Equal access to outreach mental health care? Exploring how the place of residence influences the use of intensive home treatment in a rural catchment area in Germany.

BACKGROUND: Internationally, intensive psychiatric home treatment has been increasingly implemented as a community-based alternative to inpatient admission. Since 2018, the so-called Inpatient Equivalent Home Treatment (IEHT; German: "Stationsäquivalente Behandlung", short: "StäB") has been introduced as a particularly intensive form of home treatment that provides at least one daily treatment contact in the service users' (SU) home environment. Prior research shows that this can be challenging in rural catchment areas. Our paper investigates to which extent the location of the SU home location within the catchment area as well as the distance between the home and the clinic influence the utilisation of inpatient treatment compared to IEHT. METHOD: Routine data of one psychiatric hospital in the federal state of Brandenburg in Germany were analysed for the observational period 07/2018-06/2021. Two comparison groups were formed: SU receiving inpatient treatment and SU receiving IEHT. The SU places of residence were respectively anonymised and converted into geo-coordinates. A geographic information system (GIS) was used to visualise the places of residence, and car travel distances as well as travel times to the clinic were determined. Spatial analyses were performed to show the differences between comparison groups. In a more in-depth analysis, the proximity of SU residences to each other was examined as an indicator of possible clustering. RESULTS: During the observational period, the location of 687 inpatient and 140 IEHT unique SU were mapped using the GIS. SU receiving treatment resided predominantly within the catchment area, and this proportion was slightly higher for SU receiving IEHT than for those treated in inpatient setting (95.3% vs. 84.7%). In the catchment area, the geographical distribution of SU place of residence was similar in the two groups. There was a general higher service provision in the more densely populated communities close to Berlin. SU with residence in peripheral communities were mainly treated within the inpatient setting. The mean travel times and distances to the place of residence only differed minimally between the two groups of SU (p > 0.05). The places of residence of SU treated with IEHT were located in greater proximity to each other than those of SU treated in inpatient setting (p < 0.1). CONCLUSION: In especially peripheral parts of the examined catchment area, it may be more difficult to have access to IEHT rather than to inpatient services. The results raise questions regarding health equity and the planning of health care services and have important implications for the further development of intensive home treatment. Telehealth interventions such as blended-care approaches and an increase of flexibility in treatment intensity, e.g. eliminating the daily visit requirement, could ease the implementation of intensive home treatment especially in rural areas.

Reopening Selves: Phenomenological Considerations on Psychiatric Spaces and the Therapeutic Stance.

Classical and contemporary phenomenological approaches in psychiatry describe schizophrenia as a disorder of common sense and self-affection. Although taking into account intersubjectivity, this conceptualization still puts forward an individualistic view of the disorder, that is, the intersubjective deficit resides within the person. To overcome such individualism, in this article, we first propose that schizophrenic experience might be understood as arising from a dialectic relation between the self's loss of openness to the world and the world's loss of openness to the self. To show the relevance of social factors at the onset of schizophrenic experience, we propose a phenomenological analysis of trigger situations. In the second and main part of this article, we then focus on the implications of these phenomenological insights for the clinical practice: we argue that if schizophrenia is understood as a loss of openness between self and social world, psychiatric institutions should be transformed into spaces that enable a reopening of selves. We first describe enclosing phenomena such as coercive treatment to then, in contrast, present particular forms of open psychiatric spaces such as open door approaches and open dialogue. Besides the institutional-structural level, we also highlight aspects of openness at the intersubjective level of the individual agents, thus particularly emphasizing the role of an open therapeutic stance. We thus speak of (re)opening selves as we believe that the reopening of the patients' self cannot but be related to and fostered by a reopening of the professionals' self and stance. We thus argue that openness in the therapeutic stance is key to initiating the further process of recovery, which we describe as a reattunement of selves both at the bodily and narrative level. Last but not least, we sketch out possibilities for future phenomenological research on the question of psychiatric space and draw some broader societal implications.

Person-Centered Psychiatry as Dialogical Psychiatry: The Significance of the Therapeutic Stance.

In this article, we present holistic and person-centered perspectives in psychiatry, with the aim of better understanding what a focus on personhood might really mean and what clinical implications it might have. We first introduce classical and philosophical concepts of personhood, in order to then outline person-centered approaches in psychiatry, which mainly focus on the person of the patient. We then argue that, for it to really be person-centered, psychiatry must necessarily also focus on the person of professionals. We thus explore the notion of stance, as the expression of the therapist's personhood. By unpacking the effects that a professional's stance can have on patients, we finally turn to a consideration of the interpersonal sphere. More specifically, we propose clinical considerations on a therapeutic stance that strives to support and to help the person of the patient unfold. Such a stance must - we argue - necessarily be a dialogical one. Drawing on these considerations, we thus claim that a truly person-centered approach in psychiatry must necessarily and automatically be interperson-centered and dialogical. In the concluding remarks, we finally discuss broader societal implications and outline future research perspectives.

Towards the recovery of a sense of self: An interpretative phenomenological analysis of patients' experience of body-oriented psychotherapy for schizophrenia.

OBJECTIVE: Increasing evidence supports the efficacy of body-oriented psychotherapy (BPT) for schizophrenia. Yet, so far no research has investigated outcome in relation to therapy process: Why and how BPT is effective. In this study, we qualitatively explore participants' experience of a manualized BPT for schizophrenia to shed light on the process of therapeutic change. METHOD: We conducted in-depth interviews with 6 participants who completed a 10-week BPT group intervention. Interviews explored participants' experience of change and helpful aspects of therapy and were analysed using interpretative phenomenological analysis. FINDINGS: We identified six master themes across the interviews: (i) Being a whole: body-mind connection; (ii) Being agentic and being able; (iii) Being unique and worthy: Being accepted for who one is; (iv) Changing interactions: Engaging in authentic interpersonal contact; (v) Being part of a group: Feeling integrated; and (vi) Hope and investing in the future. CONCLUSION: We discuss the clinical implications for each theme and bring the findings together by describing therapeutic change in schizophrenia as a recovery of sense of self at different but interlocked levels. Moreover, we put forward recommendations for both specific and common factors for schizophrenia therapy. Clinical or methodological significance of this article: The clinical significance of this study is twofold. On the one hand, the findings of this analysis might inform the theory and practice of BPT and might directly feedback into a further development of the manual guidelines. On the other hand, common helpful factors have been identified thatmight also be relevant for the more general clinical practice concerning patients with schizophrenia. Here, we summarize our key messages for the clinical practitioner emerging from the findings: The inclusion of bodily aspects and a focus on pre-reflective experience in psychotherapy can help persons with schizophrenia recover the sense of being a body-mind unity. Empowering persons with schizophrenia, instead of instructing them, seems to foster a sense of agency and self-confidence, which are crucial to the recovery process. A twofold therapeutic stance characterized by openness towards the other and authenticity was experienced by patients as facilitating the rapport building. This might help persons with schizophrenia engage in the relation. Social inclusion might enhance therapeutic change and recovery in schizophrenia. Group therapy might be helpful for fostering a feeling of social belonging, but the inclusion in the wider social and community context remains a critical issue. The experience of joyful moments in psychotherapy might positively contribute to therapeutic change in that it fosters a sense of hope for the future. Overall our paper contributes to the literature aiming at expanding the range of therapeutic modalities, focussing on the creation and use of mixed models of therapy within and beyond talking practices.

Interactional synchrony and negative symptoms: An outcome study of body-oriented psychotherapy for schizophrenia.

OBJECTIVE: We sought to assess the efficacy of a manualized body-oriented psychotherapy (BPT) intervention for schizophrenia, by focusing on improvement of negative symptoms and on changes in interactional synchrony. We also explored aspects of a phenomenological theory of schizophrenia, which states that negative symptoms should be understood within an encompassing disturbance of subjectivity and intersubjectivity. METHOD: Sixteen persons with schizophrenia participated in 10 weeks of BPT. General psychiatric symptomatology and negative symptoms were assessed before and after therapy. Interactional synchrony was assessed via cross-correlations of movements between patient and interviewer in interviews conducted before and after therapy. RESULTS: Psychiatric symptomatology and negative symptoms significantly improved with a medium effect size. We also demonstrated a significant increase in interactional synchrony with a strong effect size. Post hoc analyses showed a significant increase only with open-ended interviews conducted by the same interviewer. Furthermore, we explored the correlation between negative symptoms and interactional synchrony, finding a large inverse relationship. CONCLUSIONS: BPT for schizophrenia may effectively reduce patients' negative symptoms and psychiatric symptomatology. Moreover, it may yield some recovery of pre-reflective social relations. Further evidence of the specific relation between negative symptoms and interactional synchrony would support a phenomenologically informed holistic view of schizophrenia.

Therapeutic stance towards persons with psychosis - a Grounded Theory study.

OBJECTIVE: Over the last decades, psychotherapy of psychosis has increasingly gained attention. The quality of the therapeutic alliance has been shown to have an impact on therapy outcome. Yet, little is know about the influence of the therapeutic stance on the alliance. In this study, we explore psychotherapists' stance towards persons with psychosis with the aim of better understanding its characteristic-hindering and helpful-aspects. METHOD: 6 semi-structured interviews with psychotherapists from three different schools (CBT, PD, ST) were analysed with Grounded Theory. Credibility was checked through external and peer-researcher-supported debriefing. RESULTS: 4 core categories were generated and interrelated in a theoretical model. Therapists' stance was initially characterized by insecurity. Diffent ways of dealing with insecurity yielded different stances: a monological and an open one. A helpful stance was conceived as stemming from openness and was characterized by a dialogical structure. A co-presence (or "dosing") of you and I was conceived as its core aspect. CONCLUSION: These findings specify the interpersonal dynamics arising from different stances and their impact on the therapeutic alliance and process. Research is still needed to further understand the characteristics of helpful and hindering therapeutic stances, which should also inform the training of psychotherapists.

They have taken out my spinal cord: an interpretative phenomenological analysis of self-boundary in psychotic experience within a sociocentric culture.

Introduction: In the tradition of phenomenological psychiatry, schizophrenia is described as a disturbance of the minimal self, i.e. the most basic form of self-awareness. This disturbance of the minimal self at the individual level is assumed to precede the intersubjective disturbances such as boundary weakening. However, the role of intersubjective disturbances in the emergence and recovery of schizophrenic experience still remains an open question. This phenomenological study focuses on how encounters with others shape self-experience during from psychosis by analyzing this process from the perspective of cultural differences, which in current research is especially under-researched. While most phenomenological accounts are based on first person-accounts from Western, individualist cultures where the self is conceived and experienced as separate to others, the present study qualitatively investigates psychotic experiences of patients from Jaffna, Sri Lanka. Method: Semi-structured interviews were conducted with three participants with a diagnosis of schizophrenia or first episode psychosis. The interviews were transcribed and analyzed using interpretative phenomenological analysis (IPA). Eight group experiential themes were identified across interviews. Results: The data suggest that intersubjective processes of boundary weakening such as invasiveness and hyperattunement may shape minimal self-experience and more specifically contribute to a mistrust of the own senses and to hyper-reflexivity. Interestingly, boundary weakening yields pervasive emotions and can be experienced as a threat to the whole social unit. On the one hand, the strengthening of self-other-boundary was achieved through opposition, closedness and withdrawal from others. On the other hand, this study suggests that the re-opening of self-other-boundaries in response to the crisis may help establish connectedness and may lead to recovery.

Is the mainstream construction of mood disorders resistant to systemic thinking?

Introduction: In this study we explore how the diagnostic category of mood disorders is constructed in two handbooks of Psychopathology as an example of the mainstream construction of psychopathology. Despite the increasing criticism and lack of evidence, the debunked chemical imbalance theory of the etiology of depression still dominates the professional and pop/folk understanding and interventions. Methods: We analysed the breadth of the inference field and the type of etiopathogenetic contents of the explanations of mood disorders using the "1to3" Coding System. Results: Our findings show that the dominant explanations draw almost exclusively onto monadic explanations, followed by limited dyadic ones. Intrapersonal etiopathogenetic contents prevailed, and biomedical explanations were dominant in both textbooks. Discussion: We critically discuss the underpinnings of these results and address the clinical implications of these biased representations, as well as potential alternative approaches to psychopathology.

Paving the way for systemic phenomenological psychiatry - the forgotten heritage of Wolfgang Blankenburg.

Phenomenological psychopathology focuses on the first-person experience of mental disorders. Although it is in principle descriptive, it also entails an explanatory dimension: single psychological symptoms are conceived as genetically arising from a holistic structure of personal experience, i.e., the patient's being-in-the-world - and of its dynamic unfolding over time. Yet both classical and current phenomenological approaches tend to identify the essential disorder or "trouble générateur" (Minkowski) of mental illness within the individual, thereby neglecting the relevance of the social context not only for the emergence of symptoms but also for their treatment. The work of Wolfgang Blankenburg on schizophrenia represents a noteworthy approach to overcome this individualistic tendency. He introduced the concept of "loss of common sense" as the structural core of schizophrenic experience and being-in-the-world and he considered the social and most importantly familial context for the emergence of schizophrenic experience. By accounting not only for personal experience but also for interactional structures of families and social milieus in which experience is embedded, Blankenburg thereby offered ways to combine phenomenological and systemic explanations of mental disorders. Beside his most renowned work on "the loss of common sense," in this paper we also present his family studies of young persons with schizophrenia, which have so far received little if no attention. We thus discuss the different ways in which Blankenburg expanded the phenomenological approach into a more systemic and social direction. We then link Blankenburg's work with current systemic explanatory models of schizophrenia and explore the clinical and scientific implications of this link. Finally, we call for further research on the synergy effects between the two.

Flexible and Integrative Psychiatric Care Based on a Global Treatment Budget: Comparing the Implementation in Germany and Poland.

Background: The past decade has witnessed the establishment of flexible and integrative treatment (FIT) models in 55 German and Polish psychiatric catchment areas. FIT is based on a global treatment budget (GTB), which integrates funding of all acute psychiatric hospital services for a regional population. Prior research has identified 11 specific program components of FIT in Germany. In this paper we aim at assessing the applicability of these components to the Polish context and at comparatively analysing FIT implementation in Poland and Germany. Methods: Qualitative interviews about the applicability of the 11 FIT-specific components were conducted with the program managers of the Polish FIT models (n = 19). Semi-quantitative data on the FIT-specific components were then collected in 19 Polish and 10 German FIT models. We assessed the grading of each component, their overall degree of implementation and compared them between the two countries. In all study hospitals, structural and statistical parameters of service delivery were collected and compared. Results: The qualitative results showed that the German FIT-specific components are in principle applicable to the polish context. This allowed the comparative assessment of components grading and degree of implementation, which showed only subtle discrepancies between German and Polish FIT models. The little discrepancies point to specific aspects of care such as home treatment, peer support, and cooperation with non-clinical and social welfare institutions that should be further integrated in the components' definition. Conclusions: The specific program components of FIT as first defined from the German experience, serves as a powerful tool to measure, and evaluate implementation of integrated psychiatric care both within and between health systems.

Changes in German Mental Health Care by Implementing a Global Treatment Budget-A Mixed-Method Process Evaluation Study.

BACKGROUND: Internationally, there is a broad spectrum of outreach and integrative care models, whereas in Germany acute psychiatric treatment is still mostly provided in inpatient settings. To overcome this, a new legal framework (§64b Social Code V) has been introduced, promoting "Flexible and Integrative Treatment" Models (FIT64b), based on a "Global Treatment Budget" (GTB) financing approach. 23 hospitals have implemented the framework according to local needs and concepts. Prior research has already identified specific components of FIT64b. Based on this, our paper aims to examine the implementation process and underpinning change mechanisms of GTB-based FIT64b models from a staff, service user and caregiver perspective. METHOD: 31 focus groups and 15 semi-structured interviews were conducted with hospital staff (n = 138), service users (n = 63), and caregivers (n = 35) in 10 psychiatric hospitals implementing FIT64b. Using qualitative analysis, we identified 5 core themes describing the implementation process, which were theoretically modeled into a logical diagram. The core mechanisms of change were thus identified across themes. Additional structural and semi-quantitative performance data was collected from all study departments. RESULTS: The qualitative analysis showed that the shift from a daily- and performance-based payment to a lump-sum GTB and the shift of resources from in- to outpatient settings were of crucial importance for the process of change. Saved budget shares could be reinvested to integrate in-, out-, and day-patient units and to set up outreach home care. Clinicians reported feeling relieved by the increase of treatment options. They also emphasized a stronger relationship with and a better understanding of service users and a simplification of bureaucracy. Finally, service users and caregivers experienced higher need-adaptedness of treatment, a feeling of deeper understanding and safety, and the possibility to maintain everyday life during treatment. Finally, two FIT64b implementation prototypes were classified according to the semi-quantitative performance data. CONCLUSION: Based on the results, we developed 3 core mechanisms of change of FIT64b models: (1) Need-adaptedness and flexibility; (2) Continuity of care; (3) Maintaining everyday life. Our findings outline and emphasize the potential a GTB approach may have for improving psychiatric hospital services.

Interpersonal synchrony feels good but impedes self-regulation of affect.

The social benefits of interpersonal synchrony are widely recognized. Yet, little is known about its impact on the self. According to enactive cognitive science, the human self for its stability and regulation needs to balance social attunement with disengagement from others. Too much interpersonal synchrony is considered detrimental for a person's ability to self-regulate. In this study, 66 adults took part in the Body-Conversation Task (BCT), a dyadic movement task promoting spontaneous social interaction. Using whole-body behavioural imaging, we investigated the simultaneous impact of interpersonal synchrony (between persons) and intrapersonal synchrony (within a person) on positive affect and self-regulation of affect. We hypothesized that interpersonal synchrony's known tendency to increase positive affect would have a trade-off, decreasing a person's ability to self-regulate affect. Interpersonal synchrony predicted an increase in positive affect. Consistent with our hypothesis, it simultaneously predicted a weakening in self-regulation of affect. Intrapersonal synchrony, however, tended to oppose these effects. Our findings challenge the widespread belief that harmony with others has only beneficial effects, pointing to the need to better understand the impact of interaction dynamics on the stability and regulation of the human self.

Rethinking Intrusiveness: Exploring the Sequential Organization in Interactions Between Infants and Mothers.

To date, studies investigating maternal postpartum depression (PPD) have mainly focused on identifying failures in interactions of postpartum depressed mothers and their infants, often attributed to single dysfunctional maternal behaviors. Intrusiveness has been identified as a dysfunctional behavior characterizing mothers suffering from PPD. However, this research does not consider the co-constructed and sequential nature of social interactions, in which single behaviors cannot be conceived as isolated or disconnected units. The aim of the work presented in this paper was to explore the interactional dynamics underlying maternal behaviors previously identified as intrusive by mainstream literature on postpartum depression. Through a conversation analytical approach, we analyzed filmed interactions between mothers with and without postpartum depression and their 3-months-old infants. The analyses of 4 selected episodes illustrate similar dyadic activities, yet presenting different levels of mutuality and affective attunement. Results showed two normative features of social interactions that contributed to the different quality in the mutual adjustment of the partners: interactional rhythm and preliminaries. Interactional rhythm refers to the structuring of infants' spontaneous activity into a turn sequence, whereas preliminaries consist of verbal or nonverbal moves that anticipate following action. As evident from our analytical observations, what seems to be hindering the mutual coordination (previously labeled as "intrusive") is not based on specific individual behaviors but on the absence or violation of such interactional norms. Adopting an interactive and dynamical framework, we shifted the focus from maternal behaviors considered as dysfunctional to observing the unfolding of interactional aspects contributing to better or poorer sequential structuring. We argue that these aspects shape the possibilities for the infant's participation. Finally, we discuss the theoretical and methodological implications of adopting a conversation analytical approach for a better understanding of the relational dynamics related to clinical and non-clinical interactions.

The intersubjective endeavor of psychopathology research: methodological reflections on a second-person perspective approach.

Research in psychopathology may be considered as an intersubjective endeavor mainly concerned with understanding other minds. Thus, the way we conceive of social understanding influences how we do research in psychology in the first place. In this paper, we focus on psychopathology research as a paradigmatic case for this methodological issue, since the relation between the researcher and the object of study is characterized by a major component of "otherness." We critically review different methodologies in psychopathology research, highlighting their relation to different social cognition theories (the third-, first-, and second-person approaches). Hence we outline the methodological implications arising from each theoretical stance. Firstly, we critically discuss the dominant paradigm in psychopathology research, based on the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) and on quantitative methodology, as an example of a third-person methodology. Secondly, we contrast this mainstream view with phenomenological psychopathology which-by rejecting the reductionist view exclusively focused on behavioral symptoms-takes consciousness as its main object of study: it therefore attempts to grasp patients' first-person experience. But how can we speak about a first-person perspective in psychopathology if the problem at stake is the experience of the other? How is it possible to understand the experience from "within," if the person who is having this experience is another? By addressing these issues, we critically explore the feasibility and usefulness of a second-person methodology in psychopathology research. Notwithstanding the importance of methodological pluralism, we argue that a second-person perspective should inform the epistemology and methods of research in psychopathology, as it recognizes the fundamental circular and intersubjective construction of knowledge.