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Helping at-risk patients who rarely show up

Posted Jan 04 2011 9:21pm

From early on in my quest to understand the unique challenges mental health professionals face in working with patients at risk for suicide, I’ve wondered aloud about the things that make us the most nervous. I’m still working my way through a  list of questions I posted based on my notes from a series of trainings I delivered across New York State. One that has kept coming up since that time is this one:

How do we handle individuals at risk who are only marginally involved in treatment-they miss more appointments than they make, but still come enough that they remain on our caseloads?

Mental health care was not organized to fit the way many people at risk utilize services. Much of outpatient mental health is organized around a fantasy that most patients will (1) Make an appointment ahead of time for an evaluation; (2) come to that appointment at the specified time; (3) make another appointment; (4) come to that appointment; (5) work on a signed treatment plan in between.

Now, that model probably does work well for some people. But for many individuals at risk, that level of organization and consistency is not congruent with their lives. If it were, they wouldn’t need us! The situations that make professionals the most nervous are the ones where the patient (1) Makes an appointment.  (2) Comes to the appointment later in the day or the next day crying and upset, hoping to be seen. (2) Misses the next appointment.  (3) Makes it to one appointment with the psychiatrist. (4) Misses 2 of the next 3 appointments with the primary therapist (5) can’t recall the treatment plan when asked about it. Naturally, clinicians get frustrated and wish the person would either sign-up or drop out.

But of course it’s not the fault of the individual at risk that we’re set up the way we are, or that all the empirically supported treatments assume the patient is actually in treatment. I’ve addressed this issue here , here , and here when I’ve talked about how to manage patients who violate the “social contract” of being a patient. But there’s something distinctly anxiety-provoking about someone who is loosely connected to mental health services, compared with someone who actively refuses plans we suggest.  It can be especially hard if the loosely-connected person only shows up when in crisis.

This won’t be a surprise to those who have followed my posts, but my approach to the loosely connected person hinges on two core clinical tasks: connection, compassion, and documentation.

Connection means that we should have the bias of keeping people involved to the level they are able.  I know that this is difficult in the context of productivity demands and limited resources.  You can’t have 80 people on your caseload who all miss 75% of appointments.  But I think we should condition ourselves (and set up services) to have a least a few people like that because the resources might be well spent in being a bridge to life for the person.

Compassion is always core. It can be hard to feel and show compassion to someone in crisis when they haven’t taken the least first step to try ideas you’ve given. It’s easy to find yourself thinking, “Maybe if you came a little more often, you wouldn’t be in this position.” It’s especially hard to find compassion for someone who is at-risk for suicide and not showing up because it feels like they could take us down with them. All of those thoughts are natural, and it shouldn’t end there. Instead, we have to summon the courage to enter in to the suffering one more time, offering the main thing we can offer under these circumstances: a caring commitment to living.

Documentation is one way I get to that place. One barriers to compassion is fear.  It takes courage to keep working with someone who has only one foot in the room–especially when they present with suicide risk. Part of every clinician’s brain is occupied with worry under these circumstances–worry about losing a patient, worry about being blamed, worry about being sued. It’s hard to have compassion for someone if you think they could ruin your life. Having an unassailable risk assessment and other supporting documentation can put the fearful part of the clinicians brain to rest and make way for the kind of compassionate connection the hurting patient really needs. In other words, one of the key purposes of documentation is to quiet fears that might interfere with caring–and with doing the right thing. Once you’re confident about documentation, you can focus on doing what’s best for the patient, instead of feeling cornered into defensive courses of action.

Connection, compassion, and documentation share at least one thing in common: they are easier said than done. Their importance is so obvious that it may be tempting for an experienced clinician to speed passed these concepts. Anyone NOT think connection, compassion and documentation are important? Of course not. But, as with most simple good ideas, there are complex barriers to implementing them. Each person has to identify his or her own barriers and find a way to build these principles in to every day practice.


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