Reflections of a reluctant clinical ethicist: Ethics consultation and the collapse of critical distance

The obvious appeal and growing momentum of clinical ethics in academic medical centers should not blind us to a potential danger: the collapse of critical distance. The very integration into the clinical milieu and the processes of clinical decision making, that clinical ethics claims as its greatest success, carries the seeds of a dilution of ethics' critical stance toward medicine and medical education. The purpose of this paper is to suggest how this might occur, and what potential contributions of ethics to medicine might be sacrificed as a result. Medical sociology will be used for comparison. Sociologists have found that they may function either as students and critics of established medical practices and educational philosophies, or as collaborative participants in them — but rarely both. It may be that professional ethics is most effective when it plays the role of stranger rather than insider, and is continually able to question the most basic assumptions and values of the enterprise with which it is associated. As with medical sociology, ethics and humanities must ask to what extent their desire for acceptance in the clinic requires their acceptance of the clinic: specifically, acceptance of basic assumptions about optimal ways of organizing medical education, socializing physicians-in-training, providing care, and even of defining medical ethics itself. The paper concludes by recommending that ethics reassert its strangeness in the medical milieu even as it assumes a more prominent role within the medical center.     

Neuropsychological Aspects of Multiple Sclerosis

Since S. Rao's [Neuropsychology of Multiple Sclerosis: A Critical Review, A Journal of Clinical and Experimental Neuropsychology, Vol. 85, pp. 503–542] (1986) seminal review, considerable research has been undertaken on the neuropsychological consequences of multiple sclerosis. This review incorporates the research literature of the last decade in presenting an overview of the current state of our knowledge concerning the etiology, course, symptoms, assessment, consequences, and treatment of multiple sclerosis (MS). The concept of subcortical dementia is revisited in light of the most recent literature documenting the neuropsychological deficits in patients with MS. The view that cognitively heterogeneous patient groups may disguise more specific patterns of focal neuropsychological impairment is considered. A critical review of the recent literature is also presented, detailing the degree to which recent research has addressed the areas of research need identified by Rao in 1986. Given recent advances in our knowledge, the need for more attention to be directed toward the evaluation of rehabilitation and psychological intervention is highlighted.     

Outcomes in a System of Care for Youths with Emotional and Behavioral Disorders: An Examination of Differential Change Across Clinical Profiles

We assessed the utility of an empirically-derived classification system for youths with emotional and behavioral disorders in a system of care with a strong representation of juvenile delinquents. Eighty-seven youths served in a system of care were categorized by variables related to past history, current behavioral functioning, and current psychological functioning into four clinical clusters. We evaluated preliminary clinical outcomes after six months of interagency involvement for youths within each cluster and across the four clusters. Results indicated that youths in different clusters improved significantly in need-specific areas. Trends in our data indicated differential change in clinical outcomes across clusters. We discuss our findings within the context of emerging outcomes of youths involved in comprehensive community-based programs and consider implications for outcome research, treatment of juvenile delinquents, and mental health policy.     

Exercise Stage of Change and Self-Efficacy in Primary Care: Implications for Intervention

Multiple chronic diseases are caused or complicated by a sedentary lifestyle. Thus, an important and challenging application of psychology in clinical settings is changing the behavior of sedentary primary care patients. This study focused on exercise stage of change and self-efficacy in a sample of adult family practice patients recruited while waiting for their scheduled physician appointment. Regarding exercise stage of change, 15% of respondents were in the Precontemplation stage, 26% in the Contemplation stage, 50% in the Preparation stage, 7% in the Action stage, and 13% in the Maintenance stage. Mean self-efficacy scores for exercise were significantly higher among respondents in the Action and Maintenance stages of change. These cross-sectional data are consistent with the hypothesis that movement through the exercise stages of change could be encouraged by clinical interventions that increase exercise self-efficacy. The identification of multiple personal opportunities for increasing exercise self-efficacy may be clinically useful in this context. Recommendations for psychologists in primary care settings in their work with physicians are offered.     

Assessing the specific psychopathology of binge eating disorder patients: Interview or self-report?

Research addressing the assessment of binge eating and associated eating disorder psychopathology has steadily increased in recent years. Few studies have examined the relationship between the various assessment methods. This study compared an investigator-based interview, the Eating Disorder Examination (EDE), with a self-report version of that interview, the EDE-Q. Fifty-two individuals (six men and 46 women) with binge eating disorder (BED) completed both instruments. Modest-to-good agreement and significant correlations (P < 0.0001) were found between the two methods on all four subscales assessing specific eating disorder psychopathology (i.e., Restraint, Eating Concern, Weight Concern, and Shape Concern subscales). However, higher levels of disturbance were consistently reported on the EDE-Q than the EDE interview. The two methods were not significantly or reliably related to one another when assessing binge eating. This may be due in part to the difficulty inherent in identifying binges in subjects with BED. Examination of individual item scores suggest that it might be possible to improve the performance of the EDE-Q by clarifying the definitions of certain complex features, although this should not be at the expense of compromising the practical utility of its self-report format.     

Family history and gender roles: Critical factors in practitioners' views of family interactions

This study examined practitioners' perceptions of family and individual family member functioning in relationship to family roles, gender of family leadership, beliefs about the consequences of maternal employment, and paternal division of responsibility in practitioner family of origin. Practicing counselors and mental health therapists rated two videotaped family interviews, one demonstrating a matriarchal style of family interaction and the second a patriarchal style. Findings indicated that practitioners were vulnerable to view a patriarchal style of family interaction as more healthy in comparison to a matriarchal style and that their perceptions of family members were related to personal beliefs about the consequences of maternal employment and to personal family history. These and other findings suggest that practitioners may be prone to errant perceptions and misguided intervention related to personal history and attitudes.     

Treatment of overweight children: The relationship between dependent measures and a clinically significant outcome

Behavioral treatments for overweight children have not fared well in achieving or maintaining clinically significant weight losses. The use of more appropriate dependent measures which also take height, sex, and age into consideration is suggested. A multiple-baseline analysis of the behavioral treatment of seven overweight children was conducted. Results support the contention that a more clinically significant outcome emerges when appropriate measures are used.     

A Sequential Analysis of Depressive Behaviors Within Adolescent Peer Interactions

This study examined depressive and positive patterns of interactions among clinical and nonclinical adolescent peers within an interpersonal context. Ten clinical dyads with a depressed partner and 10 nonclinical dyads engaged in 16-min audiotaped conversations under positive and negative task instructions discussing positive and negative experiences. Conversations were unitized and coded according to depressive, aggressive, positive, and neutral behaviors. The clinical dyad-group demonstrated over two times more depressive behaviors than did the nonclinical dyad-group. Both dyad-groups exhibited increased depressive interactions during negative task instructions and increased positive interaction during positive task instructions. The loglinear approach to sequential analysis demonstrated significant overall bidirectional influence in the adolescents' dyadic interaction. Specifically, we found that the depressed adolescents' depressive behaviors decreased the likelihood of partners' aggressive behaviors, and increased the likelihood of partners' positive behaviors. Clinical and nonclinical dyad-groups showed reliable patterns of positive interaction sequences. Results demonstrate that depressive and positive behaviors are functional in adolescent dyadic interaction.