We are learning that people who become ill/hospitalized frequently have similar psychological reactions to their conditions, all of which to some degree are helpful, but become maladaptive when they stray too far from the mean. I was surprised at how similar these defenses and personality traits were to the ones I noticed during my time in sales, its funny how simple we are. When I read this chapter I'm constantly reminded of different customers, I think we all should have to do sales at some time in our life, convincing someone that they need something is the best type of psychological education you can get, and if you're good, you can get paid to do it. So here are the defenses: regression, denial, anxiety, depression, and anger. Each must be dealt with differently, later then dominant personality traits.
Regression: where a patient reverts to a more childlike way of thinking, they can become excessively passive. Its important to explore the reasons for this behavior with the patient, try to alleviate their fears by information and reassurance.
Denial: unconscious repression of a frightening situation that wards off the anxiety that may come along with it, can lead to delays in treatment and refusal of necessary treatments/tests. Best dealt with by introducing new information to the patient and observe how the patient incorporates and retains. Its best not to confront the denial, unless there is an emergency.
Anxiety: anxiety is a natural and necessary psychological state as a result of being ill. Too much fear, worry, and rumination however is maladaptive. In this case, elicit the specific nature of the patients fear, provide them with accurate information regrading this, and be reassuring where you can be. "there are excellent treatments" etc... given that there actually are! Don't lie.
Depression: kind of like anxiety, except with a pinch of guilt, because the patient feels somehow responsible for the illness and experiences the loss of function. Major depressive episodes are not normal, and have higher rates of not cooperating with any treatments. In this situation, its best to clarify the nature of the depression, correct any distorted notions, and reassure where it is possible.
Anger: Many people are angry at being ill. They can become hostile, paranoid and accusatory. Check for neurological issues or substance abuse, a major contributor to anger/violence. Best practices for managing angry patients are: First, prevent them from hurting themselves. Second: minimize conflicts which helps patients retain a sense of control
Third: Acknowledge anger and concerns (this is customer service type stuff)
We are also learning about a whole host of personality traits that come out with illness:
Dependant personality: these patients have fears of abandonment, lookout for unrealistic expectations of unlimited care. They may be disappointed or frustrated when something inevitably falls short of their expectations, can be demanding.
Use:
Gentle limit setting
Token compensation - trade a "tip" for good behavior or more patience
Consistency - dependent patients do better with a consistent predictable hospital visit.
Controlled personality traits: these patients are highly orderly and conscientious, need to have as much information as possible, and are heavy on the minute details. Taken to a compulsive degree they can become oppositional.
Use:
Logical explanations, they respond well from being participatory in their care. These patients can be gratified by acknowledging their exact natures "I can see you are discerning and intelligent, how would you best prefer to be informed regarding the nature of your test results?"
Self-dramatizing: naturally magnetic, charming people, long on emotion, short on specific detail. Overly familiar, needing to feel "special". Patients tend to deny the severity of their conditions.
Use:
Tread the line between the familiar and reserved, make them feel special.
Long-suffering: usually have a lifelong history of suffering, self sacrificing relationships, feel as burdens to others, appear modest and humble, and want love and acceptance but feel they may not deserve it. They view their condition as much deserved, beneath the self-flagellation look for attempts at attention and control.
Use:
Acknowledge the suffering! Acknowledge the suffering! Place the suffering in the context of all they do for others.
Suspicious traits: distrustful of doctors/nurses, tests. Somewhere on the paranoid spectrum, fear becoming exploited. Being sick and vulnerable can be a crisis because it lowers their defenses. Openly suspicious and critical.
Use:
Detailed information, including risks and benefits. Do not try and dispel their paranoia, that will only reinforce it. They are looking the "gotcha", acknowledge their concerns!
Superior personality traits: Patients can be self-important, self-centered, condescending. Look for it to be cloaked with a "patronizing false humility". They demand the best specialists, frequently engage in splitting - idealize one person while castigating another
Use:
Realize the narcissism protects them from realizing their own fragility and dependence. Inquire about the accomplishments, emphasize your own expertise and demonstrate self confidence, they need to believe they are receiving the best.
Aloof personality: Unemotional, reserved, indifferent, distant, detached, unconcerned. Look for avoidance of eye contact. Can be odd, extraordinarily concerned with either dietary habits or hyper-religious.
Use:
Respect the need for privacy!! Mirror their detachment by displaying a tempered interest. Don't try and be friendly or you will be appear intrusive and the patient will withdraw further.
Its all sales, everywhere I go, I see the same thing- our motivations are suprisingly similar. Whether you're trying to sell cutlery, booze, personal training, ketchup, or medical opinions - people all want the same two things: to be loved and to have control.
