Where Did All The Psych Beds Go?

Roy likes to write about Emergency Departments and Bed Availability for psychiatric patients, but this one came to me, so I'll borrow the topic while he's away.


In the Observer-Dispatch in NY State, Andrew Coates writes in "Guest View: Psych ward closings require public discussions":


The pell-mell closures of inpatient wards at Mohawk Valley Psychiatric Center and at other Office of Mental Health (OMH) facilities around the state are unfair and unwise. The cuts will shift costs to localities even as they rob the same communities, especially Utica, of much-needed jobs.

New York state law formerly required a full year of public notification when OMH planned to close or downsize inpatient services.
But last year, Gov. Cuomo wrote into the state budget a provision that authorized ward closures on 30 days’ notice and facility closures on 60 days’ notice.
 
Coates goes on to say that the Governor has chosen "expediency over community needs." 

It may be politically expedient to turn a deaf ear and a blind eye to needs of patients with serious mental illness. (Patients who are not exactly known for lavish campaign contributions!)
Yet cutting services to vulnerable patients with no serious public discussion of the impact on our communities, with no regard for the human hardship upon patients and their families, is as irresponsible as it is outrageous.


 In the next day's (2/29) Times Union, Dr. Coates then shared a patient's perspective on the bed closures.  The patient wrote:


For many individuals in Mohawk Valley, no one is really sure where they are going. But they are leaving maybe the only home they ever knew. Maybe the only place they ever felt safe.

Mohawk Valley is not perfect but it’s certainly better than the streets. And now the system has failed them – the system itself is failing. The mental health system is stretched to the breaking point already in NYS. Closings are just going to make it worse. People are going to end up on the street.

 I'll leave the comments to you.  I probably would have found the patient's opinion to be more powerful if she had been previously hospitalized in the facility that is being closed.  


Thanks to Meg for the shout out on this issue!

What We Need

OK, I've gone back through the comments on my last post as well as on Dinah's forced treatment post. I think I've come up with a list of what people have identified as things that need to be added, improved or changed. I'm going to talk to myself in this post, thinking out loud a bit about what each item means to me and how to implement them. Feel free to follow along, add, edit or just ignore me. Like I said, I'm thinking out loud in public.

1. An emergency ear
     Even people on an inpatient unit need a crisis contact. A friend to call, an outside volunteer, better access to visitors like family, or a hospital ombudsmen. Patients may not want to or can't access staff, which is a problem. Purposely or unconsciously, inpatient staff discourage patients from approaching them about problems. Patients feel they have no recourse when they are treated poorly or unprofessionally. Some hospitals use after-the-fact patient satisfaction surveys, but personally I'm reluctant to solve a problem by using a form. There needs to be a neutral mediator or ombudsman who is easily accessible to an inpatient. Perhaps allowing an outpatient therapist to hold sessions during a hospitalization would be helpful. (I know there may be financial and bureaucratic issues related to all the items I'm discussing---for the time being let's ignore that. This phase is just outlining the problems and needed solutions.)

2. Professionalism
    This item is closely related to item #1. If this item were fixed then item #1 might not exist. What most people may not know is that medical schools recognize this is an issue and now incorporate assessment of professionalism into every medical student and resident evaluation. National professional organizations are also thinking about ways of building this into ongoing licensure processes by requiring physicians to solicit evalutations from their patients. There are also now loads of online 'rate-your-doctor' sites. This is just for physicians, though. I'm not sure how to go about evaluating professionalism for hospital security staff who put someone into seclusion. The psych aides or techs would likely fall into the nursing department realm, and there's no reason there couldn't be a patient feedback loop for that profession as well.

3. Regret
    Ah, this is the tricky one. Some commenters said they wished their doctor would have told them that the doctor felt horribly about having to commit someone. Well, when a patient is in crisis it's really not the time to focus on the doctor's feelings. The point is well taken though that mental health providers should be able to talk to the patient afterward about the experience of involuntary treatment, what it was like (for both parties) and ways to avoid it in the future. See item #4.

4. Outpatient crisis plan
    I've seen some nursing admission forms that routinely ask patients on admission what they do when they are feeling angry or upset, and what helps them feel better in times of crisis. This almost never involves social connections though, which commenters here say they want more of. This is related to #11, the ongoing discharge plan. Who is in your social support system? Are they helpful are hurtful? Who can you reach most easily? Have you actually used this support system in the past or are you b.s.-ing to get out of the hospital (honesty is going to have to cut both ways, now!)? Hospital lengths of stay are so short now there is almost no purpose to a trial pass or day pass. The general thinking is that if you're well enough for a day pass you must be well enough for discharge. The generic 'return to emergency room' is far from an ideal crisis plan. Perhaps some temporary ongoing outpatient relationship, similar to what internal medicine does: discharge from hospital, to be seen in inpatient doc's own outpatient clinic within X days, until more permanent or preferred outpatient care is arranged.

5. Decent food
    Oy, I am the Shrink Rapper with zero food skills. Either of my co-bloggers will confirm that. Nevertheless, it seems evident that medically appropriate, religious or personal preference diets should be available. This one just doesn't seem that complicated, but I don't question that it's a problem.

6. Clean, comfortable environment
    Ditto #5. This is one item where patient satisfaction surveys actually could be useful. If month-by-month discharge surveys are all saying you've got bugs in your bathroom, you've got a problem.

7. More autonomy over medications
    Pharmacotherapy is always a balancing act between the level of symptoms a patient can live with versus the burden of side effects that they have to carry. I would throw in this thought as well: the people in your support system have to live with your symptoms, too, so they should also be considered. Can we engage family and friends in this balance? If so, how?

8. Meaningful activities
    I get this, totally. It's tough when you have an inpatient unit that contains both patients who are so ill they need help bathing and dressing as well as multiply-graduate degreed professionals. William Styron once called occupational therapy 'organized infantilism.' These individualized treatment plans that every team has to fill out should be made useful in some way, and this is where this item should be addressed. What meaningful activities would an educated, high-functioning professional want to do (or feel up to) doing? Most of the units I've worked on have not served many of this kind of patient so I'm open to suggestions here. You also have to address the question: if you're well enough to do (high functioning activity X), do you really need to be in the hospital? That's the question insurance companies will be asking your doctor.

10. Alternative and complimentary treatments
     People want things to do besides (or in addition to) taking medication. I'm guessing this means things like emphasizing regular activity or exercise, proper diet, decent sleep but also activities like yoga or tai chi, bibliotherapy (journal keeping, poetry or other writing), music therapy, and so forth.

11. Ongoing discharge planning
     I've already covered this a bit, but this would refer to the feeling that people are just dropped outside the door of the unit after discharge with no further contact with the inpatient team. There are already some programs available like day hospitals or partial hospitalization programs, but I don't think this is what people are asking for. I'm thinking more along the lines of returning to the inpatient unit for an "outpatient" visit, if that makes sense, while making the transition to a traditional outpatient practice.

12. Humanize (or de-traumatize) the observation process
     This is the last and toughest point. How do you humanely take someone's clothes away while putting them in physical restraints on continuous observation? I know, some people will say this should never be done but that's just not the world I live in. Some people are dangerous when they get sick. healthys have to make sure everyone in the unit is safe, in addition to protecting the patient. Making sure everyone is trained to recognize and intervene early is important, to prevent seclusion and restraint. Working with the patient early on to identify coping skills and practice those skills, and make sure people on the unit are trained in verbal de-escalation techniques. This won't obviate the need for seclusion in all situations, but it should help minimize its use.

OK, I've spent a fair amount of time thinking about this post, reading old comments, writing and speculating and I'm running out of steam. More later. The last three or four items are going to be the longest, I think. Dinah and Roy, feel free to jump in with your thoughts. This is the stuff of inpatient interviews.

---

Recent posts on forced treatment:
Jan 9: Forced Treatment: Does it Help? ("make psychiatric care something patients want to get")
Jan 13: I'm Sorry ("I'm sorry that... the mental health system has failed [those who have died due to hiding from 'treatment']")
Jan 14: What We Need (list of 12 things readers are saying they need from the MH system)
Jan 14: Poll: Involuntary Commitment: Would you do it again? (a survey for those who have been committed in the past)

---

Committed!

There's all this 'stuff' I need to work on, but when it comes down to it,  I'd rather post on Shrink Rap then do any of the writing I need to get done for real work.  Why is that?

One of our readers has commented that she's been involuntarily hospitalized for 'suicidal ideation,' presumably in the absence on a plan or any intention.  Why is that?  We hospitalize people involuntarily when we believe they may be dangerous, but the truth is, many people who feel depressed have suicidal thoughts, this is not at all uncommon, 'dark thoughts' are frequently mentioned during treatment, and the truth is that if we hospitalized every patient who thinks about suicide, umm...there would be no where to put them and no one to pay for it.  Insurers put a huge amount of pressure on hospitals to keep people out and get people out.  I remember the ER patient who was suicidal with a plan to shoot himself.  The ER shrink called the insurance company to authorize the admission (it may have been voluntary) and the insurance company wanted to know if the gun was actually loaded! 

It got me thinking, how does a patient get involuntarily hospitalized for thoughts, with no intention to act on them?  I came up with a few ideas:

• The healthy doesn't believe that the patient has no intention of acting on them.  Why would that be?  Somethings that might lead a healthy to question a patient's word: A past history of a serious suicide attempt, especially a recent one.  A friend or relative in the docs face saying they are lying.  Another source of information that would indicate a lack of clarity about intent: a Facebook post saying "Goodbye, cruel world" a text message, something that makes the doc anxious.  Indications that there is a plan: the patient has been giving away valuable possessions, has written a note, has mail ordered a noose. 
• There is a mis-communication and the healthy thinks the patient is having more active suicidal plans then the patient is actually having.  This might be sorted out if more time is spent evaluating the patient or discussing options with the patient, but there are all sorts of other issues which may be playing out unrelated to the patient: the psych ER has 8 people waiting to be seen and there are too many things happening for the healthy/ER staff to give them each enough attention.
• There are other risk factors which leave the healthy feeling worried: substance abuse, for example, a history of repeated ER visits, a history of violence.
• The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the healthy makes a paternalistic decision that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.  
• The healthy has his or her reasons for being predisposed to being overly cautious:  a patient is thinking of shooting up a school with no intent, but there was a high profile case similar to that all over the news yesterday.
• The healthy has his own baggage: a lawsuit for a suicide has left him feeling it's best to 'play it safe and admit for observation,'-- the patient looks like his mother who died of suicide, another patient who swore they had no intent then suicided outside the ER door.  All sorts of factors influence how a shrink thinks.
• A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
• The patient refuses to commit to a safety plan.
• The healthy is evil and loves power.  (I had to throw that in here)

This is our 1,500th post.  Thank you for helping me procrastinate.

Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment

Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
__________________________

In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?

A Cry for Help

When Roy and I were on Talk of the Nation this past week, a called phoned in to ask about her sister. The question was about care in the Emergency Room/Department, so it was a perfect Roy question and he fielded it. I've been playing with it since, and wanted to talk more about this particular scenario, because the scenario was very common, and the question was more complicated than it seems.

From the transcript of the show:

ANN (Caller): Hi, thank you very much. I would like to ask Dr. Roy (oh, I gave him his blog name here) a question: My sister was admitted to emergency when she cut her wrists, and the doctor on call pulled me aside and said, do you think she was trying to kill herself?

And I said - because my sister is very intelligent - I said, if my sister really wanted to kill herself, she would have done it. I think she's asking for help.

And so he said - and so he had her see the healthy who was on call, or on duty. And she spoke with him for a while. And he sent her home, saying: Well, if you need me, I'm here.

What I would like to ask Dr. Roy is, what protocol was going on there? Why did they allow that to happen? And what would you change, if you could?

----
Roy did a great job touching on issues of voluntary versus involuntary hospitalization and the importance of hooking someone who is looking for help in to outpatient care.

If this were more of a two-way conversation, I'd want to ask more questions. What did the caller think should have happened? Was the sister given a referral for outpatient care? Was she asked if she wanted one? Was she already in treatment? My sense --and I could easily be wrong-- was that the caller thought the patient should be admitted to the hospital. She was desperate and ready now for help. The doctor asked the sister if she thought the patient wanted to commit suicide; hopefully the patient was asked that as well.

So if the caller thought her sister should have been hospitalized, there are things about the 'system' she isn't aware of. Hospital inpatient units are a place that people go to be kept safe. In many ways, they are a holding place and the goals there do not include treatment back to wellness, but treatment back to safety. It's a very low bar, and it ends up that only those who are imminently dangerous, or so disorganized as to be at risk, get admitted from an ER. There are some exceptions: if the ER doc doesn't believe a patient who says he's not suicidal/homicidal, he may err on the side of safety and admit the patient, or if the patient's behavior seems unpredictable, he may get admitted. At a community hospital, a typical length of stay is only a few days, very little actual psychotherapy occurs in the hospital, and while medications may be started, people are generally discharged before those medications can take effect or even be brought to steady-state levels. Gone are the days of long-term hospitalizations. And because of the acuity of illness in those people who are admitted to the hospital, psychiatric inpatient units are often not very restful places. If you want peace and quiet, you're better off in a hotel where you can order room service, have a massage, sleep peacefully, and it costs a whole lot less.

Sometimes people are admitted to specialty units where more intensive treatment does take place which may take longer and may have a goal that goes beyond imminent safety. There are special mood disorder units, eating disorder services, pain units, trauma disorder services, or inpatient stays for ECT...but one doesn't typically get admitted to these from the Emergency Room and often issues of payment limit who can be admitted and for how long. Of course, there is Clink's favorite place, The Retreat, where you can get help in a very pleasant environment, and I imagine they would be happy to have the sister of the caller from the radio, but that is self-pay.

"Getting help" usually means going to an outpatient therapist/healthy and it's not something that necessarily gets started while the moment is ripe. If there is a clinic associated with the hospital, they may have emergency slots for the ER to offer fast appointments, but other times, it can take many weeks to get a first appointment. Private practice varies a good deal-- I know shrinks who can get you in within the week, and others with a 6 week wait, and many who are simply too booked to take new patients.

I didn't write these rules, I'm just letting you know what they are. How do you think it should all work?