Caring for “difficult” patients
Clinical care is complex and challenging under the best of circumstances, and it becomes much harder when treating patients who express self-destructive, hostile, overly dependent, or acting-out behaviors.14 Other patients become nonadherent when their underlying illnesses are refractory to treatment or when treatment is accompanied by severe adverse effects.3 Psychopharmacotherapy may be essential for patients with multiple problems but also may pose new and unexpected ethical concerns.
Even when focused on somatic treatments, mental health clinicians must understand fundamental intrapsychic and interpersonal dynamics that may shape the care of the patient.15,16 Psychiatrists must have a sophisticated awareness of the antecedents of maladaptive behaviors and be able to respond to the “difficult” behaviors in a manner that places patient well-being first. The ability to respond in this way requires that psychiatrists perceive the difficult behavior as a clinical sign, not unlike a skin lesion or high blood pressure. By viewing whatever is “difficult” about the patient in this way, the clinician is more likely to be compassionate and less likely to react without thinking or to inadvertently collude with or enable the pathological condition of the patient.17,18
Mintz19 has described different personality styles and offers suggestions on how to adapt prescribing styles accordingly. For example, the patient who has a dismissive attachment style or is quick to reject others will benefit from a prescribing physician who pays greater attention to explicit communication about the treatment, sets clear treatment expectations, invites the patient to identify personal treatment goals, and prioritizes the establishment of a robust therapeutic alliance before offering psychotropic medication.
Finally, the very act of prescribing medications may serve a myriad of defensive functions for the psychopharmacologist. For example, it may establish a sense of control, manage feelings of helplessness, control a patient’s affect, and subtly promote a patient’s dependency to avoid an experience of loss.20 Ongoing consultation and supervision for such difficult cases are key.3
Maintaining professional boundaries
Boundaries that separate professional conduct from behaviors inappropriate for a professional relationship (eg, ones that gratify the clinician rather than serve the patient) have important clinical and legal implications. Boundary violations are destructive to the beneficent aims of therapy and cause foreseeable harm to patients.21
The role of therapeutic boundaries is usually viewed in the context of psychotherapy but has relevance to other forms of psychiatric practice. Gabbard16 and Hoop and colleagues3 have highlighted the importance of paying similar attention to therapeutic boundaries in the context of medication management. An overt focus on somatic issues may obscure intense psychological and boundary issues. For example, in some patients, psychopathology may manifest in attempts to disrupt treatment. Being late for appointments, missing appointments, and requesting special favors demand the same consideration by the prescribing psychiatrist as the psychotherapist. Neglecting such clinical signs and failure to evaluate them further could put the relationship at risk for boundary crossings and violations.21
Perhaps where boundary issues are most relevant is in the split treatment relationship, where a patient is seeing a therapist for ongoing psychotherapy and a psychiatrist for medication management. Gabbard16 has described such treatment as a “fertile field for splitting” and other primitive defenses that may be damaging to the patient’s care. Frequent, open, and respectful communication with the psychotherapist helps ensure that the patient receives optimal care and that therapeutic goals are aligned.18