Psychosocial functioning and subjective experience in schizophrenia.

This study examines the relationship between psychosocial functioning and subjective experience in 193 individuals diagnosed with schizophrenia or schizoaffective disorder according to Research Diagnostic Criteria. Psychosocial functioning was measured as work functioning, social functioning, living situation, symptomatology, and intrapsychic aspects of the deficit syndrome. Subjective experience consisted of measures of self-esteem, satisfaction with life, and subjective distress. Multivariate analyses resulted in two major findings. The first finding is a model of psychosocial functioning that consists of two factors: disorder-related variables (symptomatology and intrapsychic deficits) and functional status variables (work, social, and living situation). The second major finding is a two-tiered model of the relationship between psychosocial functioning and subjective experience. The model suggests a primary and pervasive relationship between the disorder-related variables and subjective experience and a secondary and less pronounced relationship between functional status variables and subjective experience. The implications of these findings for treatment and rehabilitation and for the study of subjective experience in schizophrenia are discussed.

Monitoring program implementation in community mental health settings.

Evaluations that monitor program implementation provide an empirical description of a program's services, the population served, and a method for assessing whether the program as delivered matches the conceptual model on which it is based. This article presents the Daily Contact Log (DCL), an instrument that has been used to monitor the longitudinal form and content of services delivered in several community mental health care programs for persons with chronic mental illness. The instrument is described and directions for its use are detailed. The psychometric properties of the instrument are discussed, as is its evolution in multisite applications in various mental health care settings. The usefulness of the DCL for programmatic and research purposes is outlined, as are some secondary benefits to staff who use the instrument. While the viability and versatility of the DCL as an instrument for measuring important aspects of program implementation are stressed, its appropriateness for quality assurance analyses is also suggested.

Patient compliance in the mental health continuum of care.

Noncompliance--not following through on a treatment plan--is explained by the traditional acceptance of therapists that many psychiatric patients are not motivated for offered therapy. Despite the twenty-year availability, methodologies to facilitate a successful continuum of care have not been widely implemented. Instead, the patient has been blamed for his lack of motivation. The importance of the therapist's behavior, the context, the setting, and the environment of the treatment continuum are discussed. Long-standing but nontraditional program goals and concepts that facilitate a successful continuum of care are presented.

Characteristics of clients, staff interventions, and the continuum of care.

In two samples of over 200 consecutive referrals each from a psychiatric hospital to community agencies, client characteristics were generally unrelated to referral success but three staff interventions were related to completing referrals. It was concluded that known interventions are stronger predictors of successful referrals than patient characteristics. Staff telephone contacts with ethnic minorities were more successful in effecting referrals than with majority patients.

Paraprofessional role in a mental health continuing care program.

The authors report on a unique program in which paraprofessionals provide continuing care services to patients in a large public psychiatric hospital, both before and after discharge. Data from one hundred patients indicate that paraprofessional caseworkers effectively managed 85 percent of the patients' post-discharge problems without needing to directly involve their professional teammates.

Patients' requests of an outpatient clinic.

Three-hundred-twenty-five consecutive predominantly lower-class new patients at a psychiatric outpatient clinic rated the importance they attached to each of 14 categories of treatment needs or requests. Psychiatric residents subsequently rated the importance of each request for each patient at the conclusion of their initial assessment interview. Requests reflecting needs for intrapsychic therapy, clarification, and control of feelings were considered very important by approximately two thirds of the patients; needs for institutionalized contact, advice, and community triage by one half; and other requests for medication, reality contact, succorance, ventilation, confession, social intervention, administrative requests by a minority (one fourth to one third). Residents significantly underestimated the importance their patients attached to 10 of 14 requests. Factor analyses confirmed several systematic sources of disparity between patient and therapist perception of lower-class patient needs.

Videotape recording of dynamic psychotherapy: supervisory tool or hindrance?

The authors questioned residents and supervisors at a large clinic about their attitudes and experiences regarding clinical supervision. Half of the residents then videotaped one of their psychotherapy sessions and presented the tape in their next supervisory session. The procedure had little effect on patients, was anxiety-provoking for the residents, and had some diagnostic benefit for the supervisors. After the taping, the residents' views about taping were less positive than before the taping, but the supervisors' views did not change significantly.

A program for continuing care: implementation and outcome.

The authors used the records of the continuing-care program at a large public hospital in Los Angeles to determine the success of referrals for aftercare. A total of 552 patients discharged during an eight-month period were referred for continuing care; 418 of the patients kept their first appointment. Patients were most likely to keep their first appointment if it was set up for within three days of release from the hospital and if it was confirmed before discharge from the hospital. If an appointment could not be arranged within three days, a phone call to the patient improved the referral completion rate.

Medical student attitudes about quality of care and training of minority persons.

Ninety-five first year medical students agreed that there was differential medical treatment of minority vs majority persons. Implicated reasons for this phenomenon were lack of personal treatment of members of minorities, distrust of medical workers by minority members, and majority perceptions that minority persons are not good patients. Integrated treatment and training facilities, preferential academic treatment, special training for majority students, and philosophy of medical care are discussed in terms of improving medical care for all.

Drug use, attitudes, and behaviors of youth in an urban free clinic.

A questionnaire regarding drug use, attitudes, and behaviors was completed by youths attending a free clinic on randomly selected evenings. Compared to a sample of suburban high school youths, the clinic youths were heavier drug users and were more antiestablishment in their attitudes and behaviors. The clinic youth as a whole tended to have antiestablishment attitudes but within the sample drug use was, with specific exceptions, not related to such attitudes. Youths whose first drug was not marijuana tended to be relatively heavy users, as compared to youths who started with marijuana. Data regarding reasons for use are reported. A brief discussion focuses on society's influence on the implications with the phenomena of drug use and free clinics.

Personality changes and compatibility in the psychiatric resident--supervisor relationship.

Seventy-one psychiatric resident-supervisor dyads were studied in terms of Schutz's interpersonal theory of compatibility. Personality changes during the second year of psychiatric residency were also measured by means of Schutz's Fundamental Interpersonal Relations Orientation Scale. Predictions relating compatibility to satisfaction with the dyad and to ratings of competence were not confirmed. Personality changes were found, with residents showing a significant decrease in needs for wanting to be included and for expressing affection. Situational factors are proposed for the personality changes, and personality factors are suggested as influencing the selection of psychiatry as a medical specialization.

A comparison of videotaped and live patient interview examinations and written examination in psychiatry.

The authors scored the examination performance of 28 psychiatrists who were tested after conducting an interview with a real patient and after seeing a videotaped interview with an actor playing the role of either a psychotic or a neurotic patient. The also scored the performance of 15 of the same examinees who completed a written examination. Eighty-five percent of the examinees reported that the videotaped interview examination was a useful learning experience, and 81% said that it was a useful testing experience. The examiners' feelings varied regarding the use of the standardized videotaped format for certification and recertification of psychiatrists.

Which patients respond to a mental health consumer survey.

Characteristics of patients at the Los Angeles County - University of Southern California Medical Center, Adult Psychiatric Outpatient Clinic who responded to a Los Angeles County voluntary "Client Satisfaction Survey" were compared with those who did not. Three significant differences consistently emerged. If an individual was a member of a minority group (black of Spanish surname), had less than a high school education, and was taking antispsychotic medication, his chance of returning a questionnaire to a waiting-room collection box was 79% as compared to the 30% chance of returning if he had none of these three characteristics. Younger patients had "Anglos" more often used the U.S. mail than the collection box to return the questionnaires. It is important that both methods be used to minimize bias. Most of the many patient-characteristics studied did not influence return rate. These findings are discussed in relation to the return method, ethnicity, medication, chronic mental illness, diminished freedom, and consumer voice in voluntary questionnaires.

The ombudsman: a serendipitous mental health intervention.

It is proposed that the ombudsman program, originally conceived of as a protection of the political rights of individual citizens, can be profitably viewed as a primary prevention of psychological disorders. The ombudsman attempts to alleviate reality problems prior to the onset of psychological disruption by engaging in active change agentry in public and private bureaucracies. Two hundred randomly selected written complaints were analyzed to ascertain the types of problems brought to this program. The role of the mental health professional and training issues are briefly discussed.

Continuity of care between the psychiatric hospital and public schools.

Seventy-five professionals from three psychiatric training hospitals were interviewed to ascertain their attitudes and stated practices concerning educational aftercare planning and implementation. Findings revealed that 75% of the professionals did not routinely contact the schools despite their acknowledgment of the school's potential for facilitating rehabilitation. Neither discipline nor hospital were related to attitudes or to reported behavior concerning the hospital's relationship with the school. Suggestions for improving the continuum of care are discussed.

Therapists' physiological activation and patient difficulty.

The differential effects of an easy and difficult-to-interview patient on therapist self-reported behavioral arousal and physiological activation were observed. Eighteen experienced white male psychiatrists each interviewed two patient simulators believing they were real patients. Each actress was programed to act the part of a difficult-to-interview patient and an easy-to-interview patient. Each randomly played either part as assigned and the order of patient and role was counterbalanced. Differences in patient roles were validated by the participating therapists and independent raters. Fifteen-minute rest periods with soft music preceded each therapy session such that a complete experimental session consisted of rest 1, therapy 1, rest 2, and therapy 2. Self-reported arousal was assessed during each of the four periods by Thayer's factors from the Nowlis Mood Adjective List. Physiological activation was measured by electromyogram, heart rate, blood pressure (systolic and diastolic), and skin conductance. Therapist self-reported behavioral arousal and measured physiological activation during therapy were significantly greater than during rest. The difficulty of the patient did not appear to affect either behavioral or physiological activation level of the therapists. Several explanations for this are explored.