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  • Communications in Psychiatric Practice: Decision Making and the Use of the Telephone
    subjective impressionistic information is not included in the telephone consultation between Drs Newell and Gottlieb Of course similar sensory data are missing from Dr Gottlieb s experience of Dr Newell In the course of face to face supervisory meetings supervisees commonly transmit a wealth of data of direct clinical relevance to the patient by their manner in the room Can subjective information be conveyed as clearly over the telephone as it is experienced in the room with the patient or with the supervisee Perhaps it can but only if the two parties to the discussion adjust their habits of reporting listening and responding Both must learn to compensate for the loss of these stimuli by increasing their sensitivity to minor auditory cues much as the blind man does when he learns to see with his ears 7 They must be alert to silences pauses rhythms and intonations the verbal and nonverbal representations of visual cues In the psychiatric setting critical information is conveyed not only by what is said and not said but also by the nuances the feel of the spoken or unspoken message One must find new ways to communicate such impressions visual and otherwise when using the telephone for consultation The heuristics of decision making change as the selective perceptions of observer and consultant are further filtered by the telephone making them more vulnerable to the biases of recency availability and locus of control see the discussion in Chapter 3 By consulting at a technological distance Dr Gottlieb assumes the risks inherent in evaluating not only an unseen patient but an unwitnessed transaction between the patient and the therapist The patient seen by Dr Newell is not exactly the same as the patient imagined by Dr Gottlieb no matter how conscientious the resident is in presenting the case over the telephone Moreover since the consultation involves two calls two versions of the patient are described and imagined respectively In the interval between those two calls the image of the patient may become blurred in the supervisor s mind so that the second call conjures up a second image which may replace rather than augment the first Of course these problems are inherent in face to face consultations as well but the telephone adds another complex dimension In the fourth telephone call described in the case Dr Newell attempts to draw Mr Adams into the orbit of his wife s crisis however this communication has the opposite effect inviting the husband s rejection of his wife Like Drs Olsen and Gottlieb Mr Adams is physically removed from the scene of his wife s distress and the telephone helps him maintain an emotional distance as well His detachment from the experience may even play a role in the guilt and projective blaming that ultimately result in a lawsuit Some authors have found the telephone to be very helpful in the emergency setting especially when the patient is able by making a telephone call to contact someone important to the immediate crisis 6 10 Even they however caution that the telephone reinforces dyadic forms of communication In the Adams case for example interventions and interpretations occur in the context of a series of two person telephone calls Ms Adams Dr Olsen Dr Olsen Dr Newell Dr Newell Dr Gottlieb Dr Newell Mr Adams and so forth Such paired interactions make it difficult for the therapist to assess the roles and relative significance of various individuals within a complex interactional system As a result of the call to Mr Adams the patient appears crestfallen more tearful and perceptibly angry This description provides information that is vital to the ongoing evaluation The patient s response conveyed in visual and behavioral changes could of course be consistent with a failed manipulation Yet whatever those changes might signify they are lost to Dr Gottlieb and Mr Adams since neither is on the scene Technological mediation tends to minimize the perceived risks in any evaluation and decision making process 1 The telephone much like a mechanical translator may have filtered out important subjective and affective information about Ms Adams even while conveying objective data relatively intact 11 In fact the muted affect that is common in depression has been shown to be the most difficult to evaluate effectively over the telephone and anxiety the easiest 6 In addition a spontaneous neutralization of affect is an effect of reporting from the patient to the therapist to the supervisor Thus a supervisor s evaluation of the patient s affect is likely to be a diluted version of what was actually expressed in the interview 12 Hence the consultant must be particularly alert to the possibility that a sense of clinical urgency has been lost over the telephone line Dr Gottlieb concludes that the case presented by the resident is clear and free of ambiguity Has she reminded herself that even a good observer and a candid reporter her expressed view of the resident is subject to his own conscious and unconscious mediation which is further complicated by the filtering effect of the telephone The selectivity of the resident s presentation is not necessarily negative and in fact is an important element in the process of supervision 13 The model of supervision which uses reports given by the interviewer assumes that while therapists exhibit varied reactions to the material of the interview observation by the supervisor of both the interviewer s reporting style and manner and the patient s material will yield the essence of the patient s difficulties 12 However the subjective cues by which the supervisor indirectly observes the patient within and through the supervisee are difficult to elicit over the telephone The loss of the ordinary counterplay of messages in which a person reinforces what he is saying verbally through his body language or perhaps contradicts his verbal statement thus giving a mixed message increases the risk that faulty heuristics will guide the decision making process 6 Subjective data simply do not stand up well

    Original URL path: http://hauser.us/personal/publications/communication.html (2016-04-30)
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  • Paternalism in Mental Health Facilities
    help clinicians resist paternalistic responses 15 Thus rather than responding to the risks inherent in decision making with paternalism clinicians should pursue treatment precisely in order to encourage consumer independence An alternative to the paternalistic response is to treat factors underlying the variable nature of impaired autonomy to improve the patient s capacity to participate in the informed consent process 16 Unfortunately the very incorporation of respect for autonomy into enlightened clinical practice has led some clinicians to resent consumer advocacy as superfluous and mean spirited These clinicians consider patients mental illnesses as the greatest constraints on their autonomy and view human rights systems as intruding into the clinician patient relationship 17 Actually the role of the consumer advocate is essential and better outcomes are achieved when there is a healthy tension between psychiatrists and advocates Without consumer advocates history has shown that too many clinicians would routinely use beneficent purposes to rationalize intrusions on people s rights Typical Scenarios Some restrictions of rights immediately would be recognized as abusive by lay people and professionals alike For example consumers report that some hospitals routinely withhold all contact with the outside world for the first few days after admission and then restore contact as part of a graduated behavioral program In other words a legal right is being used as a discretionary reward and the consumer essentially is held incognito This is an outright abuse of human rights However many conflicts over telephone access mail and visits typically involve well intentioned attempts to reconcile competing principles or interests These clinical ethical dilemmas often elude categorization and do not lend themselves to a clearcut breakdown of the two opposing positions The dynamics of these situations are complex and call for creative synthesis on a case by case basis Telephone Access Whereas hospitalized medical patients usually have telephones in their rooms those in psychiatric facilities must share a few public telephones perhaps just one on the ward Telephones are placed in public areas because it is assumed that persons diagnosed as mentally ill may require arm s length monitoring in their use of the telephone 18 Defining the telephone as a scarce public resource can create various kinds of conflict An individual may make frequent or lengthy calls in violation of house rules thus provoking other consumers Or a person may be loud and abusive on the telephone leading hospital staff to ask that person to lower her voice or get off the telephone These are issues of ward management rather than clinical questions Maintaining a sense of quiet comfort safety and equity in the community is a legitimate institutional function It is not however strictly related to the individual patient consumer s best interest except indirectly insofar as the collective atmosphere affects the individual Mental health facilities generally assert a duty to prevent residents from harming others Advocates counter that clinicians do not have a duty to protect third parties from emotional harm and that they have a duty to address behavioral issues raised by the exercise of rights through therapy rather than through control mechanisms Mail The same questions of abuse and harassment arise with written as with spoken communications Clinicians may also be concerned that consumers will harm themselves or others by applying for obviously unsuitable jobs or making other unrealistic commitments Consumer advocates counter that such behavior is similar to that in which persons in the community frequently engage and should not serve as a basis for denying civil liberties Clinicians also may be concerned when mail from a particular person regularly precipitates regression Again consumer advocates counter that receipt of such mail is common in the community and must be dealt with through therapy rather than restrictions CASE 1 Phyllis R sent her sister daily letters stained with her own blood hostile vitriolic letters threatening revenge for the childhood sexual abuse she had suffered When her sister asked the psychiatrist to stop the flow of letters he explained that he had no real power and little clinical justification to do so Instead he suggested that her sister bring the letters unopened to the hospital where he would show Ms R in therapy sessions that they were unopened Here the psychiatrist faced with a demand from a family member that he exert omnipotent control maintained the clinical stance of fostering autonomy by trying to ally with the healthy side of the person whom he was treating 19 CASE 2 While actively psychotic Muriel B would go through the newspaper and cut out mail order forms which she sent either in her own name or someone else s name The treatment team prohibited Ms B from sending any more mail orders Her advocate opposed this arguing that the hospital had no duty to protect direct mail marketers from minor costs and inconveniences After her psychosis cleared Ms B agreed that the intervention was justified Some clinicians would say that the episode vindicates an interventionist approach as with the Thank you theory of involuntary commitment 20 From a civil rights viewpoint however the outcome was troubling If the behavior had been a product of Ms B s personality rather than her psychosis she might have resumed the mailings as soon as she was no longer being monitored If legal rights were fully respected and clinical resources and patience were unlimited the clinicians would have explored the issue with Ms B in an attempt to dissuade her from mailing the orders but would not have restrained her from doing so After all persons in the community make unwise mail order purchases and default on payment Visits Occasionally the people with whom a consumer wishes to maintain contact perhaps the only people available for such contact are those with whom in the view of clinicians the consumer has been enmeshed in destructive relationships When clinicians observe that every time a particular visitor comes the consumer is agitated or depressed for the next few days they may understandably want to curtail that person s

    Original URL path: http://hauser.us/personal/publications/paternalism.html (2016-04-30)
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