The role of region in the post White-Paper NHS.

RHAs, the eternal favourite for abolition, have suffered only some thinning out of their activities and powers in "Working for Patients". Or is this a misleading image? Warren Kinston sees the white paper ushering in an era of stronger and more controlling RHAs and argues for some long overdue management changes.

Interaction in families with obese children.

In a controlled study using recently developed and validated methods for eliciting and describing family interactions, a characteristic dysfunctional pattern of interaction was found in families with an obese child. The pattern differed from patterns predicted by previous workers on the basis of indirect evidence or non-systematic study. The pattern was present in all the families studied, but was more marked in the sub-group recruited from a local school, than from subgroups recruited through medical sources. This sub-group had a more positive attitude to obesity and a slightly lower degree of obesity. No common or characteristic interactional pattern was found in the controls. The results were not explainable in terms of demographic criteria, family structure or composition variables, or family emotional health. The findings are discussed in relation to a model of obesity as a family syndrome and a manifestation of psychosocial identity.

Emotional health of families and their members where a child is obese.

A controlled study of families with an obese child showed a small but significantly greater impairment in family functioning when this was elicited and rated using clinical methods. However no significant impairment was found when functioning was elicited with standardized objective methods. Mothers of obese children rated their families as more dysfunctional than mothers of control children. Although the emotional health of individual members in obese families was not worse than in control families, significant differences in the family patterning of emotional health were found. The more overweight the obese child, the healthier the mother rated the family, and the better her own mental health as assessed by a self-report method; and in families of obese girls, the greater the degree of overweight, the worse the rated family functioning. The findings are integrated with the literature and a theoretical explanation in which obesity is seen as an identity disturbance is offered.

Primal repression: clinical and theoretical aspects.

Primal repression, long an obscure and unusable concept, has been given a precise place in a recent re-working of the theory of repression (Cohen & Kinston, 1984); and this paper specifically examines its properties and presentation. Primal repression refers to an absence of psychic structure which can be made good in the process of emotional growth. It is a part of the mind where trauma persists; and it has a close connexion to the unrepressed unconscious. Direct emergence of primal repression is a threat to life and its activation is therefore risky. During psychoanalysis, primal repression is normally avoided by object-narcissism buttressed by neurotic defences, but it may be reached and worked with in the presence of a non-internalizable valuing and nurturing relationship which we label 'primary relatedness'. This relation is therefore the interactional context for emotional growth. Numerous clinical examples are provided to demonstrate characteristic features of this region of the mind as seen in psychoanalyses. Vignettes illustrate the experiences of patient and analyst as primary relatedness is established; the consequent re-emergence of traumatic states and unmet needs, often initially in the form of severe physical and psychological deterioration; primitive forms of symbolization in the course of repairing primal repression; and the role of action in emotional growth.

Repression theory: a new look at the cornerstone.

The purpose of this paper is to revise the theory of repression so as to resolve long-standing theoretical inconsistencies, to increase congruence with data and concepts generated by new clinical problems; and to contribute to analysts' understanding of patients. Our approach is based on Freud's conception of psychic structure as based on representations, which stem from needs mediated through satisfying experiences. We have also adhered to Freud's persistently held ideas of primal repression as a state with its roots in trauma, and of repression proper as a defensive process evolving out of primal repression. The most significant clinical findings are the possibility of primal repression at any stage of life, not just in childhood; and the possibility of healthy development without repression. The revised theory leads to a new general classification of analysands and clarifies the need for both components of the psychoanalytic method, resolving intrapsychic conflicts and facilitating emotional maturation. The most significant theoretical outcome is a reaffirmation of repression as the basis for any general theory of psychopathology.

Breathlessness and psychiatric morbidity in chronic bronchitis and emphysema: a study of psychotherapeutic management.

This paper describes a study of the outcome of psychotherapy with patients disabled by chronic obstructive airways disease giving rise to dyspnoea. Forty-three men and 22 women with severe COAD were randomly allocated for 8 weeks to one of three types of psychotherapy or to an untreated control group, and were followed up six months later. The group treated by a medical nurse without training in psychotherapy experienced sustained relief of dyspnoea but tended to undergo less psychodynamic change; psychiatric symptoms were reduced in those receiving supportive, but not analytical, psychotherapy. The psychosomatic mechanisms involved and the implications for medical and nursing practice and for liaison psychotherapy are discussed.

Hospital organisation and structure and its effect on inter-professional behaviour and the delivery of care.

Some form of organisation within and between hospitals is necessary to provide effective and integrated care to patients, to ensure that medical, nursing and paramedical services develop efficiently and coherently, and to ensure that needs of the community are met. However research into the design of structures for the provision of hospital services has been remarkably limited considering the transformation of hospital work in recent decades. The absence of clearly articulated models of organisation and lack of consensus on the relevant data make needed comparative studies difficult to mount. Nevertheless systematic empirical and evaluative studies of matters like appropriate limits to authority, working of intraprofessional hierarchies, management of clinical autonomy, and the effects of interprofessional rivalry on patient-care seem both feasible and desirable. Many studies bearing directly on these topics take the form of inquiries mounted within government departments or by professional groups with an interest in the outcome.

Pluralism in the organisation of health services research.

The variety of methods used in health services research (HSR) embody categorically different epistemological assumptions. These are examined in an effort to contribute to a usable framework for the evaluation of HSR projects, and in the light of a need in the U.K. for adequate institutional arrangements for the promotion and funding of HSR. Research into organisation has revealed that if desired values are not explicitly built into the structure, other values may appear unbidden. The adequate institutional base is one which embodies, espouses and funds a meaningful and practical scientific pluralism. A possible classification is outlined and illustrated and its implications for competition amongst scientists and the social responsibility of scientists are briefly discussed.

A theoretical context for shame.

The psychoanalytic literature on shame is critically reviewed. A vagueness and incompleteness in formulations is noted which appears to be related to an adherence to the structural and topographical models. Shame is shown to have a clearly defined place in object-relations theory, in particular within the theory of narcissism as developed elsewhere by the author. It is the signal, affective and cognitive, that a move from 'self-narcissism' to 'object-narcissism' is about to occur. The phenomenology of the shame experience as emphasized by other workers is collated and shown to be capable of coherent and consistent integration within this model. Aspects of shame which have been previously neglected are discussed including the unconscious sense of shame and specific mechanisms for dealing with shame.

Resource consumption and future organisation of medical work in the National Health Service.

Medical expenditure within the National Health Service (NHS) is based upon an arrangement whereby doctors share in common resources provided by the Health Authority. This arrangement is unsatisfactory when resources are contracting and leads to social regulation of medical activity. If doctors within the district work-group do not response to the challenge of cost-containment by internal organisation, more and more externally imposed regulations will result to the detriment of patients and doctors. The continual redevelopment of organisation to permit the optimal mix of internal and external regulation should be a subject of long-term enquiry and action for doctors in each district.

A Theoretical and technical approach to narcissistic disturbance.

This paper makes a limited contribution to the theoretical problem of narcissism and offers a possibly useful technical approach. Terminology is clarified and two concepts are introduced: self-narcissism and object-narcissism. Detailed clinical material illustrates the presence of an unwished-for self-image acting as a resistance. Interpretation leading to integration of the self-image into the self-representation results in an increase in authenticity on which conventional interpretative activity depends. Objections and alternative views of the material are breifly discussed.