Psychotherapy in Consultation-Liaison psychiatry

Psychotherapy in the Consultation-Liaison (C-L) setting is shaped by the realities of the patient's situation, since all patients referred are dealing with physical illness. The patient's state of physical and mental health will determine both the type of therapeutic work possible and the focus of such work. Tailoring the therapeutic intervention to the patient's specific needs and flexibility in altering and adapting therapeutic strategies over time in line with the patient's changing needs are essential. Although periods of treatment may range from single session to long term, supportive, insight oriented, group, family, cognitive and behavioral techniques have all been used successfully in a C-L setting, with measurable impact on well-being. Psychotherapeutic work in C-L is unique in that the focus of the therapist extends beyond the patient and family to include all caregivers, including other health care professionals, in line with the biopsychosocial model. Psychotherapy in Consultation-Liaison (C-L) Psychiatry? Is such a thing possible? Can meaningful psychotherapy take place in an acute hospital setting, with ever-decreasing lengths of stay? Is the very notion of psychotherapy and C-L something of an oxymoron? At first glance, it might seem so. By the nature of inpatient C-L, the patient usually does not seek the consultation, which is most often requested by some member of the health care team. Thus, the willing patient, eager for help, wanting something in his or her life to change, is rarely found in an inpatient C-L setting. Then there is the consideration of the impact of physical illness on a patient's ability to participate in therapy. In one extensive review of consultations, where the requesting staff identified depression as the reason for the consult, suggesting psychotherapy might be anticipated to be helpful, only 60% of the patients referred for assessment and treatment of depression were diagnosed as being depressed by the consultant, while 17% actually had dementia and/or delirium as their primary diagnosis (1). In another study of referrals in terminally ill patients, who might be expected to be depressed and potentially able to benefit from therapeutic intervention, a majority of the patients were actually delirious, with the delirium limiting the possibility of psychotherapeutic intervention (2). In our setting, a 600-bed academic medical center, with more than 1000 psychiatric consults yearly, a diagnosis of cognitive disorder is made for 45% of the patients seen in consultation and the average time spent on a consultation and follow-ups is under three hours. Can psychotherapy take place in such a context? Obviously in such a setting, the format and goals of psychotherapeutic treatment may need to be altered, but most psychiatrists who work in the field would agree that psychotherapeutic techniques remain an important part of the therapeutic armamentarium of the C-L psychiatrist, even in an inpatient setting. Increasingly, C-L psychiatrists are also working with medically ill patients in outpatient settings, where time limitations on therapeutic interactions may not be so stringent and patients more intact. Focus of therapeutic work may be on long-standing issues that have been brought to a head by the crisis of illness and hospitalization or aimed at preventing or treating an abnormal response to the illness. The history of therapeutic work with the medically ill is a long and honorable one. Interest in the interrelationship between the mind and the body is as old as the study of medicine itself, but the work of Freud, which linked specific unconscious content to symbolic expression through somatic symptoms, opened new vistas for consideration. Could unconscious conflict cause illness and could psychotherapy aimed at resolving such conflict affect the course of such an illness? Perhaps the best-known proponents of this theory were Franz Alexander and his colleagues who theorized that syndromes in a group of illnesses, the so-called "psychosomatic illnesses" or "vegetative neuroses," were associated with certain characterological patterns and emotional constellations. …