Applying Positive Ethics to Applying Positive Ethics to Difficult PatientsDifficult Patients
Sam Knapp, Ed.D.Sam Knapp, Ed.D.
John Gavazzi, Psy.D.John Gavazzi, Psy.D.
Who are “difficult” patients?Who are “difficult” patients?
High risk for failureHigh risk for failure
Emotionally drainingEmotionally draining
Increased legal and ethical risksIncreased legal and ethical risks
Multiple DimensionsMultiple Dimensions
Patient CharacteristicsPatient Characteristics
Context of TreatmentContext of Treatment
Psychologist factors and Psychologist factors and resourcesresources
Patient FactorsPatient Factors
Intense Negative AffectIntense Negative Affect
Difficulty forming and Difficulty forming and maintaining relationshipsmaintaining relationships
Limited insightLimited insight
Avoid overemphasis on diagnosisAvoid overemphasis on diagnosis
Patients may be difficult even if they Patients may be difficult even if they do not meet specific DSM categorydo not meet specific DSM category
Some patients with complex DSM Some patients with complex DSM diagnoses may be successful patientsdiagnoses may be successful patients
Avoid labeling or blaming patientAvoid labeling or blaming patient
Intense Negative AffectIntense Negative Affect
Emotionally and intellectually drainingEmotionally and intellectually draining
Vicarious PTSDVicarious PTSD
Recognition of the process of therapyRecognition of the process of therapy
Relationship deficitsRelationship deficits
Difficulty building a working relationship Difficulty building a working relationship with the psychologistwith the psychologist
May be direct or indirect issuesMay be direct or indirect issues
May also report deficient social support May also report deficient social support systems outside of therapysystems outside of therapy
Lack of insightLack of insight
Inability of patient to reflect upon his/her Inability of patient to reflect upon his/her behaviors and how these influence behaviors and how these influence consequences of actions or beliefsconsequences of actions or beliefs
Inability to understand the severity of their Inability to understand the severity of their situationsituation
If patient cannot understand the complexity and If patient cannot understand the complexity and seriousness of emotional and behavioral issues, seriousness of emotional and behavioral issues, less likely to work toward changeless likely to work toward change
Context of TherapyContext of Therapy
AmbivalenceAmbivalence
Lack of motivationLack of motivation
Pressured into treatmentPressured into treatment
Current litigationCurrent litigation
Psychologist FactorsPsychologist Factors
Skills and knowledge with particular Skills and knowledge with particular populationspopulations
Emotional resources Emotional resources at this timeat this time
External resources, such as consultationExternal resources, such as consultation
Self-ProtectionSelf-Protection
Office layoutOffice layout
Supportive staff nearbySupportive staff nearby
Safety planSafety plan
Other resourcesOther resources
Early ScreeningEarly Screening
Extensive psychiatric historyExtensive psychiatric history
At risk factors: childhood abuse, At risk factors: childhood abuse, criminal record, troubled work historycriminal record, troubled work history
Impaired relationshipsImpaired relationships
Focus on the relationshipFocus on the relationship
Failure to develop a working relationship Failure to develop a working relationship within a few session is cause to reconsider within a few session is cause to reconsider
the treatment planthe treatment plan
Alliance ruptures and repairsAlliance ruptures and repairs
Alliance ruptures do happen in Alliance ruptures do happen in psychotherapypsychotherapy
Handling the rupture and the repair Handling the rupture and the repair takes additional skillstakes additional skills
Ethical IssuesEthical Issues
Additional attention to ethical Additional attention to ethical principles with high risk patientsprinciples with high risk patients
Boundary issuesBoundary issues
Boundary crossings have a greater Boundary crossings have a greater chance of becoming more chance of becoming more problematicproblematic
Lower threshold for clinical Lower threshold for clinical contraindicated boundary crossingcontraindicated boundary crossing
Pay extra attention to self-disclosurePay extra attention to self-disclosure
Informed ConsentInformed Consent
Not a once and done processNot a once and done process
May need to revisit multiple times for high May need to revisit multiple times for high risk patientsrisk patients
Increased collaboration related to goalsIncreased collaboration related to goals
More structured treatment planMore structured treatment plan
Quality Enhancing Quality Enhancing StrategiesStrategies
ConsultationConsultation
Empowered CollaborationEmpowered Collaboration
DocumentationDocumentation
Redundant ProtectionsRedundant Protections
Quality Enhancing StrategiesQuality Enhancing Strategies
As the legal risks, the possibility of As the legal risks, the possibility of treatment failure, or patient treatment failure, or patient
complexity increases,complexity increases,
the greater the level of attention should the greater the level of attention should be given to quality enhancing be given to quality enhancing
strategies.strategies.
ConsultationConsultation
Technique oriented informationTechnique oriented information
Emotional reactions Emotional reactions (countertransference)(countertransference)
Reduction of emotional turmoilReduction of emotional turmoil
Thinking through solution togetherThinking through solution together
ConsultationConsultation
Write down issues in advanceWrite down issues in advance
Need to be open and honestNeed to be open and honest
Be willing to admit mistakes or Be willing to admit mistakes or clinical errorsclinical errors
Empowered CollaborationEmpowered Collaboration
Empowered collaboration builds upon Empowered collaboration builds upon informed consent and attempts to informed consent and attempts to maximize patient involvement in all maximize patient involvement in all essential elements of treatmentessential elements of treatment
The patient becomes more actively The patient becomes more actively involved in the process of psychotherapy. involved in the process of psychotherapy. Greater commitment leads to better Greater commitment leads to better outcomes.outcomes.
Empowered CollaborationEmpowered Collaboration
Empowering psychologists respect a Empowering psychologists respect a patient’s autonomy and decision making patient’s autonomy and decision making skills about the goals of treatment, process skills about the goals of treatment, process of treatment, and life choices.of treatment, and life choices.
Examples of tough decisions and Examples of tough decisions and ambivalent patientsambivalent patients
Documentation: Legal PurposesDocumentation: Legal Purposes
Required by insurers, State Board of Required by insurers, State Board of Psychology, APA Ethics Code, etc.Psychology, APA Ethics Code, etc.
A record of treatment for future providersA record of treatment for future providers
Useful risk management toolUseful risk management tool
Documentation: Quality EnhancingDocumentation: Quality Enhancing
Dialogue with self and patient regarding Dialogue with self and patient regarding process and goals of treatmentprocess and goals of treatment
Means to identify pertinent clinical issuesMeans to identify pertinent clinical issues
Procedure to document progressProcedure to document progress
Redundant ProtectionsRedundant Protections
Additional source of information for a Additional source of information for a difficult patientdifficult patient
Routine procedure with high risk patientsRoutine procedure with high risk patients
TransparencyTransparency
General Rule: Implement quality enhancing General Rule: Implement quality enhancing strategies with as much transparency as strategies with as much transparency as
possible.possible.
Questions, answers and Questions, answers and more discussionmore discussion
VignettesVignettes
Looking the exercise what you have Looking the exercise what you have learnedlearned
Not looking for the “correct” answerNot looking for the “correct” answer
Important IssuesImportant Issues
What factors make this a potentially difficult What factors make this a potentially difficult patient for you?patient for you?
What would your emotional reaction be to What would your emotional reaction be to the content of this scenario?the content of this scenario?
Important issuesImportant issues
How would you use a consultation?How would you use a consultation?
In what ways would empowered collaboration In what ways would empowered collaboration be of use?be of use?
Are there any issues related to documentation?Are there any issues related to documentation?
Can you think of any redundant protections?Can you think of any redundant protections?