Reconceptualizing Stabilization for Counseling Adolescents in Brief Psychiatric Hospitalization: A New Model

The efficacy of psychiatric hospitalization, particularly for children and adolescents, has been widely debated within the counseling profession. "Little comprehensive or systematic research has been conducted on the experiences of the psychiatric hospitalization of young people" (Molar, 1998, p. 5). Most outcome studies appeared to be in the context of residential treatment settings, in which adolescents were in treatment for approximately 30 days or more, as opposed to acute care programs with an average length of stay of 5 to 7 days. When an adolescent reaches a point in which safety is compromised, such as when a client is in danger of harming self or others, a crisis situation develops and inpatient psychiatric hospitalization may be necessary. The American Academy of Child & Adolescent Psychiatry (1996) defined such an intervention as a crisis residence. A crisis residence, also known as an acute care psychiatric program, is short-term (usually fewer than 15 days) crisis intervention and treatment in which clients receive 24-hour-per-day supervision. Over the past decade, acute care programs have changed in response to managed care; length of stay has decreased from 3 to 4 weeks to approximately a week (Heflinger, Simpkins, & Foster, 2002). As a result, the role of psychiatric hospitals has changed. Whereas hospitals were initially geared toward making a significant impact in addressing treatment issues, hospitals appear to be more focused on stabilization--ensuring that the client is safe from harming self or others (King, Hovey, Brand, & Ghaziuddin, 1997). Typically, hospitals have been dependent on third-party payers to identify when a client is stabilized or have allowed third-party payer guidelines to dictate when a client should be stabilized. Rinsley (1990) described the trend of shortened hospitalizations as the "phenomenon of de-institutionalization" and identified this trend as dangerous to clients because of the "revolving door" and "patch and dismiss" approach to psychiatric care (p. 10). High rates of readmission to inpatient care may have actually added to the expense of insurance and treatment paid for by insurance companies. Clients are typically discharged from the hospital when they no longer meet the requirements of acuity. When clients have verbally committed to having no intention of harming self or others, they may be considered stabilized and no longer in need of hospitalization. Because of the emphasis on client symptoms as the sole indicator of client stabilization by third-party payers (Bronfman, 1999), processing coping strategies and committing to follow-up may not have been considered essential in the process of stabilization. Clients may be discharged into the same situation that brought them to the hospital. Without any coping strategies in place, relapse to previous high-risk behaviors is highly probable (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001). We proposed a model to reconceptualize stabilization for counseling adolescents to include a three-step goal-attainment process: (a) The client identified the problem(s) that resulted in being hospitalized, (b) the client processed relevant coping skills to the identified problem(s), and (c) the client committed to follow-up. This new model incorporated the development of problem solving and coping skills in clients to promote client stability. Nystul (1995) proposed a problem-solving approach that enhanced counseling services by emphasizing the goal-directed nature of behavior and by providing a systematic method of identifying problems and implementing coping strategies. Because of the short-term nature of acute care hospitalization, such an approach, if successful, could be easily implemented into programs. The need for follow-up, defined as the necessity for continued intervention in a less restrictive environment, has been identified in research (Collins & Collins, 1994; Cornsweet, 1990; Pfeiffer & Strzelecki, 1990). …