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Home » Health Professionals » General Information » Difficult Clients » Case scenarios and solutions

Case scenarios and solutions

 

DIFFICULT CLIENTS (INJURED WORKER/PATIENTS) 

The workers compensation system can bring out the worst in people who are in pain, are financially strapped, unable to do things they use to do, and who are generally finding that they are now  having their life controlled by other people in a way they have never experienced before.  People will respond in different ways, at different times, and in different situations. In the following sections, common client "types" and  behavioral responses are overviewed and discussed   Suggestions are made about ways you might like to try to better handle these people and difficult situations with the objective of getting a win / win outcome.    

 

Aggressive - Verbally

  

A client who comes across as aggressive is energised by something they have experienced – real or imagined. The rehabilitation provider or health professional threatens something they have or want to get. Their emotional responses and subsequent behaviours are targeted at situations or people who are perceived to be blocking what they want. Sometimes they do not know what it is that is really threatening them - at other times it is blatantly clear – e.g. a W/C cheque payment to pay their mortgage or some other financial obligation they have.

The positive aspect of aggression is that it suggests motivation and energy is available to achieve a desired goal. The negative is that the associated behaviour usually means their rights and needs are addressed and put forward whereas everyone else’s is not considered, or is seen as inconsequential.

When dealing with such clients (injured workers, employers, treating professionals) the objective should be to find out what their underlying needs and fears are – i.e what do they fear they could lose, but also to make it clear that you or other parties also have needs and rights that must be met – e.g. your own right not to be abused.

This requires a balance between listening to their concerns, and drawing a line as to what behaviour, language etc will be accepted and tolerated. What is tolerable will vary from individual to individual, however targeted abuse, unjustified threats, or threats of violence are certainly not acceptable and dialogue should be immediately ceased. Feedback about such conversations should be given to supervisors.

 

Aggressive - Physically

 

Fortunately, the incidence of physical violence in injury management is not high, and the risks are generally minimal. There are situations however where consideration needs to be given. These include:

  • A known history of violence

  • Previous extreme anger outbursts

  • Previous threats of violence

  • Obvious mental health problems

  • Significant pain and sleep problems

  • A situation where something is likely to be taken away from the client - e.g. their wages or treatment support access.

 

In almost all situations, even when working withpotentially violent clients, violence can be prevented. The key considerations are:

 

  1. An awareness of the risks cited above

  2. A capacity to empathise with the client’s situation and offer support before they become enraged. Dismissal of feelings about or an issue of importance for the clients is one way to increase the chances of anger and frustration escalating.

  3. Consideration needs to be given to limit setting and careful monitoring of clients who threaten or have previously acted out violently in situations related to their W/C claim or treatment.

 

Passive Aggressive

 

The passive aggressive client will appear, at least superficially to be cooperative and obliging, but will manage to sabotage any apparently agreed upon plans to achieve a particular goal in a way that will appear to reflect badly upon the professional involved.

There are occasions when an action plan may be sabotaged in an apparently passive-aggressive manner when a rehabilitation provider or health professional inappropriately uses their power in a way that doesn’t give due consideration for the injured workers rights, concerns or fears and he or she subsequently acts in the only way thinks they can get what they want e.g. passive non compliance. There are individuals, who will however, continually undermine your efforts to achieve a RTW goal irrespective of the approach adopted. In these situations it is important to explore underlying agenda - fear of re-injury, a poor employer-employee relationship, family dynamics, a belief in substantial compensation through litigation and maintenance of disability status. Referral to appropriate professionals, education and building of trust and rapport can (in some situations) address some of these issues.

 

Forgetful

 

The injured worker who constantly forgets and misses appointments can prove expensive and frustrating for all parties involved in injury management. There are many reasons why a injured worker may “forget” to attend appointments. Some of these include:

 

  • A change in routine as a result of injury means regular appointments have to be acknowledged, remembered and attended. It is not uncommon for workers to need to attend 4-5 different appointments in a week. For workers who have never had to keep a diary and attend multiple appointments before the obligations and requirements of a W/C claim is a new experience and a systematic approach to meeting such obligations is a skill yet to be acquired.

  • Sleep deprivation through pain, depression and anxiety is common in workers who have injuries that do not resolve and memory can be directly and significantly affected.

  • Agenda such as not wanting to attend particular appointments or treatments (for a range of reasons) may occur and need to be acknowledged by those involved in a workers treatment and rehabilitation.

 

The remedy for this problem depends upon the cause - diaries may help, referral to appropriate specialists – e.g. psychologist, psychiatrist, and pain management can address some of the underlying causes.

 

Non Compliant with Treatment

There are numerous reasons why non-compliance can occur – some of these are discussed above. Others include:

 

  • Inappropriate beliefs about injury and what will make it better

  • Inappropriate treatments that do exacerbate injury and symptoms without any noticeable benefit

  • Poor education about injury or rationale for treatment

  • Conflicting Information about the rationale, benefits, side effects and desired outcomes of a proposed treatment

  • Poor relationship with therapist, or referring agency

 

Communication, a good relationship with treating specialists and referrer can address some of these issues.

 

Helplessness

 

Injured workers, their employers, and sometimes even the professionals trying to assist our clients back to work, can find the workers compensation-systems and processes frustrating, time consuming and confusing. At times they may feel helpless and disempowered to get things moving and to set in motion much needed change initiatives. As rehabilitation provider or health professionals you can do much to relieve their frustration and sense of helplessness through clear, information and dialogue with relevant parties.

There will be some clients, most likely injured workers who continue to come across as helpless, irrespective of treatment providers and your best efforts. They may continue to complain about services, or are unable to take steps forward unless they are supported or led all the way. To be able to deal with some possible reasons need to be understood as to why they may be “helpless.”

 

  • Lack of education about medical /treatment matters and belief that it is the treatment provider’s or rehabilitation provider’s role to make them better or get them a job - education about the role of various parties can help with this.

  • Underlying agenda - a reason not to get better or back to work ranging from family dynamics – e.g. enjoy sick role, poor work relationships, hate job, fear of re-injury, pending litigation – particularly common law legal case. When agenda is identified, educate about roles and responsibilities they have in W/C system and provide with relevant literature, refer to relevant professionals - e.g. rehabilitation service to help identify work place issues and remedies.

  • Personality types (disorders). There are some individuals who for a range of reasons have little belief in their own capacity to undertake or initiate change without support or supervision. They have an underlying fear of failure and either believe some one else’s continuing help is essential for a goal to be reached, or, it is better to let someone else take responsibility for “failure” if things don’t work out. When assisting these individuals emphasis should be on initial support and encouragement, with onus on them gradually taking responsibility for change initiatives themselves. After goals are established and a joint action plan developed, support should be gradually phased out and the temptation to continue propping up avoided.

 

Tearful clients

 

The client (most likely injured workers) who is tearful can evoke a range of emotional responses from us including personal distress, empathy, and contempt to anger and emotionally cutting off. Our own personality, culture, and current emotional state will effect our reactions to someone who is tearful as will the person themselves and the reason they are becoming tearful. For many people the display of strong emotion by another is distressing and something they would rather avoid. It is important however, in situations where a client is in tears, particularly on a regular basis to assess the reasons why. Some possible reasons include.

 

  • That person’s way of dealing with frustration – Some people are more comfortable with crying and may become tearful if frustrated or are experiencing moderate setbacks in life.

  • Significant psychological health problems - Many injured workers, particularly those with chronic injuries or psychological injuries experience significant depression and anxiety as a result of their injury and changed circumstances e.g. persistent pain, sleep loss, financial difficulties, unemployment –They may feel overwhelmed and can’t see a way forward in life and “breaking down” may be an indicator of the level of their psychological health problems.

  • Significant psychological health problems because of other difficulties in life e.g. relationship breakdown.

  • A combination of the above.

 

It is important to be a supportive, empathetic listener while the worker vents their distress. Then move on to offering practical strategies for addressing the issues. (If strategies for addressing the problem are proposed while he or she is still very upset they are unlikely to take on board what is being said).

When underlying psychological health issues are suspected (as is likely with many workers experiencing significant or chronic injuries) referral to an appropriate mental health professional is recommended.

 

Litigious

There are many reasons why a worker may present as being very litigious. These include:

 

  • Previous mismanagement of a claim and rehabilitation with resulting anger and frustration.

  • Problems with their employer or relationships at work.

  • Encouragement by a lawyer or other interested party to adopt a "them and us" attitude rather than teamwork.

  • Ignorance about the role of injury management advisors in insurance companies with perception that their best interests will not be served.

  • Personality Type - Some people are more guarded by nature and suspicious of the motives and agenda of others. Issues of trust are often significant for them. A litigious approach may be a form of a pre-emptive strike before a “terrorist attack” by a more powerful party - an insurer.

 

When dealing with potentially litigious client emphasis needs to be on professionalism, friendly, reliable and consistent service with correct information and procedures being offered. Threats or pending difficulties should be reported to supervisors. The emphasis on the relationship should be one of building trust and moving from a them and us approach to a joint approach in reaching mutual goals.

 

Overly Familiar

 

In contrast to the litigious and aggressive clients, the overly familiar client wants to be your mate, and get his or her way by having a relationship that he or she controls through manipulating you emotionally. Similarly to dealing with litigious clients, professionalism is importance but with emphasis on the establishment and maintenance of boundaries. Awareness of manipulation and your own reactions is important when dealing with these clients. Discussion with a supervisor or mentor can also be of help.

 

Service Over-Users

 

Service over-users believe (for a range of reasons) that they require the expertise of professionals to get better and to move on in life. While it is essential in early stages of the injury cycle that a range of evidence based treatments are provided (dependent of course on the nature and severity of the injury) longer term strategies for self management of injuries is essential when most recognised and clinically proven therapies have failed to result in a “cure”. For the injured worker to move into self management mode he/ she often has to go through a psychological process of accepting that an injury and pain may be permanent and that new hobbies, sports, interests and work needs to be taken up. To help injured workers beyond the stage where they still search for the miracle cure or wish for treatments that only offer temporary symptom relief, they may require pain/management assistance and functional restoration programs.

 

There will be occasions when a treating provider – e.g. a GP may slow the case for independence by continuing to refer for symptomatic treatment relief, further tests or specialist opinions long after there is sufficient evidence that no miracle cure is around the corner. Referral to a occupational health medical specialist or other medical specialist for an independent assessment may be warranted at that point.

 

Service Under-Users

 

In contrast to injured workers who appear to over use services, there are workers who are hesitant to attend a service or undertake a procedure. It is important to establish why. Some possible reasons include:

 

  • Some workers may see ignorance about the nature of the proposed treatment – e.g. referral to a psychologist for “pain management” as a sign that “everyone thinks it is in my head” or a sign of weakness and not coping. Fear of surgery or hospitals is another common fear by some workers for not wanting surgery.

  •  The worker wants to choose their own treatment and not be dictated to – may be a result of previous bad experiences and poor relationships with service providers.

 

When dealing with service under users initially establish trust and a good relationship, explaining your role and how you can help. Gather information about belief symptoms and thinking about treatment. As much as possible give the worker the sense of power and control of the process. Tactfully challenge incorrect belief systems and explain benefits of other approaches being proposed. Refer to relevant specialists when required – e.g. when unreasonable fear based on a phobic like response.

 

Vastly Different Value Systems - Morality

 There will be times when working with clients - injured workers, employers, other treating professionals when you will be working with people whose backgrounds are vastly different from your own. It may be a difference in education, experiences or the way they see themselves or others at work. They may have a pattern of drug use, criminal convictions, or a different code of morality (more or less rigid) than you.

These differences can effect how we deal with our clients and the quality of our relationships. We may be intimidated, awed, fearful of, or contemptuous. It is important in any professional relationship to attempt to be objective and avoid making value judgements. The ability to conceptualise a situation from their standpoint and thinking, is a helpful first step to developing and maintaining a professional relationship, whilst also articulating your needs and expectations.

 

Cultural/Language Barrier

 There are similar issues here to those cited above but with the added challenge of language difficulties in some situations. It isn’t possible to have complete knowledge of all the cultures injured workers may be from. It is possible however, to remove value judgements from your thoughts, feelings, and interactions if you wish to acknowledge that people have vastly different ways of experiencing life than you do and that their way is neither better nor worse.

When major language difficulties are evident it is essential that a qualified interpreter is used - this applies to medical and para-medical assessments and treatments, rehabilitation.

 

Unmotivated

The injured worker who remains unmotivated can be a source of considerable frustration. Despite your enthusiasm they fail to follow through with any initiatives you, or they agree to and will virtually never instigate anything themselves. To try and “remedy” this situation and change a client into a motivated participant it is important to understand why they may not be unmotivated: Reasons may include:

 

  • Ignorance about the nature of the proposed intervention with resulting fear or some other negative reaction.

  • The worker wants to choose own treatment and not be dictated to – may be a result of previous bad experiences and poor relationships with a service provider.

  • Previous mismanagement of a claim and rehabilitation with resulting anger and frustration.

  • Problems with their employer or relationships at work.

  • Encouragement by a lawyer or other interested party to adopt a "them and us" attitude rather than teamwork.

  • Ignorance about the role of injury management advisors in insurance companies with perception that their best interests will not be served.

  • Personality type - Some people are hesitant to commit themselves to a course of action for fear of failure and will get to others to take responsibility. – Also see passive-aggressive.

  • Other agenda which makes it unappealing for them to go back to work.

 

To attempt to remedy the situation or at least increase motivation:

 

  • Find possible cause

  • Try and identify workers needs and wants

  • Identify fears

  • Attempt to address the above problems

  • Attempt to develop plan with joint goals and strategies – real mutual obligation

  • Educate about obligations and rights if need be

 

Excessively Critical/Negative

 

Similar issues apply here to the litigious client and despite your best efforts and good service it is still not good enough. With the client who is excessively critical whether they be an injured worker, an employer or treatment professional, initially attempt to establish a professional relationship. Give information about your role - what it includes and does not include. Use active listening when speaking with your client and give correct advice. When excessive criticism persists it is important to remain objective. Give feedback to the client about your observations of their expectations in context of your role and its limitations. Seek advice and support from colleagues whether it is peers, supervisors or a mentor.

 

Excessive “External Locus of Control”

 

This term applies to a person whose belief about life is that good and bad things essentially occur to them from outside events and that they can do little to change the course of their life. Such individuals can be very frustrating to work with because they do not belief their actions will make a difference.

 

When dealing with such individuals it is important to firstly acknowledge and deal with your own reactions. Give feedback about how they are coming across and encourage them to take control. In situations where the problem is entrenched and likely to be an ongoing barrier to returning to work consider referral to a psychologist.

 

Multiple and Significant Physical Health Problems

 

There are some injured workers who have significant work injuries or a number of other significant and ongoing health problems that make the prospect of them returning to work unlikely.

It is important when a worker’s injuries do not appear to be resolving as anticipated, that medical assessments are sought that will identify other significant barriers – e.g. other physical or psychological health problems. A good relationship with the workers GP and good communication can help in early identification of such barriers.

Decisions will need to be made as to what role the other factors are in preventing the worker going back to work. Consideration will need to be given as to whether interventions should be paid for by the insurer if the barriers were not caused by the work injury– e.g. a worker who was overweight before injury might now have put on additional weight and this is a barrier to fitness and work capacity.

 

Client is Considered Old

Older workers, particularly male, unskilled, semi skilled and over 40 find it extremely difficult to get new employment after injury. If the new job goal has any physical activity in it whatsoever, prospective employers could perceive this as a barrier to them performing their duties or a threat of re injury. Many (if not most) employers will not take job applicants with an ongoing W/C claim. Female employees may also face similar barriers and generally speaking the bottom end of the labour market for semi-skilled jobs is highly competitive with preference given to younger, fitter applicants.

Consideration needs to be given to these and labour market factors when reviewing an injured workers job search activities. Use of SKILLED, QUALIFIED (and usually older) rehabilitation consultants who will continue to engage the client and offer support when dealing with multiple rejections is essential.

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