Difficult Professional Relationship...

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DrPrincess
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Difficult Professional Relationship...

Post by DrPrincess » Mon Sep 11, 2017 10:12 am

Hi all,

I'm not sure the 'subject' quite captures my issue so bear with me! I'm a qualified CP and have been working with one of my (adult) clients for over 12 months now (I see him weekly at both individual sessions and group therapy sessions). Therapeutic rapport is positive and we've managed to build a strong therapeutic relationship - something he has always struggled with since he's been in the service (which is a while!). As I say, I took him over from a his previous CP about 15 months ago. Said CP and client had a very difficult relationship, which prevented a lot of core therapeutic work being done. However, as part of their work together, his previous CP undertook the PCL-R (a psychopathy assessment), which CP never got round to writing up due to ill-health/lots of time off work etc. The assessment was conducted years ago - some time back in 2013 maybe, if not before. Anyway, it never saw the light of day as I say.

It came to my attention the other day that my client's psychiatrist (also his Responsible Clinician) has, without my knowledge, asked my client's previous CP to write-up the outcome of this assessment. Just to give you a bit of context, there is tension in the professional relationship between myself and the psychiatrist and we tend to disagree quite a bit about this particular client. When I discovered the psychiatrist had done this, I felt it was an attempt to undermine me professionally. Also, as I've reflected on it, I would't be at all happy to include the outcome of this assessment in any reports I write because a) it was not written up at the time of the assessment and as such, I'd question its validity, and b) the therapeutic relationship between my client and his previous CP was very poor, which would lead me to question the 'accuracy' of the information obtained during the assessment.

I just wanted a bit of advice as to whether I'm over-reacting here (entirely possible as I have some very strong emotions towards this psychiatrist!) before I decide what to do in the situation I find myself. I'll be taking this to supervision but not until next week. Any thoughts welcome!

Dr P :)

reefflex
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Re: Difficult Professional Relationship...

Post by reefflex » Mon Sep 11, 2017 11:42 am

Hi

I agree that asking for the report now may well be an attempt by the psychiatrist to develop a case for viewing the patient in a way that you might not agree with, and as such potentially to win some kind of perceived argument. However challenging the request is also potentially a landmine waiting to be stepped on. By doing so, you might open yourself up to be labelled as "over involved" or biased yourself, which would then be used as a way to negate the validity of your clinical opinions about the client.

I would take a breath, sit back and do nothing. If the assessment was carried out, it should have been written up. The PCL-R is a structured assessment of lifetime functioning, and requires the tester to identify evidence across the lifespan. Theoretically the results should therefore not depend on the nature of the therapeutic relationship with the tester. If many of the examples identified in the PCL-R results come only from the CP working with the patient, the CP has not administered it properly and this will become evident when you see the report.

You will be in a better position to "put the results into context" once they are written up. You could also then suggest readminstering the PCL-R, because if the test-retest results are widely different, this in itself is a problem in relation to diagnosing psychopathy, given that it is meant to be a stable construct.

Only other advice is also to step back and look for whether the drama triangle is at play here - strong interpersonal pulls in the system may reflect elements of your patient's internal world.

DrPrincess
Posts: 91
Joined: Wed Aug 31, 2011 5:02 pm

Re: Difficult Professional Relationship...

Post by DrPrincess » Mon Sep 11, 2017 3:07 pm

Hi reefflex,

Thank you for your thoughts. You've managed to articulate my concerns very thoughtfully (i.e. that I would be labelled as "over-involved" were I to challenge this request). Any difference in clinical opinion relating to the client is labelled as him "splitting" so I think that challenging the request might just reinforce this idea, as well as the idea that he is "problematic", which is hugely unhelpful and damaging. The psychiatrist said to me the other day, "You're clearly on The Pedestal for him. I just hope you don't fall off" (said in a way which implied 'please please fall off and hurt yourself very badly on the way down') :shock: So, yes, the client engenders very strong emotional responses from those around him!

Re-administering the PCL-R is an option, although I'd be very reluctant to do this because my formulation is different to his previous CP and 'psychopathy' does not feature in it! Clinicians have oscillated between querying ASD, Psychopathy, and Paranoid Personality Disorder for many years with this client - my formulation is it's complex trauma :roll:

I do think that my formulation of this client should be the one given priority over and above an assessment that has been sitting in a filing cabinet for years, as it reflects the most current understanding of the client, and this is the view I will be putting forward in up-coming mental health review tribunals etc. I'm not quite sure how to put this across in a way that won't get me labelled as "over-involved"! Perhaps I should just shut-up (for once :lol: ) and ride it out...

Dr P :)

Ruthie
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Re: Difficult Professional Relationship...

Post by Ruthie » Thu Sep 21, 2017 2:40 pm

I have been accused of over involvement on a couple of occasions - notably when my view differs from other team members! I did once resort to telling some people if they were so concerned about my over involvement that they should discuss it with my clinical supervisor. Of course, they never dared - much to my supervisor's disappointment :lol: !

Is the other CP still involved in the service? It may be worth discussing too with your psychology management re where they would stand on a report being written so late after the fact and also outdated as you have now taken over.

I would also offer to re-administer the PCL checklist if they are that keen to have it. As others have said a different score would be indicative of something not being quite right.

Personally, I think you are right to challenge this but get the support of psychology leads to do so. Don't get into a fruitless argument with the psychiatrist!

Ruthie
If God invented marathons to keep people from doing anything more stupid, the triathlon must have taken Him completely by surprise.

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BenJMan
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Re: Difficult Professional Relationship...

Post by BenJMan » Thu Sep 28, 2017 1:40 pm

I agree with whats been said so far, I also wonder whether the easiest route is discussing with the CP in question and asking them to politely explain to the psychiatrist that it would be best for you to handle all things related to this case now?
I think a hero is any person really intent on making this a better place for all people ~ Maya Angelou.

DrPrincess
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Re: Difficult Professional Relationship...

Post by DrPrincess » Sat Sep 30, 2017 9:29 am

Hi all,

Thank you so much for your replies. Some very good advice, thank you. It's all gone quiet at the minute so who knows...

There is also tension within my relationship with my patient's previous CP so, to be quite honest, I think she's quite enjoying all of this :roll:

The Psychology Lead however is fantastic and I know will support my decision to not include the old PCL-R (and if it's considered absolutely crucial and the clinical rationale is sound, then I can re-adminsister) in the up-coming report I'll be writing. I'm currently undertaking the IPDE (a PD assessment) so I'm not sure what the PCL-R could add to a very comprehensive personality assessment anyhow!

Oh the joys of MDT working :? When it works, it works so well; when it's fraught, it can be very damaging to both the professional and the patient.

Dr P

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