Table Of ContentTHE CHRONIC
PSYCHIATRIC PATIENT
IN THE COMMUNITY
THE CHRONIC
PSYCHIATRIC PATIENT
IN THE COMMUNITY:
Principles of Treatment
Edited by
Ivan Barofsky, Ph.D. Richard D. Budson, M.D.
Health Services Research Director, Community Residential
and Development Center Services, McLean Hospital
The Johns Hopkins Medical Department of Psychiatry
Institutions Harvard Medical School
MT~Eil
LIMITED
International Medical Publishers
Dedicated to
Anna-Lisa Sandy,
and Andrew,
Jeremy and
Vickie
Published in the UK and Europe by
MTP Press Limited
Falcon House
Lancaster, England
Published in the US by
SPECTRUM PUBLICATIONS, INC.
175-20 Wexford Terrace
Jamaica, NY 11432
Copyright © 1983 by Spectrum Publications, Inc.
Softcover reprint of the hardcover 1st edition 1983
All rights reserved. No part of this book may be reproduced in any form, by photostat,
microfilm, retrieval system, or any other means without prior written permission of the
copyright holder or his licensee.
ISBN-13: 978-94-011-6310-1 e-ISBN-13: 978-94-011-6308-8
DOl: 10.1007/978-94-011-6308-8
PREFACE
The purpose of this book is to present an integrated approach to
the treatment of the chronic psychiatric patient living in the com
munity. This requires that topics as diverse as pharmacokinetics,
psychotherapy and community organization be appropriately coor
dinated. Such an approach is partly complicated by the wide range
of differences among patients, in terms of social skills, intellectual
capacity and psychiatric diagnosis. In addition, unclear, insular or
overlapping roles of various mental health disciplines further con
found integrated treatment efforts.
Given such complexity, any single clinician's point of view is sub
ject to the distortion inherent in specialization. Too often a volume
in the field of mental health focuses either on only one aspect or
presents only one clinician's unique perspective of a task that is, in
fact, multifaceted. We have tried to avoid this pitfall by having
representatives from many of the concerned professions present a
variety of treatment approaches and associated issues in one text.
Further, the editors have attempted to illuminate the relevant clinical
and/or administrative interrelationship between the subjects of each
section through a succinct introductory commentary.
The book is divided into five sections. The first section represents
an attempt to address some of the interactive sociological, psycho
logical and pharmacological background issues common to all at
tempts at treatment of this population.
A detailed presentation of each of the psychosocial modalities
follows, including individual and group approaches to the patient and
his family as well as to his social, vocational and residential needs.
The management of medication selection, side effects and drug
refusal is presented next. These basic principles of treatment thus
elucidated, their application is explored in selected urban and rural
settings. Recognizing that comprehensive clinical care does not exist
in a cultural void, but rather is intrinsically tied to current socio
logical realities, the volume continues with a section addressing
advocacy, cost analysis and judicial issues. Finally, the editors con
clude with two summarizing chapters focused on clinical principles
and research tasks regarding this population.
The rationale of this volume is based upon the conviction that the
patient and his particular needs must be sustained as the primary
raison d'etre of the entire care delivery system. It is thus incumbent
upon the network of clinicians within that system to so operate as to
vi Preface
deliver treatment which is understandable, thoughtful and compre
hensive. The unacceptable alternative is fragmented services, which
are likely not only to bewilder, frustrate and demean the patient,
but also, in such circumstances, to be rendered ineffective. We
strongly believe that each clinician within the treatment system
must therefore develop effective collaboration which is predicated
upon a developing knowledge of how all of the parts work together
to help the individual patient. The editors hope that this volume will
make some contribution to this end by providing assistance to the
entire interdisciplinary array of developing and practicing mental
health professionals-including psychiatrists, nurses, psychologists,
social workers, vocational rehabilitation counselors and all of the
allied paraprofessionals.
To what extent we have attained our ideal is unclear. We are aware
that the individual authors may not have related their own specialties
to the rest of the care system as much as we had hoped would be
possible. The organization of the book as well as our sectional com
mentaries represent our effort to coordinate the overall text and thus
to prevent the subject matter from being experienced by the reader
as a compendium of isolated topics. The extent of the editors' effort
required to unify the text is testimony to the integrative challenge
to the clinician in the field.
Perhaps the most instructive lesson to be learned from the experi
ence is the extent to which we must respect the patient's position, in
his own need to understand the full nature of his condition and its
treatment in his quest to be a full partner in its management.
The idea for the book can properly be said to have grown out of a
meeting held in Boston, Massachusetts, entitled "The New England
Conference on the Chronic Psychiatric Patient in the Community."
The success of the meeting prompted the editors to invite some of
the participants to prepare manuscripts on the basis of their con
tributions. Additional authors were solicited to ensure the compre
hensiveness of the material included.
The conceptualization, format, composition and overall content of
the book represent the combined but equal efforts of two health care
professionals: one of them (Dr. Budson) is primarily a clinician, and
the other (Dr. Barofsky) is primarily a researcher. The background of
each editor insured that the contributions to the book reflected
information which is clinically relevant, as well as clinical statements
that can be supported by available data. The authors are listed in
alphabetical order without indication of priority.
ACKNOWLEDGMENTS
The authors are grateful to their respective institutions for provid
ing the academic environment conducive to the pursuit of a compre
hensive work in this field. Additional acknowledgment is given for
all of the support services provided which facilitated the completion
of this volume. Specifically, Dr. Barofsky is grateful to Mr. Sam
Shapiro, Director, Health Services Research and Development Center,
Johns Hopkins Medical Institutions, for his support, as well as to
Pearl German, Sc.D., for her thoughtful comments. Dr. Budson
acknowledges Shervert H. Frazier, M.D., Psychiatrist in Chief, as well
as Francis de Marneffe, M.D., General Director, McLean Hospital, for
their encouragement and support of the development of community
mental health programs at McLean.
Mrs. Dorothy Schwartz for Dr. Barofsky, and Ms. Pamela Healey
and Mrs. Mary Lou Silverman for Dr. Budson are thanked for their
secretarial assistance throughout the preparation of the manuscript.
We gratefully acknowledge the efforts of Mr. John Staffier, Senior
Associate of Sandoz Pharmaceuticals, who was instrumental in ex
pediting financial support for the meeting from which this book
evolved.
The authors thank their families for their support and understand
ing during the months of preparation of this manuscript.
CONTENTS
Preface v
Acknowledgmen ts vii
Contributors xiii
I. BACKGROUND
1. Concepts and Issues in Deinstitutionalization 5
Leona L. Bachrach
2. Preserving Chronic Patients' Assets for Self Care 29
Ernest M. Gruenberg and Janet Archer
3. Social Networks and the Long Term Patient 49
Muriel Hammer
4. Problems in Providing Effective Care for the Chronic
Psychiatric Patient 83
Ivan Barofsky and Catherine E. Connelly
II. PSYCHOSOCIAL TREATMENT PRINCIPLES
5. The Individual Psychotherapies and Their Relationship
to the Therapeutic Community 137
Alfred H. Stanton
6. The Management of the Family of the Chronic Psychiatric
Patient 159
Julian P. Leff
7. The Role of Crisis Intervention in the Management of
the Chronic Psychiatric Patient 181
Donna Conant Aguilera
8. The Vocational Preparation of the Chronic Psychiatric
Patient in the Community 205
Norman C. Hursh and William A. Anthony
ix
x Contents
9. The Place of the Partial Hospital in the Treatment of
Chronic Psychiatric Patients 241
Stephan L. Washburn
10. Psychosocial Rehabilitation Centers: Old Wine in a New
Bottle 265
Samuel Grob
1I. Residential Care for the Chronically Mentally III 281
Richard D. Budson
III. PHARMACOLOGIC TREATMENT PRINCIPLES
12. Clinical Experiences and Principles in Selection of
Medication 313
Jonathan O. Cole
13. Clinical Pharmacology and Side-Effects of Antipsychotic
and Mood-Stabilizing Drugs Used in the Treatment of
Psychiatric Patients with Chronic or Recurrent Disorders 321
Ross J. Baldessarini
14. The Clinical Management of Noncompliance 383
Theodore Van Putten
IV. SELECTED APPLICATIONS OF TREATMENT PRINCIPLES
15. Serving Long-Term Patients in the Cities 401
H. Richard Lamb
16. Rural Care: Providing Care for the Chronic Patient Under
Conditions of Dispersed Resources 417
Hans R. Huessy
17. The Community as the Treatment Arena in Caring for the
Chronic Psychiatric Patient 431
Leonard 1. Stein and Mary Ann Test
V. ADMINISTRATIVE ISSUES IN THE APPLICATION
OF TREATMENT PRINCIPLES
18. Benefit-Cost Analysis and the Care of the Chronic
Psychiatric Patient in the Community 457
Jeffrey Rubin
Contents xi
19. Advocacy in the Community 475
Louis E. Kopolow
20. Judicial Decisions and the Chronic Psychiatric Patient 497
Marien E. Evans
VI. OVERVIEW
21. Essential Principles in the Delivery of Adequate Clinical
Care to the Chronic Psychiatric Patient in the Community 527
Richard D. Budson
22. Community Survival of the Chronic Psychiatric Patient:
Research Priorities 541
Ivan Barofsky
Index 563
CONTRIBUTORS
Donna Conant Aguilera Jonathan O. Cole
University of California McLean Hospital
at Los Angeles Harvard Medical School
Los Angeles, California Belmont, Massachusetts
Catherine E. Connelly
William A. Anthony
George Mason University
Sargent School of Allied
Fairfax, Virginia
Health Sciences
Boston University
Marien E. Evans
Boston, Massachusetts
Boston, Massachusetts
Janet Archer Samuel Grob
The Johns Hopkins University Dept. of Psychiatry
School of Hygiene & Public Tufts University School
Health of Medicine
Baltimore, Maryland Boston, Massachusetts
Ernest M. Gruenberg
Leona L. Bachrach
The Johns Hopkins University
University of Maryland
School of Hygiene & Public
Baltimore County
Health
Baltimore, Maryland
Baltimore, Maryland
Ross J. Baldessarini Muriel Hammer
McLean Hospital New York State Psychiatric
Harvard Medical School Institute
Belmont, Massachusetts New York, New York
Hans R. Huessy
Ivan Barofsky
University of Vermont Medical
The Johns Hopkins Medical
School
Institutions
Burlington, Vermont
Baltimore, Maryland
Norman C. Hursh
Richard D. Budson Sargent School of Allied
McLean Hospital Health Sciences
Harvard Medical School Boston University
Belmont, Massachusetts Boston, Massachusetts
xiii
