Psychocorrective care for palliative cancer patients in a hospital setting

Rublyova Tatiana YUr'evna ORCID: 0000-0003-0569-9116 PhD in Medicine Associate Professor; Department of Criminology; Siberian Law Institute of the Ministry of Internal Affairs of the Russian Federation 660131, Russia, Krasnoyarsk Territory, Krasnoyarsk, Rokossovsky str., 20 tat-rubleva@yandex.ru Other publications by this author     Lisnyak Marina Anatol'evna ORCID: 0000-0001-5090-8779 PhD in Medicine Associate Professor; Department of Clinical Psychology and Pedagogy; Krasnoyarsk State Medical University named after Professor V.F. Voino-Yasenetsky 660022, Russia, Krasnoyarsk Territory, Krasnoyarsk, Partizan Zheleznyak str., 1 lisnyakm@mail.ru Other publications by this author

Daineko Irina Aleksandrovna ORCID: 0000-0002-0284-0965 Senior lecturer; Department of Clinical Psychology and Pedagogy; Krasnoyarsk State Medical University named after Professor V.F. Voino-Yasenetsky 600022, Russia, Krasnoyarsk Territory, Krasnoyarsk, Partizan Zheleznyak str., 1 dajnekoirina@gmail.com

Introduction.

Currently, there is a steady increase in the incidence of malignant neoplasms. To date, about 4 million people have been diagnosed with cancer. About 600 new cases of the disease are registered annually.

Over the past three years, thanks to the strengthening of the material and technical base and the successes of modern oncology, mortality has been decreasing and the five-year life expectancy of patients has been steadily increasing. Despite this progress, in some cases, modern treatment methods do not allow to cure the disease, and the patient needs palliative care.

In 2019, Federal Law No. 323-FZ dated 11/21/2011 "On the Basics of protecting the health of Citizens in the Russian Federation" was amended, among others, the definition of "palliative medical care" was updated, which now reads as follows: "a set of measures including medical interventions, psychological measures and care" ^[15].

In this regard, Russia pays attention not only to the organization and palliative care, but also to the desire to make it more accessible to patients who need to improve their quality of life in connection with the diagnosis of oncology.

Work is underway everywhere to improve the efficiency and quality of medical care. However, almost all patients of this profile face a huge range of negative experiences: fear, pain, anxiety, depression. The presence of pronounced changes in the psyche of cancer patients often manifests itself in the form of rejection of specialized treatment methods; suicidal thoughts; disorders of relationships in the family or at work ^{[1, 5]}.

The change in the psyche goes through a number of stages: the shock stage (receiving negative information about the presence of the disease); the stage of denial, displacement of information; the stage of aggression; the stage of depression, the stage of reconciliation, acceptance of one's fate.

In 1981, J. Dietz and co-authors identified four types of restorative treatment for cancer patients: preventive, restorative, supportive and palliative ^[17].

Palliative rehabilitation is used for patients with an unfavorable prognosis of the disease in order to create comfortable living conditions during the progression of the disease.

It should be noted that not much attention is paid to the field of psychological and social support, therefore, frequent difficulties faced by caregivers include high employment of caregivers at their place of main work, lack of skills and skills in care, low awareness of the population about the possibilities of providing socio-psychological services ^[2].

In our country, 3178 state organizations provide palliative care and 154 have a private form of ownership (hospices; departments included in hospitals or dispensaries) ^[8].

The socio-legal prerequisites that have manifested themselves in our country recently, as well as the experience of Russian medicine, have contributed to a change in professional and public attitudes towards the organization of medical and social care for seriously ill patients. Awareness began to emerge of the need to develop and implement comprehensive measures aimed at improving the quality of life of people with severe and incurable diseases, in turn, this was followed by consideration of the possibility of creating a palliative care system in Russia.

A new branch of domestic healthcare has appeared — "palliative medical care", this project was approved by the Federal Law of the Russian Federation "On the Basics of Protecting the Health of Citizens in the Russian Federation" dated November 21, 2011 No. 323-FZ and in 2013 for the first time entered the Program of state guarantees for the free provision of medical services. According to the initial plan, the provision of high-quality palliative care for incurable patients should be based on an interdisciplinary approach that will contribute to improving people's quality of life and increasing the effectiveness of care ^[13].

However, the presence of psychotherapist, medical psychologist, social worker and social work specialist positions in the staff list of medical organizations, and their physical presence in the staff do not meet the regulatory requirements for the provision of intended assistance. This situation significantly complicates the quality provision of the entire range of necessary actions and does not contribute to the full implementation of measures to improve the quality of life of patients ^[4].

Oncological diseases differ significantly from other severe diseases and have their own significant differences of a physiological and psychological order ^[7]. From the point of view of psychology, cancer should be considered as the most severe traumatic situation for the patient. These situations are marginal in terms of mental costs. In turn, such costs are an extreme measure that supports the psychoemotional state of a palliative patient with cancer. Psychological support for a cancer patient can reduce the level of psychoemotional stress due to the disease, in cases when the compensatory capabilities of the human psyche are no longer sufficient to prevent the occurrence of pathological reactions ^{[16, 18]}.

The structure and content of psychotrauma in oncological diseases can be considered in several aspects, for example, this complex picture of a person's condition includes: a doctor's announcement of a diagnosis; long-term and expensive treatment; a sense of uncertainty and a likely deterioration of the current diagnosis. ^[20].

Thus, the importance of medical and psychological support also lies in the fact that the cancer patient is constantly in a stressful situation. Cancer, as a rule, brings with it a whole string of related problems. These include: a decrease in an individual's work activity, up to its complete loss, a complex of complex medical interventions and the threat of human disability. To this is also added the violation of life certainty and the development of fear of unexpected death. In total, this has a negative effect on the human psyche and body, exhausting all possible resources of the body ^[3].

Long-term psychological support is provided at the stage of remission and when working with relatives of patients, whereas in palliative oncology it is short, and often ultrashort ^{[14, 21]}.

Crisis intervention is most often used in the practice of psychological support. If it is possible to hold several meetings, it is advisable to study the specifics and priorities of the patient's life. Such techniques are used as: focusing on meaning, encouraging insight, paradoxical intention, developing skills of self-awareness, minimal analysis, dereflexia, humor, mastering skills of communicative competence, decision-making skills in a situation of uncertainty, working with irrational attitudes, and patient anxiety, mastering skills of minimal planning, evaluating the effectiveness of exposure ^{[9, 10, 11]}.

Despite the opinion that incurable palliative patients are subject to total distress, practice shows that incurable patients experience changes associated with the disease in different ways and treat their disease differently ^[19,20].

With this in mind, it is necessary to take into account the peculiarities of psychological support for patients at the palliative stage.

Thus, the main goal in the work of a psychologist is the formation of an adaptive attitude of the patient to an incurable disease with a high degree of uncertainty of development and a pronounced vital threat ^{[6, 12]}. Today, psychologists have individual and group techniques in their arsenal, which are reinforcing, auxiliary, and supportive means for the basic treatment and rehabilitation of cancer patients.

However, among other problems of palliative care, there are not enough diverse programs for providing psychological and psychotherapeutic care to palliative patients.

In our opinion, with the help of a program of psychotherapeutic support for palliative care cancer patients in a hospital setting, their psychoemotional state can be improved.

Materials and methods.

To confirm this hypothesis, a study was conducted on the basis of the palliative care department of the Clinical Hospital, Krasnoyarsk Territory. The study sample consisted of 33 patients of oncological palliative profile aged 38 to 65 years who voluntarily agreed to participate in testing and psychocorrection program.

As part of the diagnostic stage, a personal conversation was held with each participant. During the conversation, attention was paid to the degree of contact, to the manifestation of initiative and attitude to testing, to the non-verbal manifestations of the subjects. Along with this, the medical records of patients were studied in order to assess the inclusion/exclusion criteria for participation in the study. Additionally, consultations with attending physicians were conducted to assess the physical condition of patients.

During the ascertaining experiment, the level of the respondents' life satisfaction index was assessed using the methodology "Life Satisfaction Index Test (IDI) (adaptation by N.V. Panina)" (Table 1).

Table 1. Distribution of the results of the life satisfaction index level, using the methodology "Life satisfaction index Test (ZHU) (adaptation by N.V. Panina)"

Table 1. Distribution of the results of the life satisfaction index level, using the methodology «Life satisfaction index Test (ZHU) (adaptation by N.V. Panina)»

The overall value of the life satisfaction index varies across the entire sample of the ascertaining study. Despite the presence of a serious illness, 27.3% of the subjects showed high values of the life satisfaction index, which indicates low emotional tension, anxiety, high emotional stability, psychological comfort, satisfaction with the situation and their role in it.

The average value of the life satisfaction index was determined in 39.4%, which indicates moderate emotional tension, moderate anxiety of a person, and reduced psychological comfort. And only 33.3% of the respondents had a low value of the life satisfaction index, which indicates high anxiety, low socio-mental adaptation and emotional resistance to events happening to them.

It should be noted that 12.1% of all respondents have high indicators of interest in life, they are characterized by: a high degree of enthusiasm, an enthusiastic attitude to ordinary everyday life. The average value was found in 21.2%, and 66.7% of patients have low indicators, which is characterized by a passive attitude to their own lives and little interest in everything that happens in it.

6.1% of all surveyed patients have high consistency in achieving their goals, they are characterized by determination and perseverance aimed at achieving goals. 21.2% of respondents have average values, and 72.7% have a low level, which indicates passive reconciliation with life's failures, submissive acceptance of everything that life brings.

High values on the scale of "Consistency between set and achieved goals" were found in 6.1% of patients, which describes them as people who are convinced of the ability to achieve important goals. The average values were determined in 39.4% of the participants. Low confidence in setting and achieving unlabeled important goals was found in 54.5% of respondents.

High indicators on the scale of "Self-assessment and their actions" were found in 9.1% of respondents, which indicates the presence of high self-esteem. The average level of self—esteem was 24.2%, while 66.7% of respondents had low self-esteem.

A high level of general mood background was revealed in only 9.1% of respondents, which implies a high degree of optimism, cheerfulness, and enjoyment of life. The average level on this scale was 27.3%, while 63.6% had a low level of general mood background, which indicates pessimism, discouragement and low satisfaction with life.

The results of the test "Toronto Alexithymia Scale" (TAS) (adaptation of the V. M. InstituteBekhtereva) are presented in Table 2.

Table 2. Distribution of test results "Toronto Alexithymia Scale" (TAS) (adaptation by V.M.Bekhterev Institute)

Table 2. Distribution of test results «Toronto Alexithymia Scale» (TAS) (adaptation by V. M. Bekhterev Institute)

The study showed the following results: 27.3% of respondents did not show signs of alexithymia, 42.4% were at risk of developing alexithymia, and 30.3% of respondents had developed alexithymia.

This condition is a psychological characteristic determined by the following cognitive-affective features: pronounced difficulty in defining and describing one's own feelings, difficulty in distinguishing between feelings and bodily sensations. As well as a decrease in the ability to symbolize, as evidenced by the poverty of fantasy and other manifestations of imagination, focusing more on external events than on internal experiences.

The results of the test "Personal scale of anxiety manifestation" (J. Taylor, adaptation of T. A. Nemchinova) are presented in Table 3.

Table 3. Distribution of the results of the Personal Anxiety Manifestation Scale test" (J. Taylor, adaptation by T. A. Nemchinov)

Table 3. Distribution of the results of the Personal Anxiety Manifestation scale test" (J. Taylor, adaptation by T. A. Nemchinov)

According to the results of the ascertaining experiment, the level of anxiety (Table. 3) in the general sample, it was distributed as follows: 18.1% of respondents have a low level of anxiety; the average level (with a tendency to low) was noted in 48.5% of patients in the entire sample; the average level of anxiety (with a tendency to high) was detected in 27.3% of patients, and 6.1% of respondents revealed a very high level of anxiety.

At the next stage of the study, the authors developed and implemented a psychocorrection program in an experimental group (17 subjects with stage 3 and 4 oncological neoplasm). The control group consisted of 16 patients with stage 3 and 4 cancer who did not participate in the implementation of the program.

Thus, the psychotherapeutic program was developed for palliative patients diagnosed with oncology who are in a hospital setting, taking into account the diagnosis and is aimed at reducing anxiety, harmonizing emotional state; working on the phenomenon of death and acceptance of the phenomenon of dying; working out anxiety. Additionally, it included methods of visualization and relaxation, art therapy.

In addition, we adhered to the principle of the complexity of methods of psychological influence (using a variety of methods, techniques and techniques from the arsenal of practical psychology).

Taking into account the above, the psychocorrection program was formed from 3 blocks (installation, correction, control). Each of the blocks performs certain tasks within the framework of psychocorrection using different methods and techniques (Table 4).

Table 4. Structure of the psychocorrection program for the emotional state of palliative cancer patients

Table 4. Structure of the psychocorrection program for the emotional state of palliative cancer patients

The duration of the psychocorrection program sessions was 3 months (12 sessions, each lasting 60 minutes).

The following forms of classes were used: interactive conversations; meditation; art therapy.

Elements of ATP therapy (isotherapy, maskotherapy, collage, drama therapy, fairy tale therapy) contribute to the release of intrapersonal conflict; make it possible to realize repressed feelings and inner experiences and develop the skill of differentiating them; increase self-esteem; allow you to get rid of unnecessary things and change your life; relieve emotional stress; help to live repressed emotions in a safe environment, to get rid of psychological and bodily clamps, to live through unfulfilled expectations through the game.

As an example, we give the plan and stages of one of the group classes of the program (duration — 60 minutes). Form of organization: conducting practical techniques in a hospital setting.

Stage 1. Warm—up, exercise "5 reminders" - 10 minutes.

The patient is given a piece of paper with the text and is asked to breathe slowly and carefully while reading and pronouncing five reminders:

1. Aging is inherent in me by nature. I can't avoid aging.

2. Poor health is inherent in me by nature. I can't avoid getting sick.

3. Death is inherent in me by nature. I can't escape death.

4. The people and things that are most dear to me will change someday. Separation from them is inevitable.

5. I inherit the results of the actions of my body, speech and mind. My actions are my continuation.

This warm-up allows the patient to come into deeper contact with the fear of death, and work on it mentally, and breathing exercise reduces the impact of this fear on the patient's current condition.

Patients are asked to close their eyes, take a comfortable position and take the deepest possible breaths through the nose, and exhale through the mouth, each reminder of 5 consists of two sentences. The first is for inhalation, the second is for exhalation.

Patients will try to breathe and make sense of each statement, doing this: "Taking a breath, I know that aging is inherent in me by nature. When I exhale, I know that I cannot avoid aging."

Stage 2. Exercise "Time trap" — 20 minutes. Equipment: sheets of paper, ballpoint pens, a desktop, or a paper tablet.

This exercise allows you to realize and accept that death is an integral part of being. Awareness of this helps to reduce the level of anxiety, and accordingly, the level of fear.

The first stage. The psychologist asks the patient to answer the question in writing: "What is good about death? In this case, the patient needs to write the first thing that comes to mind, there are no correct or incorrect answers.

The second stage. The psychologist asks the patient to answer in writing the question "What would happen to humanity if there were no death at all?". This question helps to understand that death is a natural and expedient process.

At the end of the exercise, there is a brief discussion, the participants share their opinions with each other.

Stage 3. Exercise "Letter to fear" — 20 minutes. Equipment: A piece of paper with text, a blank sheet of A4 paper, a ballpoint pen, a desktop or a tablet for paper.

This exercise allows you to express the patient's attitude to the fear of death, find the positive sides of the fear experienced, and promotes its acceptance. The patient is invited to write a letter to his fear.

Sample letter template:

Hello my fear of death… You are called (call him by his name). When you are present, I feel... Fear, you're telling me that... and you're letting me know that… Fear, you draw my attention to... and free me from the following undesirable activities: (list). Fear, you are useful to me because… You're playing a role… Fear, I thank you for... fear, you gave me the opportunity… Fear, I want…

Now imagine that fear is you. And you received a letter. What's in it? Write a fear response.

Stage 4. Completion. Exercise "Gratitude" for 10 minutes. Equipment: A rubber ball, or a soft toy.

The psychologist gives the group a small object, a ball or a soft toy. Everyone who has an object in their hands expresses a compliment or gratitude to their neighbor and passes the object to him, and so on in a circle.

In conclusion, the psychologist takes the subject and thanks the group for their work in the classroom.

At the final stage of the study, the patients of the experimental and control groups (respondents who did not participate in the implementation of the psychocorrection program) were re-examined using the same techniques as at the stage of the primary study.

Statistical data processing was carried out using the program "SPSS Statistics 21". The reliability of the differences between the initial indicators and the indicators after the end of classes for the participants of the experimental group was calculated using the T-Wilcoxon criterion.

Results and discussion.

In order to assess the change in the level of anxiety after completing the full course of the correctional program, a second examination was conducted.

The Wilcoxon T-test was used to compare the indicators measured under two different conditions on the same sample of subjects.

As a result of calculations of the Wilcoxon T-test for the study of the anxiety level of the experimental group before and after the program, the value of Temp = 14 was obtained.

Critical values of T at n=17 for the level of statistical significance: Tcr=27 (p≤0.01), Tcr=41 (p≤0.05). Therefore, the Temp

Thus, a comparative analysis of data from primary and secondary studies using the Wilcoxon T-test revealed a positive trend in changes in anxiety levels in palliative cancer patients after completing the program.

As a result of calculations of the Wilcoxon T-test for the study of alexithymia of the experimental group before and after the program, the value of Temp = 10.5 was obtained.

Critical values of T at n=17 for the level of statistical significance: Tcr=27 (p≤0.01), Tcr=41 (p≤0.05). Therefore, the Temp

Thus, a comparative analysis of data from primary and secondary studies using the Wilcoxon T-test revealed a positive trend in the level of alexithymia in palliative cancer patients after completing the program.

The analysis of the indicators of the "Life Satisfaction Index" test revealed positive dynamics after the corrective work.

Thus, 62.2% of patients had an average level on the "Interest in life" scale. As a result of calculations of the Wilcoxon T-test for the study of the level of interest in life, the value of Temp = 15.

Critical values of T at n=17 for the level of statistical significance: Tcr=27 (p≤0.01), Tcr=41 (p≤0.05). Therefore, the Temp

According to the "Consistency in achieving the goal" scale, 69.3% of respondents had an average level, the remaining 30.7% of respondents had a low level.

As a result of calculations of the Wilcoxon T-test for the study of the level of social adaptation, the value of Temp = 15.5 was obtained.

Critical values of T at n=17 for the level of statistical significance: Tcr=27 (p≤0.01), Tcr=41 (p≤0.05). Therefore, the Temp

There were no significant differences on the scale of "Consistency between set and achieved goals".

According to the "Self-assessment and their actions" scale, 92.3% of patients' test scores rose to an average level, which indicates an increase in patients' confidence in their own ability to achieve the set results.

As a result of calculations of the Wilcoxon T-test, the value of Temp = 16.5 was obtained.

Critical values of T at n=17 for the level of statistical significance: Tcr=27 (p≤0.01), Tcr=41 (p≤0.05). Therefore, the Temp

A study of the general mood background showed that 76.9% of respondents improved their indicators, which manifested itself in greater optimism. In addition, the patients noted that they enjoyed the interaction process.

As a result of calculations of the Wilcoxon T-test for the study of the general mood background, the value of Temp = 13 was obtained.

Critical values of T at n=17 for the level of statistical significance: Tcr=27 (p≤0.01), Tcr=41 (p≤0.05). Therefore, the Temp

In order to ensure the reliability of the experiment, calculations were additionally performed for the control group, whose patients participated in the testing, but did not participate in the psychocorrection program.

As a result of calculations of the Wilcoxon T-test to study the level of anxiety, the level of alexithymia, according to the test "Life satisfaction Index" (scales "Interest in life", "Consistency in achieving goals", "Consistency between set and achieved goals", "Assessment of oneself and one's actions", "General mood background") No statistically significant results were revealed.

Thus, a comparative analysis of the data from the primary and secondary studies in the experimental group using the Wilcoxon T-test showed that the participants of the psychocorrection program showed positive dynamics, while no changes were detected in the control group.

Conclusion:

By implementing the developed psychocorrection program using methods of visualization, relaxation, art therapy (isotherapy, maskotherapy, collage, drama therapy, fairy tale therapy) among palliative cancer patients in hospital settings, it was possible to reduce the level of anxiety and alexithymia, positive dynamics in life satisfaction indicators.

This fact testifies to the effectiveness of the psychocorrective work carried out with oncological patients at the palliative stage.

In this regard, the program proposed by the authors can be successfully used to correct the emotional state of palliative cancer patients in the process of treatment and rehabilitation measures.

It should be noted the importance of existing and developing new correctional programs, their implementation and the accumulation of an empirical database.