Cormorbid and complex: achieving good outcome with the “difficult” patient

Person-centred counselling with an emphasis on expressing empathy are key elements in motivational interviewing, as pioneered by Miller and Rollnick. But what makes the technique unique is a systematic strategy designed to create conditions for change by eliciting motives that lie within the individual concerned. The aim is that patients talk themselves into changing. This is the essence of motivational interviewing, described by Steve Martino, Yale University School of Medicine (New Haven, Connecticut, USA).

Patients talk themselves into changing: we just need to create the right conditions.

Shared expertise

There is shared work to be done, and both parties have expertise. Partnership, along with compassion, acceptance and evocation, make up the “motivational interviewing spirit”. We have to believe that there is something that will motivate change, even in a difficult patient who does not seem set on this course. The job of the therapist – along with the patient – is to discover what it is and then plan how the change is to come about. But there is no planning for change without prior commitment.

The therapist is listening for the patient to come out with “change talk”. Ideally, this will be expressed in terms of Desire (I want to), Ability (I can), Reason (it’s important) and Need (I should). Together, they are summarised in the acronym DARN.

Even if the patient seems stuck in talking about all the reasons they should not change (“sustain talk”), the likelihood is that there is some ambivalence; and this should be sought out.  

It takes two to tangle

When the situation is not ideal, the therapist can inadvertently contribute to maintaining the “difficult” patient. People are often under external pressure to change from family and the legal system. This is experienced as aversive and they push back. We should try not to contribute to this: avoid a confrontational setting in which the therapist is arguing for change and the patient for no change.

High levels of sustain talk and discord in sessions predict poor outcome. Although sustain talk cannot always be avoided, discord can – since it takes two to tangle. As a therapist, be fascinated not frustrated; curious not furious. Roll with resistance. And recognise that motivation to change will ebb and flow in the course of treatment.

As a therapist, be fascinated not frustrated; curious not furious.

Confronting traumatic memories

Even in cases of severe PTSD, there are highly effective interventions, and it is good to let patients know this, Seth Gillihan, Perelman School of Medicine, University of Pennsylvania (Philadelphia, USA) told the session. PTSD is characterised by avoidance: sufferers believe that the world is not a safe place and that no-one can be trusted. Because they avoid going out, they don’t encounter corrective information; and they don’t talk about the experience.

Part of the antidote is to go into the world and experience the fact that the feared consequences do not occur. Another element is learning that you can recount the trauma memory and not fall apart. In a sense, a frame is put around it.  

Frequently, feelings of guilt and lack of competence are part of the disorder. These over-generalisations can also be countered, by drawing attention to information that disconfirms erroneous beliefs.

Perhaps the key element of therapy, though, is for the patient to confront reminders of trauma in a safe environment. There is a process of graded exposure, in imagination and in reality. Gradually, the patient is encouraged to activate thoughts that trigger distress, and to undertake activities that they believe are dangerous – until a sense of mastery is achieved.

Same principles in personality disorder

CBT can also be used effectively in the case of personality disorder, regarded as one of the mental health problems which is most difficult to treat, Judith Beck (University of Pennsylvania, Philadelphia USA) said. The principles are the same as in any other disorder: conceptualize the problem before you try to treat it.

Patients have to accept all three elements in the cognitive model: the idea that the way I think influences what I do; that some of what I think is distorted; and that by changing my thinking I can feel better and behave in a way that brings me closer to my goals.

Ultimately, the patient has to become his or her own therapist.

The target cognitions may differ with different disorders. In the case of depression, for example, they relate to beliefs about the world, the self and the future. In the case of panic, they relate to the catastrophic events that the patient believes are imminent.

But in each case the way people get better is by making small changes every day. Ultimately, the patient has to become his or her own therapist.