unit #4 integrated learning experience: difficult patients speech-language pathologists and managing...

Unit #4 Integrated Learning Experience: DIFFICULT PATIENTS

Speech-Language Pathologists and Managing the Difficult Client


• We want to describe:– The conceptual model of the difficult patient.– Characteristics of some difficult patients.– “Red Flags”.– Optimal courses of action.


CONCEPTUAL MODEL OF THE

DIFFICULT PATIENT

• Patients can be seen as difficult for any number of reasons.

• These patients make us feel uncomfortable, frustrated, and ineffective.

• The clinician has certain expectations about what is ‘ideal’ client behaviour. When this behaviour deviates from what is expected, we find ourselves labeling the patient as‘difficult’.



DIFFICULT PATIENT

A. EXPRESSION OF WANTS AND NEEDS

B. OWNERSHIPC. EMOTION



DIFFICULT PATIENT

• The ideal patient falls directly in the middle of these continuums, while difficult behaviours lie at the extreme ends.

• Each difficult client will have unique characteristics, red flags and optimal courses of action

• Clinicians will perceive and react to different patients differently, according to their own unique personalities and therapeutic styles


EXPRESSION OF WANTS AND NEEDS

• Clients may attempt to influence/change clinician’s beliefs/behaviours with persuasive tactics.

• Problem is when client’s desire and/or method is felt by the clinician to be unacceptable or impossible.

• Two ends of continuum: indirect persuasion (manipulative) or direct persuasion (complainer).



COMPLAINER



COMPLAINER

Characteristics• Quick to find faults/problems, especially

unfounded ones.• Exhibits a weak capacity for controlling their

impulses and a limited ability to consider the opinions of others or adopt multiple perspectives.

• Demonstrates poor judgment and applies a very general distrust to persons in authority.



COMPLAINER



COMPLAINER

Red Flags

• Problems are stated in an accusatory manner.

• The clinician is suddenly placed on the defensive.

• The client never implicates themselves as being part of the problem, blaming others.



COMPLAINER

Course of Action• Get the client to adopt a problem-solving

perspective by asking questions and documenting specific details from their responses.

• Provide ‘either/or’ suggestions that empower and guide the patient to find a solution.

• Resolve the issue promptly, apologize for any inconvenience and express appreciation to the patient for bringing the problem to your attention.



MANIPULATOR



MANIPULATOR

Characteristics• Interacts with clinicians in dishonest or devious

ways to achieve primary goals or secondary gain.• Feigns their symptoms to prolong treatment, or

presents with other unverified medical complaints. • Seeks continuous attention that does not match

their level of need.



MANIPULATOR



MANIPULATOR

Red Flags

• Displays immediate intimacy, flattery, charm, or guilt.

• Presents with inconsistent clinical symptoms, behaviors, or moods.

• Requests special considerations and exerts subtle pressure.



MANIPULATOR

Course of Action• Explore the patient’s Hx for personal/social

information that may identify potentially motivating factors.

• Don’t allow the client’s verbal/non-verbal behaviors to affect your clinical judgment. Use I messages…

• If you suspect the client is malingering address them indirectly with a statement that seeks clarification (e.g., second opinion etc.).


OWNERSHIP OF THE THERAPUTIC PROCESS

• Clients have opportunity to assume some responsibility for therapeutic process.

• Problem is when client fails to meet implicit expectation of clinician.

• Two ends of continuum: place all responsibility on clinician (passive) or attempt to control entire process (demanding).



PASSIVE

.



PASSIVE

Characteristics• Inadvertently permits things to occur even

if not in agreement.• Intentionally or not rely on clinician’s to

lead, monitor, and make decisions regarding treatment.

• Fails to take responsibility for their treatment/condition/progress.



PASSIVE

Characteristics (cont’d)• May be due to cultural norms/language

barriers, adherence to medical model, poor comprehension, introverted personality type, or clinician dominance



PASSIVE



PASSIVE

Red Flags

• Expresses continual and increasing expectations from clinician.

• Offers limited feedback/vague responses.

• Shows reluctance to make decisions.

• Relies on clinician’s advice without question/offering suggestions.



PASSIVE

Course of Action• Elicit client’s active and independent

participation.• Explain why their participation in therapy is

important.• Ask closed ended questions (e.g. “Which

exercises are easiest for you to complete?”) followed by “Why?”



PASSIVE

Course of Action (Cont’d)• Provide the patient with tasks (e.g.

documenting home progress, making lists of pros and cons) and use these to elicit feedback

• Set aside time for clinical discussion to discuss clinical issues and set expectations for them to meet for these discussions



DEMANDING



DEMANDING

Characteristics• Has unrealistic expectations re: services you

can provide (e.g. type/amount of therapy)

• Attempts to control many aspects of therapeutic process by demanding changes be made without willingness to negotiate



DEMANDING

Characteristics (Cont’d)• Can result from lack of/incorrect

information, fear of condition/therapy, and can be motivated by the best of intentions!



DEMANDING



DEMANDING

Red Flags• Authoritarian personality type.• Task driven/needs immediate action.• Reacts strongly when they realize you are

unable to help them.• Becomes tense, raises voice, may be rude,

impulsive, and make inappropriate comments.



DEMANDING

Course of Action• Be assertive- use direct eye gaze.• Show that you are listening by leaning

forward with an open body posture.• Acknowledge the client’s emotional

response first and then give BRIEF rationale if unable to meet desire.

• Give patient choices, even if they are minor.



DEMANDING

Course of Action (Cont’d)• Don’t make promises you can’t keep &

follow through with those you make.

• Don’t raise your voice above the patient’s.

• Remember that the results of therapy can never be guaranteed!


EXPRESSION OF EMOTION

• Clients will express their anger, frustration, disappointment in different ways.

• Problem is when reactions are incongruent with clinician’s comfort level/ goals.

• Two ends of continuum: emotional breakdowns (crier) and emotional breakouts (aggressive).



CRIER



CRIER

Characteristics• May be frustrated with progress or external

pressures (e.g., family conflict, financial and work-related difficulties).

• May fear failure in treatment due to external pressures, thereby adding to own stress level.

• May be the result of a noted mental illness, emotional instability, or neurological injury.



CRIER



CRIER

Red Flags• Exhibits emotional breakdowns.

• Uses clinician as a sounding board to express their feelings and frustrations.

• Expresses concerns about their ability to complete their treatment due to extenuating circumstances.



CRIER

Course of Action• Give them time to express their needs and

concerns while showing compassion (e.g. just passing a tissue).

• Give the client a sense of control by asking open-ended questions such as “What do you think we can do to help this situation?”



CRIER

Course of Action (cont’d)• Give practical help by finding contacts and

resources if necessary (e.g. counselor, etc.).

• Try to set aside therapy sessions to discuss concerns if the client is grieving their loss of speech or language function.



AGGRESSIVE



AGGRESSIVE

Characteristics• May have external stressors that contribute to

these feelings.• May have impaired cognitive abilities that

result in a lessened ability to cope with stress, anxiety, conflict, etc.

• May have a history of hostility, especially toward healthcare workers.



AGGRESSIVE



AGGRESSIVE

Red Flags• Begins to show increased agitation or

uncharacteristic calmness in a tense situation• Exhibits numerous physical signs such as tensed

posture, a red face, clenched fists and teeth, or increased breathing

• Begins to raise their voice, swear, and launches personal verbal attacks at you as their clinician.



AGGRESSIVE

Course of Action• Remain calm and try to be empathic by

acknowledging the client’s feelings

• Calm the client by speaking slowly in a deep, soothing voice and use slow, calming gestures (avoid quick movements)



AGGRESSIVE

Course of Action (cont’d)• Don’t assume you know the underlying

issue. Ask open-ended questions and give the client time to think rationally and respond

• Ask the client how they think the situation can be resolved and offer them choices so as to give them a sense of control



WHEN AGGRESSIVE BECOMES VIOLENT

• If there is a history of violence, sit close to the exit with the client away from the door (avoid being cornered!).

• Adopt a non-threatening stance with hands open while trying to minimize direct eye contact.

• Talk empathically with the client to try to diffuse the situation.

• Do not attempt to handle the situation on your own. Always leave and get help!


SUMMARY

• No client will be in the center of the each continuum.

• Assess your personal boundaries, and be prepared with how to deal with difficult patient behaviours that fall outside of them.

• Putting this knowledge into clinical skill will require practice and experience (Workshop!).


QUESTIONS

?


RESOURCES TO TAKE HOME

• Refer to booklet provided


WORKSHOP

• Role-playing with each patient type.• “Wants & Needs”, “Ownership”, &

“Emotion” Rooms.• 3 teams of 6 start in different rooms (see

list).• 6 scenarios- 3 for each end of continuum.• Designated “buddy” gives feedback.• Move through each room.


WORKSHOP

GO!(Please Bring Booklet!)

Clinic Room A ‘Ownership’

ANNA MARIA

Clinic Room B ‘Wants and Needs’

NOEL

Clinic Room E ‘Emotion’ LINDSAY

Erin & Lesley Neetha & Aren Agapi & Sharon & Bin

Laurie M. & Urszula Nicole & Laurie R. Katie & Sarah

Tali & Julia Kirsten & Liz Heather & Talia

unit #4 integrated learning experience: difficult patients speech-language pathologists and managing...

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difficult clientunit

difficult behaviours

needs manipulator unit

patient asdifficult

different patients

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