Consultation-liaison psychiatry

1. Introduction

Version followed: the UK liaison mental health service model as set out by NHS England, the National Collaborating Centre for Mental Health and NICE (2016 guidance, version 1) and RCPsych College Report CR183 (2013), with the scope statement of the European and US consultation-liaison societies (Leentjens et al., 2011), the US Academy of Consultation-Liaison Psychiatry's description of the specialty, NICE NG225 (self-harm, 2022) as summarised by its committee members, NICE CG103 (delirium, current online version) and the Mental Capacity Act 2005 (England and Wales). Where your jurisdiction differs (Scotland, Ireland, US states, EU countries), local law and local service specifications take precedence [synthesis].

Consultation-liaison (C-L) psychiatry, called liaison psychiatry in the UK and psychosomatic medicine in parts of Europe, is a service model and specialty, not a single therapy. The US Academy of Consultation-Liaison Psychiatry describes its members as physicians providing "psychiatric care to people with coexisting psychiatric and medical illnesses", in hospitals and primary care, and explains the name by the two activities: they "consult with patients and liaise with their other clinicians about their care" [source: ACLP home page]. The 2011 joint consensus statement of the European Association of Consultation-Liaison Psychiatry and Psychosomatics (EACLPP) and the Academy of Psychosomatic Medicine (APM) set out the core roles, clinical scope and baseline competencies of psychiatrists in the field, intended for national bodies to adapt [source: Leentjens et al., 2011, repository record]. The EACLPP's work is now carried by the European Association of Psychosomatic Medicine (EAPM), and the APM is the former name of the ACLP [uncertain: not verified]. In England, RCPsych CR183 argues that every acute hospital needs liaison psychiatry, funded and planned alongside physical health services, so that mind and body are not treated separately [source: Mental Elf summary of CR183].

Core idea of how change happens. Change happens at two levels. For the patient: psychological and psychiatric problems that complicate physical illness (self-harm, depression, delirium, dementia, alcohol-related problems, distress about illness, functional symptoms) are recognised, assessed and treated during the medical episode rather than missed or deferred [source: CR183 summary; NHS England 2016]. For the system: the acute team is helped, through advice, joint planning and training, to recognise and respond to mental health needs themselves, so care is integrated rather than split between "physical" and "mental" [source: NHS England 2016; CR183 summary]. Psychological work in a C-L team is always care alongside medical treatment; it is never presented as a treatment for the physical disease itself [synthesis].

Who this guide is for. Psychotherapists, clinical and counselling psychologists and other psychological practitioners working inside a liaison mental health team or a clinical health psychology service attached to a general hospital. The team's psychiatrists (and, in many services, nurse prescribers) hold all decisions about medicines and psychiatric diagnosis; this guide contains no medication content, and any medicine question is routed to the responsible prescriber or the medical team [synthesis]. In the UK, the BPS publishes guidance for employers of practitioner psychologists in physical healthcare settings (2024, updating its 2008 document Clinical Health Psychologists in the NHS) [source: BPS 2024 page].

2. Framework

C-L has no session-numbered protocol. It has (a) a service structure, (b) a consultation episode that repeats for each referral, and (c) a liaison (indirect) function that runs continuously.

2a. Service structure (as NHS England 2016 describes it)

Functions of a liaison mental health service: identify, assess and respond to mental health crises; treat the symptoms of the crisis, including NICE-recommended care; give access to ongoing support and follow-up; and provide service-level support (links with other services, data sharing) [source: NHS England 2016].
Models: Core (the Core 24 functions but reduced hours, e.g. an urgent care centre service in working hours); Core 24 (minimum for any hospital with a 24/7 emergency department; 24/7 cover, consultant on call out of hours, nurse-led out-of-hours rota); Enhanced 24 (adds addictions, drug and alcohol and learning disability expertise, more consultant time); Comprehensive (large regional centres; adds planned-care input such as chronic pain and medically unexplained symptoms, and "greater numbers of senior staff, including consultants, senior nurses and psychologists") [source: NHS England 2016].
Response times: emergency referrals (ED or ward) get a response within 1 hour; in the ED, within 4 hours of arrival or referral the person should have had a full assessment where appropriate, a care plan and onward arrangements, or a Mental Health Act assessment should have begun; urgent ward referrals get a response within 1 hour and assessment begins within 24 hours [source: NHS England 2016]. CR183 sets a maximum of 1 hour for emergency and 1 day for urgent referrals, with all functions available five days a week and emergency/urgent cover seven days [source: CR183 summary]. Local services publish their own matrices, e.g. one NHS trust SOP: ED under 1 hour, acute medical/clinical decision units under 4 hours, wards under 24 hours, urgent ward referrals with immediate risk under 1 hour [source: BSMHFT SOP AUC03 v3, 2021].
Quality standards: the RCPsych Psychiatric Liaison Accreditation Network (PLAN) publishes standards against which liaison services are peer-reviewed and accredited [source: PLAN standards page]. The current edition number and the exact wording of individual PLAN standards are [uncertain: not verified]; check the edition your service is reviewed against.

2b. The consultation episode (one referral)

Phase	Goal	Typical format	Move on when
1. Referral and triage	Know the question, urgency, and whether the patient knows about the referral	Electronic referral plus phone call (one SOP requires a direct conversation for every ED referral) [source: BSMHFT SOP]	Question is specific; urgency category set; patient is well enough to be interviewed or an interim plan is agreed
2. Preparation	Read notes, speak to the nurse in charge, check fitness for interview, plan safety and privacy	10–20 minutes on the ward [synthesis]	You know the medical picture, current cognition, risks and the best time to see the patient
3. Bedside or ED assessment	Assess mental state, psychological needs, risk and context; begin engagement	Usually one contact of 20–60 minutes, adapted to the patient's physical state [synthesis]	You can answer the referral question or know what further information is needed
4. Formulation and recommendations	A brief biopsychosocial formulation and concrete, prioritised recommendations	Written in the acute record; summary in the team's own record [source: BSMHFT SOP]	Recommendations are specific, achievable on that ward, and allocated to named people
5. Feedback to the team	Make sure the referrer has heard and understood	Verbal feedback to the referring doctor or nurse in charge, the same day [synthesis]	The team can say what they will do
6. Follow-up during admission	Brief psychological intervention, review, joint meetings, support to staff	A few bedside contacts across the admission; frequency set by need [synthesis]	Referral question answered, problem resolved or handed on
7. Discharge from the episode	Onward plan, letters, handover	Plan to patient, carers (where appropriate) and team; GP letter (one SOP: usually within 72 hours) [source: BSMHFT SOP]	Named onward service has the information it needs

For self-harm presentations, NICE NG225 adds: psychosocial assessment at the earliest opportunity by a trained mental health professional, not unduly delayed by medical treatment, and prompt aftercare (ideally within 48 hours) where safety concerns persist [source: Mughal et al., 2023, describing NG225]. For psychological treatment after self-harm, NG225 recommends that adults be offered a CBT-informed psychological intervention of 4 to 10 sessions; this is usually delivered by a community service rather than in the hospital episode [source: Mughal et al., 2023] [synthesis on where it is delivered].

2c. The liaison function (continuous)

Advice to acute teams on individual patients; joint planning; teaching ED and ward staff local protocols, legal frameworks and mental health awareness, ideally co-produced with people with lived experience; supporting ED triage staff to spot mental health problems; links and data-sharing with community services [source: NHS England 2016]. CR183 notes that many acute staff lack training to recognise and manage these problems [source: CR183 summary].

3. Guiding principles

Integrated mind-body care [source: CR183 summary]. Practically: describe the psychological problem in terms of how it interacts with the illness, the treatment and the admission, not as a separate issue.
Answer the question you were asked, then the question that matters [synthesis]. Practically: always address the stated referral question explicitly, then add what else you found.
The acute team keeps overall clinical responsibility while the patient is on its site; liaison staff advise and remain accountable through their own governance [source: BSMHFT SOP]. Practically: write recommendations, not orders; agree who does what.
Capacity belongs to the decision and to the clinician proposing it [synthesis; supported by one SOP placing self-discharge capacity assessment with the referrer, with liaison support in complex cases: source BSMHFT SOP]. Practically: route capacity questions to the responsible clinician; you contribute communication help and psychological information.
Capacity is functional and decision-specific: understand, retain, use or weigh the relevant information, and communicate a decision, with information given in a way suited to the person [source: MCA 2005 s.3, explanatory notes]. Practically: never write "lacks capacity" in general; name the decision and the step that failed.
Presume capacity, help the person decide, and do not treat an unwise decision as incapacity [uncertain: MCA 2005 s.1 principles, not verified against the statute text]. Practically: do your communication work before anyone concludes incapacity.
Think delirium first in new confusion or changed behaviour; if delirium and dementia cannot be told apart, treat for delirium first [source: NICE CG103 1.3.1, 1.6.3]. Practically: never start psychological work on "new anxiety" or "new low mood" in a confused or withdrawn older patient without flagging possible delirium to the medical team.
No risk tools or risk stratification after self-harm; build a risk formulation from circumstances, strengths and needs [source: Mughal et al., 2023, describing NG225]. Practically: no "low/medium/high" labels and no checklist scores deciding discharge or treatment.
Compassion, not punishment: no exclusion, withholding of care or aversive approaches after self-harm; psychological treatment is not withheld because of diagnosis, comorbidity or substance use [source: Mughal et al., 2023]. Practically: challenge, kindly, any plan that sounds like a deterrent.
Believe the symptoms: in functional disorders, say what the person has, that you believe them, and that it is common and potentially reversible [source: Stone, Carson & Sharpe, 2005]. Practically: never imply imagined, put-on or "all in the mind".
Treat the underlying cause and support orientation and family involvement in delirium [source: NICE CG103 1.7.1, 1.7.2, 1.4.4]. Practically: your role is recognition, referral, reassurance and family information, not treatment of the cause.
Timeliness is part of quality [source: NHS England 2016; CR183 summary]. Practically: if you cannot meet a response time, tell the referrer, give an expected time and check nothing urgent has been missed [source: BSMHFT SOP].
Stay in scope [synthesis]. Practically: no advice about starting, stopping or changing medicines; route medicine questions, side-effect worries and diagnostic questions to the prescriber or medical team.
Psychological care alongside medical treatment, never instead of it [synthesis]. Practically: never describe a psychological intervention as treating the cancer, the heart disease or the infection.
Co-production and lived experience in staff training [source: NHS England 2016; Mughal et al., 2023]. Practically: involve people with lived experience when you teach ward staff about self-harm.
Document in both records [source: BSMHFT SOP]. Practically: the acute team must be able to read your assessment and plan in their own notes, written for non-psychologists.
Brevity and adaptation to illness [synthesis]. Practically: shorter contacts, attention to fatigue, pain, breathlessness, hearing and privacy; stop when the patient is unwell.

4. Intervention inventory

The inventory has two parts: (A) a factual description of how C-L services are organised and who delivers what, as professional bodies publish it; (B) the psychotherapist's own procedures in the team. Example language is illustrative throughout unless quoted with a source.

A1. How C-L care is delivered (descriptive)

Purpose: know the structure you work within, so your contribution fits it.
What sources describe: C-L psychiatrists consult with patients and liaise with the other clinicians caring for them, in hospitals and primary care [source: ACLP home page]. The EACLPP/APM consensus statement defines roles, scope and baseline competencies for psychiatrists, as a baseline that national societies adapt [source: Leentjens et al., 2011]. In England, liaison mental health services sit inside acute hospitals at one of four levels (Core, Core 24, Enhanced 24, Comprehensive), with defined response times and staffing; the illustrative workforce tables list consultants, other medical staff, nurses, "other therapists", a team manager, a clinical lead and administrative support, and the comprehensive model names psychologists among its senior staff [source: NHS England 2016]. Teams may include sub-specialty expertise in substance misuse, older adults and general adult liaison, and voluntary-sector workers who support de-escalation and community links [source: BSMHFT SOP]. Services can seek accreditation through RCPsych PLAN [source: PLAN standards page]; whether accreditation is required by commissioners in a given area is [uncertain: not verified].
Who may deliver it: psychiatric assessment, diagnosis, Mental Health Act work and all prescribing sit with psychiatrists and other qualified prescribers; liaison nurses and other professionals carry out psychosocial assessments within their competence; practitioner psychologists provide psychological assessment and intervention [source: NHS England 2016 competence tables, summarised; BPS 2024 page for psychologists' employment context] [synthesis on division of roles]. In the US, C-L psychiatry is a recognised psychiatric subspecialty [uncertain: not verified].
Steps [synthesis]: (1) Read your service specification and find out which level of liaison service you work in. (2) Learn the referral routes, response times and who holds medical, psychiatric and capacity decisions. (3) Agree with the team lead what the psychologist's role covers. (4) Introduce yourself to the main referring wards and say what you can and cannot offer.
Watch for: your team's own service specification may define the psychologist's role more narrowly (for example planned-care pathways only, not ED work). Follow it.

B1. Receiving and clarifying the referral question

Purpose: turn a vague request ("please see, low mood", "psych review") into an answerable question, set urgency and make sure the referral is appropriate.
When: every referral, before you go to the ward.
Steps:
1. Read the referral; note who referred, the stated question, location (ED, assessment unit, ward), medical diagnosis and current treatment phase.
2. Phone the referrer if the question, urgency or risk is unclear; one SOP requires a direct conversation for every ED referral [source: BSMHFT SOP].
3. Ask: "What decision or problem do you need help with?" Typical underlying questions are: is there a mental disorder; risk after self-harm; why is this person not engaging with treatment; distress or adjustment; functional symptoms; behaviour on the ward; capacity (route, see B4); fitness for discharge [synthesis].
4. Check the patient has been told about the referral; referrals should be discussed with the patient, and where capacity to consent is impaired clinical risk overrides consent [source: BSMHFT SOP].
5. Check fitness for interview: medically well enough, not too intoxicated or sedated; patients can be referred before they are "medically fit" for discharge if they are well enough for assessment [source: BSMHFT SOP].
6. Triage urgency against your service's response times and allocate to the clinician with the right skills (e.g. psychological intervention vs urgent psychiatric review) [source: BSMHFT SOP; NHS England 2016].
7. Signpost referrals outside the service's remit (e.g. substance use without a mental health component, under-16s, learning disability, where commissioned elsewhere) [source: BSMHFT SOP; local remit varies].
8. Log the referral and the agreed question.
Example language (illustrative): "Thanks for the referral. So I go in with the right question: is it mainly that she's tearful and you're worried about depression, or is it that she's declining the dialysis plan and you want to understand why?" / "Has he been told someone from the mental health team is coming? It goes much better if the team mentions it first."
Watch for: a hidden capacity or disposition question ("can he go home?"); a request that is really about staff distress or a conflict; signs of delirium in the referral text ("new confusion", "agitated overnight", "not himself"), which change the route (B5). Working: the referrer can state in one sentence what they will do with your answer.

B2. Preparation on the ward

Purpose: arrive informed and safe, and choose the right moment.
Steps:
1. Read the medical notes: presenting problem, investigations still pending, current cognition, observations, recent nursing entries, previous mental health contacts, safeguarding alerts.
2. Speak to the nurse in charge or the patient's nurse: sleep, eating, behaviour, visitors, any confusion that fluctuates, any statements about self-harm or leaving.
3. Check for indicators of delirium (B5) before planning psychological work.
4. Plan privacy: side room, quiet room or drawn curtains with the patient's agreement; acknowledge that curtains are not soundproof.
5. Plan safety: for high-risk ED assessments, a designated room, prior discussion with the senior nurse and security, a jointly agreed and recorded risk plan, and joint assessment by two staff where practical; observation stays the acute trust's responsibility with liaison advice [source: BSMHFT SOP].
6. Time the visit around procedures, meals, ward rounds and medication rounds; avoid waking a sleeping patient unless urgent [synthesis].
7. Arrange an interpreter (professional, not family) if needed [synthesis].
Example language (illustrative, to the nurse): "Before I see him, has his concentration or alertness changed over the last day or two? Any times he's seemed muddled or unusually sleepy?"
Watch for: fluctuating attention, new withdrawal or reduced appetite in an older patient (possible hypoactive delirium) [source: NICE CG103 1.3.2]; intoxication or withdrawal; recent sedating treatment (do not interpret it; ask the medical team whether the patient is fit for interview). Working: you can name the best time and place to see the patient and the main risks.

B3. Bedside (or ED) psychological assessment

Purpose: answer the referral question with a brief psychological and mental state assessment adapted to physical illness, and begin engagement.
Steps:
1. Introduce yourself, your role and team, who asked you to come and why; check it is a good time; offer to come back.
2. Agree how long you will stay (often 20–40 minutes at the bedside) and that the patient can stop at any point [synthesis].
3. Start with the illness story in the patient's words: what happened, what they have been told, what they understand, what worries them most.
4. Explore mood, anxiety, sleep, appetite (with care: physical illness confounds these), hopelessness, thoughts of death or self-harm, previous mental health history, substance use, and coping history.
5. Observe orientation, attention and consistency across the interview; if attention fluctuates, stop and flag possible delirium (B5).
6. Ask about supports, carers, dependants, work, housing, money and safeguarding concerns.
7. Ask about illness beliefs and expectations of treatment; ask what would help now.
8. Use validated mood or anxiety measures only if your service uses them and you are trained; describe results in context [synthesis].
9. Summarise back to the patient, say what you will tell the team, and agree next contact.
10. Write a brief biopsychosocial formulation: predisposing, precipitating, perpetuating and protective factors, linked to the illness and admission [synthesis].
Example language (illustrative): "I'm a psychotherapist with the hospital's mental health liaison team. Dr Patel asked me to see you because being in hospital for this long can be hard, and she wanted to make sure you're getting support with that too. Is now an OK time?" / "What's been the hardest part of all this for you?" / "Some people in your situation start to feel life isn't worth it. Has that happened for you?"
Watch for: fatigue, pain, breathlessness (shorten or pause); the patient feeling labelled as "mental" (B11); somatic symptoms of illness mistaken for depression; disclosures of abuse (follow safeguarding procedures). Working: the patient engages, you can answer the question, and the patient knows what happens next.

B4. Capacity questions: recognise, route and support

Purpose: ensure decision-specific capacity questions are assessed by the right person and that the patient has the best chance of deciding for themselves.
When: any referral or conversation that turns on whether a patient can decide (refusing treatment, wanting to self-discharge, consent to a procedure, discharge destination).
Steps:
1. Identify the specific decision and who is proposing it (usually the treating team) [synthesis].
2. Route the assessment to the responsible clinician; in one SOP, capacity for self-discharge against advice is assessed by the referrer, with liaison support in complex cases [source: BSMHFT SOP]. Liaison psychiatrists may advise on capacity where mental disorder is complex [synthesis].
3. Offer what you can contribute: help to present the relevant information in a way suited to the person, since incapacity cannot be found unless that has been done [source: MCA 2005 s.3(2), explanatory notes]; information about mood, anxiety, trauma or communication needs that may affect understanding, retaining, using or weighing; joint attendance if the clinician wishes.
4. Suggest practical aids: quiet setting, plain language, written or visual summaries, hearing aids and glasses, interpreter, best time of day, family present if the patient wants [synthesis].
5. If you observe signs that suggest a step of the functional test may be impaired (cannot retain the information for long enough to decide, cannot weigh it), describe the observation factually in the notes and tell the clinician; do not record a capacity conclusion yourself unless your role and local policy make you the assessor for that decision [synthesis].
6. If the patient is about to leave and there are immediate risks, tell the nurse in charge and the responsible clinician at once; the acute trust holds responsibility for observation [source: BSMHFT SOP].
Example language (illustrative, to the clinician): "The capacity question about refusing the amputation is yours as the treating surgeon. What I can add: she's very frightened, and her understanding seemed better when we used the diagram and slowed down. I'm happy to sit in when you go through it again." / (to the patient) "The doctors want to make sure you have everything you need to make this decision. Can I help you write down your questions?"
Watch for: being asked to "confirm capacity" generally; pressure to agree with a team's preferred outcome; conflating an unwise choice with incapacity [uncertain: MCA s.1 principle, not verified against statute]; delirium or intoxication that may be temporary (suggest reassessment when it improves) [synthesis]. Working: the capacity record names the decision, the information given, how it was given and the outcome, made by the right person.

B5. Delirium recognition and referral

Purpose: catch delirium early, route it to the medical team, and support patient and family.
When: any referral for new confusion, "agitation", "low mood", withdrawal, paranoia or "behaviour" in a medically ill patient, especially an older person.
Steps:
1. Look for recent changes or fluctuations in cognitive function, perception, physical function or social behaviour, reported by the person, carers or staff [source: NICE CG103 1.3.1].
2. Look actively for hypoactive delirium: withdrawal, slowed responses, reduced movement, poor concentration, reduced appetite [source: NICE CG103 1.3.2].
3. If indicators are present, tell the medical team the same day and ask for assessment; NICE states that a competent health or social care practitioner uses the 4AT (CAM-ICU or ICDSC in critical care or post-surgical recovery), and that a healthcare professional with relevant expertise makes the diagnosis [source: NICE CG103 1.6.1, 1.6.2]. Use the 4AT yourself only if you are trained and your service allows it [synthesis].
4. Record the possible signs in the notes [source: NICE CG103 1.5.2].
5. Pause psychological interventions that need concentration until the medical team has reviewed; keep contact supportive and orienting [synthesis].
6. Suggest the non-drug measures NICE lists: clear communication, reorientation, reassurance, involving family and carers, a suitable environment, good lighting, clear signage, a visible clock and calendar, cognitively stimulating activity, regular visits, a familiar team, avoiding moves between wards [source: NICE CG103 1.4.1, 1.4.4, 1.7.2]; verbal and non-verbal de-escalation first for distress [source: NICE CG103 1.7.3].
7. Give information to the person and family: delirium is common and usually temporary; what it may feel like; report sudden changes; the person may want to talk about the experience later; support groups; tailored to cultural, cognitive and language needs [source: NICE CG103 1.8.1, 1.8.2].
8. Offer a follow-up conversation after recovery for people distressed by memories of delirium [source: NICE CG103 1.8.1, on inviting people to share the experience] [synthesis on the therapist's role].
Example language (illustrative, to the medical team): "I was asked to see Mr Okoro for low mood, but his attention drifted, he wasn't sure where he was, and nursing say he's been much quieter since Tuesday. I'm concerned about hypoactive delirium; could he be reviewed today?" / (to the family) "Delirium is a sudden change in how the brain is working, usually caused by the physical illness. It's common in hospital and usually gets better as the cause is treated. You know him best, so tell the nurses if he seems different."
Watch for: labelling delirium as depression or "dementia"; when delirium and dementia cannot be distinguished, treat for delirium first [source: NICE CG103 1.6.3]; frightening perceptual experiences that patients later fear mean they are "going mad". Working: the medical team documents an assessment, the family understands what is happening, and the patient is not started on psychological work they cannot use.

B6. Psychosocial assessment after self-harm in the emergency department

Purpose: a collaborative, compassionate assessment of needs, context and safety for every person who has self-harmed, as NICE NG225 sets out.
When: ED or ward referral after self-harm, once the person is physically well enough and fit for interview.
What NICE requires (as described by guideline committee members): every person who has self-harmed should have a psychosocial assessment by a trained, age-appropriate mental health professional at the earliest opportunity, not unduly delayed by medical treatment; it should be collaborative and compassionate; risk tools and scales should not be used to predict future suicide or self-harm or to decide who is discharged or offered treatment; people should not be categorised as low, medium or high risk; clinicians build a risk formulation from circumstances, strengths and needs [source: Mughal et al., 2023]. NICE quality standard 34 calls for an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risks [source: NHS England 2016]. The full NG225 wording should be checked for exact recommendation numbers [uncertain: not verified against the guideline text].
Steps:
1. Confirm with the ED clinician that physical assessment has happened and the person is fit for interview; if intoxicated, agree a review plan with the ED clinician rather than proceeding [source: BSMHFT SOP]. A brief risk and psychosocial screen first, full assessment and care plan once medically stable and before ED discharge [source: BSMHFT SOP].
2. Find a private, safe room (B2).
3. Open with respect and with how the person is now physically; acknowledge waiting time.
4. Explore the self-harm episode in the person's words: what led up to it, what they hoped would happen, how they feel now about having survived or about the injury, and what happened afterwards (who knows, how they came to hospital).
5. Explore history of self-harm and what has helped or made things worse before, including previous experiences of services.
6. Mental state, including hopelessness, current thoughts of suicide, intent and plans; psychiatric history; substance use.
7. Social circumstances: relationships, dependants (child and adult safeguarding), housing, debt, work or school, legal problems, losses, abuse, isolation.
8. Strengths and reasons for living, supports, what the person wants from services.
9. Ask about access to means in a general way for the purpose of safety planning (storage, removal, who could hold things) without discussing methods [synthesis, consistent with lethal-means counselling].
10. Discuss involving family or carers, with the person's consent, and safeguarding where needed [synthesis].
11. Form a risk formulation (B7) and agree a plan; discuss with a senior colleague or the team psychiatrist when there is serious concern, possible mental illness requiring psychiatric review, or Mental Health Act questions [synthesis].
Example language (illustrative): "I'm here to understand what's been happening for you and to work out together what would help. Can you tell me about what led up to tonight?" / "When you took the tablets, what were you hoping would happen?" / "How do you feel now about still being here?" / "What has kept you going through the hard times before?"
Watch for: staff or your own impatience with repeat attenders; the person minimising to get home; shame and fear of being judged; intoxication; signs of a mental illness needing psychiatric review; a young person (age-appropriate pathway); safeguarding of children in the home. Working: the person feels heard, says something true about what happened, and contributes to the plan.

B7. Risk formulation and safety planning

Purpose: replace risk categories with an understanding of what increases and reduces danger for this person, and a plan they own.
Steps:
1. Summarise in narrative form: background factors, current stresses, current state of mind, triggers that might arise soon (e.g. discharge to an empty flat, court date), protective factors and strengths, and what is uncertain [source: Mughal et al., 2023 on formulation; structure: synthesis].
2. Agree a safety plan collaboratively; NG225 says safety plans may be considered, should be accessible to the person, reviewed regularly and updated as circumstances change, while noting a limited evidence base [source: Mughal et al., 2023].
3. Typical contents [synthesis]: personal warning signs; things the person can do alone; people and places for distraction; people to ask for help; professional and crisis contacts; making the environment safer (storage or removal of items, with someone else holding them where agreed).
4. Give the person a copy in a format they will use (paper, phone); share with the GP and onward services with consent.
5. Avoid "safer self-harm" advice: NG225 does not recommend it; keep instilling hope; simple wound care can sit within an agreed plan [source: Mughal et al., 2023].
Example language (illustrative): "Rather than give you a score, I'd like us to work out what tends to make things worse for you and what helps, so you have a plan for the next few days." / "Who could you text if the night gets bad? Shall we put their number in the plan now?"
Watch for: a plan written by the clinician for the person; contacts that do not exist at night; no plan for the first evening after discharge. Working: the person can describe the first two steps of their plan without looking.

B8. Aftercare and handover after self-harm

Purpose: close the gap between ED and community, when people are most vulnerable.
Steps:
1. Where safety concerns persist, arrange aftercare promptly, ideally within 48 hours, with the same professional where possible [source: Mughal et al., 2023].
2. Refer to a service that can offer the NG225-recommended CBT-informed psychological intervention (4–10 sessions for adults; DBT adapted for adolescents can be considered for young people who frequently self-harm) [source: Mughal et al., 2023]. Psychological treatment should not be withheld because of diagnosis, comorbidity or substance use [source: Mughal et al., 2023].
3. Write to the GP and onward services: what happened, formulation, plan, safety plan, follow-up arranged; one SOP: usually within 72 hours [source: BSMHFT SOP].
4. If the person leaves before a safe plan is in place: try to contact them, involve community agencies, notify the GP, and consider a police safe-and-well check according to local policy [source: BSMHFT SOP].
Example language (illustrative): "I've arranged for the crisis team to call you tomorrow afternoon. If they haven't by four, ring this number."
Watch for: referrals that bounce between services; follow-up offered only if the person rings. Working: a named service has accepted the person and a date exists.

B9. Brief psychological interventions on medical wards

The cited service standards describe the need for psychological care in the acute hospital but do not give a protocol for ward-based brief therapy; the procedures below are standard brief-intervention practice adapted to the ward and are [synthesis] unless cited. All are care alongside medical treatment.

B9a. Supportive and adjustment-focused contact

Purpose: help a patient process a new diagnosis, a complication, loss of function or a frightening event (e.g. ICU stay).
Steps: (1) invite the story and the meaning for the person; (2) name and normalise emotional reactions; (3) identify the most pressing concern; (4) separate what can be controlled from what cannot; (5) mobilise supports and the patient's own coping history; (6) agree one small next step; (7) review at the next visit.
Example language (illustrative): "It sounds like the hardest part isn't the surgery itself, it's not knowing whether you'll be able to work again." / "When you've faced something hard before, what got you through?"
Watch for: grief that is proportionate (support, don't pathologise); persistent hopelessness or thoughts of death (assess as B6, inform the team); the patient asking medical questions (pass them to the team and help the patient write them down). Working: the patient names a concern, feels less alone with it, and can identify one action.

B9b. Brief CBT-informed work for illness-related anxiety and low mood

Purpose: reduce anxiety, catastrophic thinking or withdrawal linked to illness and admission.
Steps: (1) build a simple shared formulation of the cycle (situation, thought, feeling, body, behaviour), using the patient's examples; (2) identify one key unhelpful belief ("if my heart races I'm having another attack"); (3) check whether the belief has a medical basis by asking the team, not by reassuring yourself; (4) gently examine evidence and alternatives; (5) agree a small behavioural step (sitting out, walking with physio, phoning a friend); (6) review.
Example language (illustrative): "Let's map out what happens when the monitor beeps. What goes through your mind first?" / "I'll check with the cardiology team what a fast heartbeat means for you at the moment, so we're working from accurate information."
Watch for: symptoms that may have a medical cause (new palpitations, breathlessness, pain): always route to the team before treating as anxiety; fatigue limiting sessions; patients discharged before work completes (hand on). Working: the patient can describe their cycle and has tried one new response.

B9c. Problem-solving

Purpose: practical problems (childcare, money, work, housing, transport to appointments) feeding distress.
Steps: define one problem concretely; list options without judging; weigh pros and cons; choose; plan the steps and who helps (social worker, discharge coordinator, family); review.
Example language (illustrative): "Let's take just the rent worry for now. What are all the possible ways it could be handled while you're in here?"
Watch for: problems that belong to other professions (refer to social work, welfare advice); overload. Working: one problem has a named next step and owner.

B9d. Arousal reduction and coping with procedures

Purpose: help with procedural anxiety (scans, needles, dressing changes), panic or poor sleep on the ward.
Steps: (1) ask the team whether breathing or relaxation exercises are suitable given the patient's condition (e.g. respiratory or cardiac illness); (2) teach a simple paced breathing or grounding exercise at a pace the patient tolerates; (3) agree with nursing when the patient may use it (before procedures); (4) consider a coping plan for the procedure (information, a signal to pause, distraction); (5) review.
Example language (illustrative): "Let's practise something you can do while you wait for the scan. Breathe in gently, and let the out-breath be a little longer, only as far as is comfortable."
Watch for: dizziness, breathlessness, increased distress or trauma memories (stop, switch to grounding with eyes open); exercises being used to dismiss genuine pain or symptoms. Working: the patient reports feeling more in control and the procedure is tolerated.

B9e. Conversations about ambivalence towards treatment

Purpose: understand why a patient is declining or not following a medical plan (dialysis, insulin, physiotherapy, medicines) and help them talk with the team.
Steps: (1) explore, with curiosity, the patient's reasons, fears, beliefs and practical barriers; (2) reflect both sides of the ambivalence; (3) explore values and what matters most; (4) identify the questions the patient wants answered and help them take those to the responsible clinician; (5) report the understanding to the team, so they can address it. Never advise starting, stopping or changing a treatment or medicine; that discussion belongs to the responsible clinician and the patient.
Example language (illustrative): "Part of you wants to get stronger, and part of you is worn out by all the treatment. Can you tell me more about both?" / "That sounds like a really important question to put to Dr Lee. Shall we write it down so it doesn't get lost on the ward round?"
Watch for: refusals that hinge on capacity (B4); refusals driven by depression, delirium or psychosis (flag for psychiatric/medical review); refusals that are informed and values-based (support the patient to be heard). Working: the team understands the reason and the patient's questions are answered by the right person.

B10. Communicating about functional and medically unexplained symptoms

Purpose: help a patient understand and accept a functional diagnosis (functional neurological disorder, dissociative seizures, other persistent physical symptoms), reduce shame, and engage with rehabilitation and psychological care.
When: after the medical team has made a positive diagnosis, or jointly with them; never as a substitute for medical assessment [synthesis].
Steps (drawing on Stone, Carson & Sharpe, 2005):
1. Check with the medical team what diagnosis has been given and how; agree consistent wording.
2. Start from what the person has: a real, common, potentially reversible problem with how the nervous system is working, rather than damage [source: Stone et al., 2005].
3. Say clearly that you believe the symptoms and do not think the person is mad, imagining or putting them on [source: Stone et al., 2005].
4. Say what they do not have, where relevant (e.g. no epilepsy or MS), in agreement with the team [source: Stone et al., 2005].
5. Use simple metaphors the team has used (a "software" rather than "hardware" problem) [source: Stone et al., 2005].
6. Be honest that the cause may not be fully known; that does not stop treatment [source: Stone et al., 2005].
7. Do not push psychological explanations early: present stress, mood and other factors as things that can make symptoms worse, not as the cause; do not link remote events such as past abuse to current symptoms unless you have an established relationship [source: Stone et al., 2005].
8. Emphasise the role of self-help, activity and rehabilitation (often physiotherapy), and use CBT principles: accept the symptoms, gradual activity, sleep routine, and work on unhelpful beliefs [source: Stone et al., 2005].
9. Give written information and involve family with consent [source: Stone et al., 2005].
10. Frame psychological referral positively; Stone et al. suggest that referral to psychiatry can be deferred to a later appointment and introduced as not meaning the person is "mad" [source: Stone et al., 2005].
11. Avoid judging "genuineness": the authors note clinicians are poor at detecting malingering and that it is a moral judgement, not a medical diagnosis [source: Stone et al., 2005].
Example language: "I don't think you're mad, imagining or putting on your symptoms" (short quote suggested by Stone et al., 2005) / (illustrative) "The team's tests show your nerves and brain aren't damaged, but the way the signals are being sent isn't working properly. That's real and it's common, and it can get better." / "Stress doesn't create this out of nowhere, but it can turn the volume up. Would it be useful to look at what turns it up and down for you?"
Watch for: words that offend ("psychogenic", "all in your head", "nothing wrong"); "functional" being heard as a euphemism for psychological [source: Stone et al., 2005]; new or changing symptoms (route to the medical team; functional and other illness can coexist [synthesis]); anger at the diagnosis (B11, section 5). Working: the patient can explain the diagnosis in their own words, does not feel disbelieved, and accepts rehabilitation or a psychological follow-up.

B11. Engaging a patient who did not ask to see mental health staff

Purpose: turn an unrequested visit into a useful contact.
Steps [synthesis]: (1) explain who asked and why, in non-stigmatising terms tied to the illness; (2) give the patient control (time, length, right to decline, coming back later); (3) start with the physical experience and practical worries; (4) ask what would make the admission easier; (5) if the patient declines, accept it, leave contact routes, and tell the team what you observed and any risk concerns.
Example language (illustrative): "Seeing someone from mental health can feel like being told it's all in your head. That's not why I'm here. The team knows this has been a very tough few weeks and wanted you to have someone to talk to about that side of things."
Watch for: the patient feeling blamed for symptoms; declining because of a bad past experience with services (ask about it). Working: the patient agrees to a contact or at least knows how to ask for one.

B12. Liaison with medical teams

Purpose: make sure the assessment changes care.
Steps:
1. Give verbal feedback the same day to the referrer or nurse in charge: answer to the referral question, key risks, the 2–4 most important recommendations [synthesis].
2. Write recommendations that are specific, prioritised and ward-feasible, and say who does each (e.g. "Nursing: offer the delirium information leaflet to daughter today"; "Medical team: please review for possible delirium"; "Liaison: psychotherapy review Thursday") [synthesis]. Acute teams keep overall responsibility; liaison staff advise [source: BSMHFT SOP].
3. Route every medicine, diagnostic or psychiatric-treatment question to the team psychiatrist or the responsible medical clinician; do not comment on the merits of medicines [synthesis].
4. Offer joint meetings (patient, family, medical team) for difficult news, functional diagnoses, treatment refusal or conflicts; agree beforehand who says what [synthesis].
5. Attend ward MDT or board rounds when your patient is discussed; one SOP describes a weekly liaison MDT and consultant review for diagnosis, treatment and discharge planning [source: BSMHFT SOP].
6. Support staff with behaviour plans for distressed patients: triggers, de-escalation, consistent messages; NICE recommends verbal and non-verbal de-escalation first for distressed people with delirium [source: NICE CG103 1.7.3].
7. Agree the follow-up plan and when the liaison team will close the referral.
Example language (illustrative): "In short: I don't think she's clinically depressed; she's frightened and she doesn't understand why the surgery was postponed. The most helpful thing would be for someone from surgery to explain the new plan today. I'll see her again on Thursday."
Watch for: long notes nobody reads; recommendations that need resources the ward lacks; splitting between staff; your advice being heard as a decision. Working: the team acts on at least the top recommendation and calls you appropriately next time.

B13. Working with family and carers

Purpose: involve the people who know the patient, with consent, and support their own distress.
Steps: (1) ask the patient's consent and record it (or follow best-interests and information-sharing procedures where capacity is lacking, through the responsible clinician) [synthesis]; (2) gather collateral history (recent changes, baseline cognition, mood, risk); (3) give information on delirium, self-harm aftercare or functional disorders as relevant [source: NICE CG103 1.8.1; Stone et al., 2005 on involving family]; (4) signpost carer support.
Example language (illustrative): "You know your mum's usual self far better than we do. Has anything changed in the last few days?"
Watch for: family conflict, safeguarding concerns, the carer at their own breaking point. Working: carers feel informed and know how to raise concerns.

B14. Recognising when to ask for medical or psychiatric review

Purpose: know the limits of psychological assessment and act on red flags.
Steps [synthesis]: (1) Keep the two red-flag lists below in mind at every contact. (2) When one applies, stop the psychological work and tell the patient you will pass the concern on. (3) Tell the named clinician the same day: what you saw or heard, when, and in the patient's words. (4) Record who you told and when, and check at the next contact that it was acted on.
Ask the medical team the same day [synthesis, informed by NICE CG103 1.3.1–1.3.2]: new or fluctuating confusion, drowsiness or inattention; sudden behaviour change; new physical symptoms reported to you; signs of intoxication or withdrawal; a patient reporting a possible side effect or wanting to stop a medicine (pass on what they said; do not advise).
Ask the team psychiatrist [synthesis]: possible psychosis, mania or severe depression; suicidal intent or plans; questions about psychiatric medicines; possible need for a Mental Health Act assessment; complex capacity questions involving mental disorder.
Example language (illustrative, to the patient): "That's an important question about your tablets, and it's one for your doctor. I'll let the team know today that you'd like to talk it through, and you can ask them directly too."
Watch for: reassuring a patient about a symptom you cannot assess. Working: concerns are passed on with a clear description and a named recipient.

B15. Training and supporting acute staff (the liaison function)

Purpose: build the acute workforce's capacity to recognise and respond to mental health needs.
What sources describe: liaison services train ED and ward staff on local protocols, legal frameworks and mental health awareness, responding "compassionately and appropriately", ideally co-produced with people with lived experience; ED triage staff should be competent to spot mental health problems, supported by the liaison team [source: NHS England 2016]. NG225 training should be developed with and co-delivered by people with lived experience, and staff should have supervision [source: Mughal et al., 2023].
Steps [synthesis]: (1) short, case-based teaching at handovers or teaching slots (delirium recognition, responding to self-harm, talking about functional symptoms, de-escalation); (2) reflective practice or debrief groups after distressing events (e.g. a death, an aggressive incident); (3) consultation on individual cases without a formal referral, documented per local policy; (4) feedback loops (what changed after the session).
Example language (illustrative): "Today, ten minutes on one thing: how to tell someone their scan shows no damage without them hearing 'we think you're making it up'."
Watch for: teaching that becomes blaming; staff burnout behind negative attitudes to self-harm. Working: referrals become more specific and earlier; staff use the language themselves.

B16. Documentation

Purpose: a record that the acute team can read and act on, and that meets your professional and legal duties.
Steps:
1. Write in the acute hospital record and in the liaison team's record; document plans in both [source: BSMHFT SOP].
2. Structure [synthesis]: date and time; who referred and the referral question; sources of information; consent to assessment and to sharing; brief history; mental state and cognition observations (including any delirium indicators, which NICE asks to be recorded [source: NICE CG103 1.5.2]); formulation; risk formulation (no risk category labels after self-harm [source: Mughal et al., 2023]); capacity observations, naming the decision and that the responsible clinician has been informed; answer to the referral question; numbered recommendations with owners; follow-up plan; who you discussed it with.
3. Write for non-psychologists: plain language, no jargon, recommendations first or clearly flagged [synthesis].
4. Record sensitive disclosures (e.g. trauma detail) only to the extent needed for care in the shared record; follow local policy on separate psychological notes [synthesis].
5. Report incidents under both organisations' policies where they apply [source: BSMHFT SOP].
6. Send discharge or closing letters to the GP and relevant agencies (one SOP: usually within 72 hours) [source: BSMHFT SOP].
Example language (illustrative entry): "Referral question (Dr A, acute medicine): ?depression. Answer: no evidence of depressive disorder; adjustment reaction to new diagnosis with health anxiety. Recommendations: 1. Medical team to explain biopsy result plan today (patient's main worry). 2. Liaison psychotherapy review 18/10. Discussed with nurse in charge."
Watch for: the recommendation buried in paragraph six; recording a capacity conclusion that is not yours to make; stigmatising language ("attention-seeking", "manipulative"). Working: a ward doctor can say what you recommend after reading the first five lines.

B17. Closing the episode and onward referral

Purpose: end the C-L involvement safely and visibly.
Steps: (1) agree discharge from the liaison caseload when clinically appropriate [source: BSMHFT SOP]; (2) give staff, and where appropriate the patient and carers, the management plan and follow-up options [source: BSMHFT SOP]; (3) refer onward (community mental health, primary care psychological services, clinical health psychology outpatients, specialist services) with a formulation summary; (4) tell the patient what you are passing on and to whom; (5) write the closing note and GP letter.
Example language (illustrative): "This will be my last visit while you're here. I've written to your GP, and I've referred you to the outpatient psychology service; they'll write to you with an appointment."
Watch for: open referrals left on the system; the patient learning of discharge from someone else. Working: the receiving service has accepted, and the patient knows the plan.

5. Handling problems

Most of this section is [synthesis]: the cited standards and pathways rarely describe how to handle these difficulties. Cited points are marked.

The referral question is vague or is really "clear for discharge". Phone the referrer and ask what decision they face (B1). If the request is to "clear" someone medically or legally, explain what a psychological or psychosocial assessment can and cannot answer; route capacity to the responsible clinician (B4) and psychiatric or Mental Health Act questions to the team psychiatrist. Illustrative: "I can tell you how he is psychologically and what support he needs at home; whether he can decide to go home is the capacity question, and that sits with you as the treating team. I'm glad to help you with it."
The patient is not fit for interview (intoxicated, sedated, delirious, too unwell). Do not proceed; agree a review plan and time with the acute clinician [source: BSMHFT SOP]; flag possible delirium (B5); if risk is immediate, agree observation with the acute team, who hold that responsibility [source: BSMHFT SOP].
You cannot meet the response time. Tell the referrer, give an expected time and check for missed urgent issues; if a full assessment is not possible, agree an interim plan [source: BSMHFT SOP].
The patient refuses to see you. Accept it; offer a later visit; give the team observations and any risk concerns; if risk is serious, discuss with the team psychiatrist; record the refusal and what was offered (B11).
Anger about a functional diagnosis ("so you think I'm making it up"). Acknowledge the anger as understandable given past experiences; restate that the symptoms are real and believed; return to what the person has and what can help; do not argue causation; offer a joint meeting with the medical team to go over the explanation [source on stance: Stone et al., 2005].
Disagreement between team members about the diagnosis ("it's functional" vs "it's not"). Do not take sides on medical questions; ask for a consistent message to be agreed before anyone speaks to the patient; offer a joint meeting.
Staff hostility or fatigue towards people who self-harm or attend often. Respond with curiosity, not reproach; offer a case discussion or reflective session; restate that NG225 rules out punitive approaches and that psychological treatment is not withheld because of diagnosis or substance use [source: Mughal et al., 2023]; consider a multi-agency care plan for frequent attenders.
Pressure to assign a risk level. Explain that NICE advises against risk tools and low/medium/high categories, and offer your risk formulation and plan instead [source: Mughal et al., 2023]. Illustrative: "I won't give a category, because NICE advises against them; here is what raises and lowers her risk and what we've agreed."
The patient wants to leave before assessment or against advice. Inform the nurse in charge and responsible clinician immediately; the referrer assesses capacity for self-discharge with liaison support in complex cases [source: BSMHFT SOP]; if they leave before a safe plan, follow the trust process for contacting them and informing the GP and community agencies [source: BSMHFT SOP].
Disagreement with the team about capacity. Share your observations factually, suggest a reassessment after communication aids or when delirium or intoxication improves, and ask the team psychiatrist for advice in complex cases; never record a conflicting capacity conclusion unless you are the assessor for that decision.
A patient asks you about their medicines or wants to stop one. Do not give an opinion; acknowledge the concern; pass it to the prescriber the same day and help the patient prepare their questions (B9e, B14).
No privacy. Ask for a side room or quiet room; if none, lower your voice, sit close at eye level, and avoid detailed questions about sensitive matters until privacy is available, unless risk requires it.
The patient is discharged before your follow-up. Phone or write to the patient and GP, and hand on to the appropriate outpatient or community service (B17); ask wards to notify the liaison team of discharge for open cases.
Overwhelm in the patient (crying, panic, dissociation at the bedside). Slow down; ground with eyes open and attention to the room; stop exploratory questioning; ensure nursing knows; return later.
Ruptures (patient feels you have "sided with the doctors"). Acknowledge, clarify your role and its limits honestly, and say what you will and will not pass on, within the limits of confidentiality and safety.
Interpreters and cultural factors. Use professional interpreters; check illness beliefs and the meaning of mental health contact in the person's community; avoid relatives as interpreters for risk or capacity conversations.
Your own distress (deaths, injury, repeated crises). Use supervision; NG225 expects staff to have appropriate supervision [source: Mughal et al., 2023]; staff safety issues are reviewed in supervision [source: BSMHFT SOP].

Sources

Web sources:

Publications cited:

Stone J, Carson A, Sharpe M (2005). Functional symptoms in neurology: management. Journal of Neurology, Neurosurgery and Psychiatry 76(Suppl I):i13–i21. doi:10.1136/jnnp.2004.061663.
Royal College of Psychiatrists (2013). Liaison psychiatry for every acute hospital: integrated mental and physical healthcare. College Report CR183 (cited via the summary above; report text [uncertain: not verified]).
NICE (2022). Self-harm: assessment, management and preventing recurrence (NG225) (cited via Mughal et al., 2023; guideline text [uncertain: not verified]).
PLAN quality standards for liaison psychiatry services, current edition [uncertain: not verified].
Mental Capacity Act 2005, section 1 principles [uncertain: not verified against the statute text].

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