Professional Psychological Support for Cancer Patients

7.3. Psychological support for cancer patients at various stages of treatment

Pestereva E.V., Chulkova V.A.

Traditionally, psychological support in oncology is provided by medical psychologists and psychotherapists throughout the entire course of a patient's treatment in hospital. In doing so, in accordance with clinical and psychological studies that have been conducted, account is taken of the psychological problems of cancer patients that are specific to each stage of treatment, as well as of the particular ways in which their internal picture of the illness is formed, which influences their attitude toward the illness and their means of adapting to the disease [2, 4, 6]. During the course of treatment – from the diagnostic stage to the stage of discharge from hospital – the majority of patients come to accept the malignant nature of their illness. However, psychological studies of patients with tumors of various localizations show that acceptance of the illness does not always coincide with the stages of treating the illness. Thus, for example, in some patients with malignant lymphomas, acceptance of the illness occurred not during the course of primary treatment, but only upon relapse of the disease.

Since the time when the first medical psychologists began to work in oncology institutions, changes have taken place. First, at present virtually all patients are informed by physicians of the diagnosis of their illness. Second, the development of medical technologies and the application of new methods of treatment in oncology have led to a reduction in the length of patients' hospital stays, and now a patient may not

have the time needed for certain categories of experiences that are connected with the disease and its treatment and that are important for acceptance of the illness. For example, if a patient has had no pronounced experiences during the preoperative period, especially in the case of a mutilating operation (admitted yesterday, operated on today) – this does not mean that they have disappeared entirely; on the contrary, having gone unprocessed, these experiences may intensify subsequent ones. The reduction of the stages of a patient's in-hospital treatment not infrequently leads to a situation in which the psychological problems of each specific stage of treatment are not resolved by the patient and, despite being informed of the diagnosis, the experiences associated with accepting the malignant nature of the illness not infrequently arise once the patient has already been discharged from hospital, which may contribute to the development of maladjustment. It is necessary to bear in mind that the process of informing a patient of the diagnosis of the illness is far shorter than the process of the patient's acceptance of the illness: for the latter, the patient requires time filled with emotional experiences.

A psychologist working in an oncology institution today must take the above-mentioned circumstances into account: a psychologist's ignorance of the specific psychological problems and experiences of a patient at a given stage of treatment prevents him or her from seeing a detailed picture of the dynamics of the patient's mental state during the course of treatment.

Psychological support for cancer patients at the diagnostic stage

At the diagnostic stage, the patient is confronted with the presumption that he or she has a cancerous disease and with the need to consent to examination. As a rule, at this stage the patients' experiences are determined to a greater degree by psychological causes brought about by the diagnosis of cancer than by physical causes directly related to the illness. At the same time, the patients' condition is influenced by the localization of the tumor, its rate of growth, and the biological, immunological, and hormonal effects of the tumor on the body. However, for the most part, cancer patients are characterized by the fact that they do not feel

themselves to be ill until the tumor is discovered in them; they do not consider themselves ill and pay no attention to the signs of the illness, and at times they even ignore them. In this connection, the news of having cancer is always unexpected and sudden, and it produces psychological shock. Against the background of the severe distress associated with the news of having a cancerous disease, a lengthy process of psychological adaptation of the afflicted person and of the formation in them of an internal picture of the illness begins (see Chapter 4). At the same time, psychological defenses are activated that allow patients to preserve their own integrity (see Chapter 4).

The principal task of psychological support is the formation of an active stance on the part of the patient toward further examination and treatment. The creation of an adequate orientation toward treatment is fostered by trusting, supportive relations between physician and patient. In informing the patient of the diagnosis, the physician acts upon the cognitive component of the internal picture of the illness. It should be emphasized that the formation of the internal picture of the illness is especially difficult at the stage of detecting a cancerous disease, when patients are in such a state that their capacity for objective analysis of the situation and for assimilation of information is impaired, while the emotional component of their attitude toward the illness is represented by feelings of fear, anxiety, and worry, up to the point of panic. The emotional component exerts an influence on the patient's judgments about the illness, which may manifest itself both in the form of an inadequate assessment by the patient of his or her own condition and personal capabilities, and in the patient's heightened tendency to systematize knowledge and form concepts of a paranoid or hypochondriacal nature.

In this situation, the psychologist's work is directed at providing the patient with the opportunity to express strong negative feelings. The psychologist makes use of crisis intervention and art therapy. At this stage, methods of cognitive therapy are also applied, the principal aim of which

is to change the patient's maladaptive beliefs regarding the illness and its treatment.

Another important task may be the psychologist's work with patients who have refused the proposed treatment. Refusal of treatment may be dictated by a lack of faith in the possibilities of medicine due to a negative example of treatment of someone close to the patient, by fear of the proposed treatment, by a satisfactory condition at the present moment, or by the patient's having a traumatic experience of interaction with physicians. The psychological reason for refusal may be quite disguised, implicit, and not always recognized by the patient himself or herself. Patients inclined to refuse treatment not infrequently avoid visiting physicians after the diagnosis has been established; however, knowledge of the diagnosis does not allow them to live their accustomed life. These patients, first and foremost, need to be helped to express and become aware of their feelings, and only then to move into the rational sphere of reasoning and arguments concerning the illness and its treatment.

Psychological support for cancer patients at the hospitalization stage

At the moment of hospitalization, most patients find themselves unprepared to overcome the extreme stress brought on by the discovery of the illness and the need for serious treatment. Insomnia, loss of appetite, and mental tension appear, and depressive states and elements of depersonalization, caused above all by anxiety, are not infrequently observed. Closely connected with the emotional disturbances are changes in the cognitive sphere: difficulties in concentrating attention, a reduction in the span of attention, and deterioration of memory.

The afflicted person finds himself or herself torn from accustomed life, and the need arises to adapt to the conditions of existence in the clinic, to new faces, and to the medical staff. The hospitalization stage proceeds especially hard in patients who had previously rarely been ill and were socially active. On the one hand, the change, in connection with hospitalization,

of one's habitual pattern of life and the need to adapt to the conditions of the clinic may engender in the patient a feeling of dependence on the medical staff and on the physician's prescriptions («Nothing here depends on me; I am like something on a conveyor belt»). On the other hand, patients point to positive factors in connection with admission to hospital: the beginning of treatment, the attention of the medical staff, and examples of the successful treatment of other patients («I realized that people undergoing treatment also go on living: their everyday cares do not go anywhere»).

At the hospitalization stage, a great deal of new information «comes crashing down» on the person, information that the patient at times has neither the strength nor the time to think through. Negative information about the disease, which represents a vital threat, activates psychological defenses: in the structure of patients' attitudes toward their illness, an anosognosic component not infrequently predominates.

Patients' thoughts are often focused on searching for the causes of the illness; this question is very important for forming one's own conception of the illness, which the patient needs in order to feel a sense of control in the uncertain situation of the disease. For some patients, reflections on the illness are so traumatic that, as a psychological defense, a repression of all thoughts connected with the disease occurs in them. Alongside this, there are patients who obsessively analyze their past and find no causes for the disease: self-analysis of the past is not a resource for them. Still other patients do find causes for the disease: the loss of a loved one, nervous strain, overwork, harmful work, ultraviolet rays, and other causes, not infrequently irrational. It is important for the psychologist to understand that the search for the cause of the disease points to the patient's inner psychological work, as a result of which the internal picture of the illness is formed in the patient.

The internal picture of the illness in patients at the hospitalization stage is, as a rule, not yet formed; it is fragmentary. But, in contrast to

the previous stage, patients possess information from the physician about the diagnosis of the disease and the proposed treatment. This knowledge creates in them a certain attitude toward the illness, the treatment, and the new life situation. Patients concentrate their attention on the functions of their body and listen closely to the sensations coming from the body, which are likewise a source of the internal picture of the illness. With fear and interest, they listen intently to the judgments and advice of other, more «experienced» patients, who, in turn, use this to reduce their own anxiety or for self-affirmation. It should be kept in mind that emotional tension, anxiety, and a sense of uncertainty bring about a person's heightened suggestibility: a patient is prone to «merging» with the experiences of others (for example, roommates in the ward), and to projecting onto himself or herself information, often distorted by rumors, among which negative information (death during or after an operation) is of a particularly severe character.

Psychological work at this stage should include methods aimed at reducing the patient's emotional tension, including work with strong feelings and relaxation; it is also important to be prepared to discuss existential questions with the patient.

Psychological support for cancer patients at the stage of surgical treatment

The preoperative period. Awaiting an operation is in itself a serious traumatic factor. Before an operation, as a rule, all patients have an elevated level of anxiety, which, on the one hand, is adequate to the situation. On the other hand, in a state of extreme mental tension, anxiety may be transformed into fears of various kinds: fear of death, fear of «the anesthesia», fear of «losing control» during the anesthesia.

Despite the fact that the treatment tactics have already been worked out by the physicians, in patients during the period before an operation the attitude toward the illness is unclear and contradictory. During this period, the patients actively form

the internal picture of the illness, with which the extent of the operation and their notions of the anesthesia are connected; therefore, a conversation between the physician (including the anesthesiologist) and the patient before the operation is extremely important.

The psychologist's work is directed at the patient's acceptance of the fact that the operation is necessary. In this connection, the psychologist uses various methods that allow the patient to express and become aware of his or her emotions.

The postoperative period – the first few days after the operation are physically very hard for patients. Patients experience painful sensations of varying intensity, which constrain their movements and render them helpless. During this period, asthenic-depressive and anxious-hypochondriacal syndromes predominate. In the patient's consciousness, the fear of complications, worry in connection with the consequences of the operation, and general physical fatigue come to the foreground.

Anxiety and new hopes are aroused by the anticipation of the final histological findings, which will determine the tactics of further treatment. At the same time, the patient not infrequently experiences disappointment, a feeling of the «injustice of fate», and regret over a past inattentiveness to his or her own health and insufficient care for it.

The principal task of psychological support for patients in the first days after the operation is to strive to show that their «choice» has already been made and that this «choice» was the correct one, and that they have the possibility of adapting to the new life situation.

Psychological support for cancer patients at the stage of discharge from hospital

At this stage, the most general problem is one's attitude toward the future: every patient, to one degree or another, is aware of the seriousness of his or her disease and experiences fear of relapse and metastases. Patients not infrequently exhibit an indefinite orientation toward the future, which is characterized by a contradictory state: hope for a cure and fear of the future, fear of relapse. In this connection, at the stage of discharge from

hospital, a patient may approach the psychologist with the request: «Help me forget everything that happened here». At the same time, as a rule, the patient is aware that the experience of the illness cannot be «thrown out», but does not know what to do with it. The desire to devalue this life experience of theirs points to the painfulness of the process of working through the psychological trauma associated with the disease.

Another important problem, and one that troubles patients, is connected with the fact that during treatment in hospital the responsibility for making decisions concerning health was taken on by the physicians, and it is often hard for the patient to «tear himself away» from the clinic; a fear arises in him or her that something might suddenly happen, and the physician will not be nearby. In this connection, various neurotic symptoms may appear: hypochondriacal complaints, phobias (fear of crowds, of transport, and so on), and affective lability in the form of impressionability, vulnerability, and poor tolerance of stressful situations. The stage of discharge is borne especially hard by those patients who, during the course of treatment, do not strive for active cooperation with the physician, but instead assume a passive position, submitting to him or her. Among this category of patients, phenomena of «retreat into illness» may be observed.

A typical contradiction before discharge: on the one hand, patients strive to return to work activity, but on the other, they fear the social contacts that accompany it, and point to discomfort in situations of broad interaction. A feeling of uncertainty arises from doubts about the possibility of working with the same emotional and physical exertion, and also from the patient's apprehension of not being accepted by those around them. Society's fear of cancerous diseases, the notion that a cancer patient is a dying patient, leads to the stigmatization of patients, which in patients may be transformed into self-isolation. It should be kept in mind that patients' complaints of a disruption of social contacts may be a reflection of existential problems that have been actualized in connection with the disease, one of the manifestations of which is existential isolation.

Patients not infrequently point to the presence of difficulties in disclosing their diagnosis to others. For example, one patient expressed the opinion that «illness is a manifestation of your inferiority». In this case, it is important for the psychologist to show the patient that adopting a life stance in which the entire diversity of one's personality is reduced solely to the experience of one's inferiority prevents the patient from relating responsibly to his or her life as a whole.

Psychotherapy directed at a fuller living-through by the patient of each moment of life, the ability to see in each day of life not only negative but also positive moments, and an understanding that life takes place only in the present (in the «here» and «now»), enable the patient to cope with various fears, including the fear of relapse.

At the stage before discharge, the psychologist may use not only individual forms of work with patients, but also the discussion of patients' problems in a group. Working in a group makes it possible to share one's experiences with others, to learn to give support to one another, to become convinced that one is not alone, and to gain the experience of how similar problems have been solved by other people. The possibility of expressing and sharing one's experiences with other people in a special group atmosphere gives patients strength and energy. In addition, for full-fledged psychological rehabilitation it is desirable, and in a number of cases necessary, to hold consultations for the patient's family members and relatives.

Psychological support for cancer patients at the stage of adjuvant therapy

Some patients, with regard to combined adjuvant chemoradiation therapy, experience apprehension that this type of treatment will be associated for them with physical and psychological suffering: fear of pain; fear of complications resulting from the treatment, fear of helplessness; fear of the painful tests that accompany the treatment; fear of a change in appearance as a result of the treatment. Thus, the formation of the attitude toward chemotherapy is influenced by the prevailing

opinion «that the medications used are extremely harmful to the body» («chemotherapy is poison»). Fears contribute to the formation of a negative attitude on the part of the patient toward treatment, hinder the patient from becoming aware of and accepting information connected with the disease, and also contribute to emotional and muscular tension during medical procedures, which makes them more difficult to carry out. In this connection, the positive effect of chemotherapy is not infrequently underestimated by patients.

Something entirely different occurs with patients who undergo chemotherapy not as adjuvant therapy, but in connection with metastases that have been discovered. These patients associate chemotherapy with the hope of ridding themselves of the metastases and of prolonging their life, and therefore, despite the impending complications, they relate more positively to the need for chemotherapy. In both the first and the second case, chemotherapy engenders not only unpleasant experiences, but also a desire to cope with them.

Many patients, during the course of polychemoradiation therapy, experience a constant feeling of fatigue as one of the troubling symptoms that cause distress. In addition, the patient's asthenization during chemotherapy diminishes his or her involvement in the treatment process, which reduces the patient's responsibility and engenders dependence on the physician.

In undergoing therapy, patients with differing attitudes toward treatment stand out. Patients with a pessimistic attitude toward treatment are characterized, in a certain sense, by psychological isolation and indifference toward the therapeutic interventions: patients either feel their own helplessness – «whatever I do, nothing will come of it» – or estrange the illness from themselves – «the illness is separate, the I is separate». In the case of an optimistic attitude toward treatment («Everything will be fine»), it is important for the psychologist to diagnose the motive behind the optimism: is the patient's optimism an adherence to socially approved stereotypes of the «patient's behavior» and an escape from emotional experiences, or has the patient, by delving into the meaning-related level of the experience of the illness, managed to find a foothold and a resource in his or her experiences?

This distinction can be discovered only in the course of a clinical-psychological conversation.

As polychemoradiation treatment proceeds, the internal picture of the illness is actively formed – the patient learns more and more about his or her illness, about his or her reactions to the treatment, and about how he or she can help himself or herself during the course of treatment.

The patient mobilizes himself or herself to endure the arduous treatment, but, unfortunately, it does not always bring the expected results. The discrepancy between the anticipated effect of chemotherapy and the actual result is one of the most traumatic factors during the course of treatment: the patient experiences disappointment, aggression directed both at the physicians and at himself or herself, as well as a sense of emptiness and fatigue. Despite the difficulties of the treatment, the patient's task is to motivate himself or herself for long and aggressive therapy. For most patients, the mobilizing motive in this situation is the setting of concrete goals: raising children, caring for relatives, obtaining an education, and fulfillment in the professional sphere. At the same time, patients can be identified for whom the meaning of treatment and recovery is expressed in the value of life itself («After all, I was born for some purpose…»).

Patients attempt to define the personal meaning of the disease («What is the meaning in my having fallen ill; for what purpose has this illness been given to me?»), which may change during the course of undergoing prolonged specific treatment, pointing to inner spiritual work often not recognized by the patient himself or herself.

Psychological support is directed at sustaining in the patient hope, dignity, and the search for the meaning of life during treatment. In doing so, the psychologist uses methods of relaxation, guided imagery and visualization, as well as meditative techniques, art therapy, fairy-tale therapy, and narrative therapy, which foster a more holistic perception by the patient of his or her life and allow him or her to see his or her achievements and successes.

The application of Gestalt therapy develops in the patient the ability to live in the present: to accept what is here now as something valuable and transient.

Psychological support for cancer patients at the stage of progression of the cancerous disease

Some patients experience a far greater shock upon the occurrence of a relapse compared with the initial news of the diagnosis, since they perceive a relapse, after a period of vacillation between hope and fear, as a final verdict with no hope of reprieve. Others, however, react rather calmly: «I was afraid of this, and now it has happened» – that is, upon the discovery of a relapse of the disease, the chronic tension with which the patient had lived after primary treatment is reduced.

The patient dwells in a situation of uncertainty, while the information about the return of the vital threat once again destroys the picture of the world that had been created after primary treatment. As the illness progresses, the patient once again experiences all the reactions provoked by negative information, from shock to acceptance, if it occurs.

At the same time, as the malignant process progresses, patients not infrequently show an intensified motivation for treatment: they display enormous courage and patience and endure all the difficulties associated with it. One of the dominant motives for treatment upon relapse is the fear of helplessness. Thus, for example, patients express an active and responsible attitude toward their life – «I do not want to be helpless, and I do everything toward that end». At this stage, the psychologist uses the above-mentioned methods in his or her work.

Thus, knowledge of the psychological problems of patients that are specific to each stage of treatment and of the particular features of their experiences at each stage of treatment allows the psychologist to conduct work with the cancer patient adequately and effectively.

7.4. Psychological support for cancer patients in palliative medicine

Vagaitseva M.V.

Palliative care is intended to improve the quality of life of patients and their families and to alleviate the manifestations of an incurable illness. Palliative care includes both the methods of palliative medicine (treatment of pain and other physical symptoms) and the methods of psychological support of the patient and of the relatives caring for him or her.

The «Methodological Recommendations for the Organization of Palliative Care», approved by the Ministry of Health and Social Development of the Russian Federation, No. 7180-RKh of September 22, 2008, state: «The principal directions in providing palliative care to incurable patients must be not only the reduction of patients' suffering, but also adequate psychological support, social support, and communication with relatives, making it possible to prepare family members for the inevitable ending».

One of the variants of providing palliative care is hospice care, that is, care for a dying person. In the case of

a cancerous disease, the process of inevitable decline takes, on average, 6 months. In addition to the provision of medical care to patients, palliative care in hospices is carried out in three further directions – social, spiritual, and psychological. The social worker helps the family of an incurable patient in resolving the social and legal questions that arise in connection with the severe illness and the approach of the person's death. Clergy accompany the dying patient

and the people around him or her in matters of Faith. Psychological support

in the hospice is provided by an onco-psychologist (hereinafter, the psychologist).

At present, the field of onco-psychology is taking shape in our country, whereas psycho-oncology has been known since the 1970s. Onco-psychology studies the psychological consequences brought about by cancerous diseases and is a branch of clinical psychology within which a line of providing psychological support has been distinguished, framed within the psychology of crisis and extreme situations, intended to improve the adaptation of the cancer patient and of those around him or her to the situation of the disease at all stages, including the terminal one. Psycho-oncology, on the other hand, is a field of interdisciplinary research at the intersection of oncology, psychiatry, clinical psychology, and the social sciences; it is concerned with the study of the psychological and social aspects of cancerous diseases. The principal focus in psycho-oncology is on the quality of life of cancer patients. The aim of the psychologist's work in the hospice is to reduce the emotional tension caused by the patient's physical and psychological suffering in the face of the approach of inevitable dying and death.

In doing so, the psychologist addresses the following tasks:

to soften the patient's experiences;

to diagnose the patient's comorbid disorders;

to support the patient's relatives;

to carry out prevention of emotional burnout and secondary traumatization of the medical staff;

to carry out prevention of the psychologist's own emotional burnout and secondary traumatization.

The first task of the psychologist's work in the hospice is to reduce the emotional

tension of the patient associated with admission to the hospice. As a rule, the staff of the hospice's home-visit service forms in advance a positive perception of the necessity of the patient's hospitalization in the hospice. In the admissions department of Hospice No. 1, specialists work who know how to establish contact with the patient and reduce his or her anxiety, which is inevitable upon hospitalization in a hospice; they build the patient's trust in the other staff members of the hospice. The principal task of the psychologist's first conversation with the patient is to provide psychological support and to form a positive disposition in the patient toward his or her stay in the hospice. In the event that the patient's relatives are present in the ward, the psychologist becomes acquainted with them and invites them to his or her office for a conversation.

The second task of the psychologist's work in the hospice is to diagnose the patient's comorbid disorders. Mental disorders accompanying the principal disease, such as depression, anxiety-phobic or panic disorder, may have a negative effect on the process of pain relief and on the overall level of emotional tension of the patient and of those around him or her.

The third task of the psychologist's work in the hospice is the provision of psychological support to the patient's relatives. Sometimes it happens that a mental disorder arises in a relative of the patient. In this case, the psychologist may conduct a corrective conversation himself or herself, or recommend another specialist.

The fourth task of the psychologist's work in the hospice is corrective work with the medical staff for the purpose of preventing secondary traumatization and professional burnout.

The fifth task of the psychologist's work in the hospice is self-observation and the professional and personal development of the psychologist himself or herself.

In individually counseling patients, the psychologist in the hospice applies such psychological methods and techniques as:

a standardized rapid survey;

therapeutic listening;

help in expressing and accepting negative feelings;

informing;

directed conversation: clinical-psychological and biographical;

suggestive techniques and techniques of breathing, visualization, and relaxation;

art-therapy techniques: wool felting, modeling, drawing, cinema therapy, bibliotherapy.

Today, the data of evidence-based medicine demonstrate the necessity

and effectiveness of psychological support for cancer patients

and their immediate circle. By immediate circle are meant not only the relatives and loved ones of patients, but also the physicians and the staff of the institution providing medical care to cancer patients.

Thus, three directions of the psychologist's work can be identified:

the patient, the patient's relatives, and the medical workers.

Within the framework of palliative care, psychological support

is of an eclectic nature, incorporating elements of existential, cognitive, and supportive-expressive therapy. Psychodynamic and cognitive-behavioral models of psychotherapy are used in work with the medical staff. Elements of interpersonal psychotherapy may be used in group work with patients' relatives. The hospice psychologist also carries out rapid diagnosis of the comorbid mental disorders of patients with their subsequent correction.

The psychologist's work with patients

In the work with patients of Hospice No. 1 (St. Petersburg), a tradition has developed of welcoming new patients upon admission. In the course of the first meeting, contact is established with the patient and the relatives accompanying him or her. At the same time, the psychologist conducts a rapid diagnosis of the patient's emotional state. As in everyday life, not all people who arrive at the hospice request the help of the psychologist. Incurable patients who are conscious may react in various ways to the situation of the disease and relate in various ways to interaction with the psychologist.

The subsequent psychological support of the patient includes, first and foremost, the provision of psychological support and attention to each patient. The care and involvement of each worker in relation to a particular patient is part of the philosophy of the hospice. In visiting patients, in the course of communication, psychotherapeutic targets are also formed, to which attention should subsequently be paid.

The forms of the psychologist's work are based on generally accepted methods of correction and depend on the physical condition of the patient.

Patients can be conventionally divided into three categories.

The first category of patients consists of people admitted to the hospice with pain syndrome. Pain relief and the alleviation of all distressing symptoms, when correctly selected by the physicians, improve the patient's quality of life. In these cases, patients can stay at home for a long time. Such patients leave the hospice, then, after their condition worsens, return to the hospice for a new pain-relief regimen and once again go home until the next worsening. Usually these patients are inclined toward communication and are ready for art-therapy work. In the process of interaction with the psychologist, they willingly share their life story, tell about the circumstances of their life, about their personal characteristics, about their roommate in the ward, and about their own reaction to that roommate's possible death. Patients of this category are often

occur both as a result of the direct effect of antitumor agents and as a result of a pathological immune response to the inflammatory process associated with the breakdown of the tumor, or as a consequence of damage to the capillary vessels. For improving the quality of life of «returning» patients, the prevention of these disturbances is of substantial importance. This includes bibliotherapy and cinema therapy, felting and modeling, keeping a self-observation diary, and constructing a family genogram.

Case example No. 1. A woman (48 years old) tolerates chemotherapy very poorly. Correctly selected restorative therapy allows her to return home again and again until the next course of chemotherapy. The first time, she was very distressed by her declining memory and slowed speech. She went willingly to corrective work with the psychologist – she learned poems and tongue-twisters and discussed video films. On the fourth and fifth occasions, she responded to the suggestion of wool felting and became very absorbed in it. A solo exhibition of her works has been organized in the hospice. The patient notes psychological adaptation to the changes taking place and an improvement in her quality of life.

The second category of patients consists of terminal patients with an intact psyche. As a rule, such patients are to some degree aware of the nearness of their own death and use various means of coping with this knowledge. Some use the psychological defense mechanisms of substitution and repression. Others resist this knowledge. Finally, there are patients who genuinely accept their own death. Communication with such patients is very valuable for the psychologist himself or herself as well. In working with this category of patients, the psychologist uses therapeutic listening and conversations on existential themes.

Case example No. 2. Two men of approximately the same age: one a doctor of physical sciences, the other a doctor of biological sciences. Both were, at the same time, on different wards. One fully accepted death, while the other experienced panic-stricken terror at the thought of it.

With the first patient, the psychologist in conversation touched upon existential questions

about the meaning of life, about the impending departure. And with the second – about the specifics of writing dissertations in a field close to medicine. In the first case,

relief was brought to the patient by conversation on existential themes; in the second – by conversation that supported his psychological defenses.

The third category of patients consists of dying patients in a state of cancerous intoxication. For such patients, psychological support can be provided at the bodily level, since, as a result of the loss of strength, verbal contact with them is impeded or entirely absent. This category of patients also includes elderly patients in whom disturbances of hearing and speech are observed. Adequately established contact between the psychologist and the patient may help the patient's interaction with the people around him or her. In the psychologist's work with such patients, psychological presence is important; the psychologist also uses tactile contact and, by means of gestures, establishes a connection with the patient.

Case example No. 3. A woman of 46 was in the hospice for more than five months and, during this time, did not want to work with the psychologist. She would close her eyes when the psychologist worked in the ward with other patients, refused to talk, and answered in monosyllables. Only when she had grown completely weak did she ask the psychologist to sit beside her and hold her hand. Her strength was fading; the patient would sometimes, in a weak voice, say something quietly. This went on for 15–20 minutes three times a week. Then a farewell took place, and she died.

The psychologist's work with patients' relatives

A distinctive feature of a cancerous disease is its extension over time. Relatives have time either to adapt to the irreversibility of the loss or to become emotionally burned out. They experience a feeling of guilt before the dying person. The fear of losing a loved one may manifest itself in various ways depending on the personality structure of the relative himself or herself. Usually relatives want to receive emergency psychological help and rarely seek prolonged therapy. Emergency psychological help for relatives is directed at resolving a difficulty that frequently arises in them, formulated in the question: how to interact correctly with the dying person. Work with relatives is usually conducted in the office of the hospice psychologist. The psychologist's task is

to provide information about the particular features of communicating with a patient in the terminal stage of a cancerous disease, to diagnose the relative's condition, and to recommend possible means of correcting or maintaining the mental health of the relative himself or herself. If there is a request for prolonged work, relatives are offered participation in a psychotherapeutic group, in which the experience of loss and coping with it, as well as the necessary redistribution of intra-family roles,

experiences. The aim of such work becomes the development of an attitude toward death as a natural stage of the life path of any person. In working with relatives, the psychologist applies empathy, active-listening skills, informing, and the search for meanings, and uses relaxation.

Case example No. 4. A relative who sought to spend a great deal of time in the psychologist's office had pronounced infantile and narcissistic components in his personality structure. He spent the greater part of the consultation time talking about himself in the past and future tenses. In the course of the conversation, he pointed to external resources: loved ones who would support him. Such behavior inspired great confidence in the adaptive capabilities of the person being counseled and made it possible to reduce the number of consultations.

The psychologist's work with physicians and medical staff

The aim of the psychologist's work with the staff is the prevention of professional burnout, which is expressed in emotional exhaustion, manifesting itself in fatigue, emptiness, powerlessness, and the depletion of one's own emotional resources; in phenomena of depersonalization, including cynicism in relation to patients; and also in the physician's experience of a sense of incompetence and lack of success in his or her professional sphere and a loss of meaning. At the same time, physicians, nurses, and junior medical staff may deny that they have these problems and refuse to work with the psychologist. In this connection, the hospice psychologist, whose work is still perceived as something unusual and not always understandable to those around, must become

a full-fledged member of the medical team, win their trust, and convey the essence and the possibilities of the psychologist's work within the framework of the institution, and this constitutes the first stage of the medical psychologist's professional activity in the hospice.

The second stage is the carrying out of corrective and preventive work regarding the professional burnout and secondary traumatization of the physicians and medical staff of the hospice. Hospice staff have the possibility of consulting the psychologist free of charge, including on acute family problems. Work with physicians is of an advisory nature and has no clear-cut structure. In this work, the psychologist uses diagnosis of the emotional state, testing, and relaxation techniques, and conducts seminars on the topic of «The Ethics of the Hospice».

The professional and personal qualities of a psychologist working in palliative medicine

The work of the onco-psychologist is connected with such an indispensable component of the human life cycle as death. The psychologist spends much time in an environment saturated with the experience of the fear of death, of pain, and of the loss of loved ones. This requires special skills and special psychological training on the part of the specialist. First and foremost, the psychologist must possess professional communicative skills; it is also important to be a psychologically mature person, to accept life, oneself, and other people holistically rather than fragmentarily. Of great importance is the psychologist's reflection, which makes it possible to be aware of one's feelings and thoughts at the present moment and, as a consequence, to manage them. A psychologist, like any person, may have problems, difficulties, and limitations, but he or she, unlike other people, is able to be aware of them to a greater degree.

In the course of special psychological preparation for the work, the onco-psychologist needs to work through his or her own attitude toward death, to reinforce a humanistic attitude toward patients, and to develop stable skills of non-aggressive and non-accusatory behavior in a conflict

situation, of introspection, and of the effective utilization of his or her own negative experiences. The prevention of the psychologist's emotional burnout makes it possible to prolong his or her own professional life. In addition to introspection, the psychologist should secure for himself or herself the support of the professional community, attend Balint groups, and seek supervision.

Case example No. 5. Physical and moral suffering before death usually sharply reduces the level of neuroticism of the patient's personality. Genuine relations of sincerity and trust are established between the staff and the patient. Communication with a person who is truly accepting his or her departure from life is the most valuable thing in the work for the personality of the psychologist himself or herself.

Thus, the psychologist's work in the hospice can be described as a search for the resources of the patient, of the patient's relatives, of the physicians and staff of the hospice, and of the psychologist himself or herself. Analysis of the psychologist's work in the hospice has made it possible to identify two problems, the resolution of which is most in demand by physicians and staff:

the utilization of the negative experiences associated with the situation of the terminal stage of cancer (to clear the inner space),

the recognition and use of the patient's resources (to fill the inner space) in order to maintain the patient's quality of life regardless of the length of his or her life. An example of this is the motto that was formulated by one of the hospice patients in the course of work with the psychologist: «what matters is not how long, but precisely how».