Chapter 15. Consulting on the Difficult Patient in Pain

Treating pain in a difficult patient may raise the challenge and lower the expectations from any analgesic intervention. In this section, the term difficult is applied to patients with behaviors, rather than symptoms, that are beyond the norm and that undermine treatment. Discussion of other difficult symptom presentations is beyond the scope of this chapter. Difficult patients who are in pain often are in conflict about whether or not they want care, want the care they are offered, or want pain. Groves has said, “Such patients simultaneously demand and reject care.” These patients may also simultaneously obtain and undermine treatment or flatter and frustrate their clinicians. In mild cases, they may strike a cord of uneasiness in their caregivers. In severe cases, caregivers may experience strong emotions such as fear and hate.

Some clinicians find it difficult to acknowledge or discuss patients who strike a negative chord in them. Often, this is because of the intrinsic conflict such patients raise with caregivers. Many clinicians would simply rather not dislike any patients. Disliking a patient is counter to what caregivers consciously strive to achieve—helping in every way. So, even discussing a difficult patient can make some clinicians feel uncomfortable, as if the patient is either being mistreated or ridiculed. Certainly, this may occur with certain individual clinicians in some situations. On the other hand, some patients clearly are difficult, have long histories of inciting strong negative reactions and difficult interactions with many health care providers, and place clinicians in untenable situations in which they ultimately feel bad. Not recognizing this phenomenon is a disservice to the patient. But it is also of paramount importance to recognize that most patients who make you suffer as a clinician are probably suffering much more. Patients with dysfunctional patterns of interactions with physicians usually have similar, if not worse, problems throughout the rest of their lives. Thus, the clinician’s discomfort is often just a small reflection of the patient’s much greater torment.

Although there is no easy formula for what to do in these difficult interactions, the common mistake is to miss opportunities in which commonsense adjustments can ameliorate problems and prevent escalation. Unfortunately, such difficult cases bring with them frustration and, often, even more severe emotional responses, which taken together diminish the clinician’s ability to bring common sense to bear. In such situations, it is critical to recognize dysfunctional patterns of patient and staff interactions as well as monitor one’s own internal reactions. By doing so, one can then apply greater awareness, deliberation, planning, patience, and caution to a difficult situation rather than acting from impulse or instinct. This perspective may make the clinician the only member of the treatment team able to change the tide of acrimony and reestablish effective treatment. What follows here is not new and is extensively taken from the work of James E. Groves, as well as Adler, Buie, and Maltsberger, who have published the seminal writings on this subject (see the Bibliography at the end of this chapter). Readers who are interested in furthering their understanding of the difficult patient will be well rewarded by reviewing these works.

It is a first-order task of any clinician caring for patients with complex biopsychosocial problems to expect some emotional response, which all clinicians have to their patients. Some clinicians hide their reactions better than others, whether to others or themselves. The clinician who is unaware of his or her reactions to patients may be more likely to act on these emotions in a counterproductive and potentially harmful manner. Conscious awareness of one’s feelings offers the opportunity to recognize these reactions and perhaps use this understanding to respond to difficult patients with more empathy and less animosity.

The difficult patient becomes known to a clinician in one of two ways, either directly or indirectly. Some are directly frustrating and inspire strong negative feelings. Others are noticed indirectly by virtue of the struggle that ensues among the caregivers of the difficult patient. If clinicians honestly pay attention to their reactions to patients, they will notice a constant and wide variety of positive and negative feelings. They may then come to understand some of the motivating forces behind the various ways in which they work with patients and may begin to recognize patterns. Because pain management is often performed in a team treatment setting, the same can be said for the clinician’s interactions with the treatment team.

The treatment team can be viewed as a single entity: a system that can be either united or divided. Treatment teams may be harmonious or acrimonious. When there is an unusual amount of conflict or negative feelings among caregivers without an obvious medical controversy, the initial instinct may be to wonder how the individuals on the team can be causing these problems. However, the teams’ struggle may be, at least in part, a result of information about the patient. If this scenario is not considered, then a potentially informative piece of the patient care puzzle may be missed. Thus, when the treatment team is both divided and acrimonious, a consultant should avoid the natural temptation to seek blame among the various and potentially divided clinicians. Instead, the team should be viewed as a single unit, contrasted only with the patient. The usual tendency to ally with the patient is a pitfall that may need to be resisted, because the patient’s best interest is only served if the treatment team is functional. Because a congruent team best serves the patient, the consultant’s alliance must be with the team as a whole. Once seen in this manner, the problematic system may reveal itself.

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.

Management in these difficult situations calls on the clinician’s greatest tolerance and skill. Understanding why some patients behave in such a difficult manner may serve to de-escalate frustration and help with imparting rational treatment. Often, these patients are extremely frightened and have very low self-esteem. Viewing the world in terms of extremes is often related to past experiences in which they were, in some way, injured or abandoned. As a result, the individual loses the ability to synthesize experiences that are simultaneously good and bad. Much of the struggle with the difficult patient may be a result of the patient’s perception of previous and ongoing abandonment. Such individuals often have lives that are marked by persistent feelings of emptiness, with labile moods and unstable personal relationships. It is not uncommon for such patients to present with a counter-intuitive external layer of grandiosity. Some patients may appear to have an almost carefree impassivity that contrasts with marked emotional fragility and the tendency to become easily shamed and enraged. This perspective can now temper the clinician’s view of the defense mechanisms resulting from the patient’s perceived frightened, if not victimized, position. These defenses—such as splitting, valuing and devaluing, denial and entitlement—may be the only methods the patient has to prevent what he or she perceives as impending doom.

It is all too easy, reflexively and intuitively, to view the overly demanding patient as emotionally secure. However, these patients often have extremely low self-esteem and feel an ever-present, looming risk of imminent shame and humiliation. Entitlement is the external and very thin veneer under which self-loathing and vulnerability hide. Thus, challenging this entitled position serves only to heighten the risk of shame and humiliation and intensifies the need for a demanding and entitled posture. The extreme fragility of these patients underscores the need to avoid challenging their sense of entitlement. While working with such patients, it is best to counter excessive demands with frequent and varied reminders that the patient deserves and will receive the best and most thoughtful care.

Initial management of the difficult patient requires recognizing the dysfunctional system and following some principles, described next. When working with the difficult patient, the role of the consultant is fundamentally different than that of the primary clinician; the primary clinician maintains the continuous therapeutic relationship, which can become stressed by constant demands, whereas the consultant is liberated from such longitudinal constraints. The primary clinician must maintain both an alliance with the difficult patient as well as boundaries within which good health care can proceed and harm can be avoided. Often, it is necessary to use consultants, who can offer an objective perspective, free of the long-term consequences of confronting mixed messages and inconsistent behaviors. In difficult situations, deferring to the consultant may be the primary clinician’s only means of minimizing the long-term effects of instituting necessary treatment, setting limits, or avoiding danger.

Patients who consistently encounter turbulent medical experiences may feel most comforted when their physicians are at odds. Some patients, consciously or unconsciously, may feel that a staff that is fighting among itself at least cares, whereas a harmonious team may be disinterested and may even do them harm. These patients may gravitate to a system that casts clinicians as either all good or all bad. Because it is usually insidious and fraught with pitfalls, encountering a case that involves the defense of splitting can be a struggle if not a frightening experience. The clinician who rushes into such a case with disdain for prior management and offers alternatives that inspire the patients effusive gratitude may soon be on the receiving end of disdain. The goal is to avoid this cycle of love and hate and work in a manner that offers solutions that encourage team involvement and minimize fragmentation, all without disrupting the relationship of the primary team with the patient.

Similar cycles and patterns are not limited to patients but are possible for the treatment team, as well. At any point in a case, the treatment team may defer to the consultant for relief. The team may need to overidealize the consultant for the purpose of having him or her assume the role of rescuer. Alternatively, the team may devalue the consultant as they transfer to him or her the burdensome scapegoat role. They may seek company in hating the patient or take an equally righteous but opposite position of defending the patient against the consultant and all other “evil.” The latter serves to relieve the guilt of past conflicts or treatment failures.

Because the pain management clinician rarely works in isolation from other care providers, the consultant must offer strategies that preserve self-esteem for both the patient and staff. There is almost never long-term gain to be had by assigning blame, or embarrassing or humiliating the patient or the staff. It is important to appreciate both the patient’s sense of enormous vulnerability and the team’s sense of hopelessness. The consultant should avoid being part of an atmosphere of anger or resentment toward the patient or the team. As previously noted, the team has primary responsibility for the care of the patient. The consultant who promotes the effectiveness of the primary team best serves the patient. In particularly difficult cases of hospitalized patients, where other practitioners are involved at a greater level of primary care, it is best to interact directly with the patient only as necessary to collect primary information. Otherwise, the consultant should rely on the hospital chart, existing records, and collateral sources to fill in the story. The consultant should intervene directly with the treatment team and guide them in navigating patient interactions, offering options with honor.

The consultant must evaluate both the patient and the team. Self-defeating behavior of the patient and staff should be identified and addressed. Arguing with the patient or with the staff should be avoided; although it may feel good to the frustrated clinician, it will undermine the search for constructive solutions. Sometimes, the consulting clinician may encounter secrets or information that have been revealed selectively to some but not all members of the team. In such situations, one must be wary of important facts that may have become distorted. In the long run, all parties will ultimately feel better when the facts are all true, clear, and consistent.

In the case of difficult patients who are hospitalized or those with treatment providers who can be convened, the consultant can use frequent brief team meetings to interact and ally with key representatives of the treatment team. It is necessary to honestly describe the patient’s behavior and needs as well as the pitfalls of managing such impossible demands and contradicting needs. The team may need to hear that it is understandable that there are strong negative feelings toward the patient, which may become displaced onto others. Staff should be reassured that such reactions are normal and linked to their very noble but now frustrated commitment to help others. The consultant should emphasize strengths, such as good rapport, humor, faith, or previous experiences with difficult cases that have been resolved. The team should be offered the chance to vent, and their torment and hopelessness acknowledged.

The consultant should appreciate that the staff may be too frustrated to take its usual rational and understanding position with the current patient. In explaining the complexity of the current interactions, the consultant should be clear that the present brief encounter is probably not going to allow him or her to completely comprehend the complex dynamics of the case, which are probably rooted in events that occurred long ago. The medical or surgical team should be reminded that it is not their primary job to resolve long-standing psychological patterns, issues, or pathology. Their duty is to diagnose and treat the current medical problem. If possible, the consultant can introduce lightheartedness and humor into the team atmosphere, which may have become clouded by emotions of hopelessness and anger. It may help to remember the words of James Groves: “humor is the mother of empathy.”

Limit setting is a prominent feature of managing the difficult patient in pain. Often, the amount and route of administration of opioids are areas of contention. In such cases, individualized plans must be developed; however, using contracts and strictly holding to rational pharmacotherapy will help with many problems. It is important to remember that the patient has the disease. Nonetheless, he or she may be frightened, impulsive, and very perceptive. Limits must not be confused with punishment or seen as an opportunity for revenge. Management must be offered in a professional and kind manner, without malice or blaming. As previously discussed, confrontation may be self-defeating; however, certain unacceptable or counterproductive behaviors must be addressed and limited. For any suggestion of violent behavior, threats, or imminent harm, patients must be advised of the consequences, including the use of physical restraint. Acts or threats of violence or self-injury must be met with an immediate and clear response that protects the patient and others. In these situations, formal psychiatric assistance is usually necessary.

Finally, the consultant to the difficult patient in pain must help unify the team and implement a rational plan. Unification occurs through communication. When the patient is hospitalized, it may still be impossible to meet with the entire team, so there should be a mechanism for disseminating the plan through caregivers from shift to shift. The patient will be comforted and less agitated by shift changes if staff frequently update the patient with consistent information. The rational plan should have contingencies for various outcomes. The primary team should then present the agreed-on plan, with its contingencies, to the patient and form a contract to follow through on the plan. In the most severe cases, a written agreement offers the patient the opportunity to review and consider the information over time and forms a document that can be recalled if necessary.

Managing the difficult patient in pain can be challenging but also rewarding. It is too often the case that such patients frustrate both their clinicians and themselves. Appreciating the underlying problems and following some basic principles may help de-escalate conflict and support or reestablish effective medical care.