Our time is up: forced terminations during psychotherapy training.

Forced terminations are a powerful experience for both patients and for residents. Such terminations often resemble earlier losses to patients, who may react with particular defense constellations, changes in symptoms, and profound reactions to the therapist. Similarly, prominent countertransference may manifest in attempts by residents to deny their importance to patients, to project reactions onto their patients, and to alter the therapy relationship. More intense therapy relationships usually require termination announcements months in advance. How much will be revealed to patients may best be determined prior to the announcement. Payments, gifts, subsequent contact, transfer to another therapist, and concluding therapy comments need evaluation of what is in the patient's best interest and may require creative approaches deviating from traditional therapy practices. This discussion reviewed reactions of patients and residents to forced termination, addressed the pragmatic issues confronting the resident, provided clinical vignettes illustrating peculiarities of forced terminations, and listed recommendations to assist the departing resident. Forced terminations afford powerful opportunities for contending with abandonment, disappointment, and loss directly in the therapy. While these experiences are certainly not comfortable, they can be used constructively to benefit patients if the issues surrounding the forced termination are carefully considered and addressed within the therapy.

The hyperactive child: an update.

The physician is uniquely qualified to manage the multiple facets of attention-deficit hyperactivity disorder. This clinically oriented update reviews the current state of the art regarding diagnosis and management of hyperactive children. Three case reports emphasize the wide variation of clinical problems presented by this frequently occurring disorder of childhood. Epidemiology, differential diagnosis, associated features, neurobiologic mechanisms, treatment, long-term outcome, and attention-deficit disorder in adults are addressed. Although medication is an important tool in the treatment of this condition, follow-up studies confirm the importance of a multimodal treatment approach.