We've all had them. Difficult patients can be disruptive, argumentative, non-compliant, or just plain hard to deal with. Get helpful advice on turning a difficult patient relationship into a prosperous one.
As therapists, we have all dealt with difficult patients who are disruptive, oppositional, or non-compliant. Dealing with difficult patients is indeed frustrating but inevitable. There are, however, strategies we can use to help us turn a difficult patient relationship into a positive and fruitful one.
To navigate these complex relationships, we must first understand why difficult patients behave the way they do, and then work on our approach. In this article, I’ll share 10 actionable tips for dealing with difficult patients that you can use in your practice. These tips will help you understand their perspective, get yourselves on the “same side,” and stay on track for better patient engagement.
Defining “Difficult” Patients
Let’s first define what we mean by a “difficult” patient. This can include those who demonstrate non-compliance, aggression, manipulation, passive-aggressiveness, and attention-seeking behaviors.1 These behaviors can include resisting treatment, unwillingness to follow recommendations, or even verbal confrontation.
Why Patients Can Be “Difficult”
To effectively deal with difficult patients, we need to understand where they are coming from. Patients can act out for a variety of reasons, most of which are rooted in fear, pain, or lack of understanding. Patients may be worried about their condition or their future. They are likely in some physical pain, which can understandably cause irritability. They may have had negative experiences in therapy in the past or came in with unrealistic expectations. While you can’t control all of these variables, we will focus on the issues you can influence in a positive way. Recognizing the underlying source of their behavior is the first step in addressing the issue effectively.
As therapists, we must approach the situation with empathy, compassion, and patience.
Remember that non-compliance or challenging behavior is not a reflection of your personal competence. It is a manifestation of the patient’s own struggles and concerns. In other words, have patience with yourself too! With the following tips, you can turn difficult patient relationships into opportunities for growth, ultimately benefitting you and your patients.
How To Deal with Difficult Patients
1. Active listening
We can start by actively listening without judgment. This will allow us to understand our patient’s point of view more accurately. Be aware that active listening without judgment can be challenging. Without realizing it, we’re normally listening through our own filters, making judgements and assumptions that are unintentional and innate.
Listening without judgement takes awareness and practice. Each conversation with a patient is an opportunity and a privilege to be allowed into the world of someone who trusts you in a vulnerable state. We must give them our undivided attention and avoid making assumptions. This allows us to gain insight into the patient’s perspective and experiences influencing their behaviors.
2. Stay solution-focused
Once we understand the root causes behind a difficult patient’s behavior, we can collaborate to find solutions and overcome obstacles in their care. For example, suppose a patient is non-compliant with home exercises due to discomfort and pain. In that case, we can focus on modifications like lower-impact activities, modifying the exercise volume, or trying a different time of day when pain is lower.
Another common issue is a lack of focus during sessions. In this case, we can implement solutions like limiting distractions in the treatment space or incorporating more engaging modalities. The key is identifying the root cause and then co-creating an actionable plan to address it. With a solution-focused, collaborative approach, we can turn difficulties into opportunities for growth.
3. Create shared goals
Collaborating with patients on goal-setting and care decisions can give them a sense of control. It also instills confidence that you truly care about their input and wishes. As therapists, we want our patients to feel empowered and invested in their rehabilitation process.
However, some difficult patients may try to direct their care in ways that are unrealistic or inappropriate. While collaboration is ideal, we need to set clear expectations and limits based on our clinical expertise. Difficult patients may require more education on why certain exercises or modalities are prescribed over others. With open communication and empathy, collaboration can still occur within the appropriate boundaries we set.
4. Manage expectations and set boundaries
Set clear expectations and professional boundaries. From the start, you should set clear expectations about your role and theirs. For example, explain during the initial evaluation that patients are expected to arrive on time, participate actively, and complete home exercises. You may need to establish what behaviors will result in termination of services due to non-compliance or abuse. Professional boundaries create the structure patients often need to be successful in therapy.
Ever wondered what patients really expect from you? This research study asked just that. See the results in our recent patient engagement article: The 4 Things Patients Expect from You – Manage Patient Expectations for Better Retention.
5. Educate patients
Educate patients on how your treatment techniques and home exercise programs connect. Explain how they work together to facilitate progress and reach their treatment goals. Identify possible barriers to learning, like language barriers, limited attention span, learning disabilities, or difficulty in understanding new concepts. Some factors, such as limitations in literacy, may be more subtle and harder to recognize.
You may want to use the teach-back method (also called the show-me method or closing the loop) to confirm that you have explained the information in a way that the patient understands clearly. This builds buy-in and investment and lets you know they understand your directions.
6. Reinforce positive behaviors
As therapists, we use our observational skills to read all the big and small nuances in behaviors a patient continuously provides during treatment. These observational skills start from the moment you first lay your eyes on them to the last glimpse of them leaving. This is where we can identify positive behaviors and attitudes and call attention to them by validating and encouraging those behaviors.
For example, when the patient demonstrates desirable actions like arriving early, completing home exercises, or having friendly interactions with other staff, verbal praise will help motivate continued progress. You can say things like, “I’ve noticed how dedicated you’ve been to your recovery, and I wanted to let you know I appreciate your commitment to the process.” Verbal praise and positive feedback will help motivate the patient’s continued progress.
We can also consider using tools like rewards systems or goal charts that allow patients to track achievements visually. By reinforcing positive behaviors, we shape productive patterns.
7. Diffuse attention-seeking behaviors
Complaining loudly, displaying inappropriate boundaries, exaggerating symptoms, being overly dramatic, or confronting staff are all examples of attention-seeking behavior. Patients engage in attention-seeking behaviors due to low self-esteem, loneliness, feeling unheard. It is their way of attempting to seek help and support. It’s best to avoid reinforcing these behaviors by responding with immediate, excessive attention.
To diffuse attention-seeking behaviors, you can set clear expectations for appropriate conduct. Remind patients calmly and respectfully about those standards if inappropriate behavior occurs. We can say, “I know you’re frustrated, but I cannot allow that language here. Let’s take a minute to collect ourselves and then try discussing this calmly.”
If disruptive behavior escalates, set firmer limits. However, ignoring harmless bids for attention can also diffuse the situation. The key is finding a measured response that maintains professionalism and progress.
8. Open and honest communication
When conflict arises, address issues directly yet impartially, and keep communication professional, direct, and free of emotion. For example, “I understand this exercise causes discomfort. Let’s explore some alternative modalities that may better suit your needs.” Present rational options for finding mutually agreeable solutions.
If patients become hostile or oppositional, refrain from defensiveness. Instead, pause the interaction briefly to allow tensions to diffuse. Then, revisit the discussion, maintaining composure and objectivity. For example, you can say, “Let’s table this conversation for now and constructively reapproach these concerns later once we’ve both had time to reflect.” Language like this will model the respectful discourse expected from patients.
9. Know your limits
What is your limit as a therapist? Knowing the exact answer to this can be challenging. We are hard-wired to help, support, and see the patient’s goals come to fruition. We are invested in their recovery. However, in rare cases of severe noncompliance, abuse, misconduct, or safety threats, discontinuing services may become necessary as a final recourse once all other options are thoroughly exhausted.
If a patient persists in violating conduct policies despite repeated redirection or presents an escalating physical threat, formal termination may be warranted. It is a difficult decision that we, as therapists, can rest securely in the making after extensive efforts over a reasonable timeframe to implement solutions, enforce boundaries, and protect staff and patient welfare.
When all clinically and ethically indicated options have been attempted, terminate formally in writing, providing alternative care resources. Though difficult, setting these necessary boundaries ultimately preserves wellness and safety.
10. Practice self-care and stress management
Managing difficult patients mandates prioritizing your mental and emotional health through self-care. Difficult patients are draining, so make time for exercise, hobbies, vacations, or counseling. Ask colleagues for support.
Monitor yourself for early burnout signs like irritability, lack of motivation, or fatigue. If needed, take a brief hiatus or make caseload adjustments. You cannot sustainably care for others without first caring for yourself.
With empathy, consistency, and boundaries, many difficult patients can become more cooperative over time. While we can’t prevent every challenging case, these strategies can ease the friction when difficult situations do arise. We all want the best for our patients – meeting them where they are is the first step.
Hannah le Roux OTR/L, CHT, is an Occupational Therapist/Hand Therapist with more than 20 years of experience working in South Africa, the United Kingdom, and the United States. She is now using her knowledge and skills as a consultant to other therapists and writing articles related to hand therapy, managing therapy groups, and patient care.
- Potter, M., Gordon, S., & Hamer, P. (2003). The difficult patient in private practice physiotherapy: A qualitative study. Australian Journal of Physiotherapy, 49(1), 53-61.
- Bassett, H., & Lloyd, C. (2001). Occupational therapy in mental health: Managing stress and burnout. British Journal of Occupational Therapy, 64(8), 406-411.