We studied family systems theory in our Clinical Pastoral Education program. According to Bowen’s
theory triangulation is one of the most common ways that dysfunction begins in
a family system. A full description of
that theory can be found on the Bowen
Center website. Palliative care doctors,
nurses, social workers and chaplains are all trained to look for signs of this
triangulation in order to avoid getting pulled into the triangle in a
manipulative way that obstructs care. Yet,
occasionally this does still happen. When
it does chaplains can be called in to debrief staff with one of the psychologists. Patients suffering from a terminal illness like
end stage cancer already weigh heavily on the emotions of staff, particularly if
they have been on the unit for such a significant amount of time they begin to
feel like family. Some terminal cancer
patients are easy to work with, but some are high maintenance emotionally and
draining physically and psychically. Staff
may feel a sense of being lured in to the family drama of a patient or being
pitted against one another in an unhealthy way.
This can disrupt morale on the unit and cause a staffing problem when people
begin to take “mental health” days and shift the burden to others. That leads to further resentment and triangulation.
A patient who pits
one family member against the other cause more work for the nurses who have to
manage who is in the room in order to keeping the two family members apart at
the patient’s request. When this happens
chaplains can be called in to assess the emotional and spiritual state of the
patient and/or members of the family help them to identify coping strategies to
use to lessen anxiety. Sometimes I work with the family as a unit and
sometimes with individual members if it seems that they will be less than honest
in each other presence because of a need to save face, anger, intimidation or embarrassment.
This doesn’t always take the form of mean-spiritedness or demanding, caustic behavior. Even a pleasant patient who is seemingly on
good terms with everyone, can use triangulation in a way that always leaves one
family member out and adds anxiety and stress for the family and the
staff. Sometimes there is evidence of
competing for attention, particularly if this is and elder revered family
member. The process of naming an agent
on the Advance Health Care Directive can cause this became a real bone of
contention in families. If unaddressed
it can cause the dying patient to avoid making any determination for fear of
showing a preference, alienating one family member or causing a rift in the
family. Sometimes staff can be caught up
in this dynamic choosing sides within the family and contributing to the
tension unwittingly.
When this happens,
I work with our senior psychologist to name the dynamic and help the staff to see
the manipulation as it is happening so they can catch it, check it and change
it. I work on normalizing the effect to minimize
having them get stuck in a guilty mode for having been pulled into the
trap. This kind of situation can be
emotionally draining and physically sapping as more energy goes out to this
family than to other patients. Young inexperienced
nurses can find themselves getting berated in angry outbursts by patients and
family members who are really angry at each other even while they are being manipulated
into spending more time with this patient who may have less physical need than
their other patients. Staff debriefs and
in-services on the Bowen Family System theory, setting healthy boundaries, and self-care
ideas for emotionally trying situations are ways I work to support staff in these
situations. Occasionally I arrange a Tea
for the Soul for the whole unit with coffee, tea, cookies, fruit and a
classical string quartet in the staff lounge to give them an oasis in the midst
of the change of shift from am to pm.
