Riverview Psychiatric Center focuses on the assessment, treatment, rehabilitation and recovery of adults who are challenged by major and persistent mental illness. The dedicated staff of Riverview provides this care within an open milieu structure that is to the maximum extent practicable directed by the patient themselves, towards negotiated recovery goals.

However, patients who are involuntarily committed to Riverview who do not have a major and persistent mental illness, or who cannot participate in directing their own recovery in an open environment, present a treatment and social dilemma for Riverview and for Maine.

By falling outside the skill set of Riverview’s staff, these individuals do not receive appropriate treatment and in fact may actually be unintentionally compromised emotionally and psychiatrically in this setting. Furthermore, such individuals may contribute to creating an unsafe environment for patients and staff. In many cases, they inhibit the treatment progress of those patients appropriate for the setting.

For example, individuals with severe developmental disabilities, moderate-to-severe dementias, or severe brain injury require highly specialized treatment programs, involving engagement with clinically specialized staff and may in addition require specialized treatment environments.

Individuals displaying dangerousness on occasion require a more secure facility. The Centers for Medicaid and Medicare Services (CMS) recognizes that certain individuals, due to security considerations, should not be treated in a hospital setting. The provision of a secure psychiatric unit option staffed at a corrections level of security, such as the new unit at the Maine State Prison, must be provided for the few cases that present extreme security challenges.

Individuals who have marked character pathology or personality disorder, which goes beyond what would respond to modern psychiatric treatment and whose continued placement in a psychiatric facility is detrimental to the patient, other patients and conceivably the staff around them, need a specialized program not found at Riverview Psychiatric Center.

Individuals whose prime level of functioning involves intensive and prolonged manipulation and coercion of those around them should not be treated in a psychiatric facility at all. They have easy access to a vulnerable population, which does nothing to enhance their ability to choose healthier ways of coping. These individuals need the opposite of an open environment — a highly structured one. They need an environment that is highly controlled with rigid rules that will reinforce appropriate behaviors. When they are placed in an open environment, other patients suffer the consequences of their bullying and manipulative behaviors.

For Riverview Psychiatric Center to attain its goal of becoming a state-of-the-art treatment facility, we must first provide a safe environment that allows our staff to work within its clinically defined skill set. We believe this is precisely what the patients deserve and what families, taxpayers and the government have asked us to do.

J. Harper is the acting superintendent at Riverview Psychiatric Center in Augusta. Brendan Kirby, M.D., is Riverview’s clinical director.

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