PART II PSYCHOSOCIAL TREATMENT PRINCIPLES

Transcription

1 PART II PSYCHOSOCIAL TREATMENT PRINCIPLES

2 132 Psychosocial Treatment Principles EDITOR'S COMMENTARY: PART II This section addresses the individual in the psychosocial context of his family, his work, his living situation and his social environment. The vulnerable patient when skillfully approached with insight and sensitivity within a meaningful social setting can often respond with health and strength. Good community care, as represented in these pages, is usually delivered by a comprehensive and multifaceted program. A prototypical patient-his family situation having been assessed as unsatisfactory as a result of a crisis intervention in an acute psychiatric service-may well be referred to a community residential program which will serve as an alternative living arrangement. Additionally, this same patient could conceivably be considered for vocational assessment while at a partial hospital program or social club during the day, as well as for individual therapy to help him understand his unique dynamics. Ideally, the various players upon this stage-all of the various clinicians-will meet together both initially for assessment and planning and periodically thereafter to assure a coordinated, knowledgeable treatment. This section describes the background and practice of the various components of this psychosocial program. All of these are practiced in the context of deinstitutionalization-the preservation of the "patient's assets for selfcare" and social networks, as described in the previous section. The partial program is the component which would likely assess, prescribe and monitor the pharmacologic needs of the patient, as is described in the next section. Discussion of the problems in delivering all of these services in different environments (suburban and rural) and exploration of issues common to all programs (fiscal, legal and advocacy) follow in subsequent sections of the text. In the first chapter, Stanton writes a thoughtful introduction to the role of the psychosocial therapies. He highlights man's social need to interact with his fellow man. He then distinguishes the essential differences between psychotherapy and other beneficial human interactions. He also relates psychotherapy to the importance of group living for the patient. He carefully reviews, in addition, the history of the development of psychotherapy. He emphasizes the therapist's expectation of change, and the importance of this in the therapeutic interaction with the chronic patient. He reviews the four types of psychotherapy used with chronic patients as well as the elements common to all of these. Stanton demonstrates how

3 Psychosocial Treatment Principles 133 psychotherapy alone or psychotherapy only with medication "is clearly inadequate for many of the more seriously disturbed patients." He believes that the addition of an experience in a therapeutic community as a simultaneous part of the patient's program can give major aid in working toward recovery. He reviews six different therapeutic community models and then interrelates the practice of psychotherapy with that of the therapeutic milieu. He importantly points out how more benefits are gained when the therapeutic milieu can be explored in the course of a simultaneous, ongoing individual psychotherapy. Conversely, individual psychotherapy is enriched through the ongoing reality confrontation the patient experiences in the therapeutic milieu. Ultimately, Stanton suggests that the therapeutic community itself may be a necessary condition for the successful individual psychotherapy of the chronic patient. Leff highlights in his chapter the increased burden carried by the families of psychiatric patients who have been discharged into the community. He recognizes the unique day-in and day-out strain on the family which has a chronically ill member living with it. He suggests that professionals who only spend a few hours a week with these patients may not be sensitive to the problems of patients' families. Leff makes a clear distinction between the two major diagnostic categories-manic-depressive illness and schizophrenia. He then divides his chapter between problems common to all patients and those specific to these two major illnesses. He discusses the problem of providing families with adequate information and education; the social problems encountered due to difficulties in employability and housing; and the problems encountered by the family members who are likely to experience greater social isolation due to either their own shame or to the aversion of friends and neighbors. Methods of decreasing the burden on relatives are considered. He reviews the significance of the family's influence on the course of schizophrenic disorders and on subsequently developed policies for managing these families. The issue of high-expressed emotion or emotional overinvolvement in relatives of schizophrenics as directly associated with relapse of schizophrenia is explored. Protection of the patient is first obtained by prescribing regular antipsychotic medication and then by reducing the amount of time spent with the relatives. The latt~r is accomplished by the use of either supervised lodgings or a day hospital, two methods of removing the patient from a noxious environment. It is important to note that in an effort to decrease the

4 134 Psychosocial Treatment Principles overintense contact with the family, Leff advocates the use of a variety of different modalities described in this volume, including residential care, day center care and sheltered occupations. Aguilera describes crisis intervention as an inexpensive, short-term therapy that focuses on solving the immediate problem. First, she reviews the historical background of urbanization leading to a greater likelihood of crisis development. Then she describes the history of the development of the technique of crisis intervention. She reviews the psychoanalytic contributions of Freud, Hartmann, Rado, Erikson, Lindemann and Caplan. Following this, the technique of crisis intervention is described in relation to the family's adjustment to the return of the patient to the home. This clearly relates directly to the previous chapter by Leff. Also, her comment that the social isolate in particular is more vulnerable to crisis recalls to the reader the issues explored by Hammer in an earlier chapter. Her focus on urban life relates to the Lamb chapter that follows in a later section. Hursh and Anthony emphasize how work is not only a normalizing activity but also a provider of therapeutic benefits. In particular, work contributes to "shedding one's patienthood" and improving one's self-concept. These authors focus on the psychiatrically disabled client's skills instead of on his symptoms. They approach this subject through what they describe as client-skill development in community support. In contrast to Leff, and in accordance with their focus on the patient's potential for productivity, the notion of the traditional psychiatric diagnosis is entirely repudiated, and instead a "rehabilitation diagnosis" is used. They distinguish work/ environment behaviors as being either physical, emotional or intellectual. Interviewing techniques are specifically described as "attending, observing, listening and responding," and these are used in order to acquire an assessment of "where the client is" in relation to his/her goal. The authors review work-sample techniques that help to assess the client's different work skills, as well as situational-assessment techniques, on-the-job evaluation techniques and psychometric testing techniques. The authors then take up some of the practical interferences with the setting-up of an effective program. In particular, they address the problem that results too often when vocational assessment is done in a separate geographical site, which leads to poor communication among the entire rehabilitative team. They also feel that the common view of the vocational evaluator as a specialist with unique knowledge that is different from that of other rehabilitation practitioners contributes to poor interdisciplinary communication, and they propose a number of corrective measures to

5 Psychosocial Treatment Principles 135 ameliorate this problem. The authors then explore rehabilitation programming strategies including work adjustment, career counseling, occupational skill training and career placement. Several unique training situations are described, including workshop without walls, transitional employment programs and projects with industry. This chapter is overall a very technical one; it addresses specific techniques in assessment and programming for rehabilitation counseling. It focuses more on the importance of recognizing the special value of a proper vocational assessment than on collaboration with other mental health professionals. Nevertheless, it is important that other mental health professionals begin to recognize that symptomatology and the capacity to work are two very different variables. It appears that the human personality is too complex to allow us to make a prediction regarding the capacity to work from one set of pathologic symptomatology. Rather, one would have a more accurate predictive measure using Hursh and Anthony's assessment techniques. Washburn reviews the early development of the day hospital as a replacement to a great extent for the inpatient service. He describes the criteria used to determine eligibility for his programs as well as the issue of staffing. Then he reviews outpatient vs. inpatient placement. He explores extensively a variety of followup research studies comparing the day hospital to inpatient care. He makes the general point that most patients can be handled in a day hospital, especially after a short hospital stay, and can thereby avoid the use of longterm hospitalization altogether. Grob sets the historical development of psychosocial rehabilitation centers in the context of the two major presidential commissions on mental health in 1961 and Following this, he reviews the historical antecedents to the social approach. With stunning accuracy, Harry Stack Sullivan predicted in the 1930s that patients would be helped through social psychiatry, and that there would be an increase in relapse rate if there were no intermediate facilities such as "convalescent camps and communities for those on the way to mental health." Further, it is remarkable how other authors of the same era, such as Marsh, working at Worcester State Hospital in Massachusetts, advocated expatient organizations on a national basis. The influence of the study and development of group psychotherapy is discussed, as well as the influence of Adler. Grob reviews how the experience of World War II and the rapid funding of mental health services thereafter promoted the development of psychosocial rehabilitation centers. Grob's chapter clearly relates to Hammer's in its focus on socialization. He concludes with a list of what he calls the model

6 136 Psychosocial Treatment Principles elements required in a quality program. He warns that these could too easily be lost in the bureaucratic mechanics and fiscal intricacies of expanded programs. Finally, Budson describes the evolution of community care deriving from pharmacologic, social and legal developments in the 1950s, 60s and 70s. He then reviews ten different types of sheltered housing used for the chronically mentally ill. He explores problems in appraising the effectiveness of these community residential alternatives, including the problem of "client/milieu matching." Following this, he discusses some issues in starting a new program and covers some pithy clinical topics. He concludes with an exploration of some controversial administrative issues facing community residential care-regulatory, financial, building codes, staffing and community opposition. These chapters described the elements of psychosocial treatment. In the following section, we describe the other major treatment modality: pharmacotherapy.