TABLE 1.

Challenging behaviors and example responses.

Problem behavior	Perpetuating response	Defusing response
Triangulation (also referred to as “splitting,” or when patients view/treat individual providers as entirely good/bad thus impacting treater relationships and potentially dividing a unified team approach)	-Taking a side -Being pulled into the enactment of the “good” and “bad” caretaker	-Take a neutral and team-based response -Educate team members and staff on a standardized and neutral approach to patient care -Establish with patient that clear communication with all treatment team members is an essential part of care and regularly coordinate treatment
Controlled substance requests, early requests, missing scripts	-Being a “helpful” and “good doctor” by granting the requests, often at the detriment of good clinical management or exacerbation of substance use disorders	-Listen and be curious -Explain clinical rationale for the prescribing/de-prescribing or not prescribing of controlled substances -Clearly describe clinic policies (including the use of controlled substance contracts) around early requests or missing scripts -Regular urine drug screens -Regular use of statewide controlled prescription awareness tools
Poor boundaries	-Ignore or accommodate the boundary violation at the expense of provider discomfort	-Firmly, yet kindly establish provider-patient boundaries
Suicidal thoughts or behaviors	-Ignore or judge the thoughts/behaviors	-Inquire about and acknowledge underlying distress -Affirm their life and your wish for them to live -Implement lethal means reduction and create a safety plan including crisis numbers/hotlines/emergency psychiatric services -Refer to mental health treatment
Non-suicidal self-injurious behaviors (NSSIB)	-Ignore the behavior -Judge or stigmatize the behavior	-Inquire about and acknowledge underlying distress -Ask about the context and purpose of the behavior (relieve or numb pain, distraction, boredom, triggers) -Discuss other strategies to release tension or cope with emotional pain (writing in journal, listening to music, holding ice, snapping hair tie against wrist) -Create a hierarchy of coping skills to keep with them
Emotionally labile outbursts, verbal abuse toward staff	-Yelling at the patient	-Gently and firmly redirect the patient -Remind them of clinic policies, treating patients and staff with respect -Inform the patient that the clinic may not be able to continue to work therapeutically with the patient if the behaviors continue
Escalating behaviors/“Upping the ante”	-Trying to take on the patient’s problems and solve them yourself	-Naming the behaviors and internal conflict to help the patient conceptualize and take responsibility for their underlying feelings
Accusing staff/providers of “not caring”	-Becoming defensive -Listing ways the patient is wrong	-Acknowledge that the patient feels uncared for and inquire what is driving that feeling -Explore the underlying wish or request that the patient has -Affirm that you care for the patient even if there is disagreement