Individual Therapy on Inpatient Units: Flexibility in the Face of Resistance

The length of stay for inpatient adolescent admissions has decreased significantly over time.¹ This has forced a reframing of the purpose of hospitalization as being focused on the tasks of maintaining safety, clarifying a diagnosis, optimizing medication, and arranging ongoing care. There are thus no standard approaches for the delivery of individual therapy that accommodate the complexity, heterogeneity, acuity, and time limitations of the inpatient setting. That being said, efforts continue to be made to provide some form of therapeutic engagement on inpatient units that goes beyond psychiatric assessment and basic nursing intervention. In this perspective, we describe a targeted approach toward individual therapy during acute hospitalization. This approach is applied successfully on a general inpatient adolescent unit in New England that maintains a low rate of restraints, seclusions, and readmission. Our unit treats verbal adolescents (younger youths and adolescents with significant cognitive or social learning limitations are accommodated in other settings within our community), but aspects of the approach have broader applicability. Guiding principles are drawn from a range of theoretical approaches, including collaborative problem solving,² trauma-informed care,³ and strength-based care⁴ (Table 1). The program involves staff (activity therapists and nurses) being educated around key principles of a range of therapy modalities, which are then modeled by program leadership in multidisciplinary settings, such as walking rounds and group meetings. The approach is then incorporated into how the patient is engaged throughout the milieu. Staff education begins during initial onboarding to the unit, but then occurs in an iterative way as new patients with new therapeutic needs enter the milieu.