Every psychiatrist could provide a personal list of types of patients they find problematic to treat. Such a list would be largely idiosyncratic and based on the psychiatrist's personality. Some psychiatrists like treating patients with eating disorders; others find such patients difficult and frustrating. Some find alcoholics self-indulgent and irritating whilst others enjoy treating them, and so on. This reflects variations of interest and aptitude which are natural. The positive aspect of this is that it leads to special expertise in treating specific disorders. This chapter is not concerned with these preferences. Some types of patients, on the other hand, have problems that create difficulties for most psychiatrists, in that it is difficult to form a useful therapeutic relationship with them. These individuals are sometimes called ‘heart sink patients’. The terminology is revealing, as it implies that the difficulty is at least in part related to the doctor's emotional response. ‘Heart sink’ implies that they induce a sense of helplessness and frustration.

Dysfunctional doctor–patient interactions are characterised by a failure to find an accommodation between the doctor's and the patient's agendas. These patients often carry agenda items that they cannot or will not make explicit, but which are implicit in their behaviour. They cannot always be helped. An understanding of the dysfunctional therapeutic dynamic at least eases the doctor's sense of despair.

As in many dysfunctional situations in life, both parties in these unhappy clinical situations repetitively attempt to deploy strategies that have already failed.