Understanding,respecting and integrating difference in therapeutic practice

The purpose of this paper is to promote thought and discussion around how and why we treat patients in chosen ways. In the present climate practitioners are required to treat patients following NICE guidelines in which cognitive behavioural therapy (CBT) is the treatment of choice in the majority of diagnoses. This paper raises concerns that this may lead to an homogenization of treatment, loss of invaluable skills and understanding from other treatment approaches, and loss to the patient who may be best cared for by a combination of treatments and approaches, most notably patients presenting with complex pathology. This paper aims to present this as a general principle, and by way of example, will focus on coupling two specific treatment orientations, cognitive behavioural therapy with psychodynamic psychotherapy, with the specific diagnosis of obsessive compulsive disorder (OCD).

Methods: Clinical material is drawn from case studies from practice in secondary adult mental health care services within the NHS. All patients were referred to the psychological services for treatment for OCD and provided with 1:1 therapy with UKCP‐registered therapists. Details have been anonymized by describing fictitious cases re‐constructed from clinical material. A theoretical understanding is included which provides both an overview for integrating treatment for the specific example of OCD and is intended by extension to other diagnoses.

Results: Working with the commonalities of therapeutic approaches, and integrating specific skills of CBT and psychodynamic psychotherapy, appears to offer a viable mode of treatment for cases resistant to single‐orientation therapies.

Conclusions: Coupling the skills of different therapies can be effective in treating complex patients that are referred to the secondary mental health services. Conversely, restricting practice to single orientation therapies can lead to an impoverished care for patients and diminution of invaluable therapeutic skills which may become underused, undervalued and lost in the practice of mental health care within the NHS. Acknowledgement of the skills of others, valuing these and learning from each other can help to avoid the defensive reactions of practitioners, where each may defensively retreat to their corners of specialism. Respecting and sharing skills from different orientations, and acknowledging this in the NICE guidelines, is good for both mental health services and patient care and addresses the concerns raised by practitioners exemplified by Bateman (2000 Bateman, A. 2000. Integration in psychotherapy: An evolving reality in personality disorder.. British Journal of Psychotherapy, 17(2): 147–156.  [Google Scholar], p. 147) that ‘psychotherapy continues to be bedeviled by ideological schisms with practitioners apparently ignoring alternative conceptualizations and potentially superior interventions’.     

Clinical Management of Gender Dysphoria in Adolescents

SUMMARY

This paper aims to provide professionals working with adolescents with gender-dysphoric feelings practical clinical guidelines for diagnosis and treatment. The different phases of the assessment procedure and treatment process are described. Differential diagnostic considerations and possible psychotherapeutic treatment options are given. Physical interventions, including GnRH analogues to inhibit puberty and cross-sex hormones, are described with consideration of eligibility and readiness issues. We end with discussion of post-treatment evaluation.     

Developing Standard Recommendations (Guidelines) for Genetic Counseling Practice: A Process of the National Society of Genetic Counselors

The National Society of Genetic Counselors (NSGC) supports the development of practice recommendations (guidelines) in the field of genetic counseling. This paper reviews the basic components of NSGC genetic counseling practice recommendations as well as the process for formal adoption of such documents, as approved by the Board of Directors of the NSGC.     

Individual glance strategies and their effect on the NHTSA visual manual distraction test

The purpose of this paper was to investigate how individual differences in glance strategy could impact the glance performance test defined in the NHTSA visual manual distraction guidelines. Better understanding of the test procedure could help development of new technology for safe driving. A custom in-vehicle information system was developed and assessed in a driving simulator by eighteen participants. The interfaces were designed according to recommendations in the NHTSA guidelines and contained manual radio-tuning tasks, sound settings tasks and six letter spelling tasks. Two of the six tested interfaces fully complied with the test. In addition, clear individual differences in glance strategy were found among the participants. Four individual glance strategies were identified. Two of these, long glancers and frequent glancers, highly affected the outcome of the compliance test. Participants belonging to the long glancers and the frequent glancers categories were identified as statistical outliers in many test cases. For example, if the individual values of these participants were replaced with sample mean, the number of complying interfaces would increase to five out of six, which is more in line with expectations for these interfaces. The results of this study show that individual variations in glance strategy exist. Also, these individual variations seem to have a non- negligible influence on the result when performance-testing of in-vehicle interfaces is done according to the NTHSA guidelines.     

Three Conceptual Models of Patient and Public Involvement in Standard-setting: From Abstract Principles to Complex Practice

Clinical practice guidelines have been critiqued for prescribing standardized care that neglects patients’ personal circumstances and knowledge in health care decisions. To make care more patient centred, standard-setters are urged to involve patients and the public in guideline development and use. Despite widespread principled support for such Patient and Public Involvement (PPI), the underlying principles guiding PPI in standardization of care are mired on confusion and contradiction. Based on the PPI literature in general, and informed by empirical research on guideline development, it is possible to identify three rationales that justify PPI in clinical standard setting. Each rationale gives rise to a conceptual model which outlines a distinct purpose of participation, who is to be included, and what they are expected to contribute. The Consumer Choice model aims to involve autonomous consumers to personalize clinical care. The Democratic Voice model aims for health care recommendations to better reflect collective values of citizens. The Lay Expertise model aims to re-contextualize universal evidence by including experiential patient knowledge. However, these models can and should not function as ‘Gold Standards’ to be consistently followed in practice. First, the models rely on two distinct types of representation, resulting in contradictory notions of how to be a good representative. Second, imposing models on practice requires a top-down control that is practically and politically problematic. Not only is control difficult to achieve, it may compromise the participatory ideal of participants co-determine practice, and may result in excluding the values and views of ‘real’ patients and public entirely.     

The International Test Commission Guidelines on the Security of Tests,Examinations, and Other Assessments

The amount and severity of security threats have increased considerably over the past two decades, calling into question the validity of assessments administered around the world. These threats have increased for a number of reasons, including the popular use of computerized and online technologies for test administration and the use of almost undetectable technologies for capturing test content and illegally sharing it instantly across borders and cultures. No assessment program, large or small, is immune to this potential damage. The International Test Commission has recognized the critical need for every organization with an important assessment program to be aware of these and be prepared to counter them. It was for this purpose that these guidelines were developed. Knowing the threats and the guidelines will lead to effective measures to protect the program and its assets, maintaining the value of the tests and assessments to the international community. The guidelines listed in this article provide recommendations on planning for better security, maintaining security during the development of tests and while they are administered, and responding well when a security breach occurs. Following these guidelines will create a significant protective barrier between those who willingly commit test fraud and the valuable assets a program has spent time and money to build.     

Genetic Counseling for Fragile X Syndrome: Recommendations of the National Society of Genetic Counselors

The National Society of Genetic Counselors' (NSGC) recommendations for fragile X syndrome (FXS) genetic counseling are intended to assist health care professionals who provide genetic counseling for individuals and families in whom the diagnosis of FXS is strongly suspected or has been made. The recommendations are the opinions of genetic counselors with expertise in FXS counseling and are based on clinical experience, a review of pertinent English language medical articles, and reports of expert committees. These recommendations should not be construed as dictating an exclusive course of management, nor does use of such recommendations guarantee a particular outcome. These recommendations do not displace a health care provider's professional judgment based on the clinical circumstances of a particular client.     

Decision-making in rectal and colorectal cancer: systematic review and qualitative analysis of surgeons’ preferences

Surgeons are experiencing difficulties implementing recommendations not only owing to incomplete, confusing or conflicting information but also to the increasing involvement of patients in decisions relating to their health. This study sought to establish which common factors including heuristic factors guide surgeons’ decision-making in colon and rectal cancers. We conducted a systematic literature review of surgeons’ decision-making factors related to colon and rectal cancer treatment. Eleven of 349 identified publications were eligible for data analyses. Using the IRaMuTeQ (Interface of R for the Multidimensional Analyses of Texts and Questionnaire), we carried out a qualitative analysis of the significant factors collected in the studies reviewed. Several validation procedures were applied to control the robustness of the findings. Five categories of factors (i.e. patient, surgeon, treatment, tumor and organizational cues) were found to influence surgeons’ decision-making. Specifically, all decision criteria including biomedical (e.g. tumor information) and heuristic (e.g. surgeons’ dispositional factors) criteria converged towards the factor ‘age of patient’ in the similarity analysis. In the light of the results, we propose an explanatory model showing the impact of heuristic criteria on medical issues (i.e. diagnosis, prognosis, treatment features, etc.) and thus on decision-making. Finally, the psychosocial complexity involved in decision-making is discussed and a medico-psycho-social grid for use in multidisciplinary meetings is proposed.