Treatment engagement of individuals experiencing mental illness: review and update

Individuals living with serious mental illness are often difficult to engage in ongoing treatment, with high dropout rates. Poor engagement may lead to worse clinical outcomes, with symptom relapse and rehospitalization. Numerous variables may affect level of treatment engagement, including therapeutic alliance, accessibility of care, and a client's trust that the treatment will address his/her own unique goals. As such, we have found that the concept of recovery‐oriented care, which prioritizes autonomy, empowerment and respect for the person receiving services, is a helpful framework in which to view tools and techniques to enhance treatment engagement. Specifically, person‐centered care, including shared decision making, is a treatment approach that focuses on an individual's unique goals and life circumstances. Use of person‐centered care in mental health treatment models has promising outcomes for engagement. Particular populations of people have historically been difficult to engage, such as young adults experiencing a first episode of psychosis, individuals with coexisting psychotic and substance use disorders, and those who are homeless. We review these populations and outline how various evidence‐based, recovery‐oriented treatment techniques have been shown to enhance engagement. Our review then turns to emerging treatment strategies that may improve engagement. We focus on use of electronics and Internet, involvement of peer providers in mental health treatment, and incorporation of the Cultural Formulation Interview to provide culturally competent, person‐centered care. Treatment engagement is complex and multifaceted, but optimizing recovery‐oriented skills and attitudes is essential in delivery of services to those with serious mental illness.     

Biographics art "I know me": image generation aiming at EEG control by biofeedback

"I know me" is an interactive artwork that produces images based on EEG measurements from human participants. Although artists have previously made some interactive image works, we considered using human physiological information as input because it reflects human feelings better. In this research we were interested in information about human's mental states, such as anger or sadness. Brain activity was observed with EEG, subjected to Fourier analysis and converted into an animation based on a Lissajous curve.We generated images corresponding to alpha or beta waves activity in real time and showed them to the observer. The observer understood his own mental condition from looking at the images, and could potentially control his own mental state with this interactive device.     

Donizetti and the music of mental derangement: Anna Bolena, Lucia di Lammermoor, and the composer's neurobiological illness.

The composer Gaetano Donizetti, who died in a state of mental derangement due to neurosyphilis, created some of opera's greatest scenes of psychosis. His letters reveal the clinical progression of his neurobiological illness, which was confirmed by autopsy. One can hypothesize that the composer's brain disease, which led to his psychosis and death, may have had an influence on his ability to create the powerful and unforgettable scenes of psychosis in his operas. In Anna Bolena, he captured in musical and dramatic terms Anne Boleyn's historically corroborated mental disorder during her imprisonment in the Tower of London. Sixteen years after having composed Anna Bolena, Donizetti himself would be locked up, against his will, in a mental institution. In Lucia di Lammermoor, Donizetti portrayed a girl given to hallucinations who, in her unforgettable "mad" scene, comes on stage, a pathetic embodiment of a human being in the throes of psychosis. Thirteen years after Lucia's première, Donizetti would die, psychotic and paralyzed, of untreated neurosyphilis. Studying Donizetti's neurosyphilis and the portrayals of psychosis in his operas can help one to appreciate the pain of human beings trapped in the prison of a brain subjected to the devastation of mental derangement.     

Could a neurological disease be a part of Mozart's pathography?

As expected, since we recently celebrated the 250th anniversary of birth of Wolfgang Amadeus Mozart, there has been again a renewal of interest in his short but intensive life, as well as in the true reason of his untimely dead. Mozart lived and died in time when the medical knowledge was based mostly on subjective observations, without the established basics of standardized medical terminology and methodology. This leaves a great space for hypothesizing about his health problems, as well as about the cause of his death. The medical academic community attributed to Mozart approximately 150 different medical diagnoses. There is much speculation on the possible causes of Mozart's death: uremia, infection, rheumatic fever, trichinellosis, etc. Recently some authors have raised the question about a possible concomitant neurological disease. According to available records, Mozart has shown some elements of cyclotimic disorder, epilepsy and Gilles de la Tourette syndrome. Furthermore, the finding of a temporal fracture on (allegedly) Mozart's skull, gives a way to speculations about the possibility of a chronic subdural hematoma and its compressive effect on the temporal lobe. Despite numerous theories on Mozart's pathography that also include a concomitant neurological disorder, the medical and history records about Mozart's health status indicate that he probably had suffered from an infective illness, followed most likely by the reactivation of rheumatic fever, which was followed by strong immunologic reaction in the last days of his life. Taking all the above into consideration, it is reasonably to conclude that Mozart's neurological disturbances were caused by the intensity of the infective disease, and not primarily by a neurological disease.     

Constituted through Conflict: Images of Community (and Nation) in Bulgarian Rural Ritual

Following the 20th anniversary of Benedict Anderson's Imagined Communities, this article extrapolates how attention to actual notions of community might redirect his important intervention. It suggests that locally and culturally specific ideas about collectivity shape the experience and expectations of national-level projections. To demonstrate this outcome the analysis focuses on Bulgarian mumming—spectacular winter rituals in which threatening masked figures transverse villages to banish evil and bring good fortune. While these rituals clearly reinforce social solidarity, they represent a local notion of community in which conflict, both intra-and interethnic, is elemental and constitutive. This image of community does not demand consensus or homogeneity when imagined on a national scale. Such variations in community notions may help explain the diversity of national experiences increasingly documented by ethnographers.     

L’adolescent malade: quand le soin devient violence Clinique des pathologies digestives

Admitting an adolescent suffering from a chronic disease to a somatic healthcare service for adults involves staff’s capacity to understand the specificity of the psychological working-through of the illness, in this category of patients, and staff’s consequent adaptation to the care services’ settings offered to the patient. In certain cases, healthcare staff members become subject to adolescents’ violent attitudes and feel attacked in this maternal capacity. The staff members could halt this violence and work through their own negative emotional concern. They must be able to face the painful problems of the ill child and his/her family may be confronted to questions that arise in this situation are related to the impact of a chronic disease on a child’s developmental course, the involvement of this traumatic experience into the family’s functioning, the prevention of risks of pathological interactions or the patient’s and his/her family members’ decompensation. While listening in a comprehensive way, staff may search for signs of life instinct in these patients. Then, caregivers can rely on it and realize a resuscitation of the psyche and contribute to restore the mental processes in the patient and assist his/her working-through of the traumatic experience.     

Insight in schizophrenia spectrum disorders: relationship with behavior,mood and perceived quality of life,underlying causes and emerging treatments

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social‐cognitive, metacognitive and socio‐political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others’ perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.     

A balanced psychology and a full life

Psychology since World War II has been largely devoted to repairing weakness and understanding suffering. Towards that end, we have made considerable gains. We have a classification of mental illness that allows international collaboration, and through this collaboration we have developed effective psychotherapeutic or pharmacological treatments for 14 major mental disorders. However, while building a strong science and practice of treating mental illness, we largely forgot about everyday well-being. Is the absence of mental illness and suffering sufficient to let individuals and communities flourish? Were all disabling conditions to disappear, what would make life worth living? Those committed to a science of positive psychology can draw on the effective research methods developed to understand and treat mental illness. Results from a new randomized, placebo-controlled study demonstrate that people are happier and less depressed three months after completing exercises targeting positive emotion. The ultimate goal of positive psychology is to make people happier by understanding and building positive emotion, gratification and meaning. Towards this end, we must supplement what we know about treating illness and repairing damage with knowledge about nurturing well-being in individuals and communities.     

Toward a culture-bound syndrome-based insanity defense?

The American Psychiatric Association's recent inclusion of a Glossary of Culture-Bound Syndromes within DSM-IV draws upon decades of medical anthropological and cultural psychiatric research to afford culture-bound syndromes (CBSs) a newfound legitimacy within professional Western psychiatric nosology. While DSM-IV's recognition of the CBS concept as a category of psychosocial distress has important clinical implications for mental health care practitioners throughout the world, it also has significant legal implications. Given that several CBSs involve a degree of psychological impairment that may satisfy the standard for legal insanity under certain circumstances, this essay focuses on the potential emergence of an insanity defense based on the claim that an immigrant or minority defendant was suffering from a CBS at the time of his or her criminal act. Aimed at initiating interdisciplinary debate over the reification of the CBS concept, the essay discusses the theoretical ambiguity and status of CBSs within professional Western psychiatry, describes what a CBS-based insanity defense might look like, and considers the relevant challenges facing medical anthropologists and cultural psychiatrists, on the one hand, and legal practitioners, on the other. The essay identifies a pressing need for interdisciplinary debate concerning the validity, scope, and viability of CBS-based insanity defenses.     

In search of certainty in revolutionary India

In this article, I focus on the dilemmas of a friend in Jharkhand who might have joined the revolutionary armed squads of the Maoist insurgency in India. I show how the question of why one supports a revolutionary movement, as well as the nature of that support, can change over time. In particular, I stress the importance of the dialectics between epistemological and ontological uncertainty and certainty, which may be central to the making of a revolutionary in a particular phase of a revolutionary movement. These dialectics are not just the result of an ontological uncertainty of ideological commitment to the movement, but are crucially also about the search for epistemological clarity in social relations imagined to be less opaque and hence more trustworthy. Doubt, an uncertainty about what one knows about one’s social relationships is characteristic of the epistemic murk that accompanies the breakdown of the normative order in the revolutionary situation analysed here. In this context, Maoist terror arises from the creation of epistemic clarity—the possibility that on the other side norms and relationships will be more certain. This is a certainty that is carved out of uncertainty and ambivalence, a certainty that denies or projects away uncertainty. Its weapon is paranoia, an ability to make enemies where there would be doubt, betrayal where there would be benefit of the doubt. The potential revolutionary is therefore not only unsure about his/her ideological commitments, but moreover, a crucial component of their predicament might be an uncertainty about the social relations in which they find themselves and the hope that revolutionary engagement might come with more guarantees. Becoming a revolutionary is also about being in search of certainty.     

Sinai Tschulok (1875–1945)—a pioneer of Cladistics

Sinai Tschulok emigrated from the Ukraine to Switzerland, where he studied natural sciences, in particular biology. He founded and managed his own high school, which prepared students for entry to university-level education. This left him little time for research, which may explain why his work largely fell into oblivion. He did publish two influential books, however (Tschulok, S., 1910, Das System der Biologie in Forschung und Lehre, Gustav Fischer, Jena and Tschulok, S., 1922, Deszendenzlehre, Gustav Fischer, Jena), which were cited and commented upon favourably by both Walter Zimmermann and Willi Hennig. The most important point, in their opinion, was how Tschulok's explication of biological systematics had turned the "natural system" into a proof for the "Theory of Descent". The influence of Walter Zimmermann on Willi Hennig and the development of phylogenetic systematics is well known. Here some parts of Tschulok's writings are discussed that render him a pioneer in Cladistics.
© The Willi Hennig Society 2009.     

On the epistemology of mental illness.

The most important epistemological problem in psychiatry is the detection of malingering. This is a consequence of the fact that there is no objective way to confirm any psychiatric diagnosis. Psychiatric diagnosis is based on subjective complaints. The discovery of objective markers for psychiatric diagnosis is problematic because it presupposes we can tell valid from faked subjective symptoms. But this is the difficulty. If we use pervasive irrationality as a sign of mental illness, we encounter the problem of identifying pervasive irrationality. To understand someone's behaviour, we have to assume it is largely rational. This precludes us from using behaviour to separate genuine from faked mental illness. There are a number of strategies used to solve any epistemological problem, and the most successful is the hypothetico-deductive method. If we use this, we can solve our epistemological problem. Genuine mental illness can be identified when it is the best explanation of the person's overall behaviour. Consilience of inductions is critical in supporting the validity of such explanations. This implies that it is merely a hypothesis that mental illness exists, and that we might discover that many mental illnesses, perhaps all, do not exist. We must embrace this possibility--only if we take a risk will we gain any knowledge.     

Larcher, W. Physiological plant ecology. 4th edn

At the coffee table, we sometimes philosophize about dauntingchallenges. Master students have their thesis in mind, PhD studentsmention their next research paper, staff members talk aboutthe review article they are trying to write. But we fall allsilent when we think about the enormous effort it takes to writea textbook. Such a daunting task is a true Sisyphean labour! Walter Larcher has indeed rolled his intellectual stone to thetop again, in the form of a revised and updated fourth editionof his textbook on ecophysiology. This new edition has the samenumber of pages as its     

WHAT IS IT TO BE A DAUGHTER? IDENTITIES UNDER PRESSURE IN DEMENTIA CARE

This article concentrates on the care for people who suffer from progressive dementia. Dementia has a great impact on a person’s well‐being as well as on his or her social environment. Dealing with dementia raises moral issues and challenges for participants, especially for family members. One of the moral issues in the care for people with dementia is centred on responsibilities; how do people conceive and determine their responsibilities towards one another? To investigate this issue we use the theoretical perspective of Margaret Walker. She states that ideas about identity play a crucial role in patterns of normative expectations with regard to the distribution of responsibilities in daily practices of care. The results of this study show how the identity of a family‐member is put under pressure and changes during her loved one’s illness that leads to difficulties and misunderstandings concerning the issue of responsibility. These results offer an insight into the complexities of actual practices of responsibility and highlight the importance for those caring for people with dementia of attending carefully to how they see themselves and how they see other people involved (Who am I? Who do I want to be for the other?). Answers to such questions show what people expect from themselves and from one another, and how they, at any rate, are distributing responsibilities in a given situation. Professional caregivers should take into account that family members might have different ideas about who they are and consequently about what their responsibilities are.     

Symbolic Healing of Early Psychosis: Psychoeducation and Sociocultural Processes of Recovery

This article analyzes sociocultural processes of recovery in a Danish mental health service providing two years of integrated biopsychosocial treatment following first-episode psychosis. The study is based on ethnographic research in the service and person-centered involvement with 15 clients. The analysis applies Dow's [1986 American Anthropologist 88:56-69] model of universal components of symbolic healing to elucidate sociocultural aspects of therapeutic efficacy that are alternatively disregarded as placebo or nonspecific effects. It is demonstrated how staff engaged with clients to deliver "psychoeducation" that provided scientific and biomedical theories about mental illness, constituting a shared "mythic world" that was accepted as an experiential truth and used to explain clients' illness experiences. The analysis highlights the need to supplement attention in Dow's model to the healing procedure with consideration of variability in the healing process. Depending on individual responses to the intervention, the staff's professional backgrounds and staff-client relationships different recovery models were applied. One suggested "episodic psychosis" and full recovery, and the other suggested "chronic schizophrenia" and the necessity of comprehensive life adjustments to the mental illness. The recovery models influenced clients' perspectives on illness and self as they engaged in identity work, negotiating future plans and individual life projects by including also alternative systems of explanation from the wider cultural repertoire.     

Revisiting Abbott Thayer: non-scientific reflections about camouflage in art,war and zoology

This paper reviews the achievements of Abbott Handerson Thayer (1849–1921), an American painter and naturalist whose pioneering writings on animal camouflage addressed shared concerns among artists, zoologists and military tacticians. It discusses his beliefs about camouflage (both natural and military) in the context of his training as an artist, with particular emphasis on three of his major ideas: countershading, ruptive (or disruptive) coloration and background picturing.     

Silent communication: toward using brain signals

From the 1980s movie Firefox to the more recent Avatar, popular science fiction has speculated about the possibility of a persons thoughts being read directly from his or her brain. Such braincomputer interfaces (BCIs) might allow people who are paralyzed to communicate with and control their environment, and there might also be applications in military situations wherever silent user-to-user communication is desirable. Previous studies have shown that BCI systems can use brain signals related to movements and movement imagery or attention-based character selection. Although these systems have successfully demonstrated the possibility to control devices using brain function, directly inferring which word a person intends to communicate has been elusive. A BCI using imagined speech might provide such a practical, intuitive device. Toward this goal, our studies to date addressed two scientific questions: (1) Can brain signals accurately characterize different aspects of speech? (2) Is it possible to predict spoken or imagined words or their components using brain signals?     

Walter’s two-layer hypothesis revisited: back to the roots!

Walter (Jahrb Wiss Bot 87:750–860, 1939) proposed a two-layer hypothesis, an equilibrium explanation for coexistence of savanna trees and grasses. This hypothesis relies on vertical niche partitioning and assumed that grasses are more water-use efficient than trees and use subsurface water while trees also have access to deeper water sources. Thus, in open savannas, grasses were predicted to predominate because of their water use efficiency and access to subsurface water. This hypothesis has been a prominent part of the savanna literature since first proposed. We review the literature on Walter’s hypothesis and reconsider his original intentions. Walter intended this hypothesis to be restricted to dry savannas. In his opinion, mesic and humid savannas were controlled by biotic factors and disturbances. We surveyed the global savanna literature for records of vertical niche partitioning by grasses and trees. We find that, within the scope of Walter’s original intentions, this hypothesis works remarkably well, and in some cases is appropriate for deserts as well as for dry temperate systems and even some mesic savannas.     

Erratum: “This is Why you’ve Been Suffering”: Reflections of Providers on Neuroimaging in Mental Health Care

Mental health care providers increasingly confront challenges posed by the introduction of new neurotechnology into the clinic, but little is known about the impact of such capabilities on practice patterns and relationships with patients. To address this important gap, we sought providers’ perspectives on the potential clinical translation of functional neuroimaging for prediction and diagnosis of mental illness. We conducted 32 semi-structured telephone interviews with mental health care providers representing psychiatry, psychology, family medicine, and allied mental health. Our results suggest that mental health providers have begun to re-conceptualize mental illness with a neuroscience gaze. They report an epistemic commitment to the value of a brain scan to provide a meaningful explanation of mental illness for their clients. If functional neuroimaging continues along its projected trajectory to translation, providers will ultimately have to negotiate its role in mental health. Their perspectives, therefore, enrich bioethical discourse surrounding neurotechnology and inform the translational pathway.