End Game

Higher levels of care (i.e., any form of treatment other than outpatient therapy) are meant to be brief - they offer intensive intervention to stabilize acute distress, and get clients to the point where they can continue with standard outpatient treatment. Sometimes a client is so impaired that they do not stabilize quickly, even at the highest levels of care, resulting in long-term hospitalization. Most, however, show some improvement within a few days to a few weeks of treatment.

Because of the nature of higher levels of care, clinicians have to be thinking about discharge from the very beginning of treatment. Given that treatment is meant to stabilize acute symptoms, rather than restore someone to full functioning, what are reasonable treatment goals? What will tell us that the client is ready for discharge to a lower level of care? When should we conclude that the client has gotten as much as they can from this level of care, and lengthening their stay will not be therapeutic?

The answers to these questions are rarely clear. Client self-determination is a factor - what are their goals? Do they want to stay? When do they think they should discharge? It's not the only factor, though: sometimes clients want to discharge when they're still in crisis, and sometimes clients want to stay when they've already stabilized. Another litmus test is needed. Sometimes it's clear - the client is no longer suicidal or self-injuring; psychotic symptoms have resolved; weight is restored; target behaviors have been in remission for a period of time.

There are other times, however, when it is much less clear. Often, there is only partial remission of symptoms and behaviors, so the question becomes: how much improvement is necessary to warrant discharge? There are a few rules of thumb:

• Safety is paramount - if the client poses a threat to self or others at a lower level of care, they obviously aren't ready for discharge. Safety is also a consideration from the perspective of self-care, for psychosis, as well as indirect forms of self-harm, such as eating disorders.
• A decline in functioning may indicate that a higher level of care is necessary, while a plateau can be a sign that the client has gotten all they can from the current treatment and is ready for discharge. That said, some regression is possible prior to a planned discharge, and plateaus may not last.
• Disengagement may indicate a higher level of care (when there are safety issues) or discharge (when there are not safety issues) 

Especially the latter two considerations are very ambiguous to define in practice, and require judgment calls. When discharge is considered for clients whose symptoms have not fully resolved, it's important to ensure that there is some vehicle for continued care (e.g., outpatient providers who will continue to work with the client), as well as sources of support (family, friends) who can monitor the client's safety and help him/her decide if a return to a higher level of care is necessary in the future.

How do you decide when to discharge or terminate with a client? What factors go into that decision?