Why GPs should be wary of Karpman’s Drama Triangle

Today Mr Hurting Bone came in steaming because his orthopaedic appointment went badly.  The consultant was rude, he was late, he didn’t explain, and when Mr H Bone asked questions, he ignored him.  When you ask Mr Bone what the consultant did say, Mr Bone says they said nothing.  Nothing!  Mr Bone has no idea what went on or what treatments were proposed.   Now he is here, angry and upset.  He shrugs and looks at you helplessly, waiting to hear what you say.

You feel aggrieved for Mr Bone.  Perhaps inside, you even feel a little superior to the orthopaedic doctor, with your training in communication skills.  You decide to write a stern letter on his behalf.  Eventually, Mr Bone goes through with his surgery.

Afterwards, you receive a letter of complaint from Mr Bone.  Mr Bone’s operation has been ‘life changing.’  He now feels you should have referred him earlier and that you failed to listen to his concerns.

Where did it all go wrong?

This is a fictitious case but not unusual.  Many doctors point out that it’s the patients they do the most for that complain.  But what was really going on?  This example is a classic case of Karpman’s Drama Triangle – a concept in transactional analysis.

I first became aware of Karpman’s when working in a setting that supported humanitarian workers in the field.  We received urgent phone calls about crises such as kidnappings and assaults.  Our response  was to throw our hearts into helping them.  We would spend hours on the phone, including in our own time.  But sometimes in the aftermath, we received complaints.  We had not been available enough; we had given conflicting advice that made their perilous situation even worse; we had been uncompassionate and had even abandoned them in their hour of need.

We were left feeling upset and resentful.  After all we had done!  We grumble and vowed to be less involved next time – until the next crisis hit and threatened to tear us apart as an organisation again.

And so these situations went on until we learned to use tools that aided but also contained the callers, one of which was recognising when Karpman’s Drama Triangle was at large.

So, what is Karpmans?  The drama triangle is a model of social interaction with each party assuming the role of victim, rescuer or persecutor.   The victim presents as powerless and, if there is no persecutor, they may even seek one out, as well as recruiting a rescuer to validate their negative feelings.

This may work so-so for a while but what usually happens at some point is one party (usually the victim in a medical setting), gets fed up and ‘pulls the switch.’  Everyone now moves around the triangle.  The victim now takes the role of perpetrator, complaining about the GP (now the victim) and in the example above, the orthopaedic surgeon is now the rescuer with the offer of an operation.

Drama triangles can thus whizz round and round, although each party tends to have a comfortable ‘entry point’ (guess what, GPs – you are usually the rescuer).

As GPs we are particularly vulnerable because some patients present with their symptoms feeling particularly like victims. Many doctors enjoy being rescuers (seductive, eh?) and readily present themselves as all too willing to step in.   Rescuers may find this role comfortable because it distracts them from their own real anxieties or vulnerabilities.  Uncomfortable reading, eh?

The key is to recognise when a drama triangle presents itself and thus avoid being recruited.

As a quick guideline, here are some key questions to ask:

Are you doing more than 50% of the work here?

Could you be stepping in to help when actually help may not be wanted?

Are you taking more responsibility than you should?

In the above examples, with Mr Bone, the GP might choose to direct Mr Bone to PALS to raise his concerns rather than being drawn into making judgements and ‘rescuing’ a situation when you were not party to the facts.

With the humanitarian workers, clinicians gave time-boundaried telephone appointments, the focus of which was on providing them with specific tools and information that enabled them to make key decisions themselves as opposed to clinicians spending hours listening on the phone.

This was successful until our managers got sucked into the triangle and told  us we weren’t rescuing people hard enough…such is the seductive power of drama triangles to suck people on board…

Claire Davies, GP and editor of the Network Locum (now Lantum) blog.