So how do we react to the difficult inpatient client in our caseload? That person who acts defiantly, does not comply, seems that does not want to be there, but is. Other peers in treatment are not too keen of this client and neither is staff. Does the client follow programming? Not quite.

This scenario presents a challenge to clinicians, staff, and others participating in treatment. The client behaves in such a way that gets under everyone’s skin but is not doing enough to have their treatment terminated. Every morning the news on how clients are doing revolves around this specific person. Whaaaat now? What did the client do (or didn’t do) this time?

How is the psychic and morale of the clinician affected? Do we wish this client wasn’t here anymore? Can insurance please deny further coverage? Can we just kick this person out?

Helping the client engage in treatment can be a work in progress while meeting the client where they are at can also be challenging without the support of other staff who want you, the primary clinician, to “fix the client”. Wishing this client not be in treatment can seem like the best out, but many dynamics must be addressed if we are to remain true to the importance of patient care and ethical practice.

In an individual sense, the clinician must be aware of feelings arising from the situation, be it transference related or due to pressures from others involved. In group settings where staff is present discussing the case, the clinician must be aware of how others’ comments affect their own perspective of the situation and of the individual. Are we buying into the groupthink or are we able to maintain our individual opinions?

They all deserve the best from us, always and unconditionally, whether we like them or not, independent of our opinion, and independent of our professional prognosis.

The need for supervision seems paramount in cases as such. Easy answers should not be expected as there are many factors to consider. But if we are to speak about client care and ethical practice as a priority, the following points are of relevance:

While the client is still in treatment and under our care, this person deserves nothing but the best from us and our team. That is the warranted client care. The possibility of assessing whether the client should be in this treatment episode, or not, becomes a different conversation. Until, and if, a decision as such is made, the client is still a client, no matter anything else.

Am I as a clinician aware of the power of my expectations of the client, on the client’s outcome? There is a chance of closing down possibilities to be helpful if my expectations of this client are minimal or non-existent; if I am not as present as I can be for this person; if “I know this client will fail, so why try”. They all deserve the best from us, always and unconditionally, whether we like them or not, independent of our opinion, and independent of our professional prognosis.

Picture this scenario: I take my car for a tune-up, but I am not one of those to really take good care of the car nor to follow all preventive care suggestions. It is also a bit dirty and filled with fast food reminders. How would I feel if I found out I was not given “the usual tune up” they give everyone else because the mechanics thought I did not deserve it for not taking good care of my car? I did pay the same amount as the “worthy ones”. I don’t know about you guys, but I would not be a happy camper.

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One Comment

  1. In my first five years out of college I was a live in family teacher for abused neglected and sexually/physically abused teenagers. I was absolutely astounded at some of the behaviors that I saw my first year in particular. One young lady that was 12 years old refused to sit within seven or eight feet of me at the dinner table even though there was six other people there. I took offense to that initially because I was young uneducated in the experential world ( in all honesty it was about that time in my career I realized that the framed pieces of paper that hung in my office I worked so hard for- meant nothing at this point)
    It wasn’t until years later after living with 40 and 50 of those kids that I realized how badly they were scarred not just physically, emotionally as well. It took her a year to sit next to me at dinner. Oh and have never had what I call an ” I love me wall ” since.
    So it goes with addiction issues.
    How would you treat it is if you worked at a cancer ward and every day you walked into a cancer patient who had chemotherapy- feeling sick vomiting would you say well I don’t know if we should keep them? Call in the the text book troops for a vote? Why not?

    Personally I believe something in that question is responsible for the unacceptable rate of managing addictions. I’m not so sure clinicians and others view them even similarly. That right there is the difference between success and failure, reinforcement and negative consequences in many or most programs. If anyone disagrees, please do share . I’d love to swap stories of treatment centers we have been in.
    Oh , and eventually ended up working in. Things are much different when you get the unfortunate opportunity to have excellent resumes on both sides of addiction. That’s just my 2 cents…
    Tj

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