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Liaison psychiatry on a burn unit
Liaison Psychiatry on a Burn Unit Aaron Billowitz, M.D., William Friedson, M.A., and Daniel S. l? Schubert, M.D., Ph.D. Case WesternReserve University School of Medicine and Cleveland Metropolitan General Hospital, Cleveland, Ohio
Abstract: Psychiatric liaison activities and interventions on a burn unit are described. The authors review the psychiatrist’s interventions with regard to unhealthy staff denial;educating staffabout psychiatric issues; facilitating improved staff-patient communication; and helping nurses manage patients’ inappropriate sexual behavior.
The liaison psychiatrist’s role on a burn unit has many elements similar to those described for other inpatient settings (1,2). The complex stresses specific to bum units, however, require that the liaison psychiatrist function with a distinct approach to the particular demands inherent in this setting. This report describes various types of intervention with a burn unit staff. The psychological aspects of bums have been discussed in the literature (3-6); in contrast, liaison psychiatry on a burn unit has received little attention. The practical and emotional demands on patients and staff on a burn unit often can be overwhelming. Although the types of clinical problems and pressures are not unique to burn units, many factors are combined to create a stressful medical environment. The liaison psychiatrist’s role is discussed here in terms of working with nonpsychiatrist staff concerning patient management and recognition of psychological and emotional factors that interfere with patients’ recovery and adjustment to their burn injury.
Clinical Environment Burn patients must cope with the extreme demands of long-term hospitalization. Strain and Grossman Supported in part by NlMH Training Grant 1 T 0 1 M H 14852 and NZH Internal Medicine Training Grant PE-15188-01.
300 ISSN 0163~8343/O4O3LW06602.25
have described prerequisites for patients’ successful adaptation to illness and hospitalization (7). Lengthy hospitalization on a bum unit requires strong adaptational abilities, and the liaison psychiatrist’s goal in this setting is to help patients, through liaison interventions, maintain the abilities to adapt successfully over a long recovery period. The staff’s role in helping bum patients adapt to their hospital situation can be facilitated by attention to several basic principles. The following suggestions for patient management-based on Goodstein and Hurwitz (B), who discussed the treatment of two burn cases in their paper-are particularly appropriate to burn patients. 1. Encourage all staff to interact with the patient at
2.
3. 4.
5.
times other than surgery and dressing changes in order to foster a painless relationship Anticipate questions about patient’s status and prognosis regarding appearance and length of hospitalization. Use photographs of, and talks with, recovered burn patients Foster independence with self-help responsibilities Provide adequate analgesics and sedation, but avoid “as needed” regimens and monitor total medication Begin rehabilitation plans and program early and with patient involvement. Meet the patient’s family and friends to increase communication and involvement in psychological and physical rehabilitation.
The liaison psychiatrist’s work with various medical specialties has been described (9-16). On the bum unit, conditions that are typical in various hospital units often exist in dramatic combination. That is, there are severely acutely ill and delirious General Hospital Psych&y 2, 300-305, 1980 @ Elsevier North Holland, Inc., 1980
Liaison Psychiatry on a Bum Unit
patients (similar to the ICU); physical disfigurement and deformity (similar to plastic surgery); frequent painful procedures, specifically dressing changes (as in general surgery); and severe, permanent disability having occurred without warning (similar to spinal cord and trauma units). Furthermore, a high proportion of patients’ burn injuries are a result of suicidal or nonaccidental causes, suggesting premorbid psychopathology, which must be considered in addition to attending to the many physical reactions. The liaison psychiatrist role involves relating to burn unit staff around current problems; these interactions are based on fundamental principles of liaison work, which are also applicable to other medical settings. These are: 1. Endorsement
of the medical director 2. Knowledge of the specific medical problems in the target environment 3. Maximum utilization of the participant-observer role 4. Necessity to repeat basic psychiatric principles of the pres5. Appreciation and acknowledgement sures on non-psychiatric staff 6. Recognition of healthy versus unhealthy denial in patients and staff 7. Understanding when and how to confront unhealthy denial 8. Appreciation of the source of unresponsiveness to psychiatric input, that is, resistance, lack of knowledge, inattention 9. Recognition of inappropriate staff involvement with patients.
past psychiatric histories, have received primary psychiatric management and treatment. The majority of patients have been managed by the adult social worker and nonpsychiatrist staff. Psychiatric input in these cases has been given at the weekly team meetings, periodic rounding with physicians and charge nurse, and informal discussions with the nonpsychiatrist staff on the ward. In addition, for one year the senior author met weekly with the nursing staff.
Liaison Activities and Interventions The Team Meefings The weekly team meeting is the foundation of the team’s activities. As part of the philosophy of the burn unit, the psychiatrist is accepted as an important member of the team. This acceptance has been enhanced by the psychiatrist’s continuity in working with the team for an extended period, as well as his status as a staff physician. In the team meetings, the psychiatrist contributes as a participant-observer. His part-time role of working with the burn unit enables him to become involved in patient care issues while allowing him some distance to reflect on these issues. The psychiatrist’s training as a participant-observer is valuable in allowing him to offer a detached perspective when other staff may be too closely involved to see a situation objectively. Two examples illustrate this:
Case 1 The Setting One of the authors (AB) has worked as adult liaison psychiatrist with the burn unit at Cleveland Metropolitan General Hospital for over five years. In this setting the team approach is employed as the means of practicing the philosophy of caring for the “total person”-a concept initiated by the unit director. The team consists of the bum unit director, the surgical house officers, nursing supervisor and nurses, physical and occupational therapists, dietitian, and volunteer services. Representation by mental health professionals includes the psychiatrist and social worker responsible for adult patients and the child psychologist and social worker assigned to child patients. A relatively small number of patients, mainly those with active psychiatric disorders or significant
A 40-year-old white male sustained an electrical bum, which led to loss of his hand. The patient was making good progress in his adjustment to the loss and reached the point in recovery when he was ready to leave the hospital for his first pass. The patient had commented that he belonged to a lodge which was holding its annual social event and he hoped to be able to attend. Team members discussed with some excitement the possibility of surprising the patient with news that he would be given permission to attend this large social gathering. Looking beyond this initial excitement, the liaison psychiatrist pointed out the potential drawbacks of such a social encounter. The patient had not yet observed his friends’ reactions to his disfigurement. Facing this hurdle at a large social gathering could have been awkward and uncomfortable for those with no prior knowledge of his physical appearance, thus increasing the patient’s own discomfort. 301
A. Billowitz et al.
Case 2 A 53-year-old man sustained 40% burns in a house fire. The patient had a prior history of treatment for recurrent depression. Six months prior to admission, an overdose led to severe and apparently permanent hypoxic brain damage. At the weekly team meeting, a lengthy discussion centered about the extensive medical efforts required to meet the challenge of helping the patient to survive his burns. The only question or doubt raised by the team was whether, should he survive, the patient might again become depressed with little or no desire to go on living. The liaison psychiatrist commented that while depression should be considered a treatable and fully reversible disorder, the central issue to be faced by the team was whether heroic efforts to save this patient might merely lead to prolonging a vegetable-like existence due to brain damage incurred at the time of his overdose. Defensive denial is a common feature for both staff and patients on a bum unit. Case 1 describes a patient who had not worked through his reactions to disfigurement; in this case the patient and staff evidenced denial with regard to the realities of exposing his disfigurement to friends and acquaintances. In case 2, the staff’s intense interest in the patient’s survival blinded them to the real possibility that their extensive efforts to save the patient might merely prolong his rather hopeless existence. The team meetings can provide an educational forum for the liaison psychiatrist to illustrate psychiatric principles to participants from other specialties. The psychiatrist should be alert to team members’ varying levels of psychiatric knowledge. The following case exemplifies the ambiguities which can arise when a psychiatrist makes a recommendation to the nonpsychiatrist staff. In instances such as the one described below it is important to distinguish a staff member’s response as the result of misunderstanding rather than hostility.
Case
3
Four men who were involved in an industrial accident were admitted to the burn unit. At the burn team meeting three days later, one of these patients was noted as being extremely agitated, irritable, restless, and unable to tolerate pain. He had become verbally hostile and uncooperative. The psychiatrist recommended use of chlorpromazine to try to calm the patient; this prompted comments regarding this drug’s high sedating properties. A second patient had also shown great difficulty in the immediate adjustment to his burn, but in contrast to the first patient, showed marked withdrawal and apathy. Concern was 302
raised that this behavior might jeopardize his medical care-he was reluctant to move at all, refused to eat, and lacked appropriate involvement with the staff. With regard to this patient, the resident asked the psychiatrist only one question: What dose of chlorpromazine would be appropriate for him? The psychiatrist again emphasized the need to observe and then
attempt to understand the patient’s behavior before formulating the correct plan for management. Proximity plays an important role in learning. The rotating resident’s consuming tasks of learning the fundamentals of burn care and adjusting to the overwhelming stresses of the unit may interfere with prior learning. Matter-of-fact explanations offered by the psychiatrist can be helpful in confronting situations involving a team member’s misunderstanding or subtle hostility.
Work Rounds The psychiatrist participates in daily work rounds with the unit director, the surgical residents, and one or two nurses. Although the liaison psychiatrist can often contribute important advice and information in work rounds, he also learns a great deal about the essentials of bum care and management. This knowledge helps the psychiatrist when interacting with patients; he can readily assess whether the patient has an accurate or distorted understanding of what the doctors have told him. The psychiatrist is also better prepared to assist in further edrrcating the patient without repeatedly asking doctors and nurses questions about basic medical issues. In learning about the medical aspects of burn care, the liaison psychiatrist can appreciate the enormous demands and tremendous pressure under which the medical staff and surgeons work. The psychiatrist can thus acquire a perspective on his role in the total team effort, and perhaps can better understand the occasional situations in which his recommendations are overlooked. He must maintain the appropriate respect and appreciation for his medical colleagues. Participation in work rounds also establishes the psychiatrist’s role as an integral part of the team in the eyes of patients. The medical and nursing staff’s attitude regarding the psychiatrist conveys to patients that he is indeed part of the total bum team. This tends to enhance patient acceptance of direct psychiatric intervention when indicated. Through work rounds, the psychiatrist is able to see to what extent the plans discussed at the weekly team meetings are carried through or, conversely, to what
Liaison Psychiatry
there may be friction or dissention between staff members. The psychiatrist also observes the physicians’ interaction with the patient, and can detect subtle problems in interaction or communication that are not brought up at the team meetings. He is then able to later follow-up on this. For example, one comment often made by doctors in inspecting the patient’s burn is “It looks good.” Patients may have great difficulty reconciling this statement with their own perception of their injury. The psychiatrist may later clarify to the patient the doctor’s intended message-that the burns are healing well and ultimately will improve in appearance.
extent
Meeting the Nurses The liaison psychiatrist’s regularly scheduled meetings with nursing staff were designed to help nurses work through their feelings on especially difficult and emotional aspects of their professional work. These included issues such as caring for the dying patient, dealing with parents of children with burns caused by parental abuse or neglect, working with grossly disfigured patients, and managing patients with serious psychiatric disorders. Another goal was to increase nurses’ awareness and understanding of defense mechanisms and psychodynamics in patients, and also to stimulate increased awareness of their own feelings in interacting with patients. Despite what seemed to be a reasonable set of goals, contents of the meetings were greatly influenced by acute events on the ward, and many of the original goals were of necessity neglected. For example, the death of a patient who had been on the ward for some time invariably drew the largest attendance and the most active discussions. In general, the psychiatrist found that teaching psychodynamics and defense mechanisms was only moderately successful in the context of the nurses’ group. A more useful method of teaching took place on an individual basis, discussing with a nurse the underlying reasons for the behavior of a particular patient.
Informal Liaison Activities on the Ward Once the liaison psychiatrist has established himself as a person who can be helpful, relied upon, available and approachable on the ward, the nursing staff and others may present issues to him that would otherwise remain unaddressed. In particular, the liaison psychiatrist can be helpful to the
on a Burn Unit
nursing staff in dealing with sexual issues that arise in their work with patients. The following two cases illustrate this:
Case 4 A nurse, recently graduated from nursing school, was working regularly with a patient several years her senior who had sustained 80% total body burns. The patient was in the rehabilitation phase and nearing discharge. He had been a handsome man, proud of his appearance, who was now coping with how his facial and body scars would affect his future relationships with women. The patient asked the nurse if she would be interested in going out with him after his discharge. The nurse then presented the liaison psychiatrist with her conflicts in this situation. She felt that refusing the patient would be a blow to his confidence, could lead to further depression and be a setback in his rehabilitation. On a personal level, however, she had no interest in dating the patient and in particular felt their racial difference definitely precluded any social relationship. The liaison psychiatrist had worked with the patient intensively and was well aware that he had strong feelings of pride in being black, with no interest in dating white women. The liaison psychiatrist then explained to the nurse that the patient was merely testing her and observing her reactions. The nurse was then able to see the patient’s invitation for a date as a way of asking the question, “Do you think that anyone could be interested in going out with someone who was as scarred as I am?”
The issue of patients asking nurses for dates comes up frequently in acute care inpatient settings. This often is not problematic; patients in many other settings do not see rejection as due to their medical condition. On the burn unit, asking to see a nurse socially generally represents a patient’s initial effort to test out others’ reactions to his disfigurement. Over time, most nurses recognize that such questions are not directed at them personally, and that they should respond in their professional role. For the inexperienced nurse, these deIicate situations are particularly troublesome. It is generally helpful to provide the nurse with an opportunity to ventilate associated feelings and to offer a limited interpretations of the patient’s motives. This can diminish the nurse’s anxietv, enabling her to face the patient. If the psychiatrist is asked for something specific to tell the patient, he can suggest a simple statement such as, “I’m interested in you as a patient here, but professional ethics prevent me from seeing you socially,” spoken with kindness and resolve.
A. Billowitz et al.
Case 5 With some hesitation, a nurse approached the liaison psychiatrist about a problem that developed with a 25-year-old male. The nurse had been present at the burn unit team meeting that same morning where the patient was discussed at length. Although several nurses were aware of it, there had been no mention of the patient’s habit of frequently exposing and manipulating his genitals. Up to that point, the nurses had attempted to ignore this behavior, at first pretending that it was accidental and then hoping that eventually it would subside without any intervention. The patient‘s behavior was interpreted to the nurse as being a manifestation of anxiety caused by his burns and his passive and dependent position on the burn unit. In addition to this brief and limited explanation of the patient’s behavior, the nurse was advised to tell the patient that he should not be uncovered when he could be seen by visitors or others working about the ward. Having received “permission” and direction to talk with the patient about his behavior, the nurse’s anxiety and embarrassment was reduced, and she was able to carry out the psychiatrist’s recommendation. Concurrently, the psychiatrist began psychotherapy to facilitate the patient’s appropriate working through of conflicts rather than to act out inappropriately. forced passivePhysical immobilization, dependency, and bodily disfigurement almost inevitably result in varying degress of regressed be-
havior. While appropriate regression is necessary for satisfactory adjustment to hospitalization, significant pre-morbid psychopathology can increase the likelihood of pathological regression. When regression becomes sexual, staff anxiety may be heightened to such a degree that denial and/or avoidance occur. In addressing the nurses’ concerns, attention is most usefully directed to eliminating the objectionable behavior rather than attempting to interpret the patient’s behavior.
Summary The burn team meetings are the central focus and forum for all burn unit activities. Here, the director of the burn unit grants or withholds acceptance and sanction of the liaison psychiatrist’s contributions. The director gives covert but strong messages to other team members concerning the extent to which the psychiatrist’s opinions and recommendations are to be accepted and valued. Deliberations and decisions made at the team meeting carry special weight and represent a more or less official position. In contrast to the formal plans and decisions
304
outlined in the team meetings, the psychiatrist’s participation in other liaison activities provides the opportunity to develop relationships on a more individual basis, and allows him to be responsive to the immediate day to day situations. A liaison psychiatrist cannot be effective without the endorsement of the medical team leader. In addition, he must prove his value amid the often overwhelming clinical realities. The psychiatrist’s meetings with nurses and his participation in work rounds greatly facilitate his ability to affect useful interactions and recommendations and, further, makes him appreciate the clinical context in which his recommendation are made. A liaison psychiatrist’s progress over time in working with the medical staff is greatly complicated by the medical teaching system in which house officers are transient members of the team. Other key staff members in nursing, physical therapy, occupational therapy, dietary, and volunteer services also change over time. Consequently, the psychiatrist must always be aware that issues that have been discussed once or even many times in the past may require repetition, since each new team member must work through the emotional demands of the highly charged environment. The dramatic and traumatic situations that occur so often on a burn unit give cause for the liaison psychiatrist to recognize that very basic issues and principles need to be repeated often and never taken for granted. Overwhelming clinical pressures and responsibilities or psychological factors can allow “obvious” issues to be overlooked. In the case examples presented, the basic issues involved (disfigurement, adjustments back into society, different patterns of reaction to illness, proper use of medications, the quality of life in the recovered patient, the holistic approach to the patient, and sexual concerns) had been discussed in conjunction with various cases over many team meetings. In each of the case examples presented, the liaison psychiatrist gave input which helped the team member or members to regain their ability to objectively observe a patient’s circumstances.
References Schubert DSP: Obstacles to effective psychiatric liaison. Psychosomatics 19:283-285, 1978 Lipowski ZJ: Psychosomatic medicine: An overview. In Hill OW (ed). Modern Trends in Psychosomatic Medicine. London, Butterworths, 1976, pp. l-20 Noyes, R, Andreasen NJC, Hartford CE: The
Liaison Psychiatry
4. 5. 6. 7.
8.
9. 10. 11.
12.
psychological reaction to severe bums. Psychosomatics 12:416422, 1971 Andreasen NJ: Neuropsychiatric complications in burn patients. Int J Psychiatry Med 5:161-171, 1974 Weisz AE: Psychotherapeutic support of burned patients. Modem Treatment 41291-1303, 1967 MacArthur JD, Moore FD: Epidemiology of burns: The burn-prone patient. JAMA 3259-263, 1975 Strain JJ, Grossman S: Psychological Care of the Medically III: A Primer in Liaison Psychiatry. New York, Appleton-Century Crofts, 1975 Goodstein RK, Hurwitz TD: The role of the psychiatric consultant in the treatment of burned patients. Int J Psychiatry Med 6:413429, 1975 Lipowski ZJ: Psychiatric liaison with neurology and neurosurgery. Am J Psychiatry 129:136-140, 1972 Hertzberg LJ: Cancer and the dying patient. Am J Psychiatry 128P306-810, 1972 De-Nour AK: Role and reactions of psychiatrists in chronic hemodialysis programs. Int J Psychiatry Med 463-75, 1973 Froese AI’, Kamin LE, Levine CA: Teamwork: A
13. 14.
15.
16.
on a Bum Unit
multi-disciplinary pediatric-Iiaison service. Int J Psychiatry Med 7~47-56, 1976 Cassem NH, Hackett TI? Psychiatric consultation in a coronary care unit. Ann Intern Med 759-14, 1971 Baundry F, Wiener A: Initiation of a psychiatric teachfor surgeons. Am J Psychiatry ing program 125:1192-1197, 1969 Lipowski ZJ, Ramsay RA, ViIlard HP: Psychiatric consultation in medical and surgical outpatient clinics. Can Psychiatr Assoc J 14:239-245, 1969 Gunther MS: Psychiatric consultation in a rehabilitation hospital. Compr Psychiatry 12:572-585, 1971
Direct reprint requests to: Daniel Schubert, M.D. Department of Psychiatry Cleveland Metropolitan General Hospital 3395 Scranton Road Cleveland, OH 44109
305
Abstract: Psychiatric liaison activities and interventions on a burn unit are described. The authors review the psychiatrist’s interventions with regard to unhealthy staff denial;educating staffabout psychiatric issues; facilitating improved staff-patient communication; and helping nurses manage patients’ inappropriate sexual behavior.
The liaison psychiatrist’s role on a burn unit has many elements similar to those described for other inpatient settings (1,2). The complex stresses specific to bum units, however, require that the liaison psychiatrist function with a distinct approach to the particular demands inherent in this setting. This report describes various types of intervention with a burn unit staff. The psychological aspects of bums have been discussed in the literature (3-6); in contrast, liaison psychiatry on a burn unit has received little attention. The practical and emotional demands on patients and staff on a burn unit often can be overwhelming. Although the types of clinical problems and pressures are not unique to burn units, many factors are combined to create a stressful medical environment. The liaison psychiatrist’s role is discussed here in terms of working with nonpsychiatrist staff concerning patient management and recognition of psychological and emotional factors that interfere with patients’ recovery and adjustment to their burn injury.
Clinical Environment Burn patients must cope with the extreme demands of long-term hospitalization. Strain and Grossman Supported in part by NlMH Training Grant 1 T 0 1 M H 14852 and NZH Internal Medicine Training Grant PE-15188-01.
300 ISSN 0163~8343/O4O3LW06602.25
have described prerequisites for patients’ successful adaptation to illness and hospitalization (7). Lengthy hospitalization on a bum unit requires strong adaptational abilities, and the liaison psychiatrist’s goal in this setting is to help patients, through liaison interventions, maintain the abilities to adapt successfully over a long recovery period. The staff’s role in helping bum patients adapt to their hospital situation can be facilitated by attention to several basic principles. The following suggestions for patient management-based on Goodstein and Hurwitz (B), who discussed the treatment of two burn cases in their paper-are particularly appropriate to burn patients. 1. Encourage all staff to interact with the patient at
2.
3. 4.
5.
times other than surgery and dressing changes in order to foster a painless relationship Anticipate questions about patient’s status and prognosis regarding appearance and length of hospitalization. Use photographs of, and talks with, recovered burn patients Foster independence with self-help responsibilities Provide adequate analgesics and sedation, but avoid “as needed” regimens and monitor total medication Begin rehabilitation plans and program early and with patient involvement. Meet the patient’s family and friends to increase communication and involvement in psychological and physical rehabilitation.
The liaison psychiatrist’s work with various medical specialties has been described (9-16). On the bum unit, conditions that are typical in various hospital units often exist in dramatic combination. That is, there are severely acutely ill and delirious General Hospital Psych&y 2, 300-305, 1980 @ Elsevier North Holland, Inc., 1980
Liaison Psychiatry on a Bum Unit
patients (similar to the ICU); physical disfigurement and deformity (similar to plastic surgery); frequent painful procedures, specifically dressing changes (as in general surgery); and severe, permanent disability having occurred without warning (similar to spinal cord and trauma units). Furthermore, a high proportion of patients’ burn injuries are a result of suicidal or nonaccidental causes, suggesting premorbid psychopathology, which must be considered in addition to attending to the many physical reactions. The liaison psychiatrist role involves relating to burn unit staff around current problems; these interactions are based on fundamental principles of liaison work, which are also applicable to other medical settings. These are: 1. Endorsement
of the medical director 2. Knowledge of the specific medical problems in the target environment 3. Maximum utilization of the participant-observer role 4. Necessity to repeat basic psychiatric principles of the pres5. Appreciation and acknowledgement sures on non-psychiatric staff 6. Recognition of healthy versus unhealthy denial in patients and staff 7. Understanding when and how to confront unhealthy denial 8. Appreciation of the source of unresponsiveness to psychiatric input, that is, resistance, lack of knowledge, inattention 9. Recognition of inappropriate staff involvement with patients.
past psychiatric histories, have received primary psychiatric management and treatment. The majority of patients have been managed by the adult social worker and nonpsychiatrist staff. Psychiatric input in these cases has been given at the weekly team meetings, periodic rounding with physicians and charge nurse, and informal discussions with the nonpsychiatrist staff on the ward. In addition, for one year the senior author met weekly with the nursing staff.
Liaison Activities and Interventions The Team Meefings The weekly team meeting is the foundation of the team’s activities. As part of the philosophy of the burn unit, the psychiatrist is accepted as an important member of the team. This acceptance has been enhanced by the psychiatrist’s continuity in working with the team for an extended period, as well as his status as a staff physician. In the team meetings, the psychiatrist contributes as a participant-observer. His part-time role of working with the burn unit enables him to become involved in patient care issues while allowing him some distance to reflect on these issues. The psychiatrist’s training as a participant-observer is valuable in allowing him to offer a detached perspective when other staff may be too closely involved to see a situation objectively. Two examples illustrate this:
Case 1 The Setting One of the authors (AB) has worked as adult liaison psychiatrist with the burn unit at Cleveland Metropolitan General Hospital for over five years. In this setting the team approach is employed as the means of practicing the philosophy of caring for the “total person”-a concept initiated by the unit director. The team consists of the bum unit director, the surgical house officers, nursing supervisor and nurses, physical and occupational therapists, dietitian, and volunteer services. Representation by mental health professionals includes the psychiatrist and social worker responsible for adult patients and the child psychologist and social worker assigned to child patients. A relatively small number of patients, mainly those with active psychiatric disorders or significant
A 40-year-old white male sustained an electrical bum, which led to loss of his hand. The patient was making good progress in his adjustment to the loss and reached the point in recovery when he was ready to leave the hospital for his first pass. The patient had commented that he belonged to a lodge which was holding its annual social event and he hoped to be able to attend. Team members discussed with some excitement the possibility of surprising the patient with news that he would be given permission to attend this large social gathering. Looking beyond this initial excitement, the liaison psychiatrist pointed out the potential drawbacks of such a social encounter. The patient had not yet observed his friends’ reactions to his disfigurement. Facing this hurdle at a large social gathering could have been awkward and uncomfortable for those with no prior knowledge of his physical appearance, thus increasing the patient’s own discomfort. 301
A. Billowitz et al.
Case 2 A 53-year-old man sustained 40% burns in a house fire. The patient had a prior history of treatment for recurrent depression. Six months prior to admission, an overdose led to severe and apparently permanent hypoxic brain damage. At the weekly team meeting, a lengthy discussion centered about the extensive medical efforts required to meet the challenge of helping the patient to survive his burns. The only question or doubt raised by the team was whether, should he survive, the patient might again become depressed with little or no desire to go on living. The liaison psychiatrist commented that while depression should be considered a treatable and fully reversible disorder, the central issue to be faced by the team was whether heroic efforts to save this patient might merely lead to prolonging a vegetable-like existence due to brain damage incurred at the time of his overdose. Defensive denial is a common feature for both staff and patients on a bum unit. Case 1 describes a patient who had not worked through his reactions to disfigurement; in this case the patient and staff evidenced denial with regard to the realities of exposing his disfigurement to friends and acquaintances. In case 2, the staff’s intense interest in the patient’s survival blinded them to the real possibility that their extensive efforts to save the patient might merely prolong his rather hopeless existence. The team meetings can provide an educational forum for the liaison psychiatrist to illustrate psychiatric principles to participants from other specialties. The psychiatrist should be alert to team members’ varying levels of psychiatric knowledge. The following case exemplifies the ambiguities which can arise when a psychiatrist makes a recommendation to the nonpsychiatrist staff. In instances such as the one described below it is important to distinguish a staff member’s response as the result of misunderstanding rather than hostility.
Case
3
Four men who were involved in an industrial accident were admitted to the burn unit. At the burn team meeting three days later, one of these patients was noted as being extremely agitated, irritable, restless, and unable to tolerate pain. He had become verbally hostile and uncooperative. The psychiatrist recommended use of chlorpromazine to try to calm the patient; this prompted comments regarding this drug’s high sedating properties. A second patient had also shown great difficulty in the immediate adjustment to his burn, but in contrast to the first patient, showed marked withdrawal and apathy. Concern was 302
raised that this behavior might jeopardize his medical care-he was reluctant to move at all, refused to eat, and lacked appropriate involvement with the staff. With regard to this patient, the resident asked the psychiatrist only one question: What dose of chlorpromazine would be appropriate for him? The psychiatrist again emphasized the need to observe and then
attempt to understand the patient’s behavior before formulating the correct plan for management. Proximity plays an important role in learning. The rotating resident’s consuming tasks of learning the fundamentals of burn care and adjusting to the overwhelming stresses of the unit may interfere with prior learning. Matter-of-fact explanations offered by the psychiatrist can be helpful in confronting situations involving a team member’s misunderstanding or subtle hostility.
Work Rounds The psychiatrist participates in daily work rounds with the unit director, the surgical residents, and one or two nurses. Although the liaison psychiatrist can often contribute important advice and information in work rounds, he also learns a great deal about the essentials of bum care and management. This knowledge helps the psychiatrist when interacting with patients; he can readily assess whether the patient has an accurate or distorted understanding of what the doctors have told him. The psychiatrist is also better prepared to assist in further edrrcating the patient without repeatedly asking doctors and nurses questions about basic medical issues. In learning about the medical aspects of burn care, the liaison psychiatrist can appreciate the enormous demands and tremendous pressure under which the medical staff and surgeons work. The psychiatrist can thus acquire a perspective on his role in the total team effort, and perhaps can better understand the occasional situations in which his recommendations are overlooked. He must maintain the appropriate respect and appreciation for his medical colleagues. Participation in work rounds also establishes the psychiatrist’s role as an integral part of the team in the eyes of patients. The medical and nursing staff’s attitude regarding the psychiatrist conveys to patients that he is indeed part of the total bum team. This tends to enhance patient acceptance of direct psychiatric intervention when indicated. Through work rounds, the psychiatrist is able to see to what extent the plans discussed at the weekly team meetings are carried through or, conversely, to what
Liaison Psychiatry
there may be friction or dissention between staff members. The psychiatrist also observes the physicians’ interaction with the patient, and can detect subtle problems in interaction or communication that are not brought up at the team meetings. He is then able to later follow-up on this. For example, one comment often made by doctors in inspecting the patient’s burn is “It looks good.” Patients may have great difficulty reconciling this statement with their own perception of their injury. The psychiatrist may later clarify to the patient the doctor’s intended message-that the burns are healing well and ultimately will improve in appearance.
extent
Meeting the Nurses The liaison psychiatrist’s regularly scheduled meetings with nursing staff were designed to help nurses work through their feelings on especially difficult and emotional aspects of their professional work. These included issues such as caring for the dying patient, dealing with parents of children with burns caused by parental abuse or neglect, working with grossly disfigured patients, and managing patients with serious psychiatric disorders. Another goal was to increase nurses’ awareness and understanding of defense mechanisms and psychodynamics in patients, and also to stimulate increased awareness of their own feelings in interacting with patients. Despite what seemed to be a reasonable set of goals, contents of the meetings were greatly influenced by acute events on the ward, and many of the original goals were of necessity neglected. For example, the death of a patient who had been on the ward for some time invariably drew the largest attendance and the most active discussions. In general, the psychiatrist found that teaching psychodynamics and defense mechanisms was only moderately successful in the context of the nurses’ group. A more useful method of teaching took place on an individual basis, discussing with a nurse the underlying reasons for the behavior of a particular patient.
Informal Liaison Activities on the Ward Once the liaison psychiatrist has established himself as a person who can be helpful, relied upon, available and approachable on the ward, the nursing staff and others may present issues to him that would otherwise remain unaddressed. In particular, the liaison psychiatrist can be helpful to the
on a Burn Unit
nursing staff in dealing with sexual issues that arise in their work with patients. The following two cases illustrate this:
Case 4 A nurse, recently graduated from nursing school, was working regularly with a patient several years her senior who had sustained 80% total body burns. The patient was in the rehabilitation phase and nearing discharge. He had been a handsome man, proud of his appearance, who was now coping with how his facial and body scars would affect his future relationships with women. The patient asked the nurse if she would be interested in going out with him after his discharge. The nurse then presented the liaison psychiatrist with her conflicts in this situation. She felt that refusing the patient would be a blow to his confidence, could lead to further depression and be a setback in his rehabilitation. On a personal level, however, she had no interest in dating the patient and in particular felt their racial difference definitely precluded any social relationship. The liaison psychiatrist had worked with the patient intensively and was well aware that he had strong feelings of pride in being black, with no interest in dating white women. The liaison psychiatrist then explained to the nurse that the patient was merely testing her and observing her reactions. The nurse was then able to see the patient’s invitation for a date as a way of asking the question, “Do you think that anyone could be interested in going out with someone who was as scarred as I am?”
The issue of patients asking nurses for dates comes up frequently in acute care inpatient settings. This often is not problematic; patients in many other settings do not see rejection as due to their medical condition. On the burn unit, asking to see a nurse socially generally represents a patient’s initial effort to test out others’ reactions to his disfigurement. Over time, most nurses recognize that such questions are not directed at them personally, and that they should respond in their professional role. For the inexperienced nurse, these deIicate situations are particularly troublesome. It is generally helpful to provide the nurse with an opportunity to ventilate associated feelings and to offer a limited interpretations of the patient’s motives. This can diminish the nurse’s anxietv, enabling her to face the patient. If the psychiatrist is asked for something specific to tell the patient, he can suggest a simple statement such as, “I’m interested in you as a patient here, but professional ethics prevent me from seeing you socially,” spoken with kindness and resolve.
A. Billowitz et al.
Case 5 With some hesitation, a nurse approached the liaison psychiatrist about a problem that developed with a 25-year-old male. The nurse had been present at the burn unit team meeting that same morning where the patient was discussed at length. Although several nurses were aware of it, there had been no mention of the patient’s habit of frequently exposing and manipulating his genitals. Up to that point, the nurses had attempted to ignore this behavior, at first pretending that it was accidental and then hoping that eventually it would subside without any intervention. The patient‘s behavior was interpreted to the nurse as being a manifestation of anxiety caused by his burns and his passive and dependent position on the burn unit. In addition to this brief and limited explanation of the patient’s behavior, the nurse was advised to tell the patient that he should not be uncovered when he could be seen by visitors or others working about the ward. Having received “permission” and direction to talk with the patient about his behavior, the nurse’s anxiety and embarrassment was reduced, and she was able to carry out the psychiatrist’s recommendation. Concurrently, the psychiatrist began psychotherapy to facilitate the patient’s appropriate working through of conflicts rather than to act out inappropriately. forced passivePhysical immobilization, dependency, and bodily disfigurement almost inevitably result in varying degress of regressed be-
havior. While appropriate regression is necessary for satisfactory adjustment to hospitalization, significant pre-morbid psychopathology can increase the likelihood of pathological regression. When regression becomes sexual, staff anxiety may be heightened to such a degree that denial and/or avoidance occur. In addressing the nurses’ concerns, attention is most usefully directed to eliminating the objectionable behavior rather than attempting to interpret the patient’s behavior.
Summary The burn team meetings are the central focus and forum for all burn unit activities. Here, the director of the burn unit grants or withholds acceptance and sanction of the liaison psychiatrist’s contributions. The director gives covert but strong messages to other team members concerning the extent to which the psychiatrist’s opinions and recommendations are to be accepted and valued. Deliberations and decisions made at the team meeting carry special weight and represent a more or less official position. In contrast to the formal plans and decisions
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outlined in the team meetings, the psychiatrist’s participation in other liaison activities provides the opportunity to develop relationships on a more individual basis, and allows him to be responsive to the immediate day to day situations. A liaison psychiatrist cannot be effective without the endorsement of the medical team leader. In addition, he must prove his value amid the often overwhelming clinical realities. The psychiatrist’s meetings with nurses and his participation in work rounds greatly facilitate his ability to affect useful interactions and recommendations and, further, makes him appreciate the clinical context in which his recommendation are made. A liaison psychiatrist’s progress over time in working with the medical staff is greatly complicated by the medical teaching system in which house officers are transient members of the team. Other key staff members in nursing, physical therapy, occupational therapy, dietary, and volunteer services also change over time. Consequently, the psychiatrist must always be aware that issues that have been discussed once or even many times in the past may require repetition, since each new team member must work through the emotional demands of the highly charged environment. The dramatic and traumatic situations that occur so often on a burn unit give cause for the liaison psychiatrist to recognize that very basic issues and principles need to be repeated often and never taken for granted. Overwhelming clinical pressures and responsibilities or psychological factors can allow “obvious” issues to be overlooked. In the case examples presented, the basic issues involved (disfigurement, adjustments back into society, different patterns of reaction to illness, proper use of medications, the quality of life in the recovered patient, the holistic approach to the patient, and sexual concerns) had been discussed in conjunction with various cases over many team meetings. In each of the case examples presented, the liaison psychiatrist gave input which helped the team member or members to regain their ability to objectively observe a patient’s circumstances.
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Direct reprint requests to: Daniel Schubert, M.D. Department of Psychiatry Cleveland Metropolitan General Hospital 3395 Scranton Road Cleveland, OH 44109
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