JOURNAL OF PALLIATIVE MEDICINE

Volume 18, Number 3, 2015

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2014.0248

Clinical Supervision in the Palliative Care Team Setting:

A Concrete Approach to Team Wellness

Kyle P. Edmonds, MD, Heidi N. Yeung, MD, Christopher Onderdonk, LCSW,

William Mitchell, MD, and Kathryn Thornberry, LCSW

Abstract
Clinical supervision is a structured, case-based approach to learning that is used most often in the mental health
field. An established palliative care consultation service at a large, academic medical center implemented a
modified clinical supervision model in an effort to improve team members’ awareness of their own emotions
and the way those emotions impact behavior during, primarily, clinical encounters. This report discusses
clinical supervision in detail and, by way of a case, illustrates the power of this intervention as a source of self-
care and a concrete approach to managing palliative care team well-being.

Introduction highlight here one component of this program and demon-

B urnout, compassion fatigue, vicarious trauma, sec-
ondary trauma, and empathy fatigue are all terms that
describe the cost of caring for a wide range of professionals
including first responders, child welfare practitioners, and
medical clinicians.1 This cost of caring can lead to an ex-
odus of gifted clinicians and damage to team functioning
as well as, ultimately, substandard client care. Palliative
care is particularly at risk for these outcomes as the need
to find deep compassion, patient after patient, in the midst
of sometimes overwhelming suffering can take a toll on
practitioners.2–8
Since the 1970s, much has been written about the cost of
caring and some of those concepts have more recently found
their way into the medical literature.1–8,10 The concepts of
‘‘compassion fatigue’’ and ‘‘burnout’’ are the most applica-
ble to palliative care due to their simplicity and relevance.
Compassion fatigue stems from interactions between patient
and clinician and manifests in life dissatisfaction, whereas
burnout stems from interactions between the work environ-
ment and the clinician; its manifestation is in work dissatis-
faction.1,9 Symptoms of both include exhaustion, isolation,
and feelings of being disconnected and overwhelmed.9 The
remedy for burnout is time away from work and/or changing
the work environment; the remedy for compassion fatigue is
‘‘treatment of self.’’ The first step to treating both, however,
is developing self-awareness.9
In an effort to find an antidote to these costs of caring, our
group is developing an overall team wellness program. We
strate its application by way of a case presentation.
Clinical Supervision Overview
Clinical supervision is an integral part of a mental health
practitioner’s training, but it is not familiar to most medical
professionals. It is an educational process, much like an ap-
prenticeship, whereby learning happens via a relationship
with a more practiced member of the field. As mentioned
above, self-awareness is the first step in ‘‘treatment of self’’
and is a ‘‘process of stepping back from daily, intense, hands-
on work to examine, review and explore different ways of
understanding the experiences we have had in order to
stimulate new solutions or approaches.which can be
achieved during [clinical] supervision.’’1
In standard clinical supervision, the learner and supervisor
meet, usually weekly, in a one-on-one or group setting to
examine all aspects of the learner’s life within the framework
of clinical cases. These meetings may include discussions
regarding assessment, diagnosis, treatment, and administra-
tive matters.1 This apprentice relationship lasts, on average,
two to three years and is a requirement to sit for licensing
exams for psychologists, marriage and family therapists, and
clinical social workers. In the psychodynamic model of su-
pervision, issues such as emotional responses, defense
mechanisms, transference, and countertransference are cen-
tral to the learning process and treatment of the patient (Table
1).12 Ultimately, the goal of clinical supervision is to remove
the veil between clinician and client such that the clinician

Doris A. Howell Palliative Care Consult Service, Department of Medicine, US San Diego Health Sciences, San Diego, California.
Accepted September 16, 2014.

274
CLINICAL SUPERVISION IN PALLIATIVE CARE 275

Table 1. Clarification of Terms

Alexithymia A personality characteristic whereby a person has difficulty understanding, processing,
expressing and/or regulating her or his emotional state.13–15
Defense mechanisms Unconscious processes, such as denial or intellectualization, which protect people
from unacceptable or painful ideas, feelings, or impulses.12
Transference The ‘‘set of expectations, beliefs, and emotional responses that a patient brings
to the doctor-patient relationship’’ that stem from ‘‘other important authority
figures’’ the patient has had in her or his life.12
Countertransference The clinician’s conscious and unconscious feelings toward her or his patient.12

perceives the client clearly and provides exquisite patient
care, all while protecting the clinician from the costs of
caring.
Implementing Clinical Supervision
Historically, team members on the Palliative Care Consult
Service for UC San Diego observed strong emotional reac-
tions to certain patient populations that impeded team
members’ perceived ability to provide excellent care. These
reactions were all signs of countertransference, including
ruminative emotional reactions, strong feelings of avoidance,
urges to become over-involved, or desires to be the one who
‘‘fixes’’ everything and saves the day. Although counter-
transference is a normal process, without awareness of it as a
driver of behavior, it can lead to unhelpful interventions,
maladaptive responses, and, potentially, to compassion fa-
tigue. Therefore, our group decided to implement a variation
of the mental health model of clinical supervision as a way of
exploring these interactions in a supportive milieu and
thereby increasing the team’s self-awareness.
To this end, we held a meeting with all members of the
palliative care team who were interested in participating in
such a group. The team’s senior clinical social worker pro-
vided a brief overview of clinical supervision and counter-
transference, and the group decided to trial weekly group
clinical supervision with an emphasis on exploring issues of
countertransference. An explicit conversation resulted in the
development of several group norms: 1) group discussions
would be confidential; 2) at least two participants needed to
be present; and 3) the senior team clinical social worker
would facilitate. In practice, participants rotate presenting a
clinical case that elicited a strong emotional response. The
facilitating clinical social worker: 1) keeps the presentation
rotation schedule; 2) ensures sessions are emotionally safe
and focused on the presenter and her or his goal; 3) limits
nonpresenters’ countertransference or agendas; and 4) re-
visits group goals and norms on a regular basis. Clinical
supervision meetings have been ongoing now for over a
year and include palliative care team members from every
discipline.
Our clinical supervision group has been successful, in part,
because it is participant-led and because the participants are
consistent. For this reason, we maintain a closed group and
do not include health care practitioners from outside of our
palliative care team. For each session, the presenter sets the
agenda for the group discussion and brings a case that eli-
cited a strong emotional response from her or him. The
group and facilitator ask open-ended questions to help the
presenter clarify what he or she wants to accomplish during
the session including explicitly asking the presenter whether
he or she wants general support, alternative interventions to
use with similar patients, or examination of her or his
countertransference.
Our team members have a wide-ranging experience with
introspection and self-awareness; for some, this is a very new
concept, whereas, for others, it’s in addition to a life of self-
reflection. This diversity is the primary way in which clinical
supervision in our setting differs from the classic mental
health model: Our group must not assume that every partic-
ipant cares to have the deepest emotional components of her
or his countertransference explored. Trust among the par-
ticipants has grown as the core group has continued to meet
over time and has resulted in a more frequent desire among
participants to delve deeper into their emotional responses.
Case Example
The following case is an example of one of our team’s
recent clinical supervision sessions attended by clinical so-
cial workers, pharmacists, and physicians. The presenter on
that day is a fellowship-trained palliative physician and a
recent addition to the team who brought us the case of Mr. J,
a gentleman who she consulted on in the inpatient setting.
Physician presenter
Mr. J was a 57-year-old male with metastatic gastric cancer
and recurrent bowel obstructions who was admitted with yet
another obstruction. We were consulted to help manage ab-
dominal and chronic back pain. He was unable to tolerate oral
medications and reported that they did nothing for his pain
anyway. Despite many different pain medication regimens, he
continued to report severe pain but only did so when asked. I
was frustrated because nothing we offered him helped with his
pain and his pain score always remained high. He did not
want to engage in goals-of-care discussions or exploration of
other aspects of his life that might contribute to his experience
of pain. He was receiving inpatient chemotherapy and wanted
to continue to do so into the future. That was frustrating to me
as well because I could see this was not going to end well for
him, which for me meant he was going to die in the hospital
getting all sorts of aggressive medical interventions that
would not change the outcome. To be honest, I didn’t know
what ‘‘ending well’’ would look like for him because he
wouldn’t tell me. I last saw him before I went off service at a
time when he was approaching discharge with a modestly
effective pain regimen and I was feeling unsatisfied. At that
time, I felt as if there was very little that I had done for this
patient; he had resisted all my efforts to address his total
pain and hadn’t responded well to traditional pain manage-
ment. I just couldn’t connect with this guy and it’s been
bothering me since.
276
Clinical social work perspective
At this point, one of the team’s clinical social workers
countered that we had, in fact, made an impact on this pa-
tient’s course, but it came later in his hospitalization.
Team clinical social worker:
I found Mr. J to be a pleasant and cooperative, but quiet, man
who I couldn’t connect with using my usual emotional inter-
ventions. However, when I switched to a more cognitive ap-
proach he was open to talking about concrete worries and
concerns, which often centered on his ongoing pain, insurance
coverage, and his family’s future well-being. He revealed that
he and his spouse were heavy drinkers and that she was using
alcohol to cope with his illness. With our team’s assistance,
Mr. J did express, in the presence of his spouse, the wish to
avoid ‘‘being a vegetable’’ who was hooked up to machines at
the end of his life. Mr. J subsequently developed a pulmonary
embolus, acutely decompensated and was transferred to the
ICU. There, because of the previous conversation with our
team in the presence of his wife, she made the decision not to
intubate. He died peacefully and comfortably in the ICU
surrounded by multiple family members who provided his
spouse with much needed support. From my perspective our
interventions with this patient and family were a success.
Facilitating clinical social worker:
I pointed out that a source of the physician’s frustration was
countertransference in that the doctor was unable to connect
with this patient because the patient himself was unable to
connect, physically or emotionally, with himself and that this
is not unusual for a patient suffering from alcoholism.
Group discussion
The physician presenter indicated that, on this day, her
goal was to explore alternative interventions to use with
similar patients. Therefore, the group spent the remaining
time in an exploration of the physician’s hopes, wishes, ex-
periences, and professional biases along with psychosocial
education regarding certain patient populations. The fol-
lowing concepts, issues, and ideas were discussed in depth
during this clinical supervision session.
Physicians train in an environment that engrains a strong
desire to ‘‘fix.’’ For fellowship-trained providers of palliative
medicine, much of fellowship focuses on denying the ‘‘fix-
ing’’ urge. In fact, many would say that undoing the urge to
fix by curing is one of the most important components of
training to practice in this field. At the same time, palliative
providers are highly trained for emotional situations and
saturated with tales of ‘‘the good death’’ or high-impact
emotional breakthroughs. So what can be done with an
emotion-less situation? What does communication look like
when open-ended questions are met with monosyllables and
blank stares? And although there is no urge to ‘‘fix’’ some-
one’s cancer, palliative care providers often have a strong
need to ‘‘fix’’ symptoms and vouchsafe a ‘‘good death.’’
Meanwhile, the wonderful and challenging reality of
practicing palliative care these days is that we find ourselves
increasingly up-stream with progressively larger teams and
more complex provider schedules. We rotate off-service or
sign-off or send the patient home before the breakthrough
might emerge. Much like what happened in this case: We
may plant a seed but not have the time to enjoy its growth.
EDMONDS ET AL.
At the same time, this patient was likely seen as ‘‘easy’’ by
the other teams involved in his care: he had few questions,
minimal needs, and expressed little emotion. For these same
reasons, the palliative team found him challenging and
worried that perhaps he was getting less information and less
truth-telling from other teams, simply because he wasn’t
asking for more information. Efforts at conversation on an
emotional-level were met with indifference.
Why might this patient have been reluctant to participate?
To begin, the palliative team may have been the next in a long
line of people talking with him about death—making his re-
ality that much more ‘‘real.’’ Further, he came from an alco-
holic family system, where he was likely steeped in shame and
secrets and where the only acceptable emotion was anger.15 As
a result, he was out of touch with his internal environment and,
therefore, unable to identify feelings or quantify pain.13,15
Emotional topics shut down his ability to participate in con-
versations simply because he couldn’t ‘‘go there.’’
As a result of his alexithymia (Table 1) and mechanisms of
coping, planting a seed of change ultimately happened for
this reluctant patient when we talked about his concrete ex-
periences rather than his emotion. Instead of asking him
about his feelings, the team found success by reflecting back
to him their perceptions for him to either validate or deny.
This reticent patient preferred to share information rather
than make decisions.
Conclusion
Palliative care teams are at high risk for compassion fatigue
and burnout.2,5 This can lead to loss of gifted clinicians, team
discord, and, potentially, substandard patient care. Combating
these costs of caring begins with self-awareness, ‘‘a stance that
permits the clinician to simultaneously attend to and monitor
the needs of the patient, the work environment and her/his own
subjective experience.’’4 The literature is mostly silent with
regard to concrete approaches by which teams can increase
self-awareness. At the same time, it’s not clear how best to
provide a structure to the recommendation that palliative care
clinicians participate in self-care exercises.
To this end, our team is developing a program for team
wellness within which clinical supervision is one component.
In our experience, expert-led clinical supervision has led to a
heightened awareness of our team’s emotions and biases.
Further, it results in better service to our patients and con-
sulting teams. Members of our team have found that clinical
supervision enriches their day-to-day. One person reflected
that, ‘‘I am more aware when a patient bothers me and able to
reflect on whether these are my issues instead of assuming
that it is always the patient,’’ and ‘‘it allows me to be more
present for the patient.’’ In this way, our team is investing in a
process with the dual goals of helping us provide exquisite
patient care while also retaining gifted palliative care prac-
titioners.
Although research exists to support increases in self-
awareness through mindfulness practices and reflective
writing,9 clinical supervision appears to be an additional vi-
able method of palliative care team self-care and is an area
ripe for research.
Author Disclosure Statement
No conflicting financial interests exist.
CLINICAL SUPERVISION IN PALLIATIVE CARE 277

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