The liaison function of the psychiatrist

The liaison role of the psychiatrist in an oncology setting requires him or her to recognize the common causes of stress in oncology fellows, residents, and oncologists, and how they impact the emotional care of cancer patients.

Many of the stresses on oncologists are the result of not having enough psychiatric experience to instill confidence when dealing with highly charged emotional issues. Too little time on the wards is devoted to learning communication skills from attending physicians. The experience of continuously treating seriously ill patients and confronting death, and the lack of emotional support leads to poor adaptation and bad habits. During more than 30 years of experience in a major cancer hospital, I have found that some of the psychological defenses that physicians develop can be detrimental to patient care. Physicians may try to avoid personal discomfort by denying the patient’s suffering and losses and, thus, remain uninvolved. They become excessively focused on research and clinical trials. Some become dissociated from their experience and lack the ability to empathize. They may avoid communicating a painful prognosis or may blurt it out without providing the patient and family an opportunity for questions, support, or discussion. Personal discomfort on the part of some physicians may also lead to the abandonment of patients and their family members when a clinical trial fails. Finally, and in my view, tragically, most physicians avoid looking to each other for emotional support, and they think of their stress as a sign of weakness. These problems in the physician-patient relationship contribute to the trauma experienced by patients who have cancer and increase the need of many patients and their partners to consult a psychiatrist.

It has been my experience that physicians who have had cancer often feel that the disease has made them better doctors. They have learned the importance of seeing (and treating) a person, rather than just a “patient.” Consequently, they understand the need to show that they care and want to help the patient. I have co-produced a film, “On the Edge of Being: When Doctors Confront Cancer,” that addresses these issues in 6 physicians who have had cancer and who speak about their emotional experiences as patients. The film has been used to teach medical students and residents in palliative care, psychiatry, and oncology.

Psychodynamic therapy

The psychodynamic treatment of patients with cancer may be divided into 2 broad sets of issues, those that address the needs and treatment of a patient with terminal cancer and those that address the needs of his or her caregiver/partner. Dynamic psychotherapy with cancer patients necessitates flexibility and the willingness and ability to advocate for the patient.3

Flexibility requires that the therapist adopt a schedule that fits with the medical status of the patient. In addition, the therapist needs to be comfortable visiting the patient in the hospital or making home visits. For example, a very sick patient may need short, frequent visits and not much talk but some physical contact, such as a hand on the shoulder or a hand on a hand. The therapist needs to understand that there are different challenges in various phases of the illness (eg, a bad prognosis or a recurrence may require a crisis intervention approach in contrast to an almost classic approach for a patient in remission). The therapist should also be available to accompany the patient as needed so that the appropriate procedures can be done in a timely fashion (eg, an agoraphobic patient who needs to undergo MRI).

In addition, with a terminally ill patient the psychiatrist must take on the advocacy role to ensure good quality of life for the patient and to strengthen the patient’s coping and defense mechanisms.4 Common psychological defenses of a cancer patient, such as denial and regression, need to be accessed in terms of whether they promote adaptation and optimal coping
or lead to bad decisions and poor adherence.

Requests for psychiatric consultation by oncologists or surgeons to help convince patients to accept radical surgery or aggressive chemotherapy can be problematic, because they might lead to a situation in which the psychiatric consultant has 2 allegiances. It is important for the psychiatrist to help patients arrive at their own decisions when they are ambivalent about radical treatment, which may have many adverse effects or long-term consequences. For example, an ex-marine who felt rushed into extensive pelvic surgery experienced it as rape, even though the surgical outcome was good; he required long-term inpatient psychiatric hospitalization.5 After the consequences of choosing either treatment or no treatment are explored, a dynamic formulation may help the patient make a final decision.

Because patients are very vulnerable, transference reactions tend to be intense and often regressed. Therapists can be viewed as omnipotent, which can be especially problematic for inexperienced psychiatrists. Anger and envy may be directed at the healthy therapist who has failed to gratify the patient’s wishes to be rescued or for not being helpful enough. Counter-transference reactions to these situations include feelings of helplessness, inappropriate rescue fantasies or actions, fears of angry outbursts, pessimism, passivity, depression, and survivor guilt. In fact, it is not uncommon to find all of these powerful feelings in psychiatric oncology fellows a few months after they have begun their training.

Therapists need a good support system, supervision, and possibly their own psychotherapy to help them cope with this stressful work. Some knowledge of cancer and the drugs used to treat it is clearly helpful.2 A variety of therapeutic techniques can be helpful. The therapist can learn to serve as a “container” for the patient’s anxiety by behaving in a very calm, confident manner, regardless of the circumstance.6 Cultivation of positive transference will be of great comfort to the patient, and encouraging the patient to explore whatever he or she wishes provides the patient with some degree of control and creativity in an environment of enforced passivity.7
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