American Psychological Association 5th Edition

7 downloads 33 Views 148KB Size Report
and suggesting directions for supervisors. The Need for Death Education. The literature makes it clear that issues involving death and bereavement provide.
In This Together Running head: IN THIS TOGETHER

We Are, All of Us, In This Together: Clinical Supervision in the Realm of Thanatos1 Michael Morad-McCoy The University of New Mexico

1

In this Together Page 2 We Are, All of Us, In This Together: Clinical Supervision in the Realm of Thanatos We psychotherapists simply cannot cluck with sympathy and exhort patients to struggle resolutely with their problems. We cannot say to them you and your problems. Instead, we must speak of us and our problems, because our life, our existence, will always be riveted to death, love to loss, freedom to fear, and growth to separation. We are, all of us, in this together. (I. D. Yalom, 1989) Introduction Nowhere is Yalom’s admonition more relevant and important than when considering how psychotherapists and their supervisors approach the reality of death. For, just as death will inevitably find each one of us, so too will death inevitably touch the practice of every therapist. Whether a therapist chooses to work with populations where death is common or not, inevitably a therapist will face death either through the loss of a client or through a client’s loss of a loved one. In the same way, because each therapist and each supervisor must one day face death, working with a client who is bereaved or dying will inevitably touch the therapist’s and the supervisor’s deep beliefs and fears about that encounter. This reality means it is crucial that supervisors prepare themselves and their therapists to work with these issues. However, such preparation is not a simple task. Few counseling programs—few academic programs of any kind— devote much attention to death education (Wass, 2004). An example of this can be found at this University. A search of the most recent UNM Course Catalog reveals only 12 courses containing the word “death” in the class description and a grand total of one course with the word “death” in its title. Of these, none can be found in either the Counseling or Psychology departments and only one is found in the Family Studies department. In the same way, the published literature provides little focused guidance for the supervisor. As a result, in this paper I borrow important ideas from the slightly more extensive

In this Together Page 3 literature on training counselors and health care workers to deal with clients who are bereaved or dying. I then look at specific supervisor-related information before summarizing the major ideas and suggesting directions for supervisors. The Need for Death Education The literature makes it clear that issues involving death and bereavement provide powerful emotional challenges to health care workers of all types. Counselors find situations involving death or loss more distressing than other counseling situations (Kirchberg & Neimeyer, 1991; Kirchberg, Neimeyer, & James, 1998). School counselors consider the subject their major area of discomfort (Carney & Cobia, 2003). Nursing students find caring for dying patients can be emotionally painful, distressing and personally threatening, and may feel anxiety brought on by their own fears of death (Deeny, Johnson, Boore, Leyden, & McCaughan, 2001). This discomfort is echoed by psychiatric residents (DiMaggio, 1993) and can extend so far as to tacitly prohibit discussion of death even in a dissection laboratory (William, 1992). Approaches to Death Education Because of the powerful emotions aroused by death and dying, and because of the lack of preparation in most counselor education programs, supervisors should know what approaches to death education have been found most useful. Death education programs, particularly in the U.S., are generally seen as didactic or experiential, depending on whether the program is purely lecture or involves students in reflecting on their personal beliefs, attitudes and experiences with death (DeSpelder et al., 2007; Durlak, 1978; Durlak & Riesenberg, 1991; Hutchison & Scherman, 1992; Wass, 2004). Most research finds the experiential approach is better at preparing health care workers (Deeny et al., 2001; Durlak, 1978; Hutchison & Scherman, 1992; Maglio & Robinson, 1994).

In this Together Page 4 However, the experiential approach is a broad one and can consist of any of a number of specific techniques or exercises. The most common technique appears to be personal reflection (often through journaling) and storytelling about the student’s beliefs, attitudes and fears about death (Attig, 1992; Clemens, 1976; DiMaggio, 1993; Haas-Thompson, Alston, & Holbert, 2008; Hutchison & Scherman, 1992; Wass, 2004). Reading first-hand narratives and watching films or dramas are also common (Attig, 1992; Deeny et al., 2001). More recently some programs have begun to incorporate a service learning component in their curricula (Basu & Heuser, 2003). I have personal experiences with one program that used a guided reflection to lead students through a terminal illness to death, and another program that used a game designed by bereaved children that encouraged reflection on various aspects of the loss of a loved one. Despite the specific technique, what is common is that each has the students share their personal reflections in small group settings and then process the emotions and cognitions brought forth by the experience. It appears that most, if not all, experiential programs are conducted by trained death educators who are prepared to help individuals process their reactions to the learning experience. Supervisory Issues Understanding Client Populations Therapists working with the bereaved and dying will find their clients enter this realm from various paths. The dying can take one path leading to a developmentally “normal” death or another leading to an early death. The bereaved can enter via the same routes: mourning the loss of one who has lived a long life or one who has died early. A different, typically more traumatic, journey awaits those who have been wrenched violently from their normal lives into the world of death through sudden and unexpected loss.

In this Together Page 5 Those dying a normal or an early death may present the therapist with questions about the meaning of life, sadness, regret over things not done or hurts not healed, depression, anger, and fear of death (Ringel, 2001). For those dying an early death these issues may be intensified by the loss of a “normal” life and the loss of “normal” life stages (Kiemle, 1994). Among those dying an early death are the ones who present the greatest challenge for all involved: the children. Unfortunately, the issues the child brings are usually clouded by the parents’ issues and little work has been done that provides any guidance on what the dying child is actually experiencing or the best ways to help the child (Morad-McCoy & Olguin, in press). Those bereaved by a normal or an early death present roughly the same issues as those who are dying. However, those who have lost a child face particularly difficult issues of grieving as such a loss is considered one of the most stressful events in the life of a parent and is often accompanied by a complete disruption in life patterns, the loss of hopes and dreams for the future, and even a slightly increased possibility of psychiatric hospitalization (American Psychiatric Association, 1994; Li, Laursen, Precht, Olsen, & Mortensen, 2005; Rubin et al., 2001). Those bereaved by a sudden, unexpected death, face additional issues including the possibility of long-lasting emotional damage, exaggerated responses to grief and a lack of understanding from others of how much time is needed for recovery (Brysiewicz, 2008; Rodger, Sherwood, O'Connor, & Leslie, 2006). Because the paths vary so widely, therapists and their supervisors need to understand how a particular client arrived in the realm of death and dying in order to understand the issues and emotions the client presents.

In this Together Page 6 Therapist Reactions Work with the bereaved and the dying is unique in that its emotional content is a universal of human experience. The bereaved or dying client who enters the consulting room is likely to raise strong emotions in the therapist based on the therapist’s own beliefs and fears about his or her own death, and the therapist unprepared to face those emotions may soon face difficulties (Kiemle, 1994; Ringel, 2001; Werth Jr. & Carney, 1996). Unfortunately, based on the lack of training provided most therapists (Wass, 2004), and the continued taboo and stigmatized nature of death and dying (Basu & Heuser, 2003; Kiemle, 1994; William, 1992), the therapist is, more often than not, likely to enter the room unprepared. The list of therapist emotions raised by working with issues of bereavement and death include: questions about the meaning of life, heightened fear of death, helplessness, powerlessness, inadequacy, survivor’s guilt, anger and rage, denial, grief, and sadness (Ringel, 2001; Werth Jr. & Carney, 1996). Therapists may find themselves walking a fine line between dealing with clients’ denial and allowing some sense of hope. They may become the focus of clients’ projections of anxiety that are so intense the therapists suffer depression and despair (Kiemle, 1994). Because of their fear of death, therapists may keep the client at an inappropriate emotional distance or be unable to maintain boundaries and allow inappropriate intimacy, closeness or sexual intimacy (Werth Jr. & Carney). Blurred boundaries may also trigger feelings of unresolved grief and loss (Kiemle). Supervision in the Realm of Thanatos Literature addressing specific approaches to supervision of therapists working with bereavement and death is meager and most comes from the specific area of working with HIV/AIDS clients. However, common to almost all sources is the observation that supervision

In this Together Page 7 must help therapists become aware of, process and normalize their deep emotional reactions, both conscious and unconscious, to death and dying (Jones, 2006; Kiemle, 1994; Knox, Burkard, Jackson, Schaack, & Hess, 2006; Lendrum & Syme, 1998). Ringel (2001) argues that existential issues such as the meaning of life, fear of death, and survivor’s guilt add complexity to the normal transference-countertransference dynamic of supervision and heighten the intensity of the relationship. This is partly because these issues, combined with the therapist’s feelings of inadequacy and helplessness when faced with the dying client, may lead the therapist to more strongly look to the supervisor as a figure of power and authority. The supervisor must take care in responding to this transference because the therapist will inevitably realize that no one, not even the idealized authority figure of transference, can “solve” the issues of death and dying and if this realization is not handled gently and with compassion, the therapist may react with anger to the supervisor and further isolate. In the same way the supervisor must be aware of how parallel process can be heightened. As a dying or bereaved client seeks a deep level of support from the therapist, so too might the therapist turn to the supervisor for a similar deep level of support and processing. Because of society’s attitude of denial in the face of death and illness and the tendency to use technical language to avoid the full reality of death, supervisors must work to ensure these issues are addressed with the supervisee. If the supervisor maintains the social denial of these issues, the result is likely to be that the supervisee feels additional isolation. It is also likely that inexperienced therapists will re-enact unresolved conflicts about grief, loss and abandonment in the supervisory relationship. According to Lendrum and Syme (1998) supervision of grief therapists works as: 1) restorative—where feelings created by working in the realm of death can be expressed,

In this Together Page 8 contained, and reflected upon; 2) formative—where therapists can study the implications of interventions used and processes involved; and 3) normative—by helping the therapist maintain appropriate boundaries and adhere to codes of ethics. Other writers speak of the usefulness of group supervision (Jones, 2006), the importance of sensitivity to cultural and spiritual concerns (Papadatou, 2006), and the importance of the supervisor’s ability to discuss religious beliefs (Aten & Hernandez, 2004; Stevenson, Balk, Wogrin, Thornton, & Meagher, 2007). Finally, Werth, Jr. and Carney (1996) argue the supervisor should help therapists: 1) continue to develop respect for individual differences, 2) understand their personal motivations for engaging in issues of death and dying; 3) maintain their sense of purpose and direction; 4) continue to practice ethically, and 5) craft a well-developed theoretical identity. When the Therapist Becomes the Bereaved Eventually, almost every therapist will enter the realm of death through the loss of a client. At such a time supervision becomes essential in providing the therapist with a place to grieve (Kiemle, 1994). This is particularly true in the potentially traumatic event of a client’s suicide. Unfortunately, training programs provide little information, guidance or supervision regarding client suicide. This means therapists, particularly those who do not regularly work with issues of death and dying, are likely to be unprepared for the emotional consequences. This makes it all the more important for supervisors to be prepared. Specifically, the supervisor should inform the therapist of the suicide at a time and a place that allows a chance to begin processing the information. In addition, the supervisor must provide continuing support to normalize the therapist’s emotional and clinical reactions (Knox et al., 2006).

In this Together Page 9 Recommendations As with clients, therapists (and supervisors) will enter the realm of bereavement and death through various paths. Some will consciously decide to take a path into this realm; most will enter the realm reluctantly and with trepidation as they are faced with the inevitability of client death or bereavement. No matter how therapists enter the realm, supervisors must, above all, be personally prepared to work with the powerful emotional issues raised. At the very least, supervisors should engage in some form of experiential death education to help them clarify their own thoughts and beliefs about death and dying. In the same way, supervisors should encourage therapists to engage experientially in some form of death education. If it is not possible for therapists to attend formal educational sessions, the supervisor should prepare exercises that can be carried out in supervision that help the therapist engage these issues. When supervisors work with therapists who regularly see clients who are bereaved or dying, they should be vigilant that the therapists receive supervision regularly. Supervisors should help therapists overcome the taboos and stigmas attached to talking about death and dying, ensure therapists are conscious of their own emotional reactions, encourage therapists to be aware of how the work touches their own feelings about death and dying, and explore whether the work raises issues of grief and loss that remain unresolved in their own lives. Supervisors who work with therapists who do not regularly see clients in this area should, nevertheless, encourage therapists to seek out some form of basic experiential death education. In these situations supervisors must also be highly aware that therapists who have been “surprised” by their entry into the realm of bereavement and death may be highly resistant to

In this Together Page 10 bringing into supervision the unexpected emotions the work raises. Supervisors must be ready to normalize therapists’ reactions to the work and help them begin exploring the emotions and the issues. Supervisors should also be thoroughly prepared to refer therapists to a qualified grief and loss therapist if the therapists need to process the issues and emotions in a way that extends beyond the scope of supervision. Unfortunately, this may not always be easy, especially in smaller communities. Therefore, the supervisor should explore possible referrals well before the actual need arises. Conclusion: Entering Consciously into Thanatos’ Realm Although this work has focused on deep and powerful issues and emotions that are often seen as “negative,” supervisors should be aware of the possibilities that attend the encounter with death. It is a fundamental tenet of existential psychotherapy that confronting death, particularly “my death” (I. D. Yalom, 1980, p. 159), can lead to powerful changes in how one leads one’s life, changes that have been seen in numerous studies (Attig, 1989; Block & Billings, 2005; Dobratz, 2002; Kinnier, Tribbensee, Rose, & Vaughan, 2001; Stratton, Kellaway, & Rottini, 2007; I. D. Yalom & Lieberman, 1991; Irvin D. Yalom & Vinogradov, 1988). Even when supervisors do not share this theoretical orientation, they should be aware of the possibilities for growth, be able to guide therapists accordingly and, in that way, provide motivation even for those therapists who would rather avoid Thanatos’ realm entirely. Those who consciously enter into the realm of death and dying do so for many reasons. No matter the reason, we have all discovered that the darkest journeys often have the most rewarding endings. So it is with our work with the dying and the bereaved, for in the work is the reward of helping give hope to the dying, hope and healing to the bereaved. Along with that

In this Together Page 11 reward comes another: the realization that, because we will—“all of us”—inevitably become the bereaved and the dying, in this work we help give hope and healing to ourselves. The physicality of death destroys us; the idea of death saves us. (Yalom, 1980)

In this Together Page 12 References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association. Aten, J. D., & Hernandez, B. C. (2004). Addressing religion in clinical supervision: A model. Psychotherapy: Theory, Research, Practice, Training, 41(2), 152-160. Attig, T. (1989). Coping with mortality: An essay on self-mourning. Death Studies, 13(4), 361370. Attig, T. (1992). Person-centered death education. Death Studies, 16(4), 357-370. Basu, S., & Heuser, L. (2003). Using service learning in death education. Death Studies, 27(10), 901-927. Block, S. D., & Billings, J. A. (2005). Learning from the Dying. New England Journal of Medicine, 353(13), 1313-1315. Brysiewicz, P. (2008). The lived experience of losing a loved one to a sudden death in KwaZuluNatal, South Africa. Journal of Clinical Nursing, 17(2), 224-231. Carney, J. S., & Cobia, D. C. (2003). The concerns of school counselors-in-training about working with children and adolescents with HIV disease: Training implications. Counselor Education & Supervision, 42, 302-313. Clemens, N. A. (1976). An intensive course for clergy on death, dying, and loss. Journal of Religion & Health, 15(4), 223-229. Deeny, P., Johnson, A., Boore, J., Leyden, C., & McCaughan, E. (2001). Drama as an experiential technique in learning how to cope with dying patients and their families. Teaching in Higher Education, 6(1), 99-112.

In this Together Page 13 DeSpelder, L. A., Strickland, A., Balk, D., Wogrin, C., Thornton, G., & Meagher, D. (2007). Culture, socialization, and death education. In Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement. (pp. 303-314). Northbrook, IL: Association for Death Education and Counseling. DiMaggio, J. R. (1993). Educating psychiatry residents about death and dying: A national survey. General Hospital Psychiatry, 15(3), 166-170. Dobratz, M. C. (2002). The self-transacting dying: Patterns of social-psychological adaptation in home hospice patients. Omega, 46(2), 151-167. Durlak, J. A. (1978). Comparison between experiential and didactic methods of death education. Omega: Journal of Death and Dying, 9(1), 57-66. Durlak, J. A., & Riesenberg, L. A. (1991). The impact of death education. Death Studies, 15(1), 39-58. Haas-Thompson, T., Alston, P. P., & Holbert, D. (2008). The impact of education and deathrelated experiences on rehabilitation counselor attitudes toward death and dying. Journal of Applied Rehabilitation Counseling, 39(1), 20-27. Hutchison, T. D., & Scherman, A. (1992). Didactic and experiential death and dying training: Impact upon death anxiety. Death Studies, 16(4), 317-330. Jones, A. (2006). Group-format clinical supervision for hospice nurses. European Journal of Cancer Care, 15(2), 155-162. Kiemle, G. (1994). 'What's so special about HIV and AIDS?': Stresses and strains for clients and counsellors. British Journal of Guidance & Counselling, 22(3), 343-351.

In this Together Page 14 Kinnier, R. T., Tribbensee, N. E., Rose, C. A., & Vaughan, S. M. (2001). In the final analysis: More wisdom from people who have faced death. Journal of Counseling and Development, 79, 171-177. Kirchberg, T. M., & Neimeyer, R. A. (1991). Reactions of beginning counselors to situations involving death and dying. Death Studies, 15(6), 603-610. Kirchberg, T. M., Neimeyer, R. A., & James, R. K. (1998). Beginning counselors' death concerns and empathic responses to client situations involving death and grief. Death Studies, 22, 99-120. Knox, S., Burkard, A. W., Jackson, J. A., Schaack, A. M., & Hess, S. A. (2006). Therapists-intraining who experience a client suicide: Implications for supervision. Professional Psychology: Research and Practice, 37(5), 547-557. Lendrum, S., & Syme, G. (1998). Supervision in bereavement counselling. In P. Clarkson (Ed.), Supervision: Psychoanalytic and Jungian perspectives (pp. 95-106). Philadelphia, PA: Whurr Publishers. Li, J., Laursen, T. M., Precht, D. H., Olsen, J., & Mortensen, P. B. (2005). Hospitalization for Mental Illness among Parents after the Death of a Child. New England Journal of Medicine, 352(12), 1190-1196. Maglio, C. J., & Robinson, S. E. (1994). The effects of death education on death anxiety: A meta-analysis. Omega: Journal of Death and Dying, 29(4), 319-335. Morad-McCoy, M., & Olguin, D. (in press). The child's encounter with death: Understanding death, grieving a death, facing death. New York State School Counseling Journal. Papadatou, D. (2006). Caregivers in death, dying, and bereavement situations. Death Studies, 30(7), 649-663.

In this Together Page 15 Ringel, S. (2001). In the shadow of death: Relational paradigms in clinical supervision. Clinical Social Work Journal, 29(2), 171-179. Rodger, M. L., Sherwood, P., O'Connor, M., & Leslie, G. (2006). Living beyond the unanticipated sudden death of a partner: A phenomenological study. Omega: Journal of Death and Dying, 54(2), 107-133. Rubin, S. S., Malkinson, R., Stroebe, M. S., Hansson, R. O., Stroebe, W., & Schut, H. (2001). Parental response to child loss across the life cycle: Clinical and research perspectives. In Handbook of bereavement research: Consequences, coping, and care. (pp. 219-240). Washington, DC US: American Psychological Association. Stevenson, R. G., Balk, D., Wogrin, C., Thornton, G., & Meagher, D. (2007). Religion, spirituality, and death education. In Handbook of thanatology: The essential body of knowledge for the study of death, dying, and bereavement. (pp. 315-327). Northbrook, IL: Association for Death Education and Counseling. Stratton, J. S., Kellaway, J. A., & Rottini, A. M. (2007). Retrospectives from three counseling psychology predoctoral interns: How navigating the challenges of graduate school in the face of death and debilitating illness influenced the development of clinical practice. Professional Psychology: Research and Practice, 38(6), 589-595. Wass, H. (2004). A perspective on the current state of death education. Death Studies, 28, 289308. Werth Jr., J. L., & Carney, J. S. (1996). Supervision of counselors-in-training working with clients with HIV. Counselor Education & Supervision, 36(1), 37. William, J. L. (1992). Don't discuss it: Reconciling illness, dying, and death in a medical school anatomy laboratory. Family Systems Medicine, 10(1), 65-78.

In this Together Page 16 Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books. Yalom, I. D. (1989). Love's executioner and other tales of psychotherapy. New York: HarperCollins Publishers. Yalom, I. D., & Lieberman, M. A. (1991). Bereavement and heightened existential awareness. Psychiatry, 54, 334-345. Yalom, I. D., & Vinogradov, S. (1988). Bereavement groups: Techniques and themes. International Journal of Group Psychotherapy, 38(4), 419-446.

In this Together Page 17 Footnotes 1

Thanatos was the Greek god of death from whom is drawn the word “thanatology” to

describe the study of death.