Braving cancer and helping cancer patients brave their illness aren't for the faint-hearted.
This was the general message to emerge from a session at the APA annual meeting in Honolulu in May that focused on brief outpatient
psychotherapy for cancer patients.
The speakers included Lorenzo Norris, M.D., an assistant professor of psychiatry at George Washington University (GWU) and
director of the GWU Cancer Survivorship Center; Anton Trinidad, M.D., Ph.D., also an assistant professor of psychiatry at
GWU and a psychosomatic medicine specialist; and Yavar Moghimi, M.D., a psychiatry resident at GWU.
Psychiatrists are the ideal clinicians to conduct brief outpatient psychotherapy with cancer patients because of their medical
knowledge as well as their general mental health expertise, but it is nonetheless challenging work, Trinidad acknowledged.
The chief complaints for which oncologists refer patients to him, he said, are verbalized as "My life is over," "I am overwhelmed,"
"What is my family going to do?," "These side effects are horrible," "I'm afraid of pain," and "I'm afraid of dying." Patients
also fear the possibility of cancer recurring after it is in remission, and if it recurs, a patient may experience "a hot
bed of psychopathology," Trinidad noted. In the wake of cancer and the brutal treatment it often entails, lives can change
dramatically, with one possible consequence being the crumbling of a marriage.
Furthermore, dealing with patients suffering from a terminal illness means that psychiatrists must face painful existential
issues of their own, Norris said. For example, one of his first experiences with a dying cancer patient occurred while he
was an intern. The patient had advanced testicular cancer and said to Norris, "They think that I'm going to die." Norris asked:
"What can I do for you? "Pray for me," the man responded. "But even though I'm the son of a pastor, I had trouble doing so,"
Norris admitted, explaining that at age 27, the patient was about the same age Norris was at the time, and the man's imminent
death forced him to contemplate his own mortality.
So since cancer patients face daunting challenges—challenges that concern not only mental and bodily illness and suffering,
but the essence of human existence—it poses the question of how psychiatrists can help them through brief psychotherapy.
Trinidad, who does time-limited psychotherapy with cancer patients—anywhere from 10 to 20 sessions—said that he focuses on
the here and now. He uses interpersonal therapy (IPT) to resolve interpersonal conflicts and cognitive-behavioral therapy
(CBT) to correct patients' erroneous, self-defeating thoughts, he explained. For instance, he had a cancer patient who indicated
no will to fight the disease or find any pleasure in the rest of his life since he viewed his illness as terminal. Trinidad
helped him replace that thought with "Everyone dies, but they can still experience joy while they are here."
Nonetheless, not all of cancer patients' psychological problems can be solved with IPT or CBT, Norris emphasized. Therapists
also need to be able to deal with patients' existential issues, such as their will to live, their spirituality, or their desire
for assisted suicide.
So how should a clinician approach an existential issue with a cancer patient? Perhaps by acknowledging the dire situation
a patient is in, he said, although there are other approaches that can be used as well. Once a psychiatrist ventures onto
this fragile terrain, Norris told the assembled psychiatrists, it is sort of like Dante descending, with the patient, into
the nine circles of hell. You want to help the patient dig deeper and deeper into the issue while also helping the patient
tolerate his or her pain. You want the patient to ultimately "discover meaning and awe" in his or her predicament, although
you do not yet know what the meaning and awe will be.
Yet not all cancer patients want to tackle existential issues, Norris cautioned. And even if they want to, it is critical
that they are able to tolerate the anxiety that comes from probing life at such a profound level.
Still another challenge in doing brief psychotherapy with cancer patients, Trinidad noted, is that clinicians have to be flexible
and get as much mileage out of each session as possible. For example, sometimes a clinician may have to conduct shorter sessions,
other times longer ones. Sometimes patients do not live any longer than a few weeks. In fact, each session with the most seriously
ill patients may be the last one.
However, no matter how few psychotherapy sessions a psychiatrist may have with a seriously ill patient, those sessions can
be used to provide the patient with relief from psychological anguish and to help the patient make positive life changes,
For example, he once conducted brief psychotherapy with a 40-year-old patient with breast cancer. Although the woman was not
terminally ill, the cancer and the chemotherapy she received for it had changed her mind about how she wanted to spend the
rest of her life. Moghimi helped her segue into a totally new profession—one that she had always wanted to pursue. He also
helped her deal with anxiety and panic attacks that, he explained, "revolved around reconciling the new path she had set out
for herself with the guilt that she was doing something that her dead mother would not have approved of and with the guilt
that she was using money from her mother's will to pursue it."
Another advantage of brief outpatient psychotherapy, Moghimi pointed out, is that cancer patients know that the therapy is
brief, and this knowledge can motivate them to take full advantage of it.