Introduction

and Jeffrey R. Strawn²

(1)

Department of Psychiatry and Child Psychiatry, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA

(2)

Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, Ohio, USA

Abstract

Over 60 years ago, the English pediatrician and psychoanalyst Donald W. Winnicott (1896–1971) astutely observed: “There’s no such thing as a baby” (Winnicott 1964/1947). Today, most psychiatrists are keenly aware that there’s no such thing as a “patient”; that is, a patient exists inside an environment that includes their families, the treating physicians, treatment teams, subspecialty consultants, and other clinical providers. In turn, a patient’s interactions with these groups are heavily influenced by their prior experiences, cognitive styles, attachment patterns, temperaments, and most importantly, their cultural backgrounds. Frequently, for most of those in need of aid, treatment is effectively provided and received, and recovery ensues. However, when treatment does not go according to plan, the parties involved can experience anxieties that lead to unexpected negative outcomes. If the patient’s treatment becomes derailed due to their personality or to cognitive problems, the treatment team begins to view the patient as “noncompliant” or “difficult,” and they request a psychiatric consultation. When the patient’s treatment becomes thwarted by family factors, psychiatrists are also asked to provide insight. These consultations may result in recommendations regarding psychopharmacologic strategies for various neuropsychiatric disorders (e.g., delirium, depression secondary to α-interferon therapy, postpartum psychosis) or the clarifying of psychiatric diagnoses. Sometimes, however, clinical consultations are much more complex and fraught—“difficult clinical consultations”—requiring an integrated effort that combines the careful assessment of the patient from a multidimensional perspective (psychodynamic, family, and ethical) with an informed strategy for the treatment team and the patient’s family. In Difficult Psychiatric Consultations: An Integrated Approach, we will describe effective approaches to difficult psychiatric consultations and in doing so will comprehensively discuss issues and impediments related to the patient, the family, and the treatment team. In addition, we’ll explore the ethical and cultural aspects of managing these “difficult consultations.” Our goal in presenting this systematic approach is to facilitate the psychiatric consultant’s work within the larger healthcare system and to provide reliable and usable tools for the consultant who works with complex patients and their treatment teams.

There’s no such thing as a baby

—Donald W. Winnicott (1896–1971)

Over 60 years ago, the English pediatrician and psychoanalyst Donald W. Winnicott (1896–1971) astutely observed: “There’s no such thing as a baby” (Winnicott 1964/1947). Today, most psychiatrists are keenly aware that there’s no such thing as a “patient ”; that is, a patient exists inside an environment that includes their families, the treating physicians, treatment teams, subspecialty consultants, and other clinical providers. In turn, a patient’s interactions with these groups are heavily influenced by their prior experiences, cognitive styles, attachment patterns, temperaments, and most importantly, their cultural backgrounds. Frequently, for most of those in need of aid, treatment is effectively provided and received, and recovery ensues. However, when treatment does not go according to plan, the parties involved can experience anxieties that lead to unexpected negative outcomes. If the patient’s treatment becomes derailed due to their personality or to cognitive problems, the treatment team begins to view the patient as “noncompliant ” or “difficult,” and they request a psychiatric consultation. When the patient’s treatment becomes thwarted by family factors, psychiatrists are also asked to provide insight. These consultations may result in recommendations regarding psychopharmacologic strategies for various neuropsychiatric disorders (e.g., delirium, depression secondary to α-interferon therapy, postpartum psychosis) or the clarifying of psychiatric diagnoses. Sometimes, however, clinical consultations are much more complex and fraught—“difficult clinical consultations”—requiring an integrated effort that combines the careful assessment of the patient from a multidimensional perspective (psychodynamic, family, and ethical) with an informed strategy for the treatment team and the patient’s family. In Difficult Psychiatric Consultations: An Integrated Approach, we will describe effective approaches to difficult psychiatric consultations and in doing so will comprehensively discuss issues and impediments related to the patient, the family, and the treatment team. In addition, we’ll explore the ethical and cultural aspects of managing these “difficult consultations.” Our goal in presenting this systematic approach is to facilitate the psychiatric consultant’s work within the larger healthcare system and to provide reliable and usable tools for the consultant who works with complex patients and their treatment teams.

1.1 From Psychiatric Consultation to “Psychosomatic Medicine”

Psychiatric consultation has evolved over the last half century. What is now known as “psychosomatic medicine ” began in the early 1940s and, during these early years, was often referred to as “consultation-liaison” psychiatry. A reflection of the early goals within the field, consultation-liaison psychiatry involved providing assistance to medically-oriented physicians in managing the psychiatric problems of the medically ill population in hospital settings and also in negotiating conflicts surrounding emotionally charged decisions or aspects of care. Later, consultation-liaison psychiatry formally became a subspecialty that incorporated clinical practice, teaching, and research at the borderland of psychiatry and medicine (Hunter et al. 2007; Lipowski 1983). Today, this subspecialty is referred to as psychosomatic medicine, and was formally recognized by the American Psychiatric Association in 2004 (Gitlin et al. 2004). Though psychosomatic medicine is well situated as a psychiatric subspecialty, the term itself has not become standard in medical settings, and the use of “consultation-liaison psychiatry” remains favored and will be used throughout this book. As McIntyre (2002) aptly stated, “The name of this subspecialty has been debated for years, and the choice of the name ‘psychosomatic medicine’ will not end the discussion.” He concludes: “Consultation-liaison has indeed made, and continues to make, major contributions to the practice of medicine and the education of physicians. Whatever its name, its best days lie ahead” (McIntyre 2002).

Consultation-liaison psychiatry embodies the bio-psycho-social treatment (Engel 1977, 1980) approach more than perhaps any other subspecialty. Recently, the bio-psycho-social model has come to represent the “progressive unification of the medical and behavioral sciences, including psychiatry, in a search for etiological and preventive factors in human health and disease” and underscores the importance of seeing patients as “‘united, bio-psycho-social persons’ rather than as ‘biomedical persons’ divorced from their psychological and social dimensions” (Dowling 2005). However, some have argued that this model poses demands on physicians that interfere with their clinical activities, and that bio-psycho-social issues are best addressed by consultation-liaison psychiatry . The financial implications of the care provided by physicians were also considered a relevant factor that limited its use. Nonetheless, this model, in George Engel’s words, “motivates the physician to become more informed and skillful in psychosocial areas, disciplines now seen as alien and remote unit by those who intuitively recognize their importance. . . . [It] serves to counteract the wasteful reductionist pursuit of what often prove to be trivial rather than crucial determinants of illness. The bio-psycho-social physician is expected to have working knowledge of the principles, language , and basic facts of each of the relevant discipline, he is not expected to be an expert in all” (Engel 1980). Encouraging involvement with psychiatric services, the bio-psycho-social model forwards the precept that only in addressing the psychological and social factors (e.g., cultural background and family ) can the patient be effectively treated.

1.2 The Psychiatric Consultant’s “Job Description”

The psychiatric consultant practicing in today’s busy medical center has numerous responsibilities and collaborates with many members of the medical staff, midlevel providers, and nurses, as well as with social workers and case managers. Traditionally, the consultant’s job was to determine the psychiatric diagnosis, provide recommendations regarding psychopharmacologic management , assist with conflict negotiation , distinguish the psychiatric from the psychosocial, and help determine the patient ’s decision-making capacity ; “be familiar with the routines of the medical/surgical environment and knowledgeable about medical and surgical illness…and aware of the effects that illness and drugs have on behavior, especially when they contribute to or confound the diagnosis or treatment [of the “medical-psychiatric” patient]” (Bronheim et al. 1998). The modern psychiatric consultant is additionally and importantly charged with providing a framework that the treatment team can use to promote a bio-psycho-social model, a framework that both guides their interventions and enhances the patient’s medical or psychological treatment. The effective consultant helps to bridge the patient’s subjective, illness-related perceptions, and the expertise of the treatment team that designs the necessary therapeutic interventions for him or her. The psychiatrist is also tasked with creating a psychological space that facilitates open communication, enabling the patient to convey distress and the treatment team to reassure the patient that its efforts are aimed at improving the medical outcome. When a diagnosis of a medical or psychiatric illness is given—whether or not the condition is short-term or chronic—the patient’s sense of invincibility is shattered, and the treatment team’s goal is to engender a sense of hopefulness, offering strategies and teaching coping skills that the patient can employ to attain, as closely as possible, the level of functioning they had before the diagnosis.

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