Pour une vision systémique de la psychiatrie de liaison

One of the problems of consultation-liaison psychiatry is the absence of request of the patient. Indeed, the patients do not recognize their disorder and prefer to go to the emergency unit in a general hospital. Thus, we meet in the emergency unit or in medical unit (liaison psychiatry activity). This is the reason why this first meeting has to be prepared. Consultation-liaison Psychiatry proposes to provide medical staff with the competences developed by psychiatry, and the denomination: Consultation and Liaison Psychiatry, indicates the bipolarity of its practice according to whether the intervention is addressed to the patient (consultation) or to the staff (liaison). However collaboration is sometimes difficult and the psychiatrist often meets with resistance. This is the reason why psychiatrists must work on their integration in the general hospital. Indeed, the psychiatrist works in an institution which is unfamiliar and he/she must adapt and create new practices if it is going to work. It is now clearly established that consultation-liaison psychiatry is not limited to consultations with patients, but is based on collaboration with medical staff. There are various ways of studying human problems : psychoanalysis, cognitive therapy, behavioural therapy. It is also possible to focus interest on the communication between individuals. The systemic therapies are interested in the interactions more than with any other aspect of reality, and this always from a pragmatic point of view. This concept is based on a series of designs. First of all, an intervention by problem solving aims at a change : the question is to know how a problem is maintained, hic et nunc. Secondly, humans are a sum of training by tests and errors. Finally, what we call reality is only our perception of reality : the human conflicts emerge when two persons assign a different direction to a reality which is perceived jointly. The human relationship can be defined as interaction circles, which we propose to use in our practice of consultation-liaison psychiatry. The question is no longer to know why the subject has a problem but to know how to resolve it. The call for a consultation of psychiatry is often the result of an interaction between patient and staff. We propose an assessment of the consultation-liaison-psychiatry's demand so as to offer a concrete response to medical teams and patients. 1. First of all, the claimant should be known. This first question is to be asked before even meeting the patient. In the majority of cases, it is the medical staff that suffers from the situation (and wants a change). To work only on the patient, discredits the psychiatric intervention. 2. The definition of the problem is a concrete question, which we want based on the facts and not on the comments. That which requires the consultation (the patient, his/her family or the medical team) awaits concrete answers from the psychiatrist. It is important that the objectives of the intervention are defined before meeting the patient. These preliminary exchanges facilitate the consultation-liaison intervention. 3. By knowing the solutions tried before the request for psychiatric help, the psychiatrist will be able to know the measures already tried (whether they were effective or not). 4. By proposing minimal changes, it defines small but obtainable objectives, which will be as much as to increase therapeutic alliance and the tolerance of patients sometimes difficult to understand. 5. Finally, the consultation-liaison psychiatrist must know the language of his/her interlocutors. Interdisciplinary alliance is a fundamental condition for the success of the intervention : like the patients, the medical staff must feel understood to be able to cooperate. To develop this alliance and to inhibit resistance, it is important to speak the language of the claimant. The demand will progressively become interventions, more adapted, especially when the psychiatrist is recognized and appreciated by the team, like a good consultant, credible and concrete. Thus, mentally distressed patients can benefit from psychiatric care (although they do not request it). However, two phases appear essential. First, we have to define the demand and the claimant (environment, medical staff and patient) and second, we have to support the integration of the psychiatrist in the functioning of the medical unit. Our systemic vision of the consultation-liaison psychiatry proposes a pragmatic collaboration, centred on the problem. This approach allows the patient to prepare to meet the psychiatrist, and does not a priori discredit the intervention. Presented by the staff, who know the problem in concrete terms and are ready to answer it in a concrete way, this mode of intervention is only the first step of subsequent psychiatric care.