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

Management of patient-staff and intrastaff problems in psychiatric consultations

Four possible types of management of patient-staff and/or intrastaff (PS/IS) problems in psychiatric consultations are distinguished and operationalized. The occurrence and correlates of these types of interventions were studied in a multisite investigation of 1112 consecutive consultations in five general hospitals. PS/IS problems (possibly, probably, or certainly) played a role in 28.1% of the consultations studied. The psychiatric consultants utilized a primarily patient-oriented approach in 56.7% of these 310 consultations, whereas in 42.3% they performed (covert or overt) staff-oriented case consultations. A staff-oriented approach may be contraindicated when the PS/IS problems are not very serious or too complex. In the literature staff resistance and hospital culture are frequently mentioned as obstacles to staff-oriented interventions. The present study showed, however, that it was often the consultants' own degree of security about the PS/IS problems that determined the way they handled these problems. Staff-oriented consultations took significantly more of the psychiatric consultants' time. The clinical and economic benefits of such interventions have still to be established. But the psychiatric consultant with a true biopsychosocial approach should always be cognizant of the possible occurrence of PS/IS problems and consider applying a staff-oriented intervention.

Assessment of patient-staff and intrastaff problems in psychiatric consultations

In a study of 249 consecutive inpatient consultations, the occurrence of patient--staff or intrastaff problems as determined by the psychiatric consultation team was compared with questionnaire answers, provided by the consultant following each consultation, and interpreted as indications for such staff problems. According to the consultation team, staff problems played a role in 33% of the consultations. In the questionnaires, of the nine criteria statistically significantly related to the occurrence of staff problems, the following were the most relevant: 1) emotional tone or wording of request; 2) abnormal timing of referral; 3) request unclear; 4) unjustified urgency of referral; and 5) existence of hidden questions. If none or only one of these criteria were positive, then there was little chance that staff problems were present. If three or four criteria were positive, then the probability of staff problems was much higher. If the first three criteria were negative, then staff problems were hardly ever encountered.

A family system's approach in consultation liaison services

Starting from difficulties in the cooperation of clinical and psychosocial medicine an alternative view is suggested following the principles of general system's theory and family therapy. The request for consultation is under such considerations regarded as the expression of an interactional crisis in which the whole system (patient, family and clinic) has become involved. Practical suggestions are made concerning the treatment setting, the methods of intervention and the initiation of an ongoing therapeutic contact.

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.

Adaptation of residents to consultation-liaison psychiatry. II. Working with the nonpsychiatric staff

When working with the staff in a general hospital, psychiatry residents may be overly competitive, solicitous, or detached. These defensive reactions often arise because of the special challenges of performing a consultation, including the skepticism about the value of psychiatry and the demeaning or unrealistic expectations about what the psychiatrist can do. Furthermore, the psychiatry resident feels even more challenged if the attitudes and behavior of the staff must be changed for the patient's benefit. To affect this influence on the staff the psychiatry resident may need to assume a "liaison stance." This stance involves not only establishing a collegial alliance but also using modified therapeutic maneuvers to alter staff behavior. By applying psychodynamic knowledge to understand and potentially to influence the staff, psychiatry residents, as participant observers, can feel less helpless and frustrated by difficult liaison situations.

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.

Group process interpretations in liaison psychiatry nurse groups

Nurse groups are generally viewed as supportive adjuncts to other forms of liaison psychiatry interventions. Recent developments in systems approaches to liaison psychiatry suggest that such groups may be used to alter the values, norms, and behavior of a unit system since nurses are viewed as the culture bearers and socializers of units. Examining the group process in weekly meetings offers an opportunity to expose covert group norms. Group process interpretations assist the nurses in establishing therapeutic norms and result in an altered socialization process. Of the five units in which this approach was attempted, three reported successful results throughout the unit system. Various issues in applying group process interventions are discussed, including: the establishment of resistance, conditions of success and failure, and other therapeutic elements in such groups.

Liaison psychiatry: a model for medical care on a general hospital psychiatric unit

Liaison psychiatry is traditionally practiced on the medical and surgical floors of the general hospital. The need for liaison psychiatry on the inpatient psychiatric unit as opposed to its usual setting was realized when the medical care requirements of hospitalized psychiatric patients was assessed. In many general hospitals this medical care is provided by a psychiatrist in consultation with medical and surgical colleagues. Over a three-year period at the Medical Center Hospital of Vermont 563 medical/surgical consultations were provided to the inpatient psychiatric unit. To utilize these consultations most effectively, the role best suited for the psychiatrist was that of liaison-consultee. Case examples are used to demonstrate the effectiveness of employing liaison skills in the treatment of somatic problems on the inpatient psychiatric unit. The educational implications of learning the liaison model in this context are discussed.

Group process: an adjunct in liaison consultation psychiatry

Many liaison psychiatrists have advocated staff meetings as a means of enhancing communications on a medical ward. This paper, based on a one year experience as a psychiatric consultant to a medical ward in a major teaching institution, describes the implementation of a weekly group meeting of nursing and social service staff as a component in the structure of an effective liaison service. Case material is presented to document the efficacy of group process as a teaching and therapeutic modality. By encouraging the verbalization of cogent feelings and anxieties in a weekly group meeting, members developed a sense of mutual trust and openness. In an atmosphere conducive to promoting clarification, understanding, and insight, the group members increased their self awareness of the psychological aspects of physical disease and the effect of their own emotions on the interpersonal process of patient care.