Consultation Psychiatry: Psychosomatics orPsychiatry in Medicine?

TRULS-ElRIK MoosTAD, M.D.

These notes are concerned with aspects of theposition and prophile of psychosomatic consultationand liaison services in two different hospitals in Oslo,Norway. Some of my statements may not hold truefor Norway in general, since experiences made insome few other hospitals seem to be happily differentfrom ours, or at least differently interpreted.

I should make clear in the first place that generalpsychiatric and psychotherapeutic services in Norwayare good-i.e. except in the general hospitals, wherethe most necessary consultation work has, so far, beentaken care of by the very youngest and most inexperi­enced doctors in psychiatric training; an arrangementdue to the fact that senior psychiatrists hesitate toget involved in liaison work themselves. This veryunsatisfactory situation has brought about a ratherhostile distance between medicine and psychiatry.

Medicine has moved towards technology andemergency service. On the other side, the trend inpsychiatry has-for the last two decades (at least)­been a move towards psychology and sociology-thatis away from the medical model, away from diagnosisand away from biology!-over to a non-diagnostic,non-evaluating, social- and therapeutic-communityoriented type of activity, which is opposing rather th~utilizing medicine-as an approach to the humanproblems of life and death.

This I believe is one of the main reasons why other­wise well trained psychiatrists after 5 or 6 years ingeneral psychiatric training in the psychiatric clinicsand mental hospitals in Norway, never seem to get anyreal idea at all about psychosomatics and psychiatricliaison work in the general hospitals, i.e. in medicine.

These problems of breaking through the barriers be­tween psychiatry and medicine, and thereby influencingthe somatic doctors' various doings with their patients,made us acknowledge not only the need for conceptualmodels in our own work, but even more the necessityof a lIseful position-Leo in the consultant's relation­ship to the various consumers of his services, andjust as important: the very means of communicatingour information and points of view effectively.

Read at the 10th European Conference for PsychosomaticResearch in Edinburgh 1974.

From University Hospital of Oslo, Oslo, Norway.

138

What had been done previously in this field at theUciversity Hospital, was that Dr. Finn Askevold­from when he took ovcr as senior consultant in 1959,arranged the very important, rather informal, weekly,"clinical conferences" with staff members of thesomatic doctor teams. This was for purposes ofcommunication, although even more for the specificpurpose of training somatic doctors in the basic con­cepts and techniques of psychiatry and psychosoma­tics. These meetings surely still are one of the mostimportant instruments at our disposal in our work.The next mov~ was to embark on a still more cen­trifugal project-namely one of attaching ourselvesto one somatic department and one department staff;thereby going on the wards more systematically, tosee whether this would be useful.

As very many consultants must have experienced,one just cannot easily do such a thing, because hos­pital systems are so rigidly structured. They cannoteasily open up and receive any newcomer as a bene­factor, in the first place. Furthermore, there are thedifficulties of different concepts and technical lang­uage, different styles of work, mutual distrust, andvarious forms of resistances against integration.

On the other hand we certainly were rewarded, soto speak: mainly, I believe, because we were able toprovide practical advice-here and there-as tomedication and the treatment of acute psychotic re­actions and so-called "difficult" patients. These serv­ices were provided much better on the wards, thanwhen we sat in our offices, receiving selected patientson referral. We also discovered possible strategies tocover a wider field of problems in giving an "on-the­job" advice to the somatic doctors' management ofpatients' psychiatric problems, without taking overthe care of his patient.

So we may say that a process of integration hadstarted-to place the psychiatric consultant withinthe medical team, rather than leaving him to his owndevices, remote from the medical ward. One shouldnote that the University Hospital in Oslo is not typicalof the general Norwegian hospital. Until recent yearsthe former has functioned-and surely still does, insome ways-as a kind of highest medical level insti­tution, receiving especially selected patients from thewhole country, perhaps 1600 km. away, to give serv­ice in cases considered not to be dealt with satisfac-

Volume XVI

CONSULTATION PSYCHIATRY-MOGSTAD

torily at a lower, more local level of service. Thusthis supra-regional hospital has gradually developedinto a monster of some 30 different departments andinstitutes, giving housing to many sub-specialities inorder to cover the current needs for service, researchand training on all levels: except in psychologicalmedicine, psychiatry and psychosomatics!

For 10 years the small section for psychosomaticmedicine at the University Hospital had only twopsychiatrists and one psychologist, working full time.From 1973 the staff consists of three full time psychi­atrists, one full time psychologist, and one or two part­time psychologists, mostly engaged for research pur­poses. We have several times tried to estimate thepresumed need for psychiatric and psychosomatic serv­ices in the hospital, and have, to no one's surprise,found that "need" in these terms depends, not onpatient population, but on the attitude of the somaticdoctors towards psychology and psychiatry. It alsodepended on the level of integration of the consultants,i.e. the possibility of a psychosomatic explanation andtreatment for the patient's difficulties which had notbeen successfully met by the strict organicists.

The Section for Psychosomatic Medicine at theUniversity Hospital never managed to cover the needfor its services, which is not surprising, since an in­patient population of 20,000 a year will give plentyof work to more than two or three psychiatrists.

However, the possibilities of concentrating on or­thodox psychosomatic problems have been good, be­cause so many problem cases are to be found in thefield of complex psycho- vegetative reactions and dis­turbances. They are a common type of problem pa­tient at this selected, fairly advanced level of medicalcare. In addition, patients are received because acombined medical evaluation, Le. combined physicaland psychiatric is wanted and most essential.

The feeling that we might be exclusive and a bitout of contact with general service problems, made uslook for a possibility to study psychiatry in local gen­eral hospitals, giving every day, more or less emergencyservices to a part of the town of Oslo. We were luckyto find that the third largest hospital in Norway, whichis an emergency municipal hospital in Oslo, badlyneeded a psychiatrist willing to engage in the psychiatricproblems of the two departments for internal medicineat that hospital. This opened up for a 16 months'clinical study of liaison and consultation psychiatricneeds and possibilities at Aker Hospital in Oslo.

Contrary to the University Hospital this is an em­ergency hospital-giving service mostly to the every­day needs of an area of a town of ~ million in­habitants. The two departments for internal medicinewere to have only one psychiatric consultant (myself).I had no other commitment than this: to do the job

July/August/September, 1975

as best I could, full time and a little bit more. I movedinto my office that was close to the medical wards,entered the staff meetings regularly, went along withthe ward rounds, joined the staff for lunch as well asthe doctors' offices for chats and discussions,-andvery soon found myself doing first line, emergencypsychosomatics, in the very broadest sense of the word.

The differences from the University Hospital weremany and striking: I was no longer a sheltered, remoteand mystical person. I was there!-on the very prem­ises of emergency medicine: every minute challengedwith suicidology, medication, administrative problems,diflerental diagnoses and so on. In all it proved to bea turmoil of crisis, stimulating, very laborious and al­ways challenging. This most certainly was a differentsituation from the rather calm and comparatively easygoing style of work at the University Hospital.

Without providing tables, I might illustrate the dif­ferences between the two hospitals by mentioning that,while the University Hospital group of referred pa­tients contained nearly 50% psychosomatics proper,the Municipal Hospital group had some 10%. Andwhile the University Hospital group had no intoxica­tions at all-the Municipal Hospital group containedsome 30%-mostly manipulative suicide.

While emphasis in one situation may well be on psy­chosomatic problems proper, yet in another situa­tion tasks of crisis intervention and general psychiatricservices are the problems.

Liaison psychiatry has to deal with a wide fieldof different medical problems-in a variety of differentsituations-and most often in complex transdisci­plinary professional groups. The consultant's skillsand techniques of communication are challenged inparticular. The ability to define physical reactions interms of understable psycho-physio-dynamics that canbe made relevant to the patient, the doctor and thevarious therapeutic institutions outside hospital iscrucial. Thus the consultant's job becomes one of anactive interpreting negotiator, who readily speaks thelanguage needed, to make heard his points of view.

Secondly-the term "psychosomatic" should be re­defined in concepts of a clinical and practicable rs::­chophysiology, that opens up to whatever psycholog­ical implications physical ailments and illnesses mighthave. Thirdly-that consultation and liaison servicesin general hospitals-with the consultant fairly closely,though not too rigidly, tied to the somatic teams on abasis of every day work, offers posibilities for combinedin- and out-patient services and clinical research.

Finally I might suggest the need that liaison andconsultation psychiatry concentrate more on strategiesof teaching-i.e. the consultant's teaching in the gen­eral hospital-within the framework of an "on-the­job" service oriented training set-up.

139