The purpose of this case study is to explore the issue of contempt in the therapeutic relationship. The aims are twofold; namely, to illustrate to what extent the case studied throws light on existing theories on contempt in psychotherapy, and to enquire about which stance adopted by the therapist is most appropriate in the therapeutic interaction with a contemptuous client. It investigates the validity of using the case study method in examining both the content and the process of this particular course of psychotherapy. Literature on contempt in psychotherapy is reviewed, as well as the foundation-stone on which it rests, namely, the Kleinian approach to envy . The concepts of the superego and false self are also drawn upon in understanding this particular client's dynamics. The client's therapy is then presented and explored, in order to gain insight into how a psychotherapist's understanding of the contemptuous client can clarify the process of therapy. It highlights the limitations and potentialities that exist in working in this sphere of resistance, and raises questions relevant to therapists faced with these clients. The case study shows how theory in this area is helpful in understanding the contemptuous client, and that the ability of the therapist to endure and survive the contempt of the client is a crucial factor in working with the contemptuous individual.

1. Introduction Pastaraisiais metais, ypač reformuojant stacionarinę sveikatos priežiūrą, vis didesnis dėmesys skiriamas ligoninių veiklos vertinimui daugelyje šalių, nes stacionarinei sveikatos priežiūrai skiriama 45-75% visų sveikatos priežiūrai skirtų lėšų (1). Vertinant ligoninės veiklos rodiklius, dažniausiai apsiribojama pagrindine jos funkcija - paslaugų teikimu (2-4). Tradiciškai sveikatos priežiūros organizacijų veikla yra vertinama pagal paslaugų apimtis (5), o gydytų pacientų skaičius yra labiausiai paplitęs stacionarinių sveikatos priežiūros įstaigų veiklos rodiklis. Nepaisant to, kad šiuolaikiniai sveikatos priežiūros organizacijų veiklos vertinimo modeliai apima daug įvairių aspektų ir dimensijų (tokių kaip paslaugų kokybė, pajėgumas gauti reikiamus išteklius, pajėgumas reaguoti į visuomenės poreikius, veiklos efektyvumas, veiksmingumas, produktyvumas, našumas, organizacijos kultūra ir pan.), sveikatos priežiūros įstaigų veiklos vertinimas pagal pacientų (paslaugų atvejų) skaičių išlieka kaip vienas pagrindinių rodiklių jau vien dėl to, kad daugumoje sveikatos sistemų apmokėjimas sveikatos priežiūros organizacijoms yra pagrįstas gydytų pacientų ar suteiktų paslaugų apimtimis (6,7). Tačiau analizuojant vien tik stacionarinėje asmens sveikatos priežiūros įstaigoje (ASPĮ) gydytų pacientų (atvejų) skaičių per tam tikrą laiko periodą, daryti išvadas apie ligoninės veiklą ir ypač lyginti su kitomis ligoninėmis yra pakankamai sudėtinga ir net nevisiškai objektyvu... [to full text]

Despite a wealth of literature on the aetiology of somatic distress or somatization, somatic theory has failed to expand beyond a dualistic epistemology of causation. Within the primary health context where medically unexplained symptoms are characteristically articulated as literal, symbolic gestures of internal psychological processes, individuals' subjective accounts of somatic distress are reduced to objective phenomena and thus articulated on the grounds of absence. Within this context, the body as a lived, meaningful, perceiving subjectivity is silenced in favour of the corpse, thus rendering the somatizing individual's lived and subjective experience, expression and knowledge of somatic distress inaccessible. Instead, the somatizing individual is positioned within a domain of perturbed silence - a domain in which the professional's turning away or retreat from engaging somatization on the grounds of unique, subjective and corporeal experience, positions the patient/client as a passive, silent recipient whose somatic expressions as lived are overlooked. This study attempts to initiate a theoretical focus of departure from existing articulations of somatic distress through the development of a theoretical and epistemological framework that addresses some of the tensions inherent to contemporary somatic theory. In so doing, it employs embodiment philosophy and narrative methodology as a basis for a preliminary and critical investigation into a relatively neglected area of somatization research. / KMBT_363 / Adobe Acrobat 9.54 Paper Capture Plug-in

Valproic acid (Depakote) is an antiepileptic drug approved for the treatment of bipolar disorder, migraine prophylaxis, and seizure disorders. While the exact mechanism is still unknown, thrombocytopenia, defined as platelet counts < 150,000/uL, has been reported secondary to Depakote treatment. The frequency of Depakote-induced thrombocytopenia varies greatly, with reported rates ranging from 5 to 54%. This adverse effect is dose-dependent and possible risk factors include lower baseline platelet counts, female gender, and high VPA serum concentrations.Our team came across two patient cases where thrombocytopenia during Depakote therapy was observed. Patient information was gathered through electronic medical records. The first patient was a 65-year-old male who was started on 500 mg Depakote ER three tablets at night for bipolar affective disorder. After several months on this dose, the patient’s platelets decreased to 59 X 103per microliter. One month after the drug was discontinued, the platelets recovered to 160 X 103per microliter. The second patient was a 57-year-old woman who had two occurrences of thrombocytopenia while on Depakote. The patient was started on Depakote for a seizure disorder. She was later admitted for symptomatic bradycardia, hypotension, and concern for thrombocytopenia. Her Depakote dose was decreased from 500 mg three times a day to twice a day. Approximately 5 weeks later, she presented to the emergency room for decreased arousal and hypotension. She was again found to have thrombocytopenia with a platelet count of 28 X 103per microliter with a Depakote level of 101 mcg/mL. The team discovered she had been receiving Depakote 500 mg three times a day following discharge from her last admission, not the reduced dose prescribed. On day four of admission, her platelets had not improved and the Depakote dose was decreased further to 250 mg twice daily. After Depakote was discontinued her platelets gradually improved and returned to normal after four days, the eighth day of admission. Utilizing the Naranjo adverse drug reaction probability scale, the first patient case had a probable reliability that this adverse reaction was due to Depakote, while the second patient case had a definite reliability.These cases illustrate the potential for thrombocytopenia secondary to Valproic acid use. Although this adverse event isn’t well understood, these cases add to the evidence that it can occur. Recognition of this reaction is important and clinicians should monitor hematologic labs, including platelets, for patients receiving Valproic acid.

The purpose of the study is to evaluate hospital costs in Kaunas Medical University Hospital (KMUH). KMUH is the largest hospital in Lithuania, having 1995 in-patient beds, 26 specialised in-patient departments, 5130 employees, and providing wide range of in-patient services. Methods. Methods, used in the study include assessment of inputs and outputs, evaluation of average cost per case, estimation of cost structure, estimation of case-mix dimensions in in-patient departments and clinical categories and assessment of impact of case-mix dimensions to cost per case, using multiple regressionanalysis. Cross-sectional study designwas used in the study, evaluating mainly cases and expenses of all 26 specialised in-patient departments of KMUH per year 2002. Five cost groups have been used and defined inmonetary terms in each in-patient department: labour costs; medication costs; laboratory, radiology and anaesthesiology costs; running costs of medical equipment supply andother costs (including in-patients’ mealcosts, transportation, laundry, communication, etc. costs). Case was defined as one treatment episode in particular in-patient department. Cases were analysed using following case-mix dimensions: sex, age, absenceor presence of surgical operation, patient separation status and in-patientservice group. Results. Average costs per case vary widely among in-patient departments, ranging from 126.01 Litas (36.52 Euro) to 3451.68 Litas (999.73 Euro) per case.During the study average cost per case were also estimated in clinical profiles – surgery – 1161.0 Litas (336.24 Euro), therapy – 1312.15 Litas (380.02 Euro),obstetrics and gynaecology –685.82 Litas (198.62 Euro), newborn and child care – 893.54 Litas (258.78 Euro) and intensive care – 1292.92 Litas (374.45 Euro). Using multiple regression analysis method, costper case ineach in-patient department and clinical category according case-mix dimensions were predicted. In all in-patient departments predicted values of average costs per case according case-mix dimensions, comparing with actual values, did not differ so much. Positive contributions to predictedvalue of cost per case, shows only one variable – IA in-patient service group. In any predicted case contributions of independent variables have notbeen observedas significant (p&gt;0.05). Conclusions. Inputs (measured in the number of beds) and outputs (measured in the number of in-patientcases and the number of bed-days) are different across in-patient departments, as well as outputs (measured inthe number of treatment episodes according to case-mix dimensions). The average costs per case vary widely across in-patient departments and clinical categories. The analysis of the structure of average costs per case demonstrated striking differences in in-patient departments. In all in-patient departments the predicted values of the average costs per case according to case-mix dimensions, do not differ so much comparing with theactual observed costs per case. Positive contributions to the predicted value of the cost per case, shows only onevariable – IA in-patient service group. The results of the study have proved the evidence that clinical casestreated within the same in-patient department of the hospital are not similar. The results of studyhave showedthe failure of use of “in-patient service groups” as proxy of International Disease Classification due to numberof reasons / <p>ISBN 91-7997-101-6</p>

This research project was a descriptive study conducted at a clinical psychology practicum center which investigated the relationship between supervisory ratings of student therapist competency and respective client outcome. Cases were assigned to one of four outcome categories on the basis of six outcome criteria. These included: client and therapist assessment of change in presenting complaints and adaptive functioning, client satisfaction with treatment, type of termination, and session attendance. Clinical faculty supervisors completed subjective competency ratings of student-therapists and also rated the difficulty of client cases. A semi-partial correlation was calculated between competency and outcome scores with the effects of case difficulty partialled out of the outcome scores. It was hypothesized that a significant positive semi-partial correlation would emerge. Forty-eight client cases that were month period were included in the study. seen during a six Also, 14 student therapists belonging to four practicum teams participated. The major finding of this investigation was that overall, therapist competency ratings were not significantly related to the outcomes of clients, (r=-. 12, p>.05). However, when assessing the relationship between therapist competency and outcome for each of practicum teams individually, a significant negative semi-partial correlation was found for one of them, (r=-1.03, p<.01). Problems with subjective assessments of competency were discussed and recommendations for improving evaluations were given. Results of a fine grained analysis of outcome data and related variables were presented and discussed as they apply to clinical training and service issues. / Master of Science

The development of the concept of irreverence is examined in terms of its historical, theoretical and metatheoretical contexts. The underlying assumptions of the concepts of neutrality, curiosity, and irreverence are distinguished and contextualised. Neutrality is discussed with reference to Milan systemic therapy and first- and second-order cybernetics, while curiosity is examined in the light of constructivist and narrative approaches to psychotherapy. It is argued that these two concepts represent two sides of a dualism, which is transcended through irreverence. Irreverence is interpreted as a postmodern stance, involving the questioning and relativising of therapists' basic assumptions. The pragmatic components of an irreverent stance, namely self-reflexivity, orthogonality, flexibility and accountability, are explored with reference to related concepts in the work of other authors. Throughout the text metalogues are used in an attempt to engage reader and author in a collaborative enterprise of acknowledging and reevaluating their own basic assumptions. / Psychology / M.A. (Clinical Psychology)

The development of the concept of irreverence is examined in terms of its historical, theoretical and metatheoretical contexts. The underlying assumptions of the concepts of neutrality, curiosity, and irreverence are distinguished and contextualised. Neutrality is discussed with reference to Milan systemic therapy and first- and second-order cybernetics, while curiosity is examined in the light of constructivist and narrative approaches to psychotherapy. It is argued that these two concepts represent two sides of a dualism, which is transcended through irreverence. Irreverence is interpreted as a postmodern stance, involving the questioning and relativising of therapists' basic assumptions. The pragmatic components of an irreverent stance, namely self-reflexivity, orthogonality, flexibility and accountability, are explored with reference to related concepts in the work of other authors. Throughout the text metalogues are used in an attempt to engage reader and author in a collaborative enterprise of acknowledging and reevaluating their own basic assumptions. / Psychology / M.A. (Clinical Psychology)

En partant d’une description des nombreux changements de la pratique médicale depuis quelques décennies, la thèse étudie divers aspects constitutifs du malaise du médecin. L’accroissement de la puissance médicale qu’a permis la technoscience est analysée et remise dans un contexte plus large où les technologies de l’information ont une grande place. L’augmentation considérable des connaissances pose un problème de maîtrise de la science médicale. La multiplicité des observations fait qu’il y a discordance de certaines d’entre elles avec les théories médicales largement acceptées. De cette manière, le gain d’efficacité est associé à une perte de la cohérence du discours médical. Le rôle du médecin disparaît derrière la technique, qui semble pouvoir, seule, rendre tous les progrès accessibles. Le médecin devient alors un simple distributeur de services et, à ce titre, développe parfois des offres de pratiques sans fondement, voire dangereuses.<p>Le pouvoir du médecin est évoqué, et se ramène in fine à la fourniture d’un diagnostic et d’une explication de sa maladie au patient. Le rôle des explications particulières que donne le médecin au malade est exploré à la lumière d’une conception narrative et évolutive de la vie humaine. Le rôle du médecin apparaît alors comme d’aider le patient à réécrire a posteriori le fil d’une histoire qui apparaît initialement comme interrompue par la maladie.<p>Le rôle social de maintien de l’ordre de la pratique médicale est alors évoqué. Ensuite, par une approche descriptive du phénomène religieux, on montre que la médecine du XXIe siècle a les caractéristiques d’un tel phénomène. Entités extrahumaines, mythes, rites, tabous, prétention à bâtir une morale, accompagnement de la vie et de la mort, miracles, promesse de salut, temples, officiants sont identifiés dans la médecine « classique » contemporaine. Seule la fonction de divination de l’avenir d’un homme précis est devenue brumeuse, la technoscience permettant régulièrement du « tout ou rien » là où auparavant un pronostic précis (et souvent défavorable) pouvait être affirmé.<p> L’hypothèse que la médecine est devenue une religion du XXIe siècle est confrontée à des textes de S. Freud, M. Gauchet et P. Boyer. Non seulement ces textes n’invalident pas l’hypothèse, mais la renforcent même. Il apparaît que le fonctionnement de l’esprit humain favorise l’éclosion de religions et donc la prise de voile de la médecine. La dynamique générale de la démocratisation de la société montre que la médecine est une forme de religion non seulement compatible avec une société démocratique, mais est peut-être une des formes accomplies de celle-ci, où chaque individu écrit lui-même sa propre histoire.<p>Le danger qu’il y a, pour le patient comme pour le médecin, si ce dernier accepte de jouer un rôle de prêtre, est ensuite développé. Enfin, la remise dans le cadre plus général de l’existence humaine, l’évocation de la dimension de révolte de la médecine, de son essentielle incomplétude, l’acceptation d’une cohérence imparfaite permettent au médecin de retrouver des sources de joie afin de, peut-être, ne tomber ni dans un désinvestissement blasé, ni dans un cynisme blessant.<p><p>From a description of the many changes medical practice has undergone for a few decades, the work goes on to study many sides of the modern doctor’s malaise. The gain of power made possible by technoscience is put on a larger stage where information technologies play a major role. The abundance of knowledge makes health literacy more difficult. the great number of observations makes discrepancies with general theories more frequent. The gain in power is associated with a loss of coherence of the medical speech. The doctor’s role vanishes behind technology that seems to be the only access to all medical progresses. Doctors becomes mere service providers and go on to offer unvalidated or even harmful services on the market.<p>Modern medical power resumes into the explanations and diagnosis given to the patient. The role of medical explanations is explored through an evolutive and narrative vision of human life. The duty of the doctors then appears to allow a new narration of the self that bridges the gap disease introduced into the patient’s life.<p>The role of medicine in maintaining social order is mentioned. Through a sociological approach of the religious phenomenon, one can see that XXIst century medicine is such a phenomenon. Medicine knows of extrahuman entities, myths, rites, taboos, miracles, temples; priests are present in modern mainstream medicine. Some want to derive objective moral values from medicine, and it brings companionship to man from birth to death. The only departure from old religions was the weakened ability to predict the future of an individual patient: for some diseases for which survival was known to be very poor, the possibilities are now long-term survival with cure, or early death from the treatment. <p>The hypothesis that medicine is a religion is confronted to texts from Freud S. Gauchet M. and Boyer P. Not only do they not invalidate the hypothesis, but they bring enrichment to it. Brain/mind dynamics is such that the appearance of religions is frequent, and makes the transformation of medicine into a religion easier. Society’s democratisation confronted to religion’s history shows that medicine is the most compatible form of religion within a truly democratic society, where each individual writes his own story.<p>To become a priest brings some dangers for the patient, but also for the doctor. These dangers are discussed. This discussion is put into the larger context of human life. The revolt dimension of medicine is discussed, as is its never-ending task. Their acceptance, as that of a lack of total logical coherence can open the possibility for the doctor to enjoy his work, without being neither unfeeling nor cynical.<p> / Doctorat en philosophie et lettres, Orientation bioéthique / info:eu-repo/semantics/nonPublished