Challenging patient behaviors: Effective reasoning with unreasonable dental patients

Editor’s note: This is part three of a four-part series. Part one examined early maladaptive schemas and how they influence irrational thinking and problem behaviors in dental patients. Part two examined personality disorders and how to deal with red-flag patients. Read part four: Strategies for listening to difficult patients.

Erratic behavior is unsettling in the dental office.¹ When patients with personality disorders (PDs) are in problematic situations, they will create unnecessary tension, draw more attention to themselves, and attempt to shift outcomes in their favor.² We have all dealt with these patients; they focus only on themselves, are offended easily, often ignore facts and our professional recommendations, and use emotional tactics (guilt trips, crying, sulking, threats, manipulation, whining, angry body language) to get their way.^1,2 It can be a challenge for dental professionals to maintain composure and control the situation.^1,3,4

Communication is key to obtaining necessary information from the patient and working through challenging situations.^3-6 First, consider what outside factors might be driving conflict with the patient—e.g., poor prior experience, dental anxiety, lack of finances, selfishness, fear of judgment from the provider, guilt.^1,3 Next, focus on the patient’s feelings and what is driving those feelings. It is essential that patients feel they are being heard.^2,4

Pay attention to the early maladaptive schemas (EMS) that may be involved in triggering the patient’s feelings.² It’s difficult to challenge EMS and reframe the patient’s thinking in the dental setting because we are not qualified to perform cognitive behavioral therapy, yet the dental setting may be triggering the EMS that are causing the problematic behavior. We can, however, refer the patient to a licensed therapist or counselor who can assist in reframing their thinking.²

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We can’t control our patients’ emotions and behaviors, but we can and must control our own emotions and behaviors to maintain appropriate professional standards of conduct.^1,3,4,6 Communication is essential in controlling tense situations.^3,4 Critical thinking and effective reasoning are major factors in communication: The patient thinks and puts their thoughts into words; the listener utilizes critical thinking to analyze what was said; and then, effective reasoning impacts how the provider responds.^5-7

Effective reasoning is the process of thinking critically, analyzing a situation objectively, and evaluating the facts and the patient’s feelings to make critical decisions based on all the information. By implementing effective reasoning with patients, dental providers can modify their communication to produce positive outcomes out of tense situations.^6,7 Dental providers with better critical thinking and effective reasoning skills are better communicators, because they can visualize the problem from various perspectives. They are able to assimilate their thoughts based on data and convey rational connections and expectations.^5,7

Strategies for effective reasoning^1,6

Don’t apologize for yourself.
When listening, smile and nod.
Make eye contact.
Stay calm and professional.
Accept that the patient’s thoughts may not align with reality.

When patients have been allowed to behave inappropriately in the past through the use of threats, yelling, blaming, or sulking, they will repeat those behaviors to turn situations in their favor. It can be a challenge not to take their verbal attacks personally—it’s a natural response to defend yourself and your professional expertise—but reacting to match patient behaviors will only escalate the situation.^1,3,4

Use these nondefensive communication phrases

I’m sorry you are upset.
I can understand how you might see it that way.
That is interesting. (Do not follow this by adding contradictory information.)
I can see that you are upset. Let’s evaluate this when you are calmer. (Then leave the situation.)

Try inviting the patient to be part of the problem-solving process. Shift the conversation to include their thoughts. This helps patients feel heard, and they are much more likely to cooperate and accept treatment because they feel the solution was their idea.^1,3,4,6

Phrases to include the patient in the problem-solving process

Can you help me understand why this is important to you?
Can you help me to find things to make this better for you?
Can you help me understand why you are upset?
What can we do together to solve this problem?
I wonder what would happen if …

What to do about patients who are beyond reason

No matter the level of communication skill, some patients are beyond rational thinking; you should not attempt to reason with them. Never be alone in a treatment room with patients who exhibit rage or violent behaviors. Patients experiencing delusions, paranoia, psychosis, or acute mania can quickly and easily become violent. It’s best to dismiss these patients until they are stable.

You may also be interested in … Challenging patient behaviors: Patient red flags and personality disorders

Reschedule appointments for patients who are under the influence of drugs or alcohol or experiencing symptoms of dementia or schizophrenia (where they don’t know who they are or where they are). If patients can’t understand what’s happening in the dental setting, they can’t provide informed consent for treatment. Don’t attempt to proceed with treatment in these cases.²

6 ways to improve critical thinking, effective reasoning skills

Just like all communication skills, critical thinking and effective reasoning can be improved with time and practice.⁵ Here are some ways outside the dental setting to help build your abilities and then implement them into clinical practice.^6,7

Practice conditional statements. These are facts that can be verified based on what you can observe in a situation. For example: If the coffeepot in the break room is empty, you can conclude that your coworkers drank the coffee—even though you did not see them drinking it. The pot was full, it’s now empty, and your coworkers are the only other people who have access to the pot. Hence, your coworkers drank the coffee.

Filter out biases. Train yourself to draw conclusions free from personal bias or assumptions and stick to facts. For example: If a patient arrives in pain and says, “Just give me something for the pain,” they may not be asking for an opioid. They may prefer not to take an opioid; they just want to be free from pain.

Monitor your thinking for commonsense errors. These are incorrect assumptions and ideas we all have that contain incorrect thoughts and can lead us to make poor judgments. Use sound logic and factual information to reach your conclusions. We need to determine where we lack common sense in our thoughts before we can reframe our thinking. The most common example of this is over- or underexplaining something to another person. This can happen frequently when we’re educating patients on oral hygiene instructions. For example: If a patient is high caries risk, we can work to reduce their risk, but telling them they have “soft teeth” or “were born without enamel” are incorrect explanations.

Note patterns. Noticing patterns in daily life helps grow communication skills. Reflect on what information can be drawn from these patterns. For example: If you notice that you always see commercials for trucks during a certain TV show, what can you conclude about the audience watching that TV show, and who is the target audience for the advertisements?

Make observations. Practice this skill by paying attention to the environment for details and abnormalities. This is sometimes called “people watching.” Note the patterns that can be observed in the environment. When you notice something interesting or different, think about what caused that difference, what makes it so unique, or why that difference is important.

Play games that require logic. These types of games help you practice and enhance your critical thinking, strategy, attention to detail, and decision-making. Examples include Chess, card games (Solitaire, Spades, Poker, Euchre, Bridge, Cribbage), strategy-based board games (Sequence, Settlers of Catan, Risk, Monopoly, Jenga, Backgammon), and puzzle-based games (jigsaw puzzles, Scrabble, Sudoku, anagrams, ciphers/cryptograms, brain teasers).

Author’s note: In the next article, we’ll examine listening skills and best practices to hold difficult conversations. This will conclude our four-part series on challenging patient behaviors.

Also by the author … Elder abuse and mistreatment: How should dental professionals respond?

Editor’s note: This article first appeared in Clinical Insights newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

References

Brown-Moffit M. Dealing with difficult people. Sutter Health. Updated July 2019. https://www.sutterhealth.org/health/young-adults/relationships-social-skills/difficult-people
Shannon JW. Reasoning with unreasonable people: focus on disorders of emotional regulation. Presentation and lecture notes. Institute for Brain Potential. June 18, 2022. https://www.ibpceu.com/info/reasoning-with-unreasonable-people.pdf
Evenson R. Powerful phrases for dealing with difficult people: Over 325 ready-to-use words and phrases for working with challenging personalities. Harper Collins Publishers; 2014.
Thompson GJ, Jenkins JB. Verbal judo: The gentle art of persuasion. Updated edition. Blackstone Publishing; 2017.
Choudhuri AP. Why communication and critical thinking are the most essential 21^st century skills. Higher Education Review. May 1, 2020. https://www.thehighereducationreview.com/news/why-communication-and-critical-thinking-are-the-most-essential-21st-century-skills-nid-1349.html
Zarefsky D. The practice of argumentation: Effective reasoning in communication. Cambridge University Press; 2019. doi:10.1017/9781139540926
Barratt J. Developing clinical reasoning and effective communication skills in advanced practice. Nurs Stand. 2018;34(2):37-44. doi:10.7748/ns.2018.e11109

Kimberly A. Erdman, MSDH, RDH, FAADH, FADHA. is a practicing dental hygienist and public health dental hygiene practitioner. She was a civilian-dental hygienist for the U.S. Navy and spent nine years as a forensic dental technician. She has a decade of experience in higher education and administration. Kimberly has been awarded a fellowship with the American Academy of Dental Hygiene and the American Dental Hygienists’ Association.