Understanding the drama triangle for doctors

Mrs Unwell has come to our clinic feeling very annoyed today. Her appointment with the other specialist has not gone well at all. She saw a consultant whom you know normally communicates well and is an excellent clinician. Mrs Pistov is not happy at all with the consult. She says the other consultant did not listen to her. She felt dismissed. Moreover she says she was given no management plan whatsoever, nil. When you ask what the consultant did say, she says he said nothing. In fact she recalls nothing from the consult at all, other than how aggrieved she is feeling.

You are puzzled by this. Your colleague is normally very good. Perhaps they were having a bad day? You try to keep your mind open about what happened.

Mrs Unwell is talking at length about the other consultant. You try to appear as if you are still listening attentively whilst looking at the notes. The clinic letter lists Mrs Unwell's symptoms, notes the results of recent investigations and gives some suggestions for further management. It reads like a reasonable consultation.

Maybe there was some misunderstanding? You try to explain the outcome to Mrs Unwell, thinking this will allow a fresh start to the conversation.

Mrs Unwell is having none of it. She wants you to arrange for her to see the other consultant again - and by next week. She also wants you to relay how dissatisfied she is. You know this is clinically unnecessary - and also impossible with the current constraints on the service. You try to re-explain the plan, hoping this can get the consultation back on track. You say you cannot arrange a re-consultation with the other specialist by next week, however you can help by making sure she understands the outcome of the other appointment.

Mrs Unwell is having none of it.

She tries to insist you arrange another appointment with the other consultant, as well as expressing her dissatisfaction with them. When you say you cannot do that, even apologising, she is even more annoyed.

She goes on to say that all the doctors at this hospital are useless and she is getting no help from anyone anyway.

Now you are the one feeling upset and aggrieved. You have spent a lot of time previously with this patient. Now they are basically telling you that you are useless. You are totally cheesed off.

This is a common and typical example of a drama triangle at play in healthcare. Mrs Unwell is fictitious, of course, but interactions of this flavour are everywhere.

Drama triangles are a common interpersonal dynamic - or 'game' - usually between three people, where each one takes the role of victim, rescuer and perpetrator. At some point one person will 'flip the switch' on the triangle and move into a different role. This forces others to also move roles - unless they spot the game at play and decline the invitation to play. The concept of drama triangles was originally described by US psychiatrist Stephen Karpman, who has studied them extensively.

In the story of Mrs Unwell, she enters in victim mode, claiming the other consultant is the perpetrator. You attempt to rescue the situation, which Mrs Unwell rejects, turning into the perpetrator herself. You are then moved into the role of victim. Ow.

Drama triangles are not just in health care settings. Look for them in the family home ('rescuing' children with their homework!), with the school or wherever. Most of us have a natural entry point - often rescuers as doctors although I'm sure most of us know colleagues with a tendency to the other roles.

The good news is they are easy to spot and often easy to step out of - saving your sanity in the process.

Here are three ways to start the process:

1. Recognising the game is being played. If you are working harder than you think you should be in a consultation, you may be in rescuer role.
2. Imagining the responsibility is in the middle - not all with you.
3. Asking open questions that invite the other party to be more empowered and start thinking for themselves. Examples of these are: 'what can we do to get this conversation back on track' or 'what can we do together to resolve this?' The emphasis here is on WE - which puts the responsibility back in the middle. Use 'what' rather than 'why' as why tends to lead people to start justifying themselves!

Not everyone can respond to this - some people are very entrenched in their roles - but some will and it makes a big difference to everyone.

Spotting drama triangles is often the first step in avoiding and managing conflict at work or situations that are 'energy drains.' They also ultimately help all parties as they are more empowering than 'rescuing' people which removes rather than adds power to a person.

I work with exhausted doctors to help you prioritise yourself and rescue your career. If you would like to get your energy back, avoid the drama and get great boundaries in place, drop me a message on this platform or you can send me an email here.

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