Professionals in Crisis Program

Treatment details & clinical protocols
The Menninger Clinic's Professionals in Crisis Program serves adults, ages 21 and above, who are experiencing difficulties managing the challenges of career and private life while dealing with moderate to severe psychiatric disorders.

The Houston-based program offers two tracks, one focusing on dual diagnosis (addiction and psychiatric issues) and one focusing primarily on psychiatric or psychological stressors facing today’s professionals. Both address the clinical needs of professionals as they face family, social and occupational difficulties due to moderate to severe psychiatric disorders, chemical dependency and coexisting disorders.

Women and men admitted to the program receive support from peer professionals, as well as from a staff attuned to focusing on the clinical needs of professionals, including those in business, medicine, athletics, law, religion, education and entertainment.

The psychiatric disorders track addresses the symptoms of mental illness along with professional boundary violations, impaired ability to skillfully and safely perform tasks, career issues and transitions and burnout.

The addictions track addresses the accompanying psychiatric disorder while also providing the professional who is experiencing addictive issues with education about the disease model of addiction and how his/her addiction impacts his/her life functioning. Patients are encouraged to attend 12-step meetings, such as Alcoholics Anonymous, to support recovery.

The most frequently noted principle diagnoses at the time of admission include mood disorders, personality disorders and substance dependence. Often patients have multiple diagnoses with drug and alcohol abuse and dependence.

Menninger's Professionals in Crisis is suited for the individual who has already participated in mental health treatment elsewhere and for whatever reason has not made the desired progress.



Treatment approach
The Professionals in Crisis Program is based on a bio-psycho-social (medical, emotional, social) model of patient care. Menninger believes in this approach since significant problems affect several areas of a person’s life.

As a result, treatment addresses the diagnosis and biological or inherited characteristics to the patient’s illness, as well as significant life events that affect functioning. The team strives to understand the professional in the context of his/her family and looks at how occupational and cultural issues affect the professional’s well-being. The individual’s strengths, as well as liabilities, are also assessed and explored. Understanding the whole person is crucial to attaining a clear diagnostic understanding and the development of the patient’s individualized treatment plan.

Menninger and the Professionals in Crisis Program employ a multidisciplinary team to address the bio-psycho-social perspectives of assessment and treatment. The team includes a primary clinician (responsible for overseeing and coordinating the patient’s treatment, as well as addressing family and occupational issues), a psychiatrist, activity therapist and nursing staff. An addictions psychiatrist and certified addictions counselor join the team for patients in the dual diagnoses track. A professional’s team may also include an individual psychotherapist, a marriage therapist and a psychologist to provide psychological testing when the treatment team deems they are appropriate for the patient’s clinical needs. A utilization review manager is a member of the clinical team, ensuring that needed services are provided and allocated in an effective and financially feasible manner.

As a teaching hospital, Menninger treatment teams include psychiatry residents and other mental health trainees. The residents and trainees work closely with senior clinical staff and assist the treatment team rather than serving in a primary treatment role.

Most importantly, the program believes the patient is a core member of his/her treatment team and, as such, works as a team member to assess treatment goals, participate in treatment planning and to set up relapse prevention and discharge strategies.

The treatment plan is developed by prioritizing specific symptoms and creating an action plan that focuses on these symptoms as primary goals for treatment. Treatments and interventions specially ordered by the treatment team stress the importance of development of healthy relationships with family, peers and work colleagues and consolidation of a positive and realistic professional, social and self-identity. As each patient engages in treatment, the team reviews and revises the patient’s treatment plan to ensure that it continues to fit his/her needs and the treatment goals.



Upon admission
Once admitted to the Professionals in Crisis Program:

• The patient is given a handbook that includes his/her rights and responsibilities as a voluntary patient and the responsibilities of the treatment team.
• Within the first eight hours, the patient receives an orientation to the program and staff, and nursing staff complete the nursing assessment.
• Within the first 24 hours the individual is seen by an internal medicine physician for an initial diagnostic physical and met by their primary clinician or a psychiatrist for a psychiatric interview.

By the end of the patient’s first week at The Menninger Clinic, the clinical team will complete a diagnostic assessment. It will include a psycho-social assessment with family information obtained by the patient and the patient’s family, a review of past treatment records and observations by staff members in the milieu (therapeutic environment).

When necessary, psychological testing will be obtained. Assessment findings are shared with the patient by the primary clinician and psychiatrist during rounds and in team meetings in which the patient’s diagnoses and clinical understanding are communicated along with an estimated length of stay that correlates with the patient’s treatment goals.



Core treatment program
All patients participate in the following treatment modalities.

Individual and group therapy: These therapies are central aspects of treatment and are provided by program staff. Sometimes the patient’s individual work will be done with the patient’s primary clinician. At other times, a therapist outside of the core team will be utilized. This will be determined by the patient’s treatment team within the first week of admission.

Individual therapy provides the opportunity for in-depth understanding of a patient’s problems and for the patient to work on issues that may not be appropriate in a group therapy setting. The therapeutic approaches will vary according to the patient’s needs. This may include cognitive behavioral, insight-oriented or other therapy modalities. The style and focus of individual therapy is directly related to the prioritized goals of treatment.

Group therapy provides an opportunity for patients to share their problems and receive support while also providing the same to peers. Every patient’s problems are unique, but also overlap with problems of others. Group therapy provides a sense of commonality of problems and experiences and allows patients to explore their issues in a safe and supportive environment with others in similar situations. Two mental health professionals co-facilitate the group sessions. Leaders include primary clinicians, addictions counselors, psychiatrists and nursing staff. Group methods vary from psychoeducational, experiential, therapy and skills development.



Psychopharmacology: A psychiatrist (medical doctor who has completed psychiatric residency training) on the treatment team works with the patient and other team members to establish the most effective medication regimen. Medications are used only when necessary and are based upon the patient’s behavior and diagnosis. The program psychiatrist must prescribe all medications, including over-the-counter medications such as aspirin, cold remedies and vitamins.

Upon admission the patient meets with the psychiatrist for an initial assessment of medication needs. The medication regimen is reassessed twice weekly during patient rounds. Patients receive education regarding medication, intended effects and possible side effects so that they can participate in monitoring a medication’s effects and are prepared to assume responsibility for following the appropriate medication regimen after discharge.



Milieu therapy: The milieu is a supportive holding environment in which staff work with patients to provide safety and structure while at the same time assessing the patient’s relationships and behavior. A consistent routine is maintained, which fosters predictability and trust. Milieu structure assists patients in containing negative responses and provides an opportunity to remediate such responses through staff and peer feedback and modeling.

A milieu is considered therapeutic when there the program’s community provides a sense of membership and belonging. Patients work with peers and staff to take responsibility for the welfare of others in their community and the community as a whole. The therapeutic community provides a set of values and norms for behavior with the expectation that community members will participate in activities, value one another as individuals and learn to care not only for themselves but for their peers.

The chief objective of the therapeutic community is to provide a safe, nurturing environment in which patients can share their problems, as well as reflect upon them and scrutinize themselves, their belief systems and the effects of their behavior. The milieu also provides a means for the patient to integrate new and positive experiences, practice new skills and reassess themselves in relationships with others. Activities that foster these objectives include a weekly community meeting consisting of staff and patients, patient leisure activities and daily group activities on the unit.



Specialized skill-building groups: Groups for needs such as anger management, interpersonal effectiveness, depression, and relapse prevention and discharge planning, are part of the core program. Groups also focus on issues including treatment review, social skills building and gender issues.

Therapeutic activities & recreation: Group activities and activities to promote self-esteem and self-understanding are an integral part of the Professionals in Crisis Program. An activity therapist coordinates and designs therapeutic activities to promote teamwork, develop interpersonal and social skills, and promote dynamic understanding and skill building. Physical exercise and art are incorporated into program activities. Patients and staff utilize an on-site gymnasium and walking trails.

Spiritual & cultural programming: Cultural and spiritual needs are assessed at the time of admission. The clinical team utilizes the Menninger chaplain and community resources to address these needs. The chaplain leads a weekly spirituality group and weekly nondenominational services on the Menninger campus. The Menninger chaplain is available for individual consultation.

Family workshop: Menninger provides a two-day family workshop that is open to families with a loved one in the Professionals in Crisis program. Clinicians educate families about treatments and encourage them to look at their own needs and functioning within the family system in response to their family member’s difficulties. Experiential, instructional and interactive activities are incorporated into the workshop schedule. Some activities are primarily for family members, while other groups include patients as well.

During the workshop, a patient and their family members will also meet with their primary clinician to discuss treatment issues and discharge plans.

• Specialized programming: In addition to the core program, patients are prescribed additional treatment based on their clinical needs. The team takes advantage of expertise and specialized programs throughout the hospital whenever needed.

Programming is available for patients with:

• Substance abuse issues
• Addictions other than substances
• Impulsive behaviors, anger management issues and self-injury history
• Eating disorders
• Anxiety disorders or obsessive-compulsive symptoms

Program goals

• To provide comprehensive, integrated and individualized bio-psycho-social and spiritual assessment and treatment to individuals who meet admission criteria
• To create a milieu that ensures safety, confidentiality and respect for the dignity and individuality of patients and staff while promoting the rehabilitation of the capacities that lead to resilience, adaptation and recovery
• To engage patients and their families as active collaborators in the planning and implementation of their treatment, discharge and relapse-prevention
• To create an environment that is sensitive and respectful to all patients’ family, professional, religious and cultural needs and context
• To provide evidence-based and psychodynamic treatment for specific psychiatric and addiction problems
• To meet policies, procedures and regulatory requirements of The Menninger Clinic, as well as local, state and federal regulatory agencies.

Goals of hospitalization
The patient will:

• Show improvement in the admitting symptoms and will develop skills to maintain the improvement
• Demonstrate an increased awareness of emotional strengths and limitations
• Learn strategies and develop skills to prevent relapse and re-admission to the hospital
• Be able to return to a more effective level of functioning
• Demonstrate an improvement in self-esteem and confidence
• Actively participate in discharge planning and aftercare development, as well as involve their family/support system in treatment
• Utilize available therapeutic resources in their own community

Admissions criteria (exceptions may be made after assessment)

• Patient has, or is suspected to have, an Axis I diagnosis as the principal admitting diagnosis.
• Patient has actual or potential impairment in professional functioning that requires treatment in a 24-hour care setting before re-entry into his/her profession. Symptoms must be severe enough to place the patient at risk for loss of professional standing (licensure, certification, credibility, etc.) and/or the patient is in an position in which continued substance abuse, disruptive behavior or psychiatric impairment constitutes a risk to public or personal safety.
• The patient’s condition and/or life situation requires a 24-hour care setting to prevent further deterioration.
• Patient is in need of pharmacotherapy (medication) or changes in medication that are too significant to be initiated without 24-hour supervision.
• Patient has failed to respond to a lower level of care.
• The patient’s symptoms and impairments are likely to improve with involvement in a 24-hour treatment setting; i.e., the patient is not at baseline functioning.
• Patient must be able to meet basic Activities of Daily Living (ADLs) without assistance; i.e., feed and dress himself/herself, function with basic mobility with or without assistive equipment, etc.
• Patient has mild to moderate impairment of daily functioning (Activities of Daily Living, social and occupational functioning).
• Patients must be able to actively participate in the milieu in a self-directed fashion, meeting appropriate levels of responsibility.
• Patient may have a co-morbid substance use diagnosis, but the psychiatric diagnosis must be primary.
• Age range of patients is 21 and up.
• Patient’s Global Assessment Functioning (GAF) must be in the range of 40 to 70.

Continued stay

Eligibility for continued stay in the Professionals in Crisis Program shall be based on the patient meeting at least four of the following six conditions.

1. The patient recognizes or identifies the severity of their problem(s), and documentation in the medical record indicates that the patient is progressing in treatment.
2. The patient will predictably relapse or the symptoms would worsen if the patient was moved to a lesser level of care. Termination of services would likely result in exacerbation of symptoms, requiring treatment stabilization in this level of care.
3. An unexpected decrease in level of functioning has occurred, and the treatment plan has been adjusted to address this change of status.
4. Documented evidence that further treatment in this setting can be reasonably expected to improve the patient’s condition.
5. The patient verbalizes their commitment to treatment, but does not demonstrate coping and problem solving skills needed to sustain that commitment without the support of the program.
6. The patient exhibits the ability to respond positively to the treatment program and form a collaborative relationship with the team. The patient is motivated for continued treatment as evidenced by adherence to program rules and procedures and active participation in the treatment program.

Discharge criteria

The patient is no longer considered eligible for the specialty hospital treatment for any particular episode when he/she meets the conditions of any one criterion in the following six areas.

1. Admission criteria: The patient no longer meets the admission criteria for hospitalization; i.e., GAF over 70, diagnosis has changed, etc.
2. The goals of hospitalization have been met to the best of the patient’s ability in the estimation of the treatment team.
3. Psychiatric illness or medical complication: The patient must meet the conditions of one of the following:
   1. Documentation that a psychiatric or medical condition should be treated in another setting
   2. Documentation that a psychiatric or medical condition, which is interfering with services, is not being treated
4. Chemical dependency rehabilitation/treatment: The patient must meet all conditions under at least one of the following measures.
   Patient demonstrates he/she:
   1. Is medically stable
   2. Recognizes or identifies with the severity of chemical substance use
   3. Has insight into their defeating relationship with alcohol/drugs
   4. Is applying the essential coping skills necessary to maintain sobriety either in a self-help fellowship and/or in post-treatment supportive care
   5. The primary clinician and patient have developed an individualized aftercare plan to help the patient maintain the gains made during hospital treatment.
5. Behavioral factors: The team considers:
   1. The patient is consistently uncooperative to the degree that no further progress is likely to occur, and
   2. That greater intensity of service in the Professionals in Crisis Program or transfer to another Menninger program would not have a positive impact on the problem
6. The patient requests discharge, and they are not a danger to themselves or to others.