Marco Conci interviews Stefano Bolognini

Abstract

This paper suggests that the understanding of intersubjectivity, which refers to “the dynamic interplay between the analyst's and the patient's subjective experiences in the clinical situation”, is crucial for psychoanalytic work. The analyst's inner experiences, from the first moment that he or she thinks about or meets the patient, belong to an intersubjective situation. Not only are these experiences a valuable channel through which the inner experiences of the patient can be understood, but—as Theodore Jacobs puts it—they are often complementary to that which comes from the patient. The author tries to illustrate the above through the study of the analytic process in the psychoanalytic therapy of a severely disturbed patient. This therapy from its very early phase led to the reawakening of some of the analyst's old conflicts. The patient's difficulties in tolerating the limits of the analytic setting and using free association are discussed, as are his enactments. The analyst's close observation of the interaction between her and the patient, the permanent engagement with her countertransference, and the use of her inner experiences with the patient helped her to contain the enactments, defined the nature of her interventions, and contributed to the analytic process.     

Sex differences in responding to rectal cancer symptoms

Many people who develop cancer symptoms wait inordinate amounts of time before seeking medical attention. Studies have found that symptom appraisal time–the time that passes before the individual concludes that their symptoms could be serious–accounts for most of the total delay time across subjects. It is thus important to understand the individual characteristics associated with slow recognition of dangerous symptoms. In this study, 62 patients (38 males) recently diagnosed with rectal cancer answered questions regarding the development of symptoms as well as their decisions and behaviors prior to seeking help. One subgroup of patients–males with the lowest scores on a measure of trait anxiety–took significantly longer to recognize the seriousness of their symptoms as compared to all other patients. This finding is discussed in the context of recent studies where the interaction of sex and negative affect is related to symptom reporting and other health-related behaviors.     

An exploration of attitudes toward the use of patient incentives to support diabetes self-management

Objective: To improve our understanding of the potential of incentives to enhance diabetes self-management (type 1 and type 2) and to integrate incentives into a conceptual model of diabetes self-management over time.

Design: A qualitative analysis of in-depth individual interviews with 12 patients and 9 providers.

Main outcome measures: Influence of time on patients’ needs for diabetes self-management technologies and on the use of incentives to drive behavioural changes.

Results: Ten of the 12 participants with diabetes (83%) were interested in using financial incentives to improve their diabetes self-management. We found that incentives can play two key roles in diabetes self-management: guide the learning phase during the creation of habits; and serve as an acknowledgement of efforts made in the stable phase, when providers typically only focus on the patients’ failures at self-management.

Conclusion: Patients seem receptive to the idea of financial incentives, which have the potential to support diabetes self-management through either small monetary amounts or tangible rewards. Incentives hold promise for supporting behaviour changes, especially in early stages of diabetes, but they require careful planning to avoid the undesired consequence of decreased intrinsic motivation.     

Beliefs about surgery: Development and validation of an instrument to assess cognitive representations about surgery,in the context of a chronic illness

Objectives: Within a trial of medical and surgical treatments for gastro-esophageal reflux disease (GORD), involving randomised arms and preference arms, we tested the applicability of the Beliefs about Medicines Questionnaire (BMQ) and developed and tested the validity of a new Beliefs about Surgery Questionnaire (BSQ). Methods: Patients with GORD (N = 43) were interviewed to elicit their beliefs about medical and surgical treatments. These contributed to the development of BSQ items. The BMQ and BSQ were completed by trial participants at baseline (randomised trial: N = 325; preference trial: N = 414). Factor analysis and discriminant function analysis were used to assess validity. Results: Principal components analysis (PCA) largely replicated the four-factor BMQ structure. PCA of the combined BMQ/BSQ yielded six factors explaining 54.5% variance. BSQ items loaded onto distinct factors, demonstrating divergence from BMQ. As predicted, BMQ/BSQ scores enabled correct classification of 78.5% of participants to medication and surgery groups in the preference trial (χ²(6) = 205.9, p < 0.001) but only 54.5% (no better than chance) in the randomised trial (χ²(6) = 9.4, p = 0.154). Conclusions: The BSQ is a valid measure of perceptions about surgical treatments for GORD. With the BMQ, it provides information that may guide patients’ choices about treatment. This measure may be applicable to other conditions.     

Encouraging patient participation in general practice consultations: Effect on consultation length and content,patient satisfaction and health

Abstract

Following the evidence from earlier research that one-to-one interventions can increase the patient's contribution to the consultation, this paper reports the results from a randomised control trial which assessed the effects of a leaflet designed to enhance patient participation in consultations. A random sample of patients (aged 16 to 74) waiting to see a general practitioner were given either an intervention leaflet, which encouraged the patient to take an active role in the consultation, or a control leaflet which gave dietary advice. The effects of the intervention were assessed by measuring length of consultation, number of questions asked by the patient, patient satisfaction score, doctor's feelings about the consultation, the change in patients' health in the 4 weeks following the consultation (measured by the SF-36 Health Survey) and the number of patient visits to a GP in the following year. The results showed that patients in the intervention group had significantly longer consultations than those in the control group and tended to ask more questions but there was no significant effect on patient satisfaction. The doctor tended to feel that he had a better understanding of patients in the intervention group. Overall there was no significant effect on SF-36 scores but, for patients under the age of 40, and for those in higher social classes the scores of patients in the intervention group improved to a significantly greater degree than did those for the control group. The intervention did not have any effect on the number of GP visits made by patients in the subsequent year. The study results show that a relatively simple leaflet can have an impact on patients' behaviour during the consultation, even though there were no effects on patient satisfaction with the consultation or in the number of GP visits in the following year.     

Patient role orientations,doctor-patient fit,and visit satisfaction

Abstract

Two studies were conducted using the Patient-Practitioner Orientation Scale (PPOS), an instrument that measures the role orientations of patients. In the first, 297 students responded to a pool of 61 items concerning their attitudes about doctor-patient relationships (e.g., about power-sharing and the importance of physicians' supportiveness). The scale was reduced, and associations between PPOS scores and gender, race, country of origin as well as Health Locus of Control were found. In Study 2, 90 additional students filled out the PPOS, read two doctor-patient scenarios, and rated their satisfaction as if they had been the patient. In one, the physician exhibited a controlling style, and in the other a more open style. As predicted, patient-centered physicians generated higher satisfaction, and patients were most satisfied with a physician whose style matched their own role orientation. These studies suggest the potential usefulness of the PPOS as an indicator of patient attitudes and doctor-patient fit, and as an predictor of visit satisfaction.     

Is it time for Hippocrates and Freud to have a joint consultation? MUS patients – A reflection from the front line

Patients with ‘medically unexplained symptoms’ (MUS) remain an ongoing challenge to medical practitioners using conventional approaches to diagnosis and treatment. This challenge often creates tensions and defensive enactments in the doctor–patient relationship. In this viewpoint article, a personal reflection from current clinical practice is presented as a catalyst for further dialogue. In particular, psychoanalytic thinking around the issue of MUS is advocated as bringing a valuable focus by looking at ‘meanings’ behind symptoms. Medical practitioners may benefit considerably by working jointly with psychoanalytical practitioners. This could improve the care of patients with MUS and in addition bring beneficial understanding to the dynamics of the patient relationship.     

Informed Consent

Summary

This article focuses on informed consent and the components to be reviewed with clients in the first session or as early as possible thereafter. Recent changes that give patients greater autonomy in the treatment process are also presented. The process of obtaining informed consent or informed refusal places a new responsibility on the practitioner. Informed consent as it pertains to clinical practice, supervision and training, and psychological research is also discussed.     

How a Mental Health Professional Handles Referrals and Fees

Summary

The choice of referral and the relationship between referral sources can pose clinical and ethical dilemmas, due to the potential that the relationship between the psychologist and the referral source will interfere with the treatment relationship. Once the referral has been made, the referring psychologist must be sensitive to a second, and often a more problematic level of risk: conflicts that occur between the patient and the referral recipient. The situation becomes even more problematic when a psychologist is giving or receiving any form of compensation in connection with the referral. In addition to clouding the clinical relationship, the giving or receiving of such compensation, whether it is characterized as “referral fees” or otherwise, has important legal consequences, and may well result in license revocation proceedings or even criminal liability.     

关怀哲学视阈下的自杀防控探究

自杀问题是当下社会中存在的精神卫生症候之一,从关怀哲学的视角探究自杀防控理念的历史源流、现实境遇、临床困境与价值诉求,经由医患关怀的和谐转化,医务人员可以在防控自杀病人的进程中达到“关怀”与“防控”的知行统一,一方面为自杀病人提供文化关怀的防控脉相,另一方面为医护人员在自杀防控的实践运用层面提供参考.