Applying positive ethics to difficult patient
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Applying positive ethics to difficult patient



This presentation stemmed from a book chapter authored by Sam and John.

This presentation stemmed from a book chapter authored by Sam and John.



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Applying positive ethics to difficult patient Presentation Transcript

  • 1. Applying Positive Ethics to Difficult Patients Sam Knapp, Ed.D. John Gavazzi, Psy.D.
  • 2. Who are “difficult” patients?
    • High risk for failure
    • Emotionally draining
    • Increased legal and ethical risks
  • 3. Multiple Dimensions
    • Patient Characteristics
    • Context of Treatment
    • Psychologist factors and resources
  • 4. Patient Factors
    • Intense Negative Affect
    • Difficulty forming and maintaining relationships
    • Limited insight
  • 5. Avoid overemphasis on diagnosis
    • Patients may be difficult even if they do not meet specific DSM category
    • Some patients with complex DSM diagnoses may be successful patients
    • Avoid labeling or blaming patient
  • 6. Intense Negative Affect
    • Emotionally and intellectually draining
    • Vicarious PTSD
    • Recognition of the process of therapy
  • 7. Relationship deficits
    • Difficulty building a working relationship with the psychologist
    • May be direct or indirect issues
    • May also report deficient social support systems outside of therapy
  • 8. Lack of insight
    • Inability of patient to reflect upon his/her behaviors and how these influence consequences of actions or beliefs
    • Inability to understand the severity of their situation
    • If patient cannot understand the complexity and seriousness of emotional and behavioral issues, less likely to work toward change
  • 9. Context of Therapy
    • Ambivalence
    • Lack of motivation
    • Pressured into treatment
    • Current litigation
  • 10. Psychologist Factors
    • Skills and knowledge with particular populations
    • Emotional resources at this time
    • External resources, such as consultation
  • 11. Self-Protection
    • Office layout
    • Supportive staff nearby
    • Safety plan
    • Other resources
  • 12. Early Screening
    • Extensive psychiatric history
    • At risk factors: childhood abuse, criminal record, troubled work history
    • Impaired relationships
  • 13. Focus on the relationship
    • Failure to develop a working relationship within a few session is cause to reconsider the treatment plan
  • 14. Alliance ruptures and repairs
    • Alliance ruptures do happen in psychotherapy
    • Handling the rupture and the repair takes additional skills
  • 15. Ethical Issues Additional attention to ethical principles with high risk patients
  • 16. Boundary issues
    • Boundary crossings have a greater chance of becoming more problematic
    • Lower threshold for clinical contraindicated boundary crossing
    • Pay extra attention to self-disclosure
  • 17. Informed Consent
    • Not a once and done process
    • May need to revisit multiple times for high risk patients
    • Increased collaboration related to goals
    • More structured treatment plan
  • 18. Quality Enhancing Strategies Consultation Empowered Collaboration Documentation Redundant Protections
  • 19. Quality Enhancing Strategies
    • As the legal risks, the possibility of treatment failure, or patient complexity increases,
    • the greater the level of attention should be given to quality enhancing strategies.
  • 20. Consultation
    • Technique oriented information
    • Emotional reactions (countertransference)
    • Reduction of emotional turmoil
    • Thinking through solution together
  • 21. Consultation
    • Write down issues in advance
    • Need to be open and honest
    • Be willing to admit mistakes or clinical errors
  • 22. Empowered Collaboration
    • Empowered collaboration builds upon informed consent and attempts to maximize patient involvement in all essential elements of treatment
    • The patient becomes more actively involved in the process of psychotherapy. Greater commitment leads to better outcomes.
  • 23. Empowered Collaboration
    • Empowering psychologists respect a patient’s autonomy and decision making skills about the goals of treatment, process of treatment, and life choices.
    • Examples of tough decisions and ambivalent patients
  • 24. Documentation: Legal Purposes
    • Required by insurers, State Board of Psychology, APA Ethics Code, etc.
    • A record of treatment for future providers
    • Useful risk management tool
  • 25. Documentation: Quality Enhancing
    • Dialogue with self and patient regarding process and goals of treatment
    • Means to identify pertinent clinical issues
    • Procedure to document progress
  • 26. Redundant Protections
    • Additional source of information for a difficult patient
    • Routine procedure with high risk patients
  • 27. Transparency
    • General Rule: Implement quality enhancing strategies with as much transparency as possible.
  • 28. Questions, answers and more discussion
  • 29. Vignettes Looking the exercise what you have learned Not looking for the “correct” answer
  • 30. Important Issues
    • What factors make this a potentially difficult patient for you?
    • What would your emotional reaction be to the content of this scenario?
  • 31. Important issues
    • How would you use a consultation?
    • In what ways would empowered collaboration be of use?
    • Are there any issues related to documentation?
    • Can you think of any redundant protections?