Engaging the “Difficult” Patient: Strengthening Empathic Communication Skills

Medical communications researchers Roter and Hall (1) commented that “talk is the main ingredient in medical care and it is the fundamental instrument by which therapeutic goals are achieved” (p. 8). The doctor-patient relationship has been, and remains, the cornerstone of all medical care. It is the medium by which symptom data are gathered, diagnoses are made, and the patient is engaged in the joint enterprise of treatment. An empathic connection is at the core of this healing relationship (2). Clinical empathy involves understanding a patient’s perspective, resonating emotionally, and expressing care and concern, sometimes labeled the cognitive, affective, and behavioral dimensions of empathy (3). Compassion, a similar concept, is when empathic feelings and thoughts include the desire to help. In treating a “difficult” patient, researchers have identified three sources of difficulty: the patient’s issues; the relationship between the clinician and the patient; and the social, cultural, or systemic context of the encounter (4).

Koekkoek and colleagues (5) identified characteristics of “difficult” patients. The type of patient who was uniformly described as difficult in their review was labeled the “ambivalent care seeker.” These patients frequently present with mood and personality disorders and were often demanding, demeaning, self-destructive, dependent, and untrusting. Negative countertransference emotions toward these “difficult” patients were regularly stirred up in the staff working to treat them. Undesirable terms were often used when staff described the “difficult” patient (5), and the staff subtly, or not so subtly, expressed exasperation or a wish to terminate treatment. Thus, the “difficult” patient is at risk for poor care or dropping out of care due to difficulty maintaining a steady relationship with caregivers. The very fact that these “difficult” patients may exhibit frustrating behavior that inhibits empathic connection suggests that empathic connection—the need to feel understood, accepted, and respected—may be the fundamental ingredient for engagement and treatment effectiveness.

There have been a number of curricula that include empathy and compassion training in medical education. A recent systematic review (6) of curricula suggested that 75% of studies found that the tested curricula improved physician empathy, compassion, or both on at least one outcome measure. Key behaviors that were effective included sitting rather than standing during the interview; detecting patients’ nonverbal cues of emotion; recognizing and responding to opportunities for compassion; nonverbal communication of caring; and verbal statements of acknowledgement, validation, and support. These behaviors were found to improve patient perceptions of physician empathy. Although various curricula demonstrated improvement in specific skills, there is no unified model with regard to educating clinicians in empathic skills. Most interventions have been evaluated for short-term results, utilize disparate theoretical and practical approaches, and capture only a portion of the richness of genuine empathic communication (7).

One innovative method for deepening clinicians’ empathic communication skills was developed by Marjorie Heymann. A theater director and scholar of the psychology of theater, Dr. Heymann noted that the essence of the theater experience for both actors and audience is immersion into the emotions, needs, and motivations of the characters as they interact with each other. Her seminar, “Working with Challenging Patients and Families: Maximizing Your Clinical Effectiveness,” has been offered under the auspices of The REACH Institute in New York. Dr. Heymann translated her approach to training actors into a systematic approach to training clinicians to communicate empathically, even with difficult patients. The techniques are designed to enhance understanding of the patient’s needs, emotions, motivations, and relationship to the clinician (8).

Heymann identified a key ingredient in empathic communication as the actor’s ability to listen with deep attention to the other actors. The response of the other actors must combine other-directed empathy with their ability to inhabit their own character’s reality. Heymann’s method focuses on helping clinicians understand patients’ needs and motivations in the moment of the clinical encounter. It recognizes that clinicians can be present in dealing with patients’ needs and motivations only when they first have an empathic understanding of their own needs and motivations (8).

Heymann’s method starts by helping clinicians practice dealing with distractions. Mindfulness meditation is one technique. Small distractions may be mentally acknowledged and confronted. Larger worries may be handled by making an appointment with oneself for a later time to problem-solve the issue. Having set aside distractions, the clinician is prepared to be fully present in the encounter.

According to Amsel (8), “The genius of the theatrical approach to listening is learning to hear the needs beneath the words. Heymann emphasizes that listening for needs, as opposed to listening for emotions, can make a real difference in the empathic connection. Emotions are of course important, but they are also often changeable, vague, and difficult to capture. Needs are more concrete and often more easily understood.” Major categories of needs that both clinicians and patients are likely to bring to the encounter include the needs for control, respect, acceptance, help, love (or liking), and safety. Clinicians need their patient’s trust and engagement in the healing process.