New philosophy means new facility at Western State

Wards where Western State Hospital patients watched television and played board games 10 years ago now sit vacant each weekday as their occupants attend specialized, college-like classes geared toward recovery and release.
Other wards and buildings scattered over the sprawling, 300-acre campus, once filled with hundreds of long-term residents, have been emptied altogether, their windows boarded and their doors chained shut.
In 1977, when Director of Community Services John Beghtol came to work at the hospital — which treats mentally ill people from roughly half of Virginia’s total population — it housed 1,354 patients, many with little prospect of release. Patients spent their days mostly confined to wards, where social interaction was limited to a static group of fellow patients and staff members, Beghtol said.
“In the past, Western State was a warehouse,” Beghtol said. “There were wards filled with long-term patients who had been there over 30 years, some [had been there] 40 or 50 years ... It was sad. People lost their whole lives here.”
Since the 1970s, a gradual shift, at the hospital and across the country, toward recovery-based programs and community-based outpatient services culminated in 1998, when a jolt of state funding enabled the hospital to shift to a “psycho-social rehabilitation” treatment model, moving the vast majority of its patient population off the wards and into classrooms.
Western State now houses no more than 260 patients at a time and operates perhaps the most comprehensive rehabilitation program of its kind, with more than 100 classes offered in five separate treatment “malls,” Beghtol said. On a typical day, 95 percent of patients attend classes. The average length of hospitalization is less than six weeks, he said.
Shifting from secure wards to often-unpredictable classrooms involved a degree of risk, Beghtol said, and many staff members were initially skeptical of the concept. But the results spoke for themselves: Within the first four years of the program, the restraint and seclusion rate fell by over 90 percent.
Western State’s most challenging patients — those with lowered cognitive ability and a history of violence — attend classes in the First Step treatment mall. Under the old system, many of them would be prime candidates for indefinite periods of hospitalization, Beghtol said.
On a recent weekday, the 26 First Step patients calmly moved from classroom to classroom between 20 minute sessions, sometimes gently guided by staff. Serious behavioral incidents are extremely rare, said Allen Layman, director of First Step. The release rate is remarkably high.
“We now have probably around 80 percent of these patients move on to community settings or back home,” Layman said. “But the biggest thing we’ve seen is the huge decrease in restraint and seclusion. We just don’t see it here much anymore because we try to provide other options to help patients manage their own frustration and anger.”
Most patients attend classes in the Stribling treatment mall, located in Western State’s recreation center — a function the facility still fulfills on afternoons and weekends. The Stribling mall has the feel of a casual college campus, with unlocked exterior doors and crowded hallways. The building houses four patient-staffed businesses — a restaurant, a greenhouse, an auto garage and a picture frame shop — designed to teach patients marketable “soft skills” key to finding jobs after their release.
Michael Poole, an occupational therapist in charge of the frame shop, said giving patients access to dangerous tools of the trade, such as circular saws, scalpels and oversized plates of glass, had yet to cause a serious problem.
“We go through our share of Band-Aids, but there have been no major incidents,” he said. “If you have high expectations, they’ll meet them.”
But the shift to a psycho-social rehabilitation model has not been without its difficulties, Beghtol said. The current Western State campus, built in the 1950s to house 1,800 patients, was never intended for a streamlined, therapy-based system. Not only have ill-suited ward spaces had to be converted into working classrooms, the risks of moving patients over long distances from residential areas to treatment malls each day have created security concerns and limited the degree to which some patients, particularly those transferred from jails and prisons, can interact with the larger hospital population.
The design of a new $110 million dollar hospital facility, slated for construction some time in the next couple of years, will specifically address those problems, Beghtol said. An architectural firm met with more than 100 hospital staff members in creating a preliminary plan for the building, which will probably be centered around a large courtyard with treatment malls toward the center and sleeping areas toward the periphery.
“The hospital itself will reflect the emphasis on rehabilitation and recovery,” Beghtol said.