Whence and whither ‘liaison’ psychiatry?

For much of its history psychiatry has been conspicuously absent from the general hospital, a setting which should be one of its more natural habitats. Cartesian dualism and alienist attitudes have cast a lingering shadow. Attention to the emotional factors associated with physical illness has always been an essential part of good medical practice but it is only relatively recently that organized psychiatric services have been provided to the medical and surgical departments of general hospitals. This interface of psychiatry with other medical specialties has come to be known as 'liaison' psychiatry. Sometimes the term 'consultation-liaison' is used, thereby emphasizing two distinct but related processes. In this sense, consultation refers to the assessment and advice on treatment of a particular patient in response to a request from another specialist. Liaison, on the other hand, has much broader aims whereby psychiatry is seen as having a preventive, as well as a therapeutic, role (Strain & Grossman, 1975). The psychiatrist becomes an integrated member of a clinical team, attends ward rounds and conferences, and holds teaching sessions for the other staff. Lipowski (1974) has described the psychiatrist here as mediating between patients and staff to maintain communication, allay conflicts and prevent the deterioration of clinical care. It is doubtful whether liaison psychiatry can be considered a discrete subspeciality. The term refers rather to a style and locus of practice; it is best regarded as an ill-defined area of interest in which the psychiatrist has particular skills to contribute to the care of the physically ill and to those in whom psychiatric disorder presents in somatic terms. This involves close collaboration with other doctors whom the patient initially consults. Usually this collaboration occurs within a hospital setting, but it could also take place at the level of primary care. Liaison psychiatry, as we now recognize it, is largely an American phenomenon. Its development can be traced back at least fifty years (Henry, 1929), although the term 'psychiatric liaison' first appears to have been used in the 1930s to describe the department at Colorado General Hospital, Denver (Billings, 1936, 1937). Similar units were gradually established elsewhere (Greenhill, 1977) and particularly close links with other disciplines were forged by Romano, Engel and their colleagues at Rochester, New York (Kehoe, 1961; Engel, 1967). At about this time psychosomatic medicine, of which liaison psychiatry is probably an offspring, was attracting increasing interest and support. However, some of the claims of the psychosomatic movement concerning mental and physical interaction in disease did much to discredit psychiatry; in this case the parent was more wayward than the child. Fortunately, psychiatry's contribution to medicine survived the eclipse of the various psychosomatic hypotheses and a resurgence of interest in liaison psychiatry has been one of the characteristic features of the American scene in recent years. The remarkable extent of its growth has been described by Lipowski (1978). Between 1974 and 1978 the Psychiatry Education Branch of the National Institute of Mental Health in Washington increased the funding for training psychiatrists in liaison work by 270%; liaison programmes thus consumed one-fifth of the Branch's disposable funds. As a result, there have been increases in the numbers of residency programmes providing liaison training and of post-residency fellowships. Other prominent writers have attested their belief in the importance of this area of psychiatry (West, 1973; Hackett, 1977; Moore, 1978; Eisenberg, 1979) as American psychiatry at large seeks to re-integrate itself within the medical family.