Mental institutions on a long-term basis

Psychology Treatment

For most of U.S. history up to the time of the Community Mental Health Act of 1963, the mentally ill were generally warehoused in state and local mental institutions on a long-term basis. Most had been involuntarily committed by orders from courts or physicians, and the discharge rate was very low. Before the 1950s and 1960s, there were few effective treatments for mental illnesses like depression, anxiety disorders and schizophrenia, which were commonly considered incurable. Only with the psycho-pharmacological revolution in recent decades and new anti-depressant and anti-psychotic medications has it been possible for the severely mentally ill to be treated on an outpatient basis through community mental health centers. Of course, as the old state hospitals have emptied many of the mentally ill have ended up homeless, since they are unable to hold maintain regular employment or continue on a medication regimen without supervision. According to present-day state laws, involuntary commitment to mental institutions can only apply to those judged to be a danger to themselves and others, and therapeutic practice no prefers short-term stays whenever possible. This has led to a problem of psychiatric wards being filled with patents repeatedly sent to these facilities for short stays instead of long-term commitment to state hospitals. Even worse, jails and other punitive facilities are increasingly being used as warehousing facilities in the same way as they state hospitals back during the ‘snake pit’ days before 1960.

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In the early modern era, with the growth of commercial towns in North America and Western Europe, the authorities gradually become aware of the problem of large numbers of paupers, vagrants and mentally ill persons who could not be cared for by their families and local communities. Of course, society had always been aware of mental illness, even if the causes was thought to be demon possession, although for the most part deranged individuals who were not a danger to others were not confined. From the 17th Century until well into the 20th Century, governments set up almshouses, poorhouses and workhouses that confined the elderly poor, the disabled, orphans and the mentally ill in the same institution, although in social welfare policy there was always a distinction between those who were physically and mentally capable of working and those who were not. In 1752, the Pennsylvania Hospital opened up a ward for the mentally ill in the basement, although the treatments were either nonexistent or ineffective — if not positively harmful. From the very start, most mental institutions in America were basically places of long-term confinement and warehousing for individuals who could not be treated or cured, and were unable to care for themselves (Levine, 1981, p. 15).

In 1833, Horace Mann recommended that Massachusetts establish the first hospital decided to care for the mentally ill, which opened at Worcester. At that time, physicians were still optimistic that the majority of the mentally ill could be cured, thus “removing them from the welfare rolls and saving the state money in the long run” (Levine, p. 17). In reality, of course, the new state hospitals continued the role of custodial care, with commitments often lasting for life, due to the lack of effective diagnosis and treatment of mental illness. America in the 1830s was undergoing a capitalist revolution, with the decline of the old aristocracy and its paternalist culture in many parts of the country, at least outside the slaveholding Southern states. This new society was more urban, industrialized and competitive, with a new capitalist class coming to power. At the same time, abolitionism, women’s rights and prison reform also became important for the first time in American history: indeed, they all had their origins in the same era. Many people at the time believed that mental illness was increasing as the old agrarian society was overturned and “communities badly rent by social and economic change” (Levine, p. 19). Not for the last time would many social observers associate the rise of mental illness with the pressures and strains of urban, industrial civilization.

Dr. Samuel Woodward, the first superintendent of the Worcester State Hospital, was a religious and humanitarian man who generally shared the liberal ideology of progress that was common during this period. He truly believed that the majority of the mentally ill could be cured with kind and humane treatment, and also in the “perfectibility of people” in general (Levine, p. 20). Yet long experience was to prove that the early optimism was not justified and that many of those judged to be insane could not be cured. By 1875, discharge rates from state hospitals had fallen to 30%, falling to 20% by the 1920s and often the 5%. By the 1890s, most psychiatrists like Dr. Pliny Earle had concluded that insanity was incurable, and accepted the fact that the main purpose of state hospitals would be confinement and warehousing for life. Most of their inmates were poor, immigrants and members of minority groups, although blacks were almost always confined in segregated and inferior facilities. Destitute and impoverished immigrants, crowded into slums, certainly produced a large number on mentally ill persons, and by the late-19th Century made up about 75% of the patients in many state hospitals, which basically served the poor mentally ill and provided no real treatments (Levine, p. 22). Attendants in these hospitals were poorly paid and trained, and they were chronically understaffed, so much so that in New York City common criminals were assigned to work as attendants.

Needless to say, these giant warehouses were far removed from the reformist dreams of Dorothea Dix, who more than any other individual was responsible for creating the system of state hospitals in the United States. She had also been motivated by religious and humanitarian concerns, and was “dedicated, determined, in not fanatical” in her efforts to establish mental hospitals in every state. Dix was clearly a transformational leader who did not know how to take “no” for an answer, which has always been true of most successful reformers in history, but given the limited knowledge of the time, she had no idea which treatments — if any — would be effective for mental illness. Her main concern was to “remove the insane from jails, almshouses, and workhouses, where they were kept in abominable conditions.” Moreover, in the 19th Century and well into the 20th, “commitment laws were lax” and often required only the signature of a physician to have a person confined for life in a mental institution (Levine, p. 24). State hospitals developed a reputation for confining the impoverished and dangerous, and “negative attitudes associated with welfare were associated with mental hospitals” (Levine, p. 26). State and local administrators were most often concerned with limited budgets, efficiency and cost-per-patient ratios than with therapy and treatment. Another reason for low discharge rates was the fact that many inmates in state hospitals were put to work on farms and other enterprises in order to save money for the state and local governments. Dr. Earle’s hospital never went over-budget and always earned a profit, which made it well-admired by the businessmen and managers who really ran the state government. Since Earle maintained that the mentally ill could not be treated or cured in any event, it made sense that as many of them as possible worked to pay for their keep. County farms, almshouses and infirmaries also continued well into the 20th Century, and in many cases the elderly and disabled mentally ill simply had nowhere else to go (Levine, p.29).

Before the 1950s and 1960s, the federal government had little or no influence over mental health care policy, which was almost entirely the concern of state and local governments. In 1854, for instance, President Franklin Pierce vetoed a bill for federal funding for state hospitals on the grounds that this was not the responsibility of the national government (Levine, p. 31). Under the provisions of the original Social Security Act of 1935, federal payments could not be made to patients in state hospitals and other institutions, although this changed in the 1950s and 1960s. From the 1830s to the 1960s, then, the state hospital “continued to be the mainstay of the mental health system,” funded mainly by state and local governments. About the only exception to this was the Veterans Administration that was forced to establish mental health care facilities for the large number of psychiatric casualties from both world wards — conditions then known as shell shock, combat psychosis or combat fatigue but today classified as Post-Traumatic Stress syndrome (PTSD). Even though new treatments appeared in the 1930s, such as lobotomies, insulin shock and electric shock — which turned out to be mostly ineffective — these did not change the basic nature of the system. When deinstitutionalization began in the 1960s, the elderly mentally ill were among the first to be effected, although most were transferred to nursing homes that received Medicaid and Medicare payments from the state and federal governments. Indeed, this new policy created as many problems as it solved, since new outpatient services, treatment programs and income maintenance had to be found for the elderly, handicapped, and mentally ill, and often they fell through the cracks of the system and literally ended up on the streets (Levine, p. 29).

A crisis in mental health care funding is approaching rapidly given that the Baby Boomer generation will retire over the next twenty years and expenditures for older Americans with major psychiatric disorders will double. There will also be a serious lack of mental health services, providers and funding. About 20% of all adults over age 55 have major mental illnesses such as depression and dementia, although these are often under-reported and under-diagnosed (Bartels et al., 2010, p. 261). Medicare and Medicaid expenditures for nursing homes, outpatient and inpatient services, pharmacy and emergency room visits always “increase with advancing age” especially for those age 85 and over requiring “acute and long-term care.” These expenses increase further for patients with schizophrenia and bipolar disorder, although elderly patients with these conditions are far less likely to receive mental health care than younger patients. Nearly half of all Medicare expenditures in the mental health field are for acute inpatient hospitalization, while 65-91% of nursing home patients “have a significant mental disorder,” mostly dementia and cognitive disorder (Bartels et al., p. 263). Over 57 million people have a diagnosable mental illness — about 26% of the population — and one-fifth of these are severely ill, yet only one in four actually get the mental health care they need (Videbeck, 2010, p. 5).

Medicare is open to all people over age 65% and is federally funded, while Medicaid requires 50% matching funding from the states, which are required to provide aid to the blind, disabled and mentally ill. These programs are means-tested and have other restrictions on eligibility that vary by state. Older adults and the disabled are one-third of all Medicaid enrollees and account for three-quarters of all spending. In 2006, two-thirds of its expenditures were for nursing homes and home and community-based care. It also funded one-quarter of all mental health care expenditures, more than any other insurance provider. People over 65, especially the poor disabled and mentally ill, are “dually eligible” for Medicare and Medicaid, and account for 42% of all Medicaid expenditures (Bartels et al., p. 269). The lack of parity for mental health and medical care in Medicare and Medicaid had long beeen a “standing priority for reform among consumer advocacy and provider organizations.” The 1996 Mental Health Parity Act prohibited private insurers from “setting lower annual or lifetime dollar caps on mental health benefits,” and of course when Obama Care phases in over the next few years these caps will be eliminated completely. In 2003, Paul Wellstone proposed eliminating the 50% co-payment required for psychiatric services under Medicare compared to 20% for medical care. In the 2008 Medicare Improvement for Patients and Providers Act this was scheduled to be eliminated over the following six years with co-payments reduced to 20% for mental health care services. It also increased reimbursements to providers by 1.1% per year (Bartels et al., p. 269). That same year, Congress passed the Mental Parity and Addiction Equity Act that applied to Medicaid and private insurance plans. Under this new law, they were also required to provide parity in treatment for both mental and physical disorders, and could not limit hospital days or outpatient treatment sessions or have higher co-payments and deductibles for psychiatric care. No exclusions are allowed, such as treatment for substance abuse, although plans were still allowed to drop coverage for psychiatric and substance abuse treatment completely (American Psychological Association 2008).

Although the issue of parity for Medicare and Medicaid patients was resolved in 2008, there are still a wide variety of issues for which mental health advocates would recommend urgent reforms, particularly in the context of the current economic recession and rapidly aging population. Among these are:

The Healthy People 2010 Mental Health Objectives included recommendations to increase treatment for adults with severe mental illness from 25% to at least 50%, and to 75% for those with schizophrenia. Other goals are to reduce the percentage of mentally ill homeless to 19% of the total homeless population and to increase the number of states with treatment plans for crisis intervention, screening and mental health care for the elderly (Videbeck, p. 7). This would require more funding for community-based mental health centers and inpatient psychiatric facilities.

Psychiatry is particularly expensive because of the long-term nature of the illnesses and funds for these always “lag far behind the need that exists.” Many people who are eligible for Medicaid never apply for it or are not approved, which means that millions of patients “with severe and persistent mental illness have no benefits at all” (Videbeck, p. 8). More efforts are necessary to ensure that the mentally ill who are eligible for Social Security disability, supplemental income and Medicaid actually receive these benefits.

Informal and family caregivers cost the economy at least $9 billion per year and provide essential services to the elderly mentally ill. Over 70% of Alzheimer’s patients live at home with three-quarters of their care provided by family and friends. This “shadow workforce” will require more support and training, particularly as the Baby Boomers age (Bartels et al., p. 265). Federal and state programs should provide more funding for these informal caregivers, along with in-home and visiting nursing assistance, so that these patients will not have to be placed in nursing homes or other institutions.

Although the Community Mental Health Act of 1963 reduced the trend of institutionalization and ‘warehousing’ in state psychiatric hospitals, many of the elderly mentally ill were simply transferred to nursing homes. Given that community mental health centers have never been adequately funded, especially for the elderly, nursing homes became “default mental institutions.” The Omnibus Budget Reconciliation Acts of 1987 and the Supreme Court’s Olmstead decision of 1999 all attempted to reduce the number of patents sent to psychiatric facilities and nursing homes and required these to “whether they could be receiving care in a less restrictive community-based environment” (Bartels et all, p. 266). This will also become a greater priority for Medicare and Medicaid funding as the Baby Boomers retire and costs escalate. Deinstitutionalization did not reduce the numbers of people requiring mental health care, but did increase the numbers of homeless mentally ill, as well as the number of emergency room visits by people in severe distress and short-term stays in general hospital psychiatric units by 400-500% (Videbeck, p. 5). Once again, this problem will have to be resolved by more funding for community mental health programs and psychiatric inpatient services. Perhaps the pendulum of deinstitutionalization has also swung too far in the opposite direction and should be reconsidered to some degree, since there are obviously a large percentage of mentally ill homeless adults who will have to be permanently institutionalized.

Because of inadequate Medicare reimbursements, many younger physicians have been avoiding a career in geriatric medicine, especially because they leave medical school with high student loan debts. Geriatric psychiatry is an even less popular field than internal and general medicine for the elderly. In 2007 Congress proposed student loan forgiveness for doctors and other providers who specialized in geriatrics and this should be implemented (Bartels et al., 273). Congress to take steps to provide free medical education for physicians, nurses, psychologists, and social workers who specialize in geriatric mental health care or agree to work in underserved and low-income areas.

Given the fact that the United States will have a rapidly aging population over the next twenty years, Congress should urgently consider the need for increased Medicare and Medicaid funding for the large number of elderly patients who will end up permanently institutionalized because of dementia. It should also expand money for research and treatment of Alzheimer’s Disease in order for these patients to be able to live longer, more healthy lives outside of nursing homes. Medicare, Medicaid and private insurance have already been reformed so that benefits available for physical and mental illnesses will be at parity, but greater efforts are necessary in order to ensure greater access to treatment for the poor and elderly mentally ill. These psychiatric disorders are still underfunded, under-reported and under-treated and millions of people who are eligible for benefits do not receive them. Community mental health care centers, and formal and informal caregivers who maintain patients at home also require more funding and support, so that they elderly and severely disabled mentally ill do not all end up in nursing homes — which is the most expensive method of care and already a severe burden of Medicare and Medicaid. At the same time, more permanent institutionalization may well be necessary for the homeless mentally ill in order relieve the burden on hospital emergency rooms and general psychiatric wards.

Recent studies indicate that 11% of the U.S. population suffers from anxiety disorders every year, and that 29% will experience at least one major episode of these at least once in their lives. These have been increasing in the past ten years and most go untreated, while the care provided “may not be evidence-based, especially when delivered by non-specialists” (Sullivan et al., 2007). Common forms of anxiety disorders include General Anxiety Disorder (GAD), Social Anxiety Disorder (SAD), with or without agoraphobia, Panic Disorders, Obsessive-Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD), and specific phobias. There may also be “a single negative-affect syndrome underlying unipolar depression and many anxiety disorders” or a tripartite model which “identifies three common components of anxiety and depression” (Erikson et al. 2007).

General Anxiety Disorder (GAD), for example, is “uncontrollable worry about a number of events or activities accompanying physical symptoms of anxiety,” such as worry about family, friends, school, performance and health combined with muscle tension, insomnia, headaches or clenched teeth. GAD is not focused on any particular topic, situation or phobia “but typically switches from one topic to another” (Grover, 2006, p. 276). Worry and physical symptoms “must occur more days than not for a minimum of 6 months and cause significant distress or impairment in important areas of functioning” in order for a diagnosis of GAD to be valid. Social phobias are fear of new social situations or unfamiliar persons, often accompanied by depression, in which patients “may be unaware of the fact that their anxiety is excessive or unreasonable.” If untreated, these types of social anxiety disorders can lead to failure to complete school, substance abuse and unstable relationships later in life (Grover, p. 279). One common comorbid diagnosis is anxiety and depression, combined with hyperactivity in children and adolescents (ADHD). Some studies indicate that up to 70% of children and adolescents have experienced at least one major traumatic event, and 15-25% could be diagnosed with PTSD. Symptoms of trauma can include repetitive play, separation anxiety, anxiety disorders, depression, and mood and dissociative disorders. Frequent or extreme abuse causes the “body’s normal fear response system becomes sensitized due to extremes of chronic stress” (Carron and Hull, 2009, pp. 27-29). Other studies indicate that one woman in five is sexually abused by the age of fourteen (Shachar, 2010, p. 33).

In one experiment concerning sexual addiction and sensation seeking, 539 university students were studied, divided almost equally between males and females. Men scored higher on both sexual addiction and sensation seeking, which were “associated with sex abuse experiences and poor family environments in childhood.” These compulsive behaviors require long-term treatment while “sensation seekers could possibly be effectively treated with short-term behavioral interventions” (Perera et al., 2009). Another study of 250 undergraduates determined that about one-third of both males and females had been sexually abused in childhood or adolescence.” It is well documented that such abuse results in high rates of depression, anxiety and sexual dysfunction in adulthood, as well as an increase in social anxiety (Rojas and Kinder 2009). In a 2010 study of 172 adults in their 30s and 40s who had been abused by relatives or by more than one abuser in childhood determined that those who did not discuss this in depth within a year of the actual abuse had “a greater number of mental health symptoms” (O’Leary et al. 2010).

CBT protocols for anxiety disorders are highly effective, but most often used in specialty clinics, although many clinics do not have 8-12 patients with the same anxiety disorders that would enable them to be placed in one specific group. Over the past ten years, there has also been “significant improvement in the treatment of anxiety disorders in children and adolescents” (Grover 2006). Nevertheless, about half of those who receive CBT for anxiety, panic disorder and depression “evidence significant improvement” while half require further treatment. Anywhere from 23-49% of patients fail to attend one than one therapy session and up to two-thirds terminate prematurely, while only half complete their CBT homework assignments (Westra and Dozios, 2006, p. 482). Even so, CBT for anxiety disorders has similar outcomes with both individual and group treatment.

One study (Erikson et al. 2007) was designed to apply CBT in a group therapy setting to treat a variety of anxiety disorders with a single protocol, including Panic Disorders, PTSD, Social Phobias, General Anxiety Disorder (GAD) and Obsessive-Compulsive Disorder (OCD). Of the group of 152 patients randomly assigned to the 11-week CBT treatment group or the waiting list control group, 43% were diagnosed with one or more anxiety disorders, 20% currently had major depressive disorders, 30% a depressive disorder at some point in their lives, and 7% a past substance abuse problem. The profile of this group was typical for anxiety disorders: two-thirds were women, with an age range of 19-70 years, many were taking medications for anxiety and 28% had had previous CBT treatment for anxiety. In addition, 16% did not attend any sessions and 26% dropped out after attending six or fewer sessions.

The Beck Anxiety Inventory (BAI) was administered as a baseline, at the end of treatment and again in a six-month follow-up, and the results for the immediate treatment group were superior, with over 60% showing 20-40% improvement. Additional diagnostic and assessment tools included the Beck Depressive Inventory II and Anxiety Sensitivity Index. Severity of patients’ disorders ranged from those with “a single moderate anxiety problem who had good social and occupational functioning to severely distressed clients with multiple comorbid disorders.” All had a principal diagnosis of anxiety disorder according to the Structured Clinical Interview based on the DSM IV and SCID IV. Treatment sessions included common CBT elements plus disorder-specific treatments. Behavioral elements took up the first half of the protocol and cognitive elements the second, and all patients had daily homework tasks. These included information on the aims of the group, hierarchies, treatment of anxiety disorders, exposure strategies, relaxation techniques, breathing exercises, challenging anxious thoughts, worry control, challenging cognitions, and relapse prevention. Audiotapes of the sessions were reviewed randomly to ensure compliance with treatment protocols.

The immediate treatment group showed the greatest improvement on BAI scores, with 61% achieving at least a 20% improvement and 42% a 40% improvement, versus 31% and 17% respectively in the control group. Overall, the outcome for this mixed group was less effective “than that obtained with diagnosis-specific CBT protocols.” The BAI was the main index used, and the protocol had too much information and too many skills, and might have been more effective teaching fewer of these, especially if the most severely anxious and depressed patients had been excluded from the study.

When physical, emotional and sexual maltreatment and Inter-Personal Violence (IPV) occur together, often “mothers are simultaneously victims and perpetrators” both victims of partner violence themselves and abusers of their children. Child Protective Services (CPS) and clinicians are generally not equipped “with sufficient knowledge and experience of domestic violence services systems to take advantage of opportunities for coordinated and integrated care,” while providers of domestic violence shelters and services rely on “grassroots” approaches rather than the assistance of CPS and mental health professionals. Almost half of youth involved with CPS “persist with clinically significant emotional and behavioral problems and only one-fifth actually receive mental health care” (Murphy, 2010, pp. 555-56).

About 70% of abusive parents were also abused themselves, and have problems anger, guilt, depression, substance abuse, anti-social behavior, self-abuse and lack of empathy as a result of these traumatic experiences. Only 10-15% of such parents have clinical psychiatric disorders, mostly depression, anxiety and substance abuse (Runyan et al., 2004, p. 66). Survivors will vary in the degree of memory they have of the abuse, and some will have little or no memory at all. CBT works to recover these memories in detail, although individuals should be warned of the risks of attempts to do so. In recent years, neurosciences have also “brought the importance of dissociation trauma to the fore” (Bacon, 2010, p. 141).

Shame is a normal consequence of sexual abuse, and is made more intense by the discovery process by which it is revealed to family members, police, the courts and media. Guilt is also a common reaction, but while “guilt concerns one’s own action; shame concerns one’s entire being” (Feiring and Taska, 2005, p. 328). One study drew 147 children and adolescents from New Jersey suburbs and urban areas to determine the persistence of feelings of shame over six years. Nearly all of these were referrals from Child Protective Services or medical offices, and of the original 147, 68% received some form of treatment that lasted an average of 5.4 months. At the end of six years, the study again assessed 118 of these children, and still found high levels of shame. The characteristics of this final group of were: 70% from single-parent families; 71% poor or low-income ($25,000 per year or less); 76% female; 54% age 13-17 and 46% age 18023; 39% black; 31% white; 21% Hispanic. As for the type of abuse they suffered, 67% experienced genital penetration; 35% were abused by a parent; 25% by a relative; 37% by a familiar person; and only 3% by a stranger. In the question of frequency and violence of the abuse, 30% had been abused ten times or more; 40% two-nine times; and 30% once, while 25% reported use of force and 19% the threat of force (Feiring and Taska, p. 339).

To participate in the study, minors had to have informed consent from parents or guardians, and then had structured interview in a clinical setting, which included data on abuse from the police, courts or CPS. Groups that were surveyed at the end of six years self-reported any additional sexual abuse. All participants were scored from zero to six on checklist which had questions about the relationship to the perpetrator, frequency and duration of abuse, how it was discovered, types of acts committed, the use of force and medical findings. Those with the higher scores had experienced the most severe types of abuse, with the mean score being 2.3 (Feiring and Taska, p. 340). They also answered four questions about levels of shame on a scale of zero to two, such as “it makes me feel dirty,” “people can tell from looking at me what happened” and “I want to go away and hide.” Zero meant “not true” and two “very true” in answer to these questions. They also took a test of Self-Conscious Affect for Adolescents which is “used to measure individual differences in proneness to shame and guilt,” a Trauma Symptom Inventory to index PTSD, with questions about flashbacks, anxious arousal, defensive avoidance and other symptoms, as well as other assessment tests (Feiring and Taska, p. 341).

Best practices for treating childhood and adolescent sexual and physical abuse that have withstood rigorous scientific testing are: Abuse-Focused Cognitive Behavioral Therapy; Trauma-Focused CBT; and Parent-Child Interactive Therapy. In cases of childhood trauma and abuse, CBT creates a trauma narrative that gradually describes the events in increasing detail. In adults, it targets the emotions of fear and shame “using gradual exposure to the trauma and cognitive restructuring to help process, organize, and make meaning of traumatic events” (Feiring and Taska, p. 346). In addition, CBT for adults creates a “hierarchy” of abuse-related events that produced shame, guilt or fear in the client, and “challenges dysfunctional beliefs” and behaviors associated with these traumatic events, while taking careful note of both verbal and non-verbal expressions of fear, shame and guilt. Talking, drawing and writing about past abuse “in the context of a supportive therapeutic environment” leads to Gradual Exposure (GE) of past traumas (Runyan et al., p. 72).

A major problem with CBT therapy is that patients fail to attend after the first session or drop out before completion. In a 2006 study of 55 patients with a principal diagnosis of anxiety disorders, including 45% with Panic Disorder, 31% with Social Anxiety Disorder and 24% with General Anxiety Disorder, found that Motivational Interviewing prior to treatment resulted in “significantly higher expectancy for anxiety control and greater homework compliance in CBT.” The group that had MI also had “a significantly higher number of CBT responders” compared to the control group on the waiting list (Westra and Dozios, p. 481). MI proved useful because resistance and noncompliance in therapy “is a reflection of ambivalence about change” in anxiety and depression patients, but this form of pretreatment “helps the client become a more effective advocate for their own change” (Westra and Dozios, p. 483). Applying MI principles to anxiety includes “expressing sympathy, rolling with resistance, developing discrepancies, and enhancing self-efficacy.” Its main goal is to identify and explore the reasons for changing as well as the obstacles to change and fear of change, allowing the clients to fully explore their thoughts and feelings. The role of the therapist in MI is to “evoke deeper client processing of their own ambivalence” (Westra and Dozios, p. 485). Of the group that received MI, 84% went on to complete the full CBT treatment versus 63% of the control group, and there was no variation in drop outs based on gender, age, martial status, employment or use of medications, although “completers tended to be more highly educated than drop outs” (Westra and Dozios, p. 489).

In dealing with a woman who had been sexually abused by her brother since the age of five, one therapist used guided imagery and relaxation techniques to make the patients narration of abuse easier. Survivors of sexual abuse have high levels of stress, shame and anxiety, especially at the beginning of therapy. They need to regain a sense of self-control, while preventing re-traumatization during therapy and uncontrollable flashbacks (Shachar, p. 34). Use of relaxation techniques increase the dominance of the right cerebral hemisphere and ease the processing of buried memories and emotions. In these therapy sessions, the patient was asked to choose or create images of a place where she “felt serene and confident” and then relate the memories of her sexual abuse. She recalled that her brother first abused her at age five, when he was eleven, after undressing here while they were watching television. While this was happening, she felt dissociated, as if she was “not there” and it was a dream or hallucination (Shachar, p. 37).

These memories were all highly fragmented and disconnected, as if they were outside of time. On one occasion, she remembered her brother undressing and abusing her of their parent’s bed. Her mother came home unexpectedly and her brother ran back to his room, but when asked if anything was wrong, she simply told her mother that “nothing happened.” After each revelation of these memories, the therapist had her return to the “safe place” and practice relaxation techniques. Later, she asked the patient to imagine putting her mind in a “secure glass box” while relating these memories and then imagine that she was looking at these through “binoculars” so that they would appear smaller (Shacher, p. 40)

For abusive parents, CBT offers a range of therapies including stress management, skills training, anger management, child management and problem-solving skills. For children who have been abused, CBT also uses group therapy programs, relaxation training, anger management, social skills building and expressive therapy, all of which lead to “significant improvements” (Runyan et al., p. 68). Relaxation and emotional expression techniques are vital for preparing children for GE and then processing these traumatic memories. Parent-Child Interactive Therapy has proven useful with physically abusive parents. One study of 110 such parents were randomly assigned to three types of intervention strategies: PCIT; PCIT plus enhanced, individualized services; and standard community-based parenting. All of these parents were from low-income households with a history of depression, substance abuse, antisocial behavior and physical abuse by their own parents. After 850 days, 19% of the parents in the PCIT groups were reported for abuse versus 49% in the community parenting group. Enhanced PCIT did not improve outcomes significantly. CBT types of therapy can also be used with non-offending parents and relatives who were unaware that the abuse was taking place or failed to intervene to prevent it (Feiring and Taska, p. 347). In recovering of traumatic memories, art therapy has often been found to be beneficial, as well as written narratives. There may also be a need to address the “somatic aspects of trauma” through stage-oriented treatment or sensi-motor therapy. CBT may not be appropriate for survivors of ritual, sadistic or organized sexual abuse (Bacon, p. 142).

For truly psychopathic patients with anti-social personality disorders, which are caused by damaged areas of the brain and “moral reasoning defects,” treatment involves “more a strategy of behavioral self-management than a cure,” such as the use of drugs like lithium, valproric acid and phengtorn to control aggression and impulsivity. Although such patients are often considered “untreatable” because so many previous programs have failed, especially those that are patient-run or involve anger management which turned out not to be appropriate for psychopaths. More carefully structured and controlled CBT programs that concentrate on behavior management rather than attempting to treat the core psychopathic personality, combined with drug therapy can be effective. One study with a follow up over five years of psychopathic and non-psychopathic patients who had received CBT treatment found “little difference in recidivism rates for both groups” (Vien and Beech, 2006, .pp. 169-70).

A central goal of therapeutic outcomes research is to determine which treatments are effective vs. those that have limited or no effects, and the best way to determine this is to compare groups that receive all treatments to a control groups that receives either none at all or only partial treatment (Heppner et al., 2008, p. 427). Experiments have to be designed “in such a way as to describe a phenomenon or identify relationships between constructs while ruling out as many plausible rival hypotheses or explanations as possible” (Heppner et al., p. 66). A parameter study would consider which qualitative and quantitative changes in therapy would be most effective, such as whether thirty-minute sessions were more effective than fifty-minute ones (Heppner et al., . 430). Placebo effect experiments would include one group that receives the full CBT treatment while another has only a “compassionate and caring therapist who responds empathetically to the client” with no real treatment program — or a “sham” treatment (Heppner et al., p. 431). Control groups are often put on a waiting list while the treatment groups complete the entire cycle of therapy. All experiments would have to be approved by an institutional ethics review board.

In a combined therapy experiment, groups with conditions A and B. together would require more treatment time than those with A and B. separated, or control groups receiving no treatment at all. It is critical that patients in all groups receive the exact same amount of time with the therapist, even in those offering limited or no treatment: durations of sessions should be equalized with “filler time” or “supportive listening.” CBT research requires protocol manuals with detailed procedures, and descriptions of methods and techniques for each therapy session. These will always be recorded, with 20-25% randomly selected for evaluation each day. In addition, criteria for drop outs must be determined in advance, based on a given number of missed sessions and records of the types of therapies that have the largest number of drop outs — especially those with long and complicated homework assignments (Heppner et al., pp. 224-25).

Selection criteria for therapeutic outcomes research is usually based on a particular diagnostic group, although the researcher must be mindful of the fact that many conditions tend to co-occur, such as anxiety and depression. Participants can be obtained through referrals from other mental health agencies, self-referrals, or responses to advertisements. Often, only those with the most severe symptoms are willing to participate, but these are often the first to drop out as well. All variables such as age, ethnicity, educational level, gender, and socioeconomic status should be reported and randomly assigned across the experimental groups as much as possible. Data on medical and psychiatric history, including past or current substance abuse, CBT treatments or other psychotherapies, hospitalizations and medications should also be included. One study drew 55 patients by referrals from public hospitals and mental health clinics (Westra and Dozios 2006); another had 152 patients randomly assigned to a control group or treatment group, referred from hospital outpatient services, the training clinic of a university hospital and two large teaching hospitals (Erikson et al. 2007); and a third took 1040 adult primary care patients with four different anxiety disorders, referred from twelve primary care clinics (Sullivan et al. 2007).

Researchers should also be aware of the fact that if selection criteria are too restrictive makes generalization of results more difficult (Behar and Borkovec, 2003, p. 227). In 1994, the American Psychological Association conducted a Core Battery Conference in an attempt to create a standardized assessment for pre-testing participants in outcomes experiments, including evaluations of “subjective distress,” impairment of life functioning in work and relationships, and frequency of symptoms (Behar and Borkovec, p. 230). Sample sizes will decrease when clients drop out over the length of the study, so it will be necessary to “recruit more clients than are needed so that post therapy and follow-up data will possess sufficient power to detect condition differences.” Clients should also be randomly assigned to the various groups, in waves if necessary when there are a large number of participants and a limited number of therapists (Behar and Borkover, p. 224).

Structured Clinical Interviews will confirm Axis I disorders as outlined in the DSM-IV/SCID IV to determine the primary or most functionally disabling disorder, as well as comorbidity with other anxiety orders or depression. Patients with psychosis, psychopathy, bipolar disorders, schizophrenia, current substance abuse or suicidal ideation should be excluded.

In one experiment concerning sexual addiction and sensation seeking, 539 university students were studied, divided almost equally between males and females. Men scored higher on both sexual addiction and sensation seeking, which were “associated with sex abuse experiences and poor family environments in childhood.” These compulsive behaviors require long-term treatment while “sensation seekers could possibly be effectively treated with short-term behavioral interventions” (Perera et al., 2009). Another study of 250 undergraduates determined that about one-third of both males and females had been sexually abused in childhood or adolescence.” It is well documented that such abuse results in high rates of depression, anxiety and sexual dysfunction in adulthood, as well as an increase in social anxiety (Rojas and Kinder 2009). In a 2010 study of 172 adults in their 30s and 40s who had been abused by relatives or by more than one abuser in childhood determined that those who did not discuss this in depth within a year of the actual abuse had “a greater number of mental health symptoms” (O’Leary et al. 2010).

Most experiments will have PhD-level clinical psychologists with at least 2-4 years experience with anxiety disorders in charge of each treatment group, Ignoring the impact of the therapist will have “deleterious effects on conclusions that are made in outcomes research.” About 5-8% of the differences in patient outcomes are due to the effectiveness of the therapists, and these may even be larger than treatment effects (Heppner et al., p. 445). This can be overcome by crossed design experiments in which therapists deliver all treatments of nested deign in which they deliver only one — preferably that with which they have the most skill and experience (Heppner et al., p. 446). In a dismantling design, the control group is provided with all components of treatment while other groups receive only some components (Behar and Borkovec, p. 217). If the control group receives no treatment at all, it can be placed on a waiting list provided that the treatment is later found to be effective. In an additive or constructive design experiment a group that receives two or more components of a treatment would be compared to others that received the original separate components, although not all components are easily broken down in this way (Behar and Borkovec, p. 219). A dismantling control group experiment minimizes therapist bias and uncertainty about which combination of treatment components is most likely to be effective. In a CBT experiment, for example, the researchers could dismantle the components by providing CBT plus challenging automatic thoughts or CBT plus decatastrophizing (Behar and Borkovec, p. 218).

Most research experiments include a pre-test or evaluation and a post-test to determine outcomes and treatment effectiveness. The best assessment method “is to collect data over time,” by using growth curve modeling, for example (Heppner et al., p. 444). Measuring the severity and duration of a problem should include behavioral, cognitive and emotional factors, while conclusions about treatment efficacy should look “beyond mere symptom reduction.” Pre- and post treatment assessments and analysis of data will be based on questionnaires, daily diaries, third-person reports and (blind) assessor ratings (Behar and Borkovec, p. 227). Follow-up assessments should continue for a minimum of one year after the end of treatment and possibly up to three years, and compared with those who dropped out or received no treatment. Data collectors and assessors should “always be kept in a blind condition to avoid biasing effects or biases interpretations of the data” (Behar and Borkovec, p. 230).

Diagnostic and Assessment Surveys.

These tests would be given as a baseline before the start of the experiment, after its completion, and again during the follow-up in six months, one year and eighteen months, to determine if remission and reduction of symptoms and impairment were temporary or long-term:

Anxiety Change Expectancy Scale (ACES): a 20-item self-reported test scored by a Likert Scale of 1-7, with poles from “strongly agree” to “strongly disagree.” Higher scores “indicate higher expectancy for anxiety change.”

Anxiety Sensitivity Index (ASI): useful for Panic Disorders, a 16-item test measured on a 1-5 Likert Scale.

Fear of Negative Evaluation Scale-Brief (FNEB): sensitive to Social Anxiety Disorders and agoraphobia, a 12-itemtest scored on a 1-5 point Likert Scale.

Penn State Worry Questionnaire: for General Anxiety Disorder, 21 items scored on a scale of 0-3, with higher scores indicating greater worry (Westra and Dozios, 2006, pp. 486-87).

Global Assessment Functioning (GAF): stratifies anxiety patients by duration and severity of symptoms, with a score of less than 49 indicating severe symptoms and impairment (Erikson et al. 2007).

Mini-International Neuropsychiatric Interview (MINI), section on anxiety disorders: this tool is “the simplest, most clinically relevant and easiest to learn interview” and takes about 45 minutes to administer (Sullivan et al. 2007).

CBT relies heavily on treatment manuals and standardized protocols for therapy with both groups and individuals. On manual frequently used is treating anxiety disorders in children and adolescents in the Coping Cat (CAT) Project which includes a therapist’s manual as well as workbooks designed for different age groups. The first phase concentrates of skills development, relaxation techniques, cognitive restructuring and problem solving, while the second part focuses on graded exposure to fearful situations (Grover, 2006, p. 276). It uses imaging techniques for anxiety-provoking situations with cues from the therapist “to facilitate the child’s retrieval of their worrysome thoughts” and to challenge them. Over time, the therapist obtains “a detailed description of the child’s worry scenario” and works to generate “more realistic or coping thoughts” (Grover, p. 277). For Social Anxiety Disorders and phobias, it employs muscle relaxation and breathing exercises for 20-30 minutes per day and also roleplay exercises for children with “social skills deficits” such as introducing yourself, joining a group and initiating a conversation (Grover, p. 280). With anxiety combined with depression and ADHD, the manual has games, humor, fun role plays and activities, in which families are also encouraged to participate. Its therapeutic goal is to “identify and challenge all negative thoughts and generate more realistic and adaptive thoughts” (Grover, p. 283).

Since the 1960s, the diagnosis and treatment of mental illness has become far more sophisticated than ever before in history, and the role of the federal government through Social Security, Medicare and Medicaid has also expanded exponentially. Indeed, aging Baby Boomers with senile dementia, Alzheimer’s Disease and depression are going to become the largest consumers of federal mental health care dollars in the decades ahead, especially those confined to nursing homes. In addition, the mental health care community has become aware that sexual and physical abuse is more common in the general population than previously recognized, as are depression and various stress and anxiety disorders. In recent times, treatment for these illnesses involves new classes of medications that are becoming more advanced all the time due to new research into brain structure and chemistry. Schizophrenia, which was once considered incurable, is also being treated with new classes of anti-psychotic medications. Older treatments like electroshock are no longer used except for severely depressed patients who do not respond to medications. Freudian psychotherapy has been largely discredited and abandoned in recent decades, replaced by Cognitive Behavioral Therapy (CBT) often combined with medications, and research has demonstrated the effectiveness of these new treatments. No longer are the mentally ill confined and warehoused for life in giant state hospitals, which were poorly funded, understaffed, and often abusive, while offering limited treatment options. The 1963 Community Mental Health Act was designed to close down these ‘snake pit’ hospitals in favor of outpatient psychiatric services and mental health centers, which would allow the mentally ill to live normal lives in society.

In any event, this was the dream, although in reality the state and federal governments often opted to save money simply by closing the older institutions without funding the new community mental health and outpatient services. Governor Ronald Reagan was notorious for dumping tens of thousands of mental patients into the streets in the 1960s and 1970s, but he was hardly alone. Unfortunately, millions of these people ended up homeless, unable to hold down regular jobs, and poorly served by the limited outpatient services available. Many of the elderly mentally ill were simply transferred from state hospitals to nursing homes, but still warehoused at the expense of the state and federal governments. Mentally ill persons on the streets often became the victims of crime and abuse, confined to short-term psychiatric facilities and jails that simply took over the custodial function of the old state hospitals. Deinstitutionalization, then, has turned out to mean that the mentally ill have been confined in different institutions or simply left on the streets — which was hardly the intention of Congress in 1963. This system may well have functioned much better had it been adequately funded, but unfortunately the mentally ill were never the first priority of politicians at any time in American history, and during periods of constrained public budgets from the 1970s to the present, their programs were often among the first on the chopping block. This does not mean that the country should expand the state hospitals again and broaden the laws on involuntary commitment — although this will very likely happen in the future — but replacing an obviously inadequate system with nothing at all was hardly an ideal solution to mental health care.


Bacon. H. “Book Review: Jonathan Willows, Moving On after Childhood Sexual Abuse: Understanding the Effects and Preparing for Therapy in Clinical Child Psychology and Psychiatry. (15)1 January 2010, pp. 141-42.

Bartels, S.J., A.D. van Citters and T. Crenshaw (2010). “Older Adults” in Levin, B.L., J. Petrila and K. Hennessy Mental Health Services: A Public Health Perspective. Oxford University Presss: 261-82.

Behar, E.S. And T.D. Borkovec. (2003). “Psychotherapy Outcome Research” in I.B. Weiner et al., eds. Handbook of Psychology: Research Methods in Psychology. New York: John Wiley & Sons.

Carron, V.G. And K. Hull. (2009). “Treatment Manual for Trauma-Exposed Youth: Case Studies.” Clinical Child Psychology and Psychiatry 15(1) 13 November 2009, pp. 27-38.

Chaffin, M. et al. “Parent-Child Interaction Therapy with Physically Abusive Parents: Efficacy for Reducing Future Abuse Reports. Journal of Consulting and Clinical Psychology. 72(3) June 2009, pp. 506-10.

Erikson, DH et al. (2007). “A Cognitive-Behavioral Group for Patients with Various Anxiety Disorders.” Psychiatric Services (58) September 2007, pp. 1205-111.

Feiring C. And L.S. Taska. (2005). “The Persistence of Shame Following Sexual Abuse: A Longitudinal Look at Risk and Recovery.” Child Maltreatment 10(4) November 2005, pp. 337-49.

Grover, R.L. (2006). “Treatment Modifications Based on Childhood Anxiety Diagnoses: Demonstrating the Flexibility in Manualized Treatment.” Journal of Cognitive Psychotherapy (20)3 2006, pp. 275-86.

Heppner, P.P. et al. (2008). Research Design in Counseling, 3rd Edition. Belmont, CA: Thomson Higher Education.

How Does the New Mental Health Parity Act Affect My Insurance Coverage?” (2009) American Psychological Association.

Levine, M. (1981). The History and Politics of Community Mental Health. Oxford University Press.

Murphy, R.A. (2010). “Multi-system Responses in the Context of Child Maltreatment and Intimate Partner Violence.” Child Abuse and Neglect 34(8) August 2010, pp. 555-57.

O’Leary, P. (2010). “The Effect of Severe Childhood Sexual Abuse and Disclosure on Mental Health during Adulthood.” Journal of Child Sexual Abuse (19)3 May/June 2010, pp. 275-89.

Perera, B. et al. (2009). “Childhood Characteristics and Personal Dispositions to Sexually Compulsive Behavior among Young Adults.” Sexual Addiction and Compulsivity. 16(2), April-June 2009, pp. 131-45.

Rojas, A. And B.N. Kinder. (2009). “Are Males and Females Sexually Abused as Children Socially Anxious Adults?” Journal of Child Sexual Abuse 18(4) July/August 2010, pp. 355-61.

Runyon, M.K. et al. (2004). “An Overview of Child Physical Abuse: Developing an Integrated Parent-Child Cognitive Treatment Approach.” Trauma, Violence, and Abuse (5)1, January 2004, pp. 65-85.

Shacher, R. (2010). “Relaxation and Guided Imagery with Narrative Practices in Therapy with an Incest Survivor.” International Journal of Narrative Therapy and Community Work, Issue 1 April 2010, pp. 33-55.

Sullivan, G. et al. (2007). “Design of Coordinated Anxiety Learning and Management (CALM) Study: Innovation in Collaborative Care for Anxiety Disorders.” General Hospital Psychiatry 29(5) September 2007, pp. 379-87.

Videbeck, S.L. (2010). Psychiatric-Mental Health Nursing. Wolters Kluwer Heath.

Vien, A. And A.R. Beech. (2006) “Psychopathy: Theory, Measurement, and Treatment.” Trauma, Violence, Abuse, 7(3) 2006, pp.155-74.

Westra, H.A. And D.J.A. Dozios. (2006). “Preparing Patients for Cognitive Behavioral Therapy: A Randomized Pilot Study of Motivational Interviewing for Anxiety.” Cognitive Therapy and Research (30) 2006, pp. 481-98.

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