The Brisbane Report, Nancy D. Feldman, J.D. for New Jersey Protection and Advocacy, Inc.
PART 3 -- OVERVIEW OF BRISBANE AND ITS PATIENTS
Limited by Isolated Location and Unsuitable Physical Plant
The Setting
The Arthur Brisbane Child Treatment Center is in Farmingdale, New Jersey, in Monmouth County. This location, not accessible by public transportation, makes it difficult for families to visit and attend regular family therapy sessions. Originally a private summer estate, Brisbane has a campus-like setting on 118 acres. The patients are housed in either a wing of the Main House, built as a private home in 1927, or in one of the two cottages, designated as Cottage A for females and Cottage B for males, built in 1957 to serve as the school. Brisbane patients now attend the freestanding accredited school on the campus grounds. Recreation facilities include an outdoor swimming pool and a full-sized gymnasium.
The Mission and Goal
According to Brisbane documents: "The mission of the Arthur Brisbane Child Treatment Center is to provide high quality inpatient psychiatric and residential treatment for (2) adolescents with an ongoing psychiatric disorder -- Kids First!" The goal is to have Brisbane become one of the country's best psychiatric programs for youth. Chief Executive Officer Raymond Grimaldi's vision is for Brisbane to serve adolescents with mental illness who have failed at all other treatments. He views Brisbane, with its calming, bucolic grounds, as a place where these patients can become stabilized and gain dignity and respect.
The Admissions Process: Civil Commitment Standard for Minors
The standard for civil commitment of minors (under 18) in New Jersey is pursuant to Court Rule 4:74-7A. As with civil commitment for adults, minors must be found to have a mental illness that causes them to be dangerous to themselves, others or property. However, the New Jersey standard provides special definitions for the particular needs of minors with mental illness. Childhood mental illness is defined by Court Rule 4:74-7A(a)(2) as
a current substantial disturbance of thought, mood, perception, or orientation which differs from that which is typical of children of a similar developmental stage, and which significantly impairs judgement, behavior, or capacity to recognize reality when also compared with children of a similar developmental stage. A seizure disorder, a developmental disability, organic brain syndrome, a physical or sensory handicap, or a brief period or periods of intoxication caused by alcohol or other substances is not sufficient by itself to meet the criteria for childhood mental illness.
According to the new court rule for civil commitment of minors adopted in 1997, children older than 14 years old must now meet the same definition of dangerousness to self, others or property as required for adults. R. 4:74-7A(a)(3). However, for minors under the age of 14, dangerousness to self still has a special definition:
[D]angerous to self shall also mean that there is a substantial likelihood that the failure to provide immediate, intensive, institutional, psychiatric therapy will create in the reasonably foreseeable future a genuine risk of irreversible or significant harm to the child arising from the interference with or arrest of the child's growth and development and, ultimately, the child's capacity to adapt and socialize as an adult.
Except for clients from the juvenile justice system (see below), patients are required to be screened and treated by one of the CCIS units before admission to Brisbane. If it is determined that the child cannot be stabilized at the CCIS unit and is in need of long-term hospitalization, a petition with two physician certificates is filed before a local judge documenting that the child has childhood mental illness, that this mental illness causes the child to be dangerous to self or others or property as defined by the court rule, and that the child is in need of intensive psychiatric treatment that can be provided at a psychiatric hospital and cannot be provided in the home, the community or on an outpatient basis. R. 4:74-7A(b)(1).
Most patients come to Brisbane with temporary commitment papers signed by a judge before admission. Within 14 days, the commitment is heard by an Ocean County or Monmouth County judge at a hearing on the Brisbane grounds. At that time, a legal determination is made regarding the child’s assigned status: CT, meaning that the patient still is a danger to self, others or property and still meets the commitment standard, or CEPP (Conditional Extension Pending Placement), meaning that the patient no longer meets the commitment standard and must be transferred to a less-restrictive placement. Court hearings are held for each patient every three months to review the status of the commitment and, for patients who are CEPP, the progress in finding a more appropriate placement.
Snapshot of the Adolescents at Brisbane
Brisbane serves adolescents between the ages of 11 and 17 (at the time of admission), from all New Jersey counties, who have an ongoing psychiatric disorder requiring an intensive treatment program that is not otherwise available in New Jersey. There are approximately equal numbers of male and female patients. However, there is an over-representation of African American and Hispanic patients. According to the Arthur Brisbane Child Treatment Center Annual 1997-1998 Written Plan for Professional Services (Brisbane 97-98 Plan), in fiscal year 1997, 50% of the patients were White and 48% were African American or Hispanic.
The Brisbane 97-98 Plan also reported for fiscal year 1997, that over one-third (36%) of the patients were diagnosed with conduct disorders or attention deficit disorders. A similar number of patients had major depression, depression disorders or bipolar disorders as their major diagnosis. Patients with a diagnosis of schizophrenia or psychotic disorders made up 22% of the hospital population and patients diagnosed as having adjustment disorders made up 8% of the population. A large percentage of the patients at Brisbane have a history of substance abuse and have been victims of sexual abuse.
Patients are assigned to either the Main House Coed Unit or to a cottage based on the severity of their psychiatric condition and their level of functioning. The Main House program is more restrictive. It is designed for the lower functioning patients exhibiting self-directed or isolating behavior and for the patients who actively exhibit acute psychiatric symptoms.
The cottages are meant to serve patients who are higher functioning and likely to exhibit dangerous behaviors toward others due to their mental illness or severe emotional disturbance, including such aggressive behaviors as assaults, destruction of property, stealing or sexually acting out. Brisbane patients involved in the juvenile justice system, who tend to have less severe forms of mental illness, are also assigned to the cottage program.
Programming/Therapy
Brisbane has a good reputation for success in stabilizing patients through medication, which is strongly emphasized. There are serious questions, however, whether Brisbane provides adequate individualized therapy to meet the specific needs of patients. Brisbane patients typically have an individualized therapy session only once a week, with additional opportunities for group therapy, as well as art and music therapy. Frequently lacking therapists with expertise in and experience with adolescents who have substance abuse problems or have been victims of sexual abuse, Brisbane has been unable to provide therapy targeted to helping patients deal with these critical problems. Moreover, while attempts are made to include families in therapy sessions with patients, scheduling and transportation to Brisbane for family members is a continuing problem.
Brisbane’s Juvenile Justice Population: Uneasy Co-existence
In addition to providing treatment for severely mentally ill adolescents in need of inpatient psychiatric care, Brisbane is also the only inpatient psychiatric option for youth on detainer from Jamesburg Training School and county detention centers who need mental health services and who have been refused services in private or general hospitals because of violent, dangerous behavior or risk of escape. Although the 1987 State Plan called for Jamesburg to develop a program for mentally ill juvenile offenders, this has never happened.
Typically, Brisbane is housing one or two boys on detainer status, who are assigned to Cottage B. CEO Grimaldi acknowledged concerns about the mixing of youths on detainer with the hospital population. The youths on detainer not only tend to be physically larger than the other patients, but also raise concerns about their being violent. Coming from a correctional environment, they are placed on "escape precaution" at the hospital. CEO Grimaldi stated that he "only hope[s] that nothing will happen," and observed that the situation gives him "sleepless nights." The adolescents on detainer require special programming to provide short-term stabilization so they can be returned to the detention or correctional program, making it difficult to establish a therapeutic milieu in Cottage B.
In addition to the individuals on detainer, who are fully integrated with the Brisbane hospital patients, the Juvenile Justice Commission runs two other separate correctional programs on the Brisbane grounds. The Fresh Start/Special Needs program is for 8 to 16 boys between the ages of 14 to 18. They use the same school building as the hospital patients, but enter a separate classroom from an outside door. In addition, the Juvenile Justice Commission runs an orientation unit on the grounds of Brisbane for boys who were at Jamesburg and are preparing to go to boot camp in Wharton State Forest.
Phoebe's Place: Residential Treatment for Adolescent Girls on Brisbane’s Isolated Grounds
Since September 1996, Brisbane has also operated Phoebe's Place, a one-year residential program for eight adolescent girls, who are housed in a wing of the Main House. The girls placed in Phoebe's Place usually have an extensive history of out-of-home placement and treatment failures. They have had a recent psychiatric inpatient hospitalization and have been rejected by all other in-state treatment providers. Some of the girls may be returning to New Jersey from an out-of-state placement, or they may be at risk for going out-of-state for treatment. Approximately one-half of the residents of Phoebe's Place come directly from hospitalization in Brisbane.
Unlike the Brisbane patients, the adolescent girls at Phoebe’s Place are not legally committed, but are voluntarily in the treatment program. Although they share the hospital facilities with the hospital patients, efforts are made to keep these girls separate in their programming and recreation. They go to school at Brisbane in a separate classroom. The isolation of the Brisbane campus limits the opportunities for the girls to participate in activities, or even attend school in the community.
Aged, Unsuitable Physical Plant Compromises
Safety, Supervision, Classification
While the Brisbane grounds are attractive, the housing is aged, cramped and depressing. The housing units were not built to house patients. The Main House, which is over 70 years old, was built to be a private home. The bedrooms and recreation areas are on different floors, and the patients have to pass through narrow, dark halls and stairways. The cottages, which are over 40 years old, were built to be a school. The recreation areas are downstairs, and the dormitory style bedrooms, with three or four to a room, are upstairs.
There have been maintenance and improvements to the physical plant, but there have been no major renovations altering the basic layout of the Main House and the cottages. The living units on different levels make it hard to supervise the patients, which may put patients with suicidal tendencies at risk. The narrow halls and stairways that patients have to travel during the course of their day increase the opportunities for confrontations and power struggles between staff and non-compliant, unstable adolescents.
One of the notable achievements of the past decade has been the dramatic lowering of the Brisbane population, which had soared to 80 in the late 1980's. However, CEO Grimaldi observed that even with a population at or below the capacity of 40, including eight girls at Phoebe’s Place, Brisbane can still feel crowded. Although the dormitory rooms in the cottages can each hold four beds, he prefers to have no more than three to each room. This overcrowding is exacerbated by the lack of flexibility in the housing layout. A living unit, such as Cottage B (for boys) for example, can be over capacity even when the total population of Brisbane is below capacity. Although there may be vacant beds in Cottage A (for girls) or in the Coed Unit, these options may be inappropriate for the overflow boys assigned to Cottage B. The limitations of the housing options - the two cottages and the Coed Unit have also been exacerbated by the opening of Phoebe's Place in a wing of the Main House.