Working With Cancer Patients: Expanding Your Practice

by Richard M. Suinn, Ph.D., ABPPFN1

Cancer Today One of every three persons and three of every four families can expect to be afflicted with cancer (American Cancer Society, 1988; Bonica, 1980). The following are ways counselors can help patients.

Help in Diagnosis: Counselors can help to separate normal from maladaptive emotional reactions (Fawzy, Pasnau, Wolcott, & Ellsworth, 1983):

1. Diagnostic Phase:
   When a person is being assessed for cancer Normal reactions include: disbelief, shock, initial denial,anxiety/apprehension, mild depressive episodes, anger. These are common reactions to serious illness or physical disability (Suinn, 1967). Although psychotherapy is not required, assurances that these are normal emotions can be useful to the patient and family. Maladaptive reactions include: persistence of denial/disbelief leading to refusal of further medical involvement, despair/clinical depression, substituting unproven quick cures for conventional medical contact, adoption of fatalistic belief that death is inevitable leading to refusal of further diagnoses or treatment. Psychotherapy treatment may be required here.
2. Treatment Phase:
   Once medical treatment begins for cancer Normal reactions include: anticipatory anxiety about the unknown or rumors, fears because treatment outcomes may be ambiguous, concerns about abandonment by the primary care physician or fragmentation of care, special anxieties (death, body image issues regarding sexuality, disfiguration, femininity associated with mastectomy, colostomy, genitourinary surgery). Maladaptive responses include: exaggerated pessimism, postponement of traditional treatment in favor of unproven treatment, unrealistic optimism about outcome of treatment, passivity leading to noncompliance with health-protective behaviors ("I'm dying anyway, and smoking is my only remaining pleasure so don't take it away too"), excessive fear of pain.

Psychological Treatment and Cancer. Examples of interventions counselors can provide are:

1) Coping strategies improve functioning.
Active behavioral strategies such as seeking information, adopting healthy behaviors, entering support groups are associated with fewer physical symptoms and positive affective states; physically ill patients who use active cognitive strategies also showed fewer physical symptoms and less depression, and lower fatigue (Billings & Moos, 1981; Bloom, 1982; Felton, Revenson, & Hinrichsen, 1984; Holahan & Moos, 1983; Namir, Wolcott, Fawzy, & Alumbagh, 1987). Fawzy, Fawzy, Arndt, and Pasnau reviewed 15 group, 13 individual psychotherapy and 19 cognitive/behavioral interventions for cancer patients, and found gains in coping in 31 studies and reduced distress in 27 studies.

In what is considered one of the most comprehensive and well-documented outcome studies, Gordon Freidenbergs, Diller, et al. (1980) determined that counseling increased return to vocational work, reduced negative affect, and increased reality perspective.

Finally, social support networks appear associated with adjustment to cancer, reduced distress, more vigor, and possibly recovery (Taylor, Falke, Shoptaw & Lichtman, 1986).

2) Coping to enhance the immune system.
Gruber and colleagues (1988, 1993) found indices of increased immune function among breast or other metastatic cancer patients treated with cognitive/behavior therapy. In the largest investigation of low-risk cancer patients, Fawzy, Fawzy, and Hyun (1994) offered health education, stress management, coping skills training, and psychological support to patients with malignant melanoma. Patients showed increases within six weeks in active behavioral and cognitive coping, improved quality of life, and increased in immune system function.

Some psychological interventions have increased survival rates. Spiegel, Bloom, Kraemer, and Gottheil (1989) offered group therapy to breast cancer patients for one year, and followed the patients over 10 years. Survival for the intervention group averaged 36.3 months compared with 18.9 months for the control. Fawzy, Fawzy, and Hyun also reported 91.8% of their treated group as surviving after 5 years compared to 67.5% of the control.

3) Interventions for side effects.
Anticipatory nausea is associated with chemotherapy in about 45% of adults and 29% of children, and once developed "are usually refractive to medical intervention" (Burish & Carey, 1986, p. 593; Laszlo, 1983). Chemotherapy may prolong life, but "also seriously compromise the quality of that life" such that some patients "refuse further treatment altogether" (Burish & Carey, p. 593; Wilcox, Fetting, Nettesheim, & Abeloff, 1982). Such aversive side effects are due to conditioned learning and seems especially predicted in patients with high anxiety or general distress.

Interventions to prevent such side effects aim at the conditioned learning or anxiety components (Carey & Burish, 1988). Burish, Snyder and Jenkins (1991) provided education, relaxation, and guided imagery before the patient's first chemotherapy session. Other typical interventions have used relaxation, initiating other responses to overcome nausea and act as new conditioned responses, desensitization, guided imagery, and hypnosis (see reviews by Andrykowski, 1990; Carnrike & Carey, 1990; Morrow & Dobkin, 1988). These interventions can be provided in very brief sessions; Burish, Snyder and Jenkins's procedure was one session of 90 minutes.

Pain management methods. Moderate to severe pain is experienced by about 40% of adults in intermediate stages of cancer, and 60-90 % in advanced stages (Jay, Elliott, & Varni, 1986). Bone marrow aspirations and lumbar punctures are routine but highly painful diagnostic procedures.

Counselors can provide pain management through biofeedback, hypnosis. cognitive/behavioral therapy, support groups, and education (Jay, Elliott, & Varni, 1986). Hypnosis has been among the more often used procedure, aimed at distraction through pleasant imagery, creation of anesthesia, induction of amnesia for the pain experience, or time distortion (Hilgard & LeBaron, 1982; Jay, Elliott, & Varni, 1986). Spiegel and Bloom (1983) used 5-10 minutes of hypnosis during weekly support groups for breast cancer patients to "filter the hurt out of the pain" (p. 335), by imagining competing sensations as cold numbness or warm tingling. Jay, Eilliott, Woody & Siegel (1991) designed a cognitive behavioral package (CBTP) involving film models, reinforcement, breathing, imagery for distraction, and behavioral rehearsal, for children undergoing painful medical procedures for cancer.

Closing Comment:
How to be a Helping Counselor. Expanding one's services to aid cancer patients is well within the reach of anyone's current practice. The common elements in psychological interventions have been identified as "Support, compassion, and empathy" (Fawzy, Fawzy, Arndt, & Pasnau, p. 104). In addition to these skills possessed by any successful counselor, detailed descriptions of structured procedures for cancer are available.

Spiegel's procedure is available from him through the Psychosocial Treatment Laboratory, Stanford University School of Medicine (Classen, Diamond, Soleman, Fobair, Spira, & Spiegel, 1993). Fawzy's patient manual, from the UCLA School of Medicine (Fawzy & Fawzy, 1994) details the training in coping strategies using cancer scenarios, and stress management techniques.

Jay and Elliot's (1984) cognitive behavioral package is described in detail, available from Susan Jay in Los Angeles.

Gordon et al. (1980), at Mt. Sinai Medical Center, New York, produced treatment manuals for their intervention which involved education, counseling aimed at feelings and actions, and environmental consultation. Other structured interventions include the PREP package by Burish, Snyder & Jenkins for anticipatory nausea/vomiting, and the Omega Project for coping skills and communications released as a Practitioner's Manual (Sobel & Worden, 1982).

Finally, the counselor interested in offering services to cancer patients should attend to the following practice principles (Andersen, 1992):

1. provide emotional support to address fears and anxieties about cancer
2. provide education for the patient to obtain and know how to actively request factual information about cancer and treatment
3. offer coping strategies for stress management, pain management, anticipatory side effects, and general adjustment
4. provide problem solving training in how to arrive at decision-making, e.g., obtaining second opinions, choosing between toxic regimen versus no treatment, dealing with extending survival by some margin versus accepting shorter survival but higher quality of life
5. offer focused interventions for cancer disease types, e.g., counseling on body image for breast surgery, sexual functioning for gynecologic cancer
6. consider meaningful general psychotherapy goals, such as increasing locus of control or self-esteem or dignity
7. enable family members to receive similar opportunities for their own adjustment where there is need.

Psychologists are an important resource for cancer patients; I would urge counselors to expand their services to this area of primary health care!

4/15/98

Dick Suinn Dept. of Psychology Colorado State Univ Ft. Collins, CO 80523 FAX (970) 491-1032 Ph. (970) 491-1351

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