Psychiatric Hospitals and Homelessness

Hello “FriendtoYourself Community”!

Have you ever heard of a day hospital? In the psychiatric treatment options, the day hospital is a gem. Sometimes it is known as a “Partial Hospital Program”, or PHP. This hospitalization is called a “step down unit” as well and is classically where people go when they need more than typical outpatient care with either or both of a psychiatrist and a talk therapist, but they are not needing full inpatient care in a hospital where they stay overnight. In my community, one of our hospitals is working to develop a day hospital program.

I’ve been asked about my experience with patient’s of whom I’ve referred to psychiatric day hospitals. “They” want to know about the demographics of whom I send, why the patient’s go, and their outcomes. They have a concern that by providing day hospital care, it puts the community at risk for increasing homelessness. You can see the pavers span a distance before arriving at that conclusion but it is understandable if we walk. Fears are important. None of us are above them.

Oftentimes, patients on initial evaluation come to me in crisis because they wait. They prefer to try anything else before seeking help, even resorting to unconventional methods. There has to be something in their life that pushes them to the point of willingness to see a psychiatrist. They come to me when it’s either see me or go to a psychiatric inpatient hospital bed. They may not qualify for a 5150, (a legal hold when someone is danger to self, danger to others, or gravely disabled – unable to provide food, shelter, or clothing for themselves). Yet although they are not disabled, at that time in their illness, I may still not be the best match for their medical care.

Outpatient clinical psychiatry is for people not in crisis. If you’re having an emergency, you should not be in my office. My outpatient clinic is not equipped to deal with emergencies, aside from being able to call law enforcement. For those in a psychiatrically fragile condition, they need more. In outpatient clinics, there are fewer allowances for this.

So, it was with Anna. Seeing a psychiatrist was the very last thing she was willing to do to get better.

People like Anna come to me at a critical juncture in their life. It’s a choice between visiting me or heading to the emergency room.

Let me introduce you to her. Anna is a 38 year-old mother of three. She’s been married for 15 years and comes from a family who survived their own depressive mother and a father who excessively drank alcohol. Her mother parented in the ’70s and ’80s when there were not many options for her. Her mother had tricyclics and MAOI‘s until Prozac came out in 1987. It was a different world of understanding mental illness and being able to treat it. Anna and her three siblings grew up with a depressed mother and an alcoholic father. Depression is contagious. So, Anna grew up with a household of depressives. Not only is it impossible to live with depressives without getting depressed, but she also had the added burden of her genetic loading written into her DNA. She was at high risk of developing depression herself.

In high school, Anna met her first and last boyfriend, Dave, and she thought he was everything; religion, hope, and fresh backed cake. They went to college together, moving in their freshman year and dropping out when she got pregnant. They had an active life before pregnancy, going out all the time and having common interests. They were best friends. It was the happiest time of her life. Then, when the babies came, life became more difficult. Dave started using drugs and alcohol, and they hadn’t had sex in eight months. They were not connected, and Anna found herself really loving her kids but not liking them. She could hardly stand listening to them cry. Their needs, as expressed through their angry voices, pulled on her viscerally. She felt like she was losing her mind.

Now, her children were irritable, and in this next generation, the contagion of Anna’s depression spread through the family. You can trace, now, three generations have suffered because the biological was never treated. The psychological and the sociological followed and also became misaligned.

When Anna first came to me, I was actually happy because she was entirely treatable and had huge resources that she hadn’t yet accessed. I knew Anna had this coming, and I was happy because she was totally treatable. My heart also broke to see something that was so treatable savage three generations.

Even so, I knew that the outpatient clinic was not the best treatment for Anna because, in outpatient clinics, the services we offer people in crisis are not the best for them. Anna was in crisis. She was having morbid thoughts that life wasn’t worth living. Her whole family had become emotionally ill in the context of the contagion of her depression. And she felt like she was losing hope. This was a higher level of care than what I could offer in the clinic.

In an outpatient clinic, I don’t generally see people more frequently than every three to six weeks. Anna needed to be seen much more frequently, especially in the short term while her medications were established and had time to take effect. She needed intensive therapy, more than what outpatient therapy could offer and intensive enough so that it could actually reroute the way her automatic thoughts traveled in her brain. She needed intensive dialectical behavioral therapy that helped when something triggered her mind, and the electrical conduction traveled across her neurons; then it actually chose a better pathway.

When a patient like Anna comes to see me, I refer them to the outpatient program, a higher level of care than what I can generally offer as an outpatient clinician. You can see the reverse of this as well. When a patient stabilizes from an inpatient psychiatric hospitalization, then they should be referred to an outpatient hospital program rather than to my clinic. This outpatient hospital program in this scenario is called a “step-down program”, one that allows them to continue the healing with intensive and close follow-up; (generally 5 days a week for 4-12 weeks). We call this a step-down program or a step-up program, depending on which direction the patient is coming from.

I’m happy to report that Anna went into the outpatient hospital. After nine weeks of intensive psychotherapy with weekly physician monitoring of her medication, medication adjustments, having a nurse available to her five days a week, having an individual psychotherapist assigned to her, as well as attending groups every day, I am so happy to say that Anna is back in our community. She’s back at home with her kids, and stable on medication. Her illness, her biology is healed, and now her family is starting to heal.

In fact, Anna is able to work again. She is a certified ultrasound technician, and she’s now helping to support her family. She and her husband are healing together; he is now in treatment as well for his alcoholism and no longer uses drugs to escape. And you can see how close it was for Anna to lose everything. She almost lost her family; she almost lost her capacity to be gainfully employed and contribute to her community. She almost lost her marriage; she almost lost everything that she considered worth living for. Now she has it back. It’s humbling, and now I see her in the clinic every 4 to 8 weeks depending on her needs. Sometimes we go 12 weeks because she’s stable. I always know when somebody’s stable because they really don’t want to see me that often.

And every time I see her, I really wish I could see her more often. It’s the bummer of being an outpatient psychiatrist.

Self-Care Tip: Go get medical care for emotions and behaviors that aren’t working out before they escalate. Sooner is better! And if you don’t, just go as soon as you are ready. Just get in. Keep on!

Question: Have you every gone to a day hospital? What is your opinion of having these in your community? Speak! We need to hear you.

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