By APRIL BOYKIN, MSW, LCSW

Studies have consistently shown that approximately 15 percent of all patient encounters are “difficult” (Hinchey, et. al, 2011). Beyond the complex medical diagnoses, people who are sick, injured or overwhelmed have less ability to access their coping skills and can be even more challenging to deal with.  Patient complications come in many forms such as behaviors that are resistant, clingy, somatic, complaining, help-rejecting, manipulative, demanding and entitled, or those who are simply “frequent flyers.” What is most important to know is these behaviors are all evidence of greater issues that can be managed or improved with the use of integrated behavioral health support.

The effects of challenging patient behaviors can be overwhelming.  These patients take up a disproportionate amount of time, can burn out our staff, can compromise our compassion towards them, and can ultimately become too difficult to manage. Everyone has a right to be an active participant in their own care, but when complicated patients’ behaviors create roadblocks to their own medical care it can become an ethical dilemma for their providers. Finding a solution is critical for the wellness of the patients and the efficiency of our offices. When patients demonstrate these complicated behaviors, they are really signaling depression, anxiety, lack of trust or satisfaction, or even worsening of symptoms. There is an established correlation between complex behavioral and emotional symptomology and poorer health outcomes which negatively impact provider reimbursement.

What is going on? The underlying issues that result in difficult patient encounters likely include one or more of the following:

• Anxiety-From panic attacks to worry and hypervigilance, anxiety creates ruminating thoughts. Patients seek soothing, which results in an increase in calls and appointments, as well as somatization.
• Depression-From agitation and irritability to apathy and disengagement. Depression causes patients to be less compliant and engaged in recommended treatment process.
• Personality Disorders-With a skewed perspective, patients with personality disorders are more likely to feel entitled and be demanding of your time and attention. With a lower tolerance for discomfort these patients become high utilizers.
• Unrealistic Expectations-Expecting that chronic pain will disappear, or that treatment improves symptoms immediately, these beliefs cause patients to return frequently or request premature treatment changes.
• Isolation-Loneliness and fear can make patients more dependent on attention, guidance and connection from medical providers.
• Delusions/Hallucinations and Paranoia-These are often misunderstood or overlooked at the onset because they can be hard to assess in high functioning patients. They can look like complaining, anger, somatization, or demanding behaviors.
• Cognitive Decline-As patients experience cognitive decline, we frequently field questions about the same things over and over while seeing a decrease in compliance and an increase in frustration.
• “Better than Average” Effect - These patients typically make decisions based on seeing themselves as better than they are and will stay at home often long after they should have moved into a congregate living situation putting more of a burden on medical providers because of an inability for self-care.
• Unexplained symptoms or unresponsive to treatment-Patients who present with atypical symptoms or don’t get better in the way they want begin to doubt the medical profession, they become less-complaint and present as angry, resistant, demanding etc.
• Social determinates-Many of our patients may be living without access to medications, food, or a safe or stable environment, etc. This can be embarrassing to discuss and result in non-compliance, anxiety, frustration and negativity.

How Integrated Behavioral Health Services Help: Counselors are great partners in addressing these issues with patients and helping them access or develop effective coping skills that will decrease the frequency of stressful patient encounters in the office.  Integrated behavioral health services improves health outcomes, and ultimately prevents reimbursement loss due to premature rehospitalization.

How your patients will benefit from integrated behavioral health services:

• Overcoming roadblocks
• Building problem solving skills
• Improving communication skills
• Behavioral changes
• Resolving emotional turmoil, and trauma resolution
• Setting up realistic expectations for emotional and physical wellbeing
• Creating routines for diet, exercise, sleep and taking medications
• Developing relaxation and stress management techniques
• Experiencing emotional support and a focused space to express emotions
• Processing of emotions related to distress and discomfort
• Building social connections
• Identifying community resources that patients may be eligible for
• Collaboration on psychotropic medications
• Setting up medication delivery
• Assessment and care planning

Counselors are trained and skilled at addressing all aspects of a person’s physical, behavioral, and emotional functioning, including complex presentations. If this article has made you think about a complicated patient you work with, refer them for support today.

April Boykin is a Licensed Clinical Social Worker and cofounder of Counseling Resource Services (CRS). Established in 2013, CRS is a community-based in-home integrated behavioral health agency serving the aged and disabled population in Central Florida. As a mental health counselor, she has provided individual, family and caregiver counseling to children, teens and adults.   She can be reached at april@counselingresourceservices.com