Issaiah1332

Are you asking my experiencing in working with them? I work in psychiatry, currently supervising an adult unit and geriatric unit. We do a little of everything, including a LOT of dual diagnosis. I've also done some other work in this area, as well, helping people outside of work to get connected with care and am part of a local group to help develop community actions to mental health issues (admittedly, my school schedule hasn't allowed me to make some meetings lately), and I'm currently planning a presentation for a local school. Interestingly, it's my old high school and we've lost a LOT of people in my graduating class to this epidemic. I'm doing my MSN-PMHNP right now to increase my scope for treating these people.

I think that's very fair and correct. Untreated pain can also easily lead to addiction issues that may have actually been prevented from properly managing it in the first place. Whether that's because they get them from the street in an effort to get relief or it leads to significant issues with mood that is more likely to lead to addiction. There's probably room for a mix of subjective assessment and objective assessment. So, we can and should assess the patient's perception of pain for a lot of reasons (not the least of which is diagnostic. Pain level and quality can be valuable data in a differential). We can combine this with a functional assessment to derive a bigger picture. You're right, opioids have a place. There's definitely a middle ground, albeit hard to find sometimes. What we often don't like to admit is that we're generally pretty bad at pain treatment in terms of figuring out effective, low risk options.

It's not about saying: "I'm broken but you fix it." It's merely about taking an approach that isn't riddled with negatives preconceptions, working with the patient to identify a treatment plan that is tailored to them and the way to do this is therapeutic communication. Reducing it to an issue of willpower isn't consistent with a lot of the neuroscientific literature, but, more importantly, studies indicate that the more providers emphasize this view the more it creeps into the relationship and pushes the client away from treatment.

Thanks for articulating the same questions I had, but I didn't want to get into another big debate.

In any case, I appreciate everyone's criticisms and will go back to the drawing board to evaluate some of these views. While I still hold these values as the most effective, with regards to empathy, communication, and openness, it seems the "feminist" model is poorly received. Surely, there are many others that emphasize the same approach/values but through a lens that doesn't seem as insulting on a social level. Obviously, substance abuse is an area that touches each of us. As someone that has lost many people I was close with to the opioid epidemic (a WV resident, I live in the epicenter), I simply wish to advocate for its treatment and bring attention to other approaches to treating it. Although I truly didn't intend on laying blame, if my article is perceived this way then people will not be as receptive and that defeats the purpose. If a theory is also guilty of this, then the results will be the same. Perhaps there are better ways in which one can critique the current system or advocate for its improvement that are less likely to push others away. That said, I always maintain openness and a lot of "may/maybe/possibly/can" attitudes toward these things. So if it doesn't work, then let's go back and try again to come up with better philosophies and practice. I probably won't reply much more, because there's now multiple pages of my replies and defense-as well as this one in which I can admit there may be better ways. I was simply intending to elaborate on one, I didn't assume it would be perfect and figured there would be critiques both that I identified, predicted, and agreed with-as well as those I did not. As long as this dialogue results in a dialectic of beneficial change, then it's worth being disagreed with, wishing I'd use different adjectives or models, or even being wrong. thanks for reading, engaging, and hopefully furthering the discussion in some way.

Just because I don't agree with you, doesn't mean I'm not open to your criticism. I wrote an article in which I argue that the current system is paternalistic, emphasizing things like willpower and personally responsibility in a way that may color provider's their approach to care. I argue that this approach may erode the provider-patient relationship with negative outcomes. I then say that we may be able to avoid the above by ensuring we employ a different value system and then go on to say that those interventions that use a similar value system have positive results. I gave you data to show that providers generally have attitudes that value responsibility and those values negatively impact patient care. But, I agree, we can end this "debate" (mostly you seeking to insult me, whilst launching criticism and then wondering why I may not be receptive of such criticism...which is a contextual irony here). No, I don't intend on being a nursing professor. I intend on and am pursuing PMHNP; but maybe in the future I'll teach. I will "construe it as a compliment," because, unlike you, I can see the importance of nursing theory/philosophy in practice. I also don't need to disparage people for thinking differently or taking on an area of nursing different than my own.

"It is asinine to argue a given philosophical approach (feminism) is the cure by (comically) co-opting patient centered care as that philosophy applied when it may have also been the cause. " Eh, that's a strawman. First of all, just because an intervention may be seen as arising from a philosophy doesn't mean its perceived failure is evidence that ALL interventions must therefore fail if they derive from that philosophy. Furthermore, the failure of a singular intervention doesn't negate the entire philosophy. For instance, one's criticism of Carl Rogers' approach doesn't necessarily apply to the entirety of humanistic psychology. "I agree. However, you have just argued that your article is irrelevant" Sure, if my thesis was that the only effective approach to treating any patient must utilize a single model; however, that was not at all what I argued. Obviously, some patients prefer to be more passive in their care. In which case, they may slide slightly away from the way in which the feminist model describes in some sense. Even then however, you're preserving other values that are still in line with this view and could still take a more empathetic approach that isn't so reductionist or rigid. Nursing theories/philosophies may incorporate a lens and various values that their theorists consider beneficial, but I'm quite sure that they don't presume there can be no other approaches or individualized care. For example, I see the medical system to be very disparaging with a negative perception of addicts; but I still think that most (maybe even all) providers want what is best for their clients, ultimately greater self-concept, behaviors, and decision-making. Paternally, I think this manifests in a way that sees the person as a sum of their actions and that may lead to unfair conclusions that can ultimately erode the relationship with the patient. The feminist philosophy doesn't differ in wanting the same outcome, but takes on a more maternal role in how the provider-patient relationship is viewed and how it intends on arriving at that end. It can do this in various ways, because the values it holds as paramount can be preserved in multiple ways. Indeed, such values and approaches overlap with many different philosophies. The ability to see the patient's personhood as separable from their behaviors, building the relationship on optimism and openness without judgment can overlap greatly with humanistic psychology which overlaps with many others. "This will be the third time I level the accusation of poor definitions on your part. For someone who purports to be writing about philosophy, you should realize semantics are absolutely essential when casting dichotomous aspersions. You have now conflated determinism vs free-will with feminism vs paternalism which is neither accurate nor have you made any attempt to support such a silly notion. But do go on about those terrible paternalistic doctors who demonize the disease model... what decade is it again?" Eh...you're intentionally trying to pigeonhole anything I say. I'm not conflating free will/determinism and paternal/maternal views. I am saying that one model allows for approaching the patient with understanding and hope in a way that is consistent with the disease model. If one model emphasizes "willpower" and "strength" as the most valuable traits in recovery, then the perception is that relapses are indicative of poor willpower and weakness. What I am arguing is that the current model doesn't emphasize empathy in a way that fosters a therapeutic relationship. It's built less on the concept of understanding and adaptation and more on the provider telling the patient what to do. We also know that, in general, health professionals view addicts in a negative way (Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review - ScienceDirect) and we know that this impacts their approach to care, because it impacts the provider-patient relationship. Why do I think so? Because patients say so and there are negative outcomes associated with it (Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach. - PubMed - NCBI, an example of a small study. There are others, but they all seem to have a small sample size currently). Additionally, a study indicated that the more health workers valued personal responsibility the less they regarded the patient as an individual (Healthcare professionals' regard towards working with patients with substance use disorders: comparison of primary care, general psychiatry and spe... - PubMed - NCBI) "Your claim: 1. NPOA may be helped by Patient Centered Care (PCC) 2. PCC represents applied Feminism. 3. Therefore Feminism is useful and its antithesis is harmful." That's not my claim. My claim is (all within the context of NPOA) for why feminist approaches may be successful: 1. The feminist ethic of care outlined in the work I cited advocates for certain values 2. These values are common to and underlie certain practices in a variety of ways, such as: motivational interviewing 3. Studies show that MI is effective and that patient perception correlates with positive outcomes 4. Therefore it is worth exploring new interventions or employing more widespread use within this value system The argument as to why I feel the paternal side as ineffective is elaborated on in the previous section. "Medical researchers led the research on the neurobiological changes of addiction, not feminism theorists." Again- strawman. I never made the claim that feminist nursing theorists led the research. I am advocating that the feminist approach is more compatible with the disease model. "The American Psychiatric Association endorses the disease model. Last week I heard the Surgeon General on NPR say, "addiction is a chronic disease and if we don't treat it as such, we will be doomed to continue in this vicious cycle." (Adams MD MPH)" That's great, but not something I'm unaware of. I've cited similar claims from various medical organizations to reiterate the legitimacy of the disease model. Unfortunately, even though we've improved, this has not caught up the healthcare workers on the frontlines. They still have negative attitudes that are incongruent to this research. In one of the links above, one of the most cited critiques of addicts among healthcare workers is that they are "poorly motivated."

Hello HIS, thanks for your reply. I think you ask some fair questions and raise some good critiques, that I hope I can answer adequately for you. Well, at least I hope I can defend my position adequately. That doesn't mean I will convince you, but I honestly do appreciate criticisms. If I'm wrong, then I certainly don't want to be wrong a moment longer than I need to. Forgive me for not using the "quote" function as usefully as the others, but it isn't easy to do via iPhone. "from the titles I can't tell if there's any causative link between paternalism and opioid abuse/addiction? I see a title about feminist ethics, one about statistics, one about addiction...and the 20+ yr old one about motivational interviewing?" I elaborated on the first question a bit in a previous reply to another commenter. Evidently, I didn't choose my words wisely and gave the impression that I was blaming what I call the "paternal/masculine" approach for the cause of the epidemic. I definitely was not meaning that. My point was to say that this approach is likely maladaptive for treating substance abuse. Your second question: the reason I chose Miller's work is because I see it as foundational in MI (tricky abbreviation in healthcare, lol) and where the values of it were first really laid out. I should've also cited newer research on its efficacy, but I sort of saw it as a given (there is a lot of research out there showing MI as effective in addiction) and really wanted to draw on the parallels between Miller's practical approach and the feminist theoretical approach. Hopefully, that makes a little more sense. I think that is a very fair criticism and an error in my writing style/thought process. I've built my life around psych. and sometimes presume that my audience has to; but this is obviously not a virtue when you're making an argument. "What has been your experience with paternalism? I'm curious because paternalism has been considered outdated for quite a long time. I attended nursing school in the early 2000s, and we were HEAVILY taught about advocacy and autonomy. The ONE physician who I have heard of chiding a family for questioning the surgeons (for merely pointing out a discrepancy among the POC as told by different team members) was FIRED." When I mention "paternalism" or describe it as something that is can be perceived as "punitive," I am not necessarily meaning that as "rude." What I see as paternal in the medical model are some of the values, their effects on treatment approach, and the resulting provider-patient relationship. For example- we tend to see "choice" as one of the most important values, assign moral claims where they may not be applicable and/or beneficial, and allow this to shape interactions with patients. Keep in mind, my thoughts are specific to substance abuse populations. To be more specific, many see relapse as the patient actively deciding NOT to adhere to treatment, often perceive that patient as weak or not demonstrating a serious attempt for recovery. This impacts the relationship a provider has with this patient, where they may come across as punitive and assigning blame. The other side of this is the foundation the relationship is based on, generally, in which the provider is seen as unquestionable, all-knowing, and the domineering voice in treatment. Obviously, the provider does know more about medicine but the relationship often begins in a way that reduces the patient to a passive receiver of that care. There are even many providers that refuse to even accept or acknowledge the neurobiology of addiction, because they see it as "making excuses for and enabling" addicts rather than using these findings to gain insight into the patient's circumstances. Ultimately, the paternal model tends to view the patient as fundamentally an independent agent who is on his/her own after prescribing a treatment. Where as the "feminist approach" (admittedly, I hate this term too; but I wanted to remain consistent with the terms used by theorist) is less reductionist, seeing the patient as a cohesive unit of biopsychosocial factors. While it values health and wellbeing, it does so from a place that isn't judgmental and offputting. It values empathy, acknowledges the patient's hardship, and implores the patient's active participation not only in the prescribed care but in forging the treatment plan. The provider-patient relationship is more open, cultivating trust and allowing the patient to exercise their own honesty without fear of being judged or otherwise seen as not wanting treatment or not taking it seriously. As I said somewhere else, put another way: this is very similar to the medical vs nursing model. We don't just care FOR the patient, we care WITH the patient. Nursing isn't immune to bias or stigma, but it is holistic and can be very maternal. Here's what I am not saying: I am not saying that EVERY INDIVIDUAL operates this way or that we should blame men. These are just adjectives that are used because the exercise of care correlates with associated social norms. I am also not saying that there is no place for implementing some paternal characteristics; rather, we may and even should in certain patients who may be more responsive to this approach. "By contrast, the idea that pain is whatever the pt says it is seems like it would put pressure on the provider to do what the pt wants, even if that goes against his/her professional judgment. (Speaking of **unreasonable** demands.) Don't even get me started on HCAHPS nonsense" HAHA. Don't worry, I COMPLETELY understand what you are saying and agree. No experience in healthcare can be so easily quantified in a likert scale and just because one has subjective experiences doesn't mean this cannot be evaluated by another person in an objective way (Pain ISN'T always what the patient says or believes it is). We can listen and validate patient concerns. I think this is a good thing, because it fosters communication that may result in gaining additional data valuable for treatment. That said, we can validate but that doesn't mean we agree nor that we can be bullied into providing ANY care the patient wants. There's certainly a middle ground or more appropriate positions across this spectrum.

Once again, although the origins of the opioid epidemic may have taken place in the paternal system that I elaborate on, I do not posit that it is the causative agent BEHIND the opioid epidemic. That's simply a strawman. The entire point of the article was to advocate for an approach to the treatment of this epidemic, not to cast stones about how it occurred. If I gave an impression to the contrary, then, admittedly, that was my mistake and the consequence of a poor choice of words; but it was not my intent. As far as the "pain as the fifth vital sign, catering to patient satisfaction, etc" that has been mentioned and seems to be implied by some of your language- I agree. These are things that are absolutely problems and contributory to the genesis of the epidemic. I don't disagree. If one wants to label them as "feminist" then that's fine. I would say that no matter what theory or lens one chooses to base their practice off of or look through, every patient is an individual and their care may and should fall anywhere on this spectrum as appropriate for the best outcomes. That said, however, the patient's active participation in their care within a context that is not perceived as punitive, rigid, nor judgmental is absolutely going to be more effective. This is the basis of therapy and can be exercised with validation, while simultaneously advocating for certain values such as abstinence and wellness. This piece was something I see as a companion piece to the last article I wrote about choice, pathology, and the disease model of addiction. Which, I really wish I would've elaborated on because I think it may have illustrated my meaning a bit better. Specifically, the ways in which we value and view choice as a metric for the patient's willingness for recovery. We assign blame and moral claims, label things as "bad choices," and see addiction and relapse as the patient freely exercising the decision to use (IE: "They must NOT WANT to be clean, so what's the point" mentality). This is paternalistic, the sort of thing you see with "tough love." While those same people often demonize the disease model as "enabling" simply because the implication is that their freedom of will is not quite as "free" as people would like to believe. With regard to Miller, Yes...I see his approach as compatible with the feminist approach in a lot of ways. You ask that I backup this assertion. I'm not sure what it would even mean to do so. I reference an ethic of care, which the author terms "feminist," and elaborate on what that means. Specifically, I say that it is "in agreement with the feminist perspective." Whether you agree with philosophy in the Feminist paper or not, the paper outlines certain theoretical values. Those values ARE "in agreement" with Miller's work. This isn't an invalid or unsound argument, the premises linearly lead to the conclusion. If you wish to debate the value of those premises, then that is fine; but to claim that I did not backup my assertion is untrue. It's a categorical claim, falling out from the values of one theory and the approach of another. Does that mean Miller's work is "feminist"? Well, not necessarily; but that's mostly a semantic claim. What it does mean, however, is that the values it's based on are compatible in such a way that, given one agrees with what is labeled as a "feminist approach" (clearly, this doesn't mean everyone agrees nor must) is useful for putting the theory into practice. As far as your perception of Gilligan's work, that's fine and that is your opinion. It's a philosophical view that I believe would have positive outcomes when put into practice. Not only that, but I believe that the values this philosophy advocates have already been shown to be beneficial as various treatment modalities shown as effective frequently draws on the same premise/values. You're taking issue with an adjective, but it doesn't seem readily obvious that you're making a coherent objection to the content. As some have pointed out in criticism of my article, this isn't new. It's "patient-centered care." Which, I agree that it isn't new; but I also hold that there are still many areas that need improved. This is especially true in the case of substance abuse treatment. If you don't like the particular theory I chose to evaluate this problem through, then that is fine. Call it whatever you want, but the medical model is slow to adapt. We still stigmatize this population, many people (usually those who do not specialize in this area) refuse to accept the disease model or even acknowledge the neurobiological changes that take place in the context of addiction. So long as this stigma is present, then people will not seek care, those that do will perceive the provider-patient relationship as not therapeutic as a consequence and, thusly, outcomes will not be as positive as they otherwise could be. As far as your opinion on the scholarship of my writing, that's fine. You're free to your opinion, I will take your critiques and try to improve off of them. Of course, I generally see an opinion piece like this as a fundamentally different writing style than one may otherwise take in a scholarly journal. I was making an argument for something I believe in. You may see it as a weak one, it may need strengthened to be convincing, but it was never meant to be something that I intended to be on the caliber of being published in a scientific journal.

Empathy does not have an assigned sex, although many studies have concluded that women tend to experience empathy with more intensity. Of course we all have attributes regarded as feminine and masculine, but I wasn't describing people. I was describing a system of care. Mostly, the medical model that is still pervasive in which the patient is largely a passive receiver of care. This wasn't a personal attack on a sex, individual provider, etc. It was an observation/description of what I see as a systemic problem and a reason to advocate for a certain theory of care.

Actually, as I said above, the nursing model isn't the problem. The medical problem, the domineering force in healthcare, largely is. There is a host of research into the paternal nature of the medical model. Secondly, I'm not an undergrad student. I am, however, a graduate student. I cited a paper by Green who builds off of Gilligan, theoretically. This isn't a study nor something that is meant to be published in a nursing journal, something I haven't claimed. It's philosophic in nature. Paternal/maternal is presumed dichotomous, unless you have a word for the in-between. Can it be a spectrum? Surely, most things are. By and large, however, the medical model emphasizes a relationship between the provider and patient that puts emphasizes the patient to be a passive-receiver of care and not an equal partner in the care, treatment planning, etc.

I didn't claim it gave more validity. I was simply stating this fact, because people seemed to assume a female must've written this. Drug abuse has been rampant and in no way is correlated with the vague claim that male role models are less "strong" or that education has been "feminized" (something I'd like you expand on). Trying to find causation in the opioid epidemic isn't going to be traced to something like you're claiming nor would it be possible even if it were true. I wasn't commenting on causality. I was simply saying that the paternalistic, masculine view of Society and the healthcare system likely contributes to resistance. Like I've stressed, it's not a claim that employs blame toward me. It's a social lens to examine the dynamics in a patient-provider relationship and the way it may shape treatment. It seems my error, which I'd correct if I could, was to use the words "masculine/feminine" rather than "maternal/paternal." I thought I elaborated in that, but I can see and admit I didn't in an adequate way. Another way to put it, is to compare the nursing model and the medical model. The medical model is frequently regarded as paternal, while the nursing model is seen as maternal. The results? Nursing is the most trusted profession, nurse practitioners see higher satisfaction rates and their patients often modify maladaptive lifestyle choices.

HAHA...No idea, they put the same one on another article I wrote. I imagine stock photos for substance abuse are lacking.

Paternalism is well-documented. As to the "fall apart" bit, there isn't likely a mountain of documentation that uses "maternalism" as its label. The lack of intervention or existence of its study is precisely what I argue for. Philosophically, there are social lenses we view things through to observe and evaluate the dynamics of a system.

"Maternal/Paternal" is likely better wording.