Fiduciary Duty and Boundaries: Acting in the Client's Best Interest

The task of defining boundaries and boundary violations in the therapeutic relationship is examined from several perspectives. This paper reviews the ethical rules of the major mental health associations and the American Medical Association to determine the professions' ethical positions with regard to boundary maintenance and boundary violations. It also analyzes judicially sanctioned causes of action for recovery by clients for damages suffered as a result of boundary violations. The authors examine the ways in which fiduciary theory is used in the formulation of the ethical rules and to support the imposition of civil liability for boundary violations. The authors conclude that fiduciary theory provides a useful paradigm for setting and evaluating boundaries that acknowledge and address the fiduciary nature of the therapist–client relationship. The authors point out that measuring boundary violations with the yardstick of fiduciary duty serves the interests of both the client and the therapist. © 1997 John Wiley & Sons, Ltd.     

Ecological Validity as a Key Feature of External Validity in Research on Human Development

This issue addresses the topic of ecological validity in research in human development across the life span. Although recent developments in study design, data collection methods, and data analysis techniques have greatly advanced researchers’ ability to collect large amounts of data on large groups of individuals in natural settings, it is important to approach these data with a reflected understanding of their ecological validity. Just because data were collected using everyday and familiar stimuli or ecological momentary assessment methods does not mean automatically that the ecological validity of these data is guaranteed and can go unquestioned.     

Enhanced perceived responsibility decreases metamemory but not memory accuracy in obsessive-compulsive disorder (OCD)

Mixed findings have been obtained in prior research with respect to the presence and severity of memory and metamemory deficits in obsessive-compulsive disorder (OCD). We tested the hypothesis that experimentally induced increments of subjective responsibility would lead to a disproportionately strong decline of memory confidence and enhanced response latencies in OCD while leaving memory accuracy unaffected. Twenty-eight OCD patients and 28 healthy controls were presented a computerized memory test framed with two different scenarios. In the neutral scenario, the participant was requested to imagine purchasing 15 items from a do-it-yourself store. In the recognition phase, the 15 needed items were presented along with 15 distractor items. The participant was asked to decide whether items were on his or her shopping list or not, graded by subjective confidence. In the responsibility scenario, the general experimental setup was analogous except that the participant now had to envision that he or she was a helper in a region recently struck by an earthquake, dispatched to provide 15 urgently needed goods from a nearby town. In line with prior work by our group, samples did not differ in either condition on memory accuracy in a subsequent recognition task. As hypothesized, OCD participants were less certain in their responses for the high responsibility condition than controls. Whereas patients and controls did not differ in their subjective estimates for memorized items, patients expressed stronger doubt that their earthquake mission was successful. The findings indicate that low memory confidence in OCD may only be elicited in situations where perceived responsibility is high and that patients may share higher performance standards ("good is not good enough") than controls when perceived responsibility is inflated.     

Modeling late-life adaptation in affective well-being under a severe chronic health condition: the case of age-related macular degeneration

Age-related macular degeneration (AMD) was used as a case model to longitudinally study adaptation in affective well-being under a prevalent chronic health condition. Measures of positive and negative affect, obtained at 5 subsequent measurement occasions with 3-month intervals in between, were analyzed in 90 older adults diagnosed with AMD. The authors proposed a pattern of adaptation that shows initial decline in affective well-being after disease outbreak, followed by a turnaround into a restorative phase of increase, implying nonlinear intraindividual trajectories, with changes substantially related to disease duration. Analysis was conducted by means of a nonlinear mixed models approach. Results confirmed the hypothesized adaptation pattern for positive affect but not for negative affect, which was found more stable across measurement occasions.     

Neutralizing increases discomfort associated with obsessional thoughts: an experimental study with obsessional patients

Cognitive-behavioral theories suggest that the development of neutralizing is crucial in the development and persistence of obsessional problems (OCD). Twenty-nine patients with a Diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association, 1994) diagnosis of OCD were randomly allocated to 2 conditions. Both listened to repeated recorded presentations of their intrusive thoughts and either neutralized (experimental group) or distracted themselves (control). Discomfort was rated during this 1st phase and then during a 2nd phase without neutralizing or distraction. The experimental group showed a similar level of discomfort in the 1st phase, which significantly reduced during the period compared with controls. The experimental group experienced significantly more discomfort during the 2nd phase, and significantly stronger urges to neutralize and distract at the end of this phase than controls.     

Dependence in the elderly from an interactional point of view: verbal and observational data

Dependence in the elderly was investigated from an interactional point of view. Observations as well as verbal data of the elderly and professional caregivers were considered. Samples consisted of 14 elderly people receiving regular home health care (M = 78.9, SD = 6.3 years) and 16 elderly people receiving regular nursing home care (M = 81.4, SD = 7.5 years). Results showed a strong tendency toward independence in the elderly. Sense of control in the self-care interactions observed was higher in the home health care group than in the group receiving nursing home care. Division of the elderly into subgroups with high, medium, and low perceived self-efficacy showed that the elderly high in self-efficacy were more independent in terms of observed self-care. Causal explanations of the elderly's competence and their nonuse of competence were significantly different between the elderly and staff.     

Illness perception in people with chronic obstructive pulmonary disease

Illness perception (IP) concerns how patients evaluate living with a disease. To get a broader understanding of IP in patients with chronic obstructive pulmonary disease (COPD), we investigated whether breathlessness is an important precursor of IP and whether IP in its turn is related to mental health, physical health and global quality of life (QOL). One hundred and fifty‐four patients with COPD participated in a cross‐sectional survey. Participants underwent pulmonary function testing, provided socio‐demographic and clinical information, and completed the following standardized instruments: Brief Illness Perception Questionnaire, Respiratory Quality of Life Questionnaire, Short‐Form 12 Health Survey and the Quality of Life Scale. Multiple regression analyses were performed. A high IP score indicates that a patient believes that his/her illness represents a threat. Participants with a high score on the IP dimensions consequences, identity, concern and emotional representation, experienced more breathlessness. High scores on the IP dimensions consequences, identity and concern were associated with impaired physical health and high scores on the IP dimensions consequences, identity and emotional representation were associated with impaired mental health. Impaired global QOL was associated with high scores on the IP dimensions consequences, identity, concern, coherence and emotional representation. The strength of the associations between breathlessness and physical/mental health and global QOL decreased when certain dimensions of IP were included as predictors, indicating that IP to some extent acts as a mediating factor. These findings may have practical implications of patient counselling by helping COPD patients to cope with their disease by restructuring their personal models of illness.