Political and interpersonal aspects of ethics consultation

Previous papers on ethics consultation in medicine have taken a positivistic approach and lack critical scrutiny of the psychosocial, political, and moral contexts in which consultations occur. This paper discusses some of the contextual factors that require more careful research. We need to know more about what prompts and inhibits consultation, especially what factors effectively prevent house officers and nonphysicians from requesting consultation despite perceived moral conflict in cases. The attitudes and institutional power of attending medical staff seem important, especially where innovative interventions raise ethical questions. Ethics consultants also need to address the thorny problems of the origin(s) of the consultant's authority, whistleblowing, conflicts of interest that affect the consultant, persistently poor communications in hospitals, systemic inequity in the availability or quality of services for some, and the standing of the consultant's recommendations, including their appearance in the patient's medical record.     

Behavioral case consultation with parents and teachers: An example using differential reinforcement to treat psychogenic cough

This study presents a demonstration of successful behavioral case consultation combined with case study methodology in the treatment of a 13-year-old female who presented with a brief history of psychogenic cough. Psychogenic cough is diagnosed when there is no organic or physiologic basis for the repeated, harsh coughing. We first present a brief review of treatments for psychogenic cough and then describe how we used differential reinforcement of low rate responding (DRL) and differential reinforcement of zero responding (DRO) within an A-B-C design. The DRL schedule produced significant decreases in coughing but plateaued at about one-third the baseline rate. Thereafter, a DRO schedule was employed which resulted in complete and lasting elimination of coughing. Discussion focuses on the limitations of case study methodology as well as its usefulness for conducting service related research in the schools, implications of some of the findings for practitioners, and other issues related to treatment.     

Effectiveness of a consultation intervention to promote tobacco control policies in Northwest Indian tribes: Integrating experimental evaluation and service delivery

A quasi-experimental replication of an intervention for promoting tobacco control policies in Northwest Indian tribes is described and the process of intervention including issues of collaboration among research institutions and Indian organizations is discussed. The policy intervention was evaluated using a pretest-posttest design wherein 20 tribes that had served as wait-list controls now received the intervention. The intervention comprised a tribal representative attending a kickoff orientation; follow-up visits to the tribes; distribution of tobacco policy workbooks; and phone call consultations. Policy status and stringency were assessed by means of telephone interviews with two key contacts per tribe, and by a count of enacted policies. There were significant pre-post changes in the primary outcome measure, a composite summary score of tobacco policy stringency, and changes were also reflected in enacted policies. The intervention effects observed were similar to those found in the prior randomized trial and suggest a robust, disseminable intervention. Much of the success achieved was attributed to the role of an Indian organization in planning the project and implementing the intervention and evaluation protocols.     

Ecosystemic consultation in the kibbutz: social process and narrative in two cases of community “epidemic”

This paper emphasizes working with the social component of the biopsychosocial model. A dual approach for renarrating dysfunctional community narratives and for changing the social process is described. This approach was applied to two cases of epidemics allegedly cased by mysterious environmental agents that occured on kibbutzim. The collective adoption of irrational beliefs is analyzed by using concepts from sociology and crowd psychology. The suggestive effects of the emotional contagion and of the preoccupation with a persistent belief are examined by applying the concept of monoideism. The epidemics were resolved by working in collaboration with the community. The intervention programs mobilized inner resources by helping the kibbutzim to adopt a more unified approach to their presenting problems, and by challenged them to face previously avoided more fundamental dilemmas.     

Implementing scientific practices through case studies: Examples using home-school interventions and consultation

Integrating scientific methods into school psychological practice is an essential tenet of effective service. In this article, we present two related examples that demonstrate methods by which to conduct high-quality intervention and consultation case studies with integrity. The present case studies utilized home note and consultation-based interventions to improve task completion and accuracy in mathematics for primary grade students who had demonstrated performance difficulties despite adequate intellectual ability and academic skills. Two sets of case studies were conducted. One involved the use of a home-school note implemented by parents and teachers in conjunction with a self-instruction manual. The second set of case studies used the home note and manual instituted in the context of behavioral consultation with parents and teachers. Both interventions (home-note-only and home note with consultation) increased math completion and accuracy in underachievers. Levels of performance were stable and differences between baseline and treatment conditions were statistically significant for consultation students only. Treatment integrity, maintenance of treatment gains, and consumer acceptability were also stronger in the consultation case studies. The implications for practitioners and future research are explored.     

A Work in Progress

After expressing gratitude to each contributor, and briefly commenting on each, I probe several main themes of my work, addressing the question of the apparent difference between my earlier philosophical and later clinical writings. Central to both is the reflexivity of the human agent, and that each exhibits a form of practice regardless of the specific aims embedded in each. I then address the theme of narrative writing as my work has developed over the past several decades – at the heart of which are questions of self and integrity.     

Cultural Diversity and Patients with Reduced Capacity: The Use of Ethics Consultation to Advocate for Mentally Handicapped Persons in Living Organ Donation

Theoretical Medicine and Bioethics - Living organ donation will soon become the source of the majority of organs donations for transplant. Should mentally handicapped people be allowed to donate,...     

One REBTers Model for Business Consulting

Organizational consulting offers opportunities to diversify one’s practice and increase one’s income, all the while reducing the frustrations associated with working with insurance and managed care companies. This paper describes one REBT therapist’s conception of the “personality” of any organization, a list of potential services to offer businesses, and a few practical suggestions to successfully transfer from the clinical office into the organizational world.     

Learning from experience in case conference: A Bionian approach to teaching and consulting

In case conferences as well as didactic seminars, the power of the group can bring psychoanalytic education to life. However, primitive anxieties activated by group dynamics may also interfere with teaching and learning. The authors offer the example of a stalemated private practice case conference that had unconsciously organized against learning as the members began to read Bion's work. The case conference leader, an analyst, presented her case conference, which was mired in basic assumption dependency dynamics, to our peer consultation group. Drawing upon Bion's early contributions on groups, as well as his later ideas about thinking and mental growth, the peer group facilitated the case conference's return to work-group functioning and learning from experience. Activated in the peer group, commensal container↔contained processes gradually spread throughout the entire relational system of peer group, case-conference leader, case-conference members, and patients. This example underscores the importance of promoting within our institutes a culture in which faculty view themselves as part of an evolving intersubjective matrix that works to foster the containing capacities of candidates, patients, and faculty alike.