Difficult Psychiatric Consultations: An Integrated Approach

What an odd book this is! Under the deceptively simple label of “consultation,” the authors manage to present a succinct synopsis of numerous psychotherapeutic and psychological theories. Their scope includes brief reviews of psychodynamics (including attachment, intersubjectivity, and mentalization), cognitive and temperament development, family and medical team dynamics, and the role of cultural factors, with additional chapters on ethics and how to do clinical presentations. The stated purpose of this very broad and inclusive overview is to provide consultation liaison psychiatrists and the medical teams with whom they work the missing psychological perspectives that have been lost in the simplistic world of the DSM. In turn, such perspectives can then be usefully applied to resolving challenging impasses that routinely occur in behaviorally complicated medical cases in hospitals, when the psychiatric consultant is called on to help deal with the “difficult” patient.

A consultation liaison psychiatrist has a very brief time to evaluate a patient, the patient’s family and culture, and the issues with the treatment team and then to offer a helpful intervention enabling all parties to move forward in the service of the patient’s medical treatment—no small task! The authors’ major contribution with Difficult Psychiatric Consultations is their presentation of a systematic and comprehensive approach to considering all these factors, organizing them in a way that may shed light on what still needs to be clarified, and then prioritizing a few discrete but potentially powerful interventions that may unblock the impasse and facilitate resumption of treatment. A tabular analysis, used repeatedly with the nine full case vignettes that are presented, helps the user to quickly but systematically conceptualize cases based on the observed strengths and weaknesses in the multiple aforementioned psychological domains and to prioritize interventions accordingly.

As a grateful student in the 1970s of a superb psychodynamic consultation liaison psychiatrist, Milton Viederman at New York Hospital, I immediately recognized the authors’ description of the “life narrative” method and found their description of its utility to have compelling face validity. The examples in this book ring true, and the breadth of skills and perspectives mastered by the authors must surely enhance the care of the fortunate patients they treat. Unfortunately, I fear this rather brief and ambitious book may not succeed in providing the novice with sufficient specifics and details to effectively “fill in” the novel treatment table that is proposed by the authors. It is one thing to succinctly review a wide variety of perspectives but quite another to actually use them effectively, especially in such a compact time frame as a few consultation liaison encounters. The reader will need to look elsewhere for more depth.