Category: Healthcare / Medical

Psychotherapists who work with medically ill clients often feel adrift between two seas. One ocean is the fast-paced world of medicine, in which we, as medical consultants, must efficiently develop complete answers to complex questions. The other ocean involves the deep and dark undertow of emotions: our clients are often dealing with terrifying bodily limitations and unknown outcomes. As therapists, we are called upon to integrate and understand the hypomanic world of medicine, while helping our clients tolerate the unfair and arbitrary aspects of illness and, more ominously, the inevitability of death. Though providing psychotherapy to these clients can at times feel overwhelmingly tragic, it is the solace we are able to offer those beset with illness and death that makes the work so gratifying and meaningful.

As therapists we are privileged to have access to some of the most intimate recesses of the human mind. However, those of us who work with medical patients also have to bear the burden of our clients' concrete suffering. The toll on us is significant: having to tolerate the arbitrariness of illness can either make us cynical and scared, or jolt us into appreciating the finite aspects of life. Working with people beset by medical illness can make us, as therapists and people, able to appreciate life with all its benefits, limitations, joys and disappointments. Working with clients who are medically ill not only requires us to learn more about the seemingly distant and disembodied relational aspects of medicine, but also forces us to confront painful existential realities on a daily basis.

Illness in Psychology and Medicine

When I was not yet 30 years old and had been in private practice only a couple of years, I met Anne*, a pleasant and motivated 70-year-old whom I saw as an outpatient for mild depression. I had known her only briefly, but was very fond of her. Like many elders, Anne had gotten depressed after the death of her husband. Though she had not been in therapy before, she was open to learning how her mood might impact her ability to take care of herself. And like many older clients, she was unsure how talking could help her. But she often noted that after our meetings she felt better, even if she just talked about how she was struggling with getting used to taking care of the finances herself or how much she missed her husband. She also took our appointments very seriously.

One day, Anne uncharacteristically missed an appointment and I had been unable to get in touch with her. The next day, while at a nurse's station in the cardiology unit of the hospital I worked in, I saw her primary care physician, who had referred Anne to me. Upon seeing me, the physician said, “"Oh, Tamara, your patient, the older lady, she died two days ago. She had a heart attack." He then walked away as I stood at the chaotic nurse's station, stunned and tearful.” I had known Anne only a few months, but I had been feeling hopeful about her treatment. Given that she did not have any previous history of heart disease, I couldn't believe that she had died so suddenly.

Anne's death and her physician's manner of disclosure illustrate aspects of medicine that many of us in the field know all too well. The fast-paced, energetic facet of medicine in the U.S. can be characterized as being "hypomanic." Although I am referring loosely to the familiar Diagnostic and Statistical Manual of Mental Disorders1 criteria of hypomania, my understanding of the intensely energetic nature of medicine is more akin to the ideas of Melanie Klein and what she called "manic" defenses. Briefly, Klein described manic defenses as when idealization, feelings of being powerful, and hyperactivity are employed to ward off sadness, worries about aggression, and ambivalence2. In other words, manic defenses are used to avoid difficult feelings. And since difficult feelings abound in medicine, energetic defenses offer a perfect antidote to sadness and loss.

Even minimal experience in the medical profession inevitably leads one to appreciate the consequences of a hypomanic culture. Particularly in hospitals, people talk fast, move fast, and think fast. Many healthcare workers are constantly engaged in goal-directed activity. Even in outpatient settings, patients remark that they spend only five to fifteen minutes with their physicians and commonly complain that doctors are pressed for time. This pressure- and speed-driven culture has a rational component: when a patient is critically ill, physicians and medical staff need to move quickly in order to administer urgent care, which could be life saving. Additionally, many physicians, especially those who work in inpatient settings, are chronically sleep-deprived due to the demands of long hours, call schedules, and other professional and personal responsibilities. In the outpatient setting, physicians are often tightly scheduled to see a large number of patients in a limited amount of time.

As medicine has advanced, the kinds of interpersonal connections within the profession have changed as well. Donald Winnicott described the way he noticed interpersonal differences as a result of modern medical practice:

It is a sad result of the advances in modern medicine that there is no personal clash between patient and doctor as whole persons; there is a visit to the doctor, a disease process found, treatment is given, and the disease is cured, but no one has met anyone, no one person has bumped into another person.³

What I experienced in my conversation with Anne's physician after her death seems to be a common symptom of modern medicine as Winnicott described. Medicine demands a great deal from its practitioners, and a hypomanic style in the personalities of medical professionals can be viewed as a kind of acculturation to seemingly endless demands. On the other hand, the perpetually fast pace in medical facilities also reflects a tendency and desire to not engage with patients in an emotional way.

Bodies Breaking Down: Challenges for Therapists

Although physicians often experience the hypomanic trappings of medicine, as therapists we are also subject to these intense pressures. When I worked in medical settings with a large number of clients both as inpatients and in my outpatient practice, I often found myself wishing I could offer something simple and concrete to ease my clients' suffering. But I also wanted to ease my suffering; at times it felt like helping people who were ill was too much to bear. Sitting with someone with a rare autoimmune disease who had a guarded prognosis and uncertain future, helping someone with lung cancer who was overwhelmed with self-blame regarding years of heavy smoking, or trying to soothe a young adult randomly afflicted with heart disease forced me to face the complex reality of health and illness: we can all try to take care of ourselves and do the right things in terms of our health, but the sad truth is there are many variables we cannot control. Even when clients might have endangered their health knowingly or unknowingly (as in the case of older adults with lung cancer, who grew up seeing physician advertisements for cigarettes), they still have to deal with the fact that illness has happened to them and that their body has let them down and they might not live—or, for some, live with limitations they may never have dreamed possible.

I felt more emotionally vulnerable regarding death and serious illness in my clients when I was younger. Especially then, I had a hard time knowing how to manage the feelings that were stirred up in me. This was probably exacerbated by the difficulties with mourning that are present in medicine, as I had little support in a culture in which people simply move on to the next task, even after someone dies.

One way my intense anxiety manifested at the time was that I frequently feared that I would develop the same diseases of those I was treating. Especially when I worked with people who had been subject to random or mysterious illnesses (often those thought not to have links to lifestyle behaviors), I worried that I too, would be subject to the same bad luck. When I was seeing large numbers of patients in the hospital, it often seemed unbelievable to me that anyone could be in good health, and not sick with some terrible disease! Clinicians I have supervised in hospital settings, in which they were working with severely ill people, have echoed similar sentiments. These feelings and anxieties seem especially prevalent in younger clinicians and those who have not experienced illness or death in their personal lives. However, all of us, in working with people with medical illnesses, need to come to terms with the intense anxieties and overstimulation that are associated with treating this population.

Though our feelings and experiences are filtered through our own psychology, there are many common reactions to working in medical settings and with clients who are severely ill. “Intense fear, anxiety, and thoughts and images of our own death are common reactions and not necessarily related to our own psychological problems; what we encounter is simply difficult to bear.” Serious illness and the possibility of death inherently evoke intense and disorganizing emotions in therapists when we are with our very ill clients. Since many people experience considerable shame in confronting these emotions, reinforced by a cultural mandate to move on, therapists need to create an internal and external space for these intense feelings. This involves a lot of interpersonal work, and often requires a lot of our own psychotherapy.

Those of us who work with medical patients suffer vicarious trauma. We don't talk about it much, as we are not so sure that our colleagues won't pathologize us. In fact, I felt quite misunderstood by a therapist I was seeing when I first started working with severely ill clients in a hospital setting. “When I tried to articulate my terror regarding seeing people my own age who were dying, my therapist interpreted these fears as "unrealistic."” My view was, how could my fears be unrealistic? The young people I was seeing had not engaged in risky lifestyle behaviors; they just were victims of bad luck. How was I to know that this could not happen to me?

Therapists who don't work with medically ill clients often remark that those of us who do have a skewed view of the world or that we don't have good boundaries between our clients and ourselves. Regarding the former idea, our colleagues are right. Therapists who specialize in work with medically ill adults primarily see people who have been subjected arbitrarily to illness. I did have a skewed view of the world, especially when I was younger. As I have gotten older, I realize that many medical illnesses are rare and unfortunate, and I feel privileged to have been able to help my clients at a time in their lives in which they needed someone who could tolerate randomness and unfairness of disease and illness, to acknowledge the potential of death, and most importantly to help them know they are not to blame. Indeed, many people feel that random illness must be caused by something they have done. Feeling that they have caused the illness is a way to believe that they can stop it. Sadly, this is not true. But the idea that we can predict and know of our potential to cause (and cure) our own illnesses is seductive.

A younger colleague, who works with people who have rare lung cancer, said to me recently, "When I cough, I think I have lung cancer." When she said this, I was reminded of the claims launched at me over the years by well-meaning colleagues: that my work was reducing me to a state of lowered boundaries, and that it was crazy to think I might be in the same boat as my clients. And though on one level I can understand these criticisms, on the other it feels so profoundly misplaced and misunderstood. As I said to my younger colleague, "Of course you feel this way. There is no way to work with such an unfairly beleaguered population and not feel scared about what this can mean for you. Bad things just happen."

Psychology, and especially psychoanalytic psychology, can be funny in that “we as therapists are "allowed" (especially in training) to indulge in whatever ideas and fantasies we might have about our own psychological problems, but we immediately pathologize whoever is talking if they have worries about their own bodily health”—they must be too "concrete," they must have some difficult psychological problem that allows them to somatacize. The reality, however, is the opposite of what people often perceive. When we work with medically ill people and are confronted with the random nature of illness and the cruel distribution of severe illness, it is natural that as therapists we would imagine ourselves in the same situation. After all, what else can be described as the true seed of empathy? And in my experience and those of students I know, it is this kind of empathy, "What would it mean if this were happening to me?" that is the most profound and ideal empathy we need to have inside of us to help our clients manage the painful and difficult aspects of illness they are confronted with.

The Difficulty of Engaging Clients

A few years ago I was teaching a class on psychodynamic perspectives of medical illness and mentioned a common phenomenon: many cancer patients who engage in therapy do so when they are in the active stages of their medical treatment (e.g., chemotherapy or radiation); once these stages are completed, many of them leave therapy. The therapists in the class who had worked with people with cancer laughed and seemed relieved to know that this is a common experience and not necessarily based on the therapist's individual psychotherapeutic style or practice.

While it is true that many people with medical illness (not just those who have cancer) present for psychological treatment in the more acute phases of illness and then leave when illness becomes chronic, is in remission, or in the best of circumstances, is cured, it raises the question of why this happens and how it affects the psychological health of people we try to help. One possibility is that those who are acutely ill and undergoing intensive kinds of treatment need acute and intensive psychological support, and once that phase of medical treatment is finished, they may feel that less intensive psychological treatment is needed. Although this rationale may appear to make sense, I have been surprised over the years at the number of people who have left psychotherapy after the acute phases of medical treatment, as some of these clients clearly had issues that would have benefited from longer-term psychotherapy. And even though it is true that some people, particularly those who have had psychotherapy in the past, might be inclined to continue with therapy after the acute phases of treatment, how are we to understand those who do not? And are there things we can do to increase the chance of engaging some of these people in a more meaningful and helpful therapeutic relationship?

People with medical illnesses are hesitant to engage in longer-term treatment with mental health clinicians for a number of reasons. As described, the culture of medicine and modern healthcare reflects a hypomanic culture in which "cures" are provided in a quick and often rushed manner. The practice of psychology within medicine, though valuable, offers a culturally inconsistent approach for people with severe medical illnesses. Even with the approaches often advocated within health psychology and medical care (specifically cognitive-behavioral approaches), the integration of psychology in medicine remains largely difficult.

Integration of psychological approaches and applications in healthcare has improved dramatically over recent years, yet psychological services are largely viewed as an elective treatment within the medical system. To some extent this makes sense. From a practical standpoint, many people undergoing medical care are overwhelmed with medical appointments, as well as the financial expenses involved in receiving care for an illness. Time and money spent on psychotherapy may not seem to be a priority. Physicians may not consider referrals to mental health professionals for those patients who seem to be coping well, even though therapy could be of great benefit.

However, even for people who have financial resources and time for it, therapy is often construed as not only elective, but also a burden. Psychotherapy requires a tremendous amount of resources, both internal and external. “People with severe illnesses are often taxed with the impact of bodily changes and decline, physical pain, and fear of death: surviving from day to day involves tremendous physical energy, and as a result, psychological energy that might be employed to address emotional issues is reduced.”

This relates to the idea that medical patients often present as being more psychologically "concrete." The term concrete has been associated with thinking in patients who are more severely disturbed, such as those who are psychotic or those with personality disorders. However, this way of viewing concrete thinking is very limited—and in itself concrete! A more modern perspective is that, especially under times of stress, we all can regress to a more concrete way of operating, and this is often the case with severe physical illness. In such states, we feel more sensitive to intrusions, more focused on pragmatic aspects of functioning, with less emotional space for reflection.

Trauma researchers have long known that traumatic events make it difficult for people to think in a symbolic way4. The burden is on us, as therapists, then, to help make space for symbolic thought, as opposed to demanding that our clients do so for us.

What Seems Concrete Is

Sara* was a 30-year-old doctorate-level professional when I met her. After a routine doctor visit, her physician had told her that she could not go back to work that day, but needed to be hospitalized immediately for dangerously low blood cell counts. She was diagnosed with leukemia. I met her a few days later in the hospital; she was referred for what her nurses described as almost nonstop crying and excessive controlling behaviors, such as continually asking the nurses to verify the accuracy of her medications, even when they had already told her what they were giving her and confirmed that the dosages were correct.

When I met with Sara, she was guarded and extremely anxious. Although she felt that she wanted help by talking with me, she appeared in genuine shock (as would be expected) but also panicked. When I suggested that she might feel overwhelmingly anxious, and that perhaps she even thought that the feelings she was having would cause her to die immediately, she agreed. She said that at times she felt that she could just "die right there," even though she knew she was getting treated for her disease. The panicked feelings made it difficult for Sara to cope in the hospital. Staff became increasingly concerned because she often asked for higher levels of anxiolytics and pain medications, presumably to manage her anxiety. Sara acknowledged that she just wanted to feel "numb." Although I had suggested an antidepressant, which might provide longer-term and more consistent relief from her symptoms, she refused, objecting that she did not want to feel "controlled" through medication.

As for my role while she was in the hospital, Sara was able to talk to some extent about her anxiety. However, discussions tended to focus on aspects of her life that needed to be managed and taken care of, such as who was paying her bills, what was happening in a recent financial transaction, and how others were managing her projects at work. And although I willingly discussed these topics with her, I felt as if there was little I could do to help ease her tremendous anxiety.

Sara's situation illustrates that when someone is overwhelmingly terrified in response to a serious and life-threatening illness, his or her ability to think about meaning is reduced. Sara's panicked state and her constant checking on the nurses prevented her from slowing down long enough to realize that she was not going to die immediately. They also prevented her from thinking about what she could do to help herself in her situation. She felt that her life was already over, even though she had a long road of treatment ahead of her. Feelings of hopelessness in medically ill clients are common and can be detected by a feeling of helplessness in the therapist, which I felt acutely while I was with her.

Sara attempted to manage her anxiety by becoming more watchful of her environment, including frequently checking that the nurses would not make any mistakes. Not only was Sara terrified and attempting to manage her terror, but I understood that underneath her need to be more in control of her environment was a sense of profound confusion regarding what was happening to her. Attempts at control were a way to reduce the confusion she felt. In her conversations with me, Sara felt the need to go over events in her life that she could not currently control as a way to try to maintain control. She was stuck in this way of thinking and needed me to give ample attention to these external events.

Talking about the more real issue of what she could not control (her body) was not possible, as it made her unbearably anxious and confused. Sara had been caught completely off guard by this diagnosis. As a relatively young woman, she'd had little experience with major illnesses or death. She had no risk factors for malignancies, something she eventually told me she often thought about. Not knowing why or how this had happened to her was a tremendous source of distress. The level of her confusion was so intense that at times she felt as if it would overwhelm her. This is one meaning of panic attacks that sometimes occur in people with medical problems; “anxiety, confusion, and feeling out of control become so powerful that people sometimes feel as if they will die then and there.” It is as if the idea, "Well, I might as well just die now," takes over. The price of such a way of thinking, however, is that Sara and others like her forget that they are still alive, and can maximize coping resources to fight their illness.

Although it is understandable that many people experiencing a life-threatening illness would be terrified, the kind of terror I am describing is the kind where one cannot find refuge in a logical reminder that they are not dying at that moment or that others are helping to keep them alive (meaning, in these cases, medical treatment). This is because the disorienting feelings in reaction to a traumatic illness can become overpowering. Sara could not find solace in the fact that she was being treated for a disease. Sara was so tortured by her anxiety that she feared others, even though these others were desperately trying to help her. She became wary and guarded.

Though I knew that the nurses and doctors caring for her at the time were extremely sympathetic, Sara could not absorb sympathy. Her fears had rendered her helpless, feeling paralyzed and tortured. In this state, no one can really be trusted. Additionally, in this state of mind, the act of thinking as well as having ideas, of any kind, can feel like torture. In other words, the process of thinking as we understand it can feel persecuting, because in a situation in which the body has failed, it is hard to know who to trust. Sometimes in such scenarios, people are even hesitant to access their own thoughts, as thoughts themselves (being present in one's mind) can feel equally as terrifying and persecuting.

This kind of state presents a unique problem to us as therapists, in that the people we may want to help the most are intensely (and often unconsciously) unable to take in what we have to offer. “Their terror becomes our cross to bear. In other words, the intense and barely known emotions become something we have to share and know in order to help. With Sara, I had to tolerate feeling helpless, enraged, outraged, and terrified about what was happening to her.” At the time I knew her in the hospital, she could barely acknowledge these feelings in herself. So I absorbed them and hoped for the best for her, and hoped as well that at some point she could feel her own emotional turmoil.

Sara did well with her medical treatment in the hospital, but was never able to follow up for therapy as an outpatient. And because of that, I can never quite be sure whether my work was helpful to her or not. Such is the case when working with people who are seriously ill. I do not know how Sara fared, or even whether she is still alive. This is another difficult fact of working with severely ill clients, especially in hospital work. As mental health clinicians, we are often not privy to the medical outcomes of those whose lives we become invested in. Clients struggling with illness can't necessarily follow-up in longer-term psychotherapy, for both physical and psychological reasons. As helpers in the world of medicine, we often have to tolerate not knowing whether our clients live or die.

Psychological Ramifications of Cancer Diagnoses

Most of us who are born without chronic illnesses take the functioning of our bodies for granted. When the body stops working in adulthood, this jars one's sense of self. And if the inside of the body does not work, it is very hard to know how and what to trust on the outside. Many cancer patients talk about the eerie feeling that cancer cells have been growing in their bodies without them knowing it. This may be related to both ideas and fears of cancer in our culture. Although heart disease is the number-one cause of death in industrialized countries, many people verbalize not a fear of heart disease, but of cancer.

This is most likely because the imagery associated with cancer, in which bad cells insidiously destroy good cells, resonates with the fear of the internal workings of the body being attacked by itself. This idea has roots in early developmental theories of childhood. Aggression is something we all struggle with as younger beings. Dependency, a sense of not being in control, and anger about that fact that we need to rely on others are facets of young childhood. When things go right in childhood, we can emerge relatively unscathed and able to tolerate our own (and others') limitations and need for dependency.

But when things don't go right, or when parents are preoccupied, we then struggle to tolerate the fact that at times we will need others. The sense that the body is attacking itself is common among clients with medical problems. When this feeling is excessive or pervasive, it can sometimes be a sign that, as children, these clients were often left alone to deal with angry feelings. These feelings can and do often come back to us as adults, especially when dealing with something amiss in the body that we cannot understand. “A sense that the body can attack itself feels like our own toxic anger is turning inward in ourselves, and results in disorientation and mistrust of people in the "outside" world. For some, this results in confusion, collapse, and a feeling that nothing can be trusted either internally or externally.”

Sara tried to remedy these disorganized, helpless, and out-of-control feelings by managing the nurses' behaviors with an attempt to control, in a literal way, what was being put into her body. Such patients need to be able to feel that they can control what we, as mental health clinicians, "put into" them as well.

In these situations, we need to tolerate the fact that due to a patient's suspicions and sense of terror, it may feel at times that we have little to offer. However, just being able to engage with patients like Sara goes a long way. It means a lot to listen and tolerate unbearable feelings when no one else can. People caught up in medical crises often cannot turn to their physicians, as their work requires a kind of detachment. Family members are often so scared themselves that they often tell me they can't bear to hear my clients utter anything other than positive statements. Thus, our clients need us to bear the confusion, terror and disorganization to which they are subjected.

Hope In The Trenches: The Meaning of Our Work

Janet*, a client of mine, died recently after a long battle with cancer. When I saw her for the last time, she told me she was scared of death, but relieved to have an end to her suffering. She grabbed my hand and said, "I can do this now. Thanks for helping me to know that I can let go." Our work together lasted less than a year.

I met Janet in the context of several medical problems while she lived in a skilled nursing facility, but in the process of our working together, she was diagnosed with recurrent cancer. Although she had been told that her cancer had not been cured, and that she would eventually die from the disease, she had convinced herself that her prognosis was otherwise. When she was told that her cancer was not only back, but raging with virulent intensity, I gently suggested that her lifespan was shorter than she had previously thought, and that she might want to say goodbye to those who were important to her. In the context of our relatively close therapeutic relationship, she could hear this, and no longer needed to be in denial about what would be her fate. She was able to say goodbye to those she loved, and was even able to say she was sorry to people she perceived she had hurt.

I could not continue to work with people who were enduring this kind of suffering unless it felt like there was some help I was able to provide, and it appeared that I had helped Janet to relinquish the denial she had so desperately clung to, and had eased her feeling that she was dying alone. These moments remind me of why I got into the practice of working with medical clients to begin with. And more importantly, when I come home every night to my husband, I am so grateful for what we have, now.

*Client names have been changed to protect confidentiality.

Excerpts from this article are taken (with permission) from Psychodynamic Perspectives on Aging and Illness, Springer, 2009. The paperback version of this book was released in June, 2010.

References

Diagnostic and Statistical Manual of Mental Disorders 4th ed.; DSM-IV; American Psychiatric Association, 1994.
Klein M. (1940). Mourning and its relation to manic-depressive states. International Journal of Psychoanalysis, 21,125-153.
Winnicott, D.W. (1966). On cardiac neurosis in children. In R. Shepard, J. Johns, & H.T. Robinson (Eds.), Thinking about children. New York: Addison Wesley
van der Kolk, B.A., Hostetler, A., Herron, N., & Fisler, R.E. (1994). Trauma and the development of borderline personality disorder. Psychiatry Clinics of North America, 17, (4), 715-730.