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"BRIDGING" THERAPY IN HOSPITAL
-AND COMMUNITY-BASED PSYCHIATRIC NURSING CARE: A COMPARATIVE STUDY
by
NELLY AHMED MAHGOUB SRN BSc(Hons) MSc
VOLUME I
Thesis su b m itte d to the C ouncil fo r N a tio n a l A ca dem ic Aw ards in p a rtia l fu lfilm e n t o f the require m en ts fo r the degree o f D o cto r o f Philosophy
Sponsoring E stablishm ent : D e p a rtm e n t o f H e a lth Studies S h e ffie ld C ity P o lyte ch n ic C o lla b o ra tin g Establishm ent : S h e ffie ld H e alth A u th o rity
"B R ID G IN G " TH ER A PY IN H O S P IT A L- AN D C O M M U N IT Y -B A S E D P S Y C H IA T R IC NURSING C A R E : A C O M P A R A TIV E STUDY
N E L L Y AHM ED M AHG O UB RGN BSc(Hons) MSc
A B STR AC T
This study presents a deta ile d account o f B ridging Therapy - an in n o va tive in te rv e n tio n aim ed a t pro vid in g re la tiv e ly com prehensive p s y c h ia tric nursing care fo r m e n ta lly i l l p a tie n ts. S ta rtin g a t h o s p ita lisa tio n , B ridging Therapy continues as planned nursing care based on d e ta ile d assessment o f the p a tie n t's s h o rt- and lo n g e r-te rm needs both be fo re and a fte r discharge to the c o m m u n ity , delive re d where possible by the same nurse, or by members of the same nursing team . B ridging Therapy thus presents a re m e d ia l m odel fo r c u rre n t fra g m e n te d p a tte rn s o f nursing care, based on an e c le c tic approach to psychotherapy and nursing process known as the "fle x ib le in te g ra tiv e approach" (F IA ).
The study recognises problem s caused by lack o f p a tie n t outcom e measures in p s y c h ia tric nursing; and approaches th is by developing an ap p ro p ria te assessment in s tru m e n t, the Behaviour A d ju s tm e n t In ve n to ry (BAI), w hich is in itia lly tested in c o n cu rre n t use w ith a w e ll-v a lid a te d p sych o m e tric in s tru m e n t (the GHQ); w ith a second w e ll-v a lid a te d in stru m e n t (the EPI) a ctin g as an in itia l screening device. The B A I assesses p a tie n ts ' in itia l status on admission and subsequent responses to Bridging Therapy on a fiv e -p o in t scale, used in co n ju n ctio n w ith d e ta ile d c lin ic a l c r ite ria o f behaviour and a ttitu d e change.
C lin ic a l e va luatio n o f p a tie n ts in the co n tra ste d c o n te xts o f S h e ffie ld and C airo is described. In each c o n te x t, e x p e rim e n ta l (B ridging Therapy) and c o n tro l (non- Bridging Therapy) groups are studied (S h e ffie ld to ta l N = 22: C a iro to ta l N = 18). Assessment o f in itia l co n d itio n was c a rrie d out on admission to h o sp ita l;
re co ve ry status on discharge, and a t the close o f th e ra p e u tic fo llo w -u p in the co m m u n ity. Results in d ica te s im ila r levels o f re co ve ry fo r S h e ffie ld and C a iro groups, w ith a more pronounced tendency to re co ve ry in the e xp e rim e n ta l (Bridging Therapy) groups; how ever, th is d iffe re n c e does n ot reach s ta tis tic a l
s ig n ific a n c e . .. .
PREFACE
As an Egyptian, the researcher recognised the need for improvements in the Egyptian psychiatric nursing service; especially in opening-up the of community psychiatric nursing care, which is currently non-existent in Egypt. Initially, she naively assumed that Britain would be able to provide a developed model of community psychiatric nursing care which would transfer to Egypt.
This assumption changed when the researcher was confronted with the reality of the many problems encountered by newly-discharged patients and their carers in Britain. In the first weeks of the preparatory phase, it became clear that the British system of community psychiatric nursing care has developed in an ad hoc manner; and that consequently it has numerous gaps and varies greatly across the country.
Conducting appropriate research to produce a useful model of community psychiatric nursing that would transfer to Egypt became a strong personal commitment. Initial research plans, which involved systematic appraisal of a supposedly well developed "British" community psychiatric nursing model, followed by empirical testing of this model of Egypt, had to be changed twice during the course of study.
First, a decision was made that, due to lack of a model for comprehensive community psychiatric nursing in Britain, the researcher should attempt to initiate and test a model that would be both theoretically and empirically sound. Therefore, bridging therapy was developed to suggest some solutions to one of the most pressing problems - that of bridging the gap between hospital- and community-based psychiatric nursing care.
The choice of research problem proved complex due to numerous factors, including lack of suitable assessment instrument for patient outcomes in the field of community psychiatric nursing. Considerably more time than initially anticipated was spent in developing such an instrument. Consequently, data collection in Sheffield was time-consuming, extending over two and a half years, sometimes for ten hours a day, five days a week.
This situation was not encouraging, since it indicated that, in its initial form, bridging therapy was not cost-effective in the British context. However, remarkable improvements had been noted in both groups studied in Sheffield, both in qualitative and quantitative terms. This led to the second decision - ie to test the utility and applicability of bridging therapy in Cairo. Accordingly, the research plan was further revised to become a comparative study within the context of evaluation research.
Acknow ledgem ents
I t is im possible to thank d ire c tly a ll the people who have c o n trib u te d to the em ergence and c o m p ila tio n o f the p ro je c t. H ow ever, I would lik e to acknowledge, in p a rtic u la r, a ll the s ta ff in Ward 36 and the Day H o spital as w e ll as the p a tie n ts in the P s y c h ia tric U n it, N o rth e rn G eneral H o sp ita l, S h e ffie ld .
Equal thanks are also d ire c te d to a ll the s t a ff o f E l-N ie l Sanatorium in C airo.
I would lik e also to d ire c t my special thanks to my supervisors, P ro f C P Seager, M r A Cashdan, and Dr V Reed fo r th e ir invaluable support and guidance.
I am also g ra te fu l to P ro f F Jenner, Head o f P s y c h ia tric D e p a rtm e n t o f S h e ffie ld U n iv e rs ity , D r J Snadden, C onsultan t, M r F Canny, D ire c to r o f Nursing D ivisio n a t M iddlew ood H o sp ita l, P ro f M Gawad, C a iro U n iv e rs ity , and D r F Abou- El Magged, D ire c to r o f E l-N ie l H o spital fo r th e ir tim e and patience during the e xp e rim e n ta tio n .
I would lik e also to thank D r G erald L a rk in , Head o f D e p a rtm e n t, Mrs Helen O rton, Research C o -o rd in a to r and Miss Je n n ife r M orriso n, A c tin g Head o f D e p a rtm e n t, in S h e ffie ld C ity P o lyte ch n ic fo r th e ir a d m in is tra tiv e support. Equal thanks to M rs V S in cla ir and Miss J Senior fo r th e ir s e c re ta ria l support as w e ll as M r P H o lt fo r his help in the s ta tis tic a l analysis.
F in a lly I would lik e to express my deepest g ra titu d e to the E g yptian E ducational Bureau who have generously sponsored th is p ro je c t and believed in its in herent value.
L is t o f C o nte nts
VOLUM E (1)
Page
A b s tra c t i
P reface ii
Acknow ledgem ents iii
L is t o f C onte nts iv
In tro d u c tio n and Summary 1
C H AP TER 1: B rid gin g Therapy in its C ro ss-C u ltu ra l C o n te x t 3
In tro d u c tio n 6
1.2 The Research Problem 10
1.3 The Proposed Model o f 'B ridging Therapy' - 12
1.4 The C u rre n t Study 13
1.5 Research A im and Hypotheses 15
1.6 C ro s s -C u ltu ra l Aspects o f the Study C o n te x t 16
1.6.1 Concept o f C u ltu re 16
1.6.2 S o c io -c u ltu ra l R e latio nship to M ental Illness
in E gypt and Associated C u ltu re s 17 1.6.3 Epidem iology o f M ental Illness in
E gypt and Associated C u ltu re s 20 1.6.4 P s y c h ia tric Nursing in E g ypt: E ducation, Work
and A ttitu d e s towards P s y c h ia tric P a tie n ts 24 1.6.5 T re a tm e n t and H ealing Approaches in Egypt
and Associated C u ltu re s 32
1.6.6 Research Problem s Associated w ith
C ro s s -c u ltu ra l Studies 41
1.6.7 W estern Style o f M ental H e alth Care 46
C H APTER 2 : C o m m u n ity M ental H e a lth Services 49 2.1 C onceptual Base o f C o m m u n ity P s y c h ia tric Care in UK
and A m e rica 50
Page 2.2.1 C o m m u n ity P s y c h ia tric Nursing Services in the U K 58 2.2.2 C o m m u n ity M ental H e a lth Care in the USA 61 2.2.3 C o m m u n ity P s y c h ia tric Care in E gypt 62 2.3 H is to ric a l R eview o f C o m m u n ity M ental H e a lth Service
D evelopm ent 62
2.3.1 The U K 62
2.3.2 E gypt 70
2.4 The C o m m u n ity P s y c h ia tric Nursing Role 73 2.4.1 The Ideology o f the CPN Role 73
2.4.2 Role E xp e cta tio n s 83
2.4.3 Problem s 85
2.4.4 Cost E ffe c tiv e n e s s 8 8
2.4.5 E ducational P re p a ra tio n 91 2.5 A R eview o f Proposals fo r M o d ific a tio n o f the Service 96
CH APTER 3: Models o f T h e ra p e u tic In te rv e n tio n 108
3.1 In tro d u c tio n 109
3.2 Three R e le va n t P sych oth era peutic Approaches 112 3.2.1 Thorne’s E c le c tic System 112
3.2.2 R e a lity Therapy 119
3.2.3 Supportive Psychotherapy 122
3.3 The F le x ib le In te g ra tiv e Approach (F IA ) 125 3.4 C la s s ific a tio n o f the M ain T he rap eutic Models 128
3.4.1 P sychoanalytic 128
3.4.2 H u m a n is t-E x is te n tia l 129 3.4.3 P e rcep tua l-P he nom enological 130
3.4.4 The R a tio n a l Approach 132
3.4.5 Behavioural 136
3.4.6 B io lo g ica l Model 138
3.4.7 Social Model 139
3.4.8 Group Therapy 140
3.5 P ra c tic a l Im p le m e n ta tio n and L im ita tio n s o f the F IA
-P sych oth era peutic 145
3.6 P ra c tic a l Im p le m e n ta tio n o f the F IA - Nursing Process 150
3.7 Conclusions 155
CH APTER 4: M ethodology 157
Page 159 159 160 164 169 176 178 179 181 201 204 206 208 210 211 212 217 217 219
221
223 225 226 228 229 233 235 235 240 243 243 248 250 254 Research Design4.2.1 P a rt One: T h e o re tic a l Background o f the Study 4.2.1.1 Q u a lita tiv e /Q u a n tita tiv e Techniques 4.2.1.2 The N a tu re o f The Study
Q ua si-E xp e rim e n ta l; A c tio n Research 4.2.1.3 D ata C o lle c tio n S trategies
O bservation; In-depth In te rv ie w S e lf-R e p o rt Q uestionnaires 4.2.1.4 Sampling
4.2.1.5 L im ita tio n s o f the Proposed Research Design 4.2.2 P a rt Two: The Technical Design o f the Study
4.2.2.1 C ro s s -c u ltu ra l Aspects 4.2.2.2 The Two Phases o f the Study Methods o f D ata C o lle c tio n
4.3.1 S e m i-P a rtic ip a n t O bservation 4.3.2 In-D epth In te rvie w s
4.3.3 S e lf-R e p o rt Q uestionnaires
4.3.4 C h e cklists: The B ehavioural A d ju s tm e n t In ve n to ry (BAI) and its R ecovery Index (RI)
4.3.5 D ata C o lle c tio n Instrum ents - In S h e ffie ld ; In C a iro 4.3.6 D evelopm ent o f the Behavioural A d ju stm e n t In ve n to ry
(BAI)
4.3.6.1 Main Purposes o f the B A I
4 .3.6.2 T h e o re tica l Background o f the B A I
4 .3.6.3 S tru c tu ra l Components o f the B A I
4 .3.6.4 T echnical D evelopm ent o f the B A I
4.3.6.5 D evelopm ent o f the R ecovery Index (RI) 4 .3.6.6 T h e o re tic a l Bases o f RI D evelopm ent
4 .3 .6.7 L im ita tio n s o f the B A Iio g and its RI
4 .3.6.8 V a lid a tio n Phase and New Version o f the B A I
4 .3 .6.9 Testing V a lid ity and In te r-R a te r R e lia b ility
o f B A I3Q in C a iro
Sampling S trate gy 4.4.1 In S h e ffie ld 4.4.2 In C a iro
Im p le m e n ta tio n o f B rid gin g Therapy 4.5.1 In S h e ffie ld
4.5.1.1 B ridging Therapy com pared w ith the c u rre n t conventional provision
4.5.2 In C a iro
Page
4.7 Summary 256
C H AP TER 5: Research Findings 258
5.1 In tro d u c tio n 259
5.2 D e scrip tio n o f the Samples 259
5.2.1 The S h e ffie ld Sample 259
5.2.2 The C a iro Sample 262
5.3 The Q u a n tita tiv e Findings 264
5.4 The Q u a lita tiv e Findings 274
5.4.1 D e ta ile d Case Study No. 1 (S h e ffie ld F ie ld Work) 277 5.4.2 D e ta ile d Case Study No. 2 (S h e ffie ld F ie ld W ork) 301 5.4.3 D e ta ile d Case Study No. 3 (C airo F ie ld W ork) 331 5.4.4 D e ta ile d Case Study No. 4 (C airo F ie ld W ork) 355
C H AP TER 6: Discussion 376
6.1 In tro d u c tio n 377
6.2 L im ita tio n s o f the Study 379
6.2.1 P r a c tic a lity o f B rid gin g Therapy 380 6.2.2 C o m p le x ity o f Design 382 6.2.3 L im ite d S ta tis tic a l S ignificance 385 6.2.4 Use o f a New Behavioural In stru m e n t 387 6.2.5 U nobtrusive Measures, D ata Redundancy and
Observer Tim e 388
6.2.6 C ro ss-C u ltu ra l D iffe re n c e s 388 6.3 Assessment o f T he rap eutic E ffe ctive n e ss o f B rid g in g Therapy 391 6.3.1 B ridging Therapy as E va lua tion Research 391 6.3.2 B ridging Therapy in its C ro ss-C u ltu ra l C o n te x t 396 6.3.3 B ridging Therapy as a M odel fo r Com prehensive
C o m m unity P s y c h ia tric Nursing Care 401
6.4 Discussion o f Results 405
6.4.1 Discussion o f Q u a n tita tiv e D ata 405 6.4.1.1 C o m p a ra b ility o f B A I3Q w ith GHQ Scores 406
6.4.1.2 Lack o f S ta tis tic a l D iffe re n c e s between
E x p e rim e n ta l and C o n tro l Groups 408 6.4.1.3 Lack o f S ta tis tic a l D iffe re n c e between
Page 6.4.2.2 The T he rap eutic In te rv e n tio n M odel 421
6.5 Im p lic a tio n s o f the Study 431
6.5.1 C lin ic a l Im p lic a tio n s 431 6.5.2 E ducational Im p lic a tio n s 432 6.5.3 O rga nistio nal Im p lic a tio n s 434
6.5.4 Research Im p lic a tio n s 436
6.6 Conclusion 438
References and B ib liograph y 441
LIST OF TABLES
Table 1.1 E a rly Nursing D iscip lin es and T ra in in g 25 Table 1.2 Comparison o f T ra d itio n a l and W estern T re a tm e n t
Styles 33
Table 1.3 H o sp ita l and O u tp a tie n t C lin ic s 38 Table 1.4 T o ta l Bedservice and P s y c h ia tris ts 39 Table 4.1 R e side ntial C a tegories in E l-N ie l Sanatorium 193 Table 4.2 M atch ing Process in S h e ffie ld E x p e rim e n ta l and
C o n tro l Groups 240
Table 4.3 M atch ing Process in C a iro E xp e rim e n ta l and C o n tro l
Groups 242
Table 5.1 Sex d is trib u tio n both in S h e ffie ld and C a iro Samples 259 Table 5.2 B ritis h sample d is trib u tio n - liv in g w ith fa m ily
or on own 260
Table 5.3 B ritis h sample outcom es in re la tio n to
h o sp ita lisa tio n or death 261 Table 5.4 M a rrie d /s in g le d is trib u tio n in the E g yptian sample 262 Table 5.5 GHQ measure o f im p ro ve m e n t o f the S h e ffie ld sample
a t three in te rv a ls 265
Table 5.6 B A I3Q measures o f im p ro ve m e n t o f the S h e ffie ld
sample on three occasions 266
Table 5.7 Comparison o f im p rovem ent gained by both e xp e rim e n ta l and c o n tro l groups o f the B ritis h Sample, as measured
Page Table 5.8 GHQ m easurem ent o f im provem ent in the E g yptian sample
on three occasions 269
Table 5.9 B A I3 0 m easurem ent o f im provem ent fo r the E gyptian
sample on three occasions 270
Table 5.10 Summary o f B A I3 0 Assessment fo r G e o ffre y Raymonds 298
Table 5.11 Summary o f B A I3 0 Assessment fo r Julie A lle n 329
Table 5.12 Summary o f B A I3 0 Assessment fo r Yassin E l-K h a ly 350
Table 5.13 Summary o f B A I3Q Assessment fo r Sherifa A dleby 373
LIST OF FIGURES
Figure 5.1 The lin e a r trend o f the two groups in S h e ffie ld 268 F igure 5.2 The lin e a r trend o f the two groups in C a iro 271 F igure 5.3 GHQ o f both groups in S h e ffie ld and C a iro 272 Figure 5.4 B A I3 0 o f both groups 273
LIST OF ILLU STR ATIO N S
Illu s tra tio n 5.1 In te rp re ta tiv e images:
(A) The Blackness o f D eath 322
Illu s tra tio n 5.2 In te rp re ta tiv e images:
(B) The Sad Face 323
Illu s tra tio n 5.3 In te rp re ta tiv e images:
(C) The Tom U terus 324
Illu s tra tio n 5.4 In te rp re ta tiv e images:
VO LU M E (2) APPENDICES Page Appendix 1 Day H o spital P s y c h ia tric U n it, A1
N o rth e rn General H o spital
Appendix 2 Eysenck P e rso n a lity In ve n to ry A7 Appendix 3 General H e a lth Q uestionnaire A l l Appendix 4 B A I - D r a ft fo r use w ith P ilo t Samples A15
Appendix 5 B A I R ecovery Index A21
Appendix 6 Scoring C rite ria fo r B A I A57
Appendix 7 B A I - G eneral Assessment Sheet A80 Appendix 8 M em bership o f B A I W orking Group A81
Appendix 9 B A I - D r a ft fo r use w ith Main Samples A82 Appendix 10 B A I D r a ft Manual - M o d ifie d Version I A8 8
Appendix 11 B A I D r a ft Manual - M o d ifie d Version II A114
Appendix 12 BAI Assessment Form A125
Appendix 13 A ra b ic Version o f the GHQ A133 Appendix 14 A ra b ic Version o f the EPQ A135 Appendix 15 GHQ Summary Table - S h e ffie ld Sample A139 Appendix 16 BAI Summary Table - S h e ffie ld Sample A140
30
Appendix 17 EPI Summary Table - S h e ffie ld Sample A141 Appendix 18 GHQ Summary Table - C a iro Sample A142 Appendix 19 B A I Summary Table - C a iro Sample A143
30
Appendix 20 EPQ Summary Table - C a iro Sample A144 B rie f Case Studies
Appendix 21 Ronald Black A145
Appendix 22 Rahmy Fahad A154
Appendix 23 V ic to ria C a rr A162
Appendix 24 Angela W hitehead A169
Appendix 25 Sadek A b e d -E l-H a m id A181
Appendix 26 Nadia E l-G am ale A190
In tro d u c tio n and Summary
The c u rre n t study is based on the p rin c ip le o f c o n tin u ity o f care fo r m e n ta lly il l p a tie n ts by the same nursing personnel who in itia te the th e ra p e u tic re la tio n sh ip during h o s p ita lis a tio n . I t set o u t to te s t the e ffe c tiv e n e s s o f this p rin c ip le by means o f a specially-designed m odel o f care term ed "b rid g in g th e ra p y". This te rm re fe rs to b rid g in g the e xistin g gap between hospital-based p s y c h ia tric nursing care and com m unity-based p s y c h ia tric nursing care which appeared ty p ic a l o f conve n tio n a l care in S h e ffie ld , where each service worked independently o f the oth e r. This system preven ted p a tie n ts m a in ta in in g a th e ra p e u tic re la tio n s h ip w ith th e ir nurse ke yw o rke r or nurse th e ra p is t fo llo w in g discharge fro m h o sp ita l.
The aim was to provid e a m odel o f nursing care th a t would u n ite h o sp ita l and com m unity-based p s y c h ia tric nursing care into an in te g ra te d system . An
a d d itio n a l aim was to tra n s fe r th is concept to the E g yptian th e ra p e u tic fie ld . A main hypothesis assumed th a t m e n ta lly il l p a tie n ts who re c e iv e b rid g in g therapy, e ith e r in S h e ffie ld or in C a iro , would im prove s ig n ific a n tly , and would m a in ta in this im p ro ve m e n t t i l l the end o f the fo llo w -u p period.
The design o f this in v e s tig a tio n req u ire d both q u a n tita tiv e and q u a lita tiv e approaches. The q u a n tita tiv e approach consisted o f a q u a s i-e x p e rim e n ta l technique which tested the e ffe c tiv e n e s s o f bridg ing therapy a t tw o in te rv a ls . The q u a lita tiv e approach consisted o f a d e ta ile d d e s c rip tiv e analysis o f p a tie n t outcom es in re la tio n to a number o f re le v a n t personal and social fa c to rs .
Egyptian p riv a te sanatorium em ployed a m ainly cu sto d ia l m odel o f care. In S h e ffie ld 22 p a tie n ts p a rtic ip a te d and in C a iro 18 p a tie n ts p a rtic ip a te d ( to ta l N = 40).
The sample fo r each s e ttin g was divide d in to tw o equal groups, quasi-
e x p e rim e n ta l and c o n tro l. The e x p e rim e n ta l groups rece ive d b ridg ing therapy w h ils t the c o n tro l groups receive d co n ve n tio n a l nursing care. The EPI was used as a p e rso n a lity screening te st fo r inclusion in e x p e rim e n ta l and c o n tro l groups. Assessment o f th e ra p e u tic outcom es acted as an in d ic a to r o f the e ffe c tiv e n e s s o f b ridg ing therapy. Two in stru m e n ts were used fo r th is purpose. The GHQ, a s e lf-re p o rt que stionna ire, was used to assess p a tie n ts ' p ercep tions o f th e ir general health status. The B A I^q , a la rg e ly o b se rva tional in s tru m e n t, was designed fo r purposes o f the study, and used to assess re le v a n t aspects o f each p a tie n t's health status. Assessments were ca rrie d out on three "k e y " occasions: (A ) on adm ission; (B) on discharge; and (C) a fte r a post-discharge fo llo w -u p o f 3-
6 months.
The BA I underw ent a num ber o f standardisation processes, fin a lly achieving 100 per ce n t v a lid ity and 50-75 per c e n t in te r - ra te r r e lia b ility . D e liv e ry o f b ridg ing therapy was based on a planned program m e em ploying both h o sp ita l and
co m m u n ity fa c ilitie s . The F le xib le In te g ra tiv e Approach - a d e ve lop m en tal approach based on the e c le c tic position in psychotherapy and nursing process and emphasising in d iv id u a l p a tie n t needs - was developed and em ployed fo r purposes o f the th e ra p e u tic in te rve n tio n s in this study. These in te rv e n tio n s in clud ed, e.g. ra tio n a l-e m o tiv e therapy; re a lity therapy; and supportive psychotherapy.
th e ra p e u tic approach. Both the researcher and a co n su lta n t p s y c h ia tris t jo in tly assessed the p a tie n ts using the BAI-^g*
S ta tis tic a l analysis o f varian ce in e xp e rim e n ta l data dem on strate d a highly s ig n ific a n t im provem ent o f the S h e ffie ld e xp e rim e n ta l group regarding adm ission/discharge and adm ission/post-discharge scores (p<0. 0 1 and p<0 . 0 0 1
re sp e ctive ly). This supports the e ffe ctive n e ss o f bridging therapy n ot only in helping p a tie n ts m a in ta in achieved levels o f im p ro ve m e n t; b u t also to achieve fu rth e r levels o f im p rovem ent.
How ever, the S h e ffie ld c o n tro l group had also achieved s ig n ific a n t levels o f im p ro ve m e n t during adm ission/discharge and adm ission/post-discharge periods (p<0.01). T h e re fo re , the hypothesis was only p a rtia lly supported in S h e ffie ld regarding e ffe c tiv e n e s s o f b ridg ing th e ra p y; b u t its s u p e rio rity to the
co n ve n tio n a l m odel was n o t supported. In C airo again, s ig n ific a n t im p ro ve m e n t was obtained regarding adm ission/discharge and adm ission/post-discharge periods (p < 0 .0 i fo r both e x p e rim e n ta l and c o n tro l groups). In o th e r words, the
im p rovem ent fo r the tw o groups was s im ila r, which again does not support the s u p e rio rity o f bridging therapy over the co nve ntiona l m odel. H ow ever, graphic p re se n ta tio n o f lin e a r trends dem onstrated the higher tendency fo r b e tte r
achievem ent in both e x p e rim e n ta l groups as opposed to th e ir re sp e ctive c o n tro ls . These re su lts should be viewed c a u tio u sly, bearing in mind the lim ita tio n s o f the study in re la tio n to design and c ro s s -c u ltu ra l fa c to rs (see discussion, C h a p te r 6).
between various fa c to rs in flu e n cin g the e ffe ctive n e ss o f care d e liv e ry : p a rtic u la rly as these a ffe c t the q u a lity and c h a ra c te r o f n u rse -p a tie n t in te ra c tio n s and th e ra p e u tic in te rv e n tio n s .
In conclusion, the study appeared to be a useful exercise in the developm ent o f new insights and approaches concerning com prehensive care and h o lis tic
C H A P TE R Is B rid g in g Therapy in its C ro s s -C u ltu ra l C o n te x t In tro d u c tio n
1.2 The Research Problem
1.3 The Proposed M odel o f 'B ridging Therapy' 1.4 The C u rre n t Study
1.5 Research A im and Hypotheses
1.6 C ro s s -C u ltu ra l Aspects o f the Study C o n te x t 1.6.1 Concept o f C u ltu re
1.6.2 S o c io -c u ltu ra l R e la tio n sh ip to M e n ta l Illness in E g ypt and Associated C u lture s
1.6.3 E pidem iology o f M e n ta l Illness in E g ypt and Associated C u lture s
1.6.4 P s y c h ia tric Nursing in E gypt: Education, Work and A ttitu d e s tow ards P s y c h ia tric P a tie n ts
1.6.5 T re a tm e n t and H ealing Approaches in E gypt and Associated C u lture s
1.6.6 Research Problem s Associated w ith C ro s s -c u ltu ra l Studies
C H A P TE R 1: B rid gin g Therapy in its C ro s s -C u ltu ra l C o n te x t
In tro d u c tio n
This thesis in corp orate s an eva lu a tio n o f an in n o va tive m odel o f p s y c h ia tric nursing in h o sp ita l and co m m u n ity care in tw o c itie s , S h e ffie ld in the U n ite d Kingdom and C airo in E g ypt.
I t examines re la te d nursing p rin c ip le s and techniques and applies a p a rtic u la r co n ce p t, th a t o f "B rid g in g T herapy", as a proposed means o f im p ro vin g the discharge process fro m h o sp ita l to co m m u n ity.
W ithin the c o n te x t o f the proposed "B rid g in g T herapy", a p a rtic u la r approach to th e ra p e u tic in te rv e n tio n , evolved fro m the e c le c tic p o sitio n both in psychotherapy and nursing process, was developed. This th e ra p e u tic stance was given the name o f the F le x ib le In te g ra tiv e Approach (F A I), i t is discussed in g re a te r d e ta il in C hapter Three.
The research co n ce n tra te s on a sm all group o f p a tie n ts in each h o sp ita l who were o ffe re d "B rid g in g Therapy" by the researcher who com pared them w ith groups who received the standard nursing and m edica l tre a tm e n t fo r th e ir re s p e c tiv e hospitals.
Some authors such as Brooke (1959) and Mosher (1983) co n te m p la te the eve n tu a l co m p le te disappearance o f m e n ta l hosp itals; whereas others such as Jones (1972) and Bennett (1979) condemn the G overnm ent p o licy o f closing down m ental in s titu tio n s , leaving p a tie n ts to the c ru e lty o f so ciety.
The in it ia l welcom e and praise fo r c o m m u n ity care services is beginning to wane a fte r constant c ritic is m fro m various d iscipline s including nurses, social w orkers and p s y c h ia tris ts . A d m itte d ly there are numerous problem s w h ich hinder the e ffic ie n c y o f the service provided by the C o m m u n ity P s y c h ia tric Nurses (CPNs).
Skidmore and Friend (1984a) were able to exam ine the c u rre n t CPN se rvice in B rita in and id e n tifie d a num ber o f the problem areas th a t could be studied and rem edied. These areas were m a inly associated w ith the e du cation, specialism and p ra c tic e o f the CPNs. The o rg a n isa tio n a l s tru c tu re o f the service was included as an associated fa c to r ra th e r than an independent fa c to r. T h e ir research was one o f fe w such studies w hich are concerned w ith the e va lu a tio n o f the service ra th e r than m erely a d e scrip tio n o f it .
Mangen and G r iff it h (1980) review ed one hundred and tw e n ty -n in e a rtic le s appearing over the last th ir ty years coverin g d iffe r e n t aspects o f c o m m u n ity p s y c h ia tric nursing care. They found th a t
" . . . much o f i t com prises descrip tio n s o f services, o f goals, p a tte rn s o f care and special aspects. There have been few e v a lu a tiv e studies."
A n o th e r study by Mangen and G r if f it h (1982a) exam ined the deve lop m en t o f the service, concluding th a t it s ta rte d on an ad hoc basis w ith no s c ie n tific plan or le g is la tiv e p o lic y .
th a t could com prehensively m eet p a tie n ts ' needs. R e fle c tio n s o f models o f care fro m o th e r co u n trie s did n o t re ve a l any tru e means o f e lim in a tin g the problem s.
In the W est, the USA has developed co m m u n ity m e n ta l h e a lth centres (CM HC ) to serve p a tie n ts in th e ir own enviro n m e n t and r e s tr ic t or lim it h o s p ita l admissions. T h e o re tic a lly these m ental h e a lth centres would seem to be id e a l fo r ca rry in g the service to p a tie n ts and th e ir fa m ilie s in th e ir own home, ie a n a tu ra l enviro n m e n t ra th e r than ta kin g p a tie n ts out o f th e ir home to an a r t if ic ia l p ro te c tiv e h o sp ita l enviro n m e n t. H ow ever, in p ra c tic e the C M H C service has fa lle n fa r s h o rt o f e xp e cta tio n s:
"They are unduly s e le c tiv e , fa ilin g in p a rtic u la r to serve the c h ro n ic a lly i l l and e ld e rly , are isolated fro m the m a instream o f p s y c h ia try and th e re fo re unpopular w ith p s y c h ia tris ts , and in e ffe c tiv e both in reducing adm ission to s ta te hosp itals and im p le m e n tin g the p re v e n tiv e p s y c h ia tric program m es th a t were envisaged when they were set up."
(T y re r, 1985)
A tte m p ts made by o th e r co u n trie s were studied by Singer and colleagues (1970) who v is ite d the Soviet Union and The N etherlands to exam ine the co m m u n ity p s y c h ia tric services in Moscow, Leningrad and A m sterd am . They found th a t the p s y c h ia tric nurse in ’ the Soviet Union has fa r g re a te r re s p o n s ib ilitie s than her A m e rica n c o u n te rp a rt. He/she is a nurse-social w o rk e r, (as th e re are no social w o rkers as such in the Soviet Union) involved in the to ta l care o f the p a tie n t and in any social problem s or e n viro n m e n ta l m a n ip u la tio n . The nurse o ffe rs general support and encouragem ent, w atches fo r e ffe c tiv e n e s s and side e ffe c ts of m e d ica tio n , gives in je c tio n s to those who refuse o ra l m e d ic a tio n , w orks w ith re la tiv e s and neighbours, and assists in social re h a b ilita tio n and re a d a p ta tio n . The th e ra p e u tic team in the Soviet Union consists o f the p s y c h ia tris t and the p s y c h ia tric nurse-social w o rke r.
d is tr ic t has a d is tr ic t psychoneurological dispensary (analagous to C M H C ). These dispensaries provide em ergency care, o u t-p a tie n t tre a tm e n t, day care, n ig h t care and w o rk therapy . A t each dispensary there is one psycho the ra pist fo r c h ild re n , one fo r adolescents and one fo r alco h o lics. Each dispensary is divide d in to a p p ro xim a te ly ten divisions, each served by a team o f one p s y c h ia tris t and one nurse-social w o rk e r; e ith e r or both o f them make home v is its as re quire d.
H ow ever, they expressed concern regarding the re a l s itu a tio n o f the service, eg each h e a lth d is tr ic t w ith a p op ula tion o f 350,000 to 400,000 was served by only one psych o th e ra p ist; these were n o t allow ed to make home v is its w hich
prevented them m aking a re a lis tic e va luatio n o f the q u a lity o f the service. In A m sterdam the outstanding exam ple which they provide is the team approach; once again there is a close w o rking re la tio n s h ip between p s y c h ia tris t and nurse. Hence care is an in te g ra l and im p o rta n t p a rt o f o u t-p a tie n t tre a tm e n t. Nurses fo llo w up cases on th e ir own, handle the psychosocial aspects', adjust the dosage o f m e d ica tio n and request the p s y c h ia tris t to see the p a tie n t a t th e ir d is c re tio n . A cco rding to the w rite rs , this system o f m e n ta l hea lth care w ould be v ir tu a lly the o p tim a l developm ent o f co m m u n ity p s y c h ia tric care. Nonetheless, home v is its made in A m sterd am dem onstrated th a t p a tie n ts w ith c r it ic a l co n d itio n s were lia b le to be le f t in the co m m u n ity , causing problem s fo r the fa m ilie s who then reacted in a h o stile manner tow ards the p s y c h ia tris t and demanded
h o sp ita lisa tio n fo r the p a tie n t.
A th ird system to consider is the Ita lia n experience o f "P s y c h ia tric a D e m o c ra tic a ". A rem a rkab le m odel o f co m m u n ity care is presented by the Ita lia n m e n ta l hea lth system . Again in theory the e x p e rim e n t represented a re v o lu tio n aim ed a t fre e in g p a tie n ts fro m in s titu tio n s and long te rm segregation in m e n ta l ho sp ita ls. The
d e m o c ra tic p a rty achieving power in the 1970's. In 1978 Basaglia induced the governm ent to pass Law 180, which forbade the adm ission o f any new p a tie n ts to m e n ta l h o sp ita l and review ed steps fo r th e ir closure (Jenner, 1986). As a re s u lt the Ita lia n M ental H e a lth A c t established le g is la tio n fo r the ra d ic a l re p la ce m e n t o f h o sp ita l p s y c h ia tric care w ith a co m m u n ity based service (B ro w n ,1981).
E n th u sia stic accounts in the B ritis h professional press regarded the Ita lia n
Experience as one o f the g re a t success sto rie s o f p s y c h ia tric h is to ry , y e t e m p iric a l tests, conducted by Jones and P o le tti (1985) suggested the opposite to be tru e . They found th a t m e n ta l hospitals were not closed down b u t lacked any m aintenance or re p a ir w o rk, as they were o f fic ia lly closed. There were also some 'a lte rn a tiv e s tru c tu re s ' such as 'fa m ily homes' or 'v illa s ', b u t in fa c t these were o rd in a ry m e n ta l h o sp ital wards under d iffe r e n t names. The Diagnosis and Cure U n its were disused, as it was im possible to diagnose and cure w ith in 48 hours. The pleasant, in fo rm a l Psycho-Social C entres turned out to be no more than o u t-p a tie n t c lin ic s , w ith some co m m u n ity nurses (untrained b u t w ith m e n ta l h o sp ita l experience) a tta ch e d . In southern Ita ly the problem s became g re a te r, eg in Salerno there were only 50 Diagnosis and Cure beds fo r a pop ula tion o f one m illio n and there was no o th e r service o f any kind. Jones and P o le tti found th a t d is s a tis fa c tio n w ith th is system was expressed by professional personnel in Ita ly and the gove rn m en t is now
studying a proposal fo r the re fo rm o f Law 180.
These d iffe r e n t exam ples o f co m m u n ity care service provid e a s ig n ific a n t in d ic a tio n o f the urgen t need to fin d a s a tis fa c to ry system based on e m p iric a l data and s c ie n tific outcomes th a t would a c t as a resource fo r planners in decision making.
1.2 The Research Problem
care occurs not only between d iffe r e n t co u n trie s fro m the east and west b u t also lo c a lly w ith in the same system . In B rita in , Beard (1980) id e n tifie d three
o rg a n isa tio n a l s tru c tu re s w hich c o n s titu te the shape o f the d e liv e ry o f the C o m m u n ity P s y c h ia tric Nursing service. These are:
1. H o sp ita l based CPNs, w o rking w ith in m u lti-d is c ip lin a ry or in tra -d is c ip lin a ry teams on the wards, in the day h o sp ita l, o u t-p a tie n t d e p a rtm e n t or a tta ched to s p e cia list u n its such as beh avio ura l th erapy or drug a d d ic tio n .
2. P rim a ry H e alth Care CPNs based w ith general p ra c titio n e rs in single p ra ctice s or h e a lth centres and w ith p rim a ry care colleagues such as h e a lth v is ito rs , d is tr ic t nurses or m idw ives.
3. Social Service based CPNs w o rking alongside area social w o rk team s where in te rv e n tio n , supervision and education advice are on-going processes.
Skidmore and Friend (1984b) described a fo u rth m odel ca lled the "D u a l" ie based both in the h o sp ita l and in the P rim a ry H e alth Care team . This m odel had the advantage o f h o sp ita l support in a d d itio n to the in vo lve m e n t w ith p rim a ry care. A rgum ents as to which m odel is m ore e ffe c tiv e are n ot concluded y e t and are lik e ly to co n tin u e . Sladden (1979) and C am pbell e t al (1983) were in fa v o u r o f the co m m u n ity based CPN model w hile K irk p a tr ic k (1967) and Greene (1968) favoured the h o sp ita l based CPN m odel and Beard (1980) and B rooker (1984a) favoured the p rim a ry health care model.
Brooke, 1959) ra re ly consider the meaning o f 'co m m u n ity ca re ' in p ra c tic e .
More cautious co m m e n ta to rs p re fe r to see b e tte r in te g ra tio n o f the services ( H ill 1968, Am esbury 1983, Tantam 1985). A t present th e re are problem s in the c o n tin u ity and c o -o rd in a tio n o f care fo r p a tie n ts discharged fro m h o sp ital. B ridging therapy designed by the researcher was an a tte m p t to overcom e some o f these lim ita tio n s .
1.3 The Proposed M odel o f B ridging Therapy
"B rid g in g Therapy" is the te rm given to the proposed approach fo r f illin g the gap observed in the d e liv e ry o f the service between the h o s p ita l and the
c o m m u n ity *. This gap results in the p a tie n t's discharge to so cie ty w ith o u t adequate support im m e d ia te ly a fte r leaving h o sp ita l (R ichm ond F e llo w sh ip , 1983), and "B rid g in g T h e ra p y " a tte m p ts to provide c o n tin u ity o f care im m e d ia te ly on leaving h o sp ital.
The im p o rta n ce o f this research problem is h ig h lig h te d by Papelu (1952), A lts c h u l (1972) and Mahgoub (1981), who emphasise the value o f the th e ra p e u tic
re la tio n sh ip between the p a tie n t and the nurse. C o n tin u ity o f care by the same th e ra p is t has been id e n tifie d as th e ra p e u tic a lly valuable in studies by Baker (1968) and Lancaster (1980a). F u rth e rm o re there is some evidence to suggest
th a t p a tie n ts ' lik in g o f th e ir th e ra p ists is s ig n ific a n tly re la te d to progress (Chassan e t a l, 1981).
B ridging therapy a tte m p ts to include each o f the above elem ents in a m odel o f care which may com prehensively respond to p a tie n ts ' needs. I t view s ho sp ita l
services as p a rt o f the co m m u n ity service, so th a t a p a tie n t's care plan should continue a fte r discharge to fo rm an in d iv id u a l fle x ib le and com prehensive
approach. O the r professions (p s y c h ia tris ts , psychologists or social w orkers) have adopted the m odel o f c o n tin u ity o f care by the same w o rk e r both during and a fte r h o s p ita lis a tio n , w h ils t nurses are ra re ly o ffe re d the o p p o rtu n ity to continue th e ir care in th is fashion. T h e ra p e u tic in te rv e n tio n s which take place w ith in h o sp ita l wards could be o f more b e n e fit i f continued a t discharge and fo llo w up by the same nurse ke yw o rke r.
T he rap eutic care provided by the nurse ke yw o rke r should not be co n fin e d to sim ply p ro m o tin g hygienic measures b ut, more im p o rta n t, in term s o f helping the
p a tie n t to re -s e ttle in the co m m u n ity , helping the fa m ily to understand the p a tie n t's weaknesses and p o te n tia ls and teaching both p a tie n t and fa m ily coping mechanisms and healthy adjustm e nt behaviour. T he ir fa m ilia r ity w ith the d iffe r e n t fa c ilitie s provided by the h o sp ita l and co m m u n ity ce n tre s, w h eth er these fa c ilitie s are in human or m a te ria lis tic term s, can enhance the support o f the p a tie n t
regardless o f the m ilie u .
1.4 The C u rre n t Study
1. the developed n u rs e -p a tie n t in terpe rson al re la tio n s h ip .
2. the fle x ib le approach to m eeting p a tie n ts ' th e ra p e u tic require m en ts (eg both
in and outside the hosp ital).
3. C o n tin u ity o f care by the same fa m ilia r th e ra p is t (nurse).
C le a rly the bridg ing therapy m odel could be used as an a lte rn a tiv e exam ple o f the o rg a n isa tio n a l s tru c tu re fo r the CPN service as p a tie n t care is c e rta in ly in fluence d by the org a n isa tio n a l s tru c tu re but th is is n ot the focus o f th is study.
B rid gin g therapy is n ot ano the r version o f the m odel used in Moorhaven H o sp ita l in Devon in 1957, nor a re p e titio n o f P e te r H unter's research o f schizophrenics and th e ir c o m m u n ity care (1978). The bridging therapy program m e is a s tru c tu re d e va lu a tive approach which tests th e ra p e u tic variables and assesses th e ir usefulness or e ffe ctive n e ss fo r the b e n e fit to the p a tie n t. The subjects under study are
n e u ro tic or m ild ly psycho tic p a tie n ts whose problem s are m ainly behaviour
m a la d ju stm e n t or fa m ily problem s, ra th e r than organic d ysfu n ctio n or m e d ica tio n
supervision.
A fe w problem s were expected during the course o f the research, eg role
overlapping w ith o th e r d iscipline s, nurses w o rking s h ifts , lack o f s k ills and a b ilitie s fo r e ffe c tiv e in te rv e n tio n outside the h o sp ita l and in tra -o rg a n is a tio n a l c o n flic ts . F o rtu n a te ly , M aisey’s (1975) survey pointed out th a t the p a rtic ip a tio n o f h o sp ita l based nurses in an a fte r care program m e did not a ffe c t the standards o f in -p a tie n t care, although nurses spent one q u a rte r o f th e ir w o rking week in the c o m m u n ity.
who run group therapy sessions overlap w ith p s y c h ia tris ts and psychologists, s im ila rly social w orkers overlap w ith psychologists and CPNs. T h e re fo re the overlap between the CPNs, so cia l w orkers, psychologists and p s y c h ia tris ts is not unique and should be accepted as in e v ita b le . W ith regard to in te rv e n tio n s k ills in the co m m u n ity s itu a tio n , special tra in in g may be given fo r such purposes.
A n o th e r im p o rta n t aspect o f this study is the im p le m e n ta tio n o f the b ridg ing therapy e xp e rim e n t in tw o d iffe r e n t c o n te xts and com parison o f the re s u lts . In o th e r words the developm ent o f the b rid g in g therapy program m e was to take place fir s t in S h e ffie ld and, i f i t succeeded in fu lf illin g its o b je ctive s, then it was to be tra n s fe rre d to C a iro , E g yp t, to te s t its v ia b ility in a d iffe r e n t c o n te x t and d iffe re n t c u ltu re . The reason fo r th is second te s t was to in tro d u c e a new type o f service to the E g yptian m e n ta l h ea lth system w hich c u rre n tly lacks any fo rm o f co m m u n ity p s y c h ia tric nursing care.
1.5 Research A im s and Hypotheses A im
The aim o f this research is to exam ine the e ffe c tiv e n e s s o f an in n o v a tiv e m odel o f care th a t would com prehensively m eet p a tie n ts ' needs both inside and outside the h o sp ita l. The m odel o f care is to be used in tw o d iffe r e n t c u ltu re s , E gypt and B rita in , and its e ffe c tiv e n e s s is judged in term s o f p a tie n ts ' outcom es.
From a q u a n tita tiv e p o in t o f view the n u ll hypothesis would be th a t the c u rre n t conve ntiona l methods o f p s y c h ia tric care fo r n e u ro tic and m ild p sych o tic p a tie n ts in S h e ffie ld and C a iro , are as e ffe c tiv e in term s o f p a tie n ts outcom es as 'b rid g in g ' therapy.
The Hypotheses are
psych o tic conditions w ill experience g re a te r b e n e fit fro m c o n tin u ity o f p s y c h ia tric nursing care provided by b ridg ing th erapy than fro m c u rre n t standard nursing care.
2 T h a t these d iffe re n c e s w ill be dem onstrable in term s o f: (a) Standard p sycho m e tric in strum ents
(b) A new ly derived behavioural in v e n to ry (BAI) (c) D e s c rip tiv e case studies.
3 T ha t the model o f bridg ing therapy established in S h e ffie ld is tra n s fe ra b le to C a iro .
1.6 C ro s s -C u ltu ra l Aspects o f the Study In tro d u c tio n
I t is proposed th a t bridging therapy is to be em ployed in tw o d iffe r e n t c u ltu re s , B rita in and E g ypt; th a t is to say, in a developed as com pared w ith an
underdeveloped (or developing) co u n try . Reasons fo r such an approach are (1) to introdu ce the concept o f co m m u n ity care to E gypt where such services are non e x is te n t; and (2) to in troduce an in n o va tive m odel th a t could help to reduce the
e x istin g gap between hospital care and co m m u n ity care in G re a t B rita in .
T h e re fo re the fo llo w in g re vie w w ill focus on seven main points o f d ire c t relevance to the c u rre n t study. It m ust be noted here th a t c ro s s -c u ltu ra l studies tend to be ra th e r broad and to place emphasis on m ajor issues such as a n th ro p o lo g ic a l and s o c io c u ltu ra l. It is not the in te n tio n o f the c u rre n t study to fo llo w s t r ic tly these approaches. E xa m ination o f the phenomenon under study adopts the re le v a n t p rin cip le s o f both anth ro p o lo g ica l and s o c io c u ltu ra l approaches.
1.6.1 Concept o f C u ltu re
fa c to rs and th e ir associated psychological m a n ife s ta tio n s (Cox, 1977). In re la tio n to m e n ta l health Cox quoted the d e fin itio n o f K ro e b e r and Kluckhohn, 1952 concerning c u ltu re :
"C u ltu re consists o f p a tte rn s, e x p lic it and im p lic it, o f and fo r behaviour acquired and tra n s m itte d by symbols, c o n s titu tin g the d is tin c tiv e
achievem ent o f human groups, in clu d in g th e ir em bodim ents in a rte fa c ts ; the essential core o f c u ltu re consists o f tra d itio n a l (i.e. h is to ric a lly derived and selected) ideas and espe cially th e ir a tta ch e d values; c u ltu re systems may on one hand be considered as products o f a ction s, on the o th e r as a co n d itio n in g e lem e nt o f fu rth e r a c tio n ."
The im portance o f th is n otio n is th a t it emphasises the re la tio n s h ip between m ental health and c u ltu re and is re fle c te d in the continuous e ffo r ts to fin d an answer to the question o f w h eth er m ental sym ptom s are universal or c u ltu re bound.
A t the beginning o f th is ce n tu ry K ra e p e lin trie d to show th a t m ental
sym pto m atology is universal w h ile Freud re la te d it to c u ltu re and p e rs o n a lity developm ent (K ie v, 1972).
As a re s u lt concerns about w h at c o n s titu te s ’d e v ia n t1 behaviour, ’n o rm a l1 or ’abnorm al’ behaviour.and so c ia lly orie n te d theorie s concerning ’la b e llin g ’ and ’s tig m a ’ o f m e n ta l illness were addressed by m any authors such as G o ffm a n (1961), Mangen (1982) and A rm stro n g (1983).
1.6.2 S o cio cu ltu ra l F actors A ffe c tin g M ental Illness in E gypt and A ssociated C u lture s
(1972) dem onstrated th a t th e ir e d u ca tio n a l program m e fo r schizophrenic p a tie n ts ' fa m ilie s had produced s ig n ific a n t re d u ctio n in the relapse ra te o f th e ir
e xp e rim e n ta l group over the c o n tro l. In this study by Wing and Brown (1970), e n viro n m e n ta l p o v e rty in term s o f 'fe w e st personal possessions' was highly c o rre la te d w ith a 'c lin ic a l p o v e rty syndrom e' in term s o f so cia l w ith d ra w a l, flatness o f E ffe c t and p o v e rty o f speech. Along the same line is L e ff's (1982) e xp e rim e n ta l study o f the in flu e n ce o f a social tre a tm e n t program m e fo r fa m ilie s o f schizophrenic p a tie n ts on the ra te o f relapse. In o th e r words these studies in d ica te the im p o rta n ce o f so cia l (and c u ltu ra l) fa c to rs in diagnosis and tre a tm e n t o f schizophrenia. F u rth e rm o re these studies were com parable w ith E l-Isla m 's (1982) study o f the e ffe c ts o f re h a b ilita tio n o f schizophrenics by the extended fa m ily in the A rabian G u lf area. Results favoured the extended fa m ilie s as opposed to nuclear fa m ilie s in term s o f supervision o f m e d ic a tio n , to le ra n ce o f m inor abnorm al behaviour and encouraging social s k ills and social c o n ta c t.
during the B ritis h co lo n isa tio n o f E gypt, and m e n ta l illness became a stigm a as a re s u lt o f the European cla im o f its gen etic transm ission.
Nonetheless, co n te m p o ra ry E gyptians tr y to help th e ir p a tie n ts and care fo r them as much as they can and as long as it is to le ra b le . H ow ever, as Abed E l- Rahman's (1985) study showed, the m a jo rity o f fa m ily m embers o f p s y c h ia tric p a tie n ts in the p s y c h ia tric o u t-p a tie n t c lin ic o f C airo U n iv e rs ity H o sp ita l tend to deny the p a tie n t's m e n ta l illness. Instead, they gave o th e r explanations such as o ve rw o rk, school fa ilu re or loss o f love o b je c t. They also expressed th e ir shame and a n x ie ty when they were unable to hide th e ir re la tiv e 's m e n ta l illness and recognised it as a stigm a. They also a d m itte d preve n tin g th e ir sick re la tiv e fro m s ittin g w ith guests or going out o f the house.
O th e r studies by Chaleby (1986) showed th a t the presenting p ic tu re o f p a tie n ts w ith m e n ta l illness is m o stly so m a tic. This is understandable in vie w o f (1) the stigm a o f m ental illness, (2) the h is to ric a l tendency not to separate the psyche fro m the soma in conceptual te rm s , and (3) the tendency fo r p h ysica l illness to a ttr a c t more a tte n tio n in such societies.
C le a rly in p rim itiv e societies, usually there is less sepa ra tion betw een m e n ta l and physical illness (C a rs ta irs , 1965, Lipsedge and L ittle w o o d , 1979). M e n ta l disorders are usually a ttrib u te d to supe rn atu ral powers, e v il s p irits or w itc h c r a ft. These b e lie fs are widespread in some parts o f A fr ic a as w e ll as among the non educated groups in E gypt (Okasha, 1966). Such societies pay fa r less a tte n tio n to the in te rn a l psychic m o tiv a tio n s than is the case in W estern c u ltu re (K ie v , 1972). P s y c h ia tric disorders are usually conceptualised in term s o f cu ltu re -b o u n d concepts o f ro le perform an ce and n o rm a lity . They also pay g re a t a tte n tio n to social
E gyptian fa m ilie s believe in the im p o rta n ce o f the so cia l ro le played by th e ir fa m ily members even during th e ir illness. T h e re fo re they do not abandon th e ir sick, e ld e rly or feeble, no m a tte r how im p ra c tic a l are the demands and
re sp o n sib ilitie s fo r th e ir care. The sickness o f one fa m ily m em ber is the
re s p o n s ib ility o f a ll members o f the fa m ily (M eleis and La F e vre , 1984). H owever on very rare occasions m e n ta lly i l l p a tie n ts who are c h ro n ic a lly or severely
disturbed could be abandoned i f th e ir sym ptom s become in to le ra b le .
Both c u ltu re and re lig io n re in fo rc e th is a tta c h m e n t w hich s ta rts very e a rly in the ch ild s' life w ith the m a te rn a l re la tio n s h ip . G ovaerts and P a tino (1981) found this b io lo g ic a l a tta c h m e n t n ot only w ith the b io lo g ic a l m oth er who breast feeds fo r a period o f tw o to three years, b u t also w ith o th e r fem a le fa m ily m embers who share the c h ild care.
To sum up, the E gyptian fa m ily take g re a t re s p o n s ib ility fo r th e ir sick members and only when it becomes im possible fo r them to contin ue such care fo r fin a n c ia l or o th e r reasons, p a tie n ts may be abandoned in Cairo's large m e n ta l hospitals.
1.6.3 Epidem iology o f M ental Illness in E gypt and Associated C u ltu re s
brains are in fe rio r, and they fu n c tio n in a c h ild lik e m anner. He re fe rre d to studies by K id d and C aldbeck-M eenan, 1966, Cox, 1979, and Assael e t a l, 1972, w h ich a ll showed evidence o f com parable p s y c h ia tric m o rb id ity .
In these studies c ro s s -c u ltu ra l e xa m in a tio n between Europe and A fr ic a showed s im ila r rate s o f p s y c h ia tric m o rb id ity . The WHO (1973) In te rn a tio n a l P ilo t Study o f Schizophrenia (IPSS) was a fu rth e r a tte m p t to standardise c lin ic a l diagnostic techniques. The study aimed a t id e n tify in g shared c ro s s -c u ltu ra l sym pto m a to lo g y by using the Present State E xa m in a tio n (PSE) (Wing e t a l, 1967). Nine d iffe re n t co u n trie s p a rtic ip a te d in this p ro je c t. Results in d ica te d s im ila ritie s o f sym ptom s o f schizophrenia among these d iffe r e n t nations. How ever the IPSS outcomes varied inversely w ith social developm ent o f the so ciety (K le in m a n , 1987). These outcom es encouraged O rley e t al (1979) to re p e a t the e x p e rim e n t in tw o A fric a n v illa ges. They employed thre e techniques the PSE, the Index o f D e fin itio n (ID) and CATEG O , a co m p u te r program m e. P a tie n ts a d m itte d to the h o sp ita l w ith acute disorders, w ere in te rv ie w e d and exam ined using the PSE and ID. T he ir study c o n firm e d 90 per c e n t v a lid ity and high r e lia b ility w ith the shortened version o f the PSE (ninth e d itio n ) which o m itte d the section dealing w ith psychoses. O rley e t a l showed th a t depressive disorders are more com mon and more severe among a ru ra l A fric a n fem a le population than in analogous groups liv in g in inner London suburbs.
Such e p id e m io lo g ica l studies have encouraged p s y c h ia tris ts in E gypt to pursue the same tre n d o f applying Western c la s s ific a tio n s to non-W estern p a tie n ts (Egyptians). Thus Okasha e t a l (1968) studied p s y c h ia tric m o rb id ity among a sample o f 1000 p a tie n ts atte n d in g A in Shams U n iv e rs ity P s y c h ia tric C lin ic in C a iro . They used the European c la s s ific a tio n o f m e n ta l illn ess. R esults in d ica te d schizophrenia as the com m onest c h ro n ic v a rie ty o f psychosis (13 per cent).
even paranoid schizophrenia are re la tiv e ly rare among A fric a n s ". On the c o n tra ry , they found hebephrenia, fo llo w e d by paranoia were m ost fre q u e n t.
A ffe c tiv e disorders were also common e spe cially depressive a n xie ty neurosis 22%, h y s te ric a l sym ptom s 11%, obsessive-com pulsive neurosis 3%, p e rso n a lity disorders 2%, and a d d ictio n 1%. Okasha and colleagues concluded th a t:
"A lth o u g h the incidence and co n te n t may be d iffe re n t fro m European and o th e r A fric a n p s y c h ia tric illness, m ost o f the illness can be grouped under the same p s y c h ia tric n o m e n cla tu re ."
F o llo w in g this the E gyptian P s y c h ia tric A ssociation fo rm u la te d an independent D iagn ostic Manual o f P s y c h ia tric disorders (DM P-1) in 1973, based on the In te rn a tio n a l C la s s ific a tio n o f Disease (IC D -8 ) w ith a code system a llie d to the French C la s s ific a tio n (Gawad, 1981). A fte r the p u b lic a tio n o f both the IC D -9 and the DSM -III, Rakhawy (1978) suggested fu rth e r revision o f the E g yptian DM P- 1 fo r s im p lific a tio n , coherence and co nsideration o f c u ltu ra l d iffe re n c e s as w e ll as f u lfillin g a b e tte r degree o f common language w ith the in te rn a tio n a l and o th e r n a tio n a l n e u ro lo g ica l disciplines.
Studies o f p s y c h ia tric m o rb id ity in E gypt were c r itic iz e d by E l-A k a b a w i e t al (1983) as lim ite d to m ajor urban ce n tre s and consequently n ot re p re s e n ta tiv e o f the m agnitude o f m e n ta l health problem s in the c o u n try . T h e re fo re they set up a p ro je c t to study the epidem iology o f p s y c h ia tric disorders in an E g yp tia n ru ra l v illa g e . The v illa g e was considered re p re s e n ta tiv e in many respects o f ru ra l
E g yptian com m u nitie s. I t possessed w a te r and e le c tr ic ity supplies, a p o lice s ta tio n , a p rim a ry and a p re p a ra to ry school, a ru ra l h e a lth u n it and an a g ric u ltu re c o
op e ra tive .
disorders were 37%, organic disorders 2%, m ajor depression 2%, m e n ta l
re ta rd a tio n 1% and schizophrenic disorders 1% in a random sample o f a hundred households i.e . 230 persons o f both sexes. This study showed th a t schizophrenia had the low est ra te w hile m inor p s y c h ia tric disorders were p a rtic u la rly high. These findings d iffe re d fro m the previous studies which were confined to
U n iv e rs ity c lin ic s , w hich is an in d ic a to r o f the biased sample used in the previous studies. H owever E l-A ka b a w i's study used a d iffe r e n t diagno stic c la s s ific a tio n and took place fifte e n years a fte r Okasha's study.
C ro s s -c u ltu ra l studies o f depressive sym p to m atology w ere c a rrie d o ut by Gawad and A ra fa (1980). Com parison o f the s y m p to m a to lo g ic a l p a tte rn o f depression in
the th re e samples fro m d iffe re n t cu ltu re s showed th a t th e re were s ig n ific a n t d iffe re n c e s in the p a tte rn and frequency o f the sym ptom s. H ow ever, the E g yptian and Indian studies using the same in s tru m e n t (H a m ilto n 's ra tin g scale) were more com parable. Q u a lita tiv e study o f th is phenomenon was suggested by the authors to find explanations fo r the obtained q u a n tita tiv e fig u re s.
C ro s s -c u ltu ra l studies appear to be o f considerable a ttra c tio n to p s y c h ia tris ts in E g yp t who are more in te re ste d in the e p id e m io lo g ic a l com parisons than in ethno- p s y c h ia tric aspects. Here again Okasha and colleagues (1978) conducted another study to com pare p s y c h ia tric m o rb id ity among u n iv e rs ity students in E gypt and th e ir co u n te rp a rts in the W estern w o rld . On the whole fo rm a l p s y c h ia tric disorders accounted fo r 2% com pared to 3% in Edinburgh and 3% in B e lfa s t u n iv e rs itie s . They claim ed th a t the E g yptian fig u re s could be m isleading as many students p re fe r to c o n ta c t p riv a te p ra c titio n e rs ra th e r than a tte n d the student c lin ic . F u rth e rm o re access to m edica tion is availa ble fro m the pharm acy w ith o u t a p re s c rip tio n .
among Arab fem ale students both in London and C a iro U n iv e rs itie s . Results in d ica te d th a t 22% o f the London sample scored higher than the c u t- o ff score o f 30 on the Eating A ttitu d e s Test (E A T -40 ). No s ig n ific a n t c o rre la tio n s were found between EA T scores, w e ig h t, h eight or length o f stay in the UK.
In the C airo sam ple, 12% scored p o sitive on th e EAT, w ith no s ig n ific a n t c o rre la tio n between EA T scores and age, w e ig h t or height. No cases e ith e r o f anorexia or o f b u lim ia nervosa were id e n tifie d in the C a iro sam ple. D ie tin g was com m only by fa stin g tw o days a week (w hich is a fa m ilia r fo rm o f re lig io u s a c tiv ity ) as w e ll as long distance w alking (burning out ca lo rie s). The subjects in the E gyptian sample were d iffe r e n t fro m th e ir counterparts in London. In c o n tra s t to the London group, b u lim ic tendencies such as b in g e -e a tin g , se lf-in d u ce d
v o m itin g and la x a tiv e abuse were c h a ra c te ris tic a lly absent; the subjects appeared to have had no knowledge th a t th is kind o f behaviour o ccu rre d . Nasser's re su lts in dica ted the r a r ity o f these p a rtic u la r e a tin g problem s among the fe m a le students in C airo U n iv e rs ity .
1.6.4 P s y c h ia tric Nursing in E g ypt: Education Work and A ttitu d e Towards P s y c h ia tric P a tie n ts
The c u rre n t sta tu s o f the p s y c h ia tric nursing service in E gypt is an in d ic a to r o f the problem s c o n trib u tin g to the lack o f adequate service fo r m e n ta lly i l l p a tie n ts . This section is a b r ie f p ro file o f this im p o rta n t problem w hich includes aspects re la te d to education, tra in in g and a ttitu d e s . Because o f a lack o f lite ra tu re some in fo rm a tio n is derived fro m the personal experience o f the re se a rch e r,b o th c lin ic a l and academ ic.
1.6.4.1 P s y c h ia tric Nursing Education
w hich dates fro m the tim e o f the Pharaohs (Iveson, 1982). H ow ever, it was only in the la st f i f t y years th a t o f fic ia l tra in in g o f nurses cre a te d in te re s t, re su ltin g in a b e tte r q u a lity o f care fo r p a tie n ts and im proved the p u b lic image o f the nurse.
A t the present tim e , nursing as a profession is stru g g lin g fo r id e n tity and
acknow ledgem ent, a problem shared by o th e r nurses in many p arts o f the Western w o rld . The e vo lu tio n o f nursing education in E gypt, s im ila r to Europe, sta rte d w ith u n q u a lifie d , untrain ed personnel who joined hospitals to help the m edical profession look a fte r the p a tie n ts . Many schools sta rte d to em erge and lin k w ith d iffe re n t general hospitals, u n iv e rs ity hospitals and special care hospitals.
There were tw o types o f nursing d iscip lin e as shown in the fo llo w in g ta b le : Table 1.1: E a rly Nursing D iscip lin es and T ra in in g in Egypt
D iscip lin e j
i T ra in in g Previous Schooling
j
H a kim a /M id w ive s j 3 years 9 years j
!
Nurse A ssistant 18 m onths 9 years 1
These tw o groups o f nurses were prepared a t a general le v e l, w ith no p s y c h ia tric nursing tra in in g e ith e r th e o re tic a l or p ra c tic a l (A b d e l-A l, 1978). R ecent advances both in p a tie n t care and nursing tra in in g abolished the previous tw o types o f d iscip lin e . They are replaced by secondary nursing schools (3 years o f study a fte r 9 years o f successful basic schooling).
school, th re e years p re p a ra to ry school and th re e years secondary school. P s y c h ia tric nursing is studied both th e o re tic a lly and p ra c tic a lly both fo r
undergraduate and MSc, PhD sp e cia lisa tio n . A t the secondary schools o f nursing, it is studied th e o re tic a lly only (Mahgoub, 1981).
One fe a tu re o f the p s y c h ia tric nursing c u rric u lu m in E g ypt is th a t it tends to be m e d ica lly o rie n te d . This could be due to the p ro m in e n t in flu e n ce o f W estern tra in in g o f the p s y c h ia tris ts and p s y c h ia tric nurses who shape, develop and teach these courses. The refore m ore emphasis is placed on p s y c h ia tric c la s s ific a tio n s , sym p to m a to lo g y, psychopharm acology, physical therapy as w e ll as
psycho the ra peutic measures o f in te rv e n tio n , theories o f p e rso n a lity developm ent and in flu e n tia l so cia l fa c to rs . N evertheless the tendency to take a h o lis tic approach to th e ra p e u tic in te rv e n tio n has grown s tro n g ly in the past fe w years (Rakhawy, 1980). T h e o re tic a lly speaking th is e d u ca tio n a l system could be very successful in im p ro vin g the q u a lity o f p s y c h ia tric care. H ow ever, the a ctu a l s itu a tio n is fa r fro m id eal. Maurad e t al (1976) found th a t nursing is s t ill looked down upon by the E g yptian co m m u n ity re su ltin g in a sm all num ber o f students jo in in g the H ighe r Nursing In s titu te s . A fte r graduation only 2% worked in hospitals o f the M in is try o f H e a lth , w h ils t 36% chose to work in the A rm y w hich o ffe rs high salary and rank; and another big m a jo rity , 31%, chose to w o rk in oth e r Arab and European coun trie s. The c lin ic a l fie ld s o f surgery, m edicine, o b s te tric s and p a e d ia tric s were p re fe rre d to the a d m in is tra tiv e , p u b lic h e a lth or p s y c h ia tric fie ld s. Mahgoub (1981) found th a t in Abassia M ental H o s p ita l, the la rge st m e n ta l in s titu tio n in C a iro, w ith a bed ca p a c ity o f 3000, only tw o nurses had p s y c h ia tric nursing specia lisa tio n on c o m p le tio n o f th e ir H a kim a course. The rem aining 102 nurses possessed e ith e r a general q u a lific a tio n or w ere nurse
