The nurse who worked the system
Ms. Y has been hospitalized for suicidality 49 times in 6 years. Until now, her providers have condoned her sense of entitlement. How would you intervene?
After a lengthy discussion among several psychiatrists, therapists, nurses, and attorneys, the treatment team decided to terminate outpatient care for Ms. Y at our facility because of her chronic nonadherence to treatment recommendations. Ms. Y had manipulated numerous providers in our department, called multiple doctors in our facility to ask them to care for her, and asked her ex-husband to contact the department administration on her behalf. Her behavior bordered on harassment. In addition, the interventions we provided were making her worse, not better. Factors that influenced our decision included:
- fear of Ms. Y committing suicide
- fear of setting limits
- fear of being reported to the Medical Board
- fear of a lawsuit.
Table 2
Strategies for helping 4 types of ‘hateful patients’
| Dependent clinger | |
| Behaviors | Shows extreme gratitude with flattery |
| Associated personality traits/disorders | Codependent |
| Management strategies | As early and as tactfully as possible, set firm limits on the patient’s expectations for an intense doctor-patient relationship. Tell the patient that you have limits not only on knowledge and skill but also on time and stamina |
| Entitled demander | |
| Behaviors | Intimidates, devalues, induces guilt, may try to control with threats; terrified of abandonment |
| Associated personality traits/disorders | Narcissistic, borderline personality disorder |
| Management strategies | Try to rechannel your patient’s feelings of entitlement into a partnership that acknowledges his or her entitlement not to unrealistic demands but to good medical care. Help your patient stop directing anger at the healthcare team |
| Manipulative help-rejecter | |
| Behaviors | Resists treatment; may seem happy with treatment failures |
| Associated personality traits/disorders | Psychopathy, paranoia, borderline personality disorder, negativistic, passive/aggressive |
| Management strategies | Diminish your patient’s notion that losing the symptom or illness implies losing the doctor by ‘sharing’ your patient’s pessimism. Tell your patient that treatment may not cure the illness. Schedule regular follow-up visits |
| Self-destructive denier | |
| Behaviors | Denial helps them survive |
| Associated personality traits/disorders | Borderline personality disorder, histrionic, schizoid, schizotypal |
| Management strategies | Recognize that this type of patient can make clinicians wish the patient would die and that the chance of helping a self-destructive denier is minimal. Lower unrealistic expectations of delivering perfect care. Evaluate the patient for a treatable mental illness, such as depression, anxiety, etc. |
| Source: Reference 3 | |
Table 3
Tips for managing high utilizers
Establish a collaborative treatment plan with firm limits and expectations
|
Acknowledge your feelings and countertransference
|
Explore your patient’s expectations and commitment to treatment by asking:
|
Practice safely and proactively
|
OUTCOME: The pattern continues
Ms. Y continues to receive treatment with a different outpatient psychiatrist and therapist in the area. She has not been hospitalized for almost 2 years but her financial state has deteriorated and she has had a recurrence of depression. Ms. Y’s psychiatrist recently called the hospital to ask for direct admission on the patient’s behalf, stating that Ms. Y did not want to wait hours to be seen in the ER. Hospital staff explained that she needs to first come to the ER for evaluation. Ms. Y refused to come to the ER and was not admitted. About 1 month later, Ms. Y’s psychiatrist called again, and she was directly admitted to the psychiatric hospital.
