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Objectives For Residents In Consultation Psychiatry: Recommendations Of A Task Force
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CONSULTATION-LIAISON PSYCHIATRY
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STEVEN A. COHEN-COLE, M.D. JACK HAGGERTY, M.D. DAVID RAFT, M.D.
Objectives for residents in consultation psychiatry: Recommendations of a task force ABSTRACT: The authors briefly describe the work of the Association for Academic Psychiatry Task Force on Consultation/ Liaison Objectives and discuss the principles behind the development of a proposed set of training objectives for residents in consultation psychiatry. These proposed objectives are presented in their complete form, followed by an elaboration of the knowledge objectives concerning the consultation process.
Educational experts emphasize the central importance of clearly specified objectives in an efficient, effective educational program. l -4 Such experts maintain that well-constructed objectives serve the following important functions: (I) help instructors and trainees work collaboratively toward stated goals; (2) facilitate the design of relevant teaching methods; and (3) develop appropriate evaluation instruments to monitor and modify teaching efforts. Programs without adequate Dr. Cohen-Cole is associate professor of psychiatry at the University ofAlabama School of Medicine, and Dr. Haggerty is assistant professor and Dr. Raft associate professor in the department ofpsychiatry at the University of North Carolina School of Medicine. Reprint requests to Dr. Cohen-Cole at the University of A labama School of Medicine, Birmingham, A L 35294.
JULY 1982· VOL 23' NO 7
objectives may suffer from a lack of focus, insufficiency or redundancy in the curriculum, inefficient choice of instructional procedures, and uncertainty concerning evaluation methodologies. In response to a perceived absence of coherent training objectives in the general area of consultation and liaison psychiatry, the Consultation/Liaison Section of the Association for Academic Psychiatry (Chairman, Don Lipsitt, M.D.) created a task force in the fall of 1979 to begin clarifying and systematizing current training objectives in this field. The first author (SC-C) was appointed chairman of the task force, and began work by sending a questionnaire to all NIMH-funded consultation and liaison programs asking for a summary of their objectives. Based on 40 responses, he developed a compendium of consultation (resident) and liaison (fellowship) training objectives which was presented at the Annual Meeting of the Association for Academic Psychiatry (AAP) in San Antonio in 1980 [available on request from the authors]. Based on discussions in San Antonio, and subsequent meetings of interested task force members, the authors collaboratively developed a proposed set of minimal training objectives for residents in consultation psychiatry. These competency-based objectives were constructed according to the principles of educational theory that operationally useful objectives are concrete and unambiguous, useful for guiding teaching, attainable (given specific time and resources), and measurable (for the evaluation of outcome).5 The actual content covered by the objectives was decided by several factors including 699
Consultation psychiatry (I) the frequency with which any particular objective was included in different training programs; (2) the task force's understanding of consultation and liaison literature; and (3) the personal clinical and teaching experiences of task force members. The goal was to create a set of minimal training objectives representing the basic knowledge and skills required for medical consultations that every psychiatric resident should attain before graduating from a training program. Furthermore, we attempted to create a realistic and workable set of objectives that could actually guide teaching, program development, and evaluation in the field of consultation psychiatry. Future work includes the organization of a multicenter feasibility study (already begun), the design of appropriate evaluation procedures, and a national survey of
responses to this proposed set of objectives. The proposed objectives are outlined in full below to enable interested readers to use them in their own programs. Tenninal objective: To provide competent consultation to nonpsychiatric medical personnel regarding psychiatric and behavioral problems in medical patients. This requires the mastery and integration of specific knowledge objectives with a broad range of clinical skills.
I. KNOWLEDGE OBJECTIVES A. The consultation process (see Box, below) 1. Describe the objectives, responsibilities, authority, and limitations of the psychiatric consultant in medical settings. Discuss the way these vary in different situations.
The Psychiatric Consultation Process 1. THE PSYCHIATRIC CONSULTANT a. ObJectives: The primary objective of the psychiatric consultant is to optimize patient care by providing psychiatric assessments and recommendations for medical patients. An important secondary objective is education of the referring medical person (the consultee). Each particular consultation situation requires a decision (occasionally negotiated directly with the consultee) about the relative emphasis on these two different objectives. b. Responsibilities: The responsibility of the psychiatric consultant is to provide adequate psychiatric assessments and recommendations to medical colleagues. The primary responsibility for the patient remains with the consultee. However, intermediate issues of responsibility (follow-up visits, supportive psychotherapy, writing orders for psychiatric drugs, arranging for outpatient follow-ups) should be negotiated and explicitly clarified in each consultation relationship. c. Authority: Consultation usually involves voluntary collaboration on a relatively equal level between two or more professionals. However, regardless of the special expertise of the consultant, ultimate authority and responsibility for the patient remains with the consultee. d. Limitations: The consultant should adhere to the limitations of authority and responsibility discussed above. In addition, limitations relating to the differences between consultation and psychotherapy,
700
referral, or supervision (see below) should also be recognized. 2. THE CONSULTATION RELATIONSHIP a. Consultation versus supervision: The supervisory relationship (attending physician and resident) is based on delegated authority and direct legal responsibility. The relationship is hierarchic and the supervisor can require that the supervisee carry out certain actions. In the consultation relationship, neither party has authority over the other, and the consultee can accept reject, or modify the consultant's recommendations. The consultant has no direct legal responsibility for the actions of the consultee. b. Consultation versus referral: In the case of referral, partial or total responsibility for the care of a patient is transferred from one physician to another. The physicians are directly responsible to the patient, but not necessarily to each other. Each may make and carry through autonomous decisions about treatment. In consultation, on the other hand, primary responsibility for making decisions remains in the hands of the physician who requests the consultant's help. The consultant is responsible to both the patient and the consultee. He is limited to making suggestions to the consultee, and cannot make autonomous decisions about treatment. c. Consultation versus psychotherapy: In psychotherapy, the therapist elicits, clarifies, and modifies
PSYCHOSOMATICS
2. Describe the way the consultation relationship (ie, consultant-consultee) differs from supervision, referrals, or psychotherapy. 3. Discuss the way common factors influence the initiation, process, and outcome of a consultation. 4. Describe different types of psychiatric consultation in medical settings (patient-centered, physician-centered, program-centered, and nursecentered). Discuss indications, objectives, and relevant strategies for each. B. Biopsychosocial dimensions of medical practice I. Describe the influence of psychological and social variables on the predisposition, onset, course, and outcome of somatic illness. 2. Describe common patterns of psychological
the patient's pattern of emotional or behavioral responses. The psychiatric consultant may similarly seek to clarify patterns of emotional responses in either the referring medical personnel or the patient, both of which may affect the patient's adaptation. The consultant, however, generally limits such inquiries to the clarification and modification of specific disruptions in the professional relationship between the consultee and the patient. The consultant should not attempt to modify the consultee's general adaptation to life.
3. COMMON FACTORS INFLUENCING CONSULTATION The timing of the consultation in the course of the patient's hospitalization; the preparation of the patient; the nature of the primary doctor-patient relationship; the consultee's covert expectations of the consultation; the patient's expectations of the consultation; intrapsychic or interpersonal factors in the patient's medical care environment (such as group dynamics of the medical team or recent stresses on the ward); the fit between consultant recommendations and resources/attitudes/policies in the medical setting. 4. TYPES OF CONSULTATIONS a. Patient-centered: Indicated when a referring physician desires help with the assessment or management of a particular patient. The basic objective is
JULY 1982· VOL 23 • NO 7
and social adaptation to illness. 3. Describe factors that influence a caregiver's responses to patients. Discuss the way these responses affect health outcomes. 4. Describe the basic components of general systems theory as they relate to understanding and influencing health outcomes. C. Clinical syndromes. Describe the signs and symptoms, differential diagnosis, and course of those psychiatric and behavioral conditions that are most commonly encountered in medical settings.
l. Psychiatric conditions a. Delirium/dementia and other organic brain syndromes
to determine what is wrong with the patient and how that person can be helped, and to communicate this information to the referring physician. Education is a secondary objective. The strategy is to obtain enough information from and about the patient to answer the relevant questions. Direct patient assessment is always involved. b. Physician-centered: Indicated when the referring physician wants to improve his/her management of a case. The basic objective is educational. The strategy is based on an attempt to understand the nature of the consultee's difficulty, such as lack of knowledge, skills, confidence, or objectivity. The consultant need not see the patient. c. Program-centered (liaison): Indicated when there is a mutual commitment to an ongoing relationship between a consultant and a specific program (as in a medical service, team, unit, ward, or clinic). The basic objectives may be clinical (optimal patient care) or educational (enhancing psychiatric knowledge or skills), depending on the prior mutual understanding of the participants. The strategy is to gain access to and maintain contact with the appropriate members of the program or their patients. d. Nurse-centered consultation: This can involve any of the above types of consultation with nursing personnel. The basic objectives and strategies are essentially the same. but the consultant should be aware of differences between nurses and physicians in needs, tasks, and responsibilities.
701
Consultation psychiatry
b. Somatoform disorders c. Factitious disorders d. Depression in medical conditions, including masked depression e. Drug and alcohol dependence, intoxication, and withdrawal f. Psychological factors affecting physical conditions (including traditional psychophysiologic disorders such as hyperventilation, irritable bowel, migraine headaches, and so on) g. Sexual disorders in medical patients (such as impotence in diabetes and postmyocardial infarction, and sexual dysfunction in spinal cord injury) 2. Behavioral conditions a. Behavioral side effects of nonpsychiatric drugs b. Nonadherence (including medication or treatment refusal) c. Grief, death, and dying d. Anxiety in medical conditions or situations (eg, presurgery, postmyocardial infarction) e. Personality problems affecting the doctor-patient relationship (eg, the angry, demanding, sexually provocative, dependent, or hyperindependent patient) f. Suicidal and homicidal threats in medical patients g. Obesity h. Sleep disorders in medical patients i. Chronic pain . D. Treatments t. Organic psychiatric treatments for medical patients a. Describe indications, contraindications, dosages, and side effects of psychotropic medications for the conditions described above. These include antianxiety, antidepressant, and antipsychotic agents, as well as lithium carbonate. b. Describe the way various illnesses or conditions require modification in the customary prescribing practices for psychotropic medications. These include but are not limited to kidney, liver, or heart disease, organic brain syndrome, old age. c. Describe the indications, contraindications, and side effects of electroconvulsive therapy in patients with physical illnesses. 702
2. Nonorganic treatments. Describe indications and contraindications for nonorganic treatments for the conditions described above. These include: a. Crisis intervention b. Individual, brief psychotherapy (including specific techniques of support, clarification, abreaction, confrontation, and interpretation) c. Individual long-term psychotherapy d. Family therapy e. Behavior therapy f. Intervention by non psychiatric medical personnel (behavior modification or supportive counseling by referring physician, nurse, or social worker) g. Other treatments such as biofeedback, relaxation training, and hypnosis h. Patient education (such as how to deal with noncompliance ). II. SKILLS OBJECTIVES The resident will demonstrate ability to: A. Gather data Collect information from the patient (interviewing skill), from the medical chart, from the referring physician, and from relevant other sources (family, ward staff, social agencies). B. Formulate cases I. Discuss relative biological, psychological, and social contributions to any consultation problem. 2. Distinguish the actual or expressed consultation request from the underlying intentions or needs of the referring physician. 3. Design appropriate biological, psychological, and social interventions for any consultation problem. 4. Write a tactful, clear, succinct consultation report, using nontechnical language (no jargon) that directly answers the questions posed and provides the information necessary to support the recom-' mendations. C. Intervene I. Organize and teach, when necessary, various nonpsychiatric personnel to deliver appropriate intervention (these include the referring physician, the ward staff, the patient's family, or social agencies). 2. Choose and utilize appropriate psychotherapeutic strategies in talking with medical patients. PSYCHOSOMATICS
These include support, clarification, ventilation, confrontation, interpretation, and empathy. 3. Use appropriate behavioral management techniques such as reinforcement programs, systematic exposure, and relaxation training. 4. Recognize and therapeutically utilize emotional reactions (including countertransference feelings) that arise among ward staff, referring physicians, or the psychiatric consultant. 5. Use effective techniques to prevent and reduce noncompliance (clear explanations and instructions, checking patient understanding, checking extent and causes of noncompliance, simplifying regimen, tailoring to existing habits). 0
The authors wish to acknowledge the help of the AA P Task Force on Consultation/ Liaison Objectives in the preparation of this report: J. Bird, B. Fenton, A. Freeman, C. Herring, J. Houpt, D. Kornfeld. H. Leigh, D. Lipsitt, M.J. Massie. P. Moh!, M. Notman, W. Patterson, D. Schubert, and J. Strain. In addition. we thank the 40 consul/ation / liaison program directors
who sent us a description of their training objectives. In particlliar. we found the objectives {rom the following programs (and directors) par/icularly helpful: Case Western Reserve (Agle). Cornell (Viedemum). Duke (Houpt). Stanford (Agras and Koran). and UCLA (Pasnall QIId Fawzy). The Task Force also acknowledges Houpt J, Weins/ein H. Russell M: The application ofcompetency-based education to consul/ation-liaison psychiatry, Int J Psychiatry Med, 7:295-328. 1976-1977. which contributed Significantly to the organization of "Ski/Is objec· tives." and Gerald Caplan ·s. The Theory and Practice of Mental Health Consultation, New York. Basic Books. 1970. for ilS contribution to the development of the knowledge objectives concerning the consultation process.
REFERENCES 1. Reifler B. Eaton J: The evaluation of teaching and learning by psychiatric consultation and liaison training programs. Psychosom Med 40:99-106. 1978. 2. Mager RF: Preparing Institutional Objectives. Palo Alto, Calif. Fearor) Publishers, 1962. 3. Gagne RM, Briggs, LJ: Principles of Instructional Design. New York, Holtl Rinehart & Winston. 1974. 4. Houpt JL. Weinstein HM, Russell ML: The application of competency· based education to consultation-liaison psychiatry. Int J Psychiatry Me(, 7:295-307,1976. 5. Raft D. Cohen-Cole SA. Bird J: Liaison pSYChiatry, in Cavenar J, Brodie Ht (eds): Critical Problems in Psychiatry. J.P. Lippincott, in press.
The University of Minnesota Press is pleased to announce that effective July 1,
THE MMPI IS COMING HOME TO MINNESOTA. The University of Minnesota Press. copyright owner and original publisher of the Minnesota Multiphasic Personality Inventory, resumes its role as publisher of the MMPI.
NCS Interpretive Scoring Systems of Minneapolis, Minnesota, becomes the official MMPI distributor and scoring agency, working closely with the Press on a program of vigorous research and development.
The Press believes this new arrangement will serve MMPI users even more efficiently and creatively. Look for future announcements of restandardization and a new and expanded scoring / interpretation service.
UNIVERSITY OF MINNESOTA PRESS
l5i1
Requests for MMPI materials and information should be directed to NCS Interpretive Scoring Systems, P.O. Box 1416, . Minneapolis, Minnesota, 55440. Phone 612/933-2800 (toll-free outside Minnesota: 800/328-6759).
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-
CONSULTATION-LIAISON PSYCHIATRY
-
STEVEN A. COHEN-COLE, M.D. JACK HAGGERTY, M.D. DAVID RAFT, M.D.
Objectives for residents in consultation psychiatry: Recommendations of a task force ABSTRACT: The authors briefly describe the work of the Association for Academic Psychiatry Task Force on Consultation/ Liaison Objectives and discuss the principles behind the development of a proposed set of training objectives for residents in consultation psychiatry. These proposed objectives are presented in their complete form, followed by an elaboration of the knowledge objectives concerning the consultation process.
Educational experts emphasize the central importance of clearly specified objectives in an efficient, effective educational program. l -4 Such experts maintain that well-constructed objectives serve the following important functions: (I) help instructors and trainees work collaboratively toward stated goals; (2) facilitate the design of relevant teaching methods; and (3) develop appropriate evaluation instruments to monitor and modify teaching efforts. Programs without adequate Dr. Cohen-Cole is associate professor of psychiatry at the University ofAlabama School of Medicine, and Dr. Haggerty is assistant professor and Dr. Raft associate professor in the department ofpsychiatry at the University of North Carolina School of Medicine. Reprint requests to Dr. Cohen-Cole at the University of A labama School of Medicine, Birmingham, A L 35294.
JULY 1982· VOL 23' NO 7
objectives may suffer from a lack of focus, insufficiency or redundancy in the curriculum, inefficient choice of instructional procedures, and uncertainty concerning evaluation methodologies. In response to a perceived absence of coherent training objectives in the general area of consultation and liaison psychiatry, the Consultation/Liaison Section of the Association for Academic Psychiatry (Chairman, Don Lipsitt, M.D.) created a task force in the fall of 1979 to begin clarifying and systematizing current training objectives in this field. The first author (SC-C) was appointed chairman of the task force, and began work by sending a questionnaire to all NIMH-funded consultation and liaison programs asking for a summary of their objectives. Based on 40 responses, he developed a compendium of consultation (resident) and liaison (fellowship) training objectives which was presented at the Annual Meeting of the Association for Academic Psychiatry (AAP) in San Antonio in 1980 [available on request from the authors]. Based on discussions in San Antonio, and subsequent meetings of interested task force members, the authors collaboratively developed a proposed set of minimal training objectives for residents in consultation psychiatry. These competency-based objectives were constructed according to the principles of educational theory that operationally useful objectives are concrete and unambiguous, useful for guiding teaching, attainable (given specific time and resources), and measurable (for the evaluation of outcome).5 The actual content covered by the objectives was decided by several factors including 699
Consultation psychiatry (I) the frequency with which any particular objective was included in different training programs; (2) the task force's understanding of consultation and liaison literature; and (3) the personal clinical and teaching experiences of task force members. The goal was to create a set of minimal training objectives representing the basic knowledge and skills required for medical consultations that every psychiatric resident should attain before graduating from a training program. Furthermore, we attempted to create a realistic and workable set of objectives that could actually guide teaching, program development, and evaluation in the field of consultation psychiatry. Future work includes the organization of a multicenter feasibility study (already begun), the design of appropriate evaluation procedures, and a national survey of
responses to this proposed set of objectives. The proposed objectives are outlined in full below to enable interested readers to use them in their own programs. Tenninal objective: To provide competent consultation to nonpsychiatric medical personnel regarding psychiatric and behavioral problems in medical patients. This requires the mastery and integration of specific knowledge objectives with a broad range of clinical skills.
I. KNOWLEDGE OBJECTIVES A. The consultation process (see Box, below) 1. Describe the objectives, responsibilities, authority, and limitations of the psychiatric consultant in medical settings. Discuss the way these vary in different situations.
The Psychiatric Consultation Process 1. THE PSYCHIATRIC CONSULTANT a. ObJectives: The primary objective of the psychiatric consultant is to optimize patient care by providing psychiatric assessments and recommendations for medical patients. An important secondary objective is education of the referring medical person (the consultee). Each particular consultation situation requires a decision (occasionally negotiated directly with the consultee) about the relative emphasis on these two different objectives. b. Responsibilities: The responsibility of the psychiatric consultant is to provide adequate psychiatric assessments and recommendations to medical colleagues. The primary responsibility for the patient remains with the consultee. However, intermediate issues of responsibility (follow-up visits, supportive psychotherapy, writing orders for psychiatric drugs, arranging for outpatient follow-ups) should be negotiated and explicitly clarified in each consultation relationship. c. Authority: Consultation usually involves voluntary collaboration on a relatively equal level between two or more professionals. However, regardless of the special expertise of the consultant, ultimate authority and responsibility for the patient remains with the consultee. d. Limitations: The consultant should adhere to the limitations of authority and responsibility discussed above. In addition, limitations relating to the differences between consultation and psychotherapy,
700
referral, or supervision (see below) should also be recognized. 2. THE CONSULTATION RELATIONSHIP a. Consultation versus supervision: The supervisory relationship (attending physician and resident) is based on delegated authority and direct legal responsibility. The relationship is hierarchic and the supervisor can require that the supervisee carry out certain actions. In the consultation relationship, neither party has authority over the other, and the consultee can accept reject, or modify the consultant's recommendations. The consultant has no direct legal responsibility for the actions of the consultee. b. Consultation versus referral: In the case of referral, partial or total responsibility for the care of a patient is transferred from one physician to another. The physicians are directly responsible to the patient, but not necessarily to each other. Each may make and carry through autonomous decisions about treatment. In consultation, on the other hand, primary responsibility for making decisions remains in the hands of the physician who requests the consultant's help. The consultant is responsible to both the patient and the consultee. He is limited to making suggestions to the consultee, and cannot make autonomous decisions about treatment. c. Consultation versus psychotherapy: In psychotherapy, the therapist elicits, clarifies, and modifies
PSYCHOSOMATICS
2. Describe the way the consultation relationship (ie, consultant-consultee) differs from supervision, referrals, or psychotherapy. 3. Discuss the way common factors influence the initiation, process, and outcome of a consultation. 4. Describe different types of psychiatric consultation in medical settings (patient-centered, physician-centered, program-centered, and nursecentered). Discuss indications, objectives, and relevant strategies for each. B. Biopsychosocial dimensions of medical practice I. Describe the influence of psychological and social variables on the predisposition, onset, course, and outcome of somatic illness. 2. Describe common patterns of psychological
the patient's pattern of emotional or behavioral responses. The psychiatric consultant may similarly seek to clarify patterns of emotional responses in either the referring medical personnel or the patient, both of which may affect the patient's adaptation. The consultant, however, generally limits such inquiries to the clarification and modification of specific disruptions in the professional relationship between the consultee and the patient. The consultant should not attempt to modify the consultee's general adaptation to life.
3. COMMON FACTORS INFLUENCING CONSULTATION The timing of the consultation in the course of the patient's hospitalization; the preparation of the patient; the nature of the primary doctor-patient relationship; the consultee's covert expectations of the consultation; the patient's expectations of the consultation; intrapsychic or interpersonal factors in the patient's medical care environment (such as group dynamics of the medical team or recent stresses on the ward); the fit between consultant recommendations and resources/attitudes/policies in the medical setting. 4. TYPES OF CONSULTATIONS a. Patient-centered: Indicated when a referring physician desires help with the assessment or management of a particular patient. The basic objective is
JULY 1982· VOL 23 • NO 7
and social adaptation to illness. 3. Describe factors that influence a caregiver's responses to patients. Discuss the way these responses affect health outcomes. 4. Describe the basic components of general systems theory as they relate to understanding and influencing health outcomes. C. Clinical syndromes. Describe the signs and symptoms, differential diagnosis, and course of those psychiatric and behavioral conditions that are most commonly encountered in medical settings.
l. Psychiatric conditions a. Delirium/dementia and other organic brain syndromes
to determine what is wrong with the patient and how that person can be helped, and to communicate this information to the referring physician. Education is a secondary objective. The strategy is to obtain enough information from and about the patient to answer the relevant questions. Direct patient assessment is always involved. b. Physician-centered: Indicated when the referring physician wants to improve his/her management of a case. The basic objective is educational. The strategy is based on an attempt to understand the nature of the consultee's difficulty, such as lack of knowledge, skills, confidence, or objectivity. The consultant need not see the patient. c. Program-centered (liaison): Indicated when there is a mutual commitment to an ongoing relationship between a consultant and a specific program (as in a medical service, team, unit, ward, or clinic). The basic objectives may be clinical (optimal patient care) or educational (enhancing psychiatric knowledge or skills), depending on the prior mutual understanding of the participants. The strategy is to gain access to and maintain contact with the appropriate members of the program or their patients. d. Nurse-centered consultation: This can involve any of the above types of consultation with nursing personnel. The basic objectives and strategies are essentially the same. but the consultant should be aware of differences between nurses and physicians in needs, tasks, and responsibilities.
701
Consultation psychiatry
b. Somatoform disorders c. Factitious disorders d. Depression in medical conditions, including masked depression e. Drug and alcohol dependence, intoxication, and withdrawal f. Psychological factors affecting physical conditions (including traditional psychophysiologic disorders such as hyperventilation, irritable bowel, migraine headaches, and so on) g. Sexual disorders in medical patients (such as impotence in diabetes and postmyocardial infarction, and sexual dysfunction in spinal cord injury) 2. Behavioral conditions a. Behavioral side effects of nonpsychiatric drugs b. Nonadherence (including medication or treatment refusal) c. Grief, death, and dying d. Anxiety in medical conditions or situations (eg, presurgery, postmyocardial infarction) e. Personality problems affecting the doctor-patient relationship (eg, the angry, demanding, sexually provocative, dependent, or hyperindependent patient) f. Suicidal and homicidal threats in medical patients g. Obesity h. Sleep disorders in medical patients i. Chronic pain . D. Treatments t. Organic psychiatric treatments for medical patients a. Describe indications, contraindications, dosages, and side effects of psychotropic medications for the conditions described above. These include antianxiety, antidepressant, and antipsychotic agents, as well as lithium carbonate. b. Describe the way various illnesses or conditions require modification in the customary prescribing practices for psychotropic medications. These include but are not limited to kidney, liver, or heart disease, organic brain syndrome, old age. c. Describe the indications, contraindications, and side effects of electroconvulsive therapy in patients with physical illnesses. 702
2. Nonorganic treatments. Describe indications and contraindications for nonorganic treatments for the conditions described above. These include: a. Crisis intervention b. Individual, brief psychotherapy (including specific techniques of support, clarification, abreaction, confrontation, and interpretation) c. Individual long-term psychotherapy d. Family therapy e. Behavior therapy f. Intervention by non psychiatric medical personnel (behavior modification or supportive counseling by referring physician, nurse, or social worker) g. Other treatments such as biofeedback, relaxation training, and hypnosis h. Patient education (such as how to deal with noncompliance ). II. SKILLS OBJECTIVES The resident will demonstrate ability to: A. Gather data Collect information from the patient (interviewing skill), from the medical chart, from the referring physician, and from relevant other sources (family, ward staff, social agencies). B. Formulate cases I. Discuss relative biological, psychological, and social contributions to any consultation problem. 2. Distinguish the actual or expressed consultation request from the underlying intentions or needs of the referring physician. 3. Design appropriate biological, psychological, and social interventions for any consultation problem. 4. Write a tactful, clear, succinct consultation report, using nontechnical language (no jargon) that directly answers the questions posed and provides the information necessary to support the recom-' mendations. C. Intervene I. Organize and teach, when necessary, various nonpsychiatric personnel to deliver appropriate intervention (these include the referring physician, the ward staff, the patient's family, or social agencies). 2. Choose and utilize appropriate psychotherapeutic strategies in talking with medical patients. PSYCHOSOMATICS
These include support, clarification, ventilation, confrontation, interpretation, and empathy. 3. Use appropriate behavioral management techniques such as reinforcement programs, systematic exposure, and relaxation training. 4. Recognize and therapeutically utilize emotional reactions (including countertransference feelings) that arise among ward staff, referring physicians, or the psychiatric consultant. 5. Use effective techniques to prevent and reduce noncompliance (clear explanations and instructions, checking patient understanding, checking extent and causes of noncompliance, simplifying regimen, tailoring to existing habits). 0
The authors wish to acknowledge the help of the AA P Task Force on Consultation/ Liaison Objectives in the preparation of this report: J. Bird, B. Fenton, A. Freeman, C. Herring, J. Houpt, D. Kornfeld. H. Leigh, D. Lipsitt, M.J. Massie. P. Moh!, M. Notman, W. Patterson, D. Schubert, and J. Strain. In addition. we thank the 40 consul/ation / liaison program directors
who sent us a description of their training objectives. In particlliar. we found the objectives {rom the following programs (and directors) par/icularly helpful: Case Western Reserve (Agle). Cornell (Viedemum). Duke (Houpt). Stanford (Agras and Koran). and UCLA (Pasnall QIId Fawzy). The Task Force also acknowledges Houpt J, Weins/ein H. Russell M: The application ofcompetency-based education to consul/ation-liaison psychiatry, Int J Psychiatry Med, 7:295-328. 1976-1977. which contributed Significantly to the organization of "Ski/Is objec· tives." and Gerald Caplan ·s. The Theory and Practice of Mental Health Consultation, New York. Basic Books. 1970. for ilS contribution to the development of the knowledge objectives concerning the consultation process.
REFERENCES 1. Reifler B. Eaton J: The evaluation of teaching and learning by psychiatric consultation and liaison training programs. Psychosom Med 40:99-106. 1978. 2. Mager RF: Preparing Institutional Objectives. Palo Alto, Calif. Fearor) Publishers, 1962. 3. Gagne RM, Briggs, LJ: Principles of Instructional Design. New York, Holtl Rinehart & Winston. 1974. 4. Houpt JL. Weinstein HM, Russell ML: The application of competency· based education to consultation-liaison psychiatry. Int J Psychiatry Me(, 7:295-307,1976. 5. Raft D. Cohen-Cole SA. Bird J: Liaison pSYChiatry, in Cavenar J, Brodie Ht (eds): Critical Problems in Psychiatry. J.P. Lippincott, in press.
The University of Minnesota Press is pleased to announce that effective July 1,
THE MMPI IS COMING HOME TO MINNESOTA. The University of Minnesota Press. copyright owner and original publisher of the Minnesota Multiphasic Personality Inventory, resumes its role as publisher of the MMPI.
NCS Interpretive Scoring Systems of Minneapolis, Minnesota, becomes the official MMPI distributor and scoring agency, working closely with the Press on a program of vigorous research and development.
The Press believes this new arrangement will serve MMPI users even more efficiently and creatively. Look for future announcements of restandardization and a new and expanded scoring / interpretation service.
UNIVERSITY OF MINNESOTA PRESS
l5i1
Requests for MMPI materials and information should be directed to NCS Interpretive Scoring Systems, P.O. Box 1416, . Minneapolis, Minnesota, 55440. Phone 612/933-2800 (toll-free outside Minnesota: 800/328-6759).