Working with the 'difficult' patient: the use of a contextual cognitive-analytic therapy based training in improving team function in a routine psychiatry service setting

Dealing with care disruption in High and Intensive Care wards: From difficult patients to difficult situations

High and Intensive Care is a relatively new care model in Dutch mental health care for clinical admissions. One of the goals is to keep the admission short. For some patients, this goal is not realized, which results in a long-term admission. Often, this is experienced as a disruption. Disruptions in care processes are frequently defined in terms of patient characteristics. Yet, it may be that other factors play a role. The aim of this study is to gain better insight into the perceptions of care professionals of what is characteristic for disruptions at High and Intensive Care wards and how professionals can deal with these. Qualitative research was performed by means of semi-structured interviews and a focus group with professionals. Results show that a focus on patient characteristics is too narrow and that other factors also play an important role. These factors include challenges in the relation between professionals and the patient, a divided team, and a lack of collaboration with ambulatory care. In order to deal with these factors, professionals should invest in the relationship with the patient, identify destructive team processes early, and improve communication with ambulatory care. It is recommended to develop a monitoring tool that includes all these factors. Another recommendation is to organize structured reflection on dilemmas experienced in care. In conclusion, this study shows the importance of going beyond patient characteristics in order to better understand, identify, and deal with disruption at High and Intensive Care wards.

Effective nurse-patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance

Background

Therapeutic alliance is a core part of the nursing role and key to the attainment of positive outcomes for people utilising mental health care services. However, these relationships are sometimes difficult to develop and sustain, and nursing staff would arguably benefit from evidence-based support to foster more positive relationships.

Objectives

We aimed to collate and critique papers reporting on interventions targeted at improving the nurse–patient therapeutic alliance in mental health care settings.

Design

Systematic literature review.

Data sources

The online databases of Excerpta Medica database (Embase), PsycINFO, Medical Literature Analysis and Retrieval System Online (MEDLINE) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched, eligible full text paper references lists reviewed for additional works and a forward citation search conducted.

Review methods

Original journal articles in English language were included where they reported on interventions targeting the nurse–patient therapeutic relationship and included a measure of alliance. Data were extracted using a pre-determined extraction form and inter-rater reliability evaluations were conducted. Information pertaining to design, participants, interventions and findings was collated. The papers were subject to quality assessment.

Results

Relatively few eligible papers (n = 8) were identified, highlighting the limitations of the evidence base in this area. A range of interventions were tested, drawing on diverse theoretical and procedural underpinnings. Only half of the studies reported statistically significant results and were largely weak in methodological quality.

Conclusions

The evidence base for methods to support nursing staff to develop and maintain good therapeutic relationships is poor, despite this being a key aspect of the nursing role and a major contributor to positive outcomes for service users. We reflect on why this might be and make specific recommendations for the development of a stronger evidence base, with the hope that this paper serves as a catalyst for a renewed research agenda into interventions that support good therapeutic relationships that serve both staff and patients.

Cognitive Analytic Therapy for psychosis: A case series

OBJECTIVES

Cognitive Analytic Therapy (CAT) is an effective psychological intervention for several different mental health conditions. However, whether it is acceptable, safe, and beneficial for people with psychosis remains unclear, as is the feasibility of providing and evaluating it within a research context. The aim of this study was to begin to address these questions and to obtain for the first time a rich and detailed understanding of the experience of receiving CAT for psychosis.

DESIGN

A mixed-methods case series design.

METHOD

Seven individuals who experienced non-affective psychosis received CAT. They completed assessments at the start of CAT, 16 weeks, and 28 weeks post-baseline. Qualitative interviews were completed with four individuals following completion of or withdrawal from therapy.

RESULTS

Six participants attended at least four sessions of therapy and four went on to complete therapy. There were no serious adverse events, and self-reported adverse experiences were minimal. Qualitative interviews suggested CAT is acceptable and provided a way to understand and work therapeutically with psychosis. There was limited evidence of change in psychotic symptoms, but improvement in perceived recovery and personality integration was observed.

CONCLUSIONS

The results suggest that CAT is a safe and acceptable intervention for psychosis. Personality integration, perceived recovery, and functioning are relevant outcomes for future evaluations of CAT for psychosis.

PRACTITIONER POINTS

It is feasible to conduct research evaluating CAT for people with psychosis. Within this case series, CAT appears acceptable and safe to individuals with psychosis. Within this case series, clients reported that CAT was a positive and helpful experience. There is a mixed picture with regard to secondary outcomes, but the design and aims of this case series limit conclusion that can be drawn from this data.

What makes a difficult patient so difficult? Examining the therapist's experience beyond patient characteristics

The primary aim of this study is to improve our understanding of therapists' experience of a "difficult patient" and consider the different variables involved in this label. What makes a patient be perceived as difficult by a therapist in public health services? Results of our analysis of 10 qualitative semistructured interviews of therapists working in public health service in Chile indicated that therapists' perceptions of a "difficult patient" depend on variables that go beyond the patient's intrinsic characteristics, including patients' negative attitude toward the therapist and treating team, patients' negative effects on therapists, and a difficult treatment context (e.g., work overload, scarce resources, limited number, and frequency of sessions). We illustrate the interaction of these dimensions and focus on the impact of the treating context on therapists' experience of a "difficult patient" through the case of a therapist working with a patient with complex depression in the public health system of Chile.

Trauma-informed Care and the Research Literature: How Can the Mental Health Nurse Take the Lead to Support Women Who Have Survived Sexual Assault?

Many women who access mental health services have been subjected to violent acts, including childhood sexual abuse and adult sexual assault, often at the hands of family members and partners. The vulnerability of these women can be further complicated when health professionals lack sensitivity to the issues involved; and the treatment received by the women is insensitive, leading to experiences of re-traumatisation. This article considers the principles of trauma-informed care and practice, as represented in the literature; and explains how mental health nurses can lead the way in multidisciplinary environments to ensure that women who have experienced violence receive the most appropriate health care, and are thereby supported to attain the best possible outcome.