Psychiatric Encounters Research Articles

Indigenous Suicide: A Global Perspective with a New Zealand Focus.

This perspective article describes the problem of Canadian indigenous suicide from a non-Canadian viewpoint. In particular, the article compares both similarities and differences in suicide prevention between Māori in New Zealand and indigenous peoples in Canada. It emphasises that the problem of indigenous suicide is not being indigenous but coping with losses secondary to colonisation. A useful way to translate this into helpful clinical conversations and actions is to think about loss of belonging. Culture and belonging are key components of identity and as such should be considered in all psychiatric encounters, not just in those who are considered minorities or "other." The article concludes by suggesting how some of the experiences of addressing health inequalities and suicide in Māori may be applied in Canada.

'There's the record, closed and final': Rough for Theatre II as Psychiatric Encounter.

A co-authored collaboration between a theatre practitioner and a clinical psychiatrist, this paper will examine Rough for Theatre II (RFTII) and Beckett’s demonstration of the way records are used to understand the human subject. Using Beckett’s play to explore interdisciplinary issues of embodiment and diagnosis, the authors will present a dialogue that makes use of the ‘best sources’ in precisely the same manner as the play’s protagonists. One of those sources will be Beckett himself, as Heron will locate the play in its theatrical context through reflections upon his own practice (with Fail Better Productions, UK) as well as recent studies such as Beckett, Technology and the Body (Maude 2009) and Performing Embodiment in Samuel Beckett’s Drama (McMullan 2010); another source will be the philosopher Wilhelm Windleband, whose 1901 History of Philosophy was read and noted upon by Beckett in the 1930s, as Broome will introduce a philosophical and psychiatric context to the exchange. Windelband is now a neglected figure in philosophy; but as one of the key figures of Neo-Kantianism in the late 19th century, his work was an important impetus to that of Rickert, Weber and Heidegger. Specifically, Windelband gives us the distinction between idiographic and nomothetic understanding of individuals, an approach that is of relevance to the psychiatric encounter. This academic dialogue will consider tensions between subjectivity and objectivity in clinical and performance practice, while examining Beckett’s analysis of the use of case notes and relating them back to Windelband’s ideas on the understanding of others. The dialogue took place in 2011 at the University of Warwick, and has since been edited by the authors.

Telepsychiatry: Who, What, Where, and How

Back to table of contents Previous article Next article Legal NewsFull AccessTelepsychiatry: Who, What, Where, and HowKristen Lambert,J.D., M.S.W., L.I.C.S.W., , Moira Wertheimer,J.D., R.N.Kristen Lambert,Search for more papers by this authorJ.D., M.S.W., L.I.C.S.W., , Moira Wertheimer,Search for more papers by this authorJ.D., R.N.Published Online:1 Feb 2016https://doi.org/10.1176/appi.pn.2016.2a13AbstractTelepsychiatry is an effective tool for treating psychiatric patients if state law, certain requirements, and good patient care practices are followed.Telepsychiatry is the application of telemedicine to psychiatry and is one of the most widely used telemedicine applications. Telepsychiatry uses electronic communication and various technologies to provide psychiatric care between a psychiatrist in one location and a patient in another location. A key driver behind the growth of telepsychiatry is the national shortage of psychiatrists, particularly in specialty areas and in rural and underserviced geographical areas. This article focuses on risk management issues that may arise in telepsychiatry sessions occurring between a psychiatrist and a patient. Keep in mind, however, that telepsychiatry sessions may also occur between these individuals:Physicians in consultationA physician and another health care provider (for example, a case manager, clinical nurse practitioner, or physician assistant)A physician and nonphysician mental health providers (for example, social workers, therapists, or psychologists)Here are some risk management considerations:Standard of Care: Using telepsychiatry does not change the standard of care—it is the same standard as when a patient is physically present in your office. There is little legal precedent on telepsychiatry. To date, the state boards of medical examiners have indicated that the standard of care rests at the patient site (local standard of care).Licensure: Most states require that the telepsychiatrist be licensed in both the jurisdiction where the patient is located at the time care is provided and in the telepsychiatrist’s own state (if different from the patient’s). All psychiatrists practicing telepsychiatry should familiarize themselves with state laws in both jurisdictions pertaining to providing care as laws often vary on issues such as prescribing, reporting child endangerment, participation in the civil commitment process, and supervision/collaboration with other providers.Privacy: Regulations under the Health Insurance Portability and Accountability Act (HIPAA) must be observed, as well as additional state regulations protecting patient privacy. Ensure the telemedicine system that you are using is HIPAA compliant. Many of the popular, free videoconferencing platforms are not HIPAA compliant (for example, Skype and Facetime). Additionally, under HIPAA, “Business Associate Agreements” may need to be in place when using third-party applications and services.Security: Protocols concerning network and software security to protect privacy and confidentiality and user accessibility and authentication should be in place. Measures to safeguard data against intentional and unintentional disclosure should be implemented for both storage and transmission of data.Safety: It is important to consider whether a patient is an appropriate candidate for telepsychiatry. Ensure that there are emergency plans in place should the patient need assistance.Obtain Informed Consent: Informed consent should be discussed and documented. Inform the patient of potential risks and benefits and give him or her the option of not participating in telepsychiatry. In the event that the patient elects not to participate in telepsychiatry, it is important that he is aware that care will not be withheld.Documentation: Be sure to thoroughly document the telepsychiatry session. Further, the medical records should be maintained in a similar manner to that of traditional psychiatric encounters. However, some additional aspects of the telepsychiatry session should be documented including the following:Location of psychiatrist and patientWho was present during the session and their roles Type of equipment used, including any malfunctions that may have occurredPoor transmission quality, if applicableWhen practicing telepsychiatry, keep in mind that laws vary among states, and be aware of your jurisdiction’s laws as well as the principles of medical ethics. If you have any questions, please consult with an attorney or risk management professional.For more information on this topic, please see the online risk management course “Risk Management: Overcoming Barriers to Implementation in Telepsychiatry” on APA’s Learning Center Risk Management page. ■This information is provided as a risk management resource and should not be construed as legal, technical, or clinical advice. This information may refer to specific local regulatory or legal issues that may not be relevant to you. Consult your professional advisors or legal counsel for guidance on issues specific to you. This material may not be reproduced or distributed without the express, written permission of Allied World Assurance Company Holdings, AG (“Allied World”). Risk management services are provided by or arranged through AWAC Services Company, a member company of Allied World.Kristen Lambert, J.D., M.S.W., L.I.C.S.W., is vice president of the Psychiatric and Professional Liability Risk Management Group, and Moira Wertheimer, J.D., R.N., is assistant vice president of the Psychiatric Risk Management Group at AWAC Services Company, a member company of Allied World. ISSUES NewArchived

Healer, Witness, or Double Agent? Reexamining the Ethics of Forensic Psychiatry

In recent years, psychiatrists have become ever more prevalent in American courtrooms. Consequently, the issue of when the usual rules of medical ethics should apply to forensic psychiatric encounters has taken on increased importance and is a continuing topic of discussion among both legal and medical scholars. A number of approaches to the problem of forensic psychiatric ethics have been proposed, but none adequately addresses the issues that arise when a forensic encounter develops therapeutic characteristics. This article looks to the rules governing the lawyer-client relationship as a model for a new approach to forensic psychiatric ethics. This new model focuses on the expectations of the evaluee and the ways in which the evaluating psychiatrist shapes those expectations to determine how and when the rules of medical ethics should apply to forensic psychiatric encounters. This article describes and analyzes three previously proposed approaches to that question and the closely related question of when and how a doctor-patient relationship can form in the context of a forensic psychiatric evaluation. It also explains why each of these prior approaches does not sufficiently address the issues that arise when a forensic encounter takes on therapeutic characteristics. Finally, it proposes a new approach that draws inspiration from the rules governing the lawyer-client relationship.

Communication Commentary: Time in a Bottle: The Psychopharmacologist-Patient Relationship in “Split-Treatment” Models of Care

The doctor-patient relationship has been and remains the keystone of all medical care. It is the medium by which symptom data are gathered, diagnosesmade, thepatient is engaged in the enterprise of formulating a treatment plan, the issues of motivation and adherence are addressed, and nonjudgmental support is provided to enhance the work of healing (1). Medical communications researchers Roter and Hall (2) remarked that “talk is the main ingredient in medical care and it is the fundamental instrument by which therapeutic goals are achieved” (p. 8). They noted that we in the psychiatry field are “participating in a dramatic transformation of the identity of our profession. Clinical practice is moving toward psychopharmacological evaluation and treatment monitoring as the principal role for psychiatrists in direct service provision” (p. 13). Psychiatrists often work in teams with nonphysician therapists, casemanagers, andother specialists. This model can be very effective for individualizing care such that patients may receive appropriate multidisciplinary treatment from professionals with high levels of expertise in their areas of specialization. Access to psychiatric care is often limited. A collaborative care team or “split-treatment” model in which nonphysicians provide psychotherapy and/or other psychosocial interventions and physicians provide psychiatric assessment and psychopharmacological care allows greater psychiatric access for patients in need. In fact, Interian and colleagues

Impact of Patient Language Proficiency and Interpreter Service Use on the Quality of Psychiatric Care: A Systematic Review

This literature review examined the effects of patients' limited English proficiency and use of professional and ad hoc interpreters on the quality of psychiatric care. PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were systematically searched for English-language publications from inception of each database to April 2009. Reference lists were reviewed, and expert sources were consulted. Among the 321 articles identified, 26 met inclusion criteria: peer-reviewed articles reporting primary data on clinical care for psychiatric disorders among patients with limited proficiency in English or in the provider's language. Evaluation in a patient's nonprimary language can lead to incomplete or distorted mental status assessment. Although both untrained and trained interpreters may make errors, untrained interpreters' errors may have greater clinical impact, compromising diagnostic accuracy and clinicians' detection of disordered thought or delusional content. Use of professional interpreters may improve disclosure in patient-provider communications, referral to specialty care, and patient satisfaction. Little systematic research has addressed the impact of language proficiency or interpreter use on the quality of psychiatric care in contemporary U.S. settings. Findings are insufficient to inform evidence-based guidelines for improving quality of care among patients with limited English proficiency. Clinicians should be aware of the ways in which quality of care can be compromised when they evaluate patients in a nonprimary language or use an interpreter. Given U.S. demographic trends, future research should help guide practice and policy by addressing deficits in the evidence base.

THE AXIOLOGICAL DIMENSION IN PSYCHIATRIC DIAGNOSIS

This paper addresses the need to consider the valoric constitution of patients and therapists in the context of psychiatric encounters and proposes the notion of axiogram, a depiction of values and moral beliefs to incorporate into the clinical history as a proxy to a nosological dimension complementing the traditional multiaxial approach.

Teaching critical thinking in psychiatric training: a role for the social sciences.

In 1969, a psychiatric resident admitted a young woman who confessed to her doctor that, “twenty-percent of the time I see reality, and the rest of the time I am in my dream world.” Six months later, near the end of her treatment with antipsychotic medications and psychotherapy, her resident summarized how he understood her illness: There is no question that the psychosis continues…Yet, within the overall personality there is… an ego-adaptive, coping, observing, trying to judge—albeit from a weak, uncertain and tenuous position…[often] overwhelmed in the face of inner chaos and psychosis. But there are islands of strength within the psychotic seas, and when the seas diminish, seemingly of their own accord, one can see these islands more clearly than ever before…One can only wonder if all these islands are not somehow connected beneath the sea, and if so, how does one continue to raise the land mass, that is, capacity to cope and adapt above the level of the waters of the raging impulses of her psychosis. Compare this record to one written nearly 40 years later at the same institution. Here, a psychiatric resident describes the hospital course of a man with the identical diagnosis as the woman: This is a 25 yo Hispanic male with a past psych hx of schizophrenia who brought himself to the ER with the chief complaint of command AH telling him to hurt himself and hurt his brother. ….Pt also endorsed depressed mood, decreased appetite, and insomnia. He did not have any other active SI or HI. Pt admitted that he had been off his psychotropic medications for the past 30 days.…Pt was restarted on his previous medications. On day 2, pt reported feeling improved after treatment. He denied having suicidal thoughts or homicidal thoughts. His AH frequency decreased. On day 3, pt reported improved mood, denied suicidal or homicidal thoughts. Case manager contacted the patient's brother, who stated that pt didn't get along with his family members and family members would not be willing to provide housing. The patient agreed to be discharged to a shelter. The two patients experienced nearly identical troubles, including failure to live independently, a paucity of social relationships, and persistent psychosis. In the first case, the resident took little interest in the patient's symptoms (despite the fact that antipsychotic medications had been in widespread use for over 15 years) and spent many hours learning about her life outside of the hospital and her inner psychological world. The second resident dearly cared about the patient's symptoms and viewed them as unrelated to the scarcity and loneliness that characterized his social life. These divergent representations of the patient with schizophrenia reflect dramatic changes in the social, cultural, and scientific contexts in which psychiatry is practiced. Much of what we do as clinicians is not a consequence of the natural world but, instead, results from our contingent social and cultural context and, as such, deserves critical scrutiny. Historical and anthropological approaches provide tools with which psychiatrists-in-training can reckon with the clinical challenges raised by a complex world. For the last three years, the authors have conducted a course on the social sciences and psychiatry for second-year psychiatric residents with these aims in mind. Through lectures, readings, and homework, the course engages residents in discussions about the psychiatric task. Social science is taught not as a set of abstract theories, but as a set of tools with which to be thoughtful about the responsibilities, complexities, and uncertainties of clinical work. The aim is to teach residents to critically engage the knowledge they use as psychiatrists and to make an intellectual investment in the future of their profession. This article describes the conceptual foundation of the course, its structure, and impact.

The Internet as Collateral Informant

Back to table of contents Previous article Next article Letters to the EditorFull AccessThe Internet as Collateral InformantGEOFFREY NEIMARK M.D.MATTHEW OWEN HURFORD M.D.JOSEPH DiGIACOMO M.D.,GEOFFREY NEIMARK M.D.Search for more papers by this authorMATTHEW OWEN HURFORD M.D.Search for more papers by this authorJOSEPH DiGIACOMO M.D.Search for more papers by this author,Published Online:1 Oct 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In this letter, we describe a novel and potentially important way in which the Internet has influenced our practice of clinical psychiatry—the use of the Internet as a collateral informant in the psychiatric encounter.“Mr. J” is a 38-year-old man who came to our crisis response center with suicidal ideation without a plan. Recently, the patient had been kicked out of his girlfriend’s house because of his ongoing abuse of crack cocaine. The resident on-call performed a medical history and physical examination, including a suicide risk assessment, but the patient’s denial of prior suicide attempts led the resident to believe that the patient was at low risk for suicide overall. While writing the patient’s medical history and physical examination results, the resident decided to perform an Internet “Google” search on the patient and discovered a newspaper article from 3 months earlier detailing how Mr. J was pulled by police from a nearby river and admitted to a local psychiatric hospital after he jumped off a major bridge in what was described as a suicide attempt.Internet search engines such as Google process billions of websites in a matter of milliseconds to produce a hierarchical arrangement of “hits” that match the search criteria. Thus, entering an individual’s name into a search engine can reveal interesting results, ranging from newspaper articles to personal Web pages to court cases that are a matter of public record. In the case presented, a single Internet search, performed in a matter of milliseconds, revealed information that would be vital to determining the patient’s ultimate disposition. While Internet-based mental health screening (1) and treatment (2 , 3) applications have been examined, there has been, to our knowledge, no investigation into the role of Internet-accessible personal information in the clinical evaluation of psychiatric patients. Our case illustrates some of the ways in which the Internet can be used to aid decision making in clinical situations. Although the information gleaned from the Internet frequently has, at best, an adjunctive role, this data can be, at times, invaluable in the decision-making process. What are the implications of having these new and powerful, fast, and free data sources at our disposal? Should all of our new patients be “Googled”? Should they be informed that we are indeed “Googling” them? How should we assess the quality and accuracy of Internet data? What about other potentially useful, although perhaps more controversial, sources of information on the Internet? Many states now have websites that list parole absconders and wanted fugitives and offer online registries of sex offenders. In addition, elements of patients’ financial, criminal, and civil histories can be obtained on the Internet. What, if any, role could and should this sort of information have in clinical evaluations, and what are the ethics of this? We hope that this letter is only the beginning of further exploration and discussion of these complicated and exciting new issues involving the role of the Internet in clinical psychiatry.Philadelphia, Pa.Reprints are not available; however, Letters to the Editor can be downloaded at http://ajp.psychiatryonline.org.

The Internet as Collateral Informant

Back to table of contents Previous article Next article Letters to the EditorFull AccessThe Internet as Collateral InformantGEOFFREY NEIMARK M.D.MATTHEW OWEN HURFORD M.D.JOSEPH DiGIACOMO M.D.,GEOFFREY NEIMARK M.D.Search for more papers by this authorMATTHEW OWEN HURFORD M.D.Search for more papers by this authorJOSEPH DiGIACOMO M.D.Search for more papers by this author,Published Online:1 Oct 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In this letter, we describe a novel and potentially important way in which the Internet has influenced our practice of clinical psychiatry—the use of the Internet as a collateral informant in the psychiatric encounter.“Mr. J” is a 38-year-old man who came to our crisis response center with suicidal ideation without a plan. Recently, the patient had been kicked out of his girlfriend’s house because of his ongoing abuse of crack cocaine. The resident on-call performed a medical history and physical examination, including a suicide risk assessment, but the patient’s denial of prior suicide attempts led the resident to believe that the patient was at low risk for suicide overall. While writing the patient’s medical history and physical examination results, the resident decided to perform an Internet “Google” search on the patient and discovered a newspaper article from 3 months earlier detailing how Mr. J was pulled by police from a nearby river and admitted to a local psychiatric hospital after he jumped off a major bridge in what was described as a suicide attempt.Internet search engines such as Google process billions of websites in a matter of milliseconds to produce a hierarchical arrangement of “hits” that match the search criteria. Thus, entering an individual’s name into a search engine can reveal interesting results, ranging from newspaper articles to personal Web pages to court cases that are a matter of public record. In the case presented, a single Internet search, performed in a matter of milliseconds, revealed information that would be vital to determining the patient’s ultimate disposition. While Internet-based mental health screening (1) and treatment (2 , 3) applications have been examined, there has been, to our knowledge, no investigation into the role of Internet-accessible personal information in the clinical evaluation of psychiatric patients. Our case illustrates some of the ways in which the Internet can be used to aid decision making in clinical situations. Although the information gleaned from the Internet frequently has, at best, an adjunctive role, this data can be, at times, invaluable in the decision-making process. What are the implications of having these new and powerful, fast, and free data sources at our disposal? Should all of our new patients be “Googled”? Should they be informed that we are indeed “Googling” them? How should we assess the quality and accuracy of Internet data? What about other potentially useful, although perhaps more controversial, sources of information on the Internet? Many states now have websites that list parole absconders and wanted fugitives and offer online registries of sex offenders. In addition, elements of patients’ financial, criminal, and civil histories can be obtained on the Internet. What, if any, role could and should this sort of information have in clinical evaluations, and what are the ethics of this? We hope that this letter is only the beginning of further exploration and discussion of these complicated and exciting new issues involving the role of the Internet in clinical psychiatry.Philadelphia, Pa.Reprints are not available; however, Letters to the Editor can be downloaded at http://ajp.psychiatryonline.org.

Research on the influence that communication in psychiatric encounters has on treatment.

The purpose of this article is to inform mental health professionals about the empirical literature on medical and psychiatric encounters and the influence of communicative behaviors on specific encounter outputs and treatment outcomes. A comprehensive review of the health communications literature from 1950 to 2001, using MEDLINE and PsycINFO, was conducted to identify relevant articles on the communication skills of psychiatrists and other physicians. These searches were augmented by personal correspondence with experts on changes in practice patterns in psychiatry and on medical and psychiatric communications research. A review of references within each article and information from the experts identified other relevant articles. Selection was then narrowed to include reports of studies that used structured written instruments that captured relevant physician and patient perceptions of the physician-patient relationship, content analysis of audio- or videotapes of communication in medical or psychiatric encounters, or interaction analysis systems used to categorize audio- or videotaped communicative behaviors in medical or psychiatric encounters. Twenty-five articles in medicine and 34 articles in psychiatry were selected. Medical communication researchers have observed associations between physicians' communicative skills and patients' satisfaction, patients' adherence to treatment recommendations, treatment outputs, and patients' willingness to file malpractice claims. The research has also shown that primary care physicians can be more responsive to patients' concerns without lengthening visits. In psychiatry, the literature can be organized into four discrete categories of research: negotiated treatment and the customer approach, therapeutic alliance, Gottschalk-Gleser content analysis of patients' speech, and content analysis of psychiatric interviews.

Technologic Advancement and the Psychiatric Encounter

Advanced telecommunication devices have taken their place alongside the Internet and computer software as sectors of the economy that are shaping our social system. Health care has not been immune to the social changes that are occurring as a result of these advanced technologies. The overall effect of these devices on the psychiatrist–patient relationship and the process of treatment decision-making is not known. This article will discuss the complex association between technologic advancement and social change within the context of the psychiatrist–patient relationship.

Psychoanalytic Understanding and Treatment of the Very Rich

Because personal affluence and an alloplastic adjustment tend to go together, psychiatric treatment encounters special problems in trying to help the very rich. These patients frequently show a strong sense of entitlement and a denial of any psychological problem. This creates special treatment problems. They feel entitled to the "very best," which includes the "best doctor." If their psychological problems cannot be magically erased they will switch psychiatrists until they find the "right one." Part of this is a tendency to externalize their emotional problems. Problems are thought to be caused by the environment and not by intra-psychic conflicts. This encourages the therapist to make environmental changes to improve the psychological state. Other special problems that the very rich present include the V.I.P. syndrome, excessive concern with litigation, their excessive narcissim, and their original emotional neglect by their own parents. Many were raised by parent surrogates and have problems in self-esteem. All of these special problems make the very rich difficult to treat with psychodynamically oriented psychotherapy or psychoanalysis. There are some exceptions to this problematic picture in which psychiatric treatment of the very rich can work out very nicely for both patient and psychotherapist.

Inequality in Professional Service Encounters: Verbal Strategies of Control versus Task Performance in Calls to the Police

Abstract According to the interactional form of the professional dominance (PD) thesis professional service encounters, especially of the medical sort, are arenas of negotiation, conflict or struggle in which professional service providers attempt to dominate lay service seekers through various verbal strategies for controlling the definition of the situation, the interactional agenda and the time and resources expended in the encounter. Prominent among these purported linguistic strategies are the use of interruptions, questions (and particular types of questions) and silences. Service seekers are correspondingly said to resist such attempts at control. In this paper we criticize the PD thesis as it applies to interruptions and questions through a brief re-examination of some of the analyses by C. West and by Scheff of medical and psychiatric encounters, and through a longer scrutiny of a corpus of calls to the police. Not finding any evidence of these verbal control strategies we propose an alternative ethnomethodological (conversation-analytic) account of the occurrence of overlaps (in West’s data) and of the so-called ‘abruptness’, ‘constraining influence’ and ‘asymmetry’ of questions in calls to the police. We locate these apparent features in a general account of the interactional shape of the calls, an account which sees that shape as a concerted accomplishment of the parties to them. That accomplishment, we claim, derives from the parties’ mutual orientation to (a) the occasion of the call as one directed to the performance of a set of tasks, which establish (b) the relevance of co-identification in terms of a particular set of identities and (c) a characteristic distribution of speakers’ rights to turns at talk. While not disputing (here) the structural version of the PD thesis we wish to replace the interactional version of it by an approach which begins to address how the institutional interaction reproducing that structure is produced as such in the first place.

A compliance protocol: psychiatric emergency services and brief encounters.

The documented high rates of noncompliance by psychiatric clients to their disposition plans following psychiatric emergency room treatment are a problem for psychiatric nurses. A compliance protocol is presented that approaches compliance as an interactive collaborative process based on an assumption that clients can participate in the compliance process with varying degrees of responsibility. The protocol includes an organizing system for assessment, nursing diagnoses, and interventions. The components of the protocol, mutuality, decision making, supporting systems, and intentionality are adapted from the Health Belief Model.

Patients' rights: a cultural challenge to Western psychiatry.

To some degree, all psychiatric encounters, by constraining behavioral variation and autonomous decision making, threaten a personhood already impaired by illness. The challenge presented by this and other factors in Western psychiatry is how to resolve the ethical dilemmas of justice, autonomy, and beneficence inherent in contemporary hospitalization and treatment practices for severely mentally ill persons. The author discusses this challenge in terms of the physician-patient contract, clinical standards for limiting autonomy, and the Kantian concept of equality of mutual respect. The legal code in relation to psychiatry has evolved into a contemporary interpreting mechanism for Kantian cultural tradition.

The briefest psychiatric encounter. Acute effects of evaluation.

THE PSYCHIATRIC evaluation or diagnostic interview is widely regarded as a dynamic, interpersonal process. In the past, investigation has been concentrated on how an understanding of this process enhances the ability of the interviewer to determine what is going on and what is going wrong, and to decide and facilitate what can or should be done about it. 1 What happens to the patient as a result of this experience, however, largely has been neglected from a research standpoint. A search of the literature of the past ten years turned up no papers at all on the subject. It is not rare for individual therapists to see a patient in a one- or two-session evaluation, refer the patient elsewhere, and receive a report that fairly dramatic changes have taken place in several aspects of the patient's life. The following two patients were seen in