Bresnahan, Boyd K.

Schilhaneck, Larry

English

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Henry Ford Hospital Medical JournalVolume 20 | Number 2 Article 96-1972The Psychiatric Walk-In Clinic Service: An InterimReport of Experience at Henry Ford HospitalBoyd K. BresnahanLarry SchilhaneckFollow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournalPart of the Life Sciences Commons, Medical Specialties Commons, and the Public HealthCommonsThis Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in HenryFord Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.Recommended CitationBresnahan, Boyd K. and Schilhaneck, Larry (1972) "The Psychiatric Walk-In Clinic Service: An Interim Report of Experience atHenry Ford Hospital," Henry Ford Hospital Medical Journal : Vol. 20 : No. 2 , 103-107.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol20/iss2/9Henry Ford Hosp. Med. Journal Vol. 20, No. 2, 1972 NOTES AND COMMENTS II The Psychiatric Walk-In Clinic Service An Interim Report of Experience at Henry Ford Hospital Boyd K. Bresnahan, M.D.* and Larry Schilhaneck, M.S.W.** In the time since the first Walk-In Psychiatric Clinic was conducted at Henry Ford Hospital on January 14, 1970, to May of 1972, 1,254 cases have been seen. Of this number, the authors and a resident physician work-ing directly with us handled 104 cases registered in the year from May 1971 to April 1972. Our series will be de-scribed in this paper. The outline and philosophy of the clinic has been described in detail.^ In essence, important reasons for es-tablishing the clinic had to do with eliminating the long waiting list (up to as much as six weeks) and to assist in dealing with "emergencies". An added problem was that up to one third of the new patients on the long waiting list failed to appear for ap-pointments. This constituted a sig-nificant waste of professional time. We set aside Wednesday, between the hours of 9:00 and 3:00 p.m., for patients to be seen without any ap-*Staff psychiatrist **Chief of Counseling Service, Department cf Phychiatry. Reprint requests should be addressed to the authors, c/o Henry Ford Hospital, Detroit, Mich. 48202. pointment in the Walk-In Clinic. When they arrive, they are seen first by the clinic nurse, who completes a rather detailed formal questionnaire; then, a counselor, and then a psychiatrist. Prior to the interview, the psychiatrist has a conference with the counselor and, in some cases, the nurse to share information. Disposition is made by the psychia-trist in conjunction with the opinions of the counselor. The disposition is completely open-ended and is unlike that described by Paul and Normand- ^ for certain walk-in clinics. Nor is it like the psychiatric emergency clinics described by Coleman and Zwerling in 1959'' and Coleman and Rosenbaum in 1963." These authors have outlined clinics wherein disposition has con-sisted of brief psychotherapy lasting no more than five to six visits which is described to the patients at the time of initial evaluation. At Bronx Muni-cipal Hospital Center* a psychiatric emergency clinic functioned as a 24-hour service. That clinic and many others serve not only as evaluatory and disposition agencies, but offer return visits as a significant part of their ser-103 Bresnahan and Schilhaneck vices, particularly of chronically i l l patients. At our clinic, disposition may con-sist of recommendations for admission to in-patient psychiatric care, psycho-therapy (long or short-term with either a counselor or a psychiatrist), group therapy, marital counseling, individual counseling, further diagnostic inter-views, referral to other departments, psychological testing, or referral to agencies outside the hospital, including a public hospital or clinic, or an al-coholism or drug abuse treatment pro-gram. It is our opinion that nothing would be gained by attempting to re-strict disposition to certain treatment modalities. The walk-in clinic at Henry Ford Hospital functions solely as an intake evaluation and disposition service. For practical purposes, all patients seen are new to the psychiatric department, with the exception of a few former patients whose therapists have left the staff. For many patients, revisits occur to the department, but these are not considered open clinic visits. Emer-gency psychotherapy is done in our setting, but not as mentioned in the walk-in clinic parameters. Tables 1 and 2, respectively, give a breakdown of diagnosis and disposi-tion by referral source of the 104 cases we handled. Table 2, additionally, shows the number of patients who are designated as "no returns". These pa-tients had a course of treatment recom-mended to them, made an appoint-ment, but never kept it. To some extent, they are analogous to the "dropouts" described by Salzman^ yet not as restrictive in definition. Of the 17 patients in this group, 15 had been referred for further out-patient psy-chiatric visits and two to other depart-ments. Twelve patients in the study were referred from the hospital emer-gency room. Of these, five were later referred to public clinics, five others were referred for further out-patient visits in our clinic, and two had no return recommended. Two patients from our group entered counseling, the other three were "no returns". It is noteworthy that 43 patients, or 42.2%, were referred for either counseling or psychotherapy on an out-patient, in-dividual basis. Only eight patients, 7.3%, were recommended for admis-sion. This re-inforces the impression that hospitalization can be prevented by early intervention. We will present two cases as illustrations. We plan to follow up the 17 "no returns" by phone or mail to attempt to determine the stated reason or rea-sons for not continuing. The high number of referrals to public agencies is directly related to the fact that psychiatric services are not covered by Medicaid. While our clinic has no eligibility requirements and payment is not a requirement for evaluation, only five patients with primary symptoms of drug addiction were evaluated in this group. Two patients were given return appointments which they failed to keep. Two patients were referred out to drug treatment programs and one of these followed through. The fifth wanted to be on an out-patient metha-done program which we do not operate. Case Reports The following case reports illustrate that early short-term intervention can 104 The Psychiatric Walk-In Clinic Service o 1.1 u 03 < o • m CQ •- c E c . E o 03 03 ± : OX) T3 O >-CO O T3 o o o u i> OJ E ra _ t J 3 O OT CU ,—I ,—I o o OO c» ro o i n CNJ o o m ro t o in ro CM o i n r - . CM I D cr <u'm TD o c c LU Q 21 M- CJ 0) E •a < c/l C\3 C ^ g a. a. 3 ro g DO ro 5 := = OJ <u •D . E cn ]> O § •D .1= O .E ^ " £ o ro CO o X o c o IU < CD <u S O ro E ca. ro CD Ll_ (U to C OJ C 3 c £ ro "2 5 E K? o o 0) O OT UJ U. Q-3 O OT cr in I— ro o I T-H t ro o o CNI CNJ o o m m o T-t CM ^ o CM I ro o o CNJ ^ o o ) cn CO in m ' o 0) c J : CD c < OJ E -E o ^ , t - E .3! ro t >,-!z; 3 o 01 c^J O QO S O g -J g - O 0) M- oj E o O OT UJ LL. CL 105 Bresnahan and Schilhaneck significantly alter the course of very severe psychopathology. Case I . This 35-year-old single tax analyst came with a complaint of difficulty in concentrating at work and vague paranoid ideas regarding co-workers. He had a his-tory of similar complaints in 1966 which were resolved in a short time. During the interview, he was inappropriately angry and showed an obvious thought disorder. He was given medication, re-assurance, and an early return appointment. In the second and third interviews, it became apparent that he was angry and frustrated at co-workers. These included especially subordi-nates but also his supervisor whom he felt organized the office in an inefficient way, leaving him with an excessive work load. He was unable to express these concerns to anyone and, hence, the symptoms devel-oped. With direct advice and re-assurance that expressing his feelings would not be inappropriate plus the medication, he quickly improved. At the time of the third visit, he and the therapist both felt no return was necessary except on a p.r.n. basis and treatment was discontinued. Case I I . A 33-year-old married administra-tive clerk with ulcerative colitis was referred because he felt he was being followed. He described what he believed was an elaborate system of cars and radios which kept surveillance on him. It was soon apparent that his paranoid projection was related to his wife's gynecologic problems which had caused much sexual abstinence. Underlying homosexual fears were threatening to break through. With medication and after two more psychotherapeutic visits after the initial evaluation, he stated that he was sure he had been wrong about being followed. His agitation had gone and he described himself as being well. Return was advised on a p.r.n. basis only. In both of these cases, a knowledge of psychodynamics in a short-term setting proved highly meaningful in returning emotional homeostasis. Comments We believe the most significant features of a walk-in clinic are the absence of any wait and the ability to refer a specific case to the appropriate treatment modality. The 16.3% of "no returns" compared to the figures of Salzman" and Lief' is probably too high and these will be evaluated via direct contact with each patient. Emer-gency room referrals were those least likely to return for treatment, either due to ineligibility for insurance cov-erage, or lack of need for or interest in treatment, as expressed at the time of evaluation. The psychiatric walk-in clinic is a part of the recent trend toward "com-munity psychiatry" which aims to make more treatment available to larger groups of people. In the absence of greater manpower availability, innova-tion in treatment technique is its hall-mark. Some have described it as the third revolution in psychiatry, the first being the recognition by Pinel and others that illness was not caused by demon possession; the second being the dynamic insights of Freud. In this interim report and more detailed ones to follow, we hope to aid in evaluating how and where walk-in clinics best fit into this trend. REFERENCES 1. VonBrauchitsch, H , and Mueller, K: Experience with a psychiatric walk-in clinic at a general hospital, Hosp Community Psychiat. in publication 1972 106 The Psychiatric Walk-In Clinic Service 2. Paul, L: treatment techniques in a walk-in clinic, Hosp Community Psychiat 17:49-51, Feb 1966 3. Normand, WC; Fensterheim, H, and Schrenzel, S.: Systematic approach to brief therapy for patients from a low socioeconomic community. Community Mental Health J 3:349-54, Winter 1967 4. Coleman. MD, and Rosenbaum, M; the psychiatric walk-in chnic, Israel Ann Psychiat 1:99-106, Apr 1963 5. Coleman, MD, and Zwerling, I : The psychiatric emergency clinic—a flexible way of meeting community mental health needs. Amer J Psych 115:980-4, May 1959 6. Salzman, C et al: Interviewer anger and patient dropout in walk-in clinic. Compr Psychiat 11:267-73, May 1970 7. Lief, H et al: Low dropout rate in a psychiatric clinic. Arch Gen Psychiat 5:200-11, Aug 1961 107 

The Psychiatric Walk-In Clinic Service: An Interim Report of Experience at Henry Ford Hospital

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The Psychiatric Walk-In Clinic Service: An Interim Report of Experience at Henry Ford Hospital

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