The child's conception of psychiatric cure

Twenty-two sequentially hospitalized children on a preadolescent psychiatric unit were videotaped with a semi-structured Piagetian-type interview that focused on assessing their understanding of why they were in the hospital, how they conceptualized their problems and how they thought they would get better or cured. We found six categories of “cure”: 1) there was no cure for their problems; 2) cure meant reversal of some behaviors; 3) cure involved some internal change; 4) cure was equivalent to being discharged; 5) cure meant changingother people; and 6) idiosyncratic answers. Our findings suggest that it is useful to clarify a child's understanding of treatment and cure in order to target more understandable and effective treatment.     

Commentary: toward resolving some dilemmas concerning psychiatric advance directives

Dilemmas about when psychiatric advance directives (PADs) should be overridden are complicated by conflicting legal frameworks that may nonetheless operate concurrently-a legal scheme based on decision-making capacity (or competency) set against a legal scheme based on civil commitment, in which the latter may "trump" the former. A single statute in which the strengths of both schemes are "fused" may be possible. There is evidence that the promise of PADs in enhancing patients' control over their treatment can be achieved without legislation for PADs and where civil commitment is given legal precedence. An example is the "joint crisis plan" in which, through a negotiation facilitated by an independent third party, a joint agreement is reached between patient and service provider about what treatment should be given when, as a result of a relapse of mental illness, the patient loses the ability to make treatment decisions. This clinical instrument may significantly reduce later involuntary treatment.     

Working in psychiatric research: answers tomorrow, dilemmas today.

Implementing research protocols with critically ill psychiatric patients sometimes creates professional dilemmas. It almost always intensifies countertransference issues. Working through the process assisted staff at this hospital to reaffirm their commitment to clinical research.     

The dentists' relationships and the therapists' dilemmas

In order to highlight similarities and differences in the responses and ethical decisions of therapists from different professional trainings and differing cultural backgrounds, three experienced practitioners were each invited to write a commentary on their ethical stance in response to a clinical situation provided by the Editors in the Case Notes which are presented below.     

Diagnostic delays and dilemmas. Management of affected patients in the psychiatric inpatient unit of a general children's hospital

We present the role of the medical-psychiatric unit in the management of children and adolescents with somatic symptoms in whom diagnosis remains uncertain or delayed, which can lead to severe impairment in the child's normal development and functioning and cause anger and hostility in the families. We describe two patients, one with cyclic vomiting syndrome, considered a medical disorder, and the other with conversion disorder, considered a psychiatric disorder. Both patients had had multiple ER admissions and outpatient visits with elaborate and expensive diagnostic workups. On admission to our unit, a coherent and integrated treatment plan was finally formulated and successfully implemented. We discuss the advantage of the medical-psychiatric unit for simultaneous medical and psychosocial intervention early in the development of symptoms and signs. The units need to be ready and able to cope with a wide range of medical and psychiatric disorders with different levels of gravity.