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

Abstract

ObjectiveCollusion 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.MethodSituations 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.Result1) 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 resultsThis 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.

Assessing the need for a question prompt list that encourages end-of-life discussions between patients with advanced cancer and their physicians: A focus group interview study

“…Patients experience high levels of anxiety and thus may be more reluctant to have end-of-life discussions than their physician and family members (El-Jawahri et al, 2014). Death-related topics can elicit psychologically strong emotions in patients and physicians, and may be unconsciously avoided (Stiefel et al, 2019). Since all of the patient study participants were pancreatic cancer patients with poor prognoses, they may have been more resistant to the topic of end-of life due to their imminent death.…”

Preventing Future Harm: Identifying the Drivers of an Unsafe Discharge to Improve Safety on an Inpatient Oncology Service

“…Clinician's emotional responses to difficult conversations can also lead to collusion—interconnected responses to a shared emotional trigger between individuals with a strong bond—with patients. 16 When patients such as JD resist end-of-life conversations and focus on unrealistic goals, oncologists may unconsciously collude with them by avoiding direct communication about poor prognoses or offering unrealistic treatment options. 17 JD's outpatient oncologist strongly encouraged hospice as JD's best option and informed JD that future immunotherapy was unlikely to provide benefit, and inpatient providers repeatedly documented JD's clinical decline.…”

The allure of the patient’s objects: Countertransference pitfalls and possibilities.

“…While Jacobs and Ehrlich did not ascribe to this broader view of countertransference, 3 their idea aligns with contemporary perspectives if what they described is viewed as countertransference collusion, rather than countertransference more generally. In an extensive review of the literature on collusions, Stiefel et al (2021) wrote, "At the core of collusions are unresolved issues, unconsciously shared by the participants, which interlock the colluders in this defensive, interpersonal maneuver (externalization)" (p. 5). This definition accords with the phenomenon Jacobs and Ehrlich described.…”

“…Stiefel et al (2021) asserted that enactments are instantiations of collusion-they signal that a collusion is operant in the dyad.6 In retrospect, it seems likely that the patient unconsciously induced her analyst to believe that her fear of her husband was "all in her head" as a way of averting the painful reality of her childhood trauma and its replication in her marriage. As Fairbairn famously wrote, "it is better to be a sinner in a world ruled by God than to live in a world ruled by the Devil" (Fairbairn, p. 66; quoted by Reiner, p. 69).…”