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Biomedical subjects

R L Munich

Publications and source records attributed to R L Munich.

At least 19 recordsLinked to original sources

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.

Adult↗

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. Forty-six individuals with schizophrenia or schizoaffective disorder were recruited upon discharge from an inpatient unit. Symptom levels, neurocognitive functioning (information processing, memory, and executive functioning), and symptom awareness were documented, and social adjustment was assessed in three domains: treatment compliance, social behavior, and subjective quality of life. Cross-sectional data from initial assessments are reported. Sequential linear regression analyses identified differential associations between illness characteristics and outcome domains. Treatment compliance was most influenced by insight; social behavior deficits were associated with thought disorder and neurocognitive (working memory and visuo-spatial) impairments; and quality of life was associated with mood disturbances. Outcome is multidimensional in schizophrenia, and there are differential patterns of associations between illness characteristics and domains of social adjustment. Studies such as this can guide clinicians in determining the most appropriate treatments for specific individuals and should also guide researchers in efforts to clarify the processes that underlie treatment response and recovery in schizophrenia.

Adult↗

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. Evolution from therapeutic community to continuum of care replaced the traditional inpatient setting with a range of more ambulatory-based alternatives. Comprehensive treatment matches these changes with the phase of illness and is reinforced with a flexible and supportive psychotherapy that emphasizes medication compliance and educational and problem-solving tasks.

Humans↗

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. Data from three years of operation suggest that symptom severity is not a reliable indicator of medical necessity in day treatment. As expected with a clinically based system, a composite measure of benefit and medical necessity indicators weighted toward functioning in living, learning, working, and socializing environments predicted physician reviewer denial of continued day treatment, but length of stay did not.

Day Care, Medical↗

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. Actualization of the learning depends on the psychological state and level of emotional preparedness of the individual member, the consultant's orientation and style, the composition and development of the group, and its relationship to the organization in which it takes place. An example is provided to highlight the areas of potential learning, and there is a discussion of some applications to the patient role and the practice of group psychotherapy.

Female↗

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. The authors call for a more central role for rehabilitation, which integrates treatment in the three domains and uses group methods to formulate plans and enhance client involvement.

Activities of Daily Living↗

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. An abbreviated version of the negative symptom scale was especially effective in separating groups.

Adult↗

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. Based on two years of chart review with clinical teams, principles of psychosocial rehabilitation and a dynamically oriented philosophy of inpatient treatment for the long-term patient, this presentation demonstrates one method for linking problems and goals with length of stay, quality assurance behaviors with quality of care, and integration of the multidisciplinary team into the entire process.

Forms and Records Control↗

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. Preliminary data that demonstrate the clinical usefulness of the process and its impact on a treatment service are presented.

Forms and Records Control↗

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. Its evolution and rationale are described, and an example form follows this report.

Forms and Records Control↗

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. Extreme intrasubject variability, however, was specific to schizophrenia, and may be a trait marker of the disorder.

Adult↗

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. There is a paucity of systematic research on the topic (Trauer 1987), and except for a kind of ritualized staff wrap-up following the meeting, there is virtually no formal teaching about the meaning, goals or leadership of such meetings. In the literature to date are several overlapping proposals for typologies of community meetings according to the nature of the patient population, the nature of the tasks assigned to the meeting, and the optimal degree of structure for the meeting. The task of this contribution is twofold: first, to suggest a tripartite differentiation in the types of large-group meetings, which takes into account the authors' experience as well as previous literature; second, to suggest that these are pure types and that most settings require a mixture of two or three types. In particular we are interested in those meetings most appropriate to the long-term unit. It is our hope that a clarification of types will facilitate a more systematic approach to clinical, administrative and educational dilemmas.

Group Processes↗

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.

Conflict, Psychological↗

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. These tasks are divided into functions that address organizational and human needs and are linked with prerequisite psychological valences which enhance their implementation. Examples are designed to demonstrate functional and dysfunctional consequences of the four tasks.

Health Facility Administrators↗