A Randomized Study Comparing the Treatment Environment in Alternative and Hospital-Based Acute Psychiatric Care
William B. Hawthorne, PhD; Elizabeth E. Green, PhD; David Folsom, MD, MPH; James B. Lohr, MD

Objective: Programs that offer alternatives to hospital-based acute psychiatric

care have reported promising results of lower costs, equivalent

or superior outcomes, and greater patient satisfaction. This study supplements

previous research that compared the outcomes, satisfaction,

and cost of hospital-based care and one such alternative program, shortterm

acute residential treatment (START), with an analysis of patient

and staff perceptions of the treatment environments. Methods: Patients

who participated were all veterans and were randomly assigned to receive

treatment in a hospital psychiatric unit (N=45) or in START

(N=48). Both groups completed the Ward Atmosphere Scale (WAS), a

standardized measure of treatment environment, at the time of discharge.

During the study, staff members from both types of programs

also completed the WAS (15 hospital staff and 75 START staff). Results:

Both patients and staff rated the START environment more favorably

than the hospital environment on five of ten WAS subscales. No differences

were found in congruence between staff and participants’ scores

at START or the hospital. WAS profiles for patients and staff from the

hospital closely matched published national norms for hospitals, whereas

WAS profiles for patients and staff from START more closely resembled

treatment environments recommended for the most disturbed patients

(lower levels of anger and aggression and higher levels of support,

problem orientation, and order and organization). Conclusions:

The more favorable ratings of the treatment environment at START in

this study are consistent with previously published findings demonstrating

the viability of the START model as an alternative to hospitalbased

acute psychiatric care. (Psychiatric Services 60:1239–1244, 2009)


Dr. Hawthorne, Dr. Folsom, and Dr. Lohr are affiliated with the Department of Psychiatry,

University of California, San Diego. Dr. Hawthorne is also with Community Research

Foundation, San Diego, with which Dr. Green is affiliated. Send correspondence

to Dr. Hawthorne at Community Research Foundation, 1202 Morena Blvd., Suite 300,

San Diego, CA 92110 (e-mail: hobie@comresearch.org).