Rainer Erices

Crisis-repair sequences - considerations on the classification and assessment of breaches in the therapeutic relationship

BackgroundRecent research indicates that temporary deteriorations of variables monitored continuously in the course of the therapeutic relationship are important characteristics of psychotherapeutic change. These so-called rupture-repair episodes were assessed by different authors using different mathematical methods.MethodsThe study deals with the criteria for identifying rupture-repair episodes that have been established in previous studies. It proposes modifications of these criteria which prospectively could make it possible to identify rupture-repair episodes more precisely and consistently. The authors developed an alternative criterion. This criterion is able to include crisis patterns which had not been considered before, as well as to characterize the length of the crises. As a sample application, the different criteria were applied to continuously measured assessments of the therapeutic interaction in psychodynamic therapy courses (ten shorter processes and one long-term therapy).ResultsThe analysis revealed that the number of the identified rupture-repair episodes differed depending on the criterion that was used. Considerably more crises were identified with the newly developed criterion. The authors developed a classification of crisis patterns. They distinguished five patterns of crises and their resolution in therapy processes and ascertained the frequency of distribution. The most frequent pattern was the simple V-shape. The second most common pattern was a decline over more than one session with a sudden repair. The longest downward trend comprised a period of six sessions.ConclusionsThe findings of the study give insight into basic mechanisms of change within the therapeutic relationship. A phenomenological discussion of how a crisis is defined is useful to create a methodological approach to the operationalization of crises, to differentiate specific characteristics and to specifically link these characteristics to the outcome in future studies. The methodological deliberations might be applyable to different research areas where the analysis of fluctuations in a variable of interest over time is relevant.

Strafbare Bestechlichkeit von Vertragsärzten und Ethik

ZusammenfassungFragen der Korruption von Vertragsärzten sind seit längerer Zeit höchst umstritten: Nach dem so genannten „Herzklappenskandal“ sind in den vergangenen Jahren wiederholt Pharma-Konzerne mit dem Vorwurf der Bestechung von Ärzten in die Schlagzeilen geraten. Das Thema wirft nicht nur juristische oder sozialpolitische, sondern auch ethische Fragen auf. Bislang gab es dazu in Deutschland jedoch nur wenig Reflexion. Bewertungen wurden von der Ärzteschaft vor allem Politikern und Juristen überlassen. Dabei bleibt die Frage der strafbaren Bestechlichkeit im Kern ein Problem, das Ärzteschaft und Medizinethik betrifft. Im Alltag ist es oft schwer zu entscheiden, wann es sich bei Zuwendungen um mögliche Bestechung handelt. Die Übergänge zwischen dem unproblematischen Annehmen kleiner Geschenke und Korruption sind fließend. Es bleibt fast ausschließlich dem moralischen Empfinden der Ärzte überlassen, die Grenze zwischen Kooperation und Korruption im Umgang mit Pharmaunternehmen zu ziehen: Unausweichlich vorhandene Konflikte zwischen privaten und berufsethischen Interessen müssen von den Ärzten angesichts unzureichender allgemeingültiger Richtlinien für angemessenes Verhalten individuell gelöst werden. Das Bewusstsein für die sozialpolitische und berufsethische Bedeutung von Interessenkonflikten unter Ärzten und Studierenden sollte erhöht werden. Eine offensivere Auseinandersetzung mit der Frage der Bestechlichkeit in der Medizin ist wünschenswert und erforderlich.AbstractDefinition of the problem The potential corruptibility of contracted medical practioners has been controversially discussed for a long time: following the so-called “heart valve scandal”, numerous other pharmaceutical companies have also made the headlines when being accused of trying to bribe medical practioners. The issue not only raises judicial and sociopolitical questions, but also ethical questions. Thus far, only few reflections have been made on the matter. The medical profession has preferred to let politicians and legal professionals assess these aspects.Arguments The question of criminal bribery remains in its core a problem for the medical profession and medical ethics. In daily life, it is often difficult to recognize compensations as bribery. The border between harmless acceptance of gifts and possible corruption is often not very clear. It mostly remains in the moral perception of the doctors themselves to recognize the border between cooperation and corruption when dealing with a pharmaceutical company. Inevitably there will be conflicts between private and ethical interest of the medical professionals. Since the official ruling on the matter is insufficient, doctors are forced to decide individually what behavior is appropriate in each case.Conclusion Awareness of sociopolitical and professional-ethical conflicts of interest among doctors should be improved. It is desirable to establish a more agressive dialogue on the question of bribery of doctors.

Macht der Bachelor wirklich krank? – Studienabschlussspezifische psychische Beschwerden bei Klienten einer psychotherapeutischen Studentenberatung

There is a lack of detailed surveys on the mental health of students. German university counseling centers have faced increasing demand, which is primarily due to the newly introduced Bachelor/Master system. The data of 251 students who consulted the Leipzig psychotherapeutic counseling center were examined with regard to complaints, symptoms and interpersonal problems. Significant differences were observed with respect to usage of the counseling center and interpersonal problems. Masters degree and state examination candidates sought counsel most often. Bachelors degree students were least likely to seek help. Magister and Bachelor candidates showed a higher level of symptoms and interpersonal problems. Depression and work disruptions were the concerns mentioned most frequently. The findings should be examined further using additional samples. It should be clarified whether the likelihood of usage also differs with other forms of psychological help.

Testing ground GDR: Western pharmaceutical firms conducting clinical trials behind the Iron Curtain

Western pharmaceutical companies conducted clinical trials in the Eastern Bloc during the Cold War. Recently, media reports about alleged human experimentation provoked a wave of indignation. However, a scientific and objective account of these trials is lacking. The aim of this study was to describe and evaluate the clinical trials performed in the German Democratic Republic (GDR) based on archival material from the health system and the secret service. We found documents relating to 220 trials involving more than 14 000 patients and 68 Western companies. However, no record of patient information forms or systematic documentation regarding the provision of patient consent was discovered. There was no evidence to suggest that the trials systematically and intentionally damaged patients. The trials were conducted without the knowledge of the public. GDR legislation stipulated that patients must consent to the trials, but no evidence was found to suggest that patients were systematically informed. Documents suggest that at least some of the trials were carried out without patients having a comprehensive understanding of what the trial involved. The GDR agreed to the trials due to impending bankruptcy and Western pharmaceutical companies capitalised on this situation.

The role of the State Security Service (Stasi) in the context of international clinical trials conducted by western pharmaceutical companies in Eastern Germany (1961–1990)

Background After the building of the Berlin Wall in the 1960s, a number of international pharmaceutical manufacturers from the West had their drugs tested in Eastern Germany (GDR). So far, the extensive collection of documents on the subject stored in the archives of the GDR State Security Service (Stasi, MfS) has not been systematically analysed. Until now, the role of the Stasi with respect to the surveillance of the trials has been unclear. Methods A keyword search within the database of the Stasi files was conducted. All available files were screened in order to identify institutions, companies and personnel involved in the clinical trials. On this basis, further files were requested. A total of 259 files were available for analysis. Relevant data was derived from 160 of these files. A contextualised approach was applied, which critically explored the origin, content, and impact of the data. In addition, an approach guided by the central steps of document analysis was applied. Results At least 400 clinical trials were conducted during the GDR period. The exact number remains speculative. According to references found in the Stasi files, it might have been considerably higher. Initially, the main goal of the trials was for the GDR authorities to decide whether to import certain Western drugs. By 1983, this intention had changed. Now, the primary aim of the trials was the procurement of foreign currency. The Stasi feared that the pharmaceutical companies could have a significant influence on GDR Health System. Stasi spies were holding positions in the responsible medical committees, universities, and hospitals. Constant surveillance by the Stasi served the purpose of monitoring any contact between people from the West and the East. Unknowingly, representatives of Western companies were surveilled by the Stasi. The studied documents also point to the fact that a number of clinical trials conducted during the GDR period did not comply with GDR regulations, and were therefore deemed illegal by the Stasi. The Stasi was not particularly interested in medico-ethical questions. Conclusions Clinical trials conducted during the GDR period were surveilled by the Stasi. It was their aim to monitor all people involved in the trials, including their Western contacts. Relevant medico-ethical questions like patient consent and safety with respect to the clinical trials were not the focus. Considering the significant number of conducted trials, only limited evidence exists of doctors having discussed them critically. The public was not officially informed about the trials.