La GAC 1 : grille d’analyse du contre-transfert dans le traitement des troubles graves de la personnalité

Cet article met en relief le rôle central des réactions contre-transférentielles dans le traitement de patients limites selon l’approche focalisée sur le transfert de Otto F. Kernberg (TFP : Transference Focused Psychotherapy). Une grille d’analyse du contre-transfert (GAC) est présentée pour décrire la diversité des activités mentales dans lesquelles le thérapeute s’engage pour comprendre et parvenir à utiliser les réactions que déclenchent en lui ces patients. Un exemple clinique est présenté pour démontrer l’utilité de la GAC dans le travail des réactions contre-transférentielles évoquées par une patiente présentant un trouble limite de la personnalité. Certaines données de recherche viennent appuyer l’importance du travail des réactions contre-transférentielles.This paper introduces the central role of countertransference reactions in the treatment of borderline patients in transference focused psychotherapy developed by Otto F. Kernberg. The Countertransference Rating System is presented to illustrate the diversity of the therapist’s mental activities involved in his attempts to process and use reactions call to mind by borderline patient. A clinical example is presented as such as empirical evidence in support of the usefulness of the CRS and of the importance of processing countertransference reactions.Este artículo pone de relieve el papel central de las reacciones contratransferenciales en el tratamiento de pacientes límite, según el enfoque focalizado sobre la transferencia de Otto F. Kernberg (TFP : Transference Focused Psychotherapy). Se presenta un cuadro de análisis de la contratransferencia (GAC) para describir la diversidad de las actividades mentales con las que el terapeuta se compromete para comprender y lograr utilizar las reacciones que provocan en él estos pacientes. Se presenta un ejemplo clínico para demostrar la utilidad del GAC en el trabajo de las reacciones contratransferenciales evocadas por una paciente que presenta un trastorno de personalidad límite. Algunos datos de la investigación apoyan la importancia del trabajo de las reacciones contratransferenciales.Este artigo coloca em evidência o papel central das reações de contra-transferência no tratamento de pacientes borderline, segundo a abordagem focada na transferência de Otto F. Kernberg (TFP: Transference Focused Psychotherapy). É apresentado um sistema de análise da contra-transferência (grille d’analyse du contre-transfert - GAC) para descrever a diversidade das atividades mentais nas quais o terapeuta se introduz para compreender e chegar a utilizar as reações que estes pacientes suscitam nele. Um exemplo clínico é apresentado para demonstrar a utilidade da GAC no trabalho das reações de contra-transferência evocadas por uma paciente que apresenta um transtorno de personalidade borderline. Alguns dados de pesquisa vêm apoiar a importância do trabalho destas reações de contra-transferência

Escherichia coli contamination and health aspects of soil and tomatoes (Solanum lycopersicum L.) subsurface drip irrigated with on-site treated domestic wastewater.

Faecal contamination of soil and tomatoes irrigated by sprinkler as well as surface and subsurface drip irrigation with treated domestic wastewater were compared in 2007 and 2008 at experimental sites in Crete and Italy. Wastewater was treated by Membrane Bio Reactor (MBR) technology, gravel filtration or UV-treatment before used for irrigation. Irrigation water, soil and tomato samples were collected during two cropping seasons and enumerated for the faecal indicator bacterium Escherichia coli and helminth eggs. The study found elevated levels of E. coli in irrigation water (mean: Italy 1753 cell forming unit (cfu) per 100 ml and Crete 488 cfu per 100 ml) and low concentrations of E. coli in soil (mean: Italy 95 cfu g(-1) and Crete 33 cfu g(-1)). Only two out of 84 tomato samples in Crete contained E. coli (mean: 2700 cfu g(-1)) while tomatoes from Italy were free of E. coli. No helminth eggs were found in the irrigation water or on the tomatoes from Crete. Two tomato samples out of 36 from Italy were contaminated by helminth eggs (mean: 0.18 eggs g(-1)) and had been irrigated with treated wastewater and tap water, respectively. Pulsed Field Gel Electrophoresis DNA fingerprints of E. coli collected during 2008 showed no identical pattern between water and soil isolates which indicates contribution from other environmental sources with E. coli, e.g. wildlife. A quantitative microbial risk assessment (QMRA) model with Monte Carlo simulations adopted by the World Health Organization (WHO) found the use of tap water and treated wastewater to be associated with risks that exceed permissible limits as proposed by the WHO (1.0 × 10(-3) disease risk per person per year) for the accidental ingestion of irrigated soil by farmers (Crete: 0.67 pppy and Italy: 1.0 pppy). The QMRA found that the consumption of tomatoes in Italy was deemed to be safe while permissible limits were exceeded in Crete (1.0 pppy). Overall the quality of tomatoes was safe for human consumption since the disease risk found on Crete was based on only two contaminated tomato samples. It is a fundamental limitation of the WHO QMRA model that it is not based on actual pathogen numbers, but rather on numbers of E. coli converted to estimated pathogen numbers, since it is widely accepted that there is poor correlation between E. coli and viral and parasite pathogens. Our findings also stress the importance of the external environment, typically wildlife, as sources of faecal contamination

Use of untreated wastewater in peri-urban agriculture in Pakistan: risks and opportunities

Water reuse / Waste waters / Water quality / Groundwater / Irrigation practices / Soil properties / Environmental effects / Conjunctive use / Pakistan / Haroonabad

Moving up the sanitation ladder with the help of microfinance in urban Malawi

Abstract We carried out a stated preference survey in Malawi to examine whether access to microfinance for sanitation would significantly increase the proportion of households upgrading to improved pit latrines or alternative improved sanitation technologies (urine diverting dry toilet, fossa alterna, pour flush). We presented a range of sanitation options at local market prices, initially without and then with a real microfinance option, to 1,300 households sampled across 27 low-income urban settlements in the two largest cities, Lilongwe and Blantyre. When we gave respondents a microfinance option, the proportion of households stating an intention to install improved and unimproved pit latrines decreased significantly, while the proportion stating an intention to upgrade to alternative improved sanitation technologies increased significantly. However, households in the lowest wealth quintile were more likely to state a preference for unimproved pit latrines, suggesting that the benefits of microfinance for sanitation may not accrue equally across wealth strata. Organisations seeking to improve access to safely managed sanitation by promoting alternative sanitation technologies would succeed if households have access to affordable alternative sanitation technologies and microfinance for sanitation. However, poorer households would need more affordable improved sanitation technologies, flexible microfinance options and possibly targeted subsidies to gain access to safely managed sanitation.</jats:p

La psychothérapie focalisée sur le transfert (TFP) et le fonctionnement réflexif 1

Le fonctionnement réflexif (FR) est un concept relativement nouveau et renvoie à la capacité d’un individu d’interpréter les comportements humains et les réactions interpersonnelles en termes d’intentions sous-jacentes et d’états mentaux. Il est particulièrement important dans le processus de régulation des affects et de la gestion des relations interpersonnelles difficiles. Comparativement à la thérapie comportementale dialectique (DBT) et les thérapies de soutien, la thérapie focalisée sur le transfert (TFP) a l’unique avantage de produire des changements au niveau du FR des patients limites. Dans le présent article, nous adoptons une perspective développementale pour expliquer les changements au niveau du FR induit par la TFP. Nous proposons un certain nombre de mécanismes d’action thérapeutiques par lesquels la TFP agirait chez des patients limites et plus particulièrement dans l’interprétation du transfert..Reflective functioning is a relatively new concept which broadly speaking, refers to the capacity to interpret human behaviours and interpersonal reactions in terms of underlying intentions and mental state motivations. This capacity is particularly important in the regulation of affects and the management of challenging interpersonal relations. In comparison to dialectical behavioural therapy (DBT) and supportive therapies, transference focused psychotherapy (TFP) has been shown to have unique advantages in terms of producing improvements in RF of borderline patients. In the present article, we propose a developmental perspective for understanding how TFP produces these changes in RF. Using this perspective, we identify a number of therapeutic mechanisms through which TFP facilitate the development of RF and specifically transference interpretations.El funcionamiento reflexivo (FR) es un concepto relativamente nuevo y se refiere a la capacidad de un individuo de interpretar los comportamientos humanos y las reacciones interpersonales en términos de las intenciones subyacentes y los estados mentales. Es particularmente importante en el proceso de regulación de los afectos y la gestión de las relaciones interpersonales difíciles. Comparativamente a la terapia comportamental dialéctica (DBT) y las terapias de apoyo, la terapia centrada en la transferencia (TFP) tiene la única ventaja de producir los cambios a nivel del FR de los pacientes límite. En este artículo, adoptamos una perspectiva de desarrollo para explicar los cambios a nivel del FR inducido por la TFP. Proponemos un cierto número de mecanismos de acción terapéutica por medio de los cuales la TFP actuaría en los pacientes límite.O funcionamento reflexivo (FR) é um conceito relativamente novo e refere-se à capacidade de um indivíduo de interpretar os comportamentos humanos e as reações interpessoais em termos de intenções subjacentes e estados mentais. Ele é particularmente importante no processo de regulação dos afetos e da gestão das relações interpessoais difíceis. Em comparação à terapia comportamental dialética (DBT) e as terapias de apoio, a terapia focada na transferência (TFP) tem a única vantagem de produzir mudanças ao nível do FR dos pacientes borderline. No presente artigo, adotamos uma perspectiva do desenvolvimento para explicar as mudanças ao nível do FR induzido pela TFP. Propomos um certo número de mecanismos de ação terapêutica pelos quais a TFP agiria nos pacientes borderline

Evidence on the Effectiveness of Water, Sanitation, and Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic Review.

BACKGROUND: Water, sanitation, and hygiene (WASH) interventions are amongst the most crucial in humanitarian crises, although the impact of the different WASH interventions on health outcomes remains unclear. AIM: To examine the quantity and quality of evidence on WASH interventions on health outcomes in humanitarian crises, as well as evaluate current evidence on their effectiveness against health outcomes in these contexts. METHODS: A systematic literature review was conducted of primary and grey quantitative literature on WASH interventions measured against health outcomes in humanitarian crises occurring from 1980-2014. Populations of interest were those in resident in humanitarian settings, with a focus on acute crisis and early recovery stages of humanitarian crises in low and middle-income countries. Interventions of interest were WASH-related, while outcomes of interest were health-related. Study quality was assessed via STROBE/CONSORT criteria. Results were analyzed descriptively, and PRISMA reporting was followed. RESULTS: Of 3963 studies initially retrieved, only 6 published studies measured a statistically significant change in health outcome as a result of a WASH intervention. All 6 studies employed point-of-use (POU) water quality interventions, with 50% using safe water storage (SWS) and 35% using household water treatment (HWT). All 6 studies used self-reported diarrhea outcomes, 2 studies also reported laboratory confirmed outcomes, and 2 studies reported health treatment outcomes (e.g. clinical admissions). 1 study measured WASH intervention success in relation to both health and water quality outcomes; 1 study recorded uptake (use of soap) as well as health outcomes. 2 studies were unblinded randomized-controlled trials, while 4 were uncontrolled longitudinal studies. 2 studies were graded as providing high quality evidence; 3 studies provided moderate and 1 study low quality evidence. CONCLUSION: The current evidence base on the impact of WASH interventions on health outcomes in humanitarian crises is extremely limited, and numerous methodological limitations limit the ability to determine associative, let alone causal, relationships

Mentalization and dissociation in the context of trauma: Implications for child psychopathology

Dissociation is a common reaction subsequent to childhood sexual abuse (CSA) and has been identified as a risk factor for child psychopathology. There is also evidence that mentalization contributes to resilience in the context of abuse. However, at this stage little is known regarding the relationship between mentalization and dissociation, and their respective contributions to psychopathology. The aim of this study was to examine pathways from CSA to depressive symptoms, externalizing behaviour difficulties and sexualized behaviour, through mentalization and dissociation. These pathways were examined in a sample of 168 mother-child dyads including 74 dyads where children (aged 7–12) had histories of sexual abuse. Maternal mentalization was assessed using the Parent Development Interview-Revised and children’s mentalization was assessed using the Child Reflective Functioning Scale. Children completed the Child Depression Inventory and parents completed the Child Dissociative Checklist, the Child Behavior Checklist and the Child Sexual Behavior Inventory. Direct and indirect paths from CSA to child psychopathology via children’s mentalization and dissociation were examined using Mplus. Two distinct paths from abuse to psychopathology were identified. Child mentalization partially mediated the relationship between CSA and depressive symptoms. The effects of CSA on externalizing symptoms and sexualized behaviour difficulties were sequentially mediated through mentalisation and dissociation

The Impact of Water, Sanitation and Hygiene Interventions to Control Cholera: A Systematic Review.

BACKGROUND AND METHODS: Cholera remains a significant threat to global public health with an estimated 100,000 deaths per year. Water, sanitation and hygiene (WASH) interventions are frequently employed to control outbreaks though evidence regarding their effectiveness is often missing. This paper presents a systematic literature review investigating the function, use and impact of WASH interventions implemented to control cholera. RESULTS: The review yielded eighteen studies and of the five studies reporting on health impact, four reported outcomes associated with water treatment at the point of use, and one with the provision of improved water and sanitation infrastructure. Furthermore, whilst the reporting of function and use of interventions has become more common in recent publications, the quality of studies remains low. The majority of papers (>60%) described water quality interventions, with those at the water source focussing on ineffective chlorination of wells, and the remaining being applied at the point of use. Interventions such as filtration, solar disinfection and distribution of chlorine products were implemented but their limitations regarding the need for adherence and correct use were not fully considered. Hand washing and hygiene interventions address several transmission routes but only 22% of the studies attempted to evaluate them and mainly focussed on improving knowledge and uptake of messages but not necessarily translating this into safer practices. The use and maintenance of safe water storage containers was only evaluated once, under-estimating the considerable potential for contamination between collection and use. This problem was confirmed in another study evaluating methods of container disinfection. One study investigated uptake of household disinfection kits which were accepted by the target population. A single study in an endemic setting compared a combination of interventions to improve water and sanitation infrastructure, and the resulting reductions in cholera incidence. DISCUSSION AND RECOMMENDATIONS: This review highlights a focus on particular routes of transmission, and the limited number of interventions tested during outbreaks. There is a distinct gap in knowledge of which interventions are most appropriate for a given context and as such a clear need for more robust impact studies evaluating a wider array of WASH interventions, in order to ensure effective cholera control and the best use of limited resources

Risk Perceptions of Wastewater Use for Urban Agriculture in Accra, Ghana.

Poor food hygiene is a significant risk to public health globally, but especially in low and middle-income countries where access to sanitation, and general hygiene remain poor. Food hygiene becomes even more pertinent when untreated, or poorly treated wastewater is used in agriculture. In such circumstances the WHO recommends the adoption of a multiple-barrier approach that prescribes health protective measures at different entry points along the food chain. This study sought to assess the knowledge and awareness of wastewater use for crop production, its related health risks, and adoption of health protective measures by farmers, market salespersons and consumers using questionnaires and focus group discussions. In the period from September 2012 to August 2013, 490 respondents were interviewed during two cropping seasons. The study found that awareness of the source of irrigation water was low among consumers and street food vendors, though higher among market vendors. In contrast, health risk awareness was generally high among salespersons and consumers, but low among farmers. The study found that consumers did not prioritize health indicators when buying produce from vendors but were motivated to buy produce, or prepared food based on taste, friendship, cost, convenience and freshness of produce. Similarly, farmers' awareness of health risk did not influence their adoption of safer farm practices. The study recommends the promotion of interventions that would result in more direct benefits to both producers and vendors, together with hygiene education and enforcement of food safety byelaws in order to influence behaviour change, and increase the uptake of the multiple-barrier approach

A faecal exposure assessment of farm workers in Accra, Ghana: a cross sectional study.

BACKGROUND: Wastewater use in urban agriculture is common as a result of rapid urbanisation, and increasing competition for good quality water. In order to minimize risks to farmers and consumers of wastewater irrigated produce the World Health Organization (WHO) has developed guidelines for the safe use of wastewater in agriculture. These guidelines are based on a Quantitative Microbial Risk Assessment (QMRA) model, though the reliability of this model has been questioned due to a lack of primary data. This study aimed to assess the ability of the WHO guidelines to protect farmers' health, by identifying and quantifying key exposures associated with the transmission of faecal pathogens in wastewater irrigated agriculture. METHODS: Eighty farmers were observed and interviewed during the dry and wet seasons, and water and soil samples were analysed for the presence of E. coli. STATA 12 was used for descriptive analyses of farmers' exposure and risk practices, and also to determine risk factors for soil and irrigation water contamination, while the WHO QMRA model and @Risk 6 were used to model farmers' infection risk to pathogens. RESULTS: The results showed that although irrigation water was highly contaminated (5.6 Log E. coli/100 ml), exposure to farm soil (2.3 Log E. coli/g) was found to be the key risk pathway due to soil-to-mouth events. During the observations 93 % of farmers worked barefoot, 86 % experienced hand-to-soil contact, while 53 % experienced 'soil'-to-mouth events, while no 'water' to mouth contacts were observed. On average, farmers were found to have 10 hand-to-mouth events per day. From the indicator based QMRA model the estimated norovirus infection risk to farmers was found to be higher than guidelines set by the WHO. CONCLUSIONS: This study found exposure to soil as the critical pathway of pathogen risk in wastewater farmers, and that this risk exceeded recommended health targets. The study recommends the incorporation of hand-to-mouth events, the use of actual pathogen concentrations, and the use of direct exposure frequencies in order to improve the reliability of risk estimates from QMRA models