Settling Psychosocial Barriers
in Living Donation
 Jan
Busschbach
 Psychologist
 J.vanbusschbach@erasmusmc.nl
 In
cooperation with
 Willij Zuidema
 Jan IJzermans
 Willem Weimar
 Jan Passchier
 Leonieke Kranenburg
 Medard Hilhorst
1
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
2
Barriers
 What
are the barriers?
 Sometimes hard medical issues…
 But most often soft issues
 Legal
 Cultural
 Organizational
 Psychological
3
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
4
What can we do?
 How
can we change…
 Wrong information
 Wrong risk perception
 Blocked communication
 Talking
with the potential donor and patient
Rational
Information
Interpretation
Emotion
 More
and better information…
 Gives more appropriate emotions
6
Not so rational,.. but reality
Emotion
Interpretation
Information
 Better
(more appropriate) emotion
 Better interpretation of information
7
Most likely model…
Interpretation
Emotion
Information
Interpretation
 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…
8
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.
2.
3.
Therapeutic alliance
Adherence to ‘a’ therapy
Involve system
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
15
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
16
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
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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
 Set
of roles that allow interventions
 Seems to be inconsistent
 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
21
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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Norwegian approach will be
appreciated
60
50
40
Positive
Mixed
Negative
30
20
10
0
Patients
"Donors"
23
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
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.
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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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