Consult Liaison
& Therapeutic Alliance
Tony A. Hanna
PGY-III
Psychiatry
Objectives
Define Consultation liaison psychiatry.
Understand the scope of psychosomatic
medicine.
Outline the indications for consultation in
C/L psychiatry.
Outline the model for C/L psychiatry.
Understand the approach to C/L
psychiatry.
Define therapeutic alliance and the 12
“do’s” of C/L psychiatric etiquette.
Consult Liaison Services
Dr. Fitzgerald (Attending)
Dr. Tzoneva (Fellow)
Dr. PGY (resident)
Medical student
Definition
Consultation-Liaison Psychiatry is a subspecialty of psychiatry that incorporates
clinical service, teaching, and research at
the borderland of psychiatry and medicine.
(Lipowski, 1983)
Psychosomatic medicine:
1) Studies the correlations of
psychological and social phenomena
with physiological functions
2) Focuses on the interplay of biological
and psychosocial factors in the
development, course and outcome of
all diseases.
3) Advocates the biopsychosocial
approach to patient care.
History of Consultation – Liaison
Psychiatry
Its early origins reflect the emergence of General
Hospital Psychiatry.
In the 1920s psychiatry became closer to
medicine as hospitals started to establish
psychiatric units .
The concept of psychosomatic relationships and
the role of emotions and psychological states in
the genesis and maintenance of organic
diseases emerged.
Thus, Consultation – Liaison Psychiatry became
an applied form of psychosomatic medicine.
History of Consultation – Liaison
Psychiatry
Considered the earliest advocate
for integration of psychiatry and
medicine.
Wrote the first comprehensive book
on mental illness by an American –
“Medical Inquiries and
Observations upon the Diseases
of the Mind”
Stressed that diseases of the mind
are as certainly object of medicine
as diseases of the body.
Benjamin Rush
1745 - 1813
History of Consultation – Liaison
Psychiatry
Developed the concept of
psychobiology.
Advocated the study of the
person in the
context of physical,
social, psychological
life events.
Spoke of the medically
useless contrast
between mental and
physical disorders
Adolf Meyer
(1866 – 1959)
History of Consultation – Liaison
Psychiatry
Considered one of the pioneers of
psychosomatic medicine.
Worked at the Columbia-Presbyterian
Hospital as a psychiatrist assigned to
the department of medicine.
In 1936 published the conclusions of
her study of 600 patients with
cardiovascular diseases, diabetes, or
fractures.
Helen Flanders Dunbar
Psychological factors appeared to
influence both the etiology and course
of the illness in a substantial
proportion of these patients.
In 1934/35 with Rockefeller foundation grants
five general hospitals were able to develop
psychiatric departments and stimulate closer
collaboration between psychiatrists and other
physicians.
By the 1960’s-1970’s a subspecialty scientific
literature had developed.
In 1974 the psychiatric education branch of the
NIMH decided to support the development and
the expansion of consultation liaison services
throughout the US.
By 1980, NIMH supported 130 programs
and materially contributed to the training of
more than 300 consult-liaison psychiatry
fellows.
Consult-liaison psychiatry continued to
grow during the 1980’s despite the federal
budget cuts.
The years since 2000 have seen a focus
on achieving added qualification status by
the American Board of Medical Specialty.
Fellowship training guidelines and
certification examination development are
necessary steps toward that goal.
Most common reasons for
consultation:
Delirium, dementia, amnesia and other cognitive
disorders-25%
Affective disorders, primary or secondary to
medical condition-25%
Adjustment disorder, maladaptive response to
identified stressors, including medical illness15%
Somatoform disorders, anxiety disorders,
personality disorders -each <10%
Data on the distribution of axis II disorders are
limited.
Models for Consultation
The five models for consultation:





Patient-oriented (Lipowski 1967)
Crisis-oriented (Weisman and Hackett 1960)
Consultee-oriented (Shiff and Pilot 1959)
Situation-oriented (Greenberg 1960)
Expanded psychiatric consultation (E. Meyer
and Mendelson 1961)
Approach to the Consultation
Consultation style
Patient confidentiality
Patient follow-up
Consultation style
Characteristics of effective psychiatric
consultant (Goldman, Lee, Rudd, 1983):
1. Talks with the referring physician, nursing
and other staff before and after
consultation. Clarifying the reason for the
consultation is the initial goal.
2. Establishes the level of urgency.
3. Reviews the chart and the data
thoroughly.
4. Performs a complete mental status exam
and relevant portions of a history and
physical exam.
5. Gets collateral from family, friends as
indicated.
6. Makes notes as brief as appropriate.
7. Arrives at a tentative diagnosis.
8. Formulates a differential diagnosis.
9. Recommends diagnostic tests.
10. Has the knowledge to prescribe
psychotropic drugs and be aware of their
interactions.
11. Makes specific recommendations that
are brief, goal oriented and free of
psychiatric jargon and discusses
findings and recommendation with
consultee – In person whenever possible.
12. Respects patient’s rights to know that
the identified “customer” is the consulting
physician.
13. Follows-up the patient in hospital, and
arranges out-patient care, including help
arranging postdischarge referrals.
14. Does not take over the aspects of the
patient’s medical care unless asked to do
so.
15. Follows advances in the other medical
fields and is not isolated from the rest of
the medical community.
Patient Confidentiality
Maintaining absolute Doctor-Patient
confidentiality is not possible for a
psychiatric consultant.
Explain the dual relationship to the patient.
Patient Follow-up
Frequency and duration of psychiatric
follow-up will vary widely depending on the
patient’s needs and the financial
circumstances.
Psychiatric consultant should follow-up
patient until they are discharged from the
hospital or clinic or until the goals of the
consultation are achieved.
Case Presentaion
Reason for Consult: LG- 38/y/y AAF was
assaulted and sustained multiple facial
fractures, pt. developed meningitis and
endocarditis and is treated with oral Zyvox.
Pt refused to leave the room, she thinks
that people will look at her and treat her
funny.
HPI- 38y/y AAF who lives with her mother,
grandmother, daughter and 2 grandchildren. Sits
for the grandchildren and grandmother who had
stroke.
4/21/06 spent the weekend at a motel and upon
leaving at midnight, her boyfriend dropped her
(at her request) at a disabled neighbor who lives
two blocks from the Pt’s house. According to the
patient, she wanted to check on her neighbor,
but her neighbor did not answer the door. The Pt
walked to her house but first decided to stop at a
grocery across the street from her house. Before
entering the store, she was assaulted and the
Pt. does not remember any details until she was
in the ER at LSU-S. Pt was transferred from
Monroe.
Pt denies being depressed but stated she
is self-conscious because of her left eye,
periorbital scar, loss of vision and ptosis.
”What will people say about this?” “My
grandchildren will be scared of me.”
Psychiatric review of systems
MAPSS
Mood-depression (sigecaps): sleeps 8-10 hours,+
helpless, occasional crying spells, no guilt or frustration,
not hopeless, appetite normal, good energy with normal
concentration.
Mood-mania (digfast): negative
Anxiety- no flash back, no nightmare
Psychosis- no hallucination, no delusion
Substance- no tobacco, started beer drinking at age 17
which increased to 6 beer/daily for the last year, history
of THC and cocaine abuse X 9 years, last use 3 years
ago.
Safety- no SI/HI
Social History
12th grade education, single with 6
children, liked to socialize, watch TV, go to
casino, no church activity, no military
service, no history of abuse, jailed a few
months, 13 years ago due to an altercation
and violating her parole.
Past Medical & Psychiatric History
none
Family History
Father & Mother living but separated,
no problems.
3 sisters – one sister with HTN
6 children- two daughters, 4 sons, no
problems.
MSE
A&O x4 in casual clothes, cooperative and
pleasant, speech normal, mood and affect
euthymic, TP organized, TC no
hallucinations or delusions, no SI/HI
Registration 3/3, Recall 2/3, spells
WORLD forward and backward, abstract
intact ( do not cry over spilled milk) insight
and judgment good.
Assessment
Axis I - Adjustment disorder with anxiety
- ETOH / cocaine abuse
- THC abuse in remission
Axis II- deferred
Axis III- s/p assault with facial and skull fx
meningitis, endocarditis, loss of
vision-left, ptosis, anemia NC/NC
Axis IV- unemployed
Axis V- GAF45/55
Treatment/Recommendation
Self disclosure
Examine pt thoughts
Desensitization
Alcohol and drug counseling
Follow-up with MMH upon discharge
Continue to encourage pt to walk out of
the room
No need for medication.
Follow-up
Pt was called at home 5/20/06
Mother stated that the Pt is back to her
self, not depressed and is following up
with MMH, also the Pt has weekend plans
to go away and will not return until
Monday.
What is the most important
issue in psychiatric care?
SAFETY
What is the second most
important issue?
Therapeutic Alliance
What is Therapeutic Alliance?
The readiness of a patient to work with energy with a
willing psychotherapist.
It has not commonly applied to the type of brief
encounter experience by the consultation-liaison
psychiatrist in hospital setting. Nonetheless, insofar as
the consulting psychiatrist fosters hope and expectation
in patients seen in that context, however brief the contact
, the relationship (alliance) has the capacity to promote
maturation and well-being in any patient.
The psychiatric consultant makes use of all the principals
of good psychotherapy although they are often modified
to accommodate the realities of the hospital setting and
the unusual way in which psychiatrist and patient are
brought together.
Dr. Joel Yager’s twelve
behaviors
as a list of “do’s”, somewhat
analogous to the ten
commandments of etiquette in
the psychiatric consultation
described by Pasnau.
I. Sit Down.
Sitting reduces the status difference
between MD and Pt and the likelihood that
the Pt will perceive the MD to be assuming
a lordly demeanor and also conveys to the
patient that the MD has some time to
spend with them.
Introduce yourself.
State the reason for the visit.
Ask for permission to sit.
II. Do something tangible for the
patient.
Farther the rapport.
Be helpful in small ways, do what a good
nurse will do, ask the Pt if he is
comfortable.
Increase the comfort of the Pt.
III. Touch the Patient
The physical intimacy of touch is helpful
with a frightened, dependant, and/or very
physically ill patient and conveys a human
caring that can reduce the feeling of
aloneness and alienation in dehumanizing
medical environments.
Handshake, hold Pt hand, touch Pt
shoulder
The least touched Pt – AIDS, Cancer
IV. Smile
Reduces interpersonal distance
Decreases sense of threat
Has a disarming effect
Must be culturally acceptable
V. Begin by telling the patient
what you know about his/her
situation.
Ask the patient to correct you.
The positive effects
* Pt does not have to go through the
information again.
* helps to get feed-back from Pt.
* Pt will assess the level of the
consultants understanding and concern.
VI. Ask the patient what his/her
most pressing concerns of the
moment are.
The Pt’s preoccupation with major fear or
concern needs to be cleared to have the
Pt’s full attention and cooperation.
Clears the air so the necessary
information can be used more effectively.
VII. Ask in detail about the
patient’s belief system regarding
the nature, cause and prognosis
of the illness or injury, and about
the patient’s specific concerns
about pain, disability,
disfigurement or death.
Tune into the Pt perspective and expectations of
what the Pt is confronting.
Correct misimpressions and provide education.
(facilitate cooperation with RX)
VIII. Ask in detail about the
patient’s family major social
roles such as occupation, and
the impact of the current illness
or injury on those relationships
and roles.
Pt is concerned about the negative
consequences of the illness on loved ones and
on the ability to maintain major social role
functions in family, work and community.
IX. Ask about the specific
personal characteristics,
activities and attainments the
patient has achieved in life in
which he/she takes pride and
find an opportunity to
complement these qualities.
Improve self esteem and the Pt feels that
the consultant appreciates the Pt, not as a
simply dependent creature.
X. Acknowledge the human blight
in which the patient finds
him/herself.
The physician should tell the Pt that faced
with similar circumstances, the physician
might well display similar psychological
difficulties.
Strengthen the physician/Pt relationship
Legitimize and validate the Pt and support
self esteem.
XI. Fully explain the need for
and purpose of mental status
exam in an informative way
and involve the Pt as an ally
an co-investigator.
XII. Leave the patient with
something concrete.
Give the Pt a revised formulation.
Tell the Pt what you intent to do with the
information.
Ask the Pt for feedback.
Tell the Pt when you are coming back for
follow-up.
2000 My vet gave me an Axis II
diagnosis.
Personality disorder -incompatible with
large dogs in house.
Treatment
Guido Hanna a pure-bred dachshund, who
believes he is a doberman, was added to
the family.
Guido Hanna
Discussion