Mental Health Blog

Working with challenging families

You’re in the consultation room with Anita, who first brought her 15-year-old son Vic to you two weeks ago. Vic has been suspended from school several times for increasingly dangerous behavior. Anita uses a wheelchair because she has multiple sclerosis. Today she is distraught.

Last night, she forbade Vic to leave the house, but he went anyway. He didn’t come home last night or go to school this morning. Anita has called everyone she can think of, but no one knows where he is. The police won’t help until he has been missing at least 24 hours.

Anita has come to you as a last resort. When you saw Vic, you were troubled by his history of uncontrolled behavior and his uncooperative stance. You were hoping to get him to open up in a follow-up visit. But now Anita is here alone, frantic because she doesn’t know where Vic is.

What do you do?

This is one of the scenarios Marjorie Heymann, PhD, will present next month in the REACH course Working with Challenging Patients and Families: Maximizing Your Clinical Effectiveness. In addition to serving on the faculty of The REACH Institute, Division of Child and Adolescent Psychiatry at Columbia University, and the Child Study Center at New York University, Dr. Heymann was a professional theater director for many years.

That theatrical background is the source of her use of scenarios to train pediatric primary care providers and others to communicate effectively with patients and families. She teaches healthcare professionals to see another’s point of view by, for example, “being Vic” or “being Anita”—stepping into the patient’s or caregiver’s shoes.

“Sometimes people leave the doctor’s office feeling that the doctor didn’t have time for them, didn’t respect them, didn’t hear them, didn’t trust that they know their own child,” said Dr. Heymann. By contrast, providers who start with active listening can build a therapeutic alliance, which is the foundation of effective diagnosis and treatment.

Dr. Heymann recommends a step-by-step approach to patient and family communication.

1. Be present with your own need.

When you pick up the chart, focus on your want or need in relation to this patient, for example, “I want you to trust me” or “I need you to help me help you.”

2. Get rid of distractions.

Being present for this patient means letting go of the last patient, the next patient, the disagreement you had with your colleague, and your anxiety about getting to your daughter’s softball game. If you have serious concerns in your personal life, set aside a specific time outside of clinical hours to deal with them.

3. Listen actively.

Listen not only for what the patient or caregiver is saying but also for what’s underneath the words. For example, Dr. Heymann presents a simple two-line interaction between provider and caregiver:

“How can I help you?”

“I don’t think you can help me.”

What’s under the caregiver’s response? Is he trying to take control because he’s not sure how much you care? Is he seeking respect for his knowledge of his own child’s needs? Has he given up because other providers haven’t helped? Some combination of these?

Only by listening will you learn the truth.

4. Practice active empathy.

Practice in seeing another’s point of view is essential. You’re still present with your own need, still not distracted, still listening actively—and now you work to understand the patient’s or caregiver’s story and their wants and needs.

“You want to be the doctor who pays attention and gets it right” in the family’s eyes, said Dr. Heymann. If caregivers think you’re not listening, they may not come back. Establish trust by letting them tell you what’s wrong before you decide on a diagnosis.

Only when people feel heard and respected can they participate in devising a treatment plan. Only when they participate in devising the plan will they be able to follow through.

What will you do about Anita and Vic? Right now, you can’t know what’s going on with the child. Focus on the adult in front of you. Simply being heard may be the most helpful thing that happens to Anita today. If she seems open, you can help her decide on some self-care steps to take while she waits.



For more on patient communication, consult these articles from the bibliography of the course Working with Challenging Patients and Families:

The Institute for Healthcare Communication website offers many resources for patient communication, including suggestions for effective communication in telemedicine visits.

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