Bedside psychotherapy is not only possible but invaluable for some medical-surgical patients, despite hospitals’ distractions, lack of privacy, and short stays. If you are asked to evaluate a hospitalized patient, a 5-step strategy can help you:
- identify acute psychiatric problems that psychotherapy can help
- watch for common psychodynamic themes
- choose a beneficial psychotherapy
- integrate drug/psychotherapy, as needed
- quickly establish rapport by using an effective bedside manner.
Case report: A deeply wounded patient
Ms. T, age 45, was admitted to the trauma unit with gunshot wounds. Her estranged husband shot her during an argument and killed her 14-year-old son, who tried to help her.
She underwent multiple surgeries to repair internal organs and endured intense pain. She was medically stable after 10 days, and the surgical team called on the psychiatric consultation-liaison (C-L) service to evaluate her “depression.”
Table 1
5 steps to bedside psychotherapy
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Ms. T told the psychiatrist she was having nightmares and re-experiencing the shootings. She felt overwhelming guilt and blamed herself for her son’s death. She reported hyperarousal, muscle tension, and palpitations. She also worried about facing her son’s killer in court.
The C-L psychiatrist felt Ms. T would benefit from medication and psychotherapy for anxiety while hospitalized.
Obstacles to bedside psychotherapy
Hospitalized patients do not usually seek psychiatric consultation but are referred by their physicians. Pain and injuries, medications, and illness can limit patients’ energy and motivation to participate in therapy, as well as their concentration and cognition. Moreover, bedside psychotherapy sessions are likely to be interrupted for blood draws, medical rounds, investigations, and procedures.
Despite these obstacles, medical patients are often receptive to psychiatric care.1 An alliance often develops within minutes, and the psychiatrist can achieve effective psychotherapy during a single bedside visit.2
The Academy of Psychosomatic Medicine considers psychotherapy a required skill for anyone who evaluates and treats psychiatric disorders in general medical settings.3
How to overcome obstacles
STEP 1. Identify when psychotherapy may help. Not every problem or patient benefits from bedside psychotherapy. The C-L psychiatrist’s first task is to identify:
- Problems that warrant psychotherapy. These may include depression, bereavement, adjustment disorder, maladaptive coping, anxiety related to medical procedures, acute stress disorder, posttraumatic stress disorder (PTSD), and demoralization.
- Patients likely to benefit. Look for evidence of ego strength, ability to interact in the first session, psychological-mindedness, ability to experience feeling, and absence of severe cognitive deficit.2
These patient traits are not prerequisites, however, and clinical judgment applies on a case-by-case basis.
Demoralization is the most common reason for psychiatric evaluation of medically-ill patients, though their physicians typically request a “depression” evaluation.4 Demoralization is an understandable response to serious illness or disabling, agonizing, or deforming treatment.5 Symptoms include anxiety, guilt, shame, depression, diminished self-worth, and possibly somatic complaints or preoccupation.6
Ms. T was experiencing survivor guilt—she blamed herself for her son’s death—and she described herself as feeling “lost.” Four strategies can treat demoralization (Table 2).
STEP 2. Watch for common psychodynamic themes, such as denial of illness, loss of control, dependency and regression, fear of abandonment, loss of identity, and fear of death.7 Other issues include survivor guilt, anger at the treatment team or family, and knowing someone who had a negative experience with the same illness or treatment.
Identifying these themes and integrating them into the treatment plan can improve outcomes. For example:
- Giving an empathic validation can help overcome fear of abandonment.
- Letting the patient choose the time when blood is drawn increases feelings of control.
Table 2
4 bedside strategies to treat demoralization
| Strategy | Examples |
|---|---|
| Validate the patient’s feeling and experience | Say, “I can see this is frustrating to you to be in the hospital so long,” or “You must feel as if everything is out of your control” |
| Reassure the patient that demoralization is a natural response to a difficult situation | Say, “I can imagine that anyone in your place would feel the same way,” or “It’s only natural to feel this way after what you’ve been through; this does not mean you have a mental illness or are ‘going crazy’” |
| Make simple gestures that promote an improved outlook | Use an effective bedside manner (Box 1) |
| Alleviate feelings of isolation, and foster a sense of hope | Use resilience-building questions (Box 2) |