A Crisis Model Revisited Jerzy
E. Henisz
and David Johnson
T
HE CONCEPT OF CRISIS HOSPITALIZATION in a mental health center was one that was vigorously promoted a few years ago.‘s2 Since then it has continued to be seen by its supporters as more economical of time and money and frequently as effective as more traditional hospital treatment.3 Others have raised questions about its clinical validity.4,5 Something useful may be added to the controversy by looking at the evolution of the idea of 3 day hospitalization which was defined as a model for intensive intervention by one center.’ For the purpose of this report crisis hospitalization is defined as an inpatient stay of less than 5 days which is usually followed by intensive but time-limited outpatient treatment. The characteristic clinical approach involves the use of timelimited contracts, intervention through multiple therapist teams aimed at minimizing dependency and regression, an adaptive focus in therapy, early involvement of family members and use of medication to control incapacitating symptoms. Ventilation of feelings related to those painful situations which usually precede crisis admission occurs during individual and group sessions. It starts with the identification of problems and ends when the patient is ready to return to the precrisis level of functioning. Discussion of long standing inner psychological conflicts is avoided and actively discouraged.
THE
SETTING
The Connecticut Mental Health Center in New Haven provided the locus for the study. The Emergency Treatment Unit (ETU) opened in 1967 and had initially five beds. It was planned that patients would stay up to 72 hours for “diagnostic assessment, crisis intervention and active psychiatric treatment.“6 With increased demands for service the number of beds was increased first to 7 and later to 12. In the fifth year of the Center’s operation there was a strong belief that the emergency-crisis approach to hospitalization had succeeded and it became the dominant orientation. A milieu-oriented, longer-term unit had been closed. These changes, however, resulted in a net increase of transfers to the state hospital and a dramatic decrease in the efficiency of the Emergency Treatment Unit. After 2 more years, the unit was renamed “Short and Partial Hospitalization Unit.” The maximum length of stay was extended to fourteen days and active consideration is currently being given to even further extension. From the Yale University Department of Psychiatry, New Haven, Conn. Jerzy E. Henisz, M.D.: Associate Professor of Clinical Psychiatry, and David Johnson, M.B.. M.R.C. Psych.: Assistant Professor of Psychiatry, Yale University School of Medicine. New Haven, Conn. Reprint requesls should be addressed to Dr. Jerry E. Henisz. Connecticut Mental Health Cenler. 34 Park Streel, New Haven. Corm. 06508. ,< 1977 by Grune & Stratton.
Comprehensive Psychiatry. Vol. 18. No. 2 (March/April),
1977
169
170
HENISZ
PATTERNS OF ADMISSION
AND JOHNSON
AND DISCHARGE
Source of Referral
The Emergency Treatment Unit had two major portals of entry: the Emergency Room of the local university-affiliated hospital and the Connecticut Mental Health Center. The Emergency Room, after a steady increase in psychiatric contacts over the last decade,’ experienced for the first time recently a drop in total contacts from its peak of about 4000 per year to less than 3000 in 1973/74. At the same time the Connecticut Mental Health Center significantly increased its “walk-in” and “unscheduled” services. The Center’s evaluation unit has more than 2000 admissions per year and the treatment units of the Center maintain on their books another 2000 patients on any given day. The most important change in the pattern of referrals to the Emergency Treatment Unit occurred during 1973/74. For the first time in the unit’s history the referrals from inside the Center outnumbered referrals from the emergency room. Length of Stay
The adoption of a more flexible policy about the length of stay resulted in an average extension of the length of stay by more than 2 days per patient. The increase of length of stay occurred in all diagnostic categories. However, there were differences in the length of stay according to the source of referral in 1973/74. The mean length of stay on the unit of those patients referred from the emergency room was 6 days. (6.03, S.D. 3.80). The mean stay of patients referred from the treatment units of the Center, usually psychotherapy or medication clinic, was close to 8 days (7.86; S.D. 3.77). This difference is significant (t = 3.81, df = 306, p < .OOl) and reflects the fact that patients in ongoing treatment come to the hospital for more than crisis intervention. Bed Occupancy
A psychiatric unit available for emergency admissions 24 hours per day must operate on rather low bed occupancy. During the period under study it varied between 5 l%-76%. The highest rate of occupancy was during the years 1973/74, when it was allowed to keep the patient beyond the “5 day limit.” Disposition Pattern
On an average, the emergency unit could not meet the needs of approximately 20% of patients. When the longer-term unit was closed in 1971, the overall percentage of referrals for longer hospitalization increased with a very sharp rise in that proportion of patients who were transferred to the state hospital. During the last year, when new programs were developed, there was a drop in state hospital transfers from 14% of all discharged patients to 7%. This drop is totally accounted for by the rise in day hospital referrals from below 1% to more than 9% of all dispositions. Diagnostic Pat tems
The distribution of diagnoses of patients treated on the unit did not change over the 7 yrs. Approximately x are schizophrenics; g are patients with depression;
CRISIS
171
MODEL
and l/10 are alcoholics and drug abusers. Adjustment reactions to adolescent or adult life, neurotic reactions other than “depression,” and personality disorders accounted for about l/5 of all admitted patients. It is difficult to analyze the data on diagnosis due to its low reliability and changing emphasis. A schizophrenic patient who was admitted after alcohol or drug abuse could be diagnosed as a drug or alcohol problem. An alcoholic who came to the unit after a fight with a spouse could be placed in the “adjustment reaction” or “personality disorder” categories. CLINICAL
OBSERVATIONS
The aggregated data show that over 7 years of existence the emergency treatment unit has slowly changed its character. These changes are highlighted by the increased length of stay and the addition of the day program. How are these changes reflected in the clinical characteristics of patients and care provided to them? Patients admitted to the unit tend to fit into 4 general categories: the crisis group, the brief treatment group, the short and partial hospitalization group, and those who need more than the unit can offer, the longer-term hospitalization group. The Crisis Group
The group includes patients in acute but usually transient situational crises. They may carry the diagnoses of neurosis or personality disorder. They come to the unit in acute distress, frequently with suicidal ideation or after suicidal gestures. Precipitants leading to hospitalization are easy to identify and therapy is limited to the change of environment, ventilation of feelings around the current crisis and support for purposes of developing more constructive patterns of adaptation. The classic crisis approach works best for this group of patients Brief Treatment Group
Problems experienced by patients in this group are not amenable to a 3- 5 day approach and something like 7-21 days is required before discharge can be confidently arranged. A variety of patients belong to this group. They include the following: 1) borderline patients in psychotherapy who require hospitalization; 2) patients requiring a neuro-psychiatric evaluation; 3) those suffering from schizophrenia who decompensate, usually following cessation of medication; 4) alcoholics and drug addicts in need of detoxification. The first mentioned group pose particular difficulties in treatment which merit further discussion. With the increased number of outpatient therapists available in and outside of the Center, increased demands for hospitalization of borderline patients in therapy are being made. One common characteristic of this group of patients is their difficulty in working through transference. At the time of termination of therapy, therapists’ vacations, or simply in response to some threatening aspects of the therapeutic process, they require hospitalization. At time of stress, the fear of losing the therapist’s support which frequently acts as a backup for the fragile ego boundaries becomes a terrifying idea. The patient has to be placed in the hospital. Once admitted, 2 processes take place simultaneously. First, the intensity of the transference situation is diluted and the real loss of the therapist is
172
HEN&?
AND JOHNSON
replaced by hospital walls and friendly staff. Second, the emphasis is put on testing other resources and giving help so that the patient can emerge from the state of regression. At the beginning, the patient gets worse. Being in the hospital is interpreted as a long awaited and delayed failure. Subsequently, the patient is able to mobilize the experience derived from the long-term work. External reality is seen as such rather than only as a hostile and unresponsive environment. With the skillful help of trained staff who are not discouraged by initial symptoms of depression and regression, the patient is able to find his or her own way out of the hospital. To accomplish this a minimum of 10 to 14 days in the hospital are needed. The traditional crisis approach does not work. The patient having been oriented towards psychological exploration cannot accept the rather sudden strong emphasis on reality and decreased attention to inner experience. Short and Partial Hospitalization Group
and lithium and The availability of major tranquilizers, antidepressants, increased sophistication in their use in conjunction with psychotherapy have changed the traditional approach to hospitalization for patients suffering from psychotic disorders. However, hospital observation, careful and skillful diagnostic evaluation and choice of treatment, and respect showed to the patient at the beginning of his therapy frequently cannot be replaced by anything comparable on an outpatient basis. Moreover, for the group of patients who either experience their first psychotic break or reexperience it again with very high intensity, 30 or 45 day programs are still provided in many private hospitals.g In the community mental health setting where shortage of beds rather than insurance coverage defines the length of stay, the only alternative available for these patients is partial hospitalization, This is a viable alternative only for those who have sufficient support at home and can tolerate several hours daily outside of the hospital. Without this, longer term hospitalization is required. Longer Term Hospitalization Group
There remains the group of patients for whom the total resources of the unit are insufficient and longer hospitalization is required. In the main, these patients suffer from serious psychotic illnesses but severe sociopathic disturbance is sometimes involved. The need for longer hospitalization becomes apparent in 2 ways. In one group of patients psychotic disturbance is so gross and/or the patient such a difficult management problem that it is clear within a few days that transfer to a long-term facility is needed. In the second group, while the unit is aware throughout of the serious nature of the problems, an attempt is made to deal with them within the available time limit. Frequently, at the end of this time further hospitalization has still to be arranged. When the crisis group of patients is mixed on one unit with acutely psychotic and depressed patients, alcoholics, drug addicts, and borderline character disorders, it becomes very difficult to preserve the uniqueness of the crisis approach. The treatment of patients undergoing detoxification and of relapsed psychotics provide examples where the solutions rest largely with medication. Limit setting and the enforcement of a rather rigid policy of “shape up or ship out” may work well for borderline patient9 and occasionally helps manic patients but
173
CRISIS MODEL
frequently is disastrous for schizophrenics. Efforts to create a short-term therapeutic milieu to help in the treatment of borderline and schizophrenic patients is seen by the crisis group as an invitation to stay longer in the hospital. Conflicting therapeutic needs of patients do not seem to support the concept of a one model unit.
THE
MULTIPLE-PROGRAM
UNIT
In their description of the admission process Maxmen and Tucker9 discuss different one-model units in operation. There are Crisis Intervention Units, ShortTerm Units oriented toward individal treatment or milieu therapy, Long-Term Units providing active support or custodial care. The recognition of the impact of the unit’s profile on the treatment of the individual patient supports specialization of units. A psychiatric service in a small general hospital or a mental health center frequently cannot afford maintaining more than one unit. The choice is between a totally individualized approach supported in its extreme by the findings of Reding and Maguire’O or a one-unit multiple program approach. Reding and Maguire found that psychiatric patients could be well treated on nonpsychiatric wards. The average length of stay was 9 days as compared to 30 days in a Regional State Hospital and 24 days in a psychiatric unit of a general hospital. In the Short and Partial Hospitalization Unit under study with its new multiple program structure the average length of stay was 6.6 days. In this unit with multiple clinical programs there is one ward chief, but there are 3 head nurses, each of whom act as a clinical coordinator of a program. All new patients are now placed in the evaluation program until presentation to the ward chief at an admission conference. The evaluation program is designed to serve as a selection mechanism and prevent the application of the crisis approach to every patient on the unit. Presentation usually occurs on the first day after admission. Other senior unit leadership members lead such conferences on weekends to ensure continued rapid evaluation. The patient may, however, remain in an extended evaluation Brief Treatment program up to 14 days if the clinical problems warrant it. The Crisis Program is a continuation of the old Emergency Treatment Unit model and still serves more than 300 patients per year. The 5 day limit is not so strictly enforced as in the past but a major effort is made to live up to this expectation. Thirty day follow-up is offered as a part of discharge planning.The Day Program provides a substitute for short term hospitalization combining up to 14 days’ inpatient treatment with 4-6 wk of day hospital. Stabilization of the patient’s mental status with the help of medication, milieu therapy, group psychotherapy, and, according to the patient’s needs, individual, couple and/ or family therapy are the major treatment modalities. The multiple-program unit offers most of the treatments traditionally provided on psychiatric units and reduces length of stay to an absolute minimum. The “pure crisis” group has its own crisis meetings separated from the general ward meetings of all the patients and the therapeutic community meetings of the Day Program. Patients may switch their program assignments if this is justified on clinical grounds but each program promotes its own goals, values and length of stay in treatment. Maintaining one unit provides for better utilization of staff time and continuity of care when
HENISZ AND JOHNSON
174
the patient has to move from one program to another. More than 500 patients are treated per year on this 12 bed unit. COMMENT
Historically, crisis hospitalization and the whole concept of crisis intervention seems to have followed the fate of many other treatment approaches. Initially there is the search for recognition, then the arousal of great enthusiasm which may lead to an indiscriminate use of the new approach. There follows a quiet descent to a legitimate place in the inventory of psychiatric therapies. Psychoanalysis, therapeutic milieu, behavioral modification on the psychological side of the spectrum, phenothiazines, lithium and earlier barbiturates, insulin and EST on the biological side, have been tried indiscriminately by supporters and followers and been angrily rejected by others. The hopes that the crisis approach would entirely replace what traditional hospital psychiatry had to offer in the past have vanished. However, having established the efficacy of crisis intervention it then becomes possible to incorporate it in the mainstream of clinical psychiatry. In the case of the Emergency Treatment Unit under study it slowly changed its character over 7 yr of existence. The number of beds was increased, the length of hospitalization gradually extended, and a day program was added. In the same period 2 longer-term units located in the same building (an inpatient, milieu-oriented unit and a free standing day hospital) were closed and the outpatient department absorbed its manpower and resources. The pure crisis approach fails to meet the needs of some typical psychiatric patients. Those who experience for the first time in their life the existential meaning of a psychotic world, those who are troubled by intense inner problems before their acute response to stress brings them to the hospital, those too depressed to respond to warm support and those not ready to share their feeling with others do not benefit from 3-5 day crisis hospitalization. More time is needed to build any kind of therapeutic alliance or to allow medication to show its effects. Many patients do respond, however, to brief treatment within a week or two. The evolution of the inpatient clinical service described supports the viability of two inpatient models for a community mental health center or general hospital. The crisis intervention model organized around a very small inpatient unit (or emergency room) with a length of stay of 3-5 days may act as a preventive barrier to longer term hospitalization. An alternative model calls for crisis, brief and day hospitabzation programs on the one unit. Multiple clinical programs may coexist and support each other within the single administrative structure of one unit. REFERENCES 1. Weisman G, Feirstein A, Thomas C: Three day hospitalization-A model for intensive intervention. Arch Gen Psych 21: 620-629, 1969 2. Rhine MW, Mayerson P: Crisis Hospitalization within a Psychiatric Emergency Service. Am J Psych 127: 1386- 139 1, 197 1 3. Schwartz DA, Weiss AT, Miner JM: Community psychiatry and emergency service. Am J Psych 129: 710-714, 1972
4. Rabiner CJ, Lurie A: The case for psychiatric hospitalization. Am J Psych 131:761-764, 1974 5. Quitkin F, Rifkin A, Kaplan JH et al: Treatment of acute schizophrenia with ultra-high dose fluphenazine: A failure at shortening time on a crisis-intervention unit. Compr Psychiat 16, 3:279-283, 1975 6. Redlich FC, Klerman GL, McDonald R et
CRISIS
175
MODEL
al: The Connecticut
Mental
Health
Center--A
joint ventureof state and university in community psychiatry.
Conn Med 30: 656662,
1966
7. Zonana H, Henisz JE, Levine M: chiatric emergency services a decade later. chiatr Med 4: 273-290, 1973 8. Friedman
HJ: Some problems
PsyPsy-
of inpatient
management
with
borderline
patients.
Am J
Psych 126:299 304, 1969 9. Maxmen FS, Tucker GJ: The admission process. J Nerv Ment Dis 156:327-339, 1973 10. Reding GR, Maguire B: Nonsegregated acute psychiatric admissions to general hoapitals Continuity of care within the community hospital. New Eng J Med 289:185 189. 1973
E. Henisz
and David Johnson
T
HE CONCEPT OF CRISIS HOSPITALIZATION in a mental health center was one that was vigorously promoted a few years ago.‘s2 Since then it has continued to be seen by its supporters as more economical of time and money and frequently as effective as more traditional hospital treatment.3 Others have raised questions about its clinical validity.4,5 Something useful may be added to the controversy by looking at the evolution of the idea of 3 day hospitalization which was defined as a model for intensive intervention by one center.’ For the purpose of this report crisis hospitalization is defined as an inpatient stay of less than 5 days which is usually followed by intensive but time-limited outpatient treatment. The characteristic clinical approach involves the use of timelimited contracts, intervention through multiple therapist teams aimed at minimizing dependency and regression, an adaptive focus in therapy, early involvement of family members and use of medication to control incapacitating symptoms. Ventilation of feelings related to those painful situations which usually precede crisis admission occurs during individual and group sessions. It starts with the identification of problems and ends when the patient is ready to return to the precrisis level of functioning. Discussion of long standing inner psychological conflicts is avoided and actively discouraged.
THE
SETTING
The Connecticut Mental Health Center in New Haven provided the locus for the study. The Emergency Treatment Unit (ETU) opened in 1967 and had initially five beds. It was planned that patients would stay up to 72 hours for “diagnostic assessment, crisis intervention and active psychiatric treatment.“6 With increased demands for service the number of beds was increased first to 7 and later to 12. In the fifth year of the Center’s operation there was a strong belief that the emergency-crisis approach to hospitalization had succeeded and it became the dominant orientation. A milieu-oriented, longer-term unit had been closed. These changes, however, resulted in a net increase of transfers to the state hospital and a dramatic decrease in the efficiency of the Emergency Treatment Unit. After 2 more years, the unit was renamed “Short and Partial Hospitalization Unit.” The maximum length of stay was extended to fourteen days and active consideration is currently being given to even further extension. From the Yale University Department of Psychiatry, New Haven, Conn. Jerzy E. Henisz, M.D.: Associate Professor of Clinical Psychiatry, and David Johnson, M.B.. M.R.C. Psych.: Assistant Professor of Psychiatry, Yale University School of Medicine. New Haven, Conn. Reprint requesls should be addressed to Dr. Jerry E. Henisz. Connecticut Mental Health Cenler. 34 Park Streel, New Haven. Corm. 06508. ,< 1977 by Grune & Stratton.
Comprehensive Psychiatry. Vol. 18. No. 2 (March/April),
1977
169
170
HENISZ
PATTERNS OF ADMISSION
AND JOHNSON
AND DISCHARGE
Source of Referral
The Emergency Treatment Unit had two major portals of entry: the Emergency Room of the local university-affiliated hospital and the Connecticut Mental Health Center. The Emergency Room, after a steady increase in psychiatric contacts over the last decade,’ experienced for the first time recently a drop in total contacts from its peak of about 4000 per year to less than 3000 in 1973/74. At the same time the Connecticut Mental Health Center significantly increased its “walk-in” and “unscheduled” services. The Center’s evaluation unit has more than 2000 admissions per year and the treatment units of the Center maintain on their books another 2000 patients on any given day. The most important change in the pattern of referrals to the Emergency Treatment Unit occurred during 1973/74. For the first time in the unit’s history the referrals from inside the Center outnumbered referrals from the emergency room. Length of Stay
The adoption of a more flexible policy about the length of stay resulted in an average extension of the length of stay by more than 2 days per patient. The increase of length of stay occurred in all diagnostic categories. However, there were differences in the length of stay according to the source of referral in 1973/74. The mean length of stay on the unit of those patients referred from the emergency room was 6 days. (6.03, S.D. 3.80). The mean stay of patients referred from the treatment units of the Center, usually psychotherapy or medication clinic, was close to 8 days (7.86; S.D. 3.77). This difference is significant (t = 3.81, df = 306, p < .OOl) and reflects the fact that patients in ongoing treatment come to the hospital for more than crisis intervention. Bed Occupancy
A psychiatric unit available for emergency admissions 24 hours per day must operate on rather low bed occupancy. During the period under study it varied between 5 l%-76%. The highest rate of occupancy was during the years 1973/74, when it was allowed to keep the patient beyond the “5 day limit.” Disposition Pattern
On an average, the emergency unit could not meet the needs of approximately 20% of patients. When the longer-term unit was closed in 1971, the overall percentage of referrals for longer hospitalization increased with a very sharp rise in that proportion of patients who were transferred to the state hospital. During the last year, when new programs were developed, there was a drop in state hospital transfers from 14% of all discharged patients to 7%. This drop is totally accounted for by the rise in day hospital referrals from below 1% to more than 9% of all dispositions. Diagnostic Pat tems
The distribution of diagnoses of patients treated on the unit did not change over the 7 yrs. Approximately x are schizophrenics; g are patients with depression;
CRISIS
171
MODEL
and l/10 are alcoholics and drug abusers. Adjustment reactions to adolescent or adult life, neurotic reactions other than “depression,” and personality disorders accounted for about l/5 of all admitted patients. It is difficult to analyze the data on diagnosis due to its low reliability and changing emphasis. A schizophrenic patient who was admitted after alcohol or drug abuse could be diagnosed as a drug or alcohol problem. An alcoholic who came to the unit after a fight with a spouse could be placed in the “adjustment reaction” or “personality disorder” categories. CLINICAL
OBSERVATIONS
The aggregated data show that over 7 years of existence the emergency treatment unit has slowly changed its character. These changes are highlighted by the increased length of stay and the addition of the day program. How are these changes reflected in the clinical characteristics of patients and care provided to them? Patients admitted to the unit tend to fit into 4 general categories: the crisis group, the brief treatment group, the short and partial hospitalization group, and those who need more than the unit can offer, the longer-term hospitalization group. The Crisis Group
The group includes patients in acute but usually transient situational crises. They may carry the diagnoses of neurosis or personality disorder. They come to the unit in acute distress, frequently with suicidal ideation or after suicidal gestures. Precipitants leading to hospitalization are easy to identify and therapy is limited to the change of environment, ventilation of feelings around the current crisis and support for purposes of developing more constructive patterns of adaptation. The classic crisis approach works best for this group of patients Brief Treatment Group
Problems experienced by patients in this group are not amenable to a 3- 5 day approach and something like 7-21 days is required before discharge can be confidently arranged. A variety of patients belong to this group. They include the following: 1) borderline patients in psychotherapy who require hospitalization; 2) patients requiring a neuro-psychiatric evaluation; 3) those suffering from schizophrenia who decompensate, usually following cessation of medication; 4) alcoholics and drug addicts in need of detoxification. The first mentioned group pose particular difficulties in treatment which merit further discussion. With the increased number of outpatient therapists available in and outside of the Center, increased demands for hospitalization of borderline patients in therapy are being made. One common characteristic of this group of patients is their difficulty in working through transference. At the time of termination of therapy, therapists’ vacations, or simply in response to some threatening aspects of the therapeutic process, they require hospitalization. At time of stress, the fear of losing the therapist’s support which frequently acts as a backup for the fragile ego boundaries becomes a terrifying idea. The patient has to be placed in the hospital. Once admitted, 2 processes take place simultaneously. First, the intensity of the transference situation is diluted and the real loss of the therapist is
172
HEN&?
AND JOHNSON
replaced by hospital walls and friendly staff. Second, the emphasis is put on testing other resources and giving help so that the patient can emerge from the state of regression. At the beginning, the patient gets worse. Being in the hospital is interpreted as a long awaited and delayed failure. Subsequently, the patient is able to mobilize the experience derived from the long-term work. External reality is seen as such rather than only as a hostile and unresponsive environment. With the skillful help of trained staff who are not discouraged by initial symptoms of depression and regression, the patient is able to find his or her own way out of the hospital. To accomplish this a minimum of 10 to 14 days in the hospital are needed. The traditional crisis approach does not work. The patient having been oriented towards psychological exploration cannot accept the rather sudden strong emphasis on reality and decreased attention to inner experience. Short and Partial Hospitalization Group
and lithium and The availability of major tranquilizers, antidepressants, increased sophistication in their use in conjunction with psychotherapy have changed the traditional approach to hospitalization for patients suffering from psychotic disorders. However, hospital observation, careful and skillful diagnostic evaluation and choice of treatment, and respect showed to the patient at the beginning of his therapy frequently cannot be replaced by anything comparable on an outpatient basis. Moreover, for the group of patients who either experience their first psychotic break or reexperience it again with very high intensity, 30 or 45 day programs are still provided in many private hospitals.g In the community mental health setting where shortage of beds rather than insurance coverage defines the length of stay, the only alternative available for these patients is partial hospitalization, This is a viable alternative only for those who have sufficient support at home and can tolerate several hours daily outside of the hospital. Without this, longer term hospitalization is required. Longer Term Hospitalization Group
There remains the group of patients for whom the total resources of the unit are insufficient and longer hospitalization is required. In the main, these patients suffer from serious psychotic illnesses but severe sociopathic disturbance is sometimes involved. The need for longer hospitalization becomes apparent in 2 ways. In one group of patients psychotic disturbance is so gross and/or the patient such a difficult management problem that it is clear within a few days that transfer to a long-term facility is needed. In the second group, while the unit is aware throughout of the serious nature of the problems, an attempt is made to deal with them within the available time limit. Frequently, at the end of this time further hospitalization has still to be arranged. When the crisis group of patients is mixed on one unit with acutely psychotic and depressed patients, alcoholics, drug addicts, and borderline character disorders, it becomes very difficult to preserve the uniqueness of the crisis approach. The treatment of patients undergoing detoxification and of relapsed psychotics provide examples where the solutions rest largely with medication. Limit setting and the enforcement of a rather rigid policy of “shape up or ship out” may work well for borderline patient9 and occasionally helps manic patients but
173
CRISIS MODEL
frequently is disastrous for schizophrenics. Efforts to create a short-term therapeutic milieu to help in the treatment of borderline and schizophrenic patients is seen by the crisis group as an invitation to stay longer in the hospital. Conflicting therapeutic needs of patients do not seem to support the concept of a one model unit.
THE
MULTIPLE-PROGRAM
UNIT
In their description of the admission process Maxmen and Tucker9 discuss different one-model units in operation. There are Crisis Intervention Units, ShortTerm Units oriented toward individal treatment or milieu therapy, Long-Term Units providing active support or custodial care. The recognition of the impact of the unit’s profile on the treatment of the individual patient supports specialization of units. A psychiatric service in a small general hospital or a mental health center frequently cannot afford maintaining more than one unit. The choice is between a totally individualized approach supported in its extreme by the findings of Reding and Maguire’O or a one-unit multiple program approach. Reding and Maguire found that psychiatric patients could be well treated on nonpsychiatric wards. The average length of stay was 9 days as compared to 30 days in a Regional State Hospital and 24 days in a psychiatric unit of a general hospital. In the Short and Partial Hospitalization Unit under study with its new multiple program structure the average length of stay was 6.6 days. In this unit with multiple clinical programs there is one ward chief, but there are 3 head nurses, each of whom act as a clinical coordinator of a program. All new patients are now placed in the evaluation program until presentation to the ward chief at an admission conference. The evaluation program is designed to serve as a selection mechanism and prevent the application of the crisis approach to every patient on the unit. Presentation usually occurs on the first day after admission. Other senior unit leadership members lead such conferences on weekends to ensure continued rapid evaluation. The patient may, however, remain in an extended evaluation Brief Treatment program up to 14 days if the clinical problems warrant it. The Crisis Program is a continuation of the old Emergency Treatment Unit model and still serves more than 300 patients per year. The 5 day limit is not so strictly enforced as in the past but a major effort is made to live up to this expectation. Thirty day follow-up is offered as a part of discharge planning.The Day Program provides a substitute for short term hospitalization combining up to 14 days’ inpatient treatment with 4-6 wk of day hospital. Stabilization of the patient’s mental status with the help of medication, milieu therapy, group psychotherapy, and, according to the patient’s needs, individual, couple and/ or family therapy are the major treatment modalities. The multiple-program unit offers most of the treatments traditionally provided on psychiatric units and reduces length of stay to an absolute minimum. The “pure crisis” group has its own crisis meetings separated from the general ward meetings of all the patients and the therapeutic community meetings of the Day Program. Patients may switch their program assignments if this is justified on clinical grounds but each program promotes its own goals, values and length of stay in treatment. Maintaining one unit provides for better utilization of staff time and continuity of care when
HENISZ AND JOHNSON
174
the patient has to move from one program to another. More than 500 patients are treated per year on this 12 bed unit. COMMENT
Historically, crisis hospitalization and the whole concept of crisis intervention seems to have followed the fate of many other treatment approaches. Initially there is the search for recognition, then the arousal of great enthusiasm which may lead to an indiscriminate use of the new approach. There follows a quiet descent to a legitimate place in the inventory of psychiatric therapies. Psychoanalysis, therapeutic milieu, behavioral modification on the psychological side of the spectrum, phenothiazines, lithium and earlier barbiturates, insulin and EST on the biological side, have been tried indiscriminately by supporters and followers and been angrily rejected by others. The hopes that the crisis approach would entirely replace what traditional hospital psychiatry had to offer in the past have vanished. However, having established the efficacy of crisis intervention it then becomes possible to incorporate it in the mainstream of clinical psychiatry. In the case of the Emergency Treatment Unit under study it slowly changed its character over 7 yr of existence. The number of beds was increased, the length of hospitalization gradually extended, and a day program was added. In the same period 2 longer-term units located in the same building (an inpatient, milieu-oriented unit and a free standing day hospital) were closed and the outpatient department absorbed its manpower and resources. The pure crisis approach fails to meet the needs of some typical psychiatric patients. Those who experience for the first time in their life the existential meaning of a psychotic world, those who are troubled by intense inner problems before their acute response to stress brings them to the hospital, those too depressed to respond to warm support and those not ready to share their feeling with others do not benefit from 3-5 day crisis hospitalization. More time is needed to build any kind of therapeutic alliance or to allow medication to show its effects. Many patients do respond, however, to brief treatment within a week or two. The evolution of the inpatient clinical service described supports the viability of two inpatient models for a community mental health center or general hospital. The crisis intervention model organized around a very small inpatient unit (or emergency room) with a length of stay of 3-5 days may act as a preventive barrier to longer term hospitalization. An alternative model calls for crisis, brief and day hospitabzation programs on the one unit. Multiple clinical programs may coexist and support each other within the single administrative structure of one unit. REFERENCES 1. Weisman G, Feirstein A, Thomas C: Three day hospitalization-A model for intensive intervention. Arch Gen Psych 21: 620-629, 1969 2. Rhine MW, Mayerson P: Crisis Hospitalization within a Psychiatric Emergency Service. Am J Psych 127: 1386- 139 1, 197 1 3. Schwartz DA, Weiss AT, Miner JM: Community psychiatry and emergency service. Am J Psych 129: 710-714, 1972
4. Rabiner CJ, Lurie A: The case for psychiatric hospitalization. Am J Psych 131:761-764, 1974 5. Quitkin F, Rifkin A, Kaplan JH et al: Treatment of acute schizophrenia with ultra-high dose fluphenazine: A failure at shortening time on a crisis-intervention unit. Compr Psychiat 16, 3:279-283, 1975 6. Redlich FC, Klerman GL, McDonald R et
CRISIS
175
MODEL
al: The Connecticut
Mental
Health
Center--A
joint ventureof state and university in community psychiatry.
Conn Med 30: 656662,
1966
7. Zonana H, Henisz JE, Levine M: chiatric emergency services a decade later. chiatr Med 4: 273-290, 1973 8. Friedman
HJ: Some problems
PsyPsy-
of inpatient
management
with
borderline
patients.
Am J
Psych 126:299 304, 1969 9. Maxmen FS, Tucker GJ: The admission process. J Nerv Ment Dis 156:327-339, 1973 10. Reding GR, Maguire B: Nonsegregated acute psychiatric admissions to general hoapitals Continuity of care within the community hospital. New Eng J Med 289:185 189. 1973
