Psychosocial Issues, Medicine and Clinical Psychology - Essay Example

Running Head: inter-professional working The culture of individual professions can present barriers to inter-professional working of the writer] [Name of the institution] The culture of individual professions can present barriers to inter-professional working Traditionally, clinical psychologists in hospital settings have worked with psychiatric patients. The literature suggests, however, that over the last decade, increasing numbers f clinical psychologists have begun working in hospital settings such as pediatrics, neurology, surgery, oncology, spinal cord injury units, and others (Asken, 1979; Blanchard, 1982; Dana & May, 1986; Du Toit, 1985; Gabinet & Friedson, 1980; Masur, 1979; Schlebusch, 1983; Taylor, 1987). The field f clinical psychology in the general hospital, however, remains relatively new and undefined. Practice has been inadequately described, and there is little literature as yet on the adjustments and negotiations that have to occur when psychologists interact with the medical system. On the surface, the addition f clinical psychologists to the health care team may appear to be an unproblematic process. A need for psychological expertise among medical patients has been identified, and psychologists have the requisite expertise. We hope to show in this article, however, that the involvement f the psychologist in the health team is a complex matter, subject to a number f difficulties, not the least f which is the question f professional power relationships. A prior issue, however, is that f the place f clinical psychology with regard to medical theory and practice. This interdisciplinary interface occurs within a "generalprofessional culture which cuts across regional boundaries and which is limited more by class and by educational background than by national origin" (Swartz, 1985, p. 727). Interprofessional relationships within various Western contexts are therefore discussed without particular reference to nationality. Psychosocial Issues, Medicine, and Clinical Psychology Toulmin (1978) pointed out that there are numerous medical models or ways f conceptualizing disease and illness, and these models take account f psychosocial issues to varying degrees. A distinction that may be useful in discussing these issues in medicine is that commonly drawn by medical anthropologists between disease and illness. Disease may be understood as the biological component f sickness, whereas illness has been defined as a subjective experience consisting f "an array f discomforts and psychosocial dislocations resulting from interaction f a person with the environment" (Barondess, 1979, p. 375). Disease is neither a necessary nor a sufficient condition for the presence f illness (Sullivan, 1986), in that it is possible to experience the social role f illness without any biological pathology. Conversely, pathology may exist, without any subjective experience f it, and hence a person may have a disease without being ill. Biomedicine is the dominant model in Western medicine (Fabrega, 1978). The biomedical model is said to explain health and sickness in terms f the physical, chemical, and physiological changes in the bodily systems f an individual, divorced from the person's experience f sickness and from the social context (Kleinman, 1978). The model's strength lies in its elucidation f the biological mechanisms f sickness, but it is limited by its neglect f psychosocial aspects (Bignami, 1982; Engel, 1977; Fabrega, 1978; Kleinman, 1978; McHugh & Vallis, 1986a; Rogers, 1982). Tancredi and Edlund (1983) commented that this model does not recognize "the fact that medicine is as much a social science as it is a biological science" (p. 314). Toulmin (1978) suggested that the biomedical model inappropriately facilitates the patient's being seen as the sum total f his or her biological ailments. In other words, biomedicine focuses on disease to the exclusion f illness. As an alternative to the biomedical model, Engel (1977) developed the biopsychosocial model, which is a systems approach and by which Engel attempted to take into account biological, psychological, and social factors. The extension f clinical psychological practice into nonpsychiatric hospital settings may be understood as being in keeping with the spirit f the biopsychosocial model. In spite f the development f the biopsychosocial model and other attempts to integrate psychosocial factors into medical care (Mayou & Smith, 1986; McHugh & Vallis, 1986b; Nethercut & Piccione, 1984; Schenkenberg, Peterson, Wood, & DaBell, 1981), biomedicine remains the dominant model f health and sickness in Western medicine. As an explanation for the continued power f biomedicine, Engel (1977) suggested that the biomedical model, despite originally being a scientific model, has since become a (Western) culturally derived belief system or folk model f disease: In our culture, the attitudes and belief systems f physicians are moulded by this model long before they embark on their professional education, which in turn reinforces it. The biomedical model has thus become a cultural imperative, its limitations easily overlooked. In brief, it has now acquired the status f dogma. (p. 130; original emphasis) Lock and Lella (1986) pointed out that medical knowledge and practice are historically, socially, and culturally constructed, and this makes it unlikely that the biomedical model would be supplanted purely on grounds f usefulness or adequacy f explanation. Armstrong (1987) noted that "orthodoxy traditionally manages to control the threat from the unorthodox by a strategy f either marginalization or incorporation" (p. 1213), and one may argue that both f these strategies are used to maintain the dominance f biomedicine, which has the secondary result f maintaining the devalued position f psychosocial issues in health care. In examining the work f clinical psychologists in general hospitals, one needs to bear these issues in mind, as they are subtle and unspoken and, by their very nature, are often not consciously appreciated either by psychologists themselves or by their medical colleagues (Miller, 1988). Conceptualizing Multidisciplinary Practice What precisely is the relationship between clinical psychologists and other health care personnel The term consultation-liaison has enjoyed systematic attention in the literature pertaining to different professional contributions to health care and provides a convenient focus for discussing clinical psychological practice in health care settings. Much f the relevant literature on consultation-liaison comes from psychiatry. Furthermore, health care personnel working together are commonly referred to as a team (Du Toit, 1985), but the term team does not mean the same to all who use it (Miller, 1988). We examine clinical psychological practice first from the perspective f consultation-liaison and then in the light f further issues that have been raised about teamwork. In each case, we present conceptual issues, followed by an example from clinical practice. Consultation-Liaison According to Johnson (1985), consultation and liaison activities can be distinguished in the following way: As a consultant, the psychiatrist is like any other specialist in the hospital with a specific area f expertise. [who] is asked to examine patients and offer suggestions for treatment without necessarily providing ongoing care. Thus, consulting activities typically consist f brief interaction with patients and other specialists on a wide variety f clinical services in which psychiatrists evaluate and make recommendations for dealing with specific "patient problems". In contrast, in liaison activities the psychiatrist participates as an active member f the treatment team on a specific medical or surgical service, engaging in activities such as "bedside rounds", inservice training for staff, and collaborative research. Liaison activities also frequently involve coordinating "support groups" or "psychotherapy groups" for staff or for patients' families. (Johnson, 1985, p. 270). Advantages and disadvantages f consultation and liaison Consultants seem to be independent f the unit to which they consult; they have the status f "any other specialist in the hospital with a specific area f expertise" (Johnson, 1985, p. 270) and, as such, are not subject to the authority f the head f the unit. They pay for this autonomy, however, with restricted access to the units to which they consult, by requiring invitation into these units, and with the knowledge that their recommendations are not binding in any way. In many cases, consultants have to accept the consultee's delimitation f the problem and the boundaries f the request. Liaisors, 1 on the other hand, being part f the units they work in, are far more involved with the life f the unit. Therefore, they have unlimited access to the unit; liaisors have their own perceptions f problems in the unit and may be more able to extend the boundaries f a request or intervene without an explicit request to do so. Although liaisors cannot ensure that their recommendations are adhered to, it is more probable that their recommendations would be carried through because f the liaisors' continual presence in the unit, their relationships with consultees, and their greater involvement in the intervention recommended. In other words, what liaisors sacrifice in autonomy and independent status as the "expert who is called in" (Johnson, 1985, p. 270) they make up in efficacy as a result f their closer relationships with other staff members and their continual presence in the unit. Consultation-liaison and marginalization One f the major aims f consultation-liaison psychiatry is to educate nonpsychiatric professionals about psychosocial issues (Lipowski, 1975), and yet it fails to fundamentally change the practice f medicine. Psychiatry is devalued by the rest f the medical profession (Johnson, 1986), and psychiatric consultants collude in this devaluation by, for instance, explicitly not using psychiatric terminology (Baudry & Wiener, 1975; Golden 1975), an expectation that would be ludicrous if applied to any other medical specialty (Wise & Berlin, 1981). Johnson (1985) described the marginality f the psychosocial tradition, and his comments on psychiatry apply equally to clinical psychology. For example, psychiatry does not have a technology comparable with the sophisticated biotechnology f laboratory tests and investigations, complex surgery, magnetic resonance imaging, and so on. The data important to psychiatry are particularly those data that are neglected by the rest f medicine. Consultation-liaison psychiatry is structurally marginalized: Consultants work in the departments f other medical specialties. The "patient" in consultation-liaison work may be a network f people, and their status as patients may be disputed by the consultee. This object f care is less tangible than the usual patient, and the results f intervention are also less tangible; they often cannot be written up in a patient's folder and cannot be seen to be concretely contributing to the cure f the individual patient. Conclusion: Power and Professional Relationships Psychologists working in medical settings do not have access to the knowledge f disease that is seen to be important within biomedicine. This immediately excludes them from direct access to power in this context. Furthermore, given the culturally valued position f biomedicine, medical practitioners are imbued with social status that allows them to claim expertise over all aspects f patient care. With the physician as explicit team leader, it may often be acceptable for the physician to make suggestions about the psychological welfare f patients; a psychologist's suggestions about medical care are likely to be seen as unprofessional and unwelcome. Trained to take full responsibility for their clients, psychologists in health care settings find themselves disadvantaged in the hierarchical hospital structure. Possible responses to this situation, some f which we have outlined before, include the following, each f which is related to the others and none f which excludes the others: Psychologists may be tempted to collude in the devaluation f their expertise for the sake f harmonious working relationships. This strategy has the potential not only to deprive patients f valuable expertise but also to limit the contribution f psychology to health care in the long term. Psychologists may ostensibly accept medical authority without question, but they may inexplicitly acquire power over colleagues by using therapeutic skills. This amounts to abuse and manipulation and is also potentially frustrating for the psychologist because it does not provide access to real power. Psychologists may accept and reproduce the power hierarchy by devaluing the knowledge and expertise f those professionals whose ascribed status is lower than that f both psychologists and physicians, such as nurses and social workers. Interprofessional power differentials may be directly acknowledged and confronted. Recognition f power issues between psychologists and other health care professionals represents an important first step in ensuring that health care is improved rather than simply complicated by the psychologist's presence. This, however, is not enough. Psychologists have a responsibility to make explicit the issues f power that are usually not acknowledged and to negotiate ways f working with other professionals, particularly medical professionals. This is not something that can be achieved in a single discussion, nor is it always likely to be welcomed. Continued awareness f and open response to the dynamics f professional relationships is probably difficult, in that it challenges existing power structures, but necessary if health care is to reap maximum benefit from the expertise f psychologists. References Armstrong, D. (1987). Theoretical tensions in biopsychosocial medicine. Social Science and Medicine, 25, 1213-1218. Asken, M. J. (1979). Medical psychology: Toward definition, clarification, and organization. Professional Psychology, 10, 66-73. Barondess, J. (1979). Disease and illness-A crucial distinction. American Journal f Medicine, 66, 375-376. Baudry, F. D., & Wiener, A. (1975). The surgical patient. In J. J.Strain & S.Grossman (Eds.), Psychological care f the medically ill: A primer in liaison psychiatry (pp. 123-137). New York: Appleton-Century-Crofts. Bignami, G. (1982). Disease models and reductionist thinking in the biomedical sciences. In S.Rose (Ed.), Against biological determinism (pp. 94-110). London: Allison and Busby. Blanchard, E. B. (1982). Behavioral medicine: Past, present and future. Journal f Consulting and Clinical Psychology, 50, 795-796. Dana, R. H., & May, W. T. (1986). Health care megatrends and health psychology. Professional Psychology: Research and Practice, 17, 251-255. Du Toit, Q. (1985). The role f the clinical psychologist in total patient care in a neurosurgery unit. In K. W.Grieve & R. D.Griesel (Eds.), Proceedings f the Second South African Neuropsychology Conference (pp. 234-241). Pretoria, South Africa: S. A. Brain and Behaviour Society. Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136. Fabrega, H. (1978). Ethnomedicine and medical science. Medical Anthropology, 2, 11-24. Gabinet, L., & Friedson, W. (1980). The psychologist as front-line mental health consultant in a general hospital. Professional Psychology, 11, 939-945. Gabinet, L., & Friedson, W. (1981). The impact f ward dynamics on psychiatric consultation and liaison. Comprehensive Psychiatry, 22, 603-611. Golden, J. S. (1975). The surgeon and the psychiatrist: Special problems in psychiatric liaison. In R. O.Pasnau (Ed.), Consultation-liaison psychiatry (pp. 123-133). New York: Grune & Stratton. Johnson, T. M. (1985). Consultation-liaison psychiatry: Medicine as patient, marginality as practice. In R. A.Hahn & A. D.Gaines (Eds.), Physicians f Western medicine (pp. 269-292). Dordrecht, The Netherlands: D. Reidel. Johnson, T. M. (1986). Medical education and practice on the periphery: Consultation psychiatry and the psychosocial tradition in American medicine. Social Science and Medicine, 22, 963-971. Kleinman, A. (1978). International health care planning from an ethnomedical perspective: Critique and recommendations for change. Medical Anthropology, 2, 71-94. Lipowski, Z. J. (1975). Consultation-liaison psychiatry: Past, present and future. In R. O.Pasnau (Ed.), Consultation-liaison psychiatry (pp. 1-28). New York: Grune & Stratton. Lock, M., & Lella, J. (1986). Reforming medical education: Towards a broadening f attitudes. In S.McHugh & T. M.Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. 47-58). New York: Plenum Press. Masur, F. T., III. (1979). An update on medical psychology and behavioral medicine. Professional Psychology, 10, 259-264. Mayou, R., & Smith, E. B. O. (1986). Hospital doctors' management f psychological problems. British Journal f Psychiatry, 148, 194-197. McHugh, S., & Vallis, T. M. (1986a). Illness behaviour: Operationalization f the biopsychosocial model. In S.McHugh & T. M.Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. 1-31). New York: Plenum Press. McHugh, S., & Vallis, T. M. (1986b). Preface. In S.McHugh & T. M.Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. v-vi). New York: Plenum Press. Miller, T. D. (1988). Clinical psychology in a general hospital setting: Conflicts and paradoxes.Unpublished master's dissertation, University f Cape Town, Cape Town, South Africa. Nethercut, G., & Piccione, A. (1984). The physician perspective f health psychologists in medical settings. Health Psychology, 3, 175-184. Rogers, L. (1982). The ideology f medicine. In S.Rose (Ed.), Against biological determinism (pp. 79-93). London: Allison and Busby. Schenkenberg, T., Peterson, L., Wood, D., & DaBell, R. (1981). Psychological consultation/liaison in a medical and neurological setting: Physicians' appraisal. Professional Psychology, 12, 309-317. Schlebusch, L. (1983). Consultation-liaison clinical psychology in modern general hospital practice. South African Medical Journal, 64, 781-786. Sullivan, M. (1986). In what sense is contemporary medicine dualisticCulture, Medicine and Psychiatry, 10, 331-350. Swartz, L. (1985). Anorexia nervosa as a culture-bound syndrome. Social Science and Medicine, 20, 725-730. Tancredi, L. R., & Edlund, M. (1983). Are conflicts f interests endemic to psychiatric consultationInternational Journal f Law and Psychiatry, 6, 293-316. Taylor, S. E. (1987). The progress and prospects f health psychology: Tasks f a maturing discipline. Health Psychology, 6, 73-89. Toulmin, S. (1978). Psychic health, mental clarity, self-knowledge and other virtues. In H. T.EngelhardtJr., & S. F.Spicker (Eds.), Mental health: Philosophical perspectives (pp. 55-70). Dordrecht, The Netherlands: D. Reidel. Wise, T. N., & Berlin, R. M. (1981). Burnout: Stresses in consultation-liaison psychiatry. Psychosomatics, 22, 744-751. Read More