SummaryADHD and reificationThis thesis starts with a quote from eleven-year-old Sylvia, who thinks ADHD “is like a cancer (...) but you’re not going to die from it”. ADHD is no disease like cancer, but a con- cept from the Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in its fifth edition. The DSM-5 defines ADHD with -partly overlapping- behavioral criteria such as “often has trouble waiting his/her turn” and “often interrupts or intrudes on others”. Thinking that the definitions in the DSM are concrete illnesses, such as Sylvia does, is acknowledged as a problematic phenomenon called reification. The most well- known mechanism of reification is called the “nominal fallacy”: naming behaviors carries the risk of thinking we have thereby explained them. In fact, constructs like ADHD only name these behaviors. However, confusing naming and explaining is just one of the mechanisms of reification. This thesis aims to answer the questions: how is ADHD reified in written discourse, and how often do these identified mechanisms of reification occur?Generalization and other mechanisms of reificationBesides confusing naming and explaining, generalizations can also lead to reification; particularly group-to-individual generalization. For instance, the authors of a large meta-analysis of brain-anatomy compared groups classified with ADHD with groups of “normal” individuals. They stated in their paper in 2017: “We confirm, with high-pow- ered analysis, that patients with ADHD have altered brains; therefore ADHD is a disorder of the brain. This message is clear for clinicians to convey to parents and patients”. The find- ings were in fact mere averages, and the case and control groups largely overlap. The authors wrongly suggest that all those classified with ADHD have different (smaller) brain parts. In fact, many with an ADHD classification have larger than average brain parts while many without an ADHD classification have brain parts that are smaller than average.There are many other reifying mechanisms. For instance, when reporting about case-control studies of neurophysiology and neurochemistry, researchers often select brain-images of the extremes from both samples. These images are then often pre- sented as allegedly representative of the brain activity and neurochemistry of a whole population of those classified with ADHD. In reality, case and control groups again show much overlap. Furthermore, brain activity differs strongly across people, regardless of an ADHD classification. Also within persons neurochemistry and physiology are not consistent through time.Medical jargon, for instance words like “symptom”, can also reify ADHD as the term implies that behaviors like interrupting others are the result of a disease or disorder. Speaking of criteria for ADHD is a more appropriate term, as this word refers to a stand- ard on which a decision may be based, and the word does not suggest the behaviors are caused by an innate problem.Similarly, by using metaphors, such as comparing ADHD to a meat-cleaver that splits the brains of those with ADHD, agency is ascribed to the ADHD-concept as a real entity that does damage to the human brain. This reifies ADHD and such a metaphor may also create fear and stigma. Another reifying mechanism is the suggestion of causality when only correlation is empirically proven. It is often suggested that ADHD can cause academic failure and maladaptation to the point of delinquency. However, as for instance child maltreatment can cause problems of inattention and restless behaviors –for which the ADHD-con- cept merely provides a name- both ADHD and delinquency can be confounded by adverse circumstances.ADHD can also be reified by “textual silence”: omitting important information that shows the construct does not represent a steady and reliable disorder. For instance: birth-month studies reveal that normal, age-related behaviors tend to be “diagnosed” with ADHD and medically treated. Not mentioning this important information can leave the perception of ADHD as a concrete entity intact.How often do these reifying mechanisms occur?Using a sample of 43 academic textbooks used at universities in the Netherlands, this thesis aims to quantify the occurrence of reifying mechanisms such as textual silence in relation to genetics. For instance, roughly half of the textbooks mention 60-80% heritability estimates of twin/family and adoption studies that compare behaviors of relatives to estimate the influence of genetics. At the same time, these textbooks omit that the more precise molecular genetic studies reveal a low direct influence of genes of about 5%. Only a quarter of the textbooks mention the contrasting findings, which reveal that twin/family and adoption studies cannot separate genetic from environ- mental influences very well. A quarter of the textbooks do contrast the high outcome of twin/family/adoption studies and the limited effects according to molecular studies. This “missing heritability problem”, as it is known, is not mentioned explicitly as such.Generalizations are also a common mechanism of reification. Of 36 textbooks that discuss brain anatomy in relation to ADHD, 21 (58%) do not mention that empirical outcomes are mere average findings that have little bearing on individuals classified as having ADHD. Fifteen chapters on ADHD did place such findings in perspective, by referring, for instance, to the fact that such findings are mere group outcomes. Only 3 of those, however, clearly mentioned that those with ADHD do not necessarily have different brains, or that “normal” controls can also have different/smaller brains. Only one chapter on ADHD mentioned both: no single deficit is necessary or sufficient to explain all cases of ADHD. Additionally, none of the chapters mentioned sampling bias due to the use of “supernormal” controls on the one hand and “refined phenotypes”, rigorously screened ADHD cases, on the other.Background of reificationReification is a concept from scholars filed under the sociological school of “Conflict Theory” that sees the quest for power as a foundation of social relationships. Framing ADHD as a hardwired genetic and brain-based illness can privilege medical profes- sionals. When described by the catch-all concept that ADHD is at risk of becoming, everyday behaviors like interrupting others are framed as medical problems and not as a normal part of socialization. As a result, non-medical professionals, like teachers, may feel inept.Conflict Theory also addresses the monetary basis at the heart of the production of knowledge. Differences in the availability of monetary resources (e.g. from pharma- ceutical companies) might further tilt the power balance, such as by financing dedicated companies that help to prepare presentations, write scientific papers (ghost writing) and recruit opinion leaders. However, a conflict theoretical perspective seems limited to explain the passion of some of those who believe strongly in the biological approach. Financial incentives might not necessarily have preceded this enthusiasm, and many researchers do not receive industry funding.Philosophers such as Trudy Dehue and Charles Taylor bring an additional, more “functional” perspective to explain our contemporary eagerness to reify concepts such as ADHD. Dehue, for instance, states that as biological explanations of behavior, concepts like ADHD are functional by providing an excuse for the person one is, par- ticularly if one fails to meet the neo-liberal norm of being self-reliant and successful. Taylor traced one of the roots of this neo-liberal ideology, which he calls “disengaged reason” all the way back to the likes of Plato and Descartes. Disengaged reason means that humans can find true beliefs about the world when being disengaged from it and being disengaged from one’s emotions. This ideal is represented well by Descartes’ “I think therefore I am”.The success of science, partly founded on this notion of disengaged reason, eroded the influence of the church. The influence of the normative framework that the church provided eroded as well and created a void that, from a functional perspective, needed to be filled. Psychiatry rose to the occasion to help fill this void with its’ own psychiatric bible –as the DSM is often called. Perhaps unsurprisingly, psychiatry, as the new sci- ence-based norm-setting institution, is engrained with this ideal of disengaged reason.ADHD and the ideal of disengaged reasonI argue that the rationalistic norms strongly surface in the ADHD-concept. We expect children to control their impulses, be silent in their play and await their turn. Also in the way we study human behavior and “diagnose” children as having a neurodevelopmental disorder - based on splicing their behaviors and counting “symptoms”, we lean towards disengaged reason. A diagnosis does not require asking for a child’s motives for his/ her behavior. So, both the norms we bestow upon children via the ADHD-concept, and the norms we bestow upon ourselves by the way we try to classify them without the need to involve children themselves to give meaning to their behaviour, reflect the dominance of this disengaged reason in my view.ImplicationsSo, possibly we reify and fail to be objective to the disappointing outcomes of empirical studies with the ADHD construct due to our own narrow (institutional) interests. Or, possibly we have historically embedded high hopes for the success of psychiatry’s nor- mative framework. Either way, such interests or high hopes do not necessarily overlap with the interests of the child, which should be our primary concern. So finally, some political and practical implications are offered to safeguard the child’s best interest.Future studies based on this thesis could estimate the prevalence of reifying mech- anisms and could also include different domains of discourse besides textbooks. Ad- ditionally, institutional dependency on constructs from the DSM should be examined critically. For instance, scientific funding agencies should consider the pros and many limitations of the study into the highly reified classifications and consider alternative classifications, such as using Research Domain Criteria. Another possible approach to research and providing care is using a more tentative, back-and fourth, normalizing approach such as stepped diagnosis and stepped care. From a political point of view the high interdependence of science and commercially vested interest calls for reconsider- ation of how we can use financial resources. One longstanding idea is to concentrate these resources in a fund with representatives from different branches of industry, science and government.Finally, medically framing children’s restlessness that is associated with a plethora of problems -such as the contemporary schooling system, divorce, poverty, trauma and loss- makes it easy to forget such larger issues. To avoid this, we should seek refuge in the institute that aims to protect the child’s autonomy, agency and safety in the face of the many individual and collective challenges that our children are confronted with: The Convention on the Rights of the Child. This institution should also safeguard that our current healthcare system with its classifications is part of the solution and not part of the problem.
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PURPOSE: To determine what is known from the literature about nursing care of psychiatric patients with a history of child maltreatment. CONCLUSIONS: Psychiatric nurses underline the importance of a routine inquiry of child abuse on admission of patients to psychiatric care, but are reluctant to ask about child abuse. They often feel insufficiently competent to respond effectively to patients with a history of child maltreatment. PRACTICE IMPLICATIONS: Psychiatric nurses need training in how to assess a history of child abuse and the late-life consequences of abuse in adult psychiatric patients. They also need to be trained to respond effectively to these patients.
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In psychiatric care professionals perceive some patients as 'difficult', especially patients with long-term non-psychotic disorders. For these patients few evidence-based treatments exist. An intervention program, Interpersonal Community Psychiatric Treatment (ICPT), was developed by the authors. It was evaluated with the aim to increase effective behaviours by both patients and community psychiatric nurses (CPNs).
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The concept of a working alliance is rooted in psychotherapy and has been studied extensively in that field. Much less research has been conducted into working alliances between chronic psychiatric patients and their case managers. The aim of this review was to identify what is known about the working alliance between chronic psychiatric patients and their case managers. An extensive survey of the literature produced 14 articles for this review. The results of studies conducted show that a good working alliance has positive effects on the functioning of patients, and that the quality of the alliance depends on both patient characteristics and the behaviour of the case managers. The results also indicate that the working alliance is largely determined in the first 3 months of the contact. Further research into the development of working alliances is necessary.
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Most violence risk assessment tools have been validated predominantly in males. In this multicenter study, the Historical, Clinical, Risk Management–20 (HCR-20), Historical, Clinical, Risk Management–20 Version 3 (HCR-20V3), Female Additional Manual (FAM), Short-Term Assessment of Risk and Treatability (START), Structured Assessment of Protective Factors for violence risk (SAPROF), and Psychopathy Checklist–Revised (PCL-R) were coded on file information of 78 female forensic psychiatric patients discharged between 1993 and 2012 with a mean follow-up period of 11.8 years from one of four Dutch forensic psychiatric hospitals. Notable was the high rate of mortality (17.9%) and readmission to psychiatric settings (11.5%) after discharge. Official reconviction data could be retrieved from the Ministry of Justice and Security for 71 women. Twenty-four women (33.8%) were reconvicted after discharge, including 13 for violent offenses (18.3%). Overall, predictive validity was moderate for all types of recidivism, but low for violence. The START Vulnerability scores, HCR-20V3, and FAM showed the highest predictive accuracy for all recidivism. With respect to violent recidivism, only the START Vulnerability scores and the Clinical scale of the HCR-20V3 demonstrated significant predictive accuracy.
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Objective: A key aspect of psychiatric rehabilitation is supporting individuals with serious mental illness in reaching personal goals. This study aimed to investigate whether various aspects of the working alliance predict successful goal attainment and whether goal attainment improves subjective quality of life, independent of the ehabilitation approach used. Methods: Secondary analyses were conducted of data from a Dutch randomized clinical trial on goal attainment by individuals supported with the Boston University approach to psychiatric rehabilitation (N=80) or a generic approach (N=76). Working alliance was measured with the Working Alliance Inventory (WAI) from the practitioner’s perspective. Rehabilitation practitioners had backgrounds in social work, nursing, or vocational rehabilitation. Multiple logistic regression and multiple regression analyses explored effects of working alliance on goal attainment and of goal attainment on subjective quality of life at 24 months. Analyses were controlled for client- and process-related predictors, baseline quality of life, and rehabilitation approach. Results: The WAI goal subscale predicted goal attainment at 24 months. No effect was found for the bond or task subscale. Goal attainment significantly predicted quality of life at 24 months. These effects were independent of the rehabilitation approach used. Conclusions: A good bond between client and practitioner is not enough to attain successful rehabilitation outcomes. Findings suggest that it is important to discuss clients’ wishes and ambitions and form an agreement on goals. Attaining rehabilitation goals directly influenced the subjective quality of life of individuals with serious mental illness, which underscores the importance of investing in these forms of client support.
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Background: People with severe mental illnesses (SMIs) have difficulty participating in society through work or other daily activities. Aims: To establish the effectiveness with which the Boston University Approach to Psychiatric Rehabilitation (BPR) improves the level of social participation in people with SMIs, in the Netherlands. Method: In a randomized controlled trial involving 188 people with SMIs, we compared BPR (n = 98) with an Active Control Condition (ACC, n = 90) (Trial registration ISRCTN88987322). Multilevel modeling was used to study intervention effects over two six-month periods. The primary outcome measure was level of social participation, expressed as having participated in paid or unpaid employment over the past six months, as the total hours spent in paid or unpaid employment, and as the current level of social participation. Secondary outcome measures were clients’ views on rehabilitation goal attainment, Quality of Life (QOL), personal recovery, self-efficacy, and psychosocial functioning. Results: During the study, social participation, QOL, and psychosocial functioning improved in patients in both groups. However, BPR was not more effective than ACC on any of the outcomes. Better social participation was predicted by previous work experience and a lower intensity of psychiatric symptoms. Conclusions: While ACC was as effective as BPR in improving the social participation of individuals with SMIs, much higher percentages of participants in our sample found (paid) work or other meaningful activities than in observational studies without specific support for social participation. This suggests that focused rehabilitation efforts are beneficial, irrespective of the specific methodology used.
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Purpose Self-injury is common in forensic psychiatric settings. Recent research offers some insights into the functions and management of self-injurious behaviour but generally focusses on either the experiences of staff or patients. This study aims to explore the experiences of both staff and patients with non-suicidal self-injury in a Dutch forensic psychiatric hospital. Design/methodology/approach In total, 6 patients and 11 staff members were interviewed about the functions they ascribe to self-injurious behaviour, the emotional experience provoked by this behaviour and the management of self-injurious behaviour. The interviews were transcribed and analysed using a thematic analysis. Findings Four main themes resulted from the analysis: functions; emotional distancing; patient needs; and management. Overall, findings illustrate that staff reports limited knowledge of the different functions of self-injury. To circumvent potential automatic stereotypical judgement, staff should proactively engage in conversation about this topic with their patients. In managing self-injurious behaviour, clarity and uniformity among staff members should be promoted, and collaboration between the staff and patients is desirable. Staff recognised the potential benefit of a management guideline. Staff may find detached coping strategies to be effective but should be vigilant to not let this evolve into excessive detachment. Practical implications Increased knowledge and awareness of self-injury functions among staff can allow for better understanding and evaluation of self-injury incidents. Circumvention of automatic, stereotypical judgement of self-injurious behaviour is warranted, and more accessible explanations of the variety of functions of self-injury should be used. More proactive engagement in conversations about functions of self-injury by staff, can facilitate this. Detached coping can help staff to remain resilient in their job, but requires vigilance to prevent this from turning into excessive detachment. Clarity and uniformity among staff when managing self-injury incidents is considered beneficial by both patients and staff. A guideline may facilitate this. When imposing restrictions on patients, staff should strive to establish collaboration with the patient in determining the course of action and ensure the restriction is temporary. Originality/value The impact of self-injurious behaviour on all those involved can be enormous. More research is needed into experiences of both patients and staff members regarding the impact, motivations, precipitants and functions of self-injurious behaviour, and effective treatment of it.
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Abstract Introduction: In 2017, the role of coordinating practitioner was introduced in the Netherlands in order to improve quality of care for patients who receive treatment in specialized mental health care. Psychiatric-mental health nurse practitioners (PMHNPs) can fulfil this role. Aim/Question: The aim was to obtain insight into how PMHNPs fulfil the coordinating practitioner role and what is needed to improve fulfilment of this role. Method: A survey among PMHNPs in the Netherlands was conducted between July-September 2018. In total, 381 PMHNP filled out the questionnaire; the response rate was 47.6%. Descriptive analyses were performed using SPSS 22® (IBM). Results: 92% Of the PMHNPs fulfilled the coordinating practitioner role and were generally satisfied with their role performance. The following conditions were formulated to improve this role: 1) recognition and trust in the expertise of PMHNPs, 2) a clear description of their role as coordinating practitioner, 3) strengthening multidisciplinary collaboration, and 4) sufficient training budget and opportunities. Discussion: In Dutch mental health care, PMHNPs have strengthened their position as coordinating practitioner in a short period of time. Follow-up research should be conducted to obtain further insights into elements that contribute to an optimal role as coordinating practitioner. Implications for Practice: Having PMHNPs act as coordinating practitioners can contribute to solving the challenges in mental health care regarding coordination of care and effective multidisciplinary collaboration.
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Abstract Background: Children and adolescents in mental healthcare often perceive their care needs and necessary treatment differently from their clinicians. As such discordance between young patients and clinicians may obstruct treatment adherence and compromise treatment outcomes, it is important to understand the factors associated with it. We therefore investigated the factors associated with patient–clinician discordance with regard to care needs in various areas of functioning. Methods: A cross-sectional study involving 244 children/adolescents aged 6–18 participating with their clinicians in treatment at a specialized mental healthcare center. As a previous study conducted by our research group had found the greatest patient–clinician discordance in three CANSAS care needs—“mental health problems,” “information regarding diagnosis and/or treatment,” and “making and/or keeping friends”—we used univariable and multivariable statistics to investigate the factors associated with discordance regarding these three care needs. Results: patient–clinician discordance on the three CANSAS items was associated with child, parent, and family/social-context factors. Three variables were significant in each of the three final multivariable models: dangerous behavior towards self (child level); severity of psychiatric problems of the parent (parent level); and growing up in a single-parent household (family/social-context level). Conclusions: To deliver treatment most effectively and to prevent drop-out, it is important during diagnostic assessment and treatment planning to address the patient’s care needs at all three levels: child, parent and family/social context.
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