Health Psychology Consultation in the Inpatient Medical

Setting

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Copyright © 2019 by the American Psychological Association. All rights
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Library of Congress Cataloging-in-Publication Data

Names: Labott, Susan M., author.
Title: Health psychology consultation in the inpatient medical setting / By
Susan M. Labott.
Description: Washington, DC : American Psychological Association,
[2019] | Includes bibliographical references.
Identifiers: LCCN 2018010863 (print) | LCCN 2018013516 (ebook) |
ISBN 9781433829628 (ebook) | ISBN 1433829622 (ebook) | ISBN
9781433829611 (print) | ISBN 1433829614 (print)
Subjects: | MESH: Inpatients—psychology | Behavioral Medicine—
methods | Interprofessional Relations | Referral and Consultation
Classification: LCC RC512 (ebook) | LCC RC512 (print) | NLM WX
158.5 | DDC 616.89—dc23
LC record available at https://lccn.loc.gov/2018010863

British Library Cataloguing-in-Publication Data

A CIP record is available from the British Library.

First Edition

http://dx.doi.org/10.1037/0000108-000

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To Jim—you always had my six

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Contents

ACKNOWLEDGMENTS

INTRODUCTION

I
The Inpatient Setting and Consultation Models
1. The Hospital Milieu
2. Consultation Models and Content

II
The Inpatient Evaluation
3. Preparing for the Consultation
4. Interviewing the Patient
5. Wrapping Up the Consultation

III
Psychological Issues in the Inpatient Setting
6. Adjustment to Medical Illness
7. Anxiety
8. Depression
9. Delirium and Acute Cognitive Changes
10. Substance Use and Abuse

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IV
Special Issues in the Hospital Setting
11. Decisional Capacity
12. Nonadherence
13. Pain
14. End-of-Life Issues

V
Ethics and Professional Issues
15. The Ethics of Consultation With Medical Inpatients
16. Training, Billing, and Other Professional Issues

APPENDIX A

APPENDIX B

REFERENCES

ABOUT THE AUTHOR

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Acknowledgments

Thanks to the many patients who have shared their struggles and successes
as they navigated their way through difficult medical and psychological
problems. Thanks also to my students and colleagues for helping me
collect and articulate my thoughts about this work. Finally, special thanks
and love to my parents, Arlene and Robert Labott, for everything.

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P sychological practice in the inpatient medical setting is different in
many ways from both outpatient clinical work and inpatient work in a
psychiatric unit. Yet psychology trainees usually begin their first clinical
placement in a hospital without any guidance or coursework on how to
work in that setting. The same is true of established clinicians who have
not specialized in health psychology. Although supervisors usually have a
good grasp of the relevant issues, there is never enough time to sit with
every trainee or to run a basic seminar on hospital work before the trainee
begins.
This book seeks to provide basic information on clinical and
professional issues operative in the inpatient medical setting for
individuals who already have skills in general clinical psychology but who
have little experience in a hospital. It addresses clinical questions, such as
the following:
What is delirium and how do I treat it?
How do I treat anxiety that is directly caused by medication,
rather than due to psychological concerns?
The book also addresses ethical questions, such as the following:

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 What if a patient refuses to be seen?
How do I maintain confidentiality when I am working with a
large medical team?
It addresses professional issues, such as the following:
How do I handle a patient’s death?
What do I do if I am evaluating a patient and another
provider also wants to see the patient?
It answers basic questions regarding consultation, including the
following:
How do I understand the medical information in the patient’s
chart?
What should my report look like, and where does it go?
This book provides detailed instruction on matters of significance
when working in a hospital, including interpretation of the medical record,
description of major psychological problems that occur in the hospital, and
conducting assessment and treatment in this setting. It also provides
information on attending to particular patient needs in the hospital setting,
such as evaluating decisional capacity and helping them deal with end-of-
life issues.
The theoretical approach of this book follows the biopsychosocial
model, the current standard of practice in clinical health psychology. In
this model, the biological, social, and psychological dimensions of illness
are all considered when developing a conceptualization of the patient and
his or her illness. The interventions described for use with medical
inpatients are based largely on cognitive–behavioral, evidence-based
approaches. For some of the thorny questions in this book, there is no
empirical literature; these are discussed from a practical perspective based
on the author’s many years of clinical experience in this setting.
The book is divided into five parts. Part I focuses on the hospital
setting and inpatient consultation models. Chapter 1 explains the structure
of hospital units and the hierarchy of medical teams, as well as relevant
hospital standards, including credentials and privileges. Differences
between hospital and outpatient practice are discussed, as well as

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documentation and infection control procedures. Chapter 2 describes the
biopsychosocial model—the foundation of inpatient health psychology
consultation—as well as various types of consultations and consultation
services in which a psychologist can work.
Part II addresses the nuts and bolts of performing an inpatient
consultation. Chapter 3 describes background preparation before seeing
the patient and includes information on understanding the referral,
interpreting the medical record, and generating specific topics to be
addressed in the interview with the patient. Chapter 4 describes the patient
interview and includes tips on getting it started, specific content to cover,
common problems in conducting inpatient interviews, and providing
feedback to the patient. Chapter 5 discusses gathering collateral
information, integrating data, and providing written and verbal reports to
the patient’s medical providers.
Part III addresses common psychological issues in the hospital setting.
Chapter 6 defines and describes adjustment problems faced by hospitalized
patients and describes theories of adjustment, relevant tasks and
interventions to aid adjustment, and factors that can influence adjustment.
Chapter 7 addresses anxiety and describes etiologies of anxiety that can
occur in the hospital, such as premorbid anxiety, new anxiety due to the
current medical situation, medical disorders that can present with anxiety,
and anxiety symptoms caused by medications. Treatments to address
anxiety are presented, including education, medication, and cognitive–
behavioral interventions. Chapter 8 addresses depression and includes a
description of its various etiologies, including premorbid depression, new-
onset depression secondary to a medical problem, medical disorders
associated with depression, and depression due to medication. Suicide in
hospitalized patients is discussed, as are relevant risk factors. Interventions
to address depression and depressed mood are described and include
education, cognitive–behavioral strategies, social support, and
psychotropic medication. Chapter 9 defines delirium, its clinical features,
and its causes. Means to assess and diagnose delirium are described,
together with strategies for the management of delirious patients. Chapter
10 focuses on substance use and abuse and begins with a description of
referrals for substance use. The prevalence and impacts of illicit and

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prescription drug use are presented, as well as assessment strategies.
Psychological treatments for drug and alcohol overuse are then delineated.
Part IV is focused on special issues in the hospital, that is, those
occurring frequently in the hospital but less often in the outpatient setting.
Chapter 11 addresses decisional capacity and describes referrals, criteria
for capacity, the evaluation to determine capacity, and implications if the
patient lacks decisional capacity. Chapter 12 deals with nonadherence to
medical recommendations and outlines the implications of nonadherence
and relevant theoretical models. Factors that influence adherence are
presented, as are strategies to establish initial adherence, evaluate
adherence problems, and interventions to address nonadherence. Chapter
13 is focused on pain and includes sections on assessment, factors that
affect pain, and psychological interventions to decrease pain. Chapter 14
deals with end-of-life issues. It includes details about the primary concerns
of dying patients, advance directives, death with dignity legislation, and
steps the psychologist can take to promote a good death.
Part V focuses on ethics and professional issues. Chapter 15 discusses
ethical issues that are especially relevant in the hospital, such as
confidentiality, respect for other professionals, and culture and diversity
issues. Chapter 16 provides guidance for training students in the hospital
setting, as well as billing matters. Developing a professional identity,
caring for oneself, marketing inpatient psychology services, and other
professional challenges are also discussed.
My perspective on health psychology inpatient work is derived from a
university-based medical center, but the information and examples are also
applicable for consultants working in nonacademic hospitals. The cases
and medical record samples are based on real patients and provider notes,
but identifying information has been altered to protect patient privacy.
Throughout the book, I have made some patients and providers male and
others female to avoid the cumbersome use of “he or she.”

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P roviding psychological services in an inpatient medical setting can be
intimidating to those who have not previously worked in a hospital. The
pace can be fast, the logistics of seeing patients are different from the
outpatient setting, and most patients have not requested any psychological
evaluation or treatment. There are also rules and norms to be followed that
may be wholly unfamiliar to professionals who have worked exclusively in
outpatient settings. An understanding of the structure and expectations of
the hospital setting will facilitate the health psychology consultant’s work
and also enhance her reputation among medical colleagues. These topics
are described more fully in this chapter.

Hospital Units, Medical Teams, and the Health

Psychology Consultant
Most hospitals are separated into at least some specialized units. Even
small hospitals may have specialized obstetrics, pediatric, and intensive
care units (ICUs). The larger the hospital, the more specialized units there
are likely to be, with certain floors dedicated to patients with specific
medical needs, such as cardiology, general medicine, oncology, or

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orthopedics. Some hospitals may even have specialized ICUs, for example,
for cardiology, neurosurgery, or transplant. When a referral is received, the
location of the patient may provide a clue to the patient’s main medical
issue. At times, however, floor assignment is a result of bed availability.
In teaching hospitals, patients are treated by teams of physicians.
These teams are headed by the attending physician (referred to as the
attending), who is a faculty member in the medical school and is involved
in teaching, supervision, research, and patient care activities. The attending
is ultimately responsible for the patient’s care, although much of the actual
treatment is performed by other members of the team. There is often a
fellow, who has completed his medical residency and is now completing
specialty training (such as in emergency medicine, cardiology, or
pulmonary disease), usually for 2 to 3 years. The treatment team may also
include one or more medical residents. Residents have finished medical
school and are working on their medical residency, which is required
before becoming an independent practitioner. They are sometimes referred
to as house staff because they manage all patient care under the
supervision of the attending. Residents work long hours because they are
frequently on call, spending many sleepless nights in the hospital dealing
with emergent medical issues. There may also be medical students on the
team who are currently in medical school and have little experience in
patient care. One motto of medical training is “see one, do one, teach one”;
in practice, this means the individuals on the treatment team who are
providing patient care will have varying levels of experience in
interviewing, performing medical procedures, and negotiating the hospital
system.
Members of the primary medical treatment team will see the patient
each day to evaluate the patient’s progress and to perform procedures. The
entire team will round together once daily, visiting all of the patients for
whom they are responsible. During rounds, members of the team describe
the patient’s status, plans are made regarding next steps in the treatment,
and the attending provides supervision. If the health psychology consultant
is present at the time of the primary team’s rounds, it is useful to listen to
the team’s discussion of the patient as well as their meeting with the
patient, if appropriate. This will provide the psychologist with details

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about the treatment issues and the team’s decision-making about them, as
well as an opportunity to observe interaction patterns between the patient
and his medical providers. Rounds may also provide a forum for the health
psychology consultant to update the team about the psychological issues
and the psychological treatment plan. Although it may perhaps be anxiety
provoking initially, the psychologist should be prepared to address
questions from the treatment team any time they are encountered; this is a
good opportunity for the health psychologist to provide relevant
information and to demonstrate his usefulness to the medical team and the
patient.
All members of the primary medical team rotate on and off, and not
all on the same schedule; for example, the attending may be “on service”
(which means he is leading a team in the hospital) for a month, whereas
the fellow and residents may be on the team for several months, under the
supervision of different attendings. The primary treatment team is assigned
certain patients; for example, the cardiology team will see patients
admitted for cardiac problems. In a large hospital, many of these patients
will be located in one unit. If a patient from a cardiology unit is transferred
to the ICU, the cardiology team will likely follow (i.e., continue to treat)
the patient there, although the ICU medical team may take primary
responsibility while the patient is in the ICU. In most cases, a health
psychology consultant who is following a patient will continue to treat that
patient if she moves to a different unit. An exception to this is if the new
unit has other psychological services available, for example, if a
cardiology patient is transferred to a psychiatry unit after she is stable
medically. In that case, the health psychology consultant would ensure
continuity of care, while transferring the patient to a new mental health
provider located on that unit. The health psychology consultant could
continue to see the patient if he has been working with the patient on a
specific issue that cannot be readily managed by a provider on the new
unit (e.g., if teaching specific imagery techniques for pain management, if
there are no mental health providers on the new unit with expertise in this
area).
Because most of the day-to-day care of the patient is provided by the
fellows and residents, these are the people with whom the health

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