Less Time To Do More…. Psychotherapy On Acute Care Units

 

Less Time To Do More….

As part of my brief series on the role of psychotherapy in psychiatry I thought I would pull this book off my bookshelves and discuss it.  It was published in 1993 and that was about the time I bought it.  At that time, I had just finished working as the Medical Director of a CMHC and consulting at a local hospital and was about 4 years into my role as an acute care psychiatrist on an inpatient unit.  I was trained in psychotherapy in residency and provided it across all of these settings as well as individual and group supervision to masters level psychotherapists.  That supervision included accepting cases referred from them for psychotherapy if they felt uncomfortable treating that person.

Managed care hit hard from my first day on the acute care unit.  Companies decided that they could easily deny care to psychiatric inpatients by using what was eventually became their dangerousness standard.  In other words, if a reviewer made an arbitrary decision that the patient was no longer dangerous, they would stop payment and the patient would be discharged.  As someone who did this work for 22 years that is a bizarre standard designed primarily save the insurance company money and they were very good at that. They were also successful in setting up a sham appeal process that could not be challenged.  The result is suboptimal care and inpatient units that are essentially revolving doors that discharge patients before they are stable.

If you think of a competency-based standard for psychotherapy – that is the ability to manage your own life and medical care, make decisions in your best interest, and problem solve and make good decisions in novel situations that was all a second priority to symptom stabilization.  If a patient was admitted because of mania and grandiose delusions – those symptoms were targeted with pharmacotherapy and once they were mostly gone – the patient needed to be discharged.  At some point in the late 1990s – public payors like Medicaid and Medicare stopped using contractors to do these utilization reviews and the process was internalized by health care organizations.  Instead of being harassed by an outside reviewer – the harassment became internal for patients covered by public insurance.

The additional context at the time was a rift in psychiatry between psychiatrists who identified as either biologically based, therapy based or eclectic meaning a combination of both (2).  This paper was written at the time I trained but even that description was an oversimplification. There were medical psychiatrists, consultation-liaison psychiatrists, neuropsychiatrists, and community psychiatrists.  They all had their models of care and their own ideas about how psychotherapy should or should not be integrated into that care.  I was fortunate to have access to a wide variety of psychotherapists and very active didactics.  But nobody really talked much about how psychotherapy fits into typical psychiatric practices. In a previous post, I listed supportive psychotherapy resources and that was an obvious skill needed across all settings.  It was occasionally demonstrated by attending physicians but most of what they seemed to do were diagnostic interviews. 

Less Time to Do More seemed to take on that problem specifically in the inpatient setting. The introductory chapter on therapeutic communities discussed a common model used to run inpatient units.  The regulatory function of the community was discussed to help patients with severe mental illnesses reintegrate following an episode of decompensation. Kohut’s self-psychology was presented as a possible model of the self-object matrix critical for early childhood development with groups and group processes taking on that role.  Groups leaders need to monitor the level of cohesion in both patient and staff groups to main their roles in assisting in self-regulation and reinforcing adaptive behavior.

Chapter 2 (3) starts to get to the heart of the matter. It discusses relevant psychodynamics at the individual patient and staff level. Inpatient treatment is ideally multidisciplinary. The team I worked with consisted of nurses, nursing assistants, social workers, and occupational therapists. Each team member plays an invaluable role in how the inpatient environment works and how it is therapeutic for patients. The psychodynamic model is the best way to make sense of it. Even then it is not an easy job. Most hospitals use siloed management with every discipline under different administrators. There is no assurance that any of the administrators know as much about how to care for patients as the inpatient staff does. There is internal politics as well as the question about what happens when there is an inevitable staff-wide crisis. Examples of those crises include threats or violence against staff members, serious allegations against staff by patients or their families, and incidents resulting in patient injury. Many of these complications can be prevented by staff awareness of the involved psychodynamics that includes transference and countertransference reactions and defenses that are typically used by people with severe psychiatric disorders and their families.

I have seen psychiatrists operate at two extremes in the acute care inpatient environment.  At one end I would call it the old hospital visit model.  The assumption is that inpatient care is basically a side hustle and most of the serious work occurs in this physician’s outpatient practice or clinic.  They appear briefly early in the morning on the inpatient unit, talk to the patients under their care briefly, do not participate in any team meetings, and may or may not talk with nursing staff.  They may depend on nurses to call them at points during the day with progress reports and decide whether to make medication changes or discharge the patient.  Before a hospitalist model in medicine – this is how many primary care physicians worked as attendings at hospitals.  

At the other end is the full time attending.  The inpatient unit is his or her primary job.  They have daily team meeting with all team members in attendance and discuss progress as well as problems. Those problems can be at the level of the individual patient, their family, the staff, the administration, the probate court, outside consultants, law enforcement, and the physical environment. Team meetings are necessarily complex and in a less time environment rapid decision making is the rule rather than the exception. The schedule of when patients are seen depends on what happens in that team meeting.  Any acute medical or psychiatric problems take priority, followed by systems problems like conflicts between staff and administrators, followed by discharges.  That all happens before noon and individual patients are seen (along with new admissions) over the rest of the day. That is the most straightforward description of this model where most days are far from routine.

A psychiatrist operating in that second environment needs certain technical skills. Above all else – they need to be aware of their personal reactions to what is going on in the inpatient environment.  How much of that reaction is reality based and how much is based in countertransference?  I heard a quote recently from Kernberg where he said the most significant work of a therapist is to contain their countertransference aggression and there is no better place to practice that than an inpatient unit. The psychiatrist operating in that environment is often a flash point for scapegoating when anything goes wrong or even not as well as expected. During my tenure it was common to see psychiatrists blamed for being assaulted by patients, for not discharging patients fast enough, for ignoring nursing staff requests, and for being too authoritarian.  In todays overmanaged health care environment any one of those complaints can trigger a major investigation by hospital committees and result in reports credentialling agencies or medical boards whether they are factual or not. Controlling countertransference aggression in such an environment can be an impossible task.

Ideally the psychiatrist is in a role with reasonable team members and can interact with them in such a way they recognize their value.  That occurs by genuine active dialogue with them discussing patient care and any problems that the staff member might be having. This may seem obvious but it was not until my first few years as an inpatient psychiatrist that I realized the only reason my patients were in the hospital was that they needed nursing care.  I could do my 30–60-minute visits anywhere. The nursing staff was with them 24/7 and for clear reasons.  Other disciplines also need support form psychiatry.   Inpatient social work is a clear example.  The social workers I had the privilege of working with were all excellent and found themselves doing the impossible job of discharge planning.  They were calling 20-30 places a day for a single patients trying to get them out of the hospital (we rarely discharged anyone to the street).  That is a high stress situation especially when you have a supervisor asking you why you have not seen enough of the other patients.

All of these scenarios require a psychiatrist who can intervene supportively (education, encouragement, problem solving) and existentially (empathic listening and reflection) with fellow staff members.  That does not mean they are doing supportive psychotherapy with their colleagues.  It does mean that the genuine and human interactions they have with their valued coworkers may translate well into the therapy they are able to do to assist patients.  It may also lead to valuable insights like the one I had about the nursing staff. 

Additional chapters in this book provide good information on interacting with outpatient therapists and the importance of recognizing potentially disruptive defense mechanisms like projection, projective identification and splitting and how they can be contained on inpatient units. Containing countertransference aggression was emphasized especially because it can be magnified more in an inpatient setting where there are more possible recipients.     

The authors were generally confident about providing inpatient psychotherapy to a patients with a diverse number of conditions.  Some of the time frames discussed approximated 2 weeks and these days that is about a week longer than many these days. Some variables affecting length of stay (LOS) were not discussed.  The most important one of these is involvement in civil commitment and how that is handled. I looked at the issue on my unit and it added another 21 days and even longer after the State of Minnesota passed a law allowing county sheriffs to send mentally ill inmates directly to state hospitals on a priority basis. Like all inpatient factors it was a mixed blessing – more time for all therapies and recovery but the wrath of administrators blaming staff for not using enough medication fast enough, doing too many civil commitments, or not discharging unstable patients.

My approach in the inpatient setting was to have daily team meetings, engage my team in productive patient focused discussions, and see all my patients for at least 30 minutes a day.  I would also see family members at their request when they came in to visit or scheduled family meetings with or without my social work staff and at times nursing staff of they had available time.  I was very focused on the phenomenological-empathic approach to interviewing people with severe problems. I generally felt that patients realized that I was very interested in talking to them about more than symptoms.  Just that aspect had significant effects on people who were angry, non-disclosing, paranoid and accusatory, and used projection and splitting defenses. I was able to establish long term relationships with many people who were considered refractory to treatment and they were able to make progress.

Part of those discussions involved a detailed discussion of delusional thought content and how it was affecting their life. I commonly asked for their initial experience and the very first time they had those thoughts.  We would reconstruct that incident and discuss what happened as a place to begin.  From there we would discuss how these thoughts affected their relationships and ability to manage their lives.  I found that asking them about their theory of what happened or was happening to them was a useful question. Once their theory was discussed we could discuss whether they were aware of other possible theories to explain what happened.  This is a much better approach than getting into an argument of who believes what.  “Well, I understand you believe that!” is a judgmental rather than an empathic statement that simply states that you are not interested in what the patient has to say. 

Inpatient psychotherapy is also a place where competency can not only be emphasized but it may be critical for survival.  Exploring why a patient believes that they do not have diabetes or a fatal illness and trying to help them with a working solution is one example.  Working with them on how to avoid confrontations with the police is another. I have worked with many manic patients who found themselves in life threatening situations when they overestimated their physical abilities due to mania. And there are the more frequent discussions of how to avoid hospitalizations, how to manage severe psychiatric illnesses including suicidal thoughts and inability to function at times.

The thousands of discussions I have had with these folks over the years led me to the conclusion that supportive psychotherapy is the language of psychiatry.  On the inpatient unit it operates at multiple levels in a very high stress environment.  In the next few posts, I will look at more specific interventions.

The main theme I am hoping to stress in these posts is that no matter what you are going as a psychiatrist – a psychotherapeutic intervention should be part of it. It reminds me of a thought experiment one of my brightest teachers presented to ma as we were talking after clinic one day:

“OK George - suppose you are out there as a psychiatrist for a few years and you are at a party.  A woman comes over to you at that party that you don’t know and starts to make small talk. Are you thinking like a psychiatrist or not?”

The tenor of these posts should suggest the answer…..

 

George Dawson, MD, DFAPA

 

 

References:

1:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. 1993.

This is a 1993 publication so I am not recommending it at this point. It is a good outline of necessary psychotherapeutic concepts but is not long on specifics apart from some vignettes.

2:  McHugh PR. William Osler and the new psychiatry. Ann Intern Med. 1987 Dec;107(6):914-8. doi: 10.7326/0003-4819-107-6-914. PMID: 3318611.

3:  Silver PA, Goldberg RL.  Integrating Somatic and Psychological Treatment in Inpatient Settigs. in:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. pp: 23-38.