José Luis Montoya Rico y las primeras reformas de la asistencia psiquiátrica de beneficencia / José Luis Montoya Rico and the initial reform of charitable psychiatric assistance

Revisamos en este artículo la producción escrita de José Luis Montoya Rico, psiquiatra de la Beneficencia Provincial en Oviedo, A Coruña y Alicante. Durante el tardofranquismo, escribió y dirigió los planes de reforma de la asistencia psiquiátrica en los Hospitales Psiquiátricos Provinciales de “La Cadellada”, Conxo y Jaén, dependientes de las Diputaciones Provinciales. El trabajo de Montoya ofrece una panorámica de la asistencia pública en materia de salud mental del país -estructura, necesidades y dificultades y referencias- e informa de las tensiones, modelos e influencias de la recepción profesional de la comunidad terapéutica durante ese mismo periodo. (AU)

This paper reviews José Luis Montoya Rico´s work, a psychiatrist in the Oviedo, A Coruña and Alicante charitable provincial hospitals. During the final years of Franco's dictatorship, Montoya wrote and advised the first reform plans of the “La Cadellada” and Conxo provincial mental hospitals. Montoyas’ work offers an overview of mental health care in Spain and contextualizes the professional reception of the therapeutic community during that period. (AU)

Psychic burden development related to nursing work in Psychosocial Care Centers.

OBJECTIVE: to investigate the factors that are present in the work environment of the nursing team and that contribute to emergence of psychic burden in Psychosocial Care Centers III. METHODS: this is a descriptive and qualitative study carried out in three services located in Paraíba State. Data were obtained from an interview with a semi-structured script, and textual content was treated using the software Interface de R pour Analyzes Multidimensionnelles de Textes et de Questionneires. RESULTS: the factors that trigger psychic burden arise primarily from pace of work, precarious physical structure, work with users in mental distress, lack of management support, insufficient multidisciplinary team and lack of clinical supervision. CONCLUSION: the difficulties faced by nursing professionals in the work environment cause suffering at work and hinder the effectiveness and, consequently, the quality of nursing care.

Six-month retention and changes in quality of life and substance use from a low-threshold methadone maintenance therapy programme in Durban, South Africa.

BACKGROUND: Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa. METHODS: We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency. RESULTS: The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254). CONCLUSIONS: Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.

Mental health consumer concept mapping of supportive community.

This research engaged consumers with severe and persistent mental illness receiving services in the public mental health sector in creating a comprehensive list of 110 needed community services and supports, then individually sorting and rating these items. Within the resulting concept map generated by Concept System software and as interpreted by the study participants, successfully living in the community is actualized when there is an outer layer of support regarding basic needs; financial means; individualized, comprehensive and available services; competent and caring staff; community education; legal rights enforcement; and social change directed at dismantling the discrimination and stigma associated with mental illness. Peer support and services is critical component, providing a transformational space from basic survival into recovery, supporting personal development and skills building and further social development. This study demonstrates that adult public mental health consumers actively receiving services can engage in collaborative research in meaningfully determining what their needs are, conceptualizing what the services should be and how developed, and articulating service prioritization.

Prevalence and Predictors of Mental Health Programming Among U.S. Religious Congregations.

OBJECTIVE: This study assessed the prevalence of and factors associated with congregation-based programming in support of people with mental illness. METHODS: To estimate the proportion of congregations that provide mental health programming, this study reports analyses of survey responses from the 2012 National Congregations Study, a nationally representative survey of religious congregations in the United States (N=1,327). The analysis used multivariate logistic regression to identify congregational characteristics associated with the provision of mental health programming. RESULTS: Nearly one in four U.S. congregations (23%) provided some type of programming to support people with mental illness. Approximately 31% of all attendees belonged to a congregation that provided mental health programming. Congregational characteristics associated with providing mental health programming included having more members and having members with higher incomes, employing staff for social service programs, and providing health-focused programs. Other significant predictors included engaging with the surrounding community (that is, conducting community needs assessments and hosting speakers from social service organizations) and being located in a predominantly African-American community. CONCLUSIONS: Greater coordination between mental health providers and congregations with programs that support people with mental illness could foster more integrated and holistic care, which in turn may lead to improved recovery outcomes.

A menu with prices: Annual per person costs of programs addressing community integration.

Information on costs of programs addressing community integration for persons with serious mental illness in the United States, essential for program planning and evaluation, is largely lacking. To address this knowledge gap, community integration programs identified through directories and snowball sampling were sent an online survey addressing program costs and organizational attributes. 64 Responses were received for which annual per person costs (APPC) could be computed. Programs were categorized by type of services provided. Program types differed in median APPCs, though median APPCs identified were consistent with the ranges identified in the limited literature available. Multiple regression was used to identify organizational variables underlying APPCs such as psychosocial rehabilitation program type, provision of EBPs, number of volunteers, and percentage of budget spent on direct care staff, though effects sizes were moderate at best. This study adds tentative prices to the menu of community integration programs, and the implications of these findings for choosing, designing and evaluating programs addressing community integration are discussed.

[An analysis of psychosocial care for adolescents in crisis based on their therapeutic itineraries]. / Um olhar sobre a atenção psicossocial a adolescentes em crise a partir de seus itinerários terapêuticos.

This study analyzes the care provided to adolescents in crisis in a municipality in Greater Metropolitan Rio de Janeiro, Brazil. The article reports on a qualitative health study that used Therapeutic Itinerary and Life Narratives as the methodological resources. The principal theoretical reference was psychoanalyst René Kaës. Based on the adolescents' own verbal accounts, the study aimed to grasp the collective realities that could potentially shed light on the different types of logic and professional practices applied to care for adolescents in psychosocial crisis situations. The underlying assumption was that an approach to the dialectical nature of the crisis required maintaining a framework that would allow establishing a space for transition within which to develop the necessary conditions for disruptive and paradoxical elements to be elaborated. However, crisis care in the context studied here proved to be hampered by infrastructure issues, institutional rigidity, and fragmentation of activities, with little orientation towards inter-sector work.

Um olhar sobre a atenção psicossocial a adolescentes em crise a partir de seus itinerários terapêuticos / An analysis of psychosocial care for adolescents in crisis based on their therapeutic itineraries / Un examen de la atención psicosocial a los adolescentes en crisis desde sus itinerarios terapéuticos

O artigo analisa a assistência a adolescentes em crise em um município da região metropolitana do Rio de Janeiro, Brasil. Trata-se do relato de uma pesquisa qualitativa em saúde, que utiliza como recursos metodológicos o Itinerário Terapêutico e as Narrativas de Vida, adotando como principal referência teórica o psicanalista René Kaës. Buscou-se, valendo-se de relatos orais, apreender realidades coletivas que lançassem luzes sobre as distintas lógicas assistenciais e práticas profissionais de cuidado a adolescentes em situação de crise psicossocial. Partiu-se do pressuposto de que, ao ser tomada em seu caráter dialético, a crise exige a existência e a manutenção de um enquadre que permita o estabelecimento de um espaço de transição, no qual se construam condições necessárias para que elementos disruptivos e paradoxais sejam elaborados. No entanto, a atenção à crise no contexto estudado mostrou-se atravessada por dificuldades de infraestrutura e baseada em certa rigidez institucional e fragmentação das ações, com pouco direcionamento para um trabalho intersetorial.

This study analyzes the care provided to adolescents in crisis in a municipality in Greater Metropolitan Rio de Janeiro, Brazil. The article reports on a qualitative health study that used Therapeutic Itinerary and Life Narratives as the methodological resources. The principal theoretical reference was psychoanalyst René Kaës. Based on the adolescents’ own verbal accounts, the study aimed to grasp the collective realities that could potentially shed light on the different types of logic and professional practices applied to care for adolescents in psychosocial crisis situations. The underlying assumption was that an approach to the dialectical nature of the crisis required maintaining a framework that would allow establishing a space for transition within which to develop the necessary conditions for disruptive and paradoxical elements to be elaborated. However, crisis care in the context studied here proved to be hampered by infrastructure issues, institutional rigidity, and fragmentation of activities, with little orientation towards inter-sector work.

El artículo analiza la asistencia a los adolescentes en crisis en un municipio de la región metropolitana de Río de Janeiro, Brasil. Este es el informe de una investigación cualitativa que utiliza como recursos metodológicos el itinerario terapéutico y relatos de vida, adoptando como principal referente teórico al psicoanalista René Kaës. Los relatos orales buscan una aproximación de las realidades colectivas para echar luz sobre el cuidado de las diferentes lógicas y prácticas profesionales para el cuidado de los adolescentes en crisis psicosocial. Se supone que, cuando se toman en su dialéctica, la crisis requiere de la existencia y mantenimiento de un entorno que permita la creación de un espacio de transición, donde se prepara la construcción de las condiciones necesarias para los elementos perturbadores y paradójicos. Sin embargo, la atención a la crisis en el contexto estudiado resultó estar afectada por dificultades en la rigidez y fragmentación de las acciones, con poca dirección hacia el trabajo intersectorial institucional, además de estar basado en infraestructuras.

"Waiting to go home": narratives of homelessness, housing and home among older adults with schizophrenia.

This study used thematic narrative analysis to develop an understanding of how older adults with ongoing symptoms of schizophrenia who have experienced homelessness understand and express their life course and present-time narratives of homelessness, housing, and home. Findings were developed from 26 individual interviews with five study participants and 33 systematic field observations of their homes, treatment environments and neighborhoods. Presentation of the participants' narratives illuminates how participants experienced shared challenges in unique ways and the meaning they assigned to experiences of homelessness, housing and home, particularly in regard to identity and ongoing challenges. While all participants were housed, housing did not equate to a sense of being home. Implications for social work practice and policy, and directions for future research, are discussed.

A holistic view in psychiatric rehabilitation: the effects of structure in psychiatric institutions.

Achieving independence in society following hospitalization is difficult for people with mental illness. Using quantitative and qualitative research methods, this study examines rehabilitation procedures and identifies possible deficiencies. Patients (n = 150) and employees (n = 50) were invited to participate. The results show little coordination among professionals, patients, and programs. Employees generally believe rehabilitation is more beneficial than do users. Better results could possibly be achieved if the interactional model was used along with the medical model. The findings emphasize the validity of giving patients voices that can lead to better rehabilitation and quality of life.

Implementation of the care programme approach across health and social services for dual diagnosis clients.

BACKGROUND: Care for clients with mental health problems and concurrent intellectual disability (dual diagnosis) is currently expected to be provided through the care programme approach (CPA), an approach to provide care to people with mental health problems in secondary mental health services. When CPA was originally introduced into UK mental health services in the 1990s, its implementation was slow and problematic, being hampered in part by problems occurring at a strategic level as health and social service organizations attempted to integrate complex systems. This article reports on a study of a more recent attempt to implement CPA for dual diagnosis clients in one mental health foundation trust, aiming to gauge progress and identify factors at the strategic level that were helping or hindering progress this time round. METHODS: The study took place in a mental health National Health Service (NHS) Foundation Trust in a large English city, which was implementing a joint mental health and intellectual disability CPA policy across five of its constituent boroughs. Semi-structured interviews with key informants at Trust and borough levels focused on the Trust's overall strategy for implementing CPA and on how it was being put into practice at the front line. Documentary analysis and the administration of the Partnership Assessment Tool were also undertaken. Data were analysed using a framework approach. RESULTS: Progress in implementing CPA varied but overall was extremely limited in all the boroughs. The study identified six key contextual challenges that significantly hindered the implementation progress. These included organizational complexity; arrangements for governance and accountability; competing priorities; financial constraints; high staff turnover and complex information and IT systems. The only element of policy linked to CPA that had been widely taken up was the Greenlight Framework and Audit Toolkit (GLTK). The fact that the toolkit had targets and penalties associated with its implementation appeared to have given it priority. CONCLUSION: None of the contextual challenges identified in this study were specifically related to CPA as a policy or to the needs and circumstances of dual diagnosis clients. Nevertheless, they inhibited the types of organizational change and partnership working that implementing CPA for a client group of this kind required. Unless these more generic factors are acknowledged and addressed when introducing policies such as CPA, the chances of effective implementation will inevitably be compromised.

Variation in the implementation of California's Full Service Partnerships for persons with serious mental illness.

OBJECTIVE: This study examined variation in the implementation of California's Full Service Partnerships (FSPs), which are supported housing programs that do "whatever it takes" to improve outcomes among persons with serious mental illness who are homeless or at risk of homelessness. DATA SOURCES/SETTING: Ninety-three FSPs in California. STUDY DESIGN: A mixed methods approach was selected to develop a better understanding of the complexity of the FSP programs. The design structure was a combined explanatory and exploratory sequential design (qual→QUAN→qual) where a qualitative focus group was used to develop a quantitative survey that was followed by qualitative site visits. The survey was used to describe the breadth of variation based on fidelity to the Housing First model, while the site visits were used to provide a depth of information on high- versus low-fidelity programs. PRINCIPAL FINDINGS: We found substantial variation in implementation among FSPs. Fidelity was particularly low along domains related with housing and service philosophy, indicating that many FSPs implemented a rich array of services but applied housing readiness requirements and did not adhere to consumer choice in housing. CONCLUSIONS: There remains room for improvement in the recovery-orientation of FSPs. Fortunately, we have identified several processes by which program managers and counties can increase the fidelity of their programs.

Implementation of evidence-based employment services in specialty mental health.

OBJECTIVE: Study a quality improvement approach for implementing evidence-based employment services at specialty mental health clinics. DATA SOURCES/STUDY SETTING: Semistructured interviews with clinicians and administrators before, during, and after implementation. Qualitative field notes, structured baseline and follow-up interviews with patients, semistructured interviews with patients after implementation, and administrative data. STUDY DESIGN: Site-level controlled trial at four implementation and four control sites. Hybrid implementation-effectiveness study with mixed methods intervention evaluation design. DATA COLLECTION/EXTRACTION METHODS: Site visits, in-person and telephone interviews, patient surveys, patient self-assessment. A total of 801 patients completed baseline surveys and 53 clinicians and other clinical key stakeholders completed longitudinal qualitative interviews. PRINCIPAL FINDINGS: At baseline, sites varied in the availability, utilization, and quality of supported employment. Each site needed quality improvement for this service, though for differing reasons, with some needing development of the service itself and others needing increased service capacity. Improvements in knowledge, attitudes, beliefs, and referral behaviors were evident in mid- and postimplementation interviews, though some barriers persisted. Half of patients expressed an interest in working at baseline. Patients at implementation sites were 2.3 times more likely to receive employment services during the study year. Those who had a service visit were more likely to be employed at follow-up than those who did not. CONCLUSIONS: Studies of implementation and effectiveness require mixed methods to both enhance implementation in real time and provide context for interpretation of complex results. In this study, a quality improvement approach resulted in superior patient-level outcomes and improved clinician knowledge, attitudes, and behaviors, in the context of substantial variation among sites.

Telepsychiatry: videoconferencing in the delivery of psychiatric care.

The provision of psychiatric treatment via live interactive videoconferencing, frequently termed telepsychiatry, is a viable option for psychiatrists to provide care to individual patients, populations, and communities faced with limited access and to move the point of care delivery into patients' living environments. Psychiatric providers new to videoconferencing should not be intimidated by the technology or its encompassing logistics, but they do need to develop an awareness of the salient regulatory, administrative, and clinical issues that arise in the practice of videoconferencing-based telepsychiatry. This article provides an overview of the current evidence base in telepsychiatry and reviews administrative and clinical issues in videoconferencing-based treatment. These points are then highlighted in a case example.

[Implementation of joint-crisis plans--a study of health care users and professionals]. / Einführung und Umsetzung einer Behandlungsvereinbarung--Eine empirische Studie unter Berücksichtigung von Betroffenen, Ärzten und Sozialarbeitern.

OBJECTIVE: To study effects of the implementation of joint-crisis plans (JCP) on health-care users and professionals. METHODS: The first 3 years of the implementation of JCP were followed with structured interviews with health-care users and professionals. Legal and administrative complications were documented. RESULTS: 36 of 44 subjects with JCP were assessed. Most of them had learned of JCP through other users or self-help. 55 % had prior experience with compulsory treatment. Better communication and self-determination were main goals of JCP. A relevant change in hospital treatment through JCP was not observed. Only few professionals had made direct experience with JCP. They valued JCP mildly positive. No legal and administrative complications were documented. CONCLUSIONS: Only a small minority of users signed JCP. JCP were easily employed and improved communication and self-determination.

Studying multidisciplinary teams in the Irish Republic: the conceptual wrangle.

PURPOSE: This paper addresses the conceptual wrangle that occurred during the initial stages of a grounded theory doctoral study into the nature of moral distress within multidisciplinary teams (MDTs) working within the acute mental health services in the Republic of Ireland. DESIGN AND METHODS: While grounded theory methodology directs that face sheet data (biographical details) are not collected unless they emerge as significant events within the data, practitioners within this study were asked to describe the structure, formulation, and practice of their team prior to interview, in order to establish the field of study. FINDINGS: Early analysis of the responses revealed that of 32 multidisciplinary members interviewed, none agreed on structure, formulation, and practice of their MDT. PRACTICE IMPLICATIONS: This finding suggests that caution needs to be taken in assuming a common understanding of the concept of MDT in research, policy formation, and team development.

An integrative approach to threat assessment and management: security and mental health response to a threatening client.

Workplace violence threat assessment and management practices represent an interdisciplinary approach to the diversion of potentially dangerous employees and clients. This case study illustrates such an intervention in a complex situation involving a social service agency and its client. Following a curtailment of services and an arrest, the client developed an escalating homicidal anger toward the agency administrator. Once a Tarasoff warning was received, the agency contacted a security company who organized a threat assessment and management plan involving interdisciplinary collaboration. Information developed in the course of the assessment was presented to prosecutors, who facilitated the client's arrest and involuntary psychiatric commitment until he was judged to be no longer dangerous. This case ultimately involved an integration of the services of security, law enforcement, mental health professionals, prosecutors, the courts and the state mental health system in leading to a successful diversion of the client from a path of intended violence.

'Doing things differently'--working towards distributed responsibility within memory assessment services.

OBJECTIVES: To compare initial diagnostic hypotheses made by Allied Health Professionals (AHP) (mental health nurses, occupational therapists and social workers) with subsequent formal multidisciplinary formulation based upon the full possession of investigations, neuropsychological tests and brain imaging. Design Prospective analysis. DESIGN: Prospective analysis. SETTING: Home-based assessments, secondary care based multidisciplinary memory clinic. PARTICIPANTS: 90 consecutive referrals over a 3-month period. RESULTS: Fifty eight patients (64.4%) were diagnosed by the multi-disciplinary team as having a dementia. Twenty (34%) were classified as Alzheimer's disease, 28 (49%) of mixed sub-type and 9 (16%) of vascular origin. Together, AHP's were able to detect dementia with 91% accuracy (Kappa 0.81) sensitivity was 0.88 and specificity 0.97. The diagnostic accuracy for each professional group ranged from 88% to 93% (Kappa 74-90%). CONCLUSIONS: In this study, structured initial assessment by AHP's working in a Memory Assessment Service was shown to be an accurate method of determining a diagnosis of cognitive impairment, when compared with formal MDT judgment. It is suggested that such distributed responsibility affords a viable option for the future detection of early dementia.