Less "Sledgehammer" to "Kill Gnats"
Just hours ago, "EurekAlert," which is an organization which appears to devote at least part of its attention to mental health news, uttered a review ["Youth Are Receiving Shorter Inpatient Stays for Mental Health Treatment," http://www.eurekalert.org/pub_releases/2007/-01/1-yar010407.php] of an article just appearing in in January 2007 issue of Archives of General Psychiatry [AGP] documenting the steep-- even abrupt-- decline in the length of psychiatric hospitalization for children from 12.2 days a decade ago to 4.5 days now. The purpose of this article is to engage -- not in criticism of this fine piece of medical journalism by Carol L. Viera, cviera1@lifespan.org , but to analyze the general phenomenon of foreshortening trends in child psychiatric hospitalization itself, and to engage in a bit of "advocacy" which was perhaps neither anticipated nor imagined by EurekAlert.
The first article here quotes an author of the AGP article, Dr. Brady Case of Bradley Hasbro Children's Research Center, etc., as lamenting that "... driven by financial and other pressures, mental health providers are discharging severely ill youth too early in treatment." He does go on to say, however, that "... it may be that mental health providers are using hospital resources more efficiently and that children are increasingly being treated in day programs, clinics, and private offices." I would be the-more inclined to assess the variance of shortening hospitalization to the latter propostion, coming on the somewhat economically-forced-choice condition that fostered the mental health providers' "discovery" of community-based treatment.
I can remember when "state" hospitalization of youths was an even more drawn-out-affair than a stay of twelve-on-the-average days, but more like months and months and months in places like Kentucky's Children's Treatment Services (The Bingham Unit) at Central State Hospital here in the county from which I now write. Stays were -- by today's standards-- often for clinical reasons that would be "overkill," by which I mean that often the rationale was closer to a yen for providing residential services when the real problem best needed treatment in the community, and also for cases in which mental health acuity-- psychosis, suicidality, or assaultiveness was for a time a problem in a patient/client but the intrusive use of long-long-long-term hospitalization was employed. In this last case, it may be speculated that some significant portion of such prolonged institutionalization functioned to "get the brat out of the community's hair," and "to let the family off the hook" via inordinate respite.
But any form of respite psychiatric care-- while a "treat" for the family-- amounts to custody-alone, "jail," not "therapy." Such incarceration is expressly forbidden by the laws of every state, federal case-law, the Joint Commission on Accreditation of Hospitals [JCAH], and finds its way agreeably into managed care in utilization-review companies approved by URAC [which is an organization with just those initials alone, but used to stand for "Utilization Review Accreditation Committee."] Hospitalization of a mentally/behaviorally/emotionally-disturbed kid just for a "lock-up" is thus forbidden by every/all levels of state, federal, and regulatory agency.
Nowadays, there is recognition that Acute Inpatient Treatment is only occasionally necessary, and then for cases where clear psychiatric acuity or "dangerousness-to-self-or-others" can expressly be substantiated. More than a few days is hardly ever necessary at this level of care, which very often consists of intensive use of medication and even physical restraint. For states which have an adequate child psychiatry system-- and in no wise should one think that I refer to my own Kentucky-- THE PITS WE HAVE HERE !!!-- one can quickly and inexorably refer a child who has come down from such acute need to a longer-term residential program-- or the more likely to suit the client's needs, to community-based Intensive Outpatient [IOP] or Partial Hospitalization Program [PHP.]
IF-- and I mean IF-- good resources exist in the community for the disturbed child-- again not not not like in Dark and Bloody Kaintuck-- it is highly plausible that "locking the kid up and throwing away the key" will have been anything but a cruel, and counter-therapeutic, and lavishly expensive solution. In the communities, it becomes much easier to work with families in networking and problem-solving than is in all but the most-exceptional case a possibility in [especially state- ] institutions. This holds true whether one holds that strictly biological etiology is implication in mental illness, or that psychosocial genesis for such problems is at root, or whether such conditions are epigenetic/biopsychosocial [by which I mean that both biololgical and psychosocial factors interface to "make" psychopathology.]
Maybe "money" -- filthy lucre-- the "green stuff it takes to get along"-- is the prime reason for the thrust into brevity of inpatient stays for pediatric/child psychiatric hospitalization. No matter as far as the clear virtue of-- in general and not every single time of course-- keeping intensive inpatient treatment in child psychiatry to the essentials, and thus to the minimum. The long hospitalizations which were the hallmark of the age-- not too long ago at all-- when a child who was "committed" to a state psychiatric facility could expect months and in some cases years of institutionalization, during which time many dysfunctional, iatrogenic [ "healer-caused" ], and intractable habits could be and probably were learned. This previously-common condition for the disturbed child was nothing but an affront to the dignity, human-rights and clinical conditions, for the youth may very likely come out of such glacially-slow internment in worse condition than she/he "went in."
Accordingly, provided genuine community resources in child psychiatry, I see brevity of inpatient mental health treatment for the younger members of society as naught but a positive development, which I even applaud. It is almost-- but not quite-- true that even when community resources are poor, intensive acute psychiatric treatment for a kid should be avoided. Too often in the past, psychiatric treatment of children amounted to a malapropism, like the proverbial "sledge hammer to kill a gnat": when the first need of the disturbed child is placement, or when effort needs to be made to cobble-together "real" lives for kids like these, whose social matrix is often-as-not pretty "artificial," and in order not to teach a kid bad habits [like "hospitalism" for starters], then WE BEST START "AT HOME."
--- Vernon Lynn Stephens, M.S.S.W.
D.S.M. IV # F31.2
Telephone: (502) 561-5419
E-Mail: freethink@bellsouth.net
posted by Louisville Hermitage @ 12:02 AM
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