Women in refuge: Syrian women voicing health sequelae due to war traumatic experiences and displacement challenges.

OBJECTIVE: The Syrian war created a mass exodus of people to neighboring countries. Jordan hosts approximately 1.4 million Syrians who sought refuge and protection. This research represents an effort to understand the subjective narratives of Syrian refugee women's war traumatic experiences and displacement challenges while living in Jordan and the consequences on their physical and mental health. METHODS: Data gathered between March and June 2014 included 24 in-depth interviews with Syrian refugee women who sought services from humanitarian organizations in Jordan. Interviews were conducted in Arabic and were audio recorded. A team of four researchers translated and transcribed the interviews. Group narrative methodology was utilized to analyze the interviews. RESULTS: The study suggests that Syrian refugee women experienced diverse war atrocities including shelling, loss of property, separation from family members, and threats to their lives and their beloved ones, among a few. In Jordan, they reported on multiple displacement challenges, which are perceived as a continuous traumatic experience, as well as somatization. Narratives of women also included sequelae to their physical and mental health due to such stressors. Barriers to obtaining physical and mental health services are discussed, including inadequate medical treatment, lack of mental health services, and stigma on mental health, which might be associated to somatization of mental illnesses. CONCLUSION: It is crucial that humanitarian organizations and host countries like Jordan bear the responsibility to enhancing accessibility to comprehensive trauma-focused physical and mental health services for Syrian refugees in a culturally and gender sensitive manner.

Consumer-run services research and implications for mental health care.

Mental health consumers/survivors developed consumer-run services (CRSs) as alternatives to disempowering professionally run services that limited participant self-determination. The objective of the CRS is to promote recovery outcomes, not to cure or prevent mental illness. Recovery outcomes pave the way to a satisfying life as defined by the individual consumer despite repetitive episodes of disorder. Recovery is a way of life, which through empowerment, hope, self-efficacy, minimisation of self-stigma, and improved social integration, may offer a path to functional improvement that may lead to a better way to manage distress and minimise the impact of illness episodes. 'Nothing about us without us' is the defining objective of the process activity that defines self-help. It is the giving of agency to participants. Without such process there is a real question as to whether an organisation is a legitimate CRS or simply a non-governmental organisation run by a person who claims lived experience. In considering the effectiveness of CRSs, fidelity should be defined by the extent to which the organisation's process conveys agency. Unidirectional helping often does for people what they can do for themselves, stealing agency. The consequence of the lack of fidelity in CRSs to the origins of the self-help movement has been a general finding in multisite studies of no or little difference in outcomes attributable to the consumer service. This, from the perspective of the research summarised herein, results in the mixing of programmatic efforts, some of which enhance outcomes as they are true mutual assistance programmes and some of which degrade outcomes as they are unidirectional, hierarchical, staff-directed helping efforts making false claims to providing agency. The later CRS interventions may provoke disappointment and additional failure. The indiscriminate combining of studies produces the average: no effect.

RNA-Regulated TRA-1 nuclear export controls sexual fate.

TRA-1, a member of the GLI family of transcription factors, is required for C. elegans female development. We find that TRA-1 has a sex-specific distribution consistent with its role in female development: nuclear TRA-1 is higher in hermaphrodite intestines and in specific germline regions than in males. TRA-1 patterns rely on nuclear export since treatment with leptomycin B, a CRM1-dependent export inhibitor, increases nuclearTRA-1 in males. TRA-1 export requires TRA-1 binding to the tra-2 3' untranslated region (3' UTR), as disruption of binding increases nuclear TRA-1 and female development. Our data are consistent with coexport of a TRA-1/tra-2 mRNA complex reducing TRA-1 nuclear activity, and identify an interesting RNA-based mechanism for controlling transcriptional activity and cell fate determination.

Quality of care for psychiatric emergency service patients presenting with substance use problems.

Psychiatric emergency service assessments of 683 patients were observed to better understand the quality of care substance users receive and the effects of clinicians' attitudes toward their patients on such care. Findings run counter to those of previous reports in that substance users, once recognized, are likely to receive better care than other patients.

Factors in the use of coercive retention in civil commitment evaluations in psychiatric emergency services.

OBJECTIVE: The authors examined whether factors other than civil commitment criteria influence the involuntary retention of patients who are evaluated for civil commitment in psychiatric emergency services in California general hospitals. METHODS: Logistic regression analysis was used to determine whether admission criteria, institutional constraints, social biases, and procedural justice indicators contributed to the use of coercive retention in the evaluations of 583 patients in the psychiatric emergency services of nine California county general hospitals. RESULTS: Of the 583 patients, 109 (18.7 percent) were retained against their wishes. Clinicians relied primarily on admission criteria in making the decision to retain a patient, which suggests that patients were generally afforded procedural due process during the evaluation in the psychiatric emergency service. Staff workload was a possible factor in violations of due process. CONCLUSIONS: Psychiatric emergency services need additional resources to ensure procedural due process protection for patients who are being evaluated for civil commitment.

Measuring clients' satisfaction with self-help agencies.

OBJECTIVE: Clients' satisfaction with their involvement in treatment decisions has been largely overlooked in the formulation of satisfaction measures. The authors describe the development of a scale that assesses clients' satisfaction with services and with their involvement in treatment decisions. METHODS: Long-term users of four client-operated mental health self-help agencies were interviewed at baseline (N=310) and six months (N=248) using the 11-item Self-Help Agency Satisfaction Scale (SHASS). The scale was developed on the basis of consumers' input about their satisfaction with services and their involvement in treatment decisions. To explore the relationship between satisfaction as measured by the SHASS and outcomes, the six-month interview included four outcome measures-independent and assisted social functioning, symptom severity, and a sense of personal empowerment. Internal consistency, stability, and discriminant validity were evaluated. RESULTS: Factor analyses confirmed that the SHASS has two subscales, one assessing service satisfaction and the other assessing satisfaction with involvement in treatment decisions. The scale and its subscales showed high internal consistency, moderate stability, and discriminant validity. The SHASS subscales showed modest associations with two of four outcome measures-assisted and independent social functioning. CONCLUSIONS: The SHASS is a brief instrument that can be used to measure clients' satisfaction with their involvement in treatment in mental health self-help agencies.

Social work in a managed care environment.

Managed care has created a new service environment, eliminating distinctions that have sustained social work ideology and the profession throughout its history. This paper reviews important features of managed care, considers changes it has brought to practice ideology, the practitioner/client relationship, and the practice environment, including social work employment. The paper discusses the new opportunities, challenges and problems that have emerged with this approach. While social workers should not embrace managed care, they should not run from it or blindly oppose it. They need to aggressively pursue it, fighting its major drawbacks, while adapting to a competitive market place. Given the current managed care market, the social work profession is now in the right place, at the right time, with the right skills, and available at the right price. It must now take on a leadership role to maintain its competitive position, protect its clients and insure quality practice.

Factors associated with involuntary return to a psychiatric emergency service within 12 months.

OBJECTIVE: This study examined patient characteristics and other factors that contributed to the involuntary return of patients to a psychiatric emergency service within 12 months of an initial evaluation in the service. The findings were used to consider whether the pressure to limit duration of hospital stays under managed care contributed to the patients' return to the emergency service. METHODS: Structured observations of evaluations of 417 patients admitted to the psychiatric emergency service were completed at seven county general hospitals in California. Twelve months after the initial evaluation, mental health and criminal justice records were reviewed for evidence of the patients' return for emergency psychiatric evaluation at any of the seven hospitals. Factors associated with patients' return to the psychiatric emergency service were evaluated using multivariate modeling. RESULTS: Of the 417 patients initially evaluated, 121, or 29 percent, were involuntarily returned to the psychiatric emergency service within 12 months. The likelihood of involuntary return was increased by a psychotic diagnosis and indications of dangerousness at the initial evaluation. Having insurance also increased the likelihood of involuntary return. CONCLUSIONS: The patient's initial condition in the psychiatric emergency service was found to be the best predictor of involuntary return. Brief hospitalization--an average of six days--after the evaluation did not have a significant prophylactic effect, perhaps because the reduced length of inpatient stay in the managed care environment did not allow adequate resolution of the patient's clinical condition.

Health status of homeless and marginally housed users of mental health self-help agencies.

The study discussed in this article investigated the health status of 310 homeless and marginally housed people to determine the usefulness of mental health self-help agencies (SHAs) in addressing their physical health needs. The study compared self-reported health problems among SHA users with similar reports and clinical assessments of other homeless or marginally housed populations. Findings indicate that frequencies of health problems among respondents were similar to those of other homeless or marginally housed groups and that the study group had a higher prevalence of HIV infection and tuberculosis than the general population. Because this hard-to-reach group actively seeks SHAs, these organizations may be uniquely suited to health outreach, education, testing, and treatment.

Program environments of self-help agencies for persons with mental disabilities.

Leaders of self-help agencies (SHAs) aspire to develop program environments that are different from community mental health agencies (CMHAs). This article addresses two questions. Do consumers' perceptions of SHAs approximate the characteristics leaders think ought to typify such agencies? Do SHA and CMHA consumers differ in their program perceptions? Using the Community-Oriented Program Environment Scale, leader expectations of ideal SHA environments were obtained from a national survey of 189 consumer-run agency heads, perceptions of actual environments from interviews with 310 SHA consumers, and perceptions of CMHAs from questionnaire responses of 779 consumers in 54 programs. SHA reality conforms to ideology in offering opportunities for consumers to experience involvement, support, and autonomy in the receipt of needed service. While showing only modest differences from CMHAs on relationship and treatment characteristics, SHA consumers differ in their perceived control over program rules, a fact previously found significant in promoting positive outcomes.

Social networks and psychological disability among housed and homeless users of self-help agencies.

We look at the effects of psychological disability on social networks and support of homeless and non-homeless individuals. We analyze a survey of 310 long-term users of client-run mental health agencies. Psychological disability is negatively associated with network characteristics for housed individuals, but not for the homeless. There is a positive relationship between psychological distress and network size for the homeless who receive SSI while homeless individuals who do not receive SSI show a negative, non-significant association. We suggest the financial resources of SSI enable network members to become expressively involved with homeless individuals with relatively more psychological disturbance.

Quality of care and use of less restrictive alternatives in the psychiatric emergency service.

OBJECTIVE: The study examined factors affecting clinicians' decisions in the psychiatric emergency service about referring patients to less restrictive alternatives to inpatient care. Indicators of quality of care and the severity of the patient's condition were a particular focus. METHODS: Trained mental health professionals observed the evaluations of 425 patients in seven California county general hospitals. Multivariate modeling was used to examine variables thought to predict disposition to alternative care. RESULTS: Less restrictive alternatives were available for 61 percent of the 425 patients and were used for 39 percent; they were overlooked by clinicians in 14 percent of cases and considered but not used in 8 percent. Patients' need for a controlled hospital setting, as indicated by the severity of their condition, was most important in determining use of hospital alternatives. Quality of care, especially the clinician's ability to engage patients in treatment at a level appropriate to their functioning, was also a significant predictor of whether alternative care was considered or used. CONCLUSIONS: Under managed care, clinicians are under extreme economic pressure to use less restrictive alternatives, thereby reducing costly inpatient care. To ensure quality of care in general hospital emergency services, the development of supervised hospital alternatives is crucial. Clinicians should be encouraged to engage patients in treatment if appropriate use of alternative care is a goal.

Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services.

OBJECTIVE: The study examined whether the prescription practices of clinicians in psychiatric emergency services differed for African-American patients. Prescription of antipsychotic medications and its relation to quality of care was a particular focus. METHODS: Data from 442 independently observed evaluations of patients in psychiatric emergency services were examined using multivariate analyses. The observations were made during a five-year period at four urban general hospitals in California. RESULTS: Clinicians in the four emergency services, most of whom were Caucasian, prescribed more psychiatric medications to African Americans than to other patients and devoted significantly less time to their evaluations. African Americans received more oral doses and more injections of antipsychotic medications, and the mean 24-hour dosage of antipsychotics (1,321 milligrams) was significantly higher than for other patients (825 milligrams). The tendency to overmedicate African-American patients was lower when clinicians' efforts to engage the patients in treatment were rated higher. CONCLUSIONS: The results highlight the importance of efforts to engage African Americans in the treatment process and the need for clinical skills and training to help bridge cultural distances.

Health and a residential care population.

This article describes the health status of 234 severely mentally ill (SMI) persons residing in California's supervised residential care facilities in 1973. Relocated in 1983, 63.2% reported their health as good to excellent. Over the follow-up period 80.8% maintained their SSI benefits, insuring them of health insurance coverage. Surprisingly the follow-up sample, believed to be at high risk of increased physical morbidity, compared quite favorably to low income subsamples of the National Health Interview Survey (NHIS). The SMI reported better health, access to and utilization of health services. Differences were particularly striking in the poor health category with NHIS respondents reporting poor health 3.5 times more frequently than SMI sample numbers. These results offer some support for the contribution of health insurance benefits and supervised residential settings to positive health outcomes of this vulnerable population.

Criminality of the mentally ill in sheltered care: are they more dangerous?

The sample of mental patients in sheltered care has a lower arrest rate than the general population in California in all categories of crimes, except for violent crimes. For violent crimes, the sheltered-care population is likely to be arrested at 1.33 times the rate of the state population, even when the heterogeneity of aggravated assault was taken into consideration. This indicates empirically that the mentally ill in sheltered care are more dangerous than the general population. For prediction of criminality, four factors are found to be significant predictors of resident criminality after 1973: (a) prior crime history, (b) age, (c) use of alcohol and drugs, and (d) sex (male). Among these factors, prior crime history is the single most powerful predictor of resident criminal activity. This is another confirmation of most of the previous research findings. Although there have been controversies over the issue of the dangerousness of the mentally ill, the results of this study, overall, support the most recent findings of studies in which the mentally ill population pose greater threats to the community than the general population. Now it is time to consider more specific and practical measures to monitor and carefully follow up the discharged population, especially those with prior crime history, and prevent further violent crimes. This will in turn help to promote the reintegration of the mentally ill in the community.

Factors in the quality of patient evaluations in general hospital psychiatric emergency services.

OBJECTIVES: The study examined the usefulness of a three-perspective model for determining the quality of evaluations in psychiatric emergency services. The model was used to evaluate the hypothesis that the provision of high-quality care in emergency services is primarily influenced by service objectives related to patients' clinical characteristics rather than by institutional constraints, such as workload or physical facilities, or by social biases, such as clinicians' attitudes toward patients or perceptions of community expectations. METHODS: The evaluation of 683 persons assessed in nine California public facilities were independently observed. Multivariate techniques were used to test the relative importance of patients' clinical characteristics, possible sources of social bias among clinicians, and institutional constraints in influencing three quality-of-care dimensions: technical quality, the art of patient care, and optimum investment of time. RESULTS: The findings generally confirmed the hypothesis that patients' clinical characteristics have more influence on the quality of care provided than institutional constraints or social biases. However, one institutional constraint--increased workload demands--led to reduced technical quality and to less than optimal use of time. Further, social biases reflected in the clinician's like for and preconceptions about the patient also influenced the quality of their evaluations. CONCLUSIONS: The model is a useful tool for examining quality of care in the psychiatric emergency service. Increasing workload pressures negatively affect quality of care.

The quality of psychiatric emergency evaluations and patient outcomes in county hospitals.

Quality of care is widely assumed to be related to patient outcomes, but little is known about care in relation to outcomes in county general hospital psychiatric emergency services. It was hypothesized that conformity to professional standards (technical quality) and engagement of the patient (artful care) in psychiatric emergency services evaluations would contribute to improved patient functioning (Global Assessment Scale score) and appropriate disposition. A total of 583 cases in seven facilities were analyzed. Conformity to technical standards of care was associated with retention even after constraints, biases, and admission criteria had been taken into account. Conversely, artful care was associated with lower probability of retention and improved functioning.

Measuring empowerment in client-run self-help agencies.

"Empowerment" connotes a process of gaining control over one's life and influencing the organizational and societal structures in which one lives. This study defines and validates three measures: the Personal Empowerment Scale, the Organizational Empowerment Scale, and the Extra-Organizational Empowerment Scale. Measurement efforts are based on observational work, baseline interviews (N = 310), and six month follow-ups (N = 241) in four client-run self-help agencies (SHAs) for persons with severe mental disabilities. All three study scales demonstrated strong internal consistency and stability. They were sensitive to user changes over time and have construct validity.