How Inpatient Psychiatric Units Can Be Both Safe and Therapeutic

Abstract

Inpatient psychiatric units should be therapeutic environments that support dignity and recovery. When adverse outcomes (eg, self-harm, violence) happen in these settings, clinicians and administrators can face litigation and other pressures to prioritize risk management over supporting patients' access to personal belongings, exercise equipment, and private spaces. This article describes these downward pressures toward sparser, controlling environments in inpatient psychiatric settings as a safety funnel and suggests strategies for balancing safety, humanity, and recovery in these contexts.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. Evolution of Inpatient Psychiatric UnitsInpatient psychiatric units are supposed to offer therapeutic environments for patients to recover from severe psychiatric symptoms. As far back as 1847, Thomas Story Kirkbride, a US physician, published "Remarks on the Construction and Arrangements of Hospitals for the Insane." 1,2 This treatise focused on all aspects of the design and organization of hospitals for people with mental illness, 2,3 such that, as Tomes argues, "every detail, from the design of the window frames to the table settings in the ward dining rooms, had to be arranged to sustain the impression that here was an institution where patients received kind and competent care." 1,3 Long-term psychiatric hospitals in the United States and elsewhere, often referred to as asylums, occasionally had sprawling facilities with acres of land, gardens, chapels, or other amenities for engendering tranquility among the inhabitants. 4,5,6 Although large, often state-run, facilities played a considerable role in the care of people with mental illness into the 20th century, by mid-century, increased public awareness of the conditions inside certain facilities, growing emphasis on patients' rights, and other developments led to a shift away from these types of facilities toward community-based care. 7,8 In parallel, the goal of psychiatric hospitalization shifted from long-term psychiatric and custodial care to short-term stabilization. 7,9 The evolution of inpatient psychiatric settings toward brief stays has coincided with increased clinical and legal emphasis on promoting safety and preventing adverse events. This article describes the Citation