Not all moments of encounter with patients are created equal. When I think back at the many years I’ve psychiatrically treated patients, only certain patients and, even more specifically, only certain particular interactions involving those particular patients rise up from my memory stores.

What do those particular moments have in common? Let me start by asking you a rhetorical question. Do the memorable moments you’ve spent with patients fall more in the category of ‘easy’ or ‘difficult’ moments? If you said difficult that would reflect my experiences. When we judge an event as ‘easy,’ it’s unlikely that it aroused in us negative emotions (anxiety, anger, disgust, pathos, sadness), challenged our sense of control or competence, or taught us something about ourselves or our fellow human beings. ‘Easy’ often means non-salient, predictable, and forgettable events. ‘Difficult’ can lead to increased understanding and changes us.

Today I share with you my thought – a challenge for you, in fact – to think about your own difficult patient interactions in a different way. When you have them – because, of course, you do or will – consider what makes these encounters difficult. What is the patient doing or saying that makes the situation difficult for you? And, more importantly, what is the nature of the difficulty that arises for you, that is, what do YOU struggle with at these moments of difficult interaction? Let’s start with an example.

Patient Example: Suicidal Communication

You’re with a patient well known to you who is at chronic suicidal risk. During your 30 minute session you query the patient about recent presence or escalation of suicidal thoughts. The patient admits to thoughts of suicide but denies intent or plan. This news visibly relaxes you. At the end of the session, you say to her in a friendly tone, “See you next month.”  As she’s walking out the door, she says, “Let’s hope so.” She’s gone before you can gather your thoughts sufficiently to ask her what she meant.

Why would this patient have added that parting comment? First, if she has chronic suicidal thoughts, she’s probably a person facing an ongoing and serious struggle that often overwhelms her. When she assured you in the session that she did not have suicidal intent or plan and noticed how relieved you looked, she may have felt more alone with her struggles, fears and uncertainty. By saying, “Let’s hope so” she instilled in you some of that same fear and uncertainty she lives with every day. By instilling a sense of uncertainty and, perhaps, anxiety in you, she no longer need feel so alone. She now has someone potentially sharing the same anxiety with her.

Additionally, many patients have had clinicians who are so obviously hoping the patient is not at acute risk, that the patient can react with irritation when the clinician seems too relieved the patient reports not being at risk. A patient doesn’t need to be a mind-reader to know what answer a clinician wants to hear, when asking, “You’re not at suicide risk right now, are you?” The patient in my case description may also have wanted to communicate her anger at the clinician. Although the patient’s intent may be unconscious, her communication may be to the effect of, “I’ll leave him [my doctor] feeling anxious. That will teach him to be so afraid of really trying to find out how I’m feeling, or wanting so desperately not to be inconvenienced with my struggles.”

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Learning Mindset

To return to my questions: What is the patient doing or saying that makes a clinical situation difficult for you? And, why exactly is it difficulty for you? These questions are best answered by maintaining a certain ‘learning’ mindset, one that requires treating what the patient does in their interaction with you as opportunities to learn about the patient. There are two main ways to learn about an individual: what they tell us about themselves (their report) and how they behave with us (their enactment). Patient behaviors that can be categorize as difficult provide an important window onto the patient. These behaviors give you a real-time display of the patient’s strategies in regulating their emotions, communicating to another person, influencing the relationship with important others, and, ultimately getting what they most want.

Next, during a difficult patient interaction, consider what exactly makes this situation difficult or uncomfortable for you. Do you feel bullied, anxious, afraid, uncomfortably sexually aroused, dismissive, disgusted, frustrated, rejecting, angry, bored, solicitous, empathically aroused or perhaps conflicted between more than one of these emotional responses?
Now that you’ve considered the patient’s enactment and your emotional response, consider what are the benefits and the liabilities for the patient in behaving the way they did and triggering these particular emotional (and often behavioral) reactions from you. Remember, the patient is enacting interpersonal strategies to get what they want out of life. If you think of it in this way, it’s clear the patient is doing the best they can, meaning they are acting in ways they’ve learned over the years that maximize their benefits and minimize their risks. Of course, when you objectively judge patient’s behaviors some or many of them may seem to you to be highly counterproductive. But if the patient had a ‘better way’ of getting what they want, why would they not use it?

One category of interpersonal strategy that patients use is called projective identification (PI), what has been classically considered a psychological defense mechanism. PI confers internal psychological benefits by allowing the patient to disavow unwanted aspects of themselves by projecting them on another person. It also includes interpersonal benefits by communicating – usually indirectly – to you what the patient wants, and influencing the relationship with you in such a way that you are more likely to give them what they want, even if what they want is likely to be counterproductive in the longer term. This process of the patient influencing you through engendering an emotional response in you, opens options on how you respond. You can respond in the way the patient expects and that confers short-term benefits but often long-term liabilities. Or you can break the pattern of response to the patient that can lead to their growth, to the breaking from their habitual and limited strategies. Today, I won’t share with you the possibilities I see on how to respond to our described patient case. I’ll let you mull it over and include my thoughts next time. In the meantime, why not share with us an example of a difficult patient interaction you’ve had? Thanks.

Until next time,

Dr. Jack


Today’s Quotes

“Freud wrote that patients remember nothing of their internal conflicts but express them through action. Their behavior becomes a vehicle for the conflicts they would otherwise painfully have to face. Therefore, action feels safer or at least feels temporarily relieving. It can be an excitement, a stimulation, an escape, or a revenge.”
– Projective Identification, Countertransference, and the Struggle for Understanding Over Acting Out, by Waska, 1999

“Consistently, we [the authors] concluded that a greater understanding of the patient, the therapist, and the interaction evolved out of episodes of countertransference disturbance.”
Understanding Countertransference: From Projective Identification to Empathy, by Tansey and Burke, 1989