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1.
Intensive Care Med ; 46(1): 46-56, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31690968

RESUMO

PURPOSE: Apart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one's job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics. METHODS: Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries. RESULTS: Of 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62-0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77-0.98]) were all associated with a lower intent to leave. CONCLUSION: This is the first large multicenter study showing an independent association between clinicians' intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL.

4.
Soc Sci Med ; 223: 89-96, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30739039

RESUMO

OBJECTIVE: Coercion is a controversial issue in mental health care. Recent research highlights that coercion is a relational phenomenon, although, it remains unclear how this intersubjective context should be understood. The aim of this study is to propose an interactional model of the relational aspects of coercion that enhances theoretical understanding, based on the assumptions of patients. METHOD: The research question was studied by means of interpretative phenomenological analysis. Twelve people who had psychiatric hospitalisations were interviewed in-depth, using broad open questions relating to the experience of coercion and power in psychiatry. Data were collected in 2016 and 2017 in Belgium. RESULTS: Across participants' accounts we observed a specific structure. The relational quality of coercion seemed to be embedded within a process where individuals were one-sidedly approached as a 'sick patient', which led to profound segregation between staff and patients. This segregation caused a form of de-subjectivation: participants felt that important aspects of their subjectivity were neglected and they experienced professionals as de-subjectivated. They felt as if power resides within the (non-) interactions between patients and mental health workers. De-subjectivation arose and was enlarged within relations by broken contact, by silence in coercive acts, and by the necessity of patients to conform to the professionals' treatment regime. Helpful encounters that were not deemed coercive were those where patients and staff were individuated, which altered their relation. CONCLUSIONS: To understand the relational quality of coercion, interventions like seclusion and house rules should also be understood within this structure of de-subjectivation. We need to tackle this dynamic if we want to reduce coercion in psychiatric care.

5.
J Clin Psychol ; 75(3): 329-343, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30368808

RESUMO

OBJECTIVE: Institutional promotion of psychotherapy manuals as a requirement for evidence-based treatments (EBTs) yields the assumption that manualized treatment is more effective than nonmanualized treatment. This systematic review examines empirical evidence for this claim. METHODS: An electronic database search identified studies that directly or indirectly compared manual-based and non-manual-based treatment. RESULTS: Six studies directly compared manualized and nonmanualized treatment (Hypothesis 1). None support manual superiority. Eight meta-analyses indirectly assessed effect sizes of manual-based treatment and control groups (Hypothesis 2). Three support manual superiority, five do not. One meta-analysis and 15 further studies addressed manual adherence as an indirect indicator of manual efficacy (Hypothesis 3). The meta-analysis concluded that manual adherence does not affect outcome, additional studies provided inconclusive results. CONCLUSIONS: Manualized treatment is not empirically supported as more effective than nonmanualized treatment. While manual-based treatment may be attractive as a research tool, it should not be promoted as being superior to nonmanualized psychotherapy for clinical practice.

6.
Front Psychol ; 9: 1958, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30416463

RESUMO

Auditory verbal hallucinations have traditionally especially been researched from a form-based approach, with content getting much less attention. In this article, we argue for the importance of looking at content to get a fuller understanding of the hallucinatory experience. Guided by Lacanian psychoanalysis, we conducted a thematic and a narrative analysis on interviews with 10 schizophrenic patients about their hallucinations. We discerned five themes in the data, which were based on Lacanian theory and had to do with existential questions: parenthood and authority, sexuality and relationships, gender identity, life in the light of death, and what does the other want? Furthermore, we added a theme for unclassified content. Narratively, we found that participants constructed a story of four steps about their hallucinatory experiences. These steps were disturbing events in the past posing an existential question, triggering event, period of confusion, and hearing voices that allude to existential themes. Participants succeed in different degrees in integrating their hallucinatory experiences in their own life history. These stories can be situated on a continuum by making use of three prototypical narrating styles: the meta-delusional, delusional, and chaotic narrative type. Overall, our analysis shows that hallucinations can both be thematically and narratively organized, by making use of a theoretical framework like Lacanian psychoanalysis. Our research demonstrates that hallucinatory contents are not random but are about existential issues imbedded in a life narrative. Future research would benefit of integrating content and form-based approaches.

7.
BMJ Qual Saf ; 27(10): 781-789, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29475979

RESUMO

BACKGROUND: Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). OBJECTIVES: To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. METHODS: Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. RESULTS: Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. CONCLUSIONS: The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians' behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.


Assuntos
Tomada de Decisões/ética , Unidades de Terapia Intensiva , Cultura Organizacional , Autoavaliação , Humanos , Corpo Clínico Hospitalar , Modelos Teóricos
8.
Front Psychol ; 8: 1437, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28878725

RESUMO

In the present essay, we aim to develop and contrast three different positions toward Sellars' distinction between the manifest and scientific images of man: Dennett's philosophical reconstruction of neurocognitive science, contemporary phenomenology and psychoanalysis. We will suggest that these respective traditions and the substantial differences between them can be understood in terms of a 'logic of appearance.' Related to this are differing ideas about the rights and limits of the first-person perspective, the relation between conscious experience and belief, and the issue of naturalization. In the final part, we will try to specify, on the basis of a detailed reading of the disagreement between Dennett and phenomenology, in what way psychoanalytic theory could respond to these different issues.

9.
J Am Psychoanal Assoc ; 65(4): 609-638, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28899173

RESUMO

Transference implies the actualization of the analyst in the analytic encounter. Lacan developed this idea through the syntagm presence of the analyst. In the course of his seminars, however, two completely different presences emerge, with major implications for how the treatment is directed. In the light of Lacan's idea that the transference is constituted in Real, Symbolic, and Imaginary dimensions, it can be seen how in his early work the analyst's presence is a phenomenon at the crossroads between signifiers and images. From the 1960s onward, however, the analyst's presence comes to necessarily involve the Real. This means it points to the moment at which symbolization reaches its limits. The clinical implications of this later interpretation of the presence of the analyst as incorporating the Real are manifold and affect psychoanalytic practice with regard to the position and the interventions of the analyst. Specifically, interventions targeted at provoking changes in defenses against experiences of excess or senselessness are discussed and illustrated with case vignettes and a published case. With transference considered "the navel of the treatment," the necessity that traumatic material will emerge in relation to the analyst becomes clear.


Assuntos
Apego ao Objeto , Relações Profissional-Paciente , Terapia Psicanalítica , Humanos
11.
Trials ; 18(1): 126, 2017 03 14.
Artigo em Inglês | MEDLINE | ID: mdl-28292331

RESUMO

BACKGROUND: Major depressive disorder is a leading cause of disease burden worldwide, indicating the importance of effective therapies. Outcome studies have shown overall efficacy of different types of psychotherapy across groups, yet large variability within groups. Although patient characteristics are considered crucial in understanding outcome, they have received limited research attention. This trial aims at investigating the interaction between therapeutic approach (pre-structured versus explorative) and the personality style of patients (dependent versus self-critical), which is considered a core underlying dimension of depressive pathology. METHODS/DESIGN: This study is a pragmatic stratified (dependent and self-critical patients) parallel trial with equal randomization (allocation 1:1) conducted in Flanders, Belgium. One hundred and four patients will be recruited and randomized to either 16-20 sessions of cognitive behavioral therapy for depression (pre-structured approach) or 16-20 sessions of short-term psychodynamic psychotherapy for depression (explorative approach) conducted by trained psychotherapists in private practices. The primary outcome is the severity of depression as measured by the Hamilton Rating Scale for Depression at completion of therapy. Secondary outcome measures include self-reported depressive and other symptoms, interpersonal functioning, idiosyncratic complaints, and the presence of the diagnosis of depression. Additional measures include biological measures, narrative material (sessions, interviews), and health care costs. DISCUSSION: This trial presents the test of an often-described, yet hardly investigated interaction between important personality dimensions and therapeutic approach in the treatment of depression. Results could inform therapists on how to match psychotherapeutic treatments to specific personality characteristics of their patients. TRIAL REGISTRATION: Isrctn.com, ISRCTN17130982 . Registered on 2 February 2015.


Assuntos
Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo Maior/terapia , Autoavaliação , Bélgica , Protocolos Clínicos , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/fisiopatologia , Humanos , Escalas de Graduação Psiquiátrica , Projetos de Pesquisa , Inquéritos e Questionários , Fatores de Tempo , Resultado do Tratamento
12.
Front Psychol ; 8: 2162, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29312043

RESUMO

In the present essay, we aim to develop an expressivist reading of the phenomenon of first-person authority and the adverbial meaning of unconsciousness. In the first part, Wittgenstein's grammatical remarks on the asymmetry between the first -and third-persons in psychological self-ascriptions are developed as an alternative to detectivist explanations according to which first-person authority is to be regarded as a matter of epistemic accomplishment. In the second part, this expressivist account will be used to propose a non-epistemic analysis of the meaning of unconsciousness and to offer a critical discussion of both Freud's and Lacan's respective readings of the unconscious. Regarding the latter, we will reject the idea that the concept of the unconscious (i) necessitates the introduction of a (Cartesian) "subject of the unconscious" and (ii) could be deduced from the paradoxes of first-personal reference.

13.
Health (London) ; 21(4): 441-458, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-26851263

RESUMO

In Balint groups, (para)medical professionals explore difficult interactions with patients by means of case presentations and discussions. As the process of Balint group work is not well understood, this article investigates Balint group meetings by making use of Lacan's theory of the four discourses. Five Balint group case presentations and their subsequent group discussion were studied, resulting in the observation of five crucial aspects of Balint group work. First, Balint group participants brought puzzlement to the group, which is indicative of the structural impossibility Lacan situates at the basis of all discourse (1). As for the group discussion, we emphasize 'hysterization' as a crucial process in Balint group work (2), the supporting role of the discourse of the analyst (3) and the centrality of discourse interactions (4). Finally, the potential transformation of the initial puzzlement is discussed (5). We conclude by putting forth the uniqueness of Balint group work as well as the potential usefulness of our analysis as a framework for Balint group leaders and professionals in charge of continuing medical education.


Assuntos
Atitude do Pessoal de Saúde , Pessoal de Saúde/psicologia , Relações Profissional-Paciente , Processos Grupais , Humanos
14.
Med Health Care Philos ; 20(2): 257-267, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27826684

RESUMO

Victims of disaster suffer, not only at the very moment of the disaster, but also years after the disaster has taken place, they are still in an emotional journey. While many moral perspectives focus on the moment of the disaster itself, a lot of work is to be done years after the disaster. How do people go through their suffering and how can we take care of them? Research on human suffering after a major catastrophe, using an ethics of care perspective, is scarce. People suffering from disasters are often called to be in distress and their emotional difficulties 'medicalised'. This brings them often into a situation of long term use of medication, and one can wonder if medication is of help to them in the long run. In our paper, we will explore another moral perspective, focusing on the importance of the victims' narrative and their lived experiences. We will use Paul Ricoeur's phenomenological reflections from 'Suffering is not the same as pain' for conceptualizing human suffering and how to apply it to victims of disaster. Ricoeur suggests that suffering is not a quantity that can be measured, but a characteristic that should be studied qualitatively in interpersonal and narrative contexts. Above all, the perspective of care and listening could offer an opportunity to reconcile people from their loss and suffering.


Assuntos
Desastres , Ética Baseada em Princípios , Sobreviventes/psicologia , Humanos , Princípios Morais , Narração
15.
Front Psychol ; 7: 1948, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28018280

RESUMO

This paper studies how subjectivity in capitalist culture can be characterized. Building on Lacan's later seminars XVI, XVII, XVIII, and XIX, the author first outlines Lacan's general discourse theory, which includes four characteristic discourses: the discourse of the master, the discourse of the university, the discourse of the hysteric and the discourse of the analyst. Next, the author explores the subjectivity and the mode of dealing with jouissance and semblance, which is entailed in a fifth type of discourse, the capitalist discourse, discussed by Lacan (1972). Indeed, like the other discourses that Lacan discerns, the discourse of the capitalist can be thought of as a mode of dealing with the sexual non-rapport. It is argued that in the case of neurosis the discourse of the capitalist functions as an attempt to ignore the sexual non-rapport and the dimension of the unconscious. Psychosis, by contrast, is marked by an a priori exclusion from discourse. In that case, consumerist ways of relating to the other might offer a semblance, and thus the possibility of inventing a mode of relating to the other. Two clinical vignettes are presented to illustrate this perspective: one concerning the neurotic structure and one concerning the psychotic structure.

16.
Oncol Nurs Forum ; 43(4): 505-12, 2016 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-27314193

RESUMO

PURPOSE/OBJECTIVES: To explore variations in coping with moral distress among physicians and nurses in a university hospital oncology setting.
. RESEARCH APPROACH: Qualitative interview study.
. SETTING: Internal medicine (gastroenterology and medical oncology), gastrointestinal surgery, and day clinic chemotherapy at Ghent University Hospital in Belgium.
. PARTICIPANTS: 17 doctors and 18 nurses with varying experience levels, working in three different oncology hospital settings. 
. METHODOLOGIC APPROACH: Patients with cancer were interviewed based on the critical incident technique. Analyses were performed using thematic analysis.
. FINDINGS: Moral distress lingered if it was accompanied by emotional distress. Four dominant ways of coping (thoroughness, autonomy, compromise, and intuition) emerged, which could be mapped on two perpendicular continuous axes. CONCLUSIONS: Moral distress is a challenging phenomenon in oncology. However, when managed well, it can lead to more introspection and team reflection, resulting in a better interpersonal understanding.
. INTERPRETATION: Team leaders should recognize their own and their team members' preferred method of coping and tailored support should be offered to ease emotional distress.


Assuntos
Atitude do Pessoal de Saúde , Princípios Morais , Neoplasias/psicologia , Enfermeiras e Enfermeiros/psicologia , Enfermagem Oncológica , Pacientes/psicologia , Médicos/psicologia , Adaptação Psicológica , Adulto , Atitude Frente a Saúde , Bélgica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estresse Psicológico , Inquéritos e Questionários
17.
J Interprof Care ; 30(3): 301-8, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27152533

RESUMO

This article describes a study that evaluated the quality of teamwork in a surgical intensive care unit and assessed whether teamwork could be improved significantly through a tailor-made intervention. The quality of teamwork prior to and after the intervention was assessed using the Interprofessional Practice and Education Quality Scales (IPEQS) using the PROSE online diagnostics and documenting system, which assesses three domains of teamwork: organisational factors, care processes, and team members' attitudes and beliefs. Furthermore, team members evaluated strengths and weaknesses of the teamwork through open-ended questions. Information gathered by means of the open questions was used to design a tailor-made 12-week intervention consisting of (1) optimising the existing weekly interdisciplinary meetings with collaborative decision-making and clear communication of goal-oriented actions, including the psychosocial aspects of care; and (2) organising and supporting the effective exchange of information over time between all professions involved. It was found that the intervention had a significant impact on organisational factors and care processes related to interprofessional teamwork for the total group and within all subgroups, despite baseline differences between the subgroups in interprofessional teamwork. In conclusion, teamwork, and more particularly the organisational aspects of interprofessional collaboration and processes of care, can be improved by a tailor-made intervention that takes into account the professional needs of healthcare workers.


Assuntos
Comportamento Cooperativo , Processos Grupais , Unidades de Terapia Intensiva/organização & administração , Relações Interprofissionais , Equipe de Assistência ao Paciente/organização & administração , Adulto , Atitude do Pessoal de Saúde , Comunicação , Registros Eletrônicos de Saúde/organização & administração , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Percepção , Melhoria de Qualidade/organização & administração
18.
Front Psychol ; 6: 960, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26217279

RESUMO

Most discussions of the social and interpersonal styles in individuals with strong psychopathic traits focus on their dangerousness or their affective and interpersonal deficiencies. This study has a different focus, and starts from the idea that such focus on the threat emanating from individuals with a psychopathic style might blind us from the logic inherent to their way of relating with the world. By means of a qualitative analysis (thematic analysis) of narratives from a Lacanian talking therapy, this study examines how 15 youngsters with strong psychopathic traits make sense of interpersonal events and relations. The main recurring theme across these narratives was that others in general are fundamentally distrustful antagonists that they have to protect themselves from. Especially the father figure, with whom identification seems to take place, is seen as a violent actor. Consequently, these youngsters develop multiple strategies of dealing with the threat they experience in relation to (significant) others. These relationship patterns also emerged within the therapeutic relationship, resulting in frequent testing of the therapist's trustworthiness. The results of this study, discussed in terms of Lacanian theory, might help therapists to develop treatment approaches that better fit with the interpersonal orientation of individuals with strong psychopathic traits.

19.
Front Psychol ; 6: 664, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26089805

RESUMO

Starting from the theories of leading psychiatrists, like Kraepelin and de Clérambault, the French psychoanalyst Jacques Lacan (1901-1981) formulated an original theory of psychosis, focusing on the subject and on the structuring role of language. In particular, he postulated that language makes up the experience of subjectivity and that psychosis is marked by the absence of a crucial metaphorization process. Interestingly, in contemporary psychiatry there is growing empirical evidence that schizophrenia is characterized by abnormal interpretation of verbal and non-verbal information, with a great difficulty to put such information in the appropriate context. Neuro-scientific contributions have investigated this difficulty suggesting the possibility of interpreting schizophrenia as a semiotic disorder which makes the patients incapable of understanding the figurative meaning of the metaphoric speech, probably due to a dysfunction of certain right hemisphere areas, such as the right temporoparietal junction and the right superior/middle temporal gyrus. In this paper we first review the Lacanian theory of psychosis and neuro-scientific research in the field of symbolization and metaphoric speech. Next, we discuss possible convergences between both approaches, exploring how they might join and inspire one another. Clinical and neurophysiological research implications are discussed.

20.
Patient Educ Couns ; 98(6): 685-94, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25681874

RESUMO

OBJECTIVE: As the scientific literature on Balint groups (BGs) is scattered, this paper provides an overview of the literature on BGs published in peer-reviewed journals. Study characteristics are analyzed and the principal research topics are discussed. METHODS: 'Web of Science' and 'Pubmed' databases were searched and all English-language studies on BGs (empirical and non-empirical) were included. RESULTS: Of the 94 articles included, 35 are empirical studies adopting a qualitative, quantitative or mixed methodology. The research topics that emerged include outcome, characteristics of BG participants, themes addressed in BGs, BG processes, leadership and BG evaluations. The remaining articles were classified as historical articles, reports and reflective articles, for which the main discussion themes are presented. CONCLUSION: Research on BGs proves to be diverse, scarce and often methodologically weak. However, indications of the value of BG work were found. Therefore, further research is strongly indicated. PRACTICE IMPLICATIONS: Points of interest that could to be further considered by BG workers and researchers are for instance long-term BG participation and 'modified Balint groups'. Recommendations for future research on BGs are provided.


Assuntos
Clínicos Gerais , Liderança , Competência Profissional , Relações Profissional-Paciente , Competência Clínica , Comunicação , Medicina Geral , Processos Grupais , Humanos , Relações Médico-Paciente , Pesquisa
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