Training the trainers.
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Academic Medical Centers↗
Biomedical subjects
H J Schlesinger
Publications and source records attributed to H J Schlesinger.
A new look at evidence about reduced cost of medical utilization following mental health treatment. 1984.
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Age Factors↗
The fear of being left half-cured.
The complaint, "You are leaving me half-cured" is often heard from borderline patients in mid-recovery. They fear they are losing more than they could possibly gain; losing both the familiar sense of self given by their illness and the therapist, who will lose interest and abandon them far short of their fantasized ideal. Although cast in terms of an uncertain future, the phenomenon is to be understood in relation to change that has already occurred and requires working-through its implications both for the patient's external adjustment and in relation to the patient's inner world.
Adult↗
The process of interpretation and the moment of change.
The effectiveness of analytic interpretation is conditioned by a number of factors within the patient, within the analyst, and within the analytic situation. I will focus on one of these factors, part of the technical activity of the analyst that I will call follow-up interpretation, one which omitted, or even slighted, sharply diminishes the effectiveness of interpretation.
Adaptation, Psychological↗
Facts is facts--or is they?
The author argues that to consider the place of facts in psychoanalysis one must first of all distinguish between the use of the term fact in its everyday sense, in which its opposite would be untruth, from the scientific sense in which the term refers to a construction that has been awarded the status of fact by the theory in which it is embedded. Theories in sciences of human behaviour or experience must include not just the hierarchical arrangement of concepts and constructs of the physical sciences, but also the process orientation in which time is the major organising dimension. Facts, as constructs, have different significance in each of these versions of theory, and the meaning of validation, as well as the procedures for determining validity, also differ.
Humans↗
Women and outpatient mental health services: use by black, Hispanic, and white women in a national insured population.
Factors affecting ethnic differences in women's use of outpatient mental health services were analyzed to determine whether lower use by black and Hispanic women occurred when socioeconomic and other factors are controlled. Employing the Andersen and Newman model of health use, insurance claims of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed to identify significant predictors of use. Results revealed that black and Hispanic women had lower probabilities and amounts of use when compared to white women even after controlling for a number of variables. Further research is needed to examine cultural and gender-related factors that may underlie ethnic differences; attitudinal factors and service system barriers are also implicated. Such findings have policy implications in the current climate of health care reform for which efforts are needed to increase access to care for ethnic minority women and other underserved populations.
Adult↗
Ethnicity and the use of outpatient mental health services in a national insured population.
OBJECTIVES: Factors affecting ethnic differences in the use of outpatient mental health services are analyzed in an insured, nonpoor population to determine if lower use by Blacks and Hispanics persists when socioeconomic and other factors are controlled. METHODS: To identify significant predictors of the probability and amount of use, insurance claims data for a population of 1.2 million federal employees insured by Blue Cross/Blue Shield in 1983 were analyzed with the Andersen and Newman model of health service utilization. Logistic and ordinary least squares regression models were estimated for each ethnic group. RESULTS: Blacks and Hispanics had lower probabilities and amounts of use when compared with Whites after controlling for a number of variables. CONCLUSIONS: Since ethnic differences in the use of outpatient mental health services exist even in an insured, nonpoor population, factors other than lower socioeconomic status or insurance coverage--for example, cultural or attitudinal factors and service system barriers--are likely responsible. Such findings have policy implications in the current climate of health care reform to increase access to care for the underserved.
Adolescent↗
How the analyst listens: the pre-stages of interpretation.
There has been little systematic treatment of the pre-stages of interpretation that include the process of analytic listening itself, and the gathering and sorting of information that could lead to the formulation of an interpretation. The situation of the analyst as listener is compared with that of the social listener, and the focus is on processes close to the surface of experience. Three 'modes' of listening are described that must be continuously available to the analyst, and which taken together capture the sense of 'evenly hovering attention'. The use and misuse of the concept of empathy in relation to analytic listening are discussed.
Attention↗
Ethnic differences in use of inpatient mental health services by blacks, whites, and Hispanics in a national insured population.
OBJECTIVE: We examine whether ethnic differences in use of inpatient mental health services exist when the usually confounding effects of minority status and culture are minimized or controlled. DATA SOURCES AND STUDY SETTING: Secondary analyses were conducted using a national insurance claims database for 1.2 million federal employees and their dependents insured by the Blue Cross/Blue Shield (BC/BS) Federal Employees Plan (FEP). STUDY DESIGN: The Andersen-Newman model of health utilization was used to analyze predisposing, enabling, and need variables as predictors of inpatient mental health utilization during 1983. The study design was cross-sectional. DATA COLLECTION: The study database was made up of BC/BS insurance claims, Office of Personnel Management employee data, and Area Resource File data. PRINCIPAL FINDINGS: No significant differences were found among blacks, whites, and Hispanics in the probability of a psychiatric hospitalization or in the number of inpatient psychiatric days. Regression analyses revealed younger age and psychiatric treatment of other family members as significant predictors of a hospitalization; region of residence, younger age, hospital bed availability, and high option plan enrollment were significant predictors of the number of treatment days. CONCLUSIONS: Ethnic differences in use of inpatient mental health services were not significant in this generously insured population. Further research involving primary data collection among large and diverse samples of ethnic individuals is needed to fully examine the effects of cultural and socioeconomic differences on use of mental health services.
Adolescent↗
The role of the intellect in the process of defense.
Ordinary intellectual capacities can be used for defensive as well as adaptive purposes. The author focuses on how a particular aspect of the intellect--language skills--can serve defensive functions. Using clinical examples, he examines how the defense "mechanism" of isolation operates through the use of common verbal formulas, through the deletion or substitution of conjunctions, through vagueness and indefinite reference. Other expressions of isolation include shifting emphasis away from what is important, excessive generalizing, and the development of an elliptical private language. He concludes with a discussion of how clinicians can learn both to listen to the patient empathically and to recognize and work with these defensive operations.
Adult↗
Use of inpatient services by a national population: do benefits make a difference?
This study describes changes in the use of inpatient mental health services by children and adolescents under age 18. The data were insurance claims from the Blue Cross and Blue Shield Federal Employees Program. The study focused on a cut in inpatient benefits that occurred between 1978 and 1983. The rate of inpatient hospitalization dropped significantly, and the average number of days also decreased significantly from 45.8 to 27.0 days. This study is among the first to demonstrate that the rate and amount of inpatient care provided for children and adolescents is responsive to variations in benefit coverage.
Adolescent Psychiatry↗
The effect of insurance benefit changes on use of child and adolescent outpatient mental health services.
Use of outpatient mental health services by dependent children younger than 18 years of age enrolled in the Blue Cross and Blue Shield Federal Employees Plan (FEP) is examined in 1978 and 1983 focusing on a cut in benefits and a shift from high- to low-option plan enrollment between those years. While use rates increased from 2.13% to 2.76% by 1983, the average number of visits decreased from 18.9 to 12.8. High-option plan use exceeded low-option plan use in both years--2.26% versus 0.81% in 1978 and 3.58% versus 1.93% in 1983. In addition to benefit plan, ethnicity, parent's education, type of provider, and type of treatment setting also significantly predicted amount of use. Despite the strong evidence of the effects of benefit coverage, it is likely that need exceeded use even in this insured population of children and adolescents. Implications of the findings are discussed in the context of recent dramatic changes in mental service delivery including privatization, managed care initiatives to cut costs, and growing pressures for national health insurance.
Adolescent↗
Serious physical illness as a stressor: effects on family use of medical services.
The purpose of this study was to investigate the effect of stress on the family due to the hospitalization of a family member for a serious chronic illness. The data were the health insurance claims of 3,591 families obtained from the largest U.S.A. insurer of federal employees. It was hypothesized that the nonhospitalized family members would have a stress-related increase in medical expenses for some period of time after the chronically ill person was hospitalized. Multiple regression analysis with adjustments for a number of covariates found increases in mean medical charges of $326 per person (p less than 0.01) (excluding the hospitalized person) in the 3 years following the hospitalization. This finding lends support to the theory that stress--in this case, hospitalization of one family member--affects the entire family system. No significant differences were found in medical charges between families who did and did not receive mental health treatment following the hospitalization.
Adaptation, Psychological↗
What does psychoanalysis have to contribute to the understanding of character?
While character is an indispensable term in psychoanalytic discourse, it is not primarily a psychoanalytic term. The psychoanalytic theories of neurosis and development are built around the idea of the "complementary series." While psychoanalysis has powerful theories about the "accidental" complement, it only recognizes the "constitutional" complement, and psychoanalysis has nothing to say about it. Current research may shed more light on this latter component and also provide the data for future psychoanalytic theorizing about character and personality.
Adolescent↗
Assessing consumer benefit. Cost offset as an incidental effect of psychotherapy.
In addition to improved quality of care, evidence of cost benefits associated with the provision of consultation-liaison services may be used to justify the expenses of such programs. Reductions in use of medical services following mental health treatments are not inevitable, however. Advocates of C-L should be aware of the circumstances under which cost benefits are likely to be found and focus assessments appropriately.
Cost-Benefit Analysis↗
Economic discrimination against elderly psychiatric patients under medicare.
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Aged↗
A new look at evidence about reduced cost of medical utilization following mental health treatment.
Meta-analysis of 58 controlled studies and analysis of the claims files for the Blue Cross and Blue Shield Federal Employees Plan for 1974-1978 provide mutually supporting evidence of the cost-offset effects of outpatient mental health treatment. These two complementary resources provide a powerful tool for investigating the nature of associations between mental health services and subsequent reductions in the use of other medical services. The authors found that the reductions in use of medical services are associated with inpatient rather than with outpatient utilization and tend to be larger for persons over 55 years of age.
Adolescent↗
Mental health treatment and medical care utilization in a fee-for-service system: outpatient mental health treatment following the onset of a chronic disease.
Charges for medical services of persons covered by the Blue Cross/Blue Shield Federal Employees Program from 1974 through 1978 who were first diagnosed as having one of four chronic diseases in 1975 and within one year began mental health treatment (MHT) were compared with persons who also were first diagnosed as having one of these diseases in 1975 but had no subsequent MHT. In the third year following the diagnosis, those having seven to 20 MHT visits had medical charges $309 lower and those having over 21 MHT visits had medical charges $284 lower than the comparison group. The savings in medical charges over three years of the group having seven to 20 MHT visits were a function of lower use of inpatient services and roughly equaled the cost of 20 MHT visits. Outpatient mental health treatment can be included in a fee-for-service medical care system to improve the quality and appropriateness of care and, if not extensive, may also serve to lower medical care costs.
Adolescent↗