Transcend dread: 8 ways to transform your care of ‘difficult’ patients
An empathic, relaxed approach can ease frustration and improve the therapeutic alliance
Survival strategies for clinicians
Eight strategies can help improve your care of difficult patients ( Table 2 ).
Table 2
8 strategies for managing difficult patients
| 1. Acknowledge that the patient is difficult |
| 2. Develop empathy |
| 3. Seek out supervision/consultation |
| 4. Utilize a team approach |
| 5. Lower treatment goals |
| 6. Decompress the treatment timeline |
| 7. Use ‘plussing’ (positive comments and acknowledgements) |
| 8. Use imagery (visualize the patient as a character in an unfinished novel) |
2. Develop empathy. Empathy is identification with and understanding of why a person feels, thinks, and acts as he or she does. The best way to develop empathy for a difficult patient is to learn about him or her firsthand—directly from the patient, not from reading chart notes or from information passed among colleagues.
Learning about the patient firsthand means shifting from sign-and-symptom gathering to performing a genuine inquiry about how the person thinks or feels, including interests, loves, or background. Challenging clinical circumstances—such as seeing a patient in a busy emergency department or during a 15-minute medication check—can make this difficult. In some cases, however, the time needed to establish empathy can be surprisingly brief.
The more patients feel that the psychiatrist is “on their level,” the less likely they are to project internalized anguish or impulsively act on conflicted feelings.
3. Seek out supervision or consultation. You can gain new perspectives by taking a “step back” and looking at the case with a colleague. Seeking out consultation also allows you to decompress by “getting it off your chest.” Supervision often allows clinicians to develop:
- empathy toward a difficult patient
- increased energy and creativity in subsequent sessions.
If you cannot utilize a team to carry out treatment, this approach still may help you develop a treatment plan.
5. Lower treatment goals. The nature of difficult patients makes complete “cures” a rarity. A psychiatrist whose goal is to substantially help a patient may become chronically frustrated and feel inadequate in the face of a patient’s perpetual suffering. The clinician sometimes reacts by developing therapeutic nihilism and withdrawing energy from the case. The patient, of course, senses this and increases his or her general distress level, which intensifies the negative interaction.
By lowering goals—for example, aiming for stabilization rather than improvement—you can feel less like a failure and be more relaxed. A relaxed clinician is more tolerant and in a better position to help the patient. Other lowered goals might be to reduce harm from impulsive or dangerous behaviors instead of eliminating them or better coping with symptoms rather than symptom remission.
