Belgrade systemic approach to the treatment of alcoholism: principles and interventions

This article describes an ecosystemic approach to alcoholism (ESTA) developed in Belgrade, Yugoslavia. The fundamental principle is that alcoholism is a problem of the whole context, involving the index patient, the family and wider systems including the work system.
The treatment programme, which integrates contemporary principles of the treatment of alcoholism with family-systems ideas covering biomedical-psychological-sociocultural levels, is also described and illustrated by a detailed case example.     

Toward an operant model of power in organizations

The purpose of this paper is to suggest that behavior analysis can help to explain social power. In this approach, an individual's potential for influence is thought to be partially a function of his or her access to stimuli that can be used as consequences. This access can occur either through direct authority or indirectly through social networks and exchanges. Social power is also thought to be a function of an individual's skill in delivering the stimuli in ways that will have the most impact on behavior. A number of predictions about power based on an operant approach are offered.     

The ethics of enforced medical treatment: the balance model

ABSTRACT When is it right to enforce medical treatment on a patient who is refusing that treatment? English law recognises two ethical principles as of paramount importance: the autonomy of the patient; and the consequences of not treating compared with treating. The law, by and large, operates these principles in succession. Thus, in the case of a patient refusing treatment, the law asks first, is the patient competent? Only if the answer is no, are the consequences considered. We criticise the position taken by English law and argue, first, that competence is a graded and not a binary concept, and secondly, that the two ethical principles should be applied not sequentially but at the same time. These two ideas form what we have called the balance model. This model could be used for an empirical study of individuals’ ethical beliefs, and in particular to test the hypothesis that the ethical beliefs of most individuals conform to the balance model rather than to the position taken by English law.     

Utilization of a cognitive task analysis for integrated project delivery application: Case study of constructing a campus underground parking facility

Integrated Project Delivery (IPD) has the potential to overcome inefficiencies of traditional delivery methods by enhancing collaboration among project participants, and is therefore gaining popularity in the Architecture, Engineering and Construction (AEC) industry. For owners considering an IPD approach and are incapable or unprepared to pursue a “pure” IPD project, an IPD-ish approach could be an alternative option. IPD mode is featured by implementing a range of fundamental principles. However, investigations on application of IPD-ish principles to actual construction projects are highly limited. This research mainly focused on a Cognitive Task Analysis (CTA) of the application of IPD principles to the design and construction of an IPD-ish project, and presenting a case study on an underground campus-parking facility. A case study for CTA was designed in this study: a project progress map was developed, wherein seven project phases were defined; by analyzing the project goals and technical measures in each project phase, six key IPD elements was summarized, and a few specific work measures for addressing these elements were discussed. For owners or participants intending to plan an IPD-ish project, the results of the study provide a few references on the selection and application of IPD principles in each project phase.     

Attention Training With Auditory Hallucinations: A Case Study

The case presented in this paper illustrates how Attention Training (ATT; [Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273–280.]) can be applied in an outpatient setting in the treatment of auditory hallucinations. The 25-year-old male patient presented had a 4-year history of schizophrenia and treatment-refractory auditory hallucinations. He had received cognitive behavior therapy (CBT) before starting ATT. CBT had changed his attribution of the voices, and when he started with ATT the patient no longer held the belief that “voices are dangerous,” but his processing configuration was still acting “as if” the voices were a source of threat: He would listen to them, ruminate about them, and was easily distracted by them. Eight sessions of ATT resulted in a reduction of symptoms and in a dramatic change in the perceived control and mastery of the auditory hallucinations. It is concluded that ATT may be a helpful adjunct strategy in the treatment of specific psychotic symptoms.     

Symptom dimensions in obsessive-compulsive disorder: implications for the DSM-V

In the absence of definitive etiological markers of vulnerability or a unitary profile of pathophysiology for obsessive-compulsive disorder (OCD), obsessive-compulsive (OC) symptom dimensions seem to offer a fruitful point of orientation. The complex clinical presentation of OCD can be summarized using a few consistent and temporally stable symptom dimensions. These can be understood as a spectrum of potentially overlapping features that are likely to be continuous with "normal" worries and extend beyond the traditional nosological boundaries of OCD. Although the understanding of the dimensional structure of obsessive-compulsive symptoms (OCS) is still imperfect, this quantitative approach to phenotypic traits has the potential to advance our understanding of OCD and may aid in the identification of more robust endophenotypes. Preliminary data suggest that these dimensional phenotypes may be useful in studies of the natural history, genetics, neurobiology, and treatment outcome of OCD. A dimensional approach is not mutually exclusive of other methods to parse the larger spectrum of disorders related to OCD. Thus far, age-of-onset of OCS and the individual's "tic-related" status seem to be particularly useful categorical distinctions. Finally, existing assessment methods are inadequate and new dimensional scales are needed to take full advantage of a dimensional approach in clinical and population-based studies.     

Self-reports, spouse ratings, and psychophysiological assessment in a behavioral medicine program: an application of the five-factor model.

This article describes the integration of the five-factor model into assessment procedures used with 109 patients in an outpatient behavioral medicine program. The population, program, assessment techniques, and general findings are explored. A case history involving a psychophysiological disorder is utilized to demonstrate the utility of a taxonomy of personality traits. The NEO-PI, a five-factor instrument, is integrated with other assessment techniques to assist in diagnosis, rapport building with the patient, tailoring treatment techniques and goals to the individual's intrapersonal and interpersonal dynamics, and predicting relative success and compliance with noninvasive self-regulation procedures and psychotherapy.     

OPEN DIALOGUE IN PSYCHOSIS I: AN INTRODUCTION AND CASE ILLUSTRATION

As a social construct, our approach to work with severely disturbed psychiatric patients in crisis, termed Open Dialogue (OD), begins treatment within 24 hours of referral and includes the family and social network of the patient in discussions of all issues throughout treatment. Treatment is adapted to the specific and varying needs of patients and takes place at home, if possible. Psychological continuity and trust are emphasized by constructing integrated teams that include both inpatient and outpatient staff who focus on generating dialogue with the family and patients instead rapid removal of psychotic symptoms. The main principles are described, and a case is analyzed to illustrate these.     

Moments of complexity and enigmatic action: a Jungian view of the therapeutic field

In presenting clinical case material for a panel on archetypes and/or primal phantasies an initial discussion of archetypes as emergent phenomena organizing 'moments of complexity' is given(1) . The relationship of such moments to 'moments of meeting' as developed by the Boston Change Process Study Group is commented on and explored within the context of the case. A condensed report of a multi-year analytic treatment of a bipolar patient having a severe trauma history is offered for discussion. Several unusual, enigmatic events are detailed to illustrate the occurrence of moments of complexity. Dreams highlighting psychological transformation stemming from a changing relationship to emerging archetypal material related to a psychotic process in the patient are offered to further detailed moments of complexity.     

REMEMBERING A DEPRESSIVE PRIMARY OBJECT

Memory has always been a central issue in psychoanalytic theory and practice. Recent developments in the cognitive and neural sciences suggest that traditional notions of memory based on stored structures which are also often underlying psychoanalytic thinking cannot account for a number of fundamental phenomena and thus need to be revised. We suggest that memory be conceived as a) a theoretical construct explaining current behaviour by reference to events that have happened in the past. b) Memory is not to be conceived as stored structures but as a function of the whole organism, as a complex, dynamic, recategorising and interactive process, which is always 'embodied'. c) Memory always has a subjective and an objective side. The subjective side is given by the individual's history, the objective side by the neural patterns generated by the sensory motor interactions with the environment. This implies that both 'narrative' (subjective) and 'historical' (objective) truth have to be taken into account achieving stable psychic change as is illustrated by extensive clinical materials taken from a psychoanalysis with a psychogenic sterile borderline patient.     

"La manie d'ecrire": psychology, auto-observation, and case history

This essay examines the modern psychiatric case study as a scientific method and as a genre of writing about the self. As psychological discourse became a privileged language of selfhood at the fin de siècle, the penultimate signifier of the self came to be found in the realm of sexuality, in the particular contours of an individual's sexual desire. The investigative tool used to uncover these secrets of identity was the case history. This article concerns an influential project of sexual research based on "auto-observations"-autobiographical patient narratives-conducted by Dr. Georges Saint-Paul, who published under the inverted pseudonym "Laupts." The article focuses on the central autobiography of his collection, the "roman d'un inverti," and related sexological literature to suggest how this emphasis on patient stories in psychiatric writing engendered new narrative possibilities for doctors and patients alike. Putting patient stories at the center of psychiatric investigation created a new relationship between patient and doctor, observation and diagnosis, subject and discourse. The tools of psychological observation simultaneously placed a subject's confession more firmly at the center of the investigation and made it more open to interpretation by nonspecialists. Rather than simply confirming the authority of the trained observer, the story of Laupts's enquête suggests that the method actually authorized inquiry by others.     

Nature against nurture: calcification in the right thalamus in a young man with anorexia nervosa and obsessive-compulsive personality disorder

This report describes the case of a young man with a large calcification in the right thalamus that was first diagnosed at 9 years of age. Case history reveals specific eating rituals and other obsessive-compulsive personality traits during the patient's childhood and adolescence, fulfilling diagnostic criteria of obsessive-compulsive personality disorder. After a critical life event the patient develops anorexia nervosa. We suggest that our case and further literature provide evidence for an involvement of specific thalamic structures, such as the dorsomedial nucleus, in the development of anorexia nervosa. Furthermore, the treatment of the patient by a combined psychotherapeutic and pharmacotherapeutic approach is described. We focus on the beneficial effect of the atypical antipsychotic olanzapine, which can induce weight gain by an increase of leptin levels.     

A Psychotherapist's Reaction to His Patient's Death

ABSTRACT: A case history of a patient who died during the course of psychotherapy is initially presented in the form of an essay. Three therapeutic points (one related to the therapist's awareness of his anger toward the patient) are focused on in regard to working with the dependent, suicidal patient: the importance of being in touch with one's own anger toward the suicidal patient; the need to vary one's attitude and approach toward the dependent patient as he travels through different emotional phases; the importance of promptly involving significant friends and relatives in close observation of and relating to the acutely suicidal person. The emotions and psychodynamic factors in the author and other psychotherapists in response to the death of a patient are then examined, with particular emphasis on the therapist's allowing himself to mourn the personal loss.     

Assessing the Ethics of Medical Research in Emergency Settings: How Do International Regulations Work in Practice?

Different ethical principles conflict in research conducted in emergency research. Clinical care and its development should be based on research. Patients in critical clinical condition are in the greatest need of better medicines. The critical condition of the patient and the absence of a patient representative at the critical time period make it difficult and sometimes impossible to request an informed consent before the beginning of the trial. In an emergency, care decisions must be made in a short period of time, and the more time is wasted, the more the risk of death or severe tissue damage and incapacity increases. Consent requests take time, and so the time period before treatment might put the patient’s life in jeopardy. Not requesting consent before a trial is also contradictory. A person should not be forced to participate in a trial against his or her will. Due to the dark history of medical research previously, international declarations and conventions have set up ethical principles for medical research. They emphasize the autonomy of the research participant—or his or her legal representative—to give a free and informed consent prior to the initiation of research. In the case of a critical emergency, the unconscious state of the patient, the emotional stress of family members or the lack of time to start life-sustaining measures may often restrict the possibilities of communicating with the patient or his/her representative. Therefore, written informed consent is difficult to achieve, and its voluntariness in emergency situations is, at best, open to question. The mortality of patients is high without clinical interventions in emergency research. Random selection of patients is difficult and requires extra work from personnel in the emergency rooms. Recruitment, information and asking for consent may also take time, postpone the initiation of treatment and increase the risk of death and irreversible tissue and organ damage, and therefore be risky for the patient. It is therefore essential that the health care professionals recruiting suitable research participants are well motivated and well trained. Medical research in an emergency setting should always be regarded as an exceptional situation requiring special provisions. Only such research should be done as cannot be done in other conditions. An independent body must approve the research protocol and the ways in which the consent of the participant or proxy are to be sought. In addition, the trial must be expected to result in direct and significant benefit for the research participants. If research without prior consent is not approved, the development of emergency care is threatened. On the other hand, if prior consent is not required, a person could be recruited into a clinical trial against his or her will. Doing good and avoiding harm, and respecting the autonomy of the patient are in conflict in the context of emergency medical research. To develop better medicines for patients experiencing acute medical emergencies, research into such conditions should be allowed. Research participants should have the possibility to participate or refuse to participate in research that may benefit them and other patients. The risk of irreversible damage occurring as the consequence of time delays for seeking consent is unacceptable. A prior wish about participation in clinical trials should be respected, if known. The conditions under which medical research in emergencies can be considered acceptable can be determined and agreed upon nationally and internationally. An earlier version of this paper was presented at The 7th International Conference on Bioethics on “The Ethics of Research in Emergency Medicine”, held on June 2, 2006, Warsaw, Poland.     

Behavioral Treatment of Test Anxiety in a Drug Abuse Vocational Rehabilitation Day Program

Anxiety is one of the critical factors present in initiating and maintaining a drug-dependent pattern of behavior. This study examines test anxiety. The objective was to determine if a behavioral approach can be applied to the treatment of test anxiety in a vocational rehabilitation program for drug abuse clients. A case history is presented. Procedural details for applying behavioral techniques are discussed. The results of the study indicate that the treatment strategies selected were effective in reducing test anxiety. One of the side effects of using an approach that puts the technology of behavior change into the hands of the client is that the skills learned during treatment can be used to cope with problems other than those discussed with the counselor.     

Some supplementary methods for the analysis of WAIS-IV index scores in neuropsychological assessment

Objectives. To develop supplementary methods for the analysis of the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV) in neuropsychological assessment. Design and Methods. Psychometric. Results. The following methods are made available: (a) provision of traditional confidence intervals (CIs) on index scores, (b) expression of the endpoints of CIs as percentile ranks; (c) quantification of the number of abnormally low index scores exhibited by a case and accompanying estimate of the percentage of the normative population expected to exhibit at least this number of low scores; (d) quantification of the reliability and abnormality of index score deviations from an individual's index score mean (thereby offering an alternative to the pairwise approach to index score comparisons available in the WAIS-IV manual); (e) provision of CIs on an individual's deviation scores or pairwise difference scores, (f) estimation of the percentage of the normative population expected to exhibit at least as many abnormal deviations or abnormal pairwise differences as a case; and (g) calculation of a case's Mahalanobis distance index (MDI), thereby providing a multivariate estimate of the overall abnormality of an index score profile. With the exception of the MDI, all the methods can be applied using tables provided in this paper. However, for ease and speed of application, and to reduce the possibility of clerical error, all the methods have also been implemented in a computer program. Conclusions. The methods are useful for neuropsychological interpretation of the WAIS-IV.     

Psychophysics of Remembering: The Discrimination Hypothesis

In a psychophysical approach to remembering, the events to be remembered are discriminated from other possibilities at the time of remembering, and not at the time of encoding or learning. The discrimination is specific to the retention interval at which remembering occurs, as shown by experiments demonstrating that discriminability and response bias are delay–specific. This article discusses a discrimination model for remembering that emphasizes the individual's history of learning about reward payoffs in similar experiences in the past. This model predicts the two characteristics of forgetting functions, initial discriminability and rate of forgetting.     

The Use of Psychoeducation for a Patient with Hepatitis C and Psychiatric Illness in Preparation for Antiviral Therapy: A Case Report and Discussion

The standard of care treatment for chronic hepatitis C viral infection (HCV) is a combination of pegylated interferon alfa and ribavirin for 24-48?weeks according to the virus genotype. This therapy is known to have multiple neuropsychiatric side effects. A major concern when evaluating a patient for HCV treatment with a known history of a psychiatric disorder is the risk that the patient's psychiatric disorder will flare or become unmanageable. The possibility of precipitating depression, confusion, mania, psychosis, hallucinations, or suicidal ideation or attempt is frequently an obstacle to treatment. We present the case of a 50?year-old man with HCV and an extensive psychiatric history involving alcoholism, depression, and suicidality who participated in a psychoeducation group to help prepare him for treatment with pegylated interferon alfa/ribavirin therapy. Though the patient derived much benefit from the psychoeducation group, by the time of evaluation for HCV treatment two months after the group ended he had relapsed back into a depressive episode with suicidal thoughts. His acute psychiatric status made him unacceptable for pegylated interferon alfa/ribavirin therapy. Psychoeducation groups show promise for helping patients with chronic medical illness to be ready for and endure intensive medical treatment that has substantial psychiatric side effects. The challenge is to help patients overcome barriers to treatment, particularly psychosocial problems, because available treatments are increasingly effective.     

The knower and the known

This paper is a presentation and discussion of Spinoza's view on the knower, or the mind, as an agent. The knower is on his view to be regarded as an active or generative complex cognitive experience. Imagination, reason and intuition are the cognitive principles. On account of their intrinsic relation to the first law of nature, that of selfpreservation, together with the thesis of the mind as constituted by ideas or knowledge, these principles function at the same time as moral principles. Consequently, it makes sense to speak of an individual's moral attitude toward everything be knows. A discussion of imagination, reason and intuition mainly as cognitive principles is followed by some concluding remarks on the cognitive and moral relation between human beings: To know another human being is to know his knowledge. The moral attitude of individuals to each other is a function of their mutual knowledge of knowledge.