In drama triangles we learned about psychiatrist Stephen Karpman’s system of common psychological dynamic of conflict at play.   

Drama triangles usually occur between three people, each playing a role of rescuer, victim and persecutor.  Each person will move around the roles, triggered by one person ‘flipping the switch’ and moving roles themselves.  Drama triangles are very common in healthcare settings, both between staff and with patients.   

Triangulation can also occur between two people if one person flips between two different roles.   

Let’s meet a (fictitious) character, consultant physician, Dr Totali Pistov.  Dr Pistov is a brilliant diagnostician but not very up to date.  His ward rounds go on for 6 hours, partly because Dr Pistov spends too long pontificating over clinical signs and test results; partly because Dr Pistov’s juniors then have to dig him out of the management plans he creates.   

Dr Pistov has quite good boundaries with patients but he is a deeply nice person and wants to be helpful, especially to his juniors whom he knows deep down he is indebted for digging him out of numerous holes.  Trainees seem to Dr Pistov to have a lot of issues these days – far more than in his day.  Problems getting time off for family events, strange shift patterns that preclude any form of circadian rhythm and relatively low pay.   

Dr Pistov wants to be supportive.  The other reason Dr Pistov’ ward rounds go on for so long is he is endlessly listening to the woes of his juniors.  Inevitably the ward round begins with someone having problems with the rota coordinator.  Dr Pistov will try to be helpful by making a phone call to someone in HR.   As his round goes on for so long, he feels obliged to take his team for coffee halfway through, at which point he will hear more about the rota and the impact it is having, particularly on young Siobhan who is supposed to be getting married this year. 

At the end of the ward round, Dr Pistov tries to help further by sending a few emails.  The rota is nothing to do with him, however he feels sorry for the juniors and does enjoy listening to them.   

Siobhan has just said they wish the other consultants were like him.  This makes Dr Pistov feel warm and fuzzy inside.   

It’s a nice feeling – and one the psychologist warned him about when he had some sessions after burnout.  The psychologist said there was such a thing as ‘rescuer syndrome’ and ‘over-giving.’  Dr Pistov has always thought the therapy was ‘not him’ (it was occupational health that made him go) and so he just appreciates the warm feeling as something from doing emotionally rewarding work. 

As they pass through the swing doors into the hospital corridor, Siobhan starts to cry.    Dr Pistov feels obliged to spend some more time trying to calm Siobhan down.  He listens to all about how this is affecting her.   

Dr Pistov fingers his phone in his suit pocket, wondering what time it is.  Magali (his brilliant neurosurgeon wife) will be annoyed if he is really late home again.  He mentions he has sent some emails to try and help but Siobhan says it won’t do anything. Dr Pistov is now finding this conversation draining but he doesn’t know how to get out  of it without being rude.   

He agrees to make some phone calls in the morning.  Eventually Siobhan’s bleep goes off and he says gently that she had better go and answer it before he beats his retreat to the hospital car park.   

Dr Pistov is now totally pissed off, as well as exhausted from his ward round.  He fires off a strongly worded email to HR telling them to ‘get this house in order’ over the rota. 

Dr Pistov arrives home – finally.  His twin teenage boys are engrossed in their phones and ignore him.  He is already regretting the email but tries to put it out of his mind.  Magali is already home long ago thanks to the fierce efficiency of her all female team.    

Magali tosses her auburn hair, furious with him. How dare he meddle with the training rota.  Things are already political enough, thank you.  She tosses spaghetti into a dish in the manner of someone scooping out someone’s brains after a serious accident.  

If trainees have rota issues (and Magali is well aware that they do, because not much gets passed her), they should be coming directly to her. 

Dr Pistov is shaking with upset.  Things are hard enough with Magali.  Since the menopause hit, she has been all liberated and quoting self help books written by this American woman, Brene Brown.  Here she goes again with her quotes: ‘Hustling for your own worthiness,’ she yells, wet spaghetti sliding off her wooden spoon.   

What does that even mean?  Dr Pistov is now, well, totally pissed off.  All he is doing is trying to help poor Siobhan.  What level of appreciation is this for his kindness!  Dr Pistov storms off to the box room that serves as his office, and slams the door. 

Magali has changed since she started reading all these books, for sure.  Doubtless she will be suggesting again this evening that he gets a coach but Dr Pistov just thinks all that stuff is nonsense.  He spends the evening sulking in the office, hungry and half-heartedly opening up all his un-read copies of The New England Journal of Medicine. 

At least Dr Pistov will be up to date at last.   

What can we learn from this story 

Dr Pistov has become over-involved in Siobhan’s problem with the rota.   

Dr Pistov is gaining self-worth from helping.  Helping others is generally a good thing, however, in this case his Inner Rescuer has become too involved in Siobhan’s rota problems which are outside of his responsibility. 

Siobhan does have significant rota problems but is presenting as the victim.  Nothing Dr Pistov can do is enough. 

Dr Pistov ignored the physical warning signs that his ‘Inner Rescuer’ was showing up – that warm fuzzy feeling. 

Dr Pistov got into a situation where he became the one doing all the work – another sure sign that the rescuer is at play. 

What could Dr Pistov have done differently? 

Dr Pistov could have empathised with Siobhan.  He could have asked her if she knew where to go with her problem.  He could have also explored with her what she had tried already.  Asking her what would be helpful from him might have brought some clarity to the conversation and prevented him diving in with his emails. 

Finally, he could have limited his involvement by directing Siobhan to the appropriate person who hold the true responsibility over the rota.   He may have sent a supportive email but not more than that.   

Dr Pistov may have an issue with gaining his self-worth from rescuing people.   

Dr Pistov may benefit from working with a coach to improve his rescuing tendencies, his self worth. 

This may also be an opportunity in disguise: to take an honest look at the length of his ward rounds and reflect on what he truly does have control over.