Introduction
Staff working in mental health services provide care for individuals with a variety of difficulties, including psychotic, mood, anxiety and personality disorders, which in many cases are co-morbid (Department of Health and Children, 2006). Challenges in therapeutic engagements have long been documented, with assorted terminology used to describe similar phenomena. Historically, physicians have referred to ‘heartsink’ patients: those who stir frustration and futility within the clinician, particularly in psychiatry and general practice (Stone, Reference Stone2014). The notion of ‘stuckness’ in psychiatric practice is a similar term that encompasses the feelings and behaviours around those patients that fail to sustain full recovery (Wilkinson, Reference Wilkinson2019). ‘Difficult’ patient encounters are described in all fields of medicine and arise throughout a physician’s career (Sellers et al. Reference Sellers, Salazar, Martinez, Gelfond, Deuter, Hayes, Ketchum and Pollock2012). In psychiatry, difficult encounters are mostly those where the patient is perceived by the physician as ‘uncooperative’, either due to avoidance of prescribed treatments or insistence upon treatments that the doctor does not consider to be indicated (Koekkoek et al. Reference Koekkoek, Van Meijel and Hutschemaekers2006). The frustration that emerges from these difficult encounters sometimes reflects the unconscious processes that exist between doctors and their patients; Michael Balint developed a form of reflective practice that sought to help the clinician to better understand this frustration (Balint, Reference Balint1957; Douglas & Feeney, Reference Douglas and Feeney2017).
Previous research has described doctors’ efforts to accept and overcome the helplessness associated with ‘heartsink’ or ‘difficult’ patients using interventions such as long-term professional peer support, usually over many years (O’dowd, Reference O’dowd1988; Ellis, Reference Ellis1996). Such research is largely based on physicians in general practice with many years of experience. ‘Feeling stuck’ poses a particular challenge for non-consultant hospital doctors (NCHDs), who are relatively inexperienced and often on time-limited training posts, so lack the time and expertise to work through these feelings. This can prevent the NCHD and patient from engaging in an effective therapeutic relationship, a pattern that often repeats itself with subsequent doctors. To our knowledge, the experiences of psychiatry NCHDs in these kinds of challenging clinical encounters have not been studied.
The aim of this study was to explore the experience of ‘feeling stuck’ amongst NCHDs in clinical practice.
Methods
Participants
A total of 30 participants were recruited from three psychiatric hospitals to complete a 15-item questionnaire. Eligible participants were contacted by email or at local academic sessions. All psychiatry NCHDs were eligible to participate. All NCHDs in the three centres were asked to complete the survey anonymously, either by using an online survey portal (linked from the email) or by returning a sealed paper survey. The questionnaires were distributed by three researchers (LA, EC, LD). 52 NCHDs in total were invited to participate, of whom there were 30 respondents.
Recruitment was finished when the point of saturation was reached, where coding the data generated no new themes. This is described further in the ‘data analysis’ section. The purpose of the study was described in writing to all participants prior to obtaining their consent. In order to preserve anonymity, participants were not asked for a name or any identifying information. An exemption from ethical approval was granted by the Research and Ethics Committee at the St Vincent’s University Hospital.
Survey development
The survey was designed to pursue a thematic analysis, a method used to analyse qualitative data derived from interviews or from surveys that employ open questions (rather than categorical or Likert responses) (Maguire & Delahunt, Reference Maguire and Delahunt2017). Thematic analysis is a flexible method of qualitative analysis, which can be applied to different types of data collection strategies (verbal, written, etc.) (Braun & Clarke, Reference Braun and Clarke2006). Data in this study were collected using surveys, rather than interviews, in order to gather data from a larger and broader sample. The survey was designed to elicit the doctors’ experiences of feeling stuck in clinical situations. Survey items were developed by researchers with clinical and research experience in psychiatry and clinical psychology, and were informed by a literature review (Ellis, Reference Ellis1996; Koekkoek et al. Reference Koekkoek, Van Meijel and Hutschemaekers2006; Sellers et al. Reference Sellers, Salazar, Martinez, Gelfond, Deuter, Hayes, Ketchum and Pollock2012; Stone, Reference Stone2014). The survey sought to explore the factors contributing to feeling stuck, the doctors’ experience before, during and after seeing patients with whom they felt stuck and the way doctors attempt to manage these feelings on a personal and professional level. Questions were initially open-ended to elicit data about causes of ‘feeling stuck’, for example, ‘What scenarios (with patients) create feelings of being “stuck” for you?’ ‘How would you describe these interactions?’ These open questions were supplemented by more specific questions, for example, ‘what factors within yourself contribute to the feeling of being stuck’ (Swart, Reference Swart2019).
Participants also provided information about basic demographics (age/gender, nationality, language, level of experience, level of training).
Data analysis
Qualitative analysis was carried out using NVIVO analysis software (QSR International). From the preliminary stages, researchers reflected on their own experiences and opinions of ‘feeling stuck’. This reflexivity involved an examination of the researchers’ own values and interests that may impinge on their research (Braun & Clarke, Reference Braun and Clarke2006). Bracketing, where researchers name and ‘bracket off’ their pre-existing thoughts, feelings and judgments about ‘feeling stuck’ was carried out to mitigate the potential influence of these factors within the researchers (Moustakas, Reference Moustakas1994; Tufford & Newman, Reference Tufford and Newman2012). This was especially important in this study because the researchers carrying out analysis and the subjects of the study were psychiatry NCHDs. Bracketing was undertaken throughout the process of survey design and data analysis, by researchers identifying, writing down and discussing preconceptions on a repeated and ongoing basis.
A sequential analytical method was applied, which involved coding data, generating themes and reviewing and refining themes (Braun & Clarke, Reference Braun and Clarke2006; Maguire & Delahunt, Reference Maguire and Delahunt2017). Open coding was applied, using NVIVO, by highlighting survey data and creating ‘nodes’ (categories containing similar content) to dissect the survey data and to develop a thematic analysis of shared experiences associated with the experience of feeling stuck (Boyatzis, Reference Boyatzis1998). Open coding was carried out by two researchers in parallel (LA, EC) using the same data. The two sets of coded data were compared, following which themes were agreed upon through collective discourse. This process was commenced during data collection (after 10, 20 and 30 surveys had been collected) in order to approximate the point of data saturation, which was reached when 30 surveys were analysed. Considering and reviewing the data using multiple strategies (reading, coding, discussion) was utilised as it is an effective method of estimating the point of saturation (Bernard et al. Reference Bernard, Wutich and Ryan2016).
Results
Demographics
30 NCHDs completed the survey (16 male), representing a 58% response rate (52 NCHDs contacted in total) (Table 1). Mean duration of medical practice was 5.6 years (S.D. = 2.8). 26 were on training schemes, of which five were higher specialist trainees. 19 participants were Irish, 71% reported English as their primary language. 90% described themselves as clinically ‘competent’ (or equivalent language) in their psychiatric practice, for their level of training.
Survey findings
Themes
Most participants described the kind of situations that precipitated a feeling of being stuck as ones in which they felt frustrated and unsure of what to do when a patient appeared not to be improving.
Three themes were elicited from the data. The central theme – ‘causes of feeling stuck’ – consisted of three subthemes (Table 3). Other themes, explored in less detail by respondents, were ‘the experience of feeling stuck’ and ‘responses to feeling stuck’.
Causes of feeling stuck
‘Causes of feeling stuck’ consisted of three subthemes: patient factors, system factors and doctor factors. Most NCHDs emphasised patient and system factors, with much less weight allocated to doctor factors.
Patient factors
‘Patient factors’ refers to aspects of the patients’ presentations that were deemed to influence the doctors’ experiences, such as “unrealistic expectations”, “psychological difficulties” and “lack of insight”. 15 participants referred to patients’ lack of acceptance about the realities of treatment. Patients’ attitudes to change also emerged as an important feature, with some patients being described as “ambivalent”, “unwilling” or “afraid” to follow advice. Participants described certain kinds of behaviours in their patients as the primary reasons for becoming stuck; patients who were described as “emotionally demanding”, or those who requested hospital admission or had an expectation that the doctor should “fix the problem”, were most likely to engender disturbed feelings in the doctor. Some factors named by respondents as patient-related, such as encountering patients with “a sense of entitlement”, are likely to also reflect doctor-factors, although they were not identified by respondents as such.
Diagnosis was also an important factor (Table 2). All participants cited “personality disorder” as a diagnosis that predisposes a clinical interaction to cause feelings of being stuck.
Table 1. Demographics, training schemes and version of survey responses (paper or online version)
BST, basic specialist trainee; S.D., standard deviation; HST, higher specialist trainee
Table 2. Diagnoses associated with feeling stuck. Number of participants who identified diagnosis as a predictor of feeling stuck
Table 3. Causes of feeling stuck: patient factors, doctor factors and system factors (direct quotations)
System factors
‘System Factors’ refers to constraints within the medical and mental health setting, and within wider society.
There was a palpable sense of frustration conveyed in responses related to constraints within the wider mental health system. “Inadequate resources”, especially limited access to psychological treatment, was named as a significant problem by the majority of participants. Some doctors expressed frustration and anger with suboptimal communication between services, including “lack of centralised data” and unwillingness of separate services to collaborate on interventions for “complex” patients, such as those with co-morbid mental illness and addiction.
Many responses made reference to shortcomings in wider society including “medicalisation of mental distress and normal life events” and “a lack of understanding of what a psychiatrist’s role really is”.
Doctor factors
‘Doctor factors’ represented a notably smaller proportion of responses compared to patient and system factors. Only six doctors out of 30 identified ‘doctor factors’. “Inexperience” was conceded by a small number (four participants) as a factor contributing to this phenomenon of feeling stuck. Others reported personal characteristics such as “perfectionism” (one participant) or “defensiveness” (one participant) as contributory. Some doctors recognised vulnerability within themselves around a fear that they might be considered “responsible” for their patients’ recovery or any bad outcomes, but considered this to be an outcomes of feeling stuck, rather than a contributing factor. Many participants did, however, state that formal training in psychological modalities would be useful, implicitly acknowledging some personal deficit.
Experiencing ‘feeling stuck’
Participants described their experiences of feeling stuck. Respondents generally reported having no substantive difficulty with rapport-building, but challenges arose when they felt expected to provide “solutions” to patients’ presentations. The subthemes that best capture the experience of feeling stuck are: ‘the physical response’ and ‘questioning competence’.
The physical response
Doctors described a visceral experience associated with ‘feeling stuck’. Before the interaction, they described already feeling a loss of energy (“weary”, “fatigued”), anxiety (“nervous”, “on edge”, “heart dropped”), even to the point of panic (“shallow breathing”). During the interaction, the physical responses continued to escalate, with participants feeling “tense”, “panicked” and “exhausted”. Upon completion of the interactions, NCHDs experienced a “simmering” of this response, which left them feeling “tired” and “drained”.
Questioning competence
One of the biggest challenges faced by NCHDs during these interactions was self-doubt. Whilst the majority of NCHDs stated that they felt competent for their level of training when feeling stuck they expressed a fear of “looking clueless” and “a sense of powerlessness”. Although confident about initiating the interview and establishing rapport, the course of these interactions caused them to feel “helpless” and “doubting [their] own expertise”, leaving them with a sense of “futility”. Compounding these feelings of self-doubt and futility was a fear that they would be held “responsible” for bad outcomes.
Responding to feeling stuck
The experiences around feeling stuck prompted participants to develop strategies for managing these interactions. Doctors reflected on how they responded within the clinical interaction and how they dealt with the feelings that lingered in the aftermath of the encounter.
Prior to the interaction, doctors felt “determined”, but “anxious about how to approach the situation”. During the interaction, doctors described feeling “frustrated with repeated discussions” and “trying to control everything [they] say because anything might be used against [them]”. In many of these instances, participants felt that resolution would only be reached by making management decisions that they believe to be “unhelpful” or even “detrimental to the patient”, for example, admission to an acute unit. This, they describe, left them feeling “defeated”.
Accessible clinical supervision was repeatedly identified as helpful in managing doctors’ responses to feelings of being stuck, as was support from the multidisciplinary team (MDT). Most participants stated a desire for formal training in psychotherapeutic modalities, particularly skills-based modalities, for example, dialectical behavioural therapy.
Discussion
‘Heartsink’ and ‘feeling stuck’ are phenomena that have been explored previously in clinicians, mostly in general practice. To our knowledge, the present study is the first to explore these experiences amongst NCHDs in psychiatry. The themes that evolved through this analysis were in keeping with previous studies, such as the therapeutic obstacles associated with a difficult patient encounter (Koekkoek et al. Reference Koekkoek, Van Meijel and Hutschemaekers2006). Participants were adept at describing the patient and system factors contributing to the feeling of being stuck, but, interestingly, they reflected less often and in less detail on the role of the doctor. Other than the causes of feeling stuck, doctors described the physical and emotional experiences associated with these clinical interactions and methods of managing these feelings.
Causes of feeling stuck
The central theme to emerge from these data were ‘the causes of feeling stuck’, and the starkest finding of this survey was the doctors’ apparent reticence to name factors within themselves as contributory to their experience of feeling stuck, with only six out of the 30 participants identifying any ‘doctor factor’ (in response to the question ‘what factors within yourself contribute to the feeling of being stuck’). Doctors readily identified the patient factors and the feelings that were evoked by these interactions, but it was clear that often they lacked reflection on countertransference in this process and its role in engendering a feeling of being stuck in clinical encounters. Countertransference, the feelings experienced by the therapist in response to a patient’s personality and behaviour, has long been recognised as a potential obstacle to therapeutic engagement. Awareness of this process can help to diminish any deleterious effect of these intense feelings, whereas failure to understand this emotional response can halt progress in a therapeutic relationship (Winnicott, Reference Winnicott1947). In this study, words such as “frustrated” and “tired” were used by participants when asked how they felt in such situations, but there were also potent unnamed emotions evident: anger with the wider system, resentment of patients’ unwillingness to change, fear that they themselves would be deemed “responsible” for a bad outcome and blame projected externally on the patients and the wider system. It might be that NCHDs responded psychologically to feeling stuck by placing blame on their patients, whose “limited self-reflection” and “inability to recognise their agency in getting better” they believed to be the primary cause of the failure to improve. This defensive stance was exacerbated by the solution and outcome-centred approach of the doctor, with participants expressing frustration when patients don’t follow their advice rather than reflecting on their own expectations of the clinical engagement. The compulsion felt by doctors to see their patients recover, and the effect this has on a doctor’s behaviours, is one that has been explored previously. In the historic paper and address to the British Psychological Society by Tom Main in Reference Main1957, ‘The Ailment’ described clinicians’ responses to patients failing to improve in a therapeutic community (Main, Reference Main1957). Feeling stuck caused clinicians in the community to feel personally responsible and guilty, similar to doctors in the present study. It also prompted behavioural responses that were out of sync with a clinician’s usual practice, so-called ‘therapeutic mania’, where patients were administered excessive treatments, to the point of the treatment becoming harmful. Similar to the participants in this study, the tendency was to attribute frustration to patient factors, such as diagnosis, rather than doctor factors, such as unrealistic expectations.
57% of the respondents (17 participants) identified one particular factor within the wider public as becoming problematic in recent years: the public perception of mental illness. Recent research about public attitudes towards mental illness reports positive developments, such as improved awareness and reduced stigma (Angermeyer et al. Reference Angermeyer, Matschinger, Carta and Schomerus2014). Psychiatry NCHDs in this study described the negative corollary of increased mental health awareness, where individuals label “appropriate situational sadness” as a major mental illness. This, they describe, has led to the role of the psychiatrist becoming distorted. Rather than being a physician who treats major mental illness, they have become a “fixer” of “problems that arise out of social dysfunction rather than mental illness”. This finding highlights the influence of wider societal attitudes and expectations on doctor–patient interactions. Effective public health interventions, we believe, could be employed to help societal attitudes shift somewhat from the belief that their problems can be ‘fixed’ and towards an internal locus of control, which is associated with improved resilience, reduced stress and lower healthcare utilisation (Musich et al. Reference Musich, Wang, Slindee, Kraemer and Yeh2019). This might enable individuals to be more empowered to lead their own recovery. The recent publication ‘Sharing the Vision: A Mental Health Policy for Everyone’ by the Department of Health describes many initiatives, which aim to improve society’s mental health, describing a greater role for multiple agencies to target these improvements (Department of Health, 2020).
Consequences of feeling stuck
The consequences of feeling stuck described in this and previous studies were many, including self-doubt, therapeutic mania and futility. These are all the factors that contribute to how doctors feel about themselves and their abilities. Doctor burnout is an increasingly recognised occurrence that can lead to more serious mental illness (Kealy et al. Reference Kealy, Halli, Ogrodniczuk and Hadjipavlou2016). Burnout is especially prevalent amongst those who are committed to their work, the most vulnerable being “empathic individuals who take patients’ problems to heart” (Nunn, Reference Nunn2017). Further to the personal risks associated with burnout, the experience of feeling stuck and burnt out predisposes doctors to deliver suboptimal patient care (Loerbroks et al. Reference Loerbroks, Glaser, Vu-Eickmann and Angerer2017). Patients at risk are both those who inadvertently create these feelings in the doctor and those who see the doctor following a fraught interaction with another patient. NCHDs often described feeling “exhausted” and “frustrated” after these encounters causing them to be aware they “perform” less effectively with the next patient. The emotional responses of doctors in this study suggest that many of these early career psychiatrists may already be on the path to burnout.
Psychotherapeutic training for psychiatry trainees
Doctors in this study suggested that formal psychotherapeutic training would be useful for managing these clinical encounters in the future. Doctors themselves predominantly sought skills-based training (e.g. dialectical behavioural therapy), whereas the findings of the thematic analysis suggest that they might first benefit from greater attention towards understanding psychodynamic factors, such as countertransference. The solution-focused approach of participants in this study echoes findings of previous research, in which trainees were found to seek didactic, rather than reflective, training in managing countertransference. (Jimenez & Thorkelson, Reference Jimenez and Thorkelson2012). Training in cognitive behavioral therapy (CBT) has been demonstrated as practicable and beneficial in psychiatry trainees, helping doctors to support their patients’ self-efficacy and responsibility (Ravitz et al. Reference Ravitz, Lawson, Fefergrad, Rawkins, Lancee, Maunder, Leszcz and Kivlighan2019), whereas, taking a reflective practice approach is shown to improve self-awareness and reduce ‘intense feelings’ associated with working with challenging patients (McKensey & Sullivan, Reference Mckensey and Sullivan2016). Reflective practice can also help doctors to develop the role for negative capability, where the doctor can accept their own limitations, and learn to tolerate therapeutic uncertainty (Bion, Reference Bion1995). It is likely that the most beneficial modality (or combination of modalities) is individual to each doctor and might be usefully guided by educational supervisors and mentors. The findings of our study highlight the abundant opportunities for experientially learning to manage feeling stuck and inadequate, either as individuals or within reflective practice groups.
Limitations
Participant recruitment for this study was a challenge (52 doctors were approached in order to reach an adequate number of 30 participants for data saturation). The response rate (30 respondents of 52 invitations to participate) overall was 58% (80% paper, 52% online), but this compares favourably to existing literature, of which the average response rate for paper surveys is 75% and for online surveys is 43% (Nulty, Reference Nulty2008). The modest response rate in our study is possibly attributable to the qualitative nature of this survey, which demanded time, consideration and a level of self-reflection that was possibly uncomfortable for some participants. There may also have been an element of selection bias, whereby the most frustrated doctors self-selected for this study. This could be remedied in future studies by exclusively using paper surveys that are disseminated locally at academic sessions, as there was a higher response rate when surveys were delivered manually.
The primary researchers in this study about psychiatry NCHDs were psychiatry NCHDs themselves. This increased the risk that conclusions would reflect their own experiences, although bracketing was used to attenuate this (Moustakas, Reference Moustakas1994; Tufford & Newman, Reference Tufford and Newman2012).
Conclusion
NCHDs provide a significant proportion of care in mental health services, especially in emergency settings. Whilst generally well-supported by senior colleagues, NCHDs described frequently facing situations, which caused them to feel stuck. The feeling of being stuck, whilst only applicable to a minority of clinical interactions, impacted on the doctor considerably. Our study identified two potential factors, which could be modified with targeted interventions: doctors’ reflection on their own role and the perception of mental illness within society. Further emphasis on psychodynamically informed reflective practice for trainees and targeted public health campaigns for patients would be worthwhile initiatives. Implementing such interventions could help both doctors and patients to navigate their way through challenging situations and to liberate themselves, and each other, from the feeling of being stuck.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
Authors [LA, EC, DM, LD] have no conflicts of interest to disclose.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. Exemption from ethical approval was granted by the Ethics Committee at the St Vincent’s University Hospital on the basis that there was no direct patient involvement in this study.
