Some observations can be made from this case. First, treatment was started with a broad goal but without either a clear diagnosis, an explanatory hypothesis or a preset method. Second, there was a positive working alliance with the key clinician but this did not result in positive outcomes. Third, treatment was continued despite the obvious lack of structure and success. It appears that the key-clinician had become the most important person in the care, and possibly even the life, of this patient. Patient and provider had become entangled in what may be termed a collusion.
To understand this entanglement we use the concept of illness behaviour. The combination of severe psychiatric symptoms, many social problems and especially chaotic help-seeking behaviour (eg, missed appointments, out-of-hours crisis and in-between appointments phone calls) makes it difficult for professionals to structure treatment. The lack of a proper diagnosis marks the start of a haphazard treatment process in which the lack of substance (diagnosis, goals, methods) is compensated by form (the working alliance). The combination of a clinician change and the adverse event of the robbery, makes the new key clinician offer extra care that, however, turns out to be very hard to decrease. The patient appears to have become used to the availability of the clinician and uses him as an important source of social contact (considering that the patient has few significant others).
Meanwhile, the clinician himself becomes used to a patient that requires constant attention and evokes considerable worry (eg, because of suicidal gestures). He may start to believe that the patient is unable to tolerate a less supportive contact and a more therapeutic exploration of behaviours, resulting in a treatment that does nothing more than ‘helping’ the patient through adverse situations. As long as the professional is able to offer this support, and the psychiatric service allows him to do so, there are relatively few problems. However, once the professional starts to have negative problematic encounters on behalf of the patient (eg, because professionals raise doubts about the patient's claim to illness) or becomes tired to attend to the patient so intensively, problems arise.
At this point, frustration and demoralisation may tempt the professional to attribute the patient's behaviour to purposive claiming of time and energy, deliberate obstruction of treatment, or a bad character in general. The patient then is at risk of exemption from mental healthcare because he is considered not really ill but seeking something else (eg, relief from work duties, or an ever-attentive person around). Referral may be the strategy of choice for clinicians that attribute this long-term attendance to ‘badness’. A second strategy may be to limit treatment to the least necessary to prevent exacerbation of symptoms and psychiatric crises, referred to by experts as ‘pampering and dithering’.17
The patient may respond to such a threat of losing an important figure with an increase of symptoms and demand upon the key clinician – thus only ‘proving’ that the clinician is right in assuming that the patient just wants attention.
We may describe the patient's behaviour as a form of ineffective chronic illness behaviour that has been jointly but inadvertently created by patient and professional.16 18
Analysing the situation from this perspective, another strategy – apart from referral or ‘pampering and dithering’ – is within reach: making a fresh start in the treatment process of the so-called ‘difficult’ patient. Such an endeavour includes, but is not necessarily limited to: a disentanglement of symptoms and (learned) illness behaviour, an analysis of the dynamics of the treatment alliance, a reconsideration of the given diagnosis and available treatment options, and – preferably – a discussion with the patient about aforementioned issues. In this case, we choose to discuss the issues openly with the patient, starting from the concept of the ‘difficult’ patient, who runs the risk to be expelled from every healthcare system available. We then jointly established a explanatory theory of patient's claim on care: an enduring lack of recognition of qualities and vulnerabilities by important others. We also jointly established that treatment had been reinforcing the behaviours following from this need, instead of exploring its antecedents. The consulting psychiatrist suggested a new diagnosis that explained many of the patient's symptoms (CPTSD19 20
) and proposed a treatment (consisting of both individual and group psychotherapy21
) for this disorder.
This treatment was surprisingly successful, despite its relative resemblance to earlier treatments. However, this was the very first time C's complex trauma was acknowledged by therapists and discussed within a group of peers, which may have been two very validating experiences. A psychotherapist prepared the patient for and provided the therapy, while the psychiatrist managed medication. The CPN assumed a case-manager role, coordinating efforts to ameliorate social problems (including work and meaningful contacts), to structure access to additional psychiatric care (eg, crisis intervention, hospitalisation) and to be a trusted person in the background. So far, these joint efforts have decreased the patient's symptoms, improved his social functioning and limited his healthcare use.
Practically, these collaborative efforts are increasingly being facilitated by an electronic patient file, to which clinicians from both acute and community care settings have access. This file contains a shared care plan that appears to be looked at more frequently than in the old paper file. It allows registration and consultation of all healthcare contacts by all involved professionals, which in this case prevents miscommunication and misunderstanding among professionals.
On a more theoretical level we may understand the patient's chronic illness behaviour as a function of his individual needs, the limited social system, clinician's pessimism and services’ lack of structure with patients like these.
- Difficulties in treatment interactions need analysis beyond the patient's presumed diagnosis or disorder.
- Especially when patients’ behaviour during treatment is unusual or unexpected related to the primary symptoms, a serious analysis of patients’ illness behaviour is warranted.
- The concept of illness behaviour offers an explanatory framework for patient's behaviours towards the primary clinician and in the healthcare system.
- Ineffective chronic illness behaviour may be induced in the patient by a treatment that lacks a clear starting point (preferably a diagnosis or current problems), a direction (goals) and a treatment frame (an explication of expectations and rules governing the therapeutic encounter).
- Once ineffective chronic illness behaviour is recognised, the primary clinician should structure treatment according to clear guidelines which may result in a restoration of hope and decrease of ineffective behaviours by both patient and professional.
- Once treatment is restructured, it is possible and important to keep up hope and an open eye for therapeutic options that previously seemed unsuitable.