A rural mental health research agenda: defining context and setting priorities.

This article provides a brief overview of research perspectives on rural mental health services and suggests the importance of building an agenda to bring coherence to studies in this area. The need for sound theory and methodology to guide research is emphasized. The importance of better conceptualization of the rural context as a focus of research is addressed, and 14 propositions concerning issues the authors think will advance rural research are presented. This article is intended to stimulate discussion about a research agenda that will lead to better understanding of rural needs for mental health services as well as more responsive service models.

Critical issues in reforming rural mental health service delivery.

Critical issues in reforming rural mental health service delivery systems under health care reform are outlined. It is argued that the exclusive focus on health care financing reform fails to include obstacles to effective mental health service delivery in rural area, which should focus on issues of availability, accessibility, and acceptability, as well as financing and accountability. Characteristics of rural areas are delineated and three assumptions about the structure of rural communities which are shaping the dialogue on rural health and mental health service delivery are examined. These assumptions include the notion that rural communities are more closely knit than urban ones, that rural services can be effectively delivered through urban hubs, and that rural dwellers represent a low risk population which can be effectively served through existing facilities and by extending existing services.

The vulnerability-stress model of schizophrenia: advances in psychosocial treatment.

Vulnerability models of schizophrenia are reviewed, along with psychosocial rehabilitation methods addressing functional abilities and social competence. Their relationship is discussed with a view to developing a framework in which biological and psychosocial approaches to schizophrenia can be integrated for purposes of effective clinical intervention. Such intervention is designed to improve social competence, cognitive appraisal, and coping skills for mediation of stress in vulnerable individuals.

Ethical issues for academic participants in state-university collaboration programs.

State-university collaboration programs often create ethical dilemmas for participants because of their conflicting values, goals, and expectations. Treatment and administrative staff in state agencies often seek to create an atmosphere of managed stability rather than fostering patients' autonomy. Academic participants in collaboration programs often feel impelled to change the system, even though the goal of collaboration requires them to find common ground with state agency staff. Academic participants must decide whether collaboration programs will contribute to needed reforms without overly compromising professional and academic standards. If they cannot endorse the values and quality of care provided in state systems, they must consider whether their participation should be conditioned on an agreement to work toward change. However, even in situations that are improving, clinicians must not let temporary compromises become permanent.

The mental health treatment team as a work group: team dynamics and the role of the leader.

Although treatment teams have been examined often in the mental health literature, this literature seldom addresses the crucial property of "teamness"--the key set of intangible phenomena that allow a team to function synergistically as more than the sum of its parts, and with a sense of team identity. In this paper, the concept of the work group is used to develop a framework for understanding the factors contributing to effective team functioning and identity, an their implications for the tasks of team leadership and sociotherapy: "the art of maintaining a social system in which the treatment of an individual patient can best occur" (Edelson 1970). Leadership activities that promote team cohesiveness and boundary maintenance are discussed, and suggestions are provided for ways in which the subjective experiences and emotional reactions of the leader and team members can be used to promote improved task performance and clinical care.

Toward the financial integration of public mental health services.

The public treatment of seriously mental ill patients continues to be frustrated by the lack of administrative and financial integration of state and community mental health services. Several states have initiated attempts to improve the cost-effectiveness of public mental health services through mechanisms that create financial incentives fostering community-based alternatives to psychiatric hospitalization. Examples of such mechanisms include capitation financing systems, performance contracts, regional mental health authorities, utilization review, and bed-targets. This paper reviews evidence supporting the need for and success of these efforts, and also addresses their limitations.

Public-academic linkages: a "linchpin" model.

The "linchpin" model of collaboration between state mental health agencies and university training programs has been developed in two states. This paper describes the model, pointing out both strengths and weaknesses. Recommendations for institutions seeking this type of collaboration and persons who are in the collaborative role are provided.

Training Ph.D. psychologists for rural service: a report from Nebraska.

The Clinical Psychology Training Program at the University of Nebraska-Lincoln developed a rural mental health specialty to train psychologists to work in rural settings. Preliminary data indicate that the project was relatively successful in placing graduates in rural practice. But the needs for practitioners in rural communities clearly are greater than training programs can meet. Relying on doctoral psychologists for clinical work in rural communities may not be the best strategy in workforce planning.

Recruitment, motivation, and reinforcement of preprofessionals for public sector mental health careers.

The labor intensive public mental health system needs to encourage trainees in mental health professions to consider careers in the public sector. Recent evidence is that younger professionals are choosing other career paths following their training. This paper suggests that the availability of relevant training opportunities, positive role models, financial support while in training, and a supportive group of peers are important components of training for public sector careers.

Bringing about a balance.

Kupers' comment on the cyclical nature of the recent history of mental health in the United States is important and hopeful. Another dimension of the current public mental health scene is the decrease of the federal role in the overall system. This role has been a critically important one in the recent past. Hopefully, it will be restored to its full capacity as the country strives for a balanced system of mental health care for all its citizens.

Training psychologists for work with the chronically mentally ill.

While clinical psychologists have made a strong contribution to research and service delivery to the chronically mentally ill, the profession still experiences a shortage of human resources for work in this area. The roles and functions of clinical psychologists are specified and the prevalent model of training is described in light of the needs for services to CMI.

Using the day treatment appropriateness scale with rural, alcoholic clients.

Inadequate selection of patients is one factor in the underutilization of day-treatment programs. The Day Treatment Appropriateness Scale (DTAS; Lefkovitz, P. M., Int. J. Part. Hosp. 1:45-47, 1982) is one of only two reported instruments designed to assist in patient selection; it has been shown to predict validly successful completion of a day-treatment program for chronic, psychiatric patients. This report addresses the use of the DTAS in an alcohol day-treatment program located in a rural, midwestern, community mental-health center. The DTAS was not found to predict accurately successful program completion among alcoholic clients in day treatment. Possible explanations of the findings and additional predictive variables are reported.