Two strikes and you’re out – referrals and readiness


I’m in a bit of a dilemma. As you know, health resources are scarce and it’s not easy to get an appointment for treatment of a chronic condition. There’s something to be said for making sure that our precious health care time isn’t wasted by people who would rather not be there.
On the other hand, there is also something to be said for people being in the right headspace, or in more technical terms, the right stage of readiness to engage in therapy. If the person is referred for treatment before they’re ready, it’s going to be difficult for them to engage – and they may very well do the resistance thing that we see so often ‘yes, but’, ‘OK but’ or not actually do what we’ve suggested they do to help manage their condition.

The discussion that has raised this in my mind happened on Monday.

We (the interdisciplinary team) were discussing the case of a person who had been referred to the Centre some months before, but hadn’t engaged in the programme we had recommended and eventually stopped attending. She was re-referred for another pain management programme, and the question being raised was whether she should have a comprehensive assessment before being considered for the programme, or should the referral simply be declined on the grounds that she hadn’t been inclined to participate fully the first time.

On the one hand, the argument goes that:

  • she wasn’t especially happy with our recommendations the first time,
  • hadn’t been fully engaged in the programme,
  • other treatment providers were having difficulty getting her to comply with their programmes and
  • she repeatedly told people her pain was such a problem that she couldn’t engage in the return to work elements of her rehabilitation

On the other hand:

  • she had since the last referral been seeing a psychologist to look at mood and understanding
  • there wasn’t a lot of evidence to show that she’d received much pain management
  • she repeatedly said her pain was a problem for her
  • she had originally been assessed as needing a comprehensive programme to help reduce her distress and help her develop skills she knew about, but wasn’t putting into place

Some members of the team thought she shouldn’t be accepted back – after all, she’d had her opportunity, been reviewed here medically twice, hadn’t really complied with here programme anyway, and their argument was that there wasn’t any evidence on file to show her motivation had changed.

Others argued that she represents one of the main reasons the Centre was established: someone with a long-standing pain problem, having difficulty coping, clogging up the acute health care services because of her distress (visiting Emergency Department for pain relief), and perhaps she hadn’t been at the right stage of change to get involved in learning to use pain management.

If she is accepted, and isn’t ready for pain management – she’ll have taken up an assessment space from someone who may be ready, is keen to get involved with getting on in life, and is probably a lot easier to work with!

If she isn’t accepted for further assessment and treatment, there is no support for her to develop a change in motivation, how can she demonstrate readiness to do pain management if she doesn’t know how?  And she will continue to use the coping strategies she is using now, remaining just as distressed and the health care providers she continues to see may well not have adequate expertise to help her move on and manage better.

I really don’t know what is the best thing to do.  If we pick off the ‘easy’ people to work with, we’ll get much better results, but one of the main reasons for having a chronic pain management centre operating is to help the challenging patients.  After all, a lot of the ‘easy’ people will manage quite effectively without the sledgehammer of a full-on interdisciplinary team, while the challenging ones won’t.

Then again, why waste resources on someone who really doesn’t want to be there and is very hard work and quite unrewarding in terms of outcome.

Is there some sort of intermediate step?  Is there a place for skilled practitioners to use motivational interviewing as a means to help the person recognise the need to change, to help them develop a sense of creative helplessness?  What about providing support to the GP and other health providers in the community who are probably scratching their heads at what to do with someone who is clearly quite difficult to work with? After all, they don’t have the expertise or team available to support them in managing this situation.

I’d love to hear what you think.  As you can see, I’m ambivalent about this – my initial response is to try to engage this person in some motivational approach to help her move from her very ‘stuck’ position, or at least support her health care team to manage her situation so she makes fewer demands on acute services.  My second response is to say – well, it’s her bad luck, two strikes and you’re out!  Let’s keep the resources we have for people who really want them.

If you’ve enjoyed this post, and want to keep reading – you can subscribe using the RSS feed button above.  Simply click on it and follow the directions.  Otherwise you can simply bookmark this page and come back now and again.  I post most working days, weekends off for good behaviour, and Fridays are definitely more about fun and trivia than serious stuff.  I love comments, and do respond – so please, leave me a comment, especially about today’s post.  I’d love to hear arguments for – or against – the two strikes and you’re out!

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