Archie Brodsky

Exploring psychological benefits associated with moderate alcohol use: a necessary corrective to assessments of drinking outcomes?

The aim of this paper is to identify positive psychological concomitants of moderate alcohol consumption. Current research and public-health perspectives on alcohol emphasize harms disproportionately relative to benefits. The major exception is research establishing beneficial effects of moderate drinking on cardiovascular health and overall mortality. In addition, much observational and experiential data suggest the widespread prevalence of positive drinking experiences. This paper is one of the first attempts since 1985 to codify such benefits in epidemiological terms. Methodological difficulties in accomplishing this include defining moderate drinking, controlling for confounding variables, and establishing causality. Nonetheless, evidence of psychological benefits has been found in experimental, observational, interview, self-report, correlational, and some prospective research. These positive findings are in the areas of subjective health, mood enhancement, stress reduction, sociability, social integration, mental health, long-term cognitive functioning, and work income/disability. Problem drinkers and alcoholics also seek mood and other benefits from alcohol, but are more likely to drink to counteract negative feelings and to support their egos than are social drinkers. It is as yet impossible to determine to what extent moderate alcohol consumption causes positive psychological outcomes and to what extent it is part of a complex pattern of mutually reinforcing variables.

Preventing “Critogenic” Harms: Minimizing Emotional Injury from Civil Litigation

Litigation is always stressful for the parties involved, and certain emotional injuries from litigation itself, termed “critogenic” (law-caused) harms, can be identified to aid attorneys in recognizing them. These harms include delay, adversarialization, retraumatization, violation of boundaries, loss of privacy, and arrested healing. After discussing critogenic benefits of litigation for balance, the authors offer approaches for minimizing the impacts of the above harms on clients.

The Decision-Analytic Approach to Medical Malpractice Law: Formal Proposals and Informal Syntheses

The close relationship between difficult medical decisions with potentially tragic outcomes and feared malpractice litigation has been an impetus to seeking analytic tools to aid decision makers. Although psychiatric decision making has been subject to well-publicized legal scrutiny, such scrutiny extends to all areas of medicine. During the past decade a decision-analytic reckoning of costs and benefits has been proposed as an improvement over traditional legal standards (particularly those of professional custom) for determining negligence in medical malpractice actions. For the most part, however, the courts have not adopted the mathematical approach to negligence determination used in Helling v. Carey in 1974. Nonetheless, the courts today do weigh costs and benefits, though in a less precisely numerical way, in deciding whether a physician has acted as a &dquo;reasonable and prudent&dquo; practitioner. Careful assessment of risks is specifically mandated by the informed-consent requirement, by which the physician is held responsible for disclosing the risks of alternative

Subjective data and suicide assessment in the light of recent legal developments. Part I: Malpractice prevention and the use of subjective data

The decidedness of my attitude on the subject of the unconscious is perhaps specially likely to cause offense, for I handle unconscious ideas, unconscious trains of thought, and unconscious emotional tendencies as though they were no less valid and unimpeachable psychological data than conscious ones. But of this I am certain that any one who sets out to investigate the sarde region of phenomena and employs the same method will find himself compelled to take up the same position, however, much philosophers may expostulate.

Captive patients, captive doctors: clinical dilemmas and interventions in caring for patients in managed health care.

This article explores common clinical dynamics resulting from the denial of choice that many patients experience in managed health care and proposes clinical adaptations for the treating or consulting psychiatrist. Patients who feel they have been denied the right to choose their health plan, treatment setting, or personal physician commonly go through a subjective experience analogous to that of being held captive. This sense of captivity can exacerbate the feelings of helplessness and hopelessness brought on by serious illness. It can also intensify the patients feelings of alienation and betrayal when managed care constrains patient-physician decision making by limiting treatment options. These dynamics can lead to identifiable transference reactions and, in turn, to physician countertransference. Psychiatrists can do much to ameliorate these potentially destructive dynamics both as treating therapists and as consultants to general physicians. Indications for consultation or intervention are analyzed and specific clinical strategies to enhance the patients decision-making capacity throughout the introductory, ongoing, and termination phases of the treatment alliance are reviewed.

Depression, self-love, time, and the “right” to suicide

Elizabeth Bouvia, whose legal struggle to compel a psychiatric hospital to assist her in committing suicide ended with a decision that she could be force fed by the hospital, presented the psychiatric community with a host of ethical questions concerning the rights of a patient to choose death, and the obligations of the medical profession to promote life. What the courts did not decide is when a patient is incompetent to decide her own fate, and what is the duty of the hospital to intervene with a suicidal patient. The authors suggest that there is an ambiguity present whenever a patient presents herself to a hospital or therapist as suicidal, and that a time limited period, or cooling-off period, should exist that would allow an alliance to form between patient and care-giver, if possible, and then permit them to explore underlying issues of depression. The authors believe that there is a need to acknowledge the patients ultimate right to choose death, but that autonomy should not be confused with impulsivity when anyone is faced with the irrevocability of the decision to die.

PARENS PATRIAE CONSIDERATIONS IN THE COMMITMENT PROCESS

Seventy-one commitment-seeking decisions made by 36 clinicians in a state-funded mental health center were studied to determine the extent to which clinicians attend to legally mandated “dangerousness” criteria in seeking commitment. A previous finding that clinicians rely largely on the dangerousness criteria was replicated. In addition, clinicians were found to be sensitive to clinical indicators of the patients need for treatment, a question which is central to the parens patriae approach to involuntary hospitalization. Further, patients who were judged to be more seriously ill or more dangerous were more likely to retract their requests for discharge. This finding suggests that the patients request for release and the psychiatrists petition for commitment together constitute an interactive, transactional process in which the clinicians and the patients views of the patients need for hospitalization influence each other.

Founders' Perspective on the History of the Program in Psychiatry and the Law:

The Program in Psychiatry and the Law (the Program) resides in the Department of Psychiatry, Beth Israel Deaconess Medical Center—a teaching hospital of Harvard Medical School. Over the course of three decades of collaborative work, the Program has evolved from its origins in several ways. To understand this evolution, it may be valuable to place members’ contributions into perspective by offering a conceptual biography, as it were, of the Program’s ideas and activities. Such a review will also convey some sense of the functioning of the Program itself, in addition to providing a context for the articles that comprise this first of two special issues of the Journal of Psychiatry & Law.