Consultation Psychiatry: Psychosomatics or Psychiatry in Medicine? TRULS-ElRIK
These notes are concerned with aspects of the position and prophile of psychosomatic consultation and liaison services in two different hospitals in Oslo, Norway. Some of my statements may not hold true for Norway in general, since experiences made in some few other hospitals seem to be happily different from ours, or at least differently interpreted. I should make clear in the first place that general psychiatric and psychotherapeutic services in Norway are good-i.e. except in the general hospitals, where the most necessary consultation work has, so far, been taken care of by the very youngest and most inexperienced doctors in psychiatric training; an arrangement due to the fact that senior psychiatrists hesitate to get involved in liaison work themselves. This very unsatisfactory situation has brought about a rather hostile distance between medicine and psychiatry. Medicine has moved towards technology and emergency service. On the other side, the trend in psychiatry has-for the last two decades (at least)been a move towards psychology and sociology-that is away from the medical model, away from diagnosis and away from biology!-over to a non-diagnostic, non-evaluating, social- and therapeutic-community oriented type of activity, which is opposing rather th~ utilizing medicine-as an approach to the human problems of life and death. This I believe is one of the main reasons why otherwise well trained psychiatrists after 5 or 6 years in general psychiatric training in the psychiatric clinics and mental hospitals in Norway, never seem to get any real idea at all about psychosomatics and psychiatric liaison work in the general hospitals, i.e. in medicine. These problems of breaking through the barriers between psychiatry and medicine, and thereby influencing the somatic doctors' various doings with their patients, made us acknowledge not only the need for conceptual models in our own work, but even more the necessity of a lIseful position-Leo in the consultant's relationship to the various consumers of his services, and just as important: the very means of communicating our information and points of view effectively. Read at the 10th European Conference for Psychosomatic Research in Edinburgh 1974. From University Hospital of Oslo, Oslo, Norway. 138
MoosTAD, M.D.
What had been done previously in this field at the Uciversity Hospital, was that Dr. Finn Askevoldfrom when he took ovcr as senior consultant in 1959, arranged the very important, rather informal, weekly, "clinical conferences" with staff members of the somatic doctor teams. This was for purposes of communication, although even more for the specific purpose of training somatic doctors in the basic concepts and techniques of psychiatry and psychosomatics. These meetings surely still are one of the most important instruments at our disposal in our work. The next mov~ was to embark on a still more centrifugal project-namely one of attaching ourselves to one somatic department and one department staff; thereby going on the wards more systematically, to see whether this would be useful. As very many consultants must have experienced, one just cannot easily do such a thing, because hospital systems are so rigidly structured. They cannot easily open up and receive any newcomer as a benefactor, in the first place. Furthermore, there are the difficulties of different concepts and technical language, different styles of work, mutual distrust, and various forms of resistances against integration. On the other hand we certainly were rewarded, so to speak: mainly, I believe, because we were able to provide practical advice-here and there-as to medication and the treatment of acute psychotic reactions and so-called "difficult" patients. These services were provided much better on the wards, than when we sat in our offices, receiving selected patients on referral. We also discovered possible strategies to cover a wider field of problems in giving an "on-thejob" advice to the somatic doctors' management of patients' psychiatric problems, without taking over the care of his patient. So we may say that a process of integration had started-to place the psychiatric consultant within the medical team, rather than leaving him to his own devices, remote from the medical ward. One should note that the University Hospital in Oslo is not typical of the general Norwegian hospital. Until recent years the former has functioned-and surely still does, in some ways-as a kind of highest medical level institution, receiving especially selected patients from the whole country, perhaps 1600 km. away, to give service in cases considered not to be dealt with satisfacVolume XVI
CONSULTATION PSYCHIATRY-MOGSTAD
torily at a lower, more local level of service. Thus this supra-regional hospital has gradually developed into a monster of some 30 different departments and institutes, giving housing to many sub-specialities in order to cover the current needs for service, research and training on all levels: except in psychological medicine, psychiatry and psychosomatics!
as best I could, full time and a little bit more. I moved into my office that was close to the medical wards, entered the staff meetings regularly, went along with the ward rounds, joined the staff for lunch as well as the doctors' offices for chats and discussions,-and very soon found myself doing first line, emergency psychosomatics, in the very broadest sense of the word.
For 10 years the small section for psychosomatic medicine at the University Hospital had only two psychiatrists and one psychologist, working full time. From 1973 the staff consists of three full time psychiatrists, one full time psychologist, and one or two parttime psychologists, mostly engaged for research purposes. We have several times tried to estimate the presumed need for psychiatric and psychosomatic services in the hospital, and have, to no one's surprise, found that "need" in these terms depends, not on patient population, but on the attitude of the somatic doctors towards psychology and psychiatry. It also depended on the level of integration of the consultants, i.e. the possibility of a psychosomatic explanation and treatment for the patient's difficulties which had not been successfully met by the strict organicists.
The differences from the University Hospital were many and striking: I was no longer a sheltered, remote and mystical person. I was there!-on the very premises of emergency medicine: every minute challenged with suicidology, medication, administrative problems, diflerental diagnoses and so on. In all it proved to be a turmoil of crisis, stimulating, very laborious and always challenging. This most certainly was a different situation from the rather calm and comparatively easy going style of work at the University Hospital. Without providing tables, I might illustrate the differences between the two hospitals by mentioning that, while the University Hospital group of referred patients contained nearly 50% psychosomatics proper, the Municipal Hospital group had some 10%. And while the University Hospital group had no intoxications at all-the Municipal Hospital group contained some 30%-mostly manipulative suicide. While emphasis in one situation may well be on psychosomatic problems proper, yet in another situation tasks of crisis intervention and general psychiatric services are the problems. Liaison psychiatry has to deal with a wide field of different medical problems-in a variety of different situations-and most often in complex transdisciplinary professional groups. The consultant's skills and techniques of communication are challenged in particular. The ability to define physical reactions in terms of understable psycho-physio-dynamics that can be made relevant to the patient, the doctor and the various therapeutic institutions outside hospital is crucial. Thus the consultant's job becomes one of an active interpreting negotiator, who readily speaks the language needed, to make heard his points of view.
The Section for Psychosomatic Medicine at the University Hospital never managed to cover the need for its services, which is not surprising, since an inpatient population of 20,000 a year will give plenty of work to more than two or three psychiatrists. However, the possibilities of concentrating on orthodox psychosomatic problems have been good, because so many problem cases are to be found in the field of complex psycho- vegetative reactions and disturbances. They are a common type of problem patient at this selected, fairly advanced level of medical care. In addition, patients are received because a combined medical evaluation, Le. combined physical and psychiatric is wanted and most essential. The feeling that we might be exclusive and a bit out of contact with general service problems, made us look for a possibility to study psychiatry in local general hospitals, giving every day, more or less emergency services to a part of the town of Oslo. We were lucky to find that the third largest hospital in Norway, which is an emergency municipal hospital in Oslo, badly needed a psychiatrist willing to engage in the psychiatric problems of the two departments for internal medicine at that hospital. This opened up for a 16 months' clinical study of liaison and consultation psychiatric needs and possibilities at Aker Hospital in Oslo. Contrary to the University Hospital this is an emergency hospital-giving service mostly to the everyday needs of an area of a town of ~ million inhabitants. The two departments for internal medicine were to have only one psychiatric consultant (myself). I had no other commitment than this: to do the job July/August/September, 1975
Secondly-the term "psychosomatic" should be redefined in concepts of a clinical and practicable rs::chophysiology, that opens up to whatever psychological implications physical ailments and illnesses might have. Thirdly-that consultation and liaison services in general hospitals-with the consultant fairly closely, though not too rigidly, tied to the somatic teams on a basis of every day work, offers posibilities for combined in- and out-patient services and clinical research. Finally I might suggest the need that liaison and consultation psychiatry concentrate more on strategies of teaching-i.e. the consultant's teaching in the general hospital-within the framework of an "on-thejob" service oriented training set-up. 139
These notes are concerned with aspects of the position and prophile of psychosomatic consultation and liaison services in two different hospitals in Oslo, Norway. Some of my statements may not hold true for Norway in general, since experiences made in some few other hospitals seem to be happily different from ours, or at least differently interpreted. I should make clear in the first place that general psychiatric and psychotherapeutic services in Norway are good-i.e. except in the general hospitals, where the most necessary consultation work has, so far, been taken care of by the very youngest and most inexperienced doctors in psychiatric training; an arrangement due to the fact that senior psychiatrists hesitate to get involved in liaison work themselves. This very unsatisfactory situation has brought about a rather hostile distance between medicine and psychiatry. Medicine has moved towards technology and emergency service. On the other side, the trend in psychiatry has-for the last two decades (at least)been a move towards psychology and sociology-that is away from the medical model, away from diagnosis and away from biology!-over to a non-diagnostic, non-evaluating, social- and therapeutic-community oriented type of activity, which is opposing rather th~ utilizing medicine-as an approach to the human problems of life and death. This I believe is one of the main reasons why otherwise well trained psychiatrists after 5 or 6 years in general psychiatric training in the psychiatric clinics and mental hospitals in Norway, never seem to get any real idea at all about psychosomatics and psychiatric liaison work in the general hospitals, i.e. in medicine. These problems of breaking through the barriers between psychiatry and medicine, and thereby influencing the somatic doctors' various doings with their patients, made us acknowledge not only the need for conceptual models in our own work, but even more the necessity of a lIseful position-Leo in the consultant's relationship to the various consumers of his services, and just as important: the very means of communicating our information and points of view effectively. Read at the 10th European Conference for Psychosomatic Research in Edinburgh 1974. From University Hospital of Oslo, Oslo, Norway. 138
MoosTAD, M.D.
What had been done previously in this field at the Uciversity Hospital, was that Dr. Finn Askevoldfrom when he took ovcr as senior consultant in 1959, arranged the very important, rather informal, weekly, "clinical conferences" with staff members of the somatic doctor teams. This was for purposes of communication, although even more for the specific purpose of training somatic doctors in the basic concepts and techniques of psychiatry and psychosomatics. These meetings surely still are one of the most important instruments at our disposal in our work. The next mov~ was to embark on a still more centrifugal project-namely one of attaching ourselves to one somatic department and one department staff; thereby going on the wards more systematically, to see whether this would be useful. As very many consultants must have experienced, one just cannot easily do such a thing, because hospital systems are so rigidly structured. They cannot easily open up and receive any newcomer as a benefactor, in the first place. Furthermore, there are the difficulties of different concepts and technical language, different styles of work, mutual distrust, and various forms of resistances against integration. On the other hand we certainly were rewarded, so to speak: mainly, I believe, because we were able to provide practical advice-here and there-as to medication and the treatment of acute psychotic reactions and so-called "difficult" patients. These services were provided much better on the wards, than when we sat in our offices, receiving selected patients on referral. We also discovered possible strategies to cover a wider field of problems in giving an "on-thejob" advice to the somatic doctors' management of patients' psychiatric problems, without taking over the care of his patient. So we may say that a process of integration had started-to place the psychiatric consultant within the medical team, rather than leaving him to his own devices, remote from the medical ward. One should note that the University Hospital in Oslo is not typical of the general Norwegian hospital. Until recent years the former has functioned-and surely still does, in some ways-as a kind of highest medical level institution, receiving especially selected patients from the whole country, perhaps 1600 km. away, to give service in cases considered not to be dealt with satisfacVolume XVI
CONSULTATION PSYCHIATRY-MOGSTAD
torily at a lower, more local level of service. Thus this supra-regional hospital has gradually developed into a monster of some 30 different departments and institutes, giving housing to many sub-specialities in order to cover the current needs for service, research and training on all levels: except in psychological medicine, psychiatry and psychosomatics!
as best I could, full time and a little bit more. I moved into my office that was close to the medical wards, entered the staff meetings regularly, went along with the ward rounds, joined the staff for lunch as well as the doctors' offices for chats and discussions,-and very soon found myself doing first line, emergency psychosomatics, in the very broadest sense of the word.
For 10 years the small section for psychosomatic medicine at the University Hospital had only two psychiatrists and one psychologist, working full time. From 1973 the staff consists of three full time psychiatrists, one full time psychologist, and one or two parttime psychologists, mostly engaged for research purposes. We have several times tried to estimate the presumed need for psychiatric and psychosomatic services in the hospital, and have, to no one's surprise, found that "need" in these terms depends, not on patient population, but on the attitude of the somatic doctors towards psychology and psychiatry. It also depended on the level of integration of the consultants, i.e. the possibility of a psychosomatic explanation and treatment for the patient's difficulties which had not been successfully met by the strict organicists.
The differences from the University Hospital were many and striking: I was no longer a sheltered, remote and mystical person. I was there!-on the very premises of emergency medicine: every minute challenged with suicidology, medication, administrative problems, diflerental diagnoses and so on. In all it proved to be a turmoil of crisis, stimulating, very laborious and always challenging. This most certainly was a different situation from the rather calm and comparatively easy going style of work at the University Hospital. Without providing tables, I might illustrate the differences between the two hospitals by mentioning that, while the University Hospital group of referred patients contained nearly 50% psychosomatics proper, the Municipal Hospital group had some 10%. And while the University Hospital group had no intoxications at all-the Municipal Hospital group contained some 30%-mostly manipulative suicide. While emphasis in one situation may well be on psychosomatic problems proper, yet in another situation tasks of crisis intervention and general psychiatric services are the problems. Liaison psychiatry has to deal with a wide field of different medical problems-in a variety of different situations-and most often in complex transdisciplinary professional groups. The consultant's skills and techniques of communication are challenged in particular. The ability to define physical reactions in terms of understable psycho-physio-dynamics that can be made relevant to the patient, the doctor and the various therapeutic institutions outside hospital is crucial. Thus the consultant's job becomes one of an active interpreting negotiator, who readily speaks the language needed, to make heard his points of view.
The Section for Psychosomatic Medicine at the University Hospital never managed to cover the need for its services, which is not surprising, since an inpatient population of 20,000 a year will give plenty of work to more than two or three psychiatrists. However, the possibilities of concentrating on orthodox psychosomatic problems have been good, because so many problem cases are to be found in the field of complex psycho- vegetative reactions and disturbances. They are a common type of problem patient at this selected, fairly advanced level of medical care. In addition, patients are received because a combined medical evaluation, Le. combined physical and psychiatric is wanted and most essential. The feeling that we might be exclusive and a bit out of contact with general service problems, made us look for a possibility to study psychiatry in local general hospitals, giving every day, more or less emergency services to a part of the town of Oslo. We were lucky to find that the third largest hospital in Norway, which is an emergency municipal hospital in Oslo, badly needed a psychiatrist willing to engage in the psychiatric problems of the two departments for internal medicine at that hospital. This opened up for a 16 months' clinical study of liaison and consultation psychiatric needs and possibilities at Aker Hospital in Oslo. Contrary to the University Hospital this is an emergency hospital-giving service mostly to the everyday needs of an area of a town of ~ million inhabitants. The two departments for internal medicine were to have only one psychiatric consultant (myself). I had no other commitment than this: to do the job July/August/September, 1975
Secondly-the term "psychosomatic" should be redefined in concepts of a clinical and practicable rs::chophysiology, that opens up to whatever psychological implications physical ailments and illnesses might have. Thirdly-that consultation and liaison services in general hospitals-with the consultant fairly closely, though not too rigidly, tied to the somatic teams on a basis of every day work, offers posibilities for combined in- and out-patient services and clinical research. Finally I might suggest the need that liaison and consultation psychiatry concentrate more on strategies of teaching-i.e. the consultant's teaching in the general hospital-within the framework of an "on-thejob" service oriented training set-up. 139
