The Use of DBT Skills in the Treatment of Difficult Patients in the General Hospital

The first step is to repeatedly validate the difficult experience of both the patient and the staff. Neither the patient nor the staff will be able to enter a frame of mind that allows them to consider changing their behavior until they are calmed and feel understood. Both consultant and staff should let a difficult patient know that they are fully aware of how much he or she has suffered and continues to suffer. It would also be important to state things from the patient’s point of view, e.g., “I can see that it seems like only some of the people here understand you or are able to help you get what you need. And it must seem like other people have gotten really mad at you or are blaming you.”

Similarly, with staff, the consultant needs to help each person feel that his or her “side of the story” is heard. In the hypothetical case vignette, Nurse A might have felt understood if the consultant had said, “Wow! It felt like things were going so well with the patient, and now, all of a sudden, things seem to have taken a turn for the worse in all sorts of ways. That’s frustrating.” In a similar manner, with Nurse B the consultant might have said, “Wow! It seems like it must have felt like this patient was impossible to please and was out to cause you trouble. Patients like this can be so hard to manage.”

Such statements need to be made throughout the course of a psychiatric consultation with the patient and the staff—with each inevitable roadblock all sides will need to feel like their viewpoint has been heard and understood.

The next step is to give staff an opportunity to gain a dialectical view of the difficult patient—to see him or her as both good and bad—and to help the staff realize that they themselves have become part of a dialectic by becoming polarized in their points of view about the patient. DBT emphasizes a dialectical view of the world—that reality is whole and has simultaneous good and bad qualities. Furthermore, change is not an all-or-nothing proposition but instead is a continuous process that often comprises small steps. In DBT, change is also transactional, and a given change may have both good and bad results for a person. Finally, the dialectical world view of DBT holds that one’s identity is relational and dynamic and therefore that one’s identity does not exist alone as a static, absolute concept but rather is dependent on interpersonal relationships. These ideas allow a person to see that good and bad are not mutually exclusive but in fact coexist with one another throughout life.

Linehan (2) argued that arguments (and splitting) among staff should be viewed as failures of an interpersonal synthesis among staff rather than as something to be blamed on the patient. It would be useful for the psychiatric consultant to sit down as a group with all staff members working with a difficult patient. In such situations, the consultant should, first and foremost, validate the experience of working with this patient and the difficulty of working in a situation where so much emotion and conflict has arisen. The consultant can then acknowledge that some differences in opinion have resulted and should ask each member at the meeting about his or her experience with the patient, listening carefully to each person and mediating any disagreements by validating both sides of the argument. By acknowledging that each staff member’s viewpoint is valid and true, the staff can synthesize the viewpoints into a shared and consistent view of the patient. This will allow more consistent care of the patient and help avoid further splitting and conflict.

Once the staff has had some success in synthesizing their view of the patient and has become able to interact with her in a more consistent manner, the difficult patient can be approached with the idea of a dialectic. The patient needs both to be validated and to understand that harmful actions are unacceptable. This could be framed in a dialectic by saying, “We understand how truly awful this situation is for you. You feel ill and out of control and it has seemed hard for you to get what you want. However, I think if you act this way, you won’t be able to get what you want and won’t get the care that you deserve. Maybe we can think about what it is you want and how we can help you to find a way to get it more effectively.” The dialectic is framed as two true statements: you feel awful and you can’t act this way. This acknowledges the reality for the patient but also acknowledges a larger reality that must also be addressed. Helping the patient to see both realities can allow him or her deal more effectively with the situation. In the second half of this statement, the patient is offered help in generating new ways to cope more effectively. In offering to think with the patient about the patient’s goals and how to reach them effectively, the consultant is positively reinforcing noncrisis behavior and has paved the way for a discussion of interpersonal skills.

In tandem with the discussion of dialectics, a discussion with staff about behavioral interventions can be initiated. The consultant can discuss how most patients receive positive reinforcement in the form of attention when they call for help and that, usually, this is reasonable and effective. However, the consultant should help the staff to see that an emotionally dysregulated patient may act to create crises to receive this reinforcement if it is not available any other way. Therefore, difficult patients should be rewarded at regular intervals (e.g., visitors at the bedside, removal of restraints) when they demonstrate appropriate behaviors that the staff would like to see increase, including participation in medical care, a lack of self-harm, and appropriate interpersonal interactions. Just as with outpatients in DBT, an agreement about when to call a nurse should be made. Difficult patients should be allowed to call the nursing station when they feel that they are nearing crisis or beginning to feel out of control; they can then receive a brief visit from staff or an as-needed medication. Just as with outpatients, these patients should be informed that if they call too frequently—or not frequently enough—then the plan will have to be reevaluated. In addition, patients should not be rewarded for behaviors that are harmful or disruptive. They should be informed in a nonpunitive, direct manner that if they become belligerent, initiate threats, cause harm to themselves, or disrupt their care, then restraints or medications will be employed. By trusting patients to hold up their end of the bargain, the staff will make an implicit statement of respect for the patients; such gestures of trust and respect can go a long way toward helping these patients maintain control.

Once an acute crisis has abated, DBT skills can be taught to prevent and to calm further uprisings between patients and staff (or between treaters). There are ample opportunities to teach skills to both the patient and the staff.

Teaching the Patient. Learning how to tolerate distress is a crucial skill for successfully managing the painful emotions that can often accompany a medical hospitalization. While in the hospital, a patient must cope effectively with a range of potential feelings generated by the problem that precipitated admission and the medical procedures necessary to address the problem. These might include feelings of anxiety, anger, shame, and vulnerability. Such feelings experienced under the stressful conditions of hospitalization can pose a challenge, even to patients whose emotion regulation abilities are generally adequate to meet the events of their daily lives. Thus, patients who have difficulty regulating their emotions at baseline and “well-adjusted” patients who typically have adequate distress tolerance skills can both exhibit emotionally dysregulated behavior under the stress of hospitalization. For both types of patient, hospitalization requires distress tolerance skills, and both can be helped by coaching about how to use them. Given the many stresses of hospitalization, any patient would probably have difficulty attending to in-depth didactic descriptions of skills. Therefore, briefly teaching patients having difficulty coping with painful emotions a few tricks to help them tolerate their high levels of distress would be the best initial approach to take.

For example, the psychiatric consultant might teach paients distress tolerance skills to help them temporarily distance themselves from distressing feelings. One such skill can be the use of distraction. Distraction can be achieved by focusing on thoughts and activities (e.g., writing, reading, or talking on the phone) that temporarily occupy the patient’s attention. This can direct attention away from sensations, conversations, and thoughts that reactivate the painful emotion. It is also helpful to encourage self-soothing techniques by identifying comforting, calming things (e.g., a pleasant-smelling lotion or favorite music) that patients can use while in the hospital. One technique that combines distraction and self-soothing is the use of imagery to improve a difficult moment. Patients can be encouraged to imagine a safe, relaxing, comfortable place, including as much sensory detail as possible. With practice, patients can call this image to mind as a way to “ride out” difficult situations and the painful feelings they evoke.

Once patients have learned some effective distress tolerance skills to get through the most difficult moments, they can also learn other skills to further improve their ability to cope with the hospitalization. The type of skill to be learned can be tailored to the specific difficulty experienced by the patient. For example, if the patient in the case vignette continued to ruminate about how she had been treated by Nurse B or by the senior resident, or if she became too focused on worries about the future, it may be useful to teach her mindfulness skills. To introduce the idea of mindfulness, the consultant might sit with the patient and have her calmly and nonjudgmentally observe her own thoughts as they occur. To assist the patient in letting go of ruminations and maintaining a more present-focused outlook, the consultant might have the patient imagine that her mind is like a conveyor belt and that her thoughts and feelings slowly move along the belt and get placed into a nearby box. In conjunction with this exercise, the consultant could discuss the long-term costs of “getting stuck” in thoughts of past interactions or future events on her awareness of the current moment.

If, on the other hand, a patient is having frequent battles with staff and is unable to advocate effectively for his or her needs, interpersonal effectiveness skills might be useful. The consultant might begin with a discussion of effectiveness. When discussing with the patient the idea that things are difficult, and that the patient cannot always act the way he or she wants (i.e., the dialectic of acceptance and validation versus the need to change), the consultant can ask an important question: what is it that you want to accomplish when you are interacting with the staff? The consultant and patient can then discuss what has been tried in previous interactions. They can examine how effective these methods have been, pointing out how behaviors meant to meet the patient’s goals (e.g., to get attention from nursing) ultimately led to the opposite of what was wanted (e.g., no attention from nursing for the rest of a shift). Finally, the consultant can offer to assist in thinking through future interactions with an eye toward helping the patient accomplish his or her goals in ways that work. In our example, the consultant and Ms. R could discuss how her interactions with Nurse B could be somewhat changed; even if she doesn’t like Nurse B, she is most likely to get a blanket, some water, or attention from Nurse B if she changes her style of interaction.

If the greatest difficulty is with extreme and rapidly shifting emotions, the patient could learn emotion regulation skills. To introduce these skills, the consultant could discuss the notion of identifying or naming emotions by saying, “So when you’re starting to feel out of control, you’ll know what you’re working with—are you furious, scared, or sad?” Then consultant and patient could work to identify how these emotions come about and how they might be modulated before they get out of control. For instance, the consultant could encourage the patient to observe experiences over the upcoming day to monitor what sorts of events seem to bring on painful feelings and what warning signs signal that painful feelings are about to be “out of control.” Once these triggers and warning signs are identified, both patient and staff can use the information to respond earlier in the emotional chain of events, thereby preventing disruptive behavior.

One should keep in mind that not all of these techniques will work for all patients. It will be clear when a patient “takes to” a specific skill and when another skill or technique is less effective. Furthermore, these skills often require significant repetition and time to be learned. Finally, and perhaps most important, the consultant must remember to validate the patient’s internal experience of pain as well as any attempts to change. The consultant must express that he or she understands how difficult things have been and what difficult emotions have surfaced. The consultant can tell the patient, “well, of course you feel [angry, hopeless, etc.]. Now, let’s see what we can do together to help.” Such validation must be frequent and heartfelt if the patient is to take the emotional risks that attempts at change entail. Only after the patient feels validated can the necessary skills be learned and effective changes take place.

Teaching the Staff. The consultant must be mindful that nursing staff on general medical floors often have little experience working with psychiatrically ill patients. Therefore, before introducing specific DBT skills to the staff, it is often useful to provide some brief psychoeducation regarding personality disorders and the management of one’s feelings (i.e., countertransference). Groves (11) recommends educating staff about the phenomena of splitting and projective identification seen so frequently in this population. Such education can help the staff to recognize these defenses rather than allowing them to cause staff tension and acting out against the patient.

In addition to providing basic psychoeducation about difficult patients and their defenses, the consultant can also help the staff by teaching specific DBT-based skills to improve interactions with difficult patients and to more effectively communicate with one another.

The fact that a patient does not behave like a patient “should” behave will be infuriating to the staff. There will be little appreciation, limited deference, and more testing of rules and boundaries with this patient than with most others. Nurses and others who work closely with the patient will be tempted to respond angrily or punitively as a result of this behavior. In a process that parallels the validation and exploration of goals done with the patient, the consultant can help the staff by acknowledging how difficult their experience has been and then determine what it is that the staff really wants from the patient. The staff, most likely, will want a relatively high level of cooperation and compliance with medical care and fewer requests by the patient (so that others may receive adequate care).

The consultant and the staff can then work together to see how staff can behave (using a combination of schedules of reinforcement and interpersonal effectiveness skills) to get what they want. This will likely include suppressing anger and entitlement when the patient acts either unappreciatively or rudely, and, at times, letting the patient “win” by allowing small infractions of the usual rules in exchange for compliance with major aspects of the treatment. This will be frustrating to treaters, who may feel that the patient needs either to be grateful or completely compliant. However, when framed in a way that emphasizes effectiveness (“What can we do that will cause the least amount of tension and struggle for you with this patient while we are still providing good care?”), it is most likely to be adopted by the staff.

Patients may evoke a variety of feelings in staff and may make staff want to perceive them as very different from themselves (e.g., “She’s a psych patient” or “She’s crazy”). In some ways this is protective for the staff by avoiding overidentification; in other ways it prevents an alliance or empathy with the patient from developing. By helping staff to develop some understanding of the patient’s difficulties, they will be better equipped to interact with the patient in a therapeutic way.

The consultant can encourage staff members to remember periods in their own lives that evoked feelings similar to those the patient is experiencing. By calling upon memories of their own struggles rather than distancing themselves from patients when their behavior is provocative, staff members will almost certainly find themselves able to respond in a more compassionate and effective manner.

This also applies to staff-staff interactions. In our example, if Nurse A had been able to imagine what Nurse B’s experience might have been like—getting in trouble as a result of the patient being out of restraints, seeing the patient bang her head, and being devalued by the patient—she might have understood the fear and anger that Nurse B experienced. She would then have been able to communicate with Nurse B more effectively. Likewise, if Nurse B had been able to imagine Nurse A’s horror at the patient being restrained after she had worked so hard to build an alliance with the patient and to gain Ms. R’s trust and compliance, she might have been better able to appreciate Nurse A’s perspective.

Despite numerous therapeutic interventions, the treatment of difficult patients can become frustrating and overwhelming. Behavioral techniques and the use of skills can, at times, seem to lead nowhere. No matter how skillfully a patient or a team of staff members behaves, they won’t always get what they want. In these moments, the concept of radical acceptance can be useful. By “radically accepting” a situation, a person completely gives in to the idea that a painful reality exists and accepts that it must be faced as it is. This implies that the person has, for the moment, given up on denial or on ineffective anger and has now changed the focus to tolerating a noxious stimulus. Radical acceptance does not imply approval or liking of the painful situation; rather it is the decision to accept that the pain exists and that, for now, it must be endured.

The consultant can introduce the idea of radical acceptance and suggest that a patient is going to take more of the nursing staff’s time, make them angrier, and make them feel more hopeless than they would like. Instead of trying to fight these feelings, nurses can accept them as reality (and possibly laugh at the absurdity of the situation). This does not mean that the nurse should stop trying to find ways to more effectively deal with the patient, but it does provide a “safety valve” when such tactics fail.

When any or all of these DBT skills are ineffective, it may be useful for the consultant to return to the bedside and model the skills for the staff, both for educational purposes and to momentarily relieve the staff from their sense of burden and distress. These skills may have varying degrees of success with different patients, but a consultant’s willingness to show up, to support the staff, and to continue to problem-solve with the team generally provides significant relief, even if the patient’s behavior persists.