CASE ILLUSTRATION 4
Mrs. M. is a 58-year-old woman being followed for obesity and poorly controlled high blood pressure. Her doctor is frustrated because his continued attempts to get Mrs. M. to lose weight have been unsuccessful. As a result, he is pessimistic about their ability to work together to treat her hypertension, which he feels is a clear risk to her health. When the doctor notes that Mrs. M.’s blood pressure is still elevated, he asks whether she is still taking her medication.
She responds, “Oh, I’m sorry, doctor; I ran out of my medicine 3 days ago and didn’t want to bother you for a refill.” Later in the visit the doctor asks, “Did you join that exercise program you said you would last time?” Mrs. M. replies, “I’ve been so busy. I’ll do it next week.” The doctor pulls back in his chair, thinking to himself, “This will never go anywhere.”
He leans forward and says, “Mrs. M., your actions tell me I’m pushing you to do something you don’t want to do. I’m concerned about your weight; what are your thoughts on this?” Mrs. M.’s eyes moisten and she responds, “I want to lose weight, but I can’t do it. I’ve tried for years, and it’s so frustrating.” The practitioner nods and says, “Let’s hold off on the weight control for now. How about taking one thing at a time and focusing on your blood pressure?”
When problems are being discussed, this type of patient’s non-verbal behavior is usually engaged and active: leaning forward, bright affect, and dynamic gestures. As recommendations for evaluation and treatment are made, however, the patient typically becomes withdrawn, eye contact diminishes, and language becomes significantly less animated. Verbally, during the discussion of evaluation and treatment, the patient becomes quiet, volunteers little, and characteristically offers no solutions to problems. In fact, as the practitioner makes recommendations, the patient often responds with the classic, “I’d like to do that but … .”
Frequently, this behavior indicates a passive–aggressive personality (see Chapter 29). The practitioner initially feels encouraged to offer the patient suggestions, who then invariably rejects the offer or agrees to the plan but does not carry it out.
However, there are other possibilities that are often not explored. Probably most important is that the practitioner’s plan has not taken the patient’s perspective into account and is, therefore, unrealistic or economically or logistically impossible. Another consideration is that the patient comes from a highly controlling family and is attempting to follow the recommendations but for psychosocial reasons is unable to.
Finally, the patient’s previous experiences with practitioners may have been so hierarchical and paternalistic that the thought of disagreeing or negotiating a position does not come to mind, even when the suggested approach is not acceptable.
Passive–aggressive behavior may emerge when patients do not feel capable of asserting themselves directly. They may position themselves so that others feel they want to, or must, save them. The practitioner’s attempt to solve the problem is invariably followed by the patient’s frustrating failure to collaborate. The patient successfully transfers responsibly for his or her problem to the practitioner and then rejects each solution offered. Continued failure results in repeated visits, offering the patient continuing attention while increasing the practitioner’s frustration.
Some patients who are unable to fully collaborate may have been emotionally, verbally, or physically abused or may have had family or other personal experiences that taught unquestioning submission to authority.
Most people who enter the healing professions have a desire to be helpful. Passive–aggressive patients’ solicitations for practitioners to save them can be seductive, luring practitioners into believing that these patients will singularly benefit from their expertise. The extent to which practitioners use a patient’s recovery to validate their competence or professional value may determine how frustrated and angry they will become when treatment is unsuccessful. Rather than focusing initially on outcomes, the practitioner is better served answering the questions “Am I encouraging patients to take a more active role in their care?” and “Am I giving patients the chance to say why they’re not using the treatments I thought we agreed on?”
It is important to clearly communicate that to get better the patient must take responsibility for his or her own health. To help differentiate patients who are dependent from those who cannot participate because of a definable medical or personality disorder, the practitioner can say, “I’m frustrated with how things are going. Let’s start again and see if what I see as a problem is really a problem for you.”
The next step is to ask what he or she thinks would be helpful in solving the problem. One can ask, “Do you really think you can do this?” If the question is asked in a supportive fashion, most patients who initially agreed to fulfill an unrealistic plan (perhaps to please the practitioner), respond more honestly, acknowledging that they are unable to do so. Again, if asked respectfully, patients will share their reasons. Once this is done, the practitioner can encourage collaboration by saying, “Let’s explore what we can do to solve this problem together. As we discuss options, it will really help if you tell me what’s possible for you and what’s not.”
If the patient displays passive–aggressive behavior, the practitioner can seek agreement on the nature of the problem and then make very specific contracts for what the patient will do. They can be as direct as, “So, until our next visit, you will remain abstinent from alcohol,” or “Between now and our next visit, you’ll keep a diary and record when, and under what conditions, your headaches occur.” The practitioner’s support and enthusiasm can be directly tied to the degree to which both parties carry out the contract. In this way, the practitioner can promote patient autonomy and offer support, without taking full responsibility for the patient’s behavior.
Over time, patients learn to respond to the support offered and begin to take a more active role in their care. Of course, there is always the risk that a passive–aggressive individual attempting to control the relationship will choose to seek another practitioner who can be more easily manipulated.
Patients who are unfamiliar with a collaborative model can be given specific information about the practitioner’s understanding and particular style of collaborating. Explicit requests for patients’ opinions about collaboration can be extremely useful. Over time, given the opportunity to state opinions and formulate plans, most people find such an approach satisfying, engaging, and motivating. Indeed, there is convincing evidence that patients taught to be more assertive improve their health outcomes, such as lowering blood pressure and controlling diabetes.
Educating patients who exhibit passive–aggressive behavior about such behavior can begin a process of introspection and self-awareness. Encouraging patients to explore the origins of these behaviors and consider a therapeutic relationship that facilitates the process can be rewarding for both patient and practitioner. Descriptions of behavior that hit home can provoke emotional responses in patients, but penetrating long-held psychological defenses can spur growth. The practitioner might say, for example, “You say your mother was overbearing and controlling and withheld praise. Isn’t that what your children are telling you?” In most instances, the benefits outweigh the risks.
CASE ILLUSTRATION 4 (CONTD.)
Mrs. M. agrees to take her medication and to return for a blood pressure check in 2 weeks. The practitioner gives her a card so that she can record her own blood pressure when she checks it at the drug store or the mall.
Setting limits and providing explicit feedback can teach patients to collaborate more effectively. Being aware of “yes, but” patterns can help promote a strategy of shared responsibility and prevent the ultimately unhelpful rescuing behaviors that interfere with successful treatment.
Appreciative Inquiry and Difficult Patients
Appreciative inquiry can be applied to our work with difficult patients. It allows us to shift the focus away from the sense of frustration that often accompanies these interactions to recognize and appreciate our successes. One technique is to write a brief narrative of a patient with whom you had initially a difficult interaction, but with whom your relationship became positive over time. As you reflect on the case, keep in mind the following questions to identify the factor or factors that helped transform that initially difficult relationship into one where you felt successful.
What did you say or do that contributed to moving beyond the difficulty?
What did the patient contribute to changing your relationship in a positive direction?
What was it about the environment or circumstances of your encounter that improved the situation or your relationship?
What changes did you make in your internal appraisal or perception of this patient that made a difference?
What will you do differently the next time?