachusetts, New York, Pennsylva-
can be found from former patients of both public and nia, Rhode Island, and Wisconsin) permitted the com-
private facilities (Geller and Harris 1994). mitment of insane persons to private facilities (Board
By the 1880s, most psychiatrists agreed that in- of State Commissioners of Public Charities of the
sane patients can best be managed away from their State of Illinois 1885). To relieve crowding at state
own homes (Parsons 1881, p. 586). Some psychia- hospitals, proposals were put forward to furlough pa-
trists postulated that well-equipped and well-man- tients from state hospitals to private facilities in an
aged asylums for the insane are among the most im- early version of contemporary step-down procedures
portant of the outgrowths of modern civilization and (Insane Hospital Annexes 1880). Similar procedures
benevolence (Parsons 1881, p. 567). were recently used in the state of Vermont, for exam-
The private facilities were established for wealthier ple, for the same reason.
persons able to pay for more comfort, suitable medical Private hospitals, in contrast to public hospitals,
treatment, and pursuits and diversions which are could become quite luxurious. Long Island House, in
Amityville, New York, built a small cottage consisting authority to hold patients if family or friends insisted on
of a sitting room, bedroom, bathroom, and clothes- their discharge (Dr. Stokes 1852). Some patients cer-
press for a single patient in 1900 (Long Island House, tainly left private facilities due to the inability to pay for
Amityville, NY 1900). Upham house, at McLean Asy- further care (Butler Hospital for the Insane 1856; Dr.
lum, included nine suites, each containing a sitting Stokes 1852). Ray, perhaps somewhat cavalierly, ex-
room, bedroom, and bathroom; the house had two pri- claimed, We may indeed be shocked by this balancing
vate halls, reception rooms, a dining room, a billiard of reason, Gods greatest gift to man, with a paltry sum
room, and a Turkish bath (The McLean Asylum for of money (Butler Hospital for the Insane 1856, p. 282).
the Insane 1893). Other patients were removed because family and friends
Greater resources led to remarkably favorable staff- were impatient for the results or unwilling to wait un-
ing ratios at private hospitals. In the 1850s, Friends til the disease is fully eradicated (Dr. Stokes 1852, p.
Asylum had an attendant for every six patients (The 211). Patients who were prematurely discharged from
Asylum 1851). Both Kirkbride (Pennsylvania Hospi- private facilities were not infrequently subsequently ad-
tal for the Insane 1850) and Jarvis (Association of mitted to public facilities, due to the lack of an available
Medical Superintendents of American Institutions for bed, inadequate financial resources, or the patients un-
the Insane 1853) described private attendants for ev- manageable behavior (Sawyer 1879). Others were con-
ery patient. cerned that patients discharged before they were medi-
In 1851, John Butler, superintendent of the Hart- cally ready could be a danger to the community from
ford Retreat, noted both the importance of mental oc- acts of violence (Sawyer 1879).
cupations and amusements and that many asylums By the end of the 1880s, there was recognition that
were lacking in the provision of these (Thirtieth An- the unparalleled progress in neurology, cerebral anat-
nual Report of the Officers of the Retreat for the Insane omy, physiology, pathology and localization of function
at Hartford, Connecticut 1855). He repeated this has enlarged the horizon of our knowledge of disease
theme 35 years later (Butler 1886). In this early period and of the action of causes (Andrews 1887, p. 199).
of inpatient psychiatry, the private facilities offered a re- This progress furnished a scientific and positive basis
markable array of activities for amusement and recre- for treatment in many cases of insanity which before
ation, including baseball, boating, bowling, calisthenics was unattainable (Andrews 1887, p. 199). Inpatient
and gymnasiums, concerts, cooking instruction, cro- treatments near the end of the nineteenth century in-
quet, exhibitions, fishing, French lessons, golf, horse- cluded electricity, massage, new medications and more
back riding, lantern slide shows, lectures, medicine rational prescribing, and oophorectomy (Andrews
ball, museums, pleasure grounds, reading rooms, skat- 1887); enforced rest (Sinkler 1892); hydrotherapy
ing, squash and tennis, stereoscopic views, tea parties, (Niles 1899); and physical training (Channing 1889).
and woodcarving (At the Pennsylvania Hospital for the These approaches, although suspect in retrospect, rep-
Insane 1852; Gymnasium for the Insane 1897; resented significant advances for inpatient psychiatric
Pennsylvania Hospital for the Insane 1854). Public treatment.
hospitals did less well in providing amusements but Hospitals devised new record-keeping systems to
had better developed work programs that were thought facilitate research (McLean Hospital, Waverly 1900);
to be important to patients recovery. expanded clinical-pathological laboratories (Psychia-
Despite all their efforts, private hospitals suffered try at the Sheppard and Enoch Pratt Hospital 1901);
from the premature removal of patients (Butler Hos- focused on such diseases as dementia praecox and
pital for the Insane 1856; Dr. Butler 1851; Dr. syphilis (Bloomingdale Hospital, White Plains
Stokes 1852; Pennsylvania Hospital for the Insane 1913); and hired physicians with research interests
1854; Sawyer 1879). In 1851, Butler expressed concerns and expertise (McLean Hospital, Waverly 1900). The
about the outcomes for patients who left the asylum too new focus on research is highlighted by a statement by
soon: Many have relapsed into an incurable state, Edward Brush, first superintendent of Sheppard and
while others remain half-crazed or nervous invalids, and Enoch Pratt Hospital: the most important function [of
will probably remain so for life (Dr. Butler 1851, p. a hospital] is to study disease, its causes, progress, pro-
187). Isaac Ray of Butler Hospital called the premature cesses, termination and prevention (Psychiatry at the
withdrawal of patients a most disheartening experi- Sheppard and Enoch Pratt Hospital 1901, p. 554).
ence of our calling (Butler Hospital for the Insane 1856, In the end, however, it was Thomas Kirkbride who
p. 252). The superintendents of the private facilities made the most prophetic commentary: So in regard
during this era (unlike public facilities) did not have the to the support of hospitals for the insane, it will be a
sad day for these institutions, and still sadder for the The falling percentage of patients in public hospi-
patients in them, when the rivalry of hospitals and tals in the 1930s and 1940s was due to the creation
their officers shall be, rather to discover for how little and expansion of veterans hospitals and in the 1960s
their inmates can be kept, than to secure what is best, was due, in part, to the expanding role of the general
and most thoroughly promotes the great objects for hospitals. From the 1930s through the 1960s, the per-
which they were established (Kirkbride 1875, p. 99). centage of the total psychiatric inpatients accounted
for by the private psychiatric hospitals was steady and
small. The transfer of care from public inpatient set-
The Middle Period (19211970) ting to the community during the 1950s and 1960s
contributed to the decline in utilization of state hospi-
Changes in American psychiatry between 1921 and tal beds.
1970 were dramatic and far reaching. In terms of
treatment modalities, psychoanalysis was introduced
to the inpatient setting in the 1920s. The 1930s wit-
1920s1930s
nessed the introduction of the somatic treatments: in- In 1920, the National Committee for Mental Hygiene
sulin coma, metrazol shock, and electroconvulsive surveyed institutions for persons with mental dis-
therapy (ECT) (Kalinowski and Hoch 1946). In the eases, mental deficits, epilepsy, alcoholism, and drug
1940s, attention was directed to establishing milieu addiction and found 625 institutions in the United
therapy in which all aspects of the patients life in the States, 388 public and 237 private. Thirty-two states
hospital were viewed as part of treatment (Robbins had private institutions for mental patients, but their
1966). In the 1950s, the introduction of the first anti- total census accounted for only 4% of the 232,680 per-
psychotic medication, chlorpromazine, fundamen- sons with mental disorders actually in psychiatric hos-
tally altered inpatient psychiatry (Smith 1955). And in pitals.
the 1960s, initial efforts to understand the mecha- Institutions to treat persons with mental illness
nism of action of psychotropic drugs (Snyder et al. continued to open throughout the 1920s, whereas
1970) began efforts that to this day shape our pharma- some private hospitals closed. In a 1923 report by the
cological armamentarium. U.S. Census Bureau, there were 267,617 patients in
Alternatives to psychiatric inpatient treatment, 526 (55% public) hospitals. This rate of 242 resident
such as the day hospital, were initiated and promoted. patients per 100,000 general population was an in-
Claims of being the first day hospital in North Amer- crease from the 1880 rate of 82. This change was at-
ica were made by hospital staff in Boston, Montreal, tributed to both an actual increase in the rate of mental
and Topeka. Psychiatric inpatient treatment based in diseases and a greater use of hospitals (Pollock 1925).
general hospitals developed during this period (Amer- During the 1920s, psychoanalysis was introduced
ican Hospital Association 1970; Glasscote and Kanno to hospitals. Occupational therapy, long used in public
1965). Psychiatrists attempted to improve diagnostic hospitals, became of greater interest to private hospi-
validity and reliability (Jackson 1970) and to promul- tals. It was stressed that therapeutic occupation
gate standards for inpatient psychiatric facilities should be conducted off the wards in an occupational
(American Psychiatric Association 1969). New con- building (Haas 1924)early psychosocial rehabili-
cepts, such as the rights of mental patients, emerged tation malls.
(Birnbaum 1960), and old nineteenth-century ideas In 1932, mental institutions represented 10% of
such as recovery reemerged (Menninger 1961). In- the total number of all registered hospitals but ac-
surances were developed or modified that began to counted for nearly 50% of the patient population in
cover the treatment of mental illnessboth private hospitals (Hospitals for Nervous and Mental Pa-
and public. tients 1933). Most patients were in public hospitals;
Perhaps the most outstanding change between private hospitals had just under 1% of all psychiatric
1921 and 1970 was the beginning of the shift from inpatients (Nineteen Hundred Thirty-Six Censuses
hospital-based to non-hospital-based care and treat- of Mental Patients 1938). Whereas public hospitals
ment of persons with mental illness, a movement were struggling with limited resources for ever-
retrospectively labeled deinstitutionalization but expanding patient populations420,553 nationwide
perhaps better characterized as dehospitalization in 1938private hospitals had rather impressive
(Geller 2000a). The peak year-end inpatient census for staffing ratios, with 1 physician for every 17 patients
all psychiatric patients occurred in 1955. (Hospitals for Nervous and Mental Patients 1933), 1
nurse per 3 patients, and 1 attendant per 4 patients the psychiatrist. Psychiatric patients organizing their
(Grimes 1934). own services and advocating for themselves has its
Private sanatoriums, often located near large cities, modern roots in the 1930s (Friedman 1939).
were run for profit, emphasizing comfort, hygiene,
sanitation, beauty, and pleasure (Grimes 1934). Pub-
lic hospitals were generally constructed away from
1940s1950s
population centers and sometimes replaced if an ur- The 1940s represent the nadir of Americas public
ban center spread too close to the institution. mental hospitals. Care of the mentally ill was described
The sanatoriums were often owned by physicians, as substandard and a national disgrace. Deficiencies of
wholly or in part (Grimes 1934). The ratio of physi- state hospitals are well documented in the pages of pro-
cians to patients at sanatoriums was 1:17. The nurse- fessional journals such as Mental Hygiene (Klapman
to-patient ratio was about the same, whereas the at- 1944). Exposs were available in books (Deutsch 1948),
tendant-to-patient ratio was 1:3.5 (Hospitals for Ner- magazines (Maisel 1946), and fictionalized accounts
vous and Mental Patients 1933). (Ward 1946). In 1945, The Modern Hospital noted, the
In the 1930s, somatic treatments moved from en- sorriest spectacle in hospital service to-day is the treat-
docrine replacement therapy to narcosis, insulin con- ment accorded the psychiatric patient (Modern Hos-
vulsive therapy, metrazol shock, and electroshock pital Announces Prize Competition 1945, p. 530). Pri-
therapy (Kalinowski and Hoch 1946). Other treat- vate mental hospitals could not fill the need because
ments included medication, hydrotherapy, psycho- they were just too costly. In 1945, the per capita annual
therapy, occupational therapy, physical therapy, and expenditure in state, county, and city hospitals was
even surgery. Recreation was deemed important. Psy- $391 and in private hospitals was $2,000 (Costs of
chotherapy focused on extending patients insight and Long-Term Mental-Hospital Care 1949). The middle
available affective expression (Menninger 1936). Pa- class could simply not avail themselves of private inpa-
tients discharged as recovered or improved repre- tient treatment. This meant that those with moderate
sented 65% of the total number of patients admitted incomes had no choice but the public hospital (Sher-
(Grimes 1934). man and Hoffman 1950).
There were also rest homes in the 1930s. These Attempts were made to improve inpatient treat-
provided primarily custodial care for persons with ment through the promulgation of principles and stan-
some financial means who needed mental medicine. dards, such as those put forward by the Division of
Activities were limited, discharge of patients was slow, Mental Hygiene of the U.S. Public Health Service, the
and many patients with chronic mental diseases lived National Committee for Mental Hygiene, and the
their lives out in these rest homes (Grimes 1934). APAs Committee on Psychiatric Standards and Poli-
New loci of treatment opened during the 1930s: cies, and through surveys (Liebman and French 1949).
the psychopathic hospital (Campbell 1930) and psy- One such survey found that of inpatient facilities with
chiatric ward in the general hospital (Heldt 1939). Al- fewer than 101 patients, 44 of 46 (96%) were private; of
though the presence of these psychiatric units was facilities with 1011,000 patients, 10 of 40 (25%) were
small (only 112 of 4,309 general hospitals had de- private; and of facilities with more than 1,000 patients,
partments for mental patients in 1932), general hos- 0 of 99 were private (Liebman and French 1949). A
pitals were rapidly adding psychiatric units. Such 1947 survey of private mental institutions found that
units were not always welcomed by hospital medical the total number of beds for mental illness (excluding
staff, who were concerned that noisy, destructive, vi- mental retardation, epilepsy, and alcohol and drug
olent or suicidal patients would disrupt the general abuse) in private sanatoriums, rest homes, and psychi-
hospital (Young 1939). atric units in general hospitals was 21,956. There were
The stigma of mental illness and of hospitalization 10 states and territories with no beds in these catego-
were prominent no matter what the type of hospital. ries of hospitals; 6 had fewer than 100, 26 had 100
In 1936, the American Journal of Psychiatry com- 999, and 6 had 1,000 or more beds. States in the last
mented on the worry over the disgrace of having category were, in descending order of number of beds,
been a patient in a mental hospital (The Stigma of New York, Pennsylvania, California, Illinois, Mary-
Mental Illness 1936, p. 476). This editorial sadly land, and Connecticut (Sherman and Hoffman 1950).
opined that psychosis as an illness to be considered Although there was relatively little hospital con-
and treated as a medical issue like other forms of dis- struction during the 1940s (Liebman and French
ability would do little to destigmatize the patient or 1949), the federal government became involved in the
provision of inpatient psychiatric services in ways it crease of 57% (from 5,534 psychiatrists in the United
had not done previously (Felix 1947). Much of the fed- States to 8,713) between 1950 and 1956, there was
eral effort was directed to the public sector, but the only one psychiatrist for every 19,200 citizens (Care
Hill-Burton Bill funded the construction of psychiatric and Treatment 1957). Between 1948 and 1957, during
units in general hospitals, and the National Mental most of which the public hospital census was increas-
Health Act supported research and training in private ing, the state hospitals improved their psychiatrist-to-
psychiatric facilities. patient ratio from 1:259 to 1:161. This 37.6% improve-
In the 1950s, attention turned to understanding ment still left them far from the APA minimum stan-
the psychiatric hospital as a social system (Greenblatt dard of 1:30 (Tallman 1960). It was estimated at the
et al. 1957). There was general agreement on the ob- end of the decade that an additional 12,000 psychia-
jective of any mental hospital (which sounds quite trists were needed (Squire 1961).
contemporary) to effect maximum improvement of Innovations did emerge during this dark era for in-
the individual patient as rapidly as possible. This patient psychiatry, a period made worse by the burden
should mean assisting him to return to the commu- World War II placed on these hospitals. Such innova-
nity as a contributing member of society (Myers and tions include the sending of follow-up questionnaires
Smith 1956, p. 6). If this objective could not be met, to discharged patients (Post-Release Questionnaire
the hospital was to work out the best adjustment pos- 1951), formation of ex-patient organizations (Club
sible for the patient within or without the hospital set- Formed for Patients, Ex-Patients, and Relatives
ting, with a persistent and continuous effort to im- 1950), desegregation of psychiatric hospitals (Stevens
prove the adjustment (Myers and Smith 1956, p. 6). 1952), evaluation of long-term intensive inpatient
Private hospitals accounted for less than 3% of the psychotherapy with psychotic patients, greater em-
total mental hospital beds, but they accounted for phasis on rehabilitation (Rehabilitation of the Men-
25%40% of the annual admissions to all mental hos- tally Ill 1954), and development of day hospitals
pitals (Reed 1958). Rapid turnover of patients was ac- (Hayman 1957). Somatic treatments initiated prior to
complished through a four-decade trend of maintain- 1950 continued to be used during the decade: frontal
ing fewer hard core patients, those hospitalized lobotomy (Freeman 1957), insulin shock therapy
beyond 3 years length of stay (Morris and Brunt 1957). (Brannon and Graham 1955), and ECT (Wolfe 1955).
Long-term patients were the responsibility of the state. The beginning of modern psychopharmacology
Many psychiatrists running private psychiatric hospi- was perhaps the greatest change in inpatient psychia-
tals expressed concern about these hospitals viability try in the 1950s. Treatment with chlorpromazine was
(Otis and Robinson 1951). The medical director of reported from both public and private hospitals (Ben-
McLean Hospital stated at the 1950 APA Institute (in nett et al. 1956; Kinross-Wright 1955). Research and
another quite modern-sounding refrain), The time development expanded during the later 1950s to in-
when you could run a private hospital as a hospital and clude promethazine (Erwin 1957), thioridazine (Co-
make money has gone. Operating expenses have so in- hen 1958), and imipramine (Azima and Vispo 1958).
creased that it is almost impossible to collect the cost
from our patients (Otis and Robinson 1951, p. 161).
1960s
Although some new private hospitals opened in
the 1950s, other long-established, private mental hos- In the 1960s, opinions about private psychiatric hos-
pitals went bankrupt, such as Norway Foundation in pitals varied from I doubt if many private mental hos-
Indiana and Butler Hospital in Rhode Island (Reed pitals will survive the next ten years (Barton 1962,
1958). (Butler Hospital reopened 1 year after it closed p. 661) to The private mental hospital will continue
in response, in part, to public support.) The demise of to be the central or primary resource supplying the
these two hospitals was attributed to expanding com- psychiatric needs of the community (Jones 1964,
petition from general hospital psychiatric units (Dunn p. 336). One private hospital attending psychiatrist
1951), the inability to charge patients what they could proclaimed, It is the role of the private psychiatric
afford and be able to meet expenses (Reed 1958), de- hospital to be the leader, the pilot, on all fronts, in ex-
caying physical plants, and staff dissatisfaction (Reed ploring new areas in the prevention and treatment of
1958). Health insurance coverage that excluded men- mental illness, in setting and maintaining standards,
tal disorders (Bennett 1959) made matters worse. in fostering true multidisciplinary cooperation and ac-
The absolute shortage of psychiatrists impacted tivity, and in serving the community (Bernard 1964,
negatively on all inpatient psychiatry. Despite an in- p. 22). Identified advantages of private hospitals in-
cluded creating a microcosm of the community at Betz 1960), the nurse (Payne 1966), the social worker
large (Wayne 1961); providing patient-centered treat- (Pinsky and Levy 1964), the psychiatric aide (Bernstein
ment (Bernard 1964; Wayne 1961); better integrating and Herzberg 1970), and the multidisciplinary team
inpatient services into longitudinal treatment of the (Howard 1960). Psychiatrists grappled with under-
patient (Myers 1961); better serving first admissions standing such concepts as therapeutic community
(Bernard 1964; Wayne 1961); treating patients for (Gralnick and DElia 1969) and countertransference in
shorter lengths of stay (Garber 1961); maintaining a milieu treatment (Wesselius 1968); improving inten-
better-trained staff with less administrative interfer- sive rehabilitation (Howard 1960); and understanding
ence with clinical practice (Bernard 1964; Myers the effects of social competence on prognosis (Rosen et
1961); and providing treatment in a less stigmatizing al. 1968).
environment (Garber 1961). Much happened in the 1960s that influences
Inpatient psychiatric hospitalization outside of American inpatient psychiatry to this day: American
state hospitals became more available as health insur- presidents such as Kennedy (1964) and Johnson (Pres-
ance for hospitalization expanded to include psychiat- ident Johnson Signs Comprehensive Health Planning
ric treatment (Coordinating Committee on Profes- Bill 1967) showing a greater interest in mental health;
sional Standards in Psychiatry 1961). Early efforts to members of the American bar advocating that commit-
include psychiatric treatment were made by the Federal ted psychiatric patients had a right to treatment (Ba-
Employees Health Benefits Program in 1962 (Anster zelon 1969; Birnbaum 1965); new public funding
1969), the United Auto Workers and the automobile streams for psychiatric treatment (Gibson 1967); and
industry in 1965 (Anster 1969), the Health Insurance new standards for psychiatric facilities, including those
Plan of Greater New York in 1965 (Goldensohn et al. defined by Wyatt v. Stickney (1971).
1969), Medicare in 1966 (The Effect of Medicare on In 1966, Lawrence Kubie forecasted the necessary
the Accreditation of Psychiatric Hospitals 1966), and expansion of the private psychiatric hospital into a
Blue Cross/Blue Shield nationally in 1969 (Anster treatment center with residential, vocational, edu-
1969). Problems due to the perceived misuse of insur- cational and recreational components; with simple
ance for hospitalization for mental illness were already and natural pathways in and out of the hospital; with
recognized in the 1960s. To remedy these, proposed in- intensive inpatient treatment, night-care, and day-
terventions included peer review (Anster 1969), reim- care centers; and with an expanded array of tasks and
bursement for partial hospitalization and other alterna- activities never previously thought to be functions of
tives to inpatient treatment (Felix 1965), and national the private psychiatric hospital. Kubie (1968) doubted
health insurance (Gorman 1969). Dumping and that the community could ever serve the needs of pa-
cost shifting emerged as part of the everyday life of in- tients without psychiatric hospitals. Many of Kubies
patient psychiatry. As one public hospital superinten- thoughts echo those of his nineteenth-century prede-
dent lamented, Most Blue Cross plans cover mental cessors.
illness for only 21 days. So the patient goes to a private
institution for three weeks. If he gets well, he goes
home, saved from disgrace. If he fails to get well, he
The Modern Era (19712007)
comes to us. Result: we get the failures, plus the blame
for having failures (Davidson 1964, p. 280). It was in 19691970 that the Survey and Research
During the 1960s, the public sector became focused Branch of the National Institute of Mental Health,
on psychotropic drugs effects on state hospital utiliza- and subsequently the Center for Mental Health Ser-
tion (Brill and Patton 1962) and the simultaneous use vices, began to regularly collect data on all providers of
of two or more tranquilizers, already referred to in mental health services. The National Association of
the 1960s as polypharmacy (Merls et al. 1970). Uni- Psychiatric Health Systems collects data annually on
versity departments of psychiatry and private hospitals its membership. Other data sources include the Amer-
were examining comparisons of the usefulness of the ican Hospital Association; the National Mental
different phenothiazine derivatives (Casey et al. 1960), Health Facility Study, funded by the National Institute
mechanisms of action of antidepressant medications of Mental Health, and publishing results circa 1988;
(Schildkraut et al. 1971), and the merits of unilateral the APA and the National Association for Mental
rather than bilateral ECT (Whiteborn and Betz 1960). Health conjointly as the Joint Information Service; the
Hospitals, especially private ones, were interested in National Association of State Mental Health Program
refining the roles of the psychiatrist (Whiteborn and Directors; and others.
Considering all sources of data, it is clear the total 1970s

number of inpatients in the United States declined
steadily from 1970 to 2000. The number of inpatient In the 1970s, states were contemplating phasing out
beds and percentage of the total that belonged to state state hospitals (California Announces Plans to Close
hospitals declined steadily from 1970 to 1998; private State Hospital 1973; Massachusetts Study Proposes
hospitals showed an increase of both until a decline Phase-Out of State Mental Hospitals 1974), and gen-
began after 1990; and general hospitals showed a general hospital psychiatric units were becoming more of
erally steady increase in both. In 1970, the bed distri- a presence (Flamm 1979). In 1971, the average num-
bution was state hospitals, 78.7%; private hospitals, ber of beds in a general hospital psychiatric unit was
2.7%; and general hospitals, 4.3%. By 1998, the per- 35 (median 28), representing about 9% of the hospi-
centages were 24.3%, 12%, and 20.7%, respectively. tals total beds; the average length of stay was 11 days
The number of facilities and number of occupied (Greenhill 1979). The expanding role of general hos-
beds show a similar pattern. In 1969, there were 310 pital psychiatry drew caution from some who warned
state and county hospitals with 309,969 patients; pri- general hospital staff to be on guard against some
vate hospitals numbered 150, with a year-end census growing efforts to convert general hospital units into
of 10,963; and the 604 general hospital psychiatric miniature state hospitals (Flamm 1979, p. 191).
units had 17,808 beds. By 1998, the numbers had In the early 1970s, little attention was paid to im-
shifted: 229 state and county facilities had 56,955 pa- proving the private sector s capacity for, and integrat-
tients; 348 private psychiatric hospitals had 21,478 ing the private sector into, the treatment of persons
patients; and 1,593 general hospitals had 37,002 pa- with the most debilitating psychiatric illnesses (Kanno
tients. In 2000, for the first time in three decades, the 1971). However, private psychiatric hospitals began
number of facilities decreased in all three categories. undergoing a fundamental change in the 1970s. In the
The total number of admissions increased progres- 1960s, long-term inpatient care was thought to be the
sively from 1969 through 1998, as did the percentage best treatment money could buy (Stone 2003); hospi-
of admissions accounted for by private psychiatric tals provided psychoanalytically oriented treatment at
hospitals. In the 1990s, private hospitals had small in- a leisurely pace that involved months or years of hos-
creases in the number of admissions; there were de- pitalization (Hirschowitz 1974, p. 730). Declining
creasing numbers of state hospital admissions gener- numbers of individuals willing or able to pay for such
ally compensated for by increased admissions to treatment and more readily available third-party cov-
general hospitals. From the 1960s through the 1990s, erage led to private hospitals admitting patients of dif-
the private and general hospitals consistently had a ferent socioeconomic and ethnic backgrounds and
greater percentage of admissions than they did per- keeping them for shorter lengths of stay. For some, this
centage of beds, reflecting shorter lengths of stay than shift was not made easily (Hirschowitz 1974).
at state and county hospitals. At the end of the 1970s, the president of Pennsyl-
The work settings and caseloads for inpatient psy- vania Hospital opined on the major problems facing
chiatrists shifted substantially from 1976 to 1998. In psychiatrists in American hospitals: 1) rising health
1976, there were 45 patients per psychiatrist in public care costs, 2) planning and coordinating of health ser-
facilities, 8 per psychiatrist in private hospitals, and 5 vices for the good of all segments of the community, 3)
per psychiatrist in general hospitals. Over the two de- costly, confusing, onerous, duplicative, and
cades that followed, the burden on the public psychia- counterproductive regulations, 4) growing demand
trist improved, that of the private hospital psychiatrist to collect data and provide survey information, and 5)
worsened, and that of the general hospital psychiatrist questions about the best manner in which to govern
experienced little change. By 1998, psychiatrists case- hospitals (Cathcart 1979).
loads were 20 patients in public hospitals, 12 in private
hospitals, and 4.5 in general hospitals. 1980s
Expenditures per civilian population between 1969
and 2000 decreased steadily for the public hospitals, In 1982, an article published in Hospital and Commu-
peaked for the private hospitals in 1990, and increased nity Psychiatry predicted private hospitals would in-
for the general hospitals until 1994. These expendi- creasingly be owned by large corporations, whereas
tures for the private hospitals were 345% higher in sole-proprietorship and individual hospitals would de-
1990 than in 1969 but were 23% lower in 1994, 55% crease (Pottash et al. 1982). This became true, and
lower in 1998, and 63% lower in 2000 than in 1990. more quickly than the authors might have imagined.
Expansion in the private sector in the 1980s was Proponents of psychiatric chains claimed that they
both remarkable and not distributed across the United were poised to take on the public sector: By the end of
States based on need. Distribution favored those states the decade, the private sector will have replaced most
with the fewest regulations. By the end of the 1980s, of the psychiatric services currently provided by fed-
states without certificate of need laws had an average eral, state and local governments (Kuntz 1981, p. 90).
of 33% more for-profit psychiatric beds than did regu- Although this point was never reached, innovations
lated states (Sharkey 1994). About two-thirds of pay- that could affect privatepublic partnerships were ex-
ments came from patients fees in the 1980s, but Med- plored and in some instances implemented (McNeil et
icaid and state mental health agencies began to become al. 1980).
more prominent payers as the 1980s progressed. In the early 1980s, there was a debate throughout
The 1980s presented a real opportunity for the the United States as to which sectors of psychiatric in-
growth of private psychiatric hospitals (Dorwart and patient treatment should be responsible for involun-
Schlesinger 1988; Levenson 1982). Private corpora- tary admissions and/or difficult-to-manage patients.
tions were ready to seize this opportunity to realize In 1980, the Massachusetts Psychiatric Society dis-
huge profits in the psychiatric hospital industry seminated a position paper on involuntary psychiatric
(Levenson 1982; Schlesinger and Dorwart 1984; Shar- admissions to general hospitals, asserting 1) there
key 1994). For-profit psychiatry, especially with its should be separate locked and unlocked units; 2) gen-
control of a large percentage of psychiatric beds, cre- eral hospitals should not be required to lock units; 3)
ated its own set of problems. For-profit hospitals were involuntary patients should be staffed as though they
the least likely to treat the most functionally disabled; required psychiatric intensive care; 4) not all invol-
would treat few, if any, patients who could not pay; untary patients could be treated in a general hospital;
usually had poorer staff-to-patient ratios than non- 5) unresolved legal issues impeded implementation of
profit hospitals; failed to provide education to students involuntary treatment; 6) specially designed units
and professional trainees; failed to contribute ade- would be required; 7) adequate reimbursement would
quately to research; provided a lower quality of care have to be established; 8) the general hospital must be
overall (Eisenberg 1984; Levenson 1982); were disen- able to control its admissions and discharges; 9) par-
gaged from the communities in which they were lo- tial hospital programs must be developed; and 10)
cated (Dorwart et al. 1989); and hired away graduating there could not be arbitrary governmental mandates
residents from academic and public-sector jobs with (McNeil et al. 1980).
higher salaries (Brodie 1983). Evidence accumulated Psychiatric hospitalization was becoming progres-
by mid-decade did not support the belief, much to the sively more expensive, especially for the major payers:
surprise of many, that for-profit hospitals were more business and the federal governm ent. Evidence
efficient (Schlesinger and Dorwart 1984). Nonethe- emerged that private psychiatric hospitals were at-
less, state governments began embracing privatization tempting to maximize the use of reimbursable days. A
of state mental health services (Dorwart et al. 1989). study of more than 120,000 persons ages 1322 years
In 1979, there were 7 psychiatric hospital chains showed that as days in hospital were approved at 7-day
(Levenson 1982). By 1982, most of the proprietary psy- intervals, so too was there a pattern of peaks of dis-
chiatric beds were owned by chains, and the chains charge at 7-day intervals (Sharkey 1994). In a study of
power and influence rose. In 1983, there were 25 psy- 32,240 discharges from private psychiatric hospitals,
chiatric hospital chains. By 1984, there were 75 such those discharges covered by Medicare showed a ratio of
chains. By 1983, the for-profit psychiatric chains were Medicare-covered days to total inpatient days near 1:1.
dominated by four corporations: Hospital Corporation To counteract escalating costs, employers began to
of America (HCA) in Nashville, Tennessee, with 3,162 adopt mechanisms to control psychiatric hospitaliza-
beds; Charter Medical Corporation in Macon, Georgia, tions in the late 1980s (Sharkey 1994). Early efforts,
with 2,422 beds; National Medical Enterprises, Inc., in such as prospective, concurrent, and retrospective uti-
Los Angeles, California, with 1,952 beds; and Commu- lization review, were quickly supplemented by pro-
nity Psychiatric Centers in Pomona, California, with spective payment, capitation, insurance deductibles,
1,838 beds. The growth and revenues of these for-profit copayments, and annual limits on inpatient days.
psychiatric hospital chains throughout the 1980s can Managed care companies specializing in psychiatric
only be called astounding. By the mid-1980s, the four services management sprang up and almost as quickly
major providers of private psychiatric hospitals/beds consolidated to provide a range of products to con-
controlled 85% of the market (Sharkey 1994). trol costs (Geller 1998). Some of these companies
were accused of overly restricting access because at- called into question, based in part on U.S. Department
risk contracts provided them a financial incentive to of Justice intelligence regarding fraud by private hospi-
do so. Monitoring a patients progress and refusing to tal chains (Sharkey 1994). Hospital chains began expe-
pay once the patient could be taken out of the hospital riencing major losses, as high as $201.9 million in
to less expensive alternative care was not new to this 1994. Assets were falling and lawsuits were flourish-
era. Similar processes had been used by cities and ing, with settlements in the hundreds of millions of
towns when they bore the expenses for hospitalization dollars (NME to Provide $2.5 Million in Free Patient
of their residents at asylums in the nineteenth century Care as Part of Settlement Agreement in Texas Law-
(Grob 1983). suit 1992; Sharkey 1994; Tenet Agrees to Pay Pa-
The 1980s did not lack for interest in what was oc- tients $100 Million in Malpractice Claims 1997).
curring in psychiatric hospitals, such as who was be- Several phenomena affected the fate of all psychi-
ing treated, by what methods they were treated, and atric hospitals in the 1990s. First among these is man-
what the staff s and patients perceptions of treatment aged care. By 1990, the provision of utilization man-
were. A study at Highpoint Hospital in New York agement (i.e., preadmission certification, concurrent
showed that when comparing the 1980s with the utilization review and case management) had become
1960s, inpatients in the 1980s were younger (mean a major industry in and of itself. Although utilization
age dropped from 38 to 25 years); less likely to be diag- management might have some beneficial effects,
nosed with a schizophrenic disorder and more likely to Sharfstein (1990) pointed out in 1990 that the vast
be diagnosed with an affective disorder; considerably majority of utilization management. ..has as its objec-
more likely to have a substance use disorder; less likely tive cost containment pure and simple (p. 965).
to be referred by a physician (a drop from 90% to 50%); The loss of the psychiatrists autonomy and treat-
and likely to have a length of stay half as long (a drop ment decision-making authority produced widespread
from 2 years to 1 year) (Gralnick and Caton 1992). consternation (Schlesinger et al. 1996; Sharfstein
Researchers at the Menninger Foundation con- 1990; Wickizer et al. 1996). In a survey of 2,541 psy-
ducted a study of staff perception of difficult inpa- chiatrists with active hospital affiliations, almost two-
tients. Their findings indicated withdrawn psychot- thirds reported needing prior approval from insurance
icism was the variable most related to perceived companies for admission and more than three-quar-
difficulty. The next most related factor was character ters indicated some pressure from insurance compa-
pathology. The suicidedepressed and violence nies to discharge patients earlier than they thought
aggression factors were less related to perceived dif- clinically appropriate (Schlesinger et al. 1996). Analy-
ficulty. The authors speculated that the false notion sis of 2,265 utilization management cases revealed an
violence looms large in the perception of difficulty overreliance on treatment protocols and evidence that
is secondary to administrative concerns and episodic almost all cases received prior approval for the same
concerns about violent patients (Colson et al. 1985). number of days despite a wide range of diagnoses
McLean Hospital staff studied patients satisfac- (Wickizer et al. 1996).
tion with their hospital treatment 3 months after dis- The fact that cost benefits were examined from the
charge. Rated as having the greatest degree of satisfac- perspective of the insurer but little account was taken
tion was the high quality of the staff (especially of the hospitals costs in executing repeated requests
paraprofessionals and nurses); rated as lowest was the for extensions of stay was particularly burdensome for
cost of treatment. Patients were also quite dissatisfied psychiatric hospitals (Sharfstein 1990; Wickizer et al.
with the information they received regarding their 1996). In the same analysis of the 2,265 cases just
treatment and progress (Eisen and Grob 1982). mentioned, investigators found that 70% of patients
were approved for one or more treatment extensions
and 40% of patients with extended stays had had three
1990s or more requests (Wickizer et al. 1996).
Throughout the 1990s, the total and average number Managed care did decrease length of stay, and it ap-
of beds per private hospital decreased, as did the aver- peared to do so progressively through the decade.
age length of stay (National Association of Private Psy- Shorter lengths of stay meant increased pressure on
chiatric Hospitals 1991, 1992; National Association of private and general hospitals to keep beds filled and in-
Psychiatric Health Systems 1993, 1994, 1995, 1996, creased pressure on patients. One study found that
1997, 1999, 2000, 2002, 2003). In the early 1990s, the close scrutiny by insurance companies became a ma-
practices the chain hospitals had used to fill beds were jor stressor to patients: insurance review became a
focus of treatment; staff felt pushed into demanding Olfson and Mechanic 1996), and in data from Mary-
improvement at a rate patients could not reasonably land (Minkin et al. 1994) and Massachusetts (White
meet; and the more adversarial and irrational the re- et al. 1995), for example, consistent variables emerged
view process, the more likely it was to feed into pa- that distinguished public from private admissions: be-
tients and families preexisting psychopathology havioral history, diagnoses, and insurance. A greater
(Gabbard et al. 1991). reliance on the private system for those formerly
Psychiatric hospital staff were generally dissatisfied treated in the public system precipitated many unin-
with utilization management firms. In findings re- tended consequences, including inpatient treatment
ported from a 1990 survey of 136 hospitals, 51% of farther from ones home community (Geller 1991),
hospitals indicated that patients left against medical less continuity of inpatient treatment and associated
advice after a reviewer said that treatment would not longer lengths of stay (Geller et al. 1998), new loci and
be covered; 49% reported that patients did not receive patterns of recidivism (Geller et al. 1998), and an on-
appropriate follow-up treatment because it was not going debate about quality of care in private versus
covered; 47% said that preadmission review prevented public settings (Dorwart et al. 1991). One measure of
patients hospitalizations; 48% reported that utiliza- quality of care, staffing ratios (Dorwart et al. 1991),
tion management firms lacked specific psychiatric cri- showed a narrowing of the difference between public
teria; 56% indicated difficulty making telephone con- and private facilities as the ratio of psychiatrists to pa-
tact with these firms; and 82% said that reviewers were tients improved in the public sector.
unfamiliar with local resources (Private Psychiatric The concept of treatment in the least restrictive
Hospitals Report Wide Dissatisfaction With Managed alternative affected all inpatient settings. An ill-
Care Reviews 1990). Hospitals were particularly con- defined concept, such treatment nonetheless was used
cerned about these firms lack of understanding of the to justify many alternatives to inpatient settings. The
relationship between psychiatric symptoms and social general and private hospitals were seen as less restric-
support systems. Hospital staff were taxed by spending tive than the public hospitals for not entirely clear rea-
an average of 63 hours per week on utilization man- sons (Geller 1991), but all manner of alternative ser-
agement issues (Managed Care Survey Finds Im- vice arrangements were seen as less restrictive than
provements, But Problems Remain 1991). any hospital for acute or longer-term care and treat-
By 1993, a survey of 141 private psychiatric hospi- ment (Geller 2000b; Sledge et al. 1996).
tals showed improvements had been made. Reviewers
were more often clinicians (70% of respondents), and
these reviewers usually had experience in psychiatric
20002007
or substance abuse treatment (65%). However, com- In 2001, the United States had 5,558 nonfederal hos-
plaints remained about preadmission reviews prevent- pitals, of which 479 were psychiatric hospitals. These
ing admissions (71%), reviews requiring discharges hospitals had a total of 88,762 beds and 25,078,529
too early (89%), and discharges against medical advice inpatient days. Of 4,728 general hospitals, there were
when coverage was denied (51%) (National Associa- 1,778 (37%) with psychiatric inpatient care. Inpatient
tion of Psychiatric Health Systems 1993). psychiatry in the United States had become a business.
The 1990s saw the privatization of public mental As one observer noted, Madness has become an in-
health services (Dorwart and Epstein 1993) in what dustrialized product to be managed efficiently and na-
could be considered a return to the early-nineteenth- tionally in a timely manner as it passes through the
century utilization of private hospitals for public pa- hands of clinic workers (Donald 2001, p. 435).
tients. Medicaid, Medicare, and state funds were di- In a meta-analysis comparing for-profit and non-
rected to the private sector to greater degrees (Dorwart et profit psychiatric inpatient care between 1980 and
al. 1991). States assisted freestanding private hospitals 2001, the major finding was the performance superi-
in obtaining waivers of the IMD (Institution for Mental ority of the nonprofit psychiatric providers compared
Diseases) rule (Geller 2000a) to become Medicaid eligi- with the for-profit providers. .. the overwhelming ma-
ble (Geller 1998) and developed public-sector managed jority of the studies undermine a performance ratio-
care contracts, sometimes bypassing the states depart- nale for public policy decisions to expand for-profit
ment of mental health entirely (Geller 2000b). inpatient healthcare (Rosenau and Linder 2003,
Evidence emerged that the private psychiatric hos- p. 186). Nonetheless, that is what state governments
pitals were not equally welcoming to all public-sector continued to do. Downsizing state workforces ap-
patients. In national data sets (Dorwart et al. 1991; peared to take precedence over other considerations.
The practice of psychiatry appears to have shifted liability insurance, escalating pharmaceutical costs,
in response to shorter lengths of stay. A study at and more regulatory requirements (National Associa-
McLean Hospital in 2002 comparing inpatient anti- tion of Psychiatric Health Systems 2003b).
psychotic medication use in 1989, 1993, and 1998 Oversight is increasing. As one example, the Office
showed that the chlorpromazine-equivalent final total of the Inspector General of the Department of Health
dosage of all antipsychotic medications used at dis- and Human Services has stepped up its investigation
charge in 1998 was 29.3% greater than in 1993 and of inpatient Medicaid claims for 21- to 64-year-olds
46.1% greater than in 1989. The average time from who were patients in freestanding psychiatric hospi-
admission to first antipsychotic dose decreased precip- tals (Office of Inspector General 2002, 2003) while
itously from 6.8 days in 1989 to 1.5 days in 1993 and criticizing the Centers for Medicare and Medicaid Ser-
0.9 days in 1998. Two or more antipsychotic medica- vices for conducting an inadequate number of surveys
tions were used during 20% of inpatient days in 1998, and for being too reliant on the findings of the Joint
4 times the use in 1993 and more than 10 times the Commission on Accreditation of Healthcare Organi-
use in 1989 (Centorrino et al. 2002). zations. The Office of the Inspector General recom-
Since 2000, more attention has been paid to man- mended a minimum number of facility reviews per
aged cares effects on inpatient utilization, and the cycle and a coordination of efforts of all external re-
voices of critics have not quieted. One critic lamented, viewers.
These managed care algorithms represent more than Public hospitals also face uncertain economic
they claim, for they do not represent an advance in sci- times. Medicaids progressive decrease of dispropor-
entific knowledge of the Natural world of mental ill- tionate share payments to public mental hospitals
ness so much as they reproduce a moral ideology and (Office of Inspector General 2002) is stressing some
actively encourage a notion of personhood and a psy- states ability to operate their public system at its pre-
chiatric science more suitable to business and con- 2000 scale.
sumer culture (Donald 2001, p. 435). The landscape of American inpatient psychiatry,
Much of the financial news of the early years of the both private and public, is changing dramatically in
twenty-first century bodes poorly for psychiatric hos- the first decade of the twenty-first century. In 2001,
pitals. Although overall health care spending in- the five private psychiatric hospitals remaining in
creased by 15.7% between 1992 and 1999, mental Maryland were having financial problems. More than
health and substance abuse spending decreased by 50% of their admissions were publicly funded, and re-
17.4%. Behavioral health care spending went from imbursement was about $100 per day less than costs
7.2% of total private health insurance spending to (Taylor 2001). One of these hospitals, Taylor Manor,
5.1% during this same time period (National Associa- sold its license to operate inpatient and adolescent res-
tion of Psychiatric Health Systems 2003b). idential beds to Sheppard Pratt Health System. An-
These changes are impacting all psychiatric hospi- other, Chestnut Lodge, closed its doors in April 2001
tals. Total and per-capita expenditures for services in after 90 years in operation; it was bankrupt, and a pub-
private hospitals are falling disproportionately to lic effort to save it was unsuccessful. In the spring of
lower inpatient utilization. Between 1994 and 2000, 2000, the Menninger Clinic of Topeka, Kansas, needed
utilization decreased by 32% whereas expenditures a dramatic fix. The previous year the clinic had had
decreased by 56%. The public hospitals did not fare as 2,238 admissions to its 143 beds but lost $2.9 million.
poorly: beds decreased by 25% and expenditures by Menninger Clinic transferred its 48-bed acute pro-
29%. The general hospital units actually had a lower gram to another hospital in Topeka and moved the rest
decrease in expenditures (13.5%) than in beds (23%). of its operation to Houston, Texas (Petterson 2002).
Although inpatient occupancy rates rose in the pri- In the public sector, state actions are all over the
vate hospitals (there are fewer hospitals), hospitals of- place. States, counties, and municipalities continue to
fering partial programs or those offering outpatient close public hospitals even in the face of negative press
services dropped by 20%25% between 2000 and about alternatives (Bonner 2007; Sullivan and Selig-
2001 (National Association of Psychiatric Health Sys- man 2003). Pennsylvania continued to downsize its
tems 2003a). Reimbursement rates have fallen such public bed supply, closing several hospitals. North
that they often do not even meet the total costs of care Carolina was building a new hospital to replace two
and treatment (Frank et al. 2003). As reimbursement hospitals in the Raleigh area; Massachusetts was do-
rates fall, costs to deliver treatment increase, attributing the same in the central part of the state. Vermont
able to workforce shortages, increasing professional has plans to close its 50-bed state hospital and partner
with the University of Vermont to build a new hospi- cover 13 wards with a census of 2,300 patients (Ram-
tal. Oregon is replacing its aging state hospital in Sa- seur 2005).
lem with two new facilities. Nevada has opened two In the first decade of the twenty-first century, inpa-
state hospitals since 2000. California built a 1,500- tient psychiatry appears to be in a position to move
bed facility for forensically committed individuals, back toward its roots of enlightened care and treat-
representing the first new California facility in more ment. To do so, and to avoid descending into a state
than 50 years. New Jersey replaced Greystone Park like the abyss that followed World War II, all aspects of
Psychiatric Hospital. The list goes on. inpatient psychiatric treatment should be under re-
States continue to operate their public hospitals view. Hence this book.
under two distinct models: those that take acute pa- Psychiatric hospitals are shrinking, growing, being
tients (mostly the uninsured, underinsured, publicly torn down, and being newly built all at the same time.
insured, or behaviorally out-of-control) and those that Debates are ongoing as to the actual effect of public-
direct all acute admissions to the private sector, reserv- sector managed care (Domino et al. 2004) and the
ing the state hospitals for the longer-term patients. misutilization of jails and prisons as substitutes for
Most states have seen the percentage of forensically psychiatric hospital beds (Banks et al. 2000; Domino
committed patients climb dramatically (Bloom 2006; et al. 2004). Persons in need of inpatient treatment, be
Texas Department of State Health Services 2006) de- it acute or longer term, find themselves at a loss be-
spite concurrent transinstitutionalization to jails and cause the beds do not exist (Bloom 2006). Beds may
prisons. The state hospital situation has raised more not exist or be accessible because the size of the net-
concerns about staff safety than have been heard for works providers is limited as a means of controlling
decades and led one medical director to quip, We used cost, and/or reimbursement rates are lower than the
to be civil. hospitals expenditures (Appelbaum 2003). As if that
is not enough, the Centers for Medicare & Medicaid
Services is phasing in the prospective payment system
Conclusion for inpatient psychiatry; armed forces returning from
Iraq and Afghanistan are putting new demands on the
Inpatient psychiatry started out with the best of inten- mental health system (Hoge et al. 2004); and some
tions, awash in magnificent beneficence (President fear that privatization of formerly public inpatient ser-
Franklin Pierces description), with asylums reporting vices means less oversight, with risks to persons with
cure rates approaching 100%. All too soon the power- serious mental illness (Holcomb and Heyman 2002).
ful scourge that insanity proved to be simply over- However, none of these problems is insurmountable.
whelmed available resources. Take Danvers State Hos- All persons involved in the design, implementation,
pital in Massachusetts, for example. It opened in May funding, and monitoring of hospital psychiatry need to
1878 amidst public admiration that it was light, airy, recognize the fundamental role hospital psychiatry
cheerful . . . with magnificent arrangements (Open- plays in our health care system.
ing of the Hospital 1878). The facilities were such As the future of hospital psychiatry evolves in this
that persons might not even know they were in an asy- century, perhaps we would do well to keep in mind the
lum, and hence the cutlery was stamped only Dan- sage advice Edward Jarvis gave to the AMSAII in the
vers, not Danvers Asylum or Danvers Hospital mid-nineteenth century:
(Opening of the Hospital 1878). At the turn of the
twentieth century, the hospitals caliber of profes- The wise manager of the insane carefully analyzes
sional care and treatment was such that no restraint or the condition of his patients, and ascertains what el-
ements are diseased and what are sound. Having de-
seclusion was used (Page 1904). Yet the hospitals su-
termined this, he cautiously respects and avoids all
perintendent was soon lamenting, It may be asserted interference with every power and faculty, every prin-
that the lunatic hospital, per se, is not a remedy for in- ciple, opinion, emotion, taste or desire, that is in
sanity. In fact, as generally regarded by its inmates, it good health, and applies his influence only to such as
provokes inimical effects and in some cases aggravates are not in good condition, and this he does in such a
way as not to disturb the others. He therefore, so far
the mental disease . . . . The physician may render
as is consistent with the patients recovery or best
some important service, but he is greatly in the dark as progress, applies no restraint, opposes no purpose,
to the actual requirement (Ramseur 2005, p. 103). By denies no indulgence, contradicts no opinions that
1946, conditions were simply frightening. On Septem- are not disordered, and do not minister to the dis-
ber 13 of that year, there were nine staff persons to ease. Thus he sustains as great an amount of healthy
mental and moral constitution as possible, by means Brannon EP, Graham WL: Intensive insulin shock therapy: a
of which he hopes to overcome the disturbance in five-year survey. Am J Psychiatry 111:659663, 1955
those which are diseased. (Jarvis 1860, p. 28) Brill H, Patton, RE: Clinical-statistical analysis of popula-
tion changes in New York State mental hospitals since
introduction of psychotropic drugs. Am J Psychiatry
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Part I
INPATIENT
PRACTICE
CHAPTER 2
THE ACUTE CRISIS STABILIZATION

UNIT FOR ADULTS
Ira D. Glick, M.D.
Rajiv Tandon, M.D.
W ith the introduction of a range of effective psy- creased very significantly; this fact is supported by the
chopharmacological therapies in the 1950s, the func- greater severity of illness required to meet medical
tion of psychiatric hospitalization changed from hu- necessity criteria to qualify for hospitalization and
mane long-term care to active treatment. Whereas the greater severity of illness at the time of discharge.
short-term psychiatric hospitalization back then re- These trends are not unique to the United States and
ferred to hospital stays of less than 1 year, during the are seen in countries across the world (Glick et al.
1970s the average length of short-term psychiatric 2003; Lelliott 2006; Ruud et al. 2006; Walsh 2006).
hospitalization decreased from 1 month to 2 weeks Settings in which acute inpatient psychiatric care
and has now been reduced to less than 1 week on av- may be provided vary substantially and include psychi-
erage (Glick and Hargreaves 1979; Glick et al. 2003; atry units in a general hospital, specialized private or
National Association of Psychiatric Health Systems public psychiatry hospitals, crisis stabilization units
2000; Sederer and Rothschild 1997). At the same that may or may not be attached to a hospital, and
time, the number of admissions has risen steadily, as short-term residential treatment facilities (Geller
has the severity of illness of the patients admitted to 2006; Lipsitt 2003; Walsh 2006). Of the approximately
inpatient psychiatry units. Both patient turnover and 150,000 psychiatric inpatient beds in the United
the acuity of illness on the inpatient unit have in- States today, approximately one-third are in general
We appreciate reviews and critiques by Rose Marie Sime, M.D., and Michael D. Jibson, M.D., Ph.D. We thank
Grady Carter, M.D., for his contribution to an earlier version of this chapter.
23
hospitals, one-third in state psychiatric hospitals, and for treatment for clinicians, focusing on the following
the remainder in freestanding psychiatric hospitals functions of the hospital unit:
and crisis stabilization units. It is astounding that al-
most one-fourth of all stays in U.S. community hospi- 1. Safety: Keeping a patient safe (medically and from
tals for patients 18 years of age and older7.6 million harming self) and keeping others safe from the pa-
of nearly 32 million staysinvolved depression, bipo- tient (aggression and other destructive behavior)
lar disorder, schizophrenia, and other psychiatric dis- 2. Diagnosis and triage: Providing an opportunity for
orders or substance userelated disorders in 2004, ac- intensive monitoring and diagnostic assessment
cording to a new report by the Agency for Healthcare that might, for example, enable a clinical outpa-
Research and Quality (2004). There are considerable tient impasse to be broken, and thereby changing
differences in the staffing and scope of services that can posthospital readmission patterns
be provided at each of the types of psychiatric hospital 3. Treatment: Implementing or initiating a rigorous
settings, and the licensing and other regulatory ele- treatment strategy aimed at changing the course of
ments vary as well. Although each of these settings the illness
currently experiences stress from a different set of fis- 4. Respite: Providing education and respite to caregiv-
cal and competitive pressures, the settings share sev- ers and outpatient treatment providers, although
eral common attributes and challenges. this arguably might be viewed as a luxury
Inpatient treatment is both the most expensive
and most restrictive station of psychiatric care. The
imperatives of treating patients in the least restrictive Admission Criteria and Objectives
setting and of cost containment, particularly fueled by of Hospitalization
managed care, have led to a perception that admission
to an inpatient psychiatric setting represents a failure
This model is predicated on the realities of inpatient
of treatment and is best avoided. This perception is in
practice in the United States in 2007. Average stays
sharp contrast to the traditional view of the inpatient
vary from 3 to 5 days to 1 month depending on the
psychiatry setting as an opportunity to provide neces-
population served and funding available. Whereas
sary intensive diagnostic and/or therapeutic services
general admission criteria are based on symptom acu-
that can dramatically improve the trajectory of an in-
ity and safety considerations, specific admission crite-
dividuals mental illness. We believe that this latter
ria depend on the nature and location of the inpatient
perspective remains valid, although it needs to be spe-
unit, available acute psychiatric care alternatives, and
cifically operationalized in view of current realities;
funding sources. Although specific admission criteria
this is the focus of our chapter.
vary depending on payer and health care system fac-
tors, all admission criteria include an emphasis on
Model of the Adult Inpatient Unit, dangerousness and the absence of less restrictive alter-
natives (Constantine et al. 2006; Warner 1995). A pa-
Circa 2008 tient can arrive on the inpatient unit as a transfer from
another unit or hospital, as an emergent admission
In this chapter, we share our experiences from short- from the hospitals emergency department or a central
stay (510 days) general psychiatric units from across receiving facility, or as an urgent direct admission
the country and review studies on inpatient psychiat- from an outpatient clinical facility. The focus of inter-
ric care. Evolving from an asylum model emphasizing vention is always the acute patient. Having said that,
containment in the absence of effective therapies, the we should make explicit that the role of the hospital
current model is more akin to a modern medical-sur- for the chronic psychiatric patient, hospitalized for
gical intensive care unit, with rapid diagnosis and psy- both psychiatric and nonpsychiatric reasons (usually
chopharmacological intervention as its foundation. varying amounts of suicidal ideation and/or behavior,
Although most patients will be acutely stabilized and homelessness, or substance abuse), is still unsettled
discharged within 310 days of a hospital stay, there is and problematic. Management of such patients varies
a bimodal curve in length of stay in that approximately from state to state depending on bed availability and
20% of patients require longer lengths of stay (1421 other community resources available.
days) because of symptom acuity, treatment-resistant Regardless of setting or length of stay, the objec-
illnesses, or the lack of safe discharge options in the tives of the hospital admission are to rapidly gather
community. We provide a framework and guidelines relevant history, make a diagnosis, set goals focused
The Acute Crisis Stabilization Unit for Adults 25
on the presenting problem, and promptly initiate ap- important guide for inpatient clinicians that includes
propriate treatment. Table 21 details a day-by-day the rationale for involving families at admission (and
plan for hospital treatment. after discharge), a working model of inpatient treat-
Whereas the ultimate goal for most patients is to ment, important skills to assess and treat families
change the long-term life trajectory in a positive direc- (with multiple case examples), and a discussion of im-
tion, the proximate objective is to change the patients pediments, barriers, and legal issues. In order to suc-
condition in order to enable the patient to successfully cessfully treat the kinds of patients now being hospi-
return to his or her community or other less restrictive talized, the treatment team must include not only the
setting; however, the extent of funding for hospital impaired patient but also the patients outside support
treatment constrains what can be done. In most cases, system. The individuals in the support system not
the funding is controlled by managed care administra- only serve as diagnostic informants but also provide a
tor-clinicians who are not directly involved in treat- transition to the community for the patient and offer a
ment. The dilemma is that the unit physician has the means to integrate knowledge of the patient from out-
legal responsibility for the patient but is not the ulti- side of and within the hospital setting.
mate decision maker about the length of stay that will
be reimbursed.
The single guiding principle of inpatient psychiatric Diagnostic Workup
treatment is crisis stabilization, with crisis broadly de-
fined to include issues such as dangerousness to self or It is critical that the specific objective or objectives of a
others, acute decline in function, and a therapeutic im- particular inpatient episode be spelled out early in the
passe. It should be emphasized that the primary clini- course of hospitalization and that resources be princi-
cian must think this through with each patient and the pally directed toward addressing those objectives. The
patients family (or the caseworker if no family is avail- necessary focus of an inpatient episode is formulated
able) at each hospitalization. It is critical that the inpa- by understanding the presenting complaint in the con-
tient treatment episode be viewed as one important text of the psychiatric multiaxial diagnosis and life cir-
step in a continuum of care and not as the entirety of cumstances, including recent stressors. The key ele-
care that can completely fix the problem or illness. ment in defining these focal objectives and developing
Hospitalization for psychiatric disorders has a useful treatment plan is answering the following
evolved in a manner similar to that of hospitalization question: Why is this patient here at this time? To an-
for other medical and surgical conditions: the hospital swer this question, the clinician needs input not only
is a setting where patients are admitted when they are from the patient but also from the outpatient provider,
acutely ill so that the treatment team can make one, or the family or other caregiver, and the admitting source
at most two, interventions to change the trajectory of such as the psychiatric emergency department or con-
the illness or problem. An analogy to an intensive care sultationliaison service. In conjunction with other
unit may be appropriate in that although the inpatient stakeholders, the inpatient team formulates a specific
psychiatric intervention is crucial to the overall treat- strategy for addressing the focal problem.
ment, it is one station in a continuum of care. How can one expeditiously define these individu-
alized objectives? On the inpatient units with which
The Family as Partner on we are most familiar, the tasks of defining individual-
ized objectives and reallocating resources are explicitly
the Treatment Team prioritized in order to address this function. We ac-
complish this function by expanding the roles that the
Given the acuity of the illness in the context of short staff members play in liaison and coordination with
hospital stays and the fact that persons admitted to a outpatient settings and helping staff members develop
psychiatric unit may have cognitive impairment, specific expertise in managing behavioral emergen-
working with families of psychiatric inpatients be- cies, psychopharmacology, and discharge planning.
comes mandatory. If there is no family, a case manager We have also attempted to achieve an optimal balance
is almost always a necessity. In our experience, almost between the seemingly conflicting objectives of defin-
every patient has some significant other; the critical ing the focal problem accurately and doing so expedi-
task is to find that person, which may involve some ex- tiously. Because time is at a premium, we require that
tra work by both the medical and social work staff. In the focal problem be formulated within 24 hours of
this context, Haru and Drury (2007) have written an hospitalization, even on weekends, and that a strategy
26
TABLE 21. Adult psychiatry inpatient unit crisis stabilization pathway based on a 5-day length of stay
Day 2Completion of Day 4Assessment of
Day 1Assessment assessment and initiation of Day 3Continuation safety and discharge Day 5Discharge
and crisis management focused treatment of focused treatment readiness with smooth handoff
Assessment Conduct assessment and needs evaluation
Physician: History, Finalize presumptive Assess physical health Assess patient safety Carefully assess
examination, formulation, diagnosis, evaluate and psychopathology and physical/mental patient safety
order laboratory tests, laboratory results Monitor safety, vital health Repeat physical and
consultations Define mental/physical signs, self-care, sleep Assess adequacy of self- mental examination
Nursing: Assess safety and health needs, reevaluate Review progress toward care and support needs Repeat structured
other needs safety defined target Evaluate response of assessments,
Social work: Contact Monitor safety, vital signs, outcomes target symptoms and including rating
TEXTBOOK OF HOSPITAL PSYCHIATRY

outpatient team/collateral sleep, nutrition, self-care needs scales
informants, determine Complete assessment of Assess extent to which
legal status and resources legal issues, living and focal problem has been
financial needs addressed
BEGIN TO DEFINE THE CLEARLY DEFINE THE
FOCAL PROBLEM: FOCAL PROBLEM
Why admission here, now?
Treatment Establish safety and plan Finalize and begin definitive
focused intervention interventions
Continue outpatient Initiate new medication Continue to implement Complete Review safety plan
medications as appropriate treatment and taper of prior medication plan implementation of Review postdischarge
Implement safety medication as appropriate Continue individual medication plan plan with patient and
precautions/monitoring as Use as-needed medications and group therapy as Prepare discharge family
indicated for specific target symptoms indicated prescriptions Continue various
Plan family/network as appropriate Evaluate effectiveness Continue to assess interventions as
interventions as Implement individual/group of and response to response to various appropriate
appropriate therapeutic interventions as interventions interventions Dispense
Orient patient to the unit appropriate Continue family and Evaluate learned coping postdischarge
Plan individual therapy as Implement family and other other network strategies medications with
feasible and indicated network interventions interventions as Assess patient and education
Implement individualized required family understanding
safety and behavioral/ Implement medication
cognitive plan and other patient
education
TABLE 21. Adult psychiatry inpatient unit crisis stabilization pathway based on a 5-day length of stay (continued)
Day 2Completion of Day 4Assessment of
Day 1Assessment assessment and initiation of Day 3Continuation safety and discharge Day 5Discharge
and crisis management focused treatment of focused treatment readiness with smooth handoff
Discharge Assessment of aftercare Define aftercare needs and Concretize
planning needs and resources develop a plan to address postdischarge plan
them
Assess follow-up and living Address specific Begin to arrange Identify tentative Reconfirm and
arrangements postdischarge needs: legal, outpatient return-to-work/school document
Assess financial stability and living, care, fiscal appointments date and complete postdischarge follow-
necessary paperwork up arrangements
The Acute Crisis Stabilization Unit for Adults

need for assistance Define approximate length of Identify likely discharge
Assess employment or stay on inpatient unit date Complete discharge Complete all aftercare
educational issues Coordinate other paperwork arrangements
Conduct safety evaluation in postdischarge Confirm appropriate Review follow-up plan
likely postdischarge setting arrangements as postdischarge living and confirm patient
Assess other specific needs necessary and care arrangements and family
and issues understanding
DISCHARGE
PATIENT
27
for addressing the problem be developed at the same have to support the treatment that needs to be deliv-
time. This process requires adequate staffing at all ered. It is also important to identify the immediate
times; psychiatrists must be available to make diag- stressors that have upset the balance in the patients
noses and treatment plans even during nights and life and precipitated the admission and try to alleviate
weekends, just as in an intensive care unit. them as feasible. Specific questions that clinicians
The patients preadmission course of psychiatric should ask as part of the assessment include
illness and pattern of mental health service utilization
can be instructive (Bowers 2005; Ionescu and Ruedrich 1. Why is this patient being admitted?
2006). Is this a first-time admission with or without a 2. Is the admitting diagnosis correct?
previous history of mental health treatment? If the 3. Were the medications prescribed prior to admis-
person has previously received psychiatric treatment, sion correct for the patients symptomatology
is treatment discontinued or ongoing? Does the recent (which may be different from the medications be-
course of illness suggest progressive gradual decom- ing correct for the diagnosis)? Were the medica-
pensation or a rapid acute deterioration? tions prescribed in the correct dosage and of ade-
A specific initial task is to make as accurate a diag- quate duration? Were the medications being taken
nosis as possible in a very short period of time, usually as prescribed?
1 day. This task fits nicely with mandates from the 4. Is the patient or immediate family member receiv-
Joint Commission and state regulatory agencies that ing some type of psychotherapy? What has been
require clinicians to expeditiously perform compre- the course of the psychotherapy? Have there been
hensive assessments for inpatients. A comprehensive any recent changes in the circumstances of the psy-
diagnosis, as described in the multiaxial formulation chotherapy? For example, is the therapist currently
in DSM-IV-TR (American Psychiatric Association on vacation?
2000), consists of five parts: 5. Has the patients social support system changed or
failed? Does the patient, correctly or incorrectly,
1. A phenomenological Axis I diagnosis of psychopa- anticipate a change in his or her social system,
thology based on DSM-IV-TR (e.g., bipolar disor- which includes the outpatient psychiatric clini-
der, currently depressed with psychotic features, re- cians?
current)
2. An Axis II personality disorder diagnosis (if One critical element in the diagnostic process is
present). This could also include an assessment of ruling out delirium or another psychiatric disorder
maladaptive personality features or defense mech- secondary to substance use or a general medical ill-
anisms that do not meet criteria for a personality ness. This can often be done most efficiently while the
disorder. Importantly, a personality disorder can patient is hospitalized and laboratory testing, imaging,
be primary (i.e., lifelong and starting at a young and consultants in other medical specialties are
age) or secondary to an Axis I disorder (e.g., a mood readily available. To be efficient and efficacious, spe-
disorder). cific clinical protocols must be individualized for the
3. Diagnosis of any somatic medical conditions that specific setting for each of the most common disorders
may be present treated. This is all the more important given the life-
4. A systems diagnosis focusing on the patients sup- threatening nature of some of the medical disorders
port system. This corresponds to Axis IV, which (e.g., head injury or seizure disorder) that can cause
encompasses psychosocial and environmental psychiatric symptoms. If a patient has a psychiatric
problems. diagnosis, physicians are often too ready to attribute
5. An assessment of the patients overall level of func- all of the patients symptoms to that diagnosis, while
tioning they may minimize or not conduct a serious workup
for medical conditions.
We mention all five axes because clinicians may forget It is also now incumbent on psychiatric physicians
one or another axis that may represent a crucial prob- to assume responsibility for some of the primary med-
lem area to address. ical care during an inpatient stay, no matter how short
The first priorities for the clinician should be to de- the stay. In addition to a comprehensive physical ex-
termine the nature of the disorder(s) and how this re- amination (including body mass index and extensive
lates to the presenting problem: Why is the patient neurological evaluation), all patients must receive a ba-
here now? Next, the clinician needs to determine what sic laboratory workup that includes a complete blood
kinds of resources the patient and support system count, basic renal and hepatic functions (blood urea
nitrogen, creatinine, alanine transaminase, aspartate tained specific patient vulnerabilities and system fac-
aminotransferase, bilirubin), hemoglobin A1C, lipid tors that affect treatment.
profiles, and a toxicology screening. Additional labora-
tory and radiological evaluations may be required as in-
dividually appropriate. Other medical consultations
Therapies
should be expeditiously obtained if necessary.
Because patients may have difficulty providing a The master treatment plan is developed by next an-
coherent history, another important diagnostic task is swering the question What needs to happen in order
to gather collateral information. The patients account to solve this focal problem or problems? (Harper
of the events leading up to admission must always be 1989). It is most efficacious if the focal problem is one
supplemented with accounts from family members, that the inpatient psychiatry unit can better address
friends, and especially other providers. We recognize than another type of setting such as a medical unit. Is
that family and other significant others may not be it possible to develop objectives that are specific to the
available because of alienation or schedule conflicts. needs of the patient and have some possibility of mod-
However, given the illness acuity plus the short length ifying the course of the illness and yet are modest
of stay involved in most admissions, we believe it is enough to be attainable? Our broad strategy is de-
mandatory that, just as in intensive care, staff mem- signed to address the specific circumstances of the in-
bers make every effort to contact the patients imme- patient episode in the context of the functions that an
diate family, doctor, and caseworker. inpatient unit performs best.
Hospitalization allows a variety of professionals
with different perspectives, including physicians, Case Vignette
nurses, occupational therapists, and psychologists, to
A 19-year-old female student is admitted to an inpa-
observe and evaluate the patient. The inpatient unit tient unit on account of a drug overdose that fol-
traditionally has significant resources that are relevant lowed the breakup of a significant relationship. The
to the diagnostic task. Given decreasing lengths of stay patient is in outpatient treatment and has a diagno-
and a focus on acute stabilization, clinicians are often sis of a recurrent depressive disorder and borderline
tempted to defer definitive diagnosis in favor of a not personality disorder. Her inpatient treatment must
address safety needs, a diagnostic reevaluation, pos-
otherwise specified diagnosis. However, we believe
sible changes in the therapeutic plan, and respite to
that this does the patient a disservice because it can allow resolution of the trauma of the breakup.
lead to effective treatment being deferred, and symp-
toms may be overlooked that need attention. Instead, How this patient should be treated is discussed
a most likely diagnosis or set of diagnoses should be next, and later in this chapter the vignette will con-
formulated, with necessary caveats, and appropriate tinue.
treatment should be promptly initiated.
The legal status of the patient and his or her com-
Goals of Treatment
petence and ability to understand the nature of illness
and treatment alternatives should be ascertained. In- After diagnosis, the next task is to identify the goals of
formed consent is the bedrock of treatment. If the pa- the treatment. One must always ask patients what
tient is unable to fully participate in this process, this their goals are for the hospital stay. It is important to
should be ascertained at the time of admission or prior ask patients what they would like to see happen for
to it if a scheduled admission. Appropriate steps should them in the course of this hospital stay. Equally im-
be taken to address the situation, such as approaching portant is to ask family members the same question. It
the court to seek authorization for necessary treat- must be recognized that the goals that patients, fami-
ment, family involvement, and/or appointment of a lies, or even outpatient therapists express may be dif-
guardian advocate. Delays in initiating appropriate ferent from those identified by the inpatient team. Fi-
treatment on account of the inability of the patient to nally, treatment goals should be discussed among and
provide valid informed consent should be minimized with the outpatient treatment team. Chances for good
(details vary by state). treatment outcome improve to the extent that a con-
By the end of the evaluation, the treatment team sensus on diverse objectives can be achieved. As noted
should have determined the likely clinical diagnosis or earlier, the most important tasks include identifying
diagnoses, identified the set of circumstances that ne- and alleviating, if possible, the stresses that upset the
cessitated the current hospitalization, elucidated the patients balance and interfere with his or her ability
immediate stressors and current resources, and ascer- to live outside the hospital; decreasing symptoms;
changing the posthospital life trajectory from the pre- Tandon et al. 2006). The crucial first step is to make an
hospital downward course; and beginning the process accurate diagnosis and identify target symptoms. An
of educating the patient and family. early decision point is whether to continue outpatient
medications. To make this decision rationally, the cli-
nician needs to undertake a significant amount of in-
Specific Treatment Interventions
vestigation in order to gather a medication history that
(Therapies) includes dosages, duration, rationale for use, and, most
important, prior therapeutic response and side effects.
DETOXIFICATION FROM SUBSTANCES
This labor-intensive task is essential in effectively and
Substance use disorders are highly comorbid with quickly developing an appropriate treatment plan. Tak-
other psychiatric diagnoses, and problems related to ing a patient off medications is often as helpful an in-
substance abuse frequently precipitate or substantially tervention as starting new medications, particularly
contribute to the admission. Rapid detoxification is given issues related to drug interactions and potent
among the tasks that can best be accomplished in the clinical effects of treatment discontinuation.
hospital. Although some general psychiatry inpatient In our inpatient units we tend to take a twofold ap-
units still perform this function, specialized substance proach. First, we select a primary medication for the
abuse detoxification units perform this function in patients psychiatric illness (e.g., an antipsychotic or a
many settings. mood stabilizer, or an antidepressant) and titrate it rap-
idly to a therapeutic dosage. Because antipsychotics,
FAMILY INTERVENTION mood stabilizers, and antidepressants all take days or
weeks or months to achieve their full effectiveness, we
It is very important to evaluate the patients support
treat symptoms such as agitation aggressively with as-
system. Even during a very short stay, it is virtually
needed medication (usually benzodiazepines) to pro-
mandatory to have at least one session with the people
who are most important to the patient. This allows vide patients with some short-term relief. One of the
most common, although understandable, mistakes
the clinical team to gather information, provide edu-
can be to attempt to speed up response by giving higher
cation about the patients illness and its treatment,
doses of the primary medication when what is mostly
and undertake other interventions specific to the situ-
needed is an understanding of the normal course of re-
ation. The importance of education in leading to a bet-
sponse and patience on the part of the clinician. Such a
ter outcome is underrecognized (Glick et al. 1994). As
noted earlier, the involvement of the family is also in- mistake is often made based on the unrealistic hope
that the patient will be asymptomatic at the time of
valuable in obtaining the needed consent for both in-
discharge rather than having the realistic expectation
formation gathering and treatment.
that the patients symptoms will be sufficiently re-
duced to allow continuation, and fine-tuning, of treat-
INDIVIDUAL PSYCHOTHERAPY ment in another setting.
Given the short length of stay now predominant, hos- We also recommend making only one change in
pital staffs often forget to talk to the patient. Regard- medication at a time, if possible. This strategy is often
less of how long the patient stays in the hospital, basic difficult given short lengths of stay, but our practice af-
principles of individual therapy should be followed. ter making a diagnosis is to determine what is the
These include establishing an alliance; providing sup- most effective medication with which to start and its
port, hope, and education; and even, on occasion, initial target dosage. Ideally, this is carried out concur-
making an interpretation, if it would advance the aims rently with tapering of the patients previous medica-
of the hospitalization. In fact, a 2007 study docu- tions that, by history, seemed to be ineffective or inap-
mented the effectiveness of adding both brief and in- propriate for the diagnosis. The hospital psychiatrist
tensive psychotherapy plus pharmacotherapy for de- must identify the benefits versus the costs of each
pressed inpatients (Schramm et al. 2007). medication. By cost, we mean not just financial cost
but more importantly the costs in terms of side effects
INITIATION OR MODIFICATION OF and medication interactions. The pros and cons of dis-
continuing a previous medication must also be care-
PSYCHOPHARMACOLOGICAL TREATMENT fully considered. Although pharmacotherapy must be
Medication management is usually central to the treat- individualized, evidence-based guidelines can provide
ment regimen (Glick et al. 1991; Kingbury et al. 2001; useful guidance (Tandon et al. 2006).
It is important not to undermedicate the patient. mediately prior to discharge because lowering the
Finding the best possible dosage in 310 days is a very dosage at this point may lead to an exacerbation of
difficult objective to achieve. Although there is consid- symptoms just at the time the patient must leave the
erable heterogeneity among patients with regard to the hospital. Instead, it is better to have the outpatient
optimal dosage, we recommend rapidly achieving the physician regulate the dosage. Close coordination
average target dosage for the situation and making with the outpatient team is crucial; this entails ensur-
short-term adjustments only if absolutely necessary. ing a smooth handoff to the aftercare clinic or other
The dosage selection needs to factor in diagnosis, age, setting where the patient will continue in treatment.
stage of illness, prior response, and concurrent medi- Timely transmission of necessary clinical information
cal conditions as much as possible. to the outpatient team to facilitate an effective transfer
As a rule of thumb, we recommend using fewer of care is a very high priority. This builds on coordina-
rather than more medications. It is important not to tion of care with the outpatient team from the time of
get fixed in the practice of prescribing what may be de- admission throughout the course of inpatient treat-
scribed as the usual cocktail (e.g., an antipsychotic ment. Time constraints can make such coordination
plus a mood stabilizer, an antidepressant plus a benzo- challenging (Boyer et al. 2000), but it is one of the
diazepine plus a sleeping pill) (Kingbury et al. 2001). It most important elements in ensuring good outcomes.
is important to remember that once a patient is dis- It is usually necessary both to make verbal contact
charged from an inpatient facility, the outpatient clini- with the outpatient team and to actually transmit
cian is likely to continue this treatment regimen indef- written documents, including the treatment goals and
initely, because the clinician may fear that changing medications.
the regimen may lead to worsening symptoms or a We have found rating scales to be extremely useful
downward course. in measuring the response of defined target symptoms
Although we advocate using the minimum number to prescribed psychopharmacological treatment. Al-
of medications, we also recommend not temporizing though a lengthy battery of instruments is not desir-
when considering adding a medication because of an able and may be cumbersome, the use of simple and
acute situation such as escalating agitation. The usual reliable scales as individually appropriate is strongly
mistake is to delay until an adverse event occurs, such recommended. The Clinical Global Impression Sever-
as the patient becoming acutely agitated or assaultive. ity and Improvement scales and the Brief Psychiatric
This situation arises more often when treating patients Rating Scale are useful instruments to track overall
with schizophrenia or bipolar disorder mania, but it illness severity and psychopathology (Tandon et al.
also occasionally occurs in treating patients with major 2006).
depressive disorder or even severe personality disorder To summarize, here are some basic guidelines. As a
associated with substance abuse. The usual approach is rule of thumb,
to use a short-acting benzodiazepine (e.g., lorazepam)
or diphenhydramine or increase the dosage of a sedat- Dont diagnose patients with NOS (not otherwise
ing antipsychotic. specified); make a working diagnosis as is done in
Nonadherence to medication treatment is a major the rest of medicine.
problem that often leads to repeated hospitalizations. To Do initiate treatment promptly.
improve patient adherence to treatment, we suggest Dont practice polypharmacy; less is more.
working with significant others during the hospital stay, Dont underdose; prescribe no more or less than
striving to minimize adverse effects, and focusing on pa- needed.
tient and family education. If the treatment team is in Do select treatment based on a comprehensive his-
doubt about a patients willingness to take medication, tory of previous treatment response.
team members should not hesitate to consider and pre- Dont repeat a failed treatment; if it did not work
scribe a long-acting injectable medication, if an appropri- the first time, it usually will not work the second.
ate medication is available, to ensure compliance. We do Dont assume that patients have no significant oth-
not routinely recommend obtaining medication blood ers (broadly defined); almost everyone has some sig-
levels, because they are both hard to obtain in a timely nificant other, even the homeless.
fashion and costly. It may also be useful to ask patients Dont delay initiating treatment, but dont over-
frankly if they take all their medications all the time. medicate either.
With regard to discharge medications, we recom- Do track response with the use of reliable rating
mend not making downward dosage adjustments im- scales.
Milieu Management themselves or others or are unable to care for them-

selves and often do not wish or see the need for hospi-
talization. Hospitalization serves the dual functions of
The structure and setting of the inpatient unit are cen- maintaining safety until the risk of harm is reduced
tral to its function, and the unit milieu is of critical while actively reducing the risk of such harm. Specific
therapeutic importance. The locations of patient expertise to perform these functions includes effective
rooms, group activity rooms, the nursing station, the court liaison, violence and suicide management, and
meal room, and other elements of unit geography sig- the ability to perform thorough risk assessments. This
nificantly affect the ability of the treatment team to remains an inexact sciencebut the best prediction re-
effectively carry out unit functions. An explicit stable mains a past history of severe attempts. The issue here
daily routine, along with a clear set of unit procedures for the inpatient staff is to have trained personnel avail-
and rules that are consistently implemented, facilitates able to evaluate (and document) risk because outside
a predictable and safe environment. Such an environ- stressors as well as mental status will change during
ment provides the context for effective therapy. Nurs- the course of even a brief hospitalization.
ing professionals play the key role in the creation and Individualized assessment of risk and of the pre-
maintenance of such a unit milieu. With the changing cipitants of aggressive behavior should be performed
nature of the patient population on an inpatient psy- at the time of admission (Serper et al. 2005). A careful
chiatry unit, the function of acute inpatient psychiatric history and evaluation to assess the risk of suicidal be-
nursing has continued to evolve (Bowers 2005; Deacon havior are essential components of the initial clinical
et al. 2006; Lamb and Weinberger 2005). Nursing per- workup. Staff members should be trained in appropri-
sonnel maintain safety on the unit and manage the ate techniques to manage aggressive behavior (Morri-
unit environment, collect and communicate informa- son 2003). Although seclusion and restraint should be
tion about patients, provide personal care, manage dis- utilized infrequently, if at all, staff members need to be
turbed behavior, and give and monitor treatment. trained in their safe and appropriate use (Sailas and
Nursing personnel also may lead a variety of therapeu- Wahlbeck 2005).
tic groups, such as psychoeducational groups focusing Another important clinical issue is the situation of a
on a disorder, substance abuse, or compliance. patient on an inpatient unit who has attacked or who
The role of recreational and leisure activities (ac- threatens to kill the treating psychiatrist or other staff
tivity therapy) during an acute psychiatric hospitaliza- members. The most appropriate response is to take the
tion continues to evolve. There has been a continuing threatening behavior at face value, as though it could
reduction in the use of such activities in the context of happen, rather than simply interpreting or ignoring it.
cost containment, very short hospital stays, and the One should assume that the behavior is part of the
changing role of a short-term psychiatric unit in a con- patients acute symptomatology. A second step is to
tinuum of care. The use of focused patient therapy attempt to determine from referral sources if there is a
groups, such as dialectical behavior therapy or cogni- history of threats or of actual violence. Third, it is pru-
tive-behavioral therapy, or family support groups de- dent to reevaluate the medication regimen and consider
pends on the specific setting, the resources of the inpa- increasing the dosage of medication for that particular
tient unit, and the population that it serves. Inpatient illness and/or adding a benzodiazepine, if indicated. It
psychoeducation for both patients and family members may also be advisable to transfer the patient to another
is strongly recommended. Here we suggest daytime physician or another unit, especially if the treating staff
groups for patients and evening groups for significant are uncomfortable working with such a patient.
others around topics discussed earlier. Referral to con-
sumer groups such as the National Alliance on Mental
Illness are usually very helpful over the long run. Discharge Planning
Management of Suicidal and The next task, if time allows, is to help the patient and
family change the posthospital trajectory, because the
Aggressive Behavior patient is usually on a downward slope during the
acute illness. The objective is to make one or at most
One basic role of the inpatient unit is to keep patients two interventions to change life for both the patient
safe. On our units, about 50% of patients are admitted and family after the hospital stay, targeting the types of
involuntarilythat is, they are judged to be a danger to psychosocial and environmental problems rated on
Axis IV. This strategy can be the most important part of diagnosis, formulating specific goals for the admission,
a hospitalization and has the potential to significantly determining which treatments to prescribe, reinforc-
change the course of a patients illness. Inpatient edu- ing or rebuilding the patients support system, and es-
cation programs focused on surviving outside the pro- tablishing outpatient care. The role of the family and
tected hospital setting are helpful; this may include significant others is central. Key tasks to be performed
multiple structured small-group meetings focusing on by the inpatient unit include liaison and coordination
education about the illness and coping strategies. with multiple groups (e.g., outpatient team, psychiatry
We try to link the patient to an outpatient psychi- emergency services, the court system, family mem-
atrist and other services as needed; typically, an out- bers, other caregivers, community mental health agen-
patient appointment is scheduled for the patient cies, various social and governmental agencies); rapid
within 1 week of hospital discharge. In today s envi- comprehensive assessment (e.g., descriptive and diag-
ronment, patients may also need help with other ser- nostic, medical, personality, system); maintenance of
vices such as case management and housing; one patient safety and a therapeutic environment (Boyer et
should at least begin the process of meaningfully ad- al. 2000); and smooth and expeditious transfer to an-
dressing these needs while the patient is still hospi- other residential and treatment system.
talized. Effectiveness of inpatient/outpatient handoffs This concept of the acute inpatient psychiatric
is a primary index of quality inpatient psychiatric unit as a provider of focused, individualized, intensive
treatment (Joint Commission 2008). short-term care necessitates a reconsideration of the
optimal use of staff and other resources. From a staff-
Case Vignette (continued) ing perspective, one needs to evaluate how resources
can be best utilized within local constraints to address
Let us revisit the inpatient stay of the 19-year-old
the objectives of the program. New educational pro-
female student who was admitted to our inpatient
unit on account of a drug overdose that followed the grams for staff are usually necessary to adequately
breakup of a significant relationship. As previously train clinicians of all disciplines. The organization of
noted, the patient was in outpatient treatment and the inpatient treatment team needs careful attention.
had a diagnosis of a recurrent depressive disorder Different team members have defined and differenti-
and borderline personality disorder. After initial ated roles that must be effectively coordinated. The
detoxification and life-supportive monitoring and
unit psychiatrist or service chief plays a key role as the
therapy, an individualized safety plan was developed
with the patient, and she learned coping skills in an team leader. It is important to emphasize that treat-
individual and unit group setting. In view of nonre- ment is shaped not only by how much a psychiatrist
sponse to an adequate trial of the current antidepres- knows but also by his or her attitudes and knowledge
sant, the agent was switched and a low dosage of a about the model of inpatient treatment. It is impor-
sedating antipsychotic added in view of symptoms of
tant to remember that although managed care and its
paranoia and insomnia. Three friends who reside in
the same dormitory as the patient and constitute her reviewers can suggest treatment, the inpatient psychi-
immediate support system (they had accompanied atrist and team have the ultimate responsibility for
the patient to the emergency department from which treatment decisions. Therefore it is advisable not to
she was admitted to the inpatient unit) participated make medication changes or dosage adjustments or
in two meetings with the patient and her inpatient add medications if data for the change are lacking. Re-
social worker. Following discussion with the outpa-
ceiving additional authorized days from the managed
tient therapist, the patient was referred to a dialecti-
cal behavior therapy program. care company is not a good rationale for making par-
ticular treatment decisions.
We also routinely recommend referral to appropri- The contradictions between the theory and prac-
ate consumer organizations such as the National Alli- tice of inpatient work are apparent to anyone who has
ance on Mental Illness and Alcoholics Anonymous in worked on an inpatient psychiatric unit. Current short
order to improve posthospital outcome (Glick and stays necessitate urgency, although given the slow
Dixon 2002). pace of symptom response, patience is also a necessary
virtue. Likewise, the acuity of symptoms mandates a
rapid response, yet the need for a thorough workup
Conclusion that takes time requires slowing things down. The
kind of multimodal treatment we are recommending
In summary, the following steps are involved in an in- requires a multidisciplinary staff that can be difficult
patient episode: defining the focal problem, making a to maintain in the face of economic pressures. Each
inpatient unit will need to make the appropriate com- Bowers L: Reasons for admission and their implications for
promises, depending on local conditions, in order to the nature of acute inpatient psychiatric nursing. J Psy-
chiatr Ment Health Nurs 12:231236, 2005
deliver the best treatment possible given the reality of
Boyer C, McAlpine DD, Pottick KJ, et al: Identifying risk fac-
fiscal constraints. In addition, in order to succeed and tors and key strategies in linkage to outpatient psychi-
deliver competent care, every inpatient service must atric care. Am J Psychiatry 157:15921598, 2000
have an outpatient service link. Without such a link, Constantine R, Kershaw M, Robinson P: Floridas Mental
the patient is more likely to be discharged without ade- Health Acute Care/Crisis Services: Background and
quate aftercare plans, and the risk of rehospitalization Strategies for Reform. Tampa, University of South Flor-
ida, 2006
increases.
Deacon M, Warne T, McAndrew S: Closeness, chaos, and
The approach to inpatient psychiatry we propose crisis: the attractions of working in acute mental health
focuses on creating patient-specific objectives that are care. J Psychiatr Ment Health Nurs 13:750757, 2006
congruent with the functions that inpatient psychia- Geller JL: A history of private psychiatric hospitals in the
try units can best perform. The highlights of this ap- USA: from start to almost finished. Psychiatr Q 77:1
41, 2006
proach include making an accurate diagnosis, deliver-
Glick ID, Dixon L: Patient and family support organization
ing effective medication, involving the patients services should be included as part of treatment for
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much could be accomplished in earlier periods, inpa- of inpatient psychiatric disorders: from asylum to inten-
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should include both objective measures of assessing Hospital-Based, Inpatient Psychiatric Services (HBIPS)
treatment outcome (measured against admission Candidate Core Measure Set, last updated February 15,
goals) and the commonly used patient and family sat- 2008. Oakbrook Terrace, IL, The Joint Commission,
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CHAPTER 3
THE CHILD UNIT

A. Bela Sood, M.D., M.S.H.A.
Carmel A. Foley, M.D., M.H.A.
Admission Criteria patient presentations that instantiate these criteria

most of the time.
The indications for the admission of children to acute Dangerous Behavior

inpatient psychiatric care resemble those that apply
currently to other age groupsthat is, hospitalization The harmful behavior that preadolescents admitted to
may be appropriate when an individual exhibits be- acute inpatient psychiatric care most commonly dis-
havior that warrants placement in a highly regulated play involves intermittent rageful episodes during
and supervised environment because that behavior which the child is highly aggressive and combative.
For the most part, the incidents that catalyze admis-
1. Poses danger to oneself or others; sion to hospital represent an escalation of chronic ag-
2. Impairs functioning and exceeds the capacity of gression toward more harmful behavior. Long-stand-
less restrictive available resources to manage it ef- ing difficulties with impulse control and emotional
fectively; or volatility are common in these youngsters develop-
3. Represents a symptom pattern so atypical or mental histories. These problems in turn set the stage
alarmingly quick to develop that the inpatient set- for extensive histories of both self-directed aggression
ting offers best chances for prompt, thorough as- and aggression that manifests as angry, uncontrolled
sessment and resolution. outbursts of physical and verbal assaultiveness and
damage to property. The precipitants of these behav-
By emphasizing severity rather than forms of be- iors are typically real or perceived frustrations, imped-
havioral disturbance, these indications inherently en- iments to the childs preferred activities, disagree-
compass a broad range of clinical problems. Neverthe- ments, or other relatively minor provocations that
less, among children there seem to be several specific peers handle with composure. The events that lead to
37
admission, therefore, seldom represent the onset of vi- anxiety. These youngsters might require hospital
olent behavior in a previously well-controlled individ- treatment to disrupt a pattern that may have culmi-
ual. Rather, the episode usually involves a major incre- nated in several months of nonattendance.
ment in dangerousness (e.g., use of a sharp object, Some disturbances involve disruptive behavior
aggression directed toward a baby or toddler, hurling of that poses no genuine physical danger but nonetheless
objects like classroom chairs, threats) that caregivers exceeds the capability of the childs family or educa-
can no longer handle in a less restrictive setting. tional milieu to manage it effectively. Animosity, frus-
Children at risk of harming themselves often pre- tration, hopelessness, or strains on family functioning
sent as a psychiatric emergency that warrants admis- may have so negatively impacted relationships that
sion. Fortunately, intentional self-injury occurs infre- typical outpatient interventions would have practi-
quently among children relative to adolescents, and cally no chance to succeed. Hospital admission may
suicide is rare (Kloos et al. 2007; Peterson et al. 1996). It present the most viable means to provide reprieve,
is more often childrens verbal statements about want- hopefulness for families, and the implementation of
ing to die that elicit concern. In one common scenario, interventions to promote behavioral stability.
remarks about being better off dead or maybe I
should just kill myself, or even brandishing a knife or Sudden, Medically Complicated,
wrapping material around ones own neck, arise as a or Perplexing Symptoms
result of extreme frustration in children for whom a
Outpatient and emergency department clinicians may
meltdown reflects the intensity of their distress rather
seek the monitoring and evaluative services that inpa-
than suicidal or homicidal intent. When the acute ex-
tient settings afford when they encounter children
plosion has passed, the childs overall satisfaction with
who display a sudden change in mental status, devel-
life may quickly rebound. However, the event often
leaves parents distraught, concerned for their childs opmental skills, or bizarre behavior. Pediatric special-
ties at times seek to admit or transfer patients whose
safety, and feeling guilty. Likewise, such behavior also
physiological symptoms, such as persistent vomiting,
ratchets up the concern of school personnel and com-
encopresis, pain, or nonepileptic seizures (pseudosei-
munity practitioners, making referral to inpatient care
zures), appear to have no medical etiology, and clini-
more likely. Very rarely, a single violent act of aggression
cians suspect significant psychosocial influences on
may warrant admission to acute care for evaluation.
Another scenario that warrants inpatient care to re- their emergence. Compared with pediatric wards, psy-
chiatric settings have more restrictive visiting policies
duce the risk for intentional self-harm develops when
and engage children in a broader array of activities.
children who experience sustained dysphoria dwell on
Therefore, the potential to observe the child closely
death as a solution to their chronic psychic pain. Major
both with and apart from the family appears to be a
depression, maltreatment, severe family conflict, or
reasonable approach to address these concerns.
other stressors are often the backdrop for these prob-
lems. The children may have kept these ruminations Poor adherence to treatment for established
chronic illnesses, especially among youngsters with a
to themselves for some time. As such, it is their disclo-
comorbid psychiatric disorder, may also be an impetus
sure to adults, rather than symptom or functional
to seek inpatient care. Psychiatric expertise and a well-
change per se, that often motivates admission.
controlled milieu may leverage behavior change and
Impairments Inadequately Treated perhaps identify the emotional issues suspected to un-
derlie noncompliance.
in Outpatient Care There are some disturbances for which specialized
Psychiatric symptoms may produce serious impair- hospital settings exist only in a few major centers in the
ments that prior treatment has not adequately allevi- United States; for affected children in many communi-
ated. Even if these symptoms do not entail imminent ties the general child psychiatric unit may be the only
danger, inpatient treatment may be sought so that in- available resource. For example, some youngsters pre-
terventions can be introduced at a higher intensity and sent with severe, repetitive self-injurious behavior that
frequency than is otherwise possible. For example, develops in the context of developmental disabilities.
children who refuse to leave home to attend school of- Youngsters who resist nutrition include those with
ten do so with outpatient treatment that emphasizes early onsets of the classical eating disorders (anorexia
management of anxiety and family processes to pro- and bulimia) and those with feeding disorders who are
mote attendance. However, a few children become vio- older than the age range for which pediatric manage-
lent when pushed to go to school in the face of severe ment is more typical (infancy to age 3 years).
The Child Unit 39
Other Situations notably evidence for the efficacy for children of se-
lected pharmacotherapies and of focused, practically
Family courts and child welfare authorities may refer
oriented psychosocial interventions, had at least two
children to psychiatric inpatient facilities for evalua-
important effects: 1) they changed the time horizon
tions. Their goal is to obtain input on disposition rec- for therapeutic efforts to gain traction from years to
ommendations that will address the youths behavior
months or weeks; and 2) they helped to upend the
(e.g., unmanageability in the community) or care needs
view that improvement in seriously disturbed chil-
(e.g., suitability of current living arrangements). It is
drens well-being necessitated long-term separation
best to have clarity from the outset that the agency is,
from their families. Second, a broad societal move-
in fact, the one seeking professional services, much
ment toward reduced reliance on institutional settings
like any other forensically oriented assessment. That for individuals of all ages with severe mental illness in
clarity may come in the form of a standing contract
favor of enhanced community-based systems of care
with the facility or a court order. Problems arise when
was generally successful. A parallel movement that
an agency prompts a family to initiate a voluntary ad-
strove to meet the needs of psychiatrically ill children
mission for their child in the expectation that the
and their families without separating them for long
agency will receive professional opinions that address
periods highlighted the poignancy and grief of children
its own agenda (such as removal of the child from pa- and parents separated before there was an opportunity
rental custody). The agencys goals are then apt to con-
to attempt less drastic interventions (Knitzer 1982;
flict with the hospitals primary allegiance to the child
Knitzer and Cooper 2006). In the absence of evidence
and family s therapeutic needs and confidentiality,
that long periods in treatment settings apart from
which only concerns about child endangerment can
their families offered any countervailing advantages
supersede in nonforensic situations.
for the majority of youths, the desirability of support-
ing families to manage a childs disturbance in the
Evolution of Inpatient Services least restrictive setting possible became the guiding
principle for both mental health systems planning and
for Children individual care determinations.
A third trend was developments in the financing of
Although confinement of adults with severe mental ill- mental health services that emphasized the contain-
ness was a common practice for centuries, the presence ment of costs. Lengths of stay declined markedly be-
of children in such facilities seems to have been rare. tween the early 1990s and 2004, and reimbursements
Neuropsychiatric inpatient services for children origi- to hospital facilities also declined (Blader and Carlson
nated in U.S. urban areas in the early twentieth century, 2007; Case et al. 2007; Ringel and Sturm 2001).
chiefly to provide custodial care for youngsters with pos- Nonetheless, overall annual population-adjusted rates
tencephalitic impairments acquired during the eras in- (i.e., percentage of individuals in the general popula-
fectious epidemics. By midcentury, inpatient settings tion) of psychiatric hospitalizations for children and
for children developed to treat behavioral disturbances adolescents have actually increased (Blader and Carl-
that were not accompanied by major organic or neu- son 2007).
rodevelopmental problems. The prevailing psychoana- In effect, then, these three trends brought into
lytic approaches embraced a developmental model that alignment optimism about the potential for scientifi-
rooted many forms of mental illness in unfavorable cally based advances in treatment to alter the course of
events and relationships in early life. Therefore, the mental illness, the moral imperative of providing care
placement of a child who had already begun to experi- through community-based services when possible to
ence psychiatric symptoms in a special caretaking envi- minimize separations of families, and economic inter-
ronment seemed to offer an opportunity for corrective ests in less costly care. The results for psychiatric in-
experiences that would offset earlier pathogenic influ- patient care of children have been to reorient its mis-
ences. Naturally, there was no expectation that this sion toward crisis stabilization; comprehensive (if not
would be a rapid process, and long stays in hospitals and definitive) assessment of a childs difficulties and
residential treatment settings were common. longer-term needs; and arrangement of resumption of
By the late twentieth century, three trends, each appropriate care in a less restrictive setting. It therefore
2030 years in the making, crystallized and combined occupies a specific niche within, ideally, a coordinated
to alter significantly childrens psychiatric inpatient system of care that calibrates services to current need
services. First, developments in psychiatric practice, by including an array of supportive interventions that
include home-based therapies, wraparound services, tally inappropriate and therefore accepted the
enhanced outpatient and day treatment programs, schools effort to provide special services, but they
did not seek other treatment for these difficulties.
help managing periodic flare-ups in disturbances, and
Despite his difficult start in life, Leon was a
respite care for families. At present, however, these ser- healthy boy with no medical illnesses. Psychological
vices remain unevenly available, and demand exceeds testing revealed him to be of average intelligence,
supply in many localities. Priority for intensive com- with mild weaknesses in expressive language and
munity-based services often goes to youths deemed to fine motor coordination, both of which were being
be at risk for out-of-home placement. As a practical addressed within his school program. Several place-
ments within the local school district, in ascending
matter, such risk is quite often demonstrated by prior
levels of restrictiveness, were not helpful. However,
hospitalization, and we have noted that rates of admis- by the fifth grade, Leon began an out-of-district pri-
sions have not declined among young people. vately run special education day school. The parents
In summary, although resources devoted to inpa- were quite pleased with this setting, and although
tient care have constricted and admission requires there were disruptions and altercations in the school
context, the program was well equipped to help him
greater justification, it appears doubtful that the com-
regain self-control.
pensatory supports to help children get and stay well His first psychiatric hospitalization occurred at
in their own communities have flourished to the ex- age 6 years because of aggressive, disruptive, and
tent hoped for. unmanageable behavior at home. The initial diag-
nosis was attention-deficit/hyperactivity disorder
(ADHD), and stimulant treatment was undertaken,
Case Vignette although the parents could not later recall accurately
Leon, age 11, was admitted for his fifth psychiatric the exact agents, dosages, durations, and outcomes
hospitalization. The precipitant was a new burst of of these trials. During this admission, Leon became
unbridled anger and aggression directed at both his notably less volatile, and he was discharged to family
parents, resulting in a significant knee injury to his fa- with recommendations for outpatient services.
ther. Other severe acts of aggression in the recent past However, soon after returning home, his behavior
included swinging a hammer at his older brother and dangerously worsened, and he was readmitted. This
breaking a window in the family home. In addition, he pattern recurred yet a third time. Following this third
had threatened to kill himself on several occasions, hospitalization, he was referred to a group residence
but this was invariably in the context of angry mo- in the community. The parents were initially re-
ments, and he had taken no self-injurious actions. lieved with this option, and an interim plan was
The night before the aggressive episode that led established that included extensive outpatient sup-
to admission, Leon was extremely oppositional and port as well as home-based instruction provided by
unruly at bedtime, and his parents were sufficiently his school district. Nonetheless, a month later, these
intimidated that they gave him 3 mg of clonazepam services had not been implemented, and Leon was
all at once. He was, of course, very sleepy the follow- not enrolled in any school and had received no
ing morning, and it was being readied for school that meaningful tutoring or treatment.
triggered the aggressive episode that culminated in Understandably, Leon had become quite unruly
his hospitalization. in what for him was an entirely boring environment.
Pharmacotherapy just prior to admission com- This resulted in yet another hospitalization, and the
prised olanzapine (30 mg daily in three divided agency that oversaw the group residential program
doses). He was also prescribed risperidone 0.5 mg in closed his case. This disillusioned the parents, who
the morning and evening, divalproex sodium (1,000 were now untrusting of any out-of-home placement.
mg extended-release at bedtime), and benztropine The social services system provided an intensive
(1 mg twice daily). case manager who was well regarded by the parents
Leon was adopted from an Asian country at age because she was available to them for emotional sup-
14 months by a married couple in their 40s. Nothing port by telephone, visited them regularly, and pro-
is known of his biological relatives or the rearing en- vided practical assistance such as travel vouchers
vironment during his first year of life. He walked by and some respite care. However, this did nothing to
20 months and was considered slow to develop lan- solve the ongoing meltdowns in the home.
guage. Nevertheless, he did not attend any school Disenchanted with treatment by a variety of pri-
program until he was 6 years old, when school en- vate practitioners and community mental health
rollment became mandatory. Arriving in first grade, agencies, the parents transferred his care to the psychi-
the teacher quickly expressed concerns about his atric outpatient clinic of a large tertiary care medical
short attention span, inability to sit still, tendency to center in the year prior to the current admission. By
wander around the classroom, and general disrup- now they had been informed that Leon had bipolar
tiveness in that setting. By now, the parents recog- disorder. Despite his father s admonitions, he per-
nized that the high level of activity and poor impulse sisted in accessing pornography on the Internet. The
control that he displayed at home were developmen- parents represented this to the admitting clinicians as
The Child Unit 41
evidence of hypersexuality. There was no history of One corollary is that the clinician has to be simulta-
other sexually inappropriate behaviors or evidence of neously comprehensive in obtaining sufficient infor-
abuse or neglect since coming to the United States.
mation to characterize the nature, course, and context
The parents seemed ambivalent about Leons current
treatment, conveying on the one hand that they of the individuals disturbance and focused on the spe-
thought his medication regimen was helpful yet cific behaviors and events that culminated in the per-
readily acknowledging on the other hand that his over- sons need for intensive psychiatric intervention at
all functioning remained quite impaired and in any this time. Conducting such an evaluation for children
event had not prevented the current hospitalization. has distinct elements.
At the time of admission, the parents spoke at
First, the principal informant is rarely the patient
length of their conviction that Leon had Asperger s
syndrome. They had been alerted to this condition him- or herself but rather adult caregivers. For the
by friends and had begun to read up on the subject, most part, these are the childs parents. History must
persuading themselves that the child definitely met be a composite best estimate of parent and child in-
criteria for this condition. formation. Children are more likely to provide accu-
Dramatically, following admission, Leon was
rate information about their subjective experiences of
calm and cooperative, showing no evidence of a sus-
tained mood disorder. Apart from his brittle frustra- anxiety and mood problems, whereas parents more ac-
tion tolerance that one might construe as rigidity, curately convey details of overt behavior, especially
he displayed none of the core abnormalities of a per- conduct problems (externalizing behaviors). How-
vasive developmental disorder. ever, children in nonparental care account for a fair
proportion of those admitted to inpatient services
This case exemplifies many of the challenges that (dosReis et al. 2001; McMillen et al. 2004; Pottick et
childrens inpatient psychiatric services currently con- al. 2005). The evaluations thoroughness and accuracy
front. These services lie at the conjunction of the urgent may suffer from the vagaries of agency record keeping,
need to address acutely disturbing behavior that none- staff turnover, and incomplete familiarity with the
theless is part of a chronic set of difficulties. Immense childs early years by the current caregivers.
family strain and desperation both promote and derive Second, standardized rating scales, such as the
from serial hospitalizations. Because the quality of Child Behavior Checklist (Achenbach and Rescorla
community-based psychiatric services (when available) 2000) and the Behavior Assessment System for Chil-
may be suboptimal, pharmacotherapeutic situations as dren (Reynolds and Kamphaus 2002) provide norm-
troubling as that described are not uncommon (e.g., us- referenced scores for a number of areas of clinical con-
ing concurrent antipsychotics, switching medications cern. There are versions for both parent and teacher
abruptly to deal with situational crises, enabling high- completion, and the same childs scores from these
dose benzodiazepine use for behavioral dyscontrol at two settings are often very informative, especially
parental discretion). Many of the most severe problems when there are discrepancies. Beyond characterizing
in child psychiatry elude wide diagnostic consensus, so the childs own behavior, caregivers can furnish details
that families receive cacophonous messages from clini- of family history. Besides these broad-spectrum scales,
cians. Potentially useful supportive services are un- other tools may be useful in specific situations. For in-
evenly available, which leads to gaps in care that may stance, the Child Mania Rating Scale (Pavuluri et al.
precipitate readmissions. Finally, inpatient settings of- 2006) and Childrens Depression Rating Scale (Poz-
ten face the quandary of keeping in hospitals minimally nanski and Mokros 1995) may aid differential diagno-
symptomatic children who nonetheless are very likely sis in their respective domains by guiding the clini-
to destabilize after discharge. Mindful of these difficult cians attention toward evaluating symptoms in a
contextual issues, we turn to the programmatic and op- developmentally sensitive manner and yielding a per-
erational elements of the inpatient service itself as it centile that reflects severity.
strives to fulfill its contemporary mission. Third, a developmental perspective is an impor-
tant element of any child psychiatric assessment. This
Diagnostic Workup expectation seems to intimidate some clinicians, for
whom it conjures the complexity of remembering a
long list of milestones and normal acquisition of skills
Clinical Assessment at Admission from birth onward. In truth, a straightforward ap-
The overriding goal of inpatient psychiatric treatment proach focused on major areas of practical signifi-
for patients of all ages is restoration of functioning so cance, preferably aided by a protocol of standard ques-
they can resume care in less restrictive environments. tions, will yield the most relevant clinical information.
One should learn about any major pre-, peri-, or neo- (e.g., ammonia for a child treated with valproate ac-
natal insults and toxic exposures. To the extent possi- companied by marked behavior change). Currently,
ble, a description of early temperament, emphasizing the chief role of laboratory tests among child psychi-
interest in other people, soothability, activity level, and atric patients is to rule out alternative medical etiolo-
overall emotional tone, is helpful to obtain. Disrup- gies and screen for other illnesses that may need inter-
tions in caregiving arrangements, especially when as- vention rather than to aid in differentiation among
sociated with parental incapacitation or familial con- psychiatric diagnoses.
flict, are important to document, along with other Psychological testing, once administered with
unusual or traumatic events. Significant problems or psychodiagnostic goals in mind, is now rarely routine.
delays in physical growth, sensory functions, and basic Cognitive and neuropsychological evaluations have
skills acquisition (language, motor, academic) that come to play a larger role but are still requested spar-
evoked concern or needed intervention are critical to ingly given their expense and time constraints on
identify and naturally lead to questions about current acute care admissions. Their potential to elucidate
functioning and services in the affected areas. learning or developmental deficits in a child whose dif-
The childs early experiences in preschool and ficulties were attributed to a primary behavior disor-
school settings provide crucial data about behavioral der, however, can offer tangible benefits to the patient
development, socialization, readiness for development and be particularly useful in postdischarge planning,
of academic skills, and handling of separations from including appropriate school placement.
home. The trajectory of school experiences warrants The attending psychiatrist should request consul-
thorough questioning, particularly special services or tation from the relevant pediatric specialty for children
individualized evaluations that arise from behavioral or who received treatment for a general medical condition
scholastic difficulties. The quantity and quality of peer prior to admission. The inpatient assessment may also
relationships are significant indices of functioning. Vis- involve pediatric consultation to aid diagnosis. Pediat-
its with, and activities involving, other kids outside of ric neurology may be called, for instance, to evaluate
school may reflect both major problem areas and poten- for potential seizures or neurodegenerative diseases,
tial strengths. It is not uncommon that a child shows which can manifest as phenocopies of some psychi-
markedly better functioning and adjustment outside of atric conditions. The consultant will order or recom-
home than within the family, or vice versa, and this has mend further tests as needed and provide guidance for
clear implications for treatment planning. management while the child is in the hospital.
Fourth, contextual factors hold particular rele-
vance for the severity of a childs psychiatric disorder. Observation
Changes in school setting, family composition, paren- The opportunity for experienced personnel to observe a
tal illness, peer-related events (real or perceived vic- childs behavior, mood, and interactions with peers and
timization, volatile relationships), and so on deserve family is the singular strength of the inpatient setting.
inquiry as stressors. We could also include here These observations permit more direct assessment
changes in the childs treatment regimen, including that bypasses some of the distortions that secondhand
pharmacotherapies. Of course, even without differ- reports of childrens psychiatric symptoms inevitably
ences in prescribed treatment, altered adherence may carry. One can more readily (although not always) dis-
produce unwelcome clinical change. Children on extinguish truly manic grandiosity from socially inap-
tended visits to a different household (e.g., vacation propriate bragging, weepiness secondary to unipolar de-
time with the parent in whose home they do not oth- pression from the frustrated crying that comes and goes
erwise reside) may modify treatment, owing to inad- with episodic rages, reluctance to bathe that is related
vertent confusion or skepticism about its value. to anxiety rather than oppositionality, and so forth. On
the other hand, the change in environment may at
Accessory Assessments times itself lead to a temporary reduction of symptoms
Common laboratory assessments of metabolic, hema- or a honeymoon (Blader et al. 1994). These instances
tological, and endocrine parameters as well as electro- pose a risk of identifying the presenting problem as sit-
cardiography are nearly universal in hospital settings. uation bound, especially when short stays preclude
If a childs preadmission treatment included agents for symptom resurgence in the hospital. The opportunity
which therapeutic drug monitoring is standard, these to observe family interactions beyond the limited con-
should be part of admitting orders. Nonstandard tests texts that the outpatient office affords is extremely im-
should be considered as the clinical situation suggests portant, given the salience of interpersonal factors for
The Child Unit 43
the development and the treatment of the most com- PRINCIPLES, STRATEGIES, AND TACTICS
mon psychiatric disorders of childhood (disruptive,
We noted earlier that aggressive and uncontrolled be-
anxiety, and mood disorders).
haviors are the principal reasons for the psychiatric
hospitalization of preadolescents, yet these behaviors
Therapies develop in the context of diverse forms of psychopa-
thology that may warrant distinct approaches to phar-
macotherapy (Connor 2002). To determine which ap-
Medication Treatments proach or algorithm may be appropriate for a child,
ORGANIZATIONAL ASPECTS OF HOSPITAL-BASED therefore, the clinician has to discern the relative con-
tributions of potential sources of impairment (e.g., im-
PHARMACOTHERAPY pulse-control deficits, affective instability, cognition,
Children admitted to inpatient care most often come sensory disturbance [Blader and Jensen 2007]).
with medication regimens. Ideally, the safety of the in- Overall, the principle espoused in available guide-
patient setting affords the opportunity to reexamine lines is to treat the primary disorder first (Pappadop-
prior treatment with an eye to the potential for behav- ulos et al. 2003). For instance, current guidelines for
ioral toxicity to emerge idiopathically from some med- the pharmacotherapy of aggressive behavior in the
ications or their combinations. Judicious tapering may context of a primary disruptive disorder and comorbid
afford the opportunity to reduce treatments that may ADHD recommend stimulant treatment (with behav-
be superfluous or that were initiated on the premise ioral intervention) first, leveraging the large effects of
that the child had a problem that inpatient assess- stimulant monotherapy on impulse control for this
ment does not confirm. Children with limited prior patient group. Cotherapy with an antipsychotic agent
medication treatment can start therapy in a setting or a mood stabilizer might then be considered for ag-
whose intensive monitoring permits vigorous titration gression that is refractory to optimal stimulant treat-
but whose structure and safety also permit a more pa- ment (Pliszka et al. 2006), although the evidence base
tient approach, avoiding the unwarranted dosage esca- for sequential treatment of this sort remains meager
lations that problematic behavior in less secure outpa- (Blader et al. 2007). Severe agitation developing in the
tient settings may elicit. By the same token, however, context of psychosis obviously warrants antipsychotic
this high degree of supervision should not instill a treatment first. Behavioral explosiveness seen when
false sense of security that leads one to titrate, taper, or others interfere with the compulsive behavior of a
substitute agents with undue haste. child with obsessive-compulsive disorder would like-
Cost containment efforts that emphasize ongoing wise be suitable for treatment that aims to attenuate
review of hospital course may exert a countervailing in- the youngster s anxiety disorder.
fluence on best practices (e.g., Bronfman 1999). When Recent expert consensus panels endeavor to pro-
payers scrutinize therapeutic maneuvers every 2 days or vide clinicians with evidence-based guidance on the
so, clinicians behavior may veer toward more aggres- management of aggressive behavior that does not re-
sive pharmacotherapy to demonstrate they are doing spond adequately to pharmacotherapy for the childs
something. This in turn militates against trials that primary condition (Jensen et al. 2007; Schur et al.
are long enough to establish a regimens value. Unfor- 2003). In particular, these guidelines highlight the evi-
tunately, the evidence base for the optimal care of chil- dence base for antipsychotic and mood-stabilizing
dren with illness refractory to initial treatment steps is medications and emphasize the start low, go slow
very sparse. Psychopharmacology for children admitted approach to titration.
to inpatient settings is therefore especially vulnerable to Whichever disorder or target symptom is the focus
assuming a rather improvisational character. of pharmacotherapy, quantitative assessment of out-
The transition between inpatient and community comes is strongly advised. Memory and review of chart
clinicians is another possible organizational influence notes, even if they were infallible indices of a patients
on pharmacotherapy and patient outcomes. The lim- true clinical condition, are very hard to correlate accu-
ited data available suggest that medication regimens at rately with changes in treatment. Resources may con-
discharge are often modified by outpatient providers strain such efforts, but ideally one would have fairly
(Blader 2006a). It is unknown to what extent changes in frequent rating-scale scores that reflect target symp-
pharmacotherapy are consequences of the course of the toms, other related areas of difficulty, and the childs
childs illness, the waning of a treatments tolerability functioning. These areas may change desynchro-
and efficacy, or the proclivities of individual clinicians. nously (e.g., attention better, aggression same, peer
involvement worse), so that global assessments might therapy that relies on introspection, verbal expression,
obscure important aspects of clinical response. One and linking of problematic behavioral patterns to core
useful brief rating scale that tracks several domains of emotional conflicts is seldom fruitful and in any event
behavioral difficulties is the Child Behavior Rating is regarded as more suitable for longer-term care than
Form (Kolko 1993). acute inpatient stays afford. A more concrete, essen-
tially cognitive-behavioral, approach rooted in recent
DRUGDRUG INTERACTIONS events may be productive for many children. Praise
and recognition for behaviors that reflect therapeutic
Interactions between agents might vitiate efficacy or
progress (e.g., handling provocation or frustration with
risk toxicity. Pharmacodynamic interactions arise
composure, appropriately interacting more with peers,
when joint administration of two drugs markedly in-
talking about feelings rather than acting impulsively
creases their separate risks for adverse effects on the
on them) is worthwhile. Likewise, reviewing difficult
same physiological system or organ. For instance, oral
moments in a nonconfrontational way that helps the
preparations of 2-adrenergic agonists are short acting,
child to develop and rehearse alternative reactions, and
particularly clonidine. Some patients may experience
to see an incident from different perspectives, is also
hypertensive rebound after the drugs direct pharma-
appropriate. Interactions during family visits are fur-
cological hypotensive effect subsides. The sympatho-
ther grist for the mill in helping the child identify feel-
mimetic action of psychostimulants may exacerbate
ings that lead to agitated behavior. Time can also be
rising blood pressure if administration coincides with
well spent observing the child in social interaction and
such rebound (Regino et al. 2000).
facilitating appropriate involvement.
Pharmacokinetic interactions occur when one
Many hospitalized children have experienced more
agents presence alters the absorption, distribution,
than a fair share of misfortune, if not outright trauma.
metabolism, or excretion of other compounds (Flock-
Such early life events include shuttling between care-
hart and Oesterheld 2000; Vinks and Walson 2003).
givers, maltreatment, inadequate care, family discord,
Administration of bupropion, for example, inhibits a
exposure to violence and destruction, chronic illness,
cytochrome P450 isoenzyme, 2D6 (Kotlyar et al.
and losses that include parental incapacitation, incar-
2005), that is important to the metabolism of the anti-
ceration, terminal illness, and death. Although chil-
psychotic risperidone (Shin et al. 1999). Compensa-
dren typically prefer to avoid discussing these topics,
tory mechanisms may offset a potential shortage of
empathy and support are important. It may be appro-
the key enzyme when they are coadministered. How-
priate for the clinician to let the child know of his or
ever, a bottleneck in metabolic activity may expose
her awareness and understanding of these adversities
some individuals (e.g., low producers of a particular
and to seek to alleviate the shame, self-blame, fear,
cytochrome or of alternative pathways) to suprathera-
and hopelessness to which these ordeals often give
peutic levels of a drug or its metabolites. These situa-
rise. Helping the child anticipate and be hopeful about
tions may necessitate dosage reductions to maintain
how things will turn out after discharge may provide
efficacy and tolerability. By the same token, discontin-
needed support that is otherwise unavailable. The
uation of an agent may hasten the metabolism of the
conversation may end up being rather one sided. Cli-
other drug, possibly leading to subtherapeutic bioavail-
nicians whose prior experience has been principally
ability given the same oral dose. Symptom resurgence,
with adults may find this disconcerting at first. They
therefore, might not necessarily demonstrate that the
may benefit from supervision that reassures them that
discontinued drug was effective but perhaps that the
their efforts are worthwhile. Well-intentioned efforts
remaining agent is now, in essence, underdosed.
to prod a reticent child into expressing his or her feel-
ings may be more aversive and frustrating for the child
Psychotherapies
than helpful.
Most child inpatient programs incorporate the triad of
individual, family, and group psychotherapies. FAMILY THERAPY
Family therapy on acute care inpatient settings has
INDIVIDUAL PSYCHOTHERAPY rather practical goals, given the time constraints. For
As with outpatients, the specific content of individual the majority of children, this will tend to emphasize
psychotherapy with hospitalized children varies con- development of behavioral support strategies that are
siderably as a function of the youngsters developmen- more likely to promote more cooperative behavior and
tal level and presenting problems. Insight-oriented better-modulated responses to upset. As the situation
The Child Unit 45
may warrant, other foci may include developing pa- edge through additional outreach to families. One
rental responses to, for instance, a childs dysphoria, common format is a clinician-moderated group for
worries, and severe avoidant behavior, along with rec- parents that offers presentations on a variety of topics
ognition that certain parentchild interactions may related to mental health issues and advocacy. Attend-
inadvertently reinforce a childs resorting to these ing families provide one another with assistance and
maladaptive reactions to stress. support. Parents may be invited to participate after the
The quality of the parentchild relationship is re- childs discharge as well. Family resource centers lo-
flected in warmth, positive involvement, appropriate cated on or near the unit can provide families with in-
discipline, and concern that is genuine but not over- formational materials about childrens mental health
bearing. Cultivating these may be particularly impor- and community resources.
tant for long-term outcome (Blader 2004, 2006b). The Clinicians customarily discuss pharmacotherapeu-
agenda for family treatment often also needs to ad- tic options with families, and doing so ideally also
dress many adversities that impact on the caregivers serves to educate and empower families. The conver-
well-being and capacity to handle their childs psychi- sation should clarify the treatments rationale, risks,
atric illness adequately. These include conflict be- manner of evaluating outcomes, and time frame for
tween caregivers, antagonisms between the family and judging usefulness and encourage questioning and
other service providers and schools, limited resources, voicing of concerns. The dialogue should be summa-
parental illness, and so forth. Prioritizing these con- rized via progress notes in the medical record. Separate
cerns, taking both urgency and tractability into ac- consent-to-treat documents for each therapeutic ma-
count while maintaining alliance with the family, is a neuver are seldom necessary, and the standard hospital
significant challenge for acute care settings. forms at admission usually fulfill medicolegal require-
ments for routine treatments. More formal consent
GROUP PSYCHOTHERAPY procedures in most jurisdictions pertain to certain
treatments that are relatively unusual in child psychi-
It is customary for direct care staff, with or without
atry (e.g., electroconvulsive therapy, clozapine) or to
other clinical staff, to meet with all children together
situations in which children are under the guardian-
once or twice a day. Although their agenda may seem
ship of a public agency.
administrative (discussing the schedule for the day,
In communities where multilingualism is com-
introducing new patients, offering good wishes to those
mon, hospitals typically offer interpreter services. In-
set for discharge), these meetings can be a forum for
formation in psychiatric settings, however, tends to be
children to help one another by encouraging peer praise,
far more personal, detailed, and in some ways nuanced
eliciting solutions to common difficulties, or offering
than in other hospital areas. Psychiatric services may
feedback on how ones behavior has influenced others.
need to evaluate whether the hospitalwide resources
Therapies that address childrens social skills, anger
offer the confidentiality protections and quality re-
control, and problem solving, among other things, have
quired.
shown value among outpatients (Lipman et al. 2006;
Older children in particular often harbor confusion
Lochman et al. 2006; Sukhodolsky et al. 2000). Group
over what admission to a psychiatric inpatient service
adaptations for children provide opportunities for skill
means for their emerging identities, have concerns
practice and modeling. Some of these interventions are
about stigma, and are ambivalent about treatment. As
designed to follow a sequence that builds on earlier ses-
unit composition permits, groups for these young-
sions. Implementing such treatments contends with
sters, who are usually developmentally further along
the discontinuities that short stays and shifting group
than most child inpatients, can provide needed mu-
membership produce. Clinicians often improvise by
tual support and psychoeducation. Otherwise, these
adapting these treatments into more self-contained
are appropriate emphases for individual therapy.
components. One could see these adaptations as dilu-
tions of evidence-based treatments. On the other hand, Rehabilitation and
inpatient settings offer opportunities for prompting and
coaching in the use of specific skills to address real-life Recreational Therapies
situations as they occur on the unit. In most settings, childrens education continues
throughout their stays on inpatient psychiatric ser-
Patient and Family Education vices, at least when school is in session in the commu-
Family therapy often involves psychoeducation, but nity. Participation in a hospitals school setting also
some services endeavor to provide support and knowl- provides clinicians with enormously helpful informa-
tion about the childs functioning, both academic and apply staff feedback and consequences accordingly. Be-
behavioral. Some acute care units have dedicated cause these procedures are core elements of many in-
classrooms in which children spend a full school day, terventions for childrens behavioral disorders (e.g.,
and the activities and structure unmistakably resem- Kazdin 1997), these milieu programs play a significant
ble a regular school. Other units may have a teacher role in treatment for the large number of children ad-
who provides individualized tutoring and gives assign- mitted for conduct disturbances. In addition, these
ments and materials to the patients, devoting rela- systems provide a form of structure and governance by
tively fewer hours of the day to academic involvement. codifying basic rules and how infractions will be ad-
Teachers most often have a special education back- dressed. Because these systems often include some
ground and are employees of the public educational ju- quantification of behavioral adjustment, in the form
risdiction for the hospitals environs. A few psychiatric of points and such, they can also furnish a means of
facilities operate their own accredited schools and en- plotting clinical progress.
deavor to recover tuition costs from patients home As with any good behavioral therapy program, the
school districts. Teachers perspectives and expertise consistency of feedback is paramount, especially praise
make their input on patients functioning and clinical and recognition, which should be abundant but sin-
progress an important resource. cere. This would in many cases accompany assign-
Another critical program component is structured ment of points or tokens for achieving the positive be-
activities for childrens recreation and socialization. havioral goals of the activity or time of day, which is
Staff specialists responsible for these services are typ- well defined. In some versions, each patient also has a
ically from the facilitys rehabilitation, child life, activ- few individualized goals for which he or she obtains
ities therapy, or other similar departments. Personnel praise, encouragement, or correction as well as points
are often occupational therapists and from other re- earned. The actual privileges or rewards toward which
lated disciplines. In the best of situations, patients can points accrue can involve some that are earned daily
have some choice about which of a few concurrent ac- (video game time) and some that are based on accumu-
tivities to attend. This helps keep the group sizes more lation over several days (privilege level). The former
manageable and enables more meaningful interaction. enable the patient to begin each day with a new start
Off-unit spaces (e.g., playgrounds or swimming pools) and to benefit accordingly.
and off-grounds trips can be important experiences The shortcomings of these approaches chiefly
that counteract the institutionalizing effects of longer- stem from their potential to be rigid and from their
term stays. emphasis on the application of consequences to shape
behavior (Mohr and Pumariega 2004). Individual vari-
ation in what triggers displays of behavioral distur-
Milieu Management bance and, for that matter, what constitutes a reward
can in some cases place the therapeutic value of unit-
The admission process usually culminates in an ori- wide behavioral systems at odds with their role in
entation of children and their families to the units governance. Perhaps a childs resistance to staff di-
program, routines, and rules. Parents appreciate clear rection may be reduced by a period of gentle, affable
verbal and written explanations of how cooperative be- engagement beforehand, while the typical conse-
havior is recognized and how poor rule adherence is quences for noncompliance (warnings, time-outs, loss
addressed. This information helps establish appropri- of points) most often lead to escalating agitation.
ate expectations for how staff will interact with the Time out from an activity may be a consequence
child and comfort that discipline is not arbitrary. Sim- that many children are motivated to avoid, but for oth-
ilarly, rules specifically for parents will often identify ers it may function as an escape from an undesired ac-
which items are not permitted on the unit, that visit- tivity or a means to gain attention.
ing times are not merely guidelines, the circum- To overcome these problems, most settings do
stances under which staff may direct parents to leave manage to incorporate program modifications as
the unit, and so on. needed for individual patients. Individualized assess-
On childrens units, milieu-based programs based ment of the situational context that gives rise to behav-
on behavior modification principles are nearly ubiqui- ior and the function that behavior serves in fulfilling
tous. They are often called level, point, or token some need, albeit maladaptively, is an important facet
economy systems. At their core, these programs de- of behavior therapy (e.g., ONeill et al. 1997). This type
fine specific behaviors to promote or discourage and of individualized planning within a milieu setting can
The Child Unit 47
be complicated by constraints on staffing and difficul- involves constant supervision by a specifically desig-
ties in convincing children that apparent inequities in nated staff member who keeps a written log of the pa-
staff responses do have an underlying fairness. As in- tients status at frequent intervals (one-to-one obser-
terventions involving many staff over several shifts and vation, or 1:1). Currently, many if not most hospital
hospital areas become more diverse and nuanced, they psychiatric settings do not receive additional personnel
risk reintroducing the inconsistencies and idiosyncra- when 1:1 is deemed necessary. In these cases, the rest
sies in staff. These issues may be surmountable, how- of the service makes do with reduced staffing. Varia-
ever, and several facilities are evaluating implementa- tions include orders for 1:1 assignment only outside of
tions of these approaches (Greene and Ablon 2006; structured activities where the additional surveillance
Greene et al. 2006; Martin et al., in press). Ways to may be redundant with existing oversight. The neces-
minimize staff drift, regression to the behavioral sity for these measures is usually reassessed on a daily
mean, and one size fits all approaches to patient care basis and orders renewed or discontinued accordingly.
can include frequent cross-disciplinary communica-
tion, preferably blended into existing unitwide struc- DE-ESCALATION STRATEGIES
tures (such as team meetings) rather than in separate
In few occupations does one more regularly encounter
standalone meetings; standalone meetings organized
agitated, upset, belligerent, and, at least temporarily,
on a periodic or ad hoc basis, particularly during times
irrational individuals than in providing direct care to
of transition or staff turnover or after critical incidents;
inpatients in psychiatric settings (Nijman et al. 2005).
and scheduling and documentation templates that in-
The ability to help the overwrought child handle up-
corporate best practices, individualized plans, and iter-
sets without disruptive or destructive impact is partic-
atively updated information.
ularly vital for staff on childrens units. Recent federal
regulations now require formal training, demonstrated
Staffing Patterns competence, and periodic retraining in early identifi-
cation and nonphysical intervention with patients
whose behavior might place them at risk for severe
Staffing ratios should be ideally calculated based on
escalation (Centers for Medicare and Medicaid Ser-
national benchmarks for each discipline. However, it
vices 2006). Several resources to inform such staff de-
is usually in the discipline of nursing that such bench-
velopment are currently available (American Psychiat-
marks are frequently available. Generally a 1:3 staff-
ric Association et al. 2003; Cowin et al. 2003; Grenyer
to-patient ratio for acutely ill patients and 1:5 for
et al. 2004).
longer-term patients meet national standards. Full-
Techniques for nonphysical crisis management or
time equivalents are calculated based on data such as
de-escalation in psychiatric settings share some gen-
average daily census, number of work shifts, and skill
eral principles. Many approaches emphasize detection
mix. However, patient acuity, which varies based on
of early warning signs for growing agitation. Children
multiple factors including seasonal variations, is
are perhaps less likely to show a period of sulkiness,
rarely taken into account when full-time equivalents
brooding, pacing, and glares that, for older persons, of-
are calculated. This often produces a perception of
ten signals simmering upset that further provocation
burnout and compassion fatigue in the caregivers of
can bring to boil. Rather, quick, overtly combative, or
acutely ill patients. Management of staffing is crucial
oppositional reactions to feeling thwarted or offended
to the smooth operations of an inpatient unit.
are more likely among highly impulsive youngsters.
Nonetheless, the child who seems to be in a generally
Management and Prevention of bad mood may be at higher risk on a given day, so extra
attention and support are, of course, both compas-
Suicidal and Aggressive Behaviors sionate and useful in reducing risk.
When the fuse is lit but harm has yet to occur, the
Acute Management situation is ideally handled when the adults display
calm, concern, and confidence. Hasty staff reactions
ENHANCED MONITORING that convey agitation, threats, hostility, and anxiety
Patients thought to pose increased risk to themselves may further inflame the situation. Therefore, the op-
or others may be considered for more vigilant observa- timal approach is for staff to adopt a nonthreatening
tion to enable prompt intervention and support when posture and seek clarification for what appears to be
early signs of faltering composure arise. One version troubling the child. Empathizing and offering sugges-
tions or choices for constructive engagement in deal- conditions of participation for hospitals to receive
ing with the situation provide the individual with con- funds from Medicare and, in effect, from all other rev-
trol and avert the sense of being cornered. An enues authorized by the Social Security Act, including
available staff member with whom the child has a par- Medicaid. These regulations address when a pharma-
ticularly good relationship may be most successful at cological intervention constitutes a form of re-
engaging him or her at such affectively charged times. straint, in which case administration is controlled by
A chorus of adults, however well intended, may be too a number of restraint-related provisions, including
stimulating and counterproductive, and a better out- prohibition of prn use (Centers for Medicare and Med-
come may result if others linger in the background to icaid Services 2006). Practitioners must be mindful of
intervene only if things deteriorate. Of course, if the these and other regulatory requirements governing the
situation de-escalates by virtue of the childs participa- use of medications to assist in alleviating severe be-
tion, then all can exuberantly express their admiration havioral agitation.
to the child for making good decisions and doing a
great job being in charge of your own behavior. PHYSICAL SECLUSION AND RESTRAINT
The presence of other patients may make the
The mental health codes of most North American
childs acquiescence less likely if he or she feels that
jurisdictions permit the application of involuntary
doing so would be humiliating. The incident may also
constraints on a persons mobility by hospital person-
become dangerous or upsetting to other children.
nel as a last resort in true emergencies. The isolation
When practical, it is best to help the child to voluntar-
of a person in a room with insuperable barriers to his
ily leave a group setting or at times to relocate the
or her voluntary exit is seclusion. The application to
other patients.
ones body of physical force or a device (or, in circum-
stances noted earlier, medications) to restrict move-
PHARMACOLOGICAL INTERVENTION ment is restraint.
Medications may be administered to hasten the reso- Governmental regulations specify many of the
lution of a specific episode of severe behavioral agita- procedures to be followed in these situations. These
tion that is under way or imminent. A common con- require the facility to establish a written protocol for
text f or do in g so is wh en c on cur rent st andin g handling nascent crises to avert the need for physical
treatments to improve the patients emotional volatil- interventions and the criteria for judging that these
ity, impulsivity, distorted judgment, or other psycho- interventions have not been successful before pro-
pathological processes driving dyscontrol have yet to ceeding to apply the more restrictive alternatives. In
yield the intended effects. In general, the use of medi- addition, the decision-making process, staff training,
cations in this fashion (i.e., pro re nata [prn] or statim forms of documentation, specific methods or devices
[stat] use) is disfavored for children in all but extreme applied, observation, monitoring of vital signs, dura-
situations, for reasons that derive from both practical tion of the intervention, and so forth also must adhere
pharmacological and regulatory considerations. to the standards set by governmental and accrediting
As a practical matter, children admitted to the hos- bodies. In the United States, federal regulations estab-
pital with aggressive behavior commonly receive anti- lish basic nationwide standards through the condi-
psychotic medication as part of their regular treat- tions of participation they promulgate for Medicare
ment, and the introduction of an ad hoc dose or a and Medicaid. State and local laws may establish re-
different compound (several atypical antipsychotics quirements that are more stringent than federal ones
currently lack immediate-release injectable prepara- (e.g., shorter permitted periods of seclusion or re-
tions that highly uncooperative patients may require) straint). Indeed, states can prohibit them either alto-
to the standing regimen carries risks. Benzodiazepines gether or for specific patient groups. Where localities
may increase disinhibition and aggression (Bond have separate departments for mental health and de-
1992) and are disfavored for treating childhood aggres- velopmental disabilities, there may be separate regu-
sion outside of acute use in psychosis or mania. Anti- lations that apply to those with mental retardation.
histamines are considered fairly safe in this context, All of these provisions cover children, and it is only
although their true pharmacological effect, relative to recently that maximum durations for each restraint/
the impact on the child of intramuscular administra- seclusion order differ by age (e.g., 8 years and younger,
tion per se, is questionable (Vitiello et al. 1991). 1 hour; 917 years, 2 hours; 18 years and older, 4
Regulations with the broadest nationwide applica- hours; local requirements may authorize even shorter
bility are those that the federal government issues as periods) (Centers for Medicare and Medicaid Services
The Child Unit 49
2006). Nonetheless, all incidents involving minors re- ways to minimize its use or its duration. Moreover,
ceive special scrutiny owing to their greater overall there is no evidence that the use of pulse oximetry de-
vulnerability and dependence, increased susceptibility creases restraint-related fatalities. The best approach
to the physical and psychological harms the interven- to such serious, if rare, events may be in decreasing the
tions may themselves produce, and, often, the view overall use of restraints.
that childrens limited size and strength should render It bears emphasizing that these approaches are
them seldom necessary. Of perhaps more relevance to last-resort crisis interventions and should not be con-
children is the practice of staff physically holding a strued, or justified, as treatments for psychiatric ill-
child to prevent mobility for relatively brief periods ness as such. The use of interventions whose putative
(physical as opposed to mechanical restraint). Facil- efficacy is predicated on the experience of discomfort,
ities routinely have policies for training, implementa- pain, or humiliation is unacceptable as elements of
tion, and review of their use. Tragically, incidents in- routine treatment for individuals with mental illness.
volving physical restraint of this type have accounted Unusual circumstances that might justify their short-
for the most child fatalities due to asphyxiation (Joint term use to avoid an even more dire outcome remain
Commission on Accreditation of Healthcare Organi- highly controversial.
zations 1998; Nunno et al. 2006).
Having exhausted nonphysical methods to reduce Prevention
the threats an individuals behavior poses, seclusion High-quality, well-supervised, and developmentally
and restraint interventions are often implemented in appropriate unit programming is obviously important
a stepwise fashion; that is, seclusion is thought to be for children in hospital settings. It is also beneficial for
less invasive and may be undertaken first. If the child minimizing the sorts of episodes that can culminate in
endangers him- or herself during seclusion, the team harmful behavior. Times of day during which behav-
may consider restraint as the next step. There are ioral escalations are frequent require scrutiny, espe-
concerns that the physical coercion these procedures cially when seclusion and restraint often occur. These
involve, especially restraint, may be particularly dismay coincide with periods of major transitions, sub-
turbing to children with histories of trauma or abuse optimal staff-to-child ratios, free-play times that de-
(Cotton 1989). generate into a free-for-all, and so forth. Certain rou-
Both applicable laws and institutional regulations tines that require high staff assistance (e.g., getting
delineate monitoring procedures for patients during dressed, getting ready for bed, doing homework) may
the period of seclusion or restraint. At a minimum, benefit from staggering to involve smaller groups of
these procedures require constant observation of the youngsters at a time. A single bedtime for children of
patient (in some jurisdictions achievable via closed-cir- diverse developmental levels may also contribute to
cuit television). Monitoring serves two purposes. The chaos when the overtired children become overstimu-
first is to ensure that an individual is not subject to lated whereas the far-from-tired ones dread lengthy
these interventions for longer than is necessary. Staff confinement to bed before they are biologically ready
members performing observation therefore record at for sleep. The conclusion of visiting hours may be
frequent intervals the patients behavior, efforts at stressful for children as family departs, and the whole
communicating after some period of relative calm, and period terribly so for children whom no adult comes to
periodic physicians assessments. The second purpose see. Extra care and something to look forward to at
is to guarantee the patients safety given the risks these these times may be essential. There are also, of course,
procedures pose, including tragic outcomes involving situations in which particular staff members, what-
injury or death. Consequently, periodic assessments of ever their other professional assets, may inadvertently
vital signs, respiration rates, needs for nourishment contribute to the instability of a particular phase of
and voiding, adequate slack where devices contact unit activity.
the body, and so on are required and must be docu- Children with whom staff interventions have
mented clearly. Pulse oximetry has been proposed as a come to include high utilization of seclusion or re-
direct measurement of blood oxygenation during pro- straint will often require modification to their care
longed episodes of restraint. Currently, the approach plans. Ideally, these are rooted in a functional assess-
does not constitute an accepted or even widely used ment of what appears to trigger the youngster s diffi-
standard of care, and some critics have opposed it on culties, whether there are feasible environmental
the grounds that it may sanction the use of restraint changes that can mitigate them, and what steps can
by focusing on how safe the practice is rather than on meet the childs needs more adaptively. It is tempting
to defer reassessment of a childs treatment plan and the child must not be returned to that primary care-
pin all hopes on a change in pharmacotherapy that giver s home until the suspicion is ruled out through
will pay off with vastly improved behavioral adaptabil- investigation.
ity. Unfortunately, by the time a childs severe dyscon- Informed consent must be obtained from parents
trol has become persistent in the hospital, he or she for any child for whom psychopharmacological inter-
will likely have already experienced numerous intervention is being considered. In many states, use of prn
ventions, and the prospects that the additional ma- medications may be interpreted as chemical re-
neuver will have fast and robust payoff may be slim. straints. As noted earlier, practitioners must be aware
There is the further risk that frequent application of of the state human rights laws specifically pertaining
physical interventions to control behavior degrades to seclusion and restraint.
the childs relationships and expectations of others so
that the pattern becomes self-sustaining and possibly
less responsive to pharmacotherapy.
Discharge Planning
Medicolegal and Risk Management Involvement of Community

Considerations Providers, Resources, and
Significant Others
Because children are a particularly vulnerable popula- A postdischarge care plan that leverages extended fa-
tion, their treatment on an inpatient service incurs a miliarity with a child and familys needs is one of the
few protective and regulatory obligations beyond those major goals of hospitalization. In acute care settings
that pertain to psychiatric care in general. Parents are with diminishing lengths of stay, however, planning
empowered in most jurisdictions to provide consent for continuing care needs in the community practi-
for their childs treatment throughout childhood. cally needs to begin at admission. This requires the
States differ in the age at which parental consent alone engagement of community clinicians and others to
is no longer sufficient for a voluntary admission, and learn firsthand their perceptions of the main impedi-
the patients consent to admission and treatment be- ments to the childs doing well at home and whether
comes necessary between the ages of 14 and 16. Sep- they have specific questions about the childs difficul-
aration agreements and divorce decrees may apportion ties they would like hospital-based assessment to ad-
medical decision making apart from emergency situa- dress. In the absence of laboratory or radiological tests
tions to one parent. In some instances, one parents to provide objective support or refutation of diagnostic
rights have been terminated, and there might even be beliefs, the hospital clinicians credibility will depend
court orders limiting or prohibiting a parents contact on the quality of communication and its responsive-
with the child. It is recommended that copies of these ness to what the community provider needs to know.
documents be obtained early in admission. Perfunctory discharge summaries that recite medica-
State laws also differ in the threshold required to tions and dosages, often without clear statements of
establish the need for involuntary commitment, but their rationales and textured descriptions of response,
most allow temporary detention of minors through are unlikely to serve this function well. This bidirec-
certification of dangerousness to self or others after a tional communication can only take place if the family
face-to-face evaluation by a mental health clinician. consents to it, so hesitations the family may harbor
Usually the brief period of being detained in a psychi- about doing so should be broached at admission. If
atric facility allows observation, assessment, and families wish to go elsewhere for follow-up care, the
most importantlythe development of a safety plan. appropriate linkages should start sooner rather than
A commitment hearing with a judge must occur later.
within a specified time period to determine disposi- Much the same applies to collaborating with the
tion: continued inpatient level of care, outpatient care, childs home school district, given the large proportion
or no care at all. of child inpatients who receive special education ser-
Inpatient settings can also serve to uncover abuse: vices prior to admission. Schools and clinicians may
physical, emotional, or sexual. Any clinician who sus- differ on the appropriate setting, especially for the
pects the abuse must report to the state child protec- child who was highly disruptive before hospitaliza-
tive services, and if the perpetrator is the primary care- tion. Some districts contemplating a more restrictive
giver or lives within the same household as the child, setting for a child may be willing to have the child re-
The Child Unit 51
turn to the prior program before discharge to see for mined that a child no longer needs the acute hospital
themselves, as it were, how well the clinicians claims setting, because payers may reimburse the hospital at
of improvement generalize even for a short period out- a reduced rate, corresponding to a so-called alternative
side the unit. In any event, a childs community teach- level of care. Payers may apply this rate retrospectively
ers often find the units schoolteachers reports of the (i.e., after discharge).
childs current status particularly credible, and predis- From a clinical standpoint, it will often fall to hos-
charge contact between them is often useful to facili- pital clinicians to help the child avoid succumbing to
tate. At one time it was common for a behaviorally sta- two risks. The state of limbo can understandably give
ble child to stay in the hospital for additional time so rise to despondency or apathy, exacerbated by pro-
that school authorities could devise an appropriate longed time in a small setting designed for short stays,
service plan rather than discharge a child with no ap- which can become mind-numbingly tedious. This
propriate educational setting. Financial pressures to gives rise to a second hazard, institutionalization, that
shorten lengths of stay to what is absolutely vital to may make adaptation to more normal environments
stabilize the patients clinical condition have largely difficult and anxiety provoking.
eliminated this option. It therefore behooves all par-
ties to secure appropriate services expeditiously. Specialty Day Hospital
Various forms of enhanced community-based ser- Day treatment programs for children are usually a
vices beyond routine outpatient care have been devel- melding, in varying emphases, of special education
oped with the psychiatrically hospitalized child in and psychiatric care. At one end, there are specialized
mind. These include home-based services, respite care schools for those with socialemotional impairments
for families, case management to help coordinate the that have some therapeutic component or a psychiat-
multitude of services families often require, and other ric consultant, and at the other are true day hospitals
services to support families. with primary psychiatric emphasis and specialized
A perennial source of complications for discharge education services as a major adjunct.
planning, not to mention heartbreak, is the large num- Day treatment programs have in the past cared for
ber of hospitalized children residing in surrogate care youth over fairly long periods, not unlike day hospitals
arrangements before admission. Foster parents are of- for adults with chronic severe psychiatric illness. This
ten heroic figures intensely devoted to the children in has changed somewhat, and many day treatment or
their homes despite limited support from agencies. partial hospitalization programs are now conceived to
There are instances, however, in which hospitalized provide medium-term subacute care (i.e., weeks to
children cannot return to these homes. Sometimes months, rather than years) as a station on the road to-
the agencys goal is to reunite siblings, or a biological ward full community reintegration.
parent may be on the cusp of regaining custody. A In another emerging model, the partial hospital,
number of youngsters, however, have serially resided a child is discharged to home but continues to partic-
in several homes because the severity of their disorder ipate in weekday schooling and rehabilitation activi-
has exceeded caregivers capacities. ties on the inpatient unit for 1 or more weeks. This
can be a less costly alternative for children whose post-
Transition to Next Level of Care discharge needs are not entirely clear or when there is
Acute care units at times play a pivotal role in a childs a lag until an appropriate school setting becomes avail-
admission to a residential treatment service or to sub- able. Families often value the continuity of care. How-
acute inpatient psychiatric care. This can be a lengthy ever, in many areas the family has to provide transpor-
process and often necessitates a good deal of con- tation for this service when schools do not have the
ferencing of hospital staff with potential facilities and willingness or the administrative agility to implement
the social service officials who, as the usual source of the arrangements promptly.
funding, are also involved. Some states have single
point of entry arrangements whereby the govern-
mental authority receives the relevant clinical mate-
Conclusion
rial and then deals directly with potential residential
centers. Hospital staff may have to advocate strenu- Inpatient services for children have changed markedly
ously for an interim discharge plan so the child does over the past 20 years. Once conceived as a therapeu-
not languish in the hospital unnecessarily. There are tic modality that could bring about major changes in
also financial pressures that arise when it is deter- disturbances of behavior and personality develop-
ment, the mission of psychiatric hospitalization now References

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CHAPTER 4
THE ADOLESCENT UNIT

Gary J. Gosselin, M.D.
I npatient psychiatry programs are the intensive care 2006). This chapter presents an overview of the ado-
units of the adolescent mental health service system. lescent inpatient psychiatry unit through descriptions
They are meant to address the serious risks and severe of admission criteria, assessment, treatment, milieu
impairments caused by the most acute and complex management, management of aggressive and suicidal
forms of mental illness that cannot be managed effec- behaviors, and discharge planning.
tively at any other level of care. Inpatient hospitaliza-
tion is a consultative and collaborative systems-based
endeavor geared to produce rapid clinical stabilization
Admission Criteria
that allows for an expeditious, safe, and appropriate
treatment transition to a less intensive level of mental High levels of illness severity and significant functional
health care (Pottick et al. 2001). impairments are the dual markers that signal a need for
Hospital admission should not be a default substi- inpatient psychiatry admission. Clinical criteria for ad-
tute for absent or underdeveloped community-based mission must include significant signs and symptoms
mental health programs that could provide clinically of active mental illness. Functional indicators for ad-
appropriate, less restrictive, and more economical mission usually include a significant risk of self-harm
mental health care to families and adolescents (Bart- and/or harm to others. In some cases, there might be
lett et al. 1999; Mansbach et al. 2003). The current an inability to meet basic self-care or health care needs
national health care environment has produced signif- that jeopardizes the well-being of an adolescent. Seri-
icant service shortages at all levels of mental health ous emotional disturbances that prevent participation
care for adolescents. These shortages are reflected in in family, school, or community life can also rise to a
the substantial demands faced by inpatient units that level of global impairment that can only be addressed
must provide effective, economical, and ethical care on an inpatient basis. Scales and instruments to rate
(Case et al. 2007; Dickey et al. 2001; Geller and Biebel illness severity and functional impairments are avail-
55
able to identify clinical markers for inpatient care and High-risk screening is an important part of the diag-
enhance the reliability of treatment monitoring during nostic evaluation aimed at identifying and addressing
the hospital course. Rating tools relevant to level-of- potential sources of imminent harm in a case. It covers
care screening include the Child Global Assessment past and current instances of significant physical ill-
Scale and the Child and Adolescent Level of Care Uti- ness, suicide, self-injury, violence as victim or perpetra-
lization System/Child and Adolescent Service Intensity tor, fire setting, sexual abuse as victim or perpetrator,
Instrument (Fallon et al. 2006; Shaffer et al. 1983). risky sexual behavior, and substance intoxication,
Every hospital admission has specific legal require- abuse, or dependence. Results of the high-risk screen-
ments. Voluntary or involuntary civil commitment ing are used to prioritize the clinical interventions nec-
criteria must be satisfied. Consent to admission is of- essary to establish and maintain patient safety. Risk is
ten required from parent and adolescent, especially for subsequently reassessed prospectively over the course
adolescents approaching the age of majority. Joint cus- of hospitalization to maintain safety, evaluate interven-
tody arrangements present a requirement that both tion effectiveness, and gauge readiness for discharge.
custodial parents reach agreement about the admis- The use of structured instruments to record find-
sion decision. Due process notifications related to le- ings provides systematic organization and reliability
gal rights and status must also be provided to patients to the screening and assessment process (Hughes et al.
and parents as part of the admission process. Practi- 2000). The rapid pace and high volume of work on in-
tioners should be thoroughly familiar with the specific patient units are best served by rating instruments
state mental hygiene legal standards governing their that allow for accurate, reliable, and efficient adminis-
location of inpatient practice. tration (Table 41). Structured rating forms for inter-
views, such as the Brief Psychiatric Rating Scale for
Children, that prompt clinicians to elicit and record
Assessment specific clinical findings build consistency of diagnos-
tic coverage and establish a standard systematic ap-
proach that guards against errors of omission (Hughes
General Strategies and Methods et al. 2001; Lachar et al. 2001). Questionnaires for
The diagnostic workup is a systematic screening and parents and teachers are useful to collect and organize
assessment process prioritized to identify dysfunction relevant clinical data. Computer-based assessment
that places the patient at greatest risk. The principles tasks continue to emerge as a clinically useful diagnos-
and practices outlined in the Practice Parameters for tic modality (Cawthorpe 2001).
the Psychiatric Assessment of Children and Adoles-
cents are applicable to the inpatient assessment pro-
Clinical Interview
cess (American Academy of Child and Adolescent Psy- The clinical interview remains the cornerstone of psy-
chiatry 1997). Multiple sources of information from chiatric assessment and diagnosis. It is where clinician
collateral contacts such as outpatient clinicians, pedi- and patient meet, rapport is established, the patient
atricians, community service providers, and school gains voice, cooperation is fostered, mental status is
personnel should be utilized to cross-check and verify examined, the history is obtained, and the therapeutic
assessment findings. Consents to contact collateral relationship takes shape. Interviews are performed
information sources are needed at the outset of the ad- with the patient individually, with the parents separate
mission. from the patient, and with the patient and parents
Diagnostic evaluations must take into account the together.
range of developmental phenomena possible during Adolescents are commonly seen separately from
the adolescent years, a period spanning the end of late their parents early in the admission so that their view
childhood to the start of the young adult years. A de- of the current crisis can be heard and so that they can
termination of the concordance or discrepancy among share sensitive yet crucial information that they often
the domains of physical, emotional, social, behavioral, would not speak about while in the presence of a par-
cognitive, and adaptive functioning is particularly sa- ent. Confidentiality conditions for a patients inter-
lient in assessing the impact of severe mental illness view disclosures involve a delicate balancing of an ado-
on developmental status. Failure to attain expected or lescents privacy interests with a parents right to
loss of attained developmental milestones requires know about assessment findings and treatment plan-
that a developmental disorder or neurodegenerative ning. This situation comes into vivid relief when cen-
process be ruled out. tral features of a case involve matters pertaining to re-
The Adolescent Unit 57
TABLE 41. Selected brief rating scales and diagnostic instruments for adolescent inpatient unit
Descriptive symptom profile or global functioning
Brief Psychiatric Rating Scale, Child Version (Hughes et al. 2001)
Clinical Global Impressions (Guy 1976)
Childrens Global Assessment Scale (Shaffer et al. 1983)
Specific target symptoms
Childrens Depression Inventory (Kovacs 1985)depression
Childrens Yale-Brown Obsessive Compulsive Scale (Goodman et al. 1991)obsessions and compulsions
Conners Rating ScalesRevised (Conners et al. 1998)attention, hyperactivity
Modified Overt Aggression Scale (Kay et al. 1988)aggression
Revised Childrens Manifest Anxiety Scale (Reynolds and Richmond 1985)anxiety
Young Mania Rating Scale (Young et al. 1978)mania
Side-effect measures
Barnes Akathisia Scale (Barnes 1989)
Abnormal Involuntary Movement Scale (Guy 1976)
productive health and substance abuse, both areas be capacity to address the needs of sexual assault vic-
often considered by public health laws to be the ado- tims who have been referred for admission. This entails
lescents protected health information when care is close coordination with emergency services to ensure
delivered to them in outpatient settings. Careful anal- that timely collection of physical evidence, antiviral
ysis of the unique aspects of each case must be done to prophylaxis, and emergency pregnancy prevention have
determine what constitutes a necessary disclosure to been initiated as needed prior to admission.
prevent harm and what adverse effects might result
from a confidentiality breach. It is here that clinical, Medical History, Physical
ethical, and legal analyses should pull together. Examination, and Laboratory Testing
Substance Abuse Screening Medical clearance starts with a careful and thorough
medical history and physical examination that are
Substance abuse risk looms significantly in adolescent performed by a qualified pediatric or adolescent med-
mental health populations and must be addressed in icine practitioner. When child and adolescent psychi-
every case (Hovens et al. 1994). The CRAFFT sub- atrists are called on as the primary practitioner to
stance abuse test (Table 42) is a tool that provides an complete medical clearances, they must have main-
effective and efficient screening approach to this prob- tained their knowledge of appropriate health screening
lem (Knight et al. 2002). Positive screening results on and examination skills to meet national standards of
this test indicate that closer assessment of drug treat- practice for the physical evaluation of adolescents.
ment needs is warranted. Care must be taken to iden- Care must be taken to ensure that medical evaluation
tify substance dependence and risks for substance is not shortchanged due to the presentation of the pa-
withdrawal. Intoxicated patients should be given time tient with acute behavioral and emotional issues. Sig-
to clear in a medically supervised setting before they nificant physical illness comorbidity rates have been
are admitted for psychiatric treatment. Their clinical noted in adolescent populations receiving psychiatric
condition can change markedly during this period as services (Warner 2006). A body map of injury patterns,
their intoxication resolves or withdrawal signs emerge. including scars, bruises, cuts, and abrasions, should
be completed as part of the admission physical assess-
Reproductive Health Services ment. Injury mapping provides baseline information
Reproductive health services are a core component of about findings that might be pertinent to child protec-
adolescent medicine practice. These services should be tion matters, and they are also key checkpoints in
available to address matters related to sexuality, preg- tracking of patterns of self-injury that might happen
nancy, and sexually transmitted diseases. There should over the course of treatment. The medical clearance of
TABLE 42. The CRAFFT Substance Abuse Screening Test for adolescents
C Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been
using alcohol or drugs?
R Do you ever use drugs or alcohol to RELAX, feel better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are ALONE by yourself?
F Do you ever FORGET about things you did while using alcohol or drugs?
F Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
T Have you ever gotten into TROUBLE while you were using alcohol or drugs?
Scoring: 2 or more Yes answers indicates a problem needing follow-up.
Source. Center for Adolescent Substance Abuse Research at Childrens Hospital Boston.
overdoses usually requires a period of preadmission significant history of head trauma also is a relative in-
prospective monitoring of blood levels and clinical sta- dication to pursue imaging. Cognitive decline, disori-
tus to verify physical stability. entation, and the presence of focal findings suggest a
Nutritional status should be screened routinely. stronger need to pursue neurological consultation and
Risk for cardiovascular and metabolic complications workup that are likely to include studies of brain struc-
related to obesity must be identified and managed. ture and function.
Body mass index (BMI) should be recorded and trended
across treatment settings, as there is a secular U.S. Psychological Testing
trend of increasing adolescent BMI. Weights below 75%
Psychological consultation can aid the diagnostic pro-
ideal body weight often indicate a need for inpatient ad-
cess in several valuable ways. Standardized measures
mission to address factors contributing to significant
of cognitive and adaptive functioning are useful to
nutritional compromise in the context of an eating dis-
evaluate suspected deficits in these developmental
order or another severe neurovegetative disturbance.
domains. A personality assessment such as the Min-
Immunization status and tuberculosis exposure and nesota Multiphasic Personality Inventory, Adolescent
screening history must be checked and updated. Tuber-
Version, can generate information about psychopa-
culin skin testing should be performed if it is not cur-
thology and an individuals relative strengths and
rent, particularly in individuals admitted from high-
weaknesses (Janus et al. 1998). Projective techniques
exposure-risk locations. The need for isoniazid treat-
can provide a perspective on significant alterations in
ment should be ascertained early in the hospital course
thinking that might not be readily discernible during a
because decisions about medication selection and dos- clinical interview. Psychological consultation is in-
age will be affected if isoniazid is prescribed.
valuable in the interpretation of existing psychometric
Common baseline laboratory tests and their ra-
data obtained from collateral contacts. Behavioral psy-
tionales are outlined in Table 43.
chologists can contribute operational assessment of
behaviors and effective contingency plans. Psycholog-
Imaging and ical consultation is not indicated in every case. Given
Electroencephalography the availability of limited provider resources, it should
Brain imaging in the absence of focal neurological be accessed judiciously based on the specific demon-
findings produces low yield in detection of central ner- strated individualized needs of each patient.
vous system findings in clinical populations with pri-
mary psychiatric disorders, yet severe, unremitting
psychopathology in the form of psychosis or mood
Treatment
symptoms can provide reason to pursue imaging for
possible occult lesions (Santosh 2000). Similar argu- Biopsychosocial Formulation and
ments can be made for electroencephalography or
functional brain imaging as part of the workup for pa-
Treatment Planning
tients presenting with severe, persistent symptoms if Assessment data are incorporated into a biopsycho-
disruption of brain activity has not been ruled out. A social formulation of the causal factors contributing
TABLE 43. Common laboratory tests and monitoring rationale for adolescents facing inpatient
psychiatry hospitalization
Test Monitoring rationale
Serum electrolytes Baseline health measure
Elevated bicarbonate level associated with vomiting
Blood urea nitrogen Renal function measure, hydration status
Serum creatinine Renal function measure, drug elimination
Serum phosphate Indicator of nutritional status
Critical shifts in refeeding syndrome
Complete blood count Baseline health measure, medication side effects
Liver function tests Baseline health measure, medication side effects
Pregnancy test Baseline health measure relevant to multiple aspects of care
Serum prolactin Hypothalamic pituitary function baseline, neuroleptic effects
Urine toxicology screening Detection of illicit drug ingestion
Urinalysis Baseline health measure, renal function, hydration status
Serum drug levels Therapeutic monitoring, management of overdose
Glucose, triglycerides, and Metabolic syndrome risk, medication side effects
serum lipids
Electrocardiography Cardiac baseline, medication side effects
Note. Specific laboratory testing is governed by the clinical circumstances of each case.
most directly to the need for admission. The treatment The interventions of the treatment plan should ad-
plan is tailored to meet the most acute needs and tap dress the most impairing symptoms and have some
into the strengths of each patient and family (Harper evidence of effectiveness when applied to similar
1989). The goals set in the treatment plan must be re- cases. Interventions are multimodal and are likely to
alistically attainable and consistently oriented toward include medication, psychotherapy, educational ser-
functional adaptation and the restoration of health vices, activity therapy, therapeutic recreation, case
and safety. Treatment plans and clinical documents management, and discharge planning.
should be written in language that is understandable to
adolescent patients and their families. The use of a pa-
Medication
tients or parents terms, phrases, themes, and meta-
phors adds personal relevance and power to the treat- Medication treatment is one component of a balanced
ment planning process. Patients and parents should be multimodal intervention plan informed by a formula-
invited to join treatment planning sessions as signifi- tion of the biological, psychological, and social factors
cant collaborators with the most extensive knowledge that contributed most immediately to the need for in-
of and investment in the life of the patient and family. patient admission. Psychopharmacology is symptom-
Community-based providers are essential treatment based and directed to address the most severe and im-
planning resources and should be invited to participate pairing dimensions of active psychopathology. The
in treatment planning sessions. Conference calls and main foci of inpatient medication interventions are to
speakerphones are effective technologies to support co- select or adjust appropriate agents, establish dose tol-
ordination and continuity of care with community ser- erability to treatment initiation or change, and coordi-
vice providers during treatment planning sessions. Pa- nate with outpatient providers to maintain continuity
tients can benefit from the continuity of care and of clinical management from preadmission through
clinical contact that occur when existing community- postdischarge phases of treatment. Rating scales will
based providers are able to meet with the patient in the help to structure tracking of signs and symptoms,
hospital as a member of the treatment team. treatment response, and side effects.
Medication selection should target the most impair-

TABLE 44. Target symptom approach to
ing symptom dimensions of mental illness. When mul-
tiple disorders are present, shared symptom dimen- medication selection
sions of anxiety, agitation, insomnia, thought disorder, Target symptom Medication considerations
or mood disturbance are treated with the simplest effec-
Aggression Selective serotonin reuptake
tive medication strategy. Bostic and Rho (2006) posited
inhibitor
a model for dimensional treatment and symptom tar-
geting that is well suited to the inpatient setting, where Selective norepinephrine
clinical presentations are complex and multiple disor- reuptake inhibitor
ders frequently overlap. Shaw and DeMaso (2006) also Atypical or typical antipsychotic
provided an example of target symptom prescribing Benzodiazepine
that is concordant with these principles (Table 44). Mood stabilizer
Inpatient practitioners are asked to evaluate and
Alpha agonist
adjust medication combinations with limited scien-
tific data available to support their clinical decision Beta blocker
making, particularly when addressing drug combina- Stimulant
tions in patients with very complex and treatment- Agitation Atypical or typical antipsychotic
resistant conditions (Duffy et al. 2005; Safer et al.
Benzodiazepine
2003). There should be a close working relationship
with pharmacy services to evaluate potential drug in- Diphenhydramine (younger
teractions and gather relevant drug information to in- children)
form treatment decisions. Anxiety Benzodiazepine
Because the time frames of inpatient care are often Antidepressant
shorter than the known doseresponse effects of many Buspirone
medications, coordination with referring and follow-
Gabapentin
up providers to plan in-hospital adjustments and to
map postdischarge monitoring of treatment is neces- Alpha agonist
sary to complete drug trials. The handoff of inpatient Depression Selective serotonin reuptake
care should communicate a clear monitoring plan to inhibitor
the receiving clinician, because treatment effects and Serotoninnorepinephrine
side effects can emerge from weeks to months after reuptake inhibitor
changes are made.
Inattention Stimulant
Of particular note is the need to maintain vigilance
Atomoxetine
for emerging suicide risk when treating depression
with or without antidepressant medications. When Bupropion
suicidality is present, consideration should be given to Insomnia Diphenhydramine
the potential ameliorating role of antidepressant ther- Benzodiazepine
apy. Conversely, the potential exacerbating effect of
Trazodone
antidepressant therapy must be considered if suicidal-
ity worsens during a course of antidepressant treat- Hypnotic (e.g., zolpidem,
ment. The reader is advised to be aware of the recent zaleplon)
controversies surrounding U.S. Food and Drug Ad- Amitriptyline
ministration regulations requiring that all antidepres- Mirtazapine
sants carry a black box warning about possible in-
Mania Atypical or typical antipsychotic
creased risk for suicide when they are used to treat
depression in all children and adolescents. Mood stabilizer
Medication decision making and consent proce- Psychosis Atypical or typical antipsychotic
dures on an adolescent unit are triangulated between Benzodiazepine
patient, parents, and clinician. Parental consent and
Withdrawal Clonidine
patient assent are always required for medication treat-
ment unless there are emergency exceptions or a legal Benzodiazepine
basis exists for treatment over objection. Emergency Source. Adapted from Shaw and DeMaso 2006.
conditions for medication treatment entail an acute

TABLE 45. Psychosocial treatment modality
risk of harm if immediate treatment is not provided to
address physiological compromise such as acute dys- selection based on clinical indication
tonic reactions or intolerable distress that is unrespon- Clinical indication Treatment modality
sive to nonmedication interventions. The emergency
conditions and the rationale for such emergency med- Depression Cognitive-behavioral
therapy
ication use in such situations should be well docu-
mented, and the parent should be informed of the sit- Interpersonal therapy
uation in a timely manner. Psychodynamic
Adolescents in treatment are forging lasting atti- psychotherapy
tudes about the role that medication will play in their
Family therapy
lives. Evidence demonstrates increased susceptibility
of young persons to antipsychotic side effects at higher Bipolar disorder Cognitive-behavioral
dosages (Chakos et al. 1992; Zhang-Wong et al. 1999). therapy
Around puberty, adolescents can be exquisitely sensi- Family-focused treatment
tive to any changes in bodily appearance or function Emotional Cognitive-behavioral
that is perceived to be related to illness or treatment. dysregulation therapy
The relationship of sexual side effects of drug treat-
Dialectical behavior therapy
ments to sexual maturation, treatment outcomes, pa-
tient attitudes, and participation in care has yet to be Stress and trauma Cognitive-behavioral
rigorously evaluated and merits investigation. therapy
Trauma systems
Psychotherapies interventions
Inpatient psychotherapy programs incorporate indi- Psychodynamic
vidual, group, and family therapy modalities to iden- psychotherapy
tify and support existing adaptive strengths of an ado- Psychosis Social skills training
lescent and family as they attempt to come to terms
Supportive psychotherapy
with and manage the signs and symptoms of an acute
mental illness. Psychotherapy aids the acquisition of Family therapy
new knowledge and coping skills. The psychothera- Anxiety Cognitive-behavioral
peutic frame of inpatient work is decidedly short term, therapy
with an emphasis on establishing and maintaining
Exposure
continuity in previous and future therapies. Admis-
sion of a client to an inpatient unit provides an oppor- Modeling
tunity for consultation when there is already ongoing Family therapy
psychotherapeutic work in the community. Eating disorders Family therapy
People enter inpatient treatment with diverse needs
and capacities for therapeutic engagement. This re- Multidisciplinary team
collaboration
quires an adaptable psychotherapy program with indi-
vidual, family, and group components that can be ad- Motivational interviewing
justed to meet the unique requirements of each clinical Disruptive behavior Behavioral systemic therapy
situation. The specific therapeutic techniques and ori-
Multisystemic therapy
entations available on a unit will tap into the psycho-
therapy training and skills of the staff. Cognitive-behavioral
When available, evidence should be used to guide therapy
treatment selection. For example, evidence exists for Functional family therapy
the efficacy of cognitive-behavioral, interpersonal, and Substance abuse Motivational interviewing
family therapies in the treatment of adolescent depres-
sion (Mufson et al. 2004; Weersing and Brent 2006).
Some psychosocial interventions can be considered Therapeutic alliances between clinicians, adoles-
potentially effective in the treatment of various clini- cents, and families are needed to support and sustain
cal symptoms or syndromes (Table 45). the clinical work to be done during the hospital admis-
sion. Alliance formation is fostered when a patients FAMILY THERAPY

and familys concerns are heard, appreciated, and ad-
Inpatient family therapy work identifies and supports
dressed in the clinical work. Motivation to join in the
existing family strengths, enhances effective commu-
therapeutic work will vary substantially among ado-
nication, resolves conflicts, negotiates consensus, es-
lescents and their families. Motivational interviewing
tablishes safety, provides information, and plans for
techniques are evolving as potentially useful tools to
the transition to the next setting of care (Strickland-
help adolescents participate as active agents in their
Clark et al. 2000). Family members usually need vari-
health care decision making (Erickson et al. 2005).
ous forms of support to help them cope with the anx-
Every effort is needed to have the work proceed in a
ieties and uncertainties surrounding the adolescents
collaborative spirit that is free from coercion. This is a
admission. Existing sources of support can be accessed
most challenging task to accomplish in situations in-
within the familys relationships, cultural practices,
volving involuntary commitment or in the presence of
spiritual beliefs, and community resources. The family
significant disagreements among treatment partici-
sessions are also a central location for support through
pants. A reframing of treatment orientation in terms
information sharing that enhances collaboration and
of health and safety priorities can help to build con-
choice making in the treatment process. Family ther-
sensus in such difficult situations. Sometimes partic-
apy also seeks to build consensus on the aims of inpa-
ipants must agree to disagree as outside dispute res-
tient treatment. It is here that conflicts are addressed,
olution such as involuntary commitment hearings is
differences resolved, and compromises negotiated in
pursued. Navigation of these delicate scenarios re-
the service of the adolescents care.
quires thoughtful integration and compassionate ap-
Family interventions will involve time spent alone
plication of clinical, ethical, and legal perspectives.
with the parents or guardians to take history and plan
Younger adolescents sometimes benefit from ac-
treatment. Shapiro et al. (2006) defined five types of
cess to interactive play therapy techniques as develop-
parent work, including assessment and monitoring of
mental adaptations to aid their participation in the
change, help for parents in understanding their child,
treatment (Russ 2004). Expressive therapy modalities
parent training, parent guidance, and parent counsel-
such as music, art, movement, and drama can provide
ing. Siblings, grandparents, or other significant family
entry points to the psychotherapeutic process for kids
members might also be included in the family work as
who are not ready or able to engage through talk. Vi-
indicated by the specifics of the family s circum-
sual aids such as sticker plans or behavior charts are
stances. Preparation of agenda, rehearsal of presenta-
particularly helpful with younger adolescents.
tions, communication practice, and general attitudinal
and emotional readiness for family therapy sessions
INDIVIDUAL THERAPY are frequently worked on in separate parent and indi-
vidual sessions with the adolescent. The family work
Individual psychotherapy emphasizes therapeutic ele-
also provides a venue to present findings and recom-
ments of relaxation training, stress reduction, anger
mendations related to assessment and treatment.
management, self-monitoring, safety planning, com-
munication building, symptom management, treat-
ment planning, and patient education. This is an area GROUP THERAPY
in the work where new skills or approaches can be in- Group therapy modalities draw on interpersonal dy-
troduced that might be practiced in session and then namics, perspective sharing, collective support, and
generalized to group therapy or family therapy en- consensus building as therapeutic processes. Adoles-
counters during the hospital stay. cent peer group members can provide powerful and
Individual therapy provides a partially sheltered enlightening feedback to teenagers that would have lit-
psychotherapeutic venue for the adolescent. The tle impact when spoken by adults or authority figures
scope of confidentiality for the individual therapy pro- (Cramer-Azima and Richmond 1989). Group process
cess must be explicitly delimited at the outset of treat- with adolescents must be shaped by therapists trained
ment. Boundaries of confidentiality usually end in the to do group work. Although the adolescents are the
face of impending danger when unit staff must act to most visible actors in the group setting, the therapists
preserve safety. Care must also be taken to explain the must continuously keep the process moving in a con-
role of treatment team members who will hear about structive direction. The tone and the atmosphere of
the individual therapy sessions in team meetings or groups must be calm, orderly, and respectful. There
treatment planning sessions. should be a consistent set of rules and expectations
that are reviewed at the start of each group. Printed sion, facial expressions, and muttered verbal com-
versions of the rules can be posted near the meeting munication. Each girl was approached by a staff
member who shared a good rapport and alliance with
place and distributed to group members for their infor-
her. Quiet conversations were started individually
mation. Group formats should accommodate for the with each girl as staff walked with them to their
frequent shifting of membership and the possibility rooms, while the rest of the unit assembled for com-
that patients might only be present for a single ses- munity meeting. In her conversation with staff,
sion. This is addressed by having clear instructions Betty reported that she had grown intimidated by
and expectations for participation available at the start Wilmas frequent attempts to sit near her over the
prior 2 days. She revealed a need to defend herself
of the group to help members participate (Malekoff
with aggressive words and, if necessary, physical vi-
2004). Having a record or manual of effective group olence. Wilma revealed that she felt disrespected by
procedures, structures, and activities also serves to Betty, who seemed to shun her attempts to befriend
maintain the continuity of the programming as thera- her. Each girl privately indicated a desire to reach a
pists join or leave the unit. peace settlement mediated by staff. In the ensuing
mediation session, both girls were able to share how
Therapy groups can focus on specific therapeutic
they could give and receive mutual respect. The con-
areas and skills such as anger management, relaxation flict was resolved, and a public group confrontation
training, social skills, hygiene, and grooming. They was avoided. The girls were able to save face and re-
might have a health education orientation that fo- join the milieu without further incidents.
cuses on matters of reproductive health, substance
abuse, smoking cessation, or medication treatment. Group therapy sessions offer significant exposure,
Single-gender girls or boys groups can be used to ad- desensitization, and practice opportunities for kids
dress issues related to identity formation and gender- who are having difficulties joining and participating in
based developmental issues. There are also task-ori- social situations. They are excellent settings to make
ented groups such as community meetings and goals naturalistic observations pertinent to clinical and
groups. Group tasks can be supported by individual functional assessment. Multifamily groups can be
work that helps patients to prepare goals and agenda welcome sources of support where families learn
items for presentation in goals groups and community about the treatment process, acquire parenting skills,
meetings. Goals prepared and presented by someone identify community resources, or just find time to get
in a morning goals group should state a goal for the together and share constructive diversion in a game or
day that maintains relevance with his or her individ- leisure activity. Many units hold parents nights or
ual treatment goals. Closure groups are commonly family nights for this purpose.
conducted in the evening to follow up on the work that
was done toward goals throughout the day. Patient and Family Education
Acting-out behavior can spread quickly in groups. Family empowerment is strongly rooted in the teach-
It must be monitored, prevented, and contained rigor- ing and learning that occur between family members
ously by staff interventions in a seemingly effortless and the treatment team. At its finest, it is a mutual
and calm way. Individuals at risk to act out and disrupt learning process where the treatment team gains
groups are best identified well before the start of a knowledge about how to best help the family and the
group session to assess whether they can be helped to family learns the information needed to make in-
prepare for the group or require more individualized formed decisions and be fully engaged in the care. An
programming away from the group setting. The fol- initial assessment of communication and learning ca-
lowing vignette illustrates this approach. pacities will identify needs for adaptive communica-
tion devices, language translation, or cultural inter-
Betty and Wilma, two 15-year-old girls, had ex-
pretation that must be addressed before authentic
changed hostile words about each other s close fam-
ily members in a squabble at breakfast. Staff sepa-
learning can occur.
rated them immediately. After breakfast, Betty was Teaching efforts during the admission process
frowning, avoiding eye contact, and pacing anx- should be sensitive to the needs of patients and fami-
iously. Wilma was observed mumbling under her lies as they grapple with the uncertainties and stresses
breath and staring at Betty. The units daily commu- of hospitalization and the implications of acute, seri-
nity meeting was about to begin. Both girls soon
ous mental illness in a young family member. Meet-
would be expected to join the group and as a result be
in close proximity. Unit staff noted the ongoing hos- ings with unit staff, photographs of the unit, a printed
tile and defensive tone of interaction between the unit guide, and a preadmission tour of the unit can be
girls manifested through their states of physical ten- effective aids to provide information, allay worries, and
help families to understand the nature and purpose of have been causally associated with weight gain (Cor-
hospitalization. Materials and information to support rell and Carlson 2006). Of note, hospitalization has
learning might include Web sites, pamphlets and flyers been associated with increased BMI (Putnam et al.
about adolescent health risks, medication information 1990). Patients with eating disorders will need special-
sheets, diagnosis-specific information, parenting ized meal programs and nutritional restoration plans.
skills, and developmental topics (DeMaso et al. 2002). Weight loss due to appetite disturbance secondary to
physical illness or medication side effects might need
School to be addressed through meal plan adjustments.
Every unit should have a classroom program with a
teacher who provides instruction and coordinates ed-
Religious and Cultural Needs
ucational planning with local schools to identify po- Patients spiritual needs continue when they are ad-
tential learning needs and help patients maintain con- mitted to the hospital. Availability of chaplaincy for
tinuity of academic work between the community and various faiths should be maintained to support pa-
hospital settings. The unit classroom provides an ex- tients and families if they wish to maintain religious
cellent location to observe a patients functional status and spiritual observance (Moncher and Josephson
in a naturalistic setting. Review of a students daily 2004). A unit must also find and maintain connec-
schoolwork can reveal much about how he or she is tions with its local community to develop and main-
concentrating, completing assignments, following di- tain culturally informed awareness for the needs of the
rections, and meeting the myriad demands that exist people it serves.
in a classroom setting. Records of attendance on the
unit often can be transmitted to the community home
school to maintain credit status.
Milieu Management
Rehabilitation and The unit milieu is a safe 24-hour treatment setting
Recreational Therapies with client-centered programming built from thera-
peutic and social components. All milieu interactions
Rehabilitative principles are focused to reduce impair- between unit staff and clients carry therapeutic poten-
ments caused by mental illness or comorbid physical tial and should be shaped and informed by sound psy-
disabilities. Rehabilitative emphasis is placed on the chotherapeutic principles. The tone and philosophy of
practice of activities of daily living, personal hygiene, a unit flow from the core human values that are em-
symptom management, or development of social braced and transmitted by the staff, patients, and fam-
skills. Physical therapy might be indicated when mo- ilies involved in the life of the place. All persons partic-
tor or musculoskeletal deficits are noted. Occupa- ipating on the unit should be invited to make a durable
tional therapy might be needed to address sensory in- commitment to the values of safety, health, human
tegration deficits. Speech and language specialists rights, mutual respect, nonviolence, fairness, and per-
should be available to participate in the care of persons sonal integrity. Adolescents who are developmentally
with sensory deficits or communication disorders. primed to explore the ethical and philosophical aspects
Leisure activities should be structured and well of their lives and relationships usually resonate with a
monitored in designated areas. Active involvement of values-based milieu approach. These core values can
patients by milieu staff in age-appropriate leisure ac- be codified in a set of unit rules that are transmitted in
tivities that are enjoyable and interesting is more writing and posted in a prominent location. All per-
likely to keep patients constructively engaged while sons on the unit are expected to follow the unit rules,
eliminating potential for boredom-inspired mischief. and all members of the milieu should be encouraged to
Opportunities for physical exercise and fresh air are help each other learn and follow the rules.
needed to support the physical needs of growing youth Unit scheduling and routines should convey a
(Curran 1939). Leisure planning exercises can be done sense of predictability, planning, and order. There
to help adolescents learn to organize and structure should be a daily schedule available to view in a prom-
their time. inent location. Changes in the schedule should be an-
ticipated and announced in a timely fashion. Transi-
Nutritional Intervention tions within a program are previewed with patients,
Hospitalized teenagers often require nutritional inter- and clear instructions about how to change locations
ventions. Some psychotropic medication treatments should be given. Patients should not be left in unsu-
pervised areas. Unit point or level systems should be workforce availability and the significant national
commensurate with the needs of the population shortage of practitioners with expertise to provide
served. Level systems on short-stay units must be sim- mental health services to adolescents.
ple, quick to learn, and effective in motivating adoles-
cents to participate. Well-designed inpatient behav- Management of Aggressive
ioral interventions are valuable tools that structure
treatment with components that can be applied in and Suicidal Behaviors
postdischarge settings to maintain adaptive function.
The environmental design and management of the Significant risks of aggression and/or suicide are com-
unit must guard against excessive visual, auditory, or mon indications for referral and admission to inpatient
tactile stimulation that might cause undue patient treatment settings (Olfson et al. 2005). The process of
anxiety and distress. Control of the environment also identifying and managing risks of harm from aggres-
requires surveillance for potentially harmful objects sion begins with the first contact of the referral and
and substances. Belongings checks are done by staff admission process. Patient safety and effective clinical
when patients enter the unit on admission and upon coordination are well served by an initial screening to
return from therapeutic passes. evaluate patient safety needs prior to transfer and
Media access and content must also be closely admission. Early contact between referrers and inpa-
monitored to prevent untoward exposure to question- tient staff provides a preliminary opportunity to pro-
able materials. Allowed content should be consonant vide information to the patient and family and engage
with the core values that form the basis for unit rules. them in the referral and transfer process. Having spe-
Content should be vetted by staff and families. There cific information about what will happen can allay anx-
should be clinical awareness of media content as po- iety and prevent frustration that can further fuel emo-
tential triggers for signs and symptoms of disorders. tional crises.
The selection of movies, television programming, At the time of admission, a strengths-based assess-
video games, magazines, and books provides a golden ment to evaluate effective coping strategies and
opportunity for engagement of adolescents in discus- sources of support presents an excellent opportunity
sions of core human values. to start alliance building and identify interventions
The acuity level of a units patient population that might help a patient avert acute behavioral or
will have a profound effect on the milieu. Patients emotional crises (LeBel et al. 2004). The early identi-
requiring a high level of direct individual care can fication of vulnerabilities to crises such as escalation
have broad impact on a milieu by diverting staff triggers, fears, anxieties, frustrations, and concerns
from performance of more general milieu manage- can help the clinical team and the patient work to-
ment functions. The acuity mix and staff ratios gether on a plan to establish and maintain safety dur-
must be monitored and adjusted continuously to ing the admission.
ensure that patient safety and care quality can be The safety planning process introduces a patient to
maintained. As a general rule, as unit acuity rises, staff members and forms working alliances that form
the staff-to-patient ratio must also rise. a basis of support for the patient during the admission
An inpatient milieu is supported by the collabora- (Beauford et al. 1997; Green et al. 2006). It identifies
tive work of a multidisciplinary team that might in- and strengthens the patients current adaptive coping
clude child and adolescent psychiatrists, psycholo- skills and provides a blueprint for the development of
gists, nurses, milieu counselors, social workers, new coping skills to reduce stress and build calmness.
expressive arts therapists, occupational therapists, nu- The plan identifies and provides safe locations on the
tritionists, recreational therapists, utilization review unit for the patient to use for the application or acqui-
staff, teachers, administrative managers, clerical staff, sition of coping skills. Medication use might also be
and ancillary support staff. The guiding principle of indicated to reduce distress, aid relaxation, and help a
unit staffing is to meet the individualized clinical patient participate in the acquisition of the cognitive,
needs of each patient admitted while maintaining co- emotional, and behavioral skills needed to participate
hesive program functioning. Role definition and func- in the safety plan.
tion of each member of the milieu team, regardless of A key element of crisis prevention requires knowl-
discipline, will be defined by credentialing, experience, edge of the patient, including the stresses he or she is
training, and areas of competence. The mix of disci- facing and the behavioral warning signs of impending
plines available to staff a unit will be limited by local crises of frustration, agitation, or aggression.
Anticipation of difficult phone calls, therapy ses- must be prepared to address patient concerns as they
sions, or interpersonal interactions can aid staff in be- work to restore the milieus therapeutic equilibrium.
ing available and prepared to help the patient during Consistently implemented, safe physical manage-
such difficult moments. Special attention to proper ment skills require active staff training and practice at
maintenance of interpersonal space must be individu- the individual and team levels. Mock codes or case
alized to meet the needs of each patient. Traumatized simulations combined with classroom learning
youth are particularly vulnerable to triggers that echo should be scheduled regularly. Ad hoc review and prac-
previous abuse such as physical touch or invasion of tice are also helpful to prepare for risky situations as
boundary space. Kids with processing difficulties such they occur. The effectiveness of crisis management
as language-based learning disabilities or sensory im- protocols requires ongoing evaluation to characterize
pairments can interpret neutral stimuli as hostile and track event rates, intervention outcomes, and re-
(Rutter et al. 2006). Explicit and understandable com- sults of staff training. The clinical characterization
munication must be established to prevent defensive and management of aggressive episodes can be aided
reactions leading to behavioral escalation. by instruments such as the Modified Overt Aggression
A safe and effective crisis management approach Scale (Collett et al. 2003; Kay et al. 1988; Sorgi et al.
continually aims to minimize the frequency, duration, 1991). Ratings of episode duration, severity, and be-
and severity of behavioral crises to eliminate self- havioral specifics can be tracked and trended at the
directed or interpersonal violence and implement the individual, caseload, and unit level using computers.
safest and least restrictive clinical interventions that Effective suicide prevention requires the establish-
do not require the application of physical force. Phys- ment and maintenance of communication between
ical restraint, either mechanical or chemical, is an in- the adolescent and a support network that is likely to
tervention of last resort. It should be used most spar- include parents, family, school personnel, outpatient
ingly and only to prevent immediate bodily harm. If providers, and the inpatient team. Once communica-
and when restraint is used, the staff involved must tion is established, work can be done to help develop
have specialized training, function as a team under the the self-monitoring skills of the patient and the mon-
direction of a designated team leader, and employ itoring capacities of support network members. The
sound principles of physical management that mini- therapeutic work will emphasize core symptom reduc-
mize the opportunity for physical injury of all involved tion contributing to suicide risk and the identification
(Masters and Bellonci 2002). When patients are in se- and practice of safe alternative coping strategies (Brent
clusion or restraint, they must be constantly moni- 1997; Miller et al. 2007). A means reduction compo-
tored to ensure that they are physically safe. Ongoing nent might be needed as part of a safety plan that helps
clinical monitoring of a patient in restraint or seclu- family members to eliminate or limit access to danger-
sion should track a patients level of alertness, ori- ous objects and substances in the community setting.
entation, responsiveness, body position, airway, respi- Imminently suicidal inpatients will likely need con-
rations, body temperature, circulation, and motor- stant monitoring in a safe location of the unit until
sensory status. If available, pulse oximetry can be an imminent risk of self-harm or suicide subsides. In self-
additional technology to monitor blood oxygenation injurious patients, injury patterns should be recorded
and augment detailed clinical monitoring. at the time of admission and rechecked periodically at
Debriefings of the patient, parents, and staff for points during the admission to assess clinical progress.
each restraint episode should assess the impact of the
restraint on the patient, their family, the other pa-
tients on the unit, and the unit staff. Strategies to
Discharge Planning
identify safer effective alternatives to potential future
crises should be explored. Review of any difficulties or Discharge planning begins at the time of admission
lack of coordination in the crisis response team should when efforts are made to coordinate care with services
be identified and addressed through collaboration, and resources that are already in place for the ado-
practice, and training. Staff debriefings should be used lescent in the community. The patient and parents
as a place for analysis, problem solving, and staff sup- must be engaged continuously in planning aftercare
port. The stressful nature of involvement in restraint throughout the hospital stay. Utilization management
episodes and aggression management exacts a toll on personnel support the treatment and discharge plan-
patients and staff. Reverberations will be felt through- ning process by identifying appropriate aftercare re-
out the unit following a restraint episode, and staff sources, communicating with families about options,
and coordinating care with external case managers. to ensure that the current unmet mental health needs
Stepdown care might be needed in partial hospital or of adolescents are addressed by establishing sufficient
residential settings if integrated services in a single resources to support care outside the hospital setting.
location remain indicated after sufficient clinical sta- Several trends will continue into the foreseeable
bilization occurs (Daniel et al. 2004). Informational future. Identification of clinically meaningful outcome
materials can help families and patients learn about measures will loom as a challenge to the design, eval-
options in residential, partial hospital, or other com- uation, and delivery of effective inpatient care. Train-
munity programs. Therapeutic passes can be used to ing, recruitment, and retention of staff with the spe-
phase a patient back into the home and community cialized skills for inpatient work will persist as a
settings while assessing the effects of exposure to significant unmet human resource need. Efforts to re-
environmental stress and readiness for discharge. duce coercion in treatment settings will accompany a
Impediments to discharge include a pervasive lack growing awareness of the physical and psychological
of appropriate services at lower levels of care. Adoles- risks associated with exposure to force or threats of
cents approaching the age of majority face major diffi- force. Inpatient and outpatient services w ill be
culties transitioning care to young adult or adult ser- blended via community-based teams to assist families
vices due to lack of services and lack of integration during the transition of care from the hospital to the
between adolescent and adult systems of care. Major home. There will be new ways for families and guard-
shortages exist in aftercare services for adolescents ians to participate on units via leadership and caregiv-
with dual diagnoses of mental illness and developing roles. Most optimistically, the collaboration of pro-
mental disabilities or substance abuse. Adolescents re- viders with patients and families will shape a future
covering from substance abuse disorders and addic- for inpatient care that is scientifically based, ethically
tions might benefit from referral to 12-Step recovery informed, human rightsoriented, and delivered with
programs. Return to the educational environment will compassion.
need to be coordinated between hospital and school,
often in the form of a school reentry meeting. Patients
and parents often want guidance on how to discuss the References
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CHAPTER 5
THE GERIATRIC UNIT

George S. Alexopoulos, M.D.
Compared with younger adults, geriatric (older than and Mazour 2000), there is a subset of patients who
64 years) psychiatry patients are almost twice as likely have protracted hospital stays. Factors associated with
to be treated in hospital settings (Colenda et al. 2002). increased length of stay include electroconvulsive
Common diagnostic categories are mood disorders therapy (ECT), higher Brief Psychiatric Rating Scale
particularly depressive disordersand dementias positive symptoms scores, falls, pharmacology com-
(Blank et al. 2005; Blixen et al. 1997; Weintraub and plications, multiple previous psychiatric hospitaliza-
Mazour 2000; Zubenko et al. 1997). Less frequent in- tions, court proceedings for continued inpatient stay
patient diagnoses include primary psychotic disorders or treatment, consultation delay, and lack of ECT on
(10%; Zubenko et al. 1997), bipolar disorder (8%10%; weekends (Blank et al. 2005).
Depp and Jeste 2004), substance use disorders (6.8%),
and delirium (4.7%) (Blank et al. 2005). Of note, inpa-
tient primary Axis II disorders are rare, at least in part
Admission Criteria/Considerations
due to some decline in personality disorder frequency
with aging (Abrams and Bromberg 2006). Comorbid Geriatric inpatients are admitted from a variety of set-
personality disorder rates are not as rare and appear to tingsthe medical inpatient unit, assisted living or
be highest in depressed hospitalized elderly (6%24%; skilled nursing facilities, or directly from the commu-
Kunik et al. 1994), but they may be underrecognized nity. Broad criteria for admission parallel those used
due to the acuity of Axis I disorders and medical co- for general adults. However, in the geriatric popula-
morbidities. tion, there is an emphasis on suicide risk and inability
Although, for most geriatric patients, inpatient to care for self. The elderly have the highest suicide
length of stay has shortened considerably (Weintraub risk of all age groups. Currently they represent 13% of
71
the population but account for 18% of completed sui- ric, neurological, and physical signs and symptoms,
cides (Arias et al. 2003), and the elderly suicide rate for including any decline in cognition, nutritional status,
those 75 years and older is 1.5 to 2 times that of the and functioning, as well as careful inquiry into all
general population (Kochanek et al. 2004). Elderly medical conditions and medications. Attention
white males largely account for these rates. Although should be given to potential misuse or abuse of alcohol
elderly persons attempt suicide less frequently than and over-the-counter and prescription drugs, such as
younger adults, their attempts are more often lethal opiate analgesics and benzodiazepines. These sub-
(Conwell et al. 2002a). Risk of geriatric suicide is stances are more commonly used by the elderly than
highly correlated with depression severity (Alexopou- are illicit substances of abuse (Bartels et al. 2005), may
los et al. 1999; Simon and VonKorff 1998). Additional cause mood or cognitive disorders, and place patients
factors that increase suicide risk include psychotic de- at risk for withdrawal syndromes. Because of poten-
pression, alcoholism, abuse of sedative-hypnotic med- tially poor insight due to psychiatric illness or cogni-
ication, bereavement or recent loss, and disability de- tive deficits, detailed information from family and car-
velopment (Alexopoulos et al. 2001). Presence of a egivers is critically important (Rabins et al. 1997). The
firearm in the home is independently associated with clinician separately considers psychiatric, medical,
suicide risk (Conwell et al. 2002b). Geriatric delu- and neurological differential diagnoses and then re-
sional depression is often optimally treated in an in- synthesizes the case, considering the interplay of co-
patient setting due to the elevated suicide risk and the morbidities with the presenting signs and symptoms.
likely need for ECT or combination drug strategies re- For example, an elderly patient presenting with de-
quiring close monitoring (Meyers and Chester 1994), pression in the context of a worsening chronic pain
especially in frail elderly persons with medical comor- syndrome may have depression-driven intensification
bidities. of preexisting pain. This integrated approach is a key
Elderly psychiatric patients have frequent coexist- element in successful diagnosis and treatment of the
ence of cognitive impairment and medical comorbidi- elderly.
ties. Elderly patients with dementia are often admitted Past psychiatric history should attempt to differen-
for uncontrolled aggression or severe behavioral dis- tiate early- versus late-onset disorders because these
turbances. Inability of a community-dwelling older may have distinct characteristics or prognostic signif-
person to care for him- or herself may trigger an ad- icance. Past history of substance use, including pre-
mission referral. These patients may be malnour- scription medications and alcohol, should be probed
ished, dehydrated, and inadvertently nonadherent to for. Family history should include familial or genetic
medication regimens. Due to physical frailty and med- factors of affective and cognitive illnesses, medical/
ical comorbidities or cognitive deficits, outpatient neurological illness manifesting as psychiatric syn-
evaluation and psychotropic medication stabilization dromes, and attempted or completed suicide. An age-
may be unsafe (Rabins et al. 1997). Medically ill or appropriate social history should focus on social sup-
medically high-risk patients requiring inpatient psy- port/isolation, including whether involved family
chiatric treatment may be admitted to a combined members live locally or distantly; financial status and
medical geriatric unit that offers more integrated mon- retirement issues; the ability to perform basic and in-
itoring and treatment (Folks and Kinney 2002) or to a strumental activities of daily living (ADLs); and recent
psychiatric unit within a general medical hospital. losses, including bereavement issues.
Mental status assessment should always include a
cognitive assessment. The Mini-Mental State Exami-
Diagnostic Workup nation (MMSE) is one of the most widely used, global
standardized cognitive assessments. It is brief, easy to
Evaluation requires a systematic approach, incorpo- administer, and assesses domains of orientation,
rating fundamental aspects of adult evaluation as well memory, concentration, language, and constructional
as attending to factors specific to the older adult. Psy- ability (Folstein et al. 1975). The MMSE is not sensi-
chiatric disorders in the elderly often occur in the con- tive in assessing executive function that may be im-
text of medical and neurological illness. Geriatric psy- paired in dementias and geriatric depression. A brief
chiatry inpatients have an average of five or six active and clinically relevant assessment for this cognitive
medical problems, which is comparable with geriatric domain is the Clock Drawing Test, which can reveal
medical inpatients (Zubenko et al. 1997). The psychi- executive dysfunction in depressed elderly (Woo et al.
atrist needs to conduct a thorough history of psychiat- 2004) and in elderly patients with a normal MMSE
The Geriatric Unit 73
result (Juby et al. 2002). The Mini-Cog is a brief and onance imaging or noncontrast computed tomography
effective tool for dementia detection (Borson et al. is recommended for initial dementia evaluations
2003). It combines a three-item recall question and (Knopman et al. 2001) or when focal neurological le-
the Clock Drawing Test and performs at least as well sions are suspected (Rabins et al. 1997). The clinical
as the MMSE in multiethnic elderly populations (Bor- use of functional neuroimaging is limited to special
son et al. 2005). When dementia is suspected or diag- circumstances. In particular, Medicare coverage allows
nosed prior to admission, it is important to confirm positron emission tomography as a differential diagno-
the type of dementia (e.g., Alzheimer s disease, vascu- sis tool in patients with clinical symptoms of fronto-
lar dementia, dementia with Lewy bodies) and, if nec- temporal dementia.
essary, to order targeted neuropsychological examina-
tions to aid in differential diagnosis.
A comprehensive physical and neurological exam-
Medication Treatments
ination is necessary. It is important not to confuse
normal age-related neurological changessuch as Common geriatric inpatient psychiatric syndromes
head/neck tremor, muscle atrophy of the hands, non- include severe depressive disorders and cognitive dis-
specific gait disturbance, impaired conjugate upgaze, orders. This section emphasizes treatment in these
and reduced ankle vibratory sensewith neurological domains. Treatment of geriatric bipolar disorder, delir-
disease (Mancall 2006). ium, and schizophrenia is also discussed. The primary
Admission assessment of nutritional and func- goals of inpatient treatment are to initiate safe and ef-
tional status, including gait assessment and fall risk, fective acute-phase therapies while managing medical
should be made. On an inpatient geropsychiatric unit, comorbidities, maintaining the patient in a supportive
the presence of cardiac arrhythmias, Parkinsons dis- environment, and providing sound aftercare referral
ease, dementia diagnosis, and use of ECT or mood sta- and treatment recommendations.
bilizers are associated with increased fall risk (de Carle
and Kohn 2001). Postural hypotension is also a signif- Geriatric Depression
icant fall risk (Tinetti et al. 2006), and sitting/standing
blood pressures should be a routine part of vital sign
MAJOR DEPRESSIVE DISORDER
assessment. DSM-IV-TR (American Psychiatric Association 2000)
Laboratory tests not only aid in differential diagno- describes major depressive disorder, with or without
sispossibly elucidating medical factors contributing psychotic features, that can be severe and may require
to or causing psychiatric signs and symptomsbut inpatient treatment. Geriatric major depression can
also help assess safety factors for medication or ECT be challenging to diagnose because elderly persons un-
administration. Admission laboratory screening, sim- derreport depressive mood symptoms (Gallo and
ilar to that done in younger adults, may include elec- Rabins 1999) and more frequently focus on anhedonia
trolytes, blood urea nitrogen/creatinine, fasting blood and the physical complaints of poor sleep, low energy,
glucose, liver function tests, thyroid function tests, and appetite and weight loss. These latter symptoms
lipid profile, complete blood count, urinalysis, urine may overlap with and therefore incorrectly be attrib-
toxicology, and possibly blood alcohol level. Serum uted to comorbid medical and dementing illnesses.
drug levels for nortriptyline, desipramine, lithium, val- However, in many cases, physical symptoms experi-
proic acid, and digoxin, as well as prothrombin time/ enced by depressed elderly persons have root causes in
international normalized ratio if warfarin is present, medical illness with intensification by the depressive
should be ordered. Chest X ray may be part of a delir- illness (Alexopoulos et al. 2002a).
ium workup. Electrocardiography is often ordered (Ver- Symptoms of sad mood, frequent tearfulness, and
gare et al. 2006). Standard laboratory tests for demen- recurrent thoughts of suicide and death are more reli-
tia include serum chemistries; renal, liver, and thyroid able in establishing major depression in the elderly
function tests; vitamin B12 level; and complete blood population (Alexopoulos et al. 2002c). Additional
count. Syphilis serology, urinalysis, erythrocyte sedi- symptoms of anhedonia, social isolation, hopeless-
mentation rate, heavy metal and toxicology screening, ness, helplessness, worthlessness, nondelusional
HIV testing, chest X ray, electroencephalograms, elec- guilt, psychomotor agitation or retardation, and im-
trocardiograms, and lumbar puncture may be ordered pairment in decision making and daily planning of ac-
based on historical or examination findings (Boyle et tivities can help establish the diagnosis (Alexopoulos
al. 2006). Structural neuroimaging with magnetic res- et al. 2002c).
The current DSM classification system fails to in- Awareness of this depression subtype may lead to dif-
corporate the cognitive impairments that are often ferent treatment strategies. For example, treating vas-
present in elderly depressed patients without demen- cular disease or its risk factors may ameliorate the risk
tia (Alexopoulos 1990). These include deficits in at- for or course of vascular depression. Similarly, antide-
tention, mental processing speed, and executive func- pressants with dopaminergic or noradrenergic proper-
tion (Elderkin-Thompson et al. 2003; Kindermann et ties that facilitate ischemic recovery may be superior
al. 2000; Lockwood et al. 2002). Interestingly, despite to those with -adrenergicblocking properties that
remission of depression, these cognitive impairments inhibit ischemic recovery (Alexopoulos et al. 1997b).
may persist in an attenuated state.
Major depressive disorder with psychotic features Depressionexecutive dysfunction syndrome. Some
occurs in approximately 36%45% of all inpatient de- elderly depressed patients have frontostriatal dysfunc-
pressed elderly persons (Meyers 1995). Across all age tion as suggested by neuroimaging and neuropatho-
ranges, about 25% of inpatient psychotic depression is logical studies. Fronto-striatal-limbic system dysfunc-
misdiagnosed, primarily due to lack of psychosis rection in this subset of patients has been described and
ognition (Rothschild et al. 2008). Delusions are more termed the depressionexecutive dysfunction syn-
common than hallucinations and are often character- drome (Alexopoulos 2001). Phenotypically, these pa-
ized as somatic, guilty, nihilistic, persecutory, or, less tients have psychomotor retardation, a relative pau-
commonly, jealous in nature (Alexopoulos 2004). city of vegetative symptoms, decreased interest in
activities, suspiciousness, and impaired instrumental
ADLs. Patients with this syndrome respond less well
ADDITIONAL LATE-LIFE DEPRESSIVE SYNDROMES
to antidepressants, including selective serotonin re-
Additional syndromes of late-life depression outside uptake inhibitors (SSRIs; Alexopoulos et al. 2002b,
the current DSM classification that have clinical sig- 2005b; Potter et al. 2004), but one study indicates they
nificance for treatment and/or prognosis are described respond well to problem-solving therapy (Alexopoulos
below. et al. 2003).
Depression with reversible dementia. Depression
with reversible dementiaformerly referred to as EARLY- VERSUS LATE-ONSET ILLNESS
pseudodementiais a significant risk factor for irre- In an effort to explore contributing factors of geriatric
versible dementia. A subset of depressed elderly pa- depressionincluding an association of neurological
tients (18%57%) develop a dementia that remits with disease with late-life depressionattempts have been
depression remission, although some cognitive defi- made to differentiate depressed patients according to
cits usually persist (Emery 1988). Approximately 40% time of onset. However, this classification has not
of these patients with reversible dementia develop an been particularly useful from either a clinical or theo-
irreversible dementing illness within the proceeding 3 retical standpoint. Time of onset can be difficult to de-
years (Alexopoulos et al. 1993). termine, and early depressive episodes may affect neu-
rological functioning over time (Alexopoulos 2004).
Vascular depression. The vascular depression hy- The putative mechanism for this involves depression-
pothesis characterizes cerebrovascular disease as pre- driven increases in stress that lead, through intracel-
disposing, precipitating, or perpetuating a subtype of lular mechanisms, to reduction of neurotrophic fac-
depression (Alexopoulos et al. 1997b; Krishnan et al. tors, causing decreased survival or functioning of neu-
1997). Data that support this include the high comor- rons over time (Duman et al. 1997).
bidity of vascular disease and depression as well as
awareness that vascular lesions can lead to specific be-
ACUTE-PHASE INPATIENT TREATMENT
havioral symptoms. Vascular depression has its own
phenotype. Elderly patients with this syndrome have
OF LATE-LIFE DEPRESSION
increased apathy, psychomotor retardation, and poor The Expert Consensus Guideline Series: Pharmaco-
insight but less guilt and agitation compared with eld- therapy of Depressive Disorders in Older Patients
erly patients without vascular disease risk factors (Al- (Alexopoulos et al. 2001) outlines acute-phase treat-
exopoulos et al. 1997a; Krishnan et al. 1997). These ment strategies for depression. The guideline method-
patients also have greater disability and cognitive im- ology uses quantitative survey data from experts based
pairment, particularly in the domains of verbal flu- on clinical knowledge and literature review to answer
ency and object naming (Alexopoulos et al. 1997a). practical clinical questions for which other evidence-
based studies do not exist. Although not covered here, avoided. Trazodone for antidepressant use in the eld-
continuation- and maintenance-phase treatment erly should be avoided.
strategies are also well described in this guideline. The Choosing among various antidepressant agents
inpatient clinician should be familiar with these strat- can be a challenging task for the inpatient psychiatrist.
egies and communicate them to the outpatient psy- Interestingly, the STAR*D study supports the idea
chiatric treater for optimal continuity of care. that for patients who fail to respond to a single antide-
pressant trial (citalopram in the study), basing subse-
Severe unipolar major depressive disorder without quent trials on differing versus similar pharmacologi-
psychotic features. The treatment of choice is com- cal classes of medication or putative mechanism of
bination pharmacotherapy and psychotherapy, with action does not affect treatment outcome. It also pro-
another first-line option being pharmacotherapy vides evidence for use of itemized symptom measures
alone. Treatment of geriatric depression should consist rather than global impression to detect improvement
of single antidepressant trials, with adequate dosages and effectiveness of both triiodothyronine (T3) and
for adequate duration. If there is no response, mono- lithium augmentation (Rush 2007).
therapy with another antidepressant should follow. If ECT is an alternative treatment strategy to phar-
there is partial response, augmentation strategies macotherapy. ECT has been shown to be effective in
should be initiated. SSRIs are the antidepressants of the elderly (Tew et al. 1999) and safe in patients with
choice because they are equally efficacious as the older comorbid medical conditions (Alexopoulos 2004).
tricyclic antidepressants, are safer in overdose, and Failure of two adequate trials of antidepressants, acute
have a more favorable side-effect profile, including lack suicide risk, and medical comorbidity complicating
of quinidine-like cardiovascular effects. The clinician antidepressant medication treatment are reasons to
should be aware of SSRI risks pertinent to the elderly. A consider use of ECT.
large population-based study of older adults (age > 50
years) found daily SSRI use was associated with in- Unipolar major depressive disorder with psychotic
creased risk of falls and double the risk of fragility frac- features. Expert opinion has stated that the treat-
tures (Richards et al. 2007). There has also been con- ment of choice for geriatric delusional depression is
cern that SSRIs may confer an increased risk of suicide. either combination antidepressant and atypical anti-
Compared with other antidepressants, one study re- psychotic or ECT (Alexopoulos et al. 2001). Preferred
ported almost a fivefold increased risk of elderly sui- antidepressants include SSRIs and SNRIs, although
cidebut only during the first month of SSRI initia- this awaits direct empirical testing in the elderly. How-
tion. The absolute suicide risk was low (1 in 3,353 ever, in the first randomized efficacy study in elderly
SSRI-treated patients), and many of these deaths were delusional depression, combination nortriptyline and
likely due to depressive illness and not medication. perphenazine, although well tolerated, provided no
SSRI treatment benefits appear to outweigh this small additional therapeutic benefit to nortriptyline alone
risk (Juurlink et al. 2006). Monitoring suicidality over (Mulsant et al. 2001). A multicenter randomized, pro-
the course of treatment is always prudent but is espe- spective, double-blind trial funded by the National In-
cially so during the first month after antidepressant stitute of Mental Health is under way to examinein
initiation. both geriatric and younger adultsthe acute efficacy
Serotoninnorepinephrine reuptake inhibitors of combination therapy with olanzapine and sertraline
(SNRIs) are other first-line agents. The clinician needs versus monotherapy with olanzapine (Andreescu et al.
to pay attention to potential but uncommon supine 2007).
diastolic blood pressure elevations, established as dose
dependent in the elderly for immediate-release venla-
Dementia/Delirium
faxine (Staab and Evans 2000; Thase 1998) and re-
ported in unspecified age populations for extended- Elderly persons are particularly susceptible to delirium
release preparations in daily doses ranging from 37.5 due to the increased prevalence of dementia, multiple
to 225 mg. The relationship to dosage is currently un- medical and neurological comorbidities, and poly-
clear (Thomson 2007). Bupropion and mirtazapine pharmacy. Delirium, with its broad symptom profile,
are alternative treatment strategies, as are tricyclic an- may create diagnostic confusion with other common
tidepressants in patients without cardiac conduction psychiatric syndromes such as dementia, depression,
defects. To minimize side effects, preferential use of hypomanic and manic states, schizophrenia, and sub-
nortriptyline or desipramine is recommended, and stance use disorders. Delirium is frequently missed,
doxepin, imipramine, and amitriptyline should be especially in patients who are not hyperactive or agi-
tated and thus not a behavioral problem (Armstrong et tered orally or intramuscularly, is helpful in the major-
al. 1997; Johnson et al. 1992). When in doubt, it is ity of cases. More recently, atypical antipsychotics are
prudent to assume the diagnosis of delirium, which emerging as alternative options, but further study is
should be viewed as a medical emergency and, unless needed prior to advocating their use (Seitz et al. 2007;
treated, may lead to significantly worsened outcomes, Young and Inouye 2007).
including greater mortality (McCusker et al. 2002)
and morbidity, prolonged hospital stays, and increased NEUROPSYCHIATRIC AND BEHAVIORAL DISTURBANCES
rates of institutionalization. Key features include the
ASSOCIATED WITH DEMENTIA
acute or subacute development of disturbances in at-
tention and orientation, sleepwake cycle, and psy- Neuropsychiatric and behavioral disturbances associ-
chomotor functions. Psychomotor disturbances may ated with dementia include psychosis and a range of
give rise to hyperactive states, mixed states, or (less agitated behaviors (including aggressive, physically
commonly in the elderly) hypoactive states (Arm- nonaggressive, and verbal/vocal agitated behaviors).
strong et al. 1997; Johnson et al. 1992). A systematic Inpatient psychiatric admission is primarily reserved
workup must then proceed while safety issues of the for those elderly patients with dementia whose behav-
delirious patient are attended to. A careful history and ior is a danger to themselves or others or has led to a
physical and neurological examination may guide the notable decline in functioning. It is critical to identify
selection of more tailored workups. Three points need and track specific targeted treatment symptoms dur-
to be stressed in the search of possible etiologies of de- ing the course of the hospitalization. The etiology of
lirium: the behavioral disturbances is often multifactorial,
and careful assessment is required. Common causes
1. Delirium is often multifactorial (Meagher et al. of agitation in dementia patients include superim-
2006). posed delirium, depression, and psychosis. Additional
2. The admission assessment may have already iden- important causes include dysuria, dyspnea, abdomi-
tified delirium risk factors that could guide further nal discomfort from constipation, and pruritis (Alex-
workup. opoulos et al. 2004, 2005a). Yet there are a number of
3. Common causes of delirium in the elderly are fre- patients with idiopathic agitation syndromes, per-
quently not central nervous systemrelated and in- haps due to behavioral disinhibition caused by impair-
clude polypharmacy, infections such as urinary ment of frontal and/or parietal structures.
tract infection, and dehydration (Young and Inouye
2007). NONPHARMACOLOGICAL APPROACHES
Environmental over- or understimulation, space re-
Medical and/or neurology consultation may be war-
striction, a sudden decline in a patients ability to
ranted while the basic workup (complete blood count,
communicate, and problems in caregiver approach to
electrolytes, liver and renal function tests, glucose,
the patient are common and perhaps easily reversible
electrocardiogram, urinalysis, chest X ray, and erythro-
causes of disruptive behaviors in the elderly patient
cyte sedimentation rate) is being completed. Further
with dementia (Alexopoulos et al. 2004; Cohen-
patient-specific tests may be warranted. Management
Mansfield 2001). Although frequently overlooked, en-
should proceed concurrently with diagnostic assess-
vironmental manipulationssuch as reducing over-
ment. Environmental manipulations should always be
stimulation; speaking in a soft, supportive tone; opti-
considered and include 1) correction or optimization of
mizing hearing and vision; improving communication
sensory deficits (e.g., use of glasses, hearing aids, and
through nonverbal means; or attending to a patient
dentures; adequate lighting; noise reduction); 2) mea-
during calm periodsmay be beneficial.
sures promoting familiarity or orientation to surround-
ings (a visible clock and calendar, presence of a relative
or family photos, frequent reality orientations); and 3)
PHARMACOLOGICAL APPROACHES
a reassuring and clear communication style by staff The clinician must first rule in or out delirium and
and family members (American Psychiatric Associa- treat appropriately. When agitated depressive symp-
tion 1999; Inouye et al. 1999). toms are present, an SSRI trial is indicated. Expert
The pharmacological management of delirium consensus states that antipsychotics are the preferred
mainly involves antipsychotic medications. Benzodi- treatment choice when delusions are present and are
azepines have limited usefulness, except in alcohol or even favored in nondelusional patients (although they
benzodiazepine withdrawal. Haloperidol, adminis- may not be as efficacious as when delusions are
present) (Alexopoulos et al. 2004). However, antipsy- which may lead to overdosing and serious side effects.
chotic use has come under increased scrutiny in the A useful inpatient strategy is initiation and mainte-
elderly. In April 2005, the U.S. Food and Drug Admin- nance of a low-dosage atypical neuroleptic using time-
istration issued a public health advisory and required limited, low-dosage benzodiazepines administered at
all manufacturers of atypical antipsychotics to add a fixed time intervals rather than on an as-needed basis
black box warning to their labeling describing a 1.6- (with heightened fall precautions) to symptomatically
to 1.7-fold mortality increase, primarily due to car- treat dementia-related agitation until the therapeutic
diac-related events or infections, in elderly patients effects of antipsychotics are established. Agitated and
with dementia and behavioral disturbances (U.S. Food aggressive behaviors in patients with Alzheimer s dis-
and Drug Administration 2005). An independent ease have responded to risperidone at a dosage of 1 mg/
meta-analysis of randomized, controlled studies of day or olanzapine at a dosage of 510 mg/day (Sink et
atypical antipsychotics echoed these concerns. Death al. 2005; Wang et al. 2005). Antipsychotic risk, includ-
occurred slightly more frequently with atypical anti- ing the risk of metabolic syndrome, cerebrovascular
psychotics versus placebo (3.5% vs. 2.3%; Schneider et accidents, or even death, should be discussed with the
al. 2005). family. Clinicians should document their rationale for
In a large retrospective mixed-diagnosis study, eld- choosing an antipsychotic, including other approaches
erly patients on antipsychotic medication 180 days or considered or attempted first and the riskbenefit ra-
less had a higher risk of death with conventional anti- tio. Documentation should include risk of withhold-
psychotics versus atypical antipsychotics (relative ing antipsychotic treatment.
risk, 1.37; Wang et al. 2005). More recently, the dou- Although not useful in the acute control of behav-
ble-blind, placebo-controlled National Institute of ioral disturbances in inpatients with dementia, cogni-
Mental Healthsponsored Clinical Antipsychotic tive enhancers such as cholinesterase inhibitors or
Trial of Intervention EffectivenessAlzheimer s Dis- memantine may be helpful for long-term manage-
ease (CATIE-AD) study examined ambulatory outpa- ment because they have been shown to improve not
tients with Alzheimer s disease and behavioral prob- only cognitive but also behavioral, emotional, and psy-
lems such as psychosis, agitation, or aggression chotic symptoms (Beier 2007; Cummings et al. 2000,
(Schneider et al. 2006). Patients randomly received 2004; Tariot et al. 2004; Trinh et al. 2003). Similarly,
treatment with olanzapine, quetiapine, risperidone, or SSRIs can be considered for dementia-related behav-
placebo and were followed for up to 36 weeks. Time to ioral disturbances, although they may be more useful
treatment discontinuation for any reason did not dif- in preventing future episodes than in treating the cur-
fer significantly among the medication and placebo rent ones. Nevertheless, in at least one study citalo-
groups. Median time to discontinuation due to lack of pram outperformed placebo in the acute (less than 3
efficacy was significantly longer with olanzapine (22.1 weeks) treatment of psychotic symptoms and behav-
weeks) or risperidone (26.7 weeks) than with quetia- ioral disturbances in nondepressed inpatients with de-
pine (9.1 weeks) or placebo (9.0 weeks). Discontinua- mentia (Pollock et al. 2002).
tion rates due to intolerance, adverse effects, or death
were 24% with olanzapine, 18% with risperidone, 16%
Bipolar Disorder
with quetiapine, and 5% with placebo. However, these
findings from an ambulatory population may not be Compared with elderly persons with unipolar depres-
applicable to the inpatient dementia population with sion, elderly bipolar patients are about four times as
likely more severe behavioral problems. likely to have had an inpatient psychiatric admission
Clinicians should exercise judgment in the use of over the previous 6 months (Bartels et al. 2000) and
all antipsychoticsboth conventional and atypical have a greater (non-suicide-related) mortality rate
for severe behavioral disturbances in dementia. When (Shulman et al. 1992). The prevalence of bipolar disor-
inpatient antipsychotic use is necessary, the clinician der in community populations decreases with increas-
needs to be aware of diagnostic differences in anti- ing age. Older bipolar patients have less comorbid sub-
psychotic response time. Although an antimanic re- stance use disorders compared with younger bipolar
sponse may be seen within 24 days and an antipsy- patients. They probably do not have more mixed epi-
chotic response in schizophrenia within 1 week, sodes or a poorer treatment response compared with
dementia-related behavioral and antipsychotic re- younger bipolar patients (Depp and Jeste 2004). De-
sponse may take several weeks. Therefore, there is a spite their lower substance use disorder comorbidities
danger for clinicians to generalize their experiences, compared with younger bipolar patients, elderly bipo-
lar patients have greater functional and cognitive im- patients (Brown 2001; Depp and Jeste 2004), which
pairment (Depp et al. 2005), including more confusion may reflect a longer time for comorbid medical or psy-
and disorientation (McDonald 2000). chiatric symptom resolution (Depp and Jeste 2004).
The American Psychiatric Associations (2002) Prac-
EARLY- VERSUS LATE-ONSET ILLNESS tice Guideline for the Treatment of Patients With Bipo-
lar Disorder provides some treatment guidance. An
Elderly patients with early-onset manic symptoms are
evidence-based review for late-life bipolar pharmaco-
more likely than those with late-onset illness to be
therapy treatment finds that lithium and divalproex
medication nonadherent (58% vs. 34%) and aggressive
are the two most common antimanic agents studied,
or threatening (66% vs. 37%) prior to psychiatric inpa-
and uncontrolled studies suggest that they are effica-
tient admission and to require emergency petition for
cious. However, there are little geriatric evidence-
hospitalization (37% vs. 14%) (Lehmann and Rabins
based data for therapeutic concentration ranges or
2006).
adequate duration of dosing for acute treatment with
Vascular disease is a potential etiology or risk factor
antimanic agents. No systematic drug treatment stud-
for late-onset bipolar disorder. Late-onset bipolar disor-
ies for geriatric bipolar depression were found. Like-
der is associated with a greater degree of neurological
wise, there are no geriatric bipolar treatment studies
disease and possibly less bipolar family history (Depp
comparing ECT and pharmacotherapy (Young et al.
and Jeste 2004). Additionally, compared with age-
2004). A retrospective study found no difference
matched bipolar patients with early-onset mania, those
among lithium, valproic acid, and carbamazepine
with late-onset (age 47 years and older) mania have
treatment in terms of length of geriatric inpatient stay
greater vascular risk factors or disease (hypertension,
or Global Assessment of Functioning score improve-
cerebrovascular accidents, coronary artery disease, atrial
ment (Sanderson 1998). More definitive treatment ef-
fibrillation, diabetes mellitus, hypercholesterolemia, or
ficacy answers should emerge soon. A multicenter
hyperlipidemia) (Cassidy and Carroll 2002). Elderly bi-
randomized, double-blind, prospective trial funded by
polar patients have increased frontal deep white matter
the National Institute of Mental Health is under way
signal hyperintensities compared with age-matched
to assess the acute treatment efficacy of lithium versus
community members, and data suggest that severity of
divalproex in geriatric mania. Meanwhile, current
right frontal signal hyperintensities may be associated
strategies are as follows (Young et al. 2004):
with late-onset mania (de Asis et al. 2006).
1. The treatment of choice in geriatric mania is

DIFFERENTIAL DIAGNOSIS
monotherapy with a mood stabilizer. Initial target
For geriatric patients presenting with late-onset manic range for serum lithium concentrations is 0.40.8
symptoms, the inpatient clinician should evaluate mEq/L, but patients may require levels in the range
carefully for secondary mania, a term describing ma- of 0.81.0 mEq/L. Divalproex sodium may be given
nia due to general medical conditions or substances with target serum concentrations used for younger
(Krauthammer and Klerman 1978). As described ear- adults. Carbamazepine should be considered a sec-
lier, patients with late-onset mania are more likely to ond-line treatment. For partial monotherapy mood
have vascular disease, pointing to the need to concom- stabilizer responders, the addition of an atypical
itantly assess and potentially treat conditions such as antipsychotic or a second mood stabilizer may be
hypertension, vascular heart disease, diabetes, and considered.
stroke (Sajatovic et al. 2005). Common medications 2. For geriatric bipolar depression, monotherapy with
associated with mania include antidepressants, ben- lithium may be given. Lamotrigine should be con-
zodiazepines, sympathomimetics, dopaminergic sidered using similar dosing strategies as for
drugs used to treat Parkinsons disease, and corticoste- younger adults. If necessary, an antidepressant
roids (Van Gerpen et al. 1999). Interestingly, higher may be added.
dosages of corticosteroids rather than age itself are as- 3. ECT may be considered in either phase of geriatric
sociated with increased risk (Ganzini et al. 1993; Van bipolar disorder. General rationales for ECT use in-
Gerpen et al. 1999). clude the severely ill or deteriorating patient for
whom rapid response is critical, pharmacotherapy
TREATMENT trials involving relatively greater risk than ECT,
Older bipolar patients (age > 65 years) have twice the pharmacotherapy-refractory illness, and inability
psychiatric inpatient length of stay as younger bipolar to tolerate pharmacotherapy side effects (Weiner
2001), which is often seen in the frail, medically physiological changes that alter the pharmacokinetics
compromised elderly patient. of various substances, leading to variable clearances,
free concentrations, and volume of distributions (Pol-
Schizophrenia lock 1998). Aging also leads to pharmacodynamic alter-
ations. Furthermore, aging is associated with increased
EARLY- VERSUS LATE-ONSET ILLNESS prevalence of medical and neurological comorbidities
In schizophrenia, even the age at which the term late (e.g., renal or heart failure, liver disease, Parkinsons
onset applies is in dispute, with some requiring onset disease) that confer extra vulnerabilities. Finally, the
after age 40 years and others at 45 or even 60 years (An- consequences of drug-induced adverse events may be
dreasen 1999; Howard and Rabins 1997). DSM-IV-TR more serious in the elderly. An exhaustive list of poten-
does not distinguish between late- and early-onset tial drugdrug interactions is beyond the scope of this
schizophrenia. Nevertheless, there are clinical, neuro- chapter; instead, we provide guiding principles and
psychological, neuroimaging, and genetic differences: common examples of interactions involving psychoac-
tive medications:
1. In late-onset schizophrenia, symptomatology tends
1. Dose initiation and speed of titration need to be in-
to be milder and negative symptoms, thought dis-
dividualized. Chronological age is only one factor
turbances, and first-rank Schneiderian symptoms
to be considered. Knowledge of physical health sta-
are less common. Delusions and hallucinations are
tus, including comorbid illnesses, is essential. The
common to both groups.
elderly often have side effects at lower dosages than
2. Neurocognitive deficits exist in both chronic and
late-onset schizophrenia. There is disagreement as younger adults. In light of this knowledge, start
low and go slow may apply differently to different
to whether patterns of cognitive impairments are
patients.
similar (Almeida 1999) or markedly different, with
2. Psychoactive substances should be prescribed for
cognitive decline and dementia occurring earlier
specific psychiatric diagnoses and target symp-
(within 5 years) in the late-onset schizophrenic
toms. Criteria for initiating or terminating a trial
group.
should be planned. Adequate target dosing is criti-
cal and may depend on diagnosis or type of medi-
INPATIENT TREATMENT cation used. For example, compared with younger
For newly diagnosed late-onset schizophrenia, it is im- adults, elderly persons require the same target dos-
portant to first rule out other causes and treat accord- age of SSRIs and SNRIs. For neuroleptics, the tar-
ingly. The mainstay of geriatric schizophrenia treat- get dosage in elderly patients is diagnosis depen-
ment is antipsychotic pharmacotherapy. Elder-specific dent. Compared with younger adults, elderly
concerns include an increased risk of cerebrovascular patients require lower target dosages of neurolep-
adverse events, and even death. Most, if not all, of tics for schizophrenia and lower dosages still for de-
those risks were observed in dementia patients with mentia-related psychosis and behavioral distur-
behavioral disturbances, and it is unclear whether bances (Alexopoulos et al. 2004; Madhusoodanan
they pertain to other elderly clinical samples. In a re- et al. 2007). In light of this, we propose that the
cent mixed-age study, there was similar effectiveness start low and go slow injunction should be re-
(a measure of efficacy and tolerability) between atypi- vised to start low, go slow, but get there.
cal and typical antipsychotics (Schneider et al. 2006). 3. On admission and before addition of a new medi-
Required antipsychotic dosages for elderly schizo- cation, concurrent medications need to be scruti-
phrenic patients are intermediate to those for younger nized for potential drugdrug or diseasedrug inter-
schizophrenic patients and dementia patients (Alex- actions. A number of online drug information
opoulos et al. 2004). Elderly patients with schizophre- databases (Clauson et al. 2007) as well as software
nia will need psychosocial services upon discharge. programs for handheld devices (Mattana et al.
2005) are available to assist in the detection of
DrugDrug Interactions drugdrug interactions. Their routine use should
Psychoactive medication use in late life should be ap- be considered in clinical practice.
proached with extra care. The number of medications 4. The use of psychotropic medications on an as-
used in the elderly, including those admitted to an in- needed basis should be minimized and reviewed reg-
patient psychogeriatric unit, is larger compared with ularly. As-needed use can lead to inappropriate ac-
younger populations. Normal aging is associated with cumulation of plasma levels. Frequently, such use
clouds the clinical picture and results in knee-jerk training, haloperidol (mean dose, 1.8 mg/day), traz-
reactions guided by fleeting symptoms rather than a odone (mean dose, 200 mg/day), and placebo produced
targeted treatment plan. Table 51 lists examples of comparable modest reductions in agitation in patients
various mechanisms of drugdrug interactions of with Alzheimer s disease (Teri et al. 2000).
particular clinical importance in the elderly.
Patient and Family Education

Psychotherapies
Patient and family assessment begins prior to ad-
Due to the time-limited nature of acute psychiatric mission with understanding the patients living cir-
hospitalization, traditional psychotherapy models are cumstances, whether any caregivers exist, and what
applicable to only a minority of patients. Awareness of expectations the patient and family have for discharge
basic treatment principles can guide discharge recom- arrangements. Ideally, the geriatric social worker will
mendations. Within geriatric psychiatry, the best- establish patient and family contact within the first 24
studied psychotherapy application is for the treatment hours of admission. Psychosocial assessment encom-
of major depression. Combination psychotherapy and passes safety of current living arrangement, including
psychopharmacology is the optimal acute treatment driving and ability to function alone, any presence of
strategy for geriatric depression (Alexopoulos et al. emotional and/or physical elder abuse, and the physi-
2001; Arean and Cook 2002). Cognitive-behavioral cal and mental ability of the caregiver to function in
therapy (Gallagher and Thompson 1982; Thompson his or her role, including the presence of caregiver cog-
et al. 2001), interpersonal therapy (IPT; Reynolds et al. nitive impairment or depression and the degree of so-
1999; Schneider et al. 1986), and problem-solving cial support (Thompson et al. 2006).
therapy (PST; Alexopoulos et al. 2003; Arean et al. Caregiver assessment, particularly caregiver abili-
1993) are the three therapies best shown to have effi- ties and any caregiver depression, should be empha-
cacy in geriatric major depression (Frazer et al. 2005). sized. Almost one-third of primary caregivers to com-
Modified cognitive therapy techniques have been de- munity-dwelling patients with moderate to advanced
scribed specifically for elderly depressed inpatients dementia experience significant depressive symptoms.
(Casey and Grant 1993). Relationship to patient (wife or daughter), increased
A significant proportion of elderly depressed pa- time spent caregiving, and impairment in physical
tients have comorbid cognitive impairment (Alex- functioning are all caregiver-influenced factors associ-
opoulos et al. 2002c), and therefore current psycho- ated with increased caregiver depression. Younger age,
therapies have addressed this patient population. PST lower education, white or Hispanic ethnicity, increased
has shown efficacy in depressed elders with mild exec- ADL dependency, and behavioral disturbance are pa-
utive dysfunction (Alexopoulos et al. 2003). IPT and tient-influenced factors associated with increased car-
PST have been modified for depressed elderly persons egiver depression (Covinsky et al. 2003).
with moderate cognitive impairment, but no efficacy Depending on the patients physical and cognitive
data have yet been published (Kiosses 2007; Miller state, family member roles can vary widely, ranging
and Reynolds 2007). IPT-CI (IPT for cognitive impair- from supportive to surrogate decision making. Inpa-
ment) addresses role conflicts by incorporating care- tient psychoeducation may emphasize increased care-
giver needs along with those of the cognitively im- giving skills and resource awareness. Factors corre-
paired depressed patient (Miller and Reynolds 2007). lated with degree of family involvement during
PST-CD (PST for cognitively impaired, disabled el- geropsychiatric hospitalization include complexity
ders) incorporates compensatory strategies to bypass and awareness of the patients needs and altered care-
behavioral limitations associated with cognitive defi- giver role on discharge (Owens and Qualls 2002).
cits and invites caregivers to participate in therapy Patients admitted from a nursing home often have
when the patients cannot follow the problem-solving severe behavioral dyscontrol, and transfer can happen
stages alone (Kiosses 2007). Both IPT-CI and PST-CD quickly, leaving the patient and family little time to
may be useful discharge treatment recommendations process this change. Social workers educate family
to this population and their caregivers. members about the patients disease processes and re-
Psychotherapeutic approaches to reducing agita- sultant cognitive, mood, and behavioral changes. The
tion need further research. In a large randomized, pla- entire treatment team assesses for environmental trig-
cebo-controlled clinical trial, caregiver behavioral gers and behavioral strategies to manage agitated, ag-
TABLE 51. Examples of age-related changes in pharmacokinetics and pharmacodynamics

Process Aging effects Clinical examples
Distribution Decreased volume of distribution Lithium toxicity
for hydrophilic drugs
Increased volume of distribution Diazepam accumulation with repeated dosages
for hydrophobic drugs
Phase I metabolism Decreased hepatic blood flow Accumulation of various psychotropics (e.g.,
(general effect) leading to reduced hepatic tertiary tricyclic antidepressants)
metabolism
Phase I metabolism Decline in cytochrome P450 Clozapine toxicity, especially in an elderly patient
(CYP) 1A2 activity who quits smoking
Decline in CYP3A activity Toxicity involving several different psychotropic
medications (e.g., antidepressants,
antipsychotics), especially in the presence of a
CYP3A inhibitor (e.g., certain antibiotics,
antifungals, nefazodone)
Pharmacodynamics Increased vulnerability to Risk of falls when an -blocker is combined with
orthostatic hypotension a low-potency antipsychotic
Increased vulnerability to Risk of delirium when cimetidine is combined
anticholinergic activity with a tricyclic antidepressant
gressive states. In addition, social workers teach care- emphasizes physical skills such as strengthening and
givers, both professional staff and family, successful positioning (Inventor et al. 2005). To accommodate
patient-specific behavioral strategies. For example, most levels of physical skill, group activity can be
noise-related sleep deprivation is a common environ- modified to include either seated or standing exercise.
mental cause of agitation in the nursing home and rel- Cognitive stimulation techniques are used with ge-
atively easy to modify. Social workers are also inte- riatric inpatients, although they may be of limited ben-
grally involved in discharge plans. Patients who are efit for dementia patients, who can experience frustra-
treated on specific geriatric psychiatry inpatient units tion (Rabins et al. 1997). Groups focusing on current
receive more appropriate referral to age-specific after- events are used for memory and orientation enhance-
care (Yazgan et al. 2004). ment. Wellness groups for higher-functioning patients
focus on themes of stress and anger management, so-
cial activity, and healthy living choices, including ex-
Rehabilitation and ercise and nutrition; time management skills may be
Recreational Therapies less pertinent to retired elderly.
Music therapy as an intervention for dementia pa-
tients with agitation and aggressive behaviors in long-
Activity programs ideally offer a blend of physical and
term-care settings (Gerdner 2005) may be used on in-
mental tasks and encourage patients to perform them
patient geriatric units. Pet therapy is also being used
as independently as possible. Benefits to geriatric pa-
on inpatient geriatric units. Preliminary research sug-
tients include the physical, cognitive, emotional, spir-
gests it may reduce ECT-associated fear (Barker et al.
itual, and social domains. Specific activities are de-
2003) and dementia-related irritability (Zisselman et
scribed in the book Activities for the Elderly: A Guide
al. 1996).
to Quality Programming (Parker et al. 1999). Recre-
ational group activities need to be adaptable to those
who are physically impaired. Occupational therapy Geriatric Milieu Management
may emphasize group ADL skills with the dual pur-
pose of social activity and individual skill assessment
and intervention. Geriatric occupational therapy also There is significant benefit to specialized geriatric psy-
uses rehabilitation models of functional status and chiatry inpatient units as opposed to mixed-age units.
Compared with elder care on general psychiatric units, cognitive impairment may limit psychotherapy; the
elderly patients on specialized geriatric psychiatry use of behavior as communication becomes critical.
units are more likely to receive thorough medical and Tolerance of wandering behaviors, while monitoring
structured cognitive assessments, psychotropic side- safety, is encouraged (Inventor et al. 2005).
effect and blood-level monitoring, and aging-sensitive
aftercare referral (Yazgan et al. 2004). The clinical util-
ity of mental health assessment protocols and multi-
Management of Suicidal and
disciplinary teamwork within a geriatric psychiatry Aggressive Behaviors
unit has been described (Ngoh et al. 2005). In a study
of 31 inpatient psychiatry units across the country, ge-
Among elderly patients admitted to a psychiatric inpa-
riatric professionals were surveyed to understand what
tient unit, more than 50% of suicides occur within the
practices were adopted for optimal care. Physical mod-
first week of admission or discharge (Erlangsen et al.
ifications included handrails; tub lifts; specialized fur-
2006). Once the decision to hospitalize occurs, imme-
niture such as movable geri-chairs, recliners, lowered
diate and ongoing assessment of the elderly inpa-
and/or electric beds and hospital beds; wheelchair ac-
tients suicidal risk and potential risk of harm to oth-
cessibility; specialized flooring; and increased walking
ers should be made, and an appropriate observational
areas. Safety emphasis included restraint reduction,
status should be ordered. Geriatric inpatient suicide
fall prevention plans with protocols and screening, and
risk assessment parallels adult risk assessment and
monitoring of physical signs and symptoms such as
includes such factors as history of attempts, active sui-
pain, dysphagia, and oral intake. Increased family con-
cidal ideation with lethal plan, and psychosis. A study
tact was encouraged. More than 75% of all specialized
of mixed-age psychiatric inpatients who completed
geriatric units provided reminiscence groups, family
suicide highlighted the importance of implementing
and patient education, exercise and music groups, and
continuous one-to-one observation of the high-risk
recreational/leisure activities. Fifty-five percent of the
patient (as opposed to 15-minute checks) and target-
units used nurse-led groups. Challenges to care in-
ing severe anxiety/agitation as a means of improving
cluded nursing staffing shortage, lack of staff training
suicide risk assessment and intervention (Busch et al.
in geriatric psychiatry, patient medical acuity, balanc-
2003). The use of lithium for bipolar disorder patients
ing of restraint/seclusion regulations with fall preven-
and clozapine for patients with schizophrenia or
tion, and discharge placement difficulties. Excellence
schizoaffective disorder has been shown to decrease
in multidisciplinary care (67% of respondents) was the
suicidality in mixed-age or young adult outpatient
factor most commonly identified for a successful unit.
populations (Meltzer and Baldessarini 2003; Meltzer
Additional factors included availability of geriatric
et al. 2003; Tondo et al. 2001) and may be a reasonable
medicine physicians and on-unit services (Smith et al.
strategy for reducing chronic suicide risk.
2005). Readily available on-unit geriatric medicine and
neurology consultation services are optimal, given the Management of
high degree of medical comorbidity.
The adaptation of successful geriatric psychiatry
Aggressive Behaviors
inpatient care within existing mixed-age frameworks Up to 30% of all elderly psychiatric inpatients manifest
is an alternative milieu model to an independent gero- violent or assaultive behavior over a 3-day period, and
psychiatry unit that, although perhaps ideal, may not these events significantly prolong hospital stay (Patel
be feasible for administrative or financial reasons. and Hope 1992). The presence of organic mental dis-
Faced with these limitations, one study describes an orders predicts violence. Aggressive behaviors in this
inpatient geropsychiatric unit without walls. A Se- diagnostic group are also more likely to persist. Com-
nior Team Program for geropsychiatric inpatients was pared with younger psychiatric inpatients, fellow pa-
created within an existing adult inpatient unit of a tients, as opposed to professional staff, are the more
general hospital. Geriatric patients were clustered to- common assault victims of the elderly patient (Cooper
gether, physical modifications were made, and staff re- and Mendonca 1991; Miller et al. 1993; Wystanski
ceived geriatric care training. Remarkably, over the 2000). Evaluation and treatment algorithms for this
first 14 months of the program, the elderly fall rate diagnostic group were described earlier in the section
was reduced, and no geriatric patient required re- Neuropsychiatric and Behavioral Disturbances Asso-
straints (Nadler-Moodie and Gold 2005). Additional ciated With Dementia. The clinician should ascertain
geriatric milieu management requires awareness that whether there is an underlying pattern to the aggres-
sive outbursts (e.g., occurring at times of care or only tion and to prevent rehospitalization (Boyle 1997; Hoe
with a specific staff member). Environmental interven- et al. 2005). Alternatively, patients may return home
tions should always be tried first. If there is a specific with the appropriate home-based services or, at the
syndrome present (psychosis, depression, or mania), other end of the spectrum, be admitted or returned to
appropriate psychotropic trials should be initiated. a long-term-care facility. Cost coverage restrictions
Acute management of an assaultive geriatric patient imposed by Medicare or other programs, as well as
may require treatment with atypical antipsychotics changing eligibility criteria, are ever-present barriers
and/or benzodiazepines. It is critical to note that in the to access to services. The community services net-
elderly, dementia-related aggressive behaviors fre- work for seniors becomes increasingly complex, and
quently respond to lower dosages of antipsychotics inpatient practitioners must acquire basic informa-
than violence associated with primary psychotic and tion to educate patients, families, and other health
mood disorders. Benzodiazepines are associated with a professionals about the support services available in
risk of falls and increased confusion. Agents such as each specific community. Cultivating ongoing collab-
lorazepam that lack primary hepatic metabolites are orations between the inpatient psychiatric team and
preferred. facilities and community programs is crucial to ensur-
ing continuity of care and effective transitions.
Seclusion and Restraint
Avoidance of restraints is particularly important in the Conclusion
elderly, who are often frail and have significant medi-
cal comorbidities. Acute problematic behaviors in eld-
erly patients with dementia often de-escalate through Assessment and treatment of geriatric psychiatry in-
stimulation reduction and behavioral techniques such patients require specially trained multidisciplinary
as distraction. Use of two- and four-point restraints team members skilled in an integrative approach to
should be rare. Devices such as geri-chairs, tabletops, patient care. Collateral information from families,
vest restraints, and side rails are more common re- caregivers, and clinicians and awareness of differential
straint types seen on geriatric inpatient units. Fall-pre- diagnostic issues, including the interplay between
vention monitoring devices, such as chair and bed medical and psychiatric comorbidities, are essential.
alarms, are not restraints. They alert staff when pa- The clinician needs to be familiar with acute and con-
tients at increased risk of falls attempt to transfer in- tinuation geriatric pharmacotherapy and psychother-
dependently. apy treatment paradigms. Age-appropriate discharge
planning with outpatient medical and psychiatric cli-
nicians, family, and caregivers is critical.
Discharge Planning
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CHAPTER 6
THE EATING DISORDERS UNIT

Katherine A. Halmi, M.D.
T he patient with a severe eating disorder poses a hospital care. The most compelling reasons for hospi-
substantial challenge to even the highly experienced talization center on the medical indications listed in
clinician. The confluence of significant medical com- Table 61. Many patients are hospitalized because of
promise, substantial psychological complexity, and se- their inability to block the perpetuating core symp-
rious psychiatric illness comorbidity may necessitate toms of their eating disorder, such as marked food re-
intensive treatment on an inpatient eating disorder striction, excessive and compulsive exercise, or purg-
unit. Because of the high morbidity and mortality of ing behavior, including self-induced vomiting or
these illnesses, patients cannot be subjected to ran- laxative abuse. Exacerbation of comorbid psychiatric
domized controlled studies to assess effectiveness of illness also may be a factor in the decision to recom-
hospitalization; hence there are no clear evidence- mend intensive in-hospital care. For example, the
based criteria for either hospitalization or discharge. presence of psychotic depression and/or suicidal ide-
Instead, on the basis of emerging clinical consensus, ation or of incapacitating obsessions and compulsions
established practice guidelines, and several decades of related or unrelated to the eating disorder may neces-
clinical experience from two established eating disor- sitate hospitalization. Another common factor in the
der programs, this chapter provides an overview of in- decision to hospitalize a patient may be the repeated
patient eating disorders treatment and associated is- failure of the patient to respond to a well-structured
sues, as well as the indications for such treatment. outpatient regimen and/or the need for a highly struc-
tured environment to break a cycle of continued de-
structive symptomatology. Some patients with signif-
Indications for Hospitalization icant environmental psychosocial stressors coupled
with inadequate social support systems may require
Several guidelines have been proposed for determining use of a structured inpatient program to facilitate
whether a patient with an eating disorder requires in- treatment.
89
TABLE 61. Summary of indications for inpatient eating disorder unit
Significant weight lossGenerally less than 85% of healthy weight for age and height or rapid weight decline
secondary to marked food restriction or refusal.
Medical status
For adults: Heart rate <40 bpm; blood pressure <90/60 mm Hg; glucose <60 mg/dL; potassium <3mEq/L;
electrolyte imbalance; temperature <97.0F; dehydration; hepatic, renal, or cardiovascular organ
compromise requiring acute treatment; poorly controlled diabetes
For children and adolescents: Heart rate near 40 bpm; orthostatic blood pressure changes (>20 bpm increase
in heart rate or >1020 mm Hg drop); blood pressure < 80/50 mm Hg; hypokalemia; hypophosphatemia;
or hypomagnesemia
SuicidalitySpecific plan with high lethality or intent; admission may be indicated in patient with suicidal
ideas or after a suicide attempt, depending on presence or absence of other factors modulating suicidal risk
MotivationVery poor to poor motivation; patient preoccupied with intrusive repetitive thoughts; patient
uncooperative with treatment or cooperative only in highly structured environment
ComorbidityAny coexisting psychiatric disorder that would require hospitalization
Purging behavior (including laxatives and diuretics)Needs supervision during and after all meals and in
bathrooms; unable to control multiple daily episodes of purging that are severe, persistent, or disabling despite
appropriate trials of outpatient care, even if routine laboratory test results reveal no obvious metabolic
abnormalities
Environmental stressSevere family conflict or problems or absence of family so patient is unable to receive
structured treatment in home; patient lives alone without support system
Source. American Psychiatric Association 2006.
Eating Disorder Subtypes ical problem of hypokalemic alkalosis (described later).

Most bulimia nervosa patients can be handled in out-
and Comorbidity patient or day programs. They are hospitalized only
when medical complications are present due to their
The majority of eating disorder patients requiring in- purging behavior or when they are seriously depressed
patient hospitalization have anorexia nervosa. Those and suicidal. Patients with binge-eating disorder (BED)
with the restricting type of anorexia nervosa usually are rarely hospitalized because they do not have the
have medical complications of dehydration, emacia- medical complications associated with purging. BED
tion, and severe bradycardia. Their overall psychiatric patients are usually hospitalized if they are seriously
comorbidity is considerably less than that of the binge- depressed; they may also be hospitalized for a very brief
purge type of anorexia nervosa patient. Those with a period for the purpose of stopping the bingeing behav-
restricting subtype may have a major depressive disor- ior in a highly restricted, controlled environment.
der, and about 15% will have an obsessive-compulsive
disorder unrelated to eating behavior, with an addi- Financing the Cost
tional 30% meeting criteria for a Cluster C anxious
personality disorder (Braun et al. 1994). The binge-
of Hospitalization
purge subtype of anorexia nervosa patient and those
meeting bulimia nervosa will have a greater prevalence In recent decades there have been major changes in the
of major depressive disorder (up to 80% of patients), financing of health care. Previously, eating disorder
with 30%50% meeting criteria for alcohol or sub- hospitalizations were primarily covered by private in-
stance abuse disorder and 30% having a diagnosis of a surance or unrestricted Medicaid. Today, health main-
Cluster B impulsive-type personality disorder. The tenance organizations and managed care companies
most prevalent diagnosis in the latter group is border- overseeing private insurance and public funding have
line personality disorder. For those patients who are predominately replaced private insurance as the pri-
bingeing and purging, regardless of whether they have mary source of payment. Eating disorders are unique
anorexia nervosa or bulimia nervosa, there is the med- among psychiatric illnesses because they encompass
The Eating Disorders Unit 91
both serious physical and psychological problems. purging and exercising. Patients may receive regular
Managed care companies often opt to treat the physical feedback about their weight every morning and deal
problems in general hospitals, which cannot cope with with interpersonal conflicts in a group therapy format.
the psychological issues that interfere with the physical Group therapy can occur at frequent intervals in
management. Refeeding severely emaciated anorexia the hospital setting and cover a variety of topics. It is a
nervosa patients can be time consuming and medically useful format for psychoeducation in which the pa-
complicated, thus requiring expert and experienced tients are informed about nutrition and medical com-
medical and psychiatric staff for effective treatment. plications as well as relapse prevention, assertiveness
There are serious problems concerning insurance training, self-control strategies, maturing and auton-
coverage for eating disorder patients. For patients who omy issues, and limit-setting problems. Patients may
are admitted at a very low body weight, the mental be given homework assignments of costbenefit anal-
health inpatient benefit often is only 30 days (or fewer ysis and self-monitoring. For example, the patients
if the patient has used the benefit previously in a year). could keep a daily diary that includes all foods eaten;
Studies have found that anorexia nervosa patients who symptoms they have had before, during, and after
left the hospital while still markedly underweight had meals; and other distressful symptoms. In a group for-
a poor outcome and a high rate of relapse (Baran et al. mat, patients can discuss their symptoms and have an
1995; Commerford et al. 1997; Halmi and Licinio increased awareness of their eating behavior, symptom
1989; Howard et al. 1999). Few managed care compa- triggers, and coping strategies.
nies have staff who are knowledgeable about the intri-
cacies of treating eating disorders, and thus they fail to
approve ample lengths of stay to provide proper care
Medical Management and
(Kaye et al. 1996). For example, if anorectic patients Nutritional Rehabilitation
are at 75% of ideal body weight or greater, they may be
denied coverage even though they might have extreme The medical management and nutritional rehabilita-
anxiety about eating and be unable to ingest adequate tion of eating disorder patients are best accomplished
calories outside of a structured supportive environ- in a specialized inpatient eating disorder setting that
ment. Coverage may also be denied if patients are not provides a team of individuals highly skilled in the
suicidal, if they are not given medication, or if medi- multidisciplinary management of these patients.
cations are not modified. Some insurance companies Medical management usually involves weight restora-
require intensive on-site family work and will not action, nutritional rehabilitation, rehydration, and cor-
cept telephone sessions for those families in which dis- rection of serum electrolytes. This requires daily mon-
tance and scheduling are serious legitimate problems. itoring of weight, food and calorie intake, and urine
Bulimia nervosa patients who are incapacitated with output, and in the patient who is vomiting, frequent
bingeing and vomiting and need a period of response assessment of serum electrolytes. Patients must be
prevention in a structured setting are denied coverage closely monitored for attempts to purge. Pediatricians
either if they are not actively bingeing and purging on and internists are often necessary to supervise the
the unit or the minute their laboratory tests are within medical management of severely emaciated anorexia
normal limits. nervosa patients or eating disorder patients with spe-
One study comparing eating disorder admissions to cific medical problems. Careful nutritional rehabilita-
an inpatient unit in the 1980s with admissions in the tion with the prevention of purging can effectively ini-
1990s found that the average length of stay decreased tiate the correction of most medical problems.
from 120 days to 23 days. During that time, the num-
ber of readmissions changed from less than 1% to close
to 35% (Wiseman et al. 2001). Overall, this frequent Common Specific Medical
flyer model of eating disorder treatment is unlikely to Problems in Hospitalized Eating
benefit either the patients or the economy.
Disorder Patients
General Principles
Severe Emaciation
A cognitive-behavioral framework is useful for the When a patient is below 75% of the ideal body weight
overall ward milieu. Exposure and response preven- or has a body mass index (BMI) of 15 or less, that pa-
tion techniques can be used to prevent patients from tient is usually regarded as severely emaciated. There
are likely to be problems of bradycardia, hypotension, Endocrine/Metabolic Abnormalities

dehydration, and extreme weakness. Rapid, effective
nutritional rehabilitation is the essential component Patients who are admitted because of uncontrolled
of early treatment. Some programs have successfully purging will usually have hypokalemia, hypomagnese-
utilized a strategy based on the primary use of a liquid mia, hypophosphatemia, and occasionally hypoglyce-
formula in six equal feedings throughout the day. A mia. These electrolyte abnormalities may require in-
liquid formula is efficiently digested and provides nec- travenous correction if severe; otherwise, they will
essary fluid, electrolytes, and calories for the patient. revert to normal with liquid formula feedings. Thyroid
Usually additional juices in the amount of one-half of and cortisol abnormalities will revert to normal with
the total daily amount of calories should be added. gradual nutritional rehabilitation. Some patients may
The total number of calories in these low-weight pa- have vitamin deficiencies, with low levels of folate,
tients should begin with an intake of 3040 kcal/kg/ B12, niacin, and thiamine. The liquid nutritional for-
day and can be increased very gradually if there is no mula may contain sufficient vitamin amounts so that
evidence of peripheral edema or heart failure. Most liq- additional supplements may not be necessary.
uid formulas contain the necessary amounts of vita-
mins and minerals. One randomly assigned controlled Gastrointestinal Problems
treatment study in a Japanese inpatient setting (Oka- Patients may complain of feeling bloated after ingest-
moto et al. 2002) showed that a liquid formula given ing a small amount. This may due to delayed gastric
only in the early stages of hospitalization with activity emptying and usually remits with gradual nutritional
restriction was more effective compared with a general rehabilitation. Liver enzymes may be elevated during
food program with regard to both the amount and rate refeeding and serum amylase levels elevated in purg-
of increase in BMI measured at the end of hospitaliza- ing patients. Constipation is a common problem and
tion and 6 months after discharge. Other programs may require stool softeners.
have alternatively advocated providing patients with
actual food as early as possible, although some pa- Hematological Abnormalities
tients will require significant caloric intake to gain
weight and will often need to use supplements as part Leukopenia with relative lymphocytosis is common in
of that intake. There is not clear consensus as to what emaciated anorectic patients. This will improve with
constitutes normal eating, with variability in ap- nutritional rehabilitation.
proaches to vegetarianism and red-meat avoidance.
Serum hypophosphatemia may develop during refeed-
ing, requiring phosphate supplements. Bed rest may
Nutritional Rehabilitation
be necessary, with escorted assisted walks and special
observation for development of bedsores. As mentioned earlier, severely emaciated patients
enter a nutritional rehabilitation phase with gradual
Cardiovascular and Peripheral increases in caloric intake. Nutritional rehabilitation
Vascular Problems should begin with an intake of 3040 kcal/kg/day
(approximately 1,0001,600 kcal/day) and increase to
Most anorexia nervosa patients have bradycardia, a high of 70100 kcal/kg/day after it is determined
which slowly improves with nutritional rehabilita- that the patient is tolerating the calorie load well. Add-
tion. An electrocardiogram may reveal ST-T wave ab- ing vitamin and mineral supplements when the pa-
normalities or QTc prolongation. Medications known tients are on food is particularly useful to prevent se-
to prolong QTc intervals should be avoided and elec- rum hypophosphatemia and to facilitate adequate
trolyte abnormalities corrected. nutritional rehabilitation. After the initial nutritional
rehabilitation phase, devising individual food plans
Central Nervous System Problems with food served on trays for each patient is helpful in
Anorexia nervosa patients severely ill enough to be allowing the patient to have a cognitive recognition of
hospitalized often have cognitive impairments and are the amount of food she or he is eating and the rate of
perseverative over issues of food, body weight, and ex- weight gain. During nutritional rehabilitation, ideally
ercising. They are unable to concentrate and are irri- there should be ongoing counseling and education
table. This will improve with gradual nutritional reha- provided by an experienced dietitian. These sessions
bilitation. focus on normalization of eating behavior, reduction
of irrational fears about food, and provision of accu- Therapeutic Approaches During
rate nutritional information. Research has found that
nutritional counseling has resulted in marked im- Refeeding and Blocking of Eating
provement in eating disorder symptoms and general Disorder Behaviors
psychopathology (Laessle et al. 1991).
Patients may eat together as a group around tables
but must be supervised carefully by staff to be certain During essential refeeding and/or blockade of compul-
they are not hiding or discarding food. It is desirable sive exercise, purging, and/or other core symptomatic
for each patient to receive individual nutritional coun- behaviors, patients with eating disorders often de-
seling as well as nutritional education in the form of scribe profound psychic stress and anxiety. A number
group therapy. Before discharge from the inpatient of therapeutic interventions, both pharmacological
unit, the patient should be given the opportunity to and psychotherapeutic, may be utilized on the eating
choose his or her own foods and practice at determin- disorder unit to provide support, reduce resistance,
ing an intake program that will promote either the and facilitate mutative change.
necessary continued weight gain or weight mainte-
nance. Patients should receive nutritional counseling
Pharmacological Treatment
with devising meal plans to practice after they are dis- Medications may be useful adjuncts in the inpatient
charged from the hospital. If a patient is discharged treatment of eating disorders. Cyproheptadine in high
from the hospital unit with a BMI of 19 or greater, the dosages (up to 24 mg/day) can facilitate weight gain in
chances of relapse are significantly less compared with anorectic restrictors and also provide a mild antidepres-
those discharged with a BMI less than 19 (Commer- sant effect (Halmi et al. 1986). Although chlorproma-
ford et al. 1997; Howard et al. 1999). zine was the first drug to treat anorexia nervosa, no
double-blind, controlled studies are available to show
the efficacy of this drug for inducing weight gain and
Physical Structure of an reducing anxiety in anorectic patients. In open-trial ob-
servations, chlorpromazine seemed to be helpful in the
Eating Disorder Unit severely obsessive-compulsive, agitated anorectic pa-
tient. It may be necessary to start at a low dosage of 10
To the extent possible, the design of the eating disorder mg three times a day and gradually increase the dosage
unit should take into consideration the essential im- while monitoring blood pressure. New-generation anti-
portance of sustained behavioral control and blockade psychotics such as olanzapine have been shown in pilot
of core eating disorder behaviors, including food re- studies to be useful for severely obsessive-compulsive
striction, compulsive exercise, and purging. Specific and agitated anorectic patients (Powers et al. 2002).
attention needs to be given to the dining room space Tricyclic antidepressants and serotonin reuptake inhib-
plan such that patients can be directly monitored dur- itors are not effective and have undesirable side effects
ing meals, reducing opportunities for patients to hide for emaciated anorectic patients (Kaye et al. 2001).
food and avoid caloric intake. Additionally, day room For bulimia nervosa patients who have been ad-
areas should be planned to facilitate ongoing line-of- mitted due to out-of-control bingeing and purging, the
sight monitoring of patients by nursing staff. Some medication approved by the U.S. Food and Drug Ad-
programs have successfully implemented use of ministration for treatment of bulimia nervosa is fluox-
closed-circuit television monitoring of patients to re- etine (Romano et al. 2002). The only other selective
duce the potential for surreptitious exercise. This serotonin reuptake inhibitor studied in a randomized
strategy requires the informed consent and permis- controlled trial and shown to be effective is sertraline
sion of the patient. The bathrooms on the eating dis- (Milano et al. 2004). In patients who do not respond to
order unit need to be locked to ensure patients cannot these agents, topiramate may be helpful (Hoopes et al.
surreptitiously engage in purging behaviors. One pro- 2003). However, because weight loss is a side effect of
gram has successfully utilized electronic key-con- topiramate, it should be used only in patients at a high
trolled flush switch on toilets so that patients may normal or overweight weight range. It is necessary to
have privacy when in the bathroom but must wait for begin topiramate in very low dosages of 25 mg/day,
the nurse to check the content of the toilet before it is gradually increasing the dosage to avoid adverse side
flushed. This allows for privacy and dignity while pre- effects such as paresthesias and cognitive word-find-
venting destructive behavior. ing difficulties.
Family Therapy stages, with an initial emphasis on stabilization of

symptoms and behavioral change. As treatment pro-
A clinical family analysis should be conducted on all
gresses, the behavioral coping strategies are supple-
adolescent patients who are living with their families.
mented with cognitive restructuring techniques, in-
On the basis of this analysis, it can be decided what cluding work on interpersonal issues, body image, and
type of family therapy or counseling is advisable. Fam-
affect regulation. The final stage of CBT concentrates
ily therapy and counseling are definitely necessary for
on relapse prevention and maintenance planning.
all children younger than 18 years (Eisler et al. 1997).
Although the CBT treatment model was designed
The family counseling can begin during the hospital-
as an outpatient intervention, the treatment has been
ization phase and continue through partial hospital-
utilized in a variety of settings, including inpatient
ization and outpatient treatment. In some cases where and partial hospital programs. In this regard, given the
family therapy is not possible, issues of family rela-
high level of symptom severity for patients entering an
tionships can be addressed in individual therapy or in
inpatient program, CBT stands out as one treatment
brief counseling sessions with immediate family
model that is particularly well suited for this popula-
members. Teleconferences are an available option for
tion (Bowers 1993). Thus, CBT emphasizes early be-
families outside the region. Family therapy often fo-
havior change in a structured and systematic way.
cuses on family psychoeducation, relapse prevention, Additionally, once the patient begins to stabilize and
and improvement of family dynamics. In addition,
becomes more receptive to any form of psychotherapy
some programs have utilized multifamily psychoedu-
(American Psychiatric Association 2006), the CBT fo-
cational support group meetings.
cus shifts to address salient cognitive and emotional
The randomized controlled studies of family ther-
concerns while maintaining symptom control.
apy have been conducted with outpatients, usually af-
It is recommended that hospitalized patients re-
ter a hospitalization phase. At present, there are few ceive intensive CBT in the milieu, in groups, and dur-
empirical data to indicate which type of family therapy
ing individual psychotherapy. Therapists with highly
is best for a given family dealing with an eating disor-
specific training provide a variety of CBT-based group
der. The family therapy approach developed at the
therapies including standard CBT for eating disorders,
Maudsley Hospital for adolescents tasks parents with
body image, skills training, self-esteem, and motiva-
the responsibility for overseeing refeeding (Eisler et al.
tion to change. These groups are based on salient ele-
2000). These authors found that counseling the par- ments of the standard CBT treatment protocols (e.g.,
ents separately from the child was more effective com-
Fairburn et al. 1993). Each of these important ele-
pared with conjoint family therapy in families in
ments of treatment is expanded (and modified for ado-
which the mother had high expressed emotion. Future
lescents as compared with adults), creating separate
family studies are needed to compare family therapies
and independent group therapies. The overall effect is
that do not have a parental-control-of-eating compo-
that patients receive all elements of CBT, as supported
nent with the Maudsley approach. in the literature, but in a more intensive dose. Addi-
Inpatient Cognitive-Behavioral tionally, other more specialized groups, such as CBT-
based trauma groups, can be offered as appropriate.
TherapyGroup and Individual Hospitalized patients also may benefit from inten-
Cognitive-behavioral therapy (CBT) is a well-researched sive individual CBT in which they can focus in a more
and proven method for the treatment of bulimia ner- specific way on their particular problems and conflicts.
vosa (Fairburn 2006). Although research on the effec- In this regard, it is recommended that all patients work
tiveness of CBT for the treatment of anorexia nervosa individually on stabilization of symptoms through cop-
is much more limited, clinical evidence and data in ing skills training, problem solving, and cognitive re-
support of its utility are emerging (Cooper and Fair- structuring around eating disorder beliefs and assump-
burn 1984; Hall and Crisp 1987; Pike et al. 2003). Es- tions. For some patients, however, it may be necessary
sentially, the cognitive-behavioral model for the treat- to expand beyond the standard CBT protocol to address,
ment of eating disorders emphasizes the important in a more intensive way, specific areas of concern such
role of both the cognitive (e.g., attitudes regarding the as body image, self-esteem, perfectionism, interpersonal
importance of weight, shape, and their control) and difficulties, and emotion regulation (Fairburn 2006).
behavioral (e.g., dietary restriction, binge eating) fac- Typically, the individual therapist will concentrate on
tors that maintain the eating disorder and associated one or two of these particular areas. The goal is to pro-
pathology. The treatment is presented in additive vide effective, focused, and individually specific therapy.
Examples of Other Eating Disorder and essential movement for daily activities during
movement education groups. Anorexic patients on a
Unit Group Approaches rehabilitation protocol learn the direct impact of their
high activity levels and frenetic movements on their
bodies and body image. The movement therapist can
Nutritional Education
assist these patients toward wellness using a holistic
Most inpatient units have utilized various nutritional approach to body awareness.
group approaches to impinge on irrational core beliefs
common to the eating disorder syndromes. Early in
treatment, many patients have little sense of what Specific Complexities in Treating
constitutes normal eating and have common mis- Hospitalized Eating Disorder
understandings that limit food choice. These misun-
derstandings result in a dietary regimen that is unap- Patients
pealing but makes the patient feel safe.
Patients often profess to have extensive understand- Involuntary Admission
ing of human nutrition. However, this knowledge may
be highly selective, derived from questionable sources Involuntary admission may be necessary to manage a
such as popular magazines, and it is often extreme and/ life-threatening emergency or a serious medical deteri-
or incorrect (Abraham et al. 1981). Inpatient units gen- oration when the patient is unwilling to take any steps
erally utilize a variety of group nutritional approaches to cooperate in treatment. Nasal gastric tube feeding
to provide meal planning, basic nutritional education, may be necessary for involuntary feeding and should
and family education. Some programs have imple- be administered by experienced staff. Core goals
mented therapeutic group meals later in the course of should be set for the involuntary portion of the treat-
treatment to provide patients an opportunity to as- ment, and the involuntary status should be terminated
sume greater responsibility for meal selection and con- as soon as these goals are met. Both patients and fam-
sumption in a less structured setting. ilies need to understand that involuntary admission
represents management of a life-threatening emer-
Expressive Arts Therapies gency rather than treatment that would be provided as
an ongoing eating disorder treatment program.
Expressive arts therapies may be used as a clinical ad-
Only in extremely rare severe medical situations is
junct to traditional verbal therapies in some eating dis-
total parenteral nutrition (TPN) a necessity. Such se-
order programs to assist the patients nutritional goals
vere medical conditions may be severe congestive
while he or she is learning appropriate means of toler-
heart failure or renal failure. TPN is a very compli-
ating and expressing feelings and reducing anxiety. The
cated procedure associated with infections and meta-
appropriate management of anxiety plays a significant
bolic abnormalities and requires an experienced, com-
role in aiding the patient during refeeding and blockade
petent staff with monitoring for the complications of
of eating disorder behavior. Art expression can improve
refeeding. Follow-up studies have shown that involun-
the patients regulation of body tension. Instead of rely-
tary admission and feeding do not have a detrimental
ing on restricting, bingeing, purging, or other means of
influence on outcome (Russell 2001).
self-injury to cope with stress, the patient creates art-
work as an alternative, channeling destructive im- Core Eating Disorder
pulses. Cognitive-behavioral principles in art therapy
may be utilized to assist patients in both recognizing Psychopathology
and challenging the presence of a body image distortion. The major problem in treating anorexia nervosa pa-
tients is their resistance to treatment. These patients
Movement Therapies have little desire to give up their disorder. The disorder
Some programs have utilized various forms of move- becomes ego-syntonic with strong psychological and
ment therapy groups to improve body tolerance most likely physiological reinforcement. The anorexia
through anxiety reduction and breathing techniques. nervosa becomes a defense mechanism by which the
Patients learn to identify emotions held in their body patient can avoid dealing with environmental prob-
and to express these emotions through gentle move- lems, usually of an interpersonal and developmental
ment. Patients also have the opportunity to learn the nature. To give up this routinized behavior is terrifying
differences between obsessive movements for exercise to most patients. For patients younger than 18 years,
the parents can insist that they stay in a hospital treat- tiple medical and psychiatric comorbidities. Despite
ment program for an adequate period of time. How- significant advances over the past decades in our under-
ever, patients ages 18 years and older have the legal standing of these illnesses, as well as the refinement of
right to leave whenever they wish. This forces the treatment strategies, overall morbidity and mortality
treatment staff to proceed with commitment, which remain high. Due to unfortunate changes in health care
usually is not effective unless the patient is danger- funding and an overemphasis on providing outpatient
ously medically ill or suicidal. care, many patients are not receiving adequate length of
treatment in a structured, specialized environment.
Associated Psychiatric Based in the experience of two established eating disor-
Comorbidities ders programs, we have summarized and provided the
rationale for specific elements of treatment for eating
Those patients who are bingeing and purging and re-
disorders that we have found to be effective.
quire hospitalization often have a comorbid diagnosis
of borderline personality disorder and are frequently
engaging in substance and/or alcohol abuse. Addiction References
withdrawal is often better accomplished on a special-
ized unit with transfer to an eating disorder unit at a
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APPENDIX I
Example of an Eating Disorder Unit Milieu

Manual for Patients
Introduction to the Unit No food is allowed out of the dining room, and no food
may be brought onto the unit by patients and visitors.
After meals, patients may sit in the den area for 1 hour
The patients are informed that because their eating under staff supervision.
disorder has rendered them seriously psychiatrically
and medically ill, the unit is highly structured and pa-
tients are closely monitored 24 hours a day. The main Bathroom Regulations
goals of treatment are 1) medical stabilization, 2)
weight gain for underweight patients, and 3) interrup- For medical reasons some patients may require closer
tion of eating disorder thoughts and behaviors for an- observation when going to the bathroom. All efforts
orectic and bulimic patients. Length of treatment is will be made to ensure privacy. Bathroom protocol is
determined on an individual basis according to a pa- as follows:
tients needs. All personnel have had extensive experi-
ence in treating eating disorder patients and provide a Supervised bathroomstaff monitors and records
very intensive treatment program. Family therapy ses- all output. The patient is given a commode in
sions are necessary weekly for all adolescent patients, which to void to accurately measure urine output.
and when appropriate, spouses and families of adult Open bathroomthe patient may go to the bath-
patients also may have weekly family therapy ses- room without staff supervision. Bathroom times
sions. All families participate in a weekly supportive are posted on the unit. Bathrooms are locked after
family group therapy. meals. Patients may use the bathroom if there is an
urgent need by asking nursing staff.
Eating Disorder Rules For medical reasons patients may require closer su-
pervision when showering. Shower protocol is as fol-
On admission your doctor will decide what diet will be lows:
ordered for you. If you are severely underweight, you
will be given a dietary supplement in the form of a liq- Supervised showersstaff members of same sex
uid formula. You will be given this supplement six observe patients showering.
times a day along with juice until your doctor deter- Unsupervised showerspatients shower unsuper-
mines you are medically stable. Part of your medical vised.
workup will include evaluation of electrolytes and
complete blood count weekly, or more often if needed.
Once you are medically stable, your doctor will discuss
Weights
progressing to solid food. Our nutritionist will meet
with you to devise a food plan that is in agreement All patients are weighed every morning after voiding
with your medical needs or religious preferences. We and before showering. Patients are weighed in a hospi-
cannot accommodate vegan diets, but we will imple- tal gown. No jewelry is to be worn.
ment vegetarian diets.
The dining room is open for meals at the following
times: 8:008:30 A .M . for breakfast, 12 noon12:30 Purging
P. M. for lunch, 5:005:30 P.M . for dinner, and 8:00
8:30 P. M. for snacks. Supplemental snack times are Purging is not tolerated on the unit. If vomit is found
10:0010:30 A.M., 2:303:00 P.M., and 8:008:30 P.M. on the unit, a community meeting will be held to dis-
cuss the matter. The nursing staff also will meet pri- smoke four times daily. Patients are permitted one cig-
vately with the individual involved. arette per smoke break and will receive a total of four
cigarettes daily. Patients require medical clearance
prior to smoking. Patients must be 18 years or older to
Exercise smoke.
Exercising is not permitted on the unit. Staff monitor

all patient areas and rooms at various intervals to Bedrooms
monitor for this behavior.
Patients may not enter anothers bedroom. No paper
Room Searches cups, paper towels, or napkins should be kept in
rooms. All rooms must be kept tidy, and staff mem-
Patients rooms may be searched at staff discretion at bers will check each room daily.
any time. Regular searches take place to maintain unit
safety for all patients. Patients will be informed prior Curfews
to room search and may be present.
Adolescents 17 and under must be in bed by 10:00

Groups P.M. Sunday through Thursday and by 11:00 P.M. Fri-
day through Saturday. Adults must be in bed by 11:00
All patients are expected to attend and participate in P .M . Sunday through Thursday and by 12 midnight
all groups prescribed. The unit schedule for groups is Friday and Saturday.
posted on the unit bulletin board.
Dress
Schooling
Patients should be appropriately dressed. No tight
Parents are expected to collaborate with the assigned
clothing, sleeveless shirts, shorts, or short skirts. Leg-
social worker to arrange for supplemental education
gings are to be worn with long shirts. No borrowing or
for adolescents on the unit. Individual tutoring is also
lending of clothes. Undergarments, shoes, and socks
available through creative tutoring.
must be worn at all times. No bare feet.
Off-Unit Therapeutic Activities Visiting Hours

Off-unit therapeutic activities may be requested
through the treatment team. Visiting hours are Monday through Friday, 4:004:45
P .M. and 7:008:00 P. M.; and Saturday, Sunday, and
holidays, 2:304:45 P.M. and 7:008:00 P.M. Visiting
Requests hours may be restricted for some patients. Visiting
hours for each patient will be discussed with the pa-
Requests for privileges should be discussed with your tient by the therapist. All visitors must sign the visi-
therapist. Each morning, in rounds, changes in privi- tors book upon arrival. Each family may visit once a
lege are considered. Your therapist will inform you of day for a maximum of 1 hour. Families may visit for a
the decision of the treatment team regarding your re- maximum of 2 hours on weekends. We highly recom-
quest at the conclusion of morning rounds. Rounds mend that families limit their visiting to two times per
take place 9:0010:30 A.M., Monday through Friday. week.
Smoking Guidelines for Family Visits
This is a no-smoking hospital. Patients with medical Family visits are important to patients. However, be-
clearance and courtyard privileges will be taken out to cause this in an acute care unit, visits must be closely
monitored. Therefore please help us by adhering to the they may have in struggling to cope with the pa-
following guidelines: tients illness and its impact on the family.
We ask that there be no more than two visitors per Group attendance is highly recommended for all
patient at any given time during visiting hours. families. Participants must respect the confidentiality
We ask that no food, beverages, gum, laxatives, or of patients and families by refraining from informing
medication be brought to patients. the patient and their own family of comments made
Please be aware that bathroom facilities and unit by parents or spouses of other patients.
telephones are for patient use only.
We ask that visitors refrain from bringing personal
food or beverages onto the unit.
General Dining Room Rules
Please help us by not entering the nurses station.
We will remind visitors that inappropriate personal
1. Everyone must stay in the dining room for 30 min-
physical conduct is not part of hospital protocol.
utes for breakfast, lunch, and dinner.
Please do not include other patients or families in
your visit. a. The radio can be on at all times, playing light,
Visitors who give patients contraband items may be soothing music at a low volume.
restricted from further visits. b. Patients must clean up after themselves.
The staff might interrupt the visit if the visit ap- c. There are to be no comments made about food,
pears disruptive. calories, weight, or body image.
Visitors must leave the immediate area when there d. All patients must record their intake with a staff
is a psychiatric emergency. member.
e. At 30 minutes, all patients, whether finished or
not, have to stop and record.
Family Group Meetings 2. Patients on liquid formula sit at one table.
a. Full glass of liquid formula must be poured.
The family group meets weekly on Thursday evening b. No switching or passing of liquid formula be-
from 5:00 to 6:00 P.M. The purposes of the group are tween patients.
c. No putting of fingers inside supplement con-
To provide a forum for parents and spouses to talk tainers.
together and offer support and understanding to
3. Patients on food trays sit at one table.
one another and to discuss similarities and differ-
ences in their individual and family experiences a. Nothing is to be thrown away from the tray.
with an eating disorder. b. When finished (and intake recorded), put tray
To understand family members questions about on special shelf.
psychological medical aspects of anorexia nervosa c. Extra fluids: 1 cup of either coffee, water, cocoa,
and bulimia nervosa as well as to provide education or juice once all liquids and half of each food
about the nature and treatment of psychiatric ill- item on the tray are completed.
ness. 4. Free foods
To increase family members awareness and under-
a. Patients eat at one table and serve themselves.
standing of their feelings and reactions to the pa-
tients illness as well as the nature of the patients 5. After meals everyone must sit in the den area for
experience in living with an eating disorder. 1 hour.
To provide support to family members and to re- a. Discussions about food and calories are prohib-
duce feelings of isolation and discouragement that ited in the dining room.
APPENDIX II
Example of an Eating Disorder Unit

Schedule and Daily Activities
6:007:00 A.M.: Patients escorted to the bathroom and 12:451:30 P. M.: Cognitive-behavioral group therapy
weights obtained focused on processing issues related to eating be-
7:308:00 A.M.: Vital signs measured on all patients havior and typical eating disorder obsessions and
8:008:30 A.M.: Breakfast rituals. On some days there are other groups, such
8:309:30 A . M .: Time in the den room, and some as a dialectical behavior therapy group, a news and
group therapies views group, and a creative arts group.
9:3010:00 A . M .: Bathroom escorts and courtyard 1:302:00 P.M.: Courtyard privileges
privileges 2:002:30 P.M .: Various groups, including assertive-
10:0010:30 A.M.: Snack time ness and nutritional education groups
10:30 A. M.12 noon: Patients meet with a treatment 2:303:00 P.M.: Snack time
team member. On some days between 11:00 and 3:003:45 P.M.: Group therapy, including task groups,
11:45 A.M., there are yoga classes or crafts, and on leisure planning and stress management groups,
Monday there is a community meeting. On other and body image group
days there is an Alcoholics Anonymous meeting 4:004:45 P.M.: Bathroom escorts and visiting hours
and a poetry writing workshop. 5:005:30 P.M.: Dinner
11:45 A.M.12:30 P.M.: Bathroom escorts and lunch 5:306:30 P.M.: Supervised individual time
7:008:00 P.M.: Visiting hours, followed by snack pe-
riods and then supervised individual time
CHAPTER 7
THE TRAUMA DISORDERS UNIT

Richard J. Loewenstein, M.D.
Susan B. Wait, M.D.
I npatient psychiatric units specializing in treating pa- to specialize in the inpatient treatment of severe dis-
tients with a history of psychological trauma generally sociative disorders, primarily dissociative identity dis-
are organized to serve one of two populations: predom- order (DID) and related severe posttraumatic dissocia-
inantly male active-duty soldiers or veterans with com- tive psychopathologies. In 1997, the program was
bat-related trauma or predominantly female civilians renamed the Trauma Disorders Program to reflect
with trauma related to severe childhood maltreatment the clinical reality that we were serving a broader spec-
(Busuttil 2006). Despite the evidence that posttrau- trum of patients and to reflect our understanding of
matic stress disorder (PTSD) and dissociative disorders the dissociative disorders as part of a broader spectrum
are common in the general population (Kessler 2000; of trauma-related disorders (Davidson and Foa 1993;
Waller and Ross 1997) and a history of childhood Loewenstein and Putnam 2004).
trauma is common in general inpatient psychiatric pa- Excluding patients ultimately diagnosed with non
tients (Loewenstein and Putnam 2004), only a handful trauma spectrum disorders (e.g., psychotic disorders,
of specialized trauma units exist nationwide. Success- factitious disorders), virtually all TDU patients fit cri-
ful inpatient hospital treatment models exist that can teria for complex PTSD (Courtois 2004; van der Kolk
help these patients sustain substantial recovery. Hope- et al. 1996). Complex PTSD includes a range of dis-
fully, knowledge from the trauma disorders unit rupted functions beyond the core symptoms of PTSD
(TDU) can be made more generally available so that and is found in survivors of repeated, sustained trau-
these patients receive more appropriate and helpful matic experiences occurring over long periods of time
treatment in all inpatient settings. and/or multiple developmental periods (Courtois
This chapter describes the characteristics of an in- 2004; Putnam 1997). Complex PTSD symptoms in-
patient TDU, specifically the TDU at Sheppard Pratt clude difficulties regulating mood, anxiety, and anger,
Health System in Baltimore, Maryland. Sheppard resulting in severe affective dysregulation; problems
Pratt opened its Dissociative Disorders Unit in 1992 regulating state stability and consciousness; difficulties
103
with sense of self and body image, resulting in identity stance and/or alcohol abuse or dependence usually do
problems, eating disorders, lack of attention to medical not respond to the treatment milieu of the TDU until
needs, and somatization; difficulties in forming stable they have achieved sobriety and are motivated to
relationships, with intense mistrust coexisting with maintain recovery. This is the case even if the sub-
vulnerability to victimization and exploitation; defor- stance dependence appears to be treating the pa-
mations in self-attribution and systems of meaning, tients trauma disorder symptoms. Less severe forms
with the world seen as dangerous and traumatizing of substance abuse, relapse by a trauma patient in ac-
and the self seen as damaged, shameful, defective, and tive recovery, and/or recent increase in substance use
responsible for traumatization; and a significant pro- to medicate trauma symptom exacerbations or dis-
pensity for self-destructiveness, including suicide at- tress due to acute life stress may be more treatable in a
tempts, substance abuse, self-injury, and risk-taking specialized trauma milieu. Similarly, because we do
behaviors (Arnow 2004). not have the resources to provide intensive specialized
eating disorders treatment during a TDU stay, trauma
patients with histories of eating disorders can be ad-
Admission Criteria mitted only when sufficiently stabilized to manage
their eating disorder symptoms.
Admissions to the TDU must be referred by a treating
mental health professional. The admissions coordina-
tor reviews an extensive questionnaire submitted by
Diagnostic Workup
the referring clinician and discusses the prospective
patient with the clinician. Then all potential admis- TDU patients often present with complex diagnostic
sions are reviewed with an attending psychiatrist for issues. Commonly, these include questions about the
suitability for TDU admission, including medical ne- presence of a dissociative disorder, an intercurrent
cessity criteria for inpatient level of care. Currently, psychotic process, depression, bipolar disorder, comor-
the TDU accepts both male and female patients, ages bid cognitive disorder, factitious disorder, or personal-
1865, with a history of psychological trauma. Male ity disorder and the extent to which the clinical picture
patients are screened carefully for their ability to man- is influenced by these possible concurrent diagnoses.
age in, and not be disruptive to, a mostly female hos- We also assess psychological factors that affect the pa-
pital milieu. Given the realities of modern hospital re- tients ability to undertake psychotherapy for severe
imbursement, most admissions must meet inpatient trauma-related disorders, such as the ability to form a
medical necessity criteria: imminent dangerousness therapeutic alliance despite severe posttraumatic mis-
to self or others and/or catastrophic inability to func- trust and specific transference themes that may occur
tion due to disabling posttraumatic and/or dissociative in therapy. Differential diagnosis is important; DID
symptoms. patients average 612 years of psychiatric treatment
Because patients must be motivated to participate before correct diagnosis (Loewenstein and Putnam
actively in a demanding treatment program, we gener- 2004).
ally do not accept involuntary patients or patients re- On admission, all patients undergo a complete psy-
ferred for court-ordered treatment. Trauma patients chiatric history, social and family history, trauma his-
with extensive histories of perpetrating childhood tory (to the extent that the patient can tolerate disclos-
abuse, violence toward others, or sexual assaults or ing it on initial interview), physical examination, and
with significant antisocial personality features usually basic laboratory evaluation (complete blood count,
are excluded due to their potential negative impact on comprehensive metabolic panel, and thyroid function
the TDU milieu and the difficulty in treating these tests; screenings for drugs of abuse and alcohol, syphi-
problems in a milieu focused on recovery for abuse lis, and therapeutic drug levels are obtained when indi-
survivors. Not uncommonly, however, previously un- cated). Patients are routinely screened using the office
known histories of perpetrating child abuse or violence mental status examination for complex dissociative
are revealed during TDU hospitalization. symptoms, which includes assessment of dissociative,
Patients admitted to the TDU must be medically mood, somatoform, and PTSD symptoms (Loewen-
stable. Psychotic and/or manic patients are excluded stein 1991).
because of potential disruption to the TDU milieu and Specific diagnostic assessment measures that we
difficulty participating in the treatment program. It routinely use for the assessment of dissociative disor-
has been our experience that patients with severe sub- ders include the Dissociative Experiences Scale (Bern-
The Trauma Disorders Unit 105
stein and Putnam 1986), the Multiaxial Inventory of to resolve questions about what did or did not occur as
Dissociation (Dell 2006), and the Structured Clinical fully as possible over the course of long-term trauma
Interview for DSM-IV Dissociative Disorders (Briere treatment.
et al. 1995; Steinberg 1994). For assessment of PTSD
and more general trauma-related issues, we com-
monly administer the Trauma Symptom Inventory
Therapies
(Briere et al. 1995). More specific diagnostic instru-
ments for PTSD rarely are required because most pa- Psychotherapy
tients present with obvious PTSD symptoms on clin-
ical evaluation. A variety of studies have shown efficacy of psychother-
More complete psychological assessment, by psy- apy for PTSD and DID (Foa et al. 2000; Loewenstein
chologists familiar with dissociation and trauma, may and Putnam 2004). Evidence-based models support
be needed to fully assess complex differential diagnos- the use of psychodynamic, cognitive-behavioral, hyp-
tic questions. This may include the Wechsler Adult In- notherapeutic, and progressive exposure therapies,
telligence Scale, the Minnesota Multiphasic Personal- among others. Studies of inpatient TDU treatment for
ity Inventor y, the Thematic Apperception Test, DID generally have shown robust improvement using
neuropsychology screening, and the Rorschach. a trauma-/dissociation-focused treatment paradigm
(Eliason and Ross 1997).
Reliability of Traumatic Memories
There is a debate about the reliability of memories of STAGE-ORIENTED TREATMENT
trauma, especially those that reportedly have been Expert consensus, buttressed by a variety of evidence-
subject to lack of recall at some point in the patients based treatment models, strongly supports the notion
history. This is a complex topic, and the reader is re- of a phasic treatment structure for trauma patients
ferred to definitive reviews such as those of Brown et (Brown et al. 1998; Foa et al. 2000). Although a num-
al. (1998) and Dalenberg (2006). In short, the current ber of models have been proposed, most authorities
evidence supports the position that recall of trauma support the utility of a three-phase treatment struc-
memory, like that of all autobiographical memory, is ture (American Psychiatric Association 2004; Interna-
reconstructive, not photographic. Delayed recall for tional Society for the Study of Dissociation 2005). In
traumatic experiences has not been shown to produce the first phase, the patient works toward basic safety
memories that are any more or any less accurate than and stability. In the second, the focus is on the detailed
continuous memories. Either kind may be essen- and emotionally intense recollection and processing of
tially accurate, a mixture of accuracy and confabula- trauma memories. In the third phase, the therapeutic
tion, or entirely confabulated (Dalenberg 2006). Pa- work is directed toward reintegration and living well
tients are also informed that memories recalled under in the present. In this phase, traumas are relegated
hypnotic conditions should not be deemed any more more and more to the status of bad memories rather
or less accurate than memories recalled in their usual than being relived as flashbacks, behavioral reexpe-
behavioral state (Cardena et al. 2000). riencing phenomena, or intense posttraumatic reac-
In general, TDU staff do not endorse belief or dis- tivity to current situations. For the DID patient, a ma-
belief in any particular uncorroborated memory re- jor focus in the third phase may be fusion/integration
ported by a patient. Patients and, when indicated, fam- of self states. Finally, the entirety of trauma treatment
ilies are educated about the complexity of human is directed toward the patient developing a better adap-
memory and the controversies in the field about tation to current life.
trauma memory. Patients who report severe childhood Contemporary trauma programs generally opt for
trauma sometimes are ambivalent about their own re- an inpatient TDU stay focused on developing safety
call, often believing themselves at some times and not and stability to permit better engagement in outpa-
at others. It is far more important for the clinician to tient treatment. However, some patients are so mis-
identify conflicts the patient has about his or her own trustful and demoralized that it may take several
recall than to validate or discount a patients memo- weeks for them to develop even a beginning sense of
ries. We tell patients that rather than offering belief or confidence that the TDU can help them. Sadly, at this
disbelief, we will do our best to help them begin the point, these patients may become just safe enough
process of understanding and integrating memory ma- to be discharged due to managed care limitations.
terial. The goal is to allow the patient him- or herself This can result in the patient leaving the hospital be-
fore having internalized a sense of safety in treatment. SAFETY FOCUS

Along with ongoing outside stress, this situation may
Within the overarching trauma framework, establish-
precipitate repeated brief admissions that undermine
ing safety is usually the central task for the inpatient
definitive stabilization even more. Many patients re-
TDU patient. TDU patients commonly are deeply in-
ferred to our program are so demoralized, and have
volved in a plethora of suicidal, parasuicidal, or high-
such limited ability to manage their symptoms, that
risk behaviors, some of which only become apparent
hospitalizations of 13 months are optimal to help
with sequential observation and intensive history tak-
them definitively stabilize and return to productive
ing. Many of these behaviors will be reported to have
outpatient treatment.
begun in childhood or adolescence. Frequently, admis-
sion has been precipitated by escalation in suicidal or
TRAUMA FOCUS parasuicidal behaviors. Also, these patients may make
Our treatment approach begins with a trauma focus suicide attempts in the hospital by any means that
toward the patients difficulties. This involves a mix- they find available, commonly strangulation, inges-
ture of psychodynamic and cognitive therapy models. tions, and severe self-cutting.
We attempt to understand the patients problems as In addition, most of these patients engage in self-
logically related to posttraumatic reactivity; trauma- injury that is not suicidal in intent, such as cutting,
based cognitive distortions, projections, and projective scratching, and burning, often over extensive parts of
identifications; and traumatic transference to the the body, including the genital area. Other common
staff, other patients, and the hospital environment self-damaging behaviors include head banging; hitting
(Loewenstein 1993). The patient is invited to under- objects, resulting in orthopedic injuries to the extrem-
stand his or her reactions as potentially triggered by ities; and nonlethal overdosing, among others. Be-
posttraumatic reminders that set off intense reactivity, cause patients commonly use these behaviors in an
often in the form of unconscious flashbacks or attempt to manage their symptoms, treating these be-
emotional flashbacks (Blank 1985; Loewenstein haviors is one of the central tasks of treatment during
2006). This reactivity often leads to self-destructive hospitalization so that the patients can return to a less
behavior, maladaptive interactions with others, and restrictive level of care.
emotional dysregulation, usually accompanied by Our primary approach to suicidal and self-harming
marked cognitive distortions about what is occurring. behaviors is to reframe them as attempts at self-regu-
Remarkably, through powerful projective identifica- lation and/or management of trauma experiences and
tions, others may be drawn into interactions with the related affects and cognitions. Attempts at controlling
patient that seemingly replay reported traumatic situ- these behaviors without reframing them in this way
ations from the pastwalking into the flashback to- are almost invariably doomed to failure, because they
gether, as one patient put it. reinforce the patients negative self-assessments. For
Elucidating the traumatic scenario that is being re- example, among the manifold cognitive distortions
played allows the patient to begin to separate past that may drive self-injury is the idea that Im going to
from present. The patient examines the extent to get hurt anyway, so if I control the timing and inten-
which current problems, maladaptive behaviors, trou- sity of harm, its less bad. If they [the perpetrators] see
bled relationships, inexplicably intense emotional re- that I hurt myself, maybe they wont hurt me as
activity, and/or self-destructive behaviors result from much. These ideas can be reframed as an attempt to
unconscious reliving of past trauma scenarios or at- survive the helplessness and unpredictability of re-
tempts at self-protection from anticipated traumas and peated maltreatment. They also underscore a core be-
betrayals based on past traumatic relationships. This lief of many complex PTSD patients: that maltreat-
task is fundamental to beginning successful treatment ment is inevitable, and all one can hope to control is
for this population. Remarkably, in many of these pa- the timing and intensity of it. The therapeutic goal
tients, this approach can ameliorate seemingly intrac- then becomes to exchange this survival skill for a
table problems and maladaptations relatively quickly recovery skill by developing adult non-trauma-based
(Loewenstein 2006). Patients are relieved to under- strategies for assessing ones current life situation and
stand that behaviors experienced only as crazy or level of external danger; gaining a repertoire of skills to
bad are logically related to past events. Unit staff feel keep oneself safe from self and others; and creating
more effective both by understanding better why pa- overall safety and self-protection in ones current life.
tients act as they do and by helping to develop specific Despite our prescreening, some patients have sig-
interventions based on this understanding. nificant current difficulties with aggression and/or vio-
lent dyscontrol (e.g., throwing furniture, threatening spective on how to proceed, we generally seek consul-
staff or patients). These behaviors may also have trau- tation from forensic consultants familiar with trauma
matic antecedents and may involve the patient being disorders and issues of professional misconduct.
in a dissociative state, leading to disorientation to cur- Patients who threaten harm against others (fre-
rent circumstances. To the extent that this is the case, quently against reported perpetrators) are assessed
reframing and understanding the posttraumatic un- with regard to the need to warn intended victims and
derpinnings of these behaviors may be critical in re- inform police of their threats, as required by state law.
solving them. Some violent behavior involves identifi- The need to keep everyone safe from violence, even
cation/introjection of the aggressor/perpetrator. those who reportedly have harmed the patient, be-
Working with the patient on these dynamics may be comes an important treatment issue.
helpful in reframing these behaviors as related logi- Finally, patients may report or be suspected of
cally to trauma dynamics and in helping the patient abuse or neglect of their own children. We evaluate
stop them. these cases carefully, acquiring as much collateral in-
A crucial milieu dynamic is maintaining the TDU formation as possible to assess whether mandated re-
as a safe place (or safe enough place, because no hos- porting is required. It is optimal if patients collaborate
pital unit is absolutely safe). Accordingly, milieu with us in reporting themselves to social services.
treatment interventions commonly are used to bring Mandated reporting may also be required if the patient
social pressure on actively self-destructive and/or vio- reveals information about suspected abuse or neglect
lent patients to contain their behavior. Patients who of children by current or former partners or reported
have acted unsafely are required to process the behav- childhood perpetrators who currently have access to
iors through writing, discussions with nursing staff, minor children.
and/or intensive evaluation in individual therapy and
attending rounds. Patients also may process the be-
PSYCHOTHERAPY MODALITIES
havior and their commitment to safe alternatives in
therapy groups with other patients. In the TDU, each patient has a psychotherapist, a so-
Safety crises and treatment stalemates sometimes cial worker, and an attending psychiatrist. Patients are
result from the patient having been recently victimized usually seen in 45- to 50-minute individual psycho-
in a relationship, or actually currently being exploited therapy sessions three times per week. Individual psy-
or victimized in a contemporary relationship. It is im- chotherapy is psychodynamically informed, emphasiz-
portant to have a high index of suspicion for this being concepts such as transference, defense, resistance,
cause patients are often profoundly ashamed about projective identification, and therapeutic alliance, with
these situations and actively conceal them. These de- optimal treatment drawing from a number of different
structive relationships can include current interper- psychotherapy models.
sonal violence, incestuous involvement with family Patients have daily psychiatric attending rounds
members into adulthood, and exploitation by psycho- that necessarily focus on medication and medical is-
therapists and/or medical professionals. Patients may sues as well as administrative issues such as observa-
experience contemporary betrayals as even more dev- tion levels and privileges. However, TDU attending
astating than their childhood traumas (Im grown up. physicians also carry out brief, focused psychothera-
Im supposed to know better now). In addition, these peutic interventions that facilitate goals of the overall
situations bring up complex medicolegal issues for treatment. These may include cognitive, psychody-
staff, as well as excruciating dilemmas for the patients namic, symptom management, and/or educational in-
who, just as in childhood, often are attached to those terventions (S. B. Wait, Attending Rounds, or How to
who hurt them. Milieu management may be made Establish a Therapeutic Relationship in 15 Minutes a
more complicated when these patients wish to con- Day, presented at Scientific Day, Sheppard and Enoch
tinue contact in the hospital with individuals who Pratt Hospital, Towson, Maryland, June 11, 2000).
have, or are currently, reportedly exploiting them. Patients attend groups for 3 to 5 hours per day.
With respect to abuse by current or prior treating Some groups are didactic or educational, whereas oth-
therapists, most often patients will report relation- ers focus more on psychotherapy issues and group pro-
ships that involve boundary violations and role rever- cess. In addition, patients participate in expressive
sals. Unfortunately, in all too many instances, patients therapy groups, including specialized art therapy and
report sexual involvement with a current or former creative writing, as well as trauma-oriented occupa-
treating clinician. In these cases, for additional per- tional therapy groups.
Psychoeducation. Complex PTSD and dissociative relationship boundaries; appropriate behaviors for
disorder patients require extensive, ongoing psycho- adults and children; the nature of emotions such as
education. Psychoeducation goes on in all of the unit anger, shame, sadness, and grief; the need for medical
psychotherapies. Education about treatment risks and care; and many other aspects of life that most non-
benefits primarily is carried out in individual therapy traumatized individuals take for granted. Severely
and in rounds. traumatized patients may not believe that they can say
First, patients are educated about the symptoms of no when someone wants something from them.
PTSD, complex PTSD, and/or dissociative disorders. Lacking full understanding of some of the most basic
Clarification of how dissociative disorders and PTSD aspects of human relationships and of human safety
are diagnosed and how their symptoms may mimic or and human dignity, they may be at greater risk for re-
overlap those of other disorders is especially helpful to victimization and exploitation.
patients who have carried many and varied diagnoses.
Cognitive-behavioral psychotherapy. Cognitive ther-
In addition, patients are educated about the current
apy is an essential facet of psychotherapy in address-
views of phasic trauma treatment and the risks, bene-
ing the manifold and profound cognitive distortions
fits, and controversies about current trauma treat-
found in this population (Fine 1990). Cognitive ther-
ment models, including pharmacotherapy. This in-
cludes discussing the nature of traumatic memory, apy interventions occur in psychotherapy as well as in
the milieu and in groups. Most patients attend a
delayed recall for trauma (if this is reported), and cur-
weekly cognitive therapy group to help identify and
rent controversies about these issues.
challenge their cognitive distortions.
Patients who receive a dissociative disorder diagno-
Basic cognitive distortions may include notions
sis also are educated regarding current controversies
such as anger is violence; self-harm is safety; sex
about diagnosis and treatment of dissociative disor-
ders, particularly DID. Dissociative patients may have is love; I made my abuser bad; sex is all Im good
for; if something good happens, it will just get taken
difficulty recalling educational and informed consent
away, so I should destroy it first; and so on. In the
information. They may need frequent repetition of in-
trauma population, the apparent fixity of cognitive
formation, either because they have amnesia for the
distortions may conceal significant trauma memory
discussion or because alternate self states emerge who
material that seemingly is held at bay by the cognitive
claim not to have been present when the information
was originally imparted. The notion that informed distortion.
Cognitive distortions also interconnect with pro-
consent is best viewed as an ongoing process is amply
found shame scripts that dominate these patients
demonstrated in this population.
cognitive/affective universe. One should never under-
Patients are educated about conditioned fear re-
estimate the importance of shame in the psychother-
sponses and how these relate to PTSD reminders,
apeutic approach to these patients. Recognition of,
PTSD reactivity, and intrusive PTSD symptoms. DID
patients are educated that all self states make up a sin- systematic psychotherapeutic attention to, and educa-
tion of the patient about shame-based cognitions and
gle human being and are not separate people and
behaviors best described by Nathansons compass of
that all self states will be held responsible for the be-
shameattack self, attack other, avoidance, and
havior of any other, regardless of whether the behavior
withdrawalmay lead to significant clinical leverage
is recalled and experienced as occurring under volun-
(Nathanson 1992). Attack-self scripts typically take
tary control. They are educated that all self states are
adaptations to life circumstances and that there are no forms such as Im a loser; Im disgusting; Im
hideous and loathsome; or I wish I could disappear
good or bad self states. The self states harmful,
off the face of the earth. In attack-other mode, pa-
abusive, violent behavior to self or others is not con-
tients may wish vengeance to get back at reported per-
doned but rather understood and reframed in its adap-
petrators for the humiliations caused by childhood
tive context, generally developed during childhood
abuse, but they commonly turn this back on them-
maltreatment. The clinician explores with the patient
what problem the troubling behavior may originally selves (Lewis 1990).
have been intended to solve and what beliefs the self Dialectical behavior therapy. Dialectical behavior
state may have about how the behavior solves the prob- therapy (DBT) was developed by Marsha Linehan
lem. Then more adaptive alternatives are explored. (1993a) primarily for outpatient treatment of patients
Psychoeducation also involves discussing the im- diagnosed with borderline personality disorder. It is a
portance of safety and bodily integrity; the nature of staged treatment that focuses first on modifying life-
threatening behaviors; second, on modifying behav- minutes to assess feelings, behaviors, and degree of
iors that interfere with therapy; and then on modify- orientation. Severely dissociative patients may be so
ing a defined hierarchy of problematic behaviors. In its ungrounded as to forget to do the task as often as man-
establishment of priorities, it has much in common dated. Nonetheless, patients can find this helpful in
with the stages of treatment for complex PTSD and staying present and gradually becoming more
similarly advocates deferring intensive treatment of grounded in reality.
traumatic memories until initial safety issues are well DID patients have the highest hypnotizability of
controlled. In Linehans model of treatment, the DBT any clinical group on standardized assessment mea-
skills group is only one component of the treatment. sures (Frischholz et al. 1992). Many non-DID PTSD
However, in our program, it is the one most adaptable and complex PTSD patients are also highly hypnotiz-
to an inpatient setting with a constantly changing pa- able. Accordingly, hypnotherapeutic imagery and re-
tient group. In our program, the DBT skills group laxation interventions may be particularly useful for
meets twice a week for 45 minutes, and each group fo- symptom management in the acute management of
cuses on one of the four basic skills: mindfulness, dis- TDU patients (Brown et al. 1998; Kluft and Loewen-
tress tolerance, emotion regulation, or interpersonal stein 2007).1 Hypnosis represents a set of adjunctive
effectiveness. therapeutic techniques that vary widely and may be
Group sessions start with a 2-minute mindfulness used for many different clinical problems (Spiegel and
practice, followed by group leaders discussing one of Spiegel 2004). Formal hypnotherapeutic interventions
the skills. We use handouts from Linehans DBT man- must only be performed by those with specific training
ual (Linehan 1993b). Patients read sections aloud and in hypnosis and additional training in hypnosis for
give examples from their own experience of situations traumatized/dissociative patients.
where they might find the skills useful. The group Patients may be taught to use images in formal hyp-
leaders are active and positively reinforce patients nosis. TDU patients also can be taught self-hypnosis
participation in group discussions and use of the skills for a variety of symptom containment purposes. Induc-
being taught. Patients have homework assignments to tion of self-hypnosis may increase the potency of imag-
practice the skills and to discuss in individual therapy ery for this population and allow a greater depth of re-
how they are using them. laxation and symptom control. Patients with DID and
dissociative disorder not otherwise specified in partic-
Symptom management skills training. Gr oun ding ular may be able to use imagery to reduce the intensity
is the most basic skill taught to TDU patients. This of traumatic intrusions without formal induction of
relates to patients frequently experiencing themselves hypnosis. Typically, patients are taught to visualize
as depersonalized, detached, spaced out, out of their themselves in a safe place where they experience a
bodies, not oriented to current circumstance, lost in reduction in panic, flashbacks, and hyperarousal. Pa-
memories or internal experiences, rapidly switching tients may learn to visualize containment of trau-
among alternate self states, and so on. Grounding matic memory material in imagined vaults or boxes in
techniques are methods to counter these experiences, outer space or at the bottom of the sea, for example.
often by attempting to accomplish simple orienting Some patients visualize a remote control that can
tasks using all the senses. These may include helping take away intrusive trauma images and superimpose
the patient to keep his or her eyes open, to become benign images. Patients can be taught to imagine a vol-
aware of his or her feet touching the floor or arms ume control to dial down intense affects and intru-
touching the chair, and to look around the room, iden- sive symptoms.
tifying where he or she is and with whom he or she is
speaking. Patients with marked difficulties maintain-
ing orientation to current circumstances, for example,
SAFETY AGREEMENTS
continuously going into spontaneous self-hypnotic Agreements to maintain safety are frequently used
states, can be given a 15-Minute Check-In sheet. with TDU patients by the therapist, attending physi-
Here, the patient fills out a rating scale every 1530 cian, and nursing staff. These agreements have no le-
1
We do not have space to review the controversies over use of hypnotic techniques in this population. See Brown et al. (1998) and
International Society for the Study of Dissociation (2005). See also guidelines of the American Society of Clinical Hypnosis
Committee on Hypnosis and Memory (1995). However, in general, in the TDU patient population these techniques are used to
attenuate and contain intrusive traumatic memories, not explore them.
gal force and should never be substituted for the judg- hypertensive prazosin has been found to reduce PTSD
ment of the clinician or nursing staff about the actual nightmares in combat veterans (Loewenstein 2005).
state of the patients safety (International Society for Our clinical experience supports this indication in
the Study of Dissociation 2005; Loewenstein and Put- TDU patients with severe, recurrent nightmares who
nam 2004). However, they have considerable thera- can tolerate the hypotensive effects of the medication.
peutic utility. It is best to conceptualize these as delay- Clinical experience by TDU psychiatrists suggests
ing agreements rather than as safety agreements per that other SSRIs and serotoninnorepinephrine re-
se. These agreements emphasize the patients ambiv- uptake inhibitors (SNRIs) such as venlafaxine and du-
alence about self-harm or suicide, greater awareness of loxetine, TCAs, and MAOIs are equally as effective as
the impact these behaviors have on the patient and those that have been studied in double-blind trials, al-
others around him or her, and development of honesty though the U.S. Food and Drug Administration (FDA)
about the state of ones safety. has approved only sertraline and paroxetine for use in
These agreements are most effective when paired PTSD. Other medications represent off-label uses. In
with a safety plana repertoire of alternatives to particular, a subgroup of these patients presents with
acting unsafely. Alternatives to unsafe behavior insignificant obsessive-compulsive symptoms and may
clude grounding, not isolating from others, using im- respond preferentially to clomipramine or fluvox-
agery or self-hypnosis, or going to staff and asking amine (Loewenstein 2005).
for help with psychotherapeutic interventions or as- Open-label studies using anticonvulsant mood sta-
needed medication. Some patients find it frightening bilizers (carbamazepine, valproate, topiramate, and
to verbalize a need for help, based on past traumatic gabapentin) primarily in male combat veterans sug-
experiences in which they attempted to do so and were gest these agents may alleviate PTSD symptoms
rejected, disbelieved, or additionally mistreated. We (Friedman 2000). In addition, one small double-blind
provide a help chair where patients can sit to non- study supported efficacy for lamotrigine in PTSD
verbally indicate their need for staff assistance. Some (Friedman 2000). In several double-blind studies, the
patients write their need for help on index cards if they benzodiazepines have not been shown to have specific
are posttraumatically terrified of speaking but are less effects for PTSD, although they improved sleep and
triggered by conveying their needs in writing. general anxiety responses. However, many TDU pa-
tients report significant symptom relief with benzodi-
Pharmacotherapy azepines.
Here we give a brief overview of pharmacotherapy for The benzodiazepines are safe and effective anxi-
the TDU patient. The reader is referred to reviews of olytic agents that have generated significant concern
neurobiology and pharmacotherapy of PTSD and dis- about their use, overuse, and misuse in psychiatric
sociative disorders (Friedman 2000; Loewenstein practice in general and in the treatment of patients
2005). Complex PTSD may involve extreme fear with trauma-related disorders specifically. Their safety
states, terror, profound existential despair, grief, guilt, and efficacy are flawed by their potential for depen-
self-loathing, and shame, among other extreme emo- dence and tolerance. It is important to caution pa-
tions, none of which may be clear-cut targets of cur- tients about this and warn them against stopping
rent psychopharmacology. these agents suddenly or without the advice of a phy-
Psychopharmacological treatments for PTSD for sician. Not all patients develop tolerance, however,
the most part have excluded complex PTSD and DID and many can use benzodiazepines successfully at the
patients in their protocols. In addition, studies suggest same dosage for long periods of time (Soumerai et al.
that the more trauma exposure, and the more long- 2003). The risk of tolerance may be higher in patients
standing the PTSD, the less robust the pharmacolog- with histories of alcohol abuse or dependence and with
ical response (Loewenstein 2005). Nonetheless, dou- family histories of alcoholism.
ble-blind studies in male combat veterans support the Clonazepam and lorazepam are the most com-
specific efficacy in PTSD of the selective serotonin re- monly used benzodiazepines on the TDU; they are
uptake inhibitors (SSRIs) sertraline, paroxetine, and both relatively long acting and as such are preferable to
fluoxetine (there also was a successful fluoxetine trial alprazolam, which can cause rebound anxiety between
in childhood trauma patients); the tricyclic antide- doses and life-threatening withdrawal symptoms due
pressants (TCAs) amitriptyline and imipramine; and to its short half-life. Diazepam is occasionally used as
the monoamine oxidase inhibitor (MAOI) phenelzine well; it is often less expensive than other benzodiaz-
(Friedman 2000) Also, in controlled studies, the anti- epines in its generic formulation, which may be a con-
sideration. In addition to decreasing anxiety, the ben- ical treatments are primarily shock absorbers in this
zodiazepines are sedating and cause skeletal muscle context and unlikely to be curative. Patients may be
relaxation. Patients sometimes associate the skeletal more readily able to identify helpful medication treat-
muscle relaxation with the antianxiety effect and ments in this context: I dont feel good, but if I
seem to experience it as an indicator that the medica- wasnt taking this medication and all this stuff was
tion is working. happening to me, I wouldnt be able to get out of bed.
Benzodiazepines may be given as scheduled medica- In the DID patient, it is important to assess the atti-
tions, as needed, or both. Patients often have difficulty tudes toward medications of different self states; some
asking for as-needed medications and wait until their may seek medications in an addictive way, whereas
anxiety is extreme to do so, which makes the medica- others are medication phobic. Some complex PTSD/
tions less likely to help. A twice-daily dosing regimen DID patients report being drugged as part of abuse,
with as-needed doses available seems to help keep anx- creating even more complex reactivity to medication
iety at a more manageable level. A rule of thumb for management. Accordingly, in DID patients, assent of
clonazepam and lorazepam is to limit the total daily the whole alter self state system may be important
dosage to 48 mg. If a patient requires more than this, in adherence to a medication regimen. In DID, symp-
especially if there are repeated requests for dosage in- toms such as depressed mood that are found only in
creases, it is likely that tolerance is developing, and one or a few self states, not across the whole human
other classes of medications should be considered, in- being, are less likely to be medication responsive (see
cluding neuroleptics and agents that decrease sympa- Loewenstein 2005 for additional discussion).
thetic response, such as propranolol or clonidine. Because there are few good studies of psychophar-
One study of a small group of complex PTSD pa- macology in the complex PTSD/dissociative disorders
tients treated with risperidone showed this medica- population, there are no formally developed algo-
tion was helpful in reducing intrusive symptoms of rithm s f or medication man agemen t. How ever,
PTSD (Reich et al. 2004). Again, clinical experience in commonsense principles can guide clinical decision
the TDU shows that subgroups of patients respond to making. The most important first step is a careful as-
each of the atypical antipsychotics, and a smaller sub- sessment of the symptom picture to assess the contri-
group responds preferentially to some of the older typ- bution of comorbid affective, PTSD, and dissociative
ical antipsychotic tranquilizers, primarily for reduc- disorders, among others. Next it is vital to take as
tion of thought disorganization caused by repeated complete a medication history as possible. It is com-
intrusive PTSD and dissociative symptoms; reduction mon in this population that a medication works for a
in repetitive, severe flashbacks and behavioral reexpe- period of time and then appears to become ineffective
riencing episodes; and severely disrupted sleep. TDU as the patient is overwhelmed by additional life stress.
patients with true comorbid psychotic symptoms (as Reintroduction of the medication at a later time may
opposed to dissociative pseudopsychotic symptoms), lead to a response.
subtle thought disorder, pervasive lack of reality test- A logical first step is to maximize dosages of med-
ing, or particularly bizarre PTSD or dissociative symp- ications that the patient is already taking. Medication
toms, especially with lack of robust response to other subtraction also can be important, because patients
antipsychotics, may respond to a trial of clozapine. commonly arrive on multiple medications, often stat-
Other medications found to be helpful for PTSD ing that they have been put on several medications at
symptoms in open-label trials include 2 agonists the same time, confounding assessment of efficacy
such as clonidine, -blockers such as propranolol (es- and side effects. Next, augmentation strategies may be
pecially for hyperarousal symptoms), and the - and useful, such as adding bupropion to an SSRI, espe-
-opiate receptor antagonist naltrexone, for reduction cially if there is significant motoric retardation; a low-
of compulsive self-injury, particularly when accompa- dose TCA to an SSRI (carefully monitoring TCA blood
nied by a high (Friedman 2000). We find each of levels); or mirtazapine to an SSRI. Addition of an anti-
these agents helpful in subgroups of TDU patients. convulsant mood stabilizer may be indicated if there is
significant irritability or agitation as part of the symp-
tom picture. Lamotrigine may be useful due to its pref-
PRAGMATICS
erential effects on depressed mood.
It is particularly vital to make the trauma patient a Addition of a neuroleptic, either typical or atypical,
partner in psychopharmacological management. The usually in low dosages, may be helpful for intrusive
complex PTSD patient is informed that pharmacolog- symptoms, posttraumatic panic, loss of reality orien-
tation, thought disorganization due to PTSD and re- Groups provide an opportunity for patients to as-
peated dissociation, and sleep. Neuroleptics may also sist each other in work on common issues and prob-
be given on an as-needed basis, although some, like lems. In addition, therapeutic groups represent a po-
risperidone, have a relatively slow onset of action that tential laboratory for interpersonal skills for trauma
may limit use as an as-needed medication. patients. Patients often have difficulty with self-asser-
Pharmacological interventions for sleep may involve tion, confusing this with aggression and avoiding it at
any of a number of medications, including trazodone, all costs. This can be helpfully addressed in vivo in
mirtazapine, benzodiazepines, and related sedative hyp- group settings where patients can see that the feared
notics such as zolpidem, sedating antihistamines, low- consequences of assertiveness do not occur. Addition-
dose TCAs, prazosin (for nightmares), and low-dose ally, patients who are repeatedly harming themselves
neuroleptics (Loewenstein 2005). may more readily hear about the impact of these be-
haviors when challenged by their fellow patients
Group Therapy rather than staff.
TDU patients attend a large number of groups on a Not all patients can tolerate groups equally. Very
daily basis. Groups are led by nursing staff, physicians, disorganized, overwhelmed patients or cognitively
psychology postdoctoral fellows, social work staff, re- limited patients may find process groups destabilizing.
habilitation therapists, and the consulting pharmacol- These patients can be frustrating to the patients who
ogist. Groups include those with a more didactic focus: are more insight oriented, and it may be necessary to
Containment I (a group that educates patients about remove the former from process groups until they are
PTSD, dissociation, and symptom management strat- more stable and can participate in these groups more
egies), Medication Education, DBT Skills, Cognitive effectively. Nonverbal groups such as art therapy or oc-
Therapy, Health and Stress Management, and Ask cupational therapy may be particularly helpful for
Anything (a group led by the service chief in which the these patients.
patients can ask anything), among others. Process
groups that have a more psychodynamic structure in-
Family Therapy/Psychoeducation
clude Family Issues, Transitions (related to a variety of Family interventions are discussed in treatment team
life transitions but especially to discharge issues), and meetings and are organized around what will benefit
Containment II (a group focused on patients process- the patient. The goal is to help the patient move to-
ing thoughts and feelings related to issues that brought ward stabilized symptoms and improved ability to use
them into the hospital, problems with symptom man- outpatient therapy. Interventions that seem unlikely
agement strategies, and so on). to result in these outcomes are deferred, with recom-
Patients also attend a daily Goals Group in the mendations as to when they might be revisited (in-
morning to establish goals for themselves for the day cluding never, with an appropriate explanation of
and to discuss living together on the unit. Patients may the rationale for this recommendation).
process safety problems that have affected the whole We eschew confrontation by patients in our pro-
hospital community as well. Evening groups include a gram with reported intrafamilial perpetrators of abuse.
Community Meeting and a smaller group for each team In general, these are disastrous for patient and family
(half of the patients), primarily directed to identifying members alike, no matter in what stage of therapy they
containment skills and safety strategies for evening and occur. In particular, patients who are so unsafe and
nighttime, usually times of day that childhood trauma symptomatic as to require inpatient TDU treatment for
survivors have heightened PTSD reactivity. stabilization are not in clinical circumstances to work
Certain groups require a referral by the treatment through the complex psychodynamics that usually un-
team; these include Tension Reduction, an occupa- derlie a wish to confront reported perpetrators. In gen-
tional therapy group involving leather work; Journal eral, the patient harbors a fantasy that the reported per-
Making; Family Issues; and Applied Containment. petrator will apologize or acknowledge wrongdoing
The latter is a group in which patients developing when confronted, an event that rarely occurs and that,
skills using symptom containment strategies discuss even if it does, almost never leads to the immediate pos-
the application of those skills to specific problem areas itive resolution imagined by the trauma patient. Typi-
in life. In order to be referred to these groups, patients cally, when the desire to confront arises, we attempt to
must demonstrate the ability to manage their safety educate the patient about the complexity of this issue,
and to use containment skills to tolerate discussions the risks of engaging in a confrontation, and the need to
of potentially triggering topics. focus on the goals of stabilization in the hospital while
postponing the question of confrontation until fully to develop specific symptom management and past/
worked through in long-term treatment. present separation strategies to allow better hygiene
Increasing effective family communication is an- with decreased posttraumatic reactivity. Usually this is
other important goal of the family meeting. Openness, accompanied as well by relief of deep shame, not only
clarity, honesty, and directness are the ideals. The so- about experiencing the traumas but also about having
cial worker gives feedback about communication styles had such difficulty with routine personal hygiene.
and helps family members to explore what seems to
work and what does not. Family members are encour- Journaling
aged to find their own sources of support for the feel- Pennybaker (1993) and others have studied rigorously
ings evoked by the patients illness rather than making the clinical utility of therapeutic journaling for the im-
the patient responsible. provement of symptoms in a variety of disorders. Sig-
Boundaries are often problematic for the patients nificant benefit in psychological well-being and im-
and their support systems, particularly with respect to provement in stress management, medical symptoms,
the disclosure of details of traumatic experiences. It is and even immune function have been shown to occur
hard for patients and families to believe that therapy is by using this intervention (Spiegel 1999). Accordingly,
the only place these details should be discussed, and journaling tasks may be very helpful in the treatment
then only when significant stability has been achieved. of complex PTSD/dissociative disorder patients. Bene-
Setting limits on these discussions is an important fits can include access to dissociated thoughts and feel-
way of making a patients support system more sup- ings, more coherence of experience, ability to track the
portive. It is important to clarify that the patient is re- relationship between behaviors and consequences, ex-
sponsible for managing his or her own safety issues, pression of negative affects, and better concentration.
with the help of the therapist, and that this mostly is In DID, journaling can assist in identification of, and
not a responsibility to be shared with the family. communication and coordination among, self states.
Expressive and Rehabilitative
Therapies Milieu Management
Expressive and rehabilitation therapies may be partic-
ularly helpful for complex PTSD/DID patients be- Management of the therapeutic milieu is critical for
cause these patients often have particular difficulties functioning of the TDU. As in every true therapeutic
putting their experiences into words. Observing the milieu, all members of the milieu, staff and patients
patients creations can provide understanding of trau- alike, must participate in ensuring a safe and thera-
matic experiences, coping strategies, safety issues, and peutic environment.
specific posttraumatic reminders, among others. Art
therapy has developed a rigorous system of diagnostic
Staff Management Issues
indicators, including an assessment for DID (Cohen It is important that the TDU staff be a functional
et al. 1994). Accordingly, art therapy may be particu- team with mutual respect between individual mem-
larly helpful in differential diagnosis of dissociative bers and between disciplines. The staff team must be
disorders. able to model interactions that are different from
In the TDU, the occupational therapy assessment those experienced by TDU patients in their traumatic
provides crucial information about the adverse effects relationshipsfor example, there should be clarity of
of trauma disorders and symptoms on personal hy- roles and boundaries between staff members. Staff
giene, meal preparation, money management, work, education is crucial, and we work on it continually. In
school, leisure, and unstructured time as well as the addition to teaching opportunities in regular team
patients social life or lack thereof. This may bring vital meetings to discuss patient management, we hold
information into therapy that the patient finds too weekly hourlong educational meetings for nursing
shameful to discuss and that may contrast with the pa- staff, either with the nurse manager or with the at-
tients outward presentation of apparent competence tending staff. In addition, more experienced staff
in everyday activities. It can help the patient begin to members mentor newer staff to help them develop fa-
develop specific strategies to alleviate critical hidden cility at working with symptom management and cope
difficulties. For example, a patient who avoids bathing with the stress of the milieu. A weekly hourlong Ser-
may be reacting to intrusive memories of sexual as- vice Conference is designed to foster discussion of
saults in the family bathroom. He or she can be helped milieu issues, management problems regarding spe-
cific patients, and staff discussion of their coping with no one can hear him or her and that decent medical
the milieu. At times, a specific weekly meeting has care will be provided routinely in the TDU.
been held, either with one of the TDU psychothera-
pists or with an outside counselor, to assist staff with Patient Management Issues
discussing group process issues that they might be re- A functional TDU milieu provides a significant heal-
luctant to discuss with program leadership. ing component to treatment of trauma patients. Is-
In addition, we have periodic half-day retreats to sues that have been enumerated previously in the sec-
work on program development, team building, and tions on psychotherapy are applicable to milieu
problem solving. We also have sponsored daylong di- management of trauma patients. The milieu program
dactic training programs with lectures and other learn- is focused on making the unit as safe a place as possi-
ing activities for all program staff. This has been espe- ble for all members to do the serious work of recovery,
cially important when there has been a critical level of but this is always a work in progress. The TDU is an
new staff members who need basic overall education. open system, with stabilized patients being discharged
Many new staff members have limited knowledge and new unstable patients being admitted, concerned
and understanding of basic psychological concepts others visiting and coming for family meetings, fire
such as transference, countertransference, and de- alarms going off, and so on. A focus on safety includes
fense mechanisms. Staff members working with developing honesty about the state of ones safety, rec-
trauma populations are continuously exposed to trau- ognizing the impact of ones unsafe behavior on the
matic material. Patients often go into flashbacks, lose others in the community, and learning to take real re-
reality orientation, harm themselves, and describe or sponsibility for ones behavior in the interest of genu-
reenact horrific trauma scenes. Staff may be pulled be- ine change.
tween patients negative transference responses to In addition, traumatic transference themes are
staff and their direct or indirect entreaties to staff for continuously made explicit in the milieu, with pa-
rescue. New staff members often have difficulty set- tients helping one another recognize out-of-place and
ting limits with patients, at some level believing that posttraumatic reactions to current situations. Patients
the patients are fragile and will be harmed by firm are encouraged to follow the golden rule: to behave
limit setting. In addition, staff members may be fear- toward others as one wishes they would behave toward
ful of provoking patients anger or of precipitating a oneself. Patients can help challenge one another s cog-
more extreme crisis. It is important to allow staff to nitive distortions, including cognitive distortions re-
talk about their reactions to patients self-harm and garding safety, such as If I hurt or kill myself, its not
suicidal behaviors and to help staff achieve therapeutic hurting anyone else; it doesnt involve anyone else.
distance from, and insight into, the posttraumatic ori- Community members may play out many core
gins of patients frequent negative transference reac- traumatic transference themes. For example, TDU
tions to helpers. Staff need help understanding that, patients, like other survivors of childhood violence,
fundamentally, limits and boundaries provide safety may enact interpersonal themes of victim-perpetra-
and protection. tor-rescuer (Davies and Frawley 1994) and of victim
In terms of helping staff work most effectively with and uninvolved, uncaring co-abuser (Loewenstein
patients, use of the trauma frame of reference can be of 1993). All these attributions may shift between indi-
great assistance. This model tends to help make expli- vidual patients, patient subgroups, individual staff
cable behavior that otherwise seems incomprehensi- members, and the staff group as a whole. Frequent
ble, alienating, and exasperating. For example, pa- group interpretations and confrontations in Goals
tients overreactions to minor medical issues may be Group, Community Meeting, and process groups,
enervating for staff. However, the understanding that among others, may be needed to move the community
many TDU patients suffered some form of medical toward a functional milieu.
neglect may be helpful in reframing the behavior. In Behavior that undermines others treatment must
the overreacting patients history, he or she may report be vigorously challenged and confronted directly as
not getting medical attention unless it was a life-or- such by staff. This is true of repeated self-harm as well
death matter. Accordingly, the patient, fearing neglect, as aggression toward others. For example, staff bash-
adopts the strategy of complaining as loudly as possi- ing is confronted as verbal aggression toward other
ble for any problem, no matter how small. In addition patients who may be inhibited by this peer pressure
to feeling less blaming, staff members can also let the from working with staff for their own recovery. The
patient know that he or she is shouting so loudly that patient community is invited to look at the possibility
that they are re-creating the dynamics of a violent many of our patients hunger for touch and feel un-
family: the aggressive or self-harming patient may be touchable, they also may react with anxiety, panic,
unconsciously replaying the idea that no one can, or and even physical discomfort when touched. In DID,
will, take a stand to stop violence that family members some self states may seek repeated hugs or touch, but
perpetrate on one another. Here, as in individual ther- others are phobic of touch, recalling that, in the past,
apy, we emphasize the tasks of separating past from nice touches may have progressed to inappropriate
present and discovering safe, non-trauma-based alter- touch. Some patients take issue with this rule; they
natives to problem solving. may accuse staff of being mean and thwarting what
When there has been a prolonged or repeated fail- they know will help them heal. Discussion in indi-
ure of patients to use their ability to control their be- vidual and group therapy can help educate the patients
havior and a failure to respond to other group and in- about the complex issue of touch in the complex
dividual interventions, we may shut down the PTSD population. Other patients may be particularly
community, an intervention that has been used fewer articulate about the complexity of the problem for
than 10 times in 15 years. It is important that the them and may help their peers understand that if the
TDU leadership not overuse this type of intervention TDU staff really thought this was a helpful interven-
and reserve it for only the most serious, prolonged tion, we would encourage it, not eschew it.
community breakdown. In general, this is a highly
successful intervention to restore safety and a renewed TRIGGERS
focus on treatment goals.
Patients are enjoined from a variety of topics that may
This intervention involves an extended commu-
engender significant PTSD reactivity in their peers, in
nity meeting with all patients required to attend and
part due to the nature of the topics and in part due to
all available staff, including individual therapists, join-
the natural high hypnotizability and consequent lia-
ing the meeting. All other groups and individual ther-
bility to experiencing vivid visualization in the TDU
apy sessions are cancelled. Each patient is required to
population. Discussing details of ones traumatic ex-
speak. Here, the task is not to rehash old difficulties
periences is considered potentially damaging to others
or engage in mutual recriminations. Each patient is
and, if persistent, is viewed as a form of verbal aggres-
asked to identify problems that are contributing to the
sion in the milieu. In TDU patients, increased PTSD
current situation in the community, including how he
intrusive symptoms, dissociative episodes, and/or de-
or she is contributing to the difficulties, and to de-
terioration in safety are virtually an inevitable out-
scribe practical steps that he or she can take to work
come of detailed descriptions of trauma experiences by
toward meaningful change. During this meeting, the
peers.
leadership maintains a tight focus for the group. This
In general, TDU patients are asked to be sensitive
may involve vigorously confronting patients who have
to each other s idiosyncratic PTSD reminders or trig-
been undermining the communitys function and re-
gers. Many everyday, apparently neutral topics may
directing patients who are having difficulty following
be upsetting to individual milieu members due to in-
the group task. The group only ends after all members
creased PTSD reactivity. On the other hand, patients
of the community have spoken. After the group, com-
are asked to work on developing resilience in coping
munity members focus on making changes based on
with all manner of triggers because attempts at re-
goals generated in the meeting.
stricting life to avoid PTSD triggers usually result in
the patient being deeply inhibited from engaging in
Management of Patient Boundaries many quotidian activities. Managing the dialectical
in the Milieu tensions involving the problem of graphic language
is an ongoing task for patients and staff. There is no
Boundaries between TDU patients are a continual
clear line that shows where graphic discussions or trig-
challenge. This has led to a series of unit rules for be-
gers begin and end. Patients and staff must struggle
havior between patients and specific rules for DID pa-
with the gray areas that inevitably arise in attempts
tients. Some examples are given in the following sec-
to work with these issues. These patients commonly
tions.
struggle with polarized, all or nothing, black and
white thinking (Armstrong 1995). Accordingly, as in
TOUCH other aspects of trauma treatment, it is usually a pro-
Sustained touch such as hugging, hand holding, and ductive endeavor to work on the gray areas and the
so on is forbidden between TDU patients. Although dialectical tension inherent in the recovery.
ADDITIONAL MILIEU RULES FOR PATIENTS WITH quickly. Often, a period of sleep induced by medica-
tions allows the patient to become less overwhelmed
DISSOCIATIVE IDENTITY DISORDER
and/or permits a more grounded and safe alter self
Management of DID patients in an inpatient TDU state to come forward.
milieu requires additional guidelines and rules. Pa-
tients are required to use one name consistently in the Intensive Observation Levels
milieu, no matter which self state is out. Also, the
Overall, TDU patients are managed at the least re-
patient must be responsive to his or her legal name
strictive observation level possible. Despite the sever-
when this is required for administrative purposes,
ity and chronicity of some TDU patients self-destruc-
even if that is not the preferred name for regular usage.
tive behavior, we attempt to avoid interventions such
The various names of self states may be used in indi-
as constant observation and intensive suicide observa-
vidual interaction with treatment team members, in-
tion, although we do place acutely, intractably suicidal
cluding nursing staff, but not in the milieu.
or severely, acutely, or violently self-injurious patients
on these levels. In our experience, the chronicity of
Management of Acute Behavioral many patients dangerousness to self and many pa-
tients tendency to externalize and look for outside
Dyscontrol solutions for safety may make it difficult to find an
endpoint for these intensive observation levels. Also,
TDU staff manage acute episodes of impending or ac- other patients may see these patients as receiving
tual dyscontrol and/or dangerousness to self or others more staff time and may attempt to find ways to get
with a hierarchy of interventions. First, they attempt staff to observe them more closely as well. Accord-
psychotherapeutic interventions to discuss precipi- ingly, we almost never place patients on these levels
tants of problems (upsetting phone call, being trig- for parasuicidal behaviors, preferring to move them, as
gered by something in the milieu) and to talk through well as less acutely suicidal patients, to areas where
the problem to find alternatives to help settle down. staff can observe them more or less continuously but
Other interventions may include using symptom not necessarily on a one-to-one basis. The overarching
management techniques such as relaxation, deep safety focus on the unit means that staff are skilled in
breathing, and imagery. Patients may be asked to jour- anticipating, evaluating, detecting, managing, and de-
nal or to use the quiet room to reduce stimulation. veloping longer-term treatment strategies for danger-
Staff may work with DID patients to encourage a safe ousness to self or others, often obviating the need for
self state to come forward and a dyscontrolled self intensive one-on-one observation.
state to step back within the mind.
Staff may then offer as-needed medication such as
oral benzodiazepines or neuroleptics. If the patient al-
Discharge Planning
ready has lost control of his or her behavior, or acutely
appears to be doing so, staff may administer parenteral Basic discharge planning is the same for the TDU as
medication to reduce anxiety, agitation, and dyscon- for other inpatient units, with a few salient differ-
trol. Commonly used medications for acute dyscon- ences. Many of our patients come from outside the lo-
trol are listed in Table 71. cal region or state. Therefore, the logistics of discharge
If the patient cannot stabilize acute serious danger planning with family and the referring providers may
to self or others with psychotherapeutic or pharmaco- be more complex than for local patients. Family in-
logical methods, or is so acutely agitated and unsafe volvement may have been done mostly by phone, and
that he or she refuses or cannot use these interven- discharge may allow the first face-to-face family psy-
tions, staff is urged to quickly move to physical meth- choeducation meeting.
ods to control the patient to provide optimal safety for Patients, especially those who have had a longer-
all. In most cases, going hands on, and giving med- term hospitalization, may need careful preparation to
ication, with the patient secluded in the quiet room reenter the everyday world. Due to managed care stan-
with an open door, is sufficient to change the patients dards for inpatient care, in most cases therapeutic
state to a safer and more grounded one. However, in passes are no longer a possibility to help prepare the
some cases, physical restraint may be needed. In many patient for the impact of stepdown. TDU patients
cases, TDU patients rapidly de-escalate and can be should be carefully counseled that stimuli will in-
safely moved out of the quiet room or restraints crease and that the speed of life outside the hospital
resolve issues seemingly blocking discharge. However,

TABLE 71. Commonly used medications for
transfer is very difficult to accomplish in the current
acute dyscontrol in patients with psychiatric care environment. We discuss directly with
complex PTSD or dissociative patients their inhibitions and fears of discharge and
identity disorder gently confront their anxiety over returning to prob-
lematic outpatient situations. More direct confronta-
Benzodiazepines
tion may be needed to focus patients about failure to
Lorazepam 0.52 mg po or im every 24 hours
use skills or failure to be honest about their core safety.
Clonazepam 0.52 mg po every 24 hours Patients may need to be restricted from TDU readmis-
Diazepam 510 mg po every 6 hours sion, and told so, if they do not make good-faith efforts
Neuroleptics to work the program and move toward discharge
Haloperidol 25 mg po or im every 4 hours when this is a reasonable expectation. Discussion of
Fluphenazine 25 mg po or im every 4 hours future restrictions from readmission may help galva-
nize some of these patients toward discharge.
Chlorpromazine 25100 mg po or im every 4 hours
Olanzapine 25 mg po, im, or sl every 4 hours
Ziprasidone 5 mg po or im every 4 hours* Conclusion
Droperidol 5 mg every 14 hours (can only be given
with electrocardiographic monitoring) PTSD and dissociative disorders are common in the
Other general population (Kessler 2000; Loewenstein and
Hydroxyzine 2550 mg po or im every 46 hours Putnam 2004). In addition, history of childhood
Diphenhydramine 2550 mg po or im every 46 trauma is common in general inpatient psychiatric pa-
hours tients (Carlson et al. 1998). Despite the difficulties
Note. im = intramuscular; po = by mouth; sl = sublin- presented by these patients, there are inpatient and
gual; PTSD = posttraumatic stress disorder. partial hospital treatment models, as well as outpa-
*Requires electrocardiogram to assess QT interval for tient treatment models, that can help them sustain
safety from arrhythmias. substantial recovery. Hopefully, knowledge from the
TDU can be made more generally available, so that
may seem disconcerting. Patients are encouraged to these patients receive more appropriate and helpful
practice their symptom management skills sets. treatment in all inpatient and day hospital settings.
The most common cause that patients cite for relapse
and rehospitalization is I stopped using my skills. I
stopped communicating with my parts (in DID pa-
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CHAPTER 8
THE PSYCHOTIC DISORDERS UNIT

Psychosis is a ubiquitous phenomenon in general ization. This historic change was fueled by advances
psychiatry. No inpatient setting can avoid treating in treatment, especially the promulgation of antipsy-
psychotic patients. Why then should we consider a chotic medication; by social concerns about the rights
specialty program targeting this all-too-common syn- of patients to live unsegregated in society in the least
drome? The mission of a specialized psychotic disor- restrictive manner; by documented abuses of patients
ders unit is to serve the needs of patients with severe within the confines of total institutions; and by pow-
and persistent mental illness whose psychosis is likely erful economic pressures to reduce the cost of care.
to be chronic and whose resulting disability is both Deinstitutionalization coalesced with managed care
widespread and profound. in recent decades, yet the challenge of how to best pro-
The history of American inpatient psychiatry is vide services for the chronically psychotic patient at all
very much bound up in the story of caring for these pa- levels of care has not been resolved. Many, if not most,
tients. Ever since the Pennsylvania Hospital volun- such patients receive so-called crisis stabilization for
teered to care for the sick-poor and the insane who their acute psychotic relapses on general inpatient
were wandering the streets of Philadelphia in 1751 units within local community hospitals. The restric-
(University of Pennsylvania Health System 2007), tions on length of stay placed by commercial managed
there has been a recognition in American society that care organizations, using severely curtailed and often
there is a population of severely disturbed people arbitrary criteria for hospital care, can result in pa-
whose illness is both chronic and refractory to treat- tients being discharged prematurely, with consequent
ment. The asylum movement was begun in the nine- readmissions and the evolution of the all-too-familiar
teenth century to provide humane care, if not cure, for revolving door scenario. In addition, the mixing of
these unfortunate people. By the end of the twentieth severely psychotic chronic patients with younger,
century, this national enterprise, implemented on a higher-functioning patients and/or with older, more
state-by-state basis as the state hospital system, was fragile geriatric patients leads to a predictable addi-
largely dismantled under the rubric of deinstitutional- tional pressure within the milieu to extrude patients
119
with illnesses characterized by disruptive behavior by Functionally, diagnosis notwithstanding, the hall-
discharging them early. mark of a patient treated in an inpatient psychosis pro-
The mission, then, of a specialized psychotic dis- gram is the patients cognitive dysfunction, including
orders inpatient unit is to implement state-of-the-art other negative symptoms, and its attendant disability.
diagnostic and therapeutic techniques, coupled with a Nursing staff view such patients as requiring hands on
sophisticated appreciation of the patients illness in its nursing, compared with higher-functioning patients on
community context, for the treatment of some of the general units where verbal interaction is a much more
most ill patients with the most treatment-resistant important medium of therapeutics. By hands-on, we
disorders. That community context includes social mean the need to guide such patients through many, if
(family, friends, care providers, and all manner of out- not all, of their activities of daily living; prompt them
patient treatment team members), historical (onset of continuously to attend to the milieu schedule; set limits
illness, precipitators of relapse or noncompliance, mo- (often physically) around boundaries and socially inap-
tivators of positive change, response to past treat- propriate behavior; and restore order and good hygiene
ments), economic (available therapeutics of all sorts, on the unit if there is destruction of property or soiling of
from medications to assertive community treatment linen, clothing, or the unit environment.
teams and cognitive-behavioral therapycompetent Patients with schizophreniform disorders present a
therapists), and even legal (restraining orders, crimi- special challenge. Ideally, this population would be
nal charges, mandated treatment orders) consider- best served with its own specialized program. How-
ations. The vision of such a unit is to accurately diag- ever, the point prevalence of these cases, even in a met-
nose the acutely ill or relapsed patient in the broadest ropolitan region as large as the Baltimore Metropolitan
DSM-IV-TR (American Psychiatric Association 2000) Statistical Area (2.6 million), is too low to support
multiaxial biopsychosocial framework (Engel 1977), such a unit, at least within the current commercial
implement the optimal therapeutics that can be real- managed care health insurance paradigm. Moreover,
istically expected to be followed up within the pa- the diagnostic stability of schizophreniform disorder is
tients community setting, control inpatient behav- notoriously low (Addington et al. 2006), and although
ioral problems with the greatest efficiency for the it is likely that true schizophreniform patients will go
patient and the least adverse impact on other patient on to develop unambiguous schizophrenia within 5
groups, and coordinate the handoff of treatment to the years, there are certainly some patients in the schizo-
next level on the continuum of care with minimal dis- phreniform mix who will ultimately turn out to have
ruption to the flow of treatment. bipolar disorder or a substance-induced psychosis.
There is legitimate concern that these latter patients
may not be well served by programming that empha-
Admission Criteria sizes the rehabilitation needs of the chronically ill at
the expense of more appropriately focused therapeutics
The admission criteria for such a program can be for- aimed at their affective and/or chemical dependency
mulated both diagnostically and functionally. Diag- illnesses. In addition, even the truly schizophreniform
nostically, the core target population would include patient (and the patients family) may be frightened by
patients with schizophrenia, including schizoaffective a milieu composed of older, more persistently ill and
disorder and psychotic disorder not otherwise speci- often dilapidated peers. In our experience, the decision
fied; bipolar disorder, when the course of the illness of where to admit young first-episode patients is often
resembles persistent schizophrenia and enduring psy- made on an initial best approximation, based on prog-
chotic features remain a central treatment focus; de- nostic features and level of functioning. It is not un-
velopmental disorders, including mental retardation common for the young first-episode person to start off
and pervasive developmental disorders in which there on a general short-term unit, only to be transferred to
is a significant psychotic component; neuropsychiatric the psychosis program because of failure to improve
disorders with psychotic features, including psychoses within the short-term milieu.
due to epilepsy, head injury, or Wilsons disease; and
personality change due to these kinds of medical etiol-
Special Populations
ogies, especially paranoid, aggressive, and disinhibited One specific population that bears mentioning is the
types. Some geriatric patients with dementia and be- mentally retarded. The management of psychotic dis-
havioral dyscontrol may at times be more successfully orders in the context of mental retardation can often be
treated in a psychotic disorders milieu as well. considerably problematic. Mentally retarded patients
The Psychotic Disorders Unit 121
may have an organic personality (a term used in the (necessarily) a forensic unit. Unless there are addi-
International Classification of Diseases, Ninth Revi- tional specialized resources available for the safe man-
sion [ICD-9; World Health Organization 1977]), re- agement of potentially violent forensic patients, it is
ferred to in DSM-IV-TR as personality change due to a necessary to screen out such patients at the point of
general medical condition. The general medical disor- admission. Screening criteria that we have found use-
der in this case is characterized by mental retardation, ful include determination of the most serious violence
or what more recently is termed intellectual disability. up to that point; whether there is a criminal history;
They may also have personality disorders, like anyone whether a weapon was used; whether the violence was
else. The impact on treatment, and on the rest of the self-limited or sustained; whether it was in the context
milieu, of an organic personality can be huge, depend- of a clear and avoidable precipitant, such as substance
ing on the subtype (DSM-IV-TR specifies labile, dis- intoxication or the presence of specific conflict with
inhibited, aggressive, apathetic, paranoid, combined, another person; whether the referral is coming from
other, and unspecified). Such a patient not only may an unreliable source; what the patients behavior in
present with hallucinations, delusions, a formal the emergency department was subsequently; and so
thought disorder, negative symptoms, and a mood syn- on. Even with such screening, both internally and ex-
drome but also may be impulsive, perseverative, atten- ternally, it is unfortunately to be expected that a psy-
tion seeking, histrionic, childish, and grossly primi- chosis unit will experience a significant amount of vi-
tive, superimposed on the cognitive limitations, which olence, and management of this violence is discussed
makes communication, learning, and participation in later in the chapter.
higher-functioning groups difficult. Add to that the
not-uncommon associated physical disabilities, rang- Dual Diagnosis
ing from frequent expressive language and speech dis- The patient with co-occurring substance abuse pre-
orders to more disabling problems such as ataxia or sents a clinical challenge. Although comprehensive
spasticity, and the need to assist the patient with most programming for chemical dependency may exist on
activities of daily living, from toileting to feeding, and other specialty units, the psychotic patient may not be
one begins to appreciate why this population is often able to take advantage of it, at least during the first
shunned at the time of admission. Such patients often part of the hospitalization. There is also a concern that
are unable to take advantage of the programming de- such patients may be victimized by the more socio-
signed for the rest of the psychotically ill peers in the pathic patients who are sometimes present in the
milieu; the services of a behavioral psychologist are of- chemical dependency unit. Even when they are stabi-
ten very helpful, but they are rarely available. Access to lized, there is well-documented evidence that patients
the outpatient behavioral treatment plan, often forgot- with co-occurring severe and persistent mental illness
ten by psychiatrists unfamiliar with this population, and substance use disorders can have trouble access-
can be enlightening, especially in framing the patients ing traditional therapeutics for chemical dependency
baseline behaviors before the psychotic disorder epi- because of such obstacles as residual paranoia and
sode developed, but it can be practically very difficult to thought disorder, which make participation in verbal
implement such a plan in an inpatient milieu, where 12-Step groups highly problematic (Green et al. 2007).
the staffing and training simply are incongruent with As with the first-episode psychotic patient, the deci-
the context of the outpatient behavioral plan. sion of where to admit the dually diagnosed psychotic
Aggressive patients constitute another challenging patient is often a difficult one, and the flexibility to
population. Although aggression is common in the transfer the patient (in either direction) should be an-
untreated psychotic population (Krakowski et al. ticipated after determining how the patient does in
1999; Steinert et al. 1999), the psychosis program one or the other setting for a few days.
must not allow itself to become the de facto intensive
care unit for the whole hospital, where every violent Dissociative Identity Disorder and
adolescent patient or sociopathic patient is sent to
keep the other units safe. There tends to be a dynamic
Posttraumatic Stress Disorder
of the state hospital ward even within a single hos- The psychotic patient with dissociative symptoms
pital. It is important that clinical staff throughout the and a history of physical abuse is another unique chal-
hospital have the skills to successfully manage non- lenge. There are both differential diagnostic aspects (Is
psychotic aggressive patients without triaging them to the patient truly dissociative? Is what appears to be
a psychosis program. Similarly, a psychosis unit is not posttraumatic stress disorder essentially a complicat-
ing factor in an otherwise clear-cut case of schizophre- ticularly when considering all the rare but possible
nia?) as well as practical considerations (If the patient neuropsychiatric manifestations of a host of medical
has dissociative identity disorder, is the thought disor- and neurological disorders. However, as a practical
der so severe that the patient would not be appropriate matter in the contemporary American urban health
on a trauma disorder specialty unit, because he or she care system, a great deal of screening is done prior to
would not be able to make use of the higher-order cog- the referral of a patient to a psychotic disorders unit.
nitive/behavioral therapies employed on such a unit?). One cannot stress enough the importance and value of
The triaging of such patients is further complicated by the two most basic evaluation tools: a good history
the common occurrence that the dissociative or psy- and a neurological examination. These alone, when
chotic elements are only uncovered subsequent to the combined with basic laboratory tests (comprehensive
admission, so a certain amount of collegial reassess- metabolic profile, complete blood count, urinalysis,
ment and cross-consultation between programs is re- toxicology screen, and syphilis serology), will identify
quired. the vast majority of organic psychoses that warrant
medical-surgical, rather than psychiatric, triage. The
Other Considerations addition of computed tomography scanning or mag-
Finally, certain nonmedical considerations such as in- netic resonance imaging, often now routinely done in
surance and placement resources cannot be dismissed urban em ergen cy room s f or any m en tal s tatus
from a complete understanding of why some patients changes, further improves such screening, although
are not admitted. A specialty psychosis unit has a very these tests can sometimes be ordered by the busy
specific set of skills and objectives to bring to the care emergency physician in lieu of a good history and neu-
of patients with some of the most disabling illnesses in rological examination. A lumbar puncture is war-
psychiatry. Depending on the setting, it may have an ranted for the catatonic or deliriously psychotic pa-
intermediate or long-term average length of stay. State tient, again usually done in the emergency department
hospitals, Department of Veterans Affairs hospitals, prior to admission. The only other routine test not
and forensic settings may all have programs explicitly usually available in the emergency setting is the elec-
designed for a length of stay measured in months. Our troencephalogram, and here history is usually able to
program, located in the context of a private freestand- at least identify epilepsy as a diagnosis needing further
ing psychiatric hospital, has an average length of stay assessment. In addition, electroencephalograms are
of 23 weeks and a range of 3 days to 6 months. Our usually readily available on the psychiatric inpatient
entire program is designed around what can typically service. Copper and other heavy metal assays, urine
be accomplished in a month, and this directly affects porphobilinogens, chromosome testing for Hunting-
admission criteria. For example, if a patient has only tons disease or specific mental retardation diagnoses,
5 days left of insurance, has no insurance coupled antinuclear antibody, and other more obscure testing
with a state mandate to admit regardless, or has a can be obtained on the inpatient psychiatric unit as
managed care company that is unlikely to authorize a needed, once the clinical presentation and history are
hospital length of stay to carry out comprehensive pa- clarified after admission. Brain metabolic studies such
tient care, it is probably better to triage the patient to a as positron emission tomography, single photon emis-
conventional short-term crisis unit where the entire sion computed tomography, and functional magnetic
program is focused on finding an immediate disposi- resonance imaging, as well as brain electrical activity
tion and where crisis psychopharmacology is the order mapping, remain primarily research investigations.
of the day. Likewise, specialty units will understand- Psychological testing is a much neglected evalua-
ably at times receive referrals of the most ill patients in tion tool, possibly related to the influence of managed
the state, if not the country, and yet the patients will care in recent decades. Psychological testing, when
not have the portfolio of resources needed to support done properly by skilled doctoral-level psychologists in
any kind of adequate treatment planning. Such are the sufficient depth (unhampered by clinically arbitrary
fiscal realities of psychiatry today. managed limits on units of testing), can shed impor-
tant light on matters of diagnosis, prognosis, and re-
habilitation. Projective testing can document the se-
Diagnostic Workup verity of otherwise sealed over paranoia, the extent
of formal thought disorder and its impact on function-
The differential diagnostic evaluation of the psychotic ing, and the otherwise hidden delusional themes that
patient can be extensive (Sheitman et al. 1997), par- motivate the patient. The Continuous Performance
Test (Beck et al. 1956) and the Wisconsin Card Sorting are all predicated on knowledge of historical facts
Test (Berg 1948) can document the degree of atten- regarding prior response to treatment, and the lack of
tional and frontal deficit in the medicated patient as a such knowledge severely constricts the likely accuracy
guide to appropriate discharge and rehabilitation plan- of any cross-sectional treatment decisions. Patients
ning. IQ testing and even simple proxies for IQ, such being transferred to a specialty unit from another in-
as the Wide Range Achievement TestReading subtest patient setting should always have their medication
(Jastak et al. 1993), give a snapshot of both overall cog- record sent along. One can immediately understand
nitive functioning and the degree to which that func- what exactly was being tried, and what exactly the
tioning has declined over the course of the illness. patient actually received, without having to wait for a
More specific neuropsychological testing, such as tests discharge summary to be dictated. The central pre-
of memory and praxis, can further clarify the specific mise here is that the inpatient hospitalization is not a
domains of cognitive deficit, which in turn have im- self-contained island but rather a point along a tem-
mediate bearing on disposition planning and rehabili- poral continuum of care for a chronic condition. It
tation. must address itself to what happened before, and what
As in the emergency department, taking a good will happen after, the hospitalization, if it is to be suc-
history is important on the inpatient unit. The focus cessful.
here is not to rule out the occasional outlier with a The genogram is another underutilized tool that is
neuropsychiatric illness but rather to deepen the un- useful for understanding the chronically mentally ill
derstanding of the course of illness, once confirmed as patient as well as most other psychiatric populations.
primarily psychiatric in nature. The timeline, first The genogram quickly enables the clinician to under-
championed by Kraepelin (Kraepelin and Quen 1990) stand the social reality of the patient in terms of family
and later expanded upon by Adolf Meyer (Meyer and and other intimate relationships as well as living ar-
Winters 1950), is a very helpful tool in this regard. rangements, which are often paramount in undertak-
One draws a line from birth to the present and identi- ing discharge planning and understanding relapses.
fies key historical dates, such as developmental mile- Knowing who the players are in the patients family
stones (e.g., preschool problems, school problems, nexus, including the sad possibility that there are
highest level of education, marriage/divorce/loss of a none, as well as what their attitudes toward the pa-
parent), as well as psychiatric history (first contact tient and treatment are, is an indispensable part of
with any mental health provider, first treatment with evaluating the patient in the broader psychosocial con-
medications, first hospitalization, any legal problems). text, and it is usually necessary in order to develop a
Below the line one documents treatments, including realistic aftercare plan.
names and dosages of medications as available, epi-
sodes of psychotherapy, residential placements, and so
on. Inspection of the timeline makes it clear what nec-
Therapies
essary data are still lacking (e.g., Why was the patient
at the state hospital for 5 years? What did the state Medication Treatments, Including
hospital do to be able to discharge the patient eventu-
ally?). It also reveals trends, such as the increase in
DrugDrug Interactions
treatment failures (six hospitalizations in the past A comprehensive discussion of antipsychotic thera-
8 months compared with two in the previous 5 years). peutics is well beyond the scope of this chapter, so let
The timeline also can reveal episodes of wellness, an us focus instead on certain core principles of treat-
especially important datum in the clinical history ment. The most important single point to make about
(e.g., Why was the patient stable between 1999 and psychopharmacology with this population is not about
2004? Was there a certain medication, or certain psy- the pharmacology itself. It is simply that no amount of
chosocial support, that enabled stability during that pharmacology will be helpful if the patient does not
time?). take the medication reliably. The problem of nonad-
The timeline usually results in the need to request herence is the single biggest obstacle to outpatient suc-
old records from previous treatments in order to an- cess in this population (Lacro et al. 2002). The chal-
swer some of these questions, because it is virtually lenge on the inpatient unit is to assess the reasons for
impossible to do so directly with this patient popula- nonadherence and develop a treatment plan that can
tion, owing to the fundamental brain deficits that af- optimally address them. Concerns about side effects
flict them in the first place. Our treatment algorithms certainly rise to the top of patients expressed reasons
for nonadherence and should be actively elicited and Some nonadherent patients will appear to take their
responded to by the inpatient psychiatrist. Complaints medications but will not, in fact, do so, which may re-
about weight gain, sedation, and extrapyramidal symp- quire administration of the medications in liquid form
toms can all be responded to in a rational way with al- for a period of time. Mouth checks may be needed for
ternative medications, although helping the patient some patients at the time of medication administra-
appreciate nuances may be difficult if paranoia causes tion, or patients may need to be kept in view of staff for
the patient to disparage all medications with a broad an hour or so. Administering the medication just once
brush. First and foremost, however, the psychiatrist a day may be helpful, as well as writing an order to re-
and medication nurse should present patients with the offer all refused doses of medications for the next three
clearest possible message that they can exercise choice medication times within the next 24-hour medication
over the medications and that their opinion about side cycle before documenting that day s medications as
effects is sincerely respected and responded to. Equally refused. This latter tactic has proved extremely helpful
difficult may be sorting out whether prior failures on over the years. Many acutely relapsed patients are so
certain medications were due to true medication fail- disorganized that medication refusal is not really a ra-
ures (as described as common in the Clinical Antipsy- tional decision. Offering the same medication that
chotic Trials in Intervention Effectiveness studies [Lie- was refused at 9 A.M. again at 1 P.M., at 6 P.M., and at
berman et al. 2005]) or to nonadherence. Successful bedtime often results in successful administration as
treatment with clozapine, for example, can be sus- the patients mood or suspiciousness fluctuates during
tained by discharging to a supervised residential setting the course of the day and with ongoing interaction
that ensures adherence, but it may be unnecessary if with the other therapeutic aspects of the milieu, in-
one knows for a fact that a previous clozapine trial was cluding one-to-one talks, peer conversations, illness
a failure. educational classes, and family visits.
Identification of nonadherence early in the admis- The second most important psychopharmacologi-
sion process should alert the psychiatrist to consider- cal principle is to find out what has or has not worked
ing depot neuroleptics as a pharmacological strategy. previously. Patients who are known to have done well
This technology, although more than 40 years old on a certain regimen and who are agreeable to continu-
(Kurland and Richardson 1966), is still much under- ing should not be subjected to trials of newer medica-
utilized in the United States compared with Western tions unless there is a persuasive (preferably evidence-
Europe (Glazer and Kane 1992). The inpatient setting based) rationale for making a change.
is often a good place to initiate such treatment. The Dosing is occasionally an issue with successful
hospitalization often brings with it a certain impetus antipsychotic treatment. There is good evidence that
for change from the patient, the family, or the outpa- first-episode patients may respond to lower-than-aver-
tient treatment team. The patients resistance to rec- age dosages of neuroleptics (Lieberman et al. 2003;
ommendations for depot treatment in a 15-minute McEvoy et al. 1991). However, a common problem in
clinic medication check visit may change over a pe- patients with persistent mental illness is that they re-
riod of several days, with daily psychoeducation from ceive dosages of medication that are too low and there-
doctor, nurses, and activity therapists with access to fore insufficiently effective. Tobacco dependence may
videos and pamphlets and with input from family and exacerbate this problem in some patients whose liver
outpatient treatment team members. (Bringing to bear enzymes are induced by the effects of tar in the smoke,
such a full-court press to motivate a recalcitrant pa- resulting in increased metabolism and clearance of
tient about an important treatment decision is an- neuroleptics. There is also a less well-documented but
other unique advantage of the specialized psychotic nevertheless strongly held clinical observation that
disorders unit.) If the patient does indeed cooperate many patients with persistent mental illness have de-
with initiating depot neuroleptics, careful consider- veloped a tolerance to neuroleptics, resulting in a re-
ation needs to be given to the details of treatment in markable persistence of symptoms and lack of side ef-
terms of initial dosing; choice of drug, including pay- fects in the face of objectively monitored robust
ment limitations; and the handoff to the next level of dosing. Why this should be so is a matter of some
care. Choosing a drug that cannot be delivered after speculation (Sramek et al. 1990). One strategy worth
discharge is a serious but avoidable error. considering with such a scenario is to obtain neurolep-
If depot neuroleptics are not indicated or agreed to, tic serum levels. Such levels are not routinely available
the inpatient team must still ensure that oral medica- for the atypical antipsychotics and many of the typical
tions are being swallowed during the hospitalization. agents, and even if available, they are not easily inter-
pretable unless the result is zero or very high, given the the host of medications available, there is a very real
lack of studies of clinical correlation. The one drug for danger of these patients winding up on all sorts of ir-
which levels are reliably interpretable is haloperidol, rational polypharmacy regimens prescribed by well-
which is fortunately a widely used product. Obtaining intentioned but time-stressed psychiatrists or other
a steady-state haloperidol level of 2 ng/mL in a patient physicians. It is quite common for patients to be ad-
on 40 mg/day of elixir in a well-supervised inpatient mitted to the psychosis unit while taking two neuro-
setting, for example, suggests that rapid metabolism leptics, and those taking three or even four can even be
may indeed play a role in nonresponse. Such a finding seen. Partly owing to the increased tolerability of the
might well lead to a decision to pursue an ultra-high- atypical antipsychotics, to the fact that antipsychotic
dosage strategy or switch to a product or a route (e.g., medications are still frequently carved out from other-
depot) that is more likely to achieve a therapeutic wise managed formularies, and also perhaps to the ag-
level. This problem can be further compounded by the gressive marketing of products, psychiatrists are often
artificially imposed vicissitudes of cigarette availabil- adding multiple neuroleptics for patients who con-
ity. In the contemporary environment, cigarette smok- tinue to display refractory symptoms. It has been our
ing is being eliminated altogether from many hospital experience that regimens of three and four neurolep-
campuses. The lack of access to cigarettes, coupled tics are almost never necessary and that even combi-
with the relatively longer length of stay with this popu- nations of typical and atypical antipsychotics beg the
lation, may result in deinduction of liver enzyme me- question, If the patient improved only after adding a
tabolism during the course of inpatient treatment, full dose of a typical antipsychotic to an atypical one,
with subsequent lowering of neuroleptic dosages. what is the added value of continuing the atypical
However, the patient may then relapse within a week agent? The Texas Implementation of Medication Al-
of discharge because he or she returns to smoking two gorithms (TIMA) has provided a readily accessible
packs a day or more, and the liver enzymes are rein- Web-based resource for guiding clinicians in the evi-
duced as a result. dence-based sequential treatment of patients with re-
Duration of treatment with neuroleptics cannot be fractory psychosis (Texas Department of State Health
emphasized enough in the assessment of response to Services 2007). One may quibble with a detail here or
treatment. Managed care has artificially distorted there, but overall it is vastly superior to the ad hoc and
what has otherwise been extremely well documented idiosyncratic treatment combinations that arrive at
since the 1960s (Casey et al. 1960)namely, that our doorstop on admission. TIMA also has built into
neuroleptics take time to work. Even if rapid response it the same fundamental assumptions about adequate
to initial treatment results in quick behavioral im- length of treatment trials described earlier.
provement in some critical target behaviors, such as Because the severely and persistently mentally ill
violence, the overall response to neuroleptic treatment population has illnesses that are so often treatment re-
can take up to 3 months to optimize and even as long fractory, there is always a certain risk of unwarranted
as 6 months for clozapine (Conley et al. 1997). No complacency with suboptimal outcomes. This is only
amount of dosage increase will speed up this process further bolstered by the medical necessity standards of
once the dosage has reached the therapeutic threshold some commercial managed care companies, which ap-
for a particular patient. Finding each patients thresh- pear to be structured to contain long-term risk with
old has become a bit more difficult with the atypical their psychotic patients, because such patients often
antipsychotics, because there are often no side effects transfer from the commercial policy risk pool to the
to document bioavailability of the dosing (another rea- public-sector risk pool (either Medicare, Medicaid, or
son why old records become so important!). Neverthe- local state hospital). We have often seen commercial
less, once an optimal dosage has been settled on, there managed care companies deny continued inpatient
is much value in waiting for the neuroleptic to show care for the sickest of young psychotic patients, not be-
benefit before making changes (e.g., at the behest of cause they were not sick enough but because they were
the managed care company), although the waiting not making progress and thus were categorized as
may often be done at a lower level of care. custodial and not meeting the contractual definition
Because the illness of patients in the chronic pop- of acute care.
ulation is by definition so characteristically treatment Nevertheless, one should not succumb to eco-
refractory, a structured, rational, and evidence-based nomic pressures or despair. Rather, when faced with a
approach to psychopharmacology is necessary. Be- failure in treatment, one must continue to take care of
tween the complexity of the clinical presentation and the patient, and the first medical consideration should
always be a reevaluation of the diagnosis. The major place to initiate therapy, due to the host of potential
differential diagnosis to consider when otherwise ap- complications described earlier.
propriate treatment for psychosis fails is a mood disor- Finally, electroconvulsive therapy (ECT) must be
der. Kraepelin (1921) himself continued to reevaluate considered in the treatment of difficult schizophrenia
the validity of his famous dichotomy between demen- spectrum cases. Mood symptoms in schizophrenia
tia praecox and manic depression even at the end of his will respond to ECT, as in any other mood disorder,
career, and mood disorders remain today the most and the same criteria should apply in both instances:
common confounding syndromes in assessing persis- severity of symptoms, urgency of lifesaving treat-
tently psychotic patients. Aggressive treatment for ment, and failure of pharmacological treatment. It
atypical mania, atypical depression, and coexisting should be remembered, however, that unlike bipolar I
anxiety disorders (including obsessional states and disorder, schizophrenia spectrum disorders will have
panic disorders) should always be considered in refrac- enduring psychotic symptoms that persist even as the
tory cases. Other potential but harder-to-treat compli- acute mood disorder remits with ECT. It is particu-
cations that may thwart forward progress in inpatient larly important not to unduly continue ECT after the
treatment include co-occurring personality disorders, mood disorder symptoms have improved nor to inap-
personality changes due to other neurological dis- propriately target the residual schizophrenic positive
orders, dissociative disorders, and even malingering. and negative symptoms, which are unlikely to re-
Finally, one should not lightly dismiss the somewhat spond in any fundamental way to ECT. On the other
vague but all-too -real problem of demoralization hand, catatonic symptoms, especially frank stupor,
(Clarke and Kissane 2002). The ravages of chronic psy- whether seen in a pure mood disorder or in schizoaf-
chosis, which extend across the biopsychosocial con- fective disorder or catatonic schizophrenia, usually re-
tinuum from cognitive decline at the biological level to spond well to ECT (Taylor and Fink 2003). Catatonic
the crushing of self-esteem and hope at the psycholog- excitement is also a legitimate target for ECT. Some
ical level and to loss of friends, family, vocation/role, patients with schizophrenia or schizoaffective disor-
and income at the social level, can so converge and im- der who are unresponsive to psychopharmacology
pact the patient that he or she is left with virtually no may also benefit from ECT (Fink and Sackeim 1996),
reason or motivation to get out of bed every day and including maintenance ambulatory ECT (Chanpat-
face the bleakness of current life circumstances. Such tana and Andrade 2006).
patients are extremely difficult to engage in any setting One final point to add is the powerful role that cig-
and represent the greatest collective fear we all experi- arette smoking has had in the treatment of patients
ence when we hear that someone we love has schizo- with chronic psychoses. The powerful attraction to
phrenia. nicotine observed in many patients with chronic ill-
When confronted with this specter, it is easy to un- nesses has led to some fascinating research on the pos-
derstand how clozapine has achieved a unique place in sible role of nicotinic receptors in the pathogenesis of
the therapeutic armamentarium. Although not the psychotic symptoms (Simosky et al. 2002). The nurs-
magic bullet it was originally touted to be (Wallis ing management challenges associated with smoking
and Willwerth 1992), clozapine remains the gold stan- are daunting and include problems such as theft, con-
dard for the treatment of refractory psychosis. The dif- traband, patient conflicts and assaults, and a never-
ficulty of using the drug is not to be minimized, how- ending barrage of smoking-related demands that can
ever, because the problems with agranulocytosis are literally consume whatever precious time staff have to
only the tip of the iceberg. Sedation, hypotension, ta- actually relate to patients. Our recent experience in be-
chycardia, constipation, drooling, enuresis, hyperther- coming a smoke-free hospital, although I initially op-
mia, myoclonic jerking, and generalized seizures are posed it, proved to be a complete success, particularly
also common side effects, as are the more recently in terms of the reduction in countertherapeutic staff-
documented complications of weight gain, diabetes, related interactions with patients. We have made all
acute myocarditis, and chronic cardiomyopathy. How- forms of nicotine replacement available (e.g., patch,
ever difficult this drug can be to tolerate, many pa- lozenge, gum, and inhaler). Patients often like the in-
tients do so, and some patients have indeed been haler, and it is interesting to find that they frequently
saved by it, remaining out of the hospital and living in- forget to recharge it with a new nicotine cartridge.
dependently. It therefore remains an important thera- Our recent experience with the new nicotine agonist
peutic tool to offer the patient with a treatment-refrac- varenicline is also quite promising. Together, such in-
tory illness, and the inpatient setting is often the best terventions can significantly reduce the hostility and
demandingness of the occasional patients for whom it was not so long ago that psychiatrists would actu-
the smoke-free hospital is truly an additional stress ally teach residents not to tell their patients and fam-
compounding their already exacerbated illness. ilies the correct diagnosis if it was schizophrenia be-
cause of the devastating impact the S word would
Psychotherapies have on them. It is now commonly held, in our
The inpatient unit is designed to bring specialized care present era of patient empowerment and the wide-
to the treatment of very sick patients, but it must not spread availability of patient information materials on
be forgotten that the setting is quite intentionally de- the Internet, that patients and families need truthful,
signed within a larger continuum of care. The criteria accurate information. To be sure, the impact of such
for inpatient treatment nowadays are extremely nar- information can be traumatic, and in the spirit of pri-
row and focused on the most acute and disturbed be- mum non nocere the clinician must skillfully deliver
haviors that threaten life and safety of the patient and/ the message with hope and a promise to try and help
or others. Patients in such a state are, for the most the patient regardless of the prognosis. A variety of
part, densely psychotic, and their capacity to engage in tools are now available for illness education, including
psychotherapy is consequently gravely diminished. By pamphlets, books, videos, and Internet sites. Referral
the time they are stabilized adequately to be able to en- of patients and their families to their local chapter of
gage in psychotherapy, they are usually considered the National Alliance on Mental Illness and its excel-
ready for treatment at a lower level of care, such as par- lent Web site is an equally important intervention in
tial hospitalization coupled with supervised residen- this regard. Personal support from other families af-
tial care. In addition, the demands of contemporary flicted with the pain of schizophrenia can be sustain-
inpatient medical practice, which place tremendous ing in an hour of despair.
time and productivity pressures on psychiatrists in the
context of high volumes of service, extensive docu- Rehabilitation and
mentation requirements, managed care reviews, and
collateral meetings with team members and families,
Recreational Therapies
leave little time in the day for psychotherapy. Until re- With the ever-decreasing lengths of stay in contempo-
cently, this constraint did not seem to represent a rary American managed care inpatient settings, the
problem, because the landmark Chestnut Lodge study role of rehabilitation and recreational therapies has di-
(McGlashan 1986) on schizophrenia outcomes con- minished to a huge degree. As with the psychothera-
cluded that high-quality psychodynamic intensive in- pies discussed earlier, true rehabilitation of the chron-
patient psychotherapeutic treatment did not signifi- ically psychotic patient needs to be conducted in the
cantly alter the course of the disorder. context of community living for patients whose posi-
Newer, interesting, and evidence-based cognitive- tive symptoms are not acute and distracting, and
behavioral psychotherapies have been utilized as com- where consistent and content-specific instruction,
ponents of treatment for patients with schizophrenia repetition, practicing, reinforcement, and peer support
in Great Britain and Europe in recent years (Dickerson can all combine to achieve slow but meaningful learn-
2000); however, such modalities are simply not appro- ing of specific interpersonal, survival, and vocational
priate for the short-term crisis-oriented inpatient set- skills. The acuity of the inpatient milieu, coupled with
ting as it presently exists in the United States. The the relatively short length of stay, during only part of
most helpful thing the inpatient team can do is to ed- which any given patient is likely to be well enough to
ucate the patient and family about the existence of actually be able to process rehabilitation groups effec-
these therapies and steer them toward outpatient re- tively, severely limits what can be accomplished dur-
sources as part of comprehensive discharge planning. ing an admission.
The primary content focus of our rehabilitation
Patient and Family Education groups is on illness and medication education. Pa-
If individual psychotherapy is not practicable for the tients leaving inpatient status should at least have a
acute inpatient setting, one can nevertheless attempt rudimentary grasp of what their illness is all about and
to educate patients and families about the core issues the integral role of medication in their lifelong self-
surrounding a diagnosis of schizophrenia or other se- management of the illness. Because of these patients
vere and persistent mental illnesses. There has been cognitive deficits and psychotic symptoms (both posi-
significant progress in this domain over the past gen- tive and negative), achieving such psychoeducation
eration. As documented by Miller and Mason (2002), effectively is no small task and requires a good deal of
flexibility and creativity on the part of the group leader. soothing, and judicious use of relaxation CDs with
In addition to traditional group and didactic modali- natural sounds of waterfalls or rain or beach sounds
ties, group leaders may rely on the same kind of multi- can be very effective in quieting a milieu that has be-
modal sensory learning used in the education of chil- come overstimulated. The most common inappropri-
dren with attention-deficit/hyperactivity disorder, ate recreation that staff need to constantly work with
including rapid rotation from one modality to another; patients on is, of course, sleeping. Now that cigarettes
use of video, interactive educational games, and writ- are gone from the unit, the easiest way to recognize
ing exercises; and so on to communicate a few essen- that one is on a unit for the chronically mentally ill is
tial teaching objectives. More ambitious goals, such as to notice that many, if not most, of the patients are in
vocational assessment, social skills training, and life their rooms, in bed, in the middle of the day. This
skills associated with successful independent living, withdrawal, so common that it is measured in some
must wait for lower levels of outpatient care in the detail in the Positive and Negative Syndrome Scale
continuum. The rehabilitation group leader is in an (Kay et al. 1987), can be addressed by offering the kinds
excellent position to provide the treatment team with of activities described earlier as well as assertive and
valuable data about the patients cognitive level, de- motivated nursing staff who literally go to rooms to
gree of disorganization, motivation, and negative draw patients out and into the milieu. At times, lock-
symptoms, all of which can guide disposition planning ing the bedroom areas during activities can be a last
to the extent that a continuum of different outpatient (but effective) resort if presented in a therapeutic way
programming is actually available in the patients geo- to the patient. It should never be done punitively and
graphical location. should be abandoned immediately if it has the adverse
Purely recreational groups, on the other hand, can consequence of heightening the patients antagonism.
be tremendously important in keeping the lid on an
otherwise chaotic milieu comprised of 20 or more Other Modalities
acutely psychotic human beings. Particularly with the
advent of the smoke-free hospital campuses across the The psychotic disorders unit is often the venue for
United States, patients need other opportunities be- treating patients with highly treatment-refractory con-
sides smoking to channel their energy, contain their ditions, often of considerable complexity. The ability to
anxiety, and experience a modicum of pleasure. Limi- work with such patients in a safe, coherent, and con-
tations on groups may be imposed by the overarching trolled inpatient setting with an experienced multidis-
need to maintain safety, including control over elope- ciplinary team over a period of weeks is truly a luxury
ment or impulsive self-injury. Contemporary psychiat- compared with the fragmented and chaotic everyday
ric hospital design can provide secure, enclosed, but outpatient world of the chronically mentally ill. The
very attractive outdoor courtyard space that can offer inpatient stay in such a setting can be viewed as a
patients fresh air and an opportunity to walk and ex- unique opportunity, like the eye of a storm, to pause
perience the outdoor weather as well as offer quiet pri- and reflect thoughtfully on the case and, if possible,
vate space on a bench in the sun, away from the mad- breathe new life into the treatment. For this to happen,
ding crowd of the unit. Within the confines of the of course, a certain vision must be established and
indoor unit, gross motor therapeutic activities associ- maintained under the leadership of the psychiatrist as
ated with music and group participation, such as exer- team leader. This vision is based on a deep commit-
cise and dance groups, can decrease tension and lead to ment to empiricism as embodied in DSM-IV-TR and
a sense of community. The long hallways in hospitals evidence-based diagnosis as well as evidence-based
lend themselves to a variety of bowling and pitching treatment. Time is spent in team meetings revisiting
games with soft, quiet equipment. Arts and crafts ac- preliminary assessments of the patient during the
tivities are often nonthreatening and appealing to psy- course of the current treatment. On such units it is still
chotic patients when they can experience mastery and possible for patients to remain in a single admission for
pleasure and pride at creating something attractive several months, and procedures usually reserved for re-
that they can even proudly wear and call their own. In search settings can become very helpful, including the
our setting, the television is usually not a primary use of actual rating scales. The goal of such a compre-
focus of patient attention or interest. Likewise, reading hensive and synthesizing approach is to provide the pa-
is seldom the preferred activity of choice for most tient, the family, and the outpatient team with a new
patients, usually due to significant impairment of at- perspective on the nature of the problem(s), the treat-
tention and concentration. Music can be particularly ment, and the prognosis. At its best, such an inpatient
stay serves as an extended consultation for the ongoing model are still useful in organizing a psychotic disor-
treatment of the patient, which, if well documented in ders program. Although principles of a more generic
an in-depth discharge summary that is proactively dis- milieu therapy may apply fruitfully in any inpatient
tributed to all the relevant members of the patients setting, a specifically behavioral focus for a psychotic
treatment team, can provide an ongoing guidepost to disorders program remains helpful. General principles
future clinicians as they wrestle with an illness that is include 1) defining the patient and the target psycho-
notoriously chronic and confusing. pathology using a robust behavioral perspective, with
specific behavioral descriptors of the precipitants, re-
inforcers, and contingencies surrounding the target
Milieu Management behaviors; 2) paying close attention to the degree of ex-
pressed emotion (Wearden et al. 2000) used by staff
The art of managing a unit composed of psychotic peo- and making continuous efforts to minimize and re-
ple requires close collaboration between the psychiat- express that emotion in more neutral ways; 3) mini-
ric and the nursing staff as well as a modicum of un- mizing reliance on complex higher-order verbal inter-
derstanding from the hospital administration. The personal interactions (such as might occur in confron-
most common complication in running such a pro- tational or interactive community meetings) in favor
gram is the oversaturation of the milieu with agitated, of a simpler, more concrete problem-oriented review of
disorganized, needy, attention-seeking, and aggressive the day s events and requirements; 4) avoiding any
patients, which can result in a contemporary state of purposeful, although artificial, therapeutic neutral-
bedlam. Despite progress in psychopharmacology in ity in favor of a more globally affirming and continu-
the past 50 years, effective inpatient management ously positive stance toward the patient; and 5) focus-
cannot be reduced to just aggressive medication prac- ing on core activities of daily living that are typically
tices (Coffman et al. 1987), and no amount of oral and disrupted in the course of an acute psychotic episode
intramuscular medication will consistently allow all and that can often be taken for granted in higher-func-
20 or more psychotic patients to remain perfectly calm tioning nonpsychotic patient populations.
at all times. One tool that we have found to be useful is the in-
This patient population lends itself to a more corporation of structured behavioral observations into
highly structured milieu, and ideally, with a suffi- the daily charting of the staff. Certain frequent and
ciently long length of stay, a fully implemented token clinically urgent target behaviors are routinely queried
economy can be extremely therapeutic. As first de- and documented on every shift and include nighttime
scribed by Ayllon and Azrin (1965) and later refined sleep, use of as-needed medication (and for which spe-
and demonstrated effective by Paul and Lentz (1977), cific behaviors and contexts), incontinence, vomiting,
the token economy offers a comprehensive approach and the use of any limit-setting interventions such as
to milieu management that includes a systematic ap- time-out in the bedroom or quiet room or use of seclu-
proach not only to the manifold behavioral challenges sion or restraint. In addition, a dictionary of patient-
presented by a group of actively psychotic patients but specific target behaviors is used for any staff to sponta-
also to the education and training of the nursing staff. neously add to ongoing tracking of specific patients, in-
The modified token economy, based on a point card cluding such things as yelling, cursing, threats, sexual
and real-time reports of both patient and staff behav- self-stimulation, inappropriate touching of others, in-
iors, has been demonstrated to improve long-term trusive attention seeking, failure to get out of bed, or
outcomes after discharge (Dickerson et al. 2005). In medication refusal. Such documentation can be readily
an environment where patient behaviors can be wildly reviewed, can provide insight into whether treatment
unpredictable and bizarre, disorienting even experi- interventions (be they medical or behavioral) are help-
enced staff, there is something very reassuring and ful, and can guide ongoing treatment planning.
steadying in an approach that calls for close attention The management of such a milieu can be config-
to the specifics of patient and staff behaviors, reasoned ured in a variety of ways, each with its own strengths
analysis, and problem-oriented interventions. and weaknesses. In an ideal world, even without a true
The shortened lengths of stay in recent years, cou- token economy, there is plenty of work for a doctoral-
pled with the pressure to reduce hospital labor costs, level clinical psychologist to do as a behavioral con-
have made the fully featured model of a token econ- sultant, both to the milieu in general and to specific
omy untenable in all but a few exceptional settings problem patients in particular. If such a clinician is not
nowadays. However, modifications of the original available, a physician with interest and experience in
behavioral psychology can fill a similar role, or a psy- that violence comes with the territory when running a
chology consultant can be requested on a case-by-case psychotic disorders inpatient program. Persecutory de-
basis as needed. For behavioral interventions to work lusions, ideas of reference, and thought broadcasting
best, however, a certain amount of ongoing training can all create a state of panic or hostility in patients
and education of staff is necessary, particularly if there that makes them a potential risk to themselves, peers,
is a high degree of turnover in the staff and the pool of visitors, and staff. Although scrupulously careful and
new mental health worker recruits is inexperienced. A appropriate psychopharmacology can certainly miti-
nurse manager who has had experience with behav- gate such violence, it is not a panacea, especially for
ioral therapy can be invaluable in enhancing the effec- the acutely admitted patient. First-episode patients,
tiveness of the model in terms of technical expertise, substance-intoxicated patients, patients who have suf-
but perhaps even more importantly as a role model for fered abuse, manic patients, head-injured patients,
the rest of the staff to think behaviorally. One final mentally retarded patients, antisocial patients, and
caveat, however: at times, even the most comprehen- patients with treatment-refractory illnesses all can
sive and technically well-executed behavioral program present an increased risk of violence.
will fail if the patients underlying psychopathology is The psychopharmacological approach to violence
so extreme, and so poorly controlled, as to make it vir- is straightforward and evidence based and has been
tually impossible for the patient to interact success- well described repeatedly in the literature (Petit 2005).
fully with a behavioral learning paradigm. Examples of Besides such psychopharmacological interventions, it
this include florid mania, paranoid states of panic, and is imperative for the staff to have training and confi-
dementia, all of which can overwhelm the patients dence in behavioral approaches to the agitated patient.
ability to engage with and learn from an otherwise Principles of effective management of the potentially
commendable behavioral treatment plan. violent patient include 1) transparency and clarity in
explaining the rules of the milieu and the patients le-
gal rights; 2) a neutral but respectful attitude toward
Management of Suicidal and the patient at all times, even when the patient is men-
acing or grossly out of control; 3) avoidance of any
Aggressive Behaviors threats, coupled with clear limits on what is and is not
tolerated in the milieu; 4) recognition of the counter-
The psychotic patient presents certain unique chal- transference fear of the patient or the projective iden-
lenges in terms of suicidal and aggressive behaviors. tification of rage toward the patient, either of which
The suicidal impulses of an acutely psychotic person can contaminate the therapeutic relationship and poi-
with schizophrenia can be particularly powerful, in son any treatment alliance; and 5) availability of suf-
part due to the compelling force of auditory and other ficient power (i.e., expertly trained staff) to implement
hallucinations, which bring a whole new level of real- any limit setting in as humane and safe and efficient a
ity to the already depressed and/or frightened patient. way as possible. Perhaps the single most important
Patients with schizophrenia may hurt themselves in a rule to follow, but not always the easiest, is the prompt
panic of violence in order to appease the command of and effective confrontation of threatening behavior
God or the Devil, or to escape the (mis)perceived when it first occurs. The failure to intervene imme-
threat from the paranoid other, in which case death diately, with a clear expression to the patient of the
itself is viewed as a better outcome than the horror of nature and reason for the limit, the possible conse-
being trapped by the other. The power of such delu- quences, and the need to accept additional therapeu-
sions, coupled with tremendously real affective and of- tics from the staff, almost invariably leads to escala-
ten religious energy, can result in such acts as throwing tion of the aggressive behavior until it reaches a crisis
oneself through a window, cutting (not scratching) that may, by that point, unavoidably result in some-
clear through tendons and arteries, shooting ones head one being injured. The choices of additional therapeu-
with a shotgun, putting a knife into ones heart, setting tics that should be presented to the out-of-control pa-
oneself on fire, jumping in front of a subway train, or tient are diverse and include providing as-needed
castrating oneself or removing ones eyes (cast off the medication, adding a new medication, changing to a
offending organ). Simple overdosing is often not the different medication, taking a time-out, making resti-
schizophrenic way of suicide (Hunt et al. 2006). tution to a peer, or removing oneself from the milieu in
Similarly, aggression directed toward others can be general or from a specific peer or staff member. Teach-
extreme and quite dangerous. In general it is fair to say ing staff to be facile with any and all of these options,
either singly or in combination, can greatly enhance the entire treatment system, determining what may
the therapeutic leverage of the team and is certainly need to be changed. We routinely arrange team confer-
more helpful than merely relying on as-needed medi- ences with family, outpatient case managers, housing
cations, which unfortunately can become the final care providers, and service coordinators from other
common pathway of least effort in an underresourced agencies such as developmental disabilities, social ser-
and overly stressed hospital with high acuity. vices, protective services, vocational services, educa-
Seclusion and restraint in particular are often con- tional services, and mobile treatment (or assertive
sidered when dealing with the acutely psychotic pa- community treatment) teams. We also find the modern
tient. This can begin before the hospitalization, if the speakerphone and conference calling technologies to be
police need to subdue a violent patient emergently or if an invaluable way to engage concerned outpatient par-
the emergency department staff need to seclude or re- ties who cannot physically attend such conferences and
strain the patient. To be sure, seclusion and restraint yet keep the discussion totally transparent to the pa-
are, and should always be, the last resort in responding tient, if the patient is clinically well enough to attend. It
to the potential for violence in psychotic patients. Ia- is often the outpatient psychiatrist who is least able to
trogenic worsening of an already bad situation can oc- participate in such conferences due to huge caseloads
cur if the paranoid patient is kept in a locked room with and clinical assignments spread over a variety of geo-
a camera and one-way mirror. Restraints can at times graphical locations. In fact, just reaching the outpatient
exacerbate fear because of the total helplessness and psychiatrist when he or she has the patients chart
consequent vulnerability the patient experiences, cou- available to review is often impossible in a 1-week
pled with the psychotic distortions that convince the length of stay when the outpatient psychiatrist is only
patient that the people in control are lying and wish to in that particular office once a week. We have found
kill him or her. Every effort should be made to avoid us- that most agencies are cooperative, with appropriate
ing seclusion and restraint or, if not possible, to mini- consents, to fax copies of the psychiatrists medication
mize their duration and address any iatrogenic morbid- log and recent progress notes, which can often shed im-
ity that they may introduce. Nevertheless, it must be portant light on the precipitants to the admission.
said that in our experience, complete renunciation of Families are always relevant in helping the chroni-
seclusion and restraint with the psychotic population cally mentally ill. We always begin with the view of the
has never been possible, and seclusion and restraint re- family as an ally, until proven otherwise. We try to join
main a necessary option in the safe management of with them, form a shared therapeutic alliance, and learn
psychotically aggressive patients. from them as much as we can: What motivates the pa-
tient? To whom is the patient closest? To whom will he
or she listen? Why does the patient feel this way or that?
Discharge Planning Sometimes, the family itself becomes a secondary pa-
tient, when we identify their unmet needs in response
Involvement of Community to the patients illness. If supporting the patient in the
home of 80-year-old parents has become too much, we
Providers, Resources, and try to facilitate disengagement and transition to a new
Significant Others developmental level. If the patients risk of violence has
become too great, we provide specific warning and legal
The effective treatment of the persistently psychotic
advice. Although one must of course obtain the pa-
patient must always be considered within the broader
tients consent to collaborate with the family in this
context of the patients ongoing outpatient treatment
way, such collaboration is critical to long-term success.
and rehabilitation/housing situation. It is incumbent
When families are actively caring for their relative with
upon the inpatient program to reach out to the outpa-
persistent mental illness, the old-fashioned individual
tient treatment team, including family and significant
therapy patient-centric model may be completely inap-
others, if it is to do more than merely put yet another
propriate and even hurtful and should be utilized on a
pharmacological bandage on what is, in fact, a compli-
case-by-case basis when there are specific clinical rea-
cated biopsychosocial system in crisis. Remarkably, de-
sons for following such a model (Glynn et al. 2006).
spite the ravages of managed care, the inpatient team
usually still has more resources at its disposal than the
beleaguered outpatient team and can create a kind of
Transition to Next Level of Care
therapeutic shelter or interlude during which the rele- Mobilizing psychotic patients who have begun to seal
vant parties can afford to (briefly) pause and reassess over the acute psychosis that precipitated inpatient
admission requires careful clinical assessment and tion. Although there are certainly occasional, poten-
comprehensive planning. Despite the economic pres- tially lethal drawbacks of using essentially unlicensed
sures to discharge patients as soon as they cease being and untrained laypersons (Barnhardt 2002), the alter-
aggressive or self-destructive, the clinical fact remains native of literally dumping patients on the streets, as
that psychotic patients remain fragile for some time has been reported in Los Angeles (Winton and DiMassa
even after the more florid symptoms remit. Putting 2005), is simply unacceptable. The other alternative fi-
patients back into stressful environments before they nal common pathway for homeless mentally illjails
are able to cope with them can merely result in an and prisonscan result in unspeakable horror, such as
exacerbation of symptoms and rehospitalization. the recent death by dehydration of a bipolar man kept in
Finding appropriate transitional levels of care, how- restraints in a Michigan jail (Pelley 2007).
ever, can be quite challenging. In our uniquely Ameri-
can health insurance paradigm, so-called acute treat- Specialty Day Hospital
ment (i.e., short-term hospital care) is paid for by most Because the transitional period can be a vulnerable one
commercial insurances, but chronic or rehabilita- for patients recovering from an acute psychosis, there is
tion or custodial services are viewed as uncovered a role for a day hospital model that delivers program-
and hence the responsibility of the public sector, the ming specifically tailored to the persistently ill patient.
family if they have resources, or no one at all in many General partial hospital programs, which are run out of
instances. Criterion B for schizophrenia in DSM-IV-TR a psychiatric unit embedded in a general hospital, are
is the classic Kraepelinean failure to ever fully recover typically geared for higher-functioning patients, with
(restitutio ad integrum) from what Adolf Meyer (Meyer programming that emphasizes recovery and return to
and Winters 1950) later called the life break, which in work and family. Such a milieu may be even less toler-
contemporary America is usually translated operation- ant than the inpatient unit of the deviant, deficit behav-
ally into chronic disability and poverty. Disabled pa- ior characteristic of the persistently ill patient, precisely
tients may become eligible for Social Security Disability because the high-functioning patients are themselves
Insurance (which comes with Medicare) or Supplemen- no longer so symptomatic and wish to focus on higher-
tal Security Income (which comes with Medicaid), but level problem solving. We have found that with the
getting these entitlements is no small task, the diffi- economies of scale inherent in a large freestanding psy-
culty of which literally varies from administration (the chiatric hospital, we can easily fill a special day hospital
Reagan administration raised the bar) to administra- that services the chronic patient. Such a model is a nat-
tion (the Clinton administration lowered it). Without ural extension of the longer-length-of-stay inpatient
these entitlements, paying for long-term ancillary ser- model of 30 years ago, only now delivered in a partial
vices in the community can be impossible. It is not un- setting. Whereas patients on the inpatient unit are not
common, for example, for the newly psychotic child of there long enough when they are stable to benefit from
middle-class parents with good commercial insurance social skills groups such as a cooking group, for exam-
to be unable to access the local psychiatric rehabilita- ple, they can definitely take advantage of such occupa-
tion program because it is not possible to get Medicaid tional therapy programming in a partial setting. Coor-
and neither the commercial insurer nor Medicare will dinating such a day hospital with the inpatient unit
pay for it. Likewise, paying for housing can be a tremen- allows for continuity of physician coverage as the pa-
dous obstacle to successful community adjustment for tient is stepped down to a lower level of care and higher
the person with persistent mental illness. Although level of psychosocial stress and performance demands.
some states may have dedicated funding lines to pro- This can be invaluable when medications need to then
vide supervised residential care for the mentally ill, ac- subsequently be adjusted. A registered nurse can coor-
cess often requires years of being on waiting lists. In ur- dinate closely with the care provider, and a social
ban areas of many states, a literal cottage industry has worker can do family work now that the patient is back
evolved in the past 30 years in which local homeowners at home. We have been able to, in effect, provide a 2- to
will rent out rooms and provide meals and sometimes 3-month length of treatment, if not length of stay, in
medication supervision (board and care). In our set- such a continuum and as a result see fragile patients
ting, the existence of, and collaboration with, such pro- successfully stabilized in the community and then
viders is absolutely essential to the overall successful handed off to the next level of care, namely a psychiatric
management of this chronically mentally ill popula- rehabilitation program and office practice.
Dickerson FB, Tenhula WN, Green-Paden LD: The token

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recommendations for future research. Schizophr Res
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Engel GL: The need for a new medical model: a challenge for
in a state of flux and has been so since deinstitutional-
biomedicine. Science 196:129136, 1977
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nerable population have not decreased. Creative pro- derutilized treatment option. J Clin Psychiatry 53:426
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Glynn SM, Cohen AN, Dixon LB, et al: The potential im-
services can result in relatively better outcomes, occa-
pact of the recovery movement on family interventions
sionally dramatically so. Such programming speaks for schizophrenia: opportunities and obstacles. Schizo-
well of the progress that the mental health professions phr Bull 32:451463, 2006
together have made over the years in bringing rational, Green AI, Drake RE, Brunette MF, et al: Schizophrenia and
caring, and effective therapeutics to the sickest pa- co-occurring substance use disorder. Am J Psychiatry
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CHAPTER 9
THE CO-OCCURRING
(SUBSTANCE ABUSE/MENTAL
ILLNESS) DISORDERS UNIT
Michael C. Fiori, M.D.
Mary Ella Dubreuil, R.N., L.C.D.P.
Admission Criteria disorders. In reality, however, all units at various levels

of care and expertise are faced with caring for patients
with clinically significant CODs. Ideally, patients are
The goal of the co-occurring disorders (CODs) unit is evaluated for admission to a continuum of care, their
to provide safe and effective psychiatric care to pa- needs in all realms are assessed, and a treatment plan
tients with co-occurring mental illness and substance is devised and implemented in the most effective, least
abuse. In the literature, patients with CODs may also restrictive, safest level of care possible.
be referred to as dual-diagnosis patients or mentally ill The American Society of Addiction Medicine
chemical abusers, among other terms. In this chapter, (ASAM; 2001) placement criteria have been devised in
patients with CODs refers to all patients with at an attempt to address how to safely and efficiently
least one primary psychiatric disorder and at least one match patient assessment to modality of treatment
substance use disorder (SUD). True CODs units are and treatment setting. The placement criteria are a set
specifically designed to meet the needs of patients of guidelines for placement, care planning, and dis-
with both significant active psychiatric illnesses and charge of patients with SUDs. Safety must be the cli-
significant active substance dependence issues. Such nicians top priority in assessing whether a patient
units may be rare. Far more prevalent are units whose meets criteria for admission to a CODs unit.
primary orientation and expertise are in the treatment The American Association of Community Psychi-
of either chemical dependence or primary psychiatric atrists has also produced a software system to assist in
135
patient placement decisions. The system, Level of tailored to the setting of the evaluation; an initial out-
Care Utilization System for Psychiatric and Addiction patient office evaluation of a patient complaining of
Services (LOCUS), helps to determine psychiatric and/ depression and fatigue is different from the patient
or substance use treatment level-of-care needs (Sowers who comes to a hospital emergency department and
et al. 2003) using criteria similar to ASAM. LOCUS is self-identifies as having depression and addiction.
somewhat more sensitive to psychiatric domains. The The diagnostic workup must include a multiaxial
patients acute and chronic issues determine where assessment, including evaluation for psychiatric disor-
treatment should be delivered. From a psychiatric per- ders, SUDs, medical disorders, general functioning,
spective, there are three main safety concerns shaping and personality and psychosocial issues that relate to
level-of-care decisions: the patients presentation or treatment. The evalua-
tion must also address the relationship between these
1. Presence and intensity of suicidal, self-harming, issues. Are the psychiatric problems relatively distinct
homicidal, or violent/aggressive ideation or behav- from the substance dependence issues? Does the sub-
ior; stance abuse simply exacerbate and complicate the
2. Severity of a patients depression, psychosis, or per- psychiatric illness, or does it cause the psychiatric
sonality dysfunction; and problems? Does the substance abuse arise from the
3. The patients acute or chronic cognitive dysfunction. psychiatric illness, perhaps as a maladaptive attempt at
self-treatment? A careful gathering of the history from
From a medical perspective, additional safety con- the patient and, ideally, from significant others is the
cerns relate to medical risks associated with the pa- most instructive procedure at the clinicians disposal.
tients substance abuse, health status, and risks asso- Examples of pertinent information include
ciated with different treatment options. For example,
patients with a history of delirium tremens (DTs) and/ 1. To the extent a working hypothesis can be estab-
or seizures are most at risk for those to occur during lished, which came first, the psychiatric problem or
detoxification; patients with tachycardia and hyperten- the substance abuse disorder?
sion, despite the presence of intoxication, are at higher 2. What is the effect of the substance usage on the
medical risk. Risks posed by level of intoxication, with- psychiatric symptoms and on the treatment of the
drawal history, the current episodes amount and fre- psychiatric illnesses?
quency of intake, and what psychosocial supports a pa- 3. Is there a family history of psychiatric illness or
tient possesses all interrelate to indicate whether a substance dependence?
patient meets criteria for treatment on a CODs unit. 4. What is the severity of the patients psychiatric
The ASAM placement criteria function best when symptoms during periods of sobriety?
patients are assessed in each dimension indepen-
dently and also in the interactions across dimensions. Laboratory testing can be a helpful adjunct to the
For example, a patient may meet criteria for admission history in the diagnostic assessment and can aid in
to a CODs unit, but a high level of psychosocial sup- monitoring and motivating patients with CODs. All
port might mitigate against the need for inpatient diagnostic and treatment-monitoring laboratory test-
treatment. However, clinicians must be careful not to ing described in other chapters of this book apply to
minimize the importance of any one dimension by patients with CODs. However, some laboratory ser-
simply averaging patients scores across domains. Al- vices more specifically apply to the treatment of pa-
though consideration of the interactions across di- tients with known or suspected SUDs.
mensions is an important aspect of sophisticated pa- Virtually any body fluid or tissue can be assayed for
tient evaluation, if a patient requires admission to a drugs of abuse, but most testing is performed on urine
CODs unit as evidenced by severity of ratings in sub- and blood samples. Urine is the primary fluid col-
stance dependence or psychiatric illn es s, then lected when testing for the presence of drugs of abuse
strength in other dimensions does not generally alter because it is easily and noninvasively collected, and
the clinical necessity for admission. drugs are often present in high concentrations. In the
acute care setting, laboratory testing for substance
abuse can help to identify specific drugs of abuse, his-
Diagnostic Workup tory of use, and amounts or levels of substances in the
body, which can help to guide treatment decisions.
The mainstay of the initial assessment is the taking of This chapter provides a brief overview of some of the
an adequate history. The type of assessment should be laboratory tests available; more detailed information
The Co-Occurring (Substance Abuse/Mental Illness) Disorders Unit 137
may be found in textbooks of substance abuse treat- suppressants frequently cause false positives. Com-
ment, such as The American Psychiatric Press Text- monly used assays often miss the hallucinogenic am-
book of Substance Abuse Treatment (Galanter and phetamines, methylenedioxyamphetamine, and
Kleber 2008) and Lowinson et al.s (2005) Substance methylenedioxymethamphetamine (ecstasy) un-
Abuse: A Comprehensive Textbook. less they are present in high concentration.
Immunoassays of urine samples for drugs of abuse Acute usage of alcohol can be estimated by the
can cross-react with endogenous metabolites or pre- blood alcohol level (BAL), which can be noninvasively
scribed medications, thus causing false positive re- obtained by having the patient exhale a deeply drawn
sults. Gas chromatography with mass spectroscopy is breath into a measuring device. Longer-term usage of
more expensive, sensitive, and specific for confirming alcohol can be estimated by blood tests. For tests re-
positive immunoassays. Negative tests will be reflecting the function of the liver, the -glutamyl trans-
ported if the concentration in the urine is below the ferase (GGT) is the most sensitive marker of alcohol
cutoff for the drug or its metabolite. The amount and abuse. The aspartate aminotransferase (AST) and the
duration of usage, coupled with the timing of the last alanine aminotransferase (ALT) are also elevated in
dosage, all affect urine screen results. alcohol dependence (AST greater than ALT) and are
Codeine and heroin are metabolized to morphine, commonly drawn on admission to CODs units, but
which is the target of urine assays for opioids. Poppy the transaminases are not as sensitive as the GGT. In-
seeds famously can cause false positives at the 300-ng/ creased red blood cell mean corpuscular volume is also
mL cutoff level for 48 hours after ingestion. Com- associated with alcohol dependence and is commonly
monly used immunoassays are less sensitive for oxyc- obtained; it takes 3 months for this level to normalize
odone and hydrocodone, resulting in unexpected false after initiating abstinence. Although the carbohydrate
negatives. Methadone, propoxyphene, and buprenor- deficient transferrin, which normalizes after roughly a
phine require specific assays, because standard assays month of abstinence, may be informative on admis-
often yield negative results. sion, it may be more helpful in an abstinent, long-
The interpretation of benzodiazepine immuno- term care setting.
assays is complicated by the diverse number of com- In addition to screening for the usage of drugs of
pounds and their metabolites that may show poor abuse, laboratory testing can be useful in other ways,
cross-reactivity. Different screening assays will result in including blood tests for ammonia levels, which are
false negatives depending on the benzodiazepine type correlated with cognitive dysfunction in alcoholics
and concentration. Therefore, a positive finding will af- and may be significantly elevated in the presence of
fect treatment decisions, but a negative finding should mild or even nonexistent transaminase elevation.
not override a history or a clinical concern. Similarly, a
positive finding of a long-acting, fat-soluble benzodiaz-
epine should not be taken as a sign of recent usage.
Treatment Planning and
The major cannabinoid metabolites in marijuana Therapeutic Programming
are present and detected for 12 days after a single epi-
sode of smoking, whereas long-term usage will result Challenges in Treating Patients With
in positive assays for as long as 2 months and can be
positive even in abstinent individuals after a negative Co-Occurring Disorders
urine, where the concentration may be fluctuating The successful treatment of patients with CODs re-
around the cutoff level. False-positive urine screenings quires coordinated and integrated care for each of the
for marijuana due to passive inhalation are rare. patients psychiatric disorders and SUDs. The focus of
Assays for the short-acting barbiturates are posi- the COD inpatient program is to provide safety, as-
tive for 14 days after last usage. sessment, education, and assistance in the develop-
Phencyclidine, if tested for, is positive for about ment of follow-up and relapse prevention plans. An in-
7 days after a single usage. patient stay is also an opportunity to work with the
Cocaine usage is detected by the presence of its pri- patient toward enhancing motivation for ongoing
mary metabolite, benzoylecgonine, in urine immu- treatment. Patients can be introduced to information
noassays; there are few false positives. that will help guide ongoing efforts toward recovery.
Urine tests for d-amphetamine and d-metham- It is important for both the treatment team and the
phetamine are widely available and commonly used, patient to understand the unique relationship between
but medications such as decongestants and appetite the psychiatric disorder and the pattern of substance
use. It is not uncommon for one disorder to trigger the They may not possess the information necessary to
other or for one to interfere with recovery from the truly understand the illnesses they are struggling with
other. Psychosocial factors common among patients or why they continue to behave in ways that are detri-
with CODs (e.g., financial hardship, homelessness, mental to themselves and others. They frequently en-
unemployment, legal difficulties, isolation, poor social ter treatment vulnerable and defensive. Clinical staff
support, and interpersonal conflict) may complicate must care for patients with CODs in a way that does
treatment and recovery (Laudet et al. 2000). The dif- not reinforce patients negative self-image, so that pa-
ficulty in formulating a treatment plan is further com- tients can gradually let down their defenses. The opti-
pounded by the lack of published studies in this area mal treatment team consists of people who have expe-
as well as problems with countertransference and rience w orkin g with both addiction s and other
burnout among clinical staff. psychiatric disorders. Biases in either direction can be
Difficulties may also vary by the specific diagnoses, problematic in the overall care of the patient. Impor-
further complicating the treatment plan and empha- tant relationships between the two illnesses can be
sizing the need for treatment plans to be individual- missed, unrealistic expectations might be set, and re-
ized. Substance-abusing patients with posttraumatic lapse management and prevention plans may not
stress disorder (PTSD) have greater numbers of hospi- meet the needs created by both diagnoses.
talizations for inpatient substance abuse treatment Staff should be oriented to the treatment philoso-
than those without PTSD (Brown et al. 1995). For phy of the program, program goals, and expectations.
these PTSD patients, therapy focusing on trauma and Ongoing performance feedback should be given. Core
recovering from trauma may be helpful (Ford and competencies should be clearly established and re-
Russo 2006). Patients with severe trauma and CODs flected in the annual performance evaluation so that
may come to be known as difficult patients, and staff may plan appropriate professional growth initia-
monitoring and controlling countertransference may tives. Ongoing education for staff on the CODs unit
be particularly challenging for coworkers. These pa- may take advantage of training interventions currently
tients may have found substance abuse effective in re- being developed (Hunter et al. 2005), and unit supervi-
lieving psychic distress because they lack healthy cop- sors may wish to provide clinical staff with copies of the
ing skills (Cramer 2002). Thus, patients may not be American Psychiatric Associations practice guidelines
motivated to cease abusing substances until they can and other resource documents, such as the Substance
learn healthy and adaptive coping strategies. In pa- Abuse and Mental Health Services Administrations
tients with eating disorders, those with bingeing and Treatment Improvement Protocol (TIP), Substance
purging behaviors seem to be correlated with a higher Abuse Treatment for Persons With Co-Occurring Dis-
rate of substance misuse than patients with purely re- orders (Center for Substance Abuse Treatment 2005).
stricting eating disorders (i.e., patients with nonpurg- Ongoing clinical supervision, which allows for contin-
ing anorexia nervosa). Impulse control may be a prob- ued learning, support, and self-evaluation, is a critical
lem for addictions treatment in these patients (Corcos ingredient in the delivery of compassionate care.
et al. 2001). Substance abuse in patients with schizo- Staff members need to be able to provide a safe en-
phrenia is associated with increased rates of homeless- vironment, crisis management, and group and indi-
ness, more severe psychosis, lack of medication adher- vidual therapies. They must be able to function as a
ence, violent behavior, and poor clinical outcomes team to continuously assess the patient and to develop
(Soyka 2000). Finally, comorbid personality disorders and work with individualized treatment plans. Staff
and SUDs may present challenges not only for acute members also need a venue to process countertrans-
care but also for long-term treatment planning and ference they may experience in response to the behav-
discharge placement. ior of patients with complicated, chronic, relapsing,
and sometimes treatment-resistant conditions. Clini-
Staff Selection, Education, Training, cal supervision should provide staff with a safe place to
and Supervision discuss attitudes and judgments that might arise to-
ward patients in their day-to-day interactions.
Creating a therapeutic milieu begins with people. Se-
lecting staff with a commitment to the population, pa- Stages of Change and Readiness
tience, self-awareness, and an understanding of the
process of change is important in creating an environ-
for Change
ment where patients can feel safe to learn and grow. Two major factors in formulating and carrying out a
Patients often enter treatment with shame and guilt. successful intervention include the patients readiness
to change (or stage of change) and the ability of the plan over another for all patients with severe mental
units staff and structure to match treatment to the illness and comorbid substance misuse (Jeffery et al.
patients individual needs and capabilities. 2000). New treatment models are continually emerg-
Prochaska et al.s (1992) five-step transtheoretical ing (Bellack et al. 2006), making large-scale compre-
model of change is especially applicable to the treat- hensive reviews unlikely. However, integrated pro-
ment of individuals with addictions and those with co- grams emphasizing core elements, such as active
occurring mental illness. In this model, individuals go engagement and smaller case loads, have produced no-
through five stages before finally achieving change. ticeable improvements in patient outcomes (Jerrell
The first stage is that of precontemplation, during and Ridgely 1999).
which the individual is not seriously contemplating Although patients with CODs are known to have
change. During the second stage, contemplation, one lower treatment success rates, most persons with
recognizes the problem and thinks about change. The CODs do not receive adequate, integrated treatment
third stage, preparation, involves taking steps to pre- for both disorders (Watkins et al. 2001). This is a sig-
pare oneself for the action that will effect change. nificant and unfortunate unmet need, because epi-
Fourth, one engages in actionthat is, takes direct demiological data suggest that CODs are the norm
stepssuch as chewing nicotine gum instead of rather than the exception in substance-using popula-
smoking cigarettes. Finally, during the fifth stage, tions (Minkoff 2001). Furthermore, integrated treat-
maintenance, ones goal is to maintain the change. In- ment has been shown to improve clinical outcomes.
dividuals undergoing behavioral changes frequently go When substance-abusing patients were provided with
through several cycles of the five steps before achiev- additional services for their comorbid depression, the
ing permanent change; relapse is a normal phase in course and outcomes of their treatment were similar
this process (DiClemente et al. 2004). A patient with to those of substance-abusing patients who did not
CODs may be at different and potentially conflicting have comorbid depression (Charney et al. 2001). For
stages of change for each disorder. Relapse or decom- many patients with CODs, successfully treating the
pensation in one area may impact change status in affective or anxiety disorder may remove the patients
other areas. The Center for Mental Health Services need to self-medicate. Treatment must also address
recommends the use of the stages-of-change model for the SUD in order to establish insight into the mal-
identifying and serving patients needs in the treat- adaptive substance use and to develop relapse preven-
ment of individuals with CODs (Center for Mental tion strategies. In a study comparing integrated versus
Health Services Managed Care Initiative 1997). standard treatment for dually diagnosed homeless
DiClemente et al. (2004) noted that readiness to adults, the group receiving integrated treatment had
change is distinct from readiness for treatment: Indi- fewer institutional days and more days in stable hous-
viduals can come to treatment and be open to par- ing, made more progress toward recovery from sub-
ticipating in treatment without being ready to abstain stance abuse, and showed greater improvement of
from alcohol and drugs (p. 105). For many individ- alcohol use disorders than the standard treatment
uals with CODs, substance misuse has become a group (Drake et al. 1997, p. 298). In a study of pa-
trusted coping mechanism despite its undesirable con- tients with schizophrenia and substance abuse, the
sequences. Therefore, abstinence may be implausible integration of motivational interviewing, cognitive-
for patients who have not yet developed alternative behavior therapy, and family sessions produced im-
coping skills and who have not yet worked through the provements in general functioning and abstinence
trauma or symptoms that trigger maladaptive coping from substance abuse as well as reductions in positive
behaviors. Brunette and Mueser (2006) offered a help- schizophrenia symptoms (Barrowclough et al. 2001).
ful review of treatment components and treatment The Center for Mental Health Services Managed
plans at each stage of change, emphasizing the impor- Care Initiative (1997) called for increased availability
tance of fully integrated and flexible treatment for of integrated treatment for patients with CODs as well
patients with CODs. as programs that can adapt to the needs and readiness
of individual patients. The Institute of Medicine also
Integrated Treatment and called for integrated treatment for persons with
CODs, highlighting the value of collaboration and co-
Individualized Treatment Plans ordination of care (Institute of Medicine Committee
There is insufficient evidence (due to a dearth of stud- on Crossing the Quality Chasm 2006). The commit-
ies on CODs) to recommend one type of treatment tee recommended routine sharing of information
about the patients problems and treatment (with the rocognitive performance, such as reasoning, problem
patients consent), increased screening and monitor- solving, and short-term memory (Durazzo et al. 2007).
ing for CODs, and policies and incentives to encour- It is also sometimes assumed that people with psy-
age collaboration. Better outcomes with integrated chiatric illnesses and/or addictions would not want to
treatment appear to be related to overall administra- stop smoking. This thinking has led to numerous pro-
tive or system changes that facilitate collaborative programs not addressing the issue of nicotine addiction at
gramming and enhanced support to direct-care clini- a time when the opportunity to at least educate and in-
cal staff (Minkoff 2001). crease motivation is present. Although it is true that
many patients arrive at the CODs unit ready to ad-
Smoking Cessation dress psychological issues or other SUDs but still in
The decision whether (or how) to include treatments the precontemplation stage for changing their nicotine
for smoking cessation is a critical aspect of treatment addiction, therapeutic programming on the unit may
planning on the CODs unit. The integration of smok- provide the support and resources a patient needs to
ing cessation strategies is especially recommended for become motivated or even to begin to effect change.
facilities with smoking bans, because such bans have Even if the philosophy of the inpatient COD program
little to no effect on long-term smoking cessation (el- does not include the recommendation of concurrent
Guebaly et al. 2002) but may affect patients comfort smoking cessation, it should at least provide educa-
and agitation related to nicotine withdrawal. Cigarette tion for all patients, motivational enhancement ef-
smoking is highly prevalent in individuals with CODs forts, and treatment for those who decide to engage in
and accounts for substantial morbidity and mortality smoking cessation during treatment.
in these patients; smoking may even impede success-
ful pharmacological treatment of underlying psychiat-
ric or addictive disorders by affecting the metabolism
Therapies
of other drugs (Williams and Ziedonis 2004). Among
people discharged from inpatient treatment for addic- Medication Treatments
tions, more die from tobacco-related disease than from
Skillful usage of medications helps to engage patients
alcohol-related disease (Hurt et al. 1996). Additionally,
in treatment. Generally speaking, medications may be
there appears to be a link between current cigarette
utilized to treat states of intoxication, treat with-
smoking and suicide, even after controlling for poten-
drawal syndromes, prevent relapse, and treat co -
tially confounding factors (Tanskanen et al. 1998).
occurring psychiatric conditions.
There are conflicting schools of thought on treating
nicotine addiction in early recovery. Few deny the neg-
ative consequences of nicotine addiction. However, it LIFE-THREATENING INTOXICATION STATES
has long been felt that pushing smoking cessation con- States of intoxication can be dangerous to patients,
currently with other addictions treatment puts the and associated belligerence can be dangerous to staff
person at greater risk for relapse to alcohol and other and other patients and may undermine treatment be-
drugs. Such beliefs do not appear to be supported by fore it has even begun. Life-threatening intoxication
empirical research, which has shown that smoking states are generally treated by specialists in emergency
cessation does not impair sobriety. On the contrary, medicine, but clinicians involved in the treatment of
data suggest that continued cigarette smoking may patients with CODs should be able to recognize poten-
make abstinence from other substances more difficult tially dangerous states in order to make appropriately
for patients (Gulliver et al. 2006). Cigarette smokers rapid referrals and initiate treatment. Two of the best-
are thought to be in a nearly constant state of with- studied medications are the opioid antagonist nalox-
drawal, and agitation from nicotine withdrawal may one and the benzodiazepine antagonist flumazenil,
impair an individuals ability to resist cravings and im- which are used for the treatment of opiate, benzodiaz-
pulses to relapse on other substance abuse. In one epine, and polydrug overdose.
study, smoking cessation during intervention for other Naloxone is parenterally active and binds with
substance abuse resulted in a 25% increased likelihood high affinity to all three subtypes of opioid receptors
of long-term (at least 6 months) sobriety from alcohol but is without intrinsic activity at the receptors. Thus,
or other drugs (Prochaska et al. 2004). In another in opiate-dependent patients, intravenous doses of
study, continued cigarette smoking was found to im- 0.050.4 mg may be given to patients with central ner-
pair recovery from alcoholism in measures of neu- vous system (CNS) depression and may be repeated
every 3 minutes until that depression is completely re- Alcohol. The prediction of need for detoxification
versed. For patients with respiratory depression, 2 mg and risk for severe withdrawal syndrome rests on the
intravenously is given, up to 10 mg. The half-life of patients reported history and knowledge of the alco-
naloxone at the level of the brain is much shorter than hol withdrawal syndrome. Mild to moderate with-
that of opioid agonists, so close monitoring of the pa- drawal includes anxiety, irritability, tremulousness,
tient and repeated administration of naloxone may be anorexia, insomnia, and mild cognitive and perceptual
necessary. Supportive treatment for the induced state changes. More severe withdrawal may include compli-
of opiate withdrawal should be provided as clinically cations such as autonomic instability with tachycar-
indicated. dia, hypertension, frank delirium, psychosis, and sei-
Flumazenil is a competitive antagonist at the cen- zures. Alcohol abuse may lead to dehydration, and
tral synaptic -aminobutyric acid (GABA) receptor, mild changes in vital signs can often be correlated with
which briefly antagonizes in a dose-dependent fashion excessive alcohol consumption. Restoring adequate
both benzodiazepine and nonbenzodiapine agonists at fluid intake may normalize all vital signs for such pa-
the GABA receptor (American Psychiatric Association tients. However, fever greater than 100.5F should not
2007). Flumazenil must be administered cautiously to be simply attributed to the alcohol withdrawal syn-
benzodiazepine- and polydrug-dependent patients, drome. A complete medical assessment may be war-
with the knowledge that withdrawal seizures may be ranted in order to rule out underlying disorders such
precipitated with GABA blockade. Patients who be- as urinary tract infections.
come obtunded or exhibit respiratory suppression may Traditional detoxification protocols may involve a
require it as an emergency lifesaving intervention. The loading and taper methodology. A standardized 4-day
effects and bioavailability of benzodiazepines usually protocol for alcohol withdrawal treatment might call
outlast flumazenil, requiring multiple administra- for the administration of 50100 mg of chlordiazepox-
tions of flumazenil to prevent relapsing into an intox- ide four times daily (or every 6 hours) on day 1; 50100
icated state. Patients should be managed without flu- mg three times (or every 8 hours) on day 2; twice (or
mazenil whenever possible (American Psychiatric every 12 hours) on day 3; and once at bedtime on day 4.
Association 2007). A flexible 4-day protocol might call for 50100 mg of
Special precautions are necessary when treating chlordiazepoxide every 46 hours as needed (e.g., if
patients who are showing signs and symptoms of both pulse exceeds 90 beats per minute, if diastolic blood
intoxication and withdrawal simultaneously. For ex- pressure exceeds 90 mm Hg, or if the patient exhibits
ample, patients with a blood alcohol level above 200 signs of withdrawal) on day 1; 50100 mg every 68
mg/dL (0.2) who show tachycardia, hypertension, and hours as needed on day 2; every 12 hours as needed on
tremulousness are at greater risk for withdrawal sei- day 3; and at bedtime as needed on day 4. Another
zures and DTs. Furthermore, patients with polysub- alternative is a front-loading protocol. A front-loading
stance dependence can be intoxicated from one sub- protocol for treating alcohol withdrawal with chlor-
stance while in withdrawal from another, necessitating diazepoxide might call for 50100 mg of chlordiazepox-
caution and careful monitoring to safely begin detoxi- ide as often as every 24 hours until signs of with-
fication. drawal are controlled, then 50100 mg every 46 hours
as needed on day 1, and 50100 mg every 46 hours as
DETOXIFICATION AND W ITHDRAWAL needed on days 2 and 3. No doses may be needed on
What is detoxification? Volumes of scholarly articles days 2 and 3, because the long half-life of chlordiaz-
have been written on this subject, but detoxification epoxide allows it to self-taper while withdrawal symp-
can be defined as intervention that manages an indi- toms are controlled. (These withdrawal treatment pro-
vidual safely through the process of acute withdrawal tocols are drawn from Prater et al. 1999 and Burant
(McCorry et al. 2000, p. 9). Detoxification of a patient 1990.)
on a CODs unit should include ongoing evaluation A substantial body of evidence supports benzo-
and refining of the psychiatric diagnoses. Detoxifica- diazepines as the drugs of choice for ameliorating the
tion is a necessary acute intervention in the treatment symptoms of alcohol withdrawal. There are advan-
of many SUDs; to be clinically useful, it must be inte- tages and disadvantages to the long- and short-acting
grated into the continuum of treatments. Connecting benzodiazepines. Various protocols for the use of long-
safe and humane detoxification to long-term psychiat- acting benzodiazepines, including using loading doses
ric and substance abuse treatment helps to save and monitoring the patient as the long-acting benzo-
money and prevents needless further suffering. diazepine self-tapers, are well documented. Many
studies have shown the utility of long-acting benzodi- Jager 1984; Rathlev et al. 1994). The use of -blockers,
azepines such as diazepam and chlordiazepoxide, but clonidine, and other antihypertensives has been
their erratic absorption intramuscularly and their as- shown to be useful in the treatment of tachycardia and
sociation with sedation and cognitive impairment hypertension not well controlled by adequate doses of
both in patients with hepatic dysfunction and in the benzodiazepines, but these do not prevent seizures nor
elderly have led to the use of other benzodiazepines for delirium (Center for Substance Abuse Treatment
alcohol detoxification. Lorazepam and oxazepam, 2006). Additionally, their use can mask withdrawal,
with their lack of active metabolites, moderate half- potentially leading to underdosing of necessary benzo-
lives, more predictable intramuscular absorption, and diazepines.
pharmacokinetics less affected by age and liver dis- All patients suspected of alcohol abuse should be
ease, have become popular with some clinicians. How- started on a multivitamin with minerals as well as 100
ever, there are concerns that short-acting benzodiaz- mg daily of supplemental thiamine. Some clinicians
epines may require more frequent dosing and longer recommend parenteral or even intravenous thiamine
periods of monitoring. These shorter-acting benzodi- administration as well as additional thiamine supple-
azepines may be preferred for patients with compro- mentation, particularly in the presence of Wernickes
mised hepatic functioning, whereas longer-acting ben- encephalopathy. However, experimental data are lim-
zodiazepines may be preferred for DTs and seizure ited, and at the time of this writing, data are insuffi-
prophylaxis in most other patients. Further research is cient to guide decisions about dosage, frequency, route
needed to clarify the relative risks and benefits of the of administration, or duration of thiamine replace-
various types of benzodiazepines. ment therapy for the treatment or prevention of Wer-
Benzodiazepines are essential to providing humane nickes encephalopathy or Wernicke-Korsakoff syn-
detoxification from alcohol, and a primary goal of their drome in patients with alcohol abuse (Day et al. 2004).
usage is the prevention of seizures and delirium tre- Some clinicians favor folate supplementation as well,
mens. Although it is hoped and often thought that ad- but data supporting this practice are limited. If folate is
equate dosages of benzodiazepines given early enough given, the failure of the mean corpuscular volume to
in the alcohol detoxification process will prevent DTs normalize should arouse suspicion of a vitamin B 12
(Center for Substance Abuse Treatment 2006), the deficiency. Additional mineral supplementation may
data to support this contention are lacking. Further- also be important in malnourished alcoholic patients.
more, once DTs are established, high doses of benzo-
diazepines do not abort the syndrome rapidly but Sedative-hypnotics. The issues involved in sedative-
nonetheless remain vitally important in the safe man- hypnotic intoxication, dependence, and detoxification
agement of patients. Patients with DTs require trained are similar in many respects to those discussed in the
clinical observation for withdrawal or excess sedation. treatment of alcohol dependence. However, extreme
Severe DTs, with autonomic instability, fever, and in- alcohol intoxication can be life threatening, whereas
ability to maintain adequate oral nutrition, is beyond overdose on benzodiazepines alone is rarely fatal. The
the capabilities of most CODs units and may require combination of high-dose benzodiazepines with other
intensive care unit monitoring and treatment. CNS depressants such as alcohol or opiates must be
Although benzodiazepines are central to the atten- managed aggressively to prevent mortality.
uation of moderate to severe alcohol withdrawal syn- When possible, gradual detoxification by tapering
drome, other medications may be employed. For dosages from benzodiazepines is the ideal. However,
severe withdrawal with psychosis, the use of high- many patients who take benzodiazepines have anxiety
potency antipsychotics can decrease the need for very- disorders, and even very slow detoxification will result
high-dose benzodiazepines, which can result in para- in flares of anxiety symptomatology; it is very difficult
doxical disinhibition, falls, and toxic confusion and de- to ascertain whether these symptoms are due to the
lirium perhaps caused by the benzodiazepines them- withdrawal process or represent the patients underly-
selves (Center for Substance Abuse Treatment 2006). ing anxiety. This clinical conundrum makes it very
Anticonvulsants have been utilized especially in Eu- difficult to detoxify benzodiazepine-dependent pa-
rope for the treatment of alcohol withdrawal, with tients on an outpatient basis, and the patients may do
carbamazepine and valproic acid the best studied (Mal- best on an inpatient unit. However, the length of stay
colm et al. 2001; Reoux et al. 2001). Dilantin has not on inpatient units is usually quite brief, and it is gen-
been shown to be effective in preventing alcohol with- erally not safe to rapidly taper benzodiazepine-depen-
drawal seizures (Chance 1991; Hilbon and Hjelm- dent patients (Ashton 2005; Center for Substance
Abuse Treatment 2006). Anticonvulsants such as car- tion of tapers and monitoring to minimize withdrawal
bamazepine, valproate (Dickinson et al. 2003; Rickels symptoms. Buprenorphine and methadone may also
et al. 1999), and gabapentin have proven quite helpful. be useful, but special caution may be warranted to
The anticonvulsants may be initiated and raised more minimize the risk of respiratory suppression. A thor-
rapidly in benzodiazepine-dependent patients while ough discussion of pharmacotherapy for opioid detox-
the patient is simultaneously stabilized and then ta- ification is beyond the scope of this chapter; clinicians
pered off the benzodiazepines. are urged to consult addictions treatment textbooks
To safely taper patients off CNS depressants such and other clinical resources that deal with this subject
as benzodiazepines and alcohol, symptom-triggered in more detail.
administration of benzodiazepines has proven effec- The half-life of the abused opiate determines the
tive and safe. The Clinical Institute Withdrawal As- peak of the opiate withdrawal symptomatology. Her-
sessment of Alcohol ScaleRevised (Sullivan et al. oin withdrawal peaks at 3672 hours, whereas oxy-
1989) is commonly utilized. Symptom-triggered med- codone and methadone peak at 7296 hours (Kosten
ication administration allows treatment to be tailored and O Connor 2003). Even after the symptoms of
to the individual patients needs, and when properly acute withdrawal have subsided, persistent fatigue, in-
done, it avoids the under- and overmedicating of pa- somnia, and dysphoria may last for weeks to months,
tients that can occur when medications are given ac- and Goldstein and Volkow (2002) have shown signifi-
cording to standardized protocols. cant changes in brain functioning persisting for a year
post abstinence. This delayed abstinence syndrome
Opiates. Although symptom-triggered medication may contribute to the high rate of relapse seen in pa-
administration is quite effective for alcohol- and ben- tients who are detoxified but not engaged in either
zodiazepine-dependent patients, this may be problem- long-term rehabilitation or maintenance treatment.
atic with opioid-dependent patients. The signs of opi- For many patients, long-term maintenance on meth-
oid withdrawal include anxiety, irritability, agitation, adone or buprenorphine may be appropriate.
mydriasis, diarrhea, vomiting, piloerection, yawning,
rhinorrhea, lacrimation, and anorexia. Seizures and Stimulants. Although detoxification from CNS de-
delirium do not occur. However, before the physical pressants such as alcohol and benzodiazepines may
signs and symptoms become evident, there is an emer- result in life-threatening physiological problems, the
gence of dysphoria, anxiety, irritability, and agitation; detoxification from CNS stimulants does not usually
thus, symptom-triggered medication administration, involve severe physiological morbidity. However,
which relies on vital signs and objective criteria, will abrupt discontinuation of stimulants can lead to de-
leave the patient in great subjective distress. The dis- pression and a sense of hopelessness that puts patients
satisfaction the patient feels with the detoxification at risk for suicide even in the protected environment of
process can decrease patient retention in treatment the hospital (Coffey et al. 2000; Cottler et al. 1993).
and may impair the therapeutic alliance between pa- Although this state of intense dysphoria can be persis-
tient and staff. Psychotherapeutic interventions and tent, it often improves after a few days (Coffey et al.
improved staff education, as discussed elsewhere in 2000). Although there is a growing body of literature
this chapter, may have a special role for improving the both on the lasting CNS effects of stimulant depen-
therapeutic alliance with patients undergoing opioid dence and possible medication treatments of stimu-
detoxification. Additionally, protocols are available for lant dependence, no agents have shown reliable effi-
the use of clonidine and clonidinenaltrexone for the cacy in ameliorating the symptoms of withdrawal
treatment of patients undergoing opioid detoxification (Kosten and OConnor 2003).
(Kleber 1999). A sample clonidine-aided opioid detox-
ification protocol for patients with short-acting opioid Nicotine. Nicotine dependence is very common in
dependence might call for 0.10.2 mg of clonidine patients with psychiatric and other substance abuse
three times a day (or every 4 hours), up to 1 mg, on day issues and is associated with significant morbidity and
1; 0.10.2 mg three times a day (or every 4 hours), up mortality. Pharmacological treatments include forms
to 1.2 mg, on days 2 through 4; and a specified taper of nicotine replacement and bupropion. For an excel-
protocol (e.g., reduce dosage by half each day) from day lent review of the treatment of nicotine dependence,
5 until detoxification is completed (Kleber 1996). the reader is referred to the American Psychiatric As-
Clonidine may also be used to aid in the detoxification sociations (2007) revised Practice Guideline for the
of methadone-maintained patients, but detoxification Treatment of Patients With Substance Use Disorders.
may take longer and may require additional modifica- Varenicline, which functions as a partial agonist at the
nicotine receptor, shows some promise for the treat- 4. Whether the psychiatric symptoms are commonly
ment of nicotine dependence (Oncken et al. 2006), but seen in the postacute withdrawal state.
data are insufficient to endorse its use in the acute
hospital setting at this stage. The U.S. Food and Drug Although the recommendations for psychophar-
Administration has recently raised concerns about po- macological treatment of patients with and without
tential serious neuropsychiatric side effects of the CODs are largely identical, there is controversy re-
drug. garding the usage of psychotropic medications with a
known abuse potential, such as sedative-hypnotics,
Cannabis. Contrary to the view of some clinicians
stimulants, and opiates. These medications may be
and patients, marijuana (cannabis) has been associ-
ated with complicating the course and treatment of utilized successfully if carefully monitored. Education
of the patient and other caregivers, coupled with mon-
co-occurring psychiatric disorders. In vulnerable indi-
itoring of the quantity prescribed and refill dates, can
viduals, cannabis abuse is associated with new-onset
help to lessen the risks these medicines may pose to
psychosis and earlier onset of psychosis as well as in-
patients with CODs.
creased risk of other substance abuse (American Psy-
Psychopharmacological treatment in the postwith-
chiatric Association 2007). The genetics underlying
the vulnerability for cannabis-related psychosis are be- drawal period of the SUD per se may be initiated on
the CODs unit. Emphasis on informed consent en-
ing investigated (DSouza 2007). Withdrawal symp-
sures that thoughtful caution will be exercised. For
toms include significant anxiety, dysphoria, insomnia,
example, disulfiram should be avoided in a patient
and nightmares. No specific pharmacotherapies have
who for neuropsychiatric reasons cannot appreciate
been proven efficacious in treating cannabis with-
the risks of alcohol ingestion on this medication.
drawal, nor in preventing relapse, at this time.
Appropriate treatment of comorbid mental illness
Further reading. Withdrawal syndromes are discussed has been shown to improve outcomes for patients with
in more detail in substance abuse treatment textbooks SUDs, although research on maintenance pharmacol-
(see, for example, Galanter and Kleber 2008; Lowinson ogy for patients with CODs is currently lacking (Cor-
et al. 2005), which typically include detoxification pro- nelius et al. 2003). Successful treatment of psychiatric
tocols as well. symptoms has been found to lower rates of comorbid
substance abuse in patients with schizophrenia (Green
POSTDETOXIFICATION PSYCHOPHARMACOLOGICAL et al. 2007; Scheller-Gilkey et al. 2003). Patients with
TREATMENT comorbid anxiety disorders and SUDs may find anxi-
olytics such as buspirone helpful in lessening reliance
One of the central challenges of the CODs unit is the
on substances of abuse (Cornelius et al. 2003; Petti-
initiation of medications for maintaining sobriety.
nati et al. 2003). Patients with comorbid PTSD and al-
Postdetoxification medications are utilized both in the
treatment of substance dependence and in the treat- cohol dependence had both improved PTSD symp-
toms and decreased alcohol consumption following
ment of CODs. There is no evidence to suggest that
treatment with sertraline (Brady et al. 1995). Patients
duration of treatment of psychiatric disorders is differ-
with comorbid alcoholism and major depression may
ent in patients with co-occurring SUDs, but the tim-
find selective serotonin reuptake inhibitors and tricy-
ing of the initiation of treatment is controversial. For
clic antidepressants helpful (Cornelius et al. 2003).
example, there are abundant data showing that clini-
cally significant depression and anxiety commonly co- However, some questions remain. Antidepressants
appear to reduce drinking in depressed alcohol-abus-
exist with opiate and alcohol dependence disorders;
ing men but not depressed alcohol-abusing women
there are also data suggesting that with weeks to
(Graham and Massak 2007). Furthermore, data are
months of sobriety, a significant proportion of these
mixed concerning the use of antidepressants for the
patients improve. Clinicians must consider many fac-
treatment of severe SUDs; selective serotonin re-
tors, including the following (American Psychiatric
Association 2007): uptake inhibitors appear less effective for patients
with more severe alcoholism and more severe depres-
1. Whether the psychiatric disorder(s) predates the sive symptoms, for example (Pettinati et al. 2003). It is
onset of substance dependence unclear what role, if any, anticonvulsants and mood
2. The status of the psychiatric disorder during peri- stabilizers might play in the long-term pharmacother-
ods of sobriety apy of patients with CODs. Lithium has not yet been
3. Family history of psychiatric illness studied for comorbid bipolar affective disorder and
SUDs, but it has been studied for alcoholic patients in treatment, because they provide an opportunity for
with depression and those with no affective disorder, patients to learn to share uncomfortable thoughts and
and in both cases it was not associated with increased emotions and to build deeper relationships. A strong
abstinence from alcohol (Cornelius et al. 2003). therapeutic relationship can also assist in the manage-
ment of the unit milieu by building trust and promot-
DRUGDRUG INTERACTIONS ing a feeling of safety. Patients are often uncomfortable
and even irritable when they enter treatment and will
Patients admitted to a CODs unit will not only have
better respond to someone with whom they have a
both classic psychiatric disorders and SUDs, but many
positive relationship. There may be some concern
will also have medical complications of these ill-
over staffing constraints, but individual sessions can
nesses; thus, multiple medications are often utilized
be brief and still yield positive results.
in their treatment and detoxification. The potential
for clinically significant drugdrug interactions is ever
present. Even top physicians cannot know every po- COGNITIVE-BEHAVIORAL THERAPY
tential drugdrug interaction; it appears that the best Cognitive-behavioral therapy (CBT) has been shown
practice is to have a system in place to alert the med- to be effective in the treatment of many disorders, in-
ical doctor to the probability and severity of potential cluding addiction, depression, and anxiety. The basic
pharmacological interactions. Pharmacy software pro- premise of CBT is that our thoughts result in emo-
grams now routinely alert the nursing and physician tional responses that, in turn, motivate behavior. If
staff to potential problems; if properly implemented, thoughts are negative or irrational, then the result will
they may improve patient safety. be negative emotions and problematic behavior. CBT,
Computer-assisted monitoring of known potential offered in individual sessions or in groups, can help
drugdrug interactions is ideally suited to supplement patients to identify situations that trigger irrational
but not supplant physician knowledge of pharmacology thinking and negative emotions. Once the anteced-
and careful monitoring of patients response to the ents to the behavior have been identified by the pa-
medications introduced. In addition to the very specific tient, the work will focus on assisting the patient in
knowledge of whether a medicine induces or inhibits a cognitive restructuring. Becks cognitive therapy, al-
particular cytochrome system and how this will affect though it focuses more on changing thoughts rather
the next medications efficacy and toxicity, the more than behaviors, is a similar model (National Institute
general clinical evaluation of the patients global condi- on Drug Abuse 1998).
tion must be considered. For example, because a small Analyzing the consequences of the problem behav-
number of patients in France had lethal respiratory de- ior is also an important part of the process. Patients of-
pression when intravenous buprenorphine was com- ten have a difficult time understanding why they con-
bined with intravenous high-potency benzodiazepines, tinue to behave in ways that cause problems. Teaching
many computer programs and pharmacological review patients to identify the consequences of their behavior
papers will caution about the combination of oral ben- reinforces why they continue to engage in behaviors
zodiazepines with sublingual buprenorphine; in fact, that have negative consequences for them. It also al-
there are very few clinical problems reported with this lows them to begin to think about finding healthier
commonly used combination. However, the patients ways to produce similar positive results. Finally, iden-
overall clinical status must be carefully considered. The tifying negative consequences of the behavior serves as
combination of benzodiazepines and buprenorphine in a way to motivate change; however, one of the main
patients taking methadone is particularly dangerous. goals of CBT is to facilitate the patients access to pos-
Patients who are grossly sedated from other causes, itive alternatives.
such as alcohol intoxication, should be administered CBT for CODs may involve helping patients to re-
benzodiazepines and buprenorphine with caution. learn new responses to cues for substance abuse and
Many Web sites are available where medical staff may include coping skills training, because substance
may access data regarding drugdrug interactions. Two abuse is often indicative of poor coping skills (Kadden
Web sites popular at the time of this writing are http:// 2003). In the Matching Alcoholism Treatments to Cli-
www.uptodate.com and http://www.epocrates.org. ent Heterogeneity (Project MATCH) study, outpa-
tients preferred CBT over motivational enhancement
Psychotherapies and 12-Step therapies (Donovan et al. 2002). Dual-
Relationships formed with treatment staff can be focus schema therapy (24-week manual-guided CBT
among the most powerful experiences the patient has model with integrated relapse prevention and targeted
intervention) shows promise for treating individuals as well as those for whom other therapies have failed
with co-occurring substance abuse and personality dis- (Petry et al. 2001).
orders (Ball 1998). A CBT training manual is available
from the Project MATCH study (Kadden et al. 1992). RELAPSE PREVENTION THERAPY
Relapse prevention therapy (RPT; Weiss et al. 1999) is
MOTIVATIONAL INTERVIEWING OR MOTIVATIONAL a type of psychotherapy focused specifically on relapse
ENHANCEMENT THERAPY prevention; it combines several different elements,
Motivational interviewing and motivational enhance- overlaps with skills-training methods (Kadden 2003),
ment therapy (MET) have also been used to treat pa- and is distinct from relapse prevention, an important
tients with CODs. Essentially, motivational inter- component of any treatment plan. Research has
viewing is meeting the client where he or she is in shown mixed results for RPT as a psychosocial treat-
terms of readiness to change, and working with the ment for substance abuse. It appears to be better than
person to resolve any ambivalence. One might use a no treatment, but there is less evidence to suggest that
pros and cons list, for example. MET, a time-limited, it is any better than other treatments for long-term re-
adapted form of motivational interviewing, can also be sults (Schmitz et al. 2004). Most studies, however,
integrated into group therapies. A group designed to support the use of RPT for smoking cessation (Carroll
enhance motivation might look at positive conse- 1996). If RPT is used, it may be most helpful as an ad-
quences of remaining sober compared with the nega- junct to standard treatment.
tive consequences of substance abuse. Either approach
can be used in conjunction with CBT, for example, in DIALECTICAL BEHAVIOR THERAPY
a phased approach, using motivational interviewing Dialectical behavior therapys (DBT) ability to address
first, until the patient is sufficiently motivated for the affect dysregulation may have significant potential for
work of CBT (National Institute on Drug Abuse helping patients with CODs, such as individuals with
1998). In a study with psychiatric and dually diag- PTSD and comorbid substance abuse. Research in this
nosed inpatients, those from both groups who received area has been scant. However, DBT has been shown to
motivational interviewing in addition to standard be more effective than treatment as usual for patients
treatment were more likely to attend their first outpa- with drug dependence and borderline personality dis-
tient appointment (Swanson et al. 1999). This ap- order, as evidenced by greater reductions in drug
proach involves better and more frequent measure- abuse, improvement in treatment retention, and
ment of readiness to change and stages of change in greater gains in global and social adjustment at follow-
addictions treatment. It may therefore be helpful in ups (Linehan et al. 1999). For heroin-dependent
matching treatment plans to individual patient needs women with borderline personality disorder, DBT ap-
(DiClemente et al. 2004). MET enjoyed high patient pears to be effective in reducing opioid abuse, main-
satisfaction rates in the Project MATCH study (Dono- taining reductions in use, and improving the accuracy
van et al. 2002), and as with CBT, training manuals of self-reported substance abuse (Linehan et al. 2002).
are available (Miller et al. 1992).
SUPPORTIVE PSYCHOTHERAPY
CONTINGENCY MANAGEMENT
Supportive psychotherapy, which typically follows a
Contingency management can also be added as an ad- strengths-based perspective, is often useful for estab-
junct to standard treatment, and it has been shown to
lishing a strong therapeutic alliance, which can be dif-
improve abstinence rates (Prendergast et al. 2006).
ficult in patients with CODs. It may be helpful for be-
This approach involves providing incentives or vouch-
ginning to build healthy coping skills even in resistant
ers to the patient for success; incentives may include
patients (Winston et al. 2004). Supportive psychother-
cash, prizes, privileges, and other rewards for meeting
apy can be integrated with other therapeutic methods,
treatment goals. Contingency management seeks to such as motivational interviewing, MET, or RPT.
identify specific goals for achievement, such as group
attendance, drug abstinence, continuing to take med-
icines, and other clinically significant progress. Use of
OTHER THERAPIES AND CONCLUDING POINTS
contingency management or its addition to standard Interpersonal psychotherapy follows an exploratory ap-
treatment may be helpful for patients with a wide proach, aiming to connect substance use to deficits in
range of psychiatric conditions (Weinstock et al. 2007) interpersonal functioning. In this approach, substance
abuse is a symptom of other problems, so therapy may ACTIVITY GROUPS

not address SUDs as directly as other therapies (Na-
Weaving in a variety of activities for patients is helpful
tional Institute on Drug Abuse 1998). Interpersonal
in several ways. It provides a model for practicing
therapy has been reviewed positively for the treatment
healthy alternatives, serves as a way for patients to be
of psychiatric illnesses and has been adapted for use in
exposed to social situations, fosters group cohesive-
groups, but it is not well studied for treating CODs or
ness, and allows for stress reduction. Some examples
substance abuse (DiClemente et al. 2003).
of group activities might include meditation, yoga, art
Similarly, psychodynamic therapy and rational
therapy, recovery games, and various exercise groups.
emotive therapy have received mixed results in sub-
stance abusing populations and are not currently rec-
ommended for the treatment of SUDs (DiClemente et
SPIRITUALITY GROUPS
al. 2003). Dealing with spiritual issues is an important aspect of re-
Marital and family therapy, however, shows signif- covery. The limited research available on religion and
icant promise in the treatment of substance abuse and spirituality in addictions treatment supports the widely
CODs. Behavioral couples therapy has been shown to accepted notion that spirituality and religious involve-
be effective for treating SUDs, reducing the cost of ment are strong protective factors against substance
treatment and improving clinical outcomes as well as abuse and dependence and that addressing spirituality in
psychosocial consequences of problematic substance substance abuse treatment may improve outcomes for
use (Fals-Stewart et al. 1997). Because therapeutic ap- many patients (Miller 1998). Spirituality may also suc-
proaches may vary and different therapies may be used cessfully reach some of the most challenging clients in
in marital and family therapy, additional research is substance abuse treatment; inner-city drug users, for ex-
needed to determine which models are most effective ample, found a Buddhist-based, spirituality-focused ther-
for patients with CODs. apy helpful for increasing motivation (Beitel et al. 2007).
Researchers in the Project MATCH study found Spiritual needs of people with CODs vary depend-
that patient satisfaction with the mode of therapy is ing on the diagnoses. People with SUDs often benefit
associated with higher levels of attendance, greater re- from talking about relationships, core values, and
ductions in problematic substance abuse, and im- hopes for the future. Most have witnessed themselves
proved outcomes at the conclusion of treatment behaving in ways that do not match what they truly be-
(Donovan et al. 2002). Echoing the concerns of the lieve is right. Many patients describe guilt and shame
Center for Mental Health Services and the Institute of related to this or related to their behaviors or to their
Medicine, research suggests that successful treatment illness in general. However, needs may differ signifi-
requires well-integrated therapeutic programming cantly among different diagnoses. People with schizo-
that addresses a patients stages of change and readi- phrenia, for example, may be less focused on relation-
ness to change as well as the relationship between ship building and more focused on being part of a safe,
SUDs and other psychiatric disorders. Individualized accepting, and compassionate environment.
treatment plans, highly skilled staff, and flexible clin-
ical resources may improve clinical response to psy- 12-STEP GROUPS
chotherapies for patients with CODs. 12-Step groups, such as Alcoholics Anonymous (AA)
and Narcotics Anonymous (NA) enjoy a well-deserved
Group Programming reputation for their effectiveness in reducing sub-
stance abuse (Humphreys 2003). Inpatient settings,
SKILLS-BUILDING GROUPS such as the CODs unit, offer a valuable opportunity to
Patients with CODs have a variety of skills deficits, in- introduce patients to these groups as well as to support
cluding social skills, leisure and vocational skills, and continued involvement with the groups following a re-
occasionally even the skills necessary to engage in the lapse. 12-Step groups enjoyed high patient satisfaction
activities of daily living. Daily skills-building groups ratings in the Project MATCH study (Donovan et al.
might include assertiveness training, giving and receiv- 2002), and manuals for staff training are readily avail-
ing compliments, dealing with anger, time manageable (Nowinski et al. 1992). Attendance at self-help
ment, goal setting, leisure skills, and developing meetings is a critical component of membership in 12-
healthy alternatives. Group and individual time should Step groups, and these communities can form a sup-
also focus on assisting patients to become more profi- portive social network for patients to support contin-
cient in activities of daily living. ued abstinence following discharge.
Critics of 12-Step groups have identified some con- changed when there is a significant change in risk
flict between what patients learn about their behaviors factors. There should be a plan in place for dealing with
in the groups and what they learn in CBT (National In- patients found in possession of illicit drugs. Discharge
stitute on Drug Abuse 1998). In the 12-Step model, is sometimes an option but may not be possible if the
addiction is a disease over which the individual is pow- patient has an unstable COD. The Web site for the Sub-
erless, whereas CBT teaches patients that addiction is stance Abuse and Mental Health Services Adminis-
a learned behavior that can be unlearned. Nonetheless, trations Center for Excellence in the treatment of
CBT and AA can be integrated into an effective relapse CODs (www.coce.samhsa.gov) has numerous re-
prevention plan by focusing on individual needs and sources to assist unit administrators in implementing
goals. Patients should be aware that they may hear sound risk management practices on the CODs unit.
conflicting information regarding the use of psychotro-
pic medication, because some individuals in recovery Suicide
groups advocate complete and total abstinence from all The risk of patient suicide is a serious concern for cli-
psychotropic substances based on the assumption that nicians on the CODs unit. Suicide risk assessments
total abstinence will alleviate psychological symp- are a requirement for accreditation by the Joint Com-
toms. This is rarely true for individuals with CODs, so mission (2008). Individuals with CODs often have nu-
patients should be fully informed about the nature of merous markers for suicide risk, and these risk factors
their illnesses prior to discharge. Despite limitations may compound one another, particularly in interac-
to 12-Step groups and other self-help models, many tions between certain psychiatric diagnoses and spe-
patients credit them with improved abstinence from cific types of substance abuse. Knowing the risk factors
relapse. may improve the accuracy of a risk assessment, allow-
ing clinicians to identify and monitor those patients
EDUCATION GROUPS most at risk and to select interventions that address pa-
Education groups should include illness education for tients needs, thereby minimizing the risk of suicide as
the CODs, medication education, nutrition education, well as reducing the need for seclusion or restraint.
and information about available community supports. Affective disorders carry a 15% lifetime risk of sui-
Providing education can result in increased under- cide and compose 50%70% of completed suicides; the
standing and awareness, can assist patients in feeling high-risk profile includes anxiety or panic symptoms
more control around managing their illness, and may or moderate alcohol abuse (Jacobs et al. 1999). Schizo-
decrease shame and guilt. Techniques to enhance mo- phrenia carries a 10% lifetime risk of suicide and ac-
tivation and awareness are particularly useful. counts for 10%15% of completed suicides; the high-
risk profile is a formerly high-functioning person or the
OTHER GROUPS presence of depressive symptoms (Jacobs et al. 1999).
SUDs carry a 2%3% lifetime risk of suicide and ac-
Other groups that may be included in the therapeutic count for 15%25% of completed suicides; the high-
programming of a CODs unit include CBT groups, risk profile includes interpersonal loss or comorbid de-
family education and support groups, relapse manage- pression (Jacobs et al. 1999). Additionally, [s]ubstance
ment and prevention groups, and discharge prepared- abuse is associated with greater frequency and repeti-
ness groups. Aspects of these groups are addressed tiveness of suicide attempts, more medically lethal at-
elsewhere in this book. tempts, more serious suicidal intent, and higher levels
of suicidal ideation (Moscicki 1999, p. 47). Cocaine
abuse is a contributor to completed suicide and a risk
Risk Management and Safety factor for attempted suicide (Moscicki 1999).
Alcohol abuse increases the risk of suicide in both
There are many safety issues that arise on a CODs unit, alcoholic and nonalcoholic persons. Up to 50% of in-
including suicidal behavior, use of illicit drugs, unstable dividuals who commit suicide were drinking at or near
psychiatric symptoms, and aggressive behavior. It is im- the time of death, and 89% of alcoholic persons who
portant to have procedures in place to monitor patient commit suicide were drinking at the time of their sui-
activity and status. An observation status reflecting the cide (Jacobs et al. 1999). In suicides where multiple
patients level of functioning and potential risk should substance abuse is involved, alcohol is the substance
be ordered by the physician and monitored by staff. The most frequently found (Moscicki 1999). Alcohol mis-
observation status should be reviewed at least daily and use is a well-known risk factor for suicide for all age
groups, including the elderly (Waern 2003) and youth Successful treatment of SUDs and comorbid psy-
(Moscicki 1999). Adverse consequences of alcohol chiatric illness reduces the risk of suicidal behavior, in
misuse on the life course of a patient are common dur- part by reducing two of the major risk factors for sui-
ing the last months of life in alcoholic persons who cide. Unit supervisors and other clinicians seeking to
complete suicide (Pirkola et al. 2000). Future suicide improve the management of suicidal patients will find
attempts in alcohol-dependent patients are more com- the American Psychiatric Associations practice guide-
mon when the patient has the following risk factors lines and the Center for Substance Abuse Treatments
(Preuss et al. 2003): TIPs especially helpful. TIP 42 includes a section de-
voted especially to management of suicidality in pa-
Prior suicide attempts tients with CODs. The CODs unit staff must be
Younger age aware of the increased suicide risk among patients
Separated or divorced with CODs and must implement a correspondingly
Other drug dependence higher level of safeguards on the inpatient unit than is
Substance-induced psychiatric disorders found in residential facilities or social-setting detox-
Indicators of a more severe course of alcoholism ification. Such safeguards might include quality im-
provement efforts targeting environment-of-care is-
Regarding the effect of alcohol abuse on suicide sues, lower staff-to-patient ratios, and 24-hour cover-
risk, Brady (2006) wrote: age by registered nurses, among others.
There is evidence to suggest alcohol misuse predis- Violence

poses to suicidal behavior through its depressogenic
effects and promotion of adverse life events, and both The treatment and prevention of violence is of utmost
behaviors may share a common genetic predisposi- importance in the care of patients with CODs. Active
tion. Acute alcohol use can also precipitate suicidal CODs increase the risk of violence (Scott et al. 1998),
behaviors through induction of negative affect and so risk assessments and measures to manage poten-
impairment of problem-solving skills, as well as ag-
tially violent patients should be firmly in place on any
gravation of impulsive personality traits, possibly
through effects on serotonergic neurotransmission. unit treating patients with SUDs. Generally speaking,
(p. 473) the greater the number of comorbid diagnoses, the
greater the risk of violence. A comorbid SUD was
Comorbid factors increase risk level and can poten- found in three-quarters of mentally ill homicide of-
tially interact to compound risk. Comorbid mood dis- fenders, and the presence of a triple diagnosis (in-
orders and SUDs are associated with an increased le- volving antisocial personality disorder, psychotic men-
thality risk (Moscicki 1999). Furthermore, research tal illness, and SUD) was found in roughly half of all
has uncovered strong evidence suggesting a possible homicide offenders with a psychotic illness (Putkonen
genetic link to suicide attempts among persons with et al. 2004).
alcohol dependence (Hesselbrock et al. 2004), recur- Beyond the triple diagnosis red flag, clinicians
rent early onset depression (Zubenko et al. 2004), and should learn to recognize additional risk factors that
bipolar disorder (Willour et al. 2007), underscoring the may increase the risk of violence in patients on the
importance of obtaining a thorough family history CODs unit. These other risk factors may include
during the evaluation and risk assessment. higher drinking levels, younger age, minority status,
General risk factors for suicide, such as family his- and the interaction of alcohol and cocaine (Chermack
tory of completed suicide, still apply equally to pa- and Blow 2002) as well as DTs, phencyclidine intoxi-
tients with CODs. It is therefore important for clini- cation, cocaine-induced paranoia, amphetamine
cians to follow general risk-management guidelines abuse, flunitrazepam (Rohypnol) intoxication, psycho-
for suicidal patients, taking into consideration the ad- sis, and agitation. Alcohol abuse is associated with in-
ditional risk factors specific to the patients particular creased severity in violence and resulting injuries (Mar-
diagnoses and individual situation. One should also tin and Bachman 1997) and is frequently involved in
consider the risk of suicide postdischarge, inquire family violence and child abuse (Yudko et al. 1997).
about availability of lethal means (such as firearms), Among early onset drinkers (i.e., problematic drinking
provide psychoeducation to patients and family mem- before age 20 years), low plasma levels of trypto-
bers about the increased risk of suicidality if the pa- phana precursor of 5-HTwere associated with
tient relapses, and provide phone numbers to call in high levels of depression and aggression (Pettinati et
the event of a relapse or other warning signs. al. 2003, p. 254). Patients with both cocaine and alco-
hol abuse have higher rates of criminal behavior, in- or only a substance use diagnosis (Sells et al. 2003).
cluding violent aggression (Denison et al. 1997), and Women with co-occurring schizophrenia and SUDs,
among patients in substance abuse treatment, violence for example, are at increased risk for violent victimiza-
perpetration is associated with alcohol and cocaine tion and HIV (Gearon and Bellack 1999). Intimate
abuse (Chermack and Blow 2002). The abuse of fluni- partner violence is highly prevalent and frequently bi-
trazepam, especially when used in conjunction with directional among suicidal psychiatric inpatients,
other substance abuse, such as alcohol, amphet- many of whom have CODs such as depression and al-
amines, or cannabis, is associated with a marked risk cohol abuse (Heru et al. 2006). As noted elsewhere in
for severely violent criminal behavior as well as im- this chapter, patients with CODs often misuse sub-
paired reasoning and empathy (Dderman et al. 2002). stances due to a lack of healthy coping skills. Poor con-
Among persons with severe mental illness, three flict resolution and poor anger management, com-
variables were found to have a cumulative association bined with maladaptive substance use (likely leading
with the risk of violent behavior: previous victimiza- to disinhibition), often contribute to the escalation of
tion by violence, the presence of violence in the sur- conflict and aggression in relationships of persons
rounding environment, and substance abuse (Swan- with CODs, which can further complicate the recov-
son et al. 2002). Mental illness per se is not a reliable ery process. The inpatient stay can be an ideal time to
predictor of violent behavior (Corrigan and Watson introduce patients and, possibly, their families, to con-
2005), but substance abuse is associated with an in- flict management skills and proper anger manage-
creased rate of violence in both mentally ill and non ment. Standardized, manual-guided group treatment
mentally ill persons (Steadman et al. 1998). Such vio- resources are available from numerous sources.
lence is most frequently targeted at family members Evidence suggests that successful clinical treatment
and friends and occurs most often at home (Steadman substantially reduces the risk of violence in substance-
et al. 1998). abusing patients, possibly by decreasing patient agita-
Given these troubling facts, clinicians must also tion and escalation. Integrating a contingency manage-
consider the risk of violence postdischarge and should ment model (token economy) for dually diagnosed pa-
incorporate a risk assessment and reduction plan in tients within an acute inpatient psychiatric ward was
the discharge planning if a risk of violence is present. found to result in decreased violence and increased pa-
Additional caution is warranted if a patient is known tient participation in group activities (Franco et al.
to have been violent in the past or on the unit, or if he 1995). Treatment for alcohol dependence has been
or she has shown warning signs for violent behavior. found to result in significantly decreased levels of inti-
Violent behavior in the previous year significantly pre- mate partner violence perpetrated both by individuals
dicted suicide, independent of alcohol misuse history in treatment and by their partners (Stuart et al. 2003).
(Conner et al. 2001). Violence prevention may also For patients with CODs and a history of trauma, not
perform a dual function, also reducing the risk of sui- only integrating treatments for psychiatric diagnosis
cide. Clinicians must remain conscious of the legal and substance abuse diagnosis but also addressing
duty to warn or to protect known intended victims of trauma issues may improve clinical outcomes (Morris-
potentially violent patients. This duty is articulated in sey et al. 2005).
the oft-cited case of Tarasoff v. Regents of the Univer- Seclusion and restraint should be used only as a
sity of California (1976), in which a troubled young remedy of last resort, when attempts to de-escalate a
man had expressed to his therapist his intention to kill patient through other clinical means have failed or
a young woman; he subsequently followed through on when there is imminent risk of physical harm to the
these threats, and the girls family sued numerous par- patient or to others on the unit. To minimize the risk
ties involved in the case. of violence, as well as reduce the use of seclusion and
Discharge planning and risk assessments should restraint, clinicians should carefully monitor the pa-
take into account not only the potential for violence tients treatment to ensure that clinical needs are met
perpetration but also the patients prior history and before agitation escalates.
current risk of violence victimization. Trauma and vic-
timization are risk factors for substance abuse and re- Discharge Against Medical Advice
lapse, and rates of violence victimization are likely to Discharge against medical advice is a frequent prob-
be high among patients treated on a CODs unit. Pa- lem in the treatment of patients with co-occurring
tients with CODs experience higher rates of violence SUDs and psychiatric illness. Criteria for holding a pa-
victimization than individuals with only a psychiatric tient with CODs should match that of the general psy-
chiatric inpatient population. If the patient presents important to make contact when the patient arrives in
an acute risk to self or to others, involuntary commit- the program in order to gather assessment informa-
ment for safety should be considered. The patient (and tion, and, at discharge, to review the course of treat-
his or her family, if possible) should be fully informed ment and outstanding issues to be addressed by the
of the risks associated with a discharge against medi- outpatient therapist.
cal advice. If involuntary commitment is not an op- Follow-up planning and patient placement can be-
tion, a 24-hour observation period is usually reason- come a challenge when working with people who have
able for patients with CODs; however, state law varies CODs, especially if they require long-term residential
by jurisdiction, and unit supervisors should be aware placement. Most residential programs are set up to
of the governing law and legal rights of psychiatric pa- work with either addictions patients or psychiatric pa-
tients. In the event that a patient discharges him- or tients, but rarely both. Addictions facilities may not
herself against medical advice, clinicians should have staff members trained to work with CODs or
record in the patients chart the reasons for the pa- may not be able to cope with the multiple problems
tients release and the rationale for recommending that can arise out of an exacerbation of the psychiatric
against discharge. condition. Medication management sometimes be-
comes an issue as well. In some cases, addressing the
patients CODs conflicts with the treatment philoso-
Discharge Planning phy of the program itself. On the other hand, facilities
working with patients with psychiatric illnesses may
The goal of discharge planning is to secure for the pa- not feel comfortable accepting addictions patients for
tient ongoing integrated treatment, supported by diag- fear of relapse and the impact of potential substance
nosis-specific interventions. Effective treatment for use on the premises.
dually diagnosed patients requires a comprehensive, For patients with hostility and more severe dimen-
long-term, staged approach to recovery; assertive out- sional psychiatric symptoms, retention in long-term
reach; motivational interventions; provision of help to treatment programs is difficult because they are at
clients in acquiring skills and supports to manage both higher risk for dropping out. For these patients, on-site
illnesses and to pursue functional goals; and cultural mental health services in long-term residential pro-
sensitivity and competence (Drake et al. 2001, grams seem to improve retention rates (Broome et al.
p. 469). Once the psychiatric condition is stable, par- 1999). Fortunately, there appears to be growing sup-
tial hospital and individual outpatient provider levels port for progressive models such as Assertive Commu-
of care can be useful as a stepdown option for people nity Treatment, which can be useful for delivering in-
with COD, because they provide opportunities to tegrated treatment (Essock et al. 2006), and the
practice healthy coping skills in the context of the per- Community Reinforcement Approach (Meyers and
sons own environment. The experience of having the Miller 2001). The latter may be a component of out-
support of a treatment program while working on re- patient discharge planning and sometimes includes
covery in a natural environment can help decrease de- contingency management approaches as well as a va-
nial about the challenges of the recovery process, in- riety of counseling services, including vocational
crease awareness of trigger situations, improve self- counseling, drug refusal training, and behavioral skills
confidence, and offer an opportunity for people to dis- (National Institute on Drug Abuse 1998).
cuss alternatives that are working as well as those they For individuals with CODs, sustained employ-
may need to change. Medications can be monitored ment is often viewed as a benchmark of successful
closely and adjusted as needed for both the SUD and treatment. Moreover, working has been correlated
any psychiatric disorder. with long-term improvements in self-esteem, self-
When planning outpatient follow-up care, there confidence, and feelings about life in general among
are several things to consider. Most often there will be adults with severe mental illness (Salyers et al. 2004).
a need for both an outpatient psychiatrist and a ther- In a study of veterans with severe SUDs in a partial
apist or case manager. It is helpful to establish patient hospitalization program, Kerrigan et al. (2000) found
preference as to location, type of therapy and gender of that returning to work was correlated with completion
the therapist. Transportation problems and any finan- of an alcohol or drug treatment program, placement in
cial restrictions that might interfere with follow- supported sober housing, and participation in work
through should be resolved prior to making a referral. therapy. Individual placement and support has shown
If the patient already has an outpatient clinician, it is some promise for improving employment and housing
outcomes for homeless veterans with psychiatric or a slip or exacerbation of illness. Helping patients to
substance use disorders (Rosenheck and Mares 2007). recognize the difficulty of change can help remove
Because financial difficulties and unstructured time some of the irrational thoughts, guilt, and shame that
are known risk factors for individuals with CODs, occur after relapse. People are often self-critical after
helping patients to obtain and retain gainful employ- relapse, and such thinking may actually reinforce the
ment is an important goal of treatment. Incorporating relapse rather than prompt help-seeking behaviors.
referrals to vocational rehabilitation or supported em- Relapse prevention discussions should focus on
ployment into the discharge plan may help to sustain helping the patient to recognize early warning signs of
treatment gains achieved during the inpatient stay. For relapse and to develop an action plan should they oc-
placement to be effective, however, it must be tailored cur. For example, staff may educate patients about de-
to the individual patients needs and preferences pression and how it can recur; early recognition and
(Becker et al. 2005). treatment of depressive symptoms may help the pa-
Leaving the hospital can be a frightening event for tient to avert a relapse to substance abuse. It is useful
patients. Length of stay is typically short and focused to talk about the difficulty of change and the impor-
on crisis stabilization. Patients may be entering unfa- tance of building a support network, especially in early
miliar facilities after discharge or may face severe psy- recovery. Relapse management and prevention can be
chosocial difficulties, such as family dysfunction or dealt with successfully in the group setting when re-
homelessness. In addition to presenting options for sources and time are limited, as is often the case on
follow-up, groups or clinical discussions about the pa- the acute inpatient unit.
tients discharge preparedness should include discus- When possible, family members should be in-
sion regarding the emotional aspects of leaving the cluded in the relapse prevention plan. Family mem-
safety of the hospital, what it might be like to enter a bers should be aware of triggers and symptoms in or-
new treatment environment, and fear of relapsing to der to assist the patient in relapse prevention, and
the addiction and/or other illness. families should agree on how to respond to warning
signs of an impending relapse. The patient and family
Relapse Management and Prevention members also need to reach an agreement as to what
During inpatient treatment the patient should be as- the family should do if a relapse does occur. Discuss-
sisted in developing an individualized relapse preven- ing and reaching an agreement beforehand can help
tion plan. For each high-risk situation, ideally the pa- family members to feel less conflicted if, for example,
tient should have a corresponding plan of action. they need to call a treatment provider following a re-
Teaching patients to anticipate high-risk situations lapse.
and to problem-solve ways to deal with them can de-
crease the risk of impulsive responses and falling back
Patient and Family Education
on dysfunctional coping mechanisms. Education Although it is difficult enough for someone to come to
should be provided about the various community self- terms with having a chronic illness of any kind, hav-
help programs, such as AA, NA, Double Trouble, and ing CODs comes with an additional challenge. Al-
Gamblers Anonymous, so these groups may be incor- though much has improved through the years, there
porated into the overall relapse prevention plan. still remains a certain stigma attached to both SUDs
Although it would be wonderful if prevention were and other psychiatric disorders. These misconcep-
the only issue related to relapse, clinicians must actions, biases, and judgments may be held by commu-
knowledge the reality that people often do slip back nity members, family, staff, and even the patient him-
into old patterns before making a successful change. or herself. Community and family support is impor-
The symptoms of psychiatric illnesses can return tant in the recovery process for both addictions and
through no fault of the patient, and a relapse manage- psychiatric disorders. Families can be of great help to
ment plan coupled with an ongoing treatment pro- the patient, and most would like to be. They may not
gram can make the difference in the opportunity for always know exactly how to help and may, in fact, re-
early intervention. Among substance abusers, individ- act in ways that have the opposite result they in-
uals with earlier onset of substance abuse and those tended. For patients experiencing family conflict, cli-
with comorbid psychiatric disorders (particularly ma- nicians should consider the possibility that intimate
jor depression) are more likely to relapse (Landheim et partner or other family violence may be occurring. The
al. 2006). It is important to help people understand link between substance abuse and such violence is
the importance of taking positive action in the event of well established, but families may need help to recog-
nize the importance of addressing family conflict and lated to suicide, violence, and discharge against medi-
the fact that treatment for substance abuse and men- cal advice.
tal illness can also help to reduce violence within the An inpatient stay on a CODs unit is a crucial event
family. Illness education and a support system for the in the life of a patient with both psychiatric illness and
family can make a big difference in the ability of the substance abuse and can be conceptualized as a tran-
family to provide support to the person in recovery and sition point in the recovery process. Treatment teams
to participate effectively in a relapse prevention plan. on CODs units work together to enable patients to
It has been shown that including families in treat- progress toward the next level of care while minimiz-
ment produces positive outcomes in the treatment of ing the risk of relapse. During hospitalization, patients
addictions. It is not always possible to meet individu- begin to build the skills, knowledge, and motivation to
ally with every family in a short-term acute inpatient abstain from substance misuse and to maintain gains
setting. Family education and support groups offer an achieved toward better psychiatric outcomes. The
excellent opportunity for families to come together and goals of treatment in a CODs unit are twofold: simul-
receive information and to network with other families. taneous resolution of medical and psychological crises,
Meeting families who are experiencing similar chal- so that patients may progress toward lasting, stable
lenges can be very healing. Families of patients with change.
psychiatric illnesses often feel different and can become
isolated from others. Introduction to community sup-
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CHAPTER 10
THE ADOLESCENT
NEUROPSYCHIATRIC UNIT
Developmental Disabilities and Mental Illness
Margaret E. Hertzig, M.D.
Pediatric neuropsychiatry is a rapidly evolving clini- entire panoply of psychiatric and behavioral disorders
cal discipline concerned with the diagnosis and treat- as they occur during the developmental years (Coffey
ment of behavioral and emotional symptoms in chil- and Brumback 2006). Despite this expansion of focus,
dren and adolescents with disturbances of brain traditionally organized psychiatric services are gener-
function. As such, it is not a new discipline, but in really well able to meet the needs of children and adoles-
cent years the growth of interest in and attention to cents whose behavioral and/or emotional disorders are
the neurological underpinnings of behavioral and not additionally complicated by significant cognitive
emotional impairment has been greatly enhanced by impairment. It is when behavioral and emotional dis-
advances in neuroscience, neuroimaging, and neuro- turbance is comorbid with mental retardation that
pharmacology. Increasingly, conceptualizations of specialized services specifically dedicated to the needs
neuropsychiatry are redefining the mindbrain dichot- of this subgroup of psychiatrically disturbed children
omy so that clinicians as well as investigators have and adolescents may be required.
come to accept without question that the brain is the Mental retardation is defined by significantly sub-
organ of the mind. Thus, the scope of pediatric average intellectual and adaptive functioning, with on-
neuropsychiatry has broadened to encompass consid- set before 18 years of age. Commonly used synonyms
eration of the neuropsychiatric underpinnings of the include intellectual disability, learning disability, and
159
developmental disability. The presence of mental re- of these conditions is relatively low. Combined, they
tardation has been recorded on Axis II of DSM since represented, at most, 16.5% of the total number of
1980, with the publication of DSM-III (American Psy- cases of mental retardation in 1950. Consequently, al-
chiatric Association 1980), and continues to be so lo- though improved medical interventions have pre-
cated in all subsequent revisions. The DSM-IV-TR vented thousands of cases of mental retardation, the
(American Psychiatric Association 2000) definition contribution to the overall prevalence of mental retar-
establishes an IQ of approximately 70 as obtained on dation is relatively small (Brosco et al. 2006).
an independently administered test of intelligence The increased prevalence of psychiatric disorder
coupled with impairment in adaptive functioning in at among individuals with mental retardation is well es-
least two of the following skill areas: communication, tablished, although reported rates vary significantly
self-care, home living, social/interpersonal skills, use from study to studyranging from a low of 10% to up-
of community resources, self-direction, functional ac- ward of 60% (State et al. 1997). Differences in preva-
ademic skills, work, leisure, health, and safety. The lence rates are the consequence of differences in diag-
measurement of both IQ and adaptive functioning nostic criteria employed, whether the sample was
may be affected by a range of factors, including the in- drawn from the community or from institutions, the
dividuals sociocultural background, native language, level of mental retardation, and the ages and gender of
and associated communicative, motor, and sensory the study sample (Dosen and Day 2001). The risk of
handicaps as well as education, motivation, personal- psychopathology in children and adolescents with
ity characteristics, social and vocational opportuni- mental retardation is most significantly increased
ties, and comorbid psychiatric and general medical with moderate cognitive impairment as compared
conditions (American Psychiatric Association 2000). with those with either mild or severe/profound intel-
Mental retardation is a heterogeneous condition. lectual disability (Holden and Gitlesen 2004; Kosken-
Individuals meeting criteria for a diagnosis of mental tausta et al. 2007). The term dual diagnosis is fre-
retardation display a broad spectrum of abilities and q ue n t l y u s e d t o d es c r i b e m e n t a l r e t a r d a t i o n
disabilities, liabilities and strengths. The prevalence of complicated by mental illness, although this use may
mental retardation is estimated at about 1% of the pop- be confusing to some because this term is also used to
ulation. Approximately 85% of persons with mental re- refer to the comorbidity of mental illness and sub-
tardation are classified as mildly retarded (IQ level 50 stance abuse (American Academy of Child and Ado-
70), 10% as moderately retarded (IQ level 3555) 3% lescent Psychiatry 1999; Bongiorno 1996).
4% as severely retarded (IQ level 2040) and 1%2% Higher prevalence rates of psychiatric disorder
profoundly retarded (IQ level below 20) (American Psy- among those with mental retardation are associated
chiatric Association 2000). Advances in medicine and with a range of neurological, social, psychological, and
most particularly in molecular genetics have led to the personality risk factors including impaired cognition,
identification of more than 500 genetic causes of intel- organic brain damage, communication problems,
lectual disability alone (Harris 1995) that account for physical disabilities, family psychopathology, and psy-
some 35% of individuals with mental retardation. chosocial factors. Singly or in combination, these fac-
Some 95 mental retardation syndromes have been tors increase the vulnerability of persons with mental
linked to the X chromosome, with the fragile X syn- retardation to psychiatric or behavioral disturbance
drome accounting for some 40% of all X-linked retar- (Dosen and Day 2001; Wallander et al. 2006). Cur-
dation (Feldman 1996). In less than 10%, retardation rently it is recognized that children and adolescents
may be the consequence of a malformation syndrome with mental retardation can have the full range of psy-
of as yet unknown origin. External, prenatal, perinatal, chopathology experienced by children of normal intel-
or postnatal factors including infections, trauma, tox- ligence. Anxiety disorders, depression, bipolar affec-
ins, perinatal complications, and prematurity account tive disorders, attention-deficit/hyperactivity disorder
for about one-third of cases, with etiology unknown in (ADHD), schizophrenia, and psychotic disorders have
the remainder. The prevalence of mental retardation all been described in young people with significant
caused by a number of specific medical conditions in- cognitive impairments. The types of psychopatholog-
cluding congenital syphilis, Rh hemolytic disease of ical disorders in children with mild mental retardation
the newborn, measles, Haemophilus influenzae type B are more likely to resemble those found in the general
meningitis, congenital hypothyroidism, phenylketo- population. The more severe the level of cognitive im-
nuria, and congenital rubella has decreased sharply pairment, the more difficult it becomes for clinicians
over the past 50 years. However, the incidence of each to apply existing diagnostic criteria with confidence.
The Adolescent Neuropsychiatric Unit 161
Additionally, specific chromosomal/genetic abnor- methodology that was applied in the same community
malities may also be associated with the emergence of some 4 years earlier (Chakrabarti and Fombonne
constellations of behavioral and emotional symptoms 2005). Prevalence data deriving from special education
that do not fit neatly into conventional diagnostic cat- sources have suggested a rising administrative preva-
egories. Behavioral phenotypesthe increased likeli- lence of autism and a falling administrative prevalence
hood that persons with a given syndrome will display of mental retardation. However, because schools do
certain behavioral and developmental characteristics not necessarily use standard DSM-IV-TR criteria for
when compared to those without the syndromehave assigning a label of autism to children in special edu-
been described in children with genetic abnormalities cation, and Special Education Child Count data report
associated with fragile X, Williams, Prader-Willi, only counts of primary classification without noting
Smith-Magenis, Down, and 5p syndromes. The mal- the presence of comorbid conditions, such data cannot
adaptive vulnerabilities of affected children include be considered to accurately reflect the epidemiology ei-
problems relating to others as well as difficulties regu- ther of autism and the other PDDs or of mental retar-
lating attention, arousal, and activity levels in fragile X dation (Shattuck 2006).
syndrome; indiscriminate relatedness and social dis- Throughout the nineteenth and well into the
inhibition in Williams syndrome; hyperphagia, food twentieth century, care for persons with mental retar-
preoccupations, non-food-related obsessions, temper dationregardless of whether they had comorbid psy-
tantrums, and skin picking in Prader-Willi syndrome; chiatric illness and/or displayed significant patterns of
inattention, hyperactivity, aggression, self-injury, ste- maladaptive or challenging behaviorswas pro-
reotypies, and self-hugging in Smith-Magenis syn- vided in large public institutions. The phasing out and
drome; noncompliance, stubbornness, inattention, subsequent closure of these large facilities for people
withdrawn behavior, and depression in Down syn- with mental retardation, beginning in the late 1960s,
drome; and infantile, high-pitched, cat-like crying, hy- served to highlight the special needs of those with psy-
peractivity, inattention, stereotypies, and self-injury in chiatric problems. Initially it was hoped that the level
5p (cri du chat) syndrome (Dykens 2000). A pattern of of behavioral and psychiatric disturbance found in in-
self-injurious and aggressive behavior has also been dividuals with mental retardation might have been
described in Lesch-Nyhan diseasean X-linked disor- over exaggerateda consequence of institutionaliza-
der of purine metabolism caused by a near absence of tionand would therefore substantially diminish
the enzyme hypoxanthineguanine phosphoribosyl- with the introduction of large-scale community care
transferase (Schretlen et al. 2005). programs. However, as it became increasingly appar-
The co-occurrence of autism and other pervasive ent that this was not the case, proponents of the nor-
developmental disorders (PDDs) and mental retarda- malization movement argued that the behavioral and
tion is well established. Despite differences in instru- emotional difficulties of individuals with comorbid
mentation and the bands of intellectual level reported, mental retardation should be treated within ordinary
the results of 19 recently conducted studies have noted mental health services as part of a general policy of in-
that about 30% of children with PDD scored in the tegration (Moss et al. 1997). It was opined that spe-
normal range of intelligence, about 30% scored in the cialized services would lead to increased stigmatiza-
mild-to-moderate mental retardation range, and about tion, labeling, and negative professional attitudes (Day
40% scored in the serious-to-profound mental retarda- 1994). With the passage of time, it has become possi-
tion range (Fombonne 2005). An overall increase in ble to examine the impact of this approach in practice.
the prevalence of autism and the other PDDs has also Day (1994, 2001) cogently summarized the evidence
been reported over the past 15 years. Although surveys demonstrating that generic mental health services,
conducted during the 1960s and 1970s estimated that whether provided by default or design, cannot satisfac-
four children per 10,100 had autism, recent estimates torily meet the treatment and care needs of persons
have conservatively estimated the prevalence of au- with mental retardation and comorbid psychiatric and
tism to be 13 per 10,000, and of all PDDs to be about behavioral problems.
60 per 10,000. This increased prevalence has been at- Day (2001) included the following in making the
tributed to a broadening of the concept and diagnostic case for specialized services for this population:
criteria as well as to increased awareness and improved
detection of the PDDs at all ages and at all levels of in- 1. The accurate diagnosis and treatment of psychiat-
tellectual ability. These higher prevalence rates have ric disorder in persons with mental retardation re-
been confirmed in a new survey utilizing an identical quire special expertise and experience in the face of
atypical presentation, communication difficulties, tional, residential, and recreational requirements (in-
and the frequent absence of subjective complaints. cluding respite care) of patients and their families.
2. Special regimens and careful monitoring of drug Many, if not most, dually diagnosed persons with
treatment are necessary because side effects and mental retardation can be treated as outpatients pro-
unusual responses occur frequently among those vided that there are no significant unresolved diagnos-
with mental retardation. tic problems, the illness can safely be managed in the
3. Highly specialized assessment and treatment tech- community, there are no anticipated difficulties in im-
niques are required to effectively manage disrup- plementing the treatment program, and family and
tive, self-abusive, and aggressive behaviors, many other caregivers are adequately supported (Day and
of which are unique to this population, accounting Dosen 2001). However, services to meet the needs of
for approximately half of the presenting problems. this population are few and far between, and adoles-
4. Underlying dependency levels and coexisting phys- cents are frequently referred from agency to agency be-
ical disabilities, including epilepsy, have to be taken cause they fall between the cracks of many human-
into account in treatment, rehabilitation, and after- service systems (McGee et al. 1984). Consequently,
care. patients may present for admission with an array of
5. Persons with mental retardation are disadvantaged symptoms and challenging behaviors that are more se-
and vulnerable in generic treatment settings. They vere than they would have been if appropriate treat-
do not on the whole integrate easily with other ment had been available at an earlier point in time.
mentally disordered patients, the pace of ward life The overall goals of inpatient treatment are assess-
is usually too fast for them, and it is difficult for ment, stabilization, disposition planning, and transi-
staff to tailor therapeutic interventions to their tion to less restrictive settings. Little information is
specific needs, resulting in the prolongation of available that specifically addresses the factors leading
treatment and rehabilitation. to the hospitalization of dually diagnosed adolescents.
6. Specialist services increase staff competence and Nonetheless, admission criteria can be extrapolated
skills, permit the application of knowledge gained from the results of a review by Smith and Berney
from cumulative experience, and increase owner- (2006) of the reasons for admission of 96 patients be-
ship of the task at hand, therefore increasing the tween the ages of 6 and 19 years (two-thirds of whom
probability of successful treatment. were males) accepted for treatment in specialized psy-
7. Specialist services facilitate the establishment of a chiatric inpatient units. Cognitive impairment was
cadre of experts to carry out teaching and research described as borderline to mild in 41%, moderate in
(Day 1994, 2001). 31%, and severe in 26% of this study sample. Primary
reasons for admission included 1) admission was nec-
Although these conclusions have face validity, the essary to provide an independent assessment of envi-
database underlying them derives from a limited num- ronmental contributions to escalating disruptive be-
ber of studies of adults with comorbid cognitive im- havior (23%); 2) required treatment was too complex
pairment and psychiatric disorder. In reviewing avail- or hazardous to be undertaken on an outpatient basis
able evidence, Chaplin (2004) concluded that further (16%); 3) there was an acute risk of harm to the patient
evaluation of differing patterns of service delivery is or to others (14%); 4) the patient required protection
needed to provide robust evidence as to which services from abuse (4%); 5) the environment was unable to
are to be preferred. cope with severely disruptive or destructive behavior
(27%); 6) previous treatment plans had failed (1%);
and caregivers were unable to implement the current
Admission Criteria treatment plan (15%).
Admission to adolescent neuropsychiatric units
Acute neuropsychiatric inpatient units are the most should be available to individuals between the ages of
common form of hospital-based care for adolescents 13 and 21 years of agethe upper age limit being se-
in whom behavioral and emotional disturbance is co- lected to coincide with the termination of educational
morbid with significant cognitive impairment. The in- entitlements for children and adolescents with dis-
patient unit is an important component of a contin- abilities under Public Law 94142, the federal legisla-
uum of care that addresses the provision of ongoing tion that establishes the basis for the provision of ap-
psychiatric treatment in the least restrictive environ- propriate educational services for all handicapped
ment while also providing for the educational, voca- children from birth to age 21 years. Admission should
be provided for those whose cognitive impairments nonspecific description of challenging behavior is
preclude admission to mainstream adolescent units. important for the following reasons: 1) the compre-
Consideration for admission most often arises in the hensive evaluation and resulting diagnosis may indi-
context of increasing concern on the part of usual cate a specific treatment and 2) the patients difficul-
caretakers about their ability to maintain safety of ei- ties can be reframed for staff and other caregivers as
ther the patient or staff because of escalating aggres- manifestations of illness as contrasted with bad be-
sive, destructive, suicidal, or other self-abusive behav- havior. Mental retardation itself usually has been
ior. Additionally, patients whose behavior falls short of fully assessed prior to presentation for admission to an
acute dangerousness may benefit from an admission inpatient neuropsychiatric unit. However, for some
directed toward clarifying diagnosis and/or refining patients a critical review of this aspect of the clinical
pharmacological treatment. Admission may also be picture may be indicated, most particularly because
appropriate in circumstances when the patients cur- certain behavioral patterns may suggest behavioral
rent living, educational, or working environment is a phenotypes that had not yet been identified at the
major precipitating or aggravating factor in the illness, time of initial presentation (State et al. 1997).
or community resources have identified a need to re- Accurate diagnosis begins with a full and detailed
view and revise current treatment plans. While un- history. Persons with mental retardation, even those
necessary hospitalizations should, of course, be who are only mildly impaired, may have considerable
avoided, it also should be recognized that hospital ad- difficulty in reliably describing their own behavior and
mission should not be avoided at all costs or delayed symptoms. They are usually dependent on multiple
unnecessarily for ideological reasons. Such attitudes service providers and supportive services. Therefore
may well have detrimental consequences for family, the history must incorporate information derived
other caregivers, and subsequent management of the from multiple informants. Moreover, maladaptive be-
patient in the community. Hospitalization can be a haviors may be situation specificdisruptive behavior
positive therapeutic intervention because it provides may occur only in the relatively unstructured home
an opportunity to assess the possible aggravating ef- setting but not at school where more support and su-
fects of environmental factors, and it provides a set- pervision is available.
ting in which required changes in ongoing treatment Components of a comprehensive history should
plans can be initiated (Day and Dosen 2001). include a clear description of the presenting concerns,
including behavioral descriptions of symptoms in var-
ious settings and situations and their evolution over
Diagnostic Workup time, antecedent events, and the effectiveness of al-
ready applied management strategies. Possible predis-
The evaluation of behavioral and emotional difficul- posing or precipitating factors should be thoroughly
ties in persons with mental retardation should follow explored, and the results of previous assessments
the general rules of psychiatric assessment. In princi- should be reviewed. Inform ation about current
ple, the manifestations of mental illness in people strengths and impairments in adaptive skills includ-
with mild and borderline retardation are similar to ing communication, self-care, social/interpersonal,
those in the general population, although special skills community integration, self-direction, academic,
may be required to elicit symptoms in the face of com- work, leisure, health, and safety should be specified.
munication difficulties and a paucity of subjective Behavioral changes with respect to sleep, appetite, and
complaints. Mental disorders in patients with mental weight loss, as well as loss of interest in usual pur-
retardation are often underdiagnosedperhaps be- suits, deterioration of social skills, bizarre behavior,
cause clinicians may restrict their focus only to the and other deviations from well-established behavioral
symptomatic treatment of disruptive behaviors. Di- patterns should be specified. Information should be
agnostic overshadowing, the assumption that symp- sought regarding premorbid personality and function-
toms can be fully accounted for by retardation, may ing, together with full details about any previous psy-
further impede diagnostic accuracy (Jopp and Keys chiatric illnesses and treatment experienced by the
2001). It is generally agreed that it is difficult to estab- patient and other family members. The attitudes of
lish a diagnosis of mental illness with confidence in parents and other caregivers toward the patient and
the severely retarded (American Academy of Child and their understanding of his or her disability should be
Adolescent Psychiatry 1999; Dosen and Day 2001). assessed. Information regarding medication and pos-
Nevertheless, having a formal diagnosis rather than a sible medication side effects should be carefully ex-
plored. A developmental and medical history, includ- communication deficits. Undiagnosed medical condi-
ing inquiry about past etiological assessments as well tions may result in or contribute to an exacerbation of
as past and/or current general medical disorders and behavioral symptoms. Ryan and Sunada (1997) found
their treatments, should be obtained. that 75% of adults with mental retardation referred for
The standard approach to interviewing adolescent psychiatric assessment had one or more undiagnosed
patients will require modifications appropriate to the or undertreated medical problems. In 6.5% of the pa-
patients level of cognitive functioning. Ample time tients studied, psychiatric symptomatology remitted
should be allocated or several briefer interviews may after effective treatment of the primary medical condi-
be required to complete a full mental status assess- tion. In addition, many individuals with mental retar-
ment. An effort should be made to assess mental sta- dation have co-occurring motor and sensory impair-
tus in the context of conversation. It is desirable to be- ments or seizure disorders (American Academy of
gin the interview with a discussion of the patients Child and Adolescent Psychiatry 1999; Dosen and
strengths and interests rather than problems. Only Day 2001). The incidence of epilepsy, often in a med-
later can the focus shift to clarifying the patients un- ically intractable form, is higher among patients with
derstanding of problems, disability, limitations, and mental retardation than in the general population, and
reasons for hospitalization. An effort should be made its incidence increases with the severity of cognitive
to avoid leading questions or questions requiring yes impairment. However, the diagnosis of epilepsy in this
or no answers. Of necessity, the general paucity of sub- population is often challenging, both over- and under-
jective complaints requires that the examiner be at- diagnosis is frequent, and pharmacological control of
tentive to objective data, including the patients ap- seizures may be difficult to obtain, resulting in a high
pearance, degree of relatedness, expressions of affect, level of polypharmacy (Smith 2006). Pediatric neuro-
impulse control, activity level, attention span, dis- logical consultation can assist in clarifying these and
tractibility, and the presence of unusual behaviors or other complex issues at the interface between neurol-
seizures. Evidence of hallucinations may be inferred ogy and psychiatry.
by behaviors that suggest the patient is talking to him- Although traditional nosological classifications are
or herself or responding to internal stimuli. not entirely adequate to accommodate the phenome-
Rating scales for the assessment of psychopathol- nology of emotional and/or behavioral disturbance in
ogy in individuals with comorbid mental retardation individuals with mental retardation, an effort should
can provide guides to further inform history taking and be made to clearly establish a DSM-IV-TR Axis I diag-
the direct examination of the patient. Although not nosis. A patients verbal productions provide the basis
designed to provide a clinical diagnosis, measures such for a full assessment of many DSM-IV-TR criteria.
as the Aberrant Behavior Checklist (Aman et al. 1996; Nevertheless, the nomenclature does make some pro-
Rojahn et al. 2003) or the Behavior Problem Inventory vision for situations in which the patients language is
(Rojahn et al. 2001) can be used to track symptom insufficient to describe symptoms. For example, the
change during the course of treatment. Although the criteria for major depressive episode include observa-
Autism Diagnostic Inventory may well be too lengthy tions made by others (American Psychiatric Associa-
and cumbersome to use in its entirety, it is a useful tion 2000, p. 356). For nonverbal patients, not other-
guide to obtaining information about both early devel- wise specified designations may have to be used.
opment and current functioning in adolescents with Commonly occurring comorbid conditions include
PDD (Lord et al. 1994). Elements of the Autism Diag- autism and other PDDs, psychoses and major mood
nostic Observation Schedule (Lord et al. 2000) can disorders, anxiety disorders (including posttraumatic
augment the clinical interview of adolescents with stress disorder and obsessive-compulsive disorder), tic
PDD. In addition, the Childrens Yale-Brown Obses- disorders, ADHD, and stereotypic movement disor-
sive-Compulsive Scale has been modified for use in ders. With this population, care should be taken to
children and adolescents with PDD (Scahill et al. summarize the basis for diagnosis in individual cases
2006), as has the Childrens Global Assessment Scale (American Academy of Child and Adolescent Psychia-
(Wagner et al. 2007). Additionally, it may be appropri- try 1999).
ate to update previously conducted assessments of IQ The diagnostic formulation should interpret clinical
and adaptive functioning. data in the context of the individual patients develop-
Consultation with pediatricians and pediatric neu- mental level, communicative abilities, and possible as-
rologists should be readily available. Physical illness sociated motor and/or sensory handicaps as well as life
can be easily missed in individuals with significant experiences, education, and familial and sociocultural
factors. Although caregivers may seek to distinguish be- individuals with comorbid mental retardation. As a
tween behaviors that are thought to be deliberate at- general rule, medications should be prescribed only for
tempts to gain attention or avoid disliked activities and the treatment of specific mental disorders as part of a
those that are viewed as more genuine symptoms of comprehensive treatment plan. Because medication
psychiatric illness, such efforts are overly simplistic and effects are generally not different from those expected
misguided. Persistent overtly disturbed behavior is the in the absence of mental retardation, the rules govern-
observable result of a complex interplay of biological, ing usual pharmacological practice may be applied
psychological, and social factors and comprises ele- without major modification. Nevertheless, response
ments that are learned, conditioned by environmental rates tend to be poorer and side effects more frequent
factors, and under voluntary control (American Acad- (Handen and Gilchrist 2006). Individuals with com-
emy of Child and Adolescent Psychiatry 1999). Never- promised central nervous system function can be es-
theless, persons with mental retardation frequently pecially vulnerable to the anticholinergic effects of
exhibit an array of challenging behaviors including low-potency neuroleptics (Madrid et al. 2000). Other
frequent temper tantrums, aggression, stereotypes, side effects that may occur with increased frequency in
physical disruption, rituals, hyperactivity, and self-inju- this population include disinhibition in response to
rious behaviors that cut across diagnostic lines but are a sedative-hypnotics; irritability and hyponatremia with
necessary and appropriate focus of treatment (Murphy carbamazepine; cognitive dulling and an increased
et al. 2005; Pilling et al. 2007; Schroeder et al. 2001). likelihood of toxicity as a consequence of erratic fluid
intake with lithium; social withdrawal and motor tics
with methylphenidate; tardive and other dyskinesia,
Therapies withdrawal, irritability, self-injury, and akathisia with
neuroleptics; and pancreatitis and hepatotoxicity with
The diagnostic assessment provides the basis for the valproate (American Academy of Child and Adoles-
development of a comprehensive individualized treat- cent Psychiatry 1999).
ment plan. Although most of the therapeutic methods Antochi et al. (2003) observed that although the
used for the treatment of psychiatric disorder in the number of studies devoted to the use of psychotropic
nonretarded are applicable, with little or no modifica- medications in persons with dual diagnosis of psychi-
tion, to individuals who are mildly retarded, treatment atric disorders and developmental disabilities is small,
of those with moderate and severe retardation must there is adequate evidence to suggest that a range of
take into account lower intelligence, often greatly im- antidepressants, mood stabilizers, anxiolytics, anti-
paired communication skills, and associated neuro- psychotics, and stimulants can be efficacious, with se-
logical disorders as well as specific behavioral syn- lective serotonin reuptake inhibitors, newer anticon-
dromes. Each individualized treatment plan reflects vulsants, and atypical neuroleptics being preferred
the integration of biological and psychosocial inter- medication choices. Persons with intellectual disabil-
ventions, including specifically targeted behavioral ities are more vulnerable to side effects, with poten-
treatments, family education and therapy, and habili- tially catastrophic results, including fatalities. Conse-
tative, educational, and recreational therapies. Al- q ue n t ly, t h e r i s k b e n e f i t r a t i o o f a p r o p o s e d
though it should go without saying that comprehen- pharmacological regimen must be carefully examined
sive treatment must include both biological and and thoroughly reviewed with parents or other legal
psychosocial interventions, too often these two pri- guardians who must provide informed consent before
mary modalities are conceptualized as antithetical. pharmacological treatment can be undertaken. Initial
Through the development of a comprehensive, multi- dosages should be low, increases introduced slowly,
disciplinary treatment plan, the inpatient unit plays and the emergence of possible side effects carefully
an important role in educating family and other care- monitored. Efforts should be made to limit polyphar-
takers about the potential for mutual reinforcement macy by ensuring the clear documentation of specific
that the judicious use of both interventions offers pa- indications for each medication prescribed (American
tients with intellectual disabilities (Dosen 2007). Academy of Child and Adolescent Psychiatry 1999).
Caution should be exercised with regard to the pre-
Medication scription of as-needed medications, and their use
should be carefully monitored. A retrospective chart
Medications are the principal biological interventions review has revealed that as-needed medications were
employed in the treatment of psychiatric disorder in more commonly prescribed for hospitalized children
and adolescents with comorbid mental retardation or repetitive behaviors in individuals with mental retar-
PDD as compared with nonretarded patients housed dation. Side effects include serious ongoing weight
on the same integrated 12-bed acute-care unit. In this gain, predisposing to the metabolic syndrome, and the
unit, as-needed medications were also used more fre- emergence of type 2 diabetes. Although data regarding
quently in patients receiving other psychotropic treat- efficacy are limited, aripiprazoles weight neutrality
ments, raising the risk of drug interactions or other may make it a good treatment alternative (Handen and
adverse effects (Dean et al. 2006). Gilchrist 2006).
Although it is highly desirable that the prescription
of psychotropic medication follows diagnosis, it is Electroconvulsive Therapy
sometimes difficult to entirely avoid using medications There is a paucity of empirical data regarding the effi-
to target specific symptoms in the absence of a clearly cacy of electroconvulsive therapy (ECT) in patients
established clinical diagnosis. Sometimes this is the re- with mental retardation and psychiatric disorders. Spe-
sult of gaps in our current nomenclature. For example, cific difficulties in using ECT in this patient population
DSM-IV-TR does not allow a diagnosis of separation have included diagnostic dilemmas, difficulties with
anxiety disorder, generalized anxiety disorder, social measurement of outcome, and monitoring of side ef-
phobia, or ADHD in individuals with PDD, yet symp- fects as well as professional reluctance and difficulties
toms of anxiety, rigidity, inflexibility, repetitive behav- in obtaining informed consent. Nevertheless, although
iors, inattention, easy distractibility, and impulsivity the number of treated cases is small, the responses of
often associated with the diagnosis of PDD may well be adults with mental retardation and severe or refractory
appropriate targets for treatment (Leyfer et al. 2006). psychotic symptoms or treatment-resistant mood dis-
Among the most frequent reasons for the use of psy- orders are encouraging (Aziz et al. 2001; Cutajar and
chotropic medication in persons with mental retarda- Wilson 1999; Reinblatt et al. 2004). In addition, four
tion are various forms of disruptive behavior including cases of catatonic stupor in adolescents with autism,
self-injurious behaviors, stereotyped behaviors, and ag- all of whom have been successfully treated with ECT,
gression. These behaviors are often grouped together as have been reported (Bailine and Petraviciute 2007;
disorders of impulse control, although the pathogene- Ghaziuddin et al. 2005; Zaw et al. 1999). Thus, albeit
sis may be quite different, and there is no uniform re- limited, the available evidence suggests that ECT cer-
sponse to pharmacological agents (American Academy tainly should be considered as a treatment option for
of Child and Adolescent Psychiatry 1999). adolescents with mental retardation and psychiatric
The use of medications to address target symptoms disorders for which ECT is otherwise warranted.
has been perhaps best studied in autism and other
PDDs. When administered at relatively low dosages, Psychosocial Interventions
antipsychotics, most particularly risperidone, have
Psychosocial interventions for psychiatrically ill ado-
been shown to reduce repetitive behaviors, stereotyp-
lescents with developmental disabilities include spe-
ies, and social withdrawal as well as hyperactivity, ag-
cifically targeted behavioral treatment, family educa-
gression, self-abusive behavior, temper tantrums, labil-
tion and treatment, and habilitative, educational, and
ity of mood, and irritability. Adverse effects in the PDD
recreational therapies provided in an environment
population include increased appetite, weight gain,
structured to address challenging behaviors safely and
drooling, hyperprolactinemia, and risk of drug-related
effectively while reducing symptomatology to a level
dyskinesias. Although less well studied, available evi-
that will allow the patient to return to appropriate
dence suggests that selective serotonin reuptake inhib-
community-based services.
itors may be effective in reducing repetitive behaviors
and expanding the range of interest of children and
adolescents with PDD. Restlessness, agitation, and in-
INDIVIDUALIZED BEHAVIORAL TREATMENT
somnia are commonly reported side effects. Stimulant Behavior therapy represents the mainstay of psycho-
medications have been shown to reduce hyperactivity logically based treatment of persons with moderate to
and improve focus, but they may result in increases in severe retardation. Behavioral techniques provide a
disruptive behavior, weight loss, and increased stereo- consistent and structured framework for teaching ap-
typic behavior (Malone et al. 2005). Second-generation propriate behavioral patterns and adaptive life skills.
antipsychotics, most particularly risperidone, have Although it is beyond the scope of this chapter to pro-
been found to be efficacious in controlling hyperactiv- vide details of specific behavioral treatment tech-
ity, irritability, and aggressive, self-injurious, and other niques, it should be noted that behavioral interven-
tions should be individualized based on data derived abilities continue to require close supervision, and
from a comprehensive contextual analysis that identi- their increasing size may render them harder to con-
fies to the greatest extent possible the external and in- trol and discipline. A survey of parents of children and
ternal conditions that influence the occurrence and adolescents with intellectual disability and comorbid
persistence of problem behaviors. Care should be behavioral and emotional problems identified numer-
taken to distinguish description from explanation in ous unmet support needs, including a friendly ear
clarifying events that precede the targeted behavior, with whom to share worries and concerns; respite care
consequences of the behavior, and patient characteris- and other practical and material help; mental health
tics that increase vulnerability to adverse events (Gar- care for themselves and their children; and informa-
diner et al. 2001). The behavioral treatment of persis- tion about additional services and recreational and lei-
tent inappropriate behaviors should utilize techniques sure time activities (Douma et al. 2006). Although
of ignoring, redirection, and positive reinforcement. work with families of adolescents admitted to an acute
All three steps may be employed simultaneously; for care unit must of course be individualized, providers
example, when a request for action on the part of staff should be alert to the emergence of common themes.
results in screaming behavior, the screams can be ig- Admission can stimulate recall of the experience of
nored while the caretaker assists the patient in execut- initial diagnosis, and parents and other family mem-
ing the task by providing hand-over-hand guidance. bers may benefit from an opportunity to process these
This approach does not mean that maladaptive behav- experiences anew from the expanded perspective
ior is completely ignored. Rather, the focus is shifted to gained in the course of the passage of time. At the time
the acquisition of appropriate skills and interactions of initial diagnosis, parents often experience consider-
so that the patient gradually learns that he or she will able anxiety in the face of uncertainty about the fu-
gain attention for appropriate behaviors and interac- ture. During adolescence, as future expectations are
tions and, conversely, will regularly be ignored when increasingly clarified, parents must begin to address
behaving inappropriately (McGee et al. 1984). Aver- questions about the provision of lifetime care. Work
sive behavioral techniques, including electric shocks, with families provides an opportunity to examine the
food deprivation, noxious tastes, the delivery of white impact of the patients disability on other family
noise through ear phones, and limitation of move- members, most particularly siblings (Lobato and Kao
ment when used as a punishing consequence, are 2002), and to explore each family member s need for
clearly outside of the mainstream of current psychiat- ongoing mental health treatment. Parents also should
ric practice and have no place in the therapeutic arma- be actively involved in planning the hospital treat-
mentarium of an adolescent neuropsychiatric unit. ment as well as provisions for aftercare. Even if the pa-
tient is to be admitted to, or returned to, an out-of-
FAMILY EDUCATION AND TREATMENT home placement, the role of the family should be care-
fully examined because available evidence stresses the
It has long been recognized that parents of children importance of sustaining ongoing relationships with
with mental retardation, most particularly those with
parents for the adjustment of institutionalized pa-
comorbid behavioral and emotional problems, report
tients (Ruedrich and Menolascino 1984). Additional
more parenting stress and mental health problems
referrals to either professionally led groups or to a
than parents of children without disabilities. Parental
group organized and run by other parents to provide a
stress may occur in response to episodic life events
source of ongoing support can be considered (Hastings
that may impact on any family, such as marital break- and Beck 2004).
down or bereavement, as well as from family life-cycle
transitions that may be especially pertinent to families
of children with disabilities. Relevant transition
MILIEU MANAGEMENT AND EDUCATIONAL AND
points include early childhood events such as initial RECREATIONAL THERAPIES
diagnosis and starting school. The adolescent years An adolescent neuropsychiatric acute care unit re-
may bring additional challenges as families begin to quires a multidisciplinary staff and a higher staff-to-
learn how to cope with the difficulties that physical patient ratio than would be found on a traditional psy-
maturation may impose on previously well-estab- chiatric unit. Typically, overall staffing is 23:1, with
lished routines (Hastings and Beck 2004; Schneider et the availability of 1:1 staffing on an as-needed basis.
al. 2006). Although the adolescent years usually her- The staff should have experience and training in the
ald increased independence and autonomy for typi- developmental disabilities and include a child and
cally developing children, those with intellectual dis- adolescent psychiatrist with training and experience
in the psychiatric aspects of developmental disabilities lescents are generally the same as for children without
and mental retardation, including pharmacological in- disabilities, although actual procedures may vary ac-
terventions; psychiatric nurses; social workers; special cording to state law, regulations, statutes, and man-
education teachers; recreational therapists; and be- dates. Because seclusion and restraint have the poten-
haviorally trained direct-care workers. Additionally, tial to produce serious consequences, including
the services of speech and language and occupational physical and psychological harm, loss of dignity, vio-
therapists should be available on an as-needed basis, lation of an individuals rights, and even death (Mohr
and consultation with pediatricians and pediatric neu- et al. 2003; Nunno et al. 2006; Petti et al. 2001), in re-
rologists should be similarly accessible. The milieu cent years unit administrators have actively embarked
should be organized to provide patients with a closely on programs directed toward reducing the use of these
scheduled, active, and developmentally appropriate practices in children and adolescent inpatient settings
treatment day. The execution of activities of daily liv- (Delaney 2006; LeBel et al. 2004; Miller et al. 2006;
ing must be closely supervised and guided to facilitate Schreiner et al. 2004). Strategies directed toward the
the assumption of increasing responsibility for per- prevention of aggression and self-aggression are at the
sonal care. A typical daily schedule may include school core of a program to maintain unit safety. Prevention
attendance and sessions with the occupational thera- begins at intake and continues through the admission
pist and speech and language therapist as indicated by process as a history of aggressive behavior including
each patients individualized educational plan. Orga- triggers, warning signs, repetitive behaviors, responses
nized recreational groups and supplementary thera- to previous treatments, and prior episodes of seclusion
peutic groups designed to provide social skills and and restraint is obtained. Additionally, cognitive limi-
anger management training, as well as individual be- tations and neurological deficits should be identified
havioral therapy and individual and family therapy as as well as medical conditions that might require mod-
prescribed by each patients individualized treatment ification of usual seclusion and restraint practices.
plan, complete the day (McGee et al. 1984). All staff Treatment planning should include the development
should be familiar with the content of each patients of individualized strategies to minimize aggressive be-
individual behavioral plan, which at a minimum havior, de-escalate behavior before safety is signifi-
should be implemented during all scheduled activities cantly jeopardized, and specify treatment for underly-
throughout the day. ing psychopathology. Furthermore, it is essential that
staff receive extensive training in the management of
aggressive behavior and documentation requirements
Maintenance of Safety (American Academy of Child and Adolescent Psychia-
try 2001).
Because a large proportion of patients on an acute care Every unit should have its own program directed
adolescent neuropsychiatry unit are admitted because toward the de-escalation of potentially threatening
they exhibit a high intensity and/or frequency of mal- and dangerous behavior. Such a program can be con-
adaptive behaviors that render them unsafe either to ceptualized as consisting of three levels:
themselves or others, the maintenance of unit safety is
clearly of paramount importance. Currently, standard Level 1: Nonrestrictive interventions designed to
practice in psychiatric hospitals accredited by the Joint increase the patients behavioral self-control while
Commission (http://www.jointcommission.org) and preserving safety of patient, others, and property.
regulated by the Centers for Medicare and Medicaid Examples of Level 1 interventions include verbal
Services (http://www.cms.hhs.gov) requires that the prompting; reward programs, including token
use of restraint and seclusion be limited to emergen- economies; and short periods (less than 30 min-
cies in which there is an imminent risk of patients utes) of timeout.
harming themselves or others, including staff. Be- Level 2: Restrictive interventions are employed
cause regulations regarding seclusion and restraint are when concern for safety of patient, others, and prop-
revised frequently, practitioners should review these erty is greater and use contingencies that are di-
organizations Web sites at frequent intervals. rected to supporting adaptive behavior without re-
The practice parameters prepared by the American inforcing maladaptive behaviors. Optimally, Level 2
Academy of Child and Adolescent Psychiatry (2001) interventions require advance planning and may in-
note that approaches to the use of restrictive interven- clude ignoring behavior (extinction), time-outs last-
tions with developmentally disabled children and ado- ing more than 30 minutes, and room restriction.
Level 3: These most restrictive interventions should of tendons as a consequence of long-term restriction;
only be used when clinical judgment indicates that disruption or prevention of opportunities to engage in
they are necessary to ensure safety of patient, oth- activities associated with daily living, education, and
ers, and property and after documented failure of leisure; and reduced levels of interaction with caregiv-
less restrictive interventions. Examples include se- ers (Jones et al. 2007). Nevertheless, the use of me-
clusion, mechanical restraint, and medication chanical devices to limit self-injury may be appropri-
(American Academy of Child and Adolescent Psy- ate in selected cases. The most recent (January 2008)
chiatry 2001). iteration of the Comprehensive Accreditation Manual
for Hospitals, the official handbook of the Joint Com-
The practices and procedures at all three levels remission, provides for this possibility in an exception to
quire the availability of one-to-one staffing. These pro- the applicability of the behavioral health care restraint
cedures should never be used for the purpose of punish- and seclusion standards by allowing
ment. Moreover, the use of seclusion and/or restraint
should be followed by a debriefing session that allows [t]he use of restraint with patients who receive treat-
ment through formal behavior management pro-
the patient to process and understand the episode to
grams (to which the behavior management standard
the extent that cognitive limitations may permit. in this manual appliesstandard PC13.70). Such
Although there has been increasing scrutiny of se- patients exhibit intractable behavior which is se-
clusion and restraint use in recent years, research on verely self-injurious or injurious to others, have not
the use of these practices with children and adolescents responded to traditional interventions and are un-
is limited. Available evidence suggests that rates of se- able to contract with staff for safety (for example, un-
derstand the concept of or act on criteria for discon-
clusion and restraint are highest for hospitalized chil-
tinuing restraint or seclusion). (Joint Commission
dren and adolescents with diagnoses of mental retarda- 2008)
tion, developmental disability, and neurological
impairments (Fryer et al. 2004). Additionally, youths
restrained during an acute inpatient hospitalization are Discharge Planning
more likely to be male, to have been previously hospi-
talized, to be enrolled in special education, to be in fos- When the lives of persons with developmental disabil-
ter care, or to have a history of voicing suicidal ideation ities are complicated by comorbid psychiatric disorder,
and attempting suicide (Delaney and Fogg 2005). successful integration into community life becomes
In reviewing physical restraint procedures for man- additionally problematic. Acute psychiatric inpatient
aging the challenging behaviors of adults and children services are but one point on the continuum of care re-
with mental retardation, Harris (1996) distinguished quired to meet both the residential and programmatic
between contingent and noncontingent restraint. Al- needs of this population over time. Residential services
though contingent restraint is initiated to ensure can be conceptualized as extending from long-term in-
safety in the face of escalating aggressive behavior, stitutional care at one end of the continuum, through
noncontingent restraints are used to suppress self- specialized group homes in the community, group
injurious behaviors. Examples include mechanical de- homes offering less intensive supervision, and family-
vices employed to limit movement or specially based care as provided by biological families or special-
adapted clothing to attenuate the self-injurious conse- ized foster home settings at the other end. Program-
quences of a persons actions, including helmets, matic provision may include day hospital settings, spe-
masks, and mittens. Self-injurious behavior, which cial educational placements, sheltered workshops,
may occur in between 4% and 14% of people with in- group and/or individual counseling, case management,
tellectual disabilities, is often persistent and difficult and preventive services (McGee et al. 1984).
to treat, and when untreated, it can have serious con- It is to be expected that most adolescents admitted
sequences, including permanent tissue damage and to an acute inpatient unit for adolescents will return to
secondary problems such as infection, sensory and the residential and programmatic settings from which
neurological impairment, and even death (Jones et al. they were admitted. Relatively few individuals will be
2007). Although noncontingent restraint can be effec- in need of ongoing institutional care, but this may be
tive in reducing self-injury, mechanical restraint can necessary in those instances when behavioral and
also have a number of detrimental side effects, which pharmacological interventions have not been success-
may include reinforcement of target behaviors; mus- ful in controlling severely aggressive and/or self-abu-
cular atrophy; demineralization of bones or shortening sive behavior to levels that can be safely managed in
less restrictive settings. All discharge plans must be physical illness can be easily missed in individuals
closely coordinated with receiving service providers to with significant communication deficits. A diagnostic
ensure continuity of care and that treatment goals can formulation, interpreting clinical data in the context
be sustained following discharge. Existing services of the individual patients developmental level, com-
may require expansion to include arrangements for municative abilities, life experiences, education and
ongoing pharmacological treatment, referral for indi- familial and sociocultural factors provides the foun-
vidual/family therapy, or case management services. dation for the development of a comprehensive indi-
Prior to discharge, caregivers should receive training in vidualized treatment plan integrating both pharma-
the implementation of behavioral interventions. If cological and psychosocial interventions. Ideally,
possible, home and school visits should be provided to medication should be prescribed for the treatment of
allow for generalization of behavioral expectations to specific mental disorders, but the use of pharmacolog-
other settings. If patients are to return home, referral ical agents to target specific symptoms in the absence
to ongoing case management services should be con- of a clearly established clinical diagnosis may be re-
sidered to provide a means by which the various com- quired. As response rates tend to be poorer and side ef-
ponents of ongoing careincluding outpatient psychi- fects more frequent in individuals with compromised
atric services, educational/vocational placements, and central nervous system function, the riskbenefit ratio
recreational activitiescan be coordinated. Arrange- of psychopharmacological regimens must be carefully
ments for ongoing care should also include provision assessed and reviewed with legal guardians who must
for working with families to address issues surround- provide informed consent. Psychosocial interventions
ing planning for long-term out-of-home placement. including specifically targeted behavioral treatments,
Access to appropriately experienced professionals family education and therapy, and habilitative educa-
should not be limited to inpatient settings. Persons tional and recreational therapies should be provided in
with developmental disabilities and severe behavioral a milieu which permits challenging behaviors to be
and emotional problems can be served in the commu- safely and effectively addressed, while also facilitating
nity if an appropriate range of educational, vocational, the reduction of symptomatology to a level that will al-
and residential services is available to meet their needs. low the patient to return to appropriate community
Both inpatient and outpatient services must be respon- based services. An acute care unit for adolescent neu-
sive to the needs of individual patients. Unfortunately, ropsychiatric patients requires a multidisciplinary
services are too often defined as being appropriate for staff and a staff-to-patient ratio sufficient to insure the
only the mentally ill or only those with developmental provision of 1:1 staffing on an as needed basis. Every
disabilities. Individuals who are dually diagnosed are unit should have its own program directed toward the
the losers in this either/or diagnostic game (Fleisher et de-escalation of potentially threatening and dangerous
al. 2001). A unit dedicated to the treatment of those behaviors consistent with standard practice in psychi-
who are both developmentally disabled and mentally atric hospitals accredited by the Joint Commission
ill goes a considerable distance toward remedying this and regulated by the Centers for Medicaid and Medi-
historical crack in the continuum of care available to care Services. Acute psychiatric inpatient services are
some of societys most vulnerable members. but one point on the continuum of care required to
meet both the residential and programmatic needs of
persons with developmental disability complicated by
Conclusion comorbid psychiatric disorder. Most adolescents ad-
mitted to an acute inpatient unit will return to the set-
The overall goals of inpatient treatment for adoles- tings from which they were admitted. Nevertheless,
cents with mental retardation and psychiatric disorder discharge plans must be closely coordinated with re-
include diagnostic assessment, stabilization, disposi- ceiving facilities to insure that treatment goals are sus-
tion planning and transition to less restrictive set- tained following discharge.
tings. While it is often difficult to establish a diagnosis
of mental illness with confidence in the severely re-
tarded, efforts should be made to obtain a complete References
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CHAPTER 11
THE ETHNIC/MINORITY
PSYCHIATRIC INPATIENT UNIT
Francis G. Lu, M.D.
S ince the late 1990s, national attention has focused Mental Health Care Disparities and
increasingly on the importance of reducing health care
disparities by increasing the cultural competence and Cultural Competence
workforce diversity in the delivery of health care to
meet the needs of an ever more culturally diverse pa- In August 2001, the Surgeon General issued a supple-
tient population (Agency for Healthcare Research and ment to the 1999 Mental Health: A Report of the Sur-
Quality 2007; U.S. Department of Health and Human geon General entitled Mental Health: Culture, Race,
Services Office of Minority Health 2000). During this and Ethnicity (U.S. Surgeon General 2001). This
time, there has been a parallel development in these landmark report for the first time documented com-
areas for mental health care. After first reviewing the prehensively striking disparities in mental health care
issues relevant to the mental health care of culturally for racial and ethnic minorities involving access, ap-
diverse patients, this chapter will describe one example propriateness, quality, and outcomes. Minorities were
of a psychiatric inpatient service that has focused on documented to be woefully underrepresented in re-
cultural competence and reducing mental health dis- search studies. Taken as a whole, these disparities im-
parities: the Ethnic/Minority Psychiatric Inpatient posed a greater disability burden on racial and ethnic
Programs at San Francisco General Hospital (SFGH), minorities. The following are some examples from
which began its journey toward cultural competence in the four chapters on the four major racial and ethnic
1980 to provide services for underserved populations. groups:
175
Disproportionate numbers of African Americans tion 1994) was a significant step forward in recogniz-
are represented in the most vulnerable segments of ing the impact of culture, race, and ethnicity on
the populationpeople who are homeless, incar- mental health. The report also noted that
cerated, in the child welfare system, or victims of
traumaall populations with increased risks for A few studies have examined racial and ethnic dif-
mental disorders. ferences in the metabolism of clinically important
drugs to treat mental illnesses. As the evidence base
As many as 40% of Hispanic Americans report lim-
grows, improved treatment guidelines will help cli-
ited English-language proficiency. Because few nicians be aware that differences in metabolic re-
mental health care providers identify themselves as sponse, as well as differences in age, gender, family
Spanish-speaking, most Hispanic Americans have history, lifestyle, and co-occurring illnesses, can al-
limited access to ethnically or linguistically similar ter a drugs safety and efficacy. For example, clini-
providers. cians are becoming sensitized to the possibility that
a significant proportion of racial and minority pa-
The suicide rate among American Indians/Alaska
tients will respond to some common medications at
Natives is 50% higher than the national rate; rates lower-than-usual dosages. (U.S. Surgeon General
of co-occurring mental illness and substance abuse 2001, p. 161)
(especially alcohol) are also higher among native
youth and adults. Because few data have been col- The second recommendation made was to im-
lected, the full nature, extent, and sources of these prove access to treatment. The report noted the im-
disparities remain a matter of conjecture. portance of improving geographic access for those liv-
Asian Americans/Pacific Islanders who seek care ing in rural and other medically underserved areas as
for a mental illness often present with more severe well as ensuring language access: A major barrier to
illnesses than do other racial or ethnic groups. effective mental health treatment arises when pro-
This, in part, suggests that stigma and shame are vider and patient do not speak the same language
critical deterrents to service utilization. It is also (U.S. Surgeon General 2001, p. 163). In 2000, nearly
possible that mental illnesses may be undiagnosed 47 million people18% of the U.S. population
or treated later in their course because they are spoke a language other than English at home. The
expressed in symptoms of a physical nature. 2000 census documented that more than 28% of all
Spanish speakers, 22.5% of Asian and Pacific Island
The report concluded with a chapter titled A Vi- language speakers, and 13% of Indo-European lan-
sion for the Future in which recommendations were guage speakers spoke English not well or not at
grouped in several areas. The first recommendation all. Limited English proficiency affects the persons
area was to continue to expand the science base. ability to access and receive health and mental health
Within this recommendation the report noted that care.
The third recommendation, to reduce barriers to
clinicians awareness of their own cultural orienta- treatment, is related to the subsequent Presidents
tion, their knowledge of the clients background, and New Freedom Commission on Mental Health (2003)
their skills with different cultural groups may be es- report Achieving the Promise: Transforming Mental
sential to improving access, utilization, and quality Health Care in America, which was issued in July
of mental health services for minority populations.
2003. Within the New Freedom Commission report,
While no rigorous, systematic studies have been con-
ducted to test these hypotheses, evidence suggests the primary goal for culturally diverse populations was
that culturally oriented interventions are more effec- that disparities in mental health services are elimi-
tive than usual care at reducing dropout rates for eth- nated. By way of background, this report noted that
nic minority mental health clients. While the effi- racial and ethic minorities face additional barriers to
cacy of most ethnic-specific or culturally responsive accessing and receiving quality care such as mistrust
services is yet to be determined, models already
and fear of treatment; different cultural ideas about ill-
shown to be useful through research could be tar-
geted for further efficacy research and, ultimately, nesses and health; differences in help-seeking behav-
dissemination to mental health providers. (U.S. Sur- iors, language, and communication patterns; racism;
geon General 2001, p. 161) varying rates of being uninsured; and discrimination
by individuals and institutions.
The inclusion of a Glossary of Culture-Bound The fourth recommendation area in the surgeon
Syndromes and the Outline for Cultural Formula- generals report was to improve quality of care. As
tion within DSM-IV (American Psychiatric Associa- stated in the report,
The Ethnic/Minority Psychiatric Inpatient Unit 177
Culture and language affect the perception, utiliza-

tion, and, potentially, the outcomes of mental
Case Example: The Ethnic/Minority
health services. Therefore, the provision of cultur- Psychiatric Inpatient Programs at
ally and linguistically appropriate mental health
services is a key ingredient for any programming de- San Francisco General Hospital
signed to meet the needs of diverse racial and ethnic
populations. The programming should include: 1)
language access for persons with limited English History and Overview
proficiency; 2) services provided in a manner that is The Ethnic/Minority Psychiatric Inpatient Programs
congruent, rather than conflicting, with cultural
that began in 1980 on one inpatient unit at the Uni-
norms; and 3) the capacity of the provider to convey
understanding and respect for the clients world- versity of California San Francisco (UCSF) Depart-
view and experiences. (U.S. Surgeon General 2001, ment of Psychiatry at SFGH strive to provide the high-
p. 166) est quality of care to individuals with severe mental
illnesses who largely depend on public sector services
A fifth recommendation was to support capacity due to Medicare or Medi-Cal insurance or lack of
development. Here, the importance of continuing health insurance. From 1985 to 2008, the inpatient
education for mental health staff was noted: ... many programs were on five inpatient units with a total of
providers and researchers of all backgrounds are not 97 beds. As of July 2008, the inpatient programs con-
fully aware of the impact of culture on mental health, sist of four acute diagnostic and treatment units with a
mental illness, and mental health services. All mental total of 75 beds. Each inpatient unit has developed a
health professionals are encouraged to develop their single or dual focus reflecting the cultural diversity of
understanding of the roles of age, gender, race, ethnic- both San Francisco and the patients served by the
ity, and culture in research and treatment (U.S. Sur- SFGH, the only acute public hospital in San Francisco
geon General 2001, p. 167). Lu and Primm (2006) pro- funded by the Department of Public Health of the City
vided specific analysis and recommendations for how and County of San Francisco. The U.S. Census Bureau
the field of psychiatry can play an important role in in- reported that in 2005, 33.3% of the San Francisco pop-
creasing cultural competence and reducing disparities ulation was Asian/Pacific Islander, 7.3% black, 13.7%
in medical student education consistent with LCME Hispanic, 0.5% American Indian, 44.1% white (not
accreditation standards. The Presidents New Free- Hispanic), and 2.3% two or more races (U.S. Census
dom Commission on Mental Health (2003) report Bureau 2005). In 1987, the American Psychiatric As-
also highlighted that culturally competent services sociation awarded a Certificate of Significant Achieve-
are essential to improve the mental health system ment to these programs in recognition of the innova-
(p. 52). The following definition of cultural compe- tive model program that provides specialized services
tence was given: for four previously underserved groups, including
Asian/Asian American, Latino, African American, and
Culturally competent services [italics in text] are AIDS/HIV patients as well as services geared to the
the delivery of services that are responsive to the special needs of women. In 1999, the programs were
cultural concerns of racial and ethnic minority
awarded the American College of Psychiatrists Award
groups, including their language, histories, tradi-
tions, beliefs, and values (U.S. Surgeon General
for Creativity in Psychiatric Education in official rec-
2001). Cultural competence in mental health is a ognition of creativity in addressing significant educa-
general approach to delivering services that recog- tional issues and sustained commitment to excellence
nizes, incorporates, practices, and values cultural di- in psychiatric education that can serve as a model for
versity. Its basic objectives are to ensure quality ser- other programs. Finally, in 2006, the programs were
vices for culturally diverse populations, including
awarded the San Francisco Department of Public
culturally appropriate prevention, outreach, service
location, engagement, assessment, and interven- Health Award of Excellence for Cultural Competence.
tion. (Presidents New Freedom Commission on These Ethnic/Minority Psychiatric Inpatient Pro-
Mental Health 2003, p. 52) grams began in March 1980, before the start of the in-
itiatives in cultural competence and reducing mental
As also noted in the report, Despite widespread health disparities described earlier in the chapter,
use of the concept of cultural competence, research on when I initiated the Asian Focus Psychiatric Inpatient
putting the concept into practice and measuring its Unit, which was the first inpatient psychiatric pro-
effectiveness is lacking (Presidents New Freedom gram in the United States with a focus on the cultural
Commission on Mental Health 2003, p. 52). needs of Asians/Asian Americans. It linked with pre-
existing Asian-focused outpatient/day treatment men- tant recent publications (Group for the Advancement
tal health services in the San Francisco Department of of Psychiatry 2002; Koskoff 2002; Lim 2006). Staff are
Public Health Community Mental Health Services to provided diversity training modeled after the small
provide a comprehensive system of care for the Asian group experiential work of Elaine Pinderhughes (1988)
population of San Francisco, then 22% of the city of to explore differences across race, ethnicity, gender,
685,000 people. The focus service concept was high- and sexual orientation, especially when these differ-
lighted in the 1978 report of President Carters Com- ences intersect with power differentials between staff
mission on Mental Health, Subpanel on Asian Amer- and patients; staff comfort with such differences is im-
icans (Presidents Commission on Mental Health portant in working with our culturally diverse pa-
1978), as a cost-effective way to efficiently utilize tients.
scarce human resources of bilingual/bicultural staff to
care for this underserved population. The focus ser- Ethnic/Minority Psychiatric Inpatient
vice concept brings together multidisciplinary staff,
faculty, and trainees to work with patients who could
Programs: Descriptions and
benefit from their cultural and linguistic expertise re- Admission Indications
lated to diagnosis, assessment, and treatment. The
Almost all patients admitted to Ethnic/Minority Psy-
Asian Focus Program Unit has served as a model for
chiatric Inpatient Programs are first assessed in the
the initiation and development of the other four focus
Psychiatric Emergency Service. Nearly 100% of pa-
units. Psychiatrists, nursing staff, social workers, oc-
tients admitted to the inpatient units are involuntarily
cupational therapists, and psychologists comprise the
committed because of dangerousness to self, danger-
staff. SFGH has been a major teaching hospital at
ousness to others, or grave disability (inability to pro-
UCSF since the late 1800s. Trainees include UCSF
vide food, clothing, or shelter) due to a mental disorder
postgraduate year1 psychiatric residents (23-week ro-
and because the patient is either unwilling or incapable
tation on several inpatient units); year-3 and year-4
to accept treatment voluntarily. The department has a
medical students; psychology fellows; and students of
procedure for admission indications based on staff ex-
social work, nursing, and occupational therapy. A
pertise and patient needs, which in turn is based on the
1991 article by Zatzick and Lu described the concept
San Francisco Department of Public Health Policy
of the ethnic/minority focus unit as a training site in
Number 102 on Cultural and Linguistic Competency.
transcultural psychiatry, with specific discussion of
This policy states that health care organizations should
two patients treated on the Asian Focus Program Unit.
ensure that patients/consumers receive from all staff
Each inpatient program, led by an attending psy-
members effective, understandable, and respectful care
chiatrist unit chief and nurse manager, has developed
provided in a manner compatible with the patients cul-
expertise and experience in working with individuals
tural health beliefs and practices and preferred lan-
from underserved populations who may have needs
guage. The extent to which patients are admitted to the
best served by the unit. The department is committed
unit that best meets their needs is contingent on many
to recruiting and retaining a culturally and linguisti-
factors such as bed availability and unit acuity.
cally diverse staff with this expertise. The focus service
concept is not a form of segregation, because we have
staff and patients of many ethnicities on all units. De- ASIAN FOCUS PROGRAM
spite their focus on different populations, the pro- The units staff share common linguistic and cultural
grams share a commitment to providing care that is backgrounds with many of the patients. The staff
sensitive and responsive to the complex cultural iden- speak 16 Asian languages and dialects of Chinese (in-
tity and particular needs of every individual patient cluding Cantonese, Mandarin, Toishanese), Tagalog,
and family rather than prematurely stereotyped pa- and Vietnamese. About two-thirds of the staff are
tients. The DSM-IV-TR Outline for Cultural Formu- Asian; many have migrated from countries outside the
lation provides a concise clinical tool to help guide United States. Family assessment and dealing with
clinicians and is incorporated routinely in department the intense stigma of mental illness are particularly
case conference presentations (American Psychiatric emphasized. The unit operations are more fully de-
Association 2000). The Outline was incorporated into scribed later in the chapter to exemplify how such eth-
the Practice Guideline for the Psychiatric Evaluation nic/minority focus units provide care (Gee et al. 1999).
of Adults, 2nd Edition (American Psychiatric Associa- A key textbook for staff and trainees on this unit was
tion 2006) and has been the subject of several impor- edited by the late Evelyn Lee, Ed.D., M.S.S.A., Clinical
Professor of Psychiatry at UCSF, who worked on the 2001). Herrera and Collazo (1999) described a similar
unit from 1982 to 1988 (Lee 1997). Latino-focused milieu in New York City.
Admission indications for the Asian Focus Pro- Admission indications for the Latino Focus Pro-
gram Unit are as follows: gram Unit are as follows:
A. Patients who have Asian languages as their pri- A. Patients who have Spanish as their primary or pre-
mary or preferred language. ferred language.
B. Patients whose families or significant others have B. Patients whose families or significant others have
Asian languages as their primary or preferred lan- Spanish as their primary or preferred language.
guage. C. Patients and significant others who are culturally
C. Patients and significant others who are culturally identified as Latinos or Hispanic.
identified as Asians, Asian Americans, or Pacific D. Patients who have clinically significant issues re-
Islanders. lated to culture (such as those noted earlier in the
D. Patients who have clinically significant issues re- Asian Focus Program indications).
lated to culture. Examples include E. Patients who have had prior or ongoing treatment for
1. Immigration stress Latino-focused issues with inpatient or outpatient
2. Acculturation differences among family mem- programs in order to maintain treatment continuity.
bers F. Patients who state a preference/request for the La-
3. Victims of racial violence and discrimination tino Focus Program Unit.
4. Victims of political oppression, colonization,
Contraindications for admission include the following:
and war
5. Cultural expressions or explanations of illness
A. Patients who have a history of severe physical as-
6. Use of indigenous healing systems
sault, strong ideation of assault, or history of verbal
7. Cultural supports (e.g., family or religion) or
abuse/racial harassment specifically against or by
stressors that need assessment
Latinos.
E. Patients who have had prior or ongoing treatment B. Patients who actively decline to be admitted to the
with Asian-focused inpatient or outpatient pro- unit.
grams in order to maintain treatment continuity.
F. Patients who state a preference/request for the WOMENS FOCUS PROGRAM
Asian Focus Program Unit.
Started in 1982 by Anna Spielvogel, M.D., Ph.D. (now
Contraindications for admission include the following: Clinical Professor and Associate Residency Training
Director), the Womens Focus Program works with
A. Patients who have a history of severe physical as- women needing psychiatric assessment and treatment
sault, strong ideation of assault, or history of verbal during pregnancy, postpartum, and menopause;
abuse/racial harassment, specifically against or by women dealing with parenting issues; women experi-
Asians. encing past and present trauma (such as physical and
B. Patients who actively decline to be admitted to the sexual abuse, rape, and domestic violence); and women
unit. diagnosed with major psychiatric disorders. This team
developed innovative treatment approaches for se-
verely mentally ill women, first focusing on treating
LATINO FOCUS PROGRAM
psychotic pregnant women and later developing spe-
Started in 1982, the Latino Focus Program works with cialized treatment approaches for women who self-mu-
Spanish-speaking patients and families that have lim- tilate, those doing sex trade work, and women with se-
ited English proficiency as well as with patients and vere drug and alcohol dependence.
families that are English-speaking. The patients have Admission indications for the Womens Focus Pro-
national origins from Mexico and Central and South gram Unit are as follows:
American countries. A key textbook was edited by two
former faculty members, Alberto Lopez, M.D., M.P.H., A. Women who have histories of severe trauma, in-
and Ernestina Carrillo, M.S.W., who initiated the Lat- cluding recent sexual assault, domestic violence,
ino Focus Program and worked on the unit from the and childhood trauma, and women with dissocia-
early 1980s to the early 1990s (Lopez and Carrillo tive disorders.
B. Women with obstetric/gynecological and reproduc- D. Patients who have had prior or ongoing treatment
tive issues, including pregnancy, menopause, and with black-focused inpatient or outpatient pro-
reproductive choice. grams in order to maintain treatment continuity.
C. Women struggling with multiple gender roles. E. Patients who have had difficulty linking with
D. Women with child-rearing issues, including relin- white-dominated mental health providers.
quishment. F. Patients who state a preference/request for the
E. Patients who have had prior or ongoing treatment Black Focus Program Unit.
with Womens Focus inpatient or outpatient pro-
grams, in order to maintain treatment continuity. Contraindications for admission include the following:
F. Patients who state a preference/request for the
Womens Focus Program Unit. A. Patients who have a history of severe physical as-
sault, strong ideation of assault, or history of verbal
Contraindications for admission include the following: abuse/racial harassment specifically by or against
blacks.
A. Patients who have a history of physical/sexual as- B. Patients who actively decline to be admitted to the
sault against women, strong ideation of assault, unit.
stalking, and/or harassing of women or children or
who have a history of such acts by women against
HIV/AIDS FOCUS PROGRAM
them.
B. Patients who actively decline to be admitted to the Started by Jay Baer, M.D., in 1982, the HIV/AIDS Fo-
unit. cus Program has experience in working on this medi-
cal/psychiatric interface since the start of the HIV/
AIDS epidemic that greatly affected San Francisco.
BLACK FOCUS PROGRAM
Two articles by Baer (1989; Baer et al. 1987) described
Started in 1985, the Black Focus Program has expertise the initial history of this program. In July 2008, this
in African American, African Caribbean, and African program was integrated into the other psychiatric pro-
patient issues. Family assessment, spirituality, and un- grams.
derstanding of racism, racial discrimination, and racial Admission indications for the HIV/AIDS Focus
identity development are some of the relevant issues Program Unit were as follows:
seen on this unit (Ridley 2005; Whaley 2004).
Michelle O. Clark, M.D., Associate Clinical Professor, A. Patients with medical complications of HIV/AIDS
who was the Unit Chief from the late 1980s to the late that could benefit from the close liaison with the
1990s, described the unit in 1999 (Clark 1999). AIDS consultation team. Examples include those
Admissions indications for the Black Focus Pro- with new opportunistic infections and new medi-
gram Unit are as follows: cations to be considered.
B. Patients with psychological or neuropsychiatric
A. Patients or significant others who self-identify as
complications of HIV/AIDS, such as recent sero-
black, African American, or African.
conversion leading to depression, depression due
B. Patients who have conflicts about racial identity
to catastrophic losses, and AIDS dementia.
and prefer a black-focused program.
C. Patients with social issues complicated by HIV/
C. Patients who have clinically significant issues re- AIDS, including complex relationships with signif-
lated to culture. Examples include
icant others and complex dispositions.
1. Social stressors of racism/discrimination that D. Patients with prior or ongoing treatment at the
affect development or functional ability HIV/AIDS medical service or HIV/AIDS-focused
2. Black cultural family issues inpatient or outpatient programs in order to main-
3. Black religious or spiritual supports or conflicts tain treatment continuity.
4. Cultural expressions or explanations of illness E. Patients who state a preference/request for the
5. Use of indigenous healing systems HIV/AIDS Focus Program Unit.
6. Patient or family communication in primarily
African American vernacular English, African The only contraindication for this unit was pa-
Caribbean, Arabic, or other African language. tients who actively declined to be admitted to the unit.
LESBIAN/GAY/BISEXUAL/TRANSGENDER Unit Operations: The Example

FOCUS PROGRAM of the Asian Focus Program Unit
Started in 1992, the Lesbian/Gay/Bisexual/Transgen-
der (LGBT) Focus Program has expertise in working
with patients with these sexual orientation identities
Diagnostic Workup
and relevant clinical issues. A key textbook was edited The role of culture and inpatient care infuses many as-
by Robert Cabaj, M.D., Director of the San Francisco pects of unit operation, from staff relations to clinical
Community Behavioral Health Service, on homosex- assessment and diagnosis to milieu therapy to family
uality and mental health (Cabaj and Stein 1996). work and treatment planning (Lu 2004). The contri-
Admission indications for the LGBT Focus Pro- bution of the Asian Focus Program Unit to the diag-
gram Unit are as follows: nostic workup relates to the staff s ability to commu-
nicate both verbally and nonverbally with the many
A. Patients who state a preference/request for the patients with limited English proficiency who are
LGBT team, especially those who are identified admitted. Members of the staff are able to speak 16
with these sexual orientations or who are transgen- Asian languages and dialects of Chinese, and the
dered (pre- or postsurgery). SFGH Interpreters Service has access to interpreters
B. Patients who have clinically significant issues re- for additional languages. Staff are familiar with work-
lated to sexual orientation/sexual identity and who ing with interpreters (Tribe and Raval 2003). Language
prefer/request the LGBT team. Examples include access in health care has become an important goal, as
demonstrated by the National Health Law Program
1. Conflicts about coming out
(2007) Language Access in Health Care Statement of
2. Alienation from family/friends/religious com-
Principles, signed by more than 70 organizations. In
munities
addition, the staff members not only are fluent in the
3. Complex social relations related to sexual ori-
various languages but also are trained mental health
entation/sexual identity
professionals across multiple disciplines. For example,
4. Victims of homophobic violence or discrimina-
Cantonese is the predominant Asian language spoken
tion
by the patients; we have Cantonese-speaking staff on
C. Patients with prior or ongoing treatment at LGBT- the unit in the following disciplines: psychology, nurs-
focused inpatient or outpatient programs in order ing, social work, occupational therapy, and unit clerk.
to maintain treatment continuity. Such a concentration of Cantonese speakers on the
same unit permits true multidisciplinary assessment
Contraindications for admission include the following: and treatment planning with both the patient and
families. At times, even though the patient speaks En-
A. Patients who are clearly homophobic or actively de- glish, the families have limited English proficiency.
cline to be admitted to the unit. The ability to communicate with the patients and
B. Patients who have been violent or have strong as- families in their preferred language facilitates rapport
sault ideation toward LGBT persons. and information gathering with patients and families
C. Patients who are in an acute homosexual panic. and the conduct of diagnostic tests such as laboratory
work, which can sometimes be difficult with more tra-
ditionally acculturated Asian patients, who may have
FORENSIC FOCUS PROGRAM
divergent explanatory models of illness and treatment
This 10-bed inpatient unit provides acute emergency pathway preferences.
evaluation and treatment for patients in the San Fran- Secondly, the staff use the DSM-IV-TR Outline for
cisco County Jail system. Patients are mostly newly Cultural Formulation to facilitate understanding of
charged and admitted awaiting a pretrial hearing. Un- the sociocultural issues as they affect diagnosis and
like the other three inpatient units, only patients with management. This is especially important for the dif-
charges are admitted to this unit, and their disposition ferential diagnosis as to whether a particular phenom-
is return to jail unless their charges are dropped. Staff enon represents a cultural norm, an idiom of distress,
have developed knowledge and skills to work with pa- a culture-bound syndrome, a condition that warrants
tients from the jail system. clinical attention, a sign or symptom of a mental dis-
order, or some combination of any of these possibili- Milieu Management

ties. Misdiagnosis and resultant mistreatment can be
reduced through the use of the outline. The large num- The milieu is designed to provide a multicultural, sup-
bers of multicultural staff who have direct and long- portive environment for diagnostic and therapeutic
standing experience with patients from diverse Asian purposes. First, the physical design includes signage in
cultures greatly helps in the differential diagnosis. Chinese and Vietnamese languages for patients with
It is also important to note that the cultural assess- limited English proficiency. Patient orientation bro-
ment involves for all patients not only the primary fo- chures, description of patients rights, legal and con-
cus of the unit (Asian in this case) but also any possible sent forms, and unit schedules are also translated. The
issues involving gender (Burt and Hendrick 2005), re- unit decor reflects Asian sensibilities, with appropriate
ligion/spirituality (Josephson and Peteet 2004; Koenig posters, pictures, and paintings. One of the unit tele-
2007), sexual orientation, and socioeconomic status, visions is tuned to the Chinese-language station, and
among others, especially as they intersect the other newspapers in various Asian languages are present.
cultural identity variables (Hays 2007). Finally, family Rice and tea are available at meals, and an Asian food
assessment in working with Asian patients has proven cooking group is a popular activity. Consistent with
to be an essential aspect of the diagnostic workup. As traditional Asian family norms, family members are
discussed in Evelyn Lees (1997) book and the classic generally allowed to bring in home-cooked meals for
Ethnicity and Family Therapy edited by McGoldrick et patients.
al. (2005), the clinician must be sensitive and respon- Group activities include community meetings, oc-
sive to the complexities of family dynamics across dif- cupational therapy groups, small group discussions,
ferent Asian ethnic subgroups, generations, genders, medication groups, and patio and recreational activi-
and levels of acculturation within the family, which ties. The occupational therapy staff include Cantonese-
may need to be defined beyond the nuclear family. speaking personnel, which allows the conduct of these
Family support and stress, as noted in the third part of activities using the predominant Asian language spo-
the Outline for Cultural Formulation, relates often ken by the patients in addition to English. Activities are
to the culture of the patient and family. scheduled that are popular with the Asian patients;
these include the Asian food cooking group, physical
Therapies exercise group incorporating Asian themes, and a med-
itation group. Because of the critical mass of patients
Care is provided through one of two multidisciplinary
with limited English and the multicultural and multi-
teams, each led by an attending psychiatrist. Pharma-
lingual staff, those patients who might feel isolated on
cotherapy strategies take into account the possibility
most inpatient units due to their limited English profi-
that some Asian patients may require lower dosages of ciency are able to interact not only with the multidisci-
medications to achieve therapeutic improvement and
plinary staff but also with other patients and family
to avoid side effects (Ruiz 2000). It is critically impor-
members. This process encourages socialization and
tant to understand the patient and families explana-
group cohesion and support when discussing cultural
tory model and treatment pathway preferences in
stressors such as acculturation, refugee and immigrant
order to negotiate differences with the clinicians
experiences, and intergenerational stress due to differ-
model to maximize treatment adherence. Psychother- ent levels of acculturation within a family.
apy may need modification to accommodate diverse
levels of English proficiency and health literacy, cul- Management of Suicidal and
tural identities and worldviews, and explanatory mod-
els and treatment pathway preferences. For example,
Aggressive Behaviors
Hays and Iwamasa (2006) demonstrated the impor- All the ethnic/minority focus units, including the
tant modifications necessary to optimize cognitive- Asian Focus Program Unit, pay particular attention to
behavioral therapy for culturally diverse populations. how culturebroadly speakingmay increase the
Psychoeducational material for patients and families risk for or protect a particular person from suicidal ide-
must also take these issues into consideration. Due to ation and acts (Gold 2006; Horton 2006; Wendler and
the value placed on work and education by traditional Matthews 2006). Use of the Outline for Cultural For-
Asian families, rehabilitation approaches that prom- mulation can help uncover specific cultural stressors
ise hope to return to functioning are very important as well as cultural supports that otherwise might be
for these patients and families. neglected or ignored in the assessment. For example,
an individuals religious or spiritual beliefs or practices of different ethnic and/or minority status. The specific
might not be assessed by the clinician due to personal benefits of providing care on culturally designated
or professional training issues, yet this might be an units as opposed to units not focused on these groups
important area of either stress or support for the pa- have not been systematically investigated. More re-
tient. Regarding violent patient behaviors, all of our search is needed to address this important issue.
units have been engaged in a violence reduction
project since 2006 to reduce both patient assaults on
other patients and staff and the use of seclusion and
References
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Accessed May 27, 2008.
CHAPTER 12
THE FORENSIC UNIT

Michael A. Norko, M.D.
Charles C. Dike, M.D., M.P.H., M.R.C.Psych.
The forensic unit is presented with the same clinical patients. Clinicians providing such mandated treat-
challenges that are addressed on acute or long-term ment do not need to feel apologetic about care deliv-
care units in general psychiatric hospitals. In addition ered in such circumstances, but they do need to attend
to those challenges, the forensic unit must be able to to the special circumstances created by these special
manage the mostly mandated nature of the care pro- mandates (Zonana and Norko 1993).
vided and the dual nature of forensic treatment (i.e., The dual nature of forensic treatment means that
serving both the care needs of the individual patient as all staff members on a forensic unit (including security
well as the security/safety needs of the facility and the staff) need to attend to both treatment and safety/se-
society in which it operates). Because of the nature of curity concerns, because effective treatment can never
this work, the forensic unit is positioned in the middle be delivered in an environment in which people feel
of the many competing and often adversarial postures unsafe or security is compromised. A collaborative
of various agents. model usually works best in balancing treatment and
Forensic units regularly admit acutely ill pa- safety/security concerns (Scales et al. 1989).
tientswho are often psychotic and agitatedunder Even when such balance is achieved, however, fo-
several forms of legal status (discussed later). Patients, rensic clinicians find themselves practicing in the
particularly those found not guilty by reason of insan- cross fire of multiple adversarial agents. When treat-
ity, may also stay many years on forensic units be- ment is ordered through criminal court, prosecution
cause of concerns about their risk management. and defense may both focus attention in court on the
Although much of general inpatient treatment is care provided and decisions reached by the hospital
mandated in some way (e.g., civil commitment, re- treatment teams, even though the team members are
quirements of employment, strong urging of spouse), not retained by either party. Because of the inherently
forensic inpatient treatment may also be mandated by mandated nature of most forensic treatment, legal ad-
criminal courtsoften to the displeasure of individual vocates pay particularly close attention to the rights of
185
these patients, often arguing for treatment that con- Insanity acquittees may be brought to the forensic
flicts with the units responsibility to courts and local unit for evaluation and/or treatment and custody in a
and public safety. Because forensic patients are doubly secure environment. This also requires a criminal
stigmatized, discharge planning often places the foren- court commitment after a finding that the individual
sic unit in the middle of controversies argued publicly has met the jurisdictions legal criteria for a successful
among officials representing defense, prosecution, ad- insanity defense. In some jurisdictions, the processes
vocacy, and public safety concerns, all while attempt- for release of acquittees invite even misdemeanor de-
ing to maintain hope and the momentum of personal fendants to pursue the defense, whereas in other juris-
development for the patients. dictions a strongly conservative statutory approach
skews this population to a select group of those
charged with only the most serious offenses. Despite
Admission Criteria the fact that a successful insanity defense requires that
the individual both admit the criminal act and prove a
Patients are admitted to forensic units generally under serious mental illness, the successful acquittee will of-
one of four categories: restoration of competency to ten arrive at the hospital denying both propositions
stand trial; evaluation/treatment of insanity acquit- emphatically (Zonana and Norko 1993). This compli-
tees (those found not guilty, or not criminally respon- cates therapeutic engagement and treatment plan-
sible, by reason of mental disease or defect); transfers ning. Periods of potential commitment may be quite
of inmates from correctional facilities for evaluation, long (e.g., decades), creating challenges for instilling
acute care, or placement at end of sentence; and civil hope for recovery and release.
patients (either voluntary or involuntary) admitted Patients are referred from correctional settings to
due to agitation and risk of assault that cannot be forensic units to provide acute hospital-level psychiat-
managed in other environments. ric care that cannot be adequately provided in the
Although many jurisdictions permit outpatient prison or jail. Such patients are often experiencing
competency restoration, most often this work is ac- acute psychosis, mania, or depression with suicidal
complished in secure inpatient settings due to con- thoughts/actions and may well be agitated and have a
cerns about custody as well as treatment compliance. history of violence both in the community and in cor-
These defendant-patients are sent to the forensic unit rectional environments. They are also sometimes re-
by order of a criminal court because they have been ferred for various statutorily created evaluations as part
found not competent to stand trial. They may have se- of the criminal justice process. Often inmates with
vere psychosis, severe affective disorders, dementia, or continuing serious psychiatric disabilities may be re-
cognitive effects of substance abuse or mental disorders ferred for admission to forensic units upon completion
caused by medical conditions. The goal of treatment of their prison sentence. Correctional transfer patients
for these patients is to restore the individuals abilities may arrive on a voluntary admission or an involuntary
to understand the legal proceedings and to assist in the admission (including emergency admission processes),
defense process. This means that this treatment is not often separate from usual civil processes, but with par-
directed at holistic or client centered goals, because allel provisions due to constitutional requirements.
as soon as the relevant capacities are restored, the in- These admissions are best accomplished through a
dividual is returned to court. This does not mean, how- collaborative approach between mental health col-
ever, that forensic units do not have to do adequate dis- leagues in the hospital forensic unit and the correc-
charge planning, because many defendants (e.g., those tional settings.
with low-level charges) may be released from custody Finally, the forensic unit is used in many jurisdic-
or even have their charges disposed at the time that tions as a tertiary referral cite for civil patients whose
they are found restored to competence by the court; aggressive behavior is difficult to manage in other in-
they are thus returned to the community where they patient settings. This happens because forensic units
will need ongoing services to help them maintain their are generally more secure, have increased security
health and functioning. It also does not mean that the staffing, and have experience in dealing with aggres-
forensic unit is relieved of the responsibility for provid- sive behaviors among individuals admitted through
ing services to meet immediate needs that are not various stages of the criminal justice system. Civil pa-
directly related to competency to stand trial; for ex- tients are often admitted under emergency provisions
ample, the unit may have to provide for long-neglected of civil statutes and maintain their civil status while
psychiatric, medical, or even surgical interventions. admitted to the forensic unit. Their admission most
The Forensic Unit 187
often also prompts additional scrutiny by legal advo- minimal documentation of psychiatric history or cur-
cates because admission to forensic units may entail rent mental state. Important information includes
additional curtailment of liberties, invite increased whether the patient was living in the community (in a
stigma, subject the civil patient to an environment of private residence or program) before the admission or
criminally committed patients, and delay or deter later is arriving directly from a correctional setting (prison or
successful discharge to the community. jail). If the admission is directly from corrections, it is
helpful to note if the patient had been involuntarily
medicated, had attempted suicide, or received any
Diagnostic Workup tickets for disciplinary problems. This information is
helpful in the immediate assessment of the severity of
The diagnostic process in a forensic psychiatric inpa- psychiatric disorder and current risk of suicide or vio-
tient unit is necessarily comprehensive. It involves lence.
not only an assessment of the psychiatric condition A problem often encountered during off-hours ad-
but also an ongoing assessment of needs and risks. missions from the courts is the unavailability of rec-
Therefore, a multidisciplinary team approach to diag- ords. Most of these patients were in jail or prison before
nosis is emphasized and advocated. going to court and often arrive at the forensic hospital
Immediately after an initial admission process in- late at night due to the logistics of transport by court
volving assessments by psychiatry and nursing (and marshals. It is often difficult to contact health care
sometimes social work, psychology, and rehabilitation workers from the other agencies at such a late hour.
therapy if the admission occurs during regular hours), a Even when this is accomplished, the exaggerated fear
presumptive diagnosis is made. Thereafter, the various that other colleagues hold of breaching patients confi-
disciplinespsychiatry, nursing, psychology, rehabili- dentially, even when treater-to-treater exemptions to
tation therapy, occupational therapy, social work, and confidentiality are explained to them, prevents disclo-
sometimes physical therapybegin an intense period sure of important, and sometimes life-saving, medical
of discipline-specific assessment of needs that will cul- and psychiatric information to the staff of the admit-
minate in the development of a more comprehensive ting forensic unit. Risks of not only suicide and vio-
treatment plan within a few days of the admission. A lence but also serious medical or surgical problems that
thorough medical assessment also occurs within this require close monitoring and treatment may be over-
period and includes a recommended set of admission looked.
laboratory investigations and other special investiga- Later in the assessment process, a decision is made
tions as needed. about the necessity for psychological or neuropsycho-
Every team member is involved in the assessment logical testing to assess malingering, personality char-
of risks, which includes assessing risk-relevant needs acteristics, intelligence, cognitive disorders, mood dis-
and deficits of the individual, so that interventions orders, or psychosis.
can be delivered to target those needs and enhance
protective factors (Dvoskin and Heilbrun 2001). The
patients behavior is closely monitored on and off the
Treatment
unit and in group settings for risks of suicide, violence,
or elopement. Patients preferences can be noted and The most effective treatment utilizes a multidisci-
documented in a special section in the chart. This is a plinary approach and involves biological, psychologi-
record of how a patient would like to be managed dur- cal, and social models of treatment. In addition, the
ing periods of agitation or loss of control, including spiritual dimensions of patients lives are taken into
ways in which the staff can be most helpful to the pa- account, and provisions are made, as much as possible,
tient during these times as well as those steps the pa- to allow patients to engage in their religious practices.
tient can directly take to moderate the negative state. Pastors, imams, priests, and rabbis are incorporated in
These might include time spent alone in a quiet area, treatment, especially where there is a religious element
listening to music, talking to others, or walking out- to a patients illness. Furthermore, specific cultural is-
side in the courtyard. sues that might have an impact on treatment are ad-
Obtaining collateral information is generally an dressed by inviting specialists in the culture. Despite
important element of formulating diagnosis, but it is the mandated nature of treatment on forensic units,
even more so in a forensic psychiatric hospital. Pa- opportunities to employ principles of recovery in the
tients often arrive directly from court, sometimes with work with individual patients should be sought.
Medication Treatment detection of abnormalities and prompt treatment. In

addition, abnormal involuntary movement should be
In terms of biological treatment, psychotropic medica- regularly assessed using the Abnormal Involuntary
tion treatments are the most common, but occasion- Movement Scale with patients given antipsychotic
ally, electroconvulsive therapy and hormonal therapy medications.
are indicated and prescribed. Antipsychotic medica- In some instances, however, potentially dangerous
tions, mood stabilizers, and antidepressants are the side effects or drugdrug interactions may limit med-
most common medications prescribed. Antipsychot- ication choices available for vigorously treating psy-
ics are commonly used, not only for psychosis but also chosis or aggression. The risk of physical aggression to
for agitation (Zimbroff 2003), mood stabilization, ag- other patients and staff due to inadequate treatment
gression, and impulsivity (Glancy and Knott 2003). In must then be balanced against the dangers of treat-
turn, mood stabilizers are prescribed for agitation, ag- ment to the patient. This is a complicated process that
gression, impulsivity (Glancy and Knott 2002), and should be carefully considered and openly discussed
augmentation of antipsychotic and antidepressant with the treatment team members, the patient, and
medications in addition to mood stabilization. Anti- the patients chosen advocate/representative (or ap-
depressants are used for depression, anxiety disorders, pointed guardian or conservator) as needed. On some
sexual disorders, and compulsivity/impulsivity (Coc- occasions, patients admitted for restoration to compe-
caro and Kavoussi 1997). All three groups of medica- tency have been recommended to the courts as not
tions are sometimes used for their sleep-inducing side competent to stand trial and not restorable because
effect potential. Hormonal therapy is indicated for sex concerns of side effects or adverse drug interactions
offenders (Saleh and Guidry 2003), which includes have made adequate treatment impossible.
antiandrogens (e.g., medroxyprogesterone acetate), A unique characteristic of forensic units that af-
synthetic gonadotropin-releasing hormone analogues, fects medication use is the wide age range of the unit
and oral estrogens. The use of antipsychotic medica- population, from the late teens to the geriatric. Some
tions and mood stabilizers for aggression and impul- acquittees spend decades in the hospital, and as they
sivity is not approved by the U.S. Food and Drug Ad- get older, particular attention should be paid to the
ministration (FDA). Likewise, antidepressants and dosages of their psychotropic medications. Dosages
hormones are used off-label for treating sex offenders. should be adjusted for age as patients move from
As noted earlier, the population of patients on a fo- adulthood to geriatric age in order to avoid gradual tox-
rensic unit is varied, although some treatment resis- icity that may sometimes appear to be sudden and in-
tance is a feature common to many patients. The high explicable. In addition, treatment for multiple medical
prevalence of refractory psychiatric disorders and ag- problems resulting from old age may not only compli-
gression fosters the use of high dosages of psychotropic cate psychiatric disorders but also cause dangerous
medications as well as antipsychotic polypharmacy, de- drugdrug interactions.
spite limited evidence of its usefulness (Stahl 2002). As On a positive note, forensic psychiatric hospitals
a result, the prevalence of side effects of medications, are exempt from the pressures exerted by insurance
such as involuntary motor movements and metabolic companies that lead to quick, and sometimes precipi-
syndrome, is high. A relatively sedentary lifestyle im- tous, discharges of patients from the hospital. Except
posed by a combination of the patients illnesses and for situations when the need to quickly manage ag-
the structure and nature of forensic units, compounded gression dictates otherwise, treatment teams have a
by the tendency of patients to indulge in excessive eat- unique opportunity to slowly titrate or taper dosages of
ing (food being one of the few pleasures readily avail- medications and to try various combinations that may
able to them), complicate the problem by worsening or be beneficial for their patients.
maintaining obesity, a common side effect of psycho-
tropic medications. Likewise, the risk of drugdrug in-
Psychotherapies
teractions is high. Common examples of such interac-
tions include serotonergic syndrome secondary to a Psychotherapeutic techniques include individual and
combination of medications that increase central ner- group therapy. Commonly used and available individ-
vous system serotonin and increased risk of seizures ual psychotherapeutic treatments include cognitive-
due to a combination of clozapine and bupropion. behavioral therapy, behavioral therapy, psychoanaly-
Close monitoring of the metabolic profile of pa- sis, supportive therapy, and various other forms of
tients through regularly scheduled blood tests and dynamic psychotherapy. Few forensic units have suffi-
weight documentation would hopefully lead to early cient resources to offer individual psychotherapy to
every patient, nor would it be indicated, so patients are bers of forensic patients but also to provide support to
selected for individual therapy on the basis of assessed them. Often, family members are confused about the
need and likelihood of efficacy. differences between a forensic unit and a prison, espe-
Unlike individual therapy, every patient is involved cially in situations when they have to pass through
in group therapy sessions. The more basic or routine metal detectors to get to the units. Family members
groups include groups for anger management, social also get frustrated when they are told they cannot bring
skills training, symptom management, apartment liv- certain food items or other seemingly innocuous ma-
ing, money management, medication education, relax- terials that most other hospitals gladly welcome and
ation training, and substance abuse (e.g., Alcoholics have difficulty appreciating the potential danger the
Anonymous or Narcotics Anonymous, cognitive-behav- materials pose. Therefore, family education is neces-
ioral therapy groups). There are also specialized groups sarily broad in scope and includes an understanding of
such as dialectical behavior therapy groups that target specific major mental illnesses as well as the special
patients with emotional/behavioral dysregulation re- processes and external reviewing agencies that dictate
lated to personality disorder. In addition, patients partic- certain special activities of a forensic unit.
ipate in groups that are specifically germane to a forensic In the Whiting Forensic Division of Connecticut
unit, such as competency to stand trial education, not Valley Hospital, social workers run the family support
guilty by reason of insanity, family homicide (individu- group once a month. In addition to providing educa-
als who have killed family members), legal education, tional materials covering major mental illnesses, they
and problem sexual behavior/sex offender groups. also invite certain individuals to speak to the family
Forensic psychiatry patients often have a long his- members. Speakers have included the director of the
tory of institutionalization and have either lost their Psychiatric Security Review Board, which reviews
social skills or never developed them. Anger is usually movement of insanity acquittees; a public defender as-
a big problem, and a history of childhood trauma is signed specifically to defend insanity acquittees; the
common. Group therapy provides an opportunity for director of the forensic units; and an attending psychi-
patients to learn from their peers and instructors, get atrist on one of the units. In other situations the meet-
support from their peers, and also get feedback on the ings have a social flavor, and in that context informa-
impact of their behavior on others. tion is shared informally among attendees.
Another psychotherapeutic intervention crucial to The supportive role these meetings have for family
managing difficult personality disorders, refractory members cannot be overemphasized. They provide
psychosis, mental retardation, and aggression is be- opportunities for family members to mutually support
havior therapy. Rewards and reinforcements (positive each other, share experiences, and offer advice. Those
and negative), as well as clear consequences for inap- whose relatives have been hospitalized for years share
propriate or intolerable behavior, are used to shape be- insights with others relatively new to the process. It is
havior to socially acceptable standards. Although be- believed that the more equipped and the more confi-
havioral interventions are very effective, consistent dent family members feel, the more helpful they will
application of behavioral plans through all shifts is dif- be to both the treatment team and their loved ones.
ficult. This may be due to staff vacations (especially of
trained staff), frequent use of float (work-off) staff who Rehabilitation and Recreational
are unfamiliar with the plans, and the reluctance of Therapies
staff to fully engage in the program. Behavioral plans
are often more involved than routine care and require Recreational therapies are used to treat and maintain
the physical, mental, and emotional well-being of pa-
vigilance and active participation of staff to be effec-
tients through a variety of techniques, including music,
tive. The relative scarcity of behaviorally trained psy-
relaxation, arts, sports, games, dance, drama, and com-
chologists further compounds the problem. Therefore,
munity outings. These therapies help individuals re-
despite research that clearly shows the effectiveness of
duce depression, stress, and anxiety; develop better so-
behavioral interventions in controlling difficult behav-
iors, behavioral techniques are often not utilized cial skills; and become more confident. The goal is for
patients to express their feelings in a therapeutic setting
nearly as much as they could be.
and to experience meaningful and pleasurable activities
despite the limitations of their mental illness.
Patient and Family Education In addition, therapists help long-stay patients rein-
The goal of patient and family education on a forensic tegrate into the community by teaching them how to
unit is not only to provide education for family mem- use community resources and recreational activities.
Community trips are planned for patients who have primary diagnosis of paraphilia, or paraphilia with
progressed through the maximum security units to comorbid psychotic disorder or substance misuse dis-
less secure units and who have low risks of aggression orders. A growing trend in forensic psychiatry is the
or elopement. Patients are taught how to utilize relax- admission of sex offenders to forensic units after com-
ation techniques to relieve anxiety. They are also en- pletion of their sentences in prison. Unfortunately,
couraged to develop adaptive leisure activities and currently available treatments for sex offendershor-
hobbies. Leisure activities, especially structured group mones, antidepressants, and sex offender groups
programs, are particularly helpful not only to main- have not been proven conclusively to be effective at re-
tain patients general health and well-being but also to ducing recidivism; findings of positive effect remain
decrease opportunities for aggressive behavior. controversial and await further definitive study (Col-
When patients are involved in structured activi- laborative Outcome Data Committee 2007).
ties, they may be less likely to grow bored and to in-
tentionally or unintentionally provoke each other out
of the frustration of inactivity. Exercise and sports pro- Milieu Management
grams help in dissipating energy and in generating an
overall feeling of well-being. Through team sports pa- In addition to the usual requirements of maintaining
tients learn to work collaboratively with others to an effective therapeutic milieu on an inpatient unit,
achieve a common goal. These activities also provide the staff and managers of forensic units must attend to
opportunities for therapists to teach patients anger the special demands of milieu management related to
management and appropriate methods of coping with safety and control of aggression. Forensic patients
frustration. For certain patients, especially those with have often committed horrifying acts of violence as
communication difficulties, art therapy may provide the basis of their referral, and many exhibit ongoing
an avenue for self-expression, and pet therapy may aggressive behavior that may have been unresponsive
help the patient establish a connection not only with to management in other settings. In addition, patients
the pet but also with the staff handler. transferred from correctional settings may bring with
In some facilities, forensic patients may have access them pro-criminal attitudes and a prison mentality
to a library, computers, and vocational rehabilitation ac- (including, for example, the perceived need to create
tivities such as woodcraft, leather shop, sewing and and maintain a weapon, or involvement with gangs).
mending, and cooking. A schoolteacher may be avail- In such an environment it is easy for staff and pa-
able for those patients who want to pursue further edu- tients alike to experience fear. The most common re-
cation to obtain a general education diploma. Female action to fear is anger, which then potentiates the
patients may be provided special sessions on grooming, eruption of violence (Maier et al. 1987). It is thus im-
including the use of makeup. Due to the potentially portant to manage fear in order to mitigate staff coun-
dangerous materials available in these activity centers, tertransference and patient aggression. Direct care
patients need to attain a certain level of trust in order to staff will feel a need to create structure through rules,
be allowed to participate in them. In addition, an agency schedules, and regulations in order to manage safety,
security officer is always present to ensure patients do although patients often experience this as an excess of
not secrete dangerous objects on their persons. staff control (Caplan 1993).
Other rehabilitation therapies, such as physical There are several steps to be taken in managing the
therapy, occupational therapy, and speech therapy, are milieu on a forensic unit in order to maintain safety
available as necessary to help patients achieve their and promote effective treatment. The first is to ac-
highest level of function. knowledge this task explicitly and programmatically
through training of both clinical and security staff. All
Other Modalities staff must understand the importance of being mind-
Other modalities of treatment include electroconvul- ful of safety and security as well as the need to achieve
sive therapy, which is very effective for treating severe the therapeutic goals of the unit. Ongoing discussions
depression and resistant mania. It has also been used between treatment and security staff may help keep
to treat chronic and refractory psychosis, but its effec- both these tasks operationalized in practice (Scales et
tiveness for chronic psychosis is questionable (Tang al. 1989).
and Ungvari 2003). One of the ways in which security concerns are op-
Sex offender treatment is another modality offered erationalized by all staff is by attention to the environ-
on a forensic unit. Most of these individuals have a ment. This begins with specific attention to the safety
of furniture, mirrors, building materials, hardware, tained, and patients perceive a higher level of staff con-
windows, electricity, bathroom facilities, and so on. It trol of the environment under such conditions (Phillips
also includes regular searches for contraband and and Caplan 2003). Patients perception that the envi-
weapons in all areas accessible to patients. Items that ronment is safe and well controlled has a calming effect
can be used for cutting, creating fire, or as a weapon on the unit by decreasing fears and negative stimula-
should be identified as nonpermitted items, and this tion. Too great a perception of rigid control, however,
information made available to patients and visitors in increases the sense of hostility among patients and de-
writing (Kaltiala-Heino and Kahila 2006). creases safety. Effective communication among staff
Room and common area inspections also include and patients in community meetings is important to
searching for broken items, missing screws or other maintaining this delicate balance of a controlled envi-
hardware, and missing components of appliances, in- ronment while permitting individuals to experience
cluding batteries. Both security and clinical staff par- some needed levels of privacy and freedom.
ticipate in such searches, but caution must be exer- Programmatic interventions can also play a major
cised to prevent a guard mentality from emerging role in the development and maintenance of a thera-
(Phillips and Caplan 2003). The goal is the therapeu- peutic milieu in forensic environments. For example,
tic effect of maintaining a safe milieu, not the exercise behavioral programming can be very effective when it
of control, per se. rewards nonaggressive behavior, improvement in so-
On forensic units in which both male and female cial skills and cooperation, and participation in treat-
patients are treated, attention must not only be given ment and educational activities. Social learning pro-
to the environmental factors of separated shower and grams have been instituted effectively in several
toilet facilities but also to the management of this forensic settings, reducing aggression and use of re-
mixed population. Female patients may feel particu- straint and seclusion and leading to improvements in
larly isolated and vulnerable if they are only one or two milieu management and discharge success (Beck et al.
among many more male patients on a unit. Thus, 1991; Goodness and Renfro 2002; Menditto et al.
sometimes it becomes necessary to group female pa- 1991). Although these programs require a significant
tients due to gender concerns, despite legal status, di- investment in staff training and maintenance of pro-
agnosis, or other considerations. The presence of male gram integrity, they provide a model of staff interven-
patients who have histories of sexual aggression or tion that is interactive, continuous, and positive and
physical assault on females must also be considered in that contributes to recovery.
placement decisions. Finally, it is worth recognizing that even when the
Performance improvement activities may also be physical environment is safely maintained, staffing
utilized to identify environmental root causes of times levels are adequate, and effective program models are
or places of increased incidents of aggression. In one utilized, staff members must still cope with a group of
facility, the dining rooms were identified as a focus of individuals with seriously disturbed behavior and his-
increased patient aggression. An action plan was cre- tories of extraordinary violence. Providing settings in
ated in which utensils were changed, music was pro- which staff can safely unload the effects of chronic
vided, some patients were allowed to leave the area stress and exposure to negative thoughts and feelings
earlier, food service workers received extra training in can be very helpful (Kuhlman 1988).
therapeutic communication, and courtyard and gym
areas were kept open during this time (Hunter and
Love 1996). It is also common that assaults occur Management of Suicidal and
more frequently from mid-afternoon through the Aggressive Behaviors
evening, when available activities often decline. Spe-
cial attention should be given to extending therapeutic
and recreational activities (as well as the requisite The mix of patients on a forensic unit makes it inher-
staffing) into this higher-risk time period. ently a high-risk environment. Some patients are
Staffing in general is a significant component of ef- transferred directly from correctional settings, some
fective milieu management in the forensic unit. It is of- from maximum-security or super-max prisons, with
ten perceived that higher staffing ratios should gener- a history of being in segregation for violent behaviors
ally be available on forensic units (Kaltiala-Heino and or with multiple tickets for aggression. These pa-
Kahila 2006). Direct care staff members feel more com- tients are suddenly placed onto units with patients
fortable when lower staff-to-patient ratios are main- who may be in the early phase of their legal entangle-
ment (sent for restoration to competency) or still try- ulation. Pharmacotherapeutic techniques used for
ing to make sense of their current legal situation and treating aggressivity include mood stabilizers, antipsy-
who are vulnerable by virtue of serious mental illness chotics, and antidepressants. These often need to be
or developmental disability. In addition, patients who combined with behavioral interventions to be success-
present unmanageable risks of suicide in general hos- ful. Sometimes the mere change of a patients bed-
pitals are sometimes sent to forensic hospitals for room to a room in a quiet hallway, away from the other
management because forensic hospitals are more se- patients, may decrease aggression.
cure and stricter about the availability of dangerous For the agitated patient in conflict with his or her
materials with which suicidal patients might harm peers, a short period of solitude in a time-out room
themselves. Staff in forensic units must therefore be may help de-escalate the situation more quickly. Such
more vigilant to cues that indicate high potential for use of time-out must be voluntary and may be one of
suicide or physical aggression in their patients. the actions listed by the patient on the patient prefer-
With regard to suicide, specific interventions to de- ences list. However, there are times when an agitated
crease risk include a combination of pharmacological and angry patient is unable to utilize voluntary time-
treatment, environmental manipulation, and close out but remains threatening and imminently danger-
monitoring. The presence of depression should be ous. Taking such a patient involuntarily to a time-out
carefully evaluated and vigorously treated, and person- room may be effective at immediately decreasing agi-
ality traits that include impulsivity and careless disre- tation, but the intervention would then be considered
gard for safety should be noted. Past history of suicide seclusion because it is no longer a voluntary time-out
attempts should be thoroughly explored to understand procedure.
triggers for acting out in such a manner. Family history The use of seclusion and restraints to manage ag-
of suicide or parasuicide is important, but even more gression (both self- and other-directed) on a forensic
so is the patients opinion regarding the suicide or sui- unit has become controversial in recent years. The
cide attempt. Joint Commission and the Centers for Medicare and
With regard to the physical plant or environmental Medicaid Services have announced standards that re-
manipulation, careful attention should be paid to strict the use of restraints and seclusion to emergency
sturdy and standing structures around which vulnera- situations in which there is imminent risk that the in-
ble patients could tie sheets or clothing for hanging. dividual may physically harm himself or others. It is in-
Bathrooms should have detachable shower heads, and tended that restraints are to be used only as a last resort
the divider between toilet stalls should not provide ac- and to be discontinued as soon as the imminent risk is
cess to exposed poles, wooden or otherwise. Rooms of resolved. These developments were stimulated by the
acutely suicidal individuals should be stripped of all investigative reports of Connecticuts Hartford Courant
potentially dangerous materials such as sharp objects, in 1998, which revealed a large number of deaths na-
and bed sheets should be replaced by strong blankets tionwide during restraint procedures (Appelbaum
that cannot be tied together or tied around an object. 1999). The president of the Joint Commission con-
There should be no access to windows, especially on cluded, These standards underscore the importance of
upper floors, in order to prevent patients from jump- applying great care in using interventions that can
ing to their death. harm or even kill patients (Medscape Medical News
Depending on the degree of risk of suicide, patients 2000). Not only are there restrictions on the initial ap-
are often placed under a level of observation. For pa- plication of restraint, there are also tighter policies re-
tients on continuous observation, it might be neces- garding duration in restraints, monitoring of restrained
sary to include in the physicians orders that the pa- or secluded patients by a licensed independent practi-
tient should be continuously observed even when tioner, and monitoring of the physical health of the pa-
using the bathroom. Tragedies can occur when staff tient during and after restraints/seclusion.
members try to protect the privacy of suicidal patients Advocates for some continued use of restraints and
by not observing them closely while in the bathroom/ seclusion maintain that there are certain situations
toilet. There should be open and clear communication when a patient loses control and becomes imminently
between the unit leadership and the line staff, includ- dangerous to self and others, during which the use of
ing staff members working off-unit who may not fully restraints and seclusion is appropriate to maintain
appreciate the risks involved. safety (Liberman 2006). Opponents argue that there
Management of aggression also includes pharma- are absolutely no indications for the use of restraints
cotherapy, psychotherapy, and environmental manip- and seclusion to manage aggression. They suggest that
the best practice is to train line staff in verbal de-esca- Patients restored to competency to stand trial will
lation methods, mediation techniques, and conflict be returned to court; for serious charges, they will
resolution and to detect aggressive behavior in its early likely be returned to correctional settings, so the com-
phases and hopefully mitigate it before it becomes un- ments just made about relationships with correctional
controllable (Curie 2005). A balanced approach may colleagues still apply. However, the forensic unit staff
seek to reduce the use of seclusion and restraint max- can never know what might become of a defendant re-
imally via programmatic developments and staff train- turned on less serious charges, so they must usually
ing, yet still recognize that, particularly in environ- prepare contingency discharge plans. If the patient-
ments faced with the challenge of violent patients who defendant is returned to corrections, the treatment
have been refractory to interventions in other settings, staff there will be provided with necessary information
some use of these procedures may still be necessary. for follow-up care. If the individual is released from
For forensic patients with high risk of aggressive court, there must be community plans in place for res-
behavior, the unit staff should generate a list of behav- idence, aftercare, and other supports as needed.
ioral cues that indicate increasing agitation or psycho- When insanity acquittees are discharged to the
sis that have historically been associated with violence community, it is often the result of a great deal of work
for the individual. Early detection of these behavioral with community providers to craft a detailed plan for
cues could lead to immediate removal of the patient appropriate monitoring and delivery of treatment ser-
from the aggravating situation or allow the utilization vices. Often this follows experience with graded expo-
of the patients preferred method of decreasing his ag- sures to the community through therapeutic passes or
itation as recorded in the patient preferences form. conditional releases. Family, friends, and community
Training of line staff on verbal de-escalation tech- providers are involved in the coordination of these
niques is useful. For some patients, the early use of carefully constructed plans.
medications for agitation, in addition to interventions An element of this planning that is unique to this
discussed earlier, is successful at decreasing aggres- population is the need to overcome the fears and spe-
sion. The development of social learning programs, or cial concerns of community providers, or even the pub-
other behavioral models, can have a significant impact lic, that may accompany the release of a well-known
on reducing the risk of aggression by rewarding behav- insanity acquittee who caused great anguish for the
iors that increase communication, cooperation, and community. These fears will often limit the range of
conflict resolution and thus increase skills. placement opportunities normally available to patients
with chronic psychiatric disabilities and often require
skillful negotiations on the part of social work staff and
Discharge Planning other clinicians and managers to assuage fear and pro-
mote willingness to engage with a notorious acquittee.
Patients labeled forensic, especially those who have
Involvement of Community been treated in maximum security facilities, face sig-
Providers, Resources, and nificant obstacles to successful discharge planning.
Significant Others Transition to Next Level of Care

As with all inpatient units, discharge planning on the For those forensic patients not being returned to cor-
forensic unit ideally begins at the time of admission, rectional settings, it is precisely in the transitioning
when strengths and supports available to the patient that the key to successful discharge planning lies.
in the community are assessed and the trajectory of When risk-relevant needs and deficits have been iden-
care is being plotted. There are many special varia- tified and interventions delivered to target them, it is
tions of discharge planning within a forensic setting, through demonstration data of success in graded
however. steps that risk is best managed and plans evolved for
Patients transferred from correctional settings may the transition process (Dvoskin and Heilbrun 2001).
well be returned to those settings so that issues of Successful transitioning requires the elaboration of a
housing, employment, insurance, and availability of relapse-prevention plan, detailing measures to avoid
health care are not immediate concerns. For these pa- circumstances leading to potential harm, contingen-
tients, the collaborative relationships that have been cies for containing risk when those circumstances are
built with health care colleagues in the correctional encountered, and strategies for reducing harm should
settings are important to successful continuity of care. containment plans fail (Dvoskin 2002).
In all of this planning, it is necessary to be mindful have exhibited often extraordinary levels of violence
of an ethics of risk assessment and management prac- and destruction; and the need to balance treatment
tices. Clinicians must be vigilant to focus their con- and recovery concerns for patients with security and
cerns on the clinical care of their patients, avoiding the safety concerns for patients, staff, and visitors to the
all-too-easy lapse into becoming agents of social con- facility and the outside community. Forensic units can
trol. Paul Mullen (2000) has expressed this concern poi- be challenging places to work, especially when staff
gnantly: Risk assessments...are the proper concern of members find themselves at the center of various com-
health professionals to the extent that they initiate re- peting advocacies and adversarial processes. When bal-
medial interventions that directly or indirectly benefit anced approaches are taken to the special tasks of the
the person assessed... . Confining and containing of- forensic unit, and when productive teamwork can be
fenders as punishment, or simply to prevent further of- fostered, the work can nonetheless be very rewarding.
fending, may be legitimate for a criminal justice system
but should have no place in a health service (p. 308).
References
Special Burden of the Forensic Unit
The dual mandate of the forensic unit to provide clini- Appelbaum PA: Seclusion and restraint: Congress reacts to
cal care of the individual and protection of the public reports of abuse. Psychiatr Serv 50:881885, 1999
Beck NC, Menditto AA, Baldwin LJ, et al: Reduced frequency
can often be successfully negotiated by providing good
of aggressive behavior in forensic patients in a social-
treatment that is focused on the patients clinical learning program. Hosp Community Psychiatry 42:750
needs. This is most likely to occur when the patients 752, 1991
are appropriately admitted for treatable psychiatric con- Caplan CA: Nursing staff and patient perceptions of the
ditions that are the source of the risk to the community. ward atmosphere in a maximum security forensic hos-
pital. Arch Psychiatr Nurs 7:2329, 1993
Clinical administrators of forensic units must try
Coccaro EF, Kavoussi RJ: Fluoxetine and impulsive aggres-
to guard against the admission of individuals who sive behavior in personality-disordered subjects. Arch
pose risk by virtue of criminality and antisocial per- Gen Psychiatry 54:10811088, 1997
sonality because there is no credible end point for hos- Collaborative Outcome Data Committee: Sexual Offender
pitalization of such individuals. The admission of Treatment Outcome Research: CODC Guidelines for
some such individuals is often politically and legally Evaluation. Ottowa, Canada, Public Safety Canada,
2007. Available at: http://www.publicsafety.gc.ca/res/
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forensic units for preventive detention of dangerous of seclusion and restraint. Psychiatr Serv 56:1139
individuals who would otherwise not require hospital- 1140, 2005
level care contributes to the stigma of mental illness Dvoskin J: Knowledge is not powerknowledge is obliga-
tion. J Am Acad Psychiatry Law 30:533540, 2002
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Dvoskin JA, Heilbrun K: Risk assessment and release deci-
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mum-security forensic unit. Behav Sci Law 20:495
The forensic unit is similar to other inpatient psychi- 506, 2002
atric units in the diagnoses of patients and the modal- Hunter ME, Love CC: Total quality management and the re-
duction of inpatient violence and costs in a forensic psy-
ities of treatment provided. Forensic units must pro-
chiatric hospital. Psychiatr Serv 47:751754, 1996
vide acute care to some individuals and often extended Kaltiala-Heino R, Kahila K: Forensic psychiatric inpatient
care to other individuals whose psychiatric disabilities treatment: creating a therapeutic milieu. Child Adolesc
are refractory to treatment. Psychiatr Clin N Am 15:459475, 2006
What distinguishes the forensic unit are the ex- Kuhlman TL: Gallows humor for a scaffold setting: managing
aggressive patients on a maximum-security forensic
plicit specialization in the management of aggression;
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a patient population composed of individuals who
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Maier GJ, Stava LJ, Morrow BR, et al: A model for understand- offender. J Am Acad Psychiatry Law 31:486493, 2003
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Publishing, 2003
CHAPTER 13
THE STATE HOSPITAL

Brian M. Hepburn, M.D.
Lloyd I. Sederer, M.D.
History and Nosology of Inpatient or other special containment needs. State hospitals
generally also represent the safety net for individuals
Psychiatric Service in the United who are uninsured and whose illness does not respond
States to briefer forms of intervention.
Figure 131 illustrates the dramatic change in
state hospital beds between 1970 and 2002. In 1970
State hospital psychiatry has changed dramatically there were 413,066 state hospital beds, and in 2002
over the past 50 years. With these changes, differences there were 57,263 (Foley et al. 2002, Table 19.2). This
have evolved in hospitals from state to state. As the ex- was an 85% decrease. In 1970, 33% of all hospital beds
pression goes, if you have seen one state hospital sys- were psychiatric beds. By 2002, this was reduced to
tem, you have seen one state hospital system. Differ- 14% (National Institute of Mental Health 1970).
ences among the states are the rule, not the exception. Figure 132 shows the steady decrease in the num-
For well over a century, the state hospitals in the ber of state hospitals from 310 to 222 (Foley et al.
United States provided the great predominance of in- 2002, Table 19.1). Private psychiatric hospitals in-
patient services for individuals with severe mental ill- creased from 150 to 253 (after peaking above 400 hos-
ness (Geller 2000; Goldman et al. 1983; Talbott pitals between 1990 and 1998). Nonfederal general
2004). However, since the introduction of community hospitals with separate psychiatric units increased
mental health and of Medicare and Medicaid in the from 664 to 1,232 (after peaking at 1,600 hospitals be-
1960s, there has been a dramatic increase in inpatient tween 1990 and 1998).
services at acute general and private psychiatric hospi- Figure 133 illustrates changes in psychiatric ad-
tals. In fact, these settings now provide the predomi- missions between 1969 and 2002. State hospital ad-
nance of hospital care. The state hospitals have thus missions were reduced from 486,000 to 239,000,
come to serve the severely and persistently ill popula- whereas private psychiatric hospital admissions in-
tion who cannot be managed in or gain access to the creased from 92,000 to 477,000, and general hospital
private sector, in addition to individuals with forensic psychiatric admissions increased from 478,000 to
197
FIGURE 131. Distribution of psychiatric beds by type of hospital, 19702002.

Source. Prepared by Ted Lutterman, National Association of State Mental Health Program Directors Research Institute,
using public-domain data from Foley et al. 2002.
FIGURE 132. Number of hospitals with psychiatric beds, 19702002.

The State Hospital 199
FIGURE 133. Admissions to psychiatric beds by type of hospital, 19702002.

1,095,000. There were approximately 1.2 million psy-

chiatric admissions in 1969 and 2 million admissions
in 2002 (Foley et al. 2002, Table 19.3). Current state
hospital bed utilization is 0.63 per 1,000 persons, with
rates steady for the past 3 years (Center for Mental
Health Services 2005). Almost every state operated a
psychiatric hospital in 2006 (National Association of
State Mental Health Program Directors Research In-
stitute 2006c). In 2005, 81% of individuals in state
hospitals were adults ages 2164. Twenty years ago,
persons more than 64 years old made up more than
25% of the state hospital population. Today, they make
up only 4%. Women compose 37% of the state hospital
population, and men compose 63% of the population
(Center for Mental Health Services 2005). The races
and ethnicities of the adults in state hospitals are iden-
tified in Figure 134. These data compare with those
of the general adult population: white 74%; African FIGURE 134. Racial/ethnic makeup of state
American 11%; Hispanic 11%; American Indian/Alas- hospitals.
kan N ative 1% ; an d As ian/Pacif ic Is lan der 4% Source. Public-domain data from Schacht and Higgins
(Schacht and Higgins 2002b). The majority of the 2002b.
adults in state hospitals have serious mental illnesses,
such as schizophrenia and affective disorders. In facil-
ities serving adults, approximately 35% of inpatients
Types of State Hospital Units
have co-occurring substance abuse disorders (Schacht Although there is variation between states depending
and Higgins 2002a). on the number of state psychiatric hospitals and the
number of beds, state hospital units may be identified

as follows (Santoni and Sundeen 2007):
Acute units are admission and evaluation units

where intensive intervention and treatment and
discharge planning occurs.
Continuing care units are units in which nursing
and rehabilitation services are provided in addition
to treatment for individuals who require inpatient
care beyond the acute phase of their mental illness.
Medicalsurgical units are hospital units designed to
provide medical and nursing services for co-occur- FIGURE 135. Lengths of stay for patients with civil
ring acute and chronic physical illness in addition to admission status.
hospital-level mental health treatment. Source. Public-domain data from National Association of
Forensic admission units are secure acute units to State Mental Health Program Directors Research Institute
which individuals are admitted for pretrial and Web site (www.nri-inc.org).
posttrial evaluations and for treatment after a court
adjudication of an individual as not criminally re- on stabilization, medication treatment, individual and
sponsible. group therapies, and discharge planning (including
Forensic residential units are secure units treating finding stable housing and securing entitlements).
and housing those members of the population iden- One of the important changes in state inpatient care
tified in forensic admission units with service needs has been the inclusion of rehabilitation services in ad-
similar to individuals treated in continuing care dition to traditional treatment services. Rehabilitation
nonforensic units. services aim to improve communication, work capa-
Forensic discharge units are minimum-security units bility, and daily living skills (Dhillon and Dollieslager
that treat and house forensic patients who are in the 2000).
process of leaving inpatient care. In some states, the
civil status and forensic populations are evaluated Child and Adolescent Population
and treated separately, and in other states they are
combined on the same unit. Some states do not provide state hospital services to
individuals younger than 21 years. However, across the
country, individuals younger than 21 years make up
Civil Status Population 15% of the individuals in state hospitals (Center for
The civil status population in state hospitals is made Mental Health Services 2005). Figure 136 shows the
up of individuals identified as dangerous to self or oth- racial/ethnic distribution of these youth in 2001.
ers as a result of mental illness. They may be volun- These data compare with those for individuals younger
tary or certified. The determination of dangerousness than 21 years in the general population: white 64%; Af-
has become controversial as legal standards regarding rican American 15%; Hispanic 16%; American Indian/
imminent danger to self or others have been estab- Alaskan Native 1%; and Asian/Pacific Islander 4%
lished. Consequently, individuals may be certified in (Schacht and Higgins 2002b). Most have mental disor-
one state but not another. This may result in individ- ders such as attention-deficit/hyperactivity disorder,
uals not getting treatment because they are not yet an conduct disorder, oppositional defiant disorder, or af-
imminent danger. The trend in state hospitals is to fective disorders. This group had a rate of co-occurring
only admit certified individuals. Seventy-five percent substance abuse of 14%. The rate of co-occurring men-
of this population is discharged within 30 days (Na- tal retardation or developmental disorders was 10%
tional Association of State Mental Health Program Di- (Schacht and Higgins 2002a).
rectors Research Institute 2006d; Figure 135). Crisis intervention with rapid stabilization and re-
If an individual does not stabilize on an acute unit integration into the community continues to be the
and is not able to leave the hospital, then he or she is primary focus of child inpatient treatment. Diagnostic
typically transferred to a longer-term or specialty unit. assessment, symptom management, and community
Those individuals who have stable community sup- reintegration require collaboration between parents
ports and resources will generally be able to leave the and/or guardians, the educational setting, and other
hospital sooner. Both acute and long-term units focus agencies. In addition to crisis management, state-
narily may not be forced except in an emergency. The

evaluation is done on the forensic unit, and the eval-
uators reports are then submitted to the court. The
court determines whether the individual is competent
to stand trial. Criminal responsibility is also deter-
mined at trial (Simon and Shuman 2008). In many
states, the large majority of pretrial evaluations are
conducted on an outpatient basis in the community,
and the defendant is committed only if found incom-
petent to stand trial or not criminally responsible. If
an individual is found not criminally responsible, he
or she may be committed to a state hospital for inpa-
tient care or treatment (if dangerous because of a men-
tal disorder), released (if not dangerous), or placed on
conditional release (if safe to be in the community
with services in place and other conditions imposed).
Individuals who have been committed will have peri-
FIGURE 136. Racial/ethnic distribution of
odic review hearings with a court or an administrative
individuals younger than 21 years
authority. In most states, only the court may release
admitted to state hospitals in 2001.
the individual. In some states, an agency or facility-
Source. Public-domain data from National Association of
based forensic review board will review the treatment
State Mental Health Program Directors Research Institute
Web site (www.nri-inc.org). teams findings and advise the state hospital regarding
its opinion for the court on the individuals readiness
for release or conditional release. Although the legal
operated child units provide the opportunity for more and security issues are prominent, it is important to
extensive diagnostic evaluations, complex medical note that the focus of the treatment team and the fo-
management, and coordination of care with other rensic review board is on the patients psychiatric ill-
state agencies (dosReis et al. 2003). ness and rehabilitation needs.
Similar to those for the adult population, the pub- N ear ly al l s t at e m en ta l h e alt h a ut ho r it i es
lic inpatient mental health facilities for children and (SMHAs) provide forensic mental health services (Na-
adolescents have moved in the direction of providing tional Association of State Mental Health Program
court-ordered evaluation and/or treatment. A recent Directors Research Institute 2005). Seventy-six per-
change in the use of public psychiatric child and ado- cent of states use their psychiatric hospitals to provide
lescent units is their role in determining competence. services to forensic patients. Fifteen percent of indi-
Youth found to be not competent are referred to com- viduals discharged from state hospitals in 2005 had
petency restoration services, which may be inpatient. forensic status, and 40% of residents in state hospitals
After an inpatient stay and restoration of competency, at the end of 2005 had forensic status.
these individuals are then referred back to the court One of the more recent areas of involvement for
(Grisso 1997). public mental health has been working with the foren-
sic population referred by the courts after conviction
Forensic Population for a sexual offense (Fitch and Hammen 2003). Nine-
Many state hospitals have responsibility for court- teen states have laws providing for the special civil
ordered evaluations of criminal defendants compe- commitment of sex offenders, called sexually violent
tency to stand trial or to determine criminal responsi- predators in some states (National Association of
bility (legal insanity). Many of these individuals will State Mental Health Program Directors Research In-
initially be placed on an acute unit for evaluation. stitute 2005). Generally, these laws provide for com-
However, individuals charged with higher-level crimes, mitment after an individual has completed his or her
such as murder, rape, arson, armed robbery, kidnap- criminal sentence and is about to be released. Al-
ping, or carjacking, may be evaluated on a secure fo- though the SMHA is typically responsible for evalua-
rensic unit or in a maximum-security hospital. tion and treatment, at times it may also provide or ad-
Individuals admitted for evaluation may be offered minister the facility or purchase security services. The
treatment during their stay, but medications ordi- treatment of sexually violent individuals is similar to
other state hospital patients when an underlying se- adults have a diagnosis of substance abuse (Schacht
vere psychiatric illness exists. However, only a small and Higgins 2002a). The state hospitals have become
percentage of these individuals have severe mental ill- the safety net for this additional population at a time
ness, whereas the majority are diagnosed with para- when the supply of beds is decreasing.
philias and personality disorders (Becker and Johnson In addition to the increased emergency department
2008; Berlin 2003). The main reason for their com- pressure, the limited availability of state hospital beds
mitment is related to community safety. These indi- has created problems for the court system and jails.
viduals receive postsentence commitment that may The longer waits for admission into state hospitals add
result in indefinite confinement with little opportu- to the crowding of jails with people who would be more
nity to return to the community. Their confinement appropriately served in clinical settings. Some states
may take resources away from the mental health sys- have responded by setting up diversion strategies, cri-
tem and further stigmatize the individuals with men- sis intervention teams, and mental health courts, but
tal illness. For a more extensive discussion of this im- the problem is far reaching and too few alternatives ex-
portant subject, which is beyond the scope of this ist (Boothroyd et al. 2005; Kanapaux 2002).
chapter, please see Prentky et al. (2003). The relationship between state hospital and com-
munity services varies among the states. Across the
country, 70% of expenditures of SMHA are for commu-
Impact of the State Hospital in the nity services, and approximately 30% are for state hos-
Overall Continuum of Care for Civil pitals (National Association of State Mental Health
Program Directors Research Institute 2006c). Despite
Status and Forensic Patients greater funding for community services, there contin-
ues to be a shortage of community services. As indi-
State hospitals are generally an important part of the cated previously, 70% of civil admissions are discharged
continuum of psychiatric care and affect the overall within 30 days; these represent people the state hospi-
health care system. The reduction of state hospital tal has been able to discharge to community providers.
beds in addition to the recent declines in the number The remaining 30% are significantly more difficult to
of general hospital and private psychiatric hospital return to the community because of persistent psychi-
beds has resulted in 80% of states reporting a shortage atric symptoms, the need for intensive levels of com-
in psychiatric beds (National Association of State munity services (e.g., assertive community treatment),
Mental Health Program Directors Research Institute housing, and/or other complicating social issues.
2006d). Emergency departments report taking twice The lack of psychiatric beds puts pressure on com-
as long to place individuals for inpatient psychiatric munity providers, emergency departments, jails, and
care as for inpatient physical health care (Committee the judicial system. Until recently, the impact of the
on the Future of Emergency Care in the United States reduction of state beds was buffered by the increase in
Health System 2007). private-sector beds. However, the decrease in private-
An additional complicating factor is the increasing sector beds and resulting bed crisis has illustrated the
number of uninsured individuals with substance abuse importance of including the state hospitals in the
problems using the emergency department for their planning for the health care system.
health care. In March 1996 Congress passed Public
Law 104121, which terminated Social Security and Accreditation, Patient Rights,
Social Security Disability benefits to individuals dis-
abled primarily by drug addiction and alcoholism be- and Legal Issues
cause of the perception that having these benefits con-
tributed to the individuals drug use. Many of these Joint Commission Accreditation
individuals may need psychiatric services and, in some
cases, inpatient psychiatric services. However, some and Performance Measurement
individuals appear to be using psychiatric symptoms, Since 1971, the Joint Commission on Accreditation
including threat of suicide, as a way of gaining access to of Hospital Organizations has been evaluating organi-
services they are unable to access for their substance zations that provide mental health services, including
abuse problem (Lambert 2002). This has put addi- state hospitals. In 2006, 90% of state psychiatric hos-
tional demand on emergency departments, the acute pitals were accredited by the Joint Commission (Na-
inpatient system, and state hospitals, where 35% of tional Association of State Mental Health Program
Directors Research Institute 2006b). Two of the pri- fies risks and contributing factors for problem recur-
mary areas of the Joint Commissions focus are per- rence and determines what improvements are needed.
formance and safety.
In February 1997, the Joint Commission began its Protection and Advocacy for
ORYX initiative to integrate outcomes and other per- Individuals With Mental Illness
formance measurement data into the accreditation
process. However, reporting of data for behavioral In 1975, the U.S. Department of Health and Human
health organizations, including state hospitals, was Services established a program to protect and to advo-
deferred until core measures were identified. The Joint cate for the rights of persons with disabilities (Protec-
Commission and various mental health organizations tion and Advocacy for Individuals with Mental Illness
have worked together to identify and implement a test [PAIMI] program; http://mentalhealth.samhsa.gov/
set of core performance measures (Joint Commission cmhs/P&A). In 1986, Congress passed the Protection
2008). To date, agreement has been reached on testing and Advocacy for Individuals with Mental Illness
the following measures: assessment of violence risk, (PAIMI) Act (Center for Mental Health Services
substance use disorder, trauma, and patient strengths; 2003). Protection and advocacy systems are autho-
hours of restraint use; hours of seclusion use; patients rized to access consumers and records for the purpose
discharged on multiple antipsychotic medications; of conducting independent investigations of abuse,
and discharge assessment and aftercare recommenda- neglect, and rights violations in various types of public
tions sent to the next level of care providers upon dis- and private facilities, including state hospitals.
charge. A final set of measures to meet Joint Commis- PAIMI-eligible individuals are those diagnosed with a
sion performance measurement requirements is significant mental illness who were abused, neglected,
expected for state hospitals in the fall of 2008. or had their rights violated or were in danger of abuse,
The purpose of the Joint Commissions National neglect, or rights violations while receiving care or
Patient Safety Goals is to promote specific improve- treatment.
ments in patient safety, including in state hospitals
(Joint Commission 2007). The Joint Commission em- Court Oversight, Receivership,
phasizes goals that focus on systemwide solutions. Ex- and Decrees
amples of these types of goals for state hospitals in-
Court decisions have had a major impact on state hos-
clude improved communication with consumers and
pitals. The Wyatt v. Stickney decision (Byrne 1981)
families and early identification of suicide risk.
gave patients the right to receive treatment that would
State Regulatory Accreditation result in a cure or would improve their mental condi-
tion. This landmark decision resulted in increased
and Quality Monitoring funding for state hospitals and also contributed to the
Each state has a government office that licenses and reg- movement to have treatment in the community. In
ulates hospitals and health-related institutions. This of- some jurisdictions, the court decisions have resulted
fice typically monitors quality of care and compliance in mental health systems being put into receivership
with both state and federal regulations. This office also (Johnson 2001). In others, there have been more lim-
generally undertakes complaint investigations. For ited decisions. For example, in Maryland there is a
those state hospitals that do not have Joint Commis- program for the protection of patients rights in the
sion accreditation, the state office performs regular in- state psychiatric hospitals, the Resident Grievance
spections. This office also is responsible for inspection System, which was established as part of the nego-
and certification of state hospitals participating under tiated settlement of a class-action lawsuit (Coe v.
the deemed compliance authority from the Centers for Hughes, et al. [see Maryland Department of Health
Medicare and Medicaid Services. The office may initiate and Mental Hygiene 1998]). The settlement estab-
administrative action against state hospitals that violate lished an administrative process to protect patient
state rules and regulations, and then it coordinates its rights and also established legal assistance providers
actions with the Joint Commission and the Centers for to provide legal assistance to state hospital patients.
Medicare and Medicaid Services. When hospital quality Court decisions and mental health law continue to re-
of care is in question, hospitals perform a root cause flect the tension between the interests of the mentally
analysis (RCA) as required by the Joint Commission. ill and the communitys fear of the mentally ill (Appel-
The RCA focuses primarily on systems and processes, baum 2006). Major legal areas continuing to face state
not individual performance. The state hospital identi- hospital psychiatry include the right to refuse treat-
ment, the insanity defense, and confining sex offend- care, especially for those who need a longer time to
ers postsentence. recover. It supports involuntary care when safety is at
stake and for those who will not agree to treatment be-
Summary cause their illness impairs their judgment. NAMI also
In summary, the accreditation, regulatory, and legal holds a similar position regarding involuntary medica-
environment has gained prominence in state hospitals tion: people should have a choice about medications,
over the past decades. State hospitals are under sub- although there are times when individuals who are se-
stantial scrutiny in all of these areas and need to effec- verely mentally ill are not able to act in their own best
tively staff offices to attend to these oversight require- interest. NAMI also expresses concern that incarcera-
ments. Although there may be concern on the part of tion or victimization may result if an individual does
state hospital clinicians and administrators that there not get needed state hospital treatment.
is too much oversight and the additional monitoring Some community providers argue that there is too
takes needed resources from clinical care, there is no much funding going to a small number of individuals
indication that this will change in the near future. who are in state hospitals. They assert that if there
was more funding for community supports, rehabili-
tation, supported employment, and housing, there
Consumers, Advocates, Providers, would be far less need for state hospitals. The U.S.
and the State Hospital Psychiatric Rehabilitation Association (http://www.us-
pra.org) maintains that psychiatric rehabilitation ser-
There continues to be debate within the mental health vices enable independent living and socialization and
community regarding state hospitals. Consumer produce a 65% reduction in hospital stays, a 70% de-
groups, family organizations, employees, unions, cline in homelessness, 70% fewer incarcerations, and
community providers, mental health associations, an 80% increase in employment.
and disability law advocacy organizations have differ- Mental Health America (http://www.mental-
ing opinions on state hospitals. There is not a consen- healthamerica.net) is a strong advocacy group dedi-
sus on the future role of state hospitals among these cated to improving the quality of life for individuals
organizations. with severe mental illness. It also advocates for an end
In the 1950s, nearly 35% of private-sector employ- to seclusion and restraint, except in rare circum-
ees were union members, and public employees in stances. They are in favor of Consumer Satisfaction
unions were almost nonexistent (Barone 2005). How- Teams working with state hospitals (see http://www.
ever, by 2005 about 8% of private-sector employees thecst.com). They support state hospitals being in-
were union members and between 30% and 40% of cluded as part of the continuum of care but also sup-
public employees were union members, making public port vigorous adherence to the U.S. Supreme Court
sector unions a powerful voice in the future of state decision Olmstead v. L.C. (1999) that allows individ-
hospitals. State hospital employees and unions have uals with mental illness to live in the community with
expressed concern at the trend toward state hospitals adequate supports.
providing care for an increasingly forensic population Most states have consumer organizations. Twenty
at the same time as there is pressure to stop the use of years ago, the consumer organization in Maryland
restraint and seclusion. They are concerned the state (On Our Own of Maryland; http://www.onourownmd.
hospitals are becoming unsafe for employees and pa- org) called for the closure of the largest state hospital.
tients. They also express concern at the shortage of However, since then they have called for the gradual
staff and the lack of training for staff in dealing with downsizing to smaller hospitals. Consumer organiza-
forensic patients. There has also been criticism from tions vary in their positions regarding state hospitals.
others that some public-sector employees and unions Some call for immediate closure, whereas others are in
have become obstacles to change and have created a favor of gradual downsizing and having state hospitals
system that is not responsive to consumer needs as part of the continuum of care. They are generally
(Schatz 2007). against restraint, seclusion, coercion, and involuntary
The National Alliance on Mental Illness (NAMI; medication. They are in favor of Consumer Satisfac-
http://www.nami.org) position is that state psychiatric tion Teams working with state hospitals to embrace
hospitals play an important role in the recovery of peo- the recovery model.
ple with severe mental illness. NAMI regards state The Disability Law Center advocacy organizations
hospitals as an important part of the continuum of are private, nonprofit organizations staffed by attorneys
and paralegals to ensure that people with disabilities to maximize Medicaid reimbursement through the
are accorded the full rights and entitlements afforded to Disproportionate Share Hospital (DSH) program, pay-
them by state and federal law. They may seek the clo- ments to age groups outside of the Institution for Men-
sure of state hospitals and assert that individuals tal Disease (IMD) exclusion, and through managed
rights are not being protected in state hospitals. For ex- care waivers to the IMD exclusion. In 1981, Congress
ample, they may argue that restraint and seclusion are established the Medicaid DSH program (Mechanic
used punitively and for the convenience of the staff. 2004) for hospitals that serve a significant number of
They argue that individuals with mental illness can be low-income patients with special needs. DSH pro-
successfully treated in the community if appropriate re- grams became a major source of funding for the na-
sources are in place. Their advocacy agendas generally tions state hospitals (Kaiser Family Foundation 2007).
include removing barriers to independence; preventing In 2002, 15% of the DSH payments (~$1.5 billion)
seclusions and/or restraint of children, adolescents, or went to state hospitals. The Medicaid IMD exclu-
adults in state psychiatric hospitals; protecting the sion has been part of federal Medicaid law since its
rights of persons diagnosed with a mental illness to 1965 enactment (42 CFR 431.620 [1979]). The IMD
refuse psychotropic medications; and advocating the exclusion refers to the rule that Medicaid will not pay
enforcement of the right of persons diagnosed with a for the inpatient treatment of individuals between ages
mental illness to live in the community with adequate 22 and 64 in institutions for mental diseases, de-
supports, as set forth by the Olmstead decision (see fined as any hospital, nursing facility, or other institu-
Bazelon Center for Mental Health Law [http://www. tion with more than 16 beds that is primarily engaged
bazelon.org/index.html] and Maryland Disability Law in providing diagnosis, treatment, or care of persons
Center [http://www.mdlcbalto.org/mentalhealth.htm]). with mental diseases, including medical attention,
The tension between individual rights, family rights, nursing care, and related services. Individuals younger
and community safety is often played out in discus- than 21 years make up 15% of the state hospital pop-
sions between legal advocacy and other stakeholders. ulation, and individuals older than 64 years make up
The stakeholders in the mental health community 4% of the state hospital population. State facilities can
hold varied views regarding the role of state hospitals. collect from Medicaid for these two age groups. In ad-
Some argue for the current status, some for state hos- dition, a growing number of states have used federal
pitals to be downsized but continue to be part of the Medicaid managed care waivers to bill for patients ages
continuum of mental health care, and others for the 2264 years. This has allowed those states to receive
closure of state hospitals. However, state hospitals ap- Medicaid payments for hospital care in an IMD. Ap-
pear to be an essential part of the continuum of care in proximately one-third of the funding for state psychi-
most states. Therefore, it will be important for stake- atric hospitals is estimated to come from Medicaid.
holders and the SMHA to reach consensus about the These important DSH and Medicaid trends face reduc-
transformation of state hospitals and work toward a tions, however, as DSH payment limits are imple-
best-practice model. mented and as IMD managed care waivers are elimi-
nated in fiscal year 2008. These factors will put
additional pressure on the financing of state hospital
Budget and Legislative Issues operations (Buck 2003; Draper et al. 2003; Kate 2003).
Pharmacy has been a budget item that has grown
Since World War II, state hospitals have been seen as dramatically in state hospitals. The new-generation an-
very costly, and there has been a trend to close hospi- tidepressants and antipsychotic medications as well as
tals and use the savings to reduce government spend- polypharmacy have increased costs. One response has
ing and support community-based care. The budgets been the introduction of preferred drug lists as well as
for state hospitals decreased from $3.8 billion to $2 efforts to influence the behavior of prescribers (Patrick
billion from fiscal year 1981 to fiscal year 2004. Com- et al. 2006) to reduce polypharmacy and higher-than-
munity expenditures increased from $2 billion to $5 needed dosing. Standardization protocols have been in-
billion during the same time period (National Associ- troduced to improve quality and control costs (e.g., the
ation of State Mental Health Program Directors Re- Texas algorithm project; Kashner et al. 2006). The pro-
search Institute 2006a). These figures are based on tocols have generally assumed the superiority of the
1981 dollars. new generation of antipsychotics. This may change as a
The majority of state hospital costs are covered by result of the recent Clinical Antipsychotic Trials in In-
the states. However, several strategies have been used tervention Effectiveness studies of the new-generation
antipsychotics (National Institute of Mental Health also Hogan 2003). In order to meet the goals of the
2006). Operating cost concerns have also led to the New Freedom Commission as they apply to state hos-
development of buying groups (e.g., Minnesota Multi- pitals, the following will need to happen for each New
State Contracting Alliance for Pharmacy [MMCAP; Freedom Commission goal:
http://www.mmd.admin.state.mn.us/mmcap/current_
vendors.htm]) that negotiate with manufacturers and 1. Americans understand that mental health is essen-
wholesalers for the best price. There are currently 43 tial to overall health. This goal addresses stigma and
states participating in the MMCAP. health care parity. It calls for greater anti-stigma ef-
An additional major cost to state hospital systems forts so that more individuals will get their mental
has been the growing population of individuals who health needs addressed in the community with less
are postsentence and civilly committed as sexually shame and discrimination. It also calls for parity of
violent predators. The cost of operating secure facili- services and benefits with those that physical health
ties for such individuals in the United States in 2004 care now receives. Major work lies ahead to remove
was estimated at $224 million annually. Each sexually the stigma of state hospitals and for those individu-
violent predator in hospital care costs on the average als coming out of state hospitals. Lessening or elim-
more than $200,000 per annum (Leib and Gookin inating stigma for this population will require great
2005). Only a small number of individuals actually are efforts by consumers, family members, mental
discharged from these programs, so the costs will con- health professionals (including state hospital em-
tinue to increase. There is concern that the United ployees), and advocacy groups. The integration of
States may be moving in the same direction as En- the state hospital with community mental and
gland in moving dangerous persons with severe per- physical care will be needed for this to happen.
sonality disorders into psychiatric facilities when they 2. Mental health care is consumer and family driven.
finish their prison sentences (Appelbaum 2005). The This means that consumers substantively advise on
stigma to individuals with mental illness is a concern, those matters that are most important to them, in-
and costs will escalate and may end up decreasing cluding job, home, relationships, and improving
funding for individuals with severe mental illness. quality of life. The goal is to ensure that consumers
The cost of funding state hospitals continues to be and families have choices in the care they are receiv-
problematic. States have been successful at collecting ing in state hospitals, including involvement in
Medicaid dollars for state hospital services. However, treatment and aftercare planning. It also means in-
there are indications that they may collect less from volving consumers and families fully in orienting
Medicaid in the future. There continues to be growth the state hospital toward a recovery model as well as
in the costs of state hospitals and little interest in introducing self-help, peer support, consumer satis-
most states to increase the state hospital budget ap- faction teams, consumer education programs, and
propriation. family education programs. This will be a special
challenge for state hospitals serving individuals with
forensic involvement, which appears to conflict
The Future of State Hospitals with giving consumers and families more choice.
3. Disparities in mental health services are elimi-
The future of state hospitals has been debated for de- nated. The uninsured disproportionately end up in
cades. The hospitals are often demonized and looked state hospitals. Part of this is by design, because of
upon as archaic relics of an embarrassing past, despite the safety net function of the state hospitals. How-
the fact that 90% are Joint Commission accredited, ever, it is also because the uninsured often do not
and they often provide the safety net function for un- access community services and tend to wait until a
insured severely mentally ill individuals in addition to crisis has occurred. To the extent that disparities
providing inpatient care to the mentally ill forensic are reduced in benefits and services, more people
population. There is no indication that state hospitals will obtain preventive care and obtain treatment
are going to disappear in the near future. Perhaps the early in the course of their illnesses, thereby help-
focus should be on how they need to work with stake- ing to reduce the use of state hospitals. Reductions
holders to provide services consistent with todays sci- in the uninsured and benefit disparities will also
ence and consistent with a recovery-based model fol- improve access to services for those leaving state
lowing the goals set out by the Presidents New hospital care. Another important disparity is the
Freedom Commission on Mental Health (2003; see fact that there are twice as many African Ameri-
cans in state hospitals as compared with their rep- tions between academia and state hospitals, espe-
resentation in the general population (Schacht and cially in rural areas or for hospitals that will not be
Higgins 2002b). There needs to be improved and able to have an on-site academic presence. It may
expanded culturally competent state hospital and also help with the challenge of workforce develop-
community services for this population. ment.
4. Early mental health screening, assessment, and re- 6. There is a need for SMHAs, state hospitals, and
ferral to services are common practice. There is a community providers to serve a critical role in the
growing trend for patients in state hospitals to have physical health care of people with serious mental
co-occurring substance abuse disorders. Co-occur- illness. People with severe mental illness die signif-
ring substance abuse has been identified in ap- icantly younger than their age counterparts (Na-
proximately 35% of individuals in state hospitals tional Association of State Mental Health Program
(Schacht and Higgins 2002a). The early identifica- Directors Medical Directors Council 2006). They
tion of co -occurring substance abuse enables smoke, eat poorly, and have sedentary lifestyles that
proper treatment and far better chance for recovery. can lead to chronic illnesses such as heart disease,
5. Excellent mental health care is delivered, and re- chronic pulmonary disease, and diabetes, and their
search is accelerated. In order for state hospitals to medications may produce metabolic disorders (Na-
provide quality care, there needs to be adequate staff tional Association of State Mental Health Program
that is well trained and participating in the recovery Directors Medical Directors Council 2006). State
model. Mental health workforce issues are at a crit- hospitals are uniquely positioned to promote well-
ical point (Hoge et al. 2005). State mental health ness and early detection of these chronic diseases.
systems are moving toward clinical guidelines and This may include making state facilities entirely
evidence-based practices to improve the quality of smoke free.
care (Drake et al. 2006; Lehman et al. 2004). Public 7. Technology is used to access mental health care
academic partnerships may facilitate the move to- and information. State hospitals must increasingly
ward improved care in state hospitals, for example, use modern technology. Electronic prescribing and
to reduce seclusion and restraint and increase electronic medical records are essential next steps
trauma-informed care (see the Center for Mental for safety and quality of care. Twenty-two states re-
Health Services National Center for Trauma-In- ported they are implementing electronic medical
formed Care [http://mentalhealth.samhsa.gov/nc- records in their state psychiatric hospitals (Na-
tic]; University of Maryland School of Medicines tional Association of State Mental Health Program
Evidence-Based Practice Center [http://medschool. Directors Research Institute 2006d). There is a vi-
umaryland.edu/Psychiatry/services_research/ tal need to link hospital records with the commu-
centers_ebpc.asp]; and Substance Abuse and Men- nity and other government and service agencies to
tal Health Services Administration 2006). In addi- enhance continuity of care. Telemedicine may also
tion, the partnership promotes the use of training help for workforce issues, conferences, second
sites in state hospitals for various disciplines. The opinions, and the growing links with academic set-
advantage to the state is that it is better able to have tings and the private sector. Thirty-five SMHAs are
high-quality professional staff, with university ap- engaged in activities to promote the use of telemed-
pointments, providing services in state facilities. In icine to provide mental health services (National
addition, these facilities serve as important sites Association of State Mental Health Program Direc-
from which to recruit trainees into public service tors Research Institute 2006d).
(Douglas et al. 1994; Goetz et al. 1998; Talbott
1991). Public academic partnerships also allow an
opportunity for the evaluation and treatment of in-
Conclusion
dividuals who are not responding to treatment as
well as to provide opportunities for clinical research Currently, state hospitals are an important part of the
(see Maryland Psychiatric Research Center [http:// continuum of mental health care in each state. They
www.mprc.umaryland.edu/treatment.asp]; Nathan vary in the amount of civil and forensic populations
S. Kline Institute for Psychiatric Research [http:// under their care and in the amount of acute and long-
www.rfmh.org/nki]; and New York State Psychiatric term care that is provided. In some discussions, trans-
Institute [http://nyspi.org/Kolb/index.htm]). Tele- formation assumes an end to state hospitals, with a
medicine may be a way of improving communica- view that everyone will be maintained in the commu-
nity and close to their natural supports. However, the Center for Mental Health Services: 2005 CMHS Uniform
limits of science today, coupled with the gravity of dis- Reporting System Output Tables. Washington, DC,
Substance Abuse and Mental Health Services Adminis-
order in a small but enduring proportion of people
tration, 2005. Available at: http://mentalhealth.sam-
with mental illness, will require secure and longer-stay hsa.gov/cmhs/MentalHealthStatistics/URS2005.asp.
environments for some individuals. In addition, be- Accessed April 22, 2007.
cause state hospitals are being used for forensic care, Committee on the Future of Emergency Care in the United
they serve as an essential element in a full spectrum of States Health System: Hospital-Based Emergency
state-supported services. There is an opportunity for Care: At the Breaking Point (Future of Emergency Care
series). Washington, DC, National Academies Press,
state psychiatric hospitals to become tertiary care
2007
sites, where consumers and families turn when high Dhillon AS, Dollieslager LP: Rehab rounds: overcoming bar-
levels of expertise are needed for extended periods of riers to individualized psychosocial rehabilitation in an
time. The state hospital, in effect, becomes part of the acute treatment unit of a state hospital. Psychiatr Serv
continuum of care from ambulatory to acute to ter- 51:313317, 2000
dosReis S, Barnett S, Love RC, et al: A guide for managing
tiary care and is integrated into the full spectrum of
acute aggressive behavior of youths in residential and
care needed by all large communities. The future may inpatient treatment facilities. Psychiatr Serv 54:1357
hold a valued and distinguished role for these facili- 1363, 2003
ties, not unlike the role these hospitals had in the era Douglas EJ, Faulkner LR, Talbott JA, et al: A ten-year update
of moral therapy almost 200 years ago (Sederer 1977). of administrative relationships between state hospitals
and academic psychiatry departments. Hosp Commu-
nity Psychiatry 45:11131116, 1994
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CHAPTER 14
THE VETERANS
HOSPITAL
Anne M. Stoline, M.D.
T he Veterans Hospital: for some, this phrase ferentiate VA from other health care systems, such as
conjures an image of dim corridors lined with wheel- its annual discretionary federal funding, its vast and
chairs of hollow-eyed men. Yet U.S. Department of complex administrative infrastructure, and as men-
Veterans Affairs (VA) hospitals no longer are treatment tioned, its computerized patient clinical information
options of last resort; most instead are modern facili- system. Psychosocial factors as well, such as high rates
ties offering care at least comparable with that in the of homelessness, limited social supports, unemploy-
private sector. Care in the VA may surpass that in abilitysome attributable to veterans institutional
other health care systems, not only because of the dependence from years spent in highly structured mil-
strong academic interface through research and clini- itary lifeset the VA patient population apart from pa-
cal training but also due to the VAs vast computerized tients in other settings. Clinical needs are broader than
information network and electronic patient record. those in the civilian population, because veterans also
Through this system, clinicians at the bedside have have conditions unique to military service such as
access to a broad range of patients historical and cur- combat exposure and battle injuries. Veterans psychi-
rent clinical information. atric symptoms range from time-limited problems to
VA inpatient psychiatric care resembles in most re- chronic mental illnesses, and many patients are chron-
spects that in community, university, and other public ically hospitalized. As such, a VA inpatient psychiatric
hospitals. Inpatient care is provided by multidisci- unit today may be caring for a 21-year-old just home
plinary treatment teams just as in the state and private from Iraq and a 50-something Vietnam veteran still
sectors. Though a nationwide system, VA hospitals too coping with sequelae of his war experience alongside a
are subject to state laws. However, other variables dif- World War II veteran with dementia.
211
Department of Veterans medical schools and university hospitals, veterans

benefit from care provided by faculty physicians and
Affairs System physicians-in-training who rotate through VA hospi-
tals. In fact, VA is the largest provider of health care
With earlier roots in health care for disabled soldiers training in the United States, with more than 90,000
dating back to the 1700s, the Veterans Administration health professionals receiving VA training annually.
was established in 1930. The system at that time More than half of U.S. physicians today have received
comprised 54 hospitals, 31,600 employees, and 4.7 some part of their training at a VA site (U.S. Depart-
million living veterans. The scope of the VA has broad- ment of Veterans Affairs 2007a).
ened since then, with the addition of Federal Benefits Millions of dollars from both VA and non-VA
in the 1950s and the National Cemetery Administra- sources fund extensive research activity as well. The
tion in the 1970s. In 1989, the VA was renamed the VA nationwide network makes possible large-scale,
Department of Veterans Affairs and was elevated to multicenter trials that would be daunting in smaller
Cabinet status; it is currently the second largest of the systems. Historical accomplishments in mental health
15 Cabinets under the leadership of the Secretary of attributed to VA research and development initiatives
Veterans Affairs. It operates nationwide programs for include advances in understanding the genetic under-
health care, financial assistance, and burial benefits. pinnings of schizophrenia and dementias and frontier
In fiscal year 2007, VA health care spending was esti- work on chronic pain, posttraumatic stress disorder
mated at nearly $35 billion. Of the estimated 24 mil- (PTSD), and other conditions. Current research con-
lion U.S. veterans, nearly 5.5 million received VA tinues in those and many other areas, including neuro-
health care in 2006 (U.S. Department of Veterans Af- imaging techniques (U.S. Department of Veterans Af-
fairs 2007a). fairs 2008d).
As of December 2007, the VA health care system National pride, patriotism, and veteran loyalty are
had locations in all 50 states, the District of Colum- among the factors fueling the VA volunteer workforce,
bia, and Puerto Rico, encompassing 155 medical cen- the largest volunteer program in the federal govern-
ters, 132 of which provide inpatient psychiatric care. ment. Volunteers provide a variety of comfort and an-
Outpatient mental health services and in-home ser- cillary services, such as ward recreational activities
vices are available in nearly 700 clinics located in hos- and community transportation to VA appointments.
pitals or outpatient clinics (U.S. Department of Veter- Recent statistics show more than 90,000 people na-
ans Affairs 2007c). In addition, there are more than tionwide participated in VA Voluntary Services, log-
200 Vet Centers providing outpatient counseling and ging 13 million hours of service in 2004 alone (U.S.
individual and group therapy. All services are available Department of Veterans Affairs 2008a).
free of charge to veterans who served in a combat zone
during wartime or anywhere during a period of armed Veterans Health Benefits
hostilities and to their families (see http://www.vet- Financing the VAs mandate to provide medical bene-
center.va.gov). Forty-five residential rehabilitation fits to veterans depends on appropriations annually
treatment programs, 108 home health service pro- determined by Congress and the president. This dis-
grams, and 135 nursing homes complete the spectrum cretionary process means that the VA is not fully
of care. Programs for the homeless and vocational re- funded, 1 in contrast to other programs such as Social
habilitation are other sources of help (U.S. Depart- Security. Understaffing during periods of monetary
ment of Veterans Affairs 2007a). shortfall may translate into reduced scope of services
and long waiting times for care over and above the bu-
Veterans Affairs Workforce reaucratic delays inherent in any large and complex
The VA now is the largest health care provider in the system. Given the high demand for VA medical bene-
nation. In 2006 approximately 250,000 employees, fits, budget constraints also lead to delays and limits
including about 16,000 physicians, cared for more in the enrollment process. To maintain enrollment
than 5 million people (U.S. Department of Veterans manageable with available fiscal resources, the quali-
Affairs 2007a). Through the VAs association with fications to receive benefits are evaluated annually for
1 Money for a fully funded program is set aside to meet the programs projected costs over time. No such reserves are created for
nonfully funded programs.
The Veterans Hospital 213
necessary criteria modifications. Over time, more stitutionalized. Although this mental health care
stringent enrollment criteria have been implemented. system is in place, VISNs continue to provide regional
As one might expect, this budget-balancing strategy is and local leadership and oversight, reporting to the na-
highly politicized, because the argument can always be tional administration.
made that resources should be available to meet de- Patient cost-sharing through copays and deduct-
mand, not vice versa. Some of the major adjustments ibles adds to VA health care revenue. Copay rates for
to enrollment criteria are described later. services and pharmacy benefits are calculated using
An honorable discharge is required to qualify for factors such as service connection and national income
VA health benefits, although certain exceptions apply. standards adjusted for regional differences. These ad-
Length of service criteria require (again, with certain justments too can be politically controversial, as some
exceptions) 24 months of active duty to qualify for VA feel that veterans should not have to pay anything for
benefits (U.S. Department of Veterans Affairs 2007b). VA medical care. VA bills private insurance companies
A major enrollment restriction was implemented in for services provided to their insured veterans. 3 Not
2003, limiting guaranteed enrollment only to the pe- surprisingly in light of this interface with the private in-
riod 2 years after military discharge, a change affecting surance sector and managed care, VA has implemented
veterans who served in the Afghanistan and Iraq con- private-sector models for determining aspects of care
flicts.2 Although soldiers who develop psychological or such as acuity criteria and length of stay, monitored
psychiatric symptoms during active duty can transi- closely by its utilization review program. As a result,
tion directly from military health care to VA care, the clinicians in many acute-care settings are held to stan-
clinical impact of this limit is obvious for conditions dards as strong as any in the private sector. Results are
such as PTSD, which often does not manifest until reflected in data obtained in the VA Maryland Health
years after the trauma. Another change in 2003 cre- Care System in VISN 5, where the average length of
ated a priority system for VA enrollment including Pri- stay on the acute inpatient psychiatric units in 2006
ority Group 8: not allowed to enroll for VA benefits was less than 5 days.
(Albano 2007). Although reserved for those veterans
with other opportunities for access to health care, such Information Technology
as those in higher income brackets or with other in- Compared with other branches of medicine, psychiatry
surance such as Medicare, these various limitations is not typically a high-technology specialty. Yet psychi-
have been politically controversial. Many hope that atry joined with the other medical specialties in 1996
when political tides shift, restrictions will be lifted. when VA successfully integrated computer technology
into routine clinical care. Termed VistA (Veterans
Spending and Revenue Adjustments Health Information Systems and Technology Architec-
In 1995 Congress passed legislation requiring psychi- ture), the system includes among its many applications
atric deinstitutionalization, one goal of which was cost the Computerized Patient Record System (CPRS).
savings through the transition to less intensive levels CPRS links computer terminals at points of clinical
of care. As part of that process, the national VA health care with associated services such as laboratory and ra-
care system was divided into 22 VA Integrated Service diology. Laboratory results, vital signs, and progress
Networks (VISNs) intended to consolidate resources, notes are entered into the system. CPRS facilitates
avoid duplication of services, and optimize access to daily tasks such as entering orders, requesting consul-
services at the appropriate level of care. In 2002, tations, reviewing radiographic images, monitoring vi-
VISNs 13 and 14 were merged into a new network, tal signs, scheduling laboratory services, and a host of
VISN 23 (U.S. Department of Veterans Affairs 2002). other tasks that can be completed electronically. Local
Figure 141 shows the VISN organization by state. VistA and CPRS systems store visual images, including
Deinstitutionalization and decentralization to VISNs pathology slides, X-rays, and computed tomography
necessitated creation of a continuum of care from in- and magnetic resonance imaging studies. The system
patient to outpatient, as well as community resi- is fast, eliminates errors due to handwriting confusion,
dences, outreach, and support for those no longer in- and alerts clinicians to possible errors such as ordering
2 Operation
Enduring Freedom and Operation Iraqi Freedom.
3 Conversely, under some circumstances VA is obligated to reimburse for care in the private sector for psychiatric services unavail-
able in the VA system, such as eating disorders, after patient and clinician demonstrate the necessity of such care.
FIGURE 141. Veterans Integrated Service Networks (VISN) organization map by states.
VISN 1: VA New England Health Care System (Boston, MA); VISN 2: VA Health Care Network Upstate New York (Albany,
NY); VISN 3: Veterans Integrated Service Network (Bronx, NY); VISN 4: VA Stars & Stripes Health care Network (Pitts-
burgh, PA); VISN 5: VA Capitol Health Care Network (Baltimore, MD); VISN 6: The Mid-Atlantic Network (Durham, NC);
VISN 7: The Atlanta Network (Atlanta, GA); VISN 8: VA Sunshine Health Care Network (Bay Pines, FL); VISN 9: Mid
South Veterans Health Care Network (Nashville, TN); VISN 10: VA Health Care System of Ohio (Cincinnati, OH); VISN
11: Veterans Integrated Service Network (Ann Arbor, MI); VISN 12: The Great Lakes Health Care System (Chicago, IL);
VISN 13: VA Upper Midwest Health Care Network (Minneapolis, MN); VISN 14: Central Plains Health Network (Omaha,
NE); VISN 15: VA Heartland Network (Kansas City, KS); VISN 16: Veterans Integrated Service Network (Jackson, MS);
VISN 17: VA Heart of Texas Health Care Network (Dallas, TX); VISN 18: VA Southwest Health Care Network (Phoenix,
AZ); VISN 19: Rocky Mountain Network (Denver, CO); VISN 20: Northwest Network (Portland, OR); VISN 21: Sierra Pa-
cific Network (San Francisco, CA); VISN 22: Desert Pacific Health Care Network (Long Beach, CA).
Note. In January 2002, VISNs 13 and 14 were integrated and renamed VISN 23 (VA Midwest Health Care Network [Min-
neapolis, MN]).
Source. U.S. Department of Health and Human Services Web site (http://www.hhs.gov/healthit/ahic/materials/09_07/ce/
nazi_files/images/image5.png). Accessed May 10, 2008.
duplicate tests or attempting to prescribe an agent cation trials, and providing clinical information such
listed as a patient allergy. CPRS enhances preventive as laboratory results. The use of computer information
care by posting reminders for health screening such as technology increases the quality of VA health care by
annual mammograms, pap smears, and tuberculosis improving the efficiency, efficacy, and comprehensive-
test screens. CPRS also provides standardized screen- ness of services. Its application to the inpatient psy-
ing questionnaires for conditions such as trauma, de- chiatry unit opened a new era in administrative man-
pression, and suicide attempt history. agement and patient care. The next information
VistA also links every VA facility nationwide. Clin- technology achievement is an electronic interface be-
ical information is recorded back to 1995, and paper tween the veteran him- or herself and the VA system.
charts hold earlier patient information as well as ongo- This tool, called MyHealtheVet (available at http://
ing legal paperwork, ambulance transfer reports, and www.myhealth.va.gov), went online in 2005. My-
so on. Through the remote access feature, the clini- HealtheVet is designed to enable veterans to refill pre-
cian can review hospitalizations, progress notes, labo- scriptions online, check scheduled appointments, view
ratory results, medications prescribed, and a host of copay balances, and view some parts of their electronic
other variables in every other VA facility. This capabil- medical record. Using the Track Health tool, veterans
ity proves invaluable in obtaining medical history, can record and track personal health data, including
tracking the course of an illness, reviewing past medi- blood pressure, weight, and other medical information.
National Drug Formulary vice at other recruitment phases. Lax recruiting deci-
sions result in some veterans with disqualifying con-
As in any hospital setting, VA prescribers choose med- ditions such as intellectual disability, disabling social
ications from a drug formulary. Until January 2007, and/or interpersonal skills, conduct disorders, affec-
hospitals and VISNs made their own formulary tive illness, or psychosis. With these conditions, such
choices. At that time, the VA began transitioning to a soldiers are often unable to adapt to military service;
National Formulary, at the completion of which every not an insignificant number of VA psychiatric patients
VA hospital in the country will have the same list of failed to complete basic training or had very short
outpatient prescriptions and inpatient medications. stints in the military but then require lifelong care in
Hospital and VISN pharmacy committees still retain the VA. Even more unfortunate are those ill-suited sol-
authority to impose dosage or indication restrictions diers who also have been exposed to combat or other
and to authorize nonformulary agents on a case-by- trauma; these are some of the most functionally and
case basis. For example, in the VA Maryland Health psychologically compromised veterans in the VA pa-
Care System in VISN 5, approval of duloxetine re- tient population.
quires a prior trial of venlafaxine (excepting preexist-
ing cardiovascular complications), and a review of the Major Mental Illness
potential complications of metabolic syndrome is re-
Some psychiatric disabilities are unrelated to military
quired before an atypical antipsychotic can be pre-
service; the major mental illnesses that manifest in
scribed. The VA gains cost advantages through use of
young adulthood develop in young adult soldiers as
generic substitutes, volume pricing, and its large mar-
well. However, veterans who can demonstrate the on-
ket share. The psychopharmacological armamentar-
set of major mental illness during active duty or
ium as of April 2008 is listed in Table 141.
within 1 year of separation from the military are likely
to be awarded service-connected4 disability benefits as
VA Clinical Population well as lifelong medical and psychiatric care. Others
qualify despite later disease onset. With the VA con-
tinuum of care, these veterans receive comprehensive
The VA psychiatric patient population differs in several treatment and services for conditions such as schizo-
respects from the general U.S. psychiatric population. phrenia, schizoaffective disorder, and bipolar disorder.
For example, some veterans are affected by experiences Resembling trends in the private and other public sec-
not found among civilians, such as basic training, de- tors, in the 3 years following the 1995 deinstitution-
ployment far from home, and combat exposure. Some alization policy, the number of veterans with major
clinical conditions, such as substance abuse, are not mental illnesses who were treated as inpatients de-
exclusive to veterans but occur more frequently in this creased by 30% (National Mental Health Association
population. Again using the VA Maryland Health Care 1999). Reactions to this change varied; some viewed it
System in VISN 5 as an example, the top five primary as an abandonment of the neediest veterans (particu-
admission diagnoses in 2006 were alcohol dependence, larly before the VA outpatient and community infra-
alcohol withdrawal, opioid dependence, paranoid structure was in place), whereas others lauded the
schizophrenia, and schizoaffective disorder (VA Mary- emancipation of institutionalized veterans to commu-
land Health Care System 2006). nity settings. Some staff on long-term units saw these
patients as family members and grieved their dis-
Inappropriate Enlistees charge, fearing that they would not receive comparable
Military recruitment and enlistment procedures of nurturance in the community. However, once an ade-
course influence the VA patient population. For exam- quate continuum of care was in place, the shift from
ple, the VA cares for some patients with conditions institutional to community living certainly benefited
that would have disqualified them from military ser- many deinstitutionalized patients.
4
A service-connected disability is a condition incurred during or exacerbated by military service. Disabilities are rated from 0%
to 100%, reflecting loss of earning capability. As of April 2008, a 100% service-connected veteran receives at least $2,527 annu-
ally in tax-free compensation (U.S. Department of Veterans Affairs 2007d). Not surprisingly, given the stakes involved, at times
an active claim for service-connected disability can influence a patients clinical presentation.
TABLE 141. VA National Formulary psychopharmacological agents: April 2008
Category Approved agents

Antidepressants Amitriptyline, bupropion, citalopram, clomipramine, desipramine, doxepin,
duloxetine, fluoxetine, imipramine, mirtazapine, nortriptyline, paroxetine,
phenelzine, selegiline, sertraline, tranylcypromine, trazodone, venlafaxine
Mood-stabilizing agents Carbamazepine, divalproex sodium, lamotrigine, lithium, valproic acid
Neuroleptics Aripiprazole, chlorpromazine, clozapine, fluphenazine, droperidol, haloperidol,
loxapine, molindone, olanzapine, perphenazine, pimozide, quetiapine,
risperidone, thioridazine, thiothixene, trifluoperazine, ziprasidone
Benzodiazepines Alprazolam, chlordiazepoxide, clonazepam, diazepam, lorazepam, temazepam
Aids to substance abuse Buprenorphine, buprenorphine/naloxone, disulfiram, methadone, naloxone,
recovery naltrexone, nicotine gum and patches, varenicline
Dementia treatments Donepezil, galantamine, memantine
Miscellaneous Buspirone, chloral hydrate, dextroamphetamine, gabapentin, methylphenidate,
topiramate, zolpidem
Source. U.S. Department of Veterans Affairs 2008b.
Geriatric Psychiatry ing exercises, exposure to weapons, and, of course,

battle. Modern warfare technology such as improved
Comorbid psychiatric conditions typically manifest- body armor and helmets reduce the chance of death in
ing in older adults also are reflected in the VA patient combat, but survivors of blows and jolts to the head
population. Included in this group are patients with have greatly increased the VA TBI population (U.S.
dementia; those with the long-term psychiatric se- Government Accountability Office 2008). It is esti-
quelae of alcohol and other substance abuse; and those mated that the percentage of survivors with TBI in-
with intractable psychoses, affective disorders, and/or jured in Afghanistan and Iraq will be much higher
PTSD. Elderly veterans who have treatment-refractory than in previous military conflicts, which already car-
behavioral disturbances (e.g., physical or verbal aggres- ried TBI estimates as high as 20% (G.J. Adams 2007).
sion) that render them unsuitable for in-home ser- In a study reported by the Defense and Veterans Brain
vices, community assisted-living facilities, or nursing Injury Center (see http://www.dvbic.org/cms.php?p=
home care instead remain in long-term-care psychiat- Blast_injury), more than half of all injured soldiers
ric units. As the number of aging veterans increased, screened at Walter Reed Army Medical Center were
VA forecast a time when veterans need for services positive for TBI. Many TBI insults are obvious, but
would exceed the systems resource capacity. As a re- mild and moderate TBI resulting from insults such as
sult, in January 2003 the VA suspended new enroll- repeated proximity to explosions may go undetected,
ment of veterans in Priority Group 8those without delaying appropriate treatment (G. J. Adams 2007).
service connection or compensable disability whose Psychiatric sequelae of TBI can include attentional
income exceeds the VA income threshold (U.S. De- deficits, poor impulse control, dementia, affective syn-
partment of Veterans Affairs 2008c). This was an un- dromes, organic psychotic symptoms, and behavioral
fortunate fiscal consequence for senior veterans who disturbances that result in occupational and interper-
had not consumed VA resources earlier in adulthood sonal deficits. In response to this growing need, legis-
yet perhaps counted on access to medical and nursing lation has been put forth to expand VA TBI care. The
home care in their senior years, when they would need proposed TBI treatment units will afford both clinical
it most. services and research opportunities to advance the
care of TBI in areas including diagnosis and assess-
Traumatic Brain Injury ment, psychological interventions, psychopharmacol-
Some of the most challenging clinical conditions re- ogy, behavior therapy, cognitive retraining, family edu-
sult from traumatic brain injury (TBI). Soldiers are cation an d therapy, and psychos ocial suppo rts
particularly vulnerable to injury during rigorous train- (Michaud 2007).
Combat Trauma sexual trauma (MST) is defined by law as sexual ha-

rassment, sexual assault, rape, and other acts of vio-
The major distinguishing feature of VA psychiatric care lence. It is estimated that nearly one-third of sexual
is treatment of trauma disorders. Military service en- trauma victims develop PTSD (U.S. Department of
tails a variety of situations traumatic for even the Veterans Affairs 2007a). Traumatic consequences in
staunchest individuals, from arduous training exercises the military can be compounded when victims often
(such as prisoner of war training), to threat of immi- must live and work alongside their attacker, face indif-
nent death in combat, to developing the ability to kill ference to attack by superior officers, or suffer career
another person and being called to do so in the line of disruption if they relocate to move away from their at-
duty. Soldiers suffer grief from the death of comrades, tacker. Although the majority of civilian sexual crimes
separation from family, possible physical mutilation, go unreported, military conditions further intensify
and countless other hardships. To meet the broad range the potential shame, intimidation, and stigma for sol-
of personal thresholds for experiencing trauma, VA diers reporting these events (Wolfe et al. 1998).
trauma services range from outpatient counseling to Despite its frequency, MST received little notice
long-term inpatient and residential treatment. until the early 1990s. Yet with the increasing number
From acute shell shock to chronic disabling of women in the military, the official recognition of
symptoms, PTSD is a consequence of military service MST as a valid and important issue, and the reduced
for some veterans. The National Center for PTSD was social stigma for reporting these crimes, the number of
legislated into existence in 1989 to address the treat- reported incidents of MST has reached staggering pro-
ment of Vietnam War veterans. The number and se- portions. In 2006 nearly 3,000 soldiers reported as-
verity of affected veterans brought the condition to sault or rape by fellow soldiers. It has been estimated
light, and the syndrome is now recognized as a conse- that 20% of female VA patients and 1% of male VA pa-
quence of all types of trauma. Although not exclusive tients have been victims of sexual trauma, with rates
to soldiers, PTSD today is more common in war vet- of incidents of harassment much higher (Goldzweig et
erans than any other group. Estimates of the incidence al. 2006; Public Broadcasting Service 2007; U.S. De-
of PTSD in veteran populations vary widely as a result partment of Veterans Affairs 2007e).
of sample differences and screening methods, but one In 1992, VA implemented a Military Sexual Trauma
study estimates that 10%20% of Vietnam War veter- Program for men and women, addressing the psycho-
ans experienced ongoing PTSD symptoms 20 years af- logical and physical sequelae of MST (U.S. Department
ter the war (Prigerson et al. 2002). In fact, to this day of Veterans Affairs 2007e). The length of service re-
Vietnam War veterans are admitted to the inpatient quirement is waived for MST victims to receive treat-
psychiatric unit with conditions related to undiag- ment and/or disability compensation. In addition to
nosed and/or untreated PTSD; this phenomenon may standard inpatient psychiatric care and outpatient indi-
be related to the unmasking through retirement or so- vidual and group therapy, when necessary veterans can
briety of symptoms managed through the diversions of be referred for admission to one of several VA residen-
work or substance abuse during earlier adulthood. tial MST programs nationwide (see Appendix for links).
As the result of lessons learned in the post-Vietnam Separate programs for men and women are available.
era, the U.S. Department of Defense and VA are very
invested today in screening soldiers and veterans for Substance Abuse
PTSD and referring them for treatment. Postdeploy-
More than 55,000 VA admissions annually are related
ment transitional programs are now in place and de-
to substance abuse; as noted previously, three of the
signed to educate new veterans and their families
top five admission diagnoses in one VA survey were
about the signs and symptoms of PTSD and other se-
substance abuserelated (VA Maryland Health Care
quelae of military service. It is hoped that these preven-
System 2006). Although alcohol is the most fre-
tive efforts will lead to early treatment interventions
quently abused agent (68%), cocaine (15%) and opiate
and minimize comorbidities. Nonetheless, the VA is
addictions (8%) are significant as well (Substance
preparing to handle the expected influx of new cases.
Abuse and Mental Health Services Administration Of-
fice of Applied Studies 2001, 2003). VA substance
Sexual Trauma abuse treatment services include outpatient metha-
Sexual crimes can be perpetrated anywhere, but they done and buprenorphine programs, group therapy, in-
are among the worst adversities of military service in tensive outpatient programs, acute detoxification ad-
war or peacetime for both men and women. Military missions, and residential treatment programs. VA has
developed an array of psychosocial services to inter- to stable employment than the civilian population. As
face with substance abuse treatment services. a result, vocational rehabilitation is an important part
of the VA continuum of care. With roots dating back to
World War II, VAs program for service-connected vet-
Womens Health Services erans now is called the Vocational Rehabilitation and
Employment Program. This program has developed
Eligibility for women in military service began in into a complex assessment and treatment network in-
1947 and was limited to nurses; enrollment opened to terfacing extensively with community businesses (Vo-
women in the general population starting in 1948. At cational Rehabilitation and Employment Services, San
that time, the enrollment of women was capped at 2% Diego VA Regional Office 2008). Through job train-
of the soldier population, and strict ceilings existed on ing, sheltered employment, and other work arrange-
rank attainment and approved assignments for ments, important therapeutic gains can be attained.
women. The intervening years brought progressively For veterans receiving sustained inpatient psychi-
more lenient regulations for women, allowing them atric care, work therapy assignments can provide both
to progress in rank and broaden their scope of service an important structure to daily activity and a signifi-
(Womens Research and Education Institute 2007). cant source of patient satisfaction. Stable inpatients
In 1973 the draft ended, and the U.S. military be- also participate in Compensated Work Therapy or In-
came a voluntary force. To encourage enlistment, mil- centive Therapy. These programs prepare veterans for
itary pay was raised (and became comparable with further vocational rehabilitation in the community
civilian wages), and other improvements such as sub- and provide a source of spending money for chroni-
sidies for education were implemented. Military ser- cally hospitalized veterans. For less impaired veterans
vice provided the opportunity for gender equity in job who are outpatients, Compensated Work Therapy and
performance as well as opportunities to progress in Transitional Work positions may provide critical fi-
rank, other factors appealing to women (Quester and nancial support or enable return to full employment.
Gilroy 2007). Reflecting these changes, the percentage Veterans may live in VA residential housing during
of women in the active duty military rose from 2.5% in this phase of their recovery.
1973 to nearly 15% in 2004 (Klein 2005).
More women in military service translates into
more women veterans, although women still represent Homeless Program
only 6%8% of the veteran population (Klein 2005).
Because a higher percentage of female than male vet- Veterans make up a significant percentage of the
erans use VA health care services, approximately 10% homeless male population; although only 34% of the
of the veteran patient population is female. Statistics general adult population are veterans, they compose
demonstrate that a growing percentage of substance 40% of the homeless population. Homeless veterans
abuse admissions are women (6% in 2000, up from 4% are more likely than housed veterans to be admitted
in 1995; Substance Abuse and Mental Health Services for psychiatric and substance abuse diagnoses (J. Ad-
Administration Office of Applied Studies 2003). ams et al. 2007). As a result, discharge decisions not
An office to address womens health issues was infrequently hinge on the availability of appropriate
established by the VA in 1988. VA treatment for gen- outpatient housing.
der-specific conditions such as gynecological care and Various factors render veterans vulnerable to home-
mammograms began in 1992 with nationwide imple- lessness, including unemployability, substance abuse
mentation of Womens Health Programs (see Appen- and/or major mental illness, and treatment noncom-
dix). Although in the minority on general psychiatric pliance. Studies have shown that soldiers from the
units, women veterans may also be treated in the sev- late-Vietnam and post-Vietnam eras have higher rates
eral women-only VA programs across the country for of homelessness than those who participated at the
treatment of MST and PTSD. height of the Vietnam War (Rosenheck et al. 1996).
These veterans had little exposure to combat but ap-
pear to have increased rates of mental illness and ad-
Vocational Rehabilitation diction disorders, possibly due to recruitment pat-
terns (National Coalition for the Homeless 2007).
Veterans with psychiatric illnesses may be underem- Along these lines, one might speculate that soldiers
ployed or unemployed and face more serious barriers lack of independent living experience as adults while
living in strict military organization may have deprived Adams J, Rosenheck R, Gee L, et al: Hospitalized younger: a
them of critical developmental milestones to achieve comparison of a national sample of homeless and
housed inpatient veterans. J Health Care Poor Under-
stable work and housing after military service. Veter-
served 18:173184, 2007
ans coping with prolonged and severe war memories Albano T: Veterans group seeks mandatory VA funding. Peo-
may have loosened or cut their ties to friends and fam- ples Weekly World: October 4, 2007
ily, and this social isolation may predispose to home- Goldzweig CL, Balekian TM, Rolon C, et al: The state of
lessness; however, studies have shown that homeless women veterans health research: results of a system-
veterans are less likely to have combat experience than atic literature review. J Gen Intern Med 21 (suppl):S82
S92, 2006
the nonhomeless (Rosenheck et al. 1996). For others,
Klein RE: Women Veterans: Past, Present and Future. Wash-
military skills may not be readily transferred to civilian ington, DC, Department of Veterans Affairs, Office of
jobs. the Actuary, 2005
The VA provides a safety net for those unfortunate Michaud M: House expected to pass Michaud bill to im-
veterans who are unable to afford or otherwise main- prove traumatic brain injury treatment and screening
today (5/23/07). Congressman Mike Michaud Web site,
tain shelter. In 1987, the VA Homeless Program (see
2007. Available at: http://michaud.house.gov/arti-
Appendix) was begun in order to create locally based cle.asp?id=420. Accessed May 10, 2008.
medical care programs, residential programs, and National Coalition for the Homeless: Homeless Veterans
other benefits to homeless veterans. A variety of ser- (NCH Fact Sheet #14). August 2007. Available at:
vices fall under this programs rubric, from homeless http://www.nationalhomeless.org/publications/facts/
outreach, to subsidy of community shelter beds specif- veterans.html. Accessed May 13, 2008.
National Mental Health Association: NMHA leads the fight
ically for veterans, to domiciliary settings, to long-
for better health care for veterans: seeks $64 million in
term recovery programs for homeless veterans with community reinvestments. NMHA Legislative Alert,
substance abuse. May 3, 1999. Available at: http://www1.nmha.org/
newsroom/system/lal.vw.cfm?do=vw&rid=111. Ac-
cessed May 10, 2008.
Conclusion Prigerson HG, Maciejewski PK, Rosenheck RA: Population
attributable fractions of psychiatric disorders and be-
havioral outcomes associated with combat exposure
VA hospital psychiatry today is a unique blend of tra- among US men. Am J Public Health 92:5963, 2002
ditional care and soldier-specific treatments. State-of- Public Broadcasting Service: Military sexual trauma. Now,
the-art information technology, including an elec- September 7, 2007. Available at: http://www.pbs.org/
now/shows/336. Accessed May 10, 2008.
tronic patient record, improves efficiency and effec-
Rosenheck R, Leda CA, Frisman LK, et al: Homeless veter-
tiveness. Every VA hospital benefits to some extent ans, in Homelessness in America: A Reference Book.
from VA research and education programs. The pa- Edited by Baumohl J. Phoenix, AZ, Oryx Press, 1996, pp
tient population spans adults of all ages with widely 97108
varying conditions, with the care of many further Quester AO, Gilroy CL: Women and minorities in Americas
volunteer military. Contemp Econ Policy 20:111121,
complicated by challenging psychosocial situations.
2007
VA provides specialty treatment for conditions not Substance Abuse and Mental Health Services Administra-
found in civilian treatment settings, such as combat- tion Office of Applied Studies: Veterans in Substance
related PTSD and MST. From acute inpatient stays to Abuse Treatment. The DASIS Report. Rockville, MD,
sustained and even permanent hospitalizations, the Substance Abuse and Mental Health Services Adminis-
VA hospital psychiatrist depends on multidisciplinary tration, 2001
Substance Abuse and Mental Health Services Administra-
collaboration and a full continuum of services to an
tion Office of Applied Studies: Veterans in Substance
extent unavailable to most in the private sector. All Abuse Treatment, 19952000. The DASIS Report.
told, the VA may offer the most varied clinical experi- Rockville, MD, Substance Abuse and Mental Health
ence in U.S. hospital psychiatry today. Services Administration, 2003
U.S. Department of Veterans Affairs: Statement of the Hon-
orable Anthony J. Principi, Secretary of Veterans Affairs,
References Before the Committee on Veterans Affairs, United
States Senate, May 13, 2002. Available at: http://www.
va.gov/oca/testimony/svac/13my02TP.asp. Accessed
Adams GJ: Incidence of traumatic brain injury in the mili- April 26, 2008.
tary. EzineArticles.com, September 26, 2007. Available U.S. Department of Veterans Affairs: Fact Sheet: Facts About
at: http://ezinearticles.com/?Incidence-Of-Traumatic- the Department of Veterans Affairs. December 19,
Brain-Injury-In-The-Military&id=752358. Accessed 2007a. Available at: http://www1.va.gov/opa/fact/
May 10, 2008. vafacts.asp. Accessed April 25, 2008.
U.S. Department of Veterans Affairs: Health Eligibility and U.S. Department of Veterans Affairs: VA Research and De-
Enrollment. January 16, 2007b. Available at: http:// velopmentHistorical Accomplishments. April 23,
www.va.gov/healtheligibility/eligibility/DetermineEligi- 2008d. Available at: http://www.research.va.gov/about/
bility.asp. Accessed June 13, 2008. history.cfm. Accessed May 13, 2008.
U.S. Department of Veterans Affairs: Mental Health: About U.S. Government Accountability Office: Report to Congres-
the VA Mental Health Group. September 27, 2007c. sional Requesters: Mild Traumatic Brain Injury Screen-
Available at: http://www.mentalhealth.va.gov/mental- ing and Evaluation Implemented for OEF/OIF Veterans,
health/vamentalhealthgroup.asp. Accessed May 13, 2008. but Challenges Remain (GAO-08-276). February 2008.
U.S. Department of Veterans Affairs: VA Compensation and Available at: http://www.gao.gov/new.items/d08276.pdf.
Pension Payment Rates: Veterans Compensation Bene- Accessed May 10, 2008.
fits Rate TablesEffective 12/1/07. November 27, VA Maryland Health Care System: Mental Health Clinical
2007d. Available at: http://www.vba.va.gov/bln/21/ Center, Acute Inpatient Services. June 1, 2006. Avail-
Rates/comp01.htm. Accessed April 26, 2008. able at: http://www.maryland.va.gov/services/mhcc/
U.S. Department of Veterans Affairs: Women Veterans subproduct/acute.htm. Accessed May 6, 2008.
HealthMilitary Sexual Trauma Program. April 5, Vocational Rehabilitation and Employment Services, San
20 07 e. Avai la ble at : ht t p:/ /w ww1 .va .gov/w vhp / Diego VA Regional Office: History of Veterans Voca-
page.cfm?pg=20. Accessed May 10, 2008. tional Rehabilitation. March 12, 2008. Available at:
U.S. Department of Veterans Affairs: Fact Sheet: VA Volun- http://www.vba.va.gov/ro/sandiego/vre/history.html.
tary Service. February 7, 2008a. Available at: http:// Accessed May 10, 2008.
www1.va.gov/opa/fact/volsvcfs.asp. Accessed May 13, Wolfe J, Sharkansky EJ, Read JP, et al: Sexual harassment and
2008. assault as predictors of PTSD symptomatology among
U.S. Department of Veterans Affairs: Pharmacy Benefits US female Persian Gulf War military personnel. J Inter-
Management Strategic Healthcare GroupNational pers Violence 1:4057, 1998
Formulary. April 14, 2008b. Available at: http://www. Womens Research and Education Institute: Chronology of
pbm.va.gov/NationalFormulary.aspx. Accessed April Significant Legal and Policy Changes Affecting Women
26, 2008. in the Military: 19472003. Arlington, VA, Womens
U.S. Department of Veterans Affairs: Public and Intergov- Research and Education Institute, 2007. Available at:
ernmental AffairsCurrent Benefits. April 28, 2008c. http://www.wrei.org/WomeninMilitary.htm. Accessed
Available at: http://www.va.gov/opa/vadocs/current_ May 13, 2008.
benefits.asp. Accessed May 10, 2008.
221
APPENDIX
Online Resources for Veterans
Defense and Veterans Brain Injury Center: http://www. Pharmacy Benefits Management Service: http://www.pbm.
dvbic.org va.gov
Fact Sheet: Facts About the Department of Veterans Affairs: Programs for Women Veterans: http://www1.va.gov/wvhp/
http://www1.va.gov/opa/fact/vafacts.asp page.cfm?pg=26
Fact Sheet: VA Voluntary Service: http://www1.va.gov/opa/ Research and Development: http://www.research.va.gov/
fact/volsvcfs.asp about/history.cfm
Homeless Veterans: http://www1.va.gov/homeless VA Careers: http://www.vacareers.va.gov
Military Sexual Trauma Program: http://www1.va.gov/wvhp/ VA Mental Health Group: http://www.mentalhealth.va.gov/
page.cfm?pg=20 mentalhealth/vamentalhealthgroup.asp
MyHealtheVet: http://www.myhealth.va.gov Veterans Health Information Systems and Technology Ar-
National Coalition for the Homeless: http://www.national- chitecture (VistA): http://www.va.gov/vista_monograph
homeless.org Vocational Rehabilitation and Employment Program: http://
Office of Public and Intergovernmental Affairs: http:// www.vba.va.gov/ro/sandiego/vre/history.html
www1.va.gov/opa Womens Mental Health Center: http://www.women-
vetsptsd.va.gov
CHAPTER 15
CONSULTATIONLIAISON
PSYCHIATRY
C onsultationliaison (CL) psychiatry, also known as as a subspecialty by the American Board of Psychiatry
psychosomatic medicine, is a subspecialty of psychiatry and Neurology (ABPN) and approved by the American
in which professionals focus their clinical, research, Board of Medical Specialties. The first certification ex-
and teaching efforts on the intersection of medicine and amination was given in 2005. As of 2007, 583 psychi-
psychiatry. CL psychiatrists prescribe psychotropic atrists have qualifications in psychosomatic medicine
medication and practice psychotherapy, but they also from the ABPN (www.apbn.com). In 2004, the Ameri-
may engage in making medical decisions on which pa- can Psychiatric Association (APA) formed a Council of
tients lives may depend. CL psychiatrists practice in Psychosomatic Medicine. As of 2000, almost 800 psy-
many settings, including hospital medical floors (Korn- chiatrists have received specialized training in psycho-
feld 1996b), medicalpsychiatric inpatient units somatic medicine, and almost 3,000 psychiatrists in
(Kathol and Stoudemire 2002), and outpatient facilities the United States devote at least part of their practice
(Unutzer et al. 2002). Because their field is interdisci- to CL psychiatry (Gitlin et al. 2004; Noyes et al. 1992).
plinary in nature, CL psychiatrists also are uniquely po- In addition to the APA, international organizations
sitioned to participate in broader arenas, such as med- such as the Academy of Psychosomatic Medicine pro-
ical student education, residency training, and medical vide an organizational home for psychiatrists who
ethics (Kornfeld 1996a, 2002). Research also is integral practice this subspecialty.
to CL psychiatry; however, resource limitations have As CL psychiatry has evolved, so has its nomencla-
challenged research opportunities (Ilchef 2006). ture (Gitlin et al. 2004). The term psychosomatic
The field of CL psychiatry is dynamic and expand- medicine, the official designation of the subspecialty,
ing; in 2003, psychosomatic medicine was recognized describes the broad spectrum of clinical, research, and
223
teaching activities of the CL psychiatrist. Many clini-

TABLE 151. Common clinical scenarios for
cians still refer to themselves as consultation psychia-
trists to emphasize the interaction between their prac- psychiatric consultation
tice and medical and surgical disciplines. The term Condition
liaison in this context refers to work that focuses on Delirium
the clinical needs of a specific medical team, such as
Affective illness
an intensive care unit. Medical staff can benefit from
Anxiety disorders
the presence of a psychiatrist they may have come to
know and trust (Lipowski 1986). Unfortunately, in Psychosis
part due to an inhospitable reimbursement environ- Dementia
ment, in recent years liaison activities have trans- Substance intoxication or withdrawal
formed into a less fixed and more consultation-based Suicidal/homicidal ideation
relationship (Ramchandani et al. 1997). Axis II disorders
CL psychiatrists are essentially physicians who are
Management of aggression
prepared to diagnose and treat psychiatric illness in a
medical context. (Table 151 presents a list of common Neuropsychiatric presentations
clinical scenarios for consultation.) Consultations gen- Eating disorders
erally fall into one of several categories, as described by Coping with medical illness
Lipowski (1967). First, CL psychiatrists treat psychiatric Somatoform disorders
manifestations of medical illness or its treatment. They Factitious disorders/malingering
may, for example, discover that the patient who appears
Pain
depressed actually has lupus cerebritis or a frontal brain
Capacity evaluations/ethics
mass. Second, they treat psychiatric complications of
medical illness or its treatment, such as behavioral Population
change after herpes encephalitis or mania secondary to Child/adolescent
treatment with steroids. Third, they treat medical com- Perinatal
plications of psychiatric illness or its treatment. For ex- Geriatric
ample, they may treat a patient with anorexia nervosa Cardiac
and bradycardia, or a patient who has overdosed on lith-
Burns
ium. Last, consultants may use their knowledge of psy-
chotherapeutic principles to assist with psychological Transplant
reactions to medical illness. HIV/AIDS
At any one time, the treatment strategy may in- Rehabilitation
clude pathophysiological, pharmacological, and psy- Cancer/palliative care
chodynamic approaches. Most importantly, the CL
psychiatrist aims to think on each of these levels simul-
taneously. She or he also takes into account the needs cartes (1637) famously introduced the mindbody split
of the individual patient, the patients loved ones, the (cogito ergo sum). The Dutch philosopher Baruch
medical staff, and the larger health care system (Miller Spinoza (16321677) and the English physician Will-
1973a, 1973b). The CL psychiatrist may sometimes iam Harvey (15781657) rejected this idea and pro-
feel as though she or he is treating the entire floor or posed the integration of mind and body (Lipsitt 2006).
containing the affect of the unit (Mozian and Muskin Johann Christian Heinroth is credited with coining the
2008). At times, this is exactly what is going on. The term psychosomatic as a description of the uncon-
specialized training of the CL psychiatrist, throughout scious processes that influence the health of the body
residency and fellowship, is crucial for the effective (Heinroth 1818). Other influential thinkers of the eigh-
management of the intense emotions involved in these teenth century include George Ernst Stahl, who de-
difficult cases. scribed a vital force integrating physiological events
with dynamic psychological phenomena, and Johann
Christian Reil, who called for humanistic treatment of
History the mentally ill in Germany (Lipsitt 2006). In the nine-
teenth century, the works of Benjamin Rush helped to
Physicians have been curious about the mindbody lay the foundation of modern psychosomatic medicine
problem since the early days of medicine. Ren Des- (Rush 1811); Rush, the father of American psychiatry,
ConsultationLiaison Psychiatry 225
is credited with writing the first psychiatric textbook States included CL services (Mendel 1966). During the
and founding the APA (Lipowski 1996; Lipsitt 2006). 1970s, the vision and leadership of James Eaton from
The early twentieth century witnessed significant the National Institute of Mental Health (Eaton et al.
development in theory, research, and practice. During 1977) helped to expand CL psychiatry as a field (Hack-
this time, psychosomatic medicine was heavily influ- ett et al. 2004). Some of the National Institute of Men-
enced by psychoanalytic theory, as exemplified by tal Health funding included training grants for CL fel-
Franz Alexander, who focused on the somatic impact lowships, which significantly increased the number of
of psychodynamic conflict (Hackett et al. 2004). Oth- psychiatrists specializing in psychosomatic medicine
ers, such as Walter Cannon, Morton Prince, and Felix (Gitlin et al. 2004). Flagship consultation services were
Deutsch (the latter coined the term psychosomatic founded at Massachusetts General Hospital (under the
medicine), were influential in further development of direction of Stanley Cobb, followed by Erich Linde-
theory and practice during the early twentieth century mann, Avery Weisman, and Thomas Hackett), Beth Is-
(Lipsitt 2006). Flanders Dunbar, at ColumbiaPresby- rael Hospital in Boston (Grete Bebring), University of
terian Medical Center, embraced an organic synthesis Rochester (John Romano and George Engel), Univer-
perspective, which aimed to merge physiology with sity of Colorado (Edward Billings), and Mount Sinai
psychoanalytic principles (Hackett et al. 2004). Dun- (M. Ralph Kaufman) (Lipowski 1996). Limited fund-
bar conducted research on the impact of psychological ing, comparative lack of evidence-based practice, and
factors in a large cohort of patients with medical ill- other challenges have been important issues for orga-
ness (Dunbar et al. 1936) and founded both the jour- nized CL psychiatry in recent years (Ilchef 2006). The
nal Psychosomatic Medicine (1939) and the American recent establishment of psychosomatic medicine as a
Psychosomatic Society (1942) (Lipsitt 2006). Adolf subspecialty, with field-specific interdisciplinary col-
Meyer, another influential figure of this time, devel- laboration and clinical research, has served to consoli-
oped an important center for psychosomatic medicine date knowledge and to encourage future work.
at Johns Hopkins University Hospital and later be-
came the president of the APA (Lipsitt 2006). His work
emphasized a psychobiological model with a holistic
Consultation Process
orientation (Lipsitt 2006). A significant upsurge in in-
terest in psychosomatic medicine occurred in the mid- There is no method for performing a consultation,
dle of the twentieth century, with greater emphasis because it is a process. Certain fundamental principles
placed on the social aspects of psychiatric illness, such are central to performing an effective consultation
as the health effects of combat-related stress in World (Goldman et al. 1983; Pasnau 1985). However, each
War II veterans (Lipsitt 2006). case is unique, and flexibility is key. Many of the typ-
The twentieth century also heralded the develop- ical components of psychiatric practice, such as a pri-
ment of formal CL psychiatry services in general med- vate space, a set appointment time, and a physically
ical hospitals. Lipowskis (1996) book is highly recom- and cognitively healthy patient, cannot be taken for
mended for a comprehensive overview of the historical granted (Querques and Stern 2004). At times, patients
development of this field. James Jackson Putnam and may not even know that they have been referred to a
Joseph Pratt were important figures in the Boston psychiatrist (Shakin Kunkel and Thompson 1996); in-
group, which served as a focal point for the emergence forming patients about the consultation process and
of CL psychiatry (Lipsitt 2006). George Henry, who the psychiatrists role in the medical setting may help
wrote the first article on CL psychiatry (Henry 1929 to engender trust (Smith et al. 2005).
1930), inaugurated the first formal consultation ser- An effective consultation comprises a series of
vice in 1929. Edward Billings, who created the CL ser- stages, as described by Querques and colleagues
vice at the University of Colorado, was the first to term (Querques and Stern 2004; Smith et al. 2005). A cru-
these services liaison psychiatry (Billings 1939). cial first step is to talk directly with the person re-
Crucial financial support allowed CL psychiatric prac- questing the consultation. Consultation requests are
tice to flourish. From 1934 to 1935, funding by the notoriously vague and may reflect conflicts surround-
Rockefeller Foundation (with Alan Gregg at the helm of ing the patient, inexperience of the person requesting
its Division of Medical Sciences) strengthened both the consultation, or confusing messages within the
consultationliaison and general psychiatry across the medical team. A CL psychiatrist will be attuned to
nation (Lipowski 1996). As a result, by the 1960s, al- both the implicit and the explicit meanings underlying
most 75% of all psychiatric programs in the United a teams requests (Smith et al. 2005). The various
medical services have specific expectations and ques- per his mother, who described him as a previously
tions for the consultant, which may range from a ca- gregarious and athletic college student. The psychi-
atry team was consulted for depression. The con-
pacity evaluation to a plan for disposition to an expla-
sultant felt that it was unclear whether the patient
nation of the psychosocial aspects of the patients could either understand or communicate with the
presentation (Shakin Kunkel and Thompson 1996). team and recommended magnetic resonance imag-
The consultant next gathers collateral information by ing, which revealed chronic intracranial bleeding and
perusing the patients current and prior medical communicating hydrocephalus, resulting in mut-
record, laboratory findings, and any other available ism. A ventriculoperitoneal shunt was placed, result-
ing in immediate improvement in the patients lan-
data. Close inspection of the medication list (includ-
guage and m ot or s kills. He wa s subs equently
ing dosing, timing, and route of administration) is cru- discharged to a rehabilitation facility in improved
cial. Nursing, occupational therapy, and physical ther- condition.
apy notes also may contain a wealth of information
about the patients behavior (Smith et al. 2005). As History
with all psychiatric consultations, talking with the pa-
tient and his or her family is the core of the process. A There is no more important aspect of the consulting
full psychiatric interview should be conducted when psychiatrists job than to gather the essential and com-
possible; however, medically ill patients may be too plete history from the patient, if possible. Ideally, the
physically uncomfortable or fatigued to tolerate a long psychiatric consultant will gather a full history of psy-
discussion. Expressing empathy for a patients physi- chiatric symptoms, including timing, severity, fre-
cal suffering can help to establish an alliance (Smith et quency, nature, precipitants, and any known relation-
al. 2005). The psychiatrist then makes a preliminary ship to current medical illness. The consultant should
diagnosis, which may be psychiatric, medical, or both, perform a psychiatric review of systems, asking ques-
recognizing that it may evolve with time. Direct com- tions regarding the affective, anxiety, and psychotic
munication to the team about the diagnosis and pro- realms. A substance abuse history can often be the
posed treatment is essential (Popkin et al. 1981). It is turning point of a confusing medical presentation, as
important to tailor recommendations based on the patients may be unwilling or unable to reveal their use.
teams specific needs (Shakin Kunkel and Thompson
1996). The final step is to write a complete, but suc- Case Example
cinct, note. Regular follow-up is essential to ensure An elderly woman was admitted for neurological
that the diagnostic and treatment plan is correctly in- evaluation. She was confused, disoriented, and dis-
stituted (Shakin Kunkel and Thompson 1996). Last, a inhibited. Her family reported that she never drank
wise psychiatric consultant knows the value of signing alcohol. The woman had been functioning well until
3 days before the admission, when she became agi-
off on the case (with communication to the team)
tated and confused. She reported taking no medica-
when the patient has stabilized and/or the consultations except for a Centrum at bedtime. Her daugh-
tion question has been answered completely. ter brought in two shopping bags of medications the
patient kept under her bed, which included several
empty bottles of Centrax (prazepam). The patients
Diagnostic Strategies encephalopathy resolved when she was started on a
regular dosage of a benzodiazepine, from which she
was slowly withdrawn over the following week.
One of the consultants most important goals is to
provide an accurate diagnosis for the change in the pa- Patients should be asked about current suicidal or
tients affect, behavior, or cognition. Because many homicidal ideation. No other person may have asked
medical conditions can have psychiatric presenta- such questions, fearing that the question will induce
tions, the consultants job will be to correlate or newly the thoughts. Patients may follow the dont ask, dont
identify these conditions in order that they be ad- tell philosophy about such thoughts, but they will
dressed and treated. talk about them if asked in the appropriate manner.
Information regarding past psychiatric history, such as
Case Example prior suicide attempts, hospitalizations, medication
trials, and current therapy, should be gathered. Close
A 23-year-old man was admitted to the surgery ser-
vice after a C7 spinal cord injury that resulted in near attention should be paid to the current medical ill-
quadriparesis and a complicated hospital course. ness, past medical history, home medications, and al-
When sedation was lifted, he was unusually quiet lergies. The consultant should obtain a detailed family
and social history, which may be particularly impor- tients cognitive functions (including attention, mem-
tant for those consultations that are focused on the ory, language, visuospatial, and executive functioning),
challenges of coping with medical illness. but it has limited sensitivity or specificity for a given di-
agnosis. Indications that the patient is A&O3 (alert
Examination and oriented to person, place, and time) should be held
A mental status examination is a detailed observation suspect until the consultant has talked with the pa-
tient. Confusion and disorientation may have a variety
of a patients behavior, speech, language, affect, and
of etiologies, but no accurate diagnosis can be made
cognition. Because this examination is hierarchical in
without knowing if the patient is or is not intact cog-
nature, it is important to perform it meticulously (Hy-
nitively.
man and Tesar 1994; Smith et al. 2005). Ideally, the
mental status examination would allow someone unfa- Laboratory Tests
miliar with the patient to pick him or her out of a group
of people. Sometimes this can be done quickly, creating Some diagnostic tests are particularly useful for the CL
an accurate snapshot description of the patient. psychiatrist; the specific tests ordered depend on the
concern(s). (Table 152 lists common laboratory tests
Case Example that may be useful during the course of a consultation.)
For example, for a patient with a sudden change in
A consultant receives the following page: You are mental status, life-threatening causes must be ruled
needed immediately on the inpatient internal medi-
out first (e.g., by a lumbar puncture for suspected men-
cine unit. Please dont delay. After alerting security,
the consultant finds a highly agitated young woman ingitis or a toxicology screen for a suspected overdose).
who is screaming, disoriented, and confused. She is A standard battery of tests used by the CL psychiatrist
trying to tear the electrocardiogram electrodes off her includes a complete blood count, a metabolic panel,
skin and the intravenous line out of her arm. It is im- and levels of thyroid-stimulating hormone, vitamin
possible to interview her. All that is known is that
B12, folate, and rapid plasma reagin. Specialized tests
the laboratory results indicate diabetic ketoacidosis.
After a small intramuscular dose of an antipsychotic (e.g., HIV serology, electrocardiogram, imaging study,
medication, the patient is calm enough for the med- electroencephalogram) may also be useful, depending
ical team to address her medical needs. When the pa- on the clinical situation. The consultant maintains the
tient again becomes agitated later in the day, the focus that the cause of the behavioral dyscontrol must
mental status examination provides a quick refer- be discovered, even if the behavior itself dissipates
ence point for checking her serum glucose and elec-
(Muskin et al. 1998). The psychiatrist may bring a
trolytes before administering more of the antipsy-
chotic. fresh eye to a complicated case, and tactful suggestions
regarding the diagnostic evaluation may expand the
The physical examination, which is not a typical differential diagnosis and change the medical course.
part of an outpatient psychiatrists examination, adds
important information. Attention to vital signs, cardiac
Imaging
abnormalities, gastrointestinal symptoms (e.g., stig- Imaging can be helpful to the differential diagnosis,
mata of liver disease), and other subtleties, aids im- although imaging alone does not typically confirm a
mensely in the diagnostic process. Knowledge of the diagnosis (Dougherty and Rauch 2004). There are
neurological exam and an ability to recognize focal neu- several imaging options that are easily accessible, effi-
rological deficits are essential (Smith et al. 2005). Per- cient, and useful. Computed tomography (CT) is an
haps the most important part of the physical exam is imaging method that provides rapid assessment of
testing for evidence of frontal lobe dysfunction, which anatomic structures. Although it does not provide high
may result in significant behavioral abnormalities. resolution of structural abnormalities, a CT scan
Tasks to elicit frontal lobe function include tests of mo- shows gross changes, such as the presence of an acute
tor sequencing (e.g., asking a patient to reproduce a se- hemorrhage stroke, subdural hematoma, or large mass
quence of hand gestures), language production (e.g., lesion. Magnetic resonance imaging (MRI) with angio-
asking the patient to name as many animals as possible graphy can provide high-level resolution of both paren-
in 1 minute), and abstraction (e.g., listing differences chymal and vascular structures. It is the imaging mo-
between an apple and an orange) (Smith et al. 2005). dality of choice for acute stroke (if a facility is available
The Mini-Mental State Examination (Folstein et al. in a timely fashion) as well as for the visualization of
1975) can provide an impression of the patients cog- subtle changes. Psychiatric syndromes that are most
nition. It is most useful as a concise scan of the pa- likely to produce abnormalities detected by MRI in-
Mini-Mental State Examination (Folstein et al. 1975)

TABLE 152. Common diagnostic tests in
but with more extensive and detailed questioning, and
psychiatric consultation the Trail Making Test Part B (Army Individual Test
Complete blood count Battery 1944), which assesses mental agility, execu-
tive decision making, and planning. These tests might
Chemistry panel
be most useful in documenting the degree of cognitive
Liver function tests
decline in a patient with subacute changes in mental
Thyroid-stimulating hormone (thyrotropin) status, such as with a dementing process. Projective
concentration testing, which can both detect the presence of under-
Vitamin B12 (cyanocobalamin) concentration lying psychiatric illness and provide a window into the
Folic acid (folate) concentration patients coping style, can be useful in certain settings.
Human chorionic gonadotropin (pregnancy) test
Serum and urine toxicology panel Case Example
Serological tests for syphilis A 75-year-old woman was referred for treatment of
Urinalysis dementia. She was depressed and psychotic, main-
taining that someone had entered her new home and
Antinuclear antibody stolen important papers. Her symptoms began after
HIV serology moving to an apartment following 50 years of living
Chest X ray in the same house. Neuropsychological tests revealed
superior intellectual functioning, depression, and
Electrocardiogram psychosis. Although the woman was reluctant to
Computed tomography scan take medication, after confrontation with her test re-
sults and her symptoms, she adhered to treatment
Magnetic resonance imaging scan
with an antidepressant and antipsychotic. Her symp-
Electroencephalography toms resolved over the next 2 months. When she was
Neuropsychological testing taken off medication 1 year later, fully recovered, she
was able to admit that she was out of my head.
Source. Adapted from Smith FA, Querques J, Levenson JL,
et al: Psychiatric Assessment and Consultation, in The
American Psychiatric Publishing Textbook of Psychoso- Consultation/Collaboration With
matic Medicine. Edited by Levenson JL. Washington, DC,
American Psychiatric Publishing, 2005, pp 314. Other Services
At times, the psychiatric consultant may suggest that
clude dementia, vasculitides, infectious processes, and
the primary care team request the expertise of other
mass lesions. Electroencephalography (EEG) is another
medical services. This may be particularly useful in
useful imaging modality. Findings are normal in pa-
clinical situations that lie on the interface of more
tients with depression, mania, and psychosis, but not
than one discipline. When multiple consultation ser-
in patients with delirium, dementia, and ongoing sei-
vices are involved, difficulties can sometimes arise,
zures. One limitation is that EEG may not detect deep
stemming from differences in the history, culture, and
brain activity (such as in the temporal region); thus, an
diagnostic strategies of the various disciplines (Caplan
absence of an abnormality does not necessarily mean
et al. 2008). A collaborative spirit and direct commu-
that electrical dysrhythmias are not present. Single
nication allow for effective teamwork. Even if there are
photon emission computed tomography (SPECT) and
disagreements, the psychiatric consultant should
positron emission tomography (PET) scans are not
avoid chart wars and the debasing of other services
available in every institution but offer an option to as-
recommendations.
sess abnormalities of metabolism in different areas of
the brain.
Principles of Treatment
Neuropsychological Testing
It can be useful to ask for neuropsychological testing
in certain clinical situations. These tests are divided
Biological Management
into two main categories: cognitive and projective. Ex- One of the most important decisions for the CL psy-
amples of cognitive tasks include the 100-point Mod- chiatrist is whether to start, continue, taper off, hold,
ified Mini Mental State (3MS) examination (Teng and or discontinue a patients psychotropic medication.
Chui 1987), which follows a similar format to the The first consideration is the certainty of the diagno-
sis. For example, what appears to be flat affect could issue. Psychodynamic, cognitive-behavioral, interper-
actually be apathy due to a frontal lobe lesion or the sonal, or systems-based approaches all have utility de-
masked facies that is a characteristic of Parkinson dis- pending on the patient, the problem, and the time
ease. At the same time, while the underlying cause is frame. Financial and social resources available to the
being determined, it is important to treat its conse- patient and physician are important considerations in
quent behaviors. For example, treating an agitated, de- determining what approach is practical (Miller 1973a,
lirious patient empirically with an antipsychotic has 1973b).
several benefits. The calming effect of the medication Medical illness and hospitalization is, by its nature,
increases the ability of the patient to cooperate with a regressive experience. Illness places the individual in
the evaluation, and it may shorten the length of the a situation of dependency, which replicates the devel-
hospital stay by permitting a more rapid diagnostic opmental stresses of childhood (Strain and Grossman
and therapeutic process. 1975). Regression to less reality-based and adaptive
The selection of an optimal medication for the coping is to be expected (Field 1979; M.A. Groves and
medically ill patient is an important, though compli- Muskin 2005). The defensive structure prior to medi-
cated, task. The pharmacokinetics of the medication cal illness is the starting point for each patient; the
needs to be carefully considered, including its absorp- lower this point, the more primitive the defensive
tion, distribution, metabolism, and excretion, any of structure to which the patient may regress (Muskin
which may be abnormal in a patient with physical ill- 1995). Simultaneously, patients react to this regres-
ness (Querques and Stern 2004). For example, a pa- sion and attempt to return to their baseline level of
tient with end-stage cirrhosis may have increased side function and control. These attempts are frequently
effects from medications that are extensively metabo- the reason for psychiatric consultation (Muskin 1995).
lized by the liver, and adjustments in dose and/or the A particular challenge for the CL psychiatrist is caring
choice of an alternative agent may be necessary. Drug for the difficult patient, who can elicit strong coun-
drug interactions are important to consider, as medi- tertransference reactions from staff (J.E. Groves 1975,
cally ill patients are often on a long list of medications 1978; Mozian and Muskin 2008). How productively
(Querques and Stern 2004). For example, linezolid, a the patientpsychiatrist dyad utilizes both the regres-
systemic antibiotic that has weak monoamine oxi- sion and its reaction determines the outcome of the
daseinhibiting properties, can potentially interact consultation (Rosnick 1987).
with serotonergic agents (Lavery et al. 2001). In these
cases, it can be useful to review cytochrome enzyme PSYCHODYNAMIC STRESSORS
substrates and catalysts to determine whether poten-
As Strain and Grossman (1975) noted, The vast ma-
tial interactions could be averted (Cozza et al. 2003).
jority of patients are able to cope and to assume the
Psychotropic medications also can produce deleterious
role of the patient without difficulty, and this is ex-
effects in medically ill patients. For example, multiple
traordinary in itself when one considers the magni-
psychotropic and systemic medications (each of which
tude of these stresses. According to these authors,
can impact repolarization of the myocardium) can
there are seven categories of psychodynamic stress
prolong the QT interval and make the patient vulner-
faced by the hospitalized patient (Strain and Gross-
able to arrhythmia (Glassman and Bigger 2001).
man 1975).
Psychological Management
1. Threat to narcissistic integrity. Medical illness
A CL psychiatrist utilizes a biopsychosocial approach poses a direct threat to healthy narcissism, which
to understanding a patients problem and formulating is an integral part of human functioning. To func-
the treatment. Understanding the coping skills avail- tion effectively in the world, an individual must be
able to patients when they are medically ill provides a able to trust in basic principles of bodily integrity
framework for many of the interventions in the hospi- and self-sufficiency. Medical illness, with its inher-
tal (M. A. Groves and Muskin 2005). Two consider- ent uncertainty, indignity, and lack of control, un-
ations that factor into whether or not a consultation dermines this healthy defense. Physicians may
will be requested are what the patient thinks about his then become the object of a patients frustration
or her illness and how the patient behaves in accor- that the infantile fantasy of omnipotent parents
dance with those health beliefs. How the psychiatrist (who will ensure the childs pleasurable and pro-
chooses to help a patient handle a problem will be tected existence) will not be met, which may man-
based on what works most efficiently for the particular ifest as disruptive behavior (Muskin 1995).
2. Fear of strangers. Hospitalized patients, by neces- compromised by severe physical illness, altered
sity, put their well-being in the hands of relative mental status, or medical conditions or treatments
strangers. Highly intimate processes (e.g., veni- that directly affect the central nervous system
puncture, nasogastric tube feeding, urine collec- (Muskin 1995).
tion, pelvic examination) occur commonly. The 6. Fear of loss or injury to body parts. Loss of integrity
daily changes in nursing staff and the multitude of of bodily function may promote deep-seated anxi-
relative strangers who conduct business in the pa- eties surrounding mutilation or castration. Many
tients room may add to this disquieting experi- early childhood memories are somatic; to feel safe,
ence. This situation can be a particular challenge an infant needs to have his or her bodily needs met
for patients whose psychiatric illness leads to a dif- (to be fed, held, and soothed). In later developmen-
ficulty in trusting others, whether due to paranoia tal stages, feelings of potency emerge when the
or personality disorders (e.g., borderline personal- young child can master some of his or her own
ity disorder) (Muskin 2001). In addition, patients physical universe (Muskin 1995). Medical illness,
with trauma histories (especially sexual or physical with its many manifestations of physical vulnera-
abuse) may be fearful of harm from others whose bility and potential loss of power, may result in pro-
intent is benign. Staff continuity, discretion, and found anxiety about having basic safety needs ad-
explicit explanations of procedures can be helpful dressed (Muskin 1995).
measures for the consultant to suggest in these sit- 7. Reactivation of feelings of guilt and shame and ac-
uations. companying fears of retaliation for previous trans-
3. Separation anxiety. Psychological health does not gressions. It may be inevitable that at some point a
occur in a vacuum but in a series of overlapping patient wonders why he or she has become ill.
spheres of family, community, and environment. Some patients, such as the lifelong smoker who de-
When patients are hospitalized, they are separated velops lung cancer, may feel guilt about perceived
from what is familiar and comfortable in their daily transgressions (Muskin 1995). Others might fear
lives. The noise, lights, disruptions, and lack of pri- they are being punished by an outside force. For yet
vacy of the hospital can be deeply unsettling. This others, the connection may be less clear, but the
situation is particularly problematic for patients feelings of guilt remain.
who need to rely on routine in order to function,
such as patients with dementing illnesses (Muskin PATIENT COPING STYLES
1995).
Just as regression is an inherent part of hospitalization
4. Fear of loss of love and approval. Many of the
and medical illness, so are attempts to cope with these
stresses that accompany physical illness, such as
challenges. Each patient has a particular manner (or
loss of a part of ones physical self (e.g., mastec-
character style) in which he or she addresses an ill-
tomy), may elicit fear of loss of love and approval. A
ness. Several schemas have been developed that de-
patient whose hospital course is complicated may
scribe basic coping mechanisms common to most pa-
subconsciously feel that he or she has failed the
tients (Groves and Muskin 2005). One framework,
doctor by not being a good patient who gets well
suggested by Kahana and Bibring (1964), is strongly
with treatment. In contrast, a patient who had dis-
recommended reading for the psychiatric consultant.
appointing caregivers in the past may be more
In this schema, personality categories (including de-
likely to express ongoing discontent, which is then
pendent, obsessive, histrionic, masochistic, paranoid,
externalized to the physician (Ciechanowski et al.
narcissistic, and schizoid) are described, with predic-
2001).
tions as to how patients in each category might cope
5. Fear of loss of control of developmentally achieved
with medical illness.
functions. One of the most fundamental premises
of childhood development is mastery over develop-
mental tasks, such as the ability to urinate, regu-
Case Example
late ones bowels, change clothing, and clean one- A 56-year-old accountant is hospitalized for surgery
self. Physical illness can threaten a persons ability for colon cancer. Consultation is requested when the
to perform these functions, and unresolved con- patient is reported to be asking incessant questions
about his situation. Upon interview, the patient,
flicts stemming from these functions can also flare
who has a laptop next to him, states that he has read
under duress (Muskin 1995). The ability to regu- virtually everything about his illness on the Internet
late more primitive emotions, such as rage, may be but still feels he does not know enough about what
will happen to him in the hospital. The consultant ioral interventions or in safe, time-limited, effective,
recognizes the obsessive nature of this patients cop- and approved restraint techniques, the consultant will
ing style and recommends that staff provide prag-
aim to educate them on the use of the least restrictive
matic and straightforward information to the patient
and allow him to participate actively in treatment method to manage behavior safely.
planning.
Case Example
Although published descriptions of coping mecha-
A 59-year-old woman with cirrhosis is admitted to
nisms provide a useful guide for the CL psychiatrist,
the medical service with hepatic encephalopathy.
each person is unique. At times, a patients coping Over the course of the evening, she becomes highly
style can take on pathological features. In such cases, agitated. She is found screaming incoherently and
the consultant should aim not to overemphasize a par- running down the hospital corridor. The overnight
ticular diagnosis (Geringer and Stern 1986) but medical intern requests physical restraint after med-
rather to assess how each persons internal resources ication has demonstrated little effect. The on-call
psychiatrist, noting that the restraint is increasing
can be mobilized most effectively.
the patients agitation, recommends a full-time sit-
ter instead, resulting in immediate improvement in
PHYSICIAN COPING STYLES her symptoms.
Each physician, like each patient, has a unique coping
style (Muskin 1995). Physicians bring their own Social Interventions
strengths, weaknesses, and challenges to the medical
CL psychiatrists commonly interact with the many
settinga circumstance perhaps best exemplified by
people who surround the patient, such as family, part-
Gabbards (1985) profile of the compulsive, overly re-
ners, and friends. The highly charged countertransfer-
sponsible physician plagued by guilt and doubt. As
ence responses some patients evoke in staff may re-
physicians traverse the highly intensive training pro-
quire the psychiatrist to intervene with hospital staff
cesswhich entails sleep deprivation, continually
(J. E. Groves 1978). Knowledge of group processes,
shifting priorities, constant work, and disconnection
such as splitting, scapegoating, and triangulating, can
from family and friendsthey rely on their own defen-
be essential to effective management. CL psychiatrists
sive structures to negotiate these stressors (Lurie et al.
may often find themselves holding the affect of the
1989; Muskin 1995). The CL psychiatrist can provide
unit, so that they can appropriately metabolize it in a
insight into the dyadic nature of the doctorpatient re-
way that patients stay safe and continue to get the care
lationship and help his or her physician colleagues to
they need. The psychiatrist also can serve to bridge
understand how the process of countertransference
communication gaps among family members and the
can either augment or detract from patient care
patient. In addition, the CL psychiatrist can provide
(Muskin 1995).
expertise in managing situations laden with intense
Behavioral and Safety Interventions affect, such as complicated end-of-life issues or pain
management for patients with substance dependence.
A CL psychiatrist is often asked to help manage the pa-
tient whose behavior is disruptive to a hospital unit.
For example, a behavioral plan may benefit the patient Future Challenges for
who repeatedly leaves the floor (possibly to use illicit
substances), does not cooperate with recommenda-
Psychosomatic Medicine
tions, or acts in ways that violate the hospitals cultural
norms (such as by participating in sexual activity in the Psychosomatic medicine faces several important chal-
hospital bathroom). At times, the CL psychiatrist may lenges in the future. One of these challenges involves
need to intervene actively to maintain the safety of the the artificial separation of the fields of psychiatry and
patient and unit employees. Patients whose behavioral medicine. Psychiatric conditions are an inherent part
dysregulation results in imminent risk of harm to self of medical illness, and vice versa. Patients are differen-
or others may require a stepwise series of interven- tially vulnerable to psychiatric disorders based on a
tions, which may include verbal redirection, use of an- complicated interplay of genetic, environmental, and
tipsychotic and/or sedative medications, enlistment of other factors that have yet to be elucidated. Because
security staff, and/or physical restraint (if all behavioral many psychiatric disorders do not yet have clearly de-
interventions have failed). Because many physicians fined pathophysiology, some physicians may discount
have received little or no training in the use of behav- the importance of the CL psychiatrist in the care of the
patient. The attitude that Its all in the patients services are in the process of strengthening their finan-
head can be a demeaning and devaluing view of the cial capabilities, by such means as streamlining infor-
patient and of the psychiatric consultant. mation systems, administrative processes, and billing
A second challenge is the need for increased re- functions (Hall et al. 1996; Schuster 1992). Insurers
source allocation for CL psychiatrists in general hos- who carve out behavioral health services in an effort to
pitals. In 2004, approximately 24% of all adult admis- save money actually increase the ultimate health care
sions in community hospitals involved affective, expenditures for patients in need of integrated care
psychotic, or other mental health or substance use (Kathol et al. 2006). The need for integrated medical
related disorders; an even higher percentage occurred and psychiatric services emerges as a crucial challenge
among uninsured patients (Owens et al. 2007). Al- to be overcome in order to provide patients with the
most 10 times as many patients with mental health or best possible care.
substance abuse disorders were seen in community
hospitals as in psychiatric facilities (Owens et al.
2007). Psychiatric comorbidity results in worse medi-
Conclusion
cal outcomes, longer hospital stays, and increased
hospital and aftercare costs (Francis and Kapoor 1992; The focus of a CL psychiatrists expertise is on the
Katon 1996; Koenig and Kuchibhatla 1998; Levenson evaluation and management of the affective, behav-
et al. 1990; Saravay and Lavin 1994; Saravay et al. ioral, and cognitive aspects of patients who are experi-
1991). At the same time, psychiatric interventions on encing medical illness. Practitioners of psychosomatic
medical services have been shown to decrease the medicine have an overarching view of the complex in-
length of hospital stays and increase the likelihood of terplay of medical and psychiatric diseases from both a
returning home (Levitan and Kornfeld 1981; Strain et psychopharmacological and psychodynamic perspec-
al. 1991). The current system is extremely underre- tive. Their work is by nature multidisciplinary, inter-
sourced. Suggested solutions have included a rein- active, and collaborative. The theory, research, and
statement of federal funding for clinical fellowships in practice of psychosomatic medicine and CL psychiatry
CL psychiatry to increase the number of highly trained continue to evolve. Psychosomatic medicine, in its
practitioners of psychosomatic medicine, and better modern form, is well positioned to lead clinical, re-
training in psychiatric principles for nonpsychiatric search, and educational efforts in medical psychiatric
physicians. Access to psychiatric care is quite limited practice.
for many patients with medical illness in the outpa-
tient setting, as is access to medical care for psychiat-
ric outpatients (Kathol et al. 2006). References
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1997 2845, 2002
Part II
SPECIAL
CLINICAL ISSUES
CHAPTER 16
FROM WITHIN
A Consumer Perspective
on Psychiatric Hospitals
Lisa J. Halpern, M.P.P.

Howard D. Trachtman, B.S., C.P.S.
Kenneth S. Duckworth, M.D.
The Hospital on the Hill My doctor s suggestion to use the hospital

came across as just thata suggestion or recommen-
Lisa, I think its time to take you down to the unit, dation of action, rather than a declaration, which I
was how the psychiatrist I had been seeing as an out- likely would have resisted because of my lack of trust
patient for about 3 months suggested it was time to in psychiatric systems. I reasoned that my hospital-
try hospitalization. The catalyst was my story of be- ization was merely the next hurdle my doctor and I
ing in a local subway station with a date and feeling must jump over together to get to a future place that
frozen by fear. I had started weeping but had sucked we both saw as worth fighting to reach. The notion of
in my sobs to try to avoid embarrassment. I kept using the hospital as a tool means viewing hospi-
closing my eyes because the lights were flashing too talization as a point along a circular continuum of
brightly and covering my ears to shut out the squeal- care, not a nadir of failure like the low rung on a lad-
ing noise of antiquated trainstrains that I was con- der. The concept of vertical versus circular care al-
vinced had been transported back to 1940s-era Nazi lowed me to accept the use of hospitalization when
Germany and were going to the concentration needed as an integral part of treatment.
camps. I knew that if I got on a red-line train I was My first hospitalization, on the short-term unit
going to die. Greengo. RedStop! Blood! Die! (STU) at a private psychiatric hospital, began with a
Over and over again in my head: RedDie! Die! Die! strip searcha rather frightening introduction, com-
237
ing with no explanation of what, for example, the ders unit at the same private hospital within a couple
searcher was looking for, and thus exacerbating my of months. I believe this revolving-door effect oc-
paranoia. My outpatient psychiatrist was separated curred because at the STU I concentrated what de-
from me when I became an inpatient, and there was pleted brain power I had left on getting out of the hos-
no time to get to know the doctor assigned to me in pital at any cost, rather than learning how to live a
the STU. What I did learn of him I didnt like. This recovered life outside the hospital. I didnt take the
new doctor had a very combative, aggressive, curt hospitalization seriously but saw it as a bunch of
stylehe scared me (not a tough task considering hoops to jump through, starting with entry and tri-
that I believed many people, including my landlord umphing with exit. I left the hospital with a medica-
and former classmates, wanted me dead and were action whose severe side effects I wasnt ready for.
tively working to complete that end). When he came During my admittance to the STU, I was so sick
by for rounds, he chided me for not answering his that I believed my family wanted ill for me. I only
questions promptly and wondered out loud if my contacted my parents in California (who took the
reticence was because I was biting my tongue until red-eye immediately to be by my side, meet my doc-
it bleeds. Then he declared, I have no time for peo- tors, and offer assistance) when hospital employees
ple like you and left the room. I was so perplexed threatened to contact my parents to tell them that I
and offended by this doctor, I was even further frozen was in the hospital. I also figured my discharge
into silence and determined (although not quite sure would come sooner if I could show a good family re-
how to go about it) to leave the STU quickly no mat- lationship. Although I didnt trust her and didnt
ter what I had to do, or say, to get out. want any human (physical) contact, I assumed staff
Once leaving the STU became my goal, I began would be watching my reaction, so I gave my mom a
to learn a bit about the privilege system that deter- big hug when she arrived. By the time of my second
mines where one walks, how often one goes outside, hospitalization, my family had become an integral,
and with what frequency one is checked on. The sum omnipresent, positive support in my life and with
total of all these items sort of equaled how quickly my illness. During my admittance to the psychotic
one was discharged, or at least this was how it ap- disorders unit, my mom was with me the entire
peared to me. No clear explanation was available for timethere was no strip search or mention of one
me to follow, so I tried to figure it out on my own. For and my goal was to get better, not just get out.
example, if you want to get higher privileges on a This time when I was admitted as an inpatient,
scale of 1 through 4, you had to go to groups, make steps were taken to see that my outpatient, regular
an effort to speak up in groups, and make eye contact psychiatrist would remain part of my inpatient team
with staff and other patients at groups. This under- via consultation and daily visits. I dont know
taking can be incredibly difficult, and I remained a 2 whether it was his influence, a difference in approach
w/no s/f (Level 2, not allowed sharps or flames) for because it was a longer-term unit, because the doc-
days not because I was violent or uncooperative but tors on staff were more understanding, or other in-
because I didnt understand, and no one told me, fluences coming together that made the difference,
that one of the main ways to get an increase in priv- but this time I was a member of the team and was in-
ileges was to attend groups. cluded in discussions about my treatment. I remem-
Beyond group attendance, the primary way to go ber sitting in a circle and listening to the lead doctor
about increasing hospital inpatient privileges seemed say, Clozaril is not an easy medicine to take, but
to be to ask the psychiatrist in charge to change nothing in your lifes path has shown us that you
them. Looking normal seemed to help too. When I choose to take the easy way out, ever. I signed the
was first hospitalized I would wrap towels around my papers to begin Clozaril that day and left the hospital
head to try to stop the voices from attacking my soon after.
brain. To me, placing towels over my head was a A key factor in why my second hospitalization
harmless way to try to dull the painful thoughts I was stuck whereas the first made me a repeat visitor
hearing, and my outpatient psychiatrist allowed me is the amount of time doctors spent listening to me
to place towels over my head for sessions so I could and trying to determine the difference between nat-
endure visits with him. However, what my private ural personality and interwoven illness. This is no
psychiatrist had tolerated (I would much rather see small feat when there is an inherent lack of trust.
you in session and have you here even if you want to How does one (the doctor) gain the trust of one (the
cover your eyesat least youre here!), hospital patient) who does not trust? My answer? Time and
nurses and mental health workers would not. The effort. The doctor or provider needs to put in the
staff made it clear, without telling me why, that until time listening to another persons story and find
the towels came off I would not progress toward my ways to communicate around the obstacles inherent
goal of climbing the privilege-level ladder and getting in a brain disorder that scrambles communication,
out of the hospital. such as schizophrenia.
Once I figured it outmake eye contact with ev- In my opinion, my two hospitalizations shared
eryone (no matter how that affects you), go to groups, certain positive qualitiesshort stay, goal oriented,
talk at groups (Say anything! Just talk!), and lose the clear understanding of purpose, long-term impact
turban lookI got out of the STU in a couple of days, (no repeat visits since then). My first hospitalization
but found myself rehospitalized in a psychotic disor- centered upon the goal of getting meunmedicated
From Within 239
at the timeto take some type of psychotropic med- scribed Thorazine, I was told little about my condi-
ication at a therapeutic level on a regular basis. My tion. I was not given a diagnosis, received little
second hospitalization focused on taking me off the therapy, and was not told the importance of remain-
medications I was on and starting me on Clozaril. ing on medication. I spent most of the time reading
Using the hospital when needed, as one of many and watching television and very little time speaking
options available within the comprehensive system to mental health workers, nurses, or doctors.
of psychiatric care, made it possible for me to move I returned to Boston shortly after my nineteenth
forward and focus on living a full life in recovery. birthday, and soon I was again up all night. I actually
Lisa J. Halpern called 911, and the police brought me to an emer-
gency department. I was placed in four-point re-
straints and told I was being sent to a private hospital.
My Experience With I felt betrayed when the ambulance brought me to a
Psychiatric Hospitals state hospital. I was assigned a psychiatrist who wore
black boots. Coupled with her power over me at the
Prior to my multiple admissions to psychiatric hos- hospital, at times I was convinced she was a Nazi.
pitals, I knew very little about mental health, psychi- I ended up spending 9 months on the admissions
atric treatment, and what happens in a hospital. My unit, a coed floor with three large dormitory-style
knowledge was based on what I had seen on tele- rooms. Every so often as the malefemale balance
vision and in movies such as One Flew Over the changed, we would be moved from one room to an-
Cuckoos Nest. As a young person, I recall being told other. There were only two groups a week: privilege
that a friend of mine had jumped into Niagara Falls, group and group therapy. Initially patients were re-
ending his life. This was triggered by a breakup with stricted to the unit, but once a week in the privilege
his girlfriend. At the time I couldnt understand why group, you could ask for the next level of freedom. It
a person would want to end his life. Now I know. took quite a while for me to move up the privilege
I have been interested in computers all my life ladder because I was never told how a person gradu-
and knew that Massachusetts Institute of Technol- ated to the next level. Several months elapsed before
ogy (MIT) was the best place for me to learn artificial I reached the first level, a staff pass that would, for
intelligence and build robots. I became a freshman at example, enable me to be on the grounds accompa-
MIT right after my sixteenth birthday in 1983. One nied by a staff person. The next level, a mutual pass,
of my professors told me about visiting an MIT stu- allowed one patient to take another patient out on
dent who was catatonic in a psychiatric unit. I didnt the grounds. The third level was being allowed on
think I would ever be a patient myself. the grounds by oneself. The final level was being al-
One day during my freshman year, a friend left a lowed off the grounds. My first time with a mutual
20-page suicide note in my room. Bewildered, I was privilege level, I went with another patient who dis-
advised to see an MIT psychiatrist to get this person appeared on me. When I returned to the unit, I was
help. The psychiatrist thought I also needed help, informed I had lost all my privileges and would have
but I dont recall receiving a diagnosis or any medi- to start over. This was a major setback to me.
cation being suggested. I do remember being told Group therapy met for 1 hour a week. The staff
that if matters got worse I should go to a particular must have liked me, because after a few months I
private hospital. was given my own therapist for an extra hour a week,
Just before my eighteenth birthday, I was up all which I found very helpful. Otherwise, most of my
night at the MIT Artificial Intelligence Laboratory. I time was wasted playing games and watching televi-
became convinced that artificially intelligent com- sion. I really hated not having constructive activities
puters were taking over the world and that I needed and learning skills to keep me out of the hospital.
to flee to my parents in Buffalo. While waiting to Life on the unit was traumatic. One patient kept
change planes, I started thinking that some planes trying to persuade me to have sexual relations with
were going to heaven and others were going to hell. I him. One night the staff announced he had hanged
knew I needed to read the Bible. Because I was acting himself on the grounds. Another time, while I was in
strangely, the police brought me to a crisis center. bed, a patient assaulted me.
When the doctor asked me if I heard voices, I an- There was a hallway of quiet/seclusion rooms
swered yes because I thought I was just being asked where the difficult patients would be placed, some
if I could hear people talking. As a result I was placed spending most of their time in those rooms. The orig-
in four-point leather restraints and injected with inal idea was that people wouldnt be exposed to too
Haldol. much stimulation while in these rooms, but to me it
My parents flew up in the morning, and I was dis- seemed like punishment, just like being in restraints
charged to their custody. We flew home, but I was still felt like torture. When I would be sequestered I would
in crisis and immediately walked out of the house, frequently push the door open to get fresh air, only to
barefoot, looking for a Bible. My parents initially had have the door pushed back and lockedlocked-door
difficulty having me admitted to a hospital, but once seclusion. Once a week I would be asked to sign the
they mentioned that I thought I was Jesus Christ, I required paperwork for being secluded.
was admitted to a short-term unit in a private hospi- It was never explained to me that if I didnt open
tal. Although I spent several weeks there and was pre- the door they would not have locked it and I would
have been let out much sooner. Now some state hos- sential in my recovery. Although I learned much
pitals have consumers whose job it is to debrief all from my peers, actually doing advocacy work was a
instances of restraint and seclusion and work to pre- tremendous boost. I was mentored by many people
vent future episodes. I wish that had existed back and discovered I had something to offer by helping
then. I also wonder why, when I was my sickest dur- other people both individually and systemically.
ing those 9 months in the state hospital, restraints After those 6 quality years on clozapine, I exper-
were never used, but later, in several private hospi- imented with functioning without medication, but
tals, I was frequently put into restraints. Only once soon required additional hospitalizations. Seven
in the state hospital was I given an injection to calm years ago I resumed clozapine as part of a cocktail of
down. Several friends of mine have stated they re- various medications. My outpatient psychiatrist ta-
ceived better care in state hospitals than in private pered me off the additional medications, and I have
facilities. remained out of the hospital since then. In 2005 I co-
One lesson I learned at the state hospital was founded the Boston Resource Center, a consumer-
what I now know is called learned helplessness. run program that connects people with support, in-
When I realized I needed dental care, I went to the formation and referral, and vocational opportunities.
hospital dental office, made an appointment, and Last year I completed a training program for peer spe-
kept it. When I returned to my unit following the ap- cialists and passed my written and oral examina-
pointment, the staff was angry that I did this on my tions to become a certified peer specialist.
own. Howard D. Trachtman
I formed friendships with some of the people on
the unit. We would play games or go for walks to-
gether on the campus. Most Fridays we played bingo. Nothing About Us Without Us
I was popular and was elected president of the unit,
which perhaps foreshadowed my future role as a
leader of the consumer empowerment movement. I Psychiatric hospitals serve a crucial role in the lives of
organized a car wash at the hospital to raise money individuals with psychiatric crises; yet until recently
for a pizza party.
One day my parents came to take me out on a
these specialized hospitals rarely involved their pa-
pass. I became very anxious, acted out, and feared I tients experience and feedback in conceptualizing, de-
would lose my opportunity to be with them. How- signing, or improving care. Goal 2 of the Presidents
ever, the doctor gave me some Ativan and allowed me New Freedom Commission on Mental Health (2003)
to go off the grounds with them. Her understanding defines an exemplary mental health system as one in
touched me and enhanced my respect for her.
which input and participation from consumers (those
A few months into my state hospitalization, I
was told I was being considered for discharge and who use the mental health system) and family mem-
would move into an adolescent group home. How- bers inform clinical care at all levels of the mental
ever, a fellow patient convinced me that my medica- health service system, including psychiatric hospital
tions were bad for me, and I experimented with units. As the culture of welcoming consumer input,
tonguing (pretending to take them and then throw- evaluation, and design of services continues to take
ing them out). This set my treatment back several
months. On the day of my discharge I was taken to
hold, material progress can be made toward the com-
the Social Security office to apply for disability bene- missions vision.
fits; soon after, I was required to apply for welfare and
Medicaid. The message I received was that I was pro-
foundly disabled and would never be able to work. I Whats in a Name?
also met my new therapist, whom I kept continu-
ously for more than 18 years. I developed a solid rap-
port with him and can only say good things about Psychiatric hospitals have unique power dynamics.
not having to continually look for a new therapist. The power differential between the people holding the
After discharge, even as I became medication keys, issuing orders, and deciding on passes and priv-
compliant, I continued to require hospitalizations, ileges and the people in a locked ward who may be
all of which were in private facilities. Although I was
there against their will is a structural fact of inpatient
able to maintain a relationship for several years, my
housing situation changed a few times, and I felt like psychiatric care, and language can reflect this differen-
ending my life. I went to be evaluated and told the tial. Even words like patient or chronic, which can be
doctor I wanted to kill myself. She noted I didnt have benign to doctors, may be quite charged for people re-
any previous attempts and sent me home. I took a ceiving psychiatric services who connect being a
major overdose later that night. chronic mental patient with very low status or
Eventually, after several hospitalizations, I was
prescribed clozapine and required no further hospi-
minimal prospects for improvement.
talizations for 6 years. I also discovered the con- The way we speak about people can reflect the be-
sumer empowerment movement, which became es- liefs we have about them on many levels. Referring to
From Within 241
people with disabilities by the name of the disability cient care. Consumers understandably feel safer with
for example, a schizophrenic, a paraplegicimplies guarantees of basic rights and processes to ensure
that the disability is their defining characteristic. One them.
remedy for defining people by their illness is the use of In 1997 Massachusetts consumer advocates cele-
the less limiting person first languagefor example, brated the Act to Protect Five Fundamental Rights for
a person living with schizophrenia or someone with all persons receiving services from programs or facili-
paraplegia. Accepting that people may call themselves ties operated by, licensed by, or contracted with the
consumers or peers (our terms for this chapter), resi- Massachusetts Department of Mental Health. The
dents (of a living situation), members (of a clubhouse), guaranteed rights include reasonable access to a tele-
survivors (of perceived abuse in the system), or even phone to make and receive confidential calls; the right
prosumers (consumers who work professionally in the to send and receive sealed, unopened, uncensored
system) gives a glimpse into the varying ways people mail; the right to receive visitors of ones own choos-
think about their relationship to the work of recovery ing daily and in private, at reasonable times; the right
and to the care system. Hope and dignity are key ele- to a humane environment, including living space that
ments of recovery, and language needs to reflect that ensures privacy and security in resting, sleeping,
spirit. dressing, bathing and personal hygiene, reading, writ-
Prior to a few years ago, when the philosophy and ing, and in toileting; and the right to access legal rep-
ideology of recovery began to weave its way through- resentation (Massachusetts General Laws, Chapter
out the mental health paradigm, consumers were left 123, Section 23). However, penalties for violating the
to attempt to foster ideas of hope and well-being and law were not specified, and many consumers report vi-
recovery in a mental health system that viewed seri- olations of these basic rights (Rice 2007).
ous psychiatric disorders as harbingers of doom (Cor- After a 1998 Hartford Courant investigative series
rigan and Ralph 2005). Pessimistic views of the course (Weiss et al. 1998) exposed the large number of deaths
of the conditions in psychiatry, coupled with societal nationwide resulting from the misuse of restraint and
prejudice and language, have historically added to the seclusion, consumer advocates and policy makers
burden of having a major mental illness. Unlike a combined their efforts to reduce the use of these treat-
shortened length of stay or a crisis in access to inpa- ment modalities. Although people vary in their de-
tients beds, language is fully under the control of those scriptions of their experiences, a range of difficult ex-
who use it. periences, including torture, are described in a
Human rights is an all-encompassing category that National Alliance on Mental Illness (NAMI; 2000) re-
incorporates basic human rights within the hospital, port entitled Cries of Anguish. Even patients and staff
efforts to minimize restraint and seclusion use, efforts who witness restraint and seclusion can themselves
to provide access to outdoors to inpatients, and efforts become traumatized, especially patients who already
made to make a psychiatric hospital con sumer have a trauma history.
friendly and treatment focused. Consumers who find As in other areas, consumers are at the forefront in
themselves in psychiatric hospital environments are working to reduce, and even eliminate, restraint and
at a vulnerable point in their lives, and service design seclusion for inpatients. NAMIs Consumer Council
and delivery need to be mindful of this. Although clin- created a Restraint and Seclusion Committee, and
ical and human needs are usually met in a healthy and consumers are active in each states Protection and
dignified environment and lives are saved, the Civil Advocacy for Individuals with Mental Illness Advisory
Rights Division of the U.S. Department of Justice, Council, mandated by federal statute to address abuse
pursuant to the Civil Rights of Institutionalized Per- and neglect as a top priority. Gayle Bluebird, a con-
sons Act, has recounted horrors of care in their state sumer who is a registered nurse, has championed the
psychiatric hospital investigations in multiple states. conversion of seclusion rooms into comfort or quiet
Breakdowns of safety systems, excessive use of re- rooms that function as sanctuaries where patients ea-
straint and seclusion (e.g., as punishment), abuse, in- gerly choose to go to take a break from unit activities
adequate medical care, and poor environmental con- (Bluebird 2005). With extensive occupational therapy
ditions are am ong the mo st co mmon concer ns input, hospitals in many states have designed similar
mentioned in their annual reports. Failures of leader- consumer-friendly spaces to help people calm them-
ship and funding, variables that are out of the control selves (Champagne 2006).
of consumers, are key elements in the difference be- Access to outdoor space, a right taken for granted in
tween respectful and compassionate or grossly defi- most correctional settings, is a recent addition to basic
human rights for inpatients of psychiatric hospitals. controlled entities (organizations whose boards of di-
Consumers who are denied access to the outdoors re- rectors consist of a minimum of 51% consumers and
port feeling demoralized and contained, which can re- whose employees are primarily people in recovery
sult in an increase in symptoms, leading in turn to an from mental illness and/or addictions) have formed to
increased length of stay. Because some hospitals have monitor and improve the quality of psychiatric ser-
allowed only smokers the privilege of going outside, vices. The organizations, frequently called Consumer
some individuals have tragically started smoking Satisfaction Teams, are able to be effective by utilizing
while an inpatient because it is the only means for consumers across the full spectrum of roles: as inter-
them to achieve outdoor access (Mello 2007). Con- viewers, researchers, report writers, and executive di-
sumers feel that fresh air is good for the body and soul, rectors. The first such team in the United States was
decreasing depression, stifling aggressiveness, and ul- created by consumers and family members in Phila-
timately leading to better therapeutic results. delphia, Pennsylvania, in response to the closure of
Making hospitals more consumer friendly can also the state-run psychiatric hospital in 1990. They, as
improve outcomes. Some suggestions are as simple as well as advocates and the city of Philadelphia, wanted
having a quiet space for being interviewed at intake. to ensure that not only the needs but also the prefer-
The distress of another patient nearby may be easier ences of people discharged from the hospital be con-
for the professional to tune out than the consumer. sidered in the design and delivery of community ser-
Also, having a distraught, disoriented person tell his or vices (Pearson et al. 2003).
her story multiple times to multiple people and com- In Massachusetts, consumer advocates also
plete reams of paperwork upon entry is counterpro- wanted a greater role in improving the quality of public
ductive. Although printed information is helpful, hav- mental health services. In 1998, the state Division of
ing a peer orally and visually orient a person to the Medical Assistance created a financial performance
unit and its rules is far more effective in reducing incentive for the state managed care carve-out organi-
stress. Psychiatric hospitals might even emulate some zation to implement a Consumer Satisfaction Team
practices of general hospitals that strive to attract pa- process. The new consumer-run organization (now
tients who have a choice about where to go by such called Consumer Quality Initiatives) quickly part-
small gestures as offering toiletries or care packages to nered with other organizations to further strengthen
those arriving without luggage or having snacks avail- the consumer voice in the quality of mental health ser-
able between meals. vices in the state (www.cqi-mass.org).
Most importantly, because hospital care is treat- By having consumers interview other consumers
ment focused, it is essential to involve patients in their face to face with a qualitative and quantitative instru-
treatment planning. Forming a treatment alliance ment, valuable and unique data can be collected; re-
with shared decision making, while treating patients spondents can and do reveal information that they
with respect and courtesy, helps demonstrate that the would not share with a nonconsumer staff person or
individual has value. Such valuation should continue on a sterile survey instrument. Because consumers are
through supportive outpatient/transitional care plan- the most important stakeholders in hospital quality,
ning to confirm that the hospital has optimism for the consumer researchers are best able to identify areas for
patients future. improvement and advocate for the system transforma-
tion that needs to occur. More recently, organizations
that started as satisfaction teams have grown to utilize
Consumer Evaluation Community-Based Participatory Action Research, de-
of Hospital Services liver white papers on quality improvement, and work
on service planning and needs assessment.
Consumers of psychiatric services deserve and desire

high-quality services to assist them in recovery and in
leading meaningful and productive lives. Although
Alternatives to Hospitalization
many psychiatric institutions have at least one person
responsible for quality and/or risk management, the Being proactive about ones life includes preventing
consumer advocacy movement has identified the uti- hospitalization whenever possible. From their start in
lization of consumers themselves as catalysts for sys- the mid-1800s and continuing through the modern
tem transformation (Substance Abuse and Mental movement beginning in the 1940s, consumer-run self-
Health Services Administration 2005). Consumer- help and advocacy groups have operated outside the
From Within 243
formal mental health system and have been a means and so is knowledge that anyone can have a psychiat-
to avoid hospitalization. In recent decades there has ric illness at any time in their lives. The challenge for
been increasing support and pressure to establish and us all is to integrate the best of the consumer move-
legitimize consumer-operated settings as either ad- ment into the medical service model. The resulting
juncts or alternatives to traditional, professionally run synthesis can continue to improve the quality and
services as part of the continuum of care offered by experience of care at psychiatric hospitals.
public mental health systems. As professionals con-
tinue to accept the involvement of consumers, the cul-
ture will face significant stresses and outstanding
References
opportunities.
It is estimated that more than 25 million Ameri- Bluebird G: Comfort rooms: reducing the need for seclusion
cans have participated in a mutual-help group at some and restraint. Residential Group Care Quarterly 5(4):5
point over their lifetimes and that groups for individ- 6, 2005 (Available at: http://www.cwla.org/programs/
groupcare/rgcqspring2005.pdf)
uals with mental illness are the second most fre-
Borkman TJ: Experiential, professional and lay frames of ref-
quented type of group; only groups for people with sub- erence, in Working With Self-Help. Edited by Powell TJ.
stance abuse troubles have a higher membership Silver Spring, MD, National Association of Social
(Kessler et al. 1997). Mutual-help groups function ac- Workers Press, 1990, pp 330
cording to a belief system that lived experience with Champagne T: Creating sensory rooms: environmental en-
mental illness is paramount (Borkman 1990). As a re- hancements for acute inpatient mental health settings.
Mental Health Special Interest Section Quarterly 29:1
sult of the inherent value placed on lived experience
4, 2006
and experiential knowledge, mutual-help groups are Corrigan RW, Ralph RO: Introduction: recovery as consumer
structured to reflect the assumption that all group par- vision and research paradigm, in Recovery in Mental Ill-
ticipants have something of value to contribute. ness: Broadening Our Understanding of Wellness. Ed-
Such groups currently offer support to avoid hospi- ited by Corrigan RW, Ralph RO. Washington, DC,
American Psychological Association, 2005, p 4
talization in programs such as warm lines and crisis
Deegan PE: Recovery: the lived experience of rehabilitation.
hotlines, peers in the emergency department, personal Psychiatr Rehabil J 11:1119, 1988
care assistant services, crisis respite, transitional re- Kessler RC, Mickelson KD, Zhao S: Patterns and correlates
spite, crisis stabilization units, urgent care walk-in, of self-help group membership in the United States. Soc
programs for assertive community treatment teams, Policy 27(3):2746, 1997
and so on. Proactive alternatives like Mary Ellen Cope- Massachusetts General Laws, Chapter 123, Section 23
(Rights of persons receiving services from programs or
lands Wellness Recovery Action Plan can often avoid
facilities of department of mental health)
inpatient care and maximize independence for con- Mead S, Hilton D, Curtis L: Peer support: a theoretical per-
sumers who know their risk factors and supports and spective. Psychiatr Rehabil J 25:134141, 2001
have clear communication with their outpatient care- Mello F: Right to fresh air sought for patients. Boston Globe,
givers. Advance directives for care follow the same July 8, 2007 (Available at: http://www.m-power.org/
right_to_fresh_air_sought_for_patients)
guidelines.
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Summary of Reports of Restraint & Seclusion Abuse Re-
ceived Since the October 1998 Investigation by The
Conclusion Hartford Courant (pamphlet). Arlington, VA, National
Alliance on Mental Illness, 2000
Pearson S, Sabin J, Emanuel E: No Margin, No Mission:
Hospitals that rely solely on the medical model tend to
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focus primarily on pathology and disease (Mead et al. Excellence. Oxford, England, Oxford University Press,
2001) and to define recovery as a set of predetermined 2003
outcomes that emphasize symptom elimination and a Presidents New Freedom Commission on Mental Health:
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Care in America. Final Report (DHHS Publ No SMA-
can be defeatist because it undermines hope, which
03-3832). Rockville, MD, U.S. Department of Health
has been described by advocates and consumer leaders and Human Services, 2003
as one of the cornerstones of recovery (Deegan Rice P: Incommunicado: mental health wards restrict access
1988). Consumers of mental health services face to email. Spare Change News, February 5, 2007 (Avail-
many challenges in terms of social attitudes, low so- able at: http://www.m-power.org/mental_health_wards_
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ery-Based Mental Health System (NMH05-0193). ber 1115, 1998, p 1
Rockville, MD, Substance Abuse and Mental Health
Services Administration, 2005
CHAPTER 17
WORKING WITH FAMILIES

Lisa B. Dixon, M.D., M.P.H.
Bette M. Stewart, B.S.
Family members play an integral role in the lives of tion) and are often involved in arranging for the patient
most persons with serious mental illness (SMI), and to go to the hospital. During the hospitalization, fam-
the importance of family involvement in the treatment ily members may frequently visit the patient and may
of these persons is widely recognized. The recent Pres- be an integral part of the patients support system on
idents New Freedom Commission on Mental Health discharge.
(2003) report calls for a care system that is consumer In this chapter, we first focus on common themes
and family centered. Moreover, in a large number of and issues for clinicians to appreciate in working with
randomized trials, family psychoeducation programs families in the inpatient setting. Next, we discuss a
have demonstrated robust effects in reducing patients number of potentially disruptive issues and challenges
rates of relapse (Murray-Swank and Dixon 2004). Best- that clinicians may encounter in their efforts to involve
practice treatment guidelines of the American Psychi- patients families in the treatment process. This chap-
atric Association (2004) and other professional organi- ter is focused on families of competent adults who are
zations strongly recommend family involvement in hospitalized. The issues involved in working with fam-
treatment as a critical element of quality care for per- ily members of child patients, of geriatric patients who
sons with SMI. have substituted consent, and of other specialized pa-
The inpatient phase of care may be an especially tient groups may differ. We also want to emphasize
critical time to involve family members in the treat- that we write this chapter as family members of people
ment process. During acute periods of illness and cri- living with mental illness in addition to our profes-
sis, family members often ramp up the level of in- sional roles as mental health clinicians and researchers
volvement they have with the patient. During these who focus on the delivery of services for patients with
times, family members may provide emotional sup- SMIssuch as schizophrenia, schizoaffective disorder,
port and practical assistance (e.g., housing, transporta- bipolar disorder, and depressionand their families. In
245
this chapter, we offer our perspectives grounded in our It is also important to realize the impact on family
experience as spouses, siblings, parents, and children members of visiting a loved one on an inpatient psy-
of people with mental illness. By considering this topic chiatric unit. One of us recalled first seeing our loved
from the dual vantage points of both family members one hospitalized: I burst into tears . . . it was worse
and professionals, we hope to provide a useful road than I could have imagined. This initial impact can
map to navigate clinicians work with families. be particularly jarring for family members who have
been involved in the involuntary commitment of their
loved one. Confronted with the realities of a locked in-
Working With Families in Inpatient patient unit, the family member can be filled with
Settings: Common Themes and guilt and second thoughts about Did I do the right
thing? Guilty feelings can also arise from worries
Issues in the Family Experience family members often have about whether they did
of Mental Illness something wrong to cause the illness, or worries
that they passed on bad genes to their child. A reas-
suring comment at the right moment can be greatly
The family experience of mental illness varies sub-
comforting, by showing understanding of the familys
stantially depending on the family members relation-
concerns (e.g., naturally it can be disturbing to see
ship to the patient (e.g., parent, spouse, sibling) as well
[name] in the hospital); reassuring them that hospi-
as the patients diagnosis and phase of illness. How-
talization was the right course (e.g., I just want to em-
ever, we would like to highlight several typical themes
phasize that you really did the right thing bringing
in the family experience among families who experi-
[name] into the hospital, even though he didnt want
ence the psychiatric illness and hospitalization of a
to come in. I think you might have saved his life. It
loved one. In this section, we discuss four common
took real courage and love to do what you did. He is
themes that are critical to appreciate for clinicians
very lucky he has you, and that you were there to do
who work with families in the inpatient setting.
what needed to be done to help him.); and emphasiz-
ing that their loved one will receive adequate care and
Range of Emotional Responses attention (e.g., we are going to do everything we can
As family members, we have experienced the roller to help him get better).
coaster of emotional responses that accompany an We also have found it useful to have an awareness
acute phase of illness requiring inpatient treatment. of the settings unique impact on all family members
Family members often experience profound fear, as they become familiar with the unit. For instance, it
shock, and trauma related to their relatives illness can be helpful to inquire about family members expe-
and its impact on family life. When their loved one has riences when first meeting them in the inpatient con-
become ill and requires hospitalization, this is likely to text. A clinician might say something such as, Thanks
be a time of instability and chaos in the life of the fam- so much for making the time to meet with me today.
ily. Coupled with this tremendous stress, family mem- We believe that your participation in the treatment
bers may feel a sense of relief that their loved one has process is really important. Im wondering if you have
landed somewhere with admission to the hospital. had the opportunity to meet with inpatient staff when
When interviewing family members, clinicians [name] has been hospitalized in the past. It also can
should be attuned to their emotional state and make be helpful to learn what the familys experience has
active efforts to acknowledge and normalize what they been like in the past, to provide a sense of how they
might be feeling. Techniques such as reflection (e.g., may be experiencing the current inpatient setting. For
It sounds like you are feeling frustrated) and sum- example, the clinician might say, Im also wondering
marizing statements can help family members feel if you have had any particularly good or particularly
heard and understood. Another way for a clinician to bad experiences with inpatient programs before. This
communicate this message could be to say things such can also be a point at which the clinician can orient the
as I realize that you have really been through a lot family to the unit and the hospital. Such an orienta-
during this timeyou may be feeling anxious, wor- tion and introduction can put family members at ease
ried, overwhelmed, angry, or maybe a combination of and help the clinician understand where the family is
many different feelingsthis is certainly understand- at as they are entering the often unfamiliar (and, at
able, normal, and to be expected as you are dealing times, chaotic and frightening) world of inpatient psy-
with everything going on with [patients name]. chiatric treatment.
Working With Families 247
Intense Unmet Needs atric terminology. It is best to avoid using this language
and to hold off on offering educational information un-
for Information til the interviewer has a good understanding of the
Research has consistently documented that family family members views of the patients problems.
members of people with SMI report strong, and often
unmet, needs for information and support related to Varying (and Sometimes
their loved ones psychiatric disorder (Tessler and Unrealistic) Expectations
Gamache 2000). In our experience as family members,
Families may have a wide variety of expectations of
we have felt the desperation of not knowing where to
hospitalization and treatment. Particularly in the ini-
turn in coping with the mental illness of our loved
tial years of illness, family members may have unreal-
ones. A lack of knowledge, combined with societal
istic expectations that hospitalization will fix the
stigma regarding psychiatric disorders, often leaves
problem and return their loved one back to normal on
family members feeling profoundly isolated in dealing
discharge. It is often frustrating for clinicians to en-
with the many challenges they face related to their
counter such beliefs, and we have certainly felt these
loved ones disorders.
frustrations when working with families in our profes-
It is important for clinicians to keep in mind that
sional roles. At the same time, it is critical to realize
family members may have varying levels of knowledge
that families unrealistic expectations are typically not
about mental illness. Some families may have a great
rooted in a willful denial of their loved ones illness.
deal of information about psychiatric disorders,
Instead, families beliefs often reflect a lack of infor-
whereas others may have little knowledge. It is impor-
mation coupled with an emotional coping process of
tant, therefore, to avoid making assumptions about
trying to come to terms with the painful reality of their
family knowledge (or to assume a lack of knowledge).
relatives illness.
At this point, in building an alliance with families, we
In addressing families expectations, it can be help-
have found it helpful to meet the family where they
ful to provide an orientation to the current context of
are by first supporting the family s desire to be in-
inpatient care at some point during the family inter-
volved and then asking some introductory questions
view. The following is an example of how a clinician
to assess family members understanding of their rel-
may explain the current situation:
atives problems. For example, one could begin by say-
in g, Than ks for meeting with me today about
It is important for you to know what we do here on
[names] treatment. To begin, it would be helpful to get the inpatient unit, and the role that we play in
your thoughts about the problems that [name] is seek- [names] treatment. Typically, the purpose of hospi-
ing treatment for. If it is OK with you, I would like to talization is to help get people through a crisis when
ask you a couple questions to get your input and learn their symptoms get worse, to provide an environ-
ment to ensure their safety, and to make sure they
about your understanding of things. Can you tell me a
are linked up with outpatient care as they are dis-
little bit about what you think about [names] prob- charged. Nowadays, extended periods of hospitaliza-
lems? Follow-up inquiries can include more focused tion are pretty unusual for people with mental ill-
questions such as, What do you think has caused ness. Instead, the emphasis is more focused on
[name] to have these problems?; Has anybody ever helping people get back to the community when they
given you a diagnosis for [names] problems? (if they are safe and able to return to their living environ-
ment. I know this can be difficult for family mem-
have been given a diagnosis, it is useful to follow up
bers, who sometimes experience a sense of relief
with, What is your understanding of what that diag- when their loved ones are hospitalized. It can be frus-
nosis means?); Are there things that make things trating for all of us to deal with the limits of what we
better for [name]?; and Are there things that make can accomplish while [name] is in treatment here.
things worse? However, we do hope that we can work with you as
we help [name] get her illness more under control.
Questions such as these can help the clinician learn
We also hope to address your needs for information
about family members views of their relatives psychi- about [names] illness and treatment and her plan for
atric problems. In addition, such questions can provide care while she is hospitalized here.
useful information to inform the patients treatment.
For example, family members often have valuable ob- This may also serve as a point of entry to discuss
servations about prodromal symptoms that signal a sources of support for family members, including pro-
risk for relapse in the patient. Note that these inquiries fessional family services as well as other education
avoid using the terms illness, disorder, or other psychi- programs and avenues of support. For example, some
inpatient units have educational family programs that concerns about involving their family in their treat-
provide a forum for family members to learn about ment, and family-level barriers (i.e., difficulty engag-
their loved ones illness. Community resources, such ing families and dealing with differences of opinion be-
as family education programs offered by the National tween family members and clinicians).
Alliance on Mental Illness, can offer another place to
refer families for education and support. As a practical Clinician-Level Barriers:
matter, we have found it helpful for staff who work Time Limitations and Confidentiality
with families to have a current, well-organized repos-
Contact between clinicians and families may occur in a
itory of information about mental illness and such re-
variety of ways in the inpatient context. Family meet-
sources so that information can be provided rapidly
and smoothly to families. ings may be planned during the course of hospitaliza-
tion. We have often found that contact with families
Differing Family Organization happens through a variety of more informal avenues:
during family visits to the patient, family phone calls
and Member Roles to the unit, and phone calls from the treatment team to
It is important for clinicians who work with families the family. In this section we examine two areas that
to recognize ways in which families are organized and sometimes can create stress between staff and family:
the roles that different family members of the patient 1) time and 2) confidentiality.
may play. One common theme is that one family For clinicians, the first difficulty is timenot
member may be the designated spokesperson for the enough of it. In a common scenario, family members
family when the patient is hospitalized. It is critical to may visit and request an unplanned meeting with
take the time to make a positive bond with this their loved ones physician or other staff on the unit.
spokesperson, because his or her translations of your Frequently, it is not possible for staff to drop every-
message may be the only information from which the thing and make time for such a meeting. However, in
family makes its impression of the care. Also, it is im- building an alliance with families, we believe that it is
portant to appreciate that the patients illness often critical to communicate the message that family input
prompts a reshuffling of roles in the family. and involvement in treatment is valued by the clinical
Moreover, as time passes, there may be genera- team. As family members, we have found it frustrating
tional transitions, such that siblings or other family to be brushed off by clinical staff completing paper-
members may assume a more active role as the pa- work or attending to other duties on the unit. Thus we
tients parents age. The key point for clinicians is to believe that it is important for staff to be attentive to
assess and be sensitive to who in the family are the families, within the context of their limited time and
central figures in the life of the patient. For example, other demands. For example, a busy psychiatrist with
interviewers may inquire, Who is usually involved in only 10 minutes to meet with a visiting family could
helping [name] when he has difficulties? In addition explain that their input is valuable and that talking
to appreciating these common themes in the family with them is important, but that he or she has limited
experience, it is important to acknowledge and address time at the moment, for example, I only have 10 min-
potentially disruptive issues and barriers to working utes right now, so lets set priorities in how we might
with families in the inpatient settings. use our time. Perhaps you could tell me about your
main questions and concerns, and we can come up
with a plan to make sure you are included in the treat-
Potential Barriers and Challenges ment process while [name] is being treated here.
for Clinicians Working With Families Issues of confidentiality can pose particular chal-
lenges to clinicians in working with families in the in-
in the Inpatient Setting patient setting. Professional ethics and organizational
policies appropriately require clinicians to obtain the
In this next section, we describe common barriers and consent of patients before releasing specific informa-
obstacles that clinicians encounter in working with tion about their treatment to family members (al-
families and offer strategies for clinicians to overcome though there can be specific exceptions when safety is-
these challenges and establish an effective working al- sues, such as suicide and homicide, are active). This
liance with family members. In general, these chal- consent is typically documented in a written release
lenges can be broken down into clinician-level barriers of information form. Marsh (1998) provided useful
(e.g., lack of time, confidentiality issues), patients guidelines for organizational policy and clinical prac-
tice concerning issues of confidentiality, designing ap- them. Although the primary focus of this chapter is on
propriate forms, and working with families of patients working with families, this work will be brief or non-
with SMI. existent unless the clinician has done a good job of
Perhaps one of the most difficult and common sce- talking with the patient about involving his or her
narios is when a family member contacts clinicians family members in the treatment process. Further-
asking for information about the patients treatment, more, the involvement of family in treatment should
and the patient has not provided permission to release be guided by patients preferences and views about his
information to family. In such situations, we feel it is or her family and the potential role they may play in
important for clinicians to first reinforce the family the treatment process. Consequently, we would like to
members interest in the patients treatment and to devote attention to the issue of talking with patients
recognize their effort to make contact; for example, I about involving their family in their treatment.
am so glad that you called, and that you are interested Patients may have a wide range of family experi-
in learning more about [names] treatment here. ences and preferences in regard to family involvement
Next, the clinician should provide a straightfor- in their mental health care. As an initial starting point,
ward explanation to the family member regarding the it is important to assess who the patient considers to be
relevant confidentiality issues; for example, As you their family support system and what role these in-
probably know, medical information is private and dividuals may play in helping them manage their psy-
protected. Therefore, I cant share any specific infor- chiatric disorder (if any), for example, I would like to
mation about [names] treatment at this time without ask you some questions to better understand your fam-
her permission. I know its hard for family members in ily relationships and support system. Do you have peo-
these kinds of situations; it is difficult for us, too, be- ple you would consider to be your family or like family
cause we really value the opportunity to include pa- to you? Who would those people be for you?
tients families as part of the treatment whenever we For many patients, significant family and poten-
can. What I can do is talk with [name] the next chance tial allies in treatment may include members of the
that I get to try to get her permission to talk with you support network who are not relatives (e.g., friend, pas-
more about her treatment. tor, 12-Step group sponsor). After identifying the key
It can then be helpful to ask the family member members of the support network, it is helpful to learn
about his or her needs and offer information that can about the patients level of contact with these individ-
be shared, such as answering general questions about uals, for example, does the patient live with a family
psychiatric illness, treatment programs, and resources member? If not, how close do family members live?
for family members. For example, Although I cant How often does the patient talk, e-mail, or get together
share specific information about [names] treatment, I with family members? Next, it is important to under-
would be happy to answer more general questions you stand the role that these individuals play in supporting
might have at this time. Do you have any general the patient, including any involvement in their mental
questions about our unit, or about psychiatric illness, health treatment, for example, So, you have said that
that I might be able to help with? Some types of in- you are closest to your two brothers, whom you get to-
formation that can be helpful for families include a de- gether with every couple of weeks. Im wondering if
scription of the inpatient unit, other treatment re- your brothers have been supportive as you have been
sources in the community, programs to support family dealing with your mental illness?
members of people with mental illness, and general Patients may have a variety of experiences with
information about psychiatric illness and treatment. family in relation to their illness. Interviewers should
Written materials can also be sent to family members use techniques such as summaries and reflections to
to provide them with this type of information (e.g., gain an understanding of the patients experience and
brochures or booklets about mental illness, Internet- help him or her feel supported. Finally, if it not yet
based information, flyers about specific programs). known, the interviewer can assess the degree to which
family has been involved in the patients mental health
Patients Concerns About Involving treatment in the past and the patients preferences with
regard to involving family at this time. For example,
Family Members in Their Treatment
To initiate contact with families, it is necessary to ask 1. Have your brothers been involved in your mental
the patient to identify members of his or her family health treatment by coming in to meet with your
and to obtain the patients permission to speak with doctor(s)?
2. Have they ever attended any kind of educational how to effectively interact with the patient. Thus spe-
programs or groups? cial effort is often warranted to get the family involved.
3. Would you like to have your brothers involved in When encountering this type of resistance, clini-
your mental health treatment? cians should use a range of clinical skills to effectively
4. What might be the possible benefits? negotiate issues of family involvement. Sometimes,
5. What, if any, are your concerns about having certain members of the clinical team may be more
them involved? connected with the patient and may be more likely to
get them to agree to family involvement. It is often
Overall, the goals of this discussion are to help the helpful to remember that involving the family is rarely
patient identify family members who could be allies in an all or none proposition. It can be useful to present
his or her treatment, consider the potential advan- a range of options and to encourage choices with re-
tages of family involvement in treatment, and identify gard to how the family can be involved. It is also im-
concerns the patient might have about family partici- portant to carefully consider all potential family mem-
pation. bers in the patients support system (as well as other
In some instances, the patient may be ambivalent people who are like family to the patient). Many pa-
about involving the family. This is understandable, tients may be hesitant to involve certain family mem-
given the complexity of family relationships and the bers in their treatment but very willing to allow others
possibility of the presence of abusive family members, to be involved.
as well as the personal nature of mental health treat- Even in cases in which patients are interested in
ment. When patients experience mixed feelings about their family being involved, considerable challenges
involving family in their mental health care, the pri- can arise in engaging and working with families. In the
mary task of the clinician is to help them explore the next section, we focus on two common challenges
potential value of family involvement and to make in- difficulties initiating work with family members and
formed choices, considering the potential advantages addressing situations in which the family has differ-
and disadvantages of family involvement in care. At ences of opinion with the clinical team. For a more de-
times, the patient may refuse family involvement, tailed discussion of clinical intervention with families
even when the clinical team feels that such involve- of persons with SMI (e.g., family psychoeducation),
ment would be in his or her best interest. In these sit- see McFarlane (2002), Anderson et al. (1986), and
uations it is important for the clinician to revisit the Mueser and Glynn (1999). These excellent treatment
issue during the course of treatment, especially if the manuals provide a detailed description of strategies to
patient was acutely ill or in a state of crisis when first initiate work with patients families as well as evi-
asked about involving the family. dence-based models to provide ongoing therapeutic in-
It is always a good practice to talk with patients tervention.
and obtain their consent before speaking with their
family. However, there are special situations in which Family-Level Barriers: Difficulties
safety or other imminent concerns may create the With Engagement and Differences of
need to speak with family members without the con-
sent of the patient. In these cases, the appropriate
Opinion With Family Members
practice may be to involve family members in the Engaging families as allies in the treatment process can
treatment even if the patient has not consented to be a challenge. It is important to recognize that family
such involvement. Clinicians should know and follow members may have reservations about meeting with
their relevant local rules and policies in such cases, ad- their loved ones mental health clinicians or participat-
here to principles of good clinical practice, and always ing in family services. For example, family members
try to work as collaboratively with the patient as pos- may be concerned about intruding on their relatives
sible in such circumstances. privacy or may be worried that such participation will
At times, the patients unwillingness to involve add additional caregiving demands. Practical barriers,
family in treatment may be due to acute symptoms such as limited time, child care needs, and lack of
that he or she is experiencing, such as active psychotic transportation, may also prevent family members from
symptoms, withdrawal, or disorganization. In these participating in services. Unfortunately, some family
situations, we have found that the family may be a members may have past negative experiences with the
particularly valuable source of information and can of- mental health system or family therapy, given prior
ten provide useful guidance to the clinical team about outdated theories that emphasized the family environ-
ment as a causative influence on mental disorders standing of psychiatric disorders. For example, family
(e.g., the schizophrenogenic mother). members may believe that the patient just needs to
In this regard, clinicians should appropriately com- pull him- or herself up by the bootstraps in dealing
municate the message that the illness is not the fam- with his or her problems, believing that psychiatric
ilys fault and provide educational information about medications are not needed. In these types of situa-
what is known about the etiology of psychiatric disor- tions, it is helpful to attentively listen and understand
ders. For example, when given the opportunity, a cli- the family members perspectives. To the extent that it
nician can explain thus: is appropriate, it is useful to first validate the family
members concerns or points of view. However, the cli-
Relatives often have questions about why their loved nician should follow with respectful and culturally ap-
one developed schizophrenia. Although the causes propriate educational information. If the family mem-
are not completely understood, we know that genet-
ber opposes medication and believes that the patient
ics play a big part in determining who is most likely to
develop schizophrenia. Also, we know that stressful just needs to try harder, the clinician can acknowledge
life events play a role in triggering episodes of the ill- this perspective, for example, I agree that its almost
ness. Research has shown that schizophrenia is an ill- always true that people do better if they try harder and
ness of the brain. In other words, the symptoms of believe they can be successful. So, it would be really
the illness are caused when certain areas of the brain great if [name] could try harder at cleaning up around
are not functioning properly, and the chemicals that
the house. But one of the things we are learning about
the brain uses to communicate are out of balance. I
want to emphasize that schizophrenia is not caused the illness of schizophrenia is that chemical changes in
by parenting or family behaviors. In fact, some of the the brain change a persons ability to plan and be orga-
most loving parents I have ever met have had chil- nized. It can also reduce a persons ability to feel satis-
dren who go on to develop schizophrenia. On the fied and proud of completing a task. All of these prob-
other hand, we do know that families can play an im-
lems limit someones ability to pull themselves up.
portant role in helping their loved ones manage and
cope with this difficult illness. With regard to medication, an example dialogue
may go as follows:
To engage families, clinicians must communicate
Clinician: I completely understand your hesitation
the value of family involvement to both patients and
about medication. Can you help me further under-
their relatives. Shea (1998) described a variety of inter- stand what your concerns are about [name] taking
viewing techniques that can help address the underly- the medicine?
ing fears family members may bring to the initial Family member: Well, every time he comes in, it
meeting. In one technique, the clinician openly ac- seems like they add more medicines for him to
take! And the more medicines you take, the more
knowledges the immense value of the family mem-
problems you getand I dont see any of them
ber s firsthand longitudinal knowledge of both the pa- helping.
tient and the patients care to date; for example, One Clinician: Im glad you raise these questions about
of the things I want to emphasize early on is how im- the medicines he is on, and how they might be af-
portant your input and background information are in fecting him. Let me also say that I know its frus-
our helping [name]. There is no one in the world who trating to see such limited progressI wish we had
more effective ways to help people get better
knows [him/her] better than you. We are dependent on
quicker. Lets talk more about the role that medi-
your input. I also really want to know what you think cations might play in helping [name] at this time.
has worked and what you think hasnt. The overall goal of the medications is to help re-
In their discussion of how to best engage families, duce the symptoms that are part of schizophre-
Mueser and Glynn (1999) offered three useful strate- niathings like developing unusual beliefs, not
making sense, hearing voices. When he gets sick,
gies that clinicians can use to enhance engagement:
these are the kind of symptoms that get worse for
1) letting family know they are not alone, 2) providing him.
support and allowing relatives to vent, and 3) instilling Family member: Yeah, he acts pretty crazy some-
hope for change. In addition to these strategies for in- times.
teracting with family members, persistence and flexi- Clinician: For most people, the medicines can help
bility are important ingredients in the effort to engage control these kinds of symptoms. Although they
wont make everything better, controlling these
family members as allies in treatment.
kinds of symptoms is an important first step. You
Perhaps one of the most challenging scenarios for also raised a concern about the number of medi-
clinicians is when the family has views that are in di- cines he is on and the possible side effects they
rect contrast to the current biopsychosocial under- might have. Let me tell you a little bit about each
of his medications, and the possible side effects to

watch out for. [Clinician provides appropriate in-
References
formation about specific medications.] Im so glad
that you raised these questionsthings usually American Psychiatric Association: Practice Guideline for the
work best when we can all work together[name], Treatment of Patients With Schizophrenia, 2nd Edition.
you, and Ito find the medicines that work best Washington, DC, American Psychiatric Publishing,
for him and have the fewest negative side effects. 2004
Anderson CM, Reiss DJ, Hogarty GE: Schizophrenia and the
Family. New York, Guilford, 1986
Conclusion Marsh D: Serious Mental Illness and the Family: The Prac-
titioner s Guide. New York, Wiley, 1998
McFarlane WR: Multifamily Groups in the Treatment of Se-
In summary, effectively working with families requires vere Psychiatric Disorders. New York, Guilford, 2002
a cross between the clinical skills required for working Mueser KT, Glynn SM: Behavioral Family Therapy for Psy-
with patients and the communication skills necessary chiatric Disorders, 2nd Edition. Oakland, CA, New
for interacting effectively with colleagues. In many Harbinger Publications, 1999
ways, clinicians are best viewed as consultants to fam- Murray-Swank AB, Dixon LB: Family Psychoeducation as an
evidence-based practice. CNS Spectr 9:905912, 2004
ily members, who are often faced with multiple
Presidents New Freedom Commission on Mental Health:
stresses and challenges and can benefit tremendously Achieving the Promise: Transforming Mental Health
from practical information, guidance, and support. By Care in America (DHHS Publication No. SMA-03-
establishing an effective working alliance with pa- 3832). Rockville, MD, U.S. Department of Health and
tients family members during inpatient hospitaliza- Human Services, 2003
Shea SC: Psychiatric Interviewing: The Art of Understand-
tion, clinicians can substantially improve the quality
ing, 2nd Edition. Philadelphia, PA, WB Saunders, 1998
of care, enhance treatment outcomes following hospi- Tessler R, Gamache G: Family Experiences With Mental Ill-
tal discharge, and improve quality of life for both pa- ness. Westport, CT, Auburn House, 2000
tients and their family members.
CHAPTER 18
IMPROVING SAFETY IN MENTAL

HEALTH TREATMENT SETTINGS
Preventing Conflict, Violence, and
Use of Seclusion and Restraint
Kevin Ann Huckshorn, R.N., M.S.N., C.A.P., I.C.A.D.C.
Violence in Mental Health Settings: order to prevent conflict and aggression in inpatient
settings, with a focus on improving safety for all.
Issues and Costs Seclusion is defined as the involuntary confine-
ment of a person in a room where they are physically
Violence in mental health settings has a significant prevented from leaving or think they are (National Ex-
impact on quality of care, the safety of service users ecutive Training Institute 2007). Physical restraint is
and staff, staff morale, and staff retention (Joint Com- defined as a manual method or mechanical device,
mission on Accreditation of Healthcare Organizations material, or equipment attached or adjacent to the pa-
2002; Owen et al. 1998). Research supports the grow- tients body that he or she cannot easily remove that re-
ing acknowledgment that violent incidents are often stricts the patients freedom or normal access to ones
preceded by behavioral signs but that these signs are body (National Executive Training Institute 2007).
often difficult for untrained staff to note (Duxbury Seclusion and restraint are used in mental health
2002). Owen et al. (1998) identified the need to com- settings to manage aggressive behaviors and have
bine evidence on patient propensity (individual char- been the object of increased interest, oversight, and
acteristics) for violence with environmental triggers in regulatory attention by legislators and policy makers
253
since 1998 (Substance Abuse and Mental Health Ser- deaths, and the lack of accountability for use, injuries,
vices Administration 2004; U.S. General Accounting or deaths in health provider organizations (Lieberman
Office 1999). This interest appears to be due to in- et al. 1999). The Hartford Courants findings were
creasing awareness of the short- and long-term physi- subsequently substantiated and expanded in a Con-
cal and emotional consequences of these procedures gress-commissioned study on seclusion and restraint
on both patients and staff (Honberg and Miller 2003). use by the U.S. General Accounting Office (1999).
The Hartford Courant Series Consequences of Seclusion

and Restraint Use
In 1998, The Hartford Courant, a newspaper in Con-
necticut, released a series of reports titled Deadly Re-
When conflict leads to violence and seclusion or re-
straint: A Nationwide Pattern of Death (Weiss et al.
straint, the result can be physical and emotional in-
1998). Driven by the tragic death of an 11-year-old
jury to all parties (Robins et al. 2005; U.S. General Ac-
boy, this investigative series cataloged the largely un-
counting Office 1999). Restraint interventions alone
regulated and unreported deleterious effects of seclu-
are estimated to cause up to 1,240 deaths or serious
sion and restraint on children and adults (Busch and injuries among service users each year in the United
Shore 2000). These publications sent tremendous re-
States, according to the Joint Commission (Joint
verberations throughout the mental health system in
Commission on Accreditation of Healthcare Organi-
the United States (National Association of State Men-
zations 2005). The incidence of staff injury has been
tal Health Program Directors 1999a, 1999b, 2001;
less studied, but one survey, conducted in three states,
U.S. General Accounting Office 1999).
reported 26 injuries for every 100 mental health tech-
The investigative team (Weiss et al. 1998) inter- nicians (Love and Hunter 1996). This reported injury
viewed health care officials, federal and state regulatory
rate surpassed those found in the lumber, construc-
agencies, consumers, family members, advocacy orga-
tion, and mining industries and highlighted the safety
nizations, and other stakeholders to piece together a
problems in inpatient mental health environments
picture of violence and the use of seclusion and re-
(Love and Hunter 1996). The legal consequences of
straint in mental health and intellectual disability care
inappropriate physical containment have led to in-
settings. The reporters canvassed 50 states and the creasingly frequent court findings of civil damages,
District of Columbia regarding the propensity of vio-
administrative sanctions, and criminal prosecution
lence and the use of seclusion and restraint. From 1988
(Haimowitz et al. 2006). Seclusion and restraint pro-
to 1998, 142 deaths were attributed to restraint or se-
cedures are believed to be high risk and potentially
clusion. Harvard Universitys Center for Risk Analysis
dangerous for both clients and staff and have resulted
reviewed these findings and estimated that 50150 in federal, state, and legal mandates to significantly re-
deaths occur annually as a result of these practices.
duce or eliminate use (Centers for Medicare and Med-
The Courant noted that seclusion and restraintre-
icaid Services 2006; Health Care Finance Administra-
lated deaths were occurring in a variety of venues, in-
tion 1999, 2001; Substance Abuse and Mental Health
cluding hospitals, residential facilities, group homes,
Services Administration 2004).
and other types of inpatient settings. These reports re-
vealed the disproportionate number of deaths of chil-
dren for merely refusing to obey staff orders, such as to Factors in Conflict and
move to another seat or to give up a contraband family
photograph (Weiss et al. 1998). Finally, this series de-
Violence Causality
tailed the deaths of a medically ill woman after 558
hours of restraint, a 15-year-old girl who used a pencil National and international literature reviews have
to threaten staff, and 33 others who died by asphyxia- identified the inconsistent and often idiosyncratic deci-
tion after being restrained face down (U.S. General Ac- sions that are frequently present when seclusion and re-
counting Office 1999). straint are used (Busch and Shore 2000; Duxbury 2002;
Most troubling were the lack of formalized report- Hinsby and Baker 2004; Smith et al. 2005). These re-
ing of seclusion and restraint use, the lack of stan- search studies suggest that cultural and facility-specific
dardized federal regulations guiding practice, the lack biases affect the decision to use seclusion and restraint.
of a national database recording serious injuries and Patient characteristics such as gender, race, age, staff
Improving Safety in Mental Health Treatment Settings 255
perceptions, and administrative attitudes inform these clusion and restraint in their respective facilities. A
practice choices and are often valued as more important few of these programs and facilities were highlighted
variables than other factors, such as understanding ac- in the report by the U.S. General Accounting Office in
tual antecedents to conflict (Busch and Shore 2000; 1999 and are examples of what could happen given
Legris et al. 1999). Current research demonstrates that leadership, creativity, and the will to change practice
conflict and violence causality goes beyond the tradi- patterns. These include model programs in Pennsyl-
tional focus on patient characteristics and that conflict vania, Massachusetts, and New York. Many of these
and violence frequently emerge as a result of environ- projects were co-led by physicians.
mental factors such as staff attitudes and facility cul- Following the Courant series, federal regulators
tures (Duxbury 2002; Hinsby and Baker 2004). promulgated policy and regulatory revisions in an at-
It is important that medical leaders understand the tempt to ensure the safer use of seclusion and restraint
internal and external factors that may contribute to practices (Centers for Medicare and Medicaid Services
conflict and violence. These include patient factors 2006; Health Care Finance Administration 1999,
such as having a history of violence and/or being in se- 2001). However, the latter regulations did not specifi-
clusion or restraint in the past as well as environmen- cally address the prevention of conflict or violence and
tal and agency norms (Okin 1985; Ray and Rappaport are considered minimum standards, not best practices
1995). It is telling that several studies have found very (L. Norwalk, Director, Centers for Medicare and Med-
dissimilar practices in very similar settings (LeBel et icaid Services Behavioral Health Standards, personal
al. 2004; Steinert and Needham 2007). communication, January 18, 2007). In 1999, the Na-
Similarly, it is imperative that leadership appreci- tional Association of State Mental Health Program Di-
ates the tangible impact of violence in health care set- rectors (NASMHPD) unanimously approved a policy
tings. The use of seclusion and restraint derails treat- statement committing to the reduction and eventual
ment and day-to-day unit operations. These violent elimination of seclusion and restraint, and its Medical
episodes translate into significant disruptions, staff Directors Council authored a series of technical reports
time away from service users, longer lengths of stay, on seclusion and restraint use with recommendations
higher staffing costs, greater staff turnover, and absen- for change (National Association of State Mental
teeism (LeBel and Goldstein 2005). On-unit violence Health Program Directors 1999a, 1999b, 2001).
has a direct impact on clinical care, service quality, and The Presidents New Freedom Commission Report
the fiscal bottom line (LeBel and Goldstein 2005). on Mental Health Care was published in 2003. In
Mental health care clinicians, especially physicians, 2005, the Institute of Medicine published its report ti-
must become better educated about their roles in im- tled Improving the Quality of Health Care for Mental
proving workplace safety and use that knowledge to and Substance-Use Conditions. These works provide
practice in a manner that prevents normal conflict strong support for transformative change in the deliv-
from escalating to violence (Joint Commission on Ac- ery of mental health care that includes significant at-
creditation of Healthcare Organizations 2002). This is tention to the reduction of conflict, violence, and co-
key to workforce retention; a study conducted by the ercive measures.
American Nurses Association reported that more than The United States is not alone in the growing con-
40% of nurses had been injured on the job, and 17% cern about use of coercive interventions. International
had been the target of physical assaults (as cited in Joint standard-bearing organizations have explicitly articu-
Commission on Accreditation of Healthcare Organiza- lated the essential rights of people who receive mental
tions 2002). Safety has been cited as a key factor in staff health care and experience seclusion and restraint. The
retention; without efforts to improve the safety of the United Nations adopted a resolution titled Principles
work environment, staff will leave direct-care settings, for the Protection of Persons With Mental Illness and for
and safety will further deteriorate (Joint Commission the Improvement of Mental Health Care in 1991 and
on Accreditation of Healthcare Organizations 2002). outlined inviolable basic rights recognized by the inter-
national community, including 1) the right to be pro-
tected from harm or abuse and 2) the right to be free
The Call to Transform
from restraint or seclusion unless it is used as the only
Mental Health Care means available to prevent immediate or imminent
harm to the patient or others (United Nations 1991).
Long before The Hartford Courant published its series, Despite these and other fundamental protective cove-
some organizations had started to reduce the use of se- nants adopted by the European Union and other coun-
tries, harm to individuals in psychiatric settings per- I would just like to say that I only jumped in the re-
sists nationally and internationally (Declaration of straint because, in my eyes, staff were hurting a pa-
Dresden Against Coerced Psychiatric Treatment 2007; tient and it brought back memories for when I was
Mental Disability Advocacy Center 2003). being hurt by people and no one was there to help me,
Mental health consumers and advocates have been but I figured that patient might have thought no one
was there to help her, but I was. (Female patient, age
concerned about the use of coercive interventions in
16 years)
mental health settings for years (Bluebird 2004). In re-
cent decades, the mental health advocacy movement
One of the things that doesnt get talked about very
has grown beyond its modest beginnings, and groups of much is the trauma of the staff. We talk about the
ex-patients became more organized, holding confer- trauma paradigm for our clients or people in recovery.
ences, publishing newsletters, and lobbying legislators But not very often in my 20 years of work in the field
for recognition of their issues (Bluebird 2004). The of mental health have I heard much about what hap-
mental health consumer movement is now well estab- pens to us, the workers, and I think thats an area
lished in the national arena; it is recognized as a signif- where we need to do some work. Ive seen some pretty
icant, viable, and effective stakeholder group. Many traumatic things from when I first started 20 years
states have added consumer affairs staff to their state ago. Some of those things still haunt me that Ive
mental heath agencies, and most states now host peer- seen. (Female direct-care staff member)
run drop-in centers. Peer specialists are now in 30
It became a war of words all about who had the
states, and in 6 states Medicaid has approved reim-
power. I was restrained and forcibly injected. I did not
bursement for this role (Goldberg 2007). Mental health
speak to anyone for the next 2 days, and developing
providers are recognizing peer support, peer-provided any sort of trusting relationship was seriously de-
services, paid peer staff, and self-help as critical in re- layed. (Male patient, age 32 years)
covery-oriented systems of care (National Executive
Training Institute 2007). I got put in the quiet room for pulling the alarm. I
The involvement of service users as full partners is pulled the alarm because my grandma did not visit
still limited in the private and public sectors due to a with me so I felt really bad and did not know what to
combination of fear, distrust, and discomfort (Bluebird do. (Male patient, age 16 years)
2004). However, as noted in the Presidents New Free-
dom Commission on Mental Health (2003) report I had never seen such a thing ...a blue mattress with
and the Institute of Medicine (2005) report, the sin- restraints. They strapped me in face down. I have a
memory that they also gave me an injection, but that
cere and meaningful inclusion of consumers and ad-
might have been from another time. I remember whis-
vocates in every component of the service system not
pering to the nurse, What happens now? I was petri-
only is absolutely critical but also is a mandatory best fied because all their behavior and equipment seemed
practice that distinguishes the new mental health sys- so weird. She said, Just try to sleep. (Adult female
tem from the old. patient)
Consumer and Staff Experiences The first time that I helped with a restraint, a four-
point restraint, I walked out of the room in tears be-
cause it was one of the most horrible things I had ever
It has become clear to clinical and policy experts that it
seen. (Female direct-care staff member)
is incumbent upon the mental health system to listen
and give value to self-reports by people who have
Ive been injured from time to time. Nothing severe.
personally experienced violence in health settings as I have bruises, yeah, sometimes I get headaches. I get
well as to staff who are expected to use these proce- shaky. (Male direct-care staff member)
dures (National Executive Training Institute 2007).
Personal vignettes provide a picture of individual ex- Some unexpected vignettes also identified prac-
periences that should not and cannot be minimized or tices that appeared to help individuals cope with being
ignored, even though they may not reach the level of put in restraints or seclusion, in the aftermath of the
empirical research. event.
The following experiences were recorded from people
who were involved in violent events in mental health She asked if I would be safe if she took off the re-
settings and the staff who were expected to use these pro- straints, and I said yes. She said, Well, that is a good
cedures (National Executive Training Institute 2007): safe. When she took the restraints off of my wrists and
legs, I was unable to move my right hand and shoul- some kind of significant traumatic event, and the rates
der. It was very swollen. She couldnt believe how are even higher for people who seek clinical services
swollen I was and immediately called for medical at- from public mental health and substance abuse provid-
tention. It was her passion and conviction about the ers (Cusack et al. 2004; Mueser et al. 1998). Kessler et
fact that I had not received any medical attention. She al. (1995) conducted a nationally representative study
was screaming to whoever it was. Then she got me up
of the general population in the United States. In face-
and helped me take a shower and got me food. In her
to-face interviews with 5,877 people ages 1554 years,
face I could see that she cared for me and also in her
60% of men and 51% of women reported at least one
voice. (Adult female patient)
traumatic event at some time in their lives.
It was a Palm Sunday and I wanted to go to Mass. It In a widely cited report titled Origins of Addiction:
was a Catholic hospital. The nurse let me go though Evidence From the Adverse Childhood Experiences
she knew that I was expressing suicidal thoughts. Study, Felitti (2003) found that the compulsive use
When I came back one and a half hours later, I was put of nicotine, alcohol and injected street drugs increases
in seclusion. The nurse did not talk to me. Nobody proportionally in a strong, graded, doseresponse
talked to me. I was on a little mat in the room. When manner that closely parallels the intensity of adverse
my doctor (psychiatrist) came back 2 days later after childhood experiences (p. 3) in a population-based
being gone on a long weekend, he was furious. He study of more than 17,000 middle-class American
talked to the nurse and told her, You had no right do-
adults. The impact of traumatic life events, character-
ing that. He got me out of seclusion. He then spent
ized by subjectively perceived threats of harm, has also
time with me. (Adult female patient)
been clearly defined and linked positively to posttrau-
matic stress disorder (PTSD), acute stress disorder,
Principles Underlying Trauma- poor treatment outcomes, and personal distress (Jen-
nings 2004).
Informed Systems of Care Individuals who experience trauma sometimes de-
velop PTSD, a clinical disorder characterized by stress
A core construct believed to be critical in reducing the and anxiety-related acute and chronic signs and symp-
use of seclusion and restraint is the emerging science toms (Frueh et al. 2000). PTSD is considered to be
of trauma-informed care. The implementation of the chronic and debilitating and to have serious adverse
principles of trauma-informed care is a universal pre- effects on social, familial, and occupational function-
caution when attempting to prevent conflict or vio- ing. Studies demonstrate a high prevalence rate of
lence (National Executive Training Institute 2007). PTSD in people with mental illness (up to 43%) and
These principles have been developed and studied by even higher rates of traumatic exposure in the same
clinicians and researchers for two decades but have population (51%98%) (K.J. Cusack, B.C. Frueh, T.G.
only now begun to receive significant attention (Moses Hiers, et al., The Impact of Trauma and Posttrau-
et al. 2003; National Association of State Mental matic Stress Disorder Upon American Society: Report
Health Program Directors 2005). to the Presidents Commission on Mental Health,
Mental health literature reports are now replete unpublished paper, 2003; Kessler et al. 1995; Mueser
with studies on the high prevalence of traumatic life et al. 1998). Other studies have found trauma preva-
experiences in the general public as well as in the lives lence rates of 52%90% in persons who have schizo-
of adults and children in the public mental health sys- phrenia, schizoaffective disorders, major depression,
tem (Cusack et al. 2004; Mueser et al. 1998; Saxe et al. and co-occurring disorders (Cusack et al. 2004; Frueh
2003). Traumatic life events are defined as those that et al. 2002; Green et al. 2000; Mueser et al. 1998).
involve a direct threat of death, severe bodily harm, or Leading researchers have concluded that the syn-
psychological injury that the person, at the time, finds drome of PTSD is associated with significant psychi-
intensely distressing (Rosenberg et al. 2001). Trauma atric and medical comorbidity, social maladjustment,
and traumatic events are defined as the personal ex- and poor quality of life (Frueh et al. 2006). Current re-
perience of interpersonal violence including sexual search on the neurobiology of PTSD indicates that al-
abuse, physical abuse, severe neglect, loss and/or the though it is strikingly similar to major depression,
witnessing of violence (National Executive Training PTSD has several distinctive features, including hy-
Institute 2007). peractivity of the hypothalamic-pituitary-adrenal sys-
Epidemiological studies estimate that between 36% tem and hypersecretion of corticotropin-releasing fac-
and 81% of the general population has experienced tor in the presence of normal to low cortisol levels
(Newport and Nemeroff 2003). There is also consider- restraint (National Executive Training Institute 2007).
able evidence that early traumatization is associated These principles are believed to be not only a universal
with adoption of high-risk behaviors, substance abuse, precaution against conflict and violence in our treat-
revictimization, reduced treatment adherence, poor ment settings but also a core component in creating a
quality of life among HIV-infected individuals, and in- recovery-based service system as articulated by the
creased morbidity (Whetten et al. 2006). On balance, Presidents New Freedom Commission on Mental
the literature regarding PTSD is compelling. This Health (2003) and the Institute of Medicine (2005).
complex psychiatric disorder not only results in emo-
tional distress but also has far-reaching effects, includ-
ing impaired social and work functioning, negative Effective Strategies to Prevent
life-course consequences, increased likelihood of re- Violence and Improve Safety
peat traumatic experiences, and often a duration of
many years (Kessler 2000).
The significance of trauma in the lives of the peo- Facilitating recovery, independence, and illness self-
ple with mental conditions cannot be ignored in men- management is the goal of a transformed mental
tal health environments. The following principles of health service system (Institute of Medicine 2005;
trauma-informed systems have been identified as crit- Presidents New Freedom Commission on Mental
ical in preventing adverse events and in reducing the Health 2003). Implicit in the recovery model are prin-
use of seclusion and restraint (Fallot and Harris 2002; ciples and values that require a reduction of coercive,
National Executive Training Institute 2007): violent, and involuntary procedures done to persons
with mental illness as part of a major shift in practice.
1. An understanding of the neurological, biological, The National Consensus Statement on Mental Health
psychological, and social effects of trauma and vio- Recovery was developed by the Center for Mental
lence in human experience. Health Services (2004) and describes the recovery pro-
2. An appreciation of the high prevalence of trau- cess and explicates key principles. Simply stated,
matic experience in the lives of the people who re- transformed systems of care that are recovery focused
ceive mental health services. and trauma informed are not characterized by rigid
3. The use of a standardized, early, and thoughtful rules, coercive practices, or one size fits all treat-
trauma assessment on admission to any mental ment. As such, these principles are important in un-
health service or setting, with positive results in- derstanding the rationale for preventing violence and
forming treatment. improving safety.
4. A recognition and sincere attempt to minimize the
fact that mental health treatment environments Preventing Violence Through
are often traumatizing, both overtly and covertly. a Formal Plan
5. Valuing the consumer in all aspects of care, includ-
ing highly individualized treatment planning and In order for a mental health facility to begin a conflict
shared decision making. and violence prevention effort, including a reduction
6. The use of neutral, objective, supportive person in the use of seclusion and restraint, a facility-specific
first language in policy, procedure, and daily usage. strategic action plan should be developed and struc-
7. Workforce development activities that seek to in- tured to include tasks that identify the responsible
crease staff awareness and understanding of trauma parties, due dates, and expected outcomes. Conceptu-
in the lives of people served. This principle also in- ally, the plan should address the Six Core Strategies
cludes ongoing reviews of organizational rules, prac- identified in the NASMHPD approach, because this
tices, and policies that are possibly homogenizing, model continues to integrate effective strategies from
demeaning, disrespectful, confusing, or worse. across the country (National Executive Training Insti-
8. Organization-wide practices that seek to minimize tute 2007). These strategies form the training curric-
the use of coercive practices such as seclusion, re- ulum that has been developed to assist psychiatric fa-
straint, punishment, consequences, and forced cilities in preventing both violence and the use of
medication. seclusion and restraint. The curriculum was designed
for use with mental health populations; however, the
In some settings, the implementation of these prin- strategies have been successfully adapted and applied
ciples alone has completely transformed the culture of to other populations and care settings as well. These
care and reduced or eliminated the use of seclusion and strategies are not meant to replace evidence-based and
other clinical approaches, meaningful treatment activ- of the effort and create mechanisms so that this in-
ities, or effective pharmacological management, but volvement will happen, be understood by staff, and be
rather are designed to be used in conjunction with viewed in a positive manner (Bluebird 2004). The key
these methods. The Six Core Strategies to improve issue with this strategy, based on real reduction expe-
workplace safety are paraphrased from the National riences, is that leadership is essential. If leaders are
Executive Training Institute (2007) and are described committed to the effort, significant organization-wide
in detail in the sections that follow. culture change will occur; if not, it will fail. In sum-
mary, the critical function of organizational leadership
1. LEADERSHIP TOWARD ORGANIZATIONAL CHANGE is to take an active, visible role; prioritize the initiative;
preach and teach; and hold people accountable for all
This strategy outlines the role of the executive director
aspects of the plan.
or facility administrator and other executive staff. Re-
duction of the use of seclusion and restraint must start
with clear, focused leadership. Leaders must define 2. USE OF DATA TO INFORM PRACTICE
and articulate a mission and philosophy about seclu- This strategy uses facility-specific seclusion and re-
sion and restraint reduction and outline the roles and straint data in a nonpunitive manner, provides for
responsibilities of all staff in the facility (Huckshorn healthy competition among facility units or wards,
2006). The development and implementation of the and elevates the general oversight and knowledge of
prevention plan are leadership responsibilities that re- seclusion and restraint use in real time for everyone
quire full and consistent participation by a facility ad- involved (Hardenstine 2001; Huckshorn 2006). It en-
ministrator or chief executive officer who is firmly courages the administration to identify successful
committed to this effort. The reduction plan should be staff and specific units so that effective seclusion and
presented in a continuous quality improvement restraint prevention practices can be shared.
framework that understands that culture change takes Using data in this way includes an analysis of fa-
time and that we learn as we go. cility seclusion and restraint usage by unit, shift, day,
A core activity included in this strategy is elevating and staff member involved, although this latter strat-
the oversight of every seclusion and restraint event by egy needs to be recorded confidentially for identifying
executive management. This requires that a very dif- individual staff training and supervisory needs and not
ferent level of attention be paid to these events than for disciplinary actions in general (Huckshorn 2006).
historically practiced. It ensures a timely (minimum The facility also needs to highlight seclusion and re-
weekly) senior administrative review of all incidents straint use by graphing and posting these data on all
that captures detailed information valuable in deter- units so that they are clearly visible for staff and con-
mining necessary prevention activities. It takes advan- sumers.
tage of the fact that facility leaders can implement pol- It is also important, initially, to identify the facil-
icy changes quickly due to their organizational itys baseline use of seclusion and restraint so that per-
position, power, and influence. formance improvement goals can be set, use can be
Leadership strategies include the development of a monitored over time, and progress (or lack thereof)
facilitywide policy statement that outlines the preven- can be tracked (Hardenstine 2001). This includes set-
tion/reduction approach relative to the use of seclu- ting data-driven goals and communicating these goals
sion and restraint for all staff, determines data-driven to staff. Reducing seclusion and restraint through the
goals to reduce use, announces a kickoff event and thoughtful use of data includes tracking core measures
routinely celebrates successes, identifies seclusion and such as seclusion and restraint episodes and hours and
restraint reduction champions at all levels of the orga- also tracking supplemental measures that include the
nization, and assigns these staff to specific prevention use of emergency, involuntary (usually intramuscular)
roles. The leadership strategy also includes supporting medication administration; incidence of both con-
staff practice change, with frequent communication sumer and staff injuries; and qualitative reports of
and hospital rounds done by executives (Hardenstine consumer and staff satisfaction (Bluebird 2004).
2001). Another effective action step is voluntarily rais-
ing the minimum standards of practicefor example,
reducing the maximum seclusion or restraint orders
3. WORKFORCE DEVELOPMENT
from 4 hours to 2 hours. The workforce development strategy focuses on the
Leadership must also ensure the inclusion of con- creation of a treatment environment where policies,
sumers, family members, and advocates in all aspects procedures, and practices are based on the knowledge
and principles of recovery and the characteristics of ments that are integrated into hospital policy and pro-
trauma-informed systems of care (Huckshorn 2006). cedure and each individual consumer s treatment
This strategy is implemented primarily through staff plan. This intervention includes using tools to identify
training, education, and human resources develop- risk for violence (including previous seclusion and re-
ment activities. It provides guidelines for choosing se- straint history), tools to identify persons with medical
clusion and restraint application training vendors, risk factors for death and injury, and tools to identify
particularly vendors who have data demonstrating persons with psychological risk factors that would be
success in seclusion and restraint reduction using informed by a trauma assessment; developing and us-
their particular model. ing de-escalation or safety plans (including psychiatric
This strategy ensures that staff are given the oppor- advance directives); creating sensory-based interven-
tunity to develop and practice individualized treatment tions to teach self-calming and soothing; making
planning and practice skills that integrate seclusion changes to the physical environment (including the
and restraint prevention strategies for persons served. development of comfort and/or sensory rooms); and
Included are activities that ensure adequate staff edu- implementing daily meaningful treatment activities.
cation about the experiences of consumers and staff Each of these tools has a specific purpose and asso-
with seclusion and restraint, address the common ciated goals, such as identifying people who are at
myths associated with use, introduce the rationale and higher risk for seclusion and restraint use based on past
characteristics of trauma-informed care, educate about incidents and those who are at higher risk for injury or
the neurobiological and psychological effects of death due to conditions such as obesity, respiratory dis-
trauma, and describe a prevention-based approach to ease, cardiac anomalies, medication side effects, recent
reduction. ingestion of food, prone positioning, and past trauma
Also included is facility leaderships understanding histories. De-escalation or safety plans assist the ser-
that many seclusion and restraint events occur be- vice recipient in learning illness self-management by
cause of winlose conflicts set up by facility rules and identifying emotional triggers and developing aware-
staff roles in enforcing these rules. Because of this in- ness of interpersonal or environmental stressors that
stitutionally driven risk issue, leadership must under- could lead to conflict or emotional dyscontrol. Proac-
stand the value of allowing staff to suspend institu- tive strategies can be practiced in advance of a crisis. A
tional rules and procedures, when necessary, to avoid behavior scale can offer a set of guidelines to staff to en-
or resolve conflicts when addressing individual needs sure that staff responses are appropriate to the behavior
(Huckshorn 2006). Examples of this important con- being demonstrated by the service recipient. This helps
struct are rigid policies regarding attendance at activi- to ensure that behavior truly meets the criterion of im-
ties, wake and sleep times, curfews, smoke breaks, minent dangerousness prior to the implementation of
mealtimes, and other rules designed to keep order that seclusion and restraint. Many seclusion and restraint
do not take into account individual needs or the signs incidents are initiated prematurely before the level of
and symptoms of mental illness. imminent danger occurs, often because staff do not
Other important activities include discussing the know any other approach to use.
facility s seclusion and restraint reduction plan in One of the most promising practices to aid in se-
new-hire interviews and incorporating expectations in clusion and restraint reduction efforts and the creation
job descriptions, performance evaluations, and new of alternatives to containment is the use of sensory in-
staff orientation activities (Huckshorn 2006). It is the terventions. Sensory interventions can be applied
job of senior management to ensure that the seclusion across the range of milieu-based services. This ap-
and restraint prevention plan is communicated early proach requires knowledge of occupational therapy; an
and is consistently reinforced, that staff clearly under- assessment of each service user s sensory diet (Ayers
stand their important role in the plan, and that they 1979); an understanding of specific sensory needs
are supervised throughout the process so that learning (sensory seeking or avoiding); and creation of person-
can occur. centered care plans based on that knowledge. Applying
these concepts to clinical service leads to meaningful,
4. USE OF SECLUSION AND RESTRAINT creative therapeutic activities; sensory education and
intervention practice; greater instruction in self-calm-
PREVENTION TOOLS ing and soothing techniques; and consideration of unit
This strategy reduces the use of seclusion and restraint environments. Implementing sensory interventions
through a variety of preventive tools and risk assess- at the environmental level shifts the focus from unit
space to unit place. The former indicates physical ered to do their jobs, including making mistakes or
location and boundaries, whereas the latter connotes receiving additional training (Bluebird 2004). Simi-
therapeutic meaning and purpose within the environ- larly, the inclusion of family members and external ad-
ment (Hasselkus 2002). This can be readily achieved vocates can be extremely valuable and very necessary
through thoughtful attention to the full range of sen- in childrens units where service recipients are too
sory experience throughout the unit by attending to young to participate in these kinds of roles. Inviting
color, sound, aroma, lighting, furniture placement, the local protection and advocacy organization to be
plants, muralsthe softscapeor creating specific involved can be very helpful in preventing problems
rooms to experience calm, such as comfort rooms or and developing a transparent organization committed
sensory rooms, or simply creating quiet areas or to quality improvement.
smaller seating arrangements that offer greater pri-
vacy, sanctuary, and an opportunity to restore. The 6. RIGOROUS DEBRIEFING ACTIVITIES
use of sensory rooms and interventions have been at-
tributed to decreased perceived distress, reduced mal- The final strategy uses event debriefing procedures
adaptive behavior, and enhanced participation and (defined as rigorous analysis) to reduce the use of se-
task performance among consumers in treatment set- clusion and restraint through knowledge gained from
tings (Ashby et al. 1995; Champagne 2006; Cham- a careful review of seclusion and restraint events. This
pagne and Sayer 2003; Hutchinson and Haggar 1991). knowledge is then used to inform policies, procedures,
Moreover, sensory room/comfort room development and practices to avoid repeats in the future (Huck-
has been identified as an integral component to many shorn 2006). A secondary goal of this strategy is to at-
successful restraint reduction efforts in psychiatric tempt to mitigate harm and the potentially traumatiz-
facilities throughout the country (Champagne and ing effects of a seclusion and restraint event for
Stromberg 2004; LeBel and Goldstein 2005; National involved staff and consumers and for all witnesses to
Executive Training Institute 2007). Some hospitals re- the event. Debriefing activities are separated into two
ported significant reductions (54%91%) in restraint distinct but equally important activities that follow a
and seclusion use as this preventive alternative was seclusion and restraint event.
implemented (Champagne and Stromberg 2004; The first is an immediate postevent discussion
LeBel and Goldstein 2005). that is led by a nursing supervisor or a senior staff per-
son who was not involved in the event. The purpose is
to ensure the safety of all involved parties, review the
5. FULL INCLUSION OF CONSUMERS
documentation, interview staff and others who were
AND ADVOCATES present, and attempt to return the unit to the precrisis
The full and formal inclusion of consumers or per- milieu. The use of an interview guideline and the doc-
sons in recovery, as well as family members and ex- umentation of activities immediately following the
ternal advocates, in a variety of roles in the organiza- event are highly recommended.
tion assists in the reduction of seclusion and restraint The second debriefing activity is more formal and
(Bluebird 2004). These roles can be developed by con- occurs 2448 hours later. It includes the treatment
verting vacant positions and hiring consumers into team, the attending psychiatrist, and a representative
full- or part-time jobs such as the director of advocacy from management. It uses rigorous problem-solving
services, peer specialist, drop-in center director, and methods such as root-cause analysis procedures to
consumer advocate. These roles are immeasurably review and analyze the event. The purpose of this ac-
valuable if the facility and staff understand and are tivity is to identify what happened and what can be
open to the depth and breadth of knowledge that con- changed to avoid an event in the future and to ensure
sumers bring to an organization. that, as much as possible, traumatic sequelae are mit-
It is necessary that these roles and their impor- igated for everyone involved.
tance be defined for staff and that consumer staff re- The inclusion of the consumer s perspective is
port to managers who understand and support these critical here. It is potentially intimidating to expect a
roles. The new role of a consumer in an inpatient fa- recently secluded or restrained individual to attend a
cility can be daunting, intimidating, and difficult. It is large meeting, and alternatives are recommended.
essential that all staff clearly understand this role and The service recipients perspective can be included and
that attention be given to orienting and training peo- represented by a staff advocate if the service user is
ple who undertake these new roles. It is equally impor- comfortable with this plan and is able and willing both
tant that inclusion is real and consumers are empow- to agree and to communicate his or her perspective.
This alternative is not meant to patronize or other- tors for conflict and violence along with early interven-
wise assume inability of the service recipient to partic- tion strategies so that violence can be prevented. This
ipate; it is intended only to make facility staff aware of approach directs efforts to anticipate conflicts, imme-
the possibility of a patients covert feelings of coercion diately resolve situations when they arise, and learn
or helplessness in the face of a group of professionals. new prevention strategies from an analysis process
In addition, establishing and maintaining a nonpuni- when these events do occur. This model is best under-
tive environment are essential to creating a safe space stood by the constructs of primary prevention, second-
for staff to share their thoughts and feelings. ary prevention, and tertiary prevention to guide the
In summary, the Six Core Strategies (National development of reduction activities (National Execu-
Executive Training Institute 2007) are presented for tive Training Institute 2007).
use as part of a comprehensive performance improve- Primary prevention interventions speak to the de-
ment plan to reduce both conflict and the use of seclu- velopment of treatment environments that anticipate
sion and restraint (Huckshorn 2006). They are fo- the potential for conflict to occur. Strategies include
cused on prevention and incorporate the most current the implementation of visions, values, and principles
and effective approaches known. These strategies have of care that are trauma informed; a thorough analysis
been substantiated in the literature and appear to be a of organizational values to ensure they are reflected in
common thread in successful projects (Donat 2003; current practices; and an ongoing revision of policies
Hardenstine 2001; Jonikas et al. 2004; National Exec- and procedures and early individualized assessments
utive Training Institute 2007; Visalli and McNasser of a variety of risk factors for violence, injury, or death.
2000). Secondary prevention activities speak to the im-
mediate and effective use of early interventions to mit-
A Prevention Framework igate conflict or aggression when these do occur. These
The avoidance of conflict and violence starts with the interventions include staff training focused on atti-
use of prevention tools that train staff in best practices tudes and behaviors when faced with a conflict situa-
(Huckshorn 2006). An obvious place to start this ef- tion, competency-based negotiation and de-escalation
fort is to focus on the reduction of the use of seclusion skills, and the use of individually developed crisis
and restraint procedures. This is an attainable goal plans that assist in teaching emotional self-manage-
that has been achieved by many facilities throughout ment (National Executive Training Institute 2007).
the United States and is well within the reach of every Tertiary prevention interventions address the most
committed organization. Changing these practices is effective ways to minimize the damage done to con-
much more than rethinking the use of coercive proce- sumers, staff, and others witnessing a seclusion and
dures. The essence of this effort is about transforming restraint event once it occurs. These strategies include
practice, changing treatment cultures, reflecting on rigorous problem-solving activities in event analyses
how we think about the people we serve and how to and include the mandatory involvement of the in-
educate the staff who serve them. At its core, this work volved service recipient. These types of interventions
is about improving safety and using every preventive are also focused on identifying people who may require
technique that is known and effective. specific treatment for trauma.
Traditional mental health practices have most of-
ten placed the reasons for conflict and the use of seclu- Conclusion
sion and restraint on the shoulders of the consumer
attributing acts of aggression in isolation from the en-
vironment, devoid of environmental triggers. A pre- Were seclusion and restraint regulated substances, the
vention approach is one way for physicians to take a U.S. Food and Drug Administration would probably
lead role in reorganizing agency operations and can have banned their use, given the number of people who
change the way that violence in mental health settings have died and continue to die from these procedures.
is currently viewed. Consumers are not the only victims; staff have also
In physical health, the public health prevention died or been seriously injured while engaged in imple-
model is a model of disease prevention and health pro- menting these practices (National Executive Training
motion and is a logical fit with a practice issue such as Institute 2007). The advantage to reports of seclusion
seclusion and restraint (National Association of State and restraint deaths is that these publicized sentinel
Mental Health Program Directors 1999a). The appli- events often spur calls for practice reforms, and such re-
cability of this model focuses on identifying risk fac- forms are now occurring domestically and internation-
ally (Department of Health 2005; Mental Disability Champagne T, Sayer E: The effects of the use of the sensory
Advocacy Center 2003; National Executive Training In- room in psychiatry, 2003. Available at: http://www.ot-
innovations.com/images/stories/PDF_Files/qi_study_
stitute 2007). Despite well-codified local and world-
sensory_room.pdf. Accessed September 18, 2007.
wide human rights and patient protections, the harm to Champagne T, Stromberg N: Sensory approaches in inpa-
service users and staff who serve them persists (Decla- tient psychiatric settings: innovative alternatives to se-
ration of Dresden Against Coerced Psychiatric Treat- clusion and restraint. Psychosoc Nurs Ment Health
ment 2007; Mental Disability Advocacy Center 2003). Serv 42:3544, 2004
The good news is that the knowledge about how to Cusack KJ, Frueh BC, Brady KT: Trauma history screening in
a community mental health center. Psychiatr Serv
do this work is readily available and is in the public do-
55:157162, 2004
main. Many success story facilities provide contem- Declaration of Dresden Against Coerced Psychiatric Treat-
porary testaments to transformed mental health ser- ment: The Declaration of Dresden Against Coerced
vices and lived recovery experiences. None of these Psychiatric Treatment Consensus Statement of the
stories could be told without courageous leaders who are World Network of Users and Survivors of Psychiatry,
European Network of Ex-Users and Survivors of Psychi-
willing to take an unpopular stand, manage staff anxi-
atry, Bundesverband Psychiatrie-Erfahrener, and Mind-
eties, weather perpetual challenges, and seriously com- Freedom International. Presented at the World Psychi-
mit to this initiative. Mental health facilities are encour- atric Association thematic conference, Coercive
aged to develop their own individualized safety plan. Treatment in Psychiatry: A Comprehensive Review.
Documenting a safety improvement plan that includes Dresden, Germany, June 2007
violence prevention objectives is an important first step. Department of Health: Delivering race equality in mental
health care: an action plan for reform inside and out-
Adopting prevention-oriented and trauma-informed
side services and the governments response to the in-
principles by implementing NASMHPDs Six Core dependent inquiry into the death of David Bennett.
Strategies will help facilitate an organizational culture London, Crown, 2005. Available at: http://www.
change process if committed medical and administra- dh.gov.uk/en/Publicationsandstatistics/Publications/
tive leaders are willing to chart and stay the course and PublicationsPolicyAndGuidance/DH_4100773. Ac-
cessed January 10, 2007.
commit time and personal capital to the mission.
Donat DC: An analysis of successful efforts to reduce the
use of seclusion and restraint at a public psychiatric
hospital. Psychiatr Serv 54:11191123, 2003
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Rosenberg SD, Mueser KT, Friedman MJ, et al: Developing Whetten K, Leserman J, Lowe K, et al: Prevalence of child-
effective treatments for posttraumatic disorders among hood sexual abuse and physical trauma in an HIV-pos-
people with severe mental illness. Psychiatr Serv itive sample from the Deep South. Am J Public Health
52:14531461, 2001 96:10281030, 2006
CHAPTER 19
INPATIENT SUICIDE
Risk Assessment and Prevention

Laurie Hurson
The estimation of suicide risk, at the culmination of the suicide assessment, is the
quintessential clinical judgment, since no study has identified one specific risk fac-
tor or set of risk factors as specifically predictive of suicide or other suicidal behavior.
American Psychiatric Association 2003
Dangerousness to self is among the most com- occur annually in the United States, it is estimated
mon precipitants of urgent psychiatric evaluation, and that 1,500 take place in the hospital (American Psy-
many inpatients are hospitalized because of a recent chiatric Association 2003), in some instances while
suicide attempt or current suicidal ideation and inpatients are under the highest level of suicide observa-
tent. Once patients are hospitalized, the risk of suicide tion (Busch et al. 2003). Of the sentinel events that
often persists (Busch et al. 2003; Morgan and Priest have been reported to the Joint Commission1 since
1991; Powell et al. 2000). Of the 30,000 suicides that 1995, only wrong site surgery has been reported
1A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Seri-
ous injury specifically includes loss of limb or function. The phrase or the risk thereof includes any process variation for which
a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal
the need for immediate investigation and response (Joint Commission 2007).
267
more frequently than inpatient suicide (Joint Com- sions of guilt, and hallucinations advising suicide. The
mission 2007). amelioration of these symptoms often depends at least
Thus, it is extremely important that steps are taken in part on medical treatment (i.e., medications or elec-
to minimize the risk of suicide in the hospital. This re- troconvulsive therapy) of the underlying psychiatric
quires building physical environments that are safe yet disorders. However, it also depends on the existence of
interpersonally warm, creating therapeutic milieus a milieu that is respectful, affirming, hope inspiring,
that provide support and restore hope, and performing and attuned to discerning and responding to the
suicide risk assessments to identify individuals at par- changing states and particular needs of all patients. It
ticularly high risk for suicide in the hospital so that may include special environments such as comfort
special preventive measures can be instituted. These rooms stocked with sensory modulation materials
might be viewed as universal precautions, that is, that may soothe patients who are experiencing un-
measures that are appropriate for all inpatient settings bearable psychological anguish (see Chapter 18, Im-
and all who are treated in them. The suicide risk as- proving Safety in Mental Health Treatment Settings,
sessment will identify individuals who need additional by Huckshorn and LeBel). It may include group ther-
special precautions until imminent risk subsides. apy using techniques such as dialectical behavioral
therapy that have been shown to reduce suicidal
thinking in selected populations (Linehan 1999). It is
Universal Precautions also a milieu in which staff are aware of the need to re-
main vigilant about the risk of self-harm and prepared
Safe Physical Environments to perform thorough suicide risk assessments when
appropriate.
Although it is impossible to create an absolutely sui-
cide-proof environment, certain environmental fea- Suicide Risk Assessment
tures offer suicidal patients readily obvious opportuni-
Suicide prediction is difficult for many reasons. This is
ties to hurt themselves. These include standard glass
in large measure because the community incidence in
mirrors that might easily be broken into sharp frag-
the United States is about 11 per 100,000 per year; at
ments that could be used for cutting, clothing hooks
this rate, even an unrealistically effective predictor
on walls or doors or bathroom fixtures from which
(e.g., one with false-negative and false-positive rates of
hanging could be easily accomplished, windows that
1%, respectively) would only correctly predict about
can be opened or penetrated and through which pa-
20% of suicides (MacKinnon and Faberow 1975). Even
tients could jump, electrical outlets in bathrooms that
retrospective studies of in-hospital suicides have failed
could be used for self-electrocution, and storage of
to identify risk indicators that would have allowed for
cleaning fluids and other poisonous compounds in
the prediction and prevention of studied suicidal
places where patients might come upon and ingest
events (Powell et al. 2000).
them. It is helpful to inspect clinical spaces with the
Despite these odds it is necessary to try to identify
assistance of experienced clinicians and risk manage-
persons at risk so that preventive measures can be
ment professionals to look for particular features that
instituted. Several demographic and historical factors
pose unreasonable risk. It can also be useful to consult
have been shown to be associated with increased risk
reviews such as the Guidelines for the Built Environ-
of suicide in studies of large populations. These factors
ment of Behavioral Health Facilities developed by the
include age (risk increases with age in the United
National Association of Psychiatric Health Systems
States), sex (men commit suicide more often than
(Sine and Hunt 2003) for ideas about how best to bal-
women), race (Caucasians commit suicide more often
ance the sometimes competing values of safety and
than non-Caucasians), past suicide attempts, alcohol-
therapeutic warmth.
ism, and a family history of suicide or suicide attempts
Safe and Effective Therapeutic (American Psychiatric Association 2003). These are of
epidemiological interest and help identify cohorts of
Milieus persons at an increased risk of dying by suicide at
The reduction of suicide risk in the hospital depends some point in the future. However, even large and
on the mitigation of potentially remediable psychiatric complex instruments have limited predictive value
factors that increase imminent risk. These include (Pokorny 1983), and the task in the hospital of course
such symptoms as depression, agitation, anxiety, is not to predict ultimate prognosis but to determine
hopelessness, psychological pain, self-hatred, delu- who is at special risk in the hospital during this admis-
Inpatient Suicide: Risk Assessment and Prevention 269
sion. So what can be done by way of suicide risk as- tate clinical decisions; clinicians are left to use clinical
sessment in the hospital? judgment about the selection of interventions. How-
Early risk assessment scales were inventories of de- ever, it does ask them to make their judgments after
mographic risk factors (Range and Knott 1997) with taking these factors into account.
little, if any, documented reliability and limited dem- The risk factors are grouped into three categories:
onstration of validity. The next generation of scales in- 1) expressed intentions (i.e., what the person is ex-
cluded some that were much more extensively re- pressing explicitly by word or deed about suicidal in-
searched. Prominent among these is the Scale for tent), 2) mental status findings, and 3) aspects of his-
Suicide Ideation (Beck et al. 1979; Table 191). This tory. Because each of these risk factors should come to
scale shows excellent reliability as well as good dis- light in the course of a thorough psychiatric evaluation
criminant, construct, and convergent validity. Predic- (e.g., history and mental status examination), it is ex-
tive validitywhat we are most interested inis rela- pected that the clinician will be able to answer most, if
tively weak; of all the items, only the hopelessness not all, of these questions after completing the evalu-
item predicted eventual suicide in a 10-year prospec- ation and that little, if any, additional time will be re-
tive study (Beck et al. 1985). quired at the end of the interview to complete the
A number of other scales have been developed in re- SPSRAI.
search settings and have received variable levels of em-
pirical validation (Linehan et al. 1983). Although use- Expressed Intentions
ful research tools, they are too lengthy to be acceptable There are three expressed intentions questions on the
for routine use in most inpatient settings and in any SPSRAI: Has the person made a recent suicide at-
case have not been shown to predict in-hospital suicide tempt? Does the person have current suicidal intent?
risk. Does the person have an actionable plan? A recent sui-
A handful of shorter instruments have the advan- cide attempt is very common among inpatients; it is
tage of being potentially more practical for use in fast- often the reason for admission. This factor is impor-
paced treatment environments. These instruments tant because a history of a suicide attempt is one of the
include the SAD PERSONS scale (Patterson et al. strongest predictors of subsequent attempts (Ameri-
1983), the Nurses Global Assessment of Suicide Risk can Psychiatric Association 2003).
(Cutcliffe and Barker 2004), the Positive and Negative Current intent and a plan to commit suicide that
Suicide Ideation Inventory (Osman et al. 2002), and can be implemented in the hospital have undeniable
the Scale for Assessing Suicide Risk of Attempted Sui- face validity as clinical facts that should influence hos-
cide (Tuckman and Youngman 1968). The features of pital management, especially the level of observation.
these scales are summarized in Table 191. Although Ordinarily the combination of current intent and an
they may prove helpful in various settings, it is impor- actionable plan should occasion the highest level of
tant to recognize that the clinical utility of all such in- observation.
struments is limited [due to] high false positive and
false negative rates and. .. very low positive predictive Mental Status Findings
value... . As a result, such rating scales cannot substi-
The SPSRAI includes six mental status findings that
tute for thoughtful and clinically appropriate evalua-
are believed to have a bearing on risk. Of these, as
tion and are not recommended for clinical estimations
noted earlier, hopelessness is the best-documented
of suicide risk (American Psychiatric Association
predictor of completed suicide (Beck et al. 1985). The
2003, p. 11).
rest of the features have face validity as predictors and
are commonly cited as important modulators of risk
Sheppard Pratt Suicide Risk but have limited empirical support as predictors of in-
hospital risk. These include psychosis (Busch et al.
Assessment Instrument 2003), a wish for death, self-hatred, agitation (Busch et
al. 2003), and psychic pain. The latter two borrow
The Sheppard Pratt Suicide Risk Assessment Instru- from the insightful work of Schneidman (1999) and
ment (SPSRAI; Figure 191) was designed not as a for- correspond to his notions of perturbation and psych-
mal psychometric instrument but rather as a tool to ache. The presence of these factors should lead the
remind clinicians to consider certain risk factors and clinician to consider instituting a more intensive level
protective factors in their decisions about observation of observation even in the absence of expressed inten-
levels for newly admitted inpatients. It does not dictions to hurt oneselfbecause many patients who go
270
TABLE 191. Suicide risk assessment instruments
Overview Design Risk factors assessed Scoring Comment
Scale for Suicide Ideation
This scale was developed to 19-item scale with an Wish to live Scores for each item range from Higher total scores indicate
assess intensity of emphasis on Wish to die 0 (lowest intensity of suicidal more intense suicidal ideation
suicidal intentions. psychological variables Reasons for living/dying ideation) to 2 (highest and presumably greater
Desire to make active attempt intensity of suicidal ideation). suicide risk.
Passive death wish
Duration of ideation
Frequency of ideation
Attitude toward ideation
Control over suicidal action
Deterrents to active attempt

Reason for attempt
Planning for attempt
Opportunity for attempt
Capability to carry out attempt
Anticipation of actual attempt
Preparation for attempt
Suicide note
Final acts in preparation for death
Concealment of contemplated attempt
Nurses Global Assessment of Suicide Risk
This scale was developed in 15-item observer-rated Presence/influence of hopelessness* The presence of a risk factor Face validity and content
a mental health unit in checklist of Recent stressful life event followed by * earns 3 points; validity have been evaluated.
the United Kingdom to demographic, Persecutory voices/beliefs all others earn 1 point. Predictive validity has not
help nurses, especially psychological, and social Depression/loss of interest/anhedonia* 5 or less: Low risk been well studied as yet. It
novice nurses, evaluate features that have been Withdrawal 68: Intermediate risk presently is used in inpatient
suicide risk and shown to modulate risk Warning of suicidal intent 911: High risk settings in the United
determine the of suicide Suicide plan* 12+: Very high Kingdom and is part of the
appropriate level of Family history of serious psychiatric illness Higher levels of estimated risk Tidal Model pilot assessment
engagement. or suicide call for greater engagement procedure.
Recent bereavement or relationship loss* by clinical staff.
History of psychosis
Widow/widower
Prior suicide attempt*
Socioeconomic deprivation
Alcoholism/alcohol misuse
Terminal illness
TABLE 191. Suicide risk assessment instruments (continued)
Positive and Negative Suicide Ideation (PANSI) Inventory
The PANSI is intended to 14-item self-report scale Positive Protective Factors: A 5-point Likert scale is used: The development and
measure both negative (8 positive and 6 negative Felt you were in control 1 (none of the time) to 5 (most validation of this scale
(risk) and positive factors); time reference Felt hopeful of the time). predominantly utilized
(protective) factors. Initial for rating items is the Felt excited samples of adolescents and
items were generated in past 2 weeks, including Felt confident about abilities young adults residing in the
part from adolescent and today Felt life worth living Midwest; the findings may or
college-age men and Felt confident with plans may not be generalizable.
Inpatient Suicide: Risk Assessment and Prevention

women, with subsequent Negative Risk Factors:
refinement using a more Considered killing yourself
diverse population from a Felt hopeless and wondered
Midwestern university Felt unhappy
town. Thought you could not accomplish
Thought you could not find a solution
Felt like a failure
Thought problems were overwhelming
Felt lonely
SAD PERSONS Scale
This scale was designed to 10-item observer-rated Sex (male) The presence of a risk factor Suggested interventions are as
create a practical scale Age ( 19 or 45 years) earns 1 risk point (e.g., follows:
approach to assessing Depression 67-year-old man would 02 points: Allow the patient to
suicide risk that could be Previous attempts receive 1 point each for sex go home and follow up with a
easily learned and Ethanol abuse and age). clinician.
remembered by medical Rational thinking loss 34 points: Do close follow-up
students and Social supports lacking and consider hospitalization.
nonpsychiatric Organized plan 56 points: Strongly consider
physicians in general No spouse hospitalization, depending on
hospital settings. Sickness confidence in follow-up
arrangements.
710 points: Definitely
hospitalize.
271
272
TABLE 191. Suicide risk assessment instruments (continued)
Scale for Assessing Suicide Risk of Attempted Suicide
This scale was devised to 17-item scale of mainly Age 45 years The simple unweighted scoring In this study, the unweighted
rate the risk of eventual demographic features Male method assigns a value of 1 to score was a good predictor of
completed suicide in White each risk factor. eventual suicide rate as
individuals who Separated, divorced, or widowed expressed in suicides per
attempted suicide. The Living alone 1,000 suicide attempters.
sample consisted of 3,800 Unemployed, retired Score (rate/1,000 attempters):
individuals who survived Poor physical health 01: 0.00
a suicide attempt between Psychiatric illness 25: 6.98
1959 and 1966. Of these, Medical care (within 6 months) 69: 19.61
48 went on to commit Use of firearms, hanging, jumping, or drowning 1012: 60.61

suicide during the follow- as method
up period. Attempt during warm month
Attempt during day
Attempt at home
Immediate discovery
No mention of intention
Suicide note left
Previous threat or attempt
FIGURE 191. Sheppard Pratt Suicide Risk Assessment Instrument (SPSRAI).

Source. Copyright 2006, Sheppard Pratt Health System, Inc. All rights reserved.
on to commit suicide in hospitals show these painful Setting of Observation

symptoms but deny suicidal intentions when asked
about them directly (Busch et al. 2003). Inpatients who pose imminent risk of suicide can gen-
erally be treated in the milieu. Under rare circum-
Selected Aspects of History stances they may require separation from other pa-
tients, but under no circumstances should suicidal
The selected aspects of history include a history of al-
patients be left in seclusion alone and unobserved.
cohol or drug abuse, a history of suicide in a friend or
Private rooms may be appropriate places for such ob-
relative, a recent severe stressor, and the absence of so-
servation, but it is important to be mindful of the risks
cial support from individuals, employment, or reli-
associated with such commonplace features as win-
gious affiliation. Lack of support is really the absence
dows (Can patients break through?), windowsills (Can
of significant protective factors, because it is widely be-
patients stand on them and jump to the floor?), walls
lieved that social support from individuals, employ-
(Can patients strike them with their heads?), ventila-
ment, and religion makes suicide less likely to occur
tion grating (Can metal elements be broken free and
(American Psychiatric Association 2003).
used for cutting?), wall-mounted fixtures (Can pa-
Use of the Instrument tients hang from them using cords, clothing, or bed-
ding?), movable furniture (Can it be used as a barri-
The recommended practice in our hospital is that the cade or as a platform on which patients can stand to
assessment is performed at the time of admission and get access to ceiling-mounted fixtures?), and doors
that staff are alert to changes in status along these di- (virtually every door is a potential gallows).
mensions during the hospitalization. There should be
a formal reassessment whenever there is consider- Access to Clothing and Belongings
ation of making the level of observation less intensive.
Other times when it is important to perform and doc- Suicidal patients may harm themselves in countless
ument such an assessment are when the patients ways; it is impossible to anticipate every conceivable
mental status changes suddenly and when acute psy- method. Because hanging is a common method of in-
chosocial stresses come to light in the course of the patient suicide, it is important to control the access of
hospitalization (American Psychiatric Association suicidal inpatients to belts, ropes, cords, and even cloth-
2003). ing that might prove a ready means of hanging. It is im-
portant to remember that belts, sheeting, and other
forms of clothing can be used for self-asphyxiation even
Special Precautions in the absence of a fixture from which to hang; self-as-
phyxiation may be accomplished by swallowing mate-
rial in a manner that occludes the oropharynx or by ty-
Frequency and Proximity ing a belt or article of clothing around the neck and
of Observation cinching it tightly in a manner that holds it in place and
effectively compresses the trachea. It is also important
When the clinician performing the suicide assessment
to be aware that inpatients may stockpile medications
arrives at the judgment that the patient poses immi-
(administered but not swallowed) and hide them in
nent risk of suicide in the hospital, the usual response
mattresses, wadded paper in wastebaskets, and even
is to place the patient under an intensive form of ob-
body cavities and use them for suicidal overdoses.
servation. Patients deemed at the highest level of risk
may need the full attention of a staff member stationed
Policies
no more than one arms length away at all times; this
is sometimes termed one-to-one or intensive suicidal Inpatient units must make decisions about the types of
observation. Patients presenting lower levels of risk observation options to utilize, the settings in which to
may be placed under continuous observation (i.e., al- implement them, and the limitations on access to
ways directly in view of an assigned staff member) or clothing and other belongings that should be applied
may be subject to documented checks at intervals of when the clinician makes the judgment that the risk of
no greater than 5, 10, or 15 minutes. Such checks suicide is high and immediate. These decisions should
should not occur at predictable times (e.g., not exactly be formalized into policies with which staff members
every 5, 10, or 15 minutes) and should be documented become familiar at the time of orientation and about
as they occur. which they receive regular in-service training.
Suicide-Prevention Contracts mated to pose high risk of suicide in the hospital, a va-
riety of special precautions may be instituted; most of-
ten these includeat a minimumintensive levels of
Clinicians sometimes ask their inpatients to contract observation, restricted access to personal belongings,
for safety or to commit to a no-suicide contract and a reconsideration of the treatment plan. Unfortu-
that is, a promise to refrain from suicidal behavior and nately, such measures will not prevent all instances of
to inform the treatment team if they become unable to inpatient suicide, but a systematic effort to create an
control the urge to engage in self-harm (Martin 1999). antisuicidal environment and a therapeutic program,
Such a measure may be a way of pursuing inquiry into including thorough and timely suicide risk assess-
the patients intentions or a way of communicating ments, will reduce clinical risk and legal liability and
concern for safety, particularly when there is a strong will serve to reassure the staff that everything possible
therapeutic alliance. However, because it only touches is being done to prevent this most tragic and demoral-
on a patients intentions with regard to suicidal behav- izing complication of psychiatric illness.
ior (i.e., expressed intentions) and does not take into
account relevant aspects of mental status or history,
the safety contract does not in itself constitute a com- References
plete assessment of suicide risk. It also does not pro-
tect the clinician against potential liability in the event American Psychiatric Association: Practice Guideline for the
that the patient commits suicide. Thus, such a con- Assessment and Treatment of Patients With Suicidal
tract cannot be viewed as a substitute for the perfor- Behaviors. Washington, DC, American Psychiatric Pub-
mance and documentation of a thorough suicide risk lishing, 2003
Beck AT, Kovacs M, Weismann A: Assessment of suicide in-
assessment (American Psychiatric Association 2003).
tention: the Scale for Suicide Ideation. J Consult Clin
Psychol 47:343352, 1979
Beck AT, Steer RA, Kovacs M, et al: Hopelessness and even-
Conclusion tual suicide: a 10-year prospective study of patients hos-
pitalized with suicidal ideation. Am J Psychiatry
142:559563, 1985
As many as 1,500 inpatient suicides may occur annu- Busch KA, Fawcett J, Jacobs DG: Clinical correlates of inpa-
ally, and inpatient suicide remains one of the most tient suicide. J Clin Psychiatry 64:1419, 2003
commonly reported Joint Commission sentinel Cutcliffe JR, Barker P: The Nurses Global Assessment of Sui-
events. Because many persons receiving inpatient psy- cide Risk (NGASR): developing a tool for clinical prac-
chiatric care continue to be at risk of harming them- tice. J Psychiatr Ment Health Nurs 11:393400, 2004
Joint Commission: Sentinel Event Statistics. Oakbrook Ter-
selves after admission, certain measures (i.e., univer-
race, IL, The Joint Commission, 2007. Available at:
sal precautions) are appropriate in virtually all hospi- h tt p:/ /www.joint comm iss ion.org/N R /rd onlyres/
tal settings. These include physical environments that DB894476-8834-4798-AA11-77E4FC3F1D78/0/SE_
are free of ready access to common means of inpatient Stats_033107.pdf. Accessed September 18, 2007.
suicide, clinical milieus that provide timely relief of Linehan MM: Standard protocol for assessing and treating
suicidal behaviors for patients in treatment, in Harvard
symptoms that may precipitate suicide attempts, and
Medical School Guide to Suicide Assessment and Inter-
careful assessments of suicide risk that are made at the vention. Edited by Jacobs D. San Francisco, CA, Jossey-
time of admission and at critical junctures thereafter. Bass, 1999, pp 8397
Although there is no scale or set of risk factors that re- Linehan MM, Goodstein JL, Neilsen SL, et al: Reasons for
liably predicts inpatient suicide, it is generally agreed staying alive when you are thinking of killing yourself:
that a thorough suicide risk assessment includes con- the Reasons for Living Inventory. J Consult Clin Psy-
chol 52:276286, 1983
sideration of the patients expressed intentions, the
MacKinnon D, Faberow NL: An assessment of the utility of
presence of certain mental status findings, and certain suicide prediction. Suicide Life Threat Behav 6:8691,
psychosocial, demographic, and historical features. 1975
Many of these are aggregated in the SPSRAI, a tool that Martin MC: Suicide-prevention contracts: advantages, dis-
is designed to cue the clinician to consider all these fac- advantages, and an alternative approach, in Harvard
Medical School Guide to Suicide Assessment and Inter-
torsnot only expressed intentionsin arriving at an
vention. Edited by Jacobs D. San Francisco, CA, Jossey-
estimation of suicide risk and a decision about which, Bass, 1999, pp 463482
if any, special suicide precautions may be necessary. A Morgan HG, Priest P: Suicide and other unexpected deaths
safety contract by itself does not constitute an ade- among psychiatric inpatients: the Bristol confidential
quate suicide risk assessment. When a patient is esti- inquiry. Br J Psychiatry 158:368374, 1991
Osman A, Barrios FX, Gutierrez PM, et al: The Positive and Schneidman E: Perturbation and lethality, in Harvard Med-
Negative Suicide Ideation (PANSI) Inventory: psycho- ical School Guide to Suicide Assessment and Interven-
metric evaluation with adolescent psychiatric inpatient tion. Edited by Jacobs D. San Francisco, CA, Jossey-
samples. J Pers Assess 79:512530, 2002 Bass, 1999, pp 8397
Patterson WM, Dohn HH, Bird J, et al: Evaluation of suicidal Sine D, Hunt J: Guidelines for the Built Environment of Be-
patients: the SAD PERSONS scale. Psychosomatics havioral Health Facilities. Washington, DC, National
24:343349, 1983 Association of Psychiatric Health Systems, 2003. Avail-
Pokorny AD: Prediction of suicide in psychiatric patients: re- able at: http://www.naphs.org/Teleconference/docu-
port of a prospective study. Arch Gen Psychiatry ments/REV9editedFINAL_001.pdf. Accessed September
40:249257, 1983 18, 2007.
Powell J, Geddes J, Deeks J, et al: Suicide in psychiatric hos- Tuckman J, Youngman WF: A scale for assessing suicidal
pital inpatients. Br J Psychiatry 176:266272, 2000 risk of attempted suicide. J Clin Psychol 24:1719,
Range LM, Knott EC: Twenty suicide assessment instru- 1968
ments: evaluation and recommendations. Death Stud
21:2558, 1997
CHAPTER 20
DISCHARGE DILEMMAS
John R. Lion, M.D.
Caretakers of todays hospitalized patients often find acquired by a lengthy hospital stay, staff face more
themselves uneasy about discharging those patients unknowns. In a sense, the patient remains largely a
when insurance companies threaten to deny further stranger to those who observe him or her for only a few
care. Hospital stays have become very brief, thus af- days or weeks. In past decades, relationships between
fording acutely suicidal or homicidal patients little doctors and nurses provided a measure of assurance
time for meaningful intrapsychic change. A week in- when it came time to leave the hospital. Patients were
house may well remove the patient from a pathologi- weaned from the hospital slowly, first tested with over-
cal family or relationship and relieve hostilities or de- night and weekend stays, and even allowed to have a
spair, but the patient is apt to return to exactly what he job and return to the hospital at night. Graduated dis-
or she left behind. A day hospital eases reentry, but not charge of this sort has long passed as any standard of
all patients are financially eligible for even this brief care. Yet even in these times of abbreviated stays, dis-
transition. Consequently, increasing numbers of pa- charge from any psychiatric hospital is always a major
tients are referred for consultation concerning the psychological event. The hospital provides a nurturing
safety of discharge. Often this consultation is labeled milieu in sharp contrast to the homes and situations
forensic, although rarely is there a legal problem. In- from which many patients come. Although the patient
stead, the issues at stake are clinical and pertain to may clamor to be released, anxieties are high and ex-
dangerousness. Although the overt and recurring pectations are frequently urgent and unrealistic.
question posed is whether or not the patient is safe
enough to leave the hospital, a persistent underlying
anxiety pertains to a possible lawsuit and the clini-
On No Longer Being Suicidal
cians major worry is that he or she will discharge a pa-
tient who will shortly thereafter harm him- or herself Assessing a patients suicidality or intent to harm oth-
or others. Given the lack of intimate knowledge about ers is complex and cannot possibly be addressed by
the patient and his or her family, which could be merely asking the patient a yes or no question. Yet
277
this is the schematic whereby insurance providers al- unfortunate event, the less likely it would seem that
low or deny additional care. That a patient would the clinician can be blamed for his or her decision to
come into the hospital because of an overdose and de- release the patient. In reality, doctors can be sued for
clare him- or herself no longer suicidal a few days later the acts of their patients committed months and years
defies a certain credibility. True, the patient may no later, even though the causality of events appears
longer have the same lethal intent, but the profound weaker and attendant publicity may be far less harsh.
underlying damaged self-esteem and rage toward the Sometimes, patients are generically classified as high
self still exist and are not eradicated by any pharmaco- or low risk on the basis of a checklist of behaviors such
logical regimen or group therapy. They have merely, as previous violence, alcohol use, delusions, command
for the moment, subsided in strength. Unfortunately, hallucinations, and the like (Lion 2003). A high risk
the moment that patient professes to anyone that he score leads to retention in the hospital, whereas a
or she no longer wants to commit suicideand trig- low risk justifies discharge. Risk factors are surely im-
gers a chart note to that effectthe discharge die is portant on their own, but an actual description of what
cast, even if the note is authored by the least trained constitutes the specific danger is more clinically useful
member of the mental health staff. A reviewer is quick than assigning the patient a generic category. Besides,
to seize upon such documentation. An attempt to these days many patients are discharged with a signif-
undo such a statement requires a consultant with ex- icant degree of risk anyway, thus diluting the utility of
pertise in suicidal behavior. That consultants report the term.
may be used as a bargaining chip to keep the patient
longer, but too often the extension of stay is a token
gesture of a few days. Although insurance companies Limitations of the Database
may understand the prophylaxis of intensive treat-
ment for heart or renal disease, they are not persuaded
that the urge to die is deeply configured within the Risk assessment relies upon certain facts both ob-
patient who considers or attempts it. In a sense, sui- served by talking with the patient and obtained from
cidality never fully disappears as a psychic agenda; it information related by nurses and social work staff.
ebbs and flows, as does the urge to physically harm Surprisingly, the medical record or chart is a limited
others. Unfortunately, the great pressure to admit and source of information. This is because chart notes are
discharge patients from the hospital has obliterated often reductionistic and frequently redundant (Pa-
the enormity of the problem. Some clinicians come to tient doing better, interacted well on the unit, attended
accept an insurance industrydriven view of mental group therapy). Under the pressure of time, process
illness to the point of being cavalier. They may have a descriptions of patients illnesses have given way to
secretary call to schedule the forensic consult as a objective statements of behavior. The following case
mere perfunctory measure and be absent when it takes example illustrates these complexities.
place. Other clinicians themselves call for the consul-
A mildly retarded adolescent was admitted after
tation and, more anguished about the fragility of dis-
threatening to burn down the group home in which
charge events, seek the consultants view of existing she resided. She had been in many homes and was
risk factors such as a spouse who still wishes to leave often expelled from them for insubordinate behavior
the marriage, the patients own motivation for ther- and fighting. She had made previous statements
apy, the presence of delusions, and so forth. In the end, about burning down the places in which she had
however, a decision must be reached as to whether the lived, but to the extent it could be determined, no
fires had actually ever been set. She had been ar-
patient is acutely dangerous. Acutely dangerous gen-
rested once as a minor for a marijuana charge.
erally invokes the concept of imminent. Much has Within the hospital, she was sullen and slept as
been written about the medicolegal complexity of this much as she could. She participated minimally in
term (Simon 2006); in brief, one practical definition is any ward activities and steadfastly denied that she
that imminent means hours or days, not weeks or had ever threatened fires. She presented as a mildly
angry young woman with no insight and an adamant
months. Thus having decided that a patient is not im-
desire to leave the hospital and return to the home
minently dangerous, the clinician can presumably dis- from which she had come. The home agreed to take
charge the patient without worry about the long-term her back.
future. Yet does any time parameter really protect a
caretaker from being sued? The matter is not simple. The issues here obviously pertain to the risk of a
The greater the interval is between discharge and an very dangerous behavior, but data to support the dan-
Discharge Dilemmas 279
gerousness were lacking. Given all the predictive fac- the repudiation of his grandparents and mother, it was
tors available for the assessment of violence, the past obvious that he required some form of continued par-
history of violence still remains as a prime determinant tial hospitalization. He was transferred to a quarter-
(Monahan et al. 2001). Another factor is drug abuse. In way house but immediately eloped from that facility.
this case, there is a history of cannabis use, but such us- Staff promptly wondered about seeking an emergency
age is rarely accompanied by assaultive behavior, as op- petition whereby he would be detained by the police
posed to alcohol, the substance ubiquitously associated and brought to a local emergency department for ex-
with all forms of violence. Absent any demonstration amination. In such situations, it is often useful to en-
of aggressiveness on the ward and only a chronically vision worst-case scenarios as a measure of dangerous-
sullen demeanor, verbalized threats were the only data ness. For example, it was presented to the staff that the
on which to base an assessment of risk. In such in- man could go to the very home in which he was not
stances, staff impressions are important. The consul- wanted, start an argument, and become homicidal.
tant can solicit various views of individual staff mem- His rage could be fueled by illicit drugs. Liability ap-
bers or attend a staff meeting to gather a consensus. In peared very great, particularly because family mem-
the end, however, risk relates to where the patient is ac- bers had specifically told staff that they feared him and
tually discharged. Discharging a patient in the commu- did not wish him back. In light of these considerations,
nity at large or to an uneducated family carries many it was decided that the hospital would be better served
unknowns. Lack of supervision is likewise itself a risk. if staff acted proactively and filed an emergency peti-
When unsure, discharge to a structured setting such as tion. Fantasizing outcomes is an important process in
day care or a halfway house allows for more observation risk assessment, although consultants must appreci-
and reduces risk. A group home, such as the one the ate that discussions of worst-case scenarios may well
patient ultimately went to, offers safeguards, albeit evoke anxiety in staff. Still, under the pressure of dis-
limited ones and for a short time only. The next case il- charge and the rapidity of patient turnover, treating cli-
lustrates more dire circumstances associated with dis- nicians may feel themselves to be mere triage agents
charge in the face of limited data. who address the acute crisis only, leaving the patient to
be followed by someone else. Regrettably, finding a
An 18-year-old brain-damaged and immature man place to send a patient for further treatment is far more
was admitted after threatening to assault the grand- time-consuming than hospital treatment itself. Lim-
parents with whom he lived. He had destroyed prop- ited time also enters the equation when carefully doc-
erty as well. Both grandparents left insistent mes-
umenting the reasoning for discharge in the face of cer-
sages on the social worker s phone to the effect that
he was not safe to ever return home. Even the mans tain dangers. Liability is generated when no record is
biological mother, who lived apart from her son, left made of a risk decision that goes awry. If, instead, the
such warnings. The man himself had been arrested clinician notes the parameters of the risk and articu-
for stealing a motorcycle and had a history of drug lates the decision-making process, malpractice is far
abuse. On admission, he had been paranoid and de-
less apt to be successfully proven in a legal action. All
lusional. Suicidal threats had also been uttered, al-
though on examination he denied both homicidal too often, the chart may contain numerous admission
and suicidal urges. The man talked vaguely about entries regarding the patients suicidal thoughts. Sub-
having set a fire in his home but refused to elaborate, sequent progress notes then benignly comment on the
and no further information could be obtained. patients behaviors within the hospital up to the time
of discharge, without further mention of what hap-
This case posed more serious problems of risk, not pened to the patients original desire to harm him- or
only because of previous violence toward property but herself; to the outside observer, the suicidal thoughts
also because the patient had been psychotic as a result or intentions have simply evaporated or, far worse,
of his drug abuse. However, an overwhelming issue af- been ignored by staff. For example, a discharge note
fecting risk was the massive rejection from his entire should state: Patients threat to himself temporarily
family. The fire-setting incident could not be investi- resolved by meetings with girlfriend. He is no longer
gated in the short time he remained on the ward, a acutely suicidal. Girlfriend more aware of hazards of
rather typical occurrence unless the crime can be iden- ambivalence in her behavior toward patient. Weapons
tified. Some states, such as Maryland, have public Web removed from home. Patient scheduled for visit with
sites for criminal convictions. In light of the patients outpatient psychiatrist at end of week and will attend
prior history of homelessness, his apparent use of a Alcoholics Anonymous. Risk factors and readiness for
drug that was thought to induce a psychotic state, and discharge reviewed by consultant.
Pathological Attachments In this case, staff felt sufficiently hopeful in pointing

out the pathological interactions between patient and
girlfriend that discharge seemed possible. It should be
Cases in which the patient is admitted because he or stated that long-term abusive relationships pose par-
she is suicidal or homicidal after the breakup of a ro- ticular discharge problems because the hospitalized
mance are common and pose significant discharge patient is almost always quickly remorseful and as ea-
problems. For one thing, the patient has been removed ger to return home as the victimized spouse is to have
from the source of the agony and, for the moment at him back. The clinician must recognize that nothing
least, is not confronted with the rejection. Thus the has actually changed between both parties and that the
hospital is not a true test of what will happen once dis- possibility of violence remains high, even though it
charge occurs and the patient returns to the commu- may not be acute. Thus, consideration should be given
nity. Second, the rejecting lover may be ambivalent to discharging the patient to a partial care facility, al-
about ending the affair. Third, the mere fact that the ways an unpopular choice in these circumstances,
rejection has spawned suicidality reflects the patients when both parties are so needful of one another.
own inner depletion and hopelessness. Thus the pa-
tient is already at risk for self-harm. Here the social
worker member of the staff is most helpful to the eval- Victims
uating consultant by advising him or her about the
true finality of the breakup and whether rejector or re- The next two cases highlight the crucial matter of
jectee are still in contact with one another. The follow- working with potential victims.
ing case illustrates these issues.
A 30-year-old worker was angry with his manager for
A 31-year-old unmarried man was admitted for ho- bypassing him in a promotion. He was a paranoid
micidal and suicidal ideation after he witnessed his man and harbored vague thoughts of harming the
prostitute girlfriend performing sex with another manager. He owned a gun. The patient was not
customer. The patient had fully recognized her pro- deemed to be acutely homicidal, but staff were still
fession, and he had been able to use denial in watch- divided about how to handle the discharge. Some felt
ing her enter cars and drive off with clients. However, a formal warning to the manager was indicated,
when he actually saw what she did, his rage erupted. whereas others thought that such a tactic would
He hit her before police intervened to have him hos- worsen the situation by possibly leading the manager
pitalized, and he threatened her with his revolver. In to fire the patient. The resolution appeared possible
the past, the patient had cut his wrists and over- by having the patient call the manager himself, ver-
dosed. The girlfriend called him at the hospital to in- balizing how unfairly he felt he had been treated and
quire how he was. On the ward, the patient denied asking how the situation could be remedied. This in-
any further desire to harm her and declared that he tervention proved successful by making the patient
was ready to leave. feel far less helpless.
This patient had reached a certain tenuous equilib- A controversy existed as to whether having the pa-
rium that, unfortunately, is the hallmark of today s tient confront the manager would be ameliorative of
criteria for discharge. His insurance company contin- risk or worsen the situation. This is always an issue
ually demanded to know if he was still dangerous and when little or nothing is known about how a victim
when told by the treating doctor that he indeed was, re- would react. It is a compelling argument for supervised
luctantly granted him an additional few days of stay. meetings within the hospital with staff present. Con-
Perhaps the chief utility of these added days was to frontations between patient and victim are best pre-
arrange a meeting with the girlfriend to assess how pared by rehearsal, such as role playing, so that the pa-
aware she really was of the patients dangerousness tient can, to some extent, anticipate the would-be
and what role her behavior played in the matter. Meet- victims negative reactions. Anxiolytic medication
ings of this sort remain crucial parameters to assessing may be useful in preparation for the meeting or, in this
the risk of discharge. When such a meeting is not pos- case, the phone call. In some cases, this interaction
sible or successful, and little dynamic change has oc- with the victim almost entirely dictates the outcome of
curred in either party, then the issue of a Tarasoff the case and the disposition at discharge. The follow-
warning is always raised (Gellerman and Suddath ing case example illustrates this principle of assessing
2007). Yet a formal warning is always clinically infe- dangerousness not by concentrating on the patient but
rior to any insights that could be achieved through a by focusing on the victims specific intentions at the
therapy session involving the perpetrator and victim. time of discharge.
Discharge Dilemmas 281
A 30-year-old woman with bipolar illness attempted teria to trap students he would then kill. He was
to buy poison and was intercepted by the police when ultimately discharged to a partial care facility.
the merchant reported the act. Questioned by au-
thorities, she related that she had intended to kill her The dismay of hospital staff caring for this patient
husband because he had refused to help her reduce a was palpable, particularly in light of the fact that the
large debt she had incurred during a manic episode.
college shootings had occurred only a month earlier.
The husbands immediate reaction was to announce
his intent to divorce her, but he reconsidered and, ac- The boy himself had received a diagnosis of Asperger s
cording to the patient, decided that he would accept syndrome, further alarming all concerned because
her back home after hospitalization. The clinician they saw a patient who had few social skills and little
caring for the patient asked for a consultation to de- empathy. Although well behaved within the hospital,
termine the patients safety for discharge. He had not
he remained quite aloof on the ward and inappropri-
met with the husband and considered the latter
somewhat irrelevant to the problem of danger. ately related his story to anyone who would listen. His
father owned weapons that, despite all that had oc-
Here, much hinged upon the husbands decision, curred, were still in the home. This fact alone height-
its lack of clarity, and the preciseness of his commu- ened the patients dangerousness and is a variable
nication with the patient. The patient could certainly about which inquiry should routinely be made. Con-
not be discharged outright to her home if the husband tributing to the patients high risk was his emotional
still harbored the decision to separate or divorce. On coldness. Absent from the case was a hit list, as
the other hand, an unmitigated decision on his part to sometimes seen in would-be school shooting cases
take her back in the face of her homicidal intent where students write down names of others they are
seemed most unusual and would surely require explo- angry with, or any bizarre drawings of mutilation or
ration. Thus, much work needed to be done to evalu- dismemberment, as are also sometimes found. The
ate the husbands mental state as well as the patients, consultant should always ask about such items, be-
and some degree of finality about the marriage was a cause a preoccupation with the imagery of violence or
prerequisite to safe discharge. In any event, the patient the construction of a list of victims may represent a
needed to be discharged to a partial care facility that preparatory step to the actual act. It is also the task of
could monitor both her unstable mood disorder and the evaluating clinician to ascertain to what extent the
her deranged thinking. threatener is physically capable of carrying out the act.
In the case of bomb threats, for example, the student
may have read about the construction of the device on
Copycat and Threat Cases the Internet but has not collected any of the necessary
ingredients to make him or her an acute danger. A re-
lated problem occurs when students make threats to
Highly notarized school shootings consistently evoke
hurt teachers or harm school property and, upon ex-
copycat threats in a small group of students who come
amination, deny true intent or claim the threat to be a
to the attention of teachers or counselors and are ur-
joke or prank. Here the consultant must remember
gently hospitalized. In most cases, the behaviors re-
that whether the threat is actual or not, the mere ver-
flect the poverty of judgment associated with immatu-
balization of it represents deviant judgment that must
rity or a highly pathological need for attention which,
be explored. Meetings with parents or caretakers are
although alarming, is not reflective of true dangerous-
almost always indicated. Although nowadays arranged
ness. However, a small percentage of this population
with difficulty, psychometric assessment with an em-
represents difficult risk assessments because the stu-
phasis on projective testing can shed some light on
dents preoccupation with violence appears excessive.
both the primitiveness of the patients thinking and
The following case example illustrates this matter.
his or her preoccupation with themes of violence.
Following the Virginia Tech massacre of students, a
15-year-old student was hospitalized after stating
that he wished more students had died. He further
Sexual Predatoriness
stated that he wanted to procure an assault rifle, and
this prompted police intervention. His parents re- Patients who find their way into the hospital because of
lated a history of his mutilating animals and found a
sexual concerns typically have comorbid illnesses such
collection of news clippings from the Columbine
killings. The patient himself presented with a chill- as mania or mental retardation. On rare occasions, an
ingly flat affect and inappropriate smiling as he re- attorney may advise a client to enter the hospital to
lated his desire to block the doors of the school cafe- impress the court or as an alternative to incarceration.
Patients with a pure paraphiliac condition, such as pe- ple maneuver that would have a greater deterrent effect
dophilia, should always be considered high-risk cases than any intervention with the patient. Additionally,
because the disordered behavior carries with it a high discussion ensued regarding how the victims family
degree of recidivism (Laws and ODonohue 1997). could somehow be included in a therapeutic meeting or
More passive criminal acts, such as exhibitionism, otherwise be informed about the patients condition
carry a smaller risk of escalating into predatory acts. without completely compromising privacy. These were
On the matter of discharging patients to the police, admittedly unusual recourses, but they again empha-
this should be carefully orchestrated so that sufficient size the point that whenever the victim or victims fam-
numbers of staff are present as a show of force. Occa- ily can be brought into the picture, the better the clini-
sionally, a patient may threaten suicide as a means of cal control becomes. Taking an adversarial stance in
forestalling the arrest or detention that will occur upon treating potentially dangerous patients by champion-
discharge. To distinguish true intent from manipula- ing their privacy and excluding any intervention with a
tiveness can be difficult, and it becomes untenable to victim compromises a safe discharge.
keep the patient in the hospital indefinitely while in-
carceration looms as the inevitable outcome. Assum-
ing there is no treatable depression, one strategy is to
Conclusion
ultimately discharge the patient with a written com-
munication to authorities that a suicidal threat has Dangerousness is a common presenting behavior in
been made. Such threats are familiar to prison officials todays hospitalized patients. The shortness of stay
who have some skills in management. On occasion, a precludes the resolution of many conflicts that, at the
male patient may be admitted for assessment of risk in time of discharge, remain worrisome. Rarely does sui-
connection with some inappropriate touching that has cidal or homicidal ideation simply disappear in the
occurred in an institutional setting, or the patient may course of brief treatment. This, coupled with limited
have made inappropriate sexual remarks with content observational knowledge of the patient, imposes a
alluding to violence, such as rape. Admissions of this higher level of stress on the hospital treatment team.
type are typically charged with high emotions. Veiled Risk assessment encompasses not only the patient
threats about the potential sequelae of premature dis- but also potential victims, and creative incorporation
charge can be made by the potential victim and his or of the victim in discharge planning is important. Out-
her family or spouse. Denial is apt to be the rule, and right discharge is more the exception than the rule.
an absence of insight is almost invariably present. The Good documentation of the justifications for dis-
following example is illustrative. charge is protective against litigation.
A 13-year-old boy with Asperger s syndrome was ur-

gently admitted after telephoning a neighbor s References
daughter and threatening to rape her and get her
pregnant. On the hospital unit, he remarked to a
pregnant staff member that he wished to cut out her Gellerman DM, Suddath R: Violent fantasy, dangerousness,
fetus. He smiled as he related this incident and had and the duty to warn and protect. J Am Acad Psychiatry
virtually no awareness of the impact of his actions. Law 33:484495, 2007
Laws DR, ODonohue W (eds): Sexual Deviance: Theory,
Had this boy been older, the risks of discharge Assessment, and Treatment. New York, Guilford, 1997
Lion JR: A primer on workplace violence assessment for the
would be considerably higher than they were. Nonethe- front-line clinician. Clin Occup Environ Med 3:791
less, staff were worried not so much about the physical 802, 2003
act of rape but about his again threatening his victim, Monahan J, Steadman HJ, Silver E: Rethinking Risk Assess-
given his impoverished social skills and lack of intro- ment: The MacArthur Study of Mental Disorder and
spectiveness. In meetings with staff, it became appar- Violence. Oxford, England, Oxford University Press,
2001
ent that there existed some communication between
Simon R: The myth of imminent violence in psychiatry
the victimized girls parents and the patients parents. and the law. Univ Cincinnati Law Rev Winter:631643,
That being the case, the suggestion was made that the 2006
girls parents obtain an unlisted phone number, a sim-
Part III
THE CONTINUUM
OF CARE
CHAPTER 21
RESIDENTIAL PSYCHOTHERAPEUTIC
TREATMENT
An Intensive Psychodynamic Approach
for Patients With
Treatment-Resistant Disorders
Edward R. Shapiro, M.D.

Eric M. Plakun, M.D.
Changes in Health Care and the planning aimed at moving patients quickly to less re-
strictive and usually outpatient settings. In response to
Problem of Treatment Resistance these changes, a number of high-quality, long-term
treatment centers closed their doors, patient readmis-
The transformation of both the delivery and funding of sions to inpatient hospitals increased, and the doctor
health care in the last part of the twentieth and early patient relationship continued its transformation from
twenty-first centuries had a dramatic impact on the na- an intimate encounter to a bureaucratically structured
ture of hospital psychiatry. Increasing recognition of negotiation of the need and terms of treatment with
escalating health care costs led to the emergence of third-party payers (Geller 2006; Plakun 1999; E.R.
managed care, with a concomitant decrease in length Shapiro 2001b).
of inpatient psychiatric stays, a shift in inpatient focus Although many patients struggling with mental ill-
from definitive treatment to crisis intervention, more ness have benefited substantially from advances in
attention to biological treatments, and early discharge biological treatments and short-term cognitive-behav-
285
ioral interventions, available data indicate the limita- their outpatient treatments with efforts to ward off the
tions of these approaches. For example, perhaps one- next suicide attempt or the need for another hospital
third of patients with schizophrenia fail to respond or stay. For some the risk of suicide has been the central
respond inadequately to antipsychotic medications issue keeping them in a state of crisis; for others it has
(American Psychiatric Association 2004), whereas been chronic inability to manage the transition from
nearly 75% of patients in the Clinical Antipsychotic the role of child in the family to that of functioning
Trials in Intervention Effectiveness study discontin- and autonomous adult in the world.
ued the study medication regimen before 18 months In our own focus group discussions with graduat-
of treatment (Lieberman et al. 2005). Between 15% ing psychiatric residents and practitioners in New York
and 50% of patients with mood disorders are treat- City, Chicago, and Los Angeles, we heard the repeated
ment resistant (Foa and Davidson 1997; Thase et al. view that patients with treatment-resistant illnesses
2001), and only a minority of these fully recover on were inevitably doomed to chronic crisis management.
medications alone (Rush and Trivedi 1995). Results Many of these clinicians believed that there were no
from the STAR*D trial of treatment for patients with specialized resources for these patients beyond what
major depressive disorder demonstrate that substan- they could find in their own urban setting or region.
tial numbers of patients fail to respond adequately
either to initial treatment or various switch or aug-
mentation strategies, including short-term cognitive- Intensive Residential Treatment:
behavioral therapy (Thase et al. 2007). In adolescents
with depression there are also significant rates of treat-
The Austen Riggs Center
ment resistance (Apter et al. 2005; Treatment for Ado-
lescents With Depression Study Team 2003), and, for Longer-term treatment is generally utilized for those
the subset of patients with chronic major depressive patients with disorders that fail to respond or respond
disorders and histories of serious childhood trauma or inadequately to outpatient treatment and short-term
abuse, there is evidence that psychotherapy may be inpatient settings or who have difficulty sustaining in-
more effective than medication (Nemeroff et al. 2003). dependent functioning. Several specialized inpatient
For patients with bipolar disorder, the Systematic settings offer longer-term treatment ranging from 1 to
Treatment Enhancement Program for Bipolar Disor- a few months (Menninger, Sheppard Pratt, McLean,
der study reports that only slightly more than half and others), but for patients whose treatment-refrac-
achieved recovery, and half of these had recurrences tory disorders require a more extended period of treat-
within 2 years (Perlis et al. 2006). Miklowitz et al. ment, residential programs with a continuum of care
(2007) demonstrated that intensive longer-term psy- that allows progressive step-down in staffing intensity
chosocial treatment as an adjunct to pharmacother- and cost, such as that provided at the Austen Riggs
apy is more beneficial than brief treatment in enhanc- Center, are often required.
ing stabilization from bipolar illness. The range of available residential settings is fairly
The presence of personality disorderparticularly wide, including some programs offering primarily cus-
borderline personality disordermakes a significant todial care for patients whose illnesses fail to respond
contribution to treatment resistance in mood disor- to usual treatment and have become chronic (often pa-
ders. Data from the Collaborative Longitudinal Per- tients with psychotic spectrum or pervasive develop-
sonality Disorder Study suggest that personality disor- mental disorders). Many of these programs are behav-
ders adversely affect the prognosis of major depressive iorally focused, and some use token economies. Some
disorder and are in themselves significantly associated longer-term residential programs offer a work environ-
with persistent functional impairment, extensive ment with psychiatric support within a home, farm, or
treatment utilization, and significant risk of suicide guesthouse milieu.
(Bender et al. 2006; Skodol et al. 2005). It is not sur- There is evidence, however, that for patients with
prising, then, that treatment-resistant illnesses are ex- severe personality disorders an extended residential
pensive. The cost of treating patients with treatment- treatment program with a psychodynamic focus and a
refractory mood disorders, for example, is 19 times continuum of care promotes social adaptation, re-
higher than the cost associated with treating more reduces symptoms (including the frequency of self-harm
sponsive patients (Crown et al. 2002). and suicide attempts), and decreases the length and
Patients with these treatment-resistant illnesses frequency of readmission (Chiesa et al. 2004). In ad-
are often caught up in repeated and ongoing crises in dition, data from Austen Riggs (Fowler et al. 2004;
Residential Psychotherapeutic Treatment 287
Plakun 2003; Perry et al., in press) suggest that longer- been able to benefit from treatments of lesser intensity
term psychodynamic residential treatment with step- and have been unable to sustain functioning between
down programs can be useful for that subset of pa- outpatient sessions without the support of chronic cri-
tients with treatment-refractory Axis I disorders who sis management. They demonstrate repeated struggles
have comorbid Axis II disordersespecially when with authority deriving from early family dynamics, of-
there is a history of prominent early trauma, abuse, ten presenting histories of family conflict around the
loss, deprivation, or neglect. management of relationships and generational role
For this last group, treatment resistance is often a boundaries (Berkowitz et al. 1974; E.R. Shapiro 1982a;
phenomenon related to personality pathology, ordi- E.R. Shapiro and Freedman 1987; E.R. Shapiro et al.
narily manifest in disturbances in interpersonal relat- 1975). In response to problematic family dynamics,
edness. Organizing treatment around these personality their struggles with authority contribute to consider-
resistances offers a focused and precise intervention. able and frequently unconscious rage at clinicians who
This group of patients may be able to use a longer-term take up the authority role (Prelinger 2004; E.R. Shapiro
hospital or residential treatment that addresses these 2004). Although this aggression can be a useful ele-
issues to overcome the chronic risk of suicide, achieve ment for patients to learn about during the course of
delayed age-appropriate role functioning, and take treatment, many outpatient clinicians do not have the
charge of their lives in a way that breaks the cycle of cri- specialized training or experience to notice, focus on,
sis and despair. withstand, or productively engage these patients rage
Intensive residential treatment for this popula- at authority (Kernberg 1984; Plakun 2006; E.R. Sha-
tionoffered at the Austen Riggs Centeradds to piro 1982b; Winnicott 1949).
general psychiatric treatment a set of specialized and These patients often use actions rather than words
intensive individual, family, group, and milieu psy- for communication of intense and unbearable affect
chotherapeutic and psychosocial treatment compo- states; many have histories of recurrent self-injury and/
nents (Elmendorf and Parish 2007; Fromm 2006; or suicidal behavior. They have often been unable to ad-
Mintz and Belnap 2006; Muller 2007; Plakun 2006) here to prescribed medication regimens, are exquisitely
intended to interrupt the often rageful cycles of failure sensitive to side effects, or induce countertransference
these patients experience while providing an opportu- reactions in the prescribers that confound treatment ef-
nity for them to take charge of their treatment and forts (Mintz 2002). On admission to Austen Riggs,
their lives in new ways. 50% of patients have made at least one potentially le-
thal suicide attempt, more than 40% have had six or
The Patients more episodes of self-destructive behavior, and 60%
have had three or more previous hospitalizations. Ex-
Who are these patients? The prospective, naturalistic, amination of patient histories indicates early trauma,
longitudinal Austen Riggs Center Follow-Along Study abuse, neglect, loss, or deprivation in about 60%. A pe-
has been following 226 patients every 68 months dur- riod preceding admission involving a downward spiral
ing and after treatment at Riggs for a mean of 9 years. into chronic crisis management is typical, with re-
Our data indicate complex diagnostic comorbidity, peated maladaptive patterns in relationships and be-
with a mean of six Axis I and II disorders (Plakun 2003; havior and multiple treatment failures involving med-
Perry et al., in press). Fully 80% of the patients have ication trials and inpatient and outpatient treatment.
treatment-refractory mood disorders that have failed to Nevertheless, these are also individuals with
respond to standard interventions in inpatient and out- strengths. Many have had earlier life trajectories with
patient settings. More than 80% of patients also meet academic, athletic, or artistic promise that collapsed
criteria for one or more personality disorders, most as their symptom picture unfoldedoften beginning
commonly borderline personality disorder. Two-thirds during the period of late adolescence and early adult-
of patients have histories suggesting significant early hood. Either the task of moving from the role of child
adverse experiences of abuse, trauma, neglect, loss, or in the family to that of adult in the world has been un-
deprivation, and one-third meet criteria for posttrau- manageable during this developmental transition
matic stress disorder. Nearly half have substance use (Erikson 1964a, 1964b; R.L. Shapiro 1963) or later in
disorders complicating their clinical picture, and about life they fall apart when a long-standing adaptation
one-quarter have symptoms of an eating disorder. crumbles in the face of a loss or life transition (e.g., pa-
About 15% present with psychotic spectrum disorders. rental death, the end of a long-term relationship, the
Beyond diagnosis, these patients typically have not repetition of abuse). These patients appear to have the
capacityalthough usually not the experiencefor task. Such a community can focus on examined
learning how to use words to describe their feelings living, providing feedback about the meaning and
while tolerating the associated affects. They indicate a impact of behavior and allowing patients to de-
readiness to learn how to delay acting on their im- velop a language for experience to bring into their
pulses. Often they are at a point in their lives where individual psychotherapy and family work (Belnap
they are poised between increasing desperation and et al. 2004; Elmendorf and Parish 2007; Fonagy et
readiness to change. al. 2002; Fromm et al. 1986).
Basic Dilemmas in Determination of Suitability for

Constructing Treatment Residential Care in an Open Setting
These patients raise three central dilemmas for treat- The program at Austen Riggs is predicated on these
ment: core notions; thus, the admission consultation ex-
plores them in detail. The prospective patients capac-
1. Alliance: Because of difficult past experiences with ity to take up his or her own authority in the admis-
caregivers, these patients fear and resist a treat- sion negotiation, use the relationship with the
ment alliance. To engage them in an atmosphere admissions officer for learning, and open the possibil-
that maximizes interdependency and engagement ity of finding meaning in symptoms determines the
in the task of treatment requires an unremitting fo- patients suitability for treatment. Admission requires
cus on their own authority and the importance of an explicit offer from the admissions officer after a 2-
relationships. hour consultation with the patient alone and with rel-
2. Limits: In response to efforts by others (e.g., family, evant family members. The patients interest in ac-
society, treaters) to set reasonable external behav- cepting the offerhowever ambivalentlywith ac-
ioral limits and controls, these patients inevitably knowledgement of the anxiety that must inevitably
see the limits, because of their life experiences, as ar- accompany the freedom of the setting indicates the be-
bitrary, unempathic, and rigid. In response, they ginning of an alliance. Similarly, any third party who
may attempt to defy limits and blame limit-setters may be supporting the treatment financially, such as a
for their own self-destructive behavior. To construct relative or insurance company, must also agree to the
a treatment environment that puts them in charge conditions of treatment.
and offers opportunities to gain perspective on their A central aspect of the admission consultation is a
anger and the developmental context for their attack negotiation with the prospective patient and family (if
on limitswhile helping them to remain safeis a available) about managing the risks of the open set-
formidable task. When the patients strengths allow ting. When the patients treatment-resistant illness is
it, treatment is optimally carried out in a completely organized around a rebellion against authority, it may
open setting that requires careful negotiation and be manifest in an abdication of responsibility, with the
ongoing maintenance of a therapeutic alliance expectation that those in authority will take over (and
(Knight 1953), with differential authority for pa- fail). This becomes apparent at admission when a pa-
tients and staff. The staff s recognition of patient tients presentation seems to insist that it is the insti-
authority and the responsibility that goes with it cre- tutions job to keep him or her alive. Admissions offic-
ate the basis for a therapeutic community. Interde- ers regularly note with patients the way this implicit
pendent and clearly defined role relationships in or explicit expectation is an impossible task.
such a community emphasize the centrality of the Admission is dependent on patients beginning to
commitment by both patients and staff to the treat- recognize that it is their responsibility to manage their
ment process (Kubie 1960). safety (or commit to inform staff if they become un-
3. Behavior: These patients tend to use actions to safe), while staff takes responsibility for overseeing the
communicate rather than words. To construct a treatment process. Inevitably, engaging in and main-
treatment in which they have the opportunity to taining this negotiation is not possible for someand
recognize and acknowledge the meaning of their 15%30% of those admitted are ultimately not able to
behavioral communications, translate their experi- tolerate the responsibility sufficiently to sustain their
ence into language, bear the associated feelings, treatment. Nonetheless, such an initial allianceal-
and put their feelings into historical perspective re- though often shaky and requiring ongoing vigilance
quires a therapeutic community with a focused offers the best chance for a treatment process that pa-
tients can own as the first step in taking charge of their cities. The Austen Riggs Center presents a striking
lives. This opening discussion with patients and their contrast. A completely open residential treatment cen-
families also helps put family anxieties and unrealistic ter in stately white buildings on the main street of the
expectations in perspective and begins the process of small New England village of Stockbridge, Massachu-
defining clearer roles in treatment. setts, the center offers a semirural setting for voluntary
The following vignette illustrates some of these treatment. There are no privilege systems, no locked
points. The case and treatment principles related to it doors, and no explicit requirements to attend any treat-
are described in more detail elsewhere (Plakun 2003). ments, although a lack of attendance inevitably leads
to review of the patients interest in treatment.
Ms. A was a widowed woman in her 40s with treat- Patients are admitted for an initial 6-week period of
ment-resistant depression and a borderline personal- intensive evaluation and treatment, although most
ity disorder who was referred to the center because of
stay longer. The median length of treatment in the
recurrent suicidal ideation and behavior that kept her
outpatient treatment chronically in crisis. Her insur- continuum of care (from hospital level through step-
ance company agreed to support longer-term treat- down programs to outpatient care) is 6 months, with a
ment because of the high cost to them of multiple range from 6 weeks to several years. In general, the ef-
previous short-term hospitalizations and in recogni- fort is to interrupt the cycle of thwarted treatments by
tion of her high suicide risk. In the admission con-
helping patients develop the capacity to express expe-
sultation Ms. A was able to engage with the admis-
sions officer about the rage and despair beneath her rience in language. This capacity increases the likeli-
recurrent suicidal threats and their link to an early hood that after discharge patients will be able to man-
history of sexual abuse and fears of abandonment, age outpatient psychotherapy without self-destructive
exacerbated by her husbands death several years ear- behavior or other recurring crises interrupting the
lier. She found the discussion of these issues and the work and with new abilities to engage in adaptive so-
tentative connections drawn between her symptoms
cial role functioning.
and life history helpful and surprisingly calming,
noting that she and her outpatient psychiatrist had Although a brief-stay inpatient level of care is avail-
rarely had the opportunity to explore anything but able for patients whose treatment alliance becomes
her response to medications and the level of her sui- uncertain during the course of treatment, the vast ma-
cide risk. She felt able to contain her suicidal behav- jority of patients enter a therapeutic community at
ior if admitted, and admission was offered.
one of two residential levels of care organized around
Although the patients insurance company was
willing to support treatment 1 week at a time, it
the maximal exercise of patient authority and the pos-
would not commit in advance to the minimum stay sibility of turning to others for support. The more in-
of 6 weeks. As a result, the patient, who had the re- tensive residential program focuses on individual
sources, was asked to make the usual prepayment to nursing care (often used with patients struggling to
secure the initial period of evaluation and treatment. contain impulses to harm themselves or to use sub-
On the day before admission the patient called to in-
stances), whereas the other has less intensive nursing
dicate her refusal to make the required prepayment,
stating that if she were not offered admission any- and relies more on peer groups. Having been screened
way, she would carry out her suicide plan. The ad- at admission for their capacity to engage in a verbal
missions officer noted her use of a suicide threat to psychotherapy, all patients begin and throughout their
get her way and reminded her of the work they had stay continue in four-times-weekly psychodynamic
done to get an initial perspective on her struggles. He
psychotherapy with a doctoral-level therapist. In addi-
reminded her of her competence and determination
in negotiating coverage with her insurance carrier tion, skill-based and symptom-focused groups are
and said it would be too bad if she threw away the available in the community program. All patients have
chance for a treatment that might work. He then told a psychopharmacologist who prescribes medication
her that he would not allow her to come in any way for sufficient symptom relief to allow the patient to
other than the one they had negotiated, which was participate fully in the range of treatments. Social
the same for all patients admitted. Although initially
workersoften with the individual therapist as family
enraged, Ms. A was also reassured by the holding of
limits, made the prepayment, and was admitted. co-therapistwork with their families. The same in-
terdisciplinary team that includes these clinicians and
others follows the patient in transitions through vari-
Treatments ous residences in the continuum of carefrom hospi-
tal, to group residences in the main hospital building
Many of these patients come from multiple short-term or elsewhere in Stockbridge and in the neighboring
inpatient hospitalizations in locked settings in major town of Lenox, to day treatment in patients own
apartments. The team works together over time to in- Chaired by the medical director, this conference in-
tegrate a coherent view of the patient from different vites the patient to bring his or her own treatment fo-
disciplinary perspectives. cus and questions into an interview with the medical
director and staff. Often the patients questions dove-
In a treatment team review of John, a 30-year-old tail with the issues raised in the assessment, so that
man with major depressive disorder, narcissistic per- the group can reach a formulation and treatment plan
sonality disorder, and substance use disorder, team
relevant to the patients stated goals.
members presented differing views of him. Nursing
staff found him aloof and arrogant, challenging hos-
pital policy and avoiding their efforts to engage him. Impact of the Setting
Therapeutic community staff noted Johns efforts to
help younger female patients in distress, often en- The open setting and the staff s reliance on patient au-
couraging them to speak up in community meetings. thority meet and legitimize both autonomous func-
The female therapist reported Johns deepening en- tioning and dependency needs, including the need to
gagement in therapy and his increasing recognition
belong. The structures of the program support pa-
of his defensive devaluation of her in the context of
his beginning exploration of his vulnerability and tients strengths instead of focusing relentlessly on
anxiety about potential abandonment by women he psychopathology:
depended on. The social worker reminded the team
of Johns younger sister s suicide in his youthin The open setting leans on patients capacities to
t h e con t e xt of h i s p a re n t s di v or ce and h i s manage themselves and, in a version of free associ-
mother s worsening breast cancer. The discussion
ation, gives patients room for and invites them to
put Johns confusing combination of defensively ar-
rogant devaluation of older women and his caretak- notice the choices they make each day.
ing efforts toward younger women in perspective, The therapeutic community authorizes patients
helping nursing staff to persist in their efforts to en- leadership capacities in elected positions.
gage John and to help him see the defensive nature of The activities programwhich formally removes
his withdrawal. John began to recognize the histori- them for periods of time from the patient roleof-
cal determinants for his problematic relationships
fers these students a space for creative expression
and the repetition of these patterns in his relation-
ships with community members and his therapist. and the mobilization of strengths and capacities,
conceptualized as separate from treatment.
There is an activities program, described by Austen The culture of the center is organized around pa-
Riggs staff as a nonclinical interpretation-free zone, tients developing the potential to take charge of
where patients take up the role of student, working their treatment and their lives.
in visual media, ceramics, woodworking, fiber arts, The staff is organized around the understanding
and a greenhouse. The program includes a Montessori that patient resistancetheir acting outis a
preschool for children from the local community form of communication that requires translation.
where patients may serve as volunteer aides. There is
also a community theater where patients collaborate All of these supportive and progressive structures
with members of the outside community and a profes- serve to counterbalance the inevitable regressive pulls
sional theater director to put on plays. that are an aspect of intensive and deepening individ-
ual psychotherapy.
Fran, a 36-year-old woman with an extensive history The treatment focuses on three sustaining areas:
of childhood sexual abuse and multiple abusive adult patient authority, meaning, and the importance of rela-
relationships, was reading through a script for a tionships. These patients communicate through projec-
planned play with a group of patients, Stockbridge
tive identification and enactment the meaning of their
residents, and the Austen Riggs theater director. Fran
was to take the role of the wife of an army officer. In painful life experience. In other settings, where staff
one scene, the woman dies and is carried offstage in authority is exercised to ensure treatment compliance,
the arms of the officer. As Fran read the stage direc- the patient may only be able to take up a passive role.
tions, she gasped, saying, I could never let a man This may unwittingly and paradoxically foster treat-
touch me! The theater director responded, But you
ment resistance, when resistance to treatment is the
are dead! Fran said, Oh, thats right, and went on
to do the play with great success, bringing her strug- only way left for a patient to exercise authority (Plakun
gle around her experience into her psychotherapy. 2006). Austen Riggs, through its freedom and struc-
tured examination of relationships, is designed to en-
The assessment phase culminates with a 2-hour gage this difficulty through individual psychotherapy,
case conference involving the entire clinical staff. family treatment, and the way individual transferences
are enacted through relationships with other patients therapyare a frequent part of the unfolding of the
and staff (E.R. Shapiro and Carr 1987). In a therapeutic treatment. This process helps patients to see the role
community of examined living, the resources are avail- of their self-hatred, rage, guilt, and shame in produc-
able to unpack these transferences, help tolerate them, ing desperate acts of self-abuse (e.g., cutting, burning,
and provide perspective (Muller 1999). parasuicidal and suicidal behaviors) and angry, provoc-
The community is constructed as a kind of theater ative interpersonal behaviors.
in the round, a public opportunity for patients to live The treatment environment at Austen Riggs helps
outand begin to seetheir difficulties with others. contain the impact of this behavior, translating it into
Managed by patients with staff consultation, the effort a language that allows patients to gain perspective on
is to provide a structure for the translation of behav- their own unconscious motivations. However, the
ioral communication into words. Patient-led groups work proceeds with the evolving recognition that there
and a culture of ongoing interpersonal feedback com- are two fallible human beings in the consulting room
municate in different ways the impact that individual when a therapist and patient meet. The therapy staff
and group behavior has on others. For example, if a pa- has opportunities to consult with colleagues (both on
tient begins to get involved in an exclusive relation- and off the treatment team) to help bear the intense
ship with another patient, other patients inevitably countertransference of the work and find their own
feel envious and rejected. Public discussion of these re- contribution to some of the struggles.
actions can illuminate how pairing is a group phe- Psychodynamic psychotherapy in such a program
nomenon (Bion 1961). If a patient is involved in self- focuses on character issues, paying particular atten-
destructive behavior, others inevitably become fright- tion to repeated maladaptive patterns of behavior.
ened, guilty, and worried. Discussion of these re- These are assumed to be behavioral communications
sponses helps the particular patient feel less isolated (acting out) of inarticulate and painful childhood ex-
and desperate. Characteristic individual defenses, or- periences. Interpretive work attempts to make sense of
dinarily invisible to the individual, become powerfully the problematic, usually negative, transferences that
visible in community life. Individualsbeginning to for many of these patients interfere with deepening re-
see themselves in the eyes of othershave the oppor- lationships. The effort in psychodynamic treatment is
tunity to take up authority and responsibility with to help patients put feelings into words, focusing on
others in a kind of participatory democracy (Elmen- the contexts that evoke these behavioral patterns.
dorf and Parish 2007).
Family Treatment
Individual Psychodynamic
A central context for the development of these difficul-
Psychotherapy ties for many of these patients is their families. Al-
Individual psychotherapy focuses on listening, making though parents do their best to love and support their
sense of transference experience, and an unfolding re- children, they may also unwittingly bring into the
ceptiveness to the patients newly formulated experi- family system powerful unconscious issues that can
ence (E.R. Shapiro 1982a). Many patients with severe contribute to treatment resistance. Riggs invites fam-
personality disorders manage their unbearable experi- ilies to participate in the treatment to help the patient
ence through the creation of painful and anger-filled re- and the clinicians both grasp the familys perceptions
lationships. Using the psychological mechanism of of the patients development and begin to understand
projective identification (Kernberg 1975, 1984; Klein the family dynamics in which the patients symptoms
1946; E.R. Shapiro and Carr 1991) to protect them- are embedded (E.R. Shapiro and Freedman 1987).
selves from their internal experience, patients unwit- These patients often have irrational roles in their fam-
tingly transform their internal self-critical torment ilies in which they are covertly invited through projec-
into stormy and provocative behavior with others. tive identification to carry problematic aspects of their
These patients have acute sensitivity to vulnerabil- parents past experiences (Berkowitz et al. 1974;
ities and blind spots in their therapists character that Fromm 2004, 2006; E.R. Shapiro et al. 1975; Zinner
they unconsciously use to evoke intense countertrans- and Shapiro 1975). Family work aimed at unpacking
ferences (Prelinger 2004; E.R. Shapiro 2004). Detec- these relationships places each member s history in
tion and careful unpacking of the countertransference perspective, freeing the individual patient to consider
enactments in staff discussions (Kernberg 1984; his or her own life without the pressures of family
Plakun 2001, 2007; E.R. Shapiro 1982b; E.R. Shapiro needs (Schwartz 2007; E.R. Shapiro 1982b; E.R. Sha-
and Carr 1987)and eventually in individual psycho- piro and Carr 1991; E.R. Shapiro et al. 1979).
Bill, a brilliant and obsessive 32-year-old man, had proved capacity to adhere to and tolerate potentially
failed at multiple attempts to complete his educa- helpful medication regimens and engage more fully in
tion. Unable to sustain a job because of frequent ar-
treatment.
guments with his male superiors, he had remained
at home for years, isolated in his bedroom. Filled A second group of patients uses medications to re-
with hatred for his cold, uncaring, and abusive fa- place relationships. Patients in this group experience
ther, he insists that he remains home in order to pro- their affects as symptoms and may use their clinical
tect his mother. On one occasion, confronted with diagnoses and medications to reduce their responsibil-
his own inability to motivate his son, the father had ity for and engagement in life. Although patients in
said angrily to Bill, I wish youd never been born.
this group find medication helpful and necessary, they
These family tensions and Bills periodic impulsive
outbursts of rage led him to a potentially lethal sui- often do not appear to get better with them. Such pa-
cide attempt that he survived only by accident. tients at Riggs often find engagement in the thera-
When Bill was admitted to Austen Riggs, the peutic community to be an important stimulus for
therapist and social worker invited the family to a recognizing their own reactivity and responsiveness to
meeting. A rageful argument between father and son
others, opening the possibility of recognizing their af-
erupted, requiring the therapist to intervene. Turn-
ing to the silent mother, the therapist asked, How fects as crucial information instead of pathological ill-
do you stand this? The mother responded, Ive ness (Mintz and Belnap 2006).
given up. Both clinicians remarked to the mother
thatgiven the potentially lethal outcomeshe
could not afford to withdraw. Recognizing how over- Management of
whelmed she was, they offered to assist her efforts to
help her men discover their softer sides. This inter- Financial Resources
vention opened for father and son the possibility of
revealing their shared vulnerabilities and the ways
they had deeply hurt each other. Their underlying
In the traditional medical model, othersclinicians,
love for one another, and the relationship of the fa- managed care representatives, family membersordi-
ther s angry withdrawal to his painful relationship narily manage the financing of treatment on behalf of
with his own father, slowly emerged over months of the patient. This leaves patients in a dependent posi-
work, allowing Bill some perspective on his family tion and creates an unfortunate incentive to do poorly
experience. His mother s increasing competence in
in order to prove that treatment is needed. The wish to
engaging this discussion helped Bill to recognize her
strength, allowing him to begin to separate his needs provide patients what they need in the face of resource
from hers. limitations outside their control can lead clinicians to
join patients in experiencing the resource managers
in a shared projective way as bad, withholding, and un-
Psychopharmacology empathic (E.R. Shapiro 1997). Such collusion can both
Treatment resistance is often manifest in the patients displace negative transference feelings from the therapy
relationship to the meaning of medication as much as and interfere with rational collaboration around effec-
in failure to respond to it. Mintz and Belnap (2006) de- tive and appropriate use of inevitably limited resources.
scribed the practice of psychodynamic psychophar- Helping patients deal effectively with reality is an
macology with these patients, exploring the meaning aspect of treatment. The cost of treatment and the
that medicationsand their side effectshave and limitations of financial resources must be faced in or-
the way these meanings may contribute to a nocebo der to construct a secure and reliable treatment frame-
(negative placebo) effect. These patients regularly ex- work. Patients and families regularly have irrational
perience caretakers as people likely to cause harm and emotional reactions to financial limitations, experi-
react to prescribed medication as potentially harmful. encing them through the filter of other limitations in
This may interfere with medication adherence or may life (emotional, security, health), making it difficult for
manifest as heightened sensitivity to even small them to think clearly. At Austen Riggs, a group of cli-
doses. These adverse reactions evoke countertransfer- nicians and business staff work with patients and fam-
ence in the psychopharmacologist, contributing to the ilies on resource limitations in order to help them
possibility of reactive irrational prescriptions that add grasp the actual financial facts and face the often con-
multiple medications to respond to what is essentially flicted feelings involved in using these funds (college
a psychological problem. An interpretive treatment funds, retirement assets, home equity loans) for treat-
that includes team discussions between therapist and ment. When patients who value their treatment par-
psychopharmacologist helps uncover such patterns; ticipate actively in discussions about the utilization of
translating them into words can lead to a patients im- genuinely limited resources, they can emerge from a
passive position and discover an incentive to manage learned in the event, whether the patient wishes to
themselves better so they can step down to a less ex- and is able to return to the kind of alliance needed to
pensive level of care to extend their treatment. Facing do the work, and whether the treatment can continue
the limitations of resources provides opportunities for or has been damaged beyond repair. This process is of-
both patients and families to come to terms with an- ten a powerful intervention that, when successful, has
ger, guilt, and grief about painful reality (Plakun 1996; been associated with good outcome (Plakun 1991).
E.R. Shapiro 1997). If patients engage in dangerous behaviors that sug-
gest they are unable to adhere to the terms of the nego-
tiated treatment alliance by keeping themselves safe,
Suicidal and Aggressive but they have not endangered their lives, they may step
Behaviors in Treatment up to an open inpatient level of care at the center for rel-
atively brief periods. During this time they negotiate
with nursing staff the limits of their freedom (for ex-
The open setting allows a broad range of freedom and
ample, turning in car keys or not leaving the hospital
maintains a clear distinction between behaviors that
grounds) that make clinical sense while their treatment
are potentially lethal and those that are not (Plakun
focuses intensively on monitoring their safety and de-
1994, 2001). Patients may well choose to engage in
termining whether they can repair their treatment alli-
non-life-threatening superficial cutting and burning
ance or need treatment elsewhere. The center does not
and eating behaviors as inarticulate ways of managing
use any restraint or seclusion unless acute psychotic or
(and expressing) their feelings or defining their bound-
impulsive suicidal behavior requires temporary re-
aries (Elmendorf 2007; Gunderson 2001; Sacksteder
straint prior to transfer. In such circumstances the po-
1989a, 1989b). These are ordinarily managed by nurs-
lice are called to help staff manage the situation. This
ing staff s bandaging or the local hospitals suturing
happens rarely, because the culture of the community
when needed. Clinical staff members work with pa-
ordinarily helps patients turn to staff or to one another
tients to understand the feelings, fantasies, and rela-
before they lose control.
tionship events that lie behind these actsand their
impact on othersbut recognize the futility of trying
to take on the task of preventing them. These efforts Research
over time begin to communicate to the patient that
behavior is communication, often communication
about unbearably painful feelings. Wallerstein (1986) and Gabbard et al. (1999) presented
When self-destructive behaviors threaten the pa- cohort studies of patients treated at the Menninger
tients life and the continuity of the treatment, the Clinic suggesting the value of extended treatment for
therapist immediately addresses the issue in relation similar patients. Chiesa et al. (2004) provided evi-
to the alliance. Among other things, a suicide plan is a dence that extended psychodynamic residential treat-
decision on the patients part to end the treatment. It ment with a continuum of care was an effective treat-
therefore reflects problems in the treatment relation- ment for patients with severe personality disorders,
ship that must be explored, including, potentially, the many of whom had significant Axis I comorbidity.
therapists unwitting contribution to that decision The Austen Riggs Center has been involved in
(Clarkin 2001, 2006; Kernberg 1984; Plakun 1994, studying this patient population since the 1950s,
2001). Should a patient act with actual suicidal intent, when Robert Knight (1954) wrote the seminal paper on
the clinician assumes, in keeping with the clearly ne- borderline patients. Psychoanalytic theoreticians in-
gotiated terms of admission, that the patient has cho- cluding Erik Erikson, David Rapaport, and Roy Schafer
sen to end treatment at Austen Riggs. The patient is developed the field of ego psychology at Austen Riggs in
ordinarily then transferred elsewhereto a locked set- the 1950s by working with this patient population
tingfor emergency medical and psychiatric manage- (Erikson 1956, 1964a, 1964b; Rapaport 1959, 1967;
ment. Often the patient returns to the center when Shafer 1999). Otto Will (1980) deepened his studies of
safe, at which point the focus of the work of the pa- schizophrenia at Austen Riggs, and several studies in
tient, therapist, and treatment team is on carrying out the 1970s and 1980s focused on the outcomes of pa-
a consultation over the next several weeks to deter- tients in treatment at the center (Blatt and Ford 1994;
mine why the patient chose to end treatment by end- Plakun et al. 1985).
ing his or her life, how the therapist may have unwit- Recognizing that it had an opportunity to study
tingly played a role in that choice, what the patient has this group of patients more intensively and in more
depth than colleagues could in other settingsand themselves in an open setting in which authority is
that the clinical data included the family and social negotiated between staff and patients rather than as-
contextAusten Riggs decided that it had an obliga- sumed by staff. The negotiated agreement is to explore
tion to the larger field. In 1994 it created the Erikson the patients mind and the meaning of behavior and
Institute for Education and Research to continue this relationships. The patients deviations from that
learning and apply the concepts emerging from this agreement and the related acting-out behaviorwhen
work to other settings. Since that time the center has not threatening the patients life or the treatment of
been engaged in the follow-along study described ear- othersare seen as opportunities for learning, be-
lier, examining the progression of 226 patients (51% of cause these patients tend to communicate their diffi-
the available sample) at 6-month intervals for 610 culties through behavior.
years. The hope is to learn about the natural progres- In this residential setting, attention to both the
sion of this difficult-to-treat group of patients. meaning of medication and its effects helps maximize
The first paper from the study reports on the issue its utilization. Individual psychodynamic psychother-
of suicide, showing an overall rate of completed sui- apy is designed to help the patient focus on a deepen-
cide of 2.5% in discharged treatment-refractory pa- ing intimate relationship in which aspects of the past
tients (examining 100% of the patients discharged are relived and translated into language. Because these
from Austen Riggs during the study period, including patients tend to split their transferencesoften by ide-
those who did not elect to participate in the study). alizing one relationship and devaluing anotherthe
Long-term results (a mean of 9 years of follow-up) sug- capacity of the staff to sustain and examine the pa-
gest that study patients ultimately improved signifi- tients relationships with all members of the treat-
cantly in terms of suicide-related symptoms (Perry et ment team allows the possibility of showing the pa-
al., in press). The data indicate that suicidal behavior tient how this phenomenon occurs while offering the
remitted first, followed by self-destructive behavior, possibility of reintegrating these split relationships
whereas suicidal ideation persisted longer. The find- within the individual therapy. At the same time, the
ings are consistent with the hypothesis that this experiences of examined living and constant feedback
multimodal treatment approach helps patients with from a therapeutic community help the patient trans-
previously treatment-refractory illness, many of late his or her behavior into language and meaningful
whom struggle with suicide, to begin to move from be- experience. Concurrent family work gives the patient
havior into language to manage their painful experi- perspective on the developmental context of distur-
ences as they begin the process of taking charge of bance and helps to mobilize family relationships and
their lives. resources for the treatment.
In addition, the Erikson Institute has begun to The constellation of resources available at Austen
apply the learning from Austen Riggs to some of the Riggs adds to contemporary general psychiatric treat-
problems of the larger society, ranging from admin- ment a diverse range of psychosocial treatments inte-
istration (E.R. Shapiro 2001a, 2001c), to the trans- grated by a psychodynamic understanding of person-
generational transmission of trauma (Fromm 2004, ality functioning. These patients with treatment-
2006), to citizenship (E.R. Shapiro 2003, 2005; E.R. resistant conditions may also be conceived of as dele-
Shapiro and Carr 2006). gates of their families and social contexts who are car-
rying potential learning about the unbearable difficul-
ties of the interpersonal world and the larger society
Conclusion (Elmendorf and Parish 2007; Fromm 2004, 2006; E.R.
Shapiro and Carr 1991). Far from being doomed to
There is a subset of patients with treatment-resistant chronic crisis management, the evidence indicates
illnesses, often with comorbid mood and personality that such patients are treatable and capable of finding
disorders and other comorbid disorders, for whom re- their voices and a role in society.
sistance to treatment is organized around uncon- Given the substantial problem of treatment resis-
sciously determined difficulty engaging in a treatment tance, it is important that this and similar compre-
alliance in which they can find their own voice and au- hensive, integrative, psychodynamically based resi-
thority. Recognizing that the alliance is the foundation dential treatment centers continue to be available as
that supports the treatment, the Austen Riggs Center part of the standard of care for these patients, who
has constructed a focused residential approach to have so much to offer and from whom we have so
these patients. The center places patients in charge of much to learn. In addition, the insights developed
from the intensive clinical work in this national refer- Erikson E: The problem of ego identity. J Am Psychoanal As-
ral center are applicable to other settings, including soc 4:56121, 1956
Erikson E: Identity: Youth and Crisis. Austen Riggs Mono-
outpatient settings.
graph, No 7. New York, WW Norton, 1964a
Patients with treatment-resistant illnesses emerge Erikson E: The nature of clinical evidence, in Insight and Re-
from our increasingly complex and stressful social sponsibility. New York, WW Norton, 1964b, pp 4950
contexts. Successful treatment of these illnesses re- Fava M, Davidson KG: Definition and epidemiology of treat-
quires a serious clinical commitment from the profes- ment-resistant depression. Psychiatr Clin North Am
sion both to recognize how these struggles develop and 19:179200, 1997
Fonagy P, Gergely G, Jurist E, et al: Affect Regulation, Men-
to provide a sufficient biopsychosocial treatment
talization and the Development of the Self. New York,
space so that these patients might find their way to re- Other Press, 2002
join the larger society. Fowler JC, Ackerman A, Blagys M, et al: Personality and
symptom change in treatment-refractory inpatients:
evaluation of the phase model of change using Ror-
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Psychiatry 164:739752, 2007 122
CHAPTER 22
RESIDENTIAL TREATMENT FOR

CHILDREN AND ADOLESCENTS
Michael A. Rater, M.D.
Alex Hirshberg, B.A.
Residential treatment for children and adolescents is one to several months, a period of time somewhere be-
a term describing a broad group of programs that differ tween acute and long-term, and are included in the
in many fundamental ways but share the fact that the discussion of the acute group of programs because
child or adolescent lives at the program in which he or they share most similarities in terms of staffing and
she receives treatment (B. Kamradt, C. Connolly, Re- daily programming with that group of programs.
Engineering Residential Treatment: Challenges and Treatment models also differ among these pro-
Opportunities for Purchasers and Providers, back- grams. Some treatment programs are based on a psy-
ground paper for the Children in Managed Care Initia- choeducational model in which youngsters learn the
tive Center for Health Care Strategies, April 2003; Le- skills to manage themselves in the outside world
ichtman 2006; Whittaker 2000). One subgroup of (Frensch and Cameron 2002). Others are based on a
residential treatment programs is designed to treat psychodynamic and/or relational model that empha-
more focal problems within a relatively brief time sizes the program environment, or milieu, as a treat-
frame of 1 to several weeks. These are called acute res- ment theater in which the adolescent reenacts dif-
idential treatment programs for the purposes of this ficulties with staff (Abramovitz and Bloom 2003;
chapter. Other programs are meant to treat more Kennard 2004; Redl 1966). Most programs are a blend
chronic situations that require the child to be taken out between these and other models that combine the
of the home for an extended period of time. These are teaching of objective information with the difficult-to-
designated long-term residential treatment pro- define set of clinical interactions that occur during the
grams here. Some programs operate over a period of provision of any mental health treatment.
299
This broad group of residential services, with phanages and reform schools (Zimmerman 2004).
elastic time parameters and flexible theoretical and These original sites were not structured around a self-
clinical orientations, is offered to more or less homo- consciously designed therapeutic environment but
geneous groups of children, depending on the program were the product of acts of social and religious charity
mission. Some programs are highly homogeneous, de- as well as social pragmatism that deemed it wise to
veloped for the treatment of adolescents with, for ex- isolate youth identified as social misfits (Cohler and
ample, eating disorders, obsessive-compulsive disor- Friedman 2004). The children in these programs re-
der, or substance abuse disorders. Other programs are ceived basic necessities such as food and shelter. The
designed for more heterogeneous groups of children treatment often consisted of punitive measures
running the gambit from disruptive behavior disorders taken against antisocial behavior. The goal was not
to psychotic disorders. community reintegration but community insulation
The cost of residential treatment is substantial (Zimmerman 2004).
(Dickey et al. 2001; Lyons et al. 1998; Sheidow et al. Many trends in the United States over the past sev-
2004). School systems, state social services and mental eral decades led to the shift in residential treatment to-
health budgets, and private insurance plans pay the ward a more therapeutic approach. First, the number
largest portion of these programs costs, with private in- of orphans in this country declined dramatically
surance paying the majority of the dollars spent on (Cohler and Friedman 2004). This was due to both the
acute residential treatment and public funding paying increase in life expectancy of adults and a major de-
for the majority of the costs of long-term residential crease in the number of immigrants coming to the
treatment (Dickey et al. 2001; Hirshberg et al. 1997; United States. Second, as the public became more
Whittaker 2004). A mix of private and public insurance aware of the number of incidents of child abuse in or-
and private payment pays for interim-range programs. phanages, the government wanted to ensure that chil-
In some instances a family undertakes to pay privately dren would be safe from these traumatizing experi-
for residential treatment because they feel a major in- ences (Cohler and Friedman 2004; Hylton 1964). In
tervention needs to occur for their child to recover and response to these societal shifts, the variety and qual-
there is no alternative source of payment. ity of services for children with emotional or behav-
Linking residential services to other community- ioral problems began to increase.
based treatment resources is crucial, because the gains Initially, there were no standards for the type of
made in residential treatment dissipate quickly if they care being offered to children in residential place-
are not capitalized on in the transition back into the ments. Other than providing a safe environment,
community. Family therapy has become an increasingly there was no consensus as to what model succeeded
emphasized aspect of most treatment models because with children and adolescents (Zimmerman 2004).
children and families must continually try to resolve the Early centers that included treatment used a psycho-
problems that led to the need for out-of-home place- analytic model that emphasized the importance of the
ment (Hirshberg et al. 1997; Landsman et al. 2001). The 1-hour therapy session. The other 23 hours of care
child or adolescent is typically placed as close to his or were initially deemed unimportant to the rehabilita-
her community as possible to facilitate family contact. tion of the individual, but soon psychoanalysts discov-
Residential treatment offers options in the broader ered the additive value of the time spent on the ward
continuum of care when intensive services become (Davids 1975; Redl 1966). They proposed that a ther-
necessary for children and adolescents who fail less re- apeutic milieu could allow children to relearn how to
strictive options. As of 2003, almost 66,000 youth manage their world in more adaptive ways (Davids
were living in long-term residential treatment centers 1975; Kennard 2004; Redl 1966).
in the United States, and these numbers are on the Milieu therapy was subsequently incorporated into
rise (Leichtman 2006). In addition, tens of thousands more child residential programs. One key principle of
of children and adolescents are served each year in milieu therapy, termed marginal interviewing or the
acute residential treatment settings. life space interview, encompassed the techniques of
intervening with a child or adolescent in the moment
of difficulty rather than relying on scheduled thera-
History peutic hours (Redl 1966).
Referrals for out-of-home care in the United States
Residential treatment centers existed in the eigh- numbered more than 500,000 by the mid-1970s
teenth and nineteenth centuries in the form of or- (Cohler and Friedman 2004). The amount of money
Residential Treatment for Children and Adolescents 301
allotted for these services became significant. Chil- olescents are more common in residential treatment
dren were spending years in residential facilities, and centers than in outpatient treatment settings (Lands-
many were not then able to transition smoothly back man et al. 2001).
into their communities (Zimmerman 2004). Child
advocates and public policy makers questioned the ef- Entry Points and Patient Selection
ficacy of these institutions. Did so many children need
Common entry points into an acute residential pro-
to be away from their families? Could some be served
gram include emergency departments and inpatient
as well in the community?
units. Staff in emergency departments might assess a
The Adoption Assistance and Child Welfare Act
child or adolescent as needing to be out of his or her
(P.L. 96-272) was passed in 1980. This law stated:
current environment, without requiring the full inten-
No child will be removed from a home unless he or sity of an inpatient unit. An inpatient unit might assess
she was shown to be at imminent risk of harm; that the child or adolescent as no longer requiring inpatient
authorities must at all times make reasonable ef- services but still requiring intensive work on coping
forts to assure safety and maintain the child in the skills, illness management, or family systems issues
home whenever possible; and that if a child is re- prior to being able to manage in a community setting.
moved from home, subsequent placement must be
The term level of care is a way to define and designate
in the least restrictive environment (closest to
home, closest to community). medical necessity criteria that are requisite to treat chil-
dren and adolescents in out-of-home placements (Sow-
This legislation helped promote the concept of a ers et al. 2003). If the child does not meet the require-
continuum of care, with mental health intervention ments for an inpatient stay, he or she may meet the
ranging from less restrictive community-based treat- criteria for a short-term residential facility. Alterna-
ments to out-of-home placements for those with re- tively, if safety is an acute concern, the child or adoles-
peated failures at lower care intensity levels. cent may be placed in a locked inpatient unit and then
stepped down to a residential facility prior to return-
ing to the community.
Short-Term Residential Treatment Intake staff members at short-term residential fa-
cilities assess the fit between the treatment center
Child and Adolescent Characteristics and the referred youth. Fit has to do with the youths
characteristics and treatment goals. Different residen-
Community-based interventions are successful for
tial centers have different exclusionary criteria for
many children and adolescents (Hoagwood et al.
their program. At the McLean Hospital Acute Residen-
1996; Kazdin and Whitley 2006). Outpatient therapy
tial Treatment Center, for example, adolescents with
and psychotropic medication are enough for these
moderate to severe mental retardation do not tend to
children to maintain an acceptable amount of success
tolerate the focus on group interactions and require
in school and at home. However, some children at
more individualized treatment than the program is de-
some times cannot be safely or successfully treated in
signed to offer. Youth with sexual offending behaviors
the home environment.
tend to have extremely low impulse control and frus-
The children and adolescents who cannot be
tration tolerance, and their behavioral responses pose
treated in the community typically are those who have
unmanageable risks to themselves and others in the
more than one current psychiatric diagnosis (Pottick
treatment setting.
et al. 2005). Children with these complex clinical pre-
sentations are more likely to engage in unpredictable Admissions Process
and unsafe behaviors and more likely have medi-
cation-resistant illness (Connor et al. 1997). For ex- After a child is deemed an appropriate fit by the intake
ample, substance abuse, criminal and disruptive be- staff, his or her guardian must sign the admission
haviors, and posttraumatic stress disorder are more forms. The standard forms required in this process
prevalent in residential treatment programs than in provide physical, contact, and insurance information
outpatient treatment (Hussey and Guo 2002). Resi- along with authorization for the program to treat the
dential treatment centers have an inflated population child, contact outside providers, and bill for services.
of children and adolescents raised in chaotic, abusive, Families also are routinely provided education at the
or neglectful environments. Divorce, poverty, and point of intake regarding the Health Insurance Porta-
drug abuse among the parents of the children and ad- bility and Accountability Act regulations.
In a short-term residential model, the child is seen resident only on a monthly basis (Leichtman 2006).
by a licensed clinician, either a social worker or a psy- The clinical educator is often a third treatment team
chologist, and by a psychiatrist within 24 hours of ad- member. The educator has primary responsibility for
mission (Hirshberg et al. 1997), versus the within a the programs psychoeducation and skills teaching
few hours protocol for an inpatient hospitalization. curriculum, because most children and adolescents
Case conceptualization and a plan for discharge are have ongoing academic objectives that need to be
developed rapidly. There is frequent communication maintained within the residential context.
with the insurance company. Many programs employ The short-term residential model emphasizes and
an insurance reviewer whose job is to communicate reinforces prosocial behaviors often implemented via a
focused treatment plans for the childs initial and on- point or level system (Mohr and Pumariega 2004).
going stay in the facility. Coverage is authorized in Respect and responsibility is a theme that speaks to
units of days at a time to encourage a quickened tempo the core ethic communicated to children and adoles-
to the clinical work and discharge planning (Hirshberg cents in these programs. When the child demonstrates
et al. 1997). Interventions must be brief and focused. identified positive behaviors, such as completion of a
Once focal problems are addressed, the child or ado- treatment module or sustained nondisruptive behav-
lescent can be transitioned to the community for the ior, the staff provide increased privileges and freedoms
treatment of more chronic or underlying issues (Curry to the patient (Mohr and Pumariega 2004). The child
1991; Leichtman et al. 2001; Mikkelson et al. 1993). or adolescent is seen as working toward discharge
It is imperative that acute treatment centers have with these behaviors. This ability to show cooperation
the ability to quickly identify and address these focal and motivation in treatment is a key indicator of func-
treatment goals because commercial insurance com- tioning within the parameters of the treatment pro-
panies manage residential mental health benefits gram, and it is seen as indicative of the residents abil-
tightly. When benefits are not authorized, children ity to move toward discharge and a decreased intensity
who do not meet criteria for Medicaid cannot access of clinical services.
these services unless parents or guardians can cover Family passes and visits off-site of the program are
the cost (Federation of Families for Childrens Mental important measures of success in short-term pro-
Health 2003). In order to access Medicaid services, grams. These passes, which can last from 1 hour to the
parents may have the option of sharing custody of entire day, provide a litmus test as to the childs or ad-
their child with the state. This option is anxiety-pro- olescents ability to translate his or her functioning in
ducing for all families and unacceptable for many. the program back to the home and community setting.
Many family rights agencies have been pursuing legis-
lation that would change current practices and allow Treatment Outcomes
children the access to the mental health services they Children are discharged from short-term residential
need without the issue of custody being introduced programs with the idea that they have become better
(Federation of Families for Childrens Mental Health able to manage in the community. Many studies have
2003). shown the effectiveness of short-term residential
treatment. Leichtman et al. (2001) found that short-
Clinical Course term residential treatment was effective for youngsters
In the short-term model, a child and his or her family who had not responded well to outpatient therapy and
work with a treatment team that includes a case man- brief psychiatric hospitalizations. This study found a
ager, who usually provides individual and family ther- decrease in both internalizing (anxiety/depression)
apy as well as helps coordinate transition to the com- and externalizing (disruptive/conduct disordered) be-
munity. This person can be a licensed mental health haviors up to a year after discharge. The subjects
counselor or a master s-level clinician (Hirshberg et al. showed both an increase in their functional capacities
1997). Often the case manager is a psychologist or and a decrease in their symptoms. Hirshberg et al.
social worker by training. A psychiatrist supports the (1997) found that their short-term residential pro-
case manager, manages medication during the stay, gram was able to contain and stabilize 90% of their
and communicates with community medical person- population. They also found that families whose child
nel such as psychiatrists and pediatricians. In a short- had spent time in a short-term unit overwhelmingly
term residential program, the psychiatrist meets with reported improved family relations and improved be-
the resident a few times per week, whereas in a long- havior of the child. Mikkelson et al. (1993) found that
term residential program the psychiatrist may see the children who were admitted to a short-term residen-
tial treatment facility were less likely to have future lects for affluent families, as the cost of this treatment
hospitalizations. is great. This particular group is more likely to be dem-
Although promising, the results lack the rigor of onstrating behaviors such as drug use and truancy that
true experimental design. More sophisticated research the parents cannot control (Smollar and Condelli
needs to further validate this treatment modality. Effi- 1990). A majority of children and adolescents, how-
cacy studies for residential treatment tend to have a ever, are referred through the child welfare system (An-
within-group design without a true control. Also, no drews et al. 1986). These youth tend to come from dys-
studies have shown which populations respond best to functional homes and from a low socioeconomic class
acute residential intervention or whether certain treat- (Connor et al. 2004). Their placement in a facility may
ment models better help the child prepare for a success- be due to the maladaptive behaviors they developed as
ful discharge. Although more sophisticated studies are a result of their chaotic development or simply because
necessary, the studies available provide persuasive evi- there is nowhere else these children can go. A third
dence as to the efficacy of acute residential treatment group of children and adolescents are referred through
as a needed intervention in a continuum of care. the Department of Mental Health because the severity
Although these studies tend to lack the rigor of of their psychiatric illnesses requires prolonged and
experimental research in terms of scientific method- intensive services (Teplin et al. 2005).
ology, there is nonetheless clear evidence for the ef- Child welfare agencies are always seeking alterna-
fectiveness of the short-term residential treatment ap- tives to residential placement because it is expensive
pro ac h. W h en ch ildr en can n o t suc ce ed in th e and tends to have a negative psychological effect on the
community, a brief problem-focused out-of-home family (Andrews et al. 1986). Many parents perceive
placement can allow the patient and the family to the placement into out-of-home care as a repudiation
solve the acute problems contributing to the childs of their ability as caretakers. Although attempts have
functional difficulties and set up supports that will been made to come up with a standardized way to de-
allow the child to better manage after discharge. termine the necessity of placement, such as linking
specific behaviors with a need for the service (Andrews
et al. 1986), to date there remain complex and subjec-
Long-Term Residential Treatment tive aspects to admission into these programs.
Admissions Process
Child and Adolescent Characteristics
The costs of long-term residential care can exceed
The vast majority of children and adolescents with $100,000 per year (Lyons et al. 1998). Due to the In-
mental illness respond to outpatient or intensive dividuals With Disabilities Education Act, the childs
short-term interventions. However, some do not. The school district is required to pay for the academic por-
childs or adolescents problems may be so impairing tion of the residential facility if it is determined that
that long-term behavioral work and full removal from the least restrictive place for the child to receive an ed-
a community setting are necessary. The pathology ucation is in a long-term treatment center. Schools, es-
may lie in the family and not with the child, and foster pecially those with limited funds, can be profoundly
care options may not be available. Families who have burdened by these costs. At times, the school system
children in long-term residential treatment tend to can find creative, less restrictive alternatives that work
have high rates of parental alcohol use, violence, and for the psychiatrically ill child or adolescent. At other
physical or sexual abuse (Connor et al. 2004; Hussey times, financial matters present obstacles for neces-
and Guo 2002). sary service provision. The nonschool residential
Because long-term residential care represents the portion of the cost is most often paid for by public
most structured, intensive, and costly form of treat- funding, channeled through the social services agency
ment for a child or adolescent, it is a treatment of last involved with the child and family.
resort (Frensch and Cameron 2002). The process of a A major objective of this long intake process, with
long-term care referral is lengthy and complicated. multiple diversion points to less restrictive treatment
built in, is that when a child or adolescent is ulti-
Entry Points and Child Selection mately placed in a long-term facility, the need for this
Long-term care for severely emotionally disturbed chil- placement is clear. This type of placement is often a
dren or adolescents may be initiated and paid for by highly intrusive intervention because it takes a child
their families (Smollar and Condelli 1990). This se- or adolescent away from his or her family and commu-
nity for a substantial length of time. During this time, the development of these important relationships
the facility attempts to teach the child more adaptive (Donovan et al. 2003). The use of seclusion and re-
behaviors, repair the family, and have the child be able straint techniques is most likely to occur when a child
to generalize these newly learned behaviors and modes fails to comply with the expectation made by direct
of coping in a community setting. care staff (Ryan et al. 2004). The manner in which the
expectation is communicated influences the need for
Clinical Course this intervention. De-escalation models aiming to
Many children and adolescents who reach a long-term limit the use of restraints and physical interventions
treatment center have been subjected to significant have increased greatly.
trauma and abuse (Hussey and Guo 2002). These Each resident in long-term care typically has a case
childhood experiences, along with a high rate of ge- manager and psychiatrist. Compared with time in
netic loading for a major mental illness in this patient short-term programs, the time spent with these indi-
population, leave the long-term residential group of viduals is much less (Hirshberg et al. 1997). There is
patients with severe impairments in managing emo- not the immediate need to reintegrate the child back
tions, coping with frustration, and succeeding in rela- into the community, and therefore individual therapy
tionships. It is the goal of the long-term program to es- can happen less frequently, medication changes can
tablish and offer a therapeutic milieu to shape new take place more gradually, and there are more oppor-
behaviors that are more prosocial and adaptive (Redl tunities for behavioral observation. Most of a resi-
1966). dents time is spent with milieu staff whose training
The therapeutic milieu is based on the idea that and experience are variable (Myers et al. 2004).
the troubled child or adolescent will reexperience and There are alternatives to this therapeutic milieu
reenact the difficulties he or she has had in relation- model. There has been growing popularity of more
ships with others while he or she is at the program military-style boot camp programs whose goal is to
(Abramovitz and Bloom 2003; Kennard 2004; Redl provide a structured and demanding environment that
1966). As these difficulties arise, it is the job of the teaches responsibility and respect through more pu-
child care staff to help the child learn better ways to nitive means (Weis and Whitemarsh 2005). These
function emotionally, cognitively, and behaviorally in programs offer strict monitoring, goal-directed activi-
the given situation (Bonier 1982; Hylton 1964; Youn- ties, and alternative education environments geared
gren 1991). Appropriate behavior is modeled, taught, toward individuals with histories of chronic truancy,
and reinforced. If the child makes a bad decision, the substance abuse, and antisocial behavior. Although
staff members attempt to not react emotionally or ag- this model is not as supportive as that of more tradi-
gressively, as might have been the case within the fam- tional residential programs, past participants in these
ily or community environment. A consequence may programs maintain favorable perceptions of the pro-
be given, but it is done with an attempt at neutrality of gram model, specifically citing how much care and
emotion and predictability of the consequence (Ken- concern were shown by staff as well as the fairness of
nard 2004). This predictable and muted response by practices (Deschenes and Greenwood 1998). For chil-
authority is probably the opposite of what the child is dren with more disruptive externalizing behaviors and
used to and can allow the child to feel incrementally without a clear psychiatric mood or thought disorder,
more safe and contained. Over time, the goal for the these behavior-oriented programs may be desirable.
child or adolescent is to experience relationships with
the staff based on trust and respect and to experience a
Treatment Outcomes
personal sense of agency and mastery over feelings, It has been very hard for long-term residential treat-
thoughts, relationships, and the environment. The ment to demonstrate clinical effectiveness as a treat-
importance of this relational aspect to longer-term res- ment model. Although individual agencies may do
idential care is exemplified by the finding that the abil- well at monitoring how their own populations im-
ity to make strong therapeutic relationships is one of prove as a result of treatment, no agency or group can
the most important nonspecific predictors of success provide rigorous studies with large samples (Leicht-
in residential treatment (Bickman et al. 2004; Pfeiffer man 2006). Thus although much research has been
and Strzelecki 1990). done showing that some programs have positive re-
Due to this finding, there has been an effort to sults for their residents, there is no empirical study
limit seclusion and restraint use in residential pro- that truly substantiates the use of this intensive and
grams, because such interventions can be hurtful to costly form of care.
There is some information on who tends to be more ing a more homogeneous and specialized environ-
successfully treated in long-term programs. Lyons et al. ment. Adolescents with eating disorders, for example,
(2001) used a sophisticated growth modeling technique face both medical and psychological problems related
to determine the rates of change of symptoms during a to their illness (Steiner and Lock 1998). They require
residential stay. They found tremendous variability in more medical staff on the premises than most long-
which symptoms improved and which did not. The re- term centers have available. In addition, the behavior
sults showed that residential treatment was effective at planning around meals and food intake is more codi-
reducing risky behaviors and improving depressive fied than can be effectively administered in a general
symptoms. On the other hand, hyperactivity and anx- care setting. This section explores residential treat-
iety increased over the course of the treatment stay. ment for adolescents with eating disorders as well as
The work of Conner et al. (2002) supported this other specific patient populations that benefit by spe-
finding. They found that higher internalizing scores cialized programming: substance abuse, sexual offend-
were predictive of favorable treatment gains. They also ing, emerging personality disorder, and obsessive-
found that the higher a child is functioning upon ad- compulsive disorder patient populations.
mission, the more likely he or she will show improve- Residential treatment for eating disorders is be-
ment at the end of treatment. coming more common (Frisch et al. 2006). Inpatient
Studies are beginning to focus on gender differ- hospitalizations occur for patients when their weight
ences when trying to determine who may be success- drops to life-threatening levels. The goal is to bring the
ful in residential treatment. Gender has been over- adolescent to a more normal weight and nutritional/
looked in the past as a potential treatment variable hemodynamic status. Once this is done, there is value
(Blotcky et al. 1984). Recently, however, studies have in continued acute work to address underlying causes
shown that residentially placed females demonstrate of the illness and behaviors that are likely to lead to
more behavioral and emotional problems than males rapid weight loss and rehospitalization if not ad-
in their age group (Handwerk et al. 2006). This finding dressed (Wiseman et al. 2001). Non-hospital-based
may be due to the fact that females are more likely to residential programs offer a site for this subacute
have been physically and sexually abused than males. work.
Also, because girls are not as overtly aggressive as In response to increased demand for this service,
boys, their problems may go unnoticed and unchecked residential programs focused on eating disorders have
for longer periods of time before any treatment inter- more than tripled in recent years. Therapies tend to be
ventions are begun (Handwerk et al. 2006). eclectic, ranging from cognitive therapy to spiritual
Research relating to the success of residential treat- and experiential models (Frisch et al. 2006). Along
ment has shown that, as with shorter-term residential with the difference in philosophy, there is also a great
treatment, an important variable in long-term residen- difference in cost. Program costs range from $500 to
tial treatment is the amount of contact and involve- $1,500 dollars per day. The variation in service provi-
ment the family has with the child (Joshi and Rosen- sion along with the dearth of scientific research to sub-
berg 1997; Landsman et al. 2001; Leichtman 2006; stantiate what is effective has been a major shortcom-
Whittaker 2000). Children in out-of-home care who do ing of these services (Frisch et al. 2006). Although
not have the support of their parents tend to do poorly there is clearly a need for residential eating disorders
in comparison with youth whose parents are involved programs due to decreases in inpatient stays, this bur-
in care. The goal of residential treatment to transition geoning industry will become more standardized as
the child to a less restrictive setting is helped tremen- programs are called on to provide indices for their ef-
dously by family work done with motivated and eager fectiveness.
parents or guardians. As a result of this research, resi- Alcohol and drug use is currently a major health
dential centers are pushing to make family therapy and problem for children and adolescents. Many adoles-
contact a more integral part of their treatment model cents with substance use disorders have comorbid
(Hirshberg et al. 1997). mental illness. Among individuals in substance abuse
programs, 25%61% have a comorbid affective illness.
The use of substances has also been linked to in-
Special Populations creased risk of suicidal and criminal behaviors (Weiner
et al. 2001). This group of patients tends to be highly
Although many residential centers serve individuals treatment resistant. There are high rates of recidivism
with a variety of needs, some serve populations requir- and dropout rates from treatment (Wise et al. 2001).
Two residential treatment models have shown the ally employ modified dialectical behavior therapy, an
most promising results with this population. The first, outpatient therapy for the treatment of parasuicidal
the Minnesota Model, is based on the 12-Step ap- and suicidal behaviors, within the context of a residen-
proach to substance abuse treatment. In this model, tial unit in order to help the adolescent better manage
chemical dependency is treated as a primary disease in his or her emotions, curb self-mutilation behaviors,
which the only treatment regimen that works is absti- and interact more effectively in social situations with
nence. The typical length of stay in a program is peers and family (Linehan 1993). Research has shown
1 month, and during this time the patient attends that the use of this approach reduces suicidal behavior,
group and individual therapy, Alcoholics Anonymous dropout from treatment, future psychiatric hospital-
lectures, and family counseling (Winters et al. 2000). izations, substance abuse, and overall interpersonal
The second model is termed the therapeutic commu- difficulties (Walsh 2004).
nity approach. This program emphasizes mutual self- Obsessive-compulsive disorder has a long history of
help, behavioral consequences, and a shared set of val- health care providers utilizing a behavioral approach to
ues concerning right living (Jainchill 1997; Morral et treatment. The same exposure therapies that are used
al. 2004). Instead of viewing substance abuse as the in outpatient care settings have become the primary
primary disease, this model views dependence as a means of care offered to patients in adolescent residen-
symptom of larger personality or psychiatric problems. tial care facilities for this disorder. Because behavioral
The goal of the therapeutic community is to treat the techniques require consistent reinforcement in order to
personality problems with the hope that substance use extinguish the relationship between obsession and
will decrease (Morral et al. 2004). compulsion, it is often very important that this diag-
Both program models report modest gains (Morral nostic group receive intensive residential services. Cur-
et al. 2004). However, adolescents with comorbid dis- rently, research efforts at the Menninger Clinic and at
ruptive disorders do particularly poorly in these set- Rogers Memorial Hospital in Wisconsin have both
tings (Wise et al. 2001). Ironically, increases in refer- shown promise in the intense exposure and behavioral
rals to these programs are coming overwhelmingly work that can be done with this population of adoles-
from the juvenile justice system (Teplin et al. 2005). cents in a residential treatment setting (Bjrgvinsson et
Wise et al. (2001) found that only 20% of patients who al. 2007; B. Reiman, personal communication, 2007).
had a comorbid disruptive disorder were successful
treatment participants.
Sexual offenders are a very complex population Community-Based Alternatives:
with many unique issues. Although they are likely to
get referred for treatment through the criminal justice
Multisystemic Therapy
system, they have different treatment needs than non-
sexualized conduct disorder patients (Letourneau et al. The pressure to provide least-restrictive, cost-effective
2004). Sexual offenders tend to have more internaliz- services has led to community-based treatments that
ing symptoms, are more likely to have a history of sig- manage some high-risk adolescents in the commu-
nificant sexual abuse, and are more susceptible to the nity, thereby avoiding out-of-home placement (Halli-
negative effects of congregating with conduct disor- day-Boykins and Henggeler 2004).
dered individuals (Mager et al. 2005). As a group, they Multisystemic therapy is a leading choice in a grow-
tend to respond well to intensive family-based treating continuum of less restrictive services available in
ment options. Interestingly, the variable most highly the community (Henggeler et al. 1999; Huey et al.
correlated with treatment success is the amount of 2005; Schoenwald et al. 2000; Sheidow et al. 2004).
caregiver involvement (Letourneau et al. 2004). Other The program model revolves around the idea of creat-
aspects of the work with sexual offenders involve med- ing the structure and intensity of services necessary to
ication for attention-deficit/hyperactivity disorder and stabilize an acute crisis but doing so without removing
dysthymia (M. Kafka, M.D., personal communication, the patient from the home. By embedding interven-
May 3, 2007), and cognitive-behavioral therapy ap- tions in the home environment, this treatment ap-
proaches to enable the patients to identify and disrupt proach is aimed at altering the social system of the
their abuse cycle of behaviors. child or adolescent (Schoenwald et al. 2000). As in the
The treatment of adolescents with emerging per- acute residential model, each child or adolescent in
sonality disorders in long-term residential centers has community-based treatment has a psychiatrist and a
been increasing (Walsh 2004). These programs gener- case manager. The child or adolescent also typically has
two bachelor s degreelevel crisis caseworkers who are One clear direction for residential facilities is to in-
trained in the multisystemic therapy philosophy crease connections between themselves and commu-
(Henggeler et al. 1999). With the frequent help and nity interventions (Lieberman 2004). Residential ser-
multidisciplinary aspects of staff support the child and vices have been shown to be most effective for many
family receive, multisystemic therapy is bringing very populations when the family is intensively involved.
intensive structure and expertise right into the home. Because the goal is reunification with the community,
In an effort to clearly distinguish itself from resi- there needs to be as much contact with the commu-
dential treatment, multisystemic therapy has prided nity as possible during the childs residential stay
itself on stringent standardization of care and scientif- (Leichtman 2006). There must be outreach so that the
ically rigorous research methods (Henggeler et al. skills and behaviors learned in the center can be easily
1999). Treatment studies are highly organized, with a generalized at home, which includes an increased
control group and random assignment of youth to ei- focus on family work. It is imperative that parents or
ther a residential or multisystemic treatment condi- guardians be a part of the process, both within therapy
tion. Also, professionals practicing multisystemic and in the planning of stepdown, wraparound services
therapy are consistently monitored so as to determine and other community supports.
how rigidly they are following the treatment model Residential treatment programs must also respond
and philosophy (Henggeler et al. 1999). to the calls for increased accountability. As discussed
Structured studies have reliably shown the ability earlier, residential treatment is a nebulous term;
of multisystemic therapy to keep children and adoles- there is very little that unifies these wide-ranging ser-
cents at home while stabilizing crises. Henggeler et al. vices into a cohesive whole. There must be more effort
(1999) found that this therapy effectively prevented put into standardization of care. When a child or ado-
psychiatric hospitalization in 75% of the youth it lescent is referred for long-term out-of-home place-
served. It was also able to lower the use of psychiatric ment, payers, family members, and school personnel
hospitalizations well after the 4 months of treatment must have the knowledge of which program and what
were completed. This research is important because length of stay are most likely to work for that child or
not only is multisystemic therapy keeping children adolescent. With these adaptations, intensive mental
and adolescents within their home and community, health services such as residential treatment can be a
but it also is much more cost-effective than either res- leader in the development of a connected and support-
idential placement or inpatient hospitalization. ive continuum of care for adolescents and youth.
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CHAPTER 23
HOSPITAL-BASED PSYCHIATRIC
EMERGENCY SERVICES
The Psychiatric Emergency Service recently, the widespread availability of cheap smok-
able cocaine and other powerful drugs of abuse made
as the Canary of the Mental Health disabled patients with a reliable source of public in-
Coal Mine come easy targets for drug dealers, often destabilizing
their underlying psychiatric conditions and touching
off a revolving door of frequent PES presentations
Over the past four decades, psychiatric emergency ser- and discharges. Public intolerance of visible homeless
vices (PESs) emerged and matured largely in response people and involuntary commitment laws predicated
to external changes in the public mental health treat- solely upon dangerousness led to a funneling effect,
ment system. The widespread deinstitutionalization with increasingly disturbed, volatile individuals chan-
or closure of state psychiatric beds was coupled with neled to general hospitalbased emergency depart-
poorly planned and executed community alternatives. ments.
Money that accrued from state bed closure did not fol- In response to these and other factors, the number
low patients into the community, and with notable and organizational complexity of PESs have risen sub-
exceptions, most community mental health centers stantially. Patients with primary psychiatric distur-
did not consider emergency interventions within their bances now compose at least 8% of all emergency de-
scope of business. With the advent of managed care, partment visits (Larkin et al. 2005). Additionally,
private psychiatric beds disappeared in the wake of although many perceive this to be a uniquely urban
hospital closures and network consolidations. Be- phenomenon, mental health presentations to rural
tween 1960 and 1994, the number of U.S. psychiatric critical access hospital emergency departments
beds per capita decreased by about two-thirds, from 4 show similarly troubling trends (Hartley et al. 2007).
per 1,000 to 1.3 per 1,000, with a correlative increase Despite the growingand, some would say,
in deaths due to mental illness (Currier 2000). More alarmingincrease in demand for emergency psychi-
311
atric services, mention of PESs is virtually absent in Conceptual Models of Psychiatric

both the Presidents New Freedom Commission on
Mental Health (2003; Unutzer et al. 2006) and the Emergency Service Care: Primum
more recent Institute of Medicine report on U.S. Non Nocere (First, Do No Harm)
emergency departments (Institute of Medicine 2006).
This is both troubling and baffling. Unlike other care
venues, emergency departments cannot refuse to treat In 1980, Gerson and Bassuk first articulated a triage
patients for any reason, and this open access provides model of PES care in which the main function of em-
an excellent snapshot of the level of functionality of battled and underresourced services was to decide who
the mental health treatment system as a whole. For got access to scarce inpatient beds. Diagnostic preci-
example, the numbers of presentations of children sion was downplayed, and dangerousness was the key
and adolescents seeking care at one large urban PES in determinant. Two decades later, Allen (1999) de-
Rochester, New York, have increased substantially, scribed a treatment model whereby advances in
presumably in response to school districts zero tol- medications and community programming allowed
erance policies for violence and suicidal behavior in for initiation of definitive treatment within the PES.
the wake of the Columbine incident and others. PESs This approach hinges on more rigorous diagnostic pre-
serve as the leading edge for recognizing the changing cision so that condition-specific treatments can be ini-
need for psychiatric services among specific subpopu- tiated. Treatment initiation was also fostered by the
lations. development of 48- or 72-hour extended observation
units, allowing for ongoing assessment of many pa-
tients who ultimately were found not to require inpa-
The Psychiatric Emergency Service tient care but were too unstable to discharge within
the first 24 hours. Strategies such as Depakote load-
as Black Box ing and initiation of selective serotonin reuptake in-
hibitors were possible to consider within this time
In spite of the escalating quantity of PES visits over frame. Mobile crisis teams and other hospital diver-
time, the evidence base testing clinical practice in this sion strategies were developed with varying degrees of
setting is almost nonexistent. Few descriptive studies success. Although the treatment model was a major
exist of PES protocols and procedures, and even fewer step forward in emergency care, the task of ameliorat-
high-quality randomized, controlled trials exist to test ing acute symptoms of mental illness within a few
the efficacy of treatments rendered in that environ- days remains an elusive goal. In spite of many ad-
ment. The scope, quantity, and quality of PES services vances, the primary focus of PES clinicians for the
remain poorly characterized and highly variable across majority of patients remained the decision to admit or
regions, institutions, and providers. In a survey by discharge. Unfortunately, many patients with behav-
Allen and Currier (2003, 2004) of PES directors, sev- ioral complaints who are treated in overwhelmed
eral findings helped shed some light on these issues. emergency services find the experience so off-putting
The most common reasons for presentation included that trust in the mental health delivery system can ac-
mood disorders, psychotic-spectrum disorders, and tually be damaged, hindering willingness to follow
substance abuse or dependence. A majority of patients through with prescribed care (Cerel et al. 2006).
were not subsequently admitted to psychiatric inpa- Meaningful communication with outpatient providers
tient beds from the PES, and approximately two-thirds was all too often an afterthought, and patients who re-
were discharged from the PES either with no aftercare quired assistance navigating a complex treatment sys-
or with referrals to outpatient treatments of some tem were often left to their own devices to follow up
type. In some centers, the PES can be a volatile place. with prescribed aftercare.
Use of restraints (chemical or physical) is common, as Now, another decade later, it seems possible to
is assault of staff by patients. Unfortunately, data are imagine another model of PES care that prioritizes the
not routinely collected in a uniform fashion across set- interface between the PES and outpatient treatment
tings, and comparing outcomes is hampered accord- referral sources. In this staging model, emphasis
ingly. As the leading edge of treatment for many pa- would be placed on actively engaging and educating
tients, the PES is in the unique position of detecting clients and their families about the value of following
changes in types of populations served and the after- through with appropriate prescribed care. Based on an
effects of changes in other parts of the mental health assessment of readiness to change and use of psycho-
service delivery system. therapeutic techniques such as motivational inter-
Hospital-Based Psychiatric Emergency Services 313
viewing (Miller and Rollnick 2002), clinicians may not old or who are estimated to be likely to improve rap-
only refer patients to appropriate community-based idly, who linger in the PES. What follows is a suggested
care but also increase treatment adherence and im- logical framework for dealing humanely and judi-
prove treatment outcome (Sheldon et al. 2003). We ciously with such individuals.
have recently reported results of a randomized trial us-
ing a PES-based mobile crisis team to meet with dis-
charged suicidal patients in the community and en-
Emergency Assessment Steps
gage them in further services. This intervention was
successful in 60% of cases, versus 20% for usual care It cannot be emphasized enough how important it is
(referral to an outpatient psychiatric appointment that all patients coming into the PES are searched and
within 5 business days). Novel models that capitalize that an arch or at least a wand metal detector is em-
on the providerpatient relationship developed in the ployed at triage. Contraband weapons represent a real
PES offer promise. Other models that allow represen- risk to staff and other patients. Likewise, to maximize
tatives of community mental health centers, sub- safety for all involved, protocols should be worked out
stance abuse treatment providers, and others to meet with local law enforcement departments to make gun
with the patients before they leave the PES also hold lockers available so that officers can remove their
promise. However, widespread development of such weapons prior to entering the PES.
bridging strategies will require adaptations of payment Once patients are safely through the door, hospital-
rules, because currently ambulatory providers are un- based emergency assessments are composed of a few
able to bill for services while patients are registered in steps that are largely consistent across most institu-
the PES. Further research to demonstrate the clinical tions: 1) triage, 2) medical assessment, 3) psychiatric
utility and cost-effectiveness of new approaches is assessment, and 4) disposition. Each step may be
clearly desirable. straightforward or not, depending on the complexity
of the case, but at the end of the day, each of these four
steps needs to be not only performed but also articu-
A Road Map for Psychiatric lated in the medical record.
Emergency Service Evaluation
Triage
For the practicing clinician, treating the sometimes Triage simply means to sort. The first clinician most
overwhelming volume of patients supersedes any con- patients encounter in an emergency department is a
sideration of national trends in health care delivery. triage nurse whose major function is to route patients
Clinicians are charged with making rapid decisions to either medical, surgical, or psychiatric care tracks.
based on imperfect and incomplete information. Most often, these are medical-surgical nurses with
Should things go wrong, the stakes can be high for limited specialty mental health training. As discussed
both service providers and service recipients. None- in the next section, in many institutions a cursory
theless, at its core, the goals of the PES evaluation are physical examination and pro forma set of orders for
fairly straightforward. Clinicians must first decide if a laboratory tests may begrudgingly precede a transfer to
patient belongs in the PES and route those who do not psychiatry, but from the medical/surgical perspective,
to more appropriate venues. Examples of patients who the goal is to clear patients as quickly as possible for
do not belong in a PES include individuals who are transfer.
acutely medically compromised (e.g., overdoses dis- Triage can also be thought of as the process by
closed after the triage process) and patients whose be- which PES clinicians get an initial impression of case
havior is grounded in criminality rather than mental severity as patients roll through the door. As opposed
illness. For patients who do have a mental illness that to treating patients sequentially based on time of ad-
warrants immediate voluntary or involuntary inter- mission, it makes sense to establish a two-stage as-
vention, the next order of business is to decide if de- sessment process for prioritization of potentially vola-
finitive care can be initiated within the PES or if the tile and violent cases. In other instances, if it appears
time frame for effective treatment is likely to be so on initial screening that a person clearly does not be-
long as to require inpatient hospitalization. Then the long in the PES, a clinician may decide to see such pa-
search for a bed begins. However, it is the gray zone of tients more rapidly to decompress the PES. Finally, an
patients who describe or manifest signs of mental ill- internal triage can establish quickly who should and
ness, but who may or may not meet a severity thresh- should not be allowed to leave the PES without a full
assessment, regardless of whether the person pre-

sented voluntarily or involuntarily.
There are several triage algorithms and tools avail-
able (Lewis and Roberts 2001). However, one of the
oldest, best established, and most clinically useful is
the Crisis Triage Rating Scale (Bengelsdorf et al. 1984;
Figure 231). This scale is designed specifically to aid
in making admission decisions by rating patients on
three domains: support system, dangerousness, and
ability to cooperate. Each domain has a Likert-type
scale scored from 1 (most severe) to 5 (least severe). Pa-
tients who score 8 or below warrant serious consider-
ation for admission. Isolated low scores on any one of
these particular domains also suggest an intervention
strategy while the patient is in the PES to maximize
chances for a safe discharge. For example, many pa-
tients present with suicidal thoughts without clear in-
tent and are clearly motivated to seek treatment. For
such patients, involving friends and family to shore up
the social support network may make discharge a
realistic option. Operationalizing this assessment
through the use of this or other standardized rating
tools can be enormously beneficial.
Medical Assessment
PES patients present with a large number of concur-
rent psychiatric, social, and medical needs. Proper
assessment of the latter is a debatable issue and is of-
ten a point of conflict between busy PES and medical
emergency department staff. As such, there is wide
variation across and within emergency services in
terms of the extent of medical screening and interven-
tions undertaken. Certainly, the baton model of
care, in which blanket medical clearance is granted
by emergency physicians and the patient is irrevocably
passed on to the PES, is outmoded. However, efforts to
design more appropriate treatment algorithms are
hampered by lack of consensus on the type, scope, and
duration of adequate assessment. This is worrisome
in light of the enormous medical morbidity in PES pa- FIGURE 231. Crisis Triage Rating Scale.
tients. As early as 1980, Carlson et al. (1981) docu- Source. Reprinted from Bengelsdorf H, Levy LE, Emerson
mented medical issues as the sole reason for PES pre- RL, et al: A Crisis Triage Rating Scale: Brief Dispositional As-
sentation in 7% of patients seen. By the mid-1990s, sessment of Patients at Risk for Hospitalization. Journal of
Olshaker et al. (1997) found serious medical issues re- Nervous and Mental Disease 172:424430, 1984. Copyright
1984, Lippincott Williams & Wilkins. Used with permission.
quiring urgent intervention in 19% of psychiatric pa-
tients presenting to a medical emergency department.
More recently, data from the Clinical Antipsychotic ceiving treatment, and 62.4% of subjects with hyper-
Trials of Intervention Effectiveness study indicated tension were not receiving outpatient care (Nasrallah
that metabolic syndrome was present in 36% of male et al. 2006). Compared with the general population,
and 52% of female subjects at enrollment, respectively individuals with mental illness are more often unin-
(McEvoy et al. 2005). In the same cohort, 30% of peo- sured and more often unlinked to a primary care pro-
ple who entered the study with diabetes were not re- vider (Druss and Rosenheck 1998).
Given all that, the likelihood of untreated medical tion is critical. Examples would be a thyroid-stimulat-
conditions being detected in the PES is very high. Lines ing hormone level in a depressed patient with known
of responsibility for addressing these issues are not so thyroid disease, electrolyte levels in volume-depleted
clear. The relationship between medical illness and patients, lead levels in high-risk children, and a urinal-
psychiatric conditions can be causative, contributory, ysis in elderly patients with acute mental status
or incidental. Causative medical conditions are the changes. If patients tell you they are not experiencing
reason that the aberrant behavior manifests and are current medical concerns, and they are walking and
the grounds for the emergency department visit. An talking, available evidence suggests that you can be-
example is urinary tract infections in elderly nursing lieve them (Korn et al. 2000). A wasteful and lengthy
home patients, with resulting delirium and agitation. battery of laboratory tests, drawn either in the PES or
Most prudent clinicians would agree that such cases perhaps on the medical side as a way to forestall access
usually belong on the medical side of the department, to the PES, is not advised. However, a basic panel of
at least initially. However, even when the cause of psy- screening studies (complete blood count, basic meta-
chiatric symptoms is clearly medical in nature, there bolic panel, urinalysis, and toxicology) and pertinent
will be times when a medical admission is not pru- medication blood levels, radiological studies, electro-
dent. For example, a severely agitated patients behav- cardiograms, and the like are usually necessary before
ior may prove so disruptive to the functioning of a PES patients will be accepted onto psychiatric units.
medical unit that psychiatric admission is nonetheless
warranted, even if such behavior results from recent Psychiatric Assessment
medical causes such as head trauma or encephalitis.
Such patients will clearly require close medical follow- Patients time in the PES is generally measured in hours
up, regardless of their inpatient location. On the other and sometimes, in spite of legal restrictions to the con-
end of the spectrum are incidental illnesses, often trary, in days. Documentation of clinical history and
chronic in nature, that may need tuning up but are assessments should not be static but rather should es-
well within the scope of practice of the PES psychiatrist tablish an initial set of relevant clinical data and build
in a tertiary care medical center. An example would be upon this in a linear and coherent narrative as the pe-
a known diabetic who stopped insulin treatment riod of observation lengthens. The PES medical record
briefly and needs a sliding scale written to control should prompt a series of questions that form the basis
blood sugars until her insulin doses can be verified. for an informed (if provisional) diagnosis. Untoward
This is something any competent PES psychiatrist behavior needs to be grounded in and arise from a treat-
should be able to handle. The most confusing and larg- able mental or medical disorder in order for psychiatric
est category of patients is the gray zone of contributory or medical hospitalizationas opposed to jail, shelter
conditions. These include patients with behavioral placement, or myriad other disposition alternatives
disturbances with unclear and unexplored thyroid dis- to make sense. However, because involuntary commit-
ease, lupus, alcohol withdrawal, and so on. Each PES ment laws in all U.S. states hinge on dangerousness to
staff needs to work out a relationship with medical col- self or others, and not on a firmly established psychiat-
leagues whereby these gray-zone patients can be han- ric diagnosis, a solid risk assessment for both violence
dled on a case-by-case basis, and patients can flow back and suicide is crucial. The evaluation should be inter-
and forth between psychiatry and medicine as the clin- nally consistent, with assessments by physicians,
ical picture evolves. nurses, and other clinical staff cross-referenced and in-
Another contentious issue includes blanket labora- corporated into the documentation left by each. Ulti-
tory screening. Henneman et al. (1994), writing in the mately, the assessment should conclude with a well-
Annals of Emergency Medicine, recommended a rela- reasoned and well-informed statement of the logic for
tively extensive battery of laboratory tests, a head com- the clinical course of action pursued.
puted tomography scan, and potentially a lumber Using a public health model of analysis (Table 23
puncture for all patients with new-onset psychiatric ill- 1), there are only four outcomes possible from the PES
ness. However, real-world constraints of time, cost, intervention: patients can be appropriately or inap-
and patient resistance and a high likelihood of false- propriately discharged or admitted. Each outcome has
positive results argue for a more conservative approach. potentially far-reaching consequences for patients,
Blanket laboratory screenings for all PES patients are providers, and the health system as a whole.
not recommended. However, rational and targeted test- True-positive cases represent persons who meet
ing grounded in a good history and physical examina- criteria for a treatable mental illness that can only be
TABLE 231. Roman square for psychiatric admission decisions
Admitted to Inpatient Bed Not Admitted

Appropriate for admission TRUE POSITIVE FALSE NEGATIVE
Not appropriate for admission FALSE POSITIVE TRUE NEGATIVE
addressed in the highest level of services available, the aspects of this examination warrant consideration.
inpatient psychiatric setting. Such patients may seek Data accrue over time, and documentation should re-
admission voluntarily, or if significant risk of harm to flect that fact. The parts of the assessment must be in-
self or others is established, involuntary detainment ternally consistent, and information should be added
laws (which vary from state to state) may be invoked if as it is obtained. All staff who are responsible for direct
needed. patient care should provide written information on
Patients who meet criteria for illness severity but this form, although more detailed nursing notes may
who are discharged from the PES constitute false-neg- be documented in other parts of the chart. If physician
ative cases. Inexperienced clinicians may fear the out- staff notes are not congruent with the clinical impres-
come of letting patients go based on the incomplete sions and observations of nurses, social workers, and
data set available in the PES and may be tempted to so on, any discrepancies should be addressed directly
admit every patient they evaluate. Clinicians are not in the notes.
clairvoyant, and even in the best of services, some de- In high-volume services, a two-stage evaluation
cisions are made that in hindsight appear ill advised. process is the norm. Part 1 is usually completed by a
Good documentation of the rationale for discharge is registered nurse, social worker, psychiatric resident, or
the best defense should something untoward occur af- other clinical staff member. This is a history-gathering
ter discharge (Simon 2000; Simon and Shuman 2006). phase, and salient parts of the reasons for presentation,
However, the risks of wrongful detainment are real, prior history of psychiatric conditions or substance
and psychiatric hospitalization has potentially cata- use, acute medical concerns, social history, and family
strophic ramifications for patients in terms of stigma, history are assessed and recorded. Most important, a
financial burden, and erosion of trust in mental health standardized set of questions related to dangerousness
providers. to self or others must be included and filled out com-
False-positive cases represent persons admitted to pletely. Part 2 is completed by the attending psychia-
psychiatric units who are more appropriate for detox- trist or, in some states, by a nurse practitioner who has
ification units, criminal justice environments, medi- a collaborative agreement with that physician. To save
cal services, or release to the community. A small mi- time, a check-box statement that the physician has re-
nority of patients seeking secondary gains may make viewed Part 1 and found no factual discrepancies is in-
specious threats of suicide to force clinicians hands. cluded. A multiaxial diagnosis is given, although often
Clinicians in chronically busy treatment settings may with provisional qualifiers. This note must again be
start to believe that the vast majority of patients fall dated and timed, because it usually represents the end-
into this category. This is the sine qua non of staff point of the decision-making period.
burnout, and PES managers should be mindful of the
potential for corrosive countertransference. Every ef- Disposition
fort should be made to work with outpatient providers
to make informed admission decisions. False-positive The assessment should culminate in a coherent sum-
cases can be an extreme drain on hospital resources, mary statement, often incorporating a description of
because most payers will not cover such admissions. the main sources of clinical data, the clinicians level
True-negative cases are people who do not need ad- of trust in the veracity of those sources (including the
mission, probably do not want admission, and can be patient), and a logical conclusion as to course of action
referred to ambulatory treatment settings in a safe and taken, either admission or discharge. If discharge is se-
effective manner. lected, efforts to link patients with appropriate after-
The Appendix shows an example of a clinical in- care should be explained. Every effort should be made
take form currently in use at a large tertiary care med- to inform the clinicians who will inherit the patients
ical center. This is offered simply as a model of a form about the patients PES visit(s). Changes in medica-
that has stood up to regular use in a busy PES. Several tions must be clearly articulated. The patient or family
should be educated about steps to take if the clinical Conclusion

picture declines after discharge. If a patient is to be dis-
charged under somewhat anxiety-provoking circum-
stances, it should be clear in the note that the circum- PESs are a critical component of the U.S. mental health
stances did not allow for involuntary commitment services delivery system. Policy makers are now paying
and that the patient was offered and refused voluntary increased attention to the importance of PESs in the ef-
inpatient psychiatric treatment. ficient functioning of the entire emergency response
Clinical documentation around the decision to ad- system. They are forced to do so: Demand is clearly
mit true positive cases may be appropriately rather outpacing supply by a wide margin. Emergency medi-
brief, for example: Patient still actively suicidal with cine as a specific specialty only came into being over the
plan and requires continuous monitoring to prevent past few decades. In a somewhat delayed but similar
suicide. However, writing a discharge note can be trajectory, emergency psychiatry is now clarifying and
very tricky for recurrently false positive patients. Ex- codifying the unique set of skills and training necessary
amples abound, for instance, patients who made an to practice in this challenging environment. There is
actual suicide attempt but did so while intoxicated, or growing momentum to establish fellowship training to
self-injurious patients with borderline personality dis- meet these needs. Certainly, as the portfolio of high-
order who present for PES services weekly or some- quality medical evidence grows (in the form of random-
times daily. Clinicians may be reluctant to discharge ized trial data), clinical practice will come to be based
these people, not wanting to be the last to carry the on a more sure footing. In the meantime, clinicians
hot potato. must operate largely on the basis of caring, compassion,
In closing, a few examples of discharge notes are experience, and common sense to do their best by the
provided that cover the clinical and legal bases for multiply challenged people who seek care in the PES.
these sorts of individuals.
1. The intoxicated mild overdose:

References
Mr. X. presented in the context of acute inebriation
Allen MH: Level 1 psychiatric emergency services: the tools
and the breakup of his relationship. This was an im-
of the crisis sector. Psychiatr Clin North Am 22:713
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734, 1999
his fiance, he denies any intention to harm himself
Allen MH, Currier GW: Use of restraints and pharmacother-
or others. He has no prior history of self-injurious
apy in academic psychiatric emergency services. Gen
behavior and denies symptoms consistent with a
Hosp Psychiatry 26:4249, 2004
treatable Axis I mood or psychotic disorder. He ap-
Bengelsdorf H, Levy LE, Emerson RL, et al: A crisis triage rat-
pears to be a reliable historian, and his story is ver-
ing scale: brief dispositional assessment of patients at
ified by his fiance and primary care physician. In
risk for hospitalization. J Nerv Ment Dis 172:424430,
my opinion, he is not at imminent risk of self-harm
1984
and therefore is no longer legally detainable. He de-
Carlson RJ, Nayar N, Suh M: Physical disorders among
clines voluntary admission or an outpatient coun-
emergency psychiatric patients. Can J Psychiatry 26:65
seling referral. Both he and his fiance agree to call
67, 1981
911 or present voluntarily here if his condition
Cerel J, Currier G, Conwell Y: Consumer and family experi-
worsens and SI [suicidal ideation] occurs.
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2. The frequent PES habitu: attempt. J Psychiatr Pract 12:341347, 2006
Currier GW: Psychiatric bed reductions and mortality
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sode suggests that risk has increased over this high demic psychiatric emergency services. Gen Hosp Psy-
baseline. In fact, the patient sought help by calling chiatry 25:124129, 2003
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Henneman PL, Mendoza R, Lewis RJ: Prospective evalua- Nasrallah HA, Meyer JM, Goff DC, et al: Low rates of treat-
tion of emergency department medical clearance. Ann ment for hypertension, dyslipidemia and diabetes in
Emerg Med 24:672677, 1994 schizophrenia: data from the CATIE schizophrenia trial
Institute of Medicine: IOM report: the future of emergency sample at baseline. Schizophr Res 86:1522, 2006
care in the United States health system. Acad Emerg Olshaker JS, Browne B, Jerrard DA, et al: Medical clearance
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Lewis S, Roberts AR: Crisis assessment tools: the good, the istic ideals and scientific clinical practice. Clin Psychol
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2002
APPENDIX
Sample Comprehensive Psychiatric

Emergency Program Evaluation Form
The form presented here was developed at the Department of Psychiatry, University of Rochester Medical Cen-
ter, Rochester, New York, and is not copyrighted. It is provided as a resource for the reader, as an example of an
intake form that has stood up to regular use in a busy psychiatric emergency service.
Appendix. Sample Comprehensive Psychiatric Emergency Program Evaluation Form

Appendix. Sample Comprehensive Psychiatric Emergency Program Evaluation Form (continued)






CHAPTER 24
OUTPATIENT COMMUNITY MENTAL

HEALTH SERVICES
Stephanie LeMelle, M.D.
T he locus of psychiatric treatment has progressively hospitals, and most outpatient services were offered
shifted from inpatient to outpatient care. In this chap- by clinicians in private practice to people with less in-
ter we describe this trend and some of the structures capacitating disorders. This system is still in place in
that have evolved to provide a continuum of care out- many developing countries that have not yet estab-
side of the hospital. We illustrate the general approach lished community services.
to care by using our own program, a comprehensive In the United States the movement to reduce the
service for people with severe and persistent mental use of hospital care for mentally ill people was driven
illness (SPMI), as a model. by many factors, including the introduction of anti-
psychotic medications, an increasing bias against the
use of large institutions (Goffman 1961), and a num-
Deinstitutionalization and ber of important legal decisions concerning the rights
of patients (Bloche and Cournos 1990). The evidence
Community Care suggests, however, that the most important impetus
was the opportunity for state governments to shift pa-
To provide some context, it is helpful to review the his- tients from large state hospitals, where care was paid
tory of the decline of long-term institutional care and for by the states, to alternative sheltered care, where
the growth of community-based outpatient services. newly developed federal entitlement programs such as
This trend began in the mid-1950s (Kiesler and Medicare, Medicaid, and Social Security disability
Sibulkin 1987) and continues to evolve even in the payments would pay most of the costs (Bloche and
present. In the early 1950s most seriously mentally ill Cournos 1990; Foley and Sharfstein 1983; Kiesler and
people in the United States were treated in long-term Sibulkin 1987).
327
The term deinstitutionalization is inaccurate in Principles of Community Treatment

the sense that the use of institutional care changed but
did not diminish. Rather, there was a depopulation of
state hospitals while the population of other types of The philosophies and goals of community outpatient
institutions grew (Bloche and Cournos 1990; Kiesler services have gradually shifted from maintenance strate-
and Sibulkin 1987). According to the U.S. census, a gies to recovery-based models. Following the loss of state
consistent 1.05%1.1% of the U.S. population resided hospital beds, the primary goal of community outpatient
in institutions between 1950 and 1980. However, in care for people with severe mental illness was to stabilize
1950, 40% of institutionalized people were in mental patients symptoms and prevent hospitalizations. These
hospitals, and 20% were in homes for the aged and de- are still important goals, because it is difficult to work on
pendent. By 1980, however, only 10% of the institu- longer-term strategies before patients achieve stability. A
tionalized were in mental hospitals, and 57% were in variety of strategies have been developed to promote sta-
homes for the aged and dependent. The degree to bility that are largely focused on maintaining commu-
which this represented transferring those in need of nity housing and family ties; reducing patient exposure
supervision from one institution to another is not en- to criticism and hostility (often referred to as creating en-
tirely clear, but certainly new types of institutions vironments with low expressed emotion) (Anderson et
opened to house disabled elderly and people with deal. 1986; Beels et al. 1984; Cournos 1987); and promot-
velopmental disabilities (Bloche and Cournos 1990). ing adherence to treatment through continuity of care,
A criticism of deinstitutionalization has long been outreach, and use of depot medications. Yet as the voices
that despite the establishment in 1963 of a new fed- of patients and their families grew more powerful within
eral funding stream to build community mental the mental health system, it became clearer that stability
health centers, adequate resources did not follow pa- by itself does not achieve a good quality of life and that
tients with SPMI into the community (Bloche and patients assets are often underestimated.
Cournos 1990; Greer and Greer 1984). Todays recovery-oriented programs have more am-
By the 1980s three new and intertwined concerns bitious goals that include rehabilitation strategies to im-
about people with severe mental illness became prom- prove social, occupational, and recreational skills. Reha-
inent: substance use, homelessness, and the criminal- bilitation interventions include social skills training,
ization of mentally ill people. Jails and prisons became supported employment, cognitive enhancement, and
a more frequent site for the long-term institutional illness management strategies. The body of evidence for
care of people behaving in a disorderly way as the result the effectiveness of rehabilitation interventions on role
of mental illness (Hall et al. 2003; Quanbeck et al. functioning is stronger for some interventions (e.g.,
2003). In the face of these problems, some commenta- supported employment; Anthony and Blanch 1987;
tors lamented the loss of long-term hospital care. Yet Catty et al. 2008; Cook et al. 2005) than for others (e.g.,
although hospitalization had provided housing and su- cognitive enhancement; Hogarty et al. 2004).
pervisory functions that made these problems less It has also become clearer that many illnesses are
likely, virtually every study that compared patients best treated using medication and psychotherapy to-
who remained in the hospital with those who lived in gether. Many different therapies, including family and
the community demonstrated that most patients func- multiple family group therapy (McFarlane et al. 1996),
tioned better once they left the hospital and reported an interpersonal psychotherapy (Weissman 2007), cogni-
improved quality of life (Okin 1983; Segal and Aviram tive-behavioral therapy (Weissman 2007), dialectical
1978). It became clear that there was no turning back, behavioral therapy (Lynch et al. 2006), motivational
and the work of mental health advocates has largely interviewing (Rsch and Corrigan 2002), and psycho-
focused on the development of more effective and com- dynamic therapies (Fonagy et al. 2005), have shown
prehensive outpatient services and on parity between efficacy in the treatment of major mental illnesses,
mental health care and general health care to provide with or without pharmacological interventions.
the funding needed to expand community services. Al-
though a detailed discussion of these developments is Hospital-Based Outpatient
beyond the scope of this chapter, the primary outcome
is that today hospital beds are used for increasingly Mental Health Care Programs
shorter periods of time, and the long-term manage-
ment of patients with major mental illnesses must be Community mental health outpatient services can be
carried out in the community. provided in a variety of settings. In this chapter we fo-
Outpatient Community Mental Health Services 329
cus on outpatient mental health care that is delivered Hospital emergency services afford patients prior-
as part of the ambulatory services of a hospital. Hos- ity access to the hospitals beds and other programs.
pital settings vary as to their mission and funding, de- Once patients are familiar with a hospitals services,
pending on whether they are public, voluntary, or pri- they may be more willing to move from one level of
vate and whether the hospital is a general medical care to another. Inpatient and outpatient staff can
facility or is a standalone psychiatric hospital. This readily share information and consult with one an-
chapter focuses broadly on outpatient care in a man- other. As more programs adopt electronic medical
ner that is applicable to all of these settings. records, there are unprecedented opportunities for the
Hospital-based outpatient psychiatric programs instantaneous exchange of information among a hos-
have unique structural, staffing, and patient care de- pitals components of care.
livery advantages that include benefits for staff and for Many general hospitals have outpatient or walk-in
patients. medical clinics that are open to the community. These
are good settings for detecting mental disorders, be-
Structure cause people with psychiatric illnesses often initially
Hospitals are well-organized systems with structures present to medical practitioners. In addition, patients
in place for all of the basic activities needed to estab- with established psychiatric disorders can receive gen-
lish and run outpatient programs. This includes sys- eral medical health care in these settings. Having ac-
tems to hire and train staff, register and bill patients, cess to a general hospital for patients who are on med-
provide fiscal and legal services, develop and maintain ications that require blood level monitoring or regular
code-compliant space, and respond to the multiple re- blood work can greatly improve patient adherence to
quirements of regulatory agencies. monitoring. This setup also provides opportunities for
medical and psychiatric practitioners to collaborate.
Staffing The psychiatry program can provide psychiatric as-
sessments and recommendations for patients seen by
Outpatient staff who are hired through a hospital have
medical staff, and the medical program can provide
the advantages of the resources of a large institution.
comprehensive medical care for psychiatric patients.
This can improve the types of benefit packages that
staff can choose from and may allow staff access to
unions and collective bargaining. Often licensed clini- Challenges
cians can be credentialed through the hospital, which Hospital-based outpatient services may also face some
allows them admitting privileges and the flexibility to greater challenges than programs run by community-
work in both inpatient and outpatient settings. Hos- based organizations. These might include maintain-
pitals can also provide staff with training and continuing good community relations and responding to the
ing education programs that are often too costly for unique cultural customs and languages of local popu-
freestanding clinics to provide. The common practice lations. Some patients prefer being seen in more infor-
of affiliation with a university provides an academic mal community-based settings that are not reminis-
environment for supervision of junior staff, the teach- cent of prior hospitalizations. These problems can be
ing of students, and research collaborations. These ac- reduced by including members of the local community
tivities help stimulate senior clinicians and contribute among program staff and on advisory groups and by lo-
to their staying up to date on current developments in cating some programs off site from the main hospital
psychiatry. Student programs can also be an impor- buildings. For example, we have located our outpatient
tance source of recruitment to junior staff positions. programs in the local community and have systemat-
ically recruited bilingual and bicultural staff to meet
Patients the needs of the Latino population that we serve.
Hospital-based outpatient programs also benefit pa- Often hospital-based staff earn higher salaries than
tients. One of the benefits is a continuum of psychiat- staff working for smaller, not-for-profit organizations.
ric care from emergency services to inpatient care to These staff costs can be a barrier to creating those ele-
outpatient treatment. In general hospitals, patients ments of a comprehensive program that are not well re-
can also get their medical evaluations and care in the imbursed. For example, in New York State, where our
same organization, creating the optimal conditions for program is located, cost considerations result in the op-
integrating medical and psychiatric treatment. Some eration of most housing programs by organizations that
medical evaluation and treatment is usually present in pay lower salaries than are given to the hospital-based
freestanding psychiatric hospitals as well. workforce. In general, the higher overhead incurred in
hospital settings combined with the limitations of re- group of patients. Hospitals may also elect to establish
imbursement for psychiatric disorders can make men- specialized programs that focus on children or adults
tal health outpatient services a challenge to sustain. with particular illnesses such as attention-deficit dis-
Another financial stress occurs because although orders, autism spectrum disorders, mood disorders,
private practitioners can attempt to collect fees from anxiety disorders, eating disorders, and substance use
self-pay psychiatric patients for missed appointments, problems. Hospitals that choose to target particular
such visits cannot be billed to insurance companies, illnesses and populations often set up parallel inpa-
which are the primary source of revenue for most hos- tient and outpatient services.
pital-based services. Strategies to reduce missed ap- The timing and settings in which services can be
pointments include scheduling appointments around delivered most successfully may vary with patients
patients other obligations, making reminder tele- ages. For example, children may benefit from school-
phone calls, arranging for patient transportation, of- based programs, working adults from clinics with
fering on-site child care, and obtaining the assistance early morning or evening hours, and the elderly from
of family members where appropriate. Our program is outreach teams that serve the homebound. Providing
large enough to designate on-call clinicians who leave labor-intensive services that are poorly reimbursed,
their time free for a specific morning or afternoon dur- such as geriatric outreach, often depends on the hos-
ing the week. This allows us to overschedule appoint- pital securing state or local funding or charitable gifts
ments on the assumption that if everyone shows up, to help cover the costs.
the on-call clinician can help out. It also allows us to
see patients who show up unexpectedly, which helps Patient Movement Through the
to retain patients in treatment. When on-call clini-
cians are not seeing patients they use the unscheduled
Continuum of Services
time to catch up with required paperwork. Some pro- In hospital-based outpatient programs, patients with
grams offer financial incentives for patients to come to acute and severe psychiatric illness are often seen ini-
appointments, which is a matter of some controversy tially in the emergency department, where they are
and not a practice that our program utilizes. screened, evaluated, and most commonly referred for
inpatient hospitalization or crisis services. Some hos-
pitals are in a position to take almost all of their emer-
The Continuum of Care gency patients who require admission, whereas others
may have to refer at least some patients to hospital
Outpatient services exist on a continuum from the beds outside of their system. Having a perspective on
most intensive to the least intensive interventions. A the long-term trajectory of a patients needs and cir-
comprehensive community mental health service al- cumstances should contribute to the decision about
lows patients to move from one level of care to another where he or she is hospitalized.
depending on current needs. High-intensity services Hospital-based programs should ideally have a di-
include day programs, residential care with around- rect line of communication between emergency de-
the-clock staffing, assertive community treatment, partment, inpatient, and outpatient staff. Patients with
emergency department services, and crisis interven- recurrent illness usually become familiar with staff in
tion. Intermediate-intensity services include intensive all three settings, which enhances the transfer of infor-
outpatient treatment and housing programs with more mation and gives staff a historical perspective on what
limited staff oversight. Routine outpatient treatment is helps a particular patient. When patients are moved in
most often a low-intensity service, as are peer-led pro- and out of unaffiliated systems, their histories can be
grams such as support groups and clubhouses. Most lost, and new treating staff may need to start from
hospital-based community mental health programs of- scratch each time. Acutely ill patients are often unable
fer some but not all components of this continuum of to report on important treatment and psychosocial
care and collaborate with local providers for the ele- facts that are crucial to their treatment and recovery.
ments that are not available through the hospital. There is, therefore, a distinct advantage to keeping pa-
The continuum of services needed is in part deter- tients in one system of care that has continuity.
mined by the types of patients the hospital serves. Once patients are hospitalized, there is a unique
Hospitals routinely accept Medicare and Medicaid, opportunity for input from outpatient staff regarding
which are the primary funding streams for people with patients progression toward their normal baselines.
SPMI, and many outpatient programs focus on this This input can occur through rounds and clinical case
conferences that take place on the inpatient unit and Manhattan that focuses exclusively on SPMI patients.
involve the patient and the inpatient and outpatient The program consists of two community-based outpa-
treatment teams. This collaboration improves treat- tient clinics that follow approximately 1,000 patients
ment planning and patient adherence. Collaboration and a 22-bed inpatient unit. The latter is one of three
also encourages respectful and trusting relationships, inpatient units housed at the New York State Psychi-
decreases workload, and reduces clinician burnout. atric Institute, the major research institute for the
Conversely, staff from the inpatient units can partici- New York State Office of Mental Health. WHCS is the
pate in case conferences in outpatient settings and only component of the institute that operates on clin-
have the opportunity to see how patients live and ical rather than research funds. Although WHCSs
function when they are well in the community. productivity and reimbursements are monitored by
For people with SPMI, often their outpatient psy- the Office of Mental Health, there is no doubt that
chiatric treatment providers are their major and most state funding has been key to the programs stability.
frequent social contacts. The attachment between the In addition, the New York State Psychiatric Institute
patient and treating clinician can be intense and can has an affiliation with Columbia University that has
foster an overly paternalistic and dependent relation- aided in the recruitment and retention of WHCSs
ship that can hinder the patients recovery. Having professional staff, many of whom seek and receive ac-
multiple staff members treat a patient diminishes the ademic appointments and take advantage of teaching
intensity of the patients relationship to a single pro- and/or research opportunities.
vider. In our setting we assign patients to two staff WHCS has a low turnover of both staff and pa-
members, a psychiatrist and a case manager. The case tients. The low turnover of staff can be attributed to
manager can be of any specialty (e.g., a nurse, social the philosophy of sharing risk, assigning manageable
worker, or psychologist). The role of each clinician is case loads, using community-based harm reduction
determined by the patients needs and by the comfort approaches, having an academic affiliation, and main-
and/or training of the clinicians. taining a respectful and supportive environment. The
The psychiatrist can exclusively focus on medica- low turnover of patients can be attributed to the
tion management with some patients and provide ad- unique continuum and multiple levels of care that are
ditional therapies with others. Similarly, the case provided, under the authority of one program, to a
manager can help the patient obtain concrete services population of patients with severe chronic illness re-
and/or act as the primary therapist. Patients often be- quiring long-term care. The realities of funding and lo-
come familiar with other staff as well, for example, the cation will dictate the programming that most hospi-
nurse who provides depot medication injections, the tal-based programs can provide. New York State is
receptionist who helps the patient with transportation known for its generous financial support of health care
reimbursement, or the other clinicians that patients for disadvantaged citizens. WHCS is also in an urban
meet during times of crises or therapists vacations. area where there is a high density of health care pro-
This arrangement encourages the diffusion of the fessionals and readily available patient access to trans-
transference and allows the patient to benefit from a portation, social services, and other supports. Our ur-
multidisciplinary treatment team. It also supports the ban environment, however, has very limited housing
development of a shared or collective risk among staff. opportunities, and the cost of living is high. Rural pro-
Often, when treating high-risk patients with SPMI, grams often have very different challenges. These are
there is the tendency for staff to burn out or for in- some of the variables that must be taken into consid-
dividual staff members to become overwhelmed with eration when a hospital establishes mental health out-
the fear of a patients potential for violence or for sui- patient services for a particular geographical region.
cide. The assignment of two staff members and the
encouragement of transference to the whole program Continuing Day Treatment Program
and its staff help to reduce these phenomena. To address the issue of the changing clinical needs of
The type and intensity of treatment needed for a patients, WHCS offers two levels of outpatient care, a
patient with SPMI will vary over time, and there are continuing day treatment program (CDTP) and an
different models for providing flexible care. Here we outpatient program. The CDTP, as the name implies,
use our own program to illustrate one possible model has clinical activities that run throughout the day,
for providing a continuum of treatment. 5 days per week. Patients can participate in as many or
The Washington Heights Community Service as few activities as is recommended in their treatment
(WHCS) is a hospital-based program in northern plans and can stay in the program for any length of
time deemed clinically appropriate. Patients have with all patients and their treatment plans, and they
some autonomy to choose activities and the frequency regularly participate in clinical rounds to ensure that
of contact. The CDTP is often a better fit for people these treatment plans are informed by all disciplines.
who have significant residual symptoms and who are
more disorganized. The program allows for a more Outpatient Program
structured environment with a higher staff-to-patient The outpatient program is geared to patients who are
ratio. The CDTP also allows for peer-to-peer interac- higher functioning and who would benefit from a less
tion in safe, low-expressed-emotion settings. intense, less frequent therapeutic intervention. In the
CDTP programming is geared toward rehabilita- outpatient program, patients are also assigned both a
tion and recovery. The staff-to-patient ratio is higher case manager and a psychiatrist. Typically, the case
than in the outpatient program, and the staff are a mix manager acts as the primary therapist, and the psy-
of licensed clinicians, mental health aides, and peer chiatrist provides medication management. Patients
workers. A typical day in the CDTP might include a attend the program by appointment with either clini-
social skills group targeting free-time management, a cian. The frequency of visits is dependent on a patients
medication management group that reviews the bene- needs and can vary from twice per week for new or
fits and side effects of medications, a current events acute patients, to monthly, to every 3 months for stably
group to keep people oriented to news events, a voca- maintained patients.
tional skills group geared toward future employment, For many reasons, some clinical and some psycho-
and a healthy lifestyle group geared toward diet and ex- social, patients often have difficulties keeping their ap-
ercise. These groups are designed to promote skills de- pointments. It is our program policy to see patients
velopment and provide psychoeducation to help pa- whenever they show up at the clinic. To accomplish
tients gain independence and progress toward recovery. this there is always a doctor and a case manager on call
The group settings also allow for peer interactions, to see patients if they arrive unexpectedly and their
modeling, skills practice, and feedback from both staff assigned clinicians are unavailable. This strategy im-
and peers. Specific therapeutic techniques can be used proves patient adherence and retention.
in this setting, including modified motivational inter- Patients in the outpatient program also tend to
viewing, cognitive-behavioral therapies, multiple fam- have community, vocational, and family obligations,
ily groups, and many of the other evidence-based prac- so treatment is designed to accommodate each pa-
tices that have been developed for this population. tients lifestyle with minimal disruption. Ideally, the
The rates of employment among people with se- program should be able to provide treatment before
vere mental illness are low, and many patients express and after regular working hours to improve accessibil-
a desire to engage in productive work and to earn ity for employed patients. Creating an atmosphere in
money. A variety of program models have shown effi- which patients who are parents can comfortably bring
cacy in helping patients obtain and maintain compet- their young children to the clinic also enhances adher-
itive employment, most often on a part-time basis ence, as does such simple things as offering reading
(Cook et al. 2005). Many patients receive disability materials and access to snacks for waiting patients.
payments from the Social Security Administration, The outpatient program is also sometimes used for
and if they earn too much income, they fear losing more symptomatic patients who cannot tolerate the
these benefits. There is no guarantee that patients structured therapeutic atmosphere of the CDTP.
whose disability benefits are discontinued as a result There is continuity of care between the CDTP and
of full-time employment will have them reinstated if outpatient program, and patients can move between
they cannot sustain their jobs. these two levels of care as their therapeutic and psy-
We run a transitional employment program as part chosocial needs change. Patients often start in the
of our CDTP, although we also accept outpatient pro- CDTP after an acute hospitalization, and as they re-
gram participants. We help patients who would like to cover and need a less structured or intense program,
attempt full-time competitive employment to realisti- they can transfer to the outpatient program. Con-
cally assess the disability benefits issue, and we pro- versely, patients in the latter in need of a more struc-
vide ongoing support throughout the pre-employment tured environment can transfer to the CDTP.
and employment process. There is community outreach in both programs,
Patients participating in the CDTP program have and staff attempt to understand and integrate the clin-
the opportunity to meet with their psychiatrists or case ical care of a patient with the patients life in the com-
managers as needed. Staff of the CDTP are familiar munity. As staffing allows, outpatient programs can
conduct home visits and help patients utilize other stance use. There are several models of dual diagnosis
community resources. This can include escorting pa- treatment that are often used in mental health settings.
tients to benefit offices for the purpose of helping them One is a traditional substance abuse treatment model
with entitlement applications and linking patients to that uses a peer-run, 12-Step design. This works well for
food pantries, day care, home health aides, and other patients who have a primary substance use disorder and
services as needed. Because many of the patients we a secondary psychiatric history. For SPMI patients who
see in our own program are new immigrants from have secondary substance abuse or who self-medicate
Spanish-speaking countries, we help patients access with substances, a harm reduction model (Magura et al.
English language programs, pass citizenship tests, and 2003) that involves more professional staff is often rec-
obtain legal help for immigration issues as needed. ommended. Both of these models can be adapted for use
Community outreach can also involve escorting in a day treatment or outpatient psychiatric setting.
and advocating for patients in the medical health care The model created by Drake et al. (1998) is another
system. Because members of the psychiatric treat- example of a program geared toward people with pri-
ment team often see patients with SPMI more fre- mary mental illness and secondary substance abuse.
quently than their medical providers see them, psychi- This integrated model employs a single program that
atric and nursing staff often provide some basic provides both psychiatric and substance abuse treat-
primary care services and help coordinate care across ment, using clinicians trained to treat both disorders.
the medical and psychiatric systems, advocating for Substance abuse treatment is tailored to patients
improved access as needed. who have severe mental illness and differs from many
standard substance abuse treatments by focusing on
Collaborations Promoting anxiety reduction instead of denial; emphasizing trust
and understanding instead of confrontation and criti-
Continuity of Care cism; using harm reduction approaches in place of ab-
Most ambulatory services do not have the mission, stinence; maintaining a long-term perspective instead
funding streams, or other resources to provide every el- of a focus on rapid withdrawal; providing clinical sup-
ement of comprehensive care. Although our program port beyond clinic hours; and utilizing neuroleptics
is part of a freestanding psychiatric hospital, we are on and other pharmacotherapy as needed rather than ex-
the same campus as a large general hospital (New York cluding these medications. Programming includes
Presbyterian Hospital) with which we collaborate in motivational interventions, community outreach, in-
the provision of most psychiatric emergency and crisis tensive case management, family psychoeducation,
services as well as needed medical care. We do not have and psychosocial rehabilitation in addition to medica-
the capacity to run our own housing programs, so we tion management (Drake et al. 1998).
collaborate with those providers who establish resi- In addition to the models already noted, the Na-
dential care in or near the neighborhood we serve. We tional Institute on Drug Abuse offers manuals for a
also refer patients to consumer-run programs that wide range of substance use interventions that, depend-
might benefit them, such as clubhouses that offer ing on the population served, may be usefully adapted.
evening and weekend activities or more sophisticated Substance use problems are also associated with
vocational services. These collaborations are essential medical sequelae, and people who have substance use
and often take considerable effort to maintain. disorders combined with other mental illnesses have
the highest risk of becoming infected with HIV (McKin-
non et al. 1997). Other infections, including hepatitis B,
Treating Comorbid Substance hepatitis C, and a variety of other sexually or parenter-
Abuse and Mental Illness ally transmitted infections are considerably elevated in
the dually diagnosed population when compared with
the general population (Rosenberg et al. 2001).
People with SPMI often have other co-occurring disor-
ders. It is estimated that almost half of people with
schizophrenia and other severe mental illnesses will Managing Co-Occurring
have a lifetime diagnosis of an alcohol or other sub-
stance use disorder (Kessler 2004). The use of sub-
Medical Disorders
stances in the absence of a disorder can also be problem-
atic. It is crucial, therefore, to create treatment People with SPMI are generally at increased risk for
programs that can address both mental illness and sub- many other co-occurring medical disorders. People
with schizophrenia have up to a 20% reduction in life where it is appropriate for men to cry in public, and the
span attributable to medical illness when compared clinician is not from the same cultural background,
with the general population (Marder et al. 2004). Met- the clinician may incorrectly assume the patients cry-
abolic and cardiovascular diseases are common, in- ing is a symptom of depression. It is imperative that
cluding hypertension, diabetes, emphysema, obesity, clinicians not make assumptions about what is nor-
and coronary artery disease (Marder et al. 2004). Fac- mative behavior based solely on their own cultural
tors contributing to this increased risk include pov- background. The clinician must ask the patient or get
erty, poor eating habits, decreased physical activity, al- collateral information regarding what is normal be-
cohol and cigarette use, stigma on the part of medical havior for the patients particular culture. There have
providers, and more recently the side effects of atypical been several studies that have shown that minorities
antipsychotics and other psychotropic medications. in the United States are often misdiagnosed. This is
Often the task of monitoring and coordinating medi- partially due to culturally insensitive assessments that
cal treatment falls to mental health staff. can lead to inappropriate diagnoses and treatment rec-
SPMI patients taking psychotropic medications ommendations (Copeland et al. 2003; Neighbors et al.
should have an annual physical examination with rou- 1989; Primm et al. 2005).
tine blood work. Outpatients on mood stabilizers and It is obvious but worth stating that clinicians must
certain antipsychotics such as clozapine require more be able to communicate effectively with patients. If
frequent blood work or other tests to monitor for ther- the clinician is not fluent in a patients language, a
apeutic blood levels, bone marrow suppression, liver translator is required. Even within a shared culture
toxicity, renal disturbances, and/or hypothyroidism, de- there are often multiple dialects of the same language.
pending on the medications being used. There is now a When conducting a psychiatric assessment, there are
concerted effort to get baseline metabolic parameters subtle nuances in a patients oral presentation that
and body measurements on all patients prior to starting can aid in making a diagnosis. These can be missed if
psychiatric medications to help monitor, prevent, or re- there is a language barrier, and the use of translators is
duce metabolic complications, especially among pa- second best to employing clinicians who are fluent in
tients taking newer-generation antipsychotics. Testing the languages that patients speak.
patients for HIV and viral hepatitis is now also more Our program is located in a largely Latino commu-
common, and the U.S. Centers for Disease Control and nity. Seventy percent of our patients are Spanish speak-
Prevention now recommends routine opt-out HIV testing, and a substantial number of these are monolingual
ing in all health care settings for all patients (Branson et in Spanish. We therefore conduct all programming in
al. 2006). Monitoring and coordination of medical care English and in Spanish. The majority of our staff is also
can be done through the psychiatric outpatient pro- bilingual and bicultural. The physical environment of
gram. Our program staff make considerable efforts to our clinics and our activities for patients reflect Latin
be effective across institutional boundaries to provide culture, and we accept patients incorporating tradi-
coordinated medical and psychiatric care, sometimes tional practices into their self-management strategies.
with remarkable results (LeMelle and Entelis 2005). Culturally appropriate environments and program-
ming contribute to patient adherence and retention
and also improve the quality of care that patients re-
Clinician Cultural Competence ceive. It is important, however, to understand that as
the cultural makeup of the community changes, so
When conducting assessments and selecting clinical should the culture of the mental health programming.
interventions, the culture of both the clinician and the
patient must be taken into consideration. Clinicians
use their experiences and knowledge as tools to deter-
Residential Programs
mine if a patients response or behavior is reasonable
or normal. This may pose a problem if the patient is Housing options for people with severe psychiatric dis-
from a different culture, and the clinician uses only his abilities have progressively expanded in most states,
or her own experiences as a frame of reference. There not only because they are important alternatives to
are many examples of behaviors that can be miscon- long-term hospitalization but also because disabled pa-
strued as pathological, including religious practices, tients usually live on small benefit checks that have
spiritual experiences, and expression of intense affect. not kept up with the growing cost of housing, thereby
For example, if a male patient comes from a culture making shelter otherwise unaffordable (Ropers 1988).
The levels of supervision in these residential programs Crisis residences are supported housing that can be
vary from intense, on-site, around-the-clock supervi- used in one of two ways: to help patients who have
sion to situations in which mental health organiza- housing crises and are on the verge of becoming
tions hold housing leases and provide only occasional homeless, or to help patients who have psychiatric cri-
staff visits to patients who are living relatively indepen- ses that are related to their psychosocial environments
dently in the community. These more independent in- and who need a short-term, higher level of care but do
dividuals often find that the major impediment to not qualify for inpatient hospitalization. In both cases,
moving out into their own housing is lack of affordable the stay is short, perhaps 24 months, and the staffing
opportunities (Goldfinger and Schutt 1996; Shern et is similar to transitional housing, with 24-hour cover-
al. 1997; Won and Solomon 2002). Housing programs age by a nurse, social workers, and mental health
have been shown to decrease hospitalization and aides. These programs are designed to make quick in-
homelessness, to increase quality of life, and to im- terventions to defuse crises and get patients into stable
prove social and occupational functioning (Hawthorne living environments in the community. All patients in
et al. 1994; Okin et al. 1995). These programs can be this type of residential program are required to remain
run by various organizations, including hospitals. in some sort of outpatient treatment. The residential
Some residential programs specialize in the treat- programming is geared toward psychosocial assess-
ment of patients who are homeless, dually diagnosed, ment and stabilization, benefits acquisition, and fam-
criminally involved, require a highly structured resi- ily/residential interventions.
dential program, or are otherwise not eligible for other Community residences are supportive housing pro-
types of residential options. The terms supported, sup- grams that are freestanding in the community and are
portive, and independent living are among those used staffed by mental health aides. The intensity of super-
to describe a gradual decrease in the level of structure, vision varies from 24 hours a day to occasional staff vis-
supervision, and staffing of different housing pro- its. The length of stay in this type of program can be
grams. Programs also differ in their eligibility criteria, months to years. Programs with lower levels of super-
staffing patterns, and intended length of stay. They vision are designed for higher-functioning patients who
usually require that patients participate in some type do not have significant impulse-control problems, who
of daily programming, and the programming is usually can manage and administer their medications indepen-
conducted outside of the housing setting. Patients are dently, and who are able to perform all of their activities
also usually required to sign a standard housing lease of daily living unassisted. This type of supportive pro-
to participate in these residential programs. gram is often used for patients who are transitioning to
Transitional housing is highly supervised, sup- independent housing. Patients are required to attend
ported housing that is designed to allow patients to off-site programming, which may include continuing
make a gradual transition from the inpatient setting to day programs, rehabilitation or vocational programs,
the outpatient setting. This type of housing is often competitive employment, community integration pro-
used for patients who have a history of difficulty in res- grams, or recreational programs. So-called low demand
idential programs, who have had long inpatient stays, housing relaxes these daytime requirements and serves
and/or who need a transition to less structured housing patients who do not tolerate the demands of more tra-
programs. A stay in transitional housing can some- ditional programs, for example, those who have been
times be required by other types of more permanent chronically homeless and prefer to be left alone.
housing programs to allow patients time to establish a Independent living programs are scatter-site hous-
positive track record in an outpatient setting. Transi- ing in the community that have no on-site supervi-
tional housing is staffed with 24-hour on-site coverage. sion. There are staff who meet with patients on a reg-
The staffing usually consists of a nurse, social workers, ular basis at a frequency of once per week to once per
and mental health aides. Programming includes medi- month depending on the patients needs. There is no
cation management and supervision of medication required programming associated with this type of
self-administration, social and recreational activities, housing program, but there are social activities that
links to the community, activities of daily living train- patients can participate in voluntarily. Patients are ex-
ing, behavioral interventions for safety, and discharge pected to be engaged in some sort of outpatient treat-
planning and community linkage. The average length ment program. There is little to no daily monitoring of
of stay can be up to 4 months. This is temporary hous- patient activity, and patients are allowed to have over-
ing, and the goal is to move patients as quickly as pos- night visitors, smoke, and essentially do anything that
sible to permanent housing in the community. is permissible within the usual tenant laws.
Family care programs are essentially adult foster be subject to other forms of monitoring, such as pa-
care programs where foster families take in adult pa- role, that track adherence to mandated care (Monahan
tients with mental illness. These families are screened et al. 2005).
and certified through the state and receive financial Outpatient commitment laws vary from state to
support. The families are trained and supported in the state. In New York State, an assisted outpatient treat-
general and emergency care of people with mental ill- ment law, commonly referred to as Kendras Law, was
ness. This type of housing is designed for patients who enacted in 1999. The intent of the law is to mandate
cannot tolerate living in large, communal settings treatment for people with severe mental illness who
such as a community residence and who need perma- are nonadherent, primarily to medication, and who
nent housing in a structured and nurturing setting. have a history of violence and/or multiple hospitaliza-
This is more of a custodial care model where the fam- tions. This law was enacted in response to a tragic in-
ily often acts as the representative payee or power of cident in which a young woman, Kendra Webdale, was
attorney for the patient. For many older patients, this pushed to her death in New York Citys subway system
is the ideal setting. The families are supported by the by a man with mental illness (who incidentally was be-
psychiatric staff and play an integral role in the pa- ing turned away from treatment, not refusing it). The
tients treatment and care. law requires that eligible adults be mandated to treat-
ment that must include either an assertive community
treatment team or an intensive case manager. The law
Retaining Patients in also allows for disturbed people to be picked up and
held for up to 72 hours for psychiatric evaluation. As-
Outpatient Treatment sisted outpatient treatment provides a new process for
identifying, investigating, and evaluating individuals
In contrast to most inpatient care, outpatient settings with high need. It has improved accountability in local
struggle with patient adherence to treatment. A variety mental health service systems and enhanced access to
of techniques are available to address this problem. services and coordination of treatment for these indi-
The most important of these is creating smooth and viduals. New York State allocated additional funding to
well-coordinated transitions from one level of care to support more assertive community treatment teams
another. Flexibility is crucial, so that if a patient misses and intensive case manager programs, which helped to
a scheduled appointment but shows up at another time improve community services.
a staff member is available to at least briefly see the pa- Initial outcomes of assisted outpatient treatment
tient and schedule another visit. Other strategies that showed an increased participation in case manage-
help enhance adherence are low staff turnover allowing ment from 53% to 100%, in day programs from 15% to
for long-term therapeutic alliances between staff and 22%, in substance abuse services from 24% to 40%,
patients; engaging with patients on their own goals for and in supported housing services from 19% to 31%.
recovery; use of outreach techniques when patients fail Most significantly, there was an increased adherence
to show for appointments; and the involvement of to prescribed medication from 34% to 69% in the first
families in patients treatment plans. 6 months (Brennan 2005). This program, and its
Monitoring patient adherence to psychotropic equivalent in other states, is one of several legal ap-
medication and the use of long-acting injectable medi- proaches that have been developed to assist in patient
cations for psychotic disorders are helpful in address- adherence to treatment and to decrease recidivism.
ing nonadherence to drug regimens. Assertive com- Other programs operated by the legal system include
munity treatment (Dixon 2000), intensive case man- mental health courts, specialty probation programs,
agement, and outpatient commitment are among the and criminal diversion programs (Elbogen et al. 2003).
strategies employed when seriously ill patients repeat- Patients may accept some types of treatment and
edly fail to adhere to treatment and either present a reject others. For example, some patients accept psy-
danger to themselves or others or are heavy users of in- chiatric care but refuse placement in a residential set-
patient and emergency department care (Van Dorn et ting because they object to living with others, to the
al. 2006). Small inducements may also help keep seri- rules and regulations of housing programs, or to the
ously ill patients in treatment. These include serving fact that most of their entitlement checks will be used
meals, offering transportation reimbursement, and for housing and thereby leave little spending money.
engaging patients in pleasurable activities such as cre- Other patients are willing to talk about their problems
ative arts groups and recreation. Forensic patients may but refuse to accept medication. In our program we
work with patients where they are. Using techniques ternational six-centre randomised controlled trial. Br J
that are now often referred to as harm reduction and Psychiatry 192:224231, 2008
Cook JA, Leff HS, Blyler CR, et al: Results of a multisite ran-
motivational interviewing, we help patients examine
domized trial of supported employment interventions
their own views about the advantages and disadvan- for individuals with severe mental illness. Arch Gen
tages of the choices they make and try to help them Psychiatry 62:505512, 2005
adopt health-promoting behaviors. We reserve man- Copeland LA, Zeber JE, Valenstein M, et al: Racial disparity
dated treatment for patients who do not respond to a in the use of atypical antipsychotic medications among
more collaborative approach. veterans. Am J Psychiatry 160:18171822, 2003
Cournos F: The impact of environmental factors on out-
come in residential programs. Hosp Community Psy-
chiatry 38:848852, 1987
Conclusion Dixon L: Assertive community treatment: twenty-five years
of gold. Psychiatr Serv 51:759765, 2000
The spectrum of psychiatric illness has not changed, Drake RE, Mercer-McFadden C, Mueser KT, et al: Review of
integrated mental health and substance abuse treat-
but our understanding about treatment efficacy, recov- ment for patients with dual disorders. Schizophr Bull
ery, and patients quality of life has changed, and our 24:589608, 1998
systems of care need to reflect this new knowledge. As Elbogen E, Swanson J, Swartz M: Effects of legal mecha-
large, long-term state psychiatric hospitals have nisms on perceived coercion and treatment adherence
downsized, treatment and services for people with se- in persons with severe mental illness. J Nerv Ment Dis
191:629637, 2003
vere mental illness have shifted to the community.
Foley H, Sharfstein S: Madness and Government. Washing-
Many different models of community care have ton, DC, American Psychiatric Press, 1983
evolved. There are some distinct advantages for both Fonagy P, Roth A, Higgitt A: Psychodynamic psychothera-
patients and staff to having hospital-based outpatient pies: evidence-based practice and clinical wisdom. Bull
programs, which we have enumerated in this chapter. Menninger Clin 69:158, 2005
Goffman E: Asylums. New York, Doubleday Anchor, 1961
Although varying somewhat by hospital, these advan-
Goldfinger SM, Schutt RK: Comparison of clinicians hous-
tages usually include well-developed administrative ing recommendations and preferences of homeless
structures, a continuum of integrated patient services, mentally ill persons. Psychiatr Serv 47:413415, 1996
the capacity to recruit and retain well-trained staff, Greer S, Greer A: The continuity of moral reform: commu-
and the ability to coordinate medical and psychiatric nity mental health centers. Soc Sci Med 19:397404,
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Hall LL, Graff AC, Fitzpatrick MJ, et al: Shattered Lives: Re-
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CHAPTER 25
DAY HOSPITALIZATION
AND INTENSIVE OUTPATIENT CARE
In an era of brief inpatient hospitalizations, psychiat- tion. Hospital-based programs provide a high staff-to-
ric intensive outpatient treatment has a number of impatient ratio with an array of clinical specialists ranging
portant missions. Intensive outpatient services can from psychiatrists to occupational therapists. Present-
prevent hospitalization or decrease inpatient length of day programs aim to be client centered and rely on the
stay. They allow for treatment in the least restrictive patients perception of his or her illness. Treatment de-
setting while still providing structure and support. In pends on patients active participation in choice of
this chapter, the terms intensive outpatient treatment goals and volition for achieving them (Feder 1998).
and intensive outpatient services refer to a range of This working alliance propels the treatment forward,
programs, including the partial hospital program ensuring quality care and positive rehabilitation out-
(PHP), continuing day treatment program (CDTP), come. Treatment goals include symptom stabilization
and intensive outpatient program (IOP). as well as restoration of meaningful life roles and func-
Mental illnesses affect functioning and quality of tioning. Flexibility of treatment and adequate re-
life. Intensive programs can help the participant resources provide patients with a sense of control over
sume functioning in roles that have been disrupted or life decisions and a feeling that their judgment is val-
facilitate development of new roles. Although intensive ued. The aim is to support the patients goals while
treatment can occur in a number of settings, hospital- gently challenging vague or unrealistic expectations.
based intensive outpatient programming provides an A range of potential intensive outpatient services
array of services to address the clients strengths, inter- exists. The terminology in the literature is often con-
ests, and goals by integrating a range of therapeutic and fusing and inconsistent. Different labels are being used
rehabilitative interventions, focusing not only on for the same services, and to complicate matters fur-
symptom stabilization but also on community integra- ther, services with the same label may actually be sig-
339
nificantly different, depending on location, funding posttraumatic stress disorder in World War II (Piper et
sources, and other factors. In this chapter, a PHP, at al. 1996). Bion, Foulkes, and others also contributed to
times referred to elsewhere as day hospitalization, is the development of group and milieu treatment. The
utilized to prevent inpatient admission or shorten the first day hospital in North America was started in
duration of an inpatient stay. A PHP provides up to sev- Montreal in 1946 at the Royal Victoria Hospital by
eral weeks of daily treatment, typically Monday Ewen Cameron. In 1971, based on experience with the
through Friday. Studies have shown that up to 40% of Montreal program, H.F.A. Azim opened the Edmonton
people meeting criteria for a voluntary inpatient admis- Day Treatment Program with a residential facility at
sion could be treated in a PHP setting, often with more the University of Alberta Hospital. Azim developed an
rapid symptom relief and, in the short term, improved 18-week treatment program for personality and affec-
psychosocial functioning (Kallert et al. 2007; Schene tive disorders that incorporated services research. The
2004). A CDTP typically provides care over several Massachusetts Mental Health Center also had a tradi-
months or more to enable individuals with psychiatric tion of intensive transitional services starting in 1946
disorders to stabilize and function more independently and opened a day hospital in 1956 that accommodated
in the community. In the European literature, CDTPs patients admitted directly from the community to pre-
include day treatment programs for affective and per- vent hospitalization. In the United States, the Mental
sonality disorders as well as day care centers for severe Retardation Facilities and Community Mental Health
chronic mental illnesses such as schizophrenia (Mar- Centers Construction Act of 1963 mandated an ex-
shall et al. 2001b). An IOP provides integrated individ- panded array of outpatient services to be provided by
ual and group treatments at a lesser frequency of up to community mental health centers (Kraus and Stroup
three times per week. There is support in the literature 2006). Financial issues have played a significant role in
for treating personality disorders (Gratz et al. 2006; shaping outpatient services. Funding influences men-
Gunderson et al. 2005; G.W. Smith et al. 2001) and ad- tal health policies, determining access to care and qual-
dictions (Avants et al. 1999; Gottheil et al. 1998; Kle- ity. There have been shifts in responsibilities for deter-
ber et al. 2007; Timko et al. 2003) in an IOP setting. mining reimbursement and programming among
Reviews of randomized, controlled trials provide evi- local, state, and federal governments. The introduction
dence for more rapid symptom relief in PHP, CDTP, of Medicare and Medicaid in the mid-1960s shifted fi-
and IOP levels of care compared with inpatient treat- nancial responsibility from the state to federal sources
ment (Marshall et al. 2001a, 2001b). It has been more (Gottlieb 1995). In recent years there has been a greater
difficult to compare relapse rates, cost-effectiveness, shift to managed Medicare and Medicaid, causing a re-
and functional outcomes (Priebe et al. 2006). organization of service delivery and limiting coverage
Intensive outpatient services are part of a larger for both inpatient days and outpatient services.
continuum of care in a hospital setting that includes
the emergency department, inpatient setting, and Treatment Outcomes in Intensive
clinic. A continuum of care facilitates communication Outpatient Services
and efficiency of referral to the intensive program. An-
Acute episodes of mood disorders, including unipolar
other model is that of vertical integration of services,
major depression and bipolar disorders, are often suc-
in which the same provider follows the client for con-
cessfully managed in a PHP or IOP setting or a contin-
tinuity of care (T.E. Smith et al. 1999). There are also
uum of care from inpatient unit to PHP or IOP. Liter-
many types of community-based intensive programs.
Regardless of the setting, all three forms of intensive ature focusing on outcomes for affective disorders
alone is generally positive but quite limited (Marshall
outpatient services reviewed in this chapter provide
et al. 2001a). Patients with more chronic mood disor-
assessment, stabilization, skill development, rehabili-
ders who have impairments in functioning can benefit
tation, and community integration to varying degrees.
from CDTP and IOP levels of care as well. Mood dis-
orders complicated by personality disorders and/or
History of Intensive substance abuse are more often described in studies on
the efficacy of intensive outpatient services.
Outpatient Treatment Severe episodes of major depression can often be
treated in a PHP or IOP setting to avert hospitaliza-
Group-oriented and milieu-based treatment ap- tion, providing that the patients are not acutely sui-
proaches were developed by T. F. Main in England cidal, have some supports in the community, and are
based on experiences from treating combat-related able to maintain adequate self-care and medication
Day Hospitalization and Intensive Outpatient Care 341
compliance. PHP and IOP levels of care sometimes disorders benefited more than those with Cluster A
achieve the goals of inpatient treatment with less dis- personality disorders, and an IOP was as effective as a
ruption to the patients life and are perhaps more cost- more intensive day hospital (American Psychiatric As-
effective (Goodwin and Jamison 2007b). Intensive sociation 2000; Karterud et al. 2003; Vaglum et al.
outpatient services more commonly offer a stepdown 1990). In general, evidence supports a time-limited
for patients in a resolving manic episode after suffi- day treatment program followed by an IOP for person-
cient stabilization on the inpatient unit. Goodwin and ality disorders (American Psychiatric Association
Jamison (2007c) stressed that patients must have suf- 2001; Dazord et al. 1997; Wilberg et al. 1998).
ficient insight and commitment to maintain medica- Individuals with schizophrenia often have positive
tion compliance out of the inpatient unit; for these in- symptoms, negative symptoms, and cognitive impair-
dividuals, an intensive service is helpful because ment along with poor insight into the illness. Medica-
symptoms might still fluctuate, and there is the risk of tion management and psychosocial therapies in a PHP
cycling into a depressive episode. Furthermore, pa- or CDTP address positive symptoms and poor treat-
tients with bipolar illness are at substantial risk for ment adherence (Schwartz et al. 2006). Negative symp-
suicide in the first 612 months after discharge from toms and impairments in social skills and cognition
the hospital, with the highest risk in the first week, re- are more intractable and result in chronically impaired
gardless of polarity of the acute episode, warranting functioning (Muser et al. 2006). Schizophrenia and
more intensive follow-up in a PHP or IOP (Goodwin other psychotic disorders often start in early adulthood
and Jamison 2007a, 2007c). Rucci et al. (2002) found and adversely affect acquisition of independent living
that an intensive treatment program that closely mon- skills. Repeated episodes of psychosis disrupt educa-
itored treatment adherence significantly decreased tional and vocational pursuits as well as interpersonal
suicide attempts in patients with bipolar illness recov- relationships. Day treatment is effective at preventing
ering from an acute manic episode. Also, short-term relapse and repeated hospitalizations and improving
therapies recommended for bipolar illness can be in- independent living skills and vocational functioning
corporated into PHP and IOP programming, including (Lehman et al. 1998, 2004; Miller et al. 2006). Resnick
cognitive-behavioral therapy (CBT), interpersonal and et al. (2004) reviewed data from the Schizophrenia Pa-
social rhythm therapy, and family-focused treatment, tient Outcomes Research Team (PORT) survey and
among others (Goodwin and Jamison 2007d). showed that participation in a CDTP had a significant
There is evidence that borderline personality disor- positive association with knowledge of illness and ser-
der can be effectively treated at PHP, CDTP, and IOP vices along with improvement in life satisfaction. Re-
levels of care (Gunderson et al. 2005). The goals of cently the efficacy of cognitive remediation has been
treatment are to decrease subjective distress, maladap- studied in intensive outpatient treatment with promis-
tive behaviors, interpersonal problems, and self-inju- ing outcomes (McGurk et al. 2007; Medalia and Lim
rious behaviors. An IOP level of care can effect im- 2004). Results have shown improvement in cognitive
provements in social and interpersonal functioning function, especially in areas of memory and attention.
(Bateman and Fonagy 1999, 2001; G.W. Smith et al. A 2-year follow-up also revealed a significant decrease
2001). Bateman and Fonagy (1999) studied the treat- in rehospitalization rates and overall success in achiev-
ment of borderline personality disorder in a longer- ing rehabilitation goals. Finally, CBT for psychosis, a
term psychoanalytic PHP and demonstrated fewer sui- new approach in the United States but a mainstay of
cide attempts after 6 months, decrease in anxiety and treatment for patients with schizophrenia in the
depression in 9 months, and decrease in self-harm af- United Kingdom, is a potential adjunct to services al-
ter 12 months, with consolidation of gains on follow- ready offered (Turkington et al. 2006).
up. Patients in a borderline personality disorders pro-
gram at McLean Hospital who transitioned from a Rehabilitation in Intensive
PHP level of care to an IOP were followed up over 18
months (Gratz et al. 2006). Within the first few
Outpatient Services
months there were improvements in emotional dys- Rehabilitation focuses on the patients need for a sense
regulation and parasuicidality, followed by gradual im- of mastery or the ability to cope with symptomatology
provement in functioning and quality of life. Treat- and demands of daily living. The biopsychosocial as-
ment of a range of personality disorders was studied in pects of each individual are factored into efforts to en-
a Norwegian treatment research network; individuals courage development of skills. This concept dates back
with borderline personality and Cluster C personality to the foundation of psychosocial occupational therapy
in 1917 and was supported by Adolf Meyer, who pro- supervision of medication administration is essential.
posed a psychobiological approach to mental health. In The participant must be medically stable for monitor-
1922, while director of the Henry Phipps Psychiatric ing of adjustments in the psychotropic regimen with-
Clinic at Johns Hopkins Hospital, Meyer described out inpatient supervision. The ability to tolerate four
mental illness as problems of living and not merely groups or activities per day within a structured program
diseases of a structural and toxic nature, and he pro- lasting several hours a day is a general expectation.
posed habit training. At the time it was viewed as the
most successful type of treatment program, providing Psychiatric Assessment
intensive care and re-education (Schwartz 2005b).
The initial psychiatric assessment is completed by a
Today, occupational therapy is based on a patient-cen-
multidisciplinary treatment team and actually applies
tered approach and focuses on functional skills essen-
to all levels of intensive outpatient care discussed in
tial to everyday tasks of living. this chapter. Referral documents and collateral infor-
Psychiatric rehabilitation has been an emerging
mation are obtained with informed consent of the par-
field over the past 15 years. There is a range of philo-
ticipant. A thorough history includes the elements
sophical and technical differences within the field (An-
outlined in the American Psychiatric Associations
thony and Liberman 1986; Anthony et al. 1978), but
(2006) Practice Guideline for the Psychiatric Evalua-
the common goal is to support recovery and restore
tion of Adults. Basic areas addressed at intake include
ability for independent living and effective life man- demographics, history of present illness and current
agement. The strongest value of psychiatric rehabili-
symptoms, past psychiatric history, substance abuse,
tation is that each individual has the right of self-
medical history, current medications and drug aller-
determination and the capacity to learn and grow
gies, family history, and psychosocial history. A thor-
(Pratt et al. 2002). Both occupational therapy and psy-
ough assessment of risk factors for self-injurious be-
chiatric rehabilitation models promote development
haviors and aggressive behaviors is conducted in the
of an individualized map of recovery, helping clients course of obtaining the history and mental status
acquire social and functional skills while developing
examination.
the supports needed to adapt to their environment.
The treatment team identifies acute or persistent
symptoms and maladaptive behaviors preventing opti-
Partial Hospital Program mal functioning at a lower level of care. The designated
primary therapist, a team member who may be a nurse,
social worker, or other clinician, elicits the patients
Admission Criteria grasp of warning signs of decompensation. Commonly
The PHP is a transition or diversion from inpatient used rating scales could be utilized to assess and track
level of care. Participants are acutely symptomatic but symptoms and warning signs in a more systematic
not at imminent risk of self-injurious or aggressive be- manner. Some of these rating scales are the Indepen-
haviors posing a threat to others, and they have ade- dent Living Skills Survey (Loeb 1996), Hamilton Rating
quate self-care and cognitive organization to live in a Scale for Depression (Hamilton 1960), Beck Depres-
community setting. They are not actively abusing sion Inventory (Beck et al. 1961), Brief Psychiatric Rat-
drugs or alcohol. The level of academic and intellectual ing Scale (Overall and Gorham 1988), and Positive and
functioning should be appropriate to the cognitive de- Negative Syndrome Scale (Kay et al. 1987). Data on
mands of the program. The preliminary diagnostic as- symptoms and functioning from structured interviews
sessment determines whether the patient is experienc- are then integrated into the overall formulation.
ing the acuity and intensity of symptoms that would
likely benefit from this level of care. Acute symptoms
Medical Assessment
might include depression, anxiety, hypomania, and Essential medical information includes a recent physi-
psychosis, among others. Patients with a range of diag- cal examination, laboratory tests, and an electrocardio-
noses can benefit from a PHP. Because treatment is gram. An intake assessment often includes weight, cal-
generally limited to several weeks or less, the clinician culation of body mass index, abdominal girth, vital
should identify target symptoms as a focus of treatment signs, and review of physical complaints or medication
planning. Adequate community supports, housing, side effects. Programs often develop a health assess-
transportation, and benefits must be available. The pa- ment form to be completed on day of admission by the
tient needs a support system, especially during eve- patient. If a patient does not have a primary care pro-
nings and weekends. Medication compliance or direct vider, he or she is assisted with referrals. The assess-
ment identifies the need for health maintenance ser- provider or other specialist if there are medical comor-
vices, in particular nutritional problems and conditions bidities. Nutritional counseling is ideally provided as
exacerbated by psychotropic medications. part of medical management, with referrals initiated
for better follow-up and maintenance. Education
Psychosocial Assessment about short- and long-term risks for medications is
The initial comprehensive assessment explores psy- important. A team approach to tracking symptoms
and behavioral changes allows active adjustments in
chosocial stressors precipitating the current episode.
the medication regimen and formulation of other as-
Stressors can be related to interpersonal issues,
pects of treatment.
changes in living situation, or difficulties in school or a
job, among others. The patients life story, including Treatment Planning and
current living situation, developmental milestones,
family structure, friendships, relationships, educa- Establishment of Goals
tional background, work history, and leisure interests, Effective stabilization and skill development proce-
should be explored. Premorbid and interepisode func- dures include the patient in setting goals and objec-
tioning both have significant bearing on expectations tives. It is also highly desirable to involve the family
for treatment. In addition, history of emotional, phys- and significant others in the establishment of the treat-
ical, or sexual abuse and any other trauma is obtained. ment plan. Goal setting should not be solely based on
Support systems are identified, including family, diagnosis or clinicians expectations but rather should
friends, case managers, residential counselors, and be founded on assessment of the patients strengths,
others, with an expectation of further collaboration. deficits, interests, needs, and supports. Table 251, de-
The level of insight of family and friends is also veloped by one of the authors (J.K.F.), provides a sam-
explored, including understanding of the participants pling of behaviorally written goals and objectives for
illness. If there is a legal history, contact with pro- partial hospital or continuing day treatment levels of
bation officers or other agencies might be necessary. care expressed in terms of the clients measurable func-
If the patient is a parent or caretaker, the therapist tioning. Goals should be assessed and reevaluated reg-
should explore issues around the safety of the depen- ularly, engaging the patient as much as possible. The
dents and provide links to community agencies. self-report chart shown in Figure 251 was developed
for the CDTP at NewYorkPresbyterian Hospital,
Stabilization Phase Payne Whitney Manhattan; it demonstrates how the
For direct admissions from the community, partial clients perspective contributes to the treatment plan
hospitalization provides rapid stabilization of acute and determination of discharge readiness. In the PHP
symptoms with medication trials in a setting that al- and CDTP, the client helps to steer the course of treat-
lows for frequent assessment and medical monitoring. ment and assess progress with the assistance of the
Referrals from an inpatient unit to PHP as a stepdown multidisciplinary team. Estimated length of stay,
allow for consolidation of treatment effects. Some pro- which can be driven by reimbursement and institu-
grams also offer electroconvulsive therapy on an acute tional expectations, influences goal setting.
or maintenance basis. For patients on mood stabilizers
and certain antidepressants, blood levels are moni-
Program Structure
tored. For patients on antipsychotics, monitoring of A PHP is often situated near the emergency depart-
weight, abdominal girth,and laboratory tests helps fol- ment or inpatient services department. The programs
low risk factors for the metabolic syndrome. Examina- meet Monday through Friday, generally offering
tion for extrapyramidal side effects and periodic elec- 4 hours of group a day. Individual sessions with the
trocardiograms, if indicated, should be conducted. primary therapist and psychiatrist or nurse practitio-
Depot antipsychotics such as haloperidol decanoate ner are typically scheduled on a weekly basis but may
(Haldol decanoate), fluphenazine decanoate (Prolixin occur more frequently. Some programs provide or as-
decanoate), or risperidone (Risperdal Consta) could be sist with transportation. All groups, whether they are
administered in this setting for patients with a history skills training or supportive therapy, rely on effective
of poor treatment adherence. Titration of the antipsy- group leadership. The therapist must ensure that the
chotic clozapine (Clozaril) also requires close medical group remains committed to its goals while respond-
monitoring that can be accomplished in a PHP. ing to the evolving needs of the participants to keep
The practitioner providing psychopharmacological the treatment active.
management maintains contact with the primary care Psychoeducation is an important component of
TABLE 251. Sample goals and objectives in intensive outpatient services
Goals Objectives
Improve attention and 1. Client will describe two strategies to help focus.
organization 2. Client will utilize a daily planner.
3. Client will remain at task for 50% of the group.
4. Client will verbalize two strategies to better organize the environment.
Reduce self-injurious behavior 1. Client will contract for safety.
2. Client will utilize diary cards to increase insight into self-injurious
behaviors.
3. Client will self-initiate skills coaching prior to engaging in self-injurious
behavior.
Increase social activities 1. Client will initiate conversation once a day in a group.
2. Client will report satisfaction with increase in social contacts outside of
program.
3. Client will develop three strategies to communicate needs more effectively.
Improve ability to manage 1. Client will identify three triggers to anxiety.
anxiety 2. Client will describe two coping strategies for dealing with anxiety.
3. Client will utilize one stress reduction activity on a daily basis.
Maintain sobriety 1. Client will attend Alcoholics Anonymous meetings twice per week.
2. Client will discuss two effective coping strategies to deal with stress.
3. Client will develop a daily schedule.
Improve self-care 1. Client will develop a nutritional chart.
2. Client will exercise at least 20 minutes, three times a week.
3. Client will discuss weight management activities by attending a nutritional
group on a weekly basis.
Increase work readiness 1. Client will identify vocational goals realistic to current situation.
2. Client will identify strengths in area of work.
3. Client will identify three possible internship sites.
Increase control of anger 1. Client will identify triggers to outburst.
2. Client will describe two anger management techniques.
3. Client will identify two alternative actions when experiencing an outburst.
the PHP accomplished in individual sessions and or individual provider for extended treatment issues
groups. The aim of psychoeducation is to teach symp- and relapse prevention. Many of the patients in a PHP
tom management as well as health and safety aware- are able to return to their previous level of functioning,
ness. The patient learns to monitor and share infor- which may include parenting, work, and/or school.
mation about symptoms and medications as an active Not all patients require extensive rehabilitation, al-
participant in treatment. In addition to verbal discus- though some may benefit from a referral to a job coach
sion of the risks and benefits of treatments, patients or additional vocational training. Occasionally pa-
are also directed to Internet sites providing beneficial tients do not respond adequately to treatment at the
information about their medication. A hospital is PHP level of care and ultimately require inpatient care.
likely to have its own health education department for Further decompensation of the presenting symptoms
current literature. leading to self-injurious or other types of impulsive be-
haviors would require inpatient admission. Also, med-
Discharge Planning ication management that has led to the need for more
Participants demonstrating resolution of the most intensive medical monitoring would warrant inpa-
acute symptoms but still experiencing persistent tient admission. Termination from the program may
symptoms or functional impairment can be referred to also be necessary when the patient is unable to toler-
a CDTP or an IOP. Those who demonstrate signifi- ate the intensity of the program or is not committed to
cant improvement are referred to an outpatient clinic the treatment.
PLEASE COMPLETE THE FOLLOWING FORM Yes No

Benets of treatment
Did you complete any objectives (steps) on any of your goals?
Were there any days in which your symptoms were less bothersome than usual?
Were there any days on which you were able to keep symptoms from interfering with your
activities?
Considering your involvement in community life (outside of program), did you
a. Get better at taking care of the place you live?
b. Add any hours of work (volunteer or paid) or attend a class?
c. Add any leisure activities or socialize with anyone in the community?
Considering your life as a whole, were there days in which you
a. Were particularly pleased with any of your activities?
b. Were particularly pleased with any of your relationships?
c. Felt healthier or more competent or skillful?
Were there any days in which your symptoms were worse than usual?
If day treatment services had not been available to you during this month, would this have made a
difference in the following areas?
a. Work you are doing on your goals?
b. The amount of support you needed at home?
c. Your involvement in school or work (volunteer or paid)?
d. Your involvement with other people?
e. Your involvement in leisure activities?
Please describe how you will know if it is time to move on from the outpatient program.
FIGURE 251. Sample client self-report monitor.
Continuing Day Treatment providing time-limited intensive treatment. Strong

emphasis is placed on maximum community integra-
Program tion, requiring the program to create linkages with an
array of community services including self-help
A CDTP, for the purposes of this chapter, is a compre- groups, state-funded vocational programs, indepen-
hensive, structured, and supportive program commit- dent living centers, and supportive housing. Principles
ted to sustaining individuals in the community and di- of psychiatric rehabilitation are incorporated into the
mi nis hin g need fo r repeat ed h os pitalizati on s. program because they are based on the belief that re-
Intervention is both therapeutic and rehabilitative, fo- habilitation can prevent further deterioration and help
cusing not only on symptom stabilization but also on a person function better in the community.
graded cognitive and psychosocial rehabilitation strat-
egies. The CDTP differs from the PHP in terms of du-
Admission Criteria
ration of treatment, acuity of symptoms, chronicity of CDTPs serve individuals with chronic mental illness
conditions, and baseline functioning. Length of stay and functional impairments affecting their ability to
depends on goal acquisition, regulatory demands, and sustain themselves in the community. They may have
program philosophy as well as insurance benefits. His- difficulties adhering to a medication regimen. They
torically, patients remained in programs for years, but should not be at imminent risk for suicide or aggres-
in recent years there has been a gradual shift toward sive behaviors. Participants need to verbalize personal
goals and expect to benefit from this level of intensive their own choice. The plan serves as a road map, pri-
services. Family involvement is highly desirable. Indi- oritizing overall objectives and identifying strengths,
viduals with schizophrenia, schizoaffective disorder, barriers, and time frames for monitoring the journey.
and chronic major affective disorders make up the
bulk of the population, with a core of special services Treatment
for those diagnosed with borderline personality disor- A well-designed program offers a structured environ-
der, eating disorders, or substance abuse. Other spe- ment where treatment is individualized, with clear ex-
cialized programs may be geared toward the adoles- pectations and estimated duration. Programs are gen-
cent or geriatric population. erally offered for the entire day from Monday through
Friday but may have a more limited schedule tailored
Assessment Phase to the needs of some patients. The primary therapist
The initial psychiatric and medical assessments in- oversees the treatment, providing individual therapy
clude all of the elements outlined for the PHP. The psy- and case management. The psychiatrist evaluates the
chosocial assessment is similar, although there is patient on admission and at least monthly but more
greater emphasis on assessing potential for skill devel- often if necessary for active symptoms or medication
opment and rehabilitation. Functional assessments are changes. A treatment schedule is developed between
often administered by occupational therapists who col- the patient and therapist involving an array of groups
lect data through semistructured interviews, observa- ranging from skill development to psychoeducation
tion, and standardized tests. The evaluation includes around illness management to preparation for com-
the clients history and premorbid functioning in areas munity living.
of self-care, education, work, and leisure. The present A CDTP provides an opportunity for more exten-
capabilities and problems contributing to functional sive medication trials. Medical issues that require
deficits, such as inattention, inability to focus, poor monitoring include the metabolic syndrome and ex-
planning, and organizing, are assessed (Allen 1985). Fi- trapyramidal syndromes, including tardive dyskinesia
nally, contextual factors affecting the clients functional for patients on antipsychotics. Resources are generally
performance are reviewed in depth, including living en- available to administer depot medications and pre-
vironment, finances, and health status. A comprehen- scribe clozapine, with all of the necessary laboratory
sive functional assessment also explores the clients in- tests and medical monitoring. Random urine toxicol-
terests and values regarding roles and occupational ogy screenings might be indicated. Psychoeducation is
expectations. The clients perception of his or her dis- aimed at symptom management; understanding risks,
ability and ability to engage in a therapeutic alliance is benefits, and potential side effects; and perhaps most
important (Law et al. 1998). Ultimately a functional as- importantly, compliance.
sessment will identify potential strengths and help de- Skills training and activities therapy compose core
velop realistic and applicable rehabilitation goals. The components of CDTPs. Direct instruction and expe-
assessment tool can be used at the beginning of treat- riential learning of functional skills are of particular
ment and as an integral part of the program. Occupa- importance for acquisition of new skills and generali-
tional therapists administer standardized assessments zation. Emphasis is placed on interventions that facil-
such as the Allen Cognitive Level (Allen 1985). itate basic skill acquisition (physical, cognitive, and
Liberman et al. (1995) reviewed the need to iden- social) without unduly challenging individual thresh-
tify past and present skills to guide the rehabilitation olds for stress and disorganization. Combining social
process, allowing development of a comprehensive skills training with maintenance of antipsychotic
treatment plan. Psychiatric rehabilitation specialists medication yields better social functioning while min-
stress the need to assess motivation and examine fac- imizing relapse (Liberman et al. 1995). In addition,
tors influencing rehabilitation readiness (Cohen et al. services provided during recovery may include case
1992). Areas considered include motivation and com- management, family intervention, crisis interven-
mitment to change, awareness of roles, and ability to tion, and community linkage.
establish a therapeutic alliance. Finally, goal setting is
the most critical stage of functional assessment. It is a
Group Programming
powerful tool that actively engages the client in devel- A wide range of group models is available to meet the
oping an individualized service plan. This is an ongo- therapeutic and educational needs of clients. Below is
ing collaborative process designed to provide strategies a sampling of groups offered in outpatient day treat-
for achieving patients personal goals in settings of ment programs.
INDEPENDENT LIVING SKILLS bate the symptoms. Psychoeducational groups also

focus on increasing the understanding of patients and
Independent living skills programs teach self-care
families about the phases of the recovery process and
skills such as meal preparation, nutrition, budgeting,
development of resilient behaviors. Some CDTPs use
and home maintenance. Basic foundation skills such
specific modules such as the University of California
as organization, problem solving, and decision making
Los Angeles Social and Independent Living Skills Mod-
are reviewed in these groups to increase awareness of
ules developed by Robert Liberman (Schwartz 2005a).
potential difficulties in the patients environment.
For instance, a medication management group focuses
Skills are taught using a variety of strategies involving
on teaching patients to monitor their own medications
instruction and practice, such as preparing a meal and
by being aware of side effects and learning to talk with
inviting the hospital nutritionist to review the food
the health care provider. Another psychoeducation
pyramid and special diets.
group focuses on symptom management skills to help
patients identify warning signs of relapse and become
INTERPERSONAL SKILLS more effective in coping with persistent symptoms.
Interpersonal skills groups teach social skills and com- Many other modules are available that address addi-
munication. Clients learn to identify verbal and non- tional community reentry skills, including a wide ar-
verbal communication behaviors and become more ef- ray of skills from self-care to job readiness.
fective in starting a conversation and keeping it going.
These groups involve a range of methods, including SPECIALIZED GROUPS
pencil-and-paper activities, role-playing, videotaping
Additional specialized groups may be provided in a
interactions, and modeling.
CDTP, such as the following.
RECREATION/LEISURE PLANNING Dialectical behavior therapy. Dialectical behavior

therapy (DBT) groups are most effective if they are re-
Effective use of time includes exploration of leisure in-
inforced by a DBT-certified therapist in the individual
terests. Clients are provided with information and the
sessions and throughout the day. DBT groups are de-
opportunity to explore the benefits of recreational activ-
signed for patients with the diagnosis of borderline
ities as a means to develop social skills and better man-
agement of unstructured time. In addition, providing a personality disorder who have severe emotional dys-
regulation and behavioral dyscontrol. The DBT skills
supportive community where interests can be pursued
training groups comprise four modules that address 1)
increases the likelihood that a client will further ex-
emotion regulation, 2) interpersonal effectiveness, 3)
plore the activities in his or her own community. Cli-
surviving crises without engaging in maladaptive be-
ents support each other in the pursuit of activities, and
haviors, and 4) developing a stable sense of self. Pa-
it may not be uncommon to observe two clients spend-
ing time after the program pursuing a leisure activity. tients learn to replace maladaptive behavior with more
adaptive skills. Groups involve specific skills teaching,
consultation, and homework (Linehan 1993).
COPING SKILLS
Coping skills groups focus on developing effective Cognitive-behavioral therapy for psychosis. CBT
ways to manage stress and associated destabilization. groups address the needs of patients with persistent
Clients are taught a range of adaptive skills for coping positive symptoms of psychosis and, in some cases,
with stressors and becoming more effective in crisis negative symptoms. The groups aim to reduce distress
situations. Techniques to cope better with daily life de- by challenging the patients beliefs about their symp-
mands are explored, with emphasis on developing toms. They teach how to identify and correct cognitive
problem-solving strategies and awareness of effective biases, evaluate beliefs, and assess whether the beliefs
communication patterns. Topics can include relax- can be changed. Specific cognitive and behavioral strat-
ation, assertiveness skills, or review of the stressvul- egies are developed to cope more effectively with the
nerability model. symptoms. CBT for psychosis has been utilized effec-
tively as a treatment modality in the United Kingdom
(Garety et al. 2000; Turkington et al. 2006), although it
PSYCHOEDUCATION
has limited dissemination in the United States.
Psychoeducation groups provide explicit training to in-
crease patients awareness of their symptoms, vulner- Cognitive remediation. Cognitive remediation
ability, and the environmental stressors that exacer- groups, not offered in most routine clinical settings,
are designed to treat cognitive deficits that commonly based on the needs of the patients. Permission is re-
occur in psychiatric conditions (McGurk et al. 2007; quired prior to contact but may be a stated expectation
Medalia and Richardson 2005). Groups provide cogni- of the program. Most family interventions are educa-
tive training by the use of either computer or cogni- tionally oriented, with the goals of helping family
tive-related activities. Some of the groups have been members cope more effectively with the patients ill-
combined with a focus on the relationship with daily ness and maximizing their ability to support the pa-
function and vocational training. tients recovery. Families are taught the stressvulner-
ability model and encouraged to create a low-stress
Substance abuse relapse prevention. G r o u p s f o r environment for the patient, with improvement in ef-
substance abuse relapse prevention are specifically defective communication and decreases in arguments
signed for those patients with a history of substance and use of substances. In addition, families may be
abuse, and the focus is on assessing the need for life- asked to help with medication compliance and provide
style adjustments from drug use to healthy habits of emotional and, at times, financial support. Multifam-
daily living and meaningful occupations. Integration ily groups provide a forum to disseminate recent infor-
of cognitive-behavioral interventions helps clients use mation and develop a supportive network among fam-
varying coping skills in place of substances to help ilies and patients (McFarlane et al. 2002).
them avoid relapse and return to meaningful roles
(Comerford 1999). Topics include identification of Community Integration and
triggers, development of healthy habits, and effective Discharge Planning
management of nonusing activities (Precin 1999). Cli-
ents may also be introduced to the 12-Step model and Ideally, timing of discharge is linked to completion of
encouraged to affiliate with a community-based Alco- goals established in treatment planning. At a mini-
holics Anonymous group. mum, the individual should be stabilized to the point
that relapse is unlikely. Safety assessments indicate
Work readiness. In work readiness groups, clients there is minimal risk of self-injurious or aggressive
are provided with the opportunity to explore their fu- behaviors and that self-care and other activities of
ture roles as students and/or workers in supportive re- daily living can take place with less structure. Patients
covery-oriented groups. These groups help clients ac- should be able to identify warning signs and have
quire the skills, resources, and supports necessary to acquired skills to manage persistent symptoms. Ap-
pursue their chosen work or educational goals. Under- propriate aftercare should be established for ongoing
lying skills are assessed, and a rehabilitation plan is medication monitoring, relapse prevention, and psy-
developed with the goal of establishing real work or ed- chotherapy. It is hoped that the rehabilitation phase
ucational experiences. In some settings clients can be has enabled patients to pursue a work or educational
placed in internships or attend a course while receiv- goal that may include holding a volunteer job and/or
ing treatment in the program. Ultimately, success for resuming education or paid employment.
community integration relies on programs having an
explicit focus on supporting work integration and de-
veloping relationships in the community that will Intensive Outpatient Program
support this mission. Research has shown that clients
who were discharged from day treatment to supported An IOP is intended for individuals who require more
employment improved their vocational outcome with- intensive treatment than routine outpatient care but
out experiencing any increased risk of relapse (Bailey less intensive treatment than a PHP. On the average,
et al. 1998). Supported employment has expanded in participation is up to 3 hours a day for at least 3 days a
recent years and is considered to be an evidence-based week over a period of a few weeks, although some pro-
mental health practice, providing clients with the op- grams offer individual and group therapy on a more ex-
portunity to obtain employment based on skills and tended basis. Often patients begin treatment in the
experience while providing professional help they may PHP and then step down to an IOP. However, some-
need to sustain it (Salyers et al. 2004). times the selection of the IOP is driven by the patients
insurance benefits. In general, the patients are less
Family Interventions acutely symptomatic than patients enrolled in a PHP
Psychoeducation and consultation with the families of or CDTP level of care, have some structured activities
patients are important elements in a CDTP. The def- outside of the IOP, and do not require supervision.
inition of family may extend to other support systems IOPs have been successful for treatment of some per-
sonality and affective disorders (Gratz et al. 2006; chronic mental illness and an ability to work in a mul-
Gunderson et al. 2005; G.W. Smith et al. 2001). They tidisciplinary team with a focus on rehabilitation. Vol-
allow individuals to engage in educational and voca- unteers with specific expertise such as yoga, writing,
tional pursuits while pursuing intensive treatment. In and art sometimes provide services. Staff members
some cases, insurance benefits do not support PHP or lead groups for symptom stabilization and skill devel-
CDTP levels of care, but IOP provides some structure opment and provide treatment coordination and fam-
and intensive therapy. Many of the skills and psychoe- ily counseling. Occupational therapists or other reha-
ducation groups described earlier for CDTPs or partial bilitation therapists provide treatment geared toward
hospitalization could be adapted for an IOP format. activities of daily living, work, and/or education. The
The patient is also assigned an individual psychiatrist treatment team interacts with residential settings,
and therapist. case managers, social clubs, vocational programs, peer
counseling, and advocacy organizations.
Administrative Issues Milieu

The therapeutic nature of the milieu plays a significant
Management practices and policies in outpatient psy- role in the rehabilitation of the patient. The design of
chiatric services have moved toward standardization the milieu involves a wide array of variables, including
and accountability in service delivery to increase cost- site location, architecture and design, channels of com-
effectiveness of care and ensure quality services. munication, organizational structure, and administra-
Guidelines started to be developed in the early 1990s, tion. Ultimately, the rhythm and pace of treatment all
with performance indicators for evaluating care ap- play a role in the milieu (Nosphpitz 1984). Today an ef-
pearing in the mid-1990s. Mental health monitors fective outpatient milieu incorporates the patient in all
have proliferated in recent years, although there is a levels of programming, from patient government to pa-
scarcity of data on the prevalence of these practices in tient satisfaction surveys. As a result of increasingly cli-
intensive outpatient treatment (Timko et al. 2003). ent-centered treatment, there is a high level of expecta-
Programming is influenced by many factors, including tion that patients play an active role in the program and
staffing patterns, the milieu, emergency services, doc- take personal responsibility for their recovery. At the
umentation requirements, reimbursement, and regu- same time hospitals are being challenged to personalize
latory agencies. In particular, reimbursement issues the health care experience and encourage collaboration
often dictate the range of services provided and have among patient, family members, and providers.
an influence on staffing patterns and overall accessi-
bility of services. Following is a brief discussion of ad- Emergency Services
ministrative issues that must be considered when de- Clear guidelines should be established about managing
veloping intensive outpatient services. crises outside of program hours. At all levels of outpa-
tient care, the patients should be aware of resources
Staffing available in an emergency to help maintain their safety.
Intensive outpatient services employ providers with at Emergencies requiring immediate care should be re-
least a master s-level degree in a counseling or related ferred to an emergency department or hospital evalua-
profession. A psychiatric attending physician pre- tion center. If crisis team services are available, thera-
scribes medications or supervises residents in a teach- pists, families, residential programs, and patients
ing hospital. Medication management may also be should know how to access them. If possible, the psy-
provided by a nurse practitioner with oversight from a chiatrist, therapist, or program administrator should
psychiatrist. Social workers, psychologists, and nurse be available to consult with an emergency department
practitioners are often the primary therapists, but provider or crisis team. In some programs the treat-
other mental health providers may be involved in the ment team is accessible to the patients after hours, but
case management. The rehabilitation counselors are this is not always the case, and expectations about us-
usually occupational therapists, certified rehabilita- ing community resources should be clear.
tion counselors, and/or psychiatric rehabilitation ther-
apists. In addition, mental health workers, creative art
Documentation
therapists, and substance abuse specialists may also Expectations for documentation are governed by state
work in intensive outpatient services. Staff members and federal regulations and, most importantly, the
need to have experience working with persons with hospital or program agency. A treatment chart gener-
ally includes the referral documents, initial evalua- of health or office of mental health. Community- and
tion, individual and group progress notes, treatment hospital-based programs might utilize other agencies
plans, laboratory and medical reports, and any struc- for accreditation and quality assurance, including the
tured assessments or patient self-evaluations. Docu- Commission on Accreditation of Rehabilitation Facil-
mentation also includes written consents from the pa- ities. The National Committee for Quality Assurance
tient for contacts with previous providers, community provides oversight for managed behavioral health or-
supports, and discharge planning. At the start of treat- ganizations.
ment, the patient is informed of his or her rights as a
patient in the program and provided with the institu-
tions policy on confidentiality regulations. Conclusion
Reimbursement
Intensive outpatient services such as PHP, CDTP, and
The structure of insurance benefits for various levels of IOP offer care to individuals with acute exacerbations
care varies from state to state. There is a risk that in- of symptoms or persistent symptoms who do not re-
tensive treatment will not be supported due to limita- quire inpatient level of care. They provide intensive di-
tions in spending for health care in state and national agnostic assessments, medication trials, and a range of
budgets. Private insurance generally pays for very lim- therapeutic modalities aimed at stabilization and skill
ited duration of participation in a PHP or an IOP. Lim- development to prevent future relapses and help the in-
its are set on the number of days per year covered, and dividual engage in further rehabilitation. A PHP pro-
such benefits often get subtracted from the number of vides acute stabilization for referral to a less intensive
inpatient or outpatient benefits remaining. Standards level of care. It can offer a diversion from inpatient ad-
for Medicaid payments are set on the state level, and mission or a stepdown from an inpatient service. A
Medicaid reimbursement is subjected to the con- CDTP provides more extensive skills training and re-
straints of managed care in many areas. Medicare cur- habilitation in a structured setting with some amount
rently limits billing for therapeutic activities and voca- of daily supervision. An IOP offers stabilization in in-
tional rehabilitation. Therefore, assignment to a level tegrated individual and group therapy. The goals of
of care is driven by insurance benefits in addition to these programs are to provide symptom relief, decrease
clinical considerations. Hospitals and community maladaptive behaviors, and provide improved quality
health care organizations have had to make decisions of life through enhanced interpersonal skills and func-
about which programs to maintain based on financial tional and vocational rehabilitation. Intensive services
considerations, and the issue of reimbursement for lev- provide a setting for education of trainees. They are
els of care has become one of the main considerations. also ideal sites for clinical research protocols in psy-
chopharmacology, therapeutic modalities, program-
Regulatory Agencies ming, and services research.
The Joint Commission, the arbiter of hospital accred- These programs are cost intensive. Although re-
itation, has developed reporting criteria focusing on markable benefits are apparent in many cases, quali-
outcome. A mandate was implemented in 1998 to in- tative input that defines outcome in a subjective man-
tegrate performance measures into the accreditation ner requires further research, and more objective
process (Babiss 2002). In 2001 hospitals started to quantitative measures need to be developed (Babiss
collect data on 15 measures of outcome, which are 2002). Multidimensional outcome measurements are
then submitted to the commission. Assessments of needed to establish cost-effectiveness and to provide
whether patients have resumed roles in their lives, im- longitudinal data on quality of life and community re-
proved socialization, and sustained sobriety are just a integration. Research on outcomes could preserve and
few outcome measures identified. In addition, contin- even expand funding for intensive outpatient services
uum of care from one level of service to another is while informing the design of evidence-based treat-
closely assessed by reviewers, in regard to both appro- ment. Simultaneously, the voices of patients must
priateness of the level of care and ease of transitioning never be forgotten. They provide a unique perspective
from one level to the next. Programs are additionally on treatment and the recovery process, a perspective
monitored by the Centers for Medicare and Medicaid eloquently expressed by a former CDTP patient,
Services but often are deferred to the state department Chaya, in her poem Free Dove (Figure 252).
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Part IV
STRUCTURE
AND
INFRASTRUCTURE
CHAPTER 26
ADMINISTRATION AND
LEADERSHIP
It has been said that hospitals are among the most mentaway from the hospital as the central locus of
complex of organizations. Although the narrower fo- treatment to the hospital as only one of the many lev-
cus of psychiatric hospitals, as a subset of the whole, els of service necessary on the road to recovery from
might seem to diminish the complexity somewhat, severe mental illness (Mechanic et al. 1995; Schreter
the reach of organizational, systems, business, legal, et al. 1997). For the administrator/leader, the term
regulatory, ethical, policy, clinical, professional, and hospital suggests a far narrower scope of responsibility
academic concerns central to the administration of and degree of challenge than actually exists for todays
the psychiatric hospital today raises the bar for leader- psychiatric health system leader.
ship to heights previously unknown. The complexity The complexity of the psychiatric hospital system
of this task is suggested by the degree to which the is reflected in the organizational forms these institu-
term psychiatric hospital fails to capture the depth and tions have taken. Whereas the 1980s marked a huge
breadth of the enterprise. Although the word hospital expansion in the number of (mostly for-profit) psychi-
has traditionally suggested inpatient care, psychiatric atric hospitals, fueled by changing demographics, atti-
hospitals have evolved into continuums of services of tudes toward mental health treatment, and the gener-
which inpatient care may be only the briefest compo- ous availability of insurance coverage (Geller 2006;
nent; and, increasingly, into systems of care that are Sharfstein 1995), by the early 1990s a number of im-
themselves components of integrated delivery net- portant trends had converged that would force a radical
works (Sharfstein et al. 2001). These organizational rethinking and reorganization of the roles of psychiat-
changes reflect a shiftdriven by financial pressures, ric hospitals. The first, and clearly the most important,
policy, and, to a degree, the consumer/recovery move- of these was the emergence of managed care, which
357
drove the utilization of inpatient services down dra- Modern Adaptations of

matically through techniques such as precertification
and utilization review, encouraged the growth of less the Early Asylums
intensive levels of care, and revolutionized hospital
business practices through the shift from fee-for-ser- At one extremethe closure of a hospital in substance
vice to at-risk methods of payment (Mechanic et al. and in namelies the Institute of Pennsylvania Hos-
1995; Schreter 1993). The emergence of modern psy- pital. The Pennsylvania Hospital, established in 1751,
chopharmacology had earlier provided the therapeutic was chartered to treat the sick poor and insane in
basis for fewer hospitalizations and lower lengths of the same facility. In 1841 a separate facility, the Penn-
stay, while the nascent recovery movement provided sylvania Hospital for the Insane, was established. It
an additional rationale (Davidson et al. 2006; Presi- was renamed the Institute of Pennsylvania Hospital in
dents New Freedom Commission on Mental Health 1959 and continued to operate as such until 1997. In
2003), as did the establishment of an evidence base for that year, under the relentless pressure of diminishing
shorter hospitalization for many patients (Glick and revenue from insurance providers, the institute was
Hargreaves 1979; Glick et al. 1984). The result was a closed, the facility sold, and psychiatric services down-
dramatic shift in the psychiatric hospital industry that sized and returned to the Pennsylvania Hospital
left both the for-profit and the not-for-profit hospitals (Sudak 2007). Other well-known hospitals were either
in search of survival strategies. The progressive and closing or radically reorganizing at the time. These in-
systematic underfunding of psychiatric services cluded Chestnut Lodge, which was bankrupt and
throughout America in recent years (Appelbaum 2003) closed its doors in 2001, and Taylor Manor, which sold
has created a relentless pressure either to downsize and its license to operate inpatient beds to the Sheppard
rationalize programs and services or to reinvent busi- Pratt Health System in 2002 (Geller 2006).
ness and clinical practices to make them sustainable.
Although the circumstances of individual markets The Institute of Living
may influence the survival strategy greatly (Schlesinger Established as the Hartford Retreat for the Insane in
et al. 1997), the administrative and leadership chal- 1822, the Institute of Living was the third asylum es-
lenges have been great everywhere. tablished in America and the first hospital of any kind
This chapter uses case studies and vignettes to il- in Connecticut (Goodheart 2003). The name change in
lustrate the leadership challenges and the changes in 1939 reflected the vision of then Psychiatrist-in-Chief
hospital organization, business practice, and clinical C. Charles Burlingame to fashion an institution that
models central to the evolution of psychiatric hospitals was a combined hospital, country club and university
over the past generation. We select our illustrations campus (Clouette and Deslandes 1997, p. 526). The
from the recent histories of Americas earliest asylums, institute flourished for a time in this model, although
the eight private, not-for-profit hospitals that consti- by the 1970s it had moved into the medical main-
tute the informal Ivy League of psychiatric hospitals. stream, treating the great variety of patients made avail-
These prototypical not-for-profit psychiatric hospitals, able by the emergence and growth of commercial insur-
whose efforts to remain viable into the twenty-first ance and Medicare. All was to change with the
century contain important lessons in hospital admin- emergence of managed care. In 1988 the institute oper-
istration and leadership, include the Institute of Penn- ated 420 inpatient beds with an average daily census of
sylvania Hospital, Friends Hospital, the Institute of 368 and an average length of stay of 33 days. By 1992 it
Living, Sheppard and Enoch Pratt Hospital, Butler had undergone nine consecutive downsizings and was
Hospital, the Westchester Division of New York Pres- operating only 150 beds with an average daily census of
byterian Medical Center, McLean Hospital, and the 119 and an average length of stay of 13 days (Institute
Brattleboro Retreat. As McCue and Clement (1993) of Living 1993). The downsizings and other increas-
predicted in their comparison of private for-profit and ingly frantic efforts to meet the requirements of man-
not-for-profit hospitals, the not-for-profits toward the aged care payers were not enough to ensure survival.
end of the twentieth century were disadvantaged by the Revenues did not meet expenses, and reserves in the
burden of older facilities, higher costs, the absence of form of endowments would not last forever. By 1992
ready capital, and a not-for-profitinspired sense of the institute had either to be merged, sold to a for-profit
mission. Rapid change, with the emulation of for- chain, or closed. The solution most consistent with the
profit business practices, would be required, with the institutes long history of moral treatment (antecedent
risk of closure for those who could not adapt. to the biopsychosocial model) was a merger in 1994
Administration and Leadership 359
with Hartford Hospital, a large, voluntary, not-for- in-chief, ultimately provided the degree of support nec-
profit general hospital that was physically contiguous. essary for a modified product line management.
In the process of merging with a large and successful Operating as a component of a general hospital had
general hospital, the Institute of Living gave up its pri- several immediate and significant financial ramifica-
vate psychiatric hospital license and proceeded to oper- tions. First, and perhaps most important, was termina-
ate as the department of psychiatry of a general hospi- tion of the hospitals exclusion as an institution for
tal. All of the programs and services of the Hartford mental disease (the so-called IMD [Institution for
Hospital psychiatry department were merged with Mental Disease] exclusion) from the Medicaid program
those of the institute, using a best practices analysis to for adults. The ability to hospitalize Medicaid patients
determine the program features, site, and staffing of the created a new revenue source and marked an expansion
surviving programs. The medical staff of the institute of the Institute of Livings mission to the community;
joined the medical staff of Hartford Hospital. All infra- however, (managed) Medicaid reimbursement in Con-
structure departments of the institute were either ab- necticut does not meet the cost of providing care,
sorbed into those of Hartford Hospital or eliminated. which would come to be a serious drawback. The Insti-
Although the boards of directors of the merging in- tute of Living also had to give up its established TEFRA
stitutions had committed themselves to maintaining (Tax Equity and Fiscal Responsibility Act) rate for
the mission, tradition and identity of the Institute of Medicare patients, accepting the somewhat lower rate
Living, it was clear that, going forward, the Institute of established for Hartford Hospital. The transition from
Living was now the department of psychiatry of Hart- traditional fee-for-service billing to all-inclusive con-
ford Hospital, doing business as (and looking for all the tracting was also accelerated by the merger. Prior to the
world to be) a private psychiatric hospital. The confu- merger, the Hartford Hospital department had one in-
sion of identity was heightened by the decision to main- patient unit staffed largely by private practitioners in
tain a board of directors for the institute with limited fee-for-service billing arrangements. The Institute of
responsibilities while the Hartford Hospital board as- Living, in contrast, had transitioned to all-inclusive
sumed the traditional governance role. For several years contracts staffed by contract to psychiatrists in a re-
the tension between the charge to maintain the identity lated professional corporation. With the merger, payers
of the Institute of Living and the requirement to fully were unwilling to proceed with dual billing procedures.
merge into the general hospital produced us and The growth of managed care argued strongly for tran-
them tensions. Active and creative leadership inter- sition, and the Hartford Hospital unit was moved to
ventions were necessary to strike a workable balance. the institutes inpatient building and transitioned to
Early challenges included the organization of ad- all-inclusive billing. This allowed for standardization
ministration and leadership. In the first years post- of business and clinical practices, facilitated a hospital-
merger, the Institute of Living shed its president and ist model for inpatient care, and alienated the private
several vice presidents. Harold I. Schwartz, M.D., the practitioners who felt unable to adapt their traditional
Director of Psychiatry of Hartford Hospital, ultimately practice to this new arrangement.
became the psychiatrist-in-chief of the merged entity The postmerger managerial and leadership chal-
and, in recognition of the size and complexity of this lenges faced by the Institute of Living emerged in three
service for the parent organization, the vice president of stages. In the first, the integration of the institute into
Behavioral Health for Hartford Hospital. Because the Hartford Hospital provided a secure base of operation
Institute of Living joined the hospital as a self-con- from which it could focus its attention on adapting its
tained entity, it seemed appropriate to transition the op- continuum of programs and services to better meet the
eration of the merged Institute of Living as Hartford challenges of the behavioral health marketplace. This
Hospitals first product line division. The very nature of period of stability provided an environment that al-
the merger, with the shift to Hartford Hospital support lowed the institutes research and teaching programs to
departments, meant that the organization would have flourish and adapt to changing circumstances. These
to find its way through a matrix of product line func- adaptations included the reconfiguration of research
tioning and integration with the central organization. initiatives into translational research centers that
This has been challenging in an organization not oth- aligned closely with the institutes core mission and
erwise committed to a product or service line organiza- clinical programs. In each of these examples, the closer
tion. The establishment of a collaborative manage- alignment of research and clinical programs produced
ment team consisting of medical and nursing directors synergies of benefit to the Institute of Living and its pa-
and a director of operations, along with the psychiatrist- tients. For example, the institutes Braceland Center
for Mental Health and Aging had focused for many In the third and current stage, the Institute of Liv-
years on geriatric health servicesrelated research. Typ- ing finds itself still challenged to rationalize its services
ical studies examined issues related to Medicaid fund- and programs in an era of rising costs and limited rev-
ing of geriatric mental health treatment in nursing enues. Although the huge inefficiencies of a private
homes or Medicare funding of such in the community. psychiatric hospital struggling alone in an inhospitable
Although important, such studies were distant from environment were shed by the merger, they have been
the core mission of the psychiatric hospital and its pro- replaced by the equally huge and growing overhead
grams. The center was gradually transitioned to one costs of the general hospital. Network contracting has
that focused on clinical dementia studies, and with the been successful at generating enhanced revenue from
establishment of a Memory Disorders Center, research commercial payers, but Medicaid reimbursement re-
initiatives were integrated into an important clinical mains inadequate to match the demands of mission to
program that provides clinical assessment of individu- the community. Teaching and research programs have
als in the early stages of dementing illness. The center flourished, along with a regional reputation for excel-
became a study site in the federally funded Alzheimers lence in clinical care, yet the translation of these into
Disease Neuroimaging Initiative (Thal et al. 2006), entities of financial survival value remains very much a
marking the transition to a fully relevant state-of-the- work in progress.
art research/clinical program working in an area of cen-
tral relevance to the hospitals patient base. Sheppard Pratt: From Asylum to
At the same time, a schizophrenia initiative, sup-
ported philanthropically, led to the establishment of
Comprehensive System of Care
the Olin Neuropsychiatry Research Center, a func- On his death in 1857, Moses Sheppard, a prominent
tional and structural magnetic resonance neuroimag- Quaker philanthropist from Baltimore, left $571,000
ing research center with Connecticuts first 3-Tesla to found the Sheppard Asylum. Inspired by Dorothea
magnet. Research on cognitive rehabilitation in schizo- Dix 5 years earlier, Sheppard decided to put his entire
phrenia led to the establishment of a partial hospital fortune into building an institution in the image of York
program specializing in this computer-based rehabili- Retreat in England and Friends Hospital in Philadel-
tation approach. Most recently, a genetic screening re- phia. He admonished the trustees to meet a need that
search program has been added to the mix, leading to not otherwise would be met and to do everything for
pharmacogenetic approaches to the treatment of mood the comfort of the patient. He also said, lead the
disorders and schizophrenia. The Institute of Livings way. Insisting that only the interest of his gift and not
reestablishment of its own independently sponsored the principal be used in the building of the asylum, it
(by Hartford Hospital) adult and child and adolescent took more than 30 years for the original buildings, de-
residencies has added still another important element signed by Calvert Vaux, to be built. The first patient was
to the synergy created by the mix of academic and clin- admitted in 1891. The trustees then solicited a second
ical programs. gift from another prominent Baltimore philanthropist,
The second stage of postmerger activities involved Enoch Pratt. After Pratts death in 1896, the Sheppard
the establishment, by Hartford Hospitals parent corpo- Asylum was renamed The Sheppard and Enoch Pratt
ration, of a behavioral health (partially) integrated deliv- Hospital (Forbush 1971; Gollaher 1995).
ery system, the Behavioral Health Network, consisting Sheppards Quaker heritage, with its emphasis on
(in addition to the institute) of another psychiatric hos- moral treatment (Digby 1985), evolved into a long-
pital (as a corporate subsidiary), a substance abuse treat- term inpatient hospital for those who could afford to
ment system, the psychiatry department of a subsidiary pay the fees. When psychoanalysis came to America,
general hospital, and a community mental health cen- Sheppard Pratt was an ideal place to practice the art of
ter. The network established its own behavioral health this treatment and to research its efficacy. Harry Stack
managed care organization that ultimately outlived its Sullivan was a psychiatrist in residence from 1922 to
purpose and was merged with another not-for-profit but 1930 and established an all-male schizophrenia re-
for a time helped to stabilize the environment for the search unit on the grounds. He published papers on
network partners during a period of chaotic managed his findings and established the field of social psychi-
care growth and consolidation in Connecticut. The net- atry. William Rush Dunton, another staff psychiatrist,
work has been most effective in negotiation of its carve- invented occupational therapy while at Sheppard Pratt
out managed care contracts, reflecting the enhanced re- to enrich the experience of long-term hospitalization.
gional clout of the combined entities. Originally consisting of 200 beds, Sheppard Pratt rap-
idly expanded to a high of 322 beds by the mid-1980s. hospital psychiatric units, emergency departments,
The average stay in 1970 was 140 days. Even with 90% and outpatient programs throughout the state of Mary-
of revenue coming from long-term hospitalization, the land. Utilizing the community mental health center
winds of change began with the advent of private model of the 1970s, Sheppard Pratt began to establish
health insurance and the community mental health and acquire nonprofit community agencies across the
center movement. state. These comprehensive mental health centers in-
Sheppard Pratt was the first private psychiatric cluded supervised living, supportive employment, and
hospital to establish and sponsor a community mental other rehabilitation programs and served as the major
health center with a catchment area in Baltimore community resource for patients being discharged from
County in 1972. Dr. Robert Gibson, the fourth medi- increasingly short-term settings, either from Sheppard
cal director of Sheppard Pratt, had the vision to antic- Pratt or from general hospital units. In 2003 Sheppard
ipate that this mode of community practice would be Pratt acquired another private psychiatric hospital,
the wave of the future. Although this was a small part adding an additional 40 beds, and began to plan for the
of Sheppard Pratt, by the early 1990s it proved to be a building of a new 192-bed tertiary psychiatric facility at
model for change and growth. Day hospital programs the original historic site in Towson, Maryland.
were established, and the early efforts toward rehabil- The $100 million building and renovation project
itation, supervised housing, and supportive employ- began in 2003 and was completed in 2005 (only 2 years
ment all came into place during this era. this time around!). Sheppard Pratt is the largest re-
In 1986 Dr. Steven Sharfstein was named vice gional resource for behavioral health care, with acute
president and medical director. At that time, the aver- adult crisis stabilization services and highly specialized
age length of stay at Sheppard Pratt was 80 days for units for children (ages 312) and adolescents, geriatric
adults, 125 days for children and adolescents. There patients with and without dementia, patients with eat-
were 322 beds, which were almost always full, with ing disorders, severe posttraumatic stress, dually diag-
1,000 admissions per year to fill those beds. From nosed substance abuse and mental illness, and dually
1990 to 1993, with the advent of managed care and a diagnosed mental retardation and mental illness.
broad consensus by the payers not to continue paying Sheppard Pratt, which sponsored its own residency
for long-term hospitalization, length of stay decreased program for years, affiliated with the University of
dramatically (Feldman 1992). By 1992, as Dr. Sharf- Maryland in 1996; the combined residency in child,
stein became the fifth president of Sheppard Pratt, the adult, and geriatric psychiatry continues to prosper. As
length of stay had decreased to 30 days. By the year one of the largest residency programs in the country,
2000, it decreased even further, to 10 days. In 2006, with more than 70 trainees in a variety of undergrad-
with an average stay of less than 10 days, there were uate and postgraduate programs, this academic part-
7,000 admissions to fill 220 beds (100 fewer beds than nership has been a major success. Research on long-
20 years prior), but Sheppard Pratt was fundamentally term outcomes of patients with schizophrenia and
different in a variety of other ways. clinical trials research grew as well.
With the handwriting visible on the wall, Sheppard From the early 1990s to today, three private psychi-
Pratt began a process of reinvention, initially through atric hospitals in Maryland went bankrupt and closed
reorganizing of the hospital into a health system (in- their doors. By surviving in a radically changed mar-
cluding a reduction in force) and then by embarking on ketplace, Sheppard Pratt was able to grow and develop
a growth strategy that led to Sheppard Pratt becoming services in those areas that needed them the most. Ap-
the largest provider of psychiatric, behavioral, addic- proximately two-thirds of Sheppard Pratts revenue
tion, and special education services in Maryland. In re- comes from public dollars (including Medicare and
organizing of the traditional hospital structure of de- Medicaid) and public education dollars; the rest is pri-
partments into service lines, the priority became vate funding. Sheppard Pratt is the largest provider of
growing the continuum of care (Schreter et al. 1997) special education throughout the statethat is, edu-
with the establishment of day programs, outpatient cation for severely emotionally disturbed children and
clinics, residential care, and other initiatives in com- adolescents, including those with autism, with 11 spe-
munities across the state. The trustees decided to re- cial education schools. The revenue from the educa-
invest in Sheppard Pratt by first building a 50-bed res- tion component of Sheppard Pratt Health System is
iden tial sch oo l in w es ter n M aryland an d th en approximately 30% of the overall revenue stream. The
developing programs in general hospitals throughout hospital itself represents about 40% of the revenue,
the state. Sheppard Pratt currently manages 10 general and the other 30% comes from the other special pro-
grams of Sheppard Pratt, including its community- living facility, and has been a success in a marketplace
based services and general hospital programs. in which the wealthy look for extra amenities as well
Not everything worked, however. In the early as attention from top psychiatric clinicians.
1990s, Sheppard Pratt put together its own managed In summary, the success of Sheppard Pratt, an in-
care program called the Sheppard Pratt Health Plan. dependent, not-for-profit foundation and health sys-
This program was sold in the late 1990s. It was not tem, has occurred due to a reinvention of the hospital
successful because it could not compete with the large into a health system, reorganization of the staff, focus
managed care corporations. The latter managed costs, on the development of diverse services in various com-
whereas the Sheppard Pratt plan was more focused on munities throughout the state, an economic model
providing care. Outpatient services sponsored by the that was not for profit but also not for loss, high vol-
hospital similarly were downsized and shifted to com- ume care, and the recruitment and retention of the top
munity-based programs because of the inefficiencies clinicians in the field. Luck also played a role through
and cost issues related to outpatient care. the tax-exempt bond financing that helped finance the
The leadership at Sheppard Pratt adopted the phi- new hospital in 2003$60 million was borrowed at
losophy that we were not for profit but also not for the all-time low in long-term interest rates. The suc-
loss early in this process of reinvention. Thus, new cess of the markets in the 1990s led to an important
services and programs that were added on and off cam- growth in the Sheppard Pratt endowment (the original
pus had to meet this test. Schools that were begun in gifts of Moses Sheppard and Enoch Pratt), which
various areas that did not meet this test were closed af- helped establish the good health of the balance sheet of
ter an 18-month to 2-year trial; outpatient services Sheppard Pratt to borrow money cheaply and to build a
were particularly vulnerable to this test. Additional ac- new hospital. With luck and leadership, Sheppard
quisitions and mergers allowed some outpatient ser- Pratt looks to the twenty-first century with optimism
vices to continue to grow, however. An important part- and high expectations.
ner to this process has been the public mental health
system, which contracted with the Sheppard Pratt
Health System in 2004 for care for the uninsured.
Core Components of Psychiatric
Much of this has occurred in a regulatory environ- Hospital Administration
ment in Maryland that is highly proscriptive. Hospital
rates are regulated, and there is a strong Certificate of
As our case studies suggest, the domain of concerns
Need law. These regulatory issues have helped keep
that constitute hospital administration is extensive and
for-profit medicine out of Maryland, and this has been
ranges from public policy, to business practice, to the
a benefit to the growth of the not-for-profit Sheppard
professional concerns of multiple mental health profes-
Pratt.
sions. These concerns play out in the marketplace as
Although it is hard to summarize the role of lead-
well as the community, in which the demands of mis-
ership in this process, it is important to note that the
sion add still greater complexity. For in-depth treat-
recruitment of top clinicians as well as administrative
ments of these many areas, the reader may turn to more
leaders has been a key aspect of success. Clinical lead-
extensive resources (Reid and Silver 2003; Talbott and
ers are especially critical. The Sheppard Pratt Practice
Hales 2001). For the purposes of this chapter, we will
Association has developed attractive compensation
profile the most compelling elements of administration
models as well as academic appointments at the Uni-
highlighted in our case studies, with emphasis on the
versity of Maryland, which has led to the recruitment
challenges currently presented to hospital leadership.
of some outstanding leaders in the treatment of
schizophrenia, bipolar illness, geriatric illnesses,
trauma disorders, eating disorders, and child and ado- Organizational Structure
lescent disorders. Although Maryland is the primary
focus of activity and 85% of patients come from this
and Governance
state, there is a strong regional and national pull for a
variety of our tertiary care programs. In 2004, The Re- Organizational structure has been defined as the peo-
treat at Sheppard Pratt was established as a concierge- ple, positions, functional groups, and lines of author-
level program, initially composed of 6 beds but now 16 ity and accountability designed to accomplish the or-
beds, for those who can afford to pay out of pocket. It ganizations mission, goals and objectives (Veenhuis
does not accept insurance, is licensed as an assisted 2003, p. 107). Although structure does indeed reflect
the mission and goals of an organization, overly rigid lum had become Friends Hospital, a 192-bed acute
structure may come to constrain and even dictate care psychiatric hospital with a 26-bed adult residen-
goals and objectives. Organizational structure occurs tial program located in northeastern Philadelphia, and
at multiple levels. The psychiatric hospital may func- was struggling with inadequate revenues in the face of
tion as a subsidiary of a larger parent organization a long-established and religiously driven commitment
with governance (the board of directors) at the health to provide care to those in need. A number of program-
system level. Other hospitals are governed directly by matic joint ventures and explored affiliations all failed
their boards, having integrated horizontally with a va- to produce a plan that could ensure fiscal viability. Be-
riety of owned or affiliated services. Two of our exam- tween 2000 and 2004 the hospital experienced a $20
ples, the Institute of Living and the Westchester Divi- million loss from operations and the nearly total ex-
sion of the New York Presbyterian Hospital, are penditure of unrestricted reserves (Carol Ashton-Her-
organized as components of large general hospitals but genhan, personal communication, March 2007).
do business as psychiatric hospitals. The executive committee of the hospital board ex-
The hospital leader (generally the chief executive plored all options, including closing the hospital. In
officer) operates the organization by virtue of the au- what may be one of the most creative reconfigurations
thority conferred by the governing body (board of di- of a hospital in this era, the board determined that it
rectors) (Joint Commission 2007). In those instances could both partner for profit and maintain its
in which the hospital is a component of another en- Quaker-driven commitment to the community. The
tity, the hospital director, psychiatrist-in-chief, or boards solution was to form a for-profit joint venture
other leadership position may report to a general hos- with Horizon Health Corporation, a large for-profit
pital or system chief executive who, in turn, reports to hospital chain. Friends Hospital sold an 80% interest
the board. In either case, beyond these constants, the in the buildings and assets to the joint venture in re-
organization of the hospital may vary widely, with se- turn for $16 million received by the newly established
nior leadership organized around professional disci- Thomas Scattergood Foundation, established to con-
pline, program and service lines, or (usually) some tinue the Friends mission by providing education, ad-
combination of both. vocacy, and access to care. The Scattergood Foundation
Governing boards generally play a critical adminis- (which retains a Quaker board) has significant repre-
trative role in times of crises. Our case study of the In- sentation on both the board of the joint venture that
stitute of Living provides a very clear example of the operates the hospital and the board of the hospital itself
powerful role that decisive board leadership may play (including the chairmanship in the latter case), leaving
in times of administrative crises for psychiatric hospi- the foundation with a far larger role in governance than
tals. In 1992, the board of directors of the Institute of might be suggested by its 20% ownership position. A
Living was faced with the inability of the institute to re- number of other contractual commitments are in-
main viable as a self-sustaining organization. Among tended to ensure that Friends will continue to be oper-
the available choicesclosure, merger or sale to a for- ated in a manner consistent with its Quaker mission.
profitonly one was consistent with a sense of mis- For example, the joint venture must continue to oper-
sion that could be traced to the earliest days of the ate the hospital in a manner consistent with the former
moral treatment movement: integration into a large Friends Hospital charity care policy. In addition, the or-
general hospital that, by virtue of allowing Medicaid re- ganizational entity that was the former Friends Hospi-
imbursement for adult patients, actually allowed for an tal will continue as the (not-for-profit) Thomas Scatter-
expansion of mission to the community. Another com- good Foundation, committed to a grant program that
pelling example of the role of decisive board leadership provides access to care in the Philadelphia area and to
is to be found in the story of Friends Hospital. reestablishing the Quaker heritage of being thought
leaders in mental health (Carol Ashton-Hergenhan,
Friends Hospital personal communication, March 2007).
The Friends Asylum was established by the Philadel-
phia Society of Friends in 1817. As such it is the only of Integration and Product or
the Ivy League hospitals to have been established by
a religious order. It was modeled after the York Retreat
Service Line Organization
in York, England, and was instrumental in establishing
the moral treatment movement in America (Deutsch The concept of integration has come to play an in-
1949). By the turn of the twenty-first century, the asy- creasingly important role in modern hospital admin-
istration. Virtually all successful hospitals have inte- adelphia, admitted mental patients. The New York
grated to some degree. In its most fundamental sense, Lunatic Asylum was established nearby in 1808 as de-
integration reflects the degree to which psychiatric mand grew, and moved uptown in 1821 to become the
care has transitioned from inpatient to a continuum of enlarged Bloomingdale Asylum (Ozarin 2006). The
ambulatory levels of care requiring virtually all psychi- Bloomingdale Asylum moved to White Plains, New
atric hospitals to either create such services or ally York, in 1895. The name was changed to New York
themselves with organizations capable of providing Hospital Westchester Division in 1936. The West-
them. Integration can be thought of in its horizontal chester Division, operating under the general hospital
and vertical dimensions (Santiago 2001). It occurs license of New York Hospital (rather than as a private
horizontally through the coordination between organi- psychiatric hospital), together with the Payne Whitney
zations, programs, and clinicians at a single level of Psychiatric Clinic at New York Hospitals New York
care, and vertically in systems that focus on the devel- City location, constituted the psychiatric services of
opment of continuums of care that may reach from New York Hospital and the department of psychiatry
the hospital emergency department to supportive of the Cornell University School of Medicine (later the
housing. The development of an integrated system Weill Cornell School of Medicine).
may require alliances, mergers, joint ventures, and In 1998 New York Hospital and Columbia Presby-
other creative business developments as well as the in- terian Hospital announced a full-asset merger, one of
formation systems and other business tools necessary the largest of its kind, creating the largest hospital in
to manage a broad horizontal and vertical domain. New York City, with more than 13,000 employees and
The extent of integration flows from the goals and ob- 2,200 beds (NewYorkPresbyterian Hospital 2007). At
jectives of administration. In the Institute of Living the time of the merger, Presbyterian Hospital had its
case study, the parent organization acquired additional own full-service psychiatry department, including two
mental health organizations that were geographically inpatient pavilions, a continuum of ambulatory ser-
distant enough to limit clinical program collaboration. vices, and an integral relationship with the New York
However, the capacity to contract jointly as subsidiar- State Psychiatric Institute, New York States flagship
ies of the same parent corporation has proved an effec- psychiatric research hospital. These services consti-
tive strategy. tuted the clinical base of the department of psychiatry
Our Sheppard Pratt case study reflects an organiza- of the Columbia University College of Physicians and
tion that has employed extensive horizontal and ver- Surgeons. Each hospital had its own academic depart-
tical integration. Through a program of acquisitions, ment and very significant educational and research
mergers, and contractual relationships and by estab- enterprises in addition to these clinical services.
lishing the business capacity to manage extensive at- The complexity of the administrative and leader-
risk reimbursement arrangements, Sheppard has in- ship tasks necessary to bring these behemoth institu-
creasingly fashioned itself into an organized delivery tions into an effective single entity is almost unimag-
system providing a continuum of services, with clini- inable. A service line organization for key clinical
cal and fiscal accountability to defined populations departments was one of the first business and quality
(Shortell et al. 1994). At the same time, both the In- initiatives of the merged hospital system. The purpose
stitute of Living and Sheppard Pratt attempted to ex- of the service line initiative was to inform senior lead-
tend their integrated delivery systems to include man- ership on strategic direction, quality issues, and busi-
aged behavioral care organizations but ultimately ness planning for the clinical areas (Gail Ryder, per-
withdrew from these business lines. sonal communication, March 2007). A planning and
operational committee was established, consisting of
The Westchester Division and the the two department chairs, the medical director from
Behavioral Health Service Line of each site, and the service line executive. The goals of
the committee included planning for and rationalizing
New York Presbyterian Hospital services and programs, establishing uniform contract-
We briefly review the organization of psychiatric ser- ing, and enhancing quality by establishing uniform
vices in the New York Presbyterian Hospital system to policies and procedures and quality indicators through-
highlight the complexity of product line integration in out the system. Much has been achieved to date de-
a hospital system with extensive vertical and horizon- spite the retention of separate medical school affilia-
tal integration. Opened in 1792, New York Hospital, tions and distinctive physician incentive systems (and
like its predecessor, the Pennsylvania Hospital in Phil- physician hospital organizations) at the two sites.
The establishment of the New York Presbyterian patient) care are expensive (Rosenau and Linder
Health System, consisting of 42 medical institutions 2003), and the translation of these efforts into im-
(27 hospitals) with 18,500 physicians, has added an- proved financial performance is, at best, indirect.
other level of complexity to the behavioral health ser- Relationships with funders are another issue criti-
vice line with the sharing of policies, quality initia- cal to psychiatric hospital survival. For those hospitals
tives, and contracting within the larger systems. that operate under a general hospital license (and
Indeed, integration appears to have been an impor- therefore are not subject to the IMD exclusion), Med-
tant part of the strategy for almost all of the Ivy League icaid has had an enormous influence on financial out-
hospitals as they have reorganized and reengineered come. Because Medicaid is administered by individual
themselves in the face of the fiscal constraints and states with support of and regulation by the federal
changing business practices of the past few decades. government (Silver 2003b), rates vary by state. Higher
McLean Hospital in Belmont, Massachusetts, Har- Medicaid rates in New York have contributed signifi-
vard Medical Schools largest psychiatric site, joined cantly to the revenues of the Westchester Division of
Partners Healthcare, an integrated health system con- the New York Presbyterian Hospital, whereas lower
sisting of six Boston area hospitals (three teaching af- rates in Connecticut have had the opposite effect for
filiates of Harvard Medical School), community the Institute of Living. The establishment of Medicaid
health centers, a physician network, home health, and 1115 (Research and Demonstration) and Medicaid
long-term care services (http://www.partners.org). 1915(b) (Medicaid Managed Care) waivers has led to
Likewise, Butler Hospital in Providence, Rhode Island, innovations in the administration of Medicaid that
the flagship psychiatric service for the Brown Univer- have allowed the participation of some psychiatric
sity Medical Schools department of psychiatry, be- hospitals in managed Medicaid programs (Dixon et al.
came a founding member of Care New England 2001). Participation in such programs increases the re-
Health System, consisting of three hospitals, wellness quirement for participation in integrated systems of
centers, and home health and hospice services (http:// care, often requiring publicprivate partnerships to en-
www.carenewengland.org). sure adequate care and fiscal viability.
The transition of the Medicare program to a pro-
spective payment system for psychiatric units in 2006
Core Business Domains (Centers for Medicare and Medicaid Services 2006) il-
lustrates another challenge created by the funder. The
Our case studies and vignettes have illustrated a num- complicated formula that replaced the prior exemp-
ber of intra- and extraorganizational relationships and tion from the diagnosis-related-group reimbursement
the core business functions necessary to lead the ad- methodology promised revenue enhancements to
ministration of a successful psychiatric hospital. All some hospitals and reductions to others. The ethical
psychiatric hospitals (and hospital systems) have im- challenges to health care providers of prospective pay-
portant relationships with funding, policy, and regula- ment systems have been the subject of much discus-
tory organizations. Meeting the requirements of each sion (Dougherty 1989). In anticipation of this change,
will be critical to success (Hester 2003). The require- the Institute of Living reduced its length of stay on one
ment to remain in regulatory compliance with the geriatric inpatient unit by 4 days within 6 months
Joint Commission (formerly the Joint Commission on through a variety of steps that ensured that treatment
the Accreditation of Healthcare Organizations), the goals were rapidly established and pursued, that treat-
Centers for Medicare and Medicaid Services, and state ment intensity continued through weekends, and that
and local authorities becomes a critical component of care was constantly reviewed by the medical director.
strategies to expand (through integration or new pro- Although it is beyond the scope of this chapter to re-
gram development) or contract services. The require- view, our case studies suggest the importance of exper-
ments of regulators and payers for the demonstration tise in core business functions. We mention some of
of quality and safety has led to an intensive focus on the most compelling. In our examples, strategic plan-
quality measurement, outcome studies (Docherty and ning at the level of senior administration and gover-
Dewan 1995; Sederer and Dickey 1996), and satisfac- nance has been critical to the successes achieved. Stra-
tion surveys that will only continue as pay for perfor- tegic plans are implemented through the financial
mance is introduced into hospital reimbursement analysis that creates business plans and the financial
(Pelonero and Johnson 2007). Efforts to continuously management at all levels of the organization that im-
improve the quality of psychiatric inpatient (and out- plements them (Silver 2003a). None of this can happen
in todays world without an emphasis on the manage- estate development to compensate for its downward
ment of information. The business systems necessary revenue spiral.
to create integrated hospital systems, electronic medi-
cal records with algorithm-driven order entry systems,
and systemwide outcome studies (to cite just a few ex-
Qualities of Leadership
amples) suggest that no hospital or hospital system can
succeed in the future without significant attention to The literature on organizational leadership has be-
and investments in information technology (Trabin come an industry unto itself, focusing on manage-
1996; World Health Organization 2005). Attention ment skills (Edershein 2006) and the qualities that fa-
must be paid to human resources issues, especially to cilitate organizational effectiveness, learning (Senge
relations with the medical staff strained by the chal- 1990), and change (Kotter 1996). Numerous reviews
lenge to sustain professional satisfaction as resources of theories and styles of leadership are available (Du-
and professional autonomy are diminished. brin 2001; Norhouse 1974), including a focus on lead-
An often overlooked function of hospital leadership ership within mental health administration (Levin et
is the development of philanthropy (fund develop- al. 2003; Shore and Vanelli 2001). What will consti-
ment) initiatives for the organization. These may take tute appropriate training for mental health leaders of
many forms, including annual fund drives, capital the future remains an important question (Harrison
campaigns, planned giving, or major gift development and Gray 2003; Yu-Chin 2002), as is the question of
(Fitzpatrick and Deller 2000). For older, well-estab- the leadership role for psychiatrists (Greiner 2006).
lished hospitals such as those in the Ivy League, it is A common denominator in most theories of lead-
often the case that a community of donors can be ac- ership is the distinction between management, the
cessed if this function is sufficiently addressed. Yet oversight of (and sometimes day-to-day guidance
even newer hospitals can tap into the enthusiasm of through) ongoing organizational processes, and vi-
the community in annual fund drives that can fund sionary or inspirational leadership that strategizes, fo-
capital improvements, new program development, en- cuses resources and ideas into achievable goals and in-
hancement of existing programs, research activities, centives, and empowers the people and processes that
and other initiatives that may greatly enhance quality lead to productive growth and change. Most good lead-
but would otherwise go unfunded. At the Institute of ers attend to both tasks.
Living, a major fund drive supported a schizophrenia A compelling example of the importance of leader-
initiative that funded, in part, a new neuropsychiatric ship style flows from efforts to move mental health
research institute, a day program focusing on cognitive professionals and services toward evidence-based prac-
rehabilitation for individuals with schizophrenia, and a tice (Aarons 2006). The transition in ways of knowing
family resource center. from subjective understanding to algorithmic path-
Closely related to issues of fund development is ways remains a difficult one for many psychiatrists
stewardship of the endowments and related resources (Donald 2001). Mental health clinicians attitudes to-
that a hospital may be fortunate enough to possess. ward the adoption of evidence-based practice varies ac-
Several of the hospitals discussed in this chapter have cording to individual differences such as education and
been fortunate in their geographic locations. Butler experience and organizational ones such as structure
Hospital, McLean, and Sheppard Pratt, all established and policies (Aarons 2004, 2005; Young et al. 2006).
initially in areas that would have been considered ru- Aarons (2006) studied the impact of transformational
ral, now find themselves in expensive suburbs with and transactional leadership styles on the acceptance
the opportunity to engage in real estate development of evidence-based practices by mental health clinicians
ventures that already have or will in the future contrib- in 49 programs providing mental health services to
ute significantly to the future fiscal viability of these children and adolescents. These are well-characterized
hospitals. The Brattleboro Retreat in Brattleboro, Ver- leadership styles that reflect the core distinctions cen-
mont, although still rural, has sold its dairy farm and tral to most leadership paradigms: transformational
is considering further real estate transactions (Greg leadership is visionary and inspirational (Howell and
Miller, personal communication, April 2007). In con- Frost 1989), whereas transactional leadership focuses
trast, Friends Hospital was established initially in a on practical matters such as goal setting and rewards
rural area that ultimately became northeastern Phila- through performance review (Jung 2001). Aarons
delphia, an economically deprived area. Despite a siz- (2006) predicted that transformational leadership
able land holding, Friends was not able to rely on real would influence attitudes by inspiring acceptance of
innovation through the development of enthusiasm, less (Schreter 2004). They will have to accomplish all
trust and openness, whereas transactional leadership of this while evolving technologies of diagnosis (e.g.,
would lead to acceptance of innovation through rein- genetics and neuroimaging) and treatment (e.g., phar-
forcement and reward (p. 1163). Indeed, both leader- macogenetics, vagal nerve stimulation, deep brain
ship styles were positively associated with the adop- stimulation, transcranial magnetic stimulation) are
tion of positive attitudes toward adopting evidence- reshaping our conceptions of illness and treatment. In-
based medicine. There is an important lesson here for deed, the moral and ethical dilemmas that sit at the in-
the leadership of psychiatric hospitals as we struggle terface of market-driven forces, professional values,
constantly to adapt our institutions (and the people commitments to the sense of mission, and evolving
who constitute them) to the technological, organiza- definitions of illness and treatment may be the quint-
tional, scientific, and professional changes that are essential challenge facing the leaders of psychiatric
guaranteed to dominate the psychiatric hospital indus- hospital systems in the early twenty-first century.
try throughout our lives. The most effective leaders for
the future must embrace a broad set of qualities that
range from effective frontline management, to strate-
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Talbott JA, Hales RE (eds): Textbook of Administrative Psy- within psychiatric residency training. Acad Psychiatry
chiatry: New Concepts for a Changing Behavioral 26:245252, 2002
Health System, 2nd Edition. Washington, DC, Ameri-
can Psychiatric Press, 2001
CHAPTER 27
PSYCHIATRISTS AND
PSYCHOLOGISTS
Barbara Roberts Magid, M.B.A.
In this chapter we discuss the patterns of practice and The Community-Based Private
modes of compensation of psychiatrists and psychol-
ogists in current psychiatric hospital settings. Attending Psychiatrist
At one end of the continuum of hospital relationships
with its professional staff is the community-based pri-
Patterns of Psychiatrist Practice vate attending psychiatrist (PAP) model. In this model,
the community-based PAP has hospital privileges, ad-
Hospitals use various employment and contractual mits and treats his or her own patients, and bills inde-
options to ensure that their programs are staffed appro- pendently. Psychiatrists in this model may also partic-
priately and that their patients are receiving the psychi- ipate in an on-call rotation for off-hours coverage. The
atric services they require. The relationship between advantage of this model is continuity of care; the psy-
hospital and psychiatrist can range from an exclusive chiatrist with the greatest knowledge of the patient is
employment arrangement to a private attending model. providing care. The main disadvantage is that it is
In the latter model, the community-based private psy- often inefficient both for the individual practitioner
chiatrist or psychologist admits and treats his or her and for the hospital. The PAP must find a way to see
own hospitalized patients. The psychiatrist may also the hospitalized patient daily and participate in multi-
provide contracted administrative services on a part- disciplinary team meetings at which treatment is
time basis to augment other sources of practice income. planned and reviewed; this is very difficult to fit into a
371
busy day of outpatients or other clinical work and may Roles of Psychiatrists
produce conflict with hospital staff who are mandated
to conduct the team meetings with all disciplines and Psychologists
present. Furthermore, the community-based PAP may
lack familiarity with hospital policies and procedures, The Attending Psychiatrist
documentation formats, managed care doctor-to-doc-
tor review practices, and other activities that are par-
as Clinician
ticular to inpatient settings. Finally, in many environ- The psychiatrist working with hospitalized patients
ments all-inclusive managed care contracts preclude takes a psychiatric history, performs a mental status
separate billing for professional services, rendering it examination, performs or reviews a general physical
financially impractical for independent community- and neurological examination, and reviews the results
based clinicians to provide hospital services. of diagnostic tests. Ideally the psychiatrist also makes
For these reasons, it is increasingly common for contact with other informants, including the family
hospital services to be provided by psychiatrists em- and the referring psychiatrist or other pertinent clini-
ployed expressly for that purpose. cian, in order to obtain history, particularly the details
of current or recent pharmacological treatment. At the
end of this process, the psychiatrist makes a narrative
The Employed Hospitalist formulation of the case and arrives at a working mul-
Psychiatrist tiaxial diagnosis. Psychiatrists working with hospital-
ized patients provide treatment in teams that may in-
In general medicine, there is a growing trend toward clude nurses, social workers, activities therapists (e.g.,
the use of hospital-based physicians (hospitalists) in occupational, physical, and art therapists), mental
the care of inpatients. There is evidence that the use health technicians, and utilization review specialists.
of such physicians is associated with shorter lengths These teams assemble soon after admission to iden-
of stay, greater profitability (Wachter and Goldman tifyin collaboration with the patientthe reason(s)
2002), and possibly better performance on measures for admission, the objectives of the hospitalization,
of quality (Auerbach et al. 2002). the means by which those objectives will be realized,
Although there has been very little study of the ap- the individuals responsible for those interventions,
plication of this practice model to inpatient psychiat- and the criteria by which it will be determined that
ric care, such care is increasingly being provided by discharge should occur. This discussion is docu-
employed hospital-based psychiatrists. A number of mented in the master treatment plan, the map that
employment arrangements are possible. The psychia- guides the therapeutic efforts of every member of the
trist may be employed by the hospital or by a closely team. The team meets on a regular basis to share in-
associated or hospital-owned practice association on a formation and evaluate the effectiveness of the plan.
full- or part-time basis. The contract with the psychi- Generally the psychiatrist meets individually with
atrist may be exclusive, prohibiting practice outside the patient regularly to evaluate the patients progress
the hospital contract, or it may permit or even encour- toward achieving the goals of treatment and serves as
age after-hours private practice or other professional the attending clinician. Minimally, the psychiatrist as-
activities. Hospitals may prefer an exclusive arrange- sesses the extent to which the patient is benefiting
ment because it aligns the incentives of the hospital from and tolerating pharmacological treatment. The
and the psychiatrist, ensuring that the clinicians pro- attending psychiatrist may also obtain appropriate
fessional effort is entirely devoted to meeting the consultations from medical specialists and implement
needs of the hospital and its programs. However, this their recommendations. Routine visits usually include
can be an expensive model because the hospital is obtaining additional history, coordinating care, and
forced to provide the entirety of the psychiatrists in- providing advice and counsel. Sometimes formal psy-
come, which may be substantial in some geographical chotherapy is provided as well. More than one visit per
areas where psychiatrists have the option of lucrative day may be necessary if the patient is suicidal, aggres-
outpatient practices treating a cash-paying clientele. sive, or otherwise in crisis.
Psychiatrists and Psychologists 373
Because many payers require concurrent review of staff members, and other aspects of professional prac-
the need for hospitalization, the psychiatrist may need tice and conduct. In a world marked by increasing
to speak personally with a representative of the orga- pressure to measure performance quantitatively, med-
nization responsible for managing the patients insur- ical staff members are also expected to cooperate with
ance benefit in order to make the case for continuing efforts to measure aspects of their hospital-based prac-
hospital care. tice (e.g., readmission rates, length of stay, satisfaction
with services by patients and families) and to accept
The Psychiatrist as feedback about their performance on the measured di-
Unit Medical Director mensions.
In addition, medical staff members are expected to
Most inpatient units have a designated medical direc- participate in a collaborative and constructive review
tor who receives an administrative stipend to provide of each others work on a routine basis. Most often this
essential administrative services for the unit and for involves reading and providing feedback about each
the hospital. This is usually a part-time role played by other s medical record documentation. Occasionally
an interested and capable inpatient attending psychi- peer review may be undertaken for cause, such as
atrist. The unit medical director is generally expected when concerns have been raised about the practice of a
to work closely with unit leadership (e.g., program di- particular clinician or when there is a need to review
rector, nurse leader) and hospital entities (e.g., Medi- an adverse outcome. Depending on the provisions of
cal Executive Committee, the Medical Staff Office) to the medical staff bylaws at the hospital, such review
develop practices and protocols (e.g., admissions crite- may be conducted by a specially selected senior clini-
ria, clinical pathways) and serve on hospital commit- cian or by a committee appointed for this purpose.
tees requiring the participation of medical staff leaders Psychiatrists who are interested in playing an ac-
(e.g., Medical Staff Credentialing Committee). It is tive role in the life of the hospital and/or the depart-
also often the responsibility of the medical director to ment of psychiatry may seek membership on medical
recruit, supervise, and evaluate the psychiatric medi- staff (e.g., Pharmacy and Therapeutics, Credentialing)
cal staff, organize the on-call schedule, and help screen or hospital (e.g., Quality Improvement) committees.
prospective admissions. In many settings the medical In some settings there is compensation for these activ-
director also personally provides direct patient care. ities, but in many hospitals such participation is con-
sidered part of the rights and responsibilities of medi-
Other Roles of the Psychiatrist cal staff citizenship and performed on a volunteer
in the Hospital Setting basis.
In psychiatric inpatient environments with an ac-
Psychiatrists with hospital privileges have obligations
ademic mission, psychiatrists may be involved in
not only to their individual patients but also to the
teaching medical students, psychiatric residents, and
hospital and their colleagues on the medical staff. other trainees as well as conducting clinical research.
These obligations and expectations may flow from
regulations and standards set by such certifying and Roles of the Psychologist in the
accrediting bodies as the Centers for Medicare and
Medicaid Services and the Joint Commission (for-
Hospital Setting
merly the Joint Commission for Accreditation of Psychologists who have hospital privileges may also
Health Care Organizations). These responsibilities serve on medical staff committees and participate in
may also flow from the deliberations of the Medical the governance of the hospital. Currently 37 states al-
Executive Committee, the governing body of the orga- low psychologists to serve on hospital medical staffs;
nized medical staff. These responsibilities are gener- however, this allowed status for psychologists is not
ally assembled into documents referred to as the implemented or utilized in many psychiatric hospital
medical staff bylaws and departmental rules and settings (Bailey 2006). When psychologists are creden-
regulations and are distributed to new members of tialed to work in the inpatient setting, their roles are
the medical staff at the time of orientation and avail- highly varied. The psychologist may serve in the role of
able to all clinicians with privileges at the hospital. attending clinician, although this is the exception
At a minimum, medical staff members are ex- rather than the rule. The psychologist may also per-
pected to meet medical staff and hospital standards in form psychotherapy with inpatients or may direct mi-
terms of documentation requirements, on-call avail- lieu-wide psychotherapeutic or behavioral programs
ability, collegiality, relationships with other hospital on the inpatient unit. The psychologist may also eval-
uate inpatients with psychological tests to address spe- sions, meet with and evaluate patients daily, and dis-
cific clinical questions in response to a referral from charge them more quickly. Weekend and vacation
coverage became more demanding, and it became
the attending psychiatrist. In addition, psychologists
more difficult to attract psychiatrists to perform
may serve in managerial or administrative roles in the these functions. At the same time, the hospital cen-
hospital organization (American Psychological Associ- susonce steady at 322rose and fell, causing hos-
ation Practice Directorate 1998). Like the psychiatrist pital revenues to fluctuate while professional staffing
who provides inpatient care, the psychologist is typi- costs remained fixed. It became clear that the exist-
cally part of a treatment team and provides services in ing salaried arrangement was not providing psychia-
trists and psychologists with incentives to adapt to
collaboration with other professionals, including
the new mode of practice.
nurses, social workers, and mental health technicians. In this context, Sheppard Pratts first volume- or
productivity-based model of compensationa sys-
tem based on relative value units (RVUs)was de-
Models of Compensation for signed and adopted in 1991 (Schreter et al. 1997).
The development of this system, which did not use
Employed Clinicians the RVUs developed for the Medicare program, de-
pended critically on the work of a committee that es-
tablished an RVU for each clinical service provided in
Professionals employed by hospitals may be compen- the hospital setting. RVU targets were set for every
sated by straight salary (e.g., $150,000 annually re- clinician, and annual compensation was based on
gardless of volume), per diem payments (e.g., $600 per the achievement of those targets. As the compensa-
day, regardless of volume), and/or productivity-based tion system evolved, clinicians who exceeded 100%
compensation systems (e.g., percentage-of-collec- of contracted RVUs were eligible for additional com-
pensation, which could be substantial.
tions, fee schedule, or relative value units). Each of The RVU system changed the corporate culture,
these models has advantages and disadvantages. In increased productivity, and expanded the opportu-
the decades between 1988 and 2008, Sheppard Pratt nity for clinicians to increase annual income by pro-
Health System, a freestanding not-for-profit mental viding more services. Clinicians became engaged in
health system, utilized and evaluated each of these ap- discussing the merits of providing clinical care in a
manner that was not only effective but efficient. Be-
proaches in an effort to accomplish three principal
cause the system directly rewarded the generation of
goals: 1) to change the mode of practice in response to billable services, it became easier to obtain coverage
a changing marketplace, 2) to align compensation for clinicians on vacation and to staff new programs.
with reimbursement, and 3) to recruit, retain, and mo- The system was largely self-policing; if any clinician
tivate clinicians. What follows is a description of the was below target in terms of generating a sufficient
Sheppard Pratt experience and the hybrid compensa- volume of RVUs, he or she usually made certain that
the deficit was eliminated before the end of the con-
tion system that emerged from it. tract year. Perhaps most importantly, the system
demonstrated to the administration that it was pos-
sible to develop, implement, and manage a complex
A Case Study: Professional compensation system with the support and assis-
Compensation at Sheppard Pratt tance of the clinical staff.
The RVU system also had weaknesses. Creating
In 1988 Sheppard Pratt Hospital had 322 beds, an the system was very time-consuming and labor-
average length of stay of 180 days, and an average oc- intensive and diverted attention from other impor-
cupancy of more than 90%. The professional staff of tant activities. Some clinicians objected to having
psychiatrists, psychologists, and social workers were their professional services reduced to widgets and
paid salaries that were significantly below market. protested that the system negatively affected morale.
Clinicians had private practices, and for a small However, the single greatest weakness of the RVU
tax paid to Sheppard Pratt, they could see their pri- system was that the clinician was still to some extent
vate patients in their hospital offices. There were no insulated from the realities of the marketplace. By
productivity requirements. Clinical assignments for the mid-1990sas reimbursement rates fell and the
all professionals were mostly on inpatient units, and administrative hurdles required to receive payment
the average caseload for psychiatrists and psycholo- became more unwieldylevels of bad debt in-
gists was between seven and nine inpatients. Clini- creased, and professional compensation was requir-
cians had full benefits and vacation and sick leave acing unacceptable levels of subsidization from the rest
cruals, and there were only limited expectations of of the health care system.
providing weekend or evening services. For this reason, a fundamental reexamination of
As the length of stay decreased with the advent of the compensation system was undertaken in 1997.
managed care, evolving changes in the nature of hos- The result was a decision to adopt a system that
pital work called upon staff to handle more admis- would compensate clinicians on a percentage-of-
Psychiatrists and Psychologists 375
collections basis, thereby putting clinicians much imum salary. This enables Sheppard Pratt to hire cli-
more closely in touch with the realities of the mar- nicians who are somewhat risk averse and still pro-
ketplace. The first hurdle to tackle in developing this vide an incentive for high productivity.
system was to determine how to divide the collec- Clinicians who teach residents or provide ad-
tions, that is, what percentage to allocate for clini- ministrative services are paid stipends for these ac-
cian compensation and what percentage to allocate tivities. These stipends are calculated on an hourly
for benefits and overhead. Because psychiatrists gen- basis at rates that have been standardized to ensure
erated significantly more collections in a year than that individuals performing the same administrative
the other disciplines, the cost of their benefits and duties are being paid comparably. The duties, hours,
associated practice expenses represented a smaller and rates are specified in the employment contract,
percentage of their collections; therefore it was de- and the stipends are included in clinicians biweekly
termined that psychiatrists would receive 65% of paychecks over the course of the year.
collections and psychologists would receive 50%. The percentage- of-collect ions system h as
Several years later, the compensation paid to psy- worked well in terms of keeping bad debt in check,
chologists was increased to 65% so that all doctoral- increasing levels of productivity, and aligning the
level clinicians received the same compensation; mode of practice with the demands of the market. A
this was in recognition of the time intensity of ser- major positive consequence of the percentage-of-col-
vices delivered by psychologists and the more lim- lections system has been greater clinician interest in
ited opportunities for psychologists to generate prac- billing and collections and in other aspects of finan-
tice income. cial oversight. Clinicians have come to understand
A related challenge was creating a methodology the importance of the charge ticket (paper or elec-
for paying clinicians for the care of uninsured and in- tronic) as the direct accounting link between the
digent patients from whom no collections were ex- clinical service and payment. Clinicians regularly re-
pected. To address this issue, floor payments view reports detailing such information as charges
Current Procedural Terminology (CPT) codespe- entered, collections in progress, accrued compensa-
cific minimum compensation rates funded by Shep- tion, and productivity targets; they examine and an-
pard Prattwere established for each service. These alyze their reports and on a number of occasions
payments were set at levels that eliminated financial have detected irregularities that led to the discovery
disincentives to the care of indigent patients while of systematic errors that otherwise might have gone
not creating an onerous subsidy burden on the orga- uncorrected.
nization. The percentage-of-collections system has had its
It was also essential to deal with the time lag be- problematic aspects as well. Private practice had
tween the performance of the service and the receipt been prohibited for benefited employees with the ad-
of collections. To address this time lag and the ups vent of the percentage-of-collections system. Some
and downs of the collections process, Sheppard Pratt long-tenured and highly respected psychiatrists and
extended an interest-free advance, or draw, to all psychologists resigned because they were unwilling
employed psychiatrists and psychologists. The draw to give up highly remunerative and long-standing
is a uniform sum paid 26 times each contract year outpatient private practices. In the early years of the
without regard to actual monthly collections. The system, we lost some potential recruits who wanted
draw is a strong positive element because it means the security of a salary without the pressure of pro-
that paycheck amounts remain at a constant level ductivity expectations. Some of those concerns of
even as collections ebb and flow during the contract have been addressed with our salary option, al-
term. A special challenge was developing a method though we do include a description of the volume of
for predicting the collections of individual clinicians services needed to support the guaranteed salary in
over the course of a year so that the level of the draw an addendum of the employment agreement.
could be adjusted accordingly. To accomplish this,
administrators created productivity models based on
the anticipated receipt of collections, taking into
account the professional discipline, the clinical pro-
Conclusion
gram and setting, the specific services delivered (e.g.,
distribution of CPT codes), anticipated service vol- The modern psychiatric hospital must continuously
ume (e.g., patients per day), and the number of weeks
the clinician expects to work during the contract
study the framework within which patient care ser-
year. By combining these variables, it was possible to vices are provided in order to stay responsive to pa-
arrive at an estimate of annual compensation. tients, families, and referrers. This chapter explores
Some clinicians, particularly those who are three critical questions with regard to the hospitals re-
newly graduated from residency programs, are un- lationship with the psychiatrists and psychologists
comfortable with pure productivity models. As a re-
providing patient care services: 1) Should the hospital
sult, clinicians new to Sheppard Pratt have the op-
tion of a low guaranteed minimum salary with the employ psychiatric hospitalists, rely on private at-
opportunity to earn additional income in the event tending psychiatrists based in the community, or use a
that 65% of the collections amount exceeds the min- hybrid model? 2) What are the clinical and adminis-
trative roles of the psychiatrist and psychologist in the References

modern psychiatric hospital? and 3) Is it possible to
develop systems of compensation that meet the needs
American Psychological Association Practice Directorate:
of the clinicians, align the incentives of clinicians and Practicing Psychology in Hospitals and Other Health
the hospital, and fit within the budget? All three com- Care Facilities. Washington, DC, American Psychologi-
ponents are critical to the attainment of the hospitals cal Association, 1998
goal of providing effective, responsive, and cost-effi- Auerbach AD, Qwachter RM, Katz P, et al: Implementation
of a voluntary hospitalist service at a community teach-
cient services. In an ever-changing marketplace, these
ing hospital: improved clinical efficiency and patient
three components must be evaluated as a unit and in- outcomes. Ann Intern Med 137:859865, 2002
dividually with the recognition that each component Bailey D: Psychologists hospital privileges benefit patients.
interacts with the others. Change must be carefully Monitor on Psychology, Vol 37, May 6, 2006. Available
staged, with the active participation of key clinical and at: http://www.apa.org/monitor/may06/privileges.html.
administrative staff. The goal is to create an environ- Accessed July 6, 2007.
Schreter RK, Sharfstein SS, Schreter CA (eds): Managing Care,
ment in which patients receive safe and effective treat-
Not Dollars: The Continuum of Mental Health Services.
ment and clinicians experience their work as appreci- Washington, DC, American Psychiatric Press, 1997
ated and rewarding. Wachter RM, Goldman L: The hospitalist movement 5 years
later. JAMA 287:487494, 2002
CHAPTER 28
SOCIAL WORK AND

REHABILITATION THERAPIES
Diana L. Ramsay, M.P.P., O.T.R., F.A.O.T.A.
Judith S. Gonyea, O.T.D., M.S.Ed., O.T.R./L.
Rehabilitation specialists and social workers play ready to step down to outpatient care, partial hospitals
key roles in the therapeutic process within the acute and crisis bed facilities may provide the bridge to com-
care environment. Roles vary from site to site to reflect munity-based services.
the needs of the region or community. Funding struc- Federal, state, and regional regulatory guidelines
tures can affect the breadth and mix of services. Re- further influence service standards and delivery, as do
structuring and cost-saving initiatives sometimes af- professional credentialing requirements for clinicians
fect the roles of social work and rehabilitation. within each jurisdiction. Worker shortages can have
One of the significant changes in hospital care has an impact on the availability of various types of pro-
been a drastic decline in a patients length of stay. Be- fessionals. Agencies may employ clinicians from sev-
tween 1990 and 2000, the total number of inpatient eral disciplines or may contract for specific services.
days fell by approximately one-half. Median length of Contractual providers may be available on a routine or
stay declined 63% over the decade from 12.2 days to as-needed basis, which may affect availability and
4.5 days for most diagnostic categories and across roles within the team structure (Joint Commission
types of patients and hospital settings (Case 2007). Resources 2006). Sometimes these services are per-
Admission, evaluation, intervention, and discharge formed on a contractual basis; in other instances they
phases of a stay are now compacted into a much are not part of the treatment package.
briefer time frame. Stringent limits on the length of in- The acute care team typically includes psychia-
patient stays result in a critical need for step-down and trists, nurses, social workers, psychologists, various
community-based services. When individuals are not rehabilitative therapists (occupational, recreation, and
377
psychiatric technicians), and, perhaps, a discharge co- community and family involvement, and current func-
ordinator. In these inpatient settings, tasks may be tional status are explored with a focus on the individ-
shared. Hence, it is important to differentiate which uals current needs and desired outcomes. Psychiatric,
individual or discipline will take the lead for each re- nursing, psychological, social work, rehabilitation, and
spective task or process. As noted by Rosen and Cal- any other individualized assessments the team deems
laly (2005, p. 239), effective interdisciplinary team- necessary will typically follow. These may include the
work in mental health services involves both retaining following assessments: forensic, cognitive skills, motor
differentiated disciplinary roles and developing shared skills, and/or a more intensive family evaluation.
core tasks. There must be effective leadership and ex- Assessments may occur in one-to-one or group set-
plicit mechanisms in place to resolve role conflicts and tings, depending on the hospitals admission protocol.
ensure safe practices. The team learns to operate They must be completed in a limited time frame and
quickly and efficiently. In order to continue providing therefore require completion by staff members whose
services and oversight, team members rely increas- presence is guaranteed on a routine basis. Specialized
ingly on systems and agencies outside of the hospital, assessments may be ordered by referral and may in-
such as individual practitioners, outpatient commu- clude (depending on the individuals presenting prob-
nity mental health centers, child or adult protective lems, insurance authorization, and/or the availability
services, the forensic system, residential programs, of services) psychological testing, a family consulta-
psychiatric rehabilitation programs, assisted-living tion by the social worker, a neuropsychiatric exam,
settings, peer support groups, and advocacy groups. In specialized occupational therapy testing, a substance
the wake of deinstitutionalization, hospitals are rec- abuse evaluation, and a forensic consultation. The
ognizing that interdisciplinary [teamwork] ... is an es- goal of these assessments is to obtain a more detailed
sential element of both effective patient care and orga- view of the individuals goals and specific strengths
nizational survival. The interdisciplinary team model, and challenges and to provide extra guidance and in-
long cherished in psychiatry, remains the most effica- formation for treatment planning.
cious model for carrying out the necessary tasks in After the information gathering is complete, the
acute psychiatric settings (Rosen and Callaly (2005, team collaborates with the patient to produce a work-
p. 238); these tasks include admission, diagnosis, able, meaningful, and relevant treatment and dis-
treatment planning, treatment, and, finally, discharge charge plan. Coordinated interdisciplinary discharge
planning. Although team structures may vary, effec- planning results in improved continuity of care, better
tive communication and understanding of roles are functional status, decreased length of stay, less dupli-
vital to efficient team process. Professionals within cation of services, and improved education (Hansen et
the acute care setting must also facilitate better links al. 1998).
with the community in order to develop more inte- When a patient is represented by a legal guardian,
grated mental health services. foster family, advocate, or others, it is necessary to
This chapter provides a general overview of the confirm legal authorization in order to share with and
roles of social workers and the rehabilitation team receive information from those who speak on behalf of
within the acute care treatment setting. the patient. The Health Insurance Portability and Ac-
countability Act of 1996 (U.S. Department of Health
and Human Services 2003) provides specific guide-
Admission and Diagnostic Process lines and restrictions regarding protected health infor-
mation that must be considered during any health
The first person a patient meets in the hospital may care interaction. This can create a complex scenario
not be a psychiatrist but instead may be an intake co- for individuals who have been in multiple placements
ordinator, a nurse, a social worker, or a psychiatric or who may be accompanied by someone other than
technician. Figure 281 provides an overview of the their primary guardian at admission.
acute care process from this point. In many acute care
settings, individuals are evaluated upon admission by a
cohort of professionals trained in various disciplines.
The Therapeutic Relationship
The evaluation process often begins with structured
diagnostic interviews and/or evaluations in which the The therapeutic relationship remains the key element
patient, his or her family, and/or other community in acute care assessment, treatment, and outcome. Al-
supports participate. Details of the patients history, though inpatient stays are shorter than they were in
Social Work and Rehabilitation Therapies 379
Patient enters system through emergency

room or other approved triage site and
determination is made that psychiatric
screen is indicated (insurance conrmed)
Designated team member

(MD/resident, social worker) completes Refer to outpatient or
Treat and discharge initial evaluation and determines community care
appropriate level of care
Acute
Referral
Evaluation by acute treatment team

(team members may vary): psychiatrist,
social worker, psychologist;
rehabilitation team: occupational,
recreation, art, movement, music,
speech therapies
Treatment plan includes

Group/individual therapies
Referral for specialty evaluation
Anticipated discharge plan
Intervention
Ongoing team assessment
Group and individual sessions
Discharge planning
Assessment of resources
Continued residential
Community outpatient Discharge care, supported setting
FIGURE 281. Acute care system.

the past, the results of recently developed, briefer care, social workers can use the principle of client self-
forms of therapies indicate that a significant and determination in matters where clients or their prox-
workable therapeutic relationship can be established ies are faced with such issues (National Association
within a short period of time. Team members typically of Social Workers 2005, p. 8).
become well versed in developing rapport with the pa- According to the NASW Standards for Social Work
tient. In addition, the patient on a unit is exposed to Practice in Health Care Settings National Association
many professionals trained in various disciplines, and of Social Workers 2005), professional social workers
he or she has the opportunity to interact with more are well-equipped to practice in the health care field
than one team member (Safran and Muran 1998). because of their broad perspective on the range of
physical, emotional, and environmental factors that
have an effect on the well-being of individuals and
Social Workers communities (p. 6). The focus of social work is the
transaction between the individual and his or her en-
Social workers have academic degrees (bachelor s de- vironment. Typically, if asked how to begin a patient
gree or bachelor of social work; master s degree or assessment and plan for discharge, the social worker
master of social work) and are licensed at various lev- will probably respond, I start from where the person
els. There are also social workers with doctoral de- is. The social worker assesses the interaction be-
grees. Licensure and its requirements vary from state tween the individual and the environmental systems
to state. The National Association of Social Workers that may affect the persons treatment. Some of these
(NASW) is the organization that establishes the ethics systems include the family; educational, outpatient,
and practice guidelines for social workers. The Coun- vocational, and cultural support; church or spiritual
cil of Social Work Education regulates social work ed- support; and social services systems. Social workers
ucation. Schools of social work must be accredited in have special skills in cultural awareness; it is a core
order for their graduates to be licensed and call them- value of the profession to respectfully respond to and
selves social workers. Each state has a board that, affirm the worth and dignity of people of all cultures,
along with national organizations, decides the param- languages, classes, ethnic backgrounds, abilities, reli-
eters of social work practice. Social workers are regions, sexual orientations, and other diverse features
quired to maintain their qualifications for licensure found among humans (National Association of So-
with continuing education and/or postgraduate work cial Workers 2005, p. 6). In the hospital setting, the
(Hoon et al. 1978). goals of the social worker are to assess the relevant sys-
Social workers play a central role in the mental tems, modify a system if needed (and if the individual
health system (Aviram 2002). They work in myriad and the system are able to do so) in order to optimize
public and private agencies, general hospitals, day hos- the individuals chances of success after discharge, and
pitals, outpatient clinics, mobile treatment teams, provide liaison between the inpatient setting and the
shelters, and emergency departments. Some social outside systems.
workers function as part of an interdisciplinary team, In the era of short hospital stays, social workers
whereas others may lead the team or direct a program; and other members of the treatment team are accus-
many work in private practice. In many states, de- tomed to functioning with efficiency and precision in a
pending on the level of licensure, social workers can short-term setting and to using the psychosocial as-
conduct independent practices in which they diagnose sessment in a focused manner to formulate effective
as well as treat patients with mental illness. Their du- interventions. The emphasis has shifted to planning
ties may include but are not limited to admission, for an individuals transition to home or another level
evaluation and diagnosis, treatment planning, direct of care.
treatment, psychoeducation, family work, advocacy Social workers engage with the patients family,
work, case management, and discharge planning. Ac- however that may be defined, and are involved in all
cording to the NASW Standards for Social Work Prac- steps of the inpatient process: orienting the family to
tice in Health Care Settings (National Association of the hospital, providing psychoeducation for the family
Social Workers 2005), The basic values of social and the patient, and informing them of every step in
work, from promoting an individuals right to self- the treatment. They provide individual, group, and
determination to having an attitude of empathy for family therapy and, with the treatment team, assist in
the individual, are the foundation of social work prac- formulating the discharge plan. Social workers often
tice. When confronting dilemmas or needs in health act as advocates in managing the hospital and com-
munity systems the patient may encounter. Their iors, skills, and insights to resolve. .. a current crisis
role is to give information and to give hope (R. Guth, (National Association of Social Workers 2005, p. 10).
personal communication, February 8, 2007).
No matter what the setting, social work has proven
to be very flexible in fitting into the current framework Occupational and Rehabilitation
of acute psychiatric care. Values of the social work pro- Therapists
fession such as negotiation, flexibility, and the right to
exercise autonomy are useful on the interdisciplinary
treatment team (Globerman 1995). Credentialing and licensure for each rehabilitative dis-
The psychosocial evaluation (PSE) is the basic op- cipline vary among states. For instance, occupational
erating document of the social worker. It is usually therapists enter the field at the master s or doctoral
completed within 24 to 72 hours of admission. Given level. Occupational therapy assistants enter the field
the fast pace of the setting, the social worker must be at the associate degree level. Supervised fieldwork is
able to quickly establish a therapeutic relationship required at each level, and evidence of specialized ed-
with the patient and, often, the family. Social workers ucation or training is required for some areas of prac-
look at all of the influences and aspects of a persons tice. Licensure requirements vary across states, but
life to complete a thorough assessment and treatment most states do require successful initial certification
plan with the client, the family, and other health care by the National Board for Certification in Occupa-
professionals (National Association of Social Work- tional Therapy (2003; see http://www.nbcot.org/web
ers 2005, p. 19). articles/anmviewer.asp?a=110&z=17).
The PSE is almost always conducted in an individ- Occupational and rehabilitative therapists work in
ual interview. It usually reflects the guiding philoso- tandem with other treatment team members to de-
phy of many social workers: to start with where the velop a profile of the patients needs. Team members
person is. The PSE is a comprehensive document from each discipline incorporate their specialized view
covering the following facts: basic demographic infor- of the patients needs, both within the acute care en-
mation; contact persons; plan for family involvement; vironment and upon discharge or transition to an-
information about the outpatient treatment team; other treatment setting.
notification contacts in case of seclusion or restraint; Occupational therapy practice guidelines ensure
financial information; queries concerning advance that practitioners provide services to improve the
directives, guardianships, or powers of attorney; his- ability of the individual or population to fulfill role
tory of harm to self or others; legal information; perti- obligations, to improve performance in occupations
nent spiritual and cultural factors; and living arrange- and activities, and resolve or compensate for impair-
ments. The PSE is also used to assess reasons for ments (Moyers and Dale 2007, p. 15). The Occupa-
referral, prior psychiatric history, medication history, tional Therapy Practice Framework outlines the crite-
relevant stressors, substance abuse history, family ria for development of an Occupational Profile
composition and history, growth and developmental (American Occupational Therapy Association 2002).
history (including trauma, medical problems, and This profile may be developed using a variety of as-
abuse history), management of daily activity and in- sessment instruments, both formal and informal. It is
terpersonal relationships (or other support networks), designed to identify individuals unique characteris-
and education and employment history. tics, including how they perceive themselves, why
The last part of the assessment typically includes a they are in need of or are seeking services, the context
clinical evaluation of a patients strengths and chal- from which they have come and/or to which they plan
lenges, suggestions regarding how the social system to return, their perceived roles and routines, their sup-
can be strengthened or modified to improve biopsy- ports and liabilities, and, most importantly, what oc-
chosocial functioning, participation by family and sig- cupations or life skills are most significant to them
nificant others, and social work treatment goals in dis- (Cara and MacRae 2005).
charge planning for the individual. The social work The occupational profile will drive the course of
perspective draws from the strengths and abilities of occupational therapy treatment and may indicate ar-
the patient: [A]wareness and use of the clients eas where further evaluation is needed. Additional
strengths form part of the foundation of social work evaluation may address safety in areas of general mo-
theory and practice.... The strengths perspective helps bility, personal care and care of others, cognitive pro-
patients use their past successful choices and behav- cessing ability (especially as it relates to performance
skills), and sensory processing in relation to the indi- healthy lifestyle or physical or emotional challenges.
viduals personal and environmental demands (Cara Successful hospital discharge or life planning must
and MacRae 2005; Ikiugu 2007). take into account the individuals ability to sustain
For occupational or other rehabilitative therapies, habits and routines that promote wellness while at the
cognitive and motivational strategies may be critical same time diminishing habits and routines that in-
in short-term treatment scenarios, especially those in terfere with successful transition (Christiansen and
which substance use is a relevant patient factor. A re- Townsend 2004).
view of approaches by Stoffel and Moyers (2004) indi- Occupational therapists have long been aware that
cated that motivational interviewing as part of a brief underlying sensory, motor, and processing deficits
intervention may encourage patients toward change. may contribute to an individuals challenges. These
Their review revealed that it is not enough that an in- challenges may include unusual ways in which the in-
dividual be motivated to begin treatment; his or her dividual sees, feels, smells, hears, interprets, or inter-
motivation must also be sustained and reenergized acts with his or her environment. Sensory integration
throughout the course of treatment. was identified as a primary developmental concern in
Participation is another concept that is critical to the field of occupational therapy in the 1960s. Later,
both the occupational therapists view of the patient Kings (1974) work on the sensory-motor challenges
and his or her assessment of the patients needs. Sim- faced by individuals with nonparanoid schizophrenia
ply knowing that an individual engages in or disen- further exemplified the significant link between sen-
gages from a particular behavior or task tells us nothing sory-motor processing and functional participation.
about that individuals strengths and needs. The ther- Although research continues in this area, some hospi-
apist must also consider the context of the individual tals are already implementing sensory strategies or
in his or her community, the roles he or she is expected using sensory rooms (calming or exciting) within the
to fulfill, and whether those roles are congruent with milieu design. Champagne (2006) has warned that
the individuals own perceived strengths and needs. As such strategies must be collaborative and well-
noted by Christiansen and Townsend (2004, p. 198), thought-out and -designed in order for them to provide
it is not sufficient to understand that a person or a an effective alternative to other management ap-
community is doing something. Rather, it is the explo- proaches, specifically seclusion and restraint.
ration of what they are doing, why they are doing it, For example, an adolescent admitted to an acute
and what it brings to their lives individually or collec- care unit for stabilization following repeated high-risk
tively that adds to our understanding of human behav- behaviors may have a history that suggests poor envi-
ior. A distinction needs to be made between occupa- ronmental or sensory awareness. In this case, the ado-
tions that [individuals or groups] want to do versus lescent could be referred to an occupational therapist
those that they need to do. For example, an individual for a sensory-integration or sensory-processing evalua-
who has engaged in high-risk behaviors for an extended tion (Ikiugu 2007). The occupational therapist will se-
period of time, such as substance abuse or sexual pro- lect an evaluative approach that is consistent with the
miscuity, may have a difficult time replacing those be- age and context of the client. Such an approach could
haviors with the safer behaviors that are deemed desir- include completion of an Adolescent/Adult Sensory
able by the treatment team or significant others. Profile (Brown and Dunn 2002), clinical observation,
However, those high-risk behaviors may directly relate chart review, or a variety of other sensory-referenced
to that individuals sense of community and identified evaluations and interviews. Results of these focused as-
roles. Part of the occupational therapists role may be to sessments would typically indicate how well the indi-
help refocus the patients strengths or find community vidual is processing sensory information, whether the
resources such as peer support groups that can enable individual is seeking more or less sensory information
the individual to feel motivated toward and supported than do typical individuals, and what effect the individ-
in making behavioral alterations. To facilitate the de- uals sensory processing is having on his or her ability to
sired occupational changes, the occupational therapist interact with the environment and other people. Upon
may need to work with the discharge planner to select completion of the evaluation, the occupational thera-
the most supportive environment and services. pist, in conjunction with the individual and treatment
Occupational therapy places great emphasis on un- team, would establish sensory strategies that could be
derstanding a patients habits and routines, which re- employed during and possibly after hospitalization.
flect the patterns of an individuals life. In some cases, In the case of a withdrawn suicidal patient, a refer-
these habits or routines may be reflective of an un- ral to an art, music, or other expressive therapist may
provide the best opportunity for insight into under- tients as part of their overall treatment plan develop-
lying issues or conflicts if the hospital stay is long ment. This approach was developed by Mary Ellen
enough for this type of assessment. In art therapy, the Copeland in response to her own challenges within
diagnostic workup usually includes a series of draw- the mental health system (Copeland Center for Well-
ings that are foundational to the evaluation. They pro- ness and Recovery 19952007; see http://www.cope-
vide a view of the individuals sensory, spatial, and landcenter.com/whatiswrap.html).
fine-motor processing; affect and emotion; sense of
control; symbolic references; and other global areas of
insight. Drawings completed in group also lend them-
The Master Treatment Plan
selves to interpretation of the individuals responses to
others and the group as a whole. In the case of forensic The master treatment plan (MTP) is developed by the
patients, the use of symbolism (cult, gang) or themes team on the acute care unit and becomes the guiding
(death, hopelessness, violence) may provide further document for treatment during an individuals stay.
evidence of risky affiliations or aspirations (P. Prugh, The team leader for the development of the plan may
personal communication, February 13, 2007). be a psychiatrist or other psychiatric health profes-
Recreation therapy provides the patient with a sional. It is essential to have as much information as
focused opportunity to engage in and/or explore rec- possible from all disciplines prior to creating the MTP.
reational pursuits within the milieu and for future All team members have access to every evaluation
needs. Recreational therapy interventions include completed, and this collection of data is used by the
structured activity focused on symptom reduction; team, with the patients consent and input, to develop
education on social skills, stress management, and treatment and discharge plans. An MTP typically con-
health maintenance; community functioning and insists of the following information: a diagnosis on Axis
tegration activities; adventure/challenge activities; I through V, a list of current symptoms, a list of rele-
and family interventions (American Therapeutic Rec- vant problems, current prescribed medications, patient
reation Association 2004). strengths and challenges, a plan for treatment with
proposed interventions by staff, a measure to quantify
patient improvement, and an initial discharge plan.
The Consumer Connection After the MTP is completed, and depending on the
custom of the hospital unit, the patient meets with the
Mental health consumers have found a voice within entire team or the case manager to review the MTP.
and outside the acute care environment. Consumer ad- Members of the team and the patient or patient advo-
vocates help other consumers, and in this way, patients cate sign the document to affirm the treatment plan.
find a voice for their needs and concerns. They may
also enable staff to see the patients perspective more
clearly through their ability to build trust with a client
Therapies (or Who Does What)
who may be intimidated by the system and its rules
and restrictions. Advocates also provide a concrete link Many types of therapies, both group and individual, in
to community resources. It is important for clinicians a variety of modalities are offered on an acute care
working in these fast-paced short-term settings to ap- unit. These may include occupational, activity, recre-
preciate the long-term challenges faced by the patient. ational, art, music, and other expressive therapies, de-
Clinical partnerships with consumer advocates can pending on the patients length of stay and the re-
lead to positive transitional plans across levels of care. sources available. In some hospitals, one might find
Models of care are becoming more patient/client- psychoeducational groups for patients and/or families.
centered, and many treatment settings employ new Less commonly, one might find support groups run by
approaches toward development of the individuals peers from advocacy organizations based in the local
wellness plan. One model being applied in many set- community. The leadership of various therapeutic ac-
tings is the Recovery Model (National Alliance on tivities depends on the hospital units organization, its
Mental Illness 1996), which places the individual in a theoretical preferences, its budget, and the availability
position of control, focusing on the patients need to of professionals within the hospital setting. Thus, one
understand and manage his or her own mental health might find psychiatrists, social workers, occupational
care. Another approach is the Wellness Recovery Ac- therapists, and others conducting similar groups
tion Plan (WRAP), which can be introduced to pa- across different hospital settings.
Milieu Management persons language, that should include the following

elements: a diagnosis; a clearly written list of medica-
tions; follow-up appointments for psychiatric care
Milieu management refers to the regulation of physi- and/or other medical appointments; plans for housing,
cal behaviors and personal interactions within the rehabilitation, and socialization; a number to call in
treatment environment. No matter what theoretical an emergency; and any other referrals or recommen-
methodology is followed, the success of all teams de- dations related to continued care. The major goal of
pends on clear and effective communication among the plan is that the patient achieves the highest quality
disciplines (Abramson and Mizrahi 1996). On a well- of life possible in the least restrictive environment
organized hospital unit where there is effective com- (Tuzman and Cohen 1992).
munication, the treatment team meets on a regular Because a patients length of stay is typically very
basis to discuss the practical elements of operating the short, discharge planning on an acute care unit must
unit, the unit organization, and any changes occurring begin at the time of admission. At the same time, dis-
on the unit (among the staff or in the institution) that charge planning has to be a fluid process due to the on-
might have an impact its operation. Problems in the going collection of evaluations, observations, and
milieu can affect the individuals experience and re- other data. The extent and type of family and other
sponse to treatment and the staff s satisfaction with support of the patient are major considerations. A
their work on the unit. The focus of clear communi- study on clinical decision making for discharge plan-
cation should be on open and frank discussion, prob- ning revealed that the art of good discharge planning
lem solving, and conflict management among the staff also involves the need to engage the patient, family,
members and with individual patients and their fam- and care systems within briefer time frames (Tuzman
ilies (Hansen et al. 1998). and Cohen 1992, p. 300).
All professionals should be trained to assist in the Length of hospital stay is a significant consider-
management of behavior on an acute care unit using ation in both treatment and discharge planning. The
nonconfrontational and least restrictive methods of length of stay is determined not only by insurance
control. Treatment team members may recommend constraints but also by other factors, including the
modifications of the physical environment to reduce complexity of the patients presenting problems, the
the incidence of aggressive or self-injurious behavior. preferences of the team and patient, and the availabil-
Strategies may enable the patient to calm or control ity of resources within the community for postdis-
his or her response to triggers, such as specific sights charge care. It is important to note that evidence has
or sounds within the environment (Ikiugu 2007). shown that the presence of significant psychosocial
However, some patients may not respond to typical problems is predictive of a longer length of stay (Keef-
calming or cognitive strategies. A history of trauma or ler et al. 2001; Lechman and Duder 2006) and that
neuropsychiatric problems may create a hypersensi- this should be a significant consideration when plan-
tivity that predisposes the patient to respond with ex- ning a course of treatment for a particular patient
treme behavior. The patient may display aggression, (Keefler et al. 2001).
withdrawal, hypersexuality, and other responses, The entire treatment team is responsible for the
which may be intended to be self-protective. Helping development of the discharge plan. Table 281 lists
the patient to identify the personal triggers for these the many considerations and preparation needed for
responses and/or the feelings associated with these each potential discharge setting. Because average hos-
triggers may enable him or her to develop strategies to pital stays are so short, the team has to consider that
preempt these extreme responses. The treatment the majority of an individuals treatment will occur af-
team can then work together with the patient toward ter discharge from the acute setting. Thus, knowledge
the development of more effective strategies, which of resources is vital to discharge planning. It is critical
can also continue to be used after discharge. that the team have a collective awareness of the bene-
fits and risks of individual placement options and
Discharge Planning strive to create the best match for each person. There-
fore, even though the entire team contributes, mem-
and Length of Stay bers representing specific disciplines may provide
more precise input: the social worker may be instru-
At the time of discharge, individuals will have a de- mental in providing information about public entitle-
tailed discharge plan, written in easily understood lay- ments such as Social Security, disability, or medical
TABLE 281. Discharge settings/services and considerations
Setting Considerations Preparation

Home Will individual need continuing care, Check insurance coverage.
and if so, what type? Check availability of funded services.
What community resources exist in Check transportation options if needed.
location where this individual will be Check individuals safety potential for
discharged? home and community environments.
What personal resources are available to
this individual (e.g., family or friends)?
Outpatient/ Does this individual have the ability to Check insurance coverage.
day hospital follow up or have others who can remind Check transportation options if needed.
him/her to do so? Check individuals safety potential for
Does the outpatient program provide an home and community environments.
appropriate level of care for this
individual?
Is the context/setting of outpatient
program appropriate (e.g., age,
community, culture)?
Psychiatric Does the individuals diagnosis or Check insurance coverage.

residential current status require this level of care If individual is a child or adolescent,
treatment according to guidelines? check educational program needs and
center Are there beds available for this type of availability.
individual (e.g., age cohort, treatment
needs)?
Can the anticipated plan of care be
carried out in this setting?
Group home Does the individual possess the skills Check insurance coverage
necessary for this type of setting (e.g., Check individuals safety potential for
social, personal management)? home and community environments.
Are there beds available for this type of Check potential restrictions based on
individual (e.g., age cohort, treatment background, gender, etc.
needs)? Check vocational or work expectations
Can the anticipated plan of care be and assess skills accordingly.
carried out in this setting?
Supportive living Does the individual possess the skills Check insurance coverage.
(e.g., social, personal management, Check individuals safety potential for
domestic) necessary for this type of home and community environments.
setting? Check potential restrictions based on
Are there beds available for this type of background, gender, etc.
individual (e.g., age cohort, treatment Check vocational or work expectations
needs)? and assess skills accordingly.
Can the anticipated plan of care be Check community resources (e.g.,
carried out in this setting? advocacy, peer support, transportation).
assistance; the occupational therapist may address for challenges. From the point of admission to the
safety skills; and the recreation therapist may find lei- point of discharge, the entire teams focus is on the
sure resources within the community to promote a most functional, least restrictive outcome for patients
patients engagement in the community. and their significant others.
Conclusion References
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American Occupational Therapy Association: Occupational
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CHAPTER 29
PSYCHIATRIC NURSING
Creating and Maintaining
a Therapeutic
Inpatient Environment

Suzanne Perraud, Ph.D., R.N.
P sychiatric nurses are the largest professional work- they experience their needs being recognized, re-
force on inpatient psychiatric units; recent data counts sponded to, and understood (Barker et al. 1999; Rain-
indicate 78,500 nurses work in inpatient care gruber 2003). Finally, persons who are hospitalized
(Manderscheid et al. 2004). Psychiatric nurses hold may be dealing with a chronic mental illness and are
24-hour accountability for the integrity of the inpa- engaged with their own recovery. They may be coping
tient treatment environment. They are responsible for with a recent exacerbation of their disease, and they
maintaining the processes that ensure the physical may be trying to regain a sense of control over their ill-
and psychological safety of patients. Nursing also sus- ness (Delaney 1984). Nursing must create an environ-
tains the appropriate structure for the patient popula- ment that integrates self-management strategies that
tion, which provides expectancy and routine for those support recovery, coping, self-efficacy, and resiliency.
in acute crisis. At its heart, inpatient psychiatric nurs- Herein lies the work of nursingwork that, when it is
ing is a human endeavor. An essential element of the going well, often goes unnoticed. Although nurses un-
work is providing support to patients and ensuring derstand what maintaining a milieu requires, it is
389
poorly understood outside the staff group. This chap- unit stipulate that prior to admission, a person has dis-
ter details how the everyday work of the nursing staff 1 played behaviors that have been deemed dangerous to
creates and maintains the core therapeutic elements self or others or have reached an acuity level that is in-
of the unit. terfering with the persons ability to function. This is
Much of this chapter will focus on the actual work not to imply that a patient is or should be viewed as
of nursing in the milieu. Inpatient nurses also assume dangerous but rather that the persons illness has
other responsibilities, particularly in their work with reached a point where he or she may be experiencing
the interdisciplinary treatment team. In this vein, their extreme moods that are leading toward self-harm. An
efforts parallel the broad goals of hospitalization and individual could, for example, be having a thought dis-
the work of the interdisciplinary team: crisis resolu- turbance that significantly alters how he or she pro-
tion, instituting an aggressive treatment regimen; cesses information or be undergoing periods of emo-
helping patients regain a sense of control and reestab- tional dysregulation that disrupt functioning. Given
lish movement toward recovery; and aligning services the current short length of stay on inpatient units
so that the individual moves seamlessly along the con- (National Association of Psychiatric Health Systems
tinuum of care (Delaney et al. 2000; Glick et al. 2003). 2004), it is likely that at any one time several patients
Accomplishing these goals usually involves pharmaco- are in the acute phase of their illnesses. This creates
logical intervention, which may often include adding high acuity and a milieu atmosphere that quickly
to or subtracting from the patients current medication changes, depending on admissions and discharges. In
regimen. Because they monitor positive effects and any the face of such rapidly shifting milieu conditions, the
negative reactions to medication changes, inpatient safety of patients and staff must be maintained. If the
nurses are essential to this effort (Volavka et al. 2005). basic safety of a unit is breached, no other treatments
Nurses have significant contact with patients at all can proceed until it is restored (Bowers et al. 2005).
times and are thus able to gather data on how patients
behaviors change with varying degrees of stimulation PRESCRIBED PRECAUTIONS AND MONITORING
or stress. Their ongoing assessment of unit behavior is
On the most obvious level, the safety of an individual
useful in clarifying diagnostic issues, particularly with
is maintained by a units system of precautions, such
children and adolescents (Delaney 2006b).
as implementing close watch or monitoring suicide
risk. A precautions system sets out the frequency of
The Four-S Model monitoring commensurate with estimated risk (Tem-
kin 2004). Monitoring suicide risk is a core duty of in-
patient nurses and, as a component of keeping pa-
Gunderson (1978) determined that milieu operations tients safe, is a basic function of an inpatient unit. Yet,
could be conceptualized according to five therapeutic close observation is not without controversy (OBrien
variables: containment, structure, support, involve- and Cole 2003). Patient accounts of being on close
ment, and validation. During the 15 years that the au- watch indicate that they may feel protected but at the
thors have been working with the Gunderson model, same time also experience it as an intrusive measure
we have changed the category labels and updated how that robs them of all privacy (Pitula and Cardell 1996).
they are operationalized during inpatient care (Delaney Recently, the Joint Commission (2007) placed identi-
1992; Delaney et al. 1995, 2000). Using these updated fication of safety risks as its fifteenth National Safety
variables, this chapter organizes what nurses do in in- Patient Goal. The new standards establish more ex-
patient milieus by grouping their efforts into the fol- plicit expectations for monitoring suicide risk and doc-
lowing four categories (which we have termed the Four- umenting suicide risk assessments, thus placing
S model): safety, structure, support, and self-manage- greater demands on the nurses and the interdiscipli-
ment. nary team for this extremely important, albeit time-
intensive, responsibility.
Safety
Safety is also maintained by proactive control of
More than any other element in the milieu, safety is the atmosphere of the milieu. This is accomplished by
imperative. Criteria for hospitalization on an inpatient the way staff attend to the movement of patients, the
1 Throughout this chapter, the term nursing staff is meant to denote the group of nurses and mental health workers who together
create the therapeutic nursing elements of the milieu.
Psychiatric Nursing 391
current at-risk behaviors of any particular patient, and tribute to this aspect of safety. For example, nurses and
any shifts in the pace and noise level of the milieu. At mental health workers are in the habit of telling each
the most basic level, proactive control is accomplished other when they leave a common area of the unit. This
by how staff members position themselves around the is important for two reasons: first, it raises awareness
unit and thus maintain awareness of milieu action that a staff member may be going to an unobserved
(Delaney and Johnson 2006). For instance, as they sit area of the unit; second, it ensures that staff members
in the day room, staff members may notice two pa- know each other s whereabouts moment to moment,
tients who exchange brief angry looks each time they which allows for a rapid organization of the staff group
pass by each other. As they observe such interactions, in case of an emergency. Often, these role behaviors
staff assess patients behaviors in the context of what and assessment skills are acquired over time, usually
they know about the patients and their violence histo- by novice staff members as they work alongside more
ries (Delaney and Johnson 2006). Anticipation is key experienced peers (Hanneman 1996).
to safety; it allows staff members to intervene early
and to calmly interrupt a behavior that appears to be KEEPING THE UNIT SAFE: A STUDY
heading toward a volatile end (Delaney 2006c).
Although ingrained role behaviors represent one level
This does not mean that every patient on the unit
of the safety net, most nursing interventions are not
needs intense monitoring. However, given the respon-
just reflexive but involve clinical judgment and rea-
sibility nurses hold for the welfare of both patients
soned action. Recently, two of the authors (M.J., K.D.)
and fellow staff, and given the unpredictable nature of
completed a study that entailed observing staff and
particular types of inpatient violence (Johnson 2004;
patient interactions on two inpatient psychiatric
Johnson and Delaney 2007), ongoing assessment of
units. We watched nurses interact with patients for
the milieu and patients is essential to safety. In other
600 hours, over the course of 9 months, observing
specialties, nurses use sophisticated machines to
how staff members and patients moved about the mi-
monitor patients during the acute phases of their ill-
lieu (Delaney an d Jo hnson 2006; Johnso n and
nesses. Psychiatric nurses must use the constant pres-
Delaney 2006). Interviews were conducted with both
ence of staff. Intense monitoring can be interpreted or
staff and patients. We queried staff members on how
used as authoritarian control (Goffman 1961). This is
they maintained safety and why they responded as
particularly risky on units with low involvement,
they did to particular incidents. We also asked pa-
where, for example, nurses have not explained to pa-
tients how they perceived the actions of staff as useful
tients the therapeutic context of routines and reasons
to helping them regain control. Study results detailed
behind different forms of monitoring (Alexander
how staff kept the unit safe through actions that in-
2006). Keeping units safe in a humane way demands
volved a complex set of four interconnected factors:
striking a balance; any restrictions on patient behav-
ideology, people, space, and time.
iors are enacted and explained within the therapeutic
The first dimension of safety, ideology, influences
goal of keeping every patient physically and psycho-
many aspects of unit life but was made especially evi-
logically safe (Alexander 2006).
dent by how the staff responded to patients behavior.
For example, a staff member who believed that a par-
INGRAINED ROLE BEHAVIORS OF STAFF ticular behavior was a function of the patients para-
Safety of the unit depends not only on how staff visu- noid thoughts would respond differently than a staff
ally monitor space and assess behaviors but also on member who believed that the same behavior was a
their ingrained role behaviorsactions that become sign of the patients manipulations. Staff members
second nature to inpatient staff. For instance, on any who believed that patients were in control of their be-
psychiatric unit a visitor may notice that when staff havior would respond differently than those who be-
hear a loud noise, they will immediately stop what lieved that patients, because of the nature of their psy-
they are doing and (depending on whether they can chiatric illness, were not in control of their behavior.
safely leave the area) move toward the disruption. The important point was not that one set of beliefs
This is a seemingly simple response but is one that was necessarily right or wrong but rather that the set
must occur almost automatically and with absolute of beliefs staff adopted about particular behaviors in-
consistency, given that it is key to reorganizing the fluenced how they responded to patients.
staff group in the face of a possible emergency. Likewise, the core values on the unit influenced
Staff members need to know each other s where- how the staff responded to patients. Throughout our
abouts at all times. Again, subtle role behaviors con- study, we were struck by how staff held respect as an
important value. On one of the units in particular, the a core group of individuals who had worked on each
importance of respect was overtly communicated to unit for 5 or more years. These staff members tended
patients. In community meetings and in day-to-day in- to be the leaders and the culture bearers for the unit.
teractions, patients were told to respect themselves, Because of their longevity on the unit, the staff also
respect the staff, and respect the property. Addition- knew patients who came into the hospital repeatedly.
ally, respect was communicated more subtly through Knowing each patient meant that staff understood the
staff actions toward patients. Although the patients of- patients typical patterns of behavior and knew which
ten exhibited strange behavior while in the acute phase strategies were effective with the patient. For example,
of their illness, staff members were careful not to com- during one of the investigator s observation periods, a
ment on this behavior in any way that could be inter- man well known to the staff began to slam his door re-
preted as demeaning or pejorative. Rather, when neces- peatedly in anger, yet the staff member in the hallway
sary, the staff set limits on bizarre and inappropriate did not move. When asked about this behavior, the
behavior using a kind and respectful tone of voice. staff member assured the researcher that this gentle-
People on the unitthe patients and staffare also man often acted in such a way the first few days of hos-
critical variables in the complete framework of keeping pitalization, and knowing the gentleman well, the
the unit safe (Johnson and Delaney 2006). On each of staff member was certain that the anger would dissi-
the units, there was a kind of patient that was typi- pate, which it did (Delaney and Johnson 2006).
cal. These patients might have seemed typical be- For patients, time was a factor in the pattern of
cause of repeated hospitalizations, or they might have their illness trajectories. The patients who were newly
been patients whose diagnosis or behavior was custom- admitted were more acutely symptomatic. If those pa-
ary for the unit. Staff knew how to respond to these patients were unfamiliar to the staff, it took the staff
tients because they had developed expertise working time to get a feel for the patient. However, getting to
with certain types of behavior. On one of the units, at know the patient helped the staff get a sense of how
any given time, several patients paced up and down a the patients trajectories of behavior might unfold. Ill-
long hallway. Usually, patients passed by each other ness trajectories were variable. Sometimes, patients
without incident. However, on some days, due to the who were anticipating discharge were also more symp-
particular composition of the patient group, these pass- tomatic, especially in the time between knowing they
by pacers would seem to be muttering to each other, or were leaving and actually leaving. Thus, we found
there seemed to be a certain strain in the air. Staff took that, for the staff, the most hectic days were those in
particular note of friction mounting between patients; which many patients were admitted and discharged.
often this behavior occurred between patients who Maintaining safety and stability in the milieu became
knew each other from the streets and brought outside more of a challenge on those days.
conflicts into the hospital (Delaney and Johnson
2006). By maintaining awareness of these individuals
SAFETY AND THE USE OF SECLUSION AND RESTRAINT
and their relationships, staff intervened quickly at the
first signs of mounting tension. In doing so, they main- Seclusion and physical restraint are emergency mea-
tained the safety of the unit. sures, only to be used when patients are exhibiting be-
Space is an extremely important factor in keeping a haviors deemed dangerous to themselves or others. In
unit safe; it has both objective and subjective proper- the past decade, inpatient staff members have been
ties. Objectively, the size of a space can be measured; engaged in scrutinizing practices that center on the
the space in the unit we studied was large enough to use of seclusion and restraint (Goren and Curtis 1996;
give patients room to move around. One salient con- Mohr et al. 1998; Muir-Cochrane 1996; Wynn 2003).
cept with relation to space was visibility. Larger units Tremendous effort is currently being expended in the
with more hallways or more bends and turns in the psychiatric community on strategies that could pro-
hallways were more difficult to keep safe than small duce restraint-free environments (Delaney 2006a;
units with only one hallway. Overall, the size and shape Huckshorn 2004; LeBel et al. 2004). Much of the fed-
influenced how the staff positioned themselves so that eral focus has been on staff training and culture
most parts of the open space were visible to someone change (Substance Abuse and Mental Health Services
on staff. The configuration of the unit also helped de- Administration 2005a). What has not received suffi-
termine how many staff members would be needed to cient study is how administration policies, such as
attend to the safety of patients and their needs. floating staff among varied units regardless of training,
The final factor in this scheme is time. There was mandatory overtime, and use of agency/part-time
nurses breed resentful, fatigued, or dissatisfied staff tients on the study unit said that they were seeking pro-
a factor associated with the proclivity to use restraint tection from vulnerability (created by the exacerbation
and seclusion (Morrison 1998). As nurses strive to of their illness) and needed help in empowering them-
keep units safe, they must also devise strategies to ad- selves to better cope with the outside world (Koivisto et
dress larger organizational policies that affect safety, al. 2004). These patients goals may or may not align
often policies in which they have little voice or control. with the material presented to them in groups. Thus, in
maintaining structure, employees must be mindful
Structure that the content of a group must match how individuals
define their use of the hospital for recovery. When pa-
Structure is a part of milieu operations that may at tients choose not to participate, as many do, compli-
first appear deceptively simple. At the most basic level, cated issues of power and coercion may arise.
it is about nurses and adjunct professionals work in On adult units, staff s work with regard to this is-
implementing a schedule that organizes a patients sue is complex and often involves how the personnel
day. The daily schedule usually includes a mix of ac- implement the units rules and expectations. Limit
tivities: group therapy, psychoeducation, recreational setting and enforcement of rules are sometimes viewed
activities, occupational therapy groups, and expressive by patients as nothing more than nurses exerting their
therapies such as art. Usually, the schedule of the day controlpractices that can leave patients feeling dehu-
includes a community meeting at which staff orient manized, powerless, humiliated, and isolated (Alex-
new patients and keep the patient group apprised of ander 2006; Duxbury and Whittington 2005). In such
the day s events. It is a meeting that demands little instances, there is no collaboration on the patients
participation; thus, even very ill patients can attend goals, and they become passive recipients of care (Latv-
and feel part of the process but not invaded or pres- ala et al. 2000). This is when nurses must work within
sured to communicate (Klein and Brown 1987). the interdependence of structure and self-manage-
The rationale for imposing a structure of activities ment, which demands that staff members consider
has traditionally been to provide a clear, unambiguous structure within the context of what the patients goals
scaffold to the day to control stimulation and to help are and how patients believe hospital resources, in-
patients reexperience competency (Alexander and cluding various groups, contribute to their recovery.
Bowers 2004; Schulman and Irwin 1982). This is par- On child and adolescent units, implementing ward
ticularly important for patients who may be working rules without coercion demands that youth under-
on difficulties with concentration, information pro- stand the purpose of unit expectations. Novice staff
cessing, or response flexibility (McClure et al. 2005; members may hold the belief that they need to shape
Seidman et al. 1995). In these instances, it is assumed up a childs behavior by imposing stringent expecta-
that an environment that is predictable and controls tions. Actually, the reverse is true. Although there
stimulation would enhance organization (Sederer must be some guidelines for behavior to nourish cop-
1991). ing abilities, nurses must support childrens auton-
The difficulty in imposing structure centers on omy by providing choices and rationales for ward rules
when to encourage participation and when expecta- (Skinner and Wellborn 1994). In the unit where one of
tions infringe on patients autonomy. Patients may not the authors (K.D.) practices, an effort is made to con-
want to be involved in the groups offered on the unit sciously structure the environment to reduce stress.
or, when they attend, may choose not to participate. Thus, children are afforded choices; staff aim at set-
Not all persons admitted to the unit believe they need ting coping demands that are within the childrens
such groups to regain control of their illness or move reach and providing sensible interventions that elicit
toward recovery. In a qualitative study conducted on a cooperation.
short-term unit, only a small percentage of patients On the Child Assessment Unit of the Cambridge
saw themselves getting better through development of Hospital (Cambridge, Massachusetts), nurses employ
coping skills or self-understanding. Indeed, patients a child- and family-centered care model. Here, a
saw themselves using the hospital for a variety of rea- childs refusal to attend group is met with a sincere
sons, including as a sanctuary from stress and a place staff effort to understand the reasons for refusal
to recover while the medications took effect (Delaney (Regan et al. 2006). Children are not given conse-
1984). quences for refusal. Instead, such interactions are
The results of a more recent study of patients with viewed as opportunities for problem solving and for
schizophrenic disorders confirmed this finding. The pa- helping children adopt more flexibility to events per-
ceived as frustrating (Regan et al. 2006). This model a broad concept that has been framed in psychiatry in
has met with excellent outcomes, and it challenges the the context of crisis and stress (Hoff 1995), in the so-
traditional view that the unit structure would unravel cial support literature in the context of its moderating
if child/adolescent staff took a flexible approach to effects on illness (Mittelmark 1999), and in the treat-
group attendance. ment literature in the area of supportive psychother-
Although respect for freedom and autonomy is apy (Winston et al. 2004).
critical, a balance must be struck to ensure the psycho- Psychiatric nurses view support as occurring
logical safety of all patients and personnel. Frueh et within the interpersonal aspects of care, especially in
al.s (2005) study documents the experiences of 142 the context of the nursepatient relationship. In the
patients who had been hospitalized on inpatient units. United States, this platform was established by the
Many patients reported incidents they perceived to be theories of Peplau (1952), and now, 50 years later, the
traumatic: physical assault (31%), sexual assault (8%), relationship continues as the critical vehicle for nurses
and witnessing of traumatic events (63%). In addition, to join with persons with mental illness and support
54% reported experiences of being around frightening their movement toward health (Raingruber 2003). In
or violent patients, which is a situation that erodes the Peplau framework, it is within this relationship
psychological safety. To maintain structure, staff are that persons come to master barriers to mental health
put to the task of balancing tolerance for behaviors arising from biological processes, development, or per-
not overcontrolling the environment yet not allowing sonal events (Beeber 2000). Researchers in Great Brit-
the structure to relax to the point that patients are ain and Canada have examined the nursepatient re-
frightened. lationship during hospitalization (Cameron et al.
The way in which staff members approach deci- 2005; Forchuk et al. 1998, 2000; Welch 2005). Their
sions regarding participation, rules, and behaviors de- research confirms that much of the work of nursing is
termines the unit culture; these norms then become bound within the relationship; within that context
commonly held assumptions about how persons hos- nurses help patients move toward greater well-being
pitalized on the unit should be treated. The culture of (Barker 2001; Graham 2000).
the unit can be dictated by rules and efforts to enforce The nursepatient relationship is built on nurses
them, or it can be permeated by a flexible interpreta- understanding of the patients experience. To develop
tion of what is needed to keep order on the unit. It is such an understanding requires staff s concerted and
played out every day in moment-to-moment decisions focused efforts to apprehend the patients intents, at-
and responses to patients behaviors. Currently, there tributions, and perceptions of incidents that have oc-
are inpatient ideologies whose guiding principles are curred in the past or are occurring now on the unit
healing and creating a healthy social structure in (Lewis 1978). Staff come to know the patient by ob-
which this can be accomplished (Bloom et al. 2003; serving the patients nonverbal behaviors, patterning
Regan et al. 2006). As these newer models proliferate, this presentation with what they know about the per-
so will the need to differentiate how they fit in a vari- son, and sometimes interpreting those cues and feed-
ety of populations; it will become increasingly impor- ing their interpretation back to the patient (Graham
tant to be more precise about how to change cultures 2000; Raingruber 1999). Via this understanding, the
effectively and to be mindful of how to use these flex- nurse moves into the persons meaning system and, in
ible structures while keeping the unit safe. doing so, begins to explore the significance of the ill-
ness experience for the persons life and with attention
Support to what the patient currently needs to feel safe or to be-
gin to rebuild her or his life (Barker 2001; Czuchta and
Support is an essential milieu quality that must be Johnson 1998; Koivisto et al. 2004). This field of un-
available to persons hospitalized on a psychiatric unit. derstanding is built by using empathy (Reynolds and
In their narratives of the hospitalization experience, Scott 1999), listening carefully to the patients experi-
patients have recognized the need for supportfor be- ences, being present for the patient (accessibility), col-
coming active participants in care (Latvala et al. 2000) laborating with the patient on problems, advocating
so that they might be empowered to restructure their for the patient, sharing power, and manifesting au-
lives (Koivisto et al. 2004). Most importantly, patients thenticity (Berg and Hallberg 2000; Forchuk and Rey-
need the support from a human connection that nolds 2001; Forchuk et al. 2000; Welch 2005).
makes them feel they are responded to and understood Caring and support are neither the same for all per-
(Carlsson et al. 2006; Thomas et al. 2002). Support is sons nor the same for one person at different stages of
his or her illness experience (Barker 2001). Patients A final barrier that nursing staff must overcome in
living through psychosis and its attendant experience establishing a relationship is the divide between what
of vulnerability have reported needing support in deal- nurses expect a relationship to be versus what patients
ing with the distress from a loss of self (Koivisto et al. state they need. Nursing staff may approach patients
2003). They also report the need to feel safe, to sense with the expectation that they will talk out problems
they are in a reliable environment with nurses who are and use self-observing functions to review events of
aware of and monitoring their situation (Koivisto et al. the past and their behavior (Forchuk et al. 2000). If
2004). Patients who were depressed said they valued they use the quality and quantity of one-to-one inter-
interventions that helped them regain a sense of con- action as their way of evaluating the relationship,
trol over their lives or a sense of control over their ill- nurses may not believe they are developing meaning-
nesses (Delaney 1984). Persons with a history of abuse ful relationships. However, the nursepatient relation-
particularly require that staff understand their need ship is perceived to be quite satisfying if it is judged, on
for personal boundary protection and provide explana- a practical level, by instances of nurses assisting pa-
tion for instances when unit events pose a violation tients with problem solving or helping them address
(Geanellos 2003). In all cases, the basic idea remains the everyday dilemmas of unit life (McElroy 1996;
consistent: staff need to know patients by attending to Warelow and Edward 2007). Thus, to ensure that re-
their experiences of illness and how they define their lationship-building proceeds in line with patients
needs, symptoms, and events (Cameron et al. 2005). needs, staff expectations and role definitions should
Establishing a base of support through the relation- become another important topic for supervision.
ship is not always straightforward. Several factors in-
herent in the structure of inpatient care and in the na- CARING, CONCERN, AND COERCION
ture of nurses work may impede development of a
Within this supportive stance, nursing staff maintain
supportive relationship. First, the pace of a brief hos-
responsibilities around unit structure and safety. This
pitalization unit can take up much staff time. Brief
means that the same person who is forming a relation-
lengths of stay produce high acuity, and as a result,
ship based on caring may be the one who sets limits
nurses are apt to direct their attention not to relation-
during an escalating situation. At times, one aspect of
ship building but to the most acute patient or situa-
this role may become dominant. Indeed, the nursing
tion (Cleary and Edwards 1999). Clinical tasks such as
profession has an image of toughness, promulgated in
tending to admissions, discharges, medications, and
part by the media but also by nurses themselves (Mor-
medical issues can also interfere with relationship
rison 1990). Of course, coercion should be eliminated,
building (Cameron et al. 2005; Hummelvoll and Sev-
but the reality of inpatient nursing is that, owing to a
erinsson 2001; Whittington and McLaughlin 2000).
units acuity or staff s expertise level, aggression can
Although such aspects of the role are important,
occur, and, we might add, patients and nurses might
nurses must learn to become balancing artists for
be injured in these incidents (Flannery and Walker
competing demands.
2003; Nijman et al. 2005; Ryan et al. 2004). Patients
Another barrier to the nursepatient relationship
who are involved in control situations and/or those
is shaped by interpersonal distance, sometimes mutu-
who experience being restrained during emergency cir-
ally created by patients and staff and sometimes cre-
cumstances describe feeling demoralized (Bonner et
ated when nursing staff members withdraw from pa-
al. 2002; Duxbury 2002; Johnson 1998; Olofsson and
tients (Forchuk et al. 1998). In an ethnographic study
Norberg 2001). Times of strain therefore require
of three inpatient units, Bray (1999) found that staff
skilled staff who respect the freedom of the individual;
members distanced themselves from patients who
draw on a nonauthoritarian attitude; deal with situa-
were harsh and insulting to them, those who did not
tions in a straightforward, authentic manner; and of-
take any accountability for behavior, and patients
fer the patient a way to save face (Carlsson et al. 2006;
whose stories of abuse had the potential to lead to a
Johnson and Hauser 2001; Lowe 1992).
vicarious traumatization. At times, nurses distanced
themselves from patients because they were unsure of
Self-Management
what they should to do, lacking confidence in their
ability to address a situation. Obviously, relationship The term self-management is used to reflect a pa-
building is hampered when nurses distance them- tients active participation in his or her own disease
selves from patients; therefore, such behaviors should care and generally refers to the day-to-day activities a
be examined in staff supervision. person undertakes to maintain health. Although self-
management is most often applied in interaction with the framework for how to engage patients in the en-
health care providers, the optimal situation occurs actment of and persistence in their specific desired be-
when patients are active, identifying wellness-ori- haviors. On inpatient units, this becomes a plan in
ented tasks and seeking to learn and practice wellness- progress, with staff assessing patients confidence in
promoting skills (Lorig and Holman 2003). Self-man- engaging in the specified behaviors, thus gauging the
agement in the context of disease management is not probability of success of the plan under development
new to psychiatry. But despite the rapid development (Lorig 2006). If confidence is low, then the plan is ad-
of illness management programs, the integration of justed. For instance, staff may teach patients about the
self-management into our existing mental health sys- relationship between staying active and reducing de-
tem has been slow. Recently, in its transformation pression. If patients are interested in receiving support
plan for the mental health system, the Substance for staying active, then an action plan is developed
Abuse and Mental Health Services Administration that begins with involvement in activities on the unit.
(2003, 2005b) endorsed the idea of self-management Confidence for participating in the plan (attending
as the cornerstone of a patients recovery plan. Cou- specific groups) is measured. If confidence is low, then
pled with the expectations of the Joint Commission obstacles to being active are discussed and the plan is
on Accreditation of Healthcare Organizations (2006) adjusted until the patient becomes confident in his or
regarding recovery-based inpatient care, one expects her ability to follow through. Successful enactment of
that this ideology will quickly become a component of the plan should motivate the patient; adjustment is
psychiatric hospital policy. then made to take activity to the next level. As dis-
For many inpatient nurses, recovery and self-man- charge nears, plans are developed that the patient can
agement involve increasing patient involvement in follow after discharge, using assessment of confidence
their own care, teaching self-care skills, and providing as a guide (Perraud 2000; Perraud et al. 2006).
opportunities to practice newfound skills (Forchuk et Inpatient treatment is uniquely suited to the devel-
al. 2003; Repper 2000). Providing self-management opment of self-efficacy because inpatient environ-
support on inpatient psychiatric units means that staff ments are rich in potential sources of self-efficacy. Ac-
go beyond patient teaching to activities that help pa- cording to Bandura (1997), there are four sources of
tients build confidence in their own abilities to man- self-efficacy (in descending order of influence): mas-
age their health. An inpatient self-management pro- tery performance, vicarious experience, social persua-
gram might include generic lifestyle issues such as sion, and management of physiological and affective
nutrition, exercise, and coping skills; role manage- states. The most effective way of enhancing confi-
ment; or programs that help individuals manage de- dence in ones ability to do something is to do it suc-
pression and stress (Robert Wood Johnson Foundation cessfully. Because of their sustained contact with pa-
and Center for the Advancement of Health 2001). De- tients, inpatient nurses are in an excellent position to
sired program activities should include providing self- help patients identify a desired outcome, teach the
management education and engaging in goal setting skills to reach that outcome, and routinely encourage
with patients to control symptoms and thus avoid re- practice of targeted and taught skills. The boost in
hospitalization (Bachman et al. 2006; Rogers et al. confidence provided by successful enactment of skills
1999). Much of this inpatient work will be focused on provides some assurance that, when coupled with rea-
with the notion of self-efficacy. sonable and collaborative action plans, the patient is
Self-efficacy is a framework used by some of the likely to continue the behaviors at home.
most successful self-management support programs. Self-efficacy is also boosted through vicarious expe-
It refers to the confidence that one has in his or her rience of the successful behavior performed by a role
ability to do what is necessary to achieve positive out- model. This happens on inpatient units in groups and
comes, in this case, to manage ones mental illness other milieu activities as patients actively observe and
(Perraud 2000; Perraud et al. 2006). Improving self- interact with each other. Inpatient staff can help by
efficacy for therapeutic activities will promote per- seeking and pointing out successful models for desired
severance in the performance of targeted behaviors behaviors. Social persuasion, the third source of self-
(Bandura 1997) and, based on the outcomes of other efficacy enhancement, is ubiquitous in inpatient set-
self-efficacy-based programs, will provide the re- tings. On inpatient units, nurses, physicians, and ad-
sources needed to improve outcomes (Farrell et al. junct staff exhort patients to action by convincing
2004; Lorig et al. 2001a, 2001b; Ludman et al. 2003). them that they have the capability to succeed. Per-
Self-efficacy theory supplies inpatient staff with suading patients to try, or to persist when they believe
that they cannot succeed, and pointing out successes (Forchuk et al. 2003). The team will more than likely
are critical to helping patients develop confidence in focus on helping patients through the crises of illness
their ability to function independently. Finally, as ac- and assist with symptom management. When these
tion plans are developed, managing anxiety and stress same persons reach a point where they sense their ill-
related to performance and helping patients realisti- ness has stabilized, they may then turn their attention
cally assess their performance in relation to their emo- to how they can return to a meaningful life in the com-
tions should be routinely addressed. munity (Barker 2001). Staff must move fluidly in both
In the course of action planning, staff should also areas of care. For patients to shift successfully to the
point out or provide resources to patients that can be next level of care, both processes (recovery and self-
used at home. A plethora of tools are available to help management) must be supported by the work of the
people manage their health. Electronic reminders can inpatient staff.
be programmed into pillboxes or personal digital assis-
tants to structure self-management activities through-
out the day. Self-help materials such as relaxation
Conclusion
tapes, pamphlets, and other written material can be
provided to assist patients both in the hospital and at For the multidisciplinary team to accomplish rapid
home. As patients seek such information on their stabilization of symptoms and initiation of an aggres-
own, they will undoubtedly browse the Internet. The sive treatment plan, seriously ill patients must be
Internet is an important self-management support; it cared for in a consciously structured environment.
extends access to expertise and may result in the de- Owing to their 24-hour contact with patients, nursing
velopment of active patient self-management skills staff are at the center of the effort to create a safe mi-
(Zuckerman 2003). Finally, referrals to self-help and lieu, with a structure that facilitates healing and recov-
information and support groups in the community ery and an interpersonal context that encourages au-
can be made so that patients have a place to learn and thentic interaction. It is terribly important that the
practice new self-management behaviors. work of nursing be recognized and understood. As de-
Inpatient nurses are central to the provision of self- scribed in this chapter, the skill set for maintaining
management support for chronically ill patients (Rep- psychiatric milieus is largely unarticulated outside the
per 2000), and inpatient treatment provides continu- nursing community. When the skills required to keep
ous opportunities for the process. Ultimately, the re- the milieu safe are not understood by managers and
sponsibility to manage ones health, well or poorly, hospital administration, they may fail to staff units
belongs to each individual. Nurses and the interdisci- with a nursing skill level that matches patient acuity, a
plinary team can help by collaborating with patients to situation that breaches basic principles of patient
remove barriers to optimum choices and by providing safety.
them with the information, skill, and confidence they Inpatient clinicians must find ways to collect data
need to make those choices. Seriously mentally ill pa- that make obvious when staffing patterns are no
tients with impairments in self-care ability are at longer supporting the basic functions of the unit and
higher risk for rehospitalization (Lyons et al. 1997). the staff expertise is no longer matching the intensity
There is evidence to suggest that active self-managers of the patient groups needs (Ellila et al. 2005; Furlong
of psychiatric disorders have fewer hospitalizations and Ward 1997). In other nursing specialties, the
(George et al. 2002; Pollack 1996a, 1996b, 1996c). It number and quality of staff are clearly related to pa-
is therefore imperative that staff attend to the infor- tient safety and prevention of complications (Aiken et
mation needs of patients and families as they manage al. 2002, 2003). Selected hospitals are currently in-
their day-to-day health so that they have the confi- volved in pilot-testing core measuresindicators that
dence and the ability to become active self-managers have been found to correlate with the overall quality of
(Cleary et al. 2006; Lorig and Holman 2003). care in a hospital (Joint Commission 2008; Table 29
Self-management programs are fairly robust. Pa- 1). These measures will yield important data that can
tients tell us coping with acute psychosis is exhausting be useful in correlating staffing patterns and organiza-
(Koivisto et al. 2004). The multidisciplinary team will tional characteristics with restraint use and safety.
need to partner with patients as they reach the point These correlations can ultimately demonstrate the
where they have the psychic energy to focus outward value of experienced and educated staff in preventing
and engage in specific self-management strategies errors and preserving safety.
TABLE 291. Hospital-based inpatient psychiatric services (HBIPS) candidate core measure set
The core measures for inpatient psychiatric treatment are currently in pilot testing. Measures being tested
include the following:
Assessment of violence risk, substance use disorder, trauma, and patient strengths completed
Hours of restraint use
Hours of seclusion use
Patients discharged on multiple antipsychotic medications
Discharge assessment and aftercare recommendations are sent to next level of care providers upon discharge
Source. Joint Commission 2008.
Cameron D, Kapur R, Campbell P: Releasing the therapeutic

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CHAPTER 30
FINANCING OF CARE
Paul Summergrad, M.D.
The mechanisms used to finance inpatient psychiat- tion toward the mentally ill was uncharitable and pu-
ric services have a major impact on the quantity, qual- nitive. In contrast, the Quakers in Philadelphia had a
ity, and organization of care. The focus of this chapter more humanitarian approach to the mentally ill. The
is hospital psychiatry as it is practiced in the United provincial Assembly of Pennsylvania established the
States; therefore, financing mechanisms used in the first general hospital in America in 1751 to be a Hos-
United States will be emphasized. However, it is recog- pital for the Relief of the Sick Poor of this Province and
nized that other countries may have very different ways for the Reception and Cure of Lunaticks (Mora 1975).
to finance care, and much can be learned from the dif- When the Pennsylvania Hospital opened in 1756,
ferences among systems of care in other countries. mentally ill patients were admitted to the cellar. In
1796, a new wing was built just for the mental pa-
tients. The hospital was supported by public and pri-
History vate funds. In 1770, the colonial legislature of Virginia
felt that poorhouses and jails were inadequate for the
In the eighteenth century, people with mental illness care of mentally ill persons and that it would be more
were labeled insane or lunatics and were generally equitable for the state, rather than local communities,
cared for by their families or social groups. Those per- to pay for their care. They established the first Ameri-
sons who could not be cared for by family were con- can asylum exclusively for the mentally ill, called The
fined to jails if they were deemed to be dangerous or to Public Hospital for Persons of Insane and Disordered
poorhouses if they were unable to care for themselves. Minds, in Williamsburg. The facility, which opened
These institutions were funded by local governments, in 1773, was designed to provide treatment for persons
which encouraged communities to fund as little as who had curable mental illnesses and who could ul-
possible so that poor persons would move from one timately be discharged to the community. Persons who
community to another seeking shelter. According to were a threat to themselves or others as a result of their
Mora (1975), the basic attitude of the general popula- mental illness were also eligible for confinement.
403
Chronically mentally ill but harmless individuals were grants from the Rockefeller Foundation (Summergrad
not thought to be appropriate for admission. The hos- and Hackett 1987). That development also recognized
pital had a physician on staff who was salaried, al- that some mentally ill patients had comorbid medical
though the treatment mostly consisted of restraint use conditions that might require treatment and that med-
and unpleasant treatments designed to convince per- ical or surgical patients treated at these institutions
sons to change their behavior (William & Mary Cross- might require psychiatric inpatient care. At the time,
roads Research Project 2001). Treatments included there was no reliable source of funding for these units.
restraints, harsh drugs, cold plunge baths (via the When private health insurance was initiated in the
ducking chair), bleeding, intimidation, cupping mid-1930s, coverage for mental illness was generally
glasses, and blistering salves. excluded in the belief that these services were already
Early in the nineteenth century, a number of private provided by state mental institutions, which were
institutions were established based on the experience funded by state tax dollars. The financing of psychiat-
of the York Retreat in England. Under the leadership of ric units in general hospitals changed dramatically
Samuel Tuke, the Quaker institution had an optimistic with the enactment of Medicare and Medicaid in the
view of mental illness and provided a general atmo- 1960s. Medicare was developed as a federal program to
sphere of kindness and sympathy that was referred to provide universal health insurance coverage for per-
as moral treatment. The Friends Asylum opened sons older than 65 years but was later expanded to in-
near Philadelphia in 1817. The McLean Asylum then clude younger persons who were disabled. Medicare
opened in Charlestown, Massachusetts, in 1818 as paid for care in psychiatric units in general hospitals
part of the Massachusetts General Hospital. Like the using the same cost-based reimbursement method
Pennsylvania Hospital, the McLean Asylum saw the used for other general hospital services. Medicaid was
care of the sick and the insane as part of its charter. The something of an afterthought, but it provided grants to
Bloomingdale Asylum opened in New York under the states as a way of sharing in the cost of health care for
auspices of the New York Hospital. The Hartford Re- poor people.
treat opened in 1824, the Brattleboro Retreat in 1836, At the time Medicare and Medicaid were enacted,
and Butler Hospital in Providence opened in 1847. the inclusion of mental health coverage was consid-
From 1825 to 1865, other states built public mental ered progressive, given that many private health insur-
hospitals, including Georgia, Kentucky, New York, and ance plans continued to exclude such coverage. How-
South Carolina. For the next 100 years, patients with ever, because of concerns that utilization would be
mental illness were treated in geographically separate difficult to control, both programs instituted special
institutions under the belief that asylum or refuge limitations on psychiatric coverage. Medicare limited
from the world would help heal their afflictions. Pa- care to 190 lifetime days in mental hospitals, which
tients were cared for either in institutions funded by included both state and private institutions but not
the state or in private institutions funded by their fam- general hospitals. Outpatient coverage for nervous
ilies or the generous contributions of philanthropic in- and mental conditions was limited to $250 per year
dividuals. In the second half of the nineteenth century, and was subject to a 50% copayment instead of the
state institutions admitted large numbers of immi- 20% copayment used for other medical conditions.
grants judged to be mentally ill and in need of confine- Medicaid coverage to institutions for mental disease
ment. Given the pressures on state budgets, these in- (IMD; i.e., hospitals in which more than 50% of dis-
stitutions became overcrowded and were unable to charges were psychiatric patients) was limited to per-
deliver much in the way of treatment. Regardless of the sons younger than 22 and older than 64 years of age.
exact form of financing, psychiatric hospital care be- Medicaid did not cover care for patients of all ages in
came uniquely a state rather than a municipal or fed- general hospital psychiatric units.
eral responsibility, a circumstance that has had impor- Despite the fundings limitations, its availability
tant implications for the current organization of care. led to a dramatic increase in the number of inpatient
psychiatric beds in general hospitals. In 1970 there
were 22,394 psychiatric beds in general hospitals with
Psychiatric Units in
separate psychiatric services; by 1990 there were
General Hospitals 53,479 (Center for Mental Health Services 2006). An-
nual admissions to these units increased as well, from
In the 1930s, a few academic medical centers devel- 478,000 in 1969 to 959,893 in 1990. However, by
oped inpatient psychiatric services funded in part by 2002, the number of inpatient psychiatric beds in gen-
Financing of Care 405
eral hospitals had decreased to 40,202. The number of some of those beds. Conversion to a psychiatric unit
general hospitals providing psychiatric services also required little capital investment; given the increase in
declined during this period, from 1,707 in 1998 to demand for those services, it made business sense for
1,285 in 2002 (Foley et al. 2006). Despite the recent hospitals to do that. In addition, the expansion of
reductions in psychiatric beds, the annual number of insurance to the private sector and government pro-
discharges with primary psychiatric diagnoses from grams brought increased numbers of patients into psy-
general hospitals increased by approximately 35% be- chiatric care. Patients with mood disorders, comorbid
tween 1988 and 1994, from 1.4 to 1.9 million annual medical and substance abuse illnesses, or dementing
discharges. General hospitals increasingly replaced illnesses who might have never been cared for in the
public mental hospitals as the primary institutions traditional state hospital system expanded the clinical
caring for publicly funded patients (Mechanic et al. range of patients treated in psychiatric units in general
1998). This discharge trend continued between 1995 hospitals.
and 2002, especially in patients with serious mental
illness, whose discharge rates from general hospitals
increased by 34.7% during this time (Watanabe-Gallo-
Private Psychiatric Hospitals
way and Zhang 2007). The number of beds in state
and county mental hospitals declined dramatically The increasing availability of coverage under public
over this 20-year period, from 413,066 in 1970 to and private health insurance also led to increases in
98,789 in 1990. The number of admissions declined the number of beds and annual admissions to private
as well, from 486,661 in 1969 to 276,231 in 1990. psychiatric hospitals. In 1970 there were 14,295 beds;
These trends toward deinstitutionalization had begun by 1990 this number had increased to 44,871. In 1969
in the 1950s, as advocates criticized institutions for there were 92,056 admissions to private psychiatric
warehousing patients without providing treatment hospitals; in 1990 there were 406,522 such admis-
and state legislators saw an opportunity to reduce sions (Center for Mental Health Services 2006). The
expenditures by discharging patients who no longer enhanced availability of payment for these services
needed inpatient care. The development of psychotro- encouraged the development of investor-owned psy-
pic drugs to control or treat the symptoms of mental chiatric hospitals in addition to the small number of
illness also facilitated the transfer of patients out of private nonprofit charitable institutions that had de-
large state mental hospitals. Many of these patients veloped by the mid-nineteenth century.
showed up in the emergency rooms of their local com-
munity hospitals and were admitted there, either be-
cause they preferred those facilities or because they
Cost-Containment Pressures
were unable to be readmitted to the state hospital that
had discharged them. Throughout the 1970s, overall expenditures under
Another trend that supported the development of Medicare rose rapidlyfaster than the original projec-
units in general hospitals was the inclusion of psychi- tions had predicted when the program was first en-
atric benefits in private health insurance coverage. By acted. As a result, Congress looked for ways to control
1974, 95% of health insurance plans surveyed pro- the rise in expenditures. Public Law 98-21 mandated a
vided some coverage for hospital care of mental condi- new approach to hospital reimbursement using a pric-
tions (Reed 1975). This trend of increasing coverage ing system linked to diagnosis at discharge (Iglehart
under private health insurance led advocates in many 1982). On October 1, 1983, reimbursement was deter-
states to successfully argue for mandated coverage of mined using a classification system that categorized
psychiatric care in all insurance plans regulated by the diagnoses into 468 diagnosis-related groups. There
state. was little or no previous experience using this ap-
Finally, general hospitals saw a marked reduction proach for psychiatric care; therefore, Congress
in the length of stay and, consequently, a decrease in granted an exemption from this Prospective Payment
bed utilization for medical and surgical patients as a System (PPS) for psychiatric hospitals and permitted
result of the diagnosis-related group (DRG) payment psychiatric units in general hospitals to apply for an
system for Medicare and the use of a case rate by many exemption. Congress asked the U.S. Department of
private insurers for medical-surgical admissions. As a Health and Human Services to report by the end of
consequence, many community hospitals had empty 1985 on the feasibility of including these facilities and
beds, and opening a psychiatric unit was a way to fill specialty units in the Medicare PPS. Numerous stud-
ies were done, which concluded that available classifi- to manage their psychiatric benefits. These companies
cation systems were poor predictors of resource use are often referred to as carve-outs. The growth of these
(Mitchell et al. 1987). Instead of including psychiatric companies occurred in response to rising expenditures
patients in the DRG system, Medicare continued to as psychiatric care became less stigmatized and psy-
reimburse psychiatric hospitals and exempt units in chiatric benefits were included or improved in private
general hospitals under a system enacted by the Tax health insurance as a result of consumer demand or
Equity and Fiscal Responsibility Act of 1982, which state mandates. In addition, many primary private in-
used complicated formulae and retrospective calcula- surers did not have expertise in the management of
tions to determine allowable costs and to set a target psychiatric care. The carve-out companies responded
reimbursement rate per discharge irrespective of psy- to the complaints of insurance companies that reim-
chiatric diagnosis. This was in contradistinction to bursed providers or the employers who purchased the
the DRG-based system for medical-surgical care, insurance for their employees that psychiatric care
which, mirrored by the private insurance system, re- was unstandardized and costs were growing rapidly.
duced payments for medical-surgical care, making Just as experience with Medicare had taught people
psychiatric units and hospitals relatively more profit- that psychiatric diagnosis did not predict resource use,
able and less competitive. The psychiatric cost-based purchasers were concerned that patients with similar
reimbursement system remained in effect until the diagnoses could remain in a hospital for stays that var-
development of a PPS for psychiatric hospitals and ied widely or could avoid hospitalization altogether.
exempt units mandated by the Balanced Budget Re- The carve-out companies developed programs of
finement Act of 1999, with phase-in of the new reim- preadmission review and continued-care certification
bursement rules starting January 1, 2005. The new to control the utilization of psychiatric services, par-
PPS system has a base payment rate with adjusters for ticularly on inpatient units. They developed review
patient characteristics (e.g., age, psychiatric diagnosis, criteria (generally proprietary criteria that were kept
medical comorbidities) and facility characteristics secret from providers) and hired nonphysician review-
(e.g., teaching status, presence of an emergency room, ers to apply these criteria to approve or disallow inpa-
rural versus urban location). Despite Medicare data tient admissions. Disallowals were supposed to in-
showing higher costs per case, often due to greater acu- volve a psychiatrist reviewer, and the provider was
ity and medical comorbidity in general hospital pa- permitted to appeal an adverse determination. These
tients, the Medicare PPS for inpatient psychiatry is review organizations avoided legal liability for any ad-
generally more favorable to freestanding hospitals verse outcomes that resulted from denied admissions
(Centers for Medicare and Medicaid Services 2004). or premature discharges by arguing that the clinician
However, the new PPS does not fully account for costs had the legal responsibility for admitting or discharg-
of those patients cared for in general hospitals who ing the patient, unlike the review organization, which
have significant medical comorbidities or problems was simply authorizing or denying payment. In ad-
with activities of daily living (Drozd et al. 2006). dition to reviewing admissions and continued care,
While the initial version of the PPS system for psychi- these carve-out companies negotiated rates with indi-
atry must, by statute, be budget-neutral overall, cost vidual hospitals. Unlike Medicare, which had con-
containment will depend on annual adjustments to tracts with every hospital, often standardized by re-
the base rate and the behavior of providers. A rate gion, prevailing wage, and employment costs, these
adjustment below the increase in costs may save private for-profit companies could pick and choose
Medicare money but will disadvantage hospitals, what hospitals could have their contracts. As small
whose operating margins will shrink as costs rise carve-outs consolidated or were bought up by larger
faster than reimbursement. ones, these companies developed significant purchas-
ing power. In many markets, their monopsony allowed
them to dictate rates to hospitals. Hospitals frequently
The Rise of Managed accepted rates below their costs, because not getting a
Behavioral Health Care contract would mean a loss of so much volume that
the unit would have to be downsized or closed.
In contrast to Medicares approach to cost contain- The effects of these carve-out companies on qual-
ment, beginning in the 1980s private health insurance ity of care and patient outcomes has been difficult to
turned to specialized managed behavioral health com- measure. However, patient and provider dissatisfac-
panies subcontracted as so-called fourth-party payers tion with these programs generated more complaints
to state insurance regulators than any other area of are unique components of hospital psychiatry. Prior to
health insurance. In part as a result of those com- the 1930s, 96% of all psychiatric hospitalizations oc-
plaints and because of uncertainty over the costs and curred in state or veterans hospitals. Large psychiatric
benefits of these programs, many insurers began to hospitals, often set at some remove from major popu-
bring the review of psychiatric care back into their core lation centers, accounted for 25% of all hospital beds
review activities rather than carving them out. Other in the United States. Even as late as 1970, there were
considerations in this latter trend include the recogni- 413,066 psychiatric beds in state hospitals in the
tion of the high rates of medical and psychiatric co- United States and 486,661 annual admissions (in
morbidity among patients with psychiatric illness. Pa- 1969). By 2002, these figures had declined to 57,263
tients with psychiatric illness often have undiagnosed beds and 238,546 annual admissions.
or untreated medical illness and in severely ill popula- State hospital systems vary greatly from state to
tions die at higher rates from cardiovascular, pulmo- state. In some states, state hospitals care only for
nary, and metabolic disorders than do age-matched those patients who require long-term care on transfer
controls (National Association of State Mental Health from general or private hospitals, in others, a county-
Program Directors 2006). In addition, substantial ex- based system provides acute psychiatric care in public
penditures for psychopharmacological agents, often hospitals. Some states run psychiatric emergency ser-
borne by the primary insurer rather than the carve-out vices in state facilities; other states have created mo-
payer, have led insurers to reclaim internal manage- bile non-hospital-based emergency services. States
ment of psychiatric services. have often modified their state-run systems in coordi-
nation with Medicaid waivers and have used state and
federal funding streams from both Medicare and Med-
Medicaid icaid programs to create more comprehensive systems
of care.
In the 1990s, state Medicaid programs also began to
contract with these carve-out companies to manage Financial Effects of Changing
their psychiatric benefits under special waivers from
the U.S. Department of Health and Human Services. Reimbursement
Medicaid rules define which services and hospitals are
reimbursable (e.g., by nonallowance of payment in Partly as a result of the changes in reimbursement, the
IMDs for patients ages 2264 years). States can re- number of inpatient psychiatric beds has steadily de-
quest modifications in traditional Medicaid payments clined since 1990. The number of beds in private psy-
(e.g., ability to admit patients of all ages to IMDs in- chiatric hospitals declined from 44,871 in 1990 to
cluding private psychiatric hospitals, payments for 25,095 in 2002. Beds on inpatient units in general
residential or nonhospital emergency or community- hospitals were reduced from 53,479 in 1990 to 40,202
based care). Waivers are quite variable among state in 2002 (Center for Mental Health Services 2006).
programs, depending on the organization of the state During the same time period, the number of available
mental health systems, and can be based on regional, beds in state and county mental hospitals dwindled
county, or statewide programs. Because utilization of from 98,789 in 1990 to 57,263 in 2002. These
psychiatric services is generally significantly higher in changes may also reflect evolving approaches to treat-
the Medicaid population (especially in those consid- ment, as reliance has increased on outpatient, residen-
ered disabled by their psychiatric illness) than in com- tial, or partial hospital services rather than inpatient
mercial populations, the organization of the Medicaid programs and shorter lengths of stay for admitted pa-
system has important implications for the overall sys- tients. The shorter lengths of stay may have also led to
tem of care. more readmissions, because the total number of ad-
missions increased in private psychiatric hospitals
from 406,522 in 1990 to 477,395 in 2002, and in gen-
State Mental Health Systems eral hospital units from 959,893 in 1990 to 1,094,715
in 2002 (Center for Mental Health Services 2006).
Because of the unique responsibilities that states bear As a result of the changes in reimbursement, oper-
for the direct provision of psychiatric services, the or- ating margins for psychiatric hospitals and psychiatric
ganization, budgeting, and interrelationship of state units in general hospitals have been squeezed. Inves-
mental health systems with Medicaid and Medicare tor-owned psychiatric hospitals are no longer such at-
tractive investments. Nonprofit psychiatric hospitals once again rise to encourage an expansion in the num-
have struggled to stay in the black. As an example, ber of beds. Psychiatric units in general hospitals can
McLean Hospital in Belmont, Massachusetts, has be cross-subsidized by more profitable services in car-
consistently been ranked as the best psychiatric hos- diology, oncology, or surgery. However, hospitals that
pital in the United States by the magazine U.S. News need more beds for these profitable services may look
& World Report; yet it showed a loss from operations to downsize, close, or move their inpatient psychiatric
of $136,000 in 2001 and of $1,619,000 in 2003. It unit to an off-site location.
had surpluses of $190,000 in 2002, $282,000 in The American Hospital Association (2007) in a re-
2004, and $810,000 in 2005 (McLean Hospital An- view of behavioral health care needs concluded: As an
nual Reports [www.mclean.harvard.edu/about/annual/ important player in the continuum of care, hospitals
2002/operations.php]). Such results require substan- that positively address behavioral health care needs
tial philanthropy to fund capital and keep the opera- will contribute to the more effective and efficient use
tions afloat. of health care resources, while also helping to produce
positive outcomes for patients and their communi-
ties. In contrast, investor-owned psychiatric hospi-
Revenue Sources by tals will close if they do not generate the profits ex-
Type of Hospital pected by their shareholders.
Psychiatric hospitals and services can also try to
diversify into other lines of business that may be more
An analysis of sources of revenue for different types of
profitable. However, historically, inpatient services
hospitals illuminates the financial challenges faced by
generated the surpluses that allowed other less profit-
these organizations. For private psychiatric hospitals
able services (e.g., emergency, consultation, and out-
the proportion of total revenue that came from patient
patient services) to survive. General hospitals may be
fees, including private health insurance, decreased
able to use their contractual relationships with pri-
from 61.3% in 1990 to 42.7% in 2002. For general
mary health insurers to negotiate better rates for their
hospitals during this same time period, the decrease
psychiatric services, especially as behavioral health
was from 36.5% to 31.5%. In contrast, for private psy-
carve-outs shrink. Psychiatric hospitals may then
chiatric hospitals the proportion of total revenue from
partner with general hospitals to divert less costly pa-
Medicaid increased dramatically, from 9.4% to 25.9%;
tients who do not need significant medical services
the increase for Medicare revenue went from 10.8% to
away from general hospitals and thereby increase their
18.2%. For general hospitals, Medicaid revenue was
volumes. Psychiatric services should participate in
essentially unchanged from 1990 to 2002 (24.2% vs.
quality improvement programs that assure high qual-
24.0%), but Medicare total revenue increased from
ity to the process of care and excellent patient care out-
24.2% to 36.9%.
comes (Institute of Medicine Committee on Crossing
the Quality Chasm 2006). Pay For Performance sys-
The Future Financial Viability tems could conceivably provide enhanced reimburse-
ment to high-quality programs. Psychiatric services
of Inpatient Psychiatric Services should also encourage patients who have benefited
from psychiatric treatment, whether as inpatients or
Given the trend of reimbursement increases that do outpatients, to tell their stories publicly so that the
not keep up with rising costs and a shift in revenue stigma associated with psychiatric illness and its treat-
sources toward more publicly financed patients for ment can be reduced. Grateful patients should also be
whom reimbursement is typically less than for private encouraged to provide philanthropic support to non-
patients, what can psychiatric services providers do to profit psychiatric services.
survive (Liptzin et al. 2007)? In strictly economic
terms, there is likely to be a further reduction in the References
number of beds than has been the case since 1990. If
reimbursement is not available to support the existing
beds, more hospitals will be expected to close. At some American Hospital Association: Community hospitals: ad-
dressing behavioral health care needs. TrendWatch Feb-
point, the decrease in supply will fall below the de-
ruary 2007. Washington, DC, American Hospital Asso-
mand for these services and reimbursement rates will ciation, 2007
Centers for Medicare and Medicaid Services: 42 CFR Parts Mora G: Historical and theoretical trends in psychiatry, in
412 and 413: Medicare program; prospective payment Comprehensive Textbook of Psychiatry, 2nd Edition.
system for inpatient psychiatric facilities; final rule. Edited by Freedman A, Kaplan HI, Sadock BJ. Balti-
Federal Register Vol 69, No 219. November 15, 2004 more, MD, Williams & Wilkins, 1975, pp 175
Center for Mental Health Services: Mental Health, United National Association of State Mental Health Program Direc-
States, 2004 (DHHS Publ No. SMA-06-4195). Edited tors (NASMHPD) Medical Directors Council: Morbid-
by Manderscheid RW, Berry JT. Rockville, MD, Sub- ity and Mortality in People With Serious Mental Illness.
stance Abuse and Mental Health Services Administra- Alexandria, VA, National Association of State Mental
tion, 2006 Health Program Directors, 2006. Available at: http://
Drozd EM, Cromwell J, Gage B, et al: Patient casemix clas- www.nasmhpd.org/general_files/publications/med
sification for Medicare psychiatric prospective pay- _directors_pubs/Technical%20Report%20on%20 Mor-
ment. Am J Psychiatry 163:724732, 2006 bidity%20and%20Mortaility%20-%20Final%2011-
Iglehart JK: Health policy report: the new era of prospective 06.pdf. Accessed April 24, 2008.
payment for hospitals. N Engl J Med 307:12881292, Reed LS: Coverage and Utilization of Care for Mental Con-
1982 ditions Under Health InsuranceVarious Studies,
Institute of Medicine Committee on Crossing the Quality 19731974. Washington, DC, American Psychiatric
Chasm: Adaptation to Mental Health and Addictive Association, 1975
Disorders: Improving the Quality of Health Care for Summergrad P, Hackett TP: Alan Gregg and the rise of gen-
Mental and Substance-Use Conditions. Washington, eral hospital psychiatry. Gen Hosp Psychiatry 9:439
DC, National Academies Press, 2006 445, 1987
Liptzin B, Gottlieb GL, Summergrad P: The future of psychi- Watanabe-Galloway S, Zhang W: Analysis of US trends in
atric services in general hospitals. Am J Psychiatry discharges from general hospitals for episodes of serious
164:14681472, 2007 mental illness, 19952002. Psychiatr Serv 58:496502,
Mechanic D, McAlpine DD, Olfson M: Changing patterns 2007
of psychiatric inpatient care in the United States, 1988 William & Mary Crossroads Research Project: Brief History
1994. Arch Gen Psychiatry 55:785791, 1998 of Eastern State Hospital and the Treatment of Mental
Mitchell JB, Dickey B, Liptzin B, et al: Bringing psychiatric pa- Illness in America. Available at: http://www.esh.dmh-
tients into the Medicare prospective payment system: al- mrsas.virginia.gov/crossroads/history.htm. Accessed
ternatives to DRGs. Am J Psychiatry 144:610615, 1987 April 24, 2008.
CHAPTER 31
RISK MANAGEMENT
Marilyn Price, M.D.
Inpatient psychiatric facilities share risk manage- from the moment the patient is evaluated for admis-
ment and patient safety concerns with general medical sion. When a patient first presents for assessment, the
and surgical hospitals. When a patient is evaluated in team must determine whether the patient requires an
the general emergency department or urgent care set- inpatient level of care, and if so, whether the patient
ting, clinicians seek to determine whether the patients will be admitted on a voluntary or an involuntary ba-
life is in immediate danger, whether the patients ill- sis. Involuntary civil commitment carries special im-
ness poses any risk to others, and how the treatment plications for risk management. In general medical
team may help to improve the patients condition. treatment, patients whose health status might pose a
Similarly, in the psychiatric acute care setting, the clin- danger to others are typically identifiable through
ical team must assess how the patients safety can be standardized tests for infectious diseases, and many
ensured, whether the patient poses any danger to him- notification procedures and precautions have become
self/herself or others, and how the patient can best be standardized. In contrast, in psychiatry, determining
stabilized so that treatment may be effective. Many of whether or not a particular patient poses a danger to
the risk management concerns found in general hospi- himself or herself or others can be very difficult, but
tals are pertinent to hospital psychiatry including en- the duty to protect nonetheless still applies. In general
suring patient safety and quality improvement, pre- medicine, if a patient elopes from the hospital or
venting and managing adverse events, preventing staff leaves against medical advice, the liability risk to the
misconduct toward patients, and complying with ac- physician and hospital may be minimal. Psychiatric
creditation standards and the relevant laws. patients, however, may suffer from impaired judgment
However, there are areas that pose unique chal- as a result of their mental illnesses, and an elopement
lenges for freestanding psychiatric hospitals and psy- or discharge against medical advice may not be a ratio-
chiatric units within general medical hospitals. These nal decision for which the patient bears the sole re-
special issues for psychiatric facilities are manifest sponsibility. Suicide, violence, and patients legal
411
rights are significant concerns for risk reduction in competency of staff to perform assigned tasks (Joint
hospital psychiatry. This chapter will discuss several Commission 2007a). One may also need to consider
prospective and retrospective risk management prac- technology issues, the availability of information, the
tices relevant to such scenarios. physical environment, and the security system. Prob-
lems in communication should be addressed, whether
the difficulty rests in communication among staff
Risk Management Techniques: members or communication with patients or family
A Culture of Patient Safety members. Some facilities have improved voluntary in-
cident reporting through an intervention package that
includes enhanced education, offering a range of re-
Reducing risk to patients who are hospitalized in a porting options and more feedback (Evans et al. 2007).
psychiatric facility is best accomplished within a cul- The organization must also respond proactively to
ture of patient safety (Murphy et al. 2007). This phi- safety concerns. The Joint Commission describes the
losophy signifies that there is an institutional com- process of risk management as clinical and adminis-
mitment to patient safety and quality improvement trative activities undertaken to identify, evaluate, and
that encourages all members of the staff to become reduce the risk of injury to patients, staff, and visitors
agents of change. It also implies that for questions of and the risk of loss to the organization itself (Joint
patient safety, the hierarchical environment is aban- Commission 2007a). Early indications of a problem
doned for one in which all members of the staff are en- within the system may come from analyses of incident
couraged to point out vulnerabilities in the system reports, near misses, quality control data, occurrence
(Murphy et al. 2007). Achieving a culture of patient trends, and patient complaints. Benchmarking with
safety may require changing the guiding set of values other institutions is another method of optimizing per-
of the organization in order to embrace this new ap- formance. In addition, implemented changes should
proach. Otherwise, it becomes difficult to apply new be monitored on an ongoing basis and further modi-
policies, procedures, or practices that conflict with the fied, as appropriate (Martin and Federico 2007). The
existing organizational culture. Traditionally, physi- organization should appoint a patient safety officer to
cians have considered risk management issues at the help oversee changes, paying special attention to issues
level of the care of an individual patient; they are con- that may affect the quality of care.
cerned about suicide and violence risk assessment, A culture of patient safety is enhanced by adher-
medication side effects or errors, and accurate diagno- ence to good clinical practices. These may include, but
sis. In contrast, hospitals have often approached risk are not limited to, the following practices (Simon and
management reactively, responding to a crisis by iden- Shuman 2007):
tifying the individual thought to be responsible, in
what has been referred to as an A-B-C approach: ac- Performing ongoing suicide risk assessments and
cuse, blame, and criticize. violence risk assessments, including evaluating risk
Investigation of an incident should involve exami- factors and protective factors
nation of the actions of the staff members involved, es- Continually documenting all changes in a patients
pecially when the behavior has been willful, deliberate, clinical or risk status, as well as standardized com-
or reckless or when an employee has violated well- munication of such changes to all staff members
established rules and regulations. However, this nar- who will work with the patient
row focus on individual error precludes the assess- Documenting treatment of modifiable risk factors
ment of organizational problems that could have con- Documenting communication among treatment
tributed to the problem and which, if left unchecked, team members about a patients risk level
might lead to future incidents. Within a culture of Reviewing and documenting a patients past history
safety, the focus turns to an examination of inherent of hospital admissions
weaknesses within the system that contributed to the Thoroughly documenting clinical reasoning, espe-
medical error. The ultimate goal of the investigation is cially in regard to changes in observation or privi-
to implement modifications to prevent further injury. lege status, detention for observation or safety, or
Although it is not exhaustive, the following list of is- changes in treatment regimen
sues could be considered: the behavioral or physical Involving family members in treatment (with the
assessment process, patient observation procedures, patients permission) and building an alliance with
the care planning process, the continuum of care, the patients family while remaining sensitive to
staffing levels, training programs for staff, and the protecting the patients confidentiality
Risk Management 413
Beginning discharge planning soon after admission tient identifiers to improve the accuracy of patient
Implementing strategies to decrease the risk of identification; some hospitals may also use the more
medication errors and adverse events modern technology of radio frequency identification to
Providing comprehensive and ongoing staff educa- avoid administering medication to the wrong patient.
tion, placing special emphasis on training for areas In hospital psychiatry settings, avoiding medical er-
of increased risk (e.g., the proper use of de-escala- rors is especially pertinent when treating patients who
tion techniques, seclusion, and restraint; appropri- are pregnant or have a compromised health status.
ate boundaries between staff and patients; address-
ing sentinel events and near misses)
Improving communication and documentation at Coping With the Aftermath
all levels of the organization, possibly through stan-
dardized communication methods (as discussed in
of a Sentinel Event
this chapter)
Modifying and enhancing discharge planning to ad- One of the most important aspects of risk manage-
dress clinical risk and protective factors that affect ment in hospitals is the manner in which the organi-
discharge readiness (Simon and Shuman [2007] zation handles a sentinel event or a near miss. Al-
provide a very helpful table of discharge consider- though changes should ideally be instituted before an
ations for suicidal patients) adverse event occurs, in the aftermath of a sentinel
event there is often an impetus to effect changes in the
These practices represent, at best, a minimum of risk system. The Joint Commission defines a sentinel
management practices that may help to reduce the event as an unexpected occurrence involving death or
risk of adverse events and improve patient safety. serious physical or psychological injury or the risk
The Institute of Medicine (IOM) Health Care thereof. Serious injury specifically includes loss of
Quality Initiative, begun in 1996, has brought nation- limb or function. The phrase or risk thereof includes
wide attention to concerns about patient safety and any process variation for which a recurrence would
quality in health care. The IOMs 1999 report To Err Is carry a significant chance of a serious adverse out-
Human: Building a Safer Health System was a very income (Joint Commission 2007b). The Joint Com-
fluential review of medical errors and patient deaths mission considers a patient suicide a sentinel event
resulting from preventable error in the health care sys- when the patient was housed around the clock, includ-
tem. The IOM issued another document in 2001, ing suicide following elopement from such a setting.
Crossing the Quality Chasm, which introduced sug- To demonstrate processes that are available to help
gestions for improving patient care. Following the pub- identify areas of improvement following a sentinel
lication of these reports and additional studies on pa- event, the following fictional vignette is offered for
tient safety and health care quality, there has been an illustrative purposes only:
increasingly stronger push toward standardized qual-
ity improvement, risk management, patient safety ef- Mr. J, a 32-year-old married white male, was admit-
forts, and evidence-based medicine throughout the ted for his first psychiatric hospitalization after pre-
health care system, including hospital psychiatry. senting with depression and suicidal ideation and
plan. Mr. J had recently separated from his wife and
Reducing the incidence of medical errors is among
had been living with his brother. His brother was
the Joint Commissions national patient safety goals. concerned because Mr. J had been drinking heavily
Medication reconciliation and verification with out- and had missed several days at work. Mr. Js brother
side pharmacies and other physicians involved in a pa- reported that Mr. J appeared depressed. He was not
tients care are now essential functions of risk manage- even showering or getting dressed most days. His
brother brought Mr. J to the emergency room after he
ment in health care at all levels. Like other specialties,
found a gun in the guest room. Mr. J admitted to his
hospital psychiatry strives to avoid errors in dosing brother that he had purchased the gun 2 days prior to
and administration of medicines to patients. Techno- admission and had thoughts about killing himself.
logical developments, such as automated electronic Mr. J revealed that he was spending most of his day
databases, promise to facilitate efforts to detect inap- thinking of suicide. He denied symptoms of psycho-
propriate dosages and drugdrug interactions, using ei- sis. He agreed to hospitalization. Mr. J denied any
previous psychiatric treatment or suicide attempts.
ther pharmacy management information technology
Mr. J was started on an antidepressant. His fam-
or computerized physician order entry systems. The ily was very supportive, visiting daily, and Mr. Js
Joint Commission (2007a) calls for the use of two pa- brother and parents attended a family meeting. As
the hospitalization progressed, Mr. J reported to nu- notify senior staff, management, and the critical re-
merous staff members that he was feeling more sponse team and to ensure that documentation is
hopeful. He stated that he could not consider suicide
complete before the medical record is secured. If
because of the effect that it would have on his family.
He was very active and engaged in groups. Given the equipment failure is a factor, the equipment is held
improvement in his clinical condition, the privilege and the chain of custody is maintained. Occurrence
level was advanced. A few hours later, a staff member reports should be completed. The checklist also in-
performing checks found him trying to hang himself cludes requirements for obtaining an accurate descrip-
in the bathroom. tion of the occurrence and developing a detailed time-
line, which would include response times. The names
After Mr. J was discovered, his physical stabiliza- and positions of staff members who were present are
tion was the first priority. Fortunately, he did not sus- gathered. Staff involved in the care of the patient
tain any permanent physical injury. However, in the would be interviewed.
event that Mr. J could not have been successfully re- The initial process includes assessing whether
suscitated, staff members would have had to manage there were procedures in place to prevent the occur-
their own emotional responses to the patients death rence, and if so, why they failed in the instant case.
while making difficult decisions. Family would have The investigation would likely be performed under the
needed to be notified. Decisions would have had to be auspices of a peer review committee. The initial anal-
made about who should contact the family and what ysis could indicate that immediate action must be
should be disclosed. Information about what hap- taken. The checklist also offers suggestions for gather-
pened would need to be gathered from staff and docu- ing information in anticipation of a root cause analy-
mented in the record (Leigh and Lagorio 2007). Ad- sis (RCA; discussed below) and actions to be taken in
ministrators or directors of clinical units would have determining whether there are system improvements
to be aware of any applicable mandates requiring re- that could mitigate risk.
porting of adverse events. Additionally, Mr. J. may One of the issues to be dealt with early in the pro-
have indicated that he wished to have a family mem- cess, if a serious adverse event has occurred, is its dis-
ber or other significant other contacted in the event of closure (Amori et al. 2003; Gallagher et al. 2003;
an adverse event, such as any injury suffered during Wojcieszak et al. 2006). Joint Commission Standard
the attempt or as a result of other self-injury (e.g., cut- RI 2.90 requires that, when appropriate, patients and
ting, head banging) or treatment. their families receive information about unanticipated
It has been recommended that organizations de- outcomes. The National Quality Forum (NQF) has de-
velop a checklist to guide the response to such crises. veloped key elements of safe practices for disclosing
The checklist may prove helpful to the clinical team unanticipated outcomes (NQF 2007). Appropriate in-
members so that they may respond to the immediate formation to disclose might include the facts of the
needs of the family and staff members. The list allows event, a summary of the event analysis that allows in-
for a systematic approach to information gathering, formed decision making by the patient, an expression
which can help identify the contributing factors that of regret and sympathy for the unanticipated outcome,
would need to be addressed immediately and the fac- and, when warranted, an apology if the outcome was
tors that could be studied further at a later date, using the result of an error or systems failure (NQF 2007).
various risk management techniques (Leigh and Lago- The NQF directs institutions to integrate the disclo-
rio 2007). Risk management techniques like the sure process with patient safety and risk management
checklist may be employed to improve patient safety activities. Institutions should establish background
even in near miss scenarios like the hypothetical vi- disclosure education and provide a system for disclo-
gnette described above. Prudent risk management rec- sure coaching that should be available at all times.
ognizes such near misses as opportunities to learn The institution should have a mechanism to provide
from problems and, if possible, to intervene before emotional support for members of the community in-
such problems lead to serious adverse events such as cluding administrators, health care workers, patients,
completed suicide. and their families. The NQF also recommends devel-
An inpatient suicide, which would constitute a oping performance tools to track and enhance disclo-
sentinel event, would require a comprehensive re- sure (NQF 2007). In planning for a discussion with
sponse. The checklist developed by Leigh and Lagorio the patient or family after an adverse event, a decision
(2007) is useful both for the early stages and for plan- must be reached about who would be involved and the
ning the organizational investigation. It directs staff to timing, location, and extent of information that would
Risk Management 415
be disclosed (Leigh and Lagorio 2007). Prior to making Some argue strongly for the use of apology (see, e.g.,
a disclosure, it may be appropriate to consult with Healing Words: The Power of Apology in Medicine,
legal counsel, insurance carriers, or risk management 2nd Edition [Woods 2007]), whereas others suggest
officers. Disclosures may not be warranted for near- that there may be an increase in litigation as a result.
miss scenarios. Using conceptual modeling and statistical probability
There has been a growing endorsement by insurers analyses, Studdert et al. (2007) found the chances
and risk managers of the use of apology. Some states that disclosure [of medical error] would decrease either
have taken action to mandate reporting of serious un- the frequency or cost of malpractice litigation to be
anticipated outcomes. In 34 states, protection is now remote. On the contrary, an increase in litigation vol-
offered in the event of a malpractice suit through apol- ume and costs was highly likely. Regardless of the
ogy statutes that prevent introduction of the apology approach used, consultation with the appropriate in-
at trial. However, statutes differ as to the extent of insurance carrier immediately upon discovering a prob-
formation that is protected. Massachusetts, for exam- lem that may lead to litigation is essential.
ple, narrowly defines what information is actually pro-
tected. In two-thirds of states, only the expression of
regret is protected, while admissions of fault remain
Root Cause Analysis
admissible at trial (Gallagher et al. 2007).
There is some empirical evidence foundation for General medical hospitals, as well as psychiatric facil-
the use of apology to mitigate risk of suit. Mazor et al. ities, are required to implement prospective and retro-
(2004) distributed eight questionnaires to study the ef- spective risk management techniques such as root
fect of several variables affecting the patient response cause analysis (RCA) and failure modes and effects
to disclosure. Patients had a more favorable response analysis (FMEA; discussed below). Hospitals must
when physicians fully disclosed, accepted responsibil- have a sentinel event policy that allows a rapid re-
ity, and apologized rather than when information pro- sponse. After an occurrence such as the near-suicide of
vided was vague or withheld. The severity of the out- Mr. J. in the hypothetical vignette, the Joint Commis-
come also influences the patients response. However, sion requires the hospital to undertake an analysis of
none of the vignettes in their study resulted in patient the various systems that may have contributed to the
death. Only in one scenario did full disclosure de- event. The details of conducting an RCA are beyond
crease the likelihood of seeking legal action. Kraman et the scope of this chapter; however, multiple resources
al. (2002) found that a policy of full disclosure, includ- are available at the Joint Commission Web site (www.
ing an apology and discussion of remedy and compen- jointcommission.org).
sation, not only was the proper ethical response but RCAs should be conducted after all events that have
also had financial ramifications. The authors noted resulted in serious harm to a patient or that constitute
that although the hospital they studied was in the top a near miss of serious harm. The Joint Commission
quarter of medical centers for number of torts claims clearly states that not all sentinel events equate with
filed, it was in the lowest quarter for malpractice pay- medical error but, instead, that the process is designed
outs based on these claims. to help identify problems that led to the event and to
The largest malpractice carrier in Colorado, discover what changes in process may help to avoid
COPIC, developed a program to facilitate disclosure. repetitions of the event.
The 3Rs program {(Recognize, Respond to, and Re- Each hospital is required to define a sentinel event
solve patient injury)?} includes linking disclosure to in its own policies and procedures and to establish a
no-fault compensation for patients out-of-pocket ex- procedure for conducting an RCA. Some of the events
penses up to $30,000. Because no fault is assigned, identified by the Joint Commission that may be appli-
these disclosures are not reported to the National cable to a psychiatric hospital include the following:
Practitioner Data Bank. The program provides disclo-
sure training and coaching for physicians. There are suicide of any patient receiving care, treatment and
exclusion criteria, such as death and clear negligence. services in a staffed, around-the-clock care setting or
The program is also not used when there has been a within 72 hours of discharge; an abduction or elope-
ment of any patient receiving care treatment services;
written demand or a complaint to a regulatory agency
a death in restraint; rape [any nonconsensual sexual
(Gallagher et al. 2007). conduct]; or surgery on the wrong patient or wrong
Research on the impact of disclosure to patients or body part [for example, electroconvulsive therapy on
family of unexpected outcomes is still in its infancy. the wrong patient]. (Joint Commission 2007b)
There is currently no obligation to self-report a The Joint Commission also identifies 11 steps in
sentinel event. However, the Joint Commission re- the work plan for the completion of an RCA:
quires that in accordance with the hospitals own pol-
icy, an RCA be conducted within 45 days of the event. 1. Organizing a team
Such a study is meant to focus on the underlying pro- 2. Defining the problem
cesses, not on individual actions; the outcome of an 3. Studying the problem
RCA is meant to be a systematic action plan to reduce 4. Determining what happened and why
the risk of similar events in the future. The plan must 5. Identifying root causes
include responsibility for implementation; oversight; 6. Designing and implementing an action plan for
pilot testing, as appropriate; time lines; and strategies improvement
for measuring the effectiveness of the actions (Joint 7. Designing improvements
Commission 2007b). During a site visit, Joint Com- 8. Implementing the action plan
mission representatives may ask to review an RCA 9. Measuring effectiveness of the action plan
that has been conducted so that they may determine 10. Evaluating the implementation efforts
whether or not the analysis is acceptable. Acceptable 11. Communicating the results
analyses must include the following characteristics: a
primary focus that is on systems and processes; an Creating a checklist with benchmark dates and
analysis that proceeds from special causes in clinical completion dates may be a useful tool in adhering to
processes to more common causes and organizational the 45-day timeline.
processes; an attempt to dig deeper by asking why Although the patient (Mr. J) in the vignette de-
repeatedly; and identification of potential changes in scribed earlier did not sustain any permanent physical
the systems and processes that may avoid such events injury as a result of his attempted suicide, this event
in the future. would be considered a sentinel event that justifies an
The Joint Commission identifies multiple areas RCA. In a 10-year summary of reported root causes of
that must be investigated in order for an RCA to be inpatient suicides, the Joint Commission identified
considered credible: environmental safety and security, patient assessment,
orientation and training, and communication failures
Behavioral assessment process as the most common root causes (Joint Commission
Physical assessment process 2007b). Other areas identified as problematic include
Patient identification process staffing, availability of information, continuum of care,
Patient observation procedures care planning, leadership, procedural compliance, and,
Care planning process least likely, organizational culture. Although the vi-
Continuum of care gnette does not provide sufficient information to iden-
Staffing levels tify the root cause(s) of Mr. Js attempted hanging, one
Orientation and training of staff might speculate that in the interval after the family
Competency assessment/credentialing meeting, he had had an acrimonious telephone conver-
Supervision of staff sation with a family member and that the argument
Communication with patient/family had heightened his feelings of hopelessness. If one staff
Communication among staff members member had been aware of this important event but
Availability of information failed to communicate it to other staff members, a sys-
Adequacy of technological support tems issue or a training issue might well be identified.
Equipment maintenance/management In addition, one must always evaluate the safety of the
Physical environment environment and whether or not the appropriate safety
Security systems and processes measures (e.g., breakaway bars in the bathroom) were
Medication management in place. A review of the literature might reveal areas
for potential improvement.
Not all of these processes will be relevant in every
sentinel event; however, the institution is required to
have a reasonable explanation for why analysis of a Failure Modes and Effects Analysis
certain process is not relevant to the particular RCA
being conducted. Any credible RCA must include a re- While RCA approaches risk reduction by a thorough
view of the literature and an analysis of how the liter- retrospective assessment of an adverse event, FMEA
ature applies to the case under consideration. uses a prospective approach to eliminate or decrease
Risk Management 417
risk (Battles et al. 2006). The goal of FMEA is to eval- If the process is complex, the team can decide to limit
uate the vulnerabilities inherent in a process before an the scope to one aspect of the process. Step 4 involves
adverse outcome occurs and to implement modifica- conducting a hazard analysis. This includes identifica-
tions in order to decrease or eliminate potential injury tion of failure modes, assessment of the severity and
to patients or staff (DeRosier et al. 2002). The Joint probability of the potential failure mode, and the as-
Commission requires that hospitals adopt prospective signment of a Hazard Score on the Hazard Scoring Ma-
approaches such as FMEA when addressing patient trix. A decision tree is used to determine which of the
safety concerns (Joint Commission on Accreditation failure modes merits further action. Consideration is
of Health Care Organizations 2003). given to criticality, absence of effective control mea-
FMEA was initially used as a strategy to anticipate sures, and lack of detectability. During Step 5, actions
and mitigate risk in manufacturing. In this model, a and outcome measures are planned (DeRosier et al.
risk priority number was calculated through a three- 2002). Several community hospitals have further re-
variable equation in which each variable was assigned a fined HFMEA and have adopted what is termed failure
score between 1 and 10. This process was used by med- mode effects and criticality analysis to reduce prospec-
ical device manufacturing firms to prevent problems or tive risks (Coles et al. 2005).
system failures (Cody 2006; DeRosier et al. 2002). Potential areas that FMEA might address within
FMEA uses a systematic approach to identify fail- the psychiatric hospital include credentialing of physi-
ure modes, their frequency, and the associated proba- cians, de-escalation techniques, seclusion and re-
bilities of the consequences of the failure. The premise straint, participation in treatment plans by patients,
of FMEA is that individual failures within the process prevention of medication errors, medication reconcil-
could be identified to prevent an adverse outcome. iation, management of missed appointments, suicide
During FMEA, a process map and/or a table format is prevention within the facility, prevention of patient
used to identify the contributing system components, self-injury, and elopement prevention. Choosing a
to detect the ways that different elements in a system process and examining it in advance may help to iden-
can fail, and to provide an estimate of how these fail- tify new best practices that can be implemented and, if
ure points might affect the process and lead to a neg- possible, prevent or reduce risk to both patients and
ative outcome (Battles et al. 2006). staff.
Recent studies have demonstrated the positive Prospective approaches such as FMEA offer a real
benefits of implementing changes derived from FMEA opportunity to identify areas of vulnerability and insti-
in health care applications, such as protection of hu- tute changes that will decrease risk. In the hypotheti-
man subjects in research, improved safety of intrave- cal case example of Mr. J, the RCA might have revealed
nous drug administration and trauma treatment, and that information about a new stressor was not com-
safer administration of chemotherapy (Adachi and municated to other members of the team so that the
Lodolce 2005; Cody 2006; Day et al. 2006; Robinson increased risk was not identified. The group may have
et al. 2006; Sheridan-Leos et al. 2006; Spath 2003; concluded that barriers to effective communication
Wetterneck et al. 2006; Woodhouse et al. 2004). needed to be studied further. In addition, FMEA could
In an attempt to make the FMEA process more ap- have identified other areas of vulnerability with regard
plicable to the health care setting, a hybrid model was to communication among staff members on the unit.
developed by the Department of Veterans Affairs Na- There might have been a decision to implement stan-
tional Center for Patient Safety s Prospective Risk dardized methods of communication, such as the sit-
An alys is Sys t em an d t he Tenet H ealth Sys tem uation, background, assessment, and recommenda-
(DeRosier et al. 2002). This new approach, which com- tion method (SBAR; described below), to ensure that
bines the features of FMEA, hazard analysis and critical the appropriate information would be communicated
control point, and RCA, has been termed health care in an effective and standardized manner.
failure mode and effect analysis (HFMEA) (DeRosier et
al. 2002). As implemented by the Department of Vet-
erans Affairs, the HFMEA process consists of five steps. Improved Patient Safety
Step 1 is selecting a high-risk or high-vulnerability area Through Communication
for study. Step 2 concerns the selection of a multidisci-
plinary team, including a subject-matter expert, an ad-
visor, and a team leader. During Step 3, the team devel- Communication problems in the health care setting
ops a process-flow diagram and adds the subprocesses. contribute substantially to medical errors and associ-
ated legal risks. Among the strategies for quality im- municated to all staff who will be involved in the care
provement and error reduction set forth by the Insti- of a patient. Whenever the patients status changes
tute of Medicine in its 2001 report Crossing the (e.g., immediately prior to discharge, after alterations
Quality Chasm are recommendations for improved in the observation level) or if other risks or precipi-
communication between clinicians and patients, as tating factors change (e.g., death of a loved one), the
well as improved communication among different patients suicide risk should be reassessed and any
clinical service providers. changes in the level of risk should be communicated
Hospitals have begun implementing communica- promptly to all staff members who will be working
tion improvement strategies as part of efforts to im- with the patient.
prove patient safety and reduce medical errors. Im- This discussion offers only several examples of the
proving communication among health care workers as numerous methods and models for improving com-
well as between patients and staff are among the goals munication in the health care setting. Quality im-
identified by the Joint Commission for improving pa- provement efforts that target communication through
tient safety (www.jointcommission.org); there is some systemwide administrative changes serve an impor-
evidence that approaches targeted at both forms of tant risk management function.
communication can enhance patient safety (Stebbing
et al. 2007a). The Joint Commission lists communi-
cation as Goal 2 in its Patient Safety Goals for 2007;
Boundaries and Staff Supervision
more specific recommendations are available through
the Joint Commission Web site. Patient handoffs have The study of boundary theory has evolved, in part,
been identified as one of the more problematic pre- through attempts to reduce the incidence of therapist
ventable medical errors, and the Joint Commission sexual misconduct toward patients. Gutheil and Gab-
recommends standardizing the process for handoffs. bard (1993) defined a boundary as the edge of appro-
One process that has shown some promise for improv- priate professional behavior. A boundary violation
ing handoff communication is appreciative inquiry, a occurs when a clinicians behavior crosses the line into
strengths-based approach that emphasizes building on unacceptable conduct. Sexual contact between a clini-
and learning from handoffs that have been effective in cian and a patient, which is proscribed by clinical eth-
the past (Shendell-Falik et al. 2007). ics, constitutes a boundary violation. Boundary theory
Some health care organizations have adopted com- also attempts to identify behaviors that, while not
munication models or methods used in other high- constituting full boundary violations, may nonethe-
risk settings, such as air and space travel, nuclear less be considered steps down a slippery slope to-
power plants, and the military; one such model gain- ward more egregious boundary violations (Gutheil and
ing favor in medical settings, and specifically sug- Gabbard 1998). Boundary violations are among the
gested by the Joint Commission, is the SBAR method most common reasons for malpractice suits against
of communication (Morin 2007). In the SBAR model, psychiatric treatment providers, second only to pa-
important communications must be conducted in a tient suicide (Norris et al. 2003). In the clinical set-
standardized format. First, one communicates the sitting, countertransference may lead staff to experience
uation (e.g., vital signs and presenting complaint). strong feelings of anger or affection toward patients.
Second, one provides information about the back- Helping staff to manage these feelings effectively, be-
ground (e.g., the patients mental status, known med- fore they become boundary concerns, is an important
ical conditions, and medications taken). Third, one step in managing risk on the unit. Uncontrolled anger
expresses a preliminary assessment of the problem; if may result in a staff assault against a patient, and feel-
a particular diagnosis or syndrome is suspected, this ings of attraction or affection may lead to staff sexual
should be expressed as part of the assessment. Finally, misconduct toward a patient. Patients have been
one posits a recommendation, such as suggested tests harmed and treatment providers have been success-
to be ordered and any emergency interventions or pre- fully sued as a result of both problems. Gutheil and Si-
cautions that may be required. mon (2002) note that financial exploitation of patients
In the psychiatric hospital setting, continued may be more common than sexual misconduct;
screening for suicide risk and communication about boundary training should address both sexual and
changes in suicide risk status or factors are crucial as- nonsexual boundaries.
pects of patient safety improvement. An initial suicide Helping staff to manage countertransference be-
risk assessment must be conducted, with results com- gins with staff education and training. Administrators
Risk Management 419
should provide adequate training in what is and is not reduce the risk of boundary-related problems, both
acceptable conduct toward patients, as well as tips on during the inpatient stay and following discharge, is to
how to recognize the early warning signs of boundary provide education not only to staff but also to patients
problems (Epstein and Simon 1990). Keeping a record about sexual boundaries, dual relationships, and re-
of staff training in human resources files will serve to spect for nonsexual boundaries. Such training should
document the training. Improving professionalism be documented.
among direct care as well as support staff not only will
help to lessen legal risks for the provider but also
should result in improved patient care and a more pos-
Civil Commitment
itive treatment experience for the patient and his or
her family. Hospitalization of psychiatric patients can occur on
Staff education should also address the symptoms either a voluntary or involuntary basis. Voluntary ad-
and behaviors exhibited by patients with different psy- missions are further classified as either informal or
chiatric illnesses so that staff members will be able to conditional. A patient admitted on an informal vol-
recognize manifestations of each patients illness and untary basis retains the right to sign out at any time
report back to the treating physician rather than react- unless the criteria for commitment are met. A patient
ing. For example, a manic patient may become hyper- hospitalized under a conditional voluntary basis
sexual and flirtatious toward staff or other patients; would need to provide notice of an intent to leave,
staff members should be trained to recognize such be- giving the hospital the opportunity to assess the need
havior as a symptom of the patients mania and should for involuntary commitment or to consider alterna-
report this to the patients psychiatrist when appropri- tives (Simon and Shuman 2007; Winick 2005). The
ate. Staff should also be trained in recognizing agitation issue of whether a psychiatric patient is competent to
and employing successful nonrestrictive de-escalation apply for a voluntary admission was addressed by the
techniques. This will minimize the need for seclusion Supreme Court in Zinermon v. Burch (1990; Appel-
and restraint as well as reduce the risk of harm to the baum 1990). The Court noted, The very nature of
patient or to other patients or staff on the unit. mental illness makes it foreseeable that a person
Staff selection and careful supervision are also im- needing mental health care will be unable to under-
portant ways to reduce the risk of boundary or miscon- stand any proffered explanation and disclosure of the
duct problems. Thorough background and reference subject matter. In addition, the Court recommended
checks are now required for employees or volunteers that the state establish a mechanism for assessing the
who will be working with patients or working on treat- competence of persons presenting for admission, ex-
ment units. Supervisors should be trained to recognize plaining, A person who is willing to sign forms but is
and address boundary violations as well as behavior incapable of making an informed decision is, by the
that may lead to boundary violations. Staff should same token, unlikely to benefit from the voluntary pa-
have a means by which to anonymously report known tients statutory right to question discharge.
or suspected staff misconduct so that all potential When a patient presents to the hospital in need of
boundary problems are recognized early and addressed care, the hospital may obtain an emergency certifica-
before escalating into an assault or serious miscon- tion for a specified time period (usually 4872 hours,
duct. The facility should have a policy in place for re- but sometimes as long as a week, depending on the du-
porting and dealing with an assault or misconduct if ration permitted by the state law) to help stabilize the
such an incident does occur. This policy should be patient. After the initial emergency period, a civil com-
consistent with laws and regulations mandating re- mitment may be initiated if it is determined that the
porting of adverse outcomes that govern the facilitys patient will need continued care at the inpatient level.
operations. These rules may vary from one treatment Unlike emergency certification, civil commitment re-
center to another, and it may be necessary to seek as- quires court proceedings. The question of whether or
sistance from a legal professional to ensure compli- not one can accept a health care proxy or an advance
ance with the relevant laws or rules. directive authorizing admission when the patient does
Boundaries must be appropriately maintained even not consent is a very unclear area of the law. States
after the patient is discharged. Institutions have been have varying rules regarding whether an appointed
sued for the misconduct of mental health technicians guardian can be authorized to consent to the patients
if there has been inappropriate contact between the treatment or admission. Even more stringent rules
technician and a former patient. One way to further may apply for specific forms of treatment, such as
electroconvulsive therapy. If a question arises as to the civil commitment. The typical criteria for commit-
legality of involuntary admission or treatment, it may ment are dangerousness to self or others and inability to
be necessary to consult with legal counsel. provide for basic needs (Simon and Shuman 2007).
Civil commitment of a person who is mentally ill Some commitment statutes have specific criteria, such
is a deprivation of freedom from detention. The justi- as grave disability, refusing treatment and in need of
fication for this deprivation is grounded in either the hospitalization, destructive toward property, and lack-
states parens patriae authority or in its police power. ing capacity to make rational treatment decisions (Si-
The parens patriae right is derived from the states in- mon and Shuman 2007; Winick 2005). In most states,
terest in protecting citizens who are unable to care for including Massachusetts, the commitment statutes in-
themselves due to an infirmity such as a mental ill- troduce the concept of the least restrictive alternative
ness (Simon and Shuman 2007; Winick 2005). Police (Mass. Gen. L. ch.123, 1, 2003). Winick (2005) has
power allows the state to act to protect its citizens compiled a summary of the civil commitment statutes
from harm; commitment is justified when a person of all 50 states, which allows comparison of statutes.
who is mentally ill poses a danger to others (Simon Some states have specialized commitment laws that
and Shuman 2007; Winick 2005). govern involuntary treatment for alcohol or substance
Involuntary hospitalization does not inherently al- use disorders, treatment of minors with mental illness,
low involuntary treatment absent an emergency. Most and commitment of sexually violent predators. These
states have their own procedures for substituted judg- issues are of limited applicability to general inpatient
ment in the event that a patient is deemed legally in- psychiatry. Likewise, the issue of outpatient commit-
competent to consent to treatment. It is important to ment orders (e.g., Kendras Law in New York State) is
note that although a patient may, in a clinicians judg- beyond the scope of this chapter, although information
ment, lack the capacity to make an informed decision, on this topic may be useful in discharge planning.
the patient may nonetheless retain the legal right to There are other consequences for patients involun-
refuse treatment. The law draws a distinction between tarily committed to a psychiatric facility rather than
the clinical notion of capacity to consent and the legal admitted on a voluntary basis. Many states now have
status of competence to consent. Legal proceedings statutes that restrict the access of persons with mental
such as competency hearings are usually necessary in illness or substance abuse from possessing, purchas-
order to subject patients to involuntary treatment. ing, registering, or retaining a firearm or obtaining a
Whenever possible, the clinician should allow the pa- firearm license. Some states have established a mental
tient to fully participate in treatment decisions; when health database that is accessible to police. Norris et
treatment is voluntary, the treatment alliance between al. (2006) noted that as of 2005, 22 states had a mental
the provider and the patient will help to facilitate bet- health database, some maintained by departments of
ter outcomes. mental health and others by the state law enforcement
Although there is variability in the state statutes, agency. Some states require notification from the hos-
there are common fundamental characteristics in the pital when a person has been involuntarily committed,
criteria and justification for commitment. Statutes re- whereas other states obtain this information from
quire that commitment be based on the presence of a court records of commitment proceedings (Norris et
mental illness, which can be poorly defined. For exam- al. 2006). In Massachusetts, the names of persons
ple, in Ohio, mental illness is defined as a substantial committed to state psychiatric hospitals are recorded
disorder of thought, mood, or emotion that substan- in a mental health database and are accessed during
tially impairs ones capacity for self-control, judgment, the firearm licensing process (Mass. Gen. L. ch.140,
and discretion in the conduct of personal affairs and 129[b], 2004; et seq., 26910). In the aftermath of the
social relations (Ohio Rev. Code Ann. 5233.02[a] [b], Virginia Tech tragedy, further limitations on access to
2003). The definition of mental illness in some states firearms following mandated (or perhaps even volun-
may also specifically exclude certain disorders. In Kan- tary) mental health treatment may be implemented.
sas, civil commitment for mental illness cannot be The passage of the National Instant Criminal Back-
based solely on a diagnosis of alcohol or chemical ground Check Improvement Act was intended to ex-
substance abuse; antisocial personality disorder; men- pand reporting practices of states to the National In-
tal retardation; organic personality disorder; or organic stant Criminal Background Check System (NICS) by
mental disorder (Kan. Stat. Ann. 592946, 2003). providing significant financial incentives for releasing
States also require that the impairment related to relevant records, including those contained in state
the mental illness result in one of the justifications for mental health databases (Price and Norris 2008).
Risk Management 421
Seclusion, Restraint, and medicines to forcibly subdue a patient, independent of

their therapeutic benefit, may be considered a type of
De-Escalation Techniques restraint, as such use restricts the patients freedom
(see, e.g., Mossman 2002). On the other hand, the use
The inappropriate use of manual restraint and seclu- of a neuroleptic to treat an individuals symptoms of
sion in treatment settings has contributed to injuries, psychosis may be considered a therapeutic use when
deaths, lawsuits, and negative public opinion toward used to treat psychosis rather than to control aggres-
the mental health profession. In the often-cited case sive behavior. Documenting the rationale for the use
Youngberg v. Romeo (1982), the mother of a mentally of prn medications and monitoring patient response
disabled man sued officials at the hospital where he to chemical restraint are critical steps. Care must be
was involuntarily committed, because the man had taken to avoid the use of medication as a punitive
been subjected to prolonged periods of restraint as a measure, and all uses as a chemical restraint must
result of his physically assaultive behavior. The Su- meet appropriate evaluation, clinical, and documenta-
preme Court ultimately ruled that reasonable clinical tion standards.
judgment should guide any decision to use seclusion To reduce risk, psychiatric hospitals should en-
and restraint but that patients should be afforded an deavor to reduce the use of seclusion and restraint
opportunity to learn how to reduce the need for such whenever possible and should consider implementing
restrictive interventions. In modern practice, patients a program to continuously monitor and decrease the
are typically invited to identify in advance, as early in use of seclusion and restraint. Research has shown
treatment as possible, their preferred methods for sta- that effective de-escalation and behavioral manage-
bilizing or calming down. Alternative interventions, ment strategies can successfully reduce the incidence
such as playing soothing music, sitting in a quiet of violent behavior in treatment settings as well as im-
room, and removing excessive sensory stimuli, should prove relationships between staff and patients (Bis-
be offered to patients as first-line approaches to de-es- coner et al. 2006; Dean et al. 2007; Donat 2005;
calation, and patients should indicate which methods Hunter and Love 1996; Schreiner et al. 2004). Seclu-
they prefer. Patient preferences for de-escalation inter- sion and restraint should be used only when required
ventions should be updated periodically by clinical for legitimate safety concerns and when other de-esca-
unit staff, and a form documenting the patients lation techniques have failed. The organization must
wishes should be included in the patients chart. Fol- follow the relevant rules and regulations for notifying
lowing any incident of seclusion or restraint, the pa- family members or significant others about the use of
tient should be debriefed and afforded an opportunity seclusion and restraint, particularly in the treatment
to provide feedback to staff about the incident and of children or adolescents. Adult patients may also in-
what may be improved in the event of future inci- dicate that they wish to have family members or oth-
dents. ers contacted in the event that seclusion or restraint
Joint Commission standards for seclusion and re- becomes necessary; patients wishes for such notifica-
straint call for specific policies and procedures to be fol- tion should be respected.
lowed, including mandatory debriefing after the use of In 2003, the American Psychiatric Association,
either seclusion or restraint. Furthermore, hospitals are American Psychiatric Nurses Association, and Na-
required to report to the Centers for Medicare and Med- tional Association of Psychiatric Health Systems, with
icaid Services any patient death occurring while a cov- support from the American Hospital Association,
ered patient is in seclusion or restraint. Federal rules for published a resource guide on strategies for behavioral
seclusion and restraint may be found at 42 CFR health care providers to reduce the use of seclusion
482.13(f). It bears noting that Joint Commission stan- and restraint in treatment settings, including tips for
dards and federal guidelines may differ, and both are sub- successful de-escalation (American Psychiatric Asso-
ject to ongoing and periodic changes. Hospitals are ex- ciation 2003). The guide Learning From Each Other:
pected to remain up-to-date and informed with respect Success Stories and Ideas for Reducing Restraint/
to the standards in place at any given time. Administra- Seclusion in Behavioral Health is available online at
tors should be aware that requirements may conflict; in the American Psychiatric Associations Web site
such cases, seeking assistance from legal counsel or risk (www.psych.org). The guide notes that change must be
management officers may be appropriate. systemic and offers case studies from other organiza-
Additional requirements may apply for the use of tions that have successfully im plemented such
so-called chemical restraints. The use of psychotropic changes. Included in the guide are suggestions for staff
training, milieu improvement, risk assessments, indi- uations where the patient has communicated to the
vidualized treatment plans, tips for documentation, psychotherapist a serious threat of physical violence
and information about debriefing and improving de- against a reasonably identifiable victim or victims. It
escalation techniques. The appendix to the guide is a also provided that the duty shall be discharged by the
resource document with additional tips and tools, in- psychotherapist making reasonable efforts to commu-
cluding examples of forms that may be useful for en- nicate the threat to the victim or victims and to a law
suring that documentation complies with Joint Com- enforcement agency. Weinstock et al. (2006) recently
mission and Centers for Medicare and Medicaid reviewed these statutes, finding that 27 states have
Services standards. passed laws concerning the duty to protect third par-
ties from harm by patients. These statutes are not uni-
form, and some allow for alternative actions other
Tarasoff Duty than warning. There are 9 states, along with the Dis-
trict of Columbia, that allow but do not mandate
The Tarasoff duty to protect/warn third parties stems warning; 13 states lack a statute. The states of Vir-
from the 1974 and 1976 California Supreme Court ginia and Texas do not recognize a Tarasoff duty. In
decisions in Tarasoff v. Regents of the University of Minnesota and Ohio, the threat of harm need not be
California (1976). The well-publicized and frequently communicated by the patient himself or herself in or-
discussed case involved a lovesick young man who had der to trigger the duty to protect; such notice may
disclosed to his treating psychologist an intention to come from collateral informants, such as the patients
kill an unnamed person identifiable as the young family members (Weinstock et al. 2006).
woman he had been pursuing, an intention he later Recent case law in California also suggests that the
carried out in what has since become a landmark case therapists duty to protect may be triggered by infor-
in mental health law. (For a detailed summary of the mation obtained from collateral informants. In two
case and the court decisions, see, e.g., Mossman separate suits heard by the California Court of Ap-
2006.) The victims parents sued the psychologist, the peals, the parents of a man murdered by a psychiatric
psychiatrists, and their employer for failing to detain patient sued the patients therapist (Ewing v. Gold-
the patient and failing to warn them of the danger. stein 2004) and the hospital that had discharged the
In 1974, the California Supreme Court found that patient a day prior to the murder (Ewing v. Northridge
a mental health professional has a duty based on the Hospital Medical Center 2004). The court ruled that a
special relationship between the patient and the psy- credible communication from the patients father
chotherapist: When a doctor or a psychotherapist, in about his sons threat to kill the victim was sufficient
exercise of his professional skill and knowledge, deter- to trigger the therapists and the hospitals duty to
mines or should determine, that a warning is essential warn the intended victim and law enforcement, and
to avert danger arising from the medical or psycholog- that the failure to communicate this warning could
ical condition of his patient, he incurs a legal obliga- potentially be deemed negligence for which both the
tion to give that warning (Tarasoff I). This decision, therapist and the hospital might be held liable.
which came to be known as the Tarasoff I ruling, In response to the Ewing decisions, there has been
prompted the American Psychiatric Association to file legislative action in California, an amendment to Cal-
an amicus curiae brief (summarized in Tarasoff II), ar- ifornia Civil Code 43.92, AB 733, to clarify the duty as
guing that psychotherapists cannot reliably predict fu- a duty to protect that can be discharged by warning,
ture violence and that issuing a warning would be det- but that allows other measures to protect the potential
rimen tal to the c on fident iality t hat f or m s th e victim. The reason for such legislation rests, in part,
cornerstone of the psychotherapistpatient relation- on the courts decision to impose an explicit require-
ship. The court reheard the case, and the 1976 Tara- ment to warn on the therapist, who had sought to pro-
soff II decision established a duty to protect, with a tect the victim by arranging for his patients hospital-
warning determined as one of the ways to satisfy this ization. The amendment does not change the impact
duty (Weinstock et al. 2006). of the decision of the Ewing court with respect to cred-
In response to the Tarasoff decisions and subse- ible threats communicated by collateral informants
quent decisions expanding the Tarasoff duty, there was such as close relatives.
a move in California and in other states to more In duty-to-protect situations, Simon and Shuman
clearly define and limit the duty by statute. California (2007) recommend addressing three factors: 1) sys-
Civil Code 43.92 served to confine the duty to the sit- tematic assessment of the threat, 2) identification of
Risk Management 423
the potential victim, and 3) implementation of pre- therapist is not merely protecting the potential victim
ventive measures to decrease the risk. The systematic but also helping to protect the patient by intervening
risk assessment would involve obtaining a history before the patients behavior escalates out of control,
about past or present violence and inquiring about thereby reducing risks of adverse outcomes (e.g., incar-
violence risk factors. Violence risk factors may be in- ceration, guilt) for the patient as well.
dividual (e.g., threats against a specific person, previ-
ous history of violence, accessibility of the victim, mo-
tive); clinical (e.g., diagnosis, psychotic symptoms,
Elopement
ability to control anger, syntonic versus dystonic vio-
lent behavior, nonspecific threats, history of abuse, An elopement from a psychiatric hospital can have
substance abuse, impulsivity); interpersonal (e.g., on- dire consequences (Dickens and Campbell 2002;
going therapeutic alliance, strength and value at- Hunt et al. 2007). Unlike discharges against medical
tached to personal relationships, fear of control by advice, an elopement does not afford the treatment
others); situational (e.g., presence of a specific stres- team sufficient time to assess whether the patient
sor; housing and employment stability; availability of meets the criteria for commitment or to make a deci-
lethal means, particularly firearms); and epidemiolog- sion about discharge based on an evaluation of danger-
ical (e.g., age, gender, base rates within the sociocul- ousness to self and others. There is no opportunity to
tural group, violence base rates). Simon and Shuman develop an aftercare plan, including medication and a
(2007) provide a table to guide the identification of safety plan, as appropriate. Furthermore, the patient
both risk and protective factors when determining an who elopes usually leaves without arranging any fol-
overall risk rating. low-up. Because the elopement of an unstable patient
Although the duty to protect usually applies only can result in serious consequences, the matter has
to an identifiable victim, some courts have broadened been addressed by regulatory agencies. One of the ex-
the interpretation to a foreseeable risk of harm to the amples given by the Joint Commission of a reviewable
public at large or to threats to property rather than just sentinel event is any elopement that is an unautho-
person. The duty arises in the treatment of both inpa- rized departure, of a patient from an around-the-clock
tients and outpatients. Psychotherapists need to con- setting resulting in a temporally related death (suicide,
sider the specific statute within their state when con- accidental death, or homicide) or major permanent
sidering the options for discharging the duty. Warning loss of function (Joint Commission 2007b).
the victim and notifying the police are options, but Several studies have indicated that about 50% of
there is also a responsibility to properly evaluate the patients elope primarily while off the unit on passes or
patient for more intensive treatment. Hospitalization walks (Kleis and Stout 1991; Richmond et al. 1991).
and treatment of the underlying disorder may be more Bowers et al. (1999a, 1999b, 1999c, 2000, 2003,
effective measures, and there can be liability for a fail- 2005) performed a prospective study involving inpa-
ure to hospitalize the patient when indicated. Simply tients from 12 partially locked acute wards in five dif-
warning the victim may be insufficient. In issuing a ferent hospitals in the United Kingdom. During the 5-
warning, a phone call is appropriate, especially when month study period, 175 patients absconded (i.e.,
the patient is an outpatient or when the patient elopes were absent from the unit without permission for a
from the unit and time is of the essence. The record period of more than an hour) a total of 498 times. In
should reflect that there has been a careful violence contrast to earlier studies, 88% of the patients eloped
risk assessment and should provide the reasoning for directly from the unit. This may be due to the fact that
breaching confidentiality, including the specific the wards were generally left unlocked. Of the patients
threats and the timing of the threats by the patient. who eloped, 35% were confined to the unit. However,
The note should also document the timing of the in only 1% of incidents was the unit door locked; in
warning and the content of the warning. If the poten- another 11%, a nurse was stationed at the door. For the
tial victim cannot be reached, it may be necessary to remaining cases, the unit was unlocked at the time of
contact persons who are close to the victim. When is- the incident. Of those who eloped, 58% had expressed
suing a warning is necessary, the clinician should dis- their intention to leave the unit within the previous 24
cuss with the patient the need to warn and may even hours (Bowers et al. 1999a).
invite the patient to be present during the warning (Si- These patients differed from controls in exhibiting
mon and Shuman 2007). The clinician can help the an increased frequency of noncompliant behaviors
patient to understand that in issuing the warning, the such as medication refusal and involvement in an of-
ficially reported ward incident within the previous leaving AMA showed the following characteristics:
week. They were more likely to be male, young, of mi- young age; single; male gender; comorbid personality
nority ethnicity, and a member of a non-Christian re- disorder or substance use disorder; pessimistic atti-
ligion and to have a diagnosis of schizophrenia. They tude toward treatment; antisocial, aggressive, or dis-
also had a higher incidence of absconding during a past ruptive behavior; and history of multiple previous
admission. There was no correlation with commit- AMA discharges (Brook et al. 2006; Pages et al. 1998).
ment status, level of ward security, or history of sui- AMA discharge was also predicted by the following fa-
cidal attempt or self-mutilation (Bowers et al. 1999c, cility/provider variables: failure to orient the patient to
2000). Additional interviews with the patients who the unit; failure to establish a strong doctorpatient
absconded (Bowers et al. 1999c, 2003) revealed that relationship; and time of day and time of year, with
although psychiatric symptoms were related to the de- more AMA discharges being requested during evening
cision to elope, there were other reasons, such as bore- and night shifts and during the spring and summer
dom, fear of other patients, feeling trapped or confined, months (Brook et al. 2006; Dalrymple and Fata 1993;
household responsibilities, feeling estranged from Jeffer 1993).
family and friends, and worries about the security of The majority of patients who signed out AMA
their income and property. from drug/alcohol treatment centers cited personal
Bowers et al. (2003, 2005) implemented an anti- reasons, such as family illness or reconciliation with a
absconding package. This included the use of a log spouse, or legal issues, such as a court date (Green et
book for signing in and out of the ward, careful and al. 2004). However, in a study by Blondell et al. (2006),
supportive communication of bad news to patients, 85% of patients admitted for drug and alcohol treat-
post-ward-incident debriefings, multidisciplinary re- ment who had all of the following risk factors left
view after repeated incidents, and identification of AMA: Latino ethnicity, detoxification from drugs, Fri-
high-risk patients. High-risk patients were assigned day or Saturday discharge, Medicaid or no insurance,
daily nursing times to discuss concerns and staff-facil- and not being treated by one attending physician.
itated outside social contact. The rate of absconding The case law concerning AMA discharges is lim-
was reduced by 25%. Other elopement-prevention ited. Devitt et al. (2000) were able to identify eight
measures such as the use of electronic wristbands and published court opinions involving AMA discharge,
a triage protocol have been shown to be helpful as well and only two involved patients in a psychiatric facility.
(Macy and Johnston 2007). Gerbasi and Simon (2003) found two other cases. In
Kelly v. United States (1987) and Solbrig v. United
States (1995), facilities were not held to be liable for
Discharge Against Medical Advice negligence in AMA discharges preceding severe ad-
verse outcomes (a stabbing and a patient suicide). Re-
Significant numbers of patients who would benefit viewing the potential legal ramifications of an AMA
from hospitalization do not meet criteria for commit- discharge, Gerbasi and Simon (2003) noted that vol-
ment and will not accept voluntary admission. Psychi- untary admissions comprise 73% of admissions to
atrists frequently encounter patients who wish to sign psychiatric care facilities, with the majority of these
out against medical advice (AMA). Studies have re- patients being admitted on a conditional voluntary ba-
vealed that 3%51% of patients discharge themselves sis. Therefore, for a large pool of patients, AMA dis-
AMA, and the frequency of AMA discharges appears charge is a possibility. The decision to allow a patient
to have increased over time (Brook et al. 2006). Pa- to sign out AMA is often made quickly, without a team
tients discharged AMA have been found to underuti- meeting or a full assessment of the patients capacity
lize outpatient services, instead relying on expensive to understand the potential consequences of his or her
emergency care settings (Brook et al. 2006; Haupt and actions.
Erlich 1980). They are also more likely to be rehos- There have been few studies of interventions de-
pitalized sooner than controls and with greater fre- signed to decrease the risk of AMA discharge. Targum
quency (Brook et al. 2006; Dalrymple and Fata 1993; et al. (1982) found that the rate decreased from 11.6%
Dixon et al. 1997; Pages et al. 1998). to 7.6% after a patient advocate system was started.
Seeking to identify risk factors for AMA discharges Pages et al. (1998) recommend identifying high-risk
from inpatient facilities, Brook et al. (2006) synthe- patients early in the hospitalization and initiating an
sized data from 61 articles on the subject, excluding early-discharge plan. In addition to the foundation of
patients who had eloped. Patients who were at risk of patient safety efforts discussed earlier in this chapter,
Risk Management 425
such as beginning discharge planning soon after ad- Managed Care and
mission, the following suggestions are offered from
the literature (Gerbasi and Simon 2003): Clinical Decision Making
1. Patients who are uncooperative with discharge dis- There are times when the decision of a managed care
cussions should, at a minimum, receive a referral company to deny further coverage of an inpatient stay
list with options for follow-up outpatient care. may prompt the patient to request discharge. The at-
2. Even if an AMA discharge request is received in the tending psychiatrist and the facility are faced with a di-
evening, as is frequently the case, a contemporane- lemma. The managed care company may deny reim-
ous evaluation for safety must be entered if the re- bursement, but the responsibility for decisions about
quest is to be honored. If the request is denied, a further management, including discharge, still rests
similar assessment of the clinical purpose for re- with the attending psychiatrist and the hospital. In the
taining the patient should be documented. The as- event of a poor outcome, the physician may retain lia-
sessment should evaluate the stability of the pa- bility, particularly if there has been no appeal. In Wick-
tients psychiatric illness, as well as the patients line v. State of California (1986), the California Court
ability to attend to activities of daily living. of Appeals explained: The physician who complies
3. Endeavor to include the patients family or signifi- without protest with the limitations imposed by a third
cant others in the discharge process, and provide party payor when medical judgment dictates otherwise,
psychoeducation, as appropriate. cannot avoid his ultimate responsibility for the pa-
4. Provide an appropriate follow-up treatment plan tients care. However, liability may also be attached to
and ensure reasonable access to medications, if in- managed care organizations in some circumstances in
dicated. Whether or not to provide the patient with which the Employee Retirement Income Security Act
discharge medications requires a separate risk does not bar suit. In Wilson v. Blue Cross of Southern
benefit analysis, but the mere fact that the dis- California (1990), the court held that although the at-
charge is against medical advice should not pretending psychiatrist did not appeal the decision to dis-
clude provision of reasonable pharmacotherapy. charge the patient after 10 days of hospitalization, this
failure did not preclude action against the managed
Gerbasi and Simon (2003) have offered several ad- care company. In other cases, courts have found that
ditional risk management strategies specific to AMA managed care companies that actually supervise care or
discharge concerns. assert to subscribers that they direct care may incur lia-
A patients ability to understand the consequences bility for their decisions (Gerbasi and Simon 2003).
of an AMA discharge or treatment refusal may be af- For risk management purposes, patients should
fected by the underlying mental illness. In such cases, never be discharged or otherwise denied clinically ap-
one might consider pursuing authorization for contin- propriate care merely because of restrictions imposed
ued hospitalization from a substitute decision maker by managed care. The treating physician needs to be
as allowed by law. An advance directive for psychiatric sure that the patient is safe for discharge. In cases
care can also be helpful, although there may need to be when the patients safety is at risk, the situation may
further court intervention to enforce the directive. So- require keeping the patient in the hospital, even when
called Ulysses contracts (whereby a patient indicates the managed care company denies reimbursement.
her desire for future involuntary treatment should her The hospital and physician should continue to pursue
condition worsen to the point that she would be any appeal rights that they have under the managed
deemed incompetent to consent to treatment) are not care contract. The documentation should reflect the
uniformly accepted in all jurisdictions, and subse- patients continued need for an inpatient level of care.
quent court proceedings may be necessary even where Coverage issues may arise if, for example, the hospital
such a contract exists. If the patient does not meet is not part of the managed care network, the condition
the criteria for involuntary commitment, the psychia- is not covered by the patients policy, or the length of
trist is obliged to inform the patient of the risks and stay exceeds the authorized period. However, financial
consequences of an AMA discharge and to assess the considerations are distinct from questions of clinical
patients understanding of these risks (Gerbasi and need. Patient safety and, if the patient is dangerous, the
Simon 2003). safety of others must guide clinical decision making.
Conclusion ture, but careful risk management can help to improve

the safety and quality of patient care, thereby mitigat-
ing risks to the organization.
Risk management must be continual in order to be
successful. To achieve a culture of patient safety, sys-
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CHAPTER 32
QUALITY INDICATORS
Quality of health care has assumed an increasingly 1. Efficacy: ability of the science and technology of
prominent place in the issues confronting our nation, health care to bring about improvements in health
as we realize that problems regarding lack of quality when used under the most favorable circumstances
care are hindering effective treatment and recovery of 2. Effectiveness: degree to which attainable improve-
patients (Berwick et al. 1990; Institute of Medicine ments in health are, in fact, attained
2006b). The Institute of Medicine (2000, 2001) has 3. Efficiency: the ability to lower the cost of care with-
played a major role in assessing how quality of care is- out diminishing attainable improvements in health
sues can be addressed. It has now extended the same 4. Optimality: balancing of improvements in health
thorough assessment to care for mental and substance against the costs of such improvements
use disorders by providing a detailed plan for address- 5. Acceptability: conformity to the wishes, desires,
ing issues pertinent to these areas (Institute of Medi- and expectations of patients and their families
cine 2006b). 6. Legitimacy: conformity to social preferences as ex-
pressed in ethical principles, values, norms, mores,
laws, and regulations
Characterizing Quality 7. Equity: conformity to a principle that determines
what is just and fair in the distribution of health
Quality of health care has been defined and character- care and its benefits among members of the popu-
ized in many different ways. Donabedian (2003) was lation
one of the earliest exponents of the various quality
products that emerge from the application of the sci- The Institute of Medicine under the National Acad-
ence and technology of health care: efficacy, effective- emy of Sciences has played a central role in the ad-
ness, efficiency, optimality, acceptability, legitimacy, vancement of the health care improvement agenda for
and equity. He defined these components of quality as more than a decade. Its Crossing the Quality Chasm re-
follows: port made clear the consensus that had formed around
429
the six aims of high-quality health care (Institute of a mechanism or instrument to quantify the indica-
Medicine 2001): tor (American Psychiatric Association 2002, 2007).
They logically follow a recommendation/goal, defined
1. Safe: avoiding injuries to patients from the care as an important clinical principle that reflects quality
that is intended to help them patient care.
2. Effective: providing services based on scientific In addition, exploration of variables that may lead
knowledge to all who could benefit and refraining to better results from quality measures continues to
from providing services to those not likely to ben- unfold. Examples include volumequality interaction
efit (avoiding underuse and overuse, respectively) as well as disparities found in the National Commit-
3. Patient-centered: providing care that is respectful tee for Quality Assurance Healthcare Effectiveness
of and responsive to individual patient preferences, Data and Information Set results for mental health
needs, and values and ensuring that patient values measures (Druss et al. 2002, 2004).
guide all clinical decisions
4. Timely: reducing waits and sometimes harmful de-
lays for both those who receive and those who give
Central Role of Leadership
care
5. Efficient: avoiding waste, including waste of equip- National leadership has been increasingly necessary
ment, supplies, ideas, and energy for developing meaningful and feasible quality mea-
6. Equitable: providing care that does not vary in sures in mental and substance use disorder care (Her-
quality because of personal characteristics such as mann and Palmer 2002; Hermann and Rollins 2003).
gender, ethnicity, geographical location, and socio- Quality indicators and measures in mental health
economic status have been and are being defined by many organiza-
tions, some of which are described below, as well as by
Many of the currently defined quality indicators hospitals and other health care systems. Although sig-
and measures for mental disorders developed by na- nificant progress has been made, this area lags behind
tional organizations initially focused on clinical thera- the development of quality measures in many other
pies for depression, given its prevalence as a mental areas of medicine.
health condition. Substance abuse indicators and mea- Several consensus organizations have taken an im-
sures will follow (American Medical Association portant leadership role in trying to draw all stakehold-
2007). With time, many other opportunities beyond ers together in developing core measures. Prominent
therapeutics will be developed as measures for improv- among these organizations is the National Quality Fo-
ing the quality of psychiatric care (Greenberg et al. rum, created to develop and implement a national
2006). Some aims of quality health care have been strategy for health care quality measurement and re-
more difficult to translate into meaningful mental or porting (see http://www.qualityforum.org/about) as
substance use disorder measures. The Institute of well as to integrate behavioral health care performance
Medicine has called attention to the lack of national measures into its strategy (see http://www.qualityfo-
comprehensive measures for the domains of efficiency, rum.org/publications/reports/behavioral_health.asp).
equity, and patient-centered care. It recommended Another consensus effort to identify and imple-
that to measure quality better, the U.S. Department ment a set of core performance measures for hospital-
of Health and Human Services, in partnership with based inpatient psychiatric services is currently under
the private sector, should charge and financially sup- way (Joint Commission 2008). The set of core perfor-
port an entity similar to the National Quality Forum mance measures is being collaboratively developed by
to convene government regulators, accrediting organi- the Joint Commission, the National Association of
zations, consumer representatives, providers, and pur- Psychiatric Health Systems, and the National Associ-
chasers exercising leadership in quality-based purchas- ation of State Mental Health Program Directors and
ing for the purpose of reaching consensus on and its Research Institute, along with a broad-based advi-
implementing a common, continuously improving set sory panel.
of mental/substance-use conditions health care quality The Physician Consortium for Performance Im-
measures for providers, organizations, and systems of provement (organized by the American Medical Asso-
care (Institute of Medicine 2006b, p. 14). ciation) is developing evidence-based measures with
The American Psychiatric Association Task Force links to health outcomes. Many specialty and state
on Quality Indicators has defined quality indicator as medical associations and other stakeholders are in-
a component of quality patient care and measure as volved. Measures for major depressive disorder are in-
Quality Indicators 431
cluded for both adult and child/adolescent psychiatry. porting programs, prospective patients, accrediting or-
Some measures are also available for problem drinking ganizations, and incentive programs for providing data
and tobacco use. on quality measures for additional pay, among others.
Hermann et al. (2004) brought together a panel of
12 stakeholders from national organizations to select
core process quality measures for mental health care
Developing and Selecting Quality
in seven domains (characteristics of quality) and re- Indicators and Measures
view issues, including supporting research evidence,
difficulties doing case-mix adjustment, and gathering
To meet the expectations and demands of all potential
the data. Through a consensus process, these re-
customers, we need indicators and measures that are
searchers were able to characterize a core set of mea-
reliable, valid, and carried out accurately. However, the
sures that they described as 1) meaningful, 2) feasible
considerable variability in quality indicators and mea-
to diverse stakeholders, and 3) broadly representative
sures across facilities (Williams et al. 2007) indicates
of the mental health care system. This stakeholder
the need for consensus-building efforts to identify key
panel evaluated a total of 116 process measures and
core indicators and measures. Prioritizing areas of
agreed on 28 related to treatment, safety, access, as-
health care where attention needs to be focused is also
sessment, continuity, coordination, and prevention. It
required. Data can come from ever-expanding sources.
was hoped that this process and its results could in-
They could include untoward occurrences such as
form the efforts of other groups, such as the National
medication errors and adverse drug reactions; safety
Quality Forum, involved in developing national stan-
rounds; application of current and past Joint Commis-
dardized measures.
sion national safety goals; tracer methodologies; risk
Other consensus organizations active in health
management (lawsuits and possible lawsuits); cases
care quality initiatives are the Hospital Quality Alli-
requiring reports to regulatory agencies; peer review of
ance and the AQA (formerly called the Ambulatory
identified cases; complaint letters; team rounds/meet-
Care Quality Alliance). The Hospital Quality Alliance
ings; debriefing sessions following events such as se-
is developing a set of measures to be tracked and re-
clusion or restraint use; hospitalwide concerns in pro-
ported by all participating hospitals and accepted by a
vision of care; patient rounds; community meetings of
wide range of stakeholders. There currently are no
patients and staff; findings from failure modes and ef-
quality measures for the care of mental and substance
fects analysis (FMEA) and external independent qual-
use disorders (Center for Medicare and Medicaid Ser-
ity reviews; and data from Six Sigma studies. Six
vices 2007c). The AQA, a publicprivate partnership
Sigma is a systematic method for improving the out-
representing an even larger group of stakeholders, is
put of the organization...by preventing error, solving
developing ambulatory care quality measures, many of
problems, managing change, and monitoring long-
which come from the American Medical Association
term performance in quantitative terms (Barry et al.
Physician Consortium, the Centers for Medicare and
2002, p. 13). This is done through the definition of
Medicaid Services, and the National Committee for
quality measures that address defects in the delivery of
Quality Assurance (Institute of Medicine 2006c).
services (Barry et al. 2002). As described by Varkey et
al. (2007, p. 737), Six Sigma is achieved through a se-
Customers for Quality Indicators ries of steps: define, measure, analyze, improve, and
control. A Six Sigma study from the Netherlands dem-
and Measures onstrates the improved care processes and reduced
costs (Van den Heuvel et al. 2006) that can result from
Users of quality indicators and measures can be such a methodology.
viewed as internal or external to the hospital. Inter- Measures are needed for health care areas in which
nally, there is a chain of accountability from staff to errors are most likely to occur and carry the most se-
department/discipline to hospital to board of trustees. vere consequences for patients. A patient-centered ex-
Increasingly, hospital executive leadership and their ample could be transition care from one level of care to
boards expect to be able to compare one hospital with another or from one setting to another (Coleman
another. Which hospitals run exemplary or bench- 2006; Coleman et al. 2005). Here, discharge planning
mark programs, and how do other hospitals fare in and ensuring continuity of care are the focus. Cole-
comparison? Externally, accountability is linked to man (2006, p. 272) describes a care transitions mea-
government and private purchasers of care, public re- sure of three questions for patients:
1. The hospital staff took my preferences and (2001) found that only first-time or long-term status
those of my family or caregiver into account was significantly associated with patient satisfaction.
in deciding what my health care needs
Long-term patients had a more positive impression of
would be when I left the hospital.
2. When I left the hospital, I had a good under- their care. Inpatient or outpatient setting was not re-
standing of the things I was responsible for lated to satisfaction.
in managing my health. Practice guidelines can often provide appropriate
3. When I left the hospital, I clearly understood quality indicators, although pitfalls in their use should
the purpose for taking each of my medica- be noted (Walter et al. 2004). Guidelines developed by
tions.
the American Psychiatric Association or the American
Coleman et al. (2006) demonstrated that a care Academy of Child and Adolescent Psychiatry can con-
transitions intervention can reduce serious quality de- tribute significantly to the development of specific
ficiencies that occur...and may reduce the rate of sub- quality indicators and measures, especially those that
sequent readmissions. Their coaching of chronically are evidence-based. In the American Psychiatric Asso-
ill older patients and their caregivers included medi- ciation (2006) practice guidelines, each recommenda-
cation self-management, a patient-centered medical tion is coded according to the degree of clinical confi-
record, participation in follow-up planning and activi- dence with which it is made (Irecommended with
ties, and knowledge of red flags and how to respond. substantial clinical confidence; IIrecommended with
Among the six aims of high-quality health care moderate clinical confidence; IIImay be recom-
identified by the Institute of Medicine, the domain or mended on the basis of individual circumstances).
aim of efficiency, defined as avoiding waste (Institute Patient satisfaction surveys play an essential part in
of Medicine 2001, 2006a), can be difficult to evaluate. carrying out patient-centered aims in health care every-
The goals of measuring value-based health care are where in the world. Examination of findings by gender,
to reduce underuse, overuse, and misuse of health care age group, or other characteristics (such as first-time
resources (Grazier 2006a). Another domain or aim of admission vs. long-term patients or generic vs. psychi-
quality often not addressed effectively is equity (Insti- atric-specific questionnaire) can provide opportunities
tute of Medicine 2006a), which applies to areas where for improvement (Berghofer et al. 2001; Kuosmanen et
cultural, racial, language, age, gender, sexual orienta- al. 2006; Peytremann-Bridevaux et al. 2006).
tion, or other disparities exist in the provision of care. A selection of other national organizations in-
Examples of such disparities include provision of men- volved in quality measures is summarized below (the
tal health services to women in rural areas (Hillemeier Institute of Medicine [2006c] has also provided such a
et al. 2005) and standards for diabetes care in individ- summary):
uals with mental illness (Frayne et al. 2005).
Donabedian (2003) described three approaches to The Agency for Healthcare Research and Quality
assessing health care quality: structure, process, and has a National Quality Measures Clearinghouse,
outcome. Structural measures are determined by how which includes most current evidence-based qual-
we set up our health care systemthe environment, ity measures available. However, there are currently
including the buildings, the staff, and their education no measures for mental health and substance use.
and training. Process is illustrated by the specifics of This organization regularly presents reports on dis-
how we carry out the provision of care. The process parities in provision of health care (Agency for
measure, however, has a connection to a desired out- Healthcare Research and Quality 2007).
come, thereby giving it validity (Charbonneau et al. The American Nurses Associations National Cen-
2004). Outcome measures are the gold standard. But ter for Nursing Quality manages a National Data-
because variables beyond the control of the hospital base of Nursing Quality Indicators, most of which
and its staff may influence outcomes, their use, at are generic to nursing care. Several are pertinent to
times, is limited. It is helpful to risk-adjust the results inpatient mental health services as well.
to make them more valid. Risk-adjustment issues for The American Osteopathic Association provides a
mental health services have been well described by summary of quality and pay-for-performance initi-
Hendryx et al. (2001). Gender, race, and homelessness atives in public and private sectors across the coun-
are important variables; and for readmission, length of try, both nationally and state by state.
previous hospitalization, therapy, or level of collabora- The Centers for Medicare and Medicaid Services
tion with outpatient providers may also predict out- has an extensive history of efforts to improve qual-
come (Schacht and Hines 2003). Berghofer et al. ity in health care. One of its latest programs is the
Physician Quality Reporting Initiative (Centers for electronic medical record (EMR) systems. A compo-
Medicare and Medicaid Services 2007), in which nent of such an effort has been electronic order entry.
eligible clinicians may voluntarily report results The Leapfrog Group (http://www.leapfroggroup.org)
from the application of specific Centers for Medi- has made this one of its core measures. Electronic pre-
care and Medicaid Servicesapproved quality mea- scribing can eliminate many medication errors (Gra-
sures for a bonus payment (often referred to as pay- zier 2006b). Key quality indicators and measures can
for-performance or pay-for-reporting). Several of be directly incorporated into the EMR. A close inter-
the initial measures identified are pertinent to face between a hospitals quality measurement effort
mental or substance use disorders. A Quality Mea- and its development of the EMR can constitute an ef-
sures Management Information System contain- ficient use of resources (see Chapter 33, The Elec-
ing measures used in its quality initiatives is also tronic Medical Record, by Boronow). Medicares Pay
offered (Centers for Medicare and Medicaid Ser- for Performance programs (originally called Physician
vices 2007; see https://www.qualitynet.org/qmis). Quality Reporting Initiatives) will stimulate the devel-
One of the measures relates to the acute treatment opment of such integration. Many studies are begin-
phase of depression. ning to demonstrate the feasibility of using the EMR to
The Center for Quality Assessment and Improve- elicit needed quality measures data. Baker et al. (2007)
ment in Mental Health provides a database that have shown how the EMR can be used to assess quality
can be searched for quality measures (Center for of care, although their study also revealed that missing
Quality Assessment and Improvement in Mental exclusion criteria remains an unsolved issue for medi-
Health 2007), a Directory of Measure Sources, and cation-based measures. Goulet et al. (2007) also dem-
a valuable toolkit on using process measures (Her- onstrated that quality measures can be accurately elic-
mann et al. 2002). ited from the EMR. Opportunities and challenges
The National Committee for Quality Assurance associated with use of the EMR have been addressed in
(http://www.ncqa.org), an independent nonprofit additional studies (Persell et al. 2006; Sequist 2007;
organization that accredits and certifies health Wahl et al. 2006).
plans and other entities, has refined over many
years a quality measurement program called the
Healthcare Effectiveness Data and Information Set
Interpreting and Assessing Data
(HEDIS).
Originally launched by the Maryland Hospital As- Determining what to do with measurement data in
sociation, the Quality Indicator Project (http:// mental health care is an issue that is beginning to gain
www.qiproject.org) has developed numerous indi- increased attention. Instead of data remaining avail-
cator sets, one of which covers mental health. Re- able only in the hospital or department itself, there is
ports to the many participating hospitals are sup- increasing encouragement by boards of trustees for all
plied with benchmarking percentiles. measures to be reported and for as many as possible to
The Substance Abuse and Mental Health Services have benchmarks.
Administration (SAMHSA) is actively involved in The value of comparing measurement data with
establishing national outcome measures for the standards, norms, means, or averages (Hermann and
prevention and treatment of substance use and Provost 2003) and of statistical benchmarking and
mental disorders. A program for developing bench- risk (case-mix) adjustment (Hermann and Provost
marking capabilities is to follow. SAMHSA funds 2003; Schacht and Hines 2003) has been well demon-
the Evaluation Center at Human Services Research strated. Schacht and Hines (2003) defined risk adjust-
Institute, described below. ment as a means of statistically controlling for group
differences when comparing nonequivalent groups on
the outcomes that are of interest (p. 220). Factors
Data Collection Plans such as age, gender, and legal status can have an im-
pact on the measure results for which corrections can
A major component in planning to implement quality be made. Statistical benchmarking (Weissman et al.
indicators and measures is whether there are consis- 1999) is defined as the performance achieved by the
tent, reliable data available in the medical record, phar- top 10% of providers after adjustment for the number
macy database, or other locations. Government and of patients that each provider has. A recent key study
other groups have encouraged hospitals to establish by Hermann et al. (2006) provided substantial support
for the use of statistical benchmarks to construct pro- also be helpfulfor example: Will these results (on a
cess measures of quality in mental health care. The specific measure) make any difference in how you in-
study attempted to identify levels of high performance teract/treat/care for patients? Did your work specifi-
that were potentially achievable. The authors noted cally affect this measure? The goal is to motivate staff
that the benchmark results varied widely because not just to hear the results but also to reflect on what
process measures differ not only in provider perfor- the data may mean to them, their team members, and
mance but also in the degree to which performance is patients.
under the provider s control (Hermann et al. 2006, The balanced scorecarda framework used in
p. 1465). Kiefe et al. (2001) demonstrated the effec- business for measuring a companys performance in
tiveness of using achievable benchmarks when giving four key areas (financial, customer, internal process,
feedback to physicians on their performance regarding and innovation; Kaplan and Norton 1992)has been
quality measures for diabetic patients. employed in health care quality monitoring to display
The Institute of Medicine (2006b) report on men- a core set of measures helpful to a hospital or depart-
tal and substance use conditions recommended es- ment and its leadership.
tablishing models for the use of the quality measures
for benchmarking. Examining the processes within
the benchmark hospital to see what best practices
Indicator and Measure
contributed to the end result is also useful (Lefkovitz Management
2004).
Risk adjustments are also necessary because of the Careful management of quality indicators and mea-
demand for hospitals to provide mental health quality sures ensures efficiency and avoids waste of resources.
measures for benchmarking with other similar facili- A responsible staff member and group/committee
ties. Hendryx et al. (2001) have offered an overview of oversee this responsibility. This task may be performed
issues related to development and implementation of by the departmental quality management committee
risk adjustment models in mental health care. or a similar group. Functions may include 1) establish-
ing a monitoring process for selection of indicators and
measures (including review of feedback from staff
Sharing Data members whose performance will be assessed by the
measure); 2) determining whether key findings from
The key objective of collecting and sharing data is to patient satisfaction surveys are being considered for
bring about change in performance. In a study that quality measures; 3) maintaining a history of indica-
surveyed frontline providers about their views on var- tors and measures used previously; 4) periodically as-
ious quality monitoring indicators and processes used sessing the current set of measures for value and deter-
in mental health services, Valenstein et al. (2004) mining whether any should be discontinued or have a
found that whereas 65% felt that feedback would be reduced sampling frequency; and 5) maintaining a list
valuable in efforts to improve care, only 38% felt able of potential indicators and measures that can be prior-
to influence performance, and 41% indicated that the itized and added to those already in place when re-
monitoring did not assist them in improving care. sources become available. Any staff member can add
Providers who had the most positive attitudes toward suggestions for consideration to the list.
quality monitoring measures were those who believed
that they had the power to influence these measures.
Ultimately, however, provider engagement is predi-
Education
cated on accurate implementation of measures and a
health-system context supportive of meaningful Periodic education of all staff regarding the role of qual-
change in the face of identified shortfalls (Valenstein et ity indicators and measures is needed. This provides an
al. 2004). opportunity to describe current measures and how in-
The most important challenge is how to share dicators and measures are managed. If the hospital has
quality monitoring feedback in a productive and colle- residents, medical students as clinical clerks, or other
gial way with clinical staff. Engagement of staff is more trainees in one of the health care disciplines, this train-
likely to be sustained if members are involved in the ing should be considered for the curriculum. It may be
selection of performance measures from the outset. advantageous for residents to participate in quality
Formulating some questions to ask clinical staff may management committees, groups that manage indica-
tors and measures, and peer review groups that carry The Evaluation Center at the Human Services Re-
out investigations. In addition, providing a brief over- search Institute, funded by SAMHSA, provides tech-
view to peer reviewers and attendees at morbidity and nical assistance to mental health providers (among
mortality conferences or holding staff debriefing ses- others) for improving the planning, implementation,
sions after an event involving seclusion and restraint and operation of adult mental health services (see
use, with a focus on exploring underlying causes that http://tecathsri.org). Consultations are available and
may have contributed to a specific outcome, may be subsidized by SAMHSA.
useful. Sassani (2004) has highlighted the important Finally, numerous excellent books are available for
role of the academic medical center physician in edu- individuals working in the quality indicator/measure-
cating medical students and residents in quality im- ment field (Hermann 2006; Lloyd 2004). Hermanns
provement. (2006) book Improving Mental Health Care: A Guide
to Measurement-Based Quality Improvement is an es-
pecially helpful reference.
Additional Resources
A Few Closing Observations
The Institute for Healthcare Improvement, founded in
1991, is dedicated to improving health care throughout
the world by cultivating promising concepts for im- The following observations may be helpful in the de-
proving patient care and turning those ideas into ac- velopment and use of quality indicators and measures:
tion (see http://www.ihi.org/ihi). Its programs include
In development of measure sets, consider all do-
Web-based knowledge exchange programs, confer-
mains/aims of quality for local applicability.
ences, a professional development program, innovation
Ensure that key findings from patient satisfaction/
and learning communities, and the IMPACT Network
perception surveys are considered for translation
(http://www.ihi.org/IHI/Programs/IMPACTNetwork)
into measures.
for achieving measurable improvement at the system
level. Patient safety has been a central focus, and many Emphasize emerging national core mental health
indicators and measures for accountability pur-
tools have been developed to assist staff in reducing ad-
poses.
verse events. Outcome, process, and balancing mea-
Accord equal value to hospital-developed and de-
sures are shared, the latter being measures to deter-
partment-developed measures for local quality-of-
mine whether improvements to one part of the system
care issues.
will lead to adverse effects in other parts of the system.
The Institute has developed a Global Trigger Tool for Learn to identify and respond to passivity in staff
interfacing with quality indicators, measures, and
Measuring Adverse Events, which focuses on identifi-
their results.
cation of harm or injury to patients. Harm is defined as
Value your history of indicators and measures use.
unintended physical injury resulting from or contrib-
Feasibility is essential when seriously considering a
uted to by medical care that requires additional moni-
toring, treatment or hospitalization, or that results in measure for implementation.
Design availability of key quality indicators and
death. The measure used is adverse events per 1,000
measures data into the electronic medical record or
patient days (Griffin and Resar 2007).
handwritten records.
The Center for Quality Assessment and Improve-
Provide opportunities for review and input by staff
ment in Mental Health is another good source for in-
prior to implementation of indicators and mea-
formation on quality measures in mental health. It
maintains a National Inventory of Mental Health sures.
Quality Measures and a Directory of Measure Sources
in addition to providing a valuable toolkit, Selecting References
Process Measures for Quality Improvement in Mental
Healthcare (Hermann et al. 2002).
The American Psychiatric Association (2002) task American Psychiatric Association: Quality Indicators: De-
fining and Measuring Quality in Psychiatric Care for
force report Quality Indicators: Defining and Measur-
Adults and Children (Report of the APA Task Force on
ing Quality in Psychiatric Care for Adults and Children Quality Indicators). Washington, DC, American Psychi-
is another good resource. atric Press, 2002
American Psychiatric Association: Practice Guidelines for the Greenberg MD, Pincus HA, Ghinassi FA: Of treatment sys-
Treatment of Psychiatric Disorders: Compendium 2006. tems and depression: an overview of quality improve-
Washington, DC, American Psychiatric Press, 2006 ment opportunities in hospital-based psychiatric care.
Baker DW, Persell SD, Thompson JA, et al: Automated review Harv Rev Psychiatry 14:195203, 2006
of electronic health records to assess quality of care for Griffin FA, Resar RK: IHI Global Trigger Tool for Measuring
outpatients with heart failure. Ann Intern Med 146:270 Adverse Events. Institute for Healthcare Improvement
277, 2007 Innovation Series white paper. Cambridge, MA, Insti-
Barry R, Murcko A, Brubaker C: The Six Sigma Book for tute for Healthcare Improvement, 2007. Available at:
Health Care: Improving Outcomes by Reducing Errors. http://www.ihi.org/IHI/results/whitepapers. Accessed
Chicago, IL, Health Administration Press, 2002 April 22, 2007.
Berghofer G, Lang A, Henkel H: Satisfaction of inpatients Hendryx MS, Beigel A, Doucette A: Introduction: risk-
and outpatients with staff, environment, and other pa- adjustment issues in mental health services. J Behav
tients. Psychiatr Serv 52:104106, 2001 Health Serv Res 28:225234, 2001
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APPENDIX
Online Resources
Agency for Healthcare Research and Quality (AHRQ): http:// Failure Modes and Effects Analysis (FMEA): http://
www.ahrq.hhs.gov www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/
American Academy of Child and Adolescent Psychiatry Measures/Risk+Priority+Number
(AACAP): http://www.aacap.org Institute for Healthcare Improvement (IHI): http://
American Medical Association (AMA) Physician Consor- www.ihi.org
tium for Performance Improvement: http//www.physi- Joint Commission: http://www.jointcommission.org
cianconsortium.org Leapfrog Group: http://www.leapfroggroup.org
American Nurses Association (ANA): http://www.nurs- National Association of Psychiatric Health Systems
ingquality.org (NAPHS): http://www.naphs.org
Amer ican Oste opathic Assoc iation ( AOA): h ttp: // National Association of State Mental Health Program Direc-
www.osteopathic.org tors (NASMHPD): http://nasmhpd.org
A m e r i c a n Ps y c h i a t r i c A s s o c i a t i o n ( A PA ) : h t t p : / / National Committee for Quality Assurance (NCQA): http://
www.psych.org www.ncqa.org
AQA (formerly called the Ambulatory Care Quality Alli- National Quality Forum (NQF): http://www.qualityforum.
ance): http://www.aqaalliance.org/ org
Center for Quality Assessment and Improvement in Mental Quality Indicator Project: http://www.qiproject.org
Health (CQAIMH): http://www.cqaimh.org Quality Measures Management Information System (Cen-
Centers for Medicare and Medicaid Services: http:// ters for Medicare and Medicaid Services): https://
www.cms.hhs.gov www.qualitynet.org/qmis
Evaluation Center at Human Services Research Institute Substance Abuse and Mental Health Services Administra-
(HSRI): http://tecathsri.org tion (SAMHSA): http://www.samhsa.gov
CHAPTER 33
THE ELECTRONIC
MEDICAL RECORD
T he field of medicine, which includes psychiatry, has medical record, not just a psychiatric chart (where rel-
made astonishing strides over the past century. Within evant, elements that are unique to behavioral health
this whirlwind of evolving medical science, however, it are highlighted in this chapter). The term behavioral
is equally astonishing to observe that the clinicians health is based on the revolution in health care that is
who are applying the latest therapeutics in the hospital already upon us, which has resulted appropriately in a
and clinic are doing so with antiquated tools: free-text much wider cadre of behavioral health care providers
handwriting with a pen on paper. Psychiatrists are car- including psychologists, psychiatric social workers,
ing for the most severely ill patients across multiple lev- nurse practitioners, certified addiction counselors, re-
els of care with extremely expensive modalities, such as habilitation counselors, and vocational counselors, to
state-of-the-art medications, extended hospitalization name but a few. It is extremely important that as we go
and day programs, and sophisticated treatment delivery forward in the development of a true national health
models (e.g., assertive community treatment teams). information network of medical records, as already en-
Yet despite this, in most instances we simply do not visioned in 2004 by President Bush and presently
have the clinical information needed at the point of care championed within the U.S. Department of Health
to make a well-informed, evidence-based decision. The and Human Services, the Office of the National Coor-
paper chart itself has become an obstacle to evidence- dinator for Health Information Technology, and the
based medicine, limiting our ability to transform anec- American Health Information Community, that we
dotal observations into useful quantitative data that in not be focused narrowly on a single profession within
turn conveys clinically actionable information. the larger domain of providers. One of the guiding
There are numerous specific and practical difficul- goals of the National Coordinator for Health Informa-
ties that have accrued to the paper chart (Morrissey tion Technology vision is to recognize the value of a
2006). Most if not all of these problems pertain to any patients clinical information (not limited to just one
439
particular care provider or professional role) across the (EMR) so difficult? Let us begin with productivity.
entire continuum of careanywhere, anytime. When a physician is overwhelmed with too much to
The challenges of reading handwriting are self- do from the outset, there is only one guiding rule
evident, but not trivial. Clinicians can be speeding about paperwork: get it done as quickly as possible, ir-
through a typed summary note from an emergency respective of legibility and content. In this context, the
room, only to come to a crashing halt when they get to written note is viewed as a personal aide-mmoire,
the documentation by a nurse regarding dose of medi- and its utility to anyone else is not a primary consid-
cation administered, the details of the use of restraint, eration. The same is true with physician orders. If the
or even the phone number of the key contact provided physician has already told the nurse what is ordered,
in the critical clinical information (Is that a 7 or a actually writing it down legibly and precisely for the
1?). Unfortunately, entire charts of clinical documen- pharmacist seems like an avoidable redundancy. In
tation can be literally unreadable, save for the island fact, it is precisely because nurses and pharmacists
here and there of a note written by a nurse or a social have historically performed so much of these writing
worker in impeccably clear handwriting. To encounter tasks that the Joint Commission on Accreditation of
such a note is to realize just how widespread and seri- Healthcare Organizations recently identified reduc-
ous the problem is. tion of reliance on verbal orders as a major focus of its
The handwritten order is an even more problem- safety enhancement program. The move to the EMR
prone domain. It is here that the Institute of Medicine actually threatens to radically reorganize the roles not
made its famous stand in 1999 in its report on acci- only of the physician but also of the cadre of physician
dental deaths and injuries in American hospitals, To helpers who have enabled the physician to be so pro-
Err is Human (Kohn et al. 2000). Handwritten orders ductive. Until the physician can feel comfortable with
are open to a wide variety of errors, including errors of the EMR in effectively replacing such human sup-
omission (time, date, signature, units, route, name [as ports, the old way may seem preferable.
when a physicians specific idiosyncratic abbreviation Because fixing the problem of illegibility costs time,
is used]) and errors of commission (medications that and because time represents both the ability to see all
are unavailable, misspelled, and/or illegibly written; of the patients who need to be seen and, of course,
names of medications resulting in transcription errors money, the consequences of these productivity de-
when a nurse or pharmacist makes the wrong guess mands on the physician are also financial. If a busy cli-
as to what the doctor really meant; wrong doses by nician sees 20 inpatients a day and scrawls illegible
an order of magnitude [as when a zero is left out or a notes and careless orders as quickly as possible, he or
quickly scribbled order makes seeing the tiny little dec- she will still end up working at least 8 hours (20 pa-
imal impossible]; wrong number of doses [as when tients seen for 25 minutes each). If slowing down to
hallowed Latin abbreviations like qd (daily) and qid write legible notes and precise orders costs an addi-
(four times a day)] are confused with each other; and so tional 5 minutes per patient, then 100 fewer minutes a
forth). Handwritten orders also present a serious prob- day are available, or 4 fewer patients can be seen, which
lem in terms of data management. In complex cases, is a 20% drop in productivity and income, or a nearly
just being able to readily review what the current active 20% increase in the hours a day worked (if the time is
orders are becomes a major effort. This is particularly simply added to the workday).
challenging for anyone other than the patients attend- Problems with the paper chart transcend illegible
ing physician (who may have a personal memory of the handwriting, however. There are many other stories
sequence). House officers, cross-covering attending about hospital medical records in which crucial clin-
physicians, and consultants all have to somehow re- ical information or communication is corrupted or
create the current medication list quickly. And going otherwise made unavailable because of a reliance on
to the old-fashioned paper medication administration chart- and paper-based systems. These would include
record (MAR), also called a Medex, is often no easier. innumerable kinds of faxing errors, including the fre-
Hunting through pages and pages of active and inac- quent omission of every other page when faxing two-
tive MAR entries to determine what is active is time- sided documents; the misuse or disuse of various me-
consuming and error-prone. chanical chart flags and associated paper flag lists to
So why do most hospital physicians, psychiatrists inform team members of necessary chart manage-
included, continue to accept and even prefer a paper ment tasks; allergy stickers that detach from the chart
chart? What are some of the hidden incentives that and are lost or reaffixed to the wrong chart; and miss-
make transformation to the electronic medical record ing charts that may have been misfiled, left carelessly
The Electronic Medical Record 441
in a variety of places in the nursing station, or taken to vice. There are fields to capture high-risk clinical data
an office or the medication room without any way to requested by Quality Assurance, such as the presence
determine their location. A wasteful search ensues of suicidal or homicidal ideation. And there are fields
that can easily add 5 minutes a day and nearly half an to capture Joint Commissiondriven mandates, such
hour a week to an already very busy work schedule. as pain assessments or the rationale for discharging
But the biggest problem with the paper chart is its patients who are taking multiple antipsychotic medi-
failure to organize information reliably, efficiently, and cations. Nursing documentation for seclusion and re-
retrievably. The paper page itself is the sole repository straint has become a blizzard of paper, with observa-
of clinical data elements, and it is only as useful as the tions made every 15 minutes, and page after page
attributes that define it, such as the patient ID stamp added if an episode continues for more than a short
(which validates the medicolegal patient identity), while. And, of course, all of these forms must be hand-
dates (which place data entries into temporal se- stamped with the patients ID card, front and back, be-
quence), and chart dividers (which parse related groups fore they can be filed in the chart.
of data into clinically meaningful categories). In the The result is a very thick and heavy chart compiled
bureaucratic world of twenty-first-century American within a matter of days in the hospital, with a 3-inch-
medicine, the amount of paper to be held and ordered thick, 10-pound bulk not uncommon after just a 2-
for a single hospitalized patient has bloated enor- week length of stay. The task of maintaining organiza-
mously, thanks to both regulatory and financial de- tion of this thick, heavy chart, which is a requisite for
mands, as well as the availability of faxing and Xerox- any reliable information retrieval, is considerable.
ing. There are now pages of preliminary administrative Such charts are often dropped and the papers reassem-
information, financial data, intake and contact data, bled out of order. Frequent copying and faxing of docu-
emergency room records (with their own intake data), ments also result in misfiling, both within the correct
assessments, progress notes, consults, lab results, and chart and often within another patients chart. Similar
diagnostic tests. There are outpatient records, school misfiling or data loss occurs when pages tear from fre-
records, immunization records, and documents sup- quent turning. Once again, the result is a very real deg-
plied by family and the patient providing additional radation of clinician efficiency, as the time-pressed
history. There are always legal documents in a psychi- doctor either stops to find the missing documents or,
atric inpatient chart (a signed voluntary admission worse, just gives up and makes decisions based on
form, more forms if the admission is involuntary, still memory because the documentation is just not readily
more if a clinical review panel is convened to decide on available.
involuntary medication, and yet more again if that Every one of these scenarios is familiar to workers
panel is appealed). There can be power-of-attorney doc- in other sectors of industry that require extensive real-
umentation, guardianship papers, consents of all time documentation of industrial or personnel pro-
kindsincluding releases of information, permission cesses and implemented computer-based solutions.
to reveal the presence of the patient in the hospital, per- Only medicine, a sector representing one-seventh of
mission to treat an adolescent with a specific medica- the total economy, lags behind. Without addressing
tion, and so forth. And we have not yet arrived at the this shortcoming, medicine cannot hope to achieve
current clinical documentation itself! Six Sigma quality status (Chassin 1998).
The demands of the contemporary regulatory bu-
reaucracy in American medicine have resulted in ever-
closer scrutiny of clinical documentation. This has in
What Added Value Can
turn led some organizations to develop specific clinical the Electronic Medical Record
documentation forms for every discipline to better
record what the regulators are looking for and make it
Bring to Inpatient Psychiatric Care?
easier for the auditors to find such information. The
effect has been to increase the number of pages of pa- The good news is that the EMR can robustly address
per in a chart. A physicians admitting note form can every information problem described above qualita-
be five pages long; a daily progress note can be three tively and efficiently. Legibility problems vanish. Filing
pages long. There are structured fields for data ele- accuracy, flagging effectiveness, and information ac-
ments that Medicare auditors require to calculate the cess are vastly enhanced. Data structuring is integrated
correct billing code to assign for the service provided as into the workflow, thus adding to the clinical and qual-
well as to document the medical necessity of that ser- ity assurance functions rather than detracting from
them. Data integration is performed in seconds, and a the current state of the paper workflow as it typically
current summary of all important clinical parameters exists in hospitals. The physician writes orders or
is displayed in a single view. The vessel containing and gives abbreviated verbal orders to a nurse. The written
presenting the data thus helps to transform that data orders may be taken off by a variety of staff mem-
into clinically useful information, rather than obstruct bers, including the nonmedical unit clerks, nurses,
access to it, as so often happens with paper. and, in some settings, pharmacists or pharmacist
Beyond these improvements on the paper chart, techs. The person who takes off the order documents
however compelling, there are also new quality-of-care his or her action and must then transcribe the order
concerns bearing directly on the safety of patients to onto a paper MAR, which is subject to error. The order
which the EMR can actually bring added value, even as must also be somehow communicated to the phar-
it performs the onerous task of simple documenta- macy. This may be done by faxing, which is problem-
tion. For example, the EMR allows for documentation atic if the fax degrades the physicians handwriting leg-
and justification of diagnoses and problem lists across ibility. The pharmacist must interpret the physicians
levels of care over time. Psychiatric diagnoses have order, possibly in a manner different from the nurse or
been criterion-based since Robert Spitzer leveraged the unit clerk who is transcribing the same order onto the
groundbreaking work of Research Diagnostic Criteria MAR, and then manually enter the order into the hos-
from 1978 into DSM-III in 1980 (American Psychiat- pitals pharmacy system. The pharmacy system is typ-
ric Association 1980). Yet in spite of extensive and ex- ically a standalone computer system exclusively dedi-
pensive efforts by the American Psychiatric Associa- cated to keeping track of all medications ordered,
tion to educate psychiatrists in the use of such dispensed, or returned unused to the pharmacy. The
criterion-based diagnoses, it remains nearly unheard pharmacy system software industry is to some extent
of, except in research settings, to be able to find clear parallel to the EMR industry, and only very recently
documentation that the criteria were met when a par- have there been efforts to consolidate these products
ticular diagnosis was made, much less to be able to into a single integrated applicationlargely because of
track these criteria over time, as the patients illness the major delay in adoption of EMRs by most Ameri-
evolves. By its very nature, however, the EMR can pro- can hospitals. As a result, it is the pharmacist, not the
vide a convenient way to maintain a diagnosis and physician, who has access to the online databases that
problem list across episodes of care. The ability to eas- can and do immediately alert the pharmacist that, for
ily document in a single place the diagnostic criteria example, an order is in conflict with a patients known
met at a given point in time is enormously helpful for allergy history, exceeds a certain safe dosing threshold,
the next clinician who may be facing the patient for has the potential to interact unsafely with the medica-
the first time, along with a confusing array of cross- tions the patient is already receiving, or is a duplicate
sectional signs and symptoms. Relying on the old pa- of a therapeutic treatment already ordered for the pa-
per chart, which may merely list a diagnostic label tient. Now the pharmacist, who does not usually
without any justification, as we now do so often, is fre- know the patient, must contact a nurse on the unit
quently not helpful. But an EMR maintains the diag- (though not necessarily a nurse who had anything to
nosis across episodes of care so that the evidence for do with taking off the original order), and this nurse in
the diagnosis can be documented, attached to the diag- turn must track down the doctor and deliver a call-
nosis, and passed along for all to see and add to over back. But because the nurse is at this point a periph-
time, blog-style. This last functionality is presently an erally related intermediary, the message is often un-
untested promise, awaiting future publications with clear and the physician must make a second callback
best-practice guidelines to demonstrate how it might to the pharmacist directly, to clarify the pharmacists
be optimally configured and executed. Here is an ex- question and make a decision. Having done so, a third
ample of how technology has opened an exciting win- callback is now needed, this time back to a nurse on
dow of opportunity. It will be up to clinicians in the the unit who can receive a verbal order to cancel the
next decade to take full advantage of the EMRs power original order and write a new, revised order.
and exploit it for the benefit of excellent patient care. CPOE changes the dynamics of this complex task
Computerized physician order entry (CPOE) simi- dramatically. By placing the physician directly in con-
larly enhances patient safety and quality of care in trol of the order entry process, which is now structured
many ways (Berger and Kichak 2004; Butler et al. by the computer in a way that ensures that all required
2006; Kilbridge et al. 2006). To understand the impor- data elements are present, the initial order is en-
tance of these improvements, one must first analyze teredlegibly, cleanly, logically, and completely. Just
as important, those warnings that only the pharma- not done at all (leading, at times, to serious adverse
cist had been receiving now go directly to the physi- outcomes) or is delegated to a nurse to research and
cian entering the order. Real-time warnings to the cli- prepare for the psychiatrist every morningan expen-
nician writing the order are more likely to educate a sive and clinically wasteful deployment of resources
physician about his or her own knowledge base and that might otherwise be put to better use in direct pa-
quality-of-care standards as well as demonstrably im- tient contact. A well-configured eMAR can assist the
prove patient safety (Smith et al. 2006). And the phy- psychiatrist in efficiently keeping track of all the doses
sician can remedy the problem on the spot, thus elim- of medication a patient receives. In addition, the nurs-
inating all of the callbacksand saving time for many ing documentation regarding the efficacy of the prn
staff members. The efficiency does not end there, medications can be readily displayed within the eMAR
however. The entire process of transcription, faxing, environment. Duplication of documentation for nurs-
and mailing of orders by others is removed, as are the ing is thus avoided, and the psychiatrist obtains the
errors associated with that process. The MAR be- valuable clinical information needed to make the next
comes the eMAR (electronic medication administra- set of treatment decisions.
tion record), which is now populated automatically by Another notorious problem universally associated
the EMR, based on the logic associated with the com- with paper charts and orders is the Joint Commission
puterized order. Of course, the pharmacist must still and Centers for Medicare and Medicaid Services man-
verify the order and can delay it if there is a medical or date that verbal orders be countersigned by a physi-
availability concern. But otherwise, once the pharma- cian. This requirement, which on the surface might
cist releases the order as verified, the physicians in- seem innocuous enough, is in fact the focus of a major
tent is automatically expressed on the eMAR for the national effort in American hospitals. How does an or-
next medication administration time. The complexity ganization systematically keep track of all the clini-
of the inpatient ordering process, consisting of many cians who may have given verbal orders but are not
error-prone steps, is now managed within three sys- based on the patients unit and therefore not routinely
tems: CPOE, pharmacy, and eMAR. present the next day to see the mechanical flag or re-
The industry is working toward single-integration ceive a paper flagsheet? The EMR addresses this kind
systems; in fact, some of these products were already of problem brilliantly. Unsigned orders are automati-
introduced in 2006. The time-saving value of the cally flagged to the patient list of the original ordering
eMAR to nursing can be huge. In organizations that doctor, as well as to the patient lists of any other au-
have increasingly been forced to hire per diem or thorized doctors who may, by virtue of their supervi-
agency staff to cover shortfalls in full-time nurses, a sory role or their membership in a common group
very real increase in medication errors has occurred. A practice, sign on behalf of the original doctor, thus
typical response to this problem has been to increase eliminating a problem that has consumed countless
the manual review of the paper MARs and paper or- hours of clinical administrative time. Similar efficien-
ders, often in every shift in settings with high turnover cies accrue in the handling of seclusion and restraint
and high volume. The necessity of this quality control orders, which in recent years have had their oversight
effort disappears with the eMAR, freeing the medica- ratcheted up to such a degree that reordering must be
tion nurse to engage in other, more valuable clinical done every 4 hours and face-to-face reevaluations con-
activities, such as actually conducting medication ducted every 8 hours. The EMR can greatly enhance
education face-to-face with patients. the efficiency of ensuring that such reordering and re-
The eMAR can become a very medically useful tool evaluations are done on time, by virtue of the built-in
for the inpatient psychiatrist. Certain psychiatric in- flagging rules, by organizing the patient list in a way
patients (e.g., acutely psychotic patients) often refuse that brings focus to select kinds of patients, and, in
some or all of their prescribed medications during the some scenarios, by automatically paging the doctor
early part of an admission and then receive various prn should the order renewal time lapse. From the per-
(as needed) medications instead. Keeping track of spective of auditors, monitoring compliance with
what is initially refused, what is subsequently taken, mandated policies and procedures associated with se-
and what is taken extra in the form of prn doses adds clusion and restraint becomes much easier and more
up to an extremely important information-manage- reliable, and organizations can routinely self-monitor
ment activity. It is quite difficult for a busy psychiatrist so much more easily that problems are identified and
to track this information quickly with a paper chart resolved long before Joint Commission and Centers
when making rounds; such tracking is therefore often for Medicare and Medicaid Services auditors visit. We
are able to move from a time-sampling methodology A full discussion on the vision and progress of the
delegated to external agencies to a real-time, 100%- National Health Information Network is well beyond
sampling methodology owned by the organization it- the scope of this chapter, but mention of it is relevant
self. In any management system, this counts as a ma- to the extent that such a formal federal focus clearly
jor step forward. highlights the increasing urgency with which universal
Since deinstitutionalization, inpatient psychiatry deployment of EMRs in hospitals across the country is
has evolved from the isolation of the asylum to a role being viewed. No network can exist without a preexist-
of equal partner in a continuum of levels of care. The ing backbone of EMR systems. In 2005, the Office of
need to communicateaccurately and in real time the National Coordinator for Health Information
the patients most recent history at the immediately Technology began the process of standardizing the am-
preceding level of care has never been more urgent. bulatory EMR industry with a view toward compatibil-
The fallback tool has always been the discharge sum- ity within a future National Health Information Net-
mary. work by creating the Certification Commission for
There was a time when the discharge summary was Healthcare Information Technology (see http://www.
a serviceable solution. In the current era, there are cchit.org).
many problems with this model, however. In many set- As always is the case when such global visions
tings today, the discharge summary is often not done meet the daily reality of clinical practice, there are im-
by the attending physician and in addition is often in- portant practical considerations that may have a tre-
complete and delayed. Moreover, bureaucratic obsta- mendous impact on the final implementation of a sys-
cles imposed by well-intentioned and mandatory pri- tem. Would a busy outpatient psychiatrist ever have
vacy rules mean that even if the receiving physician the time to peruse an information-packed inpatient
wishes to obtain the discharge summary completed by EMR, even if he or she did have easy access to it?
a social worker 30 days after the fact, he or she will Would the data be sufficiently standardized, given the
have to take the time to ensure that the patient com- current plan, to permit an unlimited number of soft-
pletes a detailed release-of-information form. The re- ware vendors to enable outpatient end users to find the
ceiving clinician is thus often left with just the patient same kinds of data from three different hospital
in front of him or her, having no idea all that was done EMRs? How would those data be made available to
in the previous level of care. end users? As one considers the potential problems of
An EMR by itself cannot solve the discharge sum- a global health information network, the traditional
mary problem. Some EMRs have been developed with physician-dictated discharge summary starts to look
tools that enable clinicians to cut and paste documen- better and better. It may in fact be premature to as-
tation assembled in the EMR during the patients stay sume that a National Health Information Network
and collect it into a de facto discharge summary. Such a will eliminate this important document.
quasi-summary can be quite unsatisfactory. By defini- A discussion of discharge summaries necessarily
tion, it is not actually a summary (which intentionally brings up two other often onerous chores of inpatient
implies a synthesis of a case, with an overall formula- practice: the writing of discharge prescriptions and the
tion of what was going on, why this or that did or did generation of Joint Commissionmandated medica-
not work, what the final outcome was, what the recom- tion reconciliations at every change in level or location
mended aftercare should be, and why). No cut-and- of care. The EMR has the potential to facilitate these
paste technology can create this kind of summary with- tasks enormously. The functionality to generate pre-
out heavy editing, at which point it is more efficient to scriptions directly from the inpatient orders, with only
just do the whole thing from scratch. And without such minor editing needed, already exists. Such prescrip-
editing, one is often left with, at best, a choppy sequen- tions can be signed electronically and faxed directly to
tial narrative that often fails to reveal the underlying pharmacies. If a small supply of medications must be
analytical process that is at the heart of the case. dispensed directly from the hospital pharmacy to tide
In lieu of a high-quality standard discharge sum- the patient over until the outpatient pharmacy fills the
mary, one can imagine an integrated network of health prescriptions, this duplicate work can also be speedily
information resources, with all their clinical data handled by the EMR. Medication reconciliations be-
pooled into a common system that can be accessed in come quite simple when the outpatient medication
real time by appropriately authorized clinicians in the profile generated at the time of admission by the ad-
service of providing ongoing continuity of care (Markle mitting nurse and doctor is already in the system to
Foundation 2004). populate the reconciliation, and the electronic pre-
scriptions generated at discharge automatically popu- to formularies and displaying allowed choices to
late the discharge half of the reconciliation. The clini- physicians at the point of service if the databases are
cian has saved enough time to actually think about the accurately maintained (no small task in this world of
two lists and ensure that they reconcile as intended. constantly changing benefit structures and insurance
The EMR offers the possibility of achieving an in- choices).
depth knowledge of patients over time. And this, in A final example of how the EMR is poised to trans-
turn, is a prerequisite for managing risk. A health sys- form hospital care can be seen in the realm of quality
tem with an EMR that spans all levels of care can be- assurance. Joint Commission, Centers for Medicare
gin to compete with the managed care industry by ac- and Medicaid Services, and state Medicaid authorities
quiring, organizing, and analyzing clinical data on its all look for evidence that the hospital and its profes-
own, beholden to no corporate agenda. Early efforts at sional staff are providing the highest possible quality
this were made in the 1990s by capitation programs of care for patientsnot just the highest cost. Assur-
(Braun and Caper 1999). If clinician entrepreneurs ance methods have been diverse, from the question-
were armed with high-quality longitudinal clinical able reliance on received expert opinion, as solicited
data across all levels of care and perhaps also empow- by and then published in the U.S. News & World Re-
ered to take more risk on behalf of the overall care of port Annual Rankings, to pseudo-objective scores
the patient, we might see a real revolution in patient passed out by site surveys conducted by these agen-
care that was truly managedin the best interest of cies. The managed care industry tried briefly and un-
the patient, with evidence-based therapeutics. Al- successfully to force standardized outcome measures
though such a vision is utopian today, it could only on health care in the 1990s, and measures such as the
happen with the deployment of EMRs across a large Healthcare Effectiveness Data and Information Set,
continuum of behavioral health care. developed by the National Council on Quality Assur-
Other examples of improved efficiency from an ance (Druss 2004), continue to promote this effort.
EMR include automated alerts and automated formu- How different might these measures be if the behav-
lary checking. In the paper world, the nurse, pharma- ioral health community could examine a standardized
cist, or unit clerk reminds the physician that a task data set of all of treatments and outcomes based on
needs to be done by way of a paper flagsheet, phone data-collecting tools embedded in an integrated net-
call, or Post-it note in the physicians mailbox. All of work of EMRs? Such data could serve multiple pur-
these messages can be easily ignored and have no in- poses. At the macro level, the data could be consoli-
herent audit history. The EMRs capacity to support dated from diverse regions to address epidemiological
auditable and reportable flag management exposes questions. At the systems level, the data could shed
physicians who routinely ignore reminders to renew light on the differences in patient mix, as well as treat-
orders, sign discharge summaries, and so forth. Ide- ments and outcomes among all programs. At the prac-
ally, the EMR facilitates the execution of those tasks titioner level, the information could lift the cover off
(e.g., the physician can sign an entire batch of orders the shroud of professional secrecy and arouse new in-
from a variety of places with a single click). Formulary terest in a truly exciting and informed peer review pro-
checking is computings solution to managing the process. The EMR can form the backbone of a systematic
liferation of insurance benefits currently available to and transparent data collection system that can reveal
our patients. When the consumer advantages of com- what we do so we can do it better. It is an indispensable
petition in the insurance industry are touted, the pro- part of the solution to crossing the quality chasm
viders struggle to cope with all of the different plans is (Chaudhry et al. 2006; Hillestad et al. 2005; Institute
usually not mentioned. And the consequences of mis- of Medicine 2001).
managing formulary benefit information can be worse
than just added overhead expense. The fact is, if phy-
sicians do not know what formulary a patients insur-
Obstacles to Computerized
ance uses at the point of service (in this case, when Records and Computerized
writing that first order for a new medication that will
drive the entire hospitalization), they can make mis-
Physician Order Entry
takes that result in patients being discharged on med-
ications they cannot pay for, thus having to redo the Despite the enthusiasm expressed so far for the poten-
entire treatment at the worst possible time. Comput- tial of the EMR, the field is not there yet. The prob-
ers are ideally suited to the task of matching benefits lems associated with current technology, combined
with deeply embedded industrywide disincentives, are ery order before it is released to the eMAR as an active
substantial and worthy of serious analysis (Gesteland order, or it may be left up to a nurse to question an or-
2006). To begin with, the functionality of the utilities der because it is unusual or because she sees an obvi-
described above varies greatly, and discrepancies be- ously sedated patient in front of her. Perhaps the sys-
tween the real and the ideal can be downright dismay- tem itself, if sufficiently programmed with dosage-
ing. Three examples may suffice to make this point. range checking algorithms, may prevent a dangerous
The much-vaunted computerized warning alerts, error from occurring.
designed to prevent some of the 100,000 accidental Other examples of novel electronic order mistakes
and preventable deaths documented by the Institute of include user errors that occur because of inexperience
Medicine (2001), can be terribly flawed. They can be and unfamiliarity with a complex system: lack of
set to appear for even the most trivial of antacid and awareness of a previously given dose of medication be-
diet interactions. They may be displayed in a stun- cause the view filter on the eMAR is set incorrectly;
ningly arcane format, which can make finding the failure to dispense a medication because of faulty in-
take-home message an exercise analogous to wading tegration among the EMR, the pharmacy system, and
through the PDR. Instead of quickly and efficiently re- the medication dispensing system; failure to draw a
minding clinicians of the value and importance of re- laboratory sample despite timely order entry because
membering a specific aspect of a treatment, the warn- of faulty integration with the laboratory workflow and
ings instead irritate doctors and can discourage them unanticipated requirements for entry of additional de-
from even bothering to read the messages at all. The fining data in mandatory fields programmed into the
problem is further compounded when the system does routine lab order form. Most of these errors can and
not display the message in large or bold type or re- are resolved with user experience and ongoing refine-
quires the user to expand a window or scroll through ments of the system. But they highlight a more general
reams of text to find the relevant nugget of informa- problem associated with the transition to the EMR
tion. Such computer-generated inefficiency can be just namely, the need to recognize the magnitude of the
as exasperating and debilitating as the problems de- change in daily workflow for all users, not just doctors
scribed regarding the paper chart. Perhaps, however, and nurses, and how many unanticipated complica-
these difficulties will be reduced by improved and, if tions arise as a consequence of this transition in the
necessary, customized programming to meet the initial implementation of a new EMR system.
needs of specific users and settings. Perhaps the biggest obstacle to EMR adoption in
The problems described earlier with order errors in hospitals, beyond the enormous cost, is physician-user
the paper chart may also unfortunately be supplanted adoption (Audet et al. 2004). Although a hospital can
by novel electronic order errors as the bane of Quality mandate that employees such as nurses, pharmacists,
Assurance. Although legibility and transcription mis- and lab technicians take training classes and learn new
takes vanish instantaneously with the EMR, system- technologies, learning new record-keeping techniques
and user-generated errors may create new domains of often proves quite challenging for medical staff in
risk that will require vigilant monitoring (Berger and open-staff hospitals. Doctors who admit to multiple
Kichak 2004). The simplest example is the prn order. hospitals, especially surgeons or other physicians who
In the paper world, prn orders are simply so ingrained do very specialized consulting work, are faced with a
that it is virtually inconceivable for a clinician to write daunting prospect of having to master several different
an order without the prn included. In the EMR, how- systems deployed in the various facilities in which they
ever, most systems require the prn status to be indi- work. It is hard enough to learn any one system. It is
cated by checking a prn box. This may seem trivial simply unrealistic to expect a busy physician to master
enough, but we have seen many examples in our set- two or three different systems, each with its own idio-
ting of problems with this feature in a new EMR. The syncrasies that must be learned through painful trial
new user, focused on learning all of the complexities of and error, each with its own logins, passwords, and
the EMR and distracted by the novelty of the workflow policies. The process is further compounded by the
and the pressure to get the job done quickly and move very real age-dependent variabilities in computer and
on, will simply skip the prn checkbox. The conse- typing skills across the range of younger to older phy-
quences of this mistake can be serious: a lorazepam sicians. The computer revolution and the Internet
dose of 2 mg every 4 hours can quickly become intox- have literally passed some (but by no means all!) older
icating if continued around the clock. The remedy for physicians by in the past two decades. Learning these
this problem might be for the pharmacist to verify ev- skills on the job while continuing the frantic pace of
clinical work they are used to can simply be unimag- model, based as it is on the limitations of the paper
inable to some clinicians, young or old, even if they do chart, is hampered by its status as a onetime exercise
have previous computer experience. In an open-staff subsequently relegated to a section of the chart. The
setting, physicians may simply revolt and threaten EMR has the power to transform the MTP, however.
convincingly to admit their patients somewhere else Beginning with the physician and nursing admission
that does not hassle them with such demands. A med- notes, a problem list can be jointly developed, which
ical-surgical hospital in Baltimore implemented CPOE then populates flowsheets in the EMR and is linked to
by continuing to allow physicians to write paper orders clinical documentation by nursing. The MTP confer-
and paying a technician to pass through each nursing ence itself becomes a much richer experience because
station every 2 hours and enter those orders into the the problem list has already been initiated and docu-
system, with nurses handling any urgent orders on the mented from the moment of admission and is readily
spot. Thus, the hospital reaps some of the advantages available for incorporation into the MTP itself. A truly
of the EMR order-entry functionality while the physi- master treatment plan can thus be developed, be-
cians perpetuate the timeless handmaiden tradition of cause now all relevant data are available in a summary
yore. This problem has been addressed to some degree display that includes diagnoses, vital signs, allergies,
by the rise of the hospitalist model in the past decade. significant events, and even insurance information,
As managed care has made it increasingly difficult for facilitating a comprehensive grasp of the case by all
many ambulatory internists to even afford to do inpa- team members. Progress toward objectives can also be
tient work, hospitals have come to rely more on a tracked in nursing notes linked to the MTP, thereby
closed staff of employed hospitalists, both in medical- achieving the Joint Commission Holy Grail wherein
surgical settings and in psychiatry (e.g., the Sheppard the MTP finally drives treatment as was originally
Pratt Health System). Such a staffing model facilitates intended.
adoption of the EMR, in terms of both training and Documentation of diagnosis in the MTP is greatly
corporate control, but also because staff members are simplified by the ability to draw upon the EMRs diag-
much more likely to see the value of an EMR if they are nosis list, which has been added to from the first ad-
focused on the patient care in a single setting, where mission (at any visit) since the EMR was imple-
the functionality of the system is leveraged over the en- mented. Tools such as Significant Event fields assist
tire patient caseload. the team in focusing on order-specific target problems
that the MTP will address. And discharge planning
during the MTP may be enhanced by immediate ac-
Specific Psychiatric and cess to insurance benefits contained in the system.
The end product is an order of magnitude beyond the
Behavioral Health Functionality scribbled one- or two-line documents that are com-
monly seen today. Such a document makes competent
The EMR has historically been designed for the tradi- discussion of the caseby the physician with a col-
tional medical application. Behavioral health imposes league, by the utilization reviewer with the managed
its own specialized requirements upon the EMR. As of care reviewer, and by the social worker with the family
2008, the EMR industry has not produced any fully and the referring agencypossible in a way seldom be-
functional product that comprehensively addresses fore realized.
the needs of inpatient behavioral health care. The Until now, MTP software has been a standalone
most prominent example of this needavailability gap product for inpatient applications and has not experi-
is the lack of an electronic product for generating the enced much user adoption, because of failure to inte-
master treatment plan (MTP), which has been man- grate it into a paper chart world. The vision described
dated by the Joint Commission, the Centers for Medi- above of a true EMR-based MTP requires customized
care and Medicaid Services, and most state regulatory forms development and considerable planning by the
agencies since the 1960s. The MTP is a major focus of end-user group during the preparation stage of EMR
most site visits by regulatory agencies. It is a paper deployment. In the next generation of EMR software,
document that has been divorced from routine daily it is hoped that products will be developed that have
care of patients; it is usually viewed by most clinicians such functionality already preconfigured by the devel-
as paperwork. Although this is not always the case oper, requiring only minor final tweaking by the end-
(indeed, first-class MTPs can be developed that truly user group to accommodate the functionality to the
do advance excellence in patient care), the traditional precise needs of its setting.
Another area where the EMR may excel in advanc- pitalizations, medications, stressful life events. In the
ing inpatient behavioral health care is in the domain hospital, especially with the treatment-refractory case,
of behavioral tracking. The paper chart has always val- it is often very important to be able to review the
ued the narrative note above all else. Graphing has course of treatment over time in a way that links the
always been the exception. Even in medical-surgical changes in medication to the patients behavior and
settings, it is the poor medical student who is sent off mental status. A unique twist in inpatient behavioral
to laboriously plot the labs over time and then stick it health care is that disturbed psychiatric patients often
in the chart. The routine visual display of quantita- either refuse medication or require significant addi-
tive data for clinical decision making has not been tional prn medication, thus placing another hurdle be-
easy and is thus rarely done. fore anyone wanting to plot treatment against out-
Behavioral health care often lends itself nicely to come. The traditional approach to this kind of data
semi-quantitative data acquisition and display. Partic- display has been to have a nurse or research technician
ularly nowadays, with managed care requiring only the laboriously tally up the total daily doses of medica-
highest acuity to justify even a few days within an in- tions, by type, on a daily basis, so as to display the total
patient setting, there is usually no shortage of readily daily dose (i.e., standing medication plus prn medica-
identifiable target behaviors available for documentation minus refused doses). This can then be tracked
tion: tearfulness, yelling, refusal to get out of bed, re- along the X axis over time; as the doses increase or de-
fusal to take medication, refusal to attend groups, at- crease, the medication is changed, or another is added.
tempts to elope, intrusive attention seeking at the Therapeutic drug monitoring data can be added to the
nursing station, too-loud talking, touching of other medication sequence. Above this display one can then
people, defacing of walls, and so forth. The EMR al- plot clinical behavioral data, be it rating scale items or
lows the incorporation of a behavioral dictionary of scores, frequency counts of target behaviors, or signif-
target inpatient behaviors, both pathological and icant events such as a visit from family. The resulting
prosocial/adaptive, which can then be coordinated display can summarize a complex case dramatically,
with the MTP and tracked on flowsheets just like vital clarifying the extent to which a given medication regi-
signs or intakes and outputs (I&Os). Documentation men is indeed helping (or not) and refining the overall
of quantifiable data elements within an integrated understanding of the natural history of a patients re-
electronic flowsheet structure can transform anecdotal sponse to treatment. Although no current EMR that
impressions (Sally seemed more agitated when the we are aware of is quite ready to generate such a display
family visited) into robust quasi-experiments on the off the shelf, it is safe to assume that availability of
fly (Sally had 2.4 verbal outbursts/day prior to the medication data within an eMAR and the structured
visit, 6 on the day of the visit, and 2.7 the week after behavioral data within flowsheets should ultimately
the visit.) The ability to easily plot a single rating allow custom programming to bring these together.
scale item such as a Positive and Negative Syndrome
Scale hallucinations score or a Montgomery-sberg
Depression Rating Scale item against a longitudinal
Protection of Patient Privacy
display of ongoing medication or other treatments
from the moment of admission could rationalize the The most visible subject to differentiate behavioral
approach to therapeutics, which, at present, is at risk health from the rest of medicine and surgery in every
of being oversimplified by the expediency of managed discussion of EMRs is invariably the issue of protect-
care demands. One can well imagine the EMR empow- ing patient privacy. Since the days of the Pentagon Pa-
ering a clinical team with much more actionable data pers and the burglary of Daniel Ellsbergs psychia-
to argue on behalf of their patients when managed care trists office in 1971, the public has been keenly aware
denials threaten inappropriately. These and other pos- that confidential information disclosed in the privacy
sibilities for intelligent and creative improvements to of a psychotherapeutic session could potentially be the
patient care, based on real clinical data, are virtually target of malicious abuse. (Ellsberg had leaked secret
innumerable with the empowerment of the EMR. documents from the Pentagon about the Vietnam war
A final example of unique behavioral health care to the press; to punish him for this, a break-in was au-
functionality in the EMR is the psychiatric historical thorized by the White House to obtain incriminating
time line, which displays the sequence, duration, and evidence against Ellsberg from his psychiatrists psy-
severity of psychiatric signs and symptoms over time chotherapy notes.) Psychiatrists, psychologists, and all
against other selected relevant parameters such as hos- other behavioral health care providers have tradition-
ally maintained the strictest of confidentiality stan- a hospitals organizational structure and discipline
dards with regard to such information. Most states (e.g., the professional medical staff). Even if hospital
have endorsed and supported such protections, legis- EMRs are eventually linked to the National Health In-
lating rules protecting psychotherapy notes as having formation Network as it is envisioned here, it is un-
at least limited privilege, except in a Tarasoff situation likely, as we have already suggested, that users outside
or in the event of an imminent life-and-death crisis for the hospital would have easy access to, or even want,
the patient. primary source documentation related to a patients
The 1996 KennedyKirshenbaum Health Insur- visit. The complexity and volume of data would make
ance Portability and Accountability Act (HIPAA) is such trolling from outsiders quite challenging, if not
widely perceived by the lay public as having increased impossible. However, summary documents or per-
the requirements of medical providers to drastically sonal health records regarding patient visits will likely
increase the privacy standards of all patients. How- be readily available, and if the only thing that protects
ever, from the perspective of behavioral health, the act behavioral health information is an undefined HIPAA
actually lowered the bar. The HIPAA Privacy Rule in standard of medical need to know, it is clear that
fact states that sharing medical information between many confidential behavioral health secrets may be
medical providers on behalf of a patients medical care, exposed to the unfettered cyber-breeze of the network.
including explicitly psychiatric information, does not Once information is shared between the source pro-
demand any HIPAA protection and may include in- vider and the receiver, there is no guarantee that it will
formation such as psychiatric diagnosis, psychiatric not be reshared with third and fourth parties, and be-
medications, and past psychiatric hospitalizations yond. It is for this very reason that psychiatric depart-
(Mosher and Swire 2002). The only explicitly pro- ments in large academic hospitals can be the last ones
tected behavioral health information in HIPAA is so- to adopt the hospitals EMR.
called psychotherapy notes (again recalling Ellsberg). Solutions to the confidentiality challenge are var-
The reason for this brief historical digression is ied. The most conservative privacy advocates actually
that rules and standards are currently being created demand a nonelectronic alternative to every health
that will govern exactly the kind of information that is care encounter. For those willing to embrace the inev-
or is not protected within an EMR and, more broadly, itability of the EMR revolution, options include vari-
within a national health information network that ous integrated software strategies to hide confidential
integrates these EMRs (Terry and Francis 2007). As data elements. These safeguards range from the most
HIPAA is currently written and construed, there will primitive confidential zone (an arbitrary, unstruc-
be no a priori confidentiality protections for a psy- tured password-protected subset of the clinical data-
chiatric diagnosis, psychiatric medication, or history base populated completely at the discretion of the cli-
of psychiatric hospitalization. A patients diagnosis of nician user) to a more sophisticated behavioral health
alcohol or cocaine abuse, a history of amphetamine- lock box to a highly sophisticated system of granular
treated atten tion-deficit/hyperactivity disorder privacy tags that can link discrete items such as a
(ADHD) in childhood, a hospitalization for postpar- diagnosis or historical element to a specific set of de-
tum depressionall will be fair game for any health fined confidentiality rules issued by the patient, con-
care provider who has a legitimate relationship to the trolled by the release of those data elements indepen-
patients case, including, for example, the plastic sur- dently of the clinician who originally elicited the
geon, the dermatologist, the allergist, even the dieti- information from the patient. In this last scenario,
tian and physical therapist. The potential for wide- the tags automatically display certain data to a psychi-
spread dissemination of personal information that has atrist who has bona fide electronic credentials and
historically been the privy of only the patients psychi- also a bona fide current established therapeutic rela-
atrist and perhaps the primary care provider suddenly tionship with the patient while hiding that same in-
becomes a very real possibility. Because we focus on formation from a legitimate but nonbehavioral health
inpatient psychiatry, the task of managing this pros- provider, such as a surgeon. Clearly, for the present,
pect of such widespread exposure is marginally easier no EMR is sophisticated enough to stop a clinician
than in the ambulatory world. Hospital EMR systems from just writing down privileged information inap-
are usually monolithic single entities, within the con- propriately in a public domain, such as an unpro-
text of a relatively closed system of providers and us- tected medical history. So even the most powerful
ers, the majority of whom are either employees of the software protections will inevitably only be as strong
hospital or contractually bound in significant ways to as the carefulness of the least careful provider.
Standalone behavioral health facilities have a small has been disappointing. The reasons for this are man-
advantage in this regard, given the built-in barriers of ifold and include the inherent conservatism of physi-
organizational boundaries, which preclude nonbehav- cians as a group, the very real complexity and cost of
ioral health care providers from accessing the EMR on a the task at hand, and the lack of any overarching stan-
casual or routine basis. All EMRs, however, are vulner- dards and championship from organized medicine. It
able to security lapses, including stolen laptops and is no accident that the most robustly developed sys-
hacking of servers located in distant states that can tems around the world have evolved in top-down set-
host a hospitals EMR remotely. Because of numerous tings such as the Department of Veterans Affairs and
recent widely publicized cases of wanton irresponsibil- the U.S. military or European countries with national
ity in the breaching of database security, the public is all health systems. The invention of the personal com-
too aware that no promise of data integrity is foolproof. puter and the Internet, though clearly a net gain for
In fact, it is probably safe to say that the drawbacks of the industry, also confounded it for a time, as products
the paper chart also account for its (relative) security in had to be retooled or even reinvented from scratch to
protecting privileged personal health information. As fully meet the demands of Windows, graphic user in-
Nixons plumbers discovered 35 years ago, stealing pa- terface displays, and Web-enabled functionality, none
per records is difficult and risky, and the chore of writ- of which was even remotely supported by earlier prod-
ing or copying information by hand is so tedious and ucts. The lack of standards and openness continues to
costly for the busy clinician that there is a built-in dis- hamper the industry, diverting scarce resources to
incentive to share information. Although Ellsberg him- marketing and user support and away from pooled re-
self stole other kinds of information and leveraged the search that might actually produce products that are
then-new photocopying technology to disseminate it so successful they do not require an army of techni-
publicly to the newsprint media, the power of the Inter- cians to customize, deploy, and debug in the midst of
net to splash personal secrets around the world instan- ongoing patient care. Nevertheless, helpful guidelines
taneously is simply unprecedented. The solution to are available (Amatayakul 2004).
this dilemma remains in limbo. A national effort is cur- Right now, the EMR continues to be a powerful but
rently under way, under a joint contract by the Agency cumbersome tool, solving some problems while creat-
for Healthcare Research and Quality (AHRQ) and the ing new ones, and always teasing us with the prospect
Office of the National Coordinator for Health Informa- that the best is yet to come (Technology CEO Council
tion Technology (ONCHIT), to harmonize HIPAA and 2006).
the privacy and confidentiality laws of all 50 states to
reach a consensus on how to proceed (Dimitropoulos
2007), but many privacy advocates have joined this
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tional Academies Press, 2000
CHAPTER 34
DESIGN AND ARCHITECTURE

Richard C. Lippincott, M.D.
Eugene J. Kuc, M.D.
Todd Hanson, A.I.A.
The environmental design of mental health facilities can facilitate the human
interactions essential to treatment and can help in meeting clients basic needs
for safety and security.
V.J. Willis, M.A. (1980)
A s described excellently in preceding chapters, In this chapter, we address the role of specifically
mental illness is manifested in many unique, compli- designed environments and discuss the importance of
cated, and challenging ways. Mentally ill individuals special environments for the treatment of mental ill-
often withdraw to make their experiences safer, to con- ness, its recovery, and rehabilitation. We will propose
trol their abnormal thoughts, and to manage signifi- that providing meaningful emancipatory environmen-
cant perceptual distortion of the environment. tal aspects for hospitalized individuals with mental ill-
Both the older literature and recent writings by ness is one of the psychiatric hospitals primary tasks;
evolutionary biologists suggest adaptive traits within this task also applies to the broader mental health ser-
human development that identified dangers or harm vices system. We will propose a design concept and
and led to the recognition of caves as safe; this sug- settings that discourage isolation, promote human in-
gests an image of personal development defined as teraction, and facilitate clear connections to the out-
ones own internal home. Ones environmental per- side world, as well as the community to which the pa-
ceptions are important and often result in dramatic re- tient will return; such an orientation facilitates the
sponses; surroundings that are experienced as harsh, significant design aspects of hospital treatment.
unstimulating, and highly regimented have been The chapter will be divided into several separate
shown to promote regression and social withdrawal. concepts and variables based on the system and func-
453
tion to which the setting belongs, behavioral patterns

and needs, patient age, and proposed length of stay.
Psychiatric hospitals, inpatient psychiatric units of a
general hospital, geropsychiatry units, and childrens
units will receive special and specific focus.
History
The earliest institution in America specifically and
solely dedicated to the care of mentally ill individuals
was Friends Hospital, which opened in May 1817 in
Philadelphia. The facility operated on a spiritual belief FIGURE 341. Pennsylvania Hospital for the Insane.
that insanity was a temporary impediment and the
staff saw it as their mission to help patients out of the floor plans and clarity of the environment. It is impor-
darkness. Patients were treated with kindness, respect, tant to our understanding of this history to recognize
and dignitya concept called moral treatment. that 38 hospitals of Dr. Kirkbrides design concepts
History shows that for all intents and purposes, were built and still stand (some are still in use as psy-
the opening of the Pennsylvania Hospital for the In- chiatric hospitals). As years passed, the numerous psy-
sane in 1841, with Dr. Thomas S. Kirkbride as its chief chiatric hospitals built with his design became the
physician, signaled the real focus on moral treatment model for mental hospitals in American society (Tomes
and attention to the hospital environments effect on 1984). As Levin (2005) articulated, If architecture
treatment of the mentally ill (Figure 341). When manifests scientific knowledge, as [architecture profes-
Pennsylvania Hospital for the Insane was completed sor] Carla Yanni (2003) observed, then the crenellated
and opened, it presented an architectural profile that palaces and castles of nineteenth-century insane asy-
was clearly quite different from any of its predecessors. lums certainly expressed in brick and stone their vision
Many lessons emerged from this early event. First, a of psychiatry.
congruent group of local citizens, physicians, and in- What followed, although not causally linked, was a
dividuals who were financial contributors played a de- dark period for mental health services. Involuntary
velopmental role in defining many aspects of this en- hospitalization, crowding on inpatient units, and inef-
vironment, such as location, surroundings, size, and fective treatments were all that was available. There
structural design in what today would be called ac- was limited scientific understanding and confusion
tion research problem solving (Reason and Bradbury about mental illness at this time: Was mental illness a
2001). Further, external concepts were developed to spiritual failing, bad behavior, or a real illness? An ex-
support lawns, gardens, and the impressive size of the ample of this uncertainty was reflected by U.S. Presi-
asylum building. dent Franklin Pierces veto of a congressional law that
Reflected in the design was Dr. Kirkbrides belief in would have added mental health services to the func-
a linear design, which included halls, walking spaces, tional responsibilities of the newly established Public
social meeting rooms, as well as varied accommoda- Health Administration. This veto resulted in state leg-
tions such as comfortable rooms, special accommoda- islatures becoming responsible for services, which led
tions for the dangerous mentally ill, and even apart- to a variety of treatment approaches. These included
ments for the wealthy. varying views of moral treatment, brain surgery (ex-
It is reported that Dr. Kirkbride strived to create a plored in the United States by Dr. Walter Freeman in
moral architecture that was defined by a set of spatial California), and the development of electroconvulsive
and social arrangements specifically designed to pro- therapy, which was widely used, sometimes inappro-
mote a generous confidence in healing. In 1854 he priately.
wrote and published a treatise titled On the Construc- It was not, therefore, until the 1960s and 1970s,
tion, Organization, and General Arrangements of Hos- when advances in pharmacological treatments became
pitals for the Insane (Kirkbride 1854). Contemporary available, that review and redesign of psychiatric hos-
architects such as Joseph Giovanni have acknowledged pitals resumed. Fortunately, Dr. Kirkbrides conviction
Dr. Kirkbrides contribution: The common threads are that patients could be treated and possibly cured re-
quality, individuality, and authenticity. Although he mained respected. In the 1960s, interest and research
was not an architect, Dr. Kirkbride devised the basic evidence began to show the important contribution
Design and Architecture 455
that environmental design made to variance in behav- 3. To feel or develop a sense of self-esteem or self-
iors, anxiety, and development of hostility. Systematic worth
assessments of hospital environments by Pace and 4. To develop interpersonal skills and management
Stern (1958) and Moos and Houts (1968a) showed di-
rect and predictable relationships between the psy- Within psychiatric hospital environments, espe-
chological climate on psychiatric hospital wards and cially in the past, research has shown that a poorly de-
the patients reactions to the world. signed environment extracts a significant cost, espe-
In 1976, Dr. Rudolf H. Moos published The Human cially for patients with severe and persistent mental
Context: Environmental Determinants of Behavior, an illness (Willis 1980). The cost has been reflected in so-
extensive study that stimulated significant interest and cial withdrawal, isolation, inhibitions, poor self-mon-
triggered changes in the approach to architectural de- itoring, poor affect control, and loss of motivation.
sign of psychiatric facilities, units, and wards in general This is now often defined as loss of executive func-
hospital structures (Moos 1976). A brief overview of tiona decline in cognitive activities basically in-
this work demonstrates the importance of various en- tended to achieve ones goals, whether complex or
vironmental design concepts such as space and dis- simple. Poor executive function leads to difficulty in-
tance related to friendship formation (closer is better); teracting with others, learning, solving problems of
closed versus open space in relation to mood and be- change, or performing self-care; an example of this can
havior; arrangement of furniture to facilitate social in- be seen when chronically mentally ill patients forget
teraction; and amenities such as carpets, pictures, and to take their medication (Bryan and Luszcz 2000).
light to decrease inappropriate behaviors. Focus group studies have shown that where a psy-
Studies show that individuals develop cognitive chiatric hospital includes as much as possible of the
maps of the environment in which they live and that outside community to which the patient will return
they use space in ways that are congruent with their and staff facilitate community activity, the loss of ex-
needs and images. According to Moos and Houts ecutive function is much less pronounced (Kaplan
(1968b), current personality theories subscribe to the 1977). Pending research by Lippincott and others will
belief that behavior is a joint function of both the per- address whether the rate of rehospitalization is signif-
son and the environment, representing interaction of icantly reduced and length of stay is shortened when
individuals needs and the environment press [Dr. patients with severe and persistent mental illness are
H.A. Murrys term for stress]. treated in hospitals in which the therapeutic effects of
Moos (1968b) summarized his work regarding hos- the environment are included in the design.
pitals as follows: Since the community environment It is hoped that the goal of all psychiatric hospital
to which a patient must adapt after hospitalization is treatment is the return of patients to an active quality
crucial, a hospital environment must replicate as of life in their community, where mental health pro-
much as possible the community into which the pa- grams can support treatment and rehabilitation. Con-
tient is to be discharged. And Kandel had this to say sistent with this goal is providing treatment in the
about the importance of the environment in his book least restrictive setting possible, especially for individ-
In Search of Memory: The Emergence of a New Sci- uals with serious mental illness. The data suggest that
ence of Mind: Even though I had been taught that an organized mental health services system that is in-
genes of the brain were the governors of behavior, our tegrated and responsive to patients is most effective
work showed that in the brain, genes are also servants and, ultimately, least expensive (Presidents New Free-
of the environment (Kandel 2006, p. 264). dom Commission on Mental Health 2003).
Nevertheless, outpatient services may not be
enough, and patients symptoms may evolve to the
Maintenance of Basic point that an evaluation by general hospital emergency
Patient Needs room services may be necessary. Then, based on sever-
ity of symptoms and diagnosis, admission to the gen-
Willis (1980) examined design considerations for eral hospitals psychiatric unit for stabilization is used;
mental health facilities and outlined four basic patient here, length of stay is usually limited (310 days).
needs: When patients require more intense, secure, or spe-
cialized programming, long-term care or potentially
1. To feel safe in the environment mental health commitment to a specialized psychiatric
2. To be secure hospital is needed. These psychiatric hospitals are rec-
ognized today based on primary function or purpose. units with bedrooms, showers, meeting spaces, com-
Thus, the patients needs, legal issues, age, and finan- fortable living rooms, as well as a nursing station,
cial status result in different admission choices. Public medication storage, and, as necessary, places for soli-
psychiatric facilities (e.g., state hospitals) focus on se- tude (quiet rooms).
rious and persistent mental disorders that involve dis- Another important concept is design aimed at min-
ruptive behaviors, specific security needs, legal com- imizing loss of executive function. We have proposed
mitments, and medication use problems. Here, the that design facilitate the following objectives (Davis et
goal is stabilization, recovery, medication compliance, al. 1979; Osmond 1976):
and, if possible, preservation of the patients executive
function. Individuals with these needs may include Initiating, responding to, and engaging in social in-
many with severe and persistent psychiatric disorders teractions
that involve complex Axis I/Axis II comorbidity. Engaging in real economic exchanges (for example,
Other specialty psychiatric hospitals have specific shopping in the gift shop)
populations, such as forensic facilities requiring a spe- Practicing social skills and using new information
cific security and legal focus. Childrens facilities obvi- daily
ously also have a special focus and serve unique needs. Participating in active groups
Psychiatric hospitals designed to provide services for Encouraging socially acceptable community behavior
patients with disorders such as borderline personality
disorder may have unique goals and environmental Not unique to the psychiatric hospital design but
needs. recommended is the deliberate one-way in/one-way
Important in all of these hospital settings is atten- out entrance to the facility. This entrance provides ac-
tion to the relationship between the environmental cess to the community and its functions while remain-
design and the patient populations needs and goals ing open to families, visitors, and staff in a controlled
and the role design plays in patients rehabilitation way. The entrance opens into a sizeable community
and return to the community. space, which would also have ample available seating,
prominently displayed art, and areas that specifically
facilitate everyday functions, including access to pri-
Psychiatric Hospital mary care and dental offices, a hair salon, a library, a
general store, a cafeteria, a chapel, and a complete
Design Concepts gym, among others. Available to patients on short-
term and long-term units would be access from the
The cover of the March/April 2007 issue of Medical community space for rehabilitation activities, a green-
Construction and Design Concepts carries the follow- house, and a courtyard gardenall with appropriate
ing caption: Where the recovery begins: From the security. Another new psychiatric hospital design uti-
warmth of a sun-filled room to the serene views of a lizes a mall concept that contains similar multiple
green roof, an exteriors design can profoundly impact community activities down an extended hall looking
patient health. out onto the courtyard (Figure 342).
It is essential that all psychiatric hospital designs Natural sunlight and large safety windows result in
begin with three essentials: security, safety, and a hu- a continuous interaction with the outside and nature;
mane environment. Data to date have shown that it is this feature could serve as a visual metaphor to stim-
possible to accomplish such a design with the afore- ulate the patients reintegration back into the com-
mentioned essentials without interfering with the rep- munity. In one facility, this aspect of design is empha-
resentation of the community environment within sized by a two-floor design and significant skylights
the hospital. covering community space (Figure 343). Architec-
Data developed since the mid-1980s point to sev- tural research has shown that bringing natural light
eral overarching concepts that contribute to a success- into the hospital has significant benefits: improved at-
ful design. It can be argued that the most significant is tention, reduction of stress, and reduced costs of light-
that the design must recapitulate within the hospitals ing (Joseph 2006).
controlled environment as much of the patients com- The living quarters within these designs have very
munity as possible. This would mean that the design similar principles of environment, with specific atten-
incorporates a community concept, which would tion to openness, comfortable bedrooms, treatment
include communal, spiritual, and cultural space for rooms, medication areas that are integrated, as well as
meaningful interactions as well as homelike living gathering space viewed as living rooms for client inter-
FIGURE 342. Entrance and public space, New Hampshire Hospital, Concord, New Hampshire.
The entrance and public space define the hospital's goals and purposes as a recapitulation of the real community to
which the patient will return.
Source. Image courtesy of JSA, Architects Interiors Planners, Portsmouth, NH; recipient of 1987 Award, Environmental
Design Research Association for Institutions.
action and conversation (Figure 344). Quiet or seclu- critical to comfortable, relaxing, reassuring envi-
sion rooms are recommended to facilitate behavioral ronments (Ulrich 1984).
control (Baum and Koman 1976). 2. Lightingquantity and quality (variety, natural
The living quarters can be specifically designed to lighting, and appropriateness for the specific use of
meet levels of security, intensity of illness, and risk space)
combined with attention to the importance of patient The quality and quantity of light affect both
interaction, focus on treatment objectives, and reha- performance and our health (Joseph 2006). It
bilitation programs. An important design goal is to al- has been shown to reduce depression, lessen
low as much freedom as possible to move about and agitation, and improve sleep patterns. The
within the hospital based on the assessed risk of each proper quality and quantity can be achieved
patient. The following design elements are of special with a combination of natural and artificial
importance for the living quarters: lighting. Poor-quality light can cause poor func-
tional performance. Good lighting design care-
1. Views and visual relief fully balances natural and artificial sources and
The availability of visual relief to the outdoors provides proper ambient light levels. In psychi-
is an important element of therapeutic environ- atric hospitals, this requires special attention,
ments. There have been numerous studies that especially to quiet room design.
reinforce the benefit of windows and views (Fig- 3. Acoustic considerations
ure 345). For example, studies have shown that Noise is perhaps the most overlooked element
surgical patients in hospitals recover quicker of hospital design. For example, low-level noise
and use fewer pain medications simply by hav- can cause stress, distraction, and sleep loss.
ing a window with natural views. Windows are Sudden noises such as loud voices, pagers, and
FIGURE 343. Therapeutic group room, Riverview Psychiatric Center, Augusta, Maine.
The therapeutic group room defines the treatment environment while providing light, space, and visual contact with the
outside world.
Source. Image courtesy of JSA, Architects Interiors Planners, Portsmouth, NH.
ringing phones may set off the fight or flight hallways also contributes to the mood of the
response, causing anxiety. observer.
4. Tones and colors 5. Texture considerations (visual and touch)
Numerous studies have been conducted to as- A textured rug over a shiny floor does more
certain the impact of color on our emotional than just dampen sound; it visually softens the
well-being (Joseph 2006; Moos 1976). Some of environment. Texture is an important element
the information is conflicting, but the studies of design for both aesthetic and acoustic rea-
results all indicate clearly that colors and tones sons. The touch of fabric on the arm of a chair
can relax, invigorate, or agitate. Most people re- creates a different emotional reaction from that
act in similar ways to warm or cool colors, as of smooth vinyl. Our senses react to all aspects
well as to light or darker tones. Artwork along of our surroundings.
FIGURE 344. Group room and hallway, New Hampshire Hospital, Concord, New Hampshire.
An alcove off a hallway frames space for quiet time and social interaction.
6. Temperature and comfort Confinement issues are important in the psychiat-

We all have slightly different internal thermo- ric hospital. Special considerations should include the
stats. The ability to control aspects of our envi- following elements:
ronment, to personalize them to our individual
needs, can have positive implications for our 1. Balance between freedom and control (i.e., allow-
sense of empowerment. The best option is to al- ing choices)
low people to have some level of control within The freedom to make personal choices is impor-
their private spaces and to rely on each individ- tant to all of us. Opportunities to easily change
ual dressing in a way that meets his or her com- ones setting should be available. This could
fort needs. mean having the chance to step outdoors into a
7. Spatial volume (nurturing vs. intimidating, liberat- courtyard, access social activity spaces, or re-
ing vs. confining) treat to private zones.
The volume of a room should meet the expec- Rooms set aside as quiet space have been
tations of the activity it provides. It is appropri- shown to be helpful (Baum and Koman 1976;
ate for a public activity room to have width and Moos 1976).
height to allow activity and action without over- 2. Importance of feeling safe (ability to remove bars
whelming the occupants. A private bedroom or without compromising safety)
study area should be intimate to nurture, com- Balancing privacy and supervision is extremely
fort, and reassure the patient. important. Patients need to feel safe and secure
8. Importance of variation before they can feel relaxed. In a mental health
As in nature, our environments should have treatment setting, this is true for both patients
variation that alters light, temperature, and and staff. Modern materials have allowed us to
sounds. Stimulating environments with varia- create secure environments without using
tion allow us to experience contrasts. Artwork barred windows and block walls, leading to
has been shown to have such a positive effect. quality therapeutic environments that are safer
FIGURE 345. Unit group room, Riverview Psychiatric Center, Augusta, Maine.
The unit group room offers views of the outdoors as well as quiet space for rest, relaxation, and social interactions.
than the old institutional settings of the past. cilitate appropriate interaction with their ill family
Sophisticated electronics improve supervision, member. Families comfort within the entire hospital
allow greater movement, and eliminate the environment should be seen as of equal importance to
imposing security once required in psychiatric the comfort of the patients. Providing bathrooms for
facilities. Advances in glass and plastic tech- visitors is also an important detail.
nologies have made it possible to eliminate the Data suggest that families have a complex view of
safety risks of windows and doors. their relatives hospitalization: relief and hope that
the hospital staff will provide a cure for the illness
may be intertwined with feeling like outsiders to the
Family Interaction situation and that nothing in their relationship with
their family member will be altered (Harbin 1982).
Research data and multiple reports indicate that fam- The environmental design is important to altering
ily involvement and visitation for hospitalized pa- these perceptions. Studies indicate that family in-
tients are crucial in the recovery of the mentally ill volvement (visits and interaction) with the patient
(Harbin 1982). Thus, within psychiatric hospital de- and hospital staff and length of stay are strongly influ-
sign, family needs must be considered to facilitate enced by education, improved family understanding,
their very important role. General concerns should and meeting in a comfortable homelike environment
focus on families comfort, safety, and support to fa- (Harbin 1982).
Adult Inpatient Units Within psychiatric illness, relapse prevention, and reconnec-
tion to a social support network. As issues of safety
the General Hospital precipitate most psychiatric admissions, therapies di-
rected at the reestablishment of safety must be pri-
Psychiatric units within the general hospital facilities mary concerns on the adult unit. Patients symptoms
might best be thought of in two general ways when such as suicidal or homicidal ideation, disorganiza-
considering design or architectural structure. One way tion, and difficulty meeting basic needs often result in
is to consider how the unit integrates within the local the collapse of social support networks. Thus, aspects
system of mental health services. These units may of the hospital environment and treatment directed at
provide an intermediate treatment role akin to a triage these issues, and those that involve the family and
unit functioning between the emergency room and other social supports, are paramount.
other placement settings, such as a potential transfer An inpatient unit is challenged to provide a private
to other units or to a psychiatric hospital for more nurturing environment while ensuring safety. Tech-
extensive or specialized treatment. Evaluation or com- nology facilitates monitoring, but the way in which its
mitment may lead to transfer to a psychiatric hospital. presence is manifested may either contribute to an op-
Coordination between these settings is thus essential. pressive institutional atmosphere or offer significant
The other concept is that the psychiatric unit fits support. Likewise, the location and access to computer
within the community provided by the general hos- terminals may be such that staff members hide behind
pital environment where many patients may be quite their computers and thus distance themselves from
active. Patients may frequently leave the unit to visit patients. Furthermore, computer screens with visible
radiology or laboratories for special consultations, and patient information or easy access to protected health
they may even go to the hospital gift shop after stabi- information may indicate a dehumanizing environ-
lization. Consideration of an integrated design proves ment of disrespect for the privacy of the individual pa-
helpful in maintaining contact and function. It also tient. Add to this a location in the basement with no
makes appropriate security and safety key features, re- visual relief for the patient, and the inpatient experi-
quiring door alarms, voice contact, and staff assess- ence could be dreary.
ment of risk, given that the patient may be distracted General considerations specific to the adult unit
or obtunded by symptoms or treatment. may include numerous special needs: physical access
For many patients, the general hospital unit may be (e.g., wheelchair maneuverability, accommodations
the first setting in which their mental health problems for visually impaired patients), falls risk reduction,
are addressed and thus should be regarded as very im- pregnancy, detoxification, and memory impairment.
portant to development of an appropriate attitude and Even without these complicating issues, the inpatient
approach to their treatment. It may be easy for provid- unit is a novel environment for the patient, and quick
ers to underestimate the upheaval that a psychiatric orientation to and maneuvering in the space should be
hospitalization causes in the patients and family s easily accomplished.
lives. Although the risks and benefits of hospitalization All of the space on the inpatient unit must reflect
and the decision process involved in choosing to admit concern for visual and lighting elements, acoustic sen-
a patient to a psychiatric unit are thoroughly discussed sitivity, texture, temperature, and spatial proportions.
throughout this book, the environment clearly influ- Common areas on the general unit include bedrooms,
ences the transition experience of the patient. day rooms, therapy rooms (group, individual, and
As we consider the elements of architecture and de- medical treatment), as well as spaces for staff offices
sign of an adult unit within a general medical hospital, and meeting areas.
the values of the system are reflected in decisions
made regarding the units location. The placement of
Bedrooms
the unit on the top floor, in the basement, or in a sep- Allocation of space within the hospital and general
arate building on the campus of the general hospital structural considerations often limit the arrangement
may speak volumes about how the science of the brain of rooms; thus, the layout of the unit is often similar to
and mind is integrated into the care of the patient. The a general surgical or medical unit, with patient bed-
extent to which psychiatric services are integrated or rooms opening onto rather long hallways. Such a con-
marginalized may be reflected by its location. figuration can be an obstacle for psychiatric patients,
The tasks specific to the adult unit may be sum- who need and benefit from interaction with and sup-
marized as diagnosis and treatment of symptoms of port from the community. A layout that accentuates
the sleeping quarters can only diminish this focus. Bed- should be inviting and should include all of the ele-
rooms should be arranged so that their presence is not ments already described.
a hindrance to community and therapy activity. The
layout should promote safety and limit intrusions Smoking Areas
physically, visually, or acousticallyof patients or staff. Although no responsible medical professional would
encourage smoking, smoking is often a major area of
Day Rooms focus on inpatient units. Some facilities accommodate
For better or worse, the location of the television on a this with independent access to smoking areas outside
unit will invariably be a place for congregation of pa- of the facility or in facility courtyards; increasingly,
tients. Also, group meetings, meals, and individual hospitals adopt a strict no-smoking stance anywhere
sessions will likely take place in this area. Because peo- on campus.
ple are often territorial, conflict will invariably occur in
these spaces. The elements of design are critical when
considering that these spaces need to provide varied Geropsychiatry Units
settings in which patients can choose to conduct their
work yet not be isolated from staff or the community.
As medicine becomes more successful at treating med-
Because patients will be struggling with symptoms and
ical illnesses, people survive longer and need to adapt to
may be experiencing side effects of medications, atten-
sequelae of diseases, aging, and treatments. Medicine
tion to issues of comfortvisual, auditory, personal
has made significant strides in the treatment of cardio-
space, and so onwill be tremendously helpful.
vascular diseases, neurological disorders, dementia,
Therapy Rooms and cerebrovascular accidents; advances in neurosur-
gery have produced the need for better rehabilitation
Therapy that takes place on the adult unit can be techniques and facilities in which to conduct them.
individual psychotherapy, group therapy, psycho- Design and architecture have special impact on
education, self-help groups (such as Alcoholics Anon- safety, a major function of the unit. Patients often have
ymous), education groups, and medical treatment, cognitive deficits, and their resiliencies for dealing
including physical exams, repetitive transcranial with these deficits are frequently overloaded because
magnetic stimulation, or other physical treatments. of their medical and neurological needs. The units
These rooms are invariably multifunctional; there- should be designed to facilitate medical and neurolog-
fore, the ease with which a room can be converted is ical treatmenteasy access for patients to use wheel-
largely a function of the furniture and other devices in chairs, walkers, and other similar equipment, and
the room. The basic elements of privacy, aesthetics, space for patients to walk about in an unrestricted
and lack of distraction from other activities on the way. Patients respond well to direct contact, and staff-
unit or outside of the unit should be considered. ing is largely responsible for ensuring adequate con-
Although each unit will develop its own particular tact. Design can place staff in places that optimize that
philosophy, space for occupational therapy, music contactespecially at special times of the day such as
therapy, art therapy, pet therapy, and other adjunctive at meals and early evening (the time at highest risk for
therapies should be considered for availability. sundowning).
Mobility issues deserve additional attention. Pa-
Staff Spaces tients will exhibit wandering or attempts at mobility.
The nurses station has evolved from a walled-off Often these behaviors are dangerous for the patient
room that patients would access through a window to due to, for example, instability of gait. Sometimes
largely open areas. This transition, although very use- previously agile patients are trying to adjust to neural
ful to the development of a less institutional environ- insults such as cerebrovascular accidents or the side
ment, presents limitations, especially in the area of effects of medications (e.g., anticholinergic side ef-
privacy of patient informationeither printed rec- fects) and need special attention when arising.
ords, computer screens, or telephone conversations. Present within the unit and the patients private
Staff need places to congregate, to conduct work- area should be soothing elements of sight, sound, and
related activities, and to disengage from the unit to touch, with orienting objects related to date and time,
eat meals and have breaks. Offices on the units must family photos, and other accents. Color or colored
be both accessible and safe so that staff and patients markings may be used to guide or to help orient pa-
are not sequestered in an unsafe manner. The design tients to specific spaces on the unit.
Pediatric Units disorder unit, ability of patients to safely bring personal

objects from home to help alleviate trauma and stress,
inclusion of or access to areas for spiritual reflection
Pediatric units offer a variety of issues to consider such and rituals, whether the unit is to be locked or open, lo-
as age range and specific therapeutic and developmen- cation of seclusion or restraint rooms, whether bed-
tal tasks important for a particular age range. Further- rooms are to be single- or multiple-occupancy, ability
more, the elements of design appropriate for one age to shop for snacks (e.g., at a canteen) or other personal
group may be countertherapeutic for another age care products, and access to laundry facilities.
group. As noted previously, family engagement, inter- In addition to some of the overarching principles
action, and visitation comfort are important concepts already outlined, attempts should be made to include
that need to be realized and accommodated within the quiet, pleasant colors for walls, a view if possible, art
space of the pediatric unit. for the walls, and a small library space containing
newspapers, magazines, books (including those that
Bedrooms deal with mental health), and places for patients to
Given that the goal of the therapeutic environment is write. The goal is to facilitate a positive outlook, good
to foster reintegration with the patients nonhospital mood, and maintenance of the patients executive
environment, living areas must approximate in furni- functioning.
ture, light, texture, and accents and decorations what
would be expected at his or her home. Also important
are independent work areas for schoolwork, play,
Conclusion
crafts, socialization, and other age-specific activities.
Design and architecture are very important aspects of
Day Rooms the inpatient psychiatric treatment experience and, as
described throughout this chapter, offer important is-
As with the case of the general adult unit, location and
sues for consideration. We propose that it is the re-
access to television, radio, and telephone are impor-
sponsibility of all staff to define and construct the en-
tant design elements. Their location will lead to areas
vironment to best facilitate the therapeutic work of the
of congregation and potential behavioral acting out.
psychiatric unit.
Therapy Rooms
As with the general adult unit, therapy rooms will be References
utilized in a variety of ways. In addition to the tasks
already described, functions unique to pediatric units Baum A, Koman S: Differential response to architectural
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and more family sessions and play areas. sity. J Pers Soc Psychol 34:526536, 1976
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considerations for detecting adult age differences. J Clin
Unit Layout Exp Neuropsychol 22:4055, 2000
Normal child development involves exploration and ex- Davis C, Glick ID, Rosow I: Architectural design of a psy-
chotherapeutic milieu. Hosp Community Psychiatry
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30:453460, 1979
modate normal activities of childhood in addition to Harbin HT (ed): The Psychiatric Hospital and the Family.
specific therapeutic areas. Staff will be challenged to New York, SP Medical & Scientific Books, 1982
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Therefore, another design challenge is to be able to Settings. Concord, CA, The Center for Health Design,
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Every element of design on psychiatric units deserves
New York, Plenum, 1977, pp 221233
discussion, and every unit will have specialized needs Kirkbride TS: On the Construction, Organization, and Gen-
of specific elements. For example, special consider- eral Arrangements of Hospitals for the Insane. Philadel-
ations might include placement of mirrors on an eating phia, PA, Lippincott Press, 1854
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mind. Psychiatric News 40(17):24, 2005 Achieving the Promise: Transforming Mental Health
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trends. Psychiatric News 42(2):9, 2007 3832). Rockville, MD, U.S. Department of Health and
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ior. New York, Wiley, 1976, pp 394427 ipative Inquiry and Practice. London, Sage, 2001
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1968a Cambridge University Press, 1984
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1968b Willis VJ: Design considerations for mental health facilities.
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J Educ Psychol 12:269277, 1958
Part V
THE FUTURE OF
HOSPITAL
PSYCHIATRY
CHAPTER 35
HOSPITAL PSYCHIATRY
FOR THE FUTURE
I proceed, gentlemen, to briefly to call your atten- Every state in America experienced the influx of chron-
tion to the present state of insane persons confined ically and acutely ill patients into communities with-
within this commonwealth in cages, closets, stalls, out adequate resources to treat them. Homelessness,
pens! Chained, naked, beaten with rods, and lashed incarceration of the mentally ill, and concerns about
into obedience (Gollaher 1995). From the time that public safety inevitably followed and became major
Dorothea Dix wrote those impassioned words to mem- public health and public policy questions that continue
bers of the Massachusetts legislature, we have strug- today and will persist into the future. Beginning in the
gled in this country with how best to manage the rav- late 1980s, the for-profit managed care effort to control
ages of acute and chronic psychotic illness in hospitals the cost of public and private third-party payments fur-
and community settings. The asylum movement of ther downsized inpatient treatment in private psychi-
the nineteenth century, led by Ms. Dix and her allies, atric hospitals and general hospitals (see Chapter 30,
embodied many humane principles such as moral Financing of Care, by Liptzin and Summergrad). The
treatment. It led, however, to the growth of large, im- question of the day became What, if ever, is the med-
personal, custodial institutions funded by state trea- ical necessity of hospitalizing an individual with
suries (see Chapter 1, History of Hospital Psychiatry acute psychosis or other mental illness?
and Lessons Learned, by Geller). With deinstitution- This chapter emphasizes and summarizes the ma-
alization following the introduction of antipsychotic jor theme of this bookhospital psychiatry is here to
medications in state hospitals in the 1950s, which ac- stay. Hospitalization is always based on the need for
celerated throughout the 1960s and 1970s, states 24-hour nursing care in high-technology settings. The
sought the opportunity to save money by downsizing hospital stay provides an opportunity to evaluate,
public institutions and shifting support to federal pro- diagnose, and stabilize complex and comorbid mental
grams. Patients were moved to community settings. illness. In addition, involvement of the family in the
467
process of hospital care is essential. Further, the com- Stigma has plagued and continues to plague psychi-
munity at large has a need for respite from an individ- atric hospital treatment across the world. In this coun-
ual in severe crisis. In relation to the continuing short- try, films such as The Snake Pit and One Flew Over the
fall in adequate community-based services, all of these Cuckoos Nest exemplified and exaggerated the gothic
issues make a compelling case for inpatient care and horror of insane asylums. Stigma about hospital treat-
the need for inpatient care to be an integral and critical ment is changing today in large part because of the na-
part of a continuum of comprehensive community- ture of treatment. Brief inpatient stays similar to stays
based care. Inpatient treatment is an important solu- for other medical or surgical conditions contribute
tion to the national disgrace of the neglect of persons strongly to the lessening of stigma. Modern facilities
with mental illness who are, once again, homeless, in- with private rooms, baths, and other amenities nor-
carcerated, and, in the words of Dorothea Dix, living malize a psychiatric admission as similar to any med-
in deplorable conditions (Gollaher 1995). ical or surgical admission. This is especially true in
Important demographic trends reinforce the ratio- general hospital psychiatric units but is also increas-
nale for psychiatric hospitalization, even as the differ- ingly true in modern psychiatric hospitals such as the
entiating and changing boundaries of hospital treat- new hospital at Sheppard Pratt, the Menninger Clinic,
ment raise a basic question, What is a hospital? The McLean Hospital, the Institute of Living, NewYork
hospital of the future will be a hub for a comprehen- Presbyterian Hospital, and Butler Hospital. Even with
sive system of care that is highly subspecialized and, at these changes, there may always be some stigma at-
the same time, integrated with general medical and tached to being hospitalized for a psychiatric illness.
community-based social services. The design of units to be safe requires certain physical
restrictions and constraints that remind patients that
they are on a psychiatric ward. The facts that many
Trends in the Twenty-First Century units are locked and, depending on the hospital and the
nature of the unit, that many personal items are not al-
The U.S. population is aging, and the number of indi- lowed serve to remind psychiatric patients that patient
viduals who suffer from dementias and other psychi- and staff safety are paramount. When patients require
atric conditions of old age is rising dramatically. Co- safety interventions such as seclusion or restraint, it is
occurring serious medical and psychiatric conditions an additional reminder of the different nature of a psy-
have increased. The premature death of individuals chiatric hospital stay, and this can be quite anxiety pro-
with serious mental illness (by at least 10 years) un- voking for many patients and their families.
derscores the consequences of these comorbidities Involvement of families in all phases of treatment
(Parks et al. 2006). Another major comorbidity is that (see Chapter 17, Working With Families, by Dixon
of serious psychiatric illness and substance use disor- et al.) and efforts to reduce, if not eliminate, the use of
ders. The HIV/AIDS epidemic is both a major cause seclusion and restraint (see Chapter 18, Improving
and consequence of this and other comorbidities. The Safety in Mental Health Treatment Settings, by
strong linkage of poverty and mental illness makes a Huckshorn and LeBel) help to alleviate the alienating
solid case for the public financing of psychiatric care. experience of a psychiatric inpatient stay. The facts
Although treatment continues to improve, patients that treatment is effective, that symptoms can be sta-
are better but not well (Frank and Glied 2006). We bilized well enough for rapid discharge, that medica-
will continue, for the foreseeable future, to deal with tions are key to the treatment experience, and that
halfway technologies, that is, treatments (both medi- medical insurance typically pays for the inpatient stay
cal and psychosocial) that help, that stabilize, that all help to reduce stigma. These days, we even see a re-
may prevent relapse but that do not cure. The chronic- duction in stigma for electroconvulsive therapy, not
ity of many psychiatric conditions, especially schizo- only because it is effective but also because it is carried
phrenia, schizoaffective disorder, bipolar illness, per- out as a medical procedure with anesthesia and mus-
vasive developmental disorders, major depressive cle relaxants, in titrated and localized doses adjusted
disorder, severe personality disorders, and some severe on the basis of new research findings. The fact that
anxiety syndromes, will be with us for some time. more and more health insurance offers parity of psy-
In addition to key demographic changes and the chiatric treatment with general medical/surgical treat-
growth of comorbid psychiatric conditions, there are ment also reduces stigma. Consumers and families
other trends in the wider world of hospital treatment are now better informed and, in the process of collab-
that will have a major impact on psychiatric care into oration with psychiatric professionals, have a much
the twenty-first century. more sophisticated view of what a psychiatric hospital
Hospital Psychiatry for the Future 469
stay should be and what they should demand and ex- ment (see Chapter 24, Outpatient Community Men-
pect. Diagnosis is much more of a collaborative pro- tal Health Services, by Cournos and LeMelle).
cess, and with publication of the Fifth Edition of the The Presidents New Freedom Commission Report
Diagnostic and Statistical Manual of Mental Disorders, called for system transformation with the goal of
there will be even more consumer input into the diag- recovery for everyone (Presidents New Freedom
nostic process. Overall, the trend toward more trans- Commission on Mental Health 2003). As commu-
parency and accountability will continue to grow. nity-based services are increasingly consumer cen-
A major trend for which there is growing concern is tered, so will the acute phase of inpatient hospitaliza-
the lack of access to acute psychiatric inpatient care. tion become more consumer informed and directed
Demand for care is high, again in large part due to the (see Chapter 16, From Within: A Consumer Perspec-
perception that treatment is effective and efficient. tive on Psychiatric Hospitals, by Halpern et al.). Self-
But in many areas of the country today, there are seri- directed care requires the consumer s and family s
ous bed shortages. Patients can remain for days in abilities to understand and be educated about illness
emergency rooms waiting for a psychiatric bed. Lack of and self-management through early symptom identi-
access to a bed is mostly a cost-driven phenomenon. fication and rapid treatment. Many psychosocial ser-
Psychiatric inpatient care competes with medical and vices in community settings are a key part of the effort
surgical inpatient care. With various efforts to contain to build resiliency in individuals with long-term ill-
costs, including managed care, there are likely to be ness. Individualized and specialized plans of care are
continuing bed shortages throughout the country. critical as we engage consumers and families as full
partners in the enterprise called hospital treatment.
The Presidents New Freedom Commission Report
Trends in Settings for Care and its recommendations were reinforced by the
groundbreaking Institute of Medicine study, Crossing
The vertically integrated comprehensive general hos- the Quality Chasm (Institute of Medicine Committee
pital today is being disaggregated into subspecialty ar- on Quality 2001). This report, which was a clarion call
eas and units, as well as subspecialty hospitals. Med- for culture change in all health care organizations, rec-
icine has become extremely subspecialized, and ommends health services characterized by 1) contin-
psychiatry is a leader in subspecialization. As this uous healing relationships, 2) customization of care to
book makes clear, subspecialties (such as care for chil- individual needs and values, 3) consumers as the
dren, adolescents, and geriatrics, as well as for key source of control of care, 4) free flow of information
diagnostic categories including psychoses, eating dis- and transparency of information, 5) anticipation of
orders, trauma, and neuropsychiatry) rely on the state- needs, and 6) use of best practices. The Institute of
of-the-art techniques in the biological as well as the Medicine has applied these principles specifically to
psychosocial aspects of care for each of these subspe- the treatment of mental illness and substance use dis-
cialty areas (see Chapters 312). As psychiatric pa- orders in its recent report (Institute of Medicine 2006).
tients move from general hospital wards to specialized The report underscores the need for the integration of
psychiatric units in general hospitals, we are seeing psychiatric care with the rest of medicine, even as
(and we will continue to see) difficult-to-treat patients much of that care is subspecialized and often delegated
move from units in general hospitals to specialty hos- into subspecialty arenas.
pitals. Improvements in treatment throughout the life The revolution in genetics and information sys-
span will require highly specialized physicians and cli- tems may have a profound effect on psychiatric hos-
nicians (see Chapter 27, Psychiatrists and Psycholo- pital care as psychiatric treatment is integrated more
gists, by Roca and Magid), social workers (see Chap- fully with somatic medicine. Advancements in genet-
ter 28, Social Work and Rehabilitation Therapies, by ics may allow psychiatric treatment to be tailored to
Ramsay et al.), and nurses (see Chapter 29, Psychiat- the genetic profiles of patients. For example, medica-
ric Nursing, by Delaney et al.) to deliver these ser- tion strategies may be focused on the most effective
vices. We can expect future breakthroughs in the treat- and efficient approach for affective disorders and
ment of psychoses. We can anticipate third and fourth schizophrenia as we better understand the genetic
generations of antipsychotic medications that will be substrates of these conditions. The electronic medical
free of the serious medical comorbidities of the first- record (see Chapter 33, The Electronic Medical Rec-
and second-generation medications; when that hap- ord, by Boronow) will revolutionize psychiatric treat-
pens, it will, once again, transform the prospects for ment, allowing that treatment to better integrate with
care, especially in the outpatient continuum of treat- general medicine because many, if not most, psychi-
atric patients are comorbidly medically ill and require future abide by the following principles: 1) patient and
good medical care in addition to their psychiatric family centeredness; 2) recovery as the ultimate goal; 3)
treatment. The field of consultationliaison psychia- use of evidence-based designs to improve patient safety,
try (see Chapter 15 by Epstein and Muskin) will be a including single rooms and decentralized nursing sta-
growing component of psychiatric care in the future. tions; 4) development of workplace cultures that attract
The subspecialty of psychosomatics will expand, and and retain key personnel, including physicians, psy-
many patients subjected to high-technology medicine chologists, nurses, social workers, occupational thera-
will increasingly have psychiatric consultation as part pists, and others; and 5) development of high-technol-
of their comprehensive medical treatment. As the ogy-based knowledge and delivery skills on the part of
population ages and dementias and delirium become health professionals with the ability to use the elec-
more prevalent, psychiatrists will become even more tronic medical record as an organizing technology to put
strategic within general medicine. Neuroimaging will forward appropriate treatment plans and follow-up care.
continue to grow and may become more sophisticated There is renewed emphasis and acceptance that
in the diagnosis and treatment of a variety of psychi- the patient and the family should be and are at the cen-
atric and medical conditions that are interrelated. ter of care. How can patients in the psychiatric setting
be respected as equal partners in their care, especially
in the context of acute psychotic illness? The Institute
What Is the Hospital of the Future? for Family Centered Care (http://www.familycentered-
care.org/faq.html) has developed core concepts for pa-
As this book clearly demonstrates, the hospital is tient-centered care, which include 1) conveying dignity
much more than a collection of 24-hour beds. Both and respect, and listening to and honoring patient and
clinical and financial concerns require hospital-based family perspectives in the context of varied cultural
treatment from day one to be part of a community- backgrounds and differences in values and beliefs in
based strategy to return patients, young or old, back to the ongoing delivery of care and the planning for treat-
community settings. It is in those settings that treatment; 2) sharing information in a complete and un-
ment can expand and continue. Expensive acute hos- biased manner, as a key for patients and their families
pital care must take place in a matter of days; then pa- to receive timely, complete, and accurate information
tients must be moved to less expensive alternative to effectively participate in care and decision making,
settings, including day treatment, intensive outpatient especially in the context of the stabilization of patients
care, home-based care, and other outpatient services. in the inpatient setting and rapid discharge; 3) includ-
This is and will be the challenge of the hospital today ing patients and families on an institutionwide basis;
and in the future. With the evolution and implemen- 4) collaborating with patients and families in program
tation of the electronic medical record linking home development, implementation, and evaluation; and 5)
and hospital, we can imagine todays treatments con- emphasizing patient safety.
tinuing at home with careful monitoring and oversight Who will staff the hospital of the future? We cur-
by the hospital. The hospital must be the hub of a com- rently confront a serious shortage of nurses in the
prehensive continuum of care. Rapid intervention be- United States, and for this reason, we must think cre-
comes possible when concerns about safety such as atively to sustain the critical 24-hour nursing function
suicide or homicide become apparent. A major chal- essential for the acute inpatient stay. High-touch and
lenge will continue to be to integrate the various sub- high-technology care, including the use of the elec-
specialties with the general medical comorbidities and tronic medical record, are essential. The challenge is
problems of substance use and homelessness. the handoff to community-based psychiatrists for the
medical aspects of treatment and to community men-
Principles for the Hospital tal health centers or outpatient providers for psycho-
social care. There will also be an even greater need for
of the Future a person on staffperhaps a social worker specialist
A roundtable was recently convened by the Joint Com- who knows how to obtain financing of treatment and
mission on the future of the hospital (see http:// who can help move patients through the system.
www.jointcommission.org/PublicPolicy/future.htm). Who will lead psychiatric inpatient care in the fu-
This roundtable focused on possible futures of hospitals ture? The psychiatrist administrator will be someone
and developed principles to guide all hospitals not intimately familiar with the mission of helping pa-
just psychiatric hospitals or psychiatric unitsfor the tients and families achieve outcomes that not only
future. The roundtable proposed that hospitals of the meet the treatment goals of the acute stay but also pro-
Hospital Psychiatry for the Future 471
vide for care in a continuum of services. Whether the More and more stakeholders are demanding trans-
administrative leader is a physician or not, he or she parency in the cost and quality of health care. The
must have an informed fiscal sense so that the hos- emergence of price-sensitive consumers in parallel with
pital can achieve its mission within the competitive very price-sensitive purchasers will likely depress costs
medical marketplace. Above all, the administrative of various parts of health care and diminish the oppor-
leader will need to see the big picture and have the tunity for cross-subsidization to cover money-losing
vision to anticipate and provide new programs and ser- procedures and patient care. These economic trends, I
vices that will define the next chapter of service deliv- believe, will boost the market position of specialty hos-
ery (see Chapter 26, Administration and Leadership, pitals. The opportunity to be very effective and efficient
by Schwartz and Sharfstein). focused health systems serving the subspecialized
needs of patients is happening today in cardiology and
Design Trends orthopedics and, to some extent, psychiatry. High vol-
umes and focused expertise are the hallmarks of our
What should be the future design considerations for
specialty hospitals and units; their market advantages
hospitals? How can we provide for flexibility and com-
will likely lead to their further growth.
fort and, at the same time, safety? How do we deal
Many psychiatric patients are poor, under- or un-
with the need for patient privacy and confidential dis-
insured, and chronically ill. This makes it very diffi-
cussions, the need for team-based treatment, and the
cult to deliver effective psychiatric hospital care as
involvement of numerous individuals in the care of
lower reimbursement rates and shorter lengths of stay
acutely ill patients?
often push these patients out of the hospital sooner
For psychiatric hospitals and units in general hos-
than might be desirable. Looking at outcomes of hos-
pitals, design is a very important part of the future (see
pital treatment will, in part, force a reevaluation of
Chapter 34, Design and Architecture, by Lippincott
very short hospital stays. New payment schemes, such
et al.). The use of natural light, considerations related
as pay-for-performance, will push back managed care
to privacy, provision of private patient rooms and bath-
driven discharge directives as economic incentives will
rooms that address safety and security challenges,
need to better match quality goals and results. The
minimization of the use of seclusion and restraint,
psychiatric hospital needs to fulfill its social mission
need for various fixtures throughout the institution to
in an environment of increasingly constrained pay-
be very durable and safe, and use of color to create
ments. The best way to accomplish this is through a
warmth and soften the institutional experience of the
linking of inpatient treatment to a continuum of care
hospital (Davis et al. 1979) are all vital for the psychi-
aided by new technologies such as evidence-based
atric hospital of the future.
treatments, the electronic health record, and telepsy-
chiatry. The use of the computer and home moni-
Reimbursement Trends
toring, which has already had an impact, especially
Although health costs are rising around the world, no through the Department of Veterans Affairs model for
country has costs climbing at the rate of the United highly specialized medical care such as heart disease,
States. Overall, U.S. per capita health spending is has its application in psychiatry as well. Here is the
more than 50% higher than in any other country. We concept of the migration of care from the inpatient
pay much more for pharmaceuticals, hospital stays, hospital bed and the physicians office to the patients
and physician visits, and this is a major contributor to home in the context of a new technology such as a tie-
our high cost of care. Despite all this investment, how- in to the hospital via a home computer. Through the
ever, we do not receive a more favorable rate of return home monitoring system, symptoms that indicate
in terms of higher-quality care, greater patient satis- early relapse will lead to rapid intervention.
faction, or increased breadth of access to care. Re- In the future, psychiatric treatment will be an even
cently, the number of uninsured in the United States more strategic partner with the rest of medicine than
has topped 46 million (Dubay et al. 2007). it is today. This will be especially apparent in the pay-
These high health care costs, which are borne by ment for care, as the movement and trend toward par-
government, employers, private payers, and consum- ity in public programs (such as Medicare) and private
ers themselves, have become untenable. It is crucial insurance will be an accepted fact rather than the con-
that health care plans proposed by future governmen- troversial issue it is today. Consumers especially will
tal administrators contain initiatives that will change not accept that their treatment for cancer or heart dis-
the economics and entire landscape for the delivery of ease is at all different from their treatment for depres-
medical care in this country. sion, anxiety, or schizophrenia. Inpatient hospitaliza-
tion is lifesaving and life enhancing. In a society like Gollaher D: Voice for the Mad: The Life of Dorothea Dix.
ours, which values humane care, psychiatric treat- New York, Free Press, 1995
Institute of Medicine: Improving the Quality of Health Care
ment in and out of the hospital will be an essential and
for Mental and Substance-Use Conditions. Washing-
enduring fact of life. ton, DC, National Academies Press, 2006
Institute of Medicine Committee on Quality: Crossing the
Quality Chasm. Washington, DC, National Academies
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mortality in people with serious mental illness (13th
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Dubay L, Holahan J, Cook A: The uninsured and the afford- Presidents New Freedom Commission on Mental Health:
ability of health insurance coverage. Health Affairs Web Achieving the Promise: Transforming Mental Health
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States Since 1950. Baltimore, MD, Johns Hopkins Uni-
versity Press, 2006
INDEX
Page numbers in boldface type refer to figures or tables.
AA (Alcoholics Anonymous), 33, 147148, 152, 153, 189 emergency certification for, 419
Aberrant Behavior Checklist, 164 history of, 2, 4, 10
Abnormal Involuntary Movement Scale, 57, 188 insurance company denial of, 406
ABPN (American Board of Psychiatry and Neurology), 223 involuntary, 11, 32, 50, 419421
Abuse preadmission review for, 406
of children, 107, 149 process of, 378
cognitive distortions of victims of, 108 residential treatment for children and adolescents
shame of victims of, 107, 108 long-term programs, 303304
trauma disorders unit for victims of, 103117 short-term programs, 301302
Academic partnerships with state hospitals, 207 severity of illness and, 23
Access to treatment for racial and ethnic minorities, 176 by type of hospital, 197199, 199
Accountability, 431. See also Quality of care general hospital psychiatric units, 404405
Accreditation. See also Joint Commission private psychiatric hospitals, 405
Commission on Accreditation of Rehabilitation voluntary, 419
Facilities, 350 Admissions criteria
Comprehensive Accreditation Manual for Hospitals, 169 for adolescent neuropsychiatric unit, 162163
of state psychiatric hospitals, 202203 for adolescent unit, 5556
Achieving the Promise: Transforming Mental Health Care for adult acute crisis stabilization unit, 24, 25
in America, 176 for child unit, 3739
Activities for the Elderly: A Guide to Quality Programming, for continuing day treatment program, 345346
81 for co-occurring disorders unit, 135136
Acute care process, 378, 379 for eating disorders unit, 89, 90
ADHD (attention-deficit/hyperactivity disorder), 40, 43 for ethnic/minority psychiatric inpatient unit, 178181
Adherence to medications, 31, 240 for forensic unit, 186187
at Austen Riggs Center, 292 for geriatric unit, 7172
in outpatient treatment programs, 336 for partial hospital programs, 342
in partial hospital programs, 342 for psychotic disorders unit, 120123
for psychosis, 123124 for trauma disorders unit, 104
Administrative issues, 357367 Adolescent neuropsychiatric unit, 159170
core business domains, 365366 admissions criteria for, 162163
core components of, 362 age of patients in, 162
future challenges, 367 daily schedule on, 168
for hospital of the future, 470471 diagnostic workup on, 163165
integration and product or service line organization, DSM-IV-TR diagnosis, 164
363365 interviewing adolescent patients, 164
of intensive outpatient services, 349 rating scales, 164
modern adaptations of early asylums, 358362 discharge planning from, 169170
organizational structure and governance, 362363 electroconvulsive therapy on, 166
qualities of leadership, 366367 maintaining safety on, 168169
Admission to psychiatric facility, 2324 de-escalation strategies, 168169
assessment for, 411 seclusion and restraint, 168169
discharge planning from time of, 384, 413 for self-injurious behaviors, 169
473
Adolescent neuropsychiatric unit (continued) informed consent for treatment of, 60

pharmacotherapy on, 165166 multisystemic therapy for, 306307
psychosocial interventions on, 166168 residential treatment for, 299307
family education and treatment, 167 screening for high-risk behaviors, 56
individualized behavioral treatment, 166167 victims of sexual trauma, 57
milieu management, 167168 Adoption Assistance and Child Welfare Act, 301
schooling and recreational therapies, 168 Adult acute crisis stabilization unit, 2334
treatment goals of, 162, 170 admissions criteria for, 24
treatment planning on, 165 contradictions between theory and practice on, 3334
Adolescent unit, 5567 design of, 461462
admissions criteria for, 5556 diagnostic workup in, 2529
assessment on, 5658 discharge planning from, 27, 3233
clinical interview, 5657 family as partner on treatment team of, 25
confidentiality conditions, 5657 involuntary admission to, 11
developmental perspective of, 56 location within hospital, 461
general strategies and methods, 56 managing suicidal or aggressive behavior on, 32
imaging and electroencephalography, 58 milieu management on, 32, 393
medical history, physical examination, and model for, 24
laboratory testing, 5758, 59 objectives of, 2425
Practice Parameters for the Psychiatric Assessment pathway for 5-day length of stay, 2627
of Children and Adolescents, 56 patient and family education on, 30, 32
psychological testing, 58 patient-specific treatment goals for, 2930, 34
rating scales and diagnostic instruments, 5556, 57 tasks of, 461
reproductive health services, 57 training staff of, 33
substance abuse screening, 57, 58 treatment interventions on, 3031
biopsychosocial formulation on, 5859 detoxification from substances, 30
discharge planning from, 6667 family interventions, 30, 32
management of aggressive and suicidal behaviors on, guidelines for, 31
6566 individual psychotherapy, 30
seclusion and restraint, 66 pharmacotherapy, 3031, 33
staff training for, 66 treatment planning on, 29
media access and content on, 65 Advance directives, 419
meeting religious and cultural needs on, 64 Advertising of private psychiatric facilities, 4
milieu management on, 6465, 393 Advocacy for persons with mental illness, 241242
multidisciplinary treatment team on, 65 consumer empowerment movement for, 240
nutritional interventions on, 64 organizations for, 204205
patient and family education on, 6364 Protection and Advocacy for Individuals with Mental
pharmacotherapy on, 5961 Illness Act, 203
emergency conditions for, 61 for reduced use of seclusion and restraint, 241,
parental consent and patient assent for, 6061 255256, 392, 421
target symptom approach to medication selection, African Americans, 176
60, 69 Against medical advice (AMA) discharge, 411, 424425, 426
psychotherapies on, 6163 case law on, 424
family therapy, 62 interventions to decrease risk of, 424425
group therapy, 6263 among patients with co-occurring disorders, 150151
individual psychotherapy, 62 risk factors for, 424
modality based on clinical indication, 61, 61 Age/aging
rehabilitation and recreational therapies on, 64 pharmacokinetic and pharmacodynamic changes with,
schooling on, 64 79, 81
in state hospitals, 200201, 201 of state hospital patients, 199
treatment planning on, 5859 Agency for Healthcare Research and Quality (AHRQ), 24,
Adolescent/Adult Sensory Profile, 382 432, 450
Adolescents Aggressive/violent behavior, 253263. See also Suicide
confidentiality and interviewing of, 5657 admission to child unit for, 3738, 40
eating disorders in, 58 assessing risk of, 32
nutritional intervention for, 64 causality of, 254255
residential treatment programs for, 305 civil commitment for, 419420
Index 475
consumer and staff experiences with, 32, 256257 suicide and, 148149
in copycat and threat cases, 281 treatment of withdrawal from, 141143
of elderly patient with dementia, 72, 76 among VA hospital patients, 215, 217
impact on clinical care and service quality, 255 violent behavior and, 149
pharmacotherapy for, 192 Alcoholics Anonymous (AA), 33, 147148, 152, 153, 189
in adolescent, 60 Alexander, Franz, 225
in child, 43, 48 Allen Cognitive Level, 346
in elderly patient, 7677 Almshouses, 1
prevention and management of Alprazolam, 110
on adolescent neuropsychiatric unit, 168 ALT (alanine aminotransferase), 137
on adolescent unit, 60, 6566 Alternatives to hospitalization, 242243
on adult acute crisis stabilization unit, 32 Alzheimer s disease, 77, 80. See also Dementia
at Austen Riggs Center, 293 Alzheimer s Disease Neuroimaging Initiative, 360
on child unit, 43, 4750 AMA discharge. See Against medical advice discharge
on co-occurring disorders unit, 149150 Ambulatory Care Quality Alliance, 431
on ethnic/minority psychiatric inpatient unit, American Academy of Child and Adolescent Psychiatry,
182183 168, 432
on forensic unit, 191193 American Association of Community Psychiatrists,
formal violence prevention plan, 258262 135136
on geriatric unit, 8283 American Board of Psychiatry and Neurology (ABPN),
milieu management for, 389397 223
on psychotic disorders unit, 121, 130131 American Health Information Community, 439
on trauma disorders unit, 116 American Hospital Association, 9, 408, 421
primary, secondary, and tertiary prevention of, 262 American Indians, 176
principles underlying trauma-informed systems of care, American Journal of Psychiatry, 7
257258 American Medical Association, 430, 431
in psychiatric emergency settings, 312 American Nurses Association, 255, 432
school shootings, 281, 420 American Osteopathic Association, 432
seclusion and restraint for, 253263 American Psychiatric Association (APA), 1, 9, 138, 177,
staff assault of patient, 418 421
substance abuse and, 149150 Committee on Psychiatric Standards and Policies, 7
Tarasoff duty and, 150, 280, 422423 Council of Psychosomatic Medicine, 223
on trauma disorders unit, 106107 definition of quality indicators and measures, 430
of triple-diagnosis patients, 149 founding of, 225
Agitation Learning From Each Other: Success Stories and Ideas for
in adolescents, 60 Reducing Restraint/Seclusion in Behavioral Health,
in elderly dementia patients, 76, 80 421422
pharmacotherapy for, 31, 60, 80 Practice Guideline for the Psychiatric Evaluation of
2-Agonists Adults, 178, 342
for adolescents, 60 Practice Guidelines for the Treatment of Patients With
interactions with stimulants, 44 Bipolar Disorder, 78
for posttraumatic stress disorder, 111 practice guidelines of, 432
AHRQ (Agency for Healthcare Research and Quality), 24, Quality Indicators: Defining and Measuring Quality in
432, 450 Psychiatric Care for Adults and Children, 435
Alanine aminotransferase (ALT), 137 support for family involvement in treatment, 245
Al-Anon, 153 American Psychosomatic Society, 225
Alaska Natives, 176 American Society of Addiction Medicine, 135136
Alcohol abuse and dependence Amitriptyline
biomarkers for, 137 for adolescents, 60
blood toxicology testing for, 137 avoiding in elderly patients, 75
disulfiram for, 144 for posttraumatic stress disorder, 110
pharmacotherapy for psychiatric disorders co-occurring Amphetamine, toxicology testing for, 137
with, 144145 AMSAII (Association of Medical Superintendents of
posttraumatic stress disorder and, 144 American Institutions for the Insane), 1, 2, 15
Project MATCH study of treatments for, 145146, 147 Anorexia nervosa, 8996
residential treatment programs for children and admission to child unit for, 38
adolescents with, 305306 comorbidity with, 90, 96
Anorexia nervosa (continued) dosing of, 124

financing the cost of hospitalization for, 9091 drug formulary for VA hospitals, 216
indications for hospitalization, 89, 90 duration of treatment with, 125
inpatient treatment approaches for, 9395 for elderly patients
medical management and nutritional rehabilitation for, with delirium, 76
9193 with delusional depression, 75
cardiovascular and peripheral vascular problems, 92 with dementia, 7677, 83
central nervous system problems, 92 mortality related to, 77
endocrine/metabolic abnormalities, 92 documentation for use of, 77
gastrointestinal problems, 92 for forensic patients, 188
hematological abnormalities, 92 for geriatric schizophrenia, 79
severe emaciation, 9192 history of, 6, 8
subtypes of, 90 inadequate response to, 286
Antiabsconding package, 424 interactions with -blockers, 81
Anticonvulsants laboratory testing for use of, 334
for alcohol withdrawal, 142 polypharmacy regimens of, 125
for posttraumatic stress disorder, 110 for psychosis, 123126
for sedative-hypnotic withdrawal, 143 serum levels and response to, 124125
use in persons with mental retardation, 165 time to response to, 125
Antidepressants trends in use of, 14
for adolescents, 60 use in persons with mental retardation, 165
suicidality and, 60 use on trauma disorders unit, 111112, 117
on adult acute crisis stabilization unit, 30 Anxiety disorders. See also specific anxiety disorders
for co-occurring depression and alcoholism, 144 in adolescents, 60, 61
drug formulary for VA hospitals, 216 substance abuse and, 144
for elderly patients, 7475 Anxiolytics, use in persons with mental retardation, 165
for forensic patients, 188 APA. See American Psychiatric Association
inadequate response to, 286 Apology after a sentinel event, 415
mania induced by, 78 AQA, 431
for posttraumatic stress disorder, 110, 111 Architecture. See Design of mental health facilities
STAR*D trial of, 75, 286 Art therapist, 382
use in anorexia nervosa, 93 Art therapy, 382
use in persons with mental retardation, 165 on adolescent unit, 62
Antidepressants, tricyclic (TCAs) on eating disorders unit, 95
for elderly patients, 75 on forensic unit, 190, 383
interactions with cimetidine, 81 on psychotic disorders unit, 128
for posttraumatic stress disorder, 110, 111 on trauma disorders unit, 113
use in anorexia nervosa, 93 Asian Americans, 176
Antihistamines, 112 Asian Focus Program, 178179, 181183
Antihypertensives, 142 Aspartate aminotransferase (AST), 137
Antiparkinsonian agents, 78 Aspergers syndrome, 41, 281, 282
Antipsychotics, 119 Assertive Community Treatment, 151
administration of, 124 Assessment instruments
for adolescents, 60 Aberrant Behavior Checklist, 164
on adult acute crisis stabilization unit, 30 Abnormal Involuntary Movement Scale, 57, 188
adverse effects of, 77 Allen Cognitive Level, 346
for aggression Autism Diagnostic Inventory, 164
in children, 43, 48 Autism Diagnostic Observation Schedule, 164
in elderly patients, 83 Barnes Akathisia Scale, 57
for agitation, 31 Beck Depression Inventory, 342
for alcohol withdrawal, 142 Behavior Assessment System for Children, 41
for anorexia nervosa, 93 Behavior Problem Inventory, 164
Clinical Antipsychotic Trial of Intervention Brief Psychiatric Rating Scale, 31, 71, 342
Effectiveness, 124, 206, 286, 314 Brief Psychiatric Rating Scale for Children, 56, 57
Clinical Antipsychotic Trial of Intervention Child and Adolescent Level of Care Utilization System/
EffectivenessAlzheimers Disease, 77 Child and Adolescent Service Intensity Instrument,
depot preparations of, 124 56
Index 477
Child Behavior Checklist, 41 activities program of, 290

Child Behavior Rating Form, 44 admission consultation at, 288
Child Global Assessment Scale, 56 continuum of care at, 289290
Child Mania Rating Scale, 41 determining suitability for care in an open setting,
Childrens Depression Inventory, 57 288289
Childrens Depression Rating Scale, 41 dilemmas in constructing treatment at, 288
Childrens Global Assessment Scale, 57, 164 behavioral expectations, 288
Childrens Yale-Brown Obsessive Compulsive Scale, 57, limit setting, 288
164 therapeutic alliance, 288
Clinical Global Impressions scale, 31, 57 family treatment at, 291292
Clinical Institute Withdrawal Assessment of Alcohol group therapy at, 289
ScaleRevised, 143 impact of setting at, 290291
Clock Drawing Test, 7273 individual psychodynamic psychotherapy at, 289, 291
Continuous Performance Test, 123 interdisciplinary treatment team at, 289290
CRAFFT substance abuse screening test, 57, 58 length of stay at, 289
Crisis Triage Rating Scale, 314, 314 management of financial resources at, 289, 292293
Dissociative Experiences Scale, 104 management of suicidal and aggressive behaviors at, 293
Hamilton Rating Scale for Depression, 342 overview of treatments at, 289290
Independent Living Skills Survey, 342 patient population of, 287288
Mini-Cog, 73 pharmacotherapy at, 289, 292
Mini-Mental State Examination, 7273, 227, 228 research at, 287, 293294
Minnesota Multiphasic Personality Inventory, 105 safety issues at, 288, 293
Adolescent Version, 58 therapeutic focus at, 290
Modified Mini Mental State examination, 228 Austen Riggs Center Follow-Along Study, 287, 294
Modified Overt Aggression Scale, 57, 66 Autism
Montgomery-sberg Depression Rating Scale, 448 adolescent neuropsychiatric unit for treatment of
Multiaxial Inventory of Dissociation, 105 patients with, 159170
Nurses global Assessment of Suicide Risk, 269, 270 mental retardation and, 161
Positive and Negative Suicide Ideation Inventory, 269, prevalence of, 161
271 Autism Diagnostic Inventory, 164
Positive and Negative Syndrome Scale, 128, 342, 448 Autism Diagnostic Observation Schedule, 164
Revised Childrens Manifest Anxiety Scale, 57 Autonomy of patients, unit rules and, 393394
Rorschach test, 105 Azim, H.F.A., 340
SAD PERSONS scale, 269, 271
Scale for Assessing Suicide Risk of Attempted Suicide, BAL (blood alcohol level), 137
269, 272 Balanced Budget Refinement Act, 406
Scale for Suicidal Ideation, 269, 270 Balanced scorecard, 434
Sheppard Pratt Suicide Risk Assessment Instrument, Barbiturates, toxicology testing for, 137
269, 273, 274 Barnes Akathisia Scale, 57
Structured Clinical Interview for DSM-IV Dissociative Bazelon Center for Mental Health Law, 205
Disorders, 105 Beck Depression Inventory, 342
Thematic Apperception Test, 105 BED (binge-eating disorder), 90
Trail Making Test Part B, 228 Bedrooms of hospitalized patients
Trauma Symptom Inventory, 105 on adult unit, 461462
Wechsler Adult Intelligence Scale, 105 on child unit, 463
Wide Range Achievement Test, 123 design of, 456459
Young Mania Rating Scale, 57 Behavior Assessment System for Children, 41
Association of Medical Superintendents of American Behavior Problem Inventory, 164
Institutions for the Insane (AMSAII), 1, 2, 15 Behavior therapy
AST (aspartate aminotransferase), 137 on child unit, 46
Ativan. See Lorazepam on forensic unit, 189, 191
Atomoxetine, 60 interventions of consultation-liaison psychiatrist, 231
Attention problems for persons with mental retardation, 166167
geriatric depression with, 74 Behavioral disturbances, 384.
pharmacotherapy for adolescent with, 60 See also Aggressive/violent behavior
Attention-deficit/hyperactivity disorder (ADHD), 40, 43 in elderly dementia patients, 72, 76
Austen Riggs Center (Massachusetts), 3, 286294 pharmacotherapy for, 7677
Behavioral disturbances (continued) Blue Cross/Blue Shield, 9

management strategies for, 384 Bluebird, Gayle, 241
on adolescent neuropsychiatric unit, 168169 BMI (body mass index), 58, 64, 9192
on child unit, 4748 Body map of injury patterns, 57
seclusion and restraint, 253263, 392393 Body mass index (BMI), 58, 64, 9192
(See also Seclusion and restraint) Borderline personality disorder
mental retardation and, 161, 164165 comorbid with depression, prognostic impact of, 286
Behavioral health care providers, 439 dialectical behavior therapy for
Behavioral tracking, 448 with bingeing and purging behaviors, 96
Benevolence, 4 with comorbid substance abuse, 146
Benzodiazepines, 31 eating disorders and, 90, 96
abuse or dependence on, 110 intensive outpatient programs for treatment of, 341
for adolescents, 60 residential psychotherapeutic treatment for, 287
adverse effects of, 78, 142 Boston Resource Center, 240
falls, 83, 142 Boundaries
for alcohol withdrawal, 76, 141142, 143 between patients on trauma disorders unit, 115
contraindicated for childhood aggression, 48 professional, 418419
detoxification and withdrawal from, 142143 after patient discharge, 419
drug formulary for VA hospitals, 216 staff education about, 419
flumazenil for reversal of, 141 violations of, 418
interactions with buprenorphine, 145 Brain imaging
overdose of, 142 in adolescents, 58
for posttraumatic stress disorder, 110 in consultation-liaison psychiatry, 227228
for sleep disruption, 112 in elderly patients, 73
tolerance to, 110 in psychotic patients, 122
toxicology testing for, 137 Brain surgery, 8, 454
use on trauma disorders unit, 110111 Brattleboro Retreat (Vermont), 3, 4, 358, 366, 404
for acute behavioral dyscontrol, 116, 117 Brief Psychiatric Rating Scale, 31, 71, 342
withdrawal from, 76 Brief Psychiatric Rating Scale for Children, 56, 57
Benzoylecgonine, 137 Brigham, Amariah, 2
Benztropine, 40 Brown, Nicholas, 3
Billings, Edward, 225 Brown University Medical School, 365
Binge-eating disorder (BED), 90 Brush, Edward, 5
Biopsychosocial formulation, for adolescents, 5859 Bulimia nervosa
Bipolar disorder, 40 admission to child unit for, 38
in elderly persons, 7779 comorbidity with, 90
early- vs. late-onset illness, 78 financing the cost of hospitalization for, 9091
impact on length of stay, 78 indications for hospitalization, 89, 90, 90
inpatient treatment of, 7879 inpatient treatment approaches for, 9395
secondary causes of, 78 pharmacotherapy for, 93
intensive outpatient programs for treatment of, Buprenorphine
340341 interaction with benzodiazepines, 145
psychosocial treatment in adolescents, 61 for opioid detoxification, 143
psychotic disorders unit for treatment of, 120 urine assays for, 137
suicide risk after hospital discharge, 341 VA outpatient programs for treatment with, 217
Systematic Treatment Enhancement Program for Bipolar Bupropion
Disorder, 286 for adolescents, 60
among VA hospital patients, 215 for elderly patients, 75
Black Focus Program, 180 interaction with risperidone, 44
-Blockers, 81 for smoking cessation, 143
-Blockers use on trauma disorders unit, 111
for adolescents, 60 Burlingame, C. Charles, 358
for alcohol withdrawal, 142 Buspirone
for posttraumatic stress disorder, 111 for adolescents, 60
Blood alcohol level (BAL), 137 for co-occurring anxiety and substance abuse, 144
Blood toxicology testing, 136137 Butler, Cyrus, 3
Bloomingdale Asylum (New York), 1, 2, 3, 364, 404 Butler, John, 5
Index 479
Butler Hospital (Rhode Island), 1, 3, 8, 358, 365, 366, 404, other situations, 39
468 sudden, medically complicated, or perplexing
Buying groups for medications, 206 symptoms, 38
challenges in, 4041
Caloric intake, for patients with eating disorders, 92 design of, 463
Cambridge Hospital (Massachusetts), 393 diagnostic workup in, 4143
Cannabis abuse accessory assessments, 42
psychosis induced by, 144 clinical assessment at admission, 4142
toxicology testing for, 137 observation, 4243
withdrawal from, 144 discharge planning from, 5051
Carbamazepine involvement of community providers, resources, and
for alcohol withdrawal, 142 significant others, 5051
for geriatric bipolar disorder, 78 specialty day hospital, 51
for posttraumatic stress disorder, 110 transition to next level of care, 51
for sedative-hypnotic withdrawal, 143 medicolegal and risk management issues on, 50
Carbohydrate-deficient transferrin, 137 milieu management on, 4647, 393
Caregivers. See also Family; Parents patient and family education on, 45
for elderly persons, 80, 83 pharmacotherapy on, 4344, 48
uneasiness about patient discharge, 277 drugdrug interactions and, 44
Carve-out companies, 406 organizational aspects of, 43
CBT. See Cognitive-behavioral therapy principles, strategies, and tactics for, 4344
CDTPs. See Continuing day treatment programs psychotherapies on, 4445
Center for Mental Health Services Managed Care family therapy, 4445
Initiative, 139 group therapy, 45
Center for Quality Assessment and Improvement in individual psychotherapy, 44
Mental Health, 433, 435 rehabilitation and recreational therapies on, 4546
Directory of Measure Sources, 435 schooling on, 4546
National Inventory of Mental Health Quality Measures, staffing ratios of, 47
435 in state hospitals, 200201, 201
Selecting Process Measures for Quality Improvements suicidal and aggressive behaviors on, 4750
in Mental Healthcare, 435 de-escalation strategies for, 4748
Centers for Medicare and Medicaid Services, 14, 15, 168, enhanced monitoring for, 47
170, 193, 203, 350, 365, 373, 431, 432433, 443 pharmacological management of, 43, 48
Physician Quality Reporting Initiative, 433 prevention of, 4950
Quality Measures Management Information System, 433 seclusion and restraint for, 4849
Certification Commission for Healthcare Information Children
Technology, 444 abuse or neglect of, 107
Certification in psychosomatic medicine, 223 alcohol abuse and, 149
Chains of for-profit psychiatric hospitals, 11 behavior rating scales for, 41, 5556, 57
Change collaboration with home school district of, 5051
readiness to, 138139 community-based services for, 3940, 51
stages of, 139 developmental perspective for assessment of, 4142
Chaplain, 64 evolution of inpatient services for, 3941
Charter Medical Corporation, 11 in foster care, 51
Chemical restraint, 48, 421 informed consent for treatment of, 50
Chestnut Lodge, 3, 14, 127, 358 laboratory testing of, 42
Child and Adolescent Level of Care Utilization System/ least restrictive setting for care of, 39
Child and Adolescent Service Intensity Instrument, 56 multisystemic therapy for, 306307
Child Behavior Checklist, 41 polypharmacy in, 40, 41
Child Behavior Rating Form, 44 Practice Parameters for the Psychiatric Assessment of
Child Global Assessment Scale, 56 Children and Adolescents, 56
Child Mania Rating Scale, 41 psychological testing of, 42
Child unit, 3752 reporting suspected abuse of, 50
admissions criteria for, 3739 residential treatment for, 299307
aggressive/dangerous behavior, 3738, 40 serial hospitalizations of, 4041
impairments inadequately treated in outpatient care, stressful life events affecting, 42, 44
38 Childrens Depression Inventory, 57
Childrens Depression Rating Scale, 41 mental retardation, 159170

Childrens Global Assessment Scale, 57, 164 Cognitive remediation groups in continuing day treatment
Childrens Yale-Brown Obsessive Compulsive Scale, 57, programs, 347348
164 Cognitive stimulation techniques for elderly persons, 81
Chlordiazepoxide, 141 Cognitive-behavioral therapy (CBT)
Chlorpromazine, 6, 8, 239 for adolescents, 61
for anorexia nervosa, 93 on adult acute crisis stabilization unit, 32
for behavioral dyscontrol on trauma disorders unit, 117 on child unit, 44
Cholinesterase inhibitors on co-occurring disorders unit, 145146
for dementia, 77 on eating disorders unit, 94
drug formulary for VA hospitals, 216 for elderly persons, 80
Cimetidine, 81 on forensic unit, 189
Citalopram for psychosis, 127
for dementia-related behavioral disturbances, 77 in continuing day treatment program, 347
for elderly patients, 75 on trauma disorders unit, 108
Civil commitment, 419421, 426. 12-Step programs and, 148
See also Involuntary hospitalization Collaborative Longitudinal Personality Disorder Study, 286
Civil Rights of Institutionalized Persons Act, 241 Columbia Presbyterian Hospital, 364
Civil status population in state hospitals, 200, 200 Columbia University College of Physicians and Surgeons,
CL psychiatry. See Consultation-liaison psychiatry 364
Clinical Antipsychotic Trial of Intervention Effectiveness, Combat trauma, 103, 213, 217
124, 206, 286, 314 Commission on Accreditation of Rehabilitation Facilities,
Clinical Antipsychotic Trial of Intervention Effectiveness 350
Alzheimer s Disease, 77 Communication
Clinical Global Impressions scale, 31, 57 to improve patient safety, 417418
Clinical Institute Withdrawal Assessment of Alcohol SBAR method of, 418
ScaleRevised, 143 Community care.
Clock Drawing Test, 7273 See Outpatient community mental health services
Clomipramine, 110 Community Psychiatric Centers, 11
Clonazepam Community Reinforcement Approach, 151
for behavioral dyscontrol on trauma disorders unit, 117 Community residences, 335
for children, 40 Community-Based Participatory Action Research, 242
for posttraumatic stress disorder, 110, 111 Community-based private attending psychiatrist, 371372
Clonidine Compensation for employed clinicians, 374375
for adolescents, 60 Competence determination, 29
for alcohol withdrawal, 142 Comprehensive Accreditation Manual for Hospitals, 169
interaction with stimulants, 44 Computed tomography (CT)
for opioid detoxification, 143 in consultation-liaison psychiatry, 227
for posttraumatic stress disorder, 111 for elderly patients, 73
Clozapine, 238, 240, 334, 343 for psychotic patients, 122
to decrease suicide risk in bipolar disorder, 82 Computerized Patient Record System (CPRS), 213214
for refractory psychosis, 126 Computerized physician order entry (CPOE), 442443
toxicity in elderly patients, 81 obstacles to, 445447
Clozaril. See Clozapine Conditional voluntary hospital admission, 419
Cocaine abuse Confidentiality
criminality and, 149150 of adolescent interview, 5657
suicide and, 148 electronic medical records and protection of patient
urine assays for, 137 privacy, 448450
among VA hospital patients, 217 family involvement and, 248249
Codeine, urine assays for, 137 Connecticut Medical Society, 3
CODs unit. See Co-occurring disorders unit Connecticut Valley Hospital, Whiting Forensic Division, 189
Cognitive distortions of trauma victims, 108 Consultation-liaison (CL) psychiatry, 223232, 470
Cognitive impairment certification in psychosomatic medicine, 223
in anorexia nervosa, 92 clinical scenarios for, 224, 224
in elderly persons, 72 collaboration with other services, 228
depression with, 74 consultation process, 225226
interpersonal therapy for, 80 definition of, 224
Index 481
diagnostic strategies in, 226228 Continuous Performance Test, 123

history taking, 226227 Continuum of care, 357, 471
imaging, 227228 day hospitalization and intensive outpatient services,
laboratory tests, 227, 228 339350
mental status examination, 227 hospital-based psychiatric emergency services, 311317
neuropsychological testing, 228 outpatient community mental health services, 327337
physical examination, 227 residential psychotherapeutic treatment, 285295
future challenges for, 231232 residential treatment for children and adolescents,
history of, 224225 299307
principles of treatment, 228231 social work and rehabilitation therapies, 377386
behavioral and safety interventions, 231 state psychiatric hospitals and, 202
biological management, 228229 Contract for safety, 275
psychological management, 229231 Co-occurring disorders (CODs) unit, 135153
patient coping skills, 230231 admissions criteria for, 135136
physician coping skills, 231 diagnostic workup on, 136137
psychodynamic stressors, 229230 discharge planning from, 151152
social interventions, 231 goals of, 137
reimbursement for, 224, 232 group programming on, 147148
resource allocation for, 232 activity groups, 147
settings for, 223 education groups, 148
Consumer advocates, 240, 261, 383 other groups, 148
Consumer empowerment movement, 240 skills-building groups, 147
Consumer organizations, 204, 242 spirituality groups, 147
Consumer perspective on psychiatric hospitals, 237243 12-Step groups, 147148
Consumer Quality Initiatives (Massachusetts), 242 patient and family education on, 152153
Consumer Satisfaction Teams, 204, 242 pharmacotherapy on, 140145
Contingency management. See also Incentive programs for detoxification and withdrawal, 141144
on co-occurring disorders unit, 146 from alcohol, 141142
Continued-care certification, 406 from cannabis, 144
Continuing care units in state hospitals, 200 from nicotine, 143144
Continuing day treatment programs (CDTPs), 339, 340, from opiates, 143
345348, 350 from sedative-hypnotics, 142143
admissions criteria for, 345346 from stimulants, 143
assessment phase of, 346 drugdrug interactions and, 145
community integration and discharge planning from, 348 for life-threatening intoxication states, 140141
definition of, 345 postdetoxification, 144145
difference from partial hospital programs, 345 psychotherapies on, 145147
family interventions in, 348 cognitive-behavioral therapy, 145146
group programming of, 346348 contingency management, 146
cognitive remediation, 347348 couples and family therapy, 147, 153
cognitive-behavioral therapy for psychosis, 347 dialectical behavior therapy, 146
coping skills, 347 interpersonal therapy, 146147
dialectical behavior therapy, 347 motivational interviewing, 146
independent living skills, 347 other therapies, 146147
interpersonal skills, 347 relapse prevention therapy, 146
psychoeducation, 346, 347 supportive psychotherapy, 146
recreation/leisure planning, 347 relapse management and prevention on, 146, 152
substance abuse relapse prevention, 348 risk management and safety on, 148151
work readiness, 348 discharge against medical advice, 150151
length of stay in, 345 seclusion and restraint, 150
patient perspective on, 350, 351 suicide, 148149
patient populations of, 346 violence, 149150
pharmacotherapy in, 346 treatment planning and therapeutic programming on,
treatment interventions in, 346 137140
treatment outcomes for, 340341 challenges in treating patients with co-occurring
treatment planning for, 346 disorders, 137138
of Washington Heights Community Service, 331332 integrated and individualized treatment, 138, 139140
Co-occurring disorders (CODs) unit, treatment planning admission to adult unit due to, 24, 25, 32
and therapeutic programming on (continued) admission to child unit due to, 3738
smoking cessation, 140 aggression, 253263
staffing, 138 civil commitment for, 420
stages of change and readiness to change, 138139 civil status population in state hospitals, 200, 200
Co-occurring substance abuse and mental illness, 135 discharge dilemmas related to, 277282
employment of persons with, 151152 to self, 267
outpatient community mental health care for, 333 Danvers State Hospital (Massachusetts), 15
placement criteria for treatment of, 135136 Day hospitalization, 277, 339, 340. See also Intensive
psychosocial problems and, 138 outpatient services; Partial hospital programs
safety concerns related to treatment of, 136 of children, 51
self-help groups for patients with, 147148, 152 continuing day treatment programs, 339, 340, 345348
treatment on psychotic disorders unit, 121 discharge from hospital to, 385
Copeland, Mary Ellen, 243, 383 history of, 6, 8, 340
Copeland Center for Wellness and Recovery, 383 of psychotic patients, 132
Coping treatment outcomes for, 340341
of medically ill patients, 230231 Day rooms
of physicians, 231 on adult unit, 462
self-management and, 389, 395397 on child unit, 463
Coping skills groups, 347 DBT. See Dialectical behavior therapy
Corticosteroids, 78 Debriefing after seclusion and restraint events, 261262
Cortisol, 92 De-escalation strategies
Cost shifting, 99 on adolescent neuropsychiatric unit, 168169
Cost-containment pressures, 1113, 24, 39, 43, 405406, on child unit, 4748
467. See also Managed care staff training in use of, 419
Costs. See Health care costs Deinstitutionalization, 6, 119, 311, 405, 444, 467
Countertransference, 9, 231, 291 community care and, 327328, 467
boundary violations and, 418 of veterans, 213, 215
Couples therapy, on co-occurring disorders unit, 147 Delirium
Court-mandated treatment, 15, 185 in elderly persons
CPOE (computerized physician order entry), 442443 diagnostic workup for, 7576
obstacles to, 445447 pharmacotherapy for, 76
CPRS (Computerized Patient Record System), 213214 ruling out, 28
CRAFFT substance abuse screening test, 57, 58 Delirium tremens (DTs), 136, 141, 142
Cri du chat (5p) syndrome, 161 Delusions
Cries of Anguish, 241 dementia with, 76
Criminality, substance abuse and, 149150 geriatric depression with, 74, 75
Crisis, defined, 25 geriatric schizophrenia with, 79
Crisis residences, 335 Dementia in elderly persons, 72
Crisis stabilization, adult unit for, 2334 laboratory testing in, 73
Crisis Triage Rating Scale, 314, 314 Mini-Cog for detection of, 73
Crossing the Quality Chasm, 413, 418, 429430, 469 neuropsychiatric and behavioral disturbances in, 72, 76
CT. See Computed tomography nonpharmacological management of, 76
Cultural competence, 175177, 334 pharmacotherapy for, 7677
Culture of patient safety, 412413, 426 for aggression, 83
adherence to good clinical practices, 412413 for agitation, 80
incident investigation, 412 antipsychotics and mortality risk, 77
proactive response to safety concerns, 412 cognitive enhancers, 77
reducing incidence of medical errors, 413 pseudodementia, 74
Cyproheptadine, 93 treatment on psychotic disorders unit, 120
Cytochrome P450related drug interactions Depression
in children, 44 geriatric, 7375
in elderly patients, 81 acute inpatient treatment of, 7475
bipolar depression, 78
Dangerousness, 390. See also Aggressive/violent behavior; cognitive impairment and, 74
Safety issues; Self-injurious behavior; Suicide depressionexecutive dysfunction syndrome, 74
admission to adolescent unit due to, 55 diagnosis of, 73
Index 483
early- vs. late-onset illness, 74 Diagnostic workup, 378, 379

psychotherapy for, 80 on adolescent neuropsychiatric unit, 163165
with psychotic features, 74, 75 on adolescent unit, 5658
with reversible dementia, 74 on adult acute crisis stabilization unit, 2529
vascular depression, 74 on child unit, 4143
intensive outpatient programs for treatment of, 340 by consultation-liaison psychiatrist, 226228, 228
pharmacotherapy for on co-occurring disorders unit, 136137
in adolescent, 60 on ethnic/minority psychiatric inpatient unit,
in patients with co-occurring substance abuse, 144 181182
STAR*D trial of, 75, 286 on forensic unit, 187
psychosocial treatments for adolescents with, 61 on geriatric unit, 7273
residential psychotherapeutic treatment for treatment- for delirium, 7576
resistant illness, 287 on psychotic disorders unit, 122123
suicide and, 148 on trauma disorders unit, 104105
vascular, 74 Dialectical behavior therapy (DBT)
Descartes, Ren, 224 for adolescents, 61
Desegregation of psychiatric hospitals, 8 on adult acute crisis stabilization unit, 32
Design of mental health facilities, 453463 for borderline personality disorder
adult inpatient units, 461462 with bingeing and purging behaviors, 96
concepts for, 456460, 457460 with comorbid substance abuse, 146
community spaces, 456 in continuing day treatment programs, 347
confinement issues, 459460 on co-occurring disorders unit, 146
entrance, 456 on forensic unit, 189
living quarters, 456459 on trauma disorders unit, 108109
to minimize loss of executive function, 456 Diazepam
natural light, 456 for alcohol withdrawal, 142
geropsychiatry units, 462 for behavioral dyscontrol on trauma disorders unit, 117
history of, 454, 454455 for posttraumatic stress disorder, 110111
for maintenance of basic patient needs, 455456 use in elderly patients, 81
other design considerations, 463 DID. See Dissociative identity disorder
pediatric units, 463 Diphenhydramine
to promote family interaction, 460 for adolescents, 60
safety considerations for, 268, 453, 455, 456, 461, for agitation, 31
462 for behavioral dyscontrol on trauma disorders unit, 117
trends in, 471 Directory of Measure Sources, 435
Desipramine, 75 Disability Law Center, 204205
Detoxification, 30, 136 Discharge from hospital, 277282
from alcohol, 141142 communicating with outpatient physician after, 31, 33
from nicotine, 143144 in copycat and threat cases, 281
from opiates, 143 discharge summary for, 444
from sedative-hypnotics, 142143 insurance company pressure for, 12, 13
from stimulants, 143 limitations of database for decisions on, 278279
in VA hospitals, 217 maintenance of professional boundaries after, 419
Developmental disabilities managed care, clinical decision making and, 425
adolescent neuropsychiatric unit for treatment of against medical advice, 411, 424425, 426
patients with, 159170 case law on, 424
psychotic disorders unit for treatment of patients with, interventions to decrease risk of, 424425
120121 among patients with co-occurring disorders, 150151
self-injurious behavior and, 38 risk factors for, 424
Diagnosis-related group (DRG) payment system, 365, medications for, 31, 444
405406 pathological attachments and, 280
Diagnostic and Statistical Manual of Mental Disorders premature, 5, 119120
(DSM-IV-TR), 164 settings for, 385
mental retardation in, 160 severity of illness and, 23
multiaxial system of, 28 of sexual predators, 281282
Outline for Cultural Formulation, 178, 181 suicidality and, 277278
Diagnostic overshadowing, 163 working with potential victims and, 280281
Discharge planning, 379, 384386, 385 Down syndrome, 161

from adolescent neuropsychiatric unit, 169170 Doxepin, 75
from adolescent unit, 6667 DRG (diagnosis-related group) payment system, 365,
from adult acute crisis stabilization unit, 27, 3233 405406
from child unit, 5051 Droperidol, 117
from continuing day treatment programs, 348 Drug toxicology testing, 136137
from co-occurring disorders unit, 151152 Drugdrug interactions
from eating disorders unit, 96 in children, 44
from ethnic/minority psychiatric inpatient unit, 183 computer-assisted monitoring for, 145
from forensic unit, 186, 193194 cytochrome P450related, 44
from geriatric unit, 83 in elderly patients, 7980
goal of, 384 in forensic patients, 188
from partial hospital programs, 344 in medically ill patients, 229
from psychotic disorders unit, 131132 pharmacodynamic, 44
quality measures for, 431432 pharmacokinetic, 44
risk management and, 413 in substance-abusing patients, 145
from time of hospital admission, 384, 413 DSH (Disproportionate Share Hospital) program, 205
from trauma disorders unit, 116117 DSM-IV-TR. See Diagnostic and Statistical Manual of
Discharge prescriptions, 31, 444 Mental Disorders
Discharge summary, 444 DTs (delirium tremens), 136, 141, 142
Disclosure of a sentinel event, 414415 Dual-diagnosis patients, 121, 160.
apology and, 415 See also Co-occurring substance abuse and mental
malpractice litigation and, 415 illness
3Rs program for, 415 Duloxetine, 110
Disparities in mental health care Dumping patients, 99, 132
elimination of, 206207 Dunbar, Flanders, 225
quality indicators and measures of, 432 Dunton, William Rush, 360
for racial and ethnic minorities, 175177 Duty to warn potential victims of violence, 150, 280,
Disproportionate Share Hospital (DSH) program, 205 422423
Dissociative disorders
patient and family education about, 108 Eating disorders, 9596
trauma disorders unit for treatment of, 103117 admission to child unit for, 38
Dissociative Experiences Scale, 104 in adolescents, 58
Dissociative identity disorder (DID) nutritional intervention for, 64
diagnostic workup for, 104105 psychosocial treatment of, 61
hypnotizability of patients with, 109 residential treatment programs for, 305
treatment on psychotic disorders unit, 121122 comorbidity with, 90
treatment on trauma disorders unit, 103117 as exclusion criterion for trauma disorders unit, 104
milieu management, 113116 indications for hospitalization of patients with, 89, 90
patient and family education, 108 psychopathology and resistance to treatment for, 9596
pharmacotherapy, 110112 substance abuse and, 96, 138
psychotherapy, 105110 subtypes of, 90
Disulfiram, 144 Eating disorders unit, 89101
Divalproex sodium. See Valproate complexities affecting treatment on, 9596
Dix, Dorothea, 2, 3, 360, 467, 468 core eating disorder psychopathology, 9596
Documentation involuntary admission, 95
for antipsychotic use in elderly patients, 77 psychiatric comorbidities, 96
discipline-specific forms for, 441 discharge planning from, 96
electronic medical records, 439450 financing cost of hospitalization, 9091
handwritten charts and orders, 439441 indications for admission to, 89, 90
for intensive outpatient services, 77 medical management and nutritional rehabilitation on,
of patients continuing need for care after insurance 9193
company denial, 425 for cardiovascular and peripheral vascular problems,
physician productivity and, 440 92
for risk management, 412413 for central nervous system problems, 92
for seclusion and restraint, 441 for endocrine/metabolic abnormalities, 92
Double Trouble, 152 for gastrointestinal problems, 92
Index 485
for hematological abnormalities, 92 physician-user adoption of, 446447

for severe emaciation, 9192 protection of patient privacy and, 448450
milieu manual for patients on, 98100 psychiatric and behavioral health functionality of, 447448
physical structure of, 93 behavioral tracking, 448
principles of treatment on, 91 master treatment plan, 447
sample schedule and daily activities on, 101 psychiatric historical time line, 448
treatment approaches on, 9395 quality measures and, 433
cognitive-behavioral therapy, 94 in state hospitals, 207
expressive arts therapies, 95 in VA hospitals, 211, 213214
family therapy, 94, 100 Electronic prescribing, 433
group therapies, 91, 9495 Ellsberg, Daniel, 448
movement therapies, 95 Elopement from hospital, 411, 423424, 426
nutritional education, 95 antiabsconding package to reduce risk of, 424
pharmacotherapy, 93 among patients with co-occurring disorders, 150151
visitors on, 99100 Emaciation, 9192. See also Eating disorders
Eaton, James, 225 Emergency certification, 419
ECG (electrocardiogram), 73, 92 Emergency services. See Psychiatric emergency services
Ecstasy (methylenedioxymethamphetamine), 137 Employment. See also Vocational rehabilitation
ECT. See Electroconvulsive therapy continuing day treatment program of Washington
Edmonton Day Treatment Program (Canada), 340 Heights Community Service program for, 332
Educational interventions. of persons with co-occurring substance abuse and
See Patient and family education mental illness, 151152
EEG. See Electroencephalography work readiness groups in continuing day treatment
Ego psychology, 293 programs, 348
Elderly patients. See Geriatric patients EMR. See Electronic medical record
Electrocardiogram (ECG), 73, 92 Endocrine abnormalities, in eating disorders, 92
Electroconvulsive therapy (ECT) Endocrine replacement therapy, 7
consent for, 420 Environmental safety, 268, 453, 455, 456, 461, 462.
on forensic unit, 190 See also Design of mental health facilities
for geriatric bipolar disorder, 7879 Epilepsy. See Seizure disorders
for geriatric depression, 75 Erikson Institute for Education and Research, 294
impact on length of stay, 71 Ethical issues. See also Legal issues
with psychotic features, 75 confidentiality of adolescent interview, 5657
history of, 6, 7, 8, 9, 454 duty to warn potential victims of violence, 150, 280,
for psychosis, 126 422423
use in persons with mental retardation, 166 electronic medical records and protection of patient
Electroencephalography (EEG) privacy, 448450
in adolescents, 58 Ethnicity and Family Therapy, 182
in consultation-liaison psychiatry, 228 Ethnic/minority psychiatric inpatient unit, 175183
in elderly patients, 73 awards to, 177
in psychotic patients, 122 diagnostic workup on, 181182
Electronic medical record (EMR), 439450, 469 discharge planning from, 183
added value from use of, 441445 history and overview of, 177178
computerized physician order entry, 442443 involuntary commitment to, 178
diagnosis list, 442, 447 management of suicidal and aggressive behaviors on,
discharge prescriptions, 444 182183
discharge summary, 444 milieu management on, 182
medication reconciliations, 444445 program descriptions and admission indications for,
quality assurance, 445 178181
seclusion and restraint orders, 443 Asian Focus Program, 178179, 181183
unsigned orders, 443 Black Focus Program, 180
current status of, 450 Forensic Focus Program, 181
future of, 450 HIV/AIDS Focus Program, 180
vs. handwritten charts and orders, 439441 Latino Focus Program, 179
medical errors and, 446 Lesbian/Gay/Bisexual/Transgender Focus Program, 181
National Health Information Network, 444 Womens Focus Program, 179180
obstacles to, 445447 therapies on, 182
Evidence-based practice, 207, 366 on child unit, 4445

Ewing v. Goldstein, 422 in continuing day treatment program, 348
Ewing v. Northridge Hospital Medical Center, 422 on co-occurring disorders unit, 147, 153
Exhibitionism, 282 on eating disorders unit, 94, 100
Expenditures for health care. See Health care costs on trauma disorders unit, 112113
Exposure and response prevention techniques Federal Employees Health Benefits Program, 9
for adolescents, 61 Feeding disorders, admission to child unit for, 38
for eating disorders, 91 Financing of care, 365366, 403408.
Expressive arts therapies, 381382 See also Health insurance coverage; Managed care;
on adolescent unit, 62 Medicaid; Medicare
on eating disorders unit, 95 at Austen Riggs Center, 289, 292293
on trauma disorders unit, 113 for children, 39
Expressive arts therapists, 381382 cost-containment pressures and, 1113, 24, 39, 43,
405406
Failure mode effects and criticality analysis, 417 early private psychiatric hospitals, 3
Failure modes and effects analysis (FMEA), 415, 416417, effects of changes in reimbursement, 407408
431 future financial viability of inpatient psychiatric
Falls, drug-related services, 408
benzodiazepines, 83, 142 history of, 8, 403404
in elderly patients, 81 intensive outpatient programs, 340
selective serotonin reuptake inhibitors, 75 managed care and, 406407
Family. See also Caregivers; Parents Medicaid and Medicare, 365, 407
clinicians relationship with, 248249 at private psychiatric hospitals, 405
disclosure of sentinel event to, 414415 in psychiatric units of general hospitals, 404405
education of (See Patient and family education) residential treatment for children and adolescents, 300
of elderly patient, 80 revenue sources by type of hospital, 408
emotional responses of, 246 state mental health systems and, 407
empowerment of, 63 underfunding, 358
guilty feelings of, 246 5p (cri du chat) syndrome, 161
impact of patients hospitalization on, 246 Flumazenil, 141
interviewing of, 246 Flunitrazepam, 149150
patient consent for release of information to, 248249 Fluoxetine
of patient with psychosis, 131 for bulimia nervosa, 93
respite care for, 40 for posttraumatic stress disorder, 110
roles in, 248 Fluphenazine, 117
spokesperson for, 248 Fluvoxamine, 110
support groups for, 32, 153 FMEA (failure modes and effects analysis), 415, 416417,
Family care programs, 336 431
Family involvement in treatment, 25, 30, 245252, 412, Forensic Focus Program, 181
468 Forensic unit, 185194
common issues in, 246248 admissions criteria for, 186187
differing family organization and roles, 248 diagnostic workup on, 187
intense unmet needs for information, 247 discharge planning from, 186, 193194
range of emotional responses, 246 involvement of community providers, resources, and
varying expectations, 247248 significant others, 193
hospital design and, 460 special burden of forensic unit, 194
potential challenges in, 248252 transition to next level of care, 193194
difficulties with engagement and differences of electroconvulsive therapy on, 190
opinion, 250252 management of suicidal and aggressive behaviors on,
patients concerns, 249250 191193
time limitations and confidentiality, 248249 early detection of behavioral cues, 193
social workers and, 380 seclusion and restraint, 192193
Family therapy/interventions meeting patients spiritual needs on, 187
on adolescent neuropsychiatric unit, 167 milieu management on, 190191
on adolescent unit, 61, 62 off-hours admissions to, 187
on adult crisis stabilization unit, 30, 32 patient and family education on, 189
at Austen Riggs Center, 291292 patient rights on, 185186
Index 487
pharmacotherapy on, 188 for agitation, 80

principles of treatment on, 187188 antipsychotics and mortality risk, 77
psychotherapies on, 188189 cognitive enhancers, 77
rehabilitation and recreational therapies on, 189190 pseudodementia, 74
safety concerns on, 185, 190193 treatment on psychotic disorders unit, 120
sex offender treatment on, 190 depression in, 7375
staffing of, 191 acute inpatient treatment of, 7475
in state hospitals, 200, 201202 cognitive impairment and, 74
Forensically committed patients, 15, 185 depressionexecutive dysfunction syndrome, 74
agencies referring children for evaluation, 39 diagnosis of, 73
For-profit psychiatric hospitals, 11, 467 early- vs. late-onset illness, 74
Foster care, 51 psychotherapy for, 80
Fragile X syndrome, 160, 161 with psychotic features, 74, 75
Franklin, Benjamin, 2 with reversible dementia, 74
Freeman, Walter, 454 vascular depression, 74
Friends Asylum/Hospital (Pennsylvania), 1, 3, 4, 5, 358, drug dosing in, 79
360, 363, 366, 403, 404, 454 drugdrug interactions in, 7980
Future of hospital psychiatry, 367, 467472 medical illness in, 72
design trends, 471 pharmacokinetic and pharmacodynamic changes in, 79,
principles for hospital of the future, 470471 81
reimbursement trends, 471472 schizophrenia in, 79
requirements for hospital of the future, 470 early- vs. late-onset illness, 79
trends in 21st century, 468469 inpatient treatment of, 79
trends in settings for care, 469470 suicidality among, 7172, 73
in VA hospitals, 216
Gabapentin Geriatric unit, 7183
for adolescents, 60 admissions criteria for, 7172
for posttraumatic stress disorder, 110 design of, 462
Gamblers Anonymous, 152 diagnoses of patients on, 71
General hospital psychiatric units, 404405. diagnostic workup in, 7273
See also specific types of units discharge planning from, 83
admissions to, 197199, 199, 404405, 407 factors associated with increased length of stay on, 71
conversion of other hospital units to, 405 management of aggressive or suicidal behaviors on,
design of, 461462 8283
financing of care in, 404405 seclusion and restraint, 83
history of, 7, 8, 10, 404405 milieu management on, 8182
psychiatric beds in, 23, 198, 404405, 407 patient and family education on, 8081
revenue sources for, 408 pharmacotherapy on, 7380
Genetics, 469 for bipolar disorder, 7779
Genogram, 123 for dementia/delirium, 7577
Geriatric patients for depression, 7375
bipolar disorder in, 7779 drugdrug interactions, 7980
early- vs. late-onset illness, 78 for schizophrenia, 79
impact on length of stay, 78 psychosocial assessment on, 80
inpatient treatment of, 7879 psychotherapy on, 80
secondary causes of, 78 rehabilitation and recreational therapies on, 81
caregivers of, 80, 83 GGT (-glutamyl transferase), 137
cognitive assessment of, 72 Gibson, Robert, 361
community services network for, 83 Global Trigger Tool for Measuring Adverse Events, 435
dementia in, 72 -Glutamyl transferase (GGT), 137
laboratory testing in, 73 Goals of treatment
Mini-Cog for detection of, 73 on adolescent neuropsychiatric unit, 162, 170
neuropsychiatric and behavioral disturbances in, 72, on adult acute crisis stabilization unit, 2930, 34
76 on co-occurring disorders unit, 137
nonpharmacological management of, 76 for intensive outpatient services, 339
pharmacotherapy for, 7677 for partial hospital programs, 343, 344, 345
for aggression, 83 for patients with mental retardation, 162, 170
Greystone Park Psychiatric Hospital (New Jersey), 15 for care in psychiatric units of general hospitals, 404,
Grounding techniques, for trauma victims, 109 405
Group home placement, 385 denial of, 406, 425, 426
Group therapy and programs for discharge settings, 385
on adolescent unit, 6263 for eating disorders treatment, 91
at Austen Riggs Center, 289 history of, 6, 8, 9
on child unit, 45 for intensive outpatient services, 350
in continuing day treatment program, 346348 managed care and, 1213, 406407
on co-occurring disorders unit, 147148 proportion of hospital revenue from, 408
on eating disorders unit, 91, 9495 for psychosis treatment, 122, 132
on forensic unit, 188189 for residential treatment for children and adolescents,
in partial hospital program, 343 300
patient autonomy and participation in, 393394 for suicidal patient, 278
on trauma disorders unit, 107, 112 Health Insurance Plan of Greater New York, 9
Guardianship, 29, 419 Health Insurance Portability and Accountability Act
Guidelines for the Built Environment of Behavioral Health (HIPAA), 301, 378, 449
Facilities, 268 Healthcare Effectiveness Data and Information Set
Guilty feelings of family, 246 (HEDIS), 430, 433, 445
Heinroth, Johann Christian, 224
Hallucinations Henry, George, 225
geriatric depression with, 74 Heroin, urine assays for, 137
geriatric schizophrenia with, 79 HFMEA (health care failure mode and effect analysis), 417
Hallucinogens, 137 Highpoint Hospital (New York), 12
Haloperidol Hill-Burton Bill, 8
for agitation in elderly dementia patients, 80 HIPAA (Health Insurance Portability and Accountability
for behavioral dyscontrol on trauma disorders unit, 117 Act), 301, 378, 449
for delirium, 76 Hispanic Americans, 176
serum levels of, 125 History of hospital psychiatry, 116, 467
Hamilton Rating Scale for Depression, 342 consultation-liaison psychiatry, 224225
Handwritten charts and orders, 439441 deinstitutionalization movement, 6, 119, 213, 215, 311,
Harm reduction, 337 327328, 467
Hartford Courant, 241, 254, 255 design and architecture, 454, 454455
Hartford Hospital (Connecticut), 359, 360 early years: through 1920, 16
Hartford Retreat for the Insane (Connecticut), 1, 3, 4, 5, comparison of private and public facilities, 46
358, 404 origins of private psychiatric hospitals, 23
Harvard Medical School, 365 origins of public facilities, 12
Harvey, William, 224 privatepublic interface, 34
HCA (Hospital Corporation of America), 11 financing of care, 403404
Head-injured patients, 28, 58 Friends Asylum/Hospital (Pennsylvania), 1, 3, 4, 5, 358,
treatment on psychotic disorders unit, 120 360, 363
in VA hospitals, 216 The Institute of Living, 358360
Healing Words: The Power of Apology in Medicine, 415 middle period: 19211970, 69
Health care costs, 14, 285, 471 1920s1930s, 67
in 1980s, 11 1940s1950s, 78
cost shifting, 99 1960s, 89
cost-containment efforts, 1113, 24, 39, 43, 405406, modern era: 19712007, 915
467 1970s, 10
managed care and, 1214, 119, 285, 357358, 406407 1980s, 1012
of residential treatment for children and adolescents, 1990s, 1213
299, 300, 303, 305 20002007, 1315
at state hospitals, 205206 New York Presbyterian Hospital, 364365
vs. private facilities in 1940s, 7 psychiatric emergency services, 312
for treatment-resistant illnesses, 286 for psychotic patients, 119
at VA hospitals, 213 residential treatment for children and adolescents,
Health care failure mode and effect analysis (HFMEA), 417 300301
Health care proxy, 419 Sheppard and Enoch Pratt Hospital, 360362
Health insurance coverage. See also Medicaid; Medicare state hospitals, 197199, 198, 199
Index 489
History taking, 378 Insight-oriented psychotherapy, 44

on adolescent neuropsychiatric unit, 163164 Institute for Family Centered Care, 470
on adolescent unit, 5657 Institute for Healthcare Improvement, 435
on adult acute crisis stabilization unit, 2829 Global Trigger Tool for Measuring Adverse Events, 435
in child unit, 41 Institute of Living (Connecticut), 3, 358360, 363, 365,
by consultation-liaison psychiatrist, 226227 366, 468
in continuing day treatment program, 346 Braceland Center for Mental Health and Aging,
on co-occurring disorders unit, 136 359360
on forensic unit, 187 Memory Disorders Center, 360
on geriatric unit, 72 merger with Hartford Hospital, 359
in partial hospital programs, 342 Olin Neuropsychiatry Research Center, 360
for psychotic patients, 122, 123 Institute of Medicine (IOM), 139, 255, 413, 429430, 434
on trauma disorders unit, 104 Crossing the Quality Chasm, 413, 418, 429430, 469
HIV/AIDS Focus Program, 180 To Err Is Human: Building a Safer Health System, 413,
Homeless persons, VA Homeless Program for, 218219 440
Homicidal ideation, 226, 278281 Health Care Quality Initiative, 413
Horizon Health Corporation, 363 Institute of Pennsylvania Hospital, 358
Hormonal therapy for sex offenders, 188, 190 Institution for Mental Disease (IMD) waivers (Medicaid),
Hospital and Community Psychiatry, 10 13, 205, 359, 404, 407
Hospital Corporation of America (HCA), 11 Insulin shock therapy, 6, 7, 8
Hospital Quality Alliance, 431 Intellectual disability.
Hospitalist psychiatrist, 372 See also Dementia; Mental retardation
models of compensation for, 374375 adolescent neuropsychiatric unit for treatment of
Hudson Lunatic Asylum, 1 patients with, 159170
Human rights, 241. See also Patients rights psychotic disorders unit for treatment of patients with,
Hydrocodone, urine assays for, 137 120121
Hydrotherapy, 5, 7 Intelligence quotient (IQ), 123, 160
Hydroxyzine, 117 Intensive outpatient programs (IOPs), 339, 340341,
Hypersexuality, 41 348349, 350
Hypnosis, of trauma victims, 109 Intensive outpatient services, 339351
administration of, 349
ICD-9 (International Classification of Diseases), 121 continuing day treatment programs, 345348
IMD (Institution for Mental Disease) waivers (Medicaid), in continuum of care, 340
13, 205, 359, 404, 407 discharge from hospital to, 385
Imipramine, 8 documentation for, 349350
avoiding in elderly patients, 75 emergency services, 349
for posttraumatic stress disorder, 110 financing of, 340
IMPACT Network, 435 history of, 340
Improving Mental Health Care: A Guide to Measurement- hospital-based, 339
Based Quality Improvement, 435 intensive outpatient programs, 348349
In Search of Memory: The Emergence of a New Science of milieu of, 349
Mind, 455 partial hospital programs, 342344
Incentive programs patient perspective on, 350, 351
on child unit, 46 regulation of, 350
on co-occurring disorders unit, 146 rehabilitation in, 341342
on psychotic disorders unit, 129 reimbursement for, 350
Independent living programs, 335, 347 staffing of, 349
Independent Living Skills Survey, 342 terminology for, 339340
Individuals With Disabilities Education Act, 303 treatment goals of, 339
Infectious diseases, 411 treatment outcomes of, 340341, 349
Informal voluntary hospital admission, 419 Interdisciplinary treatment team, 9, 377378
Informed consent, 29 on adolescent unit, 65
by guardian, 419 on adult acute crisis stabilization unit, 29, 33
for hospital admission, 419 at Austen Riggs Center, 289290
for treatment of adolescent, 60 behavior management strategies of, 383
for treatment of child, 50 development of master treatment plan by, 383
Injury mapping, 57 discharge planning by, 384386, 385
Interdisciplinary treatment team (continued) Laboratory testing

milieu management by, 384, 389397 of adolescents, 58, 59
psychiatric nurses, 389398 of adults, 2829
psychiatrists and psychologists, 371375 of children, 42
social workers and rehabilitation therapists, 377386 in consultation-liaison psychiatry, 227, 228
International Classification of Diseases (ICD-9), 121 on co-occurring disorders unit, 136
Interpersonal therapy (IPT) for drugs of abuse, 136137
for adolescents, 61 of elderly persons, 73
on co-occurring disorders unit, 146147 of patients presenting for psychiatric emergency
for elderly persons, 80 services, 315
for persons with cognitive impairment, 80 for pharmacotherapy, 334
Interviewing. See also History taking of psychotic patients, 122
of adolescents, 5657 on trauma disorders unit, 104
with mental retardation, 164 Lamotrigine
of family members, 246 for geriatric bipolar depression, 78
marginal, 300 for posttraumatic stress disorder, 111
Intoxication states, pharmacotherapy for, 140141 Language access to treatment, 176, 177
Involuntary hospitalization, 11, 32, 419421, 426 Latino Focus Program, 179
consent for treatment and, 420 Laxative abuse, 89
consequences to patients from, 420 Leadership, 366367. See also Administrative issues
for eating disorders, 95 for development of quality indicators and measures,
limitations on access to firearms after, 420 430431
of minors, 50 of hospital of the future, 470471
state criteria for, 420 strategies for violence prevention, 259
IOM. See Institute of Medicine Leapfrog Group, 433
IOPs (intensive outpatient programs), 339, 340341, Learned helplessness, 240
348349, 350 Learning From Each Other: Success Stories and Ideas for
IPT. See Interpersonal therapy Reducing Restraint/Seclusion in Behavioral Health,
IQ (intelligence quotient), 123, 160 421422
Ivy League psychiatric hospitals, 358, 365 Least restrictive setting, 13, 24, 39, 41, 162, 285, 303, 420
Leaving hospital against medical advice, 411
Jarvis, Edward, 3, 1516 case law on, 424
Johns Hopkins Hospital, 342 interventions to decrease risk of, 424425
Joint Commission, 170, 192, 254, 365, 373, 396, 430, among patients with co-occurring disorders, 150151
440, 443 risk factors for, 424
definition of risk management, 412 Legal issues. See also Ethical issues
definition of sentinel event, 413 on child unit, 50
in improving communication, 418 competence determination, 29
inpatient suicides reported to, 267, 275 court oversight, receivership, and decrees, 203204
National Patient Safety Goals, 203, 390, 418 Disability Law Center advocacy organizations, 204205
ORYX initiative of, 203 discharge against medical advice, 424
recommendations for accurate patient identification, 413 disclosure of sentinel event, 415
regulation of intensive outpatient services, 350 managed care and clinical decision making, 425
requirement for root cause analysis of sentinel events, Protection and Advocacy for Individuals With Mental
203, 415416 Illness Act, 203
roundtable on the hospital of the future, 470 Tarasoff duty, 150, 280, 422423
standards for use of seclusion and restraint, 421 Ulysses contracts, 425
state hospitals and, 202203 Leisure activities. See Recreational therapies
Joint Information Service, 10 Length of stay, 23, 24, 39, 358, 377, 384
Journaling, therapeutic, 113 at Austen Riggs Center, 289
in continuing day treatment program, 345
Kandel, Eric, 455 determinants of, 384
Kelly v. United States, 424 discharge dilemmas and, 277282
Kendras Law (New York State), 336 on geriatric unit, 71, 78
Kirkbride, Thomas S., 56, 454 managed care and, 119, 278, 285, 365
Kraepelin, Emil, 126 pathway for adult 5-day length of stay, 2627
Kubie, Lawrence, 9 for patients with civil admission status, 200, 200
Index 491
on psychotic disorders unit, 122 inpatient treatment of, 7879

reimbursement trends and, 471 secondary causes of, 78
for suicidal patient, 278 MAOIs (monoamine oxidase inhibitors), 110
Lesbian/Gay/Bisexual/Transgender Focus Program, 181 MAR (medication administration record), 440, 442443
Lesch-Nyhan disease, 161 electronic, 443
Level of Care Utilization System for Psychiatric and Marginal interviewing, 300
Addiction Services (LOCUS), 136 Marijuana
Life space interview, 300 psychosis induced by, 144
Limited English proficiency, 176, 177 toxicology testing for, 137
Linehan, Marsha, 108109 withdrawal from, 144
Linezolid, 229 Marital therapy on co-occurring disorders unit, 147
Lithium Maryland Disability Law Center, 205
for antidepressant augmentation in elderly patients, 75 Maryland Hospital Association, 433
for bipolar disorder Massachusetts Mental Health Center, 340
to decrease suicide risk, 82 Massage, 5
in elderly patients, 78 Master treatment plan (MTP), 383
for co-occurring affective disorders and alcoholism, electronic medical records and, 447
144145 Matching Alcoholism Treatments to Client Heterogeneity
toxicity in elderly patients, 81 study (Project MATCH), 145146, 147
Living quarters of hospitalized patients Maudsley Hospital, 94
on adult unit, 461462 McLean, John, 1
on child unit, 463 McLean Asylum/Hospital (Massachusetts), 1, 2, 5, 8, 12,
design of, 456459 14, 341, 358, 365, 366, 404, 408, 468
LOCUS (Level of Care Utilization System for Psychiatric McLean Hospital Acute Residential Treatment Center, 301
and Addiction Services), 136 Medicaid, 11, 13, 14, 48, 90, 125, 132, 197, 232, 240, 256,
Long Island House (New York), 45 327, 340, 360, 365, 407
Long-term residential treatment coverage for care in psychiatric units of general
for children and adolescents, 299307 hospitals, 404
psychotherapeutic, 285295 coverage for intensive outpatient services, 350
Lorazepam, 240 coverage for treatment of children and adolescents,
for aggression in elderly patients, 83 302
for agitation, 31 Disproportionate Share Hospital (DSH) program, 205
for alcohol withdrawal, 142 Institution for Mental Disease (IMD) waivers, 13, 205,
for behavioral dyscontrol on trauma disorders unit, 117 359, 404, 407
for posttraumatic stress disorder, 110, 111 managed care programs, 365
proportion of hospital revenue from, 408
Magnetic resonance imaging (MRI) state mental health system and, 407
in consultation-liaison psychiatry, 227228 Medi-Cal, 177
in elderly patients, 73 Medical Construction and Design Concepts, 456
in psychotic patients, 122 Medical errors, 412413.
Main, T.F., 340 See also Quality of care; Sentinel events
Malpractice litigation, 12 due to communication problems, 417418
due to boundary violations, 418 electronic medical records and, 446
due to disclosure of sentinel event, 415 To Err Is Human: Building a Safer Health System, 413,
Managed care, 1214, 285, 311, 357358, 405406, 467 440
carve-out companies, 406 Medical illness
clinical decision making and, 425 admission to child unit for, 38
denial of coverage, 406, 425, 426 consultation-liaison psychiatry for, 223232
discharge of suicidal patient and, 278 coping styles of patients with, 230231
eating disorders treatment and, 91 in elderly patients, 72
Medicaid programs, 365 infectious diseases, 411
psychosis treatment and, 119, 125 mental retardation and, 164
restrictions on length of stay, 119, 278, 285, 365 outpatient community mental health care for mental
Mania. See also Bipolar disorder illness co-occurring with, 333334
drug-induced, 78 in patients presenting for psychiatric emergency
in elderly persons, 7779 services, 314315
early- vs. late-onset illness, 78 pharmacotherapy for patients with, 228229
Medical illness (continued) Mental status examination

psychological management of patients with, 229231 for complex dissociative symptoms, 104
stresses of hospitalization and, 229230 by consultation-liaison psychiatrist, 227
substance abuse and, 333 of elderly person, 72
as threat to narcissistic integrity, 229 Metabolic abnormalities, in eating disorders, 92
Medicare, 13, 48, 73, 83, 125, 132, 177, 197, 232, 327, Metabolic syndrome, antipsychotic-associated, 314
340, 358, 360 Methadone
coverage for care in psychiatric units of general for opioid detoxification, 143
hospitals, 404 urine assays for, 137
coverage for intensive outpatient services, 350 VA outpatient programs for treatment with, 217
limitations on coverage for mental health care, 404 Methamphetamine, toxicology testing for, 137
Pay for Performance programs, 408, 433 Methylenedioxymethamphetamine (ecstasy), 137
proportion of hospital revenue from, 408 Metrazol shock, 6, 7
prospective payment system, 365, 405406 Meyer, Adolf, 132, 225, 342
state mental health system and, 407 Milieu management, 384, 389397
Medication administration record (MAR), 440, 442443 on adolescent neuropsychiatric unit, 167168
electronic, 443 on adolescent unit, 6465, 393
Medication history, 30 on adult acute crisis stabilization unit, 32, 393
Medication reconciliations, 444445 on child unit, 4647, 393
Memantine, 77 daily schedule for, 393
Memories, traumatic, 105 definition of, 384
Menninger Clinic, 14, 293, 468 on eating disorders unit, 98100
Menninger Foundation, 12 on ethnic/minority psychiatric inpatient unit, 182
Mental Health: Culture, Race, and Ethnicity, 175 on forensic unit, 190191
Mental Health America, 204 four-S model for, 389397
Mental health care disparities, 206 safety, 390393
elimination of, 206207 self-management, 395397
quality indicators and measures of, 432 structure, 393394
for racial and ethnic minorities, 175177 support, 394395
Mental Hygiene, 7 on geriatric unit, 8182
Mental retardation history of, 6, 9
adolescent neuropsychiatric unit for treatment of patient autonomy and unit rules, 393394
patients with, 159170 on psychotic disorders unit, 129130
causes of, 160 for suicide prevention, 268
challenging behaviors and, 161, 164165, 169 on trauma disorders unit, 113116
definition of, 159, 160 Military Sexual Trauma Program, 217
in DSM-IV-TR, 160 Mindbody relationship, 224
historical care of persons with, 161 Mini-Cog, 73
intellectual and adaptive functioning deficits in, 160 Mini-Mental State Examination (MMSE), 7273, 227,
medical illness and, 164 228
pervasive developmental disorders and, 161 Minnesota Model, 306
prevalence of, 160 Minnesota Multiphasic Personality Inventory, 105
psychopathology comorbid with Adolescent Version, 58
diagnosis of, 163165 Minnesota Multi-State Contracting Alliance for Pharmacy
electroconvulsive therapy for, 166 (MMCAP), 206
goals of inpatient treatment for, 162, 170 Mirtazapine
pharmacotherapy for, 165166 for adolescents, 60
prevalence of, 160 for elderly patients, 75
psychosocial interventions for, 166168 for sleep disruption, 112
rating scales for, 164 use on trauma disorders unit, 111
psychotic disorders unit for treatment of patients with, MMCAP (Minnesota Multi-State Contracting Alliance for
120121 Pharmacy), 206
rationale for specialized services for persons with, MMSE (Mini-Mental State Examination), 7273, 227, 228
161162 Models of care, 383
severity of, 160 Modern Hospital, The, 7
Mental Retardation Facilities and Community Mental Modified Mini Mental State (3MS) examination, 228
Health Centers Construction Act, 340 Modified Overt Aggression Scale, 57, 66
Index 493
Monoamine oxidase inhibitors (MAOIs), 110 National Association for Mental Health, 910
Montgomery-sberg Depression Rating Scale, 448 National Association of Psychiatric Health Systems, 9,
Mood stabilizers 421, 430
for adolescents, 60 National Association of Social Workers (NASW), 380
on adult acute crisis stabilization unit, 30 National Association of State Mental Health Program
for aggressive children, 43 Directors (NASMHPD), 10, 255, 258, 263, 430
for co-occurring affective disorders and alcoholism, National Committee for Mental Hygiene, 6, 7
144145 National Committee for Quality Assurance, 350, 431,
drug formulary for VA hospitals, 216 433
for forensic patients, 188 Healthcare Effectiveness Data and Information Set, 430,
for geriatric bipolar disorder, 78 433, 445
for posttraumatic stress disorder, 110 National Health Information Network, 444, 449
use in persons with mental retardation, 165 National Instant Criminal Background Check
Moos, Rudolf H., 455 Improvement Act, 420
Moral treatment, 454, 467 National Instant Criminal Background Check System
Morphine, urine assays for, 137 (NICS), 420
Mortality. See also Suicide National Institute of Mental Health (NIMH), 9, 75, 78
antipsychotic-related, in elderly dementia patients, 77 Clinical Antipsychotic Trial of Intervention
related to use of seclusion and restraint, 241, 254, Effectiveness, 124, 206, 286, 314
262263, 421 Clinical Antipsychotic Trial of Intervention
Motivational interviewing/motivational enhancement EffectivenessAlzheimer s Disease, 77
therapy, 312313, 382 funding for consultation-liaison psychiatry, 225
for adolescents, 61 National Institute on Drug Abuse, 333
for co-occurring disorders unit, 146 National Inventory of Mental Health Quality Measures,
in outpatient community programs, 337 435
Mount Hope Institution (Maryland), 3 National Medical Enterprises, Inc., 11
Mount Saint Vincent (Maryland), 3 National Mental Health Facility Study, 9
Movement therapy National Practitioner Data Bank, 415
on adolescent unit, 62 National Quality Forum (NQF), 414, 430, 431
on eating disorders unit, 95 Neuroleptics. See Antipsychotics
MRI. See Magnetic resonance imaging Neurological examination
MTP (master treatment plan), 383 of elderly person, 73
electronic medical records and, 447 of psychotic patients, 122
Multiaxial Inventory of Dissociation, 105 Neuropsychiatric disorders
Multisystemic therapy, for children and adolescents, adolescent neuropsychiatric unit for treatment of,
306307 159170
Music therapist, 381 psychotic disorders unit for treatment of, 120
Music therapy, 381 Neuropsychological testing
on adolescent unit, 62 of adolescents, 58
on geriatric unit, 81 of children, 42
on psychotic disorders unit, 128 in consultation-liaison psychiatry, 228
Mutual-help groups, 243 of psychotic patients, 122123
MyHealtheVet, 214 New Hampshire Hospital, 457, 459
New York Hospital, 364, 404, 468
NA (Narcotics Anonymous), 147, 152, 189 New York Lunatic Asylum, 364
Naloxone, 140141 New York Presbyterian Hospital, 358, 364365
Naltrexone New York State Psychiatric Institute, 331
for opioid detoxification, 143 Nicotine dependence, 140
for posttraumatic stress disorder, 111 pharmacotherapy for, 126, 143144
NAMI. See National Alliance on Mental Illness Nicotine replacement therapies, 126, 143
Narcotics Anonymous (NA), 147, 152, 189 NICS (National Instant Criminal Background Check
NASMHPD (National Association of State Mental Health System), 420
Program Directors), 10, 255, 258, 263, 430 NIMH. See National Institute of Mental Health
NASW (National Association of Social Workers), 380 Nortriptyline, 75
National Alliance on Mental Illness (NAMI), 32, 33, 153 Norway Foundation (Indiana), 8
Cries of Anguish, 241 Not-for-profit psychiatric hospitals, 358, 408
position on state hospitals, 204 NQF (National Quality Forum), 414, 430, 431
Nurses, psychiatric, 389398 On Our Own of Maryland, 204

on adult acute crisis stabilization unit, 32 On the Construction, Organization, and General
at Austen Riggs Center, 289 Arrangements of Hospitals for the Insane, 454
data on staffing patterns, 397, 398 ONCHIT (Office of the National Coordinator for Health
electronic medication administration record for, 443 Information Technology), 439, 444, 450
four-S model of milieu management for, 389397 One Flew Over the Cuckoos Nest, 239, 468
safety, 390393 Oophorectomy, 5
ingrained role behaviors of staff, 391 Opioid dependence
prescribed precautions and monitoring, 390391 naloxone for intoxication states, 140141
study on keeping the unit safe, 391392 urine assays for, 137
use of seclusion and restraint, 392393 among VA hospital patients, 215, 217
self-management, 395397 withdrawal from, 143
structure, 393394 delayed abstinence syndrome, 143
support, 394395 detoxification protocols for, 143
caring, concern, and coercion, 395 symptoms of, 143
hands on interventions on psychotic disorders unit, 120 Organic personality, 121
in hospital of the future, 470 Organizational structure, 362363
nursepatient relationship, 394395 Outpatient community mental health services, 327337.
occupational injury of, 255 See also Continuing day treatment programs;
shortage of, 470 Day hospitalization; Intensive outpatient services;
Nurses Global Assessment of Suicide Risk, 269, 270 Partial hospital programs
Nurses station, 462 clinician cultural competence and, 334
Nursing home patients, 80 for comorbid medical disorders and mental illness,
Nutritional assessment of elderly patients, 73 333334
Nutritional education, 95 for comorbid substance abuse and mental illness, 333
Nutritional interventions continuum of services, 330333
for adolescents, 64 collaborations for promotion of, 333
for eating disorders, 9193 continuing day treatment program, 331332
total parenteral nutrition, 95 outpatient program, 332333
patient movement through, 330331
deinstitutionalization and, 327328
Observation
hospital-based programs, 328330
of childs behavior, 4243
challenges faced by, 329330
of patient on psychotic disorders unit, 129
patient population of, 329
of patient on trauma disorders unit, 116
staffing of, 329
for suicide prevention, 267, 274
structure of, 329
Obsessive-compulsive disorder
patient retention in, 336337
eating disorders and, 90
principles of, 328
residential treatment programs for adolescents, 306
referral from psychiatric emergency services to, 312313
Occupational therapists, 381382
residential programs, 334336
Occupational therapy, 381382
Oxazepam, 142
on adolescent neuropsychiatric unit, 168
Oxycodone, urine assays for, 137
on adolescent unit, 64
on geriatric unit, 81
history of, 6, 7 Pacific Islanders, 176
occupational profile for, 381 PAIMI (Protection and Advocacy for Individuals with
on trauma disorders unit, 113 Mental Illness) Act, 203
Occupational Therapy Practice Framework, 381 PANSI (Positive and Negative Suicide Ideation Inventory),
Office of the National Coordinator for Health Information 269, 271
Technology (ONCHIT), 439, 444, 450 PAP (private attending psychiatrist), 371372
Olanzapine Paper charts, 439441
for anorexia nervosa, 93 Paraphilias, 282
for behavioral dyscontrol on trauma disorders unit, 117 Parents. See also Family
for children, 40 consent for admission of child, 56
for geriatric depression with psychotic features, 75 obtaining childs history from, 41
mortality risk in elderly dementia patients, 77 quality of parentchild relationship, 45
Olmstead v. L.C., 204 Paroxetine, 110
Index 495
Partial hospital programs (PHPs), 339, 340, 342344, 350. Personality disorders
See also Day hospitalization Collaborative Longitudinal Personality Disorder Study,
admissions criteria for, 342 286
for children, 51 comorbid with depression, prognostic impact of, 286
difference from continuing day treatment programs, eating disorders and, 90
345 intensive outpatient programs for treatment of, 340, 341
difference from intensive outpatient programs, 348 residential psychotherapeutic treatment for, 287
discharge planning from, 344 residential treatment programs for adolescents, 306
medical assessment in, 342343 substance abuse and, 138
pharmacotherapy in, 343 Pervasive developmental disorders (PDDs)
psychiatric assessment in, 342 adolescent neuropsychiatric unit for treatment of
psychoeducation in, 343344 patients with, 159170
psychosocial assessment in, 343 mental retardation and, 161
for psychotic patients, 132 prevalence of, 161
stabilization phase of, 343 PESs. See Psychiatric emergency services
structure of, 343344 Pet therapy
treatment goals of, 343, 344, 345 on forensic unit, 190
treatment outcomes in, 340341 on geriatric unit, 81
treatment planning for, 343 Pharmacodynamic and pharmacokinetic changes with
Partners Healthcare, 365 aging, 79, 81
Patient and family education, 247, 251 Pharmacodynamic and pharmacokinetic drug interactions,
on adolescent neuropsychiatric unit, 167 44
on adolescent unit, 6364 Pharmacotherapy. See also specific drugs and classes
on adult acute crisis stabilization unit, 30, 32 accurate diagnosis for, 30
on child unit, 45 adherence to, 31, 240
in continuing day treatment program, 346, 347, 348 at Austen Riggs Center, 292
on co-occurring disorders unit, 148 in outpatient treatment programs, 336
on forensic unit, 189 in partial hospital programs, 342
on geriatric unit, 8081 for psychosis, 123124
about medications, 251252 for adolescents, 5961, 60
in partial hospital program, 343344 antidepressant use and suicide risk, 60
on psychotic disorders unit, 127 target symptom approach to medication selection,
on trauma disorders unit, 108, 112113 60, 69
Patient identification, to reduce medical errors, 413 on adult acute crisis stabilization unit, 3031, 33
Patient privacy, electronic medical records and, 448450 for aggressive behavior, 192
Patient satisfaction surveys, 432 in adolescents, 60
Patient-centered care, 470 in children, 43, 48
Patients rights, 6, 9, 241242, 255, 411412 for agitation, 31
access to outdoor space, 241242 at Austen Riggs Center, 289, 292
court oversight, receivership, and decrees, 203204 for bipolar disorder in elderly persons, 78
on forensic unit, 185186 budget concerns in state hospitals, 205206
patient autonomy vs. unit rules, 393394 buying groups for medications, 206
Protection and Advocacy for Individuals with Mental for chemical restraint, 48, 421
Illness Act, 203 for children, 39, 4344, 48
refusal of treatment, 420 communicating with outpatient physician for, 31
Resident Grievance System (Maryland), 203 in continuing day treatment program, 346
use of seclusion and restraint and, 241, 255256 on co-occurring disorders unit, 140145
Pay for Performance systems of reimbursement, 408, for delirium in elderly patients, 76
433 for dementia, 7677
PDDs. See Pervasive developmental disorders for depression
Pedophilia, 282 in adolescents, 60
Pennsylvania Hospital for the Insane, 1, 2, 3, 5, 10, 119, in elderly persons, 7475
358, 403, 454, 454 discharge prescriptions, 31, 444
Pepperell Private Asylum, 1 dosage for, 31
Percentage-of-collections system of professional drugdrug interactions and
compensation, 375 in children, 44
Perphenazine, 75 computer-assisted monitoring for, 145
Pharmacotherapy, drugdrug interactions and (continued) physicianpatient relationship, 285, 288, 378380
cytochrome P450related, 44 roles of psychiatrist in hospital setting, 372373
in elderly persons, 7980 Tarasoff duty of, 150, 280, 422423
in forensic patients, 188 time limitations of, 248
in medically ill patients, 229 Play therapy, 62
pharmacodynamic, 44 Polypharmacy, 9
pharmacokinetic, 44 in children, 40, 41
in substance-abusing patients, 145 in persons with mental retardation, 165
for eating disorders, 93 for psychosis, 125
educating family about, 251252 Pornography, 41
for elderly persons, 7380 Positive and Negative Suicide Ideation Inventory (PANSI),
age-related pharmacokinetic and pharmacodynamic 269, 271
changes, 79, 81 Positive and Negative Syndrome Scale, 128, 342, 448
electronic prescribing, 433 Positron emission tomography, 73
on ethnic/minority psychiatric inpatient unit, 182 Posttraumatic stress disorder (PTSD), 103, 257
on forensic unit, 188 complex, 103104, 110
gathering history of, 30 hypnotizability of patients with, 109
history of, 6, 8, 9 neurobiology of, 257258
inadequate response to, 286 patient boundaries and, 115
laboratory evaluation for, 334 residential psychotherapeutic treatment for, 287
making changes in, 30 substance abuse and, 138, 144
for medically ill patients, 228229 treatment on psychotic disorders unit, 121122
medication administration record vs. computerized treatment on trauma disorders unit, 103117
physician order entry, 440, 442443 group therapy, 112
medication reconciliations, 444 pharmacotherapy, 110112
in partial hospital program, 343 psychotherapy, 105109
for persons with mental retardation, 165166 safety agreements for, 109110
preferred drug lists for, 205 triggers for, 115
national drug formulary for VA hospitals, 215, 216 among veterans, 103, 213, 217
for psychosis, 123127 sexual trauma victims, 217
racial and ethnic differences in drug metabolism PPS (Prospective Payment System), 365, 405
rating scales for measuring response to, 31 Practice Guideline for the Psychiatric Evaluation of Adults,
for sex offenders, 188, 190 178, 342
on trauma disorders unit, 110112 Practice guidelines, 432
for acute behavioral dyscontrol, 116, 117 Practice Guidelines for the Treatment of Patients With
using minimum number of medications for, 31 Bipolar Disorder, 78
Phencyclidine, 137, 149 Practice Parameters for the Psychiatric Assessment of
Phenelzine, 110 Children and Adolescents, 56
Philanthropy, 366, 408 Prader-Willi syndrome, 161
Physical examination Pratt, Enoch, 360, 362
of adolescent, 5758 Pratt, Joseph, 225
by consultation-liaison psychiatrist, 227 Prazosin, 110
of elderly person, 73 Preadmission review, 406
Physical therapy, 7, 64 Presidents New Freedom Commission on Mental Health,
Physician Consortium for Performance Improvement, 430 176, 177, 206207, 240, 245, 255, 256, 469
Physician Quality Reporting Initiative, 433 Primary prevention of inpatient violence, 262
Physicians Principles for the Protection of Persons With Mental Illness
adoption of electronic medical records by, 446447 and for the Improvement of Mental Health Care, 255
coping styles of, 231 Private attending psychiatrist (PAP), 371372
cultural competence of, 175177, 334 Private psychiatric facilities
disclosure of sentinel event, 414415 admissions to, 199, 405, 407
managed care and clinical decision making by, 425 financing of care in, 405
models of compensation for employed clinicians, for-profit hospitals, 11, 467
374375 history of, 415, 404
National Practitioner Data Bank, 415 not-for-profit hospitals, 358, 408
patterns of psychiatrist practice, 371372 psychiatric beds in, 198, 405, 407
physician-family relationship, 248249 revenue sources for, 408
Index 497
Privatization of public mental health services, 13 history of, 116

Privileges of hospitalized patients, 238, 239 integration and product or service line organization of,
Problem-solving therapy (PST), 80 363365
Project MATCH (Matching Alcoholism Treatments to Ivy League hospitals, 358, 365
Client Heterogeneity study), 145146, 147 leadership of, 366367
Projective identification, at Austen Riggs Center, 290, 291 length of stay and discharge planning from, 384386,
Promethazine, 8 385
Propoxyphene, urine assays for, 137 milieu management in, 384
Propranolol, 111 modern adaptations of early asylums, 358362
Prospective Payment System (PPS), 365, 405 not-for-profit, 358, 408
Protection and Advocacy for Individuals with Mental organizational structure and governance of, 362363
Illness (PAIMI) Act, 203 professional compensation at, 374375
Protection and Advocacy for Individuals with Mental psychiatrists employed by, 372
Illness Advisory Council, 241 quality of care in, 365, 469
PSE (psychosocial evaluation) by social worker, 381 quality indicators and measures, 429435
Pseudodementia, 74 regulation of, 365
PST (problem-solving therapy), 80 revenue sources by type of hospital, 408
Psychiatric beds risk management in, 411426
deinstitutionalization and number of, 6, 119, 311, 405 safety in, 390393, 412413
in general hospital psychiatric units, 23, 198, 404405, statistical benchmarking for, 433434
407 Psychiatric Nurses Association, 421
number of hospitals with, 198 Psychiatrists, 371375
in private psychiatric hospitals, 198, 405, 407 in hospital of the future, 470471
in state psychiatric hospitals, 197199, 198, 405, 407 managed care and clinical decision making by, 425
in VA hospitals, 198 models of compensation for employed clinicians,
Psychiatric emergency services (PESs), 311317 374375
assessment steps for, 313317 practice patterns of, 371372
comprehensive evaluation form, 316, 320326 community-based private attending psychiatrist,
disposition, 316317 371372
laboratory testing, 315 hospitalist psychiatrist, 372
medical assessment, 314315 roles of, 372373
psychiatric assessment, 315316, 316 attending psychiatrist as clinician, 372373
triage, 313314, 314 other responsibilities in hospital setting, 373
weapons checks, 313 unit medical director, 373
common reasons for, 312 shortage of, 8
conceptual models of, 312313 Tarasoff duty of, 150, 280, 422423
staging model, 312313 Psychoanalysis, 6
treatment model, 312 Psychodynamic psychotherapy
triage model, 312 for adolescents, 61
dearth of data on, 312 at Austen Riggs Center, 289, 291
exclusion criteria for, 313 on trauma disorders unit, 107
history of, 311 use in substance-abusing populations, 147
increasing demand for, 311312 Psychoeducation. See Patient and family education
indications for, 313 Psychologists, 373374
intensive outpatient services and, 349 Psychopathic hospital, 7
referral to community-based resources from, 312313 Psychosis. See also Schizophrenia
Psychiatric historical time line, 448 antipsychotics for, 123126
Psychiatric hospitals, 357367. inadequate response to, 286
See also Private psychiatric facilities; State psychiatric cannabis-induced, 144
hospitals depression with, in elderly persons, 74, 75
admission and diagnostic process in, 378, 379 electroconvulsive therapy for, 126
core business domains of, 365366 family of patient with, 131
core components of administration of, 362 history of inpatient care for, 119
design of, 453463 insurance coverage for treatment of, 122, 132
financing of care in, 365366, 403408 psychosocial treatment of adolescents with, 61
for-profit, 11, 467 psychotherapy for, 127
future of, 367, 470472 smoking and, 126127
Psychosocial evaluation (PSE) by social worker, 381 PTSD. See Posttraumatic stress disorder
Psychosomatic medicine, 223225. Public Hospital for Persons of Insane and Disordered
See also Consultation-liaison psychiatry Minds, The (Virginia), 403404
certification in, 223 Public hospitals. See State psychiatric hospitals
future challenges for, 231232 Public Law 94142, 162
history of, 224225 Public Law 96272, 301
Psychosomatic Medicine, 225 Public Law 9821, 162
Psychotherapy, 7. See also specific psychotherapies Public Law 104121, 202
on adolescent unit, 6163, 61 Putnam, James Jackson, 225
on adult acute crisis stabilization unit, 30
on child unit, 4445 QT interval prolongation, drug-induced, 229
in continuing day treatment program, 346, 347348 Quality Indicator Project, 433
on co-occurring disorders unit, 145147 Quality Indicators: Defining and Measuring Quality in
on ethnic/minority psychiatric inpatient unit, 182 Psychiatric Care for Adults and Children, 435
on forensic unit, 188189 Quality indicators and measures, 429435
on geriatric unit, 80 additional resources on, 435
for medically ill patients, 229231 online resources, 438
in partial hospital program, 343 for care transitions, 431432
in psychiatric emergency settings, 312 core set of, 431
on psychotic disorders unit, 127 customers for, 431
residential psychotherapeutic treatment, 285295 data collection plans for, 433
on trauma disorders unit, 105109, 105110 definition of, 430
Psychotic disorders unit, 119133 development and selection of, 431432
admissions criteria for, 120123 data sources for, 431
core target population, 120 national organizations involved in, 432433
dissociative identity disorder and posttraumatic observations on, 435
stress disorder, 121122 electronic medical records and, 433
dual diagnosis, 121 for health care disparities, 432
insurance and placement resources, 122 interpreting and assessing data from, 433434
special populations, 120121 risk adjustment, 433, 434
diagnostic workup on, 122123 statistical benchmarking, 433434
discharge planning from, 131132 leadership for development of, 430431
involvement of community providers, resources, and management of, 434
significant others, 131 patient satisfaction surveys, 432
specialty day hospital, 132 practice guidelines, 432
transition to next level of care, 131132 sharing data from, 434
electroconvulsive therapy on, 126 staff education about, 434435
length of stay on, 122 structure, process, and outcome approaches, 432
management of suicidal or aggressive behaviors on, for value-based health care, 432
130131 Quality Measures Management Information System, 433
seclusion and restraint, 131 Quality of care, 365, 469
milieu management on, 129130 aims of high-quality health care, 430, 432
mission of, 119, 120 communication to improve patient safety, 417418
other treatment modalities on, 128129 components of quality, 429
patient and family education on, 127 core measure set for analysis of, 397, 398
patient perspective on, 238 Crossing the Quality Chasm, 413, 418, 429430
pharmacotherapy on, 123126 electronic medical records and, 445
depot neuroleptics, 124 To Err Is Human: Building a Safer Health System, 413,
dosing and administration, 124 440
duration of treatment, 125 evidence-based medicine and, 207
polypharmacy regimens, 125 indicators and measures of, 429435
refractory illness, 125126 managed care and, 406407
serum levels and response, 124125 National Committee for Quality Assurance, 350, 430,
side effects and adherence to, 123124 431
psychotherapies on, 127 National Quality Forum, 414, 430, 431
rehabilitation and recreational therapies on, 127128 Physician Consortium for Performance Improvement,
smoking cessation on, 126127 430
Index 499
for racial and ethnic minorities, 176177 clinical decision making and denial of, 425, 426
reducing incidence of medical errors, 413 for consultation-liaison services, 224, 232
risk management and, 411426 cost-containment pressures and, 1113, 24, 39, 43,
(See also Risk management) 405406
root cause analysis of problems with, 203, 414, 415416 financial effects of changes in, 407408
safety and, 390393 (See also Safety issues) future financial viability of inpatient psychiatric
in state hospitals, 203, 207 services, 408
Quetiapine, 77 for intensive outpatient services, 365
managed care and, 406407, 425
Race/ethnicity Medicaid, 365, 407
access to treatment and, 176 Medicare, 365, 405406
desegregation of psychiatric hospitals, 8 prospective payment system for, 365, 405406
drug metabolism related to, 176 revenue sources by type of hospital, 408
ethnic/minority psychiatric inpatient unit, 175183 state mental health systems and, 407
language access to treatment, 176, 177 trends in, 471472
mental health care disparities and, 175177 Relapse prevention therapy (RPT), for co-occurring
quality of care and, 176177 disorders, 146, 152
of state hospital patients, 199, 199 Relative value units (RVUs), 374
children and adolescents, 200, 201 Religious-affiliated private facilities, 3
Rating scales. See Assessment instruments Reporting of a sentinel event, 414415
Rational emotive therapy, 147 Reproductive health services for adolescents, 57
Ray, Isaac, 5 Research Diagnostic Criteria, 442
RCA (root cause analysis), 203, 414, 415416 Resident Grievance System (Maryland), 203
Readiness to change, 138139 Residential programs, 334336
Recovery Model, 383 community residences, 335
Recreational therapies, 8, 9, 383 crisis residences, 335
on adolescent neuropsychiatric unit, 168 discharge from hospital to, 385
on adolescent unit, 64 family care programs, 336
on adult acute crisis stabilization unit, 32 independent living programs, 335
at Austen Riggs Center, 290 levels of supervision in, 335
on child unit, 4546 transitional housing, 335
in continuing day treatment programs, 347 Residential psychotherapeutic treatment, 285295
on forensic unit, 189190 behavioral expectations for, 288
on geriatric unit, 81 benefits of, 286287
history of, 5 determining suitability for care in an open setting,
in intensive outpatient programs, 341342 288289
on psychotic disorders unit, 127128 dilemmas in constructing treatment at, 288
on trauma disorders unit, 113 family treatment, 291292
Refeeding programs, 9293 impact of setting on, 290291
Refusal of treatment, 420 indications for, 286287
Rehabilitation specialists, 377, 381383 individual psychodynamic psychotherapy, 289, 291
Rehabilitation therapies, 8, 9, 377386 limit setting for, 288
on adolescent neuropsychiatric unit, 168 management of financial resources, 289, 292293
on adolescent unit, 64 management of suicidal and aggressive behaviors, 293
on adult acute crisis stabilization unit, 32 patients in, 287288
at Austen Riggs Center, 290 pharmacotherapy and, 289, 292
on child unit, 4546 rationale for, 285286
on forensic unit, 189190 research on, 293294
on geriatric unit, 81 settings for, 286
history of, 5 therapeutic alliance for, 288
in intensive outpatient programs, 341342 treatment overview, 289290
nutritional, 9193 Residential treatment for children and adolescents,
on psychotic disorders unit, 127128 299307
on trauma disorders unit, 113 cost of, 299, 300, 303, 305
Reil, Johann Christian, 224 future needs for, 307
Reimbursement, 365. See also Health insurance coverage; history of, 300301
Managed care; Medicaid; Medicare linking to community-based resources, 300
Residential treatment for children and adolescents Joint Commission definition of, 412
(continued) managed care and clinical decision making, 425
long-term programs, 299, 303305 on psychotic disorders unit, 121, 130131
admissions process for, 303304 seclusion, restraint, and de-escalation techniques,
characteristics of youth in, 303 421422
clinical course in, 304 after a sentinel event, 413415
entry points and patient selection for, 303 apology, 415
treatment outcomes for, 304305 checklist for, 414
milieu therapy and, 300 disclosure, 414415
multisystemic therapy as alternative to, 306307 root cause analysis, 203, 414, 415416
number of youth in, 300 Tarasoff duty, 150, 280, 422423
patient population of, 299 on trauma disorders unit, 116
referrals for, 300 Risperidone
short-term programs, 299, 301303 for children, 40
admissions process for, 301302 interaction with bupropion, 44
characteristics of youth in, 301 mortality risk in elderly dementia patients, 77
clinical course in, 302 for posttraumatic stress disorder, 111
entry points and patient selection for, 301 Riverview Psychiatric Center (Maine), 458, 460
treatment outcomes for, 302303 Rockwell, William, 3
for special populations, 300, 305306 Rohypnol. See Flunitrazepam
eating disorders, 305 Root cause analysis (RCA), 203, 414, 415416
obsessive-compulsive disorder, 306 Rorschach test, 105
personality disorders, 306 RPT (relapse prevention therapy), for co-occurring
sexual offenders, 306 disorders, 146, 152
substance abuse, 305306 Rush, Benjamin, 224
treatment models for, 299 RVUs (relative value units), 374
Respect, 392
Respiratory depression, opioid-induced, 140141 SAD PERSONS scale, 269, 271
Respite care for family, 40, 51 Safety issues, 390393. See also Risk management
Rest homes, 7 on adolescent neuropsychiatric unit, 168169
Restraint of patient. See Seclusion and restraint on adolescent unit, 60, 6566
Revenue sources. See also Financing of care on adult acute crisis stabilization unit, 32
at Sheppard and Enoch Pratt Hospital, 361362 aggression/violence prevention, 253263
by type of hospital, 408 at Austen Riggs Center, 288, 293
Revised Childrens Manifest Anxiety Scale, 57 on child unit, 43, 4750
Risk adjustment, 433, 434 communication improvement and, 417418
Risk assessment for dangerousness, 411 on co-occurring disorders unit, 136, 148150
before hospital discharge, 277282 creating culture of patient safety, 412413, 426
suicide, 32, 82, 268269, 418 on forensic unit, 185, 190193
violence, 32 on geriatric unit, 8283
Risk management, 411426. See also Safety issues hospital design and, 453, 455, 456, 461, 462
on adolescent unit, 60, 6566 incident investigation, 412
on adult acute crisis stabilization unit, 32 interventions of consultation-liaison psychiatrist, 231
boundaries and staff supervision, 418419 Joint Commission National Patient Safety Goals, 203,
on child unit, 43, 4750 390, 418
civil commitment, 419421 proactive organizational response to safety concerns, 412
on co-occurring disorders unit, 148150 on psychotic disorders unit, 121, 130131
creating culture of patient safety, 412413, 426 safety management in milieu, 390393
adherence to good clinical practices, 412413 (See also Seclusion and restraint)
incident investigation, 412 ideological factors, 391
proactive response to safety concerns, 412 importance of respect, 392
reducing incidence of medical errors, 413 ingrained role behaviors of staff, 391
documentation for, 412413 interpersonal relationships, 392
elopement from hospital, 411, 423424 prescribed precautions and monitoring, 390391
failure modes and effects analysis, 415, 416417 space and time factors, 392
on forensic unit, 185, 190193 study on keeping the unit safe, 391392
on geriatric unit, 8283 use of seclusion and restraint, 253263, 392393
Index 501
suicide prevention, 267275 on geriatric unit, 83

on trauma disorders unit, 106107, 109110, 116 Hartford Courant series on, 241, 254, 255
weapons checks in emergency department, 313 hospital policies and, 392393
SAMHSA (Substance Abuse and Mental Health Services injuries and deaths related to, 241, 254, 262263, 421
Administration), 138, 433, 435 Joint Commission standards for use of, 421
San Francisco General Hospital, Ethnic/Minority Learning From Each Other: Success Stories and Ideas for
Psychiatric Inpatient Programs, 175183 Reducing Restraint/Seclusion in Behavioral Health,
Sanitariums, private, 7 421422
SBAR method of communication, 418 legal consequences of inappropriate use of, 254
Scale for Assessing Suicide Risk of Attempted Suicide, 269, patient monitoring during, 49
272 patient perspectives on, 239240
Scale for Suicidal Ideation, 269, 270 patients rights and, 241, 255256
Schizoaffective disorder prevention framework for reduced use of, 262
psychotic disorders unit for treatment of, 119133 in psychiatric emergency settings, 312
among VA hospital patients, 215 on psychotic disorders unit, 131
Schizophrenia. See also Psychosis reducing hours of, 259
antipsychotics for, 123126 regulation of, 48, 254, 255, 421
inadequate response to, 286 risk management and, 421422
in elderly persons, 79 on trauma disorders unit, 116
early- vs. late-onset illness, 79 violence prevention plan to reduce use of, 258262
inpatient treatment of, 79 data-informed practice, 259
intensive outpatient programs for treatment of, 341 full inclusion of consumers and advocates, 261
medical illness and, 334 leadership toward organizational change, 259
psychotic disorders unit for treatment of, 119133 rigorous debriefing activities, 261262
substance abuse and, 138, 144 seclusion and restraint prevention tools, 260261
suicide and, 148 sensory interventions, 260261
among VA hospital patients, 215 workforce development, 259260
Schizophreniform disorder, 120 Secondary prevention of inpatient violence, 262
School issues, 40, 42 Sedative-hypnotics. See also Benzodiazepines
on adolescent neuropsychiatric unit, 168 detoxification and withdrawal from, 142143
on adolescent unit, 64 Seizure disorders, 28
autism, 161 alcohol-withdrawal seizures, 136, 141, 142
on child unit, 4546 mental retardation and, 164
collaboration with childs home school district, 5051 psychotic disorders unit for treatment of patients with, 120
day treatment programs and, 51 Selecting Process Measures for Quality Improvements in
educational entitlements under Public Law 94142, 162 Mental Healthcare, 435
on forensic unit, 190 Selective norepinephrine reuptake inhibitors, 60
school shootings, 281, 420 Selective serotonin reuptake inhibitors (SSRIs)
school system payment for education in residential for adolescents, 60
treatment facility, 303 for bulimia nervosa, 93
special education services, 40, 5051, 161 for co-occurring depression and alcoholism, 144
of Sheppard Pratt Health System, 361 for dementia-related behavioral disturbances, 77
Schwartz, Harold I., 359 for geriatric depression, 75
Seclusion and restraint, 4, 253263, 392393 for posttraumatic stress disorder, 110, 111
on adolescent neuropsychiatric unit, 168169 use in anorexia nervosa, 93
on adolescent unit, 66 use in persons with mental retardation, 165
advocacy for reduced use of, 241, 255256, 392, 421 Self-efficacy, 396397
principles underlying trauma-informed systems of Self-help materials, 397
care, 257258 Self-hypnosis of trauma victims, 109
alternatives to, 421 Self-injurious behavior, 390. See also Suicide
chemical restraints, 48, 421 admission to child unit for, 37, 38
on child unit, 4849 of children with developmental disabilities, 38
on co-occurring disorders unit, 150 injury mapping of, 57
definition of, 253 management at Austen Riggs Center, 293
documentation for, 441 of patients on trauma disorders unit, 106
electronic medical record and orders for, 443 residential psychotherapeutic treatment for, 287
on forensic unit, 192193 screening adolescents for, 56, 57
Self-management, 389, 395397 Shame of trauma victims, 107, 108

Sensory integration, 382 Sharfstein, Steven, 361
Sensory interventions for violence reduction, 260261 Shell shock, 217
Sentinel events, 413417 Sheppard, Moses, 3, 360, 362
apology after, 415 Sheppard and Enoch Pratt Hospital (Maryland), 3, 5, 358,
definition of, 413 360362, 366, 468
disclosure of, 414415 continuum of services of, 361, 364
elopement, 423 integration and service lines at, 361, 364
examples of, 415 leadership of, 361, 362
failure modes and effects analysis to reduce risk of, 415, managed care plan of, 362
416417 professional compensation at, 374375
inpatient suicide or attempt, 413414, 416 residency program at, 361
risk management techniques for coping with, 413415 Retreat at Sheppard Pratt, 362
root cause analysis of, 203, 414, 415416 revenue sources, 361362
Serotoninnorepinephrine reuptake inhibitors (SNRIs) Sheppard Asylum (Maryland), 3, 360
for adolescents, 60 Sheppard Pratt Health System (Maryland), 14, 103, 358,
for geriatric depression, 75 360
for posttraumatic stress disorder, 110 special education component of, 361
Sertraline Sheppard Pratt Practice Association, 362
for bulimia nervosa, 93 Sheppard Pratt Suicide Risk Assessment Instrument
for co-occurring posttraumatic stress disorder and (SPSRAI), 269, 273, 274, 275
alcoholism, 144 expressed intentions, 269
for geriatric depression, 75 mental status findings, 269, 274
for posttraumatic stress disorder, 110 selected aspects of history, 274
Settings for care use of, 274
adolescent neuropsychiatric unit, 159170 Six Sigma studies, 431
adolescent unit, 5567 Skills training
adult acute crisis stabilization unit, 2334 for adolescents, 61
child unit, 3752 in continuing day treatment program, 346347
co-occurring disorders unit, 135153 on co-occurring disorders unit, 147
day hospitalization and intensive outpatient services, group therapy for children, 45
339351 in partial hospital program, 343
eating disorders unit, 89101 on psychotic disorders unit, 128
ethnic/minority psychiatric inpatient unit, 175183 for symptom management in trauma victims, 109
forensic unit, 185194 Smith-Magenis syndrome, 161
geriatric unit, 7183 Smoking
hospital-based psychiatric emergency services, 311317 areas on facility grounds for, 462
least restrictive, 13, 24, 39, 41, 162, 285, 303, 420 cessation of
outpatient community mental health services, 327337 on co-occurring disorders unit, 140, 143144
psychotic disorders unit, 119133 on psychotic disorders unit, 126127
residential programs, 334336 Snake Pit, The, 468
residential psychotherapeutic treatment, 285295 SNRIs. See Serotoninnorepinephrine reuptake
residential treatment for children and adolescents, inhibitors
299307 Social Security, 48, 212
state hospitals, 197208 Social Security Disability Insurance, 132, 240, 327, 332,
trauma disorders unit, 103117 384
trends in, 469470 Social skills training
Veterans Affairs hospitals, 211219 for adolescents, 61
Sexual contact between clinician and patient, 418, 419 in continuing day treatment program, 346, 347
Sexual offenders, 188, 190 on co-occurring disorders unit, 147
discharge dilemmas related to, 281282 group therapy for children, 45
residential treatment programs for adolescents, 306 on psychotic disorders unit, 128
treatment in state hospitals, 201202 Social workers, 377, 380381, 386
cost of, 206 Solbrig v. United States, 424
Sexual trauma victims Special education services, 40, 5051, 161.
adolescent, 57 See also School issues
in VA hospitals, 217 of Sheppard Pratt Health System, 361
Index 503
Speech and language therapy medical care in, 207

on adolescent neuropsychiatric unit, 168 pharmacotherapy in, 205206
on adolescent unit, 64 psychiatric beds in, 197199, 198, 405, 407
Spinoza, Baruch, 224 quality of care in, 203, 207
Spiritual needs of patients, 64, 147, 187 relationships with community services, 202
Spitzer, Robert, 442 relationships with Medicare and Medicaid, 407
SPSRAI. See Sheppard Pratt Suicide Risk Assessment technology in, 207
Instrument types of units in, 199200
SSRIs. See Selective serotonin reuptake inhibitors unions and employees of, 204
Staff Statistical benchmarking, 433434
of adolescent neuropsychiatric unit, 167168, 170 Stigma, 4, 7, 152, 468
assault of patient by, 418 Stimulants
of child unit, 47 for adolescents, 60
of co-occurring disorders unit, 138 for attention-deficit/hyperactivity disorder, 40, 43
debriefing after seclusion and restraint events, 261262 depression due to abrupt discontinuation of, 143
education about quality indicators and measures, interactions with clonidine, 44
434435 use in persons with mental retardation, 165
experiences with inpatient violence, 32, 256257 Stressful life events
of forensic unit, 191 affecting children, 42, 44
of hospital of the future, 470 medical illness and hospitalization, 229231
of hospital-based outpatient mental health program, 329 psychosocial treatment of, in adolescents, 61
of intensive outpatient services, 349 residential psychotherapeutic treatment for, 287
of private hospitals, history of, 5, 67 traumatic, 257258
professional boundaries for, 418419 Structured Clinical Interview for DSM-IV Dissociative
psychiatric nurses, 389398 Disorders, 105
psychiatrists and psychologists, 371375 Substance Abuse and Mental Health Services
safety and ingrained role behaviors of, 391 Administration (SAMHSA), 138, 433, 435
sexual misconduct of, 418, 419 Substance abuse history, 226
social workers and rehabilitation therapists, 377386 Substance use disorders (SUDs)
supervision of, 418419 in adolescents
of trauma disorders unit, 113114 psychosocial treatment of, 61
violence prevention plan for, 258262 residential treatment programs for, 305306
Stages of change, 139 screening for, 57, 58
Stahl, George Ernst, 224 anxiety disorders and, 144
Standards for Social Work Practice in Health Care Settings, eating disorders and, 96, 138
380 as exclusion criterion for trauma disorders unit, 104
STAR*D trial, 75, 286 experience of traumatic life events and, 257
State psychiatric hospitals, 197208, 407 inpatient detoxification for, 30
academic partnerships with, 207 intensive outpatient programs for treatment of, 340
accreditation of, 202203 laboratory testing for, 136137
admissions to, 197199, 199, 407 medical illness and, 333
budget and legislative issues affecting, 205206 mental illness co-occurring with, 135
child and adolescent population of, 200201 employment of persons with, 151152
racial/ethnic distribution of, 200, 201 outpatient community mental health care for, 333
civil status population of, 200, 200 placement criteria for treatment of, 135136
consumers, advocates, and providers views on role of, psychosocial problems and, 138
204205 safety concerns related to treatment of, 136
demographics of patients in, 199, 199 self-help groups for patients with, 147148, 152
electronic medical records in, 207 treatment on psychotic disorders unit, 121
forensic population of, 200, 201202 personality disorders and, 138
future of, 206207 posttraumatic stress disorder and, 138
history of, 115, 197199, 198, 199, 403404, 467 relapse prevention groups in continuing day treatment
impact in continuum of care, 202 programs, 348
legal issues affecting, 203204 residential psychotherapeutic treatment for, 287
court oversight, receivership, and decrees, 203204 schizophrenia and, 138, 144
Protection and Advocacy for Individuals with Mental among state hospital patients, 202, 207
Illness Act, 203 suicide and, 148
Substance use disorders (SUDs) (continued) for patients with co-occurring substance abuse and
termination of Social Security benefits for, 202 mental illness, 147148, 152
treating dual-diagnosis patients on psychotic disorders Supportive care by nurses, 394395
unit, 121 Supportive living, discharge from hospital to, 385
treatment on co-occurring disorders unit, 135153 Supportive psychotherapy
among VA hospital patients, 215, 217218 for adolescents, 61
drug formulary for treatment of, 216 on co-occurring disorders unit, 146
women, 218 Sympathomimetics, 78
violent behavior and, 149150 Systematic Treatment Enhancement Program for Bipolar
Substance-induced disorders, 28 Disorder, 286
SUDs. See Substance use disorders
Suicide, 267275 T3 (triiodothyronine), for antidepressant augmentation, 75
among adolescents Tarasoff vs. Regents of the University of California, 150,
antidepressant use and, 60 280, 422423
screening for, 56 Tax Equity and Fiscal Responsibility Act (TEFRA), 359, 406
asking patient about, 226 Taylor Manor Hospital (Maryland), 14, 358
bipolar disorder and, 341 TCAs. See Antidepressants, tricyclic
among children, 38 TDU. See Trauma disorders unit
eating disorders and, 89, 90 Technology
among elderly persons, 7172, 73 electronic medical record, 439450, 469
incidence of, 267, 275 to reduce incidence of medical errors, 413
inpatient prevention and management of telemedicine, 207
on adolescent unit, 6566 at Veterans Affairs hospitals, 213214
on adult acute crisis stabilization unit, 32 TEFRA (Tax Equity and Fiscal Responsibility Act), 359, 406
at Austen Riggs Center, 293, 294 Tertiary prevention of inpatient violence, 262
on child unit, 4750 Texas Implementation of Medication Algorithms (TIMA),
on co-occurring disorders unit, 148149 125
on ethnic/minority psychiatric inpatient unit, 182183 The Human Context: Environmental Determinants of
on forensic unit, 191193 Behavior, 455
on geriatric unit, 82 Thematic Apperception Test, 105
on psychotic disorders unit, 130131 Therapeutic community, 9
of patients on trauma disorders unit, 106 at Austen Riggs Center, 289291
residential psychotherapeutic treatment for ongoing risk for substance-abusing children and adolescents, 306
of, 287 Therapeutic relationship, 285, 288, 378380
risk assessment for, 32, 82, 268269, 418 Therapy rooms
assessment instruments, 269, 270272 on adult unit, 462
discharge dilemmas and, 277282 on child unit, 463
Sheppard Pratt Suicide Risk Assessment Instrument, Thiamine supplementation, 142
269, 273, 274 Thioridazine, 8
as sentinel event, 413414 Thomas Scattergood Foundation, 363
special prevention precautions for, 274 Thorazine. See Chlorpromazine
access to clothing and belongings, 274 TIMA (Texas Implementation of Medication Algorithms),
frequency and proximity of observation, 274 125
policies, 274 Time outs, 46
setting of observation, 274 To Err Is Human: Building a Safer Health System, 413, 440
substance abuse and, 148149 Token economy systems. See also Incentive programs
suicide-prevention contracts, 275 on child unit, 46
threats by sexual offenders to avoid incarceration, 282 on psychotic disorders unit, 129
universal precautions for prevention of, 268269, 390 Topiramate
universal prevention precautions for for bulimia nervosa, 93
risk assessment, 268269 for posttraumatic stress disorder, 110
safe and therapeutic milieus, 268 Total parenteral nutrition (TPN), 95
safe physical environments, 268 Touching between patients on trauma disorders unit, 115
Supervision of staff, 418419 TPN (total parenteral nutrition), 95
Supplemental Security Income, 132 Trail Making Test Part B, 228
Support groups. See also 12-Step programs Transference, 291
for family, 32, 153 traumatic themes, 114
Index 505
Transition from adolescent to adult services, 67 Treatment-resistant illness, 286, 294

Transition to next level of care. See also Continuum of care residential psychotherapeutic treatment for, 285295
from child unit, 51 Triage for psychiatric emergency services, 312, 313314
from forensic unit, 193194 Crisis Triage Rating Scale, 314, 314
from psychotic disorders unit, 131132 Tricyclic antidepressants (TCAs).
Transitional housing, 335 See Antidepressants, tricyclic
Trauma disorders unit (TDU), 103117 Triggers
admissions criteria for, 104 for behavioral dyscontrol, 384
diagnostic workup on, 104105 for posttraumatic stress disorder, 115
reliability of traumatic memories, 105 Triiodothyronine (T3), for antidepressant augmentation, 75
discharge planning from, 116117 Triple-diagnosis patients, 149
exclusion criteria for, 104 Trust, patients lack of, 238
expressive and rehabilitative therapies on, 113 Tuke, Samuel, 404
history of, 103 12-Step programs
management of behavioral dyscontrol on, 116 for adolescents, 67
intensive observation levels, 116 in residential treatment programs, 306
pharmacological, 116, 117 Alcoholics Anonymous, 33, 147148, 152, 153, 189
seclusion and restraint, 116 cognitive-behavioral therapy and, 148
milieu management on, 113116 Narcotics Anonymous, 147, 152, 189
patient management issues, 114116 for patients with co-occurring disorders, 121, 147148
boundaries between patients, 115
for patients with dissociative identity disorder, 116 Ulysses contracts, 425
staff management issues, 113114 Unit medical director, 373
pharmacotherapy on, 110112, 116, 117 United Auto Workers, 9
psychotherapies on, 105110 University of Maryland, 361, 362
cognitive-behavioral therapy, 108 Urine toxicology testing, 136137
dialectical behavior therapy, 108109 U.S. Department of Health and Human Services, 439
family therapy, 112113 U.S. Psychiatric Rehabilitation Association, 204
group therapy, 107, 112 Utica State Hospital (New York), 2, 4
modalities of, 107109 Utilization management, 1113, 406.
patient and family education, 108, 112113 See also Managed care
safety agreements for, 109110
safety focus of, 106107 VA facilities. See Veterans Affairs hospitals
stage-oriented treatment, 105106 Valproate
symptom management skills training, 109 for alcohol withdrawal, 142
trauma focus of, 106 for children, 40
therapeutic journaling on, 113 for geriatric bipolar disorder, 78
Trauma Symptom Inventory, 105 for posttraumatic stress disorder, 110
Trauma-informed systems of care, 257258 for sedative-hypnotic withdrawal, 143
Traumatic brain injury. See Head-injured patients Value-based health care, 432
Traumatic life events, 257258. Varenicline, 126, 143144
See also Stressful life events Vascular depression, 74
residential psychotherapeutic treatment for, 287 Venlafaxine
Trazodone for elderly patients, 75
for adolescents, 60 for posttraumatic stress disorder, 110
for sleep disruption, 112 Vermont Asylum for the Insane, 3
use in elderly patients, 75, 80 Veterans Affairs (VA) hospitals, 211219
Treatment modalities, 383 admissions to, 199
Treatment planning clinical population of, 211, 215218
on adolescent neuropsychiatric unit, 165 admission diagnoses of, 215
on adolescent unit, 5859 geriatric psychiatry patients, 216
on adult acute crisis stabilization unit, 29 inappropriate enlistees, 215
for continuing day treatment programs, 346 patients with combat trauma, 217
on co-occurring disorders unit, 137140 patients with major mental illness, 215
master treatment plan, 383, 447 patients with sexual trauma, 217
for partial hospital programs, 343 patients with traumatic brain injury, 216
Treatment refusal, 420 substance-abusing patients, 217218
Veterans Affairs (VA) hospitals (continued) work readiness groups in continuing day treatment
differences from other health systems, 211 programs, 348
employees of, 212 Voluntary hospital admission, 419
health care training at, 212 Vomiting, self-induced, 89
homeless program of, 218219
information technology at, 213214 Washington Heights Community Service (New York),
national drug formulary for, 215, 216 331333
online resources for veterans, 221 continuing day treatment program, 331332
psychiatric beds in, 198 outpatient program, 332333
research at, 212 Weapons checks in emergency department, 313
spending and revenue adjustments at, 213 Wechsler Adult Intelligence Scale, 105
VA health care system, 212 Wellness groups on geriatric unit, 81
VA Integrated Service Networks, 213, 214 Wellness Recovery Action Plan (WRAP), 243, 383
veterans health benefits, 212213 Wernicke-Korsakoff syndrome, 142
vocational rehabilitation at, 218 Wernickes encephalopathy, 142
volunteer workforce of, 212 Wickline v. State of California, 425
womens health services at, 218 Wide Range Achievement Test, 123
Veterans Health Information Systems and Technology Williams syndrome, 161
Architecture (VistA), 213214 Willard Asylum (New York), 2
Veterans Integrated Service Networks (VISNs), 213, 214, Wilson v. Blue Cross of Southern California, 425
215 Wilsons disease, 120
Victims Withdrawal
duty to warn and duty to protect, 150, 280, 422423 from alcohol, 141142
patient discharge and working with, 280281 from cannabis, 144
sexual predators, 282 from nicotine, 143144
Violence prevention plan, 258262. from opiates, 143
See also Aggressive/violent behavior from sedative-hypnotics, 142143
data-informed practice, 259 from stimulants, 143
full inclusion of consumers and advocates, 261 Women
leadership toward organizational change, 259 as state hospital patients, 199
rigorous debriefing activities, 261262 VA health services for, 218
seclusion and restraint prevention tools, 260261 Womens Focus Program, 179180
workforce development, 259260 Worcester State Hospital, 2, 4
Virginia Tech massacre, 281, 420 Work readiness groups, 348
VISNs (Veterans Integrated Service Networks), 213, 214, WRAP (Wellness Recovery Action Plan), 243, 383
215 Wraparound services for children, 40
VistA (Veterans Health Information Systems and Wyatt v. Stickney, 9, 203
Technology Architecture), 213214
Vitamin deficiencies York Retreat (England), 3, 360, 363, 404
alcohol abuse and, 142 Young Mania Rating Scale, 57
eating disorders and, 92 Youngberg v. Romeo, 421
Vocational rehabilitation. See also Employment
at continuing day treatment program of Washington Zaleplon, 60
Heights Community Service program, 332 Zinermon v. Burch, 419
on forensic unit, 190 Ziprasidone, 117
in VA hospitals, 218 Zolpidem, 60, 112

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With Deputy Editors

1 History of Hospital Psychiatry and Lessons Learned . . . . . . . .1

2 The Acute Crisis Stabilization Unit for Adults . . . . . . . . . . . . .23

4 The Adolescent Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

5 The Geriatric Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

6 The Eating Disorders Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

7 The Trauma Disorders Unit . . . . . . . . . . . . . . . . . . . . . . . . . 103

8 The Psychotic Disorders Unit . . . . . . . . . . . . . . . . . . . . . . . 119

9 The Co-Occurring (Substance Abuse/Mental Illness)

11 The Ethnic/Minority Psychiatric Inpatient Unit . . . . . . . . . . . 175

12 The Forensic Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

13 The State Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

14 The Veterans Hospital. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211

Appendix: Online Resources for Veterans . . . . . . . . . . . . . . . . . . . . 221

15 ConsultationLiaison Psychiatry . . . . . . . . . . . . . . . . . . . . . 223

16 From Within: A Consumer Perspective on

18 Improving Safety in Mental Health Treatment Settings:

19 Inpatient Suicide: Risk Assessment and Prevention . . . . . . 267

20 Discharge Dilemmas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

21 Residential Psychotherapeutic Treatment:

22 Residential Treatment for Children and Adolescents . . . . . 299

Appendix: Sample Comprehensive Psychiatric Emergency

24 Outpatient Community Mental Health Services . . . . . . . . . . 327

25 Day Hospitalization and Intensive Outpatient Care. . . . . . . 339

26 Administration and Leadership. . . . . . . . . . . . . . . . . . . . . . 357

27 Psychiatrists and Psychologists . . . . . . . . . . . . . . . . . . . . . 371

28 Social Work and Rehabilitation Therapies . . . . . . . . . . . . . . 377

29 Psychiatric Nursing: Creating and Maintaining

31 Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411

32 Quality Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429

Appendix: Online Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438

33 The Electronic Medical Record . . . . . . . . . . . . . . . . . . . . . . 439

34 Design and Architecture . . . . . . . . . . . . . . . . . . . . . . . . . . . 453

35 Hospital Psychiatry for the Future. . . . . . . . . . . . . . . . . . . . 467

Michael C. Fiori, M.D. Kevin Ann Huckshorn, R.N., M.S.N., C.A.P.,

Richard C. Lippincott, M.D. John M. Oldham, M.D., M.S.

Rockville, MD, U.S. Department of Health and Human

HISTORY OF HOSPITAL PSYCHIATRY

Considering all sources of data, it is clear the total 1970s

Sharkey J: Bedlam, Greed, Profiteering, and Fraud in a Men- tive/presentations/082306HHSStateAffairsJoint.

THE ACUTE CRISIS STABILIZATION

TEXTBOOK OF HOSPITAL PSYCHIATRY

The Acute Crisis Stabilization Unit for Adults

Milieu Management themselves or others or are unable to care for them-

THE CHILD UNIT

Admission Criteria patient presentations that instantiate these criteria

The indications for the admission of children to acute Dangerous Behavior

Medicolegal and Risk Management Involvement of Community

ment, the mission of psychiatric hospitalization now References

THE ADOLESCENT UNIT

Medication selection should target the most impair-

conditions for medication treatment entail an acute

sion. Alliance formation is fostered when a patients FAMILY THERAPY

THE GERIATRIC UNIT

1. The treatment of choice in geriatric mania is

Patient and Family Education

TABLE 51. Examples of age-related changes in pharmacokinetics and pharmacodynamics

THE EATING DISORDERS UNIT

TABLE 61. Summary of indications for inpatient eating disorder unit

Eating Disorder Subtypes ical problem of hypokalemic alkalosis (described later).

are likely to be problems of bradycardia, hypotension, Endocrine/Metabolic Abnormalities

Family Therapy stages, with an initial emphasis on stabilization of

Example of an Eating Disorder Unit Milieu