Author Alan Lakein once said, “Planning is bringing the future into the present so that you can do something about it now.” When it comes to acute psychiatric care, all members of the treatment team know their roles; they are experienced and are able to quickly assess and adapt general treatment plans to a wide assortment of clinical admitting diagnoses. In a perfect world, every patient could be admitted, stabilized, and sent home with no fear or relapse in 3 days time. However, the world is not perfect and no matter how well-thought out the basic plan of treatment, there will always be unforeseen factors and limitations that must be taken into consideration to create the best possible outcome for the patient.
Limitations to ideal treatment come in many regularly seen forms: intellectual, emotional, chronological, financial, and environmental. A truly experienced treatment team has encountered these limitations time and time again and has developed their own preferred methods to help the patients navigate around these road blocks, as well as teaching them how to navigate them on their own once they discharge.
While some patients may be highly intelligent and functioning, it may not necessarily be the case for all patients. Unfortunately, there are many who have not developed the expanded reasoning so that they are adequately equipped to manage the stressors of life. For some this might be educational, for others it might be in relation to IQ level, or emotional readiness. It becomes important for the therapists to understand the nature of these limits so that they are able to adapt different therapeutic strategies to help the patients develop coping skills to manage these stresses. It might be a treatment plan that is more basic and focuses on simple skills like expressing feelings in a different way, or using a context that the patient is more familiar with in order to draw a parallel by example. In group therapy, this patient may also benefit from sessions with an alternative group rather than a main group who may be talking about concepts over that person’s head.
A frequent limitation is the outside environment. Some patients, when admitted, seem perfectly stable and adjusted because they are living in a highly controlled environment and able to leave the stressors of the real world on the other side of the door. Without preparing them on how to handle these stressors, they may become rapid re-admissions quickly after being discharged. While the treatment team has an influence of the patient, they typically have no influence over the patient’s outside factors. So it is vitally important for the team to keep this into consideration when developing a lasting plan. If patients lack transportation, they are unable to make appointments. If patients are being abused, and that situation is not dealt with appropriately, then nothing has changed. The treatment team will work with outside agencies such as protective services and caseworkers to enact a plan of action to manage these external influences.
On a long enough time scale, any team could take a patient from unstable to stable. The trick is discerning what is most therapeutically needed into the reduced time frame that is covered by insurance. Many patients have limited funds or are lacking them all together. If finances are the impetus for their admission, adding to that debt in exchange for services becomes a risky gambit. The treatment team understands that accurate documentation allows the doctor more options to negotiate for coverage on behalf of the patient. In expressing the dire need of acute care and the likelihood of failure if cut short, the team is able to advocate for coverage and time, allowing the patient more opportunities to gain tools for success.
Many times, the doctor may know that for the patient’s condition, a specific medication has a high degree of success. Yet, there is no purpose for the doctor to start the patient on a medication that he or she could not afford after discharge. So the doctor must have a general idea of which medications are covered by which insurance companies. Some will only authorize generic while others will only authorize brand medications. In truth, the generics and brand medications are not always the same as there are often different standards in clinical efficacy. So it isn’t as simple as saying “if not this, than that will work.” So the doctor must stay educated on the most recent studies and data of all medications if he or she is to provide the best care within the limitations.
While there are times that many of these limiting factors can seem insurmountable, there is always a way around them. It just takes a seasoned team to know the hidden paths and tricks to help deliver the best route around them. So too does this experience in dealing with these limitations further allow the health care professionals further refine what is most appropriate for a successful stabilization.
By Sajid Hafeez, M.D.