Applying positive ethics to difficult patient

Applying Positive Ethics to Difficult Patients Sam Knapp, Ed.D. John Gavazzi, Psy.D.

Who are “difficult” patients?
High risk for failure
Emotionally draining
Increased legal and ethical risks

Multiple Dimensions
Patient Characteristics
Context of Treatment
Psychologist factors and resources

Patient Factors
Intense Negative Affect
Difficulty forming and maintaining relationships
Limited insight

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

Intense Negative Affect
Emotionally and intellectually draining
Vicarious PTSD
Recognition of the process of therapy

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

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

Context of Therapy
Ambivalence
Lack of motivation
Pressured into treatment
Current litigation

Psychologist Factors
Skills and knowledge with particular populations
Emotional resources at this time
External resources, such as consultation

Self-Protection
Office layout
Supportive staff nearby
Safety plan
Other resources

Early Screening
Extensive psychiatric history
At risk factors: childhood abuse, criminal record, troubled work history
Impaired relationships

Focus on the relationship
Failure to develop a working relationship within a few session is cause to reconsider the treatment plan

Alliance ruptures and repairs
Alliance ruptures do happen in psychotherapy
Handling the rupture and the repair takes additional skills

Ethical Issues Additional attention to ethical principles with high risk patients

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

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

Quality Enhancing Strategies Consultation Empowered Collaboration Documentation Redundant Protections

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.

Consultation
Technique oriented information
Emotional reactions (countertransference)
Reduction of emotional turmoil
Thinking through solution together

Consultation
Write down issues in advance
Need to be open and honest
Be willing to admit mistakes or clinical errors

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.

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

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

Documentation: Quality Enhancing
Dialogue with self and patient regarding process and goals of treatment
Means to identify pertinent clinical issues
Procedure to document progress

Redundant Protections
Additional source of information for a difficult patient
Routine procedure with high risk patients

Transparency
General Rule: Implement quality enhancing strategies with as much transparency as possible.

Questions, answers and more discussion

Vignettes Looking the exercise what you have learned Not looking for the “correct” answer

Important Issues
What factors make this a potentially difficult patient for you?
What would your emotional reaction be to the content of this scenario?

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?

Applying positive ethics to difficult patient

by John Gavazzi

Accessibility

Categories

Upload Details

Usage Rights

Statistics

Applying positive ethics to difficult patient Presentation Transcript