23 - Emotional Difficulties

Question 1

What is the relevance of emotional distress and symptoms?

Answer 1

Our emotional state colors our experience of everything else: relationships, physical symptoms, expectations about the future, and so forth, including our experience with medical providers

Question 2

What do you need to know as a provider?

Answer 2

To provide care for a person, not just a symptoms, it is necessary to be sensitive to emotional state

Question 3

Describe the state of acute emotional distress

Answer 3

• Can be contagious and distress the provider
• Can make an exam and interview more difficult
• Can impair concentration and memory, making it more difficult for the patient to provide an accurate history and to remember the provider’s instructions

You may need to WRITE DOWN everything that you tell someone in order for them to remember and apply this

Question 4

What particular diagnoses can color medical encounters?

Answer 4

• History of trauma or having been hurt
• Depression
• Anxiety
• Psychosis

Question 5

Describe how a history of trauma or having been hurt can impact a patient-provider relationship

Answer 5

• Provider will often be seen as a threatening or frightening figure
• May be highly sensitive to pain, often does better with the provider giving control to the patient as much as possible

People with a long history of pain are more sensitive to it

Question 6

How may a patient from an abusive background react?

Answer 6

Patients from an abusive childhood

• You learn not to trust, to not open up, not expose pain
• Think that the physician might hurt me, might make it worse
• They might treat you like you’re out to get them, hostile, etc.

Question 7

How can you best manage a patient with a history of abuse?

Answer 7

You need to switch the question in your head

• Not why are they doing this to me?
• But, what happened to this patient that made them react to you like that?

The key may to be always explain WHY you are doing what you are doing

Question 8

Describe how depression can impact a patient-provider relationship

Answer 8

Depression

• May impair ability to follow a treatment plan
• May impair ability to have hope that things can improve

Question 9

Describe how anxiety can impact a patient-provider relationship

Answer 9

Anxiety

• Can manifest as extreme sensitivity to and fear about medical symptoms
• In obsessive anxiety, patients can need to tell their stories and recount symptoms in excessive detail

Example

• I was listening to my heart and it skipped a beat
• Most people never pay attention to their heart beat
• They may come in with a concern that no one ever even notices and is not troublesome

Question 10

What can anxious patients benefit from?

Answer 10

• Being able to tell you the whole story

- Being reassured that everything is okay and normal

Question 11

Describe how psychosis can impact a patient-provider relationship

Answer 11

Psychosis

• Very frightening for patient (can also be for provider)
• Hard for patient to concentrate and make sense of what is going on
• Hard for the provider to ascertain a logical sequence of what is happening for the patient

Question 12

What do we usually consider to be psychosis

Answer 12

Typically hallucination or believing something that is not real

• That the evening news is distracted at you
• The government is out to get you, there are bugs planted in your house
• Your neighbors are pumping gas into your house at night

These things are very emotionally distressing to the patinet

Question 13

Describe a patient with auditory hallucinations

Answer 13

• Typically a voice “outside” of the head
• Like people are following you around and saying something negative

Hard to get a clear story out of them because their brain isn’t allowing them to

Question 14

What are the barriers to “cooperation” for patients with emotional difficulty?

Answer 14

• Typically, there is an unspoken contract between provider and patient
• The patient makes and keeps an appointment, discloses the problem and relevant details reasonably fully and succinctly, cooperates as the provider performs an examination and asks relevant questions, and then follows through with the treatment recommendations
• Emotional difficulties can interfere with any of these steps. It is more useful to try to patients’ difficulties with any given step than to judge them non-compliant and write them off as beyond help

Question 15

How can these factors be a barrier?

Answer 15

• Hard to make an appointment
• Hard to leave the house to go to the office
• Hard to show up for the appointment
• Hard to articulate what the problem is
• Hard to be quiet and let the provider talk
• Hard to answer the questions quickly and efficiently
• Hard to let the provider touch you to do the exam
• Hard to listen to what they want them to do
• Hard to follow through on what they want you to do

The patients that are the hardest to help often need the help the most

Question 16

What are some tips on interviewing a patient who is struggling emotionally?

Answer 16

• Be supportive
• Everyone carries private pain
• Consider yourself a fellow traveler, not a superior authority expected to have all the solutions
• Don’t be scared (or at minimum, do manage your own anxiety)
• Don’t look shocked
• Aim to appreciate the other human for his/her innate dignity and complexity rather than seeing him/her as a problem to be solved

Question 17

How can you create an atmosphere that is safe and respectful?

Answer 17

Create an atmosphere of safety and respect

• Stay calm, relaxed, and patient
• Accept what the patient is saying and invite more disclosure
• Set limits if necessary (gently but firmly)
• “I have about 5 more minutes… This is what I understand so far…”

Patient who feels as if you care about them has better patient outcomes

Question 18

How can you approach the treatment of a patient who is struggling emotionally?

Answer 18

• Compile enough information for a working understanding of diagnosis
• Establish a working relationship that will allow collaboration on treatment (and referral, if necessary)

Question 19

How can you approach the history of a patient who is struggling emotionally?

Answer 19

• Listen carefully, leave ample pauses for the patient to respond. Particularly with psychosis or trauma, there is often a great deal going on inside the patient’s head s/he they needs to navigate
• Try to understand, rather than change, the patient’s point of view
• Tolerate ambiguity and uncertainty rather than trying to “fix” the person (don’t invalidate their concern, they then feel embarrassed)

Need to slow down when we are working with an emotionally struggling patient… Ask one question then wait, give them time, don’t rush or ask another question right away

Question 20

What are the areas of the history to listen form in emotionally distressed patients?

Answer 20

• Symptoms and signs of biological illness (e.g. panic attacks, inability to concentrate, irritability, hallucinations)
• Social or interpersonal problems, including acute crises and chronic stressors
• Psychological problems, such as repeated styles of interpersonal interactions that impair functioning
• All three domains relate to a patient’s emotional status, and all three need to be addressed (or appropriate referrals made) for full functioning

Question 21

How can you build a sense of safety and collaboration?

Answer 21

• Be patient. The stated chief complaint is often not the real reason for the visit, but just a needed reason to make an appointment
• If referred by someone else, offer to share what you’ve been told and ask them to correct your understanding as necessary
• Reflect back what you hear, using the patient’s language (this alone can be healing)
• Get permission to discuss the problem further before asking questions about anything other than the stated complaint

Question 22

How else can you build a sense of safety and collaboration?

Answer 22

• Look for the patient’s strengths
• Check for non-verbal cues that the patient is feeling understood and valued
• Warmth and kindness go a long way
• Allow the patient to tell his or her story while you listen attentively
• Be quick to try to understand the patient’s experience, and slow to offer advice (in terms of what to do about an emotional problem)

Question 23

What is shame and humiliation?

Answer 23

Feelings caused by the lowering of pride or self-esteem

Question 24

Define shame

Answer 24

Shame is a state of distress where the self is felt to be somehow not good, inadequate, or defective. The self is felt to have some deficiency, and the typical response is to wish to disappear

Shame is a lot more toxic than guilt - instead of wanting to “fix it” you want to hide

Question 25

Define humiliation

Answer 25

Humiliation is a temporary status of the self that is felt to be lowering or debasing, generally caused by someone else

Caused by someone else

Question 26

Define guilt

Answer 26

Guilt is a state of distress caused by the commission of a forbidden or immoral act, and the typical response is a desire to make amends

You just want to “fix it”

Question 27

What do people need to feel in order to avoid shame?

Answer 27

In order to avoid shame, people need to feel

• Loved rather than rejected
• Strong rather than weak
• Successful rather than a failure
• Clean rather than contaminated
• Good rather than bad
• Whole physically and mentally rather than defective
• In control of body and mind rather than the body and mind exhibiting out of control symptoms or behaviors

Question 28

What population is very vulnerable to shame?

Answer 28

Adolescents

Question 29

What does illness threaten for patients?

Answer 29

Particularly in the modern West, the ideals are of youth, beauty, strength, and independence. Illness, particularly serious illness, threatens all of these

Question 30

Describe how shame and humiliation effects illness and treatment

Answer 30

• When a symptom occurs, patients fear that there is a defect in their bodies or minds
• Self-esteem will be lowered or threatened if that fear comes true
• They need to expose their bodies and minds to a stranger in order to receive help
• Treatment itself can be humiliating or disfiguring

Question 31

Describe problematic outcomes when a patient feels shamed

Answer 31

• Patients often will not return for care
• Phenomenon of patients waiting until they feel better until they see the provider secondary to shame about how bad off they feel or inability to have followed medical advice
• Patients will leave out important details or will outright lie
• Patients will strike back and attempt to shame the provider, either verbally in the medical encounter, or later, as with lawsuits or complaints on websites

Question 32

What interventions can a provider offer to decrease shame?

Answer 32

• Create an environment that is welcoming and respectful, both physically and interpersonally
• Demonstrate caring and an interest in the person him or herself. Office staff can do this as well.
• Be actively protective of privacy
• Be gentle and accepting when inquiring how the patient understands the illness and what the patient has done so far to manage the symptoms or illness
• Be on time, and if you are not, offer an apology and an explanation (otherwise patients may perceive you as seeing their time as not valuable or yourself as higher status than they are)
• Offer gentle humor as appropriate; respect patients’ attempts at humor

Question 33

What other interventions can offer to decrease shame?

Answer 33

• Be watchful for times when a patient emotionally withdraws, and try to trace back what happened
• Adopt an interpersonally “real” stance rather that retreating behind excessive “professionalism” that overly masks the person of the provider
• Avoid trying to use shame to motivate behavioral change. This usually results in the patient seeking care elsewhere or not at all rather than behavioral change
• Let the patient know that it made sense for them to make the appointment, and you are glad that they came in. Many patients worry about wasting the provider’s time
• Refer to support groups as appropriate
• Be mindful of your own shame, and avoid retaliating (e.g. if patient is critical of your skills)