Jacqueline Persons, Ph.D.
In her April 3 Master Lecture, Jacqueline Persons presented her ideas on succeeding with difficult patients and stuck cases. Her first recommendation was to assess progress at every session. For example, patients could be asked to arrive a few minutes early and fill out a questionnaire such as the Beck Depression Inventory. Persons recommended graphing patients’ scores at each session. This will enable us to know when treatment has become stuck. Persons asserted that therapists tend to identify stuck treatments later than they should.
Graphing assessment scores also enables us to show patients that they have made progress, even when they encounter a setback. According to Persons, the main causes for treatments becoming stuck are:
There is no agreement on the goals of treatment. We should make sure that there is a clear agreement between us and the patient on the goals of treatment. We should not be treating a patient if we cannot agree on goals. She recommended spending three to four sessions negotiating a treatment agreement with each patient.
There is no agreement on means for reaching these goals. She suggested soliciting an agreement on how the goals will be achieved. Persons asserted that it is our responsibility to find tasks the patient is willing to complete in order to achieve the treatment goals. She showed a videotape of Marsha Linehan negotiating a treatment contract with a difficult, borderline patient.
The problem is formulated incorrectly. Persons gave the example of her own stuck treatment with a patient suffering from obsessive doubt and the inability to make a decision. Trying to help the patient collect information and make rational decisions was ineffective. Improvement occurred only when Persons reformulated the symptoms as an attempt to avoid emotional experience in the present.
Undetected problems. Persons advocated assessing all problems, not just presenting problems. Undetected problems may impede treatment of the presenting problems. Persons recommended assessing Axis II problems as well as interpersonal, medical, financial, employment, legal, and leisure problems.
The patient is not motivated. Treatment will become stuck if the patient is receiving reinforcement for the problem behavior, often in the form of attention or being excused from responsibilities. In addition, patients sometimes enter treatment because another person has told them to. Persons described a case of psychogenic vomiting where the patient was receiving attention and special consideration due to the symptom. Similarly, therapists sometimes reinforce self-destructive behavior with attention and concern.
Therapy-interfering behaviors are being overlooked. For example, missed sessions, friendly chit-chat, and reasons patients couldn’t possibly do their homework.
Using the wrong treatment model for this patient. She advocated trying several treatment models for each patient (for example - behavioral, cognitive, reinforcement) and seeing which produces progress.
We are the wrong therapist for this patient. For example, Persons cited research that oppositional patients improve more with less directive therapists.
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