the North Dakota State Hospital& state hospitals in general
g. m. johnson, phd
jamestown
the state(s) of state hospitals
private hospitals & community services vs. state hospitals
what makes a specialist a specialist and how does one get expertise?
private hospitals instead of the nd state hospital
community services versus the nd state hospital
terms some stories of woe my perspective on this nd & other links
the state(s)
of state hospitals
Cost Containment & Patient Containment
vs. Quality Diagnosis, Treatment, Containment & Rehabilitation
State hospitals across the country vary in their overall emphasis with regard to the emphasis on cost and patient containment versus mental health treatment and empowerment. Some states have opted to not have accreditation by JCAHO (the Joint Committee for Accreditation of Healthcare Organizations) and accreditation by Medicare and have focused much less on treatment than on containment. These are the stereotypical "One Flew Over the Cookoo's Nest" -type institutions that are often described as "backward dumping grounds" or "holding bins." They rely on keeping patients medically restrained, docile and contained away from the rest of society.
States that have opted to cut back on services to individuals with mental illness may now be facing radically expensive law suits and/or expensive changes as Ohmstead- based litigation is undertaken. Ironically, these states were not saving money in spite of their efforts. The few studies done on the subject suggest that providing adequate, quality mental health services seems expensive but is more cost effective when the costs of other medical services, treatment after crises and the possibility of damage to the lives of others are taken into consideration.
North Dakota has a history of establishing and sustaining quality inpatient and outpatient mental health services for its citizens.
private hospitals & community services
vs. state hospitals
Is a private hospital a treatment facility
while the ND State Hospital is a dump?
Many people imagine that a state hospital is generally something of a dumping area for the mentally ill -- something like the facility depicted in the movie "One Flew Over the Cookoo's Nest." Private hospitals are seen very differently -- usually as a treatment facility that is markedly preferable to a state hospital. However, this is not necessarily the case and is not -- at least at the time of this writing -- the case in North Dakota..
Private hospitals -- if they have psychiatric services at all -- focus on diagnosis, brief medical treatment or medication adjustment, crisis management and brief hospitalizations for containment purposes.
Unlike state hospitals, private hospitals do not generally provide rehabilitation services or long term care, nor are they equiped to handle aggressive, violent patients. They also generally refuse patients without insurance coverage.
Outpatient facilities cannot provide rehabilitation services for individuals who are confused about their situation, aggitated, resistant to treatment efforts and likely to try to avoid services if at all possible.
Outpatient facilities cannot provide long-term care for individuals who are present complex, treatment-resistant disorders that require long-term psychiatric and nursing care and who are chronically and severely confused about their situation, very frequently aggitated, resistant to treatment efforts and likely to avoid services if at all possible.
In North Dakota, when psychiatric problems are beyond what a psychiatrist can do in an outpatient hour or beyond what a community hospital's psychiatric ward can do in a week or two -- or when intensive long term care or intensive inpatient rehabilitation services are needed -- then the North Dakota State Hospital is only place such services are available.
what makes a specialist a specialist
and how does one get expertise?
Is a lot of experience better than a little? (Duh.)
When health issues call for more than the general knowledge and experience of general practicioners, we turn to the specialist and the specialized facility. A specialist has the greatest degree of focused training, expertise and experience.
In dealing with mental health issues, a general practice MD may be the first consulted. If the problem is beyond his or her experience and expertise, an outpatient psychiatrist or counselor is the next level of expert. If the problem needs more than outpatient services, the psychiatric service of a private hospital may be appropriate. If the problem is beyond the services or expertise of a private hospital's psychiatric service, the state hospital is the next level of focused expertise.
In North Dakota...
for the treatment of patients who are agitated & potentially violent...
for the provision of basic, important rehabilitation services...
for the diagnosis of complex mental health disorders...
for providing treatment of difficult psychiatric cases...
for complex treatment that is likely to take months...
the ND State Hospital has been the only place in ND where
the appropriate services and the specialists with the greatest degree
of experience and expertise can be found.
private hospitals
instead of the nd state hospital
What if there were smaller facilities around the state
doing what the ND state hospital does?
(Why do convenience stores have fewer products than a super market?)
(Why do convenience store products cost more than at the super market?)
It has been proposed in some circles that perhaps the citizens of ND -- especially the citizens dealing with serious mental illness -- would be better served in smaller facilities around the state rather than in the current state hospital located in Jamestown. There are some positives in this idea related to being closer to home communities and families and friends. There are also a few negatives:
In a small (population-wise) state, the numbers of patients served in each facility would reduce overall the level of expertise of the staff because fewer of the various types of psychiatric problems would come through the doors. If, for example, there were four facilities providing the services that the state hospital provides, there would be on average only one quarter the number of patients with a given disorder.
Because of the lower number of patients with presenting problems of a given category (e.g., antisocial, angry, substance-abusing, twenties-something young men with schizophrenia; or fourties-something formerly productive individuals dealing with depression with psychotic features; or angry, hostile, manipulative, late-twenties, self-mutilating, chronically suicidal gesturing survivors of long-term sadistic molestation; or individuals presenting with multiple personalities who present as dangerous to themselves or others), each facility would be basically in the same situation as private hospital psychiatric wards --
-
without sufficient numbers of patients presenting specific kinds of problems to be able to afford keeping focused, specializing professionals on staff because they would not be sufficiently busy;
without sufficient numbers of patients presenting specific kinds of problems to keep their professionals sharp and consistently gaining in experience like they would be able to in another, larger hospital;
without sufficient numbers of patients presenting violent potential, it would be overly costly to make each facility secure with areas dedicate to containing violent acting out upset;
without sufficient numbers of patients requiring rehabilitation services, it would be overly costly to keep TR, OT and other rehabilitation-focused professionals sufficiently busy with groups but it might be impossible to find enough patients for groups;
| Note: Current efforts to cut back on mental health services and state hospital space and staff may result in a reduction of the ability of the North Dakota State Hospital to function adequately.
If the state hospital is not there to be North Dakota's high intensity mental health facility and mental health services safety net, the morgues and prisons will be the only safety nets left. |
community services
versus the nd state hospital
what is a community and when is what cheaper and why?
A lot is said about community services. There are two basic things said, both of which are argueably true in some respects and untrue in others. First, it is said that providing services in the community is more humane -- which is debatable, depending on how one defines "community." Second, it is said that providing services in the community is cheaper -- which is true, depending on which services one is talking about.
Providing services in the community sounds like a good idea when one thinks of helping disabled, vulnerable individuals in their home community where they have the support of family and friends. This idea, however, is controversial when one looks at placing an individual in a community -- ANY community -- without respect to where he or she may have the support of family and friends. It is also controversial when one looks at the difference between providing services in what is defined as "community" on the basis of being NOT in the state hospital without respect to freedom and independence. That is, when one looks at the plight of individuals housed in an 8-bed group home in a residential area where they are not allowed to leave the house or yard and where they have a grand total of seven other adults to pick friends from and to feel community with.
Community services are cheaper than providing services at the state hospital ONLY with respect to patients who do not need the daily oversight of a psychiatrist, psychologist, social worker and RN in a secure setting. For the patient that does not require the daily oversight of one or more highly trained experts, providing services in an outpatient setting is vastly cheaper. However, for the patient that does, for some period of days, weeks or months, require the daily oversight of a multidisciplinary team that includes a psychiatrist, a psychologist, a social worker and a nurse, the state hospital is the most cost effective setting to provide those services. This is because, for reasons explained above, the state hospital provides the greatest degree of expertise and the most comprehensive services, and (for reasons outlined above) the staff is likely to be better utilized and less costly. Thus, the patient is likely to have a shorter stay -- which is therefore both more humane for the patient and cheaper for the state -- plus, whatever length the stay is, the stay is likely to be less costly to the state because of optimized staffing.
some of the terms used above
to be sure there's no confusion
"Containment" refers to the close monitoring of a patient under circumstances wherein the patient cannot suddenly depart and where any physical acting out potential can be controlled or restrained. This is necessary when an individual is deemed dangerous to self or others -- that is, he or she is though to be suicidal or likely to engage in other self-injurious behaviors.
Rehabilitation services are specialized services not usually available in private hospitals. Though outpatient rehabilitation services are often available, these are usually only appropriate after a great deal of preliminary work is done. Rehabilitation -- making a new life -- is an extensive, complex challenge faced by individuals who have experienced a loss or a life change that abruptly changes their needs and abilities. Rehabilitation services include group and individual therapy and counseling to address 1) how to accept, adjust to and cope with new strange and distressing experiences; 2) confusion about loss of abilities and the need for medications, counseling and occasional hospitalization; 3) the development of an understanding of who to talk to about strange, disquieting experiences when they happen and who not to; 4) how to mourn and accept loss of hopes and expectations and how to establish new hopes and lowered expectations; and 5) the need for new coping skills, living skills, self-care skills and other skills necessary for maximized independent living.
some stories of woe
to illustrate some points
(most of the stories below did not occur in ND)
Imagine, for example, the challenges faced by an individual who was in graduate school studying biochemistry, engaged and planning on a fine life as a well-paid professional -- and who then suddenly finds himself unable to concentrate, plagued by confusion, anxiety, frightening voices and strange ideas, told he will need to take a medication for the rest of his life that will make him feel like his brain and muscles are full of thick sludge -- and suddenly finds that his fiance breaks off the engagement and his family is angry and frightened of him because of the severe injuries he is told he caused his mother one night when in a panic that she had been replaced by an alien robot.Imagine how much more complicated treatment and adjustment to the new disability would be if this individual had been molested in childhood and more or less taught not to trust any authority figures.
Imagine how much more complicated treatment and adjustment to the new disability would be if this individual had been traumatized repeatedly during childhood and adolescence by emotional crises caused by family maltreatment of a family member with serious mental illness who was looked down on, embarassed by and kept hidden away from the world as a disgrace.
He had been in the hospital for seven years when I met him. He was polite and respectful and a little confused at times. I was assigned to be his therapist, his counselor. What he felt he needed was to deal with was depression. He knew he did some bad things and that "they" probably wouldn't ever feel comfortable with letting him out, ever. He knew that what he did would follow him the rest of his days. He mourned a whole life he once thought a sure thing, all of which went down the toilet when he began having strange thoughts when even just slightly stressed. His hopes for a future of success, his relationships, even relationships with family -- had all gone down the drain. He also mourned a whole other life -- the one that almost got going after he began to adjust to this schizophrenia thing that made him so confused and made him hear voices -- the one he started in the TL home in the community, living with others with problems like his -- a life that he never thought of positively until he thought he had lost that hope, too. It had been seven years and he was sure there was no hope of ever getting out because he believed he would always be seen as frightening and dangerous. He felt guilty about the hurt he inflicted but balanced that with insight into why it all happened. Now it seemed it was nobody's fault -- just bad luck.He had been living in a transitional living home, working on learning to live with schizophrenia, a condition that would be permanent and which meant hypersensitivity to stress, delusions, the loss of all the hopes he and his family had as he finished high school and strange thoughts and complete disability because of his sensitivity to any stress that the doctors told him would be with him for the rest of his life.
When he began to be troubled by the thoughts, he asked the staff at the TL home to make an appointment for him with his psychiatrist. He could tell that his meds were not working right. He was having disturbing homosexual thoughts about his roommate and didn't know why. He had never had homosexual thoughts before and he didn't want to be "gay." They told him they couldn't make him an appointment -- he already had an appointment in a month or so and he needed to wait. Several times over two weeks he went to the staff at the TL home and asked -- then pleaded -- for an earlier appointment. He became more and more distressed about the thoughts and more and more afraid he was going to do something he would regret. Then it came to him that if he beat up his room mate, perhaps he wouldn't find him so attractive and the thoughts would stop. In his stressed state, this sounded like a practical idea. Finally one night, while his roommate slept, he attacked him, nearly killing him.
He had been very upset, confused, anxious and distressed before he took the initiative to brutalize his roommate. In the chaotic aftermath he was even more upset, confused, anxious and distressed. It was very frightening when the police came. They were rough and uncaring. When he arrived on the psychiatric ward of the hospital and the chains were removed, the nurse told him to sit and wait. She told him it would be awhile before the doctor would see him. He felt he was going to explode and die and pleaded with her that she get him some help for the thoughts and the pressure building. He told her he really did need some medicine. She told him to wait. A few minutes later, she was at the nurses' station laughing with another nurse. The minute he heard her he was certain they were laughing about him. Before he could be pulled off of them, he had put a pencil through one nurse's eye and bit off the ear of the other.
When I met her she was in her early 40's and had been residing in a state hospital for nine years. I was to help her with her depression. She was in her late twenties when depression first struck. It was a brief time after her third child was born. She was confused and frightened much of the time and more or less got used to this as her life's status quo. There were periods of anxiety so terrible she couldn't even imagine leaving the house. She was having difficulty keeping a job because of her extensive use of sick time during these periods. As her situation worsened and her kids grew, her confusion and anxiety deepened. People she was close to were concerned. They tried to help get her into counseling but it was very difficult to get an appointment right away and the appointments that were made were forgotten by the time it was time for her to see the counselor. The day it happened was one long, horrible experience of terrible dread -- dread that something terrible was going to happen to her and to her children. By late that night she was completely frazzled and when she heard noises outside the house she was sure someone was going to break in. In her panic she decided that the only way to keep her children from harm was to kill them in their sleep.
He was a nice young man in his late teens from a supportive, loving upper middle class family. He had always done well in school until, late in high school, he began feeling strange thoughts and awarenesses. He asked his parents to get him to a doctor to see if he had a brain tumor -- a fear that seemed to be looming larger and larger in his mind -- but the possibility of a brain tumor was ruled out. By the time he graduated from high school he was trying to see if he could medicate the thoughts with marijuana, but this didn't work and even caused further problems because when he admited to his parents that he had tried it, drugs became the prominent theory of why he was behaving so strangely. He was placed in outpatient treatment and became so very upset with confrontations and pressures of group therapy that he was placed in an inpatient substance abuse program. He lasted only days in the inpatient program before being transfered to an understaffed inpatient setting for the seriously mentally ill. There he waited, per the directions of the professionals from the substance abuse program, for the suspected effects of cocaine abuse to wear off. When I met him he was extremely distressed and having enormous difficulty living with himself. He had been hospitalized for seven months, basically awaiting a consult with a doctor with expertise with both schizophrenia and substance abuse problems -- a doctor who could tell the difference between schizophrenia and the consequences of drug abuse. He was obsessed with the sense that all the women around him had rotting sexual organs. He could feel the diseased organs and this was an overwhelming perception that overpowered other thoughts, distracted him, distressed him, disgusted him. My first meeting with him was also with his mother and father. It was my first week at the hospital and I had been asked to officiate in a family meeting that was basically intended to explain that he had not gotten better and would not be returned to the substance abuse program and that the hospital was discharging him even though he had not improved. His mother was in tears, recognizing his unmistakeable repulsion with her, and was all the more devistated when he began screaming about her diseased state and the diseased state of all the women in the hospital. She began sobbing that she couldn't take her son back home. I terminated the meeting, excused the parents, focused on calming him down and asked him if he would be willing to try some medications that might help him feel better and might help him deal with his mother without feeling she was diseased. Seven days later he was released, feeling "normal" -- more normal than he'd felt since early high school -- except for some mild sluggishness from the medication. Two years later I was told by a family member that he had been very successful in getting himself a job and a life after release from the hospital and that he was engaged to get married to a wonderful girl.
my perspective on ndsh
Or, why I am here in North Dakota
I'm a psychologist. Like many professionals who might like working at a state mental hospital, I like working with high intensity, highly complex, challenging cases. In 1986, I wanted to find a position at a state hospital and I introduced myself to North Dakota and the North Dakota State Hospital more or less as an accidental afterthought. I was scheduling a few weeks of job interviews at various state hospital settings around the country and noticed that there was a position available in ND. I decided to add ND to the first of my schedule so I could practice my interview style at a job interview I didn't care about. North Dakota did not seem in the remotest stretches of possibilities. I had never been to ND. I didn't know anyone who had ever been to ND. As far as I knew, I didn't know anyone who knew anyone who had ever even heard of North Dakota.
I initially came to North Dakota as an accidental afterthought -- but I came back and stayed because of the mental health services here and the state-wide comittment to mental health services they represented and the pathetically inadequate mental health service delivery systems in all the other states I visited in my job search.
I worked as a psychologist at the North Dakota State Hospital from 1986 through 1993. I was the lead psychologist and assistant director of the PsychoSocial Unit from 1986 to 1990 and was the lead psychologist at the Child and Adolescent Unit from 1990 to 1993. I was a member of the Professional Growth & Development Committee of the state hospital from 1986 to 1993. I was the hospital’s Director of Training in Clinical Psychology from 1987 to 1993 and I was a member of the Executive Committee of the Medical Staff from 1987 to 1992. I have been a member of the Governing Board of the State Hospital since 1997. I maintain contacts with staff members at all levels of the hierarchy of the hospital.
Current events have caused a lot of stress for people who work at the state hospital and for many of the citizens of the state. It is very possible that certain individuals -- in the government of ND and even in the administration of the state hospital -- do not understand the importance of the functions of NDSH and it is hopefully a bit less possible that these individuals may push to reduce services at the state hospital and elsewhere in the Dept. of Human Services because of their misunderstanding of the importance of those services. This is largely what the Mental Health Association in ND, of which I am a part, is working to do something about.
nd & other links
where on the web is what
ND state government info
ND state government email addresses
NDDHS Testimony to Legislature
ND Legislature: Bills/Resolutions/Legislation
2003 ND Legislature Committee Hearings Schedule
'03 Senate Bills & Resolutions '03 House Bills & Resolutions
ND legislature & ND laws
ND Century Code - ND Laws
ND Supreme Court ND Attorney General
( US Supreme Court: Olmstead Decision )
ND Registered Sex Offenders
North Dakota Service Organizations Lutheran Rural Response
North Dakota University System
General information about North Dakota
ND maps -:- Map of ND -:- ND road report -:- ND topographical maps
Dirt - "a Down-to-Earth Guide to ND"
A Brief Natural History of North Dakota 1804-pres.
the North Dakota Rant
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This page is initially placed on the internet 02/11/03. It is an off-the-top-of-my-head rough draft just now and therefore may change some in the next weeks. If you have been here before and it's been awhile since 02/11/03, hit RELOAD to freshen the page. |