Boundaries in the doctor-patient relationship

Boundaries in the doctor–patient relationshipis an important concept to help healthprofessionals navigate the complex andsometimes difficult experience between patientand doctor where intimacy and power must bebalanced in the direction of benefitingpatients. This paper reviews the concept ofboundary violations and boundary crossings inthe doctor–patient relationship, cautions aboutcertain kinds of boundary dilemmas involvingdual relationships, gift giving practices,physical contact with patients, andself-disclosure. The paper closes with somerecommendations for preventing boundaryviolations.     

Genetic Counselors' Judgments of Patient Concerns: Concordance and Consequences

The aims of this prospective study were to determine (a) the concordance between patient concerns and genetic counselors' judgments of these concerns, (b) the predictors of patient and counselor judgments, and (c) the relationship between concordance and patient outcomes. Patients' and counselors' views were sought before and after 131 routine genetic consultations. Before consultations, there was concordance about level of patient concern to within one point in 63% (82/131) of consultations and about type of patient concern in 60–84% of consultations. Lack of concordance in judging level and type of concern was associated with lower satisfaction with information and higher anxiety after the consultation. The biggest predictor of counselor judgment of concern was professional background: doctors judged patients to be more concerned than did nurses. Concordance of concern was predicted by counselors' experience in genetics: less experienced counselors overestimated patient concern. Future research needs to determine whether improving judgment of concern improves patient outcome.     

Negative expectations and bad relationships: Effects of negative metastereotypes on doctor–patient relationships

This research aimed to examine the effects of negative metastereotypes (i.e., patients believe that doctors have negative opinions about them) and conflict experience on doctor–patient relationships. A 2 × 2 experimental study was conducted on 84 outpatients who were randomly assigned to either a negative metastereotype activation (NMSA) condition or a nonnegative metastereotype activation (non‐NMSA) condition. Each group consisted of patients with and without conflict experience (CE). Intergroup anxiety and doctor–patient relationships were subsequently assessed. Results showed that NMSA and CE increased intergroup anxiety and undermined doctor–patient relationships. In addition, the interaction between NMSA and CE on doctor–patient relationships was significant. When negative metastereotypes were activated, patients with CE showed more unfavorable relationships with doctors as compared with those under non‐NMSA activation condition; no metastereotype effects on doctor–patient relationships were observed among patients without CE. These findings provided insights into an important predictor of doctor–patient relationships as well as its mechanism. Future studies should consider negative metastereotypes and CE to develop interventions for improving doctor–patient relationships.     

Attachment and sensitivity in family context: the roles of parent and infant gender

This study examined the role of child gender in fathers' and mothers' sensitivity to and attachment relationships with their infants from a family systems perspective. Eighty‐seven 1‐year‐olds participated in the Strange Situation with each parent. Parental sensitivity was examined during a competing demands task. Results indicated that fathers and mothers were equally sensitive to sons, but fathers were less sensitive than mothers to daughters, and mothers were more sensitive to daughters than to sons. Although mothers and fathers within the same families were similarly sensitive to daughters and sons, daughters' attachment security with fathers and mothers was similar whereas sons' was not. Further analyses revealed that fathers were more sensitive to sons with an insecure relationship with their mothers. Results of this investigation suggest that child gender is relevant for parent–infant, especially father–infant, attachment relationships. Copyright © 2006 John Wiley & Sons, Ltd.     

Further examination of the convergent and discriminant validity of the student–teacher relationship scale

Two studies extended psychometric research on the Student–Teacher Relationship Scale (STRS) with kindergarten and preschool children (N₁ = 60–71; N₂ = 35) and their teachers. These studies used a multi‐method approach to replicate and extend previous findings concerning the convergent validity of the STRS Closeness, Conflict, and Dependency scale and to further examine the discriminant validity of the STRS. Study 1 investigated convergence between the STRS scales and child‐ and peer‐reports of the same constructs based on a multi‐trait multi‐method approach. Study 2 examined the pattern of associations between the STRS and indicators of teacher–child relationship quality rated by external observers. Support was found for the convergent validity and to a lesser extent the discriminant validity of the STRS Closeness and Conflict scale. For the STRS Dependency scale, additional research remains necessary. Copyright © 2009 John Wiley & Sons, Ltd.     

Regression and new beginnings: Michael, Alice and Enid Balint and the circulation of ideas

This article offers a new evaluation of Michael Balint's history. It starts with his growing up in Hungary and examines the central concepts of his writing: the analytic pair, regression and the basic fault and creativity, up to and including his renowned work on the eponymous Balint groups (which forged a unique link between psychoanalysis and medicine). While his name is, of course, well known, this article aims to bring his ideas to the attention of a modern analytic audience. Having trained in the 1920s with Ferenczi, Balint brought Ferenczi's literary inheritance to England where he lived until his death in 1970. His connections to Klein, Winnicott and Lacan, all of whom respected his analytic stance, are also examined. Furthermore, this article argues that his ideas were filtered through the theoretical lens of his first wife Alice Balint and later through Enid Balint, both of whom played a key - and rarely recognised - role in the development of his thought. It ends with a brief discussion of his ideas on analytic training and his quest, successful only after his death, to publish the complete Freud-Ferenczi correspondence, together with Ferenczi's diary.     

Young infants' vocalizations towards mother versus stranger: associations with the infant–mother relationship

Infants' differential vocal response (DVR) towards their mother and a female stranger at 3 months of age has been predominantly investigated as an index of early cognitive functioning. The present study explored the relationship between DVR and different infant and mother indicators of the developing relationship quality in a sample of 23 mother–infant dyads. Mother–infant interactions and stranger–infant interactions were videotaped during home visits when the infants were 3 months old. At the age of 12 months, infants' behaviour was assessed in the Ainsworth's strange situation. In both assessments, mothers noted the infants' behavioural states on 3 successive days. Results revealed a specific relation between DVR and the emotional atmosphere of the early mother–infant interaction. Particularly, DVR was less pronounced in favour of the mother when the mother displayed emotional expressions defined as rejection. DVR is discussed as an index that may indicate both infant emotional engagement and infant cognitive competencies. Copyright © 2005 John Wiley & Sons, Ltd.     

Relational discrepancies and emotion: The moderating roles of relationship type and relational discrepancy valence

Relational discrepancy theory proposes that discrepancies in the extents to which relational partners meet relational standards are associated with emotions and that perceiving relationships in specified ways moderates associations. In a range of relationships, ideal relational discrepancies were associated with dejection and ought relational discrepancies with agitation (Study 1), associations moderated by relationship type. Discrepancy valence also moderated ideal discrepancy associations. Similar associations were found in friendships, moderated by relationship type (Study 2). Finally, relationship type and valence moderated associations in relationships with supervisors but not with colleagues (Study 3). These results support relational discrepancy theory propositions.     

Construction and maintenance of parent–child relationships: Bidirectional contributions from the perspective of parents

The purpose of the present study was to investigate parents' perspectives of parent and child contributions to the construction and maintenance of the parent–child relationship. Twenty‐four mothers and fathers, with a child between 4‐ to 7‐years‐old, completed an open‐ended interview in which they described their parent–child relationship and commented on how they and their child strengthen, damage, and repair the relationship. Findings indicated that parents described their parent–child relationship with relatively similar emphasis on elements of authority, companionship, and intimacy. Parents reported that they were most likely to strengthen the parent–child relationship by interacting with their child in the companionship domain, whereas their overuse of power or authority and non‐responsiveness temporarily created damage in the relationship. Parents reported that their children were most likely to strengthen the relationship by complying with parent requests and engaging in companionate interactions, whereas not complying or challenging parent directives created relational tension. Parents indicated that both they and their children were most likely to repair interactional errors by restoring intimacy (e.g. apology, communication, or affection). Results are discussed from a framework of multiple relationship domains consisting of the interplay of vertical and horizontal dimensions of power. Copyright © 2004 John Wiley & Sons, Ltd.     

Reciprocal and complementary sibling interactions,relationship quality and socio‐emotional problem solving

Associations between reciprocal and complementary sibling interactions, sibling relationship quality, and children's socio‐emotional problem solving were examined in 40 grade 5–6 children (M age = 11.5 years) from middle class, Caucasian, Canadian families using a multi‐method approach (i.e. interviews, self‐report questionnaires, daily diary checklist, narrative task). Findings demonstrated that reciprocal sibling interactions were positively associated with warmth, mutual esteem, happy daily exchanges, and negatively related to rivalry and dominance, whereas complementary interactions were positively related to upsetting daily exchanges. Further, reciprocal and complementary interactions differed significantly in relation to several relationship qualities, with reciprocal interactions emerging as a significantly stronger correlate of happy exchanges. Only reciprocal interactions were positively correlated with socio‐emotional problem solving. Finally, birth order moderated the negative association of reciprocal interactions with rivalry and dominance and the positive association with socio‐emotional problem solving. In each case, the effect was stronger for younger members of the sibling dyad. Findings are discussed in light of recent theory on the sibling relationship and children's development. Copyright © 2007 John Wiley & Sons, Ltd.     

The patient-physician relationship and the allocation of scarce resources: a law and economics approach

Patients with insufficient financial resources place physicians in a conflict of interest between the patients' needs and the financial interests of the physician, other patients, and society. Not only must physicians act ethically, but they must avoid liability for violating their legal duties to their patients. The traditional rules of contract and malpractice law that govern the patient-physician relationship do not provide satisfactory guidelines. Better answers are found in the rules of fiduciary law, but only with regard to direct conflicts between patients and physicians and only at the risk of reducing patient access to care. Certain types of legislative action can resolve these conflicts by altering the traditional legal rules, but care must be taken to preserve patient-physician trust, which the legal rules were designed to enhance.     

Recollections of Menarche: Communication Between Mothers and Daughters Regarding Menstruation

The nature of the communication between mothers and daughters at the time of menarche was examined in an attempt to determine the kinds of messages about menstruation that mothers tend to pass on to their daughters. The sample consisted of 138 women who ranged in age from 26 to 60 years (mean age = 43.2) at the time of the interviews. They were interviewed by 138 students enrolled in Psychology of Women classes taught by the first author. Participants were asked questions regarding their education about menstruation and their experience with menstruation. The content of the responses were analyzed for information about the quality and quantity of mother–daughter communication. The majority of daughters reported that communication with their mothers about menstruation was negative in tone. Eight types of negative messages were identified, including one labeled the grin-and-bear-it message. Two cases are presented to illustrate how the grin-and-bear-it message is related to the traditional feminine gender role and how it might negatively affect a woman's relationship with her mother and with other women.     

Young children's television viewing and the quality of their interactions with parents: A prospective community study

Television is one of the most commonly viewed forms of media by children throughout the world. Excessive television viewing can influence the quality of children's relationships and interactions with their parents. We examined the emotional availability (EA ) of children toward their parents by assessing child responsiveness and child involvement , using a cross‐sectional and longitudinal design. We employed a large and representative community sample of Norwegian 4‐year‐olds (n = 995) who were followed up at 6 years old (n = 795). The results illustrate that, when viewing excessive amounts of television, children are less likely to be involved with their parents in ordinary toy‐play. We argue in favor of the displacement hypothesis, stating that time‐demanding technologies are negatively related to the quality of parent–child relationships because spending more time watching television will leave less time for developing nurturing social relationships.     

The painter and the cameraman: boundaries in clinical relationships

The issue of boundaries in clinician–patientencounters is considered through narrativeanalysis of four clinical stories in whichboundaries crossings are a self-conscioustopic. One story is by a physician as patient,two are by physicians, and one is by apalliative care nurse. The stories arediscussed using Walter Benjamin's distinctionbetween the painter, who maintains distance andsees the whole, and the cameraman, who usestechnology to penetrate realities and thenreassembles fragments. The essay argues thatdistance and closeness are ethical issues thatconstitute the possibility of clinicalencounters but the encounter also changes theclinician's sense of boundaries. The relevantethics of boundary decisions in most clinicalencounters are not procedural ethics but anethics of self-creation: in orienting toboundaries as doctors do, they createthemselves in their relations to others.     

Mapping the Social World of Classrooms: A Multi‐Level,Multi‐Reporter Approach to Social Processes and Behavioral Engagement

Understanding the social context of classrooms has been a central goal of research focused on the promotion of academic development. Building on the current literature on classroom social settings and guided by a risk and protection framework, this study examines the unique and combined contribution of individual relationships and quality of classroom interactions on behavioral engagement among low‐income Latino students in kindergarten to fifth grade (N = 111). Findings indicate that individual relationships with teachers and peers and classroom quality, each independently predicted behavioral engagement. Moreover, high‐quality classrooms buffered the negative influence of students’ difficulties in individual relationships on behavioral engagement. Findings illuminate the need to consider multiple layers of social classroom relationships and interactions and suggest the potential benefit of targeting classroom quality as a mechanism for improving behavioral engagement in urban elementary schools.     

The roles of self-regulation and partner regulation on romantic relationship quality

Research into self-regulation and partner regulation strategies has largely involved parallel lines of research, thus, it is difficult to determine the relative contribution of both forms of regulation when it comes to relationship outcomes. Therefore, the question remains as to which form of regulation is more strongly associated with relationship quality; is it more important to focus on adaptive self-regulation or adaptive strategies to regulate one's partner? The current research addresses this important gap by comparing the relative associations of adaptive self-regulation and adaptive partner regulation strategies on romantic relationship quality. A community sample of mixed gender couples (N = 114) who were predominantly satisfied with their current relationships – but nonetheless still experienced relationship conflict – were administered self-report assessments of various self-regulation and partner regulation strategies as well as a measure of relationship quality. Couples also participated in a videotaped discussion of an unresolved relationship issue that was scored by trained coders for verbal and nonverbal indicators of self-regulation and partner regulation strategies. Actor–partner interdependence modeling revealed that for both men and women, adaptive self-regulation strategies were positively associated with their own evaluations of relationship quality as well as their partner's relationship quality. In contrast, engaging in adaptive partner regulation strategies was not significantly associated with men's or women's own, or their partner's relationship quality. Findings highlight the importance of focusing on self-regulation in relationships, as it is these strategies, over partner regulation strategies, that have more positive implications for the relationship quality experienced by typically satisfied couples.     

The role of child temperament on low‐income preschool children's relationships with their parents and teachers

The current study examined the associations between low‐income preschool children's temperament (reactive and regulatory) and their relationships with parents and teachers. In particular, we focused on the moderating role of regulatory temperament on reactive temperament in the prediction of closeness and conflict with parents and teachers. Two hundred ninety‐one children (M = 53.88 months, SD = 6.44 months), their parents, and teachers from 3 different preschools serving low‐income children in 2 midwestern cities in the United States participated. Parents reported on temperament and parent–child relationships, and teachers reported on teacher–child relationships. Hierarchical regression models using SAS PROC MIXED were employed to allow for nesting of children within classrooms. After controlling for child age, gender, ethnicity, and parent education, children's reactive temperament was negatively associated with parent–child closeness and positively associated with parent–child conflict and teacher–child conflict. Children's regulatory temperament was positively related to teacher–child closeness and negatively associated with teacher–child conflict. Regulatory temperament moderated the association between reactive temperament and teacher–child closeness. These findings suggest that although reactive temperament potentially undermines closeness in relationships with teachers, regulatory temperament can buffer the influence of reactive temperament on teacher–child closeness.

Highlights

• This study examined the association between children's temperament and their relationships with parents and teachers.
• Reactive temperament was positively associated with parent/teacher–child conflict and negatively associated with parent–child closeness. Regulatory temperament was a moderator for the association between reactive temperament and teacher–child closeness.
• Improving children's regulatory temperament may be helpful for children with the reactive temperament to have better social relationships with their teachers.