Nine Recommendations to Increase Continuity of Mental Health Care For Schizophrenia Patients

Continuity of therapy is a vital component of quality care for people with serious mental illnesses and must be given more attention by consumers themselves, family members, advocates, providers, administrators, and researchers alike. At the moment, there is an important opportunity to develop a national consensus statement on the principles and practice standards that should form the basis of a continuum of therapy designed to provide realistic assurance that consumers can access vital medications when and where they are needed. Important strides have been made in identifying the specific factors which promote continuity of therapy – it is time to seize this important opportunity as yet another stepping stone to achieving the transformation of America’s mental health care system for the benefit of consumers and their families, our communities, and our Nation. A roundtable of mental health experts has developed a set of nine recommendations for enhancing continuity of medication therapy for persons with schizophrenia or serious mental illness, including schizophrenia. They are as follows:

Mental Healthcare Recommendation #1 –

Encourage collaborations between hospitals and community-based organizations. Use fiscal incentives to foster collaborations including the standardization of information and shared electronic health records.

Mental Healthcare Recommendation #2 –

Use a quality improvement approach to enhance continuity of therapy by benchmarking at the organizational level performance and outcomes standards regarding continuity of care.

Mental Healthcare Recommendation #3 –

Ensure all consumers have a level of care management for the transition from inpatient to community. Care management services should be reimbursable by all payers and the disincentives to providing it should be removed.

Mental Healthcare Recommendation #4 –

Hospitals and community providers should focus on the “Pull Model” of transition from inpatient to outpatient care. The Pull Model focuses on involving community-based providers in the transition planning process from the beginning. Provider organizations should focus on staff competency in engagement and strategies and motivational interviewing.

Mental Healthcare Recommendation #5 –

Accreditation standards should be aligned to address and improve continuity of therapy in treating serious mental illness. This may include developing standards to ensure evidence of an active process of care management and transition between levels of care, a quality review of the success of transition plans, and measuring engagement.

Mental Healthcare Recommendation #6 –

Consumers and their families should be educated about the benefits of maintaining their personal health care history. Ensuring that consumers have detailed information about their illnesses and treatment history will help ensure that providers have access to the information they need to provide appropriate care in a timely manner. The options here range from simple paper and pencil logs and medication histories to electronic records on memory sticks.

Mental Healthcare Recommendation #7 –

Consumer-driven recovery planning should include and the appropriate and necessary use of hospitalization. More thoughtful use of inpatient services could lead to a reduction in emergency room use and ultimately to a decrease in the number of hospitalizations.

Mental Healthcare Recommendation #8 –

Parties who collect data about mental health services and performance should share it with appropriate stakeholders in usable and timely ways. Many payers and public entities collect both population and individual specific information about mental health consumers and services. Population-based data should be shared with all stakeholders, including families and consumers to aid in enhancing the system of care.

Mental Healthcare Recommendation #9 –

There should be meaningful involvement of consumers and their advocates in all levels of system delivery and evaluation. Global involvement of consumers and their advocates in the care delivery process is essential. Examples include using peer specialists as part of a treatment team, active involvement in policy and planning, as well as involvement in developing and implementing performance measurement and evaluation.

Applying these Mental Healthcare Recommendations –

While we have learned that maintaining continuity of therapy has a positive impact on consumer outcomes, the barriers and other impediments to ensuring this continuum of care have been long entrenched in mental health and related care systems. An unacceptably high number of people with serious psychiatric issues – including schizophrenia, depression and bipolar disorder – are “falling between the cracks” in the transition between acute inpatient settings and the community causing harm and disruption in their own lives and those of their families and often bringing their recovery process to a halt.

A continuity of therapy initiative is likely to decrease inappropriate use of emergency room services by consumers with schizophrenia or other serious mental illnesses by assuring consistency in the disease management approach used by all community provider organizations. Both of these likely outcomes of continuity of therapy provide cost reductions for the hospital and cost offset for the investments in continuity of therapy initiative and related therapies.

In addition, the continuity of therapy initiative provides the community hospital with another very tangible benefit. The continuity of therapy initiative provides the relationships, process, and infrastructure for an overall discharge planning functionality for all consumers with mental illnesses. This discharge planning functionality is a new, and critical, element in modern behavioral health standards that began in 2007.

Family Behaviors That Grow Out of Developmental Trauma

Increasingly there are a number of families that are suffering intense multigenerational dysfunction that acts as a polluting agent that is interfering with the quality of life for all family members and significantly impairing or interrupting the normal psychological, emotional and social development of the children born into those families. This article is not a blame casting or finger pointing toward those families suffering with these well established patterns that generate pain and discontent in the lives of their members. This article is a simple examination of some of the common characteristics that emerge in these troubled families.

Many of the families that bring young children into clinical or therapeutic settings, particularly in the community behavioral health sector of mental health services, are in real emotional pain and desperate for relief and resolution. These families are frequently characterized by behaviors that show many of their collective family needs for stability, nurturance, empathy and mutual acceptance are not met in a predictable manner. This is true for the parents, and many times grandparents to the children; children to parents; and children to each other. Many of these families are well meaning, sincere people that are caught up in a pattern of poor quality attachments, emotionally explosive interactions, unpredictable reactive behaviors and some forms of physical or emotional abuse.

Many times these families come into contact with systems of care and correction such as (Child Protective Services, Schools, Juvenile probation) that tend to blame the parent for the family culture that they are actively following and treat them punitively without adequate respect, and while that is tempting to think in terms of blame, it doesn’t generally appear to be tremendously helpful to the blamed family. This is unfortunate, since that adds additional weight to an already struggling and impaired family system that can be emotionally unstable and unpredictable in the best of times. Many of these troubled families are already feeling overwhelmed and highly defended and self-protective because they lack emotional support and adequate healthy connections with others.

These families that are already in pain, frequently have low levels of trust for anyone, much less the systems that they are both trying to avoid and seeking help from. The father in one such family sat with a steady stream of tears marking his cheeks when he discussed how humiliated and manipulated he felt by the system that was supposed to be helping him, and as a result had developed an attitude of mild paranoia “I will never be treated fairly or with respect, I always get the short end of the stick, and it is usually got some nails in it… ” Feel untrusting doubtful of others motives is a common characteristic of highly disturbed families.

Sometimes when reading reports of child protective services, juvenile probation or other entities involved with these families in pain, there exists a repeated theme, Those in the system such as (Child Protective Services, Schools, Juvenile probation) tend to blame the parents, and sometime parents are accused of caring more for their own needs and wants than those of their children. This is a relatively predictable outcome of being raised in a highly disrupted family environment of chaos. Many of the parents are self-centered and very defensive, and when one wins a little of their trust, in many circumstances it becomes apparent that they have lacked adequate attention, affection, warmth, or companionship throughout their lives. The parents as well as their children are challenged to understand others, listening attentively, and/or finding effective and satisfying ways to interact with those around them.

Many of these families have competitive cycles where all the members compete for the title of being the defective one, the bad one, or the unwanted inferior one. Often the members of these families feel very much like they are unlovable. This painful emotional state may lead many of the family members endeavor to avoid or isolate themselves from those around them, as way to feel safe emotionally and reduce their disturbance of feelings. That to cope with the emotional pain they will in many circumstances remove themselves from situations that might provide support and encouragement instead frequently perceiving themselves as being different from other people, and not part of any group or community. This is characterized as frequent changes of relationships, residence and employment.

Families with the culture of dysfunction that is handed down from generation to generation are not evil people, but need increased support and the good will of others. They will not change quickly, but the first stage of that change is generally having a few trustworthy people provide acceptance and encouragement toward the growth of the individuals in the family. Harsh judgments from care and service workers, just reinforces the already painful, and misery causing emotional pain that has kept these families paralyzed from embracing real and effective changes and improvements.

Robert Rhoton PsyD Professor of Behavioral Science Ottawa University

Cognitive-Behavioral Therapy – The Current Treatment of Choice

Cognitive-behavioral therapy is currently receiving a significant degree of attention as the treatment of choice for individuals needing assistance with a variety of psychological disorders. It is a structured, pragmatic approach to dealing with problems and is appealing to those seeking therapeutic treatment. People in need of counseling are seeking out clinicians who have specialized training in CBT. Understanding the reason for this current trend in popularity of cognitive-behavioral therapy can be found in the unique characteristics which are pivotal to this modality of treatment. There is a simplicity and yet effectiveness in the model which characterizes the concepts of CBT.

Cognitive-behavioral therapy facilitates a collaborative relationship between the patient and therapist. Together, patient and counselor develop a trusting relationship and mutually discuss the presenting problems to be prioritized and explored in therapy. In CBT, the most pressing issue troubling the patient typically becomes the initial focus of treatment. As a result, the patient tends to feel relieved and encouraged that the primary problem that brought him to therapy is immediately being acknowledged and addressed.

Problems are tackled head-on in a very practical manner. The patient is coached on the ABC’s of cognitive-behavioral therapy. The therapist explains the connection between thoughts and beliefs and their impact on behavior. How the patient thinks about problems determines the way in which the individual responds to various issues. It’s the manner of thinking about life’s issues that steers the patient’s way of behaving.

Let’s assume that you work in an office and for an entire week a co-worker has walked past you without acknowledging your presence. Each day you go back to your cubicle and wonder why this colleague is treating you so unjustly. You build up thoughts about her being condescending and snobbish and begin questioning what you might be doing to annoy her. Anger begins to emerge and your start thinking, “How dare she treat me this way!” Eventually, you settle down and start to rationally consider the problem. You think, “This is stupid, why don’t I go visit her at her office and see what’s going on in her life that might be affecting this situation. You enter her office and begin starting a conversation. In the midst of your discussion, she reveals that her son is suffering from depression and needs to see a counselor. Your colleague is disturbed about the situation and confides in you that she has been on edge with everyone at the office. She asks you if you know of a qualified therapist. You give her some ideas and before you leave, she gets up from her chair and gives you a firm hug. This incident demonstrates how our thinking can be faulty and can be based upon some erroneous assumptions.

CBT is effective because it teaches the patient to modify patterns of thinking which affect behavior. CBT is a straight-forward therapy which is designed to alert the patient to self-defeating ways of thinking. Locating distorted or maladaptive thinking is accomplished through an exploratory process which is dependent upon a solid patient/counselor therapeutic alliance.

Cognitive-behavioral therapy focuses on the patient’s negative self-talk, and offers practical suggestions on how to untwist one’s thinking to make it more adaptive. The CBT therapist assists the client in thinking more rationally by examining the individual’s spontaneous thoughts, observing ways in which they may distort reality, and ferreting out underlying assumptions or beliefs that affect ways of thinking and behaving.

Spontaneous thoughts are the nonsensical things that we tell ourselves when we are under stress – “I’ll never get a date, who would ever want me!” Cognitive distortions are the lenses out of which we perceive reality – “You always make me feel like a loser” (either or thinking). Underlying assumptions are the “hot buttons” which crystallize as a way of coping and getting our needs met during childhood – “I must avoid conflict at all costs; I hate disapproval and getting my feelings hurt.”

Cognitive-behavioral therapy seeks to refute the nonsensical things we tell ourselves and assists us in developing more rational ways of responding to our maladaptive thought processes. Since homework is an integral part of therapy, patients will be encouraged to complete exercises designed to change negative thinking. One concrete procedure helps the client to identify current troubling events, negative self-talk, and ways of rationally responding to situations sited. The individual logs difficult situations, identifies self-defeating thinking and refutes the negative thought processes with more rationally, adaptive way of responding to events. During each therapy session, the log sheet is reviewed for patient progress.

With CBT, clients are in control of their own progress. They are aware of the process that is necessary for change, and diligently work at modifying faulty thought patterns. Therapeutic progress is easily monitored through self-inventories and patient feedback. Time is always left at the end of sessions to review the benefits or pitfalls of the counseling sessions. Clients are asked to assess the effectiveness of their counselor’s treatment process.

Patients often ask, “How long will this counseling treatment take?” Although each case is unique, six to eight sessions are generally sufficient to teach clients strategies for reshaping their thinking. CBT is a time-limited, user-friendly, practical process for helping individuals to assess their negative thinking and making needed transformation in the way they respond to themselves and others. Individuals with anxiety, addictive patterns and depressive disorders are particularly well suited to benefiting from this from of treatment. The good news is that many behavioral health disorders can be treated successfully through cognitive-behavioral therapy. NACBT or The National Association of Cognitive-Behavioral Therapy is a good resource for locating counselors who are sufficiently trained, certified, and specialize in this treatment approach.

Social Media Is Helping Behavioral Health Clients and Professionals E-Tool

With mental health and substance abuse providers constantly seeking out the latest in treatment information and with their clients becoming much more involved in their own treatment, Social Media is becoming the tool of choice for researching information on specific behavioral health topics.

With the proper Social Media Use Policies in place, behavioral care treatment providers can easily “connect” with client populations by authoring blogs that satisfy their informational curiosities and needs and that are written in a layman language that they can easily understand and identify with. This is only the front end of the benefit.

A successfully authored blog post also encourages it readers to share comments and to subscribe to the blog by RSS feed or even to “follow” the author on Twitter. What a great way to generate interest in those who may be curious about what a particular “expert” blogger has to share with and offer the greater client population. Often this interest results in the formation of client – treatment provider professional relationship.

In addition, Social Media affords e-clients (those who use the Web to aid in their own treatment) and Social Media savvy behavioral care professionals to help spread useful information around any network that might therapeutically benefit from it. This therapeutic online synergy can only be considered a “miracle” of Social Media. It is living proof that Web technology has further evolved to innovate more quick and efficient ways to help the mentally ill and substance abusers in more ways than ever before. Millions of people are benefiting from having enlightening information available at their fingertips at any hour of the day or evening.

Consider some of the positive ways Social Media is helping the behavioral health community forge ahead on its helping mission.

• Advocates and e-clients are now easily able to identify their legislators; review proposed legislation, online; and share their personal and advocated views directly with their elected representatives as well as with the community-at-large. As a result of the growth of Social Media, countless federal and state bills that can undoubtedly affect the lives and careers of behavioral health consumers and their treatment professionals have been suggested, supported or dumped thanks to the comprehensive dialogs conducted over the Web during their initial considerations.
• Behavioral health practitioners and field consultants are regularly sharing their thoughts and best practices on Twitter, YouTube, SlideShare, Blogs and on weekly podcasts, just to name a few outlets. What better way to stay on top of advancements and who is responsible for helping them take place?
• At their Websites, behavioral health organizations of all kinds include their recommended links for all sorts of informative articles, conference notifications, job openings and RFPs. They also often share their recommendations and reviews with an increasingly interested audience on sites like LinkedIn, Facebook, StumbleUpon and Twitter.
No longer does one have to wait for and rummage through a whole litany of monthly and quarterly professional journals and newsletters to get information that is readily available on the Web.

The “word” surrounding Social Media within the professional circles of the behavioral health treatment community has not all been positive, thus far. In fact, in many health care circles including the medical profession, there is some ambivalence about what is being called the “e-movement.” The e-movement accounts for the growing momentum of Social Media, which has made it often the very first place many people go to locate a diagnosis and to find out what treatment options, are available to them. They used to just call a Dr. or a counselor and make an appointment to come in for a consultation. Not so much, anymore.

Professionals have become very used to being considered “experts” are not all comfortable with their patients or clients becoming anything more than the passive consumers they have always considered them to be.

Lucile Packard Children’s Hospital physician Alan Greene, MD, is particularly social-media-savvy (he has a Twitter feed, Facebook page and very interactive website) – and he shares his thoughts in the article:

“A couple of generations ago, the house call was the common way physicians would find out about the real lives of people and make an impact right in the middle of their lives, and today it’s social media,” says Dr. Greene.

This is a new and harsh reality for some. The e-movement certainly levels the playing field for everyone – to a very large degree – and results in different types and perhaps much stronger (financially) health care and behavioral care partnerships that can endanger the livelihoods of both the highly competent and the unquestionable subpar individual practitioner, alike. The overall value of Social Media to e-clients and those behavioral care professionals using it as a valuable tool for better health, certainly swamp this argument. Social Media has been a boon to e-clients and practitioners in behavioral health care and there are no signs of its popularity and value waning anytime soon.

Psychosocial Development and Dreams – Prevent Sociopathic Behavior

Through dream analysis we can precisely follow the development of our personality and understand the unconscious mind. Dreams reflect our psychological content and our behavioral health. They are also a source of objective information related to any important matter in our lives, especially concerning the person we love.

Through dream therapy we can help children, adolescents, and adults develop the positive characteristics of their personality, while eliminating the negative ones. Our dreams are produced by the unconscious mind that knows everything about us and our lives, and works like a natural doctor. It sends us protective messages and guidance in all dream images and scenes. We only have to learn the symbolic dream language in order to understand the unconscious logic, and the meaning of dreams.

Now that I simplified the complicated method of dream interpretation discovered by the psychiatrist Carl Jung, everyone can reap the benefits of this knowledge. We can now very easily follow everyone’s psychosocial development through dream translation, by correcting behavioral abnormalities that cause sociopathic behavior.

The anti-social or sociopathic personality disorder is a result of the invasion of the anti-conscience, (the wild side of the human conscience) into the human side of our conscience. This is easily verified in a dream analysis, as we find dream symbols that reflect the permanent influence of the anti-conscience in our behavior.

The sociopathic behavior is characterized by selfishness, cruelty, lack of respect for the others, irresponsibility, and manipulation. Sociopathic people never feel ashamed or guilty, being totally indifferent to justice. They don’t have friends; they are rude, unfair and sneaky. They live clearly dominated by the anti-conscience, (the primitive and violent side of their conscience), which destroyed the human side of their conscience. This is why they have no human sensitivity.

Dream therapy, according to the scientific method of dream interpretation, provides the only guaranteed treatment to prevent or eliminate sociopathic tendencies. Our dreams reflect our psychological development and behavioral health, helping us eliminate all the absurd tendencies that distort our behavior when we are under the influence of the anti-conscience.

Our dreams also give us objective information about the world where we are and our social environment. They protect our mental health from serious deceptions that could cause mental illnesses by showing us how we can develop our intelligence. We learn how to avoid what could lead us to absurdity and despair. We also learn how to distinguish what is worthwhile in our personality and must be developed.

In order to prevent a sociopathic disorder we must respect the importance of dreams and follow the unconscious guidance. Sociopathic behavior generates grave mental illnesses and unbearable life situations. It is responsible for the various social conflicts, crimes and terrorist attempts that characterize our world.

We must prevent it through regular dream analysis. This is how our psychosocial development won’t be damaged by the intervention of violent animal tendencies and their tragic consequences. We will instead, develop our positive capacities, becoming calm, balanced, and sensitive.