- Email: [email protected]
The consultee-attended interview
The Consultee-Attended Interview An Approach to Liaison Psychiatry Jerome S. Gans, M.D. Chief Psychiatrist,
Bruintree Hospital, Bruintree, Massachusetts
Abstract: The consultee-attended (C-A) interview, a format in which the liaison psychiatrist interviews the patient in the consultees’ presence, is described. The background, strategy, concepts and methods, obstacles and resistances, and countertransference difficulties of C-A interview are discussed. The C-A interview is an experiential teaching instrument with which tofanhtate consultees’ “participant-observation, “a clinical posture that complements other approaches to the care ofsick people.
The author was a consultation-liaison psychiatrist on the Levine Cardiac Unit (LCU) of the Peter Bent Brigham Hospital (PBBH) over a 7-year period (1970-77). Although physicians are the official consultees for -psychiatric consultation requests on a cardiac care unit, the cardiac nurses are the de facto consultees: They frequently ask the doctor to request a psychiatric consultation, generally must deal with the patients’ psychological difficulties, and carry out the psychiatrist’s suggestions regarding patient management (1). Accordingly, the author performed psychiatric consultations divided between two consultees: physicians and cardiac nurses. Contact with the physicians followed the usual format of psychiatric consultation: Discussion about the patient occurred with the physician before and after the interview. Another dimension was introduced to this traditional psychiatric consultation; that is, the cardiac nurses were invited to attend the interview with the This work was done while the author wus a staff psychiatrist in the Peter Bent Brigham Hospital, Boston, MUSsachusetts. Division of Psychiatry,
The author wishes to thank Drs. Daniel Asnes, Thomas Gutheil, Cuvin Leetnun, and Quen tin Reges tein, and Mrs. Nancy Guns for their encouragement and criticism.
24 ISSN
~li;F~~79/010024-07/~.~
patient. This format, the consultee-attended (C-A) interview, is the subject of this report. The C-A interview assists the psychiatrist with a basic task: helping staff shift from their customary approach to disease, which is appropriate for dealing with pathophysiological processes, to one more suitable for working with psychological dimensions of sick people. The C-A interview yields for caretaker and patient an awareness that the personal interaction between them produces some degree of change in both individuals. The thoughts and feelings that patients and caretakers arouse in each other affect their perceptions and, therefore, their behavior toward one another. This awareness helps the nurses to become participant-observers and to avoid the clinical pitfalls of emotional detachment and overinvolvement. This report is a guide to the concepts, methods, and processes involved in a C-A interview for the psychiatrist interested in employing this format.
Experience with a C-A Interview The C-A interview format was used by the author over the entire 7-year period. The cardiac nurses, but not the physicians, attended the interviews. From July 1975, when the author was appointed Liaison Psychiatrist for the LCU, he worked exclusively with the cardiac nurses, and there were no physician consultees. During the 7 years, approximately 300 acutely ill patients were interviewed; the majority were between 40 and 75 years old. The C-A interview was used for 40-60 minutes, with 24 cardiac nurses present. Most patients had suffered myocardial infarctions 24 days previously; others had problems such as ventricular tachycardia, con-
General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
The Consultee-Attended Interview
gestive heart failure, cardiogenic shock, or preinfarctional angina. Ninety-seven percent of all the patients were willing to be interviewed; fewer than 10 patients refused to talk. Fewer than 20 stated a preference to talk alone rather than with the cardiac nurses present. Only 2 patients of the 50 whose family members happened to be present at the time of the interview preferred their family or spouse not to be present during the interview. Fewer than 10 of the 300 interviews were associated with morbidity as measured by increased blood pressure or pulse, exacerbation of arrhythmia, evidence or complaints of chest pain, diaphoresis, or shortness of breath. Patients rarely terminated a C-A interview or complained later to the nurses. Instead, the author usually had to terminate interviews with patients whose mood had brightened and who seemed eager to continue. Patients would frequently shake hands and invite the consultant to return. The cardiac nurses felt that as a result of the interviews they spent more time with patientsespecially those they found difficult to be with; they had more empathy for them and were more accepting (or, at least, less skeptical) of the healing effects of talking with patients. They often noted the patient’s clinical improvement in the days following the interview. Physicians’ (interns and residents) nonattendance at these interviews is puzzling. On one hand, their major interest was disease processes and their primary role model was the medical subspecialist. Yet, on the other hand, they seemed interested in the psychological dimensions of their patients and were appreciative of the psychiatrist’s contribution as a team member. At times, they sought out the author’s advice regarding personal or family difficulties. Their stated reasons for not attending were lack of time and other hospital duties.
Format When the cardiac nurses are the sole consultees, they select a patient for the psychiatrist to interview. Initially, the cardiac nurses tend to select patients with glaring psychopathology. Over time, the nurses begin to share the psychiatrist’s more basic interest in the psychological reactions of the average person to medical illness and hospitalization, as described by Strain and Grossman (2). Prior to the actual interview, the nurse assigned to the patient presents the patient to the psychiatrist as the other nurses listen. In this brief preinterview
discussion, the psychiatrist encourages the nurses to share their reactions to the patient described. The psychiatrist asks the patient’s nurse how she feels the patient might respond to the interview. Alone, the psychiatrist goes into the patient’s room and makes the following standardized introduction: I am Dr. X, a psychiatrist and member of the (cardiac care unit) team. I am interested in three things: (a) to learn what it is like for you to be a patient in this unit; (b) to learn something about you as a person so that we can feel more that we are caring for a person, not just a heart; and (c) to teach people on the health care team more about talking with patients. I like to introduce myself and tell patients what I do. I wonder how you would feel about talking with me. . . and if I am welcome, I wonder how you would feel about the cardiac nurses who are available joining us during the interview. The psychiatrist makes it clear to the patient that his1 participation is completely elective. Every effort is made by the psychiatrist to acknowledge and discuss with the patient any reservation or objection about participating in the interview. If the psychiatrist does not feel welcome in the patient’s room, he should tell the patient, even if the patient expresses overt willingness to participate. This direct approach encourages patients to participate, because they sense and appreciate the respect and lack of coercion inherent in the transaction. Thus, only those patients who truly wish to talk are interviewed. If the patient agrees to participate, the psychiatrist leaves the patient’s room and tells the nurses what transpired. The psychiatrist and nurses return to the patient’s room and the actual interview begins. After the interview, the psychiatrist and nurses reassemble and discuss the psychosocial data of the interview as well as any psychiatric topics raised by the interview material. The psychiatrist helps the nurses identify and organize the psychological data of the interview: the biography, the sequence in which material is presented, patient-psychiatrist and patient-consultee interaction, affective states, omissions, mechanisms of coping and defense, discrepancies between the patient’s portrayal of himself and his actual presentation in the interview, and the mental status examination. Psychiatric topics covered include but are not limited to differential diagnosis, anxiety and depression, delirium, psychosis, regression, death
‘To simplify discussion, male personal pronouns will be used to designate the patient or psychiatrist regardless of gender. 25
J. S. Gans
and dying, transference and countertransference, suicide, family and group dynamics, psychiatric manifestations of physical disease, and psychotrophic medication. Finally, the psychiatrist helps the nurse translate newly acquired understanding into a formulation of the case and a nursing treatment plan.
Strategy The psychiatrist conducts an interview that raises the patient’s self-esteem and, at the same time, temporarily immerses the nurses in the patient’s emotional life. This emotional bombardment temporarily robs the nurses of their professional detachment. In the postinterview discussion, the psychiatrist uses this shared emotional experience to teach the nurses about psychological data. The nurses, their reactions to the interview fresh, are now better able to comprehend and apply the didactic material presented in the postinterview discussion. In the interview, the emphasis is on acknowledging the patient’s feelings, based only on the patient’s experience; in the postinterview discussion, the psychiatrist introduces the notion that the patient might, in fact, have felt, thought, or acted in other ways. With the patient, the psychiatrist focuses on the inevitability of the patient’s feeling the way he does; with the staff, the psychiatrist takes up the patient’s own responsibility for himself. Each of these emphases has a supportive effect. The critically ill patient is not helped by the suggestion that he could or should be different; what he really needs is help in valuing himself. On the other hand, the staff is helped by seeing that the person has had some say in the way he is. This helps reduce the emotional burden on the staff, who, all too often, feel totally responsible for the patient. The fact that this is true in an intensive care setting does not keep it from being overestimated; the quality of the patient’s remaining years may well be determined more by how he decides to take care of himself than by staff intervention.
Concepts and Methods The psychiatrist knows that patients have ambivalent feelings about illness, doctors, and hospitalization. Patients tend to suppress the negative side of their ambivalence for fear that expression of these feelings would result in retaliation or abandonment. These unexpressed feelings exert a pernicious effect on the patient’s self-esteem, relations 26
with hospital staff, and, often, clinical course. If the patient can be made to feel that these feelings are normal and expected, and can be helped to express latent hostility, this destructive energy can be transformed and redirected toward self-healing. How can the psychiatrist help the patient achieve this catharsis, even though the psychiatrist is also a physician who wears a white coat? The psychiatrist invites the patient to share with him and the nurses present what it has been like to be a patient on the cardiac care unit. In response to the patient who extols the virtues of the hospital, the psychiatrist communicates mild surprise and slight disbelief, as if to say, “I guess it’s possible, although one doesn’t hear it very often.” To the patient who describes awful experiences, the psychiatrist conveys with sympathetic horror, “My god, that happened to you?” The psychiatrist either shares the patient’s negative feelings or expresses reservation or suspicion about positive (polite) statements that mask negative feelings.* The psychiatrist accomplishes three objectives by sharing these negative feelings with the patient. First, by not taking the patient’s politeness at face value, the psychiatrist acknowledges the presence of these negative feelings and thereby permits the patient to talk about them. Second, because sharing anything reduces the burden, the psychiatrist helps the patient feel less overwhelmed by these feelings; and because people tend to project feelings that overwhelm them, the patient now has less need to project. Third, the psychiatrist’s acceptance of the patient’s negative feelings about others-in this case, the doctors or the hospital-implies that the psychiatrist is not aligned with them. The psychiatrist’s purpose in dissociating himself from the medical doctors is not to undermine or blame them, but rather to make it possible for the patient to vent angry feelings about doctors while talking to one. A 34-year-old, white, married father of 2 sons sustained an MI and was hospitalized at his local hospital; within 9 months he developed congestive heart failure and was admitted to the LCU of the PBBH. A C-A interviewwas held 1 day after treadmill exercising and 1 day before his cardiac catheterization; his wife and 4 cardiac nurses were present. The patient began by saying how impressed he and his wife were with the
la&e-medical center. I responded, “Sometimes it’s
This approachis similarto an interviewingtechniqueutilizing counterprojective remarks, first described by Sullivan (3) and recently elaborated by Havens (4,5). “Counterprojective” means that the interviewer proceeds in a fashion calculated to counter (or make unlikely) negative projections by the patient onto the interviewer.
The Consultee-Attended
more impressive when you‘re not a patient.” The patient then joked good naturedly about his treadmill experience, but his discomfort was evident. I commented, with mild sarcasm, “It’s amazing what they have to do to help you.” The patient then shared his intense fear (which up to this point he had kept to himself) before going on the treadmill because a good friend had recently had a heart attack while undergoing the same test. His wife then characterized the doctors’ rounds. “They stand over you and look down at you!” A few moments later, she described how the doctors explained the cardiac catheterization. “They called me out of his room, explained how dangerous it was, and then told me to go back in, support him, and tell him it was no big deal. . . . It’s easy for them not to worry, they go home to their wives and children.”
Here, the psychiatrist’s remarks permit and assist the patient and his wife to express negative feelings about hospitalization and physicians to the psychiatrist, himself a doctor who works in hospitals. The patient and his wife are unaware of this irony-testimony to the psychiatrist’s success in becoming the patient’s ally. Once the psychiatrist establishes that he is on the patient’s side, he attempts to raise the patient’s self-esteem. Illness and hospitalization assault self-esteem by interfering with three areas that foster self-esteem: health, capacity to love, and work. The hospitalized patient has left the healthy state, often does not feel loving or loveable, and must interrupt work. The patient either is out of touch with his own past experience or feels that it is no longer of value. The psychiatrist, however, knows that every person’s experience is unique; this experience, when shared with staff, is the most humanizing force in the coronary care unit or, for that matter, any clinical setting. Thus, the psychiatrist selects methods that draw out, illuminate, and value the unique aspects of the patient’s personal experience. The psychiatrist elicits this material by adopting an interviewing style that makes him, as a personal presence, seem smaller and the patient seem larger. The patient’s personal experience-not the doctor’s knowledge-receives the spotlight. In contrast to the medical doctor, whose vast knowledge of cardiovascular pathophysiology makes the patient’s signs and symptoms recognizable as a disease entity, the psychiatrist proceeds, at this point, with the conviction that he can never “know” or “recognize” the patient but can only “keep looking” for him.3 When the patient mentions, for example, his jThese techniques resemble methods of the existential school of psychiatry as described by Havens (6).
Interview
job, a medical term, or even that he owns a home, the psychiatrist reminds himself that he does not know, especially in emotional terms, what the patient really means. By resisting every temptation to conclude anything about the patient, the psychiatrist invites the patient to describe exactly what he means; the exquisitely human story, which seems inevitably to accompany every major medical illness, emerges: A 54-year-old woman who worked as a manicurist
for half her life was stricken with a heart attack. When asked what her work was like, she compared it to performing long-term psychotherapy. When asked to tell about her most memorable “case,” she described a woman whose deteriorating marital situation mirrored her own. A young, hard-working family man in excellent physical condition was incredulous that he had suffered a heart attack, because of his belief that only obese people suffered them. His single, prodigal, and hated older brother was obese and in good health. A successful, middle-aged businessman inexplicably built a 5-bedroom home at a time when his children were leaving home and shortly thereafter suffered a heart attack. He desperately wanted to provide his children with the “home” he never had in his sad,
impoverished,orphaned youth.
This part of the interview is characterized by a falling away of labels of “sick” and “well” and by substantial, unself-conscious patient conversation. The patient’s posture changes; the drawn, sick patient is now sitting up and talking in an animated, rejuvenated way. When the patient is helped to get back in touch with his own experience and feels that the psychiatrist values it, the patient in turn revalues his experience and his self-esteem rises. The patient now talks freely, and his story has a way of encompassing the important people and events in his life. The psychiatrist organizes the patient’s story in a time framework as a way of highlighting relationships between life events which otherwise would be missed. For example, the psychiatrist focuses on the setting in which the heart attack occurred and the sequence of events: A 44-year-old, white, married father of 2 daughters, ages 16 and 13, experienced the sudden onset of excruciatingchest and left arm pain and nauseaat 5 PM on Saturday afternoon. He was in the bedroom with his wife and was getting dressed to attend a social function at their Masonic Lodge where, a year before, he had occupied the elected position of Grand Master. Because he had noticed in bending down to tie his shoe that this posture largely relieved his chest pain, he began to crawl on the floor around the bed to reach 27
J. S. Gans the bathroom. He did not say a word to his wife for fear that she would not believe his distress, because of his reputation as a clown and a practical joker. He thought that his wife noticed him, although she also did not say a word. At this time, the patient thought he was having a heart attack and was going to die. His wife rushed into the bathroom when she heard him vomiting and immediately yelled to one of the daughters to call their doctor. The patient did not remember which daughter his wife called, but, when asked which one he thought she would have called, he answered, “the 13-year-old.” When asked why, he told how, in general, the 16-year-old was highly unreliable, and, in particular, she had come in at 2:30 AM the night before. She had been out with an older man whom the patient and his wife highly disapproved of, and the patient was furious. At the breakfast table on the day of his heart attack, the patient had a heated argument with this daughter and issued a 3-month curtailment on all her social activity. The chest pains first came on, he recalled, as he wondered with tension whether his daughter would defy his edict that very night when he and his wife were not home. The patient’s physician returned the phone call and told his wife to bring him immediately to the emergency room; the patient insisted on driving them to the hospital and his wife
acquiesced.
Without directly asking, the psychiatrist learns about the patient’s personality traits and social support systems, as well as his relationship with his wife and attitudes toward his daughters. Such material becomes particularly useful to the psychiatrist in his postinterview discussion with the nurses.
Postinterview Discussion How do the cardiac nurses react as they experience the interview? First, they say that they are surpised and perplexed because, during the interview, the patient seems different from the patient they have been caring for. Second, they discuss the particular story the patient tells not “clinically” but with emotions determined by both the nature of the story and the nurses’ experience with similar issues in their own lives or the lives of their children, parents, or grandparents. Third, by the interview’s end, the nurses have freely relinquished their accustomed objective stance toward the patient; occasionally, nurses find their initial overinvolvement to be justified. The patient’s personal experience temporarily overwhelms them; not infrequently, they view the patient as an unfortunate victim of fate. Because the psychiatrist grasps these three characteristic reactions, the postinterview discussion with the nurses becomes experiential rather 28
than didactic. Thus, when nurses express surprise that the patient appeared to be so different during the interview, the psychiatrist points out that in interpersonal relations, unlike physical processes, there are no objective data. That is, the way the patient “decides” to present himself is partly, and sometimes largely, a function of the way in which staff members interact with the patient. To a great degree, staff are unaware of the ways in which their interactions with the patients provoke, enhance, or inhibit what patients reveal about themselves. In the C-A interview, the psychiatrist facilitates the emergence of dimensions of the patient previously unknown to the staff. The C-A interview demonstrates to staff how different ways of interacting with a patient can reveal the patient differently; as a result, staff are helped experientially to become participant-observers. The C-A interview also demonstrates to the staff that their fears about harming a patient by “prying” or “stirring things up” are unwarranted; at the same time, the C-A interview provides staff with a model of a professional exchange rather than ordinary conversation (7). When discussing the psychological data of the interview, the nurses tend to analyze before identifying the data. By teaching what psychological material is and how to work with it, the psychiatrist helps the nurses avoid premature conclusions about patients. Nurses often idealize the patient in the postinterview discussion. This tendency results from the psychiatrist’s use of interviewing methods that magnify the patient’s painful life experiences. The potentially negative and dangerous result of such techniques is that nurses are left with the impression that the patient is a totally good person who is the unfortunate victim of fate. What is missing in the staff’s picture of the patient up to this point is the element of personal responsibility. The antidote to the staff’s idealized view of the patient resides in the interview material the psychiatrist has kept in a time framework. Thus, the patient who sustained the MI in the context of his older daughter’s troublesome behavior appears at first glance to be a victim. The psychiatrist can invite the nurses to speculate: What is the meaning of the patient’s grounding his daughter for 3 months? What thoughts do they have about the patient’s decision to drive himself to the hospital? Or the fact that his wife let him? What would it be like to live in the same house with such a man? Hopefully, by the discussion’s end, a picture emerges of the patient, neither angel nor devil, but a human being molded in part by early life events, subject to physical dis-
The Consultee-Attended Interview
ease, affected by chance, capable of choice, and, like everyone else, with a poignant human story to tell.
Obstacles and Resistances Many factors combine to make a meeting of a psychiatrist, an acutely ill medical patient, and a group of nurses (or other consultees) in the same room an unlikely event. Patient resistance is, surprisingly, the least impediment. Money, space, and available personnel are obvious limiting factors. The format of a C-A interview must be supported by a respected medical leader who appreciates the importance of psychosocial factors in health and disease and in the functioning of a (cardiac) unit. Conversely, medical leadership that is inimical or indifferent to psychosocial forces dooms such a venture to early failure. Staff fears constitute a major resistance, especially in the early phases of instituting the C-A interview on a regular basis. First, there exists a pervasive but unsubstantiated notion that talking in a serious way with acutely ill people is harmful. Second, staff often assume that the patient really does not want to talk in such a setting. Third, there may be deep staff distrust for the psychiatric interview itself, based on the fear that the patient will be exposed, criticized, or coerced; unfortunately, staff distrust sometimes has a foundation in clinical experience. Fourth, negative staff reaction may result from overidentification with the patient in the interview. Staff imagine that they would be uncomfortable if they were the subject in such a format and conclude that the patient will also feel uncomfortable. Although staff rightly appreciate the extreme vulnerability of the patient (in the CCU), they overlook or fail to grasp the patient’s even more powerful wish to be understood and not to feel alone (8). Fifth, the nurses are familiar with seeing physicians as well as themselves do things to, for, and on patients as opposed to with them; thus, it is understandable that in the highly uncertain milieu of the cardiac care unit, the introduction of an unfamiliar technique-one in which the physician works with the patient-can raise staff anxiety. Finally, a certain resistance to having his work so freely observed by his medical and nursing colleagues may reside in the psychiatrist himself.
Countertransference
Difficulties
Mendelson and Meyer discuss countertransference problems of the liaison psychiatrist in relation to severe disease and death, patients with severe
family, and social pathology, and the physical and psychological inconveniences in working in a medical setting (9). The C-A interview introduces additional countertransference difficulties. In the beginning of the interview, the psychiatrist dissociates himself from the medical team and thereby gives the patient permission to speak negatively about experiences with doctors and hospitals. The psychiatrist’s purpose in doing so is not to suggest or document that medical doctors are bad but rather to help the patient express this anger without projecting it onto the psychiatrist. If, however, the psychiatist (especially if male) is unconsciously competitive with medical doctors (perhaps, in this setting, competitive for the nurses’ favor); is critical of the disease-oriented medical approach; or if his humanistic ideals clash with a clinical-research setting in which affairs of the body are more vigorously pursued than those of the mind, he will find it impossible to keep the patient’s “tales of woe” in perspective. The psychiatrist may then convey to the nurses that he is critical of medical doctors and believes that they do horrible things to patients. Depending on the nurses’ viewpoint, the psychiatrist will appear to be an advocate for the patient or a “holier-than-thou shrink” who does not value the benefits that patients derive from medical care or nursing staff. Eventually, reverberations from such countertransference difficulties reach key medical and administrative personnel, who may withdraw support, with some justification.
character,
Summary The consultee-attended (C-A) interview is a format in which the liaison psychiatrist interviews the patient in the consultees’ presence. The C-A interview is an experiential teaching technique used to facilitate the consultees’ role as “participant-observers” in working with the psychological aspects of their patients.
References Rahe RH: A liaison psychiatrist on the coronary care unit. In Consultation-Liaison Psychiatry. Pasnau RO (ed). New York, Grune and Stratton, 1975, p. 118 Strain JJ, Grossman G: The Psychological Care of the Medically Ill. New York, Appleton-Century-Crofts, 1975, pp. 23-36 Sullivan HS: The Psychiatric Interview. New York, W. W. Norton and Company, 1954 Havens LL: Approaches to the Mind. Boston, Little, Brown and Company, 1973 29
J. S. Gans
5. Havens LL: Participant Observation. New York, Jason Aronson, Inc., 1976 6. Havens LL: The existential use of the self. Am J Psychiatry 131:1-10, 1974 7. Shneidman SS: Postvention: The Care of the Bereaved. In Consultation-Liaison Psychiatry. Pasnau RO (ed). New York, Grune and Stratton, 1975, pp. 250-251 8. Lynch JJ: The Broken Heart: The Medical Consequences of Loneliness. New York, Basic Books, Inc., 1977 9. Mendelson M, Meyer E: Countertransference prob-
30
lems of the liaison psychiatrist. 23:115-122, 1961
Direct reprint requests to: Jerome S. Gans, M.D. Department of Psychiatry Braintree Hospital 250 Pond Street Braintree, MA 02184
Psychosom Med
Bruintree Hospital, Bruintree, Massachusetts
Abstract: The consultee-attended (C-A) interview, a format in which the liaison psychiatrist interviews the patient in the consultees’ presence, is described. The background, strategy, concepts and methods, obstacles and resistances, and countertransference difficulties of C-A interview are discussed. The C-A interview is an experiential teaching instrument with which tofanhtate consultees’ “participant-observation, “a clinical posture that complements other approaches to the care ofsick people.
The author was a consultation-liaison psychiatrist on the Levine Cardiac Unit (LCU) of the Peter Bent Brigham Hospital (PBBH) over a 7-year period (1970-77). Although physicians are the official consultees for -psychiatric consultation requests on a cardiac care unit, the cardiac nurses are the de facto consultees: They frequently ask the doctor to request a psychiatric consultation, generally must deal with the patients’ psychological difficulties, and carry out the psychiatrist’s suggestions regarding patient management (1). Accordingly, the author performed psychiatric consultations divided between two consultees: physicians and cardiac nurses. Contact with the physicians followed the usual format of psychiatric consultation: Discussion about the patient occurred with the physician before and after the interview. Another dimension was introduced to this traditional psychiatric consultation; that is, the cardiac nurses were invited to attend the interview with the This work was done while the author wus a staff psychiatrist in the Peter Bent Brigham Hospital, Boston, MUSsachusetts. Division of Psychiatry,
The author wishes to thank Drs. Daniel Asnes, Thomas Gutheil, Cuvin Leetnun, and Quen tin Reges tein, and Mrs. Nancy Guns for their encouragement and criticism.
24 ISSN
~li;F~~79/010024-07/~.~
patient. This format, the consultee-attended (C-A) interview, is the subject of this report. The C-A interview assists the psychiatrist with a basic task: helping staff shift from their customary approach to disease, which is appropriate for dealing with pathophysiological processes, to one more suitable for working with psychological dimensions of sick people. The C-A interview yields for caretaker and patient an awareness that the personal interaction between them produces some degree of change in both individuals. The thoughts and feelings that patients and caretakers arouse in each other affect their perceptions and, therefore, their behavior toward one another. This awareness helps the nurses to become participant-observers and to avoid the clinical pitfalls of emotional detachment and overinvolvement. This report is a guide to the concepts, methods, and processes involved in a C-A interview for the psychiatrist interested in employing this format.
Experience with a C-A Interview The C-A interview format was used by the author over the entire 7-year period. The cardiac nurses, but not the physicians, attended the interviews. From July 1975, when the author was appointed Liaison Psychiatrist for the LCU, he worked exclusively with the cardiac nurses, and there were no physician consultees. During the 7 years, approximately 300 acutely ill patients were interviewed; the majority were between 40 and 75 years old. The C-A interview was used for 40-60 minutes, with 24 cardiac nurses present. Most patients had suffered myocardial infarctions 24 days previously; others had problems such as ventricular tachycardia, con-
General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
The Consultee-Attended Interview
gestive heart failure, cardiogenic shock, or preinfarctional angina. Ninety-seven percent of all the patients were willing to be interviewed; fewer than 10 patients refused to talk. Fewer than 20 stated a preference to talk alone rather than with the cardiac nurses present. Only 2 patients of the 50 whose family members happened to be present at the time of the interview preferred their family or spouse not to be present during the interview. Fewer than 10 of the 300 interviews were associated with morbidity as measured by increased blood pressure or pulse, exacerbation of arrhythmia, evidence or complaints of chest pain, diaphoresis, or shortness of breath. Patients rarely terminated a C-A interview or complained later to the nurses. Instead, the author usually had to terminate interviews with patients whose mood had brightened and who seemed eager to continue. Patients would frequently shake hands and invite the consultant to return. The cardiac nurses felt that as a result of the interviews they spent more time with patientsespecially those they found difficult to be with; they had more empathy for them and were more accepting (or, at least, less skeptical) of the healing effects of talking with patients. They often noted the patient’s clinical improvement in the days following the interview. Physicians’ (interns and residents) nonattendance at these interviews is puzzling. On one hand, their major interest was disease processes and their primary role model was the medical subspecialist. Yet, on the other hand, they seemed interested in the psychological dimensions of their patients and were appreciative of the psychiatrist’s contribution as a team member. At times, they sought out the author’s advice regarding personal or family difficulties. Their stated reasons for not attending were lack of time and other hospital duties.
Format When the cardiac nurses are the sole consultees, they select a patient for the psychiatrist to interview. Initially, the cardiac nurses tend to select patients with glaring psychopathology. Over time, the nurses begin to share the psychiatrist’s more basic interest in the psychological reactions of the average person to medical illness and hospitalization, as described by Strain and Grossman (2). Prior to the actual interview, the nurse assigned to the patient presents the patient to the psychiatrist as the other nurses listen. In this brief preinterview
discussion, the psychiatrist encourages the nurses to share their reactions to the patient described. The psychiatrist asks the patient’s nurse how she feels the patient might respond to the interview. Alone, the psychiatrist goes into the patient’s room and makes the following standardized introduction: I am Dr. X, a psychiatrist and member of the (cardiac care unit) team. I am interested in three things: (a) to learn what it is like for you to be a patient in this unit; (b) to learn something about you as a person so that we can feel more that we are caring for a person, not just a heart; and (c) to teach people on the health care team more about talking with patients. I like to introduce myself and tell patients what I do. I wonder how you would feel about talking with me. . . and if I am welcome, I wonder how you would feel about the cardiac nurses who are available joining us during the interview. The psychiatrist makes it clear to the patient that his1 participation is completely elective. Every effort is made by the psychiatrist to acknowledge and discuss with the patient any reservation or objection about participating in the interview. If the psychiatrist does not feel welcome in the patient’s room, he should tell the patient, even if the patient expresses overt willingness to participate. This direct approach encourages patients to participate, because they sense and appreciate the respect and lack of coercion inherent in the transaction. Thus, only those patients who truly wish to talk are interviewed. If the patient agrees to participate, the psychiatrist leaves the patient’s room and tells the nurses what transpired. The psychiatrist and nurses return to the patient’s room and the actual interview begins. After the interview, the psychiatrist and nurses reassemble and discuss the psychosocial data of the interview as well as any psychiatric topics raised by the interview material. The psychiatrist helps the nurses identify and organize the psychological data of the interview: the biography, the sequence in which material is presented, patient-psychiatrist and patient-consultee interaction, affective states, omissions, mechanisms of coping and defense, discrepancies between the patient’s portrayal of himself and his actual presentation in the interview, and the mental status examination. Psychiatric topics covered include but are not limited to differential diagnosis, anxiety and depression, delirium, psychosis, regression, death
‘To simplify discussion, male personal pronouns will be used to designate the patient or psychiatrist regardless of gender. 25
J. S. Gans
and dying, transference and countertransference, suicide, family and group dynamics, psychiatric manifestations of physical disease, and psychotrophic medication. Finally, the psychiatrist helps the nurse translate newly acquired understanding into a formulation of the case and a nursing treatment plan.
Strategy The psychiatrist conducts an interview that raises the patient’s self-esteem and, at the same time, temporarily immerses the nurses in the patient’s emotional life. This emotional bombardment temporarily robs the nurses of their professional detachment. In the postinterview discussion, the psychiatrist uses this shared emotional experience to teach the nurses about psychological data. The nurses, their reactions to the interview fresh, are now better able to comprehend and apply the didactic material presented in the postinterview discussion. In the interview, the emphasis is on acknowledging the patient’s feelings, based only on the patient’s experience; in the postinterview discussion, the psychiatrist introduces the notion that the patient might, in fact, have felt, thought, or acted in other ways. With the patient, the psychiatrist focuses on the inevitability of the patient’s feeling the way he does; with the staff, the psychiatrist takes up the patient’s own responsibility for himself. Each of these emphases has a supportive effect. The critically ill patient is not helped by the suggestion that he could or should be different; what he really needs is help in valuing himself. On the other hand, the staff is helped by seeing that the person has had some say in the way he is. This helps reduce the emotional burden on the staff, who, all too often, feel totally responsible for the patient. The fact that this is true in an intensive care setting does not keep it from being overestimated; the quality of the patient’s remaining years may well be determined more by how he decides to take care of himself than by staff intervention.
Concepts and Methods The psychiatrist knows that patients have ambivalent feelings about illness, doctors, and hospitalization. Patients tend to suppress the negative side of their ambivalence for fear that expression of these feelings would result in retaliation or abandonment. These unexpressed feelings exert a pernicious effect on the patient’s self-esteem, relations 26
with hospital staff, and, often, clinical course. If the patient can be made to feel that these feelings are normal and expected, and can be helped to express latent hostility, this destructive energy can be transformed and redirected toward self-healing. How can the psychiatrist help the patient achieve this catharsis, even though the psychiatrist is also a physician who wears a white coat? The psychiatrist invites the patient to share with him and the nurses present what it has been like to be a patient on the cardiac care unit. In response to the patient who extols the virtues of the hospital, the psychiatrist communicates mild surprise and slight disbelief, as if to say, “I guess it’s possible, although one doesn’t hear it very often.” To the patient who describes awful experiences, the psychiatrist conveys with sympathetic horror, “My god, that happened to you?” The psychiatrist either shares the patient’s negative feelings or expresses reservation or suspicion about positive (polite) statements that mask negative feelings.* The psychiatrist accomplishes three objectives by sharing these negative feelings with the patient. First, by not taking the patient’s politeness at face value, the psychiatrist acknowledges the presence of these negative feelings and thereby permits the patient to talk about them. Second, because sharing anything reduces the burden, the psychiatrist helps the patient feel less overwhelmed by these feelings; and because people tend to project feelings that overwhelm them, the patient now has less need to project. Third, the psychiatrist’s acceptance of the patient’s negative feelings about others-in this case, the doctors or the hospital-implies that the psychiatrist is not aligned with them. The psychiatrist’s purpose in dissociating himself from the medical doctors is not to undermine or blame them, but rather to make it possible for the patient to vent angry feelings about doctors while talking to one. A 34-year-old, white, married father of 2 sons sustained an MI and was hospitalized at his local hospital; within 9 months he developed congestive heart failure and was admitted to the LCU of the PBBH. A C-A interviewwas held 1 day after treadmill exercising and 1 day before his cardiac catheterization; his wife and 4 cardiac nurses were present. The patient began by saying how impressed he and his wife were with the
la&e-medical center. I responded, “Sometimes it’s
This approachis similarto an interviewingtechniqueutilizing counterprojective remarks, first described by Sullivan (3) and recently elaborated by Havens (4,5). “Counterprojective” means that the interviewer proceeds in a fashion calculated to counter (or make unlikely) negative projections by the patient onto the interviewer.
The Consultee-Attended
more impressive when you‘re not a patient.” The patient then joked good naturedly about his treadmill experience, but his discomfort was evident. I commented, with mild sarcasm, “It’s amazing what they have to do to help you.” The patient then shared his intense fear (which up to this point he had kept to himself) before going on the treadmill because a good friend had recently had a heart attack while undergoing the same test. His wife then characterized the doctors’ rounds. “They stand over you and look down at you!” A few moments later, she described how the doctors explained the cardiac catheterization. “They called me out of his room, explained how dangerous it was, and then told me to go back in, support him, and tell him it was no big deal. . . . It’s easy for them not to worry, they go home to their wives and children.”
Here, the psychiatrist’s remarks permit and assist the patient and his wife to express negative feelings about hospitalization and physicians to the psychiatrist, himself a doctor who works in hospitals. The patient and his wife are unaware of this irony-testimony to the psychiatrist’s success in becoming the patient’s ally. Once the psychiatrist establishes that he is on the patient’s side, he attempts to raise the patient’s self-esteem. Illness and hospitalization assault self-esteem by interfering with three areas that foster self-esteem: health, capacity to love, and work. The hospitalized patient has left the healthy state, often does not feel loving or loveable, and must interrupt work. The patient either is out of touch with his own past experience or feels that it is no longer of value. The psychiatrist, however, knows that every person’s experience is unique; this experience, when shared with staff, is the most humanizing force in the coronary care unit or, for that matter, any clinical setting. Thus, the psychiatrist selects methods that draw out, illuminate, and value the unique aspects of the patient’s personal experience. The psychiatrist elicits this material by adopting an interviewing style that makes him, as a personal presence, seem smaller and the patient seem larger. The patient’s personal experience-not the doctor’s knowledge-receives the spotlight. In contrast to the medical doctor, whose vast knowledge of cardiovascular pathophysiology makes the patient’s signs and symptoms recognizable as a disease entity, the psychiatrist proceeds, at this point, with the conviction that he can never “know” or “recognize” the patient but can only “keep looking” for him.3 When the patient mentions, for example, his jThese techniques resemble methods of the existential school of psychiatry as described by Havens (6).
Interview
job, a medical term, or even that he owns a home, the psychiatrist reminds himself that he does not know, especially in emotional terms, what the patient really means. By resisting every temptation to conclude anything about the patient, the psychiatrist invites the patient to describe exactly what he means; the exquisitely human story, which seems inevitably to accompany every major medical illness, emerges: A 54-year-old woman who worked as a manicurist
for half her life was stricken with a heart attack. When asked what her work was like, she compared it to performing long-term psychotherapy. When asked to tell about her most memorable “case,” she described a woman whose deteriorating marital situation mirrored her own. A young, hard-working family man in excellent physical condition was incredulous that he had suffered a heart attack, because of his belief that only obese people suffered them. His single, prodigal, and hated older brother was obese and in good health. A successful, middle-aged businessman inexplicably built a 5-bedroom home at a time when his children were leaving home and shortly thereafter suffered a heart attack. He desperately wanted to provide his children with the “home” he never had in his sad,
impoverished,orphaned youth.
This part of the interview is characterized by a falling away of labels of “sick” and “well” and by substantial, unself-conscious patient conversation. The patient’s posture changes; the drawn, sick patient is now sitting up and talking in an animated, rejuvenated way. When the patient is helped to get back in touch with his own experience and feels that the psychiatrist values it, the patient in turn revalues his experience and his self-esteem rises. The patient now talks freely, and his story has a way of encompassing the important people and events in his life. The psychiatrist organizes the patient’s story in a time framework as a way of highlighting relationships between life events which otherwise would be missed. For example, the psychiatrist focuses on the setting in which the heart attack occurred and the sequence of events: A 44-year-old, white, married father of 2 daughters, ages 16 and 13, experienced the sudden onset of excruciatingchest and left arm pain and nauseaat 5 PM on Saturday afternoon. He was in the bedroom with his wife and was getting dressed to attend a social function at their Masonic Lodge where, a year before, he had occupied the elected position of Grand Master. Because he had noticed in bending down to tie his shoe that this posture largely relieved his chest pain, he began to crawl on the floor around the bed to reach 27
J. S. Gans the bathroom. He did not say a word to his wife for fear that she would not believe his distress, because of his reputation as a clown and a practical joker. He thought that his wife noticed him, although she also did not say a word. At this time, the patient thought he was having a heart attack and was going to die. His wife rushed into the bathroom when she heard him vomiting and immediately yelled to one of the daughters to call their doctor. The patient did not remember which daughter his wife called, but, when asked which one he thought she would have called, he answered, “the 13-year-old.” When asked why, he told how, in general, the 16-year-old was highly unreliable, and, in particular, she had come in at 2:30 AM the night before. She had been out with an older man whom the patient and his wife highly disapproved of, and the patient was furious. At the breakfast table on the day of his heart attack, the patient had a heated argument with this daughter and issued a 3-month curtailment on all her social activity. The chest pains first came on, he recalled, as he wondered with tension whether his daughter would defy his edict that very night when he and his wife were not home. The patient’s physician returned the phone call and told his wife to bring him immediately to the emergency room; the patient insisted on driving them to the hospital and his wife
acquiesced.
Without directly asking, the psychiatrist learns about the patient’s personality traits and social support systems, as well as his relationship with his wife and attitudes toward his daughters. Such material becomes particularly useful to the psychiatrist in his postinterview discussion with the nurses.
Postinterview Discussion How do the cardiac nurses react as they experience the interview? First, they say that they are surpised and perplexed because, during the interview, the patient seems different from the patient they have been caring for. Second, they discuss the particular story the patient tells not “clinically” but with emotions determined by both the nature of the story and the nurses’ experience with similar issues in their own lives or the lives of their children, parents, or grandparents. Third, by the interview’s end, the nurses have freely relinquished their accustomed objective stance toward the patient; occasionally, nurses find their initial overinvolvement to be justified. The patient’s personal experience temporarily overwhelms them; not infrequently, they view the patient as an unfortunate victim of fate. Because the psychiatrist grasps these three characteristic reactions, the postinterview discussion with the nurses becomes experiential rather 28
than didactic. Thus, when nurses express surprise that the patient appeared to be so different during the interview, the psychiatrist points out that in interpersonal relations, unlike physical processes, there are no objective data. That is, the way the patient “decides” to present himself is partly, and sometimes largely, a function of the way in which staff members interact with the patient. To a great degree, staff are unaware of the ways in which their interactions with the patients provoke, enhance, or inhibit what patients reveal about themselves. In the C-A interview, the psychiatrist facilitates the emergence of dimensions of the patient previously unknown to the staff. The C-A interview demonstrates to staff how different ways of interacting with a patient can reveal the patient differently; as a result, staff are helped experientially to become participant-observers. The C-A interview also demonstrates to the staff that their fears about harming a patient by “prying” or “stirring things up” are unwarranted; at the same time, the C-A interview provides staff with a model of a professional exchange rather than ordinary conversation (7). When discussing the psychological data of the interview, the nurses tend to analyze before identifying the data. By teaching what psychological material is and how to work with it, the psychiatrist helps the nurses avoid premature conclusions about patients. Nurses often idealize the patient in the postinterview discussion. This tendency results from the psychiatrist’s use of interviewing methods that magnify the patient’s painful life experiences. The potentially negative and dangerous result of such techniques is that nurses are left with the impression that the patient is a totally good person who is the unfortunate victim of fate. What is missing in the staff’s picture of the patient up to this point is the element of personal responsibility. The antidote to the staff’s idealized view of the patient resides in the interview material the psychiatrist has kept in a time framework. Thus, the patient who sustained the MI in the context of his older daughter’s troublesome behavior appears at first glance to be a victim. The psychiatrist can invite the nurses to speculate: What is the meaning of the patient’s grounding his daughter for 3 months? What thoughts do they have about the patient’s decision to drive himself to the hospital? Or the fact that his wife let him? What would it be like to live in the same house with such a man? Hopefully, by the discussion’s end, a picture emerges of the patient, neither angel nor devil, but a human being molded in part by early life events, subject to physical dis-
The Consultee-Attended Interview
ease, affected by chance, capable of choice, and, like everyone else, with a poignant human story to tell.
Obstacles and Resistances Many factors combine to make a meeting of a psychiatrist, an acutely ill medical patient, and a group of nurses (or other consultees) in the same room an unlikely event. Patient resistance is, surprisingly, the least impediment. Money, space, and available personnel are obvious limiting factors. The format of a C-A interview must be supported by a respected medical leader who appreciates the importance of psychosocial factors in health and disease and in the functioning of a (cardiac) unit. Conversely, medical leadership that is inimical or indifferent to psychosocial forces dooms such a venture to early failure. Staff fears constitute a major resistance, especially in the early phases of instituting the C-A interview on a regular basis. First, there exists a pervasive but unsubstantiated notion that talking in a serious way with acutely ill people is harmful. Second, staff often assume that the patient really does not want to talk in such a setting. Third, there may be deep staff distrust for the psychiatric interview itself, based on the fear that the patient will be exposed, criticized, or coerced; unfortunately, staff distrust sometimes has a foundation in clinical experience. Fourth, negative staff reaction may result from overidentification with the patient in the interview. Staff imagine that they would be uncomfortable if they were the subject in such a format and conclude that the patient will also feel uncomfortable. Although staff rightly appreciate the extreme vulnerability of the patient (in the CCU), they overlook or fail to grasp the patient’s even more powerful wish to be understood and not to feel alone (8). Fifth, the nurses are familiar with seeing physicians as well as themselves do things to, for, and on patients as opposed to with them; thus, it is understandable that in the highly uncertain milieu of the cardiac care unit, the introduction of an unfamiliar technique-one in which the physician works with the patient-can raise staff anxiety. Finally, a certain resistance to having his work so freely observed by his medical and nursing colleagues may reside in the psychiatrist himself.
Countertransference
Difficulties
Mendelson and Meyer discuss countertransference problems of the liaison psychiatrist in relation to severe disease and death, patients with severe
family, and social pathology, and the physical and psychological inconveniences in working in a medical setting (9). The C-A interview introduces additional countertransference difficulties. In the beginning of the interview, the psychiatrist dissociates himself from the medical team and thereby gives the patient permission to speak negatively about experiences with doctors and hospitals. The psychiatrist’s purpose in doing so is not to suggest or document that medical doctors are bad but rather to help the patient express this anger without projecting it onto the psychiatrist. If, however, the psychiatist (especially if male) is unconsciously competitive with medical doctors (perhaps, in this setting, competitive for the nurses’ favor); is critical of the disease-oriented medical approach; or if his humanistic ideals clash with a clinical-research setting in which affairs of the body are more vigorously pursued than those of the mind, he will find it impossible to keep the patient’s “tales of woe” in perspective. The psychiatrist may then convey to the nurses that he is critical of medical doctors and believes that they do horrible things to patients. Depending on the nurses’ viewpoint, the psychiatrist will appear to be an advocate for the patient or a “holier-than-thou shrink” who does not value the benefits that patients derive from medical care or nursing staff. Eventually, reverberations from such countertransference difficulties reach key medical and administrative personnel, who may withdraw support, with some justification.
character,
Summary The consultee-attended (C-A) interview is a format in which the liaison psychiatrist interviews the patient in the consultees’ presence. The C-A interview is an experiential teaching technique used to facilitate the consultees’ role as “participant-observers” in working with the psychological aspects of their patients.
References Rahe RH: A liaison psychiatrist on the coronary care unit. In Consultation-Liaison Psychiatry. Pasnau RO (ed). New York, Grune and Stratton, 1975, p. 118 Strain JJ, Grossman G: The Psychological Care of the Medically Ill. New York, Appleton-Century-Crofts, 1975, pp. 23-36 Sullivan HS: The Psychiatric Interview. New York, W. W. Norton and Company, 1954 Havens LL: Approaches to the Mind. Boston, Little, Brown and Company, 1973 29
J. S. Gans
5. Havens LL: Participant Observation. New York, Jason Aronson, Inc., 1976 6. Havens LL: The existential use of the self. Am J Psychiatry 131:1-10, 1974 7. Shneidman SS: Postvention: The Care of the Bereaved. In Consultation-Liaison Psychiatry. Pasnau RO (ed). New York, Grune and Stratton, 1975, pp. 250-251 8. Lynch JJ: The Broken Heart: The Medical Consequences of Loneliness. New York, Basic Books, Inc., 1977 9. Mendelson M, Meyer E: Countertransference prob-
30
lems of the liaison psychiatrist. 23:115-122, 1961
Direct reprint requests to: Jerome S. Gans, M.D. Department of Psychiatry Braintree Hospital 250 Pond Street Braintree, MA 02184
Psychosom Med