The MATRIX: A deliberate practice approach for clinical supervision in the public sector.

Clinical supervision is an essential component of psychotherapeutic practice. However, the literature suggests that the provision of supervision in the public sector has been declining significantly over the past two decades, suggesting that many health care professionals are receiving neither the guidance nor support needed to deliver safe and effective care. Identifying the distinct challenges of supervision in the public sector and proposing prospective solutions is, therefore, a burning issue. In this article, we introduce a novel analytical framework for clinical supervision-the MATRIX-striving to address the unique demands of psychotherapy in the public sector. Various applications of this framework are thoroughly presented and further exemplified using a case illustration. We conclude by discussing the contribution of MATRIX-aided supervision to the acquisition of expert performance in psychotherapy, while also addressing its limitations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Processes in Psychotherapy and the MATRIX: The Case of Projective Identification.

The MATRIX is a tool designed to analyze psychoanalytic sessions. It is composed of two axes: focus (patient, therapist, and dyad) and dimension (space, content, and order). The MATRIX was found to be a reliable tool, and valid for identifying the therapist's theoretical inclinations in psychoanalytic-oriented psychotherapy sessions. In the present study, we suggest that the MATRIX can identify different (Kleinian, Bionian, and relational) approaches to projective identification, thus providing therapists and supervisors an easy-to-use tool for monitoring, and better managing, projective identifications during psychoanalytically oriented psychotherapy.

The MATRIX, a novel tool exploring dynamic psychotherapy: Preliminary psychometric properties.

Most measures in the field of psychodynamic psychotherapy are bound to a specific theory, and usually focus only on patient processes or therapist interventions. The MATRIX is a newly developed research tool that focuses on events within both the patient and the therapist individually, as well as on dyadic events, and provides the simple and meaningful coding of content for therapy session transcripts in psychotherapy. The present study describes the inter-rater reliability and construct validity of the MATRIX. Reliability of the MATRIX was assessed by applying it to 805 fragments of psychodynamic-oriented psychotherapy sessions. Three independent experts coded fragments, and the tool was examined for reliability. Validity in identifying the theoretical inclinations was assessed by applying the MATRIX to 30 segments (containing 1309 fragments) of sessions that reflect different theoretical orientations. Findings evinced high inter-rater reliability for all dimensions. The MATRIX was found to have high degree of validity for differentiating the theoretical inclinations of segments of sessions. The MATRIX is a reliable and valid measure that may enable moment-to-moment, quantitative, analysis of psychodynamic psychotherapy.

Voting rights for psychiatric patients: compromise of the integrity of elections, or empowerment and integration into the community?

BACKGROUND: Participation of the mentally-ill in elections promotes integration into the community. In many countries, individuals with compromised mental incompetence who have legal guardians are denied the right to vote. In Israel, mental health consumers are eligible to vote. We evaluated the capacity of psychiatric inpatients with and without legal guardians to understand the nature and effect of voting. METHODS: Fifty-six inpatients with/without legal guardians were recruited to the study. Participants completed the Competency AssessmentTool for Voting (CAT-V), Brief Psychiatric Rating Scale and the Mini-Mental State Exam. RESULTS: Cluster analysis determined voting capacity using CAT-V as a continuous variable. Subjects who scored >1.6 on the CAT-V (59%) had high capacity to vote. Subjects without guardians revealed significantly higher capacity to vote. Voting capacity positively correlated with cognitive state and negatively correlated with severity of illness. Among patients with legal guardians those who scored >1.6 on the CAT-V maintained the capacity to vote. CONCLUSIONS: The right to vote is an important basic right for individuals coping with mental disorders.However, it is important to evaluate the capacity to understand the voting process among individuals with mental disorders who have legal guardians. Thus, the integrity of the elections would be preserved by eliminating the risk of undue influence or manipulation of individuals who lack the capacity to understand the nature and meaning of voting, while preserving the right to vote for those with the capacity to do so, whether or not they have guardians.

Enhancing the use of institutional ethics committees in mental health care in Israel.

Institutional ethics committees were established and functioned in Israel prior to the application of the Patients Rights Act of 1996. These committees were voluntary and comprised of multidisciplinary teams in order to obtain numerous viewpoints stemming from various different fields. This intent was based on an understanding that the issue of ethics and the process of making ethical decisions inherently address moral and social considerations which are beyond the realm of medical practice. In contrast to the voluntary institutional ethics committees, the Patients Rights Act of 1996 instituted statutory ethics committees. These committees were mandated to investigate defined areas and, in contrast to the former committees that were considered to be valuable as advisory and enlightening entities, their decisions are binding. However, it appears that the utilization of these ethics committees within the domain of mental health facilities is limited in scope and their use varies greatly between institutions. The employment of these committees in mental health institutions focuses mainly around issues that relate to information management and mentally ill patients' refusal of medical treatment. Several explanations exist for this phenomenon. Suggestions as to how the situation may be remedied are addressed as well as the complementary role that these ethics committees may play in modern day clinical practice.

Internalization of stigma and self-esteem as it affects the capacity for intimacy among patients with schizophrenia.

The study examines the relationship between internalization of stigma, self-esteem, and the ability of people diagnosed with schizophrenia to form intimate attachments with loved ones. The study included sixty patients with schizophrenia, ages 18-60, men and women. After providing informed consent, all participants completed four questionnaires: Demographics Questionnaire, Self-Esteem Scale, Internalized Stigma of Mental Illness Scale and the Intimacy Attitude Scale-Revised. Internalization of social stigma was found to be a statistically significant core factor that affects self-esteem and the ability to create intimacy among patients with schizophrenia. There was statistically significantly less internalization of stigma of mental illness among hospitalized patients than among individuals with schizophrenia who live in the community.

Culturally sensitive mental health care: a study of contemporary psychiatric treatment for ultra-orthodox Jews in Israel.

BACKGROUND: The literature describes psychiatric treatment of ultra-orthodox Jews as complex and challenging, in light of this community's unique characteristics and the ideological gap between ultra-orthodox patients and secular professionals. Recent data indicate that patient-centred culturally sensitive care contributes to the treatment outcomes among cultural minorities. AIMS: To examine the effect of the level of a physician's religiosity and cultural sensitivity, as perceived by ultra-orthodox Jewish psychiatric patients, as well as the treatment venue (i.e. the distance of the treatment facility from the patients' community) on treatment outcomes (working alliance, medical adherence and the patients' social adaptation). METHODS: The sample included 38 ultra-orthodox Jewish men and women receiving psychiatric treatment at the Lev Hasharon Mental Health Centre. The participants completed questionnaires about the physician's religiousness and cultural sensitivity, working alliance, medical adherence and social adaptation. RESULTS: Working alliance was positively related to the treatment location, meaning that patients were more committed and involved in the treatment when it took place in a facility distanced from their community. Working alliance was also correlated with medical adherence. Regression analysis revealed that the doctor's acquaintance with religion and cultural sensitivity predicted patients' reported social adaptation level. CONCLUSIONS: In contrary to common perceptions, ultra-orthodox patients are not necessarily reluctant to be treated by secular physicians. These patients prefer a discreet treatment far from their community's public eye. Their perception of a doctor who acknowledges and respects their religiosity positively affects the way that they perceive their social functioning. Culturally sensitive treatment enables patients to feel respected and acknowledged through their sociocultural affiliation, and not only through their disorder. It seems essential to train physicians about the importance of culturally sensitive treatment with this population.

A multicenter, add-on randomized controlled trial of low-dose d-serine for negative and cognitive symptoms of schizophrenia.

BACKGROUND: Observations that antagonists of the N-methyl-d-aspartate (NMDA) receptor of glutamatergic neurons can mimic symptoms of schizophrenia have raised the hope that NMDA agonists can improve symptoms. On the basis of encouraging results of trials in which NMDA agonists were added to antipsychotics, we conducted an adequately powered randomized controlled trial adding d-serine, an NMDA modulator, to antipsychotics. METHOD: This study was a 195-patient, multicenter, double-blind, randomized, placebo-controlled, 16-week trial of d-serine 2 g/d as an add-on treatment to antipsychotics. Subjects had DSM-IV schizophrenia or schizoaffective disorder and were inpatients or outpatients stabilized on antipsychotics, with persistent negative symptoms. The primary outcome measures were changes in negative symptoms and cognition as measured by the Scale for the Assessment of Negative Symptoms (SANS) and the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery, respectively. The study was performed between 2003 and 2007. RESULTS: Mean total Positive and Negative Syndrome Scale scores at baseline were 75.5. Subjects receiving d-serine and placebo improved in scores on the SANS and MATRICS, but no significant differences were observed between groups: improvement on SANS was 11.4% for d-serine vs 14.8% for placebo, F1,147=1.18, P=.32; and improvement on MATRICS was 6.8% for d-serine vs 6.1% for placebo, F1,125=0.96, P=.39, respectively. d-Serine was well tolerated. DISCUSSION: This study did not find a significant difference between drug and placebo. However, the results are limited by a relatively large placebo response and somewhat lower-achieved doses than in prior studies. Future studies will administer higher doses and will attempt to affect the NMDA receptor using other mechanisms, such as agonists of the presynaptic metabotropic glutamate 2/3 receptor or glycine reuptake inhibitors. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00138775.

The meaning in life for hospitalized patients with schizophrenia.

This study investigated the relationship between the sense of meaning in life, quality of life, medical adherence, and duration of hospitalization among 60 inpatients at the Lev Hasharon Medical Center in Israel. Participants included men and women diagnosed with schizophrenia, whose psychiatric histories dated back at least 5 years. Participants were administered the following self-report questionnaires: Purpose In Life (Crumbaugh and Maholick, 1968), Condensed Quality of Life Enjoyment and Satisfaction (Ritsner et al., 2005), Drug Attitude Inventory (Hogan et al., 1983), and Beck Depression Inventory-Fast Screen (Beck et al., 1997a). Results indicated that purpose in life correlated positively with quality of life and medical adherence, whereas negatively with depression. Furthermore, purpose in life correlated positively with the duration of the current hospitalization. The results are discussed in terms of a process of attachment to the hospital as the sense of life purpose emerges.

Ethical and Scientific Perspectives of Placebo-controlled Trials in Schizophrenia.

UNLABELLED: Clinical trials for development of new medications are essential in all fields of medicine. The requirement for a placebo arm in pharmaceutical trials presents ethical and clinical dilemmas that are especially complicated with regard to mentally ill persons whose free choice and ability to provide informed consent may be questionable. On the other hand, we do not believe that this predicament justifies unconditional rejection of placebo use in psychiatry, when the investigational drug may ultimately provide substantial benefit for some patients. At the same time it is the psychiatrist's responsibility to insure that investigators are adequately trained to conduct clinical trials and that stringent regulatory committees supervise the scientific, clinical and ethical aspects of the trials. KEYWORDS: Placebo-control; Schizophrenia; Medical ethics; Clinical trials.

Dying in the psychiatric ward.

General hospital staff is experienced in dealing with the death of a patient. However, aside from cases of sudden death among psychiatric inpatients, psychiatric medical staff faces such situations considerably less frequently. Many chronic psychiatric patients do not have a family or home, a situation which may become even more painful if the patient is dying of a physical illness. Coping with a terminally-ill oncology patient is a difficult task for the multidisciplinary staff and for fellow patients in chronic care psychiatric departments. The authors describe the slow deterioration of two psychiatric inpatients who were also diagnosed with advanced cancer, and present the dilemmas involved with continued treatment of terminal oncology patients in a psychiatric ward when the psychiatric status no longer warranted inpatient psychiatric care.

[Decision-making concerning guardianship--who is the "person that no longer has the capacity to make decisions regarding personal matters"?].

Appointment of a guardian is a complicated and important process, when necessary. It is a paternalistic intervention in the life of an individual, which aims to protect those who require that protection. Appointment of a guardian significantly impedes the rights and autonomy of the individual and should therefore remain a last resort. Alternatively, not appointing a guardian for one who needs protection could potentially expose that person to financial or physical harm, exploitation and neglect. The law allows for appointment of a guardian for a person that no longer has the capacity to make decisions regarding some or all of his/her personal matters. The law and the ruling have not defined who is considered a person that no longer has the capacity to make decisions. The criteria for financial capacity should include whether or not the patient knows the extent of his property, his income, expenses, and demonstrates ability to make logical decisions concerning these issues? The criteria for personal capacity [physical wellbeing] should include whether or not the patient can independently take care of his personal needs and care for himself in terms of: nutrition, housing, clothing, general security, and a safe living environment? We suggest that the expert opinion should specifically relate to the issues of guardianship for physical wellbeing and/or property and should provide the following: 1) Reason: What is the disorder/diagnosis that the patient suffers from? 2) Cognitive impairment: What cognitive impairment results from the patient's illness? 3) Functional impairment: What functional impairments resulting from illness affect the life of the patient?

Israeli psychiatric inpatients go to the polls.

In 1996, mobile polls were introduced in Israel, enabling physically and emotionally ill inpatients to vote. We surveyed the rate of participation of inpatients at Lev-Hasharon Mental Health Center in parliamentary elections, their feelings regarding voting, and the nature of their vote, compared with the general population. One hundred eighteen of 306 (38.6%) patients voted compared with 63.8% of the general population. Forty-nine more patients (16%) wanted to vote but were unable to for technical reasons. More patients voted in the open than the closed wards (chi=14.5; df=1; p=.001). Most patients reported positive subjective feelings, a sense of responsibility (39%), belonging to the general community (28%), and pride (22%) after voting. Psychiatric inpatients voted similarly to the general population, though their percentage of voters was significantly lower. This discrepancy can be accounted for by lack of concern and ineligibility due to lack of identification documents that may reflect fundamental illness-related problems.

[Ethical considerations of psychiatric treatment in chronic post traumatic stress following multiple casualty attacks].

Israeli society has been repeatedly exposed to traumatic stress following terrorist attacks with multiple casualties. Individuals who are subjected to these incidents experience various mental reactions, including traumatism, fear, loss and bereavement. Unfortunately, evidence based medical knowledge is lacking regarding natural methods for dealing with incidents that may precipitate traumatic stress, ways of identifying people who are more likely to develop post traumatic symptoms, or suggestions on early interventions that may avert the onset of these symptoms. Ethical problems may arise, especially in situations involving mass traumatic stress, when there are insufficient therapeutic resources. In such cases, the issues of whether to intervene, who to treat, and how, will often be influenced by conflicting personal and social interests. Another concern involves the principle of autonomy - the individual's right to decide whether he/she wants treatment. Should "latent" victims be identified in the community and referred to therapy? Diverse ethical issues emerge in situations of traumatic stress, and may potentially evoke dilemmas among health policy makers and among the therapists who work in the field. This type of discussion may enhance the understanding, help formulate key principles and assist in making reasonable and appropriate decisions when dealing with such difficult and complex situations.

Attitude of general practitioners towards psychiatric consultation in primary care clinic.

Fifty general practitioners (GPs) were surveyed about their attitudes towards psychiatric liaison-consultation services. The questionnaire differentiated among GPs' attitudes towards the liason-consultation model and towards the various possible roles of the psychiatrist who visits the GP's practice. These attitudes were analyzed in relation to the level of post-graduate training of the GPs, and to their psychological sensitivity as measured by the PMI scale. GPs with specialist registration certificates in family medicine were more interested in working together with psychiatrists and rated themselves as more sensitive to psychological issues. The largest group (39%) among the GPs thought that the main task of the visiting psychiatrist is to advise them on psycho-social issues, while leaving clinical responsibility in their hands. Less frequent responses included: diagnosis and treatment within the primary care clinic (17%), facilitating referrals (15%), and update teaching of psychiatry (12%). The predominant attitude was consistent with the finding that 96% of the GPs thought that they had good abilities at recognizing patients in distress, and 92% rated their doctor-patient relationship skills as high.