Abstract
Abstract
Clinical supervision is a structured, case-based approach to learning that is used most often in the mental health field. An established palliative care consultation service at a large, academic medical center implemented a modified clinical supervision model in an effort to improve team members' awareness of their own emotions and the way those emotions impact behavior during, primarily, clinical encounters. This report discusses clinical supervision in detail and, by way of a case, illustrates the power of this intervention as a source of self-care and a concrete approach to managing palliative care team well-being.
Introduction
B
Since the 1970s, much has been written about the cost of caring and some of those concepts have more recently found their way into the medical literature.1–8,10 The concepts of “compassion fatigue” and “burnout” are the most applicable to palliative care due to their simplicity and relevance. Compassion fatigue stems from interactions between patient and clinician and manifests in life dissatisfaction, whereas burnout stems from interactions between the work environment and the clinician; its manifestation is in work dissatisfaction.1,9 Symptoms of both include exhaustion, isolation, and feelings of being disconnected and overwhelmed. 9 The remedy for burnout is time away from work and/or changing the work environment; the remedy for compassion fatigue is “treatment of self.” The first step to treating both, however, is developing self-awareness. 9
In an effort to find an antidote to these costs of caring, our group is developing an overall team wellness program. We highlight here one component of this program and demonstrate its application by way of a case presentation.
Clinical Supervision Overview
Clinical supervision is an integral part of a mental health practitioner's training, but it is not familiar to most medical professionals. It is an educational process, much like an apprenticeship, whereby learning happens via a relationship with a more practiced member of the field. As mentioned above, self-awareness is the first step in “treatment of self” and is a “process of stepping back from daily, intense, hands-on work to examine, review and explore different ways of understanding the experiences we have had in order to stimulate new solutions or approaches…which can be achieved during [clinical] supervision.” 1
In standard clinical supervision, the learner and supervisor meet, usually weekly, in a one-on-one or group setting to examine all aspects of the learner's life within the framework of clinical cases. These meetings may include discussions regarding assessment, diagnosis, treatment, and administrative matters. 1 This apprentice relationship lasts, on average, two to three years and is a requirement to sit for licensing exams for psychologists, marriage and family therapists, and clinical social workers. In the psychodynamic model of supervision, issues such as emotional responses, defense mechanisms, transference, and countertransference are central to the learning process and treatment of the patient (Table 1). 12 Ultimately, the goal of clinical supervision is to remove the veil between clinician and client such that the clinician perceives the client clearly and provides exquisite patient care, all while protecting the clinician from the costs of caring.
Implementing Clinical Supervision
Historically, team members on the Palliative Care Consult Service for UC San Diego observed strong emotional reactions to certain patient populations that impeded team members' perceived ability to provide excellent care. These reactions were all signs of countertransference, including ruminative emotional reactions, strong feelings of avoidance, urges to become over-involved, or desires to be the one who “fixes” everything and saves the day. Although countertransference is a normal process, without awareness of it as a driver of behavior, it can lead to unhelpful interventions, maladaptive responses, and, potentially, to compassion fatigue. Therefore, our group decided to implement a variation of the mental health model of clinical supervision as a way of exploring these interactions in a supportive milieu and thereby increasing the team's self-awareness.
To this end, we held a meeting with all members of the palliative care team who were interested in participating in such a group. The team's senior clinical social worker provided a brief overview of clinical supervision and countertransference, and the group decided to trial weekly group clinical supervision with an emphasis on exploring issues of countertransference. An explicit conversation resulted in the development of several group norms: 1) group discussions would be confidential; 2) at least two participants needed to be present; and 3) the senior team clinical social worker would facilitate. In practice, participants rotate presenting a clinical case that elicited a strong emotional response. The facilitating clinical social worker: 1) keeps the presentation rotation schedule; 2) ensures sessions are emotionally safe and focused on the presenter and her or his goal; 3) limits nonpresenters' countertransference or agendas; and 4) re-visits group goals and norms on a regular basis. Clinical supervision meetings have been ongoing now for over a year and include palliative care team members from every discipline.
Our clinical supervision group has been successful, in part, because it is participant-led and because the participants are consistent. For this reason, we maintain a closed group and do not include health care practitioners from outside of our palliative care team. For each session, the presenter sets the agenda for the group discussion and brings a case that elicited a strong emotional response from her or him. The group and facilitator ask open-ended questions to help the presenter clarify what he or she wants to accomplish during the session including explicitly asking the presenter whether he or she wants general support, alternative interventions to use with similar patients, or examination of her or his countertransference.
Our team members have a wide-ranging experience with introspection and self-awareness; for some, this is a very new concept, whereas, for others, it's in addition to a life of self-reflection. This diversity is the primary way in which clinical supervision in our setting differs from the classic mental health model: Our group must not assume that every participant cares to have the deepest emotional components of her or his countertransference explored. Trust among the participants has grown as the core group has continued to meet over time and has resulted in a more frequent desire among participants to delve deeper into their emotional responses.
Case Example
The following case is an example of one of our team's recent clinical supervision sessions attended by clinical social workers, pharmacists, and physicians. The presenter on that day is a fellowship-trained palliative physician and a recent addition to the team who brought us the case of Mr. J, a gentleman who she consulted on in the inpatient setting.
Physician presenter
Mr. J was a 57-year-old male with metastatic gastric cancer and recurrent bowel obstructions who was admitted with yet another obstruction. We were consulted to help manage abdominal and chronic back pain. He was unable to tolerate oral medications and reported that they did nothing for his pain anyway. Despite many different pain medication regimens, he continued to report severe pain but only did so when asked. I was frustrated because nothing we offered him helped with his pain and his pain score always remained high. He did not want to engage in goals-of-care discussions or exploration of other aspects of his life that might contribute to his experience of pain. He was receiving inpatient chemotherapy and wanted to continue to do so into the future. That was frustrating to me as well because I could see this was not going to end well for him, which for me meant he was going to die in the hospital getting all sorts of aggressive medical interventions that would not change the outcome. To be honest, I didn't know what “ending well” would look like for him because he wouldn't tell me. I last saw him before I went off service at a time when he was approaching discharge with a modestly effective pain regimen and I was feeling unsatisfied. At that time, I felt as if there was very little that I had done for this patient; he had resisted all my efforts to address his total pain and hadn't responded well to traditional pain management. I just couldn't connect with this guy and it's been bothering me since.
Clinical social work perspective
At this point, one of the team's clinical social workers countered that we had, in fact, made an impact on this patient's course, but it came later in his hospitalization.
Team clinical social worker:
I found Mr. J to be a pleasant and cooperative, but quiet, man who I couldn't connect with using my usual emotional interventions. However, when I switched to a more cognitive approach he was open to talking about concrete worries and concerns, which often centered on his ongoing pain, insurance coverage, and his family's future well-being. He revealed that he and his spouse were heavy drinkers and that she was using alcohol to cope with his illness. With our team's assistance, Mr. J did express, in the presence of his spouse, the wish to avoid “being a vegetable” who was hooked up to machines at the end of his life. Mr. J subsequently developed a pulmonary embolus, acutely decompensated and was transferred to the ICU. There, because of the previous conversation with our team in the presence of his wife, she made the decision not to intubate. He died peacefully and comfortably in the ICU surrounded by multiple family members who provided his spouse with much needed support. From my perspective our interventions with this patient and family were a success.
Facilitating clinical social worker:
I pointed out that a source of the physician's frustration was countertransference in that the doctor was unable to connect with this patient because the patient himself was unable to connect, physically or emotionally, with himself and that this is not unusual for a patient suffering from alcoholism.
Group discussion
The physician presenter indicated that, on this day, her goal was to explore alternative interventions to use with similar patients. Therefore, the group spent the remaining time in an exploration of the physician's hopes, wishes, experiences, and professional biases along with psychosocial education regarding certain patient populations. The following concepts, issues, and ideas were discussed in depth during this clinical supervision session.
Physicians train in an environment that engrains a strong desire to “fix.” For fellowship-trained providers of palliative medicine, much of fellowship focuses on denying the “fixing” urge. In fact, many would say that undoing the urge to fix by curing is one of the most important components of training to practice in this field. At the same time, palliative providers are highly trained for emotional situations and saturated with tales of “the good death” or high-impact emotional breakthroughs. So what can be done with an emotion-less situation? What does communication look like when open-ended questions are met with monosyllables and blank stares? And although there is no urge to “fix” someone's cancer, palliative care providers often have a strong need to “fix” symptoms and vouchsafe a “good death.”
Meanwhile, the wonderful and challenging reality of practicing palliative care these days is that we find ourselves increasingly up-stream with progressively larger teams and more complex provider schedules. We rotate off-service or sign-off or send the patient home before the breakthrough might emerge. Much like what happened in this case: We may plant a seed but not have the time to enjoy its growth.
At the same time, this patient was likely seen as “easy” by the other teams involved in his care: he had few questions, minimal needs, and expressed little emotion. For these same reasons, the palliative team found him challenging and worried that perhaps he was getting less information and less truth-telling from other teams, simply because he wasn't asking for more information. Efforts at conversation on an emotional-level were met with indifference.
Why might this patient have been reluctant to participate? To begin, the palliative team may have been the next in a long line of people talking with him about death—making his reality that much more “real.” Further, he came from an alcoholic family system, where he was likely steeped in shame and secrets and where the only acceptable emotion was anger. 15 As a result, he was out of touch with his internal environment and, therefore, unable to identify feelings or quantify pain.13,15 Emotional topics shut down his ability to participate in conversations simply because he couldn't “go there.”
As a result of his alexithymia (Table 1) and mechanisms of coping, planting a seed of change ultimately happened for this reluctant patient when we talked about his concrete experiences rather than his emotion. Instead of asking him about his feelings, the team found success by reflecting back to him their perceptions for him to either validate or deny. This reticent patient preferred to share information rather than make decisions.
Conclusion
Palliative care teams are at high risk for compassion fatigue and burnout.2,5 This can lead to loss of gifted clinicians, team discord, and, potentially, substandard patient care. Combating these costs of caring begins with self-awareness, “a stance that permits the clinician to simultaneously attend to and monitor the needs of the patient, the work environment and her/his own subjective experience.” 4 The literature is mostly silent with regard to concrete approaches by which teams can increase self-awareness. At the same time, it's not clear how best to provide a structure to the recommendation that palliative care clinicians participate in self-care exercises.
To this end, our team is developing a program for team wellness within which clinical supervision is one component. In our experience, expert-led clinical supervision has led to a heightened awareness of our team's emotions and biases. Further, it results in better service to our patients and consulting teams. Members of our team have found that clinical supervision enriches their day-to-day. One person reflected that, “I am more aware when a patient bothers me and able to reflect on whether these are my issues instead of assuming that it is always the patient,” and “it allows me to be more present for the patient.” In this way, our team is investing in a process with the dual goals of helping us provide exquisite patient care while also retaining gifted palliative care practitioners.
Although research exists to support increases in self-awareness through mindfulness practices and reflective writing, 9 clinical supervision appears to be an additional viable method of palliative care team self-care and is an area ripe for research.
Footnotes
Author Disclosure Statement
No conflicting financial interests exist.