The Art Of The Psychiatric Refe

The Art Of The Psychiatric Refe

The Art of the Psychiatric Referral

Floyd P. Garrett, M.D.

The psychiatric referral puts the physician-patient relationship to the test.

Unfortunately for many patients, this is one test a lot of physicians would prefer not to run -and often with good reason. Yet the consequences of failure to refer for needed mental health care can be every bit as serious as failure to refer for any other medical condition. If the underlying process is a grave one, necessary treatment will be delayed or missed, sometimes with tragic results.

Of course, the psychiatric or mental health referral is simply not the same as a surgical referral. To pretend otherwise is useless. Instead, we should examine some of the commonly encountered difficulties in this special situation:

1. Physician skepticism of the value of the referral. It is difficult to feel good about advising a course of action to a patient if you yourself doubt its real worth; it is impossible to be persuasive in such a situation. Patients will sense the physician’s own reservations, no matter how strictly they are suppressed.
2. “It’s all in your head.” Since most patients consult their physicians for presumptive physical complaints, redefining the problem to a functional one arouses feelings of shame, weakness, and rage in the patient. The cultural stigma of mental health problems is diminishing but it is far from gone. Yet it is the task of the physician to pinpoint the true nature of the complaints and to communicate effectively a recommended course of action to the patient.

Many medical procedures are painful. It is not pain or fear alone that prevent or complicate psychiatric referral but problems of communication and a lack of mutually shared assumptions.

3. “I don’t want to be bothered with you any more. Go away!”

The fantasy (and sometimes the reality) of abandonment by the trusted and respected physician can be very hurtful and frightening to a patient.

4. “I don’t believe you. You are not telling the truth.” More

than a few patients react to the suggestion that their physical symptoms have a functional component as though they were being accused of malingering or consciously fabricating symptoms.

5. The patient is not convinced that adequate time,

attention, or tests have been applied to their complaint. Their fear is that an organic condition is being missed.

6. “You’re crazy.” For many people, seeing a psychiatrist,

or, indeed, any mental health professional means that they are crazy, pure and simple.

7. A general lack of trust in the referring physician. When

the patient is new or when no relationship of trust exists, any medical advice will be greeted with skepticism. The more frightening or unpleasant the advice, whether it is for coronary angioplasty or a psychiatric referral, the greater will be the patient’s misgivings and tendency to resort to paranoid defenses or simple denial. These responses, like most maladaptive responses in all dimensions of the patient-physician relationship, are grounded in fear.

8. The patient has a mental problem and does not respond

rationally to information or good advice. Strangely enough, this self-evident probability is often overlooked. Failure to keep the obvious in mind can cause the treating physician needless frustration.

9. “I can handle my problems myself.” The patient is

skeptical or disdainful of the value of “just talking.” They are ashamed to think that there is anything about their mental life and coping that they are not perfectly capable of dealing with unassisted. This peculiar belief is extremely widespread in contemporary American culture, usually as an unexamined assumption.

10. “What will people think?” Family and friends will usually

want to know “what the doctor said”. This creates obvious difficulties for the patient if the news is distressing and embarrassing.

These and other formidable challenges and risks often restrain the physician from recommending mental health care even when it is clearly indicated. This hesitancy is not entirely a bad thing, for a miscarried recommendation can cause the patient to sever the relationship with their physician and to retreat behind a stout wall of defenses.

The art of the psychiatric referral includes the following:

1. A satisfactory physician-patient relationship. This usually is correlated to some extent with duration, but there are many exceptions. Relationships may deteriorate as well as improve over time. Occasionally adequate confidence and trust are established at the first visit. It is usually unwise to attempt a psychiatric referral at the first visit unless special circumstances apply.
2. Communication. Many misconceptions are easily corrected by careful communication. Communication does not mean that the physician talks and the patient listens. You must be alert for subtle and not-so-subtle signs of emotional distress or confusion in the patient, and prepared to adjust course accordingly (e.g., “You seem to be uneasy about this. What’s going on?”) Emotional perturbation distorts and destroys communication. A highly anxious or angry patient may be listening more to what they think you are saying than what you are actually saying. This can and does lead to massive confusion (“that doctor said I was crazy”). Watch the patient for cues about how your words and manner are being received.
3. Important information should always be imparted with both the physician and the patient seated, preferably in the privacy of the physician’s personal office. Next to the laying on of hands, sitting down with the patient is perhaps the most important symbolic act the physician can perform. Conversely, failure to sit down with the patient, especially when important information or advice is to be discussed, adds to the patient’s feelings of fear, insecurity, and abandonment.
4. Genuine concern for the patient and a desire to be of help. This is obvious. It cannot be simulated. On the other hand, some very caring and dedicated physicians find it difficult to allow their true feelings to show, and may impose an artificial clinical facade which is easily mistaken by the patient for indifference or aloofness. Be natural; be yourself.
5. Do not use complicated words. Do not assume that the patient shares your assumptions about the meaning of simple words or of medical services with which they are often unfamiliar (mental health). For example, virtually all patients, regardless of their intelligence or level of education, believe that “psychosomatic” means unreal or imaginary. Most patients believe that everyone who sees a psychiatrist has grave mental problems or is insane.
6. Maintain continuity of care. This can cut down on feelings of abandonment. (“I’ll drop Dr. Smith a note and brief him on the results of your physical exam and lab work”). Do not tell patients you are going to call the consultant ahead of time unless you plan to do so; they invariably ask the consultant if you have called. While this situation can always be handled diplomatically by the consultant, there is simply no truthful way to repair some of the patient’s disappointment if the expected contact has not been made.
7. Provide adequate reassurance that serious physical disease has been excluded. Ask the patient if they are satisfied if this is the case, if they are worried about any specific illness, or if they feel they need some particular test. It makes no difference at all how confident the physician is that the patient is physically well; if the patient believes they are suffering from an as yet undetected malignant condition, they will not be in a frame of mind to follow through with a mental health referral. Indeed, they are more likely to question your medical competence and to seek another medical opinion. Sometimes it is useful to make a referral for a second opinion when the patient is obviously still worried despite your best efforts at reassurance. (“Well, I can see that even though we have done our best here, you are still pretty worried that we may have missed something. Let’s have you see Dr. Jones for a fresh look and a second opinion and then meet again to decide what to do then.”)
8. Keep it simple and keep it short. Effective communication, as anyone who has ever read a government document will know, does not mean lengthy, detailed, one-way filibustering. Say what you have to say and give the patient time and the invitation to respond. In conflicted situations, the interactive or discussion phase is usually the most important in determining outcome. In the context of physician-patient communication, “discussion” means: the patient talks and you listen, commenting only when necessary. And, of course, “listening” means more than merely hearing. The physician must also appear to be hearing. This means undivided attention.
9. All patients will not follow all advice. We do not expect this in other areas and we should not expect a one-hundred per cent success rate in instant compliance with mental health referrals. Sometimes the patient is simply not prepared to act on the advice when it is given, but may do so later. Consultants often hear such statements as: “Doctor Smith told me I needed to see you a year ago, but I kept putting it off. I should have listened to him then.”

Everything reduces ultimately to trust and confidence in the physician making the recommendation. Patients and relationships vary widely in this respect, as do physicians in their tendency to inspire trust. Regardless of whether the patient agrees with you or follows your advice, as long as they have the feeling that you are doing your best for them and that you really care for their welfare, recommendations for psychiatric consultation seldom will cause significant lasting problems in your relationship with them.