Culture, law and psychiatry in Hawaii.

Hawaii is a set of islands with a broad mix of cultures. The law is American, but it was predominantly derived from English Common Law. Thus, the law is derived from a very distant culture. Theoretically, this 'transplanted' law could cause difficulties for people from Pacific cultures. Indeed, it appears to create difficulties for individuals with mental illness. A substantial number of these people are arrested for disobedience of a law that is not sensible for their culture. This problem is an example of the need for cultural knowledge when a psychiatrist conducts an examination for the legal system. An individual may appear legally guilty or medically insane when acting within cultural norms.

Difficulties in integrating spirituality into psychotherapy.

The boundary between spiritual and psychotherapeutic issues is not well defined; indeed, the two may be interwoven. A patient's sense of a therapist may closely relate to the patient's assessment of the therapist's spirituality, and a therapist's recognition of the differences between psychopathological and spiritual beliefs may depend on a recognition of his or her own belief system. Changing the profession's approach to this issue is made difficult by 1) a traditional sense within many schools of psychotherapy that spirituality is outside the sphere of appropriate investigation and knowledge; 2) discomfort with personal spiritual issues in educators and trainees; 3) decreased emphasis on aspects of the therapist as important factors in patient outcome; and 4) decreased use of intensive supervision for psychotherapy in some training programs.

Feigned psychiatric symptoms in the emergency room.

Psychiatrists providing emergency services at an urban general hospital completed questionnaires on 227 patients evaluated over a two-month period to assess whether they suspected the patient of malingering or of having secondary gains, and whether the patient was confronted about the suspicions. Thirteen percent of patients were strongly or definitely suspected of feigning symptoms; none received a primary diagnosis of malingering, and less than half were confronted. Suspected secondary gains included food and shelter, medications, financial gains, and avoidance of jail, work, or family responsibilities.

Ideological singularity as a defense against clinical complexity.

Despite the existence of several theories in psychiatry, strict adherence to one is common. Sources of singularity include education, training, and the highly separate development of the theories. However, a deeper source may be the inherent uncertainty of psychiatric symptoms and research. Singularity may contribute to patient confusion and public stigma.

Phototherapy in the context of psychotherapy.

Phototherapy, or treatment with bright artificial light, has been used to treat seasonal affective disorder and related conditions. Using the cases of two patients who were treated with both psychotherapy and phototherapy, the author explores the potentially powerful psychotherapeutic aspects of this new treatment. Within a therapeutic relationship, light has a rich symbolism, and it may serve as an inanimate symbol of the therapist. Perhaps because of the lack of well-established guidelines or traditions regarding its use within psychotherapy, however, light treatment can lead to the violation of the usual boundaries of treatment. If this danger is avoided, phototherapy may be a powerful adjunct to psychotherapy.

Theoretical difficulties in the treatment of mentally ill prisoners.

Work as a psychiatrist in a correctional setting involves a difficult interface of the theories of psychiatry, the law, and corrections. The coexistence of models of punishment, rehabilitation and mental health treatment in this work create ethical and practical challenges for the psychiatrist. The lack of a singular or clear theoretical framework may contribute to a potential for countertransference issues to play a determinant role in psychiatric decisions. These difficulties are based on the intersection of the theoretical issues involved.

Adverse ocular effects of anticonvulsants.

With increasing recognition of the interface between neurology and psychiatry, the use of anticonvulsants to treat the signs and symptoms of many psychiatric disturbances is becoming commonplace. Although rare adverse reactions, such as those in the hepatic and hematological systems, have attracted considerable concern, for many anticonvulsants it is the ocular reactions that are among the most common. This article reviews the major ocular reactions to anticonvulsants and suggests guidelines for their use. It also underscores the importance of including adverse ocular effects as part of the informed consent process.

The prisoner's prisoner: the theme of voluntary imprisonment in the staff of correctional facilities.

The staff of correctional facilities voluntarily work in prisons. It seems plausible that the professionals, officers, and administrators engaged in such employment may have unconscious feelings of a desire or need for punishment. This topic does, in fact, appear common in the jokes and casual conversation in such facilities, perhaps indicating such an underlying theme. Indeed, those employees who were willing to discuss their experience in more depth corroborated the hypothesis. A sense of a need or desire for punishment in a staff's members may profoundly affect the prisoner's transference with the staff, and the staff's countertransference. These feelings may affect the many important decisions of correctional and clinical staff in prisons and related settings.

The dissolution of the dyad in psychiatry: implications for the understanding of patient-therapist sexual misconduct.

Psychiatry has undergone multiple changes in this century. Some twenty years ago, Kubie describe a move away from patients, particularly in those practitioners involved in academic psychiatry. His concern was warranted; such a trend appears to have involved much of psychiatry. There has been a markedly decreased emphasis in viewing the operative unit of psychiatric inquiry as a dyad of the physician and patient, in which the parties inescapably influence each other. Newer treatments tend to employ the physician as a more independent entity that applies necessary treatment to the patient. Concomitantly, we have seen a trend toward a diminishing focus on sexuality as a primary motivating force in all areas of human endeavor. Freud proposed that libidinal impulses dominated much of our behavior; later psychoanalytic theorists and founders of other modalities of treatment have focused on other sources of motivation. Within the context of a psychiatry less focused on the physician and patient in a dyadic sense, and less focused on sexuality as a universal source of motivation, we have witnessed a marked increase in interest in the sexual misconduct of psychiatrists. Comprehension of this disturbing issue in the service of prevention rests upon reversing these trends. We must attend to the dyad as a bipersonal field serving as the arena for misconduct. We must also parallel our strident disapproval of misconduct with an objective exploration of the dynamics of both parties and the human commonality of sexual feelings. This special section represents such an exploratory effort.