- Email: [email protected]
Benefits of Group Psychotherapy in Cirrhotic Patients on the Liver Transplant Waiting List
Benefits of Group Psychotherapy in Cirrhotic Patients on the Liver Transplant Waiting List P. Ramíreza,b,c,*, B. Febrerob,c, L. Martínez-Alarcónb,c, C. Abeteb, M. Galerab, P. Cascalesb,c, A.I. López-Navasd, M.R. Gonzálezb, A. Ríosb,c, J.A. Ponsb, and P. Parrillab,c a Regional Transplant Center, Consejería de Sanidad y Consumo de la Región de Murcia, Murcia, Spain; bTransplant Unit, Department of General Surgery, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigaciones Biomédicas, Murcia, Spain; c Department of Surgery, University of Murcia, Murcia, Spain; and dDepartment of Psychology, Universidad Católica San Antonio (UCAM), Murcia, Spain
ABSTRACT Introduction. It is well-known that patients on the liver transplant (LT) waiting list experience a high rate of psychopathologic symptoms. However, few studies have been published about the use of group psychotherapy for these patients. We sought to assess (1) the psychopathologic data in patients on the LT waiting list and (2) the attitude toward a group psychotherapy procedure and its efficacy. Material and Methods. In the pretransplant consultation phase, group therapy was offered to 20 patients on the LT waiting list. Patients who received psychotherapy were assessed previously using the Beck Depression Inventory. Results. Fifteen patients were included in the study. Significant differences were found between the psychopathologic assessment and the level of hepatopathy. In the first session, we observed that patients with hepatocarcinoma were much more reluctant to participate in the group therapy. In the second session, the group showed a high level of anxiety connected with a fear of transplantation. In the third session, a transplant physician answered all their questions, and at the end of the session patient anxiety had decreased. During the following sessions, family bonds and sharing experiences with other transplant patients were emphasized. Conclusions. Patients were initially reluctant to participate in the group psychotherapy, although this changed as sessions proceeded. It is necessary to provide more information about the transplant procedure itself to decrease anxiety. Group therapy was valued positively by all patients who participated.
T
HE LIVER TRANSPLANTATION (LT) PROCESS begins in earnest as patients and their families start to consider the idea of transplantation. Patients undergo a transplant evaluation that encompasses both medical and psychosocial domains. Specific stressors associated with the evaluation include uncertainty about whether or not a transplant program will judge the potential transplant candidate as being suitable for the list, fear of the operations involved, worries about changes to future life plans, burden on the family, and financial strain [1,2]. Even participating in the transplant evaluation may cause distress and tension for some patients. Patients may be uncomfortable with the questions asked during the psychosocial portion of the
evaluation because they are less familiar than those asked during the more routine medical portion of the evaluation. Patients may also be confused about whether revealing personal information that exposes their vulnerabilities may jeopardize their ability to present themselves favorably to maximize their chances of receiving a transplant [1]. Moreover, consideration of mental health in the evaluation may engender stress owing not only to the nature of the questions but also because the mental health professionals conducting *Address correspondence to Pablo Ramírez Romero, PhD, Crta./Madrid-Cartagena, s/n 30120, El Palmar (Murcia), Spain. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.08.033
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2382
Transplantation Proceedings, 47, 2382e2384 (2015)
BENEFITS OF GROUP PSYCHOTHERAPY
the evaluation are focused on judging suitability for transplant rather than providing treatment [3]. Once listed as a candidate, patients and their families enter what may be the most stressful period of the entire transplantation experience. Candidates and their families must balance the reality that they may not survive to the point of transplantation with the desire to make plans for life after transplantation [4]. Transplant candidates in general experience persistent anxiety about when, if ever, the call will come to inform them that a donor organ has become available. In addition, some patients experience monotony and frustration about the physical and functional limitations associated with advanced disease. The whole of this situation could lead the patient into a state of depression and affect his or her quality of life, which is important in the pretransplant stage [5,6]. Some studies have been carried out regarding the different kinds of psychological procedures for patients on the LT waiting list [7], but data about the effect of group psychology procedures are limited, although the results show that this therapy might be beneficial for these patients [8,9]. We sought to assess (1) the psychopathologic data of a group of patients on the LT waiting list and (2) the attitude and efficacy of a group psychotherapy procedure. MATERIAL AND METHODS Study Population In the pretransplantation consultation phase, group therapy was offered to 20 patients with liver cirrhosis who were on the LT waiting list. Of these patients, 10 were diagnosed with hepatocarcinoma and 10 with alcoholic cirrhosis.
Measurement Instruments The Beck Depression Inventory test was administered before beginning group therapy.
Group Psychotherapy After completing the questionnaires, all the patients signed the informed consent form to participate in the therapy program. Group therapy was directed by a psychologist and a social worker. The sessions took place every 2 weeks. In the present article, we assess the first 6 months of group psychotherapy (12 sessions).
RESULTS Study Completion
Of the 20 selected patients, 3 with alcoholic cirrhosis rejected the therapy because of the difficulty involved in travelling to the hospital owing to their poor clinical condition. Of the 17 patents who signed the consent form to begin the group therapy, 4 with hepatocarcinoma did not attend the sessions, in 2 cases because of family problems and in the 2 the patients did not give any reason. In the second session, 2 hepatitis C virusepositive patients with cirrhosis joined the group, so that the final group was made up of 15 patients (7 patients with alcoholic cirrhosis, 6
2383
patients with hepatocarcinoma, and 2 patients with the hepatitis C virus). Psychopathologic Assessment of Patients on the LT Waiting List
After assessing the questionnaires completed by the 15 patients before initiating group therapy, differences were found between the psychopathologic assessment and the level of hepatopathy between both groups. All the hepatocarcinomas were grade A patients on the ChildePugh classification. The alcoholic cirrhotic patients and the hepatitis C virusepositive patients were in a poorer clinical condition (grades B and C). Of the respondents, 53% (n ¼ 8; one-third of the patients with hepatocarcinoma, more than one-half of the patients with alcoholic cirrhosis, and the 2 patients with virus C) showed symptoms related to anxiety, depression, stress, and/ or insomnia. Slightly more than one-half the patients were in denial about their disease (n ¼ 8), especially the group with hepatocarcinoma, occurring in 83% of cases. Results of the Group Psychotherapy
During the first session, patients generally showed a reluctance to participate in the therapy, having a difficulty expressing emotions and feelings, such as the fear of accepting their circumstances, mainly among the group with hepatocarcinoma. In the second session, the group showed a high level of anxiety related to the fear of transplantation, expressed through the wish to see a transplant physician to clear up any doubts. Therefore, in the third session, a transplant physician came to the meeting and answered all their questions; at the end of the session, there was a decrease in the level of anxiety. The activities in the subsequent sessions have made it possible to significantly reduce both their psychopathologic symptoms, and their levels of anxiety. During the following 3 sessions, fear of loneliness and death were the main reasons for concern among the participants. In this phase, they were asked about the situations that led them to think about these fears, serving as an indicator of the most important and most valued things by the participants. The patients expressed a special concern for their family, with the fear of dependence and feelings of guilt appearing. This latter feeling appears most notably among those patients with alcoholic cirrhosis, who feel guilty about having caused the situation they find themselves in. Discussing personal experiences and sharing them with the rest of the patients generates empathy, which helps patients to reduce worries and fears. The therapists highlight the importance of emotional bonds and believe that patients should share feelings with their family. Another notable point is the anguish and uncertainty that patients experience through being on the transplant waiting list. One of the participants was called to be a reserve for the transplant, leading to an increase in this patient’s fears and frustration. During the eighth session, one of the participants did not attend because he or she had been a transplant. Knowing about this case and the improvement in this patient’s quality of life had a positive impact on the participants, generating feelings of encouragement and hope.
2384
The assessment of the sessions in the first 6 months of therapy was positive in all cases, and in the last sessions there was a lower attendance rate by the patients with alcoholic cirrhosis, mainly related to their clinical deterioration and the difficulty they had in getting to the hospital regularly.
DISCUSSION
The patients on the LT waiting list can present with a series of symptoms connected to mood disorders, which can affect their quality of life [5,6]. In the study group, more than onehalf of the patients presented with these kinds of symptoms, and consequently, psychotherapy could be very useful for these patients [7e9]. Throughout the waiting period, some candidates for LT feel they receive support by interacting with both transplant recipients who can provide hope, and fellow candidates who can identify with their current stressors [4]. However, jealousy may arise if 1 candidate receives a transplant before another [10]. Our data show a reluctance to participate in group psychotherapy, specifically in patients who have not deteriorated very much clinically despite being on the LT waiting list, namely, patients with hepatocarcinoma. However, with the involvement of the psychologist and the social worker, in the therapy second session, patients were less reluctant to express emotions. They starting asking questions about unknown subjects or those that cause fear and/or anxiety. In the third session, patient anxiety levels fell as they were provided with the right information about the transplant process, reminding us of the important role played by the transplant physician as an integral part of this psychotherapy. Some patients received more information as a result of the questions put forward by the other patients, making these sessions even more useful. Patients also showed a concern for the family member responsible for their care, suggesting that 3 sessions were needed to allow the group to bond. Family members of the patients on the waiting list can also present with mood disorders [11], and family members’ anxiety can affect patients’ coping strategies [12]. Therefore, psychotherapy for family members could also be beneficial, and could be a strategy for future study. In subsequent sessions,
RAMÍREZ, FEBRERO, MARTÍNEZ-ALARCÓN ET AL
interaction with other patients in the same position helps patients to empathize and show their feelings. In conclusion, these results of group psychotherapy in patients on the LT waiting list initially show reluctance on the part of the patients, although this reluctance decreases in the subsequent sessions. It is necessary to provide patients with more information about the transplant procedure to decrease their anxiety levels. Sharing feelings and experiences with other transplant patients was valued positively by all participants. REFERENCES [1] Barbour KA, Blumenthal JA, Palmer SM. Psychosocial issues in the assessment and management of patients undergoing lung transplantation. Chest 2006;129:1367e74. [2] Li PK, Chu KH, Chow KM, et al. Cross sectional survey on the concerns and anxiety of patients waiting for organ transplants. Nephrology (Carlton) 2012;17:514e8. [3] Olbrisch ME, Benedict SM, Ashe K, et al. Psychological assessment and care of organ transplant patients. J Consult Clin Psychol 2002;70:771e83. [4] Naef R, Bournes DA. The lived experience of waiting: a Parse method study. Nurs Sci Q 2009;22:141e53. [5] Rodrigue JR, Mandelbrot DA, Pavlakis M. A psychological intervention to improve quality of life and reduce psychological distress in adults awaiting kidney transplantation. Nephrol Dial Transplant 2011;26:709e15. [6] López-Navas A, Ríos A, Riquelme A, et al. Psychological characteristics of patients on the liver transplantation waiting list with depressive symptoms. Transplant Proc 2011;43:158e60. [7] Santos GG, Gonçalves LC, Buzzo N, et al. Quality of life, depression, and psychosocial characteristics of patients awaiting liver transplants. Transplant Proc 2012;44:2413e5. [8] Baines LS, Joseph JT, Jindal RM. Prospective randomized study of individual and group psychotherapy versus controls in recipients of renal transplants. Kidney Int 2004;65:1937e42. [9] Abbey S, Farrow S. Group therapy and organ transplantation. Int J Group Psychother 1998;48:163e85. [10] DiMartini AF, Crone C, Fireman M, et al. Psychiatric aspects of organ transplantation in critical care. Crit Care Clin 2008;24: 949e81. [11] Miyazaki ET, Dos Santos R Jr, Miyazaki MC, et al. Patients on the waiting list for liver transplantation: caregiver burden and stress. Liver Transpl 2010;16:1164e8. [12] Domínguez-Cabello E, Martín-Rodríguez A, Pérez-SanGregorio MA, et al. Coping strategies in liver patients as a function of relatives’ anxiety level. Transplant Proc 2012;44:2616e8.
ABSTRACT Introduction. It is well-known that patients on the liver transplant (LT) waiting list experience a high rate of psychopathologic symptoms. However, few studies have been published about the use of group psychotherapy for these patients. We sought to assess (1) the psychopathologic data in patients on the LT waiting list and (2) the attitude toward a group psychotherapy procedure and its efficacy. Material and Methods. In the pretransplant consultation phase, group therapy was offered to 20 patients on the LT waiting list. Patients who received psychotherapy were assessed previously using the Beck Depression Inventory. Results. Fifteen patients were included in the study. Significant differences were found between the psychopathologic assessment and the level of hepatopathy. In the first session, we observed that patients with hepatocarcinoma were much more reluctant to participate in the group therapy. In the second session, the group showed a high level of anxiety connected with a fear of transplantation. In the third session, a transplant physician answered all their questions, and at the end of the session patient anxiety had decreased. During the following sessions, family bonds and sharing experiences with other transplant patients were emphasized. Conclusions. Patients were initially reluctant to participate in the group psychotherapy, although this changed as sessions proceeded. It is necessary to provide more information about the transplant procedure itself to decrease anxiety. Group therapy was valued positively by all patients who participated.
T
HE LIVER TRANSPLANTATION (LT) PROCESS begins in earnest as patients and their families start to consider the idea of transplantation. Patients undergo a transplant evaluation that encompasses both medical and psychosocial domains. Specific stressors associated with the evaluation include uncertainty about whether or not a transplant program will judge the potential transplant candidate as being suitable for the list, fear of the operations involved, worries about changes to future life plans, burden on the family, and financial strain [1,2]. Even participating in the transplant evaluation may cause distress and tension for some patients. Patients may be uncomfortable with the questions asked during the psychosocial portion of the
evaluation because they are less familiar than those asked during the more routine medical portion of the evaluation. Patients may also be confused about whether revealing personal information that exposes their vulnerabilities may jeopardize their ability to present themselves favorably to maximize their chances of receiving a transplant [1]. Moreover, consideration of mental health in the evaluation may engender stress owing not only to the nature of the questions but also because the mental health professionals conducting *Address correspondence to Pablo Ramírez Romero, PhD, Crta./Madrid-Cartagena, s/n 30120, El Palmar (Murcia), Spain. E-mail: [email protected]
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.08.033
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
2382
Transplantation Proceedings, 47, 2382e2384 (2015)
BENEFITS OF GROUP PSYCHOTHERAPY
the evaluation are focused on judging suitability for transplant rather than providing treatment [3]. Once listed as a candidate, patients and their families enter what may be the most stressful period of the entire transplantation experience. Candidates and their families must balance the reality that they may not survive to the point of transplantation with the desire to make plans for life after transplantation [4]. Transplant candidates in general experience persistent anxiety about when, if ever, the call will come to inform them that a donor organ has become available. In addition, some patients experience monotony and frustration about the physical and functional limitations associated with advanced disease. The whole of this situation could lead the patient into a state of depression and affect his or her quality of life, which is important in the pretransplant stage [5,6]. Some studies have been carried out regarding the different kinds of psychological procedures for patients on the LT waiting list [7], but data about the effect of group psychology procedures are limited, although the results show that this therapy might be beneficial for these patients [8,9]. We sought to assess (1) the psychopathologic data of a group of patients on the LT waiting list and (2) the attitude and efficacy of a group psychotherapy procedure. MATERIAL AND METHODS Study Population In the pretransplantation consultation phase, group therapy was offered to 20 patients with liver cirrhosis who were on the LT waiting list. Of these patients, 10 were diagnosed with hepatocarcinoma and 10 with alcoholic cirrhosis.
Measurement Instruments The Beck Depression Inventory test was administered before beginning group therapy.
Group Psychotherapy After completing the questionnaires, all the patients signed the informed consent form to participate in the therapy program. Group therapy was directed by a psychologist and a social worker. The sessions took place every 2 weeks. In the present article, we assess the first 6 months of group psychotherapy (12 sessions).
RESULTS Study Completion
Of the 20 selected patients, 3 with alcoholic cirrhosis rejected the therapy because of the difficulty involved in travelling to the hospital owing to their poor clinical condition. Of the 17 patents who signed the consent form to begin the group therapy, 4 with hepatocarcinoma did not attend the sessions, in 2 cases because of family problems and in the 2 the patients did not give any reason. In the second session, 2 hepatitis C virusepositive patients with cirrhosis joined the group, so that the final group was made up of 15 patients (7 patients with alcoholic cirrhosis, 6
2383
patients with hepatocarcinoma, and 2 patients with the hepatitis C virus). Psychopathologic Assessment of Patients on the LT Waiting List
After assessing the questionnaires completed by the 15 patients before initiating group therapy, differences were found between the psychopathologic assessment and the level of hepatopathy between both groups. All the hepatocarcinomas were grade A patients on the ChildePugh classification. The alcoholic cirrhotic patients and the hepatitis C virusepositive patients were in a poorer clinical condition (grades B and C). Of the respondents, 53% (n ¼ 8; one-third of the patients with hepatocarcinoma, more than one-half of the patients with alcoholic cirrhosis, and the 2 patients with virus C) showed symptoms related to anxiety, depression, stress, and/ or insomnia. Slightly more than one-half the patients were in denial about their disease (n ¼ 8), especially the group with hepatocarcinoma, occurring in 83% of cases. Results of the Group Psychotherapy
During the first session, patients generally showed a reluctance to participate in the therapy, having a difficulty expressing emotions and feelings, such as the fear of accepting their circumstances, mainly among the group with hepatocarcinoma. In the second session, the group showed a high level of anxiety related to the fear of transplantation, expressed through the wish to see a transplant physician to clear up any doubts. Therefore, in the third session, a transplant physician came to the meeting and answered all their questions; at the end of the session, there was a decrease in the level of anxiety. The activities in the subsequent sessions have made it possible to significantly reduce both their psychopathologic symptoms, and their levels of anxiety. During the following 3 sessions, fear of loneliness and death were the main reasons for concern among the participants. In this phase, they were asked about the situations that led them to think about these fears, serving as an indicator of the most important and most valued things by the participants. The patients expressed a special concern for their family, with the fear of dependence and feelings of guilt appearing. This latter feeling appears most notably among those patients with alcoholic cirrhosis, who feel guilty about having caused the situation they find themselves in. Discussing personal experiences and sharing them with the rest of the patients generates empathy, which helps patients to reduce worries and fears. The therapists highlight the importance of emotional bonds and believe that patients should share feelings with their family. Another notable point is the anguish and uncertainty that patients experience through being on the transplant waiting list. One of the participants was called to be a reserve for the transplant, leading to an increase in this patient’s fears and frustration. During the eighth session, one of the participants did not attend because he or she had been a transplant. Knowing about this case and the improvement in this patient’s quality of life had a positive impact on the participants, generating feelings of encouragement and hope.
2384
The assessment of the sessions in the first 6 months of therapy was positive in all cases, and in the last sessions there was a lower attendance rate by the patients with alcoholic cirrhosis, mainly related to their clinical deterioration and the difficulty they had in getting to the hospital regularly.
DISCUSSION
The patients on the LT waiting list can present with a series of symptoms connected to mood disorders, which can affect their quality of life [5,6]. In the study group, more than onehalf of the patients presented with these kinds of symptoms, and consequently, psychotherapy could be very useful for these patients [7e9]. Throughout the waiting period, some candidates for LT feel they receive support by interacting with both transplant recipients who can provide hope, and fellow candidates who can identify with their current stressors [4]. However, jealousy may arise if 1 candidate receives a transplant before another [10]. Our data show a reluctance to participate in group psychotherapy, specifically in patients who have not deteriorated very much clinically despite being on the LT waiting list, namely, patients with hepatocarcinoma. However, with the involvement of the psychologist and the social worker, in the therapy second session, patients were less reluctant to express emotions. They starting asking questions about unknown subjects or those that cause fear and/or anxiety. In the third session, patient anxiety levels fell as they were provided with the right information about the transplant process, reminding us of the important role played by the transplant physician as an integral part of this psychotherapy. Some patients received more information as a result of the questions put forward by the other patients, making these sessions even more useful. Patients also showed a concern for the family member responsible for their care, suggesting that 3 sessions were needed to allow the group to bond. Family members of the patients on the waiting list can also present with mood disorders [11], and family members’ anxiety can affect patients’ coping strategies [12]. Therefore, psychotherapy for family members could also be beneficial, and could be a strategy for future study. In subsequent sessions,
RAMÍREZ, FEBRERO, MARTÍNEZ-ALARCÓN ET AL
interaction with other patients in the same position helps patients to empathize and show their feelings. In conclusion, these results of group psychotherapy in patients on the LT waiting list initially show reluctance on the part of the patients, although this reluctance decreases in the subsequent sessions. It is necessary to provide patients with more information about the transplant procedure to decrease their anxiety levels. Sharing feelings and experiences with other transplant patients was valued positively by all participants. REFERENCES [1] Barbour KA, Blumenthal JA, Palmer SM. Psychosocial issues in the assessment and management of patients undergoing lung transplantation. Chest 2006;129:1367e74. [2] Li PK, Chu KH, Chow KM, et al. Cross sectional survey on the concerns and anxiety of patients waiting for organ transplants. Nephrology (Carlton) 2012;17:514e8. [3] Olbrisch ME, Benedict SM, Ashe K, et al. Psychological assessment and care of organ transplant patients. J Consult Clin Psychol 2002;70:771e83. [4] Naef R, Bournes DA. The lived experience of waiting: a Parse method study. Nurs Sci Q 2009;22:141e53. [5] Rodrigue JR, Mandelbrot DA, Pavlakis M. A psychological intervention to improve quality of life and reduce psychological distress in adults awaiting kidney transplantation. Nephrol Dial Transplant 2011;26:709e15. [6] López-Navas A, Ríos A, Riquelme A, et al. Psychological characteristics of patients on the liver transplantation waiting list with depressive symptoms. Transplant Proc 2011;43:158e60. [7] Santos GG, Gonçalves LC, Buzzo N, et al. Quality of life, depression, and psychosocial characteristics of patients awaiting liver transplants. Transplant Proc 2012;44:2413e5. [8] Baines LS, Joseph JT, Jindal RM. Prospective randomized study of individual and group psychotherapy versus controls in recipients of renal transplants. Kidney Int 2004;65:1937e42. [9] Abbey S, Farrow S. Group therapy and organ transplantation. Int J Group Psychother 1998;48:163e85. [10] DiMartini AF, Crone C, Fireman M, et al. Psychiatric aspects of organ transplantation in critical care. Crit Care Clin 2008;24: 949e81. [11] Miyazaki ET, Dos Santos R Jr, Miyazaki MC, et al. Patients on the waiting list for liver transplantation: caregiver burden and stress. Liver Transpl 2010;16:1164e8. [12] Domínguez-Cabello E, Martín-Rodríguez A, Pérez-SanGregorio MA, et al. Coping strategies in liver patients as a function of relatives’ anxiety level. Transplant Proc 2012;44:2616e8.