Substance Use Decision-Making – Are Clinicians Using the Evidence?

Clinical assessment and treatment decision-making is a complex, everyday task for the substance use workforce. This Canadian study conducted with community substance use providers in the Interior region of British Columbia examines the factors clinicians pay attention to in their decision-making. A randomized factorial survey approach, using three unique vignettes embedded with factors of interest, was used to test the effect of case and respondent factors on assessment and treatment decisions. Responses were received from 106 participants, representing approximately a 35% response rate, yielding a sample size (n) of 308 vignettes. Multiple regression tested the independent effects of the vignette and clinician factors on assessment and treatment decisions. Factors within the vignette associated with withdrawal, physical illness and mental health issues emerged as the most predictive elements. The social complexity of people’s lives, client’s stated treatment preferences and readiness for change, and respondent characteristics were obscured in decision-making. This study indicates a lack of fidelity in the use of core assessment and treatment-matching tools, suggesting that clinician decision-making may, in everyday practice, be more heuristic and evidence-informed than evidence-based. Further research on normative decision-making practices in the substance-field is warranted.     

A cost of living longer: Projections of the effects of prospective mortality improvement on economic support ratios for 14 advanced economies

The economic implications of increasing life expectancy are important concerns for governments in developed countries. The aims of this study were as follows: (i) to forecast mortality for 14 developed countries from 2010 to 2050, using the Poisson Common Factor Model; (ii) to project the effects of the forecast mortality patterns on support ratios; and (iii) to calculate labour force participation increases which could offset these effects. The forecast gains in life expectancy correlate negatively with current fertility. Pre-2050 support ratios are projected to fall most in Japan and east-central and southern Europe, and least in Sweden and Australia. A post-2050 recovery is projected for most east-central and southern European countries. The increases in labour force participation needed to counterbalance the effects of mortality improvement are greatest for Japan, Poland, and the Czech Republic, and least for the USA, Canada, Netherlands, and Sweden. The policy implications are discussed.     

Respite and family support services: Responding to the need

Increased focus on the needs of parents and guardians for structured opportunities for temporary relief from care of disabled persons has stimulated policy and implementation initiatives at the state government level on behalf of these families. This article presents qualitative and quantitative data on the need for respite services not only in terms of relief, but as a positive, supportive force in the prevention of permanent placement outside the home. Current services are outlined and issues important to clinicians and managers working with such families are discussed.Planning and Development     

The sample size debate: response to Norman Blaikie

In his detailed response to our paper on sample size in qualitative research, Norman Blaikie raises important issues concerning conceptual definitions and taxonomy. In particular, he points out the problems associated with a loose, generic application of adjectives such as ‘qualitative’ or ‘inductive’. We endorse this concern, though we suggest that in some specific contexts a broad categorization may be more appropriate than a more nuanced distinction – provided that it is clear in which sense the terms are employed. However, other concepts, such as saturation, do not lend themselves to generic use, and require a more detailed conceptualization. Blaikie’s analysis also makes it clear that meaningful discussion of sample size in qualitative research cannot occur with reference to an undifferentiated conception of the nature of qualitative research; clear distinctions need to be made within this approach in terms of methodology, ontological and epistemological assumptions and broader research paradigms.     

The World Social Forum and the challenges of global democracy

Abstract Protests against economic globalization helped give birth to the World Social Forum (WSF) as a space for civil society groups to coordinate actions and articulate shared visions for global change. Since 2001 the WSF has brought together hundreds of thousands of activists from all parts of the world. But creating an inclusive political space that is also effective at generating unified action has proved challenging. In this article I explore the central tensions in the 2004 WSF and explore the possibilities for the Forum to overcome these obstacles and expand global democracy.     

Sustaining People Right Through Their Lives: Interview With Graham Martin

In this interview Graham Martin reflects on his long career in child and adolescent mental health. He shares his formative experiences with some of the pioneers in the field of attachment theory and the many varied ways that this information has influenced his work in the provision of care to children in hospital, health promotion, understanding the distress of suicidal youth, and his ongoing therapeutic work with families.     

Borderline daughters: An optimal configuration for their growth

A significant majority of patients with borderline personality disorder, in a long-term psychiatric hospital for adolescents, had been the daughters of younger middle class mothers (14–20) with fathers absent since birth or before age 5. This family configuration is optimal for the growth of a symbiotic mother-daughter relationship and the identity disorder prevalent in borderline patients. The similar histories of these patients are examined. They can be described in two categories: those who combine precocious sexuality with infantile behavior and a smaller group with a somewhat masculine pseudo-mature identity. The first group usually attempts to retreat to the father, has clinging, dependent relationships with males, sexually acts out and is at a very high risk for pregnancy and a repetition of the mothers' lives.This paper was presented at the American Association of Psychiatric Services for Children, Las Vegas, Nevada, March, 1986.Mr. Levy is at Wesleyan University