Qualitative Cancer Genetic Counseling Research, Part I: Ethnography in a Cancer Clinic

This is a report of the experience of several months' ethnographic research by a genetic counselor researcher in a cancer treatment clinic. One goal of the exercise was to directly experience a method of qualitative research known as ethnography, which relies heavily on participant-observation, in an applied clinical setting. Another goal was to explore a previously undescribed research area in the genetic counseling literature, namely, the meaning of cancer and cancer treatment for affected individuals and their support companions. Here we report on a personal account of the experiences of conducting and publishing the research. The preliminary analysis and results of this field experience are published elsewhere (Peters et al. (2001) J Genet Counsel 10(2):151–168.). These initial findings support the feasibility of genetic counselors, who are trained in specific social science methodologies, to conduct qualitative research pertinent to genetic counseling practice.This work was completed at the University of Pittsburgh before employment at the National Cancer Institute (NCI) and does not represent the views of the NCI, the National Institutes of Health, the Department of Health and Human Services, or the Federal Government     

Outcome Trajectories for Adolescents in Residential Treatment: A Statewide Evaluation

Although residential treatment represents one of the largest and most expensive components of the mental health service system for children and adolescents, little is known about the anticipated outcomes of this service. Still less is known about the trajectory through which change occurs within these settings. We examined the clinical status of 285 adolescents over a 2-year period after placement in residential treatment by the Department of Mental Health in a western state. Using a growth modeling technique, the rate of change was determined over a set of symptoms measured by the Acuity of Psychiatric Illness—Child and Adolescent Version (CAPI). Results suggest that while adolescents tended to improve overall during the course of their stays, there was considerable variation in which symptoms improved and which did not. Two symptoms actually became reliably worse with treatment. In addition, significant variation in outcomes was demonstrated across sites, with adolescents in one site getting reliably worse during the course of residential treatment. Our findings demonstrate the utility of outcomes management and have significant implications for how residential services for children and adolescents should be managed.     

A Psychometric Normative Database for Pre-Lung Transplantation Evaluations

This study describes the quality of life and psychological characteristics of a large sample (N = 201) of adult patients evaluated for lung transplantation. In light of the interdisciplinary nature of pre-lung transplant evaluations, establishing norms for measures commonly used in the assessment of transplant candidates has been a priority for the University of Florida transplant programs. Forty-eight percent of the patients reported symptoms of mild to moderate depression. Although quality of life indices were associated with disease severity and exercise tolerance, psychosocial measures generally were not. These data contribute uniquely to the transplant literature and provide valuable normative information on the largest lung transplant cohort reported to date.     

Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings.

In this study, habit reversal was evaluated as a treatment for skin picking in typically developing adult male siblings using a nonconcurrent multiple baseline across participants design. Results showed socially valid decreases in reported picking as a result of treatment.     

Cognitive-Behavioral Therapy: The Truth Behind the Allegations

In response to several pejorative statements about Cognitive Behavioral Therapy in a recent issue of Psychotherapy (Silverman, 1999), a point by point counter argument to these criticisms are presented. Among other contentions, Silverman (1999) disparaged empirically validated methods as being simplistic and scientifically impoverished. The validity of these statements are challenged and empirical evidence is presented to support each counter argument. The efficacy of Cognitive Behavioral Therapy for a broad range of disturbances and presenting problems is presented. The future of Cognitive Behavioral Therapy and other empirically validated protocols are discussed, as well as recommendations for their use.     

Residual Geriatric Depression Symptoms: A Place for Psychotherapy

Geriatric depression is a relatively commonly occurring mental disorder. A subpopulation of depressed older adults are those who have engaged in or completed pharmacotherapy, yet continue to experience depressive symptoms. We review the prevalence, psychosocial effects, and treatment of residual symptoms of depression in older adults. Data from previous studies conducted by our group are presented to support our contention that residual symptoms of geriatric depression are treatable through psychosocial means.     

Anxiety Disorders Among Older Primary Care Patients

Data from the 1997 National Ambulatory Medical Care Survey (NAMCS) were accessed to obtain information about naturalistic patterns of recognition, service utilization, and treatment for late-life anxiety in primary care. The NAMCS is a national probability sample survey of office visits to non-Federal, U.S. physicians engaged in patient care. The survey was conducted by the Division of Health Care Statistics, National Center for Health Statistics, and Centers for Disease Control and Prevention (CDC). Data are now in the public domain. For the current report, all cases indicating office visits for patients age 60 and older were selected (n = 7,687). Anxiety disorders were assigned for 1.3% (n = 99) of these visits, with anxiety disorder NOS the most frequent diagnosis. For 20.2% of these visits (n = 20), a coexistent depressive disorder also was diagnosed. Depression without coexistent anxiety was diagnosed for 2.3% of all visits (n = 176). These figures suggest that late-life anxiety may often go unrecognized and may be more difficult to detect than depression. Nevertheless, other data indicate that appropriate pharmacological treatment and mental health services or referrals are often provided when anxiety or depression is recognized. However, visits wherein these disorders are recognized require increased physician time, and significant proportions of patients in some groups may still not receive appropriate mental health care. Results are discussed in terms of the nature of usual care for late-life anxiety and the needs for future research.     

Predicting Treatment Response in Older Adults with Insomnia

This study examined potential predictors of treatment outcome in late-life insomnia. Fifty-four older adults with chronic insomnia were treated with cognitive–behavior therapy (CBT), pharmacotherapy (PCT), or combined CBT plus PCT. Pretreatment characteristics such as demographic, clinical, psychometric, and sleep variables were examined as correlates or potential predictors of treatment response. Treatment response was defined by posttreatment sleep efficiency as measured subjectively by daily sleep diary and objectively by polysomnography. The results indicate that age, insomnia duration, medical illness, and previous use of sleep medications can moderate subjective or objective treatment outcome or both of these in late-life insomnia. However, there are no reliable predictors of outcome across all treatment and assessment modalities. The implications of these findings for the treatment of insomnia in older adults seen in primary care settings are discussed.     

The Epistemology of Communitarian Bioethics:Traditions in the Public Debates

I consider the problem liberalism poses for bioethics.Liberalism is a view that advocates that the state remain neutralto views of the good life. This view is sometimes supported by askeptical moral epistemology that tends to propel liberalismtoward libertarianism. I argue that the possibilities for sharedagreement on moral matters are more promising than is sometimesappreciated by such a view of liberalism. Using two examples ofpublic debates of moral issues, I show that commonly sharedintuitions may ground moral principles even if they may be givendifferent weight by persons of different moral and religioustraditions. Nevertheless, the fact that the intuition andprinciple is widely shared may be sufficient to chart somedirections for public policy or cooperative action even if theydo not lead to complete agreement. As a result, I argue that aliberal communitarianism that presupposes a fairly minimalistepistemology is a legitimate approach to achieving sharedagreement in a pluralistic society.