Perspective—Psychotherapy and the Cancer Patient (by a psychiatrist cancer patient)

Hopeful · 09-18-2009, 01:23 PM

Dr. Krelstein, a board-certified psychiatrist, originally wrote this article for Clinical Psychiatry News, an Elsevier publication. He has treated adolescent, adult, and geriatric patients in the public and private sectors. He has practiced insight-oriented psychotherapy for more than 30 years and is based in Berkeley, Calif.

Cancer is an alienating and existential disease. As psychiatrists, we can help patients process many of the emotions they are bound to experience throughout the course of this illness.

I should know. I was diagnosed with lymphoma about a year and a half ago. Since that time, I have undergone inpatient chemotherapy, and I continue to receive outpatient chemotherapy every 2 months. I have been in remission for 1 year.

Because of the experiences I have had as both a psychiatrist and a patient, I have become convinced that we have much to offer patients who have been diagnosed with cancer. I have developed 12 recommendations for psychotherapists who are working with cancer patients.

- Know that once your patient receives the confirmed diagnosis of cancer, he will experience psychological discomfort and symptoms that may or may not meet DSM criteria. In either case, these symptoms should be treated aggressively.

- Psychotropics should be used freely to combat the anxiety, depression, and/or sleeping problems that accompany this diagnosis.

- Once the therapeutic alliance has been well established, push the patient to discuss his cancer - even if he is hesitant to do so. If talking about the diagnosis proves too difficult, drop the issue, but be sure to return to it later.

- Do not believe any patient who claims that he does not have anxiety, depression, and/or sleeping problems. If the patient tells you this, carefully study his defensive structure so that you can figure out some way to discuss his disease without it being too upsetting.

- Never dismiss a patient's symptoms as a "normal" response to having cancer. Cancer is not a normal disease.

- Work hard to overcome your own unpleasant emotions concerning your patient. Cancer can strike anyone at any time - including you - and this fact can make the need to be connected and yet detached difficult to achieve.

- Alert your patient to the great need to find an oncologist he can trust, like, talk to comfortably, and feel connected to. The oncologist often is the only person with whom the patient can feel comfortable discussing the various problems the disease presents. Good oncologists are good at what they do, but perhaps because of what they do, they often are not very psychologically sophisticated - and this is detrimental to the patient.

- Urge your patient to get someone to accompany him to his various oncology appointments. After a cancer patient enters an oncology setting, his anxiety often blocks his ability to hear what is being said. Further, encourage the person accompanying the patient to work out a series of questions before the examination and to write down the important information that is acquired from the visit.

- If your patient is getting ready to receive outpatient chemotherapy, alert him of the importance of finding a treatment facility that is physically appealing and is staffed with pleasant, caring, and upbeat people. Such a setting is very helpful for boosting morale.

- If your patient is hospitalized, visit him when appropriate. Cancer wards are grim places, and your visit will be greatly appreciated.

- Ask the patient for a schedule of his cancer-related events. Do this before the never-ending upcoming scans, blood tests, and doctors visits. It is important to secure this schedule beforehand because of the psychological upset the patient will experience as he approaches the various tasks.

- Always remember that cancer not only alters the life of your patient but also the lives of his loved ones. Therefore, find a way to include those loved ones in your psychotherapeutic work.

Cancer patients often are treated by a treatment team. I believe this should always be the case and that a psychiatrist should always be an integral part of that team. In fact, given the unique contribution that we can make to cancer treatment teams, I think there should be a subspecialty of psychiatry devoted to the psychiatric aspects of cancer care. This could be a 1-year fellowship during which the fellow could be exposed to all the different age ranges of cancers as and the multiple difficulties that accompany the multiple treatment modalities, and all the various family dynamics that vary as the disease and the treatments progress. Finally, with supervision during this experience, the fellows would have a chance to learn how to deal with the various feelings they will experience as they watch both the disease and its treatment run its course, as well as while the patient attempts to meet the various challenges inherent in dealing with the disease.

As a psychiatrist with cancer, I have a deep understanding of the extent to which our training can prepare us to address the many psychological aspects of this illness. Some psychiatrists are already dedicating their lives to this work. It's time that more of us stepped forward.

Hopeful

Chelee · 09-18-2009, 02:04 PM

Thanks Hopeful for posting this. Great article and I must say I totally agree with every thing he said.

Chelee

Brenda_D · 09-19-2009, 06:20 AM

I could have used a doctor like him, or at least some kind of support system, which I didn't have.

After being told I was Stage4 and 6 months later being told, oops, Stage3, and then the doctors acting like it's no big deal, you are ok so just get over living with the Stage4 dx for 6 months.

I'm still angry with those docs about that, and will never trust what they say again.

Chelee · 09-19-2009, 09:08 PM

Brenda, I would of been angry too had that been done to me. I'd like to see your onc in the same situation and see if he could just get over it. (NOT!) I guess they think you were suppose to do that "happy dance" once they informed you that you were really a stage III. Then maybe a big kiss on his cheek and a hug to follow. (Some oncologist just amaze me.) Keyword being "some". There are lots of wonderful onc's out there but some just don't have a clue...nor does it seem like they want too.

Only a doctor that had experience a cancer dx himself could fully understand the depth of what we live with physically, mentally & emotionally. (Like the one that wrote this article.)

I would of loved to have had someone to talk to like this guy when dx...or even now would work for me. At least you would know he would totally get "it".

Chelee

DianneS · 09-30-2009, 08:29 PM

The first onc I saw, a week after my cancer dx, said this to me, before he even said hello -

"I can't guarantee you a normal life span".

Well, that just put me into a major tailspin from which I'm still trying to recover. Oncs don't realize the power of words. Needless to say I fired him but his words still haunt me. I want a normal life span! Who is he to say I won't have one?

Thank you Hopeful, for posting this. It just takes someone walking in these shoes to understand. I mean really understand. No one else gets the anxiety, anger, fear, mental exhaustion, sadness, that we have to deal with daily. It is quite wearing. I am not the same person I was before this diagnosis. Joy and true happiness are very very rare these days. I feel like I have an elephant sitting on my head. I hope some day soon part of the 'team' will be a psychiatrist or psychologist. That would be the humane thing to do.

Dianne

09-30-2009, 09:12 PM

It would be great of oncs or primary care physicians referred patients to psychiatrists after diagnosis of cancer.

It rarely happens. You are lucky if you get someone to listen to your symptoms of depression or anxiety and prescribe appropriate meds. As a cancer patient, you are lucky to get them to deal with pain.

This is a great posting.

Mary Anne in TX · 10-01-2009, 03:03 AM

It's why this site is so very, very important to so many of us!

caya · 10-01-2009, 06:29 AM

This is a great post, Hopeful. Thanks for sharing it with us.

When I was diagnosed, my GP referred me to a psychologist who specialized in dealing with cancer patients - she was terrific. I saw her about 6 times.
My onc. was honest with me, but always upbeat from the start, and as new studies came out, especially the HERA trials, showing the wonderful Herceptin results, he always updated me and was so positive.
At the hospital where I had my chemo, they have an on-site psychiatrist who treats only breast cancer patients. My onc. got me an appointment with him after I finished chemo, had started Tamoxifen and Herceptin, and I was really edgy,emotional, overly anxious. I just needed one session, but could have had more if I or he had deemed it necessary.

all the best
caya

suzan w · 10-01-2009, 08:03 PM

thanks for this article, all very true! The doc I saw for my 1st opinion told me that no one 'ever recovers from breast cancer' not very cheery and those words still haunt me more than 4 years later

AlaskaAngel · 10-03-2009, 12:34 PM

The visit I had in September with the NP here was the only one I've had in 7 years of seeing some of the most conscientious care providers that was "tuned in" on a psychological level. That one single visit was hugely healing for me, even this far out from dx.

As I mentioned to my surgeon last year, in the entire 7 years since dx I've never had a single care provider who was ever personally treated for cancer.

Thanks for the post, Hopeful. I couldn't agree more.

AlaskaAngel

Jean · 10-03-2009, 01:26 PM

Hopeful,
As always you post the most interesting and informative posts...which help so many. This post is a must read
for all but most important for new members who are still in the early tail spin stage of dealing with the dx.

While I was reading your post my mind remembered a management book...I read a few ago...

"Walk in my shoes".....ahhh thanks for posting.

Jean

Jackie07 · 10-06-2009, 11:56 PM

In my opinion, all the staff in the cancer ward, especially the oncologist and the oncology nurse, should see a psychiatrist on regular basis (and/or have a psychiatrist on the team who could 'listen' and perhaps offers some observation/suggestion.) It will be good for their mental health, [thus] good for the patients' mental health.

It's quite a task to keep a good patient-doctor relationship. We (patients) need to be equiped with communication skills and management skills to 'survive' the 'incidents' happening every day. But the doctors/nurses really need to have a understanding about what each patient is going through. 'Experience' and 'training' are crucial for oncology staff to provide good care for their patients.