The comatose patient,the ontology of death,and the decision to stop treatment

Theoretical Medicine and Bioethics - In this paper I address three problems posed by modern medical technology regarding comatose dying patients. The first is that physicians sometimes hide behind...     

Reflections on coma: Man deprived of his consciousness

In this paper the authors reflect on the phenomena produced by the surprising communication between the unconscious of a therapist and that of a comatose patient. In a particularly disturbing context, when the patient’s sternum is open and exposed, the therapist communicates empathically with the comatose person, identifying the patient’s inexpressible experience and generating signs of a response from him in the form of the blinking of his eyelids. The absence of any reaction to pain, a pathognomonic sign of the comatose condition, could be related to the splitting‐off of the trauma, as if the situation were frozen, through a denial of the sensory and neurological perception of pain – a kind of self‐anaesthesia as a defence against the catastrophic anxieties raised by the threat of the return of the primary trauma. Starting from this encounter a relationship is formed whose guiding thread emerges in the shared illusion of a regression that makes it possible. It involves a process of returning to the past and a re‐actualization of the past that includes the question of its change through representation.     

'It's as if PBC didn't exist': the illness experience of women affected by primary biliary cirrhosis

This study investigates the illness experience of women who are affected by primary biliary cirrhosis (PBC), a rare chronic liver disease which mostly affects women. Despite the fact that PBC is medically recognised, it shares many characteristics with other chronic and controversial conditions which may lead to delegitimation of the patient's experience of illness, impacting on the construction of the patient's self-identity. Twenty three women took part in semi-structured interviews. Data were analysed using interpretative phenomenological analysis and the analysis identified three themes that are interrelated and characterised by a dynamic of normalisation. The first theme, the delegitimation of women's experience, implies denial of patients' sick-role, trivialisation of fatigue and lack of consideration of patients' needs. The second theme, PBC as a challenge to women's social identity refers to how patients face delegitimation and manage the illness's consequences for relationships and social roles. The third theme, the need for biographical continuity, focuses on how patients construct their ill identities as a consequence of both the delegitimation and the challenges posed by PBC. Results are discussed in a gender perspective, highlighting how delegitimation and identity construction processes are influenced by women's social roles and conditions.     

A Phenomenal Case for Sport

The article attempts to show some limitations to reductive accounts in science and philosophy of body-mind relations, experience and skill. Extensive literature has developed in analytic philosophy of mind recently due to new technology and theories in the neurosciences. In the sporting sciences, there are also attempts to reduce experiences and skills to biology, mechanics, chemistry and physiology. The article argues there are three fundamental problems for reductive accounts that lead to an explanatory gap between the reduction and the conscious experience. First, reductive accounts deal with objective observations; conscious experiences are subjective. Second, subjective experience seems difficult to identify with physical events described by chemistry, biology, mechanics or neurophysiology. Finally, sport involves knowing how and knowing how is also difficult to reduce to propositional knowledge, which is the reductive scientific/philosophical project. The article argues that sport provides an excellent platform to better understand what is wrong with reductive analysis in body-mind relations, since both conscious experience and knowing how are fundamental to sport performance.     

‘It's as if PBC didn’t exist’: The illness experience of women affected by primary biliary cirrhosis

This study investigates the illness experience of women who are affected by primary biliary cirrhosis (PBC), a rare chronic liver disease which mostly affects women. Despite the fact that PBC is medically recognised, it shares many characteristics with other chronic and controversial conditions which may lead to delegitimation of the patient's experience of illness, impacting on the construction of the patient's self-identity. Twenty three women took part in semi-structured interviews. Data were analysed using interpretative phenomenological analysis and the analysis identified three themes that are interrelated and characterised by a dynamic of normalisation. The first theme, the delegitimation of women's experience, implies denial of patients’ sick-role, trivialisation of fatigue and lack of consideration of patients’ needs. The second theme, PBC as a challenge to women's social identity refers to how patients face delegitimation and manage the illness's consequences for relationships and social roles. The third theme, the need for biographical continuity, focuses on how patients construct their ill identities as a consequence of both the delegitimation and the challenges posed by PBC. Results are discussed in a gender perspective, highlighting how delegitimation and identity construction processes are influenced by women's social roles and conditions.     

小儿巨大肾积水的循证诊疗策略与思考

通过典型的病例分析,分别从小儿巨大肾积水的概念、影像学诊断、无功能肾脏的判断以及治疗方式的选用等方面入手,结合循证医学实践的三大要素,包括利用最佳的临床研究证据、注重医生的专业技能和经验、尊重患者的期望和权利。简述临床上治疗小儿巨大肾积水时所应当采用的循证诊疗策略,以及从中引申出来的哲学思考。     

Comments on “The Ketamine Model of the Near-Death Experience: A Central Role for the N-Methyl-D-Aspartate Receptor”

Although ketamine can induce a state similar to a near-death experience (NDE), there is a striking difference between experiences induced by ketamine used in a recreational context and in an operating room. Ketamine is a noncompetitive antagonist of the N-methyl-D-aspartate receptor, as is ibogaine, the main alkaloid of a shrub used in Central Africa to induce NDEs in a religious context. Ibogaine can also elicit different experiences when used in a hallucinatory context or in initiatic rituals, where a superficial state of coma is induced. These data raise the question of whether the chemically-induced NDE-like experience is related to the use of a particular kind of substance or to a genuine comatose state.     

The Nature and Meaning of the Near-Death Experience for Patients and Critical Care Nurses

This study was designed to develop a conceptual framework for the near-death experience (NDE), reflecting its nature and meaning for the patient and the critical care nurse. The study used naturalistic inquiry to examine the question: What is the nature and meaning of an NDE and how has it influenced the individual's view of the self, the future, and feelings and beliefs about life and death? The NDE Scale (Greyson, 1983) was used with patients and semi-structured interview guides were used with both nurses and patients to explore the NDE from a comprehensive perspective. An NDE was defined as the report of “unusual” recollections associated with a period of unconsciousness during either serious illness or injury, or resuscitation from a cardiac or respiratory arrest. The sample included 12 patients who experienced an NDE and 19 nurses who cared for patients who experienced NDEs. This study highlighted the emotional aspects of the NDE. Patients described how the NDE transformed their lives and nurses reported how their experiences with patients changed them personally and professionally.     

Reflections for Clinical Pastoral Education Students in Psychiatric Settings

This article focuses on Donald Capps’s books on mental illness. In doing so I highlight three key insights from Capps that I have applied in my own ministry with persons with mental illness in various psychiatric hospitals. These insights, together with my own experience as a chaplain, lead to three practical lessons for clinical pastoral education students in psychiatric settings. I provide some context for my interest in mental illness and my friendship with Capps, as well as some background regarding how Capps’s writings on mental illness fit with certain broader themes in his own work as a pastoral theologian. This essay is personal throughout.     

Considerations for a Psychology of Experience: Heinz Werner's Contribution

It is proposed that three themes in Heinz Werner's psychology provide directions for a contemporary psychology of experience. The first theme is the nature of developing mind. Werner's view of the mind as incorporating nonlogical modes of thought is contrasted with the hyper-rational views that dominate contemporary psychology. The second theme is Werner's model of the gradual differentiation and integration of spheres of experience. The model can be elaborated with minimal universalist assumptions, thus providing ways of conceptualizing cultural and individual differences as well as changes within a person's life. The third theme is the theory of symbolization that Werner developed in collaboration with Bernard Kaplan. Integrating the theory of symbolization with the spheres of experience model, it is seen how internal and external acts of symbolization enter into the formation and internal differentiation of spheres.     

Age Differences Across Adulthood in Interpretations of Situations and Situation–Behaviour Contingencies for Big Five States

In the last two decades, a burgeoning literature has begun to clarify the processes underlying personality traits and momentary trait‐relevant behaviour. However, such work has almost exclusively investigated these questions in young adults. During the same period, much has been learned about adult personality trait development but with scant attention to the momentary processes that contribute to development. The current work connects these two topics, testing developmental questions about adult age differences and thus examining how age matters to personality processes. The study examines how four important situation characteristics are experienced in everyday life and how situations covary with Big Five trait‐relevant behaviour (i.e. situation–behaviour contingencies). Two samples were collected (total N = 316), each assessing three age groups: young, middle‐aged, and older adults. Using experience sampling method, participants completed reports four or five times per day across a representative period of daily life. Results suggested age differences in how situations are experienced on average, in the variability around these average situation experiences, and in situation–behaviour contingencies. The results therefore highlight that, across adulthood, age groups experience chronically different situations, differ in how much the situations they experience vary moment to moment, and differ in how much situation experience predicts their enactment of traits. © 2019 European Association of Personality Psychology     

Cultural Considerations for Psychologists in Primary Care

Many health concerns in the United States (e.g., diabetes) are routinely managed in primary care settings. Regardless of the medical condition, patients’ health is directly influenced by factors such as healthcare providers and cultural background. Training related to how behaviors influence health, coupled with training on how cultural diversity intersects with mental health, allows psychologists to have the relevant expertise to assist in the development of primary care behavioral health interventions. However, many psychologists in primary care struggle with how to integrate a culture-centered paradigm into their roles as behavioral health providers. This paper provides an introduction on how three culture-centered concepts (providers’ cultural sensitivity, patient–provider cultural congruency, and patients’ health literacy) can be applied in primary care using the Five A’s Organizational Construct and a model of cultural competence. In addition, the paper includes a section on integration of cultural considerations into consultation and training and concludes with a discussion of how the three culture-centered concepts have implications for health equity.     

The question of the other in French phenomenology

I would like to show how with Sartre, Merleau-Ponty, and Levinas, we have to do with three different ways of understanding the experience of the other. For Sartre it is a visual experience, the experience of being looked at by the other, so that the experience of the other is understood as a confrontation; for Merleau-Ponty, the experience of the other necessarily implies coexistence and what he calls “intercorporeality,” so that for him the other is never to be found in front, but instead beside me, in reciprocity with me; for Levinas, the experience of the other is the experience of a non-reciprocity, of an assymetrical relation, because the experience of the other is for him an ethical and not an ontological experience, and because this experience of the face of the other is the experience of a speaking and not in the first place corporeal presence. There are consequently three different ways of finding an access to the other : the look for Sartre, intercorporeality for Merleau-Ponty and the face for Levinas.     

Culture learning theory and globalization: Reconceptualizing culture shock for modern cross-cultural sojourners

Culture shock has long been of great concern regarding the wellbeing and mental-health of international sojourners. Over the last three decades, the world has experienced rapid globalization and the introduction of various technologies which have been found to ‘buffer’ the effects of culture shock, yet the conceptualizations concerning the nature, prevalence, and effects of this phenomenon have not been explicitly modernized to suit such a contemporary social landscape. Based on an extensive literature review, particularly concerning the research conducted with international student populations, this paper offers conceptual insight on how the experience of culture shock has evolved in the present information age, and argues modern sojourner experiences are increasingly reflective of culture learning. Specifically, this paper considers exactly how technological advancements have facilitated change in the subjective experience of the psychosocial processes during a cross-cultural immersion. A foundation for future research to explore the mechanisms of culture learning theory is also contributed.     

An Evidence‐Based Model for Understanding the Mental Health Experiences of Transgender Australians

A growing body of empirical research has documented the mental health experiences of Australian transgender people. This research indicates three key factors that appear to play a role in determining outcomes for adult transgender Australians: (a) discrimination, (b) access to hormones and/or surgery, (c) community connectedness. Two theoretical frameworks clarify why these factors exist and how they can lead to either negative or positive mental health outcomes. The first is cisgenderism, which describes the ideology that delegitimises people's own understanding of their genders and bodies. Although anyone can experience cisgenderism, it is a particularly common experience for transgender people. The second is decompensation, which describes the processes through which the cumulative effects of stressors may lead to poor mental health. Drawing on both previous empirical findings and these two theoretical frameworks, this article proposes, and provides initial testing of, a model for understanding the mental health of transgender adults in Australia. The article concludes by suggesting the need for changes regarding how decisions are made about mental health service provision for transgender people, how mental health professionals understand the lives of transgender people, and how legislation can better ensure the full inclusion of transgender people in Australia.     

Toward disentangling sources of individual differences in appraisal and anger

ABSTRACT A theoretical framework is presented to explain individual differences in situation-specific emotional experience in terms of three different sources of variance: (a) individual differences in how one appraises one's circumstances, (b) individual differences in how appraisals are related to the experience of emotion, and (c) individual differences independent from situation and appraisal. The relative contribution and nature of these sources was examined empirically for the experience of anger based on data from two directed imagery studies (total N =1,192). Consistent results across the two studies demonstrated that variability in anger experience primarily stems from variability in how a situation is appraised and to a smaller extent from individual differences in the relations between the appraisals and anger and individual differences independent of appraisal. The findings further identified frustration as the central appraisal involved in anger. Implications for emotion theories and anger management programs are discussed.     

Effects of awe on consumer preferences for healthy versus unhealthy food products

This research investigates how a discrete positive emotion (awe) impacts consumers' decisions on food choices. We probe and demonstrate that the experience of awe enhances consumer preferences for healthy versus unhealthy products. In a series of three studies, we find that awe, compared with a neutral emotion, increases consumers' likelihood to choose healthy products over unhealthy products (Study 1). Consumers' processing styles drive the observed awe effect (Study 2), whereby awe increases reliance on analytic processing, which leads to preferences for healthy products. Moreover, the experience of awe exerts a stronger influence on product choices among consumers with a chronic intuitive rather than analytic processing style (Study 3). Theoretical contributions to the research on awe, information processing, and healthy food preference, as well as practical implications for consumers and marketers, are discussed.     

<Emphasis Type="Italic">Doctor Anonymous</Emphasis>: Creating Contexts for Homosexuality as Mental Illness

In this essay, the author describes how he faced institutionalized homophobia during his psychiatric training, and how he later wrote a play inspired by the life of a gay psychiatrist. Despite Freud’s supportive stance, homosexuality aroused the antipathy of American organized psychiatry and psychoanalysis and came to be listed as an illness in the Diagnostic and Statistical Manual (DSM). Dr. John E. Fryer outed himself as “Dr. H Anonymous” at a 1972 meeting of the American Psychiatric Association, and the next year homosexuality was removed from the DSM. The 2014 play Doctor Anonymous offers a fictionalized account of this watershed moment in the history of the gay rights movement. The author discusses his own psychotherapeutic work with gay male patients, including those who had previously been treated with conversion therapy, and explores how the play mirrors his own life experience and the experience of his patients.     

Five Issues in Training Edited by Irving R. Weschler and Edgar H. Schein

This case study illustrates how combined therapy (individual, group, and marital) by the same therapist was used to resolve a woman's narcissistic transference. The author's position is that combined therapy creates a psychologically stimulating environment, which uniquely elicits a depth and range of transference feelings, thereby generating multiple therapeutic opportunities to experience and work through transference resistance in the here-and-now. Highlights of the treatment demonstrate how the synergy of three modalities is used to elicit, modulate, and resolve positive and negative aspects of the narcissistic transference. Four guidelines are suggested for treatment of patients in combined therapy.     

Discussion of “The Therapeutics of the Fee in Psychoanalysis”

This discussion of Dr. Pauley’s paper (this issue) on the therapeutics of the fee first highlights the various valuable contributions Pauley makes. It applauds his unusual openness in sharing his internal vulnerability with patients around fees, his raising the question about why fee setting is so complicated for analysts and patients alike, his focusing on omnipotent fantasies in the transference and countertransference, and his uncovering of the multiple meanings money has for therapists beyond just their income. Berger picks up on Pauley’s invitation to therapists to be more curious about their own discomforts with money. Drawing on her own teaching, writing and clinical experience, she adds to Pauley’s more global ideas, stressing instead the more specific meaning of money in each treatment dyad. Among these specifics, Berger highlights the chronic avoidance of teaching about money in analytic institutes. She clarifies some Freudian ideas about how money can become tied up with anal witholding, and offers examples of how she got stuck with three patients around setting and raising their fees. Berger describes how these patients’ believed that their fees could mean safety, value or exploitation and how these attribuitions generated countertransference blind spots for her. The discussion urges clinicians to keep digging hard into themselves for the many meanings of money, to pay attention to the devil in their own details, and thereby maximize the richness of their work with patients around a topic so loaded for all of us.