INT'L. J. PSYCHIATRY I N MEDICINE, Vol. 9(1), 1978-79

A SOCIAL SYSTEMS APPROACH TO CONSULTATION-LIAISON PSYCHIATRY

WILLIAM M. GLAZER, M.D. Assistant Professor of Psychiatry BORIS M. ASTRACHAN, M.D. Professor of Psychiatry and Director, Connecticut Mental Health Center Yale University School of Me@!cine New Haven, Conn.

ABSTRACT

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 m 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).

Introduction 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 biological and psychological characteristics and their influence upon patient behavior and pathology. As 33 0 1978, Baywood Publishing Co., Inc.

doi: 10.2190/VEYM-CR7Q-3KE2-HEBU http://baywood.com

34 1 W. M. GLAZER AND B. M. ASTRACHAN

yet, however, there is limited understanding of significance of organizational variables for the work of the consultation-liaison psychiatrist. The purpose of this paper is to introduce social systems theory as an area of consideration relevant to psychiatrists working in the field of consultation-liaison.

Historical Overview An examination of the historical development of consultation-liaison psychiatry is useful in order to elucidate the appropriateness of connecting a social systems perspective to consultation-liaison work. Lipowski identifies the work of the consultation-liaison psychiatrist as rooted in two areas: the practice of psychiatry that arose from 1. medical treatment traditions within the general hospital, and 2. the theory and clinical practice of psychosomatic medicine [ 11 . Early practitioners concerned themselves almost exclusively with the individual, focusing on the history, clinical description and diagnosis, psychodynamics and physiology of their patients [2, 31. Psychosomatic investigators, prior to the 1940’s, defined psychosomatic problems in terms of the internal psychological state of the individual and severely limited any consideration of the individual in relation to his surrounding environment [ l , 4, 51. Alexander identified the importance of developing a “synthesis of the internal psychological processes with the individual’s relationship to h s social environment,” but his own work emphasized the importance of a conflict specific (intrapsychic) theory of psychosomatic disorders [6] . In the late 1940’s and early 19.503, psychiatrists and other investigators developed interest in the impact of interpersonal and group influences upon the patient. Early observers on psychiatric wards and in outpatient settings recognized that problems that were expressed in disturbed patient behaviors frequently were found to originate in interpersonal and group dynamic issues [7-141. During the same period, a number of sociologists began to study the hospital as a social system [ 15-20]. Much of this work was chrracterized by an analytical exploration of organizational issues within the hospital. In this framework, the patient was portrayed as a passive member of the ward’s social system. Issues such as the division of labor [17], communication within systems [18], issues of authority [19], and problems of role and role relationship [ 151 were discussed as sociological constructs that might have relevance to understanding the setting of the general hospital. However, soiiological contributions (an examination of the influence of structure, role, and so forth on group behaviors) and social psychological contributions (the influence of social factors on individual behaviors) were rarely incorporated ~ i t h i nany unified framework for application to practice. In general, clinicians paid more attention to that work which might be applied directly to practice with individual patients. Recognition of the relationship between staff interaction and patient behavior was incorporated

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into approaches to practice by workers in the field of consultation-liaison [20-291. Although the work of these authors anticipated the examination of social structures on patient behaviors, theory about systems was not developed. Thus, these contributions serve to elaborate the underpinnings for the two major approaches to consultation-liaison psychiatry today. On the one hand, there is that approach that primarily emphasizes the importance of intrapsychic factors in understanding psychosomatic disease: the patient-centered approach. On the other hand, there is the interpersonal approach which emphasizes the importance of the interaction between the patient and others, particularly treatment staff, about him: the consultee-centered approach. Psychosomatic theorists have been attempting to develop a broadened conceptual base for understanding behavior. Theory has begun to move to a consideration of the influence of larger institutional and social variables on behaviors [4, 5, 30, 311. The inherent dilemmas in evolving any coherent theory which must have explanatory power in dealing with vastly different classes of phenomena have led some [S,32-34] to suggest organizing schematic approaches in order to make dvdable to clinicians and others information from multiple analytical levels. h general, these theorists offer conceptual schemes which include a consideration of the role played by social forces in bodily illness. A major conceptual problem that confronts these authors is how to deal with the wide range of structures and institutional variables that must be interposed between small groups, society and culture. Miller in a more recent paper outlines an approach to psychiatric consultation in terms of general systems theory [33, 341. He attempts to organize the wide variety of data relevant to the consultant in terms of three systems: the “psychosomatic interaction,” “dyadic and triadic systems,” and “multiple systems.” The first two systems correspond to the patient-centered and consultee-centered approaches identified above. A consideration of “multiple systems” in the hospital setting involves looking at the personnel around the patient: 1. as members of organizational systems within the ward as a part of the

hospital, and 2. as part of systems entirely outside of the hospital setting. According to Miller, this type of understanding has rarely been applied to the medical-surgical setting because of the complexity of the data which face the consultant in this setting. The consultation-liaison psychiatrist functions within a complex organizational system whose dynamics impact upon the behavior of patients, their families and staff members. Although usually acknowledging the importance of understanding social systems theory, most consultation-liaison psychiatrists have limited education in organizational theory. Thus critical organizational issues (e.g., in regard to unit boundary management, group dynamics, division

36 I W. M. GLAZER A N D 6 . M. ASTRACHAN

of authority and labor) tend to be viewed as not amenable to analysis or interventions or to be managed by the “seat of one’s pants.” Social systems theory provides a conceptual framework which organizes data in a way which may be useful to clinicians. Good clinicians are aware of the importance of the impact of home, work and hospital upon the patient’s adjustment to illness, and they d o attend to the interpersonal and organizational factors which influence any request for consultation. An awareness of social systems theory may help to emphasize this dimension of practice. Our consideration of social systems theory evolves out of the work of Rice [35-371 and Miller and Rice [38]. We will briefly identify some of their major theoretical constructs and indicate their application to the consultation to the hemodialysis unit in the general hospital (HUGH). Several case examples will be discussed to illustrate important organizational themes and to identify the usefulness of a social systems approach to consultation-liaison psychiatry.

A Social Systems Approach A. K. Rice has developed a framework for considering organizations from a social systems perspective [35-371. This framework has been applied to several organizational problems of interest to psychiatrists [33, 341, day hospitals [39] , the structure of a research ward [40], group therapy [41], individual therapy [42], and entry into treatment [43]. To our knowledge, however, no one has applied these principles to consultation-liaison work in hemodialysis units . Within this paper we cannot present Rice’s approach to a structural and systems analysis of organizations, but we will emphasize several key issues which are addressed in his analytical framework. These include: the organization as an open system, organizational boundm‘es, primaly task, division o f labor and of authority and management. We will attempt t o illustrate these themes as they apply to the HUGH, realizing h a t a complete systems analysis of the HUGH is not within the scope of this pdper. When Rice speaks about open systems, he is simply referring to the type of organization that is continually interacting with its environment. Thus a closed system would function independently from external influences. Organizations involved in complex tasks must function as open systems. The HUGH must continually interact with other systems within the hospital, e.g., radiology, the pharmacy, and medical and surgical wards, as well as systems outside of the hospital such as equipment manufacturers, private physicians, the welfare department, and taxi companies. Open systems must receive inp;-.ts, convert these inputs within their system and export their converted products back into the environment. The inputs into the HUGH are people who have end state renal disease and need assistance in handling their body chemistry as well as the effect their illness has on their lives. The outputs are either people who

CONSULTATION-LIAISON PSYCHIATRY I 37

have been given a kidney transplant and are able to function without chronic hemodialysis, or people who die as chronic hernodialysis patients. The conversion system of the HUGH is directed at changing patients’ bio-psychosocial balance so that they can function as effectively as is possible in their own environments. Examples of the conversion system would be the hemodialysis process itself, medications, social and psychological interventions. The conversion system is directed at the primaty task of the HUGH, another social systems theme which is defined as that task which a system must perform in order to survive [37]. In the case of the HUGH the primary task is a maintenance function. The unit is organized to extend the life of patients, and to maintain their functioning. The boundaty area is that region separating the organization from its environments. It is the area where the system interacts with its environments. Organizational boundaries may be identified by:

1. Territorial limits, e.g., the HUGH is a ten bed unit, serving forty patients, which is physically and geographically distinguished from other areas of the hospital. 2. Time constraints, e.g., the hemodialysis process occurs for certain people during specified five-hour periods. 3. Technological constraints, e.g., an important boundary which limits the activities of the HUGH is the number, cost and quality of dialysis machines it has.

Rice suggested that boundaries might most appropriately be located in relation to the organization’s primary task. Those activities which are directed towards accomplishing the primary task should appropriately be located within the organization’s structure. Activities which may be useful in support of the organization’s primary task, but which serve other tasks (e.g., laboratory services, hospital purchasing, food services) are located in other systems. The boundary delimits organizational activities and serves to suggest internal structures for the division of labor and of authority. Effective management of the boundary insures the provision of appropriate resources to the organization, and limits entry of extraneous supplies or tasks. Thus, the boundaries are viewed as regions of transactions through which appropriate inputs are brought into the organization or transferred from one of its parts to another and in which outputs are exported back to the environment. Organizational theorists have been concerned with issues related to the division of labor and authority, and questions of staff morale and commitment within work settings. The HUGH is primarily staffed by nurses, who are responsible for the technical aspects of dialysis and for the general care of patients. The unit’s leadership constellation includes a chief nephrologist, and an assistant, both of whom hav6 academic appointments and other research and service responsibilities. They oversee medical care on the unit, and the

38 I W. M. GLAZER AND 0. M. ASTRACHAN

chief nephrologist supervises the nurse supervisor who is also responsible to hospital nursing administration. She is administratively responsible for the nursing staff, including RNs, LF"s and technicians, all of whom are specially trained in chronic hemodialysis. Additionally, a medical social worker is part of the leadership group, is involved with family contacts and is highly regarded by the nursing staff. Two disciplines are most importantly involved in the work of the unit, nursing and medicine. Other physicians involved in the work of the unit include a full-time physician, nephrology residents and a psychiatry resident. Medical staff are responsible for monitoring the progress of treatment, for diagnosis, for management of intercurrent illness and for prescription. In the framework of social systems theory, management is most importantly concerned with regulating boundaries of the enterprise; with moderating the relationship of the parts of the organization to each other (intrasystem) and the organization to its environment (intersystem). In organizations, part of the intrasystem management function is to designate authority (division of authority) to other key people in management positions. In the HUGH the medical director delegates authority to an assistant, a nurse supervisor, and a social worker. Examples of the intersystem function of management in the HUGH is seen in the relationship of the director to the referring physicians, the director's responsibility for choosing the proper technological equipment for the unit and in the director's close interaction with various relevant groups (nephrology and neurology departments, hospital administration). These social systems concepts can be utilized in an attempt to understand consultation-liaison processes and to plan for interventions in specific cases.

Case Examples' EXAMPLE 1 [441

The patient is a fifty-six year old married, white male living at home with a wife and several children. He had been on hemodialysis for a year because of renal failure secondary to recurrent renal calculi of twenty-five years' duration. Concurrent with his history of multiple hospitalizations and severe pain, he had not worked for twenty-five years and had become addicted to heroin. He claims that his addiction is iatrogenic and due to the narcotics he was given in the treatment of his condition. At the time of the psychiatric consultation, he was on dialysis for five hours a day, three days a week, and he had been receiving methadone from a methadone maintenance clinic for several years. Psychiatric consultation had been requested by the nursing staff because of Attempts have been made to modify demographic information in order to preserve confidentiality .

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a severe recurrence of disruptive and manipulative behavior during dialysis. The patient was agitated, made derogatory and embarrassing remarks to the nursing staff, at times removed his needles and on occasion precipitously left the unit in the middle of dialysis. The precipitant of the request for consultation was an automobile accident. The patient had crashed into a telephone pole and the staff suspected suicidal intent. In the psychiatric examination, the patient was depressed. He was already on psychotropic medication, haloperidol, 2 mgm IV prior to dialysis, and diazepam, 5 mgm qlh during dialysis. He admitted to two suicide attempts within the last two months, and to having had thoughts of again attempting suicide. The patient explained his depression and behavior as resulting from the pain that he was experiencing during dialysis at the site of his fistula. He also spoke of difficulties at home. He showed no signs of psychosis or organic brain syndrome, and a diagnosis of depression was made. Because of the hstory of suicidal behavior and continuing intent, he was admitted to a shortterm inpatient psychiatric unit. Upon admission, his depression immediately improved and his suicidal ideation disappeared. Family diagnosis and evaluation were performed, and severe intrafamilial communication problems were noted. The patient was discharged back to the HUGH after four days with a diagnosis of depression secondary to medical illness. One week after his return to the HUGH, the patient’s agitation and disruptive behavior during dialysis recurred. At this point, the psychiatric consultant attempted to work with the nursing staff around ways to set limits with behavior that was increasingly seen as manipulative. Time was spent with the staff ventilating feelings of frustration and discussing attitudes towards heroin addicts. Although the aim of the discussion was to help develop empathy for the patient, it did not seem to be useful in improving the relationship between the patient and the nursing staff. Having tried psychopharmacology, hospitalization with family evaluation, and staff consultation, the psychiatrist was still hard pressed to find a solution to this problem. During the patient’s brief psychiatric hospitalization, it was noted that he had been treated by the drug dependence unit for several years, and that he had a therapeutic relation with one of the staff members there. In the hope that the drug dependence unit staff might add useful information, the psychiatric resident initiated a meeting between the hemodialysis unit and the drug dependence unit from which the patient was receiving his methadone. During this meeting, it was learned that the patient’s methadone schedule had been changed within the last three months. Because of his deteriorating physical condition (secondary to a recent attack of pericarditis), the drug dependence unit staff had decided to deliver the patient’s methadone, which was to be taken on dialysis days, to his home on the day prior to dialysis. In the joint conference, the HUGH staff speculated that the patient was taking the methadone meant for his dialysis days on the day prior to dialysis, and

40 I W. M. G L A Z E R A N D 6.M. A S T R A C H A N

that his agitation and lack of cooperation were due to his not having had his daily methadone. The patient was directed to bring his methadone in a sealed container t o the dialysis unit where a dialysis staff member would administer the drug. Once this plan was initiated, the patient’s difficult behavior ceased and good relationships between the patient and staff developed. Concurrently, his behavior improved at home. At this writing, there had been no further difficulties. DISCUSSION

Miller and R c e identify the manner in which organizations misidentify boundaries as barriers, attempting to view open systems as closed and tightly contained [38]. In this example, once the patient crossed the boundary of the hemodialysis unit, the staff as members of that delimited system related t o the patient almost entirely in the terms of that system. To some extent, the staff of the hernodialysis unit was, and is, aware of the importance of family in the treatment of the patient, but other systems impacting upon the life of the patient were almost never considered. The meeting between the drug dependence unit and the HUGH was an intergroup exercise (Astrachan and Flynn) which transcended the boundaries of the hemodialysis unit and acknowledged the fact that the patient was a member of multiple systems [45].As a result of this meeting, an explanation for the patient’s behavior was discovered. In this example, successful management of the staff and the patient’s problems was not accomplished until a social systems approach was ini ti ated. EXAMPLE 2

The patient is a sixty-two year old white female who had chronic renal failure due to chronic glomerulonephritis. Prior to her admission t o the HUGH, she had been dialyzed in a unit, in another state. She moved to the area served by the HUGH following the sudden death of her husband, wishing t o be near her married daughter. Soon after her transfer from out of state, the staff presented her t o the liaison psychiatrist because they had been receiving telephone calls from the patient’s daughter saying that her mother was unhappy with the treatment she now was receiving, especially when she compared the new unit t o the old one. The nurses perceived the patient as depressed and dissatisfied and they identified their own uncomfortable feelings toward her. Following the case discussion, the liaison psychiatrist decided t o focus his attention on the staff rather than directly upon the patient as: 1. the patient did not present herself as having any psychological problems, nor did she evidence any acute distress, and

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2. staff members vaguely identified difficulties they were having with the situation. The psychiatrist considered the possibility that the patient was depressed as a result of the loss of her husband and of her old treatment unit, but decided that psychotherapy would not be useful in the face of the patient’s major use of denial [46].Medication was not felt to be indicated. The consultant chose to work with the staff around the difficulties that resulted from the patient’s terminating from one treatment system and entering a new one. In exploring the patient’s situation with the staff, the psychiatrist learned that the patient and her daughter were still communicating with the physician in charge of the old unit. The staff had contacted nurses in the former unit to compare differences in their treatment approaches. The staff identified feelings of resentment toward the patient’s old unit, and incompetence in comparing themselves to that unit. Staff were encouraged to think about how they might most effectively facilitate the patient’s entrance into the new setting. The liaison psychiatrist suggested that the staff contact the physician of the former unit to discuss this patient’s separation problems. He also suggested a meeting with the patient’s family to clarify channels of communications between them and the new unit. The psychiatrist encouraged the staff to ventilate their own feelings about the matter and then helped them to see that the patient’s behavior reflected her sense of loss of her husband and of the former unit. Over the course of about two months, the patient became more comfortable with her new setting, the family stopped calling in, the staff felt more competent and comfortable with the patient and there was no further problem. DISCUSSION

In this example the psychiatrist considered a number of different dimensions in understanding the patient’s problem. On the basis of a social systems perspective, a clinical decision was made to focus on the problem of entry which both patient and staff were experiencing [43]. By examining problems in relationship to boundary issues, the psychiatrist bypassed the patient-centered approach (which might have included antidepressant medication and/or psychotherapy around the patient’s loss of her husband and former doctor) and focused on the entering patient and her relationship to the old and new systems. The result was an improvement in the situation. EXAMPLE 3

The patient is a fifty-four year old white, married male who had been on chronic hemodialysis for three years because of renal failure secondary to

42 I W. M. GLAZER AND B. M. ASTRACHAN

polycystic kidney disease. Psychiatric consultation was requested because the patient showed a number of symptoms of a depressive syndrome which had occurred for six weeks, since the death of his sister who had been on hemodialysis for polycystic disease in another state. At the time of her death, our patient had been hospitalized for pneumonia and was unable to attend the funeral. After psychiatric examination, a diagnosis of grief reaction was made, and the patient was seen for two psychotherapy sessions during which he ventilated feelings of grief and fear. The patient did well for a few weeks, when his condition again deteriorated, and he was presented to the psychiatric consultant. This time he was described as very irritable with his nurses, making hostile comments that upset them and which made it difficult to effectively insert the dialysis needle. In discussion among the nursing staff and the psychiatric consultant some technical problems in the dialysis were identified. The patient’s access vessels were difficult to perforate and the staff relied on the nurse supervisor and head nurse to insert the dialysis needle. At the time of the patient’s changed behavior, the nurse supervisor and the head nurse were away at a conference. Thus, the patient was being cared for by nurses who were seen as (and saw themselves as) less technically proficient than those who usually cared for him. These staff were having difficulties performing this task and the patient was frightened and angry. The nurses were having difficulty with his behavior and felt that he was “psyching” them out of inserting the needles correctly. In response t o this situation, the psychiatrist chose t o make two interventions. First, he decided t o meet with the patient and his wife to discuss feelings they had about the seriousness of the patient’s condition and their frustration with the staff. Second, and what is most relevant to this paper, the psychiatrist met with the staff and discovered resentment toward nursing leadership who, the staff felt, had left them in an impossible situation. Further exploration resulted in staff awareness that they were themselves conflicted over the responsibility they had in the absence of their supervisors. They realized that they depended upon senior nurses to care for this patient and resented this dependency. Discussion of this conflict led some staff members to recognize that during the absence of both senior nurses, they, like the patient, felt that they had n o one to turn to for help. They examined the reality of the perception that the staff was left without support. The psychiatrist worked with the staff to clarify delegated lines of authority. It became clear that, although staff nurses knew which staff members had been left in charge, they felt uncomfortable communicating with these people and affirming their authority. The psychiatrist identified the problems of communication as having t o d o with anxiety over the absence of usual authority figures. By verbalizing this anxiety, it was possible to clarify the existing authority structure. Subsequently, although staff members still had some difficulties inserting needles into this patient, they were able to turn to support from other staff members. Their

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more realistic perceptions enabled them to cope with the patient’s hostile remarks, and their own anxieties. DISCUSSION

On a patient-centered level, this situation could be understood as a reactive depression in a man with serious end stage renal disease. On a consulteecentered level, this case could be interpreted as a problem for the patient and staff in which the former was expressing conflict over his dependency needs as a result of the death of his sister and the absence of familiar authority figures. In this process, he elicits countertransference feelings from staff members who themselves are dealing with dependency issues as a result of the absence of their supervisors. On a social systems level, this case illustrates a problem for staff and patients in regard to the identification of authority in the absence of key management figures. In the presence of clearly identified management figures, particularly the nurse supervisor, authority relationships are understood and taken for granted. In the absence of the nurse supervisor, and her surrogate, the head nurse, who together bridge the medical and nursing staff members, the patient and nurses experienced diminished expertise in the unit, i.e., there is no one to identify and legitimize expertise or to be expert. By discussing this perception openly, the staff was able to more comfortably acknowledge that competent individuals clearly had been delegated authority and to rely on each other. The decision to explore and define authority relationships in an organization must be based on a careful consideration of the ability of that system to tolerate the anxiety that is generated as a result of such a discussion. In this example, it was decided that the staff was comfortable enough to accept a clarification of authority relationships and that such a clarification, although stressful in itself, was indicated because of the degree of anxiety that had resulted from the confusion over leadership.

Discussion From the brief historical review in the introduction of this paper, it is evident that the role of the consultation-liaison psychiatrist has evolved considerably over the last forty years. Our purpose in presenting a social systems perspective is to suggest that it will be useful in leading to an understanding of the impact of social factors on patient behaviors. Mirsky and his associates, in their approach to the understanding of peptic ulcer disease, present a model which has become prototypical for the understanding of psychosomatic illness in general [47]. From their work, one can conceptualize psychosomatic illness as a process which includes three variables : the biological makeup of the individual, the person’s particular psychodynamic character patterns, and a source of stress. It is the last of these

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variables-a source of stress-to which the social systems perspective directs itself. Factors in the environment of the patient which are stressful are often as specific and understandable as a person’s biological makeup and/or character structure. From the case examples presented, it is hoped that the reader will appreciate how a social systems perspective has the potential of aiding the psychiatrist’s understanding of the nature of the stress surrounding his patient. Once it is recognized that sources of stress around the individual can be understood in an organized fashion, one can then develop interventions not only related to the individual’s physiology and psychodynamics, but also to the source of that stress itself. The organizational systems in which we work should not be sources of major stress to our patients (or ourselves). To the extent that stress occurs, we ought t o understand it and enable those we serve t o deal with it. For example, whenever and wherever boundaries are poorly managed or identified (e.g., Case #l), stress will intensify. Whenever and wherever authority relationships are unclear or poorly managed (e.g., Case #3), stress will intensify. In our experience, a social systems approach facilitates attention to important issues of primaly task, boundaries, the division of labor and authority and management, which impact upon patient care and influence patient behaviors. The psychiatric consultation is itself a systems intervention. It is important for the liaison psychiatrist to be clear about the organizational issues involved in any specific request for consultation, so that they may be addressed in the service of improved patient care. Psychiatry as a profession has often been accused of overstepping its boundaries, of intervening in systems in ways that transcend its professional competence. The changing of systems requires training experiences and professional competency well beyond that provided for psychiatric residents and practitioners. The psychiatrist as a changer of systems may be a useful role, but i t requires background that must be gained from situations that lie well beyond primarily clinical situations. This role insists upon knowledge of political processes, organizational theory, economics, and so forth. Our concern in this paper has been with an understanding of systems in order t o improve care offered to individual patients. The needs of the patient are examined in the context of the systems about him and their capacity to change in order to limit stress. REFERENCES

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24. I. M. Greenberg, Approaches to Psychiatric Consultation in a Research Hospital Setting, Arch. Gen. Psychiat., 3, pp. 691-697, 1960. 25. E. Meyer and M. Mendelson, Psychiatric Consultation With Patients on Medical and Surgical Wards: Patterns and Processes, Psychiatry, 24, pp. 197220, 196 1. 26. B. Bursten, The Psychiatric Consultant and the Nurse, Nurs. Forum, 2, pp. 7-23, 1963. 27. Z. J. Lipowski, Review of Consultation Psychiatry and Psychosomatic Medicine I. General Principles, Psychosom. Med., 29, pp. 153-171, 1967. 28. Z. J. Lipowski, Review of Consultation Psychiatry and Psychosomatic Medicine II., Psychosom. Med., 29, pp. 201-224, 1967. 29. G. Caplan, The Theory and Practice of Mental Health Consultation, Basic Books, New York, 1970. 30. M. Gitelson, A Critique of Current Concepts in Psychosomatic Medicine, Bull. Menn. Clin., 23, pp. 165-178, 1959. 3 1. Z. J. Lipowski, Review of Consultation Psychiatry and Psychosomatic Medicine 111. Theoretical Issues, Psychosom. Med., 30, pp. 395-422, 1968. 32. Z. J. Lipowski, Psychosomatic Medicine in a Changing Society: Some Current Trends in Theory and Research, Comprehens. Psychiat., 14, pp. 203-215, 1973. 33. W. B. Miller, Psychiatric Consultation: Part I. A General Systems Approach, Int. J. Psychiat. in Med., 4, pp. 135-145, 1973. 34. W. B. Miller, Psychiatric Consultation: Part 11. Conceptual and Pragmatic Issues of Formulation, Znt. J. Psychiat. in Med., 4, pp. 25 1-27 1, 1973. 35. A. K. Rice, Learning for Leadership, Tavistock Publications, London, 1965. 36. A. K. Rice, Individual, Group and Intergroup Processes, Human Relations, 22, pp. 565-584, 1969. 37. A. K. Rice, The Enterprise and Its Environment, Tavistock Publications, London, 1963. 38. E. J. Miller and A. K. Rice, Systems of Organization, Tavistock Publications, London, 1967. 39. B. M. Astrachan, H. R. Flynn, J. D. Geller, et al., Systems Approach to Day Hospitalization, Arch. Gen. Psychiat., 22, pp. 550-559, 1970. 40. P. M. Newton and D. J. Levinson, The Work Group Within the Organization: A Sociopsychological Approach, Psychiatry: J. Stud. Interpers. Proc., 36, pp. 115-142, 1973. 41. B. M. Astrachan, Towards a Social Systems Model of Therapeutic Groups, Soc. Psychiat., 5, pp. 110-1 19, 1970. 42. P. M. Newton, Social Structure and Process in Psychotherapy: A SocioPsychological Analysis of Transference, Resistance and Change, Znt. J. Psychiat., 2, pp. 480-5 12, 1973. 43. D. J. Levinson and B. M. Astrachan, Entry Into the Mental Health Centre: A Problem in Organizational Boundary Regulation, Task and Organization, E. J . Miller, (ed.), John Wiley & Sons, New York, pp. 217-234, 1976. 44. W. M. Glazer and G. L. Cohn, Methadone Maintenance in a Patient on Chronic Hemodialysis, Amer. J. Psychiat., 134, pp. 931-932, 1977.

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45. B. M. Astrachan and H. R. Flynn, The Intergroup Exercise: A Paradigm for Learning About the Development of Organizational Structure, Tusk and Organization, E. J. Miller, (ed.), John Wiley & Sons, New York, pp. 47-68, 1976. 46. A. K. De-Nour, J. Shaltiel and J. W. Czaczkes, Emotional Reactions of Patients on Chronic Hemodialysis, Psychosom. Med., 30, pp. 5 2 1-533, 1968. 47. I. A. Mirsky, Physiologic, Psychologic and Social Determinants in the Etiology of Duodenal Ulcer, Amer. J. Dig. Dis., 3, pp. 285-314, 1958.

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