Journal of Women & Aging Rehabilitation Programs ...

8 downloads 0 Views 72KB Size Report
Oct 11, 2008 - ization, training verbal and nonverbal communication competencies. KEYWORDS. Schizophrenia, inpatients, token economy, cognitive.
This article was downloaded by: [UQ Library] On: 05 July 2015, At: 20:01 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: 5 Howick Place, London, SW1P 1WG

Journal of Women & Aging Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjwa20

Rehabilitation Programs for Elderly Women Inpatients with Schizophrenia a

b

Carlos M. Coelho , António P. Palha , Daniela C. c

Gonçalves & Nancy Pachana

d

a

School of Human Movement Studies , University of Queensland , Level 5, Building 26, St Lucia QLD, 4072, Australia b

Hospital de S. João, Serviço de Psiquiatria Avenida , Porto, Portugal c

Universidade do Minho, Instituto de Educação e Psicologia , Braga, Portugal d

School of Psychology , University of Queensland , Queensland, Australia Published online: 11 Oct 2008.

To cite this article: Carlos M. Coelho , António P. Palha , Daniela C. Gonçalves & Nancy Pachana (2008) Rehabilitation Programs for Elderly Women Inpatients with Schizophrenia, Journal of Women & Aging, 20:3-4, 283-295, DOI: 10.1080/08952840801984816 To link to this article: http://dx.doi.org/10.1080/08952840801984816

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no

Downloaded by [UQ Library] at 20:01 05 July 2015

representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Rehabilitation Programs for Elderly Women Inpatients with Schizophrenia

1540-7322 0895-2841 WJWA Journal of Women & Aging Aging, Vol. 20, No. 3-4, June 2008: pp. 1–20

Downloaded by [UQ Library] at 20:01 05 July 2015

Coelho et al. JOURNAL OF WOMEN & AGING

Carlos M. Coelho António P. Palha Daniela C. Gonçalves Nancy Pachana

ABSTRACT. This study aims to describe rehabilitation and resocialization methods we believe to be appropriate for application to female patients with schizophrenia, in a psychiatric unit with a predominantly older population. We briefly describe the unit and the interventions used as an example of the proposed rehabilitation and resocialization methods applied. The article provides an overview to guide accurate intervention, particularly in inpatient women, in different types of cognitive impairment under the broad category of schizophrenia. Our clinical approach includes a token economy approach, cognitive remediation therapy, and social skills training. The token economy intervention is particularly directed to patients that present with a high mental deterioration and/or debility. Cognitive remediation training is applicable to subjects with both cognitive and social dysfunction, but that do not possess signs of an organic cerebral illness or Carlos M. Coelho (E-mail: [email protected]) is Senior Research Fellow at the School of Human Movement Studies, University of Queensland, Level 5, Building 26, St Lucia QLD 4072, Australia. António P. Palha, MD, PhD Psychiatry is affiliated with the Hospital de S. João, Serviço de Psiquiatria Avenida, Porto, Portugal. Daniela C. Gonçalves, PhD Candidate, attends Universidade do Minho, Instituto de Educação e Psicologia, Braga Portugal. Nancy Pachana, PhD, works with the University of Queensland, School of Psychology, Queensland, Australia. This work was supported by a grant from the Portuguese Foundation for Science and Technology (ref. SFRH/BPD/26922/2006) awarded to the first author. Journal of Women & Aging, Vol. 20(3/4) 2008 Available online at http://www.haworthpress.com © 2008 by The Haworth Press. All rights reserved. doi:10.1080/08952840801984816

283

284

JOURNAL OF WOMEN & AGING

of substance abuse. Social skills training can be the third step to resocialization, training verbal and nonverbal communication competencies.

KEYWORDS. Schizophrenia, inpatients, token economy, cognitive remediation therapy, social skills training

Downloaded by [UQ Library] at 20:01 05 July 2015

INTRODUCTION A gradual aging of the population is already the prevailing reality in most developed countries (Kincannon, He, & West, 2005; Lutz, Kritzinger, & Skirbekk, 2006). This fact continually exerts an increasing need for an appropriate response from the health and social sectors (Baldwin & Wild, 2004; Costa, 2004; Lee, Volans, & Gregory, 2003). A decrease in infant mortality, a decline in birth rates, and an increase in life expectancy have led to an inversion of the population pyramid, whereby, for the first time in Portuguese demographic history, the percentage of older adults is higher than that of youths (INE, 2002). With an average life expectancy of 78 years (75 years for men and 82 for women; INE, 2002), the current Portuguese landscape is characterized by considerably high indices of illiteracy and poor socioeconomic conditions (Botelho, 2005). These factors, along with the functional decline that comes with ageing (Katona & Shankar, 1999, 2004), constitute risk factors for the occurrence and maintenance of psychiatric conditions (Bowling & Farquhar, 1996; Ebmeier, Donaghey, & Steele, 2006; Tafaro, Cicconetti, Zannino, Tdeschi, Tombolilla, Ettore, & Marigliano, 2002; Woods, 1999). Although cognitive deterioration resulting in significant functional impairment occurs only in pathological aging conditions, and therefore should not be considered a normative stage of aging (Baltes & Baltes, 1990), epidemiologic data point toward an increasing prevalence of symptoms related to dementia. Even though there may be fluctuations in these rates, based on the methodology selected for the assessment (Form, 2000; Paúl, Ayis, & Ebrahim, 2006) or on the samples considered—for example older adults either living in a community or institutionalized— the figures regarding symptoms of cognitive deterioration in older adults are too significant to be ignored. Blazer’s studies indicate that between 15% and 69% of elderly patients committed to psychiatric hospitals and between 35% and 70% of those in long-term institutions show signs of organic mental disorders (Blazer, 1980, 2002a, 2002b).

Downloaded by [UQ Library] at 20:01 05 July 2015

Coelho et al.

285

Population aging inevitably spurs the need for a response by professionals who deal directly with this population group. However, the inability of both older adults and their general practitioners to recognize declining medical and psychiatric states (Löpönen, Räiha, Isoaho, Vahlberg, & Kivelä, 2003; Mills, 2001; Voyer & Martin, 2003), the absence of specific training for professionals (APA, 2004; Murphy, 2000), and the specificities associated with old age psychopathology, which make it significantly different from earlier age pathological conditions (Frazer, Christensen, & Griffiths, 2005; Katona & Shankar, 2004), often obstruct the implementation of effective strategies to work with the elderly. With the purpose of overcoming some of the difficulties inherent to the use of generalized strategies with older populations, and considering the difficulties that might lead older adults and their caregivers to frustration, we have prepared an article that provides professionals working with this population with a successful framework for treatment in these particular settings and considering the specificities of older female inpatients.

UNIT AND INPATIENT CHARACTERISTICS At Bom Jesus Health Centre in Braga, Portugal, there are approximately 280 women as long-term inpatients. These patients are distributed into four units, one of which has numerous older patients and, as such, presents different and challenging characteristics. At the time this article was written, there were 77 patients in this building, which has capacity for 80. We used the Mini Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975), administered by the healthcare unit psychologist, to evaluate mental status. In addition, a questionnaire administered by the social worker, the ward nurse, and the assistant nurse, wherein the number and duration of the patients’ contact with family members or friends is recorded, was used to evaluate the patients’ existing social support. The age of the patients in this building varies between 26 and 94, with an average of 67.08; (SD = 14.39). The elderly patients (over 65 years) constitute the majority of the population (n = 46), corresponding to 59%. The patients’ entry diagnoses were made by the psychiatrists in the unit, according to the ICD 10 (1992). The clinical evaluations show a considerable percentage of schizophrenic patients (n = 34, 42%). Considering other psychosis diagnoses (n = 6), we reach a number of patients with psychotic disorders of almost 50%. The patients’ other psychiatric

286

JOURNAL OF WOMEN & AGING

Downloaded by [UQ Library] at 20:01 05 July 2015

diagnoses included schizophrenia, Alzheimer’s disease (n = 12), mental retardation (n = 10), mood disorders (n = 10), and antisocial personality disorder (n = 5). Folstein’s Mini Mental State Exam (MMSE) reveals fairly heterogeneous results. From the 77 assessed patients, 38 present results between 0 and 15; 27 patients score between 16 and 25; and 5 had between 26 and 30 points on the test. The questionnaire regarding existing social support reveals that 58 patients have some contact with their family (76%), representing around three-quarters of the total population.1

SUGGESTIONS FOR PROGRAMS SUITED FOR THE PATIENTS Taking into account the characteristics of the environment in which these patients live and their own characteristics, we summarize a few intervention proposals that we believe are compatible with this type of population. The program selection was based on the diagnosis of the patients, their chronological and functional age, the level of mental deterioration, and the existing social support network.

Token Economy Program These programs, based on social learning principles, offer incentives for patients to engage in functional behaviors that increase daily living skills and independence (Tenhula, Bellack, Suarez, Lambert, & Ford, 2003). The operant learning paradigm has been applied in psychiatric environments since the 1950s, with the purpose of changing the behavior of psychotic inpatients (Lindsley & Skinner, 1954) and was progressively generalized to all institutionalized patients in the 1960s. Relevant studies from this period include Ayllon and Azrin’s work (1965, 1968). This procedure is based on a close control of the environment, in order to structure rehabilitating behavior of a person or group of people (Encinas & Cruzado, 1993). In the case of its actual application in institutionalized mental health contexts, the final objective is psychiatric rehabilitation (Lutzker & Withaker, 2005). The Token Economy was introduced in psychiatric hospitals with the underlying theoretical rationale of operant behavior principles (Skinner, 1953; McMonagle & Sultana, 2000). The first premise, the law of effect, states that behavioral frequency is in part determined by the consequences

Downloaded by [UQ Library] at 20:01 05 July 2015

Coelho et al.

287

of that behavior or its effects. Additionally, reinforcers are more effective in changing behaviors than punishment. The second operant conditioning law or principle is the law of contiguity association, which states that two events become associated with one another if they happen together. In this case, a neutral stimulus paired with a primary reinforcer will become a reinforcer by its association with satisfying consequences. Money is a good example of contiguity, given that it is not a reinforcer by its inherent characteristics, but by its capability to satisfy us through commodities we can acquire through its use (Dickerson, Tenhula, & Green-Paden, 2005). It is also important, in order to guarantee the success of this type of intervention, to train and evaluate the staff, who have a decisive role in this kind of work (e.g., Coleman & Paul, 2001; Corrigan, Williams, McCracken, Kommana, Edwards, & Brunner, 1998; LePage, DelBen, Pollard, McGhee, VanHorn, Murphy, Lewis, Aboraya, & Mogge, 2003).

Methodology Executing the token economy system, according to Rimm and Masters (1974), involves an objective definition of the premises involved, in order to maximize their efficiency. These authors consider it essential to establish from the first moment: i) toward which patients will the intervention be directed; ii) which behaviors are therapeutically desired, are observable, and can be registered; iii) the delivery of tokens with desirable behavior, and non-delivery of tokens without behaviors that are desirable, observable, and that can be registered, and withdrawal of tokens with behaviors contrary to the desirable ones; iii) which reinforcements are effective; and v) how the benefits in tokens and the costs of reinforcements will be balanced. In order to obtain a good characterization of the behaviors we want to decrease, maintain, or increase in frequency and intensity, we recommend the use of the Time-Sample Behavioral Checklist [TSBC] (Paul, Licht, Mariotto, Power, & Engel, 1987) and REHAB (Baker & Hall, 1983) instruments. Through staff meetings, additional behaviors can also be listed. After listing and understanding the desirable and the inadequate behaviors of the selected patients, the therapists assign points to each of the listed behaviors (Coelho & Palha, 2006). Some of the desired behaviors listed might include “Greeting and starting a conversation with a member of staff or another patient” (1 token) and “Getting dressed” (2 tokens). Behaviors to be extinguished might include “Verbal aggression” (1 token) and “Leaving the table during meals” (2 tokens).

Downloaded by [UQ Library] at 20:01 05 July 2015

288

JOURNAL OF WOMEN & AGING

There should be recognition of the patient’s commitment in following his or her program with a contingent reinforcement (token), even if the attempt is not successful, in order to motivate and shape the patient toward increasingly more appropriate behaviors. For example, a patient can receive from 1 to 3 tokens for a given behavior, according to the proximity to the actual desirable behavior and the effort put into it. In the case of absence at a task for justified reasons, the patient can receive the maximum number of tokens the task has to offer. This intervention is particularly directed toward patients that present with a high mental deterioration and/or debility. Considering that this is a behavioristic rationale intervention, relatively simple in its conceptualization, it presents a significant potential for rehabilitating action, especially when working with patients with challenging or disruptive behaviors (LePage, 1999).

Cognitive Remediation Training Cognitive remediation training (CRT) is a therapeutic technique directed toward patients with schizophrenia. Its main objective is to promote cognitive functioning, which in psychotic states frequently presents prevailing deficits, interfering with the subject’s day-to-day functioning (Coleman & Gillberg, 1996). Some of the most documented cognitive deficits presented with schizophrenia diagnosis are in executive functioning, memory, and attention (Michel, Danion, Grangé, & Sandner, 1998; Warner, 1994). Each one of these deficits impacts the subject’s functioning, resulting in a general state of vulnerability toward recurrences. Recently, Reeder, Smedely, Butt, Bogner, and Wykes (2006) presented a revised program for cognitive remediation training that has its effectiveness maximized by i) working on specific cognitive functions; ii) using tangible techniques, developed in a laboratorial context; and iii) personalizing the intervention according to a subject’s unique characteristics. The cognitive remediation training is applicable to subjects who have been diagnosed with schizophrenia, with both cognitive and social dysfunction, but that do not possess signs of an organic cerebral illness or of substance abuse (Michel et al., 1998).

Methodology CRT implementation proceeds in two stages: i) early evaluation of the subject based on memory, attention, and executive functioning; and ii) individualized intervention based on the results of the previous

Downloaded by [UQ Library] at 20:01 05 July 2015

Coelho et al.

289

evaluation (Wykes, Reeder, Williams, Corner, Rice, & Everitt, 2003). Therefore, although it is an intervention based on a manual, there are guarantees that the intervention plan is individualized and adapted, considering not only the subject’s specific needs, but also maximizing his or her strengths. The implementation of the intervention program involves 3 modules (Cognitive Change, Memory, and Planning), administered in the course of 40 individual sessions, 60 minutes long, which happen with a minimum frequency of 3 times a week. The sessions are composed of tasks of increasing difficulty, which the subject should execute, addressing cognitive change, memory, and planning (Wykes et al., 2003). The fact that the therapy starts with tasks of reduced difficulty motivates the subject toward participation; however, the therapist must be alert to the subject’s reaction to the proposed exercise, given that selecting tasks that are too easy might lead to a feeling of infantalization. As long as the tasks are mainly of low difficulty, they can be adapted to each participant’s abilities, with the goal of promoting the acquisition of new competencies in the 3 designated areas. The CRT’s underlying strategies, which make it particularly useful to work with patients with schizophrenic symptomatology, are learning with minimum error, tasks difficulty adjustment, practice, positive reinforcement, and promoting information processing strategies (Reeder et al., 2006).

Social Skills Training Program With schizophrenic patients—along with cognitive disorders, failure in goal-directed behavior, and affective dulling—there is a serious compromise of social relations. The implications of behavior are evident in social interactions, as they involve responses at the right moment, with the appropriate latency periods (e.g., Bourgeois, Schulz, Burgio, & Beach, 2004). According to Liberman (1991), the abilities needed for social competency include i) being conscious of the feelings and objectives of the person with whom one is dealing, as well as their rights and responsibilities in that particular situation; ii) translating perceptions into various possible actions and being capable of choosing the best solution; and iii) conveying the chosen response to the other person, using suitable verbal and nonverbal behaviors. These prerequisites for an effective social contact demonstrate the need for training in verbal and nonverbal communication competencies and

Downloaded by [UQ Library] at 20:01 05 July 2015

290

JOURNAL OF WOMEN & AGING

training in problem solving (Bourgeois et al., 2004), as well as in comprehension and in following the social rules and norms regarding limits between the individual and others (Chen, Ryden, Feldt, & Savik, 2000; Moore & Davis, 2002). The paranoid symptomatology in an older individual might indicate schizophrenia, dementia, or paranoid psychosis, with different prevalence and prognosis for each, making the evaluation and consequent diagnosis a complex process, albeit a necessary one (Hopkins, Kilik, Day, Bradford, & Rows, 2006). Therefore, this program for training social competencies focuses on patients with that same symptomatology, not provoked or affected by dementia, in other words, for those patients with diagnosed schizophrenia and with MMSE results that reveal an absence or low index of mental deterioration. Schizophrenia promotes social losses, which limits support (e.g., Pentland, Miscio, Eastabrook, & Krupa, 2003); support which is important in reducing stress, depressive symptoms, and recovering from illnesses (Siegler & Poon, 1989). It follows that this support implies a reciprocal relationship, and that the vehicle of social support (caregiver) might experience extreme stress and depression (Bruce, Paley, Nichols, Roberts, Underwood, & Schaper, 2005). It is therefore helpful to endow the receptor with social abilities so that he or she benefits more from the caregiver.

Methodology Given that a person with psychosis experiences a loss of his sense of boundaries and, consequently, his sense of identity, the group might, at any moment, lose objectivity of speech. However, group intervention is possible as long as some crucial aspects are considered, for example, maintaining a structured and friendly environment. In this type of intervention, the therapist should also stop criticisms between patients, offer positive feedback, and avoid telling the patient that his or her answers are wrong (Coelho & Palha, 2006). The choice of positive behaviors that can be promoted should be favored over unwanted behaviors that one intends to extinguished (Liberman, 1991). The chosen behaviors should also be those that bring the most benefits to the patient and those the patient applies more frequently, for example, knowing how to ask for help. Social skills training (SST) teaches the patient to think in terms of communication competencies, problem solving, and assessment of

Downloaded by [UQ Library] at 20:01 05 July 2015

Coelho et al.

291

environmental resources. The nonverbal communication competencies include eye contact, body posture, body movement, facial expression, voice volume, and speech fluency (Carballo, 1993). These competencies serve simultaneously two purposes for the patient: expressing his or her needs as a patient and understanding the interest of the interlocutor in continuing the interaction. Finally, the evaluation of environmental resources includes negotiation with the patient about the resources available and the most effective way to use them. Examples of resources are time, space, people, objects, the telephone, money, and transportation. Basic training with these subjects includes operationalization of apparently obvious abilities, for example, starting a conversation. Even basic activities such as this can be divided into small steps: choosing an appropriate place and time, greeting, saying some words about the present situation or of general interest, assessing if the other person is listening and wants to continue the conversation, and taking the conversation with the subject in the actual desired direction (Goldstein, 1976). Each of these steps could be subdivided and trained separately according to social learning principles. The great diversity of cognitive problems and social deficits that exist in psychiatric illnesses requires an adaptation of social skills training to each subject. A generalization of the benefits, however, depends on the chances patients have to apply their learning to different contexts and different people (Martin-Cook, Davis, Hynan, & Weiner, 2005), which is ideal if there is a therapeutic involvement between all the individuals dealing closely with the patient.

CONCLUSION The description of this unit intends to show and relate the patients and their context in order to select appropriate methods of treatment. Older women with schizophrenia that began in early adult life continue to need psychiatric treatment (Dickerson, 2007), although treatment considerations may require modification with age (Lehmann, 2003). The intervention programs presented aim to prevent the deterioration caused by biological, psychological, and social factors related to age, institutionalization, and lack of social support, among others. The Token Economy, Social Skills Training, and Cognitive Training described are some of the intervention possibilities that can be used with the population of interest, namely older inpatients. It is important to consider that the selection of a

Downloaded by [UQ Library] at 20:01 05 July 2015

292

JOURNAL OF WOMEN & AGING

strategy for working with older institutionalized patients should contemplate all idiosyncrasies associated with the context, the patients, and the competencies of the therapists administering interventions (Baldwin & Wild, 2004). The existing stereotypes underlying a negative image of mental illness are frequently associated with prejudiced behavior toward older adults, attributing to them characteristics of fragility and incompetence (APA, 2004). Additionally, therapists’ attitudes often associate work with older adults to a lesser need for training (Kimuna, Knox, & Zusman, 2005) to close existing gaps in the offering of specific training for work with this group (Murphy, 2000). In order to help professional caregivers working in these types of impatient facilities, we have proposed different rehabilitation methods that we believe to be most appropriate considering each clinical situation.

NOTE 1. Family contact is considered nonexistent when the patient has had no visitors for more than six months, and this is the case for over one-fifth of the sample.

REFERENCES American Psychiatric Association. (2004). Guidelines for psychological practice with older adults. American Psychologist, 59, 236–260. Ayllon, T., & Azrin, N. H. (1965). The measurement and reinforcement of behavior of psychotics. Journal of the Experimental Analysis of Behavior, 8, 357–383. Ayllon, T., & Azrin, N. H. (1968). TheToken Economy: A motivational system for therapy and rehabilitation. Englewood Cliffs, NJ: Prentice Hall. Baker, R., & Hall, J. N. (1983). Rehabilitation evaluation of Hall and Baker. Aberdeen,: Vine Publishing. Baldwin, R., & Wild, R. (2004). Management of depression in later life. Advances in Psychiatric Treatment, 10, 131–139. Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives on successful aging: The model of selective optimization with compensation. In: P. Baltes & M. Baltes, Successful aging: perspectives from the behavioural sciences (pp. 1–34). Canada: Cambridge University Press. Blazer, D. G. (1980). The epidemiology of mental illness in late life. In: E. N. Busse & D. G. Blaser (Eds.), Handbook of Geriatric Psychiatry. New York: Nostrand Reinhold. Blazer, D. G. (2002a). Depression in late life. New York: Springer Publishing Company, Inc. Blazer, D. G. (2002b). Self-efficacy and depression in late life: A primary intervention proposal. Aging and Mental Health, 6, 315–324.

Downloaded by [UQ Library] at 20:01 05 July 2015

Coelho et al.

293

Botelho, A. (2005). A funcionalidade dos idosos. In C. Paúl & A. M. Fonseca. Envelhecer em Portugal: Psicologia, saúde e prestação de cuidados. (pp. 115–138). Lisboa: Climepsi Editores. Bourgeois, M., Schulz, R., Burgio, L., & Beach, S. (2004). Skills training for spouses of patients with Alzheimer’s disease: Outcomes of an intervention study. Journal of Clinic Geropsychology, 8, 53–73. Bowling, A., & Farquhar, M. (1996). Outcome of anxiety and depression at two and a half years after baseline interview: Associations with changes in psychiatric morbidity among three samples of elderly people living at home. International Journal of Geriatric Psychiatry, 11, 119–129. Bruce, D. G., Paley, G. A., Nichols, P., Roberts, D., Underwood, P. J., & Schaper F. (2005). Physical disability contributes to caregiver stress in dementia caregivers. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 60, 345–349. Carballo, V. E. (1993). Manual de evaluación y entrenamiento de las habilidades sociales. Madrid: Siglo Veintiuno de España Editores. Chen, Y., Ryden, M., Feldt, K., & Savik, K. (2000). The relationship between social interaction and characteristics of aggressive, cognitively impaired nursing home residents. American Journal of Alzheimer’s Disease and Other Dementias, 15, 10–17. Coelho, C. M., & Palha, A. P. (2006). Treino de habilidades sociais aplicado a doentes com esquizofrenia. Lisboa: Climepsi Editores. Coleman, M., & Gillberg, C. (1996). The schizophrenias: A biological approach to the schizophrenia spectrum disorders. New York: Springer Publishing Company, Inc. Coleman, J. C., & Paul, G. L. (2001). Relationship between staffing ratios and effectiveness of inpatient psychiatric units. Psychiatric Services, 52, 1374–1379. Corrigan, P. W., Williams, O. B., McCracken, S. G., Kommana, S., Edwards, M., & Brunner, J. (1998). Staff attitudes that impede the implementation of behavioral treatment programs. Behavior Modification, 22, 548–562. Costa, A. (2005). A depressão nos idosos portugueses. In C. Paúl & A. M. Fonseca (Coods.). Envelhecer em Portugal: Psicologia, saúde e prestação de cuidados. Cap. 6, pp. 157–176. Lisboa: Climepsi Editores. Dickerson, F. B. (2007) Women, aging, and schizophrenia. Journal of Women & Aging, 19, 49–61. Dickerson, F. B., Tenhula, W. N. & Green-Paden, L. D. (2005). The token economy for schizophrenia: Review of the literature and recommendations for future research. Schizophrenia Research, 74, 405–416. Ebmeier, K. P., Donaghey, C., & Steele, J. D. (2006). Recent developments and current controversies in depression. Lancet, 367, 137–167. Encinas, F. L., & Cruzado, J. A. (1993). Técnicas de control de contingencias. In: M. A.Vallejo, P. M. Angeles, & R. Fernandez (Eds.) Manual Prático de modificación de conduta. Madrid: Fundacion Universidad Empresa. Folstein, M., Folstein, S., & McHugh, P. (1975). Mini Mental State. Journal of Psychiatric Research, 12, 189–198. Form, A. F. (2000). Does old age reduce the risk of anxiety and depression? A review of epidemiological studies across the life span. Psychological Medicine, 30, 11–22.

Downloaded by [UQ Library] at 20:01 05 July 2015

294

JOURNAL OF WOMEN & AGING

Frazer, C. J., Christensen, H., & Griffiths, K. M. E. (2005). Effectiveness of treatments for depression in older people. Medical Journal of Australia, 182, 627–632. Goldstein, A. P., Sprafkin, R. P., & Gershaw, M. J. (1976). Skill training for community living: Applying structural learning theory. New York, Pergamon Press. Hopkins, R., Kilik, L., Day, D., Bradford, L., & Rows, C. (2006). The Kingston Standardized Behavioural Assessment. American Journal of Alzheimer’s Disease and Other Dementias, 21, 339–346. INE (2002). O envelhecimento em Portugal. Portugal: Serviço de Estudos para a População do Departamento de Estatísticas Censitárias e de População. Katona, C., & Shankar, K. (1999). Depression in old age. Reviews in Clinical Gerontology, 9, 343–361. Katona, C., & Shankar, K. (2004). Depression in old age. Reviews in Clinical Gerontology, 14, 283–306. Kimuna, S. R., Knox, D., & Zusman, M. (2005). College students’ perceptions about older people and aging. Educational Gerontology, 31, 563–572. Kincannon, C. L., He, W., & West, L. A. (2005). Demography of aging in China and the United States and the economic well-being of their older populations. Journal of Cross-Cultural Gerontology, 20, 243–255. Lee, K. M., Volans, P. J., & Gregory, N. (2003). Attitudes toward psychotherapy with older persons among trainee clinical psychologists. Aging & Mental Health, 7, 133–141. Lehmann, S. W. (2003). Psychiatric disorders in older women. International Review of Psychiatry, 15, 269–279. LePage, J. P. (1999). The impact of a token economy on injuries and negative events on an acute psychiatric unit. Psychiatric Service, 50, 941–944. LePage, J. P., DelBen, K., Pollard, S., McGhee, M., VanHorn, L., Murphy, J., Lewis, P., Aboraya, A., & Mogge, N. (2003). Reducing assaults on an acute psychiatric unit using a token economy: A 2 year follow-up. Behavioral Interventions, 18, 179–190. Liberman, R. P. (1991). Réhabilitation psychiatrique des malades mentaux chroniques. Paris: Masson. Lindsley, O. R., & Skinner, B. F. (1954). A method for the experimental analysis of the behavior of psychotic patients. American Psychologist, 9, 419–420. Löpönen, M., Räiha, I., Isoaho, R., Vahlberg, T., & Kivelä, S. (2003). Diagnosing cognitive impairment and dementia in primary health care—a more active approach is needed. Age and Aging, 32, 606–612. Lutz, W., Kritzinger, S., & Skirbekk, V. (2006). Population: The demography of growing European identity. Science, 314(5798), 425. Lutzker, J. R., & Withaker, D. J. (2005). The expanding role of behavior analysis and support: Current status and future directions. Behavior Modification, 29, 575–594. Martin-Cook, K., Davis, B. A., Hynan, L. S., & Weiner, M. F. (2005). A randomized, controlled study of an Alzheimer’s caregiver skills training program. American Journal of Alzheimer’s Disease and Other Dementias, 20, 204–210. McMonagle, T., & Sultana, A. (2000). Token economy for schizophrenia (Cochrane Review). The Cochrane Database of Systematic Reviews, 3, CD001473. Michel, L., Danion, J. M., Grangé, D., & Sandner, G. (1998). Cognitive skill learning and schizophrenia: Implications for cognitive remediation. Neuropsychology, 12, 590–599.

Downloaded by [UQ Library] at 20:01 05 July 2015

Coelho et al.

295

Mills, T. L. (2001). Comorbid depressive symptomatology: Isolating the effects of chronic medical conditions on self-reported depressive symptoms among community-dwelling older adults. Social Science & Medicine, 53, 569–578. Moore, L., & Davis, B. (2002). Quilting narrative: Using repetition techniques to help elderly communicators. Geriatric Nursing, 23, 2–5. Murphy, S. (2000). Provision of psychotherapy services for older people. Psychiatric Bulletin, 24, 181–184. Paúl, C., Ayis, S., & Ebrahim, S. (2006). Psychological distress, loneliness, and disability in old age. Psychology, Health & Medicine, 11, 221–232. Paul, G. L., Licht, M. H., Mariotto, M. J., Power, C. T., & Engel, K. L. (1987). Observational assessment instrumentation for service and research. The Time-Sample Behavioral Checklist: Assessment in residential treatment settings (Part 2). Champaign, IL: Research Press. Pentland, W., Miscio, G., Eastabrook, S. & Krupa, T. (2003). Aging women with schizophrenia. Psychiatric Rehabilitation Journal, 26, 290–303. Reeder, C., Smedely, N., Butt, K., Bogner, D., & Wykes, T. (2006). Cognitive predictors of social functioning improvements following cognitive remediation for schizophrenia. Schizophrenia Bulletin, 32, 123–131. Rimm, D. C., & Masters, J. C. (1974). Terapia de la conducta: técnicas y hallazgos empíricos. México: Trillos. Siegler, C. I., & Poon, W. L. (1989). A Psicologia do envelhecimento. In: Busse e Blazer, Psiquiatria Geriátrica. Porto : Artes Médicas. . Skinner, B. F. (1953). Science and human behavior. New York: McMillan. Tafaro, L., Cicconetti, P., Zannino, G., Tedeschi, G., Tombolilla, M., Ettore, E., & Marigliano, V. (2002). Depression and aging: A survival study on centenarians. Archives of Gerontology and Geriatrics, Supplement, 8, 371–376. Tenhula, W. N., Bellack, A. S., Suarez, E., Lambert, M., & Ford, R. (2003). Integration of a token economy program with psychosocial and psychopharmacological research on a treatment refractory schizophrenia unit. Schizophrenia Research, 60, 329–330. Voyer, P., & Martin, L. S. (2003). Improving geriatric mental health nursing care: Making a case for going beyond psychotropic medications. International Journal of Mental Health Nursing, 12, 11–21. Warner, R. (1994). Recovery from schizophrenia: Psychiatry and political economy. 2nd ed. New York: Routledge. Whanger, A. D. (1992). Tratamento Hospitalar do paciente psiquiátrico idoso. In E. W. Busse & D. G. Blazer (Orgs). Psiquiatria Geriátrica. Porto Alegre: Artes Médicas. Woods, R. T. (1999). Mental health problems in later life. In R. T. Woods (Ed.). Psychological Problems of ageing: Assessment, Treatment and Care (Chap. 4, pp. 73—110). England: John Wiley & Sons Ltd. World Health Organization. (1992) The ICD-10 Classification of Mental and Behavioral Disorders. Geneva: WHO. Wykes, T., Reeder, C., Williams, C., Corner, J., Rice, C., & Everitt, B. (2003). Are the effects of cognitive remediation therapy (CRT) durable? Results from an exploratory trial in schizophrenia. Schizophrenia Research, 61, 163–174.

Downloaded by [UQ Library] at 20:01 05 July 2015