A psychological view of people with serious mental illness.

Focusing on a variety of relevant psychological theories, this chapter addresses important elements in the recovery process for people with serious mental disabilities.

A survey on issues in the lives of women with severe mental illness.

OBJECTIVE: Women with severe mental illness were surveyed to explore issues in living with mental illness, personal relationships, and professional relationships and health care. The topics were drawn from the literature on the psychology of women and from separate focus groups of therapists and mental health care consumers. The women's survey responses were compared with men's responses to an equivalent survey to determine if the issues affected women and men similarly. METHODS: A 76-item questionnaire was completed by 107 women and 59 men from ten rehabilitation centers in Maryland. RESULTS: A larger proportion of women than men cited personal relationships as their most important formative experiences, with only 32 percent of women citing severe mental illness or related issues as formative experiences. Despite acknowledging the negative impact of several mental illness on their lives, most respondents reported normal concerns rather than illness-related ones, and most were relatively satisfied with their lives. Respondents made sense of their problems in diverse ways, although most knew their diagnosis. Women reported both more and better quality personal relationships than men. However, women were more likely than men to report a history of sexual abuse. Women reported generally good relationships with providers. About one-quarter to one-third of women reported not receiving proper care for birth control and menopause and not receiving pelvic or breast examinations. CONCLUSIONS: The survey results suggested that personal relationships are central in women's lives, that women with severe mental illness do not see their mental illness as the main feature of their identities, and that women's experience of living with severe mental illness is considerably different from that of men.

Family members' ratings of the use and value of mental health services: results of a national NAMI survey.

OBJECTIVE: Data from a 1993 survey of families in the National Alliance for the Mentally Ill (NAMI) were analyzed to examine services used by consumers and families' perceptions of the services' value. Data from 1993 and 1976 were compared to document changes. METHODS: A total of 3,099 families responded to a mailed questionnaire that was first used in a 1976 local survey of 89 NAMI members. Respondents indicated which of 11 services had been used by their ill relative in the past two years and rated the services as having "no," "some," or "considerable" value. Chi square tests examined relationships between service use and value and key variables. RESULTS: In 1993 families reported nearly universal use of medications and rated them highest in value. More than 60 percent of the ill relatives had been hospitalized in the past two years, and hospitalization was rated second highest in value. Individual therapy, used by two-thirds of the consumers, also received high ratings. Community services were used by about a third of the consumers; these services were valued less highly than office-based services and medications. Respondents in 1976 reported less use of medication and residential services, more hospitalization, and more use of individual, group, and family therapies. In 1993 all services were valued more highly than in 1976. CONCLUSIONS: The 1993 survey findings showed that more consumers used office-based services and hospitalization than community-based alternatives, and that families rated the former services more highly. Value ratings of community services rose significantly between 1976 and 1993.

Consumer perceptions of pressure and force in psychiatric treatments.

OBJECTIVE: Mental health consumers with serious mental illness were surveyed to obtain information about their experiences with and attitudes toward forced psychiatric treatment. METHODS: A 61-item survey questionnaire developed by the authors was administered by consumer volunteers to 105 persons with serious mental illness who were attending seven rehabilitation centers in Maryland. The questionnaire covered consumers' experiences and attitudes in three areas of forced treatment: medication, outpatient therapy or rehabilitation, and hospitalization. RESULTS: At some time during the course of their illness, 57 percent of the respondents reported having been pressured or forced into hospitalization. In the year before the survey, 30 percent reported being pressured or forced into taking medication and 26 percent into attending a therapy or rehabilitation program. The most common type of pressure or force was verbal persuasion. Generally, respondents reported negative effects from forced treatment, although the intensity of the negative effects varied by treatment area, and about half retrospectively felt that the forced treatment was in their best interest. Many respondents believed that pressure or force has an appropriate role in psychiatric treatment, although most wished to maintain the right to refuse treatment that they considered not in their best interest. CONCLUSIONS: Differences in patterns of response to pressure and force in the three treatment areas highlight the variety of consumer experiences and the need to know more about the role of forced or pressured treatment in their lives.

Individual psychotherapy and persons with serious mental illness: the clients' perspective.

The perspectives of persons with serious mental illness about their experiences with individual psychotherapy were obtained from a stratified random sample of 12 psychosocial rehabilitation centers from all centers in Maryland. Response and completion rates, test-retest reliability, and generalization data were positive. Eight areas were explored: (1) Utilization and duration: of the 212 respondents, 90 percent had been in therapy for a median of 12 months (mean = 3 years); only a third expected to end their therapy within 5 years. (2) Therapeutic effectiveness: most of the respondents (72%) reported that individual psychotherapy had brought positive changes to their lives, 14 percent reported negative changes, and 14 percent reported that therapy had had no effect. (3) Preferred interventions and parameters: sixteen percent felt that medication was most useful, 25 percent felt that talking therapy was most useful, and 60 percent endorsed a combination of the two. With respect to diagnosis and psychotherapy, 84 percent of respondents with schizophrenia preferred brief, less frequent sessions of reality-oriented therapy over longer, more frequent sessions of insight therapy. Respondents with bipolar and major depression were equally split between the two. (4) Therapeutic issues: human concerns were more frequently rated as important and were rated higher in importance than illness-specific symptoms. (5) Clients' view of illness: Only 8 percent thought their illness was a brain disease, a third thought it was a psychological problem, and a quarter thought it was a combination of both; a third answered, open quote I don't know closed quote. Almost half did not know what their therapists thought. (6) Therapeutic relationship: Friendliness was the quality most desired in a therapist. (7) Confidentiality: Most felt that therapists generally kept the clients' confidences. (8) Empowerment: Persons who felt empowered in therapy spent less time in hospitals, expected a shorter stay in therapy, and knew more about their problems. Suggestions are made about a more client-responsive model of individual psychotherapy for persons with serious mental illness.

Effects of bright light on mood in normal elderly women.

Reduced light appears to be a key factor in seasonal affective disorder (SAD). This study asks whether the reduced levels of light experienced by elderly persons might result in depression and other SAD symptoms, and how normal elderly persons might respond to bright light interventions similar to those used to treat SAD. In interviews with 140 senior citizens, we found virtually no seasonal variation in mood and behavior and very little depressed affect. Seventeen of these seniors who had good mental and physical health, with no major eye problems, participated in a crossover study of the effects of bright light on both positive and negative affect and sleep. Although sleep did not appear to be affected, the bright light intervention tended to make these normal elderly persons feel worse--more irritable, anxious, and agitated. These findings confirm earlier reports that bright light is not beneficial for normal individuals who are unaffected by seasonal changes.

Lateral preference and neuropsychological correlates of schizotypy.

A battery of 11 schizotypy questionnaires was administered to 316 male undergraduates. The scores of the 266 white subjects were subjected to a principal components analysis, and 73 subjects scoring at the upper and lower ends of the factor score distribution based on the first unrotated component were recalled for neuropsychological testing. The battery of neuropsychological tests consisted of four tests of motoric performance, four subtests from the Wechsler Adult Intelligence Scale-Revised, the conjugate lateral eye movement test, and a lateral preference questionnaire. Subjects high on schizotypy did not differ from low scorers on overall neuropsychological performance or performance asymmetries. High scorers did show a sinistral shift in hand and foot preference and more crossed dominance compared with controls. Asians scored significantly higher than whites on several schizotypy scales, raising the question of a possible ethnic bias in these measures.

Individual psychotherapy with schizophrenic outpatients in the public mental health system.

Forty-two therapists conducting individual psychotherapy with schizophrenic outpatients in a public mental health system responded to a questionnaire that focused on the types of interventions used and the issues and problems encountered in therapy. The therapists spent 59 percent of their time in supportive, problem-solving work and only 32 percent in traditional psychotherapeutic interventions, such as providing insight. The most common issues in therapy were relationship problems, family concerns, depression, losses, and the role of medications in the client's life. The most significant impediments to therapeutic work were the lack of community resources, the client's noncompliance with medications and lack of motivation, and dual diagnoses. Suggestions are offered for improving psychotherapy with schizophrenic outpatients in the public mental health system.

Consumers' attitudes toward psychotherapy, hospitalization, and aftercare.

A sample of 204 chronically mentally ill patients from a variety of outpatient settings was surveyed on their attitudes toward psychotherapy, hospitalization, aftercare, and their condition in life. Generally, they felt various types of psychotherapy and aftercare were helpful and reported good relationships with their therapists. However, their goals focused more on quality of life than on symptom reduction. Patients also were concerned about the perceived power of providers over their lives; unfair treatment, discrimination, and lack of respect because of their illness; and anger over their illness and its consequences. Consumers in advocacy groups showed a slightly higher rate of concern than those not in advocacy groups. However, significantly more consumers in advocacy groups reported anger over their experiences with mental illnesses.

Cost-effectiveness of providing insurance benefits for posthospital psychiatric halfway house stays.

A model insurance benefit package of post hospitalization psychiatric halfway house care was developed and administered to 32 hospitalized mentally ill persons. The therapeutic and cost effectiveness of providing a 120-day benefit package was examined over a 14-month post-hospitalization period. This was compared with the effectiveness of hospitalization benefits alone for the same patients over the 42 months prior to halfway house admission. In terms of therapeutic efficacy, there was no significant deterioration after hospitalization release in either the symptom or behavioral coping scales, except for an increase in somatization. Yearly hospital recidivism rates fell from 79% to 29%, and the average yearly length of hospital stay per patient fell from 83 days to 18 days. In terms of cost-effectiveness, halfway house benefits saved the insurers 59% of their hospitalization costs. The implications of these findings are discussed.

The use and utility of EMG biofeedback with chronic schizophrenic patients.

This study examined the efficacy of muscle relaxation training via electromyographic (EMG) biofeedback from the frontalis and forearm extensor muscles of schizophrenic inpatients. Thirty chronically hospitalized patients were randomly assigned to one of three conditions: EMG biofeedback from the forearm extensor and frontalis muscles, progressive relaxation, and a control group. Treatment consisted of one session of orientation and baseline, and six sessions of training. The results indicated that the schizophrenic patients receiving EMG training had significantly lower EMG recordings than the progressive relaxation group, which, in turn, was significantly lower than the control group. Analyses of covariance on the Tension-Anxiety scale from the Profile of Mood States revealed no significant effects, while finger-tapping rates were significantly improved only for the arm receiving feedback training in the EMG group. On the Nurses Observation Scale for Inpatient Evaluation the biofeedback group significantly improved on the Social Competence and Social Interest factors.

Clinical, psychophysiological, and neurological characteristics of volunteers with impaired smooth pursuit eye movements.

Two hundred eighty-five volunteers from a community college were screened on campus for accuracy of their smooth pursuit eye movements (SPEM) by electrooculograph (EOG). Those volunteers with the least and the most accurate SPEM were recalled to the laboratory for a comprehensive evaluation of clinical and demographic characteristics, family history, neurological status, and psychophysiological and biological measures, including SPEM [repeat EOG test and infrared (IR) test], an electroencephalogram, auditory and visual evoked potentials, reaction time (RT), the continuous performance task (CPT), platelet monoamine oxidase (MAO), plasma amine oxidase, and dopamine-beta-hydroxylase (DBH). Low-accuracy SPEM was associated with social isolation, inadequate rapport, eccentricity, and a variety of related schizotypal or schizophrenia-like characteristics, but not with generalized psychopathology or other demographic/medical/clinical history variables. Low-accuracy SPEM also was associated with neurological and psychophysiological abnormalities frequently observed in schizophrenic patients. These results suggest that impaired SPEM may reflect an underlying central nervous system dysfunction that is specifically associated with clinical and biological characteristics related to schizophrenia, even in the absence of overt schizophrenia.

The relationship between smooth pursuit eye movement impairment and psychological measures of psychopathology.

Two hundred and eighty-four male college volunteers were screened for smooth pursuit eyetracking deficiencies, a commonly reported concomitant of schizophrenia. A sample of 36 subjects, weighted with poor eyetrackers, was brought into the National Institute of Mental Health laboratory and retested on electro-oculogram and infrared tracking procedures. They were also administered psychological tests which assessed nine dimensions relevant to schizophrenic, neuropsychological, and affective disorders. In the area of schizophrenia-like symptoms, measures of attention deficits, stimulation avoidance, and identity problems predicted poor eyetracking for the whole sample. Using the poor eyetracking subjects alone (N = 24), interpersonal withdrawal was also significantly related to poor performance but not stimulation avoidance. In the neuropsychological area, measures of attention control and perceptual-motor dysfunction for the total sample, and perceptual problems and general intellectual decrements for the poor eyetrackers were significantly related to poor performance. There was no relationship between measures of affective dysfunction and poor eyetracking.

Psychobiological effects of carbohydrate- and protein-rich meals in patients with seasonal affective disorder and normal controls.

Patients with seasonal affective disorder (SAD) frequently report carbohydrate craving and note that carbohydrate ingestion energizes them. Bright artificial light has been shown to reverse the symptoms of SAD, including carbohydrate craving. In this study, 16 depressed SAD patients and 16 matched controls were fed two different isocaloric meals, one rich in protein and one rich in carbohydrates, in a crossover design. Although their biochemical response in terms of plasma large neutral amino acid concentrations was identical, SAD patients reported activation following carbohydrate ingestion, whereas normal controls reported sedation. Marked ordering effects on psychological parameters were noted, suggesting that order should be taken into account as a methodological consideration in meal studies.

Impact of an educational support group on family participants who take care of their schizophrenic relatives.

Using a stress-coping framework, we designed a six-session educational support group offering family caretakers information about schizophrenia, training in problem-solving skills for managing patient behavior, and greater access to social support and community resources. Subjects were recruited though local community mental health centers; 24 subjects participated in one of five identically structured caretakers' groups and another 24 subjects served as matched controls. Results of the multivariate analysis of covariance indicated a significant difference between the experimental and control caretakers following the intervention. Caretakers of the educational support group reported significantly reduced anxiety and personal distress and significantly more active coping behaviors (increased use of community resources and better management of home life with their schizophrenic family member). However, no changes were reported in the frequency of their negative feelings toward their mentally ill family member or in their generalized sense of self-efficacy.

Platelet monoamine oxidase activity and life stress as predictors of psychopathology and coping in a community sample.

The present study, using a diathesis-stress model, attempted to confirm prior findings with platelet monoamine oxidase (MAO) activity and stress in a middle-aged, non-clinic population. One hundred and seventy-eight adult males from a statewide community club were tested for platelet MAO activity and stressful life events and were also given a variety of psychological measures of both psychopathology and psychosocial coping. The data were examined both for correlations across the total sample and for a comparison of high-risk groups (top and bottom 15% of MAO activity) with a middle MAO group. Low platelet MAO activity was related to a higher incidence of contact with mental health professionals, and more frequent use of alcohol and cigarette smoking. High MAO activity was related to higher levels of anxiety and somatization. High levels of stress were related to increased psychosocial problems reported for female and family members, higher scores on two schizophrenia-related MMPI scales (schizophrenia and paranoia subscales), but fewer idiosyncratic associations, elevated hypomanic, depression, and anxiety scores, increased alcohol use, and increased use of prescribed antianxiety and sedative medication. Neither MAO nor stress were related to current levels of psychosocial coping. Moreover, no interaction effects were uncovered for MAO activity and stress combined.

Psychotherapy with persons suffering from schizophrenia: the need for a new agenda.

The success of the biological revolution in our understanding of schizophrenia, along with the lack of convincing evidence for the efficacy of global approaches to individual psychotherapy with schizophrenia, has led to the virtual disappearance of research and theory in this area. However, it seems timely to reexamine alternative approaches to psychotherapy that are based on an informed understanding of schizophrenia as a biological distortion of certain aspects of human experiencing. The purposes and unique role of psychotherapy within the broader range of treatments must be clarified, and more phenomenologically based, empirically tested problem-specific interventions developed. Three areas seem particularly suited for psychotherapy; (1) the human issues raised by having a chronic debilitating disorder that affects one's psychological experiencing, (2) attempts to help the patient manage the disorder, and (3) the normal psychological problems that persons with schizophrenia also face. Finally, suggestions are made about rethinking the therapeutic enterprise.

Biological markers for schizophrenia and the biological high-risk approach.

This review examines two putative biological markers for schizophrenia: reduced blood platelet monamine oxidase (MAO) activity and impaired smooth pursuit eye movements. Studies of these biological markers among patient samples are presented, including their theoretical background, measurement, genetics, validity, and specificity of the markers for schizophrenia, and the artifacts that might lessen their utility. These results are then compared with those from the biological high-risk research strategy, which selects nonpatient volunteers solely on the basis of a deviant marker, and then examines the clinical, psychological, and biological correlates of the marker. The results of these studies suggest that low platelet MAO activity is not an adequate marker for schizophrenia but is associated with characteristics related to hypomanic behavior and sensation seeking. Smooth pursuit eye tracking impairment, in contrast, seems to be directly associated with schizophrenia-related traits, such as the negative symptoms found among chronic schizophrenics, or with the characteristics observed in the biological relatives of schizophrenics. Finally, the implications of these findings are discussed.

Impaired smooth pursuit eye movement: vulnerability marker for schizotypal personality disorder in a normal volunteer population.

Impaired smooth pursuit eye movement has been proposed as a possible biologic marker for schizophrenia. Preliminary studies have suggested that this impairment may be associated with social introversion and related psychopathology in a nonpsychiatric population. To evaluate the relationship between dysfunctional smooth pursuit eye movement and schizophrenia-related psychopathology, the authors screened a new, volunteer sample of 284 male college students for eye tracking accuracy. Volunteers identified as low-accuracy trackers were significantly more likely to be diagnosed (blindly) as having a schizotypal personality disorder by DSM-III criteria than those identified as high-accuracy trackers. The authors suggest that disordered smooth pursuit eye movement may reflect a vulnerability marker for schizotypal personality disorder.