Special
Report
Highlights of the 43rd Institute on Hospital and Community Psychiatry The 43rd Institute on Hospital and Community Psychiatry, held October 20-24, 1991, in Los Angeles, drew nearly 1 ,600 participants to a program that addressed a wide variety of issues reflecting the institute’s 1991 theme, “Overcoming Challenges With Diversity.” Topics included sexual harassment in the workplace, treating people infected with the human immunodeficiency virus, the effects ofgang violence in cities, and the challenges of providing psychiatric care in remote rural areas. Seventeen professional organizations held meetings in conjunction with the institute. In a speech at the opening session, Lawrence Hartmann, M.D. president ofthe American Psychiatric Association, affirmed the need for biopsychosocial integration of the increasing knowledge in the disparate fields that explore the mind and the brain. He suggested that due to advances in neurobiology in the last 20 years, psychiatry has turned away from the biopsychosocial model of illness and health, which had served the field well, toward a more purely physiological, biomedical model. Although the biomedical model has been extraordinarily fruitful, its success has led to neglect of scientific consideration of the more personal, psychological, and social aspects of health and disease, Dr. Hartmann said. However, humane values require mental health professionals “to be aware of, care for, and treat whole people in context and over time,” he said. Major splits have developed in American psychiatry over the past 25 years in response to enthusiasms about brain biology or social and environmental factors, Dr. Hartmann
aging biopsychosocial integration and humane values in the mental health field. At the closing session, APA president-elect Joseph T. English, M.D., announced the theme of his upcoming presidential year-”Caring for Patients in Need: Challenges for the 21st Century.” He urged psychiatrists to maintain their identity as professionals to effectively deal with the radical economic changes that are
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said, and he pointed out that “new external pressures to widen splits are currently with us.” Several courts and state legislatures have attempted to ensure that a mental illness should be covered by insurance only ifit has a demonstrable organic component, he noted, and emphasized the importance of working with insurance companies to see that all mental illness is covered on a par with medical illness. Dr. Hartmann said argument about the relative importance of biological, psychological, and social ftctors in mental health and illness will probably remain central to psychiatry, but he cautioned that in this debate “we are at great risk of premature closure and of theoretical and clinical segregation rather than integration.” Dr. Hartmann added that child and adolescent psychiatric pathology and health have not received the attention they deserve, perhaps because they are dependent on family and environment-’ ‘that is, on the ‘social’ in biopsychosocial, which is so often left out of 1991 psychiatric discourse. “ He urged listeners, whatever their training or role, to apply their talents and energies to helping children and adolescents grow mentally healthier, as well as to encour-
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currently taking place in the United States. Dr. English suggested that mental health professionals should challenge the popular idea that the portion of the U.S. gross national product spent on health care is too great. “We should consider it an open question as to what percentage of our economy is to be spent on health care,” he said. “We should be suggesting that growth in employment in health care could be very healthy, at least in some parts of the country. This is not to say that we shouldn’t become more efficient and shouldn’t be concerned about overutilization or waste.” Dr. English pointed out that the development of the resource-based relative value scale (RBRVS) and proposals to pay other mental health professionals a fixed proportion of what psychiatrists are paid have created alliances that did not previously exist among various mental health disciplines. The development of the RBRVS is one of the most important factors affecting the future ofpatient care, he said. “Ifwe are not going to be paid commensurate with the importance of what we do, we will not have young talent coming into the mental health professions.” Dr. English said that as society begins to face the need for limits and choices, mental health professionals must be true to their role as professionals as they participate in this debate. He noted that the essence of a profession is to place the interests of the patient and the public first. Dr. English also stressed the importance ofmental health professionals’ maintaining a commitment to confidentiality and traditional ethics in dealing with patients. He said that ifthe mentalhealth professions begin to dilute or diminish their ethical canons, they will jeopardize the societal contract that is the basis of resolving the economic challenges they currently face. “Part ofour ability to continue to care for patients in need is the extent to which the public recognizes that we aren’t like a business in which the interests of the stockholders come first. The extent to which we keep true to our traditions will enable us
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and motivation and loss of self-esteem may lead to poor work performance. During the third stage, depression and anger arise, and the victim frequently experiences a crisis or breaking point. Victims often seek mental health care at this point. Although most women will go to great lengths
to avoid reporting the behavior to the harasser’s supervisor, a decision is often made to do so during this stage. Other options include filing a complaint with the Equal Employment Opportunity Commission or initiating a lawsuit. Because the available options often don’t work, the fourth stage is characterized by disillusionment. The victim’s co-workers often withdraw from associating with the “troublemaker. Grieving over losses-tangible and intangible-is important. In some cases, the lawsuit or complaint has occupied such a big part ofthe victim’s life that grieving over its loss, no matter what the outcome, may be an issue. The victim needs to reorient to the future and make life decisions or changes that may have been put on hold. Dr. Jensvoid added a fifth stage that is characterized by feelings of empowerment resulting from actions taken. Dr. Jensvold pointed out that psychiatry can be misused as a coercive tool ofthe harasser, who can order the victim to have a psychiatric assessment or to obtain therapy. She warned therapists who do such assessments to be very clear with patients about the boundaries of confidentiality. On the other hand, a therapist can be one of the victim’s greatest supports, especially during the complaint or lawsuit process, which is often lengthy. Dr. Jensvold advises against taking an analytic approach with these patients. The therapist may need to help the patient take an active role in dealing with the harassment. Most important, the therapist must avoid adding to the trauma by not believing the patient. The thetapist should assume that the patient is telling the truth unless it is proven otherwise. Dr. Jensvoid’s advice to harassment victims may help therapists who encounter these patients. A person who feels harassed should, preferably in writing, describe the specific behavior to the harasser and ask that it stop. Keeping a personal written record of the incidents is also important. Although most people are reluctant to talk about the incidents, Dr. Jensvold advises victims
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to care for patients in need not only now but as we enter the 2 1 st century,” he said. Highlights from some of the institute sessions are presented below. Workplace sexual harassment The role of psychiatrists in treating patients who have been-or are being-sexually harassed in the workplace was a topic addressed by Margaret Jensvold, M.D., in a wellattended session. Dr. Jensvold is director ofthe Institute for Research on Women’s Health in Washington,
D.C.
‘
‘
Many specialists in sexual harassment believe it is a major problem that has not been well articulated and that there is a great deal of misunderstanding about. “We are now where we were with rape 1 5 years ago, incest ten years ago, and domestic violence ten years ago,” Dr. Jensvold said. She described some myths about sexual harassment. One myth is that if a woman ignores the harassment, it will stop. One study found that in three-quarters of the cases, when harassment was ignored, it got worse. A second myth is that most charges are false. Those who work in this field point out that a woman has very little to gain and much to lose by making false charges. Citing work byjan Salisbury, Dr. Jensvold outlined four stages in the victim’s response to sexual harassment. In the first stage, the victim blames herself and experiences disbeliefand confusion, often miimizing or denying what is happening. After each incident, she believes that it won’t happen again. Often her performance at work suffers. In the second stage, the victim fears retaliation for not complying. Anxieties about career and finances arise. The victim may become phobic about work. Most women at this point experience at least one physical symptom. Decreased concentration
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to talk to others in detail about the harasser’s behavior. In the aftermath of the Clarence Thomas-Anita Hill hearings and in the coming years, Dr. Jensvold predicted, patients will be seeking treatment for a variety of psychiatric disorders associated with sexual harassment. She pointed out that there is a small but excellent literature on the topic and advised thetapists to learn more.
“
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Treating people with AIDS and HIV infections At the morning and early afternoon panels ofan all-day session on AIDS, medical, neuropsychiatric, and pharmacological overviews of treating HP/-infected patients were presented. Near the end of the afternoon, a panel ofthree psychiatrists discussed the impact that treating people with AIDS has on mental health caregivers. A nurse in the audience, moved by the panelists’ stories, cxpressed the wish that the all-day session had begun with this panel rather than with the usual medical reviews and overviews. Responding to the nurse’s comment, Lee Jones, M.D., of Santa Monica, California, a panel member who has been treating HIV-infected people since 1984, said, “It is easier to deal with talking about the virus, because I’m afraid I’m going to burst into tears if I don’t deal just with that.” In the brief silence that followed, many in the room seemed to struggle with emotions raised by this statement. The panelists spoke of issues in their work they felt untrained to deal with and situations they felt emotionally unprepared to handle. Danid Fast, M.D., a panelist from Santa Monica, observed that, in general, psychiatrists do not expect to work with terminally ill people. Dr. Jones commented that many physicians choose psychiatry because they want to “stay away from death and dying and blood.” The stigmatization of AIDS extends to therapists. For these and other reasons, many therapists do not treat people with AIDS, and those who do sometimes feel that if they don’t provide care to these patients, no one else will. “Inevitably we deal with burnout when we’re
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talking
about treating people with observed Dr. Fast. The third panelist, Lynn Baker,
HIV,” M.D.,
of Los Angeles,
who
works
with women with AIDS and their families, spoke ofgrandmothers who provide care to whole families who die: first the son or son-in-law, then the infected children, and then the daughter or daughter-in-law. Nothing prepares families or therapists for dealing with these terrible losses, she said.
A therapist
whoworks
with some-
one with AIDS is often the only supportive person in the patient’s life, Dr. Fast pointed out. He spoke also ofthe tremendous “burden of knowledge” on the therapist, who must know the medical and neuropsychiatric details of the disease as well as provide information about resources and interact with various agencies on the patient’s behalf. A therapist can feel overwhelmed by expectations to provide this level of emotional and instrumental support. Many doctrines ofpractice learned in training fall by the wayside when someone is dying, said Dr. Jones. Patients who are too sick to come to the office need more care, not less, he said, and home visits are important. Dr. Baker stressed the need for the therapist to know all the players in the family support network-the multigenerational family members and the multiple medical specialists caring for the family-in order to keep abreast of the family situation and provide continuity of care. She spends a great deal of time on the telephone, she said. This level ofinvolvement with patients is often important for therapists. Dr. Jones observed that frequently there is no sense of closure with patients who become ill and drop out of therapy, and closure enables the therapist to continue treating patients with AIDS. He said that one of the most important things he does is to attend memorial services and funerals-something psychiatrists are trained not to do. The services allow him to celebrate the person’s life and meet others who cared about the person. Therapists often feel things that are “too shameful to talk about,” said
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Dr. Fast, such as resentment toward the patients (“Why did they do this to themselves? Why did they do this to me?”) and superiority (“I didn’t get infected; they shouldn’t have either”). Dr. Baker said that because some of the women she works with feel that having children is a cultural imperative, they have several chilthen after being diagnosed. A therapist’s reactions to these patients can get in the way ofgiving sound, compassionate advice, she said. Dr. Fast spoke of going back and forth between feeling deeply empathic and “not wanting to be there.”
On
the
positive
side,
said
“teach” patients with severe or mild dissociative symptoms to be multipies in aprocess Dr. Weissberg called iatrogenic amplification. These therapists often rely heavily on hypnosis, which produces pseudomemories that the patient experiences as very real. In the fourth pathway, maimgering patients, usually in forensic settings, pick up cues during therapy for faking MPD. The second panelist, Cohn Ross,
M.D.,
Dr.
Jones, the epidemic has taught peopie to take care of themselves and each other and to think about the quality oflife. Caregivers often neglect themselves, he said. He told of visiting a very sick patient of his in the hospital. The patient, who was gasping for air and barely able to sit up in bed, said with concern that Dr. Jones was looking very tired. Slowly the patient opened his bedside drawer and found a dollar. “Go get a H#{228}agenDazs bar, doctor,” he said. “You need to take better care of yourself.” To cope with the many strong emotions raised in this work, Dr. Baker emphasized the importance of having “safe people” to talk with, people who understand the difficulties of working with HJV-infected patients. “And it has to be more than one person,” she said. “It has to be spread around-it’s just too much for one person to handle all the time.” For those attending the all-day seasion on AIDS, the room was full of safe people, and many took the opportunity to give and get support. Multiple personality disorder In a half-day session entitled “Multiplc Personality Disorder: Does It Exist? A Debate,” the two debaters found that they agreed on many points, including the existence of multiple personality disorder (MPD) as a serious psychiatric disorder. Michael Weissberg, M.D., of Denver outlined four pathways to the disorder, the first being “spontaneous or true MPD.” In two other pathways, wellmeaning therapists unwittingly
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of Winnepeg,
Manitoba,
a
well-known MPD researcher, agreed that patients fall into these ftur categories and that a great deal of MPD therapy is “out ofcontrol.” However, he argued that iatrogenic amplffication occurs far less frequently than in Dr. Weissberg’s view and that multiple personality disorder is relatively common. Both panelists expressed concern over what they called the sociology of MPD, which has polarized the mental health field. The uncritical acceptance ofthe existence ofsatanic ritual abuse is a litmus test in some circles ofMPD enthusiasts, said Dr. Weissberg. Descriptions by some patients ofmemories ofearly childhood sexual abuse involving torture and infant and animal sacrffice have led to a widespread beliefin a cult that practices religious worship of Satan. Dr. Weissberg pointed out that there is no independent evidence ofthe existence ofsuch a cult.
A subsector
ofthe
MPD
field that
attempts to counter what it believes are the forces of satanic ritual abuse is itselfin danger ofdeveloping some ofthe features ofa cult, said Dr. Ross. Under the care of certain therapists, patients often regress profoundly and are then hospitalized for long periods, a phenomenon he compared to the cult technique of deceptive recruitment. Many MPD patients are completely cut offfrom their families and friends by therapists who regard themselves as protectors. Dr. Ross called these developments a major problem that needs to be strictly dealt with if the dissociative disorders field is not to be discredited. Dr. Weissberg described some red flags that should alert therapists to cases in which iatrogenic amplification has played a role in the diagnosis
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of MPD. In addition to the therapist’s uncritical acceptance ofthe cxistence of satanic ritual abuse, obvious secondary gain for the patient, especially a “high audience awe factor” or greatly increased attention to the patient from family and friends, should raise a flag. The use of hypnosis in the “discovery” ofapatient’s MPD, especially when the therapist is inexperienced and there are no tapes or transcripts ofthe key sessions, should cause concern, said Dr. Weissberg. Therapists who view the disorder as akin to possession and who concretize the personality metaphor that is at the heart of MPD should be viewed with caution, as should those who believe that the patient has no control over any of the personality switches. Dr. Ross strongly endorsed Dr. Weissberg’s list of red flags. However, he pointed out that arguments against the existence of MPD by skeptics more extreme than Dr. Weissberg are often based on ideology, which prevents rational discussion. Skeptics, said Dr. Ross, often fail to cite recent research, which in the last few years has used advanced statistical methods in large, multicenter studies. He briefly described three instruments that have been shown to diagnose various dissociative disorders with the same reliability and validity achieved by diagnostic instruments widely used for other disorders. Dr. Ross discussed several reasons for what skeptics believe to be an epidemic ofmultiple personality disorder caused by clinicians’ faulty diagnoses. The prevalence of MPD probably has not increased, he said; instead, “We have just learned to ask the right questions.” With MPD and other dissociative disorders, the questions to ask relate to childhood trauma, especially childhood sexual and physical abuse. Even with new knowledge about the severe and long-lasting effects of childhood trauma, clinicians often fail to question patients about past abuse. In a recent study, Dr. Ross found that medical residents at the hospital where he teaches failed to ask patients about childhood abuse
about 90 percent ofthe time, despite the fact that in grand rounds and seminars Dr. Ross attempts to get residents to “think in a trauma mindset.” Dr. Ross believes that a major reason for psychiatry’s reluctance to accept the existence ofMPD may be that “no one likes to admit that there’s a big hole in one’s training. It generates a defensive posture.” Based on his own experiences as a resident six years ago, he believes that psychiatrists receive little training in the long-term effects of childhood trauma and in diagnosing dissociative disorders. Another reason for resistance to MPD is that childhood trauma is a very difficult issue to deal with. To know that many children are violently abused by adults “disturbs your sense ofthe world,” Dr. Ross said. Dr. Ross believes that MPD should not be-and is not-a primary diagnosis but exists within a hierarchy of other diagnoses under a primary diagnosis of chronic trauma disorder. MPD is a paradigm that will lead to a new way of thinking about psychopathology-an approach that is trauma related, he said. Within any population with a psychiatric disorder is a subgroup ofpeopie with a history of severe trauma. The given disorder will have a different phenomenology in these patients and a different pattern of family transmission. These patients will have a distinct pathophysiology and will respond differently to pharmacotherapy and psychotherapy. Dr. Ross hopes that future research will uncover such patient subgroups and lead to new and better treatment.
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.
.
.
Liability
issues
in managed
care Corporate purchasers of employee medical coverage currently view costs of mental health care and substance abuse treatment as wildly out of control. These costs have risen from 5 percent of their total health care expenditures in the early 1980s to a recently reported 15 percent. These and other statistics were reviewed by Lawrence L. Kerns, M.D., of Barrington, Illinois, during a panel on liability issues in managed care. He pointed out that in 1984
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only 10 percent ofinsured Americans were covered by managed care plans. By 1995 that figure is expected to be more than 90 percent. The other panelist, Carol J. Gerncr, J.D., an attorney from Chicago who specializes in managed care issues, agreed that very few psychiatrists now practice free of restrictions imposed on them by various forms of managed care. Liability issues arise when these restrictions threaten to interfere with a physician’s exercise of medical judgment or compliance with standards of care. She offered advice to psychiatrists on avoiding such liability. Even when dealing with large managed care companies, the mental health care provider has certain rights-the first of which is to read the contract, she emphasized. Some providers sign contracts without reading them, believing that companics are free to dictate terms. An attorney or insurance agent can help the provider understand the features that the contract would impose on the therapeutic relationship. “If you don’t try to work out language that you can live with and the company can live with, then you are not doing yourself or your patients a good 5crvice,” said Ms. Gerner. Ms. Gerner warned providers to carefully check the language of “hold harmless” clauses, which relieve the company ofliability and which, if not narrowly written, may involve the provider in covering the company’s liability. The more treatment restrictions that the company places on the provider, the more the provider should attempt to push some of the liability back to the company. All providers should review their professional insurance policies to make sure that they are covered for any contractual obligations that they assume. Once contractual terms are set, independent practitioners should vigorously challenge or appeal any utilization review decision that conflicts with medical judgment. The reviewer directly involved in the decision should be contacted, and all contacts should be documented. Providers who are more formally associated with managed care com-
19
pai described recent progress in developing a system of communitybased services in Taiwan. Within the last ten years in that country, it was common for chronic patients to be confined in makeshift restraints in their family home or given over to the care of Buddhist monks. Reports of unsatisfactory conditions in these settings spurred the government of Taiwan to commit resources to public mental health services. Taiwan’s economic progress in the last decade made possible an almost 6,000-fold increase in the country’s annual mental health budget, from $5,852 (U.S. dollars) in 1980 to more
than $34 million in 1992, the highest increase in any part of the Taiwan government. Between 1985 and 1990, total psychiatric manpower increased by 56 percent. The number of psychiatrists increased 107 percent, from 202 to 418, compared with an increase of only 22 percent in the number of physicians in general. The number of psychiatric beds increased from 11,066 in 1985 to 12,855 in 1990. This increase cxpanded the availability ofservices for chronic patients, as 90 percent of inpatient beds are used for custodial care. The number of day hospitals increased from 1 1 serving 179 patients, in 1985 to 22, serving 559 patients, in 1990. Eight community rehabilitation facilities and eight halfway houses were established. Although considerable progress has been made, more communitybased facilities are needed, and problems created by the stigma of mental illness, including families’ reluctance to have their mentally ill relatives treated in the community, must still be faced. Yanping Zheng, M.D., of Hunan, People’s Republic of China, described the rehabilitation program for chronic mentally ill patients in mainland China. Since 1976 there has been rapid development and reform. The typical model of rehabilitation combines activities of governmental agencies and academic departments at three levels: the hospital, community, and family. The program is well developed in Shanghai and Beijing and in some rural areas, but further expansion in other areas ofthe country is needed. Rehabilitation components indude group psychotherapy, music therapy, drug therapy, behavioral therapy, and social and behavioral skill training. Dr. Zheng pointed out that more attention has been paid recently to stabilizing the political situation in mainland China and less to the rehabilitation of chronic mentally ill patients. At the economic level, the mental health system is losing trained staff because these positions have poor income. Staff income must improve to encourage retention of trained staff he said.
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January
panics should also carefully read contracts to ensure that their ability to exercise independent judgment is maintained. They should review all practice protocols before deciding to affiliate with any group. Because of group liability, the credentials of all members should be checked exhaustively, and liability insurance should be rewritten to cover negligent acts by other members. Written materials provided to patients by the group should be carefully reviewed for guarantees of outcomes that cannot be fulfilled by the practitioner. Details of financial incentives, such as a year-end bonus for a low average length of stay, should be disclosed to patients to avoid the appearance that these contract features influence clinical judgments. All practitioners should maintain responsible standards ofcare. As Ms. Gerner pointed out, it is highly unlikely that the courts will ever see a case in which a physician says he committed malpractice because a utilization review committee told him to.
Treating chronic mentally ill patients in Asia A half-day session cosponsored by the H&CP Institute and the Pacific Rim College of Psychiatrists examined services for chronic mentally ill patients in Taiwan, the People’s Republic of China, Japan, and refugee camps in Thailand. The seasion was moderated by Francis Lu,
M.D., mittee trists.
chairman
of the APA’s
of Asian-American
Ching-Paio
Chien,
com-
psychia-
M.D.,
of Tai-
,
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He Qin
Yan, M.D.,
of Shanghai,
People’s Republic of China, described a two-year prospective study evaluating three modes of care for chronic mental patients: an occupational therapy group; a mass care network, organized by neighborhood, that provides psychosocial support to patients and their families; and an outpatient clinic. All three modes of intervention stimulated improvements in selfcare, social withdrawal, activities with family, and psychiatric symptoms. Patients in the mass care network improved the most, followed by those in the occupational therapy group and those in the outpatient clinic service. Morihiro Sekiyama, M.D., of Osaka, Japan, reported that private psychiatric hospitals are the main medical and residential service moclality for chronic mentally ill patients in Japan. About 327,000 patients are treated in inpatient facilities in Japan on a given day, and about half of them are chronic patients. National health insurance reimburses private hospitals at a base rate of $60 (U.S. dollars) per inpatient per day. The average length of stay for inpatients is almost 500 days. An estimated 30 to 40 percent of inpatients could be discharged if intermediate care facilities were available in the community, Dr. Sekiyama said. However, the government has not yet developed a clear policy toward chronic patients and provides no incentives for private development of community-based facilities. In addition, the stigma of mental illness means that most families prefer to have their mentally ill members treated in hospitals, away from the view ofthe community. Dr. Sekiyama suggested that community-based mental health services may come to be more readily accepted as an essential part of social services in Japan as more people leave towns to live and work in urban areas. Treatment of chronic mentally ill Vietnamese refugees in the Phanat Nikom camp in Thailand was described by Cherie Elfenbein, M.D., of New York City, a former volunteer with the camp’s mental health pro-
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r
gram, which is sponsored by the American Refugee Committee. The mental health team worked with refugees with severe disorders, such as schizophrenia, major depression, and severe posttraumatic stress disorder. Many patients, particularly those with schizophrenia, had been treated previously in Vietnam, but some patients’ disorders could be traced to the trauma of the refugee experience. Dr. Elfenbein and her staff of two nurses trained about 40 refugees to be mental health workers. Many patients she treated had been in the camp for more than five years. Most countries in which refugees are resettled will not take a refugee with mental illness; the United States requires that refugees with mental illness be symptom-free for a year before they can enter the U.S. Dr. Elfenbein remarked that this requirement created a great incentive for patients to comply with treatment. James Lavelle, L.I.C.S.W., of the Indochinese Psychiatry Clinic in Brighton, Massachusetts, reported on an epidemiological study of emerging mental health problems in Site Two, a camp for Cambodian refugees on the Thai-Kampuchean border. More than 350,000 displaced people live on the border, Mr. Lavelle said. Factors promoting mental illness in camps include ongoing threats to refugees’ physical safety posed by chaotic, violent camp conditions. Conducted in 1990, the epidemiological assessment of more than 1 ,000 Khmer adults, adolescents, and children used culturally valid bilingual instruments to measure health and occupational status and psychiatric symptoms. Fifty-three percent of respondents could be considered depressed based on DSM-lllR criteria, Mr. Lavalle said. Fortyseven percent reported having one or two nightmares a week. “The policy and scientific implications of the survey will be farreaching because of the study’s meticulous scientific design, rigorous sampling methods, culturally validated instruments, and large sample size,” Mr. Lavelle said. A training and certification program
for 50 Cambodian mental health workers based partly on the survey results was planned for late 1991.
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Services in rural areas On his visits to remote areas of Alaska Donald W. Hammersley, M.D., of Bethesda, Maryland, has seen many Alaska Native and American Indian villages in which alcoholism is a serious problem. Most health and mental health care in these villages is provided by indigenous health aides trained through the Indian Health Service, but stable, ongoing relationships with outside health care providers are rare, Dr. Hammersley reported. Turnover of mental health professionals is high due to the high cost of living, inability to adapt to a hostile climate, and problems of adjusting to indirect treatment of patients through the health aide. Multiplesource funding, including competing systems of funding for alcohol and mental health services and general health services, complicates effective planning and treatment. Dr. Hammersley suggested that effective treatment of mental illness is not possible unless the program encompasses treatment of substance abuse. Alcohol is a pervasive factor in high rates of accidental death, suicide, and fetal alcohol syndrome in remote villages. Effects of the last problem may extend over generations as parents who themselves may have some disability resulting from fetal alcohol syndrome attempt to care for children who have similar disabilities. Dr. Hammersley described an isolated community of 100 Aleuts who began a movement to abstain from alcohol. The community developed a strong mutual support system based on Native American philosophy. The movement resulted in a 90 percent rate of abstinence in a few months. But Dr. Hammersley cautioned that achieving sobriety may open up a range of other problems. Patterns of physical and sexual abuse, malnutrition, and neglect constitute “an overwhelming multigenerational burden to be resolved, of which abstaining from alcohol is but the beginning, not the end,” he said. He emphasized the need for a combined alcohol and
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mental health treatment approach to these problems. In a separate session on cultural issues in rural psychiatry, Home B. Crandall, M.D., ofColorado Springs urged mental health care providers to question stereotypes that rural penplc have conservative attitudes, are resistant to change, and live at a slower pace-”that even their crises occur at a slower pace.” These conceptions are far from the truth, she said. Dr. Crandall said that decisions affecting mental health services in rural areas are often made in cities and that rural input is scarce. She encouraged mental health professionals in rural areas to speak up at any opportunity-at APA district branches or in contacts with public mental health departments-because there is very little awareness of rural issues in urban areas. Family and religious patterns that affect mental health treatment in Appalachia were discussed by Verona Lawson, M.D., staff psychiatrist at Kentucky River Community Care in Hazard, Kentucky. Her agency provides comprehensive mental health and mental retardation services to an eight-county region with a population of about 141,000 in eastern Kentucky. The majority of the population is marginally employed and lives through subsistence hunting and farming and entitlements. The settlement pattern of isolated family groups established when the area was settled in the 18th and 19th centuries persists today. A family includes several households, and family ties are strong. The family provides support and security, but also fosters economic and psychological dependency, Dr. Lawson said. Chronic mentally ill patients, in particular, may have difficulty dealing with the overcrowding, a high degree of family enmeshment, and a high level of expressed emotion in these families. The fundamentalist Christian religions that predominate in the region provide some Appalachian penpie with a way to understand the suffering entailed in their social and economic circumstances-their faith calls them to suffer as Christ did. Many people turn first to their mm-
21
ister before seeking medical help for mental health problems. Dr. Lawson meets regularly with local ministers to help educate them about mental health issues. People who come for treatment often complain of “nerves,” a term that covers primarily anxiety but also depression, and psychotic states. Dr. Lawson suggested that use of the term “nerves” places a person’s problem in the physical body and provides a way to medicalize a mental problem and avoid the stigma attached to the term “mental.” People prefer medication rather than psychotherapy; they expect to receive a “nerve pill,” most often a minor tranquilizer. The psychiatrist is more readily accepted as the “nerve doctor,” Dr. Lawson said. Dr. Lawson suggested that lack of work may be the source of patients’ complaints about boredom, aches and pains, and negative preoccupations. She has noticed a pattern she terms the “disability syndrome,” in which people assume the sick role because of a slight injury or because of their nerves, believing they can never work again. Deborah A. Reed, M.D., staff psychiatrist at Comprehensive Care Centers of Northern Kentucky in Williamstown, Kentucky, spends one day a week at clinics in four rural counties with a combined population of 40,000. The field of psychiatry is still perceived with much fear and skepticism where she practices, Dr. Reed said. As a professional woman, she had difficulty initially defining her role in a culture where adult relations between men and women are influenced by a traditional patriarchal model. Dr. Reed reported that fatalistic attitudes and lack of information about mental health cause many patients to suffer for years without adequate treatment for their disabling psychiatric illnesses. As the only psychiatrist at the centers, her initial role was to provide diagnostic, aftercare, and medication services to chronic mentally ill patients. However, she has also had the opportunity to do psychotherapy, mostly with women. When she began working with women patients, she became aware
that the passivity that characterized their home life was also being played out in therapy. Only after months or years were they able to reveal their histories of emotional, physical, and sexual abuse. A third of the women she sees in her practice report that they have been physically or sexually abused. Halfofthe women she treats for anxiety or affective disorders report a history of severe physical or sexual abuse. Dr. Reed suggested that in working with patients who have been abused, the quietly receptive stance common in therapy is not appropriate. As soon as abuse is revealed, the therapist should express outrage and convey to the patient that such treatment is not acceptable for anyone. Dr. Reed tries to teach women to be able to talk to one another about abuse and to use the local women’s crisis center.
22
January
Gang violence An average of 5 17 people were killed or injured each month in Los Angeles as a result ofgang violence in 1990, reported Sandra Creary-Jennings, M.S.W., of Los Angeles in a session on the effects of gang violence on people who are exposed to it in the communities where they live and work. Nearly 1 ,000 gangs with a total of about 100,000 members are active in Los Angeles, but the problem is not confined to that city, Ms. Creary-Jennings said. Adolescents from fragmented and chaotic family backgrounds join gangs to gain a substitute family and a sense of belonging, she said. For many adolescents, gang membership may be a way of survival; they need the protection of gang affiliation to get from their home to school. Gang members have an average life expectancy of 19 years, she said. “Not only are gang members killing each other, killing innocent bystanders, and practically wiping out a whole generation; gang violence may create longstanding psychological problems within the community among families, teachers, police officers, health care providers, and others,” she said. Eugene L. Jennings, M.D., of Los Angeles reported on a study in which 73 people who were not members of
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No. 1
gangs were surveyed about their subjective sense of injury as a result of living where gang violence is common as well as about whether they met criteria for psychiatric disorders. Eighty-three percent of those interviewed had been directly exposed to varying degrees of gang assaults, including verbal confrontations, having property destroyed, being beaten, or witnessing significant others being attacked or shot. Twenty-five percent of the sample met criteria for posttraumatic stress disorder. Many had experienced symptoms of impaired functioning in vocational and educational areas and in emotion, cognition, and social activities. Dr. Jennings cautioned that the instruments used in the survey were
not standardized
for the population
studied, so the statistical results may be questionable. “What is not questionable,” he said, “is that this population, and perhaps the many they represent, is being exposed daily to conditions very much like war. They are suffering in ways that significantly interfere with the quality and wellbeing oftheir intrapsychic and external life styles. The psychic scars will remain, always haunting and interfering, unless conditions change, assistance is rendered, and proper interventions are instituted.” Ivan C. A. Walks, M.D., of Los Angeles said that although the unique needs of community members who are exposed to gang violence are not known, a model of treatment used for people suffering from posttraumatic stress disorder in war zones may be effective. People living in areas where gangs are active need to expect that they can be helped, but unfortunately, because of lack of community psychiatry resources, many do not have this expectation, he said. Programs that facilitate access to mental health care providers are needed. Dr. Walks also encouraged providers to make themselves available as consultants to community-based groups, including the police department and juvenile justice system, that are trying to reduce gang activity. JOANNE CONSTANCE
Hospital
and Community
WAGNER GARTNER
Psychiatry
Report
Highlights of the 43rd Institute on Hospital and Community Psychiatry The 43rd Institute on Hospital and Community Psychiatry, held October 20-24, 1991, in Los Angeles, drew nearly 1 ,600 participants to a program that addressed a wide variety of issues reflecting the institute’s 1991 theme, “Overcoming Challenges With Diversity.” Topics included sexual harassment in the workplace, treating people infected with the human immunodeficiency virus, the effects ofgang violence in cities, and the challenges of providing psychiatric care in remote rural areas. Seventeen professional organizations held meetings in conjunction with the institute. In a speech at the opening session, Lawrence Hartmann, M.D. president ofthe American Psychiatric Association, affirmed the need for biopsychosocial integration of the increasing knowledge in the disparate fields that explore the mind and the brain. He suggested that due to advances in neurobiology in the last 20 years, psychiatry has turned away from the biopsychosocial model of illness and health, which had served the field well, toward a more purely physiological, biomedical model. Although the biomedical model has been extraordinarily fruitful, its success has led to neglect of scientific consideration of the more personal, psychological, and social aspects of health and disease, Dr. Hartmann said. However, humane values require mental health professionals “to be aware of, care for, and treat whole people in context and over time,” he said. Major splits have developed in American psychiatry over the past 25 years in response to enthusiasms about brain biology or social and environmental factors, Dr. Hartmann
aging biopsychosocial integration and humane values in the mental health field. At the closing session, APA president-elect Joseph T. English, M.D., announced the theme of his upcoming presidential year-”Caring for Patients in Need: Challenges for the 21st Century.” He urged psychiatrists to maintain their identity as professionals to effectively deal with the radical economic changes that are
16
January
,
said, and he pointed out that “new external pressures to widen splits are currently with us.” Several courts and state legislatures have attempted to ensure that a mental illness should be covered by insurance only ifit has a demonstrable organic component, he noted, and emphasized the importance of working with insurance companies to see that all mental illness is covered on a par with medical illness. Dr. Hartmann said argument about the relative importance of biological, psychological, and social ftctors in mental health and illness will probably remain central to psychiatry, but he cautioned that in this debate “we are at great risk of premature closure and of theoretical and clinical segregation rather than integration.” Dr. Hartmann added that child and adolescent psychiatric pathology and health have not received the attention they deserve, perhaps because they are dependent on family and environment-’ ‘that is, on the ‘social’ in biopsychosocial, which is so often left out of 1991 psychiatric discourse. “ He urged listeners, whatever their training or role, to apply their talents and energies to helping children and adolescents grow mentally healthier, as well as to encour-
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currently taking place in the United States. Dr. English suggested that mental health professionals should challenge the popular idea that the portion of the U.S. gross national product spent on health care is too great. “We should consider it an open question as to what percentage of our economy is to be spent on health care,” he said. “We should be suggesting that growth in employment in health care could be very healthy, at least in some parts of the country. This is not to say that we shouldn’t become more efficient and shouldn’t be concerned about overutilization or waste.” Dr. English pointed out that the development of the resource-based relative value scale (RBRVS) and proposals to pay other mental health professionals a fixed proportion of what psychiatrists are paid have created alliances that did not previously exist among various mental health disciplines. The development of the RBRVS is one of the most important factors affecting the future ofpatient care, he said. “Ifwe are not going to be paid commensurate with the importance of what we do, we will not have young talent coming into the mental health professions.” Dr. English said that as society begins to face the need for limits and choices, mental health professionals must be true to their role as professionals as they participate in this debate. He noted that the essence of a profession is to place the interests of the patient and the public first. Dr. English also stressed the importance ofmental health professionals’ maintaining a commitment to confidentiality and traditional ethics in dealing with patients. He said that ifthe mentalhealth professions begin to dilute or diminish their ethical canons, they will jeopardize the societal contract that is the basis of resolving the economic challenges they currently face. “Part ofour ability to continue to care for patients in need is the extent to which the public recognizes that we aren’t like a business in which the interests of the stockholders come first. The extent to which we keep true to our traditions will enable us
Hospital
and Community
Psychiatry
and motivation and loss of self-esteem may lead to poor work performance. During the third stage, depression and anger arise, and the victim frequently experiences a crisis or breaking point. Victims often seek mental health care at this point. Although most women will go to great lengths
to avoid reporting the behavior to the harasser’s supervisor, a decision is often made to do so during this stage. Other options include filing a complaint with the Equal Employment Opportunity Commission or initiating a lawsuit. Because the available options often don’t work, the fourth stage is characterized by disillusionment. The victim’s co-workers often withdraw from associating with the “troublemaker. Grieving over losses-tangible and intangible-is important. In some cases, the lawsuit or complaint has occupied such a big part ofthe victim’s life that grieving over its loss, no matter what the outcome, may be an issue. The victim needs to reorient to the future and make life decisions or changes that may have been put on hold. Dr. Jensvoid added a fifth stage that is characterized by feelings of empowerment resulting from actions taken. Dr. Jensvold pointed out that psychiatry can be misused as a coercive tool ofthe harasser, who can order the victim to have a psychiatric assessment or to obtain therapy. She warned therapists who do such assessments to be very clear with patients about the boundaries of confidentiality. On the other hand, a therapist can be one of the victim’s greatest supports, especially during the complaint or lawsuit process, which is often lengthy. Dr. Jensvold advises against taking an analytic approach with these patients. The therapist may need to help the patient take an active role in dealing with the harassment. Most important, the therapist must avoid adding to the trauma by not believing the patient. The thetapist should assume that the patient is telling the truth unless it is proven otherwise. Dr. Jensvoid’s advice to harassment victims may help therapists who encounter these patients. A person who feels harassed should, preferably in writing, describe the specific behavior to the harasser and ask that it stop. Keeping a personal written record of the incidents is also important. Although most people are reluctant to talk about the incidents, Dr. Jensvold advises victims
Hospital
January
to care for patients in need not only now but as we enter the 2 1 st century,” he said. Highlights from some of the institute sessions are presented below. Workplace sexual harassment The role of psychiatrists in treating patients who have been-or are being-sexually harassed in the workplace was a topic addressed by Margaret Jensvold, M.D., in a wellattended session. Dr. Jensvold is director ofthe Institute for Research on Women’s Health in Washington,
D.C.
‘
‘
Many specialists in sexual harassment believe it is a major problem that has not been well articulated and that there is a great deal of misunderstanding about. “We are now where we were with rape 1 5 years ago, incest ten years ago, and domestic violence ten years ago,” Dr. Jensvold said. She described some myths about sexual harassment. One myth is that if a woman ignores the harassment, it will stop. One study found that in three-quarters of the cases, when harassment was ignored, it got worse. A second myth is that most charges are false. Those who work in this field point out that a woman has very little to gain and much to lose by making false charges. Citing work byjan Salisbury, Dr. Jensvold outlined four stages in the victim’s response to sexual harassment. In the first stage, the victim blames herself and experiences disbeliefand confusion, often miimizing or denying what is happening. After each incident, she believes that it won’t happen again. Often her performance at work suffers. In the second stage, the victim fears retaliation for not complying. Anxieties about career and finances arise. The victim may become phobic about work. Most women at this point experience at least one physical symptom. Decreased concentration
and Community
Psychiatry
to talk to others in detail about the harasser’s behavior. In the aftermath of the Clarence Thomas-Anita Hill hearings and in the coming years, Dr. Jensvold predicted, patients will be seeking treatment for a variety of psychiatric disorders associated with sexual harassment. She pointed out that there is a small but excellent literature on the topic and advised thetapists to learn more.
“
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Treating people with AIDS and HIV infections At the morning and early afternoon panels ofan all-day session on AIDS, medical, neuropsychiatric, and pharmacological overviews of treating HP/-infected patients were presented. Near the end of the afternoon, a panel ofthree psychiatrists discussed the impact that treating people with AIDS has on mental health caregivers. A nurse in the audience, moved by the panelists’ stories, cxpressed the wish that the all-day session had begun with this panel rather than with the usual medical reviews and overviews. Responding to the nurse’s comment, Lee Jones, M.D., of Santa Monica, California, a panel member who has been treating HIV-infected people since 1984, said, “It is easier to deal with talking about the virus, because I’m afraid I’m going to burst into tears if I don’t deal just with that.” In the brief silence that followed, many in the room seemed to struggle with emotions raised by this statement. The panelists spoke of issues in their work they felt untrained to deal with and situations they felt emotionally unprepared to handle. Danid Fast, M.D., a panelist from Santa Monica, observed that, in general, psychiatrists do not expect to work with terminally ill people. Dr. Jones commented that many physicians choose psychiatry because they want to “stay away from death and dying and blood.” The stigmatization of AIDS extends to therapists. For these and other reasons, many therapists do not treat people with AIDS, and those who do sometimes feel that if they don’t provide care to these patients, no one else will. “Inevitably we deal with burnout when we’re
17
talking
about treating people with observed Dr. Fast. The third panelist, Lynn Baker,
HIV,” M.D.,
of Los Angeles,
who
works
with women with AIDS and their families, spoke ofgrandmothers who provide care to whole families who die: first the son or son-in-law, then the infected children, and then the daughter or daughter-in-law. Nothing prepares families or therapists for dealing with these terrible losses, she said.
A therapist
whoworks
with some-
one with AIDS is often the only supportive person in the patient’s life, Dr. Fast pointed out. He spoke also ofthe tremendous “burden of knowledge” on the therapist, who must know the medical and neuropsychiatric details of the disease as well as provide information about resources and interact with various agencies on the patient’s behalf. A therapist can feel overwhelmed by expectations to provide this level of emotional and instrumental support. Many doctrines ofpractice learned in training fall by the wayside when someone is dying, said Dr. Jones. Patients who are too sick to come to the office need more care, not less, he said, and home visits are important. Dr. Baker stressed the need for the therapist to know all the players in the family support network-the multigenerational family members and the multiple medical specialists caring for the family-in order to keep abreast of the family situation and provide continuity of care. She spends a great deal of time on the telephone, she said. This level ofinvolvement with patients is often important for therapists. Dr. Jones observed that frequently there is no sense of closure with patients who become ill and drop out of therapy, and closure enables the therapist to continue treating patients with AIDS. He said that one of the most important things he does is to attend memorial services and funerals-something psychiatrists are trained not to do. The services allow him to celebrate the person’s life and meet others who cared about the person. Therapists often feel things that are “too shameful to talk about,” said
18
Dr. Fast, such as resentment toward the patients (“Why did they do this to themselves? Why did they do this to me?”) and superiority (“I didn’t get infected; they shouldn’t have either”). Dr. Baker said that because some of the women she works with feel that having children is a cultural imperative, they have several chilthen after being diagnosed. A therapist’s reactions to these patients can get in the way ofgiving sound, compassionate advice, she said. Dr. Fast spoke of going back and forth between feeling deeply empathic and “not wanting to be there.”
On
the
positive
side,
said
“teach” patients with severe or mild dissociative symptoms to be multipies in aprocess Dr. Weissberg called iatrogenic amplification. These therapists often rely heavily on hypnosis, which produces pseudomemories that the patient experiences as very real. In the fourth pathway, maimgering patients, usually in forensic settings, pick up cues during therapy for faking MPD. The second panelist, Cohn Ross,
M.D.,
Dr.
Jones, the epidemic has taught peopie to take care of themselves and each other and to think about the quality oflife. Caregivers often neglect themselves, he said. He told of visiting a very sick patient of his in the hospital. The patient, who was gasping for air and barely able to sit up in bed, said with concern that Dr. Jones was looking very tired. Slowly the patient opened his bedside drawer and found a dollar. “Go get a H#{228}agenDazs bar, doctor,” he said. “You need to take better care of yourself.” To cope with the many strong emotions raised in this work, Dr. Baker emphasized the importance of having “safe people” to talk with, people who understand the difficulties of working with HJV-infected patients. “And it has to be more than one person,” she said. “It has to be spread around-it’s just too much for one person to handle all the time.” For those attending the all-day seasion on AIDS, the room was full of safe people, and many took the opportunity to give and get support. Multiple personality disorder In a half-day session entitled “Multiplc Personality Disorder: Does It Exist? A Debate,” the two debaters found that they agreed on many points, including the existence of multiple personality disorder (MPD) as a serious psychiatric disorder. Michael Weissberg, M.D., of Denver outlined four pathways to the disorder, the first being “spontaneous or true MPD.” In two other pathways, wellmeaning therapists unwittingly
January
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1
of Winnepeg,
Manitoba,
a
well-known MPD researcher, agreed that patients fall into these ftur categories and that a great deal of MPD therapy is “out ofcontrol.” However, he argued that iatrogenic amplffication occurs far less frequently than in Dr. Weissberg’s view and that multiple personality disorder is relatively common. Both panelists expressed concern over what they called the sociology of MPD, which has polarized the mental health field. The uncritical acceptance ofthe existence ofsatanic ritual abuse is a litmus test in some circles ofMPD enthusiasts, said Dr. Weissberg. Descriptions by some patients ofmemories ofearly childhood sexual abuse involving torture and infant and animal sacrffice have led to a widespread beliefin a cult that practices religious worship of Satan. Dr. Weissberg pointed out that there is no independent evidence ofthe existence ofsuch a cult.
A subsector
ofthe
MPD
field that
attempts to counter what it believes are the forces of satanic ritual abuse is itselfin danger ofdeveloping some ofthe features ofa cult, said Dr. Ross. Under the care of certain therapists, patients often regress profoundly and are then hospitalized for long periods, a phenomenon he compared to the cult technique of deceptive recruitment. Many MPD patients are completely cut offfrom their families and friends by therapists who regard themselves as protectors. Dr. Ross called these developments a major problem that needs to be strictly dealt with if the dissociative disorders field is not to be discredited. Dr. Weissberg described some red flags that should alert therapists to cases in which iatrogenic amplification has played a role in the diagnosis
Hospital
and Community
Psychiatry
4
of MPD. In addition to the therapist’s uncritical acceptance ofthe cxistence of satanic ritual abuse, obvious secondary gain for the patient, especially a “high audience awe factor” or greatly increased attention to the patient from family and friends, should raise a flag. The use of hypnosis in the “discovery” ofapatient’s MPD, especially when the therapist is inexperienced and there are no tapes or transcripts ofthe key sessions, should cause concern, said Dr. Weissberg. Therapists who view the disorder as akin to possession and who concretize the personality metaphor that is at the heart of MPD should be viewed with caution, as should those who believe that the patient has no control over any of the personality switches. Dr. Ross strongly endorsed Dr. Weissberg’s list of red flags. However, he pointed out that arguments against the existence of MPD by skeptics more extreme than Dr. Weissberg are often based on ideology, which prevents rational discussion. Skeptics, said Dr. Ross, often fail to cite recent research, which in the last few years has used advanced statistical methods in large, multicenter studies. He briefly described three instruments that have been shown to diagnose various dissociative disorders with the same reliability and validity achieved by diagnostic instruments widely used for other disorders. Dr. Ross discussed several reasons for what skeptics believe to be an epidemic ofmultiple personality disorder caused by clinicians’ faulty diagnoses. The prevalence of MPD probably has not increased, he said; instead, “We have just learned to ask the right questions.” With MPD and other dissociative disorders, the questions to ask relate to childhood trauma, especially childhood sexual and physical abuse. Even with new knowledge about the severe and long-lasting effects of childhood trauma, clinicians often fail to question patients about past abuse. In a recent study, Dr. Ross found that medical residents at the hospital where he teaches failed to ask patients about childhood abuse
about 90 percent ofthe time, despite the fact that in grand rounds and seminars Dr. Ross attempts to get residents to “think in a trauma mindset.” Dr. Ross believes that a major reason for psychiatry’s reluctance to accept the existence ofMPD may be that “no one likes to admit that there’s a big hole in one’s training. It generates a defensive posture.” Based on his own experiences as a resident six years ago, he believes that psychiatrists receive little training in the long-term effects of childhood trauma and in diagnosing dissociative disorders. Another reason for resistance to MPD is that childhood trauma is a very difficult issue to deal with. To know that many children are violently abused by adults “disturbs your sense ofthe world,” Dr. Ross said. Dr. Ross believes that MPD should not be-and is not-a primary diagnosis but exists within a hierarchy of other diagnoses under a primary diagnosis of chronic trauma disorder. MPD is a paradigm that will lead to a new way of thinking about psychopathology-an approach that is trauma related, he said. Within any population with a psychiatric disorder is a subgroup ofpeopie with a history of severe trauma. The given disorder will have a different phenomenology in these patients and a different pattern of family transmission. These patients will have a distinct pathophysiology and will respond differently to pharmacotherapy and psychotherapy. Dr. Ross hopes that future research will uncover such patient subgroups and lead to new and better treatment.
Hospital
January
and Community
Psychiatry
.
.
.
Liability
issues
in managed
care Corporate purchasers of employee medical coverage currently view costs of mental health care and substance abuse treatment as wildly out of control. These costs have risen from 5 percent of their total health care expenditures in the early 1980s to a recently reported 15 percent. These and other statistics were reviewed by Lawrence L. Kerns, M.D., of Barrington, Illinois, during a panel on liability issues in managed care. He pointed out that in 1984
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only 10 percent ofinsured Americans were covered by managed care plans. By 1995 that figure is expected to be more than 90 percent. The other panelist, Carol J. Gerncr, J.D., an attorney from Chicago who specializes in managed care issues, agreed that very few psychiatrists now practice free of restrictions imposed on them by various forms of managed care. Liability issues arise when these restrictions threaten to interfere with a physician’s exercise of medical judgment or compliance with standards of care. She offered advice to psychiatrists on avoiding such liability. Even when dealing with large managed care companies, the mental health care provider has certain rights-the first of which is to read the contract, she emphasized. Some providers sign contracts without reading them, believing that companics are free to dictate terms. An attorney or insurance agent can help the provider understand the features that the contract would impose on the therapeutic relationship. “If you don’t try to work out language that you can live with and the company can live with, then you are not doing yourself or your patients a good 5crvice,” said Ms. Gerner. Ms. Gerner warned providers to carefully check the language of “hold harmless” clauses, which relieve the company ofliability and which, if not narrowly written, may involve the provider in covering the company’s liability. The more treatment restrictions that the company places on the provider, the more the provider should attempt to push some of the liability back to the company. All providers should review their professional insurance policies to make sure that they are covered for any contractual obligations that they assume. Once contractual terms are set, independent practitioners should vigorously challenge or appeal any utilization review decision that conflicts with medical judgment. The reviewer directly involved in the decision should be contacted, and all contacts should be documented. Providers who are more formally associated with managed care com-
19
pai described recent progress in developing a system of communitybased services in Taiwan. Within the last ten years in that country, it was common for chronic patients to be confined in makeshift restraints in their family home or given over to the care of Buddhist monks. Reports of unsatisfactory conditions in these settings spurred the government of Taiwan to commit resources to public mental health services. Taiwan’s economic progress in the last decade made possible an almost 6,000-fold increase in the country’s annual mental health budget, from $5,852 (U.S. dollars) in 1980 to more
than $34 million in 1992, the highest increase in any part of the Taiwan government. Between 1985 and 1990, total psychiatric manpower increased by 56 percent. The number of psychiatrists increased 107 percent, from 202 to 418, compared with an increase of only 22 percent in the number of physicians in general. The number of psychiatric beds increased from 11,066 in 1985 to 12,855 in 1990. This increase cxpanded the availability ofservices for chronic patients, as 90 percent of inpatient beds are used for custodial care. The number of day hospitals increased from 1 1 serving 179 patients, in 1985 to 22, serving 559 patients, in 1990. Eight community rehabilitation facilities and eight halfway houses were established. Although considerable progress has been made, more communitybased facilities are needed, and problems created by the stigma of mental illness, including families’ reluctance to have their mentally ill relatives treated in the community, must still be faced. Yanping Zheng, M.D., of Hunan, People’s Republic of China, described the rehabilitation program for chronic mentally ill patients in mainland China. Since 1976 there has been rapid development and reform. The typical model of rehabilitation combines activities of governmental agencies and academic departments at three levels: the hospital, community, and family. The program is well developed in Shanghai and Beijing and in some rural areas, but further expansion in other areas ofthe country is needed. Rehabilitation components indude group psychotherapy, music therapy, drug therapy, behavioral therapy, and social and behavioral skill training. Dr. Zheng pointed out that more attention has been paid recently to stabilizing the political situation in mainland China and less to the rehabilitation of chronic mentally ill patients. At the economic level, the mental health system is losing trained staff because these positions have poor income. Staff income must improve to encourage retention of trained staff he said.
20
January
panics should also carefully read contracts to ensure that their ability to exercise independent judgment is maintained. They should review all practice protocols before deciding to affiliate with any group. Because of group liability, the credentials of all members should be checked exhaustively, and liability insurance should be rewritten to cover negligent acts by other members. Written materials provided to patients by the group should be carefully reviewed for guarantees of outcomes that cannot be fulfilled by the practitioner. Details of financial incentives, such as a year-end bonus for a low average length of stay, should be disclosed to patients to avoid the appearance that these contract features influence clinical judgments. All practitioners should maintain responsible standards ofcare. As Ms. Gerner pointed out, it is highly unlikely that the courts will ever see a case in which a physician says he committed malpractice because a utilization review committee told him to.
Treating chronic mentally ill patients in Asia A half-day session cosponsored by the H&CP Institute and the Pacific Rim College of Psychiatrists examined services for chronic mentally ill patients in Taiwan, the People’s Republic of China, Japan, and refugee camps in Thailand. The seasion was moderated by Francis Lu,
M.D., mittee trists.
chairman
of the APA’s
of Asian-American
Ching-Paio
Chien,
com-
psychia-
M.D.,
of Tai-
,
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No.
1
He Qin
Yan, M.D.,
of Shanghai,
People’s Republic of China, described a two-year prospective study evaluating three modes of care for chronic mental patients: an occupational therapy group; a mass care network, organized by neighborhood, that provides psychosocial support to patients and their families; and an outpatient clinic. All three modes of intervention stimulated improvements in selfcare, social withdrawal, activities with family, and psychiatric symptoms. Patients in the mass care network improved the most, followed by those in the occupational therapy group and those in the outpatient clinic service. Morihiro Sekiyama, M.D., of Osaka, Japan, reported that private psychiatric hospitals are the main medical and residential service moclality for chronic mentally ill patients in Japan. About 327,000 patients are treated in inpatient facilities in Japan on a given day, and about half of them are chronic patients. National health insurance reimburses private hospitals at a base rate of $60 (U.S. dollars) per inpatient per day. The average length of stay for inpatients is almost 500 days. An estimated 30 to 40 percent of inpatients could be discharged if intermediate care facilities were available in the community, Dr. Sekiyama said. However, the government has not yet developed a clear policy toward chronic patients and provides no incentives for private development of community-based facilities. In addition, the stigma of mental illness means that most families prefer to have their mentally ill members treated in hospitals, away from the view ofthe community. Dr. Sekiyama suggested that community-based mental health services may come to be more readily accepted as an essential part of social services in Japan as more people leave towns to live and work in urban areas. Treatment of chronic mentally ill Vietnamese refugees in the Phanat Nikom camp in Thailand was described by Cherie Elfenbein, M.D., of New York City, a former volunteer with the camp’s mental health pro-
Hospital
and
Community
Psychiatry
r
gram, which is sponsored by the American Refugee Committee. The mental health team worked with refugees with severe disorders, such as schizophrenia, major depression, and severe posttraumatic stress disorder. Many patients, particularly those with schizophrenia, had been treated previously in Vietnam, but some patients’ disorders could be traced to the trauma of the refugee experience. Dr. Elfenbein and her staff of two nurses trained about 40 refugees to be mental health workers. Many patients she treated had been in the camp for more than five years. Most countries in which refugees are resettled will not take a refugee with mental illness; the United States requires that refugees with mental illness be symptom-free for a year before they can enter the U.S. Dr. Elfenbein remarked that this requirement created a great incentive for patients to comply with treatment. James Lavelle, L.I.C.S.W., of the Indochinese Psychiatry Clinic in Brighton, Massachusetts, reported on an epidemiological study of emerging mental health problems in Site Two, a camp for Cambodian refugees on the Thai-Kampuchean border. More than 350,000 displaced people live on the border, Mr. Lavelle said. Factors promoting mental illness in camps include ongoing threats to refugees’ physical safety posed by chaotic, violent camp conditions. Conducted in 1990, the epidemiological assessment of more than 1 ,000 Khmer adults, adolescents, and children used culturally valid bilingual instruments to measure health and occupational status and psychiatric symptoms. Fifty-three percent of respondents could be considered depressed based on DSM-lllR criteria, Mr. Lavalle said. Fortyseven percent reported having one or two nightmares a week. “The policy and scientific implications of the survey will be farreaching because of the study’s meticulous scientific design, rigorous sampling methods, culturally validated instruments, and large sample size,” Mr. Lavelle said. A training and certification program
for 50 Cambodian mental health workers based partly on the survey results was planned for late 1991.
Hospital
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and Community
Psychiatry
Services in rural areas On his visits to remote areas of Alaska Donald W. Hammersley, M.D., of Bethesda, Maryland, has seen many Alaska Native and American Indian villages in which alcoholism is a serious problem. Most health and mental health care in these villages is provided by indigenous health aides trained through the Indian Health Service, but stable, ongoing relationships with outside health care providers are rare, Dr. Hammersley reported. Turnover of mental health professionals is high due to the high cost of living, inability to adapt to a hostile climate, and problems of adjusting to indirect treatment of patients through the health aide. Multiplesource funding, including competing systems of funding for alcohol and mental health services and general health services, complicates effective planning and treatment. Dr. Hammersley suggested that effective treatment of mental illness is not possible unless the program encompasses treatment of substance abuse. Alcohol is a pervasive factor in high rates of accidental death, suicide, and fetal alcohol syndrome in remote villages. Effects of the last problem may extend over generations as parents who themselves may have some disability resulting from fetal alcohol syndrome attempt to care for children who have similar disabilities. Dr. Hammersley described an isolated community of 100 Aleuts who began a movement to abstain from alcohol. The community developed a strong mutual support system based on Native American philosophy. The movement resulted in a 90 percent rate of abstinence in a few months. But Dr. Hammersley cautioned that achieving sobriety may open up a range of other problems. Patterns of physical and sexual abuse, malnutrition, and neglect constitute “an overwhelming multigenerational burden to be resolved, of which abstaining from alcohol is but the beginning, not the end,” he said. He emphasized the need for a combined alcohol and
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mental health treatment approach to these problems. In a separate session on cultural issues in rural psychiatry, Home B. Crandall, M.D., ofColorado Springs urged mental health care providers to question stereotypes that rural penplc have conservative attitudes, are resistant to change, and live at a slower pace-”that even their crises occur at a slower pace.” These conceptions are far from the truth, she said. Dr. Crandall said that decisions affecting mental health services in rural areas are often made in cities and that rural input is scarce. She encouraged mental health professionals in rural areas to speak up at any opportunity-at APA district branches or in contacts with public mental health departments-because there is very little awareness of rural issues in urban areas. Family and religious patterns that affect mental health treatment in Appalachia were discussed by Verona Lawson, M.D., staff psychiatrist at Kentucky River Community Care in Hazard, Kentucky. Her agency provides comprehensive mental health and mental retardation services to an eight-county region with a population of about 141,000 in eastern Kentucky. The majority of the population is marginally employed and lives through subsistence hunting and farming and entitlements. The settlement pattern of isolated family groups established when the area was settled in the 18th and 19th centuries persists today. A family includes several households, and family ties are strong. The family provides support and security, but also fosters economic and psychological dependency, Dr. Lawson said. Chronic mentally ill patients, in particular, may have difficulty dealing with the overcrowding, a high degree of family enmeshment, and a high level of expressed emotion in these families. The fundamentalist Christian religions that predominate in the region provide some Appalachian penpie with a way to understand the suffering entailed in their social and economic circumstances-their faith calls them to suffer as Christ did. Many people turn first to their mm-
21
ister before seeking medical help for mental health problems. Dr. Lawson meets regularly with local ministers to help educate them about mental health issues. People who come for treatment often complain of “nerves,” a term that covers primarily anxiety but also depression, and psychotic states. Dr. Lawson suggested that use of the term “nerves” places a person’s problem in the physical body and provides a way to medicalize a mental problem and avoid the stigma attached to the term “mental.” People prefer medication rather than psychotherapy; they expect to receive a “nerve pill,” most often a minor tranquilizer. The psychiatrist is more readily accepted as the “nerve doctor,” Dr. Lawson said. Dr. Lawson suggested that lack of work may be the source of patients’ complaints about boredom, aches and pains, and negative preoccupations. She has noticed a pattern she terms the “disability syndrome,” in which people assume the sick role because of a slight injury or because of their nerves, believing they can never work again. Deborah A. Reed, M.D., staff psychiatrist at Comprehensive Care Centers of Northern Kentucky in Williamstown, Kentucky, spends one day a week at clinics in four rural counties with a combined population of 40,000. The field of psychiatry is still perceived with much fear and skepticism where she practices, Dr. Reed said. As a professional woman, she had difficulty initially defining her role in a culture where adult relations between men and women are influenced by a traditional patriarchal model. Dr. Reed reported that fatalistic attitudes and lack of information about mental health cause many patients to suffer for years without adequate treatment for their disabling psychiatric illnesses. As the only psychiatrist at the centers, her initial role was to provide diagnostic, aftercare, and medication services to chronic mentally ill patients. However, she has also had the opportunity to do psychotherapy, mostly with women. When she began working with women patients, she became aware
that the passivity that characterized their home life was also being played out in therapy. Only after months or years were they able to reveal their histories of emotional, physical, and sexual abuse. A third of the women she sees in her practice report that they have been physically or sexually abused. Halfofthe women she treats for anxiety or affective disorders report a history of severe physical or sexual abuse. Dr. Reed suggested that in working with patients who have been abused, the quietly receptive stance common in therapy is not appropriate. As soon as abuse is revealed, the therapist should express outrage and convey to the patient that such treatment is not acceptable for anyone. Dr. Reed tries to teach women to be able to talk to one another about abuse and to use the local women’s crisis center.
22
January
Gang violence An average of 5 17 people were killed or injured each month in Los Angeles as a result ofgang violence in 1990, reported Sandra Creary-Jennings, M.S.W., of Los Angeles in a session on the effects of gang violence on people who are exposed to it in the communities where they live and work. Nearly 1 ,000 gangs with a total of about 100,000 members are active in Los Angeles, but the problem is not confined to that city, Ms. Creary-Jennings said. Adolescents from fragmented and chaotic family backgrounds join gangs to gain a substitute family and a sense of belonging, she said. For many adolescents, gang membership may be a way of survival; they need the protection of gang affiliation to get from their home to school. Gang members have an average life expectancy of 19 years, she said. “Not only are gang members killing each other, killing innocent bystanders, and practically wiping out a whole generation; gang violence may create longstanding psychological problems within the community among families, teachers, police officers, health care providers, and others,” she said. Eugene L. Jennings, M.D., of Los Angeles reported on a study in which 73 people who were not members of
1992
Vol.43
No. 1
gangs were surveyed about their subjective sense of injury as a result of living where gang violence is common as well as about whether they met criteria for psychiatric disorders. Eighty-three percent of those interviewed had been directly exposed to varying degrees of gang assaults, including verbal confrontations, having property destroyed, being beaten, or witnessing significant others being attacked or shot. Twenty-five percent of the sample met criteria for posttraumatic stress disorder. Many had experienced symptoms of impaired functioning in vocational and educational areas and in emotion, cognition, and social activities. Dr. Jennings cautioned that the instruments used in the survey were
not standardized
for the population
studied, so the statistical results may be questionable. “What is not questionable,” he said, “is that this population, and perhaps the many they represent, is being exposed daily to conditions very much like war. They are suffering in ways that significantly interfere with the quality and wellbeing oftheir intrapsychic and external life styles. The psychic scars will remain, always haunting and interfering, unless conditions change, assistance is rendered, and proper interventions are instituted.” Ivan C. A. Walks, M.D., of Los Angeles said that although the unique needs of community members who are exposed to gang violence are not known, a model of treatment used for people suffering from posttraumatic stress disorder in war zones may be effective. People living in areas where gangs are active need to expect that they can be helped, but unfortunately, because of lack of community psychiatry resources, many do not have this expectation, he said. Programs that facilitate access to mental health care providers are needed. Dr. Walks also encouraged providers to make themselves available as consultants to community-based groups, including the police department and juvenile justice system, that are trying to reduce gang activity. JOANNE CONSTANCE
Hospital
and Community
WAGNER GARTNER
Psychiatry
