Introduction

Pediatric consultation-liaison (CL) psychologists spend a great deal of time collaborating with pediatricians, nurses, and other care providers in a hospital setting. Given the nature of the CL psychologist’s role, it is not uncommon to collaborate more frequently with consulting medical teams than with our mental health colleagues (e.g., psychiatrists). However, effectively collaborating with our child psychiatry colleagues is important to maximize the quality of care we provide for consult patients. Given variability in organizational structures for CL teams, the structure and methods to facilitate collaboration between CL psychologists and psychiatrists will also vary across hospital systems.

Unfortunately, there is a dearth of research on mental health outcomes when psychiatry and psychology CL services are combined. However, there is some evidence to suggest that outcomes are likely to be improved when psychiatrists and psychologists effectively collaborate to provide CL services. First, for several mental health conditions, including depression (March et al., 2004), evidence-based medicine indicates better outcomes with treatments that combine psychiatric expertise (medication management) and psychology expertise (therapy). Further, the integrated care literature supports more efficient care and better outcomes when psychiatry and psychology work collaboratively with primary care providers (Osofsky, Osofsky, Wells, & Weems, 2014). This chapter focuses on the benefits of collaboration with psychiatry during CL work, the pros and cons of different collaboration models, and strategies to facilitate effective collaborations.

Collaboration Between Psychiatry and Psychology in Non-CL Settings

While there is scant discussion on “collaborative care” between psychologists and psychiatrists, there is some review of “split treatment” in the psychiatry literature. “Split treatment” describes care in which the patient is receiving treatment from more than one caregiver, most commonly referring to a psychiatrist providing psychopharmacology and a psychotherapist providing therapy (Balon, 2001; Gitlin & Miklowitz, 2016). Research supports that many mental health disorders benefit from combined treatments of psychotherapy and psychopharmacology. However, psychopharmacologists are a very limited resource and may feel pressure to focus solely on psychopharmacology contributing to decreasing incidences of psychiatrists providing both services. The “split treatment” model has become common in mental health care (i.e., when a psychiatrist provides psychopharmacology services and collaborates with a therapist who provides psychotherapy) and review of it can be helpful in considering the positives and negatives of collaboration between psychologists and psychiatrists in CL roles.

There are many positive aspects noted for “split treatment” (which we will refer to from this point as collaboration between psychiatrists and psychologists). With more than one provider, the care will benefit from different specialized knowledge bases and skills, lending unique clinical lenses for gleaning of information, conceptualization of the patient, and developing treatment plans (Balon, 2001; Gitlin & Miklowitz, 2016; Woodward, 2002). Further, the patient potentially gains more treatment time, increased resources, and better coverage of care during provider vacation or leave. Working together, the two providers may also be able to use their different relationships with the patient to help resolve conflict with either patient-provider relationship or to enhance adherence to one another’s treatment plan. In addition, the shared provider experience may provide reciprocal support with difficult cases.

There are also negative aspects of collaborative care in comparison to one provider doing both interventions. The patient may give discrepant information to each provider, leading one provider to act on information and possibly derail the other’s care plan (Balon, 2001). Such experiences can lead to splitting of the team and possibly termination of one provider’s care. If communication between the two providers lapses, the psychiatrist may inappropriately prescribe at times when an issue may be better worked through in therapy, or perhaps stop an antidepressant when the patient has recently reported suicidal ideation in therapy (Balon, 2001). Another concern is that having two providers can reinforce the mind-body split (Gabbard & Kay, 2001; Gitlin & Miklowitz, 2016; Woodward, 2002). This may be an even greater concern in consultation-liaison work where a psychiatrist and psychologist are seeing the patient independently. This is where close collaboration between the psychiatrist and psychologist can facilitate patient and family understanding of the important interplay of psychological and physical factors.

It is reasonable to think that many psychotherapists and psychopharmacologists agree that good communication is essential to collaborative care; however, a review of a survey completed by 61 psychiatrists in 2012 suggests that communication between collaborating mental health providers occurs infrequently (Kalman, Kalman, & Granet, 2012). For the 875 patients that were being seen by two providers for psychopharmacology and psychotherapy for greater than 6 months, respondents reported no communication with the other provider on 24% of the patients, and only 18% of the respondents reported quarterly communication with the psychotherapist (Kalman et al., 2012).

In summary, while there are many benefits to collaboration between psychiatrists and psychologists (or psychotherapists) in an outpatient setting, it can be logistically challenging to maintain the extent of communication necessary for collaboration, and even in the best of collaborations there are potential problem areas that may arise. Similar dynamics are likely to occur in collaborations between psychiatrists and psychologists in consultation-liaison settings, highlighting the need to make intentional efforts to establish and maintain regular effective collaborations with our psychiatry colleagues.

Collaboration Between Psychiatry and Psychology in Pediatric CL Settings

Pediatric psychology/psychiatry CL services vary considerably in structure across different organizations. Recent surveys of psychology (Kullgren et al., 2015) and psychiatry (Shaw, Pao, Holland, & DeMaso, 2016) CL services have been published and provide some insight into the structure of these programs and extent of collaboration between psychiatry and psychology providers. A survey of 118 pediatric CL psychologists found that just over half (56%) of their pediatric hospital settings had separate CL psychology and CL psychiatry services, and most reported not having a psychiatrist on their team (mode = 0) (Kullgren et al., 2015). This may be a reflection of departmental structure for the surveyed CL psychology services as only 26% of these services were housed in a department/division of psychiatry compared to 41% housed in a psychology department/division (Kullgren et al., 2015). A survey of pediatric CL psychiatry services, in primarily academically affiliated or children’s hospital settings, found that just under half of these programs included a psychologist (Shaw et al., 2016). A similar survey of 48 pediatric CL psychiatry services found that only 11% had separate CL psychiatry and CL psychology services (Shaw, Wamboldt, Bursch, & Stuber, 2006).

The discrepancy between these surveys in percentage of hospitals with separate CL psychiatry and psychology services (56% vs. 11%) may reflect sampling biases in the two surveys due to sampling of psychologists (Kullgren et al., 2015) vs. psychiatrists (Shaw et al., 2006) as survey respondents. Interpretation of these results suggests that pediatric CL services that are labeled as psychiatry services, and/or directed by psychiatrists, may be more likely to include interdisciplinary (both psychiatry and psychology) teams, whereas services labeled as CL psychology services and/or directed by psychologists may be less likely to include psychiatrists in their CL team. However, further research is needed to verify this hypothesis. In two separate reports, the majority (65–70%) (Shaw et al., 2006, 2016) of surveyed CL psychiatry services were directed by a psychiatrist (27% with joint directorship with a psychologist), and 10% were directed by a psychologist (6% with a joint directorship with a psychiatrist) (Shaw et al., 2006).

Models for Collaboration

As demonstrated through the survey data above, collaboration between psychiatrists and psychologists to provide pediatric CL services can occur through various models of care, including with or without integrated CL teams. An integrated CL team would include both psychiatry and psychology attendings and often a variety of other team members, possibly including social workers, nurse practitioners, psychology postdoctoral fellows, psychology interns, psychology practicum students, child psychiatry fellows, psychiatry residents, pediatric residents, and medical students (Kullgren et al., 2015). Trainees from multiple disciplines have been demonstrated to provide a significant proportion of clinical care on CL teams (Kullgren et al., 2015; Shaw et al., 2006). Integrated teams often have regular, daily or weekly, team meetings to discuss patient care, which can allow for the integration of each provider’s unique expertise into each patient’s care.

Literature supports that better integration of CL services with both medical and psychiatry colleagues leads to improved training of a variety of disciplines and improved patient care. Kullgren et al. (2015) noted the infrequent integration of psychology and psychiatry/medical teams on pediatric CL teams, particularly the lack of inclusion of medical student and resident trainees, as a “missed opportunity for interprofessional collaboration.” Similarly, Shaw et al. (2006) expressed a belief that pediatric CL services that include both psychiatrists and psychologists “have a particular advantage in their ability to integrate multiple treatment modalities that are generally required in the management of children with complex medical issues.” Fortunately, the majority (69%) of pediatric CL psychologists report having good working relationships with psychiatry colleagues and only infrequently (7%) report a typically poor working relationship (Kullgren et al., 2015).

Although data is lacking regarding the specific efficacy of integrated vs. separate, CL services including psychiatry and psychology, there is significant evidence in primary care to suggest that teams including both psychiatry and psychology result in significant improvement in treatment of mental health concerns in a primary care setting (Bodenheimer, 2007; Raney, 2015). Research indicates that multidisciplinary clinical teams obtain better patient health outcomes than teams that are not integrated (Wagner, 2000), and within integrated teams those that have an organizational structure and cohesive function (Bodenheimer, 2007; Bodenheimer & Grumbach, 2006), better team cohesion (Campbell et al., 2001), and more collaborative clinical environment (Bodenheimer, 2007) are more effective and have better patient health and satisfaction outcomes. It is reasonable to hypothesize similar improved care outcomes exist with integration of psychiatry and psychology CL services.

In contrast, limited or inefficient collaboration between CL psychiatrists and CL psychologists can present challenges to patient care. For example, problems may arise in systems where roles and communication between psychology and psychiatry are not well defined, especially when separate teams are accessed through different consultation routes. One issue that may arise when psychology and psychiatry work as separate teams is the primary team may inappropriately consult the less suitable team based on their perception of the patient problem. For example, the primary team may believe a patient’s anxiety could only be managed by a medication and therefore needs a psychiatrist, or perhaps the team has misdiagnosed the problem as a functional issue leading them to consult a psychologist. This potential issue was highlighted by Aljarad, Osaimi, and Huthail (2008) in a study in which they looked at the perceived mental health diagnosis by the referring medical specialty of 157 physically ill adults compared to the mental health diagnosis reported by the CL service after evaluation. About 53% of the initial impressions by the referring team were reviewed to be inaccurate diagnoses, and only 49% referred for a depressive disorder were actually found to have a depressive disorder on assessment (Aljarad et al., 2008). Regular collaboration between psychiatry and psychology CL providers can minimize the potential negative impact of misperceptions by the primary team of the nature of the mental health problems of their patients. Review of the medical record, discussion with the primary team to better understand the consultation question, and communication between the psychologist and psychiatrist assist in a more appropriate and accurate consultation outcome. Continued review of a case after initial evaluation may also lead the psychiatrist or psychologist to involve the other discipline for differing expertise and treatment approaches. For example, the CL psychologist was consulted for assistance with agitation. However, upon reviewing the patient’s medical record the CL psychiatrist had concern for delirium. As such, it was decided that the CL psychiatrist would complete the consult. In other cases, it may be apparent that a patient would benefit from both services and providers may choose to collaborate on care at the outset. This illustrates the importance of close collaboration between psychiatrists and psychologists even before the consult has taken place.

Psychology and Psychiatry Training and Competencies

Psychiatrists and psychologists have different training and expertise that when combined, can improve our conceptualizations and treatment plans for patients. To better understand how our different expertise can work together it is helpful to consider the differences in training and competency backgrounds. Pediatric psychologists typically attend graduate school and obtain a doctoral degree in some variant of health service psychology. During their doctoral training the psychologist completes a 1-year internship to obtain greater depth and breadth in their training while being supervised by licensed psychologists. In order to successfully complete internship, an intern must demonstrate competency and knowledge of assessment; intervention; diversity; consultation and interprofessional/interdisciplinary skills; supervision; research; ethical and legal standards; professional values, attitudes, and behavior; and communication and interpersonal skills (American Psychological Association, 2015). After completing internship it has become increasingly common for the psychologist to complete a 1- or 2-year postdoctoral fellowship to further specialize and strengthen their skills and competencies in pediatric psychology. At the end of a pediatric psychologist’s training, it is recommended/expected that they demonstrate competence in the following six areas: science, professionalism, interpersonal skills, application, education, and systems (Palermo et al., 2014).

Training to become a child and adolescent psychiatrist begins with 4 years of medical school, which typically includes about 2 years of didactic curriculum followed by 2 years of clinical rotations. After earning a medical degree, the most traditional path continues through a 3-or-4-year adult psychiatry residency specializing in adult/pediatric medicine, neurology, and adult psychiatry followed by a 2-year child fellowship focused on psychiatric work with children, adolescents, and their families. There are other pathways to becoming a child psychiatrist, including a 5-year triple board residency (combined training in Pediatrics, Adult Psychiatry, and Child Psychiatry) and the 6-year post pediatric portal program (AACAP, n.d.).

During a child psychiatrists’ residency and fellowship they gain competency in professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, scholarly activity, and system-based practice (ACGME, 2018). Board certified child psychiatrists are expected to have knowledge of child development, biological and clinical science (e.g., neuroscience, epidemiology, animal models of disease, genetics, statistics, and research design), psychopathology, treatment (e.g., psychopharmacology and psychotherapy), developmental assessment and diagnostics (e.g., mental status exam, diagnostic interviewing, differential diagnosis, rating scales, diagnostic imaging, medical/laboratory/genetic testing), issues in practice (e.g., legal issues, ethics, cultural issues, etc.), and consultation (ABPN, 2017).

Overall, psychologists and psychiatrists have many areas that overlap in their training. However, in contrast to a psychologist’s training, a psychiatrist has greater knowledge of medical issues, biological and clinical science, and psychopharmacology. Although psychiatrists receive training in screeners and a basic overview of psychological testing, psychiatrists are not competent in psychological assessments. Psychologists generally receive more in-depth training in research and psychotherapy; however, many psychiatry residency programs provide extensive training leading to competency in these areas.

Benefits of Combined Expertise of Psychiatry and Psychology

From our experiences as pediatric psychologists (HSB, AEW, AML) working in pediatric CL in both a separate psychology service and an integrated psychology/psychiatry service, we believe there are several potential benefits that can arise from working in close collaboration with our psychiatry colleagues. An obvious addition to the CL team that can be provided by a psychiatrist is expertise in psychotropic medications. As psychologists, we may at times have a bias toward psychotherapy or behavioral interventions due to our training and expertise, leading us to possibly be slower to consider medication options or not recognize situations in which medication management might be a helpful addition to the treatment plan. Psychiatrists also bring more depth of expertise to the identification, assessment, and treatment of cases involving challenging clinical presentations such as catatonia, extreme changes in mental status, delirium, etc., allowing us to be more efficient in the differential diagnosis of these conditions in our CL referrals. Finally, by virtue of their medical training a psychiatrist also provides more knowledge about medicine/pediatrics that can be extremely beneficial for several reasons: (1) helping psychologists fully understand the often very complicated health conditions and treatments our patients are experiencing, (2) improving psychologists’ command of medical terminology and therefore our ability to communicate more effectively with our pediatric colleagues, and (3) improved medical sophistication of our diagnostic justifications for, or against, conditions such as Conversion Disorder and other perplexing Somatic Symptom Disorders. This may be particularly helpful in cases where symptoms are inconsistent with a primary psychological etiology and advocacy is needed to encourage further medical workup.

Barriers to Collaboration

While the above data, and experiences, indicate that integrated teams may have the potential to obtain better patient outcomes by facilitating more efficient and effective collaboration, sometimes integrated teams are not possible. The general integrated care literature cites several barriers to successful integration including funding lines, organizational structures, poor collaboration among corresponding leadership, and “turf wars” (Ling, Brereton, Conklin, Newbould, & Roland, 2012); and these barriers are likely to sometimes pose a challenge in integration of psychiatry and psychology CL services as well. For example, it can be difficult to have fully integrated teams when psychology and psychiatry are housed in different departments, and thus have different funding mechanisms, within the hospital or academic institution. Although most pediatric CL psychologists report having good working relationships with psychiatry colleagues (Kullgren et al., 2015), historical “turf wars” between our professions (Schindler, Berren, & Beigel, 1981) have likely contributed to the organizational structure of psychiatry and psychology CL teams and may at times contribute to lingering tendencies to isolate our practices from each other. Nonetheless, psychologists who work on teams that are separate from psychiatry CL services can still establish effective collaborations, and even provide integrated care services, with psychiatry colleagues, particularly if they are intentional about ensuring regular and effective communication and collaboration with psychiatry colleagues.

Guidelines for Effective Collaboration

As with any collaborative effort, consultation teams benefit from taking the time to truly develop a plan for how the collaboration will work. Establishing pathways of communication and defining roles and responsibilities can greatly increase the chance that the care provided by psychiatry and psychology is truly integrated, rather than simply co-located, and will reduce the possibility of duplicative or perhaps even contradictory efforts.

To facilitate effective collaboration, Gutheil (1994) describes the “eight Cs” (clarity, contract, communication, consent, contact, comprehensive view, credentialing, consultation) of collaborative treatment that provide guidelines for successful collaboration in care and for avoiding potential problems. Collaborative care providers are suggested to establish a contractual arrangement with clarified roles and responsibilities, determine the frequency of regular communication and when more urgent/emergent contact should occur, and assure patient understanding of roles and patient consent to the level of communication and collaboration planned (Gutheil, 1994). Further, collaborators should have a mutual understanding of the others’ credentialing and experience (Gitlin & Miklowitz, 2016; Gutheil, 1994).

There are many obstacles potentially impeding regular and timely communication including coordination of schedules, non-billable nature of time spent on communication, power differentials in the dyad that may imply who contacts whom, and possible lack of physical proximity between the two providers (Gitlin & Miklowitz, 2016). As such, one of the easiest ways to ensure good communication among team members is to schedule daily, or nearly daily, team meetings or rounds during which all active patients are discussed. Carving out time each day can seem daunting, but having all disciplines together to discuss conceptualization and treatment planning is key to truly providing collaborative care. Without this type of frequent interaction and discussion of all patients, care can quickly become fragmented and less than optimal. For example, if a patient is quickly classified as a “behavioral patient,” managed solely by the psychology side of the team, and never again discussed by the whole team, a new symptom that might actually be a sign of a medical complication or adverse reaction to a medication might be missed. When defining roles and responsibilities, it is usually easiest if either the psychologist or psychiatrist is designated as the lead provider for each patient. That person takes the responsibility for leading discussion regarding conceptualization and treatment planning and also serves as the primary contact point for the consulting service.

Collaboration in Training and Education

As mentioned above, integrated CLservices often have a variety of professionals in training including psychology postdoctoral fellows, psychology interns, psychology practicum students, child psychiatry fellows, psychiatry residents, pediatric and peds/med residents, pediatric subspecialty fellows, and medical students (Kullgren et al., 2015). Not only do psychologists and psychiatrists benefit from working on an integrated CL service, but the various trainees’ education and depth of experience is enhanced when different disciplines train together.

While there appears to be a dearth of literature on the collaboration between psychiatry and psychology trainees, there is literature indicating several benefits to having psychology interns and pediatric residents train together. When psychology and pediatric residents train and attend didactics together, it appears to increase the likelihood that they will collaborate and work together in the future (Pidano, Arora, Gipson, Hudson, & Schellinger, 2018). Integrated training assists in promoting common language, referrals, and increased collaboration when working with complex cases (Jee, Baldwin, Dadiz, Jones, & Alpert-Gillis, 2018). Pediatric residents also find it valuable to observe psychology trainees interact with patients and vice versa (Jee et al., 2018), as they report learning new strategies for conducting clinical interviews and asking questions (Pisani, leRoux, & Siegel, 2011).

From our experience, when psychiatry and psychology trainees work together on teams, it enhances their knowledge of the other profession’s education, training, and unique expertise. It is imperative that each profession fully understand the skills and services offered by pediatric psychiatrists and psychologists to assist with formulating clear (and answerable) referral questions. Furthermore, it is valuable for psychology trainees to work beside their child psychiatry colleagues to further their competence by increasing their knowledge of medical conditions, their understanding of the bidirectional influence of medical conditions and mood/behavior, gaining a basic working knowledge of laboratory results, and their awareness of the efficacy and limitations of psychotropic medications. Similarly, psychiatry residents can learn from the psychology trainee’s knowledge of assessments (e.g., cognitive and academic), research, and often more in-depth training in the various modalities of psychotherapy and specialty interventions such as clinical biofeedback. Combined training allows trainees to supervise and role-play with one another, which can further foster learning. Additionally, training together allows psychiatrists and psychologists the opportunity to collaborate on scholarly activities such as research and quality improvement projects.

Case Examples

The following two case examples demonstrate the usefulness of collaboration between CL psychiatrists and psychologists.

Case Example 1

Jen is a 14-year-old girl with Autism Spectrum Disorder, seizure disorder, and self-injurious behaviors (SIB) who was admitted for intravenous antibiotics for forearm skin infection secondary to self-inflicted bites. The primary team consulted the consultation-liaison psychiatrist for medication management of agitation and SIB. In talking further with the primary team, they express concern about difficulty with wound healing and potential future infections due to Jen’s ongoing biting behaviors. They also reported concerns that Jen is persistently biting herself and hitting nurses and is easily agitated with care. Working together on an integrated CL service, the psychologist and psychiatrist discuss the case, potential medical workup, and behavioral and pharmacological interventions. They agree to evaluate the patient together. During the interview, mother reported that Jen will use one- to two-word phrases and has a moderate intellectual disability. She screams, bites, and hits during transitions or when she is unable to have access to a desired tangible item. When Jen has a tantrum, mother will either “give in” or give her gummy worms to stop the behavior. Mother reported that during the past month her behaviors have escalated and that she cannot identify any recent life changes. Mother noted that Jen has not had mental health services or medication in the past to help with her behavior problems. Mom does note that Jen has had diphenhydramine previously for hives and that she was very agitated on this medication. Jen has had prior issues with constipation and has not had a bowel movement in a week, according to her mother. Additionally, she was prescribed a new antiepileptic medication a month ago, which has seemed to make her more irritable. Mother also reported that with the medication change Jen has had more episodes than typical for her seizures. Furthermore, Jen often has an increase in her aggression when in pain.

After the evaluation, the CL psychologist and psychiatrist discuss the case and develop a conceptualization that contributions to her self-injurious behavior and agitation are multifactorial and include her baseline communication limitations, difficulty adjusting to the hospital setting, arm pain due to her wounds, constipation, possible side effect of her new antiepileptic medication, and possibly worsening seizure disorder. The psychiatrist recommends the primary team consult neurology for possible EEG and review of current medication choice given that the timeline for Jen’s exacerbation of baseline symptoms aligns with her medication changes. It is recommended to evaluate and treat her constipation and review her current pain treatment regimen. In addition, olanzapine (atypical antipsychotic) is recommended “as needed” for moderate to severe agitation while in the hospital if de-escalation techniques cannot be successfully used. The psychologist recommends and creates visual boards representing important aspects of care with preferred rewards and models how to use this with the mother, patient, and nursing staff. In addition, the psychologist works with mother on blocking and planned ignoring of self-injurious and negative behaviors, as well as positive attention toward preferred behaviors.

As illustrated in this case, patient presentations that have both a strong behavioral component and medical component benefit nicely from having both a psychiatrist and a psychologist collaborating in provision of CL services. In Jen’s case, the conceptualization of the patient was improved by having the psychologist and psychiatrist work collaboratively. The psychologist was able to assist with behavioral interventions and recognizing the impact of the pain, while the psychiatrist was effective in assisting with medication management and encouraging consultations from other medical subspecialties, i.e., neurology.

Case Example 2

John is a 12-year-old male who was admitted for burns. A psych consult was requested to “assist with coping.” After discussing the case in consult team rounds, it was decided that the psychologist would complete the initial interview and take the lead on the case. During the interview, it was disclosed that John, his friend, and John’s father were sitting by a firepit when John’s father went inside to get some water. In his father’s absence, John took kerosene from the family shed and as he was pouring kerosene on the fire, he accidentally spilled some on his clothing causing it to ignite. He has 52% total surface area burns, including burns to his trunk, the lower third of his face, and to his dominant hand requiring thumb and fore finger amputation. John had no baseline mental health problems (i.e., depression, anxiety, ADHD). Since admission to the hospital for his burn injury, the parents and medical staff reported that John was irritable and had a flat affect. He had expressed concern that he could no longer be able to play on his baseball team because of his hand injury. John exhibited several symptoms of Acute Stress Disorder (nightmares, intrusive thoughts of the accident and of dressing changes, feeling guilty, an increased startle response) and it was very difficult to get John to talk about the incident as he became very anxious when he was asked to do so. John’s dressing changes took significantly longer than they should due to John’s anxiety, panic attacks prior to dressing changes, and avoidant behavior. The primary team had given him lorazepam (an anxiolytic) at the start of the dressing change and found it mildly helpful in decreasing his anxiety. The psychologist provided psychoeducation on trauma symptoms to John’s parents and taught the patient behavioral techniques such as visualization and distraction to manage anxiety and promote relaxation (he was unable to engage in progressive muscle relaxation and diaphragmatic breathing due to the nature of his burns). The psychologist also worked with the primary team to decrease the number of dressing changes and medical interventions occurring in the patient’s room, moving him to the bathroom when possible to do these interventions, in an effort to create a “safe space” in his patient room. In addition, the psychologist worked with John to identify themes in his nightmares and help him rescript or create and visualize the content of his nightmares to be less threatening. Despite these behavioral interventions, John continued to have nightmares and panic attacks and his anxiety had only slightly improved. In addition, his sleep became more disturbed by the nightmares, causing him to get only 3 to 4 h of sleep a night and affecting his ability to cope during the day.

In consult team rounds, the psychologist discussed the case with the psychiatrist, and it was decided that the psychiatrist would evaluate John to see if medication would be appropriate for his nightmares and panic attacks. Since John’s symptoms had only started a week prior and he did not have a history of anxiety or depression, the psychiatrist planned to continue to monitor the need for consideration of a more long-acting medication (e.g., a SSRI) while therapeutic interventions were implemented. Additionally, the psychiatrist recommended prazosin (an antihypertensive drug that appears to have some efficacy in decreasing anxiety via dampening the norepinephrine effects likely contributing to the nightmares) to help with his nightmares. It was also decided that the psychologist would accompany John to his next dressing change to assist with behavioral techniques, e.g., coaching John in imagery techniques, providing distractions, and modeling positive self-statements. With the titration of the medication and psychologist coaching during his dressing change, his anxiety decreased significantly. John did not have any additional panic attacks and the dressing change was not prolonged as it previously had been. John’s sleep also improved, and he no longer experienced nightmares.

In this case, close collaboration between the psychologist and the psychiatrist was essential to achieving desired outcomes. Given the severity of John’s anxiety and trauma symptoms at admission, the behavioral techniques the psychologist utilized were of minimal efficacy. The psychiatrist prescribed a medication beneficial in treating his nightmares and improved his sleep. The intervention allowed the psychologist’s treatment strategies to become more effective and optimized John’s treatment.

Conclusion

In conclusion, there is limited research on the collaboration of psychiatry and psychology, especially in CL settings, and future research is needed to better understand the benefits of collaboration. Despite the sparse literature, existing evidence suggests close collaboration between psychiatry and psychology in providing pediatric CL services is likely to result in more efficient care with better outcomes. When psychiatry and psychology providers collaborate effectively, they are able to capitalize on and integrate each of their unique strengths to create a more robust psychological conceptualization of the patient leading to an often more efficient and effective treatment plan. In addition to patients benefitting from collaboration between psychiatry and psychology for CL services, trainees can also benefit from training with both psychiatrists and psychologists and alongside other disciplines.