Partial hospitalization: when office visits aren’t enough
While Nathan was in high school, I’d occasionally drive past the Loma Linda University Behavioral Medicine Center (BMC) on my way to somewhere. And I would think, “However bad things have gotten with Nathan, at least we haven’t had to go in there.” Which was a foolish thing to think, because the day came when he did have to “go in there”. I’ll share our experiences to give you a sense of what can happen if your teen has to “go in there,” or a place like it.
Here’s how it started: earlier that year, Nathan had been seeing a psychiatrist whose appointments were ten minutes long: how are you doing, are you taking your meds, here’s another prescription, see you next time. Hoping to find a provider who could spend more time on the puzzling and sometimes frightening things Nathan was doing and feeling, we put him on a waiting list in March for any adolescent psychiatrist in the Loma Linda University Medical Center system. A slot opened up in September, and he started appointments with Dr. A, who was a great fit for his needs. She was also one of the few people on the planet that Nathan felt comfortable talking with. We were hopeful. (Note: she apparently is no longer on staff there.)
During Nathan’s December appointment, I saw Dr. A hurry down the hall. She looked a little rattled as she poked her head in the waiting room: “I just want to get the senior psychiatrist’s opinion on something. He’ll be talking to Nathan for a few minutes.” At the end of the session Dr. A brought me into the office for a brief chat as usual. This chat was serious. “Nathan has shared a few things that have me very concerned. Dr. Murdoch agrees with me that Nathan would benefit from going into the Adolescent Partial Hospitalization Program at the Behavioral Medicine Center. That way, several clinicians would evaluate him and give their opinions, and Nathan could get a big dose of therapy all at once. One or two office sessions with me every month will not get us very far very fast.”
We were given some literature and some time to think about it. The program is designed either for teens who have just been discharged as an inpatient, or to prevent the need for them to be admitted as an inpatient. The program was Monday-Friday from 8 to 3, for two to three weeks depending on his rate of progress. At this time of year, we could schedule at least part of it during Nathan’s Christmas break from school.
We decided to do it, for the chance to quickly gain understanding of what Nathan’s troubles were. (This was the same thinking we had used in having a SPECT brain scan done at the Amen Clinic the year before.) Nathan had many diagnoses, but whether taken alone or together, they didn’t seem to fully account for what was going on – and his thoughts were getting darker, threats stronger, behavior either more aggressive or more withdrawn. We had safety concerns.
Once we decided to go ahead, we had to pursue pre-authorization from our health insurance. There was a lot of back-and-forth between us, our insurance company, and the BMC, but we finally got it sorted out.
Nathan was generally negative about going, but that was his reaction to most things in life. His first day at the BMC happened to be December 31. As parents, we had to stick around on the first morning for intake questions. There was a long wait in the hall before anyone could attend to us (they were probably short-staffed due to the holiday), which increased Nathan’s irritability. By the time the intake was done and we left him with the staff, his anger was simmering. The situation was upsetting for all of us: I remember getting to work and venting to a coworker as I consumed half a bag of “reindeer poop” (the time-honored “chocolate-as-therapy” approach).
I returned to the BMC at 3:00 that day to pick Nathan up. You can’t just walk in: first you stop at the reception desk in the lobby, where they verify the name of the patient, your relation, and the reason for your visit. You are issued a sticker to wear. To get any further, you have to wait until the receptionist buzzes open the door that leads to the rest of the facility. Then it’s down a long hall past the cafeteria, around a corner to the elevators, and up to the second floor. The partially-hospitalized patients are in a separate area from the inpatients.
A counselor was waiting for me at the elevator and pulled me aside. It turns out Nathan had intended to walk out the door at lunchtime, and had gotten even angrier when he learned that he was locked in. Also, there was a Safety Contract (about not hurting oneself) that all participants had to sign on the first day. Nathan had refused. The counselor explained to me, as he had to Nathan, that they could not let him leave if he didn’t sign it – Nathan would have to become an inpatient.
The counselor brought Nathan over. We had a stand-off in that hallway for about 15 minutes before Nathan finally relented and signed the contract. The ride home was not pleasant.
The program was closed on New Year’s Day. In a way, it was probably a good thing for Nathan to have a break after that near-disastrous first day. We gave him as much space as possible, and hoped he was not plotting ways to get out of going back.
To our relief, he did go back on January 2nd, without much problem.
Nathan hated the program less intensely as time went on. The days were a mix of goal-setting, keeping a journal, one-on-one therapy, group discussions with peers, and lunch and snacks. He didn’t do well in the peer groups, since “these stupid kids” had no right to comment on his behavior and beliefs, and he certainly didn’t care about their problems. With kids being admitted and discharged as needs dictated, the group was ever-changing – but there was a cap on the maximum number of teens at any given time (it may have been around 12 or 15).
There was a dress code, and a list of items the teens could not bring (cell phones, MP3s, sharp metal objects, nail polish, …). The teens were checked for these items every morning on arrival, and had to turn their pockets inside out.
Once school had started again after New Years, I called in Nathan’s absence to the attendance office every morning. After a while, Mr. F (Nathan’s special day class teacher) told me to stop calling the office and just let him know when Nathan might be returning. Attendance policies might differ, so check with the school and your teen’s teachers about how the absence will be handled. Sometimes teachers will provide packets of work for the student to complete before returning to school.
Occasionally Nathan would be seen by one of the psychiatrists on staff (including Dr. A a few times). On days he’d seen a doctor, at pick-up time I might be handed an envelope with a prescription to fill, or a request to bring certain clinical records. If the doctor was available at pick-up time, we were sometimes able to have a discussion, with a disinterested Nathan present. One day toward the end of his time in the program, he was taken off-site to get a psychological evaluation.
Toward the middle of the second week, Nathan began to trust the counselors and his peers, and he started to participate more. At the end, he even had developed a fondness for the people in the program. (That was an impressive change from where we started!)
Once Nathan passed the two-week mark in the program, we started to wonder each day if he would be discharged. The counselors would give my questions a wait-and-see answer. Finally, one of them was able to tell me that Nathan had made progress: he had agreed that his own life might have some purpose, that other people’s lives might have purpose, and that graduating from high school on schedule is something he could do. This qualified as enough progress for him to be released from the program.
But we weren’t done with the BMC. Nathan’s discharge instructions said he was to attend the Adolescent Intensive Outpatient Program, which involved therapy three days a week from 3:30 to 6:30 pm, for an undetermined length of time. Our experiences there will be the subject of another post (or two).
Did we gain the understanding we sought? Not so much into Nathan’s condition, but into the reality that he presented a difficult case even for the competent, experienced staff at the BMC.