We all have our fair share of so-called “difficult” patients. And, I would suggest that how we define “difficult” is as diverse as we are as health care providers and as individuals. Some patients come to us with that reputation—perhaps, a vague descriptor in a referral letter or a note in the patient’s chart. Maybe the receptionist or nurse makes a side comment that the next patient is “challenging” or “uptight,” and we accept their assessment.
Often the difficult patient is one who is anxious and/or overwhelmed, and this is manifested as anger or demanding behavior. I can deal with these kinds of difficult patients quite effectively for the most part. I strive to be on time, to see patients at the time of their appointment by building in 10 minutes between patients to allow for delays and for patients who take more time. I am fortunate that I have this luxury and don’t have to fit patients into a predetermined template that makes no allowances for patient delays, emergencies, and other unexpected usage of my time.
My “difficult” patients tend to be those who are in conflict with their partner and who have no apparent capacity for empathy. These are the patients who want what they want when they want it, and watch out if anyone gets in their way! One of these patients is a woman who has chronic health issues in addition to a diagnosis of cancer in the past two years. She wants to be loved and appreciated and has no insight into her behavior that pushes her partner away. She has done this so effectively that he is terrified of her and has stopped making any effort to comfort her because he just can’t seem to do anything right. She contradicts him during our sessions, interrupts him when he’s talking, and negates his opinions at every opportunity. She has started to interrupt me too—and I usually say very little and instead encourage couples to talk TO each other instead of listening to a lecture from me.
I have managed to bracket my increasing frustration with her. I have pointed out this behavior to her in our individual sessions, and when I do, she smiles, apologizes, and then proceeds to interrupt me whenever I decide to make a comment or ask a question. She has little insight into her demanding attitude towards her partner and constantly blames him for all that is wrong in her life. Their primary reason for seeing me in the first place, their lack of sex in the aftermath of her treatment, has retreated into the background of her battle to be right, all the time and with her partner, and increasingly with me.
I really hope that she will one day see, with clarity and acceptance, that she is making her partner’s life a misery and that she will never receive from him what she says she most wants. He cannot love and appreciate her because when she is bitter and mean she is not lovable and it is difficult for anyone, even someone who promised to be there, “for better or worse,” to move beyond the hurt of humiliation on a daily basis.
I know that he is not without his own contribution to this mess that they have created. He escapes to his office and spends long hours avoiding her under the guise of paperwork. He has stopped trying and so is not fully engaged in the work that they need to do in counseling. His spirit has left the marriage, and as much as she pushes him away, he has gone willingly.
So why do I continue to see them? I struggle with this question every time I see her name on my schedule. I truly believe that we can change our behavior and learn to be better than our instinctual selves. I see beyond her as a difficult patient and instead see her and them as a challenge, a broken partnership that could be mended, if only we could all, and I include myself in this, be kinder and gentler and more accepting.
So every time she walks into my office, alone or with him three steps behind, I take a deep breath and hope that this time it will be different and that she will allow herself to be vulnerable just this once, that she will hear someone else’s thoughts and not just her own, and that this time she will be able to change her behavior, even just for the 50 minutes in my office.