Purpose To quantify how often physical therapists from high-income countries (HIC) travelling to low- and middle-income countries (LMIC) practise outside their scope of practice, in what circumstances, and their likelihood of doing the same in the future. Methods An exploratory descriptive study using a survey. Results One hundred and twenty-six licensed physical therapists from around the world participated. Physical therapists typically spent less than a month (73.8 per cent) in LMIC; 67.5 per cent believed (...) that physical therapists practise outside of their scope, and 31.7 per cent reported doing so. Reasons were believing that something is better than nothing (47.5 per cent ), a mismatch between the physical therapist’s and host’s expectations (40.0 per cent ), and preserving their relationship with the host (25.0 per cent ). It was deemed appropriate by 64.5 per cent to practise outside of their scope in some situations and 53.8% considered repeating the activity in the future. Half of the respondent’s first experience in LMIC occurred as a student or in their first decade of practice. Conclusions Working in LMIC requires a keen understanding of the risks and challenges associated with such experiences. To ensure best practice, a skill set that consists of critical self-reflection, systems thinking, and structural competency combined with clinical competency and accountability is imperative. (shrink)

Understanding the basics of ethics is essential for a physical therapist. Diagnostic skills, technical expertise, and knowledge of the body are insufficient; being a good clinician requires a moral education as well. Bioethics in Physical Therapy: A Reader helps students develop a deeper understanding of moral principles and their philosophical underpinnings. The text encourages readers to exercise their moral imaginations and prepares them to respond to professional conflicts in an ethical manner. The reader is organized in seven units. (...) The text begins with an introduction to classical moral theories, the fundamental philosophical pillars of biomedical ethics, and a history of ethics in physical therapy. Additional units explore such topics as moral distress and the choice to be ethical, acting with integrity in the face of uncertainty, and the importance of hope in the patient encounter. Students learn about moral courage, the broad reach of justice in the medical field, and the lived experience of illness. Each unit features an opening scenario, a section on cultivating professional values, introductions to the key topic and the readings, comprehension questions, and post-reading critical thinking questions that reference the opening scenario. Written to be engaging and accessible, Bioethics in Physical Therapy: A Reader is designed to help future therapists understand the importance of ethics in practice. It is an ideal resource for all courses in the discipline. (shrink)

Background Occupational therapists may be encountered with a variety of ethical issues. The aim of this study was to explore ethical issues of Occupational therapist’s practice in adult physical dysfunction field. Methods Ten graduated Occupational therapists were selected by purposive sampling method. Data were gathered by semi-structured interview. Data were analyzed by content analysis approach. Results Data analysis ultimately leads to the emergence of three themes which reflects Ethical issues in Occupational Therapy. These themes include: unethical practice (...) of Occupational therapists, factors influencing ethical practice and Strategies to improving ethical practice. Conclusion The findings show that occupational therapists have various ethical problems related to client’s rights in addition to their clinical practice, that according to the participants in this study, lack of awareness about professional ethics related to the occupational therapy and also lack of comprehensive monitoring rules in this field are the major causes of unethical practice. (shrink)

In recent decades, phenomenology has been utilized not only as a conceptual framework from which to understand medical encounters in healthcare settings, but also to guide medical professionals in providing care. In the realm of physical therapy, phenomenology has been touted as a philosophically-based avenue to aid in helping to understand what it means to be a patient. The works of Edmund Husserl and Martin Heidegger have been utilized as paths to approach phenomenologically-informed care in physical therapy. However, (...) to our knowledge, no significant connection has been made in regard to the work of Hans-Georg Gadamer’s phenomenology and hermeneutics in the realm of physical therapy. The authors aim to close that gap by showing the ways in which Gadamer’s philosophy can help physical therapists provide phenomenologically-informed patient care. They begin by outlining some of the touchpoints between phenomenology and healthcare and then introduce Gadamer as a figure who deserves attention in the question of how to apply phenomenology to healthcare settings. Upon analyzing Gadamer’s account of what it means to experience an altered body, they outline Gadamer’s understanding of tact, practical knowledge, and good sense in order to show how to understand at a conceptual level what it means to empathize with patients on the path to building therapeutic alliance, that is, a cooperative working relationship. They then look closely at Gadamer’s hermeneutics and particularly his comments on how to cultivate a fusion of horizons in order to attempt to help guide physical therapists in theoretically understanding how to empathize with their patients. Ultimately, they argue that physical therapists who practice phenomenologically-informed care, which they call “hermeneutical healing,” are positioned well to form strong working relationships with their patients. (shrink)

A Case-Based Approach to Learning Ethics in Physical Therapy. Ethics in Physical Therapy utilizes a unique case-based approach to teach students and clinicians how to apply theoretical concepts to real-world situations. The cases were carefully selected to encourage thinking and discussion. The accompanying text provides a framework to answer the "should" questions, such as "What should I do?" and "How should I act?" The format provides the opportunity to move beyond the individual realm, when appropriate, resolving issues within (...) an institutional or societal perspective. The text is divided into two sections: "Ethics for the Physical Therapist" and "Types of Ethical Decisions: Case Analysis." They are designed to integrate with one another, but, each section can also be used separately. Part I provides more didactic, foundational material, while Part II strives to apply ethical decision-making tools to relevant cases in physical therapy practice, with the second section focusing on case analyses. The purpose of Ethics in Physical Therapy is to give students and clinicians a lens through which to analyze contemporary ethical challenges. Philosophical theory within the text is limited to that which can be applied practically in the clinical setting. This book is not intended to be a work on ethical behavior, rather, it is designed to provide students and clinicians with a framework in which to approach the uncertainty of ethical decision making with tools to aid their inherent judgment. (shrink)

IntroductionCouple violence (CV) affects many, and the consequences of those actions are grave, not only for the individual suffering at the hand of the perpetrator but also for the other persons in the family. Violence often happens among more than just the adults within one family. Even if CV has been thoroughly investigated in the general population very few studies have investigated this objective on a clinical sample, and none of these have included family violence.AimThis article identifies and describes the (...) group of clients that have issues of physical couple and family violence. It analyses a model that can help to discover physical violence and help therapists to assess what actions to take in therapy to prevent further physical violence.MethodologyDescriptive analysis, t-tests, and structural equation modeling (SEM) are used on a sample of clients receiving couple and family therapy (CFT) in Norway (N = 830). Family violence is modeled by the partner’s expectations toward each other, levels of anger, sexual satisfaction, and self-control.ResultsOne-in-five clients experienced physical CV in their current relationship and one-in-four experienced physical family violence. The group of clients who experienced CV differed from those without such experiences in having lower income, more prior experience with psychotherapy, more experience with alcohol abuse in childhood, and far more physical family violence in their current family. Our model predicting physical coupl... (shrink)

OBJECTIVES: To identify ethical dilemmas experienced by occupational and physical therapists working in the UK National Health Service (NHS). To compare ethical contexts, themes and principles across the two groups. DESIGN: A structured questionnaire was circulated to the managers of occupational and physical therapy services in England and Wales. SUBJECTS: The questionnaires were given to 238 occupational and 249 physical therapists who conformed to set criteria. RESULTS: Ethical dilemmas experienced during the previous six months were (...) reported by 118 occupational and 107 physical therapists. The two groups were similar in age, grade, and years of experience. Fifty of the occupational therapy dilemmas occurred in mental health settings but no equivalent setting emerged for physical therapy. Different ethical themes emerged between the two groups, with the most common in occupational therapy being difficult/dangerous behaviour in patients and unprofessional staff behaviour, and for physical therapists resource limitations and treatment effectiveness. No differences were found in the ethical principles used. CONCLUSION: The ethical dilemmas reported by the therapists were primarily concerned with health care ethics, rather than the more dramatic ethics reported in much of the biomedical ethics literature. Differences were found between the two professional groups when ethical contexts and themes were compared but not when ethical principles were compared. This suggests that educators and researchers need to be aware of work settings and the interdisciplinary nature of employment as well as ethical principles held by individual therapists. (shrink)

MyJay is an open-source robot designed to facilitate play between children with and without physical disabilities. The robot acts as a proxy for children with upper limb challenges, allowing them to participate in physical games with their peers. Our design was inspired by the FIRST Robotics Competition, which involves teleoperating robots to manipulate objects. Taking a user-centred perspective, we consulted therapists and conducted remote interviews with children with disabilities and their guardians at various stages of the design (...) process. We then conducted an in-person feasibility study with 18 typically developing children in a school setting. The study involved children teleoperating the robot to pick up and throw balls into a designated goal, and the interaction was evaluated using the user experience questionnaire and the Robotic Social Attributes Scale. The results of the study show great potential for MyJay to act as a play mediator in various scenarios, and the response from the children was positive. The ultimate aim of our research agenda is to pave the way towards creating more inclusive play environments through robot-mediated interactions, breaking barriers posed by physical limitations. (shrink)

The Body in Adolescence: Psychic Isolation and Physical Symptoms examines the affective experience of psychic isolation as an important and painful element of adolescent development. Mary Brady begins by discussing how psychic isolation, combined with the intensity of adolescent processes, can leave adolescents unable to articulate their experience. She then shows how the therapist can understand and help adolescents whose difficulty with articulation and symbolization can leave them vulnerable to breakdown into physical bodily symptoms. This book introduces fresh (...) ideas about adolescent development in the first chapter. Subsequent chapters include clinical essays involving adolescent patients presenting with bodily expressions such as anorexia, bulimia, cutting, substance abuse, and suicide attempts. Attention is also paid to adolescents’ use of social media in relation to these bodily symptoms – such as their use of on-line ‘pro-ana’ or cutting sites. Clinicians can feel challenged or even stymied when presented with their adolescent patient’s fresh cut or recent episode of binge drinking. Brady uses Bion’s conceptualization of containment and the balance of psychotic versus integrative parts of the personality to examine the emergence of concrete bodily symptoms in adolescence. Throughout, Mary Brady offers ways of understanding and empathically engaging with adolescents. This book is essential reading for psychoanalysts and psychotherapists who treat adolescents and other patients with physical symptoms, as well as other readers with an interest in the psychoanalytic understanding of these issues. (shrink)

Compared to other health care professions such as medicine, nursing and pharmacy, few studies have been conducted to examine the nature of practice errors in occupational and physical therapy. In an ongoing study to determine root causes, typographies and impact of occupational and physical therapy error on patients, focus group interviews have been conducted across the United States. A substantial number of harmful practice errors and/or other patient safety events (deviations or accidents) have been identified. Often these events (...) have had moral dimensions that troubled the therapist involved. In this article, six of these transcribed cases are analyzed, using predominant bioethical theories, ethical principles and professional codes of ethics. The cases and their analyses are intended to be exemplary, improving the readers’ ability to discern and critically address similar such events. Several patient safety strategies are suggested that might have prevented the events described in these cases. (shrink)

In this paper I explicate what it means to see phenomenologically for an able-bodied researcher in the field of disability, and how this seeing yields a non-reductionistic understanding of the phenomenon of disability. My aim is to show how in this context, I, as a human and social scientist can use phenomenological methodology for both collecting and interpreting data. Though phenomenological philosophy can provide the basis of social scientific epistemology, it does not lend itself easily to a single specific or (...) programmatic social scientific methodology. I offer possible ways of using phenomenological theory, methodology and techniques in order to understand the experience of a person with physical disability learning to use a wheelchair. I use data from a clinical encounter between a physical therapist (PT) and an adult with Spinal Cord Injury (SCI) in an inpatient rehabilitation hospital in Midwestern United States in order to flesh out phenomenological seeing. I conclude with implications for qualitative researchers who use phenomenological methods to inform their work. (shrink)

IntroductionThe objectives of this study are to assess and compare differences in the intensity, frequency, and overall severity of moral distress among a diverse group of healthcare professionals.MethodsParticipants from within Baylor Health Care System completed an online seven-point Likert scale (range, 0 to 6) moral distress survey containing nine core clinical scenarios and additional scenarios specific to each participant’s discipline. Higher scores reflected greater intensity and/or frequency of moral distress.ResultsMore than 2,700 healthcare professionals responded to the survey (response rate 18.14 (...) percent); survey respondents represented multiple healthcare disciplines across a variety of settings in a single healthcare system. Intensity of moral distress was high in all disciplines, although the causes of highest intensity varied by discipline. Mean moral distress intensity for the nine core scenarios was higher among physicians than nurses, but the mean moral distress frequency was higher among nurses. Taking into account both intensity and frequency, the difference in mean moral distress score was statistically significant among the various disciplines. Using post hoc analysis, differences were greatest between nurses and therapists.ConclusionsMoral distress has previously been described as a phenomenon predominantly among nursing professionals. This first-of-its-kind multidisciplinary study of moral distress suggests the phenomenon is significant across multiple professional healthcare disciplines. Healthcare professionals should be sensitive to situations that create moral distress for colleagues from other disciplines. Policy makers and administrators should explore options to lessen moral distress and professional burnout that frequently accompanies it. (shrink)

More than one single professional group deals with therapeutic manipulations of the spine and the joints. Osteopaths, Chiropractors, Naprapaths, Physical Therapists (and a contingent Physicians) all share this interest. Each profession is also very clear about where its bulk of knowledge stems from. The disciplines that are reckoned as the oldest are from the USA. A number of “inventors” are to be found, all without a formal university degree in Medicine. Andrew Taylor Still (1828–1917) came up with his (...) system of Osteopathy in 1874. Daniel D. Palmer (1845–1913), the man behind Chiropractic, founded his system in 1894, and Palmer’s colleague and former student, Oakley Smith (1880–1967), developed Naprapathy in 1906/1907. Physical Therapists working with what is called Orthopaedic Manual Physical Therapy are on the other hand not claiming American ancestry, nor do their body of knowledge and clinical skills originate from outside the medical profession. It is an offspring of Orthopaedic Medicine (OM) which was an invention by Physicians. Date and place of birth is said to be 1929 in England. This article turns the above-mentioned chronology on its head. It will show that Orthopaedic Medicine likely is the oldest system. It will also unearth OM’s sturdy roots in a strong but forgotten, and even hidden, discourse of Mechanical Medicine found in 19th century Europe, which was ruled by Physical Therapists. Why “we” do not know about this “history” is analysed and explained from a variety of perspectives. (shrink)

Background There is continued need for enhanced medical ethics education across the United States. In an effort to guide medical ethics education reform, we report the first interprofessional survey of a cohort of graduate medical, nursing and allied health professional students that examined perceived student need for more formalized medical ethics education and assessed preferences for teaching methods in a graduate level medical ethics curriculum. Methods In January 2018, following the successful implementation of a peer-led, grassroots medical ethics curriculum, student (...) leaders under faculty guidance conducted a cross-sectional survey with 562 of 1357 responses received among students enrolled in the School of Medicine, College of Nursing, Doctor of Physical Therapy and BS/ MD Professional Scholars programs at The Medical College of Georgia at Augusta University. An in person or web-based questionnaire was designed to measure perceived need for a more in-depth medical ethics curriculum. Results The majority of respondents were female, white and mid-20s in age. Almost half of respondents reported no prior medical ethics exposure or training in their previous educational experience, while 60% of students across all degree programs reported an interest in more medical ethics education and 92% noted that an understanding of medical ethics was important to their future career. Over a quarter of students were interested in pursuing graduate-level training in medical ethics, with case-based discussions, small group peer settings and ethics guest lectures being the most desired teaching methods. Conclusions The future physician, nursing and physical therapist workforce in our medical community demonstrated an unmet need and strong interest for more formal medical ethics education within their current coursework. Grassroots student-driven curricular development and leadership in medical ethics can positively impact medical education. Subsequent integration of interprofessional training in medical ethics may serve as a vital curricular approach to improving the training of ethically competent healthcare professionals and overcoming the current hierarchical clinical silos. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Voices in the Shadows:The Hidden Complexities of Being a Medical InterpreterLiliana CraneAs a Spanish interpreter at a Hospital for 16 years, I continue to be surprised at the lack of knowledge regarding the role of a Spanish Interpreter. Often the Spanish interpreter cannot interpret word for word; the interpreter's primary role is to find the best way to culturally convey messages between the provider and the patient so they (...) can understand each other's intended meaning. I have noted a significant change in our patients' literacy and the providers' level of experience. Because of our patients' low literacy level, the providers need to lower the complexity to obtain the answers to many of their questions; however, lowering the complexity may be more challenging than it sounds for some providers.The first question a provider asks when the patient arrives at the Emergency Department (ED) is, "Why you are here?" or "What brought you here to the Emergency Department?" It seems a simple question. However, often I hear these answers: "I am here because my wife/husband brought me in the car" or "Because in 1980, my cousin had similar symptoms and died."As interpreters, we have to repeat the question differently to obtain the answer sought by the provider. If we repeat the question word by word, the answer won't change. That is when experience as an interpreter and cultural knowledge of our patients play a crucial part.The interpreter's experience and familiarity with the target population are as vital to the communication as being proficient in both languages. Our patients often use words made up from a combination of English and Spanish, such as nursa, referring to a nurse, or friza, referring to a blanket, and derived from freezing. Our patients often refer to the leg as the foot, so when the provider asks what is hurting, the patient will sometimes say, "My foot."As an interpreter working extensively with this population, I know that body part clarification is necessary. Pinpointing the body part the patient is referring to through visual confirmation is essential to treating the appropriate ailment. It is similar to doing a dual identifiers; instead of asking for name and date of birth, we ask for location (right or left) and visualization by pinpointing, with one finger, the body part being referenced. The role of clarifier is one of the interpreter's roles, and it has become the main practice for me to make communication accurate. [End Page 167]The provider should know that what the patient verbally expresses may not be what they mean to say based on their literacy levels, mental health, cultural background, and upbringing. Words may have different meanings in different languages despite being spelled the same. For example," Take this medication once daily" may be in discharge instructions, prescriptions, or medication labels. In English, "once" means "one time," but in Spanish, it means "eleven."Communicating using the limited Spanish that a provider may have, or using Google to translate words for a patient with limited English language ability is highly discouraged but often done. The problems with these methods are often overlooked. One cardiologist told an adult male patient, "Te amo," with the patient's mom in the room. I was the interpreter on-call that night. The provider called me because he thought the patient's mother gave him a weird look after telling the patient, "Te amo," which is how Google translated the words "I like you." The provider's intended message was to say that he liked working with the patient. Google does not put the words in context, so the provider told the patient he was in love with him by saying, "Te amo." After a good laugh and an education on why using Google is inappropriate, I clarified with the patient and his mother what the provider intended to say. The provider quickly learned that Googling phrases or using a little Spanish may get you in trouble.I currently work full-time as a physical therapist assistant and Spanish medical interpreter. I have a Master of Business Administration, am certified by the American College of Sports Medicine as a Certified... (shrink)

Although systems for licensing professionals are far from perfect, and their problems and costs should not be ignored, they are justified as a necessary means of protecting innocent people's vital interests. Licensing defends patients from inept doctors, pharmacists, and physical therapists; it protects clients from unqualified lawyers. We should protect people who are highly vulnerable to those who are supposed to serve them, those with whom they have a special relationship. Requiring professionals to be licensed is the most (...) plausible way of doing that. Given the overwhelming support for the licensing of these professionals, I find it odd that so many people categorically reject proposals to license parents. Although the relationship between a parent and her children is different in some respects, it is also relevantly similar to that between a professional and those she serves. To defend these claims, I show how and why the rationale for licensing parents parallels the rational for licensing professionals. I then ask whether such a program could be justifiably implemented. Finally, I describe and reject what I see as the flawed view of the relationship between parents and their children. (shrink)

Background A team-based approach has been advocated for advance care planning in nursing homes. While nurses are often put forward to take the lead, it is not clear to what extent other professions could be involved as well. Objectives To examine to what extent engagement in advance care planning practices (e.g. conversations, advance directives), knowledge and self-efficacy differ between nurses, care assistants and allied care staff in nursing homes. Design Survey study. Participants/setting The study involved a purposive sample of 14 (...) nursing homes in Flanders, Belgium. Nurses, care assistants and allied care staff (e.g. social workers, physical therapists) completed a survey. Ethical considerations The study was approved by the University Hospital of Brussels (B.U.N. 143201834759), as part of a cluster randomized controlled trial (clinicaltrials.gov NCT03521206). Results One hundred ninety-six nurses, 319 care assistants and 169 allied staff participated (67% response rate). After adjusting for confounders, nurses were significantly more likely than care assistants to have carried out advance care planning conversations (odds ratio 4; 95% confidence interval 1.73–9.82; p < 0.001) and documented advance care planning (odds ratio 2.67; 95% confidence interval 1.29–5.56; p < 0.001); differences not found between allied staff and care assistants. Advance care planning knowledge total scores differed significantly, with nurses (estimated mean difference 0.13 (score range 0–1); 95% confidence interval 0.08–0.17; p < 0.001) and allied staff (estimated mean difference 0.07; 95% confidence interval 0.03–0.12; p < 0.001) scoring higher than care assistants. We found no significant differences regarding self-efficacy. Discussion While nursing home nurses conducted more advance care planning conversations and documentation than allied care staff and care assistants, these two professional groups may be a valuable support to nurses in conducting advance care planning, if provided with additional training. Conclusions Allied care staff and care assistants, if trained appropriately, can be involved more strongly in advance care planning to enhance relational and individual autonomy of nursing home residents, alongside nurses. Future research to improve and implement advance care planning should consider this finding at the intervention development stage. (shrink)

Nursing students face various ethical issues, which may cause stress, that require coping strategies. This study investigated the thoughts and feelings underlying the coping behaviors adopted by nursing students when addressing ethical issues. Semi-structured interviews were conducted from September to October 2011 with 11 students enrolled at University A who had completed basic nursing and specialty practicums and consented to participate in the study. Data were analyzed using qualitative methods. The participant narratives about ethical issues encountered during clinical practicums were (...) organized into four themes and 20 scenarios. The ethical issues concerned the attitudes and conduct of nurses, doctors, physical therapists, and other medical professionals. Seven coping behaviors were identified. The results revealed that nursing students waver between valuing their relationships with nurses and their relationships with patients when they encounter an ethical issue. When their relationships with nurses were emphasized, their ethical values were restructured. These findings suggest the need to address the affective domain early on in lectures and in-class practice, and to create an environment in which students taking practicums can easily express their feelings and internal value system changes. (shrink)

Jeremy sustained bilateral complete brachial plexus injuries in an auto collision on an icy road a month before his third birthday. The accident rendered both upper extremities completely flail and insensate: he has no motor or sensory function of his shoulders, elbows, wrists, or digits. Jeremy does, however, have normal function of the lower extremities. Physical therapists have worked with the child for over a year with no noted improvement in arm function. Jeremy falls frequently, causing injury to (...) his face and head, and occasionally, his arms get twisted or caught in his crib and his fingers turn blue. Jeremy's mother, who carries the main responsibility for his daily care, believes that his insensate arms are too heavy and “get in his way,” causing the falls. She and Jeremy's father present to the orthopedic clinic at the children's hospital with the request of having both arms amputated. The primary orthopedic surgeon and the orthopedic team disagree with the parents that bilateral upper-extremity amputation offers any medical benefit, but Jeremy's mother tells the surgeon that, if he will not perform the surgery, her family will find a doctor who will. The surgeon, who feels ethically distressed by the parental insistence on this amputation in such a young child, requests an ethics consultation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Confidentiality and Its LimitsMaude Laliberté, John D. Lantos, and Sonia GowdaMultiple sclerosis is believed to be an autoimmune disease of the central nervous system. However, according to Italian physician Paolo Zamboni, it is related to cerebrospinal vascular insufficiency. Zamboni claims that MS can be treated by remedying this condition with venous angioplasty. This surgery is offered as treatment for MS in various countries—Poland, Bulgaria, and Costa Rica, for example. (...) But the Medical Board of Quebec, Canada, does not allow its members to perform the surgery and strongly advises patients against seeking it elsewhere. This opposition is based on the lack of evidence to support the procedure and the serious risks associated with it (including venous thrombosis, stroke, and pulmonary embolism). As a result, many Canadian MS patients have traveled to other countries to receive the surgery. Quebec physicians have been reluctant to provide surgical follow-up for patients who undergo the surgery in other countries due to the lack of information regarding the procedure. No alternative treatments are effective to partially or completely cure MS, and so the treatments available in Canada aim only to manage its symptoms.Jade is a forty-year-old Canadian woman with MS. She is on long-term disability leave, complains of growing fatigue and muscle stiffness, and has painful sensations in her limbs. She has been followed by an interdisciplinary team in a specialized hospital in Quebec for the past twenty years, since she was diagnosed. At her last appointment, Jade told her physical therapist that she recently underwent the experimental Zamboni surgery in Poland, despite her physician’s strong recommendation not to. Jade fears her physician’s reaction, so she asks the physical therapist to keep this information from the rest of her medical team.Jade is shy and tends to distrust health care professionals. It took many years for her physical therapist to gain her trust and to develop a positive therapeutic relationship with her. However, the physical therapist knows that serious complications can occur in patients who have had Zamboni’s surgery. Not telling Jade’s physician about the surgery could result in harm; Jade could have complications that are not recognized. Providing the information to the rest of the team would allow them to adjust her treatment to respond to the surgery and give her information and postoperative education that she will need. Moreover, keeping this secret could threaten team cohesion and trust if they find out about it later.Jade decided to undergo a risky surgery against her doctor’s advice in the hope of improving her quality of life. This was her autonomous choice. How should the physical therapist respond?CommentaryMaude Laliberte (bio)Laws and professional codes of ethics direct clinicians to respect their patients’ autonomy through confidentiality and informed consent unless there are compelling reasons not to do so. Health professionals are deeply committed to helping patients; above all, they want to avoid harming them. Therefore, a key component of this case is the possibility that respecting Jade’s desire to conceal information from the team may put her at direct risk if any postoperative complications are not detected, and at indirect risk if Jade’s trust in her medical team is undermined to the point where she turns away from them.The physical therapist must determine if the possible physical risks to Jade are imminent and serious enough to go against her autonomous choice. One risk that can occur following Zamboni’s surgery is inflammation of a vein caused by a blood clot. This is a life-threatening situation (although it may not be a likely complication for Jade). But the physical therapist can teach Jade to recognize the physical signs that can alert her to this problem, giving her ample time to seek treatment. Thus, even though she may be in danger from a life-threatening risk, there may be ways to manage it besides violating her confidentiality.The respect for autonomous choice is a crucial aspect of our democratic values. It promotes a process of exchange in the therapeutic alliance: the professional guides and informs the patient, but the patient is a partner in care planning and treatment. An important... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Journey to WellnessRoberta PriceI should preface this by saying that as a child and early teen years I was lean, well within my weight range for my height of 5’3”. I was physically active as a snow skier, swimmer, hiker and biker. I started running in high school until I got pregnant at the age of 17 in 1988, but even then, my family and I had a gym (...) membership and I worked out with a trainer until my belly got too big and complications from pre–eclampsia forced me to bed rest the last four weeks of my pregnancy. I gained about 80 pounds, mostly water, during this time. Post pregnancy, I lost all my weight and resumed my active lifestyle of walking etc. It wasn’t until I got married in 1990 that I found my weight creeping up on me, slowly, every year. I was still active with three kids and a husband by then, but bad eating habits and cheap carbohydrates were not my friend.My efforts to return to leanness started a few years ago, about 2006. At that point, I weighed at least 200 pounds and I was not happy. Everyone knows the best way to lose weight is to exercise and watch what you eat, so I start daily walks. While walking I started having problems with my legs going numb to the point that I could not feel my feet hit the ground. At first I thought this feeling was due to a pinched nerve as a result of a single–vehicle car accident I was in earlier that year. Some days my legs would not bother me while walking and other days only a few steps would bring on the numbness. Also, I was susceptible to feelings of panic and a racing heart beat. My doctor at the time never once mentioned my weight being an issue. The nurse would write my weight on the chart, I would cringe as I waited for the lecture from my doctor about my weight to start. It never did. It was a strange, sort of “non–issue” with him as I had three kids so I was fat from that. My physician just said, “Lose the weight, I have no idea what is causing the numbness in your legs.”Fast forward to 2011, I am now under the care of a chiropractor in hopes of relieving the numbness that is happening all too frequently now. An ultrasound of my veins showed good blood flow so that ruled out a circulation issue. The chiropractor prescribed physical therapy to help ease my lower back pain hoping that would relieve the nerves I thought were pinched. I was prescribed high blood pressure medication by my doctor, with adverse side effects such as a nagging cough that would not go away—no matter how much cough medicine I consumed. It was during these sessions with my physical therapist that I was able to lose 10 pounds.There is a lot of self–talk in the life of an overweight or obese person. Everyday I woke up, knowing I had to lose weight. Every single time I looked in any mirror or saw any photo (which I was careful to be the photographer and not a subject as denial had become my best and worst friend). It was the subject of many a late night conversation with my husband, whom by the way, at his worst weight was 30 pounds over his preferred height to weight ratio. Not a single doctor I saw previous to this offered any hope for weight loss other than to shove a piece of paper at me telling me to eat these “healthy foods” listed. Since I was the family chef and chief purchaser of food, I was buying and eating vegetables, fruit, whole grains, and attempting to cut down on the processed foods—although, we were heavy eaters of potatoes, pastas, bagels, pizzas and other high carbohydrate foods. Over the years, [End Page 112] the most weight I had lost “counting calories” or portioning out “slow carbs” over “fast carbs” only afforded me a 15 pound loss, to be gained... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Transformation:Power in Persistence and PerspectiveTyler BendrickWe've got another meth napper," my resident stated. With an introduction like that, it is hard not to be immediately labeled as a "difficult patient." Being the only Spanish-speaking person on the team, I, a third-year medical student, became the primary point of contact for this severely injured patient. He was an only-Spanish-speaking, 36-year-old male admitted [End Page 7] to our trauma service (...) after he was hit by a truck while riding his bicycle. Unbeknownst to me at the time, the 14 days I spent caring for this man would become one of the most pivotal learning experiences of my medical school career. It changed not only how I understand and approach "difficult patients" but expanded my knowledge of the complexities and challenges of the current healthcare system and how we, as physicians and healthcare providers, can deliver the best care to patients with low health literacy and limited resources.So, what is a "meth napper?" I questioned. "Well, meth is a super stimulant," my resident explained. "When people are frequent meth users, they get used to functioning normally with high levels of stimulants in their body, reducing the normal regulation of wakefulness. When the amphetamine is removed (such as upon admission to the hospital), the body is left to fend for itself, and thus patients oftentimes sleep for 23 hours a day for about 3 to 5 days while their body works to detox and normalize hormones."As predicted, my new friend, "Joe," was napping when I first went to see him. Thinking back, the word "napping" does not accurately describe his level of somnolence. He was virtually unarousable, and I took to a sternal rub to wake him up at 5 a.m. after his traumatic exploratory laparotomy the night before. Once aroused, he was furious. "Estoy bien. Tengo dolor y tengo hambre," he grunted at me. (I am fine, and I am in pain and hungry!). "Ok, Joe," I replied in Spanish, "I am just going to do a quick exam and you can go back to sleep. We will give you medications for your pain. You had a big surgery on your intestines, so you cannot eat or drink right now. If everything goes well in the next couple of days and you start walking around, we can advance your diet." He begrudgingly let me examine him, never opening his eyes, and I left and went about my day.We continued this routine for five days. I would periodically check on him and usually found him sleeping. When awake, he refused to work with physical therapists, get up and walk or go to the bathroom, shower, use his spirometer, or converse with the nursing staff. He seemed completely disinterested in recovery. About day three, we slowly advanced his diet to clear liquids so he could quench his thirst. Sometimes his wife was there, and she would ask for updates, to which I could only reply, "We have to wait until he is more awake or willing to work with us." I was getting frustrated, as it seemed that his noncompliance was becoming his barrier to discharge.But on day six, everything changed. I went to check on Joe, and he was wide awake, vomiting, and irate. He shouted that he was in incredible pain, and his incision was wet. He was also complaining that he had not eaten in five days, and was insisting that we were starving him. Again, I calmly explained (as I had multiple times a day for the past five days) that his major abdominal surgery prevented us from feeding him until his intestines healed. We were giving him fluids and nutrition through his IV lines, so he was not starving to death. I rushed to get my resident to examine his oozing wound, and after a CT scan and an x-ray, we discovered what we feared: His wound had opened down to the fascia, "dehiscence," as it is called. On top of this, he now had a bowel obstruction, causing his vomiting. His lack of mobility for the past five days had slowed his... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Response To June Boyce-Tillman, “Towards an Ecology of Music Education”Elizabeth BauerJune Boyce-Tillman explores the values implicit in the Western musical traditions that also dominate music education. She examines the five interlocking areas of materials, expression, construction, values, and spirituality and how these areas create a more holistic way of conceptualizing the musical experience within music education. By describing the divide between the values of system A and system B, (...) Boyce-Tillman reminds us that these issues are persistent and demand our constant attention as music educators. She supports the conviction that music [End Page 186] curricula should not be dictated by a national curriculum. Instead, education should be a powerful way of supporting the dominant value system of a culture. As an educator focusing on the population of students with special needs, I find myself agreeing with her advocacy of holistic education and suggest that she look at the model of special education to implement this ecology of music education. Boyce-Tillman's proposal evokes a number of responses, of which I will mention two.My first response is to her belief in the individual within the community. This is often problematic in current educational circles. States and countries are being held to standardized curricula. While in and of themselves standards are not bad because they set educational expectations, dictated curricula do not allow for individuality and creativity. Special education addresses this problem by the use of an individualized education plan (IEP). This plan is devised to meet the abilities and capabilities of each individual student. An IEP states the educational goals for the student with special needs for one academic year. Although the IEP contains year-long educational goals, it also contains the methods for how a student will meet those goals. No two students with special needs will have the same educational curriculum. This idea is supported by humanistic ideas in that the individual child is more important than a fixed curriculum. Furthermore, the IEP is developed by all teachers working with the child. For example, a child with Down syndrome normally works with a speech therapist, physical therapist, occupational therapist, general education teacher, and several other subject specific teachers (music, art, physical education, and so on). During the creation of the IEP, all therapists and teachers work together to devise the best educational plan for the student. This helps to ensure continuity between therapies and teaching methods.Currently, many music teachers are excluded from the process of devising the IEP. This also supports Boyce-Tillman's ideas on how national curricula often support the dominant value systems and reinforce the notion of subjugating other value systems. However, I propose that the inclusion of the music teacher in the IEP process because music class is one of the easiest ways to make the student with special needs feel part of a community. The music classroom supports the idea of working together to accomplish a common goal.My second response relates to the valuing of process. While Western culture has typically placed value on product, the converse is true in special education. Throughout the devising of the IEP, the process of learning is valued. Although special education teachers have an ultimate goal for what the student is to accomplish, it is more important to examine the process of how the student achieves that goal. Furthermore, students with special needs are not given rigid time-lines in which they have to accomplish a goal. Instead, a student is allowed to move at his or her own pace. [End Page 187]Moreover, while the students with special needs are moving at their own pace, they are also nurtured by the teacher. In the United States it is common for students with special needs to be educated in the classroom with their nondisabled peers. This is referred to as inclusion. For certain parts of the day, the students with special needs may leave the regular classroom and receive tutoring in certain subject areas by the special education teacher. Many teachers who do not have experience in teaching students with special needs have noticed how the students with special needs achieve more when they are with their special education... (shrink)

The aim of this paper is to offer theoretical insights into the care of the self, which often initiates therapist-patient relationships in clinical practice. The reason is that when patients care about their health status, they are inclined to establish a therapeutic relationship with physical therapists. Hence, the care for self may bridge the world of the patient's private experiences and the world of the healthcare system together with its interventions, which is represented by the physical therapist (...) In this framework, care means not only the patient's choice to undergo therapy but also his/her commitment to sustaining its effects in private life. This involves educational interventions by the physiotherapist who inscribes him/herself in his/her patients’ care of the self in order to alter their habits of physical exercise, diet, personal hygiene, body posture, etc. The argument in this paper is informed by the concepts of ethics developed by Michel Foucault and Richard Shusterman. (shrink)

To assess—from a qualitative perspective—the perceptions and attitudes of Spanish rehabilitation professionals (e.g. rehabilitation doctors, speech therapists, physical therapists) about Brain–Computer Interface (BCI) technology. A qualitative, exploratory and descriptive study was carried out by means of interviews and analysis of textual content with mixed generation of categories and segmentation into frequency of topics. We present the results of three in-depth interviews that were conducted with Spanish speaking individuals who had previously completed a survey as part of a (...) larger, 3-country/language, survey on BCI perceptions. 11 out of 15 of these Spanish respondents (survey) either strongly or somewhat accept the use of BCI in rehabilitation therapy. However, the results of our three in-depth interviews show how, due to a strong inertia of attitudes and perceptions about BCI technology, most professionals feel reluctant to use BCI technology in their daily practice (interview). (shrink)

Well-trained, competent therapists are crucial for safe and effective psychedelic-assisted therapy (PAT). The question whether PAT training programs should require aspiring therapists to undergo their own PAT—commonly referred to as “experiential training”—has received much attention within the field. In this article, we analyze the potential benefits of experiential training in PAT by applying the framework developed by Rolf Sandell et al. concerning the functions of any training therapy (the therapeutic, modeling, empathic, persuasive, and theoretical functions). We then explore (...) six key domains in which risks could arise through mandatory experiential training: physical and psychological risks; negative impact on therapeutic skill; justice, equity, diversity, and inclusion; dual relationships; privacy and confidentiality; and undue pressure. Ultimately, we argue that experiential training in PAT should not be mandatory. Because many PAT training programs already incorporate experiential training methods, our exploration of potential harms and benefits may be used to generate comprehensive risk-mitigation strategies. (shrink)

Depression experienced by older adults is proving an increasing global health burden, with rates generally 7% and as high as 27% in the USA. This is likely to significantly increase in coming years as the number and proportion of older adults in the population rises all around the world. Therefore, it is imperative that the effectiveness of approaches to the prevention and treatment of depression are understood. Creative arts interventions, including art, dance movement, drama and music modalities, are utilised internationally (...) to target depression and depressive symptoms in older adults. This includes interventions led by trained arts therapists as well as other health and arts professionals. However, to date there has not been a systematic review that reports effects and examines the processes (why) and mechanisms (how) of creative arts interventions are used to address depression in this older age group. This systematic review of studies on creative arts interventions for older adults experiencing depression examined: outcomes of four creative arts modalities (art, dance movement, drama, and music); with particular attention paid to processes documented as contributing to change in each modality; and mechanisms considered to result from these processes. Our analysis of 75 articles (17 art, 13 dance, 4 drama and 41 music) indicates mostly significant quantitative or positive qualitative findings, particularly for interventions led by creative arts therapists. Mechanisms of change gleaned from the studies that were common across modalities include physical (e.g. increased muscle strength; neurochemical effects, such as endorphin release), intra-personal (e.g. enhanced self-concept, strengthened agency and mastery; processing and communication of emotions), cultural (e.g. creative expression, aesthetic pleasure), cognitive (e.g. stimulation of memory) and social (e.g. increased social skills and connection), that were all considered to contribute to reduced depression and symptoms. Recommendations for future research include a stronger focus on testing of processes and mechanisms. (shrink)

This study explores how therapists deal with ethical dilemmas in psychotherapy with older adults. Semi-structured interviews were conducted with 14 therapists and analyzed using grounded theory methodology. Findings clustered around three themes: (i) respecting autonomy when interacting with family of vulnerable and dependent older patients; (ii) prioritizing respecting autonomy in risk situations and in suspected financial abuse without impaired judgment; and (iii) prioritizing protecting the patient in risk situations of patients with dementia and of suspected physical abuse (...) or neglect. These findings highlight several important issues regarding the management of ethical dilemmas in psychotherapy with vulnerable and dependent older adults. (shrink)

In August 2024, The U.S. Food and Drug Administration rejected Lykos Therapeutics, Inc.'s new drug application for midomafetamine with psychological intervention (MDMA-AT) to treat post-traumatic stress disorder (PTSD). Among the many issues raised during review was concern about a highly publicized case of alleged sexual misconduct by an unlicensed therapist during a Phase 2 study of MDMA and the potential risk of future abuse. This incident of misconduct, along with several other publicized cases of misconduct by guides, facilitators, and shaman (...) offering psychedelic retreats, has raised the question of whether physical contact is ever appropriate during psychedelic-assisted therapy (PAT). Drawing on research about supportive touch in other clinical contexts and taking into consideration features of psychedelics that exacerbate the potential for harm associated with supportive touch, we advocate for a precautionary approach to harm-reduction while arguing that supportive touch ought not be thrown out whole-cloth. (shrink)

Autonomy is good for you. A strong sense of competent self-control and effective choice-making promotes both physical and psychological well-being. Loss of autonomous control—and a sense of helplessness—causes depression, increased sensitivity to pain, greater vulnerability to disease, and death. Well established by a wide range of psychological and physiological studies, the positive effects of patient autonomy are well known to competent physicians, nurses, and therapists. Conscientious caregivers are thus moving beyond grudging acceptance of informed consent toward clinical respect (...) for patient autonomy. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Expose of a BreakdownIngrid HindellIregard my pension as a social wage, and even though I wish it took my disability and the extra costs that brings into consideration, eighteen years ago, I felt privileged to be able to work in the community, not in a sheltered workshop.At this time, a number of us worked voluntarily for numerous little organizations when the government cut their funding and in effect, took (...) away our jobs.It was around this time that I started a “stress cough.” Foolishly, I didn’t take much notice. I was enjoying “life”—studying, working, taking part in a documentary called “Untold Desires” and being a member of the “Friendship Group”—in which a group of us tackled the subject and nature of friendship for people with and without disabilities....The processes and the cohesion of the group brought up a lot of “stuff” for me that I wasn’t able to articulate. It made me question the wisdom of my lifestyle up to then—of marrying a person without a physical disability, for example.My mother used to tell me to tell him to tidy the flat, not in the least realizing that: i) it was distressing that I couldn’t do this; ii) that given all our interests it was difficult to tidy up. (This situation was also not helped, I now realize, by us trying to live and run home businesses from my small three–roomed accommodation behind my parent’s home, without enough support worker hours....)The flat was always cluttered, not conducive to encouraging a feeling of ease in us bringing clients onto the premises. As Robert’s massage workload grew, so did our underlying tension, I see now. And when I was starting to counsel other people with disabilities the situation was made worse....Added to this, my mother had, just prior to this period in our lives, stopped giving us our main meal because we were becoming more and more interested in eating organic and vegetarian food.At the same time, listening to other group members’ stories made me realize how “undervalued” people with disabilities are in society as I had been brought up in a loving extended family and had not long been “out.”It made me realize how much people with disabilities were constrained by lack of governmental funding for recreational—especially relationship options—with each other and with able–bodied people. The government was trying to close down little advocacy organizations that could keep this issue in the forefront of policy makers’ minds. No wonder I was getting close to breaking point! [End Page E1]When I got really bad, my husband almost went mad himself trying to cope with me. I had been the outgoing partner in the relationship for the past 12 years. Now I was getting panic attacks and clinging like poison ivy....And the therapists I went to at that stage didn’t help. The Naturopath was so expensive she made me much worse. She had told a “friend” of Rob’s that she would treat me for $30.00 a time. She did not say that she would present me with an ever– increasing bill every time I had an appointment—to pay her back when I could! And that her admin assistant would keep commenting, in my hearing, that people wouldn’t pay their bills on time.... At last, when the amount got to $450.00, I paid her all my savings, and managed to quit.I now also believe she treated me with a totally inappropriate therapy—colonic irrigation—for far too long, any natural therapist would say nowadays—five weeks!I believe it made my mental state worse. People say that an unquiet mind can stress the body into illness but I believe losing too much weight too fast as I certainly did, stressed my mind, instead of other way around.By this time I wasn’t only having panic attacks. I had slipped into, what I recently discovered, was a clinical depression. This brought in its wake, a terror so real, so all encompassing that I wonder I lived through a day of it—much less four... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.4 (2005) 301-305 [Access article in PDF] The Beauty of Psychotherapy R. D. Hinshelwood Keywords awe, psychotherapy, representation, self-esteem The Enlightenment was devoted to clear uncontaminated reason; its success has given us the terrific achievements of science and technology. However, it has bequeathed problems too. Untrammeled reason has led to the devaluing and exclusion of emotions. Emotions are irrational—self-deception, akrasia, and so on. They were (...) a problem for the eighteenth-century philosopher Kant and right through to the modern therapist Aaron Beck. Callender rightly looks around the edges of rationalist thought to see what can be said about the emotional and subjective side of mankind. He argues that there is more to the human mind than cognition. Something has been left out. What can be found to fill the gap?Callender has searched for the missing link that might complete our view of human nature. And he came back with aesthetics. Meaning The Enlightenment failing is writ large for therapists who are confronted with people who feel things. So we need to ask what place the emotions have in understanding the nature of man? It is not a hypothetical question, but a very practical one for a therapist. Emotions, Callender says, and most people would agree with him, are what gives meaning to life, a sense of purpose in living, even an ill-defined or delusional purpose.He presents Kant's description of aesthetics. Aesthetic judgements have a number of features, the most enigmatic and perhaps profound is a "purposiveness without purpose." A work of art, say a portrait, may have a purpose insofar as it represents a person for his aggrandizement or for his descendents through many generations, but the aesthetic quality does not come from that purpose. The aesthetic purpose involves a different set of judgements. They are about the painting as a piece of art in itself. If it is possible to compare this kind of aesthetic judgement with a judgement of a person's life, then I find myself reminded of Wollheim's definition of a person: The simplest way of putting the matter, which is not to be taken as a metaphysical claim, is this: There are persons, they exist; persons lead lives; and as a result, in consequence—in consequence that is, of the way they do it—there are lives, of which those who lead them may, for instance, be proud, or feel ashamed. So there is a thing, and there is a process, and there is a product. (Wollheim 1984, 2) Although many things do not lead lives, we do. And our lives have a process and a product. Like an aesthetic product, our lives have a sense of emotional meaning, without it having a clear purpose.Aesthetic judgements are therefore of a particular and somewhat peculiar kind. They judges talent for producing "that for which no determinate [End Page 301] rules can be given," as the paper quotes Kant. Other kinds of judgements do have determinate rules. First are empirical judgements for getting practical things done; and moral judgements for assessing ethical good from bad. Aesthetic beauty does not have clear rules, although many systems of rules have been proposed starting with the rules of perspective as they were laid out by renaissance painters, through to systems of color, such as that proposed by Paul Klee, once color was correlated with electromagnetic wavelengths. However, artists have always kept one jump ahead and evaded imprisonment in codified rules. So too it is with leading a life, perhaps. The really creative life is not lead according to rules. The art of life is to live meaningfully without simply running along tramlines. Although moral conduct and the practicalities of life remain significant, perhaps leading a life implies simply a "flare for living." Representation Of these three kinds of judgements that a mind makes, two do have sets of rules. Only one based on rationality, empirical evidence, and reason. Reason judges what can be done and achieved in the real physical world. It is about pragmatics and the usefulness of action. Moral judgements, about what... (shrink)

The military service of combat soldiers may pose many threats to their well being and often take a toll on body and mind, influencing the physical and emotional make-up of combatants and veterans. The current study aims to enhance our knowledge about the combat experiences and the challenges that female soldiers face both during and after their service. The study is based on qualitative methods and narrative analysis of in-depth semi-structured personal interviews with twenty military veterans. It aims to (...) analyze the narratives of American and Israeli female combat soldiers regarding their military service, with emphasis on the soldiers’ descriptions, in their own words, about their difficulties, challenges, coping and successes during their service and transition to civilian life. A recurring theme in the interviews with the veterans of both militaries was the need to be heard and the fact that societies, therapists, and military institutions do not always truly listen to female veterans’ experiences and are not really interested in what actually ails them. Our research suggests that conventional methods used in research relating to veterans might at times be inadequate, because the inherent categorization might abstract, pathologize, and fragment a wide array of soldiers’ modes of post-combat being. Moreover, female veterans’ voices will not be fully heard unless we allow them to be active participants in generating knowledge about themselves. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Trauma, Recognition, and the Place of LanguageJuliet Mitchell (bio)Definitions of trauma abound within the psychoanalytic discipline. My own definition is going to be simple. A trauma, whether physical or psychical, must create a breach in a protective covering of such severity that it cannot be coped with by the usual mechanisms by which we deal with pain or loss. The severity of the breach is such that even (...) if the incident is expected, the experience cannot be foretold. We cannot thus make use of anxiety as a preparatory signal. The death of a sick relative, the amputation of a diseased limb may be consciously known about in advance, but if they are to be described as traumatic then the foreknowledge was useless. In trauma we are untimely ripped.Whether it is as childhood seduction, infantile abuse, shell shock, or war violence, or as a preoccupation with the place of neoteny and the trials of human birth, trauma is continually posited as the hypothetical “origin” of psychic states. However, although “trauma” is crucial to psychoanalytic theory, trauma in itself is not really the focus of its analysis. Freud proposed a “biological bedrock” on which psychic states were formed, but this bedrock was not the object of psychoanalytic inquiry. I suggest that what emerges as a motif in the many retheorizings of psychoanalysis time and again, as another “bedrock,” is trauma. One might call it an “experiential bedrock.” As with biology, it is crucial—but as the area of another mode of inquiry. Psychoanalysis is equipped to contribute to the understanding of the reaction to trauma, not to the trauma itself.In a colloquial context we tend to look from the perspective of the observer and label a range of difficult or tragic occurrences “traumatic.” Instead, I want to define trauma from the perspective of the person who experiences it. This means both that the same event will not always be traumatic for different people, and that the experience of different events, if they are experienced as trauma, will be the same whatever the event and whoever the sufferer. It was essentially for this reason that Freud eventually disagreed with the rich findings of Otto Rank, who proposed the trauma of birth as the origin of mankind’s neurosis. Trauma is the great equalizer. What differentiates us, since we were all born? Furthermore, what appears to be the trauma from the observer’s perspective may, from the viewpoint of the psychic response of the recipient, only be the catalyst that brings to the surface an experience which, were it not for this later event, might not in itself have been traumatic (or vice versa). Even so extreme an experience as the Holocaust may not breach the defenses of a particular individual. The catalytic event in the present triggers an earlier occurrence which becomes traumatic only by virtue of its retrospectively endowed meaning.Probably all animate matter can be traumatized; it would seem likely that the response to the breach in the human defensive system takes place at a generalizable psychosocial level. Recognition and language are interactional social processes; without another person neither a psyche nor language is possible. Object relations analysts, notably D. W. Winnicott, whom Max Hernandez addresses in his paper in this issue, have devoted their work to aspects of the psyche, Lacanians to language. To me the fields are interdependent and gain from being looked at together, both in their practice and in the theories that can [End Page 121] be applied to them. When we have a physical trauma it is common for an immediate aftereffect to be some uncertainty about words; even the ability to spell correctly can temporarily disappear. There are undoubtedly physiological explanations for this. But I shall argue that there are psychological parallels. Every patient whom I would regard as having had some relevant form of trauma had a specific relationship to language, and it is this that concerns me. In addition, Max Hernandez describes the breach in the defenses caused by the anal rape of a patient when he was a young boy. But neither the patient’s symptom nor his complaint on coming to a therapist for treatment pertains to... (shrink)

_Demons in the Consulting Room: Echoes of Genocide, Slavery and Extreme Trauma in Psychoanalytic Practice_ isthe second of two volumes addressing the overwhelming, often unmetabolizable feelings related to mourning, both on an individual and mass scale. Authors in this volume explore the potency of ghosts, ghostliness and the darker, often grotesque aspects of these phenomena. While ghosts can be spectral presences that we feel protective of, demons haunt in a particularly virulent way, distorting experience, our sense of reality and our (...) character. Bringing together a collection of clinical and theoretical papers, _emons in the Consulting Room_, reveals how the most extreme types of trauma can continue to have effects across generations, and how these effects manifest in the consulting room. Essays in this volume consider traumas that have affected multiple generations of people, such as the Holocaust, experiences in the gulags, and the experience of slavery. Authors here consider the clinical challenges of working with the demonic force in severe childhood abuse and the effects of serious and prolonged physical injury and illness. Inevitably, there is in such difficult clinical work, the combined effects of hauntings in the analysts and in patients and often in the surrounding culture. In this book, distinguished psychoanalysts explore the myriad forms of ghosts and the demonic, which interfere and disrupt the endlessly difficult psychic work of mourning. It will be of interest to psychotherapists and psychoanalysts, as well as social workers, family therapists, psychologists, and psychiatrists. _emons in the Consulting Room _ill appeal to those specializing in bereavement and trauma and, on a broader level, to sociologists and historians interested in understanding means of coping with loss and grief on both an individual and larger scale basis. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Why the Phenomenology Remains FoundationalRobert Harland (bio)Keywordspsychology, cognitive-behavioral therapy (CBT), phenomenology, psychiatry, depressionDemian Whiting in his paper criticizes an exclusively cognitive approach to the treatment of emotional problems. There is no doubt that the cognitive model of the mind has been recently in the ascendancy and therapies based on it are to be found in almost every subspecialty of psychiatry. Cognitive-behavioral therapy (CBT) in particular is "discovered" as being (...) effective in everything from posttraumatic stress disorder to psychosis. The heartland of the approach is and remains anxiety and depression, the two most common emotional states that psychiatrists and psychologists are asked to deal with. As Dr. Whiting describes, leaving aside the behavioral aspects, the basic principle is about eliciting and challenging distorted cognitions. Cognitive theory suggests that distorted cognitions are the cause of, the substance of, and the maintaining factors in most if not all depression and anxiety.The author accepts that in certain cases distorted cognitions lead to an experience that is represented contra to reality. He suggests that in certain circumstances a cognitive therapist could help a patient to reappraise the world they find themselves in and by gathering evidence with the therapist, to challenge these distortions. So in depression, a patient sees themselves as worthless and their therapist suggests they gather evidence that helps them form a more balanced perspective. The cognition "I am worthless" is shown empirically to be a distortion. Whiting argues, correctly in my opinion, for the limitation of this approach. In doing so he argues against a growing psychological hegemony, one that sees itself as developing evidence-based practice that should be applied (on the back of national guidelines) to many presentations before or exclusively of others such as medication or alternative psychotherapeutic approaches.Whatever the outcome in the clinic, as opposed to the randomized controlled trials, many clinicians and health care managers are attracted to CBT because of its pragmatic, short-term, problem- and consumer-orientated nature. It has an approach tailored for most disorders and therefore fits very well within the organization of modern mental health services. With this background, nonclinical readers may more readily appreciate the potential target of Dr. Whiting's critique.Whiting suggests three examples where eliciting cognitions can at best be seen as secondary [End Page 247] to the problem in hand: First, where a drug (e.g., alcohol) or state (e.g., tiredness) directly causes an emotion; second, where an emotion causes a mistaken understanding of a situation; and third, where the representation is accurate but the response defective (e.g., the pedophile in his article, or more routinely a person particularly sensitive to anxiety). The phenomenology, before the prism of analysis, is that in all three cases the patients find themselves in an emotional state where any putative cognitive etiology is at best post hoc and at worst tautological. Furthermore, as the author states, in the cases where accurate representations elicit the wrong kinds of emotions, the question why cannot be answered by referring back to the person's representations.To answer the question of why someone is particularly sensitive to anxiety or gets aroused by children, Dr. Whiting points to several possibilities that all impact on treatment: First, the influence of noncognitive desires and emotions; second, physical contamination; third, an idiosyncratic or abnormal constitution; and fourth, a defective emotional acculturation. In all these cases, suggesting that the patient's problems will be resolved through altering eliciting cognitions seems illogical.The paper then preempts two criticisms from the cognitive approach. The first again rightly expands that, if a higher order evaluative level is proposed, this in no way answers a noncognitive critique. Either the higher level of evaluation is simply an unnecessary (or unpredictable) cognitive confirmation of a negative (or positive) representation, or the evaluation is a cognitive foil for an emotional reaction that is simply not cognitive; when someone says they are worthless they are merely giving voice to their depressed emotional state. Second, that retreating to a position where the cognitive approach is used to challenge distorted representations that are secondary to, and yet maintain, an inappropriate emotion may have a role, but does not mean that... (shrink)

Although touch frequently occurs in psychotherapy with children, there is little written on the ethical considerations of therapeutic touch. Because physical contact does occur, therapists must consider if, how, and when it is used, for both their clients' safety and their own. In this review, I further develop the issues suggested by Aquino and Lee (2000) in the use of nurturing touch in therapy by considering many types of touch that occur in psychotherapy with children; the possible positive (...) role of touch; clients' perception of touch in therapy; considerations related to the therapist, the child's safety, and any history of abuse in the child's and family's background; and other practical considerations. I list guidelines. (shrink)

This discussion paper is drawn from a qualitative research project comparing the effect of special and ordinary schools on the lives of children, young people and their families. Special schools are recommended by health professionals who seldom know how ineffective these schools are. We question the beneficence and justice of health professionals' advice on education for children with disabilities and other difficulties. Cooperation with local education authorities (LEAs) plays a considerable part in the work of community paediatricians, clinical medical officers, (...) therapists and other health professionals encountering children with "special needs". The "needs" range from physical disability and sensory impairment to learning difficulties and emotional or behavioural difficulties. This cooperation involves routine administrative problems, but it raises broad ethical issues too, particularly in respect of current tendencies in state schooling towards the integration or inclusion of these children in mainstream schools and classes. (shrink)

There is increasing recognition within psychoanalysis and related therapies that awareness of the body is important in understanding and treating patients. Psychic Threats and Somatic Shelters explores the ways in which adults and children become acquainted with the range of physical issues that arise within their psychoanalytic or psychological treatments. Nitza Yarom discusses in a practical and clinically focused way the large variety of physical outlets which today's person uses to shelter from the many troubles and restrictions that (...) are placed on everyday life. Her book is divided into two main sections: Somatic shelters, which explores the variety of physical symptoms encountered by patients, including problems with weight and eating; with sensation through sight, sound, smell and taste; in movement through hyper activity or rigidity and through the communication of physical pain. Embodied dialogue, in which the author updates the use of the basic technical principles of psychoanalysis to involve the body in the treatment including transference and counter-transference between analyst and patient. In Psychic Threats and Somatic Shelters the emotional communication of these body narratives are vividly demonstrated in the treatments presented, here the interaction in the consulting room is revealed in bodily resonance and its therapeutic effects. This book is written for psychoanalysts and psychotherapists, psychologists, body therapists, family therapists, social workers and art/movement therapists. (shrink)

The purpose of this paper is to contextualize the study of metaphors within constructivist-informed research, in the hope that this process will orient cognitive scientists to the usefulness of implementing qualitative research methodologies, especially to using the person of the researcher as the primary research instrument. First, I explore some of the differences between Johnson and Lakoff’s Contemporary Metaphor Theory (CMT) and approaches evolving from it on one hand, and the clinical approach to metaphor based on a constructivist therapy model, (...) on the other. CMT has been one of the most significant forces that helped shift cognitive science toward an embodied approach to cognition. While it has succeeded to place physical experience back where it belongs in reason and meaning, CMT has, however, also fallen into some positivist traps which lead to problems such as a dualism, a split between the knower and the known, and with that, to a distrust of introspective, first-person accounts. In the process of finding conceptual metaphors — generalizations that govern metaphorical expressions — CMT often deletes the idiosyncratic characteristics and presuppositions implicit in linguistic metaphors; it divorces them from people’s sensory experiences, the “here and now” and the intent of their communications. The constructivist approach to metaphor that I present here accepts as a priori assumptions much of what workers of CMT are out to prove. In particular, it takes the correlation of conceptual metaphors and physical experience, as well as the unity of language and thought as pragmatic givens. Emulating the constructivist therapist’s approach to metaphors, I show how it is possible to deconstruct conceptual metaphors into minute sensory distinctions, using one’s own person as the main tool, for the purpose of helping people change their experiences in desired ways, at will. I illustrate this process by numerous examples from a wide field of applications, including mathematics education and psychotherapy. (shrink)

The current techno-scientific revolution has transformed the concepts of person and human being. Techno-scientific developments raise questions about our very own humanity and bring again the Übermensch, about whom Nietzsche once spoke, for discussion. Technology has increased the desire to modify our human condition, aiming for the perfection of the physical, intellectual and psychological abilities. Different sciences and disciplines have had the necessity to adapt themselves to these techno-scientific transformations. Psychology has not been the exception and, because of that, (...) a new paradigm of approaching the human mind has been recently established. Concepts such as cybertherapy, virtual reality therapy to treat patients with phobias, and the use of Artificial Intelligence have revolutionized Psychology. Therefore, the purpose of the article is to establish whether the use of Artificial Intelligence in Psychotherapy actually contributes to the improvement of human beings by making possible progress within the field of Mental Health Care or, on the contrary, it poses a risk to humanity, which might face the possibility of replacing human therapists with intelligent machines. (shrink)