Aichhorn revisited

August Aichhorn first published Wayward Youth in German in 1925. His willingness to approach a problem as difficult as delinquency in terms of psychoanalytic theory and to then test his theories with groups of delinquents in a reformatory setting were truly pioneering. Perhaps his greatest success as an educator was in attracting other psychoanalytic leaders, most notably Sigmund Freud and Kurt Eissler, to extol and extend his early efforts. The turn of the century seems a fitting time to revisit Aichhorn's views, to assess his impact on colleagues, and to place his contribution in the perspective of current research and practices.

Family treatment and medication dosage reduction in schizophrenia: effects on patient social functioning, family attitudes, and burden

The effects of 2 family intervention programs (supportive family management [SFM], including monthly support groups for 2 years; or applied family management [AFM], including 1 year of behavioral family therapy plus support groups for 2 years), and 3 different neuroleptic dosage strategies (standard, low, targeted) on social functioning of patients with schizophrenia. their relatives' attitudes, and family burden were examined. AFM was associated with lower rejecting attitudes by relatives toward patients and less friction in the family perceived by patients. Patients in both AFM and SFM improved in social functioning but did not differ, whereas family burden was unchanged. Medication strategy had few effects, nor did it interact with family intervention. The addition of time-limited behavioral family therapy to monthly support groups improved family atmosphere, but did not influence patient social functioning or family burden.

Integrating harm reduction therapy and traditional substance abuse treatment

One-size-fits-all therapy has not worked well for a majority of substance users seeking help. New approaches to substance abuse treatment are desperately needed. Traditional models of service delivery offer little, if any, help to people who may not choose abstinence as a goal. To address this concern, the Bridging the Gap Conference was sponsored by the San Francisco Department of Public Health. The overall goals of the conference were to improve standards of care, develop best practice principles for integrating harm reduction approaches into traditional substance abuse services, and increase the accessibility of quality services to people in need of alcohol and drug treatment. G. Alan Marlatt gave a keynote address on the integration of harm reduction therapy into traditional treatment services, an expanded version of which is presented in this article. Such integration would broaden the scope of services available to a larger group of consumers of substance abuse treatment. Furthermore, harm reduction therapy would infuse traditional treatment practices with scientifically-based pragmatism that pays close attention to individual and community public health needs. Because of its tolerance of treatment goals other than abstinence, harm reduction therapy offers the greatest hope to expand the availability of substance abuse services to people who have not benefited from traditional abstinence-based treatment models.

Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors

BACKGROUND

Social support theory and observational risk factor studies suggest that increased antenatal psychosocial support could prevent post-natal depression. We used empirical knowledge of risk and protective factors for post-natal depression not employed previously in order to develop and evaluate an antenatal preventive intervention.

METHODS

We conducted a pragmatic randomized controlled trial in antenatal clinics. We screened 1300 primiparous women and 400 screened positive, 69 screen-positive women were untraceable or not eligible. Of 292 women who completed baseline assessment, 209 consented to randomization, of these 190 provided outcome data 3 months post-natally. 'Preparing for Parenthood', a structured antenatal risk factor reducing intervention designed to increase social support and problem-solving skills, was compared with routine antenatal care only. We compared the percentage depressed at 3 months after childbirth using the self-completion General Health Questionnaire Depression scale and Edinburgh Post-natal Depression Scale (EPDS), and the Schedules for Clinical Assessment in Neuropsychiatry a systematic clinical interview.

RESULTS

Assignment to the intervention group did not significantly impact on post-natal depression (odds ratio for GHQ-Depression 1.22 (95% CI 0.63-2.39), P = 0.55) or on risk factors for depression. Forty-five per cent of the intervention group women attended sufficient sessions to be likely to benefit from intervention if effective. Attenders benefited no more than non-attenders.

CONCLUSIONS

Prevention services targeting post-natal depression should not implement antenatal support programmes on these lines until further research has demonstrated the feasibility and effectiveness of such methods. The development of novel, low cost interventions effective in reducing risk factors should be completed before further trial evaluation.

Prevention research in eating disorders: theory and new directions

BACKGROUND

Over the past two decades, scores of articles and several books have been published calling for more attention to the prevention of eating disorders, but less than two dozen prevention intervention studies have been conducted to date.

METHODS

This paper reports the results of a systematic review of 20 empirical intervention studies on eating disorders prevention, discussing the data accumulated on what has and has not been effective. Beyond a description of study design and findings, this paper devotes special attention to the theoretical orientations of the studies and their implied assumptions about preventive strategies.

RESULTS

Though there has been a compelling interest in social, political and economic factors influencing the incidence of disordered eating, little of this interest has been carried over into the prevention end of eating disorders research. Most studies reported thus far have been designed to target and measure change principally on the individual level, to the exclusion of considering leverage points for intervention in the larger social environment.

CONCLUSIONS

This paper concludes with a recommendation for new attention to a model of proactive primary prevention targeted at environmental change and cross-disciplinary collaboration to achieve a reduction in the incidence of eating disorders.

Abstinent-contingent housing and treatment retention among crack-cocaine-dependent homeless persons

This study investigated Behavioral Day Treatment attendance in relation to treatment outcome among homeless persons dependent on crack-cocaine. Participants (N = 141) were 72.3% male and 82.7% African American. Days attended, activities attended, and follow-up rates over a 12-month period were positively affected by the more attractive treatment of providing immediate, rent-free, abstinent-contingent housing during a 2-month Behavioral Day Treatment program. Results replicated previous findings that abstinence is a function of treatment attendance and more treatment is associated with greater abstinence. The loss of predictive power at long-term follow-up, limitations of a retrospective design, need to identify most predictive therapeutic activity types, and potential influence of mental disorders were discussed. Analytical techniques used in this study allows for the planning, predictability, and measurement of drug abuse treatment success as a function of service utilization.

Characteristics of women in jail and treatment orientations. A review

Women who have been incarcerated are a high-risk group for criminal recidivism, and criminal justice statistics indicate that females are increasing in numbers more rapidly than the male detainee population. According to data from epidemiologic studies, incarcerated women are often young, single, mothers from ethnic minority backgrounds who have little education and poor work histories. Mental illness, drug abuse, and risky behaviors relating to contracting HIV/AIDS are common problems among female detainees. In this report, research into characteristics of women in jail and literature relating to treatment programs for incarcerated women are reviewed. Implications relating to treatment needs, program development, and further research are discussed. A case example and treatment intervention are presented based on this review.

Mechanisms of change in multisystemic therapy: reducing delinquent behavior through therapist adherence and improved family and peer functioning

The mechanisms through which multisystemic therapy (MST) decreased delinquent behavior were assessed in 2 samples of juvenile offenders. Sample 1 included serious offenders who were predominantly rural, male, and African American. Sample 2 included substance-abusing offenders who were predominantly urban, male, and Caucasian. Therapist adherence to the MST protocol (based on multiple respondents) was associated with improved family relations (family cohesion, family functioning, and parent monitoring) and decreased delinquent peer affiliation, which, in turn, were associated with decreased delinquent behavior. Furthermore, changes in family relations and delinquent peer affiliation mediated the relationship between caregiver-rated adherence and reductions in delinquent behavior. The findings highlight the importance of identifying central change mechanisms in determining how complex treatments such as MST contribute to ultimate outcomes.

Phase-specific psychosocial interventions for first-episode schizophrenia

Phase-specific psychosocial interventions for first-episode schizophrenia are outlined and described using examples from clinical practice with 68 patients. These interventions are based on the unique aspects of the first episode and patients' clinical states. Although schizophrenia may run an uneven and often unpredictable course, most patients experience three distinct phases: (1) the acute phase, (2) the healing phase, and (3) the maintenance phase. The timeliness of phase-specific interventions is crucial in helping both patients and families understand the illness, evaluate options, accept treatment, and adjust to changes in functioning and expectations.

Community reinforcement approach for combined opioid and cocaine dependence. Patterns of engagement in alternate activities

We compared outcomes for agonist-maintained patients with combined opioid and cocaine dependence who were treated in an earlier clinical trial with group drug counseling (DC; n = 57) or in a current trial with the Community Reinforcement Approach (CRA; n = 60). The association between engagement in nondrug-related activities and abstinence was also evaluated. There were no significant differences between the treatments in retention or drug use. The total number of hours and average hours per week engaged in nondrug-related activities was significantly higher for CRA-treated patients who achieved abstinence from opioids, cocaine, or both combined than for those who never achieved abstinence. Although CRA was not more effective overall than DC, the finding that engagement in reinforcing community activities unrelated to drug use (e.g., planned pleasurable events or parenting activities) was associated with abstinence suggests that the planning and reinforcement of specific nondrug-related social, vocational, and recreational activities is a crucial component of CRA.

Sensory and movement-led approach to design for elderly severely mentally ill units

The evolution of a design embodying the alliance of movement to sensory stimulus for confused and Alzheimer sufferers. The paper is an account of the design concept of an Elderly Severely Mentally Ill (ESMI) unit under the Government Private Finance Initiative (PFI) rules. Previous papers by the author recorded the development of elderly care nursing units that sought to use the planning of circulation as a means to provide stimulation for patients. The results demonstrated a therapeutic value for this approach. In the latest version for ESMI, the concept has been taken further with the creation of a "Memory Trail" that provides a choice of routes with organised points of interest containing stimulus for the senses in order to trigger memory. This is seen as beneficial not only for patient but also provides a positive role for relatives in escorting and planning the "journey". The paper records how the design amended the original brief by the participation of user groups re-evaluating the requirements in discussion and visits to earlier versions of this approach.

Facilitating adjustment to inflammatory bowel disease: a model of psychosocial intervention in non-psychiatric patients

BACKGROUND

There is no consensus about the most appropriate psychosocial interventions for people with inflammatory bowel disease (IBD) or the most appropriate criteria by which to select which patients might benefit from the available interventions. Nonetheless the perception that stress and other subjective factors contribute to suffering in IBD is persistent and professionals are often called upon to offer appropriate support. A model of normal psychosocial adjustment to IBD and the interventions which can improve difficulties with adjustment will facilitate rational therapeutic intervention and needed research in this area.

METHODS

A model of normal adjustment to IBD is developed from a synthesis of the empirical literature and clinical experience in a tertiary care medical/surgical IBD centre and is used to identify potential points of psychosocial intervention.

RESULTS

Normal adjustment to IBD can be understood as a process involving the interaction of a triad of adaptive challenges: illness uncertainty, loss and change, and suffering. Each of these challenges requires different criteria of psychosocial assessment and may lead to different interventions.

CONCLUSIONS

Although the interventions available for improving adjustment to IBD have not been exhaustively investigated, the existing data support the value of further study. The model of psychosocial adjustment presented here provides a synthesis of the existing data and a starting point for further research.

[Investigation of personal niche as basis of supportive psychotherapy]

According to the ecological theory of Willi 1996, people create and maintain their psychic wellbeing through constant shaping of their environment, i.e. setting up a personal niche. The personal niche in turn responds to, guides and challenges further personal development. This study explores what kind of solutions single patients with psychiatric invalidity can find in order to form their environment as a niche in which they may develop effectiveness and use it for their psychic regulation. 30 people were questioned with a semi-structured interview: they were patients of a psychiatric out-patient's clinic, living alone and psychiatrically invalidated (2/3 with schizophrenia of the residual type). The results were ranked after their increasing demands in a relational and in an activity inventory. The more relationship is based on mutuality expectations of others, personal disclosure and binding the more the subjects feel overstrained. The investigation of these inventories serve as a technical aid in supportive psychotherapy.

Description and immediate impacts of a preventive intervention for conduct problems

A population-based randomized intervention trial for the prevention of conduct problems (i.e., oppositional defiant disorder and conduct disorder) is described. The LIFT (Linking the Interests of Families and Teachers) intervention was designed for all first- and fifth-grade elementary school boys and girls and their families living in at-risk neighborhoods characterized by high rates of juvenile delinquency. The 10-week intervention strategy was carefully targeted at proximal and malleable antecedents in three social domains that were identified by a developmental model of conduct problems. From 12 elementary schools, 671 first and fifth graders and their families participated either in the theory-based universal preventive intervention or in a control condition. The intervention consisted of parent training, a classroom-based social skills program, a playground behavioral program, and systematic communication between teachers and parents. A multiple measure assessment strategy was used to evaluate participant satisfaction and participation, fidelity of implementation, and the immediate impacts of the program on targeted antecedents.

Retrospective analyses of additional services for methadone maintenance patients

We report on the 6-month outcome of a retrospective analysis of additional treatment services for patients entering a methadone maintenance program who transferred from community methadone treatment programs (n = 83) or entered off the street (n = 83) not currently on methadone. Patients were participating in a clinical treatment trial examining the effectiveness of Community Reinforcement Approach and Relapse Prevention. Patients in the methadone transfer group were using less heroin at intake than patients newly initiated onto methadone and both groups improved from additional treatment services in the following problem areas specifically: drug, alcohol, legal, employment, social, and in some measures of psychiatric distress. Therefore, both groups of patients in this study benefited from additional treatment services.

Addictive disorders in adolescents

Physicians should recognize the importance of individual differences in the etiologic pathway to drug abuse. Drug use in most adolescents subsides or stops by adulthood; however, adolescents with behavioral or affective dysregulation, poor social skills, a limited social network, and substance abuse during late adolescence are at increased risk for substance dependence in adulthood. Research is needed, however, to clarify the developmental emergence and interaction between individual and contextual risk factors. Understanding person-environment processes within a developmental perspective not only yields a better understanding of the causes but also informs about taxonomy, prevention, and readiness to change and compliance in treatment and after-care. Treatment outcome research suggests that (1) relapse is likely to occur within the first 3 months after treatment completion and, to a lesser extent, over the year following treatment completion; (2) relapse is more likely in adolescents who have comorbid psychiatric disorders and other problems, such as high stress, low social skills, lack of involvement in productive activities or active leisure, and no follow-up intervention; (3) continued after-care treatment may maintain treatment gains; (4) the effectiveness of treatment and aftercare is likely to vary by the amount, mode, and the consistency with which it is delivered; (5) gender differences might have an impact on treatment outcome; and (6) adolescents presenting for treatment are likely to respond well to interventions based on family therapy and CBT approaches.

Coping and social skills training for alcohol and cocaine dependence

Coping and Social Skills Training (CSST) has been in the forefront of the addictions literature for over two decades. In this review, we provide an outline of empirically validated CSST assessment measures and treatment protocols for alcohol dependence and cocaine dependence. Key elements covered in CSST include communication skills training, cue exposure treatment with urge coping skills, and cocaine-specific coping skills training. We conclude with a summary of the research to date in support of CSSt and future directions for the treatment of addictive behaviors.

[Psychiatric vocational therapy--concepts, practice and scientifically-based results]

Work therapy is a widespread form of socio-therapy. In contrast to pharmacological and somatic forms of treatment, proof of efficacy is difficult to produce in multimodal therapy of psychiatric patients. Within the framework of an extensive study on vocational rehabilitation of mentally ill patients, we carried out a naturalistic follow-up study of 112 mostly schizophrenic patients attending outpatient work therapy programmes. The courses of illness and rehabilitation were documented prospectively over a three-year period. At the end of the study 23% of the patients were integrated into the open labour market, 25% were working in sheltered employment, 25% remained in work therapy, and 27% were unemployed. Controlled studies with schizophrenic patients show, that work therapy contributes to improved vocational integration, a reduction of rehospitalizations and a stabilisation of the psychopathological status.

The therapeutic use of ritual and ceremony in the treatment of post-traumatic stress disorder

The therapeutic purposes and effects of specially designed ceremonies in the treatment of persons with post-traumatic stress disorder are described. Ceremonies compartmentalize the review of the trauma, provide symbolic enactments of transformation of previously shattered relationships, and reestablish connections among family and with society in general. Four ceremonies used with Vietnam combat veterans are described which focus on the themes of separation from and return to the family, forgiveness of the living, and releasing the dead. Ritual and ceremony are highly efficient vehicles for accessing and containing intense emotions evoked by traumatic experience. Evaluation by family and veterans judge these ceremonies to be the most effective components of treatment.

The treatment of avoidant personality disorder by social skills training in the clinic or in real-life settings

Twenty-eight outpatients who met DSM-III diagnostic criteria for avoidant personality disorder completed 14 one and a half hour sessions of social skills training in the clinic only or a combination of four sessions in the clinic, four sessions in real-life and six follow-up sessions in the clinic. Subjects were assessed before treatment began, after four sessions, at the end of treatment and at three month follow-up points. Training in real-life did not enhance social skills training; no significant difference between the groups at any assessment points was found. In both groups improvement in time was significant and clinically worthwhile. The treatment effects were maintained up to the three month follow-up, where available. Social skills training appears to be a useful and promising intervention for avoidant personality disorder but its long term impact remains to be investigated.

Conduct disorder: long-term outcomes and intervention effectiveness

OBJECTIVE

To review the literature on conduct disorder in two areas: long-term outcome and the effects of interventions.

METHOD

The sources of the articles for review were computer searches, but the articles were selected for this review to illustrate key findings in the long-term outcome area and to review critically four intervention strategies to prevent or treat conduct disorder, namely, parent- and family-targeted programs, social-cognitive programs, peer and school-based programs, and community programs.

RESULTS

Conduct problems in childhood predict the same increased rates of psychiatric disorder overall in men and women but the patterns are different: for externalizing disorders, the prediction is stronger in men and for internalizing disorders, the prediction is stronger in women. In the intervention domain, the literature provides limited evidence of the effectiveness of either primary or secondary prevention.

CONCLUSIONS

Prospective studies of community samples of children provide the best opportunity to understand more thoroughly the adult outcomes of conduct disorder. Because of the heavy burden of suffering of conduct disorder, and the limited effectiveness of clinical interventions, there is a compelling argument in favor of an increased emphasis on primary prevention efforts.

A multicomponent behavioral treatment for social phobia: social effectiveness therapy

The development of a new, comprehensive and multicomponent treatment for social phobia is described. Initial results of a pilot study with the new treatment also are reported. The treatment was found to be effective with severe (generalized) social phobics, most of whom had co-occurring Axis I and/or II conditions. In addition to significant change on a host of outcome variables, a normative-based endstate functioning index was used to determine treatment efficacy. The results are discussed with respect to the implementation of the treatment and in terms of the need for a comprehensive approach to treating social phobia.

Psychosocial interventions in the management of recurrent headache disorders. 1: Overview and effectiveness

This is the first in a series of three articles addressing nonpharmacologic therapies for management of recurrent migraine and tension-type headache. It provides an overview of the commonly employed nonpharmacologic therapies for recurrent headache, reviews scientific evidence of their efficacy, and identifies the psychosocial interventions that have the greatest potential to enhance the management of recurrent migraine and tension-type headache in primary care settings internationally. In the second article, the authors offer practical guidelines for the administration of recommended nonpharmacologic interventions. The third article explores healthcare policy implications involved in a decision to incorporate psychosocial interventions into primary care practice.