Mental Health Blog

Getting through to difficult patients and families

It’s 10:30 Monday morning, and you’re 45 minutes behind. Earlier, you had to confront a receptionist about coming in late again. You have to get out today by 4:30 so you can get to your daughter’s softball game. Beating under all this stress is worry about your mom, who has been diagnosed with stage 2B breast cancer.

And now you have a new patient. The intake form says that 11-year-old John has injured his wrist, but there’s something about — crashing a stolen car? Can that be right? And he’s here with his grandmother, not his mom. Oh, this isn’t going to be an easy visit.

Already you suspect a behavioral health issue in addition to the physical problem. You know that listening and empathy are key to quality care. But you’re short on both time and patience right now.

How are you going to be there for your new patient and his caregiver?

Although the intellectual knowledge you learned in medical school and residency is important, you need practice to set the stage for a therapeutic alliance.

“Active listening involves hearing the needs underneath the words. You also have to adjust how you get your own needs met based on what you get from the other person,” said Marjorie Heymann, PhD, who is both a psychologist and a former theater director. “You have to practice active listening so you can internalize it. Then you can really be present for your patients and caregivers.”

Dr. Heyman created the REACH communication course, Working with Challenging Patients and Families. In this course, theater techniques are adapted to be life skills while participants practice six essential steps to improve the therapeutic alliance:

  1. Be present.
  2. Get rid of distractions.
  3. Listen actively for the needs underneath the spoken words.
  4. Practice active empathy, experiencing the needs, story, and point of view of the patient or caregiver.
  5. Arrive with the patient and caregiver at a shared understanding of the problem.
  6. Agree jointly with the patient and caregiver on an intervention plan.


The first four steps are necessary for the last two, which are likely to be your goal for the visit. In fact, each step builds on previous steps.

  • You can listen actively only when you are present to the family and not distracted.
  • You can empathize only when you listen actively.
  • You can arrive at a shared understanding of the problem only when you have empathy.
  • You can agree on an intervention plan only when you have a shared understanding.


The whole process starts with being present. Get in touch with your own need, which might be, for example, “Help me help you.” You must also get rid of distractions. For big worries like your mother’s diagnosis, you may have to make a date with yourself to deal with your feelings, for example, tonight after the kids go to bed. Now you are ready to be present with the patient and caregiver.

In the room with Johnny and his grandmother, you use your active listening skills to get in touch with what’s going on besides a sore wrist (which seems to be a mild sprain, but you order radiography to be sure).

Ms. Smith tells you that Johnny left school and started a teacher’s car. “He wasn’t stealing!” she says. “He was just showing off for his friends!” But the car ran into another car. Now Johnny faces expulsion. This doesn’t seem to be the child’s first run-in with school authorities.

When you ask John what happened with the car, he shrugs and says nothing.

You feel a strong need to talk to grandmother and grandson separately. You don’t have time today, but you set up a visit next week to check on that wrist and come to a better understanding of Johnny’s behavior.

In that next visit, you’ll again practice being present before you step into the examining room. You’ll ask open-ended questions. You’ll listen carefully for the needs under the words.

  • When Ms. Smith says, “Everyone has always said he’s a real handful,” she may be saying, “Please help me keep this child safe.”
  • When Johnny says, “People always make me do stuff I don’t want to,” he may be saying, “No one cares about me. Do you?”


You’ll hear the need under the words only if you listen. You need to feel what is going on with both patient and caregiver in order to arrive at a shared understanding of the problem. You need that shared understanding to establish a treatment plan Ms. Smith and Johnny can buy into.

“There’s a simple bottom-line principle clinicians have to keep in mind with any family,” said Dr. Heymann: “‘I can’t do it without you.’ The caregiver is your partner in developing a workable solution.”



Experience Dr. Heymann’s unique approach in Working with Challenging Patients and Families, October 9 and 10 on Zoom.

Dr. Heymann’s website Empowerment Through Theatre has videos and scenarios to illustrate the power of being present, active listening, and active empathy.

Dr. Heymann recommends these articles by her colleague Kimberley Hoagwood at New York University:

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““It is great to be a part of a continuing medical education course with others within the same department. Change is always hard, but easier with teamwork.”

Jennifer Mullally, MD
Fargo, ND