Facilitating Patient Acceptance of a Psychiatric Referral

Harold Bursztajn, MD, Arthur J. Barsky, MD
(Arch Intern Mad 1985;145:73-75)

There are five common ways in which a patient may object to a physician's suggestion of a psychiatric referral. The patient may reject the referral because of the social stigma of being a psychiatric patient; because the referral damages his or her self-esteem; because the patient does not understand the role of emotions in physical discomfort; because the patient feels rejected by the referring physician; or because of the effects of psychiatric Illness. Following a thorough medical workup, the physician can best discharge his or her responsibility to the patient by paying attention to these possible misunderstandings. The physician can discuss the role of social stigma, offset the blows to the patient's self-esteem, educate the patient about the psychosomatic model of disease, and assure the patient of the physician's continuing interest and involvement.

Many medical patients who could benefit from a psychiatric referral find the idea unacceptable. A psychiatric referral can cause a patient to feel humiliated, accused, or disliked. However, the referring physician's understanding and attention can frequently overcome the patient's reluctance to consult a psychiatrist.

The difficulty in completing a psychiatric referral is particularly unfortunate in light of the high prevalence of psychiatric disorder in general medical practice. [1] Twenty-five percent to 30% of ambulatory medical patients have diagnosable psychiatric disorders, [2-4] yet the rates of recognition by physicians are generally in the range of 1% to 5%, [1,3,5,6] and 0.07% to 2.5% of patients seen in general practice are referred to psychiatrists. [1,7,8] Although many of these patients may be treated well by their primary physicians, these figures still suggest that there are many patients who could benefit from a referral but either are not asked to see a psychiatrist or do not follow the suggestion.

The low rate of completed referrals reflects a number of factors. One, the focus of this article, is reluctance on the part of the patient, [9-13] and another is physician reluctance. The latter has been found to be related to the absence of training in psychiatric diagnosis; adherence to a biologic rather than biopsychosocial model of disease; and a pessimistic and negative orientation toward psychiatry coupled with a belief that patients are unreceptive to psychiatric referrals. [9,14-18] Psychiatrists themselves have not facilitated the referral process, and their feedback and assistance are at times disappointing. [19] Finally, the mental health system itself, with its remoteness and barriers to access, hinders the referral process. [20]

We present a clinical example of the referral process, describe what makes a psychiatric referral difficult for many patients, and discuss how the referring physician can deal with the problem.

REPORT OF A CASE

The referral process in this case was far lengthier and more intensive than most internists have time for, but the case illustrates many of the issues involved.

A 28-year-old graphic designer for an advertising firm was receiving outpatient treatment for systemic lupus erythematosus, diagnosed six months earlier. The patient's disease was manifested primarily by joint involvement. A year before her illness, after having lived on her own for six years, she had moved across the country back to her parents' home following the unhappy end of a love affair. Since the onset of her illness the patient had withdrawn socially and had felt depressed. A skilled designer who earned her living by precise freehand sketching, she complained that pain prevented her from using her hands. Her physician thought she was depressed; she agreed to a trial of antidepressant therapy, but she refused a psychiatric referral. She did, however, agree to an extended consultation with another primary care physician in the clinic who was also a psychiatrist.

In their first meeting, the patient described how depressed, demoralized, and hopeless she felt because her disease had rendered her unable to draw. The consultant addressed her despondency by saying, "Now, when your doctor suggests a psychiatrist, it might feel like he's giving up on you too. . . . Many patients believe that their doctor has referred them to a psychiatrist because there's nothing left to do. But that's not really true."

During the second visit, patient and physician discussed how stress and unhappiness can worsen physical symptoms: "For example, a little cramp feels like a serious pain if you're frightened and upset to start with." The consultant also introduced the idea that stress can be internal as well as external in origin. Having to rely on her parents again after having been completely independent could be an important stress for the patient. "It's not surprising you feel a conflict between wanting what little pleasure you get from being taken care of, and wishing you could take care of yourself."

In the third visit, problems of social stigma and self-esteem were addressed. "What will my family say?" the patient exclaimed. "If I go to a psychiatrist they'll think there's really something wrong with me." The consultant acknowledged that the family might well have this concern, but that this did not mean that the patient had to think of herself as "crazy." The patient then wondered if being depressed meant that the suffering and disability she had experienced were only in her mind, that she had just "imagined" them. She admitted that feelings of chagrin, shame, and disapproval accompanied the idea that her physical suffering and impairment just reflected an inability to control her own emotions.

In the final meeting she and the consultant discussed how psychotherapy might be helpful. The patient was worried that she might lose her primary physician if she began visiting a psychiatrist. The consultant emphasized the former's continuing involvement. The patient then accepted a referral for psychotherapy to discuss her emotional reactions to her disease. Her psychotherapy subsequently was helpful in improving her level of function, ameliorating her depression, and helping her to cope with the consequences of systemic lupus erythematosus.

PATIENTS' OBJECTIONS TO THE PSYCHIATRIC REFERRAL

Fears of Social Stigma

Having a psychiatric illness can cause a great social stigma. One's overt behavior may not betray a mental illness, but a visit to a psychiatrist, by designating one as a psychiatric patient, makes one vulnerable to stigmatization. The mentally ill are generally considered in highly negative terms. [21,22] Psychiatric patients are feared, distrusted, and disliked. They are suspected of being at best weak and at worst immoral, depraved, and worthless. [23-26] Mental illness, unlike most forms of medical illness, is viewed by the public as socially unacceptable, embarrassing, and not to be discussed or overtly acknowledged. [27] The patient in the foregoing example voiced these concerns in her third visit when she worried about her family's reaction to the news that she was visiting a psychiatrist.

Threats to Self-esteem

Visiting a psychiatrist can change how one thinks about oneself. Many patients, including the patient described earlier, believe that psychological problems and emotional difficulties betray a weakness, personal failing, or character defect. Going to a psychiatrist then means that one is weak and incapable and must turn to someone else to be "fixed." Having to rely on someone else to help with one's emotions when one feels one should be able to manage them oneself can be a major blow to self-esteem, generating a sense of inadequacy, defectiveness, and even badness.

For a patient who has already endured physical discomfort and disability, the suggestion that he see a psychiatrist is additionally disturbing. It implies that the problem may have been "only" in his mind, that he somehow "made it all up," that "it was not real." He wonders whether his suffering was unnecessary and whether his limitations were self-imposed. The patient may even come to suspect himself as a malingerer or faker. In the clinical vignette presented here, the patient was chagrined by what she felt to be her "self-deception."

Misconceptions About the Effects of Emotions on Physical Symptoms

Psychiatric care seems irrelevant to a physically symptomatic patient who does not understand the interaction of psyche and soma. [28] These questions were addressed by the consultant during the second visit in the clinical case example. Many patients believe that physical symptoms must have physical causes, a view that is congruent with our cultural focus on disease (the biologic derangement), rather than on illness (the experience of and reaction to that pathologic change). [29]

The patient's understanding of psychiatric treatment can be equally important. It is commonly believed that psychiatric illness is incurable and unalterable. Given such a belief, the idea that one's physical symptoms have a psychological cause must be rejected out of hand. To consider it is to entertain the thought that one's physical pain and disability will never be relieved or assuaged.

Fears of Rejection by the Primary Physician

The referral is a personal act on the part of the primary physician to which many patients (correctly or incorrectly) impute a particular meaning. They view the referral as a rejection or dismissal. Buried in the referral for some patients is the implicit message that one has not told a good enough story to be accepted, that the patient and/or his illness are insufficiently interesting or serious to engage the physician. There may be the sense that one has auditioned for a role and not been selected. Often, in fact, there is an implicit or explicit communication that the patient is being "dumped" or "turfed." In the clinical example given earlier, the patient explicitly worried in the fourth visit whether her primary physician would continue to see her after she began seeing a psychiatrist.

At times the patient's sense of rejection may be fueled by the referring physician's attitude. The physician may be frustrated by a patient whom he has been unable to help. Finding "nothing wrong," the medical physician sees no reason to continue their relationship. His frustration and impatience combine to deepen the patient's sense of rejection and of the referral as a way of discontinuing care.

Psychopathology

The negative emotional responses many persons have do not necessarily imply any notable psychopathologic condition. However, in addition to these general reactions, persons may have specific objections to seeing a psychiatrist that are intrinsically tied to particular psychiatric disorders.

Depression, for example, causes a diminished sense of one's own worth and a feeling that one deserves punishment. Depressed patients may therefore refuse a psychiatric consultation, feeling that they do not deserve to feel better and are not worth treating. Somatization is another psychiatric problem that makes referral difficult. Somatizers distract themselves from emotional distress by focusing on physical symptoms, thus substituting physical discomfort for emotional discomfort. A psychiatric referral implies that the suffering is actually emotional, which is precisely what these patients are trying to avoid. The patient reacts to this threat by denying the need for the remedy, ie, by refusing the referral. Finally, persons who are especially private, shy, hypersensitive, and mistrustful may perceive a psychiatric referral as particularly threatening, since psychiatrists are thought to pry into personal matters, to ask intrusive questions, and even to reap minds.

MANAGING THE REFERRAL

To facilitate acceptance of the psychiatric referral, the physician must first foster an open and trusting physician-patient relationship. This will allow the patient to voice his concerns openly and honestly and discuss them in detail. The physician therefore encourages the patient to express his feelings about the proposed referral and then clarifies the meaning of the suggestion to the patient.

The process outlined here may seem too complicated and time consuming, but the problem is an important and common one. Moreover, simply getting the patient to the psychiatrist's door is of little value if the patient arrives too frightened, angry, confused, or defensive to be able to listen or work at the therapy. The patient who accepts the psychiatric referral out of compliance, or simply to please or placate the referring physician, may still remain closed to any psychiatric input. [30] The goal of a referral is not simply to force an unwilling patient to spend a few minutes with a psychiatrist, but to help the patient visit the psychiatrist with some openness and hopefulness.

Medical Workup

The physician's first task is to pursue medical workup and management as thoroughly as possible. Not only is this clinically obligatory, but it forms the foundation of the therapeutic relationship with the patient. It also demonstrates that the physician takes the patient seriously and appreciates the patient's decision to come to him rather than to a psychiatrist. Finally, it eliminates (as far as possible) one source of ambiguity from the referral process: that something about the patient's medical status is being overlooked. If the patient feels the referral is premature, he will feel ignored and shortchanged; this will prevent him from considering the idea openly.

Making the Referral

The physician should suggest the referral in a direct and straightforward manner, explaining his reasons for recommending it. Then the physician should observe the patient and listen carefully for anger, apprehension, or confusion that might indicate resistance to the idea. It is helpful to present the consultation as an attempt to treat the patient's discomfort, rather than an attempt to diagnose a psychological cause for the physical symptoms.

It is not necessary to force the dubious patient into a premature response. The referral can be discussed over the course of several visits. As illustrated in the clinical vignette, the physician aims for an open-ended process in which a painful idea can be assimilated, rather than an open-and-shut proposition that is to be accepted or rejected as is.

Dealing With the Patient's Objections

The fear of social stigma and the blow to the patient's self-esteem are confronted with the aid of two interviewing techniques: empathy [31,32] and counterprojection. [33] Empathic statements acknowledge and validate the patient's emotional experience: "It must feel ridiculous to be told to see a psychiatrist when the pain you're feeling is real." Counterprojective statements address the negative feelings others may have about psychiatric patients. They help to reassure the patient that the physician does not share—and that the patient need not share—the prejudice that a person who goes to a psychiatrist is a malingerer or is dependent, defective, or worthless.

In dealing with social stigma, it is useful to find out exactly whose opinions the patient is most concerned about. What consequences does the patient most fear when these persons learn about the consultation? When the important persons are family members, especially family members with whom the physician has already had some contact, it may be useful to have them return with the patient and jointly discuss the referral and what it means to the physician, patient, and family.

If the patient lacks an intellectual understanding of the role of psychological factors in physical suffering, education, information, and explanation may be helpful. [29,34]

Patients With Serious Psychopathologic Disorders

When the patient's reluctance is itself an integral part of a major psychiatric disorder, it can be useful to point this out to the patient. The physician can explain that the patient's resistance is part of the problem that needs treatment and that if his psychiatric problem troubled him less, he would not feel the same wish to avoid psychiatric care. Learning about the patient's prior experiences with psychiatric care can help clarify his objections and make it possible to satisfy them or work around them.

Reassurance of Continuity

Finally, the physician attempts to counter the patient's feeling or rejection at being referred to another physician. He reassures the patient that the referral is not a rejection and explains that he will still be there as the patient's physician. This can be demonstrated concretely by scheduling a follow-up appointment shortly after the patient's initial visit to the psychiatrist. If the referring physician feels reluctant to schedule such a follow-up appointment, he needs to make sure he is not in fact rejecting the patient.

CONCLUSION

While there is much theory on the indications for psychiatric referral, we have tended to ignore the clinical reality that many patients refuse a referral, no matter how much it is indicated. This problem deserves clinical attention because it is common and because it interferes with optimal care. The problem also deserves empiric investigation because it has important conceptual ramifications. Understanding the objections patients have to psychiatric care can help us understand how persons conceive of mental illness, causes of disease, and mind-body interaction.

This study was supported in part by grant 5T01-MH-16460-03 from the National Institute of Mental Health (Dr Bursztajn).

Archie Brodsky, Thomas G. Gutheil, MD, Leston L. Havens, MD, and John D. Stoeckle, MD, provided comments and support.

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