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Making ‘PEACE’ with hostile, unwilling patients

Vol. 3, No. 8 / August 2004

Often we encounter patients who are angry about having been “forced” to see a psychiatrist:

  • In the emergency room or inpatient setting, patients who present with an apparent medical problem may become upset after learning that a psychiatric evaluation has been ordered without their knowledge or against their wishes.
  • In outpatient clinics, patients who arrive under “coercion” from parents, spouses, or employers can also be hostile.

Defusing the hostility and engaging the patient are critical first steps toward a therapeutic alliance. When faced with a hostile patient, take a deep breath, control your emotions, and follow the PEACE principle: presence, empathy, acceptance, collaboration, and empowerment.

Presence. From the outset, make it clear that the patient has your undivided attention. Nonverbal cues such as sitting down, maintaining comfortable eye contact, and not writing notes during the interview’s initial stages give this impression.

Empathy. As you sit quietly and attentively, encourage the patient to vent his or her anger over being “forced” to see a psychiatrist. Most of us can empathize with a person who feels powerless, patronized, or coerced.

Acceptance. Acknowledging the patient’s distress can go far toward diminishing or defusing the anger. For example, tell the patient, “I understand that this is unsettling for you,” or “I, too, wish the circumstances were different because this is obviously difficult for you.”

Collaboration. Tell the patient you only want to help him, to be his partner in a therapeutic alliance.

Empower. Never force the evaluation. Rather, let the patient decide whether to proceed. Tell her, “I want to help you with what’s been going on in your life, but it’s totally up to you to continue. I cannot—and don’t want to—force you to do something you choose not to do.”

Then offer alternatives such as:

  • a follow-up appointment
  • a visit the next day if the patient is hospitalized
  • or telling the emergency physician that the patient declined the psychiatric evaluation.

I find that when using this approach the patient usually agrees to a therapeutic assessment.

Dr. Christensen is associate professor of psychiatry, University of Florida College of Medicine, Jacksonville, and director of its community psychiatry program. Jacksonville

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