The Drama Triangle

Dr Andrew Tresidder explores how to maintain professional detachment in a consultation, drawing on the psychological concepts around the Drama Triangle. He is a GP Patient Safety Lead for Somerset CCG, GP Appraiser, member of the Somerset Clinician Support Service, and member of the European Association of Physician Health. He is a former Somerset LMC rep and Bristol Medical School Academy GP Lead.

Effective communication makes for good consultations, but some simple factors can easily turn a good consultation into a poor one. Psychological factors such as the Seat of Power, the Drama Triangle and the Four Agreements all apply to good communication and can make or break its success.

“Every profession is a conspiracy against the laity,” wrote George Bernard Shaw in The Doctor’s Dilemma. Two people approach a consultation, both independent adults. The expert knowledge lies with the professional – the layman, through ignorance or fear/anxiety, may give away his power and autonomy to the professional.

The wise professional – remembering Transactional Analysis and the three roles of Parent, Adult, Child – shares power as much as possible (Adult to Adult), uses it wisely for the patient, then hands it back; finishing the consultation with both people as independent adults once more. Otherwise, patient and physician enter the Drama Triangle of relationships.

The Drama Triangle has three roles – one Child, and two Parent. The Child gives away their power to a Parent, then plays Victim, with the script “If you help me/save me/protect me, I will give you my power (and my approval)”. The Parent (very often the physician) takes the power and becomes Rescuer (doctors go into medicine to help people get better). The underlying assumption may run “If you give me your power, I will protect and help you (as long as you also give me your approval)”. Sometimes the doctor’s inner Child craves the approval of the patient’s Parent.

Patients may judge doctors on the basis of how they feel – in which case there are only two types of doctor – good and bad – or even the ‘best in the world’ and ‘rubbish’. And the difference between the two? Half a second – because that’s how long it takes Victim to change their mind about Rescuer, take back their power, and change role into Persecutor: “You nasty person, you took my power and abused me, now I’m going to abuse you.”

The sign on an Australian GP’s door reads: “Your health is my concern, but your responsibility”. As practitioners we must avoid allowing patients to transfer responsibility for their health to us, otherwise we happily accept the Rescuer role, and should not be surprised to be persecuted when things don’t go well.

It is very easy to be enticed into, and then chased around, this triangle of dependency. The sting in the tail (Edwards’ insight) is when the patient sees illness, death, cancer or any medical diagnosis as Persecutor, takes the role of Victim, and sets up the physician as Rescuer – in a no-win situation.

It takes considerable skill for the physician to help lift the patient out of the Child role of victim, yet can be part of the most rewarding aspects of medicine.

One key pitfall is to avoid being enticed into collusion with the patient. It’s very easy to agree to support the patient (in their angry or distressed state) – and find oneself moved from Rescuer into Persecutor, possibly against a fellow professional.

Unconscious collusion in the Drama Triangle is emotionally draining and may lead towards physician burnout – it certainly leads to mutual patient and physician dissatisfaction. An understanding of these dynamics can illuminate consultations and help avoid both complaints and emotional exhaustion.

What are the answers?

Firstly, be authentic – be yourself, and understand the traps of the Drama Triangle. To thine own self be true (Shakespeare). Second, read Games People Play by Eric Berne. Third, use The Four Agreements; native South Americans, the Toltecs, developed a system of wisdom about how to live life – it is said that four key points were these “agreements”.

Be impeccable with your word

Your word is an affirmation of your intent, a casting out of your will into the world, reinforced by power. So, say only what you mean, and speak with integrity. Don’t waste the power of your word in idle gossip or putting yourself down. Use your word, as a vehicle for the power of your will, for good, with integrity – if you lie, you’re only lying to yourself.

Take nothing personally

Even though we are all part of an interconnected universe, we each have our own experiences and interpretations. My stuff is my stuff, yours is yours. Nothing you do is because of me – it’s your stuff. How I interpret that is my stuff – but better to take nothing personally – for nothing is done personally, even though it feels it. If I do take it personally, then I choose to suffer!

Make no assumptions

Ask the little question “Why?” often, and find clear answers for yourself. Express your wishes clearly to avoid misunderstanding. Communicate clearly with others to avoid needless mistakes, upsets and emotions.

Always do your best

In life, everything is always changing – if we do our best, whatever the circumstances, we express our selves with integrity and avoid self-criticism and regret. Beware emotional attachment to the outcomes of your efforts. Everything we do is guided by positive intention – try and find out what the other person’s positive intention is, and life becomes a whole lot easier.

Useful links

• Karpman, S, Fairy tales and script drama analysis, Transactional Analysis Bulletin, 7(26), 39-43 (1968
• Edwards, G, Conscious Medicine, Piatkus pp130-133 (2010)
• Ruiz, DM, The Four Agreements, Amber-Allen Publishing (1997)

Case study

GP Dr A consulted 57-year-old Mr J. He complained of considerable pain in his left knee. The pain had stopped him playing golf, although he continued to work. His BMI was 35. Dr A strongly advised him to lose weight, and gave analgesia. An x-ray showed moderate osteoarthritis.

After six months Mr J insisted on referral to an orthopaedic surgeon Mr B, as his medication had not helped the pain. His weight was unchanged. Dr A reluctantly referred him. Several months later, after the usual pre-op counselling that included possible complications, Mr B performed an uncomplicated left total knee replacement.

A year later he returned to Dr A, angrily complaining that the knee was worse, and that he was in constant pain. He said he wished he’d never been referred, because then he wouldn’t have had the operation. He threatened to sue Dr A and Mr B.

Learning points

The patient, in Victim mode, took no personal responsibility for his weight and health condition, but looked for someone else to sort it out (first a GP and then a consultant as Rescuer). When he had no benefit, even though he knew this was a possible outcome, he felt Victim to the pain, decided to take back his power and wield it, this time as Persecutor.

Mr J then sought to make the GP collude with him in his attempt to shift responsibility for his condition squarely onto someone else. Dr A could either deal with the issue or avoid it. If Dr A seeks to avoid the thorny issue of helping Mr J gain insight and maturity about the position, Dr A may be pulled into the role of Persecutor against Mr B.

If he seeks to deal with it, Dr A may have a challenge to help Mr J come to terms with the consequences of his own decision because Mr J has already shown his disinclination to take responsibility. However, this is the only long-term win-win solution.