Social Psychiatrists Research Articles

Recovery From Mental Health Problems: Scratching The Surface Without Ethnography

This article examines a central plank of mental health policy (‘recovery’) in societies which have attempted to reverse the long-term warehousing of those with a diagnosis of mental disorder (de-institutionalisation). The emergence of the concept is traced in relation to the shift from an institutional to a more dispersed and community-based form of service organisation. Different usages of the term ‘recovery’, each with distinct implications for practice are considered on the part of three main interest groups (traditional bio-medical psychiatrists; social psychiatrists emphasising social skills training; and dissenting service users). These different usages suggest that ‘recovery’ is a polyvalent concept that creates an uneasy consensus point to define the management philosophies of local services enacting mental health policy. Also mental health work is about more than the group of patients mainly considered in relation to recovery (those with ‘severe and enduring mental health problems’). Practice-near research strategies are now required to investigate the varied practical scenarios these contradictions generate and ethnographic research is therefore indicated. Without multiple ethnographies, we will be left with competing rhetoric about recovery and its meaning or meanings may be rendered worthless.

Do Perceptions of Dysfunction and Normality Mediate Clinicians’ Judgments of Adolescent Antisocial Behavior?

Are mental health clinicians guided by the injunctions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in making judgments of mental disorder in youth engaging in antisocial behavior? The DSM requires clinicians making a judgment of mental disorder to first make complex mediating inferences about internal dysfunction and rule out the possibility that behaviors are normal reactions to a problematic environment. Responding to a case vignette in which the social context of antisocial behavior was systematically varied, a sample of 1,500 social workers, psychologists, and psychiatrists made judgments about the presence of mental disorder, internal dysfunction, and normality in the antisocial behavior of a youth. Perceptions about the presence of internal dysfunction and normality are found to be related to judgments of mental disorder, but they do not fully mediate the relationship between the influence of social context and judgments of mental disorder.

The urban aminal: population density and social pathology in rodent and humans

In a 1962 edition of Scientific American, the ecologist John B Calhoun presented the results of a macabre series of experiments conducted at the National Institute of Mental Health (NIMH).1 He had placed several rats in a laboratory in a converted barn where – protected from disease and predation and supplied with food, water and bedding – they bred rapidly. The one thing they were lacking was space, a fact that became increasingly problematic as what he liked to describe as his “rat city” and “rodent utopia” teemed with animals. Unwanted social contact occurred with increasing frequency, leading to increased stress and aggression. Following the work of the physiologist, Hans Selye, it seemed that the adrenal system offered the standard binary solution: fight or flight.2 But in the sealed enclosure, flight was impossible. Violence quickly spiralled out of control. Cannibalism and infanticide followed. Males became hypersexual, pansexual and, an increasing proportion, homosexual. Calhoun called this vortex “a behavioural sink”. Their numbers fell into terminal decline and the population tailed off to extinction. At the experiments’ end, the only animals still alive had survived at an immense psychological cost: asexual and utterly withdrawn, they clustered in a vacant huddled mass. Even when reintroduced to normal rodent communities, these “socially autistic” animals remained isolated until death. In the words of one of Calhoun’s collaborators, rodent “utopia” had descended into “hell”.3 Calhoun’s experiments with rats and mice proved extremely influential. His findings resonated with a variety of concerns, including population growth, environmental degradation and urban violence. In the course of a project on the history of stress, Jon Adams of the London School of Economics and I have traced how evidence of crowding pathology, generated in the rodent laboratories of NIMH, travelled to an alternative setting: the buildings, institutions and cities of the social scientist, city planner, architect and medical specialist. While urban sociologists and social psychiatrists explored correlations between density and pathologies in their statistical studies, environmental psychologists moved to the laboratory and fields such as the prison, the school and the hospital. Social and medical scientists were attracted to the possibility of providing evidence of how a physical and measurable variable – density – had important consequences demanding policy response. Many had already begun using Calhoun’s rats to support family planning programmes or for improving the physical design of the city.4 However, results from human studies of crowding proved inconsistent. In an influential series of experiments by the psychologist Jonathan Freedman, individuals employed to carry out tasks under varying conditions of density displayed few pathologies.5 Focus now shifted away from simply identifying the pathological consequences of density and towards factors that mediated its effects. This was aided by a distinction between “density” as a physical measure and “crowding” as a subjective response.6 Feeling crowded was determined by a range of social and psychological factors: an individual’s desired level of privacy, their ability to control a situation or their social role. Increased density might be inevitable but human beings were capable of coping with crowding. Yet this did not mean that Calhoun’s research was rejected. Researchers recognized that Calhoun’s work was not simply about density in a physical sense, as number of individuals-per-square-unit-area, but was about degrees of social interaction. By reducing unwanted interaction through improved design of space – providing prisoners with individual cells or patients with independent living areas – crowding stress could be avoided.7 This had been the focus of Calhoun’s later research. Through improved design and increased control, Calhoun attempted to develop more collaborative and adaptable rodent communities capable of withstanding greater degrees of density.8 Continued problems of prison overcrowding and transport congestion ensure that the subject of crowding stress remains pertinent, but the relevance of Calhoun’s experiments is less commonly acknowledged. Towards the end of his career, Calhoun, who died in 1995, would be increasingly dismayed that it was a simplified, negative message – population density equals pathology – that was more commonly associated with his work, making his contribution seem not only flawed in the human context, but dangerous. In the words of the sociologists Fischer & Baldassare: “A red-eyed, sharp-fanged obsession about urban life stalks contemporary thought.”9 In focusing upon crowding, not only were the benefits of dense city-living ignored, but other causes of urban pathology, such as poverty and inequality, were neglected. Yet Calhoun’s work considered many of these factors, suggested how they could be overcome, and as such, his role deserves reconsideration. ■

`Recovery' and current mental health policy

This article examines a central plank of current mental health policy--'recovery'. The latter is being used increasingly as a harbinger of progress, when discussing improvements in service quality and social inclusion. Mainly using Britain as a case study, different usages of the term are considered on the part of three main interest groups: traditional biomedical psychiatrists; social psychiatrists emphasizing social skills training; and dissenting service users. These different usages suggest that 'recovery' is a polyvalent concept, which creates an uneasy consensus point to define the management philosophies of local services enacting mental health policy. It has also emerged during a time when government health policy is seeking to support people with chronic conditions in community settings on the one hand and minimize the risks they might pose on the other. This tension is particularly relevant for those with mental health problems.

`Recovery' and current mental health policy

This article examines a central plank of current mental health policy--'recovery'. The latter is being used increasingly as a harbinger of progress, when discussing improvements in service quality and social inclusion. Mainly using Britain as a case study, different usages of the term are considered on the part of three main interest groups: traditional biomedical psychiatrists; social psychiatrists emphasizing social skills training; and dissenting service users. These different usages suggest that 'recovery' is a polyvalent concept, which creates an uneasy consensus point to define the management philosophies of local services enacting mental health policy. It has also emerged during a time when government health policy is seeking to support people with chronic conditions in community settings on the one hand and minimize the risks they might pose on the other. This tension is particularly relevant for those with mental health problems.

Encouraging Unreliable Forensic Practices?

In contrast to its 1992 ethical code, the American Psychological Association's proposed ethical code allows psychologists to embrace novel scientific hypotheses and unproven clinical conjectures. Unlike the 1992 code, the proposed code neglects the significance of “scientifically derived information.” The proposed code also no longer obligates psychologists to acknowledge the limits of their data or conclusions when testifying in legal proceedings. While detailing changes between the 1992 code and the proposed code, well-prepared cross-examination could embarrass and discredit psychologists. Compared to the ethical obligations of social workers and psychiatrists, the proposed APA code is less demanding. Adopting the proposed APA code, in its present form, is therefore ill-advised.

Private Practitioners’ Perceptions of the Changes in Their Use of Treatment Modalities Following Participation in Managed Care Panels

Private practicing social workers, psychologists, and psychiatrists were surveyed to assess their perceptions of how their use of treatment modalities has changed since joining managed care panels. Social work respondents report that they perceive managed care organizations as certifying them to practice individual therapy more since joining managed care panels than they practiced individual therapy prior to joining managed care panels. However, they perceive managed care organizations as certifying them to practice group and family therapy less often since joining managed care panels. Psychologist respondents report that they perceive managed care organizations as certifying them less often for all treatment modalities except individual therapy. Likewise psychiatrist respondents report they perceive managed care organizations as certifying them less often for all treatment modalities except medication management. These results have potential implications for educators and practitioners interested in pursuing careers in solo or group practice.

The working practices of the police in relation to mentally disordered offenders and diversion services.

A research study was undertaken to examine the working practices of four bridewells in Hampshire in relation to mentally disordered offenders (MDOs) and diversion services. A consecutive sample of individuals detained in cells and not identified by the police as having a mental disorder were screened for the presence of mental disorder and their suitability for diversion. Custody and detention staff were observed and interviewed to elicit their views and working practices in relation to MDOs. The findings revealed that in bridewells with diversion schemes an average of about 7% of detained individuals had mental disorders who were suitable for diversion but were not detected by the police. In the bridewell without a diversion scheme the figure was 14%. Conversely, many individuals without a formal mental disorder were inappropriately referred to diversion schemes. The effectiveness of screening processes by custody staff was variable. Facilities in the bridewells were not suitable for containing disturbed individuals. Delays in obtaining mental health assessments caused considerable concern for police officers and prolonged the discomfort of vulnerable individuals. Further preparation and training of custody staff is needed to improve screening procedures. Reception and detention facilities for mentally disordered individuals should be reviewed and response times for approved social workers (ASWs) and psychiatrists would benefit from improvement.

Examining the Landscape of Managed Behavioral Health Care Through the Market Paradigm

ABSTRACT The purpose of this article is to examine the market paradigm's impact on private practicing social workers, psychologists and psychiatrists who are reimbursed for services by managed behavioral health care organizations (MBHCOs). Five hundred eighty-two private practitioners from across the nation responded to a mailed survey in which they were asked a series of questions concerning changes in their business practices subsequent to joining MBHCO provider panels. Results indicate that despite the concerns about MBHC, these practitioners have sustained their practices. The market paradigm's use in explaining MBHC's impact on the private practitioners was found to have limited utility.

Psychiatric epidemiology: progress and prospects in the year 2000.

In the last half century, the field of psychiatric epidemiology has been born and is rapidly coming of age. The emergence of chronic disease epidemiology in the 1940s and 1950s was conceptually joined to the revival of interest in psychiatric disorders that came about after World War II, in a publication by the Milbank Memorial Fund, in 1950, which used the term psychiatric epidemiology (1). For 25 years following, sometimes called the of psychiatric epidemiology (2), the field was dominated by sociologists and social psychiatrists, who applied newly developed household survey techniques to the problem of estimation of the prevalence of mental problems and who studied causal factors such as socioconomic stratification (3, 4), social integration (5), and social stress (6). There were relatively few epidemiologic studies of specific mental disorders, and those that existed focused efforts on measuring the extent of disorders in the population, that is, descriptive epidemiology (7). Research directed toward understanding the etiology of disorders— analytic epidemiology—used measures of psychological distress or global impairment, precluding integration with laboratory and clinical research and hindering construction of credible etiologic hypotheses. During this second generation of psychiatric epidemiology, there were developments in related fields that were to overtake and change the field drastically. One important advance was the development of the empirical basis for psychiatric diagnosis. In the latter half of the decade of the 1960s and into the 1970s, several studies (8, 9) showed that the reliability of psychiatric diagnosis was so weak as to allow the charge that diagnoses were myths or ideology (10,11). Empirical work on

Private practitioners' documentation of outpatient psychiatric treatment: questioning managed care.

This study investigates how social workers, psychologists, and psychiatrists document the treatment they provide clients to managed behavioral health care organizations. The rosters of the Register of Clinical Social Workers, the American Psychological Association, and the American Psychiatric Association yielded a sample of 168 private practicing social workers, 158 psychologists, and 258 psychiatrists from across the nation. Results indicated that practitioners differed based on age, amount of time spent in private practice, racial self-identification, percentage of time with clients diminished due to communicating with managed behavioral health care organizations, and documentation of clients' prognoses. Some practitioners believe it is necessary to report treatment needs in ways to assure certification rather than in ways that accurately depict clients' clinical profiles. The ramifications for clinicians' evaluation of their own practices, reimbursement for their services, and meeting clients' needs while working under managed behavioral health care guidelines are discussed.

The development and evaluation of a hybrid decision support system for clinical decision making: The case of discharge from the military

This article reports on the development, implementation, and evaluation of a decision support system (DSS), a hybrid of a statistical model (regression equation) and expert rules, to support this decision. The study focused on the decisions made by social workers, psychologists, and psychiatrists serving as military mental health officers to recommend discharge from compulsory duty in the Israeli army because of mental or emotional difficulties. The process involved three consecutive steps: modeling decisions by statistical analysis of past and current decisions and by eliciting expert rules, developing o hybrid decision support system, and evaluating the DSS through empirical validation and a user survey. The validity of this hybrid DSS was established. The DSS was able to predict 86.5 percent of new decisions made by mental health officers and 70 percent of post decisions. User acceptance, on the other hand, was low. This article discusses these findings and their implications for practice. Key words; clinical judgment; decision support systems; expert rules; mental health officers; military Social workers and other helping professionals make clinical judgments on a routine basis. Many of these decisions have important consequences for clients. Relying on clinical judgment and expertise, practitioners make daily decisions whether to accept clients for treatment, render services, hospitalize, discharge, or commit to involuntary care; such decisions can be of immeasurable significance to people's lives. Our empirical study of these important judgments and decisions made in the helping professions revealed how these professions are fallible and prone to error (Gambrill, 1990; Gibbs & Gambrill, 1996; Nisbett & Ross, 1980). Almost all clinical decisions are made under some degree of uncertainty (Hogarth, 1980). Many factors in the decision-making process, such as incomplete or unreliable information relevant to the decision, and errors or inconsistencies in the application of decision-making rules introduce uncertainty. Much of the uncertainty results from the probabilistic nature of the outcomes of decisions. Decisions made under what seem to be identical situations lead to different outcomes (Cooksey, 1996). Fallibility, therefore, is an inseparable feature of clinical judgment under uncertainty. Our study focused on the decisions made by social workers, psychologists, and psychiatrists serving as military mental health officers (MHOs) to recommend discharge from compulsory duty in the Israeli military services because of mental or emotional difficulties. This decision has significant consequences for the individual soldier, as well as for the soldier's social environment. Compulsory service in the military is a major duty and right of all Jewish citizens in Israel (most non-Jewish citizens are exempt from compulsory service). A discharge on the basis of psychiatric dysfunction stigmatizes the individual in civilian life. Consequences range from difficulties in obtaining a driver's license or in securing employment to less blatant discriminatory attitudes in Israeli society. On the other hand, a misguided decision not to discharge a dysfunctional soldier may lead to dire outcomes such as psychotic breakdown, suicide, and violent behavior within the unit, which in turn could lead to failure in battle (Benbenishty, Zirlin-Shemesh, & Kaplan, 1993). Military MHOs, the majority of whom are social workers, assess the soldier and decide whether or not to lower the soldier's medical rating on psychiatric grounds, thereby causing an immediate dismissal from the military. This decision is based on clinical judgment and not on any preset requirements or guidelines. Thus, it is open to the same problems in judgment identified in so many other contexts. Furthermore, given the consequences of the decision, the need to maintain consistency among MHOs making the decision is of special importance. …

Recent Developments in the Treatment of Nonpsychotic Morbid Jealousy: Introduction

" . . . trifles, light as air, Are to the jealous, confirmations strong As proofs of holy writ." Othello, Act III iii, 323-5. Jealousy is a complex syndrome that fascinates the literary world and arouses the interest of social scientists, psychologists and psychiatrists. It is believed to be an innate part of a human condition influenced by culture. It is thought to be prevalent in cultures that favor sexual monogamy. In its mild form it can be viewed as evidence of love and care; some writers would call it possessiveness. When the emotional and behavioral aspects are beyond control, when jealousy torments its victims, harasses the partner and probably others, then it becomes morbid. Research workers had difficulty agreeing on a definition. This may be related to the differences in theoretical background, and the population subject to that particular study. Sociologists studying sexual or romantic jealousy will include the reaction to actual infidelity. To the clinician this may be viewed as normal jealousy, and the absence of a rival would be an essential aspect for the definition of morbid jealousy. The clinician would divide morbid jealousy into psychotic and neurotic forms. The present issue deals mainly with the neurotic forms of jealousy. Other classifications reflect the different theoretical backgrounds of the authors. The prevalence of the problem is unknown. Most studies report higher prevalence among men, yet the method of collecting the sample may influence the outcome (Tarrier, Beckett, Harwood, & Bishay, 1990). Shepherd (1961) provided a detailed account of the diversity of the clinical presentations. Tarrier and colleagues (1990) viewed the manifestations as responses in cognitive, emotional and behavioral domains. The central feature of morbid jealousy is the intrusive thoughts/suspicions about the partner's fidelity. In psychotic forms of morbid jealousy, the central delusions of infidelity are held with absolute conviction; in nonpsychotic forms they resemble automatic thoughts (Bishay, Tarrier, & Petersen, 1989) and are accepted without challenge. The clinical picture is further extended by the efforts of the patient to substantiate the clinicians' suspicions. Different attempts were made to identify etiological factors. Delusional forms were described in patients suffering from psychotic illness, organic brain disease and head injury, and affective disorders. The interaction of the jealous thoughts and the functional illness is complex and cannot be viewed as cause and effect. Different schools of thought offered psychopathological models. Some emphasized personality predisposing factors. The psychoanalytical literature emphasized the role of early mother fixation, repressed homosexuality, the Oedipal situation and the pathological castration complex. The behaviorists equated jealous thoughts and checking behavior with the ruminations and rituals of obsessive compulsive neurosis. Ellis emphasized the role of the culture and society as well as the individuals need for a partner's love, together with a pervasive feeling of inadequacy if that love is lost. A cognitive behavioral model (Tarrier et al., 1990) considered the central feature to be the individual's tendency to make systematic distortions and errors in the perception and interpretations of events and information. Activated schemata about the sexual behavior of other members of the opposite sex and the individual's lack of attractiveness play a role in maintaining these cognitive errors. Chemotherapy is suggested as the main treatment in the presence of an associated psychotic or affective illness. For the nonpsychotic forms of morbid jealousy individual and interpersonal approaches as well as communicationnegotiation skills were used. …

Assessment of Child Physical and Sexual Abuse Offenders

A variety of techniques have been used to evaluate offender characteristics thought to be related to child maltreatment. Current assessment approaches include the use of interviews, observations, general personality measures, and offender specific measures. Evaluations are needed for a variety of purposes, which include screening, report confirmation, treatment planning, treatment evaluation, and recidivism prediction. However, there is often a paucity of data on the appropriateness of using existing assessment techniques in each of the different evaluation situations. Because most child protective services providers and many health professionals use interviews and observational techniques to evaluate parents, this article will begin with a description of these approaches and associated problems, such as interviewer bias. Given the increasing use of standardized personality measures, particularly by psychologists (Straus, 1993), and the relatively recent development of offender specific measures, the present review will focus on some of the most frequently used standardized and specialized offender assessment approaches. To the extent possible, psychometric data presented will include reliability and validity information, including individual classification rates (correct classifications of offender status sensitivity , correct classifications of nonoffender status specificity, misclassifications of offender status false negative classifications , and misclassifications of nonoffender status false positive classifications ). INTERVIEWS In most cases, the interview procedure attempts to assess offender characteristics using a question and answer format. In structured interviews, information is gathered through a planned process, where an effort is made to systematically ask questions about different domains of interest (e.g., risk factors). Structured interviews, which tend to generate more reliable data than unstructured interviews, have been developed to assess individual characteristics, such as depression (Hamilton Rating Scale for Depression; Hamilton, 1986) and how parents view their children (e.g., Altemeier, O'Connor, Vietze, Sandler, & Sherrod, 1982; Kelly, 1983; Murphy, Orkow, & Nicola, 1985). The success of the structured interview depends upon a variety of factors (Milner, 1991d). General training in interviewing techniques and specific training in the evaluation of the characteristics of interest (e.g., depression, parental expectations) are needed. The interviewer must establish rapport with the client, and must adhere to the recommended interview structure, which at times may be difficult because the interview process is interactive. A criticism of interview procedures is that they frequently have lower reliability and validity than objective tests. Never-the-less, some argue that the interview process has the advantage of allowing for idiographic assessment, in that the interviewer can deviate from the planned format to obtain personality data unique to the individual. In child maltreatment assessment, there is a paucity of research on the predictive power of interviewing procedures in offender evaluations. Recently, however, there has been an interest in evaluator bias in child abuse assessment. Research suggests that factors unrelated to the abuse event can impact child maltreatment evaluations and/or reporting decisions made during the interview. For example, in a national sample, Nuttall and Jackson (1994) found that professionals (i.e., clinical social workers, pediatricians, psychiatrists, and psychologists) who had been sexually and/or physically abused as children were more likely to believe allegations of child sexual abuse. The findings did not vary by discipline. In terms of personal beliefs about the veracity of children's reports of sexual abuse, Kendall-Tackett and Watson (1991) found that professionals who believed that children do not lie about sexual abuse, compared to those who were neutral, were more likely to be convinced by case data that child sexual abuse had occurred. …

Cognitive Therapy in Israel: Thinking With One’s Heart

There is an Israeli saying: "When two Israelis meet there are three opinions." When we started to think about what is cognitive therapy in Israel we soon discovered that we have at least three opinions about cognitive therapy in Israel: (a)"Doing cognitive therapy in Israel is not different from what is done in Philadelphia or in Kent, Ohio"; (b) "The Israeli client reacts to cognitive therapy completely different from the average client in the Western world"; (c) "The clients in Israel are not different from the clients in the rest of the world, however, the average Israeli therapist is uniquely different from his or her colleagues in the Western world." We are sure that our three different opinions are all true reflections of the practice of cognitive therapy in Israel. Furthermore, we both agree that when any one of our cognitive therapist colleagues in Israel will read our paper, he or she will have another two opinions about cognitive therapy in Israel that will be different from ours. Does this sound completely irrational? May be. But in Israel we think not only with our heads but also with our hearts. Things may feel right and that is what makes them right, even if they are logically contradictory. Just watch two Israelis arguing to become convinced that emotions and cognitions are closely linked to each other and none has a primacy over the other. With all that said, we are not claiming that the Israeli psychotherapists are not interested in cognitive therapy. Workshops on cognitive therapy are usually well attended with an eager, but often skeptical audience of social workers, psychologists and psychiatrists. In fact, since we have introduced cognitive methods to the practice of behavior therapy, we were able to attract the interest and attention of many of our colleagues who were raised in the psychodynamic tradition. Behavior therapy without the addition of the word "cognitive" was never well accepted by Israeli psychotherapists. The old brand of behavior therapy was often conceived as being too mechanical, inhuman, too technical, superficial, reductionist, dangerous, limited in scope, and not respectful of the client (Rosenbaum, 1988). Following the lead of the European Association of Behavioral & Cognitive Therapies, the Israeli Association of Behavioral and Cognitive Therapies (IABCT) has just recently added the term "cognitive" to its name. The association has currently over 100 registered members. Under the active leadership of the second author, Dr. Tammie Ronen, IABCT has invited outstanding cognitive- behavior therapists from abroad to lead one- or two-day workshops. Invitations included people such as: Albert Ellis. Edna Foa, Fred Kanfer, Isaac Marx, and Bob Niemeyer. We are grateful to those people who were willing to give workshops for nominal fees and thus enabled the attendance of many Israeli professionals who are generally on low salaries. Indeed, our workshops are very well attended and not only by members of IABCT. Almost every psychology or social work department in Israel offers one or two courses in cognitive-behavior therapy. A few. years ago the School of Social Work at Tel Aviv University offered a two-year training program in cognitive-behavior therapy for psychiatrists, social workers and psychologists. About 40 people completed this program (which was highly rated by the participants). Because of lack of funds the program had to be suspended. A number of Israeli psychiatric hospitals have established outpatient therapy units that solely use cognitive-behavioral techniques. Although such units reflect on the growth of cognitive-behavior therapy in Israel, they also reflect on the fact that cognitive-behavior therapy is not in the main stream of psychological treatments in Israel. The most dominant therapeutic orientation in the academic and clinical institutions in Israel is still the psychodynamic orientation. Israel is blessed with a high proportion of clinical psychologists who practice psychotherapy. …

Urbanization and mental health in developing countries: A research role for social scientists, public health professionals and social psychiatrists

Urbanization in developing countries involves changes in social support and life events which have been shown to affect mental health; mainly depression and anxiety, particularly among low income women. Although depressive and anxiety disorders have a high prevalence and account for a large proportion of visits to primary health services there is little international health research in this field. The determinants, extent and outcome of the association between urbanization and mental health requires multi-disciplinary research by social scientists, social psychiatrists and public health professionals. An appreciation of different conceptual models and associated methods is required before effective research can begin. Other issues such as the avoidance of environmental determinism; the separation of macro-social and micro-social variables; the weakness of urban/rural comparisons of mental health; the role of rural to urban migration; the debates about cross-cultural psychiatry; and the policy-relevance of research, all need consideration in the development of research into this rapidly emerging, but relatively neglected problem.

MODERN WITCH HUNT—CHILD ABUSE CHARGES

The 1974 act—sometimes known as the Mondale Act, after one of its sponsors—was implemented to fight a genuine problem. Up to that year, child abuse was rarely reported and frequently covered up. It was Congress's intent to rectify this deplorable situation by providing incentives for states to set up programs for child abuse research, identification, prosecution and treatment. Federal funding was made available to match state spending, and this served as an incentive for states to create such programs. The law, however, has had results that its authors did not intend. In America today, child sex-abuse accusations are burgeoning. In many cases, it is probable that the charges are valid. But when the charges arise from vicious child custody disputes, where the vengeance element and the opportunity for exclusion of a hated spouse is operative, or in venues such as day-care centers, where the potential pedophile has little opportunity for contact with the child alone, the prevalence of child abuse is in reality quite low. The Child Abuse Establishment Nevertheless, the number of charges in these areas escalate. The primary reason: The Mondale Act has strengthened the "child abuse establishment"—a network of social workers, psychiatrists, psychologists and law enforcement officials—that through its very existence frequently validates an individual's charges. In other words, this establishment, unintentionally or intentionally, encourages charges of child abuse whether they are reasonable or not.

The impact of vendorship legislation and interprofessional competition in the market for social workers' services

The results of this article suggest that, in the short run, vendorship legislation will not result in a large shift of social workers from organized settings into private practice. However, vendorship legislation appears to increase the number of social workers in private practice in areas that have not attracted as many psychiatrists. Thus, vendorship may have a favorable impact on the geographic distribution of mental health providers. Vendorship legislation may result in increases in private practice social workers in underserved areas. The results also suggest that social workers and psychiatrists compete in the market for mental health services. In counties with higher psychiatrist-to-population ratios, fees for social workers' services are lower. Further, in counties with higher psychiatrist-to-population ratios, the number of social workers in private practice decreased after vendorship. Finally, there is a large range of optimal practice size for social workers. Social workers with 20 or more clients per month can provide mental health services at the lowest average cost per client. Thus social workers operating either full-time or part-time practices with more than 20 clients per month can provide mental health services efficiently.

Community Mental Health Care: Clients' Perceptions of Services and an Evaluation of a Voluntary Agency Support Scheme

A questionnaire assessment of mental health and of perceptions of formal care was conducted with a sample of clients before they received a voluntary agency mental health intervention in addition to normal community psychiatric and social services. The assessment was repeated three months later. A matched control group who received only the normal services were also assessed twice over a period of three months. Both groups improved significantly on the mental health measure over the three months and there was little difference between the treatment and control group. Clients in the voluntary agency group were less satisfied with community psychiatric services and may have chosen the voluntary agency as an alternative source of help. Women in both groups showed less improvement in measured mental health than men. Community Psychiatric Nurses (CPNs) were seen more frequently than social workers, psychologists and psychiatrists. Contacts with CPNs and social workers were rate most favourably.

Psychotherapy as an eductional process

Clients in psychotherapy with social workers, psychiatrists and psychologists learn things that they did not know previously. This learning modifies their view of reality and themselves. Clients learn that their problems are, to an extent universal, interpersonal—both “out from” themselves and “to” themselves from others, due to experiences in their past in their families, perhaps solvable by identifying with successful others, often due to unrealistic expectations about themselves, others and existence in general. Successful therapy is marked by culture-building interaction by the client and the therapist with the client's subjective understanding modified to enable greater autonomous action.