Dr. David B. Adams – Psychological Blog

Psychology of Injury, Pain, Anxiety and Depression

Hostile Dependency

Technical skills, even clinical, skills are often independent of social and interpersonal skill. Unquestionably, some of the finest clinicians are among the coldest, most aloof, emotionally remote and inaccessible individuals. They are, after all, just _people, flawed like all people.

By the time the injured worker has access to a specialist, most often far too long after injury, s/he has become appreciably frustrated, fearful and resentful. Despite consistent physical complaints, the patient was run through the gauntlet of having their symptoms dismissed as insignificant. But eventually they enter the arena of increasingly invasive diagnostic studies and then the beginning of aggressive and perhaps invasive care.

Along the way, the patient meets many people from insurers to health care extenders to allied health providers to a string of primary providers. Some of these professionals are kind, but many are cold. Some are invested, but many are indifferent. And a few are outright abrasive, obnoxious and often hostile and rejecting.

A serious problem arises during this prolonged passing of the chain of command. The patient has become both increasingly dependent and increasingly angry. Hostile-dependency makes for a difficult and problematic patient. While the patient is entreating you to assist, s/he is also concurrently berating you for all that has happened before the two of you even met.

At this stage, the individual who can help the patient the most is often the same individual whom the patient trusts the least.
Hostile dependency places the patient in a very vulnerable position for which others must be prepared and from which the patient must be protected. The concurrent devaluing of the most skilled, and the risk of idealizing the least skilled doctors places the patient at great risk.

Patients uniformly tell me that their doctors _work (only) for the insurance company._ Despite the skills of these providers, the patient responds to them with resistance, distrust and passive-aggression.

Concurrently, patients tell me of someone that they would prefer to see. Quite often this is a charming but also highly manipulative individual who has expressed appreciable empathy, warmth, compassion. He has also indicated to the patient that he can now completely ameliorate a condition that other/lesser doctors cannot.

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