Transcript Social Work with Difficult Cases and Vulnerable Populations What is a difficult case? • “When we call a client difficult, what we really mean is.

Social Work with
Difficult Cases and
Vulnerable
Populations
What is a difficult case?
• “When we call a client difficult, what we
really mean is that we, the therapists, are
having difficulty working with him/her.”
(Wessler)
What is a difficult case?
• “Difficult patients are those who make us feel
frustrated, uncomfortable, or ineffective . . ..”
(Duxbury)
• Difficult patients present some type of threat:
They can reject us or harm us. (Duxbury)
• Difficult patients are those whose disorders don’t
respond to treatment. (Pollack)
• Difficult families are those that don’t allow
separation and differentiation. (Bergman)
Difficult cases are characterized
by:
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1.
2.
3.
4.
5.
multiple treatment failures
high risk of suicide
high risk of violence
high risk of abuse
high risk of legal action
We may define difficult people as those who
lead us to do things we don’t want to do: We
may define difficult people as those who lead
us to do things we don’t want to do:
• 1.
• 2.
• 3.
• 4.
react in ways we are not happy with
do our jobs ineffectively
feel guilty, anxious, upset, frustrated,
inferior, defeated, etc.
do their share of the work
Difficulty is about unmet needs.
• The behaviors that make it difficult for us to
work with clients result from our failure to
meet their needs.
• When needs are not met, patients react by
demonstrating:
Patient reactions
• 1. withdrawal – refusing to interact
• 2. passivity – failure to take action
• 3. manipulation – use of devious or
dishonest means
• 4. aggression – expression of anger with
an implication of violence
• 5. violence – physical act that is intended
to cause damage to self, others, or property
Staff Skill Deficiencies
• 1. Failure to greet patients, introduce themselves,
and explain procedures.
• 2. Failure to elicit important information such as
major worries and expectations.
• 3. Acceptance of imprecise information.
• 4. Failure to establish mutual understanding.
• 5. Neglect of nonverbal cues provided by the
patient.
• 6. Failure to encourage or to adequately respond
to questions.
Staff Skill Deficiencies
• 7. Avoidance of information about personal,
family, and social situations.
• 8. Failure to elicit information about the patient’s
perceptions of the problem.
• 9. A directive style that interferes with the
patient’s telling of their story.
• 10. Focusing too quickly.
• 11. Failure to provide adequate information.
• 12. Failure to provide adequate reassurance.
Twelve types of difficult clients
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intimidating clients
critical clients
rageful clients
threatening clients
autonomous clients
acting-out clients
Twelve types of difficult clients
• 7. wealthy, influential clients
• 8. angry victim with cultural or gender
differences
• 9. uncooperative clients
• 10. passive-aggressive clients
• 11. mistrustful clients
• 12. unempathic clients
Poor responders to CT
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1. Severity (Beck Depression Inventory > 30).
2. Duration of current episode > 6 months.
3. Inadequate response to previous treatment.
4. Previous episodes > 2.
5. Associated psychopathology. (Axis II features)
6. Overall impairment as estimated by clinician as
moderate or severe.
• 7. Poor estimated tolerance for life stress.
Indicators of Axis II features.
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1. Life-long nature of a problem.
2. Persistent non-compliance with treatment.
3. Initial improvement comes to a plateau.
4. Patient seems unaware of the effect their
behavior has upon others.
• 5. Therapist suspects the patient of lacking
motivation to change.
• 6. Problems are reported as seeming natural to the
patient—”That's the way I am”.
Rigid negative schemas
• Conditional schemas – e.g. “Unless I am
loved, I am worthless.”
• Unconditional schemas – e.g. “I am
unloved.”
What makes a case difficult?
a.
b.
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d.
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f.
g.
diagnostic dilemma
poor prognosis
multiple problems
lack of interagency coordination
involuntary participation
lack of progress
malingering and deception
What makes a case difficult?
h.
i.
j.
k.
l.
m.
imminent danger
cultural competency gaps
conflicting ethical principles
eligibility limitations
limited resources
unacceptable client expectations
Are there natural categories of
difficult cases?
Natural categories
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Challenges to the professional’s skill
Challenges to the professional’s personality
Unmatched expectations
System issues such as eligibility and
coordination problems
Physically dangerous clients
Legally dangerous clients
Socially dangerous clients
How should we respond to
difficult cases?
Responses to Difficult Cases
1.
2.
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5.
6.
7.
Identify the challenge
Assess expectations
Assess skill level
Assess personality strength
Assess dangers
Evaluate danger-mitigating options
Decide whether to keep or to refer the
client
Six categories of intervention
• A. Authoritative categories
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Prescriptive interventions
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ii. Informative interventions
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iii. Confrontational interventions
• B. Facilitative categories
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i.
Cathartic interventions
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ii. Catalytic interventions
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iii.
Supportive interventions
What is the connection between
difficult cases and vulnerable
populations?
What are some vulnerable
populations?
What about those situations
makes the people in them
vulnerable?
To what are vulnerable
populations vulnerable?
References
Bergman, J.S. (1985). Fishing for barracuda, Pragmatics of brief systemic
therapy. New York: Norton.
Duncan, B.L., Hubble, M.A., & Miller, S.D. (1997). Psychotherapy with
“impossible” cases: The efficient treatment of therapy veterans. New York:
Norton
Duxbury, J. (2000). Difficult Patients. Oxford: Butterworth-Heinemann.
Pollack, M.H., Otto, M.W., & Rosenblum, J.F. (Eds.). (1996). Challenges in
clinical practice: Pharmacologic and psychosocial strategies. New York:
Guilford.
Wessler, R., Sheenah, H., & Stern, J. (2001). Succeeding with difficult clients:
Application of cognitive appraisal therapy . Sand Diego, CA: Academic Press
Williams, Ruth M. (1994). Cognitive therapy for difficult patients--a review.
International Review of Psychiatry, 6, 2/3, pp 175-187.