I went to graduate school in a large city, and I was lucky to have over a dozen hospital sites to apply to once I knew I wanted inpatient experience. The problem was that I didn’t realize how much variation existed within the world of hospital training. Knowing what kind of hospital you’re applying to will help you focus your cover letters, know what you’re walking into on interviews, and pick the site that best fits with the experiences you want. While you’ll probably want to cast a wide hospital net when you apply for practicum, in the jumble of names that invariably include terms like “behavioral,” “psychiatric,” “center,” “health,” and “hospital,” it’s important to know what you’re headed for. Applying to the nearest Psychiatric Behavioral Health and Hospital Center is meaningless, unless you know what type of hospital it is. So here’s a brief primer to help you find your way, along with some questions to guide you. (While Veterans Administration sites also provide inpatient training, they aren’t discussed in this article.)
What Kind of Hospital is it?
- General Hospitals – those Grey’s Anatomy-type places that provide surgery, or where you would go to have a baby – may have one or more units devoted to psychiatric care.
- Psychiatric Hospitals – sites that only treat psychiatric patients. There won’t be an intensive care unit, general emergency department, or cardiac floor.
By the way, it’s called psychiatric care because you’re in a hospital. And in hospitals, medical doctors rule the roost.
Public Hospitals vs. Private Hospitals
Public hospitals are funded by taxpayers and the government, and they can’t turn patients away. For mental health care where I live, public-sector hospitals are divided into city- and state-level institutions. In other locations, a county hospital may take the place of a city hospital. In the public sector, city and county hospitals generally provide short-term treatment, while state hospitals provide long-term treatment. Because they can’t turn patients away, there are more patients at public hospitals from the lower end of the socio-economic spectrum; these patients may not be insured, or they may not have an insurance plan accepted by a private hospital. Private hospitals may be more selective about whom they admit, based on factors like a patient’s insurance or ability to pay for treatment. However, particularly with emergency situations, they may not turn patients away, and where I live, some accept Medicaid – the health care program for low-income individuals and families – but this may not be the case across the country.
What About Hospitals with “University” in the Name?
Some hospitals are affiliated with universities or their medical schools, and these partnerships exist in the private and public sector. In Los Angeles County, Harbor-UCLA Medical Center is a public teaching hospital affiliated with a public university. In New York City, Bellevue Hospital Center, a public city hospital, is affiliated with New York University, a private university. Finally, there are private hospitals affiliated with private universities. The bottom line: affiliation with an academic institution doesn’t determine whether a hospital is publicly or privately funded, and sometimes it can be a mix.
How are Patients Admitted?
Where I live, almost all patients in public hospitals arrive through the emergency room or through a psychiatric emergency room, if there is one. They are then evaluated and either admitted onto a unit, given a referral elsewhere, or determined not to be in need of hospitalization. The vast majority of patients who were admitted onto the inpatient unit where I worked were brought to the emergency room via ambulance after someone had called 911. Generally, the admissions criteria for inpatient hospitalization is that the patient poses a danger to self or others and cannot be treated in a less restrictive setting. However, the definition of acuity may vary based on location and timing. If you are in a unit that needs to fill beds, standards for admission may become more lax, and if you are on a unit in which beds are in high demand, a patient’s condition will need to be that much more dire to warrant admission. Psychiatric admission to a private hospital functions much the same way as public hospitals, although at some, treatment providers for outpatients needing hospitalization may be able to arrange for an inpatient bed without the patient going through an emergency room first. Admission to public psychiatric hospitals varies by state – and they’re often called state hospitals. In New York State, for instance, patients are only admitted by referral from another institution, like a hospital or a prison. When people talk about psychiatric deinstitutionalization, they are usually referring to emptying these state hospitals. More about this below.
What Will I be Doing on the Unit?
Whether public or private, general hospitals are often the front lines for psychiatric treatment. If you’re looking for information about what kind of patients you’ll be working with on the psychiatric service of a general hospital and you don’t find anything, it’s safe to assume you’ll be providing acute care. Acute units are generally shorter-stay in duration. Some hospitals aim to keep patients on acute wards for as little as one to two weeks, although they may stay for a few months if they don’t improve or safe discharge is tricky. Patients admitted to an acute unit are usually in the most severe phase of a crisis: they may be actively suicidal with an intent and plan, or they may have already made a serious attempt to end their lives. Patients may also be floridly psychotic or intensely manic – sometimes both at the same time. Patients may have also used substances before or during the episode that brought them to the hospital, complicating the diagnostic picture. In an acute setting, you will get to see more patients and more varied presentations, but you will work with your patients for a shorter period of time. In both general and psychiatric hospitals, there may also be units devoted to specific conditions, like mood or personality disorder units. There may also be units based on specific age ranges, like geriatric or adolescent units. Some hospitals provide units organized around particular treatment modalities, such as a Dialectical Behavior Therapy, and others may have units providing treatment in a language other than English. If you want to gain expertise with a particular age group, diagnosis, or treatment modality, look for hospitals that have inpatient opportunities that fit with your goals. Most hospitals mentioned so far are now used for patients with fundamentally short-term stays – in broad terms, under six months in a full-time inpatient setting. Because of managed care, insurance, and public mandates, there is pressure on hospitals to get patients out, not keep them in. Private psychiatric hospitals may have units where patients can stay for longer than they might in a general hospital, but even for people with great coverage, insurance only pays for so much. While most patients stabilize in a general hospital or in a private psychiatric hospital, those who don’t may be referred to public hospitals paid for by state funds. These state hospitals often go by other names, so when you look up a public hospital, look up the governing body – is it controlled by a city, a county, or your state?
So What Exactly is a State Hospital?
State hospitals are public psychiatric hospitals governed at the state level and paid for by state and federal funds. In many states, patients can’t just walk into a state hospital the way they would walk into an emergency department – they have to be directly referred from a public or private hospital, or from a jail, prison, or forensic psychiatric center. The number of beds in psychiatric centers has decreased markedly since 1955, and the number of per-capita state beds is so low that it rivals the number of state beds available in the mid-1800s, according to a 2012 report by the Treatment Advocacy Center. Because of this shortage, working in a state hospital means you working with some of the most treatment-refractory cases of severe and persistent mental illness, which often take the form of schizophrenia spectrum disorders. But you’ll also see and learn about the effects of persistent trauma and be exposed to more personality disorders. Personality disorders can be harder to see on an acute unit, because patients are usually there for what we used to call Axis I conditions. Some state hospital patients will also be forensic patients, meaning they are involved in the legal system. They may have committed crimes and been found not guilty by reason of insanity, while others may be in mandated treatment to restore competency in order to be tried for a crime.
Depending on the circumstances, patients may stay in a state hospital from a few months to a few decades. It depends on the severity of their illness, the hospital’s ability to make a safe discharge, or, in the case of forensic patients, the amount of time it takes to move through the legal system. Like other hospitals, state hospital units can vary: it’s worth knowing if you’ll be on an acute unit, a long-stay unit, or a population-specific unit. You may be able to provide longer-term treatment to fewer individual patients, since there is less turnover in comparison to a general hospital.
How do I Choose a Hospital that is Right for Me?
1. Do Your Research
Use your network to talk to current practicum students at the sites you’re interested in, and ask the current practicum students about their overall experience. It’s also a good idea to ask about supervision, safety, and their take on the pros and cons of where they are. Here are two ways to find trainees to talk to:
- If you’re just starting out in practicum training, talk to older students in your program to see if they know anyone at the sites you’re interested in. If you’re a few years in, you’ll probably know people who know people – ask them to put you in touch.
- If that doesn’t help, your director of clinical training (DCT) may be able to reach out to other DCTs to help you find someone at the hospital you’re interested in.
2. Keep Internship in Mind
Some sites like to take former practicum students as interns, and others have policies of not doing so. Ask classmates, look at the site’s written material, or ask your DCT if you’re not sure, and factor this into your decision.
3. Consider Your Long Term Goals
This is a no-brainer if you are trying to build experience in a particular area: look for the site with the experiences you want, whether it’s working with forensic patients, a particular theoretical orientation, or a certain population.
4. Go With Your Gut
Sometimes it can be on the commute to the hospital, walking around the hospital itself, or during the interview. You may find yourself thinking, “I could really see myself here” or “there’s something that didn’t feel right.” You’ll be at the site for a year, so don’t ignore the feeling. Regardless of where you end up, having inpatient experience will help you throughout your career. So get your hospital ID card, grab your DSM, and go!
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