568226 research-article2015
APY0010.1177/1039856214568226Australasian PsychiatryLittle
Australasian
Psychiatry
Psychotherapy
Hesitancies in saying ‘No’ John Little Capital and Coast DHB, Wellington, New Zealand, and; Kapiti CMHT,
Australasian Psychiatry 2015, Vol 23(2) 139–141 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214568226 apy.sagepub.com
Paraparaumu, New Zealand
Abstract Objective: This paper aims to explore why staff, agencies and families, might be reluctant to use ‘no’ as a therapeutic manoeuvre. Conclusion: Various factors contribute to this hesitancy and when understood and acknowledged, may serve to return the clinician to the task at hand. Keywords: no, limit setting, reluctance
F
rom both a child and adolescent and adult perspective, an argument has been made for the therapeutic use of ‘no’,1 with clinical examples from working with people with borderline personality disorder in the community described elsewhere.2 However, there are contextual factors that tempt clinicians instead to retreat, reward, rescue or retaliate. Apart from the latter two phenomena which are discussed elsewhere,3,4 the purpose of this paper is to continue to examine why this might be the case. It includes legal and ethical concerns, consideration of the person’s biological capacity for change, the fear of being considered authoritarian and an honesty surrounding ‘self-imposed, impossible tasks’. Whilst mindful of legal consequences, there is a literature whereby a clinician may legally choose not to treat a person, cease treating a person, or refuse to treat at any time and for any reason except during an emergency or when a patient who is in need of treatment is left without an alternative recourse.5 The Canadian Psychiatric Association 2012 guidelines note that legal abandonment is unusual and requires case-by-case consideration, including the possibility that further treatment is no longer beneficial and termination itself may be a constructive therapeutic manoeuvre.6,7 A letter is useful to inform the person on how to access emergency treatment, how the patient might contact those alternatives and how, by continuing to behave in ways that are unhelpful, the person is distracted from their own goals. Gutheil’s article on the medico-legal pitfalls of discharging people with borderline personality disorder who are suicidal is reassuring for the clinician.8 Ethical concerns also inhibit limit setting. It is the renal literature that is instructive. Embedded within a philosophy of care, troublesome dialysis patients were thought about in a multidisciplinarian format and the decisions
arising from that process, including the possibility of discharge, discussed with the patient.9 In an explicit discussion of the ethical dilemmas, the authors acknowledge that although health care professionals have a moral obligation to deal with the difficult, disruptive patient, this should be balanced against the treatment of other dialysis patients and staff. When there is real or threatened harm to other patients or staff, the balance should swing in favour of protecting others.10 That is, options are considered and monitored as to whether the feared consequences are confirmed, or disconfirmed, but with the acceptance that in situations of risk, negative outcomes cannot always be avoided.11 For people with borderline personality disorder, “…it is the clinician’s duty to understand the patient as fully as possible and tenaciously to bring to bear on his or her treatment the best science or art can offer, but no more”.7 Given the unexpectedly high heritability and the documented neurocognitive differences in the person with borderline personality disorder, a third possibility to explain the hesitancy in using limits relates to whether the person can reasonably be held responsible for, or realistically change, their communication styles.12–14 However, those variances alone will be insufficient to explain away behaviour. Morse notes: Let us first clarify an error that often bedevils thinking about the relation between scientific discoveries of causes of behaviour and traditional conceptions of responsibility. Discovering a cause for behaviour,
Corresponding author: John Little, Capital and Coast DHB, Kapiti CMHT, Warrimoo St, Paraparaumu, 5032, New Zealand. Email: [email protected]
139
Australasian Psychiatry 23(2)
whether it is biological, psychological or sociological, does not mean that the agent is not responsible for the behaviour. All behaviour has causes. If causation were an excuse, no one would ever be held responsible for any behaviour.13 Further, there will be a need to demonstrate in what way any differences may affect the mental capabilities to inform intent. In order to excuse responsibility, it must be argued that everyone with this difference is likely to behave in this way on each and every occasion, without capacity to change. The more likely scenario is that the person can have ‘neurocognitive deficits’, be responsible and be able to change.15 A further area to consider relates to the personal and professional reluctance of staff to view themselves as disciplinarians. Traditionally, an appeal of therapeutic practice has been its humanism. Sensitised by the inherent power differential between ourselves and those with whom we work, and being aware of societal criticism of psychiatry being an agent of social control, taking control of someone’s life may make the clinician feel dictatorial. Setting limits is thus avoided.16 However, it is only by saying no that we can concentrate on what is really important, and the issue becomes not whether to say no or not, but how and when. Abroms notes: “If very serious forms of acting out are not controlled, a fiasco may result in which therapy turns into just another avenue for the patient’s habitual pathology”.17 Finally, difficulties in setting limits can be examined from a perspective of honesty and of a realistic, rather than the ‘self-assigned impossible’ task. In an extraordinary pilot project, the UK Cabinet Office were tasked to explore alternative approaches towards the chronically homeless.18 One project involved 25 sessions of a psychodynamically orientated psychotherapy to a group of people who were “too chaotic, too unwell or simply too out of their minds to benefit from conventional stand alone therapy and who were batted from one service to another”. The authors noted the tension that exists between the genuine wish to help and the hostility at being expected to do so with clients who were unlikely to make use of therapy. The temptation to blame management and political agendas in failing to keep some people out, “the them”, was correctly seen as a distraction which prevented further thinking around this dilemma. Instead, the authors wondered whether through the concepts of hospitality and ‘the self-assigned impossible task’,19,20 difficulties in accepting reality and saying no could be better understood. Whilst we may wish to include everyone, this is dishonest, for hospitality is only possible when offered by a host who is master in his or her home and who already sets a limit on what is offered; “…however hospitable we might claim to be, crossing the threshold would always involve a submission to our house rules”.18 Further, there is temptation to further avoid reality by constructing a
140
‘self-assigned impossible task’. To help requires a capacity for empathy; to stand momentarily in the other’s shoes and experience their pain using what we have learned as a guide as to how best to respond. The difficulty with this is that there is often a close resemblance between staff’s own painful experiences and those of their client, which constantly threatens this capacity. In order to manage, one defence is to accentuate differences – ‘they’ are the sick or mad or needy ones; ‘we’ are the sane, strong, helping ones. The work in this case will be structured to support the distance between staff and clients using rigid timetables, programmes and hierarchy. In other places, particularly those trapped in the ‘self-assigned, impossible task’, the dominant defence is to deny differences – to stand so much in the other’s shoes that the person is seen only as a victim. Being overwhelmed by their pain and despair, satisfaction is found instead from endurance and from disdain towards those who say ‘no’. In contrast, realistic task definition, by making some success possible, increased the capacity to tolerate inevitable disappointment21 and as a result, “…we also found more about who we were as therapists; who we could work with, what we could tolerate and what remained beyond our limits despite our optimism”.18
Concluding remarks Saying ‘no’ is an important therapeutic manoeuvre. However, there is a readiness instead to retreat, reward, rescue or retaliate. There are a number of aspects to this reluctance that, when understood and acknowledged, may serve to return the clinician to the task at hand. Russell notes: “There is, then, a necessary and continuous tension between the press for action, on the one hand, and the need for delay in the service of competence, on the other”.22 It is hoped that this paper reminds the clinician of the therapeutic use of ‘no’ when thoughtfully and respectfully applied. Acknowledgements My thanks to Heather Dryburgh for typing and to Susan Hope and Mary Newman, Reference Librarians, Wellington Medical and Health Sciences Library for both this paper and for the original paper on “The therapeutic use of ‘no’” which was presented at the ISSPD Conference, Copenhagen, 2013. My special thanks are extended to Marg Little for her remarkably continued support, and to Robbie Little for his patience, good humour and referencing.
Disclosure The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.
References 1. Little J and Thomson D. Stories from the Border: Reflections on ways of working with people with borderline personality disorder living in the community. New York, USA: Nova Science Publishers, Inc, 2014. 2. Little J. The therapeutic use of ‘no’. Australasian Psychiatry 2015; 23: 128–130. 3. Tartaglia M and Little J. Clockwatching and hate. Australasian Psychiatry Submitted. 4. Little J. Rescuing – a universal phenomenon. Australasian Psychiatry 2014; 22: 533–535.
Little 5. Gutheil TG and Simon RI. Abandonment of patients in split treatment. Harv Rev Psychiatry 2003; 11: 175–179.
15. Little J and Little B. Borederline personality disorder: Exceptions to the concept of responsible and competent. Australas Psychiatry 2010; 18: 445–450.
6. Tapper CM. Unilateral termination of treatment by a psychiatrist. Guidelines of the Canadian Psychiatric Association. Can J Psychiatry 2012; 2–7.
16. Pam A. Limit setting. Am J Psychother 1994; 48: 432–440.
7. Maltsberger JT. Calculated risks in the treatment of intractably suicidal patients. Psychiatry 1994; 57: 199–212. 8. Gutheil TG. Medicolegal pitfalls in the treatment of borderline patients. Am J Psychiatry 1985; 142: 9–14. 9. Sukolsky A. Patients who try our patience. Am J Kidney Dis 2004; 44: 893–901. 10. Hashmi A and Moss AH. Treating difficult or disruptive dialysis patients: Practical strategies based on ethical principles. Nat Clin Pract Nephrol 2008; 4: 515–520. 11. Carroll A. How to make good-enough risk decisions. Adv Psychiatr Treat 2009; 15: 192–198. 12. Glannon W. Our brains are not us. Bioethics 2009; 23: 321–329. 13. Morse SJ. Criminal responsibility and the disappearing person. Cardozo Law Rev 2006; 28: 2545–2575. 14. Vincent NA. Neuroscience and Legal Responsibility. Oxford: Oxford University Press, 2013.
17. Abroms GM. Setting limits. Arch Gen Psychiatry 1968; 19: 113–119. 18. Brown G, Kainth K, Matheson C, et al. An hospitable engagement? Open-door psychotherapy with the socially excluded. Psychodyn Pract 2011; 17: 307–324. 19. Scanlon C and Adlam J. Refusal, social exclusion and the cycle of rejection: A cynical analysis? Crit Social Policy 2008; 28: 529–549. 20. Roberts VZ. The self-assigned impossible task. In: Obholzer A and Roberts VZ (eds) The unconscious at work: Individual and organizational stress in the human services. London: Routledge, 2004, pp.110–120. 21. Obholzer A. Authority power and leadership. In: Obholzer A and Roberts VZ (eds) The unconscious at work: Individual and organizational stress in the human services. 2004, pp.39–47. 22. Russell PL. The role of paradox in repititon compulsion. In: Trauma, repetition and affect regulation: The work of Paul Russell, Teicholz JG and Kreigman D (Eds). New York: The Other Press, 1998, pp.1–22.
141
Copyright of Australasian Psychiatry is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
APY0010.1177/1039856214568226Australasian PsychiatryLittle
Australasian
Psychiatry
Psychotherapy
Hesitancies in saying ‘No’ John Little Capital and Coast DHB, Wellington, New Zealand, and; Kapiti CMHT,
Australasian Psychiatry 2015, Vol 23(2) 139–141 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856214568226 apy.sagepub.com
Paraparaumu, New Zealand
Abstract Objective: This paper aims to explore why staff, agencies and families, might be reluctant to use ‘no’ as a therapeutic manoeuvre. Conclusion: Various factors contribute to this hesitancy and when understood and acknowledged, may serve to return the clinician to the task at hand. Keywords: no, limit setting, reluctance
F
rom both a child and adolescent and adult perspective, an argument has been made for the therapeutic use of ‘no’,1 with clinical examples from working with people with borderline personality disorder in the community described elsewhere.2 However, there are contextual factors that tempt clinicians instead to retreat, reward, rescue or retaliate. Apart from the latter two phenomena which are discussed elsewhere,3,4 the purpose of this paper is to continue to examine why this might be the case. It includes legal and ethical concerns, consideration of the person’s biological capacity for change, the fear of being considered authoritarian and an honesty surrounding ‘self-imposed, impossible tasks’. Whilst mindful of legal consequences, there is a literature whereby a clinician may legally choose not to treat a person, cease treating a person, or refuse to treat at any time and for any reason except during an emergency or when a patient who is in need of treatment is left without an alternative recourse.5 The Canadian Psychiatric Association 2012 guidelines note that legal abandonment is unusual and requires case-by-case consideration, including the possibility that further treatment is no longer beneficial and termination itself may be a constructive therapeutic manoeuvre.6,7 A letter is useful to inform the person on how to access emergency treatment, how the patient might contact those alternatives and how, by continuing to behave in ways that are unhelpful, the person is distracted from their own goals. Gutheil’s article on the medico-legal pitfalls of discharging people with borderline personality disorder who are suicidal is reassuring for the clinician.8 Ethical concerns also inhibit limit setting. It is the renal literature that is instructive. Embedded within a philosophy of care, troublesome dialysis patients were thought about in a multidisciplinarian format and the decisions
arising from that process, including the possibility of discharge, discussed with the patient.9 In an explicit discussion of the ethical dilemmas, the authors acknowledge that although health care professionals have a moral obligation to deal with the difficult, disruptive patient, this should be balanced against the treatment of other dialysis patients and staff. When there is real or threatened harm to other patients or staff, the balance should swing in favour of protecting others.10 That is, options are considered and monitored as to whether the feared consequences are confirmed, or disconfirmed, but with the acceptance that in situations of risk, negative outcomes cannot always be avoided.11 For people with borderline personality disorder, “…it is the clinician’s duty to understand the patient as fully as possible and tenaciously to bring to bear on his or her treatment the best science or art can offer, but no more”.7 Given the unexpectedly high heritability and the documented neurocognitive differences in the person with borderline personality disorder, a third possibility to explain the hesitancy in using limits relates to whether the person can reasonably be held responsible for, or realistically change, their communication styles.12–14 However, those variances alone will be insufficient to explain away behaviour. Morse notes: Let us first clarify an error that often bedevils thinking about the relation between scientific discoveries of causes of behaviour and traditional conceptions of responsibility. Discovering a cause for behaviour,
Corresponding author: John Little, Capital and Coast DHB, Kapiti CMHT, Warrimoo St, Paraparaumu, 5032, New Zealand. Email: [email protected]
139
Australasian Psychiatry 23(2)
whether it is biological, psychological or sociological, does not mean that the agent is not responsible for the behaviour. All behaviour has causes. If causation were an excuse, no one would ever be held responsible for any behaviour.13 Further, there will be a need to demonstrate in what way any differences may affect the mental capabilities to inform intent. In order to excuse responsibility, it must be argued that everyone with this difference is likely to behave in this way on each and every occasion, without capacity to change. The more likely scenario is that the person can have ‘neurocognitive deficits’, be responsible and be able to change.15 A further area to consider relates to the personal and professional reluctance of staff to view themselves as disciplinarians. Traditionally, an appeal of therapeutic practice has been its humanism. Sensitised by the inherent power differential between ourselves and those with whom we work, and being aware of societal criticism of psychiatry being an agent of social control, taking control of someone’s life may make the clinician feel dictatorial. Setting limits is thus avoided.16 However, it is only by saying no that we can concentrate on what is really important, and the issue becomes not whether to say no or not, but how and when. Abroms notes: “If very serious forms of acting out are not controlled, a fiasco may result in which therapy turns into just another avenue for the patient’s habitual pathology”.17 Finally, difficulties in setting limits can be examined from a perspective of honesty and of a realistic, rather than the ‘self-assigned impossible’ task. In an extraordinary pilot project, the UK Cabinet Office were tasked to explore alternative approaches towards the chronically homeless.18 One project involved 25 sessions of a psychodynamically orientated psychotherapy to a group of people who were “too chaotic, too unwell or simply too out of their minds to benefit from conventional stand alone therapy and who were batted from one service to another”. The authors noted the tension that exists between the genuine wish to help and the hostility at being expected to do so with clients who were unlikely to make use of therapy. The temptation to blame management and political agendas in failing to keep some people out, “the them”, was correctly seen as a distraction which prevented further thinking around this dilemma. Instead, the authors wondered whether through the concepts of hospitality and ‘the self-assigned impossible task’,19,20 difficulties in accepting reality and saying no could be better understood. Whilst we may wish to include everyone, this is dishonest, for hospitality is only possible when offered by a host who is master in his or her home and who already sets a limit on what is offered; “…however hospitable we might claim to be, crossing the threshold would always involve a submission to our house rules”.18 Further, there is temptation to further avoid reality by constructing a
140
‘self-assigned impossible task’. To help requires a capacity for empathy; to stand momentarily in the other’s shoes and experience their pain using what we have learned as a guide as to how best to respond. The difficulty with this is that there is often a close resemblance between staff’s own painful experiences and those of their client, which constantly threatens this capacity. In order to manage, one defence is to accentuate differences – ‘they’ are the sick or mad or needy ones; ‘we’ are the sane, strong, helping ones. The work in this case will be structured to support the distance between staff and clients using rigid timetables, programmes and hierarchy. In other places, particularly those trapped in the ‘self-assigned, impossible task’, the dominant defence is to deny differences – to stand so much in the other’s shoes that the person is seen only as a victim. Being overwhelmed by their pain and despair, satisfaction is found instead from endurance and from disdain towards those who say ‘no’. In contrast, realistic task definition, by making some success possible, increased the capacity to tolerate inevitable disappointment21 and as a result, “…we also found more about who we were as therapists; who we could work with, what we could tolerate and what remained beyond our limits despite our optimism”.18
Concluding remarks Saying ‘no’ is an important therapeutic manoeuvre. However, there is a readiness instead to retreat, reward, rescue or retaliate. There are a number of aspects to this reluctance that, when understood and acknowledged, may serve to return the clinician to the task at hand. Russell notes: “There is, then, a necessary and continuous tension between the press for action, on the one hand, and the need for delay in the service of competence, on the other”.22 It is hoped that this paper reminds the clinician of the therapeutic use of ‘no’ when thoughtfully and respectfully applied. Acknowledgements My thanks to Heather Dryburgh for typing and to Susan Hope and Mary Newman, Reference Librarians, Wellington Medical and Health Sciences Library for both this paper and for the original paper on “The therapeutic use of ‘no’” which was presented at the ISSPD Conference, Copenhagen, 2013. My special thanks are extended to Marg Little for her remarkably continued support, and to Robbie Little for his patience, good humour and referencing.
Disclosure The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.
References 1. Little J and Thomson D. Stories from the Border: Reflections on ways of working with people with borderline personality disorder living in the community. New York, USA: Nova Science Publishers, Inc, 2014. 2. Little J. The therapeutic use of ‘no’. Australasian Psychiatry 2015; 23: 128–130. 3. Tartaglia M and Little J. Clockwatching and hate. Australasian Psychiatry Submitted. 4. Little J. Rescuing – a universal phenomenon. Australasian Psychiatry 2014; 22: 533–535.
Little 5. Gutheil TG and Simon RI. Abandonment of patients in split treatment. Harv Rev Psychiatry 2003; 11: 175–179.
15. Little J and Little B. Borederline personality disorder: Exceptions to the concept of responsible and competent. Australas Psychiatry 2010; 18: 445–450.
6. Tapper CM. Unilateral termination of treatment by a psychiatrist. Guidelines of the Canadian Psychiatric Association. Can J Psychiatry 2012; 2–7.
16. Pam A. Limit setting. Am J Psychother 1994; 48: 432–440.
7. Maltsberger JT. Calculated risks in the treatment of intractably suicidal patients. Psychiatry 1994; 57: 199–212. 8. Gutheil TG. Medicolegal pitfalls in the treatment of borderline patients. Am J Psychiatry 1985; 142: 9–14. 9. Sukolsky A. Patients who try our patience. Am J Kidney Dis 2004; 44: 893–901. 10. Hashmi A and Moss AH. Treating difficult or disruptive dialysis patients: Practical strategies based on ethical principles. Nat Clin Pract Nephrol 2008; 4: 515–520. 11. Carroll A. How to make good-enough risk decisions. Adv Psychiatr Treat 2009; 15: 192–198. 12. Glannon W. Our brains are not us. Bioethics 2009; 23: 321–329. 13. Morse SJ. Criminal responsibility and the disappearing person. Cardozo Law Rev 2006; 28: 2545–2575. 14. Vincent NA. Neuroscience and Legal Responsibility. Oxford: Oxford University Press, 2013.
17. Abroms GM. Setting limits. Arch Gen Psychiatry 1968; 19: 113–119. 18. Brown G, Kainth K, Matheson C, et al. An hospitable engagement? Open-door psychotherapy with the socially excluded. Psychodyn Pract 2011; 17: 307–324. 19. Scanlon C and Adlam J. Refusal, social exclusion and the cycle of rejection: A cynical analysis? Crit Social Policy 2008; 28: 529–549. 20. Roberts VZ. The self-assigned impossible task. In: Obholzer A and Roberts VZ (eds) The unconscious at work: Individual and organizational stress in the human services. London: Routledge, 2004, pp.110–120. 21. Obholzer A. Authority power and leadership. In: Obholzer A and Roberts VZ (eds) The unconscious at work: Individual and organizational stress in the human services. 2004, pp.39–47. 22. Russell PL. The role of paradox in repititon compulsion. In: Trauma, repetition and affect regulation: The work of Paul Russell, Teicholz JG and Kreigman D (Eds). New York: The Other Press, 1998, pp.1–22.
141
Copyright of Australasian Psychiatry is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
