Coping with Heartsink Experiences

“Current general practice is increasingly rushed and there is a tendency to count the number of consultations rather than to attribute any depth to them. However, the way a practice copes with its difficult patients may be a useful indicator of how the practice is functioning as a team”.

T. O’Dowd C. Bass

Coping/Management StrategiesCoping/Management Strategies

1. Consider what you are dealing with (medico/psychological/social)

- review notes

- seek help from others, e.g. a partner

- request assessment/consultation with

experienced colleague, e.g. cardiologist,

psychiatrist, specialist mental health worker.

2. Consider and treat existing medical/psychiatric disorders. Avoid iatrogenic harm.

3. Attempt to listen to patient, think about their mode of communication, acknowledge their distress and write down their words.

4. Work towards a consistent approach with regular fixed intervals for consultations (? Monthly) Set boundaries/contracts, consider spacing during crises.

5. Avoid multiple referrals and clarify aims when

patient referred on.

Avoid passing patient between partners.

6. Reduce expectation of cure, think about damage

limitation, containment, chronic disease

management, acknowledgement and acceptance.

7. Some heartsink patients settle down in time: ? changes in their lives/morbidity ? good management

? both

8. Consider shared care with contact between

professionals involved in a network of support.

9. Doctor needs to consider:

- own stresses

- personality

- impact of working with heartsink patients on

self and practice staff etc

- task of containing and thinking about feelings/

impulses which arise

11. Doctor needs to recognise need for support:

- consultation partners/colleagues

- clinical review meetings in and outside practice

- further CPD e.g. re the personality dimension/

somatisation disorder etc

- starting/joining support group

12. Work towards ‘Good Enough Management’ of

this heartsink population. Audit cost effectiveness

of management strategies.

The Psychodynamics of HeartsinkThe Psychodynamics of Heartsinkin a Nutshellin a Nutshell

A communication from the patient to the doctor

- do something!

“I’m suffering, but I can’t stand it”

- experienced by the doctor as heartsink

Dictionary Definition of PsychodynamicsDictionary Definition of Psychodynamics

1. Explanation or interpretation (as of behaviour, or of mental states) in terms of emotional forces or processes.

2. Motivational forces acting especially at the unconscious level.

Emphasise the importance of unconscious processes as these are the less accessible aspects of patients and the practitioner and interactions with this patient group result in demanding and confusing moments.

Practitioner may be tempted to act rather than think, e.g. with new prescription, send out another referral etc.

The Working Alliance

Definition: The working alliance is the agreement

between patient and therapist that they will work

together on the patient’s emotional or psychological

problems. It is a contractual arrangement and is a

rational and adult transaction.

The Transference The Transference

Definition: Transference is the transferring of

feelings which belong to a relationship from the past

into a present relationship. This process is

unconscious. The attributions are inappropriate to

the present relationship.

The CountertransferenceThe Countertransference

Definition: Countertransference is the feeling or

feelings elicited in the therapist by the patient’s

behaviour and communications.

Heartsink patients are often unable to tolerate and

communicate with the dynamic forces within parts

of him or herself. Strong unwanted impulses and

feelings are expelled into others and into their bodies

and he/she is unable to contain his or her own bits.

The patient rids himself of unwanted feelings, for

example, guilt, pain or terror and unconsciously

controls the receptacle (i.e. GP).

Patients with severe early disruption in personality

development often use immature defences to defend

themselves against being rejected, abandoned,

wiped out etc.

1. Splitting

People split into good and bad. Patients externalise

their incapacity to integrate good and bad parts of

self.

e.g. The marvellous GP who listens, gives

extended appointments becomes the bad

thoughtless GP overnight when refuses to

visit at night.

2. Primitive Idealisation

Absence of conscious or unconscious feelings of

aggression towards doctor. There is no concern

for GP, his time limits etc as patient talks non-

stop for 30 minutes about their shopping list of

problems whilst waiting room fills up.

3. Denial

Patient denies reality. Removal of affective links.

If doctor aware of the possible significance of

mother’s death when patient aged 8, patient denies

significance and continues to blame doctor for not

getting to bottom of back pain.

4. Control/Projective Identification

Disowned, unconscious feelings e.g. shame, rage,

impotence are firmly experienced and believed by

patient to exist within others, e.g. GP.

There is a fantasy of magical control. GP is often

left with strong feelings, e.g. guilt, annoyance,

impotence when heartsink patient is in the room

and after they leave.

The DoctorThe Doctor

Beliefs often held in medics challenged in their work with

heartsink patient. Beliefs are part of the myth of rescue. Omnipotence, power and control feature in working lives of most

medics. Aim to cure, alleviate suffering, find out the answers, solve

problems. Feel guilty, useless, worthless if not live up to unrealistic

expectations. Hard to face limitations. Difficult to be “good enough”, especially with heartsink patients.

Basic Fault Basic Fault

“In my view, the origin of the basic fault may be

traced back to a considerable discrepancy in the

early formative phases of the individual between his

bio-psychological needs and the material and

psychological care, attention and affection available

during the relevant times.

M Balint

This creates a state of deficiency. A two-person

relationship.

“Only one of the partners matters, his wishes and

needs are the only ones that count and must be

attended to. The other partner, though felt to be

immensely powerful, matters only in so far as he is

willing to gratify the first partner’s needs and desires

or decides to frustrate them”.