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.