Managing the difficult child Managing the difficult boss Managing the difficult Physical Therapist Managing the difficult fill in the blank Stan Bennett MS OTRL CDR USPHS Therapist Category Day ID: 683804
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Slide1Slide2
Managing the difficult spouseSlide3
Managing the difficult
childSlide4
Managing the difficult
bossSlide5
Managing the difficult
Physical TherapistSlide6
Managing the difficult
(fill in the blank)Slide7
Stan Bennett MS, OTR/L
CDR USPHS
Therapist Category Day
USPHS Scientific and Training Symposium
June 12, 2014
Managing the difficult
patientSlide8
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
settingSlide9
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.Slide10
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
.
Slide11
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)Slide12
“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?Slide13
“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. Slide14
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)Slide15
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. Slide16
DSM-V Personality Disorder Diagnoses
Cluster 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-CompulsiveSlide17
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 DisordersSlide18
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 PersonalitySlide19
Managing the difficult patient
Your goal is to avoid the
DRAMA!
Rescuer
I’m helping / I’m special
Persecutor
I’m correcting / I’m right (powerful)
Victim
I’m wounded / I’m blamelessSlide20
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 participateSlide21
Proactive techniques to manage difficult patient behaviors
Be 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/personalitySlide22
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”Slide23
References
American 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
d
isorders
in
social
w
ork
and
health
c
are
(
3
rd
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.