Transitions in Psychiatric Inpatient Clinical Social Work

Because of the accelerating costs of hospital care and administration and increased competition, length of stay in psychiatric hospitals has dropped precipitously since the mid-1980s. Third-party payers, both public and private, have been unable to cover protracted hospital stays (Graham, 1991b); as a result, preferred provider organizations and managed care companies have proliferated and insurance benefits have decreased (Cummings, 1987; McGuire & Dickey, 1985; Perry, 1991). Every mental health professional has had to adjust to these economic changes (Behar, 1990; Keeneo-Osborn, 1991). Inpatient psychiatric clinical social workers, because of their traditional role in disposition and family work, have been particularly affected, and many have been laid off because of program cuts (Farley, 1991; Graham, 1991a). Other social workers have had to make major changes in what they do on the job and have had considerable responsibility for implementing the changes. The nature of the changes and how social workers have coped was the focus of a descriptive exploratory study described in this article. Method Twenty-seven psychiatric inpatient clinical social workers participated in personal interviews with the author. Structured interview questions asked the social workers about their perception of the degree of decrease in length of hospital stay from 1989 to 1991; what they were doing differently clinically to accommodate the accompanying changes; and what effect the changes had on their relationships with the interdisciplinary team, patients, and families. Unstructured open-ended questions were asked about their feelings about the change, the stresses they had experienced, and what they were doing to cope with the stresses. Also elicited were their thoughts about the future of their jobs and social work as a profession. The social workers were from nine of the 12 psychiatric hospitals in the Denver metropolitan area. Social workers were not interviewed from a large state mental health institution, the largest employer of inpatient clinical social workers in the area. This institution had reported a slight increase in length of stay over the past two years. One private hospital's social workers had been working less than two years and had not experienced the change in climate. The city-county hospital, traditionally a crisis facility, also had no appreciable change in length of stay. Only four social workers from the nine hospitals surveyed were not interviewed because of time and availability restraints. The 27 workers interviewed represented 87 percent of the total inpatient social worker work force from these settings. Table 1 describes the type of institution and the units where the survey social workers worked. The workers had an average of 10 years of postmaster's clinical social work experience, with a range from 2.6 years to 29.0 years. Four years was the average time in inpatient work, with an average of 2.5 years on the current job. Extent of Change The definitions of long-term and short-term hospitalization changed dramatically from the social workers' perspective between 1989 and 1991. Although much can be clinically argued for or against a decreased length of hospital stay, the length of stay has changed not because of any change in philosophy or innovative treatment discovery, but rather because of payer capability. Goals, Modalities, and Techniques The social workers defined their short-term work as focused, directive, and confrontational. The work is very circumscribed around a crisis event or a particular behavior or management issue. Table 1 Institution Type and Population of Social Workers Interviewed Chemical Institution Type Adult Adolescent Child Dependency Total For profit 4 1 -- -- 5 Nonprofit 4 7 7 1 19 State 3 -- -- -- 3 Total 11 8 7 1 27 The goals of hospitalization are stabilization or return to prehospital state, rather than definitive change. …