PSYCHOSOCIAL CARE

My role in psychosocial care encompassed mental health assessment, staff support, and therapeutic interventions. My immediate team in the hospital comprised a psychologist and psychiatrists working alongside staff from other hospital departments including palliative care, oncology, and haematology. The inpatient hospital setting is distinct from traditional psychology practice where sessions are planned in advance and timed precisely. In the hospital, a flexible approach was essential to accommodate a patient's needs including meals, washing, medication regimens, ward rounds, and fluctuating mental state. As a team we often saw patients opportunistically without a specific appointment time on the ward. As a person who thrives on structure, there were times I felt like a fish out of water, working “on the hop” and encountering unfamiliar medical terms. Through seeing patients with acute stress and illness, I learned to maintain realistic expectations about what I could offer on a ward admission. I also gained appreciation for shorter bedside reviews, and brief, opportunistic psychotherapy.

A core part of care was supporting the multidisciplinary team caring for the patients. There were several patients during the year who was referred to our team and who evoked strong emotional responses in the multidisciplinary team. I was often confronted with these situations on busy inpatient wards that often triggered a strong response in me to “do something” to help in the heat of the moment. I struggled at times to strike a balance between responding to the team's concerns but not acting or advising them prematurely. Through supervision and team discussions I learned to use information about our team to gain insights into the patient and how he or she may relate to others, often reflecting on transference. I also learned to assert myself with referring clinicians and create space for all parties to reflect on what would be best for the patient.

I was fortunate to have psychology and psychiatry mentorship and supervision throughout the fellowship. One of my key learnings centered on the interface of psychology and psychiatry in the medical setting. I was encouraged to learn by observing psychiatry colleagues as they reviewed patients, a form of training I was unaccustomed to. I observed the skillful way colleagues wove medical symptom and medication assessments into the psychosocial encounter. This increased my awareness of syndromes like delirium and somatisation, as well as my knowledge of psychotropic medication. I learned to fine tune my assessment skills of depression in end of life care and to recognize grief and demoralization (Endicott, Reference Endicott1984; Clarke & Kissane, Reference Clarke and Kissane2002; Noorani & Montagnini, Reference Noorani and Montagnini2007; Breitbart & Dickerman, Reference Breitbart and Dickerman2012).

I also learned about referral pathways and how referrals are triaged to psychologists, psychiatrists, or sometimes both disciplines. This was challenging at first adjusting to flexible case-by-case decision making and having no fixed rules to follow. Through discussions with the team I learned there are many factors that influence a referral pathway including time, clinician availability, severity, and nature of the problem. There are also a variety of reasons for following up patients on the ward including clinical need, learning experiences, and providing a consistent presence. When discussing referrals I became accustomed to speaking the hospital language and referring to “patients,” instead of “clients” a term I usually refer to in non-medical settings.

Another learning goal was developing my psychotherapy skills. My postgraduate counseling psychology training placed strong emphasis on development of an emerging theoretical orientation. This can be likened to a therapist's worldview that explains which models of psychology or therapy he or she uses in the work (Halbur & Vess Halbur, Reference Halbur and Vess Halbur2010). The fellowship provided a rich opportunity develop my therapeutic orientation through delivering cognitive-behavioral interventions including psycho-education, breathing, and relaxation strategies for patients with pain and anxiety concerns (Beck, Reference Beck1976; Moorey & Greer, Reference Moorey and Greer2002). I also developed a deeper appreciation for psychodynamic approaches through attending tutorials. This involved reading a psychoanalytical-oriented paper each week and listening to the facilitator's reflections on issues presented. Specific writings included Freud's (Reference Freud1917/1957) Mourning and Melancholia and the work of Dinora Pines (Reference Pines1994) exploring a woman's unconscious use of her body. Pines' insights continue to help me reflect on the impact of pregnancy, miscarriage, and menopause in the patient's life story and adjustment to illness.

There were however challenges with applying particular therapeutic approaches in the medical setting. My client-centered, humanistic values were challenged on occasion when there was pressure to intervene quickly and “do something” for the patient's distress. There was not always time to develop a trusting, growth-facilitative connection with the patient that is characteristic of the humanistic approach (Rogers, Reference Rogers1951; Schneider et al., Reference Schneider, Bugental and Fraser Pierson2001). Further, the patient was sometimes too unwell to engage in a self-reflective process and a more direct approach was required. The challenges and benefits of engaging a person-centered approach have been documented by other professionals working in medical settings (Freeth, Reference Freeth2007). Similarly, it is not always possible to offer structured cognitive-behavioral treatment plans and “homework” schedules for people who have brief stays on the ward.

I believe that despite these challenges, a variety of therapy models and worldviews are useful in palliative care and psycho-oncology. This requires an appreciation and willingness to work within (and challenge where appropriate) other views and demands of the medical environment. I also had the opportunity to see a number of outpatients for longer-term therapy, following therapeutic models in their more traditional formats, which helped develop my psychotherapy skills and therapeutic orientation. Being able to develop longer-term therapeutic relationships with patients was rewarding and I felt able to release my parachute a little more, and glide more confidently into the uncertain skies.

EDUCATION AND WORKSHOPS

During my fellowship I participated in departmental workshops designed to educate health professionals about psychosocial concerns in cancer care. I participated in these courses as an observer and facilitator, learning from my colleagues' presentations styles and developing my facilitation skills. I helped demonstrate basic counseling skills through role play exercises and facilitated a mindfulness-based technique (Kabat-Zinn, Reference Kabat-Zinn2003) with participants. The courses were unique for the patient and family participation, where people who have been affected by cancer present their experience to the attendees, often using creative modalities. This experience was evocative and provided a human voice alongside the theoretical information I was learning. I was moved hearing stories of older and younger people, adjusting to cancer, and barriers encountered when engaging with supports. These workshops also provided opportunity to learn from other professionals working in palliative care and psycho-oncology settings.

The psychosocial cancer care department have a crucial role supporting the multidisciplinary teams caring for patients and families who are living with cancer and terminal illness. This support is partially offered through formal reflective practice sessions. I had opportunity to observe our other psychologist facilitate many of these sessions focused on case discussion and specific topics such as supporting people with depression and pain management. I facilitated a reflective practice session focused on understanding and managing behavior on the hospital ward. This experience provided a flavor for acting in a supervisory role and the challenge of engaging a group.

In the beginning of the fellowship I was given a basic structure of the educational activities offered in the hospital and encouraged to attend those that sparked my interest. The grand rounds were case presentations from each medical specialty, which I attended on behalf of the psychosocial cancer care team. As highlighted in the beginning of this essay, I participated in seminars alongside junior doctors who were undertaking specialist rotations in medical departments. In this setting, I sometimes felt isolated being of a different professional background and working more autonomously. I used lots of initiative to build relationships and introduce myself to others; there was not always someone to orientate me to new settings. To feel more connected with my medical colleagues I arranged to observe a head and neck cancer surgery. This experience also gave me a deeper empathy for the patient's cancer journey. Stepping outside of the psychosocial setting into a new, operation theatre environment was in itself challenging; however, helped me appreciate what it might be like for people coming to psychologist for the first time. In this process, I began to feel more integrated, the parachute on my back felt more familiar, the skies seemed clearer. I reflected on my brave expedition into surgery and how feeling ‘different’ had led me to seek out a unique, memorable learning experience.

RESEARCH AND SERVICE AUDIT

One of the fellowship roles was to participate in a research project in a palliative care and psycho-oncology area. In the year I was involved in two research projects. One project explored the psychosocial sequelae of corticosteroid use in people with haematological cancer. My initial role was to identify and recruit participants to the study, track their treatment regiments, and progress. The participants were then followed up by the principal researcher by telephone and interviewed about the impact of their treatment. In this role, I networked closely with clinicians on the ward and in the cancer day center to identify people with newly diagnosed haematological cancer. I enjoyed getting to know patients in this way outside of the clinical role and was pleased patients responded positively to the study. I found the Cancer Treatment section of the Macmillan Cancer Support website (2011) helpful in providing easy-to-follow descriptions of chemotherapy medicines and regimens.

I also began developing a psychological group support targeting young adult offspring of parents with cancer. I believe in the importance of conducting clinically relevant research and wanted to offer a potential benefit to participants through the process of the group. Following a review of the literature and consultations with colleagues, a plan for a group was developed. I hoped this group could fill a gap in support services offered by the hospital and complement standard multidisciplinary support. I also had opportunity to network with CanTeen psychologists, CanTeen being an organization supporting young adults living with cancer, and young adults who have a parent with cancer. The processes of furthering my group support plans are ongoing as I navigate challenges in engaging these young people. The literature in this area has identified barriers to engaging young adults in support such as the tendency to focus more heavily on patient welfare (e.g., Patterson & Slawitschka, Reference Patterson and Slawitschka2007; Frank & Slatcher, Reference Frank and Slatcher2009). A positive outcome in this group project process was opportunity to support some young adults individually, which helped develop my skills engaging this age group in coping with parental cancer, identity issues, relationship discord, and assertiveness.

SUPERVISION

The importance of supervision is ingrained in the psychology profession from the beginning of training. Prior to the fellowship I had experience as a supervisee with a variety of supervision approaches. These experiences fostered my self-awareness during the assessment and therapeutic process including strengths and blocks in my practice. In the fellowship, I built on this experience using clinical case presentations and receiving didactic and interactive teaching of guided imagery and neuropsychological assessment tools such as the Neuropsychiatry Unit Cognitive Assessment Tool (Walterfang et al., Reference Walterfang, Siu and Velakoulis2006).

Fortunately, I had opportunity to receive supervision from all clinicians in the team. My psychiatrist colleagues provided supervision on a rotating basis including case discussion and teaching of specific topics including pain management, delirium, and existential theory. The other psychologist in the team provided supervision every two weeks with a main focus on professional identity exploration and outpatient therapeutic interventions. Supervision was instrumental in forming my learning objectives for the year. I was also introduced to a guided imagery tool that I could use for self-care but also teach to patients. Horowitz and Breitbart (Reference Horowitz, Breitbart, Breitbart and Holland1993) highlight that imagery can be useful not only in symptom control but in helping patients feel more confident and engaged in their care. I appreciated each supervisor for his or her unique input. One supervisor was helpful with attention to detail, empathic presence, and expertise navigating the complex interplay of medical and psychosocial issues. Another supervisor offered space to expand on my psychodynamic learning and grounding strategies to cope with acute crisis situations.

Supervision with a psychologist was more prominent toward the latter half of the year as my outpatient caseload increased. A psychologist's input was valuable in helping with therapeutic planning and adapting the cognitive-behavioral approach in my patient work. This input also introduced me to the potential benefits of value clarification as part of the acceptance and commitment therapy model (Hayes et al., Reference Hayes, Luoma, Bond, Masuda and Lillis2006). Talking with my supervisor also helped me stay in touch with my professional identity as a psychologist and adapt my practice to suit the hospital and hospice settings.

There were some challenges having three supervisory approaches during the fellowship. From a practical perspective it was difficult at times to coordinate regular meetings with each person. Supervision was prioritized but the schedule faced inevitable interruptions around holidays, workshops, and other commitments. This required me to be assertive in planning supervision in anticipation of upcoming commitments. I also found it challenging to synchronize my learning across all three supervisory approaches. Each supervisor offered different insights on cases presented and this required some reflection to integrate these views and develop my own formulations. This provided opportunity for me to tune into my intuitions about a patient and when to intervene or stand back from care. I found the mid-year progress review helpful in consolidating all these learning points, progress in supervision and planning future goals. Alongside the professional input, I was grateful for opportunity to spend time outside the workplace with the team at social events. Reflecting on my initial feeling of being parachuted into this new environment, I felt supervision was crucial in my integration with the team. Similarly, my journey through the skies became less lonely as I shared questions, joys, and frustrations with my colleagues in a supportive environment.

WHAT I LEARNED ABOUT MYSELF AS A PSYCHOLOGIST

The fellowship was valuable for helping me adapt my psychological practice to a medical setting and understand how my unique perspective could benefit the multidisciplinary team. I learned that with ongoing self-reflection I can be flexible working with people who have acute and chronic medical needs. I learned to be more aware of a patient's physical needs and the value of propping up pillows or adjusting a bedside table alongside talking therapy. I learned that my role, though often brief, can be valuable to a person facing the trauma of illness and death. I learned that loss comes in all forms — the loss of life, health, potential, relationships, beliefs and ideas, or loss of objects. I also learned to identify anger and rage that often go along with shame, loss and grief as outlined in models of coping with dying (e.g., Kübler-Ross, Reference Kübler-Ross1969). This helped me develop a deeper understanding of a person's loss and grief beyond illness, death and dying. I learned that sometimes psychologists and psychiatrists have to break the barriers to learn in a hospital setting and hope that I was able to do this through owning my unique perspectives amongst my medical colleagues. Finally, I became more compassionate towards myself in my professional struggles and appreciate these as learning opportunities rather than failures. There will always be storms and heavier clouds crossing my skies, rocking my parachute and I welcome challenges that help me grow as a clinician and human being.

WHAT I LEARNED ABOUT MYSELF AS A PERSON

In the fellowship I became more aware of my curiosity into the medical aspects of a person's life story. I had many opportunities to indulge this interest during the fellowship and hope that it contributed to improved quality in my practice. I learned that my enthusiasm for medical learning also made it difficult to ‘switch off’ and give energy to all relevant aspects of a person's life. I learned that I am impacted by this work through a depletion of my physical energy and I've developed yoga, mindfulness, and supervision routines to replenish my energy.

Working in a setting where there is abundance of loss and grief inevitably caused me to reflect on experiences of loss. My thoughts returned to the experience of being parachuted back to Australia from Europe, the loss and trauma of moving countries, leaving friends behind, and how this manifested in my practice. Having space to reflect on personal loss was important for me in feeling connected with my colleagues and aware of my identity as a human being outside of the psychologist role. Similarly, there are times when it is necessary to pause and reflect on my own process, to allow my parachute flow freely, appreciating the journey rather than the destination.

SUMMARY AND FUTURE DIRECTIONS

Overall I found the fellowship a rich and diverse training program that met my core learning objectives. I feel well placed to continue working in the field of psychosocial cancer care and am currently building on my learning from the fellowship. I also envisage that my skills in working with chronic illness are translating into new roles including support for people with type I diabetes and stroke carers. I hope to progress my work with young adults through the group work but also in a community or student welfare setting. I am also planning to place more emphasis on working in an emotion-focused model (Greenberg, Reference Greenberg2002; Elliott et al., Reference Elliott, Watson, Goldman and Greenberg2003) and longer-term counseling support. As I navigate these future plans I remain open to where my parachute travels next and trust that the ground is never far below me.