MMD8386 - SECTION 8: HOW TO DISCUSS POSSIBLE MEDICAL PROBLEMS WITH A MENTAL HEALTH CLIENT
Section 8: How to Discuss Possible Medical Problems with a Mental Health Client
There are three very important considerations to keep in mind when the assessment of a client causes the mental health clinician to suspect the presence of a medical problem.
To begin with, the mental health clinician must be very cautious not to present the information about the possible medical problem to the client in a manner that operates outside one's area of competence.
When the clinician is a nurse practitioner – such as your author - with a substantial background in medical practice, knowledge of the medical components of various conditions, and experience in working with patients in medical settings, there is more latitude to directly address the medical symptoms as an expert, with the concomitant professional authority of one who is operating within her realm of expertise.
For those clinicians who do not possess this medical background, knowledge and experience, it is very important to clarify to the client the boundaries of your knowledge base. One must take great care to avoid any pretense of making a definitive medical diagnosis. Operating beyond one's area of competence not only diminishes the clinician's professional authority, it also runs the risk of placing the client in harm's way. In both instances, it represents an ethical concern.
If the mental health clinician lacks a background in medical issues, it is always be important to be clear and forthright about the provisional nature of one's knowledge. It is better to view this interaction as a careful and deliberate information gathering process, performed in collaboration with the client. In such instances it is best to structure the interaction with the client using questions about the medical symptoms rather than suggesting definitive answers.
Next, a certain number of clients will present in treatment with modest or even poor skills in gathering, assembling, integrating and assessing complex information, in contrast to the mental health clinician - who is trained in these very skills. This skill deficit can leave clients very vulnerable when gaps exist in the delivery of proper medical services. They may not know what questions to ask - or what symptoms to look for - that indicate the need for further services.
It is very important for mental health clinicians to remain acutely aware of the potential limitations of their clients in understanding the nature of their own problems and in accessing adequate health care as informed consumers. Clients may become overwhelmed with what they do not know. They often abandon necessary services due to embarrassment, or due to frustration with the difficulties in finding services or service providers where they feel comfortable and safe.
Whether the problems are caused by mental health issues - or by untended medical problems – there can be create life threatening outcomes. The mental health clinician's task in this area is to discern the level of competency on the part of the client – and to help the client feel comfortable and secure in the skills that can help them access treatment. This requires the clinician to address such issues sensitively and compassionately.
This leads directly to our third important consideration. It is important to keep in mind the purpose of addressing possible medical concerns with the client. If the mental health clinician is the point of entry and the gatekeeper into the health care system for the client, or if the mental health clinician has concerns that the health care needs of the client are not being fully met by the client's other health care providers, there is a clear responsibility to simultaneously do three things:
1) Direct the client to the right services to meet his or her most important problems;
2) Prepare the client emotionally for addressing those problems; and
3) Support the client's ability to advocate successfully for their own health treatment.
In terminology that is familiar to mental health clinicians, the process is very important to the progress – and it can be a very delicate process indeed for some clients. In some cases, the possibility of medical problems can be frightening to consider.
In other cases, it may actually be a relief for the client to view the problem as something that is medical in nature, as there still remains for many people a certain stigma about acknowledging that one has mental or emotional problems. Very early in the assessment process, it is important to attempt to gather information about the client's possible reaction to this kind of issue. you should decide how to frame this issue for the client based upon your best estimate of how the client will respond.
When it is time to address the potential medical problem, it is very important to work with the client in a way that: 1) carefully educated about what potential health care problems might be occurring. It is important to do this without creating excessive alarm nor bringing insufficient weight and gravity to the need for accurate assessment, and 2) he or she is helped to learn how to use the health care system in order to receive proper care – without presenting this information in a manner that creates resistance or damage to the emerging therapeutic relationship.
The framing of this approach might look something like this:
"I have noted that you had a somewhat serious car accident about three years ago, and I wanted to make sure about the medical care that you received after that accident. You may or may not be aware that sometimes when people have injuries from that kind of trauma, it can lead to some problems with depression. Did the doctors who treated make sure that your injuries were followed carefully over time? . . .Was there ever a referral to a neurologist to make sure that the injuries didn't create any problems with depression or other kinds of problems with how you were feeling? . . .Have you had any lasting physical problems, like headaches, after that accident, and have you been keeping your doctors aware of these problems? . . .I'm not a medical doctor, and I'm not an expert in these kinds of things, but since the depression seems to have started almost exactly the same time as you had your car accident, I'd like to make really sure that there isn't a physical problem that is making it harder for you to keep your depression under control. I'd like to have a chance to discuss things with your doctor, and see if there is any reason we might want to consider a referral to a specialist who can rule out any kind of medical problems that might be contributing to the depression you are feeling."
Handled with care and skill, this kind of discussion can be instrumental in directing clients to appropriate services. It will not hinder the development of professional authority. Rather, the thoroughness of this sort of approach can strengthen the professional authority in ways that support the mental health components of the work.
Statistic: A phone survey conducted by the National Patient Survey Foundation found a misdiagnosis rate of between 8 and 42 percent for medical conditions .