Ambivalenz in der psychiatrischen Organisation

For the past 100 years Bleuler??s ambivalence terminology has been applied to many aspects of the psychiatric treatment of patients, particularly in the realm of diagnostics and therapy. It has, however, been adopted in an approach mainly limited to psychopathological phenomena. This article discusses whether advanced concepts of ambivalence can facilitate the analysis of current challenges and problems of institutional psychiatry, placing them in a new light. It describes a wide range of psychiatry-specific ambivalence experiences by investigating the field of activity of individual therapists as well as of interdisciplinary therapeutic teams. Particular attention is given to an ambivalence-oriented perspective of clinic management taking uncertainty and complexity into consideration. In such different contexts modern ambivalence concepts give way to a psychodynamic understanding of clinical areas of conflict, thus extending the possibilities of multimodal therapy. When dealing with complex leadership and planning tasks, sensibility and tolerance towards ambivalence phenomena and conflicts prove to be unusual but valuable problem solving resources.     

Identifying outpatients with entrenched suicidal ideation following hospitalization

The purpose of this study was to identify outpatients who experience entrenched suicidal ideation following inpatient psychiatric hospitalization. Our findings suggest that the use of a suicidal ambivalence index score was helpful at discriminating those who reported significantly greater ratings of suicidal ideation across a 1-year period of time, whereas splitting patients based upon suicide attempt history yielded nonsignificant results. Similar findings resulted from a dimensional analytic approach, as well. Application of the suicidal ambivalence index may help administrators identify patients who require more intensive clinical services to resolve their suicidal ideation.     

Group Attachment and the Reduction of Value-Driven Ambivalence

This article analyzes the effects of value-driven ambivalence and group attachment on response variability in public attitudes toward campaign finance reform. The analysis demonstrates that group attachment, when activated by affective cues, moderates the effects of ambivalence on response variability. By tipping the balance of considerations in one direction or the other, group attachments make it easier for ambivalent respondents to make tradeoffs between competing values during policy choices and, as a result, dampen response variability. Methodologically, the results offer an important cautionary note about the use of linear ambivalence scales by calling into question the assumption that indifference is an intermediate state between preference and ambivalence.     

Ambivalence and decisional conflict as a cause of psychological discomfort: Feeling tense before jumping off the fence

It has long been assumed that people experience evaluative conflict or ambivalence as unpleasant. In three studies we provide direct evidence for the assumption that ambivalence is unpleasant, but only when one has to commit to one side of the issue. In those situations ambivalence will be related to outcome uncertainty and feelings of discomfort. We examined this prediction using both self-reports and physiological measures. In a first study we manipulated ambivalence and whether or not participants had to take a clear stand vis-a vis the attitudinal issue and choose a position for or against it. Results indicate ambivalence was only related to physiological arousal when a choice had to be made. Feeling ambivalent about an issue without the necessity to choose did not result in higher levels of arousal. A second study replicated and extended these findings by including a measure of subjective uncertainty about the decision. Results showed the same pattern as in Study 1, and indicate that the relation between ambivalence and arousal is mediated by uncertainty about decisional outcomes. In the third and final study these findings are corroborated using self-report measures; these indicated that ambivalence-induced discomfort is related to specific (negative) emotions.     

Utilizing a Music Listening Technique in Inpatient Psychiatric Group Counseling

ABSTRACT

The purpose of this article is to describe and illustrate through a hypothetical case example how counselors can utilize an expressive arts technique called music listening in inpatient psychiatric group counseling. The authors give a rationale to implement here-and-now interventions, specifically music listening, in response to the critique of current inpatient therapy in psychiatric hospitals following a shift from long-term inpatient psychiatric care to brief stabilization admissions.     

Is the Ambivalence a Sign of the Multiple-Self Nature of the Human Being? Interdisciplinary Remarks

Ambivalence is a constituent feature of human beings. The aim of this article is to systematise the fundamental sources of ambivalence (neuropsychic, socio-cultural and situational) and highlight that ambivalence can be considered as an external sign or manifestation of a complex and multiple internal human nature; that is, a human being constituted by multiple selves. In this paper the self is viewed as a principle of organization and integration for action, that is, as a complex neurological process and not as a static entity. The purpose is to show how by assuming ambivalence and the multiple-self, social and anthropological theories can offer a more realistic view of human beings.     

Written Exposure Therapy for Suicide in a Psychiatric Inpatient Unit: A Case Series

Patients with posttraumatic stress disorder (PTSD) are at an elevated risk of suicide. For patients hospitalized for suicide risk, psychosocial treatment and stabilization are routinely offered; however, the availability of evidence-based, manualized therapeutic interventions for PTSD is sparse. Typically, the short duration of hospitalization makes it difficult to accommodate evidence-based, trauma-focused treatments. This article presents the clinical course of four active-duty service members with PTSD who were hospitalized in a psychiatric inpatient unit for acute suicide risk and treated with Written Exposure Therapy for Suicide (WET-S). WET-S is a brief, five-session therapy based upon Written Exposure Therapy and augmented with Crisis Response Planning for Suicide Prevention. Both posttraumatic stress symptoms and suicidal ideation were reduced from pre- to posttreatment for three of the four patients treated. WET-S shows promise as a manualized therapeutic intervention that can be delivered on an inpatient psychiatric unit.     

In Defense of Ambivalence and Alienation

In this paper, I argue against certain dogmas about ambivalence and alienation. Authors such as Harry Frankfurt and Christine Korsgaard demand a unity of persons that excludes ambivalence. Other philosophers such as David Velleman have criticized this demand as overblown, yet these critics, too, demand a personal unity that excludes an extreme form of ambivalence (“radical ambivalence”). I defend radical ambivalence by arguing that, to be true to oneself, one sometimes needs to be radically ambivalent. Certain dogmas about alienation are even more entrenched. Allen Wood’s entry on “alienation” in the Oxford Companion to Philosophy begins as follows: “A psychological or social evil, characterized by one or another type of harmful separation, disruption or fragmentation, which sunders things that belong together.” I think that it is not true that self-alienation is necessarily “harmful.” I argue that radical ambivalence is a form of self-alienation. Thus, because faithfulness to oneself sometimes requires radical ambivalence, to be true to oneself, one sometimes needs to be alienated from oneself.     

Self-ambivalence and resistance to subtle self-change attempts

Recent research has demonstrated the malleability of self-views to subtle situational influence but has not uncovered features of the self-concept representation that make it susceptible to such change. Using research on attitude ambivalence as a foundation, the current article predicted that the self would be most likely to respond to a subtle change induction when the targeted self-beliefs were objectively ambivalent (e.g., possessed both positive and negative features). Using self-esteem conditioning (Experiment 1) and outgroup stereotype priming (Experiment 2), it was found that people were more susceptible to subtle change inductions as objective self-ambivalence increased. Notably, the consistency between dominant self-views (positive or negative) and the change induction did not influence these results. These effects held for objective ambivalence, but not subjective ambivalence, and only when the objective ambivalence measure was relevant to the change induction. Mechanisms of the observed moderation and the implications of self-ambivalence for understanding self-change are discussed.     

Therapeutic Assessment With Child Inpatients

Growing evidence supports Therapeutic Assessment (TA), a collaborative and therapeutic approach to psychological assessment, as an effective method for enhancing motivation for and engagement with psychotherapy across a variety of clinical populations and treatment settings. However, to date there are no known studies assessing the use of TA in child psychiatric inpatient settings. This article briefly reviews the structure of child and family TA, enumerates the challenges and risks associated with short-term inpatient stays, and proposes a path for integrating TA into these units as a way to enhance the quality of care and reduce the risk of rapid rehospitalization. The authors provide three case examples from a child psychiatric inpatient unit, each using a modified version of TA and each integrating assessments into brief family interventions. The authors conclude with suggestions for best practice for child psychiatric inpatient TAs.     

Group-as-a-whole concepts and the therapeutic milieu on the inpatient psychiatric unit

This paper focuses on large group process on the inpatient psychiatric unit. General systems theory and group-as-a-whole concepts are used to understand the dynamics of the therapeutic milieu. Using this information as a tool, the therapist can make various interventions on an individual and group level that will help patients understand and deal with their own psychopathology. Another benefit of this process is that it will develop a community on the psychiatric unit where patients help each other to get well. Three clinical examples are used to illustrate the relevance of this concept. With the advent of short-term psychiatric hospitalization, the therapeutic milieu has shown a drastic decline. Emphasis has been placed on the individual as opposed to the group and a valuable therapeutic tool has been lost. Using a group-as-a-whole concept can help reverse this trend and make the milieu on the inpatient psychiatric unit instrumental in the recovery of the patient.     

Environmental risk factors in hospital suicide

Suicide of hospitalized patients is the most common sentinel event reviewed by The Joint Commission on Accreditation of Healthcare Organizations. Shorter lengths of stay, sicker patients, and higher patient to staff ratios challenge the ability of the hospital to maintain safety. Risk factors associated with the physical environment of the inpatient psychiatric unit, cited as the most common root cause of inpatient suicide, may be neglected because evaluation of these factors is generally not included in medical education and training. Minimization of fixtures that can facilitate strangulation and other high risk aspects within the hospital environment is an important element in the prevention of suicide on psychiatric units.     

Systemische Therapien bei Menschen mit psychotischen Verhaltens- und Erlebnisweisen

Systemic therapy for persons who have been diagnosed as having schizophrenic or schizoaffective psychosis has been practiced since the 1950s, not everywhere and routinely but in many psychiatric hospitals and outpatient clinics with a strong psychosocial orientation. Evidence of the effectiveness is well documented in randomized controlled studies. This article describes three systemic approaches in which the authors are actively involved: (1) systemic constructivist family therapy developed in Heidelberg for outpatient contexts, (2) need-adapted treatment and open dialogue developed in northern Europe that has gained access to psychiatric clinics through regional training within integrated care projects and (3) the concept of systemic therapeutic methods of acute psychiatric treatment (SYMPA) a systemic family-oriented inpatient treatment.     

A family-oriented psychiatric inpatient unit.

This article presents the structure and policies of a psychiatric inpatient unit that was developed with the goal of fully integrating family-oriented treatment approaches into its therapeutic program. There is an explanation of different methods to involve families in the hospital treatment process and delineation of a variety of treatment techniques specific for families of inpatients. The role of the nursing staff is described as well as some of the contradictions and paradoxes that are inherent in this type of inpatient unit.     

Ambivalenz und gleichschwebende Aufmerksamkeit

Starting from some aspects of a case study the clinical significance of the concept of ambivalence will be exposed. It will be shown that beyond all the different symptoms ambivalence plays an important role in evenly-suspended attention, a concept which was developed by Freud at nearly the same time as ambivalence itself. As far as this attention is not freely suspended, ambivalence means that the suspension is always threatened by the danger of a crash. When it is right, that from a psychoanalytical viewpoint the achievement of the subject lies particularly in a misachievement, in the Freudian slip, the promise of efficiency and cure in an analysis will prove itself in its failure. The young man in the case study tells the psychoanalysis about the ambivalences it is involved in and in this he is very efficient. Ambivalence as an essential part of the evenly-suspended attention will reveal itself as a strong means of deconstructing efficiency.     

A time-limited dynamic approach to adolescent inpatient group psychotherapy

In response to sharply curtailed lengths of stay of adolescents in an inpatient psychiatric program, new therapeutic modalities need to be implemented. A time-limited dynamic approach to adolescent inpatient group psychotherapy is presented. The model integrates psychoanalytic and crisis theory into a group format. The primary focus in this model is upon resolution of problematic interpersonal interactions as they are related to the current crisis state. The group process, as related to the adolescent, involves three phases. These include an initial intake phase, which incorporates an ego-functioning assessment; a second or middle phase which focuses on making actions ego-alien; and the termination phase, which incorporates the learning experience and how it relates to the resolution of precipitators of the admission.     

Conscious Ambivalence

Although ambivalence in a strict sense, according to which a person holds opposed attitudes, and holds them as opposed, is an ordinary and widespread phenomenon, it appears impossible on the common presupposition that persons are either unitary or plural. These two conceptions of personhood call for dispensing with ambivalence by employing tactics of harmonizing, splitting, or annulling the unitary subject. However, such tactics are useless if ambivalence is sometimes strictly conscious. This paper sharpens the notion of conscious ambivalence, such that the above tactics cannot be applied to ordinary moments of explicit and clear ambivalent consciousness. It is shown that such moments reveal ambivalence as an attitude that is part of human life. The argument employs three features of consciousness that together capture its outgoing character (a notion that combines intentionality and self-consciousness). In the last section some of the implications of conscious ambivalence for consciousness and the mind are clarified as the analysis of conscious ambivalence in this paper is compared with Hume’s and John Barth’s phenomenalist conceptions.     

Mental health policy and the psychiatric inpatient care of children

Recent changes in psychiatric inpatient treatment of children and youth are placed in the more general context of, first, the inpatient treatment of adults and, second, multiple public policies affecting children. For adults, the experimental evidence shows that the majority of psychiatric inpatients could be treated in programs outside the hospital more effectively and less expensively. For children, no such data base exists. Contrary to policy intent, between 1980 and 1985 inpatient care of children and youth increased substantially in residential treatment centers, private psychiatric hospitals, and scatter hospitals (general hospitals without any formal specialized units). Thus, psychiatric inpatient care of children and youth is increasing, dramatically so at largely uninvestigated and more expensive sites. The failure of children's mental health policy is placed in the context of the multiple policy failures for children regarding health, welfare, education, and housing. Recent positive efforts by federal agencies are described, but the need is great for data on efficacy and cost-effectiveness of inpatient treatment of children.     

Predicting Readmission to a Child Psychiatric Inpatient Unit: The Impact of Parenting Styles

The risk of rehospitalization after a child receives psychiatric inpatient treatment is generally high. Although disorder-specific behavior contributes to the need for treatment, other environmental variables may also play a role in the need for inpatient psychiatric treatment. Therefore, we examined the influence of parenting styles (authoritarian, authoritative, and permissive) on children’s risk for readmission to an inpatient psychiatric facility. Analyses were conducted with a sample of 80 children (57 males, 50% Black) ranging from 6 to 12 years of age (mean age = 8.90 years). Race was examined as a moderator of the relation between parenting style and risk for readmission. Permissive parenting was the only parenting style that was associated with an increased risk for readmission. The relation between parenting styles and risk for readmission was not moderated by race.