Medical Psychology: Putting Mind and Body Together

Death and dying

2010-08-01T16:36:00.000-04:00

8/1/10
I spent this afternoon with a very decent and good man who is dying from lung cancer. He and his wife were seen together some years ago for trauma and a significant loss. His wife died suddenly a few weeks ago in her sleep and he is not long for this world. This is something that I have not gotten used to and probably never will: the fact that many of my patients are sick and die. He and his wife are not the first patients I have lost and will not be the last, of course. It is that his passing is particularly poignant to me. He has been ill for some time now and has known of his demise. He has been accepting and has approached his death from the start with remarkable calm. His only concern has been the impact of his death on his family. His calm acceptance and sanguinity about his death and his coping with his increasing disability has taught me much about the resilience of human beings and the importance of religious faith, especially in his case. It also reminds me that none of us live in a vacuum and how we live and how we die impacts others in ways we can never know. I only hope that my life will impact as many people as his has and in such positive ways. It is not the things that we acquire in life that matters but the relationships we form and nurture.

Sally M. Duffy

Why Psychology and Medical Psychology? Blog #1 in a series

2010-06-30T21:45:00.001-04:00

Psychology permeates every aspect of our lives, whether we realize it or not. Whether learning in school and out of school, shopping and making decisions about what to purchase, entertainment and what we enjoy doing, making choices about how to spend our lives in terms of careers, making ethical decisions about right and wrong, who we love and choose as mates, psychology is involved. Marketing, retail, advertising are all about psychology. How we make choices about what to eat involves psychology: whether to chose a Big Mac or a salad, for example. At one time, philosophy was considered the Queen of the Sciences. Now, I believe that Psychology can be considered as such. Psychology also interacts with biology and how our brains and minds work. If we could not learn and think also known as cognitive psychology, there would be no physics, no astronomy, no paleoanthropology, no sciences of any kind, with due respect to my various scientific colleagues. I suppose I could be accused of over-stating the impact and importance of psychology, but I am proffering this thesis to get people to really think about the status of psychology in their own lives. And once one does, I believe you will find it be just as pervasive as I do.

I am also introducing my blog in this manner to distinguish it from the many excellent and academic psychology blogs out there (see top 40 psychology blogs). Most of these are dedicated to recent research findings which are very important. Unfortunately, there are no blogs in the top 40 that pertain to Health and Medical Psychology and I do not intend this to be a strictly academic blog. Rather, this is geared to more personal reflections based on my own experiences in the field and my own life.

So, next, what is Medical and Health Psychology? Recently, Medical Psychology has been used to delineate only those psychologists who can prescribe psychotropic or psychiatric medications. Now, unfortunately, this is very limited to only a few states and Guam but it is hoped that this will improve significantly over the next few years. For my purposes, I consider myself a Medical and Health Psychologist as I typically deal with individuals who have various medical and health conditions and illnesses, with a primary specialty in chronic pain. Chronic pain can result from accidents, medical conditions such as rheumatoid arthritis or MS, surgeries that leave scar tissue or other problems. Sometimes chronic pain has no definitive cause. Fibromyalgia is a chronic pain condition for which there is no definitive genesis although some theories have been offered. How does chronic pain interact with psychology? Chronic pain is pain that typically lasts longer than 3 months or sometimes 6 months depending on whom one consults. Chronic pain that is not adequately managed is like water on a stone and can wear people down resulting in depression and anxiety with attendant symptoms of irritability, diminished stress tolerance and a tendency to over-react to minor stressors, anhedonia (an inability to enjoy usual activities), social withdrawal, negative thinking or rumination and pessimism, among other symptoms. Suicidal ideation is not uncommon. Chronic pain is also often accompanied by many losses such as the loss of a job or profession, friends, hobbies and marital and family satisfaction and relationships. Sometimes it is complicated by worker's compensation and adversarial issues. Expectations that a person should be "100%" before returning to work can also be problematic. These issues are only some of those attendant to chronic pain, though, and this is only a brief summary. My basic agenda in dealing with someone wiht chronic pain is that a decent quality of life is still possible despite chronic pain and my approach is to help people learn to cope effectively with having chronic pain.

The Making of a Medical and Health Psychologist. Blog #2 in series

2010-06-29T20:07:00.000-04:00

There are actually not that many psychologists who specialize in medical and health psychology and even less who specialize in pain management. The training is typically a bit more rigorous and seemingly unending in
many ways. I am learning every day as a matter of fact; there is still so much I do not know.

Educationally, I always enjoyed philosophy and biology/physiology. There's not much call for practicing philosophers, however, so I found a field that seemed to meld the best of both which turned out to be psychology. In fact, I pestered my parents for a microscope and a dissection kit at the age of about 11 and soon devised ways of rendering frogs unconscious but not dead so that when I dissected them, the hearts were still beating. My mother was aghast and limited me to reptiles and amphibians only. However, I found it fascinating and my love affair with biology and physiology began at that point. It is sometimes surprising that I did not simply go into medicine, but being 'young and dumb', I mistakenly thought that a graduate degree in psychology would not take as long as medical school. So, I ended up in psychology with a BS from the University of South Carolina. I worked for a year and then went to Eastern Kentucky University for a 60 hour, 2 year MS in Clinical Psychology. I then worked for 4 years, one of which was in the mountains of eastern Kentucky, from which I have some great stories. I then worked for 3 years in Louisville at a Rehab Hospital where I found my calling. I returned to graduate school in Counseling Psychology at the University of Kentucky where I also became quickly affiliated with the Medical School. My training therefore included courses in both psychology and the school of medicine. (By the way, there are philosophical differences between clinical and counseling psychology, which led me to choose a PhD in Counseling rather than Clinical Psychology.) I did the required clinical practica and internship and I then did a post-doctoral fellowship in pain and neuropsychology at the Medical University of South Carolina in Charleston,SC. Graduate school, practica, internship, and fellowship all totalled many more years of school and equalled med school with a residency. I also had the happy experience of a part-time job while in graduate school at a clinic specializing in chronic pain, which helped crystalize my career goals. So I ended up in Medical and Health Psychology initially through my interests, and then by a remarkably inaccurate belief that I could enter a career by taking a short cut. As most of us know by middle-age, this never works. However, the outcome has been happy and I enjoy my work, although I do not enjoy insurance companies and managed care.

When Medical and Health Psychology Becomes Personal: Blog # 3 in series

2010-06-28T16:58:00.000-04:00

It may be interesting to some to note that my first two initial blogs were composed while sitting at my mother's bedside while she has been very ill recovering from a radical nephrectomy because of renal cancer from which she has incurred a few complications. I live in Charlotte, NC where my practice is and I have a brother here in Charleston, Rocky, a sister in Atlanta, and another brother in Connecticut. We had a sister who lived about a mile from my mother who died suddenly this past December. My brother in Charleston and myself have basically been providing most of her care although my sister is coming this evening and my other brother next week. In the meantime, my brother, Rocky, took her to all of her MD appointments prior to the surgery, and I have been staying most nights and days at the hospital. However, being human, which trumps being a psychologist, I left late the other night to get some sleep away from the hospital and my brother took off work and stayed all yesterday, to provide me some much needed relief.

Why am I relating all of this? After all, I have been planning my blog for many months, and we only found out about the renal cancer a few weeks ago. I think it is important for people to know that psychologists are people first. I have worked with many people over the years who have been diagnosed with cancer and was able to reassure my mother that it is normal to feel anxious and desperate to have a foreign mass removed and to help her through the weeks prior to the surgery and during this time after surgery. However, having such skills does not mean that I am not immune to my own feelings of exhaustion, fear, and anxiety about her health. I am also including this because this situation illustrates the fact that most people at some point in their lives will deal with illness and pain in a loved one or themselves and could benefit from the findings of medical and health psychology as a field and by the skills possessed by medical/health psychologists in terms of coping with such difficult situations.

As a caregiver, one is told to "take care of yourself". Unfortunately, this is not built in; there are often not enough resources to enable this to occur, time is a huge problem, and the person who is sick is the usual focus of care, not the caregiver. The caregiver often feels guilty for taking a break or taking care of him/herself. This is often exacerbated by the naked need of the sick individual who is frightened of being left alone, either at home or at the hospital and it is very difficult to say 'no' and 'I need a break'. However, if the caregiver does not take care of him/herself, s/he will not be able to do a good job taking care of the ill individual. Further, resentment builds. Resentment results from unmet needs and these needs have to be met by the caregiver; one cannot expect someone else to magically meet them. Ask for help from others for a break, hire respite care, allow yourself to go out to a movie or dinner with friends. I promise that such activities can actually make a person a better caregiver in the long run.

Effective communication is also crucial. This includes communication with doctors and other healthcare providers, including writing down questions that one wants to ask the doctor and the answers that are provided. People usually think that they will remember their questions and the answers but they seldom remember them, and then often inaccurately. It is also important to consider clarity of communication. Most doctors speak their own arcane, professional medical language which is incomprehensible to most laypeople. I want to stress that it is okay and appropriate to ask the doctor to speak in a manner that is understandable to you as a layperson. This will not make you look foolish or 'stupid'. Think in terms of an auto mechanic or electrician. They also have their own professional languages and they have to clarify the problems to the laypeople they deal with as well. Communication issues are also important with family and friends. When someone feels ill or in pain, there is a tendency to either respond irritability and to take out frustration on family members and friends or to withdraw from them. These are the people who love us and are potentially the best support we have in difficult circumstances. Alienating them through anger or withdrawal is not in anyone's best interest and can lead to many problems down the road. After nearly 30 years in this field, I have never seen a marriage break up simply because of illness, pain, or disability; but I have seen many break up over abusive, demanding, nasty, hostile, unreasonable, and aggressive behavior which has been blamed on illness and pain which as far as I am concerned is an excuse, not a reason. This often calls for professional intervention, such as by a medical/health psychologist.

Healing takes time and patience. Pain and nausea are the 2 worst physical sensations that we humans can experience. There are also psychological consequences of feeling ill, including depression, anxiety, a sense of hopelessness that one will ever feel better, and general psychological malaise. A lack of motivation can also become problematic such as unpleasant diets or no food for days at a time, walking down hospital hallways when exhausted, needles and medications, and having to undergo unpleasant medical tests. Serious surgeries involving spine surgeries or open, large abdominal surgeries lead to their own unique problems as well, and recovery requires engaging in behaviors that are often resisted such as walking, walking, walking and staying out of bed as much as is possible. Narcotic pain medications, general anesthesia during surgery, open abdominal surgeries themselves, and inactivity can lead to serious bowel complications. Avoidance as much as is reasonable of narcotic pain meds, and walking as much as possible are important but most patients are less than thrilled to comply. Of course, it is also known that controlling post-operative pain as much as possible also improves healing, but the downside are bowel complications. So there is a benefit to risk ratio that always has to be considered. This also pertains to managing chronic pain and chronic health problems as well.

Well, this has gone on long enough, but there is also so much else to say. So, later in another blog which I also hope will be shorter!

So, What does a Medical/Health Psychologist DO? Blog #4

2010-06-27T20:47:00.000-04:00

My day usually starts at about 7:30 AM and I try to be home by about 6:30 PM or sooner. The older I get, the longer these days feel! I see about 9 patients per day, write reports and notes, call physicians and call back patients who have called in, deal with insurance companies (although I have an excellent Administrative Assistant who does most of that; she also schedules patients and collects co-pays). I also go through the mail, encode payments from insurance companies on an excel spread sheet, pay the bills associated with having a practice, and occasionally talk to colleagues. Sometimes, I visit hospitalized patients or patients in hospice.
As I noted in my first blog, my basic agenda is to enable a person with chronic pain or a chronic health condition to have an improved quality of life. For example,this may involve teaching basic anatomy about the back and back pain, how sciatica or other pain can develop from a nerve that is being impacted, how scar tissue can cause pain, how pain and stress impact on serotonin levels leading to depression, among other things. I use models and charts as aids in this regard. Physicians generally do not have the time to explain such basics but I think it is important for people to understand as much as possible about their pain and/or their condition. This can dispel some of the fear and anxiety that develops as a result of pain and physical dysfunction. Sleep is almost always an issue and I may discuss sleep basics and something called sleep hygiene to help improve sleep. I stress the importance of pacing and modification of activities in order to re-engage in missed activities in some form again. Managing pain and chronic health conditions frequently involves problem-solving and I address this on a regular basis so that my patients can eventually learn to problem-solve on their own. Effectively communicating with health care providers is taught because such communication is essential in healthcare. Providers often talk over their patients' heads and patients often do not go to the appointments prepared with written questions that need to be asked. Communication with family and friends can be adversely affected when someone does not feel well and this can lead to alienation and isolation which only makes someone feel worse and impair family functioning.

I use a philosophical approach that is referred to as a biopsychosocial model of illness and pain which most medical psychologists endorse. This involves the interaction of biology, psychology, and social factors that impact on an individual and their health. For example, if someone is improving physically, but is living with an abusive alcoholic, that social aspect of their situation will impede recovery and has to be addressed. In terms of therapy, I utilize cognitive-behavioral therapy also known as CBT, this is an approach favored by most pain and health psychologists. Basically, negative beliefs and how we think and appraise or judge situations are going to impact on how we feel and how we behave. For example, if we tell ourselves that we are never going to get better or our pain will never improve, this will lead to feeling hopeless and depressed with a lack of motivation to do those things that have been suggested to aid in recovery or improvement. Learning to think accurately is critically important and my patients probably get tired of my incessantly asking them if what they are telling themselves is fact-based or emotion-based and inaccurate. The facts are almost never as bad as what we tell ourselves about a situation.
In CBT, it is also important to identify automatic thoughts or inaccurate, emotion-based beliefs that develop prior to adolescence. These are such thoughts as "I am not good enough unless I do everything perfectly". Of coures, this is inaccurate and emotion-based and not based on facts and will only lead to feeling depressed, anxious and worthless. Such over-learned beliefs are identified and challenged with facts. This has to be done consistently since these kinds of beliefs can be difficult to effectively change.

I also do evaluations for Spinal Cord Stimulators and Intrathecal Pumps. These are physically implanted devices to aid in managing pain. The first involves a small generator implanted in the upper buttock (usually) with leads attached to wires placed under the spine and as close as possible to the spinal cord. In order to feel pain, the signals have to register in the brain and a SCS serves to block some of those incoming pain signals, thus providing pain relief. An intrathecal pump is a larger device that is also implanted that contains narcotic or opioid medication that is sent more directly to the spinal area and typically requires less medication than narcotics taken by mouth. Pumps also have less impact on brain functioning and fogginess that can be problematic with narcotics.