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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”.