Putting suffering into perspective: implications of the patient's world view.

The need for suffering patients to reexamine their assumptions about life presents therapists with unique challenges and opportunities. Patients with a religious world view often struggle with whether God cares about, or has sent, their pain. Atheistic patients also search for the meaning in their lives but reject the answers offered by traditional authorities. Patients who are uncertain or ambivalent about their world view may challenge a therapist to provide an audience, insight, or direction. Using case examples, the author explores the therapist's role in helping patients with differing world views to integrate their suffering.

Cancer and the meaning of work.

The importance of work in patients with cancer has received relatively little attention. This article reviews the existing literature and uses case examples to illustrate the themes that characterize work-related distress. Whereas loss of occupational identity can be a source of significant anxiety and depression, continuing or returning to the workplace allows many patients to maintain a sense of normalcy or control. The experience of discrimination can become a focus for strong feelings about fairness. Clinicians need to both address work-related distress directly and appreciate the larger significance these themes may have in their patients' coping. A closer look at the importance of work in oncology suggests several areas for future research.

A stage of change approach to addiction in the medical setting.

Despite recent advances in its understanding and treatment, addiction remains a difficult challenge for clinicians within medical settings such as the general hospital. The use of single, traditional paradigms (disciplinary, therapeutic, educational, or libertarian) for approaching addiction-related problems have often failed to embrace the complexity of the patients' motivation to change. Prochaska and DiClemente's [7] stage of change model offers a realistic, practical, and broadly applicable means by which clinicians can facilitate behavioral change from the stage of denial (precontemplation) through that of sustained recovery (maintenance). Clinicians can help addicted individuals to move from precontemplation to contemplation by enhancing their ambivalence; from contemplation to preparation by considering their history of change; from preparation to action by flexibly intervening based on this understanding; and from action to maintenance by evaluating the outcomes of these interventions. A stage of change model is also useful in understanding the process of change in clinicians' own approaches to patients with substance use disorders.

Marital crises in oncology patients. An approach to initial intervention by primary clinicians.

Life-threatening illnesses such as cancer may precipitate marital crises in vulnerable relationships, and oncology clinicians often feel uncertain about how to approach them. This paper presents a framework for initial intervention based on the nature of the principal threat to the relationship. Immature relationships need distance and support for their identity as a couple; hostile dependent couples need to find consensus in order to structure communication; physically abusive relationships require monitoring in order to promote safety; and estranged couples need help in understanding their disappointment and identifying available support. Clinicians working in oncology can help couples in crisis by promoting a realistic balance of independence and dependence, clarifying the complexity of factors contributing to the crisis, considering referral for couples treatment, communicating with the team while respecting patients' confidences, and by choosing clear and compatible clinical roles. Primary clinicians can stabilize and treat marital crises, but need access to medically knowledgeable couples' therapists.

Treating patients who request assisted suicide. A closer look at the physician's role.

Growing interest in assisted suicide and more favorable attitudes toward it have led to a focus on the tasks of finding common ground with patients who wish to die and of defining appropriate procedural safeguards. Less attention has been directed to the unique opportunities and responsibilities that are inherent in the role of the physician as healer. This article suggests that rather than assisting in their suicide, physicians should address the needs that prompt patients to request it. In addition to relieving the physical causes of suffering, they can help patients to establish realistic hopes by expanding their possibilities, bear suffering by assuring them that their suffering is understood and by remaining with them, and achieve perspective by reviewing the meaning of their life. The argument that these opportunities constitute compelling responsibilities is rooted in the medical traditions of beneficence, virtue, and sharing of power. Physicians' inability to meet all of their patients' needs does not detract from the importance of the psychological, personal, and pastoral aspects of their role.

A closer look at the role of a spiritual approach in addictions treatment.

Twelve Step Programs such as AA play a major role in addictions treatment, and their members are increasingly accepting of psychotherapy and medication. However, many clinicians question the role of an approach defined by these Programs as spiritual. This paper explores the nature, indications, and limitations of a spiritual approach to addiction and the implications for collaboration with mental health professionals. It suggests that Twelve Step Programs not only provide accessible group support and a clear ideology regarding addiction but address individuals' needs for identity, integrity, an inner life and interdependence within a larger social and moral, or spiritual context. It examines the ways in which the religious connotations of the Program remain an obstacle for many patients and clinicians. Clarification of the different needs met by modalities such as AA can improve the specificity and the comprehensiveness of treatment for patients with substance use disorders.

Difference between nurses' and physicians' approach to denial in oncology.

A psychiatrist and a psychiatric nurse interviewed 33 physicians and 94 nurses at a cancer center about their experience working with oncology patients, including their usual approach to "denial" seen in these patients. Most respondents viewed denial as a useful, nearly universal defense mechanism, potentially capable of interfering with treatment. Physicians described a pattern in which their patients were presented with the facts one time during diagnosis and formulation of a treatment plan, after which denial was allowed and new facts not offered unless the denial was viewed as interfering with the medical intervention. Nurses more often referred to denial as a phase, stressing the importance of honesty in dealing with patients who are prone to deny. They experienced discomfort when patients who were suffering adverse effects of treatment seemed to need greater honesty from their physicians. Discussion of these differences includes the effect of the contexts in which nurses and physicians encounter denial as well as their complementary roles in patient care, and the differential goals and values of the two professions.

Relationships with patients in oncology: can a clinician be a friend?

Encounters with patients who are experiencing a life crisis such as cancer can be profoundly meaningful to both patients and those caring for them. Intense emotional involvement with patients can also lead to difficulties including "burnout" (Davitz and Davitz 1975), interstaff conflict (Burnham 1966; Pollack and Battle 1963; Robinson 1984; Weintraub 1964), and violation of professional boundaries (Applebaum 1990; Gartrell et al. 1986; Gutheil 1989a, 1989b). Nicholi (1988) has reviewed the challenges that psychotherapists face in maintaining relationships with patients that are both close and therapeutic. However, there has been little research into the relationships that clinicians in other medical disciplines have with their patients. This report describes both the stresses and rewards of relationships with oncology patients in a comprehensive sample of 192 staff members at a regional cancer center, interviewed about factors affecting their job satisfaction.

Emotional support for patients with cancer who are undergoing CT: semistructured interviews of patients at a cancer institute.

To understand and improve the experience of cancer patients undergoing computed tomography (CT), 79 patients who underwent CT at a cancer institute participated in semistructured interviews about their experiences with CT. All patients had previously undergone CT; 75% (n = 59), three times or more. Anxiety about results was the most common concern during first and subsequent CT examinations. Technical aspects were a common concern during initial scanning, but not subsequently. Methods of relaxation most used by patients during CT were following instructions (56% [n = 44]), meditating and visualizing (44% [n = 35]), and praying (42% [n = 33]). Patients suggested several ways in which the radiology staff can support them during the evaluation of their malignancy. Fifty-five (70%) of the patients said they would like the radiologist to tell them the results of their scanning. Optimal care of patients with cancer who undergo CT goes beyond technical to emotional and spiritual support.

Presenting a diagnosis of cancer: patients' views.

BACKGROUND: Although in general, patients in the United States are now told if they have been diagnosed as having cancer, little information is available either about the way in which this is done or about patients' satisfaction with how they are told. METHODS: Thirty-two patients were interviewed who had been given a diagnosis of cancer; one half were being treated at a comprehensive cancer center and one half at a community hospital. The study instrument, presented in a semistructured interview conducted by psychosocial clinicians, included specific questions about the setting and the manner in which the patients were told, their reactions to the diagnosis, and their suggestions of how physicians should inform others who have to be informed of a similar diagnosis. RESULTS: All patients were told of their diagnosis by a physician; 84% of the time the diagnosis was given in person. Patients said that being told with hope, information, and caring, and with respect for their privacy and wishes to have a supportive person present were particularly helpful. Almost 40% of patients reported at the time of the interview that their hopes were directed toward remission and optimal quality of life rather than toward a cure. Four of the six patients whose conditions had initially been misdiagnosed described subsequent mistrust of information received from physicians. CONCLUSIONS: These findings confirm the importance of a physician providing hope for and fostering trust in patients to whom they are presenting the diagnosis of cancer. The results indicate that physicians' help in providing treatment information contributes more to hope than does cheerfulness or optimism, and that patients who have been given a misdiagnosis require special consideration in order to reestablish trust.

Problematic behavior of drug-dependent patients in the general hospital. A clinical and administrative approach to management.

Drug-dependent patients in general hospitals behave in ways that are difficult for medical and surgical staff to manage. Common problems include drug-seeking, states of intoxication and withdrawal, poor compliance, and behavior that is disruptive or dangerous to others. The authors describe an approach to these problematic behaviors based upon early recognition, a clinical perspective, and administrative action. Institutional initiatives are needed to overcome the practical and conceptual obstacles to effective management of these patients.

Job stress and satisfaction among the staff members at a cancer center.

Although it is evident that working with cancer patients can be stressful, explanations have differed as to why this is so and little attention has been paid to the rewards of this work. One hundred ninety clinical staff members at a comprehensive cancer center representing 91% of eight disciplines studied were interviewed using a semistructured format about the factors influencing their job satisfaction. The fact that the staff members almost uniformly rated their satisfaction as high (8.2 on a scale of 1 to 10) precluded the detection of discriminating variables. Satisfaction with the way they met their goals also was high; most identified potentially achievable goals, relied heavily on the interdisciplinary team, and experienced changes in their attitudes and approach during their first 2 years in the field, primarily increased realism. A major discomfort for physicians was the inability to provide optimal care. Ethical issues were a major discomfort for nurses. Death itself and staff conflict were less important sources of discomfort than in previous reports.

Delirium after elective orthopedic surgery: risk factors and natural history.

Forty-six orthopedic patients were studied to determine the incidence, natural history, and risk factors associated with post-operative delirium. Pre-operatively, patients were given a neuropsychological screening evaluation, the Mood Adjective Checklist (MACL), the Zung Depression Scale, the Anxiety Inventory Scale, and the Health Assessment Questionnaire (HAQ). A psychiatrist interviewed each patient on post-op day four for evidence of delirium as defined by DSM III criteria. Of the patients studied, thirteen (26%) were possibly or definitely delirious following surgery. Treatment with propranolol, scopolamine, or flurazepam (Dalmane) conferred a relative risk for delirium of 11.7 (p = 0.0028). Delirium was associated with increased post-operative complications (p = 0.01), poorer post-operative mood (p = 0.06), and an increase of about 1.5 days in length of stay (not significant). Delirious patients were significantly less likely than matched controls to improve in function at six months compared with a pre-operative baseline HAQ (t = 6.43, p less than 0.001).

Pain characteristics and treatment in an outpatient cancer population.

Thirty of 100 consecutive outpatients at a comprehensive cancer center were assessed by their physicians as having pain due to cancer severe enough to require regular or narcotic medication. These 30 patients and their physicians then were approached with a semistructured questionnaire about pain characteristics and management. Pain severity correlated only with age older than 55 years. Patients tended to rate their pain as more severe than did their physicians, but believed that pain medications generally were effective. Side effects of pain medication and patient fears of dependence on medication appeared to be more important limiting factors in achieving complete pain relief from medication than undermedication by physicians. Both patients and physicians acknowledged a relationship between emotional state and pain, but there was a greater appreciation among patients than physicians of the usefulness of techniques such as relaxation and distraction in pain control.

A closer look at the concept of support: some application to the care of patients with cancer.

The connotations of the term "support" have contributed to a widespread, diverse, and imprecise psychological usage. Oversimplification of complex clinical issues is most likely to occur when the concept of support is applied by staff with varied training and experience to patients with a serious illness such as cancer. This report distinguishes four principal meanings of support--comfort, strengthening, maintenance, and advocacy--offering a basis for individualized care of patients in a variety of clinical contexts.

Psychological aspects of artificial feeding in cancer patients.

Anorexia and weight loss are major physical and psychological problems for patients with cancer, and nutritional support has become an increasingly important part of cancer treatment. Reports discussing the psychological aspects of parenteral feeding have emphasized the importance of the nature of the underlying illness, but special problems surrounding the use of artificial feeding in patients with cancer have not been described. Patterns of emotional response to artificial feeding in such patients are most directly influenced by two interacting sets of variables: the diagnosis and prognosis of cancer, and personality characteristics of patients and family members involved. Typically, management problems result when demoralized patients respond to artificial feeding by becoming more passive, when independent patients struggle over artificial feeding in order to maintain a sense of control, or when anxious patients or families express fears about dying in the form of extreme preoccupation with eating and maintaining weight. An understanding of these patterns has specific implications for improving the patient's cooperation and quality of life.

Patient viewing of videotaped psychotherapy. Part I: Impact on the therapeutic process.

A seminar for psychotherapy supervision of residents employed videotapes of interviews as the focus. When patients and therapists together reviewed the tapes, a number of therapeutically valuable results ensued including a) retelling of corrected histories and new commitment to the therapy; b) increased awareness of denied areas of experience and insight into transference, defense, hidden affects and so on; c) a variety of forms of confrontation. In addition, this report reviews indications, difficulties, problems, and failures encountered with this technique.