Relationships between patients' perceived improvement and their evaluations of treatment components in a behaviorally-oriented psychiatric inpatient unit

Patients on a behaviorally-oriented inpatient psychiatric unit were asked to rate their perceptions of treatment outcome and the value of 16 program components in producing that outcome. Significant correlations were found between perceived outcome and positive evaluations of the overall behavioral treatment plan, individual meetings with nursing staff, individual meetings with team psychologists, assertion group training, and daily group therapy. Patients perceived individual meetings with the nursing staff to be the single most valuable program component among those related to favorable outcome. Implications for the increased utilization of nursing staff during a time of dwindling resources for mental health are discussed.     

PREVENTING SCHOOL VANDALISM AND IMPROVING DISCIPLINE: A THREE-YEAR STUDY

Vandalism is a major problem facing educators and taxpayers alike. The present investigation analyzed how vandalism costs and student disruption were related to the implementation of a training and consultation package designed to increase the reinforcing ambience of the school. A positive environment, it was posited, would displace previous events that may have set the occasion for vandalism, with cues to promote productive school performance. Eighteen elementary and junior high schools were involved over a 3-year period. Using a delayed treatment control design, treatment was delivered following either 4 or 13 months of baseline. During treatment, teams of school personnel attended training workshops in behavioral strategies for reducing vandalism and disruption by students in school. Each team also met regularly on its campus to plan and implement programs on a schoolwide basis. To demonstrate that reinforcing procedures were actually implemented and accompanied by change in student performance, these variables were periodically probed throughout the study. Project staff also provided consultation. Vandalism costs decreased significantly (p < .05) more in treatment than control schools, with an average reduction of 78.5% for all project schools. Rates of praise delivered by project teachers and other randomly selected teachers in the school increased significantly (p < .05), and rates of off-task behavior by students decreased significantly (p < .05) following treatment. The staff development model used in this study appeared to be both feasible and economical.     

PYRAMIDAL STAFF TRAINING IN THE EXTENSION OF TREATMENT FOR SEVERE BEHAVIOR DISORDERS

We implemented a pyramidal training procedure for staff working with individuals who exhibited self-injurious behavior (SIB), aggression, and disruption. Two adults with developmental disabilities and their direct-care staff and supervisors participated. Following successful treatment by the experimenters, two types of baselines were conducted with the clients and their direct-care staff. During an initial baseline, the staff implemented preexisting procedures. Staff members then received instruction on the new treatment procedures using training methods common throughout the institution, and data were collected during this “post-in-service” baseline. Experimenters then taught unit supervisors to implement treatment, collect and interpret data, and provide similar instructions and feedback to the staff members. The supervisor training was implemented in a multiple baseline design across subjects (clients and direct-care staff). Results showed little change following in-service training but noticeable improvements in direct-care staff behaviors and corresponding decreases in the clients' inappropriate behavior following the pyramidal training intervention with supervisors. Six additional clients (along with their direct-care staff and supervisors) participated in pre- and posttreatment replication designs, and their results provided additional support for the efficacy of the supervisor training procedures.     

Schematherapie bei antisozialem Verhalten und Psychopathie

In the Netherlands schema therapy is the first evidence-based treatment to be recommended for patients with personality disorders in forensic settings. Initial results show that schema therapy can even be effective in cases of “psychopathy”. The central concept in schema therapy are schema modes which can also be seen as emotional states or “parts of the personality”, which dominate temporary thoughts, emotions and behavior. Schema modes are the basis of individual mode models, which guide understanding and treatment of the disorder throughout the complete therapy. The schema therapeutic analysis of delinquency is part of the schema mode model and connects the sequences of the crime with the offender’s schema modes. With respect to the mode treatment, emotion-focused techniques and the therapeutic relationship are of special importance. The schema therapeutic treatment plan combines short-term behavior-related therapeutic goals with the underlying themes (needs and modes) in order to plan concrete interventions based on this. This has to be embedded into the individual structure of therapeutic options in the respective institutions (e.?g. individual psychotherapy, nursing staff, occupational therapy). This article demonstrates the practice of the schema therapeutic approach with a forensic case study and discusses resources and limits of the schema therapeutic approach in a forensic setting.     

Personality,Demographic, and Intellectual Variables Associated with Readiness for Discharge from Psychiatric Treatment

This study examined the relationship between staff rated discharge readiness and patient personality, demographic, and intellectual variables. Chi square and t test analyses were performed on data of 88 male and female adult patients of a short-term residential psychiatric treatment program. Patient diagnosis, trait anxiety level, marital status, age, and abstract intelligence scores assessed at admission were found to be significantly associated with staff ratings of patients’ readiness for discharge following six weeks of treatment. Findings were discussed in terms of prior process and outcome literature and implications for future research.     

Case vignette: premature surrender

Three commentaries are offered on the following case: George, age 57, is a previously healthy man who recently underwent surgery for removal of a low-grade malignant thymoma. At the time of admission to the hospital, George stressed to the staff that he had long ago signed a "living will," which he renewed immediately after he learned of his cancer diagnosis. At the time of surgery, the tumor was found to extend into his mediastinum; although it was removable, this required revision of part of the sternum and grafting of the vessels feeding the heart chambers. Because of the resultant tissue damage and neuronal hyperactivity, George experienced postoperative episodes of cardiac arrhythmia and bronchospasm. Unanimous medical opinion was that this situation was a temporary problem that would resolve itself as the tissues healed. Until that time, however, it will be difficult to wean him from ventilatory support. When his stay in the intensive care unit became prolonged, George and his family began to insist that his status be changed to "do not resuscitate" and reminded the staff about his longstanding living will. All of this is happening despite the fact that the patient and family seemingly comprehend that although the short-term interventions are invasive, there is a high probability of a successful outcome. George's cancer prognosis is excellent, and, although he may well have an episode of life-threatening arrhythmia, he is likely to respond to resuscitation interventions. Once the immediate postoperative period is over, his potential for a long and productive life with full capacities is excellent. Consider the following questions: (a) Should George's expressed wishes be respected, or should the staff take additional steps to help him survive the postoperative period, even if that means violating his stated wishes? and (b) What steps might the staff follow in sorting through this problem?     

Counselling in the workplace: How time‐limited counselling can effect change in well‐being

Background: Many employers provide counselling support on work and personal issues for their employees, but in times of economic pressure such services can be at risk if their effectiveness is not demonstrated. Aim: To evaluate whether time‐limited counselling in a workplace can effect sustained change in well‐being. Method: The study was carried out by a staff counselling team in a university setting. The Warwick‐Edinburgh Mental Well‐being Scale (WEMWBS) was completed by clients at the beginning and end of counselling, and at three and six months following. A non‐treatment comparison group completed the survey at the same intervals. Results: The results of our investigation show clearly that the effect of time‐limited counselling (average seven sessions) on distressed clients is positive. The evidence of our treatment group suggests that they acquire an increased sense of well‐being as a result of the experience of counselling with a significant statistical difference between pre‐and post‐counselling treatment group scores on the WEMWBS and consistently higher scores found post counselling. The improvement was maintained at the same level for at least six months following the end of counselling. Conclusions: The provision of time‐limited counselling by employers is an effective support for personal difficulties affecting work.     

Do Health Care Workplaces Affect Treatment Environments?

Previous research has demonstrated that characteristics of the health care workplace influence staff outcomes such as morale and burnout, but the potential effect of health care workplaces on the treatment environment has been little studied. Building on a model proposed by Schaefer and Moos (1993), we propose that the workplace factors of supervisory work environment (e.g. support from supervisors, managerial control) and programme philosophical orientation (e.g. disease model of addiction, psychosocial learning model of addiction) predict four treatment environment elements: patient autonomy, staff control, staff sensitivity, and patient alienation. Multiple regression analysis of data drawn from a survey (response rate = 86%) of 327 staff members at 15 Veterans Affairs (VA) inpatient substance abuse treatment programmes revealed that greater managerial control over staff predicted greater patient alienation, lower staff sensitivity towards patients, and greater staff control over patients. Stronger disease model programme orientations predicted less patient alienation and greater staff sensitivity, whereas stronger psychosocial model programme orientations predicted less staff control. These results suggest that health care workplaces may influence treatment environments. Implications for further research and practice are discussed. © 1997 John Wiley & Sons, Ltd.     

Setting up inpatient behavioral treatment programs: The staff needs assessment

Despite the success that behavior therapy has demonstrated in treating severely mentally ill adults, widespread impact of behavioral treatments on this population has been limited because the staff of many inpatient settings do not routinely utilize these strategies. Surveying staff regarding their perception of programatic and organizational needs is proposed as a valuable first step for selecting behavioral strategies to be introduced in these settings. Goldfried and D'Zurilla (1969) developed a behavioral assessment survey that is especially useful for identifying staff needs vis-à-vis behavioral rehabilitation. Using these strategies, survey questions addressed five problem areas: Administrative, Staff, Patient, Resource, and Programatic. Results using this survey with 40 clinicians on the extended care unit of a state hospital showed that staff members had greatest concern with the Patient Problem Area (i.e., aversive patient behaviors that are not sufficiently addressed by treatment plans). Further analyses showed staff members were interested in addressing Patient concerns using incentive procedures. The needs assessment in this study not only provided useful information that might be generalized to other treatment settings, but also showcased a reliable survey approach that program developers might implement prior to designing training curricula for behaviorally naive staff in inpatient settings.     

Counselling Requirements in a Voluntary Advice Agency

Voluntary advice agencies are frequently used by people during times of their lives when they are under emotional pressure: for example, following marital disruption, bereavement or redundancy. In order to assess the nature of personal problems and the psychological effects of such life-events, one such advice agency was observed. From a detailed analysis of a sample of client contacts, it was concluded that there was a well-defined need for counselling to be available in addition to the provision of practical and legal information. Using an action-research strategy, the training of existing volunteer staff was extended, and recommendations were outlined for the recruitment of counsel ling-trained staff.     

The use of behavioral skills training to improve staff performance of discrete trial training

Well‐trained staff are a prerequisite for successful implementation of treatment plans when working in human service contexts. The high rate of turnover makes the use of efficient and effective staff training all the more important. Previous research has used behavioral skills training to train teachers in correct implementation of discrete trial training of children with autism. They showed that a brief 10‐min procedure could effectively train staff and result in improved performance. The current study elaborated on previous work by using participants without prior exposure to the method, including treatment integrity data and testing for maintenance 1 month after training ended. The mean percentage of correct teaching responses for the three participants increased from 70%, 58%, and 66% during baseline to 97%, 96%, and 99%, respectively, following training. Results indicated that the training package was effective and the results were maintained 30 days later.     

The voices of the medical record

The medical record, as a managerial, historic, and legal document, serves many purposes. Although its form may be well established and many of the cases documented in it ‘routine’ in medical experience, what is written in the medical record nevertheless records decisions and actions of individuals. Viewed as an interpretive ‘text’, it can itself become the object of interpretation. This essay applies literary theory and methodology to the structure, content, and writing style(s) of an actual medical record for the purpose of exploring the relationship between the forms and language of medical discourse and the daily decisions surrounding medical treatment. The medical record is shown to document not only the absence of a consistent treatment plan for the patient studied but also a breakdown in communication between different health professionals caring for that patient. The paper raises questions about the kind of education being given to house staff in this instance. The essay concludes with a consideration of how such situations might be more generally avoided.     

Video training of support staff in intervention plans for challenging behavior: Comparison with live training

We compared video versus live training as respective components of a program for training support staff in individualized intervention plans for people with severe disabilities and challenging behavior. Procedures constituting behavior plans for three individuals were presented to staff through an initial training session and then follow‐up assessment and training on the job. Twenty staff received the initial training in small groups by watching a video of a behavior analyst describing a plan along with informational bullets, and 18 staff received the initial training in live sessions with the behavior analyst. Results of knowledge quizzes and on‐the‐job observations and questions with staff indicated video and live training were both effective. Video training was more efficient regarding time required by staff trainees and trainers' direct‐contact time with staff. However, additional trainer time (and staff videographer time) was required to make the videos. Both types of training were well received by staff, though live training was slightly better received based on staff ratings. In light of results supporting effectiveness of video training, suggestions are offered regarding when such training is likely to be more and less advantageous from an efficiency perspective. Future research areas discussed focus on the ways to enhance the utility of video training. Copyright © 2008 John Wiley & Sons, Ltd.     

A Death in the Family: Report of a Single-Session Trauma Group for Nursing Home Residents and Staff

This article describes a single-session trauma-debriefing group conducted at a nursing home following the death of a resident on an outing. The group had as its core an existing weekly therapy group in the facility, with the addition of affected staff, family, and other residents who were on the outing. The treatment illustrates four principles relevant to counseling and psychotherapy in nursing homes: 1) recognition of death; 2) treatment in and of the milieu; 3) flexibility and structure; and 4) dealing with countertransference. Along the way, we see how the residents are capable of giving, and not merely receiving.     

合并精神疾病患者剖宫产术麻醉优化与医患安全保障

合并精神疾病患者接受剖宫产术时,由于此类患者的特殊性,患者以及其家属、医务人员心理表现都有别于普通情况。合理遵守此类患者的如下麻醉方案优化原则：麻醉操作可以实施原则、麻醉效能有效控制原则、避免诱发或加重精神疾病原则、患者无痛和新生儿安全原则、术后镇痛衔接原则、全程心理干预原则和替代麻醉预案制定原则,同时科学制定患者围术期如下管理规章制度：应急程序的及时启动、患者家属及监护人的沟通与知情同意、麻醉前后特定病房或医疗单位的建立和麻醉医疗期间医患合法权益的保障,只有这样医患双方安危和权益才能得到最佳保障。     

Interpersonal loss and self-mutilation

Self-mutilation was hypothesized to increase in frequency during periods of interpersonal loss in a treatment program for seriously disturbed adolescents. The study examined changes in the frequency of acts of self-mutilation, aggression, and running away for 32 teenagers who experienced interpersonal loss when staff members left employment. Data were collected for a 4-year period. Statistical findings indicated that the frequency of self-mutilation increased significantly during the time period of anticipated loss, 2 weeks prior to staff terminations. There was no significant increase in the frequency of self-mutilation immediately following the staff terminations. Also, there was no significant change in the rates of aggression or running away either before or after the loss events. It was concluded that the time of anticipated loss was the period of highest risk for these adolescents in terms of self-mutilative behavior.     

Evaluating the quality of training delivered by direct-care staff in a state mental retardation center

This study evaluated a center-wide training system in a state-operated mental retardation center. Staff performance was assessed under varying conditions with collateral measures collected on resident behavior. The quality of training delivered by direct-care staff was measured following the completion of an inservice training program and when individual feedback and praise were available or a group contingency where feedback, praise, and money were available. Inservice training was not found to be sufficient to maintain staff training skills. Providing feedback and praise had mixed results in maintaining staff behavior. A group contingency using feedback, praise, and money was found to be immediately effective in improving and maintaining staff behavior. Collateral measures on student behavior were also provided that indicated that consistent, quality training by staff resulted in increased student skill acquisition. These results are discussed within the framework of conducting research in applied settings.     

Diaries of significant events: socio-linguistic correlates of therapeutic outcomes in patients with addiction problems

The principles of narrative therapy imply that autobiographical diaries written by patients in treatment will not only facilitate but also elucidate progress. The relationship between the linguistic content of diaries and progress in treatment was examined in this study. Complete sets of daily diaries of ‘significant events’ written by 16 patients receiving treatment for drug, alcohol and food addictions at a residential centre, using the 12-step approach of the Anonymous fellowships, were typed up for analysis. Three forms of socio-linguistic enquiry were employed: narrative characterization; evaluative statement coding and computer analysis of word strategies. Results indicated that success in treatment as rated by counselling and psychiatric staff was associated with the following characteristics of diary narratives. They are (a) focused on individual progress, whether adopting a ‘positive interpretative’ or ‘negative reactive’ style; (b) less critical of self over time and more positive about others external to the treatment centre; (c) both positive about the treatment programme and critical of self; (d) using words indicative of ‘insight’ and ‘negativity’ as assessed by Pennebaker's LIWC programme. It is concluded that autobiographical material can usefully be employed to assess progress in treatment, and that its intrinsic value in effecting change should be further explored. © 1997 John Wiley & Sons, Ltd.     

Item-by-Item Versus End-of-Test Feedback in a Computer-Based PSI Course

This study examined the effects of three different types of computer feedback on the following variables in a Personalized System of Instruction (PSI) course: unit quiz and final exam performance, the amount of time tutors and other teaching staff spent answering student questions, and students' preference for each type of feedback. The feedback conditions were the following: (a) end-of-test, (b) item-by-item with the option to skip questions during the test, and (c) item-by-item without the option to skip questions during the test. Students who received item-by-item feedback with the skip option performed the same as students who received end-of-test feedback on the unit quizzes and final exam. However, the teaching staff spent significantly less time answering questions when students received item-by-item feedback with the skip option than when they received end-of-test feedback. Finally, 65% of the students preferred item-by-item feedback with the skip option. The authors concluded that this type of item-by-item feedback decreases the workload on teaching staff in a PSI course without sacrificing performance, and students like it more than the other types of feedback.