Psychologists pave the way for transplant success

The role of transplant psychologists has become increasingly vital as the number of organ transplants has surged, rising from 28,956 in 2013 to 48,137 in 2024. These specialists usually are part of a multidisciplinary transplant team, although some are health psychologists employed by another area of the hospital who work on transplant as needed.

“Having health psychologists embedded with a transplant team affords a lot of opportunity for improved outcomes and improved patient satisfaction and patient care, starting at the very beginning of the transplant process,” said Kelly Bryce, PhD, the lead transplant psychologist at Henry Ford Hospital in Detroit. They participate in the initial evaluation for transplant, see patients yearly while they are on the waiting list, and “once patients are transplanted, we can get involved as early as the moment they wake up from sedation,” Bryce said.

Transplant psychologists help patients qualify for transplant by identifying and recommending therapy for untreated mental health problems and contributing to improved patient outcomes and satisfaction by addressing psychological barriers to medication adherence and recovery. The demand for transplant psychologists outstrips the current supply, presenting both challenges for health care teams and patients and opportunities for psychology students interested in the field and the academic programs educating them.

Psychoeducation and communication are big aspects of the transplant psychologist’s role. Educating patients about the importance of immunosuppressant medication after transplant to prevent organ rejection, for example, helps them stay out of the hospital and live longer, said transplant psychologist Stephan Weinland, PhD, at Virginia Commonwealth University (VCU) Medical Center in Richmond. Transplant psychologists can do this directly or show others how. In one recent study, a transplant center cut organ rejection rates among young kidney recipients in half after psychologists trained staff to use nonjudgmental communication and problem-solving when discussing medication adherence with patients (Hooper, D. K., et al., American Journal of Kidney Diseases, Vol. 79, No. 3, 2022opens in new window).

Weinland also spends time helping physicians understand their patients’ behavior. “I emphasize to physicians that there is no such thing as a ‘difficult patient,’ only patients with difficult problems,” he said. “That recognition puts the emphasis where it needs to be, on the issues to be addressed, and it can reduce burnout and help physicians remember why they got into medicine.”

[Related: Changes in the field of transplant psychology]

Once a kidney dialysis center or a physician refers a patient to a transplant center, the patient must undergo an evaluation by a multidisciplinary team to determine if they are a good candidate.

The surgeons and medical specialists on the transplant team evaluate patients’ physical health. For some organs, such as livers, patients with the most advanced organ failure and pressing need are placed higher on the waiting list. At the same time, some illnesses will eliminate transplantation as an option. For instance, patients with cancer may be denied a spot on the waiting list. Other patients may be told they need to lose weight before they can secure a spot.

The psychologist on the transplant team conducts interviews with most patients, assessing for multiple psychosocial factors that can contribute to success or difficulty with transplant.

“The first is the presence of untreated or undertreated mental health conditions,” said Weinland. “We need to make sure that the patient can take care of an organ if they’re given one. For every patient who gets an organ, there may be someone else on the waiting list who could pass away because they did not get an organ.” Depression, anxiety, post-traumatic stress disorder (PTSD), and basic mental health concerns can be addressed across the transplant process with psychotherapy or medications, but some situations can disqualify patients for transplant. Someone with an untreated delusional disorder who thinks posttransplant antirejection drugs are poison and would not take them, for example, would likely be ineligible for transplant, said Weinland.

Transplant psychologists, along with social workers on the team, also assess the patients’ social supports. “If you get a liver transplant, for the first few weeks you may be learning to walk again, eat again, and go to the bathroom again, to do basic functions,” said Weinland. For a transplant to succeed, patients need a dedicated caregiver to help them through recovery, manage their medications, drive them to appointments, and take on household chores, he said.

“Another domain that we’re assessing is the patient’s use of any substances that might be contraindicated or contribute to different problems with transplants, and that includes both illicit substances as well as nicotine, tobacco products, and alcohol,” said Yelena Chernyak, PhD, the lead psychologist for the Advanced Heart and Lung Care Center at Indiana University Health, where thoracic transplants take place.

Patients must also have the ability to understand the risks and benefits of transplant. For example, while a transplant can extend life, it can also fail if the body rejects the donor organ or the organ stops working. And finally, they must be willing and able to follow pre- and posttransplant regimens, including antirejection medications and lifestyle changes that are critical to transplant success. For example, Weinland assesses whether the patient has a history of rule-breaking behavior or other antisocial tendencies that could interfere with working with a doctor or person in authority.

“For transplant psychologists, the assessment is an opportunity to identify strengths and barriers or challenges to transplant and provide or recommend additional support that would help patients succeed and maximize overall outcomes posttransplant,” said Elizabeth Steinberg Christofferson, PhD, a pediatric psychologist with the solid organ transplant team at Children’s Hospital Colorado.

Psychologists attached to kidney and liver transplant teams also meet with living donors, who make up a little less than a third of all organ donors. They want to make sure that people who volunteer to donate a kidney or a lobe of their liver understand the weeks-long recovery that follows the laparoscopic surgery, the need to monitor their kidney or liver function annually after donation, and the importance of addressing ongoing mental health conditions, said Jody Jones, PhD, a clinical psychologist at the Transplant Institute of University Hospitals Cleveland Medical Center. “Emotionally, it can be challenging” because the surgery turns a healthy person into a temporarily ill one, Jones said.

At Tampa General Hospital’s Transplant Institute, the transplant team includes physicians, surgeons, nurse coordinators, social workers, financial counselors, pharmacists, and, for close to 30 years, psychologists, said Christine Machado-Denis, PsyD, the director of transplant psychology at the institute. “We are very fortunate,” she said.

When presenting the results of their evaluation, transplant psychologists must frequently educate the medical team. Sometimes patients are not following instructions—for instance, to stop smoking—and the physicians may consider the patient noncompliant, said Machado-Denis. “We can help the provider team use different language, help them see the patient in a different light,” she said. The psychologist can explain that with therapy, the patient may be able to stop smoking and eventually become a good candidate for transplant. In such a case, the transplant psychologist can help arrange therapy with the goal of reevaluating the patient for the waiting list once the behavior is addressed.

Psychologists also decode for the team how psychological factors might impact the patient’s care and recovery. For instance, the psychologist can advise a physician to make longer visits to build trust with a patient who fears doctors or to use pictures to explain transplant to a patient with low health literacy, said Machado-Denis. “We advocate for the patient and at the same time increase physician satisfaction because we’re giving them tools to understand this patient from that whole-person care model,” she said.

During the initial evaluation, the three transplant psychologists at Henry Ford, each specializing in a different organ, often see anxiety and depression in patients, who, after all, are wrestling with life-threatening chronic diseases, said Bryce. Typically, the psychologists refer these patients out for therapy. “We’re the evaluating psychologist at that point, and so to avoid the potential of any dual relationships, that treatment goes elsewhere,” she said.

Patients who end up receiving a donor organ also often grapple with depression because of the lengthy recovery process and permanent lifestyle changes such as taking lifelong antirejection drugs. It has been estimated that depression affects, for example, 85% of kidney recipients (Zimbrean, P. C., Current Opinion in Organ Transplantation, Vol. 27, No. 6, 2022opens in new window). From 30% to 40% of patients will meet criteria for major depressive disorder after a liver transplant, said Machado-Denis. “We see increased rates of adjustment disorder, and sometimes that can progress into depressive symptomatology, anxiety, and sleep problems,” she said.

In addition, patients can have some PTSD after extended hospitalizations or from complications during their hospital stay. Some patients suffer from delirium and brain fog after a turn in the intensive care unit, said Kristin Kuntz, PhD, the director of transplant psychology at The Ohio State University Wexner Medical Center.

Some struggle with survivor’s guilt. “Organ recipients may say, ‘For me to live, someone has to die. It’s not fair,’” said Kuntz. “It doesn’t feel right to them, especially for patients who struggle with depression and self-esteem issues.” This may be especially true for patients whose behavior contributed to or caused their condition, for instance, people with alcohol-related cirrhosis or chronic obstructive pulmonary disease related to smoking. They may compare themselves with their deceased donor or ask themselves if it is fair that they receive an organ while those whose behavior did not contribute to their illness may not, she said.

After a transplant, Bryce, Kuntz, and other transplant psychologists treat mental health symptoms related to the transplant or any behavior concerns linked to recovery, such as experiencing survivor’s guilt, avoiding follow-up appointments because of transplant-related emotional trauma, or struggling to comply with the medication regimen. In a 2023 literature review, the authors found that psychosocial interventions significantly improve adherence to immunosuppressant drugs (de Zwaan, M., et al., Deutsches Ärzteblatt International, Vol. 120, No. 24, 2023opens in new window).

Transplant psychologists have seen demand for their expertise climb as the number of organ transplants has steadily grown. “When I first started working on transplant in the late 1990s, it was definitely not common to have a health psychologist as part of the transplant team,” said Jones. Programs relied more heavily on social workers, and many still do. But most larger transplant programs have now hired transplant psychologists, she said.

Demand for transplant psychologists outstrips the number of psychologists trained in the field, and job openings are going unfilled. And yet the job is tremendously rewarding, said Jones. “Never, ever do I forget that it’s a miracle, that someone has died and a family in terrible grief wipes their tears and makes the decision to share that person’s life with numerous other people,” she said. “I just love it.”

Weinland’s transplant program at VCU has been advertising for two additional transplant psychologists since spring 2023. Tampa General Hospital’s Transplant Institute is also looking to hire two more health psychologists, said Machado-Denis. And there are openings at other transplant programs around the country.

Some psychologists may not want to be part of a medical team in a hospital and prefer the flexibility of private practice, said Jones. In addition, “organ failure can be painful to witness, and you have to sometimes have a pretty strong stomach for what these people are going through,” she said. Furthermore, “there are a lot of people getting trained in health psychology,” Jones said, “but if their graduate program is not at a center where transplants are done, then there’s not even an opportunity to do a rotation with somebody who works in the field.”

For the open positions, Weinland is willing to train health psychologists without transplant experience, he said. So is Machado-Denis. “If you’re willing to learn [about transplantation], I’m willing to teach you,” she said, adding that a psychologist with experience in neuropsychology or in addressing chronic pain or substance use would be a welcome addition.

To fill the educational pathways, VCU, Tampa General Hospital, Henry Ford Hospital, and Children’s Hospital Colorado offer postdoctoral fellowships in clinical health psychology devoted to transplant or with a rotation in transplant. About 6 years ago, Chernyak and her colleagues created a postdoctoral fellowship with a focus on transplant at Indiana University School of Medicine. “We’re trying to prepare the next generation of psychologists in this field,” she said.