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

[Hopeful]

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