It is common for mental health professionals to label a patient as “difficult”; however, it remains unclear as to what the classification actually means or what it entails. Koekkoek and colleagues reviewed 94 articles published between 1979 and 2004 in order to answer 3 questions: (1) “What are the defining characteristics of difficult patients?” (2) “How is the difficulty explained?” and (3) “Which treatment strategies are available?” Their findings were published in the June 2006 issue of Psychiatric Services.

The researchers placed difficult patients into 3 categories: the unwilling care avoider, the ambivalent care seeker, and the demanding care claimer. Unwilling care avoiders included patients with paranoid psychosis and personality disorders. These patients were predominantly male and exhibited behaviors that included being withdrawn, hard to reach, and aggressive. Demanding care claimers included substance abusers and those with personality disorders. They were also predominantly male and exhibited behaviors such as attention seeking, manipulating, aggression, and destruction. Ambivalent care seekers included patients with chronic depression, and personality disorders. This group consisted predominantly of females who could be demanding, claiming, self-destructive, and dependent.

The studies offered 4 explanations for difficult patients: chronicity, dependency, character pathology, and lack of reflective capabilities. Some authors focused on transference and countertransference issues in explaining what they conceived as not a difficult patient, but a difficult therapeutic relationship.

A variety of treatment interventions were suggested. These included common practices such as careful listening and being nonjudgmental. A so-called holding environment, in which limits are set and the patient feels safe to experience different feelings and experiment with different behaviors, was among the other approaches suggested, along with individual supervision of the therapist and interdisciplinary team consultation. Koekkoek and associates concluded that ambivalent care seekers are the most challenging to treat and are “constantly subject to different judgments about their health status by professionals.”