In the 27 years Barbara Sher, MA, OTR/L, worked as an occupational therapist in Northern California before moving to Saipan – part of the Commonwealth of the Northern Mariana Islands, a U.S. territory near Guam – she had one autistic patient. In her first year on Saipan, she had 12.

One of her autistic patients – a young boy – was really giving her trouble: He wouldn't acknowledge her existence. "He would never look me in the eyes," Sher says.

Sher usually gets lots of feedback from patients, to gauge her effectiveness. But with this patient, she couldn't get any response at all, and it was disheartening.

Concerns seeped into Sher’s mind for fear that she was failing the one patient – and then she began wondering if she was failing her other patients, too. Her experience with such a non-responsive patient was making her doubt her ability to help her other patients, even the ones who obviously enjoyed working with her.

Nightmare Patient or Therapist Insecurity?

“A difficult patient is one who resists treatment, who sabotages treatment, who denies having a problem, who blames other people, who gets dramatic, who becomes quickly dependent on the nurses for everything, one who has an anxiety disorder, one who has a personality disorder even before they’re injured or ill [and] one whose behavior taps into feelings of insecurity in the therapy personnel,” says Carol Leslie, OTR/L, an Ohio-based occupational therapist and author.

According to Leslie, therapists working with difficult patients say things, such as, “I hate that patient.”

“Sounds like you should be saying, ‘That patient makes me feel inexperienced.’ You hate the way being disempowered makes you feel – you don’t hate the patient,” explains Leslie. “The patient is not responsible for your sense of wellbeing. We’re all human beings first, but we’ve got to be aware of our sense of inadequacy around patients who are treatment-averse.”

This feeling of inadequacy can cause therapists to judge and label patients as “difficult” says Gail Jensen, PhD, professor of physical therapy at Creighton University in Omaha, Neb., who recommends therapists think about how that label itself is impairing the patient’s therapy.

“You have to ask therapists, ‘What is a difficult patient? What makes them difficult?’” says Jensen. “One of the things that can happen is we’re quick to judge patients, which cuts off the inquiry process so you don’t see what’s really going on. The first thing is to try to suspend judgment about the patient. By judgment, it’s explaining away what you might not be able to handle. It becomes easier to discount patients when they’re labeled – it’s not my fault, I can’t help you. Patients come to us. They’re very complex [and] they don’t come to us just with their physical problems. Better to see the process as collaborative, take some of the responsibility for a patient’s noncompliance.”

Finding Ways to Connect

As a therapist, it’s helpful to keep in mind that patients are often afraid and their behavior comes from fear. Leslie says it’s important determine where the patient is emotionally. For example, if they are depressed, your behavior needs to be softer and more subdued.

“The big picture has to be explained to a patient,” says Leslie. “Hear what’s important to a patient. Find out what’s important in their home environment and their work environment and replicate that. The best of all cases is when a patient can really explain what they did in OT – we worked on my ability to clean my kitchen. Otherwise, all they’ve done is stack cones and play bingo.”

Leslie has also seen success in what she calls “paradoxing” a patient. She suggests telling a patient that you feel as if you’re “missing the mark,” you don’t think you can work with them any longer and another therapist will be taking your place soon.

Leslie says nine times out of 10 they’ll say they would rather keep you as their therapist. When they do, you should explain that they seem stuck in a rut. 

“And they’ll say, ‘I’m not stuck. Give me the weights!’” predicts Leslie. “Patients don’t like to be stuck.”

Jensen says turning to other therapists for help is also a valuable option.

“If we have difficult patients we may [complain] to our colleagues to let off steam. It would be good for us to really seek colleagues’ advice,” says Jensen.

If all else fails, Jensen says, ask for another therapist to work with the patient.

Learn from the Difficult Patients

In Sher's case, the solution to her difficult equation came with resourcefulness and determination.

One day, Sher asked the autistic boy's parents to bring him to the beach for a session in the water because Saipan is, after all, a tropical island and Sher likes to work with her patients in the ocean.

Sher brought the boy into the water. "He loved it. He, for the first time, noticed me, and playfully splashed me. I splashed him back. He was beginning to play! His parents had never let him go in the ocean before and he looked at me affectionately as if he knew that I was the reason he was in the water,” Sher says.

Sher and her patient often met in the water after that, with the boy acknowledging and interacting more with her. The turnaround also alleviated Sher’s worries about the effectiveness of her work with other patients.

Sher’s therapy sessions with her other autistic patients began vastly improving, and she soon thereafter formed a weekly hydrotherapy group for kids with autism. "The water holds them like a gentle but firm hug," says Sher.


Arin Greenwood is a freelance writer and lawyer living in Saipan, an island near Guam. Questions and comments can be directed to editorial@therapytimes.com.