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|Clinician's Digest - Page 6|
Dealing with Chemo Brain
Psychologist Barry J. Jacobs, who specializes in working with families dealing with serious medical issues, still remembers an intellectually adept, 60-year-old cancer patient who discovered that, after he underwent chemotherapy, much of his mental acuity had drastically eroded. Hoping it was just a short-term side effect, he waited for his concentration, verbal fluency, and short-term memory to come back. They never did. Angry and depressed until the day he died, he often told Jacobs he wished he'd never decided on the chemotherapy, even though it had gained him another five years of life.
The man, a high school principal, claimed that he hadn't been warned about the side effects, and that if he had, he wouldn't have agreed to the chemo. That's possible. The realization that chemotherapy can have permanent cognitive effects on about 15 percent of people who undergo prolonged, highly toxic treatments is relatively recent. It was once thought that most cognitive loss from chemotherapy was short term and caused as much by the emotional stress of being diagnosed with cancer. But it's also possible that the man was told, says Jacobs. Many cancer patients and their family members, wrestling with fear, stress, and anxiety, must make difficult treatment decisions, and with their survival at stake, they often underestimate what living with the side effects will be like. Later, experiencing impaired memory, difficulty with word retrieval, incorrect word substitution, and the loss of deep focus, they question their decision. Sometimes that regret can be caused by the brain damage itself, which can make their thinking more rigid and cause them to fixate on what they've lost.
Weighing survival against future quality of life is terribly difficult, and knowing who's more likely to regret some cognitive deterioration is part of the art of counseling these patients. Jacobs believes that people who base much of their ego strength on their intellect are particularly likely to regret their reduced intellectual capacity. Surprisingly, pessimistic people may actually have an edge in dealing with the tough trade-offs in these kinds of treatment decisions—a fact often ignored in today's Positive Psychology tsunami. "People who think life has always thrown them curveballs and who have always had to fight to cope and adapt," says Jacobs, "often do better accepting the loss."
Is Therapy a Science?
What does science have to do with what therapists actually do in their offices? According to a 36-page report from the Association for Psychological Science (APS), which was widely publicized by science editor Sharon Begley in the October 12 Newsweek, not a whole lot. Calling for a complete restructuring of how therapists are educated and licensed, the APS report said that therapists rely too much on unreliable clinical experience and intuition and not enough on the array of research-supported treatments with established clinical track records. In her column, Begley concluded that, as a result of the gap between practice and research, "millions of patients" currently receive useless therapy.
In one especially provocative section, the APS report accuses the American Psychological Association (APA) of helping to foster a "prescientific" approach to psychotherapy by not fostering more rigorous scientific education, training, and licensing, and thus turning out inadequately skilled therapists who are akin to physicians who once relied on bleeding to balance the body's humors. Katherine Nordal, the APA's Executive Director for Professional Practice fired back a response to Newsweek, insisting that, "The assertion by Begley that many psychologists are not trained in, nor do they use, evidence-based practices is untrue." But like Begley's article, Nordal's letter didn't address the more important points raised by the APS report.
Since its inception in 1988, APS has positioned itself as more science-based than the APA, its membership consisting primarily of professors and researchers, rather than clinicians. Their report issued a call for an accreditation system that focuses primarily on science and screens out graduate student applicants who lack a solid track record in science and mathematics. It also called for faculty who are "successful in producing high quality research products, securing extramural research support, and developing, testing, and implementing experimentally supported interventions." Nevertheless, the APS report, unlike Begley's column, acknowledged the large body of research showing that factors common to a variety of treatments, which rest more upon therapists' relational skills and client variables than upon therapists' knowledge of the research, have a great deal to do with successful outcomes. (For a fuller discussion of this, see Jay Lebow's article on page 32 of this current issue). In fact, no studies have yet shown that therapists' knowledge of the research has any impact, positive or negative, upon therapy outcomes. In her longer blog response to Newsweek and to the APS report, Nordal writes that "psychologists combine our understanding of the research with how to best understand the patients who come into our offices with their complicated problems. . . . We have to realize the limitations of science in regard to the generalization of research results to the individual patient."