- Email: [email protected]
Once more into the breach: Doubts about liaison psychiatry
Commentary and Perspective From time to time, the Journal receives manuscripts which can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.
Once More into the Breach: Doubts about Liaison Psychiatry John R. Neill, M.D. Associate
Professor,
Department
of Psychiatry,
College of Medicine,
Abstract: The author, a consultation/liaison psychiatrist, reviews five important questions about liaison work which are pressing, but remain unanswered. With some trepidation, he seeks to temper the enthusiasm of his colleagues who, by prematurely promising more than can ever be delivered in the name of “holistic” and “biopsychosocial” medicine, may lead our discipline astray.
The tide of enthusiasm for liaison psychiatry may be at full flood. Since the first reports in the early 193Os, (1,2) the psychiatrist has found a legitimate and useful niche as a hospital consultant to his medical colleagues. From the start, there appears to have been little “resistance” amongst medical staff to psychiatric consultants when the consultant psychiatrist performed like his colleagues in other medical specialties. In this format the psychiatrist is called by a colleague to see a patient who is problematic, investigates, derives a diagnostic formulation, and communicates his findings to his colleague with perhaps some recommendations for treatments. Lippitt, (3) however, reminds us that General Hospital Psychiatry
5, 205-208, 1983 0 Elsevier Science Publishing Co., Inc. 1983 52 Vanderbilt Avenue, New York, NY 10017
University of Kentucky,
Lexington,
Kentucky
the consultant is a “psychological outsider” who forms only a temporary relationship with the system. Thus, he is “outside” the hierarchical power system in which his consultee is embedded, wielding limited influence. The 1930s and 1940s witnessed great interest in teaching the physician, early in his professional life, psychiatric principles bearing on patient management (4). This educational aim, in time, supplanted the more limited goal of patient diagnosis and management and led to the liaison concept. By the 1950s some workers were forming liaison relationships, that is, psychiatrists were “based” on an identifiable geographic or service unit such as a general medical ward or hemodialysis program. Now, the psychiatrist was available not only for consultation about patients, but through teaching conferences and rounds, able to advance his other aims of education, awareness of group process, and psychosomatic research. As a consequence, there was an increase in the number of patients seen. For example, in the 193Os, Rennie (2) at Johns Hopkins, acting simply as a consultant, saw 265 cases in a 205 ISSN 0163-8343/83/$3.00
J. R. Neil1 year while, in the 1950s Kaufman’s group at New York’s Mount Sinai Hospital operating in a liaison framework, selecting their own consultation requests, saw 2,309 patients in a two year period (5)! The coming of the liaison concept coincided with the high water mark of psychoanalytic influence in psychiatry, and understandably the emphasis in hospital work turned to such key concepts as transference-countertransference patterns and the nature of defenses in interactions between doctors and patients (6). During this period, “the liaison period,” problems began to appear in the form of “resistance” in colleagues as their own behavior and attitudes, and not solely that of their patients came under scrutiny. Convinced that “responding” was not enough, psychiatric liaison workers sought to demonstrate the “value of the psychologic point of view” (psychoanalysis) in “understanding the whole patient” (6). The psychiatrist was to become a role model and an “ambulatory superego” (7) for the ward staff promoting the examined life as a means of better serving patients. This was a big change from the more humble role of the psychiatrist as a consultant elaborated in the pre-psychoanalytic days by psychiatrists under the influence of Adolf Meyer (1,2). The Meyerians had been satisfied with simply explaining the patient’s personality to the physician and weeding out the clearly “psychiatric” cases from the medical case load. Federal support for liaison psychiatric research became available in the 1960s. Psychiatric attention was given to technological advances in medicine which were thought to have deleterious psychological effects-intensive care units, cardiac care, surgery, and hemodialysis. Consultation-liaison was advanced as a legitimate subspecialty of psychiatry and financial support was forthcoming for trainees in the area. Subspecialty journals and societies arose. Over these past 25 years, a great deal of literature has been published about liaison work, much of it stemming from pilot projects and model programs. All of it has been written by psychiatrists. Yet, after all this, there remain a number of fundamental unanswered questions which need to be answered if our work is to continue beyond this high water mark. I would now like to examine five of these questions in detail. 1. Is a liaison presence in the medical setting perceived as a pressing need? Studies by psychiatrists and psychologists report that one-third to one-half of hospitalized patients show some prima-
ry or secondary psychological morbidity (8,9). American studies tend to agree that “psychological problems are important in medical practice” although “underdiagnosis” of such problems in the hospital setting is common (10). There is the suggestion that psychological problems, however important, should be treated by mental health personnel (11). We need to know why this is so. Could it be that the physician’s continuing “underdiagnosis” of psychological difficulties is solely or mainly the result of his ignorance of clinical presentation? A more likely possibility is that “psychological problems” in an acute care rapid turnover subspecialty practice institution may not seem that pressing or that relevant to the treating physicians in such a setting. In other words, psychosocial problems may be “seen” but seen as problems for someone else to solve. If this is so, we face a major obstacle to any enduring liaison work. 2. Is a liaison relationship considered desirable by institutions (hospitals) themselves? We find in the literature that reported administrative support of liaison programs seems to be restricted to a few individuals who created or found suitable institutional arrangements to promote their ideas. For example, George Engel at the University of Rochester and James Strain at New York’s Montefiore Hospital found favorably disposed hospital administrators (12,13). Perhaps most hospital psychiatry departments find themselves not in such propitious circumstances. The seeming exceptions mentioned above may prove the rule-that it’s hard to change the established institutional cost/benefit derived practices unless evidence is produced for financial advantage. 3. Do other physicians “welcome” the involvement of the liaison psychiatrist in the treatment of their hospitalized patients? We see repeatedly, in the context of establishing a liaison relationship, that the psychiatrist has difficulty in becoming a “member of the team.” This has been construed as the psychiatrist’s problem in accommodating to the “medical image,” an effort which may border on the masochistic. Psychiatrists are urged to wear white coats, carry stethoscopes, attend medical-political functions, “hang around’ the wards, keep up on medical literature, go on ward rounds, treat one’s patient’s medical problems, and even become primary care physicians (14,15). One may wonder, along with Hackett (16), if the prize is worth the race. Even after becoming a “member of the team,” a psychiatrist’s position may be precarious (17).
Doubts about Liaison Psychiatry
What about the reception in the medical press? Is there, in print, testimony from other physicians? Surprisingly, I am unable to find a single article, editorial, or letter to the editor in the medical literature written by a nonpsychiatrist to his colleagues extolling the benefits of having a liaison psychiatrist at one’s disposal. Why is this so? Perhaps we need to urge the friends of our discipline to step forward and be counted. 4. Are the interventions performed by psychiatrists on the liaison service valuable from the administrative point of view-reducing excessive use of services, providing better patient care, and improving staff function? The literature indicates that in some practice situations such as renal units, cardiac units, and family practice programs, psychiatrists have been welcomed enthusiastically only to be phased out as procedures become more standardized and staff becomes more familiar with the dynamics of the treatment process (18). Often it is cheaper and administratively more expedient to hire one’s own nurse, social worker, or psychologist full-time to replace the liaison psychiatrist. To justify a continuing liaison we have to demonstrate, in terms translated into dollars, why we should be there. Saying we have a better way-the biopsychosocial model-is not enough. We also have to delineate what is the optimal liaison role for the psychiatrist. Nurses (19) and psychologists, specialists in the new discipline of behavioral medicine (20), feel they belong in the inpatient setting. 5. Who will pay for liaison activities? One would think, from the dearth of remarks in the literature, that liaison activities are financially attractive to the individual psychiatrist and the administrative unit (i.e., the Psychiatry Department). This is not so. Hackett mentions that liaison psychiatrists “make substantially less than in private practice,” (21) thus, liaison programs must rely on “innovative” ways of generating monies or grants. Grants, however, for such programs are disappearing and innovation may be the luxury of one a few centers. Departments of Psychiatry may be reluctant to underwrite such operations, and third party insurers are likely to remain uninterested. A recent survey (22) concludes that there seems to be no generalizable way of funding psychiatric liaison activity. Liaison psychiatry holds that the psychiatrist provides the vehicle through which integrative, holistic, or biopsychosocial treatment will be infused into the corpus of medical teaching and practice (12,14,15,17). Yet the literature of the past 25 years reports no great successes. Even apparent suc-
cesses one has to suspect because our colleagues will often “simulate . . . a holistic viewpiont” (23). For teaching purposes, it seems clear that a liaison relationship is a much more logical way for medical students and housestaff to learn about psychiatry in medicine and medical psychology than on an inpatient or outpatient psychiatric service. Yet, it is doubtful that the more visionary aims of reconstruction of medical practice or changing institutionally supported attitudes and behaviors will ever make much headway. Reducing these institutional, social and political constraints to questions of “transference” or the psychiatrist’s “image,” seems naive.
Conclusion As one views historically the development and implementation of liaison psychiatry, we see many “bandwagon” characteristics of which we have so sagely been warned (24). Again, like the missionary who would convert the heathen, we are possessed of a good idea which clashes with the culture in which we find ourselves. It is easier to see ourselves as surrounded by the ignorant who know not what they do than to humbly revise our goals (25). Along this line, I propose that liaison workers should teach where we can, to willing pupils who come forward, and abandon our overt and covert efforts at “converting” medicine to our point of view-holistic, biopsychosocial, or whatever. This means that we should concentrate on consultation and not on liaison work. In the long run, even though we have a “good thing” in liaison psychiatry, it will not sell itself without being advertised. We can turn the attention of medicine to the importance of liaison work only if we prove, in “cost-benefit terms” the utility of our model and methods. There certainly must be more and better records kept and more follow-up studies of the results of our interventions. Most importantly there must be better organization among liaison psychiatrists at the national level, and especially, given the current political climate, at the state and regional levels, in order to exchange ideas and experiences.
References 1. Henry general 1929 2. Rennie N Engl
GW: Some modern aspects of psychiatry in hospital practice. Am J Psychiatr 86:481-499, TAC: Psychiatric service to a general hospital. J Med 217:346-351, 1927 207
J. R. Neil1
3. Lippitt R: In Blake R, and Mouton, JS Consultation Mass: Addison-Wesley, 1976 4. Teaching psychotherapeutic medicine. New York: Commonwealth Fund, 1947 5. Kaufman MR: A psychiatric unit in a general hospital. J Mt Sinai Hosp 24:572-579, 1957 6. Bibring G: Psychiatry and medical practice in a general hospital. N Engl J Med 254:366-372, 1956 7. Beigler JS, Robbins FP, Lane EW, et al: Report on liaison psychiatry at Michael Reese Hospital, 1950-1958. Arch Neurol Psychiatr 81:733-738, 1959 8. Maguire GP: Psychiatric morbidity and referral on two general medical units. Br Med J 1:268-270, 1974 9. Pasnau RO (ed). Consultation Liaison Psychiatry. New York, Grune & Stratton, 1975 10. Knights EB, Folstein MF: Unsuspected emotional and cognitive disturbance in medical patients. Ann Interm Med 871723-724, 1977 11. Karasu TB, Plutchik R, Conte H, et al: What do physicians want from a psychiatric consultation service? Compr Psychiatry 18:73-81, 1977 12. Strain JF, Grossman S. Psychological care of the medically ill. New York: Appleton’s, 1975 13. Engel G: Psychological development in health and disease. Philadelphia, W. B. Saunders, 1963 14. A liaison psychiatrist can advocate the psychosomatic approach to medicine much more effectively than can a consultation psychiatrist, since the liaison psychiatrist ‘suffers along with the staff making 6:30 a.m. rounds.’ ” Clinical Psychiatry News 9:32, 1981 15. Strain JJ: The medical setting: Is it beyond the psychiatrist? Am J Psychiatry 134:253-256, 1977
208
16. Hackett TP. Consultation psychiatry held valid, liaison held invalid. Clinical Psychiatry News, January 1982, p 36. 17. Mohl PC: The liaison psychiatrist: Social role and status. Psychosomatics 20:19-23, 1979 18. Benson R: Problems in liaison psychiatry: Letter to the Editor Am J Psychiatry X34:1050, 1977 19. Lewis A, Levy JS: Psychiatric liaison nursing. Reston Va., Reston Publishing Co., 1982 20. Lipowski ZJ: Liaison psychiatry, liaison nursing, and behavioral medicine. Compr Psychiatry 22:554-561, 1981 21. Interview with Hackett TP. Consultation liaison psychiatry. Today in Psychiatry 5:1-4, 1979 22. Fenton BJ, Guggenheim FG: Consultation-liaison psychiatry and funding: Why can‘t Alice find Wonderland? Gen Hosp Psychiatry 3:255-260, 1981 23. Houpt JL: Evaluating liaison programs’ effectivenss: The use of unobtrusive measures. Int J Psychiatry Med 8:361-370, 1977-78 24. Grinker RR: Psychiatry rides madly in all directions. Arch Gen Psychiatry 10:228-237, 1964
Direct reprint requests to: Dr. Neil1 Department of Psychiatry College of Medicine University of Kentucky Lexington, KY 40536
Once More into the Breach: Doubts about Liaison Psychiatry John R. Neill, M.D. Associate
Professor,
Department
of Psychiatry,
College of Medicine,
Abstract: The author, a consultation/liaison psychiatrist, reviews five important questions about liaison work which are pressing, but remain unanswered. With some trepidation, he seeks to temper the enthusiasm of his colleagues who, by prematurely promising more than can ever be delivered in the name of “holistic” and “biopsychosocial” medicine, may lead our discipline astray.
The tide of enthusiasm for liaison psychiatry may be at full flood. Since the first reports in the early 193Os, (1,2) the psychiatrist has found a legitimate and useful niche as a hospital consultant to his medical colleagues. From the start, there appears to have been little “resistance” amongst medical staff to psychiatric consultants when the consultant psychiatrist performed like his colleagues in other medical specialties. In this format the psychiatrist is called by a colleague to see a patient who is problematic, investigates, derives a diagnostic formulation, and communicates his findings to his colleague with perhaps some recommendations for treatments. Lippitt, (3) however, reminds us that General Hospital Psychiatry
5, 205-208, 1983 0 Elsevier Science Publishing Co., Inc. 1983 52 Vanderbilt Avenue, New York, NY 10017
University of Kentucky,
Lexington,
Kentucky
the consultant is a “psychological outsider” who forms only a temporary relationship with the system. Thus, he is “outside” the hierarchical power system in which his consultee is embedded, wielding limited influence. The 1930s and 1940s witnessed great interest in teaching the physician, early in his professional life, psychiatric principles bearing on patient management (4). This educational aim, in time, supplanted the more limited goal of patient diagnosis and management and led to the liaison concept. By the 1950s some workers were forming liaison relationships, that is, psychiatrists were “based” on an identifiable geographic or service unit such as a general medical ward or hemodialysis program. Now, the psychiatrist was available not only for consultation about patients, but through teaching conferences and rounds, able to advance his other aims of education, awareness of group process, and psychosomatic research. As a consequence, there was an increase in the number of patients seen. For example, in the 193Os, Rennie (2) at Johns Hopkins, acting simply as a consultant, saw 265 cases in a 205 ISSN 0163-8343/83/$3.00
J. R. Neil1 year while, in the 1950s Kaufman’s group at New York’s Mount Sinai Hospital operating in a liaison framework, selecting their own consultation requests, saw 2,309 patients in a two year period (5)! The coming of the liaison concept coincided with the high water mark of psychoanalytic influence in psychiatry, and understandably the emphasis in hospital work turned to such key concepts as transference-countertransference patterns and the nature of defenses in interactions between doctors and patients (6). During this period, “the liaison period,” problems began to appear in the form of “resistance” in colleagues as their own behavior and attitudes, and not solely that of their patients came under scrutiny. Convinced that “responding” was not enough, psychiatric liaison workers sought to demonstrate the “value of the psychologic point of view” (psychoanalysis) in “understanding the whole patient” (6). The psychiatrist was to become a role model and an “ambulatory superego” (7) for the ward staff promoting the examined life as a means of better serving patients. This was a big change from the more humble role of the psychiatrist as a consultant elaborated in the pre-psychoanalytic days by psychiatrists under the influence of Adolf Meyer (1,2). The Meyerians had been satisfied with simply explaining the patient’s personality to the physician and weeding out the clearly “psychiatric” cases from the medical case load. Federal support for liaison psychiatric research became available in the 1960s. Psychiatric attention was given to technological advances in medicine which were thought to have deleterious psychological effects-intensive care units, cardiac care, surgery, and hemodialysis. Consultation-liaison was advanced as a legitimate subspecialty of psychiatry and financial support was forthcoming for trainees in the area. Subspecialty journals and societies arose. Over these past 25 years, a great deal of literature has been published about liaison work, much of it stemming from pilot projects and model programs. All of it has been written by psychiatrists. Yet, after all this, there remain a number of fundamental unanswered questions which need to be answered if our work is to continue beyond this high water mark. I would now like to examine five of these questions in detail. 1. Is a liaison presence in the medical setting perceived as a pressing need? Studies by psychiatrists and psychologists report that one-third to one-half of hospitalized patients show some prima-
ry or secondary psychological morbidity (8,9). American studies tend to agree that “psychological problems are important in medical practice” although “underdiagnosis” of such problems in the hospital setting is common (10). There is the suggestion that psychological problems, however important, should be treated by mental health personnel (11). We need to know why this is so. Could it be that the physician’s continuing “underdiagnosis” of psychological difficulties is solely or mainly the result of his ignorance of clinical presentation? A more likely possibility is that “psychological problems” in an acute care rapid turnover subspecialty practice institution may not seem that pressing or that relevant to the treating physicians in such a setting. In other words, psychosocial problems may be “seen” but seen as problems for someone else to solve. If this is so, we face a major obstacle to any enduring liaison work. 2. Is a liaison relationship considered desirable by institutions (hospitals) themselves? We find in the literature that reported administrative support of liaison programs seems to be restricted to a few individuals who created or found suitable institutional arrangements to promote their ideas. For example, George Engel at the University of Rochester and James Strain at New York’s Montefiore Hospital found favorably disposed hospital administrators (12,13). Perhaps most hospital psychiatry departments find themselves not in such propitious circumstances. The seeming exceptions mentioned above may prove the rule-that it’s hard to change the established institutional cost/benefit derived practices unless evidence is produced for financial advantage. 3. Do other physicians “welcome” the involvement of the liaison psychiatrist in the treatment of their hospitalized patients? We see repeatedly, in the context of establishing a liaison relationship, that the psychiatrist has difficulty in becoming a “member of the team.” This has been construed as the psychiatrist’s problem in accommodating to the “medical image,” an effort which may border on the masochistic. Psychiatrists are urged to wear white coats, carry stethoscopes, attend medical-political functions, “hang around’ the wards, keep up on medical literature, go on ward rounds, treat one’s patient’s medical problems, and even become primary care physicians (14,15). One may wonder, along with Hackett (16), if the prize is worth the race. Even after becoming a “member of the team,” a psychiatrist’s position may be precarious (17).
Doubts about Liaison Psychiatry
What about the reception in the medical press? Is there, in print, testimony from other physicians? Surprisingly, I am unable to find a single article, editorial, or letter to the editor in the medical literature written by a nonpsychiatrist to his colleagues extolling the benefits of having a liaison psychiatrist at one’s disposal. Why is this so? Perhaps we need to urge the friends of our discipline to step forward and be counted. 4. Are the interventions performed by psychiatrists on the liaison service valuable from the administrative point of view-reducing excessive use of services, providing better patient care, and improving staff function? The literature indicates that in some practice situations such as renal units, cardiac units, and family practice programs, psychiatrists have been welcomed enthusiastically only to be phased out as procedures become more standardized and staff becomes more familiar with the dynamics of the treatment process (18). Often it is cheaper and administratively more expedient to hire one’s own nurse, social worker, or psychologist full-time to replace the liaison psychiatrist. To justify a continuing liaison we have to demonstrate, in terms translated into dollars, why we should be there. Saying we have a better way-the biopsychosocial model-is not enough. We also have to delineate what is the optimal liaison role for the psychiatrist. Nurses (19) and psychologists, specialists in the new discipline of behavioral medicine (20), feel they belong in the inpatient setting. 5. Who will pay for liaison activities? One would think, from the dearth of remarks in the literature, that liaison activities are financially attractive to the individual psychiatrist and the administrative unit (i.e., the Psychiatry Department). This is not so. Hackett mentions that liaison psychiatrists “make substantially less than in private practice,” (21) thus, liaison programs must rely on “innovative” ways of generating monies or grants. Grants, however, for such programs are disappearing and innovation may be the luxury of one a few centers. Departments of Psychiatry may be reluctant to underwrite such operations, and third party insurers are likely to remain uninterested. A recent survey (22) concludes that there seems to be no generalizable way of funding psychiatric liaison activity. Liaison psychiatry holds that the psychiatrist provides the vehicle through which integrative, holistic, or biopsychosocial treatment will be infused into the corpus of medical teaching and practice (12,14,15,17). Yet the literature of the past 25 years reports no great successes. Even apparent suc-
cesses one has to suspect because our colleagues will often “simulate . . . a holistic viewpiont” (23). For teaching purposes, it seems clear that a liaison relationship is a much more logical way for medical students and housestaff to learn about psychiatry in medicine and medical psychology than on an inpatient or outpatient psychiatric service. Yet, it is doubtful that the more visionary aims of reconstruction of medical practice or changing institutionally supported attitudes and behaviors will ever make much headway. Reducing these institutional, social and political constraints to questions of “transference” or the psychiatrist’s “image,” seems naive.
Conclusion As one views historically the development and implementation of liaison psychiatry, we see many “bandwagon” characteristics of which we have so sagely been warned (24). Again, like the missionary who would convert the heathen, we are possessed of a good idea which clashes with the culture in which we find ourselves. It is easier to see ourselves as surrounded by the ignorant who know not what they do than to humbly revise our goals (25). Along this line, I propose that liaison workers should teach where we can, to willing pupils who come forward, and abandon our overt and covert efforts at “converting” medicine to our point of view-holistic, biopsychosocial, or whatever. This means that we should concentrate on consultation and not on liaison work. In the long run, even though we have a “good thing” in liaison psychiatry, it will not sell itself without being advertised. We can turn the attention of medicine to the importance of liaison work only if we prove, in “cost-benefit terms” the utility of our model and methods. There certainly must be more and better records kept and more follow-up studies of the results of our interventions. Most importantly there must be better organization among liaison psychiatrists at the national level, and especially, given the current political climate, at the state and regional levels, in order to exchange ideas and experiences.
References 1. Henry general 1929 2. Rennie N Engl
GW: Some modern aspects of psychiatry in hospital practice. Am J Psychiatr 86:481-499, TAC: Psychiatric service to a general hospital. J Med 217:346-351, 1927 207
J. R. Neil1
3. Lippitt R: In Blake R, and Mouton, JS Consultation Mass: Addison-Wesley, 1976 4. Teaching psychotherapeutic medicine. New York: Commonwealth Fund, 1947 5. Kaufman MR: A psychiatric unit in a general hospital. J Mt Sinai Hosp 24:572-579, 1957 6. Bibring G: Psychiatry and medical practice in a general hospital. N Engl J Med 254:366-372, 1956 7. Beigler JS, Robbins FP, Lane EW, et al: Report on liaison psychiatry at Michael Reese Hospital, 1950-1958. Arch Neurol Psychiatr 81:733-738, 1959 8. Maguire GP: Psychiatric morbidity and referral on two general medical units. Br Med J 1:268-270, 1974 9. Pasnau RO (ed). Consultation Liaison Psychiatry. New York, Grune & Stratton, 1975 10. Knights EB, Folstein MF: Unsuspected emotional and cognitive disturbance in medical patients. Ann Interm Med 871723-724, 1977 11. Karasu TB, Plutchik R, Conte H, et al: What do physicians want from a psychiatric consultation service? Compr Psychiatry 18:73-81, 1977 12. Strain JF, Grossman S. Psychological care of the medically ill. New York: Appleton’s, 1975 13. Engel G: Psychological development in health and disease. Philadelphia, W. B. Saunders, 1963 14. A liaison psychiatrist can advocate the psychosomatic approach to medicine much more effectively than can a consultation psychiatrist, since the liaison psychiatrist ‘suffers along with the staff making 6:30 a.m. rounds.’ ” Clinical Psychiatry News 9:32, 1981 15. Strain JJ: The medical setting: Is it beyond the psychiatrist? Am J Psychiatry 134:253-256, 1977
208
16. Hackett TP. Consultation psychiatry held valid, liaison held invalid. Clinical Psychiatry News, January 1982, p 36. 17. Mohl PC: The liaison psychiatrist: Social role and status. Psychosomatics 20:19-23, 1979 18. Benson R: Problems in liaison psychiatry: Letter to the Editor Am J Psychiatry X34:1050, 1977 19. Lewis A, Levy JS: Psychiatric liaison nursing. Reston Va., Reston Publishing Co., 1982 20. Lipowski ZJ: Liaison psychiatry, liaison nursing, and behavioral medicine. Compr Psychiatry 22:554-561, 1981 21. Interview with Hackett TP. Consultation liaison psychiatry. Today in Psychiatry 5:1-4, 1979 22. Fenton BJ, Guggenheim FG: Consultation-liaison psychiatry and funding: Why can‘t Alice find Wonderland? Gen Hosp Psychiatry 3:255-260, 1981 23. Houpt JL: Evaluating liaison programs’ effectivenss: The use of unobtrusive measures. Int J Psychiatry Med 8:361-370, 1977-78 24. Grinker RR: Psychiatry rides madly in all directions. Arch Gen Psychiatry 10:228-237, 1964
Direct reprint requests to: Dr. Neil1 Department of Psychiatry College of Medicine University of Kentucky Lexington, KY 40536