Thursday, May 31, 2018

Space for Wondering

I recently read a wonderful book: When Professionals Weep: Emotional and Countertransference Responses in Palliative and End-of-Life Care, Edited by Renee S. Katz and Therese A. Johnson.

In this book, I learned that those working in palliative and end-of-life care, being human, are subject to a range of emotional responses based on our own histories, social locations, and many other factors, and that when we are not aware of what in the relationship with a patient or family member is arising from our side, there is the potential to offer care that isn’t actually helpful or may even be harmful. In sum, we have to know what our stuff is so we don’t unconsciously visit it upon others, and we have to be familiar with how our own defenses typically manifest so we can spot them when they arise: e.g., feeling judgmental, becoming sleepy, avoiding certain patients, zoning out, keeping a conversation at a social level, feeling the urge to “be helpful” or deliver a quick fix.

I was interested to learn about parallel process: how the dynamics between a caregiver and her supervisor may mimic and thus afford valuable clues to the relationship between the patient and the caregiver. I learned that patients may pick up caregiver opinions without the caregiver realizing it. For instance, a patient who says she would like to utilize the End of Life Options Act to choose the time of her own death may have picked up her physician’s unstated feeling that her situation is hopeless. Conversely, it can also happen that a patient may indirectly cause a caregiver to feel what she is feeling. There is an anecdote in the book about a seemingly placid cancer patient who suddenly leaves a series of hateful, aggressive voice mails for one of her providers. The provider feels attacked and traumatized—and then realizes that her patient also feels attacked and traumatized as she faces the end of her life.

I learned that patients who want to choose the time of their own deaths may be trying to communicate fears about becoming more dependent on others and how they will respond or fail to respond. “When patients feel safe in the knowledge that it is the doctor’s role to gain an understanding of their distress … they may be more forthcoming with their deeply held fears and concerns.”

At the end of many chapters is a “Countertransference Tool Box” offering exercises and questions to help the reader become aware of and deal with potential pitfalls. Individual or group therapy may be helpful, and mindfulness and loving-kindness practices are explicitly recommended. “Being kind to oneself and feeling free to have fun and joy is not a frivolity in this field but a necessity without which one cannot fulfill one’s professional obligations or one’s professional contract.”

In her chapter, Bev Osband describes how a major loss—she lost a child in an accident—can trigger an uncomfortable sense of vulnerability, which we sometimes defend against by feeling guilty. “Guilt of this sort exacts a toll and at some point becomes paralyzing. Yet, relinquishing it means nothing feels safe.” After many years of grieving, she recognized the working of something she labeled “fate,” which delivers both bad and good experiences. (For me, this resonates deeply with Buddhist ideas of causes and conditions, impersonally unfolding, and of the Eight Worldly Winds.) “That is not to say that I no longer feel anguish at having lost my daughter. … What has become possible, though, is a sense of greater spaciousness for wondering, for reflecting, and for making meaning.”

Readers are encouraged to consider their own attitudes about death and end of life in order to become aware of unprocessed emotions as well as what they have learned about how to cope with bereavement. Accordingly, I considered my earliest experiences with death. When I was about four, a puppy that I had brought home perhaps only days earlier—I have almost no memories of him—escaped from our yard and was killed by a car.

His body was kept from my sight and, as I recall, there was no discussion of his death and no ritual. It didn’t seem sad—it seemed horrible, the dead body evidently a ghastly thing a child must not see, the whole thing somehow shameful. This may have arisen from the guilt my parents, who are as a rule highly responsible, likely felt about this innocent creature’s traumatic death. Writing about this allowed tears finally to come, 50 years later.

My next encounter with death was when my father’s mother died of cancer when I was five. I remember my father weeping—he was just 29 years old—an arresting sight I would not see again for at least a decade. This death seemed sad, due to my father’s tears, and also alarming, for the same reason, and even frightening, a feeling that arose from my not being permitted to attend the funeral. I don’t remember wanting to; I just remember understanding that a funeral was not a proper place for a child. I think I picked up the idea that one might see something horrendous, specifically a dead body. I know my grandmother either did not want to discuss her impending death or was not permitted to know how serious her condition was, or both, which I think must also have contributed to the air of shame and dread that surrounded this death, as I remember it.

Both of these experiences point to the importance of ritual, of openly discussing death, of making room for sorrow, and of finding ways to include and to accompany all who are bereaved.

Once we have become educated about the ways countertransference may manifest in our work, our most powerful tool is mindfulness, which allows noticing our emotions and reactions and provides the space in which we can consider, as Roshi says, what truly will serve. I typically practice this with patients by noticing my posture and whether there is a sense of ease and physical comfort or not. Via mindfulness, we can also remember to slow down, which allows for inspiration or intuition to arise. (Roshi: “A wise person slows the process down.”)
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