The Unseen Spouse: Pitfalls and Possibilities for the Individual Therapist

Individual therapists often hear a great deal about our patients' spouses or partners, and naturally develop ideas and beliefs about that unseen other and about the causes of any relationship difficulties the patient reports. Not uncommonly, therapists can lose touch with the fact that their impressions of an unseen spouse are constructions that have emerged from the transference/countertransference field, based on only partial or limited information—not veridical truths. They can then talk with the patient about his or her partner or relationship issues in ways that can ultimately do both patient and spouse a significant disservice and perhaps distract from the patient's own issues and analytic goals. This paper discusses several factors that seem to contribute to the development of this problematic dynamic, including various qualities of the transference/countertransference field, and offers suggestions for avoiding or reducing it. Clinical material is used to illustrate key points.     

Demeter's Compromise: Separation,Loss, and Reconnection in Mothers with Daughters Entering Adulthood

Drawing on contemporary theory of female development that focuses on the dynamics of the mother/daughter relationship regarding issues of separation and individuation, this article examines the treatment of a middle aged mother as she navigates her way through her daughter's adolescence and early adulthood. Psychoanalytic object relations, psychoanalytic relational theory, and feminist theory serve to frame an understanding of the case material in terms of developmental challenges that are uniquely female. Issues around mother/daughter attachment, separation, competition, conflict, and love are explored in the relationships between the patient and her mother, the patient and her daughter, and the patient and the therapist. The therapist's countertransference, intensified by her relationships with her own mother and daughter, suggests the possibility of both pitfalls and opportunities in the treatment. The article attempts to address a gap in psychoanalytic developmental theory, which offers little understanding of the challenges for women in midlife.     

Beyond Ritalin: The importance of therapeutic work with parents and children diagnosed ADD/ADHD

It is estimated that as many as 5 million children in America are being medicated with psycho-stimulants for Attention Deficit Disorder (ADD) and/or Attention Deficit/Hyperactivity Disorder (ADHD). Parents frequently seek psychotherapy for their child up to one and a half years after medication has been tried due to a high degree of symptom recidivism. The parents should be engaged in the therapeutic work, if at all possible. An intricate web begins to unfold as the current parent-child relationship resonates with the parents' relationship with their own parents, siblings and childhood experiences. Working with the parents is essential if one is going to know anything about the cross-generational dynamics involved and if real and helpful change is going to occur. Conscious and unconscious parent—child dynamics of hyperactive behaviour in children are discussed. A clinical case illustration is described. Alternatives to medicating children are also described.     

Why Ask Why? Logical Fallacies in the Diagnosis of Fetal Alcohol Spectrum Disorder

A diagnosis of Fetal Alcohol Spectrum Disorder (FASD) ascribes cause to developmental disability; however, there are logical issues in causation with ethical implications. This article focuses on the use of fallacious logic (affirming the consequent) in FASD, focusing on the Canadian Guidelines for diagnosis, and knowledge translation issues from science to practice. The clinician’s logical fallacy is an ethical issue of veracity in the clinician–patient relationship; this then leads to issues of nonmaleficence, because the diagnosis in turn blames the mother for her child’s difficulties. Suggestions for revised diagnostic practices that avoid allusions to causation and responsibility are discussed.     

Good Grief—What Becomes of the Lost Relationship: Reply to Commentaries

In replying to the discussions of Gilbert Cole and Stefanie Solow Glennon, I focus on several issues raised, including the continuing intrapsychic relationship with a dead parent who may have been destructive to the patient; the analyst's facilitating role in enabling the patient to connect with, and construct the future of, the lost relationship; the potential meaning of an enactment with a bereaved patient; and some thoughts on the dyad's needs to work creatively postloss in multiple affective time zones.     

Ethical issues in pediatric life-threatening illness: dilemmas of consent, assent, and communication

The treatment of life-threatening illnesses in childhood is replete with ethical issues and with clinical issues that have ethical implications. The central issues are those involved with a child's participation in the decision-making process and with communication of information about the illness and treatments to children. This article examines the questions of patient autonomy and of parental responsibility and prerogative in the context of pediatric oncology. Included in this examination of the ethical dimensions of pediatric life-threatening illness is a discussion of the many related aspects involved, including medical, cultural, psychosocial, legal, and developmental. A multidimensional approach that considers the ways in which these multiple aspects interact with one another, and which focuses on establishing a strong working alliance between the health care team and the pediatric patient's family, can help to avoid or resolve potential ethical and clinical conflicts.     

CONFUCIAN ENVIRONMENTAL ETHICS,CLIMATE ENGINEERING,AND THE “PLAYING GOD” ARGUMENT

The burgeoning literature on the ethical issues raised by climate engineering has explored various normative questions associated with the research and deployment of climate engineering, and has examined a number of responses to them. While researchers have noted the ethical issues from climate engineering are global in nature, much of the discussion proceeds predominately with ethical framework in the Anglo‐American and European traditions, which presume particular normative standpoints and understandings of human–nature relationship. The current discussion on the ethical issues, therefore, is far from being a genuine global dialogue. The aim of this article is to address the lack of intercultural exchange by exploring the ethics of climate engineering from a perspective of Confucian environmental ethics. Drawing from the existing discussion on Confucian environmental ethics and Confucian ethics of technology, I discuss what Confucian ethics can contribute to the ethical debate on climate engineering.     

THE ENCHANTED BEDSIDE

This paper is based on the authors' work offering psychological therapies to patients and their families in a specialist palliative care unit, pre‐ and post‐death. In addressing issues of family interaction around the bedside of the dying patient, the authors have noted a pattern of events that arise from strongly ambivalent relationships.

In particular, family adjustment to the declining health of the patient is acted out in a physical and emotional move around the bedside, with a ‘hierarchy of bereavement’ indicating the status of the relationship to the patient. Previously conflicted feelings towards the dying patient are replaced by an impermeable idealization, lasting throughout bereavement.

In trying to understand this process of idealization the authors have used an analytical frame, referring to Freud and Klein and their work on mourning. This leads on to an exploration of the implications for clinical practice within palliative care. An unshifting idealization can be problematic for many reasons. The reader is left with a discussion about how to work best with families whose initial protective defence can easily crystallize into a long‐term grief reaction.     

Ethical Issues in Neurografting of Human Embryonic Cells

During the last decade neurotransplantation has developed into a technique with the possible potential to repair damaged or degenerating human brain. Effective neurotransplantation has so far been based on the use of fetal brain tissue derived from aborted embryos or fetuses. The ethical issues related to this new therapeutic approach therefore not only concern the possible adverse side effects for a neural graft-receiving patient, but also the relationship between the requirements for fetal tissue and the decision-making process for induced abortion. Although for decades human embryos and fetuses have been the subject of biomedical studies, and, in principle, their use has therefore not been seen as ethically objectionable, the above points made it necessary to reconsider the moral issues. The present paper points out several of these issues, both from the donor and acceptor (patient) point of view. The conclusion is that under a series of restrictions intended to prevent the use of grafts from encouraging induced abortions and to maintain high standards of respect for life and human dignity, neurotransplantation using embryonic or fetal brain tissue parts cannot be rejected on moral grounds.     

Is it beneficial to involve a family member? A meta-analysis of psychosocial interventions for chronic illness.

Links between chronic illness and family relationships have led to psychosocial interventions targeted at the patient's closest family member or both patient and family member. The authors conducted a meta-analytic review of randomized studies comparing these interventions with usual medical care (k=70), focusing on patient outcomes (depression, anxiety, relationship satisfaction, disability, and mortality) and family member outcomes (depression, anxiety, relationship satisfaction, and caregiving burden). Among patients, interventions had positive effects on depression when the spouse was included and, in some cases, on mortality. Among family members, positive effects were found for caregiving burden, depression, and anxiety; these effects were strongest for nondementing illnesses and for interventions that targeted only the family member and that addressed relationship issues. Although statistically significant aggregate effects were found, they were generally small in magnitude. These findings provide guidance in developing future interventions in this area.     

Allocation of resources at the bedside: the intersections of economics, law, and ethics

In the preceding article, Mehlman and Massey examine possible legal responses to the issues that confront physicians faced with treating patients who have insufficient financial resources. This commentary explores the same issues from the perspective of ethics, including a comparison of the way law and ethics interpret the physician-patient relationship, the ethical obligations of physicians that are inherent in that relationship, and the propriety of Mehlman and Massey's legal and ethical proposals to ameliorate physicians' conflicting obligations in providing or withholding care on grounds of conservation of society's resources.     

When transference isn't transference: Iatrogenesis of multiple role relations between practicing therapists

Charismatic, grandiose and authoritarian senior therapists often develop complicated relationships not only with practicing therapists who are their colleagues, but also their friends, supervisees, as well as patients. The patient/therapist in a multiple role relationship with such a senior person may be extremely vulnerable and very unaware of the true nature of the problem Under certain conditions, some of these patient/therapists have suffered ego dysfunction and decompensation which appeared to be iatrogenic in origin rather than due to the patient's transference resistance. The implications of these issues for the field of psychotherapy, and underlying dynamics in vulnerable patient/therapist's, and in grandiose, narcissistic group leaders, are highlighted, along with ways of identifying the intrapsychic, interpersonal, and institutional roots of this problem An earlier draft of this paper was presented at the 1990 Meeting of the American Group Psychotherapy Association in Boston.     

The emerging debate over the shape of informed consent: can the doctrine bear the weight?

Informed consent has traditionally focused on treatment-related issues. However, since the mid-1990s, courts have debated whether informed consent should be stretched to accommodate other concerns. For example, some courts have considered whether economic limitations on treatment availability must be made known to a patient as part of the informed consent process. Other courts have considered whether characteristics of the treatment provider (e.g., experience with a particular procedure) should be disclosed as part of informed consent. Consideration of these issues turns in large part on whether the information in question would be considered "material" to a decision to accept or reject treatment. This article discusses these developments, and suggests that expanding informed consent beyond treatment-related issues in some circumstances may erode trust in the clinical relationship, thus undermining one of the central values of the informed consent doctrine. It concludes with some suggestions on how research could inform this debate.     

Reflections on the use of patient records: Privacy,ethics, and reparations in the history of psychiatry

One of the most common questions we get asked as historians of psychiatry is “do you have access to patient records?” Why are people so fascinated with the psychiatric patient record? Do people assume they are or should be available? Does access to the patient record actually tell us anything new about the history of psychiatry? And if we did have them, what can, or should we do with them? In the push to both decolonize and personalize the history of psychiatry, as well as make some kind of account or reparation for past mistakes, how can we proceed in an ethical manner that respects the privacy of people in the past who never imagined their intensely personal psychiatric encounter as subject for future historians? In this paper, we want to think through some of the issues that we deal with as white historians of psychiatry especially at the intersection of privacy, ethics, and racism. We present our thoughts as a conversation, structured around questions we have posed for ourselves, and building on discussions we have had together over the past few years. We hope that they act as a catalyst for further discussion in the field.     

Bridging Conversations: Discussing the Intra‐professional Relationship between Medical Family Therapy and Family Therapy

This article examines the conceptual and practice relationship between medical family therapy (MedFT) and its parent field, family therapy, with MedFT viewed as the extension of relational sense‐making and understanding into a specific venue; that of medicine. The extension of this relational meaning system into medicine is typified by the ability of the therapist to negotiate and connect three main areas of conceptual difference that often account for conflictual relationships between mental and biomedical healthcare providers: (i) patient and provider conceptualizations of issues and goals, (ii) linear and circular understanding of issues and goals and (iii) consultative and expert positions on issues and goals. Two case examples are offered to describe how these three areas of tension are reconciled in practice.     

The agony of opportunity in negotiation: Number of negotiable issues,counterfactual thinking,and feelings of satisfaction

It has long been believed in the negotiation literature that increasing the number of issues in a negotiation is a positive feature because it increases integrative opportunities. But does this also increase negotiator satisfaction? Two studies are presented that examine this relationship between the number of issues in a negotiation and feelings of satisfaction immediately following the negotiation. Results indicate that those who negotiated the most issues felt the worse about their outcome. The proposed mechanism for this effect, that negotiators who deal with more issues generate more counterfactual thoughts imagining better possible outcomes, was tested and confirmed.     

Religious,Ethical and Legal Considerations in End-of-Life Issues: Fundamental Requisites for Medical Decision Making

Religion and spirituality have always played a major and intervening role in a person’s life and health matters. With the influential development of patient autonomy and the right to self-determination, a patient’s religious affiliation constitutes a key component in medical decision making. This is particularly pertinent in issues involving end-of-life decisions such as withdrawing and withholding treatment, medical futility, nutritional feeding and do-not-resuscitate orders. These issues affect not only the patient’s values and beliefs, but also the family unit and members of the medical profession. The law also plays an intervening role in resolving conflicts between the sanctity of life and quality of life that are very much pronounced in this aspect of healthcare. Thus, the medical profession in dealing with the inherent ethical and legal dilemmas needs to be sensitive not only to patients’ varying religious beliefs and cultural values, but also to the developing legal and ethical standards as well. There is a need for the medical profession to be guided on the ethical obligations, legal demands and religious expectations prior to handling difficult end-of-life decisions. The development of comprehensive ethical codes in congruence with developing legal standards may offer clear guidance to the medical profession in making sound medical decisions.     

The development of a psychoanalytic outcome study: choices, conflicts, and consensus

This article tells the story of the development of an outcome study of psychoanalysis and describes the debate that took place over critical methodological issues. The protocol committee included career psychotherapy researchers who have conducted rigorous outcome studies, clinical psychoanalysts, study methodologists, and a statistician with clinical trial expertise. The committee worked for two years to develop the study design. This project is based on the premise that clinical psychoanalysis is a treatment. Areas specifically addressed are the goals and hypothesis of the study, inclusion and exclusion criteria, choice of psychotherapies as comparison treatments, definition of treatments and selection of therapists, use of medication, development of a treatment adherence measure, randomization of patient assignment vs. patient self-selection, and primary outcome measures. The execution of this outcome study will require significant effort and resources. A positive result would boost the standing of psychoanalysis, but the results may not support the primary hypothesis that there are therapeutic benefits unique to psychoanalysis and that psychoanalysis can effect demonstrable changes in a patient's mental life and adaptation that are not achieved by treatments of different orientation and/or lesser intensity. However, more important than whatever specific results emerge is what executing such a study requires of our field: the process of addressing the clinical issues that a study design requires, the creation of a network of analysts around the country working on a common project, and the joining of the clinical psychoanalytic community with a community of psychodynamic researchers.     

Ethics, Engineers and Drama

This paper describes four plays which illustrate ethical themes relevant to engineers and which could be used as a resource for engineers who wish to explore ethical topics and their relationship with professional practice. The plays themselves have been chosen because a character in the play is involved in engineering activities. Each play is analysed to highlight some of the ethical issues the play raises. Often ethical topics are presented in abstract terms but the plays relate ethical issues to individuals and individual actions in specific situations that connect either directly or figuratively to practical situations engineers find themselves in. The paper describes how the resources have or could be used in an educational programme.     

Weight perception, weight change intentions, and alcohol use among young adults

Obesity and binge drinking are important health issues for young adults in the United States. Several studies have investigated the relationship between these constructs with mixed results. One possible explanation to disentangle this relationship suggests that how people feel about their weight, regardless of their actual weight, may explain some variation in alcohol use. This study (n = 4497) investigated the relationship between two types of body weight concerns--weight perception and weight change intentions--and binge drinking. Controlling for measured body weight, we considered whether body weight concerns increase risk for binge drinking. Findings suggest that women who reported trying to lose weight had an increased risk of binge drinking. Conversely, men who perceived themselves overweight were significantly less likely to participate in binge drinking. We conclude with a discussion of the finding's implications.