According to Marcia Fowler, M.A., J.D., commissioner of the Department of Mental Health, the new hospital represents the largest non-road construction project in the Commonwealth’s history. The 430-square foot structure, adjacent to the old hospital, will contain 320 beds – 60 for adolescents and 260 for adults – in a revolutionary design that mirrors the “natural structure of home, neighborhood and community,” according to the commissioner.

During a recent media tour, New England Psychologist had an opportunity to view the new hospital first-hand. In sharp contrast to the old hospital, WRCH features private rooms, complete with their own bathrooms and durable, specially designed furnishings, explains Anthony Riccitelli, the hospital’s chief operating officer. Each of the five 26-bed units bears its own identity and color scheme. “It has a non-institutional look, but more of a residential look,” he says. “The intent is to provide a private, quieter space.”

Once the patient steps outside his private room, he will enter a hallway bordered by family meeting rooms, kitchenettes, recreational rooms – in essence, a neighborhood. The neighborhood, which represents a transition to “downtown,” forms a ring around the entire building and facilitates recovery by inviting clients to participate in everyday activities, such as cooking and socializing with others. Clinicians, social workers and other therapists will teach independent living skills and clinical-based functions in the activity rooms.

WRCH will also contain a unit for individuals who are hearing impaired and every unit is equipped with an electronic messaging board. “This is an effective way to communicate,” says Fowler.

The “downtown” area epitomizes a public and energetic venue that includes a bank, gift shop, café, gym and a multi-denominational chapel, complete with Plexiglas stained glass windows and acoustic panels that were designed with input from eight children from two different inpatient and residential programs. “We held a series of focus groups. Children in the groups chose the colors and the lines of the room,” says Riccitelli.

Classrooms in the adolescent wing will enable younger clients to continue schooling without interruption while hospitalized. A staffed library will carry printed material and have computers for client use. Two fitness rooms and a half-court basketball court in the gymnasium will foster physical activity. A general store will offer items for purchase and also allow clients to practice life competencies in a safe learning environment. A pavilion holds center stage in the downtown where outside vendors will operate a coffee shop for patients and their families. Seven contiguous enclosed courtyards with an eighth one located near the “downtown” area offer clients the chance to participate in a pick-up basketball game, stroll in the fresh air or meditate.

The Village Green forms the exterior centerpiece of the building where decorative landscaping and a fountain will add a meditative element and a glass canopy will enable outdoor walks, regardless of the weather.

The second floor boasts two conference rooms with state-of-the-art audio-visual capabilities. Fowler explains that this high-tech equipment will facilitate training sessions across the Commonwealth. “We will be able to transmit to all units and other facilities in the state. We can train staff statewide and they don’t have to be present,” she says.

A second conference room will serve as judge’s chambers. During commitment hearings and other proceedings, video and audio equipment will allow for remote access. “Witnesses don’t need to be in the room,” Fowler says.

A multi-disciplinary team of social workers, psychiatrists, psychologists and other clinicians will staff the hospital; specific staffing levels for mental health professionals have not yet been determined, according to Anna Chinappi, director, Office of Communications and Community Engagement at the DMH.

The Division of Capital Asset Management, in partnership with Ellenzweig Associates, Inc. and Gilbane Construction, was responsible for oversight, design and construction, respectively, of the new psychiatric hospital. WRCH aims to provide safe and respectful treatment in conjunction with active rehabilitation with return to community living as the end goal.

The building design will foster efficient and cost-effective operations and will be LEEDS Gold Certified, a designation awarded to new construction that adheres to certain standards. Specifically, the building incorporates energy efficiency and water conservation practices; a healthy indoor environment; use of low-maintenance/long-life materials; reduced environmental emissions; waste recycling building management system technology; and systems commissioning and operational training. In a tribute to the past, some of the stonework from the original hospital has been used in the new construction. “This is an acknowledgement of the legacy of the original hospital,” says Chinappi.

The final price tag for the project is estimated at $305 million and annual operating costs will be approximately $60 million.

The commissioner notes that the design “is unique to Massachusetts and will set a standard for rehabilitation and patient care across the country.”

“This is what people with persistent and serious mental illness deserve,” says Fowler. “This state-of-the-art facility represents an environment of care.”

Fowler says, “This hospital is testimony to the commitment of the administration to recognize that persons with mental illness deserve a facility that promotes reintegration into the community in a timely fashion. The building represents the stages of recovery from the ability to leave a private space and engage with others and then move into the larger community until they are ready to reintegrate back into the community where we think people should be treated.”

The closing of the Taunton state hospital in Dec. 2012 should have no impact on the number of beds, the workforce in the state or the patient census at WRCH. Fowler indicates that the operating dollars from the Taunton facility will be realigned to the new hospital in Worcester.

The Centers for Medicare and Medicaid Services cut Medicare psychotherapy payment rates in 2006, but since then, due to persistent pressure from the APA Practice Organization and grassroots psychologists, four laws successfully restored 5 percent of that payment. But the “Middle Class Tax Relief and Job Creation Act of 2012” effective March 1 did not include that provision.

Katherine C. Nordal, Ph.D., Executive Director for Professional Practice, American Psychological Association Practice organization, said these cuts impact funding not only for psychotherapy outpatient services, but community behavioral health centers, state hospitals and private hospitals with mental and behavioral health units.

“That unfortunately has a trickle-down effect in the sense that when reimbursement rates are cut, it means institutions have to come up with other ways of meeting their budgets,” Nordal said. “It could mean staff layoffs in very important programs. It could adversely impact psychology post-doctorate positions or psychology intern positions. There’s not any part of the psychology community that doesn’t see an impact when you see a rate cut in Medicare.”

Nordal said in addition to the economic impact to psychologists, the cut will negatively impact patient care and recovery if qualified, licensed mental and behavioral health providers leave the Medicare program.

“It could reduce the provider pool and could make access to care more difficult for people,” and that could disproportionally affect rural or suburban areas where the provider pool is not large to start with, she said.

A 2008 APA survey indicated that 11 percent of practicing psychologists reported they withdrew from their participation with Medicare, citing low reimbursement rates as a primary cause. The APA estimates that more than 3,000 psychologists who once participated have left the Medicare program.

Cheryl Pelletier, Ph.D., a clinical psychologist in Bangor, Maine, said she thinks more psychologists will leave Medicare as a result of the recent legislation.

“I have been struggling with this decision myself,” Pelletier said. She said approximately 20 percent of her patients are in the Medicare program. She said she polled a group of Maine psychologists about the percentage of their clients on Medicare and respondents said that 20 to 50 percent of their caseloads are Medicare clients.

Pelletier said that if psychologists continue to leave the Medicare program, she fears there will be a hole in treatment available to patients. “Our services are unique and proactive,” she said. “Our clinical work and the research we do provide important contributions to the progress of mental health treatment.”

For example, according to Pelletier, psychological and neuropsychological assessments provide specific information regarding diagnostic factors and recommendations for treatment. “We are able to tap into multiple aspects of cognitive functioning and diagnostic criteria leading to clear treatment plans; which are often connected to evidence based practice,” she said.

She said her elderly clients tend to present with multiple issues. “For example, an individual diagnosed with dementia may also have depression,” Pelletier said. “Many seniors are treated primarily with medication. Medication alone does not provide a robust outcome without some form of psychotherapy and behavior management. When medication is helpful, it provides added energy and optimism to do the psychological work. In my experience, without the psychological work, there is rarely significant change and life enhancement.”

Nordal indicated that reimbursement cuts and diminished access to care may push more people onto medication as a short-term or primary option, or they may end up in crisis resulting in more visits to Emergency Departments. “That lack of access to good quality outpatient care leads to leaning on those systems that are much more costly,” she said.

Prior to the legislation being passed, Federal Advocacy Coordinators for the APA Practice Organization prompted a grassroots effort that generated thousands of emails and letters to elected officials, and face-to-face meetings with them, about the importance of maintaining the increased psychotherapy payments.

“We were really proud of our grassroots network,” Nordal said. “It was a wonderful show of advocacy by our members. They made a big impression.”

In fact, advocates were assured that the restoration was in the bill, she said. “It literally came out at the very last minute.”

The new legislation does, through 2012, avert the Medicare Sustainable Growth Rate payment cut of 27.4 percent that was scheduled to take effect.

“I think that kind of rate cut really would be a tipping point for providers across the country, and I think Congress realizes that,” Nordal said.

Nordal said advocates are pushing for better solutions. “A good part of our effort now is going to be on the Sustainable Growth Rate,” she said. “That particular formula, that is used to help determine reimbursement rates for providers under Medicare, is something that has been a problem for a number of years, and it’s something that congress needs to deal with.

“We do have to find a way to control Medicare costs, but the balance is we need to do that and still be sure we have an adequate provider pool of qualified people that can perform services that Medicare beneficiaries need.”

Matthew Siegel, M.D., wrote the study and published it in the Journal of Autism and Developmental Disorders. Siegel is the medical director of the Developmental Disorders Program at Spring Harbor Hospital in Maine, which is home to one of these specialized units. Siegel, who is also an assistant professor of psychiatry at Tufts University School of Medicine, says the twofold force behind the rise in these units is increased identification of children with autism (66 percent of the population of the inpatient units have an autism spectrum disorder, or ASD), and the increasing recognition that children with ASD have high rates of co-occurring mental illness that can respond to specialized treatment.

For psychologists unfamiliar with these units, they have multiple advantages, Siegel said. Children with ASD don’t usually benefit from admission to standard psychiatric units because most are designed for short-term stays that focus on modifying acute risk factors, he said. They also heavily rely on medication, he said. However, Siegel explained, children with ASD and serious behavioral problems “tend to live in a state of chronic crisis, created by multiple factors such as inadequate communication systems, unmet sensory needs, ineffective behavioral management and undiagnosed mental illness.”

“To effectively treat this picture takes a highly specialized team of practitioners who can manage the acute externalizing behaviors and simultaneously address the sources of chronic crisis,” he said. “If you treat it as an acute crisis with a single facet etiology, then you are simply making a plan for readmission.”

Spring Harbor’s unit, like similar units, employs speech language pathologists, occupational therapists and special educators who help the hospital take a multi-pronged approach to problem behaviors. “A typical admission for us,” Siegel said, “is an 11-year-old child with ASD and mild ID with limited verbal ability who is on four to seven psychotropic medications, has received in-home behavioral services and possibly a day-treatment program, and is still being aggressive or self injurious 20-100 times a day.”

Gerald Tarnoff, M.D., is the unit chief of the Child and Adolescent Treatment Unit at Rhode Island’s Butler Hospital, the location of another of New England’s specialized child psychiatric units. Tarnoff said that aggressive, self-injurious behavior often comes from an autistic adolescent who in many ways is developing like a typical teenager but without a teenager’s typical cognitive skills to cope with maturation.

“A lot of their development is slower, and [specialized psychiatric units] provide a place to evaluate them and the possibility of co morbidity,” said Tarnoff, who has led Butler’s unit for three years. “As hard as it is to diagnose depression, etc., in persons with good verbal skills, it’s even harder to diagnose in someone without them.”

Siegel’s study did more than produce a scholarly paper: All nine units noted in the study have joined forces to forward autism research and develop joint-study protocols that involve the hundreds of patients with autism who are admitted to their programs each year. In 2011, the hospitals formed the national Autism and Developmental Disorders Inpatient Research Collaborative (ADDIRC).

Until recently, Kim Loika-Smith, LICSW and clinical director of the child psychiatry unit at New Hampshire’s Hampstead Hospital said clinicians involved with these units have felt like they were “on their own” because there are so few. She calls Hampstead’s participation in ADDIRC “exciting.”

Hampstead frequently has a waitlist for patients to be admitted, according to Loika-Smith and it is something she attributes to the growth in the autistic population.

“These children really do need specialized care,” she said, while noting that those providing care must be equally special. “There is a lot of risk involved: there is a high rate of staff turnover; staff are continuously managing [patient] aggression.”

“For staff working [on these units] it takes a special dedication,” Tarnoff said. “It takes a lot of patience and skill to understand [this population] and to work with them. The staff who are really good, really enjoy working with these kids. They’re not easy to find.”

In addition to Spring Harbor, Butler and Hampstead Hospitals, Rhode Island’s Bradley Hospital is also an ADDIRC member.

A number of factors contribute to treatment disparity, including stereotyping, according to Richard Gabriel Frank, Ph.D., Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy at Harvard Medical School. “An African-American with schizophrenia is more likely to be hospitalized and get older antipsychotic drugs than whites. Hospitalization costs more and is less appropriate or effective,” he says. “The individual suffers impairment from functioning, working and participating in larger society. There is also a greater risk of homelessness.”

Stereotyping aside, better collaboration between medical doctors and mental health practitioners could reduce complications due to co morbid conditions. “Medical doctors don’t look at a patient’s psychological health, but it goes both ways. Mental health professionals are quite lax in terms of physical health issues,” Frank says. “For instance, bipolar disorder and schizophrenia come with lots of physical problems, such as diabetes, heart disease and hypertension. Mental health clinicians are far less attuned to those things than they should be. There is a tendency to want the primary care physician to explain [psychological concerns], but the mental health community has to look in the mirror.”

According to Stacey Lambert, Psy.D., director of the Latino Mental Health Program at the Massachusetts School of Professional Psychology, cultural practices and values account for some of the disparity. “[Asian-Americans’] worldview is the most dissimilar to Americans about the mind-body conception of a problem. It does not translate to mainstream American psychological care,” she says.

African-American values are not quite as dissimilar, but this group uses a “collectivist/family approach,” Lambert explains. “They go through informal channels like family or church.”

Lambert adds that limited clinic hours, lack of on-site childcare services and few or no Spanish-speaking administrative personnel form additional barriers, but one of the most significant factors is an inadequate supply of minority psychologists, particularly those who speak Spanish. “According to the American Psychological Association, only two percent of psychologists self-identify as Latino, but between 15 and 25 percent of the population is Latino,” she says “Compared to the number of mental health providers, this represents a supply-demand mismatch.” She points out that recruiting minority students continues to pose a challenge.

Cognizant of the issue, accrediting bodies have begun to advocate integrating cultural competencies throughout psychology programs. “In the last 15 years, the APA has mandated multi-cultural courses,” Lambert says. MSPP offers a Latino Health Program, an immersion experience comprising language training, didactics and social construct. “We’re trying to educate providers about cultural and language competency to make services more accessible,” Lambert says.

In addition to disparities between ethnic minorities and whites, children have been left behind insofar as appropriate mental health care is concerned, according to Nicholas Covino, Ph.D., MSPP’s president. “We have knowledge of the Jimmy Fund and other causes, but the numbers of children with mental illness pale against medical conditions. Depression among children is bigger than cancer in its incidence and impact,” he says, citing escalating rates of anxiety, schizophrenia and suicide among young individuals. “Policy makers, politicians and health care companies look beyond mental illness and fail to see a contribution to other health issues and their repercussions.”

But hope may be on the horizon. More than $100 million has been earmarked for the creation of programs within mental health centers as part of the Affordable Care Act (ACA), Frank reports. “This will bring more mental health training and expertise to family health centers. Coverage expansions are targeted at low-income minorities and communities. These people are over-represented among the uninsured,” he says. “They will be getting fairly comprehensive insurance for the first time. The really important thing the ACA does is give greater fairness and participation for people with mental disorders. Coupled with parity, this is a good thing.”

Gov. Peter Shumlin in April signed into law a bill that shifts care from the institution-based system to a more community-based focus.

The Vermont House of Representatives and Senate each approved plans in February, but the bills had one difference: the size of the state-owned and operated acute inpatient psychiatric facility to be built in central Vermont. The House approved a bill calling for construction of a 25-bed facility; the Senate approved a 16-bed facility, which was what the state’s plan recommended.

However, in mid-March, Shumlin’s office announced that the governor and lawmakers had worked out an agreement. The parties agreed to a proposal to create 45 acute care beds in the state’s mental health care system – including up to 25 beds in a new hospital – with six at the Rutland Regional Medical Center and 14 at Brattleboro Retreat.

While many, including the Vermont State Employees Union, advocated for a larger hospital, the state had asserted that a psychiatric hospital larger than 16 beds would not be eligible for Medicaid funding. The state aimed to preserve that funding while also moving toward a decentralized mental health system that includes “step-down” facilities, relies more on a regionalized community care system and offers increased peer services.

In announcing the agreement in a press release, the governor’s office said the Shumlin administration received assurances from the federal Centers for Medicare and Medicaid Services (CMS) that, through the Global Commitment Demonstration, Vermont can expect financial reimbursement for patients in a 25-bed facility or reduce the number of beds to 16 if the Global Commitment Demonstration is not renewed in 2013 and reimbursement is denied.

Other than differing opinions on the number of beds for the new facility, Vermont Mental Health Commissioner Patrick Flood says legislators and advocates have been very supportive of the state’s plan.

“There have been some tweaks of the various parts of language in the bill, but they are not substantive changes of the plan,” Flood says. “What’s amazing in this story is that something as complex and what has been controversial for so long – we have 98 percent of the people agreeing on 98 percent of the bill.

“They not only have approved the idea that we’re going to ramp up our community services so that people are not likely to go into crisis – which is a key element of this bill – but they’ve also agreed that having distributed acute psychiatric beds is also acceptable.”

Flood says the legislation should quickly address immediate needs for intensive care capacity because it authorizes the use of federal disaster relief funds for renovations at Brattleboro Retreat and Rutland Regional Medical Center, two of the facilities that have been assisting with the overflow of patients since Vermont State Hospital was evacuated in August. “That will enhance our capacity right away,” Flood says.

Since August, private facilities throughout the state have been taking on patients who would normally be at Vermont State Hospital. “I really can’t say enough good about what they’ve done,” Flood says. “First of all, they literally took this on overnight. They had no warning this was coming. And they opened their door and they really didn’t know what they were in for. Certainly it hasn’t been 100 percent smooth. There have been challenges and there remain some challenges, but I just can’t say enough about what those hospitals have done to help us in this situation.”

Employees from Vermont State Hospital have continued working at various facilities in other parts of the state, but the state announced in February that about 80 former employees were being laid off, effective in April.

Renovations will continue this year and through 2013 and should see the addition of 15 new beds, for a total of 125 beds, says Robert E. Simpson Jr., MPH, DSW, president and CEO since 2006.

Simpson says the Brattleboro Retreat will likely add about 35 additional employees to its team of about 640 during the upgrades, which include expansion of services, improvements to existing clinical areas and a new inpatient program for patients formerly served at Vermont State Hospital.

“When I came, we were an organization that was trying to decide what to do, how to grow,” Simpson says. What started as some cosmetic upgrades to the buildings and campus has transformed into plans for a complete renovation to every unit.

“We’re going to grow and build this hospital and make it as state-of-the-art as it has been, but make all the units meet modern day and beyond standards for the best psychiatric care you can get,” he says.

The Omnicell system is scheduled to be in place this spring; and the electronic health record system – by the end of this year. The technology will take the center to a new level, he says, making it easier for staff to manage and review documentation, incidents and patient histories and to track and cross-reference.

The Brattleboro Retreat also has a new unit for acute care in the works. After Hurricane Irene forced the closure of the 54-bed Vermont State Hospital last year, the Brattleboro Retreat took in a number of patients who had been at the facility. In April, the governor signed a bill giving the go-ahead to a new, decentralized system of mental health care in the state, which includes 14 acute care beds at the Brattleboro Retreat. Work on the new adult intensive unit is scheduled to begin in May and finish by November, according to Simpson. The state may benefit from FEMA emergency funds to help pay for those renovations.

In addition to all of the units, renovations include the pharmacy, cafeteria and grounds, including a secure outdoor space for patients to leave the inpatient unit.

Among recent projects – the center re-opened its LGBT adult inpatient program this spring; and the Children’s Inpatient Program re-opened in January following an extensive remodeling project for the unit, which cares for children ages 5-12. New elements include an alternative low stimulation area and a host of safety features ranging from slanted window sills to safety ceiling tiles.

Simpson says the Brattleboro Retreat is continuing to look at ways to expand or improve programs, such as in its young adult (ages 18-26) unit and autism program. They are also considering the fact that youth today are “technology era” kids. “So we have to think about, ‘How do we incorporate technology into the care of these kids? How do we incorporate that into thinking about treatment?’”

The Brattleboro Retreat expanded its Uniformed Service Program (USP), which assists combat veterans, fire fighters, emergency service personnel, police and correctional officers suffering from duty-related trauma and associated conditions. The USP program had seen steady growth in the past two years, and a 28-day track was added to an existing short-term component. New trauma services include neuro-feedback, exposure therapy and Eye Movement Desensitization and Reprocessing.

The Brattleboro Retreat has also been offering leadership training to employees. “We’ve designed a special program to train all of our leaders – including medical staff, nurse leaders, directors, etc., – in how to lead in nine core topic areas,” he says. It’s been very effective at helping clinicians think about leadership and pass those skills on to other employees. The program has also helped in recruiting new employees.

“With a little bit of luck,” Daniel Mumbauer, the New Bedford-based nonprofit organization’s president and chief financial officer, says of the timetable.

So far luck has been on High Point’s side. The 65,000 square foot facility on the edge of downtown at 52 Oak St., was donated to High Point by Mary O’Donnell, a member of its board of directors. She acquired the property in 2002, but plans to develop affordable housing there fell through and other potential uses explored never materialized. The property has been gutted and asbestos already removed, Mumbauer says.

High Point currently operates a total of 769 beds that includes 16 inpatient psychiatric beds, 24 dual diagnosis beds, 120 detoxification beds, 184 clinical stabilization beds, 76 transitional support beds, 87 recovery home beds, 103 permanent housing beds, and 159 shelter beds. Seven outpatient clinics are in the communities of Brockton, Manomet, New Bedford, Plymouth, and Taunton. High Point had a $45 million operating budget for the fiscal year that ended June 30, 2011, according to its last annual report.

At least 200 new jobs will be created at the new facility including doctors, nurses, social workers, therapists and other mental health specialists, Mumbauer says.

The 16 inpatient psychiatric beds at High Point’s Plymouth campus in Manomet will move to Middleborough where the total of such beds will increase to 40. The expansion will meet a significant need, Mumbauer says.

“We’ve been full for years,” he said. “We really haven’t been in a position to meet the needs of folks trying to refer clients to us.”

The expansion will also give High Point flexibility in segregating clients based on age or severity of their illness. About 25 percent of its clients are now under the age of 25. The small size of Manomet’s unit makes it difficult to group clients with similar characteristics and needs together, says Michael I. Liebowitz, M.D., chief of psychiatry and addiction medicine at High Point’s Plymouth campus in Manomet.

“We certainly are looking forward to the change,” Liebowitz said. “I believe that the new location has approximately two to three times the space that we have now.”

The new campus will also  house 56 addiction treatment beds to be divided between dual diagnosis and detox units. A portion of those beds will be for adolescents. High Point presently has only one 25-bed unit in Brockton to treat adolescents with substance abuse problems.

“We have families who call with adolescents who need a higher level of care that we can’t accommodate,” Mumbauer said.

Mumbauer had actually toured the site about 15 years ago when High Point was looking to expand. “We weren’t big enough to take on that project. We were a much smaller organization at that time,” he said.

High Point hopes to have financing in place by fall and go out to bid next spring.

TPC is a four-site non-profit organization that provides mental health and substance use services to more than 11,000 children, adolescents and adults across the state. TPC submitted an application to open the recovery school that it will operate in conjunction with its current TPC School, which opened in 1989. The TPC School now serves nearly 100 students ages 3-21 at its Hope Street location. The recovery school will operate according to criteria outlined in the state’s Recovery High Schools Act that was passed last year.

Ian A. Lang, TPC’s vice president for Advancement and External Relations, will oversee the new school. For Rhode Island psychologists familiar with recovery high schools elsewhere in the region, Lang said it will be comforting to know there is now a program in Rhode Island.

“There’s a real movement in New England to provide this level of support to kids,” Lang said. “In many ways, when we send a kid back into the school system it’s like saying to a recovering alcoholic, ‘Glad you’re feeling better. Now, go sit in a bar for eight hours but don’t drink.’ For many people, school is that place.”

Recovery high schools typically provide a safe haven for students who have finished substance abuse treatment can focus on their studies while being mindful of the factors that contributed to their substance abuse. They attend classes as they would in their traditional school.

According to a press release sent by TPC about the need for a R.I. recovery high school, the new recovery high school can’t open soon enough. According to TPC statistics, Rhode Island has the country’s highest rate of substance abuse in kids ages 12 and over, and more than 90 percent of students are offered drugs their first post-treatment day back at school. More than 50 percent return to their addiction within 90 days according to TPC.

“Hopefully, in two years we will prove the efficacy of this and really help people understand what can be accomplished,” Lang said. “Treatment is a first step. It’s critically important. But we also have to be committed to offering resources and support as they move through the necessary processes. The [recovery high school] model shows promise.”

In Rhode Island, a student’s per-pupil expenditure will follow them from their previous or “typical” high school to recovery high school. If the program is successful and lasts beyond the 2-year trial, graduates will receive their diploma from their own school district in spite of being taught at recovery high school. The recovery high school’s content areas will comprise English, math, physical education/health, various sciences, and social studies. Existing TPC teachers who are dually certified in special education and regular education will teach classes.

Edited by Candice A. Alfano and Deborah C. Beidel

American Psychological Association

Washington, D.C., 2011

Book covers wide therapeutic landscape

Reviewed by James K. Luiselli, Ed.D., ABPP, BCBA

Social fear is synonymous with excessive shyness, social withdrawal and more definitively, social anxiety disorder (SAD). SAD occurs across the lifespan, with the average age of onset being mid-adolescence. As the editors of this book inquire, “What is it, then, about this particular developmental stage that seems to be the critical period for the onset of this debilitating disorder?” You’ll find that the book more than answers this question with precision and uncompromising scholarship.

Psychologists Candice A. Alfano and Deborah C. Beidel assembled 15 chapters from notable professionals who concentrate on anxiety disorders among adolescents and young adults between 12-25 years of age. They adopt “a developmental framework to review and integrate research and theory on the factors that give rise to, maintain, exacerbate and/or protect against the development of SAD during the period of greatest risk.” Accordingly, the book covers a wide therapeutic landscape that includes approaches to symptom reduction, risk management and primary prevention.

Section I provides an overview of SAD in adolescents and young adults, comparing and contrasting the disorder with older people and age-specific life events. These chapters detail clinical presentation, comorbidity, etiology and neurodevelopmental influences. The consensus from the authors is that SAD is best conceived within an interactive developmental psychopathology model which encompasses predisposing, precipitating and maintaining factors.

Section II has chapters about individual differences, contexts and outcomes from social anxiety in young people. One of the key areas which has emerged from epidemiological studies is the relationship of SAD to depression, alcohol and drug use and peer victimization. I was particularly impressed with the coverage given to newly emerging areas, namely social anxiety among adolescents with autism spectrum disorder and lesbian, gay, bisexual and transgendered youth.

A central theme throughout this section is the vulnerability that characterizes puberty in the face of physical maturation, expanding social networks, sexual activity and familial conflict.

The comprehensive coverage of SAD found in the book is represented further in Section III, where the editors feature chapters on assessment, behavioral and cognitive-behavioral treatment, pharmacotherapy and the impact of culture on young people who are African American, Asian American, Hispanic and Latino and Native American.

For those of you who provide services outside of an office and clinic, the book comes up strong with chapters about school-based intervention and addressing social and performance anxiety associated with school refusal and avoidance.

If your professional interests and expertise are with socially anxious adolescents and youth, you don’t want to overlook this book. None of the chapters is overly long but all of them present the most contemporary research findings and practice recommendations. Also, the editors kept a keen eye on writing style – every chapter is easy to read and free of academic vernacular that so often burdens the reader. And unlike similar books, this one gives you pragmatic suggestions that, true to its title, facilitate “translating developmental science into practice.” I also advise college and university instructors to consider the book for coursework in clinical psychology, developmental psychopathology, and seminars devoted to psychotherapeutic methods.

James K. Luiselli, Ed.D., ABPP, BCBA, is senior vice president, applied research, clinical training and peer review at the May Institute in Norwood, Mass.

Many facilities have similar programs, from cancer screening programs to AIDs awareness to support groups or recovery programs. They run on similar modalities – education, therapeutic interventions, self-awareness exercises and more.

But what makes a program succeed?

For the administrators of the Quitting Time Program at Hampstead Hospital in N.H., the piece that really makes the difference is the staff. When it comes down to it the success of a program it depends on the intangible qualities contributed by the people who manage and run the program.

“I think that’s what makes our program unique, the clinicians,” said Patti Shea, Psy.D., director of clinical operations for the hospital. “We have people with a variety of skill sets and some who can bring their own personal experience with recovery.”

Quitting Time is an intensive outpatient chemical dependency program facilitated by Master’s level clinicians who use a motivational approach to provide education and improve personal insight. The program admits approximately five people per week for its first phase and offers a family support group as well. Clients come primarily from residential or acute care facilities although some may also come from outside referral.

The goal of the program is to give these clients a chance to stay with their daily routine including jobs or school while receiving recovery treatment services. The program condenses a larger number of sessions into a shorter time period than traditional treatment programs to offer a convenient and cost-effective way to address the addiction.

Operated in 3.5-hour sessions, four days a week, the program recently expanded from evenings to include a morning session.

“We reformatted in July,” said Shea, “and doubled the clients we can serve. With more staff, we have been able to focus even more on meeting people where they are at in their recovery process.”

Meeting people in convenient settings is a key element. For some, they may be ready to attend outside meetings and work a 12-step program. Others may not be there yet. Each patient meets individually with the clinicians to evaluate their treatment goals.

“We are, of course, striving for every person to remain in recovery and remain abstinent,” said John Iudice, LICSW, LADC, the clinical director for the program. “But that is not going to happen with every client.”

Success for a recovery program should not be based, he said, on whether everyone is able to stay clean. Instead, it should look on how the clients use the program itself.

“With everyone who comes through, we see positive changes made,” he said. “Some will say up front when they leave that they plan on drinking still on weekends or using opiates. That is not necessarily success but they gained education on where to go when they see that plan is not going to work for them.”

After the first phase of the program, clients must attend at least four weeks of a weekly aftercare group. This part, not covered by insurance, is free to all alumni and many continue to come long after their four week requirement is complete.

There are others who return to go through the entire program again.

“Recovery is a process and it is a tough process,” said Shea. “Not everyone who completes the process is done … That is the true success of a program, to be a place where people can come back if they are having a hard time.”