Collusive induction in perverse relating: Perverse enactments and bastions as a camouflage for death anxiety

Collusion in palliative care: an exploratory study with the Collusion Classification Grid

OBJECTIVE

Collusion is a largely unconscious, dynamic bond, which may occur between patients and clinicians, between patients and family members, or between different health professionals. It is widely prevalent in the palliative care setting and provokes intense emotions, unreflective behavior, and negative impact on care. However, research on collusion is limited due to a lack of conceptual clarity and robust instruments to investigate this complex phenomenon. We have therefore developed the Collusion Classification Grid (CCG), which we aimed to evaluate with regard to its potential utility to analyze instances of collusion, be it for the purpose of supervision in the clinical setting or research.

METHOD

Situations of difficult interactions with patients with advanced disease (N = 10), presented by clinicians in supervision with a liaison psychiatrist were retrospectively analyzed by means of the CCG.

RESULT

1) All items constituting the grid were mobilized at least once; 2) one new item had to be added; and 3) the CCG identified different types of collusion.

SIGNIFICANCE OF RESULTS

This case series of collusions assessed with the CCG is a first step before the investigation of larger samples with the CCG. Such studies could search and identify setting-dependent and recurrent types of collusions, and patterns emerging between the items of the CCG. A better grasp of collusion could ultimately lead to a better understanding of the impact of collusion on the patient encounter and clinical decision-making.

Collusions Between Patients and Clinicians in End-of-Life Care: Why Clarity Matters

Collusion, an unconscious dynamic between patients and clinicians, may provoke strong emotions, unreflected behaviors, and a negative impact on care. Collusions, prevalent in the health care setting, are triggered by situations which signify an unresolved psychological issue relevant for both, patient and clinician. After an introductory definition of collusion, two archetypal situations of collusion-based on material from a regular supervision of a palliative care specialist by a liaison psychiatrist-and means of working through collusion are presented. The theoretical framework of collusion is then described and the conceptual shortcomings of the palliative care literature in this respect discussed, justifying the call for more clarity. Finally, cultural aspects and societal injunctions on the dying, contributing to the development of collusion in end-of-life care, are discussed.

THE ULTIMATE INSIGHT: THE PATIENT'S AWARENESS OF MOTHER'S FILICIDAL WISHES

The author reviews myths and traditional tales in which the protagonist is a filicidal mother. In a displaced form, filicidal mothers appear as the ubiquitous witches of folklore. This imago is universal in fantasies and pavor nocturnus in children, regardless of the quality of care of the real maternal figures. To this phenomenon-the result of defensive externalization of primitive fears-a fundamental dimension is added when this dread seems corroborated by the mother's manifestly murderous wishes and behavior. Clinical examples of this pathogenic circumstance are provided, with comments on the development of dissociation versus repression, depending on the severity of early traumas. The evolution of symptoms and character disorder in adulthood is discussed, as well as interpretive and technical dilemmas posed by these patients.