Biomedical subjects
Publications and source records attributed to H P Lefley.
The roles of psychology and psychiatry are rapidly changing with respect to people with serious mental illness. The development of these roles will seriously impact the quality of care available for this vulnerable population.
We need to develop living arrangements for persons with severe mental illness that are durable and available as long as needed and that provide a sense of community.
As persons with severe and persistent mental illness age, large numbers continue to live with their elderly parents or receive substantial social and economic support from them. Prospective studies suggest that when caregivers die, individuals with mental illness experience housing disruptions and potentially traumatic transitions. This paper describes the scope of the problem and addresses pragmatic and psychological issues involved in preparing both caregivers and patients for parental aging and eventual loss. It outlines the practitioner's role in helping patients and families overcome specific psychological barriers to planning for continuing care management, appropriate residential alternatives for patients, and their timely placement. The discussion emphasizes helping patients control their own futures by proactively ensuring resources for maintaining or improving their quality of life. The Planned Lifetime Assistance Network (PLAN), now available in some states through the National Alliance for the Mentally Ill, is described. PLAN, and similar organizations, provide lifetime assistance to disabled individuals whose parents or other family members are deceased or no longer able to provide care.
Cross-cultural studies of families' experience of mental illness are discussed, in terms of uniformities in and differences between belief systems and values, caregiving norms, perceived burden and distress, and expectations, with suggestions for further research and applications to practice.
Transformed treatment philosophies, egalitarian roles, crossover competencies, and engagement of consumers and families are essentials in training.
In Modern Western cultures, conceptual models of mental illness are interwoven with value systems of individualism, agency, internal locus of control, and fear of dependency. These values have translated into psychological theory and practice, affected families' relationships with the professional, legal, and consumer communities and have often exacerbated family burden. Culturally patterned attributions of individual accountability also affect family-patient interactions and may have an effect on relapse and prognosis. The family and consumer movements are discussed in terms of their orientations, services, social impact, and influence on epistemology, particularly with reference to the different effects of protective paternalism and individualistic autonomy. Questions are raised regarding cultural values and differential prognoses in modern and developing countries and whether the process of recovery may be shaped by different cultural introjects. It is suggested that the era of family and consumer empowerment may be heuristic in discovering parameters of mental illness and potential for recovery, and ideas are offered for future cross-cultural research.
Families' difficulties in getting treatment for highly disruptive, assaultive, or suicidal family members are compounded by patients' resistance, their resentment if relative seek forced interventions, and systemic and legal barriers to timely care. Consumer services and outreach may be a route to voluntary treatment.
Research on families of people with severe mental illness has identified significant caregiving burden. Although professional interventions generally assume that families have a major role in the client's progress, the focus of the consumer movement on recovery through empowerment, peer supports, and consumer-run services may have important, as yet unquantified, effects. Keeping in mind the functional heterogeneity of individuals with mental illness, it is suggested that consumer emphasis on autonomy may provide the major relief for family burden.
The authors describe a six-month training module in public psychiatry developed in 1991 at the University of Miami Medical School. The module is centered on weekly intensive site visits to a range of community and advocacy programs, including the state hospital, services targeted to different groups at various community mental health centers, substance abuse treatment programs, forensic sites, rehabilitation centers, and family and consumer groups. Preliminary evaluation results indicate that residents gain a better understanding of community services and of system linkages and barriers and appear to develop a more positive prognostic attitude. They also gain a clearer picture of the many roles of community psychiatrists.
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Family burden reported by parents of offspring with severe mental illness was examined to determine whether burden increases with age. Older parents were troubled by cognitive dimensions of burden, while younger parents were distressed by their offspring's behavior, suggesting that interventions should vary according to parents' age as well as developmental stage of their child's illness.
This article describes the frequency of possible risk factors that emerged during a cross-cultural study of psychosocial response to sexual assault among African-American, Hispanic, and non-Hispanic white women presenting for treatment at a major urban rape treatment center. Of 881 victims screened, 51% had no observable risk factors while 49% fell into categories of variables that previous research has associated with increased vulnerability. Included were mental disability (psychiatric or developmental), a prior history of rape or incest, tourist or visitor status (site unfamiliarity), and homelessness. Ethnic groups differed significantly in these categories, suggesting socioeconomic and cultural variables that may affect rape statistics and that should be taken into account in rape prevention programs in the community.
Cultural definitions of rape were assessed among 101 African-American, Hispanic, and non-Hispanic white female rape victims and 89 nonvictims matched for ethnicity, age, marital status, and socioeconomic status. Hispanics scored highest and whites lowest both in perceived community victim-blaming and in victims' psychological distress. Social and treatment implications are discussed.
Research on schizophrenia has suggested an association between relapse of patients and high expressed emotion (EE), defined as criticism, hostility, or emotional overinvolvement of at least one family member. In international studies, however, the majority of families of persons with schizophrenia demonstrate low expressed emotion. These families are described as empathic, calm, and respectful by EE researchers, who also reject the idea of family schizophrenogenesis. The author discusses expressed emotion as a construct, its validity and stability over time, and the direction of the relationship between relatives' expressed emotion and patients' symptoms and behavior. She reviews studies indicating significant differences in levels of expressed emotion across cultures, examines the social policy implications of programming based on the construct, and suggests research on EE analogues in clinical and rehabilitative environments.
This paper traces the sixteen year history of a unique community mental health center which has combined academic and service provider roles in delivery of culturally appropriate care. Initially an arm of a department of psychiatry and derived from an anthropological research project, the center model was based on seven teams serving discrete ethnic communities, with subsequent development of a network of neighborhood-based "mini-clinics" as well as centralized aftercare facilities. The team staff-social scientists, clinicians, and paraprofessionals all of matching ethnicity to the populations served-became a core of "culture brokers" with a service, teaching, and research role at the interface of the university, medical center, and community. Subsequently the university was funded for a cross-cultural training institute for mental health professionals. Center staff extended training in culturally appropriate care to 174 mental health professionals from 97 facilities throughout the nation, as well as other spinoffs improving cultural expertise of staff in public sector agencies. Data on effectiveness of services and training are given and significant findings are discussed. The description includes the impact of historical shifts in funding, the effects of external events on community mental health center structure, and the current state of cross-cultural training and public-academic linkages in this particular program.
The relationship of culture to chronic mental illness is reviewed in a cross-national and cross-ethnic perspective. The author critically examines the argument, based on differential prognosis for serious mental illness in developing and industrial countries, that chronicity is a cultural artifact. Key questions include whether cultural beliefs and practices that minimize social stigma, self-devaluation, and patients' assumption of the sick role are linked to better prognosis. World view, religion, alternative healing resources, values of interdependence, extended kinship structure, family support, and professionals' willingness to work collaboratively with families are viewed as cultural strengths that may help to mediate the course of mental illness. Issues that are relevant to treatment of long-term psychiatric disability in ethnic patients in the United States include interethnic differences in the distribution of cases and service utilization patterns, diagnostic and medication issues, and development of culturally relevant treatment modalities.
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Explore the source record for details and available documents.