The psychiatric management of medically and surgically ill inpatients requires skills associated with general and emergency psychiatry, crisis management, and various psychotherapies (1). Furthermore, the medical setting imposes major modifications on assessment and treatment. The practical challenges to developing and maintaining a therapeutic relationship in the general hospital setting include brief and unpredictable lengths of stay, lack of privacy, unpredictability of patient availability, and ambiguity about whether the indication for consultation arises in response to the needs of the inpatient, a family member, or the treating team. Despite these special circumstances, at this time there is no single model that adequately integrates the unique requirements, limitations, skills, and knowledge base involved in inpatient consultation-liaison psychotherapy.
At our center, residents have reported that they prefer to conceive of consultation-liaison psychotherapy as eclectic, integrating techniques from a variety of modalities, rather than a comprehensive or specific modality in itself. However, residents had not been provided with a coherent concept of consultation-liaison psychotherapy that would facilitate such integration. Our residents’ experiences echo the opinion expressed in a recent article (2) that emphasizes that psychotherapy should be taught in a way that is integrated with the rest of psychiatry and medicine and that responds to real clinical issues with “creative eclecticism.”
Therefore, we developed a description of consultation-liaison assessment and formulation which attends to frequently encountered scenarios on inpatient wards, and draws upon a variety of clinical techniques. In this model, the central challenge for the hospitalized patient is to adapt to the new circumstances determined by his or her illness and its treatment.
The skills the resident needs to develop are 1) identification of common themes of adaptation to illness; 2) identification of patient and illness characteristics that guide management strategies to improve adaptation; 3) choosing whether to offer psychotherapy as a part of that management; and 4) choosing when to employ anxiety-reducing, supportive methods and when to use anxiety-provoking, change-oriented methods.
This model was developed at Mount Sinai Hospital, University of Toronto, Canada, in response to a needs assessment of consultation-liaison training for psychiatry residents. Residents completing a 6-month consultation-liaison rotation participated in a semistructured interview by a senior resident (M.G.) about their experience with consultation-liaison psychotherapy. The results indicated wide discrepancies in residents’ assessments of the definition and application of consultation-liaison psychotherapy.
In response to this survey, two senior supervisors (J.J.H. and R.G.M.) prepared a seminar series to complement the existing program of individual clinical supervision and didactic teaching of core consultation-liaison topics. The curriculum was based on the supervisors’ experience in clinical care and teaching and was designed to meet the goals outlined above. The series has been repeated with a new group of residents twice yearly over eight iterations, with modifications in response to resident feedback. The process of semistructured interviews was repeated with residents who received the first version of the seminar, who expressed greater confidence in identifying aspects of consultation-liaison work which constitute psychotherapy, and who reported more attention to opportunities and barriers to psychotherapy in medical and surgical inpatients. Since the first iteration, the series has grown from four to six 1-hour seminars, three on assessment and three on interventions. We report here on our development of a teaching module for the assessment of patients that focuses on their adaptation. How this approach guides the actual delivery of psychotherapy will be reported subsequently.
Stress is “a process in which environmental demands tax or exceed the adaptive capacity of an organism, resulting in psychological and biological changes” (3). The unifying theme of this model is that being ill in hospital is a stress which requires an adaptive response. Adaptation occurs through multiple processes of coping, biological regulation, and interpersonal interaction. When these processes are insufficient to meet the stressful challenge, symptoms occur, such as distress or conflict, often resulting in a request for psychiatric consultation.
Being ill in hospital involves having signals that humans generally assess as dangerous: pain, impaired cognition, reduced capacity to respond effectively physically, unusual physical sensations, uncertainty about one’s current and future safety, losses of body parts or functions and social roles, threat to life, separation from one’s usual supports, intimate contact with relative strangers, and disruption in one’s ability to perform activities with mastery. Patients use previously established patterns of response in their attempts to adapt to these new circumstances, but these strategies may or may not be appropriate in the novel illness environment.
In addition to the usual domains of the psychiatric interview, consultation-liaison trainees are encouraged to focus on the following aspects of the person as particularly pertinent to the assessment of their current adaptation and adaptive capacity.
Psychiatric diagnosis is a critical step that guides management, and a high degree of suspicion is required for syndromes that are common in medical illness, including delirium, depression, anxiety disorders, posttraumatic stress disorder, somatoform disorders and substance abuse (1). Accurate diagnosis is only the first step, however. In a classic consultation-liaison paper (4), the authors noted that “psychiatric diagnosis (alone)…is not a helpful guide to the patient’s capacity to integrate themselves into the working necessities of a medical ward.” Clinicians also make note of how psychopathology affects the adaptive challenge, whether or not it meets full syndromic criteria. For example, one recognizes not just how a patient with obsessive-compulsive disorder and contamination fears struggles to adapt to a new ileostomy, but also how a breast cancer patient’s obsessive attention to detail interferes with communication with her physicians. When the goal of the consult shifts to assessment of adaptation, away from a singular focus on DSM-IV diagnosis, the resident’s capacity to respond to clinical situations that are problematic but fly under the radar of formal diagnosis is improved.
Adaptive Capacity Prior to the Current Illness Events
Consultation-liaison assessments are often compromised by time pressure, lack of privacy, and the patient’s physical distress. Efficient assessment of personal history can occur via a review of major stressful life events and the patient’s response to them, including past adaptive successes. We incorporate three approaches that have clinical utility in a consultation-liaison setting: a) personality style, b) coping or defensive style, and c) attachment style. Trainees are encouraged to “mix and match,” including in their formulation only those elements with the greatest explanatory power and utility for a particular patient, here and now.
Personality Style: Clinicians tend to employ prototypical personality types to organize clusters of interpersonal, affective and cognitive strategies. The consultation-liaison assessment de-emphasizes personality disorders, which are especially difficult to assess accurately if the stress of hospitalization temporarily brings a person’s least adaptive traits into prominence. Sacrificing comprehensiveness, we emphasize four prototypical personality types, which are common in the hospital setting and have previous standing in the consultation-liaison literature (5).
The histrionic personality is associated with dramatic, vivid, often anxious expression of affect, and impressionistic processing of information that may lead to miscommunication. A histrionic patient often appears distressed and seeks help, but is unable to specify his or her dysphoria beyond being, for example, “terribly upset.” Illness events may interfere with self-regulation of affect, leading to frantic efforts to signal danger and draw others near. Behavior that appears to be attention-seeking and disruptive may also be an adaptive effort to regulate distress through seeking proximity to others.
The obsessive personality has an orderly or even dull affective presentation, with underlying anxiety expressed indirectly through exaggerated attention to detail. Illness may be experienced as a loss of control (5). The attempt to adapt by attending to details and weighing all options often impairs clinical decision making.
The narcissistic personality is characterized by a self-centered, demanding, and often angry presentation. Narcissistic traits maintain a fragile sense of self in the face of a world experienced as hostile, and illness behavior (e.g., haughty devaluation of a health care worker) is an adaptive effort to reestablish a positive view of self. This formulation leads the clinician to seek therapeutic options that reestablish a sense of integrity, rather than options that increase insight.
The paranoid personality is characterized by attitudes of mistrust and blame. Like the patient with a narcissistic personality, the paranoid patient may emphasize grievances about the lack of justice in his or her predicament. Given the fixity of the paranoid stance, we encourage residents to educate staff about this personality style, so they can adapt to it, rather then to attempt any change of the individual’s personality.
Two other personality subtypes, the dependent personality and the borderline personality, we choose to define in terms of preoccupied attachment and disorganized attachment, respectively. Although not an exact match, we have found the attachment formulation to be helpful and easily understood and communicated to patients, family, and staff in a nonpejorative manner (6).
Coping Style and Defenses: A second way to evaluate adaptive capacity is to review characteristic strategies that are employed to face stress and conflict. In Folkman and Greer’s model (7), a stress which appears controllable elicits problem-focused coping, such as information-seeking, problem solving, and direct action. If the stress appears to be less controllable, it may elicit emotion-focused coping (intended to reduce distress), such as avoidance, support-seeking, and cognitive reframing. If such efforts do not lead to resolution of the stress, as is typical of long-term experiences with chronic illness, meaning-focused strategies are employed toward the goal of understanding what has happened and relinquishing unattainable goals. A grieving process and its successful resolution may be central to establishing a sense of meaning that is both positive and realistic. Identifying where an individual’s response lies in this spectrum helps to clarify the adaptive task.
The consultation-liaison assessment surveys current coping strategies to determine whether they are helpful. Denial, in the restrictive sense of complete unawareness of an anxiety-provoking reality, clearly interferes with decision-making and adaptation. Denial this extreme is much less common than various forms of cognitive and behavioral distancing that are employed to reduce distress (e.g., disavowal, optimism, humor, behavioral avoidance of frightening things) and which are associated with health over the long term (8). When other immature defenses, such as splitting and projective identification, are observed on the medical or surgical ward, it indicates a failure of adaptation and a particularly challenging clinical situation. The assessment and management of the difficult patient who relies on such primitive strategies is an important topic in itself, with its own literature (9, 10), and is beyond the scope of this review.
Adult Attachment Style: Attachment theory describes patterns of expectation and behavior in close relationships. Although attachment style and personality are related (11, 12), they do not map easily onto one another (13), and it is helpful to consider these to be separate and complementary aspects of assessment.
For the consultation-liaison assessment, we advocate a modification of Bartholomew’s two-dimension, four-category model of attachment, and teach residents to evaluate where an individual sits on the two dimensions of attachment anxiety and attachment avoidance. Individuals high in attachment anxiety (preoccupied style) display anxiety, lack of resilience, dependency on others, and worry that others will not be available or responsive when needed (14). Expressions of distress tend to be frequent, and vigilance for the responsiveness of others is readily apparent, which may be experienced by staff as demanding and excessively needy. Staff and family may react to amplified distress by distancing and avoidance, which in turn drives the attachment behaviors to become more pronounced.
On the other hand, individuals high in attachment avoidance (dismissing style) have a muted expression of distress, a preference for self-reliance, and difficulty tolerating the sorts of events that increase personal vulnerability, such as physical dependency, uncontrolled symptoms, general anesthesia, and compliance with treatment regimens and hospital policies. The fact that these two dimensions are not simply inversions of each other (15) is demonstrated clinically by individuals who are high on both dimensions of attachment insecurity. These so-called fearful patients are anxious and lack resilience and yet are socially inhibited and avoid the support of others (14).
Patients with disorganized attachment may present conflicting messages to staff, consisting of help-seeking, distrust, and regression, which typically create strong negative feelings among staff. These patients are poorly equipped to adapt to a hospital setting, and their expectations of threat and disappointment from caregivers often give rise to the type of more severe difficulty that is discussed elsewhere (9, 10).
The same illness event presents different adaptive challenges at different stages of life. For example, learning to use an assistive device, such as a walker or a wheelchair, will have a different meaning for a 75-year-old man, who is married and living in a retirement community, than it does for a single 20-year-old man living in residence in university. Furthermore, the link between chronological age and developmental stage is loose. Using Erikson’s nomenclature (16), it is not difficult to call to mind patients in their 40s who continue to struggle with the challenge of establishing autonomy or intimacy while others in their 20s have resolved that challenge and moved on to those associated with generativity. Appreciating the individual’s developmental stage, independent of their chronological age, deepens awareness of their adaptive requirements.
Previous Experience With Trauma
A review of previous trauma can help the clinician assess the risk of further traumatization by illness, diagnosis, or treatment, and help to understand why some experiences in hospital elicit an extraordinary degree of anxious arousal or avoidance for a particular patient. Similarly, Hackett and Weisman (17) stress the relevance of previous hospital experience in determining reactions to a current stay. A review of previous experiences with stress should specifically include previous experience with illness in the patient, illness in their significant others, nonillness stresses and trauma, and previously feared events (18).
Personal Meaning of Events
The subjective meaning that a patient draws from illness influences his or her response (19). For example, two women experience precisely the same illness event—a choice between lumpectomy and mastectomy for primary breast cancer. One woman perceives mastectomy to represent a disfiguration or a loss of femininity. A second woman sees mastectomy as her greatest chance to avoid cancer and wishes no half-measures. Of losing a breast she remarks “Well, it’s not like it’s my arm, I don’t need it anymore.”
The meaning of illness is often best assessed by engaging in an active and curious conversation about a person’s course of illness, allowing them to indicate the aspects of the process that have elicited a strong affective response, and the thought processes behind their most significant treatment decisions. When efforts to have such a conversation do not provide a sense of what the illness means to the patient, we encourage consultation-liaison trainees to review the “Five D’s” with a patient. According to this scheme, the common meanings attributed to illness are 1) distance (interrupting interpersonal relationships), 2) dependency (forcing the ill person to rely on caregivers); 3) disability (interruption in achievement), 4) disfigurement (changes in the physical and sexual self), and 5) death (20). Patients differ in their approach to these challenges. For example, many patients dread dependency and “being a burden” (21), although we frequently encounter patients whose dependency on hospital staff or family as a result of illness, socially sanctioned through the “sick role” (22), is a relief to them.
Characteristics of Illness, Treatment, and Setting
Characteristics of the illness are an important determinant of the adaptive challenge. Is the time course acute or chronic, continuous or unpredictably marked by relapses and remissions? Is it painful, life-threatening? Does it interfere with restorative sleep or functions that are important for an individual’s work or satisfaction? Answers to these questions suggest quite different challenges. A similar list of questions relates to aspects of treatment and hospital care. Is the environment safe? Does it provoke intense emotional responses? Have procedures and expectations been adequately explained? This incomplete list of questions is long enough to indicate that when assessing the adaptive challenge facing a hospitalized patient, the clinician must understand the illness condition and its treatment in their particulars.
The Traumatic Impact of Illness and Treatment
Investigations, diagnosis, and treatment may each be experienced as traumatic stressors (23, 24), sufficiently threatening to result in the core stress response symptoms of avoidance, intrusion, and arousal (18). The overattention to bodily sensation of people after diagnosis of a cancer, for instance, is effectively modeled as hypervigilance as a consequence of the unexpected intrusion of the diagnosis. We have observed intrusion and arousal following a variety of medical investigations, including small bowel enema, magnetic resonance imaging, endoscopy, insertion of subclavian intravenous lines, transvaginal ultrasound, digital vaginal exams, and a variety of painful procedures. Studies of risk factors for posttraumatic stress disorder suggest that the risk of a stress response syndrome following a traumatic event is higher in people with a previous history of psychiatric illness or a previous history of trauma (25, 26). This is one of the reasons that probing for stress response syndromes related to medical care is of pragmatic importance—the history of trauma may explain an otherwise misunderstood avoidance of care and provide an opportunity to ameliorate this obstacle to optimal treatment.
Horowitz (18) describes a number of common responses to traumatic experiences, which may guide enquiry. These include fear that trauma will recur (e.g., a patient with a chronic illness of relapse and remission who has previously been hospitalized fears that the complications experienced in a previous admission will occur during the current stay), fear that one’s own outcome will match that of a loved one who has been ill, sadness over losses, shame and rage over vulnerability, rage at the (real or displaced) source of the trauma, and guilt over survival.
As noted earlier, adaptive strain can also result from failures of the larger system to which the person belongs. Therefore, stressors related to hospitalization are not limited to the space and time of the actual hospital stay. The domains of social context that we emphasize include current financial and housing resources, the presence of other major stresses in addition to the current health situation, family relationships and their impact on health and illness, adequacy of communication (e.g., facility communicating in English, difficulties with hearing or speech), and availability of social support (27). Typically, in addition to information gleaned from the resident’s assessment, this domain is explicated through collaboration with nurses and social workers.
Our setting is a general hospital with an ethnoculturally diverse patient population. Furthermore, our residency program emphasizes issues of transcultural psychiatry. Within the adaptation model, trainees are encouraged to consider culturally determined presentations of emotional or somatic illness (28) and attitudes to truth-telling around terminal prognoses (29). Sociocultural issues often interact, such as when an immigrant family with poor English skills and few monetary resources lacks the means to access transportation to the hospital to support an ailing or dying family member. Staying centered on the task of optimizing adaptation, however, often serves to clarify which details need to be addressed to maximize coping, even if clinicians are unfamiliar with a particular culture.
Although the assessment of adaptation is presented in our teaching and in this article as a series of interrelated modules, with practice it leads to a formulation that is a coherent description of the strengths and vulnerabilities of a particular person in a particular situation, and of the aspects of their circumstances that are preventing an optimal adaptive response. It is not expected that every one of these categories of assessment variables will apply to every patient, but rather that evaluating them will lead the clinician to a succinct understanding of the most pertinent issues in each individual case.
This model of adaptation provides a conceptual basis for the assessment of patients in consultation-liaison psychiatry and is designed to provide residents with the means to formulate the difficulties of a medical or surgical patient according to a framework that facilitates psychotherapeutic decision-making. The nature of consultation-liaison work requires that the clinician integrate a wide range of psychiatric skills. This flexibility, when combined with the need for rapid and focused assessment, as well as brief and sometimes interrupted interventions, places the consultation-liaison psychiatrist at risk of becoming a “jack of all trades and master of none.” The educational corollary is that residents learning the psychiatric management of general hospital patients may see psychotherapeutic interventions as applied in a haphazard rather than integrated manner.
Several approaches to consultation-liaison psychotherapy have been described previously (30–39). Hackett and Weisman’s seminal papers on managing “Operative Syndromes” (17, 40) recognized the limitations placed on standard psychiatric interviewing in the consultation-liaison setting, and emphasized the value of a “therapeutic consultation,” that focused on “helping the patient through a difficult hospital course”—a concept clearly related to adaptation. Also similar to this adaptation model, they described three factors that affected the patient: the intrapersonal, interpersonal, and impersonal dimensions. A three-paper series by Lipowski (41–43) laid out the foundations of consultation-liaison psychiatry, including emphases on the relevance of the personality structure of the patient, the personal meaning of illness, previous experience with illness, and the state of their interpersonal relationships. Viederman (44) emphasizes the role of narrative in establishing a mutual understanding between the patient and consultant about the meaning of the illness episode, and how doing so may establish an alliance quickly and effectively. In our setting, feedback from residents suggested that adhering to only one theoretical model was limiting. An approach that organizes seemingly disparate parts of psychological theory into a coherent whole is valuable.
We do not claim that this curriculum is either comprehensive or entirely distinct from previous presentations. However, it is derived in response to a specific learning need of our residents training in consultation-liaison psychiatry. The theme of optimizing adaptation provides coherence and diminishes the potential for disorganization in assessment or management. It is easily communicated to nonpsychiatric staff and patients. It also serves as a common ground from which consultation-liaison supervisors who do not participate in the seminar series can use familiar principles when supervising individual cases. In a large staff of consultation-liaison supervisors, many of whom work on subspecialty services, this provides a useful way to increase continuity and cohesiveness in supervision.
In the adaptation model of consultation-liaison psychotherapy, multiple domains of psychological function and experience are selectively assessed in order to 1) evaluate the patient’s success in adapting to illness-related tasks, 2) understand the obstacles to adaptation, and 3) intervene to improve adaptation. The multifocal assessment provides the information required to identify the one or two factors that interfere most with adaptation for a given patient, and thus provides the framework from which to choose and design management recommendations. The resident is encouraged to choose the “best fit” from a variety of psychotherapeutic techniques (acquired in previous training rotations), ranging from education, through cognitive-behavioral techniques, to dynamic individual or family therapy to address the specific foci identified.
This model, because it is drawn from the clinical experience and preferences of two supervisors, has the advantage of coherence to an underlying theme. In comparison to a curriculum defined by a broader consensus of consultation-liaison teachers, however, some choices and points of emphasis are idiosyncratic. It awaits empirical testing to determine whether this model contributes to useful outcomes for students and benefits to patients.