Dynamic Psychotherapy for Cancer Patients and Their Partners

Norm Straker, MD;

Dynamic Psychotherapy for Cancer Patients and Their Partners

August 1, 2008

Norm Straker, MD

Publication

Article

Psychiatric TimesPsychiatric Times Vol 25 No 9

Volume 25

Issue 9

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 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.

The liaison function of the psychiatrist

The liaison role of the psychiatrist in an oncology setting requires him or her to recognize the common causes of stress in oncology fellows, residents, and oncologists, and how they impact the emotional care of cancer patients.

Many of the stresses on oncologists are the result of not having enough psychiatric experience to instill confidence when dealing with highly charged emotional issues. Too little time on the wards is devoted to learning communication skills from attending physicians. The experience of continuously treating seriously ill patients and confronting death, and the lack of emotional support leads to poor adaptation and bad habits. During more than 30 years of experience in a major cancer hospital, I have found that some of the psychological defenses that physicians develop can be detrimental to patient care. Physicians may try to avoid personal discomfort by denying the patient’s suffering and losses and, thus, remain uninvolved. They become excessively focused on research and clinical trials. Some become dissociated from their experience and lack the ability to empathize. They may avoid communicating a painful prognosis or may blurt it out without providing the patient and family an opportunity for questions, support, or discussion. Personal discomfort on the part of some physicians may also lead to the abandonment of patients and their family members when a clinical trial fails. Finally, and in my view, tragically, most physicians avoid looking to each other for emotional support, and they think of their stress as a sign of weakness. These problems in the physician-patient relationship contribute to the trauma experienced by patients who have cancer and increase the need of many patients and their partners to consult a psychiatrist.

It has been my experience that physicians who have had cancer often feel that the disease has made them better doctors. They have learned the importance of seeing (and treating) a person, rather than just a “patient.” Consequently, they understand the need to show that they care and want to help the patient. I have co-produced a film, “On the Edge of Being: When Doctors Confront Cancer,” that addresses these issues in 6 physicians who have had cancer and who speak about their emotional experiences as patients. The film has been used to teach medical students and residents in palliative care, psychiatry, and oncology.

Psychodynamic therapy

The psychodynamic treatment of patients with cancer may be divided into 2 broad sets of issues, those that address the needs and treatment of a patient with terminal cancer and those that address the needs of his or her caregiver/partner. Dynamic psychotherapy with cancer patients necessitates flexibility and the willingness and ability to advocate for the patient.³

Flexibility requires that the therapist adopt a schedule that fits with the medical status of the patient. In addition, the therapist needs to be comfortable visiting the patient in the hospital or making home visits. For example, a very sick patient may need short, frequent visits and not much talk but some physical contact, such as a hand on the shoulder or a hand on a hand. The therapist needs to understand that there are different challenges in various phases of the illness (eg, a bad prognosis or a recurrence may require a crisis intervention approach in contrast to an almost classic approach for a patient in remission). The therapist should also be available to accompany the patient as needed so that the appropriate procedures can be done in a timely fashion (eg, an agoraphobic patient who needs to undergo MRI).

In addition, with a terminally ill patient the psychiatrist must take on the advocacy role to ensure good quality of life for the patient and to strengthen the patient’s coping and defense mechanisms.⁴ Common psychological defenses of a cancer patient, such as denial and regression, need to be accessed in terms of whether they promote adaptation and optimal coping
or lead to bad decisions and poor adherence.

Requests for psychiatric consultation by oncologists or surgeons to help convince patients to accept radical surgery or aggressive chemotherapy can be problematic, because they might lead to a situation in which the psychiatric consultant has 2 allegiances. It is important for the psychiatrist to help patients arrive at their own decisions when they are ambivalent about radical treatment, which may have many adverse effects or long-term consequences. For example, an ex-marine who felt rushed into extensive pelvic surgery experienced it as rape, even though the surgical outcome was good; he required long-term inpatient psychiatric hospitalization.⁵ After the consequences of choosing either treatment or no treatment are explored, a dynamic formulation may help the patient make a final decision.

Because patients are very vulnerable, transference reactions tend to be intense and often regressed. Therapists can be viewed as omnipotent, which can be especially problematic for inexperienced psychiatrists. Anger and envy may be directed at the healthy therapist who has failed to gratify the patient’s wishes to be rescued or for not being helpful enough. Counter-transference reactions to these situations include feelings of helplessness, inappropriate rescue fantasies or actions, fears of angry outbursts, pessimism, passivity, depression, and survivor guilt. In fact, it is not uncommon to find all of these powerful feelings in psychiatric oncology fellows a few months after they have begun their training.

Therapists need a good support system, supervision, and possibly their own psychotherapy to help them cope with this stressful work. Some knowledge of cancer and the drugs used to treat it is clearly helpful.² A variety of therapeutic techniques can be helpful. The therapist can learn to serve as a “container” for the patient’s anxiety by behaving in a very calm, confident manner, regardless of the circumstance.⁶ Cultivation of positive transference will be of great comfort to the patient, and encouraging the patient to explore whatever he or she wishes provides the patient with some degree of control and creativity in an environment of enforced passivity.⁷Helping the partner of a terminally ill patient

In my experience, it is vitally important to understand how to help the partner who presents with psychiatric symptoms both during the illness and after the loss of a patient. His or her psychic pain is often far greater than that of the patient, who is taken care of by the full medical team. The mental health of the partner is, of course, vital to the whole enterprise of cancer treatment and to the survival of the family. Some general observations based on my experience are:

• Men tend to have much greater difficulty in accepting a bad prognosis and use denial more frequently.
• Men are more likely than women to look for more alternative methods of treatment.
• Men have much less support from friends but have less difficulty in finding a new mate after the loss of their partner.

Complicated grief-a serious complication of loss-is more likely to occur in those who have highly dependent or idealized relationships; those who are not prepared for loss either because of denial or a lack of preparation; and those with poor support systems. Specific interventions are indicated to address these factors. For example, in the case of a terminally ill cancer patient whose partner is in denial, it is important to ask the partner what the issues are that make him or her not see the obvious. This gentle approach allows the denial to be challenged and the partner to be prepared. In the case of the partner with a highly dependent or idealized relationship, longer-term therapy may be needed.

The distinct challenges facing partners of terminally ill patients include loss of hope, overwhelming anxiety, anger, loss of faith, functioning as the sole parent, preparing for the loss, preparing children for the loss, grieving, and beginning a new life. The Table provides some interventions that may be helpful to the surviving partner.

It is important to accept that each person grieves in his own unique manner. Do not expect grieving to unfold in a pattern of stages. Factors that affect grieving include age, the relationship to the deceased, the nature of the relationship, the personality of the bereaved, support systems that the bereaved has access to, and the preparation for loss and the relationship to the dying patient in the terminal phase.

Summary

Each of the phases of the cancer experience presents emotional challenges that can destabilize a patient’s defenses. A dynamically oriented approach with interventions that shore up defenses is recommended. The challenges of treating the dying patient deserve separate attention because they are the most demanding and because they probably cause the greatest anxiety in the therapist. The therapist will be better prepared if he recognizes that this experience will stir up anxiety about one’s death, feelings of helplessness, fear of the patient’s anger, and survivor guilt. However, if done well, this work is very rewarding. Doing it well requires that the therapist focus on:

• Preserving the patient’s identity and dignity.
• Affirming and validating the person’s life.
• Helping the patient transcend pain.
• Helping the patient find some meaning in his experience.

Allow the patient to review his life, affirm his accomplishments, help him feel good about himself, and remind him of the person he still is, ie, preserve his identity in spite of weakness and infirmity. Some patients are inclined to explore unfinished goals, define a legacy, and resolve problematic relationships. When the end is near, the therapist should promote regression and provide a good self-object as the patient drifts into coma.

Following the loss of a loved one, I recommend an approach that facilitates grieving, monitors the health of the bereaved, and finally, helps the survivor return to the world. This may, at the appropriate time, include encouraging a return to work and an attempt at a romantic relationship.

Previous psychotherapy, which focused on resolving conflict with the deceased, can play a constructive role in the grieving process. In my experience, recognizing survivor guilt in both the families and the therapists of dying patients is extremely important. The conscious or unconscious wish for the ordeal and suffering to be over often gets confused with the wish for the death of the spouse and leads to guilty self-recriminations and questions about one’s caregiving behavior.

I recommend updating Freud’s theories of mourning to incorporate more contemporary views.^8,9This includes the development of a new internalized relationship with the deceased rather than a “decathesis” of the lost object. Rather than moving on and giving up the old relationship, an acceptance of the loss and a new internal relationship of memories of the deceased is stressed. Attention is also directed to guiding parents in helping their children grieve. It is now accepted that children are capable of grieving, especially if they are not distracted by adults and are helped to face their omnipotent fears and wishes toward the deceased.¹⁰

Finally, when people ask me whether I find this kind of work depressing, I always reply, “No, in fact I find that this work is very rewarding and uplifting.” Working with seriously ill and vulnerable people is challenging, meaningful, and creative, especially when the pressure of time motivates both patient and therapist to make the best of it.