Sustaining and Expanding Systems of Care to Provide Mental Health Services for Children, Youth and Families Across America

The Substance Abuse and Mental Health Services Administration has been instrumental in supporting the development and implementation of systems of care to provide services to children and youth with serious mental health conditions and their families. Since 1993, 173 grants have been awarded to communities in all 50 states, Puerto Rico, Guam, the District of Columbia, and 21 American Indian/Alaska Native communities. The system of care principles of creating comprehensive, individualized services, family-driven and youth-guided care and cultural and linguistic competence, supported by a well-trained and competent workforce, have been successful in transforming the field of children's mental health and facilitating the integration of child-serving systems. This approach has achieved positive outcomes at the child and family, practice and system levels, and numerous articles have been published using data collected from system of care communities, demonstrating the effectiveness of this framework. This article will describe lessons learned from implementing the system of care approach, and will discuss the importance of expanding and sustaining systems of care across the country.     

Therapeutic turn

This paper offers a systematic and critical exploration of contemporary theology of pastoral care in the Evangelical Lutheran Church of Finland in light of the history of the practice of care-giving and Western cultural change. Currently, pastoral care is characterized by a therapeutic approach that aims to offer sincere help for earthly suffering and to promote the good things that the individual chooses to reach for. This has been drastically different than historical models from Luther to the early twentieth century that were spiritual and paternalistic in nature. The therapeutic turn connects to the therapeutic culture that has set self-actualization as a central idea determining Western cultural ethos. The therapeutic approach calls into question how the spiritual task of the church is carried out. The prevailing pastoral-psychological theology of pastoral care proves to be problematic. The spiritual task of pastoral care should be based on the basic Lutheran theology of God as objective and not conditioned upon the human mind. Yet, the therapeutic aim should still be maintained as the basic approach of care.     

Pain Control in the African Context: the Ugandan introduction of affordable morphine to relieve suffering at the end of life

Dr Anne Merriman is the founder of Hospice Africa and Hospice Africa Uganda. She is presently Director of Policy and International Programmes. Here she tells the story of how HAU was founded. Dr Richard Harding is an academic researcher working on palliative care in Sub-Saharan Africa. This paper described Dr Merriman's experience in pioneering palliative care provision. In particular it examines the steps to achieving wider availability of opioids for pain management for those with far advanced disease. Hospice Africa Uganda has been a model facility in achieving high quality clinical care embedded in a strategy of advocacy and education, using a multifaceted approach that has addressed logistical, policy and legislative barriers. Until 1990 control of severe pain in Sub-Saharan Africa was non-existent except in Zimbabwe and S Africa. Oral affordable morphine was brought to Kenya through Nairobi Hospice that year, and to Uganda through Hospice Africa Uganda in 1993. This paper offers an example of a highly effective and cost efficient model of care that has transformed the ability to humanely manage the problems of those with terminal illness, and to offer a culturally appropriate "good death". Thus it is now possible to complete the ethical circle of care in resource poor circumstances.     

When clinical care is like research: the need for review and consent

The prevailing “segregated model” for understanding clinical research sharply separates it from clinical care and subjects it to extensive regulations and guidelines. This approach is based on the fact that clinical research relies on procedures and methods—research biopsies, blinding, randomization, fixed treatment protocols, placebos—that pose risks and burdens to participants in order to collect data that might benefit all patients. Reliance on these methods raises the potential for exploitation and unfairness, and thus points to the need for independent ethical review and more extensive informed consent. In contrast, it is widely assumed that clinical care does not raise these ethical concerns because it is designed to promote the best interests of individual patients. The segregation of clinical research from clinical care has been largely effective at protecting research participants. At the same time, this approach ignores the fact that several aspects of standard clinical care, such as clinician training and scheduling, also pose some risks and burdens to present patients for the benefit of all patients. We argue that recently proposed learning health care systems offer a way to address this concern, and better protect patients, by developing integrated review and consent procedures. Specifically, current approaches base the need for independent ethical review and more extensive informed consent on whether an activity is categorized as clinical research or clinical care. An ethically sounder approach, which could be incorporated into learning health care systems, would be to base the need for independent ethical review and more extensive informed consent on the extent to which an activity poses risks to present patients for the benefit of all patients.     

Imagining ethical globalization: The contributions of a care ethic

Approaches to global ethics have drawn on a number of diverse theoretical traditions, such as Kantianism and utilitarianism. While emerging frameworks contribute to a growing awareness of and interest in ethics within a global society, the values that they prioritize are not adequate for realizing a just, equitable and fair system of global governance. This article considers the possibilities of an alternative ethic—a feminist ethic of care—and explores how it can bear on present circumstances, including global inequity and injustice. This care ethic has been put forward as a viable normative approach to politics and policy. Little attention, however, has been paid to the potential of a care ethic within the globalization and ethics debate. This article illustrates how the values and corresponding principles of care, grounded in relationships and responsibilities, are essential to responding adequately to the current challenges of globalization. By examining the relevance of care in this context, the article seeks to broaden dominant ethical worldviews and contribute to the articulation of normative tools for examining globalization while at the same time avoiding the trappings of conventional universality—the abstract and a priori thinking typically associated with conceptions of global ethics.     

Cognitive-Behavioral Therapy in the Digital Age: Presidential Address

Our field has come a long way in establishing cognitive-behavioral therapy as the empirically supported treatment of choice for a wide range of mental and behavioral health problems. Nevertheless, most individuals with mental disorders do not receive any care at all, and those who do often have difficulty accessing care that is consistently high in quality. Addressing these issues is complex and costly and thus progress has been slow. We are entering an exciting stage in which emerging technologies might offer novel solutions to the treatment gap. This paper discusses a number of technology-enabled solutions to our field’s challenges, including Internet-based and smartphone-based cognitive-behavioral therapy. Nevertheless, we must remain attentive to potential pitfalls of these emerging technologies. The paper incorporates suggestions for how the field may approach these potential pitfalls and provides a vision for how we might develop powerful, scalable, precisely timed, personalized interventions to enhance global mental health.     

Understanding public opinion relating to the establishment of community mental health facilities: implications of a discourse analytic approach

This paper demonstrates a novel approach to investigating the problem of public opposition to community mental health facilities. With the move towards community care, organizations setting up mental health facilities have encountered public opposition. It has been argued that this is due, in part, to the attitudes held by the public towards mentally ill people. A knowledge and understanding of attitudes towards this client group therefore has the potential to be of practical use to policy makers and practitioners who have a responsibility to consult on, and implement, community care for mentally ill people. The survey approaches and hypothetical situations used in previous British studies of community attitudes towards mentally ill people have, however, failed to take account of the rhetorical richness and complexity of the attitudes likely to be expressed in real‐life community care contexts. By contrast, the study reported in this paper used a discourse analytic approach to explore the views expressed about mentally ill people in a ‘hot situation’. Specifically, people's views were explored in the contexts of the arguments they used to challenge or advocate a supported accommodation project for mentally ill people in their community. This paper examines some of these arguments and discusses the theoretical implications for traditional approaches to attitude research. In conclusion, the potential practical utility of the findings is considered. Copyright © 1999 John Wiley & Sons, Ltd.     

How Managed Care Can Help Couples Cope

ABSTRACT

This article traces how managed care became a quick fix to curb out-of-control healthcare costs rather than a real effective approach to managing care. To date, the impact has been not only a negative experience, but impediment to treating couples facing relationship and related problems. The author is optimistic about how managed care will evolve to recognize the importance of couples and family treatment as we enter the future with integrated systems of healthcare. ? The future will also require significant shifts in the thinking and practice patterns of providers and an emphasis on quality and outcomes.     

What's new about evidence-based assessment?

A clear consensus has emerged around the world concerning the desirability and even the urgency of basing health care delivery systems on evidence. Among behavioral health care providers such as psychologists, evidence-based practice (EBP) has been focused largely on interventions. Psychologists have long emphasized a scientifically based psychometric approach to the development of assessment procedures. Nevertheless, the era of evidence-based assessment highlights 2 somewhat different issues. First, sophisticated assessment is closely integrated with our emerging conceptions of psychopathology, rather than standing separate from these conceptions. Second, broad-based ongoing outcomes assessment systems are increasingly required for EBP on the part of governments and health care policymakers. This article summarizes these developments and looks to the future.     

Out of the depths

A fundamental approach of theology as practiced within the palliative setting is care for the whole human being, with particular focus on spirituality and the spiritual dimension. Theology and medicine come together in palliative care in which the spiritual aspect is an important component together with the physical, psychological, and social. This article is based on a mixed methods study of spirituality among persons receiving palliative care. Findings revealed the importance of spirituality and its multidimensional elements by which spirituality was perceived as a complex phenomenon relating to religious and non-religious aspects of human life. Theological reflection based on the present findings indicates that a sharp distinction between the concepts of religion and spirituality is not beneficial. It also reveals the significance of the spiritual dimension and that theology has an important role in creating a deeper understanding of this complex part of human existence. Spiritual needs, expressed in various ways, were evident among the participants receiving palliative care. The findings confirm that the theological approach in palliative care, with its focus on the whole human being and emphasis on spirituality and the spiritual dimension, continues to be the hallmark of practicing theology within palliative care.     

Managed Care and Pastoral Counseling: An Opportunity for Spiritual Growth

Managed care has forced changes on pastoral care. Among these changes are increased demand for and volume of clients. An appropriate response to this demand is for pastoral counselors to adopt a more short-term oriented treatment approach. While this approach has historically been at odds with the pastoral counseling movement, the authors argue that a combination of the therapies of Albert Adler and Albert Ellis provides a framework for addressing the needs of clients. Social Work at the     

Applications of Trauma Treatment for Schizophrenia

Because of the high rates of trauma and posttraumatic stress disorder in individuals with psychotic disorders, there has been increasing emphasis on incorporating trauma treatment into comprehensive care for schizophrenia. Yet, despite heightened awareness of the need, limited information has been provided specifying an effective approach tailored to this population. Significant advances in trauma treatment have been made in recent years that can provide a general framework for guiding such interventions for individuals with schizophrenia. This article provides a brief review of the relationship between trauma and schizophrenia and offers a heuristic view of applications of current trauma treatment to psychotherapy for schizophrenia.     

A model of short-term counselling in primary care

Counselling in prima y care settings has received much interest throughout Britain. Many surgeries employ counsellors or psychologists as part of the primay health care team. This paper describes a model of primary care counselling using an example of a case encountered in general practice. It emphasizes the advantages of offering on-site counselling services, such as better possibilities of liaison with the referring doctor and coordination of patient care. Progress was made in seven sessions of short-term cognitive-behavioural treatment and a more stigmatizing referral (for example, to psychiatric services) was avoided. The case can be seen as an appropriate referral in the context of primay care counselling and illustrates the benefit of this approach to the treatment of psychological and social problems in general practice. Names and details have been changed to preserve confidentiality.     

Interpersonal communication in the health professions: A focus on training

The field of Health Psychology has enjoyed a prodigious growth over the past 15 years. The interpersonal dynamic of the practitioner-patient relationship is one of the areas which has been illuminated thereby accentuating its contribution to effective levels of health care. This paper examines the concepts of interpersonal communication and communication skill. The contribution of skilful communication by health workers to the success with which they discharge their professional duties is considered and present standards of practice critically assessed. Specific areas of inadequacy are identified and possible causative factors postulated. Amongst such factors would appear to be a relative neglect of the interpersonal dimension of the work of the health practitioner during training. A case is made for increased attention being devoted to promoting this facet of professional competence. The major thrust of the paper develops this theme by elaborating a systematic and structured framework for instruction, Communication Skills Training, as an approach to promoting interpersonal efficiency in the health care context.     

Criminal behavior and r/K selection: An extension of gene-based evolutionary theory

An r-selected approach to reproduction emphasizes producing large numbers of offspring with minimal care given to each offspring by its parents. At the other end of the continuum, K-selection is an approach in which few offspring are produced, but maximal care is taken to insure reproductive viability of each offspring. This article argues that several heretofore seemingly unrelated factors which have been found associated with serious victimful criminal behavior (i.e. serious violent and property offenses) in numerous countries are predictable by hypothesizing that criminal behavior is part of an r-selected approach to reproduction.     

Evaluating the Effectiveness of Cognitive-Behavioral Teletherapy in Depressed Adults

Telephone psychotherapy is an emerging form of delivery of care that has recently demonstrated utility and efficacy for adult depression when provided as an adjunct to antidepressant treatment in primary care trials. This study constitutes one of the initial evaluations of cognitive behavioral therapy-telephone treatment (CBT-TT) as a stand-alone treatment for adult depression in specialty care. Thirty adults initiating psychotherapy for depression at a mental health clinic participated in the trial. The majority of participants (69%) were very satisfied with the 8-session CBT-TT, reduction in depression severity was significant over 3 and 6 months, and 42% of participants were considered recovered at termination. These outcomes closely parallel the findings from an earlier primary care trial, despite specialty care participants beginning treatment with more severe depression and without adjunctive antidepressant medication. These findings suggest that CBT-TT for adult depression is feasible and has potential as a stand-alone treatment. Implementation of this telephone-based delivery approach in primary and specialty care settings is discussed.     

From “Longshot” to “Fantasy”: Obligations to Pediatric Patients and Families When Last-Ditch Medical Efforts Fail

Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from “longshot” to “fantasy” is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.