17 | AWARE 4 – Agenda & Resources

Host: This is a nice segue way into the next AWARE factor – Agenda, cause often patients with personality disorder and substance misuse are considered to have an agenda, like are they trying to get admitted or they are trying to que jump and get a back door detox, sometimes these agendas are related to social factors like they have got housing issues and are just attempting to get rehoused through an admission and so on. Were these the kind of scenarios that were highlighted under the agenda theme of the AWARE study?

Expert: Yes that is correct. Essentially we want assessors to pause and think HOW OFTEN ARE YOU RESPONDING TO AN AGENDA IN AN ASSESSMENT AND IS IT SKEWING THE OUTCOME?

Host: How would you define an agenda?

Expert: Put simply an agenda is a desire or motivation to achieve a particular outcome. Sometimes they are clearly stated and other times its implied or perceived by the assessor. What we found in the AWARE study was that once you pick up an agenda it begins to influence information processing.

Host: So that relates to your opening statement about agendas when you asked our listeners to pause and think, how often are you responding to agendas?

Expert: Yes, it does, throughout the assessment the assessor is interacting with people, processing and accepting the referral, triaging, collating information, and the face to face assessment itself with the person in distress and their family. During these activities’ agendas may be picked up in a referrer / patient/ carer by assessing practitioners, to which they end up consciously or unconsciously responding.

Host: How does an assessor know that they are responding to an agenda?

Expert: It is not unusual for an assessor to try and work out, what are the person’s need? Why do they want this? Why now? Now that is fine, that’s what an assessment is, assess to establish the needs, and you can change the person to the referrer, patient, family member etc. but when you begin to wonder is there a secondary gain, is there a hidden agenda, essentially when you begin to second guess what someone is saying as the reason for their referral, you can rest assured that you feel there is an agenda.

Host: You mentioned agenda in the referrer, what agenda could a referrer have when requesting an assessment other than getting the person assessed?

Expert: Rightly or wrongly, assessors very frequently felt that the referrer had an agenda. Generally they were judgement calls on Referral Appropriateness. Referrer credibility was often scrutinized when reviewing a referral, this varied from conclusions about a referrer’s risk taking to passing the buck as they were going on leave and wanted someone else to take responsibility.

Host: What kind of statements did you get in the AWARE study?

Expert: So we had statements like: “…I felt that the reasons for the referral weren’t really appropriate.  He was someone that they’d (Locality Team) only seen twice, the reason for referral was that he was being actively suicidal.  But I felt the risk was kind of raised so we’d go and see him…” Often we would pick up an implied statement – You are passing the buck to me without doing your part

Host: What kind of statements did you get that related to patients having an agenda?

Expert: I have a nice example here: “…Suicidal ideation was in the context of depression… because she has a child, so I think it’s always worth having a look when there’s a child, I got the clear sense that she was downplaying it as she did not want social services involved, we needed to do something…” So in this example the assessor felt that the patient was not being very open as she was worried about her child and social services involvement.

 Host: So in the first statement the assessor’s interpretation of an agenda resulted in decreased sensitivity to suicide risk i.e. they have only seen her twice and have not done their part and in the second she might be trying to conceal her symptoms increases the assessors awareness of risk related factors.

Expert: Yes, almost diametrically opposite impact. Altered care responses were most obvious when judgement calls were made about the appropriateness of the referral. Assessors often did not accept the referral if they felt that the referrer had not done their part, and even if they did, it impacted on the assessment outcome. The risk and the need in the person in distress does not change with whether there is any truth to the claim of lack of diligence on part of the referrer.

Host: And then there was the opposite where they might have got over involved or more intrusive or more risk averse if they felt that the patient did not want to engage for some reason.

Expert: True, attempts to avoid hospitalisation were picked up and responded to fairly robustly. Other than influencing risk sensitivity there was also a spectrum in terms of the type of response, sometimes the response was positive, and other times negative, which actually escalated the risk.

Host: Can you provide an example of a perceived agenda in a patient which actually increased the risk.

Expert: These were primarily the implied requests, e.g. for admission in people with a diagnosis of borderline personality disorder were often met with skepticism.

Host: Given inpatient beds are such a scarce resource and in the previous episode you talked about how the focus for chronic risk, as in people with borderline personality should be psychoeducation and safety planning, rather than admission at every presentation, isn’t skepticism warranted.

Expert: Yes, it is but it is the way in which the conversations pan out. When we have finished all the aware factors we will do some case based discussions regarding what and how to communicate with a person in crisis who has a borderline personality disorder. In brief certain agendas brought about a non empathic response, for example ‘she is angling for an admission, I need to keep her out of hospital’. This became adversarial in nature, and the study revealed that the assessors were often unconscious of this mental stance. But the patient perceived this stance very quickly, remember people with borderline personality are hyperaware of abandonment and rejection. So when they perceive this stance in a clinician who is discounting how unsafe they are currently feeling, they feel a pressure to prove their suicidal distress, and this escalates the risk in the situation.

Host: What about positive responses?

Expert: Our study revealed that carer requests regarding their ability to care, or struggling with burnout particularly when openly stated received a positive and empathic response from assessors. This was of course perceived as positive and helped with relational safety and carer confidence. Here is a statement relating to a spouse: “I think her husband felt that she needed to come into hospital …he was quite distressed by what she had done again. He felt it was a heavy load to carry at the moment. Too much to cope with…” One can see the thinking of the assessor that the carer is desperate for a break and needs our help, perhaps to keep caring for the longer run.

Host: So openness brought out a positive response.

Expert: This is true in all walks of life. Yes, generally if the referrer, patient or carer were open about what they wanted assessors seemed to pay heed to the request and tried to accommodate it, its when they felt that someone was trying to work the system that their position would harden and the perceived agenda would begin to influence the information processing and the decision that was arrived at.

Host: So perception of an agenda leads to a particular kind of response that may escalate the risk.

Expert: Yes we do want assessors to reflect on whether their response to the person they are assessing whether that is escalating the risk in anyway. The AWARE study clearly showed that assessor responses had a range of foreseeable as well as unforeseeable outcomes. From making a patient with borderline personality disorder feel that now they had to prove their distress by self harming to a patient downplaying their symptoms in response to a conservative approach in an assessor. We also saw the converse in terms of empathic responses to stated or perceived agendas, such responses were clearly perceived as helpful by the person, the family, and the referrer.

Host: So let’s pull this together in terms of what assessors need to do.

RECOMMENDATION

Expert: Assessors need to mindfully scan themselves ‘am I picking up an agenda’. If they find one, avoid the temptation to rationalise their response like this is just an anxious GP who refers everyone or this case manager is going on leave so is referring everyone on their caseload. Such judgement calls change the outcome of the assessment without addressing the actual cause for the presentation, i.e. the risk has remained the same or might be even worse as now the patient feels that the hope they had for help has now been dissipated. This is not an uncommon theme in serious incident reviews where a patient attempts to take their life after a presentation for admission or what they believed would result in an admission. So if you perceive an agenda, make the implicit – explicit, seek clarity from the patient and their family, bring it out into the open as to what you feel may be there expectations. Do it with sensitivity and have an open and honest discussion with them regarding the reasons for why they might feel the way they do. This is a fairly nuanced discussion and we will discuss this further when we do a case based discussion.