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Decision tree for the management of substance-abusing psychiatric patients
Journal of Subslance Abuse Treatment, Printed in the USA. All rights reserved.
Vol. 9, pp. 215-220,
1992 Copyright
074&5472/92 $5.00 + .OO 0 1992 Pergamon Press Ltd.
ARTICLE
Decision Tree for the Management of Substance-Abusing Psychiatric Patients
JOANNE
INTRATOR,
MD,*
EDWARD
ALLAN,
MD,?
AND MARC
PALMER,
BFA$
*Department of Psychiatry, Bronx VA Medical Center, Bronx, New York TDepartment of Psychiatry, FDR VA Hospital, Montrose, New York SAmbulatory Care, FDR VA Hospital, Montrose, New York
Abstract - This paper describes a short-term approach developedat a time of numerous drug-related incidents occurring at a large VA Hospital to help staff managepsychiatricpatients abusing alcohol or drugs during hospitalization. This was accomplished through the development of a decision tree designed to improve the clinical problem-solving process by identifying key decision points. Prior to this, staff responded emotionally either by prematurely discharging patients or by not recognizing the problem at all. Decision Trees have widespread applicability for resolving complex clinical problems.
Keeords-
decision tree; dual diagnosis; algorithm; mentally ill addicts; addiction and mental illness.
the direction of greater numbers of patients admitted to psychiatry having dual diagnosis disorders. This paper is a description of a short-term approach utilizing a decision tree that was developed to help staff manage the problem of substance abuse related incidents. Decision trees have been utilized in clinical problem solving to maximize successful outcomes given limited information (Aspinall, 1981) by breaking complex decisions into easier components, with treatment alternatives determined by outcomes of particular clinical questions. The complex decision facing clinicians in this dilemma was whether or not to discharge psychiatric patients who abused alcohol or drugs on inpatient units. The key alternative points will be discussed later.
AN ESCALATING PROBLEM of substance abuse on inpatient units faced staff members at the FDR VA Hospital, a large psychiatric facility offering inpatient and outpatient services to veterans in the metropolitan and suburban New York area. With several cases of drug overdoses of inpatients in 1987, the administration developed a task force to respond to the drug problem on the hospital grounds. Two groups of patients were believed to be involved in drug-related incidents: the first group were psychiatric patients not previously identified as substance abusers; the second group were known substance abusers with previously uncharacterized psychiatric pathology; both groups are variations of what is commonly called dually diagnosed. Specifically, these patients exhibit psychiatric symptoms not as a result of substance abuse, but as an additional facet of their pathology. This population trend has been on the increase, particularly with the young chronic psychiatric patient (Ridgely, Osher, & Talbott, 1987). In the VA hospitals throughout the United States, a trend has been identified since 1984 consistently in
BACKGROUND
At the time of the need for this decision tree, psychiatric units were populated by traditional psychiatric patients as well as an increasing number of patients who were substance abusers unable to benefit from traditional alcohol and drug treatment, exhibiting many of the characteristics previously described by other authors (Carey, 1989; Westermeyer & Neider, 1988). Among
Requests for reprints should be addressed Bronx VA Medical Center, Department bridge Road, Bronx, NY 10468.
to Joanne Intrator, MD, of Psychiatry, 130 W. Kings-
215
216
J. Intrator
the psychopathological symptoms associated with this group are depression, paranoia, and organicity. Admissions for these patients were brief and frequent. Usually they would be admitted for detoxification, then transferred to rehabilitation programs and would subsequently either sign themselves out of the hospital or be asked to leave for reasons of noncompliance, including inpatient substance abuse. The outcome for those who managed to complete rehabilitation programs was often a poor adjustment to outpatient life ending in readmission to psychiatric units after a short time due to regression or escalation of psychiatric symptoms. However complex the psychiatric difficulties were, once they had returned to the hospital their pathology was overshadowed by continued substance abusing behavior, that is, rumored dealing, use of drugs and alcohol, and verbal and physical threats. The authors felt that staff needed clear guidelines for the management of these cases, particularly regarding the issue of discharge. It is therapeutic under the correct clinical circumstances to discharge patients and, although staff were aware of this, the utilization of this option was often inconsistent. Patients involved in substance behavior would be monitored as if they were in a therapeutic 12-step-oriented community where members are automatically discharged for their use of drugs, or they would be treated as if the behavior were fully attributable to their psychiatric disorder, beyond the individual’s control, and therefore tolerated. In cases in which staff tolerated the behavior and did not discharge the patient, the course was usually to confine a patient for one or two days, only to have to repeat this measure days later for repeat incidents. THE SETTING
OF THE DECISION
TREE
The decision tree was initiated on a 56-bed open psychiatric unit. The team worked harmoniously and was usually in agreement with the management of difficult cases. Dissension developed around diagnostic and management issues of the emerging population of dually diagnosed patients. As stated before, psychoses, anxiety, and depression characterized many of the patients’ mental states. However, these mental health issues began to be subverted as the team struggled to maintain its integrity with this difficult group. The treatment team began to be divergent in their views concerning the management of patients who were tested positive for substances. Some were becoming increasingly punitive toward these patients and consistently recommending immediate discharge, while others were more tolerant. One staff member in particular was punitive and intolerant of any rule infractions. His lack of flexibility in dealing with psychiatric patients had previously not been problematic because his opinions were tolerated but outvoted. In this new clinical environment, he galvanized other staff members into re-
et al.
sponding more punitively. This growing restrictive inflexible environment was further reinforced by police searches conducted on the unit with specially trained dogs seeking contraband. Johansen (1983) discusses how fire setting in a unit over a period of time eroded the milieu and provoked staff into a regressive position where countertransference problems developed. In Johansen’s example, staff were divided in terms of management, and consequently the therapeutic atmosphere deteriorated into a policelike state. Although the situation was not as overtly dangerous as fire setting, a similar process developed on the unit at Montrose, centering around the issue of patients’ substance-abusing behavior. The aim of the decision tree was to minimize the possibility of countertransference by providing a structured framework for such decisions. In preparation for defining the components of the decision tree the authors decided to review problematic cases in which disciplinary discharges had been challenged by patients and were later reversed. The treatment team’s decisions to discharge certain substance-abusing patients were often overturned because they were considered to be lacking in sensitivity toward patients’ pervasive psychiatric symptomatology, which necessarily required further hospitalization. CASE EXAMPLE
The patient, a 34-year-old single, unemployed veteran, had a long history of substance abuse, including LSD, PCP, cocaine, and alcohol. He had numerous brief psychiatric hospitalizations. Although other psychiatric diagnoses were considered, the patient would sign himself out of the hospital before any consensus could be achieved. Two weeks into treatment he was told his urine was positive, which he challenged. He was then discharged. He was readmitted the next day, despite staff objections. He was disheveled, tense, depressed, fearful of losing control, confused, and had difficulty communicating his needs coherently. He became agitated, paranoid, and stuck his hand through glass when a request for bed rest was denied. DISCUSSION
OF CASE
There were several factors that interfered with the staff’s perception of the extent of the patient’s condition. The repugnance of his behavior prevented the understanding of it in the context of his psychopathology. At a time when the hospital was facing an escalating drug problem, staff were increasingly frustrated and felt hopeless in their efforts to control this behavior. When this patient was readmitted the staff felt their efforts were being undermined by administration. This patient’s frequent fighting and verbal threats also affected staff’s ability to evaluate him clearly. Since he
Decision Tree
217
was seen only as a drug user (despite other diagnostic possibilities raised in the record), the criteria for the team’s decision to discharge him from the hospital were borrowed from the behavioral techniques used in the treatment of classic substance abuse in which a positive urine sample is the basis for therapeutic discharge. When the patient was readmitted a day later, rather than reassess his presentation in light of more complicated pathology still emerging, the staff perceived the readmission as a lack of support by administration of their efforts to deal with this pervasive problem of drugabusing behavior. Poor verbal skills, a personality style of constant externalization, impulsivity, and manifest rage, all of which this case manifested, have been described in the literature as particularly problematic for clinicians contributing to “therapeutic pessimism” (Strasburger, 1986). Defining this patient simply in terms of his antisocial substance-abusing behavior avoided coming to terms with this therapeutic pessimism, which would leave the treatment team feeling as inadequate as their patient. Calling him antisocial not only avoided assessing a complex psychopathology, but circumvented important aspects of countertransference that were demoralizing the treatment team.
DESIGNING
THE DECISION
TREE
The decision tree’s aim was to minimize the risks of premature discharge. The crucial decision points that emerged from this case discussion and similar ones consisted of (a) timeliness of urine results, (b) assessment of patient’s psychiatric stability, and (c) whether the patient has been previously compliant with treatment plan (Figure 1). Thus a patient with a positive urine for drugs would have had to have this information presented quickly. If the results were delayed beyond a week it would be disregarded. If the drug screen tested positive, the patient would be assessed for psychiatric stability. A psychotic, suicidal, homicidal, or medically ill patient had to be stabilized prior to addressing the substance abuse. If the patient was stable, his previous compliance with treatment was assessed, looking at general compliance issues such as following nursing rules and performing activities of daily living (ADLs), in addition to specific items such as timeliness and participation in groups. If the patient was stable and compliant, he was confined to the unit for a week in pajamas to focus on the consequences of substance abuse behavior. The following week he would be permitted to go to the dining room and therapeutic activities off the ward. Since many of the patients had not been previously known as substance abusers, staff was asked to reevaluate the treatment plan, incorporating substance abuse. If the patient had not been compliant with the treat-
ment plan previously, and was assessed as stable, he would be discharged from the hospital.
PRINCIPLES OF THE DECISION ALTERNATIVE POINTS
TREE
Timely Results
Given these patients’ impulsive character style, a prompt response to substance-abusing behavior was crucial for patients and staff. Whatever the response might be, it was necessary to move quickly after a positive urine because patients with impulsive disorders have an impaired sense of time. For example, these patients frequently complained that they should not be held accountable for “old behavior.” This characterological distortion of time has been well illustrated by Shapiro (1965), who describes patients with impulsive disorders as “inevitably dominated by the present so that the significance of the distant future shrinks. Such characters are impaired in reflection, planning, and anticipation. Their behavior is dominated by their immediate needs without contemplation of its future effects” (Shapiro, 1965). Asking such a patient to be accountable for “old” behavior is like expecting a two-year-old to behave on the basis of rewards promised hours later. These patients’ sense of time also affects the staff who treat them. When staff loses track of this cognitive defect, they expect a distant or delayed response to misbehavior to be adequately interpreted by the patient. When the anticipated response does not occur, the staff become angry and frustrated. This anger can then trigger additional noncompliant or aggressive behavior by the patient, often leading to premature discharges. In an effort to establish parameters and reinforce timeliness, Laboratory Service arranged to do all urine screens on a stat basis. It was also decided that results not conferenced in less than one week, would be disregarded.
Stability
The authors believed that there were two groups of patients involved in substance abuse on the units. These groups consisted of psychiatric patients not previously identified as substance abusers and known substance abusers with additional psychopathology. The team was asked by the authors to diagnose the patients using DSM-III-R at the time of utilization of the decision tree. After positive laboratory results were returned, the team was instructed to rule out the possibility that symptomatology might be drug related. This was particularly important for patients not previously diagnosed with problems other than substance abuse. Clinicians were also asked to assess the patients’ psychiatric stability at the time of evaluation, using delib-
2 co
URINE/BREATHALYZER
VER!FY (TIMELINESS) v v 0 YES Cl NO (BEYOND
I
MEDICAL
n
!I
PSYCHOTIC
COMPLICATIONS
HOMICIDAL/ASSAULTIVE
SUICIDAL
In
1
I-JYES' ______)
STABLE
ACTIVELY
PATIEN;
I
@ CHECK ~AGNOSIS (AXIS I,II,& III)
r] Go I
_______)
p+
0
IE
T A B I L I Z
S
TO MEDICINE
UNIT
1.C.U
:" 1
) NO -_T ) YES I
DATE
0 REGULAR
SIGNATURES
DISCHARGE M.D.INITIALS
DRUG NAME
TODAY'S
TEAM
0 RE-EVALUATE !~REATMENT PLAN ADD SUBSTANCE ABUSE
I
) /I PAJAMAS AND NO PRIVILEGES FOR SET # OF DAYS
AS INDICATED
FIGURE 1. Decision tree for urine testing and breathalyzer.
TRANSFER
ADMISSION
PSYCHIATRIC
SECLUSION
MEDS
COMPLIANCE PLAN
F/U TESTING
TREATMENT
USE / KNOWN HISTORY
AS INDICATED
USE / OBSERVED
F/U TESTING
/ RUMORED
EVALUATE/ADJUST
CHECK PREVIOUS WITH TREATMENT
ENTER HERE
1 WEEK)
POSITIVE URINE/BREATHALYZER (NON-PRESCRIPTION ABUSED DRUG)
NEGATIVE
RANDOM SCREEN: ENTIRE UNIT / GROUP INDICATION FOR TESTING: BEHAVIOR CHANGE
Decision Tree erately broad criteria of stability. Anything short of acute psychotic decompensation, suicidal or assaultive behavior, or medical instability was expected to be treated on the unit. The aim was to change the accustomed management of these situations, which had previously consisted of immediate transfer to an acute unit or, in some cases, discharge. The message to the staff was that they were capable of containing the patient and providing the appropriate treatment without penalizing the patient for the very behaviors that established a dual diagnosis. The message conveyed to patients was one of having to work within defined treatment parameters. The desired outcome was to preserve the milieu. It was found that by reducing the frequency of transfers and discharges, their disruptive effect was minimized, thus allowing staff and patients to work in a more contained atmosphere. Containment, like timeliness, was considered to be a powerfully therapeutic agent in the treatment of these patients, especially in a population whose object relations were commonly founded on experiences and expectations of rejection, neglect, or stigmatization (Gunderson, 1978). Containment also had a positive effect on the staff. As more patients remained on the unit instead of being discharged, the staff realized that the programs on the unit were not sufficient to provide a therapeutic atmosphere for patients confined there. This led to the authors’ initiating a focus on program development resulting in an on-unit posttraumatic stress disorder (PTSD) group, an assertiveness training group, and more counseling about substance abuse. Thus, as the boundaries of the unit evolved and were defined, the therapeutic tasks were clarified and implemented. This process ultimately led to the formation of a Dual Diagnosis Unit.
Previous
Compliance
Another related problem with patients and staff centered around the need for a concrete definition of compliance. Patients defined as stable were assessed for their degree of compliance as part of the determination of whether they were to be discharged or confined to the unit. Although the concept of compliance is commonly used as a component for managing patients in institutional settings, it is a vague and difficult concept - especially for this population of patients. It was necessary to define compliance concretely for both patients and staff. By refining a working definition of compliance, patients were able to focus on specific required behaviors, such as ADLs, cleanliness, timeliness, and participation in groups. Staff were then allowed to be clear about the basis of their responses. The act of identifying the behavioral elements of compliance eliminated the potential for staff distractions of subjective issues such as feelings and emotions, which are often linked to behaviors.
219 Treatment
Plan
Once a patient had been assessed as stable and previously compliant with the treatment plan, staff was then ready to determine the consequences of the substance abuse. The authors strongly maintained that all patients, both those initially determined as stable and those who had been stabilized, should be held accountable for their behavior, regardless of their additional psychiatric diagnosis. This was done by retaining the patient on their unit in a therapeutic setting. Holding the patients responsible for their behavior accorded them dignity as an individual; containing them in the hospital and in the unit reinforced recognition of their illness and the corresponding need for treatment. Staff decided that an appropriate consequence would be one week of confinement to the unit, with activity restricted to prescribed therapeutic sessions, followed by a second week of returning to off-ward detail or therapeutic assignments.
DISCUSSION The decision tree was developed as a temporary measure at a time of crisis at the FDR VA. Its aim was to reduce substance abuse related incidents and manage carefully the clinical outcomes when such incidents did occur. This was achieved by providing a stepwise process that allowed staff to choose a course of action when faced with different alternatives. It would have been helpful to compare incidents on the unit prior to its implementation with the reduction of incidents since its inception. It would have been desirable to compare staff attitudes in advance and after the implementation of the Decision Tree to assess its influence on countertransferential issues. It is conceivable that the process fostered by the decision tree could impact other clinical settings. Mention has already been made of the distortion and rigidification of staff responses caused by uncontrolled dangerous behaviors and how this resembled the effect of fire starting in another setting. Other issues that surfaced were the unexamined beliefs of many staff that patients were malingering psychiatric symptoms to increase Service Connected Disabilities, avoid the judicial system, or shelter their homeless condition. The consequent loss of therapeutic perspective resembles what Travin and Protter (1982) have described in the setting of a court clinic, where severe psychopathology is often underdiagnosed because of the psychiatrists’ “response set,” their tendency to view patients as “bad” rather than “mad” because of the abhorrent nature of their behavior or the risk of a psychiatric diagnosis being used as a shield from legal responsibility (Travin & Protter, 1982). The basic tenets that emerged-timeliness, containment, concrete definition of compliance,
J. Intrator
220
and an insistence on patient responsibility- have broad clinical application and could be supported by various descriptive and therapeutic theories. What was particularly satisfying about our approach, however, was its simplicity, its “do-ableness,” and the clear impact it had on staff and patients while setting the climate for the Dual Diagnosis Unit, whose aim was the continuation of the process of integrated assessment and treatment of this complex patient population.
REFERENCES Aspinall, M.J. (1981). Decision makingforpatient care. New York: Appleton-Century-Crofts. Carey, K.B. (1989). Emerging treatment guidelines for mentally ill chemical abusers. Hospital and Community Psychiatry, 40,
341-349.
et al.
Gunderson, J.G. (1978). Defining the therapeutic process in psychiatric milieus. Psychiatry, 41, 327-335. Johansen, K.H. (1983). The impact of patients with chronic character pathology on a hospital inpatient unit. Hospital and Com-
munity Psychiatry, 34, 842-846. Ridgely, M.S., Osher, F.C., & Talbott, J.A. (1987). Chronic mentally ill young adults with substance abuse problems: Treatment and training issues. Alcohol, Drug Abuse and Mental Health Administration. Shapiro, D. (1965). Neurotic styles. New York: Basic Books. Strasburger, L.H. (1986). The treatment of antisocial syndromes: The therapist’s feelings. In Unmasking the psychopath, edited by W.H. Reid et al. New York: W.W. Norton. Travin, S., & Protter, B. (1982). Mad or bad? Some clinical considerations in the misdiagnosis of schizophrenia as antisocial personality disorder. American Journal of Psychiatry, 139,
13351338. Westermeyer, pathology
J., & Neider, J. (1988). Social networks and psychoamong substance abusers. American Journal of Psy-
chiatry, 145, 12651268.
Vol. 9, pp. 215-220,
1992 Copyright
074&5472/92 $5.00 + .OO 0 1992 Pergamon Press Ltd.
ARTICLE
Decision Tree for the Management of Substance-Abusing Psychiatric Patients
JOANNE
INTRATOR,
MD,*
EDWARD
ALLAN,
MD,?
AND MARC
PALMER,
BFA$
*Department of Psychiatry, Bronx VA Medical Center, Bronx, New York TDepartment of Psychiatry, FDR VA Hospital, Montrose, New York SAmbulatory Care, FDR VA Hospital, Montrose, New York
Abstract - This paper describes a short-term approach developedat a time of numerous drug-related incidents occurring at a large VA Hospital to help staff managepsychiatricpatients abusing alcohol or drugs during hospitalization. This was accomplished through the development of a decision tree designed to improve the clinical problem-solving process by identifying key decision points. Prior to this, staff responded emotionally either by prematurely discharging patients or by not recognizing the problem at all. Decision Trees have widespread applicability for resolving complex clinical problems.
Keeords-
decision tree; dual diagnosis; algorithm; mentally ill addicts; addiction and mental illness.
the direction of greater numbers of patients admitted to psychiatry having dual diagnosis disorders. This paper is a description of a short-term approach utilizing a decision tree that was developed to help staff manage the problem of substance abuse related incidents. Decision trees have been utilized in clinical problem solving to maximize successful outcomes given limited information (Aspinall, 1981) by breaking complex decisions into easier components, with treatment alternatives determined by outcomes of particular clinical questions. The complex decision facing clinicians in this dilemma was whether or not to discharge psychiatric patients who abused alcohol or drugs on inpatient units. The key alternative points will be discussed later.
AN ESCALATING PROBLEM of substance abuse on inpatient units faced staff members at the FDR VA Hospital, a large psychiatric facility offering inpatient and outpatient services to veterans in the metropolitan and suburban New York area. With several cases of drug overdoses of inpatients in 1987, the administration developed a task force to respond to the drug problem on the hospital grounds. Two groups of patients were believed to be involved in drug-related incidents: the first group were psychiatric patients not previously identified as substance abusers; the second group were known substance abusers with previously uncharacterized psychiatric pathology; both groups are variations of what is commonly called dually diagnosed. Specifically, these patients exhibit psychiatric symptoms not as a result of substance abuse, but as an additional facet of their pathology. This population trend has been on the increase, particularly with the young chronic psychiatric patient (Ridgely, Osher, & Talbott, 1987). In the VA hospitals throughout the United States, a trend has been identified since 1984 consistently in
BACKGROUND
At the time of the need for this decision tree, psychiatric units were populated by traditional psychiatric patients as well as an increasing number of patients who were substance abusers unable to benefit from traditional alcohol and drug treatment, exhibiting many of the characteristics previously described by other authors (Carey, 1989; Westermeyer & Neider, 1988). Among
Requests for reprints should be addressed Bronx VA Medical Center, Department bridge Road, Bronx, NY 10468.
to Joanne Intrator, MD, of Psychiatry, 130 W. Kings-
215
216
J. Intrator
the psychopathological symptoms associated with this group are depression, paranoia, and organicity. Admissions for these patients were brief and frequent. Usually they would be admitted for detoxification, then transferred to rehabilitation programs and would subsequently either sign themselves out of the hospital or be asked to leave for reasons of noncompliance, including inpatient substance abuse. The outcome for those who managed to complete rehabilitation programs was often a poor adjustment to outpatient life ending in readmission to psychiatric units after a short time due to regression or escalation of psychiatric symptoms. However complex the psychiatric difficulties were, once they had returned to the hospital their pathology was overshadowed by continued substance abusing behavior, that is, rumored dealing, use of drugs and alcohol, and verbal and physical threats. The authors felt that staff needed clear guidelines for the management of these cases, particularly regarding the issue of discharge. It is therapeutic under the correct clinical circumstances to discharge patients and, although staff were aware of this, the utilization of this option was often inconsistent. Patients involved in substance behavior would be monitored as if they were in a therapeutic 12-step-oriented community where members are automatically discharged for their use of drugs, or they would be treated as if the behavior were fully attributable to their psychiatric disorder, beyond the individual’s control, and therefore tolerated. In cases in which staff tolerated the behavior and did not discharge the patient, the course was usually to confine a patient for one or two days, only to have to repeat this measure days later for repeat incidents. THE SETTING
OF THE DECISION
TREE
The decision tree was initiated on a 56-bed open psychiatric unit. The team worked harmoniously and was usually in agreement with the management of difficult cases. Dissension developed around diagnostic and management issues of the emerging population of dually diagnosed patients. As stated before, psychoses, anxiety, and depression characterized many of the patients’ mental states. However, these mental health issues began to be subverted as the team struggled to maintain its integrity with this difficult group. The treatment team began to be divergent in their views concerning the management of patients who were tested positive for substances. Some were becoming increasingly punitive toward these patients and consistently recommending immediate discharge, while others were more tolerant. One staff member in particular was punitive and intolerant of any rule infractions. His lack of flexibility in dealing with psychiatric patients had previously not been problematic because his opinions were tolerated but outvoted. In this new clinical environment, he galvanized other staff members into re-
et al.
sponding more punitively. This growing restrictive inflexible environment was further reinforced by police searches conducted on the unit with specially trained dogs seeking contraband. Johansen (1983) discusses how fire setting in a unit over a period of time eroded the milieu and provoked staff into a regressive position where countertransference problems developed. In Johansen’s example, staff were divided in terms of management, and consequently the therapeutic atmosphere deteriorated into a policelike state. Although the situation was not as overtly dangerous as fire setting, a similar process developed on the unit at Montrose, centering around the issue of patients’ substance-abusing behavior. The aim of the decision tree was to minimize the possibility of countertransference by providing a structured framework for such decisions. In preparation for defining the components of the decision tree the authors decided to review problematic cases in which disciplinary discharges had been challenged by patients and were later reversed. The treatment team’s decisions to discharge certain substance-abusing patients were often overturned because they were considered to be lacking in sensitivity toward patients’ pervasive psychiatric symptomatology, which necessarily required further hospitalization. CASE EXAMPLE
The patient, a 34-year-old single, unemployed veteran, had a long history of substance abuse, including LSD, PCP, cocaine, and alcohol. He had numerous brief psychiatric hospitalizations. Although other psychiatric diagnoses were considered, the patient would sign himself out of the hospital before any consensus could be achieved. Two weeks into treatment he was told his urine was positive, which he challenged. He was then discharged. He was readmitted the next day, despite staff objections. He was disheveled, tense, depressed, fearful of losing control, confused, and had difficulty communicating his needs coherently. He became agitated, paranoid, and stuck his hand through glass when a request for bed rest was denied. DISCUSSION
OF CASE
There were several factors that interfered with the staff’s perception of the extent of the patient’s condition. The repugnance of his behavior prevented the understanding of it in the context of his psychopathology. At a time when the hospital was facing an escalating drug problem, staff were increasingly frustrated and felt hopeless in their efforts to control this behavior. When this patient was readmitted the staff felt their efforts were being undermined by administration. This patient’s frequent fighting and verbal threats also affected staff’s ability to evaluate him clearly. Since he
Decision Tree
217
was seen only as a drug user (despite other diagnostic possibilities raised in the record), the criteria for the team’s decision to discharge him from the hospital were borrowed from the behavioral techniques used in the treatment of classic substance abuse in which a positive urine sample is the basis for therapeutic discharge. When the patient was readmitted a day later, rather than reassess his presentation in light of more complicated pathology still emerging, the staff perceived the readmission as a lack of support by administration of their efforts to deal with this pervasive problem of drugabusing behavior. Poor verbal skills, a personality style of constant externalization, impulsivity, and manifest rage, all of which this case manifested, have been described in the literature as particularly problematic for clinicians contributing to “therapeutic pessimism” (Strasburger, 1986). Defining this patient simply in terms of his antisocial substance-abusing behavior avoided coming to terms with this therapeutic pessimism, which would leave the treatment team feeling as inadequate as their patient. Calling him antisocial not only avoided assessing a complex psychopathology, but circumvented important aspects of countertransference that were demoralizing the treatment team.
DESIGNING
THE DECISION
TREE
The decision tree’s aim was to minimize the risks of premature discharge. The crucial decision points that emerged from this case discussion and similar ones consisted of (a) timeliness of urine results, (b) assessment of patient’s psychiatric stability, and (c) whether the patient has been previously compliant with treatment plan (Figure 1). Thus a patient with a positive urine for drugs would have had to have this information presented quickly. If the results were delayed beyond a week it would be disregarded. If the drug screen tested positive, the patient would be assessed for psychiatric stability. A psychotic, suicidal, homicidal, or medically ill patient had to be stabilized prior to addressing the substance abuse. If the patient was stable, his previous compliance with treatment was assessed, looking at general compliance issues such as following nursing rules and performing activities of daily living (ADLs), in addition to specific items such as timeliness and participation in groups. If the patient was stable and compliant, he was confined to the unit for a week in pajamas to focus on the consequences of substance abuse behavior. The following week he would be permitted to go to the dining room and therapeutic activities off the ward. Since many of the patients had not been previously known as substance abusers, staff was asked to reevaluate the treatment plan, incorporating substance abuse. If the patient had not been compliant with the treat-
ment plan previously, and was assessed as stable, he would be discharged from the hospital.
PRINCIPLES OF THE DECISION ALTERNATIVE POINTS
TREE
Timely Results
Given these patients’ impulsive character style, a prompt response to substance-abusing behavior was crucial for patients and staff. Whatever the response might be, it was necessary to move quickly after a positive urine because patients with impulsive disorders have an impaired sense of time. For example, these patients frequently complained that they should not be held accountable for “old behavior.” This characterological distortion of time has been well illustrated by Shapiro (1965), who describes patients with impulsive disorders as “inevitably dominated by the present so that the significance of the distant future shrinks. Such characters are impaired in reflection, planning, and anticipation. Their behavior is dominated by their immediate needs without contemplation of its future effects” (Shapiro, 1965). Asking such a patient to be accountable for “old” behavior is like expecting a two-year-old to behave on the basis of rewards promised hours later. These patients’ sense of time also affects the staff who treat them. When staff loses track of this cognitive defect, they expect a distant or delayed response to misbehavior to be adequately interpreted by the patient. When the anticipated response does not occur, the staff become angry and frustrated. This anger can then trigger additional noncompliant or aggressive behavior by the patient, often leading to premature discharges. In an effort to establish parameters and reinforce timeliness, Laboratory Service arranged to do all urine screens on a stat basis. It was also decided that results not conferenced in less than one week, would be disregarded.
Stability
The authors believed that there were two groups of patients involved in substance abuse on the units. These groups consisted of psychiatric patients not previously identified as substance abusers and known substance abusers with additional psychopathology. The team was asked by the authors to diagnose the patients using DSM-III-R at the time of utilization of the decision tree. After positive laboratory results were returned, the team was instructed to rule out the possibility that symptomatology might be drug related. This was particularly important for patients not previously diagnosed with problems other than substance abuse. Clinicians were also asked to assess the patients’ psychiatric stability at the time of evaluation, using delib-
2 co
URINE/BREATHALYZER
VER!FY (TIMELINESS) v v 0 YES Cl NO (BEYOND
I
MEDICAL
n
!I
PSYCHOTIC
COMPLICATIONS
HOMICIDAL/ASSAULTIVE
SUICIDAL
In
1
I-JYES' ______)
STABLE
ACTIVELY
PATIEN;
I
@ CHECK ~AGNOSIS (AXIS I,II,& III)
r] Go I
_______)
p+
0
IE
T A B I L I Z
S
TO MEDICINE
UNIT
1.C.U
:" 1
) NO -_T ) YES I
DATE
0 REGULAR
SIGNATURES
DISCHARGE M.D.INITIALS
DRUG NAME
TODAY'S
TEAM
0 RE-EVALUATE !~REATMENT PLAN ADD SUBSTANCE ABUSE
I
) /I PAJAMAS AND NO PRIVILEGES FOR SET # OF DAYS
AS INDICATED
FIGURE 1. Decision tree for urine testing and breathalyzer.
TRANSFER
ADMISSION
PSYCHIATRIC
SECLUSION
MEDS
COMPLIANCE PLAN
F/U TESTING
TREATMENT
USE / KNOWN HISTORY
AS INDICATED
USE / OBSERVED
F/U TESTING
/ RUMORED
EVALUATE/ADJUST
CHECK PREVIOUS WITH TREATMENT
ENTER HERE
1 WEEK)
POSITIVE URINE/BREATHALYZER (NON-PRESCRIPTION ABUSED DRUG)
NEGATIVE
RANDOM SCREEN: ENTIRE UNIT / GROUP INDICATION FOR TESTING: BEHAVIOR CHANGE
Decision Tree erately broad criteria of stability. Anything short of acute psychotic decompensation, suicidal or assaultive behavior, or medical instability was expected to be treated on the unit. The aim was to change the accustomed management of these situations, which had previously consisted of immediate transfer to an acute unit or, in some cases, discharge. The message to the staff was that they were capable of containing the patient and providing the appropriate treatment without penalizing the patient for the very behaviors that established a dual diagnosis. The message conveyed to patients was one of having to work within defined treatment parameters. The desired outcome was to preserve the milieu. It was found that by reducing the frequency of transfers and discharges, their disruptive effect was minimized, thus allowing staff and patients to work in a more contained atmosphere. Containment, like timeliness, was considered to be a powerfully therapeutic agent in the treatment of these patients, especially in a population whose object relations were commonly founded on experiences and expectations of rejection, neglect, or stigmatization (Gunderson, 1978). Containment also had a positive effect on the staff. As more patients remained on the unit instead of being discharged, the staff realized that the programs on the unit were not sufficient to provide a therapeutic atmosphere for patients confined there. This led to the authors’ initiating a focus on program development resulting in an on-unit posttraumatic stress disorder (PTSD) group, an assertiveness training group, and more counseling about substance abuse. Thus, as the boundaries of the unit evolved and were defined, the therapeutic tasks were clarified and implemented. This process ultimately led to the formation of a Dual Diagnosis Unit.
Previous
Compliance
Another related problem with patients and staff centered around the need for a concrete definition of compliance. Patients defined as stable were assessed for their degree of compliance as part of the determination of whether they were to be discharged or confined to the unit. Although the concept of compliance is commonly used as a component for managing patients in institutional settings, it is a vague and difficult concept - especially for this population of patients. It was necessary to define compliance concretely for both patients and staff. By refining a working definition of compliance, patients were able to focus on specific required behaviors, such as ADLs, cleanliness, timeliness, and participation in groups. Staff were then allowed to be clear about the basis of their responses. The act of identifying the behavioral elements of compliance eliminated the potential for staff distractions of subjective issues such as feelings and emotions, which are often linked to behaviors.
219 Treatment
Plan
Once a patient had been assessed as stable and previously compliant with the treatment plan, staff was then ready to determine the consequences of the substance abuse. The authors strongly maintained that all patients, both those initially determined as stable and those who had been stabilized, should be held accountable for their behavior, regardless of their additional psychiatric diagnosis. This was done by retaining the patient on their unit in a therapeutic setting. Holding the patients responsible for their behavior accorded them dignity as an individual; containing them in the hospital and in the unit reinforced recognition of their illness and the corresponding need for treatment. Staff decided that an appropriate consequence would be one week of confinement to the unit, with activity restricted to prescribed therapeutic sessions, followed by a second week of returning to off-ward detail or therapeutic assignments.
DISCUSSION The decision tree was developed as a temporary measure at a time of crisis at the FDR VA. Its aim was to reduce substance abuse related incidents and manage carefully the clinical outcomes when such incidents did occur. This was achieved by providing a stepwise process that allowed staff to choose a course of action when faced with different alternatives. It would have been helpful to compare incidents on the unit prior to its implementation with the reduction of incidents since its inception. It would have been desirable to compare staff attitudes in advance and after the implementation of the Decision Tree to assess its influence on countertransferential issues. It is conceivable that the process fostered by the decision tree could impact other clinical settings. Mention has already been made of the distortion and rigidification of staff responses caused by uncontrolled dangerous behaviors and how this resembled the effect of fire starting in another setting. Other issues that surfaced were the unexamined beliefs of many staff that patients were malingering psychiatric symptoms to increase Service Connected Disabilities, avoid the judicial system, or shelter their homeless condition. The consequent loss of therapeutic perspective resembles what Travin and Protter (1982) have described in the setting of a court clinic, where severe psychopathology is often underdiagnosed because of the psychiatrists’ “response set,” their tendency to view patients as “bad” rather than “mad” because of the abhorrent nature of their behavior or the risk of a psychiatric diagnosis being used as a shield from legal responsibility (Travin & Protter, 1982). The basic tenets that emerged-timeliness, containment, concrete definition of compliance,
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and an insistence on patient responsibility- have broad clinical application and could be supported by various descriptive and therapeutic theories. What was particularly satisfying about our approach, however, was its simplicity, its “do-ableness,” and the clear impact it had on staff and patients while setting the climate for the Dual Diagnosis Unit, whose aim was the continuation of the process of integrated assessment and treatment of this complex patient population.
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