Ambivalent connections: a qualitative study of the care experiences of non-psychotic chronic patients who are perceived as 'difficult' by professionals

Contains fulltext : 90688.pdf (publisher's version ) (Open Access)Background: Little is known about the perspectives of psychiatric patients who are perceived as 'difficult' by clinicians. The aim of this paper is to improve understanding of the connections between patients and professionals from patients' point of view. Methods: A Grounded Theory study using interviews with 21 patients from 12 outpatient departments of three mental health care facilities. Results: Patients reported on their own difficult behaviours and their difficulties with clinicians and services. Explanations varied but could be summarized as a perceived lack of recognition. Recognition referred to being seen as a patient and a person - not just as completely 'ill' or as completely 'healthy'. Also, we found that patients and professionals have very different expectations of one another, which may culminate in a difficult or ambivalent connection. In order to explicate patient's expectations, the patient-clinician contact was described by a stage model that differentiates between three stages of contact development, and three stages of substantial treatment. According to patients, in each stage there is a therapeutic window of optimal clinician behaviour and two wider spaces below and above that may be qualified as 'toxic' behaviour. Possible changes in clinicians' responses to 'difficult' patients were described using this model. Conclusions: The incongruence of patients' and professionals' expectations may result in power struggles that may make professionals perceive patients as 'difficult'. Explication of mutual expectations may be useful in such cases. The presented model gives some directions to clinicians how to do this.11 p

What makes community psychiatric nurses label non-psychotic chronic patients as ‘difficult’: patient, professional, treatment and social variables

Contains fulltext : 99981.pdf (publisher's version ) (Open Access)Purpose To determine which patient, professional, treatment and/or social variables make community psychiatric nurses (CPNs) label non-psychotic chronic patients as ‘difficult’. Methods A questionnaire was designed and administered to 1,946 CPNs in the Netherlands. Logistic regression was used to design models that most accurately described the variables that contributed to perceived difficulty. Results Six variables were retained in the final logistic model. Perception-related variables (feeling powerless, feeling that the patient is able but unwilling to change, and pessimism about the patient’s change potential) dominated treatment-related variables (number of contacts per week and admission to a locked ward in the last year) and social variables (number of psychosocial problems). Conclusion This research shows that perceived difficulty is related to complex treatment situations, not so much to individual patient characteristics. If the constructed model has good predictive qualities, which remains to be tested in longitudinal research, it may be possible to accurately predict perceived patient difficulty. When used as a screening tool, such a model could improve treatment outcomes.9 p

Promotion of variant human mammary epithelial cell outgrowth by ionizing radiation: an agent-based model supported by in vitro studies

IntroductionMost human mammary epithelial cells (HMEC) cultured from histologically normal breast tissues enter a senescent state termed stasis after 5 to 20 population doublings. These senescent cells display increased size, contain senescence associated beta-galactosidase activity, and express cyclin-dependent kinase inhibitor, p16INK4A (CDKN2A; p16). However, HMEC grown in a serum-free medium, spontaneously yield, at low frequency, variant (v) HMEC that are capable of long-term growth and are susceptible to genomic instability. We investigated whether ionizing radiation, which increases breast cancer risk in women, affects the rate of vHMEC outgrowth.MethodsPre-stasis HMEC cultures were exposed to 5 to 200 cGy of sparsely (X- or gamma-rays) or densely (1 GeV/amu 56Fe) ionizing radiation. Proliferation (bromodeoxyuridine incorporation), senescence (senescence-associated beta-galactosidase activity), and p16 expression were assayed in subcultured irradiated or unirradiated populations four to six weeks following radiation exposure, when patches of vHMEC became apparent. Long-term growth potential and p16 promoter methylation in subsequent passages were also monitored. Agent-based modeling, incorporating a simple set of rules and underlying assumptions, was used to simulate vHMEC outgrowth and evaluate mechanistic hypotheses.ResultsCultures derived from irradiated cells contained significantly more vHMEC, lacking senescence associated beta-galactosidase or p16 expression, than cultures derived from unirradiated cells. As expected, post-stasis vHMEC cultures derived from both unirradiated and irradiated cells exhibited more extensive methylation of the p16 gene than pre-stasis HMEC cultures. However, the extent of methylation of individual CpG sites in vHMEC samples did not correlate with passage number or treatment. Exposure to sparsely or densely ionizing radiation elicited similar increases in the numbers of vHMEC compared to unirradiated controls. Agent-based modeling indicated that radiation-induced premature senescence of normal HMEC most likely accelerated vHMEC outgrowth through alleviation of spatial constraints. Subsequent experiments using defined co-cultures of vHMEC and senescent cells supported this mechanism.ConclusionsOur studies indicate that ionizing radiation can promote the outgrowth of epigenetically altered cells with pre-malignant potential

On being objective about the subjective: Clinical aspects of intersubjectivity in contemporary psychoanalysis

This paper attempts to set out the conceptual history of countertransference and intersubjectivity. I will attempt to show the different histories that have occurred within British object relations compared with the developments in the post-ego-psychology era in North America

Do Unconscious Processes Affect Educational Institutions?

In this article I discuss the way that aspects of school and teaching have unconscious roots. Where anxiety about the process, for teachers and children, is high then there is the risk that unconscious defensive processes may occur resulting in institutionalized phenomena. These take the form of cultural attitudes and common practices which may not necessarily enhance the work and in some cases may actively interfere. </jats:p

Psychoanalytic research: Is clinical material any use?

Practical [limitations of RCT design] include the dilemma that while the RCT may be the only convincing method currently available to investigate causality in the relation between treatment and outcome, nevertheless the recognition of this fact should not lead us to forget that it is also, in many ways, lamentably inadequate to the task (Richardson, 2001, p. 170). I have argued that the case study, now held in disrepute, is nevertheless necessary to test psychoanalytic hypotheses and, if properly formulated, can indeed test, not merely generate, hypotheses (Edelson, 1986, p. 89). This paper discusses some of the issues in the current debate about the evidence of the validity of psychoanalytic knowledge. It argues that there is a place for single-case research as potentially as rigorous as other science-like disciplines, provided that the research design is carefully chosen and a prediction is formulated precisely. Research confidence in clinical material, always the empirical basis of evidence in psychoanalysis, has declined. This paper questions what needs to be done, what conditions to apply, in order to rehabilitate clinical material as an important evidence base for psychoanalysis. Public servants with fiscal or risk-management pre-occupations want specific outcomes in terms of changed people. However, outcome studies can tell us little about the details of what interpretations to formulate and how to use them. This paper, like psychoanalytic interventions themselves, may challenge unspoken assumptions

Group Therapy as Psychic Containing

This article will examine how the psychoanalytic idea of containing can be used in group therapy to form a conceptual bridge such that the group dynamics are not simplistically reduced to individual dynamics, nor that the individual is lost in the “group–as–a–whole” concept. I take the concept of “containing” as versatile in the sense that Bion (1970) meant it to be—that is, the psychological phenomenon of containment is manifest at various system levels: intrapsychic, interpersonal, group, and societal. This article will explore how far this “bridging concept” can be pursued to understand groups theoretically. The article will review various forms of containing, following Bion's ideas, and in particular a therapeutic, or flexible, form in contrast to rigid and fragile forms

Organizational schism: Looking after a psychiatric service

What is opposed to psychoanalysis is not psychiatry but psychiatrists. (Freud, 1916–1917, p. 254) The defence that schism affords against the development-threatening idea can be seen in the operation of schismatic groups, ostensibly opposed but in fact promoting the same end. (Bion, 1961, p. 159) This paper deals with group dynamics, not about therapeutic groups, but about professional groups. Mental health workers labour in a setting of high stress. One of the forces that affect groups under stress is that they can divide into two, which often exist in mutual opposition: Psychodynamic psychotherapy itself has never been free of oppositional relations with other groups. We need a framework for thinking about the schisms that we are a part of, on the one hand with orthodox psychiatry and psychiatrists, and on the other, with psychologists and CBT. This paper will attempt to look at the stress of uncertainty and the stress of risk management, stresses which arise from the work, and emerge as interdisciplinary feuds