Psychooncology care

Facing a diagnosis of cancer is one of the most difficult, stressful and feared situations in today’s society. Few illnesses give rise to so many psychological problems. This is because cancer occurs in a series of circumstances that, in themselves, are generating psychological distress: its chronicity, uncertainty about its evolution, side effects of treatments and the social meaning of the word cancer. The focus of interest of Psychooncology is aimed at studying the different modes of coping and the most useful therapeutic strategies to improve the quality of life of the patient.

We work from the need of psychological intervention in the different moments of the disease. We use a variety of therapeutic tools to provide psychological assistance to patients and their families at different stages of the disease to achieve a better quality of life.

Why is it important to receive psycho-medical support?

Illness is a fact and a fundamental experience in human life. All people are more or less affected by the disease, either as a potential threat that we all have, as a reality that we have lived, or as suffering in people close to us (family, friends).

Illness, when it is threatening, implies a rupture of the inner world of the person, in the sense that it causes the experience of one’s own limitation and interrupts the realization of the personal project of human existence. Sickness, somehow, entails facing a world hitherto unknown and often denied.

Cancer is one of the most important diseases of our time, both because of its high incidence and the consequences of it, being one of the most important health problems of our century. In the western countries, cancer is one of the three most important causes of mortality alongside heart disease and traffic accidents.

Being diagnosed with cancer is one of the most stressful and dreaded situations in today’s society. It is one of the diseases that causes more psychological problems in the person who suffers. In cancer there are a number of circumstances that are a source of psychological distress: its chronic nature, uncertainty about its evolution, side effects of the treatments that are usually used for its control and the social meaning of the word cancer.

Before chronicity the person has to “learn” to coexist with the disease, modifying their habitual schemes of functioning and putting their coping resources in motion. Being a disease whose etiology and evolution is unknown brings with it uncertainty as a reality and will be the origin of most of the emotional alterations that the cancer patient will feel. The treatments usually used for cancer control (surgery, radiation therapy, chemotherapy, bone marrow transplantation …) have side effects that not only physically affect the person, but also, and very importantly, socially and psychologically.

To all of the above the social meaning of the word cancer is added. If we ask anyone what the word cancer means, most will tell us that pain, death, disfigurement, fear, hopelessness, uncertainty, incapacity and alteration of daily life. What is at the basis of all this is that cancer is perceived as a painful, insidious disease that can deteriorate the person and lead to death. It has the weight of being a social stigma. All this makes us face a person who is in a very difficult, painful situation that has to face multiple fears and fears and whose quality of life is greatly diminished. The way in which the person faces the disease depends on the awareness he has of the same, his personal history, the meaning he gives, the consequences that derive from it and, above all, the coping resources That can put into action before the situation that is touching to live.

The interest in connecting the medical and psychological aspects has led to the emergence of Psychooncology, a discipline that studies the relationship between psychological processes and neoplastic pathology, as well as the usefulness of psychological interventions to address the problems associated with the diagnosis and treatment of this disease. Its focus is aimed at studying the different modes of coping and the most useful therapeutic strategies to improve the quality of life of the person with cancer.

PSYCHOSOCIAL IMPACT OF ILLNESS

Oncological disease is characterized by being a time-consuming process, in which the person has to face multiple stressful situations, which begin with the appearance of the first symptoms, the fear that the diagnosis will be confirmed and, subsequently, the assumption of it. It continues with the concern and fears aroused by the different treatments they will receive and their side effects, and with the consequent decrease in quality of life.

This time is characterized by uncertainty and fear that the disease will appear again. In other cases, the disease may appear again, a phase known as relapse or recurrence, which involves starting anew the different treatments. This is one of the most difficult moments both physically and emotionally. If the cancer cannot be controlled and it continues to advance, the patient will inevitably arrive at the terminal phase of the disease, at which time Palliative Care plays a key role.

The different stages of cancer are as follows:

Diagnosis

The confirmation of a cancer diagnosis supposes a great emotional impact that generates reactions of fear, anxiety, uncertainty, sadness, rage … and is one of the moments of greatest tension.

The person has to face the certainty of the disease and the uncertainty of its evolution. Also to their vulnerability – “this is happening to me” – and, above all, to thinking of death as something closer and more real.

Questions arise: “Why me?”, “What have I done?”, “Why now?”, and do not have a clear answer and sometimes none.

In these cases we develop our psychotherapeutic intervention with the following objectives:

Provide individualized attention to the family and primary caregiver.
Promote the expression of feelings, fears and anxieties.
Detect and evaluate vulnerability factors that can interfere in the process of adaptation to the disease.
Identify expected reactions and reduce anxiety, depressive symptoms, and “maladaptive” emotional reactions.
Promote in the family (and the patient through the family) a sense of personal control and active participation in decision-making, promoting communication skills.
Provide the family (and the patient through the family) strategies to cope with stress.
Offer tools to facilitate relationships within the family and with the professionals involved.
Offer an individual follow-up or plan psychotherapeutic strategies.

Treatment

As already mentioned, the treatments that are commonly used in cancer control: surgery, radiotherapy, chemotherapy, bone marrow transplant, among others, are aggressive, with multiple side effects that are often difficult for the patient to understand, because in the short term they experience a worsening of their physical and emotional state instead of an improvement, without the security of obtaining a total cure, only in the hope of controlling the disease.

Reactions of anxiety, fear, loss of control, helplessness, feelings of worthlessness are common during this phase. These side effects vary from person to person, depending on the characteristics of the medication which has been prescibed and the personality of the patient. We will briefly point out the most important aspects of these treatments in order to understand their consequences and the alterations they produce.

Surgery. It is a strong stressor in itself, due to the fear of anesthesia, pain and, above all, its consequences. Depending on its location, it can represent the loss of a function, an organ or a limb. An example of this is found in the loss of speech as a consequence of a larynguectomy; normal bowel function after a colostomy and loss of limb due to amputation. The loss of a woman’s breast affects both her body image and her femininity.

Radiotherapy. Contact with a machine and fear of technical failure can cause emotional reactions of an anxious nature, in some cases phobic, accompanied by feelings of fear.

Chemotherapy. For all its side effects: alopecia, nausea and vomiting, fatigue, neuropathies, etc., it is normally poorly tolerated physically and psychologically. Patients present symptoms of anxiety, depression, low self-esteem, difficulty in concentrating, among others.

The following objectives are pursued in this period:

Facilitate adaptation to disease during the biome treatment process
Encourage active coping styles.
Facilitate therapeutic adherence to medical treatments.
Alleviate the negative side effects associated with some of the therapeutic techniques and procedures
Provide guidance and surgical psycho-prophylaxis in the event that the indication is surgery, to reduce anxiety in the face of it.
Provide the patient with strategies to face the fears and anxieties related to the different treatments (chemotherapy, radiotherapy, hormone therapy, etc.) and the uncertainty regarding the results of the tests that determine the extension diagnosis.
Facilitate the management of associated and conditioned reactions to the effects of the treatments: anxiety, nausea and anticipatory vomiting, phobias to the devices, etc.
Provide the patient with strategies that allow them to control acute pain associated with diagnostic procedures and chronic pain characteristic of pathology.
Guide against the appearance of symptoms that distress the patient and their family (as a side effect of the main treatments or due to the pathology itself).
Inform and guide about sexual dysfunctions that appeared during treatments, offering strategies that favored sexual expression.

Remission

When the treatments have finished and there is no evidence of disease, this period is considered as remission or disease-free period.

At the physical level, recovery begins. This is not always understood by the patient and family members who think that, once the treatments are finished, they will immediately feel good, “as before”, and this is not the case: it is a recovery little by little, sometimes more slower than they would like.

Psychologically it can be a troublesome time. In daily practice it is common to find people who feel scared, helpless, insecure, they are no longer sick, but they are not yet “normal”. Just as we are talking about a process of adaptation to the disease, now the process of adaptation to normality is considered and, curiously, it is at this time that some patients request psychological support. They are those who have not passed through a process of mourning as a consequence of their diagnosis and treatment of a life-threatening disease and it is now, when they no longer have to dedicate their efforts and energy, to treatments, and it is now when they become “depressed” or, put another way, when they can get depressed and deal with the emotional.

This is one of the moments in which the demand for psychological attention occurs very frequently and is an important phase in the “awareness” of their psychic suffering. It is also the moment when the big questions arise about their autonomy-dependence, their affective life and projects and, therefore, the possibility of a more lucid therapeutic work opens up.

This phase is characterized by feelings of vulnerability and uncertainty about the future. It is the moment where the fear of relapse may appear with greater intensity, what we know as “Damocles Syndrome”, this being a unique psychological entity in the experience of the survivors, the fear that the disease will return.

Thinking that the disease can return, having to go through all of the above, disability and the possibility of death, is a source of chronic stress that explains the psychological discomfort found in a significant number of patients. These fears are intensified when the patient has to go for revisions. In the days prior to them, patients may experience increased anxiety, difficulty concentrating, sleeping, which in some cases requires pharmacological treatment. Also fear and anxiety intensify at any physical symptom, it is inevitable to associate it with the presence of the disease.

The therapeutic objectives at this time are:

Provide a space for the expression of doubts and uncertainties.
Facilitate proper handling of information.
Facilitate the expression of the fears and concerns of the patient and their family.
Provide the patient with strategies to manage any emotional disturbance (anguish and / or depression).
Facilitate the patient’s return to their daily activities.
Facilitate adaptation to the physical, psychological and social consequences that the disease may have caused.
Facilitate reincorporation to activities and significant interests for the patient.
Provide the patient with resources to face anxieties and fears related to the so-called: “Damocles Syndrome”.

Relapse

We speak of relapse or recurrence when the disease reappears after a more or less long disease-free interval.

This situation has great physical and, above all, psychological repercussions. The patient realizes that the possibilities of treatment are more limited. They can feel angry an furious with themselves, feeling guilt for not having managed to overcome the illness and also with the doctor for not having been able to cure them, or because he was not effective in detecting the progress of the disease, which means meeting his fears and the subsequent experience of failure.

Treatments will start again, which may be similar to those received or new, which means going through the physical and psychological effects again. It is common to find that the patient feels anger, sadness, anxiety, anguish, fear, uncertainty, depressed; being helpless in view of the lack of control they have over the illness and as a consequence depression, the most predominant and most intense emotions.

From a therapeutic point of view it is one of the most difficult situations to handle. The person remains for a long time with the feeling of failure, verbalizations such as: “what am I going to fight for, if it’s useless”, “when I was diagnosed I thought I could be cured, but now I’ve gone back… there’s nothing left to do”, “to think that I have to go through the same thing again…”, are common and frequent before the relapse of the disease.

Once the strategy has been decided upon, most patients are able to cope adequately with the situation, gradually reducing the intensity of their emotions, and can put their adaptive resources into action. It is important at this time to be able to listen to the patient’s complaints, understand their suffering and try not to give “stereotyped advice”, which does not help the person in any way.

The psychological support in this phase has therapeutic objectives:

Prevention and treatment of depressive states.
To provide the patient and family with resources that facilitate adaptation to the new state of the illness.
To facilitate the expression in patients and families their fears and anxieties related to this new “shock”.
To provide a space for the expression of emotions for patients and families.
To facilitate coping strategies in the patient to face new treatments and overcome logical uncertainty and fears of the proximity of death.

The last phase of life

In cancer patients, a series of parameters are accepted that define this phase: presence of advanced, progressive or incurable disease; little or no possibility of response to active treatment; presence of intense problems or symptoms and limited vital prognosis, among others.

The problems usually faced by the patient at this time are both physical and psycho-emotional. The emotional reactions in this phase are determined by the patient’s awareness of the situation. As in the diagnosis and treatment phases, a process of adaptation can also take place now, and three important moments can be distinguished:

That of the impact of the current situation which can lead to denial and anxiety reactions.
That of coping which one will react to the fear, anger, rage and depressed moods.
The one of adaptation where a decrease of the previous emotional alterations will take place and the patient will utilize their personal resources to diminish the psychological discomfort.

It is estimated that a large number of patients manage to adapt to the situation of illness and death, but this does not mean that it is easily achieved and that everyone can do so. The process is painful, long and difficult, and must become the goal of care.

As we can see, from the diagnosis to the terminal phase, the oncological patient has to face multiple stressful situations that cause emotional alterations of different nature and intensity. The role of the family, the support they can provide, and the care team that attends to the patient is fundamental throughout the process.

The objectives of psychological intervention are:

To help control physical symptoms such as pain.
To detect and attend to psychological difficulties that the patient and his/her family may present (anguish, depression, communication problems, among others).
Detect and redirect spiritual needs.
Accompany the patient in the process of dying and his or her family in the development of grief.
Preventing traumatic grief by detecting risk factors.
Identify and encourage the expression of psychological suffering in the dying patient.
Encourage the expression of feelings of both the patient and their family.
Detect bonding interaction problems and prevent risk situations in the family, especially in the main caregiver.
Stimulate the participation of the patient in the decision making process, especially by evaluating the information available to them.
Foster the doctor-patient relationship by accompanying the actions of the various professionals who are part of the team.

HOW TO COPE AND ADAPT TO THE DISEASE

The process of adaptation to the disease has several fronts and usually takes place over a long period of time, where sometimes decisions must be made in unknown and highly distressing situations.

Coping is a cognitive and motor activity used by a sick person to preserve their physical and psychic integrity, to recover impaired functions in a reversible way and to compensate as much as possible for any irreversible deterioration. This definition includes the two main types of coping: coping with the problem (the illness) and coping with the emotion (reducing personal discomfort).

Adaptation to the disease from a practical and vital point of view is not easy to define. We could approach it if we propose that adaptation has a direct relationship with an acceptable level of emotional well-being and quality of social and working life, as well as the assumption of treatment and its physical, social and psychological consequences as a necessity after the onset of the disease.

There are five types of coping strategies and their influence on the course of the disease. These are: Spirit of struggle, avoidance or denial, fatalism or stoic acceptance, helplessness and anxious concern.

We must be cautious about overemphasizing the importance of the patient’s active and collaborative role in recovery, as it can be overwhelming and a burden of excessive responsibility, making it difficult to achieve precisely what we are trying to do.

In some informative publications about cases of known people who have suffered from this disease, the message seems to be conveyed that on order to be cured it is enough just to want it and put a lot of effort into this idea, which can be confusing and demanding for the patient at a time when this may serve to blame or depress them more. This is called the “tyranny of positive thinking”: “for many patients, cancer is the most difficult and frightening experience they have ever faced. All these trickeries, which proclaim that if one does not have a positive attitude and is depressed the tumor grows faster, invalidate the natural and understandable reactions of people to something that threatens their life.

PSYCHOLOGICAL INTERVENTION

Given the complexity of the oncological disease, it is essential to approach it from a biopsychosocial perspective. We adapt the psychotherapeutic techniques, making them all agree with the idea that “the sick man does not want to be sick and suffers the symptoms of the disease”.

It is essential that the patient maintains a good quality of life throughout the process. Intervention on psychosocial factors can take place in different contexts, depending on the time of the illness and the needs of the patient:

Support in the process of adaptation in the different phases of the disease.

Preparation for surgery: some results show a better post-surgical recovery in patients who have previously received psychological interventions to reduce their anxiety and fears.

Adaptation to the changes in body image caused by the treatments.

Coping with bone marrow transplant: it is a very stressful situation physically and emotionally, it is important to prepare the patient for tolerance.

Reducing anxiety, depression, and emotional maladaptive reactions.

Promote a sense of personal control and active participation in the entire process.

Provide information to the patient or help the patient to find it.

Facilitate appropriate communication with the family and care team.

Management of the so-called “paradoxical situation” that can occur when the treatments are started (the patient who was feeling well, usually feels worse after starting the treatment), or when they finish (they feel insecure, since while they were receiving it they felt they were controlling the disease and when they finish there is concern about a possible recurrence).

Facilitate the process of adaptation to “normality”.

– To help the patient express and manage their fears, review their values, the meaning of their life and learn to control their suffering. To be able to think and talk about life and death

Adjuvant Psychological Therapy (APT)

It was developed by Moorey and Greer (1989) as a comprehensive cognitive-behavioral model based on Beck’s depression therapy.

The objectives of the APT are:

To reduce anxiety, depression and other psychological symptoms.
To improve mental adjustment to cancer by encouraging a positive fighting spirit.
To promote a sense of personal control and active participation in treatments.
To develop effective coping strategies to deal with the problems of the disease.
Improve communication between the patient and the family.
Encourage the open expression of negative feelings, especially anger.

Therapy focuses on the problem or problems posed by the patient, whether emotional, interpersonal or those related to the disease.

Counselling

Counselling is a process through which you can help patients to communicate and relate better to those around them, to understand their problems and how to deal with them, and to improve their attitude and motivation to facilitate change. Key components of this process include:

Providing information.
Expressing and discussing feelings.
Maintaining or re-establishing social support.
Managing concerns and problems that may arise throughout the process.
Search for alternatives to face the problems with maximum efficiency and with the least emotional cost possible.

Counselling is an interactive process that promotes motivation to change from respect for oneself and others. In order to put it into practice, it is necessary that the professional be sensitive to suffering and trained in its management; that they commit themselves to facilitating the development of a dignified life in the people they serve, within a framework where acceptance, love and reconciliation are present.

Fundamental attitudes in the therapeutic relationship which stand out:

Empathy: understanding and transmitting understanding to the other person.
Congruence-truthfulness, with what one lives and feels.
Unconditional acceptance, which entails accepting the history of the other person as well as their way of life without reservations or value judgments.

Counselling is based on the dynamics of choice, not control, exploring, asking, informing and making the patient reflect so that they can take the decisions that they feel are best for them.

Interventions with families.

Here the work consists of providing a space of containment during the whole process of illness. The interventions are individual and group, depending on each case and time. The therapeutic objectives of these interventions are:

To favour the expression and verbalisation of emotions, fears, guilt fantasies, reproaches, etc.
To offer clarification and orientation in relation to the emotions that are mobilized in this vital crisis that the presence of illness represents.
Encourage communication with the treating medical team.
To detect risk factors related to pathological grief in some of the family members.

Interventions with the Healthcare Team.

We also carry out interventions with health professionals who work with this population, as well as with multidisciplinary teams that attend to oncology patients. The objectives are:

To provide resources and tools to health professionals to improve their relationship with patients: health professionals often face the difficult task of having to give bad news and handle situations with a lot of emotional burden. I have been involved in the process of informing, answering difficult questions and detecting the concerns of the patient.
Providing emotional support to the team: the difficult situations experienced with patients and their families have meant an emotional drain that I have sought to have redirected so as not to negativley affect the work carried out (“Burnout” syndrome).