Transplanting an organization: how does culture matter.

Cultural differences are often cited as a major obstacle to the successful transition/integration into new situations of organizations. In this contribution, the author details the changing cultural factors impacting the operation and move of the Menninger Clinic from autonomous status to an affiliation with and first year of operation in the Baylor College of Medicine and Methodist Hospital Health Care System. Both functional and dysfunctional consequences are outlined, and specific examples illustrate how the organization's leadership and staff struggled to adapt during this complicated process.

Psychiatric and sociotherapeutic perspectives on the difficult-to-treat patient.

IN SPITE of substantial advances in the effective treatment of psychiatric illness, there is a growing perception among clinicians that those patients who present for inpatient care are more difficult to treat. The authors review the history of contributions about the patient who is difficult to treat and propose a new typology for characterizing acute, severe and complex dimensions of this cohort. They hypothesize first that patient difficulty cannot be conceptualized independently from the treatment context; and second, that treatment complexity leads to a specific strain between the on- and off-floor treatment staff, thus enhancing the perception of difficulty.

Efforts to preserve the mind in contemporary hospital treatment.

The author proposes a restructured and refocused extended length-of-stay inpatient treatment program designed to maintain an emphasis on the whole person. He suggests that the conditions for implementing a genuine biopsychosocial approach to treatment are now more possible than ever before. Note is made of the evolution of the new structures, the change in treatment constraints, and the type of patient currently presenting for inpatient treatment.

Leadership and restructured roles: the evolving inpatient treatment team.

The author discusses the impact on unit leadership of the dramatic changes in contemporary inpatient treatment. In addition to substantial changes in the role of the unit chief, there are concomitant changes in the relationship between the organizers and the providers of care. The author proposes a model for hospital care that reshapes and empowers the multidisciplinary team to maintain the quality of care and narrow the gap between leaders and clinicians.

The relative influences of symptoms, insight, and neurocognition on social adjustment in schizophrenia and schizoaffective disorder.

Impaired insight and neurocognitive deficits are commonly seen in schizophrenia. No study to date, however, has documented the relative influences of insight deficits, neurocognitive functioning, and psychotic symptoms on overall social adjustment in this population. This was done in a cohort of individuals recovering from acute exacerbations.

Contemporary treatment of schizophrenia.

Over the past decade the treatment of schizophrenia has changed in each of its biopsychosocial domains. Advances in neuroscience, particularly in the knowledge of the receptor site, led to increased effectiveness of antipsychotic medication. Development of more sophisticated psychoeducational and rehabilitative techniques enhanced the chances for fuller recovery.

Development of clinical methods for utilization review in psychiatric day treatment.

When a time-limited day treatment program was reconfigured to serve individuals with long-standing psychotic disorders, the number of treatment episodes exceeding six months rose to 70%. To justify this concentration of resources, the program needed methods to identify individuals for whom sustained treatment was appropriate. This report describes development of utilization review methods adapted to publicly funded day treatment of individuals with serious mental illness and training of clinicians in new documentation skills.

The boundaries of psychiatric rehabilitation.

The authors describe the development of modern psychiatric rehabilitation, from its early association with occupational therapy to its present state as a discipline with an armamentarium of treatment strategies. Psychiatric rehabilitation addresses difficulties in three domains of patients' lives: clinical status, functional status, and quality of life. The authors suggest that the acceptance of rehabilitation as a separate discipline has been slow due to boundary conflicts between these domains and between the disciplines that traditionally represent them.

Varieties of learning in an experiential group.

Variously described as enhancing sentence, supporting professional identity, providing insight and introducing the resident to covert group processes, the experiential group has been a part of residency education for over 25 years. This article specifically focuses on and identifies the potential areas for learning about group process in such an experience. These areas are organized around the contribution of individual psychological, social-psychological, and group-as-a-whole issues in the group.

Quality assurance and quality of care: II. Monitoring treatment.

The absence of meaningful linkages between quality assurance programs and quality of care has alienated them from each other, especially in psychiatry, where standards of care and process and outcome of treatment are vaguely defined and vigorously debated. This paper describes several factors contributing to the gap between quality assurance and quality of care as well as a treatment-monitoring process that attempts to bridge the gap. The form and review process described are criteria-based and concurrent, and they use methodology that both assesses documentation and promotes an interactive clinical review.

Negative symptoms and reaction time in schizophrenia.

This study explored the association of negative symptoms and reaction time. Negative symptoms were specifically associated with reaction time slowing and variability in schizophrenics, but not in affective disorders. The finding of specificity did not extend to other measures of the deficit syndrome nor to motor performance.

Quality assurance and quality of care: I. Finding the linkages.

Efforts to adapt the problem-oriented record to the complex biopsychosocial determinants of illness and therapeutics are especially difficult with the seriously and persistently ill patient who requires more than a minimal hospital stay and for whom standards of care have not been developed. By focusing on a treatment system's capacity to achieve its goals, this report demonstrates one method for linking quality assurance behaviors with quality of care and integrating the work of the hospital psychiatrist and multidisciplinary team into the medical record. The vehicle for implementing this method is a multidisciplinary treatment-planning form currently used in the charts of an extended-length-of-stay treatment service.

Linking quality assurance and quality of care.

Since the introduction of the problem-oriented record into hospital work nearly 30 years ago, psychiatry has struggled to adapt it to the complex bio-psycho-social determinants of illness and therapeutics. This struggle has been especially difficult with the seriously and persistently ill patient who requires more than a minimal hospital stay. Justification of the work with the longer-stay patient has now come under extreme pressure from utilization review, third-party payors and quality assurance, but hospital psychiatrists continue to have the same difficulties with documentation.

Voluntary motor performance in psychotic disorders: a replication study.

Voluntary motor performance was used to investigate the hypothesis of a continuum of psychosis from depression through schizophrenia. 43 schizophrenic, 36 schizoaffective, 50 major depressive, 20 manic, and 25 nonpsychotic patient controls were tested for tapping speed, finger dexterity, hand grip strength, and neuropsychological motor performance. Sex was included as an independent variable, and the effects of psychotropic drugs were evaluated.

Types of large-group meetings in the therapeutic community: with special emphasis on the long-term unit.

LARGE-GROUP meetings in which all of the patients and staff of a unit or small hospital gather together have been an invariable component of therapeutic communities since the time of Maxwell Jones (1953). Equally invariable is the finding in the large-group event in group relations conferences that work is extremely difficult to accomplish in the large group (Turquet 1975). Considering how much the large group is used in therapeutic communities, how many claims are made for its usefulness, and how many human resources are employed, only a modest amount of literature now exists on the large group in the therapeutic community.

Reaction time impairment in schizophrenia and affective illness: the role of attention.

A young but chronic group of schizophrenic and affective disorders patients was tested for simple reaction time (RT) and RT while engaged in a concurrent task. The affective disorders patients were subdivided by the presence of psychotic features. The results show that extreme slowing of RT is due to psychoticism and is not characteristic of nonpsychotic affective illness.

Conceptual trends and issues in the psychotherapy of schizophrenia.

A review of the theoretical principles of exploratory, insight-oriented psychotherapy of schizophrenia shows three major trends: drive theory, object-relations theory, and ego-psychology. These trends follow the development of psychoanalytic theory and may relate to symptom clusters of the illness. Current considerations of countertransference follow similar lines.

The role of the unit chief: an integrated perspective.

The practice of modern hospital psychiatry has led to a dramatic increase in the complexity of the role of the unit chief. Although there is a large literature on leadership functions in general, the specific and unique tasks of this role have not been delineated. In this paper, four interrelated tasks of the unit chief are described: boundary management, generation of resources, the mobilization of consensus, and consultation and evaluation.

Depersonalization in a female adolescent.

This paper demonstrates the relationship between the onset and persistent manifestation of the depersonalization phenomenon in a femal adolescent. On the basis of a case report it is postulated that certain external stimuli coinciding with anxiety lead to a physiologically induced altered state of consciousness which defends against the maintenance or repetition of these events. If the state functions effectively, as in the presented case, a symptom pattern develops which resembles very closely that altered state of consciousness.