Keywords: Palliative care, Hospice, Burnout, Psychodynamic group psychotherapy.
Abstract: The aim of this article is to propose a psychodynamic model of group therapy to reduce the burnout risk in health professions working on palliative care in oncology hospices.
Applying the Bion’s model, a clinical intervention was proposed, in order to foster the group organization and to reduce the risk to compromise the team efficiency.
Quality of work life and burnout risk of the operators was measured and monitored using two scales: LBQ and CORE-OM.
Results: After two years from the beginning of the treatment, the assessment of the team members showed a reduced risk of burnout and a good level of satisfaction related to work life.
Introduction
This article is describing the clinical experience of psychological support carried out during four years to a multidisciplinary team, operating in a territorial oncology hospice in Lazio.
The latest (2010) guidelines of the Italian Ministry of Health are indicating the obligation to guarantee psychological support from a healthcare company to those who work in the field of palliative care and remain in daily contact with the topic of death and loss.
Hospice work implies, for the professionals involved, a constant comparison with the experience of the disease, suffering and anxieties connected to the mourning. This kind of comparison takes place with a significant human, existential, spiritual, personal and professional involvement of all health workers.
The resulting relational engagement with the patients is intense and charged with emotional content related to both the relationship with the patient and the dynamics of interaction among team members. This type of environment could be characterized by a number of risk factors that can lead practitioners to experience stress, anxiety and burnout risk.
Hospice and palliative care
Palliative care is a combination of physical and psychological care aimed to relieving suffering caused by the illness.
Palliative care affirms life and view death as a natural event, they neither hasten nor delay death, promotes relief from pain or other symptoms, integrates the psychological, social and spiritual elements of care, and ensures family support during illness and mourning.
Palliative care is aimed at improving the well-being and dignity of the person.
Pain therapy is the set of diagnostic and therapeutic interventions aimed at chronic disease forms, in which adequate pharmacological, surgical, instrumental, psychological and rehabilitative therapies are proposed for the suppression and control of the pain.
In 2010, Law No. 38 of March 15, 2010 was issued. It concerns the “Provisions to guarantee access to palliative care and pain therapy” (Gazzetta Ufficiale No. 65 of March 19, 2010). This is a law that guarantees access to palliative care and pain therapy by the patient, within the scope of the Essential Levels of Assistance – LEA.
Hospice palliative care is aimed at people with a chronic and evolving disease for which there are no therapies, or they are inadequate or ineffective for the purpose of stabilizing the disease and significantly prolonging life. They consist of an integrated system of medical, psychological, nursing and rehabilitation health care services. Furthermore, social, health and hospitality interventions and spiritual support are proposed for the benefit of the sick person.
Palliative home care, as part of the network of care for the terminally illness, consists of the same complex of health and social services.
We are talking about an intervention that provide continuity of cares that are planned and articulated over the seven days, guarantee medical availability over 24 hours, including need to provide support to the family and/or caregiver.
The description of how the continuity of care is organized in a territorial oncology hospice
let us clearly understand the level of physical and psychological commitment that health care professionals have to support on a daily basis.
Theoretical references
The theoretical reference model mainly used in this clinical intervention refers to the work carried out by Bion with therapeutic groups (1961).
According to Bion, a group is characterized by a mental life on its own. In the group mental life converges the contributions, impulses and desires and of all the members. These individual contents become uniform in a way of thinking that belongs to the group. Therefore, the group mindset does not correspond to the conscious and rational goals of the participants, but is characterized by unconscious needs which may conflict with the rational objectives of the group.
The conscious aspects of the group can be considered the foundation of the “working group,” that is, the rational organization of the group, aimed at achieving shared objectives, such as problem solving.
Bion writes: «Cooperation is voluntary and relies on a certain degree of intellectual ability of the individual. Participation in an activity of this type is possible only for people with years of experience and who have developed intellectually by their readiness to learn from experience».
«Organization and structure are tools of the working group. They are the product of cooperation among group members and, once established in the group, have the effect of demanding an even greater cooperative effort on the part of individuals» (Bion 1961).
The set of unconscious needs, impulses and tendencies that can manifest in the group, and be parallel to the work group, are called “basic assumptions”. These are behaviors that have the function of reducing the unpleasant sensations resulting from having to face reality. Dealing with reality through the work group is painful, basic assumptions create a sense of security through the satisfaction of primitive needs, reducing frustration. This would structure a group a mentality in which is imagined that problems are solved in a magical way.
Therefore, in a working team coexists the aspects of the working group, which is more efficient and rational and the basic assumptions, which is more regressive and irrational. As result the group may experience two mental states: one conscious and rational, the other unconscious and instinctual.
The basic assumptions are unconscious fantasies of the magic-omnipotent type, which, as we said, are oriented to keep the group away from experiencing the frustration associated with learning from experience, which is always a painful endeavor by itself.
There are three basic assumptions: mating, dependence and attack/escape.
Mating: this is characterized by the hope that a couple will succeed in ensuring the survival of the group. A salvific, messianic-type figure is imagined as the one who will solve all the group’s problems. A constant expectation emerges from the group: a Messiah will come to save everyone.
The messianic image does not have to be a real person, it could be an idea or a situation to hold on to that will protect them against the feelings of hate and destruction.
Dependence: the group binds itself to a leader who protects it, an external object with the function of providing security, nourishment and support to a fragile and immature organism.
Attack-escape: the group organizes itself as if it were to flee or attack someone or something, they gang up against an external entity, the salvation is sought in avoiding the problem. The leader of this group is the one who can best organize a plan of attack or defense toward this external entity.
The oscillation between the two mental states, the rational and the irrational, is called “group culture,” meaning the prevailing organizational structure of the group.
Bion writes: «The emotional states associated with the basic assumptions can be described by the current terms of anxiety, fear, hate, love and the like. But the emotional states common to each basic assumption are imperceptibly influenced by each other, as if they were in a particular combination for the active basic assumption. That is, in practice the anxiety that appears in the dependency group has a different quality from that which appears in the coupling group, and so on for the other feelings…» (Bion 1961).
In light of these theoretical observations, we can imagine how the suffering that characterizes work in a palliative care setting in oncology can generate defense from pain reactions in caregivers, and how the group can easily swing from a group culture that is more rational and oriented toward learning from experience to a culture that functions in a primitive way and avoids pain through the satisfaction of irrational needs.
Objectives
The proposed clinical intervention was structured to identify and contain all the psycho-emotional factors and the relationships that may be at the origin of stressful, anxiogenic, and depressive experiences within the team. At the same time, it was designed also to allow the team members to develop a set of skills and reinforce existing ones in order to be able to handle such stressful experiences independently.
Tools
On a yearly basis, team members were assessed with respect to burnout risk and well-being and quality of work life using two rating scales:
– Link Burnout Questionnaire (LBQ), an instrument for assessing the burnout in the care professions. It is a self-report questionnaire consisting on four scales each one defined by three items with positive polarity and three items with negative polarity. The four scales are: Psychophysical Exhaustion (PE), Deterioration of Relationship (DR), Professional Inefficiency (PI), Disillusion (DIS).
– Clinical Outcomes in Routine Evaluation – Outcome Mesure (CORE-OM), an instrument used to assess clinical treatment outcomes by examining changes in the “core domains of problems”. It is a self-report questionnaire consisting of 34 items answered by the subject on a 5-point scale. Four domains are assessed: Subjective Well-being, Symptoms/Problems, Life Functioning and Self-Healing Risk.
Group
Participants in the group were all professionals employed in various structures of the hospice, both at the residential level and at home-based interventions. The team consisted of 32 staff members, including physicians, psychologists, social workers, nurses, physical therapists, social health workers and administrative staff.
Method
The therapeutic group was designed as an open space that could be accessed by all members of the team. The duration of the clinical treatment was four years. Meetings with the group were organized on several levels of intervention in order to maintain a group setting that met on a weekly basis.
1. Clinical case discussion group. The “staff support case” was organized biweekly and was open to all members of the team. The purpose of this group was to discuss a clinical case handled by the team on the Hospice or in the home-care and to assess, through the description made by the staff members, whether emotionally based elements that made the work difficult or exposed them to stress factors were present (Balint, 1957).
2. Category subgroups. This was an intervention targeted at the subgroups that characterized the team. Specifically, the following subgroups were identified:
– Managers of the various clinical intervention areas (Primary Caregiver, Head Nurse and Psychologist);
– Physicians;
– Nurses;
– Social and health workers;
The group was held biweekly, so the commitment of each subgroup, in this area, was one meeting every two months. The goal was to discuss and explore any difficult and stressful emotional dynamics that might specifically affect a category of professionals working in the hospice.
3. Individual clinical interviews. Aimed to support and individual practitioner and to assess the burnout risk, they were based on free and thematic discussion. They were conducted on a rotating basis with all operators with a frequency of one month to one and a half months.
4. Psycho-educational seminars. Seminars were offered to discuss the topics of psycho-oncology and communication with the cancer patient and his family, they were focused on how to handle complex situations and give the information to patients and family members appropriately.
Therapeutic interventions
The main objective of the therapeutic work was to encourage insight into the recognition of how the group functioned, in order to highlight not-adaptive elements of a group culture based on basic assumptions
and encourage the demonstration of the group work. Therapeutic interventions in the group were organized on both a supportive and expressive side (Gabbard, 1990).
A number of techniques from psychodynamic psychotherapy have been useful in facilitating this process, following the list.
-Psychoeducational interventions: referred to the reading and knowledge of emotions in the context of the care relationship; providing, in addition, elements of psycho-oncology applied to hospice, end-of-life issue and palliative care.
-Advises and praise: this type of intervention, in the group setting, rarely come expressed by the therapist, but much more frequently the advice and praise were a mode of self-help that the caregivers used among themselves in difficult events and situations.
-Observation: this was the foundation of the therapeutic work, because the analysis of group members’ behaviors during the work, which was told in the group session, it was providing important elements that allowed understanding of the prevailing group dynamic.
-Empathic validation: this type of intervention was also often carried out not only by the therapist, but also by other group members, when an emotional dimension expressed by a member of the group towards the user, family or colleagues was defined and enhanced. This was also providing an important information about the level of functioning of the group
-Clarification: this was often the way to clarify and understand more adequately what was going on and how group dynamics were being defined.
-Encouragement to elaborate: group members were invited to focus on a particular associative flow in order to define together the meanings that characterized it.
-Confrontation: bringing the group to observe emotional issues that they usually avoided, such as conflicts between practitioners, unspoken words or elements of tension on a relational basis.
-Interpretation: sometimes this was the most effective form of intervention, aimed at revealing the unconscious dynamics that could be defined behind the behaviors of group members.
Results
Administration of the instruments after one and two years of psychotherapy treatment shows an overall improvement in self-perceived well-being and a reduction in work-related stress.
Table 1. – LBQ
-LBQ. Evaluation of the average scores of the scales shows at the first administration a critical issues related to two variables: Psychophysical Exhaustion (EP) and the Deterioration of Relationships (DR) scale. In the second and third administrations, at one and two years of treatment, it is possible to see a decrease of these values, an indicator of an increase of general well-being with respect to work activity.
Table 2 – CORE-OM
– CORE-OM. The assessment of the mean scores of the scales shows at first administration a level of life functioning, symptoms, subjective well-being, and self-healing risk that is not clinically relevant. It is possible, however, to observe through the “subjective well-being” scale how, at one and two years of treatment, subjects have a perception of an improvement in their quality of life in the work context.
Conclusions
The proposed clinical intervention aims to express the need to structure actions to support professionals working in the field of palliative care and specifically in territorial hospices.
This is a type of work that exposes professionals to the risk of a slow psychological deterioration that can result in manifestations of more or less severe psychopathological symptoms and the risk of developing a burnout syndrome.
The proposed clinical intervention can be thought of as a preventive medicine, oriented to avoid the development of these elements of suffering in the team.
The setting must necessarily be conceived as a multiple model, where at some moments the whole team is involved, and at others, depending on the criticality of the moment, the subgroups that are part of the team are involved. A space should also be designed to provide elements of psychoeducation about emotions and the topic of cancer illness.
Individual interviews provide a listening space for the individual caregiver to deepen their personal knowledge and relationship with the theme of illness, mourning and death, in order to construct their own personal story and come closer to understand the unconscious motivations behind the choice of that kind of work.
All these elements, if properly managed, reduce the risk of the group functioning with a primitive group culture, in which suffering is driven away through aggressive, mating and/or immature dependency acts. The functioning of the group on the basis of a culture of basic assumptions risks exposing the patient and family members to caregiving deficiencies given the increasing levels of stress.
The point of this therapeutic approach of psychological support to the staff is to best ensure the functioning of the team as a working group, oriented toward a rational goal, which in this case is the care of cancer patients.
The idea of proposing this approach today is because the challenges facing the National Health System are increasing, due to the spread of a whole range of clinical manifestations and pathologies that require a great commitment in terms of infrastructure, personnel, economic resources and, last but not least, emotional resources.
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