Psychiatry

Post-traumatic stress syndrome (PTSD) may occur when an individual has been exposed to a traumatic event and responds with fear, helplessness, or horror. It is now recognized that a small percentage of patients being treated for cancer experience PTSD. The trauma-related symptoms in patients with cancer have been under increasing study. Individuals with a history of PTSD are at a substantial risk for continued emotional difficulties so it is encouraged that these patients receive timely and effective treatment for this syndrome.

It is difficult to recommend a “best therapy” approach for PTSD. Most clinicians recommend a multimodality approach, using components of therapy that meet the specific needs of each patient, taking into account any concurrent psychiatric disorders such as depression or substance abuse.

A crisis intervention approach is often recommended in order to facilitate the adjustment of patients experiencing cancer. In this approach, the therapist takes an active stance focusing on problem resolution, teaching specific coping skills, and providing a safe and supportive environment. Cognitive-behavioral approaches have proven very effective. This approach includes the former in addition to the use of relaxation techniques, restructuring cognitions or negative thoughts, and providing exposure to opportunities that provide systematic desensitization of the symptoms being experienced. Support groups have also been shown to benefit people who experience PTSD. In the group setting, patients can receive emotional support from others who have experienced similar symptoms, thereby validating their own feelings and learning coping strategies from others.

For patients with severe symptoms, psychopharmacology may prove effective. Antidepressants may be used when the symptoms of depression occur with PTSD. Antidepressants are also useful in decreasing the hyperarousal and intrusive symptoms that often accompany PTSD. Antipsychotic medications may reduce flashbacks and antianxiety medications may help reduce arousal and anxiety. Therefore, the best therapeutic approach to PTSD may be a combination of therapies tailored to the individual’s experiences and symptoms. Most importantly, therapeutic intervention is highly recommended for any person experiencing any of the symptoms associated with PTSD. Post-traumatic stress syndrome (PTSD) may occur when an individual has been exposed to a traumatic event and responds with fear, helplessness, or horror. It is now recognized that a small percentage of patients being treated for cancer experience PTSD. The trauma-related symptoms in patients with cancer have been under increasing study. Individuals with a history of PTSD are at a substantial risk for continued emotional difficulties so it is encouraged that these patients receive timely and effective treatment for this syndrome.

It is difficult to recommend a “best therapy” approach for PTSD. Most clinicians recommend a multimodality approach, using components of therapy that meet the specific needs of each patient, taking into account any concurrent psychiatric disorders such as depression or substance abuse.

A crisis intervention approach is often recommended in order to facilitate the adjustment of patients experiencing cancer. In this approach, the therapist takes an active stance focusing on problem resolution, teaching specific coping skills, and providing a safe and supportive environment. Cognitive-behavioral approaches have proven very effective. This approach includes the former in addition to the use of relaxation techniques, restructuring cognitions or negative thoughts, and providing exposure to opportunities that provide systematic desensitization of the symptoms being experienced. Support groups have also been shown to benefit people who experience PTSD. In the group setting, patients can receive emotional support from others who have experienced similar symptoms, thereby validating their own feelings and learning coping strategies from others.

For patients with severe symptoms, psychopharmacology may prove effective. Antidepressants may be used when the symptoms of depression occur with PTSD. Antidepressants are also useful in decreasing the hyperarousal and intrusive symptoms that often accompany PTSD. Antipsychotic medications may reduce flashbacks and antianxiety medications may help reduce arousal and anxiety. Therefore, the best therapeutic approach to PTSD may be a combination of therapies tailored to the individual’s experiences and symptoms. Most importantly, therapeutic intervention is highly recommended for any person experiencing any of the symptoms associated with PTSD.

Thank you for your question. I do not know that there is anything that is specifically defined as ‘palliative care counseling’ or that would necessarily be qualitatively distinct about this work. However, counseling or various modes of supportive psychotherapy with patients who are dealing with psychological issues related to facing a serious life-threatening illness is a crucial need, is likely underutilized and underprovided, but is essential to good quality palliative care which ought to be multidimensional and multidisciplinary in approach in order to achieve its mission of addressing emotional concerns, social stressors, as well spiritual matters and physical symptoms, all of which are often encountered, and in a very different way than may have been experienced in the past. By and large, these broad issues constitute indications for involving mental health practitioners to offer support when providing palliative care. Indeed, then, it would seem that most people would benefit from such counseling in the context of palliative care to receive emotional support for addressing these matters. These issues are part of the general indications for psychotherapeutic work which is to improve coping and adaptive functioning by gaining a better understanding of anxieties and inhibitions with respect to one’s self and one’s role in the context of life changes. However, like any other area or focus, there are certainly specific themes that uniquely emerge when dealing with such issues, and resultant depressive and anxiety symptoms, for instance, in the palliative care setting. End of life, itself, may be conceived as a phase of development with unique conflicts and challenges, and, indeed, may subsume a period of tremendous growth, particularly when these are satisfactorily addressed. Unique issues most salient during this time are even such that a corresponding framework from which to understand and address them has been established – Existential concerns and psychotherapy, respectively. Indeed, these issues are so universal that they are conceived to apply on some level to anxieties and fears faced at many points in life, and not just at its end when, however, they perhaps most readily and directly apply. These concerns may be subsumed in the domains of “the self”, “free choice”, “meaning”, and “anxiety”. Some major topics distinctly encountered in the approach to the palliative care patient for psychological support include dealing with demoralization, or a loss of meaning, and with lack of dignity. To address such issues, certain psychotherapeutic methods have been established, including the general application of interpersonal psychotherapy, or modified psychodynamic therapy, and various types of existential psychotherapy, such as meaning-centered psychotherapy, as well as dignity therapy. Thank you for your question. I do not know that there is anything that is specifically defined as ‘palliative care counseling’ or that would necessarily be qualitatively distinct about this work. However, counseling or various modes of supportive psychotherapy with patients who are dealing with psychological issues related to facing a serious life-threatening illness is a crucial need, is likely underutilized and underprovided, but is essential to good quality palliative care which ought to be multidimensional and multidisciplinary in approach in order to achieve its mission of addressing emotional concerns, social stressors, as well spiritual matters and physical symptoms, all of which are often encountered, and in a very different way than may have been experienced in the past. By and large, these broad issues constitute indications for involving mental health practitioners to offer support when providing palliative care. Indeed, then, it would seem that most people would benefit from such counseling in the context of palliative care to receive emotional support for addressing these matters. These issues are part of the general indications for psychotherapeutic work which is to improve coping and adaptive functioning by gaining a better understanding of anxieties and inhibitions with respect to one’s self and one’s role in the context of life changes. However, like any other area or focus, there are certainly specific themes that uniquely emerge when dealing with such issues, and resultant depressive and anxiety symptoms, for instance, in the palliative care setting. End of life, itself, may be conceived as a phase of development with unique conflicts and challenges, and, indeed, may subsume a period of tremendous growth, particularly when these are satisfactorily addressed. Unique issues most salient during this time are even such that a corresponding framework from which to understand and address them has been established – Existential concerns and psychotherapy, respectively. Indeed, these issues are so universal that they are conceived to apply on some level to anxieties and fears faced at many points in life, and not just at its end when, however, they perhaps most readily and directly apply. These concerns may be subsumed in the domains of “the self”, “free choice”, “meaning”, and “anxiety”. Some major topics distinctly encountered in the approach to the palliative care patient for psychological support include dealing with demoralization, or a loss of meaning, and with lack of dignity. To address such issues, certain psychotherapeutic methods have been established, including the general application of interpersonal psychotherapy, or modified psychodynamic therapy, and various types of existential psychotherapy, such as meaning-centered psychotherapy, as well as dignity therapy.

Palliative Care Psychiatry, or as I call it, Palliative Psychiatry, is not a formal field, per se, though Psychiatry in Palliative Medicine is a growing area of study and practice. ‘

The most commonly and officially cited definition of Palliative Care is that put forth by the World Health Organization (WHO): “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Of course, you will note psychosocial issues are subsumed therein.

Indeed, the modern Hospice Movement, from which Palliative Care emerged and in which, in its current realization within the U.S., Palliative Care is practiced, is largely seen as coming from the field of nursing as its founder, Dame Cicely Saunders, is largely recognized as a nurse, though she also became a social worker and, eventually, a physician. Indeed, much of the practice of interdisciplinary treatment conducted in the palliative care and hospice setting stems from the tradition of such practice that has existed within Psychiatry. Palliative Care practioners, in the same way that has historically been the case for Psychiatric consultants, have come to often be called upon to by overwhelmed medical providers to help deal with complex psychosocial issues which are difficult to face without such further support. As such, the field of Palliative Care has much to learn from the vast literature within Psychiatry and, specifically, its own subspecialty of Psychosomatic Medicne or Consultation-Liaison Psychiatry, in addressing these issues and the charged dynamics that may exist between patient, family, and provider in such circumstances of heightened and multifaceted distress.

Palliative Care as a formal medical subspecialty is called Hospice and Palliative Medicine, and probably subsumes the most potentially broad area, as such, in medicine (amongst the American Board of Medical Subspecialties), allowing physicians within 10 different specialty medical boards – Internal Medicine (not to mention all of its core subspecialties) Family Medicine, Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry, Neurology, Radiology, and Surgery – to pursue training in the field, not to mention the various other fields of medical care which have specialty-level Palliative Care education, including Nursing, Social Work, and Psychology.. A major factor in this, as I understand it, is that Palliative Care is as much a philosophy and approach to medical practice, as it is a distinct subspecialty, as evidenced by a major mission in the field being education. I mention this further to point out that Psychiatry is subsumed within this. One might think twice about some of these areas, though on quick consideration a clear rationale for involvement is evident. Palliative Care in Emergency Medicine is an area of huge import, even from a public health perspective, and is an active and flourishing area of study at present. Radiology includes interventional techniques which may address burdensome symptoms such as pain with minimal invasiveness. Surgery, likewise, can be conducted for palliative indications, again an area of important consideration. Anesthesiology, PM&R, and Neurology are all involved in pain management, for one. Internal Medicine may be most obvious, including, in particular, the subspecialty fields of Geriatrics and Oncology. Psychiatry takes on substantial focus, apart from the others, and does potentially subsume an entirely independent area of work if only for its relative lack of recognition, particularly with respect to the magnitude of its importance.

In the defining text on the topic now approaching its 3rd Edition, – the Handbook of Palliative Care in Psychiatry, the authors, William Breitbart and Harry Max Chochinov, refer to the evolving field as Psychiatric (or Psychosocial) Palliative Care and note that the last decade has seen an “all-encompassing multidisciplinary approach to care for the dying beginning to take hold” in palliative care which had heretofore been predominantly focused on somatic issues, overshadowing focus on psychological, existential, and spiritual issues at the end of life. How could it not? The universal issues facing people approaching death – “encountering illness, facing vulnerability, and confronting mortality”– have psychological import. In the Foreword to the 2nd Edition, Kathy Foley writes that, while psychological distress, while common, diagnosable, and treatable, in patients with serious life-limiting illnesses is often under-assessed, undertreated, and sometime stigmatized. She gives examples of potential issues including managing a family’s grief, caring for a dying child, providing pain management for a patient with a substance use disorder, or addressing death and dying in patients with serious or chronic mental illness.

To the extent that palliative care, most broadly defined, is expanding a focus of care to managing the burdensome symptoms related to an illness and its treatment, and their associated distress and burden/ impingement on quality of life, alongside the prospect of pursuing treatment only targeting the disease itself, issues addressed in palliative care by psychiatry generally include the management of psychiatric symptoms – such as the manifestations of delirium (agitation and confusion), depression, or demoralization, or existential despair/ crisis, anxiety/ fear/ nervousness, as well as insomnia, or even fatigue, concentration problems, or lack of appetite– in addition to physical ones like pain (which is only artificially extracted from a psychological underlay) or nausea. Psychiatric palliative care involves a range of interventions beyond psychopharmacologic maneuvers, including individual, group, or even family psychotherapies with supportive and existential approaches as well as bereavement focus, and separate spiritual or pastoral care. Some additional important topics in Palliative Care that fall in the psychiatric realm include Physician Assisted Suicide (only recognized in certain states, specifically Oregon and Washington)/ Euthanasia (prohibited in the U.S.) and desire for hastened death, and providing staff support.

Some well-known psychosocially oriented Palliative Care programs throughout the country include the San Diego Hospice which has an integrated Psychiatry and Palliative Care program, the Psychosocial Oncology program at Dana Farber Cancer Institute in Boston, as well as institutions with which I have been affiliated: the pre-eminent Division at Mount Sinai Hospital in New York where I attended medical school, and Department of Pain Medicine and Palliative Care at Beth Israel Medical Center, where I currently have a dual appointment along with the Psychiatry Department as part of my role serving as Director of Cancer Supportive Services at Continuum Cancer Centers of New York, as well as programs where I trained, including Memorial Sloan-Kettering Cancer Center where the field of Psycho-Oncology was founded in emergence with an early Palliative Care program, and the more recently developed service at Bellevue Hospital Center in New York, an institution well-known for its psychiatric service, where I completed my fellowship in Pain and Palliative Care and my residency in Psychiatry, respectively.

As an addendum, the first program which I mention, the San Diego Hospice, is that which is indicated as being the first of its kind in the country and founded by Dr. Scott Irwin, who is cited in the additional response to this question that I noticed been has helpfully posted. Palliative Care Psychiatry, or as I call it, Palliative Psychiatry, is not a formal field, per se, though Psychiatry in Palliative Medicine is a growing area of study and practice. ‘

The most commonly and officially cited definition of Palliative Care is that put forth by the World Health Organization (WHO): “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Of course, you will note psychosocial issues are subsumed therein.

Indeed, the modern Hospice Movement, from which Palliative Care emerged and in which, in its current realization within the U.S., Palliative Care is practiced, is largely seen as coming from the field of nursing as its founder, Dame Cicely Saunders, is largely recognized as a nurse, though she also became a social worker and, eventually, a physician. Indeed, much of the practice of interdisciplinary treatment conducted in the palliative care and hospice setting stems from the tradition of such practice that has existed within Psychiatry. Palliative Care practioners, in the same way that has historically been the case for Psychiatric consultants, have come to often be called upon to by overwhelmed medical providers to help deal with complex psychosocial issues which are difficult to face without such further support. As such, the field of Palliative Care has much to learn from the vast literature within Psychiatry and, specifically, its own subspecialty of Psychosomatic Medicne or Consultation-Liaison Psychiatry, in addressing these issues and the charged dynamics that may exist between patient, family, and provider in such circumstances of heightened and multifaceted distress.

Palliative Care as a formal medical subspecialty is called Hospice and Palliative Medicine, and probably subsumes the most potentially broad area, as such, in medicine (amongst the American Board of Medical Subspecialties), allowing physicians within 10 different specialty medical boards – Internal Medicine (not to mention all of its core subspecialties) Family Medicine, Anesthesiology, Emergency Medicine, Obstetrics and Gynecology, Pediatrics, Physical Medicine and Rehabilitation, Psychiatry, Neurology, Radiology, and Surgery – to pursue training in the field, not to mention the various other fields of medical care which have specialty-level Palliative Care education, including Nursing, Social Work, and Psychology.. A major factor in this, as I understand it, is that Palliative Care is as much a philosophy and approach to medical practice, as it is a distinct subspecialty, as evidenced by a major mission in the field being education. I mention this further to point out that Psychiatry is subsumed within this. One might think twice about some of these areas, though on quick consideration a clear rationale for involvement is evident. Palliative Care in Emergency Medicine is an area of huge import, even from a public health perspective, and is an active and flourishing area of study at present. Radiology includes interventional techniques which may address burdensome symptoms such as pain with minimal invasiveness. Surgery, likewise, can be conducted for palliative indications, again an area of important consideration. Anesthesiology, PM&R, and Neurology are all involved in pain management, for one. Internal Medicine may be most obvious, including, in particular, the subspecialty fields of Geriatrics and Oncology. Psychiatry takes on substantial focus, apart from the others, and does potentially subsume an entirely independent area of work if only for its relative lack of recognition, particularly with respect to the magnitude of its importance.

In the defining text on the topic now approaching its 3rd Edition, – the Handbook of Palliative Care in Psychiatry, the authors, William Breitbart and Harry Max Chochinov, refer to the evolving field as Psychiatric (or Psychosocial) Palliative Care and note that the last decade has seen an “all-encompassing multidisciplinary approach to care for the dying beginning to take hold” in palliative care which had heretofore been predominantly focused on somatic issues, overshadowing focus on psychological, existential, and spiritual issues at the end of life. How could it not? The universal issues facing people approaching death – “encountering illness, facing vulnerability, and confronting mortality”– have psychological import. In the Foreword to the 2nd Edition, Kathy Foley writes that, while psychological distress, while common, diagnosable, and treatable, in patients with serious life-limiting illnesses is often under-assessed, undertreated, and sometime stigmatized. She gives examples of potential issues including managing a family’s grief, caring for a dying child, providing pain management for a patient with a substance use disorder, or addressing death and dying in patients with serious or chronic mental illness.

To the extent that palliative care, most broadly defined, is expanding a focus of care to managing the burdensome symptoms related to an illness and its treatment, and their associated distress and burden/ impingement on quality of life, alongside the prospect of pursuing treatment only targeting the disease itself, issues addressed in palliative care by psychiatry generally include the management of psychiatric symptoms – such as the manifestations of delirium (agitation and confusion), depression, or demoralization, or existential despair/ crisis, anxiety/ fear/ nervousness, as well as insomnia, or even fatigue, concentration problems, or lack of appetite– in addition to physical ones like pain (which is only artificially extracted from a psychological underlay) or nausea. Psychiatric palliative care involves a range of interventions beyond psychopharmacologic maneuvers, including individual, group, or even family psychotherapies with supportive and existential approaches as well as bereavement focus, and separate spiritual or pastoral care. Some additional important topics in Palliative Care that fall in the psychiatric realm include Physician Assisted Suicide (only recognized in certain states, specifically Oregon and Washington)/ Euthanasia (prohibited in the U.S.) and desire for hastened death, and providing staff support.

Some well-known psychosocially oriented Palliative Care programs throughout the country include the San Diego Hospice which has an integrated Psychiatry and Palliative Care program, the Psychosocial Oncology program at Dana Farber Cancer Institute in Boston, as well as institutions with which I have been affiliated: the pre-eminent Division at Mount Sinai Hospital in New York where I attended medical school, and Department of Pain Medicine and Palliative Care at Beth Israel Medical Center, where I currently have a dual appointment along with the Psychiatry Department as part of my role serving as Director of Cancer Supportive Services at Continuum Cancer Centers of New York, as well as programs where I trained, including Memorial Sloan-Kettering Cancer Center where the field of Psycho-Oncology was founded in emergence with an early Palliative Care program, and the more recently developed service at Bellevue Hospital Center in New York, an institution well-known for its psychiatric service, where I completed my fellowship in Pain and Palliative Care and my residency in Psychiatry, respectively.

As an addendum, the first program which I mention, the San Diego Hospice, is that which is indicated as being the first of its kind in the country and founded by Dr. Scott Irwin, who is cited in the additional response to this question that I noticed been has helpfully posted.

I personally have specialty-level training in the field of Pain Medicine, having completed a fellowship in Pain and Palliative Care, so I have an understanding of the varied options and multifaceted approaches to pain management. With my background in psychiatry, I additionally have an understanding about the importance of the interdisciplinary approach, as its roots stem from psychiatric care is best applied to treating any psychiatric or medical condition, including quite substantially the treatment of pain, particularly when chronic, as well as in the cancer patient. For better or worse, the experience of pain is a complex and multidimensional phenomenon, so its management also requires utilizing an array of techniques. In addition to the continuing advances in interventional pain medicine, which include nerve blocks and injections and infusions or continuous delivery of medications including anesthetic agents and opioid pain medications as well as corticosteroids which have potent anti-inflammatory properties, as well as electrical stimulation, delivered to or around the central nervous system; and the use of medications in a variety of classes – opioid pain medications which can be administered in pill form and via host of other routes, corticosteroids, NSAIDs (non-steroidal anti-inflammatory drugs) many of which are available over the counter but present a host of potential medical risks, what are called muscle relaxants, anesthetic agents, and other classes called “adjuvants” which include some antidepressants, anti-seizure medications also used in psychiatry, and other channel blockers; there are other somatic treatments that involve electrical stimulation as well as the delivery of other types of energy – thermal, mechanical, or chemical – across the surface of the body, such as Transcutaneous Electric Nerve Stimulation or Cranial Electric Stimulation – and physical therapy – key to most types of persistent pain to improve functional status, as well as psychotherapeutic techniques, ranging from supportive psychotherapy and cognitive behavioral therapy, to incorporating mindfulness-based, relaxation, and hypnosis/ hypnotherapy techniques, to biofeedback, and support groups, along with non-medical treatments such as massage, acupuncture, and other mind-body approaches.

I am not an interventionalist, so I basically do nothing with a needle. That rules out a fair amount of the mainstream approach to pain management as it exists in practice today. Psychiatry happens to be one of four medical fields in which there is formal sub-specialization in Pain Medicine, the others being Neurology, Physical Medicine and Rehabilitation (PM&R or Physiatry), and Anesthesiology which is the most common. Since training generally entails the same program regardless of specialty, anyone completing a fellowship program in the field can pursue expertise in the main existing approaches. The involvement of psychiatry comes from an understanding, which certainly needs much further characterization, that psychiatric factors are indelibly and complicatedly interwoven with the experience of pain, both driving and exacerbating or, for that matter, ameliorating, pain and resulting from it. While people, particularly those who suffer from the very real experience of pain, are troubled when they perceive others think that “it is all in their head”, and, conversely, family, friends, lay people, or even clinicians, can become distraught when dealing with someone who is debilitated from that which does not present with a clear physical manifestation or appearance, there is no truth more useful to recognize in dealing with the mysteries of pain than the fact that “pain is in the brain”. While it is a controversial and weighted statement, there can be nothing closer to the truth. In dealing with psychiatric problems, psychiatrists and their patients, alike, are used to confronting stigma, and dealing with uncertainty, complexity, and compound logic which may involve, and typically expects, more than one explanation for things, so that dealing with the, at times elusive, problem of pain is something which we may be particularly adept and uniquely skilled to pursue, though one might argue that the trouble with pain is even greater due to the expectation of a physical explanation that often escapes the understanding of what is typically framed as a physical problem. However, a distinction must be made from the term “nociception” which is specifically defined as the ‘neural processing of noxious stimuli’ and is that which is specifically at play when we think about the sensation from the physically harmful effects of tissue injury. "Pain", on the other hand, the end product of nociception, if you will, is a perceptual phenomenon and, as such, is nothing other than a brain phenomenon. With this in mind (no pun intended) how could one’s emotions and thoughts, also perceived and processed, respectively, in the brain, not affect and interact with the experience of pain? This is such a simple concept that is unfortunately lost on so many, because it is, at the same time, somewhat difficult to grasp with respect to our expectations.

This all goes to explain the underpinnings of the multidimensional approach to pain, and the richness and importance of the psychiatric understanding, support, and treatment for someone with pain, and the value added by the involvement of a psychiatrist, with expertise in medical pain management, in the approach to the patient with pain. What is called ‘needle-jockeying’ involves highly technical procedures which would not be conducive to a psychotherapeutic encounter. Assessment of non-interventional pharmacologic approaches to pain is within my practice, as my input with potentially overlapping psychiatric medication can be helpful, but, without being able to give details depending on the case and the setting, I generally do so in the context of multidisciplinary pain management. In addition to medication evaluation for juxtaposed pain and psychiatric issues, psychotherapy is a main focus of all of my practice, on some level. In addition to psychopharmacology, I have expertise in psychotherapy which incorporates basic training in hypnosis, an evidence-based intervention for pain. The meaning of pain to a given individual, and the dramatic effects it has in changing one’s life when it enters, calls for such work. I personally have specialty-level training in the field of Pain Medicine, having completed a fellowship in Pain and Palliative Care, so I have an understanding of the varied options and multifaceted approaches to pain management. With my background in psychiatry, I additionally have an understanding about the importance of the interdisciplinary approach, as its roots stem from psychiatric care is best applied to treating any psychiatric or medical condition, including quite substantially the treatment of pain, particularly when chronic, as well as in the cancer patient. For better or worse, the experience of pain is a complex and multidimensional phenomenon, so its management also requires utilizing an array of techniques. In addition to the continuing advances in interventional pain medicine, which include nerve blocks and injections and infusions or continuous delivery of medications including anesthetic agents and opioid pain medications as well as corticosteroids which have potent anti-inflammatory properties, as well as electrical stimulation, delivered to or around the central nervous system; and the use of medications in a variety of classes – opioid pain medications which can be administered in pill form and via host of other routes, corticosteroids, NSAIDs (non-steroidal anti-inflammatory drugs) many of which are available over the counter but present a host of potential medical risks, what are called muscle relaxants, anesthetic agents, and other classes called “adjuvants” which include some antidepressants, anti-seizure medications also used in psychiatry, and other channel blockers; there are other somatic treatments that involve electrical stimulation as well as the delivery of other types of energy – thermal, mechanical, or chemical – across the surface of the body, such as Transcutaneous Electric Nerve Stimulation or Cranial Electric Stimulation – and physical therapy – key to most types of persistent pain to improve functional status, as well as psychotherapeutic techniques, ranging from supportive psychotherapy and cognitive behavioral therapy, to incorporating mindfulness-based, relaxation, and hypnosis/ hypnotherapy techniques, to biofeedback, and support groups, along with non-medical treatments such as massage, acupuncture, and other mind-body approaches.

I am not an interventionalist, so I basically do nothing with a needle. That rules out a fair amount of the mainstream approach to pain management as it exists in practice today. Psychiatry happens to be one of four medical fields in which there is formal sub-specialization in Pain Medicine, the others being Neurology, Physical Medicine and Rehabilitation (PM&R or Physiatry), and Anesthesiology which is the most common. Since training generally entails the same program regardless of specialty, anyone completing a fellowship program in the field can pursue expertise in the main existing approaches. The involvement of psychiatry comes from an understanding, which certainly needs much further characterization, that psychiatric factors are indelibly and complicatedly interwoven with the experience of pain, both driving and exacerbating or, for that matter, ameliorating, pain and resulting from it. While people, particularly those who suffer from the very real experience of pain, are troubled when they perceive others think that “it is all in their head”, and, conversely, family, friends, lay people, or even clinicians, can become distraught when dealing with someone who is debilitated from that which does not present with a clear physical manifestation or appearance, there is no truth more useful to recognize in dealing with the mysteries of pain than the fact that “pain is in the brain”. While it is a controversial and weighted statement, there can be nothing closer to the truth. In dealing with psychiatric problems, psychiatrists and their patients, alike, are used to confronting stigma, and dealing with uncertainty, complexity, and compound logic which may involve, and typically expects, more than one explanation for things, so that dealing with the, at times elusive, problem of pain is something which we may be particularly adept and uniquely skilled to pursue, though one might argue that the trouble with pain is even greater due to the expectation of a physical explanation that often escapes the understanding of what is typically framed as a physical problem. However, a distinction must be made from the term “nociception” which is specifically defined as the ‘neural processing of noxious stimuli’ and is that which is specifically at play when we think about the sensation from the physically harmful effects of tissue injury. "Pain", on the other hand, the end product of nociception, if you will, is a perceptual phenomenon and, as such, is nothing other than a brain phenomenon. With this in mind (no pun intended) how could one’s emotions and thoughts, also perceived and processed, respectively, in the brain, not affect and interact with the experience of pain? This is such a simple concept that is unfortunately lost on so many, because it is, at the same time, somewhat difficult to grasp with respect to our expectations.

This all goes to explain the underpinnings of the multidimensional approach to pain, and the richness and importance of the psychiatric understanding, support, and treatment for someone with pain, and the value added by the involvement of a psychiatrist, with expertise in medical pain management, in the approach to the patient with pain. What is called ‘needle-jockeying’ involves highly technical procedures which would not be conducive to a psychotherapeutic encounter. Assessment of non-interventional pharmacologic approaches to pain is within my practice, as my input with potentially overlapping psychiatric medication can be helpful, but, without being able to give details depending on the case and the setting, I generally do so in the context of multidisciplinary pain management. In addition to medication evaluation for juxtaposed pain and psychiatric issues, psychotherapy is a main focus of all of my practice, on some level. In addition to psychopharmacology, I have expertise in psychotherapy which incorporates basic training in hypnosis, an evidence-based intervention for pain. The meaning of pain to a given individual, and the dramatic effects it has in changing one’s life when it enters, calls for such work.

This is a fair question. I do not usually recommend that people seek information about treatments on their own without consulting directly with a specialist to discuss treatment options for their individual care. Quite basically, what’s good or might work for one person may not be the case for another. Furthermore, I cannot say that there is much in the way of substantially novel approaches to managing depression or anxiety, as the mainstays of treatment consist of psychopharmacology or medication management which have been used for several decades.

That being said, there may be, and certainly is, ongoing refinements to and studies of the efficacy of the psychological therapies as well as establishment and evolution of varying approaches in the field; as well as continual research and development of drugs in the rapidly expanding and burgeoning field of psychopharmacology in which there continues to be refinement of the neurotransmitter receptor profiles, delivery systems, and formulations, in existing classes of medications – mainly the antidepressants which, you should know, are generally the first-line treatment for both depressive and many anxiety disorders, despite the potentially deceptive name – to achieve better tolerability (based on modifications to the molecule), ease of dosing (e.g. long-acting/ extended release versions) and administration (e.g. liquid or transdermal formulations for people who have difficulty with swallowing pills or cannot absorb them when taken by mouth) – all factors which are potentially important particularly for an individual with cancer who might, at a given point in the course of the illness, face a host of obstacles to quality of life including medication administration that may be eased with these options – as well as exploration of other targets for novel classes of drugs that no longer need directly involve the neurotransmitter systems.

There are also other major classes of both ‘biological’ – or what some might call “somatic” – approaches and other ‘non-medical’ interventions. With respect to the latter, these may include alternative therapies which, likewise, include approaches involving chemical consumption – such as herbal therapies – and those that do not – such as the variety of holistic and mind-body approaches. While such alternative approaches are not novel, per se, as they have typically existed for a long time, often long predating modern/ Western medical approaches, they are actively being studied to corroborate their efficacy. Particularly with respect to the holistic/ mind-body approaches, these may appeal to patients with medical illness as they would not necessarily subsume active effort or additional extrinsic compounds which may have the potential only to add to the burdensome medical list and potential risk of side effects to a condition which is already physically trying in its own right, and they may be most conducive to welcome measures of conserving, harnessing, and healing. But herbal therapies are also an area of active research with respect to both psychiatric conditions, including depression and anxiety, and cancer treatments. However, it must again be stressed that, for this reason, consultation with your oncologist and a psychiatrist is essential and is the most optimal source for information about the approaches being sought. Many herbal supplements also run the risk of side effects and deleterious drug interactions, like pharmaceuticals, compounded by the lack of careful standardization in their composition since they are not subject to the same restrictions by the Food and Drug Administration as prescription drugs. With respect to the former, a major field is that of the brain stimulation therapies. Traditionally, this included ECT – electroconvulsive therapy or what has commonly come to be known as “shock” therapy – still actually a highly effective approach which has had the misfortune of stigma through association in the popular media which has conveyed it as a less than humane treatment, and as a byproduct of it having withstood the test of time from its early days when, indeed, the approach was much cruder than the way it is currently conducted with refinements making it quite tolerable However, this is another approach that would not likely be pursued in a patient who has newly emergent depressive or anxiety symptoms in the context of grappling with cancer diagnosis and treatment. It is not that it subsumes potential logistical and medical complications in a patient with active medical comorbidity – as it may, indeed, be conducted safely, if necessary, as it is typically used and effective, for patients with a psychiatric condition that is of long-standing or has not responded well to other treatment approaches – but, rather, that many patients who experience depression or anxiety in the setting of cancer may not require such an approach. Their symptoms might be related simply to a normative adjustment process, or to transitory struggles with adapting to a dramatic life change. But even if a patient’s depression could benefit from a somatic approach, if you will, a first trial of an antidepressant medication will often be effective for someone who may not have experienced such symptoms in their past.

However, I mention the brain stimulation therapies not just because they continue to be a most fruitful field of study, and represent some of the most recent developments in treatment, in psychiatry but I think they represent a potentially appealing approach for people with cancer or other chronic medical conditions. Some of the approaches, such as Vagal Nerve Stimulation, or Cranial Electric Stimulation, have developed since ECT, have been around for a while, and have ultimately had less than appealing results. A more novel procedure, Deep Brain Stimulation – wherein an electrode is implanted in an area of the brain that is below the surface or “cortex” so must be accessed surgically – originally developed, to my awareness, for treating Parkinson’s Disease, is now being studied in a variety of medical conditions, including OCD and Depression. This invasive technique is not the one I would highlight, however. The most recent approach developed as been TMS or Transcranial Magnetic Stimulation. I am mentioning this both in response to the question and to indicate that it is potentially attractive as a very non-invasive and well-tolerated approach – a probe that generates a magnetic field on the surface of the brain to produce current that may either stimulate or inhibit certain areas of the brain – has been shown to be effective, and is FDA approved, for treating depression. It is quite feasibly better tolerated than psychiatric medication. Furthermore, there is evidence for is effectiveness as a treatment for pain, which many cancer patients do experience, (though studies in cancer pain are less robust and the treatment would be delivered with different settings and sites). For someone with cancer, with recent surgery possibly limiting one’s oral intake, this could perhaps be interesting to consider, at least hypothetically. That being said, it is fairly new, and the gains achieved in research were modest and inconsistent. Typically, one’s oral intake has been advanced at least to baseline following an operation before being discharged from the hospital, so that issue will likely be moot. It also does entail repeated frequent, albeit brief, visits for a period of a few weeks to receive the treatment each session, and this may not be feasible for someone who also has a grueling chemotherapy or radiation therapy schedule, or, even when an active phase of treatment is complete and such an intervention may be more doable, who still has a host of medical appointments to make and deferred or changing social issues that need attention. Finally, I will add that a related but newer brain stimulation technique, Transcranial Direct Current Stimulation -- involving direct electrical current, rather than a magnetic field -- may also have a similar good tolerability profile and be easily manpulated and performed, and is being studied as an intervention in both psychiatry, including depression amongst other disorders, as well as pain.

This is part of the reason why, with all of this, there is still no replacement for the mainstay approaches of psychopharmacology and/ or psychotherapy, at least to be considered first, and there is really no substitute, and no better resource that I can recommend for reviewing the current approaches to treatment of anxiety and depression, than going straight to the source – a psychiatrist. This is a fair question. I do not usually recommend that people seek information about treatments on their own without consulting directly with a specialist to discuss treatment options for their individual care. Quite basically, what’s good or might work for one person may not be the case for another. Furthermore, I cannot say that there is much in the way of substantially novel approaches to managing depression or anxiety, as the mainstays of treatment consist of psychopharmacology or medication management which have been used for several decades.

That being said, there may be, and certainly is, ongoing refinements to and studies of the efficacy of the psychological therapies as well as establishment and evolution of varying approaches in the field; as well as continual research and development of drugs in the rapidly expanding and burgeoning field of psychopharmacology in which there continues to be refinement of the neurotransmitter receptor profiles, delivery systems, and formulations, in existing classes of medications – mainly the antidepressants which, you should know, are generally the first-line treatment for both depressive and many anxiety disorders, despite the potentially deceptive name – to achieve better tolerability (based on modifications to the molecule), ease of dosing (e.g. long-acting/ extended release versions) and administration (e.g. liquid or transdermal formulations for people who have difficulty with swallowing pills or cannot absorb them when taken by mouth) – all factors which are potentially important particularly for an individual with cancer who might, at a given point in the course of the illness, face a host of obstacles to quality of life including medication administration that may be eased with these options – as well as exploration of other targets for novel classes of drugs that no longer need directly involve the neurotransmitter systems.

There are also other major classes of both ‘biological’ – or what some might call “somatic” – approaches and other ‘non-medical’ interventions. With respect to the latter, these may include alternative therapies which, likewise, include approaches involving chemical consumption – such as herbal therapies – and those that do not – such as the variety of holistic and mind-body approaches. While such alternative approaches are not novel, per se, as they have typically existed for a long time, often long predating modern/ Western medical approaches, they are actively being studied to corroborate their efficacy. Particularly with respect to the holistic/ mind-body approaches, these may appeal to patients with medical illness as they would not necessarily subsume active effort or additional extrinsic compounds which may have the potential only to add to the burdensome medical list and potential risk of side effects to a condition which is already physically trying in its own right, and they may be most conducive to welcome measures of conserving, harnessing, and healing. But herbal therapies are also an area of active research with respect to both psychiatric conditions, including depression and anxiety, and cancer treatments. However, it must again be stressed that, for this reason, consultation with your oncologist and a psychiatrist is essential and is the most optimal source for information about the approaches being sought. Many herbal supplements also run the risk of side effects and deleterious drug interactions, like pharmaceuticals, compounded by the lack of careful standardization in their composition since they are not subject to the same restrictions by the Food and Drug Administration as prescription drugs. With respect to the former, a major field is that of the brain stimulation therapies. Traditionally, this included ECT – electroconvulsive therapy or what has commonly come to be known as “shock” therapy – still actually a highly effective approach which has had the misfortune of stigma through association in the popular media which has conveyed it as a less than humane treatment, and as a byproduct of it having withstood the test of time from its early days when, indeed, the approach was much cruder than the way it is currently conducted with refinements making it quite tolerable However, this is another approach that would not likely be pursued in a patient who has newly emergent depressive or anxiety symptoms in the context of grappling with cancer diagnosis and treatment. It is not that it subsumes potential logistical and medical complications in a patient with active medical comorbidity – as it may, indeed, be conducted safely, if necessary, as it is typically used and effective, for patients with a psychiatric condition that is of long-standing or has not responded well to other treatment approaches – but, rather, that many patients who experience depression or anxiety in the setting of cancer may not require such an approach. Their symptoms might be related simply to a normative adjustment process, or to transitory struggles with adapting to a dramatic life change. But even if a patient’s depression could benefit from a somatic approach, if you will, a first trial of an antidepressant medication will often be effective for someone who may not have experienced such symptoms in their past.

However, I mention the brain stimulation therapies not just because they continue to be a most fruitful field of study, and represent some of the most recent developments in treatment, in psychiatry but I think they represent a potentially appealing approach for people with cancer or other chronic medical conditions. Some of the approaches, such as Vagal Nerve Stimulation, or Cranial Electric Stimulation, have developed since ECT, have been around for a while, and have ultimately had less than appealing results. A more novel procedure, Deep Brain Stimulation – wherein an electrode is implanted in an area of the brain that is below the surface or “cortex” so must be accessed surgically – originally developed, to my awareness, for treating Parkinson’s Disease, is now being studied in a variety of medical conditions, including OCD and Depression. This invasive technique is not the one I would highlight, however. The most recent approach developed as been TMS or Transcranial Magnetic Stimulation. I am mentioning this both in response to the question and to indicate that it is potentially attractive as a very non-invasive and well-tolerated approach – a probe that generates a magnetic field on the surface of the brain to produce current that may either stimulate or inhibit certain areas of the brain – has been shown to be effective, and is FDA approved, for treating depression. It is quite feasibly better tolerated than psychiatric medication. Furthermore, there is evidence for is effectiveness as a treatment for pain, which many cancer patients do experience, (though studies in cancer pain are less robust and the treatment would be delivered with different settings and sites). For someone with cancer, with recent surgery possibly limiting one’s oral intake, this could perhaps be interesting to consider, at least hypothetically. That being said, it is fairly new, and the gains achieved in research were modest and inconsistent. Typically, one’s oral intake has been advanced at least to baseline following an operation before being discharged from the hospital, so that issue will likely be moot. It also does entail repeated frequent, albeit brief, visits for a period of a few weeks to receive the treatment each session, and this may not be feasible for someone who also has a grueling chemotherapy or radiation therapy schedule, or, even when an active phase of treatment is complete and such an intervention may be more doable, who still has a host of medical appointments to make and deferred or changing social issues that need attention. Finally, I will add that a related but newer brain stimulation technique, Transcranial Direct Current Stimulation -- involving direct electrical current, rather than a magnetic field -- may also have a similar good tolerability profile and be easily manpulated and performed, and is being studied as an intervention in both psychiatry, including depression amongst other disorders, as well as pain.

This is part of the reason why, with all of this, there is still no replacement for the mainstay approaches of psychopharmacology and/ or psychotherapy, at least to be considered first, and there is really no substitute, and no better resource that I can recommend for reviewing the current approaches to treatment of anxiety and depression, than going straight to the source – a psychiatrist.

First off, most importantly, I would recommend that you seek evaluation and management by a psychiatrist. To find one, you can start by discussing referral with your surgeon, medical oncologist, and/ or current prescribing physician. A psychiatrist with specialization in palliative care or, more typically, psychosomatic medicine can be beneficial, since such training and practice is geared toward helping people with psychiatric problems – be they emotional concerns, behavioral difficulties, or problems with cognition or thinking, concentration, and memory – related to medical conditions, or addressing these issues as they emerge in the context of a serious chronic or advanced illness. A psycho-oncologist is a psychiatrist who works with cancer patients and has a specialty in psychosomatic medicine, also called consultation-liaison or C/L psychiatry because much of the work involves consultation for physicians in other fields and acting to facilitate complicated dynamics between patient, family, and provider within the medical setting. A psychiatrist with a specialty in palliative care is less common but specializes in dealing with the various psychiatric issues – e.g. mood or anxiety symptoms or emotional concerns – and their interaction with physical symptoms, along with social issues, and spiritual concerns that emerge for people dealing with a chronic advanced disease. On a practical level, such training subsumes developing additional skills in management of physical as well as emotional symptoms, and, for psychiatrists, provides a better understanding of their interaction within the patient who ought to be treated as a whole person rather than a manifestation of the consequences of a disease and a variety of associated symptoms. Less commonly, psychiatrists may have training in pain medicine given the complex interface of this physical symptom, in particular, with other elements within the psychiatric realm that are processed in the brain – such as mood, anxiety, and perception.

Regardless, a psychiatrist with expertise or experience dealing with patients and issues related to your medical problem is always helpful. There may be a psychiatrist within or closely affiliated with the practice of the physician who initially screened for depression, and specifically addressed the issue and prescribed a medication. Whatever the case may be, psychiatric evaluation and management in addressing problems with mood is essential and ought not be substituted or overlooked.

For one thing, clarifying and refining a diagnostic impression over time requires careful and ongoing assessment by an expert, in part to rule out and further assess the multitude of other factors which may potentially be contributing to the decline in mood – including related psychiatric conditions, other medical issues, and a host of distressing issues that may be at play in one’s social circumstances, with a variety of possibilities in each domain for which one is at risk, given a close association, after undergoing surgery or during chemotherapy treatment for cancer.

Pursuing a psychiatric evaluation is important for evaluation of psychopharmacologic – or medication management – options, as well as non-pharmacologic interventions for depression in cancer, including psychotherapy. Additionally, seeking counseling and support from a social worker, if on staff where you are being treated, be it at a cancer center, or in the practice of the oncologist providing your care, can be invaluable. Social workers providing clinical care in the oncology setting can help to provide counseling and emotional support as needed, as well as referral to community resources and practical assistance with the various stresses that emerge in the life of a someone with cancer or other medical illness – in relationships with family and friends, financially, and at work or school, etc.

There are a variety of medications to treat depression, with reasonable evidence to support their efficacy in cancer patients, including those in several classes of antidepressants, as well as other classes of medication which may be used adjunctively or alternatively. Choosing a medication to alleviate depressive symptoms requires careful consideration of a variety of factors which should be carefully assessed by a psychiatrist.

Conducted by psychiatrists, psychologists, social workers, or other types of therapists, various forms of psychotherapy and emotional or behavioral counseling, conducted supportively, are an important aspect of optimizing adaptive functioning when facing the challenges associated with a medical condition and associated mood changes. There are a variety of approaches, such as psychodynamically-oriented supportive or supportive-expressive psychotherapy, cognitive behavioral therapy, various existential therapies, and client-centered or humanistic approaches that may be used and have been shown to be beneficial – be it observationally or experimentally – and seem generally to be related in part to the establishment of a rapport between a patient and clinician to develop a working alliance in the service of improving one’s psychological well-being. This is routinely conducted on an individual or one-on-one basis, but work with families, couples, or in a group setting amongst peers, may also be valuable as a means of addressing emotional difficulties encountered, particularly in the setting of relationships affected by one’s illness. In addition to providing a safe and open space to engage in the task of processing one’s thoughts and feelings, psychotherapy in an individual and group setting involves an educational and informational component. Alternative therapies which may be beneficial and available in the medical setting include the creative arts therapy – such as art therapy, music therapy, and drama therapy – as well as other mind-body techniques, such as hypnosis or hypnotherapy, guided imagery, relaxation techniques, and mindfulness-based approaches – and may be incorporated to the approach of a given therapist. There are additional integrative therapy approaches provided by practitioners who are not just mental health providers. In general, when dealing with issues related to medical conditions, a supportive approach is employed to help the individual foster the use of pre-existing internal resources which may be challenged when confronted with mortality and the threat to one’s livelihood but can be harnessed or aided in providing assistance for coping with an otherwise overwhelming experience. In this vain, the individual is the agent of change with the support of the provider, such that approaches to helping oneself may be found within one’s own self, environment, and lifestyle, and, as such, may even include improving healthy behaviors such as exercise and diet and reducing harmful behaviors such as substance abuse. First off, most importantly, I would recommend that you seek evaluation and management by a psychiatrist. To find one, you can start by discussing referral with your surgeon, medical oncologist, and/ or current prescribing physician. A psychiatrist with specialization in palliative care or, more typically, psychosomatic medicine can be beneficial, since such training and practice is geared toward helping people with psychiatric problems – be they emotional concerns, behavioral difficulties, or problems with cognition or thinking, concentration, and memory – related to medical conditions, or addressing these issues as they emerge in the context of a serious chronic or advanced illness. A psycho-oncologist is a psychiatrist who works with cancer patients and has a specialty in psychosomatic medicine, also called consultation-liaison or C/L psychiatry because much of the work involves consultation for physicians in other fields and acting to facilitate complicated dynamics between patient, family, and provider within the medical setting. A psychiatrist with a specialty in palliative care is less common but specializes in dealing with the various psychiatric issues – e.g. mood or anxiety symptoms or emotional concerns – and their interaction with physical symptoms, along with social issues, and spiritual concerns that emerge for people dealing with a chronic advanced disease. On a practical level, such training subsumes developing additional skills in management of physical as well as emotional symptoms, and, for psychiatrists, provides a better understanding of their interaction within the patient who ought to be treated as a whole person rather than a manifestation of the consequences of a disease and a variety of associated symptoms. Less commonly, psychiatrists may have training in pain medicine given the complex interface of this physical symptom, in particular, with other elements within the psychiatric realm that are processed in the brain – such as mood, anxiety, and perception.

Regardless, a psychiatrist with expertise or experience dealing with patients and issues related to your medical problem is always helpful. There may be a psychiatrist within or closely affiliated with the practice of the physician who initially screened for depression, and specifically addressed the issue and prescribed a medication. Whatever the case may be, psychiatric evaluation and management in addressing problems with mood is essential and ought not be substituted or overlooked.

For one thing, clarifying and refining a diagnostic impression over time requires careful and ongoing assessment by an expert, in part to rule out and further assess the multitude of other factors which may potentially be contributing to the decline in mood – including related psychiatric conditions, other medical issues, and a host of distressing issues that may be at play in one’s social circumstances, with a variety of possibilities in each domain for which one is at risk, given a close association, after undergoing surgery or during chemotherapy treatment for cancer.

Pursuing a psychiatric evaluation is important for evaluation of psychopharmacologic – or medication management – options, as well as non-pharmacologic interventions for depression in cancer, including psychotherapy. Additionally, seeking counseling and support from a social worker, if on staff where you are being treated, be it at a cancer center, or in the practice of the oncologist providing your care, can be invaluable. Social workers providing clinical care in the oncology setting can help to provide counseling and emotional support as needed, as well as referral to community resources and practical assistance with the various stresses that emerge in the life of a someone with cancer or other medical illness – in relationships with family and friends, financially, and at work or school, etc.

There are a variety of medications to treat depression, with reasonable evidence to support their efficacy in cancer patients, including those in several classes of antidepressants, as well as other classes of medication which may be used adjunctively or alternatively. Choosing a medication to alleviate depressive symptoms requires careful consideration of a variety of factors which should be carefully assessed by a psychiatrist.

Conducted by psychiatrists, psychologists, social workers, or other types of therapists, various forms of psychotherapy and emotional or behavioral counseling, conducted supportively, are an important aspect of optimizing adaptive functioning when facing the challenges associated with a medical condition and associated mood changes. There are a variety of approaches, such as psychodynamically-oriented supportive or supportive-expressive psychotherapy, cognitive behavioral therapy, various existential therapies, and client-centered or humanistic approaches that may be used and have been shown to be beneficial – be it observationally or experimentally – and seem generally to be related in part to the establishment of a rapport between a patient and clinician to develop a working alliance in the service of improving one’s psychological well-being. This is routinely conducted on an individual or one-on-one basis, but work with families, couples, or in a group setting amongst peers, may also be valuable as a means of addressing emotional difficulties encountered, particularly in the setting of relationships affected by one’s illness. In addition to providing a safe and open space to engage in the task of processing one’s thoughts and feelings, psychotherapy in an individual and group setting involves an educational and informational component. Alternative therapies which may be beneficial and available in the medical setting include the creative arts therapy – such as art therapy, music therapy, and drama therapy – as well as other mind-body techniques, such as hypnosis or hypnotherapy, guided imagery, relaxation techniques, and mindfulness-based approaches – and may be incorporated to the approach of a given therapist. There are additional integrative therapy approaches provided by practitioners who are not just mental health providers. In general, when dealing with issues related to medical conditions, a supportive approach is employed to help the individual foster the use of pre-existing internal resources which may be challenged when confronted with mortality and the threat to one’s livelihood but can be harnessed or aided in providing assistance for coping with an otherwise overwhelming experience. In this vain, the individual is the agent of change with the support of the provider, such that approaches to helping oneself may be found within one’s own self, environment, and lifestyle, and, as such, may even include improving healthy behaviors such as exercise and diet and reducing harmful behaviors such as substance abuse.