Perhaps one place to start is to find out from the patient why they're so defiant and difficult to manage! In my experience as a clinical psychologist in a preventive cardiology clinic, patients are often overwhelmed with suggestions from their other caregivers (all of which are incredibly important and must be acted upon immediately, of course) and frequently do not feel that their concerns or reservations have been heard. (The most poignant thing I commonly see is a patient at the end of his appointments staring ruefully down at a handful of prescriptions in his hand, seemingly wishing that he'd never come to our clinic.) Most patients are less defiant after they've been heard out. And as for being difficult to manage, I join Franco (the other reply to your message) in thinking that most difficult-to-manage patients see their practitioners as difficult to manage, too, because in not listening to them the practitioners are not addressing their perceived needs. In short, if you want people to understand you, start by understanding them. Collaborate with them on developing a treatment plan that addresses their issues and concerns. There's a much better chance of them getting motivated to do what you would like them to do when they're also doing what they want to do.
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