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.

Confronting the Language Barrier: Spanish for Mental Health Professionals

While I absolutely love my internship experience thus far at Harbor UCLA Medical Center, there is one skill I lack that immensely takes away from my ability to be a competent social worker on the inpatient milieu: I struggle with my ability to communicate with Spanish speakers.

Even though I studied Spanish in both high school and college (for a combined total of 5 years!), I can barely hold a conversation with patients. To say I am embarrassed is an understatement. Lucky for me, a good friend and classmate found a local Spanish class that is designed for psychologists, social workers, and other mental health professionals. The class meets every Friday morning from 8:30 a.m. to 10:00 a.m. at the Family Services of Santa Monica.

Unlike my grammar-focused Spanish classes in high school and college, the class is much more conversational. There are about eight social workers who attend the class, at varying degrees of Spanish competency. We spend a lot of time learning and talking to each other about Latino culture, in addition to practicing words that are helpful in a mental health setting. As a result, I no longer have to rely on the word "triste" to describe my patients' sad moods or affects. I now know words like aguitado (kind of depressed), desatendido (disregarded), depreciado (depreciated) and desilusionado (disappointed). Additionally, the teacher, Eugenio, is very laid back and very patient with all of us novice speakers. We also use the following text book: Spanish for Mental Health Professionals. I highly recommend the class to anyone who is looking to improve their Spanish-speaking skills. See the flyer below for contact information.
Spanish Class for Mental Health Professionals

You Say Mercedes, I say Mental Illness

"God is playing jai alai and you are the ball" 

Dan Neil, a Wall Street Journal reporter recently wrote this catchy description for a review of the new Mercedes CL63 AMG. While I thought this was a cute way to the describe how it feels to accelerate in the coupe, I could not stop thinking about how well these words describe the psychotic symptoms of mental illness, specifically the delusional and hallucinatory symptoms of schizophrenia and other thought disorders.

As an intern for Harbor UCLA Medical Center for the past three months, I have been exposed to a number of patients who are battling severe and persistent forms of schizophrenia. Patient's minds are often transfixed or paralyzed in nightmarish, violent, or persecutory states. Extreme distortions of reality can often have scary and real consequences.

For example, a patient was recently admitted to the inpatient unit after experiencing harrowing ideas of reference. Chorus lyrics from a rap song spoke to the patient in such a way, that he exhibited homicidal ideation towards members in his family. The patient internalized the lyrics and started to believe he was a God-like figure. He reasoned the only way he could preserve his status was to kill members of his family. Fortunately, the patient was admitted before he acted on any of these thoughts.

Another patient, also suffering from schizophrenia, held highly persecutory beliefs concerning her family. The patient was extremely paranoid, and believed her family worked for the FBI and they were plotting to kill her. The patient became distrustful of everyone around her, including her family and the treatment team.

As evidenced by these examples, patients succumb to an outside force that is much larger and stronger than themselves. As one does with a jai alai ball, these patients are figuratively swung around, flung high, and slammed by a disorder that pirates their perception of reality.

Outsiders might stigmatize these experiences as crazy, ridiculous or downright nonsensical. But to victims of mental illness, these experiences are tangible and overpowering. What is even more frustrating, is medicine to treat thought disorders does not suppress or eradicate delusions or hallucinations; patients simply have to learn to live with them.

Photo credit: Jamespot