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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Discussions with so-called "difficult patients"
Discussions with so-called "difficult patients"
"All patients are similar and should be handled similarly." This ideal is not borne out in reality, as in fact only a limited amount of affective neutrality is feasible. Various studies (Gotthardt, Morgan, Peterson, Ritvo) showed that doctors and nurses certainly differentiated between "nice" and "unpleasant", or "liked" and "disliked" patients.

The so-called "difficult" patient is, as it were, at the extreme of the range of "unpleasant" and "disliked". He is the opposite of the "ideal patient". An ideal patient (according to Rohde, quoted by Gotthardt) is one who most suits the personal work-related requirements of the staff. He recognizes their authority and agrees without resistance to all therapy and procedures. He has no disturbing individual peculiarities and requirements, shows trust and is grateful, replies honestly, openly and comprehensively when he is asked questions, but otherwise says nothing if he is not asked, and is quite satisfied with the amount of communication which is allotted to him.

On the other hand, the "difficult patient" asks for too much, he does not fit in, he refuses investigations and suggestions for treatment, shows suspicious behaviour, does not react in the way that is expected or usual, is critical of the doctors, nursing staff, hospitals and practices, appears untrusting and inconsiderate, aggressive and ungrateful. Further characteristics are that it is difficult to motivate him, resulting in poor compliance, anxiety and hypochondria, apathy, indolence, "clinging behaviour", and a tendency to demand too much attention from the team. In a word: the difficult patient creates opposition, inhibits the working atmosphere, costs a lot of time and frustrates doctors and nursing staff.

Are there predisposing characteristics for difficult patients? Sex, age and disease have no significant importance in the development of "difficult" patients according to the studies of Gotthardt. It could be that prolonged hospitalization or illness (over 3 months) is a predisposing factor. One interesting fact is that there is an increased tendency to shun patients of the same sex rather than the opposite sex, as shown in studies of medical teams by Morgan and Cheadle.

One of the preconditions for dealing successfully with difficult patients is an initial analysis of the possible reasons for the behaviour. The question should be raised at the start of the review of the situation as to whether it is only I who consider that the patient is unpleasant, difficult or problematic, and is his behaviour, from his point of view, quite legitimate and understandable? This is particularly difficult when a decision has already been taken that the patient is difficult, and he is referred to with a remark to this effect.

What reasons are there for a patient appearing difficult and problematic?

The cozy interpretation is that this is an expression of a primary psychopathological personality structure. However this explanation probably really only applies to a few of the so-called difficult patients. An objective criterion for decision can be obtained by taking a social history, which will give clues as to whether the personality is one which does not only create problems when the patient is ill, or whether this also occurs in others areas of his life.

Further reasons can be a high, but quite well-founded need for information or a inbuilt critical approach to problems. The patient may have grown into the role of a difficult patient as a result of experiences in which he received poor or disappointing treatment. Influences which are specific to the illness play a role, especially in chronic disease or prolonged difficult situations (intensive wards). In addition, the status of a difficult patient can arise as a mask for other disorders and illnesses, such as depressive mood disorders or drug and alcohol-dependence. Of course egoistic elements and an excessively demanding attitude can really be at the basis of difficult behaviour.

Nevertheless it is important to be clear that a patient who comes with inappropriate expectations is often perceived as difficult by the treatment team.
In other words, the phenomenon of a "difficult patient" should be regarded as a symptom and not as a disturbance of daily clinical life, if one intends to deal satisfactorily with these patients by discussion and other means.

Groves (1978) divided "difficult" patients into four groups:
dependent clingers
entitled demanders
manipulative help rejectors
self-destructive deniers

The dependent clingers make themselves known by an apparently inexhaustible hunger to be noticed, which can lead to the most extreme pleading for one's presence and care. The "long-winded" also are included in this group. There is often a dread of neglection or separation based on life-long experience. It does not help these patients to be told what the limits are for medical care, as this can lead to a sort of vicious circle with increasing anxiety. Meerwein recommends that these patients are offered a framework to their treatment, which is tailored to their requirements, which they understand and accept, and keep to. Coping with the patient in this reassuring manner, always involving him and letting him know what is expected in the future, can often suffice to rescue him from the unhealthy circle of his dependent clinging and the resulting defensive reaction of the treatment team. The entitled demanders are the sort of patients who insist that they are not receiving the best treatment, neither what is best for them nor what they are worthy to receive. They very often use pressurizing tactics such as defamation, threats of lawyers or refusal to pay, any of which understandably can lead to opposition on the part of the doctor. Anxieties are also usually present, in the sense of dread of worthlessness. The objective of managing these patients is to take as many steps as possible to raise their feeling of self-worth, and to impress upon them the particular quality of the diagnostic measures and therapy which will be arranged for them.

The manipulative help rejecters are those patients who are always presenting with fresh symptoms, and as soon as one is treated, another arises, leading to an unbreakable chain of treatments, operations, and contact with doctors. This behaviour should not be simply dismissed as "hypochondria", as it arises from dread of losing the doctor, to whom the patient is very deeply attached and on whom he depends. There is often a history of disturbance of the psychological development due to frequent changes of personal attachments. This anxiety "of the fragility and changing nature of personal relationships" must be taken into account, and a frequent change of doctor avoided.

The self-destructive deniers have usually given up all hope of fulfilling their desires, and believe that self-destruction is the only way of self-actualization. These are often people who suffered repeated mistreatment as children. They project their destructive desires onto the doctor, releasing aggressive reactions and make treatment exceedingly difficult. In many cases, only psychiatric treatment has a chance of success.

What can doctors and treatment teams do, so that difficult patients do not have to remain difficult?

The following ways are available:
1. The basic principle of discussion and management is value-free acceptance of the so-called difficult patient. This also means that a new patient who is referred to as "difficult", should not be automatically categorized as likely to raise problems. An unheard groan is a poor way to commence discussions with these patients.
2. There has to be some attempt to analyze the reasons why the patient is (apparently) behaving in a difficult or problematic way or drawing attention to himself. This can lie in the patient himself, in his illness, in the situation or in the medical team. One of the most common causes is anxiety.
3. It is especially important to be obliging and polite. If not, the tone of the discussion is likely to become heated very quickly.
4. It is important to make the patient clearly aware of empathy, and to let him know that he is accepted without prejudice. As these patients are usually "experienced patients", they become aware of the attitude that they are faced with immediately.
5. It can be particularly helpful to check with these patients whether in fact differing realities are creating the difficulties.

Dealing with the "difficult patient" 
1) Basic premise: 
The "difficulties" of a patient is not fate but a symptom.
2) Analysis of causes: 
1. Anxiety (separation, loss, desertion, worthlessness)?
2. Due to illness (chronic disease, extreme situations)?
3. Inappropriate expectation on the part of the team?
4. Incorrectly "labeled" as difficult?
5. A generally critical approach?
6. High need for information?
7. Negative experiences?
8. Pathological personality disorder?
9. Egoistic attitude?
3) Strategy 
1. Acceptance without prejudice
2. Unbiased look at requirements and criticisms
3. Clearly show empathy
4. Demolition of anxieties
5. Particularly welcoming tone
6. Relaxation techniques (metacommunication)
7. Check whether different realities are contributing
6. Discussions with difficult patients are usually characterized by a tense atmosphere. Therefore the introduction of relaxation techniques can lead to a loosening of the discussion and make the patient more approachable, a precondition of which is that the person leading the discussion is himself aware of the tension and attempts to reduce it. Occasionally it is possible to remove tension by mentioning the problem openly with metacommunication.

If the "difficulties" of a patient is perceived as a symptom that has various and possibly removable causes, it is possible to prevent what otherwise is taken for granted: that the difficult patient will always be difficult. 

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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