• Open Access

The essential elements of a therapeutic presence

Authors


Abstract

The model of therapeutic effectiveness developed by Chochinov et al can be applied to oncology clinicians. Implementation requires changes in organizational culture and realignment of incentives.

The science of caring for patients with cancer has evolved alongside advances in experimental and translational oncology. After all, the goal of delivering personalized cancer care assumes not only knowledge of molecular pathogenesis and disease mechanisms, but also a comprehensive understanding of the preferences, values, and goals of individual patients. The challenge facing oncologists today is to identify ways to uphold the human connection, as care is increasingly fragmented and delivered at multiple sites. Practice models continue to evolve, care is now delivered in teams, and patients and their family caregivers play a more active role than ever before. Health economists are tracking clinical outcomes, and a new vocabulary of efficiency has crept into our daily language. Given this changing landscape, it is important to bear in mind that therapeutic relationships are valuable, meaningful, and instrumental in helping patients and their caregivers live well in the face of a life-altering illness.

Efforts to provide humane and compassionate care are inspired by conviction and are driven in roughly equal parts by a shared sense of professional mission and by individual responses to the suffering of patients. We learn about suffering from witnessing stories that teach us about resilience, courage, and grace while confronting adversity. We learn from essays and autobiographies that stimulate reflection and deepen our understanding of the breadth of human experience. And we also learn from art and music, which provide a conduit to emotion and nurture our empathic abilities. The integration of these experiences enlightens us about the uniquely personal and subjective experience of suffering.

One theme common to narratives of illness and suffering is that patients want to be known and respected by their professional caregivers. Another is that relationships matter too and have a healing quality, even in the face of therapeutic failure. Research specifically designed to capture the patient experience of receiving bad news and living with a serious illness supports this contention: patient stories are concerned with relationships.1 Patients are comforted by feeling they are working with physicians and nurses from the time of diagnosis and appreciate an atmosphere that is supportive and a personal touch.1 Feeling the caring concern and engagement from their treating oncologists provides a source of hope and strength for patients during vulnerable times.2

Research designed to analyze the subjective experience of cancer patients has validated the importance of strong bonds between patients and professional caregivers. Qualitative studies support fostering relationships based on compassion and respect. There is no need to lament the lack of level 1 evidence simply because it is unethical to imagine a randomized trial designed to measure the therapeutic effect of compassion. Our collective efforts have focused instead on training clinicians to improve their communication skills, recognize distress, and provide referrals and support to patients along the disease continuum.

Professional societies have supported the call to improve quality of care by affirming the role of patients in decision making and enforcing competencies in communication and relational skills for clinicians. Although there are lists of competencies and skills, there is no compendium of essential elements that define a therapeutic presence and no single measurement instrument or checklist to rate performance. Modeling clinical skills continues to play a key role in training. There is a need to define more precise conceptual frameworks and to standardize training for clinicians working in different roles within multidisciplinary teams.

In this issue of Cancer, Chochinov and colleagues provide a model of therapeutic effectiveness derived from expert advice given by experienced mental health professionals.3 They invited 78 psychosocial oncology clinicians who were experienced in counseling patients with emotional distress. Participants were convened from 24 health care centers across Canada and attended 3 focus groups each. The sample was comprised of 50 social workers, 8 physicians, 6 psychologists, 5 nurses, 5 spiritual care providers, and 4 counselors who did not belong to the prior categories. In total, 29 groups were held over 2 years, during which clinicians articulated therapeutic factors deemed most helpful in mitigating psychological distress. The content was sorted into major themes and then subjected to qualitative analysis. Researchers defined 3 primary domains and 3 overlapping domains and devised a model of optimal therapeutic effectiveness they then tested in training workshops.

The 3 primary domains identified are personal growth and self-care, therapeutic approaches, and creation of a safe space. The 3 overlapping or hybrid domains are therapeutic humility, therapeutic pacing, and therapeutic presence. The first domain, personal growth and self-care, consists of 6 themes with a simple message: the mental well being of the clinician is a “precondition of being therapeutically effective.”3 The capacity for self-reflection was identified as indispensable. Maintaining emotional health was described as a continuous process requiring conscious effort, openness to learning, and personal growth. The participants valued opportunities to debrief with colleagues and improve their knowledge and skills. With respect to clinical performance, they identified 16 tasks that encompass a teachable skill set. Among these are knowing when to probe for feelings and when to focus instead on problem solving. The third domain, the creation of a safe space or refuge, deals with intention rather than location.

Secondary or hybrid domains recognized additional themes the researchers believed could be classified in more than 1 area. The first is therapeutic humility. This refers to practice and implies self-awareness. Humility is recognized as the capacity to tolerate ambiguity and recognize the patients' expertise. The second hybrid domain is therapeutic pacing. This provides recommendations for controlling the tempo to make patients feel safe and at ease. Here again, expert clinicians recommended gentleness; good judgment; and not rushing, remaining attentive to the patient's cues and adjusting immediately to enhance the therapeutic effect. Finally, they define 8 themes that relate to therapeutic presence. These are the classic attributes of an outstanding clinician: being compassionate and empathic, respectful and nonjudgmental, genuine and authentic, trustworthy, fully present, valuing the intrinsic worth of the patient, being mindful of boundaries and being emotionally resilient.

This model of therapeutic effectiveness, which was developed primarily for psychosocial oncology professionals, can serve to guide our expectations and standards of professional behavior for oncologists. It addresses the core values of patient-centeredness, takes into consideration the wisdom of experienced mental health professionals, and crystallizes the elements of a therapeutic identity and role. Perhaps the most formidable barrier to the implementation of such lofty standards is the culture of organizations. Time pressures and financial incentives conspire to distract physicians from mission-driven work. The capacity for self-reflection, described as essential for a therapeutic persona, is eroded by moral dilemmas, lack of balance between work and home lives, and the complete absence of peer observation and feedback. If our commitment to “quality care” is sincere, then we need to realign incentives and reconfigure the professional culture. Training in communication skills and setting high standards for practice are now within reach. It will take resolve, resourcefulness, and commitment to create a new culture designed specifically to honor the needs of patients and allow clinicians to thrive in their professional roles.

FUNDING SOURCES

No specific funding was disclosed.

CONFLICT OF INTEREST DISCLOSURES

The authors made no disclosures.

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