Techniques for Other Challenging Situations
Essential Concepts
The hostile patient.
The seductive patient.
The tearful patient.
Be firm, fair, and understanding. Hold the reins in one hand and a lump of sugar in the other.
–Elvin Semrad The Heart of a Therapist
THE HOSTILE PATIENT
When a patient becomes hostile during an initial interview, remember that it’s not your fault. Unless you’re laughably incompetent or a real creep, a hostile attack is a product of the patient’s pathology. Common causes of patient anger during the first meeting include paranoid psychosis, irritability due to depression or mania, and borderline personality disorder. The best way to defuse hostility is to diagnose its cause and then target your intervention accordingly.
The Hostile, Paranoid Patient
The hostile, paranoid patient is angry at you because he perceives you as a direct threat or perhaps as part of an elaborate conspiracy. A good way to counteract this false projection is to use self-effacing humor or general goofiness, which is easier to pull off. The patient usually perceives this attitude as inconsistent with evil intentions.
CLINICAL VIGNETTE
A patient with the diagnosis of bipolar disorder was admitted involuntarily to the inpatient unit because of paranoia concerning her husband, who she believed was trying to have her killed. It was clear from the outset of the interview that she thought that she had been wrongly committed and wanted to leave immediately.
Patient: How can you keep me here? You have no right. I can call a lawyer.
Interviewer: You can certainly call a lawyer. The reason we…
Patient: (Interrupting) I can call a lawyer, but it’s not going to do any good, is it? All the lawyers are part of a big game, and they’re going to say just what you want them to say.
Interviewer: What kind of game do you think this is? Last I checked, this was just a psychiatric hospital.
Patient: You know exactly what’s going on here, and wipe that innocent look off your face.
Interviewer: I’m not innocent. I plead guilty to being a psychiatrist. I’m trying to help you. And if you believe that, I have a bridge in Brooklyn you might be interested in.
Patient: What bridge?
Interviewer: Oh that’s just an old joke, and a bad one. I find that I have to use humor to keep me sane here, you know? But enough about me. What were we talking about?
Patient: The people who are trying to have me killed.
At this point, the patient opened up significantly, and a productive conversation ensued. The attempt at humor was unexpected enough to derail an increasingly hostile train of thought.
The Irritable, Depressed Patient
Depressed patients can come across as hostile, but it is a hostility that cloaks a reservoir of pain. A good technique is to make a fairly direct interpretation, such as
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