The Clinician's Voice and the Limits of Bioethics

The bioethics movement has long promulgated a model of ‘principled decision‐making’ in which ethical dilemmas and conflicts between various rights, interests, and ethical principles are central. In many respects this movement has had a laudatory impact on health care and on health professionals, but we will also argue that the bioethical model of ethical analysis has important limitations. The model's theoretical orientation is discontinuous with the training and skills of health professionals, the manner in which health professionals conceptualise and solve problems that arise in a clinical setting, and the time constraints inherent in most clinical situations. As such, the model is not readily applicable to much of the day‐to‐day work of clinicians and, in particular, to the routine ethical questions and situations that arise in caring for patients. What we suggest is that the bioethical model does not take into account that health care professionals, as part of their daily work, encounter and manage difficult, often conflictual situations and that they do so by bringing to bear conceptual frameworks and therapeutic techniques that have, embedded within them, the ethical values and goals of their own fields, as well as established ways of dealing with problems and addressing competing priorities. We further argue that from a systems perspective, the bioethical model and the pragmatic, problem‐focused ethical decision‐making of clinicians operate on different levels of complexity; whereas the former is especially appropriate for situations that resist consensus or that raise significant issues of public policy, the latter serves as an effective framework in less difficult or complex situations that can be moved effectively toward consensus and closure.     

Corporate political power and US foreign policy, 1981–2002: the role of the policy-planning network

Theory and Society - Recent empirical work has offered strong support for ‘biased pluralism’ and ‘economic elite’ accounts of political power in the United States, according...     

Factitious Illness by Proxy: Understanding Underlying Psychological Processes and Motivations

Children are put at risk of emotional and physical harm when parents seek unnecessary medical care. Understanding why parents seek medical interventions that create risk for their children requires us to consider how past experiences, and the mental representations of these experiences influence current behaviour. Past experiences of danger affect how parents interpret ‘dangerous’ situations in the present and how they organise protection of their child. This article demonstrates how the notion of mental representations (that dispose parents to act in particular ways) can assist in engaging, assessing and treating parents who display factitious illness by proxy behaviour. When classified using the Dynamic‐Maturational Method, the Adult Attachment Interview (AAI) allows both assessment of implicit and explicit representations and also understanding of the developmental process through which parents have learnt to attribute meaning to information and to organise their behaviour. In this case study, psychosocial assessment of the family included an AAI with each parent. The use of this assessment tool both aided the therapy team in the process of case formulation and intervention planning, and had therapeutic value in and of itself. We argue that treatment is more likely to be effective if the parents and professionals have a shared understanding of the parents' intentions and the developmental process that led to unsafe behaviour, which requires change.     

Feminism and Beyond: Interview with Carolyn Quadrio

In interview with Kasia Kozlowska, Melbourne‐born psychiatrist Carolyn Quadrio describes the impact of growing up in a Greek migrant family, the significant influences on her choice of profession, and the ways in which she gradually developed a feminist position simultaneously with embracing a systemic perspective on ‘depression’ and other diagnostic categories. Quadrio talks frankly about her challenges to the male‐dominated psychiatric establishment, her struggles to get her critique of it published, her excitement about the family therapy field, and her later disillusionment with it. Her current work is in the area of forensic psychiatry.     

Managing autonomy in university–industry research: a case of collaborative Ph.D. projects in the Netherlands

Review of Managerial Science - Research partnerships between university researchers and industry partners are becoming increasingly prevalent. For university researchers, maintaining autonomy is...     

The Body Comes to Family Therapy: Utilising Research to Formulate Treatment Interventions with Somatising Children and their Families

Children and adolescents with functional somatic symptoms are challenging to understand and to treat. The challenges begin at the very outset of the intervention – with the neurological and psychiatric assessments. Patients presenting with functional somatic symptoms, as well as their families, frequently deny any emotional or family problem, and parents are often genuinely baffled as to why a child has suddenly become so ill and why no medical explanation is forthcoming. Families can be unwilling to engage in family assessment and therapy, and therapists may find that standard approaches to family therapy simply can end up alienating these families – the door to therapy is slammed shut. This article is the story of my struggle to understand somatising children and their families and to find a common language to enable us to co‐construct formulations, to agree to a treatment plan, and to work together towards a pathway to health. It is also about the role of research and how knowledge from different system levels – and most specifically about the body – may need to be integrated into the therapy to help bring about change.     

Maltreated Children: A Systems Approach to Treatment Planning in Clinical Settings

Children exposed to significant abuse, neglect and household dysfunction often present a confusing and difficult‐to‐treat clinical picture. This paper discusses the use of systems theory to develop treatment plans for maltreated children in clinical settings. Although its value is well recognised in the literature, systems thinking is not easy to implement in ordinary clinical settings and the systemic approach is not universally practised. Systems theory is an integrative theory, which helps clinicians identify and prioritise key areas of difficulty, and organise information from multiple system levels into a well‐defined treatment plan. Treatment plans take into account not only patient but also service factors, and to be viable in clinical settings must function within the limits of organisational reality. A case vignette is provided.     

Choosing a Valid Assessment of Attachment for Clinical Use: A Comparative Study

This article addresses the clinical issue of selecting assessments of attachment that are relevant to decision making for families. The validity of three commonly used methods of assessing attachment in preschool‐aged children was compared using a sample of 51 low‐income mother—child dyads. Thirty‐eight of the children had been abused or neglected. The dyads were seen in a Strange Situation that was classified using each of the three methods: (a) the Ainsworth‐extended method, (b) the Cassidy‐Marvin (C‐M) method, and (c) the Preschool Assessment of Attachment (PAA). Validity was evaluated in terms of maltreatment status, maternal sensitivity, child DQ, and maternal attachment strategy. The PAA and C‐M classifications matched in only 37% of cases. The Ainsworth‐extended method differentiated secure versus insecure children on two variables. The CM method differentiated secure versus insecure children on one variable. The PAA differentiated secure versus insecure children on all four variables and subgroups on one. Moreover, it was tied to other family relationship variables in meaningful ways. If applied in clinical settings, these three methods would result in very different groups of children being seen as safe and at risk. We argue that clinicians cannot afford to be uninformed about the validity of alternative means of assessing attachment.     

The Bowl of Terror: A Case Study of an Adolescent Perpetrator of Sexual Abuse

This article describes a complex multimodal intervention with a family where inappropriate sexual contact had occurred between Taro and his younger sister Lara, when they were young children. The family presented to clinical services when Lara was brought to hospital with suicidal ideation, traumatic flashbacks and regressed behaviour at 13 years of age. Treatment involved multiple components: family work with all members of the family individual work with Lara, joint work with Lara and Taro, and finally, a brief intervention with Taro. This article focuses primarily on the therapist's work with Taro, the perpetrator of the inappropriate sexual contact. The Adult Attachment interview (AAI), a semi‐structured interview, was used by the therapist to assess Taro's developmental experiences and psychological functioning. Information from the AAI helped the therapist identify both the relationship factors that had contributed to the perpetration of sexual abuse and the self‐protective strategies Taro had come to use in order to elicit maximum comfort and protection from neglectful attachment figures. The therapist used the functional formulation derived from the AAI to structure a time‐limited intervention.