How to Engage a Difficult Patient

Alyssa* is a 45-year-old Eastern European female admitted to the inpatient psychiatric unit for being a danger to others and for being gravely disabled. Alyssa’s landlord contacted Santa Monica Police after she threatened to kill tenants living in her building. Law enforcement brought her to the hospital after she verbally threatened to stab the police with a knife hidden in her nightstand. Upon arrival, Alyssa was extremely paranoid and claimed that numerous individuals are plotting to kill her. Upon a Biopsychosocial assessment, Alyssa threatened the social worker numerous times, stating that if she wasn’t discharged immediately, she plans to sue the hospital and have the treatment team arrested.

The above vignette is a common example of the type of patient I see on the inpatient unit at Harbor UCLA Medical Center. As a social work intern, interacting with patients who believe they do not belong on the unit is incredibly challenging. When interviewing or assessing newly admitted patients, it is not uncommon for patients to verbally threaten me, make snide or rude comments, or sit in silence. To be fair, it is completely understandable that patients are frustrated, angry, or embarrassed when they are legally required to stay at the hospital.

After trying a number of different ways to engage with patients like Alyssa, I now have a few go-to strategies that strengthen rapport, and ultimately, increase my ability to help patients during their stay.

1. Encourage Med Compliancy: While this might be controversial, I often tell patients that a surefire way to expedite discharge is through medication compliancy. This is a great way to align patient goals with those of the treatment team, as patients tend to stabilize much quicker when consistently adhering to medication regiments. Plus, there is no question that length of stay for those who take medication is shorter than those who don’t.

2. Alleviate boredom: Whether it’s retrieving a bible, a magazine from the hospital gift shop, or requesting the occupational therapist to play a song during exercise group, finding small ways to alleviate boredom allows me to form an alliance with patients.

3. Contact Collateral: Contacting patients’ family or friends can be a great way to connect with a difficult patient. Because patients do not always have change for the payphone or have access to the phone at the nursing station, I will often bring patients back to my office to make a phone call. The sentiment is definitely appreciated, especially when a patient is calling long distance.

4. Catch Patients Doing Good: Due to the nature of the inpatient milieu, the treatment team often focuses on patients who are either disrupting the unit, or refusing the take their medication. I have found it to be extremely important to “catch” patients who exhibit good behavior. Verbally reinforcing these instances is not only a chance to build rapport, but also shows the patient that the treatment team genuinely wants to see improvement.

5. Internet Research: Whether its providing patients with a brochure to an outpatient care provider or looking up an address so they can write a letter, conducting quick internet searches for patients can help link them to outside resources.

*Patient identity has been concealed.