Relational Mental Health: Beyond Evidence-Based Interventions PDF
Preview Relational Mental Health: Beyond Evidence-Based Interventions
Relational Mental Health Beyond Evidence-Based Interventions Relational Mental Health Beyond Evidence-Based Interventions Jose´ Guimo´n UniversityofGenevaMedicalSchool Chene-Bourg,Switzerland KLUWER ACADEMIC PUBLISHERS NEW YORK,BOSTON, DORDRECHT, LONDON, MOSCOW eBookISBN: 0-306-47967-2 Print ISBN: 0-306-47857-9 ©2004 Springer Science + Business Media, Inc. Print ©2004 Kluwer Academic/Plenum Publishers New York All rights reserved No part of this eBook maybe reproducedor transmitted inanyform or byanymeans,electronic, mechanical, recording, or otherwise,withoutwritten consent from the Publisher Createdin the UnitedStates of America Visit Springer's eBookstore at: http://www.ebooks.kluweronline.com and the Springer Global Website Online at: http://www.springeronline.com ThisbookisdedicatedtoJose´,PabloandMariana Contents Acknowledgements.................................................... ix Foreword................................................................ xi Chapter1. MentalHealth:ConceptsandTrends ................... 1 Chapter2. IsMentalHealthFoundedonTrulyScientific Conceptions?......................................................... 11 Chapter3. Aetiology:VulnerabilityandHomeostasis............. 19 Chapter4. TheoriesandIdeologiesinMentalHealth ............. 33 Chapter5. RelationalAspectsofMentalHealth, Part1:PsychologicalFactors ........................................ 59 Chapter6. RelationalAspectsofMentalHealth, Part2:SocialFactors................................................. 77 Chapter7. ClinicalAssessment...................................... 83 Chapter8. RelationalAssessment:DynamicAspects.............. 91 Chapter9. RelationalAssessment:SocialAspects ................. 101 Chapter10. RelationalDiagnosis.................................... 109 Chapter11. Organic,IncludingSymptomatic,Mental Disorders(F00–F09).................................................. 121 Chapter12. MentalandBehaviouralDisordersDueto PsychoactiveSubstances(F10–F19)................................. 131 vii viii Contents Chapter13. Schizophrenia,Schizotypal,andDelusional Disorders(F20–29)................................................... 143 Chapter14. Mood(Affective)Disorders(F30–39) .................. 165 Chapter15. NeuroticDisorders(F40–49)............................ 179 Chapter16. Stress-RelatedDisorders................................ 185 Chapter17. SomatoformDisorders(F45).Behavioural SyndromesAssociatedwithPhysiologicalDisturbances andPhysicalFactors(F50–59) ....................................... 193 Chapter18. DisordersofAdultPersonalityandBehaviour (F60–69)............................................................... 207 Chapter19. IndividualPsychotherapy .............................. 217 Chapter20. GroupTherapy.......................................... 235 Chapter21. MilieuTherapy.......................................... 249 Chapter22. CombinedTreatments .................................. 263 Chapter23. CommunityMentalHealthInterventions:The PresentandtheFutureofPsychiatricCare......................... 273 Chapter24. EfficacyofPsychosocialInterventions................. 283 Chapter25. MentalHealthProfessionals ........................... 299 Chapter26. Psychiatrists:FromSorcererstoBureaucrats.......... 315 Chapter27. TheTherapeuticTeam.................................. 337 Chapter28. TheProfessionalintheInstitution..................... 347 Chapter29. TheBurn-OutSyndrome ............................... 357 Chapter30. TrainingTomorrow’sMentalHealthWorkers......... 373 Chapter31. TrainingofNon-PsychiatristProfessionals ........... 387 Index .................................................................... 397 Acknowledgements ToDeloriesDunnforthetranslationofmostofthematerialofthisbook ToBrocherFoundation(Geneva)forthesupportgiventotherealization ofthemanuscript ix Foreword The present volume, authored by one of the most prestigious European psychiatrists,ProfessoroftheDepartmentofPsychiatryoftheUniversity of Geneva Medical School, offers a refreshing, actual, broad scope per- spectiveontheprofessionofpsychiatryanditsroleinthefieldofmental health.Itoffersthereaderaclearlystated,balancedviewofwherethefield of mental health delivery systems is moving at this time, and the role of psychiatryandthementalhealthprofessionatlargeinthisrapidlychang- ingprofessionalarea.Itsmainpurpose,excellentlyachieved,istoprovide the psychiatrist, the biological researcher, the psychoanalyst, the mental health practitioner, the educator and the researcher in these areas with a broad overview of the concepts of mental health and mental illness, and thepresentcontroversiesregardingetiology,psychopathology,treatment, and prevention. Dr. Guimo´n’s text is one of the very rare ones that com- binesadeepunderstandingofbiologicaldeterminantsofillnesswiththe psychodynamicconceptofpersonalitydevelopment,andthecontribution ofthesocialsciencestoboth. FortheAmericanreader,theinformationaboutrecentdevelopments inpsychiatryinEurope,integratedwithathoroughunderstandingofcor- respondingdevelopmentsintheUnitedStatesprovidesacriticalperspec- tiveregardingtheissuesthepsychiatricprofessionisstrugglingwithtoday. Thus,ithelpstotranscendthepotentiallyrestrictedviewpointsdetermined byanylocalscene.Thefactthatabroadhistoricalperspectiveintroduces manyareasofcontemporarycontroversiesregardingetiology,diagnosis, andtreatmentalsocontributestoelevatingthelevelofdiscoursebeyond narrowspeculations.Guimo´nelegantlyindicateshowtherevolutioninthe neurosciencescanbecomplementedwithacontemporarypsychodynamic approach derived from psychoanalytic understanding. He appropriately xi xii Foreword challenges the psychoanalytic profession to reexamine its responsibility towardboththescientificdevelopmentofitsfieldanditssocialresponsi- bilityinthepreventionandtreatmentofmentalillness.Whileclearlysym- pathetic to psychoanalytic approaches, Guimo´n points to both strengths andweaknessesinpsychoanalyticcontributions,andiscriticalofpsycho- analytic education as well as of frequently narrow perspectives in psy- chiatricresidencytraining.Hiscriticalreviewofpsychodynamicresearch approachesstrengthensthiscritique. Thisbookexamineslucidlythecontributionsoftransculturalstudies intheevaluationofetiology,frequency,andsymptomsofmentalillnessas theyareinfluencedbysocio-culturalfactors,andexplorestheintegration of this perspective in the clinical management of the main psychopatho- logicalconstellations.Theoverviewofthetreatmentoforganicmentaldis- orders,themajorpsychoses,andthepersonalitydisordersisenrichedby thiscombinationofbiological,psychodynamic,andsocio-culturalperspec- tives.Thereaderwillfinduptodatesummariesofthepresentstrategies oftreatmentthatreflectthisintegrationofapproaches. The major emphasis of this volume is on psychosocial modalities of treatment,bothinthecontextofinstitutionaltherapeuticprogramsaswell as in the individual treatment of patients. In this context, it provides the readerwithdetailedinformationaboutthepresentstateofgroupandfam- ily interventions, that are taught in a rather perfunctory manner in most textsofpsychiatrictherapeutics.Guimo´nprovidesthoughtfulinformation regardingareaswhereevidencebasedtreatmentsmaycontributesignifi- cantlytoclinicalpractice,andareaswherethisisnotthecase:hepresents anoriginalexplorationofthenaturallimitsofevidencebasedtreatments. Nowadays,therearefewcomprehensivetextsinpsychiatrystillwrit- ten by a single author. The field of psychiatry has become so broad and complexthatmulti-authoredtextbooksaretheorderoftheday.Guimo´n’s volumeshowsthatanextremelyknowledgeable,original,andpassionate scholarstillmayprovideasynthesisthatenrichesthefield;stimulatesthe reader to become concerned with it beyond his or her limited personal sphere of activity; and, in explaining the present in terms of its develop- mentfromthepast,signalsnewroadsandchallengesforthefuture. ∗ OTTOF.KERNBERG,M.D. ∗ Director,PersonalityDisordersInstitute,TheNewYorkPresbyterianHospital,Westchester Division ProfessorofPsychiatry,WeillMedicalCollegeofCornellUniversity. TrainingandSupervisingAnalyst,ColumbiaUniversityCenterforPsychoanalyticTraining andResearch 1 Mental Health Concepts and Trends Weshallbeginbydefininganumberofmentalhealthconcepts,andthen address the concept of abnormality, ending with a discussion of the sci- entificbasisofkeyconceptsonwhichcurrentdiagnosticandtherapeutic interventionsinmentalhealtharebased. MENTALHEALTHORPSYCHIATRY? MentalHealth:AnEndeavour The term mental health has been progressively gaining ground as an alternative to psychiatry, to underline its preventive aspects—as first recommended by the World Health Organization (WHO)—and the fact thatthisfieldrequirestheparticipation,notonlyofpsychiatrists,butalso other professionals, as well as segments of the general population, legis- lators,andpoliticians.Therefore,morethanascienceorasimpleclinical activity, mental health is an endeavour, and a burning issue, involving socialandhumanitariancommitment. The mental health field is wider than that of clinical psychiatry, be- cause it also includes the detection of undiagnosed cases in the general population,andpreventioninnormalsubjects,toavoidtheircontracting psychological disorders. Indeed, in a survey conducted during the Epi- demiologicalCatchmentArea(ECA)project(anepidemiologicalstudyin the United States), approximately 30% of the general population had, in theprevious6months,presentedapsychiatricdisorderasdefinedbythe AmericanPsychiatricAssociation’sDiagnosticandStatisticalManual.This prevalencewouldhavebeenatleast10%higherifsubstanceabusehadalso 1
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