When Patients Get Stuck

“I just don’t know what to do anymore. This patient keeps repeating himself over and over, and regardless of what I tell him, he keeps saying the same thing over and over.”

The last clinician who told me this was a mid-career psychiatrist, who called me for a case consultation. However, he was not the first; he was far from a handful, and he will certainly not be the last one. Whether psychiatrist, Nurse Practitioner, Psychologist, Social Worker or Licensed Mental Health Counselor, several clinicians consult with me on challenging cases, and many times, the initial statement is either, “I feel stuck,” or “this patient got stuck.” This article represents an extract of a consultation session with one of my colleagues.

Step 1.

The crucial point is that it may be more successful for us to change a behavior after we have accepted it and sometimes even formulated it. Having said that, acceptance is rather a question of attitude, spirit and “show not tell.” It also entails us realizing that this patient, for example, is repeating himself, in this case, for a reason. Repeating himself makes it hard for us to make progress in discussing “important matters,” and we need to find a way to manage this behavior. The best way for me to manage this behavior is far from trying to oppose it, resist it or fight back by interrupting him. Rather, the best way for me to manage it is to, again, accept it, then wonder what this is about and how I can help to manage it.

Step 2.

We may be more successful in changing our patients’ behavior by making them our partner, our ally and our collaborator. This happens by making it “us” instead of “you versus me.”

Step 3.

We may be more successful in obtaining collaboration and alliance from our patients by allowing them to trust us. And we will be more successful at allowing them to trust us by accepting them for who they are. Opposing them, resisting them, arguing with them, confronting them or judging them will lead to the exact opposite.

None of this means we will fail to establish safety or let things go as status quo or not intervene; no, not at all. The above three steps are part of a process, and, as this process unfolds, we need to intervene and establish and maintain safety.

The question is: how do we do this?

• Part A.
• Because we practiced acceptance, it becomes easier for us to validate. Because we validate, our patients are likely to feel heard and are more likely to become receptive to our intervention.
• Part B.
• Because our patients’ behaviors are likely to have existed for a long time, we are unable to expect that they will change overnight or as soon as we validate them. The expectation is rather that the behavior will continue, and our response is to be consistent: validate, then intervene; validate, then intervene and repeat until we have reached the desired outcome—a change in the behavior. We also need to remember to ensure that we are validating and intervening effectively. Otherwise, we need to adjust. For our patients do not fail our interventions, our interventions fail our patients. This is far from a slogan, and as long as we fail to believe and live this wisdom, we subject ourselves to one frustration after the next.

Step 5.

We may be more successful by being strategic in our interventions. Therefore, after we validate, it may be best for us to intervene in the form of strategic questioning, often by starting with the WHY. For example, for the patient, who keeps repeating himself, even after a complete validating statement, we can ask, “I am unsure if you notice this is the third time you have told me that lots of people are bothering you. Now, many times people say things several times until they feel that someone is really listening, hearing and understanding them. And I wonder how much you think that I am really hearing and understanding you.” A strategic intervention can also be a short statement followed by a validation. Again, in the case of this patient, after a complete validation, you can say: “You want to go to the hospital. This is very important for you, and we can work together to look into this. Now, I wonder if I can ask you this, ‘I wonder if you could tell me why you want to go to the hospital?’” This takes me to the next point:

Step 6.

The best way to collaborate with our patients is through strategic goal setting. And when our patients come with something in mind, we can use the 10 Commandments to Answer for What We Want (CAWW). (Please refer to previous articles on this topic).

In conclusion, we are likely to be more successful in implementing the above 6 steps by first preparing ourselves and continue practicing. For it is likely to be harder when in the midst of it. Therefore, the following three steps are recommended:

1. Set an outcome for each session or meeting you have with your patients (for example: “I want to accept that this patient repeats himself). It may slow us down, but we are unlikely to successfully manage it unless we recognize that he is doing the best he can; and he may need a different way of coping before we take this one away from him. He will be unlikely to follow my recommendations unless he trusts me, and I can help him trust me by accepting him for who he is and by validating him.
2. Spend 2 to 3 minutes visualizing yourself getting frustrated by the patient’s incessant repetition and practice managing your frustration by validating him and intervening strategically.
3. At the end of each session, take 1 minute and ask: “What could I have done differently during my time with you today, and how can I make our next session a better one?” (We need to hear whatever feedback the patient gives and simply answer: “Thank you, I am going to give some more thought to this, and we will continue to work on improving our time here together.”). Then, at the end of the day, set aside 2 to 3 minutes to reflect and wonder what you could have done differently and how you could have responded differently. Stay away from beating yourself up, just incorporate, adjust and grow.

I have given you the above recipe to use whenever our patients “get stuck.”