Transitioning from a hospital rehabilitation programme to home: exploring the experiences of people with complex regional pain syndrome

Complex regional pain syndrome (CRPS) is difficult to diagnose and is characterised by burning pain in one or more limbs. Treatment is palliative not curative and focuses on improving function. This requires patients to make long-term changes to their behaviour. As with all such regimens, adherence is often poor. This study explored the lived experience of 10 patients who had returned home after completing a two-week in-patient treatment programme. The interviews focused on how they coped with the transition from hospital to home, and on the things that they considered had facilitated or hindered this transition. Battling for control was an overarching theme that connected the four superordinate themes: 'gaining momentum' that facilitated the implementation of treatment advice, 'distance from the pool of expertise' that detailed the barriers to adherence experienced; 'It helped me realise it was not all in my head' that detailed a facilitative process, and the 'nag list' that was a technique patients' used to garner support. This article offers insights into the transition experience. A key outcome is the recognition of the need to better prepare patients for their transition back home.     

Assembling the sense of home in emigrant elite athletes: Cultural transitions,narrative and materiality

ObjectiveDespite a growing body of literature on cultural transitions, little is known regarding how emigrant elite athletes experience and intra-act with the non-human environment in the host country, and how this affects their sense of home. This study explores the relationships between the material world and the embodied narratives, both personal and socio-cultural, regarding the process of assembling a new sense of home.Design and MethodsSeven Colombian emigrant elite athletes (4 female and 3 male), that emigrated pursuing the Olympic Dream, participated in this study. The philosophical concept of assemblage, from New Materialism approach, was used as a companion and extension of narrative dialogical analysis to analyse life-story interviews.ResultsEmigrant athletes define home as a place of refuge where they can express emotions, behave, and communicate in ways that ‘feel natural’. During cultural transitions, these athletes assembled a sense of home in two environments: the housing and the sport facilities. The relationships with (a) architectural spaces, (b) objects, (c) food, (d) technological apparels and (d) sport materiality facilitated or hindered the process of assembling a new sense of home in the host country.ConclusionsThe transformation of housing and the sport facilities into Home is a crucial process to improve the quality of emigrant athlete’s cultural transition. A deeper appreciation of materiality in research and applied practice is needed.     

Ferenczi and Freud – From psychoanalysis as a “professional and personal home” to the creation of a “psychoanalytic home” for the patient1

Abstract

The author explores the relationship between Sándor Ferenczi and Sigmund Freud in the light of their correspondence. This allows us to see how Freud was able to offer and create for Ferenczi a “professional and personal home” that enabled the latter to find a much more meaningful and creative contact with himself. According to the author, this experience played an important role in Ferenczi’s later readiness to offer to and create with his patients a similar “psychoanalytic home.” As Freud was not able to share such clinical research work with Ferenczi, a conflict developed between them whose nature has occupied psychoanalysts ever since, and whose seeds can be found in the 1246 letters that they exchanged between January 1908 and May 1933. From this point of view, Ferenczi’s Clinical diary (written in 1932 and published only in 1985) can be seen as the continuation of the dialogue they had entertained for so many years, as well as Ferenczi’s attempt not to give up the “professional and personal home” that they had created together.     

‘Damned one way or another’: Bariatric surgeons’ reflections on patients’ suboptimal outcomes from weight loss surgery

Objective: A minority of patients show sub-optimal outcomes after weight loss surgery. Research has identified predictors of poor outcomes focusing on the patients’ perspective. No research has explored surgeons’ accounts. Design: Ten Bariatric surgeons were interviewed using a critical incident approach to explore their explanations for sub-optimal outcomes in the context of a real-life case. Data were analysed using thematic analysis. Results: Three main themes were developed: ‘Challenges to success’ highlighting the role of psychosocial issues, poor adherence and patient non-disclosure; ‘Ideal world solutions’ describing who should identify and address psychosocial issues; and ‘Real world compromise’ reflecting the impact of limited resources and weighing up risk between carrying out versus not carrying out surgery. Transcending these themes was the notion of ‘responsibility’ with surgeons balancing the role of the patient, themselves and the health care system. Conclusion: Some surgeons concluded that if they had known before surgery what they know now, they may not have operated. All emphasised that they could only know what was disclosed by the patient, that they were not convinced that not operating would have resulted in better outcomes in the longer term and many felt that they were ‘damned one way or the other’.     

The Hepatitis C treatment experience: Patients’ perceptions of the facilitators of and barriers to uptake,adherence and completion

Objective: This study explores the perceptions of patients receiving treatment for Hepatitis C to determine what factors influence their decision to commence treatment, ability to maintain adherence and complete their treatment program.

Design: Semi-structured interview techniques were used in a qualitative study of 20 patients undergoing treatment for Chronic Hepatitis C (CHC).

Main outcome measures: To explore patients’ perceived barriers and facilitators of Hepatitis C treatment adherence and completion.

Results: Analysis of patient interviews identified four key themes: (1) motivations for commencing CHC treatment – fear of death and ridding themselves of stigma and shame; (2) the influential role of provider communication – patients reported that information and feedback that was personalised to their needs and lifestyles was the most effective for improving adherence to treatment; (3) facilitators of treatment adherence and completion – social, emotional and practical support improved adherence and completion, as did temporarily ceasing employment; (4) barriers to treatment adherence and completion – these included side effects, stigma, a complicated dosing schedule and limitations of the public healthcare system.

Conclusion: To increase treatment adherence and completion rates, a patient-centred approach is required that addresses patients’ social, practical, and emotional support needs and adaptive coping strategies.     

Resilience,religiosity and treatment adherence in hemodialysis patients: a prospective study

Resilience and religiosity have received attention as an important process in the experience and management of chronic comorbidities; however, there is no study evaluating resilience in hemodialysis patients and its association with other psychological dimensions or with treatment adherence. This observational prospective study assessed resilience (25 item Wagnild and Young Resilience Scale), religiosity under three dimensions (organizational, non-organizational and intrinsic) using DUREL scale, depressive symptoms (Patient Health Questionnaire-9) and health-related quality of life (Short Form-36 questionnaire). The main outcomes were medication adherence using the Morisky Medication Adherence Scale-8 (MMAR-8) and the missing/shortened dialysis sessions in the following six months. Of 208 patients approached, 202 (97.1%) agreed to participate. One hundred twenty-three patients (60.9%) were males and mean age was 52.8 ± 14.8 years-old. The median time on hemodialysis was 36 months (IQR, 12, 84). 82 (40.6%) patients obtained a MMAS-8 score <6 and were considered as having ‘poor adherence’. Overall, the mean score of medication adherence was low (5.7 ± 2.1). About adherence to hemodialysis sessions, patients missed a total of 234 (1.6%) hemodialysis sessions. Forty-eight patients (23.7%) missed an average of at least three sessions in six months. Regarding adherence to medication, there was no association in the uni- or multivariate analysis between religiosity dimensions and MMAS-8 score. After adjustment, resilience was positively associated with MMAS-8 score (standardized β coefficient .239, p = .016). Organized and intrinsic religiosity were associated with adherence to dialysis sessions (standardized β coefficient .258, p = .004 and .231, p = .026, respectively). Interestingly, opposite to medication adherence, more resilient patients were associated with less adherence to hemodialysis sessions (standardized β coefficient ?.296, p = .001). Religiosity was associated with dialysis adherence but not with medication adherence. Resilience was associated with higher medication adherence but lower adherence to dialysis sessions.     

The relative importance of patients’ decisional control preferences and experiences

Objective: Patients’ role in treatment decision-making can influence psychosocial and health-related outcomes (i.e. satisfaction, felt respect, adherence). We examined decisional control in a surgical context, identifying correlates of patients’ preferences and experiences.

Design: 380 patients and 7 surgeons were surveyed during initial surgical consultation visits in a low-income outpatient clinic.

Measures: Patients reported preferences for (pre-consultation) and experiences of (post-consultation) decisional control, demographics, satisfaction with care, and adherence to treatment recommendations. Surgeons rated patients’ health status.

Results: Preferences for and experiences of decisional control were unrelated, suggesting significant preference–experience misalignment. However, this misalignment did not appear to be consequential for patient outcomes. Rather, more decisional control, regardless of patients’ preferences, predicted greater satisfaction with care and greater self-reported adherence as assessed at a post-surgical appointment.

Conclusions: Decisional control predicts better outcomes for patients, regardless of their preferences for control over treatment decisions. These findings suggest that interventions should aim to increase patients’ degree of decisional control when feasible and appropriate.     

On psychic elements in a case of autistoid perversion

The paper explores the formation of psychic elements from an epistemological point of view, drawing on the work of Bion to examine a clinical case of autistoid perversion. Distinguishing the qualification of psychic elements from the realization of pre‐conceptions, the paper argues that psychical elements are constituted through a mutually shared experience of presence, and so they should be understood in a paradoxical way – through being‐O and transformations into K. These ideas are explored via a clinical case concerning a patient with an autistoid–perverse organization. The patient had been denied any bodily contact with her parents during her first year of life due to an infection; in later life she exhibited an autistoid coprophilic perversion. During the course of her treatment, as it became possible to break down the autistoid organization, the nameless contents surfaced in a mutually shared experience of presence. The analyst was able to hold on to their meaning, which was unavailable to the patient. The absent analyst, however, turned into the mother who ‘put the child down’ and was experienced by the patient as a suicidal threat. In being‐O, the analyst was able to endure the paradox of being the one who ‘put her down’ in order not to put her down; the paradox of being‐O functioned as a container for the destructive objectal dimension of the state of ‘being put down’.     

Consensus and Power in Deliberative Democracy

On Certainty can be understood in the light both of criticism of the Tractatus's implication that judgments need the mediation of present experience to apply to the world, and of the Investigations’ remark that the primitive response to the world is not an intuition but an action. Suppose a ‘system of judgments’ is a system of practices (in which judgments are somehow immanent) and the ‘judgments’ in which there is ‘agreement’ are fundamental to the very sense of what we say. To say they were open to the question: True or false? would be to call in question the truth of an entire cultural Weltbild and give ‘truth’ a metaphysical emphasis of which it is not susceptible.     

Why is Ethics First Philosophy? Levinas in Phenomenological Context

This paper explores, from a phenomenological perspective, the conditions necessary for the possession of intentional content, i.e., for being intentionally directed toward the world. It argues that Levinas's concept of ethics as first philosophy makes an important contribution to this task. Intentional directedness, as understood here, is normatively structured. Levinas's ‘ethics’ can be understood as a phenomenological account of how our experience of the other subject as another subject takes place in the recognition of the normative force of a command. This supplies a condition that—as the paper shows by examining Husserl and Sartre on how our experience of the Other constitutes an ‘objective’ world—earlier phenomenologists have misunderstood, because they have treated ethical experience as ‘founded’ on a prior theory of representation (‘ontology’ in Levinas's language). Ethics is first philosophy because it is only by acknowledging the command in the ‘face’ of the Other that we can account for the sensitivity to the normative distinctions that structure intentional content. Throughout, the paper shows how Levinas's analyses, in Totality and Infinity, draw upon and develop the analyses of Husserl and Sartre.     

‘The lesser of two evils…’ – views of persons with rheumatoid arthritis on medication adherence: a qualitative study

Objective: This study aimed to explore medication adherence among adherent and non-adherent persons suffering from rheumatoid arthritis (RA). A special focus was put on the reasons accounting for successful medication adherence and on potential barriers or facilitating factors.

Design: A qualitative study with semi-structured interviews was conducted. Eighteen participants were recruited through stratified purposive sampling according to their medication adherence level. Interviews were analysed by interpretative phenomenological analysis.

Results: Medication adherence behaviour was described on a continuum ranging from non-adherent to adherent. Participants’ current adherence level was represented as a result of inner negotiations between a variety of influential factors and the successful application of a range of strategies. The influential factors were: experiences with medication, outcome expectations, knowledge of therapeutic options, the traits ‘openness’ and ‘conscientiousness’, belief in medical progress, characteristics of the medication, level of trust in one’s physician, and perceived autonomy. Facilitating strategies were: establishing routines, using social support and the deliberate suppression of information about potential adverse events.

Conclusion: The experience of and the reasons for medication (non-)adherence from the perspective of people with RA were explored comprehensively. Participants’ ongoing negotiations between adherence and non-adherence emerged as a key finding with implications for health service providers.     

Love,passion, and peak experience: A qualitative study on six continents

Abstract

Qualitative inquiry promotes deeper understanding of human experiences that can be reduced and decontextualized when examined solely via quantitative methods. In this study, we interviewed 150 people in 22 countries on six continents, asking them, ‘What do you love?’, ‘What is a great passion in your life?’, and ‘What has been a peak experience in your life?’. Love, passion, and peak experience share definitional and theoretical overlaps. However, they have not been explored simultaneously across cultures using qualitative methods. We utilized a pragmatic, inductive, thematic methodology, and 11 key themes emerged from the data. Other people and learning and growing were the top two themes for all three constructs, and data patterns suggested more variation within than between continents. We suggest that love, passion, and peak experience may promote self-determination and/or psychological complexity via integration with and differentiation from the environment, and suggest directions for future research.     

Hidden feelings 1945-95

Abstract

It was a fact learnt early in life: wherever I travelled in Europe as a teenager, it paid me to explain that I was Dutch, not German. And when I left home at 18, in search of the elusive key to good faith and freedom, and came to Britain, crossing the Channel to reach the sole part of Europe untouched by enemy invasion, I felt I was welcomed like a lost daughter; many people told me of the part they played in the liberation of Holland in 1945. And now, fifty years after the historic events of the Second World War have passed, I still like to invoke the ‘magic’ if I can. While staying in a bed and breakfast in Coventry recently, I pointed out to the landlady that a morning call, as written down by the German guest, was requested at 7.15, instead of, as she had read, at 9.15. ‘Oh’, she said, annoyed, realizing the mistake: ‘Do they cross their number seven? We never do’. I was instantly eager to clear my name: ‘The Dutch never do so either’     

Counselling young people: Counsellors' perspectives on ‘what works’ – An exploratory study

Aim: Counsellors who work with young people in a range of contexts know that they are not engaging with ‘mini‐adults’. The issues young people bring to counselling are often complex, challenging and wide‐ranging, as adolescents are experiencing times of turbulence and change in their physical, emotional, social and psychological development. This paper focuses on a research project undertaken with five counsellors who work with young people, and asks the question: ‘What works?’ Method: The research project is an in‐depth qualitative study into the counsellor's experience of counselling young people, using a narrative approach. Findings: Four key shared themes emerged: the significance of ‘safety’ in the relationship; building the therapeutic alliance; flexibility and integration relating to theoretical orientation; and the use of creativity. Outcomes: This paper offers counsellors the opportunity to reflect on ‘what works’ and consider the professional knowledge, which underpins their own counselling practice with young people.     

Spinoza and mental health

With the proviso that Spinoza's concerns were philosophical, not medical, we examine the Ethics with a view to bringing out those aspects of it which are of import for mental health. We find that the Ethics surrounds the idea that man can be egoless in the Buddhist sense of that term. This concept provides a criterion of mental health. Further, according to Spinoza's theory of the Affections, those which are passive include some which are based on pain. These he ‘enumerates among the diseases’. And for them he provides, in Part V, specific ‘remedies’. This in turn leads him to equate ‘Mental Freedom or beatitude’ with a ‘healthy Mind’. We thus have in Part V additional possible criteria of mental health. Finally, there is the suggestion that philosophy for Spinoza was a kind of therapy.’

There is not a philosophical method, though there are indeed methods, like different therapies. — The philosopher's treatment of a question is like the treatment of an illness. — A main cause of philosophical disease — a onesided diet . . .

Wittgenstein

This doctrine of knowledge first and action later is not a minor disease . . . My present advocacy of the unity of knowledge and action is precisely the medicine for that disease.

Wang Yang‐ming

When asked by two disciples which of the views of each was correct, Wang replied: both are. Which is used depends on the kind of person you are trying to help. Some persons need this one, others that.     

Towards emotional containment for staff and patients: developing a Work Discussion group for play specialists in a paediatric ward

This paper describes the evolution of a staff Work Discussion group run by a child psychotherapist in a teaching hospital for more than 15 years. It offers insight into the emotional experience of both NHS staff and patients as seen through the lens of the discussion of the staff’s work. The author identifies three main stages in the evolution of this group, as trust and the feeling of a safe space gradually developed. The first stage was identifying and understanding the emotional experience of patients, through the use of observational skills and psychoanalytic concepts; the second emerged as staff began to include their own emotional experience in the narrative; the last stage saw a qualitative shift in the staff’s capacity to share the pain generated by the work, knowing about it through holding it in the group’s mind and being able to reflect on it, allowing them to process experience in a way that made the work more bearable – akin to Bion’s concept of ‘containment’. This evolution is illustrated with relevant vignettes in the light of some theoretical and historical considerations. The paper demonstrates the value of Work Discussion groups in terms of indirectly supporting hospitalised patients, as well as promoting staff’s resilience and professional capacities in difficult contexts.