The difficult patient can elicit intense feelings, ranging from
extremely good to extremely bad. Such intense feelings toward a
patient should serve as a “red flag” of caution.
Being unaware of overly positive feelings toward a patient may lead
a clinician to resist addressing issues that may be either unpleasant
or otherwise unappealing, yet appropriate. Overly negative feelings
may signal conscious or unconscious anger and hostility and can
lead to avoidance or inappropriate confrontation. Such strong reactions,
particularly when disparately held by members of a treatment team,
can bring about chaos. Difficult patients may be extremely independent
or dependent, entitled or submissive, engaging or seemingly impossible
to connect with, or idealizing or devaluing of their caregivers.
Caregivers may be as struck by rage from the patient as from themselves.
On the other hand, the only clue for the clinician may be an unusual
lack of either concern for, investment in, or connection with the
patient. In the most severe form, these patients can become enraged,
violent, impulsive, and both physically and emotionally threatening.
Although complaints or demands may seem to be endless, there is
often another process at work. Sometimes, this process is marked
by particular treatment team members being cast in an extremely
positive or negative light. Team members may feel like either adored
insiders or thankless scapegoats. Their designation by the patient
as either all good or all bad may precipitously change from one extreme
to the other. This process is termed splitting and is a hallmark
feature of some difficult patients.