When do you “draw the line” in working with a client?  Is there a time when ACT clinicians have to put out a “you must – or else!” statement?

I think there are rare occasions where an ultimatum is understandable.  Mostly in my experience it’s been related to concerns of violence towards the team or others.

In a 1990 paper  titled The Use of Ultimatums in Psychiatric Care (Click to view) Dr Schwartz looks at this thorny issue.  While not directly addressing ACT I think the issues are very pertinent.

I believe in the use of contingencies but as Schwartz points out:

“The threat to end treatment is not just another contingency in the context of ongoing treatment.  When we make that threat, we invoke the final contingency available when all the usual contingencies we employ have failed.  At that moment we issue an ultimatum: “Either you do as I say [enter an alcohol treatment program, take this medicine, come to sessions regularly] or I will not work with you”.  Only the language of ultimatums captures the unique power of this moment…”

He goes on:

“An ultimatum can be very powerful indeed, but the particular nature of its power must be appreciated.  Often it represents an abuse of power or a disregard of responsibility.  Yet it may be the only way out of meaningless or harmful treatment.”

Schwartz then lays out 7 principles for consideration.  The first is, beyond ethical issues a reminder as to practicality.

“An ultimatum controls the psychiatrist’s future behavior and limits the range of responses to the patient”. ultimatum-cartoon

Ain’t that the truth – the ultimatum restricts the one putting it out there leaving them little choice as to what path to take next.  And using an ultimatum doesn’t exactly invite a collective problem solving approach now does it?

Another point:

“Do not neglect the potential gain in therapeutic alliance that comes from trusting the patient unless the trust is proven to be misplaced.”

I especially admire Schwartz’s sixth point:

“Be wary of institutional pressures to trust conventional wisdom over the patient’s understanding of his own needs”. 

Read the whole article.  Even better – present it to the team to read it together as part of an educational session.  Open it up for discussion. And let me know what you think.

Thanks again for stopping by.

Shalom Coodin


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