Showing papers in "Psychiatric Services in 1979"
TL;DR: Providing care for the chronically ill and preparing for future deinstitutionalization means that the issue must be reconceptualized not as one of where people should be housed but as the need to provide the full range of treatments and services that are available in a total institution.
Abstract: The reasons for the problems created by deinstitutionalization have only recently become clear; they include a lack of consensus about the movement, no real testing of its philosophic bases, the lack of planning for alternative facilities and services (especially for a population with notable social and cognitive deficits), and the inadequacies of the mental health delivery system in general. Providing care for the chronically ill and preparing for future deinstitutionalization means that the issue must be reconceptualized not as one of where people should be housed but as the need to provide the full range of treatments and services that are available in a total institution. Attitudinal and institutional biases and discriminatory practices must be combated, planning for community facilities and services must be improved, and funding for both institutional and community services must be provided during the phasing down of institutional services. The author proposes a set of ten commandments or basic rules to guide future deinstitutionalization activities.
116 citations
TL;DR: The author urges professionals to begin dealing with relatives as allies instead of adversaries and to devise new modalities that make them collaborators in the treatment process.
Abstract: Believing that families are a valuable yet virtually untapped resource in treating and rehabilitating the mentally ill, the author surveyed 89 people to find out how they coped with their relative's long-term illness. Through trial and error, such families have developed a wealth of information about how to live with and manage chronic patients. The author also investiaged the types of service and supports families need. She urges professionals to begin dealing with relatives as allies instead of adversaries and to devise new modalities that make them collaborators in the treatment process.
91 citations
TL;DR: The author summarizes evaluation studies related to general-hospital psychiatric units and recommends, among other points, truly evaluating the effects of short-term treatment and eliminating the current competition for the shortest stay.
Abstract: Despite the network of community mental health centers, the general hospital has become the focal point for the delivery of mental health care in the U.S. The author presents an overview of the psychiatric unit in the general hospital, including its history, structure, and function, and its relationship to the hospital itself and to the continuum of mental health services in the community. The units' goals are not clearly defined, but appear to be crisis intervention, acute treatment, correction of decompensation, prevention of chronicity, and speedy return of the patient to the community; there is little attempt to serve chronic patients. Paradoxically, the psychiatric unit also does not serve the hospital it is part of, as it rarely accepts patients from medical-surgical wards. The author summarizes evaluation studies related to general-hospital psychiatric units and recommends, among other points, truly evaluating the effects of short-term treatment and eliminating the current competition for the short...
57 citations
TL;DR: A retrospective study of 50 patients found that 44 per cent of the patients were secluded during their stay, with the four most common reasons being agitation, uncooperativeness, anger, and history of violence.
Abstract: Because of the use of seclusion is controversial, a retrospective study of 50 patients was designed to examine how seclusion is actually being used on a short-term inpatient crisis intervention unit. It was found that 44 per cent of the patients were secluded during their stay. Neither sex nor race seemed to be a factor in whether a patient was secluded, but elderly patients and depressed patients were less likely to be secluded. Most of the seclusions occurred on the first day of hospitalization, with the four most common reasons being agitation, uncooperativeness, anger, and history of violence. The author speculates that the use of seclusion on the crisis unit is related to the characteristics of the patient population as well as to the short duration of patient stay.
51 citations
TL;DR: Wherever the chronically mentally ill live, whether in the hospital or in the community, their requirements must be made the primary focus in mental health planning.
Abstract: At the present time, deinstitutionalized services for the chronically mentally ill are less than satisfactory. If planning for the future is to reverse the trend of incomplete service delivery for this population, it must start with the recognition and application of certain fundamental concepts. Effective planning requires idealism, vision, and a sense of reality. Six separate but interrelated dimensions of reality must be taken into account: the need for mental hospitals; the importance of precise planning goals; the unique service needs of the chronically mentally ill; the need for interagency planning; the importance of a functioning and sensitive patient tracking system; and appreciation of the attitudinal structure within which services are delivered. Wherever the chronically mentally ill live, whether in the hospital or in the community, their requirements must be made the primary focus in mental health planning.
44 citations
TL;DR: In attempting to build a successful program for chronic patients at the Somerville (Mass.) Mental Health Clinic, the authors found it necessary to uncover, address, and resolve six fundamental paradoxes engendered by deinstitutionalization that were stressful to mental health clinic staff and inhibited effective programming.
Abstract: In attempting to build a successful program for chronic patients at the Somerville (Mass.) Mental Health Clinic, the authors first found it necessary to uncover, address, and resolve six fundamental paradoxes engendered by deinstitutionalization that were stressful to mental health clinic staff and inhibited effective programming. The paradoxes involve issues relating to community mental health ideology, clinicians' sources of self-esteem and professional ability, and clinicians' views of chronicity and the deinstitutionalization movement in general. Resolution of the paradoxes requires major value changes, which can be brought about by effective clinical leaders who serve as role models and teachers, and who set the tone for patient care.
41 citations
TL;DR: Comparisons showed that the mean number of children per woman and levels of unwanted and unplanned fertility did not differ in the different diagnostic groups, and the rates were not lower for the psychiatric patients than for the general population.
Abstract: The fertility rates of 223 female schizophrenic outpatients and 479 female nonschizophrenic outpatients were compared to a probability sample of 300 women residing in the same geographic area, metropolitan Atlanta, and from the same social strata as the patients. Age- and race-adjusted comparisons showed that the mean number of children per woman and levels of unwanted and unplanned fertility did not differ in the different diagnostic groups. Furthermore, the rates were not lower for the psychiatric patients than for the general population. In order to reduce an important source of psychiatric morbidity, those in the mental health professions need to pay more attention to the family planning desires of their patients.
38 citations
TL;DR: Three factors associated with deinstitutionalization and a community-based delivery system appear to have contributed to the growing trend to transfer mental health service delivery from civil mental hospitals to prison facilities.
Abstract: In Massachusetts there is a growing trend to transfer both direct and indirect mental health service delivery from civil mental hospitals to prison facilities. Three factors associated with deinstitutionalization and a community-based delivery system appear to have contributed to the trend. Those factors are the over-all compromising of programming caused by unitization of state hospitals and the requirement that a full range of psychiatric services be available in every community, the decrease in morale and training of state hospital employees not involved in community treatment, and the lack of outreach to patients in the community who are dangerous or difficult to deal with.
38 citations
TL;DR: There is a growing demand for more patient autonomy in the doctor-patient relationship, and legal reformers believe that an expanded dodctrine of informed consent is the key to change.
Abstract: There is a growing demand for more patient autonomy in the doctor-patient relationship, and legal reformers believe that an expanded dodctrine of informed consent is the key to change. Informed consent is meant to force the doctor to give the patient the knowledge that will make his an equal bargaining partner. However, most evidence demonstrates that the majority of patients do not comprehend or retain medical information. Further, the legal doctrine of informed consent has never been coherently worked out. Informed consent in psychiatry is particularly complicated, because of the constitutional implications of right-to-refuse-treatment litigation and because patients may be incompetent to give informed consent as a result of their illness. One of the special problems for psychiatry is that complex consent requirements have been mandated by those who oppose certain somatic therapies. The author discusses the implications of these legal developments. He lists the kinds of informed-consent and refusal-to-consent situatons psychiatrists face and comments briefly on the most troublesome.
32 citations
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TL;DR: The author observes that psychiatry has proved to be a weak adversary for patients' legal advocates; the result has been a one-sided advocacy system that has advanced patients' rights at the expense of their needs.
Abstract: In an era in which advocacy has become a buzzword, both psychiatry and the legal profession have climbed aboard the advocacy bandwagon. Yet the American Psychiatric Association's notion of advocacy--championing the medical needs of patients--is often in direct conflict with the lawyers' notion of advocacy--championing the legal rights of their clients. The author observes that psychiatry has proved to be a weak adversary for patients' legal advocates; the result has been a one-sided advocacy system that has advanced patients' rights at the expense of their needs. He believes that if the APA is to become an effective advocate for patients, it must hire lawyers and work with them to reverse the trend of turning rights into needs.
32 citations
TL;DR: The seeds of staff burnout are planted when mental health professionals who work with long-term patients do not recognize that patients vary greatly in their potential for rehabilitation, which leads to unrealistic expectations and frustrations for staff.
Abstract: The seeds of staff burnout are planted when mental health professionals who work with long-term patients do not recognize that such patients vary greatly in their potential for rehabilitation. This situation leads to unrealistic expectations and frustrations for staff. The concept of normalization, if misapplied, can lead to the same result. Contributing to the frustration is administrative pressure on staff to produce impossible results. Staff's ambivalence about gratifying dependency needs of patients and uncertainty about their own needs and motivations also can lead to burnout.
TL;DR: The flight of psychiatrists from public mental health facilities must be halted if the sickest psychiatric patients--the severely and chronically mentally ill--are to receive the best care and treatment possible.
Abstract: The flight of psychiatrists from public mental health facilities must be halted if the sickest psychiatric patients—the severely and chronically mentally ill—are to receive the best care and treatment possible. The author emphasizes the need for commitment by organized psychiatry, universities, and communities to support the public sector and those working in it. He examines the factors that influence psychiatrists to enter public service and those that eventually cause them to leave. He notes that the departure of public hospital psychiatrists for quasi-public settings has paralleled the transfer of patients to community settings, and that these psychiatrists may now be treating in such settings patients they once saw in the hospital.
TL;DR: Federal and state support should be increased for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hospitals, community mental health centers, and similar facilities, which would result in the recruitment and retention of greater numbers of psychiatrists in public service settings.
Abstract: There are approximately 25,000 to 30,000 psychiatrists in the United States, some 17,000 of whom are in actual clinical practice. As part of an overview of psychiatric manpower, the authors show the distribution of psychiatrists by state and present population-per-psychiatrist ratios. In discussing the distribution of psychiatrists in various work settings, they note that the decreasing percentages of psychiatrists in community mental health centers may be related to such factors as the large number of non-hospital-based centers, growing antimedical attitudes in centers, and psychiatrists' inclination to work in a setting similar to their training site. They believe that federal and state support should be increased for university-affiliated psychiatric training programs based in settings where psychiatrists are needed: state hospitals, VA hospitals, community mental health centers, and similar facilities. Such an approach would result in the recruitment and retention of greater numbers of psychiatrists i...
TL;DR: The author summarizes several studies supporting his opinion that short-term hospitalization is usually indicated for the majority of patients, provided that continuity of care is ensured and that supervised living arrangements are available for patients who require them.
Abstract: In recent years there has been a significant decrease in the length of hospital stays for psychiatric patients. The author examines whether the shorter stays are justified by results of controlled studies and, if so, what is the most appropriate hospital milieu for short-term units. He summarizes several studies supporting his opinion that short-term hospitalization is usually indicated for the majority of patients, provided that continuity of care is ensured and that supervised living arrangements are available for patients who require them. He believes a medical-model milieu with a clear structure and delineation of roles is most appropriate for short-term in-patient units.
TL;DR: The analysis of letters written in response to an invitation to comment on the hospital experience showed that the older the patient and the fewer the number of previous hospitalizations, the greater was the satisfaction expressed.
Abstract: A private psychiatric hospital's evaluation research unit assessed consumer satisfaction with service by analyzing the content of letters written in response to an invitation to comment on the hospital experience. Respondents included relatives and referring agents of those who had received treatment. They expressed greatest satisfaction with the helpfulness of the hospital, general patient care, and the quality of the clinical staff. They expressed much dissatisfaction with communication, such as adequacy of information about patients' treatment and progress, and with management issues, such as efficiency, length of stay, and hospital rules and procedures. The analysis showed that the older the patient and the fewer the number of previous hospitalizations, the greater was the satisfaction expressed.
TL;DR: The authors describe the design principles and philosophies they followed in the remodeling of an in-patient treatment and research service in a university psychiatric hospital and indicate where cost and code constraints resulted in a less than ideal solution.
Abstract: The physical environment of a treatment program affects patient outcome, but how and to what degree is not known. However, decisions about the design of the environment must be made, and they must be made in the face of cost and building-code constraints and widely varying patient characteristics and treatment models. The authors describe the design principles and philosophies they followed in the remodeling of an in-patient treatment and research service in a university psychiatric hospital and indicate where cost and code constraints resulted in a less than ideal solution. They point out that many apparent amenities, such as a ward kitchen, are significant milieu therapy resources, and they advocate the involvement of all levels of staff in the planning process.
TL;DR: As a result of the deinstitutionalization movement, increasing numbers of former state hospital patients are being rehospitalized in general hospital psychiatric units and general hospital staff members have to be educated to develop competence in working with the new patient population and a tolerance for chronicity.
Abstract: As a result of the deinstitutionalization movement, increasing numbers of former state hospital patients are being rehospitalized in general hospital psychiatric units. Because of this change in patient population, the general hospital has had to adjust its treatment strategy to emphasize meticulous review of previous psychiatric history, including medications; plans for meeting the patients' posthospital housing, vocational, and social needs; and development of plans with community care-givers for continuing care. General hospital staff members have to be educated to develop competence in working with the new patient population and a tolerance for chronicity; that can be done through several forums ranging from large staff meetings to individual supervision.
TL;DR: The author discusses differences that hinder the optimal use of general-hospital psychiatric units, such as funding, regulatory controls, and regional variations in length of stay.
Abstract: The number and the roles of psychiatric units in general hospitals have been growing rapidly in recent years, and general-hospital psychiatry presents broad opportunities for service delivery, education, and research. Most or all the basic components of a community mental health center can be found within a general hospital, and as psychiatrists move back into the mainstream of medicine, the general hospital takes on added value. Training advantages include the exposure of medical students and primary care residents and physicians to mental illness and its impact on families as well as the interaction between psychiatric and nonpsychiatric trainees at various levels. The author discusses differences that hinder the optimal use of general-hospital psychiatric units, such as funding, regulatory controls, and regional variations in length of stay.
TL;DR: Data on variables often used in recidivism studies were gathered from state hospital records of 129 patients released within a two-year period to a three-county area in West Virginia, finding inhospital variables were found to be the best predictors for all three outcome measures.
Abstract: Data on variables often used in recidivism studies were gathered from state hospital records of 129 patients released within a two-year period to a three-county area in West Virginia. The variables were categorized as prehospital, inhospital, or posthospital; the relationship between each variable set and recidivism was determined. The three criteria of recidivism were readmission within one year following discharge, number of days in the community, and number of days to first readmission. Inhospital variables were found to be the best predictors for all three outcome measures. When the number of variables in the set was controlled for, the posthospital set and the inhospital set had the same predictive power for readmission within one year of discharge and number of days to readmission. Posthospital variables were poorest at predicting, among recidivism criteria, the number of days in the community.
TL;DR: An evaluation of the combined deinstitutionalization and phasing down of a state hospital in Pennsylvania indicated conflicts in the areas of case management, community and political support, and administrative flexibility.
Abstract: Deinstitutionalization of patients is an inevitable fore-runner of hospital phase-down or closure, but if the two processes are carried out at the same time, they will be counterproductive. An evaluation of the combined deinstitutionalization and phasing down of a state hospital in Pennsylvania indicated conflicts in the areas of case management, community and political support, and administrative flexibility. A substantial problem was that deinstitutionalization is time-consuming and must be flexible enough to allow for the development of essential community supports and for largely unpredictable reactions from patients, families, communities, and service providers. Conversely, hospital consolidation must be relatively quick and inflexible to permit the orderly redisposition of staff and patients, reduce unnecessary staff resistance and anxiety, and withstand changing political pressures.
TL;DR: The past two decades have witnessed several important trends in mental health care: a decline in the resident census in public mental hospitals, an increase in outpatient treatment and facilities, relative stability in the number of hospitalization episodes per 100,000 population, and briefer duration of hospitalizations.
Abstract: The past two decades have witnessed several important trends in mental health care: a decline in the resident census in public mental hospitals, an increase in outpatient treatment and facilities, relative stability in the number of hospitalization episodes per 100,000 population, and briefer duration of hospitalization. The combined result of these trends is increased pluraslism, diversity, and deinstitutionalization in mental health care. The changes are primarily the consequences of the success of psychopharmacologic agents, new forms of psychotherapy, changing attitudes of the public and the profession, and increased financial support by the federal government.
TL;DR: This article argued that the nonverbal media employed by creative arts therapists tap emotional rather than cognitive processes and evoke responses more directly and immediately than traditional verbal therapies, and that creative arts therapies are reality-based and provide a more immediate and real link to a patient's experience than something he can portray only verbally.
Abstract: Elements of a standard definition of psychotherapy are used to support the argument that the creative arts therpies should not be characterized as adjunctive therapies, or discredited as not being "real therapies." Two concepts widely acknowledged as important in the application of the creative arts therapies are discussed: first, that the nonverbal media employed by creative arts therapists tap emotional rather than cognitive processes and evoke responses more directly and immediately than traditional verbal therapies, and, second, that creative arts therapies are reality-based and provide a more immediate and real link to a patient's experience than something he can portray only verbally.
TL;DR: A survey of schizophrenic residents of six board-and-care homes in the Los Angeles area found that the schizophrenic who adjusts to the setting experiences a schizoid-compliant pattern of outcome on antipsychotic drugs that is characterized by blunted affect, passivity, and lack of initiative, interest, and spontaneity.
Abstract: A survey of 46 randomly selected schizophrenic residents of six board-and-care homes in the Los Angeles area found that the schizophrenic who adjusts to the setting experiences a schizoid-compliant pattern of outcome on antipsychotic drugs that is characterized by blunted affect, passivity, and lack of initiative, interest, and spontaneity. The authors conclude that it is those negative symptoms of schizophrenia, mistakenly attributed to the presumed inadequacies of the board-and-care environment, that have given the board-and-care home a bad press both in the newspapers and in the psychiatric literature.
TL;DR: In 1974 members of the Ohio Psychiatric Association were surveyed to determine the extent to which psychiatrists performed physical examinations and their attitudes toward conducting such examinations, and those who felt more confident in their diagnostic skills tended to perform examinations more frequently.
Abstract: In 1974 members of the Ohio Psychiatric Association were surveyed to determine the extent to which psychiatrists performed physical examinations and their attitudes toward conducting such examinations. Responses from 222 psychiatrists showed that most believed psychiatric patients should have a physical examination, but that it should be conducted by a physician other than a psychiatrist. Those who felt more confident in their diagnostic skills tended to perform examinations more frequently than psychiatrists who were unsure of their skills. Regardless of whether they performed examinations, the respondents were almost universal in the belief that their medical training and experience added an important dimension to their skills.
TL;DR: Using the Massachusetts Mental Health Center as the model, the authors describe how an inpatient unit operates as part of a deinstitutionalized network of services for seriously ill patients.
Abstract: Recalling the important statement about the bankruptcy of the state hospital system and the need for a multitude of treatment settings made by Harry Solomon, M.D., in 1958, the authors acknowledge that the changes he prophesized have largely come about. Using the Massachusetts Mental Health Center as the model, they describe how an inpatient unit operates as part of a deinstitutionalized network of services for seriously ill patients. They discuss the five general types of patients admitted and the problems of providing adequate care to such a diverse population. Finally, they make a strong plea for the establishment of regional facilities to care for patients with unusual, complicated problems.
TL;DR: Although the problems with the system extend beyond psychiatry and the mental health field, the author suggests that psychiatrists could force some positive changes by refusing as a profession to practice in institutions that provide inadequate care, and by supporting the delivery of public services by nongovernmental bodies.
Abstract: A 1977 survey of public attitudes toward psychiatry found that the quality of institutional psychiatry was one of several factors associated with negative attitudes toward the field. Noting the shortage of psychiatrists in public institutions, the author questions whether the public associates psychiatrists with conditions in the institutions despite their lack of involvement, or because of it. He believes that the inadequate care provided in many public facilities is a result of a tacit social contract between the public and private sectors that enables private institutions to maintain their fiscal integrity and their quality of care by moving undesirable patients to public institutions that provide inadequate care. Although the problems with the system extend beyond psychiatry and the mental health field, he suggests that psychiatrists could force some positive changes by refusing as a profession to practice in institutions that provide inadequate care, and by supporting the delivery of public services by nongovernmental bodies. The ultimate answer, he believes, lies in research into more effective treatment for mental illness that would make such institutions unnecessary.
TL;DR: To make it easier for researchers to tract down dropouts, the author suggests that when patients enter a program they should be required to give names, addresses, and telephone numbers of at least two friends or relatives who would know where they were.
Abstract: Staff at a VA-sponsored drug treatment center followed up dropouts one year after they left the program; they were able to locate 80 per cent of those clients. The staff found several contacts useful in locating the difficult-to-find population, including the addicts' mothers, other drug programs, prisons, and the department of motor vehicles. To make it easier for researchers to track down dropouts, the author suggests that when patients enter a program they should be required to give names, addresses, and telephone numbers of at least two friends or relatives who would know where they were. Staff should emphasize to patients that the infonnation is for research purposes and that confidentiality will be preserved.
TL;DR: The author feels that the future of general psychiatry does not lie in primary care per se but in its being an identified specialty closely allied to super-specialists and to primary caretakers alike.
Abstract: For psychiatry to be successfully integrated into the general hospital, the psychiatrist must function within the medical model, and his mode of practice must be consistent with general-hospital caretaking The author discusses the positive effects of consultative and liaison psychiatry linkages in the general-hospital setting as well as the problems of financing; there are inequities of reimbursement for consultation and a lack of payment for liaison services He makes several suggestions about the education of the psychiatrist; it should not be geared exclusively toward the psychiatrist's role as a primary caretaker Medical schools should introduce students to the discipline of psychiatry and its interrelationships with other disciplines Teaching hospitals should train the psychiatrist in the medical model The author feels that the future of general psychiatry does not lie in primary care per se but in its being an identified specialty closely allied to super-specialists and to primary caretakers alike