The hateful patient revisited (2015)

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“The Hateful Patient” Revisited:

A Transactional View of the

“Difficult” Physician-Patient Relationship

GREG$ SAZIMA,$ MD,$ Senior' Behavioral' Faculty,' San' Jose5O’Connor' Family' Medicine' Residency' Program,' San' Jose,' CA' (Affiliate,' Department' of' Family' and' Community' Medicine,' Stanford' University'School'of'Medicine) Contributors/Acknowledgements:5This5document5was5developed5out5of5research5material5presented5at5a5 colloquium5conference5series,5“The5Difficult5PaBent”,5presented5to5Family5Medicine5residentsGinGtraining5at5 the5San5Jose/O’Connor5Family5Medicine5Residency5Program,5San5Jose,5CA.55GCS5is5grateful5for5the5 contribuBons5of5his5Behavioral5Science5Faculty5colleagues5at5the5program:55Katherine5Mullins,5MD;5Frances5 Respicio,5MSW;55Robin5Beresford,5RN,5LMFT,5PAC;5and5Michael5Stevens,5MD.5 DeclaraBon5of5interests:55GCS5declares5no5conflicts5of5interest.

It is an early evening in 1978. The harried physician descends in the elevator from her primary care clinic office, irritable and depleted from her final clinical interaction of the day - the patient in question peppering her with head-to-toe somatic worries from a list covering an entire legal pad page. The doctor responded the way she always does - with a new fusillade of lab tests and consultation requests, the ordering of which pushes her work day way past sunset. As she exits the elevator to the strains of a Musak version of “Staying Alive”, missing the irony, the physician’s heart sinks as she sees the patient waiting for her by the lobby door, clutching her left forearm to her chest as if to keep it from falling off. “Oh, doctor, there was this one more thing you need to look at…. I think it’s cancer!”

It is an early morning in 2015. The well-regarded and nattily-dressed psychopharmacologist glides to his desk and, like a fighter pilot, begins his familiar multitasking: speakerphone speeddialed to voicemail, laptop snapped open for a quick perusal of the daily’s schedule and the overnight emails to attend to. As he sips his half-soy double latte’, he almost spit-takes his brew as he reads an email from a rather entitled, litigious patient insisting that a flash-drive of his clinical record be prepared for his pickup later in the morning. The doctor's crime: the latest anti-depressant trial not working “fast enough”. Angrily clicking through to his schedule, he finds the patient’s next appointment and hits “delete”.

2 It has been over 35 years since James Groves, MD published his influential article, “Taking Care of The Hateful Patient”. His powerful description of four archetypal patient styles that evoke dread in their caregivers has become standard reading in training programs both in primary care medicine and psychiatry.

In developing a teaching conference series on the doctor/patient

relationship for residents-in-training, my colleagues and I built on upon Groves’ work - framing a view of patient archetypes as well as of archetypal physician character styles - to advance a model of a transactional cycle between patient and doctor, fueled by the personality dynamics of both parties in the transaction. With an emphasis on trainees’ cultivation of self-awareness in the moment-to-moment interaction with the patient, we use this cycle model to suggest tactics and practices that the physician may use with each of the difficult patient archetypes to make care more effective.

WHAT IS A “DIFFICULT” PATIENT? GROVES’ FOUR ARCHETYPES, REVISITED

Groves identified four archetypal patterns of “hateful” patients; the less pejorative term “difficult” will be used here to typify the range of negative impacts of these patient types on the physician and vice versa. Such relationships test the idealized image of the compassionate, intelligent healer, curing or reducing the suffering of a compliant, appreciative patient. Instead, much of that image can get turned upside down: one can witness resentment of and acting out against the physician’s help and displacement of the patient’s conflicts of past and present personal life onto the clinical relationship. If unattended to, a counter-therapeutic manifestation of these circumstances can ripen, creating shared helplessness, mutual hostility, and even abuse and abandonment - none of which aspire to the ideals of Hippocrates or Maimonides.

All archetypes operate with an unhealthy style of alliance or attachment to the physician. We can dust off valid concepts from the psychoanalytic work of Melanie Klein to help identify these defensive behaviors via the concept of projective identification. Medical vulnerability is manifest as a self-critical distortion: “I’m sick” being equated with “I’m bad”, then broadcasted behaviorally in the clinical setting with the treating physician as the target. The unconscious projection of that tension/judgment mix onto the doctor serves both a diagnostic purpose – “let’s see what she does with this load of pain, maybe I can learn something” - and also a therapeutic one – “at least I’m not alone in this state… look, the doctor feels bad, too!” That subsequent identifying with the now resonating physician, comparing notes on the virtual, shared experience, completes the cycle– projection, then identification.

Commonly, this interaction is a replay of disruptions in attachment - the bond between the young child and parents/caregiver for basic security and soothing of suffering. This early challenge in

3 bonding depends upon consistency and reliability in the caregiver’s response to the child’s experience, and has been studied intensively by John Bowlby, Mary Ainsworth, Mary Main and others. As an additional line of association, we can see how the milestone types of insecure attachment described by those researchers may well represent early drivers for subsequent interpersonal difficulties, particularly in the doctor-patient relationship (Figure 1).

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Insecure' AJachment,' disorganized/disoriented' type:! ! This5 child5 presents5 with5 chaoBc5 behaviors5G5compulsive/stereotypic5rocking,5hi]ng5themselves,5dissociaBng5G5in5the5se]ng5of5 traumaGrelated5 parental5 states;5 barely5 or5 poorly5 soothed5 back5 into5 their5 prior5 steady5 state.5 There5 is5 no5 real,5 effecBve5 connecBon5 to5 a5 caregiving5 figure.5 5 The5 style5 echoes5 the5 deep,5 dysphoric5primiBvity5that5typifies5the5later$Borderline$archetype.5

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Felitti and Anda’s ongoing ACE (Adverse Child Experiences) study has uncovered a clear association between disruptive early childhood experiences and subsequent rates of “fallout” psychological suffering and poor physical health in later life.

Grove’s archetypes may also be defined via broadly-researched personality constellations in psychiatric practice – including the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) series, now in its fifth edition. As with the DSM diagnostic schema, it is important to note that more commonly than not, patients do not fit cleanly into one archetype but may share the characterological traits or styles of two or more archetypes. With that caveat in mind, here are brief summary descriptions of these reframed archetypes: Anxious/Hypersensitive (“Dependent Clinger”): aligns with elements of a DSM-informed anxious/hypersensitive personality type, driven by core, intense anxiety. Deeply needy and requiring constant reassurance and attention, these patients tend to be dramatic, suggestible and prone to somatic pre-occupation and catastrophic thinking.

Common behaviors include

challenging and violating time and space boundaries – such as in outpatient visits which routinely run over scheduled appointment time, frequent “emergency” contacts outside of office hours, and insatiable requests for elaborate lab tests or the latest medication for routine ailments.

Angry/Narcissistic (“Entitled Demander”): squares up with elements of the DSM narcissistic personality, driven by anger as the felt experience of narcissistic grievance and injury.

This

archetype poorly tolerates medical suffering, repressing/disavowing a sense of being “broken” but instead projecting it in hostility on others who may only marginally trigger or deserve that intense, negative judgment.

There is often an insistence on attention, control, and even

humiliation through righteous demands for extra time, special consultation, and unnecessary tests.

Such patients are prone to verbal complaint, intimidation, and legal maneuvers.

Passive/Aggressive (“Manipulative Help-Rejecter”): contains elements that are familiar to passive/aggressive personality types, binding the physician’s attention through “staying sick” professing a positive bond to treater and treatment while passively compromising or even sabotaging appropriate treatment. The doctor/patient relationship itself is hedge against, and testing of, the deeper suffering of being abandoned – a deep, depressive position that is repressed but, again, gains life via covertly confounding treatment.

5 Borderline (“Self-destructive Denier”): with personality elements that clearly mirror the wellknown borderline personality. The “denial” referred to is of the purported purpose of the medical transaction, instead using the “stage” of the doctor’s office to play out the wish of having one’s intense rage observed and understood. Groves describes these patients as displaying “unconsciously self-murderous behaviors”, not as some well-intended but poorly directed sense of regaining control but instead as a perverse, hostile way of expressing hopelessness. Such patients are commonly barely in empathic contact with their physician, if only to express grievance through acting out in self-destructive ways with the physician as audience.

“PHYSICIAN ARCHETYPES”: THE OTHER SIDE OF THE TRANSACTION While Groves emphasizes patient behaviors, patient archetypes do not behave in a vacuum but instead interact with their physician in a co-created cycle of experience and reciprocal behavior.

Physicians have our own unique psychological qualities that are often beneficial to self and society. Yet we nevertheless also exhibit our own archetypal, unhealthy character attributes, the humble (and perhaps painful) “due diligence” identification of which can help us better understand and manage the broader cycle.

Three such core physician archetypes are described here: perfectionism, narcissism and what can be termed counter-dependency or “false altruism”. As with patient archetypes, a individual physician may have a unique mix in type and intensity of the features mentioned, and should get to know one’s own mix well.

Perfectionism: An outsized drive toward mastery is a familiar characteristic of individuals who enter the intellectually and affectively complex field of medicine. The cognitive abilities required for the profession self-select for those who are more highly motivated by a heightened, even compulsive need for perfectionism. These tendencies can also trend toward intolerance of or poor adaptability to the inevitable ambiguity and imperfection of the deeply human processes involved in health care, “difficult” patient or not. The threatened perfectionist may defend more actively with a hyper-fixation on the fix – more tests, more effort, compulsive energy put toward achieving a solution. and a reflexive, mindless overemphasis on tests, procedures and low-yield treatments.

Narcissism:

While perfectionism is a more comfortable tendency to identify with, an

exaggerated desire to be thought well of is perhaps more difficult to own up to. This narcissistic style – a hypersensitive need to see oneself as worthy and even extraordinary – is classically considered a defense against a insecure sense of one’s own unconditional self-worth and inherent

6 value. Ironically, the initial transaction here is often unrealistically positive – the difficult/needy patient and special doctor colluding on an idealized construction of the physician as different and better. That idealization inevitably gets challenged, painfully - such as in the setting of a patient who does not respond to treatment, reflects anger, or otherwise sabotages effective care.

Narcissistic types may respond to this denting of the self in a more active way, via confrontation with the difficult patient; or via a more passive response of retreat into inaction.

Counter-dependency/“false altruism”: This style manifests an ego-driven portrayal of selflessness in the service of patient care. This physician couches the need for specialness of purpose in a style that tends to engage the patient in a regressive and condescending way, often treating the patient in a condescending, child-like way, as a “victim of circumstance”.

Such

physicians reflexively, mindlessly extend extra time and effort in professional service, with little awareness of imbalances generated in the physician’s own personal life and threatening a healthy and more balanced direction of personal resources both within and outside the professional role.

This style may also be described as “false altruism” to distinguish it from authentic altruism, a true opening in compassion to the patient’s suffering. Psychoanalytic theory tells us that this false compassion represents an unconscious acting-over to suppress angry affects at being unfairly overburdened. Buddhist psychology has a blunter term for this state: “idiot compassion”, suggesting a masquerading of the ego in the costume of caring.

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7 CYCLES OF DIFFICULT INTERACTIONS Figure 1. The Doctor/Patient Transactional Cycle.

With this background refining of characteristic temperamental tendencies in both patients and physicians, we can approach “difficult patient” archetypes not as static snapshots but instead an interactive cycle fed by the personality dynamics of both parties. Each brings their own “baggage” to the trip and, ultimately, may perpetuate a mutually reinforced cycle of ineffective interaction. As seen in figure 1, each cycle has some emblematic features: •

a core patient vulnerability which tends to generate a predictable defensive reaction – what can be termed a “power move”;

•

a familiar experience - a “felt sense” - in the physician, which may generate or amplify vulnerabilities typical of that physician’s archetypal mix of tendencies;

•

contingent on that physician’s level of awareness and alertness to the interaction and tendencies thereof, the physician’s own reactive behaviors may reinforce the dysfunctional cycle, as opposed to attending to the cycle to resolve it in the service of a more effective transaction.

Letting the cycle run out of awareness only gives it power and perpetuates it. Understanding, anticipating and cultivating a skill set in full awareness of this cycle - including both the patient’s and the physician’s contributions - can lead to tactics that can help to break the ineffective cycle and lead to better medical outcomes. While every transaction is its own drama, there are some characteristic reactions and counter-reactions to look for, summarized in Figure 2, and described in more detail below.

Anxious/Hypersensitive Cycle: The characteristic felt experience of a physician in the setting of the needy, anxious archetype tends toward a sense of depletion – of “nursing to empty”, to use a maternal metaphor. A more self-aware analysis of the felt sense of depletion interprets it not as a personal intrusion but instead as a marker of patient anxiety and insecurity. If that subjective, “gut” sense of being depleted is poorly attuned to, it may manifest in some characteristic ways, all with the common theme of suppressing/avoiding other than attending to the affect generated.

8 •

the perfectionistic physician responds with further effort, harder work, and compulsive action on behalf of solving the puzzle but avoiding the underlying affects; then ultimately disengaging via “burning out” in failed effort.

•

The narcissistic physician may feel it as an ego boost but inevitable let down as the patient’s incessant neediness is not solved;

•

The counter-dependent physician may respond with a regressive rushing-in of the “mother’s milk” of extra time in consultation, or new and special treatment; later disengaging using a contrived frame of “helpless” retreat.

Modeling predictability and good boundaries in the physician’s own actions is essential here, including setting appropriate, firm expectations around scheduled visit times and visit length, expectations for attending to non-emergent contacts outside of scheduled visits, and the finite nature of outpatient appointments in attending to what may be a long problem list. A metaphor often used in our clinical teaching is of a “dose of doctor” - the interaction itself sometimes operating as an addictive substance for the anxious, needy patient, and best prescribed in a deliberate, structured, standard (rather than PRN) regimen. Lastly, reframing care as collaboration, with patient as a partner in the mission, challenges the undercurrent, “needy child testing the parent” transaction. Self-monitoring diaries and coaching in healthy self-care (rest, nutrition, exercise, stress management tactics) all can truly help in this regard.

Angry/Narcissistic Cycle:

The angry narcissist, driven by poor tolerance of interior tension,

shows an externalized, aggrieved reaction. The gut-level reaction of the physician is of feeling attacked. Opening to the experienced anger of the narcissistic patient can lead to understanding it as at least in part a projected manifestation of the patient’s own projected shame, borne of a sense of feeling imperfect or flawed. Each of the characteristic archetypal physician styles will have its own tendencies in managing that sense of attack first via reflexive engagement, then by withdrawal: •

The perfectionistic physician again responds to attack with a familiar flurry of more action to fix the problem and avoid interacting with the vivid, angry affect generated. As the patient’s angry, entitled style does not wane with the extra effort and may often, in fact, amplify as time and grievances over unresolved inner tension pile up, the perfectionist burns out.

•

The narcissistic physician attending to an angry narcissistic patient can be a combustible interaction, with a mutual need to be appreciated as extraordinary– a shared idealization doomed to mutually disappoint. The narcissistic physician may personalize the felt sense

9 of being attacked as “ego injury” – and mirror it back via confrontation with the patient.

A well-intended setting/re-setting of boundaries around angry patient demands may bloom into a more sadistic withholding of appropriate treatment or a more passive tack, delaying the call made, refill called in, or form filled out.

•

The counter-dependent physician tends to respond to the push of threat, entitlement and attack by reframing the work in a regressive way – “I can soothe this poor, angry creature”- that avoids directly addressing the impact of apparent anger on the interaction.

Such interventions may be perceived by the angry patient as further devaluing in the wrestling for power in the interaction, leading to more tension. With minimal returns on those efforts efforts, passive retreat may ensue.

Being tuned in one’s awareness to one’s own rising “boiling point” is essential, as perceived attack is a trigger for the physician’s own fight/flight reactivity. As the patient's frustration may be a valid manifestation of the physician's own real shortcomings in practice, a careful review of one’s own clinical actions and decisions is necessary and valuable, to see what could be improved and what reasonable but unsuccessful interventions may be nevertheless being misinterpreted by the patient. Most of all, acknowledging and empathizing the patient’s discontent - “you seem angry - if so, I want to understand that better” – can be helpful in coaxing the latent tension into a verbalized rather than an acted-out state. Many physicians are reluctant to comment with empathy on the patient’s angry state, fearing it will bring further attack or even represent an admission of guilt. Opening in conversation to the whole display – the patient’s medical suffering And how they psychologically ache about it – is more likely to make it safer for the narcissistic patient to collaborate on a healthier view of medical care as a well-intended, at times imperfect, and almost always emotionally provocative experience. In those rare circumstances in which the patient’s unrelenting negativity and even threat bluntly interferes with the treatment process, early detection, acknowledgement and documentation of the patient’s reactive behaviors can be of benefit in the subsequent events, which may include management of litigation and/or transfer of care to another physician.

Passive/Aggressive Cycle: The Passive-Aggressive patient acts out poorly tolerated interior states of tension via passive sabotage of treatment. The typical felt-sense reaction of the physician to the dissonance between perceived alliance with the patient in face-to-face encounters and observation of counter-therapeutic behaviors outside of the consulting room is one of uncertainty, of “what’s wrong with this picture?” Each of the characteristic archetypal physician styles will have its own tendencies in reacting to this dilemma:

10 •

The perfectionistic physician defends against feeling the covert hostility expressed in “defeated” attempts to help by avoiding the feeling generated and funneling that energy into a difficult intellectual task to be completed. As with the other interactions, this cycle can only run so long, then trend toward burnout and retreat. The passive-aggressive patient may well respond by ”upping the ante” in terms of poor self-care in ways characterized as factitious behavior in the DSM manual - self-destructive behavior without a clear secondary gain, but that nevertheless preserves the “dance” with the doctor.

•

The narcissistic physician initially attends to the passive/aggressive patient’s presentation with attraction to the initial professed need of the patient pulling on the doctor’s own idealizing cravings - risking enmeshment in a symbiotic way with the sick-role interaction. Subsequent frustration from ongoing treatment failure can become amplified and personalized over time. Chronically defeated care can lead eventually to a rejection of the patient: covertly, by not responding to poor compliance with visits (in essence, colluding with the patient’s covert poor self-care by letting them go from treatment without comment), or via bringing the hostility from a covert to an overt state via confrontation and firing. The consequence of the latter may provoke a more overt selfdestructive response from the patient, as it recapitulates a chaotic, ambivalent parental relationship likely experienced in early childhood.

•

The counter-dependent physician is faced with a kind of similarity with the passive/ aggressive patient: both parties tend to suppress negative affects in service of a stable, if superficial interaction and avoidance of overt conflict. The physician allies with only the positive, surface identity of the patient as victim of medical circumstance; the patient covertly creates the conditions to stay sick and preserve the regressive cycle of interaction.

The “I know what’s right for you” physician style may, then, mesh

symbiotically with the patient’s for long periods of time, while the ultimately necessary exposure of the patient’s self-sabotage is avoided.

The physician’s perception of uncertainty here is perhaps the subtlest of “difficult patient” reactions and a testament to the latent, often stable symbiosis that this particular interaction creates. With its recognition comes the challenge of broaching the pattern with the patient, who may be only minimally aware of his/her role in the ineffective interaction and threatened by bringing the psychological aspect into open discussion. Allying in empathy with the projected felt sense – “your treatment hasn’t been all that successful - how do you feel about that?” - can start to build a more reality-based alliance with a patient who one can reasonably speculate feels uncertain and conflicted, too. This involves empathizing with the underlying affect but not the

11 defensive tactic; instead, reality testing the difficult state in an accepting way, diminishing the fear that losing the symptom will result in losing the doctor. In re-engaging the alliance on more realistic ground, negotiating (as opposed to dictating) explicit expectations and monitoring around follow-through of treatment recommendations is an essential tactic.

Borderline Cycle: The psychoanalytic term “borderline”, referring historically to a border between neurotic and psychotic states, is more clearly understood today as identifying the most unstable and primal of temperamental tendencies.

Per Graves, these patients endeavor to

“ruthlessly destroy the very care they crave.” Like the Passive/aggressive, the Borderline archetype acts out interior tensions via sabotage of treatment, but is much more overt in expressing and manifesting the intense rage and anxiety over perceived abandonment – commonly with roots in a chaotic, traumatic early life. The typical felt-sense reaction(s) of the physician in the care of such a profoundly troubled individual are truly fluid and will often include all of the other described archetypes (depletion, attack, and uncertainty) - and ultimately generating a “meta”–reaction of disgust with the total interaction – a clear projection of the patient’s own radiating self-loathing.

This dynamic can also manifest in the overall healthcare setting via “splitting” behaviors. In essence, the patient splits off intense mixed feelings toward the medical interaction by identifying some parties in the interaction as “all good”, others as the opposite. Unusual interpersonal tension among treating staff, especially in inpatient environments, is a reliable marker of Borderline pathology.

Each of the characteristic archetypal physician styles will have its own tendencies in reacting this most challenging interaction: •

The perfectionistic physician reacts to the chaotic, minimal alliance with the patient, and the disgust it generates, with familiar “fixing” defenses.

As the core drive of the

Borderline is not to fix the problem but rather to use the relationship as a stage to re-enact suffering, there is very little “fixing” incentive for the perfectionist to counterweigh the understandable urge to exit the relationship. The patient in essence projects on the physician a sense of any solution not mattering.

•

The narcissistic physician may well have an automatic, immediate reaction to the repulsive intensity of the interaction– a resonance with that patient’s intense negative reactivity to the perceived self-centered style of the physician. While there may be serial moments of craved-for idealization feeding the narcissistic physician from the Borderline patient, their fleeting nature and tendency to morph into rebound rage ultimately repels doctors of this archetype.

Both temperamental styles operate in hypersensitivity and

12 trading of aggression, even tending toward sadistic, mutual abuse in the relationship if not observed and managed.

•

The counter-dependent physician manages intense disgust via dropping into a selfless, parental-istic approach with limited expectations for the patient’s role and self-control.

Of the three physician archetypes it may be the best suited to co-exist with the Borderline, as in absolute terms any physician is wise to limit, yet not eliminate, expectations for a productive, effective treatment relationship. Yet the counter-dependent physician risks particular fallout from inattention to the repressed sense of hatred in the interaction.

Losing empathy completely, but needing to couch that in condescending

terms, this physician may allow any and all wayward, self-destructive behavior as OK – a radical acceptance of “that’s just that Borderline patient” – without therapeutically confronting the obvious.

This represents a false presence, a therapeutic absence that

often echoes an aspect of the Borderline’s own early attachment difficulties – a parent perhaps physically present but absent in terms of care, direction and security.

Often, such clinical interactions escalate with the patient testing the ability of the physician to tolerate increasing chaos in terms of suicidality, self-harm, and refusal to tend to medical illness.

Such testing can also be seen as a form of sadism inflicted on the doctor - a projection of the patient’s own self-destruction – that needs to be forthrightly identified and confronted as a condition of ongoing treatment, with intensive, secure psychiatric treatment a default response for such behaviors.

A more mindful approach to the interactions with this most difficult type of patient begins with monitoring and even lowering one’s own realistic expectations for success. These are incredibly troubled human beings manifesting their suffering in a provocative fashion. Any expectation of smooth sailing is an unrealistic one; gains are best measured in terms of a gradual improvement over time in the frequency and severity of behavioral milestone events, such as fewer outbursts of acting out or self-harm – signs of marginal but gradual gains in their self-control in the relationship.

Besides these managing of physician expectations, it is similarly essential that

patient expectations be clearly and deliberately set from the start. These include setting ground rules for scheduled visits (timeliness and duration), appropriate reasons/triggers for emergent contacts, and clear expectations of what behaviors will generate an emergent (i.e. 911)

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Anxious/ Hyper. sensi/ve1

“feel1bad1=11 AM1bad”1

“dependent' clinger”'

Angry/ Narcissis/c1 “en.tled' demander”'

“feel1bad1=1 who’s1to1 blame?”1

Depleted;1 exhausted1by1 needs1

Threat11 ALacked1

Cri/cism1 En/tlement1

Intolerable1 anger1

“’manipula.ve' help5rejecter”'

(thus1buried,1 covert)1

“’self5destruc.ve' denier”'

More1aLen/on1 Boundary1 breaks1

Passive/1 Aggressive1

Borderline1

P:1“I’ll1figure1it1out,1just1 work1harder”1

Neediness1

Rage1over1 abandonment1 1(quite1overt)1

Needy,1but1 sabotages1 treatment1

Uncertain;1 “what’s1wrong1 with1this1 picture?”1

Overt1self. destruc/ve1 behaviors1

All1of1the1 above;1disgust1

Minimal1 alliance1for1tx1

N:1“He/she1needs1me”1 C:1“the1poor1thing”1

“This1makes1you1 anxious1–1I1 understand”1 Set1boundaries1 “Dose1of1MD”1

P:1Frozen1(hard1to1work1 when1aLacked)1

“This1makes1you1angry1 –1I1understand”1

N:1“No,1how1dare1YOU?”1

Watch1own1reac/on1

C:1I1can1soothe1the1beast”1

Be1thorough1

P:1Endless1tests…1

“This1must1be1difficult1 for1you”1

N:1Mixed1(sick.role1feels1 good,1but1tx1failure1not)1 C:11Allies1with1“poor1 thing”,1stuffs1the1disgust1

“Here’s1how1we1need1 to1work1together”1(set1 explicit1expecta/ons)1

P:1Doesn’t1maLer1if1I1 figure1this1out”1

“This1all1feels1out1of1 control,11you1agree?”1

N:1“Don’t1want1this”1

Manage1(lower?)1your1 expecta/ons1

C:1“I1wish1him/her1well,1 but1….”1

Set1basic1expecta/ons1 for1behavior1

MD1Archetype1styles:11P=Perfec/onis/c11N=Narcissis/c11C=Counter.dependent1

Figure 2. “Difficult” patient archetypes and cycles.

14 response from the physician. Finally, as with other patient archetypes, working to cultivate the verbalizing (rather than acting out) of tension and discontent is the broad goal in a mature doctor/ patient reaction. Routinely pointing out, without judgment, the reality of the patient’s out-ofcontrol behaviors can be challenging but can open to a shared goal of working together to improve it.

BUILDING BETTER AWARENESS A necessary, even at times sufficient antidote to the patterning described above is to cultivate an awareness – a mind’s eye or “landscape” view - of the interpersonal interaction occurring in the consulting room. While any physician may have the understandable tendency to flee or minimize the intense emotional load that difficult patients transfer in interaction, cultivating one’s own “gut” - the felt, subjective sense of being in the midst of a particular transaction - and critically observing the outcome can help identify and break the cycle. Without a developing awareness of and ability to identify how each of the patient archetypes “makes us feel”, to use another cliché but appropo term, physicians and patients are prone to inevitable cycling.

Bateman and Fonagy have written deeply on this subject in the area of psychiatric care of personality disorders – employing the term mentalizing to refer to a trainable practice of attending to and conceptualizing mental states in oneself and other(s) in the interaction.

Mentalizing as described the those authors is a mostly pre-conscious, imaginative activity applying intuitive skills based on what one knows about the background of the individual as well as one’s own temperamental tendencies to help shape the interaction. This “landscape” view of the interaction promotes a process of parallel, side-by-side attention, valuing a mutual goal of shared understanding. It models and reinforces managing states of tension not by behavioral acting out, but instead by reflection, self-awareness and verbal communication.

Physicians can help cultivate a broader self-awareness in general and a mentalizing, felt sense in particular, by a range of practices and attitudes.

First, doctors need to reality-test and corroborate their subjective experience by the use of peer/ mentor support and mirroring. This can take the form of an as-necessary curbsiding of the felt experience of a particular case with a colleague. More organized endeavors such as Balint groups, commonly offered to medical residents for support and insight, also suffice. However exercised, some deliberate intention to process with trusted others both the “video” (witnessed narrative) and the “soundtrack” (somatic/emotional felt tone generated) of the doctor/patient interaction can help correct distortions and help reinforce one’s own developing awareness.

15 Besides the support and corroboration of colleagues, cultivating one’s psychological/emotional self-awareness is often an interior affair. Mindfulness meditation is a superior mode of training in this goal – not just in treating one’s own ambient tension, but more importantly in entraining the observation of one’s own mental processes in a gradually more subtle, granular way. Whether via basic sitting meditation or by mindful movement practices, awareness training sharpens one’s ability to tune in, in clarity, to the complex interaction and its effect on the individuals involved.

Finally and mirroring the discrete structuring recommended for patient interactions, physicians can benefit by modeling some structure and expectation management in one’s own attitude and approach in and out of the medical setting. Such structure includes intentional setting and holding to reasonable work hours; adequate rest; routinized breaks for leisure; and an cultivated, active personal life outside the professional identity. These suggestions are admittedly obvious, even cliché’; yet remarkably poorly adhered to by many physicians, owing in part to the temperamental tendencies described above.

Effective medical care of individuals in states of medical suffering is benefitted by physicians cultivating a deepening awareness of the basic interpersonal interaction - between two individuals, doctor and patient, each with their own complex landscapes of mind. Particularly with “difficult” patients, identifiable because they can generate considerable emotional reactivity in physicians – awareness of both the patient’s temperament, the physician’s own temperamental tendencies, and one’s in-the-moment “felt sense” in clinical interactions – helps inform how physicians may model and reinforce a healthier interaction and more effective medical care in the here and now.

16

Anxious/ Hyper. sensi/ve1

“feel1bad1=11 AM1bad”1

“dependent' clinger”'

Angry/ Narcissis/c1 “en.tled' demander”'

“feel1bad1=1 who’s1to1 blame?”1

Depleted;1 exhausted1by1 needs1

Threat11 ALacked1

Cri/cism1 En/tlement1

Intolerable1 anger1

“’manipula.ve' help5rejecter”'

(thus1buried,1 covert)1

“’self5destruc.ve' denier”'

More1aLen/on1 Boundary1 breaks1

Passive/1 Aggressive1

Borderline1

P:1“I’ll1figure1it1out,1just1 work1harder”1

Neediness1

Rage1over1 abandonment1 1(quite1overt)1

Needy,1but1 sabotages1 treatment1

Uncertain;1 “what’s1wrong1 with1this1 picture?”1

Overt1self. destruc/ve1 behaviors1

All1of1the1 above;1disgust1

Minimal1 alliance1for1tx1

N:1“He/she1needs1me”1 C:1“the1poor1thing”1

“This1makes1you1 anxious1–1I1 understand”1 Set1boundaries1 “Dose1of1MD”1

P:1Frozen1(hard1to1work1 when1aLacked)1

“This1makes1you1angry1 –1I1understand”1

N:1“No,1how1dare1YOU?”1

Watch1own1reac/on1

C:1I1can1soothe1the1beast”1

Be1thorough1

P:1Endless1tests…1

“This1must1be1difficult1 for1you”1

N:1Mixed1(sick.role1feels1 good,1but1tx1failure1not)1 C:11Allies1with1“poor1 thing”,1stuffs1the1disgust1

“Here’s1how1we1need1 to1work1together”1(set1 explicit1expecta/ons)1

P:1Doesn’t1maLer1if1I1 figure1this1out”1

“This1all1feels1out1of1 control,11you1agree?”1

N:1“Don’t1want1this”1

Manage1(lower?)1your1 expecta/ons1

C:1“I1wish1him/her1well,1 but1….”1

Set1basic1expecta/ons1 for1behavior1

MD1Archetype1styles:11P=Perfec/onis/c11N=Narcissis/c11C=Counter.dependent1

17

!FS! !V!

5

References/5AddiBonal5Readings5

Groves5JE:5Taking5care5of5the5hateful5paBent.5N5Engl5J5Med51978;5298(16):883G887.55 American5Psychiatric5AssociaBon.5(2013).5DiagnosBc5and5staBsBcal5manual5of5mental5disorders:5 DSMG5.5Washington,5D.C:5American5Psychiatric5AssociaBon.55 Klein,M.51946.5Notes5on5some5schizoid5mechanisms.5InternaBonal5Journal5of5Psychoanalysis.5 27:99G110.55 Bowlby5J;5A\achment5and5loss,5Vols5I5and5II.5Hogarth5Press,5London5(1974)55 Ainsworth,5Mary5D.5(Salter),5Mary5C.5Blehar,5Evere\5Waters,5and5Sally5Wall.51978.5Pa\erns5of5 A\achment:5A5Psychological5Study5of5the5Strange5SituaBon.5Hillsdale,5NJ:5Erlbaum.55 Main,5M.,5&5Solomon,5J.5(1990).5Procedures5for5idenBfying5infants5as5disorganized/disoriented5 during5the5Ainsworth5Strange5SituaBon.5In5M.T.5Greenberg,5D.5Cicche]5&5E.M.5 Cummings,5A\achment5during5the5preschool5years:5Theory,5research5and5intervenBon.5 pp.5121–160.5Chicago:5University5of5Chicago5Press.55

18 Feli]5VJ,5Anda5RF,5Nordenberg5D,5Williamson5DF,5Spitz5AM,5Edwards5V,5Koss5MP,5Marks5JS.5 RelaBonship5of5childhood5abuse5and5household5dysfuncBon5to5many5of5the5leading5 causes5of5death5in5adults.5The5Adverse5Childhood5Experiences5(ACE)5Study..5Am5J5Prev5 Med.519985May;14(4):245G58.55 Groves5JE:5Borderline5PaBents,5in5Hacke\5TP,5Cassem5NH5(eds):5The5MGH5Handbook5of5General5 Hospital5Psychiatry,5ed.51.5St.5Louis,5CV5Mosby5Co,51987,5pages5184G207.55 Balint,5M.5The5doctor,5his5paBent5and5the5illness.5London.5Pitman5Medical.52nd5ediBon5(1964,5 reprinted51986)5Edinburgh:Churchill5Livingstone;51957.55 Berne,5Eric5Games5People5Play5–5The5Basic5Hand5Book5of5TransacBonal5Analysis.5New5York:5 BallanBne5Books(1964).5 Krebs,5EE,5JM5Garre\,5TR5Konrad.5The5difficult5doctor?5CharacterisBcs5of5physicians5who5report55 5 frustraBon5with5paBents:5an5analysis5of5survey5data.5BMC!Health!Services!Research.55 5 2006;56:128.55 Hass5LJ,5Leiser5JP,5Magill5MK,5Sanyer5ON.5Management5of5the5Difficult5PaBent.5American!Family!! !

Physician.52005515;572(10):52063G2068.5 Lipsenthal,5L.55The5Physician5Personality:5ConfronBng5Our5PerfecBonism5and5Social5IsolaBon.55 5 HolisBc5Primary5Care,5Vol.56,5No.53.5Fall,520055 Gabbard,5G.5The5Troubled5Physician5and5the5Perils5of5PerfecBonism.55Grand5Rounds,5Menninger55 5 Department5of5Psychiatry5and5Behavioral5Sciences,5Baylor5College5of5Medicine,52005.5 Banja,5JD.55Medical5Errors5and5Medical5Narcissism.52295pp.5Sudbury,5Mass.,5Jones5and5Bartle\,55 5 20055 Alexander5GC5et5al.5Brief5Report:5Physician5Narcissism,5Ego5Threats,5and5Confidence5in5the5Face55 5 of5Uncertainty.55Journal5of5Applied5Social5Psychology,52010,540,54,5pp.5947–955.55 Oakley5B55et5al,5Pathological!Altruism,5Oxford5University5Press,52012.5 Bateman,5A.W.,5Fonagy,5P.5(2004).5MentalizaBonGbased5treatment5of5BPD.5Journal5of5personality55 5 disorders,518,536G51.5 5 Allen,5J.G.,5Fonagy,5P.5(2006).5Handbook5of5mentalizaBonGbased5treatment.5Chichester,5UK:5John55 5 Wiley.555 55 h\p://well.blogs.nyBmes.com/2009/10/15/forGdoctorGburnoutGmeditaBonGandGmindfulness5 KabatGZinn5J.5Wherever5You5Go,5There5You5Are:5Mindfulness5MeditaBon5in5Everyday5Life.555 5 Hyperion5Books,520055

19 Michael5S.5Krasner;5Ronald5M.5Epstein;5Howard5Beckman;5et5al.55AssociaBon5of5an5EducaBonal55 5 Program5in5Mindful5CommunicaBon5With5Burnout,5Empathy,5and5A]tudes5Among55 5 Primary5Care5Physicians.55JAMA.52009;302(12):1284G12935 This$CME$ar9cle$revisits$a$classic$paper$about$complex$doctor/pa9ent$interac9ons,$framing$a$ novel$transac9onal$model$for$aFending$to$both$pa9ent$and$physician$character$styles$and$ providing$strategies$for$iden9fying$and$managing$these$interac9ons.$ Key$Points:$ •$ “Difficult$pa9ents”$oOen$have$lifelong$struggles$with$their$view$and$value$of$self:$ manifest$in$difficulty$with$experiencing$and$tolera9ng$inner$tension$and$acted$out$in$ rela9onships$–$including$the$doctor/pa9ent$rela9onship$ •$ Physician/pa9ent$interac9ons$are$complex$and$involve$the$contribu9on$of$ temperamental$characteris9cs$of$both$par9es$ •$ par9cular$"archetypes"$of$difficult$pa9ents$tend$to$generate$some$iden9fiable$interior$ reac9ons$T$deple9on,$feeling$aFacked,$uncertainty,$and$disgust$T$which$the$physician$may$use$ produc9vely$to$inform$treatment$ Q/A 1

In Groves’ paper “The Hateful Patient”, “entitled demander” is a “difficult patient" archetype that aligns with which DSM-based personality style?

A B C D E

Anxious Narcissistic Schizotypal Borderline Obsessive/Compulsive

2

Which classic psychoanalytic defense mechanism is identified as prominent in most “difficult patient” interactions?

A B C D E

Reaction Formation Sublimation Repression Projective Identification Dissociation

3

In Felitti and Anda’s Adverse Childhood Experiences (ACE) study, early childhood adverse experiences are associated with high rates of which medical and/or psychological manifestations in adulthood?

A

Mood Disorders

20 B C D E

Cardiovascular Disease Auto-immune Disorders Chemical Dependency All of the above

4

The typical projected, “felt sense” experience of the physician in interacting with the anxious/ hypersensitive (“dependent clinger”) patient archetype is:

A B C D E

Depletion Disgust Elation Feeling attacked Uncertainty

5

The term "mentalizing" as developed by Bateman and Fonagy refers to:

A B C

Rationalization of affects experienced in working with patients Suppression of feelings A trainable practice of attending to and conceptualizing mental states in oneself and other(s) in the clinical interaction Imagining human responses from other species

D