should general hospitals accept involuntary psychiatric patients?

Should General Hospitals Accept Involuntary Psychiatric Patients? A Panel Discussion1

Cavin P. Leeman, M.D. Chief of Psychiatry, Framingham Union Hospital, Framingham, and Associate Clinical Professor of Psychiatry, Boston University School of Medicine, Boston, Massachusetts

Lloyd I. Sederer, M.D. Director, Inpatient Psychiatric Service, Massachusetts General Hospital, and Instructor ofPsychiatry, Harvard Medical School, Boston, Massachusetts

Jerome Rogoff, M.D. Associafe Chief of Psychiatry, Faulkner Hospital, Boston, Massachusetts

Howard S. Berger, M.D. Chief of Psychiatry, TheMemorial Hospital, and Associate Professor of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts

John Merrifield, M.D. Director of Psychiatric inpatient and Emergency Services, Concord Area Comprehensive Mental Health Center/ Emerson l?os$tal, Conco;d, Massachusetti U

Abstract: The issue of whether involuntary patients can be treated safely and effectively on inpatient psychiatry units of general hospitals is addressed from several points of view. Parallels are drawn befween contemporary reform efforts and 19th century hospital psychiatry, and the danger of repeating errors of the past is poinfed out. An accounffollows, illustrating the recent planning process for mental health care in Mas- sachusetts and recommending theactiveparticipation of psychiatrists in that process. Also discussed are the differences in the process of establishing a treatment alliance with voluntary and involuntary patients. The practical considerations in the development of a locked unit in a general hospital are explored, with respect fo its effect on reimbursement, the private practice model, and the length and appropriateness of stay. In conclu-

‘This paper is based on a presentation at the American Psychiat& ksociation annual meeting, May 8, 1980, in San Francisco, California (Issues Workshou #34. Should General Hospitals Accept Involuntary Patients? Gavin I’. Leeman, M.D., Moderator). All authors are members of the Massachusetts Psychiatric Society’s Committee of Directors of Psychiatric Units in General Hospitals, of which Dr. Leeman is Chairman.

sion, the shared concern is stated that, in respect to making the transition from onesystem of care to another, safeguards be built in to protect and expand good treatment.

I. Introduction

Cavin P. Leeman, M.D.

One of the most exciting trends in hospital psychiatry of the past 10 to 15 years has been the growth of open psychiatric units in general hospitals and the demonstration that most patients who are severely ill enough to need hospitalization- including the full range of diagnostic categories- can be admitted voluntarily and treated on these unlocked units, often located in their own communities. For the most part, these units have established and maintained high standards of care. Gen- erally they are heavily staffed with well-trained

Generai Hosprfal PsychiatT 3, 245-253, 1981 @I Elsevier North Holland, Inc., 1981 52 Vanderbilt Avenue, New York, NY 10017

245 ISSN 0163-8343/81/030245-CFWO2.50

C. P. Leeman et al.

professionals who provide comprehensive clinical evaluation and short-term intensive treatment, including active work with family members and other significant persons in the patient’s social network. Thoughful discharge planning that often begins at the time of admission facilitates brief hospitaliza- tions and continuity between the inpatient and outpatient phases of treatment.

Now, for a mixture of idealistic, economic, and political reasons, general hospitals are being asked to accept a still broader segment of the psychiatric population in need of inpatient treatment, particu- larly patients who will not accept voluntary hospitalization, as well as some who are difficult or impossible to treat safely and effectively on an unlocked unit. While supporting the expansion of psychiatric services provided by general hospitals, the Massachusetts Psychiatric Society has been concerned that, without adequate safeguards, general hospitals might be pressured into admitting patients for whom they could not provide safe and effective treatment. An even more serious ramifica- tion of the pressure on general hospitals to accept involuntary patients and the contraction of state- operated facilities might be the locking of currently open psychiatric units in general hospitals and the indiscriminate mixing of groups of patients with markedly different clinical needs. The result might be the destruction of much of what has been gained in recent years. Because of these concerns, the Society adopted a position paper in which it tried to delineate what would be required for general hospitals to provide high-quality care for involuntary patients (1).

This discussion begins where the Massachusetts Psychiatric Society’s position paper leaves off. First, Dr. Lloyd Sederer draws a parallel between the contemporary effort to relocate inpatient care from state hospitals to general hospitals and the decline of moral treatment in nineteenth-century hospital psychiatry. He points out that we are in serious danger of repeating the errors of our past. Next, Dr. Jerome Rogoff discusses the recent and current planning process for mental health care in Mas- sachusetts, pointing out that active partiupation by psychiatrists is crucial, if quality care is to be pro- served and advanced. Dr. Howard Berger then discusses both the importance and the fragility of the therapeutic alliance with voluntary patients, drawing a comparison to the situation with involuntary patients. While no less important, the alliance with involuntary patients starts from a different place and has more to overcome. These con-

siderations buttress the conclusion of the position paper that:

To provide high-quality care in a “least restrictive” environment that meets each patient’s individual needs, separate locked and unlocked psychiatric units should be provided. The locking of all or most psychiatricunits in general hospitals in order to serve a minority of involuntary patients is unacceptable. Most genera1 hospital psychiatric units should be unlocked and continue to serve only voluntary patients.. . . [Even with the development of locked units,] not all involuntary patients can be cared for within the genera1 hospital setting. Several types of involuntary patients require specialized units more appropriately located in psychiatric hospitals on a regional or statewide basis, whether public or private (1).

Dr. John Merrifield concludes the discussion by taking up a series of practical considerations that should be considered by any general hospital contemplating the development of a locked unit for the treatment of involuntary psychiatric patients. The reader is referred to the position paper itself for a discussion of architectural issues and of public rela- tions and medical liaison.

A legal issue, the right to refuse treatment, has assumed increased importance since the development of the position paper was undertaken. The decisions in the Rennie case and the Rogers case, perhaps not yet rendered in their ultimate form, have implications for psychiatric units admitting involuntary patients (2,3). They pose the threat of greatly increased administrative and procedural problems and, more importantly, of increased tension, fear, and physical danger, as the professional staff becomes severely limited in its control of psychotic behavior. Most fundamentally, they pre- sent the paradox of admitting to psychiatric units involuntary patients who cannot legally be treated and cannot safely, perhaps not even legally, be discharged.

The positions taken by the Massachusetts Psychiatric Society, and by the authors of this paper, should be regarded as constructive rather than obstructive. My opinion is that the private sector, and to a considerable degree that means general hospitals, potentially can provide better treatment for involuntary patients than state facilities have done. Our shared concern is that in making the transition from one system of care to another, we must build in the safeguards that will protect and expand good treatment, rather than relocate bad treatment and destroy good treatment.

Should General Hospitals Accept Involuntary Psychiatric Patients?

II. Reforming the State Mental Hospital: An Historical Perspective

Lloyd 1. Sederer, M.D.

In Massachusetts, as in many other states, a con- certed effort is under way to abolish or reform the public mental hospitals. The State of Mas- sachusetts’ Department of Mental Health is seeking to bring quality mental hospital care to those patients who have heretofore been cared for under ward conditions that range from good care, to be- nign indifference, to shameful control and destructive neglect.

While the progressive intentions of this reform effort are honorable and necessary, they are fraught with the dangers that accompany do-goodism. They threaten, in an efflorescence of misguided idealism, not only to not improve the lot of state hospital patients, but to dilute and destroy the quality care provided to psychiatric patients in general and private hospitals.

A strikingly parallel situation to the one we face today existed in mid-19th century hospital psychiatry (4-10). A zealous reform movement, rooted in a mixture of democratic availability of treatment for all and an enlightenment belief in order and reason, resulted in the breakdown of humane, psychosocial care that had been provided by the asylums of that day. It was this reform movement that helped to create the state mental hospital system which we are trying to dismantle today.

The asylums of the early 19th century were ha- vens for moral treatment. The deterioration of these psychosocial treatment facilities and the birth of custodial care can be traced to certain problems that are as timely and pertinent today as they were over 100 years ago.

Overcrowding and indiscriminate mixing of patients. Small, short-stay hospitals became inun- dated with patients requiring longer stays and with poor immigrants who suffered a variety of ills, including insanity. Individualized care vanished as bulging patient populations were indiscriminately mixed. Hospital staff became obsessed with control, not cure, in order to preserve order. A similar dilemma could occur today if contemporary state facilities try to relocate care to the private sector without adequate regard for numbers and nosol-

ogy.

Gatekeeping. Without control over who enters and who leaves the hospital, the moral asylums of the 19th century could take no action to correct the ills of indiscriminate mixing and overcrowding. Short- and long-stay patients, and those with dif- fering behaviors and diagnoses that would require varied treatment and facilities, could not be appropriately separated. Humane care for 100 short-term patients became coercion or neglect for the diverse 1000 that collected within the hospital wails. This must be a focus of concern for today’s reformers in order that a patient-centered system of care be established.

Economics. Quality inpatient care is expensive. It is even more expensive to provide care humanely to combative and extremely disorganized patients. It was cheaper, or more “cost-effective,” 100 years ago, as it is today, to house patients with minimal care in large hospitals than it was to build, staff, train, and treat patients in hospitals and in the community in a manner that attended to their specific clinical and social requirements (12,12). Re- markably, severe economic inflation plagued the nation in the mid-1800s, as it does today. Mental hospital care was not made an economic priority then and the results were, and are still, an embar- rassment.

Errant do-goodism and scientism. Dorothea Dix of yesteryear, like public officials of this year, was determined to bring psychiatric care to the mul- titude. Dix’s efforts did result in increased numbers of hospital beds, but inadequate for the numbers of patients her labors brought to the hospitals for care. In essence, she relocated poor care from the almshouses, county jails, and streets to the asylums. Likewise, poor care could become the stan- dard in the general hospital and private sector, as it is now in the public sector, if mere relocation occurs. We already see the results of relocating state hospital patients to the community without adequate resources to receive them.

Furthermore, science is limited, as is humane care, in the care of the chronically and severely mentally ill. This is no call for pessimism, merely a warning against resurrecting scientism, or the irra- tional belief in science, that occurred late in the past century. Ninteenth century scientism held that patients were not cured because we did not know enough about medicine. The prevailing, excessive faith in science kept professional and public leaders from recognizing the need to provide comprehen-

247

C. P. Leeman et al.

sive and enduring psychosocial care in order to minimize suffering for the more severely ill psychiaticpatients. One form of modern day scientism may be the social scientism that proposes that asylums make patients ill. This notion can errone- ously lead to the conclusion that closing the asylum or relocating its patients will render them well. Perhaps history’s lessons, our patients, and our increased clinical knowledge can keep our efforts modest and specific enough to be realizable.

The Massachusetts Psychiatric Society’s committee of directors of psychiatric units in general hospitals has studied the problems inherent in relocating care from state facilities to general hospitals. Clini- cal, legal, architectural, economic, liaison, and administrative issues have been discussed by this committee and its report has been adopted by the Massachusetts Psychiatric Society (1). The issues echo the events, and the mistakes, of 19th century hospital psychiatry.

With history as a guide, perhaps this time around we will incorporate all potential caregivers into a workable, modern progressive movement. Without effective alliance, collaboration, and planning between public officials, the state hospital system, the community mental health system, the general hospital, and the private mental hospital, psychiatry may once again reach a common, but pathetically compromised level of patient care. In reforming the state hospitals without attending to history’s lessons, public officials will accomplish their well-meant but misguided goals. Misguided reform may once again usher in an era replete with professional demoralization and patient neglect.

III. Mental Health Care Planning For the 80s: Psychiatry’s Crucial Role

]erome Rogoff, M.D.

Because of the rapid bureaucratization of health planning, and the inclusion of the private sector in that process, psychiatrists can no longer remain aloof. Indeed, the welfare and interests of our patients, to say nothing of our own interests, depend in large measure on our own willingness and ability to involve ourselves. As the example of Mas- sachusetts has shown, events throw the problems affecting public and private sectors into a common pool, where the real issue becomes the maintenance of quality of care for all patients. Psychiatry must make common cause around a shared knowledge of

clinical realities and programmatic needs to educate those who hold the fiscal and administrative power that now directly impinges on and often controls practice in both sectors.

When the Commonwealth of Massachusetts, in the early 197Os, made the decision to begin to close the state hospitals and to rely primarily on community resources to care for the mental patient, the growing number of general hospital psychiatric units were to be the keystone of this shift. To permit such a transfer of responsibility, general hospital units would need to agree to admit involuntary patients. To accomplish that, the Massachusetts Department of Public Health and Department of Mental Health jointly issued a paper, in October 1977, entitled “Progress Toward Psychiatric Stan- dards and Criteria,” adopted by the Public Health Council, which controls the Determination of Need process (13). These guidelines were the result of a Task Force, including representatives from the Health Services Agency, the Departments of Public Health and Mental Health, the Rate Setting Com- mission, the Department of Public Welfare, Blue Cross, the Massachusetts Hospital Association, and the Massachusetts Medical Society. With no psychi- atrist representation, they therefore reflected the viewpoints of the authors and the members of the Task Force, and made no mention of the programmatic impact of their recommendations. Their ratio- nale was: “Acceptance of involuntaries by general hospitals is essential to the integrity of Common- wealth mental health services, and is a necessary prerequisite to closure of state mental institutions.” Their concerns were stated as humanitarian and fiscal. What was mandated was a plan that re- vealed a typically bureaucratic sameness and ri- gidity, with arbitrary length of stay requirements, catchment area definitions, and, most centrally, the insistence that all units accept involuntary patients, even to the extent of making architectural modifications in existing units. The implications for the open unit concept and for patient alliance were not discussed. Quality of care issues not only were not debated, but were not even considered.

The crisis that got many general hospital psychiatrists actively involved in the planning process was that of the temporary but peremptory closing of a Community Mental Health Center’s inpatient service to any new admissions because of inadequate staff/patient ratios. We had all relied on that facility as a back up for patients when our own facilities were full, as well as a resource for truly violent patients, unremittingly chronic patients, and involuntary patients. Our colleagues in the CMHC

248


were finally taking a stand that was in fact long overdue-that even if the ultimate responsibility lay with the state-run facility, that was no reason to collude in the provision of substandard care. After some mutual recriminations, we began to see that our struggle was a common one, along the lines not of public vs. private sectors, but of psychiatry and its medical value system committed to quality of care vs. a state bureaucracy in which, increasingly, such issues were taking second place to fiscal and cost-containment concerns.

The upshot of the crisis was a series of task forces-all with solid input from psychiatrists in both public and private sectors, as well as from other clinicians, health planners, and adminis- trators (14-16). The recommendations of these task forces are summarized below:

1. There was a need to gather data on bed need by area, patterns of referral and commitment, and numbers of involuntary commitments of the various types (i.e., violent patients, irreducibly chronic patients, seriously medically ill patients).

2. The State had to continue to fulfill its ultimate responsibility for the mentally ill, and could not just close institutions and send patients into community and private sectors ill-equipped to receive and care for them. It retained responsibility for the care of the violent patient, the chronic patient who could not be managed in the community, the patient who was both seriously medically and seriously mentally ill, and the indigent patient. Such responsibility could be discharged in various ways, e. g., by contracting out, or by funding the patient on a capitation basis. The number of State facilities should be reduced to one or two, with enough funding to ensure excellent staffing and staff support (education, benefits, supervision, and improved staff/patient ratios and salaries). The State could not divest itself of its ultimate fiscal responsibility for the indigent patient.

3. The notion that all units had to accept involuntary patients was replaced with the idea that each area or region needed the capacity to treat such patients within it; this was to be accomplished by requiring treatment of involuntary patients, when necessary, in new units, and by establishing financial incentives to encourage the opening of more locked units in general hospitals. Existing open units were to be left open, and the idea of a mix of different services and units in each area was to be promoted as long as all patients were adequate- ly cared for.

4. The kinds of supports in the Commonwealth needed for general hospitals to assume this new

responsibility had to be in place, or well on the way

to being a place, before those hospitals would accept the new responsibilities. It would be of no benefit to the mentally ill to shift the terrible prob-

lems of the state hospital system to the private

sector, thereby compromising the excellent stan- dard of care most of the mentally ill in the State were already able to receive.

5. The notion that closing down the state system would imply monetary savings for the state had to be abandoned. Good quality care costs more than poor quality care, even with the savings of effi- ciency that were supposed to be inherent in the private sector. A good, reliable community mental health program, with all the community supports necessary, would, by all available evidence, cost more, not less, than the current system.

6. Finally, the catchment area concept needed to be less rigidly applied and more flexibly adapted to patient needs.

The original guidelines were replaced with more widely accepted ones, and agreement, in principal, has been reached on the state’s continuing responsibility for the care of the violent and chronic patient outside of the general hospital; on open units re- maining open; on data gathering; and on more flexible application of the catchment area concept. The vital importance of maintaining quality of care and getting psychiatric input has been acknowledged and accepted. Some of this is still only prom- ise: the State Task Force report was adopted (16), yet current regulations still ignore it. The final reso- lution of the locus of therapy of all the nonviolent involuntary patients remains elusive.

Much more needs to be done-if only to secure the advances we have made by seeing them in practice, not in rhetoric. We must see to it that clinicians of all points of view, from both public and private sectors, are centrally involved in all the mental health planning in our states from the beginning. Only if clinicians are central to the planning process will equitable solutions that preserve quality of care be found.

IV. The Therapeutic Alliance in Voluntary and Involuntary Hospitalization

Howard S. Berger, M.D.

Much of the progress over the past ten years in hospital psychiatry has been the demonstration that most patients who are severely ill enough to need hospitalization-including the full range of diagnostic categories--can be treated on unlocked psychiatric

249

C. P. Leeman et al.

units of general hospitals. A cornerstone of this suc- cess is the voluntary agreement made by the patient to participate in his or her own treatment (1).

This voluntary agreement between patient and therapist, often known as the therapeutic alliance, therapeutic contract, or working alliance, is such a fundamental principle of current psychiatric treatment that it is often taken for granted. As is well known, the concept of the therapeutic alliance was not self-evident in the early practice of psychoanalysis and psychotherapy. As it was assumed to develop with little activity on the part of the therapist, it was relegated secondary to transference reactions. The pioneering clarifications of Zetzel(17), Greenson (18), and others are develop- ments of the past 25 years. The later widespread emergence of unlocked psychiatric units followed a recognition that even many suicidal and psychotic patients had sufficient observing ego to recognize that they were ill enough to need hospitalization and to agree to stay. Since the goals of hospitalization are sometimes limited to crisis intervention and the initiation of outpatient treatment, the strengthening of the therapeutic alliance may often be the main objective of hospitalization in order that a psychotic or suicidal patient may be safely discharged.

The initial relationship with an involuntary patient is radically different. Since involuntary patients do not recognize the need for hospitalization, the committing physician or judge overpowers the patient’s conscious wishes and exercises protective authority, under law, as a consequence of com- prehending his underlying distress and assessing the likelihood of serious harm if nothing is done. This is exemplified by the patient who clearly com- municates suicidal intent and then refuses help, unconsciously testing to see whether anyone cares enough to stop him. However empathic the under- standing and however benevolent the intent, compelling a person’s entrance into a hospital is based on power, not on a voluntary contract. Without special legal sanction, this same behavior would be considered kidnapping and sometimes assault and battery. To develop an alliance with an involuntary patient, one must recognize that the patient feels overpowered and humiliated, even if no physical force has been used and, as early as appropriate, introduce an acknowledgement of this fact. In many instances the early stage of therapy with an involuntary patient is marked by helping him become aware of the need for hospitalization and

thereby develop a therapeutic alliance. At this point he can change his legal status from involuntary to voluntary.

Even in a voluntary setting, the beginning therapeutic alliance may be fragile because it con- tains some element of subjective involuntariness. Most patients seen in an office (outside of special settings such as court clinics) feel more voluntary than those admitted to hospitals. The most well- motivated, purely voluntary inpatient, who recog- nizes the need for treatment, often feels coerced by intense inner suffering and the possibility of suicide or psychosis and ashamed of not being able to function to the point of having to seek hospitalization. Also, many hospitalized patients, who do not seek help as early as they might have, come with some degree of external coercion from friends, family, or therapists. Still others consent to voluntary hospitalization only under threat of involuntary commitment. Sophisticated psychiatric units know better than to assume that legal voluntary status implies a full degree of subjective voluntariness and cooperation: the patients who sign out against medical advice within a day or two bear witness to this. Since most patients enter a hospital with feelings of humiliation, failure, shame, and guilt about hospitalization itself, special attention must be given to these feelings on admission and thereafter.

Although the nuances of how therapeutic al- liances are fostered in voluntary units from the moment of admission cannot be detailed here, some highlights can be mentioned. In essence, the patient is approached in a manner that respects his dignity and appeals to the healthier aspects of his functioning, not as a helpless child who needs parental protection. Admission precedures are de- signed to minimize the patient’s feeling de- humanized. He is oriented to the unit in person and often given some basic written material to let him know what patients and staff can expect from each other. In community meeting, anxieties over being hospitalized are openly acknowledged, and the newcomer is helped by those recently admitted. If the patient is too ill initially to assimilate informa- tion, it is introduced when he is ready. Most important of all, attention is paid to the step-by-step process by which the patient came to the hospital and how he feels about it.

This brief overview of the complexities and sub- tleties of the therapeutic alliance in voluntary settings leads to the viewpoint that a locked door, the regular use of seclusion rooms, the presence of committed patients, or any one of these, would

250


threaten this fragile alliance by tending to make all patients feel captive (1). Many patients would not consent to admission in the first place if they did not know they had the power to leave. The constant reminder that some patients cannot is very threatening and changes the experience of all. The locked door is a real barrier, not merely a symbolic one.

This discussion points to the need for general hospitals to develop a second kind of psychiatric inpatient unit. If general hospitals are to treat new groups of patients effectively without jeopardizing the good quality care they now provide, locked units must supplement open units, not replace them, Otherwise the best interests of the majority of patients now being treated in open units would be sacrificed, in order to serve a minority of patients whose needs are different.

It is important to note that the population of voluntary patients is not quite the same as the population that can be treated on unlocked units. A few patients, for example, who will not participate in any agreement to be hospitalized, must be admitted involuntarily, but will not make any active effort to leave or to hurt themselves or other people. Thus they can be treated safely on unlocked units. Other patients, with extremely poor control of self- destructive and aggressive impulses, are safely treated only on locked units, even though they may have legally consented to admission. Thus, it is a combination of legal status and overt behavior that determines where a patient is best treated. Un- locked, voluntary units tend to be stimulating therapeutic environments that emphasize in- volvement, interaction, sharing of feelings, and various psychotherapies, including group modalities. The emphasis in a locked unit should be on containment, security, support, decreased stimulation, and appropriate forms of individual attention (29). Not only would involuntary patients disrupt a vigorously interactive therapeutic environment, but a vigorously interactive therapeutic environment might disrupt these patients (20). This distinction provides another compelling reason not to try to satisfy the diverse spectrum of patient needs on a single unit. The necessity for flexibility in applying the milieu therapeutic approach within each unit (21) does not nullify the marked distinc- tions that necessitate two different units to serve two distinct patient populations.

In conclusion, any one unit in a general hospital cannot be all things to all people. Specificity of treatment is increasing both in the office and in the

hospital. If we lock the currently open units in general hospitals and indiscriminately mix groups of patients with markedly different clinical needs, we will have destroyed a major advance in modern hospital psychiatry. The deficits in our understand- ing of the major emotional disorders are immense and are the reality we must struggle with daily. That is unavoidable, but ignoring what we do know and have learned is tragic and preventable.

V. Treatment of Involuntary Psychiatric Patients in General Hospitals: Some Practical Considerations

Iohn Merrifield, M . D .

It has been pointed out that in order to treat both voluntary and involuntary patients safely and effectively in general hospitals, separate locked and unlocked psychiatric units should be provided (1). This section will discuss some of the practical considerations that should be given by any general hospital contemplating the development of a locked unit for the treatment of involuntary psychiatric patients.

The intensive care analogy. Intensive care units have proliferated in general hospitals and, despite their problems, have proved useful. They are small, expensive, heavily staffed, and characterized by high technology and severely ill patients. Should, then, involuntary patients in general hospitals be served by units called Psychiatric Intensive Care Units? Certainly there should be intensity of focus. Small size by itself provides no clinical or economic advantage. Moreover, physical spaciousness is of value to some patients, especially given a unit which may be locked. The behavior that necessi- tates hospitalization on a locked unit requires close observation and intensive treatment, necessitating more numerous and specially trained staff (1,22). The expense per day, therefore, is likely to be higher than for voluntary patients. A psychiatric I.C.U. should not be crowded with monitoring devices, and its patients must sometimes be left alone to collect themselves rather than receive constant infusions from the staff. The implication of severe illness is relevant: the great appeal of the term “intensive care” is that it reminds everyone that freufmenf is the goal, rather than custodial or police functions. In sum, intensive care is a useful analogy to help gain acceptance for a unit that treats

251

C. P. Leeman et al.

involuntary patients, but the analogy is no substi- tute for careful program planning.

Reimbursement. Whether for humanitarian or regulatory reasons, most general hospitals must accept all patients suitable for their services regard- less of economic status. Since a high percentage of involuntary patients formerly sent to state hospitals are medically indigent or insured through Medicaid, reimbursement problems are implicit for general hospitals admitting them. The shift from incarceration in the state hospital, fully funded by the state, to treatment in the general hospital, partly funded or unfunded by the state, is attractive to state governments.* Indeed, it has been charged that the pressure to close state hospital beds derives primarily from economic considerations (23). In- dustry and insurance carriers, however, are show- ing signs of tighter control and resistance to absorb- ing these costs. There is a potential for patients to be caught in the middle of this confusion between quality and third parties’ fiscal shuffling.

Private practice. Although much policy planning for mental health care seems to ignore the existence of private practice, the prevalent model for providing psychiatric treatment in community hospitals utilizes private practitioners (24). Yet the integration of hospital work with office practice is problematic at best; it is expensive and time con- suming for someone in office practice to see one or two voluntary patients in the hospital, discuss their care with staff, and get back to the office. And these issues are further accentuated in an involuntary setting: administration is more elaborate, involving re- ports, legal status changes, supervision of restraint and seclusion, commitment proceedings, and constant vigilance to ensure that restriction not become protective custody or punishment. In addition, low- er levels of reimbursement for such patients’ care will adversely affect privately practicing psychiatrists; either they will work with these difficult patients, with significantly reduced financial return, or, more likely, they will have to relinquish at least some of their role in general hospital psychiatry to hospital-based salaried staff members (2). Finally, the tension already existing between salaried, Men- tal Health Center affiliated psychiatrists and private psychiatrists working at the same general

*The costs of Medicaid are shared by Federal and state governments; the costs of free care and bad debt generally are passed on to full-paying patients and third parties.

hospital-around competing access to limited beds as well as less tangible issues-will most likely increase as hospitals plan for involuntary patients, if only from the inevitable uncertainty of change itself.

Length and appropriateness of stay. As noted elsewhere, the impact on average length of stay to be expected by the admission of involuntary and other patients to a locked unit would depend on the goals of hospitalization and the services to be provided. If patients were admitted solely for evaluation and urgent treatment and then transferred to psychiatric hospitals for intermediate or long-term hospitalization, average length of stay need not increase. On the other hand, definitive treatment tends to take longer for involuntary patients. More time is required to form a treatment alliance; such patients tend to manifest more disorganized behavior; they are likely to have fewer social and economic resources, complicating discharge planning; and the very process of protecting the involuntary patient’s rights sometimes requires lengthy guardianship proceedings (1,25).

As for appropriateness, no new rules need to made; the criterion is one of active treatment. The problem comes, as it does now, when active treatment is not taking place and there is no decent place to send the patient for extended care.

Mental health network. Locked units in general hospitals must be seen as one component of a network of mental health services. They can treat chronic patients in crisis, psychotic patients with concurrent medical problems, and various acutely ill patients who will not accept voluntary hospitalization or who cannot be treated safely on unlocked units. Locked units in general hospitals will not do well unless the state keeps its commitment to be the provider of last resort for unremittingly psychotic or persistently violent patients. The problems of finite capacity and fluctuating demand also must be addressed, since no unit can provide good care if it has to operate (as state hospitals traditionally have) as though its capacity were unlimited (1). Also, mental health planning for a community must take account of the fact that, for many patients, hospitalization is not the treatment of choice; a variety of outpatient services and partial hospitalization programs also must be available. Communities vary markedly in the spectrum of services provided. Outpatient services may be minimal or absent. Partial hospitalization may be available for certain kinds of patients,

252


but not for others, or may be limited to those who can pay. Nursing homes which accept the mentally ill, or which have the skills to care for them may not be available, nor may sheltered workshops. Multi-

ple obstacles may exist to the development of half- way houses and other community residences. Ideally, all these services should spring forth at once, to avoid logjams of patients in inappropriate settings, either too restrictive or dangerously unat- tended. The problem for a general hospital is that the planning process must begin several years before implementation, and the hospital must make a commitment to develop an involuntary service in hopes that the above-mentioned community supports will be in place when needed. The corre- sponding fear is that once the general hospital says yes, the state hospital will close, the community will continue to resist local support services, and the general hospital will be operating a “mini state hospital.“

The process by which these issues will be re- solved is staunchly political and likely to remain so. It seems important, therefore, that those who want hospital services to flourish and to be properly utilized, participate constructively in the political process and not regard the general hospital as a refuge from mental health politics.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

Leeman CP, Berger HS: The Massachusetts Psychiat- ric Society’s position paper on involuntary psychiatric admissions to general hospitals. Hosp Commu- nity Psychiatry 31:318-325, 1980 Leeman CP: Involuntary psychiatric admissions to general hospitals: progress or threat? Hosp Commu- nity Psychiatry 31:315318,198O Leeman CL’: The “least restrictive environment”: From rhetoric to practice. Gen Hosp Psychiatry 3:229-232. 1980 Sederer Li: Moral therapy and the problem of morale Am J Psychiatry 134:267-272, 1977 Rothman DJ: The Discovery of the Asylum. Boston, Little Brown, 1971 Bockoven JS: Moral treatment in American psychiatry. J Nerv Ment Dis 124;167-194, 292321, 1956 Zilboorg G: A History of Medical Psychology. New York, WW Norton, 1941 Foucault M: Madness and Civilization. New York, Vintage Books, 1973 Rothman DJ: Conscience and Convenience: The

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

Asylum and Its Alternatives in Progressive America. Boston, Little Brown, 1980 Ozarin LD: Moral treatment and the mental hospita1. Am J Psychiatry 111:371-378, 1954 Bassuk EL, Gerson S: Deinstitutionlization and men-

tal health services. Scientific American 238(2):46-53, 1978 Stein LI, Test MA: Alternative to mental hospital treatment. Arch Gen Psychiatry 37:392397,400405, 1980 Getson J, Murphy R, Viet H: Progress Towards Psvchiatric Standards and Criteria. Office of State Health Planning, Commonwealth of Massachusetts Department of Public Health, 1977 Kinzer DM, Okin RL: Memo re recommended re- vised policy on serving involuntary psychiatric patients. Mental Health Project of the Massachusetts Hospital Association and the Massachusetts De- partment of Mental Health, 1979 90-Day Task Force to Assess Public/Private Collabora- tion in the Delivery of Mental Health Services in HSA IV: Clinical Subcommittee Report. Health Planning Council for Greater Boston, 1979 Acute Psychiatric Standards and Criteria Task Force: Final Report. Office of State Health Planning, Com- monwealth of Massachusetts Department of Public Health,1979 Zetzel E: Current concepts of transference. Int J Psy- choanal37:369-376, 1956 Greenson R: The working alliance and the transference neurosis. Psychoanal Q 34:155-181, 1965 Gunderson JG: Defining the therapeutic process in psychiatric milieus. Psychiatry 41:327-335, 1978 Putten T van: Milieu therapy: Contraindications? Arch Gen Psychiatry 29:640643, 1973 Leeman CP, Autio S: Milieu therapy: The need for individualization. Psychother Psychosom 29:84-92, 1978 Rosen H: The impact of the psychiatric intensive care unit on patients and staff. Am J Psychiatry 132:549- 551, 1975 Arnhoff FN: Social consequences of policy toward mental illness. Science 188:1277-1281, 1975 Greenhill MH: Psychiatric units in general hospitals: 1979. Hosp Community Psychiatry 30:169-182, 1979 Gove WR, Fair T: A comparison of voluntary and committed patients. Arch Gen Psychiatry 34:669- 676,1977

Direct reprint requesfs to:

Cavin P. Leeman, M.D. Chief of Psychiatry Framingham Union Hospital 115 Lincoln St. Framingham, MA 01701

253

should general hospitals accept involuntary psychiatric patients?

Documents