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New prospects for liaison psychiatry
PERSPECTIVE
z. J. LIPOWSKI, M.D.
New prospects for liaison psychiatry Consultation-liaison psychiatry has emerged in the past decade as a major subdivision of clinical psychiatry, one concerned with mental health problems of patients treated by nonpsychiatric physicians in medical settings. Both the physically ill patients and those who, despite being physically well, communicate their distress in the form of somatic symptoms and seek medical help for them come within liaison psychiatrists' purview. Pioneered in this country 50 years ago, liaison psychiatry gained a measure of popularity in a few teaching general hospitals in the 1930s and 4Os, and then receded into the background until the 70s.1.2 Its lean years coincided with psychiatry's drift away from medicine in the 50s and 60s. Partly in an effort to reverse that drift, the National Institute of Mental Health decided in 1974 to support the development ·of psychiatric consultation-liaison services in general hospitals throughout the country.1
That decision was also influenced by the assumption that the emphasis in medical training and practice would shift towards primary care, where about three fifths of psychiatric patients are first seen and psychosocial problems abound.' Since liaison psychiatrists presumably had knowledge of and clinical experience with the psychiatric and psychosocial aspects of medical practice, it seemed logical to call on them to help train present and future physicians for comprehensive primary care. In the eyes of government planners such care promised to be both economical and popular, and therefore politically advantageous. Given official blessing and a boost in the form of training grants, liaison psychiatry began to develop rapidly. Bright young psychiatrists became attracted to this once-marginal clinical activity in growing numbers. New services were established and old ones expanded in general hospitals from coast to
Dr. Lipowski is prOfessor of psychiatry at Dartmouth Medical School. Reprint requests to him there, Hanover, N H 03755. 806
coast. The liaison literature took on a new life and has flourished. Liaison psychiatry has thus been given a chance to become a major component of the mental health care system. All these changes justify talking about new prospects for the subspecialty. New opportunities, of course, tend to go hand in hand with new pitfalls. Liaison psychiatry'S new popularity could tum out to be its undoing should its practitioners allow it to become a bandwagon from which promotional blarney is beamed. A familiar sequence of events would predictably follow: first, boundless enthusiasm and heady promises, then disillusionment, recriminations, and decline. To ensure liaison psychiatry'S growth and survival, realistic goals need to be set and their realization carefully planned and monitored. Emphasis on high-quality clini~al service, teaching, and research must take definite precedence over missionary zeal and excessive opportunism. In the discussion to follow I shall propose several concrete measures PSYCHOSOMATICS
aimed at securing liaison psychiatry a deserved, if modest, place in the health care system in the years to come. Three key aspects of liaison psychiatry will be taken up separately: organization, education, and investigation. Organization Consultation, therapy, and liaison have constituted the clinical service rendered by psychiatric consultants to medicine. Consultation here refers to giving expert opinion on a patient's psychological condition, and advice on its proper management, at the request of a nonpsychiatric colleague. In some cases, the consultant may undertake, with the consultee's consent, direct therapy (usually' brief psychotherapy or some form of behavior therapy) with the referred patient. Liaison, the most ambiguous of the three terms, implies sustained professional contact between a consultant psychiatrist or allied mental health worker and the staff of a medical or surgical ward, special unit, or clinic. The aim of liaison is to develop a working relationship with the staff in order to create optimal conditions for the consultant to help prevent, detect, and manage psychiatric disorders; to mediate in conflicts between patients and staff; and to teach. This brief clarification is needed to appreciate the nature of recent controversy over what part liaison, in the above narrow sense, should play. According to some, consultation and liaison represent alternative modes of delivering clinical service. Liaison, the argument goes, is the superior, and consultation, the inferior, obsolete, mode; hence it is desirable that consultation increasingly give way to liaison. This argument is based on the false SEPTEMBER 1981 • VOL 22 • NO 9
premise that liaison and consultation are mutually exclusive activities. Strictly speaking, consultation is an essential clinical service rendered by liaison psychiatrists, while liaison is a strategy aimed at promoting a favorable climate for referrals and for the acceptance of the consultant's presence and advice. The proper question is not whether to consult or to do liaison, but how much liaison is needed (and can be afforded) to provide effective consultation throughout the given medical setting. Consultation remains the cornerstone of the liaison
Hovering about a medical ward for hours daily luis not been shown to be necessary for the provision of competent and useful consultation or for effective teaching. psychiatrist's clinical service, without which he would lose his raison d'etre. To resolve this divisive argument, I would propose two measures: First, let liaison psychiatrists focus on what they are trained for, that is on consultations involving complex medico-psycho-social diagnostic and therapeutic problems. And second, let liaison nurses do much of the day-to-day liaison, an activity for which they are singularly well suited by virtue of their training in both medical and psychiatric nursing.3 Consultation, if done right, involves considerable contact between the consultant and the consultee (and often other members of the medical team)that is to say, a goodly measure of liaison.4 Hovering about a medical
ward for hours daily has not been shown to be necessary for the provision of competent and useful consultation or for effective teaching. In any case, even if all American psychiatrists volunteered for liaison work, there would not be enough of them to serve all the wards and units of the 6000 or so community general hospitals. A properly trained liaison nurse can effectively consult with medical and surgical nurses who, in turn, are well placed to influence psychosocial aspects of patient care both directly and indirectly-directly, by responding sensitively to patients' psychological needs; indirectly, by influencing the attitudes, practice, and psychiatric referral patterns of ward physicians. Liaison nurses can identify patients needing emotional support or referral to a psychiatric consultant. They can provide support or suggest referral at their discretion. As a result, standards of psychosocial patient care are apt to rise, the consultants can focus on consulting and teaching, and the patients and their physicians are likely to be satisfied with the service provided. One other organizational measure may be suggested to strengthen the therapeutic aspects of the service. I would propose merger of consultation-liaison services with divisions of behavioral medicine into integrated entities. Practitioners of behavioral medicine, most often psychologists, apply psychological methods derived largely from learning theories to health problems.s More specifically, techniques of behavior modification are applied in an effort to change undesirable illness behavior or physiologic responses to life situations (stress), or both, for the purpose of treating disease 807
Perspective
or preventing its occurrence. Behavioral medicine, whose emergence has paralleled the revival of liaison psychiatry, has already enriched the therapy of chronic pain and of a whole range of other somatic symptoms. It would be unfortunate if its practitioners and the liaison psychiatrists ended up competing against one another, despite cogent reasons in favor of their close collaboration. Formation of integrated liaison psychiatry-behavioral medicine divisions in the general hospitals would allow, I believe, maximal utilization of the personnel and resources available to improve psychosocial, psychological, and psychiatric aspects of patient care in medical settings.
Education Liaison psychiatrists have been called upon to teach medical students and residents, attending physicians, psychiatric residents, liaison fellows, nurses, physicians' assistants, and so forth. There is clearly a limit to what a handful of liaison psychiatrists can be reasonably expected to do. The lines must be drawn somewhere. I would propose that teaching efforts be focused on medical students, liaison fellows, and psychiatric residents. If liaison psychiatry is to help prepare future physicians to identify, manage, and properly refer psychiatric and psychosocial problems encountered in their practice, then its teaching efforts should focus on medical students. Psychiatric clinical rotation for medical students should be confined to or at least include work on a liaison service, a setting where they would learn psychiatry and behavioral medicine as they are applied to the problems encountered in day-tolI08
day medical practice. The mmlmum skills that one would expect the student to acquire are: to elicit psychosocial history; to diagnose psychiatric disorders; to use psychotropic drugs properly; to understand the importance of the physician-patient relationship; to apply brief psychotherapy; and to refer patients appropriately for psychiatric consultation and for behavioral treatment. A student who acts as an apprentice psychiatric consultant to medicine and surgery learns at firsthand those attitudes of physicians that are incompatible with good psychosocial care of patients and are a common source of frustration to liaison psychiatrists. He or she can observe the effects of insensitive dealing with patients' complaints and emotional needs, or of disregard for the individual patient's sociocultural background and personal coping style. As a consultant the student must deal with consultees who make token referrals just before the patient's discharge or who disregard the consultant's advice. Such firsthand experiences are likely to influence the student's future professional behavior more than formal lectures and seminars. To offer intensive teaching for medical students presupposes the availability of competent liaison teachers, and that, in tum, implies training of liaison fellows and psychiatric residents. About 60 liaison fellows have been trained annually for the past seven years. Very little has been written about this new training, and it is unclear what its objectives should be in terms of knowledge and skills acquired by the fellows at the end of their training. At Dartmouth, the fellowship comprises five interrelated aspects:
theoretical teaching in the form of seminars on psychosomatic medicine; clinical experience with a wide range of problems; supervision of medical students and psychiatric residents; liaison with a selected clinical area; and conduct of a clinical or scholarly research project. The fellows are closely supervised by members of the liaison faculty. They are expected to be competent general psychiatrists skilled in dealing with psychiatric problems encountered in medical settings, and able to communicate effectively with other physicians. They are encouraged to adopt an eclectic and critically commonsense approach to clinical work and psychiatric theories.
Investigation Research activities are essential if liaison psychiatry is to survive and make a lasting contribution. Several major areas for investigation may be suggested: • Psychiatric complications of all the major chronic diseases, such as coronary heart disease, chronic obstructive pulmonary disease, and cancer.6 • Somatoform and factitious disorders, which comprise a significant portion ofdiagnostic problems encountered in liaison work. Psychalgia (psychogenic pain), for example, requires systematic research to develop more effective diagnostic and therapeutic techniques. Conversion and somatization disorders and hypochondriasis often baffle consultants as much as consultees and place a strain on therapeutic resources. • Organic brain syndromes are among the main psychiatric disorders encountered by liaison psychiatrists, yet they have been neglected by researchers.7 Delirium, PSYCHOSOMATICS
dementia, and other organic syndromes are becoming more prevalent as the number of people age 65 and over (currently about 24 million) grows. Formulation of the diagnostic criteria for these syndromes in DSM-III should encourage and facilitate research on them, and liaison psychiatrists are strategically placed to do it in collaboration with other physicians and neuroscientists. New investigative tools to measure regional cerebral blood flow and metabolism should lead to rapid advances in this area. • Evaluation of the various techniques of behavior modification in the treatment of medical disorders
is an area in which collaboration between liaison psychiatrists and clinical psychologists could result in better therapies. Psychologists can have a salutary effect on research at the borderland of medicine because of their training in research methodology, which liaison psychiatrists often lack. • Evaluation of the effectiveness of consultation-liaison work in its clinical and teaching aspects is overdue.
Conclusions The future of liaison psychiatry looks bright at this time, yet the field faces formidable challenges
Supported in part by GP Special Training Grant, NIMH l3l7UJI.
REFERENCES
3. Lipowski ZJ, Wolston EJ: Liaison psychiatry: Referral patterns and their stability over time Am J Psychiatry. to be published. 4. Lipowski ZJ: Consultation-liaison psychiatry: An overview. Am J Psychiatry 131:623-630. 1974. 5. McNamara JR (ed): Behavioral Approaches to Medicine. New York, Plenum. 1979.
6. Lipowski ZJ: Physical illness and psychiatric disorder: A neglected relationship. Psycr"atria Fennica. suppl, 1979. pp 32-57 7. Lipowski ZJ: Organic mental disorders: Introduction and review of syndromes. in Kaplan HI. Freedman AM, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, ed 3. Baltimore. Williams & Wilkins. 1980. pp 1359-1392
1. Lipowski ZJ: Consultation-liaison psychiatry. Past failures and new opportunities. Gen Hosp Psychiatry 1:3- 1O. 1979. 2. Lipowski ZJ: Holisfic-medical foundations of American psychialry: A bicentennial. Am J Psychiatry 138:888-895. 1981.
SEPTEMBER 1981 • VOL 22 • NO 9
and pitfalls. Organizational changes as well as clear formulation of objectives in teaching and research are needed. Sensible division of labor and close collaboration with liaison nurses and psychologists practicing behavioral medicine are called for. Liaison psychiatry offers enough intellectual challenge to attract bright young people. To succeed, they will have to put high-quality clinical service and research Before apostolic zeal and proselytizing. 0
lI09
z. J. LIPOWSKI, M.D.
New prospects for liaison psychiatry Consultation-liaison psychiatry has emerged in the past decade as a major subdivision of clinical psychiatry, one concerned with mental health problems of patients treated by nonpsychiatric physicians in medical settings. Both the physically ill patients and those who, despite being physically well, communicate their distress in the form of somatic symptoms and seek medical help for them come within liaison psychiatrists' purview. Pioneered in this country 50 years ago, liaison psychiatry gained a measure of popularity in a few teaching general hospitals in the 1930s and 4Os, and then receded into the background until the 70s.1.2 Its lean years coincided with psychiatry's drift away from medicine in the 50s and 60s. Partly in an effort to reverse that drift, the National Institute of Mental Health decided in 1974 to support the development ·of psychiatric consultation-liaison services in general hospitals throughout the country.1
That decision was also influenced by the assumption that the emphasis in medical training and practice would shift towards primary care, where about three fifths of psychiatric patients are first seen and psychosocial problems abound.' Since liaison psychiatrists presumably had knowledge of and clinical experience with the psychiatric and psychosocial aspects of medical practice, it seemed logical to call on them to help train present and future physicians for comprehensive primary care. In the eyes of government planners such care promised to be both economical and popular, and therefore politically advantageous. Given official blessing and a boost in the form of training grants, liaison psychiatry began to develop rapidly. Bright young psychiatrists became attracted to this once-marginal clinical activity in growing numbers. New services were established and old ones expanded in general hospitals from coast to
Dr. Lipowski is prOfessor of psychiatry at Dartmouth Medical School. Reprint requests to him there, Hanover, N H 03755. 806
coast. The liaison literature took on a new life and has flourished. Liaison psychiatry has thus been given a chance to become a major component of the mental health care system. All these changes justify talking about new prospects for the subspecialty. New opportunities, of course, tend to go hand in hand with new pitfalls. Liaison psychiatry'S new popularity could tum out to be its undoing should its practitioners allow it to become a bandwagon from which promotional blarney is beamed. A familiar sequence of events would predictably follow: first, boundless enthusiasm and heady promises, then disillusionment, recriminations, and decline. To ensure liaison psychiatry'S growth and survival, realistic goals need to be set and their realization carefully planned and monitored. Emphasis on high-quality clini~al service, teaching, and research must take definite precedence over missionary zeal and excessive opportunism. In the discussion to follow I shall propose several concrete measures PSYCHOSOMATICS
aimed at securing liaison psychiatry a deserved, if modest, place in the health care system in the years to come. Three key aspects of liaison psychiatry will be taken up separately: organization, education, and investigation. Organization Consultation, therapy, and liaison have constituted the clinical service rendered by psychiatric consultants to medicine. Consultation here refers to giving expert opinion on a patient's psychological condition, and advice on its proper management, at the request of a nonpsychiatric colleague. In some cases, the consultant may undertake, with the consultee's consent, direct therapy (usually' brief psychotherapy or some form of behavior therapy) with the referred patient. Liaison, the most ambiguous of the three terms, implies sustained professional contact between a consultant psychiatrist or allied mental health worker and the staff of a medical or surgical ward, special unit, or clinic. The aim of liaison is to develop a working relationship with the staff in order to create optimal conditions for the consultant to help prevent, detect, and manage psychiatric disorders; to mediate in conflicts between patients and staff; and to teach. This brief clarification is needed to appreciate the nature of recent controversy over what part liaison, in the above narrow sense, should play. According to some, consultation and liaison represent alternative modes of delivering clinical service. Liaison, the argument goes, is the superior, and consultation, the inferior, obsolete, mode; hence it is desirable that consultation increasingly give way to liaison. This argument is based on the false SEPTEMBER 1981 • VOL 22 • NO 9
premise that liaison and consultation are mutually exclusive activities. Strictly speaking, consultation is an essential clinical service rendered by liaison psychiatrists, while liaison is a strategy aimed at promoting a favorable climate for referrals and for the acceptance of the consultant's presence and advice. The proper question is not whether to consult or to do liaison, but how much liaison is needed (and can be afforded) to provide effective consultation throughout the given medical setting. Consultation remains the cornerstone of the liaison
Hovering about a medical ward for hours daily luis not been shown to be necessary for the provision of competent and useful consultation or for effective teaching. psychiatrist's clinical service, without which he would lose his raison d'etre. To resolve this divisive argument, I would propose two measures: First, let liaison psychiatrists focus on what they are trained for, that is on consultations involving complex medico-psycho-social diagnostic and therapeutic problems. And second, let liaison nurses do much of the day-to-day liaison, an activity for which they are singularly well suited by virtue of their training in both medical and psychiatric nursing.3 Consultation, if done right, involves considerable contact between the consultant and the consultee (and often other members of the medical team)that is to say, a goodly measure of liaison.4 Hovering about a medical
ward for hours daily has not been shown to be necessary for the provision of competent and useful consultation or for effective teaching. In any case, even if all American psychiatrists volunteered for liaison work, there would not be enough of them to serve all the wards and units of the 6000 or so community general hospitals. A properly trained liaison nurse can effectively consult with medical and surgical nurses who, in turn, are well placed to influence psychosocial aspects of patient care both directly and indirectly-directly, by responding sensitively to patients' psychological needs; indirectly, by influencing the attitudes, practice, and psychiatric referral patterns of ward physicians. Liaison nurses can identify patients needing emotional support or referral to a psychiatric consultant. They can provide support or suggest referral at their discretion. As a result, standards of psychosocial patient care are apt to rise, the consultants can focus on consulting and teaching, and the patients and their physicians are likely to be satisfied with the service provided. One other organizational measure may be suggested to strengthen the therapeutic aspects of the service. I would propose merger of consultation-liaison services with divisions of behavioral medicine into integrated entities. Practitioners of behavioral medicine, most often psychologists, apply psychological methods derived largely from learning theories to health problems.s More specifically, techniques of behavior modification are applied in an effort to change undesirable illness behavior or physiologic responses to life situations (stress), or both, for the purpose of treating disease 807
Perspective
or preventing its occurrence. Behavioral medicine, whose emergence has paralleled the revival of liaison psychiatry, has already enriched the therapy of chronic pain and of a whole range of other somatic symptoms. It would be unfortunate if its practitioners and the liaison psychiatrists ended up competing against one another, despite cogent reasons in favor of their close collaboration. Formation of integrated liaison psychiatry-behavioral medicine divisions in the general hospitals would allow, I believe, maximal utilization of the personnel and resources available to improve psychosocial, psychological, and psychiatric aspects of patient care in medical settings.
Education Liaison psychiatrists have been called upon to teach medical students and residents, attending physicians, psychiatric residents, liaison fellows, nurses, physicians' assistants, and so forth. There is clearly a limit to what a handful of liaison psychiatrists can be reasonably expected to do. The lines must be drawn somewhere. I would propose that teaching efforts be focused on medical students, liaison fellows, and psychiatric residents. If liaison psychiatry is to help prepare future physicians to identify, manage, and properly refer psychiatric and psychosocial problems encountered in their practice, then its teaching efforts should focus on medical students. Psychiatric clinical rotation for medical students should be confined to or at least include work on a liaison service, a setting where they would learn psychiatry and behavioral medicine as they are applied to the problems encountered in day-tolI08
day medical practice. The mmlmum skills that one would expect the student to acquire are: to elicit psychosocial history; to diagnose psychiatric disorders; to use psychotropic drugs properly; to understand the importance of the physician-patient relationship; to apply brief psychotherapy; and to refer patients appropriately for psychiatric consultation and for behavioral treatment. A student who acts as an apprentice psychiatric consultant to medicine and surgery learns at firsthand those attitudes of physicians that are incompatible with good psychosocial care of patients and are a common source of frustration to liaison psychiatrists. He or she can observe the effects of insensitive dealing with patients' complaints and emotional needs, or of disregard for the individual patient's sociocultural background and personal coping style. As a consultant the student must deal with consultees who make token referrals just before the patient's discharge or who disregard the consultant's advice. Such firsthand experiences are likely to influence the student's future professional behavior more than formal lectures and seminars. To offer intensive teaching for medical students presupposes the availability of competent liaison teachers, and that, in tum, implies training of liaison fellows and psychiatric residents. About 60 liaison fellows have been trained annually for the past seven years. Very little has been written about this new training, and it is unclear what its objectives should be in terms of knowledge and skills acquired by the fellows at the end of their training. At Dartmouth, the fellowship comprises five interrelated aspects:
theoretical teaching in the form of seminars on psychosomatic medicine; clinical experience with a wide range of problems; supervision of medical students and psychiatric residents; liaison with a selected clinical area; and conduct of a clinical or scholarly research project. The fellows are closely supervised by members of the liaison faculty. They are expected to be competent general psychiatrists skilled in dealing with psychiatric problems encountered in medical settings, and able to communicate effectively with other physicians. They are encouraged to adopt an eclectic and critically commonsense approach to clinical work and psychiatric theories.
Investigation Research activities are essential if liaison psychiatry is to survive and make a lasting contribution. Several major areas for investigation may be suggested: • Psychiatric complications of all the major chronic diseases, such as coronary heart disease, chronic obstructive pulmonary disease, and cancer.6 • Somatoform and factitious disorders, which comprise a significant portion ofdiagnostic problems encountered in liaison work. Psychalgia (psychogenic pain), for example, requires systematic research to develop more effective diagnostic and therapeutic techniques. Conversion and somatization disorders and hypochondriasis often baffle consultants as much as consultees and place a strain on therapeutic resources. • Organic brain syndromes are among the main psychiatric disorders encountered by liaison psychiatrists, yet they have been neglected by researchers.7 Delirium, PSYCHOSOMATICS
dementia, and other organic syndromes are becoming more prevalent as the number of people age 65 and over (currently about 24 million) grows. Formulation of the diagnostic criteria for these syndromes in DSM-III should encourage and facilitate research on them, and liaison psychiatrists are strategically placed to do it in collaboration with other physicians and neuroscientists. New investigative tools to measure regional cerebral blood flow and metabolism should lead to rapid advances in this area. • Evaluation of the various techniques of behavior modification in the treatment of medical disorders
is an area in which collaboration between liaison psychiatrists and clinical psychologists could result in better therapies. Psychologists can have a salutary effect on research at the borderland of medicine because of their training in research methodology, which liaison psychiatrists often lack. • Evaluation of the effectiveness of consultation-liaison work in its clinical and teaching aspects is overdue.
Conclusions The future of liaison psychiatry looks bright at this time, yet the field faces formidable challenges
Supported in part by GP Special Training Grant, NIMH l3l7UJI.
REFERENCES
3. Lipowski ZJ, Wolston EJ: Liaison psychiatry: Referral patterns and their stability over time Am J Psychiatry. to be published. 4. Lipowski ZJ: Consultation-liaison psychiatry: An overview. Am J Psychiatry 131:623-630. 1974. 5. McNamara JR (ed): Behavioral Approaches to Medicine. New York, Plenum. 1979.
6. Lipowski ZJ: Physical illness and psychiatric disorder: A neglected relationship. Psycr"atria Fennica. suppl, 1979. pp 32-57 7. Lipowski ZJ: Organic mental disorders: Introduction and review of syndromes. in Kaplan HI. Freedman AM, Sadock BJ (eds): Comprehensive Textbook of Psychiatry, ed 3. Baltimore. Williams & Wilkins. 1980. pp 1359-1392
1. Lipowski ZJ: Consultation-liaison psychiatry. Past failures and new opportunities. Gen Hosp Psychiatry 1:3- 1O. 1979. 2. Lipowski ZJ: Holisfic-medical foundations of American psychialry: A bicentennial. Am J Psychiatry 138:888-895. 1981.
SEPTEMBER 1981 • VOL 22 • NO 9
and pitfalls. Organizational changes as well as clear formulation of objectives in teaching and research are needed. Sensible division of labor and close collaboration with liaison nurses and psychologists practicing behavioral medicine are called for. Liaison psychiatry offers enough intellectual challenge to attract bright young people. To succeed, they will have to put high-quality clinical service and research Before apostolic zeal and proselytizing. 0
lI09