Is This Relevant? Physician Perceptions,Clinical Relevance,and Religious Content in Clinical Interactions

Despite wide support among physicians for practicing patient‐centered care, clinical interactions are primarily driven by physicians’ perception of relevance. While some will perceive a connection between religion and patient health, this relevance will be less apparent for others. I argue that physician responses when religious/spiritual topics come up during clinical interactions will depend on their own religious/spiritual background. The more central religion is for the physician, the greater his or her perception of religion's impact on health outcomes and his or her inclusion of religion/spirituality within clinical interactions. Using a nationally representative sample of physicians in the United States and mediated path models, I estimate models for five different physician actions to evaluate these relationships. I find that a physician's religious background is strongly associated with whether or not he or she thinks religion impacts health outcomes, which is strongly predictive of inclusion. I also find that not all of the association between inclusion and physicians’ religious background is mediated by thinking religion impacts health outcomes. Issues of religion's relevance for medicine are important to the degree that religious beliefs are an important dimension of patients’ lives.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Doctors,Patients, and Nudging in the Clinical Context—Four Views on Nudging and Informed Consent

In an analysis of recent work on nudging we distinguish three positions on the relationship between nudging founded in libertarian paternalism and the protection of personal autonomy through informed consent. We argue that all three positions fail to provide adequate protection of personal autonomy in the clinical context. Acknowledging that nudging may be beneficial, we suggest a fourth position according to which nudging and informed consent are valuable in different domains of interaction.     

Relationship Between Posturography,Clinical Balance and Executive Function in Parkinson´s Disease

This study aimed to evaluate the relationship between posturography, clinical balance, and executive function tests in Parkinson´s disease (PD). Seventy-one people participated in the study. Static posturography evaluated the center of pressure fluctuations in quiet standing and dynamic posturography assessed sit-to-stand, tandem walk, and step over an obstacle. Functional balance was evaluated by Berg Balance Scale, MiniBESTest, and Timed Up and Go test. Executive function was assessed by Trail Making Test (TMT) and semantic verbal fluency test. Step over obstacle measures (percentage of body weight transfer and movement time) were moderately correlated to Timed Up and Go, part B of TMT and semantic verbal fluency (r > 0.40; p < 0.05 in all relationships). Stepping over an obstacle assesses the responses to internal perturbations. Participants with shorter movement times and higher percentage of body weight transfer (higher lift up index) on this task were also faster in Timed Up and Go, part B of TMT, and semantic verbal fluency. All these tasks require executive function (problem solving, sequencing, shifting attention), which is affected by PD and contribute to postural assessment.     

A Review of “Risk Management: Clinical,Ethical, & Legal Guidelines for Successful Practice”

Abstract

Between Mothers-In-Law and Daughters-In-Law: Achieving a Successful and Caring Relationship, by Helene S. Arnstein. New York: Dodd, Mead&;Company, 1985, 225 pages, $8.95 paperback

When Living Hurts: Directives for Treating Depression, by Michael D. Yapko. New York: Brunner/Mazel, 1988, 217 pages, $22.50

The Illustrated Manual of Sex Therapy, 2nd ed., by Helen Singer Kaplan. New York: Brunner/Mazel, 1987, 181 pages, $22.50

Reforming the Law: Impact of Child Development Research, edited by Gary B. Melton New York: The Guilford Press, 1987, 307 pages, $30.00.

Doing Things: A Guide to Programming Activities for Persons with Alzheimer's Disease and Related Disorders, by Jitka M. Zgola. Baltimore: The Johns Hopkins University Press, 1987, 149 pages, $20.00 hardcover, $8.95 paperback

Domestic Revolutions: A Social History of American Family Life, edited by Steven Mintz and Susan Kellogg. New York: The Free Press, 1987, 244 pages, $22.50

Handbook of Measurements for Marriage and Family Therapy, by Norman Fredman&;Robert Sherman. New York: Brunner/Mazel, 1987, 218 pages, $27.50     

Does Depression Affect Clinical Practice?

Abstract

While recent autobiographical accounts of women psychotherapists with depressive illnesses have provided vivid and compelling portraits of therapists' experiences in therapy (e.g., Jamison, 1995; Manning, 1995), further research is needed to clarify the impact that depression and its treatment have upon both collegial relationships and clinical practice. A subset of the membership of the Association for Women in Psychology (AWP) was surveyed concerning therapists' experiences with depression and its treatment. Of 220 respondents, 76% reported some form of depressive illness. Eighty-five percent of respondents indicated that they participated in personal therapy. When evaluating their clinical work, respondents reported both positive and negative consequences resulting from their depression. While some respondents noted improvement in collegial relationships, many felt judged and avoided.     

Clinical psychology—Art or science

This paper questions the oft-repeated statement that clinical psychology is an art by examining the main functions of clinical psychologists, i.e., diagnosis and treatment. In examining the concept of diagnosis, evidence is presented which supports the notion that a diagnostic statement has meaning only when it has a referent in the future—when it provides a prediction. A prediction (probability-statement) is determined empirically and may be stated in terms of a regression equation or in terms of a crude generalization from clinical experience. Treatment likewise is determined by tacit or expressed predictions of behavior under alternative conditions. The various conceptions of art as applied to clinical psychology are examined and the conclusion is drawn that clinical psychology is a scientific as opposed to an artistic or intuitive enterprise.Paper read at the 49th annual meeting of the American Psychological Association at Evanston, Illinois, September 3–6, 1941.This analysis may be applied with little modification to the fields of social work, psychiatry, vocational guidance, and related professions.     

The “Activist Client”: Social Responsibility,the Political Self,and Clinical Practice in Psychotherapy and Psychoanalysis

The idea of the “activist client” is intended to be taken both literally and metaphorically—applying to some extent to a wider range of clients than actual activists. The paper develops a set of ideas about a “political turn” in psychotherapy and psychoanalysis, using the tag “the inner politician.” There is a focus on working directly with political material in the session, and the pros and cos of this practice are reviewed. Wider issues such as social responsibility and social spirituality are discussed, as well as an exploration of the limits of individual responsibility. Some specific topics covered in the paper include the political roots of depression, difficulties with the concept of the therapeutic alliance from the point of view of democratic perspectives on clinical work, and a challenge to the unquestioned valuing of empathy (based on a reading of therapy though a Brechtian lens). There are numerous clinical examples.     

Clinical notes: Masking devices and The Edinburgh Masker—Clinical applications within a prison setting

This paper outlines portions of the writer's therapeutics in the field of stuttering with emphasis upon use of masking the hearing of stutterers as a part of a total therapeutic approach. Commencing with devices providing continuous noise to override the voice of the stutterer so that he cannot hear himself and, thus, eliciting fluency. Described is the use of the voice actuated Edinburgh Auditory Masker within an intensive stuttering program in a prison setting since September 1978. It is concluded that the use of masking and the Edinburgh device has been helpful and productive with severe stutterers.     

The MMPI–2 Restructured Clinical (RC) Scales and Redundancy: Response to Tellegen,Ben-Porath,and Sellbom

In this article, we examine 5 criticisms of Tellegen, Ben-Porath, and Sellbom (2009/this issue) about our study demonstrating the redundant relationships of the Restructured Clinical (RC) scales with extant MMPI–2 scales. We discuss differences in univariate versus multivariate comparisons of the RC scales and our “proxy” scales using their data. We show that (a) both the RC and extant proxy scales identified in our analyses account for most of the variance in the Clinical scales; (b) the proxy scales are redundant with the RC scales; (c) the proxy scales matched the 6 RC scales in accounting for variance in the Clinical scales exactly in three cases, differed by ≤.02 in 2 cases, and reached a maximum of .11 in one case; (d) the item overlap between RC1 and HEA is not at issue but rather their correlation with Scale 1; and (e) the evidence for the construct validity of the RC scales is weak using findings on the incremental validity of RC4 as illustrative.     

Clinical Ethics: Theory Or Practice?

This article starts with a brief historical account of the ongoing debate about the status of clinical ethics: theory of practice. The author goes on to argue that clinical ethics is best understood as a practice. However, its practicality should not be measured by the extent to which clinical-ethical consultants manage to mediate or negotiate resolutions to ethical conflicts. Rather, clinical ethics is practical because it is characterized by a profound concern for the well-being of individual patients as well as the moral parameters of swift and urgent medical action in the face of limited supportive information.     

How Robust is the Influence of Causal Explanation on Clinical Judgments? Assessments in Structured Clinical Interviews

When causal life-event explanations for disorder symptoms are available, clinicians tend to explain away those symptoms (Ahn, Novick, &; Kim, 2003 Ahn, W., Novick, L. R., &; Kim, N. S. (2003). Understanding behavior makes it normal. Psychonomic Bulletin Review, 10(3), 746–752. doi:10.3758/BF03196541[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]; Meehl, 1973 Meehl, P. E. (1973). Why I do not attend case conferences. In P. Meehl (Ed.), Psychodiagnosis: Selected papers (pp. 225–302). Minneapolis, MN: University of Minnesota Press. [Google Scholar]), eschewing formal diagnostic guidelines such as the DSM-5 (American Psychiatric Association, 2013 American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.[Crossref] , [Google Scholar]). We asked whether this effect is attenuated in the context of a structured diagnostic clinical interview procedure, which deliberately directs evaluators' attention to symptoms alone, or whether it is robust enough to continue to emerge. Across two experiments, lay evaluators given causal life-event explanations for disordered behaviors gave them lower judgments of abnormality and need for treatment compared to evaluators not given such explanations, regardless of whether they used a structured clinical interview. Thus, causal life-event explanations may have significant impact on clinical evaluations regardless of the mode of assessment. Implications for the clinical utility of structured interviews and the role of life-event context in diagnosis and classification are discussed.     

What Kind of Doing is Clinical Ethics?

This paper discusses the importance of Richard M. Zaner’s work on clinical ethics for answering the question: what kind of doing is ethics consultation? The paper argues first, that four common approaches to clinical ethics – applied ethics, casuistry, principlism, and conflict resolution – cannot adequately address the nature of the activity that makes up clinical ethics; second, that understanding the practical character of clinical ethics is critically important for the field; and third, that the practice of clinical ethics is bound up with the normative commitments of medicine as a therapeutic enterprise.     

The Environment of Ferenczi’s Clinical Diary

The author evokes the tragic death of Ferenczi’s colleague and analysand Dr. Elisabeth Radó-Révész in 1923. She died of pernicious anemia, the same illness that ended the life of Ferenczi 10 years later, at age 59. Can this be a tragic coincidence? Following notes in Ferenczi’s Clinical Diary, the author considers the deep disappointments both Ferenczi and Radó-Révész had experienced and explores some of the Tragic Man qualities of Ferenczi.     

Clinical Utility of the MMPI–2 Restructured Clinical (RC) Scales in Therapeutic Assessment: A Case Study

Summary: In a recent paper, Haan and Livson reported sex differences between male and female psychologists in their evaluations of adult men and adult women. Their conclusions have implication for the validity of clinical, assessments and were interpreted in terms of stereotypic sex rote perceptions. However, their statistical analysis was in fundamental error. When the data they employed were reanalyzed, no reliable sex differences between men and women psychologists were found, a finding in accord with a number of previous investigations of this problem.     

Gender Policing in the Clinical Setting: Discussion of Sandra Silverman’s “The Colonized Mind: Gender,Trauma, and Mentalization”

This is a discussion of Sandra Silverman’s clinical paper “The Colonized Mind: Gender, Trauma, and Mentalization.” Her patient, David née Ava, started early in life as a gender variant child. In adolescence, she became more stereotypically gender conforming. She entered treatment with Silverman as a young adult who was feeling great shame about both her past and present gender dysphoria. This discussion focuses on the clinical problem of gender policing, its external and internal manifestations as well as its appearance in the countertransference.     

Review of “Clinical Psychology and Psychotherapy as a Science: An Iconoclastic Perspective,” by Luciano L'Abate

Abstract

adult children of divorce speak out, by claire berman. new york: simon&;schuster, 1991, 285 pages, $18.95

adolescents and their families: paths of ego development, by stuart t. hauser with sally i. powers and gil g. noam, new york: free press, 1991, 318 pages, $29.95

alcohol and the addictive brain: new hope for alcoholics from biogenetic research, by kenneth blum, in collaboration with james e. payne. new york: free press, 1991, 320 pages, $24.95     

Richard Zaner’s Phenomenology of the Clinical Encounter

The clinical ethics propounded by Richard Zaner is unique. Partly because of his phenomenological orientation and partly because of his own daily practice as a clinical ethicist in a large university hospital, Zaner focuses on the particular concrete situations in which patients and their families confront illness and injury and struggle toward workable ways for dealing with them. He locates ethical reality in the clinical encounter. This encounter encompasses not only patient and physician but also the patients family and friends and indeed the entire lifeworld in which the patient is still striving to live. In order to illuminate the central moral constituents of such human predicaments, Zaner discusses the often-overlooked features of disruption and crisis, the changed self, the patients dependence and the physicians power, the violation of personal boundaries and their necessary reconfiguring, and the art of listening.     

Promoting the Scientist–practitioner Mindset in Clinical Training

While the scientist–practitioner model of training has enjoyed wide-spread appeal, difficulties in implementing the model have continued since its inception. Despite these difficulties, we remain advocates of the model and believe responsibility for inculcating a scientist–practitioner mindset rests with both training programs and trainees themselves. Thus, we offer several suggestions for both trainees and training programs in hopes of perpetuating the scientist–practitioner ideal.