Facteurs sociodémographiques et construction de l’alliance thérapeutique aux urgences psychiatriques

Therapeutic alliance is a clinical concept considering the non-specific aspects and the common factors of the therapeutic relationship. In emergency, the therapeutic alliance seems to be one of the essential elements of crisis management, as the first stage of therapeutic framework. The aim of this study was to investigate the influence of sociodemographic factors in the constitution of the therapeutic alliance between patient and psychiatrist at the emergency psychiatric unit of a university general hospital. The study concerned 140 patients, requiring during workdays an urgent psychiatric intervention. Data were collected during four months. The exclusion criteria were the acute psychotic disorders, mania, delirium and dementia, situations interfering with the understanding of the study and with the patients' informed consent. The level of therapeutic alliance was estimated by means of the French translated questionnaire of “Helping Alliance” of Luborsky, completed separately by psychiatrists and patients. The results show a relatively limited influence of socio-demographic factors on the therapeutic alliance. The patients' age is a factor influencing alliance only for the psychiatrists, with a better alliance for the less than 25-year-old patients and more than 45 years. The patients with a lower instruction level have a better type I alliance. The scores of alliance with the French-speaking psychiatrists do not differ for the immigrant patients and the native French-speaking patients. Further than the epidemiological interest, this preliminary study suggests the interest of the consideration of the emergency time, in the construction of the therapeutic alliance.     

The therapeutic alliance in the treatment of personality disorders

Because personality disorders are associated with significant impairment in interpersonal relationships, special issues and problems arise in the formation of a therapeutic alliance in the treatment of patients with these disorders. In particular, patients with narcissistic, borderline, and paranoid personality traits are likely to have troubled interpersonal attitudes and behaviors that will complicate the patient's engagement with the therapist. While a strong positive therapeutic alliance is predictive of more successful treatment outcomes, strains and ruptures in the alliance may lead to premature termination of treatment. Therefore, clinicians need to consider the patient's characteristic way of relating in order to select appropriate interventions to effectively retain and involve the patient in treatment. Research has shown not only the importance of building an alliance but also that this alliance is vital in the earliest phase of treatment. The author first reviews several definitions of the therapeutic alliance with reference to how they apply to the treatment of patients with personality disorders. Issues relevant to forming a therapeutic alliance with patients with personality disorders are then discussed in terms of the three DSM-IV-TR personality disorder clusters. However, the author notes that these categories do not adequately capture the complexity of character pathology and that clinicians also need to consider which aspects of a patient's personality pathology are dominant at the moment in considering salient elements of the therapeutic alliance. In dealing with Cluster A personality disorders (schizotypal, schizoid, and paranoid personality disorders), what is most relevant for alliance building is the profound impairment in interpersonal relationships. The Cluster B "dramatic" personality disorders (antisocial, borderline, histrionic, and narcissistic) are all associated with pushing the limits. Consequently, clinicians need to exercise great care to avoid crossing inappropriate lines in a quest to build an alliance with patients with one of these disorders. Patients with Cluster C "anxious/fearful" personality disorders (avoidant, dependent, and obsessive-compulsive personality disorders) are emotionally inhibited and averse to interpersonal conflict. These patients frequently feel guilty and internalize blame for situations even when there is none, a tendency that may facilitate alliance building because the patients are willing to take some responsibility for their dilemma and may engage somewhat more readily with the therapist to sort it out, compared with patients with more severe Cluster A or B diagnoses. The author then reviews considerations relevant to treatment alliance that arise in the different treatment approaches that may be used with patients with personality disorders, including psychodynamic psychotherapy/psychoanalysis, cognitive-behavioral therapies, and psychopharmacology. The author also discusses issues, especially splitting, that arise in the alliance when patients with personality disorders are treated in inpatient psychiatric hospital settings.     

The Psychiatric Consultation Checklist: a structured form to improve the clarity of psychiatric consultation requests

Medical specialty consultation is requested to obtain expert review of a patient's condition. The specialist usually receives a case synopsis with pertinent positives and negatives and a specific request for assistance. In contrast, the psychiatrist often gets a statement of diagnostic speculation (e.g., "depressed") with a request to "please evaluate." Classically, the psychiatric consultant begins with open-ended empathic questioning in an attempt to redefine the written consultation question. However, given the difficulty consultees have in forming questions, and increasing time limitations, a more structured approach to obtaining data might assist both the consultee (M.D. requesting assistance) and the consultant (psychiatrist). The Psychiatric Consultation Checklist (PCC) was devised to function as a paper "expert" questioning system to provide such assistance. In a pilot study, 10 administrations of the PCC took an average of 3.6 minutes. In comparison to consultations using standard forms, more data were supplied in several categories when the PCC was used, particularly regarding patient stressors, patient behaviors of concern, and consultee speculation on psychiatric diagnostic formulation. The PCC may be used in consultation research, for assessment and education of physicians in training (regarding psychiatric issues in the medical/surgical setting), and for general clinical consultation purposes.     

Transference and countertransference implications of psychotherapy conducted in a foreign language.

Psychotherapy possesses distinct characteristics when it is conducted in the patient's native language if this language is not also the therapist's mother tongue, a fairly common situation with immigrant patients. The choice of a native therapist, who speaks the foreign patient's mother tongue but lacks perfect command of that language, involves some specific implications, including conflicts around issues of control, regression, and separation-individuation. The author presents several clinical vignettes to demonstrate these conflicts as they are manifested in the therapeutic encounter, especially in various transferential and countertransferential phenomena. He suggests that the therapist-patient relationship in such cases has significant positive therapeutic implications that can facilitate rather than complicate treatment.     

Psychiatric Eclecticism: a cognitive view

Pluralism is necessary in psychiatry to compensate for the errors and biases characteristic of the equipment we use to appraise clinical "reality"--our own perceptual-cognitive apparatus. Our attention to clinical situations is skewed: we notice "data" consistent with past assumptions and formulations, and consequently, those views are reinforced by our perceptions. The eclectic posture involves approaching each clinical situation from multiple theoretical perspectives and settling on a perspective that most closely agrees with the patient's needs and wishes without sacrificing the best information available to the psychiatrist. Such eclecticism defines the psychiatrist's role as that of a broad-based scholar who can apply what he knows to the clinical situation. The author discusses the implications for clinical practice and psychiatric education.     

The place of psychodynamic psychiatry in consultation-liaison psychiatry with special emphasis on countertransference

Psychodynamic theory can be applied to all aspects of consultation-liaison work. There are various psychodynamic treatment approaches that can have a powerful meaning to the patient. This can include understanding the patient's life trajectory through the elicitation of a life narrative, understanding defense mechanisms, and utilizing the patient's fantasies about illness. Patients who are physically ill regress and want to be understood. When this is achieved through a psychodynamic approach, the patient will be more likely to accept a referral for psychiatric follow-up when it is indicated. The consultation-liaison psychiatrist will also encounter transference and countertransference manifestations. Of particular usefulness can be derivatives of classical countertransference, which can be seen as reactions and identifications by the treating psychiatrist or the medical team to the patient that may interfere with effective care. "Countertransference Rounds" is a technique for examining such manifestations during the C-L team's discussion of patients.     

Perceived treatment difficulty and therapeutic alliance on an adolescent psychiatric hospital unit

On an 8-bed adolescent psychiatric unit, 69 patients were rated over the course of more than one year [corrected]. A set of rating scales was used to determine the relationships of treatment and therapeutic alliance difficulties with staff ratings of patient qualities, family issues, and treatment outcome. Findings underscore the clinical relevance of treatment difficulty and therapeutic alliance in conceptualizing the therapeutic action of the hospital treatment.     

Disorders of the gastrointestinal tract in children: consultation-liaison experience

Disorders of the gastrointestinal tract are common in children. Fortunately, many are short-lived, related to infection, food intolerance, or specific etiology. Those that persist or recur require greater attention on the part of the physician and can require psychiatric consultation. The frequency of consultation will depend in large part on the psychosocial sophistication and philosophy of care of the referring physician. When consulted, the child psychiatrist can complement the medical care by examination in greater detail of the psychosocial environment of the child, the family, and by psychiatric evaluation of the child. Formulation of these factors may then point the way to more helpful management of the child and treatment. The most serious problems, such as regional ileitis and ulcerative colitis, require not only collaboration of pediatricians and child psychiatrist, but surgeons as well if patients are to receive optimum care.     

Training psychiatric staff to treat a multicultural patient population

Cultural and linguistic barriers have long been problems in establishing an effective therapeutic alliance between patients and therapists from different cultural, ethnic, and racial backgrounds. The current emphasis on cultural psychiatry has stimulated the inclusion of culturally relevant material in the curricula of American psychiatric residency programs, such as the program at Howard University Hospital in Washington, D.C. After a preliminary study of foreign patients treated on the psychiatry service, the department of psychiatry established a program of seminars and didactic sessions intended to familiarize staff and trainees with cultural patterns of the largest groups of foreign students attending the university. The department also participated in a transcultural fellowship program for medical students sponsored by the American Psychiatric Association and the National Institute of Mental Health. After describing the programs, the authors briefly discuss such culturally related issues as foreign patients' return to their original language when they develop psychiatric illnesses.     

The role of the psychiatrist in organ transplantation

The psychiatrist has multiple roles on the transplant team, beginning with the transplantation psychiatry consultation (TPC). It addresses such issues as risks of exacerbation or recurrence of a psychiatric illness, pharmacokinetic and pharmacodynamic considerations due to organ failure, potential drug interactions involving psychotropic and immunosuppressant medications, adequacy of support system, history of medical compliance, emotional and cognitive preparedness for transplantation, mental status findings supplemented by standardized cognitive testing and psychosocial rating instruments, and decision-making capacity. The consultation concludes with an overall assessment of the patient's psychosocial strengths and limitations, and recommended interventions to optimize his or her candidacy for transplantation. The consultation findings aid the psychiatrist and the transplant team in striving for fairness and the ideal of "neutrality" in an effort to serve the needs of the patient, other transplant candidates, and society with regard to optimal organ stewardship.     

Teaching psychiatry to medical students on a consultation service

Medical students experience psychiatric consultation as part of their undergraduate psychiatric clerkship experience. This allows further identification of the medical student with the psychiatrist in management of psychiatric problems in patient who are primarily non-psychiatric. Reaction has tended to be favourable from the medical students without a great loss of speed or efficiency in terms of the service committment.     

Beyond the chief complaint

Key to the psychiatric evaluation is opening the narrative of the life events and emotional states associated with the emergence of the presenting symptoms. This is fundamental to establishing a therapeutic alliance and laying a foundation for the psychotherapeutic part of the treatment plan. Three composite case examples illustrate common patterns of such discovery in a psychotic illness, panic disorder, and depression.     

"Big MAC": the role of consultation liaison psychiatry in hospital medical advisory committees

OBJECTIVES: The aim of this paper is to describe the participation of a consultation-liaison (CL) psychiatrist within a hospital medical advisory committee (MAC) and examine how this may generally contribute to improved patient care as well as assist in the development of governance within the hospital. CONCLUSIONS: Psychiatrists have a role in a MAC in enhancing the recognition of psychiatric care issues within the hospital, educating other members of the committee with respect to improved recognition of mental illness affecting hospital inpatients and enhanced care of patients requiring substitute decision-making. The psychiatrist also has a role in advising the committee on psychosocial issues generally affecting the hospital service as well as informing on psychological issues that impact on hospital staff performance. To an extent, CL psychiatry also encompasses issues involving all the other medical craft groups in hospitals, offering the opportunity for a "global" perspective that may be expressed through participation in a MAC.     

Pharmaceutical formulations and adherence to pharmacological treatment in psychiatry: the example of oral disintegrating tablet of olanzapine

Adherence to treatment in psychiatric as in other chronic or recurrent conditions, is often suboptimal. A high proportion of relapses is due to non-adherence to prescribed treatment. Adherence to treatment is a potent predictor of effectiveness, both in clinical trials and cohort studies, therefore is a very relevant area where any improving tool is looked forward. Orally Disintegrating Tablets (ODT) were developed with the aim to improve patient's compliance due to their fast oral absorption. They are particularly useful in psychiatric patients who often simulate drug assumption or experience difficulties in taking pills. ODT formulations have been developed for many antypsychotics including olanzapine. The ODT formulations of olanzapine show to be significantly different one from the other in the dissolution time, thus having a potential impact on compliance. In this review, the results of different studies consistently highlight the positive risk/benefit profile, the contribution to patient's compliance and their preference while using ODT formulation of olanzapine produced throughout the ZYDIS technology (Velotab). Moreover, the differences between olanzapine ODT (Velotab) and the standard formulation of olanzapine and other antipsychotics are described focusing on in efficacy, safety, patient acceptance and health economic impact. The ODT formulation of olanzapine (Velotab) seems to ameliorate patient's adherence thus improving psychiatrist/caregiver/patient alliance.     

Pain in the neck, face, and head. Role of the consultation-liaison psychiatrist

The special nature of pain in the face, head, and neck is not emphasized in the psychiatric literature on chronic pain. Although chronic pain of all types and locations share many features the psychological and symbolic significance of the head in the development of self-esteem, body image, and interpersonal relationships often confers special characteristics of pain on this area. As psychiatric consultation is not likely to be requested for patients with head, face, and neck pain in the absence of blatant "psychiatric" problems, it behooves the psychiatrist to exercise his liaison functions to enhance patient care in the inpatient setting and to help physicians recognize the utility of early psychiatric assessment on an outpatient basis with patients not yet requiring hospitalization. A collegial relationship with internists, dentists, neurologists, and surgeons facilitates the psychiatrist's role as a "team participant," often more effective in providing brief diagnostic, therapeutic, and management recommendations for patients who are usually not psychologically-minded and reluctant to pursue ongoing psychiatric treatment. However, the consultation-liaison psychiatrist can play an important role in expanding his colleagues' awareness of the multiple meanings of pain and the accompanying illness behavior, provide pedagogic help in the interviewing or history-taking process, offer suggestions about psychopharmacologic and other drug treatment, and serve as a resource for appropriate referral to sources of a variety of chronic pain treatments, including biofeedback, acupuncture, and family consultation. To fulfill both his consultative and liaison functions, it is incumbent upon the psychiatrist to be knowledgeable as well about nonpsychiatric aspects of pain of the head, face, and neck. We must acknowledge also how much we yet do not know: for example, why the psyche "chooses" a locus of pain in the body; how an external (or internal) stimulus is converted via cognitive, neuroendocrine, enzymatic, and other pathways to a somatic representation; the biochemistry of pain reduction by naturally occurring and synthetic drugs; and what characteristics distinguish the continuously creative individual who sustains persistent pain with barely an utterance from another who may "cave in" to seemingly trivial distress that results in total invalidism.     

Psychiatric consultation on an otolaryngology liaison service

Otolaryngology patients (especially those with tracheostomies) present a significant challenge to psychiatrists from both a diagnostic and therapeutic standpoint. To date, no study has been made of psychiatric disorders among this important group of patients. At the Mount Sinai Medical Center, a liaison psychiatrist has been involved with a specialized otolaryngology cluster unit since 1979. Using a 384-item computerized database protocol developed at Mount Sinai, data on 139 otolaryngology patients were recorded and compared with 1662 "Other" inpatient psychiatric consultations on the medical and surgical services during 1980-1987. The otolaryngology patients as a group were more likely to be male (p = 0.011), married (p = 0.001) and employed (p less than 0.001). Cancer was the most common medical disorder, and the average level of stress as reported on DSM-III's Axis IV (5.1, severe) was significantly greater (p less than 0.0001) than that for the "Other." The most common psychiatric response was adjustment disorder (36%). The length of stay of those ENT patients seen in psychiatric consultation was 26.4 days, in contrast to 11.1 days for all ENT patients. However, the length of stay of those patients on ENT receiving a psychiatric consultation was not different from the "Other" psychiatric consultation cohort (26.3 days). Despite the higher level of stress, the incidence of significant psychiatric morbidity was lower for the ENT cohort. The primary effect of the liaison psychiatrist was to lower the threshold for case identification that enhanced the referral rate on the ENT unit.