By-Person Factor Analysis in Clinical Ethical Decision Making: Q Methodology in End-of-Life Care Decisions

Objective: To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues.

Design: Qualitative study using by-person factor analysis of subjective Q sort data matrix.

Setting: University medical center.

Participants: Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center.

Interventions: Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases.

Measurements and Main Results: Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r ² < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study.

Conclusions: Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.     

Compounding Vulnerability: Pregnancy and Schizophrenia

The predominant ethical framework for addressing reproductive decisions in the maternal–fetal relationship is respect for the woman's autonomy. However, when a pregnant schizophrenic woman lacks such autonomy, healthcare providers try to both protect her and respect her preferences. By delineating etic (objective) and emic (subjective) perspectives on vulnerability, I argue that options which balance both perspectives are preferable and that acting on etic perspectives to the exclusion of emic considerations is rarely justified. In negotiating perspectives, we balance the etic commitment to protect the vulnerable patient and her fetus from harm with the emic concern to empower a decisionally incapacitated woman. Equilibrium is best achieved by nurturing interdependent relationships that empower and protect the vulnerable woman. The analysis points to the need for better social support for mentally ill patients.     

David and Judith

SUMMARY

This paper begins with a discussion of Dialogicai Psychotherapy-that “healing through meeting” which comes when the relation between therapist and patient is central-and explores inclusion, making present, confirmation, and the “normative limitation of mutuality.” Secondly, it discusses a Dialogicai Psychotherapy particularly important for couples therapy-Ivan Bos-zormenyi-Nagy's Contextual (intergenerational family) Therapy with its emphases on multidirected partiality, trustbuilding, rejunction, and the intergeneration merit ledger. The third part of the paper applies Dialogicai and Contextual therapy to the case of David and Judith, a couple who show clearly the importance of families of origin.     

Training Community-Based Clinicians in Transgender Care

SUMMARY

Community-based care of transgender individuals can help promote access for individuals whose needs are not well met by a centralized, institution-based system. As there is wide variability in transgender expertise and familiarity among community-based practitioners, practice guidelines and clinical training are needed to promote consistency and quality of care. This article suggests frameworks for training clinicians working in the community setting. Suggested core competencies are followed by an outline for basic, intermediate, and advanced levels of clinical training, and a discussion of education priorities.     

The Satisfaction With Life Scale and the emerging construct of life satisfaction

Since its introduction in 1985, the Satisfaction With Life Scale (SWLS; Diener, Emmons, Larsen, & Griffin, 1985 Larsen, RJ, Diener, E and Emmons, RA. 1985. An evaluation of subjective well-being measures. Social Indicators Research, 17: 1–18. [Crossref], [Web of Science ®] , [Google Scholar]) has been heavily used as a measure of the life satisfaction component of subjective well-being. Scores on the SWLS have been shown to correlate with measures of mental health and to be predictive of future behaviors such as suicide attempts. In the area of health psychology, the SWLS has been used to examine the subjective quality of life of people experiencing serious health concerns. At a theoretical level, extensive research conducted since the last review (Pavot & Diener, 1993 Pavot, W and Diener, E. 1993. Review of the Satisfaction With Life Scale. Psychological Assessment, 5: 164–172. [Crossref] , [Google Scholar]) has more clearly articulated the nature of life satisfaction judgments, and the multiple forces that can exert an influence on such judgments. In this review, we examine the evolving views of life satisfaction, offer updated psychometric data for the SWLS, and discuss future issues in the assessment of life satisfaction.     

Childhood Sexual Abuse and Intimate Partner Violence in a Clinical Sample of Men: The Mediating Roles of Adult Attachment and Anger Management

This study examined the association between men’s experience of childhood sexual abuse and later perpetration of intimate partner violence, considering the roles of attachment insecurity and poor anger regulation. The sample was 302 Canadian men undergoing counseling for relationship difficulties or aggression. They completed questionnaires assessing childhood sexual abuse, the two dimensions of attachment insecurity (anxiety and avoidance), anger regulation processes, physical and psychological aggression, and social desirability bias. Path analyses showed that men who experienced childhood sexual abuse scored higher on attachment anxiety, which in turn was associated with aggressive behaviors directly and through four anger-related variables (trait anger, anger-in, anger-out, and low anger control). Attachment-related avoidance predicted psychological aggression, but not physical aggression, through men’s trait anger and anger-in.     

A School-Based,Primary Violence Prevention Program

Summary

This article presents findings from an evaluative study of a multidisciplinary violence prevention project jointly administered by a family practice clinic and junior high school in Santa Fe, New Mexico. The project team hypothesized that an intervention established on a public health model and aimed at enhancing adolescent self-esteem through cognitive and behavioral strategies would reduce the tendency to engage in violence of participating students. The project united health care personnel, social workers and legal profession-als in an effort to teach students specific cognitive tools for the reduction and avoidance of violent encounters. The experimental results do not reveal Project effectiveness in boosting self-esteem indicators among students, although the Project docs seem to have contributed to the control of students' behavioral aggression. Although a clear relationship between self-esteem and violent behavior is not demonstrated by the experimental results, the project study suggests that school-based, anti-violence programs based on a public health model can have a positive effect in the reduction of physical and verbal aggression among adolescents.     

Sexual Contact Between Psychologists and Patients

Summary

This article discusses sexualized dual relationships between psychologists and patients, including both sexual contacts while treatment is in progress and after its termination. The reported prevalences of sexual contact between psychologists and patients and between psychologists and former patients are discussed as well as practitioners attitudes towards these two types of relationships. The profiles of both psychologists and patients likely to be involved are outlined as are the clinical and professional consequences of these behaviours. Finally, the APA Ethics Code (2002) is examined to determine whether its inclusions in these areas are adequate and to shed more light on clinicians' continued roles and responsibilities even after treatments have concluded.     

Victimization and Polyvictimization Among Spanish Adolescent Outpatients

This article aimed to analyze lifetime and past-year victimization and polyvictimization experiences in adolescent outpatients from a southern European country. The sample included 149 adolescents (35.6% boys, 64.4% girls), aged 12 to 17 (M = 14.28, SD = 1.45). Experiences of victimization were assessed using the Juvenile Victimization Questionnaire (JVQ; Finkelhor, Hamby, Ormrod, & Turner, 2005). Results showed that 99.3% of those interviewed had experienced at least one type of victimization during their lifetime, and 84.6% reported past-year victimization. Gender and age differences were found. Based on community criteria, the proportion of polyvictims in the sample was 32.2% for lifetime victimization and 20.1% for past-year victimization. When assessing children in the context of outpatient mental health services, it is essential that clinicians explore any history of exposure to violence, as this information is crucial in determining the young person’s therapeutic needs.     

Eyes wide open: Facilitating student therapists’ experiences with the unfamiliar

Psychotherapists and counsellors work increasingly with culturally different or unfamiliar clients in the context of global migration and relocation. This paper explores the learning processes of trainee therapists within a South African community clinic context which confronts trainees with cultural diversity and a range of complex and traumatic presenting problems. Learning within this context entails interfacing with the ‘unfamiliar’, a process which challenges students both culturally and personally. Drawing upon the ideas of Wilfred Bion we suggest the importance of supervisory reverie in helping students convert raw sensory data into reflective practice. We suggest that working within community clinic contexts prompts personal anxieties as well as context-related anxieties of persecution or annihilation, of narcissistic injury and of contamination. It is hoped that a psychodynamic understanding may prompt further debate regarding the training of therapists working with diverse populations and problems.