The Psychiatric Consultation and Liaison Service of Harlem Hospital Center has a number of functions, some of which exceed the ordinary tasks of such a service. It has become an effective instrument for primary, secondary and tertiary prevention of psychiatric disorders. Its developmental history reveals the many problems that are treated or encountered by this sort of psychiatric activity.
A physician (intern, resident or attending) oi a nonpsychiatric ward requests, usually in writing, a psychiatric evaluation for help in diagnosis, treatment, management, disposition, determination of a patient's capacity for informed consent, or ability to take care of his own affairs. The psychiatrist (resident or attending) reviews the chart, talks to staff members, interviews the patient, writes a report and, if possible, confers with the referring physician. This procedure takes one to two hours for the skilled, and more for the learning psychiatrist. An obstacle in most cases is that an objective history is neither available nor obtainable, because family members or friends are lacking or ouLof reach.
2. Psychiatric Treatment
Psychiatrists and liaison nurses follow up the patient and often provide short-term psychotherapy for the patient, as well as support and supervision for ward staff in managing the patient and the psychotropic medication. In special cases, individual or group therapy is offered to discharged patients, e.g., when referral elsewhere would destroy the patient's motivation. Liaison nurses (occasionally psychiatrists) involve family members if they are available, but not routinely, in consultative or therapeutic efforts.
Psychiatrists and liaison nurses meet with nonpsychiatric ward staff in conferences, joint seminars, rounds and cardex rounds. Communication (especially feedback) with education of nonpsychiatric personnel as well as shaping of attitudes takes place here.
Lectures, conferences, presentations and supervision are provided for the permanent staff of the service, as well as for psychiatric residents from the Harlem Hospital Center Department of Psychiatry and from affiliated state hospitals, who rotate through the service in periods of three or four months. One of these months is predominantly spent on a neurological ward. Lectures, rounds and seminars in neurology stud the resident's weekly program for the entire length of his assignment to the Consultation Service. Coordination is done by the chief of the Consultation Service. The activities mentioned in the foregoing paragraphs comprise elements of training for psychiatric and nonpsychiatric staff. In addition, members of the service are engaged in teaching medical students, nurses, social work students and OB-GYN technicians.
Transfers to other divisions of the Harlem Hospital Department of Psychiatry are smoothed by providing those divisions immediately with a report of the consultation and followup visits, including liaison nurses' notes. This saves work-up efforts. Referral to other agencies is implemented and facilitated by the liaison nurses. The various activities of the liaison psychiatrists and nurses during the patient's hospitalization and discharge have served to increase the patient's motivation for aftercare. This is particularly true lor alcoholics, with whom the liaison nurses have organized group meetings during their hospital stay.
II DEVELOPMENT AND PROBLEMS:
When the Department of Psychiatry at Harlem Hospital Center came under the aegis of Columbia University in l%2, it became obvious that the staff of the general hospital wards needed constant help in managing the many psychiatric disorders and psychological reactions to physical illness among the ward populations. A limited ward consultation service was started immediately. In 1964 the service was made the full-time responsibility of an attending psychiatrist.
Many problems had, and still have, to be faced. Some are logistic in nature, others are inherent in the consultation process.
1. Consultation Services
Nonpsychiatric physicians have to be taught when to call on a psychiatrist and when not, and how to present it to the patient.1 When the consultation is done, the task is to help the consultée to follow the advice given in regard to medication, management and approach. The consultée has to learn the therapeutic and side effects of psychotropic medications, the meaning of various diagnostic labels and the basics in recognition of the psychiatric disorders. Until 1970, many patients with delirium tremens who showed predominantly psychiatric, rather than physical symptoms, had to be diagnosed and their treatment partly supervised by the psychiatrist. As the number of departments staffed by Columbia University increased, fewer brain syndromes and more functional disorders were referred for consultation. The problem of overcoming the conscious and unconscious resistance of nonpsychiatric physicians to psychiatric consultation is a continuous one.2 However, it is mild at Harlem in comparison to some hospitals where the patient's private attending physician is more fully in charge and more "protective" of his patient than is the resident in a municipal hospital, who can make many relatively independent decisions and whose income does not depend on the patient's immediate or positive reaction to aspects of his medical management. The resistance is manifested not only in neglecting to call for a psychiatrist but also in the reluctance to follow through with the consultant's advice. The underlying fears are of disruption of the doctor-patient relationship, ' of incompatibility of the suggested psychiatric regimen with the medical regimen (particularly in the area of medication) and of acknowledging the psychiatrist as an authority. The view underlying this resistance sees the consultant as a domineering intruder, a critic or a competitor and often represents the consultee's transference image of the consultant. There is also the problem of different frames of reference and the difficulty of understanding psychiatric concepts, even if they have been explained in nonpsychiatric terminology. Psychiatry is sometimes considered to be something anybody with common sense can do, so why call in the psychiatrist? Finally, there is the hope of the over-burdened nonpsychiatric physicians that the psychiatric consultant take the "difficult" patient off his hands and transfer him to the psychiatric inpatient service. This expectation runs counter to a major task of the consulting psychiatrist in this hospital, namely, to provide psychiatric treatment, whenever possible, on the general hospital ward. The advantages of this are:
1. Continuity tit physical care (the psychiatric inpatient service is located in a different building).
2. The saving of psychiatric bed space, which at present is insufficient to fill the needs of the community.
3. Maintaining the quality ol medical-surgical care, which would not be possible in the psychiatric inpatient service because of the physical layout, limitations in budget and, naturally, expertise, as well as the nature of the patient population.
The psychiatrist's refusal to transfer a physically ill psychiatric patient from the general ward causes the ward physician to be angry, disillusioned and less inclined to call the psychiatrist the next time, unless he can be shown that he can be an effective therapist by virtue of the consultation process. The house and attending staffs at Harlem Hospital Center are relatively responsive to recommendations which focus on the common goal - better care for the patient.
In addition to consultee resistances, there is the resistance of hospital bureaucracy and administration that has to be overcome to solve many logistic problems- a time and energy consuming process. The almost proverbial attitudes of civil service employees (that may have survival value), power and city politics, as well as misconceptions about psychiatry play a role here. Since the arrival of the new executive director of the hospital, our chances are improving.
In 1964 second year residents from four state hospitals, as well as from the Harlem Hospital Department of Psychiatry, began rotating through the Consultation Service. Their training and education were added to the tasks of the attending. This, and the lesser skill of the learning resident, partly undid the benefit of added manpower.
The resident arriving on the Consultation Service usually has difficulty in assessing the patient's affect, formal thought disorder, degree of pathology, and the interplay of emotional and physical factors. He over-diagnoses schizophrenia, tends to miss subtle signs of organic brain syndrome, is inclined to misdiagnose neuroses and personality disorders, does not see the underlying functional psychiatric disturbance in addicts and alcoholics, and is liable to over-medicate physically debilitated patients. State hospital residents, as well as very "dynamicallyoriented" residents, tend to mistake less obvious psychotic disorders for neurosis, and to miss inconspicuous psychopathology altogether. Many psychiatric residents seem to have difficulty in seeing other etiologies of an organic brain syndrome than cerebral arteriosclerosis or senility. Interviewing skills have to be improved constantly. As the chief of the service, I have to help residents frequently to identify the factors in themselves (cuiturai or personality) which hinder their effectiveness in their work with patients.
4. Racial Issues
Problems rooted in racial difference arise surprisingly rarely, although the awareness of this difference naturally pervades the hospital. On occasion, racial tension may emerge in a disguised form, such as staff conflicts of a heirarchical or interdisciplinary nature, or in staff-patient relationships. White members of the liaison service may elicit spontaneous remarks from the Black patients such as: "I want a White doctor; " "It's my own people who hurt me; " "You don't know what the life in the street is like." A Black patient may react more positively when there are Black members of the team interviewing him rather than only Whites.
Non-Black resident physicians (psychiatric and nonpsychiatric) raised outside the United States can empathize with minorities, since they represent a minority themselves. However, many ol them tend erroneously to see themselves free of prejudice, considering racial bias an American invention. The situation is complicated in that White staff represents a minority among Black siati members and patients. Lack of familiarity among Whites with aspects of ghetto life, sub-cultural differences and idiosyncrasies of special Black religious groups may sometimes increase the distance between White and Black. Although the most important instrument for overcoming this dislance is a genuine wish to relate as equal human beings, a particular sensitivity for sore spots created by the racial situation is highly desirable.
5. Liaison Nurses
In 1967 a liaison nurse was added with relatively undefined tasks. As the number of nurses has gradually grown to three, their responsibilities have become distinct though comprehensive:
1. They often establish the first contact between the Consultation Service and the referring service, since psychiatric consultants may not always be immediately available.
2. Follow-up visits to patients by nurses provide a feed-back for the psychiatric consultant, as to whether his advice has been followed or was effective and what accounted for negative results. These visits also can assume the form of brief psychotherapy for the patient.
3. Conferences and cardex rounds with nurses of various hospital wards are used to help the ward staff cope with their patient's emotional and behavioral difficulties and to increase communication between Consultation Service and the hospital ward.
4. The liaison nurses interview and advise on the nursing management of patients in whose case psychiatric consultation should have, but has not, been requested, because of the ward physician's resistance or inability to ask for help or to see the problem as psychiatric. Relatively rarely are patients in this category seen who need no psychiatric consultation. Often, the intervention by the liaison nurse leads to a request for psychiatric consultation. This contrasts with the misconceived role of the psychiatric liaison nurse in another hospital, where the nurse broke out of the team, practically functioned as a competitive service and, thereby, frequently deprived patients of the benefit of psychiatric consultation.
5. The liaison nurses provide education to nurses of the general hospital ward and to OB-GYN technicians. They also participate in the inservice education of psychiatric nurses.
6. The liaison nurses sometimes meet with families and teach them the relationship between physical illness and psychiatric symptoms. They open up new avenues of communication between patients and their families and offer the families support during a time of crisis.
7. The referral of patients to other services or facilities is implemented or helped by the liaison nurses.
The senior liaison nurse has a master's degree in psychiatric and community mental health nursing: the other liaison nurses are about to obtain Bachelor of Science degrees.
6. Working Conditions
The conditions under which the consulting psychiatrist and the liaison nurses had to work were difficult before 1970. Elevators were slow or out of order, there was no air conditioning, the wards were overcrowded, smelly, and roach infested. Most hallways were turned into wards, juice bottles were used as urinals, and privacy could be found nowhere. Since the level of house officer was below today's, the psychiatrist had to be more aware of the physical implications of his advice and had to help the house officer with the treatment of organic conditions, particularly delirium tremens. For three years, it was a formidable task to try to understand the mumbling of delirious or schizophrenic patients through the hacking sounds of pressure drills, coming from the construction site of the new building and to come up with workable suggestions. Often the lack of chairs did not even permit the psychiatrist to sit at the bedside. The headquarters of the service was one small room with two desks shared by five physicians and one or two nurses.
Physical circumstances improved when most of the patients were moved into the new Martin Luther King Pavilion, which opened in 1970, although elevator service remained a problem lor the consultant's mobile way of working. The Consultation Service managed to obtain office space in the new building, since most ol Harlem Hospital's 900 inpatients are now housed there.
The case material has changed from predominantly organic cases to various personality disorders, neuroses and psychoses (schizophrenia, involutional disorders and depressions of psychotic proportions). Psychosomatic conditions are in the hospital but come infrequently to the attention of the consulting psychiatrist. Conversion symptoms are mainly found in the neurological and OB-GYN wards. Reactions to physical illness are usually handled by the ward staff. Monthly, over 60 consultations are done, 300 to 400 visits are paid to these patients, and 100 to 150 patients are under the care ol the Service at any one time. Only two to live patients per month have to be transferred to the psychiatric inpatient service. Most of the other patients are sent home and referred to the Psychiatric Clinic, a great number to the Alcoholism Clinic, a few to the Harlem Rehabilitation Center (geared to the rehabilitation of psychiatrically or physically handicapped), or the various day care programs in the hospital, to nursing homes, and to chronic disease hospitals.
8. Special Activities
Areas of special attention are the Burn ICU and the Hemodialysis Unit. Rounds and conferences with the respective staffs try to handle the many emotional problems of these special patient populations.
I am involved in the selection of patients for hemodialysis.·' Since machines are available, only severe organic brain syndromes, severe psychoses, and suicidal patients are excluded, it they suffer from these disorders to a degree sufficient to render them a hazard to themselves and fellowpatients under the sensitive conditions of hemodialysis. These intensive criteria, however, increase the frequency of adverse emotional reactions among our dialysis patients. The senior liaison nurse and I provide psychotherapy for these patients while they are in the hospital, and group psychotherapy once they are discharged home and are undergoing dialysis at a satellite unit on an ambulatory basis (in lieu of home dialysis since most homes in this area are not suited for home dialysis). The greater the patient's pre-dialysis psychopathology, the more significant will be his difficulties in adjusting to the change ol his social, socioeconomic c\nd occupational position, to his altered role in the family, and to the hemodialysis machine. The main psychiatric problems are depression, selfdamaging denial, psychosis, dissociation, aggressive acting out, and suicidal tendencies. The latter are particularly worrisome since dialysis patients reportedly are 100-400 times more prone to suicidal4 or otherwise motivated self damaging5'6 acts than the average population. Outpatients' suicidal acts consist mainly of neglecting to attend dialysis and violations of the dietary regimen which, in a few cases, have been fatal. Psychotropic drug treatment is supervised by myself, since phenothiazines and tricyclic antidepressants are practically not dialyzable.7 The patients discharged to the (out-of-hospital) satellite unit miss the personal and caring atmosphere of the hospital dialysis unit. Lack of gratification of needs for dependency and affection lead to aggravation or recurrence of their maladaptive behavior patterns. Since these patients do not relate well to new personnel, we provide aftercare (group, and in selected cases individual, psychotherapy) which utilizes our relationship, established with them during their hospitalization, and allows them to have one more time with the hospital, which has become a kind of community center for them.
The burn patients seem to have a greater incidence of pre-accidental psychopathology than the average population."''1 Many of our burn patients (referred from various parts of New York City, New York State and New Iersey) are alcoholics. This, as well as the endotoxic and metabolic noxia, account for the overwhelming occurrence of organic brain syndromes after admission in our patient population.
Simultaneously or later, depression, body image difficulties and or psychoses develop which, together with the pre-existing psychopathology and the brain syndromes, make up the varied etiology of uncooperativeness in most burn patients, particularly when exposed to pain-aggravating procedures. Pain becomes the battleground on which nurses and patients tend (o oppose one another. The psychiatric consultant and the liaison nurse have to deal here with the patient's, his family's and other staff's feelings. Although ultimately a good relationship between patient and staff is achieved, burn patients frequently get lost to at tere .ire and later to society by leading a withdrawn, unproductive life."' We .ire in the process of trying to prevent this by involving ourselves actively in the altercare process based on the same premises as in the case of hemodialysis patients.
Finally, the problems of the dying patient have become of increasing concern to the consulting psychiatrist during the last 10 years. Our task consists in helping the patient's physician to understand the dynamics of living" anil to time his interventions accordingly1, alter we have interviewed the patient and obtained a fair picture of his particular situation.