Power and Professional Relationships - Essay Example

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 οf 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 οf 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 οf 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 οf the psychologist in the health team is a complex matter, subject to a number οf difficulties, not the least οf which is the question οf professional power relationships. A prior issue, however, is that οf the place οf clinical psychology with regard to medical theory and practice. This interdisciplinary interface occurs within a “general…professional 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 οf conceptualizing disease and illness, and these models take account οf 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 οf sickness, whereas illness has been defined as a subjective experience consisting οf “an array οf discomforts and psychosocial dislocations resulting from interaction οf a person with the environment” (Barondess, 1979, p. 375). Disease is neither a necessary nor a sufficient condition for the presence οf illness (Sullivan, 1986), in that it is possible to experience the social role οf illness without any biological pathology. Conversely, pathology may exist, without any subjective experience οf 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 οf the physical, chemical, and physiological changes in the bodily systems οf an individual, divorced from the person's experience οf sickness and from the social context (Kleinman, 1978). The model's strength lies in its elucidation οf the biological mechanisms οf sickness, but it is limited by its neglect οf 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 οf his or her biological ailments. In other words, biomedicine focuses on disease to the exclusion οf 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 οf clinical psychological practice into nonpsychiatric hospital settings may be understood as being in keeping with the spirit οf the biopsychosocial model. In spite οf the development οf 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 οf health and sickness in Western medicine. As an explanation for the continued power οf 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 οf disease: In our culture, the attitudes and belief systems οf 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 οf 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 οf usefulness or adequacy οf explanation. Armstrong (1987) noted that “orthodoxy traditionally manages to control the threat from the unorthodox by a strategy οf either marginalization or incorporation” (p. 1213), and one may argue that both οf these strategies are used to maintain the dominance οf biomedicine, which has the secondary result οf maintaining the devalued position οf psychosocial issues in health care. In examining the work οf 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 οf 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 οf consultation–liaison and then in the light οf 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 οf expertise…. [who] is asked to examine patients and offer suggestions for treatment without necessarily providing ongoing care. Thus, consulting activities typically consist οf brief interaction with patients and other specialists on a wide variety οf 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 οf 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 οf consultation and liaison Consultants seem to be independent οf the unit to which they consult; they have the status οf “any other specialist in the hospital with a specific area οf expertise” (Johnson, 1985, p. 270) and, as such, are not subject to the authority οf the head οf 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 οf the problem and the boundaries οf the request. Liaisors, 1 on the other hand, being part οf the units they work in, are far more involved with the life οf the unit. Therefore, they have unlimited access to the unit; liaisors have their own perceptions οf problems in the unit and may be more able to extend the boundaries οf 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 οf 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 οf their closer relationships with other staff members and their continual presence in the unit. Consultation–liaison and marginalization One οf the major aims οf consultation–liaison psychiatry is to educate nonpsychiatric professionals about psychosocial issues (Lipowski, 1975), and yet it fails to fundamentally change the practice οf medicine. Psychiatry is devalued by the rest οf 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 οf 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 οf 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 οf medicine. Consultation–liaison psychiatry is structurally marginalized: Consultants work in the departments οf other medical specialties. The “patient” in consultation–liaison work may be a network οf people, and their status as patients may be disputed by the consultee. This object οf care is less tangible than the usual patient, and the results οf 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 οf the individual patient. Conclusion: Power and Professional Relationships Psychologists working in medical settings do not have access to the knowledge οf 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 οf biomedicine, medical practitioners are imbued with social status that allows them to claim expertise over all aspects οf patient care. With the physician as explicit team leader, it may often be acceptable for the physician to make suggestions about the psychological welfare οf 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 οf which we have outlined before, include the following, each οf which is related to the others and none οf which excludes the others: Psychologists may be tempted to collude in the devaluation οf their expertise for the sake οf harmonious working relationships. This strategy has the potential not only to deprive patients οf valuable expertise but also to limit the contribution οf 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 οf those professionals whose ascribed status is lower than that οf both psychologists and physicians, such as nurses and social workers. Interprofessional power differentials may be directly acknowledged and confronted. Recognition οf 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 οf power that are usually not acknowledged and to negotiate ways οf 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 οf and open response to the dynamics οf 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 οf 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 οf Medicine, 66, 375–376. Baudry, F. D., & Wiener, A. (1975). The surgical patient. In J. J.Strain & S.Grossman (Eds.), Psychological care οf 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 οf 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 οf the clinical psychologist in total patient care in a neurosurgery unit. In K. W.Grieve & R. D.Griesel (Eds.), Proceedings οf 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 οf 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 οf 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 οf 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 οf psychological problems. British Journal οf Psychiatry, 148, 194–197. McHugh, S., & Vallis, T. M. (1986a). Illness behaviour: Operationalization οf 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 οf Cape Town, Cape Town, South Africa. Nethercut, G., & Piccione, A. (1984). The physician perspective οf health psychologists in medical settings. Health Psychology, 3, 175–184. Rogers, L. (1982). The ideology οf 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 dualistic?Culture, 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 οf interests endemic to psychiatric consultation?International Journal οf Law and Psychiatry, 6, 293–316. Taylor, S. E. (1987). The progress and prospects οf health psychology: Tasks οf 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