Patient relations: How best to handle patients who are manipulative

"I don't know what I'm going to be able to do tonight if you don't increase my dose of medicine, maybe I'll cut my wrists because it's too painful." This is one of the many calls for help faced by Marie Auclair, hospital pharmacist, assistant to the head of the pharmacy department of the CISSS de l'Outaouais and secretary of the group of expert pharmacists (RPE) in psychiatry at the Association of Pharmacists of Quebec Health Institutions (APES). One of her patients with borderline personality disorder and anxiety had tried several times to convince the various medical professionals at the hospital to increase his doses. The patient hoped to calm the inner emptiness he felt, and for him, it was a question of life or death. Read: Practice management: When it's time to part ways “I went to talk to him, after his insistent requests to my nursing colleagues, and it took a week to make him understand little by little that this was not a solution," says Auclair. It's a lot of work to explain that [medication] is just a big band-aid. All [the patient] wanted was to stop suffering and quickly." It is not always easy to know how to deal with manipulative-seeming patients who appear ready to do anything to achieve what they want: obtaining certain medications, increasing the dose, obtaining sick leave or a particular diagnosis for benefit from accommodations or benefits. According to the Canadian Medical Protective Association (CMPA), 15% of doctor-patient consultations are considered difficult. It is therefore important to know how to recognize this type of situation and to have the tools to deal with it. Read: Can vitamin D really improve cardiovascular health? Understand what's going on in the patient's head First of all, you have to be careful before affixing a label to a patient. Some “remain vulnerable and we must keep an open mind to what is really happening in front of us,” says Dr. Armand Aalamian, family physician and associate professor in the Department of Family Medicine at McGill University. How to recognize manipulation? Clinical psychologist and associate professor at the University of Quebec in Montreal, Geneviève Beaulieu-Pelletier, gives the following definition: "Manipulatory behavior occurs when there is a dynamic of disrespect between two people, one of whom seeks to destabilize the other so that events unfold to his advantage. However, it remains difficult to determine if this is indeed a context of manipulation since the person can do it unconsciously," she says. Sometimes the refusal to comply with a patient's request leaves him upset. However, he will rarely say concretely that he is dissatisfied, but rather you must read his non-verbal signs, advises Dr. Marie-Thérèse Lussier, a professor in the Department of Family Medicine and Emergency Medicine at the University of Montreal. She also suggests trying to pay attention to one's own non-verbal gestures that might irritate the patient, such as a change in tone or an exasperated look. These non-verbal signs can sometimes be associated with the beginning of manipulation and identifying them makes it possible to better respond to the patient's request and defuse a possible escalation of emotions. Defuse manipulation Manipulation is what we want to avoid at all costs. We must try to see what is hidden behind the patient's request: "What needs are not met other than the inadmissible request?" says Beaulieu-Pelletier. For her part, Dr. Lussier advises taking the time to understand and name the problem by asking, for example: "It seems very important for you to obtain this medication, can you explain to me what brings you here?” This makes it possible to explore what the doctor's “no” really means to the patient and the intentions that may be hidden behind it. She says the openness of the health professional to take an interest in what the patient is going through and to find other solutions is a technique of de-escalation in consultation. Pharmacist Philippe Vincent, an associate clinical professor at the Faculty of Pharmacy at the University of Montreal, agrees. “Going beyond the request to try to understand the real problem, the irritant behind it, is a technique that has often worked in my case," he says. "I try to see if I can involve the patient in the solution, if there is a middle ground that would work for them and that it would also be reasonable to prescribe." He cites the example of a patient who desperately wanted a drug to help him sleep, claiming that the others weren't working as well. However, the drug was no longer available at his pharmacy. The patient began to raise his voice and accuse the pharmacist of wanting to harm him and prevent him from sleeping. The pharmacist then sought to understand further: the patient explained to him that his reluctance to try a new medicine was due to the fact that he was afraid of not sleeping well and of not being able to work the next day. “Understanding the context for why a patient is angry is important for maintaining good relationships and understanding the need behind the demand,” he says. “Was it then reasonable to prescribe perhaps a tiny bit higher dose of another drug to reach a middle ground? In this specific case, it was the solution,” says Vincent. Setting clear limits, finding a common goal, sharing the search for solutions and creating a bond of trust with the patient is the recipe for success, according to Vincent. “Most of the time, we follow a patient for a long time and there is a care trajectory, a relationship has been established. It is more difficult to be manipulated if you have a patient's file in front of you and you have a well-established bond of trust too,” says psychologist Claude Richard, a specialist in doctor-patient communication. Even in a particularly untenable situation, it can be ethically difficult to sever ties with your patient. In addition, "if we leave the patient to another health professional, he may end up getting what he wants one way or another," says Beaulieu-Pelletier. Nevertheless, setting limits becomes essential, especially in more extreme cases. For example, if threats are made or the patient makes inappropriate or sexual comments, then it may become necessary to take steps to end the therapeutic relationship and refer the patient to another more specialized professional. This article has been translated from its original French and first appeared on our sister site Profession Santé.

Patient relations: How best to handle patients who are manipulative

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