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The contemporary failure of nerve and the crisis in psychoanalysis.

The American Academy of Psychoanalysis is undergoing an identity crisis at this time, which is at least to a large extent a function of the whole current identity crisis in the field of psychoanalysis itself. In order to better understand this crisis, in this article I have first reviewed a similar situation which occurred in the history of classical Greece. Plato's famous Academy underwent a progressive deterioration and disintegration and fragmentation, until it ended up merely the handmaiden of another discipline, Christian theology, for a thousand years. I then propose that the identity crisis in psychoanalysis today has to do with our failure of nerve in the teeth of the abusive behavior of insurance companies regarding the payment for psychoanalysis and the current cultural ambience demanding "fast-fast-fast" relief. I call in this article for a return to Freud's basic principles as a focus for our identity. Of course we cannot ignore new discoveries in neurobiology if they are well established, or what we learn from the study of enactments in the here-and-how of the analytic procedure. Certainly the findings of Freud that are contradicted by firmly accepted empirical findings in neurobiology and other disciplines call for revision of some of his ideas, as do his mistaken views on the psychology of women and on certain other topics such as art, religion, and evolutionary biology. But this should not be permitted to blur our continuing focus on the fundamental principles of the clinical practice of psychoanalysis as Freud developed them over his lifetime. In this article I briefly reviewed those basic principles and proposed that we employ them as the basis for our identity as psychoanalysts and psychoanalytic psychiatrists. It represents a failure of nerve to drift this way and that with current fads and with the continuously deteriorating ambiance of our culture as the world slides into rampant global capitalism. Franz Alexander said years ago that psychoanalytic psychotherapy is one of the last remnants of the humanistic ideal, focussing on the individual unique person and his or her transcendent possibilities as well as maladaptive pathology. This article represents a clarion call for a debate on the identity of the American Academy of Psychoanalysis and what it stands for, which can only be clarified if we have a sharp focus on what we basically mean by "psychoanalysis." As Saul Bellow puts it (Atlas, 2000) in discussing the disappointing current situation for the arts and the humanistic disciplines, the intelligent public is waiting to hear from these disciplines what it cannot hear from pure science: Out of the struggle at the center has come an immense, painful longing for a broader, more flexible, fuller, more coherent, more comprehensive account of what we human beings are, who we are, and what this life is for...the individual struggles with dehumanization for the possession of his soul, (p.462). Below points out, in talking about writers, and in a discussion equally applicable to psychoanalysts, that if we do not "come again into the center it will not be because the center is preempted. It is not. [We] are free to enter if [we] so wish" (p.462).

Adult↗

Psychoanalytic peregrination. V: The Zollikon Lectures.

This article is to prepare the reader, along with the previous peregrination, for the article that follows by Professor Lang. It introduces the thinking of Heidegger at the Zollikon Seminars, conducted by the Swiss psychoanalyst Medard Boss, founder of Daseinanalyse and presented to a group of Swiss psychiatrists. Heidegger opposed Freud's scientific Weltanschauung and his hydraulic system of metapsychology, objecting that it dehumanizes the patient. He emphasized the importance of the therapist's "presence" and openness to the patient. He utilized phenomenology to prevent relating to the patient as an "other" or "thing" and advocated a hermeneutic approach instead. This approach involves the use of questions and answers to gain a gradual explicit understanding of the unique communications from the individual patient. He opposed the approach of the drug companies that impel psychiatry to use classification of disorders through manuals such as DSM-IV and then subject the patient to the recommended drug for that disorder, which he maintained was a form of domination of the patient as the "other."

Humans↗

De facto disentitlement in an information economy: enrollment issues in Medicaid managed care.

This article discusses enrollment issues in New Mexico's Medicaid managed care (MMC) system and seeks to illuminate reasons for persistent problems reported by workers and clients. It argues that between 1997 and 2000, the MMC and welfare reforms raised enrollment barriers by complicating and dehumanizing the system, thus "technically disenfranchising" workers and clients. Specifically, the new system increased the need for professional, in-person enrollment assistance precisely when the state decreased its provision of it. Some aspects of the State Child Health Insurance Program (SCHIP) reforms indirectly aggravated those same problems, and though they also significantly lowered barriers in some areas, overall the new system was plagued with preexisting barriers as well as new, unmet needs that produced "de facto disentitlement" to health services.

Health Care Rationing↗

The organization and delivery of craniofacial health services: the state of the art.

The dominant organizational structure providing care for cleft palate and other craniofacial conditions is the health care team. Various types of health care team organization are profiled, including intradisciplinary, multidisciplinary, and interdisciplinary teams. Effective team-based care delivery has the ability to address the fragmentation and dehumanization that can result when a variety of specialists and disciplines are required to provide assessment and technical care. A team's leadership and its hierarchy of professional authority can be expected to affect its ability to function effectively. Health reform and managed care are considered for their impact on the team and on the doctor-patient relationship. Trends in team regionalization, quality assurance, outcomes research, and consumer advocacy are reviewed. The cleft palate and craniofacial team is profiled as an organizational model that is being affected by the forces of health system change.

Cleft Lip↗

Psychiatric nursing in the 1990s & beyond.

In the decade of the '90s, psychiatric mental health nursing will need to take stock of itself--its practice, its education, and its research--if it is to successfully prepare for the changes in care of the mentally ill. Like psychiatrists, we will need to rethink our agendas in light of new science and technology and rationalize the mental health delivery system and our role in it through systematic research and advocate for a system that provides quality care for the chronically ill and the poor. In the next century, we will need to rethink the basics of nursing care and the leadership roles of nurses as hospitals and the doctor's role within them changes. Psychiatric mental health nurses will need to be at the forefront in advocating for a delivery system that listens to patients and families, that humanizes the dehumanizing experience of hospitalization. The challenges before us are formidable.

Costs and Cost Analysis↗

Stressors and coping strategies of homeless men.

1 Major stressors commonly encountered by homeless men are violence to self, theft of belongings, inability to meet basic needs, inconsistent enforcement of rules by shelter staff, and other people's dehumanization or humiliation caused by behavior toward the men. 2 Cognitive, sociocultural, and spiritual coping strategies were frequently used and found to be effective in coping with stressors by homeless men who were either in crisis or alcohol/drug dependent. 3 Severely and persistently mentally ill men had lower mean scores for both use and effectiveness of coping strategies in physical, cognitive, psychological, sociocultural, and spiritual strategies. 4 The longer the duration of homelessness, the lower the mean scores for frequency and effectiveness of use of coping strategies in any of the dimensions.

Adaptation, Psychological↗

Families: a link or a liability?

Hospitalization in a critical care setting has multiple effects on patients and their families. For patients, it can be a frightening and dehumanizing experience, while families are confronted with stressors that can disrupt normal family functioning. The nurse is the pivotal figure in the health care system who can positively affect family coping through the support offered. With family needs met, they are then strengthened and able to support their family member. This article examines the roles and relationships of families, social support systems, and nurses. Through the framework of social support, nurses provide emotional, instrumental, spiritual, and appraisal assistances to families. This can potentially positively affect the family's adaptation to a stressful situation, and thus the family's ability to provide support to the patient. A case study analysis is described to illustrate the interactions and interventions through a model of family support.

Adaptation, Psychological↗

[Physicians and professionalism. Patients and information].

In the present time, the advances in sciences brought by technology are worshiped. This contributes to dehumanize human relationships. Medical profession is a commitment to oneself, society and social justice. Scientific and humanist formation must coexist during the training of new physicians. The main objective of medical profession is the relationship with patients. Patients have acquired increasing autonomy and a deliberative relationship is the closest to the ideal medical action. The relationship must be based in autonomy, beneficence, lack of maleficence and justice. The patient must receive all the information about his ailment and the diagnostic and therapeutic alternatives in a clear and intelligible language. This will allow to obtain a fully conscious informed consent from the patient. Asking for this consent, gives the patient the opportunity to practice his responsibility and to decide the best for him in a friendly and confident environment. In the middle of science and technology, a close contact with ethics and humanism will allow a better understanding of the integrity of subjects, specially when they are ill.

Education, Medical↗

Oral testimonies: the other face of the HIV story.

Women's needs are different from men's; the research and services related to HIV/AIDS have been focused in men's needs. The implication of this approach is that it has had very serious consequences for women who live with HIV/AIDS. It has resulted in health professionals failing to understand the emergence of the symptoms, the complications, the necessary treatments, and the complex patterns of progression of the disease. Oral testimonies are an alternative methodology for the development of theoretical and intervention models that incorporate issues pertaining to the life-styles and world-view of women with HIV and other socially alienated people. Through the testimonies of three women living with HIV the author discusses concepts such as social stigma, family, spirituality, and human solidarity and denounces the oppression, exclusion and dehumanization experiences that these brave women have experienced as a result of living with this condition.

Acquired Immunodeficiency Syndrome↗

The virtuous manager. Renewing the experience of work.

In healthcare, as in any other field, work can become dehumanizing, meaningless drudgery. But good managers can transform their organizations and renew the experience of work. Good management demands not only good business skills, but character, rooted in truthfulness and vision. Three virtues are particularly important: prudence, justice and fortitude. The moral skill of prudence enables healthcare managers to know what is to be done; justice creates honest relationships; and fortitude enables managers to seek a good that is difficult to achieve--to do the right thing. Businesses must also explore their potential for sacramentality and find ways in which employees--and employers--can become better, holier people through their work. Organizations should strive to achieve subsidiarity and keep employees well-informed of their missions. Establishing a sense of connectedness is important, as is open and honest communication. Finally, managers-and healthcare organizations-must always work for the common good.

Communication↗

Litigating life and death.

In cases involving the "right to die," courts are faced with the agonizing task of developing legal standards governing termination of an incompetent patient's medical treatment. In this Article, Professor Rhoden criticizes the two dominant approaches courts have developed--the "subjective" and "objective" tests--and proposes that these standards be abandoned for a legal presumption in favor of family decisionmaking. She maintains that the "subjective" test, which requires the family to provide clear proof that termination of treatment is what the incompetent would have chosen, is often unworkable because a patient's character traits, and even her prior statements about medical treatment, seldom rise to the evidentiary level that courts purport to require. Similarly, she argues that the "objective" test, which requires the family to prove that the burdens of the patient's life, measured in terms of pain and suffering, clearly and markedly outweight its benefits, dehumanizes patients by suggesting that only their present, physical sensations count. Professor Rhoden suggests that the subjective and objective tests are not nearly as distinct as courts have made them. She argues that the rigidity of these legal standards reflects courts' acceptance of the medical profession's presumption in favor of continued treatment, a presumption that places a heavy burden on families seeking to terminate treatment. Drawing on the special qualifications of families as decisionmakers in such cases, Professor Rhoden proposes that courts recognize a presumptive right of families to exercise discretion over treatment decisions. Such a standard would recognize that, although doctors and others can readily prove that terminating the treatment of a patient who can still enjoy life is wrong, it is very hard for families to meet the current standards, which essentially require them to prove that termination is right.

Decision Making↗

Diagnosis of Holocaust survivors and their children.

Survivors of the Holocaust and their children have tended not to be given formal diagnoses by their therapists. There seem to be a series of reasons: the events themselves were so terrible that it seems inappropriate to focus on the response, diagnosis implies comparing the condition with responses to other more minor traumata, the process of diagnosis is dehumanizing, the evil nature of the perpetrator is neglected, therapists feel it distances them from their patients, and it ignores the extraordinary achievements of many survivors who cope and live full lives. The DSM and its five axes are proposed as a suitable diagnostic vehicle, and Holocaust survivors with serious symptoms will tend to be diagnosed as chronic PTSD, child survivors as complex PTSD often with associated personality disorders, and second generation may well have identity problems and personality disorders. Only by using diagnoses can comparable research be carried out.

Adolescent↗

Types of personnel projected to meet the future dental needs of society.

There is mounting pressure to re-examine the traditional methods for delivery of dental care. Good health, which includes good oral health, is becoming recognized as a basic right of all people and governments are obliged to subsidize health care in many countries. Part of the cost lies in the training of health professionals in the medical and dental schools. Though conditions vary in different countries, there is an almost universal shortage of fully trained dentists, and with increasing demand for dental care there is no possibility of producing a sufficient number to meet the need. The profession finds itself overwhelmed by the need for treatment of dental disease and prevention is relatively neglected. It is necessary to determine whether the present methods of delivering dental care are the most efficient in terms of cost, always remembering that dentistry is a personal service and must not be dehumanized. There is ample experience to show that auxiliaries can be trained to undertake a range of tasks to a high standard and with an ethical approach to the patient. A number of such schemes are discussed in detail. Though it is clear that no single pattern will fulfil the needs of each individual country, some form of team dentistry in which the graduate dentist must always be the key member seems likely to be the best way of meeting the future dental health needs of the world.

Allied Health Personnel↗

[Medical tele-imaging: a good chance for the future].

Tele-imaging is an important part of telemedicine: it includes the transmission of medical digital images and plays a role in all fields of telemedicine, such as expertise, consultation, teaching and research. Tele-imaging has been made possible through the digitalization of medical imaging. There are two possibilities: either digitalization of conventional radiological film or direct acquisition of digital images. The transmission of medical imaging requires a high data rate so as to obtain a good quality transmission of the initial images in a reasonable delay. In order to deal with the great amount of information to be stocked and transmitted, a compression of the data, without loss of information, is usually necessary. Interactivity is very important in all these types of transmissions. These tele-transmission techniques are already used world wide, especially in Japan and in the United States, to help in therapeutic or diagnostic decisions. In France, we have been performing real time interactive tele-imaging sessions between radiology and endocrinology departments of Hotel Dieu in Montréal and Hôpital Cochin in Paris. This experimental device includes a visual-conference link between the medical teams and a real time link between two CT scanners. The CT scanner slices appear simultaneously both CT scanner screens; it is even possible to guide a CT scanner examination using remote control from the other hospital. We have successfully repeated the experiment between Cochin and a private hospital in Paris. In the case of the "Prison de la Santé", we have been using telemedicine in order to reduce problematic transfers of prison inmates. Moreover, access to doctors in the prison is sometimes difficult. The system ensures the daily transmission of X-rays, which are immediately read by radiologists at Cochin. In the past, 50 to 70 X-rays had to be read during one weekly visit. Medical tele-imaging raises certain legal, ethical and economic issues, such as problems concerning confidentiality, the right to compensation, patient information. It would be interesting in this context to open a discussion on the possible dangers of telemedicine, its value for the patients and the physicians, its role in emergency care, and the possibility of creating imaging data storage that may help radiologists in making diagnoses, especially for unusual images. Drawbacks not to be ignored: Poor digital images could lead to difficulties in their reading and interpretation. There is still a debate as to whether tele-diagnosis is reliable or not. Further evaluations must be made to as certain the effectiveness of these techniques. A certain dehumanization of medicine due to an increase in the distance between the physician and patient is another difficult issue. The great number of people involved in the process of tele-imaging could confuse the issue of determining individual responsibility. Such consultations of experts may reduce the freedom of patients to choose their doctor. Tele-consultation must not be performed without the patient's consent. If consent was not obtained before tele-transmission, the patient should be informed after the procedure; and the use of tele-consultation should be mentioned in the report. The utilization of public networks could lead to the manipulation of data as well as undermine confidentiality. These pitfalls must be avoided. Lastly, the financial ramifications of these new technologies must not be overlooked.

Confidentiality↗

Ethnographic interviews to elicit patients' reactions to an intelligent interactive telephone health behavior advisor system.

Information technology is being used to collect data directly from patients and to provide educational information to them. Concern over patient reactions to this use of information technology is especially important in light of the debate over whether computers dehumanize patients. This study reports reactions that patient users expressed in ethnographic interviews about using a computer-based telecommunications system. The interviews were conducted as part of a larger evaluation of Telephone-Linked Care (TLC)-HealthCall, an intelligent interactive telephone advisor, that advised individuals about how to improve their health through changes in diet or exercise. Interview findings suggest that people formed personal relationships with the TLC system. These relationships ranged from feeling guilty about their diet or exercise behavior to feeling love for the voice. The findings raise system design and user interface issues as well as research and ethical questions.

Anthropology, Cultural↗

[Birth environmental modification: needs of mother and child in modern obstetrics].

This paper evaluates changes which all ready has been done and still are taking place in obstetrics according to World Health Organisation recommendations in relation to women's increasing expectation from obstetric hospitals and maternity units. The needs of parturients and theirs children are not in contrary to the needs of modern obstetrics. An attempt has been done to disclose concurrent points to work up the best obstetrics health care model after 2000 year. The author emphasizes that progressive technicalization in obstetrics could not indicate its dehumanization.

Environment↗

Studying and teaching the history of medicine in Greece: the National University of Athens experience (1837-1997).

In medical education, little interest is shown in medical history. However, the history of medicine is one vital pathway to the proper study of the evolution of medicine, from ancient to modern times, and it should be a requisite of the medical curriculum. The value of medical history in the understanding of the present and in creating the medicine of the future, is enormous. Our experience has indicated that medical students and younger physicians who ignore the mistakes of their forefathers are destined to repeat them. Furthermore, the history of medicine is needed not only to broaden the students' horizon, it is also necessary in order to prevent the physicians of the 21st century from becoming dehumanized by their bio-technological training. The history of medicine, therefore, is the best antidote to overconcentration on, and overspecification in medical technology and it is the most useful stimulus to more humane professional behaviour and optimal medical education. The new history of medicine does not consist only of the accumulation of dates, events and names; it is a discipline needed for life and action. Tomorrow's historians will view the last years of the second millennium as an eventful and critical period for the medical education of the future.

Education, Medical↗

Fish can't see water: the need to humanize birth.

Humanized birth puts the woman in the center and in control, focuses on community based primary maternity care with midwives, nurses and doctors working together in harmony as equals, and has evidence based services. Western, medicalized, high tech maternity care under obstetric control usually dehumanizes, often leads to unnecessary, costly, dangerous, invasive obstetric interventions and should never be exported to developing countries. Midwives and planned out-of-hospital births are perfectly safe for low-risk births.

Cesarean Section↗