The International Journal of Psychosocial Rehabilitation

Creating a New Culture

Establishing a Transitional Living Community at a State Hospital

(A Short Report)



Deborah J. Mazzarella, Psy.D.
Director of Psychology and Forensic Services
Eastern State Hospital
4601 Ironbound Road
Williamsburg, VA 23187-8791
Karen Marsh-Williams, OTR/L
Director of Rehabilitation Services
 Eastern State Hospital
Williamsburg, VA

Mazzarella, D.J., Marsh-Williams, K. (2005). Creating a New Culture. Establishing a Transitional
 Living Community at a State Hospital.
   International Journal of Psychosocial Rehabilitation. 
10 (2) 5-10

Acknowledgements: The TLC could not have been established without the support of James Reinhard, MD, Commissioner, DMHMRSAS, John M. Favret, NHA, Hospital Director, ESH, Gabriel Koz, MD, Medical Director, ESH, Barbara Lambert, APRN, BC, Clinical Nurse Specialist, ESH, and Olga Baez, MPA, Risk Manager, ESH.


The Recovery and Empowerment model has been successful in many types of programs.  Attempting to establish such a change of culture in a traditional medical model hospital has been well worth the efforts.  This model, adopted in the Transitional Living Community (TLC) at
Eastern State Hospital, narrows the gap that is intrinsic when moving from inpatient hospitalization to living in the community, provides a more appropriate level of care, is a much less restrictive environment and alleviates some staffing and budgetary difficulties.

Keywords: Recovery and Empowerment, Psychosocial Rehabilitation, Culture Chang

Eastern State Hospital, located in Williamsburg, Virginia, is the oldest public mental health facility in the United States.  The hospital is a 412- bed inpatient facility serving adult, forensic and geriatric populations.

Non-geriatric and non-forensic patients are admitted through the Intensive Treatment Program.  The average length of stay in the Intensive Treatment Program (ITP) is 42 days, with approximately 52% of the people admitted to Eastern State Hospital (ESH) being discharged from this program.  Those who cannot be discharged from the ITP are transferred to the Psychosocial Rehabilitation (PSR) program.  The Psychosocial Rehabilitation Program at ESH was developed in 1998 to provide centralized services to meet the active treatment needs of our seriously mentally ill adults.

Why the Transitional Living Community (TLC) was created
Eastern State Hospital is committed to providing excellent quality care. Ongoing program evaluation and development is essential in the process of enhancing efforts toward individualized care.  Three main factors contributed to the development of the new program at ESH: programming deficits, budget concerns and staffing issues.

In evaluating the program’s efforts, it was determined that there was a segment of the ESH patient population who might no longer be benefiting from the traditional inpatient model. It was determined that  quality care could be improved by taking a closer look at how resources were being utilized with respect to individual patient needs.

Within the hospital there are individuals who are psychiatrically stable and ready for discharge, but who are unable to leave due to non-behavioral reasons.  Problems with funding and placement issues in the communities are encountered and, although community efforts toward outpatient placement are strong, a large number of clients remain awaiting discharge.  At any given time, there are approximately 50 clients on the Discharge Ready List.  

Forensic clients with unescorted community privileges are another segment of Eastern State Hospital’s population for whom programming was deemed insufficient.  These individuals require minimal supervision and staff intervention, display an absence of significant psychiatric symptoms and possess levels of social competence compatible with increased expectations for self-sufficiency and independence.  They participate in a full schedule of programming, maintain their privilege levels on a consistent basis and are actively involved in their recovery process.  As such, these patients have needs reaching beyond that which could be offered in our traditional inpatient units.  The acute care level of treatment traditionally offered and the restrictiveness of the environment is unnecessary and inhibits personal growth. These clients were developing the skills necessary for a high level of independent living while hospitalized but were unable to practice those skills due to the restrictions inherent in living in secured residential buildings.

Additionally, the national nursing shortage crisis has impacted health care everywhere.  ESH has experienced an increase in mandatory overtime with subsequent staff burnout, recruitment and retention difficulties, and a large increase in spending for overtime pay.  The average monthly expenditure for overtime was contributing to budgetary constraints.

Movement toward an empowerment and recovery model to develop independent community living skills for the patients who have maximally benefited from inpatient programming but are unable to be discharged was therefore considered.  This model, adopted in the Transitional Living Community (TLC) at ESH, narrows the gap that is intrinsic when moving from hospitalization to living in the community.   This provides a more appropriate level of care, is a much less restrictive environment and alleviates some staffing and budgetary difficulties.

Recovery Empowerment Plan

“Our vision is of a community-based system of services that promotes self-determination, empowerment, recovery, and the highest possible level of consumer participation in work, relationships, and all aspects of community life” (Governor’s Conference: Self-Determination, Empowerment and Recovery, December, 2004).

The basic principles of psychiatric rehabilitation remain consistent with all programming efforts:

a)     equipping clients with skills;

b)     emphasizing client self-determination;

c)      using the resources of the environment;

d)     emphasizing social change;

e)     providing different assessment and care;

f)        emphasizing employment;

g)     emphasizing the here and now; and

h)      providing early intervention.  (Cnaan, Blankhertz, Messeger & Gardner, 1990).

The establishment of a Recovery/Empowerment Model in the TLC at Eastern State Hospital is a natural extension of our existing rehabilitation model.  The TLC attempts to promote recovery by facilitating individual preferences in regard to personal goals and the skills and supports required to reach those goals.

ESH created an environment that encourages and supports the development of autonomy and skills necessary for successful community tenure.   Self-management skills are emphasized, to include self-medication, scheduling and performing home management and self-care tasks (meal planning and preparation, laundry, cleaning, money management, budgeting, shopping, making and keeping appointments, etc.).  Individuals pursue their goals for employment or volunteer experience within the hospital or in the community.  They explore community resources and support services, participate in off-campus AA/NA meetings and consumer groups, and practice resource acquisition skills.  Opportunities for role development, peer counseling, self-advocacy and the development and practice of personal and social boundaries exist. It creates a smoother transition from being an inpatient to an outpatient and moving from forensic status to civil status.   It increases the clients’ self-confidence and decreases public safety concerns as they gain successes in the community.  Community Services Boards are able to assess clients’ progress in a less restrictive setting and are able to provide more suitable housing as available.  This program also enables direct admission to a step-down level of care after being stabilized in the community.  Finally, with the increased autonomy of the clients, nursing staff and other resources are able to  redeploy to other areas of the hospital, thereby decreasing overtime.

The individuals referred to this program by their treatment teams are encouraged to function as independently as possible in this more normalized setting while working through their barriers to discharge. Individual goal setting and opportunity for achievement are an integral focus of the Transitional Living Community.  The consultative model proposed that the program be staffed with one psychologist, one consulting psychiatrist, one social worker, one rehabilitation services staff member and, per shift, one direct services associate.  One LPN comes to the unit twice daily for medication management issues.  There is no full time nursing staff assigned to this unit.

How it was created

What did it take to make such a large change in the treatment modality? 

1.      Readiness for Change

2.      Culture Change toward Recovery and Empowerment

3.      Commitment from the top of the organizational structure (DMHMRSAS, Hospital Director, and Medical Director)

4.      Committed staff

5.      Innovative thinking

6.      Belief in the clients

7.      Clients’ belief in themselves

8.      Appropriate staff support

9.      The ability to adapt to change

ESH was ready for a change and the aforementioned budget crisis and nursing shortage was pronounced.  The Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services (DMHMRSAS) began implementation of a Recovery, Empowerment, and Self-Determination model of care and based on this philosophy, ESH Hospital Director, John Favret, redeveloped the idea of creating a TLC that was originally proposed in 1997.

The first step was to create a place for this community.  One of the wards housed patients whose medical needs outweighed their psychiatric needs.  These patients were not benefiting from the centralized programming available in PSR.  It was decided that they would maximally benefit from the proximity and services available in our Medical Services Unit (MSU) and they were therefore relocated.  The MSU contains medical equipment, medical and physical rehabilitation clinics, x-ray, lab, and pharmacy resources, and is staffed by several internists.  ESH received several notices from the families of these medically fragile patients who were pleased with this move.

This relocation of patients left one 19-bed ward open for the use of the TLC candidates and allowed 11 members of the nursing staff to be redeployed to assist other wards experiencing staffing shortages.

A Recovery Council comprised of consumers and individuals who possessed an enthusiasm for the project was formed.  The goals were established with the following premise in mind:   “…recovery is a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles” (Anthony, 2000).

      Recovery Objectives to Support Individuals:

1.      Making increasingly independent decisions by identifying risks and benefits of daily living choices.

2.      Moving toward self-management of medication and healthcare.

3.      Learning to co-exist with peers in supportive environment.

4.      Learning to problem-solve with decreasing staff involvement.

5.      Developing a personal recovery plan.

a.      Setting daily, short and long-term goals

b.      Identifying and seeking resources, assistance and support

c.      Accepting consequences of personal choices

d.      Re-evaluating/self-evaluating individual plan

e.      Other independent choices

     Admission criteria were created for the unit. 

1.                  Interested, willing and capable of living in a co-ed setting with appropriate staff assistance, according to the TLC guidelines.

2.                  Able to safely manage unescorted grounds privileges during free time.  If NGRI status, must have unescorted community privileges and be adequately managing their risk factors.

3.                  Is an active participant in programming that may include but is not limited to: Vocational/Clubhouse/Living Skills Groups.

4.                  Is knowledgeable about prescribed medications (i.e., can name medications and state the reasons for taking them).  Is able to identify the risks/benefits of taking the prescribed medications and can state the risks associated with discontinuation.

5.                  Can assist in the management of their physical illness, if applicable.

6.                  Is capable of maintaining personal hygiene and room management.

7.                  Any history of assaultive or self-harm behaviors is carefully evaluated and does not contraindicate TLC placement.

8.                  Any history of sexually aggressive behaviors or sexual trauma is carefully evaluated and does not contraindicate TLC placement.

9.                  Actively participates in the discharge planning process.

Due to a large number of forensic patients referred for the TLC, the Internal Forensic Review Panel approved candidates to the unit and revised Risk Management Plans. 


The TLC opened May 31, 2005.  The individuals housed on the TLC are very happy.  One of the biggest changes came when the people referred to the unit were referred to as “individuals” and no longer as “patients.”  They established their own recovery goals and are the leaders of their treatment team (now called a Recovery Team).  These were new concepts for the staff, as the hospital has historically been based on the medical model.  They understand they are the “pioneers” of this new concept and have been very excited about their new autonomy.  They are a self-governing body and are learning to work together in decision-making. 

The three rules the individuals suggested were:  “1) Be honest, 2) Respect others and their stuff; and 3) Keep the peace.”  They have more choices, more personal freedom and subsequently more sense of self-worth.  The positive change in the affect of some of these individuals is so pronounced, it begets the question, ”Why didn’t we do this sooner?”  One of the individuals on the unit eloquently expressed himself in a progress note.  With his permission, I have included it here:

“My name is ___ and these are the reflections relating to my stay, and thoughts thereof, in the TLC unit at Eastern State Hospital. Being one of the pioneers of transitional living here, and pretty much the country, has been an honor only my fellow peers can identify with.  It is a step to the positive in the further humanization of people who are mentally ill.  We have faced challenges together and I believe each one of us is inspired to the better.  My mind is in the best shape it has ever been in and my horizons, as I see them, are expanding.  I continue to religiously take my medicine and understand and check it.  As I move closer to discharge, I can’t help but speak about the many positive attributes I have acquired while staying here in Eastern State.  No it wasn’t a bucket of roses but yes it has been a learning experience.”

The community is the ideal location for consumers to actualize their potential.  However, the reality of limited facilities in the community, reinvestment issues, discharge planning responsibilities placed on the communities, inadequate community resources for the seriously mentally ill individuals, and the growing forensic population increases the demand for specialized inpatient services at this time.  Establishment of the Transitional Living Community supports the pursuit toward individualized care and allows for improved utilization of staff and space resources for the individuals who require greater levels of treatment and staff intervention.    

Eastern State Hospital’s mission is to assist patients and their families to efficiently utilize resources that encourage living within a community at the highest level of personal independence.  The Transitional Living Community is a move toward that mission.


1. Anthony, W., A Recovery-Oriented Service System:  Setting Some System Level Standards, Psychiatric Rehabilitation Journal, 24-2:159-169, 2000.

2. Cnaan, Blankhertz, Messeger & Gardner, Experts’ Assessment of psychosocial rehabilitation principles, Psychosocial Rehabilitation Journal, 13-3: 61-77, 1990

3. Governor’s Conference: Self-Determination, Empowerment and Recovery, Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services, pamphlet, 12/9/04.

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