Providing psychological consultation in medical settings, or consultation-liaison (C-L) services, provides opportunities to expand the practice of psychology and diversify a psychologist’s practice. These services may be provided in a hospital or in other medical settings.
In hospitals, psychologists have traditionally provided consultations on psychiatric units, but increasingly are providing consultations on general medical units and hospital emergency departments.
The role of the C-L psychologist is to assist the attending physician with assessment and treatment. Referrals are typically made when the physician seeks assistance with assessing a patient’s mental health needs but may also include assisting with the care of patients who have mental health or behavioral problems complicating their treatment for medical conditions.
C-L psychologists need to be knowledgeable about the bio-social model of health and illness. This will often require an understanding about how mental health symptoms, behavioral patterns, relationship factors, cultural influences and other factors interact and may contribute significantly to the patient’s medical needs.
Psychologists may be called upon to provide input into differential diagnosis questions, such as helping to rule in or rule out psychiatric disorders. They may help with questions about whether the patient’s behavioral symptoms are the result of a medical condition or a separate (but often related) mental health condition.
They may also be asked to help assess suicide risk or competency to consent to treatment, to help manage behavioral problems on the unit or in the physician’s office and other treatment concerns for which the attending physician may not have the interest, training or time to manage.
C-L services often include assisting with communication about behavioral concerns with multiple members of the patient’s medical team – this is the “liaison” part of the C-L role. C-L services often are needed in situations in which there are several key participants (patient, family, attending MD, consultants, unit or office staff, system administrators, concerned outsiders) who may have differing agendas.
For example: the patient may want to be discharged; the family may be lobbying for extending the stay; the MD may be uncertain about what to do and the hospital or clinic administrative staff may be concerned about reimbursement or risk factors. Input from the C-L psychologist can help the attending MD or other medical staff sort out how to manage the competing concerns.
The consulting environment may be busy, even hectic. Working on inpatient medical units requires the ability to multitask; comfort using hospital EHRs; the ability to focus on your work and to tune out background conversations, the sound of call buttons, and other background activity; and the ability to summarize your findings concisely for the busy MD or other staff who requested your consultation. Other medical settings may not have this level of intensity but still are likely to be much busier than the average office practice environment.
Having solid relationship skills, particularly being able to establish relationships quickly with people with diverse backgrounds and agendas, are some of the most important skills that a C-L psychologist will provide for the consultation.
Motivational interviewing skills are helpful when working with all participants, including the MD who ordered the C-L. One of the most challenging C-L situations occurs when the attending MD has an expectation for the outcome of the consultation that is different than your findings and you have to find a way to work out an understanding.
This often can be an opportunity to offer information to the MD or even, if the MD is receptive, to educate him or her about the patient’s mental health needs and how they are impacting medical treatment needs.
Overall, probably the most crucial factor in developing a successful C-L practice is the quality of your relationships with the referring medical staff. It is crucial to be able to understand their perspective and their needs – often including significant pressure to “get that behavioral patient off our unit/out of my office.”
Some will value psychological services right from the start, but some will need to be educated about what we can realistically provide, how we are different from psychiatrists and other mental health professionals and the unique skills that we offer – how we add value to the patient’s treatment.
It also helps to be willing to learn, and there is always something to learn in a typical C-L practice. There is an emerging body of research that supports the benefits of a mind-body approach to treating many common medical conditions, but it can be challenging to keep up.
There are many obscure or complex medical diseases (MDs and medical staff are often interesting in talking about them and helping the C-L consultant with their medical knowledge). And, working with people from diverse cultures and different stages of life may challenge you to diversify your own skills.
To summarize, it will take time to cultivate relationships with the medical team and to establish a reputation for adding value with C-L services. For a hospital-based practice, you probably will need to cultivate a relationship with a physician or administrator willing to “sponsor” you to be credentialed by the hospital.
Whatever the practice setting, developing a C-L practice can be challenging but can both add to diversity to your practice and allow you to make significant contributions to the care of people in need – many of whom are experiencing a life-threatening or life-changing crisis – which can be very rewarding.
Richard Sethre, Psy.D., is in independent practice in Minneapolis, Minn. He has provided C-L services for a local hospital system for 18 years. His email is: firstname.lastname@example.org.