Transcend dread: 8 ways to transform your care of ‘difficult’ patients

7. Use ‘plussing.’ Because we experience dread with difficult patients, clinicians often avoid, refrain from, or simply don’t see opportunities to use positive comments and acknowledgements (“plussing”) when they arise. Most patients (as well as clinicians) want to be liked, and small compliments—when genuinely and appropriately placed—sometimes can make a huge difference in patients’ willingness to cope or try new things.

8. Use imagery. Visualize your patient as the central character in an unfinished novel about his or her life. You are in the book as well. Imagine that you are somewhere in the middle of reading this novel. As the once-removed passive reader, you can enjoy the rich, complex nature of the characters and their interactions without feeling overwhelmed by responsibility. You are much better able to accept that your patient is just 1 character, influenced by a myriad of factors other than you. As a character yourself, you are keenly aware of your strengths and weaknesses.

This technique might allow you to see the humorous side of yourself as the hardworking, well-intentioned yet ineffectual psychiatrist. You don’t know how the story will unfold, but you can accept this as you would in any other unfinished novel.

CASE CONTINUED: A more effective approach

Dr. B realizes Ms. D is a difficult patient for him and takes the case into supervision. He is stunned when he is unable to answer several of his supervisor’s questions about Ms. D, including “What was her upbringing like?” and “What are her strengths or interests?” He realizes he knows little about Ms. D and becomes aware that he has focused most of their sessions on either fixing her immediate and never-ending crises or defending himself.

The supervisor points out that Dr. B’s lack of empathy for Ms. D keeps him from helping her—being anxious and defensive makes him less likely to be supportive or creative. Dr. B feels better after the supervision session. He experiences some catharsis and develops a plan to improve the situation.

Dr. B structures the next session to get to know Ms. D better. He mentally decompresses the treatment timeline and refocuses on the need to develop empathy instead of attempting to ameliorate symptoms. Dr. B begins by letting Ms. D know he wants to help her but doesn’t know much about her. She initially rejects his attempts at empathic communication, but with gentle persistence he learns about her upbringing and interests. Dr. B is able to genuinely compliment her on coping with previous traumas and begins to better understand her strengths. Over the next several weeks, Ms. D seems more able to accept supportive interventions and eventually begins a part-time job.

Related resources

• Colson DB. Difficult patients in extended psychiatric hospitalization: a research perspective on the patient, staff, and team. Psychiatry. 1990;53(4):369-382.
  
• Koekkoek B, van Meijel B, Hutschemaekers G. “Difficult patients” in mental health care: a review. Psychiatr Serv. 2006;57:795-802.
  

Disclosure

Dr. Battaglia reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.