NADD Bulletin Volume IV Number 1 Article 2

Complete listing

Creating a Continuum of Intensive Psychiatric Services for Individuals with Dual Diagnosis: A Perspective on the Massachusetts Experience II. Partial Hospitalization

Karen J. Shedlack, MD

The “snapshot” of a dually diagnosed patient’s symptoms and behavior provided by the standard outpatient office visit, even if the patient is accompanied by a knowledgeable family member, residential staff person or DMR service coordinator is by definition, limited. The limitations are multiple and may require time frames that are unreasonable to accomplish in an outpatient clinic setting. Symptoms may be variably expressed in different settings and as such, variably observed and interpreted by personnel in the work, residential, and medical office settings and by family. A particular act or comment can become labeled as either “illness” or “behavior” by observers who do not have access to or familiarity with the patient’s history nor comprehensive information about the patient’s current situation. The standard inpatient setting, while permitting skilled observation in a single venue and over a more extensive time frame, can also provide an inaccurate impression of a patient’s current difficulties, as the dually diagnosed patient has been removed from the settings where the behaviors occur and may additionally be unable to adapt to the acuity of the typical psychiatric inpatient ward.

Partial hospitalization is a setting which melds elements of both the staff-accompanied, focussed office visit and the individualized, longitudinal perspective of the inpatient ward. As such, it is particularly well-suited to the assessment and treatment of the dually diagnosed. Historically, the development of partial hospital programming in American psychiatry has its roots in the Community Mental Health Act of 1963, which mandated deinstitutionalization for people with chronic mental illness and established funding for less restrictive alternatives (DiBello, Weitz, Poynter-Berg, & Yurmark, 1982). Increasingly, partial hospitalization has become a treatment modality which can accommodate the shorter and shorter psychiatric inpatient lengths-of-stay by providing a step-down level of care upon discharge from an inpatient facility. Partial hospitalization has also grown to provide an alternative to inpatient care for those patients who do not require the restrictive security of a locked ward but who are experiencing new onset of psychiatric symptoms or acute exacerbations of chronic psychiatric conditions.

A partial hospital patient experiences a minimum of disruption in their activities of daily living, as they continue to reside in their family homes or their community residential settings while attending partial hospital on a daily basis. Patients continue to have daily access to their familiar residential staff and families at times when this would otherwise be impossible due to the intrusion of psychiatric symptoms. Partial hospital essentially substitutes for outpatient psychopharmacology, outpatient psychotherapy and the work setting at a time when these services and work may be untenable due to disruptive symptoms and behavior. The outpatient therapist and psychiatrist act as liaison to the partial hospital treatment team and return the patient to their practices upon partial hospital discharge. Familiar work personnel can also play a key role in assessing progress made and in providing transitional programming for a gradual return to work. Thus, the partial hospital treatment modality permits continuity for both patients and their outpatient provider teams.

In 1996, the Psychiatric Partial Hospital Program for Adults with Developmental Disabilities was established as a joint venture between McLean Hospital, one of the leading psychiatric hospitals in America and a teaching facility of the Harvard Medical School, and the May Institute, a nationally-recognized non-profit corporation specializing in the spectrum of care for people with developmental disabilities. The program is located on the grounds of the McLean Hospital and is staffed by a psychiatrist, nurse, social workers, and mental health specialist from McLean, as well as a team of cognitive-behavioral specialists from the May Institute which include doctoral, masters and bachelors level psychologists. In the three years since its inception this unique program has treated over 200 patients with lengths-of-stay ranging from a few weeks to over a year. The average length of stay has steadily fallen, but for the first half of this calendar year is at 40 days. The average daily census ranges between 12-18 patients, while the program has capacity for up to 20 enrolled patients at any one time. The structure of the program has been described in detail elsewhere (Luiselli, Lisowski, & Weiss, 1998; Luiselli, Benner, Stoddard, Lisowski, & Weiss, 2000). Comprehensive assessment, treatment planning and therapies are all delivered in the partial hospital setting. Cognitive-behavioral therapy is delivered via group therapies and milieu treatment as well as by individual plans for patients who require this level of intervention. Psychotherapy is provided as per an individual patient’s ability to utilize this modality. Psychopharmacology is a major focus of each patient’s treatment and includes both the introduction of new medications as well as the careful elimination of unnecessary medications.

In our experience, the partial hospital is an ideal modality for the level of assessment, coordination of care and carefully controlled delivery of treatment that is often required when dealing with dually diagnosed patients and the many systems in which they interact. Stays of at least several weeks are ideal for partial hospitalization as there is considerable time invested initially by the case manager social workers and the psychiatrist in gathering the history from all sources and in synthesizing the often disparate records, reports and opinions from these multiple sources. In addition the program staff spends time detailing their skilled observations and in developing the initial levels of planned interventions. Medication trials must be titrated slowly and patients observed carefully both at the program and at home so as to be accurate in one’s observations of a medication’s efficacy or lack thereof. Cognitive behavioral plans must be adjusted as per persistence of some behaviors and symptoms as others recede or are accentuated. Often, the need for further consultation by neurology or neuropsychology is identified or the need for medical assessment is identified during the course of partial hospitalization. In all, we believe the partial hospital’s greatest resource lies in providing a single site where comprehensive biopsychosocial assessment and treatment can be delivered with a minimum of disruption to the dually diagnosed patient’s life style and with a maximum focus on maintaining the individual’s personal integrity while restoring them to an adequate level of functioning in their community.

References

DiBello, G. A. W., Weitz, W., Poynter-Berg, D. & Yurmark, J. L. (1982). Partial hospitalization: Historical roots and development. Handbook of Partial Hospitalization (pp. 3-9). New York: Brunner/Mazel.

Luiselli, J. K., Lisowski, K. & Weiss, R. (1998) Behavioral assessment, analysis and support in a psychiatric partial hospital program for adults with developmental disabilities. Journal of Developmental and Physical Disabilities, 10, 407-421.

Luiselli, J. K., Benner, S., Stoddard, T., Lisowski, K., & Weiss, R. (2000). Behavior support intervention in psychiatric partial hospitalization for adults with mental retardation: Two case studies. Mental Health Aspects of Developmental Disabilities, 3, 1-7.

For further information:

Karen Shedlack, M.D.
McClean Hospital
115 Mill Street
Belmont, MA 02478