The Chronic Psychiatric Patient in the Community: Principles of Treatment PDF
Preview The Chronic Psychiatric Patient in the Community: Principles of Treatment
THE CHRONIC PSYCHIATRIC PATIENT IN THE COMMUNITY THE CHRONIC PSYCHIATRIC PATIENT IN THE COMMUNITY: Principles of Treatment Edited by Ivan Barofsky, Ph.D. Richard D. Budson, M.D. Health Services Research Director, Community Residential and Development Center Services, McLean Hospital The Johns Hopkins Medical Department of Psychiatry Institutions Harvard Medical School MT~Eil LIMITED International Medical Publishers Dedicated to Anna-Lisa Sandy, and Andrew, Jeremy and Vickie Published in the UK and Europe by MTP Press Limited Falcon House Lancaster, England Published in the US by SPECTRUM PUBLICATIONS, INC. 175-20 Wexford Terrace Jamaica, NY 11432 Copyright © 1983 by Spectrum Publications, Inc. Softcover reprint of the hardcover 1st edition 1983 All rights reserved. No part of this book may be reproduced in any form, by photostat, microfilm, retrieval system, or any other means without prior written permission of the copyright holder or his licensee. ISBN-13: 978-94-011-6310-1 e-ISBN-13: 978-94-011-6308-8 DOl: 10.1007/978-94-011-6308-8 PREFACE The purpose of this book is to present an integrated approach to the treatment of the chronic psychiatric patient living in the com munity. This requires that topics as diverse as pharmacokinetics, psychotherapy and community organization be appropriately coor dinated. Such an approach is partly complicated by the wide range of differences among patients, in terms of social skills, intellectual capacity and psychiatric diagnosis. In addition, unclear, insular or overlapping roles of various mental health disciplines further con found integrated treatment efforts. Given such complexity, any single clinician's point of view is sub ject to the distortion inherent in specialization. Too often a volume in the field of mental health focuses either on only one aspect or presents only one clinician's unique perspective of a task that is, in fact, multifaceted. We have tried to avoid this pitfall by having representatives from many of the concerned professions present a variety of treatment approaches and associated issues in one text. Further, the editors have attempted to illuminate the relevant clinical and/or administrative interrelationship between the subjects of each section through a succinct introductory commentary. The book is divided into five sections. The first section represents an attempt to address some of the interactive sociological, psycho logical and pharmacological background issues common to all at tempts at treatment of this population. A detailed presentation of each of the psychosocial modalities follows, including individual and group approaches to the patient and his family as well as to his social, vocational and residential needs. The management of medication selection, side effects and drug refusal is presented next. These basic principles of treatment thus elucidated, their application is explored in selected urban and rural settings. Recognizing that comprehensive clinical care does not exist in a cultural void, but rather is intrinsically tied to current socio logical realities, the volume continues with a section addressing advocacy, cost analysis and judicial issues. Finally, the editors con clude with two summarizing chapters focused on clinical principles and research tasks regarding this population. The rationale of this volume is based upon the conviction that the patient and his particular needs must be sustained as the primary raison d'etre of the entire care delivery system. It is thus incumbent upon the network of clinicians within that system to so operate as to vi Preface deliver treatment which is understandable, thoughtful and compre hensive. The unacceptable alternative is fragmented services, which are likely not only to bewilder, frustrate and demean the patient, but also, in such circumstances, to be rendered ineffective. We strongly believe that each clinician within the treatment system must therefore develop effective collaboration which is predicated upon a developing knowledge of how all of the parts work together to help the individual patient. The editors hope that this volume will make some contribution to this end by providing assistance to the entire interdisciplinary array of developing and practicing mental health professionals-including psychiatrists, nurses, psychologists, social workers, vocational rehabilitation counselors and all of the allied paraprofessionals. To what extent we have attained our ideal is unclear. We are aware that the individual authors may not have related their own specialties to the rest of the care system as much as we had hoped would be possible. The organization of the book as well as our sectional com mentaries represent our effort to coordinate the overall text and thus to prevent the subject matter from being experienced by the reader as a compendium of isolated topics. The extent of the editors' effort required to unify the text is testimony to the integrative challenge to the clinician in the field. Perhaps the most instructive lesson to be learned from the experi ence is the extent to which we must respect the patient's position, in his own need to understand the full nature of his condition and its treatment in his quest to be a full partner in its management. The idea for the book can properly be said to have grown out of a meeting held in Boston, Massachusetts, entitled "The New England Conference on the Chronic Psychiatric Patient in the Community." The success of the meeting prompted the editors to invite some of the participants to prepare manuscripts on the basis of their con tributions. Additional authors were solicited to ensure the compre hensiveness of the material included. The conceptualization, format, composition and overall content of the book represent the combined but equal efforts of two health care professionals: one of them (Dr. Budson) is primarily a clinician, and the other (Dr. Barofsky) is primarily a researcher. The background of each editor insured that the contributions to the book reflected information which is clinically relevant, as well as clinical statements that can be supported by available data. The authors are listed in alphabetical order without indication of priority. ACKNOWLEDGMENTS The authors are grateful to their respective institutions for provid ing the academic environment conducive to the pursuit of a compre hensive work in this field. Additional acknowledgment is given for all of the support services provided which facilitated the completion of this volume. Specifically, Dr. Barofsky is grateful to Mr. Sam Shapiro, Director, Health Services Research and Development Center, Johns Hopkins Medical Institutions, for his support, as well as to Pearl German, Sc.D., for her thoughtful comments. Dr. Budson acknowledges Shervert H. Frazier, M.D., Psychiatrist in Chief, as well as Francis de Marneffe, M.D., General Director, McLean Hospital, for their encouragement and support of the development of community mental health programs at McLean. Mrs. Dorothy Schwartz for Dr. Barofsky, and Ms. Pamela Healey and Mrs. Mary Lou Silverman for Dr. Budson are thanked for their secretarial assistance throughout the preparation of the manuscript. We gratefully acknowledge the efforts of Mr. John Staffier, Senior Associate of Sandoz Pharmaceuticals, who was instrumental in ex pediting financial support for the meeting from which this book evolved. The authors thank their families for their support and understand ing during the months of preparation of this manuscript. CONTENTS Preface v Acknowledgmen ts vii Contributors xiii I. BACKGROUND 1. Concepts and Issues in Deinstitutionalization 5 Leona L. Bachrach 2. Preserving Chronic Patients' Assets for Self Care 29 Ernest M. Gruenberg and Janet Archer 3. Social Networks and the Long Term Patient 49 Muriel Hammer 4. Problems in Providing Effective Care for the Chronic Psychiatric Patient 83 Ivan Barofsky and Catherine E. Connelly II. PSYCHOSOCIAL TREATMENT PRINCIPLES 5. The Individual Psychotherapies and Their Relationship to the Therapeutic Community 137 Alfred H. Stanton 6. The Management of the Family of the Chronic Psychiatric Patient 159 Julian P. Leff 7. The Role of Crisis Intervention in the Management of the Chronic Psychiatric Patient 181 Donna Conant Aguilera 8. The Vocational Preparation of the Chronic Psychiatric Patient in the Community 205 Norman C. Hursh and William A. Anthony ix x Contents 9. The Place of the Partial Hospital in the Treatment of Chronic Psychiatric Patients 241 Stephan L. Washburn 10. Psychosocial Rehabilitation Centers: Old Wine in a New Bottle 265 Samuel Grob 1I. Residential Care for the Chronically Mentally III 281 Richard D. Budson III. PHARMACOLOGIC TREATMENT PRINCIPLES 12. Clinical Experiences and Principles in Selection of Medication 313 Jonathan O. Cole 13. Clinical Pharmacology and Side-Effects of Antipsychotic and Mood-Stabilizing Drugs Used in the Treatment of Psychiatric Patients with Chronic or Recurrent Disorders 321 Ross J. Baldessarini 14. The Clinical Management of Noncompliance 383 Theodore Van Putten IV. SELECTED APPLICATIONS OF TREATMENT PRINCIPLES 15. Serving Long-Term Patients in the Cities 401 H. Richard Lamb 16. Rural Care: Providing Care for the Chronic Patient Under Conditions of Dispersed Resources 417 Hans R. Huessy 17. The Community as the Treatment Arena in Caring for the Chronic Psychiatric Patient 431 Leonard 1. Stein and Mary Ann Test V. ADMINISTRATIVE ISSUES IN THE APPLICATION OF TREATMENT PRINCIPLES 18. Benefit-Cost Analysis and the Care of the Chronic Psychiatric Patient in the Community 457 Jeffrey Rubin Contents xi 19. Advocacy in the Community 475 Louis E. Kopolow 20. Judicial Decisions and the Chronic Psychiatric Patient 497 Marien E. Evans VI. OVERVIEW 21. Essential Principles in the Delivery of Adequate Clinical Care to the Chronic Psychiatric Patient in the Community 527 Richard D. Budson 22. Community Survival of the Chronic Psychiatric Patient: Research Priorities 541 Ivan Barofsky Index 563 CONTRIBUTORS Donna Conant Aguilera Jonathan O. Cole University of California McLean Hospital at Los Angeles Harvard Medical School Los Angeles, California Belmont, Massachusetts Catherine E. Connelly William A. Anthony George Mason University Sargent School of Allied Fairfax, Virginia Health Sciences Boston University Marien E. Evans Boston, Massachusetts Boston, Massachusetts Janet Archer Samuel Grob The Johns Hopkins University Dept. of Psychiatry School of Hygiene & Public Tufts University School Health of Medicine Baltimore, Maryland Boston, Massachusetts Ernest M. Gruenberg Leona L. Bachrach The Johns Hopkins University University of Maryland School of Hygiene & Public Baltimore County Health Baltimore, Maryland Baltimore, Maryland Ross J. Baldessarini Muriel Hammer McLean Hospital New York State Psychiatric Harvard Medical School Institute Belmont, Massachusetts New York, New York Hans R. Huessy Ivan Barofsky University of Vermont Medical The Johns Hopkins Medical School Institutions Burlington, Vermont Baltimore, Maryland Norman C. Hursh Richard D. Budson Sargent School of Allied McLean Hospital Health Sciences Harvard Medical School Boston University Belmont, Massachusetts Boston, Massachusetts xiii
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