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Managing a distraught patient during psychotherapy

Vol. 2, No. 4 / April 2003

When a patient revisits past trauma during psychotherapy, strong reactions may surface. There is no single best way to confront emotions such as anger or despair, nor does the patient warn you before an outburst happens. The emotional reaction could be part of the healing process or could signal the need for additional treatment. You must decide on the spot whether to move up the next session, check on the patient the next day, or hospitalize the patient for his or her protection.

Keys to assessment

Before gauging a distraught patient’s needs, consider:

  • How well do you know the patient? An established patient can be appraised fairly quickly. Assessing a new patient with confidence may take more time, however.
  • Can the patient set emotional boundaries? Can he or she make sound choices and consider their consequences?
  • Does the patient have adequate support? Is the patient going home to an empty room, a loving family or significant other, or a situation between the two?
  • What therapy model are you employing? For example, cognitive therapy might address the meaning a patient places on a situation or reaction.

Dealing with emotional reaction

When a patient becomes overwrought:

  • Encourage the patient to talk about the issue. This allows the patient to problem-solve and gives you time to think and plan.
  • Extend the therapy session, especially if you fear a prompt discharge would endanger the patient. Consider the patient’s cognitive and emotional state. If you are uneasy with his or her degree of self-control, don’t discharge that patient.
  • Formulate a plan to address the trauma. You might say: “It seems clear that this is troubling you. How can we work together to ease the burden? Can you comfortably think it through so that we can work it out next week? Would writing down your feelings and thoughts help?”
  • Move up the patient’s next appointment. If the patient typically reacts badly to a certain issue or cannot handle feeling distraught, bringing him or her back sooner can be reassuring.
  • Call the patient that evening or the next day. A distraught patient who does not need immediate hospitalization may benefit from extra contact. Decide whether to call the patient at a set time or to arrange for the patient to contact you. These usually brief calls reassure you that the patient has gained some perspective toward the problem and convey to the patient that you care.

Arrange to admit the patient to the hospital until the acute situation is resolved or perspective restored. Consider a brief hospitalization:

  • when a situation or issue seriously challenges the patient’s coping mechanisms
  • for patients with a history of self-harm when stressed
  • for a patient who is psychotic and whose response to the emotional state is unpredictable
  • when drugs or alcohol cloud the patient’s sensorium
  • for a patient who lives alone.

Dr. Schuyler, a cognitive therapist, is clinical associate professor of psychiatry, Medical University of South Carolina, Charleston.

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