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Jan Busschbach Psychologist

J.vanbusschbach@erasmusmc.nl

In cooperation with Willij Zuidema

Jan IJzermans

Willem Weimar

Jan Passchier

Leonieke Kranenburg

Medard Hilhorst

Settling Psychosocial Barriersin Living Donation

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Living donor transplantation: are the outcomes good enough?

Advantages Reduces the waiting list

Increases craft survival

Are the outcomes good enough? Should we pursue living donation?

Are the better outcomes worth the costs?

• Are the outcomes more valuable than the cost to overcome the barriers

From a descriptive point of view… The answer is might be no…

Living donation is not widely pursued

The effects do not outweighed the cost to overcome the barriers

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Barriers

What are the barriers? Sometimes hard medical issues… But most often soft issues

Legal

Cultural

Organizational

Psychological

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Psychological barriers

Negative emotions towards living donation Inappropriate emotions

Issues that related to inappropriate emotions …

Information Wrong information

Risk perception Wrong risk perception

Communication between patient and donor Blocked communication

* Kranenburg LW, Zuidema WC, Weimar W, Hilhorst MT, IJzermans JN, Passchier J, Busschbach JJ. Psychological barriers for living kidney donation: how to inform the potential donors? Transplantation. 2007 Oct 27;84(8):965-71

What can we do?

How can we change… Wrong information

Wrong risk perception

Blocked communication

Talking with the potential donor and patient

Rational

More and better information… Gives more appropriate emotions

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Information Interpretation Emotion

Not so rational,.. but reality

Better (more appropriate) emotion Better interpretation of information

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InformationInterpretationEmotion

Most likely model…

Need to work on both information and emotion Next question: how?

Talking with the patient and the potential donor

But there is not yet a ‘evidence based’ way…

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InformationInterpretation

EmotionInterpretation

Looking for the best psychotherapy..

Not much difference between psychotherapies Many very different therapies seem to work equally well

Research into non-specific factors Success factors in counseling

Most important non-specific factors Therapeutic alliance

Therapy adherence

System involvement

• Family

• Friends

Therapeutic alliance

Biggest generic success factor Sexton & Wiston (1992)

“…research has confirmed [that] the success of any therapeutic endeavor depends on the participants establishing an open, trusting, collaborative relationship or alliance.”

• http://personcentered.com/research.html

Control of emotion Safe environment

How do we establish such alliance Listening and talking…

Is it so simple?

Counter-transference

Our own ‘psychological schemes’ interfere Alternatively: Use theoretical scheme It does not matter much which…

Behavioral therapy

Cognitive therapy

Schema focus

Mentalisation

Reduces influence of own ‘psychological schemes’ Helps to build a “…open, trusting, collaborative

relationship or alliance.”

In order to control emotions

Treatment adherence

Treatment adherence is fatal It does not matter which therapy

As long as one use ONE therapy

Created a consistent… Framework

Language

In a confusing world

Thus consistency is important In time

Within the team

Protocols: adherence

Involve system

Patient part of ‘system’ System

Family

Friends

College's

Neighborhood

System is strong Involve system when necessary

In living donation, the system is important Obviously…the donor is part of the system

3 success factors

1. Therapeutic alliance

2. Adherence to ‘a’ therapy

3. Involve system

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What stops us?

Fear for pressure on the potential donor But we put pressure on patients on a routine basis

“If you don’t take the medicine you will become sick”

Not the medical domain The donor is not a patient

It is not ethical… to talk to the potential donor

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Not the medical domain?

Potential donor is not a patient Excludes caregivers

Exclude prevention

Suggests that patients are independent subjects, and not part of a system

The potential donor is in the medical domain

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Not ethical?

In spoken language: good or bad In science: consistent set of rules

Rules that are valid

Rules we agree on…

Is talking with the potential donor and patient ethical? Is there a consistent set of rules?

• Rules that are valid

• Rules we agree on…

That forbid or allow such interference

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Forbid interference

Non-directivity and value neutrality Talking with the potential donor is directive

But there is no such thing as non-directivity and value neutrality in counselling in general

• This rule can not applied validly anywhere

One should not change personal beliefs Assumes that beliefs are stable,… which they are not

• Personal beliefs have formed…

• There is no reason to believe they are completed

Assumes that beliefs are always right… which they are not

Assumes that it possible not to interfere…

No consistent sets of rules..

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Allow interference in beliefs

Stephen Toulmin Beliefs are a model of logical arguments Arguments are not fixed, but dynamic, Interferences can refine the model of arguments

Rawls Beliefs are a model of reflective equilibrium Beliefs represents a network of idea’s and facts Interferences can help to keep communication within the

network open

It is ethical to talk to the donor*

Ethics is a consistent set of rules Rules we would like to endorse

Set of rules that hold back interventions Seems to be inconsistent

Set of roles that allow interventions Consistent

Outcome in terms of process variables

* Hilhorst MT, Kranenburg LW, Busschbach JJ. Should health care professionals encourage living kidney donation? Med Health Care Philos. 2007;10(1):81-90

Existing interventions

Most standard Physician talks with patient

• Information

• Emotion regulation

Patient talks with potential donor

• Patients brings donor to the physician

More active towards donor…. (Rotterdam) Information meetings

For both patients and relatives (perhaps the donor)

“semi targeted” information towards donor

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Norwegian approach

Dr. Anders Hartmann The physician communicates directly with the

potential donor Physician discusses system with patient

Physician asks permission from patient

And calls the donor

No motivation of any refusal is given: “donor is not suitable”

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0

10

20

30

40

50

60

Patients "Donors"

Positive

Mixed

Negative

Norwegian approach will be appreciated

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James Rodrique

Activates communication in family (systems) “Very local” information meeting Especially in minorities RCT results:

Increase in knowledge

Willingness to discuss living donation

Decrease concerns

Outcome in terms of better model of arguments Toulmin, Ralws

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Rodrigue et al. Increasing live donor kidney transplantation: a randomized controlled trial of a home-based educational intervention. Am J Transplant 2007;7:394-401.

Illustration of a theoretical framework

MST: MultiSystemic Therapy Crime prevention in youth

Involving the whole system

Blueprint therapy evidence-based

Practical “Whatever it takes”

But what about Own psychological schemes?

Treatment adherence?

Treatment adherence MST

Conclusions

There are psychosocial barriers In living donation

It is ethical to interfere Outcomes define in process variable

These barriers can be overcome Building a constructive alliance

• Controlling emotions

Treatment adherences

Involve system

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