Psychosocial Approaches in Inpatient Psychiatry
Richard L. Munich
Pamela K. Greene
Admission to an inpatient psychiatric facility is a major treatment intervention. Its goals include an evaluation of and recovery from disabling symptoms, an assessment and possible modification of precipitating factors, and the promotion of community reintegration and tenure. As described in the first chapter and as will be amply documented throughout this book, the last 60 years have seen radical alterations in the specific goals, structure, and length of stay of this intervention. In the era between 1946 and 1975, admission criteria were expansive, and stays of several months that provided a psychosocial moratorium in a psychotherapeutically oriented and structured milieu were the recognized standard for effective care.1, 2, 3, 4 After the changes in inpatient psychiatry of the last three decades, only a handful of inpatient facilities capable of utilizing such a model of inpatient care continue to exist, some as specialized units within larger psychiatric hospitals.
Advances in treatment, especially psychopharmacologic treatment and more focused psychotherapies, active community interventions, ambiguous results of extended lengths of stay, and powerful economic factors account for contemporary ideology and practice in which less is more and perhaps better, especially with respect to mitigating regressive tendencies and institutional dependency. To complicate matters further, treatment advances utilized in outpatient work in combination with increased financial constraints organized around medical necessity have led to the admission of more complicated and difficult-to-treat patients.
Nevertheless, in many cases the inpatient stay is now 4 to 8 days with rapid assessment, symptom reduction, and environmental manipulation as primary goals. In this time frame, treatment goals must be integrated with discharge planning virtually from the time of admission. In acute care facilities and on psychiatric units in general hospitals, criteria for admission are now more restrictive and include a failure of outpatient treatment, acute and life-threatening symptoms—especially danger to self or others or deteriorating ability to care for oneself—and changes in treatment arrangements that require containment and close monitoring.5 Diagnostically, these categories generally appear in schizophrenia, schizoaffective and major mood disorders, decompensated borderline personality disorder, substance abuse crisis or withdrawal, severe eating disorders, post-traumatic stress disorder, and situational conditions. Special requirements for extended length of stay are addressed later in this chapter.
Naturally these changes decrease the range and depth of psychosocial approaches available to the hospital psychiatrist. Assessments are perforce somewhat abbreviated and require an intense focus, treatments are barely tested and begun, and precipitants—ideally with family help—identified as clearly as possible. Under these circumstances, the milieu takes on as much a holding and containing as it does a diagnostic and therapeutic function. Staff hierarchy and cohesion and clear delineation of discipline roles take precedence over the less efficient sharing of responsibility and overlap of function. Another constraint, especially for group therapy and milieu functioning, is that the implementation of various approaches is closely related to the degree to which the unit has a diagnostically homogeneous or heterogeneous patient population. It is well known, for example, that the more homogeneous the population, the more coherent and consistent—therefore, the more effective—staff interventions can be. In a heterogeneous patient group, similar cohorts of patients can influence the tenor of a unit in important ways that may be dysfunctional for other cohorts. These shifts are chronicled in many publications, and reflected comprehensively in the review edited in 1992 by Munich and Gabbard,6 and monographs edited in 1993 by Leibenluft et al.7 and in 1997 by Sederer and Rothschild.8 Nevertheless,
certain principles prevail whether the patient is in an acute, an intermediate length-of-stay, or residential, or a custodial-care facility.
certain principles prevail whether the patient is in an acute, an intermediate length-of-stay, or residential, or a custodial-care facility.
Much of what follows assumes the ideal access to resources for the inpatient unit. Rarely does the current training situation reference older psychosocial modes of and resources for inpatient practice; therefore, current trainees may remain unexposed to the best of the past. Therefore, the authors elaborate what might be accomplished under the best of circumstances. These resources include adequate time for assessment and implementation, space and facilities, and numbers of trained staff. For example, a carefully calibrated ladder of privileges and responsibilities for the recovering patient to test therapeutic gains will necessarily be modified in a reduced length of stay. Or a group or therapeutic activities program may be constrained by gaps in communication and continuity when the psychiatrists in charge of cases are not part of the unit staff and need to see their patients according to their own busy schedules. Or, even in a closed system or one depending on hospitalists, treatment must be shaped in a more practical and efficient way when the interdisciplinary team simply consists of a psychiatrist and a nursing staff who are responsible for most of the treatment tasks.
Comparing Contemporary Inpatient Settings
Other than the generally accepted notion that a unit functions better and has better outcomes when the staff is of one mind about general principles of treatment delivery, there are no data to justify one method of organizing treatment over the other. Naturally the more extended the length of inpatient stay, the more sophisticated the structures can become, the more focused individual treatments will be, the more opportunities there are for patients to become involved in their treatment (e.g., patient government, unit event planning, creative arts participation, etc.), and the more likely it will be for the treatment milieu to exert its influence. The length of stay also influences the repertoire of specific psychosocial modalities that may be utilized. Therefore, before discussing those modalities, the chapter will briefly compare acute, inpatient specialty and residential treatment settings under the rubrics of admission criteria, average length of stay (ALOS), and treatment focus.
As indicated earlier, admission criteria for acute care settings usually include an emerging crisis in which the patient is a danger to self or others, is unable to care for himself or herself, or where an adjustment in treatment is disruptive enough to require more containment than can be provided in the community. As noted, the ALOS in acute care settings is 4 to 8 days, and the focus of treatment is on symptom reduction, stabilization, and environmental adjustments that facilitate treatment compliance and the initiation or restoration of outpatient treatment.
Admission criteria for inpatient specialty units include unexplained treatment stalemate, recalcitrance, or noncompliance; situations where there have been multiple admissions in a relatively short period of time; diagnostic complexity (multiple diagnoses or various combinations of Axis I and II symptoms); the emergence of new diagnostic information; and dual diagnoses. The length of stay on an inpatient specialty unit varies between 4 and 8 weeks, and the focus is on diagnostic clarity (e.g., how might personality factors be interfering with treatments designed to ameliorate a primary diagnosis), institution of behavioral models to reduce secondary deterioration or gain from illness (e.g., eating disorder, substance abuse, or obsessive compulsive disorder programs), providing a second opinion to faltering outpatient treatment, or helping to start or restart stagnating mental processes that preclude effective treatment. Important goals of an intermediate length of stay are to provide the least restrictive environment and help patients assume more agency for their illness, treatment, and recovery.
Finally, admission criteria for longer-stay, residential treatment include persistent treatment noncompliance, the need for a psychosocial moratorium for a disturbed adolescent who has failed one or two shorter-term admissions, or to provide more time to uncover and understand persistent, complicated, and dysfunctional emotional and behavioral patterns (complicated combinations of diagnoses or Axis I and Axis II psychopathology) for patients who are engaged in treatment on a specialty unit. The ALOS on residential units is 4 to 8 months, and the focus of treatment is on conflict resolution, structural change, and rehabilitation. Wilderness programs with longer lengths of stay may include more explicitly behavioral interventions. Obviously, the potential for behavioral regressions, secondary gain from treatment, and institutional dependency must be carefully monitored in residential programs.
Patients with antisocial personality, most organic syndromes, and previous longer-term hospital treatment are not candidates for inpatient specialty or residential programs. For milieu integrity, staff morale, and utilization review, it is extremely important to differentiate between the severely ill patient who can begin to engage or reengage in a treatment process and one who cannot and, therefore, would benefit from a low-intensity or environment, group home, or custodial facility.
Organization, Structure, and Process
To balance optimum levels of containment, safety, and treatment focus on the one hand and continuity with the referring environment on the other, inpatient units ideally have an organizational structure that provides a coherent and manageable boundary. This boundary is most visibly represented by a Unit Chief or Program Director who has a direct reporting relationship with and accountability to the overall director of the hospital in general or director of the psychiatric service more specifically. In addition and crucially important for effective functioning, the Unit Chief is responsible for the generation of resources for the unit, mobilization of a consensus among the various disciplines involved in providing treatment, and consultation to and evaluation of patients and staff.9 Invariably, a clinician, usually a psychiatrist (in which case the title may either be Medical or Clinical Director), fills the role. On many units, a psychologist, social worker, or advanced practice nurse fills it. The Program Director usually collaborates in leadership with senior staff including a psychiatrist, nurse manager, social worker, and possibly the director of therapeutic activities.
Whatever the constituency of the unit’s senior staff, the Program Director has final responsibility for the unit’s structure and performance. This includes the unit’s interaction with the admitting office; its overall treatment processes and outcomes; its educational, quality improvement, and safety initiatives; and its relationship with regulatory and accrediting bodies, medical records, and utilization review. Psychiatrists are also responsible to their hospital’s Medical Board. The overall hospital administration or medical school Department of Psychiatry conjointly manages many of these elements. Further details of these structures and their interactions are discussed in detail in chapters by Russakoff (see Chapter 6), Pristach (see Chapter 7), and Weinstock (see Chapter 8).
The Interdisciplinary Team
Turning inward, the bulk of the unit’s therapeutic work is managed by interdisciplinary teams, the number depending on the unit’s census. The interdisciplinary team represents the treatment arm(s) of the unit’s senior staff and reports directly to it. The authors prefer the contemporary term interdisciplinary to the traditional multidisciplinary team designation because it more accurately reflects the interrelated aspect of the various roles and the importance of the collaborative nature of the treatment task. Furthermore, it is basic to the psychosocial approach that there are limitations in the capacity of any one observer or discipline fully to identify and appreciate the many factors involved in a patient’s clinical state and hospital course. This limitation is especially true for those patients with multiaxial diagnoses and complex psychosocial situations, who potentially benefit from the different perspectives derived from the unique role and task of each team member. The importance and centrality of collaborative relationships between various team members cannot be overemphasized, and therefore the following descriptions of the roles perforce involve dyads. Congruent with effective treatment and the requirements of most regulatory bodies, the patient is an essential member of the team. This important membership arrangement ideally begins the process of restoring the patient’s sense of agency by demystifying the decision making about care and enhancing involvement throughout the hospital stay.
There are many tasks to be accomplished by the interdisciplinary team, most of which, as mentioned, are accomplished in various dyadic configurations. To begin with, the psychiatrist team leader is responsible for working with the patient on the initial diagnostic assessment as well as the overall organization and coordination of the treatment. The psychiatrist is the key figure in determining what other medical or psychiatric resources are required for the assessment. Because the psychiatrist is responsible for many patients, each patient may be assigned a primary clinician with whom the psychosocial and family assessments are completed.
The primary clinician, often a psychologist, social worker, or advanced practice nurse, has a smaller case load and serves as the patient’s ombudsperson, meeting daily and linking him or her with individual, group, and family treatments; maintaining contact with the family and referring clinician during the evaluation and treatment; and implementing a discharge plan. On an acute care unit, the primary clinician may also take the role of the individual psychotherapist. Ideally, the primary clinician is present with the psychiatrist during the initial intake. Because of the primary clinician’s role in the treatment and familiarity with potential resources to support the treatment, the psychiatrist and primary clinician collaborate in constructing the interdisciplinary treatment plan as well as actively participating in ongoing utilization review.10
In an increasingly cost-conscious hospital environment, the primary clinician may be seen as an unnecessary luxury, the main work accomplished by the psychiatrist and the nurse. On teaching units, the role of primary clinician may be filled by residents or even medical students with close supervision and codocumentation by the psychiatrist.
Naturally the psychiatrist and patient’s primary nurse are responsible for the ordering and administration of, feedback about, and compliance with somatic therapies. Because of their continuous presence on the unit, nursing staff also has primary responsibility for the milieu as a whole. One reason the primary nurse is so important in this role is that he or she has the most reliable data about the patient’s level of functioning with respect to activities of daily living, social and relational skills and deficits; eating and sleeping patterns; and participation in therapeutic activities such as creative arts, occupational therapy and rehabilitation modalities, and spiritual life. The other reason is that the stability and coherence of the milieu has a major impact on individual patients, and it most clearly provides the unit’s essential stabilizing and containing functions. The patient’s primary nurse or his or her delegate (perhaps a mental health worker) may have regular one-to-one meetings with the patient. On many units, substance abuse counselors, chaplains, and therapeutic activities personnel collaborate with and report through nursing staff, but there is much variability and no standard of practice in this arrangement.
Under the aegis of the psychiatrist and the primary clinician and following the initial assessments of the patient and family, all members of the interdisciplinary team collaborate on constructing the interdisciplinary treatment plan. Ideally signed by the patient, this written document serves as a road map to the treatment, outlining major problems and goals with time frames, and parsing out the various psychosocial modalities and psychopharmacologic treatments that will ensue. Usually the plan is in place within the first 24 hours so that all staff have a sense of who the patient is and where the treatment is meant to go. More than likely, the patient will be more or less restricted within the unit boundaries for at least the first 24 hours to ensure safety, to observe for anything important that might have been missed on admission, and to allow time for the patient to acclimate to his or her new surroundings. For ideal communication with different shifts, the treatment plan is updated regularly and no less than weekly, a process that usually takes place in the context of treatment team meetings after consultation with the patient.
Following the initial period of restriction to the unit, many units have a carefully graded ladder of increasing freedom and responsibility through which patients progress as they recover. The patient’s status on the ladder and the initiation of more autonomous activities and therapeutic passes are the responsibility of the primary nurse and the primary clinician. A number of graduated level systems have been developed. The most useful is one that is relatively simple to understand and can be implemented with consistency. Ideally, most patients will see the level system as having value. The idea is for each patient to have as much autonomy or freedom as his or her behavior would indicate to be prudent. The number of different levels and the criteria for each level, needs to be well known by staff and patients and used consistently. That is, each patient who is on a certain level in a given system knows what to expect and expects the same freedom as every other patient on that same level.
The number of different levels in a level system will vary, in part based on the patient population, the geographic setting, and the ALOS. If a patient is admitted in crisis, he or she is initially likely to need a high degree of supervision for safety. As the crisis begins to resolve and staff have an opportunity to become familiar and establish trust with the patient, it may be feasible to allow a patient to join a small group of patients and leave the unit with staff accompaniment, or even go off the unit independent of staff for predetermined lengths of time with specified purposes and destinations. A hospital that is freestanding, contained with an actual structure around the perimeter, an ALOS of 5 to 7 days, and not
part of a general hospital will have more options than an inpatient unit with a shorter ALOS. A facility that has a campus-like feel will have more possibilities than a structure that has no outdoor space for leisure time.
part of a general hospital will have more options than an inpatient unit with a shorter ALOS. A facility that has a campus-like feel will have more possibilities than a structure that has no outdoor space for leisure time.
As mentioned, the primary nurse and primary clinicians provide the most input about increases in level and are empowered to reduce levels on the ladder. Medical-legal constraints require that increases must go through the psychiatrist team leader, although actual criteria for movement on the ladder are usually more behavioral than medical-psychiatric. For example, the best indicator for an increase in status is how things have gone on the current status; or the best indicator for a therapeutic pass was how the last one or how the last meeting went with the person(s) with whom the patient is to go out. In collaboration with the patient, the primary nurse and the primary clinician are in the best position to assess these factors. The observational and interpersonal roles filled and data obtained by all members of the nursing staff, especially mental health technicians or aides, in the above-mentioned matters cannot be overemphasized.
It is the responsibility of interdisciplinary team members to identify and resolve strain within the team and between the team and the unit, to maintain the flow of information from the patient’s various treatment modalities back to the team, to ensure the patient’s involvement in treatment and connection to the therapeutic values of the unit, to provide regular updates and modifications of the initial assessment and interdisciplinary treatment plan, and to arrange for a seamless transition to the next level of care. This includes detailed communication with the providers at the next level of care and as complete and timely a discharge summary as possible.
The responsibilities and tasks enumerated earlier are achieved in several ways. On an acute or psychiatric intensive care unit, the team might meet and round with the patient every day or even twice a day. These rounds share information, assess progress, adjust short-term and long-term goals, and distribute treatment responsibilities. As the patient shows improvement and becomes less acutely ill, the rounding schedule usually becomes more flexible. In the spirit of collaboration and to the extent that it is not overly stimulating or disruptive, team meetings may include the patient. Although it is often useful for staff to disagree, negotiate, and resolve issues in the presence of the patient, even the most highly functional teams need at least one meeting a week without their patients present. Many treatment teams schedule a separate case conference to discuss a difficult patient in more depth, and often this can be a unit-based event. Consistent documentation of the patient’s progress and the team’s observations and work is vitally important. Notes indicating the process and decisions of the team meetings must be signed by each member attending and include his or her role.
Treatment team meetings are different from the unit’s weekly staff meeting. The weekly staff meeting is important for the discussion of general matters such as the unit’s relation to the overall hospital, introduction of and farewell to staff members and trainees, scheduling of unit events, coordinating changes in coverage, and communication between disciplines. The staff meeting is also important for more complex matters and may be held on an impromptu basis to discuss emergent situations or dysfunctional events, for staff support and morale, the management of collective disturbances, working out more difficult disagreements about treatment issues, or even interdisciplinary matters unrelated to but possibly effecting specific patient care.
Specific Psychosocial Modalities
INITIAL ASSESSMENT
In the following chapters that deal with specific conditions, therapies specific to the disorder are discussed; therefore, this section of the chapter addresses more general considerations. With each patient, however, the initial assessment takes on special significance: First, because the situation is already tense and confusing for the patient and family members and also because this may be the patient’s first encounter with a mental health caretaker or hospital psychiatrist. The importance of an accurate diagnosis and unfamiliarity of the setting and time pressures only increase the importance of these first encounters, but there are generally agreed-upon goals and techniques of the initial interview and clear standards about elements that must be assessed. The interviewer must create an atmosphere of relative ease, balancing between the need to provide conditions for as much disclosure as possible
with enough structure so that the patient feels safe. There are no hard-and-fast rules about this, but the interviewer might want to invite a patient’s significant other into the interview, or for ease of patient egress, or for interviewer safety leave the door to the interview room ajar. The traditionally accepted format is ideal for coming to a categorical or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis and includes a more or less systematic collection of the identifying data, chief complaint, history of the present illness, past psychiatric and medical history, family history, and mental status examination. Specific assessment for suicidality and substance abuse are mandatory for initial assessment and treatment planning. Even in the traditional format, an unspoken goal of the initial interview is to make subsequent interviews and assessments possible.
with enough structure so that the patient feels safe. There are no hard-and-fast rules about this, but the interviewer might want to invite a patient’s significant other into the interview, or for ease of patient egress, or for interviewer safety leave the door to the interview room ajar. The traditionally accepted format is ideal for coming to a categorical or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis and includes a more or less systematic collection of the identifying data, chief complaint, history of the present illness, past psychiatric and medical history, family history, and mental status examination. Specific assessment for suicidality and substance abuse are mandatory for initial assessment and treatment planning. Even in the traditional format, an unspoken goal of the initial interview is to make subsequent interviews and assessments possible.
Following on this idea, MacKinnon et al.11 indicate another way of thinking about the initial data, one that might provide a more dimensional and narrative view of the patient. They divide the important information into three categories: content and process, introspective and inspective data, and affect and thought. Content relates to the factual information that is gathered, and process relates to the way or manner in which the patient relates to the interviewer, including functional and dysfunctional defensive operations. Introspective data are the information the patient provides verbally about his or her mental state and experiences, whereas inspective data involve nonverbal communications. These data also importantly include those limiting factors the patient brings to the situation. Affect, of course, involves the patient’s feelings in general and about the current situation specifically. Thought refers to the quality and quantity of thought, especially its content and degree of organization (pp. 7-9). Thinking about the initial interview(s) in the less formal way of these very experienced authors, especially when the interviewer’s point of view is also noted and included, may foster a more robust treatment alliance that will facilitate patient participation, acceptance of treatment, and ultimately greater compliance.
In the case of an admission precipitated by the emergence of difficult-to-manage material or transference/countertransference stalemate or other dysfunctional aspect of an outpatient treatment, it is particularly important to have the input of the outpatient treater before proceeding too far. As Adler12 points out, these data include the history of the treatment, the therapists’ formulation, and hypotheses about transference and countertransference issues. Because of the complicated boundary between the inpatient and outpatient setting as well as feelings on both sides, the role of referring clinicians is often minimized or ignored. Therefore, a valuable source of information is lost; and if the patient is referred back, whatever might have transpired in the treatment to precipitate the admission may well be repeated.
It is crucial that there is as much participation as possible by the social worker assigned to the family and the nurse assigned to the patient in the initial assessment. In addition to hearing the story first-hand, they collect vital family and somatic information that will be central to the treatment plan. Not only does this enhance the quality of the data collected but it also provides the fabric for interdisciplinary collaboration around the case. As soon as the acute situation begins to stabilize, ancillary assessments including substance dependence and abuse, and also, in the case of a longer stay, rehabilitation readiness and spiritual needs can play a role. As mentioned earlier, the written treatment plan is entered into the chart and follows as closely as possible the initial assessments and appears following the assessments and precedes the progress notes.
On the basis of the unit’s philosophy, ALOS and resources, and the patient’s clinical status, a repertoire of psychosocial interventions above and beyond what has been described as basic to the milieu will be available to the patient. Naturally, these treatments are geared to achieving the goals outlined in the treatment plan and may include combinations drawn from the following sections. The reader will find references to these throughout the rest of the volume related to specific syndromes.
INDIVIDUAL PSYCHOTHERAPY
Perhaps the most reasonable outcome for individual work on the inpatient unit is an increasingly clear picture of the patient’s psychopathological situation, a determination of what kind of treatment might be most helpful, and finally the patient’s capacity and motivation to pursue individual work. During very short stays and with payers’ insistence on medical necessity, even these goals may be too ambitious, and whatever exploration that ensues needs to be tempered with much supportive work. It is also often the case that what was expected to be a short stay of a few days more or less suddenly turns into something more complicated and extended. In these cases, it is extremely valuable to have had an individual, such
as the primary clinician as mentioned earlier, assigned to the patient for more one-to-one exploration of the complicating factors and support during the treatment complication or impasse that has developed.
as the primary clinician as mentioned earlier, assigned to the patient for more one-to-one exploration of the complicating factors and support during the treatment complication or impasse that has developed.
Several recent studies have identified those patients who are most likely to benefit from a psychotherapeutic intervention. These patients include those who are open to a psychosocial causal attribution of illness and a psychotherapeutic approach,13 patients with a moderate as compared with a high level of anxiety,14 patients who have higher levels of global functioning from the beginning of treatment,15 patients with whom there appeared to be an initial alliance,16 and female patients who acknowledged a perception of interpersonal problems and had a low estimation of their capabilities.17 Specific attachment patterns do not seem relevant for individual psychotherapy, but a secure attachment may predict a better outcome for group psychotherapy.18 Because special techniques have been developed for many of the clinical situations covered in this book, the reader is referred to the specific chapter for particular approaches in individual treatments.
Obviously, the psychological signs and symptoms leading to the present admission assume priority in the individual psychotherapy. As Bennett19 points out, the precipitants most often represent a failure of the individual to adapt to a stressful situation. The stressors might include the loss of a significant relationship or job, the loss of hope, or a major problem in the outpatient treatment; but what usually leads the person into the crisis is a failure of his or her adaptive defenses or absence of important interpersonal support. In focal psychotherapy, while more medical-psychiatric means are addressing the underlying illness, the first step might be to assist the patient in identifying and restoring those usually effective defenses that have failed. Notably, in one patient group studied, turning against the self was the most frequent and ineffective defense mechanism used.20
Insofar as psychotherapy is an element of the treatment plan, the assigned psychotherapist usually has more responsibility for collecting relevant psychiatric data and bringing together the biologic and psychosocial data about the patient. Unlike outpatient treatment and in the case of a therapist-administrative split on longer-term units, the individual therapist must coordinate the work with the interdisciplinary team and milieu while making every effort to maintain confidentiality. Naturally, confidentiality does not extend to self-destructive or treatment- and milieu-destructive behaviors, but other personal matters may be kept between patient and therapist. After the initial assessment, the therapist necessarily takes a more active and interactive stance, saving exploratory and expressive techniques for later so as to protect vulnerability and minimize emotional distress. Because of regressive tendencies, cognitive-behavioral (see also Chapter 10) and mentalization-based techniques (see also Chapter 14) are often more useful at this point to learn more about how the patient was thinking. In fact, a growing body of evidence suggests that cognitive techniques are superior to dynamically oriented treatments for patients with psychotic disorders.21
Although usually provided in groups on inpatient units, a growing utilization of and evidence for the effectiveness of dialectical behavior therapy (DBT) on an individual, group, and inpatient basis is reported.22,23 DBT is especially useful in the treatment of suicidal, parasuicidal, or dangerous dissociative episodes and other dysfunctional behaviors that may be associated with the need for admission. Basically a cognitive and behavioral technique and utilizing target lists (as in a treatment plan), it combines sequenced and focused interventions with a validating environment. During the inpatient stay, the goal is to focus on the current episode, leaving more chronic patterns for longer inpatient and outpatient treatments. Treatment proceeds in three phases—commitment, restoring control, and getting out—and is reinforced in individual, group, and milieu contexts. The result is an increase in distress-tolerance, emotion-regulation, mindfulness, and self-management skills.
No matter what sort of individual therapy is provided, the degree of support, exploration, reinforcement, interpretation, and confrontation utilized by the individual psychotherapist will be determined by many of the factors suggested earlier. Valuable here-and-now information derived from the enactments of basic interpersonal relationship patterns and interactions between the patient, the team, and the milieu enrich the psychotherapy, preventing it from turning into an unhelpful refuge.24,25 By providing a consistent figure, a regular and private space, and an agreed-upon session length and time, not only does an inpatient psychotherapy provide an opportunity for the patient to unburden himself or herself, understand much of the mystery of what is happening, and receive much-needed support but it also illuminates for the therapist much more about the impact of the patient’s relatedness in the world. Naturally, problems that arise between therapist and patient are often reflective of the kinds of difficulties the patient encounters in life in general and provide even more information to support
treatment efforts. Although this is extremely valuable information for the patient’s treatment, it puts additional pressure on the shoulders of the individual psychotherapist. Such issues have been amply described in works about psychodynamically informed hospital treatment from Main1 and Burnham26 to Gabbard27 and Munich and Allen.28
treatment efforts. Although this is extremely valuable information for the patient’s treatment, it puts additional pressure on the shoulders of the individual psychotherapist. Such issues have been amply described in works about psychodynamically informed hospital treatment from Main1 and Burnham26 to Gabbard27 and Munich and Allen.28
When patients have the psychological and material resources to benefit from a longer (several weeks to a few months) hospital stay, the individual psychotherapy usually takes on a more important role in the treatment plan. In most treatment centers that provide such treatment and depending on how disturbed the patient is, the psychotherapy function is carried out by someone different from the person or interdisciplinary team responsible for the clinical-administrative aspects of the patient’s care. In this way, the individual psychotherapist is able to get a better picture of the patient’s patterns of manifest and more subtle adaptive and maladaptive behaviors and ways of thinking, illuminate any tendency to provoke conflicts (splitting) between significant figures, and identify important transference and countertransference trends. This capacity is true whether or not psychodynamic, mentalization-based, dialectical, or cognitive-behavioral techniques are being employed in the psychotherapy. Because inpatients are very often more fragile than outpatients, staff members as well as psychotherapists must perform auxiliary ego functions such as reality testing, assistance with impulse control, anticipation of consequences (judgment), and sharpening of thinking and boundaries. In addition, the therapist must maintain contact with the team around such issues as attendance and general themes, and especially when the patient, another patient, or a staff member may be in some danger. Therefore, because of the holding nature of the inpatient milieu, the availability of and more frequent contact with the psychotherapist, inpatient psychotherapy is inherently less confidential and more supportive.29
GROUP THERAPY
Group therapies of various sorts are likely the most widely utilized mode of providing psychosocial treatment on the inpatient unit. Since their inception, there have been many forms of group interventions ranging from traditional process and exploratory techniques to more structured and educative models through problem-solving and social-skills groups, to those organized around a specific technique for specific illnesses (body-image disturbance, substance abuse). Insofar as one of the main reasons for hospital treatment relates to the deterioration or loss of an important relationship and its support, the inpatient group that focuses on interpersonal relations becomes a key therapeutic instrument.
General principles for group work on the inpatient unit as outlined by Yalom,30 Kibel,31 and Kemker and Kibel32 include ensuring that the group is fully authorized and integrated into the unit structure with regular scheduling, leadership, and time and space boundaries. Insofar as possible, patients should not miss or be called from the group for other appointments. Because of the rapid turnover of patients, their heterogeneity of psychopathology, and varying levels of motivation and intactness, groups may be organized according to the interdisciplinary team responsible for their treatment or according to level of severity of illness. This kind of grouping facilitates the group process that ideally focuses on the here-and-now interpersonal factors relevant to the admission, minimizes conflict, and attempts to create a safe, supportive, and constructive atmosphere. Leadership should help the group form agendas and otherwise be active and directive to facilitate the emergence of relevant issues, especially interpersonal concerns. Generally speaking about units with a shorter length of stay, the authors cited earlier indicate the importance of not trying to “fix” problems, reducing a focus on the past, and minimizing critical feedback and confrontation.
The goals of inpatient group therapy on the contemporary inpatient unit have mainly to do with giving patients the idea that expressing their issues will be helpful, that doing so will promote therapeutic processes and engagement. Furthermore, participation in group therapy will decrease both the isolation that has come about from the stigma of his or her illness and the anxiety associated with a hospital stay that includes witnessing conflicts and disturbed behaviors in the milieu. Recent studies have demonstrated the effectiveness of inpatient group therapy, especially in patients who exhibited symptoms of mood disorder,33 in utilizing cognitive therapy techniques for patients with active symptoms of schizophrenia,34,35 in patients having vocational strains and conflicts,36 in helping survivors of incest improve coping strategies,37 and in catalyzing continuity of treatment after discharge.38
Naturally, a more extended length of stay and stable group membership create the potential for more ambitious goals and expansive exploratory techniques, consistent with those sought in outpatient
treatment. These include a less directive approach by the therapist, more focus on group process and dynamics, and therefore more tolerance for interpersonal conflict and confrontation. Inpatient group therapy on the intermediate and longer length-of-stay unit will have a greater relationship to processes on the overall milieu than on the shorter-term unit and therefore can become a valuable learning tool for the individual’s relationship to his or her social environment.
treatment. These include a less directive approach by the therapist, more focus on group process and dynamics, and therefore more tolerance for interpersonal conflict and confrontation. Inpatient group therapy on the intermediate and longer length-of-stay unit will have a greater relationship to processes on the overall milieu than on the shorter-term unit and therefore can become a valuable learning tool for the individual’s relationship to his or her social environment.
PSYCHOEDUCATION
The last decade has seen a great increase in psychoeducational techniques employed on inpatient units, usually practiced in a group format. On the basis of success with family groups39 and patient satisfaction data indicating that patients have a great interest in learning more about their illness and obtaining techniques for coping, these groups are focused on such matters as details of etiology and symptoms of various illness configurations, affect regulation and management, mindfulness, relationship building, the many issues related to medication utilization and compliance, trauma, and social skills training. The groups are enhanced by an active and interactive stance of the leader(s), didactic elements and problem-solving exercises, role playing, and homework assignments. These techniques support the reestablishment of patient agency by reducing stigma, modifying guilt and blame, and expecting participation that involves patients more actively in their treatment. Other than in the realm of psychoeducational work with families, there is far less published evidence for the effectiveness of these techniques on the inpatient service than there is for group therapy.40,41
Related posts:
The Ins and Outs of 200 Years of Psychiatric Hospitals in the United States
Pharmacologic Approach to the Psychiatric Inpatient
Psychiatric Education on the Inpatient Unit
Hospital Treatment of Depression and Mania
The Patient with Borderline Personality Disorder
Evaluation and Management of Substance Use Disorders on the Inpatient Psychiatric Unit
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