Chronic pain as a posture towards the world

This article discusses what chronic pain is “about”, what the intentional object is of pain, and what is the intentional relation like? My approach is based on Maurice Merleau‐Ponty’s phenomenology, with an aim is to understand a two‐way relationship: how the sufferers bestow meaning on chronic pain, and how pain, on the other hand, signifies peoples’ life. In contrast to biomedical and cognitive‐behavioral theories, chronic pain is not only meaningful, but as an intentional emotion as well; it does not simply “happen” in the nervous system. I analyzed meanings assigned to pain through the narratives of three patients with chronic pain. Pain is described as creating a discontinuity in the patient’s Lebenswelt at the narrative level. When attempting to find meaning to their pain, patients point both to everyday life and biomedical referents. The structure of bestowing meaning is, metaphorically, like a necklace with everyday world and biomedical interpretations strung like beads, one after the other. The intentional object of pain, on the contrary, is constituted of the patients’ world in its wholeness. My results don’t confirm Drew Leder’s idea of disrupted intentionality, but underline directness as the basic relation of human experience also in case of pain and disease. Pain in itself is an e‐movere, an intense passionate movement, an intentional relation with and a bodily posture taken towards the world.     

Giving Voice to Patients: Developing a Discussion Method to Involve Patients in Translational Research

Biomedical research policy in recent years has often tried to make such research more ‘translational’, aiming to facilitate the transfer of insights from research and development (R&D) to health care for the benefit of future users. Involving patients in deliberations about and design of biomedical research may increase the quality of R&D and of resulting innovations and thus contribute to translation. However, patient involvement in biomedical research is not an easy feat. This paper discusses the development of a method for involving patients in (translational) biomedical research aiming to address its main challenges.After reviewing the potential challenges of patient involvement, we formulate three requirements for any method to meaningfully involve patients in (translational) biomedical research. It should enable patients (1) to put forward their experiential knowledge, (2) to develop a rich view of what an envisioned innovation might look like and do, and (3) to connect their experiential knowledge with the envisioned innovation. We then describe how we developed the card-based discussion method ‘Voice of patients’, and discuss to what extent the method, when used in four focus groups, satisfied these requirements. We conclude that the method is quite successful in mobilising patients’ experiential knowledge, in stimulating their imaginaries of the innovation under discussion and to some extent also in connecting these two. More work is needed to translate patients’ considerations into recommendations relevant to researchers’ activities. It also seems wise to broaden the audience for patients’ considerations to other actors working on a specific innovation.     

Exploring Positive Learning Experiences in the Context of Practical Theological Education

Abstract. This article presents findings from an empirical study exploring student and teacher perspectives on positive learning experiences in practical theological education. Forty‐five students and twenty teachers were interviewed in focus groups in four educational institutions delivering programs in practical theology. The findings indicated that students valued practical theological education when it enabled them to think critically in relation to their personal or professional experience, and that students valued tutors, their peers and a flexible curriculum design in promoting this kind of learning. There was a high correlation between students’ views of positive learning experiences and what tutors perceived as important qualities that they hoped their students would develop. Difficulties associated with the students’ lack of clarity about the learning process and the tensions between academic and professional contexts are also discussed.     

On the biomedicalization of alcoholism

The shift in the prevailing view of alcoholism from a moral paradigm towards a biomedical paradigm is often characterized as a form of biomedicalization. We will examine and critique three reasons offered for the claim that viewing alcoholism as a disease is morally problematic. The first is that the new conceptualization of alcoholism as a chronic brain disease will lead to individualization, e.g., a too narrow focus on the individual person, excluding cultural and social dimensions of alcoholism. The second claim is that biomedicalization will lead to stigmatization and discrimination for both alcoholics and people who are at risk of becoming alcoholics. The third claim is that as a result of the biomedical point of view, the autonomy and responsibility of alcoholics and possibly even persons at risk may be unjustly restricted. Our conclusion is that the claims against the biomedical conceptualization of alcoholism as a chronic brain disease are neither specific nor convincing. Not only do some of these concerns also apply to the traditional moral model; above that they are not strong enough to justify the rejection of the new biomedical model altogether. The focus in the scientific and public debate should not be on some massive “biomedicalization objection” but on the various concerns underlying what is framed in terms of the biomedicalization of alcoholism.     

Caring for the Caregiver: Identifying the Needs of Those Called to Care Through Partnerships with Congregations

As the older adult population continues to grow, the prevalence of chronic diseases is also increasing, leading to the need for novel ways of managing this large population of patients. One solution is to focus on informal caregivers. These informal caregivers already make a substantial contribution to our nation’s healthcare finances and patient health outcomes. Caregivers also derive benefits from caring for their family member or friend; however, it is not uncommon for these individuals to experience negative health consequences, or what is often called “burden of care.” Those called to care are not without their own burdens, and they must frequently make significant lifestyle adjustments that impact their own health. Therefore, for caregivers to be effective, caring for the caregivers must be a focus of medicine in the twenty-first century.     

临床药师问诊与实践体会

问诊是临床医师的基本技能之一.医师通过问诊可以获得病史资料,从而做出临床决策.随着医学模式从传统的生物医学模式向生物心理社会医学模式转变和临床药学的蓬勃发展,药学服务模式从传统的以保障药品供应为中心向以患者为中心模式转变.药师从药房逐步走向临床,参与合理用药和提供药学服务,问诊也应成为临床药师的基本技能之一.本文通过笔者问诊实践,阐述问诊对于临床药师的重要性、药师问诊的内容及其与医生问诊的区别.     

Sound escapes: images of spirituality from music teachers and students

This on-going piece of research seeks to identify what music teachers, performers and students from high school through to university understand by the word spirituality in relation to music. From this it is hoped to be able to look at the relevance of the term spirituality in the music classroom. In this paper, data are presented from qualitative research gained in the form of interviews with 37 respondents and four focus groups of children, and quantitative research from questionnaires completed by 38 trainee music teachers. From these data, we identified five themes relating to the respondents’ understanding of the term ‘spirituality’ in relation to music. These were: to what extent spirituality is seen as a religious concept; whether spirituality is an inner or outer experience; to what extent words are relevant to spiritual experiences; the role that knowledge and emotion play and whether musicians experience a sense of spirituality more when listening or performing. From these data we go on to identify implications for the music classroom.     

Infertility,epistemic risk,and disease definitions

I explore the role that values and interests, especially ideological interests, play in managing and balancing epistemic risks in medicine. I will focus in particular on how diseases are identified and operationalized. Before we can do biomedical research on a condition, it needs to be identified as a medical condition, and it needs to be operationalized in a way that lets us identify sufferers, measure progress, and so forth. I will argue that each time we do this, we engage in epistemic risk balancing that inevitably draws upon values and interests, often including social and ideological values. My main interest here is in the conceptualization of infertility as a disease. Infertility is a rich test case for exploring the interplay between interests and epistemic risk management. There is no uncontested or standardized definition of infertility. The various definitions of it are internally ambiguous and tension-ridden, and in spectacular contradiction with one another. Many interest groups who are invested in framing infertility as a pressing problem deserving of social and medical redress are quick to insist that it is a legitimate ‘disease,’ but they cannot agree on which disease it is, what its symptoms or diagnostic markers are, or even what its basic ontology is. I suggest that there are political explanations for this epistemic mess. Indeed, I contend that there are good scientific and ethical reasons to reduce away the category of ‘infertility,’ especially understood as a scientific or medical category; I argue that we should excise the concept from our research and clinical practices.

     

Student Changes, Program Influences, and Adult Development in One Program of Counselor Training: An Exploratory Inductive Inquiry

This qualitative study explored how students in 1 program changed as a result of their professional preparation experience. We interviewed 15 counseling students via one-to-one interviews and a focus group. Students were asked how they had changed and what had influenced those changes in their educational experience. Responses were clustered with the assistance of a text analysis computer program. Three broad change themes were named (1) increased reflexivity, (2) increased autonomy, and (3) capacity for dialogue. Four program influences were also identified. They are providing students with (1) experiences in social construction of knowledge, (2) experiential learning, (3) opportunities for independent thinking, and (4) a supportive environment. Connections to adult-development themes and specific instructional strategies that are suggested by the data are named.     

Presymptomatic testing for huntington diseases: Recommendations for counseling

The discovery of a genetic marker linked to the Huntington disease (HD) gene made it possible to perform presymptomatic genetic testing for this late onset disorder. The first two pilot research programs in the United States, at Massachusetts General Hospital and Johns Hopkins Hospital, began offering testing in the Fall of 1986. Twenty-three centers are now offering this testing as part of their clinical service. As testing for this and other late onset diseases becomes more widespread, it is important to assess what we have learned about offering this test to those at risk. This article presents recommendations based on the author's 5 years of experience offering presymptomatic testing for HD in order to alert counselors to the complexities of offering this type of service.     

The practice of empathy as a prerequisite for informed consent

The patient-physician relationship, as formulated in the traditional biomedical model of medicine, is inherently flawed. In entering this relationship, most patients seek simply to be delivered from illness back to normal psychosocial functioning. The physician, however, almost invariably responds with a purely biologic approach to diagnosis and treatment that often does not effectively address the patient's needs. This precludes the opportunity for a consensus between them, and may in fact lead to the physician manipulating the patient's decisions about the course of therapy. The relationship should be reshaped within a new scientific model of patient care that combines the biomedical analysis of disease with an empathic understanding of the patient's illness experience. Truly informed consent is viewed as a natural outcome of the application of this more comprehensive framework.     

Connections between experience, beliefs, scientific knowledge, and self-evaluated expertise among investigators of child sexual abuse in Finland

The purpose of this study was to investigate whether clinicians investigating child sexual abuse (CSA) rely more on scientific knowledge or on clinical experience when evaluating their own expertise. Another goal was to check what kind of pre-trial beliefs the clinicians had. The connections between these different factors were investigated. A questionnaire covering items concerning demographic data, experience, knowledge about CSA, self-evaluated expertise and beliefs about CSA was given to 126 social workers, 60 child psychiatrists and 134 psychologists. The results showed that the clinicians relied more on their clinical experience than on scientific knowledge when evaluating their expertise as investigators of CSA. Furthermore, social workers possessed stronger attitudes in favor of children than the other groups, while child psychiatrists had more negative attitudes towards the criminal justice system. Male participants had less strong beliefs than did the female participants. The findings indicate that the education of CSA investigators should focus more on theoretical knowledge and decision-making processes as well as the role of pre-trial beliefs.     

Achieving “Narrative Flow”: Pre-Medical Education as an Essential Chapter of a Physician’s Story

This article explores the disconnection between what pre-professional students expect from college and what their undergraduate education might foster, between the focus on "getting into medical school" and the development of humanistic physicians. It reviews the longstanding challenge inherent in helping pre-meds acquire not only sufficient scientific background but also well-developed interpersonal skills to help them understand patients' experience of illness and their own interactions with other members of the health care team. Clinical experiences from the NEH Institute are interpreted from the perspective of a pre-med advisor who also teaches literature; they are also incorporated into an undergraduate course on literature about illness.     

临床决策中患者及其家属的地位与作用

医生、医院每天都在为患者做临床决策。而在各个决策中患者与家属应该处于什么地位的问题早有争论。除了疾病外患者性别、年龄、家庭、经济、社会地位的个体差异决定了医生决策的不同。患者要真正参与,就必须真正全面知情。关于患者参与多少的问题要因人而异,可能只是提出意愿,可能提出耗资的底线,可能权衡费效比,可能以生活质量为唯一原则。总之,临床决策中患者及其家属的地位因人而异。     

Body image satisfaction and anxiety of a Turkish sample of university students with skin diseases

The aim of this study was to evaluate perception of body image and anxiety of 221 university students presenting to the dermatology outpatient clinic with a skin disease and 205 students without skin disease. Analysis of anxiety and body image scores yielded differences by sex and age in both groups. The group with skin disease had lower scores on body image. Acne vulgaris seems to be the most disturbing among the skin diseases, and this was more prominent in younger patients.     

Art and emotion in psychoanalysis

Freud's view that art satisfi es psychic needs has been taken to mean that art has its source in the unconscious and that it unifi es pleasure and reality. The author argues that there is a third point that Freud repeatedly emphasizes, which should not be overlooked, that art infl uences our emotions. The author examines what Freud means by this claim, in particular, his reading of Michelangelo's Moses. Freud's focus here on emotions as fundamental to subjective experience, as subject to regulation and as potentially healthy forms of communication serves to supplement and even challenge what he says in his theory of affect. The author concludes by making inferences about a contemporary psychoanalytic theory of affects: that it ought to be inclusive of science (more receptive to neurobiology and less bound to Freud) as well as art (preserving the focus on subjective experience, especially the processing of complex emotions), which is illustrated with the concept of mentalized affectivity.     

Exploring the Spiritual/Religious Dimension of Patients: A Timely Opportunity for Personal and Professional Reflection for Graduating Medical Students

Teaching about spirituality in medical school training is lacking. Spirituality is a dimension of humanity that can put experiences of health and illness into a meaningful context. Medical students might benefit from understanding how spirituality is an important element in learning to care for patients. Spirituality also provides a context for medical students to explore their own motivations for doctoring. This article describes a longitudinal senior elective course at the end of their medical school training to delve into matters of religion/spirituality surrounding patient care. The authors pose their own perspectives on what both students and faculty gained from the experience.     

Sustained empathic focus and the clinical application of self-psychological theory in group psychotherapy

The concept of focus can provide a meaningful bridge between theory and practice. The authors' aim in this paper is to demonstrate that for theory to be clinically useful, it should provide a sense of focus and organization for clinical work. They illustrate how their particular use of a self-psychological/intersubjective model leads to an emphasis on what they refer to as "sustained empathic focus." The authors' choice of concepts leads them consistently to stress the patient's subjective experience and emerging vulnerability.     

A Place to Stand: Intersubjectivity and the Desire to Dominate

Research indicates that upwards of 80% of our students experience the devastation of bullying during their school years. To date, research on bullying has mainly employed empirical methodologies, including quantitative and qualitative approaches. This research has largely concluded that bullying is situated in a lack of skill, understanding, or self-control and involves intentional action directed toward status dominance. Based upon these assumptions current anti-bullying strategies focus on training students toward more appropriate avenues of status acquisition and social interaction. Against the backdrop of an actual bullying encounter this paper employs a psychoanalytic philosophical lens to offer a fresh perspective on this enduring educational issue. Employing the philosophical work of Adam Phillips, Jessica Benjamin, and Emmanuel Ghent I ask the question: What is the desire to bully a desire for? Here I consider what is sought and what is at stake in the typical bullying encounter. Through careful analysis I argue that the domination represented in bullying is not simply situated in a lack of social skills or in disregulated aggression––skill deficiencies that require training. Instead, or perhaps in addition to these possibilities, I contend that bullying is foundationally a move toward establishing identity, a self. On this view bullying becomes an activity of self construction through attempted omnipotence. I argue that the status dominance inherent in bullying should be seen not as an end (a tool to secure resources or privilege), but as a means to something more foundational. I conclude that status dominance becomes a means toward the end of providing a secure place for the self to stand. Hence, instead of advocating that we train students to get along better this paper outlines the futility, as well as the insatiability of bullying, opening up new territory focused upon a re-construction of the bully through the relational bonding and differentiation available in the concrete Other.     

Standing out in Canada and Japan

The need for separation or individuation is held to be a prime motive in Western psychology. Varied accounts of the meaning of selfhood in Japan indicate that separation may be much less important-or as important-for understanding the construction of self-identity in that culture. We focus here on personal distinctiveness, one vehicle for separation from others. We propose that the desire for distinctiveness is not absent or negligible in Japan, but is subject to more constrained expression than in the West. The results of two studies comparing Japanese and Canadian students suggest that Japanese are less desirous of standing out for their own sake and more likely to experience this form of distinctiveness as aversive. The results also suggest that although Japanese and Canadians derive positive distinctiveness from much the same sources, Japanese are less gratified by this type of experience.