William T. Merkel

Teaching Humanistic and Psychosocial Aspects of Care: Current Practices and Attitudes

ObjectiveTo assess current practices and attitudes toward teaching humanistic and psychosocial aspects of care in internal medicine residency programs.Design and participants: Survey questionnaires were sent to residency directors at all 434 internal medicine residency programs accredited in 1985–1986. Response rate for two mailings was 71%.Measurements and main results: 78% of residency directors and 70% of department chairpersons bad high or moderately high levels of commitment to teaching bumanistic/psychosocial aspects of care, but only 44% of responding programs offered mandatory training, and only 18% offered elective training in these areas. Obstacles to expanded teaching of the bumanistic/psychosocial aspects rated high or moderately high by residency directors included insufficient curriculum time (51%), lack of trained faculty (44%), and pressures to reduce both training costs (40%) and patient-care costs (37%).Conclusions: Most of the training that does occur in the humanistic/psychosocial aspects of care probably happens informally via mentoring and role modeling. Appeals to expand teaching in these areas raise questions regarding what to include in medical training and the proper scope of internal medicine. Sustainable change will depend on the politics of resource distribution and the influence of general internal medicine and primary care on traditional training.

Inpatient behavior therapy: The St. Louis University model

Many of the problems that impede the practice of behavior therapy on traditional psychiatric and medical inpatient services can be avoided by a separate behaviorally-oriented inpatient unit, but few guidelines exist for establishing such a unit. The present paper describes the inpatient Behavioral Treatment Unit developed at St. Louis University Medical Center. Critical administrative and clinical features of the Unit are discussed, including the administrative philosophy which emphasizes unit autonomy and participative management, the central role of nursing staff, the importance of the clinical team system, the development of referral sources, admission procedures and criteria, and basic approaches to assessment and treatment.

Behavioral science training in family practice residency education: A first evaluation

Although behavioral science training is an essential component of family practice residency education, there have been few evaluations of its effects. In this study, selected behaviors of senior residents and their patients in two different family practice residency programs were compared. One program emphasized behavioral science, the other did not. Residents in the more behaviorally oriented program had more positive attitudes toward both social factors in illness and the importance of a warm physician-patient relationship. In addition, these residents claimed to know more about non-pharmacologic treatments for depression and anxiety and felt more confident in their ability to handle them than their less behaviorally trained counterparts. In regard to patient care, patients of residents in the program which emphasized behavioral science were more likely to receive a psychosocial diagnosis and resident counseling or mental health referral than patients of residents in the program which did not. On a patient satisfaction questionnaire, patients of the two programs differed on only one subscale which concerned convenience of care. Although these early results are encouraging, behavioral science training needs continuing clarification and evaluation of its goals and accomplishments.

A CAUTIONARY NOTE ON THE APPLICATION OF FAMILY THERAPY PRINCIPLES TO ORGANIZATIONAL CONSULTATION

Family therapy principles only partly apply to organizations. Although families and organizations are alike in some ways, they differ in goals, rules for participation, and membership. Family therapists can use organizational consultation to cross-validate systemic theories, increase nonclinical income, and influence organizations. They will succeed only to the extent that they advance organizational goals.

The use of covert sensitization and social skills training in the treatment of an obscene telephone caller.

This case study examines the use of covert sensitization and social skills training to treat an obscene telephone caller on a behaviorally-oriented inpatient psychiatric unit. Rapid decreases in penile tumescence associated with obscene telephone calling were obtained after covert sensitization treatment and were maintained at one year follow-up. Social skills training led to a decrease in social anxiety and increase in social behavior. Results support the combined clinical effectiveness of covert sensitization and social skills training for the treatment of obscene telephone calling.

Systems theory and its discontents: Clinical and ethical issues

Abstract Historically, general systems theory has been one of the conceptual foundations for family therapy. However, there are indications that systems theory, originally developed for nonhuman systems, may have significant limitations in accounting for family dysfunction and for guiding intervention. Clinically, systems concepts have been applied in a “one-size-fits-all” manner to families, with little attention to which intervention approaches are optimal for specific families. Ethically, systems therapy presents significant dilemmas in a society that reveres individual rights and well-being. These challenges to the family therapy field are discussed within the context of William Perrys model of intellectual and ethical development.

Reexamination of the Relationship between Birth Order Obsessive-Compulsive Disorder

In order to examine the hypothesis that being a firstborn or only child is specifically associated with obsessive-compulsive disorder, the birth order positions and sibship sizes of 62 patients with obsessive-compulsive disorder were compared with those of 60 agoraphobic and 92 depressed patients. No significant group differences were found for men, women, or both sexes combined. Results conflict with earlier findings which supported the hypothesized relationship between birth order status and development of obsessive-compulsive patterns in men. In addition to possible differences in methodology, discrepancies between the present findings and those of earlier studies may reflect a decline over the past 20 years in the percentage of male obsessive compulsives that were either firstborn or only children.

The effects of three methods of observation on couples in interactional research

Abstract Reactivity to observation can affect both internal and external validity of experimental studies. Although the effects of observation have been well documented in groups and parent-child interaction, there have been few studies of observer effects on couples. This study assessed the effects of three different methods of observation—one-way mirror, audio-recording and video-recording—on 30 volunteer, nonclinical couples. No differences were found among couples in the three observational conditions on measures of interactional behavior on a problem-solving task, participant appraisals of self-consciousness, discomfort and reactivity for themselves and their spouses, or on pre-post observation measures of anxiety and feelings toward spouse. The results suggest that these different types of observation do not produce significantly different effects on nonclinical couples and that studies utilizing these three methods may be compared.

Status of Behavioral Medicine in American and Canadian Medical Training

This article reports a survey of attitudes and current practices regarding behavioral medicine in American and Canadian medical school departments of psychiatry. Participants were eighty-two chairpersons of departments of psychiatry. Five major areas were addressed concerning the existence, location, and composition of behavioral medicine faculty and their contribution to training and research programs. Results indicate that behavioral medicine is represented in the majority of medical schools and teaching hospitals. Faculty tended to be located in psychiatry. A majority of the respondents did not think that behavioral medicine should be considered a separate clinical specialty area, but in actual practice behavioral medicine was distinct from consultation/liaison psychiatry as often as integrated with it. The analysis of subjects and methods taught in residency training programs suggested a meaningful trend in the data. The implications of these results for models underpinning traditional medical education and psychosomatic medicine are discussed.

Relation of Depression to Specific Medical Complaints in Psychiatric Inpatients

Although there is strong evidence for the relationship between depressive symptoms and medical problems, few studies have directly examined the association between depression and specific medical complaints. The purpose of the current research was to investigate the relationship between depression and complaints in specific bodily systems in a sample of psychiatric inpatients. 55 patients, with a mean age of 40.72 yr. (SD = 13.98), completed the Beck Depression Inventory and the Cornell Medical Index Health Questionnaire. Significant relationships were found between level of depression and the frequency of symptoms reported in the cardiovascular, skin, and nervous systems.