Learning to deal with challenging ‘heart-sink’ patients

‘There are wounds that never show on the body that are deeper and more hurtful than anything that bleeds.’
 
– LK Hamilton, Mistral’s Kiss
 
‘He’s truly valiant that can wisely suffer
The worst that man can breathe, and make his wrongs
His outsides, to wear them like his raiment, carelessly,
And ne’er prefer his injuries to his heart,
To bring it into danger.’
 
– Shakespeare’s Titus Andronicus
 
In the tearoom this week, one of my colleagues sighed audibly:
 
‘Oh my, I’m seeing David^* again today. You know I just can’t bear it. Nothing ever changes and he complains about everything. He gets really irritable and I’m so frustrated by the time we finish the consultation, I hate seeing him. He’s a real heart-sink patient.’
 
The boy who once was
The conversation got me thinking about patients who we as practitioners find particularly difficult. I recalled, John,^* a 46-year-old man who I saw at the multidisciplinary clinic at which I work.
 
John was a patient no one wanted to see, with good reason. He was aggressive and emotionally labile, had a history of intimate-partner violence perpetration with a long forensic history, and had been in and out of jail from age 14. He complained repeatedly about his chronic back pain and how he had been tricked into attending our clinic and started on methadone maintenance.
 
John spoke loudly in the waiting room about how he wasn’t like the other ‘awful’ people at our clinic who injected drugs, about how everyone cheated him and blamed him, and how he was going to make a complaint and take us all to court.
 
The first time I saw John, I had heard all the stories and had steeled myself for a difficult encounter. Straight away, he told me how horrible everyone at the service was and how no one could help him and how he had been waiting for hours.
 
I took a deep breath and tried a new trick. I moved the conversation off this same old track. I had noticed on his file that John was working in a labouring job, so I asked him how work was going. He blinked. Then he told me about how much he enjoyed his work, and about how methadone dosing was starting to interfere with getting to work on time.
 
I noted that John’s urine drug screen didn’t show any substances other than methadone and he gave no other history of problematic drug use. He was attending the clinic daily for dosing, travelling some distance to do so.
 
As he was doing so well and enjoying work, I suggested that he might benefit from picking up his doses at his local pharmacy. John thought that was a great idea. I arranged to see him every month in the first appointment of the day so he wouldn’t have to wait.
 
Every time I saw him after that, I’d make a deliberate effort to talk about what was going well for him and how well he was managing his pain and work. He’d tell me stories of how he enjoyed job and regale me with tales from the work site.
 
John would still fall into complaining about everything in consultations, and I’d let him talk for a while before redirecting the conversation to what was working well and how I knew he had so much potential to create the life he wanted.
 
When I first saw him, John had told me that his childhood was great. Over time, as we got to know each other, he started hinting at the real truth. About growing up in regional NSW. About how his mother had died when he was four. About how his father would drink and drink, and then beat him without mercy. About a life spent moving between different houses and schools. About leaving home at the age of 14, only to end up in juvenile detention soon after.
 
I listened and grieved for the boy who once was.
 
At our last appointment, John looked at me with a wry smile. ‘You know, Doc, I’ve realised this clinic isn’t that bad. I still hate coming here, though,’ he said.

I couldn’t help but smile.
 
Loneliness and trauma
Another challenging patient who has stuck with me is Diane,^* a 44-year-old woman who attended my GP practice several times a week.

She would have a regular ‘turn’ in the waiting room, or engage our receptionists in long, meandering conversations that they found hard to deal with or move on from. She would attend consultations with a long list of non-specific ailments, repeatedly asking for alprazolam while refusing to consider changing her high level of cannabis smoking or seeing a counsellor.
 
But, as with John, there was a lot more to the story.
 
Diane had been a victim of intimate-partner and family violence. As a child, she had been repeatedly sexually assaulted by her uncle. She had left her last (violent) relationship and was now living on her own in Department of Housing accommodation. She was struggling with loneliness, as well as the cumulative trauma of a difficult life.
 
Over time, Diane and I worked to address her alprazolam dependency. She transferred to diazepam, before slowly cutting down that medication over two years. She refused any other intervention but successfully stopped all benzodiazepines and cannabis. Diane continues to need high levels of support from our practice, so we have set up regular short appointments that once again focus on her future and her potential.
 
Patients like John and Diane are challenging for us as practitioners. Their behaviours are difficult and easy for us to judge – particularly if we do not know their often-saddening backstories.
 
They can make our work places unsafe or frustrating. These patients can be intensely difficult to like, and can trigger our own frustration or anger. We are human, too and, faced with difficult people, we can easily find ourselves putting up barriers, avoiding them, or sometimes going beyond what we would usually do for a patient.
 
The most important thing that I have had to learn is to recognise that these are behaviours undertaken by desperate and wounded people. That to even begin to help them, we need to walk a middle line, one that respects and values the person and works to change the behaviour collaboratively, while at the same time maintaining clear boundaries.
 
I have learned that it is vital to understand how interpersonal trauma can deeply affect people’s ability to manage their lives. That means this is long-term, slow and careful work. It means that we as GPs have to do regular check-ins with these patients, and set boundaries in the practice around who does what for the patient. These boundaries need to be always about creating safety for the patient and for the staff, while respecting the person and understanding how trauma impacts them and their interaction with others.
 
Does it work? It can. Just take Diane. To combat loneliness, she joined a craft group, where she discovered knitting. She now spends hours and hours making amazingly colourful knitted blankets with intricate designs from reclaimed op-shop wool. Now, she says that life is okay.
 
* Patient names have been changed
 
For GPs interested in this area, the Australian Society for Psychological Medicine (ASPM) and the RACGP will run a joint conference, ‘Trauma informed care in general practice’, over the weekend of 1–2 June in Melbourne.

challenging patients continuity of care trauma