Not a lot of information is available online for teachers who want to support their students returning to school after a stay at the hospital for psychiatric care for behavioral health reasons. With privacy laws, school policies and families who, understandably, might not want to share details about a student’s psychiatric hospitalization, a caring teacher may find themselves lacking information on how best to support a student’s return to school. Here is a breakdown of information about helping students after a mental health hospitalization.
Psychiatric Hospitalization: Where do the students go when they are hospitalized?
Not all students who are ‘hospitalized’ actually sleep at the hospital. Depending on the behavioral health needs of the student, they may find themselves staying at the hospital for inpatient treatment or staying at home for outpatient treatment and going to a behavioral health day program.
Getting admitted to a psychiatric hospitalization care program
The needs and circumstances of the student’s behavioral health crisis are what determines if a student will receive inpatient or outpatient behavioral health programming. In my experience the difference is determined after an evaluation by hospital staff, typically a social worker in the ER or a behavioral health specialist after making a non-emergency appointment for a behavioral health evaluation.
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The difference between an immediate ER visit and a non-emergency behavioral health evaluation should come down to whether or not the student or individual feels they can be safe by themselves at home. If there is a concern that this is not the case if the student is having suicidal ideation, the student should be brought to the ER for an immediate evaluation.
Types of Psychiatric Hospitalization Programs
IOP- Intensive Outpatient Program- Typically 3 hours a day, sleep at home
PHP- Partial Hospitalization Program- 6 hours a day, sleep at home
Inpatient Treatment- 24 hours a day, sleep at hospital
Locations of Programs
In my experience there are three determining factors for where a student will receive these behavioral health services: insurance, time of year and program capacity.
Locations of Programs- Insurance
The better insurance a family has, the better access to quality psychiatric programming. Unfortunately psychiatric hospitals are not all created equal and there are some really bad programs out there.
Having had both HMO and PPO insurance in my life, I can tell you that a high quality PPO program is the gold standard for access to mental health programs. That is not to say that HMO insurance is bad. HMOs can be a great cost savings option if you and your family are physically healthy and will never need mental health services. Unfortunately HMO insurance keeps costs down by contracting services with only a handful of service providers. If you find yourself in need of accessing a mental health program with HMO insurance, you will have to go to the program the HMO will pay for and chances are it is not going to be the best program in the area. With an HMO, families have extremely limited options for mental health services.
If you are incredibly wealthy and can pay out of pocket you probably don’t need to worry about insurance coverage and can pick any program that has a vacancy.
Locations of Programs- Time of Year
The need for inpatient behavioral health hospitalization programs typically runs with the school year. Many hospitals do not find the need to staff these programs in the summertime and will often close for the summer months, until they need to reopen when school resumes.
Locations of Programs- Capacity
Inpatient hospital programs, ones where students stay overnight on the adolescent behavioral health ward, need to have the ability to monitor the patients in the program to ensure patient safety. In order to do this programs might reach capacity since they have a lower patient threshold.
The program I had personal experience with, a large hospital in the suburbs of Chicago, had a maximum patient capacity of 14 adolescents. If a 15th adolescent arrived in the ER and required a stay, they would have been outsourced to another hospital adolescent behavioral health program.
Psychiatric Hospitalization: What to expect when students stay at the hospital?
If a student goes to the hospital for a mental health crisis and the staff recommends an inpatient stay at a hospitalization program, that doesn’t mean the student would automatically stay at that specific hospital.
First the hospital needs to have a behavioral health ward. When individuals are hospitalized because they are feeling suicidal, they don’t stay on the hospital floor with other patients at the hospital who are physically sick or recovering from a medical incident. The behavioral health patients stay on the ward that is specially designed to limit the safety risk of these individuals.
Furniture, Food & Clothing in the Program
This inpatient behavioral health ward should be highly secure and allow for constant monitoring to ensure the safety of all patients. The furniture is designed to keep patients safe. Chairs and tables are designed to be extra heavy, to limit throwing them. The TV in the lounge area has a protective cover and can only be used by remote control, most likely held at the nurse’s station. The mattresses in the rooms are not comfortable bed mattresses, all items that could be used to hurt an individual have been removed.
Food is delivered on cardboard trays instead of plastic due to the safety risk. Clothes are limited to items that do not have strings or added decorations that could detach or be ripped off to use for self-harm.
Due to the secure nature of the behavioral health ward, patients do not leave during their stay. This means they do not go outside.
Visiting Hours & Calls
Visiting hours are extremely limited for family members. In our experience there were two fifty minute visiting sessions offered each week and only immediate family members over the age of 18 were allowed to visit. Phone calls were allowed at designated times of the day each day.
Daily Schedule
Inpatient Hospitalization has a very structured day. Students do not have access to cell phones, tablets and even the internet. To keep the students occupied, they are busy with counseling, checking in with a psychiatrist, group therapy, yoga, art therapy etc. throughout the day. Students have some down time in the evening before they are to go to bed at 10PM.
Clothes & Showering
Clothes can be dropped off for the patient, but they need to have all strings and other safety hazards removed or cut out of them. For example a hooded sweatshirt with a drawstring would need to have the drawstring removed. Before the clothes are handed to the patient, a nurse or counselor is tasked with going through the clothes to make sure they are safe.
Each bedroom has a bathroom. Some patients may feel uncomfortable with the idea of showering at the hospital due to the lack of privacy as patients are monitored every 15 minutes.
PHP & IOP: What to expect when students go to a Partial Hospitalization Program or Intensive Outpatient Program?
IOP- Intensive Outpatient Program- Typically 3 hours a day, sleep at home
PHP- Partial Hospitalization Program- 6 hours a day, sleep at home
Students will most likely start with the Partial Hospitalization Program and work their way down to the intensive outpatient program as they transition back to attending school.
The PHP we experienced started the program at 8:00 AM and ran until 2:00 PM with one hour of tutoring and lunch. Throughout the day patients would experience many similar things from a hospitalization program including individual and group therapy, expressive therapy, cinematic therapy and check-ins with a psychiatrist 2-3 times a week.
When the patient transitions to the IOP there should be a school transition meeting with the student, parents, staff from the program and the school. Staff from the school will most likely include the school counselor, psychologist, social worker and in our experience the wellness coordinator (a person whose full-time job is to facilitate the return to school who are hospitalized).
As students move to the IOP program, they would leave the program at 11:00 and go to school for the remainder of the day.
Transportation can be an issue as many families have working parents that are unable to transport their students to school. It was not uncommon for taxi services to be arranged for student transportation back to school.
IOP & Return to School Full time: What to expect when students come back to school?
As students transition back to their typical school routine there are a few things teachers should keep in mind.
- Sensory Overload – Students who have worked through the various hospitalization programs have most likely been outside of school for 3-6 weeks. They may struggle with various overwhelming feelings as they return to a middle or high school environment. Noise canceling headphones, passes to leave prior to passing period, check ins with a mental health specialist (social worker, counselor, psychologist etc) and access to a quiet space may be accommodations that are beneficial for these students.
- Safety Concerns- Anxiety can be a big trigger for students returning from a mental health crisis. Specific locations and times in the school day tend to be more challenging for a student’s anxiety. If a student thinks one of these locations are unsafe, they may decide to avoid those locations. Specifically check in with the student about:
- Bathrooms- Does the student feel the bathrooms are safe? How often do they go during the day? What bathroom in the school could they use comfortably. While this topic might feel like TMI, a lot of students who struggle with their mental health are quite skilled at avoiding uncomfortable situations. If the bathroom makes them uncomfortable, it is probably not hard for them to hold off the need to go to the bathroom all school day. Some suggestions for decreasing the challenges of the bathroom include:
- Identify a safe to use bathroom- are there any bathrooms with staff members standing nearby?
- Students might struggle to comfortably use the nurse’s bathroom as they might think of it as the ‘sick’ bathroom. This might be a specific trigger for individuals who struggle with OCD
- Lunch- Similar to the bathrooms, lunch can be an overwhelming sensory experience with a lack of structure. Many unexpected behaviors can happen during lunch causing a student’s anxiety to increase. Does the student have a safe, quiet space they can go to during lunch?
- Buses & Entry/Dismissal Times- All of these times and locations are all the most unstructured and chaotic time of the school day. Riding the bus to and from school is quite different than the loud chatter of a teaching riding the bus during a field trip. Loud chaos is probably a fair description of many bus rides, which can increase anxiety. Some suggestions for decreasing the challenges of these times include:
- Work with families to see how to best get the student to and from school.
- Provide a quiet/cool off time before going to class in the morning.
- Give the student a pass to leave their last period class a few minutes early at the end of the day in order to be out of the school prior to dismissal
- Think flexibly about the student’s schedule. Do they need a first period class? Can someone drop them off during first period? Is it possible to have a less rigorous class first period in order to transition to the remainder of the school day.
- Bathrooms- Does the student feel the bathrooms are safe? How often do they go during the day? What bathroom in the school could they use comfortably. While this topic might feel like TMI, a lot of students who struggle with their mental health are quite skilled at avoiding uncomfortable situations. If the bathroom makes them uncomfortable, it is probably not hard for them to hold off the need to go to the bathroom all school day. Some suggestions for decreasing the challenges of the bathroom include:
- Make Up Work- Teachers that work with the wellness coordinator, social worker or individual who coordinates the missing assignments can alleviate additional stress for the student. One shared doc of missing assignments is helpful for the student to stay organized.
- Discuss Grades Honestly- Students who miss 3-6 weeks of material may struggle to continue on with lessons. While accommodations should be made to help them get caught up, students have a few options of getting back on track. They might need to be prepared for a less than perfect grade. The other option is that they might need to drop the class and retake it during summer school. While this option might sound bad, it might lighten the student’s academic load during the day and make it easier to focus on one class over the summer.
- Read more about different ways to support students at school.
- How Teachers Can Support Students Returning From Hospitalization– Georgetown Behavioral Health Institute
- Having a Child in Emergency Treatment– Child Mind Institute
- Your Child’s Psychiatric Hospitalization: Working with the School– William James College
What is the cause of increased hospitalizations for mental health crisis in the student population?
I have been a teacher since 2004 and have seen firsthand the shift in students over the years. In those years we, as a society, have become much more aware of the impact anxiety and depression can have on an individual.
School districts, at least the ones near me, are responsive and have invested in mental health supports like adding full time social workers and school psychologists in the elementary school buildings (as well as Middle & High Schools), school districts investing in Social-Emotional Learning Curriculums, and a significant push for teacher professional development on building relationships with students (morning meetings, restorative practices etc.)
While the increased investment in mental health in education is a fantastic thing, there is no doubt in my mind that there is an increase in students who become or are dysregulated throughout the school day. Research shows that the increase in screen time has a negative impact on emotional regulation.
I personally believe that many of the students struggling with psychiatric hospitalization are struggling with their mental health due to an underlying executive functioning challenge, most likely due to some type of neurodiversity (ADHD, Sensory Processing Disorder, Autism, etc). Many people may struggle with depression, but I think it is helpful to consider if depression is the cause of the mental health challenge or a symptom of something else.
If someone struggles with various executive functioning skills– time management, self-regulation, task initiation, attention, impulse control, cognitive flexibility, it is not hard to imagine how those areas of deficit could compound to leading someone to struggle with anxiety and depression.
I am not a trained medical professional, so please seek out the appropriate medical opinions. However, if you are not finding the answers you are looking for or feel like you might want to read more on ADHD and executive functioning. I really like the book Smart, But Scattered.
You can read more research about executive functioning and anxiety & depression, ADHDH & suicidal thoughts here, here , here, here, here, here, and here. You can also Google ‘executive functioning and suicidal thoughts’ and have access to quite a few research articles- but they are behind a paywall.
What if the hospitalization program doesn’t fix the students problems?
Unfortunately insurance coverage seems to be the guiding principle for making decisions like program length.
Insurance is willing to pay for X amount of days, so the student gets X amount of days in the program.
When insurance is done, students return to school. If they need more time in the program, they are expected to return to school until they struggle with the same feelings that got them in the program in the first place. The student would then start the program over again by going to either the ER or get another behavioral health evaluation, which would most-likely restart the behavioral health program.
If the student continues to struggle with repeat hospitalization programs, one option (depending on insurance) is a residential teen & adolescent treatment center.
Conclusion
Unfortunately students who experience a mental health crisis and find the need for psychiatric hospitalization is increasing and the support for school staff is as well. Continued research in the area of student mental health is greatly needed.
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