Ute Goerling (ed.)Recent Results in Cancer ResearchPsycho-Oncology201410.1007/978-3-642-40187-9_9
© Springer-Verlag Berlin Heidelberg 2014
Psycho-Oncological Interventions and Psychotherapy in the Oncology Setting
(1)
Institut Universitaire de Psychothérapie, Département de Psychiatrie, Centre hospitalier universitaire vaudois, Avenue de Morges 10, 1004 Lausanne, Switzerland
(2)
Service de Psychiatrie de Liaision, Département de Psychiatrie, Centre hospitalier universitaire vaudois, Rue du Bugnon 21, 1011 Lausanne, Switzerland
Abstract
A person who faces the diagnosis of cancer is subjected to changes within his body, but also with regard to his view of himself and his social relationships. Cancer-related psychological distress occurs frequently and has been reported to have different prevalence according to cancer type and stage of disease. Psychological disorders are known to be underdiagnosed and thus undertreated in the oncology setting, since clinicians might miss the symptoms of psychological distress, misinterpret them, or lack the time and resources to respond adequately. The main psychiatric disturbances observed in patients with cancer are adjustment disorders and affective disorders (anxiety and depression), which in the majority of patients are due to stressors related to the disease and pre-existing psychological vulnerabilities; however, they might also be a direct consequence of biological causes either resulting from treatment side effects or from modifications induced by the cancer. This chapter aims to provide theoretical and practical information concerning psycho-oncological approaches, complemented by some reflexions on their clinical and scientific evidence, focussing essentially on verbal psychological interventions and especially on psychotherapy in patients with cancer.
1 Introduction
A person who faces the diagnosis of cancer is subjected to changes within his body, but also with regard to his view of himself and his social relationships. Since each individual reacts differently when facing such a life-threatening event, the psychological responses should not be considered as «adequate» or «inadequate» but rather as whether the response is adaptive or an expression of psychological disturbances. Cancer-related psychological distress occurs frequently: for example, prevalence of major depression is estimated to occur in 10–25 %, of depressive symptoms in 21–58 % (Massie 2004; Mitchell et al. 2011; Pirl 2004), and of pathological demoralization in 14 % (Kissane et al. 2004a, b) of patients with cancer. Furthermore, anxiety disorders were reported in 15–28 % of cancer patients (Kerrihard et al. 1999), and a recent meta-analysis showed that 38.2 % of them suffered from any type of emotional disorders (Mitchel et al. 2011), a finding which is confirmed by a large prevalence study which identified 35.1 % to suffer from distress at a clinical level (Zabora et al. 2001). Psychological distress has been reported to have different prevalence according to cancer site: it was found to be highest in pancreatic (56.7 %), lung (43.4 %), and brain cancer (42.7 %), and lower in gynecological (29.6 %), prostate (30.5 %), and colon cancer (31.6 %) (Zabora et al. 2001). Also patients with advanced stages may be more vulnerable to psychological distress, especially when taking into account acute confusional states (Massie 2004; Razavi and Stiefel 1994); however, some research, for example in breast cancer, suggests that stage of cancer does not influence prevalence of psychological distress (Kissane et al. 2004a, b).
Psychological disorders are known to be underdiagnosed and thus undertreated in the oncology setting (Razavi and Stiefel 1994), since clinicians might miss the symptoms of psychological distress, misinterpret them or lack the time and resources to respond adequately.
This chapter aims to provide theoretical and practical information concerning psycho-oncological approaches, complemented by some reflections on their clinical and scientific evidence, focusing essentially on verbal psychological interventions, and especially on psychotherapy in patients with cancer.
2 Psychological Challenges for Patients Facing Cancer and Its Treatment
The main psychiatric disturbances observed in patients with cancer are adjustment disorders and affective disorders (anxiety and depression), which in the majority of patients are due to stressors related to the disease and pre-existing psychological vulnerabilities; however, they might also be a direct consequence of biological causes either resulting from treatment side effects or from modifications induced by the cancer (e.g., treatment with interferon or radiation therapy, brain metastases, hypercalcemia, paraneoplastic syndroms, hypothyreosis) (Razavi and Stiefel 1994).
Therefore, treatment of psychological distress calls for a careful evaluation in order to determine the most appropriate intervention, which might be to focus on biological, psychological, psychopharmacological or combined causal factors. In the following, we will only focus on distress for which psychological interventions are appropriate and beneficial.
From the moment of the diagnosis, the patient is confronted with a new situation that he will need to understand, shape, and accept and which will modify his perception of himself, his interpersonal relationships, and his sense of belonging to a group: he might reflect on his past and will definitely have to adjust to the present and adapt his plans for the future. Pre-existing self-image, quality of interpersonal relationships, and sense of belonging are therefore factors that can either contribute to the protection of the individual against stress and emotional difficulties or they might be a source of increased vulnerability.
Adjustment to cancer is associated with six distinct hurdles, as defined by Faulkner and Maguire (1994): (1) managing uncertainty about the future, (2) searching for meaning, (3) dealing with loss of control, (4) having a need for openness, (5) emotional, and (6) medical support. Failing to deal with these hurdles might lead to psychosocial difficulties. Psychological interventions are often initiated in order to help the patient with these issues so as to help him to cope and adjust to the disease, and have been demonstrated to have a positive effect on distress, anxiety, and depression (Devine and Westlake 1995; Meyer and Mark 1995; Sheard and Maguire 1999).
While the spectrum of psycho-oncological interventions is large, from psychopharmacological treatments, relaxation and music-therapy to psychotherapy, we will concentrate on the verbal psychological interventions and focus on psychotherapy for patients with cancer.
3 Psychological Interventions
3.1 Psychoeducation
Psychoeducation refers to the education offered by a professional to a patient about a mental or physical condition that causes psychological stress. By learning about his condition the patient is thought to feel more in control, which might help to reduce psychological distress.
3.2 Psychological Support
Psychological support knows many definitions and covers approaches from individual psychological support interventions (Hellbom et al. 1998), single techniques derived from psychotherapies, such as relaxation or structured problem-solving, to community or peer support services, and range from one to several sessions. The aims of supportive interventions might be to contribute to alleviate worries of the patient, to increase his perception of mastering the situation, to help him to regulate stress, or to facilitate his participation in the treatment. Psychological support might be presented by health personal or other persons, since its use is generally not regulated or controlled by training institutes or licensing bodies.
3.3 Psychotherapy
Psychotherapy has been defined by Frank (1988) as the relief of distress or disability in one person by another, using an approach based on a particular theory or paradigm, with the requirement that the agent performing the therapy has had training. Franck and Frank (1991) identified four broad dimensions shared by all therapeutic approaches: (i) a relationship in which the patient considers that the therapist is competent and cares about his state; (ii) a setting which is defined as a place of healing; (iii) a rationale which explains the patient’s suffering and how it can be overcome; (iv) a set of procedures requiring active participation of the patient and the therapist and of which both believe to be means of restoring the patient’s health.
These general dimensions allow the inclusion of all psychotherapeutic interventions, but they lack the specificity to identify an included approach as a psychotherapeutic intervention. Wampold (2001) and Lambert and Ogles (2004) also underline the necessity that psychotherapy is a professional activity or service that implies a certain level of skills, which have to be formally recognized by training institutes and licensing bodies, and anchored in a psychological theory; in addition psychotherapeutic treatment should be supported by scientific evidence and provided by mental health specialists, who undergo training and who benefit from regular supervision and continuous postgraduate education. In many countries, psychotherapeutic treatments can therefore only be provided by certified psychiatrists and psychologists.
In the following, we will present and discuss the three most widely used psychotherapeutic approaches: psychodynamic, systemic, and cognitive behavioral psychotherapy. These approaches have a long history of theoretical and conceptual development and are widely utilized in psychiatric and somatic settings, including oncology. Some of them have gained an important body of evidence confirming their effectiveness and all provide specialized and certified training programs and allow a large clinical application. Finally, the important movement of psychotherapy integration will also be discussed.
3.3.1 Psychodynamic Psychotherapy
Psychodynamic psychotherapies are derived from Freud’s work, object relation theory elaborated by Klein and Winnicott and self-psychology based on Sullivan’s interpersonal psychotherapy (Lewin 2005). Psychodynamic techniques are intended to develop self-understanding and insight into recurrent problems. In the therapeutic process, symptoms and interpersonal difficulties are identified, analyzed, and interpreted based on the assumption that the subsequent insight and the experiences in the therapeutic relationship can be transferred to «the world outside the therapeutic setting» (Kaplan and Sadock 1998).
Psychodynamic psychotherapies rely on key theoretical concepts, such as (i) the existence of an unconscious, which influences our thoughts, emotions, and behaviors; (ii) the impact of early development on later stages of life; (iii) the organization of the psyche by the ego, which has the capacity to reason and to anticipate, the id, which is a source of sexual and aggressive drives, and the superego, which contains theses drives by a «guilty conscience»; (iv) the protection of the individuals’ equilibrium by (unconscious) defense mechanisms, such as rationalization, projection, or denial, which are triggered by threatening emotions or thoughts; and (v) the observation, that unresolved issues of the patient are re-enacted in the therapeutic setting, where they can be identified, discussed, interpreted, and modified.
The different types of psychodynamic psychotherapy reach from insight-oriented psychotherapy, which uncovers repressed, unconscious thoughts and feelings, and aims to enhance patient’s autonomy, to supportive psychotherapy, which aims to suppress anxiety-provoking material and to foster ego functions and adaptive defenses (Lewin 2005). Supportive psychotherapy is more often indicated for patients in a palliative phase of their illness, as for most of these patients, the objective is to enhance adaptation, to diminish dysfunctional coping, to decrease psychological distress, and to restore psychological well-being (Guex et al. 2000; Rodin and Gillies 2000; Stiefel et al. 1998). Insight-oriented therapy is suitable for less vulnerable patients with intact ego functions, who are motivated to explore their thoughts and feelings in order to enhance reflection, and have the capacity to analyze adverse events (Rodin and Gillies 2000). A special form of psychodynamic psychotherapy is the Psychodynamic Life Narrative (PLN), which can be understood as a way to conceptualize maladaptive responses to physical illness. PLN aims to help the patient to understand their current psychological reactions to illness by linking it to important elements of their life trajectory (Viederman 1983; Viederman and Perry 1980). This type of therapy provides the patient with an opportunity to enhance a sense of control and coherence when facing illness (Viederman 2000).
With regard to the content of therapeutic interventions, the occurrence of cancer is not conceived as being the sole focus of the encounter with the patient, but other questions, such as how the specific reaction of the patient toward disease can be understood or why his relationships have been modified by the disease, are addressed (Krenz et al. 2013, submitted). A given psychological symptom is not just a target to suppress, since psychodynamic therapies aim to understand its underlying meaning: for example, it would be important for a psychodynamic-oriented therapist to understand whether the depressed mood of a women with breast cancer is due to the fact that she feels pressured by an increasing difficulty to fulfill her duties (loss of pre-existing capacities), to a modification of her self-image (loss of her breast), or to an alteration of her relationship with her husband (loss of commitment to the relationship). Depending on the source of the depressive symptoms, the therapeutic approach would be different, focusing on diminishing superego pressure, (pre-existing) difficulties with self-esteem or construction, and meaning of relationships.
While there are only few clinical trials evaluating the effectiveness of psychodynamic therapies in the physically ill (Ando et al. 2007, Ludwig et al. 2013, submitted), several single cases studies have been published over the past few years (Lacy and Higgings 2005; Redding 2005; Tepper et al. 2006).
3.3.2 Systemic Psychotherapy
Systemic psychotherapy is based on general systems theory, which conceives a system, such as the family, as organized and tries to understand the functions of its different elements, and their interrelations. Therefore, systemic psychotherapy views social coexistence of people as a complex and integrated whole, which is greater than the sum of its parts (Minuchin 1988; Sameroff 1983). Family therapists utilize special techniques and focus on variables, such as cohesion and hierarchy of the family, as well as attributed roles and implicit and explicit rules (Bressoud et al. 2007). Family members are considered to be helpful resources to by the patient, who can assist him in decision making and provide emotional and practical support (Xiaolian et al. 2002), but who may at times also be the source of conflict and suffering (Lyons et al. 1995).
In a report on the evidence of systemic family therapy, Stratton (2005) indicates that systemic therapy started with a common basis, but has over the past 50 years grown in various directions, with the most significant specific interventions belonging to the work of Bateson and the Palo Alto team (Jackson 1968a, b), the family structural therapy by Minuchin (1974), the strategic family therapy developed by Haley (1976) and Madanes (1981), and the approaches of Selvini Palazzoli and the Milan team (1978, 1991).
Being a systemic therapist does not imply that clinical care is restricted to social systems; systemic therapists also treat individual patients, but they are probably more sensitive to achieve an integrated systemic perspective in the analysis of the patient’s problem and address more systematically intergenerational and intrafamilial problems and resources. Family response to illness is an important feature of systemic therapy with the physically ill: for example family myths—beliefs about a family member, such as «he has always been quickly irritated and prone to give up»—and family paradigms, such as «we function best by denying disagreements and avoiding difficulties», play an important role in systemic therapies.
Examples of scientifically evaluated systemic therapies in the medical and oncology setting are the Medical Family Therapy (Doherty et al. 1994) and the Family-Focused-Grief Therapy (FFGT), a preventive intervention for high-risk families (Kissane et al. 2006). FFGT is based on the assumption that the family is the primary provider of care for the terminally ill patient and that the type of functioning of the family is essential for the patient (Kissane et al. 1996a, b). Its aim is to optimize family functioning and to facilitate common grief. FFGT is a time-limited intervention (four to eight sessions of 90 min each), over a 9–18 month period, based on a manual with specific guidelines and clinical illustrations; its efficacy has been demonstrated in a randomized controlled trial (Kissane et al. 2006).
An other systemic approach, which has been examined in mostly qualitative research, is narrative therapy developed by Michael White and David Epston (White and Epston 1990). Narrative therapy is based on the concept that our identity is shaped by narratives and stories that we tell ourselves and others. Reality is thus a co-construction between different individuals, and the relational consensus produces the judgment that a perception is acceptable or not. Thus, not only the mind creates impressions based on observations, but confirmations of these impressions are sought with members of the society, the family or other systems, leading to interpersonal exchange which finally colors the way we perceive life. Therefore, the way a patient perceives his cancer, and the way he talks about it to his family or to medical professionals, will influence the perception and meaning he attributes to the disease and thus the psychological impact the situation will have. Narrative therapy implies that the patient is motivated to explicitly verbalize his thoughts and feelings with regard to the current situation, to communicate how he relates them to his life history and to evaluate the meaning he attributes to his disease in light of his trajectory.
In addition, systemic psychotherapy plays an important role in the treatment of childhood cancer, childhood cancer survivors, and their families. For example, Kazak (1989) found that multifamily group intervention reduced the posttraumatic stress symptoms and anxiety in childhood cancer survivors and their families. Furthermore Martire et al. (2004) demonstrated that systemic interventions for people with chronic illness (including cancer) were more effective than standard care.
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