Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Relationship. Show all posts
Showing posts with label Relationship. Show all posts

Friday, February 23, 2024

How Did Polyamory Become So Popular?

Jennifer Wilson
The New Yorker
Originally posted 25 Dec 23

Here is an excerpt:

What are all these open couples, throuples, and polycules suddenly doing in the culture, besides one another? To some extent, art is catching up with life. Fifty-one per cent of adults younger than thirty told Pew Research, in 2023, that open marriage was “acceptable,” and twenty per cent of all Americans report experimenting with some form of non-monogamy. The extramarital “entanglements” of Will and Jada Pinkett Smith have been tabloid fodder for the past two years. (Pinkett Smith once clarified that their marriage is not “open”; rather, it is a “relationship of transparency.”) In 2020, the reality show “House Hunters,” on HGTV, saw a throuple trying to find their dream home—one with a triple-sink vanity. The same year, the city of Somerville, Massachusetts, allowed domestic partnerships to be made up of “two or more” people.

Some, like the sex therapist (and author of “Open Monogamy, A Guide to Co-Creating Your Ideal Relationship Agreement,” 2021), Tammy Nelson, have attributed the acceptance of a greater number of partners to pandemic-born domestic ennui; after being stuck with one person all day every day, the thinking goes, couples are ready to open up more than their pods. Nelson is part of a cohort of therapists, counsellors, and advice writers, including Esther Perel and the “Savage Love” columnist Dan Savage, who are encouraging married couples to think more flexibly about monogamy. Their advice has found an eager audience among the well-heeled attendees of the “ideas festival” circuit, featured in talks at Google, SXSW, and the Aspen Institute.

The new monogamy skepticism of the moneyed gets some screen time in the pandemic-era breakout hit “The White Lotus.” The show mocks the leisure class as they mope around five-star resorts in Hawaii and Sicily, stewing over love, money, and the impossibility, for people in their tax bracket, of separating the two. In the latest season, Ethan (Will Sharpe) and Harper (Aubrey Plaza) are an attractive young couple stuck in a sexless marriage—until, that is, they go on vacation with the monogamish Cameron (Theo James) and Daphne (Meghann Fahy). After Cameron and Harper have some unaccounted-for time together in a hotel room, Ethan tracks down an unbothered Daphne, lounging on the beach, to share his suspicion that something has happened between their spouses. Some momentary concern on Daphne’s face quickly morphs—in a devastatingly subtle performance by Fahy—into a sly smile. “A little mystery? It’s kinda sexy,” she assures Ethan, before luring him into a seaside cove. That night Ethan and Harper have sex, the wounds of their marriage having been healed by a little something on the side.

Here is my summary:

The article discusses the increasing portrayal and acceptance of non-monogamous relationships in contemporary culture, particularly in literature, cinema, and television. It notes that open relationships, throuples, and polyamorous arrangements are gaining prominence, reflecting changing societal attitudes. The author cites statistics and cultural examples, including a Gucci perfume ad and a plot twist in the TV series "Riverdale." The rise of non-monogamy is linked to a broader shift in societal norms, with some attributing it to pandemic-related ennui and a desire for more flexibility in relationships. The text also delves into the historical roots of polyamory, mentioning the Kerista movement and its adaptation to conservative times in the 1980s. The author concludes by expressing a desire for a more inclusive and equitable representation of polyamory, critiquing the limited perspective presented in a specific memoir discussed in the text.

Friday, May 5, 2023

Is the world ready for ChatGPT therapists?

Ian Graber-Stiehl
Originally posted 3 May 23

Since 2015, Koko, a mobile mental-health app, has tried to provide crowdsourced support for people in need. Text the app to say that you’re feeling guilty about a work issue, and an empathetic response will come through in a few minutes — clumsy perhaps, but unmistakably human — to suggest some positive coping strategies.

The app might also invite you to respond to another person’s plight while you wait. To help with this task, an assistant called Kokobot can suggest some basic starters, such as “I’ve been there”.

But last October, some Koko app users were given the option to receive much-more-complete suggestions from Kokobot. These suggestions were preceded by a disclaimer, says Koko co-founder Rob Morris, who is based in Monterey, California: “I’m just a robot, but here’s an idea of how I might respond.” Users were able to edit or tailor the response in any way they felt was appropriate before they sent it.

What they didn’t know at the time was that the replies were written by GPT-3, the powerful artificial-intelligence (AI) tool that can process and produce natural text, thanks to a massive written-word training set. When Morris eventually tweeted about the experiment, he was surprised by the criticism he received. “I had no idea I would create such a fervour of discussion,” he says.


Automated therapist

Koko is far from the first platform to implement AI in a mental-health setting. Broadly, machine-learning-based AI has been implemented or investigated in the mental-health space in three roles.

The first has been the use of AI to analyse therapeutic interventions, to fine-tune them down the line. Two high-profile examples, ieso and Lyssn, train their natural-language-processing AI on therapy-session transcripts. Lyssn, a program developed by scientists at the University of Washington in Seattle, analyses dialogue against 55 metrics, from providers’ expressions of empathy to the employment of CBT interventions. ieso, a provider of text-based therapy based in Cambridge, UK, has analysed more than half a million therapy sessions, tracking the outcomes to determine the most effective interventions. Both essentially give digital therapists notes on how they’ve done, but each service aims to provide a real-time tool eventually: part advising assistant, part grading supervisor.

The second role for AI has been in diagnosis. A number of platforms, such as the REACH VET program for US military veterans, scan a person’s medical records for red flags that might indicate issues such as self-harm or suicidal ideation. This diagnostic work, says Torous, is probably the most immediately promising application of AI in mental health, although he notes that most of the nascent platforms require much more evaluation. Some have struggled. Earlier this year, MindStrong, a nearly decade-old app that initially aimed to leverage AI to identify early markers of depression, collapsed despite early investor excitement and a high-profile scientist co-founder, Tom Insel, the former director of the US National Institute of Mental Health.

Monday, November 23, 2020

Ethical & Legal Considerations of Patients Audio Recording, Videotaping, & Broadcasting Clinical Encounters

Ferguson BD, Angelos P. 
JAMA Surg. 
Published online October 21, 2020. 

Given the increased availability of smartphones and other devices capable of capturing audio and video, it has become increasingly easy for patients to record medical encounters. This behavior can occur overtly, with or without the physician’s express consent, or covertly, without the physician’s knowledge or consent. The following hypothetical cases demonstrate specific scenarios in which physicians have been recorded during patient care.

A patient has come to your clinic seeking a second opinion. She was recently treated for cholangiocarcinoma at another hospital. During her postoperative course, major complications occurred that required a prolonged index admission and several interventional procedures. She is frustrated with the protracted management of her complications. In your review of her records, it becomes evident that her operation may not have been indicated; moreover, it appears that gross disease was left in situ owing to the difficulty of the operation. You eventually recognize that she was never informed of the intraoperative findings and final pathology report. During your conversation, you notice that her husband opens an audio recording app on his phone and places it face up on the desk to document your conversation.


From the Discussion

Each of these cases differs, yet each reflects the general issue of patients recording interactions with their physicians. In the following discussion, we explore a number of ethical and legal considerations raised by such cases and offer suggestions for ways physicians might best navigate these complex situations.

These cases illustrate potentially difficult patient interactions—the first, a delicate conversation involving surgical error; the second, ongoing management of a life-threatening postoperative complication; and the third, a straightforward bedside procedure involving unintended bystanders. When audio or video recording is introduced in clinical encounters, the complexity of these situations can be magnified. It is sometimes challenging to balance a patient’s need to document a physician encounter with the desire for the physician to maintain the patient-physician relationship. Patient autonomy depends on the fidelity with which information is transferred from physician to patient. 

In many cases, patients record encounters to ensure well-informed decision making and therefore to preserve autonomy. In others, patients may have ulterior motives for recording an encounter.

Tuesday, August 4, 2020

When a Patient Regrets Having Undergone a Carefully and Jointly Considered Treatment Plan, How Should Her Physician Respond?

L. V. Selby and others
AMA J Ethics. 2020;22(5):E352-357.
doi: 10.1001/amajethics.2020.352.


Shared decision making is best utilized when a decision is preference sensitive. However, a consequence of choosing between one of several reasonable options is decisional regret: wishing a different decision had been made. In this vignette, a patient chooses mastectomy to avoid radiotherapy. However, postoperatively, she regrets the more disfiguring operation and wishes she had picked the other option: lumpectomy and radiation. Although the physician might view decisional regret as a failure of shared decision making, the physician should reflect on the process by which the decision was made. If the patient’s wishes and values were explored and the decision was made in keeping with those values, decisional regret should be viewed as a consequence of decision making, not necessarily as a failure of shared decision making.



This case vignette highlights decisional regret, which is one of the possible consequences of the patient decision-making process when there are multiple treatment options available. Although the process of shared decision making, which appears to have been carried out in this case, is utilized to help guide the patient and the physician to come to a mutually acceptable and optimal health care decision, it clearly does not always obviate the risk of a patient’s regretting that decision after treatment. Ironically, the patient might end up experiencing more regret after participating in a decision-making process in which more rather than fewer options are presented and in which the patient perceives the process as collaborative rather than paternalistic. For example, among men with prostate cancer, those with lower levels of decisional involvement had lower levels of decisional regret. We argue that decisional regret does not mean that shared decision making is not best practice, even though it can result in patients being reminded of their role in the decision and associated personal regret with that decision.

The info is here.

Wednesday, July 15, 2020

Empathy is both a trait and a skill. Here's how to strengthen it.

Kristen Rogers
Originally posted 24 June 20

Here is an excerpt:

Types of empathy

Empathy is more about looking for a common humanity, while sympathy entails feeling pity for someone's pain or suffering, Konrath said.

"Whereas empathy is the ability to perceive accurately what another person is feeling, sympathy is compassion or concern stimulated by the distress of another," Lerner said. "A common example of empathy is accurately detecting when your child is afraid and needs encouragement. A common example of sympathy is feeling sorry for someone who has lost a loved one."


A "common mistake is to leap into sympathy before empathically understanding what another person is feeling," Lerner said. Two types of empathy can prevent that relationship blunder.

Emotional empathy, sometimes called compassion, is more intuitive and involves care and concern for others.

Cognitive empathy requires effort and more systematic thinking, so it may lead to more empathic accuracy, Lerner said.  It entails considering others' and their perspectives and imagining what it's like to be them, Konrath added.

Some work managers and colleagues, for example, have had to practice empathy for parents juggling remote work with child care and virtual learning duties, said David Anderson, senior director of national programs and outreach at the Child Mind Institute….   But since the outset of the pandemic in March, that empathy has faded — reflecting the notion that cognitive empathy does take effort.

It takes work to interpret what someone is feeling by all of his cues: facial expressions, tones of voice, posture, words and more. Then you have to connect those cues with what you know about him and the situation in order to accurately infer his feelings.

"This kind of inference is a highly complex social-cognitive task" that might involve a variation of mental processes, Lerner said.

The info is here.

Tuesday, January 28, 2020

Examining clinician burnout in health industries

Cynda Hylton Rushton
Cynda Hylton Rushton
Danielle Kress
Johns Hopkins Magazine
Originally posted 26 Dec 19

Here is an excerpt from the interview with Cynda Hylton Rushton:

How much is burnout really affecting clinicians?

Among nurses, 35-45% experience some form of burnout, with comparable rates among other providers and higher rates among physicians. It's important to note that burnout has been viewed as an occupational hazard rather than a mental health diagnosis. It is not a few days or even weeks of depletion or exhaustion. It is the cumulative, long-term distress and suffering that is slowly eroding the workforce and leading to significant job dissatisfaction and many leaving their professions. In some instances, serious health concerns and suicide can result.

What about the impact on patients?

Patient care can suffer when clinicians withdraw or are not fully engaged in their work. Moral distress, long hours, negative work environments, or organizational inefficiencies can all impact a clinician's ability to provide what they feel is quality, safe patient care. Likewise, patients are impacted when health care organizations are unable to attract and retain competent and compassionate clinicians.

What does this mean for nurses?

As the largest sector of the health care professions, nurses have the most patient interaction and are at the center of the health care team. Nurses are integral to helping patients to holistically respond to their health conditions, illness, or injury. If nurses are suffering from burnout and moral distress, the whole care team and the patient will experience serious consequences when nurses' capacities to adapt to the organizational and external pressures are eventually exceeded.

The info is here.

Friday, September 27, 2019

Empathy choice in physicians and non-physicians

Daryl Cameron and Michael Inzlicht
Originally created on September 11, 2019


Empathy in medical care has been one of the focal points in the debate over the bright and dark sides of empathy. Whereas physician empathy is sometimes considered necessary for better physician-patient interactions, and is often desired by patients, it also has been described as a potential risk for exhaustion among physicians who must cope with their professional demands of confronting acute and chronic suffering. The present study compared physicians against demographically matched non-physicians on a novel behavioral assessment of empathy, in which they choose between empathizing or remaining detached from suffering targets over a series of trials. Results revealed no statistical differences between physicians and non-physicians in their empathy avoidance, though physicians were descriptively more likely to choose empathy. Additionally, both groups were likely to perceive empathy as cognitively challenging, and perceived cognitive costs of empathy associated with empathy avoidance. Across groups, there were also no statistically significant differences in self-reported trait empathy measures and empathy-related motivations and beliefs. Overall, these results suggest that physicians and non-physicians were more similar than different in terms of their empathic choices and in their assessments of the costs and benefits of empathy for others.


In summary, do physicians choose empathy, and should they do so?  We find that physicians do not how a clear preference to approach or avoid empathy.  Nevertheless, they do perceive empathy to be cognitively taxing, entailing effort, aversiveness, and feelings of inefficacy, and these perceptions associated with reduced empathy choice.  Physicians who derived more satisfaction and less burnout from helping were more likely to choose empathy, and so too if they believed that empathy is good, and useful, for medical practice.  More generally, in the current work, physicians did not show statistically meaningful differences from demographically matched controls in trait empathy, empathy regulation behavior, motivations to approach or avoid empathy, or beliefs about empathy’s use for medicine.  Although it has often been suggested that physicians exhibit different levels of empathy due to the demands of medical care, the current results suggest that physicians are much like everyone else, sensitive to the relevant costs and benefits of empathizing.

The research is here.

Tuesday, September 10, 2019

Physicians Talking With Their Partners About Patients

Morris NP, & Eshel N.
JAMA. Published online August 16, 2019.

Maintaining patient privacy is a fundamental responsibility for physicians. However, physicians often share their lives with partners or spouses. A 2018 survey of 15 069 physicians found that 85% were currently married or living with a partner, and when physicians come home from work, their partners might reasonably ask about their day. Physicians are supposed to keep patient information private in almost all circumstances, but are these realistic expectations for physicians and their partners? Might this expectation preclude potential benefits of these conversations?

In many cases, physician disclosure of clinical information to partners may violate patients’ trust. Patient privacy is so integral to the physician role that the Hippocratic oath notes, “And whatsoever I shall see or hear in the course of my profession...if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.” Whether over routine health care matters, such as blood pressure measurements; or potentially sensitive topics, such as end-of-life decisions, concerns of abuse, or substance use, patients expect their interactions with physicians to be kept in the strictest confidence. No hospital or clinic provides patients with the disclaimer, “Your private health information may be shared over the dinner table.” If a patient learned that his physician shared information about his medical encounters without permission, the patient may be far less likely to trust the physician or participate in ongoing care.

Physicians who share details with their partners about patients may not anticipate the effects of doing so. For instance, a physician’s partner could recognize the patient being discussed, whether from social connections or media coverage. After sharing patient information, physicians lose control of this information, and their partners, who may have less training about medical privacy, could unintentionally reveal sensitive patient information during future conversations.

The info is here.

Tuesday, March 26, 2019

Should doctors cry at work?

Fran Robinson
BMJ 2019;364:l690

Many doctors admit to crying at work, whether openly empathising with a patient or on their own behind closed doors. Common reasons for crying are compassion for a dying patient, identifying with a patient’s situation, or feeling overwhelmed by stress and emotion.

Probably still more doctors have done so but been unwilling to admit it for fear that it could be considered unprofessional—a sign of weakness, lack of control, or incompetence. However, it’s increasingly recognised as unhealthy for doctors to bottle up their emotions.

Unexpected tragic events
Psychiatry is a specialty in which doctors might view crying as acceptable, says Annabel Price, visiting researcher at the Department of Psychiatry, University of Cambridge, and a consultant in liaison psychiatry for older adults.

Having discussed the issue with colleagues before being interviewed for this article, she says that none of them would think less of a colleague for crying at work: “There are very few doctors who haven’t felt like crying at work now and again.”

A situation that may move psychiatrists to tears is finding that a patient they’ve been closely involved with has died by suicide. “This is often an unexpected tragic event: it’s very human to become upset, and sometimes it’s hard not to cry when you hear difficult news,” says Price.

The info is here.

Wednesday, March 13, 2019

Why Sexual Morality Doesn't Exist

Alan Goldman
Originally posted February 12, 2019

There is no such thing as sexual morality per se. Put less dramatically, there is no morality special to sex: no act is wrong simply because of its sexual nature. Sexual morality consists in moral considerations that are relevant elsewhere as well being applied to sexual activity or relations. This is because the proper concept of sexual activity is morally neutral. Sexual activity is that which fulfills sexual desire.  Sexual desire in its primary sense can be defined as desire for physical contact with another person’s body and for the pleasure that such contact brings. Masturbation or desire to view pornography are sexual activity and desire in a secondary sense, substitutes for normal sexual desire in its primary sense. Sex itself is not a moral category, although it places us in relations in which moral considerations apply. It gives us opportunity to do what is otherwise regarded as wrong: to harm, deceive, or manipulate others against their will.

As other philosophers point out, pleasure is normally a byproduct of successfully doing things not aimed at pleasure directly, but this is not the case with sex. Sexual desire aims directly at the pleasure derived from physical contact. Desire for physical contact in other contexts, for example contact sports, is not sexual because it has other motives (winning, exhibiting dominance, etc.), but sexual desire in itself has no other motive. It is not a desire to reproduce or to express love or other emotions, although sexual activity, like other activities, can express various emotions including love.

The info is here.

Wednesday, January 16, 2019

What Is the Right to Privacy?

Andrei Marmor
(2015) Philosophy & Public Affairs, 43, 1, pp 3-26

The right to privacy is a curious kind of right. Most people think that we have a general right to privacy. But when you look at the kind of issues that lawyers and philosophers label as concerns about privacy, you see widely differing views about the scope of the right and the kind of cases that fall under its purview.1 Consequently, it has become difficult to articulate the underlying interest that the right to privacy is there to protect—so much so that some philosophers have come to doubt that there is any underlying interest protected by it. According to Judith Thomson, for example, privacy is a cluster of derivative rights, some of them derived from rights to own or use your property, others from the right to your person or your right to decide what to do with your body, and so on. Thomson’s position starts from a sound observation, and I will begin by explaining why. The conclusion I will reach, however, is very different. I will argue that there is a general right to privacy grounded in people’s interest in having a reasonable measure of control over the ways in which they can present themselves (and what is theirs) to others. I will strive to show that this underlying interest justifies the right to privacy and explains its proper scope, though the scope of the right might be narrower, and fuzzier in its boundaries, than is commonly understood.

The info is here.

Saturday, November 17, 2018

The New Age of Patient Autonomy: Implications for the Patient-Physician Relationship

Madison Kilbride and Steven Joffe
JAMA. Published online October 15, 2018.

Here is an excerpt:

The New Age of Patient Autonomy

The abandonment of strong medical paternalism led scholars to explore alternative models of the patient-physician relationship that emphasize patient choice. Shared decision making gained traction in the 1980s and remains the preferred model for health care interactions. Broadly, shared decision making involves the physician and patient working together to make medical decisions that accord with the patient’s values and preferences. Ideally, for many decisions, the physician and patient engage in an informational volley—the physician provides information about the range of options, and the patient expresses his or her values and preferences. In some cases, the physician may need to help the patient identify or clarify his or her values and goals of care in light of the available treatment options.

Although there is general consensus that patients should participate in and ultimately make their own medical decisions whenever possible, most versions of shared decision making take for granted that the physician has access to knowledge, understanding, and medical resources that the patient lacks. As such, the shift from medical paternalism to patient autonomy did not wholly transform the physician’s role in the therapeutic relationship.

In recent years, however, widespread access to the internet and social media has reduced physicians’ dominion over medical information and, increasingly, over patients’ access to medical products and services. It is no longer the case that patients simply visit their physicians, describe their symptoms, and wait for the differential diagnosis. Today, some patients arrive at the physician’s office having thoroughly researched their symptoms and identified possible diagnoses. Indeed, some patients who have lived with rare diseases may even know more about their conditions than some of the physicians with whom they consult.

The info is here.

Wednesday, October 31, 2018

Learning Others’ Political Views Reduces the Ability to Assess and Use Their Expertise in Nonpolitical Domains

Marks, Joseph and Copland, Eloise and Loh, Eleanor and Sunstein, Cass R. and Sharot, Tali.
Harvard Public Law Working Paper No. 18-22. (April 13, 2018).


On political questions, many people are especially likely to consult and learn from those whose political views are similar to their own, thus creating a risk of echo chambers or information cocoons. Here, we test whether the tendency to prefer knowledge from the politically like-minded generalizes to domains that have nothing to do with politics, even when evidence indicates that person is less skilled in that domain than someone with dissimilar political views. Participants had multiple opportunities to learn about others’ (1) political opinions and (2) ability to categorize geometric shapes. They then decided to whom to turn for advice when solving an incentivized shape categorization task. We find that participants falsely concluded that politically like-minded others were better at categorizing shapes and thus chose to hear from them. Participants were also more influenced by politically like-minded others, even when they had good reason not to be. The results demonstrate that knowing about others’ political views interferes with the ability to learn about their competency in unrelated tasks, leading to suboptimal information-seeking decisions and errors in judgement. Our findings have implications for political polarization and social learning in the midst of political divisions.

You can download the paper here.

Probably a good resource to contemplate before discussing politics in psychotherapy.

Monday, September 24, 2018

How to find the right therapist

Nicole Spector
Originally posted August 5, 2018

Here are two excerpts:

What does therapy mean to you? What areas of your life do you want to explore and how? Do you want to talk about your family, or would you rather focus on a very specific past trauma or would you just like someone to talk with about whatever might be troubling you that week? The answers to these questions may change over time, but when you first go into therapy, ideally you should have some picture of what you want.

“You should know what you want to work on [when beginning therapy],” says Dr. Cira. “Do you feel really strong that you don't want to focus on your past and only the present? Do you want to focus more on things that have happened to you in the past? Do you want someone to help you ‘solve’ your problems or someone who will really sit with you in your pain or both? These are all things you should ask yourself that will help guide your search.”


“Listen to your intuition,” says Humphreys. “If you feel instinctively unsafe with a therapist, that will probably inhibit the progress you will make. In contrast, if you feel you ‘click’ with a therapist, that's a good sign that you will be able to build a working alliance with them.”

Jor-El Caraballo, a licensed therapist, wellness coach and co-creator of Viva Wellness, notes that while there are measures that are clinical in nature there is also “a visceral feeling of just being comfortable enough to sit in a room with someone for the therapy hour. That can't be replaced and if you don't feel comfortable enough in a few sessions then it's probably best to tell your therapist this and work toward moving on.”

The info is here.

Friday, September 21, 2018

Surprised By A Medical Bill? Join The Club. Most Americans Say They Have Been

Alison Kodjak
Originally posted September 2, 2018

Here is an excerpt:

Most survey respondents — 57 percent — have been surprised by a medical bill they thought would be paid for by their insurance companies, the survey from the research group NORC at the University of Chicago finds.

"People get surprised by all kinds of bills, for all kinds of reasons," says Caroline Pearson, a senior fellow at NORC.

Pearson herself says she was not expecting the problem to be so widespread.

The survey shows that 53 percent of those surveyed were surprised by a bill for a physician's service, and 51 percent got an unexpected bill for a laboratory test – like the urine test featured in our earlier story.

Hospital and health care facility charges surprised 43 percent of respondents, and 35 percent reported getting unexpected bills for imaging services, like the CT scan featured by NPR.

The survey shows that while some of the unexpected bills come because doctors or hospitals where patients are treated don't participate in the patients' insurance networks, the majority come because patients expect their insurance to cover more than it actually does.

The info is here.

Thursday, September 13, 2018

How Should Clinicians Respond to Requests from Patients to Participate in Prayer?

A. R. Christensen, T. E. Cook, and R. M. Arnold
AMA J Ethics. 2018;20(7):E621-629.


Over the past 20 years, physicians have shifted from viewing a patient’s request for prayer as a violation of professional boundaries to a question deserving nuanced understanding of the patient’s needs and the clinician’s boundaries. In this case, Mrs. C’s request for prayer can reflect religious distress, anxiety about her clinical circumstances, or a desire to better connect with her physician. These different needs suggest that it is important to understand the request before responding. To do this well requires that Dr. Q not be emotionally overwhelmed by the request and that she has skill in discerning potential reasons for the request.

The info is here.

Tuesday, June 26, 2018

The alliance in adult psychotherapy: A meta-analytic synthesis.

Fl├╝ckiger C, Del Re AC, Wampold BE, & Horvath AO
Psychotherapy (Chicago, Ill.) [24 May 2018]


The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance-outcome association for face-to-face psychotherapy was r = .278 (95% confidence intervals [.256, .299], p < .0001; equivalent of d = .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices.

The research is here.

Thursday, May 17, 2018

Empathy and outcome meta-analysis

Elliott, Robert and Bohart, Arthur C. and Watson, Jeanne C. and Murphy, David
(2018) Psychotherapy 


Put simply, empathy refers to understanding what another person is experiencing or trying to express. Therapist empathy has a long history as a hypothesized key change process in psychotherapy. We begin by discussing definitional issues and presenting an integrative definition. We then review measures of therapist empathy, including the conceptual problem of separating empathy from other relationship variables. We follow this with clinical examples illustrating different forms of therapist empathy and empathic response modes. The core of our review is a meta-analysis of research on the relation between therapist empathy and client outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r= .28 (p< .001; 95% confidence interval: .23 –.33; equivalent of d= .58) for 82 independent samples and 6,138 clients. In general, the empathy-outcome relation held for different theoretical orientations and client presenting problems; however, there was considerable heterogeneity in the effects. Client, observer, and therapist perception measures predicted client outcome better than empathic accuracy measures. We then consider the limitations of the current data. We conclude with diversity considerations and practice recommendations, including endorsing the different forms that empathy may take in therapy.

You can request a copy of the article here.

Tuesday, April 24, 2018

When therapists face discrimination

Zara Abrams
The Monitor on Psychology - April 2018

Here is an excerpt:

Be aware of your own internalized biases. 

Reflecting on their own social, cultural and political perspectives means practitioners are less likely to be caught off guard by something a client says. “It’s important for psychologists to be aware of what a client’s biases and prejudices are bringing up for them internally, so as not to project that onto the client—it’s important to really understand what’s happening,” says Kathleen Brown, PhD, a licensed clinical psychologist and APA fellow.

For Kelly, the Atlanta-based clinical psychologist, this means she’s careful not to assume that resistant clients are treating her disrespectfully because she’s African American. Sometimes her clients, who are referred for pre-surgical evaluation and treatment, are difficult or even hostile
because their psychological intervention was mandated.

Foster an open dialogue about diversity and identity issues.

“The benefit of having that conversation, even though it can be scary or uncomfortable to bring it up in the room, is that it prevents it from festering or interfering with your ability to provide high-quality care to the client,” says Illinois-based clinical psychologist Robyn Gobin, PhD, who has experienced ageism from patients. She responds to ageist remarks by exploring what specific concerns the client has regarding her age (like Turner, she looks young). If she’s met with criticism, she tries to remain receptive, understanding that the client is vulnerable and any hostility the client expresses reflects concern for his or her own well-being. By being open and frank from the start, she shows her clients the appropriate way to confront their biases in therapy.

Of course, practitioners approach these conversations differently. If a client makes a prejudiced remark about another group, Buckman says labeling the comment as “offensive” shifts the attention from the client onto her. “It doesn’t get to the core of what’s going on with them. In the long run, exploring a way to shift how the client interacts with the ‘other’ is probably more valuable than standing up for a group in the moment.”

The information is here.

Friday, March 9, 2018

Dealing with Racist Patients

Kimani Paul-Emile, Alexander K. Smith, Bernard Lo, and Alicia Fernández
N Engl J Med 2016; 374:708-711

Here is an excerpt:

Beyond these general legal rules, when patients reject physicians on the basis of their race or ethnic background, there is little guidance for hospitals and physicians regarding ways of effectively balancing patients’ interests, medical personnel’s employment rights, and the duty to treat. We believe that sound decision making in this context will turn on five ethical and practical factors: the patient’s medical condition, his or her decision-making capacity, options for responding to the request, reasons for the request, and effect on the physician (see flow chart). It’s helpful for physicians to consider these factors as they engage in negotiation, persuasion, and (in some cases) accommodation within the practical realities of providing effective care for all patients.

The patient’s medical condition and the clinical setting should drive decision making. In an emergency situation with a patient whose condition is unstable, the physician should first treat and stabilize the patient. Reassignment requests based on bigotry may be attributable to delirium, dementia, or psychosis, and patients’ preferences may change if reversible disorders are identified and treated. Patients with significantly impaired cognition are generally not held to be ethically responsible.

The article is here.