Countertransference and Transference

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Journal of Social Work in End-of-Life & Palliative Care

ISSN: 1552-4256 (Print) 1552-4264 (Online) Journal homepage: https://www.tandfonline.com/loi/wswe20

Counter Transference in the Face of Compassionate Care

Kimberly E. Giamportone

To cite this article: Kimberly E. Giamportone (2015) Counter Transference in the Face of Compassionate Care, Journal of Social Work in End-of-Life & Palliative Care, 11:3-4, 220-223, DOI: 10.1080/15524256.2015.1107804

To link to this article: https://doi.org/10.1080/15524256.2015.1107804

Published online: 14 Dec 2015.

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Counter Transference in the Face of Compassionate Care

KIMBERLY E. GIAMPORTONE St. Luke’s University Health Network, Palliative Care, Bethlehem, Pennsylvania, USA

As the social worker on the palliative team, maintaining professional boundaries goes beyond being mindful of ethical practice; it is an essential component to psychological well-being. Being cognizant of countertransfer- ence potential and assisting staff who are not trained in the strengths model of care is part of my everyday role. However, even those of us mindful of boundaries and limitations can be tested and challenged.

I first met C.A. on a cold winter afternoon. He was alone in his hospital room on the adult oncology floor of the hospital. The room was dark and his head was hidden under the covers. C.A. was 17 years old; his birthday was one day away when he would officially become an adult. His emotional age was closer to that of a 12 year old. The mother of two teenage boys, I recognized the potential trigger and tried not to imagine my own children in his place. I took a moment to recall the social work boundary lectures I had ever delivered or received before proceeding with the introductions.

There was little in the medical chart regarding his background and family contacts; the information listed was incomplete or needed correcting. C.A.’s mother was documented as the primary contact; unfortunately, she had died 2 years prior from breast cancer. The case management team shared that the patient’s biological father had attempted to visit on admission but was intoxicated and escorted out. No other visitors were noted. C.A. was a scared boy, diagnosed with Acute Myelogenous Leukemia (AML), currently in a blast crisis, with no one to advocate or comfort him. My motherly self wanted to scoop him up and protect him; my professional self of course said, ‘‘This is not your child; this is his journey.’’ I took solace in the fact that I was well within my purview as the palliative care social worker to advocate for his needs and well-being.

The next day, C.A.’s room had a few birthday balloons and stuffed bears from the nursing staff. He was quick to state that he asked his family not to

Address correspondence to Kimberly E. Giamportone, MSW, LSW, St. Luke’s University Health Network, Palliative Care, 801 Ostrum Street, Bethlehem, PA 18015, USA. E-mail: [email protected]

Journal of Social Work in End-of-Life & Palliative Care, 11:220–223, 2015

Copyright # Taylor & Francis Group, LLC

ISSN: 1552-4256 print=1552-4264 online

DOI: 10.1080/15524256.2015.1107804

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come because he was concerned about germs. C.A. explained that he has lived with his aunt, a family friend, since his mother’s death. He had two half-siblings, an older deceased brother, and a younger brother, aged 5, living with his grandmother. He had school friends that he would text, but they did not have transportation to visit. As he explained his history to me, C.A. took pride in his racial mixture; his mother was African American, his father was Hispanic, and his maternal grandmother was Caucasian. Unfortunately, finding a bone marrow match with these unique genetic features would prove to be unachievable.

I knew the palliative care physicians would address the physical symptoms; his pain was real as was his lack of ability to regulate his anxiety and fear. I was privileged that C.A. learned to trust me as an advocate.

Pt was listening to music on his headphones, but did agree to sit and talk with MSW. Pt expressed frustration that nobody listens to him. He feels that staff ‘‘talk at him’’ and not ‘‘with him.’’ Pt noted that he is made to feel like a child; states he does not want to share concerns or ask ques- tions of the physicians because they just ignore his concerns anyway. Pt was asked if he would share his concerns with MSW and he agreed . . . . Pt asked MSW several times if she really intended to help him. MSW agreed to help pt find answers to his medical questions. MSW returned with the palliative care physician having arranged for a conversation together. Pt shared that he felt palliative care attending understood his concerns and thanked the team for listening to him. (MSW personal notes)

Complicating the management of his physical needs, was the issue of behavioral outbursts. Although he exhibited age appropriate behaviors, staff quickly became irritated and wanted him to act like the patients who were older. Nurses were frustrated that C.A. would manipulate the I.V. machine regulating the flow of fluids, especially when he was lonely. He discovered which alarms needed to sound in order to make the nurses run into his room. I thought this was quite clever; the nursing staff was not amused. Eventually, the floor manager provided C.A. with a VCR, not standard in most rooms, so that he could watch movies in an effort to self-pacify.

One week later, I was notified that C.A. had been placed on a 1-to-1 watch due to a suicide attempt. My heart sank as I rushed to his room. C.A. looked at me sheepishly and explained that the event was being ‘‘blown out of proportion.’’ C.A. discovered that if he pushes on his carotid artery long enough, it makes him ‘‘pass out.’’ He used this technique in the past when trying to fall asleep during difficult times. We were able to talk about the emotions behind his behaviors, and I was struck at the raw vulnerability this child was sharing with me. C.A. asked me to stay with him for the day. I explained the difficulty of C.A.’s request as I needed to visit other patients. It was a simple request that I could not grant; I felt like a horrible ogre saying

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no to him. I was cognizant of the countertransference and kept pushing away the image of my own sons, wondering how I would act if they were in his place. I was angry and judgmental toward his family for not being there to comfort him through this scary life event.

My attempts to advocate with the primary team for C.A. to be transferred to a children’s hospital more capable of meeting his physical and emotional needs was met with physician ego, judgment, and dismissive remarks. I was infuriated and keenly aware of my limitations within the scope of my role. C.A. again shared some of his concerns with me.

Pt was concerned that MSW might be a therapist. Pt said he does not like therapists because they label people . . . . MSW reassured pt that her role was to assist pt with communicating his needs and to help advocate for those needs. Pt expressed that he was scared about the discharge plan- ning and fears that he will be alone to deal with his illness if he has another event related to the AML. Pt is fearful of teasing and status among his school friends if his hair falls out from the chemo treatments. He is concerned that the nurses avoid him because he is difficult to deal with sometimes. MSW provided emotional counseling around behavioral issues. Pt stated he will try to behave so the nurses will visit more fre- quently. (MSW personal notes)

One month after his admission date, C.A. was deemed medically stable for discharge. Emotionally, however, he had become used to the support of the team. C.A. reverted to tantrum behaviors (i.e., throwing books and VHS tapes, yelling at the staff), and eventually curled into a ball sobbing under the covers. His aunt was no longer willing to house him based on her belief that once he became 18 she would no longer receive monetary compensation for him. C.A. talked to me about the physical and sexual abuse he suffered under his father’s care and returning to that home was not an option; his grand- mother had enough on her plate caring for his younger sibling and could not take him in either. C.A. screamed,

What is the point of undergoing all this treatment, if I don’t have anyone to care for me when I leave? It’s a death sentence, and I may as well jump off the bridge when you people kick me out of the hospital.

He was right; tears filled my eyes as we sat together in contemplating next steps. The hospital administration was tired of dealing with his behaviors. His oncology team, still refusing to transfer him to a children’s hospital, stated he needed to learn how to cope on his own. We discussed available options with the assistance of the case management social worker on the floor. Without a home, the hospital would have to connect him with a shelter for the night. We decided to reach out to his aunt one more time. His aunt

222 K. E. Giamportone

was willing to take C.A. back into her home, and added that she was just trying to scare him into behaving.

C.A. left the hospital that day, but returned four additional times during the year. Eventually, he was admitted to a university hospital in the city due to an eye infection and for assessment of bone marrow transplant candidacy. C.A. spent 3 months there; his only comment about the experience was that he was glad to be out.

Nearly one year to the date of our first meeting, C.A. was back in our hospital. Here he was at 18, dying afraid and alone. He asked me to gently rub his back, as my children often do, while he fell asleep. I had felt like a complete failure.

The next morning I learned that he was moved to the MICU; he was intubated and restrained. As I neared his room, I was greeted by cousins, his step-mother, and two clergy members from his church. I wanted to scream, ‘‘Where have you been?! What gives you the right to show up, NOW, and direct who is allowed to be in the room holding this child’s hand?’’ It hurt to be reminded by their presence that I was not the one to companion him any further on this journey. He was not my child to comfort; his family had assumed their rightful place, albeit late, as C.A. has always wanted.

In the end, I was never able to facilitate the care that I would have wanted for him. However, C.A. did finally get his wish — his family, friends, and clergy surrounding his bedside with expressions of love for him as he took his final breath.

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