Proc. 4th Congr. Int. College Psychosom. Med., Kyoto 1977 Psychother. Psychosom. 31: 98-105 (1979)
Liaison P sy ch iatry in th e West The View from 1977 Adam J. Krakowski Psychosomatic Service and Research, Champlain Valley-Physicians Hospital Medical Center, Plattsburgh, N.Y.
Abstract. Current status of consultation-liaison psychiatry in the West is reviewed. Its aims, functions, and scope in diagnosis and treatment of general hospital patients outside of psychiatric departments are described. A critical appraisal is made with regards to the triadic relationship of its participants. Its benefits vis-à-vis resistances are illuminated in the context of psychosocial process. Its role in research and medical education is recounted. Thoughts about its future developments are offered.
Definition and Scope
The term ‘liaison psychiatry’ called also ‘consultation psychiatry’ is defined as services rendered by psychiatrists outside of the psychiatric department of the general hospital (Lipowski, 1967). It should be distinguished from mental health consultation on the broad level of community agencies (Kaplan, 1970). The definition of liaison psychiatry was implemented by the present author {Krakowski, 1973a, 1975a, b) through recounting its trifold scope: (1) to help physicians with those patients whose problems may be primarily psychiatric, or whose psychiatric or psychosocial problems interfere with, complicate, or stem from somatic illness; (2) to broaden consultées’ practical and theoretical knowl edge required for management of such patients in the future, and (3) to help consultants gather data for research purposes, primarily in the field of psycho somatic medicine. To this must be added its role in educating for a holistic approach to the patient.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 10:13:05 PM
A historical review shows that the creation of liaison services followed a need. A psychiatric department in the general hospital was first established in 1902; by 1970 some
Current Status of Consultation-Liaison Psychiatry
99
22.4% of American psychiatrists were active in 770 such units in the United States (Lipowski, 1974). The introduction of psychotropic agents and greater biological research into mental illness led to further expansion. This in tum involved primary physicians in the treatment of the mentally ill on a community level, hereby creating a need for assistance in the management of such patients (Krakowski, 1975b).
Liaison psychiatrists met this educational need of their medical colleagues by developing a psychosomatic model stressing the biological, social and psycho logical parameters of health and illness. Thus a holistic approach and patient orientation replaced the narrow confines of disease orientation. Such a method requires the consultation psychiatrist to be knowledgeable in such nuances as somatic illness and pain, psychological phenomena that center around personal ity adaptation in illness, bereavement, disability, hospitalization, psychody namics of illness, effect on social adaptation at various age levels and finally the meaning of the consultation to the patient, his family and the consultée and even the effects of its inner workings on the consultée and the consultant.
Organization, Approach and Tactics
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 10:13:05 PM
Empiricism prevailed at first but presently refined organizational methods are used. On the whole there is a close relationship of the liaison to the parent service: the psychiatric department of the general hospital. Teaching institutions employ several senior members and a number of trainees in psychiatry, psychol ogy and social work as well as psychiatric nurse clinicians (Cleghorn, 1974). In a well-organized service, liaison psychiatrists become members of appropriate services and participate in the work of such subdivisions on a steady basis. This permits them to be useful when needed and to become well acquainted with the likes and dislikes, idiosyncrasies and resistances of the members of the thera peutic team. They may identify with the specialists to become knowledgeable in their fields. At the same time they must not try to make even part-time psychiatrists of their non-psychiatrist colleagues. But above all, they must avoid the use of involved theorizing, psychiatric jargon, condescension and professional onesidedness {Kaufman, 1953; Engel et al., 1957; Krakowski, 1973a). They must help to make the diagnosis and take over the psychiatric management of the patient, if necessary, but their tasks must not interfere with the patient’s primary therapy. They may choose either the patient-oriented approach, which focuses attention on the needs of the patient, or the consultee-oriented approach which aims at assisting the consultee more than anyone else, or the situation-
100
oriented approach which resolves the difficulty of the patient, his family, and the consultee, thus exerting a positive influence upon the total patient situation (
Liaison P sy ch iatry in th e West The View from 1977 Adam J. Krakowski Psychosomatic Service and Research, Champlain Valley-Physicians Hospital Medical Center, Plattsburgh, N.Y.
Abstract. Current status of consultation-liaison psychiatry in the West is reviewed. Its aims, functions, and scope in diagnosis and treatment of general hospital patients outside of psychiatric departments are described. A critical appraisal is made with regards to the triadic relationship of its participants. Its benefits vis-à-vis resistances are illuminated in the context of psychosocial process. Its role in research and medical education is recounted. Thoughts about its future developments are offered.
Definition and Scope
The term ‘liaison psychiatry’ called also ‘consultation psychiatry’ is defined as services rendered by psychiatrists outside of the psychiatric department of the general hospital (Lipowski, 1967). It should be distinguished from mental health consultation on the broad level of community agencies (Kaplan, 1970). The definition of liaison psychiatry was implemented by the present author {Krakowski, 1973a, 1975a, b) through recounting its trifold scope: (1) to help physicians with those patients whose problems may be primarily psychiatric, or whose psychiatric or psychosocial problems interfere with, complicate, or stem from somatic illness; (2) to broaden consultées’ practical and theoretical knowl edge required for management of such patients in the future, and (3) to help consultants gather data for research purposes, primarily in the field of psycho somatic medicine. To this must be added its role in educating for a holistic approach to the patient.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 10:13:05 PM
A historical review shows that the creation of liaison services followed a need. A psychiatric department in the general hospital was first established in 1902; by 1970 some
Current Status of Consultation-Liaison Psychiatry
99
22.4% of American psychiatrists were active in 770 such units in the United States (Lipowski, 1974). The introduction of psychotropic agents and greater biological research into mental illness led to further expansion. This in tum involved primary physicians in the treatment of the mentally ill on a community level, hereby creating a need for assistance in the management of such patients (Krakowski, 1975b).
Liaison psychiatrists met this educational need of their medical colleagues by developing a psychosomatic model stressing the biological, social and psycho logical parameters of health and illness. Thus a holistic approach and patient orientation replaced the narrow confines of disease orientation. Such a method requires the consultation psychiatrist to be knowledgeable in such nuances as somatic illness and pain, psychological phenomena that center around personal ity adaptation in illness, bereavement, disability, hospitalization, psychody namics of illness, effect on social adaptation at various age levels and finally the meaning of the consultation to the patient, his family and the consultée and even the effects of its inner workings on the consultée and the consultant.
Organization, Approach and Tactics
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/6/2018 10:13:05 PM
Empiricism prevailed at first but presently refined organizational methods are used. On the whole there is a close relationship of the liaison to the parent service: the psychiatric department of the general hospital. Teaching institutions employ several senior members and a number of trainees in psychiatry, psychol ogy and social work as well as psychiatric nurse clinicians (Cleghorn, 1974). In a well-organized service, liaison psychiatrists become members of appropriate services and participate in the work of such subdivisions on a steady basis. This permits them to be useful when needed and to become well acquainted with the likes and dislikes, idiosyncrasies and resistances of the members of the thera peutic team. They may identify with the specialists to become knowledgeable in their fields. At the same time they must not try to make even part-time psychiatrists of their non-psychiatrist colleagues. But above all, they must avoid the use of involved theorizing, psychiatric jargon, condescension and professional onesidedness {Kaufman, 1953; Engel et al., 1957; Krakowski, 1973a). They must help to make the diagnosis and take over the psychiatric management of the patient, if necessary, but their tasks must not interfere with the patient’s primary therapy. They may choose either the patient-oriented approach, which focuses attention on the needs of the patient, or the consultee-oriented approach which aims at assisting the consultee more than anyone else, or the situation-
100
oriented approach which resolves the difficulty of the patient, his family, and the consultee, thus exerting a positive influence upon the total patient situation (
