Jana Bolduan Lomax, PsyD
Over the past several decades, the field of psychosocial oncology has matured into an invaluable subspecialty that helps patients with cancer and their caregivers deal with the existential issues that arise in cancer, especially in the advanced-disease setting. In an effort to add to this important clinical issue, The ASCO Post spoke with Dr. Jana Bolduan Lomax, PsyD, a licensed clinical health psychologist specializing in coping with cancer and survivorship.
‘A Specialty That Found Me’
Could you tell us a bit about your background, and what drew you to psychosocial oncology?
I grew up in a health-care family; my father is a physician, and my mother was a nurse. I had a strong interest in health care and mental health from an early age. I was involved in a lot of health-care jobs early in my career, such as in a nursing home and a mental health treatment center for children, a medical office, and on crisis hotlines. While I was pursuing a Bachelor’s degree in psychology, Itook a health psychology course in my undergraduate studies; it really pulled everything together in terms of working with people dealing with medical and life-and-death issues and helping them cope with difficult life challenges. So, I pursued a doctoral degree in clinical psychology with a specialization in Health Psychology and Behavioral Medicine.
Psychosocial oncology is a subspecialty of Health Psychology that sort of found me. As many oncology nurses also say, you’re basically chosen for this field. I completed a generalist psychology internship at Denver Health Medical Center and was looking for postdoctoral training in a medical setting. I was fortunate to secure a postdoctoral position with the Blood and Marrow Transplant team at the University of Colorado Hospital and was quickly immersed in one ofthe most intensive oncology arenas.
After completion of postdoctoral work and licensure, I accepted an academic appointment there for 4 years, providing psychological assessment and therapy for patients, families, and even colleagues coping with the physical and emotional demands of hematologic malignancies, transplants, postcancer life, and death. Those early years have resulted in a career specializing in psychosocial oncology treatment and program development.What I truly love about it is treating individuals across the life span who experience a major life change due to dealing with chronic or life-threatening disease and grief, many of whom have never had a reason for psychotherapy treatment until cancer entered their life.
Please tell us about your current work.
I was employed at hospitals and outpatient cancer centers in psychosocial oncology for about 12 years. I changed gears in 2017 and launched a private psychology practice treating patients who are currently undergoing cancer treatment, people who are years out from their treatment, caregivers of loved ones with illness, adults facing chronic illnesses, and bereaved family members. In addition to the psychotherapy practice, I teach courses in Health Psychology at the University of Denver Graduate School of Professional Psychology. I also supervise doctoral psychology candidates in their clinical work with health psychology patients, and I consult to burgeoning survivorship programs and supportive oncology programs across the country.
Therapeutic Strategies in Late-Stage Cancer Care
What types of therapeutic approaches do you consider the most effective when dealing with patients who have late-stage cancer and are facing existential crisis?
In the late-stage setting, in which a patient with cancer is receiving palliative care or hospice interventions, communication with loved ones about desires, hopes, and fears usually plays the biggest role in their therapy.Many patients I’ve seen over the years are concerned about leaving their loved ones as well as feeling a burden and unresolved relationship issues. Some of the interventions will involve family meetings to facilitate difficult but much-wanted conversations.
I have found that patients and their family members are often at different stages of readiness in facing mortality issues. Some patients with late-stage cancer struggle to recognize that they are dying, but the family is desperate to have meaningful conversations about the dying process and fulfilling their loved one’s final wishes. Or the converse scenario also occurs, in which patients with cancer have acknowledged their own impending death, and family members are in denial, pressing for continued treatment, even though it has no clinical benefit. It’s a way to keep hope alive in their minds, but it is also a complex dance of love, support, and avoidance.
In these cases, the intervention is creating a space for people with different perspectives to feel safe to open up and come to terms with the reality of the situation and find ways to effectively communicate about feelings, fears, and hopes. Mindfulness-based interventions and meditation have been shown to help reduce anxiety and aid people to live in the present moment; these strategies can be effective tools for managing uncertainty.This type of therapy can address a roadblock to living in the present by decreasing anxiety and depression, which are common in end-of-life scenarios.
One area of psychotherapy for patients with advanced cancer that I am very interested in is the growing use of psychedelics in end-of-life care. I have long been a strong advocate for early palliative care intervention in the cancer care trajectory, which coincides with a holistic approach to overall cancer care.To that end, there is promising research demonstrating that the proper clinical use of certain psychedelics can enhance greater inner peace and a sense that patients are connected to something bigger than themselves. It might be effective for some individuals who are overwhelmed by fear of death. I hope there will be an opportunity to explore the effectiveness of agents that can ease emotional suffering of patients dying from cancer and to deal with the existential trauma that is attendant in late-stage disease. Furthermore, reducing emotional and existential crises in the dying patient will result in decreased emotional and social distress in their loved ones and their care providers.
Preexisting Psychiatric Conditions
Are there special ways to engage patients with cancer who have underlying psychiatric conditions?
The same psychiatric conditions that we deal with in the general population exist in patients with cancer and have to be treated accordingly. One of the most complex issues is substance abuse or substance dependence and how tricky that can be in the cancer setting, where drugs of abuse are necessary tools. One tool for providers is to use motivational interviewing techniques to examine an individual’s readiness and confidence in him or herself to change problematic addiction behavior.
It can be challenging to work with patients who have a preexisting trauma history because they have a significant sensitivity to the experience of vulnerability; therefore, it is essential for these individuals to develop trusting relationships with their health-care providers. If there are sign and symptoms of preexisting posttraumatic stress disorder, we need to help identify the triggers that increase the patient’s sense of vulnerability and panic responses.
Open communication between patients and care providers is essential for compassionate cancer care with trauma survivors, but time for such meaningful conversations in these settings is in short supply. At times, patients will have to utilize medications to help them cope with their immediate emotional distress and then ultimately help them to become their own advocates with their health-care providers. A psychologist like myself or a social worker may facilitate conversations between providers and patients about their clinical needs and how their goals can be accomplished.
Clinical depression with suicidal ideation is a very challenging psychiatric disorder to treat in the cancer setting. Sometimes these individuals will refuse treatment or, at a minimum, profoundly struggle with adherence to difficult cancer treatments due to their own ambivalence about living.In these situations, we need to employ a full array of interventions, from goals of care interviews to interactions with family members and possibly psychotropic medications. An important consideration in this setting is to attempt to understand the patient and assist them in developing a sense of self-worth and dignity, no matter what treatment choices they make.
Looking Toward the Future
Please share a closing thought or two on the future of psychosocial oncology.
I’d like to see the conversation around life after cancer to continue to grow and increase effective physical, emotional, and social interventions for late treatment effects. One issue that needs more attention is posttraumatic stress disorder among cancer survivors. It is real and increasingly recognized—and it is treatable—but it needs to receive greater awareness across oncology and postcancer settings.
A foundational change that needs to happen in oncology care is to create more time and place more value in understanding the unique psychosocial needs of patients in order to help them holistically. However, the growing aging population will increase the burden on oncology providers, which will ultimately decrease the time and resources for individualized care for patients and cancer survivors.
DISCLOSURE: Dr. Lomax reported no conflicts of interest.