Management of Patient-Staff and Intrastaff Problems in Psychiatric Consultations Michiel W. Hengeveld, Coen L. Tuinstra, Ir.
M.D., Ph.D.,
Abstract: Four possible types of management of patient-staff andlor intrastaff (PSI1.S~problems in psychiatric consultations are distinguished and operationalized. The occurrence and correlates of these types of interventions were studied in a multisite investigation of 1112 consecutive consultations in five general hospitals. PSIIS problems (possibly, probably, or certainly) played a role in 28.1% of the consultations studied. The psychiatric consultants utilized a primarily patient-oriented approach in 56.7% of these 310 consultations, whereas in 42.3% they performed (covert or overt) staff-oriented case consultations, A staff-oriented approach may be contraindicated when the PSIIS problems are not vey serious or too complex. In the literature staff resistance and hospital culture are frequently mentioned as obstacles to staff-oriented interventions. The present study showed, however, that it was often the consultants’ own degree of security about the PSIIS problems that determined the way they handled these problems. Staff-oriented consultations took significantly more of the psychiatric consultants’ time. The clinical and economic benefits of such interventions have still to be established. But the psychiatric consultant with a true biopsychosocial approach should always be cognizant of the possible occurrence of PSIIS problems and consider applying a staff-oriented intervention. To allow for methodologically sound cost-offset/ cost-effectiveness research in consultation-liaison (CL) psychiatry, there is a great need for operationalization of CL interventions [l]. An essential element of the CL psychiatrist’s management is the From the State University of Leiden and Psychiatric Consultation-Liaison Service, University Hospital Leiden, Leiden (M.W.H.); Psychiatric Consultation-Liaison Service, University Hospital Dijkzigt, Rotterdam (R.C.v.d.M.); and DeDartment of Medical Informatics, State Universitv of Leiden Mehical School, Leiden (C.L.T.), The Netherlands.Address reprint requests to: Michiel W. Hengeveld, M.D., Ph.D., Department of Psychiatry, Bl-l’, University Hospital, P.O. Box 9600, NL-2300 RC Leiden, The Netherlands. General Hospital Psychiatry 13, 31-38, 1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Rose C. van der Mast, M.D., and
handling of patient-staff and/or intrastaff (E/IS) problems. l’S/IS problems may be defined as problems or conflicts of a psychologic nature that give rise to difficulties in the hospital care of the patient. Such problems can be experienced 1) intrapersonally within physicians, nurses, or other general hospital ward staff; 2) interpersonally between the patient and one or more members of the ward staff; or 3) interpersonally among various members of the ward staff [2-41. According to our own studies specifically directed at determining the incidence of ES/IS problems, possible or certain PS/IS problems were found in one third of all inpatient psychiatric consultations, excluding consultations with patients admitted to the hospital following a suicide attempt [2,3,5]. In a previous publication we described the assessment of PYIS problems in psychiatric consultations [3]. This article will first present an operationalization of the ways a CL psychiatrist can handle PS/IS problems, followed by a report on a multisite investigation by members of the Netherlands Consortium for ConsultationLiaison Psychiatry (NCCP) into the occurrence and correlates of staff-oriented interventions.
Operationalization Interventions
of Staff-Oriented
In general, the relevant literature contains more descriptions of the appearance and causes of I’S/ IS problems than reports of management. Virtually no quantitative research has been carried out to investigate how often a staff-oriented approach of PS/IS problems is applied. Lowe et al. [6], who expressly aimed at performing consultee-oriented 31 ISSN 0163~S343/91/$3.50
M. W. Hengeveld et al.
consultations, achieved this in 20.5% of 307 referrals. Lipowski and Wolston [7], in two comparative reports on 1000 consultations, mentioned that staff mediation in staff-patient conflicts was performed in 12% and 5% of the referrals, respectively. In an earlier study by Hengeveld [2], it was found that the consultants applied a staff-oriented approach in 15.8% of the 562 consultations investigated. The case examples described by various authors provide an impression of how to handle IS/IS problems. The psychiatrist may transfer the patient, alter psychotropic medication, or advise the use of restraint, with the ulterior motive of helping to solve the IS/IS problems [8-lo]. Alternatively, he or she may provide more accurate information about the patient on the chart, thus, for example, minimizing the possibility of aggressive fantasies among the staff [ll]. The consultant may also spend more time with the patient, or partly take over the care of the patient, in order to lighten the emotional burden of the staff [9,10,12-141. In these examples, there is strictly speaking no question of a staff-oriented case consultation, as classically defined by Caplan [15]; the psychiatrist does not try to teach the ward staff to improve their emotional handling of such patients. One might say that the consultant performs an almost completely patientoriented consultation, but in doing so he or she is taking the IS/IS problems into account. Many authors emphasize the importance of explaining the personality [16], the behavior [8,11,17191, the problems [20], the psychiatric disorder [10,21], the defense mechanisms [12], or the possible primitive ambivalent feelings [22] of the patient. Giving the staff a conceptual framework to understand the patient could increase their tolerance for the patient’s behavior, reduce tension on the ward, and enhance patient-staff communication [ 1819,231. If the consultant expresses the feelings a patient evokes, this may support the staff by making it easier for them to accept having such emotional reactions to the patient [18]. By emphasizing that not all treatment is curative, in either medicine or psychiatry, the psychiatrist may lower the expectations of the staff and alleviate feelings of hopelessness or depression [11,13]. In these cases, the consultant’s activities are expressly focused upon the IS/IS problems, with the intention, be it in an implicit way, of teaching the staff to improve their emotional handling of such a patient. Consequently, such an approach can be identified as covert staff-oriented case consultation. The importance of probing the emotional prob32
lems of the physician or nurses in relation to the patient is stressed by many authors [19,23]. This may be done to foster a deeper awareness of the staff’s own emotional reactions [24-261, or to enable them to ventilate their concerns, frustrations, or anger [20,23]. One may also discuss the dynamics of the patient-physician relationship [10,27,28], thus revealing some of the implications of the staff’s attitudes to the patient’s behavior [25,29]. Because in these cases the ES/IS problems are explicitly talked about with the ward staff, one might speak of overt staff-oriented case consultation. It is often not easy to draw a borderline between covert and overt staff-oriented consultation. There is a fairly smooth transition between the two categories. But if one uses the criterion of the consultant openly discussing their own emotional problems with the physician or ward staff, one is able in most cases to categorize the staff-oriented activities. Subsequent to the introduction of the abovementioned categorization and operationalization of staff-oriented interventions of PS/IS problems in CL psychiatry, we were able to investigate the occurrence and correlates of such interventions.
Methods and Patients This study was appended to the collaborative 1984 registration of psychiatric consultation data by the NCCP [30]. Through this nationwide registration project, a standardized 30-item data base was compiled, including the following patient and consultation characteristics: sociodemographic patient characteristics, referral characteristics, patients’ treatment history, somatic and psychiatric diagnoses, diagnostic recommendations and actions, ward management, discharge and aftercare management, and termination data. The psychiatric consultants of three university hospitals and two general hospitals in various urban parts of The Netherlands enrolled in this particular IS/IS problems study. They were asked to record for each consultation whether, in their own opinion, PYIS problems had certainly, probably, or possibly played a role. When this was the case, they scored whether they had strictly performed a patientoriented consultation, had taken the IS/IS problems into account, or had performed a (covert or overt) staff-oriented case consultation. Demographic characteristics of the five hospitals involved (excluding psychiatry and pediatrics) are presented in Table 1. Included in our study were
Patient-Staff
Table 1. Characteristics
of the five hospitals
Table 2. Characteristics patients (%)
involved Range 370-903 Number of beds Number of admissions per annum 10,051-22,562 Mean length of patient 10.8-12.3 stay (days) Sex of patients 42.5-50.0 Male (%) 50.0-57.5 Female (%) Age of patients 35.6-46.0 15-44 yr (%) 27.7-37.9 45-64 yr (%) 19.0-36.7 More than 64 yr (%) Psychiatric 0.9-3.0 consultation rate (%)
All hospitals 3,081 81,941 11.6 48.0 52.0 42.5 32.0 25.4 1.6
inpatient psychiatric consultations on all wards of these hospitals, with the exception of the pediatric wards. Excluded were consultations with patients admitted following a suicide attempt, as these patients’ stay in the hospital is usually very short, and because for these admissions, psychiatric consultations are often performed as a matter of routine. The number of consultations studied amounted to 1118. The characteristics of these consultation patients are shown in Table 2. The psychiatric consultation data were collected on a DEC minicomputer and through remote communication analyzed on an IBM mainframe, using SAS and SPSS for statistical analysis.
Results According to the psychiatric consultants in three university and two general hospitals, WIS problems possibly, probably, or certainly played a role in 312 (28.1%) of 1112 consultations (data of six consultations were missing). Table 3 presents the consultants’ approach when PS/IS problems were identified (data of two more consultations were missing). The consultants of the five hospitals did not differ statistically significantly in their approach to PYIS problems. If we relate the figures to the entire group of consultations studied, it appears that (covert or overt) staff-oriented case consultations were applied in 11.8% of all 1112 consultations.
and Intrastaff
Problems
of the 1112 consultation
Sex Male Female Age 15-44 yr 45-64 yr More than 65 yr Marital status Single Married or living together Separated or divorced Widowed Referring service Medicine Neurology Surgery Obstetrics/gynecology Other Psychiatric disorder (DSM-III) Organic mental Substance abuse Affective/anxiety Somatoform, factitious, psychophysiologic Adjustment Other Diagnosis deferred No psychiatric disorder Main somatic disorders (sections of ICD-9) Neoplasms Endocrine, nutritional, metabolic, immunity Nervous system and sense organs Circulatory tract Digestive tract Injuries Other
49.9 50.1 33.5 33.2 33.2 22.9 54.0 7.9 15.1 48.6 8.5 37.4 3.7 1.8 31.2 10.0 13.4 8.2 12.5 6.5 5.4 13.3 18.1 9.1 9.0 10.7 9.9 8.0 35.3
Correlates of Staff-Oriented Case Consultations There appeared to be a strongly significant relationship between the consultants’ degree of certainty about the presence of WIS problems and their approach to these problems (X2 test, p < 0.001). The consultants performed stafforiented case consultations in only 29.0% of the cases where PWIS problems were possibly present, whereas they did so in 57.8% of the consultations when they were certain of the presence of PYIS problems. The correlation between the consultants’ degree of certainty and the consultations’ orientation was 0.25 (Pearson product-moment correlation test, p = 0.001). Univariate X2 testing was performed in order to test the relationships between the orientation of 33
M. W. Hengeveld et al.
Table 3. Management
of ES/IS problems
Not at all Taken into account Covert staff-oriented case consultation Overt staff-oriented case consultation
111 68 96 35
(35.8%) (21.9%) (31.0%) (11.3%)
Total
310 (100.0%)
the consultation (patient- or staff-oriented) on the one hand, and the 30 patient and consultation characteristics registered on the other hand. No relationships were found with sociodemographic and patient treatment history characteristics. Nor were referral characteristics, such as the specialty of the referring physician, the type of ward, the urgency of the referral, or the reason for referral, related to the orientation of the intervention. Psychiatric and psychosocial diagnostic recommendations or actions appeared to be inversely related to stafforiented case consultations (a staff-oriented intervention was realized in only 17.2% of the consultations in which the psychiatric consultant recommended or performed further psychosocial or psychiatric diagnostic actions). As far as somatic and psychiatric diagnoses were concerned, we found a slightly significant relationship between grouped DSM-III Axis I diagnoses and the consultation’s orientation. Staff-oriented consultations were performed less often with patients with nonorganic psychotic disorders (16.7%) and organic mental disorders (28.6%), and more often with patients with somatoform disorders (57.1%) or with no psychiatric disorder (56.3%). Psychotherapeutic treatment of the patient on the ward appeared to be related to staff-oriented consultations (53.9%). Other relationships with ward management characteristics could not be shown, nor were discharge and aftercare management characteristics related to the orientation of the consultations. We found, however, several relationships with three variables indicating the time spent on the consultation. Stafforiented consultations were performed in 54.8% of the consultations in which the first visit lasted at least 1 hour, in 50.9% of the consultations with a mean follow-up visit duration of more than 20 minutes, and in 51.1% of the consultations with a total duration of at least 85 minutes. Table 4 gives a summary of the seven variables that correlated with the direction of the approach of the PS/IS problems. The significant relationship between the orien-
34
Table 4. Variables significantly related to a staff-oriented management of the consultation Variable High probability of PI/IS problem No psychiatric or psychosocial diagnostic actions or recommendations DSM-III Axis I classification: somatoform disorder; no psychiatric disorder Psychotherapeutic treatment on ward Long duration of first visit Long mean duration of follow-up visits Long total duration of entire consultation
p-value (x’ test)
M.D., Ph.D.,
Abstract: Four possible types of management of patient-staff andlor intrastaff (PSI1.S~problems in psychiatric consultations are distinguished and operationalized. The occurrence and correlates of these types of interventions were studied in a multisite investigation of 1112 consecutive consultations in five general hospitals. PSIIS problems (possibly, probably, or certainly) played a role in 28.1% of the consultations studied. The psychiatric consultants utilized a primarily patient-oriented approach in 56.7% of these 310 consultations, whereas in 42.3% they performed (covert or overt) staff-oriented case consultations, A staff-oriented approach may be contraindicated when the PSIIS problems are not vey serious or too complex. In the literature staff resistance and hospital culture are frequently mentioned as obstacles to staff-oriented interventions. The present study showed, however, that it was often the consultants’ own degree of security about the PSIIS problems that determined the way they handled these problems. Staff-oriented consultations took significantly more of the psychiatric consultants’ time. The clinical and economic benefits of such interventions have still to be established. But the psychiatric consultant with a true biopsychosocial approach should always be cognizant of the possible occurrence of PSIIS problems and consider applying a staff-oriented intervention. To allow for methodologically sound cost-offset/ cost-effectiveness research in consultation-liaison (CL) psychiatry, there is a great need for operationalization of CL interventions [l]. An essential element of the CL psychiatrist’s management is the From the State University of Leiden and Psychiatric Consultation-Liaison Service, University Hospital Leiden, Leiden (M.W.H.); Psychiatric Consultation-Liaison Service, University Hospital Dijkzigt, Rotterdam (R.C.v.d.M.); and DeDartment of Medical Informatics, State Universitv of Leiden Mehical School, Leiden (C.L.T.), The Netherlands.Address reprint requests to: Michiel W. Hengeveld, M.D., Ph.D., Department of Psychiatry, Bl-l’, University Hospital, P.O. Box 9600, NL-2300 RC Leiden, The Netherlands. General Hospital Psychiatry 13, 31-38, 1991 0 1991 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Rose C. van der Mast, M.D., and
handling of patient-staff and/or intrastaff (E/IS) problems. l’S/IS problems may be defined as problems or conflicts of a psychologic nature that give rise to difficulties in the hospital care of the patient. Such problems can be experienced 1) intrapersonally within physicians, nurses, or other general hospital ward staff; 2) interpersonally between the patient and one or more members of the ward staff; or 3) interpersonally among various members of the ward staff [2-41. According to our own studies specifically directed at determining the incidence of ES/IS problems, possible or certain PS/IS problems were found in one third of all inpatient psychiatric consultations, excluding consultations with patients admitted to the hospital following a suicide attempt [2,3,5]. In a previous publication we described the assessment of PYIS problems in psychiatric consultations [3]. This article will first present an operationalization of the ways a CL psychiatrist can handle PS/IS problems, followed by a report on a multisite investigation by members of the Netherlands Consortium for ConsultationLiaison Psychiatry (NCCP) into the occurrence and correlates of staff-oriented interventions.
Operationalization Interventions
of Staff-Oriented
In general, the relevant literature contains more descriptions of the appearance and causes of I’S/ IS problems than reports of management. Virtually no quantitative research has been carried out to investigate how often a staff-oriented approach of PS/IS problems is applied. Lowe et al. [6], who expressly aimed at performing consultee-oriented 31 ISSN 0163~S343/91/$3.50
M. W. Hengeveld et al.
consultations, achieved this in 20.5% of 307 referrals. Lipowski and Wolston [7], in two comparative reports on 1000 consultations, mentioned that staff mediation in staff-patient conflicts was performed in 12% and 5% of the referrals, respectively. In an earlier study by Hengeveld [2], it was found that the consultants applied a staff-oriented approach in 15.8% of the 562 consultations investigated. The case examples described by various authors provide an impression of how to handle IS/IS problems. The psychiatrist may transfer the patient, alter psychotropic medication, or advise the use of restraint, with the ulterior motive of helping to solve the IS/IS problems [8-lo]. Alternatively, he or she may provide more accurate information about the patient on the chart, thus, for example, minimizing the possibility of aggressive fantasies among the staff [ll]. The consultant may also spend more time with the patient, or partly take over the care of the patient, in order to lighten the emotional burden of the staff [9,10,12-141. In these examples, there is strictly speaking no question of a staff-oriented case consultation, as classically defined by Caplan [15]; the psychiatrist does not try to teach the ward staff to improve their emotional handling of such patients. One might say that the consultant performs an almost completely patientoriented consultation, but in doing so he or she is taking the IS/IS problems into account. Many authors emphasize the importance of explaining the personality [16], the behavior [8,11,17191, the problems [20], the psychiatric disorder [10,21], the defense mechanisms [12], or the possible primitive ambivalent feelings [22] of the patient. Giving the staff a conceptual framework to understand the patient could increase their tolerance for the patient’s behavior, reduce tension on the ward, and enhance patient-staff communication [ 1819,231. If the consultant expresses the feelings a patient evokes, this may support the staff by making it easier for them to accept having such emotional reactions to the patient [18]. By emphasizing that not all treatment is curative, in either medicine or psychiatry, the psychiatrist may lower the expectations of the staff and alleviate feelings of hopelessness or depression [11,13]. In these cases, the consultant’s activities are expressly focused upon the IS/IS problems, with the intention, be it in an implicit way, of teaching the staff to improve their emotional handling of such a patient. Consequently, such an approach can be identified as covert staff-oriented case consultation. The importance of probing the emotional prob32
lems of the physician or nurses in relation to the patient is stressed by many authors [19,23]. This may be done to foster a deeper awareness of the staff’s own emotional reactions [24-261, or to enable them to ventilate their concerns, frustrations, or anger [20,23]. One may also discuss the dynamics of the patient-physician relationship [10,27,28], thus revealing some of the implications of the staff’s attitudes to the patient’s behavior [25,29]. Because in these cases the ES/IS problems are explicitly talked about with the ward staff, one might speak of overt staff-oriented case consultation. It is often not easy to draw a borderline between covert and overt staff-oriented consultation. There is a fairly smooth transition between the two categories. But if one uses the criterion of the consultant openly discussing their own emotional problems with the physician or ward staff, one is able in most cases to categorize the staff-oriented activities. Subsequent to the introduction of the abovementioned categorization and operationalization of staff-oriented interventions of PS/IS problems in CL psychiatry, we were able to investigate the occurrence and correlates of such interventions.
Methods and Patients This study was appended to the collaborative 1984 registration of psychiatric consultation data by the NCCP [30]. Through this nationwide registration project, a standardized 30-item data base was compiled, including the following patient and consultation characteristics: sociodemographic patient characteristics, referral characteristics, patients’ treatment history, somatic and psychiatric diagnoses, diagnostic recommendations and actions, ward management, discharge and aftercare management, and termination data. The psychiatric consultants of three university hospitals and two general hospitals in various urban parts of The Netherlands enrolled in this particular IS/IS problems study. They were asked to record for each consultation whether, in their own opinion, PYIS problems had certainly, probably, or possibly played a role. When this was the case, they scored whether they had strictly performed a patientoriented consultation, had taken the IS/IS problems into account, or had performed a (covert or overt) staff-oriented case consultation. Demographic characteristics of the five hospitals involved (excluding psychiatry and pediatrics) are presented in Table 1. Included in our study were
Patient-Staff
Table 1. Characteristics
of the five hospitals
Table 2. Characteristics patients (%)
involved Range 370-903 Number of beds Number of admissions per annum 10,051-22,562 Mean length of patient 10.8-12.3 stay (days) Sex of patients 42.5-50.0 Male (%) 50.0-57.5 Female (%) Age of patients 35.6-46.0 15-44 yr (%) 27.7-37.9 45-64 yr (%) 19.0-36.7 More than 64 yr (%) Psychiatric 0.9-3.0 consultation rate (%)
All hospitals 3,081 81,941 11.6 48.0 52.0 42.5 32.0 25.4 1.6
inpatient psychiatric consultations on all wards of these hospitals, with the exception of the pediatric wards. Excluded were consultations with patients admitted following a suicide attempt, as these patients’ stay in the hospital is usually very short, and because for these admissions, psychiatric consultations are often performed as a matter of routine. The number of consultations studied amounted to 1118. The characteristics of these consultation patients are shown in Table 2. The psychiatric consultation data were collected on a DEC minicomputer and through remote communication analyzed on an IBM mainframe, using SAS and SPSS for statistical analysis.
Results According to the psychiatric consultants in three university and two general hospitals, WIS problems possibly, probably, or certainly played a role in 312 (28.1%) of 1112 consultations (data of six consultations were missing). Table 3 presents the consultants’ approach when PS/IS problems were identified (data of two more consultations were missing). The consultants of the five hospitals did not differ statistically significantly in their approach to PYIS problems. If we relate the figures to the entire group of consultations studied, it appears that (covert or overt) staff-oriented case consultations were applied in 11.8% of all 1112 consultations.
and Intrastaff
Problems
of the 1112 consultation
Sex Male Female Age 15-44 yr 45-64 yr More than 65 yr Marital status Single Married or living together Separated or divorced Widowed Referring service Medicine Neurology Surgery Obstetrics/gynecology Other Psychiatric disorder (DSM-III) Organic mental Substance abuse Affective/anxiety Somatoform, factitious, psychophysiologic Adjustment Other Diagnosis deferred No psychiatric disorder Main somatic disorders (sections of ICD-9) Neoplasms Endocrine, nutritional, metabolic, immunity Nervous system and sense organs Circulatory tract Digestive tract Injuries Other
49.9 50.1 33.5 33.2 33.2 22.9 54.0 7.9 15.1 48.6 8.5 37.4 3.7 1.8 31.2 10.0 13.4 8.2 12.5 6.5 5.4 13.3 18.1 9.1 9.0 10.7 9.9 8.0 35.3
Correlates of Staff-Oriented Case Consultations There appeared to be a strongly significant relationship between the consultants’ degree of certainty about the presence of WIS problems and their approach to these problems (X2 test, p < 0.001). The consultants performed stafforiented case consultations in only 29.0% of the cases where PWIS problems were possibly present, whereas they did so in 57.8% of the consultations when they were certain of the presence of PYIS problems. The correlation between the consultants’ degree of certainty and the consultations’ orientation was 0.25 (Pearson product-moment correlation test, p = 0.001). Univariate X2 testing was performed in order to test the relationships between the orientation of 33
M. W. Hengeveld et al.
Table 3. Management
of ES/IS problems
Not at all Taken into account Covert staff-oriented case consultation Overt staff-oriented case consultation
111 68 96 35
(35.8%) (21.9%) (31.0%) (11.3%)
Total
310 (100.0%)
the consultation (patient- or staff-oriented) on the one hand, and the 30 patient and consultation characteristics registered on the other hand. No relationships were found with sociodemographic and patient treatment history characteristics. Nor were referral characteristics, such as the specialty of the referring physician, the type of ward, the urgency of the referral, or the reason for referral, related to the orientation of the intervention. Psychiatric and psychosocial diagnostic recommendations or actions appeared to be inversely related to stafforiented case consultations (a staff-oriented intervention was realized in only 17.2% of the consultations in which the psychiatric consultant recommended or performed further psychosocial or psychiatric diagnostic actions). As far as somatic and psychiatric diagnoses were concerned, we found a slightly significant relationship between grouped DSM-III Axis I diagnoses and the consultation’s orientation. Staff-oriented consultations were performed less often with patients with nonorganic psychotic disorders (16.7%) and organic mental disorders (28.6%), and more often with patients with somatoform disorders (57.1%) or with no psychiatric disorder (56.3%). Psychotherapeutic treatment of the patient on the ward appeared to be related to staff-oriented consultations (53.9%). Other relationships with ward management characteristics could not be shown, nor were discharge and aftercare management characteristics related to the orientation of the consultations. We found, however, several relationships with three variables indicating the time spent on the consultation. Stafforiented consultations were performed in 54.8% of the consultations in which the first visit lasted at least 1 hour, in 50.9% of the consultations with a mean follow-up visit duration of more than 20 minutes, and in 51.1% of the consultations with a total duration of at least 85 minutes. Table 4 gives a summary of the seven variables that correlated with the direction of the approach of the PS/IS problems. The significant relationship between the orien-
34
Table 4. Variables significantly related to a staff-oriented management of the consultation Variable High probability of PI/IS problem No psychiatric or psychosocial diagnostic actions or recommendations DSM-III Axis I classification: somatoform disorder; no psychiatric disorder Psychotherapeutic treatment on ward Long duration of first visit Long mean duration of follow-up visits Long total duration of entire consultation
p-value (x’ test)
