This work addresses the different techniques of specialized psychological intervention for families of cancer patients, both in the case of terminals and nonterminals, addressing different areas of interest from clinical and social phases of first contacts diagnosis of cancer starting up the final stages of attention to death and mourning.
Dr. Elisabeth Kubler-Ross (1975), specializing in serious and terminally ill, relates a case which may serve as an illustration of “the inescapable need to psychologically serve the household, not just the isolated sick.”
This is a case of a cancer patient, adult male with multiple metastases in the digestive system in stage III, and progressive deterioration and wasting physical . Focused the attention of the staff in providing medical and paramedical support and assistance to the patient, no one noticed the anguish that was desarbolando mental life of his wife. woman very dependent, depressed, frightened and without resources or emotional backing to face cancer her husband, chose to end his life through a massive ingestion of barbiturates.
According left written testimony in his diary, he was unable to face the test of everyday contemplate the destruction of life and body of her young husband, and living a future suffering loneliness. Equally crucial was the fact of suffering how to diagnosis of cancer and subsequent revenues hospital her husband, both friends and family as coworkers made them empty, they stopped calling them and left them alone without any help from disease , which frequently occur also in other instances.
After the suicide of his wife, two weeks before the husband went as atonement burden of guilt of knowing cause of the disappearance of his wife, whom he loved.
This sad story and many others (Pérez 1965) we shows clearly the “absolute necessity” to keep in mind the family and couple to the design and implement programs of prevention and treatment of cancer battle. This recognition implies a new clinic as developed by Dr. Marie Hennezel (1996), therapist specializing in serious and terminally ill with cancer, HIV :
“堥stábamos wrong before we were facing the disease suffer as if only one person . individual patient But really sick the patient and his family, the patient and his parents, the patient and his family坚n our center, from the beginning face today what should come along with the husband, father, sister, children堐articipan in our groups , self-help in the briefings, sometimes need and receive professional care and psychological support more urgently than the patient妱uot ;
Need for family care diseases chronic and / or serious
Since any patient, not only with cancer, does not live in isolation, appear in logical and obvious principle that hospitals should care for the family that is most immediately the patient, who knows him best, spending more time with him, with which it has more intense emotional bonds, and you can get more and better resources to support the patient (Cobb 1954; Die 1999).
However, actual practice it turns out that the family is serviced only by the systematic and 27% of cases through a program of chronic care (Holland et alt 1990). It is easy to check through any of the systematic reviews conducted by different authors, that psychosocial interventions have been privileged applied to cancer patients, and only more recently with some systematicity the family. (Andersen 1992; Bayes 1985; Cruzado et alt 1996; Font 2006, Vidal 2002). As an example, we can mention the subject of the study of family burden and possible burn-out of family caregivers in the literature for the case of cancer is much lower than that developed for the case of illness of Alzheimer (R Alamo 2004).
In addition, a prime source of wasted also free information first hand on the patient and their evolution , as well as an important means of effective intervention and co-therapeutic support. Family should be referred by the clinical establishment as an essential and active ally in the fight against the disease, and not as a passive entity and potentially annoying to be kept on the periphery of exclusively medical problem.
Therefore it is highly recommended that, at the stage of diagnosis, and recorded in the medical history of the patient an assessment of the family (Barreto 2000, Bowen 1987, Thomas et alt, 1973), of:
- How is the structure of the patient’s family: it closed or open, nuclear or extended, friendly-hostile, indifferent to the sick, etc..
- What kind of discourse premium family about cancer: terrifying, denier, culpabilizante, persecutory, seconder, etc..
- What kind of key role played each of the family members (family cohesive, he fixes problems , the eternal complainer, the dynamic of the group , etc.), and what conflicts can be expected to generate the reconfiguration have those papers because disease.
- How to live the patient your partner and family, while the family how the patient lives (in some cases, it is considered dead 婮
- What behaviors or dulling facilitators expect from each household member: alliances, hatred, emotional or economic or instrumental supports.
It also requires a careful assessment of the family to identify needs of specific family group level or for one of its members especially interventions, whether it be psychological, health, socioeconomic level or in other areas. This is recommended:
- Strong organizational, explicit and systematic support from the highest rungs of hospital management entity and the Public Administration .
- A training specific to the medical staff (doctors, psychologists, social workers, nurses).
- The development of programming prior, with protocols based on the best available evidence on what activities to do in Family Care, not leaving it to chance or good intentions of the staff.
Care for families of cancer patients nonterminals
He appoints and relatives of patients who are in early stages or means of disease (I, II, III sometimes), but with few hospitalizations without risk of death or immediate foreseeable.
The objective would be Princeps “Involve the family, to the greatest extent possible and with the acquiescence and will as co-therapeutic active agent, in order to be useful for the patient and for himself, and secondarily for the medical profession” (Matthews-Simonton 1993).
To accomplish this it is necessary to have a series of operational resources (Barker 2000, Neidhardt et alt 1989; Snowy et alt 2007; Nezu et alt 1999; Schwartz et alt 1998):
- To provide a realistic family about cancer , its causes, conditions and expected developments. Such information helps: 1-reduce myths sometimes terrifying cancer, 2 – mitigate fears and misunderstandings, 3 – increase the feeling of family monitoring and accountability on the sick. 4 – Additional family in turn transmits the sick one image realistic of his illness, functioning as “reality” of distorting fantasies of the patient, helping to admit it less traumatic form of cancer patients their condition.
- Being able to train at least some familiar skills communicating effectively with patients, to verbal and non-verbal level. It is thus: 1 – break the destructive conspiracies of silence, 2 – to know ventilate these ghosts but not aerated clouding everyday patient-family, 3 – to lessen the feeling of isolation and loneliness of the sick. It is essential to know to practice “active listening”: take care not to interrupt the patient when speaking of his illness, useincentives verbal assent and care, accompanied with appropriate gestures and facial expressions, body posture care lest it defensive, keep eye contact, summarize what was said by the other and suggest expanding information etc..
- Advise the family about how to deal with a chronic or serious ill. It can be about such topics: 1 – Respect for privacy and setting the limits of privacy in the home, 2 – assertive rejection, but not aggressive, childlike behaviors of the patient or other family members (excess dependence claudication responsibilities, etc.) and manipulative (emotional blackmail, threats of suicide, etc.), 3 – management possible.. crises depressed, anxious or crying (yes do: stay by her side, all you hear say without interrupting, avoid interrupting others crying, be quiet but seconder with physical contact, etc., and what not to do. trying to follow the patient not crying, trying to encourage trivially, change the subject, let alone call others to that address the issue, minimize its worth, culpabilizarle appealing to their ethics or that causes suffering to another, etc..).
- Offer training in solving specific problems of cancer, preparing family but likely to face difficult situations. With this: 1 – the emotional shock is minimized when such a situation comes to stand, 2 – increases the effectiveness of home health 3 intervention – consolidates the safety of the patient to be in good hands and not fear being abandoned as appears a problem.
- Facilitate the joint family to attend informational sessions, counseling or therapy (with the consent of the patient). So, you can try to clarify and resolve issues specifically partner or family such as: 1 – habits of intercourse , 2 – preparation of minor children to a possible increase of hospitalizations of their parental or even their death, 3 – decide what level of information must be provided to friends, work, etc., 4 -. appropriate behavior in social situations involved 5 – negotiate necessary changes in household routines of family members, 6 – Common expectations and development plans future to share among 7 – degree of mutual feedback optimal and desirable, 8 – establishing healthy lifestyle and self-care (see relevant section below), etc..
Some results in practice
One could question whether this approach is not really delegating family responsibilities additional overhead to the already supported and which may not be ready some of its members, and could finally reach agobiarles and facilitate the table “burn-out” (Garcìa-Pinan 2004) of family caregivers of cancer patient.
Response can present the experiences gathered by Jeanne Achterberg and colleagues (1976), which clearly show that when the couple or family is actively involved as co-therapists oncology patients, the quality of life subjectively valued by the latter greatly improves (up to 86% of cases), are enriched family life and are more satisfied with it (74% of cases), and there is an improvement both in their dysphoric moods, psychometrically validated (68% of cases).
Authors who work with seriously ill and terminal cancer, such as Carl and Stephanie Simonton et alt (1975, 1976, 1993, 1994, 1996) or Bancon et alt (1952) and Spiegel (1992) even suggest that the median survival time of these patients could see increased those immersed in a cohesive and seconder (both emotional and instrumental) family structure. Likewise, other statistics show a delayed onset of disabling symptoms subjectively (Greer 1987, Holland et alt 1990) in the areas of pain, psychomotor disorders, nausea and dizziness, cognitive dysfunction (disorientation, mental confusion, apathy, apathy, deficits memory婮
Keep in mind that cancer is a disease whose symptoms closely dependent on the opportunistic state of the system immune, secondary infections, allergies induced堨Rasmussen 1996). And there is a wide and proven experience in psychosomatic clinic indicates that the negative affective states of stress , anxiety, loneliness, hopelessness, and depression negatively affect the neuroendocrine internal environment and the state of the systemsof autoimmune defense. (1991 Bovberg Die 1999 Doloman 1996; Guir 1983; Kissen et alt 1994, Lazarus 2000, Simonton 1996). Therefore any effort to maintain emotional stability and cognitive impact of the cancer patient in real optimizing their physiological level purely biological organism (Bayes 1985; Simonton et alt 1975) resources. The family (and even the type volunteering NGOs ) in this aspect of psychosocial support can become a “carrier of life” for the cancer patient (Matthews-Simonton 1993, Thomas et alt 1973).
Report on cancer family
The initial diagnosis of cancer, if not properly communicated and handled by clinical staff from the beginning, can mobilize pathologically varied kinds of anxieties both the patient and their family (Hennezel 1996): uncertainty about the future overall , fears of disability and / or death, fear of pain, separation anxiety and loneliness, excessive responsibilities弯font>
This causes a series of emotional reactions can be very intense (Cruzado et alt 1996, ACS 1994, Kubler-Ross 1975), such as depression or fits of panic , suicidal ideation to avoid the bleak picture of the future, emotional blockage which can reach catatonic derealization or depersonalization, blocking decreasing cognitive ability to understand the data targets and thus make effective decisions, denial of illness (“the doctor is wrong”) with the corresponding pilgrimage from clinic to clinic seeking another diagnosis more benevolent or doctor-omnipotent that easily solves the problem of cancer, looking guilty outbursts of disease (an unjust God, the slow Doctors perform tests , the boss by overwork, the other spouse for his incompetence or smoking or conducting淫childlike behaviors and seeking refuge and security over the family of origin (return to living as a teenager with dad and mom), establishment of “conspiracy of silence” by the family around the patient to not see him suffer, listing among family secret alliances or groups competing for control the process of cancer treatment, etc..
It has been found that an effective way to avoid or minimize such maladaptive reactions, is to develop programs hospitals well structured to inform those affected and their families (including how “giving bad news “) programs in which medical and health need to be properly trained and supervised frequently (Font 2006; Barreto et alt 2000, Andersen 1992).
We detail below the recommendations on this particular advocated the American Cancer Society since 1994:
|1 – What do they want to be informed of those with cancer and family?
2 – What do you want to know the family (even if they are caregivers at home)?
3 – On what issues they want to be informed patients and their caregivers?
Regarding what professional reviewers (. oncologists, physicians, assistants, therapists such as psychologists or therapists, nurses, social workers, etc) on how to report in the case of cancer, the following conclusions are drawn:
The 1-most considered adequately inform the affected family and provides higher quality of life because:
2 – At what point has to report?. Do not give all the information at once:
3-Professional reviewers to follow the following guidelines when giving information:
Therapeutic Family Care
Sometimes it is necessary to advice, support or therapy of any family member of a cancer patient, suffering clinical disorders or personal problems generated by living a difficult situation (Astudillo et alt 1999; Barreto 2000, Davis et alt 2000; Duch et alt 1997; Echeburúa 2004, Levine et alt 1999, Romero 2003).
According to surveys conducted in relatives of terminally ill , they may have the following tables in need of specialized care, ie not spontaneously refer to themselves shortly (American Cancer Society 1994):
- Minors somatoform disorders (insomnia, diarrhea , gastritis, headache, hypertension , alopecia, various pains, etc.): 63%
- Depression: 35%
- Feelings of intense guilt: 28%
- Increased consumption of Alcohol or drugs : 25%
- General anxiety: 24%
- Retraction and social isolation: 20%
- Irritability, aggression: 16%
- Hypochondria and other obsessive ideas: 13%
- Higher somatization and conversion: 11%
- Panic attacks and panic attacks: 11%
- Paranoid ideation: 7%
- Suicidal ideation: 6%
Care for families of terminally ill
Deserves special attention the family unit and its components to the nearest or actual death of a patient with terminal cancer, as shown for example contained in the “Declaration of the Rights of the Terminally Ill and Family “1995 – Statement of Care Palliative Barcelona (From Hennezel 1996).
The work of professional assistance to the dying and the survivors
died of cancer requires rigorous and specialized training, selection of candidates (not everyone goes for it), a number of hours of supervised practice, and regular attendance at group supervision (Feisntein et alt 1994, Kubler-Ross 1975 and 1989, Kubler-Ross et alt 2006; Neimeyer 2002, Worden 1992; Zamorano 2005).
They are attitudes that should show the appropriate medical establishment or paramedic, to a family whose patient just died (Nevado 2005, Ruiz et alt 1994; Servan 2003):
- Help the survivor to accept the recent loss, thus avoiding denial of the fact (“this can not happen to me”), as the massive idealization of the recently deceased (“the best always die, and my son was the best, was Perfect “) as a distortion of the event (eg looking for scapegoats,” has died because doctors have given cheap medicines “).
- Facilitate the externalization of emotions through careful listening as hard emotional release, but later serving rational containment of affects (“auxiliary ego”). This is positive for the surviving family to vent their fear of uncertain future even economically, their anguish against loneliness and helplessness, his grudge against the patient himself, his rage against a cruel God or against incompetent doctors, staff impotence I could not avoid death by more than it did in some way, his feeling of unreality or of absurdity to the recent event …
- Listening the pain of others, not anxious for it (such pain returns then amplified), also without trying to cover it with empty verbiage content only plays a role defensively for the listener, also without physically run away with some excuse, etc..
- Reduce frequent feelings of guilt of the survivor (“if I had done this or that, now would be alive”, “if he had not smoked during pregnancy , my daughter would not have had leukemia “) and reduce other possible cognitive distortions such type ” thought magic “(” now I’m going to die, and I have to be the next “).
- Empathically accompany the family. That is, being able to get on your skin , be able to feel, identify and share the emotions that the survivor is experiencing at the time. So the family may feel that there is another who understands you and who really looks for it, which is not isolated in their pain and other accepts and share their experiences.
- Being able to keep some distance while, nevertheless, to keep the necessary balance psychological and fulfill their specific task: to provide supportive but professional help, an effective way for the family and for the helper. And must be able to maintain their interpersonal relationship within the limits of loving empathy, but “without going”. If not, can the professional be flooded emotionally pain survivor who wants to help, locked in a state of shock shared which can not think or act rationally, or traumatized by recativaciòn their own unresolved conflicts with death (eg for unprocessed own grief regarding the death of a parent or spouse).
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Alfredo R. Poplar
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