An Advocacy for the Academic Underpinning of Psychiatric Liaison

LP, also known as consultation liaison psychiatry, is the branch of psychiatry that focuses on the interface between somatic medicine and psychiatry. The role of PC activity is to provide psychiatric and psychotherapeutic care for the medically ill with psychiatric morbidities or psychological problems at the request of the treating medical or surgical team. The role of LI activity is to work with referring colleagues in different ways and for a variety of reasons (e.g., transfer of psychiatric knowledge, offering support, etc.) [1]. LP teams usually consist of psychiatrists, psychologists, psychiatric nurses and social workers. In some countries, LP overlaps and/or is covered by neighborhood disciplines, like psychosomatic medicine or medical psychology. However, psychosomatic medicine and medical psychology are clinical approaches whose purpose is to interlace the psyche and the body, which can be partly provided by specifically trained general practitioners.

In the middle of last century, when general hospitals started to call on psychiatrists for the treatment of the medically ill with mental health comorbidities, referrals were most often limited to patients who attempted suicide. As experienced by F. Stiefel while working as a resident in internal medicine in the early 90’s, in such situations, the psychiatrist came and left, sometimes leaving a note or just stating “the patient can go home after receiving medical treatment”. This PC model, with psychiatrists working outside the hospital, had many disadvantages, including the fact that patients with other than severe and obvious psychiatric disorders remained undiagnosed and untreated due to a lack of exchange between the medical and psychiatric discipline. The birth of the so-called psychiatric liaison (LI) activity, namely the collaboration of psychiatrists with their somatic colleagues, then aimed to compensate for this lack [1]. In the beginning, the purpose of LI was to sensitize clinicians to the psychological dimension of their patients and hereby increase referral. The general hospital started to integrate psychiatrists who embodied the psychological dimension of illness and, by their very presence, evoked the psychological suffering of the medically ill. The further development of specialized services with more human resources and visibility increased referral but not the adequacy of the referral indication. For example, at the beginning of his professional career as a liaison psychiatrist, F. Stiefel still faced requests like “patient is crying”. To remedy that problem, LI attempted to help referring physicians to refine their indications through activities like teaching or implementing psychometric screening instruments to increase the psychiatrists’ efficiency. Despite these efforts, epidemiological investigations, such as the multicenter European Consultation and Liaison Workgroup’s study [2] revealed that psychiatric consultations were initiated for too little patients, occurred too late during their hospitalization, and were more oriented by the needs of the clinicians than those of the patients. In this regard, it has been observed that LP still resembles emergency psychiatry, intervening for “noisy” and thus “disturbing” patients whose conditions were not immediately treatable (e.g., personality disorders), while “cooperating” and “silent” patients (e.g., depressed or affected by hypo-alert and hypo-active delirium) did not benefit from psychiatric consultations. Referral to LP is a complex issue and depends on various factors that may be related to the patient (anosognosia, masking of distress or somatic expression of psychiatric disorders, etc.) or to the clinician (lack of training, defensive attitudes towards the psychological suffering of the medically ill, etc.), on determinants in relation with the institution (lack of continuity of care, focus on medical problems, etc.) and the sociocultural context (stigmatization of psychiatric patients, shame associated with psychiatric morbidity, etc.). As referral, the screening of patients is a complex and unresolved issue for LP. While an in-depth discussion of the benefits and limits of screening is beyond the scope of this paper, we would like to illustrate possible ways of proceeding with the example of a LI intervention using the INTERMED. The Swiss National Accident Insurance funded rehabilitation clinic (SUVA) in Sion has adopted this biopsychosocial assessment system to detect patients in need of interdisciplinary and psychiatric treatment since almost twenty years [3]. The INTERMED is based on the concept of biopsychosocial case complexity and is scored using a semi-structured interview (or a patient self-assessment). It has shown to identify patients with medical and psychosocial morbidities who are at risk of benefiting less from medical interventions compared to non-complex patients. The INTERMED has been used as an effective means to target patients who benefit from LP. These targeted interventions were demonstrated in randomized clinical trials to increase patients’ quality of life, and to decrease their psychiatric morbidity and health care utilization upon follow-up [4]. Along these efforts, LI has also promoted more individual and group supervisions, another way to increase clinicians’ psychological competences and to support them in their daily work.

From our viewpoint, up to now LI interventions pursued four objectives: the sensitization of clinicians for the psychological suffering of the medically ill, the refinement of indications for psychiatric referral, the systematic identification of patients benefiting from liaison psychiatry, and the support of clinicians. Depending on local resources and settings, these objectives are fulfilled to different degrees.

So far so good. However, on closer inspection, it seems that LI suffers from being marginalized, shows an inability to adapt to the evolution of clinical practice, and lacks empirical foundation. Moreover, LI is not a formal part of the liaison psychiatrists training and most of the liaison psychiatrists are absorbed by the PC activity. The fact that many activities of LP are not sufficiently reimbursed hampers their development; this being especially the case for LI.

We also observe that after the introduction of supervisions and Balint groups [5], only a few other types of LI interventions have been developed and were widely implemented. An example are communication training programs, which are, however, almost exclusively intended for oncology professionals [6]. Communication training is a powerful tool to address clinicians’ preoccupations when encountering patients and to increase their communicational and relational competences [7, 8]. However, these are punctual interventions, addressing a specific population of professionals and particular problems. Furthermore, while clinicians are situated, which means that they are part of a context (institutional, cultural, social, and societal), LI interventions solely address the psychological dimension of their work; the contextual determinants of their experiences are not dealt with in traditional LI interventions [9, 10].

While PC activity can rely on a body of scientific evidence, study of LI is almost non-existent. For example, individual and team supervisions, which are among the main activities of LI, remain largely underresearched [11].

Finally, training of future liaison psychiatrists focuses on PC activities; residents may occasionally participate in supervisions provided by a senior liaison psychiatrist, but they have to learn LI by doing.

From our point of view, this small body of clinician-centered research can contribute to fill LI interventions with contents that are meaningful for clinicians, shape the pedagogical methods accordingly, and adapt LI interventions to the evolution of medicine and the changing profession of clinicians. Once these objectives are achieved, formal training of future liaison psychiatrists should be considered.

To illustrate how LI can be improved and effectively evolve by using new intervention approaches, we discuss the example of the PENbank (Professional Experience Narrative bank) [20].

The PENbank, developed as part of a Spark grant from the Swiss National Science Foundation (CRSK-3_190887/1, 2020–2021 https://p3.snf.ch/project-190887) with the aim to collect physicians’ narratives about their lived experiences in the hospital, serves as an observatory providing a voice and visibility to physicians’ experiences and feedback to hospital management authorities as well as providing a data resource for researchers.

The PENbank is a website [21] allowing physicians of the Centre Hospitalier Universitaire Vaudois (CHUV) and Unisanté to securely and anonymously send oral, written, or visual narratives recounting their experiences. Narratives are stocked in a secure repository. The collected narratives are regularly visualized. For example, the PENbank has a monthly column in the CHUV’s electronic newsletter, which is received every Friday by about 13,000 people, and is featured in the Instagram stories of the CHUV. Furthermore, three winning narratives from the ninety-nine-word stories challenge organized for the official launching of the PENbank were publicly displayed on posters throughout the hospital site. Enhancing the understanding of the challenges physicians face in practicing medicine by visualizing their experiences hopefully contributes to a more realistic and adequate relationship between physicians, other hospital collaborators, patients, their relatives and significant others, and the public. For example, an analysis of narratives collected during the first wave of the Covid-19 pandemic identified the psychological challenges front line physicians had to face and how they adapted or maladapted to the situation. These results were presented to the senior staff members of the Internal Medicine Division to provide them with clues to identify physicians who might be at risk to be overwhelmed by the task [22].

The PENbank, as an institutional intervention, exemplifies both how to develop and structure LI when resources are limited, as well as how to create new ways of reaching out to clinicians. The PENbank can be considered as a LI intervention on different levels. On an individual level (micro-liaison), it allows clinicians to recount their lived experiences, which is a means to reflect on their daily work life, to express what affects them, and to give a voice to these professionals who are constantly subjected to expectations, institutional prescriptions, and projections. On a collective level (macro-liaison), the PENbank material can be used and has been used to raise awareness among senior staff members of clinical services on how physicians face challenges. On an institutional level (meso-liaison), making physicians’ narratives visible has provoked many positive reactions among physicians and health care professionals who were hereby enabled to access or, ultimately, identify with experiences of colleagues. The next step will be to bring physicians’ narratives into the city and the society (meta-liaison) with the aim to reach the population and engage in dialogue between physicians, PL researchers and clinicians, and the public.

This example illustrates how LI can evolve by adopting a systemic perspective and develop supportive interventions, which address and eventually modify institutional and social determinants of clinicians’ experiences.