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FacilitatingPatientAcceptanceofaPsychiatric
Referral
HaroldBursztajn,MD,ArthurJ.Barsky,MD
(ArchInternMad1985145:7375)
Therearefivecommonwaysinwhichapatientmayobjecttoaphysician'ssuggestionofapsychiatric
referral.Thepatientmayrejectthereferralbecauseofthesocialstigmaofbeingapsychiatricpatient
becausethereferraldamageshisorherselfesteembecausethepatientdoesnotunderstandtheroleof
emotionsinphysicaldiscomfortbecausethepatientfeelsrejectedbythereferringphysicianorbecause
oftheeffectsofpsychiatricIllness.Followingathoroughmedicalworkup,thephysiciancanbest
dischargehisorherresponsibilitytothepatientbypayingattentiontothesepossiblemisunderstandings.
Thephysiciancandiscusstheroleofsocialstigma,offsettheblowstothepatient'sselfesteem,educate
thepatientaboutthepsychosomaticmodelofdisease,andassurethepatientofthephysician'scontinuing
interestandinvolvement.
Manymedicalpatientswhocouldbenefitfromapsychiatricreferralfindtheideaunacceptable.A
psychiatricreferralcancauseapatienttofeelhumiliated,accused,ordisliked.However,thereferring
physician'sunderstandingandattentioncanfrequentlyovercomethepatient'sreluctancetoconsulta
psychiatrist.
Thedifficultyincompletingapsychiatricreferralisparticularlyunfortunateinlightofthehigh
prevalenceofpsychiatricdisorderingeneralmedicalpractice.[1]Twentyfivepercentto30%of
ambulatorymedicalpatientshavediagnosablepsychiatricdisorders,[24]yettheratesofrecognitionby
physiciansaregenerallyintherangeof1%to5%,[1,3,5,6]and0.07%to2.5%ofpatientsseenin
generalpracticearereferredtopsychiatrists.[1,7,8]Althoughmanyofthesepatientsmaybetreatedwell
bytheirprimaryphysicians,thesefiguresstillsuggestthattherearemanypatientswhocouldbenefit
fromareferralbuteitherarenotaskedtoseeapsychiatristordonotfollowthesuggestion.
Thelowrateofcompletedreferralsreflectsanumberoffactors.One,thefocusofthisarticle,is
reluctanceonthepartofthepatient,[913]andanotherisphysicianreluctance.Thelatterhasbeenfound
toberelatedtotheabsenceoftraininginpsychiatricdiagnosisadherencetoabiologicratherthan
biopsychosocialmodelofdiseaseandapessimisticandnegativeorientationtowardpsychiatrycoupled
withabeliefthatpatientsareunreceptivetopsychiatricreferrals.[9,1418]Psychiatriststhemselveshave
notfacilitatedthereferralprocess,andtheirfeedbackandassistanceareattimesdisappointing.[19]
Finally,thementalhealthsystemitself,withitsremotenessandbarrierstoaccess,hindersthereferral
process.[20]
Wepresentaclinicalexampleofthereferralprocess,describewhatmakesapsychiatricreferraldifficult
formanypatients,anddiscusshowthereferringphysiciancandealwiththeproblem.

REPORTOFACASE
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Thereferralprocessinthiscasewasfarlengthierandmoreintensivethanmostinternistshavetimefor,
butthecaseillustratesmanyoftheissuesinvolved.
A28yearoldgraphicdesignerforanadvertisingfirmwasreceivingoutpatienttreatmentforsystemic
lupuserythematosus,diagnosedsixmonthsearlier.Thepatient'sdiseasewasmanifestedprimarilyby
jointinvolvement.Ayearbeforeherillness,afterhavinglivedonherownforsixyears,shehadmoved
acrossthecountrybacktoherparents'homefollowingtheunhappyendofaloveaffair.Sincetheonset
ofherillnessthepatienthadwithdrawnsociallyandhadfeltdepressed.Askilleddesignerwhoearned
herlivingbyprecisefreehandsketching,shecomplainedthatpainpreventedherfromusingherhands.
Herphysicianthoughtshewasdepressedsheagreedtoatrialofantidepressanttherapy,butsherefused
apsychiatricreferral.Shedid,however,agreetoanextendedconsultationwithanotherprimarycare
physicianintheclinicwhowasalsoapsychiatrist.
Intheirfirstmeeting,thepatientdescribedhowdepressed,demoralized,andhopelessshefeltbecause
herdiseasehadrenderedherunabletodraw.Theconsultantaddressedherdespondencybysaying,
"Now,whenyourdoctorsuggestsapsychiatrist,itmightfeellikehe'sgivinguponyoutoo....Many
patientsbelievethattheirdoctorhasreferredthemtoapsychiatristbecausethere'snothinglefttodo.But
that'snotreallytrue."
Duringthesecondvisit,patientandphysiciandiscussedhowstressandunhappinesscanworsenphysical
symptoms:"Forexample,alittlecrampfeelslikeaseriouspainifyou'refrightenedandupsettostart
with."Theconsultantalsointroducedtheideathatstresscanbeinternalaswellasexternalinorigin.
Havingtorelyonherparentsagainafterhavingbeencompletelyindependentcouldbeanimportant
stressforthepatient."It'snotsurprisingyoufeelaconflictbetweenwantingwhatlittlepleasureyouget
frombeingtakencareof,andwishingyoucouldtakecareofyourself."
Inthethirdvisit,problemsofsocialstigmaandselfesteemwereaddressed."Whatwillmyfamilysay?"
thepatientexclaimed."IfIgotoapsychiatristthey'llthinkthere'sreallysomethingwrongwithme."The
consultantacknowledgedthatthefamilymightwellhavethisconcern,butthatthisdidnotmeanthatthe
patienthadtothinkofherselfas"crazy."Thepatientthenwonderedifbeingdepressedmeantthatthe
sufferinganddisabilityshehadexperiencedwereonlyinhermind,thatshehadjust"imagined"them.
Sheadmittedthatfeelingsofchagrin,shame,anddisapprovalaccompaniedtheideathatherphysical
sufferingandimpairmentjustreflectedaninabilitytocontrolherownemotions.
Inthefinalmeetingsheandtheconsultantdiscussedhowpsychotherapymightbehelpful.Thepatient
wasworriedthatshemightloseherprimaryphysicianifshebeganvisitingapsychiatrist.Theconsultant
emphasizedtheformer'scontinuinginvolvement.Thepatientthenacceptedareferralforpsychotherapy
todiscussheremotionalreactionstoherdisease.Herpsychotherapysubsequentlywashelpfulin
improvingherleveloffunction,amelioratingherdepression,andhelpinghertocopewiththe
consequencesofsystemiclupuserythematosus.

PATIENTS'OBJECTIONSTOTHEPSYCHIATRICREFERRAL
FearsofSocialStigma
Havingapsychiatricillnesscancauseagreatsocialstigma.One'sovertbehaviormaynotbetraya
mentalillness,butavisittoapsychiatrist,bydesignatingoneasapsychiatricpatient,makesone
vulnerabletostigmatization.Thementallyillaregenerallyconsideredinhighlynegativeterms.[21,22]
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Psychiatricpatientsarefeared,distrusted,anddisliked.Theyaresuspectedofbeingatbestweakandat
worstimmoral,depraved,andworthless.[2326]Mentalillness,unlikemostformsofmedicalillness,is
viewedbythepublicassociallyunacceptable,embarrassing,andnottobediscussedorovertly
acknowledged.[27]Thepatientintheforegoingexamplevoicedtheseconcernsinherthirdvisitwhen
sheworriedaboutherfamily'sreactiontothenewsthatshewasvisitingapsychiatrist.

ThreatstoSelfesteem
Visitingapsychiatristcanchangehowonethinksaboutoneself.Manypatients,includingthepatient
describedearlier,believethatpsychologicalproblemsandemotionaldifficultiesbetrayaweakness,
personalfailing,orcharacterdefect.Goingtoapsychiatristthenmeansthatoneisweakandincapable
andmustturntosomeoneelsetobe"fixed."Havingtorelyonsomeoneelsetohelpwithone'semotions
whenonefeelsoneshouldbeabletomanagethemoneselfcanbeamajorblowtoselfesteem,
generatingasenseofinadequacy,defectiveness,andevenbadness.
Forapatientwhohasalreadyenduredphysicaldiscomfortanddisability,thesuggestionthatheseea
psychiatristisadditionallydisturbing.Itimpliesthattheproblemmayhavebeen"only"inhismind,that
hesomehow"madeitallup,"that"itwasnotreal."Hewonderswhetherhissufferingwasunnecessary
andwhetherhislimitationswereselfimposed.Thepatientmayevencometosuspecthimselfasa
malingererorfaker.Intheclinicalvignettepresentedhere,thepatientwaschagrinedbywhatshefeltto
beher"selfdeception."

MisconceptionsAbouttheEffectsofEmotionsonPhysicalSymptoms
Psychiatriccareseemsirrelevanttoaphysicallysymptomaticpatientwhodoesnotunderstandthe
interactionofpsycheandsoma.[28]Thesequestionswereaddressedbytheconsultantduringthesecond
visitintheclinicalcaseexample.Manypatientsbelievethatphysicalsymptomsmusthavephysical
causes,aviewthatiscongruentwithourculturalfocusondisease(thebiologicderangement),ratherthan
onillness(theexperienceofandreactiontothatpathologicchange).[29]
Thepatient'sunderstandingofpsychiatrictreatmentcanbeequallyimportant.Itiscommonlybelieved
thatpsychiatricillnessisincurableandunalterable.Givensuchabelief,theideathatone'sphysical
symptomshaveapsychologicalcausemustberejectedoutofhand.Toconsideritistoentertainthe
thoughtthatone'sphysicalpainanddisabilitywillneverberelievedorassuaged.

FearsofRejectionbythePrimaryPhysician
Thereferralisapersonalactonthepartoftheprimaryphysiciantowhichmanypatients(correctlyor
incorrectly)imputeaparticularmeaning.Theyviewthereferralasarejectionordismissal.Buriedinthe
referralforsomepatientsistheimplicitmessagethatonehasnottoldagoodenoughstorytobe
accepted,thatthepatientand/orhisillnessareinsufficientlyinterestingorserioustoengagethe
physician.Theremaybethesensethatonehasauditionedforaroleandnotbeenselected.Often,infact,
thereisanimplicitorexplicitcommunicationthatthepatientisbeing"dumped"or"turfed."Inthe
clinicalexamplegivenearlier,thepatientexplicitlyworriedinthefourthvisitwhetherherprimary
physicianwouldcontinuetoseeheraftershebeganseeingapsychiatrist.
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Attimesthepatient'ssenseofrejectionmaybefueledbythereferringphysician'sattitude.Thephysician
maybefrustratedbyapatientwhomhehasbeenunabletohelp.Finding"nothingwrong,"themedical
physicianseesnoreasontocontinuetheirrelationship.Hisfrustrationandimpatiencecombinetodeepen
thepatient'ssenseofrejectionandofthereferralasawayofdiscontinuingcare.

Psychopathology
Thenegativeemotionalresponsesmanypersonshavedonotnecessarilyimplyanynotable
psychopathologiccondition.However,inadditiontothesegeneralreactions,personsmayhavespecific
objectionstoseeingapsychiatristthatareintrinsicallytiedtoparticularpsychiatricdisorders.
Depression,forexample,causesadiminishedsenseofone'sownworthandafeelingthatonedeserves
punishment.Depressedpatientsmaythereforerefuseapsychiatricconsultation,feelingthattheydonot
deservetofeelbetterandarenotworthtreating.Somatizationisanotherpsychiatricproblemthatmakes
referraldifficult.Somatizersdistractthemselvesfromemotionaldistressbyfocusingonphysical
symptoms,thussubstitutingphysicaldiscomfortforemotionaldiscomfort.Apsychiatricreferralimplies
thatthesufferingisactuallyemotional,whichispreciselywhatthesepatientsaretryingtoavoid.The
patientreactstothisthreatbydenyingtheneedfortheremedy,ie,byrefusingthereferral.Finally,
personswhoareespeciallyprivate,shy,hypersensitive,andmistrustfulmayperceiveapsychiatric
referralasparticularlythreatening,sincepsychiatristsarethoughttopryintopersonalmatters,toask
intrusivequestions,andeventoreapminds.

MANAGINGTHEREFERRAL
Tofacilitateacceptanceofthepsychiatricreferral,thephysicianmustfirstfosteranopenandtrusting
physicianpatientrelationship.Thiswillallowthepatienttovoicehisconcernsopenlyandhonestlyand
discussthemindetail.Thephysicianthereforeencouragesthepatienttoexpresshisfeelingsaboutthe
proposedreferralandthenclarifiesthemeaningofthesuggestiontothepatient.
Theprocessoutlinedheremayseemtoocomplicatedandtimeconsuming,buttheproblemisan
importantandcommonone.Moreover,simplygettingthepatienttothepsychiatrist'sdoorisoflittle
valueifthepatientarrivestoofrightened,angry,confused,ordefensivetobeabletolistenorworkatthe
therapy.Thepatientwhoacceptsthepsychiatricreferraloutofcompliance,orsimplytopleaseorplacate
thereferringphysician,maystillremainclosedtoanypsychiatricinput.[30]Thegoalofareferralisnot
simplytoforceanunwillingpatienttospendafewminuteswithapsychiatrist,buttohelpthepatient
visitthepsychiatristwithsomeopennessandhopefulness.

MedicalWorkup
Thephysician'sfirsttaskistopursuemedicalworkupandmanagementasthoroughlyaspossible.Not
onlyisthisclinicallyobligatory,butitformsthefoundationofthetherapeuticrelationshipwiththe
patient.Italsodemonstratesthatthephysiciantakesthepatientseriouslyandappreciatesthepatient's
decisiontocometohimratherthantoapsychiatrist.Finally,iteliminates(asfaraspossible)onesource
ofambiguityfromthereferralprocess:thatsomethingaboutthepatient'smedicalstatusisbeing
overlooked.Ifthepatientfeelsthereferralispremature,hewillfeelignoredandshortchangedthiswill
preventhimfromconsideringtheideaopenly.
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MakingtheReferral
Thephysicianshouldsuggestthereferralinadirectandstraightforwardmanner,explaininghisreasons
forrecommendingit.Thenthephysicianshouldobservethepatientandlistencarefullyforanger,
apprehension,orconfusionthatmightindicateresistancetotheidea.Itishelpfultopresentthe
consultationasanattempttotreatthepatient'sdiscomfort,ratherthananattempttodiagnosea
psychologicalcauseforthephysicalsymptoms.
Itisnotnecessarytoforcethedubiouspatientintoaprematureresponse.Thereferralcanbediscussed
overthecourseofseveralvisits.Asillustratedintheclinicalvignette,thephysicianaimsforanopen
endedprocessinwhichapainfulideacanbeassimilated,ratherthananopenandshutpropositionthatis
tobeacceptedorrejectedasis.

DealingWiththePatient'sObjections
Thefearofsocialstigmaandtheblowtothepatient'sselfesteemareconfrontedwiththeaidoftwo
interviewingtechniques:empathy[31,32]andcounterprojection.[33]Empathicstatementsacknowledge
andvalidatethepatient'semotionalexperience:"Itmustfeelridiculoustobetoldtoseeapsychiatrist
whenthepainyou'refeelingisreal."Counterprojectivestatementsaddressthenegativefeelingsothers
mayhaveaboutpsychiatricpatients.Theyhelptoreassurethepatientthatthephysiciandoesnotshare
andthatthepatientneednotsharetheprejudicethatapersonwhogoestoapsychiatristisamalingerer
orisdependent,defective,orworthless.
Indealingwithsocialstigma,itisusefultofindoutexactlywhoseopinionsthepatientismostconcerned
about.Whatconsequencesdoesthepatientmostfearwhenthesepersonslearnabouttheconsultation?
Whentheimportantpersonsarefamilymembers,especiallyfamilymemberswithwhomthephysician
hasalreadyhadsomecontact,itmaybeusefultohavethemreturnwiththepatientandjointlydiscuss
thereferralandwhatitmeanstothephysician,patient,andfamily.
Ifthepatientlacksanintellectualunderstandingoftheroleofpsychologicalfactorsinphysicalsuffering,
education,information,andexplanationmaybehelpful.[29,34]

PatientsWithSeriousPsychopathologicDisorders
Whenthepatient'sreluctanceisitselfanintegralpartofamajorpsychiatricdisorder,itcanbeusefulto
pointthisouttothepatient.Thephysiciancanexplainthatthepatient'sresistanceispartoftheproblem
thatneedstreatmentandthatifhispsychiatricproblemtroubledhimless,hewouldnotfeelthesame
wishtoavoidpsychiatriccare.Learningaboutthepatient'spriorexperienceswithpsychiatriccarecan
helpclarifyhisobjectionsandmakeitpossibletosatisfythemorworkaroundthem.

ReassuranceofContinuity
Finally,thephysicianattemptstocounterthepatient'sfeelingorrejectionatbeingreferredtoanother
physician.Hereassuresthepatientthatthereferralisnotarejectionandexplainsthathewillstillbe
thereasthepatient'sphysician.Thiscanbedemonstratedconcretelybyschedulingafollowup
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appointmentshortlyafterthepatient'sinitialvisittothepsychiatrist.Ifthereferringphysicianfeels
reluctanttoschedulesuchafollowupappointment,heneedstomakesureheisnotinfactrejectingthe
patient.

CONCLUSION
Whilethereismuchtheoryontheindicationsforpsychiatricreferral,wehavetendedtoignorethe
clinicalrealitythatmanypatientsrefuseareferral,nomatterhowmuchitisindicated.Thisproblem
deservesclinicalattentionbecauseitiscommonandbecauseitinterfereswithoptimalcare.Theproblem
alsodeservesempiricinvestigationbecauseithasimportantconceptualramifications.Understandingthe
objectionspatientshavetopsychiatriccarecanhelpusunderstandhowpersonsconceiveofmental
illness,causesofdisease,andmindbodyinteraction.
Thisstudywassupportedinpartbygrant5T01MH1646003fromtheNationalInstituteofMentalHealth(DrBursztajn).
ArchieBrodsky,ThomasG.Gutheil,MD,LestonL.Havens,MD,andJohnD.Stoeckle,MD,providedcommentsandsupport.

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