Offering Psychological and Pragmatic Tools to Improve Coping and Adaptation During Serious Illness:

Clinician Perspective

Madeline Gittleman, PsyDAttending Psychologist

Department of Pain Medicine and Palliative CareBeth Israel Medical Center

Acknowledgment

Thank you toNomita Sonty, PhD

Craig Blinderman, MD

Columbia University Medical Center

New York Presbyterian

Case

A 64-year-old female diagnosed with Stage 4 Pancreatic Cancer five months prior to her initial admission. She was hospitalized with extreme visceral/abdominal pain and ascites and evidenced extreme anxiety regarding her worsening condition. From the initial encounter, the pt. and her family stood out. Although the family’s private room, clothing, designer luggage and other possessions were indicative of affluence, they were humble and down to earth. They made the pt. feel at home in her hospital room-hanging family photos, bringing in the patient’s personal bedding and food from her favorite restaurants. They welcomed providers as warmly as they would close friends (with a degree of familiarity and respect). The family devotion and warmth was readily apparent and powerful in drawing the care providers to them.

Introduction

The often intimate nature of palliative care generates intense emotions and countertransference in clinicians.

Countertransference is typically an unconscious and insidious process that can weigh on clinicians’ objective stance.

Countertransference may lead clinicians to cross and/or violate boundaries. Particularly with “likable” patients, clinicians may be unaware of these changes in practice because it “feels right.”

Although extant literature addresses the challenges of treating difficult patients, little information is available on working with “likable” patients.

A palliative care case is presented to demonstrate countertransference among clinicians from different disciplines. Based on these cases and work of Meier et al, a hypothetical model for teaching, self-reflection and effective practice is proposed.

Definitions

Countertransference: is understood as both the conscious and unconscious feelings one develops toward another person based on one’s own past experiences and relationships.

Boundaries: ideal ethical, physical, and

emotional constraints that delineate the limits of any relationship and provide safety when inequality exists between two individuals

Nasrallah S et al. Journal of Palliative Care. 2009: 12(12).

Definitions Continue

Boundary Crossing Ideal limits of a

relationship have been traversed but the risks and/or benefits of this crossing have not clearly been established

Boundary Violation When ideal limits

are traversed leading to detrimental outcomes for one or both parties.

Nasrallah S et al. Journal of Palliative Care. 2009: 12(12).

Model Introduction

While some training programs teach introspection, consultation, support and other insight oriented modalities, other programs neglect these strategies.

To address this educational gap we developed a hypothetical model of countertransference in palliative care based on case analyses and literature review.

Clinician Behavior•Excess Self-Disclosure•Over-Involvement•Under-Involvement•Breaking of personal boundaries•Breaking of professional/ethical boundaries

Denial

Clinician Cognitions

Triggering Patient Characteristics•Likable/Graceful•Ease with vulnerability•Appreciative•Similar to “us” •Intriguing•VIP

Clinician Emotional Responses•Sadness/tearfulness•Anger•Increased hopefulness for a cure/miracle•Difficulty leaving work behind•Wish to be with the patient•Wish to avoid the patient

Common Clinical Vulnerabilities•Previous Personal Loss•Past Trauma•Need To Please•Perfectionist Tendencies•Feelings of Omnipotence•Spiritual Conflict/ Existential Dilemmas

Rationalization Minimization Concern Curiosity Insight

Clinician Behavior•Thoughtful Self-Disclosure•Assessment of pt’s clinical and emotional needs•Joining patient •Loosening of boundaries for patient care•Seeking consultation, collaboration & support

Positive Treatment Outcomes•Clinician becomes more empathic•Clinician remains objective •Therapeutic relationship is strengthened•Trust and cohesiveness in treatment team•Decrease in boundary violations.

Negative Treatment Outcomes•Subpar and unequal clinical care•Clinician becomes intrusive to patient•Clinician loses sight of patient’s needs•Clinician burdens patient with their own needs•Clinician burns out

Defensive Characteristics

Awareness Characteristics

MODEL

Addressing Our Emotions

Name the feelingAccept the normalcy of the feelingReflect on the emotion and its possible

consequencesConsult a trusted colleague

Meier DE, Back AL, Morrison RS JAMA 2001:286(23)

Case Example

Triggering Patient Traits

Clinician Emotional Responses

Cognition Behavior

Extremely likable Sadness Ex: “This family had me in tears in almost every visit”

Gained insight through Supervision

Loosening of boundaries Ex: Sharing emotional moment with family

Intriguing/affluent Wish to be with/be liked by the patient

Denial Breaking of Boundaries Ex: Giving out cell phone numbers

Similar to "us“ Over-identification “She could be my mother”

Rationalization Over-involvement Ex: Staying at work late/multiple visits

Conclusion

While empathy and compassion create a foundation for working effectively, there are clear lines between:

empathic attunement and over-identification treating a patient compassionately and employing favoritism between clinical flexibility and boundary violations.

The case is presented to reflect on the process of discovering overwhelming countertranference and to encourage a greater sense of awareness among all clinical providers.

This model can be used as a teaching tool for all disciplines. It is hoped that through use of this model and other insight-oriented modalities clinicians will become more aware of their countertransference, thereby decreasing clinician burn-out and improving patient care.

References

Katz, R., & Johnson, T. (2006). When Professionals Weep: Emotional and Countertransference Responses in End-of-Life Care. New York: Taylor and Frances Group.

Katz, R., & Genevay, B. (2002). Our patients, our families, ourselves. American Behavioral Scientist, 46(3), 327-339.

Kearney, M.K., Weininger, R.B., Vachon, M.L.S., Harrison, R.L. & Mount, B.M. (2009). Self-care of physicians caring for patients at the end of life “being connected…a key to my survival”. Jama 301(11) 1155-1164.

Maguire, P. (1985). Barriers to psychological care of the dying. British Medical Journal, 291, 1711-1713.

Meier, D. E., Back, A.L. & Morrison, S. (2001). The inner life of physicians and care of the seriously ill. Jama, 286(23), 3011-3014.

Nasrallah S, Maytal G, Skarf LM. (2009). Patient-Physician Boundaries in Palliative Care Training: A Case Study in Discussion. Journal of Palliative Medicine 12(12), 1159-1161.

Novak et al. (1997). Calibrating the physician: Personal Awareness and Effective Patient Care. JAMA 278(6) 502-509.

Owens, D. (2007). Countertransference in palliative care and hospice. Journal of Hospice and Palliative Nursing, 9(6), 294-295.

Sherman, D. W. (2004). Nurses’ stress & burnout: how to care for yourself when caring for patients and their families experiencing life-threatening illness. American Journal of Nursing 104(5), 48-56.

Weintraub, W. (1964). "The VIP syndrome": a clinical study in hospital psychiatry. Journal of Nervous & Mental Disease, 138(2), 181-193.