Helper Syndrome as a Source of Motivation for Helping Professions in Hospice Care

It is specifi c for helping professions that the most common motive for choosing them is the relationship towards help as such. Paradoxically, the personality of the helping worker thus becomes a risk factor for professional work and a potential source of problems. The article focuses on one of the causes of motivation to help, the helper syndrome. The aim is to refl ect the work of people with the syndrome in hospice care. We want to point out the risks associated with the relationship of the helper to the dying, caring, and survivors, which also aff ects the functioning of a multidisciplinary team and the fulfi lment of hospice care goals.


Introduction
Th e professionalism and stability of the work team is one of the basic preconditions for the fulfi lment of the mission and goals of the organisation. In this context, the personal level of each employee and his motivation is an indispensable aspect. From surveys conducted in the area of helping professions, 1 we see that, for example, social workers chose their profession because 1) they wanted to work with people (37%), or 2) they wanted to help them directly (41%). Almost 4/5 of the respondents stated motivation based on their relationship with other people. 2 Nurses responded similarly (68%) in a recent large-scale questionnaire survey of the Ministry of Health of the Czech Republic. 3 In addition, hospice care workers have a specifi c motivation to choose working with the dying based on previous personal 1 Musil points to the lack of a defi nition of the term helping profession. It simultaneously arises from the description of individual words and their combination. Th e term is then defi ned as '… an organised group of workers who provide people in diffi culty with a specialised type of support or resources in order to enable them to manage their problems or meet their needs. ' Libor MUSIL, Sociální práce a jiné pomáhající obory/profese, in: experience of death (most oft en a close person). 4 Also, participants in courses related to the processes of dying or grief counselling are mostly motivated to self-education in this area through the personal experience of accompanying a close person in the three stages of dying -pre fi nem, in fi nem, post fi nem. 5 However, an individual's motives as psychological causes of behaviour can manifest themselves unconsciously. 6 Th e personality of the employee infl uences his view of the client, the framework of his work procedures, the use of methods, strategies, his evaluation, the fact whether the work with the client was or was not successful, etc. 7 For these reasons, the personality of the helping worker can be described as a risk factor for professional work and a potential source of problems that (taking into account the status of the profession) can be associated with the abuse of power. Th is also jeopardises the competence 8 of the helping worker, the stability and the identity of the profession. Consequently, especially in social work, refl exive practice is increasingly emphasised. It is the ability to critically understand one's own infl uence when working with a client. Th e aim is to cultivate oneself and improve work. 9 Navrátil perceives the usefulness of refl exivity in reviewing employee prerequisites and other facts relevant for the employee's entering into a relationship with the client. He points out that 'the helping professional is (also a person) who may mentally want to accept various methodological, managerial or ethical rules but yet he may not succeed. ' 10 Th e personality of the worker, his motivation and ability to self-refl ect are part of the topic of this study. We will focus on one of the risk motivations of helping professions, the helper syndrome (hereinaft er helpless helper / pathological altruist), 11 specifi cally in hospice care. Research in the fi eld of professional motivation of hospice employees appears in the form of graduate theses of students of health and social sciences. Professional discourse refl ecting the motivation of employees who choose work in hospice-type facilities is currently missing. 5 Th is statement results from the participation of the author in these courses or from her own lecturing in these courses. 6 Professional motivation and its theory form a separate topic which is elaborated in detail by the psychologist and university professor M.
Nakonečný Die hilfl osen Helfer: Über die seelische Problematik der helfenden Berufe. 13 Th e helper syndrome is characterised by a pathological eff ort to help. Th is is not based on the moral principle of selfl ess service to one's neighbour (altruism) but on the need to heal one's soul. 14 Th e helper syndrome can be hidden behind expressions of solidarity, altruism, empathy, etc. A helpless helper is generally characterised by acting in unconscious self-defence. He suppresses personal experiences, emotions, and avoids self-refl ection. His need to help and save others leads to self-humiliation and self-harm, and neglect of all social relationships except professional ones. Th e result is oft en the development of anxiety, depression, burnout, and many health complications. 15 Th e helper syndrome could be viewed from the point of view of many psychological theories, from the point of view of sociology, theology, biology, evolution, etc. Currently, two views are discussed, which are mainly credited to Schmidbauer and Oakley.
(1) Schmidbauer's concept is specifi cally focused on the reasons for the development of the helper syndrome. He sees the cause in the traumas and unmet needs of childhood. 16 Th e goal of his psychoanalytic approach is a gradual 'healing' based on an awareness of childhood experiences and an understanding of their impact on current behaviour. Doležel relates this concept to the concept of deep psychology according to which the choice of future profession is formed in the fi rst fi ve years of a child's life. In addition to this, however, the infl uence of later psychological development, including mental injuries, is also emphasised.
During this period [i.e., childhood], we take over and internalise the ideals of our parents which we oft en consider a lifelong commitment. Th eir violation causes us feelings of guilt. It is these ideals that play an important role in choosing a later profession. In addition to these circumstances, one's own mental injuries suff ered during mental development also play a role in choosing a helping profession (…). According to the concept of depth psychology, traumas continue to live as displaced feelings of wrongdoing, anger, fear, inferiority, or as unfulfi lled and unacknowledged desires. So until the traumas of childhood and later development become conscious again, there is no hope of a real healing of the helper or his clients. 17 American psychologists Holmes and Rahe have created a range of life events as signifi cant stressors which, if summed up, can be a signifi cant disturbance of mental balance. Th e highest number of points (100) was given to the death of a partner. 18 Death represents a diffi cult life situation which is related to a change of identity, loss of integrity, a sense of threat characterised by fear, anxiety, etc. Th erefore, today, with an emphasis on the individuality of the process, the concept of distinguishing between 'normal' / uncomplicated and complicated / pathological grief is abandoned. Nevertheless, aspects that can complicate the processing of the death of a loved one remain in one's consciousness. 19 Despite the individuality of the grief process, Špaténková points out that it is undesirable for a grief counsellor (including every hospice worker) not to be fully able to cope with the death of a loved one. Otherwise, there is a high probability of inability to decide whether he is acting professionally. Th e risk is, for example, coping with death by ineff ective strategies using ego-defence mechanisms. 20 A worker aff ected by loss may use sublimation and projective identifi cation in this context. Both of these unconscious defensive attitudes, in turn, combine the personal experience of losing a loved one with subsequent charity. Research shows 21 that the actual experience of the death process of a loved one or the accompanying is a frequent motivation for work in hospice care.
(2) While the above focus is on the helpless helper, Oakley addresses the problem of the pathological altruist in relation to the consequences of his actions. Th is concerns the target person or group of people who should be assisted, as well as the eff ects of acting in the wider social environment, that is the family, work collective, other social ties of a helpless helper, the whole society. 22 Th e emergence of the syndrome of pathological altruism stems from evolutionarily benefi cial manic behaviour. 23 Her concept is close to a systemic approach in social work. Each cause/action has a consequence and changing the interaction rules is assumed to cure the problem cause. Th e therapy of a pathological activist does not lie in the psychoanalytic retrospection of a helpless helper. It is based on the search for alternatives to change his actions or communication patterns that lead to the solution of consequences/problems that have arisen. Th at is, we do not ask the question 'why' but, above all, 'how' (what solution will cause a change in the behaviour of the pathological activist).
In the following part of the text, we want to point out the motivations of a helpless worker for choosing a helping profession, specifi cally in hospice care. 24 Here, too, we cannot objectively assess whether the helper syndrome in hospice care workers arose aft er the incomplete processing of the death of a loved one, or manifested itself earlier, and the encounter with death only motivated them to choose work with the dying in hospice care. 25 Specifi cally, we will address the specifi c potential manifestations of the syndrome in hospice workers which, to a large extent, threaten not only the dying person and his family but the entire multidisciplinary team and the goals of hospice care. Each chapter is presented by an instrumental case study written in the form of casuistry. Th ese are model examples that are fi ctional due to the ethical side of the issue. Th e strategy of combining several anonymised real case reports from the practice of hospice care in the Czech Republic was used to write these cases. 26 Th eir main purpose is to point out the symptoms common in pathological altruists who work in hospice care, to understand important aspects of When providing palliative care, the goal is the quality of life of the patient in accordance with his expressed wishes and attitudes, being the previously expressed wishes. 28 Th e basic rule of autonomy 'volenti aegroti suprema lex' 29 applies here. If we omit the legal aspect of the relationship between the hospice worker and clients, 30 the mutual ethical aspect of this relationship is generally dealt with by ethical codes of helping professions and codes or standards of hospice associations and individual organisations. 31 Th ey defi ne a relationship based primarily on 1) human dignity, and 2) a focus on quality of life. 32 Realising both values can be complicated for a helpless worker. Based on Hermann Stenger, Doležel develops three risky motives for helping workers in the helping professions: (1) gain recognition and love, (2) have power over other people, and (3) have a 'share in life' . 33 Using his helping activity, the pathological altruist unconsciously compensates for his own inability to experience and express his emotions, to fulfi l his needs and goals. Th ere is an emotional dependence of the helpless helper on the dying person and his family/carer. Th e helper's dependence, including the hidden need to process his own experiences, 34 leads him to try to evoke similar emotional experiences in his clients in the hope that they will be able to accept and process these emotions. Th is denies professionalism and dignity/respect for man in the sense of Kant's categorical imperative according to which man can never be only a means but an end in himself. Th us, paradoxically, the helpless helper loses sight of the object of the helping professions which is the person himself with his vulnerability, with his problem. Th e dependence of a helpless helper is in confl ict with the position of the dying/sick which is connected with the tendency to an asymmetry of the relationship. Th at is, especially in healthcare, we still encounter the paternalistic model of the relationship between health care provider and patient. Th e helpless helper unknowingly exploits this asymmetric situation by delegating his addiction to the people he cares for. Helpless workers oft en seek unnecessary control over clients.
Th is can intrude on the privacy of the dying person and his family, limiting his personal will. In practice, then, adults may be treated as children. 35 Th us, this can bring the situation of violating human dignity and the principle of 'volenti aegroti suprema lex' and the situation of violating 'lege artis' procedures. According to Sláma, the 'lege artis' procedure involves jointly formed decisions on the basis of the full knowledge of the dying person. Th ere must be a cooperative relationship between the worker and the dying person. 36 Dependence also means that a helpless helper may feel threatened if other people enter into a relationship between his client/caregiver. Due to the consolidation of the position of a helpless worker in the family, the roles of other members of the multidisciplinary team may be taken over or verbal attacks may be made directly against other team members (see example no. 3). Th e standard of specialised hospice care is, among other things, care for the grieving. 37 It is clear from many case studies 38 that grief counselling is a very specifi c area. It concerns both subjects of the relationship in an existential way. It confronts them with their own mortality, the topic of personal helplessness, their own experiences of death of loved ones. Špaténková may therefore state that grief counselling … requires not only specialised knowledge and skills but also a diff erent approach in relation to clients. More than any other, helping counselling (or helping relationship) depends primarily on the personal competencies of the counsellor. (…) In addition, the mortality grief counsellor should be balanced with his own, aware of his own losses, and his reactions to the themes and situations of dying, death, and grieving. 39

Th e Helper Syndrome in the Care of the Grieving
It follows from the above that the personality of the grief counsellor requires enormous skills in the fi eld of introspection, self-refl ection, and continuous supervision. Th ese aff ect the quality of the counselling process and especially develop the personality of the worker and his ability to implement ethical principles of the profession into practice. 40 However, a helpless worker is characterised by a limited ability to self-refl ection and a negative attitude towards supervision. In practice, lay help and support for the grieving (one-off and regular) is provided by any member of the hospice team, most oft en by a nurse, social worker, carer, or doctor. Th is is due to the fact 37 Cf. RADBRUCH, Standardy…, p. 25. Note: Care of grieving ones is one of the indicators of specialised hospice care. It stays in contrast to the general form of hospice care provision which does not off er continuous care to the grieving by core specialist workers who are part of a multidisciplinary team. 38 Cf. ŠPATÉNKOVÁ,Poradenství…,p. 19. 39 ŠPATÉNKOVÁ,Poradenství…,25. 40 American Council on Social Work Education defi nes (as the fi rst three requirements) abilities to practise the profession: (1) the ability to think critically, (2) the ability to implement ethical principles in practice, and (3)  that direct care workers oft en interact with the loved ones during the care of the dying person and are also the fi rst to meet the grieving in the post fi nem stage. Th e meeting of the grieving ones with a psychologist, psychotherapist, grief counsellor, or member of the clergy usually takes place aft er an expression of interest. It is especially suitable when the grieving shows some factors of complicated mourning. 41 In practice, therefore, every worker from the helping profession in hospice care will meet the grieving. Yet this help requires a lot of knowledge, skills, and personal prerequisites. Musil and Doležalová present four levels of implementation of this help: (1) psychological, (2) pragmatic, (3) informational, and (4) economic. 42 Based on ongoing interactions, the personality of the helping worker enters into a relationship with the grieving (see Introduction). At the same time, through the relationship, the spiritual aspects of the life of the grieving are deepened. In this context, Doležel points out that, according to the International Federation of Social Workers, each intervention takes place in fi ve contexts, including a spiritual context. 43 Th erefore, the abovementioned four levels of implementation of help should be supplemented by levels (5) social and (6) spiritual.
In the abovementioned case study, we point out some risks associated with the helpless worker's care of the grieving. In the case of a helpless helper, there are situations in which the worker is motivated by the need for help but, paradoxically, he tries to delay the termination of the contract with the grieving as much as possible, or tries to change the roles in the relationship between the two entities into friendship. Th e reason for such procedures is again the worker's need for dependence (see point 1). 44 Th erefore, he solves ever-emerging situations without supporting the grieving in their own activities, that is, to make the most of their own abilities and possibilities in their primary social environment. Th us, this procedure of a helpless worker does not correspond to the goal of grief counselling which is primarily focused on support of the ability to shape one's own life without the deceased, to build new relationships. 45 Th e frequency of meetings and their form 46 should be based on the real needs of the grieving. Th e helpless worker has a repeated tendency to form an exclusive competence for help to the grieving. A worker who does not suffi ciently refl ect upon the symptoms of complicated mourning is not motivated to delegate the grieving to the care of another competent professional in time. Failure to comply with the principle of subsidiarity, involving not only a multidisciplinary team but also external experts, can have existential consequences. Th is 'inaction' , especially for the grieving who have risky symptoms of complicated mourning, can lead to the development of mental disorders, addictions, various forms of aggression, and the risk of suicide. She is very selfl ess to the dying and their families. She needs to see herself as the one who helps the most, and the most professionally. Also, she needs to be loved by the dying and their loved ones the best -more than other team members. She strives for the perfection which she requires not only for herself but also for others around her, including her family. She transfers these high demands, that is, she expects others to strive for perfection too. She has problems with her co-workers and superiors. Internally, she fi ghts not only for the recognition of clients but also for the favour and praise of her superiors. If she receives positive feedback from a family, she likes to brag about it. Concerning other team members, however, she can tell their every little failure to the superiors. She fi ghts especially against those who are able to do something or to know something better. She oft en secretly depreciates them and creates an image of herself as a perfect person. On the contrary, as soon as someone says something she does not like, she immediately needs to defend herself, to oppose him. She manifests herself more as an 'individual player'. Working with other team members is diffi cult for her. She does not accept the roles of other members of the multidisciplinary team. She believes that she can help many of the families better at a given time. She thinks that other members of the team could break the trust that the dying and their family have built in her. In a group, she needs to have the main say or at least space for her own opinion, and she does not accept diff erent opinions. Silence is a big problem for her. She cannot be in a community where there is a moment of silence. She always has the urge to have the main say or to ask questions. She also has an answer to every question right away. She is unable to refl ect on the recommendations of her superiors. Aft er all, she 'means everything in a good way' and 'does not want anything for herself '. She refuses supervisions, she does not realise her problem. She always blames other people for the causes of confl icts. Th e above examples represent a helpless worker as an 'individual player' who does not accept teamwork or subsidiarity due to his sense of exclusive competence. He prefers to work independently in order to gain personal merit, recognition, etc. Th is is related to taking the roles of other members of a multidisciplinary team, incompetent actions, or even securing a position by humiliating other team members. Similar behaviour of a helpless worker then becomes a source of professional confl icts in the team and in relation to superiors (for example, in the context of not accepting strategies for the development of the organisation or organisational guidelines). Th e bio-psycho-socio-spiritual model of caring for the dying person and his loved ones can only be fully realised through functional cooperation within a multidisciplinary team. Th e pathological activist is also characterised by the need for constant verbal communication which, according to Schmidbauer, can be understood as a defence against awareness of displaced personal experiences. Moreover, the helper syndrome can be amplifi ed through faith in Jesus Christ. Th e Christian-motivated helper accepts Jesus as an example of realising practical love to one's neighbour. However, the pathological activist, when practising this 'type of love' , does not refl ect the freedom of each person as the highest value and gift of God. 47