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Psychotherapy Casebook

The Healthy Vet

The Healthy Vet

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EDITOR’ S NOTE

Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist and a member of the palliative care team at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Prim Care Companion CNS Disord 2017;19(6):17f02236

https://doi.org/10.4088/PCC.17f02236

Published online: November 23, 2017.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (deans915@comcast.net).

Potential conflicts of interest: None.

Funding/support: None.

Additional information: Patient information has been de-identified to protect anonymity.

As a member of the palliative care team, I get a chance to speak with many veterans. I ask about their place of birth and family of origin. I ask about their education and military service. I ask about their marriages and their children. I ask where they have lived and when they came to Charleston, South Carolina. I always ask about their alcohol and smoking habits. I want to know how they sleep, their appetite for food, their weight, their energy level and fatigue, their memory, and their mood. I want to know whether they consider themselves an anxious (nervous) person. The answers to these questions define a diagnosis of depression. This process takes about 10 minutes and helps to establish a general working relationship with the patient.

Then, I ask about their health and direct the inquiry to earlier in their life. Virtually all the veterans I speak with tell me that their general health was "always good." Some have never even consulted a physician. Finally, I ask about their presenting complaint.

When I ask about their chief complaint, I want a detailed history of what they noticed, what they did about it, and the result. It strikes me that most of the military veterans I interview state that they "have always been in good health." What happens then when cancer or heart disease or chronic obstructive pulmonary disease enters one’s life?

Clearly, illness affects one’s thoughts. When I tell people that I have (and others in their lives have) similar thoughts, they often look at me perplexed. It is how one deals with these thoughts that matters, not the thoughts that come to mind. If the choice is made to focus on these thoughts, it is very likely that anxiety will result—for them, for me, for anyone. Recently, while working with Mr A, I faced this issue again: a medical situation prompting an emotional response and posing a problem.

PSYCHOTHERAPY

Mr A, a 50-year-old white man, has been married to his third wife for 20 years and has 3 adult sons. His parents are deceased, and he is the eldest of 3 children. He is a high school graduate and served in the Air Force for many years. After his service, he moved to Charleston and married his current wife. He has worked in a variety of capacities and for a variety of employers. His health has always been good. He has had regular yearly physical examinations.

Recently, he noticed the onset of abdominal pain. When he was examined, a mass was found in his abdomen. A biopsy was inconclusive and was repeated. Finally, a diagnosis of cancer was made. He had an abdominal sarcoma.

When he inquired about a treatment plan, the following procedure was presented to him: a biopsy followed by a CT scan followed by chemotherapy. I urged him to speak up, ask questions, and represent himself well. He replied that he’ d always done things the right way. He never drank, never smoked, and was always active.

He told me about the thoughts he has had, and I cautioned him not to think about the future. I told him that the best predictor of his outcome would be the way he had lived his life until now. He would very likely live another 30 or 40 years. His task was to divert his attention whenever thoughts about his disease came to mind. He was in charge of his life, I told him, not cancer. If he felt anxiety, he was its producer—an anxiety-producing machine.

He had a good job. He was counted on at work. He had a wonderful family and marriage. His doctors had a plan for him. If he had questions about the plan, he needed to ask them. We made another appointment for a month later so I could follow his progress. For me, he represented another veteran who had been in good health and was now facing a disease that could dominate his existence. I wanted him to hear from me that it didn’ t have to be that way.

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