Hospitalization or inpatient care is the most restrictive form of treatment for a psychiatric disorder, addictive disorder, or for someone with more than one diagnosis . Whether it is voluntary or involuntary, the patient relinquishes the freedom to move about and, once admitted, becomes subject to the rules and schedule of a treatment environment. Hospitalization is necessary in cases where an individual is in imminent danger of harming himself or others or has made a suicide attempt. Crisis stabilization, behavior modification , supervised substance abuse detoxification , and medication management are compelling reasons to consider hospitalization. Ideally, hospitalization is at one end of a comprehensive continuum of services for people needing treatment for behavioral problems. It is generally viewed as a last resort after other less restrictive forms of treatment have failed.
In order to be admitted to a hospital, a medical doctor (in the case of mental health, most often a psychiatrist ) must "admit" the patient or approve the patient's request to be admitted. Although hospitalization may be considered a drastic treatment intervention, it can be essential in keeping people safe, helping monitor and adjust medications, treating medication side effects, supervising alcohol and/or drug detoxification, and stabilizing a patient after an acute psychiatric episode.
Before an individual is hospitalized, an evaluation and a diagnosis must be made by a medical professional. This is required in order for the patient to receive maximum insurance coverage and to receive the most appropriate treatment.
In the public mental health system, less restrictive forms of treatment other than hospitalization are strongly recommended first. In the late 1960s the patients' rights movement led to reforms governing involuntary hospitalization . Today the criteria for admission, particularly in the case of involuntary hospitalization, are extremely narrow, reflecting a strong reluctance in this country to infringe on any person's liberty. The unintended consequences of this public policy are often observed in the numbers of people with mental illnesses who are homeless. So long as they are not posing a danger to themselves or others, they are likely to remain outside the traditional treatment system.
Hospitalization has long been negatively characterized in the media, contributing to the stigma of seeking inpatient treatment, even when it is voluntary. Scenes from the 1975 movie One Flew Over the Cuckoo's Nest have defined the worst in psychiatric hospital treatment. Such conditions cannot exist long in today's more sophisticated mental health, consumer-focused environment. A reputable facility will be accredited by the Joint Commission on Accreditation of Health Care Organizations, or by a similar governing body, which usually assures a minimum level of service. Most hospitals now have a Patient Advocate, usually an attorney who is on-site daily, or accessible by phone, and whose job is to investigate complaints and protect a patient's rights. In addition, a federal law mandates that every state have a Protection and Advocacy Agency to handle complaints of abuse in hospitals. While their effectiveness varies from state to state, they can be helpful in explaining the rights of a hospitalized patient. Some states have also implemented ombudsman programs to address patient complaints and to help people negotiate the mental health system.
Treatment facilities may be locked or unlocked. A locked unit will have tighter security to protect patient privacy and to keep patients from running away. In most cases when a patient is voluntarily admitted, he or she may leave treatment at any time, invoking the right to do so against medical advice (AMA).
In the past, patients were often not part of their own treatment planning process. The rise of the patients' rights movement has led to more active patient involvement in all phases of treatment. They have the right to refuse certain forms of treatment. Most hospitals now have a clearly posted Patient's Bill of Rights and may also have a patient's council or other body to represent their interests and recommend changes to the inpatient environment.
Confidentiality is paramount in a hospital setting, so much so that hospital staff seldom acknowledge that a specific patient has been admitted. Group therapy rules generally stress the importance of keeping members and the content of group sessions confidential.
Most hospital rooms are similar to basic hotel rooms and are generally large enough for two people. In the case of public hospitals, the rooms may be larger and contain more beds. Men and women are in separate wings or on separate floors. If a treatment program is housed in a medical hospital, it may cover one or more floors.
While there is wide variation in the quality of the physical surroundings and the resources available, most inpatient facilities are highly regimented. Patients get up, go to bed, eat, and take medication (if indicated) on a regular schedule. Days are filled with scheduled activities such as individual, family, or group therapy, expressive and occupational therapies, psychoeducation, recreation, and, in the case of children or adolescents, several hours of school.
Most hospital inpatient programs are based on a therapeutic milieu, which means that all the people involved in the patient's care and all the activities are designed to have a therapeutic function for the patient. For example, direct care workers are not simply aides, but they are supportive of the patient and provide valuable feedback to the physician, psychologist , and social worker about the patient's conduct and progress.
Even voluntary hospitalization can be overwhelming and anxiety-provoking. As a result, when first admitted, a patient will be closely observed by the staff. If the patient was admitted because of a suicide attempt or a violent episode, a "suicide watch" may be set up with more intensive staffing or in a room that can be monitored easily by nursing staff.
As the patient adjusts to the hospital routine, more privileges and freedom will be made available. For example, a patient may earn privileges or rewards like outings with staff, a weekend pass to go home for a visit, or some other positive consequence if he or she follows hospital rules and engages in therapeutic activities.
An interdisciplinary treatment team made up of a psychiatrist, psychologist, social worker, nurse, direct care worker (sometimes called a psychiatric technician), and an expressive therapist usually oversees a patient's care while he or she is in the hospital. Treatment goals are developed by the team with patient input, with discharge as a major objective.
Optimally, inpatient treatment prepares a patient to deal with the realities of life outside the hospital. Emphasis is placed on how a patient will behave differently in order to remain healthy and avoid future hospitalizations. During the discharge phase, a patient may be scheduled for outpatient therapy and informed about various medications. Often, a patient experiences anxiety at the thought of leaving the hospital, and this apprehension is addressed in therapy sessions as discharge nears.
In the past, a patient might be admitted to a hospital for a minimum of 30 days. Today's rising health care costs and the prevalence of managed care have led to dramatically reduced hospital stays. An optimal outcome under these conditions is medication adjustment, monitoring, and the beginning of stabilization. Studies are underway to determine if shortened stays ultimately lead to more frequent hospitalizations later.
National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. <http://www.nami.org> .
National Association of Protection and Advocacy Systems. 900 2nd St. NE, Washington, DC 20001. <http://www.napas.org> .
National Mental Health Association. 1021 Prince St., Alexandria, VA 22314. <http://www.nmha.org> .
National Mental Health Consumers' Self-Help Clearinghouse. 1211 Chestnut St., Suite 1207, Philadelphia, PA 19107. <http://www.mhselfhelp.org> .
Judy Leaver, M.A.