Thomas: Tell me about your interest in psycho-oncology. Is it unusual for a psychoanalyst to be involved in this field?
Straker: I believe I'm one of the very few psychoanalysts involved in this psychiatric subspecialty. In fact, I was one of the original group of liaison psychiatrists at Sloan-Kettering in the seventies who were part of the development of psycho-oncology. As the only psychoanalyst in the group I was able to be especially helpful in the development of psychotherapeutic techniques for dealing with cancer patients. At present, in addition to work with psychoanalytic patients, which makes up the majority of my private practice, I treat patients with cancer, relatives of cancer patients, and patients with problems of bereavement, as well as physicians who work directly with these patients. My teaching and research activities reflect my interest in psychoanalysis, psychodynamics, and psycho-oncology. So I have come to the point where I am comfortable viewing myself as a psychoanalyst, psychiatrist, and psycho-oncologist.
Thomas: I know this is a very exciting and productive period in your professional life, including the recent completion of a superb film about doctors confronting cancer. However, before you talk about the movie, perhaps you could explain why a psychoanalyst would become so deeply interested in working with patients most of whom will soon die.
Straker: As a psychoanalyst I find this work especially interesting and gratifying, because it validates our theories. This is apparent in the acute onset of psychological symptoms and the success of brief therapeutic interventions based on psychoanalytic understanding. Emotional issues become very clear in the light of our various psychodynamic models, and the interventions work exceptionally well. Possibly, this is so in part because everyone involved is aware that time is limited. The life crisis produced by the cancer diagnosis obviously causes great stress, and the resultant regressive pulls are not unlike those arising out of the infantile anxieties that appear once an analysand begins work on the couch. It can readily be understood that transferences are especially intense, defenses newly erected, while anxious and depressive affects are usually on the surface. The countertransferences observed in caregivers, including doctors, nurses, and psychiatrists, are also quite intense. Conflicts between patients and staff, as well as among staff members, are not infrequent. In this atmosphere psychoanalysts have a very special expertise, as well as a point of view to offer, especially in the hospital setting. However, we must always be careful to be viewed as understanding, so as not to be seen as analyzing everyone. The fact is that caregivers are deeply concerned that they will be criticized. Many are ashamed of the high rates of mortality in this work and hence often feel inadequate and guilty. A point of view that is offered by the psychoanalyst is one of empathy and understanding for the predicament that both patients and caregivers find themselves in. This is a highly charged, emotionally disturbing environment in which pain, anxiety, suffering, and death are faced every day. While most staff members are well defended, these facts take their toll on everyone. Where in the early stages of the disease a positive transference to the trusted surgeon, oncologist, or radiation therapist is usual, this can change quite suddenly. The initial equilibrium can become upset because of the character of the patient, the response of patient and family to a poor prognosis, or simply a rapidly escalating downward course. It is at such times that a psychiatric consult is often requested. In these situations I have acted as a supervisor of psychiatric colleagues, as a seminar leader, and as a consultant directly responsible for treatment.
Thomas: I am sure you are eager to discuss the film just recently premiered, to rave reviews I might add, at Grand Rounds at New York Hospital's Department of Psychiatry. I understand that it is scheduled to be aired on PBS later this year. More than thirty thousand copies are available, with an accompanying book for distribution with a Category I C.M.E. credit. Special efforts are being made for it to be shown at medical schools and hospitals. The film is certainly worthy of a lengthy review, as its impact on audiences is already apparent. Could you give us some idea of its content?
Straker: On the Edge of Being—When Doctors Confront Cancer is a C.M.E. video program just released to bridge the gap between cancer patients and caregivers. Six physicians, four oncologists, and two psychiatrists, as well as a nurse, spoke candidly with me about their own personal confrontation with cancer. At the time they were filmed, two were cured, two were receiving active treatment, and three had lost members of their family, either a spouse or a child.
The movie is narrated by Jason Robards and introduced by former U.S. Surgeon General C. Everett Koop. In Dr. Koop's words, “The physicians (and nurse) in this film share with us the gamut of their experiences. Though we cannot put ourselves in their skin, they ask us to be open to their suffering and anxieties in the hope that each of us will have the passion to renew our spirits as caregivers in the art of medicine.” The film, produced by Ruth Yorkin Drazen, takes its title from Anatole Broyard, who said in a book about his experience with cancer, “The doctor… has little to lose and everything to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror, and exultation of being on the edge of being….” It was my privilege to interview each of the film's subjects in depth and to rely on Robert Fruchtman, its director and editor, to put it all together, in consultation with Ruth and myself.
The film addresses the problems that caregivers have in dealing with the deeply distressing emotions occasioned by caring for seriously ill and dying patients and their families on a daily basis. The skills for coping with these experiences are rarely taught. The physicians in this film speak directly to this dilemma and are distressed when speaking about their colleagues, who are now their doctors, whom they feel unable to reach out to as one human being to another. They speak about how their experience as patients has changed the way they now practice medicine. They make suggestions on how doctors can cope better, and be more empathic with their patients, and avoid burnout. They speak about the needs of medical students, whose natural concern and empathy for patients should be encouraged by faculty rather than ridiculed, and about a model of medicine that focuses more on people with diseases than on diseases alone. The film offers demonstrations of empathic communication with dying patients, as well as an in-depth discussion of pain management by Dr. Kathleen Foley, Chief of the Pain Service at Memorial Sloan-Kettering. Coping mechanisms that encourage optimal patient adaptation are also illustrated and discussed.
Norman Straker, M.D., a member of the faculty of the New York Psychoanalytic Institute, is a psycho-oncologist at Memorial Sloan-Kettering Cancer Center; Clinical Associate Professor of Psychiatry at Cornell University Medical College, and Adjunct Lecturer at the Mount Sinai School of Medicine.
Thomas: You have chaired group discussions at the Winter Meetings of The American in New York on “Psychodynamic Issues in the Psychotherapy of Cancer Patients.” Would you tell us about this?
Straker: We have had two group discussions. The first, in 1991, discussed two cases in which analysts were confronted with a patients desire to commit suicide. In one of the cases, suicide was indeed the outcome, while in the other the patient responded to psychoanalytic psychotherapy and antidepressants and gave up the idea. The patient's character, defenses, and past history in the two cases were compared, along with transference and countertransference issues. The 1992 group discussion focused on the issue of patient compliance. Two patients who refused to comply with recommendations of treatment for the cancers were referred to a consultant analyst. In both, resistance to psychotherapy, as well as other transference issues, was noted to parallel problems with compliance regarding the cancer treatment. This winter two new cases are to be presented, with an emphasis on cancer in women.
Thomas: Could you recommend any reading for those who might want to participate?
Straker: Yes, I could suggest a 1982 article in Psychosomatics that I coauthored with Bukberg entitled “Psychiatric Consultation with the Ambivalent Cancer Surgery Candidate,” another with Wyszynski on denial in cancer patients, which appeared in 1986 in Internal Medicine for the Specialist, and one with Massie and Holland in Handbook on Psycho-Oncology, put out by Oxford University Press. And I would also recommend reading Kurt Eissler's The Psychiatrist and the Dying Patient, written in 1955 but still quite valuable today.
Thomas: Thankyou for talking to us. It's been very instructive. I hope all of our readers will have an opportunity to see the film and, if they come to the meetings, to attend your seminar. Thank you again.