From Consultation–Liaison Psychiatry to Integrated Care for Multiple and Complex Needs

Abstract

The aim of the present study was to review the ways in which contemporary medicine addresses physical/psychiatric multimorbidity, to review the underlying concepts and methodologies used, and to propose a novel approach that may help consultation–liaison psychiatry (CLP) position itself better in the health-care field. A Medline search of the terms ‘consultation-liaison psychiatry’, ‘integrated care’, ‘quality assurance’ and ‘qualitative methodology’, was complemented by study of the literature on complexity theory and by discussions with colleagues in both the health science and sociology fields. There is a growing realization that presentation with multimorbidity of both physical and psychiatric disorders is the norm. Other health-care disciplines have responded quickly to meeting the multiple and complex needs of such patients, attracting funding to an extent that CLP has been unable to achieve. Uncritical application, however, of integrated care technology based on evidence from randomized controlled trials has produced disappointing results. There is a growing realization that such quantitative methods need to be complemented by in-depth exploration using non-traditional methods including qualitative ones, and drawing on complexity theory. The Cochrane Collaboration is exploring this. As CLP and other medical and health-care disciplines face the challenge of patients with multimorbidity, they need to find acceptable answers to the question of what works for whom in what context for patients with multiple and complex needs. CLP can contribute its rich experience in the qualitative approaches that will be needed in research addressing this question, but needs help from other disciplines to refine its techniques so that its contributions are considered valid. The context for implementing effective interventions derived from such studies will in future be that of transdisciplinary teams whose mode of working is empirically based and transparent. CLP is well placed by dint of its psychodynamic and systems theory roots to provide leadership in this transformation in health-care delivery.

Keywords

complexity consultation–liaison psychiatry integrated care multimorbidity qualitative methodology

In launching Lancet's mental health campaign, its Editor, Richard Horton, emphasized the importance of mental health for physical health, and chided the World Health Organization (WHO) for not ensuring that this relationship is addressed [1]. This is what consultation–liaison (CL) psychiatrists and their predecessors have contended with throughout the century of their existence, but with only limited acknowledgement [2–5]. Aligning themselves with new allies such as those that Horton represents may help CL psychiatrists to make better use of the wealth of new data available in attempting to resolve their continuing difficulties with justification and funding worldwide, and to survive as a discipline [6–8]. As consultation–liaison psychiatry (CLP) moves its focus to that of patients with the multiple and complex needs of multimorbidity, it needs to review and find new support for its theoretical basis as well [9, 10]. CLP's resistance to reductionism, to objectification of the mind and to the denigration of subjectivity, has estranged it from both psychiatry and medicine, as those disciplines embraced the evidence-based medicine (EBM) movement, with its privileging of quantitative methods such as randomized controlled trials (RCTs) that require such objectification [11]. Hope for the revitalization and acceptance of CLP lies in it exploring new theories of human experience and using research methods that respect complexity; these new developments are increasingly accepted in health-care research [12, 13].

Importance of physical/psychiatric multimorbidity and somatization

The relative lack of success that CLP has had in gaining recognition and support belies the substantial evidence for the importance of the matters in which it specializes; the complex presentations of physical/psychiatric multimorbidity and somatization [7, 8]. We should note here that the term ‘multimorbidity’ is now preferred over ‘comorbidity’ because within each of these domains of disorder, physical and psychiatric, there are large numbers of people with more than two disorders [14, 15].

Prevalence

Physical/psychiatric multimorbidity is so common that it is close to the norm of illness in many communities [8, 16–19]. This is not a transient association; the majority of hospital and primary care patients with physical/psychiatric multimorbidity and somatization still experience significant psychiatric symptomatology over the following 12 months [20–24].

Clinical significance of physical/psychiatric multimorbidity

Physical/psychiatric multimorbidity matters clinically as well, compared with single-disorder presentations. First, it matters in terms of the additional suffering of patients, carers and non-psychiatric staff who have to deal with such patients, often without appropriate support [3]. Second, it seems that it has unique and additive effects on patient functioning and outcome, even in the case of subthreshold psychiatric symptoms [8, 25, 26]. It appears to constitute an independent risk factor for increased risk of all-cause mortality, only minimally explained by suicide [27–30]. In the case of the most intensively studied specific association, that of depression and coronary heart disease, meta-analyses have established that depression is a significant and somewhat independent risk factor for development of the disease [31], and that it presents a twofold increased risk for all-cause mortality, cardiovascular mortality and cardiovascular events when it occurs following myocardial infarction [31–33].

Not surprisingly, physical/psychiatric multimorbidity matters economically as well. A large WHO study found that depression/physical multimorbidity was associated with a 17–46% increase in health-care costs [34]. CL psychiatrists, however, have had difficulty providing evidence for cost benefits of CLP activity [35]. They need to work with health-care economists to utilize evidence from much wider outcome measures; there is much available [36].

For all of these issues, the caveat is made that these questions so posed make the assumption that psychiatric and physical disorders are separate entities, comorbidities. The causality relations, however, are yet to be sorted out [31].

Does treatment help in multimorbidity?

Thus physical/psychiatric multimorbidity and somatization are extremely important clinically, but in the era of economic rationalization, health-care funders require evidence of efficacy of interventions and of the effectiveness of their application in the clinical setting when determining resource allocation. They privilege evidence from RCTs. The results from such trials on efficacy of interventions for physical/psychiatric multimorbidity are so far inconclusive.

For example, three recent, large and expensive studies of pharmacological and psychological interventions for depression following myocardial infarction showed neither positive effects on mortality and cardiac events, nor sustained effects on depression in the primary analyses [37–39]. The difficulties encountered epitomize the problems of applying RCT methodology to such complex problems; underestimation of power requirements, the struggle to obtain ethics approval, the challenge of timing of screening for depression and of defining it, the struggle to ensure a meaningful difference between the intervention and usual care, and the problem of disciplining the therapists. Upshur argues that in matters as complex as this, huge and lengthy RCTs may be needed to provide a robust finding for even the simplest of efficacy questions [12]; these are unlikely to occur.

Is integrated care effective?

The issue of evaluation of integrated care interventions for the complex needs of multimorbidity in general faces similar problems. A systematic review of reviews of integrated care programmes for chronically ill patients of different types using quantitative methodology concluded that there was only limited evidence that they had positive effects on outcome, function, quality of life or costs [40]. Tieman et al. reached similar conclusions in their systematic study of integration, coordination and multidisciplinary approaches in primary care [41]. They found that while it appeared that there were improved outcomes for some patients, there was not an established body of definitive evidence supporting the effectiveness or cost benefits of such approaches.

Efficacy of tools of integrated care

There is only limited evidence from quantitative studies of efficacy for the tools of integrated care; shared care of chronic illness between specialists and general practitioners including that for mental health problems [42], case management for multimorbidity [43], and disease management planning [44]. Although targeting either the provider or the patient is associated with significant improvements in disease control, the effect was large only in the case of financial incentives to patients.

The important next stage, testing of effectiveness in practice, is largely lacking; there are few studies, and CL psychiatrists have found it almost impossible to carry out audits of outcome of their practice. Field studies are vital because RCTs ignore the role of values, in particular of patients’ preferences, and this is considered to be a major factor in disparity between results of trials and outcomes in practice [45]. New methodologies aimed at the better understanding of how complex interventions fare when introduced to health care promise some resolution of this problem [46], as do methodologies for predicting the generalizability of successful introductions [47].

Paradoxical popularity of integrated care

Paradoxically, given the paucity of supporting evidence from the application of quantitative methodology, integrated care and its component tools listed in the previous section have become popular concepts, funded and implemented widely without question by disciplines such as nursing, under rubrics that include ‘dual disability’, ‘patient-centred practice’ and ‘care pathways’. An example is the Australian Government's National Chronic Diseases Strategy, which includes the promotion of integrated care [48]. The Strategy pays general practitioners to write multidisciplinary management plans and promote self-management programmes, both of which lack evidence from RCTs [49, 50].

Other approaches to establishing evidence

CLP should learn from these other disciplines’ successful strategies, which are based on their claim that the EBM movement has avoided the phenomenon of multimorbidity, and that a broader evidence base is required to deal with it [51]. They argue that the results of the application of quantitative methodology in the field of multimorbidity contradict those reported from clinical experience. These include accounts by CL psychiatrists of the miracles that can be achieved when a patient is able to tell his or her story in a way that permits a skilful biopsychosocial formulation to be made and an appropriate intervention applied [52]. CLP needs to review its approach to the issue of evidence. It needs to pay heed to the fact that health-care methodologists are beginning to address ways of using these key, authentic clinical experiences to help operationalize and research appropriately the question of what works for whom in what circumstances [53]. This new wave of research is based on acceptance of the fact that in multimorbidity we are dealing with complexity.

Complexity

‘Complexity’ differs from ‘complicated’, which means simply a combination of elements, albeit in an involved way [54]. The laws of Newtonian physics apply here. We speak of the complications of an operation, or the fact that a patient's cardiovascular pathology is complicated by respiratory pathology. Provided that we know enough about these conditions and the way that they interact, that is, the laws that they follow, such complication can be dealt with efficiently, and does not warrant the label ‘complex’.

‘Complex’ means intricate, not easily analysed or disentangled [54]. The laws of Newtonian physics cannot address its manifestations, that is, the patterns that emerge through the interaction of multiple agents, where behaviour is altered instantly and unpredictably [55]. Such patterns can be perceived but not predicted, because the number of agents and the number of relationships defy categorization or statistical analytic techniques. Patient presentation can become complex in this way when there are major psychological and social forces at work. Patient care is likely to become complex when more than one specialty or discipline is involved, especially when systems issues and unconscious processes are not addressed adequately. Complicated presentations may become complex when they exceed existing knowledge of the laws of biology, and clinicians struggle with their inadequacy. Complexity characterizes multimorbidity and integrated care, and therefore CLP.

Methodologies for studying complexity

Attempts have been to quantify complexity [56]. For complexity in patient presentation, the counting of diseases, as in diagnosis-related groups, is an almost universal tool of health-care funding now, despite its poor predictive value. Including measures of severity has proven remarkably difficult. For complexity of care, measures tried include counting the tests, medications, interventions, specialists involved and the length of stay, but these fail to capture the essence of multiple and complex needs.

Complexity theory

Clearly we need other methods to study complex manifestations. Complexity theory has emerged as the theoretical underpinning for this. It challenges the universal truth of the assumption of order, of rational choice and of free will [55]. It challenges reductionist theory, which holds that one kind of entity, for example a thought, is no more than a structure of other kinds of entities, such as neurons and molecules, and that a complex system can be explained by the behaviour of its parts [57]. Reductionist theory assumes that all entities are material ones, or can be represented materially, and that each can be identified in ways that permit entities to be equated, even if they occupy different levels in a system. Complexity theory by contrast holds that the identity of a human being is multiple and dynamic; the mind cannot be pinned down to the fixed object required for scientific study. It recognizes that any individual under study is under the influence of a vast number of current and past factors, many unremembered and perhaps unknown and therefore not able to be controlled for. Complexity theory has implications for CLP in two respects: first, the collection and analysis of data both in daily practice and in research; and second, in organization of services for patients with multimorbidity. This requires a discussion of alternatives to positivism as the evidential basis for such activity.

Qualitative methodology

In the field of health care and the social sciences generally, there is intense interest in exploring alternatives to positivism in searching for knowledge. A modification of positivism, neopositivism, begins to recognize the importance of subjectivity by allowing for the effects of the observer, but is regarded as failing to allow for the need to interpret the meaning of the interaction [58]. It fails to allow for the reflexive nature of human psychology, that is, the capacity of human beings to be responsive to theories about themselves and to renegotiate meanings [58]. Addressing this deficit, sociology developed qualitative methodology, which draws on the concept of anthropology and social constructivism that in order to understand meaning you must locate it in context [58].

Within the qualitative field there is a division between those who privilege mental processes and those who put more emphasis on social influences: the social constructivists. Social constructivists developed discourse analysis, emphasizing linguistic analysis. Those privileging mental events developed narrative analysis techniques, described by Frosh as ‘the kind of interpretive activity that people engage in all the time in everyday life’ [58].

All forms of qualitative research emphasize the importance of transparency and scrupulous documentation and presentation of data. It is on that basis that qualitative methodology makes its claim for a status alongside quantitative methodology rather than in a subsidiary place in a hierarchical order, with the implication, as in the EBM movement, that it is a lower order activity [58].

Complexity theorists incorporate qualitative methodology. Like CL psychiatrists, they favour narrative techniques, story telling, in eliciting ‘truth that goes beyond evidence’ [12, 59]. There is growing recognition of the need to complement controlled trials with qualitative methodology, as illustrated by establishment of the Cochrane Qualitative Research Methods Group [60]. This is particularly necessary in the exploration of the effectiveness of managing complex presentations [61, 62].

Using qualitative methodology in consultation–liaison psychiatry

CL psychiatrists’ practice is already radically different to that of other specialist medical practitioners, and now even to that of other psychiatrists, although not to that of general practitioners, whose methodology is similar by necessity [63]. CL psychiatrists use Lipowsky's conceptual framework for operation, that of working within medical, surgical and other specialty units rather than providing only consultations; this is the liaison model [5, 64]. In liaising, CLP promotes integration of care rather than integrated care by a single clinician, as George Engel's noble but impossible biopsychosocial model had proposed [52]. Thus CL psychiatrists acknowledge and relish complexity and its inherent uncertainty, and strive to help other doctors to work with it. This approach, consistent with post-modern strategies generally, is not surprising given liaison's psychoanalytic roots and the importance that it places on values and unconscious drives as determinants of behaviour. But, like Engel, CLP failed to operationalize its methods.

The radicality of CL psychiatrists’ practice lies in the extent to which they value narrative accounts of patient presentation and the systems in which they are embedded [52]. They tend to base their interview technique on that described by Engel and Morgan [65], which emphasizes introspection and dialogue in addition to observations: Engel's ‘basic methodologic triad for clinical study and for rendering patient data scientific’ [66]. Engel's model also introduced allowance for what he called the ‘somatopsychic phenomenon’ [67], that is, the way in which bodily processes (somatic processes) can and do affect the mind. Engel argued that the application of his triad and its allowance for both somatopsychic and psychosomatic influences permitted a reunification of biological and psychosocial models of psychiatric illness, and that it facilitated a biopsychosocial formulation, something that the static Axial schema of the DSM and ICD taxonomies did not do. Such formulation is another way in which CL psychiatrists’ practice is radically different.

Other important influences on CL psychiatrists’ diagnostic and formulatory practice were Balint, Mechanic and Pilowsky (reviewed in Smith and Strain [52]). Based on his action research work with general practitioners, Balint described the important concepts of the ‘apostolic function of the doctor’, ‘the doctor as drug’ and ‘illness behaviour’ [68]. The latter concept was elaborated by Mechanic and Volkart, Pilowsky, and others including Engel in a development of Parson's concept of the ‘sick role’ [52, 69, 70]. The argument proposed is that what a patient makes of his or her symptoms is what determines what they do about them, and about any advice given to them. The increasing interest by patients in the basis for doctors’ practices makes this acutely pertinent.

A number of challenges to the biopsychosocial model have been mounted [52]. In essence they claim that although the biopsychosocial model was a useful statement about the domains of enquiry necessary in working with patients, it was not operationalized sufficiently to permit a logical integration of data, and the formulations derived cannot be tested empirically. The challengers call for more specific examination of this global theory rather than uncritical perpetuation of it as a concept. Psychoanalytic psychotherapy faces the same challenge [71]. For both CLP and psychotherapy, valid use of qualitative methodology offers a solution to the challenges.

Use of qualitative methodology in everyday practice

From what has been described here, it is obvious that CL psychiatrists already use qualitative methodology in their routine practice. They, like good general practitioners, elicit stories. CL psychiatrists also tell their stories to others, unlike general practitioners, unless they are in Balint groups or similar reflective practice situations. CLP narratives report the patient's experience of being ill and of reactions to this encountered in others. Patients tell them what it is like to become ill, to become a patient, to enter hospital, to be referred to a psychiatrist when their experience is physical, to be labelled with a disease, to accept treatment, to move into the sick role, and so on. A number of stories are involved; that of the patient as told to the doctor, that of others involved, and that told by the doctor to another in a report or in supervision. In supervision, I always ask to hear about the patient from the moment that the trainee first heard of him or her. This means, for instance, hearing of the colourful vernacularisms used by other doctors in their description of patients with psychiatric symptoms, and the trainee's feelings about that. I ask the trainee to say what he or she thought when they first laid eyes on the patient, and to describe the setting. I invite the trainee and other supervisees if present to free associate to what they are hearing as the story unfolds. I encourage them to write a narrative account that includes these data in addition to their more formal account. This forms the basis for their formulation: ‘Why is this patient ill in this way at this time, and why was he or she referred in this way at this time?’.

In making these experiential notes and writing a formulation, a CL psychiatrist is performing a piece of qualitative research. It is precisely the method used in that form of qualitative research called narrative analysis [72]. Narrative analysis enables exploration of reflexive subjectivity while also respecting the need to address the role of language as the mediator of cultural constructions of the self, factors emphasized by the social constructivist and various post-modern movements. Narrative analysis is in vogue because it provides a way of addressing what is seen as the avoidance of issues of the self in contemporary Western society. The underpinning theoretical perspective is that of phenomenology, with its emphasis on that which matters to the individual, on self-interpretation [72]. In that this can be defined only in relation to other people, the theories of social constructivism are also pertinent.

Interpretive phenomenological analysis (IPA) shares this realist epistemology with narrative analysis. It also is based on phenomenology, as well as on hermeneutics and idiography [73]. It emphasizes the double hermeneutic process. In the case of CLP, this consists of the patient's expression of the meaning of the events, and the doctor's formulation of the meaning of the data collected. IPA emphasizes that the latter may take into account perceived unconscious factors, and encourages free association to the material during the analysis phase in order to facilitate this. In this sense, IPA broadens the concept of cognition, as is beginning to occur elsewhere in that field [74]. The CL psychiatrist is thus also using IPA in the analytic process of formulation.

The problem here is that CL psychiatrists are not explicit about the fact that they are using methodology appropriate to the complexity of the patient presentation, and that to use more reductionist techniques would likely be unethical. The analyses they make, their formulations, are strikingly convincing. If subjected to peer review in supervision or peer group processes, they qualify as transparent, validated accounts of the patient's presentation, and of the interventions that need to be tried. Complexity theory emphasizes that in the presence of complexity, and in order to avoid chaos, it is better to try multiple approaches in order to identify what seems to work best, rather than use reductionist troubleshooting [63]. This of course is the CLP model. It seems to work in collaborative care for depression in primary care, as a recent systematic review shows [75].

Research

Although idiographic in their focus, that is, concerned with the individual, narrative analysis and IPA have the potential to be used nomothetically to establish the degree of generalizability of findings, as aggregation of studies proceeds and techniques for meta-analysis of qualitative data and integration with quantitative data are developed. CLP needs to work with qualitative methodologists to translate their successful individual case work into larger-scale projects.

An example of application of qualitative research to CLP issues is that of Clarke et al.: an examination of the experience of ‘depression’ in hospitalized medically ill patients using an ethnographic analysis [76]. It showed that demoralization, which involves feelings of being unable to cope, helplessness, hopelessness and diminished personal esteem, characterizes much of the depression seen in such patients. This has implications for management. Other examples of application of qualitative research to the field include the experience of medically unexplained illness [77]; the experience of irritable bowel syndrome [78]; readiness to initiate HIV treatment [79]; the experience of antiviral treatment for hepatitis C [80]; the ethics of organ donation [81]; patients’ preferences for integrated care [82]; multiprofessional collaboration in a palliative care team [83]; and general practitioners’ inclination to propose somatic interventions for medically unexplained symptoms [84].

Outcome measures

Reductionist approaches narrow the focus of outcome measures. In CLP work, which is largely with inpatients, one of the few outcomes that can be used routinely is the opinion of the patient and referrer. Qualitative methodology legitimizes this approach. In longer term studies, such methodology can capture the impact of physical/psychiatric comorbidity on carers and other health-care professionals; this is an important component of cost analysis.

Synthesis of data

Research on multimorbidity will require both quantitative and qualitative methods in future. This poses a challenge for synthesis of data, for example to those who write the meta-analyses on which medicine now depends for justification for interventions. Data synthesis is but one of the many challenges of knowledge translation, about which there is a burgeoning literature [85]. The Cochrane Collaboration emphasizes the importance of this new field of ‘knowledge to action’, particularly through its Cochrane Effective Practice and Organization of Care Group [86].

There is growing realization that in prioritizing RCTs, earlier meta-analyses may have failed to retrieve important literature. There is a risk that the measurable pushes out the important. The extent of the concern is epitomized by a remarkable statement made by the Editors of the prestigious United States Institute of Medicine's report on cancer survivorship: ‘Despite the lack of evidence to support the use of survivorship care plans, the committee concluded that some elements of care simply make sense – that is, they have strong face validity and can reasonably be assumed to improve care unless and until evidence accumulates to the contrary’ [13].

The Cochrane Qualitative Methods Group is promoting studies on how best to synthesize quantitative and qualitative data [60, 62]. For example, ‘realist review’ focuses on mechanisms and contexts [87]. It involves active and ongoing interaction with both theorists and practitioners at all points of writing of the review. An example of such synthesis is that of Larun and Malterud on coping experiences in chronic fatigue syndrome [88]. A pertinent example of the application of the principle of incorporating both RCTs and qualitative studies and also using qualitative methodology in the analysis is the proposed Cochrane systematic review of case management [89].

New ways of creating disease guidelines will need to be found to help practitioners manage multimorbidity, especially when application of existing disease-specific guidelines involves pharmacological and other contradictions.

Theory building

The process of theory building used in CLP, that of accumulating clinical examples that seem to fit with an underlying premise, is known as enumerative inductivism [90]. Although used widely in medicine, and indeed in human reasoning in general, it is not a critical practice [90]. Its use rules out interpretation of the data differently, and indeed it may also restrict the type of data collected in a clinical situation. The tool of formulation, so fundamental to the biopsychosocial model, is subject to the same criticism [91]. CL psychiatrists say that the formulation is a hypothesis, to be tested by observing the effects of interventions based on it. The danger, however, is that it becomes regarded as the truth about a patient, particularly when that form of testing is not possible. For all of these reasons, there is a pressing need to find other ways of understanding the phenomena of complex presentations.

In the wider health field, the concept of patient-centred medicine has emerged as a dominant paradigm [92]. Contemporary undergraduate curricula emphasize the concept. The movement sees the biopsychosocial perspective as valuable but insufficient for a full understanding of the patient's experience of illness. It has produced a large number of systematic studies and a number of tools for measuring the concepts involved. An example is the WHO Quality of Life Project [93]. Another is the empirical studies on the measurement of doctor–patient interaction [92]. CLP needs to take note of the new data emerging from such positivist, quantitative studies, but should also be noting developments in methodology that are truer to its hermeneutic underpinning.

Organization of services

The growing acceptance of the importance of multimorbidity and recognition of the way in which it challenges the medical model raises issues for the way in which services to patients with physical/psychiatric multimorbidity are organized and delivered.

Specialty model: is it still appropriate?

In most developed countries the North American model of creating a specialty as a way of organizing and funding services to patients with physical/psychiatric multimorbidity and somatization has been adopted. But only in North America, Australia/New Zealand, Germany and the UK can the specialty of CLP be considered to be fully developed [6]. Such achievements, however, are recent: in the mid 1990s for Australia/New Zealand, later in that decade for the UK and Germany, but not until 2003 for North America, when CLP was accorded subspecialty status within the American Board of Psychiatry and Neurology under the name of psychosomatic medicine [94].

The specialty model is based on the assumption that medicine is a pie that could be sliced into sections, with these sections being subdivided when required. Stevens argues that many of today's specialties and subspecialties are cross-specialties, and that it has become impossible to create a diagram of the entire specialty structure in a way that makes any sense of the whole to an outsider such as a member of the public [95]. There are forces at work, however, that help maintain this flawed model. As Stevens argues, specialty status is a mark of acceptance professionally and politically [95]. The importance of this is illustrated by the way in which achievement of specialty status has revitalized CLP in North America, just as it did in Australia and New Zealand when CLP was given the status of Section within the Royal Australian and New Zealand College of Psychiatrists in the mid 1990s.

Stevens argues that the current specialty model established by a self-serving organization of doctors may be replaced by one that is driven by the marketplace [95]. Duffy et al. describe how this is already happening for internal medicine in the USA: public demand for subspecialists, evidenced by the fees that they can charge, drives training, which in turn pressures the relevant Board to recognize the new subspecialty [96]. Consumer groups play a part in this, and managed care organizations mediate much of this change. In such a system, the role of Boards would be primarily that of arbiter of competence rather than arbiter of professional entity.

Given these factors – the changing nature of professional organization and accreditation, the increasing acceptance of the importance of multimorbidity and its challenges and the involvement of other disciplines in the field – we must ask whether the medical specialty model is still the most appropriate structure for organizing and funding services to patients with physical/psychiatric multimorbidity and somatization.

Eastern European countries in particular are challenging the CLP specialty model. Some there propose that we return to Engel's model of integrated care by individual doctors but, because CLP emerged, to some extent, because of the failure of that model, reinstituting it would require an understanding of why doctors, particularly specialists, find it so difficult to maintain a holistic view of their patients, and of how they can be re-educated. The results of efforts to work with general practitioners in this way show how difficult this can be. Fink and Rosendal attribute this to confusing terminology and unproven theory [97]. Salmon et al. attribute it to the devaluing of their own psychological skills by general practitioners [84]. Balint, however, conceptualized this constriction of focus as being a defence against thinking and the anxiety that it provokes [68]. He gave us a model of investigation, ‘the Balint group’, which has been used widely ever since. By facilitating the group's exploration of their free associations and feelings about the material presented, Balint was able to allow doctors to see that their preoccupation with physical diagnosis and authoritative prescription was often a defensive reaction and did not meet the needs of their patients. Although modern medical education emphasizes the biopsychosocial model, it requires something other than the didactic approach to allow doctors to understand the nature of the doctor–patient relationship. It is as if doctors require ongoing psychotherapy, that is, ongoing working through of defences that have to do with unconscious processes.

One can argue that these defences have become enshrined in specialization and EBM. As EBM changes its sights, acknowledging that RCTs, although necessary, are not sufficient, we are seeing an increasing valuation put on anti-foundationalism movements in the emergence of what is called ‘post-modern medicine’ or ‘post-normal medicine’ [12]. These movements recognize the importance of incorporating a ‘dynamic, emergent, creative and intuitive view of the world’ [63].

An example of the way in which new models are emerging is the New South Wales Health System's trial of a new category of doctor, the ‘hospitalist’ [98]. This doctor, a medical case manager, ‘will focus on coordinating clinical care for patients in a hospital or community setting to ensure that their patient journey is smooth, effective and safe’. This project is being piloted in the context of the Australian Government's National Chronic Diseases Strategy, which includes the promotion of integrated care [48].

Interprofessional collaboration

The most difficult challenge for models of integrated care is the achievement of interprofessional collaboration within what is known as the ‘clinical microsystem’ [99]. In the emergent literature on interprofessional collaboration a consensus is emerging that it is not sufficient only to bring collaborating professionals together; this must be done within a theoretical framework of collaboration [100]. But there are relatively few models, and few of these have been subjected to evaluation of their constructs. Three models that have emerged are (i) interagency collaboration, which often involves written communication only, with no ground rules about the method of collaboration; (ii) multidisciplinary teamwork, which requires only a degree of cooperation and conferring, without a defined philosophy; and (iii) transdisciplinary teams, which are characterized by a degree of a discipline-free, often novel approach that requires transparency of the conceptual basis of their functioning and interventions [100].

Sharing is fundamental to collaborative work. But how do you share professional perspective without prejudicing disciplinary integrity? How can this be achieved when the team of professionals involved will likely differ from patient to patient? These are questions that face not only CL psychiatrists but all integrated care endeavours. They pose a particular challenge to emerging initiatives that tackle the problem of how best to assess and manage those in the community who have extremely complex physical, mental and social needs; an example is the Multiple and Complex Needs Initiative of the Victorian State Government [101]. Experience shows that members of care teams need to meet face to face is ongoing, trusting process of reflection, operationalized in a way that provides them with a ready framework on which to base their collaboration. Can CLP move from the multidisciplinary model, with its unspoken rules, to a transdisciplinary model with a transparent mode of collaboration? Can there be truly eclectic sharing?

This is a big opportunity for CL psychiatrists. Collaboration is an example of group function, about which psychoanalysis, process and systems theory have a lot to say. These are the roots of CLP. Liaison skills are based on them. Good liaison aims at the construction of a patient-centred collective action appropriate to the complexity, and the construction of a team life that integrates perspectives and engenders trust and respect [102]. Successful CL psychiatrists working in liaison mode use their medical and psychiatric authority in the service of these aims. There will always be a need for specialized psychiatric input in managing multimorbidity, but the future of the discipline lies in this systemic role.

Advocacy

In order to achieve policy change there needs to be a proactive seeking out of consumer and support groups and encouragement of them to press for health policy changes [103, 104]. This is especially so for people with physical psychiatric multimorbidity and somatization. Action on this and the other issues raised in this paper would show that psychiatry, through its CLP component, wants to continue to take intellectual responsibility for the whole spectrum of psychiatric disorder, not just for the low prevalence disorders. It can do this by offering creative leadership in transdisciplinary mode.

Conclusions

CLP and other health-care disciplines face the challenge of moving their focus to patients with multimorbidity who have multiple and complex needs. They must find acceptable answers to the question of what works for whom in what context for patients with multiple and complex needs. This requires that RCTs be complemented by qualitative methodology interpreted on the basis of psychodynamic, systems and complexity theory. CLP can contribute its rich experience in these approaches, but needs help from other disciplines to refine its techniques so that its contributions are considered valid.

The context for implementing effective interventions derived from such studies will in future be that of more transdisciplinary teams whose mode of working is empirically based and transparent. CLP is well placed by dint of its psychodynamic and systems theory roots to provide leadership in this transformation in health-care delivery.

Footnotes

Acknowledgements

I acknowledge the many helpful discussions with my academic colleagues David Clarke, Frits Huyse, James Strain and Carla Lipsig-Mumme, and colleagues on the Multiple and Complex Needs Initiative Panel, Margaret Hamilton and David Green.

References

1. Horton

. Launching a new movement for mental health. Lancet 2007; 370: 806.

2. Smith

. From psychosomatic medicine to consultation-liaison psychiatry. Med J Aust 1993; 159: 745–749.

3. Smith

. From consultation–liaison psychiatry to psychosocial advocacy. Aust N Z J Psychiatry 1998; 32: 753–761.

4. Smith

. The future of consultation–liaison psychiatry. Aust N Z J Psychiatry 2003; 37: 150–159.

5. Lipsitt

. Psychosomatic medicine: history of a ‘new’ specialty. Psychosomatic medicine, Blumenfield

Strain

. Lippincott Williams and Wilkins, Philadelphia, PA 2006; 3–20.

6. Smith

. An international view of consult-liaison psychiatry. Psychosomatic medicine, Blumenfield

Strain

. Lippincott Williams and Wilkins, Philadelphia, PA 2006; 21–26.

7. Prince

Patel

Saxena

. No health without mental health. Lancet 2007; 370: 859–877.

8. Moussavi

Chatterji

Verdes

Tandon

Patel

Ustun

. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 2007; 370: 851–858.

9. Smith

Clarke

. Assessing the effectiveness of integrated interventions: terminology and approach. Med Clin North Am 2006; 90: 533–548.

10.

10. Lyketsos

, Levenson

with the Academy of Psychosomatic Medicine [APM] Task Force for Subspecialization . Proposal for recognition of ‘Psychosomatic Medicine’ as a psychiatric subspecialty. Chicago: Academy of Psychosomatic Medicine, 2001.

11.

11. Huyse

Smith

. Consultation-liaison: from dream to reality. A systematic approach to developing C-L mental health service delivery. Psychiatr Bull 1997; 21: 529–531.

12.

12. Upshur

REG

. If not evidence, then what? Or does medicine really need a base?. J Eval Clin Pract 2002; 8: 113–119.

13.

13. Hewitt

, Greenfield

, Stovall

. From cancer patient to cancer survivor: lost in transition. Washington, DC: Committee on Cancer Survivorship: Improving Care and Quality of Life, Institute of Medicine and National Research Council, 2006. [Cited 30 July 2008.] Available from URL: http://www.nap.edu/catalog.php?record_id=11468 .

14.

14. Fortin

Hudon

Bayliss

van den Akker

. Multimorbidity's many challenges. BMJ 2007; 334: 1016–1017.

15.

15. Britt

Harrison

Miller

Knox

. Prevalence and patterns of multimorbidity in Australia. Med J Aust 2008; 189: 72–77.

16.

16. Andrews

Hall

Teesson

Henderson

. The mental health of Australians. Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care, Canberra 1999.

17.

17. Kisely

Goldberg

. Physical and psychiatric comorbidity in general practice. Br J Psychiatry 1996; 169: 236–242.

18.

18. Fortin

Bravo

Hudon

Lapointe

Dubois

Almirall

. Psychological distress and multimorbidity in primary care. Ann Family Med 2006; 4: 417–422.

19.

19. Gureje

Simon

Ustun

Goldberg

. Somatization in cross-cultural perspective: a World Health Organization study in primary care. Am J Psychiatry 1997; 154: 989–995.

20.

20. Cole

Bellavance

Mansour

. Prognosis of depression in elderly community and primary care populations: a systematic review and meta-analysis. Am J Psychiatry 1999; 156: 1182–1189.

21.

21. Koenig

George

Peterson

Pieper

. Depression in medically ill hospitalized older adults: prevalence, characteristics, and course of symptoms according to six diagnostic schemes. Am J Psychiatry 1997; 154: 1376–1383.

22.

22. Kisely

Goldberg

. The effect of physical health on the course of psychiatric disorder in general practice. Br J Psychiatry 1997; 170: 536–540.

23.

23. Balestrieri

Bisoffi

De Francesco

Eridani

Martucci

Tansella

. Six-month and 12-month mental health outcome of medical and surgical patients admitted to a general hospital. Psychol Med 2000; 30: 359–367.

24.

24. Gureje

Simon

. The natural history of somatisation in primary care. Psychol Med 1999; 29: 669–676.

25.

25. Sherbourne

Wells

Hays

Rogers

Burman

Judd

. Subthreshold depression and depressive disorder: clinical characteristics of general medical and mental health specialty outpatients. Am J Psychiatry 1995; 151: 1777–1784.

26.

26. Ormel

Vonkorff

Oldehinkel

Simon

Tiemens

Ustun

. Onset of disability in depressed and non-depressed primary care patients. Psychol Med 1999; 29: 847–853.

27.

27. Huppert

Whittington

. Symptoms of psychological distress predict 7 year mortality. Psychol Med 1995; 25: 1073–1086.

28.

28. Engel

Jr Liu

Hoge

Smith

. Multiple idiopathic physical symptoms in the ECA study: competing-risks analysis of 1-year incidence, mortality, and resolution. Am J Psychiatry 2002; 159: 998–1004.

29.

29. Wulsin

Vaillant

Wells

. A systematic review of the mortality of depression. Psychosom Med 1999; 61: 6–17.

30.

30. Myint

Luben

Surtees

. Self-reported mental health-related quality of life and mortality in men and women in the European prospective investigation into cancer [EPIC-Norfolk]: a prospective population study. Psychosom Med” 2007; 69: 410–414.

31.

31. Nicholson

Kuper

Hemingway

. Depression as an aetiological and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. Eur Heart J 2006; 27: 2763–2774.

32.

32. Van Melle

de Jonge

Spijkerman

. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: a meta-analysis. Psychosom Med 2004; 66: 814–822.

33.

33. de Jonge

van den Brink

Spijkerman

Ormel

. Only incident depressive episodes following myocardial infarction are associated with new cardiovascular events. J Am Coll Cardiol 2006; 48: 2204–2208.

34.

34. Chisholm

Diehr

Knapp

Patrick

Treglia

Simon

. Depression status, medical comorbidity and resource costs: evidence from an international study of major depression in primary care [LIDO]. Br J Psychiatry 2003; 183: 21–131.

35.

Saravay

Intervention studies in general hospital patients. In: Blumenfield

, Strain

. Psychosomatic Medicine. Philadelphia, PA: Lippincott Williams & Wilkins, 2006:867–877.

36.

36. Kathol

Saravay

Lobo

Ormel

. Epidemiologic trends and costs of fragmentation. Med Clin North Am 2006; 90: 549–572.

37.

37. Classman

O'Connor

Califf

. Sertraline treatment of major depression in patients with acute MI or unstable angina. JAMA 2002; 288: 701–709.

38.

38. Berkman

Blumenthal

Burg

. Effects of treating depression and low-perceived social support on clinical events after myocardial infarction: the enhancing recovery in coronary heart disease patients [ENRICHD] randomized trial. JAMA 2003; 289: 3106–3116.

39.

39. Van Melle

de Jonge

Honig

. on behalf of the MIND-IT investigators. Effects of antidepressant treatment following myocardial infarction. Br J Psychiatry 2007; 190: 460–466.

40.

40. Ouwens

Wollersheim

Hermens

Hulscher

Grol

. Integrated care programmes for chronically ill patients: a review of systematic reviews. Int J Qual Health Care 2005; 17: 141–146.

41.

Tieman

Mitchell

Shelby-James

Integration, coordination and multidisciplinary approaches in primary care: a systematic investigation of the literature. Canberra: Australian Primary Health Care Research Institute, 2006. [Cited 25 April 2008.] Available from URL: http://www.anu.edu.au/aphcri/Domain/MultidisciplinaryTeams/ .

42.

Smith

Allwright

O'Dowd

Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database Syst Rev 2007; (3):CD004910.

43.

Latour

van der Windt

de Jonge

Nurse-led case management for ambulatory complex patients in general health care: a systematic review. Psychosom Res 2007; 62:385–395.

44.

Weingarten

Henning

Badamgarav

Interventions used in disease management programmes for patients with chronic illness: which ones work? Meta-analysis of published reports. BMJ 2002; 325:25–32.

45.

45. Ritchie

. Health care quality and multimorbidity. Med Care 2007; 45: 477–479.

46.

46. May

Finch

Mair

. Understanding the implementation of complex interventions in health care: the normalization process model. BMC Health Serv Res 2007; 7: 148–154.

47.

47. Bonell

Oakley

Hargreaves

Strange

Rees

. Assessment of generalisability in trials of health interventions: suggested framework and systematic review. BMJ 2006; 333: 346–349.

48.

48. National Health Priority Action Council [NHPAC]. National Chronic Disease Strategy. Canberra: Australian Government Department of Health and Ageing, 2006.

49.

49. Esterman

Ben-Tovim

. The Australian coordinated care trials: success or failure?. Med J Aust 2002; 177: 469–470.

50.

50. Jordan

Osborne

. Chronic disease self-management education programs: challenges ahead. Med J Aust 2007; 186: 84–87.

51.

51. Fortin

Dionne

Pinho

Gignac

Almirall

Lapointe

. Randomized controlled trials: do they have an external validity for patients with multiple comorbidities?. Ann Fam Med 2006; 4: 104–108.

52.

52. Smith

Strain

. George Engel's contribution to clinical psychiatry. Aust N Z J Psychiatry 2002; 36: 458–466.

53.

53. Campbell

Murray

Darbyshire

. Designing and evaluating complex interventions to improve health care. BMJ 2007; 34: 455–459.

54.

Brown

The new shorter Oxford English dictionary. Oxford: Clarendon Press 1993.

55.

55. Kurtz

Snowden

. The new dynamics of strategy: sense-making in a complex and complicated world. IBM Syst J 2003; 42: 462–483.

56.

56. de Jonge

Huyse

Stiefel

. Case and care complexity in the medically ill. Med Clin North Am 2006; 90: 679–692.

57.

57. Bennett

Hacker

PMS

. Philosophical foundations of neuroscience. Blackwell, Oxford 2004.

58.

58. Frosh

. For and against psychoanalysis. Routledge, London 2006.

59.

59. Allen

Varga

. Complexity: the co-evolution of epistemology, axiology and ontology. Nonlinear Dynamics Psychol Life Sci 2007; 11: 19–50.

60.

60. Mays

, Pope

, Popay

Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy 2005; 10(Suppl. 1):6–20. Available from URL: http://www.joannabriggs.edu.au/cqrmg/about.html .

61.

61. Dixon-Woods

Agarwal

Jones

Young

Sutton

. Synthesising qualitative and quantitative evidence: a review of possible methods. J Health Serv Res Pol 2005; 10: 45–53.

62.

62. Bravata

McDonald

Shojania

Sundaram

Owens

. Challenges in systematic reviews: synthesis of topics related to the delivery, organisation and financing of health care. Ann Int Med 2005; 142: 1056–1065.

63.

63. Plsek

Greenlhalgh

. The challenge of complexity in health care. BMJ 2001; 323: 625–628.

64.

64. Lipowsky

. Review of consultation psychiatry and psychosomatic medicine III. Theoretical issues. Psychosom Med 1968; 30: 394–422.

65.

65. Engel

Morgan

Jr . Interviewing the patient. WB Saunders, Philadelphia 1973.

66.

66. Engel

. On looking inward and being scientific: a tribute to Arthur H. Schmale, M. D. Psychother Psychosom 1990; 54: 63–69.

67.

67. Engel

. Psychological development in health and disease. WB Saunders, Philadelphia 1962.

68.

68. Balint

. The doctor, his patient and the illness, millennium reprint of the2nd edn. Churchill Livingstone, New York 2000.

69.

69. Mechanic

Volkart

. Illness behavior and medical diagnosis. J Health Hum Behav 1960; 1: 86–94.

70.

70. Pilowsky

. Abnormal illness behaviour. Br J Med Psychol 1969; 42: 347–351.

71.

71. Smith

. Challenges for psychotherapy and psychoanalysis. Aust J Psychother 2006; 25: 32–55.

72.

72. Crossley

. Narrative analysis. Analysing qualitative data in psychology, Lyons

Coyle

. Sage, London 2007; 131–144.

73.

73. Smith

Eatough

. Interpretive phenomenological analysis. Analysing qualitative data in psychology, Lyons

Coyle

. Sage, London 2007; 35–50.

74.

74. Brown

. Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model. Psychol Bull 2004; 130: 793–812.

75.

75. Bower

Gilbody

Richards

Fletcher

Sutton

. Collaborative care for depression in primary care. Br J Psychiatry 2006; 189: 484–493.

76.

76. Clarke

Cook

Coleman

Smith

. A qualitative examination of the experience of ‘depression’ in hospitalized medically ill patients. Psychopathology 2006; 39: 303–312.

77.

77. Nettleton

Watt

O'Malley

Duffey

. Understanding the narratives of people who live with medically unexplained symptoms. Patient Educ Couns 2005; 56: 205–210.

78.

78. Jamieson

Fletcher

Schneider

. Seeking control through the determination of diet: a qualitative investigation of women with irritable bowel syndrome and inflammatory bowel disease. Clin Nurse Spec 2007; 21: 152–160.

79.

79. Nordqvist

Sodergard

Tully

Sonnerborg

Lindblad

. Assessing and achieving readiness to initiate HIV medication. Patient Educ Couns 2006; 62: 21–30.

80.

80. Fraenkel

McGraw

Wongcharatrawee

Garcia-Tsao

. Patients’ experiences related to anti-viral treatment for hepatitis C. Patient Educ Couns 2006; 62: 148–155.

81.

81. Sque

Payne

. Dissonant loss: the experiences of donors’ relatives. Soc Sci Med 1996; 43: 1359–1370.

82.

82. McCaffrey

Pugh

Guy

O'Connor

. Understanding patient preference for integrated care. J Gen Intern Med 2007; 22: 1500–1505.

83.

83. Junger

Pestinger

Elsner

Krumn

Radbruch

. Criteria for successful multiprofessional cooperation in palliative care. Palliat Med 2007; 21: 347–354.

84.

84. Salmon

Wissow

Carroll

. Doctors’ attachment style and their inclination to propose somatic interventions for medically unexplained symptoms. Gen Hosp Psychiatry 2008; 30: 104–111.

85.

85. Graham

Logan

Harrison

. Lost in knowledge translation: time for a map?. J Contin Educ Health Prof 2006; 26: 13–24.

86.

86. Grimshaw

Santesso

Cumpston

Mayhew

NcGowan

. Knowledge for knowledge translation: the role of the Cochrane Collaboration. J Contin Educ Health Prof 2006; 26: 55–62.

87.

87. Pawson

Greenhalgh

Harvey

Walshe

. Realist review: a new method of systematic review designed for complex policy interventions. J Health Serv Res Pol 2005; 10(Suppl 1)21–34.

88.

88. Larun

Malterud

. Identity and coping experiences in chronic fatigue syndrome: a synthesis of qualitative studies. Patient Educ Couns 2007; 69: 20–28.

89.

89. Zwarenstein

, Stephenson

, Johnston

Case management: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2008; (2):CD002797.

90.

90. Fonagy

Target

. The place of psychodynamic theory in developmental psychopathology. Dev Psychopathol 2000; 12: 407–425.

91.

91. Johnstone

. Controversies and debates about formulation. Formulations in psychology and psychotherapy, Johnstone

Dallos

. Routledge, London 2006; 208–235.

92.

92. Mead

Bower

. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000; 51: 1087–1110.

93.

93. Orley

Saxena

Herrman

. Quality of life and mental illness. Reflections from the perspective of the WHOQOL. Br J Psychiatry 1998; 172: 291–293.

94.

94. Gitlin

Levenson

Lyketsos

. Psychosomatic medicine: a new psychiatric subspecialty. Acad Psychiatry 2004; 28: 4–11.

95.

Stevens

RA.

How are certification and professional competence linked? Paper delivered at ABMS Conference on Professional Competence and Board Certification, March 18–19, 1999. Cited in Landon BE, Normand S-L T, Blumenthal D, Daley J. Physician clinical performance assessment: prospects and barriers. JAMA 2003; 290:1183–1189.

96.

96. Duffy

Goode

Langdon

. Why we should enhance subspecialty training: indicators of areas for program development. Am J Med 2002; 112: 431–535.

97.

97. Fink

Rosendal

. Recent developments in the understanding and management of functional somatic symptoms in primary care. Curr Opin Psychiatry 2008; 21: 182–188.

98.

98. New South Wales Government. Hospitalist pilot. Sydney: New South Wales Government Health Department, 2007. [Cited 23 April 2008.] Available from URL: http://www.imet.health.nsw.gov.au/page/hospitalist_pilot.html .

99.

99. Barach

Johnson

. Understanding the complexity of redesigning care around the clinical system. Qual Saf Health Care 2006; 155(Suppl)i10–i16.

100.

100. D'Amour

Ferrada-Vidella

San Martin Rodriguez

Beaulieu

M-D

. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care 2005; 19(Suppl 1)116–131.

101.

101. State Government of Victoria. Human Services (Complex Needs) Act 2003 summary notes. Melbourne: State Government of Victoria, 2003. [Cited 14 February 2007.] Available from URL: http://www.dhs.vic.gov.au/complexclients/downloads/actsummarynotes.pdf .

102.

102. San Martin-Rodriguez

Beaulieu

M-D

D'Amour

Ferrada-Vidella

. The determinants of successful collaboration: a review of theoretical and empirical studies. J Interprof Care 2005; 19(Suppl 1)132–147.

103.

103. Royal Australian and New Zealand College of Psychiatrists. Policy options discussion paper. Melbourne: Royal Australian and New Zealand College of Psychiatrists, 2002.

104.

104. Mechanic

. Improving the quality of health care in the United States of America: the need for a multi-level approach. J Health Serv Res Pol 2002; 7(Suppl 1)35–39.