Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.

Women, letter-writing and the life of the mind in England, c.1650-1750

Drawing on national and regional letter collections dating from the late seventeenth and early eighteenth centuries, this article explores women's experiences of the life of the mind through an analysis of their letter-writing. This study also highlights the shortcomings of the compartmentalised nature of scholarship on women's writing and intellectual lives and proposes the letter both as a beneficial historical source and methodological tool for research on women's mental worlds. By employing an inclusive definition of intellectual and creative life, and eschewing traditional benchmarks of achievement, this article contends that women took a full part in the cultures of knowledge of their time. 

Emotions and identity in the figured world of becoming a doctor

CONTEXT: There is little room in clerkship curricula for students to express emotions, particularly those associated with the development of a caring identity. Yet it is recognised that competence, alone, does not make a good doctor. We therefore set out to explore the relationship between emotions and identity in clerkship education. Our exploration was conceptually oriented towards Figured Worlds theory, which is linked to Bakhtin's theory of dialogism.

METHODS: Nine female and one male member of a mixed student cohort kept audio-diaries and participated in both semi-structured and cognitive individual interviews. The researchers identified 43 emotionally salient utterances in the dataset and subjected them to critical discourse analysis. They applied Figured Worlds constructs to within-case and cross-case analyses, supporting one another's reflexivity and openness to different interpretations, and constantly comparing their evolving interpretation against the complete set of transcripts.

RESULTS: Students' emotions were closely related to their identity development in the world of medicine. Patients were disempowered by their illnesses. Doctors were powerful because they could treat those illnesses. Students expressed positive emotions when they were granted positions in the world of medicine and were able to identify with the figures of doctors or other health professionals. They identified with doctors who behaved in caring and professionally appropriate ways towards patients and supportively towards students. Students expressed negative emotions when they were unable to develop their identities.

CONCLUSIONS: Critical discourse analysis has uncovered a link between students' emotions and their identity development in the powerful world of becoming and being a doctor. At present, identity development, emotions and power are mostly tacit in undergraduate clinical curricula. We speculate that helping students to express emotions and exercise power in the most effective ways might help them to develop caring identities.

Loyalism, Women and Standpoint Theory

Most recent studies of Loyalism in Northern Ireland have focused on the nature and development of Loyalist paramilitaries and their methods, ideology and attitudes to the peace process. This article argues that the nature of Loyalist paramilitarism is primarily masculinist and that there is a perspective that has gone generally unheard from women in Loyalist communities. Using standpoint theory, evidence from interviews with women in Loyalist communities associated with Belfast is analysed and a picture is formed that suggests that there are gendered attitudes towards women who become involved in the conflict through paramilitary organisations and that paramilitaries are not representative of their communities. It is concluded that researchers need to bear in mind the gender dimensions of their work and be aware of who is present and who is absent when research is being carried out.

In My 'Mind's Eye': Introspectionism, Detectivism, and the Basis of Authoritative Self-Knowledge

It is widely accepted that knowledge of certain of one’s own mental states is authoritative in being epistemically more secure than knowledge of the mental states of others, and theories of self-knowledge have largely appealed to one or the other of two sources to explain this special epistemic status. The first, ‘detectivist’, position, appeals to an inner perception-like basis, whereas the second, ‘constitutivist’, one, appeals to the view that the special security awarded to certain self-knowledge is a conceptual matter. I argue that there is a fundamental class of cases of authoritative self-knowledge, ones in which subjects are consciously thinking about their current, conscious intentional states, that is best accounted for in terms of a theory that is, broadly speaking, introspectionist and detectivist. The position developed has an intuitive plausibility that has inspired many who work in the Cartesian tradition, and the potential to yield a single treatment of the basis of authoritative self-knowledge for both intentional states and sensation states.