Introduction

Abstract

Over 60 years ago, the English pediatrician and psychoanalyst Donald W. Winnicott (1896–1971) astutely observed: “There’s no such thing as a baby” (Winnicott 1964/1947). Today, most psychiatrists are keenly aware that there’s no such thing as a “patient”; that is, a patient exists inside an environment that includes their families, the treating physicians, treatment teams, subspecialty consultants, and other clinical providers. In turn, a patient’s interactions with these groups are heavily influenced by their prior experiences, cognitive styles, attachment patterns, temperaments, and most importantly, their cultural backgrounds. Frequently, for most of those in need of aid, treatment is effectively provided and received, and recovery ensues. However, when treatment does not go according to plan, the parties involved can experience anxieties that lead to unexpected negative outcomes. If the patient’s treatment becomes derailed due to their personality or to cognitive problems, the treatment team begins to view the patient as “noncompliant” or “difficult,” and they request a psychiatric consultation. When the patient’s treatment becomes thwarted by family factors, psychiatrists are also asked to provide insight. These consultations may result in recommendations regarding psychopharmacologic strategies for various neuropsychiatric disorders (e.g., delirium, depression secondary to α-interferon therapy, postpartum psychosis) or the clarifying of psychiatric diagnoses. Sometimes, however, clinical consultations are much more complex and fraught—“difficult clinical consultations”—requiring an integrated effort that combines the careful assessment of the patient from a multidimensional perspective (psychodynamic, family, and ethical) with an informed strategy for the treatment team and the patient’s family. In Difficult Psychiatric Consultations: An Integrated Approach, we will describe effective approaches to difficult psychiatric consultations and in doing so will comprehensively discuss issues and impediments related to the patient, the family, and the treatment team. In addition, we’ll explore the ethical and cultural aspects of managing these “difficult consultations.” Our goal in presenting this systematic approach is to facilitate the psychiatric consultant’s work within the larger healthcare system and to provide reliable and usable tools for the consultant who works with complex patients and their treatment teams.

There’s no such thing as a baby

—Donald W. Winnicott (1896–1971)