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Have we swapped Balint groups for Facebook rants?

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I knew my blog criticising zero tolerance wouldn’t be popular. But as Churchill said: ‘You have enemies? Good. That means you’ve stood up for something, sometime in your life.’

For me there is a bigger issue at stake here than how we treat abusive patients, and that is the therapeutic relationship between doctor and patient - something I would stand up for again and again.

Too often I hear patients being denigrated, blamed, laughed at and generally moaned about. The more stress we are under, the more commonplace it seems to be. I don’t think it does our profession any credit. Patients are not the enemy, they are the reason why we get up in the morning and go to work.

However, there’s no doubting that patients can be difficult - some are even hateful. I use the word very deliberately, because there are times when we can actually come to hate certain patients - to resent them, dread seeing them, despise them even. When that happens, what should we do?

In 1978 James E Groves wrote an excellent article titled ‘Taking care of the hateful patient.¹ He doesn’t mince his words and talks in detail about the feelings of anger and frustration that certain patients will invoke in the doctor - and the usefulness of recognising, expressing and naming such feelings.

And I agree with him. What I am not arguing is that GPs should ignore these feelings and just try to be more cuddly so that difficult patients can walk all over us.

Groves talks about the ‘entitled demander’ (most of our abusive patients will come from this group). He notes the natural desire in the doctor to counterattack such patients, but also how such an approach can make the doctor more vulnerable since this sort of patient will hit back, and does have the power to really hurt us.

In fact, he says: ‘The most helpful therapeutic strategy with the entitled demander is to support the entitlement, but to rechannel it in the (right) direction.’

GPs have always had to deal with the negative emotions inherent to our role, and it’s not just abusive patients that can be challenging - there are issues of dependency, manipulation, self-rejection and more. We need to have a constructive way of dealing with these emotions, for our own sake, as well as for our patients.

The influential psychologist Carl Rogers described the therapeutic value of holding patients in ‘unconditional positive regard’, and if it were always easy for doctors to do then he would not have had to stress its importance.

It’s for the challenging patients that positive regard is so vital, so difficult, and yet so valuable both for the doctor and patient. As we listen to their story and try to understand, we find a way of dealing with our negative emotions, as well as helping the patient to develop more positive behaviours.

Rogers stresses the contrast with the potentially destructive ‘conditional positive regard’ - there are echoes here of the modern right wing concept of the deserving and undeserving poor.

In the past we had Balint groups to help us gain insight, find new approaches and generally keep ourselves going. Such groups could be demanding, and time-consuming, but then again complex problems can take time to solve.

But has the modern-day equivalent of a Balint group now become an online forum where we just moan about our patients? I sincerely hope not.

Let’s try to be more positive than that. To quote Rogers: ‘When I look at the world I’m pessimistic, but when I look at people I am optimistic.’

Dr Martin Brunet is a GP in Guildford. You can tweet him @DocMartin68.


1 Groves, J. E. Taking Care of the Hateful Patient. NEnglJMed 298, 883–887 (1978).

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Readers' comments (19)

  • Simple answer...give the person the option of seeing someone else..the problem may lie as much with one side of the equation as the will be much more frustrating for the person labelled by Martin to continue having to consult him than just making a change. Trouble is Balint supporters come over as too smug and holier than thou........remember too Balint groups are really not watertight confidential - even members of the groups do gossip . Some like to publish - anonimising of course.just like those who post on post, Viva Pulse and the internet.

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  • " If you've never hated a person, only a behaviour, then you're better - and rather less human - than me!"

    Part of being human is having a capacity to reflect on our emotions.

    If you feel hatred in a consultation, you can go down one path and attribute (in your mind) that hatred to the patient and label the patient (which may be detrimental to the patient). Or alternatively you could go down another path and attribute (in your mind) that feeling of hatred to your response to the patient's behaviour or to the interplay of behaviours in the consultation.

    At the end of the day, humans can make choices about how they think about their emotions.

    Also it's worth bearing in mind that that the doctor-patient relationship is not a typical, everyday relationship. There is an inherent power imbalance in the consultation. Doctors have access to tests, investigations, medicines, treatments, social care and welfare support that patients don't have access to.

    If you reflect on the fact that patients are vulnerable and in need at the start of every session, then you might feel less inclined to label patients and make patients themselves, the objects of your feelings of hatred.

    You have choices.

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  • Try to remember why you wanted the difficult job of being a doctor in the first place. Or try another job that suits your personality.

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  • I think Dr Brunet writes with thought and care. I applaud that Dr Brunet is willing to explore some of the more difficult aspects of the doctor-patient relationship.

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  • Nobody should be using people they claim to 'hate' as a tool for analyzing their own psyches....(or even to use as material in Balint groups) -pay a therapist. What is the 'reward' for continuing to consult with somebody who arouses such negative feelings? Balint was a man of his time and wrote some pretty unpleasant accounts of those who consulted him by the way! Balint groups suit some people but constrain what individuals can to express honestly whereas the internet has given the sort of freedom Balint could not have imagined. By the way the posts on Pulse express as much negativity towards other members/leaders of the profession as towards those who consult them - it is doubtfull whether it would be possible to attain the degree of trust anonymity allows, in any professionally organised group. seems there is a pay off - anonymity is not a great way to get views heard some of which do go too far,yet it is better than being silenced altogether because of fear of the consequences . It is actually a sad reflection on the state of the profession.

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  • Good article
    Also good reply 1.27
    Part of the problem is that gps are stressed and overloaded and like other human beings have to deal with that however they can and it may be counterproductive but should not have blame attached
    Balint is useful analysis but assumes ideal conditions that unfortunately do not exist
    Often the real answer given that caveat is as ever this system is in desperate need for more gps
    In the UK we start our training with the bizarre belief that ten minutes is enough why?
    It ain't nearly enough and we all know it
    The only reason is the gross underfunding and under doctoring of our system
    Look at Sweden and many other more advanced nations

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  • wow amazing. his last article pretty much everyone criticised his views. let me guess - did you get your VTS minions to post supportive comments for you?
    i sincerely hope that one day you get a vexatious complaint that goes to the gmc who strings you along for a few months and see how compassionate you feel towards abusive or vengeful patients after that.

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  • 1.18pm anonymous

    This is exactly to type of comment that Martin refers to as a rant. I accept that this forum allows stressed professionals to let of steam but hoping that a colleague has to endure a vexacious complaint is not acceptable.

    What p***es me off on here is the people who in one post complain about the stress and recruitment crisis but in the next breath are denigrating the profession. I really hope prospective GPs are not reading these negative comments - why would you want to become a GP! Yes there are plenty of negatives but in general being a GP is as priveleged position - the pay is still good relatively, the job isn't boring, the on-call is nothing like some hospital specialties. We have had a relatively golden period of high pay and are going through the cycle of low morale falling pay and recruitment issues that always follow similar to the economic cycle. When things get bad eventually the pendulum swings,public and media attitudes change and governments have to do something or risk political suicide. Unfortunately the deepest recession/ depression since the 30s hasn't helped but putting things in perspective at least most of us still have a job unlike some people who have lost everything.

    Please colleagues hold in there things will change. they may be different but after every storm comes a period of calm.

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  • Well said 11:31.

    Sadly when things do change for the better there will still be contributors to this forum moaning that there's nothing to moan about.

    Some folk are really only happy when they're miserable

    And, if you're a regular reader of these forums, you couldn't be blamed for believing that most of those folk are GP's.

    Sad very sad

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