Young adults looking back at their experiences of treatment and care for nonsuicidal self-injury during adolescence: a qualitative study.

BACKGROUND: Nonsuicidal self-injury (NSSI) is associated with stigma, and negative attitudes among healthcare professionals toward NSSI have been reported. A person-centered approach that focuses on how individuals with lived experience of NSSI perceive the treatment and care they receive is invaluable in reducing barriers to help-seeking and improving treatment and mental healthcare services. The aim of the current qualitative study was to explore the perceptions of young adults when they look back upon their experiences of psychiatric treatment for NSSI during adolescence. METHODS: Twenty-six individuals with lived experience of NSSI who were in contact with child and adolescent psychiatry during adolescence were interviewed. The interviews were analyzed using thematic analysis. RESULTS: Three main themes were developed: Changed perceptions in retrospect, The importance of a collaborative conceptualization and Lasting impression of the relationship. Participants' perception of themselves as well as the treatment changed over time. The importance of a joint understanding of NSSI and an agreed-upon treatment focus was emphasized. The relationship to the mental health professionals, and experiences of how NSSI was communicated, were salient several years later. CONCLUSIONS: Healthcare professionals need to communicate about NSSI in a respectful manner and include the perspective of the adolescent with lived experience of NSSI in a joint conceptualization of NSSI and treatment focus.

Self-reported attachment style, trauma exposure and dissociative symptoms among adolescents.

The aim of this study was to analyze whether self-reported attachment style (measuring avoidance and anxiety) among adolescents was associated with dissociative symptoms, in addition to self-reported potentially traumatic experiences. A group consisting of 462 adolescents completed three self-assessment questionnaires: Linkoping Youth Life Experience Scale (LYLES), Experiences in Close Relationships, modified version (ECR) and Dissociation Questionnaire Sweden (Dis-Q-Sweden). Self-reported attachment style had a stronger association with dissociative symptoms than self reported traumas. It was also found that scores on a dissociation questionnaire correlated strongly with scores on self-reported attachment style in adolescence. Discussion concerns reasons why self-reported attachment style is an important factor that may influence dissociative symptoms during adolescence.

Treatment costs and clinical outcome for first episode schizophrenia patients: a 3-year follow-up of the Swedish "Parachute Project" and two comparison groups.

OBJECTIVE: To evaluate "need-specific treatment" of first episode schizophrenia syndrome patients. METHOD: Sixty-one consecutive first episode schizophrenia syndrome patients were followed over 3 years. They were compared with a Historical "treatment as usual" group (n = 41) and a Prospective group from a high quality social and biological psychiatry centre (n = 25). RESULTS: Symptomatic and functional outcome was significantly better compared with the Historical group and equal with the Prospective group. During the first year, the direct costs for in- and out-patient care per patient in the Parachute project were less than half of those in the Prospective group. CONCLUSION: The study confirms the feasibility, clinically and economically, with a large scale application of "need-specific treatments" for first episode psychotic patients.

One-year outcome in first episode psychosis patients in the Swedish Parachute project.

OBJECTIVE: Implementing a system designed to treat first episode psychotic (FEP) patients. METHOD: Every FEP patient (n=253) from a catchment area of 1.5 million inhabitants were asked to participate in this 5-year project. One historical (n=71) and one prospective (n=64) FEP group were used for comparisons. RESULTS: A total of 175 patients (69%) were followed up through the first year of treatment. Global Assessment of Functioning (GAF) values were significantly higher than in the historical comparison group but similar to the prospective group. Psychiatric in-patient care was lower as was prescription of neuroleptic medication. Satisfaction with care was generally high in the Parachute group. Access to a small overnight crisis home was associated with higher GAF. CONCLUSION: It is possible to successfully treat FEP patients with fewer in-patient days and less neuroleptic medication than is usually recommended, when combined with intensive psychosocial treatment and support.

Patterns of consistency and deviation in therapists' countertransference feelings.

The author addressed the question of consistency in psychotherapists' countertransference feelings. Research findings have indicated that the therapist's own personal feeling style may be more important than the patient's impact on the therapist's feelings. In this study, the feelings of 9 psychotherapists toward 28 patients were followed by using checklist self-report after each session during moderately long psychotherapies. ANOVAs and discriminant analyses showed that the therapists were very consistent in their feeling style over different patients and over time. The consistency in feelings toward the individual patients was smaller. Deviations from consistency are analyzed, and their importance for the understanding of different aspects of the countertransference is discussed. It is suggested that a meaningful use of the countertransference concept ought to be based on systematic identifications of recurrent and deviant patterns in the therapist's reactions.

On the importance of congruence between psychiatric staff and patient about the patient's status.

This study explores the usefulness of a method for comparing the congruence of the staff's and the patients' perceptions of the patients' well-being. At a psychiatric rehabilitation clinic, a comparison was made between the patients' and the staff's views of the patients' well-being. The staff and the patients completed questionnaires about the patients' well-being on ten occasions during a 5-year period. Through a principal components analysis of the questionnaire scores, two conceptually similar dimensions (health-illness, and contact-distance) were identified on each set of scores. The staff and patient ratings on the two dimensions could thus be compared. During the time of the study, a reorganisation of the clinic was made. This made it possible to compare older and newer units. The results indicated that the staff at long-existing units rated the patients' health as lower than the patients did, whereas the staff at newer units rated the patients' health as better than the patients did. The staff at units where the patients lived in their own apartments saw the patients as less contact-seeking than the patients did, and the staff at in-patient units saw the patients as more contact-seeking than the patients did. The two-dimensional PC-models made it possible to visually illustrate the developments for three individual patients. The results thus showed that the method is useful for research purposes as well as for clinical evaluations. In the final section, problems and assets of the method are discussed.

Associations between staff feelings toward patients and treatment outcome at psychiatric treatment homes.

This paper presents, as part of a national Swedish research project, a study of associations between staff feelings toward patients and treatment outcome at 23 small psychiatric inpatient units. The outcome was measured with a composite scale based on structured interviews. Staff feelings were reported on a feeling checklist. Few and scattered correlations were found between staff feelings and treatment outcome when the whole group of patients was analyzed together. More meaningful patterns were found when data for psychotic and borderline patients were analyzed separately. For psychotic patients, positive outcome was associated with low levels of negative feelings throughout treatment. For borderline patients, positive outcome was associated with negative feelings at the beginning of treatment, followed by strong positive feelings in the later part. Staff feelings were more strongly associated with outcome for borderline patients than for psychotic patients. Patients with different structural diagnoses need different kinds of staff "feeling milieus."

Staff feelings and patient diagnosis.

OBJECTIVE: To assess the associations between staff feelings toward patients and the patients' diagnoses, in view of the fact that clinical reports of such associations have not been corroborated by systematic research. METHOD: At 24 psychiatric units, 143 patients were assessed according to their personality organization, and staff feelings toward these patients were followed for 5 years. The feelings were reported on a feeling checklist twice yearly, and outcome was assessed as the effect size at year 5, using ratings on Kernberg's structural model complemented with ratings on Strauss-Carpenter's function scale. RESULTS: The study showed that it was possible, using discriminant analyses, to separate diagnostic groups by the different feelings that they evoked in the staff. Patients with borderline personality organization (BPO) evoked fewer relaxed and more aggressive feelings, in contrast to patients with psychotic personality organization (PPO). In contrast to patients with neurotic personality organization (NPO), who evoked feelings of sympathy and helpfulness, PPO patients evoked more feelings of insufficiency and disappointment. A stepwise discriminant analysis of reactions to patients with positive treatment outcome separated the 3 personality organizations with 2 functions using only 2 feelings, "relaxed" and "objective." The feeling relaxed separated the NPO patients from the BPO patients, and the feeling objective separated the PPO patients from the other groups. The patients' diagnoses accounted for larger proportions of variance in feelings for the patients with positive outcome. CONCLUSION: The results implied that the patients' different personality organizations evoked different staff feelings in this treatment context and that positive treatment outcome was associated with more pronounced and clear-cut staff reactions.

Countertransference feelings and the psychiatric staff's self-image.

This paper presents a study of associations between psychiatric staff's habitual feelings towards their patients and the staff's self-image. At 22 psychiatric treatment homes for psychotic and other severely disturbed patients, 163 male and female staff recurrently rated their feelings towards the individual patients on a feeling checklist. At the beginning of the study period, they also rated different aspects of their self-image (the introject and the mother and father images) using Structural Analysis of Social Behavior (SASB). Over time and over patient, correlations between the individual staff ratings on the feeling checklist and ratings on the SASB were studied for all staff and for male and female staff separately. The analyses showed a number of associations between the staff's feelings and aspects of their self-image. Staff who habitually tended to feel helpful and autonomous towards their patients had a more positive image of mother, whereas staff who tended to feel more rejecting, unhelpful, and controlled had a combination of negative images of mother and father and a protecting introject. Some notable differences between male and female staff were found. Overall, self-image accounted for larger proportions of the male staff's feelings than of the female staff's. Negative feelings for male staff were associated more with a critical father image, whereas for female staff these feelings were associated more with an image of the father as a freedom giving.

The influence of patient diagnosis and self-image on clinicians' feelings.

This paper presents an analysis of the relations between the patients' psychiatric diagnoses, their self-image, and the staffs feelings toward the patients. At 17 treatment units for severely disturbed psychiatric patients, the staff rated their feelings toward the patients on a feeling checklist twice a year for 5 years. The patients were diagnosed on DSM-III-R (axis I and II) and rated their self-image on a self-rating instrument, the Structural Analysis of Social Behavior. First, comparisons between reactions toward patients with different axis I diagnoses, toward patients with different axis II diagnoses, and toward patients with either axis I or axis II diagnoses were made with one-way ANOVAs. No significant differences were found in any of these comparisons. The amount of variance in feelings explained by these groupings was between 2% and 4% (mean = 3%) for axis I, between 3% and 14% (mean = 8%) for axis II, and between 4% and 17% (mean = 9%) for the combined comparison. Differences between axis II diagnoses had the largest influence on the staffs feeling reactions. Second, comparisons between the influence of the patients' diagnoses and of their self-image on the therapists' feelings were made by way of blockwise multiple regression analyses. The results showed that the patient's self-image was more important in influencing the staffs feelings than the diagnosis but that diagnosis and self-image were virtually independent in this respect.

The patient's contribution to the therapist's countertransference feelings.

Countertransference feelings of psychiatric milieu therapists toward their patients were studied by using a self-report feeling word checklist. The feelings were scored on subscales of feeling states in a circumplex model. By using an analysis of variance model, comparisons between reactions to patients individually and reactions to patients with different personality organizations and with different Health-sickness rating scale scores could be made. A total number of 244 therapists at 21 small treatment homes were studied. It was found that approximately 15% of the therapists' countertransference feeling reactions could be accounted for by recurrent reactions to patients individually. Surprisingly, the personality organization and the Health-sickness rating scale score of the patient accounted for almost no variance in therapists' feelings. The results are discussed, and possible explanations are evaluated.

Psychological climate and countertransference in psychiatric treatment homes.

The associations between milieu therapists' feelings towards patients and the unit's psychological climate were studied at 21 small treatment homes for severely disturbed psychiatric patients. The milieu therapists filled out self-report instruments where they rated their feelings towards patients on a feeling-word checklist and their opinion about the psychological climate on a Bion-based scale. Scores on the climate scale were used as independent variables in a series of regression analyses, with scores on the feelings as the dependent variables. It was found that a substantial component of the average differences between units with regard to feelings towards patients could be attributed to the unit's climate. Correlations showed that units characterized by "Work' and "Pairing' had high scores for helpful and autonomous feelings, while unhelpful feelings were evoked in units characterized by "Dependency' and "Fight'. Close feelings were evoked in units characterized by "Dependency'.

Emotional reactions to psychiatric patients. Analysis of a feeling checklist.

In psychodynamic milieu treatment, the relations between patients and nurses are the main tools for understanding and helping the patients. For this reason, it is important to construct methods to follow the development of relations and to study characteristics of helpful and nonhelpful relations. In this article, a checklist with feeling words given to nurses and aides in psychiatric treatment facilities is presented and its measurement properties are described. The analysis showed that the checklist as a whole measures the amount of emotional arousal in a reliable way. The individual feeling words have acceptable variance. A factor analysis gave a limited number of factors that are clinically understandable. The checklist seems to be well worth further study.

Congenital cytomegalovirus infection and disease in Sweden and the relative importance of primary and secondary maternal infections. Preliminary findings from a prospective study.

In a prospective Swedish study started in 1977 and still in progress 10 328 newborn infants in an urban district were investigated for cytomegalovirus (CMV) excretion in the urine by the virus isolation test. Congenital infection was found in 50 cases (0.5%). Of 47 infected infants with known clinical status at birth 9 (19%) had hepatomegaly, splenomegaly, jaundice and/or petechiae. The symptoms were moderate or mild. Of the infants followed up, 2 (25%) of 8 neonatally symptomatic ones and 3 (9%) of 35 asymptomatic ones developed neurologic sequelae. Altogether 5 (12%) of 43 had permanent neurologic symptoms corresponding to 0.06% in the general population. The children ranged in age from 6 months to 4 yr at the last examination. 21 mothers of the 47 infants with known status at birth had a confirmed or presumed primary infection, 15 a confirmed or presumed secondary infection and 11 an undetermined type of infection. Of the 5 infants with neurologic sequelae, 1 with a grave psychomotor retardation and deafness was born to a mother with a primary infection in the 1st trimester; 1 infant with a moderate retardation and 3 deaf infants were all exposed to confirmed or presumed secondary maternal infections. Prospective serological studies of maternal sera in early pregnancy would have suspected only the gravely retarded infant to be at risk.