Miles F. Shore

Seclusion and Restraint: A Review of Recent Literature

&NA; An October 1998 Hartford Courant investigative series highlighted alleged cases of brutality and death suffered by involuntarily secluded, restrained, and/or emergently medicated patients. The resulting public and professional furor prompted a spate of new federal regulations and legislative initiatives setting national standards for reporting and clinical oversight. These events provide stimulus for this literature review.

Perspective: A Culture of Respect, Part 2: Creating a Culture of Respect

Creating a culture of respect is the essential first step in a health care organizations journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organizations leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment.When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station.Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

Megacolon as a manifestation of familial autonomic dysfunction.

Summary A case of familial autonomic dysfunction in a non-Jewish 3-year-old white male child is presented. The clinical manifestation of megacolon in this patients is strikingly absent in previously reported cases. The similarities of this syndrome and others seem to reflect a diffuse disturbance of central nervous system function and perhaps other tissues as well. The relationship of familial autonomic dysfunction to a wide area of pathologic physiology is presented.

Training the existing workforce.

In August 1993, The American Association of Chairmen of Departments of Psychiatry held an unprecedented meeting in Seattle to discuss the impact of managed behavioral health care on the tripartite academic mission of education, research, and clinical service. The hastily assembled meeting was precipitated by a rapidly growing awareness that managed care would not go away, and would likely expand its threat to academic psychiatric programs. Managed care companies were steadily signing up patients who had traditionally sought care from academic clinical services and faculty private practices. There was also concern that academic departments were regarded by managed care companies as expensive, inefficient providers of outdated care who emphasized long term intensive psychotherapy to the exclusion of a broader range of treatments that were the stuff of managed care. An undertone of panic was generated by the fact that academic departments had customarily relied on clinical care to provide teaching cases for trainees, subjects for clinical research protocols, and income to support the varied activities of the departments. At the meeting, a few of the department chairs shared their experiences in launching their own managed care operations. Most had war stories to tell about their encounters with managed care, chiefly in the form of utilization review imposed from outside. There was talk of starting a national academic managed care consortium, and/or regional groups to capture more restricted markets. All of them sought help with their questions, and all of them knew they needed more information in order to respond effectively to what was happening (Moffic, Krieg, & Prosen, 1993).

Prevention of psychiatric disorders.

&NA; Psychiatric disorders are highly prevalent and cause an enormous burden of suffering, loss of productivity, morbidity, and mortality. This article will review prevention of psychiatric disorders in a manner that is relevant to the mental health clinician. Clinicians may increasingly play a role in preventive interventions through (1) identifying individuals at risk, (2) consulting with agencies, school personnel, and employers who may identify individuals at risk, (3) providing treatment that can reduce the chronicity, severity, and total duration of psychiatric illness, and (4) providing mental health care to a specific population within our evolving health care system, in which health promotion and disease prevention play an increasingly important role. Appropriate literature was located by searching the English‐language citations since 1985 in Index Medicus (search terms included prevention, preventive psychiatry, early intervention, mental disorders, risk factors, and primary prevention), reviewing several textbooks on psychiatric preventive services, and finding additional sources cited in the reference sections of these publications. This paper presents the public health model of disease prevention, which divides prevention activities into primary, secondary, and tertiary interventions. The model is applied to childhood psychiatric disorders and to adult‐onset schizophrenia, depressive disorders, and substance use disorders. The review concludes with a discussion of the implications for the clinician and for public health policy.

A Survey of What Clinicians Should Know

There is general agreement among the major stakeholders—providers, consumers, payors, and managed behavioral health companies—that managed care poses significant challenges for behavioral health professionals, particularly those whose primary work has been in independent practice rather than organized care settings. In traditional independent practice, clinicians were free to employ relatively unstructured, goal-free approaches to care with an emphasis on patient insight and self-knowledge. Formal written treatment plans were a rarity and there was little external pressure on clinicians to complete treatment within any specified period of time. Often, little attention was paid to the efficient use of financial and service resources, and decisions to begin and end treatment were the purview of the therapist and the patient. Patients were generally seen as financially responsible for their treatment regardless of employment based benefits. Indeed, such an approach to practice was consistent with the ways in which most behavioral health professionals were trained. In contrast, clinicians practicing in todays managed care environment are typically required to develop written, goal-focused, time limited treatment plans emphasizing the return of the patient to an adequate level of day-to-day functioning while making efficient use of resources (Austad & Berman, 1991). Decisions to begin and end treatment, at least the part to be paid for through the benefit plan, are made by the therapist and patient together with a third party—the managed care entity. In order to work effectively within this context, clinicians must be both willing and able to change their practice patterns, to at least accommodate

Replacing cost with value.

In Lord Darlington’s terms, discussions of health economics have been unrelentingly cynical in focusing almost exclusively on the price of care rather than its offsetting economic benefits. Psychiatric care in particular has been judged by what it costs, reflecting the canard that major disorders are incurable, and minor disorders, disguised self-indulgence. Now, the recognition that health care-and particularly psychiatric care-has value that can be quantified is gaining credence. Epidemiologists assessing global burden of illness are changing their measures of the health status of populations to give increasing weight to disability, making psychiatric disorders much more important than in the past. And a new genre of research by health economists is establishing the value of psychiatric treatment by identifying what untreated mental disorders cost and how those expenses might be reduced by effective treatment.

Homelessness and the Chronically Mentally Ill

In some respects, homelessness is the basic human service problem. Before there was an organized public response to mental illness, mental retardation, family disruption, or even physical illness, provision was made for the care of the homeless.

Adapting to the Realities of Managed Care

For physicians who are well established in practice, the advent of managed care in its various forms has been a dose of strong and distasteful medicine. Being accountable to outsiders strikes at the heart of medical tradition by violating the principle that the physician is accountable only to professional standards for the patient’s well-being. Worse, the restrictions imposed by cost containment have significantly altered what the physician can do and how he or she can do it. For psychiatrists, this noxious prescription is especially unpleasant because of the continuing lack of panty in insurance coverage for mental illnesses in relation to other diseases. Thus, it is no surprise that the response of many psychiatrists to managed care has been intense resentment of and opposition to the current environment. Recently, the leadership of the Assembly of the American Psychiatric Association‘ stated that psychiatry “should keep an open mind about whether future health care should be delivered exclusively through organized systems of care.”

Psychological issues in counselling the genetically handicapped

Publisher Summary This chapter provides an overview of the psychological issues in counseling the genetically handicapped patients. The psychological issues are concerned with the quality of life, which implies an emphasis upon the enhancement of potential rather than simply the correction of problems. There is a general principle in modern psychology that reality reinforcement of the irrational sequel of psychological development works against adaptation and serves as an organizer of distress and symptomatology, which take on a life of their own. Just as Mendelian principles underly the inheritance of both normal adaptive phenotypes and maladaptive or abnormal ones, modern psychological principles apply to normal adaptive behavior as well as to neurotic symptoms. Counseling the genetically handicapped begins with the family—if possible during the pregnancy but always as soon after birth as the defect is recognized. The patients siblings and other relatives may be involved and in some cases, the broader community must be included in ameliorative efforts. The process may be deflected by guilt or hostility and show up as over-solicitousness or rejection of the child. Deep understanding must always be accompanied by a clear definition of goals and by restraint based upon respect for natural psychological processes as these are powerful forces whose direction is toward the mastery of psychological stress.