SEVEN QUESTIONS TO: KATALIN MUSZBEK
By Luigi Grassi
Katalin Muszbek took her degree in Medicine in Budapest and her diploma in Psyhciatry in 1978. She was assistant professor psychiatry at the Jahn Ferenc Hospital, Department of Psychiatry, and chief of psychiatry at the National Institute of Mental Health, Department of Psychotherapy. Later she was chief of Psycho-Oncology at National Institute of Oncology, and at St. Stephen Hospital, Gyneco-oncology Department. She is currently Director of the Hungarian Hospice Foundation.
Katalin Muszbek has been President of Hungarian Hospice-Palliative Association until 2004. At present, She is also Honorary president of the Hungarian Psychooncology Society and Vice-president of Eastern and Central European Palliative Task Force (ECEPT).
QUESTION (Q): What is the situation relative to Psych-Oncology and Psycho-Oncology services in Hungary?
ANSWER (A): Organized psycho-oncological care was launched in Hungary in 1988. I was asked by the former president of the UICC, Dr Sándor Eckhardt to set up a psycho-oncology service in the National Institute of Oncology. There had been some scattered initiations before, as well as some exciting studies on the application of the Rorschach Test on cancer patients. The first period from 1988 to 1993 was very successful, a team of six psychologists, psychiatrists and social workers provided psychological care for cancer patient in the National Institute of Oncology.. The expansion of such initiations to the entire country was supported by a great number of lectures, trainings and conferences. Nowadays, 10 out of 27 oncological departments in the country have psycho-oncological services.
In 1990, some colleagues involved in psycho-oncology established the Hungarian Oncological Society Psychooncology Group, It was set up4 different special work groups on education, on research, on psycho-social clinical work and business federation. We divided Hungary into four regions, with one representative in each to coordinate the psycho-oncological work on that special territory. In 2003, this scope of activity was renewed and this had culminated in the establishment of the Hungarian Psycho-Oncological Society which manages just about the same duties as its predecessor.
Q.: Is there any specific profession and recognized position of psycho-oncologists, in Hungary?
A.: In Hungary, a specialization in psycho-oncology does not exist. So it is up to psychiatrists, psychologists and mental care workers to offer psychological support to cancer patients. Social workers, in turn, tend to specialize in social problems. Unfortunately, psycho-oncology is a difficult domain of medical attendance. The oncological departments of hospitals are dominated by a strong hierarchal order and a somatic attitude. This is why psycho-social professionals find themselves in a lonely and subordinate position. This, in turn makes this line of work all the less attractive to psychologists and psychiatrists. The appearence of hospice movement has changed this attitude to a great extent. Hospice care means working in a multi-disciplinary team and people involved in oncological attendance have learnt to benefit from this. Experiences gathered in the last few years show that oncologists have become more open to a psycho-social attitude as well hospice care.
Q.: Palliative care is one of the areas where different professionals work in multidisciplinary teams. What is your recommendation as far as the training?
A.: Hospice care was launched in Hungary in 1991. In this period, medical team traditionally included a physician and a nurse. Other experts had rarely been involved in medical work. Palliative care requires an entirely different approach; a multidisciplinary team provides the care and, each of them being equally important. This line of work can only be done by people who are very well trained psychologically and professionally and have good communication skills. When recruiting such a multi-disciplinary team, motivation and personality traits are just as important as knowledge and practical experience. Considering the difficulty of this kind of work and the respect of the principles of hospice care, it is very important to sort out candidates who have personality disorders, those suffering from a serious disease or struggling with some sort of unmanaged loss or simply uncapable of such work for some other reason. Being fit for work in hospice care means having acquired its philosophy, being ready to work in a team and take part in extension trainings. Special competences in palliative care as well as the basics of psycho-oncology are aquired in theoretical and practical trainings preceding the start of work. Theoretical lectures are complemented by sensitizing role plays, psychodrama, communication trainings (e.g. telling bad news, preparing people for death). Continuative education and the mental care of our staff is highly important, since burnout is a constant danger our colleagues have to face. Extension trainings and professional programmes help keep their knowledge and skills fresh and applicable, they help maintain high professional quality as well as reinforce their original motivation and a sense of competence. Regular supervisional group sessions, Balint groups are highly recommended
Q.: How do you imagine to reach the public as regards to their sensitization in stigmatized" areas such as psychology/psychiatry in oncology and palliative care?
A.: In public mind cancer means suffering, pain and death. The silence surrounding the patient leads to a communicational gap of denial that condemns the patient to loneliness and lay serious problems on the relatives. Cancer is still a taboo and is, just like psychiatric disorders, stigmatized.In the early nineties the psychooncology groups tried to change this attitude. Later on hospice movement undertook the challenge of changing public mind, and a change towards open communication and stop this denial of cancer. The purpose is to draw the attention to the problems of cancer patients and to make the right to pain-free life, effective palliative care and home care obvious and demandable. Addressing and sensitizing the public to this subject is a slow process and the media plays a significant role. In 2002 we decided to organize a media campaign to reinforce social solidarity for the dignity of life and death. We made public advertisements involving TV starring celebrities and artists. Three TV spots based on very emotional testimony" of their personal experiences to a loss of a relative appeared on the TV screen every day for two whole month. It was accompanied by press material, in- and outdoor posters. That was the most comprehensive media campaign in the field of medical care of any time in Hungary. In addition, we launched a toll-free, informational telephone line to help fight the wide-spread aversion towards psychological attendance and improve the psychological culture of the population.A public education program was introduced at the same time. Monthly assemblies and educational lectures enable regular encounters with the local population and an exchange of experience. Receiving support and participation from small local communities, e.g. through the organization of open days, is very important. We are delighted that due to these freshly applied methods more and more cancer patients benefit from psychological support and that the awareness of hospice care within the whole population has grown by more than 30%
Q.: Different training models have been proposed for communication skills, form intensive workshop to consolidation. What is the role of efficacy nowadays, after 50 years, of Balint groups and how is it possible to run these groups in palliative care settings?
A.: One of the greatest problems in Hungary is open communication with patients. Even though it is their legal obligation, physicians tend to avoid the word cancer", they say malignant cells" or " malignant tumor" instead of cancer. Also, they often tell bad news to family members rather than the patient him- or herself. 1989 was the first year we organized the symposium called Dilemmas of Communication on the Diagnosis". Among the about 300 participants were several old professors and physicians telling us quite heatedly how dangerous it was for patients to know their diagnosis. They also told us that they were very proud of not telling one single patient within the course of their 40 to 50 years of practical experience that they had cancer. The numerous lectures and trainings held on this subject helped a lot to rise above this old-fashioned attitude.
An other important topic is the mental health of the caregivers. The Balint group is a method that proved very effective in oncological and hospice teams. In our Foundation, we have got Balint group sessions every two weeks led by a psychiatrist from outside. This gives an opportunity for the members of the staff to better understand their own attitudes, emotions and anger towards the patients. In our team that has been working together for six years now, I can see a growth that is incredible, both in palliative care and in managing losses.
Q.: What are your suggestions and ideas for fostering the cooperation in terms of research and training in a cross-cultural way between European countries?
A.: After a long period of preparation, we finally managed to introduce a new monitoring system for cancer patients following the American model. This system allows us to identify patients with severe anxiety, depression and distress and offer them psycho-social support. If you compare the results we had gained in this terrain to international outcomes you may declare that cancer patients in Hungary are in a particularly bad psychological condition. I think it would be very useful to introduce such a screening system in those countries in Europe which did not introduce such a monitoring jet. International experience and methods that had previously been shown effective may be very helpful in this stage, as we can tell by our own experience. In Hungary, this was the first nationwide research in this territory that supplied a long felt need.
The main importance of psycho-oncological research in Hungary lies in the possibility to convince people involved in oncological care that patients do need firm psycho-social support beside medical expertise and help to be able to carry the burden of cancer and to have better chances for recovery. Surveys are means of monitoring at the same time that help to sort out all the patients who are in need of help. We need to integrate psycho-oncology with the broader domain of oncology, and to achieve this, we have to yield results. One crucial part of this process is a change in the attitude of medical staff and the acquirement of the knowledge that is necessary. International experience can be very useful and so is the international educational curriculum that is being conceived by IPOS, based on an American model as well.
We need research to support lobbying efforts for the appearance of psycho-oncology at the level of EU policy. International collaboration is especially crucial in this question. For example, it would be very exciting to monitor distress management in all EU-member countries within the framework of a well-organized study, to assess the knowledge and the skills of the different medical staffs, the needs of patients and their relatives. Later, the outcome of this project could be summarized on an international level, as well as in an advocacy material which could later be presented at the special forums of the EU. The same goes for the WHO, in fact, if psycho-oncology were more explicitly present in the National Cancer Control Programme of the WHO, it would promote development on a national level, considering that the national cancer control programmes conceived by the single countries are becoming more and more complex, and these programmes seek to implement the suggestions of the WHO with a growing accuracy.
In Hungary, when we do some lobbying for palliative care, we apply the suggestions of the EU and the WHO when we try to explain to decisionmakers the ways of solution we had elaborated, ways that suit the international practice. This seems to be the right way to go, in fact, all national governments are trying to meet the requirements that had been put on them at different European forums.
Q.: What is the relationship between psychiatry and clinical psychology in the field of oncology in Hungary. Is mental health totally devoted to severe psychiatric disorders? What do you suggest to implement the strong cooperation between the two professions?
A.: In Hungary, most of the psychiatrists and psychologists used to work in the domain of classical psychiatry. The collapse of the former socialist regime in 1989 had opened the ways of free thinking. In the communist way of thinking, psychological problems did not exist, since everything was materialized. Psychotherapy, for example, had been a discipline liable to prosecution. Fortunately, the psychoanalytic school had always been very strong in Hungary. The psychoanalytic school of Budapest led by Sándor Ferenczi brought forth some excellent psychoanalysts. Psychoanalytic training went underground", I am the trainee of a follower of Ferenczi myself. The more open atmosphere after the fall of the socialist regime allowed the capacity of psychotherapy that had been lurking under the surface to function in somatic care as well. That is how psychological care became part of the medical attendance of patients suffering from psycho-somatic disorders, cancer, cardiovascular diseases and other disorders that lead to psychological problems.
In 2003, the Bristol-Myers Squibb Foundation from New York offered a great opportunity to enhance the psycho-oncological system in Hungary. We had the possibility to develop a three-level psycho-oncological programme within the framework of a two-year project, organized by the Hungarian Hospice Foundation. Toll-free telephone line offers special counselling for cancer patients and their relatives for the first time. The outpatient psycho-oncological service set up at Budapest Hospice House offers the opportunity of a face to face counseling. Five regional oncology centers in Hungary offer depression and distress monitoring that is accompanied by psychotherapy.To introduce this project it was very important to collaborate with leading psychiatrists, members of the councils of oncology and nursing, leaders of medical universities, experts from the Ministry of Health, representatives of patients organizations and leading personalities of Hungarian psycho-oncology. In the introduction phase of the programme, we organized a very successful one-day policy conference with the participation of the organizations mentioned above, as well as the leaders of the national and regional centres of the BMS and JC Holland. The introduction of a new psycho-oncology programme, as well as the activation of the related organizations and the exchange of experience between them may warrant a large-scale psycho-social care.
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