MANAGING THE DIFFICULT SPOUSE
MANAGING THE DIFFICULT CHILD
MANAGING THE DIFFICULT BOSS
MANAGING THE DIFFICULT PHYSICAL THERAPIST
MANAGING THE DIFFICULT (FILL IN THE BLANK)
Stan Bennett MS, OTR/L
CDR USPHS
Therapist Category Day
USPHS Scientific and Training Symposium
June 12, 2014
MANAGING THE DIFFICULT PATIENT
OBJECTIVES
1. Distinguish between a “psychotic” disorder and a “personality” disorder.
2. Identify unique characteristics of personality disorders
3. Describe the faulty problem-solving process identified with personality disorders
4. List 5 proactive techniques to utilize with managing difficult behaviors in your practice setting
MANAGING THE DIFFICULT PATIENT
Between 10 and 60% perceived as being “difficult” (Wasan et al, 2005)
Perceived “difficult” patients often evoke feelings of:
Anger / frustration / emotionally drained / incompetency / confusion / upset / anxiety / guilt / manipulation / decreased productivity /
retaliation / fear
Healthcare provider characteristics / perceptions / attitudes also contribute to difficult patient encounters. Jackson and Kroenke (1999) noted that healthcare providers with decreased empathy and poor attitudes towards patient psychosocial issues perceived more patient-encounters as difficult.
MANAGING THE DIFFICULT PATIENT
Jackson and Kroenke (1999) also noted difficult patients tended to have and/or elicit greater depression/anxiety disorder, poor functional status, unmet expectations, reduced satisfaction and a greater utilization of health care services.
Hahn (2001) reported that difficult patients tend to have psychosomatic symptoms, abrasive personality styles and meet the diagnostic criteria for personality disorder.
PERSONALITY DISORDER
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment
(Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, 2013)
“SOCIAL SCREENING” FOR PERSONALITY DISORDER
By other Professionals’ Reactions:
Referrals preceded by an apology
By Your Internal Experience:
When relating to them you feel as though you are the “crazy one”
By your Emotional Response:
Consistent feelings of annoyance or irritation
By “Everyday-Language” Diagnosis:
jerk / idiot / weirdo / creep / &%@$#
However, is there any legitimacy to defining patients by your responses?
“SOCIAL SCREENING” FOR PERSONALITY DISORDER
Colli et al (2014) found a “significant and consistent relationship between therapist reactions and specific personality disorders”.
Cluster B personality disorders evoked more negative and decreased emotional control from their treating therapists as compared to clusters A and C personality disorders.
If you and no one else has a problem with a patient then you probably have a personality conflict
However, if you and other healthcare providers share the same negative emotional responses about a specific client then that person likely has a very strong personality trait or undiagnosed personality disorder.
CHARACTERISTICS OF PERSONALITY DISORDER
Only one pervasive “way to be”
Only one tool in their behavioral toolbox
Unable to observe their behavior
“Sense of Agency” / “Observational Ego”
Drama pattern instead of problem-solving pattern
(identity validation motive rather than problem solving motive)
WHAT CAUSES PERSONALITY DISORDER
Psychoanalytic Theory (Freud) – Disruptions in the relationship of a young child to significant others resulting in the creation of distorted experiences and dysfunctional behaviors. Current data does not support this theory
Genetic Theory – Hereditary transmission of neurological abnormalities. Identical twins do not have 100% concordance rates (average: 58%). No reliable genetic markers have yet to be found
Biopsychosocial Theory (Current prevailing theory) - Temperament factors (heredity/neurology) and character factors (psychological, environmental/experiential) combine to create a pattern of distorted experiences and dysfunctional behavior.
DSM-V PERSONALITY DISORDER DIAGNOSESCluster A – “Mature” Type (odd, eccentric)
Paranoid
Schizoid
Schizotypal
Cluster B – “Immature” Type (dramatic, emotional, erratic)
Antisocial
Borderline
Histrionic
Narcissistic
Cluster C – “Anxious” Type (anxious, fearful)
Avoidant
Dependent
Obsessive-Compulsive
Disorder of feelings/behavior
Exhibit traits
(Parkinson’s Disease)
Frequently does not respond to medication / behavioral therapy
Disorder of thought/perception
Exhibit symptoms
(ex: cold / flu)
Frequently responds to medication
PSYCHOTIC DISORDERS / PERSONALITY DISORDERS
Psychotic Disorders Personality Disorders
Difficulties in life lead to survival-based pattern of validating their position called “identity”
Identity-validation process:
Problem is defined “personally”
Reactions/behaviors justified
Original problem is amplified
More problems are created
The goal is to validate their position by
creating DRAMA.
Difficulties in life lead to survival-based pattern of problem solving
Problem-solving process:
Problem defined operationally
Possible actions are considered
Actions are selected
Outcomes are evaluated
The goal is to produce solutions
PROBLEM-SOLVING PROCESS NORMAL VS DISORDERED PERSONALITY
Normal Personality Abnormal Personality
MANAGING THE DIFFICULT PATIENT
Your goal is to avoid the DRAMA!
RescuerI’m helping / I’m special
PersecutorI’m correcting / I’m right
(powerful)
VictimI’m wounded / I’m blameless
PRIMARY CHARACTERISTICS OF DRAMA
Overt purpose is to make their behavior seem justifiable and reasonable
Covert purpose is to validate their identity rather than produce a workable outcome
Involves unexpected switch in identity
Creates stimulation (confused/upset) in service of validating their identity
Produces new problems, intensifies problems or leaves problems unaddressed
Survival-based and resistive to both exposure and intervention.
Designed to propagate itself (survive) and to get others to participate
PROACTIVE TECHNIQUES TO MANAGE DIFFICULT PATIENT BEHAVIORSBe Active and Responsive:
Stay out of their DRAMA: They will try to make you feel bad for not participating in their problems
Anticipate the “Drama Switch”
Maintain Empathetic Neutrality
Refuse to take assigned position in the drama
Refuse to take things personally
Maintain a Position of Freedom and Power
“NEED” less than the individual
Have lower intensity of personal drama
Stick to the issue and not the person/personality
PROACTIVE TECHNIQUES TO MANAGE DIFFICULT PATIENT BEHAVIORS
Have Consultation Team Available:
Talk to your colleagues or supervisor. They will convince you that you are not crazy
Be Comfortable Using Silence; Go Slowly
Have the Willingness to Disavow Responsibility for Success or Failure:
Be willing to succeed or fail WITH POWER!
Have an ability to make mistakes
Be comfortable with Reality-Based Confrontations
Be comfortable with Saying NO
Be willing to Break the “rules” of the Drama; to be defined as “wrong”
REFERENCESAmerican Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
Colli, A., Tanzili, A., Dimaggio, G. & Lingiardi, V. (2014). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry, 171, 102-108.
Hahn, S. R. (2001). Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Annals of Internal Medicine, 134, 897-904.
Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody, D., Williams, J. B., Linzer, M., & deGruy, F. V. (1996). The difficult patient: Prevalence, psychopathology, and functional impairment. Journal of General Internal Medicine, 11, 1-8.
Jackson, J. L., & Kroenke, K. (1999). Difficult patient encounters in the ambulatory clinic. Archives of Internal Medicine, 159, 1069-1075.
Lester, G. (2003). Personality disorders in social work and health care (3rd ed.). Cross Country Education
Wasan, A. D., Wootton, J., & Jamison, R. N. (2005). Dealing with difficult patients in your pain practice. Regional Anesthesia and Pain Medicine, 30, 184-192.