1. Coping with Heartsink Experiences

2. 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

3. 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.

4. 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. 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

6. 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

7. 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.

8. The Psychodynamics of Heartsink in 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

9. Dictionary 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.

10. 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.

11. 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.

12. 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.

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

14. 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).

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

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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

22. 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.