▪ Abstract Clinical neuropsychologists have adopted numerous (and sometimes conflicting) approaches to the assessment of brain-behavior relationships. We review the historical development of these approaches and we advocate an approach to clinical neuropsychology that is informed by recent findings from cognitive neuroscience. Clinical assessment of executive and emotional processes associated with the frontal lobes of the human brain has yet to incorporate the numerous experimental neuroscience findings on this topic. We review both standard and newer techniques for assessment of frontal lobe functions, including control operations involved in language, memory, attention, emotions, self-regulation, and social functioning. Clinical and experimental research has converged to indicate the fractionation of frontal subprocesses and the initial mapping of these subprocesses to discrete frontal regions. One anatomical distinction consistent in the literature is that between dorsal and ventral functions, which c...

Adult clinical neuropsychology: lessons from studies of the frontal lobes.

Patients with limited focal frontal and nonfrontal lesions were tested for visual perspective taking and detecting deception. Frontal lobe lesions impaired the ability to infer mental states in others, with dissociation of performance within the frontal lobes. Lesions throughout the frontal lobe, with some suggestion of a more important role for the right frontal lobe, were associated with impaired visual perspective taking. Medial frontal lesions, particularly right ventral, impaired detection of deception. The former may require cognitive processes of the lateral and superior medial frontal regions, the latter affective connections of the ventral medial frontal with amygdala and other limbic regions.

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The frontal lobes are necessary for `theory of mind'

This article describes the critical ingredients of the assertive community treatment (ACT) model for people with severe mental illness and then reviews the evidence regarding its effectiveness and cost effectiveness. ACT is an intensive mental health program model in which a multidisciplinary team of professionals serves patients who do not readily use clinic-based services, but who are often at high risk for psychiatric hospitalization. Most ACT contacts occur in community settings. ACT teams have a holistic approach to services, helping with medications, housing, finances and everyday problems in living. ACT differs conceptually and empirically from traditional case management approaches. ACT is one of the best-researched mental health treatment models, with 25 randomized controlled trials evaluating its effectiveness. ACT substantially reduces psychiatric hospital use, increases housing stability, and moderately improves symptoms and subjective quality of life. In addition, ACT is highly successful in engaging patients in treatment. Research also suggests that the more closely case management programs follow ACT principles, the better the outcomes. ACT services are costly. However, studies have shown the costs of ACT services to be offset by a reduction in hospital use in patients with a history of extensive hospital use. The ACT model has been hugely influential in the mental health services field. ACT is significant because it offers a clearly defined model, and is clinically appealing to practitioners, financially appealing to administrators and scientifically appealing to researchers.

Assertive Community Treatment for People with Severe Mental Illness

OBJECTIVE: This study examined the effectiveness of the Pathways to Housing supported housing program over a five-year period. Unlike most housing programs that offer services in a linear, step-by-step continuum, the Pathways program in New York City provides immediate access to independent scatter-site apartments for individuals with psychiatric disabilities who are homeless and living on the street. Support services are provided by a team that uses a modified assertive community treatment model. METHODS: Housing tenure for the Pathways sample of 242 individuals housed between January 1993 and September 1997 was compared with tenure for a citywide sample of 1,600 persons who were housed through a linear residential treatment approach during the same period. Survival analyses examined housing tenure and controlled for differences in client characteristics before program entry. RESULTS: After five years, 88 percent of the program's tenants remained housed, whereas only 47 percent of the residents in the ci...

https://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.51.4.487

Pathways to Housing: Supported Housing for Street-Dwelling Homeless Individuals With Psychiatric Disabilities

The authors discuss what can be learned from our experience with deinstitutionalization. The deinstitutionalization of mentally ill persons has three components: the release of these individuals from hospitals into the community, their diversion from hospital admission, and the development of alternative community services. The greatest problems have been in creating adequate and accessible community resources. Where community services have been available and comprehensive, most persons with severe mental illness have significantly benefited. On the other hand, there have been unintended consequences of deinstitutionalization-a new generation of uninstitutionalized persons who have severe mental illness, who are homeless, or who have been criminalized and who present significant challenges to service systems. Among the lessons learned from deinstitutionalization are that successful deinstitutionalization involves more than simply changing the locus of care; that service planning must be tailored to the needs of each individual; that hospital care must be available for those who need it; that services must be culturally relevant; that severely mentally ill persons must be involved in their service planning; that service systems must not be restricted by preconceived ideology; and that continuity of care must be achieved.

http://www.antoniocasella.eu/archipsy/Lamb_Bachrach_2001.pdf

Some Perspectives on Deinstitutionalization

Eight published literature reviews of case management were evaluated to determine areas of consensus regarding outcomes associated with full service, broker, and hybrid models. Full service was recommended for “best practice” status and the effectiveness of the broker model was seriously questioned. Research evaluating paraprofessional and peer assisted models of case management, a potential method for improving outcomes, was also reviewed. One promising peer-assisted model was identified and described. Although the use of paraprofessionals and peers in case management holds promise, much more research is needed before the effectiveness of this approach can be confidently determined.

Case management: the current best practices and the next generation of innovation.

Project HELP was established in New York City in 1982 as a mobile outreach unit providing crisis medical and psychiatric services to impaired homeless persons. The authors describe the demographic characteristics of the population served, the disposition of patients accepting treatment or shelter services, and the adaptation of the homeless to weather extremes. They discuss the difficulties in providing services to a population whose members are distrustful of authority and are unwilling to provide information about themselves. They conclude that the more disaffiliated members of the homeless population, such as those served by Project HELP, need even more extensive services than the homeless who use some kind of existing sheltered care, and they suggest various kinds of services to meet their needs.

The Mentally Ill Homeless: Isolation and Adaptation

The authors describe New York City’s program to remove seriously mentally ill homeless people from the streets to a public hospital They report on the 298 patients hospitalized during the first year of this program Most of the patients were male (66%), single (77%), and from outside ofNew York City (79%) and claimed a history of previous psychiatric hospitalization (92 %) and that they had been homeless for more than 1 year (66%) Most of the patients suffered from schizophrenia (80%) and had additional medical diagnoses (73%) Follow-up contact with the patients 2 years after initiation ofthe program revealed that 55% of the patients either were living in a community setting or were under institutional care (Am J Psychiatry 1990; 147:1557-1561)

Psychiatry takes to the streets: the New York City initiative for the homeless mentally ill.

Unlike specialists in other areas of medicine, psychiatrists are often faced with having to treat patients against their will. Lack of awareness of their illness and lack of motivation to seek trea...

Taking the Suspected Mentally Ill off the Streets to Public General Hospitals

In a treatment program for obesity utilizing hypnosis, internal Rotter I-E scores correlated (r = .60, p < .025) with measures of weight loss. The depth of hypnotic trance did not correlate with outcome, so was not considered an important aspect of the treatment. Externally focused obese patients appear to be at highest risk as treatment failures. Suitable treatments for this group would require greater control over situational eating cues or exploration of the issues underlying their inability to feel in control. Locus of control measures might potentially serve as a screening tool for selecting a suitable treatment plan for obese individuals if these findings can be replicated.

Neal L. Cohen

Papers

Case management: the current best practices and the next generation of innovation.

The Mentally Ill Homeless: Isolation and Adaptation

Psychiatry takes to the streets: the New York City initiative for the homeless mentally ill.

Taking the Suspected Mentally Ill off the Streets to Public General Hospitals

Locus of control as a predictor of outcome in treatment of obesity