Facing death: physicians' difficulties and coping strategies in cancer care

UMEÅ UNIVERSITY MEDICAL DISSERTATIONS

______________ New Series No. 395-ISSN 0346-6612__________________ From the Department of Psychiatry, Umeâ University and Department of

Education Uppsala University, Sweden

FACING

DEATH

P h y s i c i a n s '

d i f f i c u l t i e s a n d

c o p i n g s t r a t e g i e s

in c a n c e r car e.

Margareta Andrœ

From the Department of Psychiatry, Umeå University , and Department of Education, Uppsala University, Sweden.

FACING

DEATH

P h y s i c i a n s '

d i f f i c u l t i e s a n d

c o p i n g s t r a t e g i e s

i n c a n c e r care.

AKADEMISK AVHANDLING

som med vederbörligt tillstånd av Rektor vid Umeå Universitet för avläggande av Medicine Doktorsexamen kommer att offentligen

försvaras i Tandläkarhögskolans sal B onsdagen den 11 maj 1994, kl 10.00

av

MARGARETA ANDRÆ med. lic, leg.läkare

UMEÅ UNIVERSITY MEDICAL DISSERTATIONS

N ew Series No. 395-ISSN 0 3 4 6 -6 6 1 2-ISBN 91- 7174-875-X

Androe, M argareta (1994) Facing d eath Physicians' difficulties and coping strategies in cancer care.

D octoral dissertation from th e D ep artm en t of Psychiatry, U m eå U niversity, S-901 85 UMEÅ and D epartm ent of Education, U ppsala University, S-750 02 UPPSALA, Sweden.

ABSTRACT: Even if the treatm ent of can cer has developed over the last decades

50% of the patients still die of their cancer. The doctor's w ay of dealing with his and his p atien t's anxiety m ust surely be of significance for the treatm en t the patient receives.

In the first part of the thesis earlier studies of physicians' stress and ways of coping are reported. There is a lack of system atic studies w hich show how doctors w orking with can cer patients adjust to this work. The aim of this investigation is to study can cer doctors' difficulties and coping strategies. The theoretical fram e of th e study em b ra c e s parts of p sy ch o an aly tical th eo ry and c o p in g m odels, em phasizing that both unconscious and conscious psychological processes play their part in the coping process.

The seco n d , em pirical part of the study includes 23 physicians strategically selected out of a population of physicians w ho work with institutional care and w ho have daily co n tact with adult can cer patients. The m ain m ethod of data collection has b een a series of recorded interviews. The focus of the interview was the physician's perception of how he reacts, thinks, talks and acts in different p h ases of th e c a n c e r d isease. To illustrate the d e fe n c e strategies of th e interview ers, the projective percept-genetic test, the "D efence M echanism Test" (DMT) is used. The "Structural Analysis of Social Behaviour" (SASB) has been used to study the doctors' self image.

The results indicate that the stated difficulties deeply affect the doctor as a hum an being. The statem ents reflect conflicting feelings and w ishes in relation to authority, conflicting feelings and wishes in relation to frightening and injuring, conflicting feelings and wishes in relation to intim acy/distance. Thirty them es of co p in g strategies frequently recur and they have been g ro u p ed into seven categories. M ost of the doctors "seek know ledge" and support from scientific literature. The m ajority of them state that attem pting to "solve a problem " is their m ain strategy. M ost of the doctors "seek support " as a part of their coping strategy. An interesting observation is that the doctors to a higher extent "seek a relation" to their patients rather than to their colleagues. Almost o n e third use "denial of the severity of a situation" as their m ain strategy. All the doctors consciously or unconsciously use "diverting strategies", i.e. undertake tasks which are devoid of co ntact with patients, such as research and adm inistration or other activities w hich allow them to avoid the patient. O n e third use "projective m anoeuvres" but this is never a main strategy.

In the third part of the study the credibility of the results and their pedagogical and practical im plications are discussed.

UMEÅ UNIVERSITY MEDICAL DISSERTATIONS

______________ New Series No. 395-ISSN 0346-6612_________________ From the Department of Psychiatry, Umeå University and Department of

Education Uppsala University, Sweden

FACING

D E A T H

P h y s i c i a n s "

d i f f i c u l t i e s a n d

c o p i n g s t r a t e g i e s

i n c a n c e r car e.

Margareta Andrœ

1994

..because their anxiety

also my anxiety..."

UMEÅ UNIVERSITY MEDICAL DISSERTATIONS

New Series No. 395-ISSN 0346-6612-ISBN 91- 7174-875-X

A n d rc e , M a rg a r e ta (1994) F a c in g d e a t h Physicians' difficulties and coping strategies in cancer care.

D octoral dissertation from the D epartm ent of Psychiatry, Umeå University, S-901 85 UMEÅ and D epartm ent of Education, Uppsala University, S-750 02 UPPSALA, Sweden.

ABSTRACT: Even if the treatment of cancer has developed over the last decades 50% of the patients still die of their cancer. The doctor's way of dealing with his and his patient's anxiety must surely be of significance for the treatm ent the patient receives.

In the first part of the thesis earlier studies of physicians' stress and ways of coping are reported. There is a lack of systematic studies w hich show how doctors working with cancer patients adjust to this work. The aim of this investigation is to study cancer doctors' difficulties and coping strategies. The theoretical frame of the study em braces parts of psychoanalytical theory and coping models, em phasizing that both unconscious and conscious psychological processes play their part in the coping process.

The second, em pirical part of the study includes 23 physicians strategically selected out of a population of physicians who work with institutional care and who have daily contact with adult cancer patients. The main m ethod of data collection has been a series of recorded interviews. The focus of the interview was the physician's perception of how he reacts, thinks, talks and acts in different phases of the can cer disease. To illustrate the defence strategies of the interviewers, the projective percept-genetic test, the "Defence M echanism Test" (DMT) is used. The "Structural Analysis of Social Behaviour" (SASB) has been used to study the doctors' self image.

The results indicate that the stated difficulties deeply affect the doctor as a human being. The statem ents reflect conflicting feelings and wishes in relation to authority, conflicting feelings and wishes in relation to frightening and injuring, conflicting feelings and wishes in relation to intimacy/distance. Thirty themes of coping strategies frequently recur and they have been grouped into seven categories. Most of the doctors "seek knowledge" and support from scientific literature. The majority of them state that attempting to "solve a problem" is their main strategy. Most of the doctors "seek support " as a part of their coping strategy. An interesting observation is that the doctors to a higher extent "seek a relation" to their patients rather than to their colleagues. Almost one third use "denial of the severity of a situation" as their main strategy. All the doctors consciously or unconsciously use "diverting strategies", i.e. undertake tasks which are devoid of contact with patients, such as research and administration or other activities w hich allow them to avoid the patient. O ne third use "projective manoeuvres" but this is never a main strategy.

In the third part of the study the credibility of the results and their pedagogical and practical implications are discussed.

Foreword

In th e m id -1 9 8 0 s I w as o u t fell-w alking w ith o n e of my b est frien ds. W e w e re ta lk in g a b o u t m y jo b , m y "w ork situatio n". She m a d e a c o m m e n t w h ic h really struck ho m e, "You m ust b e in a c o n s ta n t state of grief." S he w a s right. W h a t I had reflected o v er w as n am ely th e fact th a t half of my p atien ts d ie . I kept losing th e m . It w as n o t th e case th a t my situ atio n w as different from o th er oncologists. T he scien c e of m e d icin e has n o t c o m e th a t far.

N aturally w e h ave m ad e very real progress in th e trea tm e n t of certain form s of p articu lar tu m o u rs b ut th e "over all" survival rates w e h av e not im proved o v e r th e last te n y e a rs, d e s p ite all th e a d v a n c e s in m e d ic in e a n d te ch n o lo g y .

My friend co u ld see th e feelings th a t I m yself had b o rn e but w h ich I h ad no t in tellectu a lly p erceiv ed : grief an d pain. My frien d 's rem ark lead m e to an insight w h ic h has had m ajor c o n s e q u e n c e s for m e. It g ave m e th e idea of acq u irin g a better u n d erstan d in g of w h at my w ork en tailed . O v e r th e years I h ad b een aw a re th a t I often ex p ressed feeling s w h ic h w e re reg ard ed by certain c o lleag u e s as signs of w eakn ess, by others as sensitivity an d by still o th ers as aw aren ess. I co u ld see h o w differently w e d o cto rs v iew ed d eath an d se p a ra tio n . It b e c a m e c le a r to m e th a t th e re w as a relatio n b etw ee n h o w o n e v iew ed d e a th an d disease, ho w o n e m astered all th e w o rry th a t o n e 's w o rk brings on a w ard an d h ow this in turn influ en ced o n e 's w ork, i.e. th e o rg an izatio n of o n e 's w ork.

T h ere w e re c o n v e rsa tio n s a b o u t p atien ts havin g different w ay s of co p in g w ith th e ir illness. In su ch co n v ersatio n s it w a s often said th a t th e p a tie n t "was taking it very well".

D octors w ork in g w ith c a n c e r p atients again and again are co n fro n te d w ith serio u s an d life-th reaten in g illnesses. Every d a y w e m ust d o m o re th a n m erely u n d e rsta n d in tellectu a lly an d tell p atien ts a b o u t results. W e feel c a n c e r w ith o u r h an d s and see it in p ictures an d in th e m icro sco p e. I h av e n o ticed th a t w e d octo rs ex p erien ce this differently. T here w as a tim e w h en I let m yself b e co n v in c e d th a t a certain w ay of actin g an d reac tin g w as th e co rrect w ay.

Step by step I c a m e to u n d erstan d w h a t I h ad seen o v er th e years, nam ely th a t certain d o cto rs have strategies to c o p e w ith th eir w ork w h ich offer th e p atien t w ell-b e in g but w h ich "w ear out" th e d o cto r. O th ers h ave so lu tio n s w h ic h m ake th e p atien t an d staff co n fu sed an d /o r d isa p p o in te d b u t w h ich giv e th e d o c to r sa tisfa c tio n . T h e re is p ro b a b ly a large re p e rto ire of strategies.

T his insight m a d e m e cu rio u s a b o u t h o w in d iv id u als d eal w ith th rea ts, d istress a n d an xiety. W h ich initally w a s m erely a d e sire to a c q u ire for m yself a n ew w ay of b eh av in g w h ich w o u ld be co n sc io u s an d flexible led to m e w a n tin g to im p ro v e my k n o w le d g e an d u n d e rs ta n d in g of o th e r c a n c e r d o cto rs' different em o tio n al and beh avioural responses.

CONTENTS

FOREW ORD 5

CONTENTS 7

P A R T I

PROBLEMS, RESEARCH PERSPECTIVES A N D

M E T H O D O L O G Y

11

CHAPTER I

PROBLEM AREA 13

T he d o c to rs ' ed u ca tio n a l persp ectiv e 13 T he pressure on d o cto rs - "stress" 14

CHAPTER 2

EARLIER RESEARCH AND THE AIM OF

THE PRESENT STUDY 19

C h o ic e of search strategy 19

A nalysis of earlier studies 2 0

Stress, em o tio n al reaction s an d co p in g 21 Stress, em o tio n al reactions, d efensive m an oeu vres

an d c o p in g 23

C o n se q u e n c e s of previous research for th e design

of th e p resen t study 29

The aim of this study 31

CHAPTER 3

RESEARCH PERSPECTIVES 33

P sychoanalytical c o n ce p ts 33

Intrapsychic conflict and guilt 34

Defence theories 36

T he c o n c e p t of c o p in g 41

The evaluation of stress 41

The coping process 42

A m odel for u n d erstan d in g th e c o n n ec tio n

b etw ee n d efen c e m ech an ism s and co p in g 4 4 Exam ples of co n n e c tio n s b etw een d efen c e m ech an ism s

CHAPTER 4

CHOICE OF M ETHOD 49

Study g ro up 49

M eth od of d ata co llectio n 50

The Interview 51

Defence Mechanism Test (DMT) 52

Structural Analysis of Social Behaviour (SASB) 53

D ata co llectio n 54

Interview 54

Defence Mechanism Test (DMT) 57

Structural Analysis of Social Behaviour (SASB) 58

P rocessing and analysis of d ata 58

Ethical co n sid eratio n s. 58

P resen tatio n of results 59

P a r t II

RESULTS 61

CHAPTER 5

DIFFICULTIES ex p ressed by th e d octo rs 63

C ateg orizatio n 63

D ifficulties c o n c e rn in g th e disease. The "Actor" 65 D ifficulties c o n c e rn in g th e interaction.

The "Interactor" 68

D ifficulties c o n c e rn in g th e ph y sician 's o w n reactions.

The "Reactor" 70

A su m m ary of th e stated difficulties of th e physicians 77

CHAPTER 6

CONFLICTING FEELINGS AND WISHES 81

C onflicting feelings and w ish es in

relation to authority 82

C onflicting feelings and w ishes in

relation to frightening and injuring 83

C onflicting feelings and w ishes in

relation to intim acy /distance 84

T he relation b etw ee n conflicting feelings and

CHAPTER 7 C O PIN G STRATEGIES 89 C atego rizatio n 89 Seeking knowledge 91 Seeking solutions 92 Seeking support 94

Building up a relation with the patient 95

Denying the gravity of the situation 96

Distracting activities 97

Projective manoeuvres 98

C o ping patterns 99

A sum m ary of th e c o p in g strategies 99

CHAPTER 8

THE DEFENCE MECHANISM TEST (DMT) AND THE

STRUCTURAL ANALYSIS OF SOCIAL BEHAVIOUR (SASB) 101

D efen ce M ech an ism Test 101

Structural A nalysis of Social B ehaviour 102

PA RT III

INTERPRETATION, D ISC U SSIO N A N D

C O N C L U S IO N S 103 CHAPTER 9

RELATIONS BETWEEN DIFFERENT FOCUSES IN

THE EMPIRICAL STUDY 105

C o ping patterns illustrated by m eans of th e results

from th e DMT an d th e SASB 105

C o ping patterns in relation to conflicting

feelings an d w ish es 107

C onflicting feelings and w ish es - DMT - c o p in g 109

CHAPTER 10

C O N C L U D IN G ANALYSIS A N D DISCUSSION 111

D iscussion of results 112

Difficulties 112

Conflicting feelings and wishes 114

Coping strategies 115

C om p ariso n w ith earlier studies 117

D iscussion of th e m etho d 123

The credibility of the investigation 124

Effects of th e study on th e physicians 126 D iscussion of clinical and ped ago gical im plications 127

P roposals for ed u ca tio n a l p rogram m es 129

D iscussion of further research 130

GENERAL CO NCLUSIO NS. 131

LAST W O R D 133

ACKNOWLEDGEMENTS 135

Part I

PROBLEMS, RESEARCH

PERSPECTIVES AND

CHAPTER 1

PROBLEM AREA

Even if th e tre a tm e n t of c a n c e r has d e v elo p ed o v er th e last d e c a d e s 50% of patien ts still d ie of th eir can c er. P ro b ab le c a n c e r is still th e m ost frightening of d ia g n o ses. For m ost p e o p le w h o are stru ck w ith c a n c e r th e d iag n o sis brings on an existential crisis w ith a high m easure of d eath anxiety. This th e p a tie n t's state of crisis, has b een th e su b ject of research for m an y y ears an d h as given rise to k n o w led g e o n p a tie n ts' attitu d es an d to a n ew w a y of w o rk in g w ith th e p a tie n t. W h a t h a p p e n s to th e d o c to r is, h o w e v e r, of interest as w ell. T he d o c to r's w ay of d ealin g w ith his o w n an d th e p atie n t's an x ie ty o f d e a th m u st su rely b e o f sig n ific a n c e for th e re c e p tio n an d tre a tm e n t w h ic h th e p a tie n t receiv es. A look at th e literatu re, h o w ev er, reveals an o b v io u s d earth of sy stem atically co llected d a ta o n this area and th e re is a n eed for explorative studies.

The doctors' educational perspective

In o rd e r to o b tain inform ation a b o u t th e patien t th e d o c to r has to establish a re la tio n (H olm 198 5) w h ic h c a n ta k e o n e of m a n y form s. T he d o c to r interacts w ith an o th e r h u m an b ein g w h e th e r he likes it or not. T he d o c to r's first e n c o u n te r w ith a p atien t d u rin g his ed u ca tio n m ay be a m eetin g w ith a d e a d body. This w as th e c a se at m ed ical co lleg es in S w ed en in th e 19 60s an d it is still th e c a se at certain co lleg es ev en to d a y in th e 19 9 0 s. At th e sam e tim e stu d en ts are recruited in S w ed en as in o th e r W estern c o u n tries fro m a s o c ie ty w h e r e d e a th is s e ld o m p re s e n t (K a ste n b a u m 1 9 7 6 ). H o w e v e r, th e c lin ic a l reality is th a t th e th re a t of in c u ra b le d is e a s e , ta n ta m o u n t to d e a th , is co n stan tly present. "The d o c to r is co n fro n te d every d a y w ith o th e r p e o p le 's e m o tio n a l im b a la n c e , w o rry , suffering, fear of disease, b erea v em en ts and grief an d is e x p e c te d co n stan tly to give priority to th e p a tie n t's feelings an d d em ands" (H olm 1985 p22-23).

T he d o c to r h as very little form al sp a c e to co n sid er, b o th d u rin g th e seven y ears e d u c a tio n (U tb ild n in g sp lan 1993) an d later d u rin g his pro fessio nal life, th e p erso n al e m o tio n a l reac tio n s an d p o ssib le difficulties w h ic h th e d o c to r m ay brin g a lo n g a n d w h ic h m ay b e a c tiv a te d in th e w o rk w ith

s e rio u sly ill an d d y in g p a tie n ts. M ed ical stu d ie s e n ta ils th e s tu d e n t to p lu n g e , at an intensive p a c e , into th e stru ctu re of th e h u m an b o d y from a fu n ctio n al p o in t of view as a system of g en etic, m o lecu lar, cell-b io lo g ical a n d p h y sio lo g ical p ro cesses. B esides, h e sh o u ld b e a b le to a n a ly z e an d u n d e rs ta n d th e c o m p le x system w h ic h th e h u m a n b o d y c o n stitu te s an d a b o v e all to u n d erstan d an d attack th e c h a n g e s w h ich c an h a p p e n w ithin this system , and w h ic h are referred to as p ath o lo g ical. In o rd er to b e c o m e a d ia g n o stician th e stu d e n t of m e d icin e n e e d s this factual k n o w led g e of th e b o d y 's no rm al stru ctu re an d b io logical p ro cesses to b e ab le to d e te c t th e d istu rb an ces.

The pressure on doctors - "stress"

D o cto rs are p re p a re d for in tellectu a l c h a lle n g e s. T he p h ysical stress to w h ic h th e y are su b jected to has been o b serv ed an d d e sc rib e d . D uring th e 197 0s an d 80s th e re w as a d e b a te in S w ed en , n o t at least am o n g st ju n io r d o c to rs , a b o u t lon g w o rk in g day s. As a m a tte r of fact in to th e 1 9 7 0 s w o rk in g h o u rs legislation d id n o t ap p ly to d o cto rs. D uring th e 19 70 s an d 1 9 8 0 s , th e e m o tio n a l a s p e c ts of th e w o rk in g e n v ir o n m e n t w e r e d o c u m e n te d for o th e r professional groups su ch as firem en, social w orkers an d n u rses (M aslach 1986). H o w ev er, th e em o tio n a l strains for d o c to rs h av e not attracted so m u ch attention (Fain 1989), e x ep t Balint (1966) w h o , as early as in th e 19 5 0 s an d 196 0s, invited d o cto rs to e x a m in e th e ir o w n w a y o f reac tin g an d th e c o n s e q u e n c e of th e ir attitu d es to w a rd s p atien ts w h o d id n o t c o m p ly w ith th e p re s c rib e d th e ra p y o r w h o w e r e n o t d ia g n o s a b le a c c o rd in g to s o m e te x tb o o k m o d e l, i.e. h e a rt an d u lc e r patien ts. D u rin g th e last d e c a d e th e re h av e b een alarm in g rep o rts a b o u t psy ch o lo g ical stress, self a b u se an d high d iv o rce an d su icid e rates am o n g d o cto rs, th e latter ap p ly in g to fem ale d o c to rs in p a rtic u la r (A rnetz 1 98 7; LARM 19 8 7 ; H ellström M 19 93 ; H ellström L 1982). T he risk of d o cto rs to b u rn o u t w h ile tre a tin g AIDS sufferers, serio u sly ill c h ild re n a n d w h e n d e a lin g w ith th e v ictim s of c a ta s tro p h e s an d ro ad a c c id e n ts h as b e e n d escrib e d (LeBourdais 1989; Fain 1989). Le Bourdais reports a co n v ersatio n w ith a fem ale d o c to r w h o looks after AIDS patien ts saying: "A d o c to r is ju st a sh o rt step aw ay from G od an d w e 'r e used to th in k in g o f o u rselv es as b ein g so stro ng a n d not n e e d in g any h elp . W e n ev er get sick, w e n ev er bu rn o u t, w e n ev er fail. So it's h ard for us to re c o g n iz e w h e n w e are in tro u b le , h a rd for us to a d m it it to o u rselv es" (p 4 4 1 ). H o w e v e r, th e d o c u m e n ta tio n is c o n s id e ra b ly less e x te n siv e w ith reg ard to d o c to rs ' v u ln erab ility w h en c a rin g for o th e r c h ro n ic a l d iseases th a n AIDS, su ch as

patien ts w ith c a n c e r (Feifel 1965; F eigenberg 19 76 ; M aguire 1989; V achon 1987).

T h e re h a s b e e n a c o lle c tiv e re s is ta n c e from d o c to rs to d is c u s s in co u n sellin g /su p erv isio n groups, difficulties w h ich a re reg ard ed by so m e as stress and by others as psychological discom fort. Allison (1981) d escrib e s a su rv ey w h e re s tu d e n ts p a rtic ip a te d in d isc u ssio n g ro u p s d u rin g th e ir e d u c a tio n . T hey left th e gro up s ev en th o u g h th e activity in th e grou ps w as c o m m itte d . M an y p a rtic ip a n ts s e e m e d to b e g e n u in e ly in te re s te d in ex plorin g th e ir interactions w ith patients an d th eir ow n em o tio n al reactions. T he reason w h y th e stud ents sto p p ed atten d in g th e gro up s w as th e o b v io u s rift b e tw e e n th e ir c lin ic a l te a c h e r s a n d th e g ro u p le a d e rs w h o w e re p sy ch iatrists. T h e stu d e n ts c o u ld not re c o n c ile th e te a c h e r s ' a p p a re n tly co n tra d icto ry ap p ro a c h e s to w ard s m ed icin e. H olm (1985 ) c o n c lu d e d that, "O n th e o n e h an d , th e students are studying to b e c o m e scientifically train ed an d skilled clinicians, seeking so-called o b jectiv e hard d ata an d d e v elo p in g th e ir intellectual cap a city . O n th e o th er h an d , in th e d iscu ssio n grou ps, an o p p o rtu n ity w as o ffered to a p p ro a c h p a tie n ts from a v ie w p o in t w h e re k n o w le d g e o f e m o tio n s an d insight into h u m a n re la tio n s w e re u sed to u n d e rsta n d th e p atien t as a w h o le p erso n . T he co n flict w as ag g ravated by so m e of th e clinical te a c h e rs o p e n ly sh o w in g th eir scep tical attitu d e to th e groups. In o rd er to avoid this co nflict of v alues and th e d isco m fo rt w h ic h it brought, m any of th e stu dents w ere forced to take th e ir c h o ic e for o r against o n e of th e a p p ro a c h e s. They c h o se th e m odel w h ic h m ost e n h a n c e d th e v alu e of th e ir ed u ca tio n as a w h o le, i.e. th e hard d ata m odel" (p 31).

M cC u e (1982) also claim s th a t th e re is a re lu c ta n c e to a c k n o w le d g e o n e 's e m o tio n a l d ifficu lties w h e n o n e has s p e n t u p to a th ird of o n e 's life betterin g o n eself and has ex p ectatio n s of o n e 's profession w h ich c o m e into c o n flic t w ith th e reality on later e n c o u n te rs. H e fo rm u lates th e fear an d n o tio n th a t a d o c to r c o u ld p o ssib ly lose c o n tro l, th a t a d o c to r c o u ld b e c o m e e m o tio n ally to o involved, w h ich co u ld p rev en t him from fulfilling his prim ary task, n am ely revealing th e nature of th e d isease or injury, w h ich is th e fo rem o st o f H ip p o c ra te s ' (4 6 0 -3 7 7 B.C.) rules for d o c to rs. It still g u id e s for d o c to rs in m ost p arts of th e w o rld to th is v ery d a y . But H ip p o c ra te s ' m e d ic a l sc h o o l also h ad a s e c o n d ru le, to c o m fo rt a n d palliate, a very central te n e t w h ich B ennet (1987) ex p o u n d s in "The W o u n d a n d th e D octor". H e claim s th a t in every d o c to r is a p atien t an d in every p atien t a d o cto r. T he d o cto r stan ds for po w er, k n o w led g e an d ability w h ile th e p atien t represents w eak n ess, fear and h elp lessness. T hese tw o roles are nev er fully sep arated . N o d o cto r is ev er o n e h u n d red p erce n t d o c to r an d no p a tie n t o n e h u n d re d p e rc e n t p a tie n t. R ather th e re is a c o n tin u u m . T he d o c to r sh o u ld b e reg ard ed as th e ex p ert w h ich he is, b u t also as having th e

w e a k n e ss a n d h elp lessn ess w h ic h p ertain s to th e ro le of p atien t: "For th e p ra c tisin g d o c to r, th e 'd o c to r p o le 1 of th e c o n tin u u m is m a n ifest a n d d o m in a n t, w h ile th e 'p a tie n t p o le ' is latent. But th e latent w e a k n e ss an d h elp lessn ess is th e re , an d , if it c a n be c o n sc io u sly a c c e p te d , it is w h a t is m e a n t by th e c o n te m p o ra ry d o c to r by th e te rm 'w o u n d '." (p208-9) It is B en n et's o p in io n th a t th e re is a "collective m edical fantasy of th e d o c to r as a perso n w h o is ab o v e h u m an frailties, an d w h o has to survive th e hospital years as a kind of 'rite d e passage'" (p7).

T rain in g p ro g ra m m e s w h ic h o n ly fo cu ses o n th e p a tie n t's feelin g s an d b e h a v io u r are in c o m p le te . G orlin (1983) n o te s th a t th e d o c to r-p a tie n t relatio n n e e d s to b e d efin ed as w ell as th e d o c to r's feelings an d h o w th e d o c to r d e a ls w ith th e se also n e e d s to b e e x p lo re d . T he d o c to r's feelings a b o u t th e patien t, th e d isease and his ow n role affect th e diag n o stic acu ity a n d c h o ic e of th erap y , as w ell as th e d o c to r's w ay of co m m u n ic a tin g w ith th e p a tie n t an d , in th e long run, th e o u tc o m e of th e tre a tm e n t. If o nly th e p a tie n t's m ed ical an d psycho log ical p ro b lem s are tak en into co n sid era tio n th ro u g h o u t th e c o u rse this im plies th a t th e d o c to r's psy chological p rob lem s are trivial or sh o u ld b e repressed.

In her d octo ral thesis, H olm (1985) show s th a t m edical stu dents durin g their e d u c a tio n d e v e lo p "instrum ental thinking" an d sh e refers to o th e r a u th ers w h o h av e m a d e th e sam e o b serv atio n (G uze 19 79 ; P arson 1 9 5 1 ; G orlin 1983). G orlin (1983) d escrib es a range of typical situ ation s (ch ap ter 2 p23) for e x a m p le , th a t p a tie n ts w ith in c u ra b le illnesses an d th e te rm in a lly ill m ak e th e d o c to r feel im p o ten t an d in c o m p ete n t. His self-esteem falls and h e feels frustrated. P atients in a state o f em o tio n al crisis give th e d o c to r a sen se of help lessn ess and loss of co n tro l. O th e r situation s, for in stan ce th e m eetin g w ith self-d estructiv e patients, m ay c a u se ang er, w h e re a s an o v er­ d e p e n d e n t p a tie n t m ay initially give th e d o c to r a sen se of g ratifica tio n w h ic h is follo w ed by a feeling of im p atien ce, guilt and an ger. W h e th e r or n o t th e s e re a c tio n s a re reg ard ed as try in g an d stressful d e p e n d s o n th e in d iv id u a l's a ttitu d e to w a rd s his o w n re a c tio n s (L azarus 198 4). G o rlin (1983) claim s th a t a m edical stu d en t w h o reacts strongly in th e face of very ill an d d y in g patients, at best, feels lonely. At w orst, he e x p e rie n c e s guilt, sh a m e o r bitterness. If th e m edical stu d en t u n d erstan d s th a t all d o cto rs n o w an d th e n e x p e rie n c e positive an d n eg ativ e feelings an d im pulses, h e can begin to co n sid er w h e th e r he m ight share th e reaction w ith s o m e o n e else or w h e th e r it is very perso nal in th e face of certain ty pes of p atien t o r certain diseases.

It d o e s n o t n ecessarily h av e to be d eath itself w h ic h gives th e d o c to r th e feeling of, for ex am p le, being insufficient. P robably h e can a c c e p t th a t th e re are limits to ex p ert ability. T he strain - "stress" - w h ic h th e d o c to r feels m ay h av e o th e r cau ses. T hat w h ich disturbs o r con fu ses d o e s not n eed to b e th e situatio n o r d ev e lo p m e n t itself b u t m ay b e th e su rro u n d in g p re c o n c e p tio n s and d elu sio n s (V achon 1987).

In this first ch ap ter, I h ave d escrib ed how th e d o c to r d u rin g his e d u c a tio n is tra in e d ch iefly to v iew th e p a tie n t as an o b je c t a n d is tra in e d to view h im self as o b je c tiv e . H o w ev er, th e d o c to r is n o t m e re ly an o b je c tiv e ly re p la c e a b le instrum ent. H e has both rational and irrational w ays of acting, reactin g an d in teracting. The d o c to r tries to assum e co n tro l an d to av oid a sen se o f in c o m p e te n c e . R esearch w h ich e x p a n d s this area is d iscu ssed in c h a p te r 2. T he w ay w h ic h h e c h o o s e s is e lu c id a te d in th is stu d y using c o n c e p ts from psy ch o an aly tical th e o ries an d from th e o ries of stress, w h ich are d escrib e d in m o re detail in c h ap ter 3.

CHAPTER 2

EARLIER RESEARCH AND THE AIM

OF THE PRESENT STUDY

Choice of search strategy

In o rd er to an sw er th e qu estio n h ow d o cto rs every day, from y e a r's e n d to y e a r's en d , c o p e w ith w orking w ith c a n c e r patients, I em b ark ed on a search for e a rlie r d o c u m e n ta tio n on th e su b je c t. I w e n t th ro u g h fo u r d a ta b a se s, n am ely "MEDLINE", "PSYC" (Psychological abstracts), "SOCA" (Sociological abstracts), a n d "NAHL" (N ursing and Allied H ealth Literature). T he focus of th e se a rc h w a s d o c to rs ' re a c tio n s an d a ttitu d es to w a rd s c a n c e r p a tie n ts (search w o rd s w e re "doctor","stress", "anxiety", "serious d isease", "cancer", "death", "p sy c h o lo g ic al ad ju stm en t", "coping" a n d "defence"). T h ro u g h MEDLINE o n ly a b o u t ten articles w e re identified for th e p erio d 1 9 6 6 to 1 9 9 1 . A c o u p le of th e se d escrib e h ow d o cto rs relate to th e ir o w n c a n c e r (M ullan 1 9 8 5 ; S ta u te m ire 1 9 8 3 ) a n d a c o u p le d e s c rib e th e sp e c ia l v u ln e ra b ility of d o c to rs w h o tre a t c h ild re n w ith c a n c e r (Jankovic 1 9 8 9 ; M ulhern 1981). Som e o th e r stu d ies d escrib e th e c o m m u n ic a tio n b etw ee n d o c to r an d p atien t (Hill 1977) or co n sid er d o c to rs' attitu des to w ard s d e a th (C ohen 1982) or th e ir n eed of further training to reco g n ize m ental disorders (A dam s 19 7 8 ). In PSYC (P sy cholo gical abstracts) 1 9 6 7 -1 9 9 1 - w ith th e sam e search w o rd s - te n m ore articles w e re fou nd . Som e d e sc rib e th e stress of c a n c e r d o c to rs (U llrich 1 9 9 0 ; A h lberg 1 9 8 7 ; Slaby 1986) an d a few d e s c rib e h o w d o c to rs h av e a d a p te d to th e ir stressful w ork (K ahlra 1 9 8 7 ; S train 1 9 8 6 ; S laby 19 86 ). D ata s e a rc h e s th ro u g h SO C A (S o cio lo g ical ab stracts) 1 9 6 3 -1 9 9 1 g av e th e sam e refe re n c e s as PSYC (Kalra 1987). S earch in g th ro u g h NAHL (N ursing an d A llied H ealth Literature) g av e a referen ce to an article on d o c to rs' attitu des to inform ing a p atien t th a t he is te rm in ally ill (P ach ec o 1989). In o rd e r to o b ta in m o re articles a w id e n e d search on MEDLINE w as m ad e, i.e. I w e n t in an d studied titles an d abstracts from th e 19 8 0 s w ith a view to find interview studies describing h o w do ctors e x p e rie n c e situation s arising at different stages of a c a n c e r illness a n d how th ey th e n c o p e w ith th ese. I did not locate a single study. H ow ever, th ro u g h th e s e a rc h w o rd s "em pathy" an d " p a tie n t-d o c to r in teractio n ", I o b ta in e d so m e furth er references on d o cto rs stress, reactio n an d c o p in g in an article

by Fain (1989) w h o referred to V ach on (1987) an d to M cC u e (1982) an d G orlin (1983).

O n th e o th e r h an d , several a c c o u n ts of p atien ts' w ays o f c o p in g w ith th e stress w h ic h s e rio u s an d life -e n d a n g e rin g illn e sse s b rin g h a v e b e e n p u b lish e d . A m ongst o th ers, Lazarus (1984) has in this co n te x t in tro d u ced th e te rm "coping" an d W eism an (1979) has re p o rte d his o b se rv a tio n s of c a n c e r p atien ts in th e b oo k "C oping w ith can cer". D urin g th e 1 9 8 0 s a n d 1 990s, at scientific m eetings su ch as th e "European C o n feren c e on C linical O n c o lo g y a n d C a n c e r N ursing" (ECCO) an d th e "E uropean S o ciety for P sy c h o lo g ic a l O n co lo g y " (ESPO), fu rth e r stu d ie s o f p a tie n ts ' w a y s o f h an d lin g c a n c e r illnesses have b een rep orted . At th e se m eetings, it has also b e e n re p o rte d h o w care g iv ers e x p e rie n c e an d rela te to th e ir w o rk w ith c a n c e r p atien ts. T h ere h av e b een several p re se n ta tio n s of ev a lu a tio n s o f train in g p ro gram m es for caregivers. H ow ever, few if any d o cto rs hav e tak en part in su ch train in g p ro g ram m es w ith th e ex ce p tio n of th o se offered and rep orted by M aguire (1985) sin ce th e m id-eighties.

T he gu ilt of survivors, in clu d in g staff an d , in p articu lar, d o c to rs has b een investigated. At th e N ordic C onference on "Care at th e End of Life" (O m sorg ved Livets Slutt) a p a p e r w as p re se n te d (M oe 1988) w h ic h referred to a British n eu ro su rg eo n , psy ch iatrist and stress rese a rc h e r w h o h as c o m p ile d his ex p erien ces in th e book "The W o u n d and th e D octor" (Bennet 1987).

Analysis of earlier studies

In o rd e r to illustrate earlier research , I h ave ch o sen to p resen t so m e studies in m o re detail. They exem plify h ow different m eth o d s have b een used both in th e c o llectio n an d analysis of d ata. They offer ex am p les of analyses both o f s ta te m e n ts ta k e n from in te rv ie w s, o f o b s e rv a tio n s p e rfo rm e d on e d u c a tio n co u rses an d th e o re tic al discu ssion s on th e basis of c o m p a riso n s w ith o th e r professional gro up s an d e x p e rie n c e s from th e ra p y situ atio ns. In so m e stu d ies c o n c e p ts su ch as "stress" an d "coping m echanism s" are used. O th e r s tu d ie s d e s c rib e th e re a c tio n s w h ic h d o c to rs h av e e x p re sse d in testin g situ atio n s an d h o w th e y a d a p t to a n d /o r w ard off d isco m fo rt in th e situ atio ns d escrib e d .

In th e presen tatio n of earlier research , I hav e ch o sen to p resent th e different stu d ies a c c o rd in g to th e different th e o re tic al c o n c e p ts w h ich are variously d e sc rib e d as: "stress", "em otional reactions" and "coping", as c o m p a re d to "stress", "em otional reactions", "defensive m anoeuvres" an d "coping". I h av e g ro u p ed th e stud ies on th e basis of th e c o n c e p ts w h ic h th e v ario us au th o rs

hav e used to illustrate th e strains of th e w ork an d th eir c o n s e q u e n c e s for th e ph ysician. After th e p resen tatio n of th e references, th e re follow s a sum m ary of th e a u th o rs' th e o re tic al perspectives an d ho w th e se h av e in flu en ced th e

layout of this study.

Stress, emotional reactions and coping

T he au th o rs o f th e stu d ies b ein g p resen te d in this sectio n have d e sc rib e d n o t o n ly th e stress b u t also th e e m o tio n a l re a c tio n s in th e s e stressful situatio ns an d h o w th e physicians c o p e w ith th e se reaction s.

T he p e d ia tric ia n s Fain an d S ch reier (1989) claim th a t feelings o f fear an d vuln erab ility h av e not b een perm itted in th e m ed ical cu ltu re, i.e. it has no t b e e n p erm itted to ex p ress th e se feelings. T hey p o in t to th e n ece ssity of su p p o rt for d o c to rs w h o h av e b e e n involved in c a ta s tro p h e s of v ario u s kinds so th a t th eir reactio n s in th e afterm ath sh o u ld be as sm all as possible. T he au th o rs w rite in th e ir article, "Disaster, stress an d th e doctor", th a t th ey co n sid er th a t th e re has b een paid little attention to stress sym ptom s am ongst th o s e w o rk in g in h e a lth c a re . T h ey c la im th a t g re a t d e m a n d s a n d e x p e c ta tio n s are p la c e d on d o cto rs. T heir inability to sav e p a tie n ts' lives ca n lead to feelings o f failu re an d guilt. T he a u th o rs refer to th e b o d y of k n o w led g e w h ic h has been built up on p o st-traum atic stress in individuals an d th e y e m p h a siz e th a t d o cto rs are not em o tio n ally im m u ne. T hey claim th a t a fa c e of in d ifferen ce in d o c to rs "m ay h id e th e c o p in g m e c h a n ism w h ic h ty p ically in clu d es den ial an d d etach m e n t" (p92). Fain an d S ch reier offer e x a m p le s of h o w fe e lin g s of d e s p o n d e n c y , fru s tra tio n , a n g e r, d e p re s s io n , d esillu sio n , ph ysical illness a n d guilt m ay be re d u c e d . O n e m e th o d is to establish su p p o rt gro up s th a t fo cus on certain c h a ra c te r traits w h ic h c an m o d e ra te th e stress. Exam ples of su ch traits w o u ld b e a high d eg ree of in vo lv em en t an d a positive attitude to w ard s taking on ch allen g es. T hey discuss w h e th e r m edical stud ents sh o u ld be train ed to b e c o m e aw are of th e ir o w n feelings of stress and th ey c o n c lu d e th a t this is a necessity for c o p in g w ith stress.

Fain an d S chreier (1989) refer to M cC ue (1982), a d o c to r and w h o b ased his ju d g e m e n ts on ex p e rie n c e from train in g p rog ram m es and surveys m ad e by o th e r a u th o rs. It is n o t a p p a re n t w h e th e r Fain an d S ch reier b a se th e ir o b serv atio n s on sim ilar ex p erien ces. M cC ue reports in "The Effects of Stress o n P hysicians and th e ir M edical Practice" th a t su icid e is th e s e c o n d m o st c o m m o n c a u s e o f d e a th a m o n g st m e d ic a l stu d e n ts. T h e s u ic id e rate a m o n g st d o c to rs is tw o to th re e tim e s h ig h e r th a n in th e rest of th e

p o p u la tio n an d serious drug ab u se is 1.6 tim es higher am ong st d o cto rs th a n am o n g st n o n -d o cto rs. D octors co n su lt p sychiatrists te n tim es m ore as th e g en eral p o p u la tio n . M cC ue assum es th a t d o cto rs' ad ju stm en t to stress leads to certain typical p attern s of b eh avio ur, su ch as em o tio n al w ith d raw al. H e g iv e s th e fo llo w in g e x a m p le . T h e d o c to r a v o id s his fa m ily . T h e c o n s e q u e n c e of this em o tio n al retreat, says M cC ue, is w orry an d suffering. M cC u e asks th e q u estio n w h y d o cto rs to le ra te failu re in th e ir o w n fam ily lives a n d w hy n o n -m e d ic a l interests b e c o m e u n in terestin g a n d lose th e ir a p p e a l. H is co n c lu sio n is th at, a m o n g o th e r things, th is is d u e to p ressu re from co lleag u e s and fear of failing in th eir w ork. M cC ue holds th a t in secure d o cto rs c a n m a x im ize th e ir c o n te n tm e n t at th e ho sp ital, w h e re th e y give orders an d m ake im p o rtan t decisio ns, etc. At h o m e th e d o c to r is m erely an o rd in ary spouse.

M cC ue (1982) gives an o th er ex am p le of th e p h y sician 's ad ap tatio n to stress i.e. social isolation. H e claim es th a t th e p h e n o m e n o n of w ith d raw in g from n o n -m ed ical life usually starts du rin g th e d o c to r's ed u c a tio n and d ev elo p s, to an alm o st c o m p le te av o id a n c e of n o n -m ed ical situ ation s. H e m ain tain s th a t d o cto rs are often locked defensively in auth o ritarian professional roles, w h ic h rarely are ch allen g ed by n o n -m ed ical professionales. T he isolation is d ifficu lt to b reak , b e c a u s e th e d o c to rs a re d e fe n d in g th e m s e lv e s from so ciety . This is fu rth er ag g rav ated by th e fact th a t n o n -m e d ic a ls b e c o m e delig h ted if a d o c to r reveals a vu ln erab le h u m an face.

A cco rd in g to M cC ue, a further ad ju stm en t to stress is th a t th e d o cto rs an d p atien ts often c o n sp ire to d e n y co m p lex ities, u n certain ties a n d lim itations w h ich a re part of th e m edical reality. For ex am p le, th e o rd erin g of a lot of laboratory tests is used to pro tect against fear an d insecurity.

Finally M cC ue (1982) states th a t d o cto rs establish g ro u p su p p o rt th ro u g h a jarg o n of c o d e w o rd s w h ic h often are cyn ical and insensitive. H e says th a t th is, th e p h y s ic ia n 's b est kn ow n an d m ost d e sp ise d a d ju stm e n t to stress fa c to rs, fo r n o o b v io u s p u rp o s e , is p ro b a b ly th e least d a m a g in g of b eh av io u rs.

M cC u e's (1982) o b serv atio n s sh ow ho w v u ln e ra b le d o cto rs are if th e y are n o t p rep ared for th eir ow n reactio n s to d eath and th e suffering, th e fear, th e in tim a c y a n d th e u n c e rta in ty th e y e n c o u n te r in th e ir in te ra c tio n w ith patien ts. This c a n lead to d ram a tic c o n se q u e n c e s, su ch as su icid e. M cC ue focu ses on "negative" strategies. H e believes th a t th e se negative ad justm en ts to stress c a n be av o id ed by im proved train in g of m ed ical stu d en ts w h ich w o u ld provid e th e m w ith an aw aren ess of th e im plications of th e ir w ork.

G orlin (1983), a m ed ical d o cto r, portrays both th e em o tio n al reac tio n s an d th e b e h a v io u ra l resp o n ses in freq u en tly o c c u rrin g clin ica l situ a tio n s. H e based his o b serv atio n s of "Physicians' R eactions to Patients" on ex p erien ces from tra in in g p ro g ram m es for m e d ic a l stu d e n ts a n d d o c to rs c o n tin u e d ed u c a tio n cou rses. H e differs from o th er autho rs in defining difficult clin ical situ atio n s an d d escrib in g d o c to rs' reac tio n s an d c o p in g strategies in th e se situ a tio n s. A c c o rd in g to G orlin th e p h y s ic ia n 's e m o tio n a l re sp o n se s in te rm in a l illness an d in c u ra b le d ise a se h av e c o m p o n e n ts o f sy m p a th e tic id e n tificatio n , feelin g s of im p o te n c e , lo w ered self-estem a n d fru stratio n . T he p h y sician 's b eh avio ural resp on ses m ay b e d en ial, re lu c ta n c e to discuss illness, a v o id a n c e of p a tie n t and fam ily. H e h as also sug gested h o w th e se n eg ativ e em o tio n a l resp o n ses c a n b e d e a lt w ith . S om e e x a m p le s of su ch c o p in g strategies are th e attem p t to an aly ze an d u n d erstan d h o w to m aster feelings w h ic h lead to a v o id a n c e of th e p a tie n t and also d iscu ssio n s w ith co lleag u es.

T he k ey sto n e o f G o rlin 's (1983) p ro g ram m e is th a t m e d ical stu d en ts first learn to recogn ise an d a c c e p t th at destab ilizin g em o tio n al reactio n s h a p p en a n d as th e n ext step a c c e p t th a t th e se are justified an d u n d e rsta n d a b le and finally learn to c o p e w ith th e se em otion s.

Stress, emotional reaction, defensive manoeuvres

and coping

In th is sectio n I p resen t au th o rs w h o d e sc rib e stress, em o tio n a l re a c tio n s an d th e c o n c e p t o f c o p in g in th e light o f d efen siv e m a n o e u v re s to avoid psych olog ical distress.

V ach o n (1987) d escrib e d an in d iv id u al's "coping responses" as co m p risin g his ability to o b serv e, a n d to c o m p re h e n d his b eh av io u r. She allies herself w ith Lazarus (1984) w h o by "coping responses" m ean s "som e of th e th in gs th a t p e o p le d o , th e ir c o n c re te efforts to d eal w ith th e life-strains th e y e n c o u n te r in th e ir different roles" (p25). In her b oo k "O c cu p atio n al Stress in th e C are of th e C ritically III, th e D ying and th e B ereaved", V ach o n has presen ted an analysis of interview s w ith 6 0 0 health care p rofessionales w ith different sp ecia liz atio n s and b ack groun ds, w ork in g in different d ep artm en ts at university h ospitals and palliative care units, in h om es for th e ch ro n ic ally ill an d co m m u n ity ho sp ices in C an ad a, USA, Europe and A ustralia. 7 1 % of th e interview ees w e re w o m en . O f th e m en 65 % w ere d o cto rs.

V a c h o n 's (1987) stu d y is d escrip tiv e. B esides d e m o g ra p h ic v aria b les, sh e stud ied th e p articip an ts' c o n scio u s m otivation for w o rking w ith seriously ill an d dy ing p atien ts, th e ir p erson al v alu e system s a n d th e ir "co p in g style".

V a c h o n b u ild s h e r an a ly sis o f c o p in g o n p e rs p e c tiv e s w h ic h w e re in tro d u c e d by L azarus (1984) (ch ap ter 3, p42). L azarus m e a n s th a t th e individual co n tro ls his stress partly by m a n ip u latin g th e c a u s e of th e stress, prob lem -reg ulatio n, an d partly by ch eck in g his feelings to w ard s it, em o tio n - reg u latio n . As c o n c e rn s cases o f p ro b lem -reg u latio n , V ach on p oints to th e d ev e lo p m e n t of a gro up ph ilo so p h y and th e creation of su p p o rt groups. The s h a p in g of p erso n n el and ad m in istrativ e p o licies, c re a tio n o f fo rm alize d d e c isio n a n d su p erv isio n gro u p s an d train in g p ro g ram m es, th e ab ility to influ ence, th e possibility of both variation in and co ntro l o ver th e w ork an d finally th e possibility to ch a n g e or q u it th e jo b b elo n g here, as w ell.

C op ing te c h n iq u e s w h ich she prim arily sees as em o tio n -reg u latin g are th e s e n s e th a t o n e h as th e fre e d o m to m a k e d e c is io n s an d th a t o n e has c o m p e te n c e in th e clin ical situ atio n . T he ability to d elim it o n e 's field of interest, w h ic h m e a n s th a t o n e attain s a sen se of m astery o v er a lim ited area , sh o u ld be in c lu d ed in this con text. A further strategy w h ic h b elon gs h ere b u t w h ich sh e regards as a prob lem -reg u latin g strategy, is th e lifestyle w h ich o n e ado pts, i.e. o n e 's habits c o n c e rn in g ex ercise, diet, drugs. T hose w h o w o rk e d in o n c o lo g y re p o rte d th is as th e s e c o n d m o st im p o rta n t strategy. Several of th e p articipants expressed th at th ey w o u ld not be ab le to w o rk w ith d yin g p atien ts if th ey w o u ld n o t have private p h ilo so p h y a b o u t d e a th . V ach o n fo u n d th a t m en gave th is re sp o n se m o re fre q u e n tly th a n w o m e n an d th a t d o c to rs n am ed this c o p in g m e c h a n ism m ore often th a n o th e r g ro u p s. T he c o n s c io u s o r u n c o n s c io u s d e fe n s iv e p s y c h o lo g ic a l strategies cited by th e p articip a n ts are also in c lu d ed in this g ro u p of this g ro u p o f em o tio n -reg u latin g strategies. V ach o n fo und th a t th e p articip a n ts tried to p ro tec t th e m se lv e s from a id en tification w ith th e ir p atien ts. T hey w ith d ra w from th e ir p a tie n ts to av o id feelin g s o f h e lp le s s n e s s a n d h o p e le s s n e s s . As an e x a m p le of th is s tra te g y , s h e m e n tio n s th e ca te g o riz a tio n of p atien ts as d ia g n o stic labels in stead of p e o p le , i.e. th e p a tie n t is d e p e rs o n a liz e d . She calls this a tactic of d ista n c in g an d asserts th a t it m ay be far m ore th a n ju st a m atter of physically w ith d raw in g o n eself from th e p a tie n t. F u rth erm o re , V ach o n fo u n d th a t m a n y h e a lth c a re pro fessio n als held th a t further train in g m a d e it e a sie r to w o rk w ith d ying p atien ts. T he im prov ed k n o w led g e an d e x p e rie n c e of d ying affected both o n e 's o w n a w a re n e s s a n d o n e 's ability to assert a n d ap p ly b o th o n e 's k n o w le d g e and o n e 's ideas. Finally, h u m o u r w a s n am ed as an im p o rtan t strategy of keep in g pain at bay.

In c o n c lu sio n , V ach o n (1987) fo un d th a t in reg ard to th e c o n tro lin g o f feelings o f stress, e m o tio n regu latio n a c c o u n te d for 6 4 % of th e identified c o p in g m e ch an ism s, w h ile 3 6 % w e re ex p ressio n s of p ro b lem reg u latio n . T hese p ro p o rtio n s w ere th e sam e for all sp ecializatio n s, professions and age gro up s and for both sexes.

H er survey is im p o rtan t in th a t it co n trib u tes to clarifying c o p in g strategies in a v u ln e ra b le gro up , n am ely th o se carin g for ch ro n ic ally sick a n d dying p a tie n ts. H o w ev er, h er in terest w as n o t e s p e c ia lly d ire c te d to w a rd s th e s itu a tio n o f d o c to rs . S he h as s y s te m a tic a lly a n a ly z e d p a r tic ip a n ts ' s ta te m e n ts by u sin g c o p in g m o d e ls a n d at th e s a m e tim e a p p ly in g p sy ch o an aly tic al c o n c e p ts. H o w ev er, th e p sy ch o an aly tic p ersp ectiv e w as not, specifically ex p lain ed .

M a g u ire (19 89 ), a p sy c h ia trist, a n d w ith a lo ng h isto ry o f o b s e rv in g e x p e rie n c e d d o c to rs in train in g situ atio n s, fo cu ses o n h o w th o s e d e fe n d th e m s e lv e s from c o m in g into c o n ta c t w ith th e p a tie n t's p sy c h o lo g ic a l d isco m fo rt. In "B arrier to P sy ch o lo g ic al C are of th e D ying" (1989) h e d escrib es h o w d o cto rs co nstan tly use distan cin g tactics so as n o t getting to o c lo se to p a tie n ts' suffering an d h o w they use th e se strateg ies to "survive". H e sees a risk in th e d o c to r b u ild in g a b arrie r b e tw e e n h im self a n d th e p atien t. As an e x a m p le o f a d ista n cin g ta ctic , M ag uire d escrib e s h o w th e e x p e rie n c e d d o c to r o b se rv e s a p a tie n t's suffering a n d a ssu m e s th a t h e "understands" w h y th e p a tie n t is reactin g as h e d o es an d actu ally answ ers th e p a tie n t on th is s e le c tiv e u n d e rs ta n d in g . T yp ical m a n o e u v re s , says M ag u ire, in c lu d e giving false po sitiv e m essag es an d h a v in g a s e le c tiv e p e rc e p tio n to w a rd s th ing s w h ich d istract from u n certain ty o r anx iety. For ex am p le, this m ay co n ce rn ch an g in g th e su b ject of co n v ersatio n . A ccording to M aguire, th e se d efensive m a n o eu v res are often u n c o n sc io u s. H o w ev er, th e y are w h e th e r c o n s c io u s o r u n c o n sc io u s, in so far im p o rtan t, as th e y affect th e d ia lo g u e w ith th e p atient.

T he resu lt of n o t w an tin g o r d arin g to m e et th e p a tie n t m ay b e th a t o n e d ev elo p s a cy nical, rigid attitu de to w ard s critically ill an d an x io us patients. O n e m ay find c h a n g e s stre n u o u s an d m ay easily feel se lf-c o n te m p t. A c o n s id e ra b ly less se lf-d e s tru c tiv e w a y o f d is ta n c in g o n e s e lf from th e psych olog ical distress is by using hu m ou r.

In this w ay , like M cC ue (1982), h e b eliev es th a t th e d o c to r n e e d s th e se d e fe n c e s in o rd er to survive. Like all th e o th e r autho rs, M aguire h o ld s th a t th e s e d e fe n c e s c a n be m o d e ra te d . An im p o rta n t ste p in this p ro c e ss is b eco m in g aw are o f o n e 's feelings and d efe n c e strategies.

B en n et (1987), a n e u ro su rg e o n an d p sychiatrist. H e stu d ie d h o w p e o p le re a c t to e x tre m e p h y sical a n d p s y c h o lo g ic a l stress. H e h a s w ritte n a p e rso n a l b o o k from th e d o c to r's p o in t of view , "The W o u n d a n d th e D octor". In this w o rk he d escrib e s th e d o c to r's life an d w o rk in g situ atio n . H e do es n o t refer to an y p articular study, b u t b ases his ob serv atio n s and his analy sis o n an ex ten siv e read in g of th e literature, on his o w n stu d ies an d su b jectiv e ex p erien ces. In ad d ictio n to an ov erv iew of th e d o c to r's w orking

s itu a tio n , B ennet gives an analysis of th e d o c to r's b e h a v io u ra l resp o n se p attern s an d illustrates ho w th e se respo nses are reflected in his actio n s an d b e h a v io u r. H e b ases his an aly se s on his p ersp ectiv e as a su rg eo n , stress re s e a rc h e r an d p sy ch iatrist w ith in a p sy ch o an aly tic al fram e o f referen ce. T h ro u g h o u t his w ork, B ennet u ses th e term "to p ro te c t oneself" to refer to th e m e c h a n is m s w h ic h th e d o c to r e m p lo y s to m a in ta in a " c o h e siv e exterio r". T he p h y sic ia n m u st p ro te c t h im se lf ag a in st an o v e r-in tru siv e in te ra c tio n w ith o th e rs. B e n n e t's m ain aim is n o t o n ly to d e s c rib e th e a ctio n s o f th e d o c to r b u t also to try to u n d erstan d th e d o c to r's n eed s. It is his o p in io n th a t m a le d o c to rs, to a h ig h er d e g re e th a n fe m a le d o c to rs, o rg an iz e th e ir w ork aro u n d th e ir ow n n eeds.

B ennet (1987) finds it possible, by stud yin g th e in d iv id u al's n e e d s an d th e profit h e gain s th ro u g h e sta b lish in g a c e rta in lifestyle, to m a k e o u t th e c o n to u rs o f th e in dividu al d o c to r's m o tiv atio n . H e claim s th a t th e re is a c o n sid e ra b le n u m b er of possible behaviou rs w h ich th e d o c to r m ay em ploy. T he alternativ e w h ich is ch o sen is in ten d ed , ab o v e all, to avoid anxiety. As d e sc rib e d in c h a p te r o n e, h e asserts th a t w h e n a d o c to r e q u ip s him self to c a re for a person w ith an illness, his m edical aw aren ess is activ ated . At th e sam e tim e , th a t w h ic h B ennet d e sc rib e s as th e p a tie n t p art is activ ated : terro r, help lessn ess and th e longing for to be looked after. If this so -called "p atien t part" is repressed, th e phy sician b e c o m e s an "all-know ing" d o c to r w h o a c ts as if d is e a s e w e re q u ite s e p a ra te from feelings. T h e p h y sician d is p la c e s th e p a tie n t's e x p e rie n c e w h ich clash e s w ith th e rational d o c to r p a rt a n d w h ic h d o e s n o t a d m it a n y fe e lin g s. F u rth e rm o re , B e n n e t s p e c u la te s , th e d o c to r p ro jec ts his u n c o n s c io u s p a tie n t p a rt o n to th e patien t, for ex am p le th e n eed for intim acy and d e p e n d e n c e .

A c c o rd in g to B enn et (1987), a d a p tin g to th e c o n d itio n s of w o rk follow s certain pattern s w h ich are m ost clearly seen in d o cto rs w h o h av e p ro blem s in c o p in g w ith a n x iety an d p sy c h o lo g ic a l stress - p ain - b u t w h ic h all d o cto rs p resen t m o re or less. O n e e x a m p le is th e phy sician w h o sets up a b arrier of social d ista n c e b e tw e e n him self an d th e p atien t, p u rsues u n iq u e skills an d eso teric k n o w led g e w h ich can on ly b e p ractised by th e d o c to r him self in certain places, i.e. m edical tem ples.

T h e fo llo w in g is a su m m a ry of h o w B en n et p re c ise ly illu stra te s his exam ples: The d o c to r sits face to face w ith a p atien t b u t w ith a large desk in b e tw e e n . T he desk is co v ere d w ith e.g. X-ray slides w h ic h sy m b o lize th e d o c to r's superiority. T he atm o sp h ere in th e room is o n e of stress.

T he te le p h o n e is left to ring an d p eo p le dash in and out, w h ich prevents th e p atien t from asking sensitive q uestion s and even m ore from c o m m en tin g on info rm atio n from th e d o c to r. T he d o c to r sets up a b arrier w h ic h p rev en ts c o m m u n ic a tio n . T he p a tie n t's o p p o rtu n ity to c o n trib u te is re d u c e d w h ich

m e a n s th a t d e c isio n s ex clu siv ely are m a d e by th e d o c to r. T he d o c to r's p o w e r is b a se d o n his c a p a b ility to in te rv e n e as n o -o n e e lse c a n in s itu a tio n s of m e d ic a l crisis. T h e ab ility to d eal w ith a large a m o u n t of inform ation gives th e im pression th a t th e d o c to r is in p o ssessio n of a vast bo d y of k no w ledg e, far b ey on d th a t of o rd in ary p eo p le. T he d o c to r m ay use th is b elief to ta k e co n tro l o v er his p atien ts an d th e situ a tio n . T h e d o c to r m ay e n h a n c e his p o w e r in so far as h e c an m aintain th e p a tie n t's sen se o f in secu rity in reg ard to th e c o u rs e of th e d is e a s e a n d th e effect o f th e th e rap y .

B en net (1987) is p ro v o cativ e. His a p p ro a c h is interesting th o u g h b e c a u se h e d o e s n o t m erely stu d y ac tio n s a n d b e h a v io u r b u t also illu strates th e d o c to r's v u ln e ra b ility an d n e e d s, to safeg u ard his frag ile self. B e n n e t's im p o rtan t insight into th e n a tu re o f th e w o rk can b e ex em p lified by th e follo w ing q u o tio n : "The m edical profession is po w erful. Individual d o cto rs are also pow erful, an d face to face w ith patients th e y c a n b e h a v e in w ays w h ic h e n a b le th e m to e n h a n c e th e ir p o w e r a n d av o id th e ir v a rio u s a n x ietie s...d o cto rs are largely u n a w a re of th e w ays in w h ich th e y m ain tain th e ir a sc e n d a n c y ov er th o se th e y are em p lo yed to help" (p67).

Feifel (1965), a psychologist has in a frequently q u o ted study, "The Function of A ttitudes T o w ards D eath", ex a m in e d fourty d o c to rs ' a ttitu d e s to w a rd s d eath by m ean s of interview s. H e found th a t th e y th o u g h t less a b o u t d e a th a n d th a t th e y w e re m o re afraid o f d eath th a n th re e co n tro l g ro ups, tw o c o n sistin g o f p atien ts an d o n e co n sistin g o f n o n -p ro fessio n al h e a lth -c a re w orkers. Feifel points o u t th a t o n e sh ou ld be aw are th a t th a t w h ich is tak en for an a ttitu d e to w a rd s d e a th m ay in ste a d re p re s e n t c a s tra tio n a n d sep aratio n anxiety just as w ell as over-p ro tectiv en ess, fear of loss an d of th e u n k n o w n . F eifel's c o n trib u tio n illustrates th e c o m p le x ity o f th e feeling s w h ic h th e fear of d eath en co m p asses.

This brings to an en d th e presen tatio n of th e stu d ies on p h y sician s w h ich w e re o b ta in e d from th e v ario u s d a ta se a rc h e s u n d e rta k e n . H o w e v er, in O c to b e r 1993 a study w a s p u b lish e d w h ic h is of re le v a n c e to this study. H olm (1993), by m ean s of observ ation s, interview s an d psych olog ical tests, h as stu d ie d 4 0 p h y sician s. T hey w e re su rg eo n s an d in ternists w o rk in g in university clin ics an d sm aller h osp itals and g en eral p ractitio n ers from th e city an d co u n try sid e. T he aim of th e study w as to find o u t w h a t strains th e phy sician s w e re su b ject to an d w h ich psy cho logical strategies th e y used to c o p e w ith these.

In th e analysis of her m aterial sh e ex am in ed th e external w o rk in g situations, th e v ariou s interactive co n tex ts an d th e internal p sy cho lo gical states o f th e p h y sician s. M any p h y sician s said th a t p ro b lem s d u e to th e o rg a n iz a tio n

w e re th e m ost stren u o u s; o n e th ird th o u g h t th a t p ressed tim e s c h e d u le s w e re th e m ost trying. The sam e p ro p o rtio n c laim e d th a t th e stress w as in d e a lin g w ith th e patien ts. A few d escrib e d th e tre a tm e n t an d d iag n o sis as p ro b lem atic. A q u a rte r o f th e m th o u g h t th a t c o n ta c t w ith th e m e m b ers of staff w as th e m ost trying aspect.

H olm (1993) g ro u p e d th e p sy ch o lo g ical strateg ies of th e p h y sician s into eigh t categ o ries, based on ob servation s, interpretatio ns and th e p h y sic ia n s' re a c tio n s to h er in terp reta tio n s. S he fo un d th a t m an y w e re u sing a w ell- devised m odel for h o w to c a re for an d h a n d le p atients and m ake d ecisio n s. T h ey all s o u g h t b e tte r k n o w le d g e . S om e w e re striv in g to d e v e lo p th e ir professional roles by m ean s of c o n tin u e d e d u c a tio n co u rses in in teractio n a n d e m p a th y . S everal u n d e rlin e d th e im p o rta n c e of ta k in g tim e o u t to reflect o v er things. M ost of th e m w an ted to a c t im m ed iately , i.e. th e y tried n o t to p u t th in g s off b u t to b e reso lu te. S o m e m a d e use of c o m p le te c o n c e n tra tio n an d m ental p resen ce w h en d ealin g w ith th e patient. Several n am ed th e im p o rtan ce of seeking stim ulation thro u g h fleeting co n tacts w ith th e ir c o lle a g u e s. S om e m a d e use of jo cu larity , a few co n stan tly . S om e of th e m h ab itu ally used rigid d efe n c e m ech an ism s such as in tellectu alizatio n , ra tio n a liz a tio n , d e n ia l, re a c tio n fo rm atio n , tra n s fe re n c e o r c o m p u ls iv e a c tiv ity . T his s tu d y is o f s p e c ia l im p o r ta n c e b e c a u s e H o lm h as sy stem atically in vestigated e x p e rie n c e d p h y sician s. H er startin g p o in t has b e e n th a t th e te rm c o p in g e m b ra c e s b o th c o n s c io u s an d u n c o n s c io u s actio n s an d attitud es as w ell as u n co n scio u s d efen c e m ech an ism s.

This c o n c lu d e s th e p resen tatio n of studies on p h y sic ia n s1 stress, em o tio n al reactio n s, d efen siv e m a n o eu v res an d co p in g . H ow ever, so m e stu d ies h ave b een c o n d u c te d w ith th e p u rp o se to ex am in e o th er h ealth c a re -p e rso n n e P s a tte m p ts to av o id p sy c h o lo g ic a l d istre ss in th e ir w o rk . For e x a m p le , M en zies (1970), a p sychologist, carried o u t a w ell-k n o w n stu d y of nu rses w h e re sh e ex em p lifies ho w striving to av o id an x iety in th e p ra c tic e of m e d ic in e le ad s to th e d e v e lo p m e n t of a so cial d e fe n c e sy stem . This sy stem 's m eth o d of fun ctio n in g is d eterm in e d , am on gst o th e r things, by th e m em b ers' psych olo gical n eed s for pro tection ag ainst psych ological distress. This p ro te c tiv e o r d e fe n c e system d ev elo p s in tim e an d is th e resu lt of a "secret", u n s p o k e n in te ra c tio n a n d a g re e m e n t, o ften u n k n o w n to th e particip an ts in th e social context, e.g. a hospital d ep artm en t.

M en zies (1970) claim s th a t th e se o rganisatory, socially stru ctu red d e fe n c e m e ch an ism s te n d to b e c o m e a "culture", part of th e "external reality" w h ich old and ev en n ew p articip an ts in th e con text have to ad ju st to . T he p u rp o se of th e n atu re of th e social d efe n c e system is to h elp th e individual to avoid anxiety, guilt, d o u b t and uncertain ty.