Quote Originally Posted by Christopher M
On the other hand, medication compliance, particularly with psychotic populations, can be extremely low. And this idea that it is the patient's responsability to put forth the effort to attend and benefit from therapy is part of a particular culture of therapy rather than a necessary principle of therapy in general. It's possible to do extremely beneficial therapeutic work with inpatients, it just takes a different mindset than therapists are typically trained to have.
Well, part of it may be mindset. Part of it is that if you are only keeping a person in inpatient care until they are no longer a threat to themselves or others, then by definition, they are in a state in which they are not equipped to attend to or benefit much from therapy. This is not to say that they cannot benefit at all, just that if thereapy is to be conducted, it must have very specific, simple, and short-term goals. Further, it may be sad to accept, but the system for the most part is just not set up for this. The people in the best position to conduct therapy in an inpatient unit are the nurses, and they simply have too much to do to be able to work with each patient in this way. I know of one hospital in Columbus in which they actually do some inpatient therapy (conducted by the psych nurses), but that hospital is selective about what patients it takes. When all your patients are insured or can pay for their care, and are not mainly substance abusers with behavioral issues (but rather legitimately ill people), you can afford to reduce the patient to nurse ratio somewhat and can actully get some therapy done.

Regarding the whole patient's responsibility to engage therapy, I'm not saying we should write off patients that are unable or unwilling to actively participate in therapy, but in my opinion it is simply a fact that until someone accepts that they are ill and takes an active interest in getting better, no therapy is going to be an effective long-term solution. Therapy=work. The therapist can try to help a person to understand why the work is worthwhile, medication can help clear a person's thoughts so they can start to make decisions that are in their best interests, but ultimately, I can't think of a therapy that works with patients who are not actively participating. If there is such a therapy, please refer me to some resources/research.


Quote Originally Posted by Christopher M
Right, but the problem is that it isn't clearly anyone's role any more. Which is probably why active therapeutic approaches, such as that mentioned above, are so rare. Even clinical psychologists are largely abandoning psychotherapeutic roles for strictly psychodiagnostic ones. Good therapists typically have training as therapists alongside whatever profession they have, but this is preventing the development of 'therapist' as a professional identity, along with the benefits that this would bring.
As someone who is training to ultimately prescribe and conduct therapy, this comment strikes close to home. The whole chaotic nature of the professional environment for people like myself (who see the value of therapy and want it to be a large part of what they do) makes me very nervous about my future. There are big problems with the system right now in terms of poor continuity of care within mental health and the absence of mechanisms to help people stay on track when they have the will but sometimes lack the cognitive or financial resources to do so.