title: Moving Perspectives on Patient Competence: A Naturalistic Case Study in Psychiatry.
abstract: Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder (OCD), and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient's autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient's and the therapist's perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist's approach, who used motivational interventions with a view to appealing to the patient's responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions.
authors.affiliation: Department of Psychiatry, VU University Medical Center and GGZ inGeest, Amsterdam, The Netherlands. a.ruissen@vumc.nl.|Department of Medical Humanities, VU University Medical Center, Vd Boechorststraat 7, 1081 BL, Amsterdam, The Netherlands. a.ruissen@vumc.nl.|EMGO+ Institute, VU Medical Center, Amsterdam, The Netherlands. a.ruissen@vumc.nl.
authors.forename: A M
authors.initials: AM
authors.lastname: Ruissen
authors.affiliation: Department of Medical Humanities, VU University Medical Center, Vd Boechorststraat 7, 1081 BL, Amsterdam, The Netherlands.|EMGO+ Institute, VU Medical Center, Amsterdam, The Netherlands.
authors.forename: T A
authors.initials: TA
authors.lastname: Abma
authors.affiliation: Department of Psychiatry, VU University Medical Center and GGZ inGeest, Amsterdam, The Netherlands.|EMGO+ Institute, VU Medical Center, Amsterdam, The Netherlands.
authors.forename: A J L M
authors.initials: AJ
authors.lastname: Van Balkom
authors.affiliation: Department of Psychiatry, VU University Medical Center and GGZ inGeest, Amsterdam, The Netherlands.|Tilburg Law School, Tilburg University, Tilburg, The Netherlands.
authors.forename: G
authors.initials: G
authors.lastname: Meynen
authors.affiliation: Department of Medical Humanities, VU University Medical Center, Vd Boechorststraat 7, 1081 BL, Amsterdam, The Netherlands.|EMGO+ Institute, VU Medical Center, Amsterdam, The Netherlands.
authors.forename: G A M
authors.initials: GA
authors.lastname: Widdershoven
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D036262:Empirical Research; D005260:Female; D006801:Humans; D016743:Mental Competency / Q000523:psychology*; D009771:Obsessive-Compulsive Disorder / Q000523:psychology* / Q000534:rehabilitation; D010361:Patients / Q000523:psychology*; D011369:Professional-Patient Relations; D011570:Psychiatry; D012720:Severity of Illness Index
keywords: Autonomy; Competence; Decisional capacity; Informed consent; Narrative approach; Naturalistic case study; Obsessive compulsive disorder