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Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP
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Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Mar 26, 2015

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Page 1: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Success with Treatment Resistant Clients

Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP

Page 2: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Objectives

• Peruse data on the importance of the subject• Explore most common types of treatment

resistant clients• Examine why some clients become

treatment resistant• Importance of the therapeutic alliance• Eight strategies to improve care of difficult

patients

Page 3: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

What do we do when a client is treatment resistant?

Page 4: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

“Step On Them Until They Get It”

Page 5: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

“For Online Counseling, Simply Yell at the Computer”

Page 6: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Definition

• Bad Definition-TRD has been defined in conceptually restrictive terms as symptomatic non-response to physical therapies alone, with little systematic study of etiology made.

• Good Definition-TRD should be re-defined as the failure to reach symptomatic and functional remission after adequate treatment with physical and psychological therapies.

Page 7: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Proposed Criteria for Treatment Resistance

• TRD is the failure to achieve sustained remission

• (Remission) defined as absent or minimal depressive symptoms and absent or minimal functional impairment, for at least 8 weeks.

• There has been adequate treatment of comorbid physical and psychological disorders.

• Wijeratne & Sachdev, 2008

Page 8: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

EAP “Real Life Considerations”

• Economic variables suggest that clients want to exhaust “all of their sessions”

• EAP clinicians feeling more obligated to accommodate client needs

• The value added for providing excellent care instead of simply referring has a domino effect (happy accounts and families)

Page 9: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Counselor Negative Feelings

• Feeling sorry for patient • Feeling powerless• Worrying about patient • Feeling a failure • Feeling deskilled• Feeling drained by patient• Finding patients painful• Frustration with work

Page 10: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Counselor Positive Feelings

• Enjoying the challenge• Satisfaction with work• Embracing needed changes in clinical

practice– Difficult clients expand our expertise– Sharpen our intuition about tx options– Give us a history to rely upon for future

encounters

Page 11: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

The “Best Practices Caveat”

• Remember, do what’s best for the client’s care

• Sometimes referring is the best option

• Don’t allow the client to talk you into doing work that is unbeneficial or unethical

• Always consider the reality of mental health disorders

Page 12: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Why is this subject important?

Page 13: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

The Numbers

• Mental Health Conditions ranked as one of the top five most costly conditions

• Mental Health Conditions had the largest increase in expenditures from 1996-2006

• The number of people with expenditures associated with the top five conditions increased the most with Mental Health Conditions 19.3 million to 36.2 million

Page 14: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Expenditures for the Five Most Costly Conditions (billions)

0

10

20

30

40

50

60

70

80

Heart Cancer Trama Asthma Mental

19962006

Page 15: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Number of People with Expenses for the Top Five Most Costly Conditions

(millions)

05

10

1520

2530

3540

4550

Heart Cancer Trauma Asthma Mental

19962006

Page 16: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Why are clients resistant?

• Socio-demographic variables– Economic status– Quality of life

• Genetic variables– Family predispositions

• Cultural variables– Does treatment adequately account for cultural

significance (spirituality, family, natural supports)

Page 17: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

How Do We Know When a Patient is Resistant? Current Psychiatry

• denial of illness

• poor stress-coping and relationship skills

• social and professional isolation

• inability to accept feedback

Page 18: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

How Do We Know When a Patient is Resisitant

• complacency and overconfidence

• failure to attend support group meetings

• dysfunctional family dynamics

• feelings of self-pity, blame, and guilt.5

Page 19: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Most Common Resistant Types

• ‘Dependent’- Demand continuous attention yet are unaware of their neediness

• ‘Entitled’- May use intimidation, guilt, threats to get counselor to conform

• ‘Help Rejecting’- Demand care but don’t show faith in tx. Don’t follow tx plans

• ‘Self-destructive’- appear unaware of their dangerous actions

Page 20: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Substance Abuse and Comorbidity

Page 21: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Psychiatric Comorbidity

• Posttraumatic stress disorder

• Other anxiety disorders (such as panic disorder without agoraphobia, simple phobia, or social phobia)

• Major depressive disorder

• Cognitive impairment (organic disorders)

Page 22: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Medical Comorbidity

• Medical

• Hypertension

• Fatty liver disease

• Gastrointestinal hemorrhage

• Brain atrophy

• Reproductive system irregularities

Page 23: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

What About The Brain?

Page 24: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Getting The Brain “On Track”

• Goal Setting

• Mental Rehearsal

• Self Talk

• Arousal Control

• Sounds like short-term EAP work to me!!

Page 25: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

What Are the helpful therapeutic variables?

Page 26: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

The Doctor-Patient Relationship

Page 27: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Psychological Model vs. Pharmaceutical Model

• Psychological Model - explains resultsof treatment in terms of the personality ofthe doctor, the personality of the patient, and the

relationship that they develop

• Pharmacological Model - explains results • of treatment in terms of biological changes

in the brain caused by the specific pharmacological agent

Page 28: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Doctor Patient Relationship

• A study showed that the outcome oftreatment with antidepressants for patients of doctors who were experienced as lacking in communicative skills deteriorated—at least when it came to disability and activity limitation—while patients of doctors experienced as good communicators improved (Van Os et al., 2005).

Page 29: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Doctor Patient Relationship

• Those results can be seen as evidence

for the psychological model, in that prescription of antidepressants are only effective in the context of a relationship

with a doctor who is experienced as

empathic and understanding.

Page 30: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Why Counseling?

• The large-scale Sequenced Treatment Alternatives to Relieve Depression

(STAR*D) and other studies have suggested that a structured psychotherapy such as cognitive behavior therapy may be as effective as medication in initial drug non-responders.

Page 31: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

How Long Do We Treat the Difficult Client

• 12 weeks average before determining patient was severely treatment resistant

• CBT counselors more likely to refer than Psychodynamic counselors

• CBT clinicians more likely than Psychodynamic clinicians to use treatment approaches based on efficacious research results

Page 32: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

EIGHT STRATEGIES TO IMPROVE CARE OF TX RESISTANT CLIENTS

John Battaglia, MD

Page 33: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Acknowledge That the Client is Difficult

• Acknowledgement breeds relaxation

• Denying frustrations can lead to mistakes

• Clients can sense our “flux”

• Depending on your theoretical orientation, “bring it in the room”; i.e., “I’m finding it difficult to find just the proper resource, I’m wondering if you can shed some light?”

Page 34: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Develop Empathy

• Empathy- Identifying with and understanding why a person feels, thinks, and acts as he or she does

• Learn from the client not the textbook

• Interview as if you want to write a brief bio

of the patient

• Think relationship not pathology or symptoms

Page 35: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Seek Out Supervision or Consultation

• Gain a new prospective from colleagues

• Increase your energy and creativity

• Decompress by “getting it off your chest”

• Stay out of trouble by not having your judgment clouded

• Remember ethics; peer supervision is a major component of the profession

Page 36: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Utilize a Team Approach

• Difficult clients are exhausting

• Having a team can lessen the liability

• Can decrease the client’s intensity of targeting one counselor to have the answer

• Helpful in developing a multi-disciplinary approach

Page 37: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Lower Treatment Goals

• Aim for stabilization before improvement

• Behavior modification is gradual– Success breeds success

• Allow the client to conceptualize the change

• Client may be in precontemplation stage

• Sometimes we’re treating the wrong symptoms; consider changing the goal

Page 38: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Decompress the Treatment Timeline

• Person-centered counseling- am I reflecting my client in therapy

• Don’t make time the marker, instead allow improvement to be milestones

• Manage care is not as hard to navigate as we think; negotiate the terms of therapy with case managers when possible

• Visualize treatment plan as being maintenance- driven as appose to cure-driven

Page 39: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Use “Plussing”

• Plussing- using positive comments and acknowledgments, small compliments

• Difficult clients can be dreadful, don’t let them change the temperature of the room

• When patients are liked, they are willing to try new interventions

Page 40: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Use Imagery

• Visualize client as the central character

in an unfinished novel of their life

• You as the clinician are in the book as well

• Enjoy the rich, complex nature of each character, without personalizing the results.

Page 41: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Expanding the Literature

• More data needed on reaching and retaining remission in counseling

• How do counselors better account for client’s natural supports?

• What is the value of cultural nuances in treating difficult clients?

• Capture more data on interpersonal therapies that are at least qualitatively successful (counselor’s intuition)

Page 42: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Resources

• www.star-d.org

• www.currentpsychiatry.com

• PsychiatricAnnalsOnline.com

Page 43: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Sources• ANKARBERG, P. & FALKENSTRO¨M, F. 2008. Treatment of depression

with antidepressants is primarily a psychological treatment. Psychotherapy Theory, Research, Practice, Training, 45(3), 329-339.

• Battaglia, J. 2009. An empathic, relaxed approach can ease frustration and improve the therapeutic alliance. Current Psychiatry, 8(9), 25-29.

• MCPHERSON, S., WALKER2, C., & CARLYLE, J. 2006. Primary care counsellors’ experiences of working with treatment resistant depression: A qualitative pilot study. Counselling and Psychotherapy Research, 6(4): 250-257

• Muskin, P.R. & Epstein, L.A. 2009. Clinical guide to countertransference: Help medical colleagues deal with difficult patients. Current Psychiatry, (4), 25-32.

• Rush, J.A., Kilner, J., Fava, M., Wisniewski, S.R., et al. 2008. Clinically relevant findings from STAR-D. Psychiatric Annals, 38(3).

Page 44: Success with Treatment Resistant Clients Gabriel Rogers, Ph.D., LPCS, CEAP, LEAP.

Sources, Continued

• Soni, Anita. The Five Most Costly Conditions, 1996 and 2006: Estimates for the U.S. Civilian Noninstitutionalized Population. Statistical Brief #248. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st248/stat248.pdf

• Stewart, R. E. & Chambless, D.L. 2008. Treatment Failures in Private Practice: How Do Psychologists Proceed? Professional Psychology: Research and Practice, 39(2), 176–181.

• Wijeratne, C. & Sachdev, P. 2008. Treatment resistant depression: critique of current approaches. Australian and New Zealand Journal of Psychiatry, 42, 751-762.