Naturally, doctors who had not previously worked with psychologists did not understand us at first. In this huge hospital, there had been a single psychologist for the entire institution for years, and suddenly we were there in such numbers. They used to say: ‘Why do we need so many psychologists?’ That changed when they began to see real results and to see how even their own lives were changing. 

Often, even the patient does not want to see you. To them, a psychologist is a ‘weak link’ — after all, you cannot refuse a doctor or a nurse, but you can refuse a psychologist. That is completely normal and human. People do not come to a hospital to work with psychologists; they come for medical treatment. We are secondary assistants, often invisible and unnoticed, and it is important to recognise this in advance.

If few people in society as a whole seek psychological help, then in a palliative care department, where our work is genuinely needed, we certainly cannot rely on a patient's direct request. We must come forward ourselves — explaining and demonstrating why it matters.

Another significant part of my life is teaching. In 2016, my colleagues from Yerevan State University and I, with support from the Open Society Foundations, developed a course in palliative psychology. We were assisted by Stephen Connor and Kathleen Foley. Later, I developed a psychology course for somatic departments. I believe it is essential to pass on to psychology students the experience of working not only with mental illnesses but also with somatic patients. 

Ksenia: Were you acquainted with Yeva before then, or did you simply follow her on social media?

Sofya: I simply followed her, although she once examined us at university. I am not sure whether she remembers it; most likely not.

Yeva A.: I tend to block out such terrifying moments from my memory (laughs).

Sofya: Quite understandably (laughs). I received either 19 or 20 points back then and was absolutely delighted. Anyway, when I finally arrived for the volunteer interview, I fell in love with the centre straight away. It was fairly easy for me to adapt. Of course, the structure and specifics here are entirely different, but the core theme — supporting people with oncological conditions — aligned with my past experience.

A few months later, Yeva called me to offer me a job.

After earning a bachelor's degree, I enrolled in a master's programme at Yerevan State University, specialising in clinical psychology and psychotherapy. Above all, I wanted to pursue clinical psychology. I graduated with my master's degree in 2020, at the height of COVID-19, and began working at the intersection of clinical and educational psychology. My role involved assessing children's needs, adapting school curricula, and providing psychological counselling to children with special needs and their families.

Yet my love for clinical psychology never went away. I also wanted to return to working with adults. Currently, I work with adults with oncological conditions. I do not think I could work with children with cancer; that would be too difficult for me. I feel my boundaries very clearly here.

I learned about palliative care from Yeva Asribabayan, who lectured on the subject during our master's programme. A few years after graduating, I wrote to Yeva to say I wanted to volunteer in the palliative care service, and Yeva took me on.

At present, I do not work in the palliative department like Sofya and Yeva Ghukasyan. I primarily work with patients undergoing chemotherapy. However, when my patients finish chemotherapy and are transferred to the palliative department — or, conversely, are transferred from the palliative department to the oncology department — I always follow their care. Teamwork is extremely important to us; we always decide together which specialist will work with a specific patient.
   

My grandfather died of cancer, and my cousin was diagnosed with cancer at a very young age and successfully underwent treatment. These events, along with the experiences of my loved ones and their families, had a profound effect on me and perhaps reinforced my desire to work specifically in this field.

Ksenia: Thank you so much, Yeva. Now I would like to address Yeva Asribabayan. What a fantastic team you have! Could you please tell us how you managed to bring them together?

Yeva A.: In fact, Sofya and Yeva are the second generation of psychologists in our palliative service. We initially worked with a different team. However, after some time, those specialists left one by one: some moved into private practice, others emigrated. When Merine joined the oncology department, we decided to unite and create a single psychosocial service for the hospital.

For this second attempt, the management and I decided to take a new approach.
 

I started out very young, so I chose to trust others as my senior colleagues once trusted me. And it was worth it. When Sofya, Yeva, and Merine arrived, they did not disrupt the system — they improved it. A system is vital: one cannot work on a whim or according to one's mood. When a system is resilient, staff turnover does not destroy it. For me, that is the clearest sign that our plan has succeeded. And now I know that everything will function as it should, even if I leave.

Another indicator is the team's initiative and drive. It is difficult to keep people consistently motivated. From the outside, it seems wonderful: applying for a scholarship or attending an international conference! In reality, it requires tremendous energy, and not everyone is prepared to invest that much. Yet without it, progress is impossible. I believe the second key to our success is the team's genuine interest. New ideas are constantly emerging: going somewhere, accomplishing something, such as designing a research study or a training session for the medical staff. It is also important to build connections, including international ones.

Felix: How is your work structured? Could you tell us a bit more about the system you mentioned earlier?

Yeva A.: By the word ‘system’, I encompass two concepts: conceptual and organisational. Let us start with the organisational one. Because our palliative service employs two psychologists and a visiting psychiatrist who comes twice a week, and the department is designed for 28 beds, we have the capacity to attend to all patients. This means that every day during ward rounds — whether medical rounds or our own separate ones — we can see each patient and their loved ones, talk with them, assess their condition, and identify who needs help first and foremost.

Naturally, everything is documented. The psychologists maintain their own caseloads, assign new patients, and provide ongoing support. There is also a division of roles: if, for instance, one psychologist works with the patient, the other works with the family. If family meetings are planned, they conduct them together.

We have a set protocol in place for when a patient dies. The medical staff are required to call the psychologists, who come to assist the family and help stabilise their emotional state.
Furthermore, in complex cases where we identify risks of prolonged grief (for example, if loved ones are left entirely alone after a loss), we continue to provide support. We offer families the opportunity to visit us for up to a year to receive free psychological support whenever they need it.

Another crucial element of the system is our work with medical personnel. Unfortunately, our medical education system still does not offer courses on communication among doctors, nurses, and patients. We all emerged from the same Soviet school, which was entirely non-patient-centred.

Therefore, an important part of our work involves discussing clinical cases with doctors and nurses. To a psychologist working outside the medical field, this might seem unusual, but within a hospital it amounts to advocating for the patient's needs and rights. On rare occasions, this can lead to minor friction, but the benefit to patient well-being always outweighs it.

We also aim to provide regular psychological support for staff. Psychologists routinely hold support groups, bereavement rounds, and art-therapy sessions. However, we encounter a classic scenario: people want it yet feel hesitant. Medical staff often find it difficult to attend, open up, and relax; later, Sofya and Yeva will explain in greater detail the challenges they face in this regard.

The second important aspect of the system is conceptual, namely research. We have virtually no local, native research studies, yet palliative care has its own cultural nuances that are essential to consider. Academic work serves as our bridge to the international professional community. One cannot live in isolation within one's hospital, detached from the wider world.

Without a continuous link to the academic and scientific community, the risk of such ‘vitrification’ is very high.

As for the rest of the hospital, that is where Merine works. Regrettably, we cannot clone her, so she cannot conduct daily rounds across the entire hospital, which spans 18 departments. We have structured the process so that she takes on new admissions, while other patients are referred to her by doctors upon request. However, because we operate as one team, we always assist one another with various cases. Everyone knows what is happening with their patient at every stage. If a patient is transferred from palliative care to the general ward, Yeva or Sofya can go there, visit them, and offer support. All our bridges are in place.
   

Felix: Yeva Ghukasyan, Sofya, could you tell us a bit more about the protocols: how do you divide the work with patients in the palliative department and their loved ones?

Sofya: We conduct daily ward rounds with the doctors. If we have other tasks scheduled for that time, we conduct a separate round later. The main priority is to visit the patients every day. During these visits, we assess their primary needs.

Yeva G.: Right at the start of our work, we created a reference guide: what exactly needs to be learned during the initial meeting, what we ought to know about the patient, and what we, for our part, should convey to the patient and their family, including how to explain our service.

Sofya: The priority is to understand the patient’s primary needs. Of course, we frequently encounter depression and anxiety. After the rounds, we distribute the workload. We take on new patients in turn: either Yeva Ghukasyan or I. After that, we always work with the family. If we see the need for more in-depth psychological work, we separate the cases — referring relatives to each other so that different specialists work with the patient and their family.

Ksenia: How do the Armenian context, culture, traditions, and attitudes towards death and grief influence your work?

Yeva A.: In Armenia, there remains a tendency to conceal the diagnosis from patients. For me, however, the question of whether to inform them does not even arise — it is purely a question of how to do it correctly.

Incidentally, Armenian legislation has supported the patient's right to information since 1994 — the law prohibits disclosing a diagnosis to relatives without the patient's consent. But because the law specifies no sanctions for violations, in practice the opposite occurs.

In the meantime, we frequently encounter situations in which relatives prohibit us from disclosing the diagnosis or prognosis to the patient.

Ksenia: Have there been instances when you managed to persuade the family, and they agreed to tell the person the truth?

Sofya: Yes, of course, such cases arise, and thankfully, they are not rare. But behind this always lies an immense amount of work with the family. It is essential for us to explain to them how the process of adapting to a diagnosis works, so they understand that we will not simply dump all the information on them, but will gently guide them towards an understanding of the situation.

We recently had a successful case of this kind. The patient was eager to understand his condition and asked questions constantly. It took us about a month and a half of working with the relatives, and fortunately, time and the patient's condition allowed us to wait until the family consented. Ultimately, the attending doctor communicated the diagnosis.

I would like to express my special thanks to our medical staff for their monumental support. We have worked alongside them for years and have been a pillar of strength for one another.

Merine: We want to organise an educational programme for medical professionals on how to break bad news properly — placing the emphasis on the communication process itself rather than on concealing this information.

Yeva A.: The year before last, the Ministry of Health asked us to develop a protocol for breaking bad news. Drawing on international experience, we chose SPIKES as our foundation. The catalyst was Armenia's transition to a digital healthcare system. This led people to log in to their personal online portals and see diagnoses, for example, osteosarcoma. Naturally, families began asking questions: why should a person learn about a life-threatening illness in this manner, via a screen? This prompted the Ministry of Health to reach out to us. Some steps are already underway; some specialists are attempting to apply the SPIKES protocol, but it is not yet a systemic solution. 

Yeva A.: What supports me most right now is transcendence — the very process of passing on experience. Knowing that the process has been set in motion and will certainly endure and evolve brings me joy and gives me the greatest strength.

As for personal self-care... To be honest, I am a bit of a ‘failure’ at looking after myself. I am still learning. I dream of eventually reaching at least a standard five-day working week, but I am still very far from that.

Ksenia: What aspects of the psychosocial service do you plan to develop over the next three to five years? What would you like to improve?

Yeva A.: The first thing that comes to mind is translating and adapting leading international methodologies. For a long time, we have had an idea we have not yet pursued because of its scale: we want to translate assessment tools and protocols (such as the Mini-Mental State Examination and other screening tools) into Armenian. This represents a major academic undertaking. Clearly, the beneficiaries of this process will be not only our clinic's patients but also the entire palliative care system of the country.

As I mentioned earlier, palliative care in Armenia has often developed from the top down. But I genuinely hope that our practice will now also generate meaning that ascends ‘to the top’ as standards. From my perspective, the future lies in more systemic education, academic development, and translating the methodological framework.

Merine: I completely agree. I see our service developing over the next five years through continuous learning and refinement. We need to recruit more volunteers. In addition, there is significant organisational work to be done within the oncology centre: we want to streamline routing so that the transition and referral of a patient from the attending doctor to the psychologist and social worker happen ‘seamlessly’. And, of course, we need to keep learning how to take care of ourselves to maintain our motivation.