Dealing With Difficult Dealing With Difficult

PatientsPatients

Dr Marjorie DochertyDr Marjorie Docherty

Clinical Professor.Clinical Professor.

�� Or difficult encounters,Or difficult encounters,

�� Difficult diseases,Difficult diseases,

�� Difficult Dr / px pairing.Difficult Dr / px pairing.

Difficult Doctor.Difficult Doctor.�� Difficult Doctor.Difficult Doctor.

The Patient and The HealerThe Patient and The Healer

�� Wounded patient…Wounded patient…

�� Possible wounded healer….Possible wounded healer….

FOO; Abuse, alcoholism, anger, violence, FOO; Abuse, alcoholism, anger, violence, �� FOO; Abuse, alcoholism, anger, violence, FOO; Abuse, alcoholism, anger, violence, neglect, fear, wars, religious and cultural neglect, fear, wars, religious and cultural issues and confines.issues and confines.

Physician factorsPhysician factors

�� Work load.Work load.

�� Poor communication skills.Poor communication skills.

�� Discomfort with uncertainty.Discomfort with uncertainty.

Inexperience.Inexperience.�� Inexperience.Inexperience.

�� Personality factors / disorders.Personality factors / disorders.

�� Ego issues.Ego issues.

�� Lack of humility.Lack of humility.

Patient FactorsPatient Factors

�� Diagnosis.Diagnosis.

�� Ability to understand.Ability to understand.

�� Fear.Fear.

Emotional plasticity.Emotional plasticity.�� Emotional plasticity.Emotional plasticity.

Patient FactorsPatient Factors

�� Sub clinical behavioral traits.Sub clinical behavioral traits.

�� Personality disorders.Personality disorders.

�� Relatives.Relatives.

Untrue Information.Untrue Information.�� Untrue Information.Untrue Information.

Health Care factors.Health Care factors.

�� Pressure re numbers, financing.Pressure re numbers, financing.

�� Fragmentation of visits and caregivers.Fragmentation of visits and caregivers.

�� Lack of information continuity.Lack of information continuity.

Patient doctor relationship is less certain Patient doctor relationship is less certain �� Patient doctor relationship is less certain Patient doctor relationship is less certain in current dynamics.in current dynamics.

European Task ForceEuropean Task Force

�� Patients expectations of carePatients expectations of care

•• “Humaneness”“Humaneness”

•• CompetenceCompetence

•• AccuracyAccuracy•• AccuracyAccuracy

•• Involvement in decisionsInvolvement in decisions

•• Time for careTime for care

•• Timely access to careTimely access to care

•• Honesty and opennessHonesty and openness

Understanding the patientUnderstanding the patient

�� Their agenda.Their agenda.

�� Hopes, fears , beliefs ,needs.Hopes, fears , beliefs ,needs.

�� Recognizing what else is in the room.Recognizing what else is in the room.

Not missing psychiatric illness. e.g.. Not missing psychiatric illness. e.g.. �� Not missing psychiatric illness. e.g.. Not missing psychiatric illness. e.g.. somatic presentations of mood disorder.somatic presentations of mood disorder.

�� Subtle dementia.Subtle dementia.

�� Substance abuse.Substance abuse.

Difficult EncountersDifficult Encounters

�� Patient.Patient.

�� Physician.Physician.

�� System Factors.System Factors.

The environment.The environment.�� The environment.The environment.

�� Time constraints.Time constraints.

�� Confounders.Confounders.

Stressors to the medical “dream”Stressors to the medical “dream”

�� The chronic incurable.The chronic incurable.

�� The “nothing works.”The “nothing works.”

�� I “have nothing to offer.”I “have nothing to offer.”

Pain that is untreatable.Pain that is untreatable.�� Pain that is untreatable.Pain that is untreatable.

�� Power struggles.Power struggles.

Setting The StageSetting The Stage

�� What does the physician take into the room?What does the physician take into the room?

•• KnowledgeKnowledge

•• SkillsSkills

•• ExperienceExperience•• ExperienceExperience

•• Practicing environmentPracticing environment

•• Personality Personality

•• Psychological difficultiesPsychological difficulties

•• Medical illness in the physicianMedical illness in the physician

•• Psychiatric illness in the physician.Psychiatric illness in the physician.

Dynamics in the RoomDynamics in the Room

�� What does patient ask of youWhat does patient ask of you

�� Is their request / need reasonable?Is their request / need reasonable?

�� Can you meet their needs?Can you meet their needs?

What are your needs and issuesWhat are your needs and issues�� What are your needs and issuesWhat are your needs and issues

�� Dr “here to give what you need not what Dr “here to give what you need not what you want”you want”

�� What transference / counterWhat transference / counter--transference transference issues may existissues may exist

Dealing with difficult interviewsDealing with difficult interviews

�� Heightened self awareness.Heightened self awareness.

�� Be aware of your own reactions.Be aware of your own reactions.

�� Why do I find this patient irritating.Why do I find this patient irritating.

Is this about my past?Is this about my past?�� Is this about my past?Is this about my past?

�� How is the illness affecting the patient.How is the illness affecting the patient.

�� Where do our personalities clash.Where do our personalities clash.

�� Am I biased , stubborn, oppositional?Am I biased , stubborn, oppositional?

Patients Reactions to IllnessPatients Reactions to Illness

�� Initial anger.Initial anger.

�� Shock Shock -- disbelief.disbelief.

�� Passive non feeling.Passive non feeling.

Inappropriate humor as a defense.Inappropriate humor as a defense.�� Inappropriate humor as a defense.Inappropriate humor as a defense.

�� Anxiety.Anxiety.

Reactions to IllnessReactions to Illness

�� Bargaining.Bargaining.

�� Inability to hear, relate or remember.Inability to hear, relate or remember.

�� Grief of loss of the ideal of self; things are Grief of loss of the ideal of self; things are never the same.never the same.never the same.never the same.

�� Loss of the ego ideal of self.Loss of the ego ideal of self.

�� Depression.Depression.

Common Themes of IllnessCommon Themes of Illness

�� Fear of Dysfunction of body.Fear of Dysfunction of body.

�� Erosion of confidence.Erosion of confidence.

�� Sense of loss of control.Sense of loss of control.

Loss of time and money.Loss of time and money.�� Loss of time and money.Loss of time and money.

Common Themes of IllnessCommon Themes of Illness

�� Conflicting multidirectional medical advice.Conflicting multidirectional medical advice.

�� Ambivalence re surrender and intimacy.Ambivalence re surrender and intimacy.

�� Anger.Anger.

Fear of death and dying.Fear of death and dying.�� Fear of death and dying.Fear of death and dying.

Medically ChallengingMedically Challenging

�� Interpersonally difficultInterpersonally difficult

�� Multiple problemsMultiple problems

�� Always time consuming.Always time consuming.

ManipulativeManipulative�� ManipulativeManipulative

Medically ChallengingMedically Challenging

�� Poor compliancePoor compliance

�� Lacking in social supportLacking in social support

�� Chronically medically illChronically medically ill-- no cureno cure

Psychiatrically illPsychiatrically ill�� Psychiatrically illPsychiatrically ill

Overview of Common Personality DisordersPersonality Disorders

Hysterical personalityHysterical personality

�� Exaggerate,charming ,seductive,dramatic.Exaggerate,charming ,seductive,dramatic.

�� Want an intense personal relationship.Want an intense personal relationship.

�� Seek approval.admiration,reassurance.Seek approval.admiration,reassurance.

Management.Management.�� Management.Management.

Exhausting!Exhausting!

•• Boundaries!Boundaries!

•• Summary Summary -- the big picture of the illness.the big picture of the illness.

•• Appropriate reassurance.Appropriate reassurance.

Antisocial PersonalityAntisocial Personality

�� Chronic behavior problem in your office.Chronic behavior problem in your office.

�� Selfish,demanding,no remorse,manipulates.Selfish,demanding,no remorse,manipulates.

�� Little respect,aggression may increase with Little respect,aggression may increase with

illness.illness.illness.illness.

�� Management.Management.

•• Set limits early.Set limits early.

•• Refuse to be manipulated.Refuse to be manipulated.

•• Don’t let them abuse you or staff.Don’t let them abuse you or staff.

•• All care givers unite.All care givers unite.

Narcissistic PersonalityNarcissistic Personality

�� Grandiose,vain,arrogant,patronize.Grandiose,vain,arrogant,patronize.

�� Fragile self esteem,need to be perfect.Fragile self esteem,need to be perfect.

�� Will idealize and devalue care givers.Will idealize and devalue care givers.

�� Illness threatens perfection and autonomy.Illness threatens perfection and autonomy.�� Illness threatens perfection and autonomy.Illness threatens perfection and autonomy.

�� Management.Management.

•• Be very straightforward in communication.Be very straightforward in communication.

•• Summarize clear plan and instructions.Summarize clear plan and instructions.

•• Don’t be drawn into the web!Don’t be drawn into the web!

Borderline PersonalityBorderline Personality

�� Unstable mood,manipulates,splits.Unstable mood,manipulates,splits.

�� Devalues self and others,very needy.Devalues self and others,very needy.

�� Mutilation,suicidal gestures,illness accentuates.Mutilation,suicidal gestures,illness accentuates.

�� Management.Management.�� Management.Management.

•• Set limits,firm kindness.Set limits,firm kindness.

•• Treat mood.Treat mood.

•• Acknowledge their successes and efforts.Acknowledge their successes and efforts.

•• Avoid splitting in care givers.Avoid splitting in care givers.

•• Short visitsShort visits-- DON’T Rescue.DON’T Rescue.

Dependent PersonalityDependent Personality

�� Helpless,passive,poor confidence.Helpless,passive,poor confidence.

�� Fear abandonment,regress when ill.Fear abandonment,regress when ill.

�� Increased demands and complaints.Increased demands and complaints.

Management.Management.�� Management.Management.•• Short visits.Short visits.

•• Reassure that if well wont be abandoned.Reassure that if well wont be abandoned.

•• Communicate with the “Team.”Communicate with the “Team.”

•• Set limit re contact, therapy etc.Set limit re contact, therapy etc.

Compulsive PersonalityCompulsive Personality

�� Emotionally reserved,rigid,perfectionist.Emotionally reserved,rigid,perfectionist.

�� Controlling,orderly,fear loss of control.Controlling,orderly,fear loss of control.

�� IllnessIllness-- loss of controlloss of control--repressed anger and repressed anger and

emotions.emotions.emotions.emotions.

�� Often critical,depression is common.Often critical,depression is common.

�� Management.Management.

•• Careful detailed instructions,allow control.Careful detailed instructions,allow control.

•• If choices exist offer them.If choices exist offer them.

•• Don’t power struggle, participation is key.Don’t power struggle, participation is key.

Passive Aggressive PersonalityPassive Aggressive Personality

�� Overtly cooperative, hidden aggression.Overtly cooperative, hidden aggression.

�� Procrastinate,stubbornness,forgetfulness.Procrastinate,stubbornness,forgetfulness.

�� Can be dependent with poor confidence.Can be dependent with poor confidence.

�� Non compliant in treatment,creates frustration.Non compliant in treatment,creates frustration.�� Non compliant in treatment,creates frustration.Non compliant in treatment,creates frustration.

�� Confront the dysfunctional behavior encourage Confront the dysfunctional behavior encourage

and praise the positive.and praise the positive.

�� “ of the options discussed today what could you “ of the options discussed today what could you

reasonably commit to do before your next reasonably commit to do before your next

appointment.”appointment.”

Paranoid PersonalityParanoid Personality

�� Fearful,guarded,suspicious,oversensitive.Fearful,guarded,suspicious,oversensitive.

�� Expects worst from everyone.Expects worst from everyone.

�� Cant accept criticism.Cant accept criticism.

�� IllnessIllness-- increased fear and anger.increased fear and anger.�� IllnessIllness-- increased fear and anger.increased fear and anger.

�� Management.Management.

•• Acknowledge ,fear ,anger,view point.Acknowledge ,fear ,anger,view point.

•• Be honest open and consistent.Be honest open and consistent.

•• Keep interpersonal distance.Keep interpersonal distance.

•• “I can see that this would be a frightening Dx for “I can see that this would be a frightening Dx for

you”you”

Schizoid PersonalitySchizoid Personality

�� Remote,reclusive,loner, little emotion.Remote,reclusive,loner, little emotion.

�� Illness forces contactIllness forces contact-- feels threatened.feels threatened.

�� Denial and avoidance may be issues.Denial and avoidance may be issues.

�� Management.Management.�� Management.Management.

•• Don’t try to draw out Don’t try to draw out -- respect their privacy needs.respect their privacy needs.

•• Don’t expect and emotional response.Don’t expect and emotional response.

•• Deal with the facts information openly.Deal with the facts information openly.

Defining Common Style DifficultyDefining Common Style Difficulty

What does it do to us as physicians?What does it do to us as physicians?

�� Dependence “clingers” Dependence “clingers” –– evoke aversionevoke aversion

�� Entitled “ demanders” Entitled “ demanders” -- counter attack!counter attack!

Manipulative “help rejecters” Manipulative “help rejecters” –– DepressionDepression�� Manipulative “help rejecters” Manipulative “help rejecters” –– DepressionDepression

�� Self destructive “deniers” Self destructive “deniers” -- Anger / MaliceAnger / Malice

Mindful practice.Mindful practice.

�� Mindfulness in the moment…Mindfulness in the moment…

�� the ability to be both a participant and observer the ability to be both a participant and observer

during clinical interactions to self monitor, to during clinical interactions to self monitor, to

adjust to information…..body language, behavior adjust to information…..body language, behavior adjust to information…..body language, behavior adjust to information…..body language, behavior

and feelings in oneself and others and to and feelings in oneself and others and to

integrate this with ones professional knowledge integrate this with ones professional knowledge

and experience.and experience.

MindfulnessMindfulness

Changes in perception of self and relationship to Changes in perception of self and relationship to

our own emotions.our own emotions.

We don’t have to “be” our emotions.We don’t have to “be” our emotions.

Be with them , empathic curiosity and Be with them , empathic curiosity and Be with them , empathic curiosity and Be with them , empathic curiosity and

understanding.understanding.

Have a sense of staying in the “presence” of “here Have a sense of staying in the “presence” of “here

and now” in your body and its sensations of and now” in your body and its sensations of

emotional perceptionemotional perception..

Finding the Origins of Emotions.Finding the Origins of Emotions.

�Satir’s concepts;What are you feeling and where.What are you feeling and where.

What does it bring to mind; when did you first feel What does it bring to mind; when did you first feel

it.it.it.it.

How does it relate to now.How does it relate to now.

Is it an appropriate response.Is it an appropriate response.

Power of vision and change.Power of vision and change.

MindfulnessMindfulness

“Overwhelmed by anger”“Overwhelmed by anger”

Chest tightness, fast breathing…Chest tightness, fast breathing…

sense…… fear of losssense…… fear of loss

sense…… previous pain of losssense…… previous pain of loss

Aware of SelfAware of Self

Acknowledging self, being with emotions, allows Acknowledging self, being with emotions, allows

other sensations to reach awareness.other sensations to reach awareness.

Instead of repeat catharsis or repression of our Instead of repeat catharsis or repression of our

ghosts the honest exploration allows for real ghosts the honest exploration allows for real ghosts the honest exploration allows for real ghosts the honest exploration allows for real

ability to shift and change.ability to shift and change.

Need to develop a loving kindness of self as a Need to develop a loving kindness of self as a

starting point for change.starting point for change.

Perception and Reality!Perception and Reality!

� People perceive the same situation differently.

� “Hard wiring” – “ buttons”

� Are you being “your child” or an adult in the

situation.situation.

� Has your relationship developed such that you

are always the parent or the child.

� Life experiences.

Childs perception

Adult reaction

Childs reaction

Childs perception

situationsituation

Adult reaction

Doctors agenda

Patients needs

Consider an emotional differential diagnosis.

Difficult encounters.Difficult encounters.

�� Appropriate apologies.Appropriate apologies.

�� Rambling patient, Rambling patient, -- kind redirection.kind redirection.

�� Anger, Anger, -- identify the issue.identify the issue.

�� Female patients may have more anger Female patients may have more anger �� Female patients may have more anger Female patients may have more anger

expression difficulty.expression difficulty.

Difficult encounters.Difficult encounters.

�� Rude or aggressive ,Rude or aggressive ,-- stay calm,keep safe.stay calm,keep safe.

�� Non compliant engage them as a team Non compliant engage them as a team decision maker.decision maker.

�� Help identify their goals.Help identify their goals.�� Help identify their goals.Help identify their goals.

�� Consider “Time out”.Consider “Time out”.

�� If you and/or the patient are “hateful” seek If you and/or the patient are “hateful” seek help.help.

The Unlikable PatientThe Unlikable Patient

�� Try to find some aspect of the patient you can Try to find some aspect of the patient you can

respect or relate to.respect or relate to.

�� Remember that they are sick and you only have Remember that they are sick and you only have

to episodically treat them and you don’t have to to episodically treat them and you don’t have to to episodically treat them and you don’t have to to episodically treat them and you don’t have to

walk in their shoes or live their life.walk in their shoes or live their life.

�� If your own counter transference is interfering If your own counter transference is interfering

with care you may have to seek help in with care you may have to seek help in

management.management.

Psychotherapeutic Approach to Psychotherapeutic Approach to

IllnessIllness

� Establish a therapeutic alliance.

� Foster a sense of patient control.

� Provide meaning and understanding.

� Give hope where appropriate.� Give hope where appropriate.

� Kindness,understanding and compassion are

powerful therapeutic tools.

� Be self aware.

Goals and Limits of CareGoals and Limits of Care

�� To cure seldomTo cure seldom

�� To alleviate oftenTo alleviate often�� To alleviate oftenTo alleviate often

�� To comfort alwaysTo comfort always