The Challenge of the “Difficult” Patient

It is common for mental health professionalsto label a patient as “difficult”;however, it remains unclear asto what the classification actuallymeans or what it entails. Koekkoekand colleagues reviewed 94 articlespublished between 1979 and 2004in order to answer 3 questions: (1)“What are the defining characteristicsof difficult patients?” (2) “Howis the difficulty explained?” and (3)“Which treatment strategies are available?”Their findings were publishedin the June 2006 issue of PsychiatricServices.

The researchers placed difficultpatients into 3 categories: the unwillingcare avoider, the ambivalent careseeker, and the demanding careclaimer. Unwilling care avoidersincluded patients with paranoidpsychosis and personality disorders.These patients were predominantlymale and exhibited behaviors thatincluded being withdrawn, hard toreach, and aggressive. Demandingcare claimers included substanceabusers and those with personalitydisorders. They were also predominantlymale and exhibited behaviorssuch as attention seeking, manipulating,aggression, and destruction.Ambivalent care seekers includedpatients with chronic depression, andpersonality disorders. This groupconsisted predominantly of femaleswho could be demanding, claiming,self-destructive, and dependent.

The studies offered 4 explanationsfor difficult patients: chronicity,dependency, character pathology,and lack of reflective capabilities.Some authors focused on transferenceand countertransference issuesin explaining what they conceived asnot a difficult patient, but a difficulttherapeutic relationship.

A variety of treatment interventionswere suggested. These includedcommon practices such as carefullistening and being nonjudgmental.A so-called holding environment, inwhich limits are set and the patientfeels safe to experience different feelingsand experiment with differentbehaviors, was among the otherapproaches suggested, along withindividual supervision of the therapistand interdisciplinary teamconsultation. Koekkoek and associatesconcluded that ambivalent careseekers are the most challenging totreat and are “constantly subject todifferent judgments about their healthstatus by professionals.”