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Patients with schizophrenia are treated with medication, psychotherapy and psychosocial interventions. Medications such as antipsychotics are dangerous drugs and doctors must consider the following factors before prescribing:demographic,other conditions,pregnancy,smoking status,severity, frequency of symptoms,risk-to self and others.I find that clients with schizophrenia that are deemed as high-risk get prescribed a stronger dose of medication.To begin with, tablet medication treatment is the best way to go. However, if the client is not compliant then fortnight IM Injections are given to client.If antipsychotics don't work at a moderate dose (reduce frequency and intensity of symptoms and improved functioning) then the dose is increased. There are guides regarding dose limits-due to toxicity.If medications like Seroquel or Abilify don't work then (client has treatment resistant illness) the Doctor may prescribe Olanzapine or Risperidone (tablet or IM Injections).If the above still do not work then the doctor may try Clozapine or other newer antipsychotics that are stronger (or better at treatment resistant schizophrenia) when compared to the others.Psychosocial treatment for schizophreniaOther than medications, it is very important for a client to receive psychosocial interventions. I believe that the community area mental health allied health/case manager psychosocial rehabilitation treatment model is the best model to treat people with severe mental illness like schizophrenia.The above treatment model does not work in isolation. The above treatment model is linked to the local hospital, and other teams such as the crisis assessment treatment team and mobile support team.It's a complicated model that doesn't work in isolation. Case managers can refer their clients to an impatient unit if they deteriorate rather quickly, or request that the crisis assessment treatment team monitor their client after hours if they believe their client warrants such a service.It was set up by the Australian government and has been in place for many years-basically since people with severe mental illness were de-institutionalised.Canada has a similar mental health system to Australia's.The client is referred to an allied health clinician (Clinical psychology, social work, occupational therapist or psychiatrist nurse) for case management. The clinician works as part of a multidisciplinary team that is headed by the psychiatrist and clinic manager.The clinic also provides:Psychology specific therapy,Group therapy,Carer consultant,Carer support groups,Consumer consultant.The clinician has about 30 clients allocated to them at any given moment with pressure to discharge ASAP (client numbers have been going up and funding for the system has been going down).Initially, the clinician meets with their client on a fortnightly basis and the client meets with the psychiatrist on a monthly basis to ensure they are stable.Clients can meet their workers more regularly, but if this continues for too long then they are better suited for a more intensive outreach team such as the mobile support team. They operate similarly to the community mental health outpatient team.If the client in non-compliant with medication and treatment plan and poses a significant risk to themselves or others they are placed on community treatment orders that stipulate the treatment conditions that they have to comply with.Many people without insight have no idea they have schizophrenia and refuse to engage in treatmentThe case manager works to stabilise the client and links them in with other community run (NGO's funded primarily by government grants) services to assist with their rehabilitation.For example, the clinician can refer the client to:social groups (to deal with the isolation that people with schizophrenia face),a community worker that helps them find part time work if the client is able to work,an art group,other services.The treatment regime for each client is different based on their needs. The case manager works closely with the client, their family or carers and they complete an Individual Service Plan (ISP). The plan has short- and long-term goals, deadlines, and allocated responsibilities.The clinician and team are held accountable if the client continues to fail to reach the goals.From my experience, this type of treatment regime is the best for people with severe mental illness and yields much better outcomes compared to medication alone or psychotherapy.The problem is that the USA and most other countries do not offer this type of service. Perhaps the elite or those with top notch health cover can find a private clinic that uses the allied health/case manager psychosocial rehabilitation treatment modelKamal

Thank you for the A2A. Wow these are multiple questions at once! Prepare for a long answer. Probably the longest one I’ve ever written!Original question: How is disaster response organized in Indonesia? How does BNPB work at disaster? How is medical help organized?-PART ONE: How is disaster response organized in Indonesia? How does BNPB work at disaster?Answering these two questions together. You might want to quick read my answer about disaster management cycle in general first to get a picture how the whole strategy is designed. Let me show the illustrated cycle:Variety of the 4 phases of the cycle exists around the world but these 4 phases are the main ones you should know first:[1][2]Mitigation - Minimizing the effects of disaster.Examples: building codes and zoning; vulnerability analyses; public education.Preparedness - Planning how to respond.Examples: preparedness plans; emergency exercises/training; warning systems.Response - Efforts to minimize the hazards created by a disaster.Examples: search and rescue; emergency relief .Recovery - Returning the community to normal.Examples: temporary housing; grants; medical care.The whole disaster cycle is done by the organization structure Incident Command System practiced on many nations that is used for emergency response against various population threat (hostage crisis, terrorist attack, natural and man-made accidents, etc).Back to IndonesiaWhat you first need to know is that in Indonesia a rough equivalent of USA’s FEMA, called the BNPB (Badan Nasional Penanggulangan Bencana/Indonesian National Board for Disaster Management), is the highest authority that reports directly under the President. It is one of the non-ministrial goverment agency formed in 2008 with the following duty:[3]Provide guidance and direction on disaster management effort that includes disaster prevention, emergency response, rehabilitation, and reconstruction in a fair and equitableAssigning the standardization and implementation of disaster management needs based on laws and regulationsDelivering information to community disaster management activitiesDisaster management reporting to the President once a month in normal conditions and at all times in a state of emergencyUse and account for donations / support national and internationalAccount for the use of funds received from the State BudgetCarry out other obligations in accordance with laws and regulationsDevelop guidelines for the establishment of the Regional Disaster Management AgencyThey are at the top center of the whole system, overseeing how the whole 4 phases of the disaster cycle are run. They coordinate how civilian, military, NGO, and government agencies of various sectors work together to as a joint task force.[4] External supports from both NGOs and international organization (such as those from UN) are to coordinate with BNPB to be integrated into the task force. To be more specific, the local/regional disaster management board (BPBD: Badan Penanggulangan Bencana Daerah) is directly responsible for the joint task force. [4] Inside the joint task force there are various units such as: Law&security, logs, information, storage, search and rescue, psychological, sheltering, sanitary, communication, medical, transportation, public relations, evacuation, and more I’ve yet to mention.Other than leading the various regional BPBDs for all 4 phases of disaster cycles, the BNPB have their own quick rapid response teams, they are called The Indonesia Rapid Response and Assistance (INDRRA) or Satuan Reaksi Cepat Penanggulangan Bencana (SRCPB). They are specific stand-by team (see team structure below) that goes ahead while the BNPB coordinates the BPBD and external forces to form joint task force from various organizations. Usually they either arrive first, with or after local search-rescue team or Basarnas. Their main job includes immediate rapid assessment of damage & needs while administering rescue and relief efforts.[5] On their way of doing rapid response, other rapid response team/tim reaksi cepat (from community based/volunteers, local Red cross, etc) may join together as part of the SRC team to help in medical assistance, search and rescue, sanitation, logistic, etc. Take note that in disaster always expect that the demand for help may be beyond current their capacity. So any help will be organized quickly for efficiency.Below is how BNPB and BPBD hierarchy relates to the government level. BNPB is on the same level or ministries, while BPBD works on both provincial and regency level. [7]Disaster management law and status declaration [4] [5]Disaster management in Indonesia is governed by the LAW OF THE REPUBLIC OF INDONESIA NUMBER 24 OF 2007 CONCERNING DISASTER MANAGEMENT (English)[6]Regarding disaster status declaration let me quote the text from Indonesia: Disaster Management Reference Handbook 2015 page 48:As authorized by the disaster management law, the Government decides on the disaster emergency status dependent on the scale of the disaster.• National disaster emergency status declared by the President• Provincial disaster emergency status declared by the Governor• Regency/City disaster emergency status declared by the Regent/MayorOnce a disaster emergency status has been declared the National and Regional Disaster Management Agencies (BNPB & BPBD) obtain easy access to:• Mobilization of human resources, equipment, and logistics• Immigration, excise, and quarantine• Licensing• Procurement of goods/services• Management and accountability for money and/or goods• Rescue• Command over sectors/institutionsThe 2004 Indian Ocean earthquake and tsunami, is an example of national disaster emergency status declared by the president (which would’ve been led by BNPB if it was formed before that time). The recent mount Agung volcano evacuation is mainly led by BPBD of Bali province together with the lower BPBD of its regency.Other regulations follows after the 2007 initial organization (table taken from here) [7]Now so many different government and external agencies of various sectors, it can look confusing how one is given task and another. The table below is example of programs outline for tsunami disaster from the appendix of the BNPB national disaster management plan book.[5] It’s divided into Mitigation, preparedness, early warning, emergency response, and rehabilitation & reconstruction. See how various agencies such as the BMKG, LIPI, ministry of maritime affairs, LIPI are involved in mitigating disasters by mapping disaster risk areas. Kementrian PU is involved on structural mitigation. Contigency plan is designed, led by BNPB, with joint effort with Ministry of Health,TNI, Polri, Ministry of Energy and Mineral Resource, etc. Early warning is led by BNPB. Initial assessment and emergency response is led by the SRC, followed search-rescue, evacuation and medical response by Basarnas (National search and rescue agency), TNI (Indonesian National Armed Forces), POLRI (Indonesian National Police), Ministry of Health, and the Indonesian Red Cross. During rehabilitation-reconstruction, the Bappenas (Badan Perencanaan Pembangunan Nasional/Ministry of National Development Planning) is involved in starting the reconstruction until finishing. Finance minister is involved in damage & loss assessment and reconstruction planning. Ministry of Health and Social continues their ongoing medical-psychosocial support. See table below for the comprehensive list. Other NGOs with their specific skills assist the following disaster management roles accordingly.-PART TWO: How is medical help organized?Prior to reading this part I strongly recommend reading my other answer here to get a picture how medical help is organized on the field during emergency response phase:Alrein Putrananda's answer to What is the first aid in an accident?-Below are the three official medical providers during disaster management. More often than not, their work overlap each other. By official agencies, I exclude NGOs.A. Center for Health Crisis Management (Pusat Penanggulangan Krisis Kesehatan: PPKKOrganized planned medical response to disasters by the ministry of health started in 1991. Today, i’s called the Center for Health Crisis Management (Pusat Penanggulangan Krisis Kesehatan: PPKK).[7]See table below for it’s history.It’s a specific department under the Ministry of Health consisting of monitor-information, emergency response-recovery, and prevention-mitigation & preparedness unit. They coordinate with BNPB or BPBD with and the local public health office (Dinas Kesehatan/Dinkes). [7]B. Medical Response Team (MRT)Almost every local health office and hospital has a Medical Response Team (MRT) that includes, doctors, nurses, logisticians and drivers. The regional PPKK is involved in quality assurance of the MRT in accordance with their guideline.[8] Below is a summary of the MRT: [7] [8]The Ministry of Health has regulation on the Guideline of Human Health Resources on Disaster Management (as of Kepmenkes No. 66/Menkes/SK/II/2006), composition and minimum qualification requirements:[7] [8]C. The Indonesian Red CrossThe Indonesia Red Cross (PMI) in coordinance with the BPBD-BNPB part of the joint-task force on medical sector, sets up a command post (a.k.a POSKO) at its headquarters and the disaster scene. The HQ’s POSKO coordinates with regional PMI and the International Federation of Red Cross and Red Crescent Societies (IFRC), as well as other concerned organizations such as POSKO of the local government, BNPB/BPBD.PMI also privdes Medical Action Team (MAT) at the request of the central/local government, foreign government or IFRC. They are usually mobilized by a district PMI in cooperation with volunteer groups (TSR/Tenaga Suka Rela) registered from medical education institutions. MAT is composed of doctors, nurses, midwives, pharmacologists, drivers, logisticians, and first responders. When emergency response and rehabilitation phase have passed, PMI provides first aid training for volunteers, private companies, and community-based organization as part of their emergency preparedness education for the community.I’ve yet to explain about field hospital. But, I’m close to falling asleep. That is all for today I will update this as soon as possible.Footnotes[1] The Disaster Management Cycle[2] Disaster Management: A Disaster Manager's Handbook[3] BADAN NASIONAL PENANGGULANGAN BENCANA[4] Indonesia: Disaster Management Reference Handbook 2015[5] https://www.bnpb.go.id//uploads/renas/1/BUKU%20RENAS%20PB.pdf[6] http://www.ifrc.org/docs/IDRL/956EN.pdf[7] The survey on the current situation of disaster/emergency medicine system in the ASEAN region : fina l report. -[8] Buku Pedoman Teknis PKK-AB

Psychological Aspects of Spinal Cord Injuryby Katharine S. Westie, Ph.D.Spinal cord injury (SCI) is a massive assault to the psyche as well as the body. Within mo­ ments, a person who had been active and inde­ pendent becomes immobilized, loses control of bowel, bladder, sexual and other bodily func­ tions, and is dependent on others to meet the most basic needs. The instantaneous effects of the injury result in total disruption of the victim's life, and the beginning of a life-long psychological adjustment process. Optimal emotional adjustment is imperative to the re­ covery and rehabilitation process, due to the tremendous psychological energy and motiva­ tion required for a SCI patient to learn self- care, independence, and psychosocial coping skills.Theories ofPsychological AdjustmentPsychological adjustment to SCI has been conceptualized in terms of three major models. The first is referred to as the "stages" theory, and is derived from the well known work on grieving done by Lindeman and Kubler- Ross.7 , 6 This theory proposes that individuals adjusting to losses, such as SCI, experience certain psychological stages in the readjustment process. These include (1) shock and denial, (2) depression, (3) anxiety, (4) anger, (5) "bar­ gaining," and (6) adaptation. In using this model, it is important to understand that not all patients go through all stages, that a patient may go through a stage more than once and that stages are not necessarily experienced in agiven order. This model is helpful in recog­ nizing these emotional responses as a normal, healthy, and appropriate part of adjustment to SCI.The second model is referred to as the "de­ velopmental" theory. It is derived from Er- ikson's work on psychosocial stages of devel­ opment, from infancy to adulthood.4 As ap­ plied to SCI, the developmental theory assumes that the trauma results in a natural re­ gression, followed by a reworking of some de­ velopmental tasks previously mastered in child­ hood, starting with (1) basic trust, (2) au­ tonomy, and (3) initiative. Physically and emotionally, SCI patients must progress through tasks of infancy and childhood again. Like infants, they initially may be unable to verbally communicate, need to be fed and moved, have no bowel and bladder control, and are totally dependent. As they progress through rehabilitation, they relearn childhood tasks such as rolling, feeding, developing a bowel and bladder routine, mobility, and other basic activities of daily living. They experience the adolescent task of separation from parental figures as they work toward the independence1 of adulthood. The rehabilitation program can be seen as facilitating attainment of these de­ velopmental landmarks.The third model, the "individual differ­ ences" theory, proposes that adjustment is pri­ marily related to individual differences in pa­ tients' premorbid personalities.These models provide three different ap­ proaches to understanding psychological ad-justment to SCI. However, they need not be seen as mutually exclusive. In fact, when used together, they provide a more complete picture of SCI patients' complex adjustment process.Psychological Responses of StaffRehabilitation professionals working with SCI may find that certain patients elicit grieving responses in them, similar to those of their patients. When staff members identify with or become emotionally attached to pa­ tients, they may find themselves experiencing symptoms of depression, anger, or even denial. Highly motivated staff may also find it difficult to cope with noncompliance of depressed or angry SCI patients. Occasionally, when staff members' goals for resistant patients are not met, they may blame themselves for perceived failures or subconsciously direct anger and frustration toward patients. Although these are normal emotional responses, they may interfere with staff members' well-being and effective­ ness. When situations such as these occur, con­ sultation with the rehabilitation psychologist can provide the staff member with behavioral management techniques and enhance personal coping skills and insight. Professionally facili­ tated groups designed to provide peer support, teach stress management skills, and prevent"burnout" are also recommended.Head Injury in SCIClosed head injury (CHI) frequently accom­ panies traumatic SCI, though it often goes un­ recognized. The reported incidence of head in­ jury in SCI ranges from 10% to 58%.5 Recent studies indicate that neuropsychological deficits are common among SCI patients.2 , 3 , 1 3 Morris, et al. state that 50% of all SCI patients may be expected to exhibit evidence of CHI and some degree of cognitive impairment.8Even mild head injuries can significantly af­ fect cognitive and emotional functioning, espe­ cially during the first months post-injury. The most prominent areas of cognitive dysfunction following CHI are in learning, memory, and speed of information processing, all important to learning of new skills in rehabilitation set­ tings.2 Thus, patients' ability to acquire new knowledge may be greatly diminished at theprecise time that intense demands to learn are placed on them.1 CHI-related behaviors such as poor social judgment, poor frustration toler­ ance, impulsivity, emotional lability, persever­ ation, difficulty in initiating behavior, de­ creased mental stamina, fatigability, and irrita­ bility are often misperceived by staff as enduring premorbid personality traits. Neuro­ psychological testing can enhance patient and staff insight into the effects of CHI and facili­ tate treatment planning.Psychological Treatment Approaches in the Rehabilitation SettingThough the primary responsibility for psy­ chological care of the SCI patient is assigned the psychologist and social worker, other reha­ bilitation professionals on the interdisciplinary team play an important role. Sensitivity to the patients' emotional status allows for treatment planning and interaction that maximizes phys­ ical and psychological rehabilitation.Ideally, psychological rehabilitation begins in the Intensive Care Unit (ICU) soon after in­ jury. At this time, many SCI patients are intu­ bated and unable to verbally communicate. They often experience disorientation, depres­ sion and anxiety, sensory and sleep depriva­ tion, and perhaps the temporary delusional and hallucinatory state known as "ICU psychosis." This is a critical time for team members to offer emotional support, establish a communication system and determine what the patient wants to know. Some need extensive information about their injury and care in order to best cope with fears and anxiety. Others clearly want to delay knowing more about their condition. Most wel­ come reassurance that their emotional re­ sponses and concerns are normal and accepted.As the patient progresses through acute care into the rehabilitation setting, regularly sched­ uled psychotherapy sessions can facilitate the adjustment process. The psychologist can help the team understand the patient's stage of ad­ justment, and provide consultation on behav­ ioral management approaches.Emotional responses dealt with by psycho­ therapy include a range of ego defenses, most commonly repression and denial. It is impor­ tant to recognize that these defenses protect the psyche from material too traumatic to deal withconsciously, thereby preventing decompensa­ tion. In this regard, denial and repression are adaptive, and indeed may be the reason SCI pa­ tients are able to function in the stressful reha­ bilitation situation so soon post-injury. Typi­ cally, as denial decreases over time, depres­ sion, anxiety, and anger increase. How these emotions are expressed depends largely on the patient's premorbid personality style.Normal emotional responses to SCI may be manifested in behaviors which impede progress in the rehabilitation setting. For instance, de­ pression may cause psychomotor slowing, de­ creased motivation, and social withdrawal. Anxiety may create psychogenic somatic symptoms and poor concentration. Anger may result in noncompliant or destructive behavior. Psychotherapy can help via reinforcing adap­ tive coping skills and teaching new coping strategies. The psychologist may also work with the interdisciplinary team to develop be­ havioral modification programs, based on learning theory, to decrease these behaviors. Contingency management and behavioral "contracting" are most frequently used in re­ habilitation settings. Approaches emphasizing positive reinforcement to "shape" desired be­ haviors are particularly effective.10 Although such programs may be time-consuming ini­ tially, they can rapidly decrease maladaptive behavior and ultimately increase the patient's sense of control and self-esteem.Psychological treatment of SCI often in­ cludes group psychotherapy, which is an excel­ lent method to both maximize patient learning and efficiently use therapist time. Patient groups can provide emotional support, peer role models, teach new coping skills, and de­ crease social discomfort. Likewise, multiple- family group psychotherapy is a powerful and effective tool for facilitating family adjustment to S C I . 9 , 1 2 Family members experience similar emotional responses to the patient and similarly benefit from psychological intervention. If not included in the team effort, a well-meaning family member could inadvertently sabotage the independence-oriented rehabilitation ap­ proach, or be too psychologically distressed to provide the emotional or physical care the pa­ tient needs.Other issues which need to be routinely ad­ dressed by the psychologist, in conjunction with the rehabilitation team, are sexual adjust­ment, vocational rehabilitation and pain man­ agement training. Prevention of medical com­ plications, particularly those which have signif­ icant behavioral/emotional components, need to be emphasized. An example is pressure sores, which often occur when depression and/ or substance abuse lead to poor self-care.Psychological Response to Orthotic DevicesSCI patients' ability to emotionally adjust to orthotic devices (sometimes referred to as "gadget tolerance"), is related to type of orthosis, premorbid personality factors, and stage of emotional adjustment.Orthoses used to stabilize the spine after sur­ gery sometimes become the "target" of pa­ tients' emotional distress. For instance, it is easier for the patient who is denying the seri­ ousness of his SCI to blame pain and decreased function on the TLSO. Anger expressed toward an inanimate object is "safe," whereas anger directed toward family or staff may have nega­ tive repercussions. Insight into these psychody- namics can help the orthotist deal with constant requests for adjustments to orthoses, or anger responses of post-surgical SCI patients.Upper and lower limb orthoses used to in­ crease independence elicit a variety of emo­ tional responses. The potential for increased function often provides a major psychological "lift," enhancing patients' sense of compe­ tence and self-esteem. However, inclusion of psychological factors in the selection of candi­ dates for orthoses is critical. Fitting a patient who is not emotionally ready for an orthosis will result in loss of time and a failure experi­ ence for all concerned.There are numerous reasons why SCI pa­ tients may resist orthotic devices, or are unsuc­ cessful with them, including the following:Body imageMany SCI patients value the fact that they look "normal" except for the wheelchair. The magnitude of disability may be "invisible." When orthoses are introduced, patients some­ times report that people stare at them more. Their sense of "being different" and social discomfort increases. For this reason, sensi-tivity to aesthetics is important in designing orthoses for this population.Independence-Dependence ConflictsIn some patients, there are secondary gains in their dependent state, though they may not be consciously aware of this. For example, when an upper limb orthosis significantly in­ creases independence in activities of daily living, the patient may experience withdrawal of valued reinforcers (e.g. time and attention from caregivers). This can lead to rejection of the orthosis. If significant others (family and staff) are willing to provide extra attention and reinforcement for the new independence be­ haviors, these issues usually resolve well.Self-ConceptSCI patients may not integrate disability into their self-concept for some time. In one study, 130 SCI patients were interviewed about their dreams in order to examine subconscious con­ tent regarding self-perception. The authors found that 75% of these patients, injured less than one year, had never seen themselves in a wheelchair in dreams.1 1 This is one illustration of the initial need of SCI patients to maintain an underlying self-image as nondisabled. Orthoses may conflict with this self-image in more re­cently injured SCI patients.DenialOrthoses may threaten patients' denial systems. Patients not yet ready to acknowledge the extent or permanence of their disabilities frequently reject orthoses. Alternatively, they may accept temporary orthoses, but reject de­ finitive ones. Patients with self-image and de­ nial issues benefit from psychotherapy and being given more time to adjust emotionally to their disability. They should be provided with information on obtaining recommended orthoses for the future. At the other extreme, patients sometimes build denial systems based on unrealistically high hopes for orthoses. For example, a patient using lower limb orthoses for ambulation may find they are not practical for use in valued pre-injury activities. This could lead to breaking down of denial and in­ creased depression or anger, which may tempo­ rarily create decreased motivaton or rejection of the orthoses. Clear communication, empha­sizing realistic expectations before introducing orthoses, may prevent some of these responses.Premorbid PersonalityLongstanding personality attributes (such as poor frustration tolerance, risk-taking behavior, and substance abuse) and stage of adjustment (especially depression) can lead to poor self- care resulting in pressure sores or poor follow- through in any activities requiring sustained ef­ fort. Attention to psychological factors in se­ lecting candidates for orthoses is the most important factor in preventing these problems.SummarySpinal cord injury results in an over­ whelming physical and emotional adjustment process. By understanding emotional re­ sponses, and applying them in treatment plan­ ning and interaction with patients, rehabilita­ tion professionals can greatly enhance the psy­ chological adjustment of SCI patients.AuthorKatharine S. Westie, Ph.D.