Dealing With Difficult Patients

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Experienced psychiatrists tend to take pride in having good communication skills, such as careful listening and patient-centered communication. That is one reason that dealing with difficult patients, who seem to thwart these skills, is so frustrating. Researchers suggest that 3 sources of difficulty may be present: the patient’s issues, the relationship between the clinician and the patient, and the systemic or social context of the encounter.^1,2

As for the patient’s issues, unfortunately, one thing that makes difficult patients difficult is that they seem to interact in a way that makes it hard to empathize with them. As for relationship issues, they often involve a perception by the patient that the clinician is not understanding them in an empathic fashion or is not communicating this empathy. In other words, improved empathic communication may be the key to success in encounters with difficult patients.

In one study, experienced psychiatrists demonstrated more empathy than residents,³ suggesting that they may learn more from repeated practice—in effect, from trial and error—than from training and education. Other than clinical experience, there is no unified model of how to educate clinicians in empathic communication skills, either in the field of psychiatry or in medicine generally.^4,5 Many educational intervention trials have attempted to improve the empathy of medical students, residents, and practicing physicians (including psychiatrists).⁵ They generally have been tested only for short-term results, have captured only a part of what empathic communication involves, and have quite different theoretical and practical approaches. Thus, this central clinical skill still has no generally accepted training approach.

Marjorie Heymann, PhD, a director of cutting-edge, avant-garde theater productions and a scholar of the psychology of theater, made a surprising observation: The skills involved in theater arts are precisely the skills of empathic communication. She noticed that the very essence of the theater experience, for both the audience and the actors, is immersion into the emotions, needs, and motivations of the characters as they interact with each other. If audience members do not bring emotional and motivational attentiveness to the experience, they do not really appreciate the art form and will likely not come back to the theater.

This observation led Heymann to her key insight: Certain systematic approaches used to train actors could be translated into a systematic approach for training clinicians to communicate empathically, even with difficult patients.

Heymann therefore developed a course that uses the art and heart of theater to deepen clinicians’ empathic communication skills: Working with Challenging Patients and Families: Maximizing Your Clinical Effectiveness, offered under the auspices of The REACH Institute. The trainees include not only mental health clinicians but also primary care providers, who increasingly are required to treat common mental health disorders but typically have had little training in empathic listening.

As a psychiatrist with 30 years of experience, when I took the course, I was surprised at how it opened a whole new dimension of deep listening and empathic response. I was so impressed that I trained to be one of the co-teachers of the course with Heymann.

The Need for More Systematic Training in Empathic Communication:

For Psychiatrists

Although psychiatrists tend to pride themselves on their skills in communication, they nevertheless can benefit from Heymann’s approach for 2 reasons. First, the emphasis in modern psychiatry on objective assessment of DSM-5 criteria and psychopharmacology has led to decreasing emphasis on the doctor-patient relationship.^6,7 Yet psychiatrists value empathic engagement with their patients as a core competency.⁷ Thus, the current generation of trainees needs greater emphasis on empathic communication skills.

A key point is that communication skills are not just for delivering psychotherapy. The basic tasks of diagnostic interviewing or treatment planning require empathic communication as much as therapy does. To identify correct diagnoses or develop a plan the patient will follow, psychiatrists must understand the patient’s emotions, motivations, and relationship to the psychiatrist.

Second, even though psychiatrists already have communications skills, they can deepen their capacity for empathic listening. Difficult patients are difficult to communicate with. Their stories seem to change; they seem to ignore their psychiatrist’s advice and to undermine themselves at every step. Often, they are projecting the locus of problematic behaviors onto others. They may perceive that their psychiatrist does not respect them; they may not trust their psychiatrist. Such patients can challenge the empathy of even the most experienced clinicians. However, if psychiatrists can see the difficulty as their own inability to communicate empathically and resolve to improve their skills, even difficult patients can come to feel understood and become willing to participate in the therapeutic alliance.

For Primary Care Clinicians

With the increased demand for mental health services and the shortage of trained mental health clinicians, primary care providers (PCPs) are increasingly being asked to address mental health issues. Many PCPs have great skills in interviewing patients about their physical disorders but have little experience in communicating around emotional issues. The emerging model of mental health in primary care will call on psychiatrists to train, supervise, and collaborate with PCPs. Fortunately, Dr. Heymann’s course is a fast, efficient, and effective training program for imparting empathic communication skills to PCPs.

The Relationship Between Theater and Empathic Communication

The recognition that the experience of a theatrical performance depends on empathy goes as far back as Aristotle.⁸ When audience members leave the theater debating how well an actor portrayed a character, they are tapping into their empathic listening skills. Heymann understood that the untrained individuals who make up a theater audience have a highly empathic appreciation of the characters’ emotional states, needs, wants, and motivations. This appreciation depends on the actors’ ability to communicate empathically.

This insight led Heymann to work full-time to support actors in empathic communication. A key ingredient is the actor’s ability to listen to the other actors’ lines with deep attention and focus. The response—the actor’s own lines—then must combine that other-directed empathy with their ability to inhabit their own character’s reality. With this approach, actors can mobilize the audience’s potential for empathy.

After honing this approach for actors, Heymann had an epiphany: This systematic approach to inculcating empathy-based skills in actors could be a model for training clinicians to listen and speak empathically. With this insight, the idea for a course to improve clinicians’ empathic communication through theater arts was born.

How Theatrical Techniques Can be Used to Teach Empathy

There are many schools of thought about how to teach drama. Heymann identified basic common elements and organized them into a systematically sequenced structure. The unique contribution of her method is how it teaches clinicians. It focuses on helping clinicians understand patients’ needs and motivations in the moment of the clinical encounter. It recognizes that clinicians can be present to patients’ needs and motivations only when they first have an empathic understanding of their own needs and motivations.

Heymann’s goal is not to turn clinicians into actors but to teach them how to empathize with their patients. Her course helps clinicians acquire a specific set of skills in a stepwise fashion. Acquisition of skills requires repeated practice, followed by critique, and eventually the addition of new skills with added practice and critique. Only with the basics of deep listening under their belt do participants tackle role plays, in which they begin to combine skills to understand the wants and needs of patients in all their complexity. The steps add up to a method to help clinicians provide what patients need and want most: to be understood, with kindness and empathy.

Heymann’s method begins by engaging clinicians in mindfulness exercises, followed by practice in dealing with distractions. Some distractions are relatively minor “before and after” needs, such as thinking about what one should have said in the argument last night or projecting how hard it will be to get to school on time to pick up one’s child. Others are major, such as worry about a serious illness or coping with a past or future loss. Heymann teaches participants first to respect these issues and then to clear them out of the way before the clinical encounter. We may be able to solve minor problems simply by taking a few minutes to think them through or making a call. For major distractions, Heymann recommends making an appointment with oneself to think about the issue and deal with the feelings: “Tonight from 9 to 10 pm, I will think about mom’s cancer diagnosis and consider how I can support her.”

Having set aside distractions, the clinician is ready to identify and acknowledge the specific needs they and their patients bring to the clinical encounter. Heymann outlines major categories of needs that both clinicians and patients are likely to bring into the room: the need for control, respect, help, and love (or liking), among others. Another salient need for clinicians is their patients’ trust; without this, clinicians cannot enlist patient participation in the healing process.

The genius of the theatrical approach to listening is learning to hear the needs beneath the words. Heymann emphasizes that listening for needs, as opposed to listening for emotions, can make a real difference in the empathic connection. Emotions are of course important, but they are also often changeable, vague, and difficult to capture. Needs are more concrete and often more easily understood.

A simple but powerful exercise involves using the same words to mean different things representing different underlying needs. A patient who says, “I do not think you can help me,” for example, could be expressing a need for control or could, paradoxically, be asking for help. To help clinicians learn to listen for meaning, and not just for the literal words, 2 course participants play a clinician and a patient, saying this dialogue with long pauses between each set of words:

Clinician: How… can I… help you?

Patient: I do not think… you can… help me.

The pair repeat this dialogue several times, with the patient communicating different needs each time: the need for help, the need for respect, or the need to antagonize. In the silences, the clinician can reflect on the needs underneath the words, attending deeply to both verbal and nonverbal clues. Participants who are watching this dialogue are asked to identify which need they perceive.

The exercise serves as a microscope on communication. By attending to this brief exchange over and over, the trainees become sensitized to slowing down and hearing all the rich meanings they might otherwise miss. Having heard the needs beneath the words, the trainees are in the position to hear each patient’s story as an actor inhabits a character. The ability not just to know about the situation, but to experience it from the patient’s perspective is the beginning of empathy.

Once a clinician achieves that experience, their words to the patient take on a different valence. The patient can then experience that the clinician is present and really making the effort to help. This kind of mutual empathic experience, which is rare in everyday communication, can draw the patient into a therapeutic alliance. At that point, the clinician can share information, enlist the patient’s agreement, and partner with them in a plan for healing—all based on deep understanding of the patient’s needs and wants.

Concluding Thoughts

After 2 days of immersion in this and similar exercises, course participants describe the effect on themselves and their communication skills as profound. Some participants who were hesitant to role play have expressed an understanding that empathic communication skills can be imparted only through experiencing the sequence of exercises. Others have expressed an appreciation of how the experiential learning mirrored the goal of experiencing the patient’s need, not just understanding it abstractly. Many have expressed frustration that they had not learned such basic and powerful skills in their professional training.

Dr Amsel joined the faculty of Columbia University in 1992 as a clinical and research psychiatrist, where he worked on suicide risk factors, the long-term effects of childhood trauma such as exposure to 9/11 or the criminal justice system, and decision theory and game theory models in psychiatry. At The REACH Institute, he helped develop a training program for primary care physicians on how to integrate mental health into primary care practice.

References

1. Black DW. Managing ‘difficult’ patient encounters. Cur Psych. 2021 July;20(7):12-19.

2. Koekkoek B, Berno van Meijel CNS, Hutschemaekers G. “Difficult patients” in mental health care: a review. Psychiatr Serv. 2006;57(6):795-802.

3. Khajavi F, Hekmat H. A comparative study of empathy: the effects of psychiatric training.Arch Gen Psychiatry. 1971;25(6):490-493.

4. Esagian G, Esagian-Pouftsis S, Kaprinis SG. Empathy in psychiatry and psychotherapy. Psychiatriki. 2019;30(2):156-164.

5. Patel S, Pelletier-Bui A, Smith S, et al. Curricula for empathy and compassion training in medical education: a systematic review. PLOS ONE 2019;14(8):e0221412.

6. Bracken P, Thomas P, Timimi S, et al. Psychiatry beyond the current paradigm. Br J Psychiatry 2012; 201: 430-4.

7. Ross J, Watling C. Use of empathy in psychiatric practice: constructivist grounded theory study. BJPsych Open (2017);3,26-33.

8. Sachs J. Aristotle: Poetics. Internet Encyclopedia of Philosophy. Accessed June 1, 2022. https://iep.utm.edu/aristotle-poetics