Incorporating Psychotherapeutic Concepts and Interventions Within Medicine

With the Heart in Mind

Shamit Kadosh, Asaf Rolef Ben-shahar

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781351376297
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This book provides doctors with insights into psychological and relational dynamics to better understand themselves and their patients, deepen their understanding of somatic and psychic dimensions of illness, and give them diagnostic and therapeutic tools to design better treatment procedures for patients.

In the first part of the book, the authors explore cognitive, emotional, and somatic strategies that are supportive of doctors' well-being. In the second part, they introduce theoretical knowledge and applicable skills from psychotherapy that can illuminate the complexity of the doctor-patient relationship, broaden doctors' approaches, and upgrade their communicative skills. The third part introduces some of the basic tenets of somatic psychotherapy that can deepen doctors' understanding of symptoms and illness, providing them with richer therapeutic tools and a deeper knowledge of bodily and psychological aspects, interweaving in a variety of medical conditions.

This text not only provides a helping hand to both doctors and psychotherapists in designing an amalgamated approach to clinical treatment but also provides doctors with better tools for understanding and managing the intricacies of the doctor-patient relationship.

Part I
The Doctor as a Human Being, Incorporating a Doctor-Centred Approach

1 The Price of Caring

It is the end of an arduous day in the clinic. I am an hour beyond schedule and still need to get over with paperwork before going home, when the nurse is telling me there is one more patient to see. I feel exhausted. I have been taking care of patients all day. I can still feel inside myself Jenifer’s anger at me for not helping her with her fibromyalgia pain; Dan’s anguished eyes after telling him that cancer is back; my helplessness with Barbara’s worsening heart failure and Michael’s unexplainable weight loss.

While being flooded by those feelings, I sense myself becoming numb and caring less. I find myself encountering the symptoms and signs instead of the human beings, getting easily angry and impatient while listening to my patients’ stories. I try to fight for threads of humanity that I know exist inside, but from time to time they slip away.

What has happened to me? Is this what I was dreaming of?

Being a doctor has awarded me with precious, touching, and fulfilling moments that fill me with gratification and gratitude. Special experiences of intimacy and human care, eureka moments when making the right diagnosis, and times when I feel being attentive and helpful interweave together and keep reminding me of what I appreciate in practicing medicine. Nonetheless, there are times when feelings of helplessness, frustration, and exhaustion take over, fading my expertise and making me care less.

I was a six-year-old child when my professional training as a doctor began. My father’s struggle with cancer made me an expert in attending to suffering and alleviating it. It was then when I decided to dedicate myself to medicine. I was inspired by doctors’ knowledge and humanity and admired them for saving my father’s life time and again. I made a commitment that expertise, humanity, and honesty will be my Northern Star as a doctor, and I promised myself never to forget.

And here I am at the end of the day with my painful familiar feelings of helplessness, anger, and numbness and the remnants of my shattered old dream.

1.1 The Shattered Dream

Practicing medicine confronts us with a wide breadth of duties and challenges. We are required to endure stressful workloads, manage critically ill patients, make influential decisions under pressure, and encounter human suffering. We are expected to do all that empathically and professionally. It is not surprising, therefore, that many doctors may suffer psychological stress and dissatisfaction (Gunasingam et al., 2015). While medical literature is abundant with studies regarding patients’ feelings and emotions during the medical encounter, physicians’ emotions and their emotional responses have received far less attention (Roter & Hall, 2006). We all want to be empathic, attentive, and lenient with our patients. While being unaware of our emotional responses or trying to supress them (Roter & Hall, 2006), constant exposure to human suffering, demanding patients, and intense levels of stressful work expose us to intensities of feelings and sensations and may predispose us to long-term damages (Hadad & Rolef Ben-Shahar, 2012).

The healthcare field is becoming increasingly aware of the profound impact exposure to human suffering and patients’ traumatic stories have on health care providers. Most of us enter the medical profession with strong ideals, beliefs, and faith in our ability to make a difference. As our beliefs become eroded, we might feel disappointed and hopeless (Benson & Margaith, 2005). Our professional lives have become but a faded version of what our dreams once used to be.

Medical training based on scientific objectivity, expertise, and perfectionism that is deficient in an empathic and non-judgemental attitude towards its students and residents, and does not encourage self-compassion and self-care as basic skills, could have significant implications on doctors’ coping styles. Facing human suffering and highly demanding duties in such a context might force doctors to survive rather than be fully present.

Is it too much to wish to thrive as doctors?

The following sections explore some research from adjacent fields of care, illustrating the price we pay for our profession of choice, and highlighting some possible directions for reducing the physician’s difficulties.

1.2 Vicarious Traumatisation

The concept of vicarious traumatisation (Mac Ian & Pearlman, 1990) describes professional counsellors’ complex traumatic reactions deriving from cumulative exposure to traumatic patients. By recognising that trauma may not only expose those directly impacted by it, but might also gravely impact those who come in contact with the trauma sufferer, vicarious traumatisation represents changes in the counsellors’ life following working with traumatic material. The reported psychological symptoms attributed to vicarious trauma may include depression, despair, cynicism, and other psychological and physical symptoms ( Pearlman & Saakvitne, 1995).

While broadly studied in mental health practitioners, vicarious traumatisation has received very limited attention in medical literature (Palm et al., 2004).

Because encountering human suffering, traumatic, and life-threatening events in people’s life is part and parcel of practicing medicine, we believe that vicarious traumatisation has significant implications on doctors and deserves appropriate attention. Studies report high prevalence of doctors feeling emotionally exhausted and stressed, showing diminished interest in their work and experiencing features of burnout (Gunasingam et al., 2015).

1.3 Empathy and Compassion Fatigue

Empathy and compassion have been shown to be an indispensable element in maintaining an effective therapeutic alliance with patients, in delivering high-quality care and increasing doctors’ well-being (Gleichgerrcht & Decety, 2014; Neumann et al., 2008).

Empathy is the basis for human connection. It informs us about the other’s need and enables us to translate our humanity and act compassionately (Hadad & Rolef Ben- Shahar, 2012). Physician’s empathy is defined as the ability of the physician to understand the patient’s situation, perspective, and feelings, communicate that understanding and check its accuracy, and act on that understanding with the patient in a helpful way (Mercer & Reynolds, 2002).

Unfortunately, studies illustrate that maintaining appropriate levels of clinical empathy is challenging and empathy declines even during medical school and residency (Neumann et al., 2011; Gleichgerrcht & Decety, 2014).

Why would such an important feature of human interaction be harmed by the practice of medicine?

In describing the phenomenon of empathy fatigue, Stebnicki (2008) believes that it results from a state of psychological, emotional, mental, physical, spiritual, and occupational exhaustion that occurs as the healthcare providers’ own wounds are incessantly revisited by their patients’ life stories of chronic illness, disability, trauma, grief, and loss. Empathy fatigue may be experienced as an obscure sense of loss, grief, or stress. It has both acute and cumulative emotional, physical, and systemic reactions that are unique to each individual, resulting in varying degrees of professional impairment and competency.

Compassion involves feelings of caring and kindness towards oneself and others in the face of personal suffering combined with the recognition to one’s suffering. We may consider compassion as consisting of three fundamental components. First, is the ability to extend kindness to oneself rather than criticise and judge. Second, is the capacity to see human experiences as part of larger humanity rather than as separating and isolating, that is to recognise that our suffering is not unique and singular. The third element refers to holding one’s painful thoughts and feelings in balanced awareness rather than overidentifying with them (Neff, 2003, p. 224; Birnie et al., 2010).

Epstein (2017) identifies three components of compassion: noticing another’s suffering, resonating with their suffering in some way, and then acting on behalf of another person. He delineates how compassion nourishes the practitioner by releasing endogenous opioids, dopamine and oxytocin which attenuate our own pain, promote a sense of reward, and generate feelings of caring, affiliation, and belonging. Epstein (ibid.) believes that while compassion fills doctors with a deep sense of purpose and well-being, it may also provoke distress and a natural human tendency of withdrawal as a means of self-protection. Sometimes feeling empathetic when there is so much suffering around us can simply prove too much to bear.

Compassion fatigue has been referred to as the emotional ‘cost of caring’ for others. It is understood as a stress response emerging suddenly as a consequence of working with people who have experienced stressful events. Possible symptoms include helplessness, confusion, isolation, exhaustion, and dysfunction (Figley, 1995; Rudolph et al., 1997).

Medical professionals are continuously exposed to overwhelming situations. Physicians require a facilitative safe-enough environment which could foster connection with empathy and compassion for their patients as well as for themselves.

Unfortunately, when insufficiently attended to, empathy and compassion fatigue may lead to burnout (Benson & Margaith, 2005; Solcum-Gori et al., 2011).

1.4 Burnout

Burnout could be understood as physical, emotional, and mental exhaustion caused by long-term involvement in emotionally demanding situations (Figley, 1995). Burnout is often expressed as a negative shift in the way professionals view people they serve and how they feel about themselves. It encompasses three dimensions: emotional exhaustion, depersonalisation, and reduced personal accomplishment (Gunasingam et al., 2015; Maslach, 2003). Characteristic symptoms include fatigue, exhaustion, inability to concentrate, depression, anxiety, and irritability. The hallmark of burnout is a loss of interest in one’s work or personal life (Gundersen, 2001).

Burnout is endemic in healthcare professionals with up to 60% of practicing physicians reporting relevant symptoms. It is associated with various physical problems, substance abuse, higher prevalence of doctor suicide, adverse impact on personal relationships, and lower quality of care (Gundersen, 2001; Irving & Dobkin, 2009; Krasner et al., 2009).

Various causes for burnout have been identified in the literature. Long working hours, poor work-life balance, diminished self-care, denial of emotions and own needs, increased administrative duties, and a perception of loss of control have all been associated with burnout (Gundersen, 2001; Gunasingam et al., 2015; Krasner et al., 2009). All these factors are commonplace in the life of a physician.

Avoiding the temptation to protect ourselves from loss and pain by denial or repression is a difficult practice, particularly since it is almost counterintuitive to allow pain to penetrate us. Remen (2000, 2006) portrays how protecting ourselves from loss by denial rather than grieving our losses is one of the major causes of burnout. She enlightens the significance of grief, self-care, and support in coping with feelings of detachment and burnout. Consider the following case material, the price it takes and the promises it holds:

The nurse opens the door, walking Sara into the room. Her thin, brittle, tenuous body and her pale skin almost hide her warm, vital eyes. She can hardly walk; her lymphoma cells keep spreading in her body despite chemotherapy. I miss her former visits a year ago, coming blissfully with her granddaughter asking me to read letters for her since she couldn’t read. It was way before her persisting cough, the mediastinal lymphoma, and chemotherapy.

Her blood count is deteriorating and she is slowly being defeated by cancer.

“You look tired, doctor”, she surprises me.

“Just a busy day”. I smile at her.

“How are you, Sara?” I ask.

“Well, you know . .. I’ve known better days. Fever again . .. you know, hospital, antibiotics and so on . .. the regular routine”.

I look at her brown, beautiful eyes; sadness is spreading throughout my body when I see her exuberant humanity, slowly giving way to signs of impending death.

“Chemo is not working, ha?” she says.

“I am so sorry”, I say and we are holding hands sharing agony together for a few inconsolable yet precious moments reviving my own humanity and compassion.

“Thank you doctor, for everything” she says on her way out, “and take care of yourself”.

The door is closed now; it’s late at the end of a busy day. I gather my things and go out. I am on my way home to meet my ow...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Introduction
• PART I The Doctor as a Human Being, Incorporating a Doctor-Centred Approach
• PART II The Doctor-Patient Relationship, Exercising Therapeutic Skills Without Being a Psychotherapist
• PART III With the Body in Mind: Incorporating Body-Mind Skills in Medical Treatment
• Index