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Defuse patient demands and other difficult behaviors

Vol. 5, No. 6 / June 2006

Mishandling patients’ suicidal thoughts, delusions, medication demands, and other difficult behaviors can damage the therapeutic alliance, cause you unnecessary consternation, and even endanger patients’ lives.

The following strategies can help you overcome six of psychiatry’s clinical conundrums (Box).


6 conundrums of clinical psychiatry

Assessing suicidality

Dealing with insistent delusions

Defusing intimidation

Weighing medication demands

Protecting patient confidentiality

Documenting patient complaints

1. Assessing suicidality

Not having a suicide plan is not necessarily protective; a patient with unremitting depression can deteriorate rapidly from “no plan” to high risk.

Besides probing for plans, ask what is stopping a patient with suicidal thoughts from completing suicide. Suspect increased risk in patients who:

  • say they have not tried suicide because they fear the attempt will fail
  • cannot express a reason to live.

On the other hand, risk may be mitigated in patients who say they have not attempted suicide because of strong family commitment or religious beliefs.

2. Dealing with insistent delusions

If a delusional patient complains that previous physicians thought he was “lying” or “crazy” and asks if you believe his delusional statements:

  • reassure him that you feel he sincerely believes what he says is true.
  • affirm that you believe he is accurately and truthfully reporting his feelings.

3. Defusing intimidation

When an intimidating patient demands that you prescribe a controlled substance, be calm, patient, and firm. If the patient stands up and leans toward you or shows other threatening postures, calmly ask him to “please sit down.”

Refuse the patient’s request for the controlled substance by gently informing him that:

  • the substance is not medically indicated
  • the substance could be “detrimental to your health”
  • prescribing the substance would not be good medical care
  • you are prescribing a safer substitute.

Schedule a follow-up appointment, and tell the patient you expect to see him again at that time.

4. Weighing medication demands

Patients who demand specific medications—controlled or not—might in fact be asking for a reasonable choice. Weigh the request against the patient’s symptoms and history. Don’t be put off by obnoxious, demanding patients who complain about providers who deny their requests for medication.

Barring contraindications or side effects, respect a competent patient’s desire to take an older medication he prefers.

Judge medication requests from incompetent or psychotic patients on a case-by-case basis. In many cases they can remember what worked best in the past.

5. Protecting patient confidentiality

Information about your patients from collateral sources can be valuable. Remember that you are not breaching the patient’s confidentiality when you:

  • listen to someone who offers unsolicited information
  • do not disclose that you are treating the patient to someone who calls you about him or her.

6. Documenting patient complaints

View with skepticism any history that patients tell you about collateral sources until you confirm the information. All persons—delusional or competent—filter their experiences through their own beliefs.

Be cautious about documenting a patient’s report of abusive treatment as factual. Preface documentation of derogatory or accusatory statements with comments such as, “The patient claims…” or “The patient feels….”

Dr. Roth is attending psychiatrist, Department of Veterans Affairs Medical Center, North Chicago, IL

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