Coping with Heartsink Experiences

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• Coping with Heartsink Experiences

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• 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. ODowd C. Bass

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Coping/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.

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• 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.

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• 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
  

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• 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

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• 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.

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The Psychodynamics of Heartsinkin a Nutshell

• A communication from the patient to the doctor
• - do something!
• Im suffering, but I cant stand it
• - experienced by the doctor as heartsink

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Dictionary Definition of Psychodynamics

• Explanation or interpretation (as of behaviour,
  or of mental states) in terms of emotional forces
  or processes.
• Motivational forces acting especially at the
  unconscious level.

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• 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.

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• The Working Alliance
• Definition The working alliance is the
  agreement
• between patient and therapist that they will work
  
• together on the patients emotional or
  psychological
• problems. It is a contractual arrangement and is
  a
• rational and adult transaction.

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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.

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The Countertransference

• Definition Countertransference is the feeling
  or
• feelings elicited in the therapist by the
  patients
• behaviour and communications.

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• 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).

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• Patients with severe early disruption in
  personality
• development often use immature defences to defend
• themselves against being rejected, abandoned,
• wiped out etc.

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• 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.

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• 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.

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• 3. Denial
• Patient denies reality. Removal of
  affective links.
• If doctor aware of the possible
  significance of
• mothers death when patient aged 8, patient
  denies
• significance and continues to blame doctor
  for not
• getting to bottom of back pain.

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• 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.

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The 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.

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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

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• 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 partners needs and
  desires
• or decides to frustrate them.