Transcript EIGHT STRATEGIES TO IMPROVE CARE OF TX RESISTANT

Success with Treatment Resistant
Clients
Gabriel Rogers, Ph.D., LPCS,
CEAP, LEAP
Objectives
• Peruse data on the importance of the subject
• Explore most common types of treatment
resistant clients
• Examine why some clients become
treatment resistant
• Importance of the therapeutic alliance
• Eight strategies to improve care of difficult
patients
What do we do when a client is
treatment resistant?
“Step On Them Until They Get It”
“For Online Counseling, Simply
Yell at the Computer”
Definition
• Bad Definition-TRD has been defined in
conceptually restrictive terms as symptomatic
non-response to physical therapies alone, with
little systematic study of etiology made.
• Good Definition-TRD should be re-defined as
the failure to reach symptomatic and functional
remission after adequate treatment with
physical and psychological therapies.
Proposed Criteria for Treatment
Resistance
• TRD is the failure to achieve sustained
remission
• (Remission) defined as absent or minimal
depressive symptoms and absent or minimal
functional impairment, for at least 8 weeks.
• There has been adequate treatment of
comorbid physical and psychological
disorders.
• Wijeratne & Sachdev, 2008
EAP “Real Life Considerations”
• Economic variables suggest that clients
want to exhaust “all of their sessions”
• EAP clinicians feeling more obligated to
accommodate client needs
• The value added for providing excellent
care instead of simply referring has a
domino effect (happy accounts and
families)
Counselor Negative Feelings
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Feeling sorry for patient
Feeling powerless
Worrying about patient
Feeling a failure
Feeling deskilled
Feeling drained by patient
Finding patients painful
Frustration with work
Counselor Positive Feelings
• Enjoying the challenge
• Satisfaction with work
• Embracing needed changes in clinical
practice
– Difficult clients expand our expertise
– Sharpen our intuition about tx options
– Give us a history to rely upon for future
encounters
The “Best Practices Caveat”
• Remember, do what’s best for the client’s
care
• Sometimes referring is the best option
• Don’t allow the client to talk you into doing
work that is unbeneficial or unethical
• Always consider the reality of mental health
disorders
Why is this subject important?
The Numbers
• Mental Health Conditions ranked as one of the
top five most costly conditions
• Mental Health Conditions had the largest
increase in expenditures from 1996-2006
• The number of people with expenditures
associated with the top five conditions
increased the most with Mental Health
Conditions 19.3 million to 36.2 million
Expenditures for the Five Most
Costly Conditions (billions)
80
70
60
50
1996
2006
40
30
20
10
0
Heart
Cancer
Trama
Asthma
Mental
Number of People with Expenses for
the Top Five Most Costly Conditions
(millions)
50
45
40
35
30
25
20
15
10
5
0
1996
2006
Heart
Cancer
Trauma
Asthma
Mental
Why are clients resistant?
• Socio-demographic variables
– Economic status
– Quality of life
• Genetic variables
– Family predispositions
• Cultural variables
– Does treatment adequately account for cultural
significance (spirituality, family, natural
supports)
How Do We Know When a
Patient is Resistant? Current Psychiatry
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denial of illness
poor stress-coping and relationship skills
social and professional isolation
inability to accept feedback
How Do We Know When a
Patient is Resisitant
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complacency and overconfidence
failure to attend support group meetings
dysfunctional family dynamics
feelings of self-pity, blame, and guilt.5
Most Common Resistant Types
• ‘Dependent’- Demand continuous attention
yet are unaware of their neediness
• ‘Entitled’- May use intimidation, guilt, threats
to get counselor to conform
• ‘Help Rejecting’- Demand care but don’t
show faith in tx. Don’t follow tx plans
• ‘Self-destructive’- appear unaware of their
dangerous actions
SUBSTANCE ABUSE AND
COMORBIDITY
Psychiatric Comorbidity
• Posttraumatic stress disorder
• Other anxiety disorders (such as panic
disorder without agoraphobia, simple
phobia, or social phobia)
• Major depressive disorder
• Cognitive impairment (organic disorders)
Medical Comorbidity
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Medical
Hypertension
Fatty liver disease
Gastrointestinal hemorrhage
Brain atrophy
Reproductive system irregularities
WHAT ABOUT THE BRAIN?
Getting The Brain “On Track”
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Goal Setting
Mental Rehearsal
Self Talk
Arousal Control
Sounds like short-term EAP work to me!!
WHAT ARE THE HELPFUL
THERAPEUTIC VARIABLES?
The Doctor-Patient Relationship
Psychological Model vs.
Pharmaceutical Model
• Psychological Model - explains results
of treatment in terms of the personality of
the doctor, the personality of the patient, and the
relationship that they develop
• Pharmacological Model - explains results
• of treatment in terms of biological changes
in the brain caused by the specific
pharmacological agent
Doctor Patient Relationship
• A study showed that the outcome of
treatment with antidepressants for patients of
doctors who were experienced as lacking in
communicative skills deteriorated—at least
when it came to disability and activity
limitation—while patients of doctors
experienced as good communicators improved
(Van Os et al., 2005).
Doctor Patient Relationship
• Those results can be seen as evidence
for the psychological model, in that
prescription of antidepressants are only
effective in the context of a relationship
with a doctor who is experienced as
empathic and understanding.
Why Counseling?
• The large-scale Sequenced Treatment
Alternatives to Relieve Depression
(STAR*D) and other studies have suggested
that a structured psychotherapy such as
cognitive behavior therapy may be as effective
as medication in initial drug non-responders.
How Long Do We Treat the Difficult
Client
• 12 weeks average before determining patient
was severely treatment resistant
• CBT counselors more likely to refer than
Psychodynamic counselors
• CBT clinicians more likely than
Psychodynamic clinicians to use treatment
approaches based on efficacious research
results
EIGHT STRATEGIES TO
IMPROVE CARE OF TX
RESISTANT CLIENTS
John Battaglia, MD
Acknowledge That
the Client is Difficult
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Acknowledgement breeds relaxation
Denying frustrations can lead to mistakes
Clients can sense our “flux”
Depending on your theoretical orientation,
“bring it in the room”; i.e., “I’m finding it
difficult to find just the proper resource, I’m
wondering if you can shed some light?”
Develop Empathy
• Empathy- Identifying with and understanding
why a person feels, thinks, and acts as he or
she does
• Learn from the client not the textbook
• Interview as if you want to write a brief bio
of the patient
• Think relationship not pathology or symptoms
Seek Out Supervision or
Consultation
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Gain a new prospective from colleagues
Increase your energy and creativity
Decompress by “getting it off your chest”
Stay out of trouble by not having your
judgment clouded
• Remember ethics; peer supervision is a major
component of the profession
Utilize a Team Approach
• Difficult clients are exhausting
• Having a team can lessen the liability
• Can decrease the client’s intensity of targeting
one counselor to have the answer
• Helpful in developing a multi-disciplinary
approach
Lower Treatment Goals
• Aim for stabilization before improvement
• Behavior modification is gradual
– Success breeds success
• Allow the client to conceptualize the change
• Client may be in precontemplation stage
• Sometimes we’re treating the wrong
symptoms; consider changing the goal
Decompress the Treatment
Timeline
• Person-centered counseling- am I reflecting
my client in therapy
• Don’t make time the marker, instead allow
improvement to be milestones
• Manage care is not as hard to navigate as we
think; negotiate the terms of therapy with case
managers when possible
• Visualize treatment plan as being maintenancedriven as appose to cure-driven
Use “Plussing”
• Plussing- using positive comments and
acknowledgments, small compliments
• Difficult clients can be dreadful, don’t let
them change the temperature of the room
• When patients are liked, they are willing to try
new interventions
Use Imagery
• Visualize client as the central character
in an unfinished novel of their life
• You as the clinician are in the book as well
• Enjoy the rich, complex nature of each
character, without personalizing the results.
Expanding the Literature
• More data needed on reaching and retaining
remission in counseling
• How do counselors better account for client’s
natural supports?
• What is the value of cultural nuances in treating
difficult clients?
• Capture more data on interpersonal therapies that
are at least qualitatively successful (counselor’s
intuition)
Resources
• www.star-d.org
• www.currentpsychiatry.com
• PsychiatricAnnalsOnline.com
Sources
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ANKARBERG, P. & FALKENSTRO¨M, F. 2008. Treatment of depression
with antidepressants is primarily a psychological treatment. Psychotherapy
Theory, Research, Practice, Training, 45(3), 329-339.
Battaglia, J. 2009. An empathic, relaxed approach can ease frustration and
improve the therapeutic alliance. Current Psychiatry, 8(9), 25-29.
MCPHERSON, S., WALKER2, C., & CARLYLE, J. 2006. Primary care
counsellors’ experiences of working with treatment resistant depression: A
qualitative pilot study. Counselling and Psychotherapy Research, 6(4): 250257
Muskin, P.R. & Epstein, L.A. 2009. Clinical guide to countertransference:
Help medical colleagues deal with difficult patients. Current Psychiatry, (4),
25-32.
Rush, J.A., Kilner, J., Fava, M., Wisniewski, S.R., et al. 2008. Clinically
relevant findings from STAR-D. Psychiatric Annals, 38(3).
Sources, Continued
• Soni, Anita. The Five Most Costly Conditions, 1996 and 2006:
Estimates for the U.S. Civilian Noninstitutionalized Population.
Statistical Brief #248. July 2009. Agency for Healthcare Research and
Quality, Rockville, MD.
http://www.meps.ahrq.gov/mepsweb/data_files/publications/st248/stat
248.pdf
• Stewart, R. E. & Chambless, D.L. 2008. Treatment Failures in Private
Practice: How Do Psychologists Proceed? Professional Psychology:
Research and Practice, 39(2), 176–181.
• Wijeratne, C. & Sachdev, P. 2008. Treatment resistant depression:
critique of current approaches. Australian and New Zealand Journal of
Psychiatry, 42, 751-762.