1. Offering Psychological and Pragmatic Tools to Improve Coping and Adaptation During Serious Illness: Clinician Perspective Madeline Gittleman, PsyD Attending Psychologist Department of Pain Medicine and Palliative Care Beth Israel Medical Center

2. Acknowledgment Thank you to Nomita Sonty, PhD Craig Blinderman, MD Columbia University Medical Center New York Presbyterian

3. 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.

4. 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.

5. 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).

6. 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).

7. 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.

8. 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 RationalizationMinimizationConcernCuriosityInsight 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

9. Addressing Our Emotions Name the feeling Accept the normalcy of the feeling Reflect on the emotion and its possible consequences Consult a trusted colleague Meier DE, Back AL, Morrison RS JAMA 2001:286(23)

10. Case Example Triggering Patient Traits Clinician Emotional Responses CognitionBehavior Extremely likableSadness 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/affluentWish to be with/be liked by the patient DenialBreaking of Boundaries Ex: Giving out cell phone numbers Similar to "us“Over-identification “She could be my mother” RationalizationOver-involvement Ex: Staying at work late/multiple visits

11. 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.

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