applying positive ethics to difficult patient

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.


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


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 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.


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?

applying positive ethics to difficult patient

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