Psychiatric consultation. II. Conceptual and pragmatic issues of formulation

Notes on a contextual approach to medical ward consultation: the importance of social system mythology

The psychiatric consultant requires a broad understanding of the context of consultation to supplement his knowledge of psychodynamics. The authors propose viewing the medical ward in the model of a “quasi-open community,” in which a culture is transmitted from one generation of personnel to the next through a ward mythology-which embodies ideals, for example, for the roles of Nurse and Doctor. Requests for psychiatric consultation often result from the partial breakdown in this mythology; the consultant's immediate task is to reconstruct group ideals and facilitate community re-unification in order to promote the recovery of patients. Later on, when the staff has had a chance to distance itself from the threat to its solidarity, the consultant can help the ward community understand both the adaptive and non-adaptive aspects of its own mythology. Case examples illustrate how respecting the quasi-open character of the medical ward and giving credence to its mythology can promote the reconstitution of ward communities in disarray and aid individual patients as well.

Consultation-liaison psychiatry: the first half century

Consultation-liaison psychiatry is over 50 years old. Its main goal has been to bring medicine and psychiatry closer together so as to improve patient care in its psychosocial and psychiatric aspects. The history of this field may be divided into four overlapping phases: the beginnings, the organizational phase, the phase of conceptual development, and the phase of rapid growth. The highlights of each phase are outlined. The author concludes that C-L psychiatry has achieved the status of a full-fledged subspecialty of psychiatry, one whose main contribution has been to draw attention of clinicians and researchers to psychosocial aspects of physical illness, and to the psychiatric complications of such illness and of the medical and surgical therapies.

Psychiatric consultations at the NIH

The history of the consultation-liaison psychiatry movement in America is briefly reviewed. Evaluation of a consultation-liaison program in a research hospital setting at NIH is described in the context of the historical paradigm.

Systemic consultation in a general hospital

Consultation psychiatry has long offered the potential for psychiatrists to impact on the mental health of large numbers of individuals. However, workers in consultation psychiatry have often described it as a stressful, ungratifying experience. Over the last fifty years, since the initiation of consultation psychiatry, a series of models of consult work has been presented in the literature. These models have increasingly become more complex in the system of organization in which they operate. Moreover, there has been a constant movement toward viewing the function of the psychiatrist as intervening in behavior outside of the patient. After reviewing the history of consultation psychiatry, the authors conclude that a logical development would be a systemic model in which the entire hospital system is seen as the focus of consultation and in which the goal of the consultant's work is seen as creating a more open and flexible hospital system. The authors, therefore, describe a systemic model in which the potential crisis offered by any request for consultation work is seen as a tool for intervening with the hospital system. The difficulties of attaining the objectivity necessary for implementing a systemic intervention are discussed. A method of systemic diagnosis of the hospital is presented as well as a number of strategies of intervention with the hospital system. The authors conclude that using a systemic model (with the hospital as the focus of consultation) can lead to the development of a more comprehensive science of consultation which will lead to an increase of gratification for the psychiatrist and a more healthy functioning hospital system.

Decision making in an interdisciplinary team

Decision making in an interdisciplinary team occurs at the interface between groups with varied backgrounds, orientations, interests, and goals. Most interdisciplinary teams attempt to identify the complex set of variables influencing their decisions and then utilize this knowledge to maximize efficiency in health care delivery. Models of information and decision analysis developed by general systems theory are suggested as a method for advancing the understanding of where, when, and how decisions are made by the interdisciplinary team. A university-affiliated psychiatric service in a private general hospital is studied. Here the following forces meet, complement, compete, and collide: the community, university, hospital administration, private practitioners, insurance companies, consultation and liaison psychiatrists, university staff psychiatrists and residents, nurses, aides, social workers, activities personnel, patients and their families, the patient group, the ward milieu. Considering these factors, we describe: (1) the flow of information and feedback loops into, within, and out of the psychiatric service; (2) the location of decision nodes; (3) decision-making echelons. The general systems theory concepts utilized in this analysis are proposed as pragmatic tools for improving interdisciplinary team function.

A review of systems approaches to consultation-liaison psychiatry. The need for synthesis

Five applications of systems theories to liaison psychiatry are reviewed. "Systems" is noted to have three distinct meanings as applied to consultation-liaison psychiatry: as a metatheoretical construct, as a decision-making process, and as an organizing construct for social variables. It is proposed that the time is ripe for synthesis of the social systems theories, reduction to the most parsimonious use of variables, and empirical testing of their importance. General systems theories are seen as needing further development before they will be routinely useful in consultation-liaison psychiatry.

A social systems approach to consultation-liaison psychiatry

Consultation-liaison psychiatry traditionally has emphasized an approach to clinical practice based upon an understanding of the ways in which intrapsychic dynamics, personality characteristics and biological phenomena interact in a process that can be understood to relate to symptoms and disease in the individual. More recently the field has considered the interaction of interpersonal and group phenomena with individual characteristics and their influence upon patient pathology. Currently, however, there is limited understanding of the significance of organizational variables for the work of the consultation-liaison psychiatrist. In this paper, several organizational themes are discussed in terms of social systems theory and the relevance of these themes are applied to case material taken from a year's experience of consultation-liaison in a hemodialysis unit of a general hospital (HUGH).

The application of competency-based education to consultation-liaison psychiatry: II. intervention knowledge and skills

Although psychological and pharmacological intervention is an important aspect of the treatment of patients seen in consultation on medical and surgical wards, little attention has been directed to the method of training psychiatric residents in these areas. In this paper, the authors continue the application of the competency-based model of training to the problems of clinical intervention. Behavioral objectives are presented as a focus for residency supervision and their application to a clinical situation is illustrated. The objectives are designed to consider the activities of the consulting psychiatrists as he relates to the patient as well as other members of the treatment milieu.

The application of competency-based education to consultation-liaison psychiatry: I. Data gathering and case formulation

In the first of three papers, the authors present a competency-based model for training in consultation-liasison psychiatry which addresses the issues of how residents are taught to collect and formulate patient data. This model emphasizes the use of behavioral statements to describe the process of how a consultation is done. By comparing the resident's performance with prestated behavioral objectives, a method for residency supervision is offered. The second paper carries this one step further with the application of the model to clinical intervention strategies. The final paper discusses the implications of this approach to some of the issues that surround residency training in this field.