To best serve those "difficult" clients, try to understand the psychology behind disability and chronic illness.

"When are you going to fix my wheelchair?" screamed Gary into Marion's voice mail. "I have been waiting forever! I can't stand you or your company! I am going to turn you in to the Better Business Bureau!"

Gary is a 67-year-old widowed man who has had secondary progressive multiple sclerosis (MS) for 23 years. He uses a power wheelchair for locomotion, which he says has been unreliable due to a faulty joystick. Marion, his rehabilitation technology supplier (RTS), was running out of patience. Despite her best efforts, the necessary part to fix the joystick had still not arrived from the manufacturer. Marion ignored Gary's message, along with the other 12 messages that he had left in the past 2 weeks.

WHAT MAKES A "DIFFICULT" CLIENT DIFFICULT?

As a customer service provider and/or an RTS for clients with disabilities, it is highly likely that you have encountered a challenging client such as Gary. Some of the most common client issues providers experience include:

• frequent displays of irritability or anger;
• impatience;
• being demanding (particularly irrational demands);
• unjustified complaining or whining;
• verbal abuse;
• making threats;
• noncompliance;
• equipment abuse; and
• making late payments.

WHY ARE SOME CLIENTS DIFFICULT?

Individuals who use mobility assistive equipment (MAE) often experience a variety of challenging life changes. Applying a biopsychosocial model can help you gain insight into these changes. Attempt to view an individual's challenging behavior within a context of biological, psychological, and/or social factors.

Biological Factors
Physical changes: Changes in physical functioning (spasticity, hemiparesis, paralysis) are typically the most noticeable after an injury or illness that necessitates use of a cane, walker, or wheelchair. However, other changes may impact a client.

Pain: Whether pain is due to osteoarthritis, neuropathy, back problems, or a host of other medical problems, pain can profoundly impact mood and social interaction. As one client stated, "Some people view me as angry, but really, I am in pain!"

Fatigue: Research indicates that 75% to 92% of individuals with MS experience fatigue, with fatigue also occurring in other conditions such as brain injury and stroke. Additionally, any medical condition that affects mobility can result in decreased activity, deconditioning, and associated fatigue.

Sensory deficits: Whether the result of an injury, a disease, or simply the aging process, sensory deficits such as hearing loss and vision impairment can significantly affect communication. For example, if your client can't hear you explain how equipment works, compliance rates will suffer.

Medications: Although medications can certainly be an integral part of a client's treatment, it is important to note that many medications can impact alertness (some antispasticity medications can contribute to drowsiness).

Psychological Factors
Emotional liability (otherwise known as pseudobulbar affect, emotional incontinence, or, more recently, involuntary emotional expression disorder [IEED]): Generally speaking, these terms describe an individual having difficulty regulating their emotions, often being unable to control emotions in a purposeful manner. For example, think of a client laughing uncontrollably at something that is only mildly amusing, crying for no apparent reason, or demonstrating irritability or agitation in excess of what would be expected in the situation. Emotional liability can occur in those who have experienced neurological conditions such as stroke, Alzheimer's disease, amyotrophic lateral sclerosis (ALS), a traumatic brain injury, or MS.

Carey A. Pawlowski

Emotional issues: Numerous feelings about one's own injury or illness may arise. Clients with disabilities may feel mistreated, ignored, inconsequential, or otherwise marginalized. Some clients perceive that others treat them like "dummies" because they use mobility equipment. They also may feel—or may actually be—susceptible to being taken advantage of, and they may become defensive.

Other psychological processes such as denial can be common. Denial may extend to physical limitations, long-term outcomes, or the potential progression of illness. Although denial can be an effective coping mechanism at times, it can also be problematic if it interferes with choosing appropriate MAE for future needs.

Mental health issues: Two of the most common mental health issues reported after injury or illness are depression and anxiety. Whether these are a reaction to illness, a result of illness, and/or a premorbid condition, mental health issues add a layer of challenge.

Cognitive: Many individuals with neurological disorders experience cognitive issues ranging from problems with memory, attention, and mental processing speed to difficulties with visual-spatial skills or executive functioning (organizing, planning, and reasoning).

Language issues: Illiteracy, learning disabilities, and language barriers can create challenges, particularly when providing instructions about MAE.

Social Factors
Social challenges: Individuals with disabilities may lack appropriate social support. Additionally, relationship changes after illness or injury are common. Relationships with spouses or partners, children, parents, and friends all may be dramatically altered. Furthermore, role changes (going from caregiver to care recipient) can impact self-esteem and worsen mood swings.

Financial concerns: Unemployment or underemployment due to disability issues is quite common. In fact, it has been estimated that approximately 70% of people with disabilities in the United States are not employed. Certainly, financial stresses and increased medical bills are ubiquitous for those with catastrophic or chronic health issues.

Cultural differences: Keep in mind that cultural or ethnic factors may affect how clients relate to you and vice versa.

At face value, any of the above client characteristics or behaviors may be frustrating, annoying, or even aggravating to those who provide services to the client. However, it is important to note that not only are the difficult behaviors grounded in underlying factors, they are typically a result of a combination of multiple factors. For example, in the case of Gary—with some basic questioning and listening skills—Marion was able to ascertain that he had severe neuropathic pain in both of his legs. A recent exacerbation of his MS left him with fine motor coordination deficits that made it impossible for him to properly change his hearing aid battery, and his right-hemisphere stroke left him with emotional liability. In determining the various challenges clients may be facing, the intent is not to give excuses for poor behavior. Rather, the goal is to promote a better realization that contributing factors must be taken into consideration. And some of these factors can be eliminated by providers to reduce the challenge for both parties involved.

ENHANCE YOUR RELATIONSHIP WITH CLIENTS

Communicate! It is impossible to have a good relationship (any kind of relationship) without communication. For example, taking time to make a few 5-minute phone calls to update clients on the status of wheelchair parts they have been waiting for can go a long way. In Gary's case, Marion might consider calling the manufacturer as many times as necessary to check the status, and communicate this information to Gary on a regular basis. Given that individuals with disabilities may already lack a sense of control over certain aspects of their lives (feeling betrayed by a body that does not obey), providing information may help clients to feel a bit more in control.

Good communication also means being a good listener. What is your client saying to you? What do they want to know? Pay attention to both the message content (what is said) and the message process (how it is being said). Remember the value of nonverbal communication. Many of us tend to overvalue words and undervalue other ways of communicating, which is ironic given that approximately 80% to 90% of communication is nonverbal (facial expressions, body language, nonverbal sounds).

SET BOUNDARIES

It is important to establish boundaries of what you are willing to do and what you are not willing to do as a service provider. What is under your scope of responsibility and what is not? While this is important with any client, it is particularly important in the case of clients who may be verbally abusive or who make threats.

Always respect clients no matter how disrespectful they may be. Even though it may be tempting to respond to an irritable comment with a snappy comeback, there is no reason you have to "stoop to their level" in your response. Continuously strive to think before reacting. Keep in mind that since you are the professional, you are the one who has a sense of professional ethics that you must follow.

Carey A. Pawlowski, PhD, is a licensed psychologist in neuropsychology and family services at The Rehabilitation Institute of Kansas City, Mo. She can be reached via e-mail: .