Vol. 68, No. 3
219
Psychiatric Day Treatment, The Therapy of Choice S. ALAN SAVITZ, Director
JAMES L. EVANS, M.D., PAUL D. SULLIVAN, M.D., and WILLIAM G. TOMPKINS, M.D., Silver Spring Day Treatment Center, Silver Spring, Maryland
SINCE the 1930's psychiatric day treatment has been the wave of the future but little used. Numerous reports have demonstrated that day treatment is a viable alternative to inpatient treatment and, in fact, provides many advantages not the least of which in this time of medical inflation is its cost effectiveness.'12 A continuing problem of day treatment has been convincing practitioners to utilize its facilities when adjacent or affiliated 24-hour inpatient services are available. The reasons for this are numerous and include unfamiliarity with the concept of partial hospitalization, the accepted custom of treating the acutely ill in inpatient facilities and the inertia of third-party payors. In one study, patients were designated for treatment in a day hospital in a statistically randomized order after the decision that they required hospitalization had been made. In this study, 189 patients or 66%, proved treatable in the day hospital.3 In another study the average number of days from random admission to either day or inpatient facility until the patient was discharged from inpatient or day treatment and lived in the community for at least one week was 48.5 days for the day patients and 119 days for the inpatients. "The results show that, in virtually every measure used to evaluate outcome, there was clear evidence of the superiority of day treatment.4" The purpose of this paper is to describe the unusually intensive, comprehensive treatment program in an independent, private, freestanding day treatment center and to discuss the advantages of this modality of psychiatric treatment.
THE DAY TREATMENT CENTER PROGRAM
Facilities. The Center is located close to the population which it serves and only a short distance from a general hospital with a psychiatric unit, should hospitalization or emergency medical care be necessary. It is readily accessible by public transportation. Both planned and impromptu recreational excursions are readily available. The Center is within walking distance of central shopping. Thus, the patient is able to incorporate a wide range of community facilities within his life's activities. The size of the Center is large enough to allow subdivision of the patients and to provide a reasonable staffpatient ratio, but small enough to avoid break-up of the group and possible isolation of an individual. Patients, as they improve, become capable of adjusting to groups of different sizes. It is beneficial to offer the individual patient the opportunity of alternating between temporary solitude and human contact. The location of the Center is in a non-institutional setting, a professional office building which promotes the impression of an ambulatory and not a custodial facility. This is augmented by the purposeful lack of special windows, locked doors or seclusion areas. TREATMENT PROGRAM
Psychiatric Group Rounds. Each patient in the Center attends group rounds which are led by a psychiatrist, social worker and nurse. The patient discusses what he has been doing in and out of the Center and receives feedback from the staff and patients.
220
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
The psychiatrist and staff make a daily evaluation of each patient and can make decisions that are indicated. It is during the psychiatric rounds that medication is prescribed. Side effects are promptly reported and changes can be made immediately. Chemotherapy fulfills many of the restraining and ego supporting functions of an inpatient setting and is especially important in day treatment. Group Psychotherapy. Group psychotherapy is conducted by the psychiatrist with a social worker co-therapist in a small group setting. The therapists focus particularly on affect and day-to-day behavior. Maladaptive behavior, the motivation for which may be explained in terms of avoidance of anxiety and search for security, is explored in historical perspective. Individual Psychotherapy. All patients within the Center have individual psychotherapy, predominantly concerned with explorations of historical background and systems of beliefs that support underlying patterns of behavior and defenses. This encourages the patient to learn some aspects of introspection. Family Psychotherapy. Participation of the family in weekly psychotherapy helps the family to cope with the initial shock and disruption created by mental illness. Often the patient is a chronic source of frustration within the family; the family may help aggravate or resolve the patient's illness. We have found that the involvement of the family in the treatment program is essential to the patient's improvement. Tri-Partite Groups. The tri-partite groups, which are unique to the Center, are divided into admission, mid and termination phases of therapy. Each group meets three times a week and makes recommendations on issues ultimately decided upon in daily rounds. In the admission group the nurse orients the patient to the day treatment program. In the mid-phase group the patient begins to put into action treatment goals that have been defined in the admission group. The termination group assists the patient in reviewing the changes that have started to occur in his life, in understanding and dealing with the
MAY, 1976
difficulties of separation, and in organizing and beginning appropriate outpatient treatment. Community Meetings. These are twiceweekly meetings where discussions and decisions are made relevant to the functioning of the general environment, and of issues that arise in daily living at the Center. Wrap-Up Meeting. The wrap-up meeting occurs at the end of each day treatment day. The nursing staff and patients review the day, anticipate any difficulties that may occur during the evening, and plan ways of dealing appropriately with them. These meetings are essential to the maintenance of the patient until the next day treatment day. Additional Groups. Other groups are led by the nurses or activity therapists to encourage the patients to use and develop skills in relating to the community in a more realistic and rewarding way. These consist of vocational group, art therapy, psychodrama, dance therapy, writing workshop, current events, and a variety of recreational groups. Therapeutic Milieu. Experience has increasingly indicated the importance that the total environment has on behavior. This influence is distinct from the influence of any particular part of the program. It has been found that, in general, helpful influences are those which lead to autonomy, socialization, and responsibility within the patient. The staff must maintain a high level of expectation of the patients so that the patients can assume these goals for themselves. USES OF THE CENTER
Acutely Psychotic Patients. Day treatment can be used as a definitive treatment modality for many patients who are now treated in full time hospitals. Patients often do not need the protection of the physical barriers which occur with inpatient hospitalization. Patients Who Have Had Inpatient Hospitalization. Another value of day treatment is as a transition to the community from inpatient hospitalization. Discharge to the community directly from inpatient hospitalization can result in an increase in symptoms and regression.
Vol. 68, No. 3
Psychiatric Day Treatment
Previously Well-Functioning Individuals. Day treatment can be the focus of rehabilitation of persons who have had social and vocational deficits resulting from their mental illness. The purpose of day treatment would be to re-establish work patterns and to facilitate social rehabilitation. Unsocialized Individuals. Day treatment can be used as a means of socializing the patient who has never had a satisfactory social adjustment. The patient may have had psychotherapy for a period of time and dropped out. Many of these people have very poor employment records and have few or no social skills. Their relationships are often limited only to the immediate family, and these are often disturbed. These patients are severe neurotics, severe character disorders, or borderline psychotics. DISCUSSION
Decrease in Regression. A day treatment center is in a unique position to foster independence and a quick return to normal living. Patients go home every evening and on weekends. Thus, the likelihood of chronic dependence upon the institution is lessened. Furthermore, there is a natural integration of the patient's home milieu with that of the center milieu which increases the relevance of one to the other. Day treatment discourages excessive dependency that results from the feelings of being shut-in, removed from ego supporting, self-sustaining activities. Long periods of boredom and inactivity are avoided. Regression is decreased by the implicit expectations of the patient; social skills required for residence at home are maintained; the patient maintains those independent activities of which he is capable despite his mental illness; the day treatment schedule approximates the customary work week; the patient is maintained within the family; there is less sexual frustration for the patient and spouse; the tendency to extrude the patient from the family is avoided. Flexibility. As a patient improves the density of institutional contact can be reduced, allowing a flexibility not possible with inpatients. He can make a transition to
221
part-time work and, for example, can attend day treatment three days a week and work three days a week. By maintaining an intensive contact with the day treatment milieu at a decreasing frequency, therapy can continue for the long term patient, while the patient reintegrates into the community. Cost. One of the most important advantages of day treatment over inpatient treatment is the decrease in cost. Staffing costs are reduced by the elimination of two of the three traditional shifts and by reduction from a seven day to a five day week. The capital costs of the day treatment facility are different because of the diminished physical structure. For patients with similar diagnoses the cost of the day treatment center is onequarter of the cost on an inpatient facility.5 CONCLUSION
The importance of psychiatric day treatment as an alternative to inpatient hospitalization, and as a definitive treatment for certain problems, becomes more apparent each year as these centers are developed and utilized and as reports are published describing favorable experience. Psychiatric day treatment is a flexible, economical and comprehensive community resource in the treatment of acute and serious psychiatric illnesses. As practitioners become more aware of the nature of day treatment and its special advantages, they should begin to avail their patients of this modality. LITERATURE CITED 1. GLASSCOTE, R. M. and A. M. KRAFT, S. M. GLASSMAN, AND W. W. JEPSON, Partial Hospitalization for the Mentally Ill, A Study of Programs and Problems. Washington, D.C., 1969. 2. ZWERLING, I. The Psychiatric Day Hospital in S. Arieti, ed. American Handbook of PsychiatryVolume III New York, N.Y., 1966 pp. 563-576. 3. ZWERLING, I. and J. WILDER, An Evaluation of the Applicability of the Day Hospital to the Treatment of Acutely Disturbed Patients. Israel Ann. Psychiat. 2:162-185, 1964. 4. HERZ, M. I. and H. J. ENDIES, R. L. SPITZER, and A. MESNIFOFF. Day Versus Inpatient Hospitalization: A Controlled Study. Amer. Journ. Psychiat., 127:10, 1971. 5. SAVATZ, A. et al. Cost Effective Alternative for Intensive Psychiatric Care. J. N.M. A., 68:231-233, 1976.
219
Psychiatric Day Treatment, The Therapy of Choice S. ALAN SAVITZ, Director
JAMES L. EVANS, M.D., PAUL D. SULLIVAN, M.D., and WILLIAM G. TOMPKINS, M.D., Silver Spring Day Treatment Center, Silver Spring, Maryland
SINCE the 1930's psychiatric day treatment has been the wave of the future but little used. Numerous reports have demonstrated that day treatment is a viable alternative to inpatient treatment and, in fact, provides many advantages not the least of which in this time of medical inflation is its cost effectiveness.'12 A continuing problem of day treatment has been convincing practitioners to utilize its facilities when adjacent or affiliated 24-hour inpatient services are available. The reasons for this are numerous and include unfamiliarity with the concept of partial hospitalization, the accepted custom of treating the acutely ill in inpatient facilities and the inertia of third-party payors. In one study, patients were designated for treatment in a day hospital in a statistically randomized order after the decision that they required hospitalization had been made. In this study, 189 patients or 66%, proved treatable in the day hospital.3 In another study the average number of days from random admission to either day or inpatient facility until the patient was discharged from inpatient or day treatment and lived in the community for at least one week was 48.5 days for the day patients and 119 days for the inpatients. "The results show that, in virtually every measure used to evaluate outcome, there was clear evidence of the superiority of day treatment.4" The purpose of this paper is to describe the unusually intensive, comprehensive treatment program in an independent, private, freestanding day treatment center and to discuss the advantages of this modality of psychiatric treatment.
THE DAY TREATMENT CENTER PROGRAM
Facilities. The Center is located close to the population which it serves and only a short distance from a general hospital with a psychiatric unit, should hospitalization or emergency medical care be necessary. It is readily accessible by public transportation. Both planned and impromptu recreational excursions are readily available. The Center is within walking distance of central shopping. Thus, the patient is able to incorporate a wide range of community facilities within his life's activities. The size of the Center is large enough to allow subdivision of the patients and to provide a reasonable staffpatient ratio, but small enough to avoid break-up of the group and possible isolation of an individual. Patients, as they improve, become capable of adjusting to groups of different sizes. It is beneficial to offer the individual patient the opportunity of alternating between temporary solitude and human contact. The location of the Center is in a non-institutional setting, a professional office building which promotes the impression of an ambulatory and not a custodial facility. This is augmented by the purposeful lack of special windows, locked doors or seclusion areas. TREATMENT PROGRAM
Psychiatric Group Rounds. Each patient in the Center attends group rounds which are led by a psychiatrist, social worker and nurse. The patient discusses what he has been doing in and out of the Center and receives feedback from the staff and patients.
220
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
The psychiatrist and staff make a daily evaluation of each patient and can make decisions that are indicated. It is during the psychiatric rounds that medication is prescribed. Side effects are promptly reported and changes can be made immediately. Chemotherapy fulfills many of the restraining and ego supporting functions of an inpatient setting and is especially important in day treatment. Group Psychotherapy. Group psychotherapy is conducted by the psychiatrist with a social worker co-therapist in a small group setting. The therapists focus particularly on affect and day-to-day behavior. Maladaptive behavior, the motivation for which may be explained in terms of avoidance of anxiety and search for security, is explored in historical perspective. Individual Psychotherapy. All patients within the Center have individual psychotherapy, predominantly concerned with explorations of historical background and systems of beliefs that support underlying patterns of behavior and defenses. This encourages the patient to learn some aspects of introspection. Family Psychotherapy. Participation of the family in weekly psychotherapy helps the family to cope with the initial shock and disruption created by mental illness. Often the patient is a chronic source of frustration within the family; the family may help aggravate or resolve the patient's illness. We have found that the involvement of the family in the treatment program is essential to the patient's improvement. Tri-Partite Groups. The tri-partite groups, which are unique to the Center, are divided into admission, mid and termination phases of therapy. Each group meets three times a week and makes recommendations on issues ultimately decided upon in daily rounds. In the admission group the nurse orients the patient to the day treatment program. In the mid-phase group the patient begins to put into action treatment goals that have been defined in the admission group. The termination group assists the patient in reviewing the changes that have started to occur in his life, in understanding and dealing with the
MAY, 1976
difficulties of separation, and in organizing and beginning appropriate outpatient treatment. Community Meetings. These are twiceweekly meetings where discussions and decisions are made relevant to the functioning of the general environment, and of issues that arise in daily living at the Center. Wrap-Up Meeting. The wrap-up meeting occurs at the end of each day treatment day. The nursing staff and patients review the day, anticipate any difficulties that may occur during the evening, and plan ways of dealing appropriately with them. These meetings are essential to the maintenance of the patient until the next day treatment day. Additional Groups. Other groups are led by the nurses or activity therapists to encourage the patients to use and develop skills in relating to the community in a more realistic and rewarding way. These consist of vocational group, art therapy, psychodrama, dance therapy, writing workshop, current events, and a variety of recreational groups. Therapeutic Milieu. Experience has increasingly indicated the importance that the total environment has on behavior. This influence is distinct from the influence of any particular part of the program. It has been found that, in general, helpful influences are those which lead to autonomy, socialization, and responsibility within the patient. The staff must maintain a high level of expectation of the patients so that the patients can assume these goals for themselves. USES OF THE CENTER
Acutely Psychotic Patients. Day treatment can be used as a definitive treatment modality for many patients who are now treated in full time hospitals. Patients often do not need the protection of the physical barriers which occur with inpatient hospitalization. Patients Who Have Had Inpatient Hospitalization. Another value of day treatment is as a transition to the community from inpatient hospitalization. Discharge to the community directly from inpatient hospitalization can result in an increase in symptoms and regression.
Vol. 68, No. 3
Psychiatric Day Treatment
Previously Well-Functioning Individuals. Day treatment can be the focus of rehabilitation of persons who have had social and vocational deficits resulting from their mental illness. The purpose of day treatment would be to re-establish work patterns and to facilitate social rehabilitation. Unsocialized Individuals. Day treatment can be used as a means of socializing the patient who has never had a satisfactory social adjustment. The patient may have had psychotherapy for a period of time and dropped out. Many of these people have very poor employment records and have few or no social skills. Their relationships are often limited only to the immediate family, and these are often disturbed. These patients are severe neurotics, severe character disorders, or borderline psychotics. DISCUSSION
Decrease in Regression. A day treatment center is in a unique position to foster independence and a quick return to normal living. Patients go home every evening and on weekends. Thus, the likelihood of chronic dependence upon the institution is lessened. Furthermore, there is a natural integration of the patient's home milieu with that of the center milieu which increases the relevance of one to the other. Day treatment discourages excessive dependency that results from the feelings of being shut-in, removed from ego supporting, self-sustaining activities. Long periods of boredom and inactivity are avoided. Regression is decreased by the implicit expectations of the patient; social skills required for residence at home are maintained; the patient maintains those independent activities of which he is capable despite his mental illness; the day treatment schedule approximates the customary work week; the patient is maintained within the family; there is less sexual frustration for the patient and spouse; the tendency to extrude the patient from the family is avoided. Flexibility. As a patient improves the density of institutional contact can be reduced, allowing a flexibility not possible with inpatients. He can make a transition to
221
part-time work and, for example, can attend day treatment three days a week and work three days a week. By maintaining an intensive contact with the day treatment milieu at a decreasing frequency, therapy can continue for the long term patient, while the patient reintegrates into the community. Cost. One of the most important advantages of day treatment over inpatient treatment is the decrease in cost. Staffing costs are reduced by the elimination of two of the three traditional shifts and by reduction from a seven day to a five day week. The capital costs of the day treatment facility are different because of the diminished physical structure. For patients with similar diagnoses the cost of the day treatment center is onequarter of the cost on an inpatient facility.5 CONCLUSION
The importance of psychiatric day treatment as an alternative to inpatient hospitalization, and as a definitive treatment for certain problems, becomes more apparent each year as these centers are developed and utilized and as reports are published describing favorable experience. Psychiatric day treatment is a flexible, economical and comprehensive community resource in the treatment of acute and serious psychiatric illnesses. As practitioners become more aware of the nature of day treatment and its special advantages, they should begin to avail their patients of this modality. LITERATURE CITED 1. GLASSCOTE, R. M. and A. M. KRAFT, S. M. GLASSMAN, AND W. W. JEPSON, Partial Hospitalization for the Mentally Ill, A Study of Programs and Problems. Washington, D.C., 1969. 2. ZWERLING, I. The Psychiatric Day Hospital in S. Arieti, ed. American Handbook of PsychiatryVolume III New York, N.Y., 1966 pp. 563-576. 3. ZWERLING, I. and J. WILDER, An Evaluation of the Applicability of the Day Hospital to the Treatment of Acutely Disturbed Patients. Israel Ann. Psychiat. 2:162-185, 1964. 4. HERZ, M. I. and H. J. ENDIES, R. L. SPITZER, and A. MESNIFOFF. Day Versus Inpatient Hospitalization: A Controlled Study. Amer. Journ. Psychiat., 127:10, 1971. 5. SAVATZ, A. et al. Cost Effective Alternative for Intensive Psychiatric Care. J. N.M. A., 68:231-233, 1976.
