Engaging the “Difficult” Patient: Strengthening Empathic Communication Skills

Medical communications researchers Roter and Hall (1) commented that “talk is the main ingredient in medical care and it is the fundamental instrument by which therapeutic goals are achieved” (p. 8). The doctor-patient relationship has been, and remains, the cornerstone of all medical care. It is the medium by which symptom data are gathered, diagnoses are made, and the patient is engaged in the joint enterprise of treatment. An empathic connection is at the core of this healing relationship (2). Clinical empathy involves understanding a patient’s perspective, resonating emotionally, and expressing care and concern, sometimes labeled the cognitive, affective, and behavioral dimensions of empathy (3). Compassion, a similar concept, is when empathic feelings and thoughts include the desire to help. In treating a “difficult” patient, researchers have identified three sources of difficulty: the patient’s issues; the relationship between the clinician and the patient; and the social, cultural, or systemic context of the encounter (4).

Koekkoek and colleagues (5) identified characteristics of “difficult” patients. The type of patient who was uniformly described as difficult in their review was labeled the “ambivalent care seeker.” These patients frequently present with mood and personality disorders and were often demanding, demeaning, self-destructive, dependent, and untrusting. Negative countertransference emotions toward these “difficult” patients were regularly stirred up in the staff working to treat them. Undesirable terms were often used when staff described the “difficult” patient (5), and the staff subtly, or not so subtly, expressed exasperation or a wish to terminate treatment. Thus, the “difficult” patient is at risk for poor care or dropping out of care due to difficulty maintaining a steady relationship with caregivers. The very fact that these “difficult” patients may exhibit frustrating behavior that inhibits empathic connection suggests that empathic connection—the need to feel understood, accepted, and respected—may be the fundamental ingredient for engagement and treatment effectiveness.

There have been a number of curricula that include empathy and compassion training in medical education. A recent systematic review (6) of curricula suggested that 75% of studies found that the tested curricula improved physician empathy, compassion, or both on at least one outcome measure. Key behaviors that were effective included sitting rather than standing during the interview; detecting patients’ nonverbal cues of emotion; recognizing and responding to opportunities for compassion; nonverbal communication of caring; and verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perceptions of physician empathy. Although various curricula demonstrated improvement in specific skills, there is no unified model with regard to educating clinicians in empathic skills. Most interventions have been evaluated for short-term results, utilize disparate theoretical and practical approaches, and capture only a portion of the richness of genuine empathic communication (7).

One innovative method for deepening clinicians’ empathic communication skills was developed by Marjorie Heymann. A theater director and scholar of the psychology of theater, Dr. Heymann noted that the essence of the theater experience for both actors and audience is immersion into the emotions, needs, and motivations of the characters as they interact with each other. Her seminar, “Working with Challenging Patients and Families: Maximizing Your Clinical Effectiveness,” has been offered under the auspices of The REACH Institute in New York. Dr. Heymann translated her approach to training actors into a systematic approach to training clinicians to communicate empathically, even with difficult patients. The techniques are designed to enhance understanding of the patient’s needs, emotions, motivations, and relationship to the clinician (8).

Heymann identified a key ingredient in empathic communication as the actor’s ability to listen with deep attention to the other actors. The response of the other actors must combine other-directed empathy with their ability to inhabit their own character’s reality. Heymann’s method focuses on helping clinicians understand patients’ needs and motivations in the moment of the clinical encounter. It recognizes that clinicians can be present in dealing with patients’ needs and motivations only when they first have an empathic understanding of their own needs and motivations (8).

Heymann’s method starts by helping clinicians practice dealing with distractions. Mindfulness meditation is one technique. Small distractions may be mentally acknowledged and confronted. Larger worries may be handled by making an appointment with oneself for a later time to problem-solve the issue. Having set aside distractions, the clinician is prepared to be fully present in the encounter.

According to Amsel (8), “The genius of the theatrical approach to listening is learning to hear the needs beneath the words. Heymann emphasizes that listening for needs, as opposed to listening for emotions, can make a real difference in the empathic connection. Emotions are of course important, but they are also often changeable, vague, and difficult to capture. Needs are more concrete and often more easily understood.” Major categories of needs that both clinicians and patients are likely to bring to the encounter include the needs for control, respect, acceptance, help, love (or liking), and safety. Clinicians need their patient’s trust and engagement in the healing process.

Clinical Vignette

Ms. Tami Thompson is a 20-year-old college student who recently took a leave of absence from a college several hours away because of erratic moods, self-injury (cutting), suicidal ideation, and conflict with her roommate. She has been in treatment with Dr. Patel for the past 3 years. Ms. Thompson burst into the psychiatric office waiting room and checked in. She took a seat near the receptionist, opened a magazine, and began to flip through the pages loudly. Her sense of urgency was palpable.

Dr. Patel sat in her office, her eyes closed, breathing deeply in mindfulness meditation. She opened her eyes, looked at the clock, took one last deep breath, walked to the door, and opened it.

“Please come in,” she said, motioning to Ms. Thompson.

Ms. Thompson practically leapt out of her chair and entered the office. Before she sat down, Ms. Thompson blurted, “You gave me bad advice, Dr. Patel!”

Dr. Patel, slightly taken aback, replied in a calm voice, “Really? I’m sorry. Tell me what happened.”

“Well, you know I’ve been dating this guy, Danny,” began Ms. Thompson. “You said that I should be honest with him about why I am taking a leave of absence from college. Just like I thought, he broke up with me! He said that he thought a long-distance relationship would be too hard. I’m only 2 hours away! I was just starting to trust him, too! I think that when I told him I was dealing with depression, it scared him off. And you told me to tell him! I started cutting again. I was suicidal too, but you should be proud of me that I didn’t do anything. My mom said that I would have to go back to the hospital if I did. Well, if I were dead, I wouldn’t have to worry about any of this, would I? Oh, and by the way, you also said the medicine would help. It doesn’t seem to be, does it?”

Dr. Patel’s eyes grew soft as her gaze met her patient’s. She reviewed in her mind the skills practiced in the theater workshop she took on empathic connection. The mantra—focus on needs—came clearly to mind. What needs was Ms. Thompson voicing? Certainly, she was voicing the need to feel heard and validated. She needed to feel in control, as evidenced by her accusing tone. She needed to feel helped and cared about. Dr. Patel chose her words carefully.

“I hear you, and I am very sorry this is happening,” said Dr. Patel. “Trusting is very hard for you, and it was brave of you to tell Danny the truth about your depression. I understand how you must feel betrayed—by Danny and by me.”

“So, now I have new scars,” said Ms. Thompson, “just when my old ones were starting to heal.”

“Cutting must help you feel in control when life feels out of your control,” said Dr. Patel. “I’m sorry that you cut yourself. Thank you for not going further. You didn’t attempt to kill yourself, even when you felt like it. You told the truth and trusted that it was the right thing to do. Being honest brings you closer to others. It also can make you vulnerable to getting hurt. I’m very sorry about the hurt.”

Ms. Thompson continued, “Well, my mom said that if he didn’t accept me with my depression, it probably wouldn’t have worked anyway. What does she know? Maybe she’s right. I don’t know. I feel confused and angry.”

“And hurt,” added Dr. Patel.

“Of course, I feel hurt,” said Ms. Thompson. “Wouldn’t you? Oh, and my mom said she doesn’t think the medication is helping. I thought it was, and now I don’t know. I just want this pain to go away!”

“The emotional pain is agonizing,” said Dr. Patel, “and you want something that can really help.”

“Yes,” said Ms. Thompson. “Cutting helps for a while, but then the emotional pain is worse than ever. Perhaps I need a second opinion. This medication trial is taking too long.”

Dr. Patel asked, “Do you want a second opinion about the medication, the treatment plan, the therapy, or all of them? Of course, you are welcome to get another opinion. But I hope we can also discuss what your experience has been—what, if anything, has helped. Any side effects. What are you looking for in a treatment partnership to help you feel less depressed and more in control?”

Ms. Thompson was quiet, and a single tear began to trickle down her cheek.

“Well, you have stuck with me for 3 years now. That’s way longer than any other psychiatrist. So, I guess I mostly trust you. I mean, as much as I trust anyone, which isn’t very much.”

Dr. Patel ventured a reserved smile. “I don’t know. I think you have made some good progress on honesty and trust. You came today and were honest about how you felt. How can we move forward with your safety and your treatment?”

Dr. Patel and Ms. Thompson reiterated the safety plan. They made an extra appointment for several days hence to provide more support and to discuss medication and treatment plans more fully. Ms. Thompson smiled as she left.

“See you on Friday, Dr. Patel,” she said. Then, she followed with a quip she couldn’t contain: “Maybe.”

“Yes, see you Friday—for sure,” Dr. Patel countered. When she closed the door to her office, Dr. Patel sat, shut her eyes, and took a deep breath.

Tips for Working with the “Difficult” Patient

Empathic attunement, compassion, predictability, trustworthiness, and honesty are traits that are important in working with all patients—but are essential in working with the “difficult” patient. Although some clinicians may be more natural at acquiring and regularly demonstrating empathic communication skills, these are skills that can be learned (4, 6, 9).

A unique, although not entirely new, method of sharpening empathic skills is the use of theater training. Improvisation is one method of honing empathic communication (10, 11). The art of theater improvisation includes a combination of acceptance of an offer (“yes, and”), strong listening skills, helping your partners be successful, and knowing when to end a scene (or a topic). Although not everyone will want or need to take an “improv” class, an acting class, or a course on empathic listening, there are generalizable skills that, if practiced consistently, will improve empathic connection and help identify the need that a “difficult” patient is expressing. The following are recommendations from theater arts that may be practiced to deepen empathic listening (10, 11).

1. Clear your mind. Mindfulness exercises are one way of focusing and clearing one’s mind. Deal with distractions (or make a time later in the day to think them through, solve, and let go of the worry) so that you are ready to be completely present for your patient.

2. Do not pre-plan what to say next. Improvisation (as is therapy) is about staying in the moment and listening fully to your partner. Simply accept what the person shares, with gratitude. Then respond genuinely.

3. You do not need to agree with the person’s opinion. If the person’s statement seems inappropriate or disrespectful, you might say, “I know it wasn’t your intent, but that made me feel uncomfortable.” Rudeness or disparaging remarks may be confronted in an open manner.

4. Be grateful to the person communicating with you. If a patient has a complaint, first thank them for bringing the situation to your attention. Then you can explore the issue and make sure you understand the problem with which they are struggling.

5. Do not interrupt. Listen intently to the entirety of the other person’s communication before reflecting and responding.

6. Replace “yes, but” with “yes, and.” Saying “yes, and . . .” demonstrates that you listened carefully and that you are willing to explore new ideas.

7. Mirror what the other person said. A powerful way to confirm that you are listening and truly want to understand is to restate what the person said in your own words. Then, ask if you understood correctly.

8. Replace “should” with “could.” Beginning a sentence with “should” may sound critical and shut down communication. Beginning your response with “could” is more collaborative and helpful and may prevent the other person from becoming defensive.

9. Know when to end. If a conversation is not productive, despite all efforts at empathic communication, acknowledge the impasse. Offer another topic or issue that may be more productively considered in the remaining time.