Michael Bloom, Ph.D.

Michael Bloom, Ph.D.

A Parable Against Persecution (1755/1760) by Benjamin Franklin 1. And it came to pass after these Things, that Abraham sat in the Door of his Tent, about the going down of the Sun. 2. And behold a Man, bowed with Age, came from the Way of the Wilderness, leaning on a Staff. 3. And Abraham arose and met him, and said unto him, Turn in, I pray thee, and wash thy Feet, and tarry all Night, and thou shalt arise early on the Morrow, and go on thy Way. 4. And the Man said, Nay, for I will abide under this Tree.

5. But Abraham pressed him greatly; so he turned, and they went into the Tent; and Abraham baked unleavend Bread, and they did eat. 6. And when Abraham saw that the Man blessed not God, he said unto him, Wherefore dost thou not worship the most high God, Creator of Heaven and Earth? 7. And the Man answered and said, I do not worship the God thou speakest of; neither do I call upon his Name; for I have made to myself a God, which abideth alway in mine House, and provideth me with all Things. 8. And Abraham s Zeal was kindled against the Man; and he arose, and fell upon him, and drove him forth with Blows into the Wilderness. 9. And at Midnight God called unto Abraham, saying, Abraham, where is the Stranger?

10. And Abraham answered and said, Lord, he would not worship thee, neither would he call upon thy Name; therefore have I driven him out from before my Face into the Wilderness. 11. And God said, Have I born with him these hundred ninety and eight Years, and nourished him, and cloathed him, notwithstanding his Rebellion against me, and couldst not thou, that art thyself a Sinner, bear with him one Night? 12. And Abraham said, Let not the Anger of my1 Lord wax hot against his Servant. Lo, I have sinned; forgive me, I pray Thee: 13. And Abraham arose and went forth into the Wilderness, and sought diligently for the Man, and found him, and returned with him to his Tent; and when he had entreated him kindly, he sent him away on the Morrow with Gifts.

Patient is a 57-year-old who was seen in the hospital along with her daughter after being referred by her Dr. because of a lack of effort at PT and repeated demands for more opioids. She was admitted to the hospital because of a sacral fracture as a result of a fall. She also has a history of chronic pain with a diagnosis of CRPS. Patient describes her pain as excruciating. She says it is made worse by any muscular effort of the back or legs and is only made better by medications, reclining and her daughter messaging her legs. She is on opiates for pain management. She states she has been in so much pain that she cannot do anything.

She and her daughter had complaints about physical therapy. They felt the physical therapists were not being helpful because before she could do any movement of her legs she needed at least a 1/2 hour massage. Her daughter lives in Texas but came immediately to her mother when she was hospitalized and has been in regular attendance with her since. Her daughter states she cannot return to Texas until she knows her Mother is well cared for.

Unhelpful Approaches Blaming the patient (who s responsible for resolving the problem). Feeling powerless. There is almost always something to try to improve the situation. Expressing anger at the patient or acting like an authoritarian parent (some exceptions). Treating the patient like they are ignorant or sick in the head

Risk Factors for Conflicts 1. Healthcare providers and patient have different goals. 2. The family medical expert does not agree with the health care team. 3. Denial of serious illness. 4. Control or authority issues. 5. Using the hospital as a refuge from an uncomfortable home life or other environment. 6. Not wanting discharge because needs better met in hospital than home. 7. Needs of family met by illness behaviors of pt. 8. Dependent personality (or somatization); borderline personality (manipulation/splitting); opioid or other drug dependency.

Assessment 1. What needs are getting met by the problem behavior? 2. Expect resistance to change what form is it likely to take? 3. How might patient and family needs get met as well by nonproblem behaviors? 4. What changes in cognition (frame of reference) and behavioral sequences might occur that will lead to a more acceptable outcome for everyone?

Useful Interventions 1. While joining the patient and family establish clear boundaries. 2. Provide patient and family with a new framework that supports new behaviors, for example, the pleasure of self-efficacy for the dependent patient. Communicating this framework must have an emotional component as well as a rational component for change to occur. 3. Develop a behavioral program that adequately meets the patient needs and family needs cannot be forgotten, while avoiding problems.

Take-Home Points 1. Patients who are difficult are often unconsciously motivated to fulfill important needs using their illness. 2. Assessing how their needs might get met in a non-problematic way is a first step towards developing a strategy toward resolution. 3. Providing the patient with a different frame of reference which promotes new behaviors is frequently helpful. 4. Developing a behavioral reinforcement plan, which blocks getting their needs met in problem ways, while reinforcing getting needs met in less problematic ways is frequently helpful.