Applying positive ethics to difficult patient


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

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Applying positive ethics to difficult patient

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