There was a time when patients who suffered from one of the major mental illnesses such as Paranoid Schizophrenia were condemned to waste away in the back wards of state mental hospitals where they lived out their tragic lives. Ever since the advent of anti psychotic medications it became possible to release these patients into the community where they could live, attend continuing treatment in local clinics and receive medications to control their symptoms. For some it even became possible to work in jobs that were not too stressful.
One of the great discoveries about the treatment of the mentally ill was that they not only responded to these new medications but even benefited from participation in groups. Prior to this, it was believed that the mentally ill were completely isolated and unable to interact with other people because of their psychotic symptoms that interfered with reality.
Now it is known that there is more to the treatment of the psychotic illnesses than only the application of medications to relieve symptoms. In my experience working with acutely mentally ill people, one of the most effective forms of treatment combines medication for the control of symptoms along with immersion of the patients in a total social and community milieu that is designed to enable patients to understand, regulate and control their symptoms for the purposes of avoiding future decompensation and psychiatric hospitalizations and to help them live and work in the community to the best of their ability. Another way of stating this is that the goal of treatment of psychotic patients is rehabilitation and return to living and functioning in the community. To these ends was created the Psychiatric Day Hospital and Continuing Day Treatment.
Following is a description of my experience of working with patients diagnosed with schizophrenia in a wonderful Day Hospital. Here is how entry into a Day Hospital occurs.
When Psychiatric Hospitalization Occurs:
When someone experiences a psychotic break they lose touch with the real world. The reason for this loss of touch with reality is that their minds are taken over by hallucinatory experiences. This means that they hear, see and feel things that are not there in the real world. Accompanying these hallucinations are equally unrealistic ways of thinking that bear no relationship to what is happening in the actual environment. For example, a person by begin to experience bizarre and frightening thoughts that Federal agents are out to shoot and kill this person. The combination of hallucinations and delusional thoughts, all of which are real to the individual who is becoming ill, can cause behaviors that could be either harmful to their self, harmful to others or could disturb the peace. It is usually under one or all of these circumstances in which someone is acting very bizarre and scaring everyone else that they are brought to the hospital.
In the large cities there are hospitals that have separate emergency rooms for mentally ill people who are brought there either by the police, family or friends for evaluation. A team of psychiatrists, psychiatric nurses, psychologists and social workers examine the patient and determine whether or not they need to be hospitalized or not. The criterion for hospitalization is to what degree they may pose a threat to themselves or others. If a person is judged to be a suicidal or homicidal risk, they are hospitalized. Again, in the large hospitals found in big urban centers there are often psychiatric wards somewhere within the hospital. In smaller communities where hospital have neither a psychiatric emergency room or inpatient psychiatric services patients are transferred to nearby psychiatric facilities for evaluation and disposition.
Once a person is diagnosed and hospitalized they spend a period of time on the psychiatric ward where medications are administered and where they attend both group psychotherapy sessions and individual meetings with their psychiatrist. The length of the hospitalization depends on how quickly the patient is stabilized. Stabilization means that the combination of medications used are effectively working so that this individual is no longer a threat to their selves or to others.
A Day Hospital is a total therapeutic milieu for people suffering from the schizophrenias and other psychotic illnesses. The Day Hospital may be part of the psychiatric hospital or may be housed on a separate floor from the inpatient ward. In my experience, the door into the Day Hospital ward is locked so that people need permission to enter. However, unlike the inpatient ward in a psychiatric hospital, the doors leading out of the ward are unlocked so that patients may leave if they wish to but cannot re enter without permission.
Early in my career I had the privilege of working with psychotic patients in a Day Hospital. What Day Hospital refers to is the fact that some of the patients live in supervised housing in the community, some live at home with parents or guardians and others are married and live at home with their spouse and children. Those living in supervised housing are driven by van to the Day Hospital. These patients, recently released from inpatient hospitals, spend the hours from 8 AM to 3 PM in the therapeutic environment of the Day Program.
At the Day Hospital, there is a small population of patients with a high number of professional staff. At the time I worked at Day Hospital the ratio was one staff member to every seven patients. All staff members, whether psychiatrists, psychologists, social workers, music and art therapists and vocational counselors, are responsible for observing patients in the community so that any serious or dangerous symptomatic behavior could be reported and handled in a constructive and therapeutic way.
The goals for most patients at Day Hospital were for patients to understand and control their illnesses and symptoms, understand the function and importance of their medications and learn how to avoid the stressors that can cause a decompensation. Anti psychotic medications are effective in reducing or eliminating the positive symptoms of psychoses. The positive symptoms are the hallucinations and delusions that plague these people. Negative symptoms are more difficult to eliminate and include such things as passivity, withdrawing into complete social isolation and wanting to sleep most of the day. Life in total community experience helps psychotic patients learn to reduce these negative symptoms while learning how to socialize with others in ways that are helpful and adaptive.
A Day at the Day Hospital:
One of the unique things about Day Hospital treatment for those who are acutely ill with a psychotic illness is how it teaches people to normalize their lives.
7:30 to 8:30 AM, Coffee
People slowly begin to arrive at the Day Hospital early in the morning, some time between 7:30 and 8:30 AM. Patients can then enter the kitchen where there is decaffeinated coffee, tea, hot chocolate and toast or muffins. Staff and patients join together at this time and read the newspaper or just sit and talk. In my experience, even the most isolating and paranoid of patients will, after a month or two in the program, gravitate toward this warm and non pressured atmosphere. People chat about anything and simply relax. The point is not what everyone it talking about but just that they are sitting and relaxed in a typical breakfast situation no different than can be found at home or in a diner during the early morning.
8:30 to 9:00 AM, Community Meeting
At 8:30 all staff and patients go to the main meeting room where Community Meeting takes place. Here, important news and information is announced for the entire community. The meeting is then open to the entire community. New patients are introduced and welcomed into the community. Patients and staff are free to discuss any and all issues pertaining to things that may be perceived as unfair, where certain clients have gone, who is absent among staff and clients, etc. Leadership for the meeting is rotated among the staff members who lead the meeting a week at a time. Plans for holidays and celebrations are also announced and planned.
9:00 to 9:10, Brief Staff Meeting
This very brief staff meeting is to share any observations about the community meeting and to clarify the issues of the day ahead.
9:15 until Noon, Groups
After the meeting ends at 9:15, everyone attends their first group of the day. There is an individualized schedule for clients to follow. Groups range in interest from group therapy, self grooming, cooking, house keeping, art therapy, vocational counseling, men's issues group and women's issues group and various types of drug and alcohol counseling groups. Either a psychiatrist or psychiatric nurse leads a medication group for new patients all of whom are encouraged to learn about their illness, medications and how they work. Each patient meets with their psychotherapist at least once per week or as the need arises.
Mid day is punctuated by lunch which is also taken together by staff and clients in order to increase socialization and provide a sense of real community.
Any patient who feels too paranoid to attend all groups on a particular day have private and quiet areas to which they can retreat.
12:45 to 2:30, PM Groups
More group therapy takes place during this period of time.
Day Hospital closes and patients return either to their supportive residences or to their homes where they live with their families.
Full staff meeting to share and process all that happened during the day. Both the community as a whole is discussed as well as each individual patient who poses a problem, is experiencing symptoms, has difficulties at home or is nearing discharge.
Once per month, evening Multi Family Group
Once per month there is a multi family group that meets with the patient, if they wish. Families and patients get support from one another and learn how best to cope with a loved one who suffers from a chronic mental illness.
Length of stay is from a minimum of six months to two years for this type of treatment and depends upon the severity of the individual case.
Discharge is either to a program that continues treatment in a similar mode for patients who are chronically ill. That type of program is usually referred to as Continuing Day treatment and this takes place in a private, not for profit type of agency. For others, it might be possible to attend college or even go to work with a lot of psychosocial support provided by outside agencies in the community. Arrangements are always made for continuing medication and psychosocial support regardless of the patient. Families are always included in the treatment from the start of Day Hospital until and including plans for discharge. Patients fully participate in planning their discharge with the help and support of their therapist in Day Hospital. In fact, patients choose the goals for treatment and the groups they wish to attend from the first day of entry into Day Hospital.
Day Hospital was an intense experience for both patients and staff. It required that staff work closely and cooperatively together to help these fragile people move towards recovery. On more than a few occasions we felt their pain and identified with the stigma and prejudices they faced just by having an illness that was no fault of their own. Like parents protecting their children, we sometimes guarded our patients and over protected them only to have this unhelpful behavior discussed by the staff. In other words, there was plenty opportunity for us to learn about our selves as there was for patients to learn about themselves.
It was at this time that I came to understand and appreciate the individuals who suffered this terrible illness. For example, we all observed that schizophrenia was a truly democratic illness. In other words, all races, nationalities, ethnic groups and religions are vulnerable to schizophrenia. The Day Hospital Population was a veritable United Nations with almost every group in the world represented. We had patients who had been medical students, doctors, engineers, policemen, lawyers African American, Caucasian, Asian, Jewish, Catholic, Protestant and Islamic, before they developed the full psychotic illness called Schizophrenia.
Not only as a staff but as a full community, all of us, patients and staff alike, cried, laughed, celebrated and mourned when the lives of community members were affected by life events.
What I witnessed from the time I began my work until the day I left, four years later, were patients who progressed in their treatment from being paranoid and isolated to full participating members of the community.
Cost Effective: The Revolving Door:
In my experience and according to the literature, there are several advantages to Day Hospital Treatment over lengthy inpatient stays. For one, Day Hospital is less expensive because patients do not have to be cared for over-night. Second, the intensity of the treatment is such that the revolving door of re-hospitalizations is reduced. Finally, patients seem to like the Day Hospital experience because it is safe and they gain in self confidence as they learn how to live in the community without decompensation.
Why is Day Hospital Underutilized?
What no one seems to understand is why Day Hospital has not become a more fully utilized method of treatment all across the nation. What ever the reasons may be it is my opinion that, at least as of the present, there is nothing to equal the positive impact of Day Hospital.
Your comments are welcome and encouraged