Oncology clinicians' defenses and adherence to communication skills training with simulated patients: an exploratory study.

The aim of this exploratory study was to assess the impact of clinicians' defense mechanisms-defined as self-protective psychological mechanisms triggered by the affective load of the encounter with the patient-on adherence to a communication skills training (CST). The population consisted of oncology clinicians (N = 31) who participated in a CST. An interview with simulated cancer patients was recorded prior and 6 months after CST. Defenses were measured before and after CST and correlated with a prototype of an ideally conducted interview based on the criteria of CST-teachers. Clinicians who used more adaptive defense mechanisms showed better adherence to communication skills after CST than clinicians with less adaptive defenses (F(1, 29) = 5.26, p = 0.03, d = 0.42). Improvement in communication skills after CST seems to depend on the initial levels of defenses of the clinician prior to CST. Implications for practice and training are discussed. Communication has been recognized as a central element of cancer care [1]. Ineffective communication may contribute to patients' confusion, uncertainty, and increased difficulty in asking questions, expressing feelings, and understanding information [2, 3], and may also contribute to clinicians' lack of job satisfaction and emotional burnout [4]. Therefore, communication skills trainings (CST) for oncology clinicians have been widely developed over the last decade. These trainings should increase the skills of clinicians to respond to the patient's needs, and enhance an adequate encounter with the patient with efficient exchange of information [5]. While CSTs show a great diversity with regard to their pedagogic approaches [6, 7], the main elements of CST consist of (1) role play between participants, (2) analysis of videotaped interviews with simulated patients, and (3) interactive case discussion provided by participants. As recently stated in a consensus paper [8], CSTs need to be taught in small groups (up to 10-12 participants) and have a minimal duration of at least 3 days in order to be effective. Several systematic reviews evaluated the impact of CST on clinicians' communication skills [9-11]. Effectiveness of CST can be assessed by two main approaches: participant-based and patient-based outcomes. Measures can be self-reported, but, according to Gysels et al. [10], behavioral assessment of patient-physician interviews [12] is the most objective and reliable method for measuring change after training. Based on 22 studies on participants' outcomes, Merckaert et al. [9] reported an increase of communication skills and participants' satisfaction with training and changes in attitudes and beliefs. The evaluation of CST remains a challenging task and variables mediating skills improvement remain unidentified. We recently thus conducted a study evaluating the impact of CST on clinicians' defenses by comparing the evolution of defenses of clinicians participating in CST with defenses of a control group without training [13]. Defenses are unconscious psychological processes which protect from anxiety or distress. Therefore, they contribute to the individual's adaptation to stress [14]. Perry refers to the term "defensive functioning" to indicate the degree of adaptation linked to the use of a range of specific defenses by an individual, ranging from low defensive functioning when he or she tends to use generally less adaptive defenses (such as projection, denial, or acting out) to high defensive functioning when he or she tends to use generally more adaptive defenses (such as altruism, intellectualization, or introspection) [15, 16]. Although several authors have addressed the emotional difficulties of oncology clinicians when facing patients and their need to preserve themselves [7, 17, 18], no research has yet been conducted on the defenses of clinicians. For example, repeated use of less adaptive defenses, such as denial, may allow the clinician to avoid or reduce distress, but it also diminishes his ability to respond to the patient's emotions, to identify and to respond adequately to his needs, and to foster the therapeutic alliance. Results of the above-mentioned study [13] showed two groups of clinicians: one with a higher defensive functioning and one with a lower defensive functioning prior to CST. After the training, a difference in defensive functioning between clinicians who participated in CST and clinicians of the control group was only showed for clinicians with a higher defensive functioning. Some clinicians may therefore be more responsive to CST than others. To further address this issue, the present study aimed to evaluate the relationship between the level of adherence to an "ideally conducted interview", as defined by the teachers of the CST, and the level of the clinician' defensive functioning. We hypothesized that, after CST, clinicians with a higher defensive functioning show a greater adherence to the "ideally conducted interview" than clinicians with a lower defensive functioning.

The independent psychological effects of participation in demonstrations

Street demonstrations have received the lion's share of scholarly attention to collective action. This article starts by returning to this research in order to raise some methodological questions about how to collect data on demonstrations and on the validity of the subsequent results. Next, based on my own research on demonstrations, I suggest some questions that deserve to be analyzed. In particular, I argue that we should work more on the psychological effects of participation in demonstrations. One potential line of investigation would be to more systematically explore the socializing effects of political events. Indeed, vivid political events should be important catalysts because they can have significant effects. Events may have an impact at any age but socializing effects will differ based on one's position in the life cycle, from conversion for younger participants to substantiation for older participants. I hypothesize, in line with Mannheim's (1952) "impressionable years" model of socialization research, that people especially recall events as important if they happened in their adolescence or early adulthood.

Altruism across disciplines: one word, multiple meanings

Altruism is a deep and complex phenomenon that is analysed by scholars of various disciplines, including psychology, philosophy, biology, evolutionary anthropology and experimental economics. Much confusion arises in current literature because the term altruism covers variable concepts and processes across disciplines. Here we investigate the sense given to altruism when used in different fields and argumentative contexts. We argue that four distinct but related concepts need to be distinguished: (a) psychological altruism, the genuine motivation to improve others' interests and welfare; (b) reproductive altruism, which involves increasing others' chances of survival and reproduction at the actor's expense; (c) behavioural altruism, which involves bearing some cost in the interest of others; and (d) preference altruism, which is a preference for others' interests. We show how this conceptual clarification permits the identification of overstated claims that stem from an imprecise use of terminology. Distinguishing these four types of altruism will help to solve rhetorical conflicts that currently undermine the interdisciplinary debate about human altruism.

Identité et filiation : enfants enlevés-appropriés, adultes restitués dans le contexte de la dernière dictature militaire en Argentine (1976-1983)

Durant la dernière dictature argentine (1976-1983), !a junte militaire organisa le vol de nourrissons, enfants de leurs ennemis, pour qu'ils puissent être élevés dans des familles proches du pouvoir. L'association « Grands-Mères de la Place de Mai » comptabilisa environ 409 vols. Au moment de l'exploration du terrain de récherche, en 2004, une quarantaine avaient été retrouvés dans des familles qui ne connaissaient pas leurs origines tandis qu'une vingtaine étaient dans des familles liées à la junte ; c'est à cette dernière catégorie que s'intéresse ce travail. Durant leur enfance ou à l'âge adulte, ces enfants apprirent un jour la vérité sur leurs origines biologiques et la justice la leur restitua ; c'est pourquoi ils sont dits « restitués ». Cette contribution vise à interroger l'identité individuelle comme une dynamique intime qui s'articule à la filiation et s'insère dans une collectivité, une société. Trois hypothèses l'ont organisée : une première concerne la connaissance des origines biologiques et ses conséquences psychologiques identitaires, qui passe nécessairement par la justice et la société. Une deuxième hypothèse explore les éventelles conséquences traumatiques de l'enlèvement des personnes restituées et de la restitution. Enfin, la troisième hypothèse interroge le rapport de la construction identitaire à la société, qu'elle se fasse par des investissements politiques et associatifs ou par les médias et l'Histoire. Ces hypothèses nourrissent un questionnement sur les liens entre restitution et travail de symbolisation des origines. Sept entretiens semi structurés avec des personnes restituées ont. été menés puis qualitativement analysés dans une perspective que l'on peut référer, de manière large, à une « anthropologique clinique », au croisement d'une psychologie clinique éclairée par la psychanalyse et de l'anthropologie. Au travers d'une analyse approfondie de leur parcours identitaire des personnes enlevées, adoptées et restituées, ce travail se livre à une recherche empirique sur la construction identitaire. Le concept de transmission se trouve mobilisé, qui concerne l'inscription de l'individu dans la subjectivité d'un couple avec le prénom, dans une lignée ou dans un collectif avec le choix professionnel ou les liens avec l'association « Grands-Mères de la Place Mai ». De plus, la thèse apporte une contribution à la compréhension des enjeux du clivage, des blessures primitive et narcissique, des processus d'affiliation et des secrets de famille et propose également de penser, en prolongement, les enjeux de la « défiliation » et de I'« amalgame ». La question du traumatisme, de sa répétition et de son élaboration, ainsi que celle des facteurs de resilience sont également discutées. Ce travail ouvre sur une réflexion plus large du concept d'identité. - During the last dictatorship in Argentina (1976-1983), the military junta organized the kidnapping of infants - children of its enemies - in order to raise them in families close to the authorities. The association "Mothers of the Plaza de Mayo" estimates that approximately 400 children have been kidnapped in this way. During their childhood, or as adults, they have come to learn the truth about their biological origins, restituted to them by justice: They are therefore known as "restituted" children. At the time of the field research in 2004, around 40 children had been found in families unaware of their origins. About 20 other came from families close to the junta. The present work is particularly interested in the latter category. This contribution investigates the individual identity as an intimate dynamics by examining its articulation with filiation and its insertion within a community, a society. It revolves around three hypotheses: the first concerns the knowledge - necessarily transmitted through justice and society - of biological origins and its psychological consequences on the identity. The second explores the eventually traumatic, consequences of kidnapping and restitution among the restituted persons. Finally, the third hypothesis questions the relation between identity construction and society, whether it is made through political and associative involvements, media or History. These hypotheses lead to the examination of affiliations between restitution and symbolization process of the origins. Seven semi-structured interviews with restituted persons have been conducted and qualitatively analyzed in a perspective that can, in a large sense, be referred to as "clinical anthropology": an approach/intersection between clinical psychology, psychoanalysis and anthropology. Through an in-depth analysis of the identity itinerary of the kidnapped, adopted and restituted persons, this work is conducted as an empirical research on identity construction. For that purpose, it uses the concept of transmission to describe an individual's affiliation with the subjectivity of a couple through the first name, with a lineage or a community through professional choices or through his/her connections with the association "Mothers of the Plaza de Mayo". Further, it makes a meaningful contribution to the understanding and implications of the notions of cleavage, of primal and narcissistic wounds, of processes of affiliation and of family secrets. In addition, it also proposes a reflection on and the implication of the notions of "deviation" and "amalgam". The question of trauma, its repetition and elaboration, and of resilience factors are aiso being discussed. This work concludes with results in a iarger consideration of the concept of identity.