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An Inverted Container in Containing and Not Containing Hospitalized Patients—A Multidisciplinary Narrative Inquiry

An Inverted Container in Containing and Not Containing Hospitalized Patients—A Multidisciplinary... ORIGINAL RESEARCH published: 08 July 2022 doi: 10.3389/fpubh.2022.919516 An Inverted Container in Containing and Not Containing Hospitalized Patients—A Multidisciplinary Narrative Inquiry 1 † 2† Gillie Gabay * and Smadar Ben-Asher 1 2 Multi-Disciplinary Studies, Achva Academic College, Shikmim, Israel, Educational Psychology, Achva Academic College, Shikmim, Israel Objective: Patient-centered care calls to contain patients in their time of crisis. This study extends the knowledge of provider patient interactions in the hectic environment of acute care applying Bion’s container-contained framework from psychoanalysis. Methods: Following ethical approval, we performed a narrative inquiry of the Edited by: Anat Gesser-Edelsburg, experiences of ten patients upon discharge from lengthy hospitalizations in acute care. University of Haifa, Israel Interviews were conducted upon discharge and about one-month post-discharge. Reviewed by: Royi Barnea, Findings: Data analysis suggests four modes of containing of patients by providers. Assuta Medical Center, Israel In nurturing interactions, typical of an active container-contained mode, patients Yaarit Bokek Cohen, experienced humanized care, symptom control, hope, and internal locus of control. Israel Academic College in Ramat Gan, Israel This mode yielded patient gratitude toward providers, wellbeing, and post-discharge *Correspondence: self-management of diseases. In rigid and wall-free modes of containing, patients Gillie Gabay experienced a sense of powerlessness and discomfort. A new mode of container- [email protected] contained was identified, the “Inverted Container”, which extends Bion’s theory ORCID: Gillie Gabay and contradicts patient-centered care. In inverted containers, patients contained the orcid.org/0000-0002-1767-8710 providers yet reported feeling gratitude toward providers. The gratitude constitutes a Smadar Ben-Asher defense mechanism and reflects a traumatic experience during hospitalization, which orcid.org/0000-0002-6264-822X led to post-discharge distrust in providers and hospitals and poor self-management Specialty section: of illness. This article was submitted to Public Health Education and Conclusions: To effectively provide patient-centered care, provider-patient interaction Promotion, in lengthy hospitalizations must move along a clinical axis and a relationship axis. This a section of the journal shifting may facilitate containing patients in their time of crisis so essential processes of Frontiers in Public Health reflection, projection, and transference are facilitated in-hospital care. Received: 13 April 2022 Accepted: 30 May 2022 Keywords: narrative, acute care, clinicians, hospitalization, containing, patient-centered care Published: 08 July 2022 Citation: Gabay G and Ben-Asher S (2022) An INTRODUCTION Inverted Container in Containing and Not Containing Hospitalized The Institute of Medicine (IOM) defined patient-centered care (PCC) as one of the six Patients—A Multidisciplinary Narrative fundamental aims of health care systems (1, 2). PCC is care that establishes a patient-provider Inquiry. Front. Public Health 10:919516. partnership; ensures respect for patients’ needs, and preferences; assures that patients have doi: 10.3389/fpubh.2022.919516 the required literacy to make decisions; and supports patient involvement (3, 4). The key Frontiers in Public Health | www.frontiersin.org 1 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care dimensions of PCC are (a) Respect for patient values, preferences, in medical encounters focusing on the development and growth and needs; (b) Coordination and integration of care, information, of patients whose providers encourage and empower them in communication, and education; (c) Physical comfort, entailing healing processes. Bion (18, 19) described the mother as a pain management, assistance in daily living, and comfortable container that provides the baby an emotional presence without surroundings; (d) Emotional support and alleviation of fear words, through attention to the baby who is unable to express and anxiety; (e) Involvement of family; (f) Transition and itself in words. The mother perceives signals from the helpless continuity of care; and (g) Access to care (5, 6). Orienting care baby, picks up the messages and names them. This broadcast- around patients’ needs improved patients’ clinical outcomes, translation function is the most important containment function reduced both under-utilization and overutilization of health (Appendix—Exhibit A elaborates on this broadcast translation services, and enhanced satisfaction of patients and providers function and identification mechanisms). Bion (18) presented alike (7). One influential model underlying PCC is the Planetree three modes of ’container-contained’ which differ in the extent to Model (8) that explicitly recognizes the importance of human which the psychotherapist, in short-term interventions, contains interaction in medical care. It views effective interactions as the client, allowing them to reflect and process emotional nurturing interactions, encompassing kindness, presence, and stressors through a transformative process. Incapacity to contain empowerment of patients from diverse backgrounds (8, 9). PCC constrains such transformations. places value on the individual’s personhood and autonomy, The first mode of container-contained is the active container, including patient’s wishes regarding their healthcare (10). which contains the client, allowing psychodynamics to take place. Research demonstrated that nurturing patient-provider The second mode is a container that inconsistently contains the interactions shape the quality of care (2, 11). Nurturing client, and the third is a rigid container, which rejects information interactions of providers with patients require inner resources from the client (verbal and non-verbal), as though fully blocking and a human touch (6). PCC requires providers to understand the dynamic between the subject and the object. Since Bion (18) patients’ biopsychosocial context, ensure patient understanding focused on relationships with asymmetrical power, such as the of the clinical condition, and share power and responsibility relationship between mother and baby, it is appropriate to apply (4, 11, 12). PCC emphasizes an egalitarian relationship between this theory in exploring asymmetrical relationships of power patients and providers with the recognition that power between providers and patients in acute care. We argue that in a asymmetries can be detrimental to patients, particularly to those provider-patient relationship, the provider’s emotional capacity, whose complaints are dismissed or disputed, and for those not necessarily verbal, can signal an understanding of the lacking knowledge and skills to facilitate communication with patient’s distress and mitigate anxiety and fear (12). The provider providers (11, 13). may translate the patient’s pain, fear, and distress into words Despite the essential importance of PCC to higher quality of and provide the patient with hope for a good future where the care, and despite the growing evidence regarding its importance patient may develop resilience, cope with the pain, and manage to patients, providers, and health systems, hospitals are far from the illness (4). The provider may instill hope for improving achieving PCC (6, 11, 14–17). Previous studies theorized the the patients’ health condition. In the patient-relationships, the benefits of nurturing provider–patient interactions, and other provider’s emotional presence is of great significance (20). studies tested the implementation of PCC in community settings, Applying Bion’s theory (19) to address the uniqueness of but studies that elucidate the perspective of patients and their each patient, the provider, as a container, must be free to explicit expectations of providers in acute care are scant (2– absorb the patient’s unique experience. The inner container is 4). It is important to examine how providers implement PCC an expression of the type of ability that varies from person to in practice in acute care. This study fills a gap in the state-of- person, associated with curiosity and learning from experience. the-art, borrowing from psychoanalysis to medicine to explore It is not related to an interpersonal dimension but expresses patterns of provider-patient interactions from the perspective of the ability to look at the world as a source of knowledge (18). patients who underwent lengthy hospitalizations in acute care. The words give meaning to emotions, clarify and sooth. The We draw on the theoretical framework of Bion’s container- theoretical understanding of projective identification enables us contained theory. to examine the provider-patient relationship in situations where mental content is transmitted to the provider, evoking anxiety or a feeling of disintegration in patients (21–23). The provider can absorb this content as a temporary container, BION’S CONTAINER-CONTAINED THEORY holding the unbearable inner experience of the patient until the The central concept of the ’container’ in psychoanalysis, as patient can deal with the emotions evoked. When providers formulated by Bion (18), relates to a helper accepting the manage to absorb the patient’s anxiety and hold it empathetically needy and their needs, an initial emotional contact that is a for that patient, they serve as a “container-container”. These critical dimension in every interaction. Bion’s conceptualization container-container relationships may constantly evolve and of the container in relationships emerged from psychoanalysis, grow in an ongoing process of mutual influence that allows for originating in the description of patterns of responses by a the transformation of thoughts and feelings. A second condition mother to her baby’s needs. Since patients completely depend is when providers hear the patient’s complaints but are unable on their providers, similarity in characteristics to those of the to hold the experiences, thoughts, and anxieties and collect mother and baby enable us to apply Bion’s theory to relationships them for the patient, thus, acting as a “rigid container” (24). Frontiers in Public Health | www.frontiersin.org 2 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care TABLE 1 | Sociodemographic data by group, type of disease and profession. METHODS Age group Disease Profession and No. of Children Recruiting Participants status We employed a maximum variation approach in recruiting participants to include a wide range of perspectives (25). Young Spine Cancer; Software, employed; 0–2 Participants were 10 Jewish secular Israelis (six men and four (319–36); Uterus Cancer; Engineer (self- women), ages 29 to 81, with diversity in participants’ age, gender, Three Neurological; employed); Dancer participants Crushed both (self-employed); geography, illnesses, profession, and work status. Participants arms and hands Designer were hospitalized in a large hospital (1,202–3,200 beds) or (self-employed) medium hospital (300–700 beds). Sample size was determined Middle Breast cancer; Teacher (employed); 2–4 by the information saturation method (26). Table 1 presents (42–58); Upper limbs injury; Architect (self- demographics and health attributes by group (27). Participants Four Lung cancer employed); were hospitalized due to cancer, heart disease, neurological participants Photographer (employed) disorders, or life-threatening accidents. Older Sternum cancer; Consultant (self- 2–4 A snowball sampling was used to locate subjects during (66–81); Neurological; employed); Insurance their initial recovery process upon discharge from an acute-care Five Uterus Cancer; (employed); setting in a public general hospital. Participants were hospitalized participants Heart Psychotherapist for about 3 weeks. Interviews were audio-taped, transcribed (self-employed); Retired verbatim, and translated from Hebrew to English. Procedures The rigid container does not allow any expression of contents Ethical approval was granted (IRB #099, September 2017). to seep into it. The container seems to refuse to comment on Following ethics approval, participants were recruited. The first what was inserted into it. The third mode describes providers author assured participants that their participation would have who do not perceive the patient’s distress at all act and as a no influence on their future treatments at the hospitals and “container without walls”. This state is present when the content informed them that they could stop the interview whenever conveyed in the process of projective identification is loaded they choose. She asked participants to sign a written statement turbulently and has “explosive” qualities. The provider is unable of informed consent regarding participation in the study and to contain and hold the content for the patient. In such cases the publication. Participants acknowledged their understanding that provider-patient relationship is fragile, and the main experience parts of their narrative will be published (27). All identifying of the patient is that of lack of capabilities. Since we argue that demographics of individuals were omitted from the Findings there is a similarity between the mother-baby’s interaction and section to ensure anonymity and confidentiality (27). All names that of provider-patient, we examined the theoretical principles used are pseudonyms. After transcribing the interviews, each presented by Bowen in this relationship. participant received a copy and approved their content. Two In the present study we borrow Bion’s (18, 19) theory participants asked to omit a paragraph from the interview of container-contained from psychotherapy to provider- due to risk of disclosure. The first author presented herself patient relationships in lengthy hospitalizations, seeking to as a researcher from academia studying the hospitalization examine the modes of containers in interactions between experience. She presented the goal of the study as education and providers and patients in lengthy acute care hospitalizations. In improvement based on patients’ experiences. She also presented hospitalizations, patients expect providers to contain their pain, the study methodology. A total of 20 interviews were conducted, understand it, and acknowledge their crisis (4). Having their two interviews for each participant to share the hospitalization expectations met may alleviate their anxieties and concerns. experience with the interviewer. The first author conducted the The provider who contains emotions and thoughts of patients interviews at participants’ homes upon discharge during the contribute to understandings of patient’s processes, emotions, initial phase of recovery. The first interview was conducted and thoughts. When patients’ expectations are unmet by within the first 2 days after discharge, and the second interview providers, there is no containing. If the patient can contain the about a month after. Interviews ranged in length from 90 min to frustration, it may facilitate growth (4, 12, 20). The current study, 2 h; two interviews lasted 3 h and one interview lasted 4, due to examining the provider-patient interaction, aims at identifying considerations of physical discomfort or emotional distress that the container-contained modes that providers use and their required breaks. Participants stressed that although it was very relation to attaining PCC. There is a paucity of literature challenging for them to meet so soon upon discharge, they had a discussing the modes of container-contained in provider-patient purpose, i.e., to improve the experience for others. relationships in lengthy acute care hospitalizations. The research As in narrative interviews, the first author asked one general, questions are: (1) How did patients experience the provider open-ended question aimed at generating a deep, unstructured as a container during their lengthy hospitalization in acute narrative (28): “Please tell me, how you arrived at the hospital care? (2) What conduct of providers characterizes each mode and what did you experience there?” From then on, participants of container-contained? (3) How does each mode of containing shared their experience from the first appearance of symptoms promote or undermine PCC? until discharge. The interviewer listened actively and made Frontiers in Public Health | www.frontiersin.org 3 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care no attempt to comment on, ask questions, or judge what obtained information that allowed us to make inferences from the participants said. To allow participants to express themselves data regarding the provider-patient relationship and the mode freely throughout the emotional interviews, the first author of container-contained. endeavored to have her body language send a message of acceptance even when it was emotionally difficult to contain the FINDINGS narratives (29). In this section we present the testimonies of patients describing Research Quality Criteria their personal encounter with physicians. We present the analysis We maintained general quality standards of qualitative research of all the interactions that characterize and demonstrate each (25). We acknowledged our own theoretical positions and of the three containers in the provider-patient dynamic and values regarding the research issue; we acknowledged our shared examples of a fourth mode, the inverted container where the experience with participants requiring examination of our critical patient is concerned with the wellbeing of the provider. reflections from hospitalizations (30), and our privileged position as academic researchers and as native Hebrew-speakers from the The Active Container same culture. To support the transferability of the findings, we The physician perceives the patient’s distress as an active described the methodology of the study in detail and provided container and feels responsible not only for the technical dense descriptions of participants’ points of view. Narratives were aspects of the treatment but also for the person themself. This told in upon discharge and a month later during the initial phase physician seeks a personal connection, is interested, listens, and of healing, in the patients’ homes. Narratives were anchored tries to solve problems. The patient feels free to communicate within three contexts that affected the participant’s choice of themselves, their fears, and loneliness, creating a sense of the narrative the broad context, the micro-context, and the togetherness. The experience of caring empathy and shared time immediate context (28). The broad context of the narratives was enables increased confidence and affects the patient’s ability to the Israeli universal health care system providing all residents cope with the disease. broad health services (31). Similarly, to other health systems in the Organization for Economic Co-operation and Development “I was happy when the anesthetist came and introduced himself, (OECD), the Israeli health system exposes its patients and told me what would happen, and how I would feel” (Ella, 66); providers to difficulties of shortages in resources (32). There I remember the moments with the doctors along all the winding, is a shortage of providers and a decreasing rate of beds per tangled roads. They were concerned, attentive, and I received much support. Their benevolent presence encouraged me. (Michelle, 74). population (33). In 2013, the Israeli Health Ministry instructed hospitals to adopt PCC as the cornerstone of quality health care. The micro-context was each participant’s stage of life and career. One of the significant components of the container is the personal Finally, the immediate context of the “here and now” may have care that provides the patient with their unique identity and offers also affected the narrative: the way the first author defined the hope: study, her academic identity as an audience for their story, and participants’ wish to participate in the study. Thus, the narrative “A tiny doctor with hair standing-on-end came into the room, hugged me, and said: You will not die on me.” (Koby, 52). is the story each participant chose to tell rather than everything that happened during the hospitalization (34). The patient and the doctor sometimes have a close relationship: Data Analysis Thematic analysis was guided by Saldana (35), aimed at exploring “I talked to her about things I could not talk to anyone.” “She (the patient experiences in the relationships with providers and the oncologist) was sitting with me, talking philosophy, film, literature, mode of container: active, containing, or rigid. We identified music, I connected with her on a very intimate level, that’s how she maintains relationships with her patients” (Koby, 52) themes, i.e., units derived from patterns such as recurring meanings and feelings, by bringing together elements of ideas While providing care it is sometimes necessary to choose or experiences, which often, when viewed alone, are meaningless but make sense in a specific context (35). Themes emerged from among treatment options. Involving the patients in decision making is part of creating trust and acknowledging their possible the data through six analytical steps: (1) We independently read and re-read the interviews and listed patterns of experiences contribution to making the right decision: through direct quotes. (2) We then identified all data that related to the patterns already classified. (3) We sorted all “Then she asked me what I do in life.” (Ella, 66); “The doctor treated me like a person, asked about my children.” (Daniel, 35) data according to the corresponding pattern. (4) We combined and categorized related patterns into sub-themes to obtain a comprehensive view of the emerging modes of container What is special about these testimonies is the acknowledgment of contained. (5) We pieced together themes in a meaningful the patient as a person who has another life outside the hospital, way to form a comprehensive picture representing the patient’s and the disease is not the person but rather an event in the interpretation of their collective experience of their relationships person’s life. The emotional presence is not necessarily verbal. with providers (35). (6) By referring back to the literature, we Eye contact, attention, and stopping at the patient’s bedside and Frontiers in Public Health | www.frontiersin.org 4 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care checking the treatment they are receiving all create an ongoing feelings of fear. They assess their experience of contact with the experience of a benevolent presence. doctor according to the doctor’s ability to alleviate fear: “My doctor and I became emotionally connected. She started at 7 “Maybe he spoke like a professional doctor, but I understand the in the morning, arriving with coffee, chocolate and would stay after words and it shocked me. I was terrified. I thought he would talk to work.” (Koby, 52); “The department director would see me in the me about what symptoms I have, explain to me if the symptoms are hallway and call out: “It’s going to take you a while but everything’s normative so I wouldn’t be so anxious. But he didn’t even share the fine. He always asked how I was, even when he saw me from a test results with me.” (Jacob,78) distance, although he did not treat me, it was important for him to encourage me (Martin, 62). In the rigid container, patients report that they experience the connection with the doctor as satisfying their physical needs The provider was perceived as helping and assisting both without actively absorbing their difficult feelings and helping medically and emotionally: process them. “She said I can always spin the rules of the game to get the best out of it, it helped me overcome my fears, get back to life as whole A Wall-Free Container as possible, she strengthened me so I could deal with the disease. This mode describes the provider as failing to meet patient’s (Martin, 62); “I shared with the doctor what I was going through, needs. For patients the phenomenon mostly described the and especially the anger and sadness and my resistance to accept my provider as ignoring them: new medical reality, I was very upset. She listened, and then said to me, “I thought about what you said and told me.” (Michelle, 74) “The two doctors talked about the medical procedures I have to go through as a routine arrangement, like arranging flowers.... I In the patient-provider relationship, there is a common tendency wondered if they see me at all. Do they know it’s my cancer?” (Ella, to attribute to providers the powers of a savior or angels. This 66); “The doctors just don’t hear anymore.” (Joel, 81) de-personalizes and distances providers from everyday human reality: The main experience is ignoring them: “The team was really a legend” (Joel, 81); They are angels doing sacred work there.(Michelle, 74). “I don’t think the doctor came to visit me after the surgery” (Jacob, 78); “No one spoke to me. Not a surgeon, not a social worker, not a The Rigid Container psychologist. The feeling of loneliness was difficult.” (Ella, 66) When the doctors hear the patient’s complaints but continue to follow regular procedures without changing or empathetically The patient’s difficulty lies in not being seen as a suffering person: containing the pain, we describe it as a rigid container mode: “The young doctor in the emergency room did not take my “I shouted...” Nurse. . . .Nurse. . . .. Finally the nurse came with a complaints of excruciating pain seriously (Daniel, 35);” When we paper pot, turned on the light, waking all the other patients. Only got to the emergency room this time, there was the same doctor much later did she return to take the pot. When I needed to pee again. I had such strong pains, and he didn’t understand the again, she brought me the same pot. The pot collapsed beneath me intensity of the pain at all. Sent me back to the community for and I lay in a puddle of urine.” (Ella, 62) testing. . . . I think that he recognized me. He dumped me like a dog “Go do an abdominal, liver, kidney ultrasound.” (Joel, 81); “There is It seems that the nurse was working according to procedures but a lot of loneliness”. (Ron, 60); The whole conversation between them without relating to the patients to whom she is delivering care. was over my head. Gathering around the bed talking about you like Patients describe esteemed professionals as doing a very good job you’re a piece of meat” (Jacob, 78); “All the doctors talked about me clinically but not “seeing” the patient: like I’m not in the room. Like I’m not there . . . not a person. . . a museum exhibit.. just another object.” (Ella, 66) “He is a professional.”; “The surgeon is very matter-of-fact but does not accompany you, he is like a technician who comes to repair the Some patients experience the lack of humane treatment as abuse. damage”; The hospital is an industrial plant, and I am the kettle One patient asked for answers and the doctor ignored his request. that needs to be fixed.“ (Ella, 66); ”The nurses are technocratic, they When the patient complained to the nurse, she replied that she is do not talk with you, they do their job and that’s it“ (Mike, 35); ”I not the doctor’s lawyer. Another patient recounts a medical abuse would ask providers to remember that the patient is a person just like them, with feelings, scared, sad, weak, exposed, vulnerable, just when he was helpless: like them. All they have to do is say “hello”, smile, ask how you feel... Overall, it takes a few minutes with each patient.“ (Ella, 66) I woke up one night in the hospital with stab wounds in the hand. I opened my eyes to see a young woman with a needle trying to Fear is the main emotion that patients report. One patient jab me in the hand.. she said she was practicing... I was drugged explains the distance that doctors create from patients as a and unable to complain.” (Koby, 52); “They didn’t listen to me even defense mechanism that prevents their encounter with patients’ though I told them I was sensitive to iodine” (Gigi, 29). Frontiers in Public Health | www.frontiersin.org 5 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care The data analysis revealed a fourth container mode, an inverted of PCC. This study makes several contributions. Theoretically, container, where the patient is the one who contains the the study elucidated providers’ conduct in provider-patient provider’s distress. interactions, extending the knowledge on nurturing interactions in the hectic environment of acute care. Applying the container- The Inverted Container contained framework, we identified an emerging fourth mode of The inverted container is where the patient attends to the container-contained, the ’Inverted Container’. Methodologically, provider’s distress and is preoccupied with it. In this situation the this study is a rare investigation of patients’ experiences and patient assumes the role of the ”good patient“, avoids reporting perspectives upon discharge from a lengthy hospitalization pains to the provider to avoid giving further burden. Some of and again, about a month post-discharge. Practically, this the participants presented attitudes of empathy toward providers study makes recommendations for developing active modes of in distress: container-contained in the delivery of hospital care. “They have insane workloads. . . .“their living conditions are Container-Contained Modes in Provider’s unbearable” (Dalia,72); “They are so burned out, they are Conduct in Acute Care and Patient missing nurses, missing technicians, they are completely dehydrated (Ron, 60). Experience Four modes of containing were identified. Participants who experienced nurturing interactions, typical of an active The doctors and nurses become the object of concern; they container-contained mode, expressed gratitude toward providers must take care of their wellbeing so as to able to continue their medical work: and reported higher wellbeing. Participants experienced comfort through humanized care, symptom control, hope, and internal “The morning before I was discharged, my mother asked the nurse, focus of control (4, 20, 36, 37). Discomfort was caused by “How are you?”... and the nurse answered, “Well, it’s nice someone participants’ sense of loss and powerlessness. The inverted is asking how I feel”. . . ...She was so bitter“ (Daniel, 35); I do what I container in which the patients contained the providers depicts can to help, sometimes I closed my eyes. All the horrible sights you a defense mechanism by patients who experienced traumatic see there.” (Martin, 62) or poor relationships with providers, breaching their trust in physicians and in the hospitals, and negatively affecting Patients themselves become preoccupied with their doctors’ self-management of illness post-discharge, all contradicting the experience, their physical and mental difficulties, their moral imperative and the PCC approach. Rigid containers and employment conditions, their fatigue, and also their knowledge inverted containers distance hospitals from capacity to achieve limitations: PCC. Below the provider’s conduct in each of the four modes of containers. “Doctors shoot a lot in the dark, their motives are altruistic, and they try to help as much as they can, but their knowledge is limited. Conduct in Active Container-Contained They carry insane burdens.” (Gigi, 29). Mode Four participants experienced being nurtured when providers In a state of inverted containers, the patient develops feelings of attempted to reduce their distress by taking the time to talk pity for the doctors and a desire to help them: with them patiently, to explain things, and legitimize their emotional experience (37, 38). Participants expressed gratitude “I felt sorry for the doctors who work so hard. It is difficult to survive as a doctor in a hospital. The doctor cannot help due to when providers enabled them to talk about their fears, anxieties, heavy workloads and not enough resources” (Ella, 66); The doctors and problems, alleviating their anxieties (38). Participants felt are too tired... exhausted. They have a hard time making a living. that providers offered them comfort and reassurance when (Michelle, 74) they provided bedside presence before procedures, creating the opportunity for intimate, private communication, and Patients engaged in receiving physicians’ distress signals are closeness that enabled participants to ask more questions and deeply anxious because the physician’s weakness threatens their share their concerns and feelings (20, 37). This private time chances of receiving proper care, thus, being empathetic to the empowered participants, showing that the provider believes provider may mitigate their anxiety. Figure 1 presents the four in their ability to overcome the temporary distress and to Modes of Container and Implementation or Undermining of improve self-management of illness. They felt the provider as PCC in the provider-patient interaction. very involved in their medical situation, providing a sense of safety and security that alleviated negative thoughts and emotions. Providers demonstrated respect for patients’ values DISCUSSION and preferences by active listening to their concerns, providing This study borrowed Bion’s (18) container-contained theory information, relieving participants’ distress, and encouraging from psychoanalysis to medicine to explore container-contained them to express their emotions. Providers reflected on room modes in provider-patient interactions in lengthy acute care for improvement of patients’ conditions and enhanced patients’ hospitalizations, based on patient narratives within the context perceived control of the situation, which was found to promote Frontiers in Public Health | www.frontiersin.org 6 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care FIGURE 1 | Modes of containing and not containing in patient-provider interactions and their impact on PCC implementation. self-management of illness and quality of life post-discharge and their distress. Participants longed for providers’ presence as a (4, 36, 37, 39). Such a provider-patient nurturing relationship reassurance that they will get well. Some participants perceived assisted participants in the face of emotional difficulties in the provider as distancing from them. A distant relationship their time of crisis due to the hospitalization or readmission, is not nurturing as it does not facilitate the patient’s health in cases of a progressive disease or acute conditions (37). literacy and sense of control but rather encourages a focus on Participants needed to feel the provider’s attention, empathy, and symptoms, procedures, pharmaceutical treatment, detrimental to acknowledgment of their crisis, facilitating wellbeing and growth their wellbeing. (4, 20). Conduct in Rigid Container-Not Contained Conduct in a Container-Contained Mode Wall-Free Mode Three participants experienced an authoritative attitude of Lack of nurturing in provider-patient relationships made three providers toward them, i.e., those providers know best what they participants feel that providers focus only on their physiological need and want, rather than empowering them. Disempowerment conditions and on treatment, disregarding the “person inside” was conscious. Participants reported that their views were Frontiers in Public Health | www.frontiersin.org 7 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care unheard. Providers were perceived as technical, alienated, previous studies, participants experienced comfort through uncaring. Lack of provider presence made participants feel that humanized care and empowering relationships with providers the providers do not see them; they felt objectified, vulnerable, (45). In relationships of nurturing and comfort, patients’ trust and powerless (4). They felt marginalized, and their self- in the providers leads to improved medication-adherence and value depreciated, exacerbating their anxiety and distress. To self-management of disease post-discharge [(36, 39); Guba, 2020; our surprise, six of the participants who experienced a rigid 2020b]. It should be noted, however, that the god-like image of container-contained mode, expressed empathy toward providers providers interferes with the formation of a container that allows and justified their misconduct. person-to-person closeness with the patient. Inverted containers are dangerous due to patients’ avoidance of reporting their Conduct in an Inverted Container-Not pain and physical distress, making it difficult to diagnose and treat the disease appropriately. Furthermore, inverted containers Contained Mode are dangerous since they foster distrust of providers and Participants with poor experiences identified with the provider hospitals with grave consequences post-discharge that contradict despite the poor experiences of lack of bedside manner, PCC. Moreover, the phenomenon of inverted containers raises incompetency, and apathy toward participants and their basic concerns regarding the capacity of hospitals and professionals to needs. We named this paradoxical phenomenon, ’An Inverted provide PCC. Container’, extending the three modes of container-contained Since 2013, Israeli hospitals report embracing patient- to a fourth mode, representing the patient’s defense mechanism centeredness, but this study suggests that providers representing in lengthy acute care hospitalizations. Our explanation of two out of four containers undermine PCC. This understanding the inverted container phenomenon draws on the Stockholm emphasizes the challenge of implementing PCC in acute care. syndrome (40, 41). The Stockholm syndrome refers to a This study supports previous studies that documented dynamics paradoxical psychological phenomenon (based on an internal of asymmetrical power between providers and patients in the contradiction), when people who are held captive express provider-patient interaction (11, 46). Providers adopting the appreciation, praise, and positive feelings toward their captors. modes of rigid container, wall-free container-contained, and the These positive expressions seem irrational considering the inverted container, did not recognize patients’ distress signals captives’ poor experiences but are viewed as a response typical (11). Furthermore, providers who interacted through modes of under emotional pressure, depression, fear, anxiety, leading the rigid container, the wall-free container mode, and the inverted captive to mistakenly interpret lack of abuse as a kind-hearted container, practiced power asymmetry in their interactions with gesture (42, 43). This response provides the captive an artificial participants, and communicated in a manner that fell short of sense of safety (44). We view the inverted container as a mode PCC and even contradicted it (11). Moreover, echoing previous in which the patient contains the provider, rather than the studies, some providers even presented clinical information to provider serving as a container for the patient. We view the patients in a way that elicited anxiety and fear (47). Other inverted container as a specific response of dependent patients providers, although aware of their power, spoke over the patient’s to their negative experiences with providers in relationships of head rather than humanized themselves (46). Our findings reveal asymmetrical power. We present the inverted container as a a critical disconnect between hospitals’ desire to provide PCC and behavioral response to traumatic experiences. practicing its tenets. Previous studies described traumatic experiences of Hospitals focus on outcomes and relate to efficiency patients in crisis due to progressive illness and misconduct and effectiveness. The highly charged environment of acute of professionals in lengthy hospitalizations (4, 20, 37). The care places a priority on clinical competence. Yet patients’ context often dictates reactions and in hospitalization, positive psychological and emotional needs are also in critical need of patient experiences may lead to trust, gratitude, adherence, attention at the time of their crisis (48). The capacity to attend and resilience. Negative experiences may lead to distrust, to patients’ psychological as well as physical needs, is essential to anger, anxiety, lack of adherence and refusal to return to PCC. Caring is an essential prerequisite of balancing life-saving the hospital in the future (4). Yet, patients with traumatic interventions with psychosocial care. Thus, although providers hospitalization experiences may act as inverted containers, work in a time-constrained work environment, with limited paradoxically justifying their providers’ misconduct and framing resources and a hectic pace, their attitudes rather than resources it positively, not only during hospitalization but also after are key to forming nurturing provider-patient interactions. discharge. Justifications entailed empathy, understanding, and Furthermore, without nurturing relationship meaningfulness in discounting the aggravation and the depreciation of self-worth providers, their job-dissatisfaction and burnout will deepen (49). caused by providers. Participants attributed the poor conduct of Prioritizing care to meet patient’s expectations will enhance providers to their burnout, overload, stress, lack of training, and both the short-term value and the long-term value of providers’ organizational culture. work (49). Container Modes and PCC To effectively provide PCC, provider-patient interaction in Only the active container-contained mode showed nurturing lengthy hospitalizations must move along two axes: a clinical provider–patient interactions with positive attitudes toward axis and a relationship axis. Patients in repeated re-admissions patients. Such interactions demonstrate PCC and positively due to progressive disease or acute conditions experience a crisis impact patients’ outcomes and wellbeing (20). Supporting (4, 12). Shifting as required between the clinical axis and the Frontiers in Public Health | www.frontiersin.org 8 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care relationship axis, a provider may contain the patient at their The transformation that takes place in the provider, according time of crisis, alleviate anxiety, build patient trust, and form a to Bion (18), depends on the flexibility of providers’ capacity partnership that enables involvement, higher health literacy and for containment. In other words, the ability to receive and carry post-discharge adherence. In the provider-patient interaction, the patient’s contents as well as to use them for the therapeutic processes of reflection, projection, transference take place just as process depends not only on clinical competency but also on they do in the clinic (18, 19, 50). When the provider listens to the ability to investigate countertransference reactions among the patient, reflects the patient’s experience, and acknowledges providers accompanied by mental pain. Based on theory and the patient’s crisis, the provider is actively containing the patient; clinical experience, Fleming (57) suggests that mental pain is an transformation takes place, enabling the patient to better process inherent part of the daily medical work. The clinical example the traumatic experience of the body’s betrayal and promote that Fleming gives illustrates the consequences of the provider’s healing (12, 37, 51). Active listening and clarification enable this mental pain on the course of treatment of the patient and its transformation to take place through intrapersonal processes so importance for working properly to be attentive to patients. that the patient can change. Without active listening the patient The threshold of mental pain that provider are willing to bear is not contained. as part of their profession, and the strategies they develop Eigen (52) emphasizes that providers need to be sensitive to for dealing with the mental pain caused by the provider- challenges and constraints rather inhibit their ability to nurture patient interaction, are important issues for training and patients. He calls upon providers to integrate “being” with professional support. “doing”. His writing is dedicated to all those seeking to turn the sacred therapeutic space into a place of ”being“ despite burnout and a broken soul. Providers will be able to nurture, Practice Implication PCC is resource-intensive and can only occur within supportive support, and collaborate with patients and other providers if they adopt the active container-contained mode in the complex medical systems (60). Providers require ongoing capacity- building, adequate resources in terms of redesigning how care relationships with patients. Only then will patients be better able to process their trauma. The provider is called upon to is offered, incentive schemes, as well as active assessment and feedback (61). Providers work in complex, fast-paced navigate the patient through this processing, over and over, to slowly create an experience of wellbeing, growth, and resilience. environments where competing clinical priorities and growing patient rosters make basic quality care, let alone PCC, difficult Devoted providers go beyond subjectivity and inter-subjectivity, to the primacy of being and experiencing, as a foundational to achieve (11, 62). Without adequate organizational support, providers desiring to deliver PCC may lack a clear understanding condition of their existence and mission. of how to balance competing demands (63). Interventions to Providers work under increasing physical and mental stressful conditions when exposed to patients, and the physical and implement PCC are a). Work with providers to acknowledge their power and its relevance within the patient interactions in mental strain causes burnout resulting in psychological distance called Compassion Fatigue (49, 53–55). Compassion fatigue is acute care. b). Guide providers to routinely reflect on patient- provider power dynamics (46). C). Support providers with on- manifested in the provider’s inability or reduced ability to feel and express empathy and support for patients, limiting the capacity going education and professional development on PCC, with explicit training about how to contain patients in delivery of for implementing PCC (53). Previous studies indicated that 25% of providers show signs of compassion fatigue and are even care. d). Expose providers to the Treatment Escalation Plans to explain conditions, share decisions with patients whose health characterized as being post-traumatic (56). While the patient’s distress is key in assessing the quality of care, the therapist’s is deteriorating (64). e). Since reducing gaps in training on PCC communication is challenging given the high stress and burnout distress is scarcely mentioned in the literature. of providers, hospitals are called upon to focus on “person- Fleming (57) discusses the mental pain experienced by therapists in their daily work. She asks how the therapist deals centered care,” as a prerequisite to PCC, and practice policies that mitigate providers’ stress. f). Last, modifying the term PCC with a patient who evokes suffering and how the therapist’s tolerance for their own mental suffering affects the success to “person-centered care” may shape a perception of patients as people with needs beyond the clinical perspective (61). of the therapeutic relationship. Following Fleming, we raise the question of how providers lacking inner resources due Training should be directed at (a) Shaping the caring virtue. (b) Reflecting on providers’ convictions about the needs and to burnout and compassion fatigue treat patients who expose them to damage to their inner self? At the same time, Fleming interpretations of interactions with providers. (c) Discuss what it means for patients “to be comfortable”. (d) Ways to incorporate recognizes mental pain as inevitable in work with a patient. To enable change, providers must accept, feel, and bear the mental insights into practice, e.g., interventions to optimize patient’s comfort. Managements are called upon to establish mechanisms pain that arises in the countertransference and therefore must strengthen their mental transformation skills. Providers must go to contain the distress, suffering and grief of providers, enabling beyond observation and interpretation, as major players in the them to serve as containers for patients (48). Continuing education for providers may focus on the art of Doing and Being recuperating process- to interact with the patient and deal with projective identification that turns the provider-patient dyad into and on integrating empathy and compassion into practice by analysis of container modes in patients’ narratives. one unit that constitutes change (58, 59). Frontiers in Public Health | www.frontiersin.org 9 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care LIMITATIONS perspective on their identity and foci, as providing clinical care, or clinical care and emotional support. Modes of containing The emergence of the novel mode of inverted container may patients may be explored as well as barriers to use the active be, as in any qualitative study, dependent on socio-cultural container-contained mode in delivery of care. Such insights will characteristics of providers and raises the question regarding promote continued education to promote PCC. existent modes of containers in acute care in other countries between providers and patients who depend on their providers to DATA AVAILABILITY STATEMENT fulfil their emotional needs. Also, because emotionally processing the hospitalization is a multi-phase temporal process, the times The original contributions presented in the study are included of conducting the interviews may have shaped the choice of the in the article/supplementary material, further inquiries can be narrative. Last, the differences in age among participants may directed to the corresponding author/s. shape differences in patient expectations of being contained. ETHICS STATEMENT DIRECTIONS FOR FUTURE STUDIES The studies involving human participants were reviewed and Future qualitative studies may validate the containing modes approved by the Ethics Board of the College of Management identified in this study with a large sample and add an interview Academic Studies. The patients/participants provided their during the hospitalization period. Future empirical quantitative written informed consent to participate in this study. studies are called upon to examine the prevalence of each container mode in provider-patient interactions in lengthy AUTHOR CONTRIBUTIONS hospitalizations. We also suggest that quantitative studies will testing the prevalence of the modes of containing by attributes GG: conceptualization, methodology, data collection, data conceptualized in this study. 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Violence Conflict of Interest: The authors declare that the research was conducted in the Gender. (2018) 5:67–9. doi: 10.1089/vio.2017.0076 absence of any commercial or financial relationships that could be construed as a 43. Price JS, Gardner Jr R, Erickson M. Can depression, anxiety and somatization potential conflict of interest. be understood as appeasement displays? J Affect Disord. (2004) 79:1– 11. doi: 10.1016/S0165-0327(02)00452-4 Publisher’s Note: All claims expressed in this article are solely those of the authors 44. Woody S, Rachman S. Generalized anxiety disorder (GAD) and do not necessarily represent those of their affiliated organizations, or those of as an unsuccessful search for safety. Clin Psychol Rev. (1994) the publisher, the editors and the reviewers. Any product that may be evaluated in 14:743–53. doi: 10.1016/0272-7358(94)90040-X this article, or claim that may be made by its manufacturer, is not guaranteed or 45. Coelho A, Parola V, Escobar-Bravo M, Apóstolo J. Comfort experience endorsed by the publisher. in palliative care: a phenomenological study. BMC Palliat Care. (2016) 15:71. doi: 10.1186/s12904-016-0145-0 Copyright © 2022 Gabay and Ben-Asher. This is an open-access article distributed 46. Nimmon L, Stenfors-Hayes T. The “handling” of power in the physician- under the terms of the Creative Commons Attribution License (CC BY). The use, patient encounter: perceptions from experienced physicians. BMC Med Educ. distribution or reproduction in other forums is permitted, provided the original (2016) 16:1–9. doi: 10.1186/s12909-016-0634-0 author(s) and the copyright owner(s) are credited and that the original publication 47. Henderson L. The Compassionate-Mind Guide to Building Social Confidence: in this journal is cited, in accordance with accepted academic practice. No use, Using Compassion-Focused Therapy to Overcome Shyness and Social Anxiety. distribution or reproduction is permitted which does not comply with these terms. Oakland, CA: New Harbinger. (2011). Frontiers in Public Health | www.frontiersin.org 11 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care APPENDIX Bion (18, 19) based the container-container function on Melanie Klein’s projective identification mechanism, whereby Exhibit A: The Broadcast-Translation discomfort resulting from hunger, fatigue, pain, etc., creates Function and Identification Mechanisms frustration and difficult, unprocessed experiences for the baby. The mother transforms the messages the baby conveys (59). The baby throws the frustration at the parent, while the to her into actions that optimize the baby’s chances of parent tries to take in and process (termed “reverie”) what developing physical and mental health. When the mother provoked the baby’s frustration response and provides the is emotionally unavailable, anxious, or confused, she may baby with a response. With time and accumulation of similar leave the baby’s distress untranslated or translate signals experiences, the parent’s processing action resonates again and into confusion. The container is active rather than passive, again in the baby, until the baby begins to recreate it on its as often mistakenly described. An active container has a own, thus forming a container-container relationship. When the mother suffers from the inability to reverie, to process the capacity to contain searching, asking, examining, and debating. Containing capacity involves creativity, which is made possible frustrations and fears of the baby, she does not function as an optimal container. The object, who is expected to mitigate, filter, when a mother is free to feel and contain the baby within her. The mother, functioning as a suitable container for and process the threat and fears, is perceived as a poor object. The mother reacts, at times, aggressively to the experiences of the the baby’s needs, can turn hunger into satisfaction, pain into pleasure, loneliness into togetherness, and fear of death baby, without offering internal processing and containment, and leaving the baby exposed to boundless fear. into serenity. Frontiers in Public Health | www.frontiersin.org 12 July 2022 | Volume 10 | Article 919516 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Frontiers in Public Health Pubmed Central

An Inverted Container in Containing and Not Containing Hospitalized Patients—A Multidisciplinary Narrative Inquiry

Gabay, Gillie; Ben-Asher, Smadar
Frontiers in Public Health , Volume 10 – Jul 8, 2022
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ORIGINAL RESEARCH published: 08 July 2022 doi: 10.3389/fpubh.2022.919516 An Inverted Container in Containing and Not Containing Hospitalized Patients—A Multidisciplinary Narrative Inquiry 1 † 2† Gillie Gabay * and Smadar Ben-Asher 1 2 Multi-Disciplinary Studies, Achva Academic College, Shikmim, Israel, Educational Psychology, Achva Academic College, Shikmim, Israel Objective: Patient-centered care calls to contain patients in their time of crisis. This study extends the knowledge of provider patient interactions in the hectic environment of acute care applying Bion’s container-contained framework from psychoanalysis. Methods: Following ethical approval, we performed a narrative inquiry of the Edited by: Anat Gesser-Edelsburg, experiences of ten patients upon discharge from lengthy hospitalizations in acute care. University of Haifa, Israel Interviews were conducted upon discharge and about one-month post-discharge. Reviewed by: Royi Barnea, Findings: Data analysis suggests four modes of containing of patients by providers. Assuta Medical Center, Israel In nurturing interactions, typical of an active container-contained mode, patients Yaarit Bokek Cohen, experienced humanized care, symptom control, hope, and internal locus of control. Israel Academic College in Ramat Gan, Israel This mode yielded patient gratitude toward providers, wellbeing, and post-discharge *Correspondence: self-management of diseases. In rigid and wall-free modes of containing, patients Gillie Gabay experienced a sense of powerlessness and discomfort. A new mode of container- [email protected] contained was identified, the “Inverted Container”, which extends Bion’s theory ORCID: Gillie Gabay and contradicts patient-centered care. In inverted containers, patients contained the orcid.org/0000-0002-1767-8710 providers yet reported feeling gratitude toward providers. The gratitude constitutes a Smadar Ben-Asher defense mechanism and reflects a traumatic experience during hospitalization, which orcid.org/0000-0002-6264-822X led to post-discharge distrust in providers and hospitals and poor self-management Specialty section: of illness. This article was submitted to Public Health Education and Conclusions: To effectively provide patient-centered care, provider-patient interaction Promotion, in lengthy hospitalizations must move along a clinical axis and a relationship axis. This a section of the journal shifting may facilitate containing patients in their time of crisis so essential processes of Frontiers in Public Health reflection, projection, and transference are facilitated in-hospital care. Received: 13 April 2022 Accepted: 30 May 2022 Keywords: narrative, acute care, clinicians, hospitalization, containing, patient-centered care Published: 08 July 2022 Citation: Gabay G and Ben-Asher S (2022) An INTRODUCTION Inverted Container in Containing and Not Containing Hospitalized The Institute of Medicine (IOM) defined patient-centered care (PCC) as one of the six Patients—A Multidisciplinary Narrative fundamental aims of health care systems (1, 2). PCC is care that establishes a patient-provider Inquiry. Front. Public Health 10:919516. partnership; ensures respect for patients’ needs, and preferences; assures that patients have doi: 10.3389/fpubh.2022.919516 the required literacy to make decisions; and supports patient involvement (3, 4). The key Frontiers in Public Health | www.frontiersin.org 1 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care dimensions of PCC are (a) Respect for patient values, preferences, in medical encounters focusing on the development and growth and needs; (b) Coordination and integration of care, information, of patients whose providers encourage and empower them in communication, and education; (c) Physical comfort, entailing healing processes. Bion (18, 19) described the mother as a pain management, assistance in daily living, and comfortable container that provides the baby an emotional presence without surroundings; (d) Emotional support and alleviation of fear words, through attention to the baby who is unable to express and anxiety; (e) Involvement of family; (f) Transition and itself in words. The mother perceives signals from the helpless continuity of care; and (g) Access to care (5, 6). Orienting care baby, picks up the messages and names them. This broadcast- around patients’ needs improved patients’ clinical outcomes, translation function is the most important containment function reduced both under-utilization and overutilization of health (Appendix—Exhibit A elaborates on this broadcast translation services, and enhanced satisfaction of patients and providers function and identification mechanisms). Bion (18) presented alike (7). One influential model underlying PCC is the Planetree three modes of ’container-contained’ which differ in the extent to Model (8) that explicitly recognizes the importance of human which the psychotherapist, in short-term interventions, contains interaction in medical care. It views effective interactions as the client, allowing them to reflect and process emotional nurturing interactions, encompassing kindness, presence, and stressors through a transformative process. Incapacity to contain empowerment of patients from diverse backgrounds (8, 9). PCC constrains such transformations. places value on the individual’s personhood and autonomy, The first mode of container-contained is the active container, including patient’s wishes regarding their healthcare (10). which contains the client, allowing psychodynamics to take place. Research demonstrated that nurturing patient-provider The second mode is a container that inconsistently contains the interactions shape the quality of care (2, 11). Nurturing client, and the third is a rigid container, which rejects information interactions of providers with patients require inner resources from the client (verbal and non-verbal), as though fully blocking and a human touch (6). PCC requires providers to understand the dynamic between the subject and the object. Since Bion (18) patients’ biopsychosocial context, ensure patient understanding focused on relationships with asymmetrical power, such as the of the clinical condition, and share power and responsibility relationship between mother and baby, it is appropriate to apply (4, 11, 12). PCC emphasizes an egalitarian relationship between this theory in exploring asymmetrical relationships of power patients and providers with the recognition that power between providers and patients in acute care. We argue that in a asymmetries can be detrimental to patients, particularly to those provider-patient relationship, the provider’s emotional capacity, whose complaints are dismissed or disputed, and for those not necessarily verbal, can signal an understanding of the lacking knowledge and skills to facilitate communication with patient’s distress and mitigate anxiety and fear (12). The provider providers (11, 13). may translate the patient’s pain, fear, and distress into words Despite the essential importance of PCC to higher quality of and provide the patient with hope for a good future where the care, and despite the growing evidence regarding its importance patient may develop resilience, cope with the pain, and manage to patients, providers, and health systems, hospitals are far from the illness (4). The provider may instill hope for improving achieving PCC (6, 11, 14–17). Previous studies theorized the the patients’ health condition. In the patient-relationships, the benefits of nurturing provider–patient interactions, and other provider’s emotional presence is of great significance (20). studies tested the implementation of PCC in community settings, Applying Bion’s theory (19) to address the uniqueness of but studies that elucidate the perspective of patients and their each patient, the provider, as a container, must be free to explicit expectations of providers in acute care are scant (2– absorb the patient’s unique experience. The inner container is 4). It is important to examine how providers implement PCC an expression of the type of ability that varies from person to in practice in acute care. This study fills a gap in the state-of- person, associated with curiosity and learning from experience. the-art, borrowing from psychoanalysis to medicine to explore It is not related to an interpersonal dimension but expresses patterns of provider-patient interactions from the perspective of the ability to look at the world as a source of knowledge (18). patients who underwent lengthy hospitalizations in acute care. The words give meaning to emotions, clarify and sooth. The We draw on the theoretical framework of Bion’s container- theoretical understanding of projective identification enables us contained theory. to examine the provider-patient relationship in situations where mental content is transmitted to the provider, evoking anxiety or a feeling of disintegration in patients (21–23). The provider can absorb this content as a temporary container, BION’S CONTAINER-CONTAINED THEORY holding the unbearable inner experience of the patient until the The central concept of the ’container’ in psychoanalysis, as patient can deal with the emotions evoked. When providers formulated by Bion (18), relates to a helper accepting the manage to absorb the patient’s anxiety and hold it empathetically needy and their needs, an initial emotional contact that is a for that patient, they serve as a “container-container”. These critical dimension in every interaction. Bion’s conceptualization container-container relationships may constantly evolve and of the container in relationships emerged from psychoanalysis, grow in an ongoing process of mutual influence that allows for originating in the description of patterns of responses by a the transformation of thoughts and feelings. A second condition mother to her baby’s needs. Since patients completely depend is when providers hear the patient’s complaints but are unable on their providers, similarity in characteristics to those of the to hold the experiences, thoughts, and anxieties and collect mother and baby enable us to apply Bion’s theory to relationships them for the patient, thus, acting as a “rigid container” (24). Frontiers in Public Health | www.frontiersin.org 2 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care TABLE 1 | Sociodemographic data by group, type of disease and profession. METHODS Age group Disease Profession and No. of Children Recruiting Participants status We employed a maximum variation approach in recruiting participants to include a wide range of perspectives (25). Young Spine Cancer; Software, employed; 0–2 Participants were 10 Jewish secular Israelis (six men and four (319–36); Uterus Cancer; Engineer (self- women), ages 29 to 81, with diversity in participants’ age, gender, Three Neurological; employed); Dancer participants Crushed both (self-employed); geography, illnesses, profession, and work status. Participants arms and hands Designer were hospitalized in a large hospital (1,202–3,200 beds) or (self-employed) medium hospital (300–700 beds). Sample size was determined Middle Breast cancer; Teacher (employed); 2–4 by the information saturation method (26). Table 1 presents (42–58); Upper limbs injury; Architect (self- demographics and health attributes by group (27). Participants Four Lung cancer employed); were hospitalized due to cancer, heart disease, neurological participants Photographer (employed) disorders, or life-threatening accidents. Older Sternum cancer; Consultant (self- 2–4 A snowball sampling was used to locate subjects during (66–81); Neurological; employed); Insurance their initial recovery process upon discharge from an acute-care Five Uterus Cancer; (employed); setting in a public general hospital. Participants were hospitalized participants Heart Psychotherapist for about 3 weeks. Interviews were audio-taped, transcribed (self-employed); Retired verbatim, and translated from Hebrew to English. Procedures The rigid container does not allow any expression of contents Ethical approval was granted (IRB #099, September 2017). to seep into it. The container seems to refuse to comment on Following ethics approval, participants were recruited. The first what was inserted into it. The third mode describes providers author assured participants that their participation would have who do not perceive the patient’s distress at all act and as a no influence on their future treatments at the hospitals and “container without walls”. This state is present when the content informed them that they could stop the interview whenever conveyed in the process of projective identification is loaded they choose. She asked participants to sign a written statement turbulently and has “explosive” qualities. The provider is unable of informed consent regarding participation in the study and to contain and hold the content for the patient. In such cases the publication. Participants acknowledged their understanding that provider-patient relationship is fragile, and the main experience parts of their narrative will be published (27). All identifying of the patient is that of lack of capabilities. Since we argue that demographics of individuals were omitted from the Findings there is a similarity between the mother-baby’s interaction and section to ensure anonymity and confidentiality (27). All names that of provider-patient, we examined the theoretical principles used are pseudonyms. After transcribing the interviews, each presented by Bowen in this relationship. participant received a copy and approved their content. Two In the present study we borrow Bion’s (18, 19) theory participants asked to omit a paragraph from the interview of container-contained from psychotherapy to provider- due to risk of disclosure. The first author presented herself patient relationships in lengthy hospitalizations, seeking to as a researcher from academia studying the hospitalization examine the modes of containers in interactions between experience. She presented the goal of the study as education and providers and patients in lengthy acute care hospitalizations. In improvement based on patients’ experiences. She also presented hospitalizations, patients expect providers to contain their pain, the study methodology. A total of 20 interviews were conducted, understand it, and acknowledge their crisis (4). Having their two interviews for each participant to share the hospitalization expectations met may alleviate their anxieties and concerns. experience with the interviewer. The first author conducted the The provider who contains emotions and thoughts of patients interviews at participants’ homes upon discharge during the contribute to understandings of patient’s processes, emotions, initial phase of recovery. The first interview was conducted and thoughts. When patients’ expectations are unmet by within the first 2 days after discharge, and the second interview providers, there is no containing. If the patient can contain the about a month after. Interviews ranged in length from 90 min to frustration, it may facilitate growth (4, 12, 20). The current study, 2 h; two interviews lasted 3 h and one interview lasted 4, due to examining the provider-patient interaction, aims at identifying considerations of physical discomfort or emotional distress that the container-contained modes that providers use and their required breaks. Participants stressed that although it was very relation to attaining PCC. There is a paucity of literature challenging for them to meet so soon upon discharge, they had a discussing the modes of container-contained in provider-patient purpose, i.e., to improve the experience for others. relationships in lengthy acute care hospitalizations. The research As in narrative interviews, the first author asked one general, questions are: (1) How did patients experience the provider open-ended question aimed at generating a deep, unstructured as a container during their lengthy hospitalization in acute narrative (28): “Please tell me, how you arrived at the hospital care? (2) What conduct of providers characterizes each mode and what did you experience there?” From then on, participants of container-contained? (3) How does each mode of containing shared their experience from the first appearance of symptoms promote or undermine PCC? until discharge. The interviewer listened actively and made Frontiers in Public Health | www.frontiersin.org 3 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care no attempt to comment on, ask questions, or judge what obtained information that allowed us to make inferences from the participants said. To allow participants to express themselves data regarding the provider-patient relationship and the mode freely throughout the emotional interviews, the first author of container-contained. endeavored to have her body language send a message of acceptance even when it was emotionally difficult to contain the FINDINGS narratives (29). In this section we present the testimonies of patients describing Research Quality Criteria their personal encounter with physicians. We present the analysis We maintained general quality standards of qualitative research of all the interactions that characterize and demonstrate each (25). We acknowledged our own theoretical positions and of the three containers in the provider-patient dynamic and values regarding the research issue; we acknowledged our shared examples of a fourth mode, the inverted container where the experience with participants requiring examination of our critical patient is concerned with the wellbeing of the provider. reflections from hospitalizations (30), and our privileged position as academic researchers and as native Hebrew-speakers from the The Active Container same culture. To support the transferability of the findings, we The physician perceives the patient’s distress as an active described the methodology of the study in detail and provided container and feels responsible not only for the technical dense descriptions of participants’ points of view. Narratives were aspects of the treatment but also for the person themself. This told in upon discharge and a month later during the initial phase physician seeks a personal connection, is interested, listens, and of healing, in the patients’ homes. Narratives were anchored tries to solve problems. The patient feels free to communicate within three contexts that affected the participant’s choice of themselves, their fears, and loneliness, creating a sense of the narrative the broad context, the micro-context, and the togetherness. The experience of caring empathy and shared time immediate context (28). The broad context of the narratives was enables increased confidence and affects the patient’s ability to the Israeli universal health care system providing all residents cope with the disease. broad health services (31). Similarly, to other health systems in the Organization for Economic Co-operation and Development “I was happy when the anesthetist came and introduced himself, (OECD), the Israeli health system exposes its patients and told me what would happen, and how I would feel” (Ella, 66); providers to difficulties of shortages in resources (32). There I remember the moments with the doctors along all the winding, is a shortage of providers and a decreasing rate of beds per tangled roads. They were concerned, attentive, and I received much support. Their benevolent presence encouraged me. (Michelle, 74). population (33). In 2013, the Israeli Health Ministry instructed hospitals to adopt PCC as the cornerstone of quality health care. The micro-context was each participant’s stage of life and career. One of the significant components of the container is the personal Finally, the immediate context of the “here and now” may have care that provides the patient with their unique identity and offers also affected the narrative: the way the first author defined the hope: study, her academic identity as an audience for their story, and participants’ wish to participate in the study. Thus, the narrative “A tiny doctor with hair standing-on-end came into the room, hugged me, and said: You will not die on me.” (Koby, 52). is the story each participant chose to tell rather than everything that happened during the hospitalization (34). The patient and the doctor sometimes have a close relationship: Data Analysis Thematic analysis was guided by Saldana (35), aimed at exploring “I talked to her about things I could not talk to anyone.” “She (the patient experiences in the relationships with providers and the oncologist) was sitting with me, talking philosophy, film, literature, mode of container: active, containing, or rigid. We identified music, I connected with her on a very intimate level, that’s how she maintains relationships with her patients” (Koby, 52) themes, i.e., units derived from patterns such as recurring meanings and feelings, by bringing together elements of ideas While providing care it is sometimes necessary to choose or experiences, which often, when viewed alone, are meaningless but make sense in a specific context (35). Themes emerged from among treatment options. Involving the patients in decision making is part of creating trust and acknowledging their possible the data through six analytical steps: (1) We independently read and re-read the interviews and listed patterns of experiences contribution to making the right decision: through direct quotes. (2) We then identified all data that related to the patterns already classified. (3) We sorted all “Then she asked me what I do in life.” (Ella, 66); “The doctor treated me like a person, asked about my children.” (Daniel, 35) data according to the corresponding pattern. (4) We combined and categorized related patterns into sub-themes to obtain a comprehensive view of the emerging modes of container What is special about these testimonies is the acknowledgment of contained. (5) We pieced together themes in a meaningful the patient as a person who has another life outside the hospital, way to form a comprehensive picture representing the patient’s and the disease is not the person but rather an event in the interpretation of their collective experience of their relationships person’s life. The emotional presence is not necessarily verbal. with providers (35). (6) By referring back to the literature, we Eye contact, attention, and stopping at the patient’s bedside and Frontiers in Public Health | www.frontiersin.org 4 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care checking the treatment they are receiving all create an ongoing feelings of fear. They assess their experience of contact with the experience of a benevolent presence. doctor according to the doctor’s ability to alleviate fear: “My doctor and I became emotionally connected. She started at 7 “Maybe he spoke like a professional doctor, but I understand the in the morning, arriving with coffee, chocolate and would stay after words and it shocked me. I was terrified. I thought he would talk to work.” (Koby, 52); “The department director would see me in the me about what symptoms I have, explain to me if the symptoms are hallway and call out: “It’s going to take you a while but everything’s normative so I wouldn’t be so anxious. But he didn’t even share the fine. He always asked how I was, even when he saw me from a test results with me.” (Jacob,78) distance, although he did not treat me, it was important for him to encourage me (Martin, 62). In the rigid container, patients report that they experience the connection with the doctor as satisfying their physical needs The provider was perceived as helping and assisting both without actively absorbing their difficult feelings and helping medically and emotionally: process them. “She said I can always spin the rules of the game to get the best out of it, it helped me overcome my fears, get back to life as whole A Wall-Free Container as possible, she strengthened me so I could deal with the disease. This mode describes the provider as failing to meet patient’s (Martin, 62); “I shared with the doctor what I was going through, needs. For patients the phenomenon mostly described the and especially the anger and sadness and my resistance to accept my provider as ignoring them: new medical reality, I was very upset. She listened, and then said to me, “I thought about what you said and told me.” (Michelle, 74) “The two doctors talked about the medical procedures I have to go through as a routine arrangement, like arranging flowers.... I In the patient-provider relationship, there is a common tendency wondered if they see me at all. Do they know it’s my cancer?” (Ella, to attribute to providers the powers of a savior or angels. This 66); “The doctors just don’t hear anymore.” (Joel, 81) de-personalizes and distances providers from everyday human reality: The main experience is ignoring them: “The team was really a legend” (Joel, 81); They are angels doing sacred work there.(Michelle, 74). “I don’t think the doctor came to visit me after the surgery” (Jacob, 78); “No one spoke to me. Not a surgeon, not a social worker, not a The Rigid Container psychologist. The feeling of loneliness was difficult.” (Ella, 66) When the doctors hear the patient’s complaints but continue to follow regular procedures without changing or empathetically The patient’s difficulty lies in not being seen as a suffering person: containing the pain, we describe it as a rigid container mode: “The young doctor in the emergency room did not take my “I shouted...” Nurse. . . .Nurse. . . .. Finally the nurse came with a complaints of excruciating pain seriously (Daniel, 35);” When we paper pot, turned on the light, waking all the other patients. Only got to the emergency room this time, there was the same doctor much later did she return to take the pot. When I needed to pee again. I had such strong pains, and he didn’t understand the again, she brought me the same pot. The pot collapsed beneath me intensity of the pain at all. Sent me back to the community for and I lay in a puddle of urine.” (Ella, 62) testing. . . . I think that he recognized me. He dumped me like a dog “Go do an abdominal, liver, kidney ultrasound.” (Joel, 81); “There is It seems that the nurse was working according to procedures but a lot of loneliness”. (Ron, 60); The whole conversation between them without relating to the patients to whom she is delivering care. was over my head. Gathering around the bed talking about you like Patients describe esteemed professionals as doing a very good job you’re a piece of meat” (Jacob, 78); “All the doctors talked about me clinically but not “seeing” the patient: like I’m not in the room. Like I’m not there . . . not a person. . . a museum exhibit.. just another object.” (Ella, 66) “He is a professional.”; “The surgeon is very matter-of-fact but does not accompany you, he is like a technician who comes to repair the Some patients experience the lack of humane treatment as abuse. damage”; The hospital is an industrial plant, and I am the kettle One patient asked for answers and the doctor ignored his request. that needs to be fixed.“ (Ella, 66); ”The nurses are technocratic, they When the patient complained to the nurse, she replied that she is do not talk with you, they do their job and that’s it“ (Mike, 35); ”I not the doctor’s lawyer. Another patient recounts a medical abuse would ask providers to remember that the patient is a person just like them, with feelings, scared, sad, weak, exposed, vulnerable, just when he was helpless: like them. All they have to do is say “hello”, smile, ask how you feel... Overall, it takes a few minutes with each patient.“ (Ella, 66) I woke up one night in the hospital with stab wounds in the hand. I opened my eyes to see a young woman with a needle trying to Fear is the main emotion that patients report. One patient jab me in the hand.. she said she was practicing... I was drugged explains the distance that doctors create from patients as a and unable to complain.” (Koby, 52); “They didn’t listen to me even defense mechanism that prevents their encounter with patients’ though I told them I was sensitive to iodine” (Gigi, 29). Frontiers in Public Health | www.frontiersin.org 5 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care The data analysis revealed a fourth container mode, an inverted of PCC. This study makes several contributions. Theoretically, container, where the patient is the one who contains the the study elucidated providers’ conduct in provider-patient provider’s distress. interactions, extending the knowledge on nurturing interactions in the hectic environment of acute care. Applying the container- The Inverted Container contained framework, we identified an emerging fourth mode of The inverted container is where the patient attends to the container-contained, the ’Inverted Container’. Methodologically, provider’s distress and is preoccupied with it. In this situation the this study is a rare investigation of patients’ experiences and patient assumes the role of the ”good patient“, avoids reporting perspectives upon discharge from a lengthy hospitalization pains to the provider to avoid giving further burden. Some of and again, about a month post-discharge. Practically, this the participants presented attitudes of empathy toward providers study makes recommendations for developing active modes of in distress: container-contained in the delivery of hospital care. “They have insane workloads. . . .“their living conditions are Container-Contained Modes in Provider’s unbearable” (Dalia,72); “They are so burned out, they are Conduct in Acute Care and Patient missing nurses, missing technicians, they are completely dehydrated (Ron, 60). Experience Four modes of containing were identified. Participants who experienced nurturing interactions, typical of an active The doctors and nurses become the object of concern; they container-contained mode, expressed gratitude toward providers must take care of their wellbeing so as to able to continue their medical work: and reported higher wellbeing. Participants experienced comfort through humanized care, symptom control, hope, and internal “The morning before I was discharged, my mother asked the nurse, focus of control (4, 20, 36, 37). Discomfort was caused by “How are you?”... and the nurse answered, “Well, it’s nice someone participants’ sense of loss and powerlessness. The inverted is asking how I feel”. . . ...She was so bitter“ (Daniel, 35); I do what I container in which the patients contained the providers depicts can to help, sometimes I closed my eyes. All the horrible sights you a defense mechanism by patients who experienced traumatic see there.” (Martin, 62) or poor relationships with providers, breaching their trust in physicians and in the hospitals, and negatively affecting Patients themselves become preoccupied with their doctors’ self-management of illness post-discharge, all contradicting the experience, their physical and mental difficulties, their moral imperative and the PCC approach. Rigid containers and employment conditions, their fatigue, and also their knowledge inverted containers distance hospitals from capacity to achieve limitations: PCC. Below the provider’s conduct in each of the four modes of containers. “Doctors shoot a lot in the dark, their motives are altruistic, and they try to help as much as they can, but their knowledge is limited. Conduct in Active Container-Contained They carry insane burdens.” (Gigi, 29). Mode Four participants experienced being nurtured when providers In a state of inverted containers, the patient develops feelings of attempted to reduce their distress by taking the time to talk pity for the doctors and a desire to help them: with them patiently, to explain things, and legitimize their emotional experience (37, 38). Participants expressed gratitude “I felt sorry for the doctors who work so hard. It is difficult to survive as a doctor in a hospital. The doctor cannot help due to when providers enabled them to talk about their fears, anxieties, heavy workloads and not enough resources” (Ella, 66); The doctors and problems, alleviating their anxieties (38). Participants felt are too tired... exhausted. They have a hard time making a living. that providers offered them comfort and reassurance when (Michelle, 74) they provided bedside presence before procedures, creating the opportunity for intimate, private communication, and Patients engaged in receiving physicians’ distress signals are closeness that enabled participants to ask more questions and deeply anxious because the physician’s weakness threatens their share their concerns and feelings (20, 37). This private time chances of receiving proper care, thus, being empathetic to the empowered participants, showing that the provider believes provider may mitigate their anxiety. Figure 1 presents the four in their ability to overcome the temporary distress and to Modes of Container and Implementation or Undermining of improve self-management of illness. They felt the provider as PCC in the provider-patient interaction. very involved in their medical situation, providing a sense of safety and security that alleviated negative thoughts and emotions. Providers demonstrated respect for patients’ values DISCUSSION and preferences by active listening to their concerns, providing This study borrowed Bion’s (18) container-contained theory information, relieving participants’ distress, and encouraging from psychoanalysis to medicine to explore container-contained them to express their emotions. Providers reflected on room modes in provider-patient interactions in lengthy acute care for improvement of patients’ conditions and enhanced patients’ hospitalizations, based on patient narratives within the context perceived control of the situation, which was found to promote Frontiers in Public Health | www.frontiersin.org 6 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care FIGURE 1 | Modes of containing and not containing in patient-provider interactions and their impact on PCC implementation. self-management of illness and quality of life post-discharge and their distress. Participants longed for providers’ presence as a (4, 36, 37, 39). Such a provider-patient nurturing relationship reassurance that they will get well. Some participants perceived assisted participants in the face of emotional difficulties in the provider as distancing from them. A distant relationship their time of crisis due to the hospitalization or readmission, is not nurturing as it does not facilitate the patient’s health in cases of a progressive disease or acute conditions (37). literacy and sense of control but rather encourages a focus on Participants needed to feel the provider’s attention, empathy, and symptoms, procedures, pharmaceutical treatment, detrimental to acknowledgment of their crisis, facilitating wellbeing and growth their wellbeing. (4, 20). Conduct in Rigid Container-Not Contained Conduct in a Container-Contained Mode Wall-Free Mode Three participants experienced an authoritative attitude of Lack of nurturing in provider-patient relationships made three providers toward them, i.e., those providers know best what they participants feel that providers focus only on their physiological need and want, rather than empowering them. Disempowerment conditions and on treatment, disregarding the “person inside” was conscious. Participants reported that their views were Frontiers in Public Health | www.frontiersin.org 7 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care unheard. Providers were perceived as technical, alienated, previous studies, participants experienced comfort through uncaring. Lack of provider presence made participants feel that humanized care and empowering relationships with providers the providers do not see them; they felt objectified, vulnerable, (45). In relationships of nurturing and comfort, patients’ trust and powerless (4). They felt marginalized, and their self- in the providers leads to improved medication-adherence and value depreciated, exacerbating their anxiety and distress. To self-management of disease post-discharge [(36, 39); Guba, 2020; our surprise, six of the participants who experienced a rigid 2020b]. It should be noted, however, that the god-like image of container-contained mode, expressed empathy toward providers providers interferes with the formation of a container that allows and justified their misconduct. person-to-person closeness with the patient. Inverted containers are dangerous due to patients’ avoidance of reporting their Conduct in an Inverted Container-Not pain and physical distress, making it difficult to diagnose and treat the disease appropriately. Furthermore, inverted containers Contained Mode are dangerous since they foster distrust of providers and Participants with poor experiences identified with the provider hospitals with grave consequences post-discharge that contradict despite the poor experiences of lack of bedside manner, PCC. Moreover, the phenomenon of inverted containers raises incompetency, and apathy toward participants and their basic concerns regarding the capacity of hospitals and professionals to needs. We named this paradoxical phenomenon, ’An Inverted provide PCC. Container’, extending the three modes of container-contained Since 2013, Israeli hospitals report embracing patient- to a fourth mode, representing the patient’s defense mechanism centeredness, but this study suggests that providers representing in lengthy acute care hospitalizations. Our explanation of two out of four containers undermine PCC. This understanding the inverted container phenomenon draws on the Stockholm emphasizes the challenge of implementing PCC in acute care. syndrome (40, 41). The Stockholm syndrome refers to a This study supports previous studies that documented dynamics paradoxical psychological phenomenon (based on an internal of asymmetrical power between providers and patients in the contradiction), when people who are held captive express provider-patient interaction (11, 46). Providers adopting the appreciation, praise, and positive feelings toward their captors. modes of rigid container, wall-free container-contained, and the These positive expressions seem irrational considering the inverted container, did not recognize patients’ distress signals captives’ poor experiences but are viewed as a response typical (11). Furthermore, providers who interacted through modes of under emotional pressure, depression, fear, anxiety, leading the rigid container, the wall-free container mode, and the inverted captive to mistakenly interpret lack of abuse as a kind-hearted container, practiced power asymmetry in their interactions with gesture (42, 43). This response provides the captive an artificial participants, and communicated in a manner that fell short of sense of safety (44). We view the inverted container as a mode PCC and even contradicted it (11). Moreover, echoing previous in which the patient contains the provider, rather than the studies, some providers even presented clinical information to provider serving as a container for the patient. We view the patients in a way that elicited anxiety and fear (47). Other inverted container as a specific response of dependent patients providers, although aware of their power, spoke over the patient’s to their negative experiences with providers in relationships of head rather than humanized themselves (46). Our findings reveal asymmetrical power. We present the inverted container as a a critical disconnect between hospitals’ desire to provide PCC and behavioral response to traumatic experiences. practicing its tenets. Previous studies described traumatic experiences of Hospitals focus on outcomes and relate to efficiency patients in crisis due to progressive illness and misconduct and effectiveness. The highly charged environment of acute of professionals in lengthy hospitalizations (4, 20, 37). The care places a priority on clinical competence. Yet patients’ context often dictates reactions and in hospitalization, positive psychological and emotional needs are also in critical need of patient experiences may lead to trust, gratitude, adherence, attention at the time of their crisis (48). The capacity to attend and resilience. Negative experiences may lead to distrust, to patients’ psychological as well as physical needs, is essential to anger, anxiety, lack of adherence and refusal to return to PCC. Caring is an essential prerequisite of balancing life-saving the hospital in the future (4). Yet, patients with traumatic interventions with psychosocial care. Thus, although providers hospitalization experiences may act as inverted containers, work in a time-constrained work environment, with limited paradoxically justifying their providers’ misconduct and framing resources and a hectic pace, their attitudes rather than resources it positively, not only during hospitalization but also after are key to forming nurturing provider-patient interactions. discharge. Justifications entailed empathy, understanding, and Furthermore, without nurturing relationship meaningfulness in discounting the aggravation and the depreciation of self-worth providers, their job-dissatisfaction and burnout will deepen (49). caused by providers. Participants attributed the poor conduct of Prioritizing care to meet patient’s expectations will enhance providers to their burnout, overload, stress, lack of training, and both the short-term value and the long-term value of providers’ organizational culture. work (49). Container Modes and PCC To effectively provide PCC, provider-patient interaction in Only the active container-contained mode showed nurturing lengthy hospitalizations must move along two axes: a clinical provider–patient interactions with positive attitudes toward axis and a relationship axis. Patients in repeated re-admissions patients. Such interactions demonstrate PCC and positively due to progressive disease or acute conditions experience a crisis impact patients’ outcomes and wellbeing (20). Supporting (4, 12). Shifting as required between the clinical axis and the Frontiers in Public Health | www.frontiersin.org 8 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care relationship axis, a provider may contain the patient at their The transformation that takes place in the provider, according time of crisis, alleviate anxiety, build patient trust, and form a to Bion (18), depends on the flexibility of providers’ capacity partnership that enables involvement, higher health literacy and for containment. In other words, the ability to receive and carry post-discharge adherence. In the provider-patient interaction, the patient’s contents as well as to use them for the therapeutic processes of reflection, projection, transference take place just as process depends not only on clinical competency but also on they do in the clinic (18, 19, 50). When the provider listens to the ability to investigate countertransference reactions among the patient, reflects the patient’s experience, and acknowledges providers accompanied by mental pain. Based on theory and the patient’s crisis, the provider is actively containing the patient; clinical experience, Fleming (57) suggests that mental pain is an transformation takes place, enabling the patient to better process inherent part of the daily medical work. The clinical example the traumatic experience of the body’s betrayal and promote that Fleming gives illustrates the consequences of the provider’s healing (12, 37, 51). Active listening and clarification enable this mental pain on the course of treatment of the patient and its transformation to take place through intrapersonal processes so importance for working properly to be attentive to patients. that the patient can change. Without active listening the patient The threshold of mental pain that provider are willing to bear is not contained. as part of their profession, and the strategies they develop Eigen (52) emphasizes that providers need to be sensitive to for dealing with the mental pain caused by the provider- challenges and constraints rather inhibit their ability to nurture patient interaction, are important issues for training and patients. He calls upon providers to integrate “being” with professional support. “doing”. His writing is dedicated to all those seeking to turn the sacred therapeutic space into a place of ”being“ despite burnout and a broken soul. Providers will be able to nurture, Practice Implication PCC is resource-intensive and can only occur within supportive support, and collaborate with patients and other providers if they adopt the active container-contained mode in the complex medical systems (60). Providers require ongoing capacity- building, adequate resources in terms of redesigning how care relationships with patients. Only then will patients be better able to process their trauma. The provider is called upon to is offered, incentive schemes, as well as active assessment and feedback (61). Providers work in complex, fast-paced navigate the patient through this processing, over and over, to slowly create an experience of wellbeing, growth, and resilience. environments where competing clinical priorities and growing patient rosters make basic quality care, let alone PCC, difficult Devoted providers go beyond subjectivity and inter-subjectivity, to the primacy of being and experiencing, as a foundational to achieve (11, 62). Without adequate organizational support, providers desiring to deliver PCC may lack a clear understanding condition of their existence and mission. of how to balance competing demands (63). Interventions to Providers work under increasing physical and mental stressful conditions when exposed to patients, and the physical and implement PCC are a). Work with providers to acknowledge their power and its relevance within the patient interactions in mental strain causes burnout resulting in psychological distance called Compassion Fatigue (49, 53–55). Compassion fatigue is acute care. b). Guide providers to routinely reflect on patient- provider power dynamics (46). C). Support providers with on- manifested in the provider’s inability or reduced ability to feel and express empathy and support for patients, limiting the capacity going education and professional development on PCC, with explicit training about how to contain patients in delivery of for implementing PCC (53). Previous studies indicated that 25% of providers show signs of compassion fatigue and are even care. d). Expose providers to the Treatment Escalation Plans to explain conditions, share decisions with patients whose health characterized as being post-traumatic (56). While the patient’s distress is key in assessing the quality of care, the therapist’s is deteriorating (64). e). Since reducing gaps in training on PCC communication is challenging given the high stress and burnout distress is scarcely mentioned in the literature. of providers, hospitals are called upon to focus on “person- Fleming (57) discusses the mental pain experienced by therapists in their daily work. She asks how the therapist deals centered care,” as a prerequisite to PCC, and practice policies that mitigate providers’ stress. f). Last, modifying the term PCC with a patient who evokes suffering and how the therapist’s tolerance for their own mental suffering affects the success to “person-centered care” may shape a perception of patients as people with needs beyond the clinical perspective (61). of the therapeutic relationship. Following Fleming, we raise the question of how providers lacking inner resources due Training should be directed at (a) Shaping the caring virtue. (b) Reflecting on providers’ convictions about the needs and to burnout and compassion fatigue treat patients who expose them to damage to their inner self? At the same time, Fleming interpretations of interactions with providers. (c) Discuss what it means for patients “to be comfortable”. (d) Ways to incorporate recognizes mental pain as inevitable in work with a patient. To enable change, providers must accept, feel, and bear the mental insights into practice, e.g., interventions to optimize patient’s comfort. Managements are called upon to establish mechanisms pain that arises in the countertransference and therefore must strengthen their mental transformation skills. Providers must go to contain the distress, suffering and grief of providers, enabling beyond observation and interpretation, as major players in the them to serve as containers for patients (48). Continuing education for providers may focus on the art of Doing and Being recuperating process- to interact with the patient and deal with projective identification that turns the provider-patient dyad into and on integrating empathy and compassion into practice by analysis of container modes in patients’ narratives. one unit that constitutes change (58, 59). Frontiers in Public Health | www.frontiersin.org 9 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care LIMITATIONS perspective on their identity and foci, as providing clinical care, or clinical care and emotional support. Modes of containing The emergence of the novel mode of inverted container may patients may be explored as well as barriers to use the active be, as in any qualitative study, dependent on socio-cultural container-contained mode in delivery of care. Such insights will characteristics of providers and raises the question regarding promote continued education to promote PCC. existent modes of containers in acute care in other countries between providers and patients who depend on their providers to DATA AVAILABILITY STATEMENT fulfil their emotional needs. Also, because emotionally processing the hospitalization is a multi-phase temporal process, the times The original contributions presented in the study are included of conducting the interviews may have shaped the choice of the in the article/supplementary material, further inquiries can be narrative. Last, the differences in age among participants may directed to the corresponding author/s. shape differences in patient expectations of being contained. ETHICS STATEMENT DIRECTIONS FOR FUTURE STUDIES The studies involving human participants were reviewed and Future qualitative studies may validate the containing modes approved by the Ethics Board of the College of Management identified in this study with a large sample and add an interview Academic Studies. The patients/participants provided their during the hospitalization period. Future empirical quantitative written informed consent to participate in this study. studies are called upon to examine the prevalence of each container mode in provider-patient interactions in lengthy AUTHOR CONTRIBUTIONS hospitalizations. We also suggest that quantitative studies will testing the prevalence of the modes of containing by attributes GG: conceptualization, methodology, data collection, data conceptualized in this study. 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Coelho A, Parola V, Escobar-Bravo M, Apóstolo J. Comfort experience endorsed by the publisher. in palliative care: a phenomenological study. BMC Palliat Care. (2016) 15:71. doi: 10.1186/s12904-016-0145-0 Copyright © 2022 Gabay and Ben-Asher. This is an open-access article distributed 46. Nimmon L, Stenfors-Hayes T. The “handling” of power in the physician- under the terms of the Creative Commons Attribution License (CC BY). The use, patient encounter: perceptions from experienced physicians. BMC Med Educ. distribution or reproduction in other forums is permitted, provided the original (2016) 16:1–9. doi: 10.1186/s12909-016-0634-0 author(s) and the copyright owner(s) are credited and that the original publication 47. Henderson L. The Compassionate-Mind Guide to Building Social Confidence: in this journal is cited, in accordance with accepted academic practice. No use, Using Compassion-Focused Therapy to Overcome Shyness and Social Anxiety. distribution or reproduction is permitted which does not comply with these terms. Oakland, CA: New Harbinger. (2011). Frontiers in Public Health | www.frontiersin.org 11 July 2022 | Volume 10 | Article 919516 Gabay and Ben-Asher Patient-Provider Interactions in Acute Care APPENDIX Bion (18, 19) based the container-container function on Melanie Klein’s projective identification mechanism, whereby Exhibit A: The Broadcast-Translation discomfort resulting from hunger, fatigue, pain, etc., creates Function and Identification Mechanisms frustration and difficult, unprocessed experiences for the baby. The mother transforms the messages the baby conveys (59). The baby throws the frustration at the parent, while the to her into actions that optimize the baby’s chances of parent tries to take in and process (termed “reverie”) what developing physical and mental health. When the mother provoked the baby’s frustration response and provides the is emotionally unavailable, anxious, or confused, she may baby with a response. With time and accumulation of similar leave the baby’s distress untranslated or translate signals experiences, the parent’s processing action resonates again and into confusion. The container is active rather than passive, again in the baby, until the baby begins to recreate it on its as often mistakenly described. An active container has a own, thus forming a container-container relationship. When the mother suffers from the inability to reverie, to process the capacity to contain searching, asking, examining, and debating. Containing capacity involves creativity, which is made possible frustrations and fears of the baby, she does not function as an optimal container. The object, who is expected to mitigate, filter, when a mother is free to feel and contain the baby within her. The mother, functioning as a suitable container for and process the threat and fears, is perceived as a poor object. The mother reacts, at times, aggressively to the experiences of the the baby’s needs, can turn hunger into satisfaction, pain into pleasure, loneliness into togetherness, and fear of death baby, without offering internal processing and containment, and leaving the baby exposed to boundless fear. into serenity. Frontiers in Public Health | www.frontiersin.org 12 July 2022 | Volume 10 | Article 919516

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