CHECK POINTS
- Flexibility and the ability to advocate for the patient are essential.
- Each phase of terminal cancer illness presents new psychiatric challenges.
- The psychic pain of a partner is often far greater than that of the terminally ill patient.
- Both family and therapist must recognize survivor guilt.
The estimated number of patients with cancer in this country is 10.5 million. Close to a million and a half are new cases, and it is estimated that 560,000 people die of cancer each year.1 There is clearly a large group of cancer patients and their families at high risk for serious psychiatric illness. In this article, I focus on the advantages of a psychodynamic approach and address how this approach is helpful in the liaison function and psychotherapy of cancer patients and their partners.
Advantages of the Psychodynamic Model
Why use a psychodynamic approach for the treatment of cancer patients and their families? Although comparative controlled studies are lacking, in my experience a psychodynamic model has many practical advantages. It provides a method for understanding how stressful events, such as getting a diagnosis of cancer, can interfere with one’s usual defenses and cause panic. It can also provide a rational basis for therapeutic interventions that reestablish old defenses and bring about homeostasis.2 For example, consider the following vignette.
Case Vignette
Mr A, a 46-year-old chief financial officer of a major corporation, was referred for psychotherapy after complete remission of non-Hodgkin lymphoma. His referring oncologist was extremely puzzled by his behavior. During the diagnostic and treatment phase of the cancer illness he was a model patient. He appeared to accept the diagnosis and arduous treatment that included adverse effects without so much as a whimper or complaint. However, after 6 months of chemotherapy, and on being told that he was cured, he became panicky and frightened for his life. He was unable to work, complained of insomnia, had recurrent dreams about dying, and could not concentrate or be reassured.
Early personal history revealed a boy from a very poor but intact family who began delivering newspapers at age 8. He had learned very early that if he wanted anything that cost money, he had to work for it, and there was no one he could rely on. He supported himself through school and college and was known as hardworking, ambitious, and as a workaholic.
My psychodynamic formulation was that this man, who prided himself on never being sick and on being totally self-reliant, was traumatized by the helplessness and feelings of dependence that occurred when he was told he had cancer. His pseudoindependent, defensive style was challenged, and he temporarily dissociated his feelings so that he felt nothing about his diagnosis and treatment until he was pronounced cured and was discharged by his oncologist. I diagnosed posttraumatic stress disorder and approached him by emphasizing that I recognized that he was a self-made man who prided himself on his self-reliance and on never being sick. I described how a diagnosis of cancer, for which one is generally unprepared, often produces feelings of vulnerability and dependence, no matter how strong the patient. Furthermore, I suggested that to deal with the trauma, he had blocked out all feelings so that he could get through the chemotherapy in his usual stoic fashion without emotionally depending on anyone. When the danger had passed and he no longer saw his charismatic oncologist, whom he had idealized, he began to experience the feelings that most people have when their illness is first diagnosed.
In addition to prescribing an SSRI and a minor tranquillizer, I set in motion a program for stress reduction, including good diet, exercise, decreased alcohol(Drug information on alcohol) intake, and frequent meetings with me to satisfy his need for dependence and reassurance and to ward off fears of a cancer recurrence. Equilibrium was restored quickly, and as he became less symptomatic and more self-reliant, he was able to decrease the number of sessions we had.
A psychodynamic approach also provides a useful model for understanding the highly emotional and complicated relationship between the physician and cancer patient. A brief clinical example is offered.
Case Vignette
Mrs B, a 58-year-old married mother of 3 children with a diagnosis of uterine cancer, was referred for a psychiatric evaluation for nonadherence to her radiation oncology regimen. A detailed history revealed childhood sexual abuse with some vaginal penetration. Residual effects from this trauma were noted in adulthood in her relationships with men and her attitudes toward sexual issues.
Her refusals to “submit to” vaginal examinations, as well as radiation implants in her vagina were understood by her psychiatrist as being related to her abusive early life experiences. At some point in the psychotherapy, she accused her psychiatric therapist of being too intrusive and abusive, especially when asked about her thoughts when she was silent. She became particularly upset when the therapist inquired about her desire to keep him at a distance. She decided to stop therapy.
Her psychological reactions to the radiation oncologist and psychiatrist were best understood using a psychodynamic transference model. Her feelings toward the one who had abused her as a child were transferred to her physicians. Despite the accuracy of the interpretation that offered her the opportunity to accept the treatment, she felt compelled to triumph over the perceived abuser by quitting the therapy. She did, however, continue with the medical treatment.
