The Case Manager
Recently, I spoke with an occupational therapist about a patient we are working with and the challenges we faced in helping her overcome the barriers affecting her progress. During our conversation, the therapist said, “Anne, this is what we call self-sabotage.”
I had heard many terms used to describe patient behaviors, but this was new to me. I decided to look it up and learn more.
I found that self-sabotage refers to behaviors, habits, or thought patterns that interfere with a person’s long-term goals, well-being, or relationships, even when they consciously want to succeed.
As I read more about this concept, I began to recognize some of these behaviors in my patient. More importantly, I started to understand that I needed to change my approach to working with her.
I wanted to share some of what I learned in case you recognize similar behaviors in the patients you work with.
Recognizing Self-Sabotaging Behaviors
Self-sabotage can manifest itself in several ways, including:
- Procrastination and Avoidance: Delaying important tasks or responsibilities, sometimes because of fear of failure or feeling overwhelmed.
- Perfectionism: Refusing to take action unless conditions are perfect, which can interrupt progress or lead to abandoning goals.
- Relationship Withdrawal: Pushing people away, withdrawing from support systems, or becoming disengaged when facing emotional challenges.
- Impostor Syndrome and Low Self-Worth: Believing you are not capable or deserving of success, resulting in missed opportunities or diminished confidence.
As nurse case managers, we often encounter patient behaviors that may resemble self-sabotage. These might include missing important appointments, difficulty following complex medication regimens, not completing recommended therapies, or withdrawing from the care team just as their health begins to stabilize.
However, what appears to be self-sabotage may actually be a coping mechanism influenced by fear, previous trauma, low self-confidence, anxiety, or feeling overwhelmed by the demands of managing a medical condition.
As I reviewed the definition and signs of self-sabotage, I began to see my patient in these descriptions. I also realized that I needed to take a step back and reconsider how I was approaching the situation.
Here are some strategies nurse case managers can use when working with patients who exhibit these behaviors. These will help you educate your patients and lower your stress levels at the same time.
1. Reframe “Sabotage” as Ambivalence
The first step is shifting our perspective from frustration to curiosity. Rather than focusing on what the patient is not doing, we need to understand what might be preventing them from moving forward.
- Recognize the Righting Reflex: Nurse case managers are naturally inclined to fix problems and find solutions. However, lecturing patients or repeatedly correcting their behaviors can create resistance and cause them to disengage. Sometimes, we need to step back, listen, and allow patients to express their concerns.
- Identify the Root Cause: Avoiding a treatment plan may reflect a patient’s fear of failure, desire to maintain some control, lack of confidence, or difficulty adjusting to changes in their health and daily routine.
To my surprise, I realized I was doing some of these very things and that my approach might actually be making the situation worse.
I needed to return to a technique I had learned previously to better understand the patient, such as Motivational Interviewing.
2. Apply Motivational Interviewing (MI)
Motivational Interviewing is an evidence-based communication approach that helps patients explore their ambivalence and identify their own motivation for change.
One useful framework is OARS, which includes:
- Open-Ended Questions: Instead of asking, “Why didn’t you take your medication?” consider asking, “What does a typical morning look like when you are trying to manage your medications?”
- Affirmations: Recognize the patient’s efforts and strengths to help build confidence. For example, “You’ve managed a very difficult week with your symptoms, and that takes a lot of strength.”
- Reflective Listening: Repeat or reframe what the patient shares to demonstrate understanding and empathy. For example, “It sounds like you are feeling overwhelmed by how much your daily routine has changed.”
- Summarizing: Bring together what the patient has shared to help identify concerns, priorities, and possible next steps.
These techniques allow patients to feel heard rather than judged and help build a trusting relationship.
3. Gently Develop Discrepancy
Rather than pointing out a patient’s failures or inconsistencies, nurse case managers can use reflective communication to help patients recognize the difference between their long-term goals and their current behaviors.
For example:
“You mentioned that your top priority is staying out of the hospital so you can attend your grandson’s graduation next month. Help me understand how your current medication routine fits into your goal of staying healthy enough to be there.”
This approach invites self-reflection rather than defensiveness. It also gives patients an opportunity to express their own reasons for making changes. In Motivational Interviewing, this is referred to as eliciting “change talk.”
4. Develop Small, Achievable Plans to Build Self-Efficacy
Patients who struggle with self-sabotaging behaviors may have limited confidence in their ability to succeed. Complex, multi-step care plans can feel overwhelming and may cause patients to give up before they even begin.
Nurse case managers can help by:
- Start Small: Break the care plan into manageable steps. Instead of addressing multiple lifestyle changes at once, identify one achievable goal for the week. For example, begin with checking blood sugar as recommended by the treating provider before introducing additional changes.
- Develop Action Plans: Work with the patient to create a simple, easy-to-understand plan that identifies exactly what they will do, when they will do it, and what support they may need.
Small accomplishments can build confidence and encourage patients to take the next step.
5. Establish a Safety Valve for High-Stress Moments
Self-sabotaging behaviors may become more noticeable during transitions of care, changes in treatment, or when a chronic illness becomes more difficult to manage.
Nurse case managers can help patients anticipate these situations by asking questions such as:
“When you begin to feel overwhelmed by your care plan, what usually happens? Do you stop checking your numbers, miss appointments, or avoid returning phone calls?”
Once these patterns are identified, work with the patient to establish a plan for those difficult moments.
For example, agree that when the patient feels overwhelmed, they can call or leave a message for the nurse case manager rather than withdrawing from communication altogether.
The goal is to keep the patient connected to their support system, even when things become difficult.
6. Involve the Interdisciplinary Team
Nurse case managers are coordinators of care, and we should recognize when a patient’s challenges may require additional professional support.
If behaviors appear to be associated with depression, anxiety, trauma, or other behavioral health concerns, consider involving the appropriate professionals. Social workers, behavioral health specialists, and therapists can provide additional resources and interventions.
Working collaboratively with the interdisciplinary team helps ensure that the patient’s physical, emotional, and psychosocial needs are addressed.
Final Thoughts
My conversation with the Occupational Therapist introduced me to a term I had not previously considered when working with patients. More importantly, it reminded me that sometimes we need to step back and look at a situation differently.
As nurse case managers, we spend considerable time identifying barriers to recovery and developing plans to overcome them. But we also need to recognize that some barriers may be rooted in the patient’s fears, beliefs, past experiences, or lack of confidence.
Before labeling someone as noncompliant or difficult, perhaps we should ask ourselves whether something else is happening that we have not yet recognized.
Sometimes, helping a patient move forward begins with changing how we approach them.
Have you encountered patients who exhibit self-sabotaging behaviors? What strategies have you used to help them recognize and overcome these barriers? I would love to hear about your experiences and learn from one another. Email me at anne@nursesadvocates.com
Have a good week!
