Foundations of Consultation-Liaison Psychiatry

The Bumpy Road to Specialization

Don Lipsitt

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781138906259
• eBook ISBN: 9781317443445
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Foundations of Consultation-Liaison Psychiatry: The Bumpy Road to Specialization documents the development of Consultation-Liaison Psychiatry from its inception to the present. The book draws on contributions from philosophy, physiology, psychoanalysis, epidemiology and other disciplines to define the broad scope of the field. Distinctions and similarities between Consultation-Liaison Psychiatry and Psychosomatic Medicine will be of interest to psychiatrists, social workers, and health psychologists, as well as students, residents, and fellows pursuing careers in these disciplines.

Section I
Seeds and Roots

Preamble: We are certainly not the first to say that history is relevant! The quote of Santayana that those who cannot remember the past are condemned to repeat it is almost hackneyed in its familiarity. If some parts of history can be discarded, others are worthy of repetition and retention, if only to appreciate where we have come from and upon whose shoulders we have built contemporary knowledge and thought. Many ideas and beliefs of the past are silently embedded in today’s practices. To have familiarity with them broadens our scope and appreciation of the world around us. To that end, we survey the many contributions to the foundation of consultation-liaison (C-L) psychiatry, looking, like Janus, both forward and back.

Depending on whom one reads, the origins of consultation-liaison are variously evolved from psychosomatic medicine, general hospital psychiatry, physiology, or epidemiology, or, like Topsy, “just growed.” ¹ This section takes a Topsy-like position, assuming that the discipline grew from an indeterminate garden of seeds and—as exclaimed by the referee when asked about baseball pitches, “it ain’t nothin’’ til I calls it”—only became “C-L psychiatry” when it was named. The chapters of this section explore roots in philosophy, physiology, psychoanalysis, psychosomatic medicine, and epidemiology.

Each of these “seeds” enters the consultation process without announcement. This section is capped with a chapter on the consultation.

Note

1 Topsy was the young slave girl of the nineteenth-century Uncle Tom’s Cabin, who, when asked where she came from, said, “I s’pect I growed. Don’t think nobody never made me.”

1
Remnants of Philosophy

The Vexing Mind-Body Problem

And how far is it from the point where we find ourselves today back to the late eighteenth century, when the hope that mankind could improve and learn was inscribed in handsomely formed letters in our philosophical firmament?

—Sebald, 2004, p. 112

Few psychiatrists would fancy themselves philosophers, yet every endeavor aimed at melding perturbations of the mind with expressions of bodily distress pays homage to philosophy and to philosophers who have made our task virtually automatic. Philosophic reflections are perhaps the last thing on the consultation-liaison psychiatrist’s mind when consulting at the bedside, but philosophy is in his or her DNA. And Karl Jaspers, psychiatrist-philosopher, has said that “[If a psychiatrist] thinks he can exclude philosophy … he will eventually be defeated by it in some obscure form or another” (Jaspers, 1963, p. 770).

Why would a C-L psychiatrist be concerned about the place of philosophy in the history of C-L psychiatry? Haven’t we gone far beyond that? Aren’t the ancient philosophers dust? Because we are specialists who deal with mind-body problems on a regular basis, it is enlightening to know about the controversies that surrounded this problem in the past, to understand why solutions are not readily forthcoming, and to have a greater sense of the wider world than merely our own. Fundamentally, all philosophy proposes that we all grow up with both a worldview (weltanschauung) and a view of ourselves (dasein).

Ghaemi (2003), a contemporary psychiatrist attracted to pluralism as a useful concept in psychiatry, thinks of philosophy as more-or-less simply “thinking hard,” a shared function of both scientists and philosophers. Similarly, William James defined it as “an unusually stubborn effort to think clearly” (Fulford, Stanghellini & Broome, 2004). In his book The Concepts of Psychiatry: A Plural-istic Approach to the Mind and Mental Illness, Ghaemi (2003) takes a broad sweep of nineteenth- and twentieth-century philosophers whose ideas articulate with today’s psychiatric practitioners, beginning with the salient quote of Sir Aubrey Lewis: “The psychiatrist then is confronted, whether he likes it or not, with many of the central issues of philosophy” (p. 1). In this, Jaspers and Lewis concur (Angel, 2003).

Unless the C-L psychiatrist has made a purposeful study of philosophy, he or she is likely to draw a blank on philosophers’ names, except for that of Rene Descartes and his dualistic formulations. Most of these great thinkers lived in a monistic (if not monastic) world wherein they addressed the difficult big questions of life and civilization; physicians practiced a “holistic” medicine. Descartes shattered that world with the split enduring to today as “Cartesian dualism,” virtually divorced from the man who initiated it. He said we consisted of two parts, the thinking mind (res cogitans) and the mechanical body (res extensa). In our industrialized and technologized world, the notion of human as machine, with reparable or replacement parts, is too seductive to abandon. So, Descartes’s (1637) ideas seem to have endured longer than even more sage utterances through the ages. And while controversy continues to swirl around the “mind-body” question, significant doubts of their relationship no longer persist as philosophers consider repercussions.

To be curious and to search for answers are, in essence, the preconditions that make everyone a philosopher. Virtually all philosophies begin with questions about the relation of mind and body and of both to the surrounding world (Denys, 2007). Thus, it is no surprise that psychiatrists would find philosophy and psychiatry most companionable (see e.g., Ghaemi, 2003; Havens, 1993; Jaspers, 1963; Hundert, 1991; Fulford, 2004; Kendler, 2005). According to Wallace, “it is difficult to imagine a more perennially vexing topic to philosophers, scientists, and physicians than the mind-body problem” (1988, p. 4). Those wedded to a “scientific life” and “practicality” are apt to disparage the work of professional thinkers in philosophy as “metaphysics” or “armchair psychologizing” or “only philosophy.”

Perhaps to counteract negative attitudes toward philosophers, the Scottish religious philosopher David Hume (1738) said, “Generally speaking, the errors in religion are dangerous; those in philosophy only ridiculous” (Bk 1, pt 4, sect 7). And the American satirist Ambrose Bierce (1906), in The Devil’s Dictionary, defines philosophy dismissively as “a route of many roads leading from nowhere to nothing.” More optimistically, Briquet, in his treatise on hysteria, speaks of philosophy as that “which most often is nothing other than the establishment in scientific form of the reigning traditions and ideas of the age” (Briquet, 1859, p. 132).

If one is to ponder, observe, and understand mind-body relations—essentially where it all began when the curious wanted to understand human nature and how humans behaved, thought and felt—one cannot ignore the philosophical underpinnings of our work (Kendler, 2005). Philosophers and metaphysicists have rendered the building blocks on which contemporary thinking of mind-body interaction rests; thus, they are the scaffold upon which our psychological and psychiatric theories are built. Indeed much of what we know of homeostasis, Claude Bernard’s milieu interieur, or physiology derives from physicians who were also philosophers of their day, the polymaths among them also being mathematicians, poets, physicists, and theologians.

The brief panoramic view I take here is a bit like standing on a cliff overlooking the Grand Canyon. We admire and exult in the beauty of the moment but may not comprehend the evolving transformations that have brought us this spectacle. As a small speck on an almost incomprehensible landscape, we can only attempt to grasp what it is, not especially how it has become. We can settle for an instant photo that fixes the moment in our perception. To know more, we will need to exert effort and diligence, to “think hard.” For the interested reader of how philosophy may influence the practice of psychiatry, no better example exists than that of Yalom, writing of Heidegger, Sartre, Boss, Laing, and Rollo May as they influence the practice of existential psychotherapy (Yalom, 1980).

Yalom focuses his existentialism on the four “givens” of the human condition: freedom, isolation, meaninglessness, and mortality, with one or all giving rise to any other. He expounds on the significance in life of a search for meaning, quoting psychologist Viktor Frankl, a holocaust survivor.

Personal Philosophy

Although we may not name it as such, we all carry our personal philosophy into the work we profess. Contemplation of one’s being and surround was rampant in “prescientific” ages. When facts of life are not known, there is much room for controversy or, if you will, philosophizing. Psychiatry, a discipline shrouded in much uncertainty, provides great latitude for philosophical beliefs. Beyond mind-body deliberations, one can have a philosophy about anxiety, about depression, about the relationship of the physician to his or her patient. The fact that life does not fit snugly into scientific or diagnostic paradigms is likely what prompted both Jaspers and Freud to switch interests in their pursuit of answers.

Wittgenstein, a contemporary philosopher, has written that one’s “narrative” encompasses reason, imagination, and meaning and that the way these unite in one’s experience constitutes one’s unique “personal narrative” or philosophy (Wallang, 2010).

For example, my own philosophy of patient care is that I am unable to assume responsibility for all that patients do. If I see patients once or twice a week or even more, I cannot possibly know what they do the other many hours they are not in my office. As a C-L psychiatrist, I subscribe to an attitudinal philosophy of considered risk taking in how much latitude to allow patients (and myself) free will in decision making about medication taking, hospital admission/discharge, or participation in psychotherapeutic activity. This is my “philosophy” of treatment.

Such a philosophy embraces a broad approach to the act of suicide and substantially modifies “rescue fantasies” inculcated in medical training. I can “take care” of patients when they are with me but not when they are independently functioning. I can be caring, concerned, and professionally responsible, but I cannot prevent them from getting sick, doing harm to themselves, or even killing themselves.

Others may have similar or different personal philosophies, subscribe to oriental ideas about life, or be influenced by religious percepts about human behavior—all philosophies by which individuals construct their personal or professional lives. Some psychiatrists have personal philosophies that appear “out of the mainstream” of contemporary theory and practice, so that they may be labeled “strange” or “idiosyncratic.” The “philosophic” notion of Thomas Szasz (1961), for example, that mental illness is but a myth is such a case; his position on this important issue clearly affects how he treats patients and mental function.

Knowing something of how others have accomplished theirs adds power to the creation of our own personal philosophy. Exploring the landscape of philosophy in its relation to C-L psychiatry would require great diligence by one steeped in the history and epistemology of philosophical thinking. This brief review of selected philosophical musings intends only to help establish the fact that by standing on the shoulders of many who came before us, we may be able to see further than they did over 2000 years ago. It is exhilarating as well as humbling to see how much thinking of our forebears resembles our own, though modified and expressed in different language and societal coloration, and to accept philosophy as a basic foundation of C-L psychiatry (Kendler, 2005).

Our Forebears

The essential occupation of philosophers forever has been contemplating the large mysteries of existence. Since at least the 3rd century AD, philosophers were the alchemists of the day, with the professional search for the philosopher’s stone, that with which base metals would be turned to gold. In contemporary times, the universal quest for a way to assure happiness, health, and wealth is perpetuated through such meanderings as those of a Harry Potter in search of the sorcerer’s or philosopher’s stone. The enduring wish to find the “elixir of life” is only slightly disguised in today’s voluminous consumption of supplements or “programs” promising “miracle cures” or at least improved health.

Both philosophy and psychology have long believed that humans’ emotions, thoughts, and behavior somehow originate in the head (brain). Primitive evidence is implied in ancient remnants of trephined skulls. Contemporary surgery may find holes in the skull useful for reduction of pressure on the brain, but providing egress for demonic spirits was the more likely rationale thousands of years ago.

Philosophical Roots

Enter the philosophers. Before much was known about anatomy, physiology, or chemistry, there were Socrates, Plato, Aristotle, Democritus, Sophocles, Hippocrates, Luke, Galen, Paracelsus, and Descartes, to allude to only a few who struggled with the complexities of life, especially of the mind/soul and body.

Regarding science and philosophy, Macklin (1978) has succinctly stated, “The methodology and evidential support adduced may differ in philosophical and scientific theories, but there is nevertheless an overlap in the two domains…. The difference between these two approaches to understanding man is largely a matter of emphasis” (p. 86). For example, Freud’s psychodynamic theory of development echoes Plato’s conception of how reason and passion interact to create personality, although the two thinkers are separated by over 2000 years. Macklin elaborates:

The arguments put forth in favor of one or another theoretical system are, at bottom, philosophical. Whether the proponents of these arguments identify their field of research as psychology, psychiatry, or philosophy, when engaged in this sort of metatheoretical dispute they are taking a philosophical stance on the issue.

(p. 99)

The cogitations and theorizing of earliest ...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• Preface
• Acknowledgments
• Prologue
• Psyche and Soma: Struggles to Close the Gap
• SECTION I Seeds and Roots
• SECTION II Crises and Benefactors
• SECTION III The Process of Specialty Recognition
• SECTION IV Post-Specialization
• Appendix One: Dramatis Personae
• Appendix Two: Personal Reflections of a C-L Psychiatrist
• Index