When Professionals Weep

Emotional and Countertransference Responses in Palliative and End-of-Life Care

Renee S. Katz, Therese A. Johnson, Renee S. Katz, Therese A. Johnson

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317505754
• Edition: 2
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

When Professionals Weep speaks to the humbling and often transformational moments that clinicians experience in their careers as caregivers and healers—moments when it is often hard to separate the influence of our own emotional responses and worldviews from the patient's or family's. When Professionals Weep addresses these poignant moments—when the professional's personal experiences with trauma, illness, death, and loss can subtly, often stealthily, surface and affect the helping process. This edition, like the first, both validates clinicians' experiences and also helps them process and productively address compassion fatigue, burnout, and secondary traumatic stress.

New material in the second edition includes increased emphasis on the burgeoning fields of hospice and palliative care, organizational countertransference, mindfulness, and compassionate practice. It includes thought-provoking cases, self-assessments, and exercises that can be used on an individual, dyadic, or group basis. This volume is an invaluable handbook for practitioners in the fields of medicine, mental health, social work, nursing, chaplaincy, the allied health sciences, psychology, and psychiatry.

Part I Introduction

1 When Our Personal Selves Influence Our Professional Work

An Introduction to Emotions and Countertransference in Palliative and End-of-Life Care

Renee S. Katz

DOI: 10.4324/9781315716022-1

As helping professionals working in palliative and end-of-life care, we are deeply affected by loss, heartbreak, and tribulation in our personal as well as professional lives. In fact, many of us have chosen to work in palliative and end-of-life care as a result of our own experiences with dying, trauma, and loss. Whether we are physicians, chaplains, nurses, social workers, psychologists, physical therapists, or occupational therapists, we have certain values and ethics, sociocultural influences, personal life histories and memories, and preconceived notions and assumptions that we inescapably bring to our work (Katz & Genevay, 2002).

The “C” Word

When we invited our contributing authors to write about their experiences and the subtle ways in which they can get “hooked” when providing palliative and end-of-life care, we discovered an abundance of preconceived notions and biases about the “C” word (countertransference). The authors were concerned that countertransference implied a distant, impersonal, even sterile work style. They pictured caricatures of stereotypical Freudian psychoanalysts using academic and theoretical intellectualization to avoid being truly present, truly genuine, or truly human. We had to challenge the authors to look beyond the stereotype of the distant, tabula rasa analyst and understand that the “C” word is every bit as relevant to health-care professionals working with patients and families living with serious illness or the threat of death as it is to psychoanalytic psychotherapists. We had to make the case that countertransference is a concept that actually beckons helpers to look at their humanness in the face of serious illness, dying, death, and bereavement rather than avoiding it.

It is true that the concept of countertransference was initially described by Freud as an unconscious process involving the arousal of the analyst’s unresolved conflicts and problems (Freud, 1910). In Freud’s classical definition, countertransference was regarded as an obstacle to treatment, a blind spot that the analyst had to overcome to work effectively (Freud, 1912). Over the years, however, the definition of countertransference extended to include the totality of feelings experienced by the clinician toward the patient—whether conscious or unconscious or whether prompted by the client’s dynamics or by issues or events in the clinician’s own life (Beitman, 1983; Kernberg, 1965; Langs, 1983; Shubs, 2008). Countertransference is now regarded as a natural, appropriate, and inevitable emotional response (Gabbard, 1999; Maroda, 2004; Racker, 1968), and “a crucial source of information about the patient” (Gabbard, 1995, p. 475). Working with countertransference is regarded as a positive and important therapeutic tool, “an indispensable instrument” (Gill, 1994, p. 102) in our work. It is the basis for empathy, compassion, and a deeper understanding of both the patient’s and the clinician’s own processes (Beitman, 1983; Heimann, 1950; Little, 1951; Shubs, 2008; Wishnie, 2005).

Sandler, Dare, and Holder (1973), Dunkel and Hatfield (1986), and others have delineated the necessity of examining countertransference dynamics in interactions beyond strict psychoanalytic or psychotherapeutic treatment. We, too, believe that countertransference is part and parcel of all helping relationships, as we shall see in the writings that follow.

Countertransference in the Context of Palliative and End-of-Life Care

In palliative and end-of-life care, professionals of all disciplines and levels of experience are subject to powerful reactions to their work. These responses are far more diverse than simply “compassion fatigue” or “vicarious traumatization.” Some of these responses originate in the helper, some “belong” to the patient (but are knowingly or unknowingly incorporated by the empathic helping professional), and some belong to that ‘alchemy,’ that ‘space’ that takes its own place in the poignant relationship between helper and patient. The context of critical illness, death, and dying brings these responses into an altogether unique realm of thought and practice. Countertransference responses can be complex and often enormously subtle in their manifestations. They inevitably affect every interaction, every theoretical discussion, every diagnostic workup, and every treatment plan.

Whether we are psychologists in private offices struggling to sustain an empathic environment for those who suffer profound loss and deep trauma, whether we are physicians wrestling with those words that will dim the hope in our patient’s eyes, whether we are clergy or hospice social workers painstakingly striving to help patients make meaning at the end of life, whether we are administrators and teachers of clinical and residency programs working hard to prepare and support those in the trenches—all of us require an understanding of this subtle yet complex process that impacts our work every day.

For example, do you recognize any of the following scenarios?

The Midwest doctor who has sworn an oath to do everything possible to sustain life—how does he ‘help’ an elderly Chinese woman whose family culture does not permit her to ‘know’ of her imminent death and the lack of further curative treatments?

The conservative Catholic social worker whose father committed suicide when she was 12—how does she ‘help’ a family in its decision to stop all antibiotics and tube feedings for their 45-year-old father who is now brain dead?

The young psychiatrist who simply prescribes psychotropic medication for the elderly Jewish patient who can’t stop scrubbing his arms—how does he ‘help’ when he has missed the chart note explaining that this man survived the Holocaust by burying dead bodies in Auschwitz?

We believe that understanding countertransference processes is invaluable in all therapeutic relationships, and working with patients and families living with serious illness or facing the end of life is no exception. Thus, in the chapters that follow, we use the term countertransference as an “abbreviation” for the totality of our responses to our work—emotional, cognitive, and behavioral—whether prompted by our patients, by the dynamics incumbent to our helping relationships, or by our own inevitable life experiences.

The Dovetailing of the Personal and the Professional

Our real, often intense reactions to work in palliative and end-of-life care tell us that there is a personal-professional interface between our own life developmental tasks and our professional interactions (Genevay & Katz, 1990). Yet, how many of us take the time to reflect on the convergence of our personal lives and those of the patients and families with whom we work? How many of us have been trained to stop, breathe, and reflect on the dynamics that may be affecting us in this profoundly privileged work? Can we be sure that we are making the ‘right’ decisions on behalf of our patients if we have not examined the multiple facets that impact our thinking, feeling, and behavior in this very personal work?

Personal work? No, this is professional work, one might argue. In fact, in the pages that follow, we propose that our professional work with seriously ill, dying, and bereaved patients is extremely personal in nature, that we are profoundly influenced by our patients and their families as much as they are impacted and influenced by us, and that our emotional responses do impact the clinical moment—whether we want them to or not, whether we are aware or not, whether we can admit it or not.

And, therein lies the rub. With medical training that emphasizes physical symptom relief, treatment, and cure, health-care providers have borne the expectation and the responsibility of effecting therapeutic outcomes based on their evaluations of the patient, on the technical science, and on the “facts” as they know them. Yet, providers are often taken aback: the facts don’t add up. How can that be?

Attending to the whole of the patient-clinician experience may provide a vehicle for understanding this phenomenon. With the advent of quantum physics, the definition of an entity, of an experience, and even of a unit has changed. Scientific explorations of objectivity and subjectivity have revealed fascinating new discoveries about what has long been understood as the “gestalt”—the whole that is greater than the sum of its parts. These findings demand that we face the truth, that we, as ‘experts,’ cannot responsibly divorce ourselves from this whole—nor from the alchemical reaction that occurs when two individuals engage with each other at what is, perhaps, the most vulnerable time in a human being’s existence, living with serious illness and the threat of death. Patients, their subjective experience of their own illnesses, their families, and their worlds—everything, in fact—is irrevocably changed with our entry into the helping relationship. Taking responsibility to examine and explore how we influence the individual and the individual’s processes and outcomes, how the patient influences us, as well as taking stock of the ways in which these impact our professional actions, is long overdue in the literature on palliative and end-of-life care.

Thus, in this volume, we scrutinize ourselves in our part of the dyad. We examine what we bring to the therapeutic relationship and, conversely, the ways in which it impacts us. The authors have taken great risks in inviting us into their therapeutic realms. They disclose uncomfortable, even embarrassing, moments, actions, and outcomes of their work; they reveal interactions diagnoses, treatment recommendations, and the like, which upon their later reflection were not as objective and helpful as they would have liked to have believed. And, paradoxically, the authors reveal that some of these same ‘failures’ were, in fact, exactly what the patient needed!

In so admitting our professional foibles (influenced by our personal life histories, experiences, and cultural overlays), we hope to encourage other professionals working in palliative and end-of-life care to confront and examine their own denial, fear, helplessness, and anger related to death and loss as well as their need to control, cure, save, and ‘do good.’ In the pages that follow, we examine dynamics such as how practitioners both over-help and under-help patients and families; how personal feelings, cultural and religious biases, and prior life experiences can contribute to inappropriate diagnosis, referrals, and interventions; and why treatment is prolonged with some patients and terminated prematurely with others. We invite helping professionals to examine their inherent assumptions about a ‘good death,’ about resilience and hope when, in fact, the meanings attributed to these words become so relative and so differently understood by the patients, families, and communities with whom we work.

The Courage to Be Honest

It is our belief that if we have the courage to identify and confront the totality of our responses in palliative and end-of-life care, we can use them to inform and enrich our work. If we do not, we may find ourselves entangled in potentially damaging situations. It is our hope that examination of these complex personal and professional interactions will be requisite training for each and every person working with seriously ill, dying, or bereaved patients. And for those of us already deeply immersed in this work, we trust that this volume will serve as a guide to unraveling and understanding our own responses to this profou...

Table of contents

• Cover Page
• Half Title Page
• Other Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Contributors
• Series Editor's Foreword
• Foreword
• Preface
• Part I Introduction
• Part II Special Issues in Palliative and End-of-Life Care
• Part III Specific Populations and Settings
• Part IV Social, Legal, Ethical, and Organizational Influences
• Part V Implications for Practice
• Part VI Conclusion
• Part VII Epilogue
• Index