Using Basic Psychotherapy Techniques

As is often the case, a general medical approach may not be sufficient to help a difficult patient. After a brief period of immersion in the patient's complaints, the family physician can respond with empathic responses, initially acknowledging the patient's fears and symptoms (see Table 46-1). If this is not helpful, the physician can use general psychotherapeu-tic techniques, such as confrontations, clarifications, or interpretations, directed toward the current problem interfering with medical care.

A confrontation is an observation by the physician offered to a patient for examination. It is usually a comment that draws attention to contradictions in the patient's beliefs, thoughts, feelings, or behaviors. For example, one might say to an anxious-somatic patient who denies that psychosocial factors might be contributing to her symptomatology, that her physical complaints may be caused by medical, psychological, or social stresses, and that her high levels of anxiety could be making her physical symptoms worse.

A clarification adds new information or perspective or elucidates misunderstandings, miscommunications, or other information that seems vague or confusing. The need for repeated clarifications occurs regularly with difficult patients. It is important to use clarifications before suggesting a new plan to correct the problem.

Interpretations are integrating comments that link confrontations and clarifications with the patient's current problem that is interfering with medical care. Interpretations can be made about the immediate medical situation and may address the patient's core beliefs, irrational thoughts, fears, maladaptive symptoms or behaviors, defense mechanisms, or coping style. Interpretations can also be directed at a difficulty in the physician-patient interaction, problems with the patient coping with the disease, problems in the patient's life circumstances, or patient refusal of a necessary medical workup or treatment. For example, an interpretation to a somatic patient who is refusing to acknowledge any psychosocial contribution to her symptoms might be the following:

I think you want relief from your physical symptoms. However, your refusal to consider that any of your psychosocial stress is contributing to your pain makes relief from your physical symptoms less likely [confrontation]. You then get annoyed with me and more depressed, which leads you to have new physical symptoms, and then you feel hopeless [clarification]. Instead of accepting my help to look broadly at all factors causing your pain, you blame me for not making you better. Your physical symptoms become an excuse for why you have difficulty managing your life [interpretation].

Such interpretations take practice but can powerfully restore a realistic and helpful physician-patient relationship.

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