Medical hermeneutics: Where is the “text” we are interpreting?

The present paper is a commentary on an article by Drew Leder [1]. Leder identifies a series of texts in the clinical encounter, emphasizes the central role of interpretation in making sense of each of these texts, and articulates ordering principles to guide the interpretive work.The metaphor of clinical work as textual explication, however, creates the expectation that there is a text somewhere to be found. Such an expectation invites doctors and patients to search for the text and runs the risk of conceptualizing patients as more static than they are. If one is to use the textual metaphor, one must appreciate the radical extent to which the clinical encounter is a mutually produced and shifting entity. The qualities of mutuality and indeterminacy are not those one usually associates with texts. One might ultimately be better served by a different metaphor based more directly on uncertainty.     

The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

Pediatric Psychology: Child Psychological Health in the Next Century

The future of pediatric psychology is reviewed and placed in brief historical context in relation to children's psychological health care. Contemporary trends affecting the delivery of psychological services, research, and clinical training are highlighted, with suggestions for future development. Pediatric psychology is a child-based, developmentally-focused multidisciplinary practice directed toward psychosocial and neuropsychological issues of health and illness in children and youth. Pediatric psychologists need to develop strong professional identities as health care psychologists combined with a collegial and collaborative arrangement with physicians to ensure the future growth and development of pediatric psychology in the next century as a major vehicle to promote children's health care.     

IDENTIFYING THE EDUCATIVE AND SUPPRESSIVE EFFECTS OF POSITIVE PRACTICE AND RESTITUTIONAL OVERCORRECTION

Two major features of the overcorrection procedure, restitution and positive practice, were analyzed for their educative and suppressive properties in the treatment of profoundly retarded adults. Positive practice techniques that were topographically similar and dissimilar to the target behavior were studied. Eating behavior and puzzle performance were observed. Restitutional overcorrection and both forms of positive practice were effective for suppressing inappropriate behaviors. Even when appropriate behaviors had been acquired by positive practice, restitution and dissimilar positive practice were generally ineffective for increasing their rate of occurrence. However, topographically similar positive practice was successful as a means of teaching new appropriate behaviors.     

Reaction times of younger and older men and temporal contingencies of reinforcement

Influences of extended training and temporal contingencies on reaction time were studied in relation to developmental differences. Older and younger men were trained on a chained schedule in which completion of a variable interval produced a terminal link in which reaction time was measured. The reaction-time procedure involved a conditional discrimination with matching to sample in one component and oddity matching in the other. During baseline training, no time limit was placed on the response to the discrimination choice stimuli. Subsequently, increasingly severe time limits were imposed over a series of sessions. Older and younger men showed increased speeds (decreased reaction times) when temporal contingencies were imposed, and these changes were maintained during post-training baseline sessions when there was unlimited time in which to respond. The younger men generally responded faster than the older ones, and age differences were not appreciably reduced during the course of the experiment. The results indicated the feasibility of studying reaction time in human subjects using operant procedures analogous to those developed for the study of nonverbal organisms.     

The effects of instructions, incentive, and feedback on a community problem: dormitory noise

A reinforcement system utilizing instructions, modelling, feedback, and group reinforcement was employed in an attempt to reduce disruptive noise on three university residence halls. A fourth hall received the same treatment program without the reinforcement component. Noise scores were determined by recording the number of discrete noise occurrences over a criterion decibel level. On all four residential floors, noise scores during treatment conditions were lower than initial and final baseline levels. Additionally, periods of noise reduction corresponded to the changing criterion multiple-baseline and reversal designs utilized. Pre- and posttreatment questionnaire responses from the three reinforcement floors paralleled changes in objective noise data. At posttreatment, residents reported less noise disturbance of study and sleep and more control over the noise situation and floor problems in general. These results indicated that a comprehensive behavior-modification treatment package was effective in reducing disruptive noise in university residence halls. Difficulties in data collection and anomalies in the data are discussed. Future directions for field-based behavior-modification research are outlined.