Crisis theory and possibilities of therapeutic intervention

Does adherence therapy improve medication adherence among patients with schizophrenia? A systematic review

Non-adherence to medication is highly prevalent in patients with schizophrenia. Adherence therapy aims to improve medication adherence of these patients by applying techniques of cognitive behavioural therapy, psycho-education, and motivational interviewing. Even though adherence therapy is frequently discussed and researched, its effectiveness is still uncertain. This paper aims to review the effectiveness of adherence therapy on the medication adherence of patients with schizophrenia. To this end, six electronic databases were systematically searched for randomized, controlled trials on adherence therapy from January 2002 to March 2013. Four trials met the inclusion criteria and were incorporated into the review. The findings suggest that adherence therapy does not improve patients' medication adherence in comparison to treatment as usual or a control intervention. However, all the studies reviewed showed high-adherence ratings at baseline. Thus, further well-designed studies that target adherence therapy to patients who are non-adherent to their medication are needed for a more profound understanding of its effectiveness. In addition, if adherence therapy is aimed not only at improving medication adherence, but also to reach an agreement whereby the patient's decision not to take his medication is accepted, the shared decision-making process needs to be assessed as well.

Beyond the mental hospital: crisis intervention and continuity of care in Trieste. A four year follow-up study in a community mental health centre

A sample group of 39 new patients with acute and severe crises underwent a 4-year follow-up study at the community mental health center in Trieste (CMHC). The CMHC is a full-time service, open 24 hours a day and 7 days a week, and is fully integrated into a network of services which has completely replaced the preexisting mental hospital. Evaluation shows: 1) a generally good outcome of the initial crisis; 2) a low relapse rate; 3) a tendency towards favourable long-term outcomes. In terms of practice, voluntary and compulsory hospitalization were avoided in favor of short-term day and night support in the CMHC. There were no suicides, no crimes, no drop-outs. Social adjustment remained unchanged. Accessibility and continuity of care were favored by not separating special crisis services. Instead, crisis intervention was integrated into a comprehensive Mental Health Service offering a wide range of preventive and rehabilitative responses. The study demonstrates that the mental health services in Trieste are able to cope with acute crises without psychiatric hospitalization.

Deinstitutionalisation--from hospital closure to service development

The necessary components of a comprehensive service of local non-institutional forms of care for the seriously mentally ill have been researched separately in pilot trials, but not within integrated programmes for defined populations. Reported outcomes are at least as favourable as for traditional long-term hospital care, but alternative provisions are no less costly. A case manager system may allow co-ordinated formal and informal services to meet the individual needs of chronically ill patients. Poorly integrated programmes will expose discharged patients to disadvantages.

The place of crisis intervention in psychiatry

This paper examines the concept of crisis intervention and its relevance to psychiatric practice. Crisis theory originated in relation to healthy subjects disturbed by major life hazards. Its application, however, has been widened in an uncritical manner to include patients with psychiatric disorders. To what extent crisis theory and intervention can be applied is discussed and relevant research on the outcome of their use in a variety of settings reviewed. It is concluded that although crisis theory cannot be transplanted in its entirety into psychiatry, modified versions might prove useful. The role of crisis in inducing behaviour change in a variety of psychiatric settings and the ways in which this might be harnessed are of considerable interest and worthy of careful investigation.

Psychiatrists in primary health care settings

An increasing number of psychiatrists are now working partly in primary care settings. This paper describes how the movement began and how both psychiatrists and other members of the specialist psychiatric treatment team have explored ways of working with family doctors in the diagnosis and management of psychiatric disorders. Various styles of collaborative work, the declared advantages of such attachment schemes, the reservations being expressed about their further extension, and their research and educational potential are explored. If such enterprises, designed to help the family doctor identify psychiatric morbidity in the practice and to extend his skills in managing such patients and their relatives, are to be commanded, they must be carefully monitored so that the cost-benefit balance can be established.

Home assessment and treatment in a community psychiatric service

The work of a new community-based crisis intervention team is described. 326 psychiatric emergencies were seen over a period of 3 years. An increasing proportion of these were acutely psychotic at the time of assessment. Home treatment was effective for a significant number of patients, including those with a previous history of hospital admission. Some practical and theoretical aspects of the service are discussed.

Brief marital therapy outcome: personality correlates

The purpose of the study was to investigate with regression analyses the relationship between personality and background variables and outcome of brief marital therapy. Twenty personality dimensions from the Personality Research Form and data on age, education, number of previous unions, number of children and number of sessions were used as independent variables. The dependent variable was provided by ratings of over-all improvement in affective communication: sexual, verbal, and social, provided by clinical records of 30 couples. The main result was that only the husband's traits were found to be important correlates of improvement in affective communication of both husbands and wives. The important traits involved husband's cognitive efficiency in the area of reflection and accurate judgement of situations, submissiveness, and sensitivity to social approval of his behaviour. The number of individual therapy sessions given to wives was also a notable predictor of improvement. Other personality and background variables were not significantly related to outcome.

Compulsory admissions in a London borough: II. Circumstances surrounding admission: service implications

The circumstances immediately surrounding compulsory admissions are examined. These circumstances can be seen largely to derive from the long-term psychiatric and social difficulties of patients described in Part I. A constellation of factors is identified which often limits any alternative to a compulsory admission. A number of recommendations are made based on these findings which are designed to diminish the need for compulsion in the future.

Assessment of patients for psychotherapy

Factors in the patient which have been commonly cited by therapists as relevant in assessment for psychotherapy are examined as well as the research done on them. These factors are discussed under four categories: (a) factors related to the illness, (b) personal factors related to the treatment, (c) personal factors not directly associated with the illness and (d) current life circumstances. Research on methods of assessing patient suitability is discussed together with an account of the reasons for the rather disappointing contribution of systematic research.

Psychosocial adjustment to breast cancer: a review of selected literature

The following is a review of the clinical and research literature concerning women's emotional adjustment to the detection of breast cancer and its subsequent management. The review is organized into ten themes which focus on three general areas: 1) women's response to the diagnosis of breast cancer; 2) involvement of spouse, family and professional providers; and 3) the patient's milieu--how it impinges on the course of her treatment and rehabilitation. Also noted is the paucity of systematic research dealing with the effectiveness of support interventions, their content and duration, and the appropriate individual to provide such support.

Life events and the onset of neurotic illness: an investigation in general practice

New cases of neurotic illness identified during one month by each in turn of eight general practitioners in a London borough were investigated by means of standardized clinical and social interviews. When compared with a matched control group of consulting patients, the index group was found to have experienced significantly more life events during the three months before the onset of illness. Events particularly associated with neurotic illness were unexpected crises and failure to achieve various life goals. The distribution of events suggested that serious, threatening events have an important aetiological role; minor events appear to play a small contributory part which may become critical when the morbid risk is already high. The problems of method involved in this type of investigation are discussed.

The reason for admission as a focus of work for an adolescent unit

In recent years provision of care for psychiatrically disturbed adolescents has received increasing attention. The present situation was summarized in a leading article in the British Medical Journal (1971) which emphasized one aspect of this provision—the need for adolescent in-patient facilities based within the community. This paper describes the ideas and practices of an adolescent unit which was opened at Hill End Hospital, St. Albans, in September 1969 to take younger adolescents (up to 16) of both sexes, from the area of the North-West Metropolitan Regional Hospital Board. This area covers 13,000 square miles and has a population of 4½ million, which the Unit aims to serve with 11 available beds. Who should be admitted to these places is clearly a critical question.

Social imitation--a neglected factor in psychotherapy?

The treatment of neurotic emotional responses and behaviour patterns has probably generated more controversies and fewer verifiable observations than any other aspect of psychiatric practice. Tentative hypotheses have been all too quick to take root, expanding into comprehensive theoretical systems, and often obscuring the growth of objective information. Lately, however, a more cautious and empirical attitude appears to be gaining ground. For example, Marks (1971) has pointed out that workers in this field increasingly recognize the presence of factors influencing outcome which are not explained or even contradicted by those concepts and strategies which underlie the techniques employed. Psychotherapists of both behaviourist and psychodynamic persuasions are beginning to express an awareness of the limitations and dangers of a too rigid theoretical approach. Such a movement towards uncommitted empiricism seems a healthy trend. This may be furthered by the more careful examination of specific treatment regimes applied to a variety of diagnostically homogeneous groups of patients, an approach which is clearly preferable to sterile arguments about their relative overall effectiveness in the usual heterogeneous collections of neurotic patients with which the literature abounds. In the recently published Handbook of Psychotherapy and Behavior Change (1971), the editors comment on the frequency with which their contributors criticize the lack of replicated studies and the common failure to describe in adequate detail the specific features of patient, method and therapist. From whatever aspect it is viewed, psychotherapy emerges as a complex personal interaction containing many components, all difficult to quantify and unlikely to combine their effects in an easily predictable way.