Age / Sex: 31-year-old bi-racial male admitted to hospital through. Background:

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1 Stephen M. Goldfinger, MD Chart Review: The Patient You Hate to Treat PATIENT INFO 31 / Male Age / Sex: 31-year-old bi-racial male admitted to hospital through Background: Psychiatric Emergency Services. Brought to ER by police after he smashed furniture in the homeless shelter where he lives. Third hospital admission in the last 6 months, and his 14th in our hospital. Was discharged from hospital 3 weeks ago after 3-week stay. Other: Somewhat uncooperative at discharge, but denied violent urges, suicidal thoughts, and hallucinations. Had been stabilized on olanzapine 15mg/day, divalproex sodium 500mg bid*, quetiapine 100mg hs*. Accepted prescriptions and referral to 12-step program to address drug use he disclosed in group therapy. Refused any residential program but accepted shelter referral. Shelter reluctantly accepted him despite previous assault on another resident. Presenting Complaint: Appears angry, fearful, somewhat disheveled. Cursing at police and ER staff. * bid = twice daily; hs = at bedtime. BEST PRACTICES List three best practices agreed to by the group in your chart review session: 1. Clinicians want to love all, cure all, know all. They can t. 2. The most dangerous hate is one that is unconscious. Allow yourself to acknowledge you may hate a patient; just don t act on it. 3. Patients usually don t follow directions. Begin with relationship development (therapeutic alliance), maximizing patient independence and autonomy to maximize likely adherence.

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3 The Patient You Hate to Treat Chart Review Stephen M. Goldfinger, MD SUNY Downstate Medical Center

4 Stephen M. Goldfinger, MD Disclosures Research/Grants: Avantis Medical Systems, Inc.; Danippon Sumitomo Pharma; H. Lundbeck A/S; Janssen, LP; Pfizer Inc.; Roche Labs Speakers Bureau: Teva Pharmaceutical Industries Ltd. Consultant: Teva Pharmaceutical Industries Ltd. Stockholder: None Other Financial Interest: None Advisory Board: None

5 Learning Objective Describe strategies to better engage difficult patients in a constructive therapeutic relationship in the inpatient setting

6 Case: Mr. Jones 31-year-old bi-racial male admitted to hospital through Psychiatric Emergency Services Brought to ER by police after he smashed furniture in the homeless shelter where he lives Third hospital admission in the last 6 months, and his 14th in our hospital Appears angry, fearful, somewhat disheveled Cursing at police and ER staff

7 Case: Mr. Jones (cont.) Was discharged from hospital 3 weeks ago after 3-week stay Somewhat uncooperative at discharge, but denied violent urges, suicidal thoughts, and hallucinations Had been stabilized on olanzapine 15mg/day, divalproex sodium 500mg bid, quetiapine 100mg hs Accepted prescriptions and referral to 12-step program to address drug use he disclosed in group therapy Refused any residential program but accepted shelter referral Shelter reluctantly accepted him despite previous assault on another resident bid = twice daily; hs = at bedtime

8 What 3 Questions Do You Most Want Mr. Jones to Answer? MY list would include: Have you ever found anyone in the mental health or residential system helpful? WHY? Have you ever taken ANY medication that you d want to continue taking? Did you? Why did you stop? If YOU were me, how would you help the guy sitting in front of you? What would be hardest in getting him what he wants?

9 Management Strategies for Difficult Patients in the Inpatient Setting Scant data on management strategies in difficult patients General recommendations based on literature: Maintain a validating attitude Create strict boundaries within a clear treatment structure Remain conscious of patient s background and one s own limitations Consultation and supervision may provide new perspectives Koekkoek B. Psychiatr Serv 2006;57:

10 Discussion Questions What would you do with Mr. Jones while on inpatient service? What would you expect the primary issues to be? Would you accept him as an outpatient? Would you want him as an outpatient? What community resources would you need to work with? How many of those resources exist in your community? Who can access them?

11 Selected References Lieberman JA, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005;353: Lehman AF, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations Schizophr Bull 2004;30: Maltsberger JT, et al. Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatry 1974;30:

12 an educational series offered by CME Outfitters, LLC This CME/CE activity is co-sponsored by

13 The Patient You Hate to Treat Stephen M. Goldfinger, MD Koekkoek B. "Difficult patients" in mental health care: a review. Psychiatr Serv. 2006;57: