SEVEN QUESTIONS TO: JIMMIE C. HOLLAND
by Luigi Grassi
Jimmie C. Holland, M.D. has, over the past twenty years, been central to the establishment of psycho-oncology as a subspecialty within oncology dealing with the psychological, social, and behavioral aspects of cancer. She is Chair of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan-Kettering Cancer Center and holds the Wayne E. Chapman Chair in Psychiatric Oncology. Under her direction the past two decades, the Department of Psychiatry at Memorial developed the largest clinical training program and spearheaded research in the psychological dimensions of cancer. She is also Professor and Vice-Chairman of the Department of Psychiatry at Weill Medical College of Cornell University.
Dr. Holland was the Founding President of the American and international societies of psycho-oncology. From 1977 - 2001, she chaired the Psycho-Oncology Committee of the Cancer and Leukemia Group B a committee that pioneered the study of psychosocial issues in cancer and quality-of-life in treatment outcomes. Besides co-editing the Psycho-Oncology journal, Dr. Holland edited the first textbook on psycho-oncology in 1989, and in 1998, Psycho-Oncology, an updated review of the field, followed 2 years later with The Human Side of Cancer for patients and families.
Dr. Holland received her undergraduate degree at Baylor University in Waco, Texas, and her medical degree at Baylor University School of Medicine in Houston. She interned at St. Louis City Hospital and did a psychiatric residency at Malcolm Bliss Mental Health Center in St. Louis and at Massachusetts General Hospital. She held academic appointments at SUNY School of Medicine at Buffalo, at Albert Einstein College of Medicine, where she served as consultation-liaison psychiatrist at Montefiore Hospital, before coming to Memorial Sloan-Kettering Cancer Center and Cornell University Medical College.
In 1994, Dr. Holland received the Medal of Honor for Clinical Research from the American Cancer Society. She was elected, in the following year, a Fellow in the Institute of Medicine, National Academy of Sciences. In 2000, she was awarded the Presidential Commendation of the American Psychiatric Association.
Question (Q): What is the status of psycho-oncology in oncology? Should it remain as a single subspecialty or break up into smaller divisions related to discrete areas, such as cancer prevention, clinical treatment, or palliative care?
Answer (A):Psycho-oncology deals with two aspects of cancer: 1) the psychological responses to the illness on the part cancer of patients, their families and the medical caregivers from the time of diagnosis through treatment and survivorship to palliative care; 2) the psychological, social, and behavioral factors that contribute to cancer risk and survival. I believe that it is important to maintain the specialty of psycho-oncology because it can focus on all of these areas of care and research. This ensures a networking of psycho-oncologists around the world, which can combine efforts to train new clinicians and investigators, and to advocate for this domain of care by seeking resources to support research and training.
One of the potential dangers to our field is the fact that, as the specialty matures, investigators and clinicians tend to focus on a particular area, for example, cancer prevention and become more closely identified with other prevention researchers than with other psycho-oncologists. Similarly, the psycho-oncologists working in palliative care tend to relate more to palliative care clinicians from other disciplines, for example, pain investigators, oncologists, pastoral counselors. The ideal situation is one in which psycho-oncologists maintain a dual identity: within psycho-oncology as a whole and within their distinct area of expertise.
Q: Psycho-oncology is almost 30 years old. What are the most important goals reached? For the future?
A: Psycho-oncology has achieved status as an identified sub-specialty of oncology, with its own tools for assessment of quality of life and psychosocial issues, training and curriculum, scientific data base and a research agenda. It has impacted clinical care by focusing attention on the psychological aspects of patient care.
However, the psychological aspect of care is still far less valued and respected as an area of scientific investigation. This likely stems from the long-present stigma related to mental illness, These attitudes make it difficult to obtain the needed resources to advance and expand the field. Support for training, research and clinical care are needed to improve patient care and expand the research agenda.
Q: Has the work of psycho-oncologists improved patient care?
A: Data from the U.S. suggest that around 30% of outpatients have significant levels of distress, yet far less than 10% receive any kind of formal psychological intervention. This is a serious gap that must be addressed by setting minimum standards for psychosocial services in cancer centers and clinics.
Q: The field of psychiatry has less interest in the care of the medically ill, seeing its primary mission as the care of the psychiatrically ill and community psychiatry. How can we change this?
A: Psychiatrists working with medical illness (and those working in cancer) do not fit very well in the overall, traditionally defined specialty of psychiatry. They must live with "having one foot in medicine and one foot in psychiatry." Consequently, it is true that they are not fully members of either discipline. Psycho-oncologists have the same problem: to be in oncology, yet outside oncology, bringing insights from psychiatry to oncology. I believe that psycho-oncology will survive better with its major identity as a subspecialty of oncology.
Q: How do we convince other specialties about the need for psychiatry in patient care?
A: I believe that patients and their families are our best advocates. We should do more to utilize their strong beliefs that the psychological aspect of care is as important as the physical.
Q: How do we get psychological care for cancer patients to all hospitals?
A: Some hold the opinion that psychosocial care is expensive and requires many professionals to provide it. I believe that if the staff in clinics and hospitals would become more familiar with the range of psychosocial services (mental health, nursing, social work, patient volunteers, pastoral counselors, creative therapies such as art, music and writing), they would refer patients to the already existing and available resources, and, hence, this type of care would not add greatly to the overall cost of care.
Q: How do we make oncologists more aware of their patients psychological problems?
A: Training of oncologists increasingly includes how to communicate better with patients and how to inquire about and recognize distress in patients. Nurses are excellent observers of patients distress and can easily bring this to the oncologists attention. The real need is a close connection between the primary staff and the mental health professionals to ensure that patients are easily referred without their feeling that they have been stigmatized as having a "mental problem."