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Poor Communication (poor + communication)
Selected AbstractsTransitioning the patient with acute coronary syndrome from inpatient to primary care,JOURNAL OF HOSPITAL MEDICINE, Issue S4 2010FACPE, Tomás Villanueva DO Abstract Patients with acute coronary syndrome (ACS) undergo several transitions in care throughout the hospital stay, from prehospitalization to the postdischarge period when patients return to primary care. Hospitalist core competencies promote safe transitions in care for patients with ACS, including hospital discharge. These competencies also highlight the central role of the hospitalist in facilitating the continuity of care and as a key link between the patient and the primary care provider (PCP). Core competencies address key decision points and processes that occur during hospitalization for ACS including the initial evaluation and risk stratification, medication reconciliation, and discharge planning. Discharge is a crucial transition and one where hospitalists can both facilitate the transition to primary care and improve adherence to quality measures established for ACS. Poor communication during discharge reportedly results in postdischarge adverse events, most often related to medications and lack of follow-up related to pending test results. Standards for a safe discharge such as Project RED (Re-Engineered Discharge), initiatives to improve outcomes after discharge like Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), and adaptive tools including the ACS Transitions Tool support timely and accurate communication of complex information between the hospitalist, the PCP, and the patient. While the role of hospitalists is evolving, it is clear that they have a central role in ensuring safe transitions in care for ACS. Journal of Hospital Medicine 2010;5:S8,S14. © 2010 Society of Hospital Medicine. [source] Latest news and product developmentsPRESCRIBER, Issue 5 2008Article first published online: 3 APR 200 Newer antidepressants no better than placebo? A new meta-analysis suggests that newer antidepressants are no superior to placebo in most patients with depression , the exception being those with very severe depression, who can expect a small benefit. Writing in the online-only open access journal PLoS Medicine (5:e45.doi:10.1371/ journal.pmed.0050045), researchers from Hull and the US analysed published and unpublished trials submitted to the Food and Drug Administration in marketing applications for fluoxetine, paroxetine, venlafaxine (Efexor) and nefazodone (no longer available). Using the Hamilton Rating Scale for Depression (HRSD) score as an endpoint, meta-analysis of 35 trials involving 5133 patients and lasting six to eight weeks showed that mean HRSD score improved by 9.6 points with drug treatment and 7.8 with placebo. The authors say the difference of 1.8 was statistically significant but below the criterion for clinical significance (3.0) set by NICE in its clinical guideline on depression. A review of the study by the NHS Knowledge Service (www.nhs.uk) points out that it omits trials published after the drugs were licensed (1999) and those not sponsored by the pharmaceutical industry. It did not include any patients with severe depression and only one trial in patients with moderate depression. An earlier US study of data submitted to the FDA (N Eng J Med 2008;358:25260) showed that published trials of antidepressants were more likely to be positive (37/38) than unpublished ones (3/25). Further, FDA analysts concluded that 51 per cent of trials (published and unpublished) demonstrated positive findings compared with 94 per cent of those that were published. Audit reveals variations in hospital psoriasis care There are unacceptably large variations in the quality of care for patients with psoriasis in UK hospitals, a report by the British Association of Dermatologists and the Royal College of Physicians reveals. The audit of 100 hospital units found that 39 per cent restricted access to biological therapies because of cost, and over one-third of pharmacies could not supply ,specials' such as topical coal tar preparations. More positively, the units are adequately resourced to provide timely communication with GPs. RCGP responds to Public Accounts Committee The Royal College of General Practitioners has agreed with the Commons Public Accounts Committee that drug package labelling should include the cost of the medication. The suggestion was made by the Committee in its report Prescribing Costs in Primary Care. While recognising the importance of generic prescribing, the RCGP cautions against frequent medication switches because it may unsettle patients. ,Any changes must be carried out for sound clinical reasons with good communication between GPs and their patients,' it adds. Statins for patients with kidney disease? Statins reduce cardiovascular risk in people with chronic kidney disease, a new study suggests, but their effects on renal function remain unclear (BMJ 2008; published online doi: 10.1136/bmj. 39472.580984.AE). The meta-analysis of 50 trials involving a total of 30 144 patients found that statins reduced lipids and cardiovascular events regardless of the severity of kidney disease. However, all-cause mortality was unaffected and, although proteinuria improved slightly, there was no change in the rate of decline of glomerular filtration rate. An accompanying editorial (BMJ 2008; published online doi:10.1136/ bmj.39483.665139.80) suggests that the indications for statin therapy to reduce cardiovascular risk in patients with chronic kidney disease should be the same as for those with normal renal function. New NICE guidance New clinical guidelines from NICE (see New from NICE, pages 14,15) include the diagnosis and management of irritable bowel syndrome in adults in primary care, the care and management of osteoarthritis in adults, and the diagnosis and treatment of prostate cancer. In a public health guideline on smoking cessation services, NICE endorses the use of nicotine replacement patches for 12,17 year olds. Suspect additives in children's medicines The Food Commission (www.foodcomm.org.uk) has drawn attention to the presence in children's medicines of food additives it says are linked with hyperactivity. The Commission, a national nonprofit organisation campaigning for ,the right to safe, wholesome food', says that seven common additives (including tartrazine, sodium benzoate and Ponceau 4R) are associated with hyperactivity in susceptible children. Checking the SPCs, it found that 28 of 70 children's medicines , including formulations of paracetamol, ibuprofen, amoxicillin, erythromycin and codeine phosphate throat linctus , contain at least one suspect additive. Digoxin may increase mortality in AF patients An observational study has suggested that digoxin may increase deaths in patients with atrial fibrillation (Heart 2008;94:191,6). The study was a planned subgroup analysis of a trial evaluating anticoagulant therapy in 7329 patients with atrial fibrillation. Of these, 53 per cent were treated with digoxin. Mortality was significantly higher among digoxin users than nonusers (4.22 vs 2.66 per cent per year); myocardial infarction and other vascular deaths (but not stroke, systemic embolic episodes and major bleeding events) were significantly more frequent with digoxin. Poor communications cause readmission Elderly hospital patients are often discharged with inadequate information or arrangements for care, causing almost three-quarters to be readmitted within a week, say investigators from Nottingham (Qual Safety Health Care 2008;17:71,5). Retrospective review of records for 108 consecutive patients aged over 75 found that readmission was related to medication in 38 per cent and, of these, 61 per cent were considered avoidable. Almost two-thirds had no discharge letter or were readmitted before the letter was typed; two-thirds of discharge letters had incomplete documentation of medication changes. Copyright © 2008 Wiley Interface Ltd [source] Patients' experiences with partial dentures: a qualitative studyGERODONTOLOGY, Issue 4 2005Patricia A. Smith Objective:, The aim of the study was to gain insight into people's experiences of being given and using partial dentures. Methods:, In-depth semi-structured interviews were carried out with 23 people of varied age, social background and denture wearing experience in Tayside, Scotland. Participants were encouraged to discuss how they came to have partial dentures, their day-to-day denture use and their interactions with dentists. The interview data were systematically coded using key theme headings, and summary charts were constructed to facilitate analysis. Results:, The initial decision that a partial denture was needed was generally difficult to accept. People perceived the main benefits of partial dentures to be improved appearance and confidence, but experienced a variety of difficulties with their dentures and often coped with these by only wearing them on social occasions. Participants had not always told their dentists about the difficulties they experienced. Barriers to seeking help with denture problems included financial constraints, previous experience of rushed appointments or poor communication from dentists and a perceived lack of entitlement to help when partial dentures were issued free. Conclusions:, Partial dentures can be difficult to cope with. People experience a range of difficulties in wearing them, not all of which have been discussed with dentists. Informative and supportive communication when partial dentures are first needed, and subsequently, can improve the quality of patients' experiences and may help promote effective use and appropriate help-seeking by partial denture wearers. [source] Fatigue in patients with rheumatoid arthritis: British and Dutch nurses' knowledge, attitudes and managementJOURNAL OF ADVANCED NURSING, Issue 4 2009Han Repping-Wuts Abstract Title.,Fatigue in patients with rheumatoid arthritis: British and Dutch nurses' knowledge, attitudes and management. Aim., This paper is a report of a study conducted to compare the knowledge, attitudes and current management of rheumatoid arthritis-related fatigue in British and Dutch rheumatology nurses. Background., After pain, fatigue is the most important symptom for patients with rheumatoid arthritis, but little is known about the current management of this fatigue by healthcare professionals. Methods., A questionnaire was mailed in 2007 to rheumatology nurses who were members of British Health Professionals in Rheumatology (N = 267) and the Dutch Society of Rheumatology Nurses (N = 227). Descriptive statistics, independent samples t -test and Pearson chi-square tests were used for statistical analysis. Results., A total of 494 nurses returned questionnaires (response rate 48%). In general, their knowledge about rheumatoid arthritis fatigue was in accordance with the literature and all indicated a positive attitude towards assessing and managing rheumatoid arthritis-related fatigue. However, respondents reported contradictory views about managing fatigue. Although they believed that other team members could help patients, they seldom referred patients on to other professionals. Although nurses believed that other advice besides pacing and balance between activity and rest might help, they did not offer this to patients. Despite acknowledging that there is poor communication about fatigue between patients and nurses, respondents reported that it is patients rather than nurses who raise the issue of fatigue in consultations. Conclusion., British and Dutch rheumatology nurses are sympathetic but do not know how to manage rheumatoid arthritis-related fatigue. Strategies to support self-management for this fatigue, and to increase communication between healthcare professionals and patients, should be initiated to help improve patient outcomes for rheumatoid arthritis-related fatigue. [source] Social semantics: altruism, cooperation, mutualism, strong reciprocity and group selectionJOURNAL OF EVOLUTIONARY BIOLOGY, Issue 2 2007S. A. WEST Abstract From an evolutionary perspective, social behaviours are those which have fitness consequences for both the individual that performs the behaviour, and another individual. Over the last 43 years, a huge theoretical and empirical literature has developed on this topic. However, progress is often hindered by poor communication between scientists, with different people using the same term to mean different things, or different terms to mean the same thing. This can obscure what is biologically important, and what is not. The potential for such semantic confusion is greatest with interdisciplinary research. Our aim here is to address issues of semantic confusion that have arisen with research on the problem of cooperation. In particular, we: (i) discuss confusion over the terms kin selection, mutualism, mutual benefit, cooperation, altruism, reciprocal altruism, weak altruism, altruistic punishment, strong reciprocity, group selection and direct fitness; (ii) emphasize the need to distinguish between proximate (mechanism) and ultimate (survival value) explanations of behaviours. We draw examples from all areas, but especially recent work on humans and microbes. [source] Improving the coordination efficiency of limited-communication multi,autonomus underwater vehicle operations using a multiagent architectureJOURNAL OF FIELD ROBOTICS (FORMERLY JOURNAL OF ROBOTIC SYSTEMS), Issue 4 2010Christopher C. Sotzing This research addresses the problem of coordinating multiple autonomous underwater vehicle (AUV) operations. An intelligent mission executive has been created that uses multiagent technology to control and coordinate multiple AUVs in communication-deficient environments. By incorporating real-time vehicle prediction, blackboard-based hierarchical mission plans, mission optimization, and a distributed multiagent,based paradigm in conjunction with a simple broadcast communication system, this research aims to handle the limitations inherent in underwater operations, namely poor communication, and intelligently control multiple vehicles. In this research, efficiency is evaluated and then compared to the current state of the art in multiple AUV control. The research is then validated in real AUV coordination trials. Results will show that compared to the state of the art, the control system developed and implemented in this research coordinates multiple vehicles more efficiently and is able to function in a range of poor communication environments. These findings are supported by in-water validation trials with heterogeneous AUVs. © 2010 Wiley Periodicals, Inc. [source] Challenges confronting clinicians in acute careJOURNAL OF NURSING MANAGEMENT, Issue 6 2009VICKI PARKER RN Aim, To engage acute care clinicians in prioritizing professional issues of concern and to help them identify and design change projects. Background, In order to meet and respond to challenges and to ensure safety, efficiency and positive patient and staff outcomes, it is imperative to understand the nature of difficulties faced by health professionals and for clinicians to be included in decision making and change. Method, A three-phase mixed-method design utilizing descriptive and interpretive approaches. Data were collected via survey, focus groups and nominal group workshops. Results, Communication, skill mix and work environments were identified as issues of most concern. Participants were able to identify and prioritize a range of projects to help them better understand and alleviate workplace problems. Conclusion, This study highlights key directions for practice change and confirms previous findings identifying urgent need for research that aims to overcome poor communication and skill shortages. It differs from other studies by providing a platform for participants to design projects leading to solutions and participate in change. Implications for nursing management, Support must be provided for managers in rostering, staffing, and resource procurement and allocation. The results of the present study highlights a need to refocus management styles on staff empowerment, participation and team building. [source] Civilians Versus Police: Mediation Can Help to Bridge the DivideNEGOTIATION JOURNAL, Issue 3 2000Vivian Berger The increasing frequency of notorious cases of conflicts between police officers and members of the general public (which in New York City has led to incidents of death, battery, and sexual assault) is cause for alarm. At the root of many police-community conflicts are an incomplete understanding of the work of the police, poor communication on the part of the police and the public, or simple misunderstanding. A number of communities, including New York City, are turning to mediation to provide a forum for the potential resolution of complaints made against police by citizens. After a brief survey of the work of such programs nationally, the author focuses on three New York cases in which she served as a mediator, using them to illustrate the pitfalls and special rewards of mediating in this context. The author believes that the mediation process itself can work in a transformative way, improving strained relations between police and the general population [source] Proceedings of the 20th Annual Conference of the Japanese Association for Adolescent Psychotherapy, 16 November 2002, Tokyo, JapanPSYCHIATRY AND CLINICAL NEUROSCIENCES, Issue 5 2003Article first published online: 28 AUG 200 Inpatient treatment of obsessive,compulsive disorder in a child and adolescent psychiatry ward M. USAMI National Center of Neurology and Psychiatry, Kohnodai Hospital, Chiba, Japan This is a case report of a 13-year-old-boy (2nd grade in junior high school). His father had poor communication; his mother was a very fragile woman. The boy had been overprotected by his parents, as long as he responded to their expectations. He did not have any other siblings. He played well with his friends since he was young, and did not have problems until the 1st term (from April to July) of 1st grade in junior high school. However, in September he started to have difficulties going well with his friends, and going to school. He spent most of his time in his room, and began to repeat checking and hand-washing frequently. Even at midnight, he forced his mother to touch the shutter from outside of the house for many times. He also ritually repeated to touch his mother's body, after he licked his hands, for over an hour. He became violent, when his parents tried to stop him. In April, year X, his parents visited our hospital for the first time. From then, his mother could not tolerate her son's coerciveness any longer. His father explained to the boy that ,your mother has been hospitalized', and she started to live in the next room to the boy's without making any noise. After 3 months he noticed that his mother was not hospitalized, and he got very excited. He was admitted to our hospital with his family and relatives, in October, year X. At the initial stage of hospitalization he showed distrust and doubt towards the therapist and hospital. He had little communication with other boys and did not express his feelings. Therefore, there was a period of time where he seemed to wonder whether he could trust the treatment staff or not. During his interviews with his therapist he repeated only ,I'm okay' and did not show much emotional communication. For the boy, exposing himself was equivalent to showing his vulnerability and incompleteness. Therefore, the therapist considered that he was trying to denying his feelings to avoid this. The therapist set goals for considering his own feelings positively and expressing them appropriately. Also, the therapist carried out behavioral restrictions towards him. He hardly had any emotional communication with the staff, and his peer relationship in the ward was superficial. Therefore, he gradually had difficulty spending his time at the end of December On the following day in which he and the therapist decided to return to his house for the first time, he went out of the ward a few days before without permission. From thereon it was possible for him to share feelings such as hostility and aggression, dependence and kindness with the therapist. The therapist changed his role from an invasive one to a more protective one. Then, his unsociability gradually faded. He also developed good peer relationships with other boys in the ward and began to express himself feeling appropriately. He was also able to establish appropriate relations with his parents at home, and friends of his neighborhood began to have normal peer relationships again. During childhood and adolescence, boys with obsessive,compulsive disorder are known to have features such as poor insight and often involving their mothers. We would like to present this case, through our understanding of dynamic psychiatry throughout his hospitalization, and also on the other therapies that were performed. Psychotherapy with a graduate student that discontinued after only three sessions: Was it enough for this client? N. KATSUKI Sophia University, Tokyo, Japan Introduction: Before and after the psychotherapy, SWT was administrated in this case. Comparing these two drawings, the therapist was provided with some ideas of what kind of internal change had taken place inside this client. Referring to the changes observed, we would like to review the purposes and the ways of the psychotherapy, as well as the adequacy of the limited number of the sessions (vis-a-vis result attained.) Also we will discuss later if any other effective ways could be available within the capacities of the consulting system/the clinic in the university. Case: Ms. S Age 24 years. Problems/appeal: (i) awkwardness in the relationship with the laboratory colleagues; (ii) symptoms of sweating, vomiting and quivering; and (iii) anxiety regarding continuing study and job hunting. Diagnosis: > c/o PTSD. Psychotherapeutic setting: At the therapy room in the clinic, placed at the university, 50 min-session; once a week; paralleled with the medical treatment. Process: (1) Since she was expelled from the study team in the previous year, it has become extremely difficult for her to attend the laboratory (lab) due to the aforementioned symptoms. She had a feeling of being neglected by the others. When the therapist suggested that she compose her mental confusions in the past by attending the therapy room, she seemed to be looking forward to it, although she said that she could remember only a few. (2) She reported that she overdosed on sedatives, as she could not stop irritating. She was getting tough with her family, also she slashed the mattress of her bed with a knife for many times. She complained that people neither understood nor appreciated her properly. and she said that she wanted revenge on the leader of the lab by punishing him one way or other. (3) Looking back the previous session, she said ,I had been mentally mixed up at that time, but I feel that now I can handle myself, as I stopped the medication after consulting the psychiatrist. According to what she said, when she disclosed the occurrences in the lab to her mother, she felt to be understood properly by her mother and felt so relieved. and she also reported that she had been sewing up the mattress which she slashed before, without any reason. She added, " although I don't even know what it means, I feel that this work is so meaningful to me, somehow". Finally, she told that she had already made her mind to cope with the situation by herself from now on, although it might result in a flinch from the real solution. Situations being the above, the session was closed. Swt: By the remarkable changes observed between the two drawings, the meanings of this psychotherapy and its closure to the client would be contemplated. Question of how school counselors should deal with separation attendant on students' graduation: On a case in which the separation was not worked through C. ASAHARA Sophia University, Tokyo, Japan Although time limited relationship is one of the important characteristics in school counseling, the question of separation attendant on it has not been much discussed based on specific cases. This study focuses on the question of separation through looking at a particular case, in which the separation was not worked through, and halfway relationship continued even after the student's graduation and the counselor's resignation. I was a part time school counselor at a junior high school in Tokyo. The client was a 14-year-old female student, who could not go to her classroom, and spent a few hours in a sick bay when she came to school. She was in the final grade and there was only half a year left before graduation when we first met, and we started to see each other within a very loose structure. As her personality was hyper-vigilant and defensive, it took almost 2 months before I could feel that she was nearer. Her graduation was the first occasion of separation. On that occasion, I found that there had been a discrepancy between our expectations; while I took it for granted that our relationship would end with the graduation, she expected to see me even after she graduated, and she actually came up to see me once in a while during the next year. A year later, we faced another occasion of separation, that was my resignation. Although I worried about her, all I have done for her was to hand a leaflet of a counseling office, where I work as a part time counselor. Again I could not refer to her feelings or show any concrete directions such as making a fixed arrangement. After an occasional correspondence for the next 10 months (about 2 years after her graduation), she contacted me at the counseling office asking for a constant counseling. Why could I not deal with both occasions? and how did that affect the client thereafter? There were two occasions of separation. At the time of the client's graduation, I seemed to be enmeshed in the way of separation that is peculiar to the school setting. In general in therapeutic relationship, mourning work between counselor and client is regarded as being quite important. At school, however, separation attendant on graduation is usually taken for granted and mourning work for any personal relationship tends to be neglected. Graduation ceremony is a big event but it is not about mourning over one's personal relationships but separation from school. That may be why I did not appreciate how the client counted on our relationship. At the time of my resignation I was too worried about working through a change from very loose structure which is peculiar to the school setting to a usual therapeutic structure (fees are charged, and time, place are fixed). That is why I did nothing but give her a leaflet. In this way, we never talked about her complex feelings such as sadness or loneliness, which she was supposed to experience on separation. Looking at the aforementioned process from the client's viewpoint, it can be easily imagined that she could not accept the fact of separation just because she graduated. and later, she was forced to be in double-bind situation, in which she was accepted superficially (handed a leaflet), while no concrete possibility was proposed concerning our relationship (she could never see me unless she tries to contact me.) As a result, she was left alone and at a loss whether she could count on me or not. The halfway situation or her suspense was reflected in her letter, in which she appeared to be just chatting at first sight, but between the lines there was something more implying her sufferings. Above discussion suggests that in some case, we should not neglect the mourning work even in a school setting. To whom or how it is done is the next theme we should explore and discuss in the future. For now, we should at least be conscious about the question of separation in school setting. Study of the process of psychotherapy with intervals for months M. TERASHIMA Bunkyo Gakuin University, Tokyo, Japan This is a report on the process of psychotherapy of an adolescent girl who showed manic and depressive state. At the time of a depressed state, she could not go to a college and withdrew into home, and the severe regressive situation was shown. Her therapy began at the age of 20 and she wanted to know what her problem was. The process of treatment went on for 4 years but she stopped coming to sessions for several months because of failure of the therapist. She repeated the same thing twice. After going through these intervals the client began to remember and started to talk about her childhood , suffering abusive force from her father, with vivid impressions. They once were hard for her to accept, but she began to establish the consistent figure of herself from past to present. In this case, it could be thought that the intervals of the sessions had a certain role, with which the client controlled the structure of treatment, instead of an attack against the therapist. Her object relation, which is going to control an object offensively, was reflected in these phenomena. That is, it can be said that the ambivalence about dependency , difficult to depend but desirous of the object , was expressed. Discontinuation of the sessions was the product of the compromise formation brought about the ambivalence of the client, and while continuing to receive this ambivalence in the treatment, the client started to realize discontinuance of her memories and then advanced integration of her self-image. For the young client with conflict to dependence such as her, an interval does not destroy the process of treatment but in some cases it could be considered as a therapeutic element. In the intervals the client could assimilate the matter by herself, that acquired by the sessions. Psychotherapy for a schizoid woman who presented eccentric speech and behaviour M. OGASAWARA Osaka University Graduate School of Medicine, Osaka, Japan Case presentation: A case of a 27-year-old woman at the beginning of therapy. Life history: She had been having a wish for death since she was in kindergarten and she had been feeling strong resistance to do the same as others after school attendance. She had a history of ablutomania from the age of 10,15, but the symptom disappeared naturally. and she said that she had been eliminated from groups that she tried to enter. After graduating a junior college, she changed jobs several times without getting a full-time position. Present history: Scolded by her boy friend for her coming home too late one day, she showed confusion such as excitement, self-injury or terror. She consulted a psychiatrist in a certain general hospital, but she presented there eccentric behaviours such as tense facial expression, stiffness of her whole body, or involuntary movement of limbs. and because she felt on bad terms with the psychiatrist and she had come to cause convulsion attacks in the examination room, she was introduced to our hospital. Every session of this psychotherapy was held once a week and for approximately 60 min at a time. Treatment process: She sometimes presented various eccentric attitudes, for example overturning to the floor with screaming (1), going down on her knees when entrance at the door (5), entering with a knife in her mouth and hitting the wall suddenly (7), stiffening herself just outside the door without entering the examination room (9), taking out a knife abruptly and putting it on her neck (40), exclaiming with convulsion responding to every talk from the therapist (41), or stiffening her face and biting herself in the right forearm suddenly (52). She also repeated self-injuries or convulsion attacks outside of the examination room in the early period of the therapy. Throughout the therapy she showed hypersensitivity for interpersonal relations, anxiety about dependence, terror for self-assertion, and avoidance for confrontation to her emotional problems. Two years and 6 months have passed since the beginning of this therapy. She ceased self-injury approximately 1 year and 6 months before and her sense of obscure terror has been gradually reduced to some extent. Discussion: Her non-verbal wariness and aggression to the therapist made the sessions full of tension and the therapist felt a sense of heaviness every time. In contrast, she could not express aggression verbally to the therapist, and when the therapist tried to identify her aggression she denied it. Her anxiety, that she will be thoroughly counterattacked to self-disintegration if she shows aggression to other persons, seems to be so immeasurably strong that she is compelled to deny her own aggression. Interpretations and confrontations by the therapist make her protective, and occasionally she shows stronger resistance in the shape of denial of her problems or conversion symptoms (astasia, aphonia, or involuntary movements) but she never expresses verbal aggression to the therapist. and the therapist feels much difficulty to share sympathy with her, and she expresses distrust against sympathetic approach of the therapist. However, her obvious disturbance that she expresses when she feels the therapist is not sympathetic shows her desire for sympathy. Thus, because she has both strong distrust and desire for sympathy, she is in a porcupine dilemma, which is characteristic of schizoid patients as to whether to lengthen or to shorten the distance between herself and the therapist. This attitude seems to have been derived from experience she might have had during her babyhood and childhood that she felt terror to be counterattacked and deserted when she showed irritation to her mother. In fact, existence of severe problems of the relationship between herself and her mother in her babyhood and childhood can be guessed from her statement. Although she has been repeating experiences to be excluded from other people, she shows no attitude to construct interpersonal relationship actively. On the contrary, by regarding herself to be a victim or devaluating other persons she externalizes responsibility that she herself should assume essentially. The reason must be that her disintegration anxiety is evoked if she recognizes that she herself has problems; that is, that negative things exist inside of her. Therefore, she seems to be inhibited to get depressive position and obliged to remain mainly in a paranoid,schizoid position. As for the pathological level, she seems to have borderline personality organization because of frequent use of mechanisms to externalize fantastically her inner responsibility. For her high ability to avoid confronting her emotional problems making the most of her verbal ability, every intervention of the therapist is invalidated. So, it seems very difficult for her to recognize her own problems through verbal interpretations or confrontation by the therapist, for the present. In general, it is impossible to confront self problems without containing negative emotions inside of the self, but her ability seemed to be insufficient. So, to point out her problems is considered to be very likely to result in her confusion caused by persecution anxiety. Although the therapy may attain the stage on which verbal interpretation and confrontation work better some day, the therapist is compelled to aim at promoting her ability to hold negative emotion inside of herself for the time being. For the purpose, the therapist is required to endure the situation in which she brings emotion that makes the therapist feel negative counter-transference and her process to experience that the therapeutic relation itself would not collapse by holding negative emotion. On supportive psychotherapy with a male adolescent Y. TERASHIMA Kitasato University Health Care Center, Kanagawa, Japan Adolescent cases sometimes show dramatic improvements as a consequence of psychotherapy. The author describes how psychotherapy can support an adolescent and how theraputic achievements can be made. Two and a half years of treatment sessions with a male adolescent patient are presented. The patient was a 19-year-old man, living with his family. He had 5 years of experience living abroad with his family and he was a preparatory school student when he came to a mental clinic for help. He was suffering from not being able to sleep well, from difficulties concerning keeping his attention on one thing, and from fear of going to distant places. He could barely leave his room, and imagined the consequence of overdosing or jumping out of a window. He claimed that his life was doomed because his family moved from a town that was familiar to him. At the first phase of psychotherapy that lasted for approximately 1 year, the patient seldom responded to the therapist. The patient was basically silent. He told the therapist that the town he lives in now feels cold or that he wants to become a writer. However, these comments were made without any kind of explanation and the therapist felt it very difficult to understand what the patient was trying to say. The sessions continued on a regular basis. However, the therapist felt very useless and fatigued. Problems with the patient and his family were also present at this phase of psychotherapy. He felt unpleasant at home and felt it was useless to expect anything from his parents. These feelings were naturally transferred to the therapist and were interpreted. However, interpretation seemed to make no changes in the forms of the patient's transference. The second phase of psychotherapy began suddenly. The patient kept saying that he did not know what to talk about. However, after a brief comment made by the therapist on the author of the book he was reading, the patient told the therapist that it was unexpected that the therapist knew anything of his favorite writer. After this almost first interaction between the patient and the therapist, the patient started to show dramatic changes. The patient started to bring his favorite rock CDs to sessions where they were played and the patient and the therapist both made comments on how they felt about the music. He also started asking questions concerning the therapist. It seemed that the patient finally started to want to know the therapist. He started communicating. The patient was sometimes silent but that did not last long. The therapist no longer felt so useless and emotional interaction, which never took place in the first phase, now became dominant. The third phase happened rapidly and lasted for approximately 10 months. Conversations on music, art, literature and movies were made possible and the therapist seldom felt difficulties on following the patient's line of thought. He started to go to schools and it was difficult at first but he started adjusting to the environment of his new part-time jobs. By the end of the school year, he was qualified for the entrance to a prestigious university. The patient's problems had vanished except for some sleeping difficulties, and he did not wish to continue the psychotherapy sessions. The therapist's departure from the clinic added to this and the therapy was terminated. The patient at first reminded the therapist of severe psychological disturbances but the patient showed remarkable progress. Three points can be considered to have played important roles in the therapy presented. The first and the most important is the interpretation by behavior. The patient showed strong parental transference to the therapist and this led the therapist to feel useless and to feel fatigue. Content analysis and here-and-now analysis seemed to have played only a small part in the therapy. However, the therapist tried to keep in contact with the patient, although not so elegant, but tried to show that the therapist may not be useless. This was done by maintaining the framework of the therapy and by consulting the parents when it was considered necessary. Second point is the role that the therapist intentionally took as a model or target of introjection. With the help of behavioral interpretation that showed the therapist and others that it may not be useless, the patient started to introject what seemed to be useful to his well being. It can be considered that this role took some part in the patient going out and to adjust to the new environment. Last, fortune of mach must be considered. The patient and the therapist had much in common. It was very fortunate that the therapist knew anything about the patient's favorite writer. The therapist had some experience abroad when he was young. Although it is a matter of luck that the two had things in common, it can be said that the congeniality between the patient and the therapist played an important role in the successful termination of the therapy. From the physical complaint to the verbal appeal of A's recovery process to regain her self-confidence C. ITOKAWA and S. KAZUKAWA Toyama Mental Health Center, Toyama, Japan This is one of the cases at Toyama Mental Health Center about a client here, we will henceforth refer to her simply as ,A'. A was a second grade high school student. We worked with her until her high school graduation using our center's full functions; counseling, medical examination and the course for autogenic training (AT). She started her counseling by telling us that the reason for her frequent absences from school began because of stomach pains when she was under a lot of stress for 2 years of junior high school, from 2nd grade to 3rd grade. Due to a lack of self confidence and a constant fear of the people around her, she was unable to use the transportation. She would spend a large amount of time at the school infirmary because she suffered from self-diagnosed hypochondriac symptoms such as nausea, diarrhea and a palpitation. She continued that she might not be able to have the self-confidence to sit still to consult me on her feelings in one of our sessions. A therapist advised her to take the psychiatric examination and the use of AT and she actually saw the medical doctor. In counseling (sessions), she eventually started to talk about the abuse that started just after her entering of junior high school; she approached the school nurse but was unable to tell her own parents because she did not trust them. In doing so, she lost the rest of her confidence, affecting the way she looked at herself and thought of how others did. At school she behaved cheerfully and teachers often accused her of idleness as they regarded this girl's absences along with her brightly dyed hair and heavy make-up as her negligent laziness. I, as her therapist, contacted some of the school's staff and let them know of her situation in detail. As the scolding from the teachers decreased, we recognized the improvement of her situation. In order to recover from the missed academic exposure due to her long absence, she started to study by herself. In a couple of months her physical condition improved gradually, saying ,These days I have been doing well by myself, haven't I?' and one year later, her improved mental condition enabled her to go up to Tokyo for a concert and furthermore even to enjoy a short part-time job. She continued the session and the medical examination dually (in tangent) including the consultation about disbelief to the teachers, grade promotion, relationships between friends and physical conditions. Her story concentrated on the fact that she had not grown up with sufficiently warm and compassionate treatment and she could not gain any mental refuge in neither her family nor her school, or even her friends. Her prospects for the future had changed from the short-ranged one with no difficulty to the ambitious challenge: she aimed to try for her favorite major and hoped to go out of her prefecture. But she almost had to give up her own plan because the school forced her to change her course as they recommended. (because of the school's opposition with her own choice). So without the trust of the teachers combined with her low self-esteem she almost gave up her hopes and with them her forward momentum. In this situation as the therapist, I showed her great compassion and discussed the anger towards the school authorities, while encouraging this girl by persuading her that she should have enough self-confidence by herself. Through such sessions, she was sure that if she continued studying to improve her own academic ability by herself she could recognize the true meaning of striving forward. and eventually, she received her parents' support who had seemed to be indifferent to her. At last she could pass the university's entrance exams for the school that she had yearned to attend. That girl ,A' visited our center 1 month later to show us her vivid face. I saw a bright smile on her face. It was shining so brightly. [source] The Quality of Health Insurance Service Delivery for Kidney Transplant Recipients: A Patient PerspectiveAMERICAN JOURNAL OF TRANSPLANTATION, Issue 10 2010E. J. Gordon Increased attention has been devoted to improving quality care in kidney transplantation. The discourse on quality care has focused on transplant center metrics and other clinical parameters. However, there has been little discussion on the quality of health insurance service delivery, which may be critical to kidney recipients' access to transplantation and immunosuppression. This paper describes and provides a framework for characterizing kidney transplant recipients' positive and negative interactions with their insurers. A consecutive cohort of kidney recipients (n = 87) participated in semistructured interviews on their interactions with insurance agencies. Patients reported negative (37%) and/or neutral or positive (79%) interactions with their insurer (a subset [16%] reported both). Perceived negative experiences included: poor service, logistical difficulties with confusing and time-consuming paperwork, poor communication, rude behavior and concerns about adequate coverage. Positive experiences related to: having good coverage, a simple application process, straightforward transactions and helpful communication. Findings suggest that even when patients have insurance coverage, difficult interactions with insurers and limited skills in navigating insurance options may limit their access to needed medications and health services. Future research is needed to test this hypothesis in a larger population. [source] The attitudes and beliefs of healthcare professionals on the causes and reporting of medication errors in a UK Intensive care unitANAESTHESIA, Issue 1 2007I. S. Sanghera Summary Our aim was to explore the attitudes and beliefs of healthcare professionals relating to the causes and reporting of medication errors in a UK intensive care unit. Medication errors were identified by the unit pharmacist and semi-structured qualitative interviews conducted with 13 members of staff involved with 12 errors. Interviews were analysed using a model of human error theory. Staff identified many contributing factors, including poor communication and frequent interruptions. Organisational factors included lack of clarity on the responsibility of the second nurse's check for medication administration, lack of feedback on medication errors, and a common and accepted practice of administering medication without a complete medication order. Barriers to reporting included administrative paperwork and lack of encouragement by management. Greater feedback on medication errors seems essential to improve current practice and increase reporting. [source] Community cooperation with natural flood management: a case study in the Scottish BordersAREA, Issue 3 2009Olivia Ruth Howgate The cooperation of communities and landowners in the upper catchment is vital for the successful implementation of natural flood management (NFM) projects as few incentives are in place to reward them to host such projects. The aim of this paper is to initiate an exploration of the issues that affect a community's decision to cooperate. The results of a case study in Scotland show that willingness to cooperate is affected by concern about alternative flood management techniques, a sense of responsibility to help connected communities at risk of flooding and the expectation of beneficial impacts from the project. Indeed, these issues appeared to over-ride the hostility generated towards the project as a result of poor communication and engagement with the community from organisations associated with the proposed project. The results of the research suggest that if NFM projects are to proliferate, close attention must be paid to community attitudes towards flood management and related communities at risk, and that NFM projects must be developed and implemented according to well-established principles of public participation. [source] | ||||||||||