March/April 2012 Issue

Residential Treatment — When to Consider It, What to Look For
By Michael Brodsky, MD
Social Work Today
Vol. 12 No. 2 P. 8

One mark of a seasoned psychotherapist is the ability to discern when a higher level of care is needed to help keep clients safe, ease them through an acute crisis, or manage worsening psychiatric symptoms or dysfunction. Most clinicians are familiar with the indications for acute inpatient psychiatric hospitalization, which include acute danger to self or others or the grave inability to provide adequate self-care.

More ambiguous and less apparent are the indications that a patient may benefit from a treatment setting that is more intensive than multiple outpatient sessions per week yet less intensive and restrictive than inpatient hospitalization. There are three major treatment modalities that fall within the middle ground between pure outpatient and pure inpatient treatment: intensive outpatient programs, which typically involve multiple extended sessions per week of varying treatment duration and format; partial hospitalization programs, in which patients spend most or all of their daytime hours in specialized programming but return to their homes overnight and on days off; and residential treatment centers, where patients are housed and supervised around the clock while they receive treatment and observation for periods ranging from weeks to months or even years.

This article focuses on residential treatment options for adults with primary psychiatric illnesses.

Indications for Residential Treatment
Neither the psychiatric nor the social work literature contains well-established formal guidelines about the indications for referrals to adult residential treatment. Generally speaking, patients enter residential treatment in acute or subacute crisis situations during which their needs are too intense to be managed with outpatient treatment but which do not rise to the level of severity requiring inpatient treatment.

Some patients are referred to residential treatment following a period of inpatient hospitalization. Patients who are deemed to no longer be a danger to themselves or others, but nevertheless remain too impaired to live independently, may spend periods of recovery in residential settings. Typical patients for whom such a “step-down” strategy is used include, for example, patients recovering from a first episode of psychosis or mania who require additional supervised time for psychosocial adjustment and treatment planning.

Another category of patients who go to residential treatment following an inpatient hospitalization includes those whose psychosocial recoveries from an acute exacerbation of mental illness are complicated by physical disabilities such as paraplegia or cerebral palsy. Much more common than these step-down referrals to residential treatment, however, are referrals originating from outpatients and outpatient clinicians. Many such referrals from the outpatient realm share one or more of the following attributes:

• Outpatient treatment has failed to contain the symptoms or ameliorate the impairments in social and occupational functioning that accompany the patient’s mental health condition. Increases in the intensity and/or the frequency of outpatient contacts have not stemmed the tide of distress and dysfunction.

• Available emotional resources for support from psychotherapists, psychiatrists, friends, and family systems have become depleted or drained—sometimes for reasons entirely unrelated to the patient’s mental condition—leaving the patient with inadequate networks of support on which to rely on during periods of heightened symptomatology or psychosocial stressors.

• There is no clear indication for acute inpatient hospitalization.

• There is considerable diagnostic ambiguity that may be clarified or eliminated by regular or round-the-clock behavioral observations in a controlled environment—for example, to determine whether a behavioral disturbance is more properly attributed to a rapid-cycling mood disorder or to concealed substance abuse.

• There are safety issues, such as escalating levels of substance abuse, disordered eating or purging behaviors, or self-injurious behaviors, that may be reduced in a controlled (but not necessarily locked) treatment milieu that features round-the-clock behavioral observations.

Matching of Facility Resources and Patient Needs
Once the decision is made that residential treatment is a useful treatment modality to consider, patients and their clinicians face the formidable task of selecting among the myriad facilities that advertise nationwide. As is true between patients and psychotherapists, the goodness of fit between patients and residential facilities is essential to optimizing the chances of a favorable outcome.

Like therapists, residential facilities vary widely in their goals, their theoretical orientation and treatment paradigms, and the specific features of their treatment settings. Patients may gravitate toward the relative intimacy of four- to six-bed facilities housed within single-family residences or they may lean toward larger institutional facilities housing dozens of patients on bigger campuses.

Residential treatment centers also vary widely in their geographic distribution, cost, emphasis on amenities, emphasis on group cohesiveness within the milieu, and length of stay. The expected or typical length of stay also varies widely among residential treatment facilities. Many facilities recommend minimum lengths of stay of between one and three months. A few facilities have lengths of stay that range from six months to two years or more.

Social workers and clients seeking markers of quality are urged to ask many questions before committing to a particular program. There are no standardized or nationwide ratings of residential programs, and the process of evaluating programs is complicated by the fact that many facilities compete for the same pool of patients. Generally speaking, high-quality residential treatment facilities will have in common the following characteristics:

• Accreditation and/or licensure: High-quality residential facilities tend to subject themselves to scrutiny and oversight by state licensing authorities or other entities providing accreditation for healthcare organizations. Such licensing and accrediting authorities tend to require strict standards for evidence-based care, documentation, medication storage and handling, and other key aspects of residential care.

• Fully credentialed staff: Practitioners who work in residential facilities must be sensitive not only to the dynamics of each individual patient but also to group dynamics, the dynamics of conflicts between staff and patients and, perhaps most importantly, the often-subtle indications that a patient may be decompensating and in need of more intensive monitoring or even acute hospitalization. Prior experience in inpatient facilities can be quite helpful for residential facility staff members.

• Capacity to increase staffing acutely: Residential facilities with flexible staffing capacity can respond to the fluctuating levels of acuity within the treatment milieu. Effective treatment centers have the ability to “staff up” to the meet the needs of sicker or more agitated patients who may require more intensive monitoring (e.g., on a schedule of wellness checks every 30 minutes, every 15 minutes, or even continuous one-to-one observation). Such capacity not only protects the individual patient but also helps ensure that the affective environment of the treatment milieu can be modulated by the presence of additional staff members as warranted.

• Ready access to urgent and emergency care facilities: Accidents happen and so do intentional acts of self-harm. Residential facilities that have working relationships with local hospitals and urgent care facilities are well positioned to transition patients in crisis to a higher level of care with a minimum of disruption to the milieu.

Outpatient Therapist and Residential Treatment Team
The outpatient therapist of the patient referred for residential treatment has a key role to play in helping ensure a positive outcome. The therapist is likely to be the most reliable informant of the patient’s preadmission functioning and symptoms and is likely to have a prioritized list of the most urgent symptoms in need of assessment and treatment. Therapists are typically contacted within 24 hours of admission to a residential treatment facility for this reason. Many outpatient therapists wish to remain apprised of their patients’ status; some will be interested in phone contact or in-person visits with the patient; and a few will be interested in continuing a direct psychotherapy role throughout the period of the residential stay. The last of these roles is not always permitted by individual treatment centers, but it does not hurt to ask.

Residential facilities tend to have a fairly flat administrative hierarchy, with the work of primary therapists and/or psychiatrists supervised by a clinical director and/or a medical director. Outpatient therapists should clarify at an early stage which member of the residential treatment team should be the primary contact person. On rare occasions, communication with outpatient therapists may be delayed by patients who are ambivalent about authorizing the release of information to outside parties. In these circumstances, residential staff will tend to work rather intensively to persuade the patient that the quality and continuity of their treatment is optimized by open communication among all involved clinicians.

Planning for aftercare is likely to begin soon after admission, although in some cases will be delayed by the need for diagnostic clarification. Outpatient therapists should always be included in the aftercare-planning process, and usually this inclusion can be accomplished by phone or e-mail without the need for therapists to attend meetings in person. If all goes well, the residential stay will preclude the need for inpatient hospitalization, and the patient will be ready to return to outpatient treatment following discharge. A small minority of patients elect to remain in contact with the clinicians who treated them during their residential stay, but most patients do not.

Residential treatment represents just one of the higher levels of care available to therapists whose patients have a worsening clinical course, but it is a valuable one to consider when inpatient admission is not warranted and when the patient would be well served by living temporarily in the same setting in which they are receiving treatment.

— Michael Brodsky, MD, is the medical director of Bridges to Recovery, a private residential treatment center in Pacific Palisades, CA, and a member of the teaching faculty of the psychiatry department at UCLA.