Physicians' "compliance with treatment" in the context of consultation-liaison psychiatry: The role of "triangle" relationships and projective identification

Unwillingly traumatizing: is there a psycho-traumatologic pathway from general surgery to postoperative maladaptation?

BACKGROUND

Surgery may possibly be undermined by psychologic, psychiatric and psychosomatic problems, as long as these problems interfere with a patient's capacity to cope with surgery adaptively. Recent studies have shown that interpersonal trauma, e.g. abuse or neglect, and its correlates are involved in the adaptation to surgery. This observation is heuristically coherent, given the respective traumatization is an interpersonal event occurring in a relationship. Notably, surgery inevitably leads to the violation of physical boundaries within a doctor-patient relationship. Based on the principles of psycho-traumatologic thinking, such a constellation is deemed qualified to activate posttraumatic symptoms in the traumatized.

METHOD

The present topical review summarizes the respective findings which point to a subgroup of patients undergoing surgery, in whom difficulty bearing tension and confiding in others may cause adaptive problems relevant to surgery. Although this theorizing is empirically substantiated primarily with respect to total knee arthroplasty (TKA), a pubmed-research reveals psychopathologic distress to occur prior to surgery beyond TKA. Likewise, posttraumatic distress occurs in large numbers in the context of several operations, including cardiac, cancer and hernia surgery.

CONCLUSION

Aspects of psychological trauma may be linked to the outcomes of general surgery, as well, e.g. biliary, hernia or appendix surgery. The mechanisms possibly involved in this process are outlined in terms of a hierarchical organization of specific anxiety and negative affect as well as in terms of psychodynamics which imply the unconscious action of psychologic defenses at their core.

IMPLICATIONS

Not least, we encourage the screening for trauma and its correlates including defenses prior to general surgery in order to identify surgical candidates at risk of, e.g. chronic postoperative pain, before the operation.

Countertransference in the general hospital setting: implications for clinical supervision

Psychiatry residents completing their consultation-liaison (CL) rotations are implicitly expected to recognize and consider countertransference reactions when offering clinical recommendations. Residents often lack formal guidance in this role, as there exists limited examination of clinical scenarios from a psychodynamic perspective. The authors present a historical review of the literature on countertransference with the medically ill and describe a clinical vignette illustrating the vicissitudes of liaison work. The case involves a psychotic patient with mental retardation and acute renal failure. Through refusal of care and a tumultuous clinical course, this patient elicited various countertransferential reactions from the primary care and CL teams, in turn adversely impacting treatment. The case illustrates how clinicians' failure to collaborate led to hospital administrators having to take on the liaison role. (1) A review of literature corroborates the importance of CL psychiatrists' assistance in the management of countertransference. At the same time, it is notable for a paucity of guidance in teaching these skills to psychiatry trainees. The psychiatry resident-in-training faces challenges and shortcomings in the management of countertransference. Formal training in this aspect of psychiatric consultation is lacking, as evidenced by extant publications. The authors propose future directions for research and teaching, with emphasis on clarifying the liaison component of CL psychiatry and advocating for establishment of psychodynamic psychotherapy training guidelines in the general hospital setting.

Medical countertransference and the trainee: identifying a training gap

OBJECTIVE

Although consultation-liaison (CL) psychiatrists are implicitly expected to recognize and consider interpersonal dynamics in clinical settings when offering recommendations, few guiding principles have been established, strongly suggesting the presence of a training gap.

METHODS

Trainees in psychiatry residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) were invited to complete an Internet-based, 20-item, Likert scale questionnaire assessing practices and opinions concerning countertransference management and training.

RESULTS

Of 192 respondents, 162 (84%) reported having participated in a rotation on the CL service for at least some period of time and were eligible to complete the survey; 136 (71%) reported having completed at least 2 months of CL rotations. Approximately 80% identified a frequent need to address countertransference reactions when working with primary medical/surgical teams, but less than a quarter reported doing so regularly. The motivation for addressing such issues in over half of the respondents was the belief that it would be "clinically beneficial" to patients, although 40% of respondents also feared that this practice could "worsen the relationship between the CL consultant and the primary team." Regarding training, 95% of respondents felt didactics addressing counter-transference would be "clinically beneficial"; however, three fifths of the respondents reported that "very few" to none of their didactics explored this issue.

CONCLUSIONS

Results of this study suggest that discrepancies exist between trainee perceptions of the utility of countertransference management in CL psychiatry and actual training in this area. The authors discuss possible explanations for these discrepancies and advocate for the establishment of formal guidelines in training CL residents in such aptitudes. (Journal of Psychiatric Practice 2012;18:109-117).