Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Perpetuted Dependency

Often case managers and physicians will say “I wish he/she had an attorney and would stop continually bothering me.” Equally as often, we create and/or perpetuate these dependencies by being initially flattered that they invest so much trust in us. That is our problem; not theirs.

There are, however, two aspects to this dilemma: I. what causes this pathological clinging and II. how do we manage it?

I. Causes (these are overlapping):

A. Patient has poor understanding of clinical problem, options, and how to cope. And the patient believes accurately that you are well-versed in these matters, are the expert and it is best to entirely defer to you.

B. Patient fears that he/she is not being told the truth, also that you likely have data that you are not sharing, you have access to data otherwise unavailable to them and a closeness to you insures that nothing will be hidden from them.

C. Patient harbors appreciable anger at how the injury has been managed. Not only was the injury preventable, but the employer lacked empathy and the physicians involved are indifferent if not hostile. You are the only person who truly cares about the suffering.

D. Patient’s clinging is actually a sublimation: he/she bitterly resents you and feels you are part of the problem, but the fear of being alone does not allow him/her to realize this, and the clinging helps defend against the resentment. It is much like feeling that you cannot leave an abusive and/or dangerous husband.

E. The reality is that the patient is correct: you truly do know more than others involved in the case, you are the quite often the only one who has meticulously documented and tracked what has occurred and the only one upon whom they can rely.

II. Management (one or more of the following):

Verbalizing Limits

Setting up realistic access

Keeping it uncomplicated

Verbalizing your concerns

A. At the point of meeting the patient, delineate your time availability. Tell the patients that you are managing many cases, that their case is just as important as anyone else’s, but that you must remain available to all for whom you are responsible.

B. Remind them that they are in good hands and that you track how they are progressing.

C. Have them create a journal of their days and visits and to make a copy for you so that you car refer to it. Tell them that there is no need to verbalize all the details since the journal will communicate to you what is occurring.

D. Do not give out cell phone or home phone numbers. Make certain that your office voice mail message is warm but asks for a brief message and encourages them to write an e-mail which you can check later in the day and from other locations.

E. Open a g-mail, yahoo, or hotmail account to which they can write. Tell them that you will respond at the close of the day. You can create an account for each case and terminate those accounts as each case closes. Make your e-mail responses very brief, objective, and over time, they will do the same.

F. In live communication, begin with a statement of wanting to touch base with them briefly, do not permit them to extend the conversation to the point where they become anxious about the conversation coming to an end.

F. Verbally reward them when they are independent, do not verbally encourage dependency and do not indirectly threaten abandonment when you become burdened and fatigued.

The combination of recognizing the cause and having multiple concurrent approaches will help you manage these situations. Great question.

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