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:
• 1.
multiple treatment failures
• 2.
high risk of suicide
• 3.
high risk of violence
• 4.
high risk of abuse
• 5.
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.
react in ways we are not happy with
• 2.
do our jobs ineffectively
• 3.
feel guilty, anxious, upset, frustrated, inferior, defeated, etc.
• 4.
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
• 1.
intimidating clients
• 2.
critical clients
• 3.
rageful clients
• 4.
threatening clients
• 5.
autonomous clients
• 6.
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
• 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.
• 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. diagnostic dilemma b. poor prognosis c. multiple problems d. lack of interagency coordination e. involuntary participation f.
lack of progress g. malingering and deception

What makes a case difficult?
h. imminent danger i.
cultural competency gaps j.
conflicting ethical principles k. eligibility limitations l.
limited resources m. unacceptable client expectations

Are there natural categories of difficult cases?

Natural categories
• 1.
Challenges to the professional’s skill
• 2.
Challenges to the professional’s personality
• 3.
Unmatched expectations
• 4.
System issues such as eligibility and coordination problems
• 5.
Physically dangerous clients
• 6.
Legally dangerous clients
• 7.
Socially dangerous clients

How should we respond to difficult cases?

Responses to Difficult Cases
1.
Identify the challenge
2.
Assess expectations
3.
Assess skill level
4.
Assess personality strength
5.
Assess dangers
6.
Evaluate danger-mitigating options
7.
Decide whether to keep or to refer the client

Six categories of intervention
•
•
•
• A.
Authoritative categories i.
Prescriptive interventions
•
• ii.
Informative interventions iii.
Confrontational interventions
•
• B.
Facilitative categories i.
Cathartic interventions ii.
Catalytic interventions 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.