“What about my pain?” Sandra asked, her brow furrowed. “It’s my back. My primary care doctor says I need more meds.”
“You can ask the nurse for Tylenol or ibuprofen,” I said, trying to maintain my composure seated across from Sandra on the inpatient psychiatric ward, “or I can add some naproxen, if you would like.”
“But I’m in so much pain!” Her voice was rapidly escalating, both in tone and volume. “What you’re giving me just won’t work. I’ve got to have Dilaudid.” Sandra was at a feverish pitch now. She gesticulated wildly, bouncing out of her chair for emphasis.
We had been going in circles for what felt like forever but had likely been just a few minutes. She was admitted. I was her doctor while she was here and I wanted, desperately, to relieve her discomfort. And yet there was her substance use and her continued unwillingness to even talk with us about what brought her to the hospital. I knew that ordering the opiates would be a short-term solution that would only backfire in the long term. I could feel the color rising to my cheeks as my frustration crept ever higher. I was wavering, unsure what to say next. I did not know how to proceed, but did know one thing: This was not going well.
If only Mitch Abblett’s book, The Heat of the Moment in Treatment: Mindful Management of Difficult Clients, could have arrived a week earlier than it did, before I met Sandra. How I could have used it! I became a psychiatrist for all the empathic, do-gooder reasons anyone enters the field of mental health. And yet, despite my best intentions, patients can infuriate me, befuddle me, and leave me feeling ragged after an intense interaction. Learning to deal with challenging patients is necessary for any successful career. While much of this training happens informally, with teaching at the bedside by a mentor or by trial and error, Abblett’s book provides an in-depth look at how we can deescalate things when clients get under our skin.
Abblett is well suited to write this book. A licensed psychologist, he is the clinical director of a Harvard University–affiliated therapeutic day school for children and adolescents — certainly a difficult job with a difficult population. In this book, Abblett is careful to focus on the part of testy interactions that we can control: That is, our own reaction.
In the first section, Abblett explores why we as clinicians react the way we do. To individuate the experience, he includes in each chapter a number of exercises for the reader. Through these, we can examine particular interactions with particular clients.
Abblet then moves from helping us understand how our personal patterns contribute to why things go wrong, to how we can begin to think more flexibly during these moments with patients and thus alter the outcomes. There are more exercises to foster empathy for those patients we might consider our least sympathetic. Abblett then has us apply the self-management skills taught in the first half of the book. He covers such topics as the timing of clinical interventions, ways to increase authentic engagement, and how to limit setting — just what I needed when dealing with Sandra.
Abblett’s style is entertaining and engaging, and he fills the book with real-life cases and other personal experiences. His willingness to share his own struggles — and missteps — with clients creates a safe space for us as readers. It allows us to take a brutally honest view of our own contributions to difficult situations and how changing our thinking can alter them for the better.
Through the text’s examples I was able to see my own mistakes and consider how things could have gone differently. I also appreciated Abblett’s ability to break things down into their component parts. For example, he spends time on how to establish mutual values with patients, and goes so far as to give sample questions one could ask to further that goal.
While nothing beats the power of firsthand experience, The Heat of the Moment in Treatment encourages us to slow down and take a deliberate look at our interactions. Everyone in the mental health field encounters challenging individuals. Having worked through Abblett’s book, I feel more prepared to handle the next Sandra that comes under my care.
The Heat of the Moment in Treatment: Mindful Management of Difficult Clients
W. W. Norton & Company, May 2013
Paperback, 368 pages