In a recent post, I chronicled the first half of my 24 years of employment as a clinical psychologist at Eastern State Hospital, a public psychiatric hospital in Lexington, Kentucky, which opened in 1824. If you would like to catch up and read part 1 first, it’s right here.
In the early 2000’s, “recovery” entered the scene as a new way of thinking about treatment. The concept of recovery had primarily been used in reference to substance use concerns, but it was now being extended to encompass all mental health conditions. This work was strongly influenced by principles of psychiatric rehabilitation, which had come to prominence in the 1980’s.
It’s important to note that recovery was not meant to convey a “cure” or a complete absence of symptoms or problems. It was defined instead as “a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential” (National Consensus Conference on Mental Health Recovery, 2004).
In the spring of 2005, we formed several work teams to develop a new hospital-wide treatment program based on the recovery approach. We modeled our program after the work done by Middletown Psychiatric Center in New York state in the mid-1990’s. Middletown had developed a “Treatment Mall,” a central treatment area in the hospital apart from the patients’ treatment units. Patients would go to the mall each day and participate in a variety of educational groups and therapeutic activities. The mall also featured a café and a boutique.
Several other state psychiatric hospitals had replicated Middletown’s treatment mall. Warren State Hospital, in western Pennsylvania, published a report showing that following implementation of the treatment mall, outcomes included enormous increases in the daily amount of active treatment time patients engaged in. Additionally, they found decreases in psychiatric symptom levels and increases in social adjustment. Patient aggression and falls also decreased throughout their hospital.
Our teams tackled three large tasks, including: a) how to redesign existing facility space to create a spacious and therapeutic “mall” area, b) how to develop the groups, classes and activities to include in the program curriculum, and c) how to address logistical issues such as patient safety, and timing of daily meals, breaks, and medication administration.
Perhaps the most exciting development during the planning for the new program was to include consumer and family representatives on the work teams. Our local NAMI (National Alliance on Mental Illness) chapter was an active and progressive group, and they were eager to help us design the program to include the voice and perspectives of patients and their families. In retrospect, I believe this collaboration was one of the most significant advances in patient care in the entire history of the hospital.
As we neared the opening of the program, a new staff position was created for a director of our new treatment mall. I applied for the job and was selected. This position afforded me the opportunity to oversee the program, further develop recovery-based programming and to immerse myself in the growing research literature on recovery, peer support, and psychiatric rehabilitation. I was also fortunate to be able to forge closer relationships with community, family, and advocacy groups and organizations.
After 15 months of preparation, our “Recovery Mall” opened on May 1, 2006, which also happened to be the hospital’s 182nd anniversary. An entire floor of one of the hospital buildings, over 30,000 square feet, had been redesigned to create the mall space. New paint and furnishings along with vibrant artwork done by patients created a pleasant and inviting space. The mall included the following areas:
- Welcome Center: Reception area and private rooms for staff-patient interviews.
- Learning Center: Classrooms for educational groups and a relaxation room.
- Resource Center: Full-service library plus a music listening room.
- Leisure Center: Leisure options (large TV, ping-pong, air hockey and pool tables), arts and craft room, snack area, and outside courtyard.
- Gift Shop: Sundries and gently used clothing. Patients could shop for free, using points received from attending mall groups.
- Gymnasium: Fitness and sports programs; could also be used as an auditorium for special programs.
- Skills Center: Full kitchen, group areas and a computer lab with Internet access.
- Consumer and Family Center: Group rooms, music therapy room and NAMI office.
- Relaxation Station: Salon for haircuts, shampoos, and makeovers.
The Recovery Mall was somewhat like a college for mental health. Each patient had an individualized mall schedule, developed with the assistance of a staff “recovery coach.” Each weekday, patients came to the mall in the morning, attended two groups or classes, had a lunch break, then returned for three more sessions in the afternoon. Additionally, there were breaks for snacks and time outside. Evening and weekend programming was also provided. One of our staff, who was a great teacher, told patients that while our “mall” didn’t have a bunch of stores and restaurants, it was a place they could “shop for new ideas” for health, healing and wellness.
The Recovery Mall programming was diverse and extensive with over 60 different program options. Over 300 hours of evidence-based programming were provided each week by hospital staff and NAMI-affiliated peer support specialists. We organized the program options around the following “4 dimensions of recovery” as developed by SAMHSA (the US Substance Abuse and Mental Health Services Administration):
HEALTH: Options included groups on symptom management, drug and alcohol education, fitness, group sports, WRAP (wellness recovery action plans), managing difficult emotions, and physical health and nutrition.
HOME: Groups and classes included home management skills, healthy relationships, managing finances, and meal preparation and planning.
PURPOSE: These program options covered topics such as getting and keeping a job, computer skills, GED preparation, literacy coaching, and creative expression through arts, crafts, and leisure activities.
COMMUNITY: Programs included leadership skills, community field trips, sharing one’s personal recovery journey, spirituality and worship services, and current events.
Another shift that occurred with the advent of the Recovery Mall was that patients no longer spent long periods of time outside smoking cigarettes. There were still a few short breaks each day for patients to go outside and smoke. A few years later, the hospital and campus went smoke-free, catching up with virtually every other modern hospital’s policy. No patient had to go “cold turkey;” nicotine replacement options (patches, gum, and medications) were freely offered. In some respects, I believe the change to a smoke-free campus was harder on some of our staff who were smokers than it was on the patients!
Needless to say, the Recovery Mall was a big hit. Patients loved all the groups and activities. One patient wrote: “At classes here in the Recovery Mall, meeting new people and making new friends are easy to do. That’s why I am glad I met all of you, and I thank God for all of you. The Recovery Mall has made its name good, and it says what it means—Recovery. The staff here at the Recovery Mall care about all of us. They have given new ideas and new hope for lasting wellness. So make the most of every day here. They are here to help if you allow them to. So I say, “Thanks” to all of you.”
Staff also appreciated how patients were off the units and more engaged in therapeutic activities. The program received positive feedback from external organizations as well. Over the next few years, the Recovery Mall received awards from the state department for behavioral health, NAMI, Mental Health America, a regional medical news publisher and even one of the leading national pharmaceutical companies. We also consulted with the three other Kentucky state psychiatric facilities and helped them establish similar treatment mall programs.
Another exciting offshoot of the program was our annual Recovery Festival. In the gymnasium, we hosted a fun-filled day with dozens of tables with resource information from recovery-oriented community agencies, live music, inspirational personal accounts of recovery, and refreshments.
It was gratifying to help bring about this positive shift in our approach to care and to see so many patients tangibly benefit from the exciting and diverse array of treatment options in the program. The “treatment mall” model has now spread to dozens of inpatient psychiatric hospitals throughout the US. Not long after our program was established, the hospital underwent its regular three-year re-accreditation survey from The Joint Commission. The surveyors were very impressed with the mall programming and one surveyor commented that the program represented “best practices.”
While this dramatic transformation of our treatment services to a more recovery-based approach was a tremendous milestone, we still faced the reality of being housed in a deteriorating physical facility now over 180 years old. But efforts were already underway that would lead to the funding and construction of a new hospital. That part of the story is covered in the third and final part of this series.
Here’s a question: How have you seen recovery-based approaches incorporated in inpatient psychiatric facilities? Please leave a comment. Also, please subscribe to my blog and feel free to follow me on X (formerly Twitter) or Instagram, “like” my Facebook page, or connect on LinkedIn. Finally, if you enjoyed this post, please share it with a friend. Thanks!