Frederick (Fritz) Engstrom: Troubled Retreat is operating within a dysfunctional system

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The recent news articles about the Brattleboro Retreat indicate that its poor financial condition will likely lead to unprecedented action in the near future. I was the lead psychiatrist (chief medical officer) at the Retreat for many years, and left in spring of 2018. While I do not have any current inside information about the Retreat, I believe I can offer some insights about its situation.

The Retreat's financial situation is dire, and simply cutting expenses will not effectively salvage the situation. Its lenders (banks) will soon dictate its direction, which in turn will lead to replacement of its current leaders, and a change of focus. The State of Vermont needs the Retreat, and I suspect that in one way or another the banks will negotiate with the state, with the end result being the closure of all programs except for those involving involuntary patients: child and adolescent units, and one or two adult units. The state will run a few units dedicated to care for involuntary patients, and other services will close.

This scenario is quite sad, and will be another devastating blow to the economy of the Brattleboro region. I now work in Franklin County, Massachusetts, the poorest region of Massachusetts, and it is clear to me that the State of Vermont itself has played a major role in decimating the Retreat. The practice of inpatient psychiatry in Massachusetts is much more effective and professionally rewarding than in Vermont for several reasons. Policies and approaches in Massachusetts are much more conducive to helping the most seriously mentally ill, and two large, new psychiatric hospitals have recently opened in central/western Massachusetts, with a third in the planning stages.

How is Massachusetts different?

Mental health centers in Massachusetts are deeply committed to inpatients, and these agencies regularly send professionals to meet individuals in the hospital to coordinate aftercare services. In Vermont, in contrast, mental health centers are fiefdoms with little interest in reaching out to hospitalized patients. My experience in Vermont is that mental health services often do not even return telephone calls.

Medicaid in Massachusetts does not deny payments if seriously ill inpatients cannot be discharged if proper aftercare is not in place. Instead, the payers actively help find aftercare to facilitate discharge. The experience in Vermont is diametrically different: the representatives from Medicaid deny payment frequently but do not help place patients.

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If psychiatric patients are boarding in emergency departments of medical hospitals for three days or longer (when psychiatric facilities have refused to admit them), the State of Massachusetts has authority to place them in any appropriate psychiatric facility in the state. This lessens the burdens on emergency departments, and provides care for these patients.

Massachusetts has a "three-day rule" which essentially allows clinicians time (up to three days) to evaluate and treat inpatients who impulsively decide to leave the hospital despite still being suicidal and/or craving drugs or alcohol. Vermont got rid of a similar provision several years ago without public discourse, and I am aware of at least one suicide directly linked to that decision in Vermont.

The court system in Massachusetts decides within days whether an individual who is highly psychotic and dangerous can be medicated involuntarily. In Vermont it takes months, during which time such patients deteriorate, injure other patients and staff, and create a turbulent treatment milieu.

Individuals in Massachusetts with serious substance misuse and who jeopardize their lives with overdoses or other dangerous behavior can be sent involuntarily by the court to a rehabilitation facility. Vermont, on the other hand, has no such system, and in fact did nothing to fill the gap when a rehabilitation facility had to close. Instead, in Vermont, addicted individuals do not as often break the cycle, and either have dozens of admissions, or die.

Given such inadequacies in the Vermont system, it is thus not surprising that new hospitals do not choose to open in Vermont despite the pressing demand for such services, why the Retreat is unlikely to find a buyer, and why so few psychiatrists choose to do inpatient work in Vermont. While the current leadership of the Retreat is accountable for recent deterioration, they are operating within a dysfunctional system.

Frederick (Fritz) Engstrom, MD, was a psychiatrist at the Brattleboro Retreat from 1998 to 2018, and is now a staff psychiatrist at Baystate Franklin Medical Center in Massachusetts. The opinions expressed by columnists do not necessarily reflect the views of the Brattleboro Reformer.


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