When patients? needs go beyond ?traditional? care

Psychologists?training prepares them well for helping cancer patients.

By Sandra Haber, PhD

Ever wonder what you would do if your patient started to talk about shark cartilage, laetrile or vitamin drips? If you?re a psychologist who works with cancer patients, this can be part of a typical therapy session.

My work with cancer patients?and my effort to understand their options?has taken me on an uncharted and unanticipated voyage into the world of alternative medicine. Information on the topic was never covered in any of my traditional preparation in psycho-oncology. The results of this quest have yielded vast quantities of information, which vary from the obscure to the invaluable.

The impetus for this mission was driven by a patient named Ruth.

Ruth?s story

Ruth gave many mixed messages. She often told me that if it weren?t for her breast cancer she never would have shown up in my office. She had no interest in whatever she imagined psychotherapy to be about, and just wanted help with her illness.

She also let me know that she needed me to cope with her illness and that she played the self-hypnosis tape I made for her every day. She liked to hear my voice. And as if it were a child?s teddy bear, she kept the tape on her pillow at night, and it went along on her many hospital stays.

Ruth and I had forged a mutually strong bond as we struggled through her illness. Our work went through many stages and, other than an all-too-brief window following her chemotherapy treatments, my 38-year-old patient faced a relentless battle with advanced breast cancer. We exhausted surgery, radiation, chemotherapy treatments, bone marrow transplant, even the possibility of clinical trials.

As her health deteriorated and her desperation increased, her brother-in-law, a psychiatrist, pushed her (and me) toward alternative treatments. For without some other intervention, Ruth was rapidly approaching death. Ruth reluctantly consented to visit a Canadian practitioner, but came back feeling uncomfortable with the visit. She clearly preferred to be treated in her cancer hospital, although her physicians were clear that they could no longer help her.

This reality, which would come and go, provided her with a rather half-hearted motivation to continue to explore other treatment options. Her journey became my journey as we both tried to make order from chaos in alternative medicine.

Seeking alternatives

As my cancer patients?and those with other chronic illnesses?have become tired of treatments that have little impact on their condition, frustrated by toxic side effects, and attracted to the philosophy of strengthening the immune system to fight disease, they have begun their own exploration of alternative medicine. Many of them have asked their psychologist to join their journey.

My term for this particular role is 'metapsychology'?literally beyond psychology?a word that delineates the role of psychologist as navigator, synthesizer, interpreter, educator and assessor of the goodness of fit of various medicinal practices as applied to the individual patient.

There are a number of reasons psychologists can be considered to be metapsychologists. Specifically:

? Psychologists are experts in learning and teaching and can serve as educators for those open to exploring alternative forms of medical treatment.

? Psychologists are trained in scientific research and statistical analysis. They can explain data so patients can make an informed medical decision regarding choices in alternative medicine.

? As acknowledged experts in personality assessment, psychologists can help patients identify and match their individual preferences with the various alternative practices available.

? Psychologists, through their close relationship with patients, are uniquely able to assess, respect and enhance quality-of-life choices for each individual patient. For example, in traditional medicine, side effects are typically underplayed; the psychologist can help the patient prepare for and cope with serious side effects.

? Psychologists address fears of recurrence as primary psychological issues in post-treatment cancer patients. Unfortunately, traditional medicine offers frequent medical monitoring as its only way of addressing post- treatment anxieties.

? Psychologists embrace the doctor-patient relationship as central to the effectiveness of all interventions. Recent changes in health care have seriously limited that relationship, as physicians are increasingly pressured into briefer interactions.

Ruth?s treatment

After each of her treatments (both traditional and alternative), Ruth always gave me a duplicate set of the information she received, and for every physician interview she?d had, I received a tape of what occurred. She continued this sharing with me as she tried to carve a path with various medical alternatives, and she began to depend on me to help her sort through the myriad information in a search for hope?a hope that was uniquely right for her. What Ruth wanted was a partner?another pair of eyes to see what she read, another pair of ears to hear what she heard. Mostly, she wanted reassurance that it was OK to reject the treatments that made her uncomfortable.

On one occasion, I found the name of a credible medical researcher who had a service that integrated the various alternatives that were particularly suited for each individual?s cancer. Ruth was interested in this and contacted him. We both eagerly awaited his response.

I will never forget the session when she finally received the report. I entered, anticipating her reaching some resolution and a comfortable treatment decision. She entered the session in a state of rage.

The report started off by suggesting that the treatment of choice for her advanced cancer was in Germany. She never read further. In the two years of our work, through the awfulness of chemotherapy, the terror of a bone-marrow transplant, the pain of nerve damage, I had never seen her so enraged. She threw the report on the floor and was fitful for most of the session.

The report that she had hoped would hold the key to her life was recommending that this 38-year-old, single, Jewish woman go to Germany for her treatment. To her, it was a death sentence clearer than any of the oncology messages she had heard. She stopped payment on the researcher?s check and called him to do battle?unheard-of actions for this young woman.

I understood her rage. I also knew that as much as I had been there for her, I could have done more in this situation. Treatments, particularly alternative treatments, demand a match not only with the patient?s illness, but with the patient?s psyche and belief system. This single young woman, with a limited support system, deeply Jewish ties and strong feelings about the Holocaust, heard the researcher?s suggestion as one more German Solution.

If I had seen the report first, I would have known to prepare Ruth for his recommendation so that it could be heard by her. I understood, too late, that even greater involvement on my part could have been more helpful.

From that beginning, and from the many patients who came later with both different yet similar stories, my involvement in alternative treatment continues to develop.

What to think about

Getting your bearings in the field of alternative medicine can be complicated, particularly since there is no central, organizing body of information.

Consideration of the following issues can help to get you oriented:

? History counts. Although we would like to think that science underlies medical policies, it is frequently true that political and economic forces are equally as critical. In the 1960s the AMA sponsored a 'Committee on Quackery,' which worked to eliminate chiropractors as a profession, declaring chiropractic an 'unscientific cult' and making it unethical for medical practitioners to associate professionally with such 'unscientific practitioners.' This position was ultimately changed, not by advances in medicine or scientific information, but by a federal judge who found that the AMA and other medical groups were in violation of the Sherman Antitrust Act.

? Medical treatments rest not only on facts but on broad assumptions of how facts are organized. These assumptions can lead to a rejection of helpful information and useful treatments. A notable example: Louis Pasteur was thrown out of the Academy of Medicine for suggesting that microbes invisible to the naked eye were responsible for food spoilage.

? For approved medicine, money counts. One of the limitations of modern-day treatments are the laborious and expensive barriers that stand in the way of FDA approval of new drugs. Some potentially effective and valuable treatments are not available to patients because they lack the funding for the tests required by the FDA.

? Patients want options. Despite the lack of scientific evidence and approval of the traditional medical community, the public has literally spent billions pursuing alternative medicines.

? Not all alternative treatments are created equal. Some alternative treatments involve completely unproven methods with no theoretic or face validity. Others are interventions that have long, accepted, scientific histories in other cultures (e.g., Chinese medicine and Ayurvedic medicine.)

? Think legal. As a psychologist, you cannot recommend, suggest or in any way imply that a patient should participate in alternative medicine in general or in an alternative medicine specifically. You can, however, educate your patient, explain statistical information and research design skills, and coach them in decision-making processes. Consult your lawyer for the appropriate language that you can and cannot use.Y

Sandra Haber, PhD, is a private practitioner in New York City and is president of APA Div. 42 (Independent Practice).