Psychological Issues

Psychosocial

The appropriate treatment for psychological symptoms associated with cancer can be determined by clarifying the nature of emotional distress (anxiety, depression, psychosis), the use of pharmacotherapy to relieve acute and chronic symptoms, and the selection of appropriate psychosocial interventions for treating problems related to anxiety, depression, existential concerns, somatic symptoms, and social or communication problems.^32–34 The efficacy of psychosocial treatments for depression and anxiety in medically ill patients, particularly brief psychodynamic, educational, supportive, and interpersonal therapies, hypnosis, and behavioral and cognitive-behavioral methods, has been supported by numerous outcome studies.^35–39

Psychoeducational Interventions

Principles of Psychoeducational Intervention

Medical knowledge enhances the sense of control and mastery a person has over his or her disease, and educational interventions generally yield positive outcomes. Interventions for medical patients are usually more effective when they provide patients with cues for using the knowledge related to their disease and daily management²⁹ or with some emotion-focused components, which helps them to adjust and live through the different phases of the illness. Anticipatory guidance is an important component of these interventions, helping patients to prepare to respond to future as well as current disease-related problems. The evaluation of outcomes of psychoeducational interventions indicates consistent if modest improvement.^38,40–46

Coping Skills Training

Education-based group interventions that provide informational support can facilitate the initial adjustment of early stage breast cancer patients by improving self-esteem, body image, and perceived control and by reducing uncertainty about the illness.^47,48 Women who lack personal resources and support benefit the most. Many of these approaches have demonstrated benefit in controlled trials. One cognitive-behavioral stress management group program proposed a multimodal type of intervention combining 20 therapy hours of relaxation training, coping skills training, cognitive restructuring, assertiveness and anger management training, and social support for women with breast cancer. Patients improved in self-reports of benefits from cancer, but no improvement on the distress measures was found.⁴⁹ In this study, the greatest changes in positive benefits were reported by women who were low in optimism. An eight-session educational intervention, providing training in stress management, problem solving, goal setting, and assertiveness, produced improvements in general quality of life, as well as specific competence in managing emotional, financial, and legal problems.⁵⁰ A five-session family intervention for women with recurrent breast cancer, designed to improve communication, enhance information seeking, improve coping, and manage symptoms, did not affect overall quality of life but did reduce negative appraisal of the cancer and reduced hopelessness.⁵¹ A multidimensional cancer rehabilitation program produced improvements in physical functioning and reductions in distress.⁵² A more existentially oriented approach emphasized finding ways to develop a sense of meaning and has been shown to enhance self-efficacy, optimism, and self-esteem among breast and colorectal cancer patients.⁵³ It is quite clear that facing the existential threat posed by cancer in a supportive way improves coping and reduces distress rather than demoralizing cancer patients.^34,54–56

Mindfulness Training

Mindfulness-based stress reduction is an adaptation of Zen Buddhist meditation techniques taught in weekly courses. The focus is on enhancing the ability to live in the moment and to tolerate stresses as real but transient phenomena, while more comfortably relating to one’s body, and often employing gentle yoga exercises as well.⁵⁷ Such techniques have been used to good effect with cancer patients. A meta-analysis of 10 studies documented a significant (moderate effect size; d = 0.48) overall improvement in quality of life and possible benefit for various aspects of physical health.⁵⁸ A 7-week group training for patients with a variety of cancers resulted in significantly reduced distress.⁵⁹ Other studies have shown that a combination of such techniques with more traditional group therapy produced reductions in intrusive thinking and other post-traumatic stress symptoms⁶⁰ as well as reduced depression and fear of recurrence and produced higher energy levels⁶¹ among women with breast cancer. A recent study of mindfulness for primary breast cancer patients demonstrated greater reductions in stress symptoms than in an intervention involving emotional expression or a control group, and that both treatment conditions resulted in normalization of diurnal cortisol levels.⁶² Similar mindfulness interventions have also been shown to result in lower mean cortisol, reduced Th1 (proinflammatory) cytokines, and lower systolic blood pressure,⁶² as well as improved natural killer cell cytotoxicity.⁶³

Electronic Technology-Based Interventions

Technology-assisted interventions have proven highly effective. A peer-modeling videotape shown to patients shortly after diagnosis produced increases in vitality and post-traumatic growth and decreases in depression and intrusive thoughts.⁶⁴ A combined home visiting and telephone intervention resulted in reduced pain.⁶⁵ Computer-based patient support tools provided information, decision support, and interaction with other patients and produced not only increments in knowledge, but also better patient–doctor interactions and enhanced social support.⁶⁶ Support groups have been adapted to the Internet with remarkably good effect. Online-mediated social support for cancer-related fatigue have proven very beneficial as well.⁶⁷ Real-time leader-conducted groups for breast cancer patients have produced significant reductions in depression and pain.⁶⁸

Excellent Internet resources for information about various types of cancer and their treatments, as well as supportive services, are now available. These include the National Cancer Institute’s Web site, its database of cancer treatments, and its associated phone information line. Web sites with authoritative information about supportive care services include those sponsored by the American Cancer Society. The Wellness Community Web site is maintained by the Cancer Support Community, a collaboration of the Wellness Community and Gilda’s Clubs, which maintain a network of facilities that provide free community supportive services, including classes and support groups. Another excellent example is the Breast Cancer Connections Web site.

Cognitive-Behavioral Therapy

The cognitive-behavioral approach⁶⁹ is built on the assumption that previous social learning, developmental history, and significant experiences lead people to form a unique set of meanings and assumptions, or cognitive schemas, about themselves, the world, and their future. These schemas are then used to organize perception and to govern and evaluate behavior.⁷⁰ When specific schemas are activated, they directly influence the content of a person’s perceptions, interpretations, associations, and memories from a given time. Cognitive-behavioral therapy (CBT) was developed as a short-term (12 to 20 sessions) intervention for depression, targeting patients’ thoughts and their relation to behavior and their affect. CBT for cancer patients generally features a multicomponent intervention integrating coping skills training, stress management, and an intervention designed to enhance cognitive and behavioral processes that will be useful in adjusting to illness.³⁶ The CBT therapist seeks to identify maladaptive cognitions, turn them into testable hypotheses, and submit them to empirical investigation, so the patient can then reject, modify, or retain these thoughts based on the evidence. Alternatively, more adaptive cognitions and behaviors are similarly examined and tested. In the early sessions, the goal of CBT is to establish a therapeutic relationship, identify primary problems, produce symptom relief, and educate the patient about the process of psychotherapy, CBT, and the role of thoughts, images, and beliefs on emotions and behavior. Together, the therapist and patient decide on the treatment goal, a plan for subsequent therapy sessions, and homework assignments intended to augment the therapy and direct structured practice. The initial homework might require the patient to identify and record maladaptive cognitions (e.g., automatic thoughts). As therapy progresses, verbal techniques are employed to trigger automatic thoughts and associated assumptions and reveal core beliefs or schemas. In an environment of collaborative empiricism, the patient learns to identify, logically and empirically evaluate, and justify the usefulness of systematic biases, cognitive distortions and dysfunctional assumptions, and thoughts, images, and beliefs that underlie emotional distress. The therapist helps the patient challenge cognitive distortions such as overgeneralization, catastrophizing, “should” statements, magnification, minimization, dichotomous thinking, and the fallacies of control, worry, fairness, and attachment. Cognitive restructuring techniques and guided discovery help the patient choose more adaptive cognitions and behaviors. Cognitive techniques used in CBT include thought stopping, self-instruction, distraction, direct disputation, labeling distortions, and development of replacement imagery. Behavioral techniques such as activity scheduling, relaxation training, social skills training, mastery and pleasure ratings, assertiveness training, bibliotherapy, homework, behavioral rehearsal, and in vivo exposure are also employed.

The efficacy of CBT as a treatment for depression is well established.⁷¹ A review of empirically supported treatments for psychosomatic disorders determined that CBT is efficacious for chronic pain management and some cancers.³⁶

Group Psychotherapy

Group intervention in a variety of forms has become an increasingly popular, effective, and efficient means of providing psychosocial support for cancer patients.^72,73 Groups of different types may encompass theoretical approaches that include the psychodynamic, existential, educational, and cognitive-behavioral, among others.⁷² Although some cancer patients are disinclined to join a support group, most are initially reluctant to undertake other aspects of cancer treatment as well. Factors associated with reluctance include less favorable views of such groups, feeling less control over their cancer, using less active coping styles, and having less distress.^74,75 Although men may initially be more reluctant than women to openly discuss emotional problems relating to cancer, cognitive aspects of coping can be a good starting point, and men with prostate cancer report information sharing with other patients as a helpful aspect of group experience. Although reactions to catastrophic illness may differ for individuals with preexisting psychopathology, most cancer patients share with their emotionally healthy counterparts the need for support in dealing with diagnosis and treatment, changes wrought by disease, social isolation, and existential issues.

Common elements of group psychotherapeutic intervention include the following:⁷³

1. Social support. Psychotherapy, especially in groups, can provide a new social network with the common bond of facing similar problems. At a time when the illness makes a person feel removed from the flow of life and when many others withdraw out of awkwardness or fear, group psychotherapeutic support provides a new and important social connection. Indeed, the very thing that damages other social relationships is the ticket of admission to such groups, providing a surprising intensity of caring among members from the very beginning. Furthermore, members find that the process of giving help to others enhances their own sense of mastery of the role of patient and increases their self-esteem, imbuing the experience of illness with a new meaning.

2. Emotional expression. The expression of emotion is important in reducing social isolation and improving coping. Yet patients often believe that they are controlling the psychological and even physical impact of the disease by suppressing their emotional reaction to it. This attitude is often reinforced by friends and family who are made anxious by a display of appropriate fear or sadness in the patient, and by medical professionals as well, who perceive a patient’s sadness as an indication of nihilism about treatment or loss of hope. Persistent negative affect, as is seen in depression, often elicits anger in those involved with the patient, because the patient seems unwilling rather than unable to modulate his or her feelings. However, normal anxiety and sadness related to having cancer is phasic and is better managed through expression and discussion. Indeed, there is evidence that emotional expression actually facilitates the resolution of long-term negative emotion.^25,54 Encouragement of emotional expression can enhance intimacy in families, providing opportunities for direct expression of affection and concern. The use of the psychotherapeutic setting to deal with painful affect also provides an organizing context for handling its intrusion. When unbidden thoughts involving fears of dying and death intrude, they can be better managed by patients who know that there is a time and a place during which such feelings will be expressed, acknowledged, and dealt with. Furthermore, disease-related dysphoria is more intense when amplified by isolation, leaving the patient to feel that he or she is deservedly alone with the sense of anxiety, loss, and fear that he or she experiences. Being in a group where many others express similar distress normalizes their reactions, making them feel less alien and overwhelming.

3. Detoxifying dying. Processing existential concerns by facing rather than avoiding issues such as dying and death, which could be considered likely to exacerbate depression, actually helps to reduce it. This approach encourages patients to face what they most fear and find some aspect of it they can do something about (e.g., control the process of dying when death is unavoidable). This helps patients to feel more active and less helpless, even in the face of dying. Others have combined principles of cognitive therapy with a focus on existential concerns,⁷³ finding it an effective approach to reduce symptoms of distress. Death anxiety, in particular, is intensified by isolation, in part because patients often conceptualize death in terms of separation from loved ones. This can be powerfully addressed by psychotherapeutic techniques that directly confront such concerns in a supportive social setting. Yalom⁷⁶ has described the ultimate existential concerns as death, freedom, isolation, and meaninglessness. Rather than avoiding painful or anxiety-provoking topics in attempts to “stay positive,” this form of group therapy addresses these concerns head-on with the intent of helping group members make better use of the time they have left. The goal is to help those facing the threat of death to see it from a new point of view. Facing even life-threatening issues can directly help patients shift from emotion-focused to problem-focused coping.^29,30,77 The process of dying is often more threatening than death itself. Direct discussion of death anxiety can help to divide the fear of death into a series of problems: loss of control over treatment decisions, fear of separation from loved ones, anxiety about pain, and control of the manner of one’s own dying. Discussion of these concerns can lead to means of addressing, if not completely resolving, each of these issues. Even the process of grieving can be reassuring at the same time that it is threatening. The experience of grieving for others who have died of the same condition constitutes a deeply personal experience of the depth of loss that will be experienced by others after one’s own death.

4. Reorganizing life priorities and living in the present. The acceptance of the possibility of illness shortening life carries with it an opportunity for reevaluating life’s priorities. Facing the threat of death in a way that facilitates a sense of active coping can aid in making the most of what remains in life.⁷⁸ This can help patients take control of those aspects of their lives they can influence, while grieving and relinquishing those they cannot. Progress in life goal reappraisal, reorganization of priorities, and perception of benefits may also mediate improvement in symptoms and enhance quality of life.⁷⁹

5. Enhancing family support. Psychotherapeutic interventions can also be quite helpful in improving communication, identifying needs, increasing role flexibility, and adjusting to new medical social, vocational, and financial realities.⁸⁰ The group format is especially helpful for such a task, in that problems expressing needs and wishes can be examined among group members as a model for clarifying communication in the family.

6. Improving communication with physicians. Support groups can be quite useful in facilitating better communication with physicians and other health-care professionals.^81,82 Groups provide mutual encouragement to get questions answered, to participate actively in treatment decisions, and to consider alternatives carefully.

7. Symptom control. Many group and individual psychotherapy programs teach specific coping skills designed to help patients reduce cancer-related symptoms such as anxiety, anticipatory nausea and vomiting, and pain. Techniques used include specific self-regulation skills such as self-hypnosis, meditation, biofeedback, and progressive muscle relaxation. Hypnosis is widely used for pain and anxiety control in cancer to attenuate the experience of pain and suffering and to allow painful emotional material to be examined.⁸³ Group sessions that involve instruction in self-hypnosis provide an effective means of reducing pain and anxiety and consolidate the major themes of discussion in the group.^84,85 Hypnosis is an altered state of consciousness, composed of heightened absorption in focal attention, dissociation of peripheral awareness, and enhanced responsiveness to social cues.⁸¹ It has a long tradition of effectiveness in controlling somatic symptoms such as pain and anxiety. Patients with the requisite hypnotic capacity can be taught to utilize self-hypnosis to reduce or eliminate pain and the tension that accompanies it. Hypnotic techniques have been shown to effectively reduce cancer pain^81,84,85 and to facilitate medical procedures.⁸⁶ Hypnotic intervention actually alters perceptual processing in the brain, with reduced response to painful stimuli as measured by event-related potentials⁸⁷ and positron-emission tomography.⁸⁸

OUTCOME

Clinical trials have demonstrated the benefit of group therapy for breast cancer patients,^76,89–91 with notable reductions in pain^84,85 and emotional distress.^54,92 A systematic review of the literature that included two meta-analyses and nine well-designed randomized controlled trials indicated that psychoeducational interventions not only enhance patient knowledge about their cancer and its treatments, but also reduce depression, anxiety, nausea, and pain.³⁸ A Cochrane database review concluded that group psychotherapy for cancer patients significantly reduces depression, even in the setting of advanced disease.⁹³

IMPLICATIONS FOR CANCER PROGRESSION AND MORTALITY

There are literature that raises the possibility that psychotherapeutic intervention may affect survival time as well as quality of life.^94–98 Eight of 15 published randomized trials demonstrate such an effect.⁹⁹ Spiegel et al.⁹⁴ initially reported that a year (minimum) of supportive-expressive group psychotherapy resulted in a significant 18-month increase in survival time in metastatic breast cancer patients. A 6-week cognitive behavioral group intervention composed of education, stress management, coping skills training, and psychological support for malignant melanoma patients found significantly lower death rates at 10-year follow-ups in the treatment group.¹⁰⁰ A study of individual psychotherapeutic support offered at the bedside early in the course of disease to a group of gastrointestinal cancer inpatients also had favorable results on survival,⁹⁷ which has been confirmed at 10-year follow-ups.⁹⁷ A randomized replication trial of supportive-expressive group psychotherapy among 125 women with metastatic breast cancer found positive effects on mood,⁵⁴ but no overall survival advantage,¹⁰¹