The reflecting team: dialogue and meta-dialogue in clinical work

A "stuck" system, that is, a family with a problem, needs new ideas in order to broaden its perspectives and its contextual premises. In this approach, a team behind a one-way screen watches and listens to an interviewer's conversation with the family members. The interviewer, with the permission of the family, then asks the team members about their perceptions of what went on in the interview. The family and the interviewer watch and listen to the team discussion. The interviewer then asks the family to comment on what they have heard. This may happen once or several times during an interview. In this article, we will first describe the way we interview the family because the interview is the source from which the reflections flow. We will then describe and exemplify the reflecting team's manner of working and give some guidelines because the process of observation has a tendency to magnify every utterance. Two case examples will be used as illustrations.     

Critical Interaction Therapy: Couples Therapy in Combat-Related Posttraumatic Stress Disorder

There is a need for family therapy interventions that are specific to the conditions found in families of traumatized people such as combat veterans. In these families, the historically "real" event of the trauma often continues to exert influence on the family system despite collusive arrangements that serve to keep it hidden. In families of combat veterans, a situation develops whereby the veteran becomes triangulated with a dead buddy without the spouse's knowledge. The discrepancy between past and present emerges in what we call the critical interaction between the spouses. This article outlines a method of couples therapy that attempts to demystify this critical interaction, and begins to integrate the discrepant narratives of each spouse. The establishment of a nascent mutuality of perspective within the couple releases energies that can be directed toward support rather than symptom-formation in the family system.     

An Effect Of Change In Patient Status On Marital Interaction

In the treatment of couples and families, even more so than of individuals, therapists invariably are forced to face the problem of assessment of change in the marital or family "system." The purpose of the present study was to investigate changes in marital interaction for a special population, that is, in which one member of each married pair had been, but was no longer, a hospitalized psychiatric patient. The primary question we addressed was whether changes in marital interaction could be amply detected and whether these changes could be attributed to the particular role shift that had occurred in one spouse--from "patient" to "nonpatient." Utilizing a technique called Interaction Testing, which the senior authors devised in 1960, we found that such alterations in marital interaction do indeed arise when one member of the couple moves out of a patient role and that our instrument is useful in elucidating the nature of such effects. In addition, it can be expected that a study of this kind will be of theoretical and methodological value in dealing with the general issues of problem-solving interaction in couples and families. The clinical aspect of the study may also be expected to stimulate useful thinking regarding family theapy in hospital settings, patient management, and aftercare.     

Alternative strategies for creating "relational" family data

A major problem facing family clinicians and researchers is creating data that will reflect the family as a unit. To address this problem, we present a framework for family assessment based on three measurement strategies: individual family member assessment, relational family assessment, and transactional family assessment. Within this context, we present several categories of methods for combining individual family member data into "relational" scores that reflect the couple or family as a unit. The problems and benefits of each method are presented, and it is suggested that the choice of method is dependent upon the content of the assessment, the theory underlying the content, and the statistical properties of the individual family member scores.     

一个多值逻辑的一阶谓词系统

鞠实儿曾提出一个开放类三值命题逻辑系统,这一逻辑也可以推广到任意m值逻辑情形,成为一个联结词函数完全的逻辑。本文将对推广的命题逻辑系统L^＊建立一种一阶谓词系统,并证明其可靠性、完全性。     

Advancing a family perspective in health research: models and methods

In this essay we review and respond to four problems that have impeded the application of family theory to health research: the difficulty in translating family concepts to empirical health research; the confusion and uncertainty in measuring "wholes" and "parts" of a family in a single health project; the apparent conflict between circular-causal and linear perspectives in model building; and the putative, implicit "violation" of a family perspective by the employment of certain data management and design strategies. We argue that current, complex conceptualizations of the family have to be matched with equally complex research designs and methods, and that techniques are available to reach these goals. We distinguish between theoretical models and research methods, and review several strategies, design issues, and alternatives for data analysis. Throughout, we point to 1) the need to maintain consistency among theory, construct, and indicator, 2) the employment of multidimensional family assessment in health research, and 3) the use of readily available but infrequently used methods and procedures for appreciating the richness of multivariate family data.     

Families of persons with Down syndrome: new perspectives, findings, and research and service needs

To understand the families of offspring with Down syndrome, this article begins by describing the change in orientation--from "negative" to "stress-and-coping" perspectives--in studies of families of offspring with disabilities. In reviewing the existing studies, mothers, fathers, and siblings cope slightly better than family members of persons with other disabilities, a phenomenon called the "Down syndrome advantage." Beyond this more general finding, however, much remains unknown. Most studies examine only parental or sibling levels of stress or coping, leaving unknown the marital, occupational, health, educational, and other "real-world" outcomes for these family members. Increased research attention is needed to understand the life-span needs of families of persons with Down syndrome and the impact of cultural and sociocultural diversity on family outcomes. It will also be important to relate family outcomes to differences in the offspring's behaviors, development, relationships, medical conditions, psychopathology, and the presence (and effectiveness) of needed support services. Although these families have received some research attention over the past several decades, we now need to make family research in Down syndrome more concrete, more life-span, and more tied to characteristics of the individual with the syndrome and the family's surrounding support system.     

Procuring organs from a non-heart-beating cadaver: commentary on a case report

Procurement of organs from non-heart-beating cadaver donors raises concerns. Standards for optimal patient care during withdrawal of life-sustaining therapy are evolving and continue to be debated and studied. Consensus on specific procedures and methods has not been attained, however, and protocols for the procurement of organs from patients following the withdrawal of life-sustaining therapies may compromise the evolving standards and harm the patient and the attendant family. In addition, there is little evidence to suggest that such protocols will significantly increase the number of organs procured. "Non-heart-beating cadaver" protocols that do not give comprehensive attention to optimal patient/family care at the time of withdrawal of life-sustaining therapy ought not to be endorsed.     

Experiential Family Therapy: An Innovative Approach to the Resolution of Family Conflict in Genetic Counseling

Experiential family therapy is an intuitive approach that utilizes active, multisensory techniques. These techniques, such as role plays and drawings, increase the family's expression of affect and uncover new information. Increased affect and uncovered information stimulate change and growth in the family system. Experiential techniques are especially useful when more traditional, verbal-based communication is not effective. In this article, I will present a pediatric case in which the patient, a 7-year-old boy diagnosed with autism, was referred to the genetics clinic to rule out the presence of an associated genetic disorder. I will then describe a hypothetical second counseling session with the same family and suggest how three experiential family therapy techniques: family drawing, empty chair technique, and continuums might be used in the session to help resolve a marital conflict between the patient's parents.     

Family assessment: developing a formal assessment system in clinical practice

In a previous paper, we reviewed the literature on family assessment and set out some principles that can be derived from previous work. This paper describes the development of a system for family assessment which uses these principles and then gives a brief account of the practical difficulties encountered in applying such a system. (Empirical data on the system will be presented in subsequent papers as they become available.)     

Patient classification in neuropsychological research

In a number of papers we have been concerned with the type of inferences that are legitimate in "experiments of nature" where the experimenter does not and cannot control the modifications to the cognitive system that are introduced by brain damage. We have argued that in such cases very restrictive conditions must be met in order to be able to draw valid inferences about the structure of normal cognitive mechanisms. Two consequences of these conditions are (1) patient classification into syndrome types (e.g., phonological dysgraphia, agrammatism, and so forth) can play no useful role in research concerned with issues about the structure of normal cognitive functioning or its dissolution under conditions of brain damage; and (2) only single-patient studies allow valid inferences about the structure of cognitive mechanisms from the analysis of impaired performance. Zurif, Gardner, and Brownell (1989, Brain and Cognition, 10, 237-255) have taken exception to our conclusions and propose to show the limitations of our arguments. In this paper we respond to their criticisms.     

Anorexia Nervosa: The Hospital's Role in Family Treatment

When an anorexia nervosa patient requires hospitalization for her ¹ 1 We will use the pronoun “her” to refer to anorexic patients since the overwhelming majority are female. Our discussion will focus mainly on younger adolescent girls who are still living with their families.
medical condition, the treatment team faces the problem of integrating the individual focus of inpatient care with the systems focus of family therapy. In this paper we propose a family-systems model of hospitalization, the aim of which is to facilitate such integration. The model draws on current theories of anorexia nervosa, as well as general concepts from psychodynamic, developmental, and family systems theories. The major hypothesis of the model is that all members of the anorexic family are developmentally arrested in the area of separation-individuation. On this assumption, we propose that the entire treatment team (including medical professionals and therapists) needs to function as “parents” to the anorexic family in much the same way that two cotherapists become parental figures in family therapy. Specifically, the team needs to provide those parenting responses that facilitate the family's individuation process.     

Decision making and free will: a neuroscience perspective

A thorough analysis of the question of whether we possess "free will" requires that we take into account the process of exercising that will: that is, the neural mechanisms of decision making. Much of what we know about these mechanisms indicates that decision making is greatly influenced by implicit processes that may not even reach consciousness. Moreover, there exist conditions, for example certain types of brain injury or drug addiction, in which an individual can be said to have a disorder of the will. Examples such as these demonstrate that the idea of freedom of will on which our legal system is based is not supported by the neuroscience of decision making. Using the criminal law as an example, we discuss how new discoveries in neuroscience can serve as a tool for reprioritizing our society's legal intuitions in a way that leads us to a more effective and humane system.     

The Salvational Process in Relationships: A View from Projective–Introjective Identification and Repetition Compulsion

On the basis of mechanisms such as projective–introjective identification, basic affect, affect regulation, and repetition compulsion, we shall try to explain the essence of intrapsychic, interpersonal, and relational family dynamics. We will also try to explain how relational connections mutually intertwine in the family system, what sustains them, and why they are created and recreated again and again. It is in this regard that we will also be able to consider the essential salvational process, which occurs precisely on the basis of these mechanisms, that is, those that represent fundamental purification and salvation. Some basic biblical theological concepts are applied. These provide the basis for integrating the psychological and theological domains of family systems.     

"Enmeshment" and the Too Richly Cross-Joined System

This paper traces out a connection between Minuchin's concept of an "enmeshed" family and Ashby's discussion of the problems inherent in a system in which all the parts are tightly interlocked. Adaptiveness to change in such a system will depend on the possibility for the joins between parts to become temporarily inactive. This observation supports maneuvers in family therapy that emphasize the creation of boundaries between subsystems, differentiating individuals from one another, and blocking customary sequences of interaction.     

Rational-emotive therapy applied to relationship therapy

RET is a comprehensive mode of relationship therapy that takes a double-barreled psychotherapeutic approach of helping all the partners in a relationship to accept responsibility for their own disturbances and failings and to work at correcting these-while, at the same time, helping them to understand and work actively at changing the marital or family system in which they are relating and the conditions in this system that are contributing to their practical and emotional problems. Rational-emotive relationship therapy is a form of cognitive behavior therapy that includes the following features: (1) It importantly stresses the cognitive or philosophic causes of emotional disturbance and of family disruption. (2) It teaches partners that they largely disturb themselves and that they can effectively refuse to continue to do so. (3) It almost always employs a number of cognitive, emotive, and behavioral techniques but employs them not merely to achieve symptomatic change but to help couples achieve a profound philosophic reconstruction that will, hopefully, lead to elegant and permanent change. It clearly acknowledges the biological as well as the sociological bases of disturbance, and therefore stresses vigorous and forceful, active-directive methods that will impinge upon and help alter the strongly held disturbances that partners frequently experience. (5) It holds to a rigorously scientific and yet highly humanistic outlook in both its theory and its practice. (6) It stresses a phenomenological, intraindividual, and depth-centered approach to understanding and tackling human disturbance, but at the same time uses practical problem-solving and skill-straining methods of changing family situations and interactions.     

Should the "slow code" be resuscitated?

Most bioethicists and professional medical societies condemn the practice of "slow codes." The American College of Physicians ethics manual states, "Because it is deceptive, physicians or nurses should not perform half-hearted resuscitation efforts ('slow codes')." A leading textbook calls slow codes "dishonest, crass dissimulation, and unethical." A medical sociologist describes them as "deplorable, dishonest and inconsistent with established ethical principles." Nevertheless, we believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely to be ineffective, the family decision makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order. In such cases, we argue, physicians may best serve both the patient and the family by having a carefully ambiguous discussion about end-of-life options and then providing resuscitation efforts that are less vigorous or prolonged than usual.     

Evidencing superdiversity in the census and beyond

Abstract

Starting from the proposition, in both my own work and that of Steve Vertovec, that there is something about superdiverse neighbourhoods or societies that is qualitatively different from those that are merely diverse, this paper asks whether it is possible to identify religious superdiversity within quantitative population data, such as the census in England and Wales, in order to test such a proposition. In doing this the paper will ask whether it is possible to find any evidence for superdiversity, as Vertovec defines it, in data sets such as the census and whether such data can help to identify where to set the boundary between ‘diversity’ and ‘superdiversity’. The paper will then explore what would need to be measured in order to designate an area as superdiverse in religious terms and whether the census data can offer any material that can be used for this purpose. The author concludes by suggesting that we need a range of methods, both quantitative and qualitative, to define any area as superdiverse and that it is only in this way that we can begin to test the kind of hypothesis offered by the author at the start of the paper.     

Supererogation and Intentions of the Agent

It has been claimed, by David Heyd, that in order for an act to count as supererogatory the agent performing the act must possess altruistic intentions (1982 p.115). This requirement, Heyd claims, allows us to make sense of the meritorious nature of acts of supererogation. In this paper I will investigate whether there is good reason to accept that this requirement is a necessary condition of supererogation. I will argue that such a reason can be found in cases where two people act in the same way but with only the person who acted with altruistic intent counting as having performed an act of supererogation. In such cases Heyd’s intention requirement plays an important role in ruling out acts that intuitively are not supererogatory. Despite this, I will argue that we should reject Heyd’s requirement and replace it with a moral intention requirement. I will then investigate how to formulate this requirement and respond to two objections that might be raised against it.