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PubMed1994

Terror, silencing and children: international, multidisciplinary collaboration with Guatemalan Maya communities.

In recent years psychologists and other mental health workers have begun to document the effects of state-sponsored violence and civil war on civilians and to develop specific clinical and community interventions to address these issues. During the past decade between 50,000 to 100,000 Guatemalans have been murdered and at least 38,000 people disappeared. Over 400 rural villages were destroyed and the Guatemalan army's scorched earth policy forced hundreds of thousands who survived to flee, either to another part of the country or to leave Guatemala altogether. State-sponsored terror and silencing persists in Guatemala despite a return to civilian government. This article describes some of the problems encountered by Maya children in situations of ongoing war and state-sponsored terror and the development of one specific response, Creative Workshops for Children, an international, interdisciplinary program organized by mental health workers from Argentina, Guatemala and United States. The inadequacies of psychological theory based on a medical model that sees trauma as an intrapsychic phenomenon and conceptualizes its effects in situations of war as post-traumatic stress are described and a reconceptualization of trauma as psychosocial is proposed. The accompanying need to address the "normal abnormality" of war and state-sponsored terror through a community-based group process is presented. The model incorporates drawing, story telling, collage and dramatization in a group process that seeks to create a space and time in which the child can express him or herself, communicate experiences to others, and discharge energy and emotion connected to previous traumatic experiences. The work draws on existing cultural traditions (e.g. oral story telling and dramatization) and resources (e.g. nature, plants) of indigenous communities, offering additional resources to those seeking to collaborate in the development of mental health in their communities and suggesting alternative bases from which to understand the cultural and social psychological effects of war. Through participation in the creative workshop the child survivor enhances natural means for communication that will facilitate the expression of physical and mental tensions and the development of a capacity to construct an identity that is not exclusively subject to the dehumanizing and traumatizing reality of war. The strengths of this work and the limits of psychoassistance work within a context of war are enumerated and discussed.

Child↗

PubMed1993

Humanism in emergency medicine.

Emergency medicine has not yet appropriated "humanism" as a term of its own. Medical humanism needs to be interpreted in a way that is consistent with the practical goals of emergency medicine. In this essay, humanism in emergency medicine is defined by identifying the dehumanizing aspects of sudden illness and exploring of ways for sustaining the humanity of emergency department patients. Excerpts from Dr Oliver Sacks' autobiographical work A Leg to Stand On give voice to the human needs created by sudden illness and its treatment.

Attitude to Health↗

PubMed1989

Preoperative nursing assessment. A research study.

This study identified characteristics of preoperative nursing assessments performed on ambulatory and morning admission patients by nurses at two facilities. Two tools used to identify these characteristics were developed by the investigators using the OR nursing criteria list adapted from the Rush-Medicus Process Monitoring Criteria Master List, and the "Competency statements in perioperative nursing." Results were compared between hospitals, between observed and self-reported activities, and between assessments made by perioperative nurses with differing demographic attributes. Significant results were found in nine items comparing the number of observed versus self-reported activities, and in two items comparing diploma nurses with baccalaureate nurses. The study has implications for entry into practice, for nursing activities in relation to prospective payment, and for relating conceptual models to nursing assessments. It strongly suggests the need for future research in the quality and characteristics of preoperative nursing assessment and documentation. Emphasis on providing the humanistic component of nursing care will help offset the dehumanizing elements of new methods of providing health care that are a result of the changing economic climate. After all, the ultimate focus of nursing care in general--and perioperative nursing in particular--is the patient, not the economic system. The determination of existing nursing assessment activities by this study provides baseline data for evaluating future changes in nursing care.

Ambulatory Surgical Procedures↗

PubMed2000

Labeling bias and attitudes toward behavior modification revisited.

Twenty-three years ago, Woolfolk, Woolfolk and Wilson (1977, Journal of Consulting and Clinical Psychology, 45, 184-191) described a study about labeling bias and attitudes toward behavior modification. When videotaped depictions of behavior modification procedures were described as "humanistic education", college students rated them more favorably than when the same procedures were called "behavior modification". One implication of this study is that behavioral terminology may be perceived as dehumanizing by potential consumers, leading to lower acceptance of the approach regardless of its effectiveness. With lower acceptance comes the risk of under utilization. More than two decades have passed since the Woolfolk et al. study was published so we felt the time was right to repeat the experiment with a new generation of students. In our study, two groups of college undergraduates (N = 144) gave their opinions about a 10 minute videotape that showed a therapist working with an autistic child. The therapist used behavior modification procedures to treat the child, except in one case the procedures were described as "humanistic educative therapy", and in the other as "behavior modification". An appropriate rationale was provided for each of the two conditions. Unlike Woolfolk et al., we found no differences in how the two depictions were evaluated. In both cases, they were perceived favorably regardless of what they were called, as were the personal qualities of the therapist. These results suggest that negative attitudes toward behavior modification have weakened over the last two decades, and there is wider pubic acceptance of behavioral treatments now than there was then. Implications of the study are briefly discussed.

Adult↗

PubMed2003

Quality of care in institutionalized deliveries: the paradox of the Dominican Republic.

OBJECTIVES: To better understand the paradox in the Dominican Republic of a relatively high maternal mortality ratio despite nearly universal institutionalized deliveries with trained attendants, a rapid assessment using an adaptation of the strategic assessment method was conducted. METHODS: A multi-disciplinary team reviewed national statistics and hospital records, inventoried facilities, and observed peripartum client-provider interactions at 14 facilities. RESULTS: The major referral hospitals, where more than 40% of births in the country occur, were overcrowded and understaffed, with inexperienced residents overseeing care provided by medical students, interns and nurses. Uncomplicated labor and deliveries were overmedicalized, while complicated ones were not managed appropriately; emergencies were not dealt with in a timely fashion. In the peripheral hospitals physicians were seldom present and clients were either turned away or delivered by unprepared nursing staff. Providers in the busiest facilities suffered from compassion fatigue, and were demoralized and overworked. In all facilities, quality of care was lacking and the delivery and birthing process was dehumanized. CONCLUSIONS: Access and availability of institutional delivery alone is not enough to decrease MMR, it is also the quality of emergency obstetric care that saves lives.

Attitude of Health Personnel↗

PubMed2002

"Tooth worms", poverty tattoos and dental care conflicts in Northeast Brazil.

While medical anthropologists have studied doctor-patient clinical conflicts during the last 25-30 years, dentist-patient communication clashes have received scant attention to date. Besides structural barriers and power inequities, such conceptual differences further dehumanize dental care and lower service quality. Potential for dentist-patient discordance is greater in developing regions--such as Northeast Brazil--where there exists a wider socio-economic gap between professionals and laypersons. A critical anthropological evaluation of oral health services quality is undertaken in two rural communities in Ceará, Brazil where the PAHO-inspired Local Oral Health Inversion of Attention Program was implemented in 1994. This 6-month qualitative field study utilized ethnographic interviews with key informants, participant-observation and projective techniques to probe professionals' and patients' explanatory models (EMs) of oral health. Despite the recent expansion of services into rural regions, the authors conclude that the quality of dental care remains problematic. Patients' culturally constructed EMs of teeth rotted (estraga) by "tooth worms" (lagartas) differ substantively from dentists' model of dental decay by Streptococcus mutans. "Exploding chins" (queixo estourado), "spoiled, rotting teeth" (dente pĵdi) and "false plates" or teeth (chapas) tattoo and stigmatize the poor, reinforcing gross class inequities. Dentists' dominant discourse largely ignores lay logic, ridicules popular practices and de-legitimates, even castigates, popular healers despite their pivotal role in primary oral health care. Poor parents are not only barred from clinics but are blamed for children's rotten teeth. In sum, universal access to dental care is more a myth (even nightmare) than a reality. Dentists all too often "avert"--not "invert"--attention from poor Brazilian patients. In order to improve oral health in this setting, both "societal decay" and bacteria-laden plaque deposits must be removed.

Attitude to Health↗

PubMed1996

ICU scoring systems allow prediction of patient outcomes and comparison of ICU performance.

Too much time and effort are wasted in attempts to pass final judgment on whether systems for ICU prognostication are "good or bad" and whether they "do or do not" provide a simple answer to the complex and often unpredictable question of individual mortality in the ICU. A substantial amount of data supports the usefulness of general ICU prognostic systems in comparing ICU performance with respect to a wide variety of endpoints, including ICU and hospital mortality, duration of stay, and efficiency of resource use. Work in progress is analyzing both general resource use and specific therapeutic interventions. It also is time to fully acknowledge that statistics never can predict whether a patient will die with 100% accuracy. There always will be exceptions to the rule, and physicians frequently will have information that is not included in prognostic models. In addition, the values of both physicians and patients frequently lead to differences in how a probability in interpreted; for some, a 95% probability estimate means that death is near and, for others, this estimate represents a tangible 5% chance for survival. This means that physicians must learn how to integrate such estimates into their medical decisions. In doing so, it is our hope that prognostic systems are not viewed as oversimplifying or automating clinical decisions. Rather, such systems provide objective data on which physicians may ground a spectrum of decisions regarding either escalation or withdrawal of therapy in critically ill patients. These systems do not dehumanize our decision-making process but, rather, help eliminate physician reliance on emotional, heuristic, poorly calibrated, or overly pessimistic subjective estimates. No decision regarding patient care can be considered best if the facts upon which it is based on imprecise or biased. Future research will improve the accuracy of individual patient predictions but, even with the highest degree of precision, such predictions are useful only in support of, and not as a substitute for, good clinical judgment.

Bias↗

PubMed2002

Did Weir Mitchell anticipate important concepts in ambulatory care and clinical epidemiology?

During the decade from 1977 to 1986, four models of care pertaining to ambulatory medicine and certain aspects of clinical epidemiology were proposed. All were concerned with the frequently heard accusation that medicine was becoming dehumanized by being overly dependent on powerful new technologies. Some of the authors went so far as to suggest that the view, according to which medical science must restrict itself to "hard" data of the kind provided by the serum multichannel analyzer, should be considered outdated and, in fact, unscientific. Their plea was to develop a science of the clinical encounter that would shift the emphasis from explication to prediction and management, the latter term being virtually synonymous with decision making. For this change to come about, they wrote, it would be necessary to collect "soft" data on such subjects as family relationships, psychic traits and states, perceptions of life quality, patient expectations and many others. We believe that some of these subjects as well as the models themselves were anticipated in the writings, both medical and fictional, of Weir Mitchell, nearly a century earlier. This paper, after presenting a brief overview of the career of a colorful and commanding figure from the annals of American medicine, will seek to illustrate his extraordinary farsightedness as a practitioner of primary care and his relevance for some aspects of clinical epidemiology. Because the attempts to link his ideas to modern concepts are ours, we accept the possibility that, here and there, we may have read things into his writings that he did not intend.

Ambulatory Care↗

PubMed1987

Physiotherapy methods of relieving pain.

Management of pain in the person with arthritis requires interdisciplinary team work with the patient being the final manager. It is important that any health care provider perceive the patient as a person who happens to have arthritis--not as 'an "arthritic".' Defining a person by one's disease process is dehumanizing. The patient has the same aspirations as anyone who is ablebodied--to be free from disease. While the patient may know that a cure is not imminent, there is still the hope for one. Therefore, as the patient comes for physiotherapy, there may be a hidden wish that the moist packs, TENS, or therapeutic pool will be curative. It is important that the patient understand that no equipment in the physiotherapy department has curative powers. This will help avoid unnecessary dependency behaviours on the part of the patient. Careful instruction and supervision of the patient by the physiotherapist, in concert with reinforcement from the physician, can prepare the patient to apply heat, cold, or a variety of treatments at home. Although the patient is given the responsibility for this part of his care, periodic follow-up and reassessment should be completed to determine changes in his physiological, psychological, and functional status. Physiotherapists who have a clear understanding of the physical treatment of pain associated with the rheumatic diseases can be a valuable asset to medical care.

Humans↗

PubMed1997

Reconnecting: the experiences of nurses caring for hopelessly ill patients in intensive care.

The aim of this grounded theory study was to examine the experiences of intensive care nurses caring for patients whom they did not believe were going to survive. Participant observation was undertaken in a large intensive care unit (ICU), and formal unstructured interviews conducted with 14 qualified nurses, in order to discover the nurses' perspectives, dilemmas, and role in caring for hopelessly ill patients and their families. The data were analysed by coding and memos, using a constant comparative analysis. The findings emerged into 11 themes which were condensed into three categories: (i) family separation; (ii) trust; and (iii) family reconnection. The core category is 'reconnecting'; the process by which nurses attempt to overcome the dehumanizing aspects of dying in a technological environment. The context, conditions and consequences of this process are discussed and depicted in a conceptual framework. The conclusions drawn include the idea that nurses require instruction regarding managing death in ICUs to enable as peaceful death as possible, not only for the benefit of the patients and their families, but also for the nurses themselves.

Adult↗

PubMed1998

Reflections on technology: increasing the science but diminishing the art of nursing?

Technology has had a huge impact on the delivery of health care over the last 10-20 years and although this has been, in general, in the Intensive Care (ICU) environment, the Accident and Emergency (A & E) department has not been immune from technical developments and innovations, a trend that looks destined to continue. The impact of technological developments has given rise to much nursing literature relating to the effects technology has had in 'dehumanizing' the patients in their care, as critical care nurses in all fields endeavour to balance the need for technical competence with the traditional and still important traditional arts of nursing. This paper explores some of the definitions and terminology surrounding technology, nursing, art and science in an attempt to illustrate that technical proficiency, scientific knowledge and nursing artistry can be combined by skilled nurses to achieve a balance of care which preserves the humanity and dignity of patients and their relatives in a critical care environment.

Art↗

PubMed1997

The more things change, the more they stay the same: whither midwifery?

The pace of change is said to increase over the next few years. One of the most significant recent changes has been the "McDonaldization of Society". The notion of "fastness" is permeating all society, including health and education. The concentration of rationalization through the principles of efficiency, calculability predictability and control, when extended to its logical conclusion, results in irrationality or dehumanization. Childbirth has been "McDonaldized" by the medical profession, but modern midwifery, is leading the way in an anti McDonald's movement to rehumanize it. Returning to past values contained in aesthetics, use of the partnership model, different forms of research and political action, midwifery is taking control of childbirth away from the rationalists and returning it to women. It is reclaiming childbirth by placing value on women and empowering them to take control of their own childbirth.

Australia↗

PubMedDate not supplied

[Modification of nursing practice through reflection: participatory action research].

Technology and complex techniques are inevitably playing an increasing role in intensive care units. They continue to characterize nursing care and in some cases dehumanize it. The general aim of this study was to stimulate reflection on nursing care. The study was based on the participation of the investigators with the goal of producing changes in nursing practice. Qualitative methodology in the form of participatory action research and the Kemmis and McTaggart method were used. Data were collected through systematic observation, seven group meetings and document analysis. Eight nurses took part in the study. The meetings were recorded and transcribed verbatim into a computer. This process and the meaning of the verbatim transcription (codification/categorization process and document synthesis cards) were analyzed. The results of this study enabled exploration of the change in nursing practice and showed that the reflection in action method stimulates changes in practice. The new way of conceiving nursing action has increased nursing care quality and its humanization since it shows greater respect for the patient, provides families with closer contact and greater support, improves coordination of nursing care acts and increases collaboration among professionals.In conclusion, participatory action research is a valid and appropriate method that nurses can use to modify their daily practice.

Critical Care↗

PubMed2000

Stigma and mental disorder: conceptions of illness, public attitudes, personal disclosure, and social policy.

The end of the last millennium witnessed an unprecedented degree of public awareness regarding mental disorder as well as motivation for policy change. Like Sartorius, we contend that the continued stigmatization of mental illness may well be the central issue facing the field, as nearly all attendant issues (e.g., standards of care, funding for basic and applied research efforts) emanate from professional, societal, and personal attitudes towards persons with aberrant behavior. We discuss empirical and narrative evidence for stigmatization as well as historical trends regarding conceptualizations of mental illness, including the field's increasing focus on genetic and neurobiological causes and determinants of mental disorder. We next define stigma explicitly, noting both the multiple levels (community, societal, familial, individual) through which stigma operates to dehumanize and delegitimize individuals with mental disorders and the impact of stigma across development. Key developmental psychopathology principles are salient in this regard. We express concern over the recent oversimplification of mental illness as "brain disorder," supporting instead transactional models which account for the dynamic interplay of genes, neurobiology, environment, and self across development and which are consistent with both compassion and societal responsibility. Finally, we consider educational and policy-related initiatives regarding the destigmatization of mental disorder. We conclude that attitudes and policy regarding mental disorder reflect, in microcosmic form, two crucial issues for the next century and millennium: (a) tolerance for diversity (vs. pressure for conformity) and (b) intentional direction of our species' evolution, given fast-breaking genetic advances.

Attitude to Health↗

PubMed2004

Medical intellectuals: resisting medical orientalism.

In this paper, we propose analogies between medical discourse and Edward Said's "Orientalism." Medical discourse, like Orientalism, tends to favor institutional interests and can be similarly dehumanizing in its reductionism, textual representations, and construction of its subjects. To resist Orientalism, Said recommends that critics--"intellectuals"--adopt the perspective of exile. We apply Said's paradigm of intellectual-as-exile to better understand the work of key physician-authors who cross personal and professional boundaries, who engage with patients in mutually therapeutic relationships, and who take on the public responsibility of representation and advocacy. We call these physician-authors "medical intellectuals" and encourage others to follow in their path.

Authorship↗

PubMed1989

Intergroup aggression: its predictors and distinctness from in-group bias.

Investigated predictors of intergroup aggression and its relations to in-group bias. In a questionnaire, 156 Israeli adults reported perceptions of their own religious group and of the ultraorthodox Jewish out-group and expressed aggression toward the ultraorthodox (opposing institutions that serve their needs, supporting acts harmful to them, and opposing interaction with them). Respondents showed in-group favoritism in trait evaluations, but this bias was unrelated to aggression. Perceived inter-group conflict of interests, the postulated motivator of aggression, predicted it strongly. The effects of conflict on aggression were partially mediated by 2 indexes of dehumanizing the out-group (perceived value dissimilarity and trait inhumanity) and by 1 index of probable empathy with it (perceived in-group-out-group boundary permeability). These variables related to aggression more strongly among persons who identified highly with their in-group. The variables also mediated the effects of religious group affiliation on aggression. The value dissimilarity finding supports derivations from belief congruence theory.

Adult↗

PubMed1998

Heritability and biological explanation.

Modern neuroscientific and genetic technologies have provoked intense disagreement between scientists who envision a future in which biogenetic theories will enrich or even replace psychological theories, and others who consider biogenetic theories exaggerated, dehumanizing, and dangerous. Both sides of the debate about the role of genes and brains in the genesis of human behavior have missed an important point: All human behavior that varies among individuals is partially heritable and correlated with measurable aspects of brains, but the very ubiquity of these findings makes them a poor basis for reformulating scientists' conceptions of human behavior. Materialism requires psychological processes to be physically instantiated, but more crucial for psychology is the occasional empirical discovery of behavioral phenomena that are specific manifestations of low-level biological variables. Heritability and psychobiological association cannot be the basis for establishing whether behavior is genetic or biological, because to do so leads only to the banal tautology that all behavior is ultimately based in the genotype and brain.

Biology↗

PubMed1975

Naturalistic studies of aggressive behavior: aggressive stimuli, victim visibility, and horn honking.

Three studies extended laboratory research on aggression to a naturalistic setting which involved horn honking from drivers as a measure of aggression; the studies were adapted from Doob and Gross. The results from a survey (Study 1) of 59 drivers suggested that they were frequently irritated by and aggressive toward other drivers. A second study (using a 3x2 factorial design with 92 male drivers) indicated that manipulations of a rifle in an aggressive context and victim visibility (dehumanization) both significantly influenced horn honking rates subsequent to obstruction at a signal light. A third study with 137 male drivers and 63 female drivers examined the interactive effects of a rifle, an aggressively connotated bumper sticker, and individual subject characteristics (sex and an exploratory index of self-perceived status) on horn honking. The results for three studies in naturalistic settings offer possible extensions of laboratory based findings on aggression. The role of inhibitions in modifying the pattern of results was also discussed.

Aggression↗