Jordan House: a community alternative to hospitalization; A provider organization offers a "natural" environment to people in psychiatric crisis.

Sometimes developing an innovative program for the treatment of psychiatric illnesses does not necessarily require coming up with a new idea--but rather returning to a great one. Although the Jordan House psychiatric crisis stabilization program opened its doors in April 2005, its components were carefully crafted after Crossing Place, which was started 30 years ago in Washington, D.C.

Background

Jordan House, operated by So Others Might Eat, Inc. (SOME) in Washington, D.C., serves as a homelike, community alternative to psychiatric hospitalization for people in acute crisis. The idea for an effective treatment alternative to hospitalization goes back to the early 1970s. Loren Mosher, a psychiatrist in Northern California, decided to test his theory that a therapeutic milieu could be just as effective as the standard of care in reducing the symptoms of schizophrenia. His research led to a program called Soteria, and its offspring, Crossing Place, came about a few years later in 1977. Several research studies validated his claim, demonstrating that alternatives to hospitalization, when implemented correctly, can be more cost-effective and have equal symptom-reduction and recidivism rates compared to a hospital stay. (1,2) Such "crisis bed" facilities also allow clients more integration with the community during their stay and can offer more freedom and autonomy than a hospital allows.

Jordan House's staff has attempted to closely follow the original Crossing Place model. The following are some components that have been suggested as essential to the accomplishments of similar programs:

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* maintaining a small and homelike family environment with two staff members, a man and a woman, on duty for 24-hour shifts;

* providing intensive one-on-one support by "being with" and "doing with" residents without being intrusive;

* having a minimal hierarchy so residents are encouraged to maintain their autonomy;

* offering supportive counseling and therapeutic activities such as art, outings, gardening, shopping, and cooking, but no formal therapy; and

* encouraging residents to maintain relationships with the staff, program, and other alumni following discharge.

These essential ingredients helped guide the formation of Jordan House's program.

Although psychotropic medications were not used in the original Soteria model, they were routinely used in its offspring, Crossing Place, and are an important part of the Jordan House program, as well. Jordan House staff and psychiatrists emphasize the importance of receiving accurate information about each medication prescribed so that residents can make an informed choice to continue the right medications without coercion after discharge.

In its first two years, Jordan House's staff excelled in quickly stabilizing residents' psychiatric symptoms. They accomplished this by creating an environment that enabled residents to:

* form positive relationships that continue after their stay is complete;

* develop coping methods to prevent another crisis;

* connect with desired resources in the community; and

* build independent living skills.

Relationships

Jordan House is a homelike family setting where counselors essentially reside with residents, whose stays are usually less than 14 days. Male and female counselors work 24-hour shifts, spending day and night with residents. The counselors have stated that some of the most therapeutic conversations take place during ordinary activities such as drinking morning coffee together, driving to an appointment, or baking a cake to celebrate a resident's birthday.

Because Jordan House is a more natural setting, the staff has been able to more easily engage resistant individuals. Jordan House has had many previously institutionalized (incarcerated, hospitalized, etc.) residents who reacted defensively upon arrival, thinking that Jordan House is another place that attempts to control behavior. The counselors have built strong therapeutic alliances by offering a nonhierarchical environment and encouraging residents' autonomy. Counselors encourage residents to develop their own goals rather than dictating what they believe is in residents' best interest.

Jordan House has an alumni group and encourages residents to maintain contact after discharge. Former residents have facilitated alumni meetings, organized an open house celebration, and supported current residents. This group, initiated by a former resident, has helped residents to feel valued, to increase their self-esteem, and to build community involvement and responsibility. Jordan House invites former residents to drop in for words of encouragement or to share news of their successes and to occasionally join in dinner as part of the extended Jordan House family.

Coping Skills

Jordan House's staff works hard to encourage residents to develop the coping skills necessary to prevent another crisis. Sometimes this encouragement takes place as part of a stress management support group or discussion with the psychiatrist, but more often it is in the "here-and-now" interactions of daily life together. Staff model effective coping skills and prompt residents to take note of how their thoughts or behaviors in the therapeutic community are exacerbating their psychotic symptoms or feelings of despair. The staff serves as a mirror, reflecting to residents how positive actions such as taking medications, eating properly, and talking about their feelings have resulted in an increased stabilization of their symptoms. Because Jordan House is a normal environment, the residents are more easily able to continue these behaviors in a new location after discharge. Jordan House also has a certified WRAP (Wellness Recovery Action Plan) trainer who volunteers her time to help residents develop self-designed plans for staying well.

Community Resources

Although the length of stay is very short, it is often a time of tremendous action, especially in connecting to community resources. Along with the support of the staff and other case managers in the community, residents are linked to medical care, health insurance, Social Security benefits, employment, day socialization programs, substance abuse treatment, mental healthcare, GED programs, legal assistance, and much more. These resources often meet needs that have been neglected for some time. In certain instances addressing these additional needs has prevented hospitalization and even death.

Independent Living Skills

Jordan House encourages participation in household activities in order to model independent living skills, to teach coping skills, and to simply recreate together, thus enhancing the therapeutic community. Residents regularly have art projects, do stress/relaxation exercises, cook meals together, clean the house, do gardening projects, and visit parks, the zoo, museums, and other places. Residents previously unable to successfully live in the community because of paranoia, disorganized behaviors, or limited skills learn how to trust others and give back to a community environment. Residents often offer to do additional chores and maintenance in the house as they take pride in their community environment.

Outcomes

The therapeutic ingredients outlined above have resulted in positive outcomes for our residents. Of 147 residents served in the first year, only 5 required a transfer to hospitalization during their Jordan House stay. Jordan House's level of care, although much less restrictive than a hospital, was capable of successfully stabilizing psychiatric symptoms for 85% of our residents with severe and acute mental health symptoms. For its efforts, Jordan House was recognized with a 2006 Lilly Reintegration Award.

Conclusion

The majority of Jordan House's staff members does not hold advanced degrees or have certificates from training institutes offering the secrets to psychiatric stabilization. They are simply compassionate, diligent individuals with the desire and commitment to being a therapeutic presence for others in distress. This personal commitment of all staff members, combined with the team's strong belief in the power of a therapeutic environment, has enabled Jordan House to experience its early success.

Audrey Read Brown, LICSW, is Director of Behavioral Health Programs at So Others Might Eat, Inc., in Washington, D.C.

To contact the author, call (202) 797-8806, ext. 1123, or e-mail aread@some.org.

References

1. Fenton WS, Mosher LR, Herrell JM, Blyler CR. Randomized trial of general hospital and residential alternative care for patients with severe and persistent mental illness. Am J Psychiatry 1998;155(4):516-22.

2. Kresky-WolffM, Matthews S, Kalibat F, Mosher LR. Crossing Place: A residential model for crisis intervention. Hosp Community Psychiatry 1984;35(1):72-4.

BY AUDREY READ BROWN, LICSW