Difficult Psychiatric Consultations: An Integrated Approach PDF
Preview Difficult Psychiatric Consultations: An Integrated Approach
Sergio V. Delgado Jeff rey R. Strawn Diffi cult Psychiatric Consultations An Integrated Approach 123 Difficult Psychiatric Consultations . Sergio V. Delgado (cid:129) Jeffrey R. Strawn Difficult Psychiatric Consultations An Integrated Approach SergioV.Delgado JeffreyR.Strawn DepartmentofPsychiatry DepartmentofPsychiatry andChildPsychiatry andBehavioralNeuroscience CincinnatiChildren’sHospital UniversityofCincinnati MedicalCenter Cincinnati Cincinnati Ohio,USA Ohio,USA ISBN978-3-642-39551-2 ISBN978-3-642-39552-9(eBook) DOI10.1007/978-3-642-39552-9 SpringerHeidelbergNewYorkDordrechtLondon LibraryofCongressControlNumber:2013953921 #Springer-VerlagBerlinHeidelberg2014 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpartof the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,broadcasting,reproductiononmicrofilmsorinanyotherphysicalway,andtransmissionor informationstorageandretrieval,electronicadaptation,computersoftware,orbysimilarordissimilar methodologynowknownorhereafterdeveloped.Exemptedfromthislegalreservationarebriefexcerpts inconnectionwithreviewsorscholarlyanalysisormaterialsuppliedspecificallyforthepurposeofbeing enteredandexecutedonacomputersystem,forexclusiveusebythepurchaserofthework.Duplication ofthispublicationorpartsthereofispermittedonlyundertheprovisionsoftheCopyrightLawofthe Publisher’s location, in its current version, and permission for use must always be obtained from Springer.PermissionsforusemaybeobtainedthroughRightsLinkattheCopyrightClearanceCenter. ViolationsareliabletoprosecutionundertherespectiveCopyrightLaw. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publicationdoesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesareexempt fromtherelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. While the advice and information in this book are believed to be true and accurate at the date of publication,neithertheauthorsnortheeditorsnorthepublishercanacceptanylegalresponsibilityfor anyerrorsoromissionsthatmaybemade.Thepublishermakesnowarranty,expressorimplied,with respecttothematerialcontainedherein. Printedonacid-freepaper SpringerispartofSpringerScience+BusinessMedia(www.springer.com) To Michelle Alexandra and Erin. —SVD To Lara Suzanne and my parents. —JRS . Preface Thisbookiswrittenwithseveralaudiencesandseveralaimsinmind.First,weaim toexpandthepsychiatricconsultationliteratureandtopresentaneffective,collab- orative approach to working with the complex or “difficult psychiatric consultations.” Second, we aim to integrate what have been historically seen as competingpsychologicaltheoriesintoausefulandeffectiveapproachtopsychiat- ricconsultationinvolvingpatients,families,andtreatmentteamsthatpresentwith competing agendas. Third, we aim to guide experienced clinicians, psychiatric residents, clinical fellows, as well as clinical psychologists to use a multi- dimensional approach with difficult clinical consultations. Herein, we provide relevantcasesthatallowthereadertobeinthemindofthepsychiatricconsultant and also include tables that allow for a practical approach to review relevant information to be used in tailoring the interventions needed. We are aware that, despite the effectiveness of these psychodynamic and family-based approaches to the patient, ground is rapidly being lost to “DSM-only” focused approaches and morelimitedbiologicandpsychopharmacologicinterventions. Wealsorecognizethat,aswithanyapproach,therewillbeskeptics.Amongthe arguments that may be levied against this strategy is that multiple theoretically diverseapproachescannotbefullyintegrated.However,wewouldarguethatthese seemingly disparate theories are already integrated within our difficult clinical consultations, in that the issues related to family systems, attachment styles, relational processes, and cognition are part and parcel of everyday consultative work. Second, the argument may be made that our approach involves closeness with the patient, the family, and the treatment team and that this closeness could compromise “true objectivity.” Certainly however, we now recognize—based on contributionsfromattachmenttheoryandintersubjectivity—that“trueobjectivity” isarelativemyth.Whatatreatmentteammayviewasanenmeshedfamilyinfact may be functioning in a psychologically and culturally appropriate way which facilitates compliance by the patient. Third, some practitioners may be concerned thatthisapproachwouldbeprohibitivebecauseofthetimeinvolvement.Here,we wouldnotethatindifficultclinicalconsultations,themildincreaseintimeinvolve- mentisjustifiedascaseswithhighfamily,patient,andtreatment-teamconflicttend tohavegreateradverseoutcomes,longerhospitalizations,andagreaterlikelihood of medical–legal sequelae. Thus, we would argue that this approach, while some- whatmoretime-intensive,ismorecost-effective. vii viii Preface Thedecisiontowritethisbookoriginatedinthefallof2011whenmembersof the American Academy of Child and Adolescent Psychiatry Committees on Psy- chotherapy, Family, and Ethics were asked to develop a collaborative program to integratepsychotherapeutic,familysystems,andethicalaspectsof“difficult”cases. Aftersomediscussion,itbecameapparentthattheconsultingpsychiatristworking with“difficult”consultationsinadultswasoftenencumberedbythesesameissues. Wequicklyrealizedthatclinicianshadanurgentneedforapracticalandclinically- relevant approach to integrate these clinical perspectives with regard to psychodynamicthinking,familysystems,andethicalaspectsofthecases. We hope that this book provides the student, in the broader sense of the term, with a clear, relevant, and practical approach to the difficult psychiatric consulta- tion.Ultimately,thisbookwillhaveday-to-dayclinicalrelevancetothepracticing psychiatrist. Herein, we emphasize the value of collaboration in the consultation processanddescribethewaysinwhichawell-aligned,multidisciplinarytreatment teamcanprovideasenseofsafety,compassion,andunderstandingforthepatient and his family. However, we also provide examples of the misaligned treatment teamandstrategiestopreventtreatmentsabotage.Theintimateandcomplexwork withadifficultpsychiatricconsultationisessentialtothepersonalandprofessional growthofapsychiatrist.Thecapacitytotoleratestrongaffectsandintegratevaried perspectives provides a sense of security and comfort to the distressed patient or family by creating what psychoanalyst and pediatrician Donald Winnicot, M.D., termeda“holdingenvironment.”Finally,wehopethattheseasonedclinicianmay beabletousethisbookasapracticalguidetohelphisorhertraineestoembarkon morein-depthdiscussionsofpsychodynamic,familysystems,cultural,andethical aspectsofpatients’illnesses,astheattentiontothesetopicshaswanedoverthelast severaldecades. Cincinnati,OH SergioV.Delgado JeffreyR.Strawn Acknowledgments Wewouldliketoexpressourheartfeltgratitudetoourpatients,whounknowingly contributed to this book in remarkable ways, providing the clinical material and keepingusonourtoeswhenworkingwiththem.Wealsowishtothankourmentors and teachers, who provided the foundation for our appreciation of the multiple theories and complexities that must be considered if we are to understand our patients and their families. Additionally, we are indebted to our students, who helped us appreciate the pressures of trying to “fit in” as one learns about psychodynamicandfamilysystemstheories,andweespeciallythankthosestudents whocourageouslychallengedus(andourtheoreticalapproaches)whenneeded. We want to express our warm thanks to Corinna Schaefer, associate editor, clinicalmedicineforSpringerPublishing.Weweresurprised,honored,andscared to death when she asked if we would write this book. Her steadfast support has provided the energy behind these pages. Importantly, Corinna believed in us and supportedthisprojectinspiteofthemanychangeswemade.Also,wewishtothank Nicola Masonfor her fantasticeditorialassistance,her attentiontodetail, andher abilitytomakecleareroursometimesmuddledsentimentswithhermasterfuluseof thewrittenwordandgrammaticalprowess. We are grateful to our fellow AACAP members, Mary Cook, M.D., Basil Bernstein, M.D., and Heather Adams, M.D., for their guidance and thoughtful comments as we prepared our presentation “What’s your angle? Bringing clarity to complex clinical presentations, integrating psychodynamic, family systems, medico-legal, and ethical lenses,” which provided the inspiration for this work. Wearedeeplyindebtedtothosewhoreadourmanuscriptandwerekindenoughto be “not so kind” in pointing out what we had missed or did not get right. Kirby Pope,M.D.,ourclosefriendwhoreadthefirstdraftofthismanuscript,wasgentle insharingcommentsthathelpedshapetheflowofthecontent,aswasourcolleague Elizabeth Burstein, M.S.W., who also read selected chapters and was not shy in providingconstructivecriticism.We alsoexpress ourgratitude toMichael Sorter, M.D.,whokindlysupportedourworkonthisproject.Toall,wesaythankyou! IamindebtedtoErin,mytruebetterhalf,whoprovidedthewarmththatkeptme from giving up, provided the useful “unedited” critiques needed to improve the readabilityofthisbook,andwasinstrumentalinhelpingtheauthorskeeptheireyes on the project as there were plenty of times we would have preferred to quit. Finally, I want to thank my friend and co-author Jeff, who tolerated my Hispanic ix
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