The ethical issue of competence in working with the suicidal patient

In this article, I discuss the ethical need for competence in the assessment and management of the suicidal patient, and further suggest that this specific competence be considered a routine element in professional psychological practice. I also argue that this particular competence necessitates adequate training in working with this high-risk population, as well as the need for every clinician to personally evaluate her or his own technical and personal competencies to work with suicidal patients before beginning independent practice activities in clinical situations wherein he or she may be called on to evaluate or treat a suicidal patient. This article concludes with a discussion of specific ethical dilemmas (e.g., the issue of confidentiality), and a list of suggestions for specific competencies in working with the suicidal patient is provided.     

The Ethical issue of Competence in Working With the Suicidal Patient

In this article, I discuss the ethical need for competence in the assessment and management of the suicidal patient, and further suggest that this specific competence be considered a routine element in professional psychological practice. I also argue that this particular competence necessitates adequate training in working with this high-risk population, as well as the need for every clinician to personally evaluate her or his own technical and personal competencies to work with suicidal patients before beginning independent practice activities in clinical situations wherein he or she may be called on to evaluate or treat a suicidal patient. This article concludes with a discussion of specific ethical dilemmas (e.g., the issue of confidentiality), and a list of suggestions for specific competencies in working with the suicidal patient is provided.     

Treating an HIV/AIDS Patient’s PTSD and Medication Nonadherence With Cognitive-Behavioral Therapy: A Principle-Based Approach

HIV/AIDS patients with medication adherence problems are vulnerable to developing drug resistance, immune system degradation, and opportunistic infections. Poor adherence to antiretroviral medication regimens can be aggravated by psychiatric problems, including depression and posttraumatic stress disorder. This article presents the case study of a patient with HIV/AIDS who was unable to adhere to his antiretroviral medication regimen primarily because of PTSD and depressive symptoms resulting from a sexual assault that had caused his seroconversion. Exposure-based cognitive-behavioral therapy was instrumental in helping the patient overcome his PTSD and depressive symptoms so that he could tolerate his HIV medications. The patient’s symptom relief was evidenced by improved scores on the Impact of Event Scale and Beck Depression Inventory. The article discusses the importance of accurate assessment, therapist flexibility, and principle-based treatment versus strict adherence to manual-based protocols.     

Positional dyslexia

Position-specific errors in word reading are usually associated with neglect or visual extinction on the same side as the reading problem. In this study, two patients with left-hemisphere lesions showed visual extinction on the right but reading difficulty on the left side of words and pseudowords. Further study of one patient revealed that he also had problems reading the beginning of words presented tachistoscopically or in vertical orientation. In addition, the positional difficulty was apparent when he named the letters in words. The pattern of results indicates that the positional dyslexia in these patients was not likely attributable to general deficits in visual perception or attention but may have reflected a disorder at a later stage of letter processing.     

The interface between counselling and neuropsychological assessment of patients with AIDS/HIV

Manifestations of central nervous system dysfunction in adults and children with AIDS/HIV are common. The contribution of counselling in relation to these patients is described. This includes: contributing to the assessment of patients, addressing ‘dreaded issues' while patients are still well, helping patients to find solultions and manage problems, engaging the support of friends and the family in managing patients, ‘translating’ the results for the patient from formal assessments, discussing treatment options and helping parents and prospective parents to manage behaviour problems in their children. Counsellors also have a special role in advising and consulting colleagues about the management of these patients. Counselling in a clinical setting is, however, inextricably bound to limitations in the medical care of this patient group.     

Jewish biomedical ethics and care of the AIDS patient

Jewish biomedical ethics form part of the broader Judeo-Christian ethical system that prescribes appropriate social conduct for most Americans. They are based on law(halachah) that is derived from the Hebrew Bible and its interpretations. The principle on which they center is that every person is sanctified by God and therefore of infinite value. Therefore, every effort must be made to preserve and protect human life. The management of the patient with AIDS engenders many problems of an ethical nature. An appreciation of the Judaic solutions to these problems may assist physicians caring for patients with AIDS in making their management decisions.     

Regression in the countertransference: working with the archetype of the abandoned child

Abstract :  The author describes briefly some experiences of his sense of non-existence as an analyst in relation to five patients. He considers the possible countertransference significance of these experiences and puts forward a hypothesis that his sense of non-existence as an analyst might be a clue to regression in the patient to the anxieties of a baby without a mother, even though other clinical evidence of regression might be lacking. Referring back to Jung's early formulation of transference and countertransference as aspects of the unconscious identity shared between analyst and patient, he further develops his hypothesis, suggesting that, in the cases he has presented, analyst and patient were relating through shared dynamic roots in the archetype of the abandoned child. He briefly demonstrates how the understanding thus achieved was of clinical use in the analyses of the patients he has presented.     

The patient in the family and the family in the patient

The notion that the family is “the unit of care” for family doctors has been enigmatic and controversial. Yet systems theory and the biopsychosocial model that results when it is imported into medicine make the family system an indispensable and important component of family medicine. The challenge, therefore, is to provide a coherent, plausible account of the role of the family in family practice. Through an extended case presentation and commentary, we elaborate two views of the family in family medicine — treating the patient in the family and treating the family in the patient — and defend both as appropriate foci for care by family doctors. The practical problem that arises when the family is introduced into health care is deciding when to concentrate on the family system. The moral problems that arise concern how extensively doctors may become involved in the personal lives of their patients and families. The patient-centered clinical method provides a strategy for handling both problems. Thus, making the family a focus of care in family medicine can be justified on theoretical, practical, and moral grounds.     

From Knowing to Discovering: Some Suggestions for Work with Anorexic Patients

ABSTRACT

In this article I offer some technical suggestions for psychoanalytic work with anorexic patients. Although focused on an outpatient setting, certain parts of the article will also have utility for inpatient work. As an outpatient therapist working with an anorexic patient, especially in the acute stages of the illness, there are case management demands that need immediate attention. The setting up the particular frame is required to augment the therapeutic work. The most urgent pressure felt by the clinician is the precariousness of the patient’s physical health. This can be experienced as if there is a gun to the head of the therapist. This deathly force must be carefully and constantly grappled with, and particularly so in the most symptomatic stages of the illness. The clinician must work with a patient who might die at any time, yet an anorexic patient cannot be managed the way a suicidal patient would be. The question of technique in this situation is a complex one. Above all, the patient must be met where s/he is. Notwithstanding the uniqueness of each patient there are some specific themes that often arise in the acute stage of the illness. Certain technical suggestions are offered.     

From Dead to Alive: Desire,Dissociation and Passion in the Analytic Dyad

When patients present in a deadened state, the analyst may feel a sense of futility and shame in his efforts to have impact. This may cause him to withdraw and contribute to an enactment in which both participants purge themselves of wanting anything from the other, sapping the treatment of purpose and aliveness. The author presents a model in which the analyst can reawaken his desire for recognition and connection and utilize it to introduce the patient to his or her own dissociated longings. This involves fortitude on the therapist’s part, since he must withstand the rejection that had caused him to withdraw in the first place, and also be sensitive to the patient’s fear of retraumatization. But if the analyst can do this, he can not only break through the impasse, but enliven the patient and infuse the treatment with a sense of purpose and hope.     

Mutilation of self and object: the destructive world of the paranoid-schizoid patient and the struggle for containment and integration

Using case material, I have described the three overlapping phases of treatment that occur with some borderline, narcissistic, or psychotic patients. These patients are dealing with paranoid-schizoid experiences of the self and the object. In this part-self, part-object world, many shifting, opposing, and contrary states of feeling and thought occur. Acting out is the first phase of analytic treatment. This is an externalization of persecutory anxiety, primitive guilt, and phantasies of annihilation. Projective identification, splitting, and denial are common and tend to make for difficult transference and countertransference problems. During the middle phase of treatment, pathological superego states and manifestations of death instinct color the analysis. The death instinct reacts defensively to the sadistic superego. Technically, the destructive internal conflicts created by these two elements must be clarified and interpreted in the transference. Flexible analytic management and containment are crucial supplements to ongoing interpretation. If these chaotic patients are able to stay in treatment for a period time, the acting out and the superego/death instinct phase gradually give way to phantasies of loss. This is still a paranoid-schinoid perspective of loss, making it persecutory experience. Although depressive anxieties do enter the picture, these still involve pathological anddestructive states of guilt and all-or-nothing threats of abandonment and attack. A case was presented in which the patient managed to continue into the third stage of analytic treatment, long enough to benefit frominternal, structure change. In this final stage, the patient "O" was able to acknowledge, work through, and integrate her prior feelings and phantasies of loss, persecution, and abandonment anxiety into more manageable and reality-based depressive functioning.     

Reflections on the papal allocution concerning care for persistent vegetative state patients.

This article critically examines the recent papal allocution on patients in a persistent vegetative state with regard to the appropriate conditions for considering "reformable statements." In the first part of the article, the purpose and meaning of the allocution are assessed. O'Rourke concludes that give consideration of the individual patient's best interest, prolonging artificial nutrition and hydration is not, in every case, the best option. Although he stresses favorability for preservation of the life of the patient through artificial nutrition and hydration, costs and benefits to the patient should be weighed. Ultimately, he argues in favor of leaving the decision to the patient, his caregivers, and others immediately involved in the case.     

On the Patient's Becoming an Individual: The Importance of the Analyst's Personal Response to a Deprived Patient and Her Dreams

What patients mainly want—which Ferenczi noted as early as 1932 in his clinical diary and which Bion later expressed in his Cogitations (1992)—and what some patients need, is to experience how the analyst lives and processes the interpersonal events that lie at the origin of their affective and mental suffering. This is especially true with schizoid patients who were profoundly emotionally deprived in childhood. In this paper, the author investigates this crucial aspect of the intersubjective analytic relationship in his treatment of just such a patient, an extremely silent and inert young woman. Through a detailed examination of clinical material from various stages of her analysis, he explores how the analyst's unconscious emotional response serves as both a tool for comprehension and a key element of environmental facilitation—a “new beginning,” to use Balint's phrase—that may help the patient attain a level of development and emancipation that he or she has never experienced before.     

The Axis II group: treating severely characterologically disturbed patients

Treating the chronically mentally ill involves not only working with patients suffering from schizophrenia and other prolonged or recurrent psychotic illnesses, it also means providing treatment for patients with severe personality disorders. Many of these patients are also active substance abusers. This article examines the therapeutic and management issues raised for outpatient clinicians who work with these patients. Consideration is devoted to the special problems in treating the dual diagnosis patient, issues of patient and therapist safety, limit setting, splitting dynamics, and countertransference reactions. A set of recommendations is offered for conducting outpatient group therapy, specifying what is needed from both the clinicians and the facility in which this type of treatment is provided.     

Distinguishing representation deficits and processing deficits in a case of acquired dysgraphia

The same acquired disorder of spelling may be due to deficits affecting lexical representations of word spelling or deficits affecting the mechanisms that process those representations. This study sought to distinguish these possibilities in a dysgraphic patient. The integrity of the patient's lexical orthographic representations was assessed by having him decide whether or not pairs of words presented auditorily rhymed. Although the patient was impaired on a variety of spelling tasks and with all types of stimulus material, he showed a normal effect of spelling on the rhyme task. Like normal subjects, he was faster at deciding that words rhymed when they were spelled similarly (e.g. tool-cool) than when they were spelled dissimilarly (e.g. rule-cool) and slower at deciding that words did not rhyme when they were spelled similarly (e.g. toad-broad) than when they were spelled dissimilarly (e.g. code-broad). Therefore, as the patient's lexical representations of word spelling seemed to be generally intact, his spelling problems were probably due to difficulty in processing those representations.     

Determinants of patient satisfaction with the medical consultation

Abstract

This study assessed patient satisfaction with the medical consultation in ambulatory settings. A multistage sampling method, stratified by geographical location in metropolitan Sydney and type of medical practice, was employed. Two hundred and seventy-two patients attending medical consultations completed a brief questionnaire and interview immediately following a medical consultation with either a general practitioner or a medical specialist. Factor analysis of the questionnaire indicated that 58% of the variance in patient satisfaction ratings was accounted for by the level of interpersonal warmth and respect and the amount of information communicated by the doctor. Other factors impacting on satisfaction included the number of patient requests perceived to be met by the doctor, and the characteristics of the medical encounter, such as the length of the consultation and whether the visit was a first or subsequent consultation. There was no association between level of satisfaction and gender of doctor or the type of medical practice attended.     

癌痛规范化治疗的制约因素分析

癌痛严重影响中晚期癌症患者生活质量,通过使用第三阶梯强阿片类止痛药物,绝大部分患者疼痛能得到很好的控制。微观上,癌痛治疗的疗效与患者及医务人员的认识程度密切相关,也与医院麻醉科等其他科室的参与程度有关。宏观上,社会人文、经济、政策管理等方面的不足都制约着癌痛规范化治疗的有效实施。癌痛的规范化治疗是一项管理措施,需要进行疼痛评估、家庭支持及宗教组织的参与帮助等。我们国家在文化、经济、教育等各个方面取得长足进步时,癌痛治疗会更加规范、合理、人性化。     

Left occipital lobectomy and the preangular anatomy of reading

Two patients had alexias after left occipital lobectomies. Case 1 was a 55-year-old man with a glioblastoma. At 4 months after surgery he could read slowly, but reading was neither efficient nor pleasant. Case 2 was a 19-year-old male who had a more restricted, medial occipital lobectomy for an encapsulated mesenchymal chondrosarcoma. The tumor did not invade brain initially, and the patient recovered efficient reading after 15 months. It is postulated that Case 2 was able to recover efficient reading because he still had a field of left ventrolateral occipitotemporal cortex connected to homologous cortex on the right.     

A disturbance of interpreting,of symbolisation and of curiosity in the analyst‐analysand relationship: (The patient without insight)1

The author examines the function of the analyst who may distort the unconscious communication with the patient by means of the expression of his countertransference. He studies a disturbance in curiosity and in symbolisation in a patient with a narcissistic pathology. Both problems were related to this failure in interpreting. The curiosity of the patient, which initially seemed to be non‐existent, was found to be directed towards investigating the mind of the analyst, this being his sole purpose. The disturbance in symbolisation was manifested as a constant verbal acting out, which was expressed as verbal communication empty of meaning. A change in the interpretative attitude enabled a modifi cation in the objective of the curiosity, which became focused on investigating his own inner world, and the emptiness of the verbal communication was replaced by representations. This change in communication allowed the analyst to relate the facts of the psychoanalytic relationship both with the patient's phantasy and with the events in his history. An idealised identifi cation with destructive aspects of the mother towards the father was discovered. This idealisation had been sustained by the analyst by means of his errors in interpreting. The author explores disturbances in symbol formation and in the use of symbols, and he considers the different states of emptiness.     

The effect of therapist interventions on the therapeutic alliance with borderline patients

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.