0010.1177/1039856215579524Australasian PsychiatryTartaglia and Little research-article2015




Clockwatching – is that really hate?

Australasian Psychiatry 2015, Vol 23(3) 265­–267 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856215579524 apy.sagepub.com

Michael Tartaglia  Consultant Psychiatrist, Capital and Coast DHB, Wellington, New Zealand John Little  Consultant Psychiatrist, Capital and Coast DHB, Wellington, New Zealand

Abstract Objective: To consider experiences of hate, which occur in clinical encounters. Method: A review of the electronic and manual literatures. Results: Hate has become diluted to a euphemism, the ‘difficult patient’. Conclusion: Retaining use of the word hate avoids overlooking subtle cues in the unfolding relationship. Keywords:  hate, difficult patients

However much he loves his patients he can not avoid hating them, and the better he knows this, the less will hate and fear be the motives determining what he does to his patients – Winnicott 1949.1 In 1959, Main published what has become a classic paper, The ailment.2 Aware of the seduction of therapeutic success, he was cautious when recovery was slow or incomplete. He noted how the therapist becomes more passionate, reinforced by aggression before deteriorating in maturity with doubts, guilt and ultimately despair. Main also noted how previously held, and unexpressed, feelings emerge and intensify between and within staff and patient groups and subsequently influence treatment recommendations. Of the original patients, seven were given continuous narcosis, one received a leucotomy, four were transferred to a closed hospital and two subsequently died. Two other patients committed suicide. As Main commented, the sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment. His work confirmed his clinical impression that in spite of professional ideals, ordinary human feelings are inevitable. When feelings can safely be explored, rather than hidden behind pharmacological traffic, staff become more sincere in tolerating their own feelings and the patients, better understood, become calmer. Medication use was also substantially reduced. This paper has been written by two clinicians, one at the start (MT) and the other (JL) at the end of their clinical practice. It arose from an unexpected experience for the first author who became aware of his hatred for a patient, this universal of experiences being confirmed by the second. Strong feelings, including fear,3 love4 and hate,4–6

arise from therapeutic encounters but it was hate, with both its conscious and unconscious manifestations, that we wished to explore. In contrast to an earlier and rich psycho analytic literature, recent reviews seemed to have replaced hate by ‘the difficult patient’.

‘The difficult patient’ The phrase ‘the difficult patient’ suggests an easily distinguishable group of patients. However, attempts to define ‘the difficult patient’ are quickly thwarted and become increasingly complex.7 Facets considered include the patient (e.g. unrealistic expectations and rigidity to alternatives), the illness (e.g. chronicity and unexplained symptoms), the clinician (e.g. unrealistic expectations and rigidity to alternatives) and health care system factors (e.g. limited resources, bureaucratic processes). Difficult mental health patients were more likely to be male between the ages of 26 and 32, unemployed, poorly educated and to have either psychotic or personality disorders. That only 6% of 445 patients in a psychiatric hospital were considered ‘difficult’ by at least two members of an inpatient nursing team,8 compared with 15% in general medical outpatients,9 suggests that the psychological mindedness that might be expected from a psychiatrically trained staff may mitigate against, but not eliminate, this seemingly universal observation.

Corresponding author: Michael Tartaglia, Capital and Coast DHB, Wellington Hospital, Private Bag 7902, Wellington, 6242, New Zealand. Email: [email protected]

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Australasian Psychiatry 23(3)

One suggestion for this phenomenon may be the rigidity of the bio medical paradigm. Simplistically, patients suffer from diseases that can be characterised in the same way as other natural phenomena. Each disease has a cause and the task of research is to find the cause. The role of the doctor is to diagnose and treat that cause. Throughout the process, the patient remains the passive recipient. This model is less helpful when symptoms are without identifiable cause, when they persist, cross the mind–body divide or when the person breaches the tacit understanding of the sick role. The ill person, having been excused certain responsibilities, is expected to seek and accept designated treatment, but does neither. Conscious, skilful action in the best interests of the patient is replaced by litigious retaliation, loss of professional self-respect and time-intensive, organisational responses. The patient is difficult.

Hate Admitted or not, the fact remains that a few patients kindle aversion, fear, despair or even downright malice in their doctors. Emotional reactions to patients can not simply be wished away, nor is it good medicine to pretend that they do not exist. Groves5 It is the authors’ contention that the difficult patient may have become a euphemism for hating the patient. It has been described as a mixture of aversion and malice.6 The clinician is more likely to be aware of aversion, whereas malice is muted and the guises are many. The patient may induce in the clinician an inner fear or foreboding, that ‘sinking feeling’ akin to having to swallow a bitter pill when there is something the clinician does not want but is having to accept.10 The clinician may notice a tendency to daydream about ‘being somewhere else, doing something else with someone else’, or experience a feeling of ennui, tiredness or clockwatching as the clinician scrambles to end the session. As tolerance for the other becomes exhausted, the clinician begins to doubt, over-investigate or question whether they are suited to work in the health sector. Feelings of inadequacy, hopelessness and despair intervene. For some, this may translate into penance as the doctor is unable to accept that they may hate someone who is ill and seeking their privileged help. Heroic, but futile attempts to rescue, or control through the excessive use of restrictions and hospitalisations, may ensue. The clinician can no longer take risks, has lost objectivity and as a result is now the helpless prisoner of the clinical interaction. Unacknowledged, the patient is rejected and suffers indifference or pity and ultimately may be ejected from the relationship either by referral, transfer or premature discharge from a protecting environment. Sometimes these experiences coalesce around recognisable dispositions. Although considered pejorative today, four groups have been described including dependent clingers, entitled demanders, manipulative help rejecters

and those who engage in self-destructive denial.5 The labels are self-explanatory and seductive in the easy way descriptions of groups are reduced to a single phrase. They are pejorative because they contain hate and because they obscure the underlying and unifying fear of being alone. Frightened to be alone, the ‘dependant clinger’ seeks seemingly endless reassurance through repeated explanation, investigation and intervention. When the inevitable referral to another is considered, the patient correctly interprets this as rejection, for the doctor has become the inexhaustible mother and the patient the unplanned, unwanted, unlovable child. In contrast, ‘entitled demanders’ refuse to be alone. Rather than using flattery, they use hostility, devaluation and a sense of innate deservedness. The temptation to retaliate or to defend one’s reputation may occur. The third group was originally labelled as the ‘manipulative help rejecter’ characterised by the ‘Yes, but…’ response. Investigations were normal and treatment does not work but rather than disappointment, the news is accompanied by the faint but distinctive sense of satisfaction. The satisfaction comes from relief, for cure would mean the loss of this relationship and of being alone again, a sadness too difficult to bear. The clinician’s anxiety is heightened by the fear that a treatable illness has been overlooked and overinvestigation and increasingly elusive disorders are sought. Irritation and doubt soon follow as the referral to another specialist is made. Finally, there is the group of ‘self-destructive deniers’, ‘I don’t care that I’m alone!’ This person seems oblivious to their own destruction, may gain pleasure from defeating others’ attempts at keeping them alive, and often let themselves die. If identifiable, this person is often profoundly sad, alone and has given up any hope of having their needs met. The common clinical response is heroic rescue or joining them in their hopelessness with the unspoken wish that they would just die and get it over with. These observations appear in all clinical practice irrespective of specialty. In psychiatry, hatred may unconsciously manifest itself through the pejorative use of diagnosis, for example for people with borderline personality disorder, resulting in exclusion from service provision or when admitted, by increasingly shorter length of stays and the unchallenged continuation of restraint and seclusion practices. Hatred may also drive other coercive practices, including the inappropriate use of the Mental Health Act, of medications, either by polypharmacy or the parenteral route or the use of electroconvulsive therapy (ECT). Hate has also influenced psychiatrists’ views of patients,11 has been associated with ‘blacklisting’ certain patients from hospital12 and when coupled with malignant alienation, where the person feels that everyone has not only given up but actually hates then, is linked to suicide.13

Treatment There are many texts and articles suggesting techniques and strategies to assist in the management of the

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Tartaglia and Little

difficult patient. However, this paper concerns itself with the precursor to successful intervention, acknowledging hatred. We often predicate our professional self-respect on not being rejecting, punitive, sadistic, murderous and disgusted in patients. An able therapist can not permit himself to behave according to such feelings, but neither can he afford the illusion that he differs from other human beings. Maltsberger and Buie6 The traps are familiar – the aspirations to heal all, know all and to love all. However, these are no more accessible to the clinician than they were to Faust and unless understood, staff will be subject to a sense of Faustian helplessness and discouragement. It is psychiatric staff who are particularly prone to this unrealistic hope, those in mental health specifically utilising their warmth and humanity as a therapeutic tool. For this reason, we are prone to confuse the limitation of our professional capacity to heal with our sense of personal worth.6. Hate is a strong term. Unlike anger, it feels pointed and personal. Informal comments on this paper doubt whether the word is appropriate for the phenomenon used to illustrate its presence in clinical work. Clockwatching may be the first glimmer of counter transference rather than hatred. The authors argue that to tread lightly, to not describe clockwatching as hate, runs the risk of overlooking subtle cues as to the nature of the unfolding relationship: could I hate this person and, if so, in what way might that assist in understanding their presentation? The yield is high when this valuable source of data, our own feelings in response to our patients’ presentations, is carefully explored and sensitively fed back to the patient, as Main’s study starkly demonstrated. It is for this reason that we as authors had difficulty in developing distinct vignettes upon which we could both agree would elicit hatred. Each of us bought our own history and each vignette was capable of invoking hatred for one author but not the other. This phenomenon represents the uniqueness of the interaction between therapist and patient that, when noticed, usefully informs clinical work. For the medical practitioner who is not trained in psychiatry, a number of useful strategies have been suggested.14 In the public mental health system, it helps that those with whom the person has contact can meet

together and develop an agreed, consistent and realistic approach to care. Identifying issues early facilitates early management, including the important setting and maintenance of boundaries. This includes open and honest communication as to what can or cannot be reasonably expected and respectfully discussing with the patient in our experience. Such information is valuable data, as it is likely to reflect the experience of others they have met. Asking ‘What has happened to you?’ rather than ‘What is wrong with you?’ shifts the emphasis from the patient to the patient’s story – this can lead to the process of re-connecting with the person, rather than continuing to be overwhelmed by the behaviour. Documentation ultimately saves time and may usefully be written in a style for the patient to read, share and be part of an ongoing process. Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Winnicott DW. Hate in the Counter-Transference. J Psychother Pract Res. 1994; 3: 348–356. 2. Main TF. The ailment. Br J Med Psychol 1957; 30: 129–145. 3. Haldipur CV, Dewan M and Beal M. On fear and the counter transference. Am J Psychother 1982; 36: 240–247. 4. Gabbard GO. Love and hate in the analytic setting. Lanham, MD: Roman and Littlefield Publishers, Inc., 1996. 5. Groves JE. Taking care of the hateful patient. New Engl J Med 1978; 16: 884–887. 6. Maltsberger JT and Buie DH. Countertransference hate in the treatment of suicidal patients. Arch Gen Psychiatr 1974; 30: 625–633. 7. Haas LJ, Leiser JP, Magill MK, et al. Management of the difficult patient. Am Fam Physician 2005; 72: 2063–2068. 8. Koekkoek B, van Meijel B and Hutschemaekers G. “Difficult patients” in mental health: a review. Psychiatr Serv 2006; 57: 795–802. 9. Jackson JL and Kroenke K. Difficult patient encounters in the ambulatory clinic. Arch Intern Med 1999; 159: 1069–1075. 10. Hithcock J. The sinking feeling. Psychoanal Study Child 1984; 39: 321–329 11. Lewis G and Appleby L. Personality disorder; the patients psychiatrists dislike. Br J Psychiatr 1988; 153: 44–49. 12. Neeleman J and Watts V. Preventing the admission of difficult patients. J Roy Soc Med 1996; 89: 149–151. 13. Watts D and Morgan G. Malignant alienation. Br J Psychiatr 1994; 164: 11–15. 14. Robinson G, Beasley R and Aldington S. From medical student to junior doctor: the “difficult patient”. Student Br Med J 2006; 14: 265–308.

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Clockwatching--is that really hate?

To consider experiences of hate, which occur in clinical encounters...
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