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Psychiatric consultation to the burn unit: The psychiatrist's perspective
HERBERT OCHITILL, M.D.
Psychiatric consultation to the bum unit: The psychiatrist's perspective Approximately one percent of the population receives burns annually. Most burns are accidental, and occur in persons from lower socioeconomic levels, with poor housing, and who live in densely populated areas. Burns can confront the burn unit staff with the need to treat some of the most disfiguring and disabling of human injuries. Such patients require the intensive services of medical and surgical professionals. Burn patients differ from patients in other intensive care settings, such as the coronary care unit, in that proneness to burns is associated with psychiatric disorders, alcoholism, senility, and neurologic disorders. Attention to psychiatric disturbances should thus prove beneficial in the prevention of burns and in assisting patients to recover from these injuries. The staff is called on for lengthy treatment of patients, more than a few of whom have a history of psy-
chiatric disorder and whose injuries heavily tax the resilience and stamina of the most capable individual. The strain on the staff is compounded by the necessity of applying procedures that can be very painful, a process bringing staff and patient together on occasions of necessary suffering. Several studies'·3 have indicated the relatively common history of psychiatric disorder in burn patients. Noyes and associates 3 found that almost half of the patients studied had prior psychiatric conditions, including anxiety, alcoholism, organic brain syndrome, and personality disorder. A few burn patients had been admitted after suicide attempts. Also present was a relatively high prevalence of previous physical problems. Andreasen 4 examined preadmission psychiatric problems in relation to patient adjustment in the burn unit, correlating preadmission psychopathology with the development of
Dr. Ochiti/l is chief. consultation-liaison service ofthe department ofpsychiatry at San Francisco General Hospital. Reprint requests to him at the hospital. 1001 Potrero Avenue. San Francisco. CA 94/10.
depression, regressive behavior, or delirium. Psychiatric treatment On the burn unit many of the needed psychological interventions are effected by the attending staff. When there is an outstanding history or current symptoms of mental disorder, the psychiatrist needs to be actively involved in care. The very few patients seen for insightoriented psychotherapy are likely to have had preexisting psychological difficulties that can interfere with burn care, but that are optimally treated with psychotherapy. Otherwise, supportive therapy is the mainstay of psychotherapeutic involvement and stresses understanding of the current situation and active involvement by the therapist. It has been suggested S that depression and withdrawal in the burn patient are especially appropriate indications for psychotherapy. Behavior therapies including operant conditioning, desensitization, and modeling have been used in a limited way to alter behavior and ease anxiety before (continued on page 697)
SEPTEMBER 1984' VOL 25 • NO 9
689
Surgeon's perspective
(continued/rom page 693)
pIe, the burn unit staff, who are seen as inflictors of pain. They may become frustrated by this response from patients on whom they are expending much time and effort. A common response is to minimize contact with such angry patients, which leads to less than optimal care. Another case will serve as an example of this problem. Case 4 A 38-year-old industrial worker suffered 50% burned BSA at work. Approximately three weeks after admission, he became very angry at several members of the burn unit. At the same time, he was repeatedly arguing with his wife, who was seeking a divorce. After several days of increasing anger, he began to refuse some procedures. Staff members became upset with his abusive remarks and interacted with him only when necessary. The situation progressively worsened over the next few days. The psychiatric consultant met with him several times, and they discussed his injury, his treatment by the burn unit staff, and his situation. The patient then seemed to be able to identify that his anger was largely due to the conflicts with his wife. He became more willing to participate in treatment, with fewer outbursts toward the nurses or others.
Psychiatric consultants can help in such cases in two ways. They can help the patients identify their cause for anger and can instruct them in more acceptable means of expressing their feelings. Furthermore, a consultant can assist staff members in understanding the origins of the patient's anger and thereby in regarding such behavior as an expected reaction. The staff can then aid the patients in expressing their feelings in a more acceptable manner.
Bum team relationships Burn unit care involves management of critically ill patients for extended perjods of time and is one of the most stressful specialties in medical care. The staff members usually hav~ some experience in dealing with the emotional and psychiatric problems of bum patients. However, they rarely have much formal training in psychiatric care. Nurses, physicians, and therapists may be more able to review objectively their role and relationship with the patients during care conferences. The psychiatric professional can frequently direct such
SEPTEMBER 1984' VOL 25 • NO 9
REFERENCES 1. McDougal WS. Slade CL. Pruitt SA Jr: Manual 01 Burns New York Springer·Verlag, 1978. p 1. 2. Mendelsohn IE Liaison psychiatry and the burn center. Psychosomatics 24:235-243. 1983 3 Steiner H, Clark WR: Psychiatric complications of burned adults: A classification. J Trauma 17134·143,1977 4. White AC Psychiatric study of patients with severe burn Injuries. Br Med J 184:465-467, 1982
Psychiatrist's perspective
(continued from page 689)
procedures. Pharmacotherapy is useful in several clinical contexts. Antipsychotic agents are given for symptomatic relief in burn patients with acute organic brain syndrome. These drugs have also been a useful adjunct for pain relief. Minor tranquilizers help patients to tolerate procedures and to sleep soundly. Antidepressants currently have a minimal role in the burn unit. Whether their utility with chronic
discussion and provide insights. Problem cases involving patients who are especially difficult to manage can be approached with this method. Generally, these conferences are most useful when held on a regular basis. Conflicts will occasionally arise between members of the bum unit and the psychiatric consultant over a variety o( problems. For example, the staff may feel that the psychiatrist is interfering with their delivery of care, or the psychiatrist may believe that the staff is not sufficiently responsive to the patient's needs. However, after objective analysis, the conflicts are usually found to result from a lack of direct communication. Regularly scheduled conferences and frequent informal rounds or meetings will nearly always eliminate such conflicts. 0
pain patients suggests applications in this setting is a question that awaits investigation.
Cooperation with the staff At San Francisco General Hospital, a psychiatrist and psychiatric nurse work with bum unit patients and staff. The psychiatric nurse assists the nursing staff to optimize psychological care of the patients. This nurse is available on a case-by-case basis, attends staff meetings, and
runs a periodic conference that specifically grapples with psychosocial nursing issues. The psychiatrist provides case consultation and participates in medical staff rounds. Staff members are likely to discuss the disfigurement associated with bum injuries, their impatience with the slow recovery of some pa~ tients, the demanding behavior of others, the unnerving experience of giving painful treatments, particularly to children, or their helpless-
Psychiatrist's perspective
ness as witnesses to the death of a patient. Meetings provide an opportunity for the divestiture of feelings, review of specific problems, and expression of peer support. The psychiatrist who seeks to work in the unique surroundings of the bum unit faces significant obstacles. Features distinctive of the setting, the patient care, and the other health-care professionals significantly influence the collaborative relationship that develops. In the bum unit it is commonplace for patients to be in pain, deformed or disabled, immobile, infected, or dying, Bum care includes a variety of surgical procedures, respirators, physical therapy, and other at times complex supportive assistance. The patient's tenuous medical status and stay in the unit may continue for weeks or months. In this context, acute behavioral disturbance, a considerable risk at every stage of bum care, is highly disruptive and poorly tolerated by the staff. The relatively long stay of many patients argues for more than intermittent crisis intervention. Nevertheless, often the major staff expectation is for rapid response by the psychiatrist to acutely disturbed patients, while great inertia prevails regarding the development of systematic procedures for the identific.ation of patients at high risk for behavioral disturbance. Even the upgrading of staff skills in the prediction, prevention, and management of behavioral disorders may be resisted. At the outset of involvement with the burn unit, it is useful for the psychiatrist to indicate interest in developing these elements in addition to case-centered psychiatric consultation. A specific example of the kind of assistance provided by a psychiatric consultant follows.
Case 1 A 55-year-old man was admitted to the
unit for second-degree burns over 40% of his body. On the sixth day of hospitalization, he became grossly agitated and disoriented, and evinced signs of clouded sensorium. From admission, the clinical picture included electrolyte imbalance and edema that were being addressed in the treatment plan. In reviewing the clinical course, the psychiatrist noted that the staff had documented increasing nocturnal restlessness and insomnia for several nights prior to the gross disturbance in behavior. However, no attempt had been made to incorporate these observations into the clinical assessment or treatment. Measures recommended by the psychiatrist for the delirious condition included avoidance by the patient of sensory deprivation or overload; organized, consistent activity within the unit; inVOlvement of familiar care providers, friends, and family; allowance for mobility as possible; greater attempts to preserve the patient's sleep; review of the medication regimen; and care emphasizing clear, simple identification of person and purpose during brief, frequent contacts with the patient. The psychiatrist used this clinical experience to review patients at risk and the prodrome of delirium with the staff. The bum unit staff is highly accomplished in its biologic care of bum patients. Staff members must master a complicated range of medical and surgical therapies. Interest in critical care medicine is high; interest in psychosocial care is variable and, at times, minimal. Optimally, the psychiatrist evinces interest and familiarity with biologic medicine while introducing concepts of psychosocial care to the staff, some of whom have a limited approach to patient care. The psychiatrist should share their specifically medical interests while nur-
turing potential involvement on their part in the opportunities for comprehensive care. When participating in case review with the staff, the psychiatrist will find that asking about the risk of infection or a particular treatment approach can prompt a fruitful, comprehensive review of the patient's care. In instances when a dialogue has not been forthcoming, the consultant indicates his respect for the staff's culture and values through his active participation. This is particularly helpful during the early stage of work or when the staff attempts to avoid a clinical dilemma. In one case, following the psychiatrist's general comment that there seemed to be special difficulties in preventing infection in burn patients, staff members offered their view of the particular features of infection prophylaxis in this clinical context. After a general perspective was shared, they added that the behavior of several patients compounded the difficulties. Thereupon, they and the psychiatrist reviewed the recognition and management of organic brain syndromes in the context of burn care. No department of the hospital has greater involvement in the treatment of severe and often continuing pain than the burn unit. This feature of burn care has several implications. The patients must cope with extreme discomfort over extended periods of time, often with limited pain relief being possible. Burn victims thus receive relief that falls short of their hopes, while experiencing the distractibility, irritability. and insomnia that accompany significant pain. Healthcare professionals, who are highly intent on relieving suffering, must tolerate the provision of incomplete (conlinlled on par,e 701) PSYCHOSOMATICS
Psychiatrist's perspective
(conlin ued from page 698)
pain relief. More than that, dressing changes and other necessary treatments entail considerable pain. The irritable patient becomes angry or uncooperative when anticipating or receiving treatment. The psychiatrist strives to maintain a neutral perspective in this difficult situation, it not being desirable to ally fully with the patient or staff. It can be recommended that staff members provide adequate prior information and explanation regarding procedures, have some kind of analgesic available at all times for patients, especially to aid sleep, and be prepared to treat coincident anxiety. Vernick and associates6 demonstrated that daily treatments that included explanation, teaching of cognitive strategies, and instruction in physical skills for pain management could significantly enhance pain tolerance. The following case illuminates the approach to an initially difficult patient. Case 2 The psychiatrist was asked to see an "angry and belligerent" 32-year-old man who had been admitted three weeks before with first- and seconddegree burns over 30% of his body. He had become increasingly hostile to the staff before and during dressing changes. He refused some treatments altogether. Although acknowledging the discomfort of the wound dressings. the staff regarded his behavior as a manifestation of character pathology. The implication was that the patient was a "bad seed" in any context
and refractory to changes in the treatment approach. On interview, the consultant learned that the patient was aware of and bothered by his reputation among the staff. While appreciative of their perspective, he felt misunderstood. He related frustration with the multiple hardships wrought by the fire in which he was burned and with his own helplessness. He conceded that he tended to become generally irritable with those around him. He was en· couraged to describe the pattern of his pain experience and was able to characterize pain peaks. When reviewing his findings with the staff. the consultant noted the patient's reflections on his experience, his consideration of the staff perspective, and his desire to improve relations. Appreciating the complexities of the patient's feelings. the staff shared their own ambigUities. The psychiatrist pointed out the patient's need to lessen his helplessness. In accordance with this need, staff members tried to reduce his perplexity by helping him to better understand problems of treatment, the direction of therapy. and the framework for burn recovery. They were explicitly complimentary when he was able to act on his own behalf, and they looked for opportunities for him to assist in ongoing care. They were especially careful to avoid a negative response if he asked for help. A new interactional contract developed between the patient and the staff members.
Nonphysician staff figure prominently in the care of bum patients. The psychiatrist must relate effec-
tively to both nurses and physicians. In units where a struggle exists between these groups as to the relative distribution of responsibilities, the psychiatrist's involve-ment with one group can jeopardize work with the other. Naturally, the psychiatrist avoids any suggestion of alliance with either group in this struggle. It may be possible to aid by diplomatically identifying the problem. Staff meetings attended or sponsored by the psychiatrist offer a forum in which a clear, mutually satisfying division of responsibilities can be developed. This development, if not explicitly explored, can be fostered by encouraging role clarity in case-related discussions. Staying in the unit for weeks or months, bum patients are more than transient visitors. When the staff believes that a bum injury is precipitated by a mental disturbance, resentment may arise toward the patient and sometimes the psychiatrist. Although usually implied and not explicit, the belief can arise that these injuries are unnecessary and preventable by the patient or the mental health care system. Such an idea can be a source of irritation for the psychiatrist and the bum unit physician, and the psychiatrist should avoid reacting defensively or assuming the role of the apologist for the limitations of mental health treatment. Rather, this belief can be used in recommending greater commitment to furthering care of emotional disorders. 0
and burn InJunes. J Trauma 19131-134. 1979. 4 Andreasen NJ. Noyes R. Hartford CE: Factors InfluenCing adJustment of burn patients during hOsPitalization. Psychosom Med 34517·525. 1972 5 Jorgensen JA. Brophy JJ Psychiatric treat-
ment of severely burned adults Psychosomat14331-335. t973. 6 Vernick RL. JaremkO ME. Taylor PW Pain management In severely burned adults A test of stress Inoculation J Behav Med 4.1 03·1 07. 1981
Staff conflicts
REFERENCES 1 Klein RM. Charlton JE Behavioral observation and analySIS of pain behaVior ,n Critically burned patients. PaIn 927·40. 1980 2 Avnl J The severe burns. Adv Psychos om Med 1057-77.1980 3 Noyes R. Fryer SJ. et al Stressful life events
SEPTEMBER 1984' VOL 25 • NO 9
ICS
701
Psychiatric consultation to the bum unit: The psychiatrist's perspective Approximately one percent of the population receives burns annually. Most burns are accidental, and occur in persons from lower socioeconomic levels, with poor housing, and who live in densely populated areas. Burns can confront the burn unit staff with the need to treat some of the most disfiguring and disabling of human injuries. Such patients require the intensive services of medical and surgical professionals. Burn patients differ from patients in other intensive care settings, such as the coronary care unit, in that proneness to burns is associated with psychiatric disorders, alcoholism, senility, and neurologic disorders. Attention to psychiatric disturbances should thus prove beneficial in the prevention of burns and in assisting patients to recover from these injuries. The staff is called on for lengthy treatment of patients, more than a few of whom have a history of psy-
chiatric disorder and whose injuries heavily tax the resilience and stamina of the most capable individual. The strain on the staff is compounded by the necessity of applying procedures that can be very painful, a process bringing staff and patient together on occasions of necessary suffering. Several studies'·3 have indicated the relatively common history of psychiatric disorder in burn patients. Noyes and associates 3 found that almost half of the patients studied had prior psychiatric conditions, including anxiety, alcoholism, organic brain syndrome, and personality disorder. A few burn patients had been admitted after suicide attempts. Also present was a relatively high prevalence of previous physical problems. Andreasen 4 examined preadmission psychiatric problems in relation to patient adjustment in the burn unit, correlating preadmission psychopathology with the development of
Dr. Ochiti/l is chief. consultation-liaison service ofthe department ofpsychiatry at San Francisco General Hospital. Reprint requests to him at the hospital. 1001 Potrero Avenue. San Francisco. CA 94/10.
depression, regressive behavior, or delirium. Psychiatric treatment On the burn unit many of the needed psychological interventions are effected by the attending staff. When there is an outstanding history or current symptoms of mental disorder, the psychiatrist needs to be actively involved in care. The very few patients seen for insightoriented psychotherapy are likely to have had preexisting psychological difficulties that can interfere with burn care, but that are optimally treated with psychotherapy. Otherwise, supportive therapy is the mainstay of psychotherapeutic involvement and stresses understanding of the current situation and active involvement by the therapist. It has been suggested S that depression and withdrawal in the burn patient are especially appropriate indications for psychotherapy. Behavior therapies including operant conditioning, desensitization, and modeling have been used in a limited way to alter behavior and ease anxiety before (continued on page 697)
SEPTEMBER 1984' VOL 25 • NO 9
689
Surgeon's perspective
(continued/rom page 693)
pIe, the burn unit staff, who are seen as inflictors of pain. They may become frustrated by this response from patients on whom they are expending much time and effort. A common response is to minimize contact with such angry patients, which leads to less than optimal care. Another case will serve as an example of this problem. Case 4 A 38-year-old industrial worker suffered 50% burned BSA at work. Approximately three weeks after admission, he became very angry at several members of the burn unit. At the same time, he was repeatedly arguing with his wife, who was seeking a divorce. After several days of increasing anger, he began to refuse some procedures. Staff members became upset with his abusive remarks and interacted with him only when necessary. The situation progressively worsened over the next few days. The psychiatric consultant met with him several times, and they discussed his injury, his treatment by the burn unit staff, and his situation. The patient then seemed to be able to identify that his anger was largely due to the conflicts with his wife. He became more willing to participate in treatment, with fewer outbursts toward the nurses or others.
Psychiatric consultants can help in such cases in two ways. They can help the patients identify their cause for anger and can instruct them in more acceptable means of expressing their feelings. Furthermore, a consultant can assist staff members in understanding the origins of the patient's anger and thereby in regarding such behavior as an expected reaction. The staff can then aid the patients in expressing their feelings in a more acceptable manner.
Bum team relationships Burn unit care involves management of critically ill patients for extended perjods of time and is one of the most stressful specialties in medical care. The staff members usually hav~ some experience in dealing with the emotional and psychiatric problems of bum patients. However, they rarely have much formal training in psychiatric care. Nurses, physicians, and therapists may be more able to review objectively their role and relationship with the patients during care conferences. The psychiatric professional can frequently direct such
SEPTEMBER 1984' VOL 25 • NO 9
REFERENCES 1. McDougal WS. Slade CL. Pruitt SA Jr: Manual 01 Burns New York Springer·Verlag, 1978. p 1. 2. Mendelsohn IE Liaison psychiatry and the burn center. Psychosomatics 24:235-243. 1983 3 Steiner H, Clark WR: Psychiatric complications of burned adults: A classification. J Trauma 17134·143,1977 4. White AC Psychiatric study of patients with severe burn Injuries. Br Med J 184:465-467, 1982
Psychiatrist's perspective
(continued from page 689)
procedures. Pharmacotherapy is useful in several clinical contexts. Antipsychotic agents are given for symptomatic relief in burn patients with acute organic brain syndrome. These drugs have also been a useful adjunct for pain relief. Minor tranquilizers help patients to tolerate procedures and to sleep soundly. Antidepressants currently have a minimal role in the burn unit. Whether their utility with chronic
discussion and provide insights. Problem cases involving patients who are especially difficult to manage can be approached with this method. Generally, these conferences are most useful when held on a regular basis. Conflicts will occasionally arise between members of the bum unit and the psychiatric consultant over a variety o( problems. For example, the staff may feel that the psychiatrist is interfering with their delivery of care, or the psychiatrist may believe that the staff is not sufficiently responsive to the patient's needs. However, after objective analysis, the conflicts are usually found to result from a lack of direct communication. Regularly scheduled conferences and frequent informal rounds or meetings will nearly always eliminate such conflicts. 0
pain patients suggests applications in this setting is a question that awaits investigation.
Cooperation with the staff At San Francisco General Hospital, a psychiatrist and psychiatric nurse work with bum unit patients and staff. The psychiatric nurse assists the nursing staff to optimize psychological care of the patients. This nurse is available on a case-by-case basis, attends staff meetings, and
runs a periodic conference that specifically grapples with psychosocial nursing issues. The psychiatrist provides case consultation and participates in medical staff rounds. Staff members are likely to discuss the disfigurement associated with bum injuries, their impatience with the slow recovery of some pa~ tients, the demanding behavior of others, the unnerving experience of giving painful treatments, particularly to children, or their helpless-
Psychiatrist's perspective
ness as witnesses to the death of a patient. Meetings provide an opportunity for the divestiture of feelings, review of specific problems, and expression of peer support. The psychiatrist who seeks to work in the unique surroundings of the bum unit faces significant obstacles. Features distinctive of the setting, the patient care, and the other health-care professionals significantly influence the collaborative relationship that develops. In the bum unit it is commonplace for patients to be in pain, deformed or disabled, immobile, infected, or dying, Bum care includes a variety of surgical procedures, respirators, physical therapy, and other at times complex supportive assistance. The patient's tenuous medical status and stay in the unit may continue for weeks or months. In this context, acute behavioral disturbance, a considerable risk at every stage of bum care, is highly disruptive and poorly tolerated by the staff. The relatively long stay of many patients argues for more than intermittent crisis intervention. Nevertheless, often the major staff expectation is for rapid response by the psychiatrist to acutely disturbed patients, while great inertia prevails regarding the development of systematic procedures for the identific.ation of patients at high risk for behavioral disturbance. Even the upgrading of staff skills in the prediction, prevention, and management of behavioral disorders may be resisted. At the outset of involvement with the burn unit, it is useful for the psychiatrist to indicate interest in developing these elements in addition to case-centered psychiatric consultation. A specific example of the kind of assistance provided by a psychiatric consultant follows.
Case 1 A 55-year-old man was admitted to the
unit for second-degree burns over 40% of his body. On the sixth day of hospitalization, he became grossly agitated and disoriented, and evinced signs of clouded sensorium. From admission, the clinical picture included electrolyte imbalance and edema that were being addressed in the treatment plan. In reviewing the clinical course, the psychiatrist noted that the staff had documented increasing nocturnal restlessness and insomnia for several nights prior to the gross disturbance in behavior. However, no attempt had been made to incorporate these observations into the clinical assessment or treatment. Measures recommended by the psychiatrist for the delirious condition included avoidance by the patient of sensory deprivation or overload; organized, consistent activity within the unit; inVOlvement of familiar care providers, friends, and family; allowance for mobility as possible; greater attempts to preserve the patient's sleep; review of the medication regimen; and care emphasizing clear, simple identification of person and purpose during brief, frequent contacts with the patient. The psychiatrist used this clinical experience to review patients at risk and the prodrome of delirium with the staff. The bum unit staff is highly accomplished in its biologic care of bum patients. Staff members must master a complicated range of medical and surgical therapies. Interest in critical care medicine is high; interest in psychosocial care is variable and, at times, minimal. Optimally, the psychiatrist evinces interest and familiarity with biologic medicine while introducing concepts of psychosocial care to the staff, some of whom have a limited approach to patient care. The psychiatrist should share their specifically medical interests while nur-
turing potential involvement on their part in the opportunities for comprehensive care. When participating in case review with the staff, the psychiatrist will find that asking about the risk of infection or a particular treatment approach can prompt a fruitful, comprehensive review of the patient's care. In instances when a dialogue has not been forthcoming, the consultant indicates his respect for the staff's culture and values through his active participation. This is particularly helpful during the early stage of work or when the staff attempts to avoid a clinical dilemma. In one case, following the psychiatrist's general comment that there seemed to be special difficulties in preventing infection in burn patients, staff members offered their view of the particular features of infection prophylaxis in this clinical context. After a general perspective was shared, they added that the behavior of several patients compounded the difficulties. Thereupon, they and the psychiatrist reviewed the recognition and management of organic brain syndromes in the context of burn care. No department of the hospital has greater involvement in the treatment of severe and often continuing pain than the burn unit. This feature of burn care has several implications. The patients must cope with extreme discomfort over extended periods of time, often with limited pain relief being possible. Burn victims thus receive relief that falls short of their hopes, while experiencing the distractibility, irritability. and insomnia that accompany significant pain. Healthcare professionals, who are highly intent on relieving suffering, must tolerate the provision of incomplete (conlinlled on par,e 701) PSYCHOSOMATICS
Psychiatrist's perspective
(conlin ued from page 698)
pain relief. More than that, dressing changes and other necessary treatments entail considerable pain. The irritable patient becomes angry or uncooperative when anticipating or receiving treatment. The psychiatrist strives to maintain a neutral perspective in this difficult situation, it not being desirable to ally fully with the patient or staff. It can be recommended that staff members provide adequate prior information and explanation regarding procedures, have some kind of analgesic available at all times for patients, especially to aid sleep, and be prepared to treat coincident anxiety. Vernick and associates6 demonstrated that daily treatments that included explanation, teaching of cognitive strategies, and instruction in physical skills for pain management could significantly enhance pain tolerance. The following case illuminates the approach to an initially difficult patient. Case 2 The psychiatrist was asked to see an "angry and belligerent" 32-year-old man who had been admitted three weeks before with first- and seconddegree burns over 30% of his body. He had become increasingly hostile to the staff before and during dressing changes. He refused some treatments altogether. Although acknowledging the discomfort of the wound dressings. the staff regarded his behavior as a manifestation of character pathology. The implication was that the patient was a "bad seed" in any context
and refractory to changes in the treatment approach. On interview, the consultant learned that the patient was aware of and bothered by his reputation among the staff. While appreciative of their perspective, he felt misunderstood. He related frustration with the multiple hardships wrought by the fire in which he was burned and with his own helplessness. He conceded that he tended to become generally irritable with those around him. He was en· couraged to describe the pattern of his pain experience and was able to characterize pain peaks. When reviewing his findings with the staff. the consultant noted the patient's reflections on his experience, his consideration of the staff perspective, and his desire to improve relations. Appreciating the complexities of the patient's feelings. the staff shared their own ambigUities. The psychiatrist pointed out the patient's need to lessen his helplessness. In accordance with this need, staff members tried to reduce his perplexity by helping him to better understand problems of treatment, the direction of therapy. and the framework for burn recovery. They were explicitly complimentary when he was able to act on his own behalf, and they looked for opportunities for him to assist in ongoing care. They were especially careful to avoid a negative response if he asked for help. A new interactional contract developed between the patient and the staff members.
Nonphysician staff figure prominently in the care of bum patients. The psychiatrist must relate effec-
tively to both nurses and physicians. In units where a struggle exists between these groups as to the relative distribution of responsibilities, the psychiatrist's involve-ment with one group can jeopardize work with the other. Naturally, the psychiatrist avoids any suggestion of alliance with either group in this struggle. It may be possible to aid by diplomatically identifying the problem. Staff meetings attended or sponsored by the psychiatrist offer a forum in which a clear, mutually satisfying division of responsibilities can be developed. This development, if not explicitly explored, can be fostered by encouraging role clarity in case-related discussions. Staying in the unit for weeks or months, bum patients are more than transient visitors. When the staff believes that a bum injury is precipitated by a mental disturbance, resentment may arise toward the patient and sometimes the psychiatrist. Although usually implied and not explicit, the belief can arise that these injuries are unnecessary and preventable by the patient or the mental health care system. Such an idea can be a source of irritation for the psychiatrist and the bum unit physician, and the psychiatrist should avoid reacting defensively or assuming the role of the apologist for the limitations of mental health treatment. Rather, this belief can be used in recommending greater commitment to furthering care of emotional disorders. 0
and burn InJunes. J Trauma 19131-134. 1979. 4 Andreasen NJ. Noyes R. Hartford CE: Factors InfluenCing adJustment of burn patients during hOsPitalization. Psychosom Med 34517·525. 1972 5 Jorgensen JA. Brophy JJ Psychiatric treat-
ment of severely burned adults Psychosomat14331-335. t973. 6 Vernick RL. JaremkO ME. Taylor PW Pain management In severely burned adults A test of stress Inoculation J Behav Med 4.1 03·1 07. 1981
Staff conflicts
REFERENCES 1 Klein RM. Charlton JE Behavioral observation and analySIS of pain behaVior ,n Critically burned patients. PaIn 927·40. 1980 2 Avnl J The severe burns. Adv Psychos om Med 1057-77.1980 3 Noyes R. Fryer SJ. et al Stressful life events
SEPTEMBER 1984' VOL 25 • NO 9
ICS
701