The Doctor-Patient-Family Triangle: Training Residents to Work With Triangulation in the Clinic Encounter

This is is part of the Pecha Kucha: A Special Families and Health Blog Series.

Valerie Ross, MS, LMFT

At age 9 I took up the cello. It has been one of the joys of my life and surprisingly an important influence in my approach to teaching physicians.

To learn to play an instrument, you perform in front of a teacher who uses everything they know to coach you to play proficiently and musically. They first listen, they demonstrate and teach specific skills like how to hold the instrument or draw the bow, asking questions and offering encouragement. Then you go home and practice and come back for more coaching.

Imagine for a moment if we taught musicians the way we teach most health care clinicians. A learner would rarely play their instrument in front of their teacher. They’d describe their perception of their playing. We’d learn how they think about playing their instrument but not how they actually play. It does not make sense to us to think about training musicians or athletes without observation and coaching, and yet this is the way many health care providers are taught. We need to define, hear, see, and model the concepts and skills we want our learners to practice.

As a family therapist and behavioral scientist in a family medicine residency, I regularly observe residents in clinical encounters; in this context I find opportunities to teach them about the family systems concept called triangulation.  

Two founding fathers of a family-oriented primary care approach, Bill Doherty, PhD, and Mac Baird, MD, observed that the doctor-patient relationship is always a triangle involving the clinician, the patient, and the family.

A clinician can use her or his position in the triangle therapeutically. However, if we are unaware of this triangle, we neglect to think about family members who are not in the room and we risk the possibility of unconscious “triangulation.”

In architecture, triangles are considered a strong and stable form because force is equally spread through all three sides.  

This idea of spreading stress to create some stability is at the heart of emotional triangulation.  Emotional triangulation was first defined by Murray Bowen, MD, a psychiatrist who is considered one of the fathers of family therapy. Emotional triangulation is defined as what happens when a two-person relationship is under stress and a third person is drawn into the middle of the relationship either consciously or unconsciously to try to relieve that stress. Triangulation is natural; we all do it. Some examples include:

• When we find ourselves anxious due to relational conflict or drama we may gossip or even have an affair. We pull someone in the middle to try to relieve some of the discomfort or anxiety we feel.
• A child develops symptoms (headaches, stomachaches, or increases in blood sugar) in response to fighting parents, and paradoxically parental concern over those very symptoms may decrease conflict by bringing the parents together for a time.

These unconscious triangles may temporarily relieve stress. But, when conflict remains unaddressed or unspeakable, and triangulation substitutes for direct communication and finding common ground, family members may experience damage in the form of distance, being cut off, or somatic symptoms. Clinicians are often invited into the middle of family stress. We need to help trainees learn to avoid a triangulated position and instead use the doctor, patient, and family triangle to help family members find common ground to support our patients’ abilities to creatively address the stresses and conflicts in their lives.

A resident recently invited me into a session to watch her with two elderly patients with whom she was struggling. The husband had recently had a stroke. His diabetes was out of control. His wife was angry at him because he was not eating healthy and was sneaking cookies. The resident thought starting insulin was the best approach for diabetic control, but due to the effects of the stroke the patient had suffered, the wife was the one who needed to administer the insulin and she did not want this responsibility. They couldn’t agree on a plan. There was high anxiety in the room. The resident felt stuck in the middle, frustrated by the wife’s anger but not understanding it, and she didn’t know how best to support her patient.

The drama triangle, a form of triangulation first described by Stephen Karpman, MD, describes the roles that members of a relationship triangle can fall into unconsciously. The roles are victim, persecutor, and rescuer. As I listened to the resident and watched the interaction in the room, I could see a form of this dance was starting to happen. The husband was becoming seen as the victim due to his illness and dependency on his wife, the wife was becoming seen as a persecutor because of her anger and the resident felt she needed to rescue the husband.

Back to music for a moment: when an orchestra is not playing well together, a conductor may ask each section to play their part separately to hear where the disharmony is happening. As each section listens to the other, players gain awareness of what they are doing, and may hear the way their part fits into the whole better.

A person who has become triangulated needs to step out of the relationship disharmony by accessing their inner conductor and:

• Avoid taking sides
• Build an alliance with each person through the use of reflective and empathic listening
• Summarize both sides of the conflict  
• Listen for and promote common ground
• Set appropriate boundaries

The first step when we are observing is often to can ask residents to notice if they are feeling caught in the middle or feeling pulled to take sides?

In our case, the resident easily identified that she felt stuck in the middle and protective of her patient. I encouraged the resident to find out more about this couple, their history together, and why the wife did not want to administer insulin. It started with a simple question: tell me more about your relationship, how did you both meet and fall in love?

The common ground she found was their 50-year love for and commitment to each other. They had immigrated together with almost nothing in their pockets, raised kids, started a business and built a rich life together. It turned out the wife was afraid of hurting her husband if she gave the wrong dose of insulin and was afraid of his dying from his diabetes if it remained out of control. Fear of losing him was fueling her anger.  

The resident no longer felt pulled to protect her patient, the couple became two people who loved each other struggling to care for each other in the face of diabetes and other diseases of aging.

Finding this out decreased the tension in the room and freed the resident to offer a creative treatment plan that worked for all three of them.

Residents have already been exposed in medical school to the basic skills they need to step out of the middle: empathic and reflective listening.  

We can coach them further to:

• Recognize triangulation
• Listen to each family member   
• Set appropriate boundaries around listening as needed
• Remind them to assess family stressors when patients present with medically unexplained symptoms

Each clinical encounter is unique and the skills we teach look different in different contexts. When we’ve done our job well, residents take the skills we teach and become like great musicians, aware of their position and able to creatively improvise in each encounter with patients and families.