Functional and Somatic Disorders (Jones, 8/5/2026)

 A recording of this presentation is available HERE

Check back for a written summary

Difficult (aka Dysregulated) Patient Encounters (Pimental, 7/29/26)

 A recording of this presentation is available HERE

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Thanks to Dr. Britni Pimental, who gave us a fantastic presentation on Difficult Patient Encounters. She started by changing our word choice from "difficult" to "dysregulated".  When we label patients as difficult (angry, demanding, emotionally intense), we should be really calling them dysregulated-- shifting this label can help us shift in how we see patients. 

There were SO many pearls in this presentation, I definitely recommend listening to it yourself. But for the notes version:

It's not surprising that patients being seen in the clinic or hospital are dysregulated-- their nervous system is literally being stressed-- they are scared, in pain, feeling a loss of control, triggering old trauma and sensing systemic pressures.

When people get overwhelmed, their executive function goes down. They cannot listen. They cannot process high level medical information.

Clinician response to dysregulation can lead to to an unfortunate feedback loop:

Trigger>>>> Arousal>>>> Behavior>>>>Clinician Response>>>Trigger 

We are not neutral. We are human beings too.

Countertransference is the phenomenon in which our own emotional reaction to the patient is shaped by our own previous experiences. This can lead to helplessness, frustration, avoidance, over compensation, and assertion of control. 

We must strike a balance between empathy and limits/boundaries. Empathy does not require agreement. Most people do better with limits and effective boundary setting helps people who are dysregulated. Rather than being exclusive, empathy and boundaries are complementary.

3 steps to empathic boundary setting:

1. Validate the emotion
2. Set clear limits (without excessive justification-- see above, people's ability to tolerate info is low)
3. Offer alternatives (a small # of choices) to give control back

Restore regulation

Our tone, posture, body language and pacing will impact our patients' behaviors.  Clinician regulation is the most powerful de-escalation tool. Patients are highly attuned to non-verbal cues from clinicians (pacing, tone, body language)

The goal of de-escalation is NOT to win the argument or to convince the patient of a particular viewpoint. The goal is to maintain a functional relationship, create a safe and collaborative environment. 

Self-regulation for clinicians

-lower tone

-slow speech

-adapt a non-threatening posture

-sit down (if safe)

NURSE

Name

Understand

Respect

Support

Explore (options)

Offer choices as much as possible. Patients want to feel they have some say in their care.

Allow for pauses>> to avoid rushed decision-making. People need wiggle room. 

Ask open ended questions

Practice reflective listening

Avoid escalation

-avoid interrupting

-avoid power struggles

-avoid defensive responses

-avoid arguing the facts

A simple self-check re. countertransference:

What am I feeling right now?

What is this patient activating in me?

How is this helping/hurting their car?

Re-engage with your own executive function

-pause

-slow breathing

-relax your shoulders

-consciously slow your speech

-decrease your own physical arousal

RESPOND INTENTIONALLY RATHER THAN REACTIVELY 

The clinician-patient alliance builds trust, creates psychological safety and decreases emotional arousal. Regulation+ relationship + respect= safer encounter