Problems to anticipate in treating difficult patients in a long-term psychiatric hospital

Psychiatric and sociotherapeutic perspectives on the difficult-to-treat patient

IN SPITE of substantial advances in the effective treatment of psychiatric illness, there is a growing perception among clinicians that those patients who present for inpatient care are more difficult to treat. The authors review the history of contributions about the patient who is difficult to treat and propose a new typology for characterizing acute, severe and complex dimensions of this cohort. They hypothesize first that patient difficulty cannot be conceptualized independently from the treatment context; and second, that treatment complexity leads to a specific strain between the on- and off-floor treatment staff, thus enhancing the perception of difficulty. Finally, the authors suggest innovations in the structure of the treatment environment that may facilitate treatment of these patients. These innovations operate especially in the area of reducing interstaff tensions and helping patients use rather than resist that treatment.

Staff feelings and patient diagnosis

OBJECTIVE

To assess the associations between staff feelings toward patients and the patients' diagnoses, in view of the fact that clinical reports of such associations have not been corroborated by systematic research.

METHOD

At 24 psychiatric units, 143 patients were assessed according to their personality organization, and staff feelings toward these patients were followed for 5 years. The feelings were reported on a feeling checklist twice yearly, and outcome was assessed as the effect size at year 5, using ratings on Kernberg's structural model complemented with ratings on Strauss-Carpenter's function scale.

RESULTS

The study showed that it was possible, using discriminant analyses, to separate diagnostic groups by the different feelings that they evoked in the staff. Patients with borderline personality organization (BPO) evoked fewer relaxed and more aggressive feelings, in contrast to patients with psychotic personality organization (PPO). In contrast to patients with neurotic personality organization (NPO), who evoked feelings of sympathy and helpfulness, PPO patients evoked more feelings of insufficiency and disappointment. A stepwise discriminant analysis of reactions to patients with positive treatment outcome separated the 3 personality organizations with 2 functions using only 2 feelings, "relaxed" and "objective." The feeling relaxed separated the NPO patients from the BPO patients, and the feeling objective separated the PPO patients from the other groups. The patients' diagnoses accounted for larger proportions of variance in feelings for the patients with positive outcome.

CONCLUSION

The results implied that the patients' different personality organizations evoked different staff feelings in this treatment context and that positive treatment outcome was associated with more pronounced and clear-cut staff reactions.

Struggling for control: the care experiences of 'difficult' patients in mental health services

Although there is increasing recognition of the existence of 'difficult' patients who present particular challenges to mental health nurses, no research has been conducted into their perceptions of services and their experiences of care. This study identifies mental health service users who are defined by nurses as 'difficult' and explores their perceptions of their care experience. The results support earlier studies which suggested that 'difficult' patients challenge nurses' competence and control: despite their different roles both nurses and 'difficult' patients were aware of the struggle to gain or retain a notion of control. Respondents were able to identify the qualities of nurses and nursing interventions which had a positive effect on their care experience. Where nurses were perceived to demonstrate respect, time, skilled care and a willingness to give patients some control and choice in their own care, feelings of anger were reduced. These findings are discussed within the conceptual framework of 'power over' and 'power to' and implications for practice and research are considered.

The patient's contribution to the therapist's countertransference feelings

Countertransference feelings of psychiatric milieu therapists toward their patients were studied by using a self-report feeling word checklist. The feelings were scored on subscales of feeling states in a circumplex model. By using an analysis of variance model, comparisons between reactions to patients individually and reactions to patients with different personality organizations and with different Health-sickness rating scale scores could be made. A total number of 244 therapists at 21 small treatment homes were studied. It was found that approximately 15% of the therapists' countertransference feeling reactions could be accounted for by recurrent reactions to patients individually. Surprisingly, the personality organization and the Health-sickness rating scale score of the patient accounted for almost no variance in therapists' feelings. The results are discussed, and possible explanations are evaluated.

Difficult patients in extended psychiatric hospitalization: a research perspective on the patient, staff and team

A series of publications has emerged from a comprehensive research project on difficulties in extended psychiatric hospital treatment, each of which describes factors that may influence difficulty: staff perceptions, difficult patient profiles, countertransference, intrapsychic features, organic brain impairment, problematic areas of treatment. This paper is intended to provide an overview and clinical integration of those diverse findings and an application of the findings to clinical conceptualization. The research supplements existing knowledge about treatment difficulty and countertransference in dyads by providing information about how such phenomena are influenced by clinical teams, by professional roles or disciplines, and by the treatment delivery system. Finally, I will describe future issues, questions and research efforts that are generated by these findings.

Patients who hate

Few experiences in the life of the mental health professional are more unpleasant than being intensely hated by a patient he is trying to help. In most cases the hatred is mitigated by periods where the patient sees the treater as more helpful and less malevolent, a shift that makes the treatment process more tolerable. However, there are patients who hate relentlessly, presenting a challenge that taxes the therapist's emotional and intellectual resources to an extraordinary degree.