Kenneth Lakritz, MD

Psychiatrists, like all physicians, sometimes ask patients to endure painful or unpleasant procedures in the course of diagnosis and treatment. Patients want treatment, but they also want to avoid pain—so we expect ambivalence and resistance. Distraction is one of the most effective forms of patient resistance.

Distraction can be very effective, as described in an Arabian folk tale in The Book of One Thousand and One Nights. The story tells of a cruel Persian king who marries a virgin every night, and every morning he has his new wife executed. On the night the king marries Scheherazade, she tells him a story but leaves off the ending. The king keeps Scheherazade alive for another day to find out how the tale ends, but she then starts telling another story. This practice keeps Scheherazade alive for 1,001 nights.

Like Scheherazade,patients can employ distraction to avoid an unpleasant experience. A recently retired schoolteacher consulted me because he wanted to travel but was afraid of flying, driving long distances, and spending the night alone away from home. He and I agreed on exposure and response prevention therapy, and he made good progress at first. But then treatment stalled.

My patient was a kind man from a large, turbulent family. He was always rescuing someone from divorce, bankruptcy, school failure, or criminal indictment. Discussing these crises started to dominate our treatment sessions, and there never was a good time to get down to business.

In my experience, this pattern of regular, distracting crises occurs often with:

• patients undergoing treatment for anxiety disorders
  
• drug and alcohol abusers
  
• patients referred by other physicians because the patient is avoiding a necessary procedure.
  

These strategies can help you refocus a distracting patient and manage “Scheherazade syndrome”:

Consider time-limited therapy when appropriate.

Quickly decide if a crisis that disrupts treatment is genuine or merely a distraction. A patient who has lost a loved one or suffered a life-threatening illness can be excused, but view lesser emergencies as suspect. My schoolteacher always had a good reason to avoid working on his fears, but the regularity of his excuses was a clue.

Confront the patient when you detect a pattern of avoidance. Make sure he remains interested in accomplishing the original objective.

Consider negotiating a new treatment plan. Your patient may need preliminary cognitive therapy, a gentler schedule, medication, or inpatient treatment.

Propose more structured therapy. Instruct the patient to keep a treatment diary and bring it to sessions. Sign a treatment contract, recommend a support group, or enlist the help of family members.

Reconsider the diagnosis if nothing is working. Attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, posttraumatic stress disorder, psychosis, or other cognitive problems can seem like anxiety or procrastination.

Psychiatrists, like all physicians, sometimes ask patients to endure painful or unpleasant procedures in the course of diagnosis and treatment. Patients want treatment, but they also want to avoid pain—so we expect ambivalence and resistance. Distraction is one of the most effective forms of patient resistance.

Distraction can be very effective, as described in an Arabian folk tale in The Book of One Thousand and One Nights. The story tells of a cruel Persian king who marries a virgin every night, and every morning he has his new wife executed. On the night the king marries Scheherazade, she tells him a story but leaves off the ending. The king keeps Scheherazade alive for another day to find out how the tale ends, but she then starts telling another story. This practice keeps Scheherazade alive for 1,001 nights.

Like Scheherazade,patients can employ distraction to avoid an unpleasant experience. A recently retired schoolteacher consulted me because he wanted to travel but was afraid of flying, driving long distances, and spending the night alone away from home. He and I agreed on exposure and response prevention therapy, and he made good progress at first. But then treatment stalled.

My patient was a kind man from a large, turbulent family. He was always rescuing someone from divorce, bankruptcy, school failure, or criminal indictment. Discussing these crises started to dominate our treatment sessions, and there never was a good time to get down to business.

In my experience, this pattern of regular, distracting crises occurs often with:

• patients undergoing treatment for anxiety disorders
  
• drug and alcohol abusers
  
• patients referred by other physicians because the patient is avoiding a necessary procedure.
  

These strategies can help you refocus a distracting patient and manage “Scheherazade syndrome”:

Consider time-limited therapy when appropriate.

Quickly decide if a crisis that disrupts treatment is genuine or merely a distraction. A patient who has lost a loved one or suffered a life-threatening illness can be excused, but view lesser emergencies as suspect. My schoolteacher always had a good reason to avoid working on his fears, but the regularity of his excuses was a clue.

Confront the patient when you detect a pattern of avoidance. Make sure he remains interested in accomplishing the original objective.

Consider negotiating a new treatment plan. Your patient may need preliminary cognitive therapy, a gentler schedule, medication, or inpatient treatment.

Propose more structured therapy. Instruct the patient to keep a treatment diary and bring it to sessions. Sign a treatment contract, recommend a support group, or enlist the help of family members.

Reconsider the diagnosis if nothing is working. Attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, posttraumatic stress disorder, psychosis, or other cognitive problems can seem like anxiety or procrastination.

Psychiatrists, like all physicians, sometimes ask patients to endure painful or unpleasant procedures in the course of diagnosis and treatment. Patients want treatment, but they also want to avoid pain—so we expect ambivalence and resistance. Distraction is one of the most effective forms of patient resistance.

Distraction can be very effective, as described in an Arabian folk tale in The Book of One Thousand and One Nights. The story tells of a cruel Persian king who marries a virgin every night, and every morning he has his new wife executed. On the night the king marries Scheherazade, she tells him a story but leaves off the ending. The king keeps Scheherazade alive for another day to find out how the tale ends, but she then starts telling another story. This practice keeps Scheherazade alive for 1,001 nights.

Like Scheherazade,patients can employ distraction to avoid an unpleasant experience. A recently retired schoolteacher consulted me because he wanted to travel but was afraid of flying, driving long distances, and spending the night alone away from home. He and I agreed on exposure and response prevention therapy, and he made good progress at first. But then treatment stalled.

My patient was a kind man from a large, turbulent family. He was always rescuing someone from divorce, bankruptcy, school failure, or criminal indictment. Discussing these crises started to dominate our treatment sessions, and there never was a good time to get down to business.

In my experience, this pattern of regular, distracting crises occurs often with:

• patients undergoing treatment for anxiety disorders
  
• drug and alcohol abusers
  
• patients referred by other physicians because the patient is avoiding a necessary procedure.
  

These strategies can help you refocus a distracting patient and manage “Scheherazade syndrome”:

Consider time-limited therapy when appropriate.

Quickly decide if a crisis that disrupts treatment is genuine or merely a distraction. A patient who has lost a loved one or suffered a life-threatening illness can be excused, but view lesser emergencies as suspect. My schoolteacher always had a good reason to avoid working on his fears, but the regularity of his excuses was a clue.

Confront the patient when you detect a pattern of avoidance. Make sure he remains interested in accomplishing the original objective.

Consider negotiating a new treatment plan. Your patient may need preliminary cognitive therapy, a gentler schedule, medication, or inpatient treatment.

Propose more structured therapy. Instruct the patient to keep a treatment diary and bring it to sessions. Sign a treatment contract, recommend a support group, or enlist the help of family members.

Reconsider the diagnosis if nothing is working. Attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, posttraumatic stress disorder, psychosis, or other cognitive problems can seem like anxiety or procrastination.

When consulting on a medical or surgical ward, consider asking the patient, “How are they treating you here in the hospital?” The response to this straightforward question often clarifies the reason for the consultation and helps establish the patient’s psychiatric diagnosis.

Asking about the patient’s experience in the hospital can reveal the dynamics of his or her interpersonal relationships. In a well-functioning ward, healthy answers are, “Everybody is really nice,” or “The staff is great, but I can’t wait to go home.” Any other answer should be investigated.

Questioning reveals disorders

Patients with borderline personality disorder (BPD) will describe a hospital staff split into idealized and rejected components and try to enlist you in their fight. However, most BPD patients won’t need encouragement to discuss their conflicts with the staff.

Unhappy narcissistic patients will com-plain about assaults on their dignity—often housekeeping issues such as poor-quality food and linens, indifferent cleanliness, or delayed response when they use the call button. Happier narcissistic patients will celebrate their doctors’ outstanding credentials and clinical brilliance.

Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.

Depressed patients may guiltily apologize for wasting everybody’s time.

When patients hint that they are enjoying the hospital experience or would like to prolong their stay, inquire into their situations outside the hospital. They may be homeless, abused, or destitute. Malingerers and patients with factitious disorder typically will insist on their desire to be cured and discharged.

Proper phrasing is essential

As phrased, the question is a “counterprojective” maneuver.¹ It distances you from patients’ suspicions, resentments, and presuppositions. By referring to hospital personnel as “they,” you signal that you are distinct and neutral if the patient is feuding with the staff. By comparison, asking “How are my friends on the medical staff treating you?” would invalidate this counterprojective effect, align you with the hospital staff, and subtly encourage the patient to keep his problems to himself.

If the question elicits a complaint, try to stay neutral as long as possible. Guard against perceived defensiveness and the patient’s projections by saying, “I’m sorry to hear things aren’t going well. Tell me more.” Offer to help if there is a concrete and reasonable solution.

Patients might not tell you about problems with their care in the hospital unless you ask. Some patients are too polite to say anything. Others are afraid to complain because they recognize that their comfort and perhaps even survival are in the hands of hospital staff.

When consulting on a medical or surgical ward, consider asking the patient, “How are they treating you here in the hospital?” The response to this straightforward question often clarifies the reason for the consultation and helps establish the patient’s psychiatric diagnosis.

Asking about the patient’s experience in the hospital can reveal the dynamics of his or her interpersonal relationships. In a well-functioning ward, healthy answers are, “Everybody is really nice,” or “The staff is great, but I can’t wait to go home.” Any other answer should be investigated.

Questioning reveals disorders

Patients with borderline personality disorder (BPD) will describe a hospital staff split into idealized and rejected components and try to enlist you in their fight. However, most BPD patients won’t need encouragement to discuss their conflicts with the staff.

Unhappy narcissistic patients will com-plain about assaults on their dignity—often housekeeping issues such as poor-quality food and linens, indifferent cleanliness, or delayed response when they use the call button. Happier narcissistic patients will celebrate their doctors’ outstanding credentials and clinical brilliance.

Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.

Depressed patients may guiltily apologize for wasting everybody’s time.

When patients hint that they are enjoying the hospital experience or would like to prolong their stay, inquire into their situations outside the hospital. They may be homeless, abused, or destitute. Malingerers and patients with factitious disorder typically will insist on their desire to be cured and discharged.

Proper phrasing is essential

As phrased, the question is a “counterprojective” maneuver.¹ It distances you from patients’ suspicions, resentments, and presuppositions. By referring to hospital personnel as “they,” you signal that you are distinct and neutral if the patient is feuding with the staff. By comparison, asking “How are my friends on the medical staff treating you?” would invalidate this counterprojective effect, align you with the hospital staff, and subtly encourage the patient to keep his problems to himself.

If the question elicits a complaint, try to stay neutral as long as possible. Guard against perceived defensiveness and the patient’s projections by saying, “I’m sorry to hear things aren’t going well. Tell me more.” Offer to help if there is a concrete and reasonable solution.

Patients might not tell you about problems with their care in the hospital unless you ask. Some patients are too polite to say anything. Others are afraid to complain because they recognize that their comfort and perhaps even survival are in the hands of hospital staff.

When consulting on a medical or surgical ward, consider asking the patient, “How are they treating you here in the hospital?” The response to this straightforward question often clarifies the reason for the consultation and helps establish the patient’s psychiatric diagnosis.

Asking about the patient’s experience in the hospital can reveal the dynamics of his or her interpersonal relationships. In a well-functioning ward, healthy answers are, “Everybody is really nice,” or “The staff is great, but I can’t wait to go home.” Any other answer should be investigated.

Questioning reveals disorders

Patients with borderline personality disorder (BPD) will describe a hospital staff split into idealized and rejected components and try to enlist you in their fight. However, most BPD patients won’t need encouragement to discuss their conflicts with the staff.

Unhappy narcissistic patients will com-plain about assaults on their dignity—often housekeeping issues such as poor-quality food and linens, indifferent cleanliness, or delayed response when they use the call button. Happier narcissistic patients will celebrate their doctors’ outstanding credentials and clinical brilliance.

Patients with substance abuse disorders will respond by discussing the timing and adequacy of their opioid and benzodiazepine prescriptions.

Depressed patients may guiltily apologize for wasting everybody’s time.

When patients hint that they are enjoying the hospital experience or would like to prolong their stay, inquire into their situations outside the hospital. They may be homeless, abused, or destitute. Malingerers and patients with factitious disorder typically will insist on their desire to be cured and discharged.

Proper phrasing is essential

As phrased, the question is a “counterprojective” maneuver.¹ It distances you from patients’ suspicions, resentments, and presuppositions. By referring to hospital personnel as “they,” you signal that you are distinct and neutral if the patient is feuding with the staff. By comparison, asking “How are my friends on the medical staff treating you?” would invalidate this counterprojective effect, align you with the hospital staff, and subtly encourage the patient to keep his problems to himself.

If the question elicits a complaint, try to stay neutral as long as possible. Guard against perceived defensiveness and the patient’s projections by saying, “I’m sorry to hear things aren’t going well. Tell me more.” Offer to help if there is a concrete and reasonable solution.

Patients might not tell you about problems with their care in the hospital unless you ask. Some patients are too polite to say anything. Others are afraid to complain because they recognize that their comfort and perhaps even survival are in the hands of hospital staff.