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'Difficult' patients: how to improve rapport.

As psychiatrists, we all come across patients who press our buttons and engender negative feelings, such as anger, frustration, and inadequacy. (1) These patients have been referred to as "hateful" or "difficult" because they disrupt the treatment alliance. (1,2) We are quick to point our fingers at such patients for making our jobs harder, being noncompliant, resisting the therapeutic alliance, and in general, being "problem patients." (3) However, the physician-patient relationship is a 2-way street. Although our patients knowingly or unknowingly play a role in this dynamic, we could be overlooking our role in adversely affecting this relationship. The following factors influence the physician-patient bond. (1-2)

Countertransference. We may have negative feelings toward a patient based on our personalities and/or if the patient reminds us of someone we may not like, which could lead us to overprescribe or under-prescribe medications, conduct unnecessary medical workups, distance ourselves from the patient, etc. Accepting our disdain for certain patients and understanding why we have these emotions will allow us to better understand them, ensure that we are not impeding the delivery of appropriate clinical care, and improve rapport.

Listening. It may seem obvious that not listening to our patients negatively impacts rapport. However, in today's technological world, we may not be really listening to our patients even when we think we are. Answering a text message or reading the patient's electronic medical record while they are talking to us may increase productivity, but doing so also can interfere with our ability to form a therapeutic alliance. Although we may hear what our patients are saying, such distractions can create a hurdle in listening to what they are telling us.

Empathy often is confused for sympathy. Sympathy entails expressing concern and compassion for one's distress, whereas empathy includes recognizing and sharing the patient's emotions. Identifying with and understanding our patients' situations, drives, and feelings allows us to understand what they are experiencing, see why they are reacting in a negative manner, and protect them from unnecessary emotional distress. Empathy can lead us to know what needs to be said and what should be said. It also can demystify a patient's suffering. Not providing empathy or substituting sympathy can disrupt the therapeutic alliance.

Projective identification. Patients can project intolerable and negative feelings onto us and coerce us into identifying with what has been projected, allowing them to indirectly take control of our emotions. Our subsequent reactions can unsettle the physician-patient relationship. We need to be attuned to this process and recognize what the patient is provoking within us. Once we understand the process, we can realize that this is how they deal with others under similarly stressful conditions, and then react in a more supportive and healthy manner, rather than reviling our patients and negatively impacting the therapeutic relationship.


(1.) Strous RD, Ulman AM, Kotler M. The hateful patient revisited: relevance for 21st century medicine. Eur J Intern Med. 2006;17(6):387-393.

(2.) Groves JE. Taking care of the hateful patient. N Engl J Med. 1978;298(16):883-887.

(3.) Boland R. The 'problem patient': modest advice for frustrated clinicians. RI Med J (2013). 2014;97(6):29-32.

Kaustubh G. Joshi, MD

Dr. Joshi is Associate Professor of Clinical Psychiatry and Associate Director, Forensic Psychiatry Fellowship, Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine, Columbia, South Carolina.


The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
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Title Annotation:Pearls
Author:Joshi, Kaustubh G.
Publication:Current Psychiatry
Geographic Code:1USA
Date:Aug 1, 2017
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