The so-called "inappropriate" psychiatric consultation request on a medical or surgical ward

Seven cases of psychiatric consultations on medical and surgical wards are reviewed to show how intrapsychic conflicts in the staff may make the consultation request appear inappropriate. On deeper examination, such requests may signify staff dysfunction caused by arousal of conflictual feelings about the behavior of illness of the patient. Mutilated, mute patients appear to arouse fear of agression in their caregivers, who in turn reject such patients, see them as alien and violent, and become illogical in their management. Patients who publicly display sexual behaviors appear to arouse shame over exhibitionism, voyeurism, and masturbation; their caregivers become too passive to effect common-sense measures appropriate to the situation. Very sick and dying patients and ungrateful, demanding patients can arouse anger and despair. Their caregivers may become depressed about failure, feeling helpless and out of control; using projection, they can see such patients as evil or suicidal, and may eventually turn against themselves. The psychiatric consultant, recognizing the conflicts that make the requests seem inappropriate, seeks to substitute higher-level cognitive operations and coping behaviors in the staff (distancing, rationalization, intellectualization, undoing, and altruism) for distortion projection, over-identification, reaction formation, and turning against the self.