An Important Lesson Managing A Withdrawn Patient. Case Study #1

Be brave enough to acknowledge the emotion

Working with very withdrawn or reserved patients can be challenging for both parties. You may feel frustrated that you are unable to get relevant and helpful information from this type of patient.

Case Study #1

Early in my career as a physiotherapist I was working in a specialist clinic after completing an intense year of post graduate musculoskeletal physiotherapy. I had been trained to take on and sort out challenging spinal and sporting injuries.

A local doctor referred a 16-year-old boy with the referral saying “Back pain, please treat” into the clinic and I was the clinician he would see.

This young man was quiet and a little withdrawn. I didn’t think this was uncommon as I had seen a number of teenagers, especially boys, who presented like this. I assumed he was like the others that I had seen.

It took some time to get out of him any information about his condition. I spent 45 minutes asking lots of the mostly closed questions I’d been taught to ask. I also did any testing that I thought would help me help this young man. At the end of the consult, I struggled to have any clear direction in which to take his management.

I asked him to do some things over the next few days and take note of the response. I was hoping that this information would help me narrow down a potential source of his back pain.

When he came back 2 days later there was no change in his condition. I still found it very difficult to get information from him but I continued on with more questioning, again usually closed questions, and further testing. I was determined to help this young man recover from his back pain.

He response to my closed questions were ‘yes’ or ‘no’ and other responses were generally vague and non-specific.

In that second session I was considering medical reasons for his condition as I became unconvinced the pain was musculoskeletal in nature.

Finally I gave him things to do and asked him to come back to see me the following Tuesday. If he was no better I planned to send him back to his doctor.

He didn’t turn up for his next session which to be honest, didn’t surprise me as I had failed to identify the cause of his symptoms or help him in any way. I also struggled to build rapport with this young man. I hadn’t adapted my default way of consulting, which was “Directive” as I was unaware of varying consulting styles. I persisted with the what I had been taught in both my undergraduate and post graduate training.

The front desk staff followed him up and 2 weeks later his mother rang.

A Day I Will Never Forget

She apologised for him not turning up that Tuesday afternoon. She had come home to her son in his room where he had hung himself!

This young man had committed suicide.

I remember that day as if were yesterday.

As you can imagine, I felt like my world had fallen apart. I was in shock and of course devastated. I spoke to her for some time. She told me that neither she nor the young man’s doctor had realised that he was suicidal. At that moment this information gave me little comfort.

This experience influenced the way I interacted with my patients for the rest of my career and is partly the driving force for what I do now.

I had been taught to ask questions, analyse information and manage musculoskeletal conditions. I failed to comprehend that first of all I was dealing with another human being who was presenting with a problem.

It was also one of those life moments that had me considering the importance of the clinical relationship when treating patients. It especially had me thinking about who’s agenda should dominate in any consultation.

What Did I learn?

This experience taught me three important things when it comes to communicating with patients or for that matter anyone:

  1. No matter who you are talking to, be prepared to connect with them as a human being first.
  2. When a conversation isn’t going the way you expect, take the time to step out of your world and into the world of the person you are talking to. The aim is to see what you can learn before focusing on what message you want to get across. This is a real skill that takes time to develop. To help with this I have provided an exercise for you below.
  3. Listen to what’s being said beyond the words that are being used. Non-verbal communication, I believe is more powerful than the spoken word.

If there is one thing that I hope you can take away from my story I hope it will be this:

If a conversation isn’t going the way you would like it to go, rather than persist with your agenda or get frustrated with the other person, take a few seconds to consider the perspective of the person you’re talking to.

See what you learn. It may influence what you have to say and help you come to an outcome that is beneficial for both parties.

At the very least you will earn the respect of the other person for taking the time to be considerate of their point of view.

An exercise to learn how to see things from different perspectives.

Take a conversation that hasn’t gone the way you would have liked. Remember it vividly as if you are reliving the incident.

Step 1

See, hear and feel yourself in the conversation as it was going on. Take whatever time you need for this.

Step 2

Move away from the spot you were in and move to position where can ‘watch’ you and the other person talking as if in a movie. See what you learn from ‘watching’ this.

Step 3

Now move into the position of the other person as if you were that person. See, hear and feel the conversation from their perspective.

Step 4

Move away from the spot you were in and consider any useful information that you have found out whilst being the other person.

Step 5

Lastly go back into your position with any new information and re-live the conversation again. What did you learn? Would you have done or said anything different?

5 strategies that can help you engage in a productive conversation with a withdrawn patient.

With patients that are withdrawn and not very talkative you need to engage all the communication skills you have to connect with them, gain their trust and gather useful information.

1. Make no assumptions

When you see a patient who is withdrawn and unresponsive you have no idea of the reasons for this. What’s important is that you don’t start making assumptions. If it is important to clarify the reason for their presenting emotional state then ask.

You must be in very good rapport to ask questions about emotional states. If the timing is not right and you still need to build a more solid relationship then hold off querying on emotional state until the time is right.

2. Be brave enough to acknowledge the emotion

This point leads on from the one above with regards to being in rapport.

Acknowledging strong emotional states is hard and can feel very uncomfortable if you are not used to doing this. Whether that is anger, frustration or in this case being withdrawn most of us struggle to confidently deal with these emotions.

Talking about the emotional state your patient is in with compassion and curiosity indicates that you care and want to help them. In some way acknowledging a strong emotion diminishes it just a little.

3. Clarify patient expectation at the start of the session

Ask them at the start of the session what they want to get out of the time they have with you and what evidence they need to know they have achieved their goal. It is an open question and will require more than a ‘yes’ or ‘no’ answer. The answer will help you both as you have a common goal and something solid to reference back to.

4. Use open questions

Asking closed questions can lead to a very strained interview with patients that don’t say very much. You still need quality information to be able to help them. What often happens is that you have to ask the same question a different way or a completely different question. This can get very tiring and strain the relationship.

It puts you in the question/answer trap where your concerns predominate.

When you ask open questions it becomes more difficult for the patient to answer them with a ‘yes’ or ‘no’.

So how do you ask an open question?

Start the questions with ‘what’, ‘how’, ‘when’, ‘where’, ‘tell me more’, ‘why might you…’ or ‘what’s the next step if any?’.

5. Use reflective listening with a summary

Reflective listening is when you repeat exactly what your patient has said. It gives the speaker evidence that you are listening. Use common sense when implementing this tool.

Reflective listening with a summary is when you repeat exactly what your patient has said and then add a short summary of how you interpreted their message.

You could also summarise with a metaphor by adding “is that like….?” The word ‘like’ introduces a metaphor. If the metaphor resonates with your patient they will agree with you. Better still if the metaphor doesn’t resonate, they are likely to give you a metaphor that is meaningful to them.

If your summary is incorrect they will usually be more than happy to correct you. This helps open communication.

If they give you a metaphor then you might find it useful to talk in reference to the language they use for describing the metaphor. For some people it is easier to talk about the metaphor because it’s easier for them to associate with the metaphor than the situation they find themselves in.

Summary

In summary, for you to help a withdrawn person you have at least 5 things you can do.

  1. Make no assumptions as to the reason they are quiet
  2. Be brave enough to talk about their emotional ‘state’
  3. Clarify what the patient wants to get out of the session with you
  4. Use open questions
  5. Use reflective listening with a short summary, with or without introducing a metaphor

If you think the person you are seeing maybe presenting with a serious mental illness then refer on to an appropriate health practitioner.

BEYOND BLUE

BLACK DOG INSTITUTE

To get some ideas on how to engage the depressed client download this PDF

“Tips to engage the depressed client 

To learn more about motivational tools through effective communication download my eBook

“Improving Patient Motivation In Physiotherapy”

I wrote this eBook in response to the most common question I get asked and that is “How do I motivate my patients?”

If you would like to fine-tune your communication skills when working with resistant patients, you might consider working with a coach or mentor.

Or perhaps your staff would benefit from training in this area.

Contact us, and find out more about what we can offer you

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