Psychotherapeutic Treatment of Cancer Patients

Jane Goldberg

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351307666
• Edition: 1
• Topic: Medicina
• Subtopic: Oncologia

When this book first appeared in 1981, it was the first to deal comprehensively with major issues in the psychotherapeutic treatment of cancer patients. It remains the standard volume in the field, drawing together a broad spectrum of work using psychological approaches to treatment of cancer patients and to understanding the disease's sociological and psychological implications. Distinguished contributors from medicine, psychiatry, psychoanalysis, psychology, social work, family and group therapy, and nursing examine key issues, including the role of aggression in the onset and treatment of cancer; sexual functioning of patients; cancer as an emotionally regressive experience, cancer in children, and the countertransference responses of a therapist working with a cancer patient. This volume will be of particular value to helping professionals who deal with cancer patients and their families.

PART I
Theoretical Considerations

It has not yet been possible to formulate a theory of cancer that includes its every aspect. Despite research that enables us to more successfully identify personality patterns of the cancer-prone person, patients defy the statistics, and all kinds of personalities are found to develop the disease. Despite massive epidemiological studies that help us to predict expected survival time for all types of cancers, patients still defy the statistics. Some live longer than their bodies seem to have the strength for, while others die without physiological reason.

To put some theoretical construct around a disease that is as varied and unpredictable as cancer is surely an attempt to impose order on apparent chaos. While the study of cancer has generated no new theoretical ideas, it has yielded creative and useful application of old ideas in new ways.

Virtually every theory from the fields of psychology, psychiatry, and medicine have been applied to cancer. It has been seen alternatively as a virus, a lowering of immunological defenses, a biochemical imbalance caused by nutritional deficiencies, a breakdown of cellular communication, a characterological defense against aggression, a resistance to a positive transference to a psychoanalyst, a somatization of pre-oedipal impulses, a freezing of energy, and much more. Research can be found to support any of the above hypotheses.

Both clinical practice and research share a problem inherent to the process of investigation; they cannot see everything at once. Isolating a single factor as contributory to the cancer has been a successful method of investigation. The state of the art is such that we now have many separate, single factors that have been pinpointed as relevant. We know little, however, about the cumulative or synergic effects of these variables. Most practitioners and researchers now agree that cancer is surely a multi-determined phenomenon.

Treatment is often designed to address only one of the variables considered to be catalytic or causative. Nutritional therapies, for example, aim to restore the bodily biochemical balance, but a body wracked with psychological stress will not be able to digest and utilize the proper nutrition. Similarly, psychological therapy may relieve psychic discomfort, but an organism that has cellular malnutrition needs nutritional support from food, as well as from words. Ideal treatment, then, may consist of approaches that address more than one of the determinants of the disease.

The amazing recuperative powers of the body often permit patients to get well even without ideal treatment. Psychological factors are only beginning to receive attention, and until very recently, most cancer patients who have gotten well did so without the benefit of psychological treatment. Nutritional and immunological supports are also now thought to provide considerable help in aiding the body to restoration of health. These too have only recently received sufficient attention that cancer patients have begun to profit from the scientific advances in these areas.

Psychological approaches to an understanding of cancer are themselves varied. In spite of equally convincing alternative theories about what treatment technique works, patients claim to be helped by individual analysis, family treatment, groups with leaders, groups without leaders, by the release of aggression, by the release of love, and so on. We can only conclude that, although our knowledge and our ability to apply our knowledge remain partial, we are still able to offer considerable help to the cancer patient.

Part I outlines prominent theoretical approaches to the psychology of cancer. Chapter 1, by Jane Goldberg, provides the reader with some of the theoretical background and pertinent research to view cancer as a disease with psychosomatic components. Chapter 2 gives a historical perspective to the concept of psycho-physiological interaction in disease. Carl Jung was one of the first analysts to see that illness manifested on a somatic level may have psychological meaning. Russell Lockhart, in chapter 2, applies Jungian thought to an understanding of the symbolic meaning of cancer. Chapter 3 regards stress as a determining factor in the development of cancer. Stress is usually thought of as a psychological mechanism, but it effects physiological change. Hans Selye’s discoveries about stress show that deterioration of an organism occurs with either too much or too little stress. Paul Rosch applies Selye’s ideas to cancer, and documents the fact that cancer is a disease which is highly responsive to stress. Chapter 4, by Herb Bilick and William Nuland, represents a new concern in the treatment of cancer. A model is presented whereby the cancer patient actively participates in his or her own treatment plan.

1 Experimental Validation of Psychosomatic Aspects of Cancer

Jane G. Goldberg

The popular notion that cancer can strike any one at any time, in democratic fashion, is largely a myth. Most of the literature—both research and clinical—points to the fact that certain pre-existing conditions must obtain before the disease is contracted. Because of the long latency period during which the symptoms of the disease are not yet overtly manifest (some cancers can take up to twenty years from the time of exposure to the triggering substance), the determination of cause and effect is particularly difficult.

Research to determine the various psychological and social-psychological precursors of cancer have included the personality of the individual and various life events, such as death of a loved one or divorce. It is postulated that these psychological and psychosocial phenomena find representation on the physiological level through the mediating mechanisms of the limbic system, the endocrine system, hormone levels, and/or the central nervous system.

The idea that somatically manifest disease can be traced to psychological phenomena has its roots in the early observations of Breur. In 1895, he observed that psychopathological symptoms come into being as a result of pent-up emotion. Freud thought this was correct, and mentioned “strangulated affects” (eingeklemnte affekte).

Freud, himself, however, was not particularly interested in the concept of the conversion of psychological conflict to physiological effect. His initial interest in conversion hysteria may have foreshadowed the mantel taken up by his followers—most notably Franz Alexander. Here, though, despite the fact that symptoms mimicked those of physical diseases (paralysis, anesthesia, blindness, convulsions, or headaches), there was no actual physiological involvement. These diseases were, then, strictly diseases of the mind.

Freud’s disinterest in psychosomatic disease is actually explained by his own theory. Psychoanalytic theory of disease is a psychosexual developmental schema, where disturbance can occur at any point along the ascending developmental ladder. Inadequate mastery of any stage inhibits further progress onto the next stage. Freud was primarily interested in the neurotic conflict of the oedipal period, which reaches culmination in the child at the age of seven. Here, separation from the primary love object has become sufficiently strong that the child is permitted the choice between the old love object (mother) and yet another love object (father). It is in the possibility of choice that the conflict arises.

The psychosomatic diseases are thought to differ from the psychoneurotic symptomotologies in the date of origin of the repression. In cases where the trauma becomes manifest in somatic symptomotology, the fixation point is before such separation-individuation has occurred, and, importantly, before acquisition of language (usually the first two years of life). Thus, the conflict arises out of and centers around the primary love relationship (mother and infant). And since language is not accessible as a means of discharge or resolution of the conflict, the body itself becomes the vehicle through which the conflict gains physical representation.

Psychological research on cancer patients has validated many of these psychoanalytic concepts. Two broad ideas have generated most of the work done in this area: (1) the “personality” hypothesis, which specifies that there are particular personality characteristics found more frequently in the cancer patients than in normal controls, and (2) the “loss-depression” hypothesis, which suggests that an emotional trauma of separation or loss precedes the development of cancer, with ensuing feelings of helplessness and hopelessness. The personality hypothesis offers the construction of a type C personality, analogous to the type A personality found to be prone to heart disease.

The idea that certain types of emotional conflicts predispose a person to developing cancer (the personality hypothesis) has a history as old as medicine itself; it was a prevalent view of physicians for large segments of time. Galen, as far back as the second century, observed that women who manifest depression seem more inclined to develop breast cancer than those with less melancholic dispositions.¹ The idea finds its next recurrence in seventeenth and eighteenth century England, where physicians alternatively ascribed cancer to black bile and melancholy (Wiseman),² to fright or violent grief (Gendron),³ to “uneasy passions of the mind” (Burrows).⁴ These ideas continued in England into the nineteenth century: Walshe mentioned the “habitual gloominess of temper;”⁵ Sir James Paget was convinced of the vital role of depression;⁶ Snow, who performed the first statistical analysis of the relationship between cancer and personality, stated neurotic tendency to be the most powerful causative factor.⁷ Similarly, in nineteenth century France, ideas were promulgated: Amussat considered cancer to be caused by grief;⁸ and von Schmitt suggested ambition, frequent rage, and violent grief as primary causes.⁹

Despite the historical popularity of these notions among physicians, twentieth-century medicine was not initially interested in pursuing these ideas. Cancer treatment was developing rapidly from art to science, and the physical treatments of surgery and radiation seemed to be adequate and powerful tools. Further, Freud’s broad influence had not yet taken hold, and the ability of physicians to cope with emotional problems was still quite limited.

While early medicine may have contented itself with clinical observations, modern science has become more demanding. The twentieth-century development of sophisticated assessment and statistical procedures has dramatically altered the method of investigation. Complex studies with analysis of multiple variables can now be performed on large numbers of people. This research method is a far cry from the mere observations made by a single physician who was limited by the number of patients in his practice.

Research has been successful in validating a number of observations on the cancer personality made by the early clinicians. A “personality profile” for the cancer patient has now been experimentally established. A comprehensive analysis of these studies yields three dimensions of emotional qualities that seem to characterize the cancer patient. Segmentation of these dimensions does not imply independence from one another; rather, there is much overlapping both within the personality profile dimensions and with the alternative loss-depression hypothesis, as well. Many studies have looked at and confirmed a number of variables to be coincidental to both theories. The three main character traits found to describe the typical cancer patient are: repression of feeling, inhibition of aggression, and, finally, an inordinately pleasant personality.

The idea that cancer can be caused by a repression of emotions follows the earlier thinking of Breuer and Freud. Experimental validation is found in the research of Thomas, Bahnson, and Kissen. Caroline Thomas’ study of medical students at Johns Hopkins in 1946 spurred the interest of researchers to identify and quantify more exactly the psychological dimensions of the cancer personality.¹⁰ At that time, she began a longitudinal epidemiological study to discover the precursors of coronary heart disease, hypertension, mental disorders, malignant tumors, and suicide. She initially conceived of cancer as being a condition without psychological factors, and was startled to find striking similarities between those who developed cancer and those who committed suicide. These were people who reported a history of cold and remote parental relations, and who were little given to the expression of emotion.

Studies done subsequent to the Thomas study have used many of her seminal findings as hypotheses. Bahnson tested experimentally the idea that cancer patients are more likely than others to repress feelings.¹¹ He administered a test to cancer patients and controls where each gave verbal associations to a neutral sound (a kind of auditory Rorschach). The finding that cancer patients gave more positive and benign associations was interpreted as an indication of greater repression of negative thoughts and feelings.

Kissen compared heavy smokers who had lung cancer with those who did not.¹² Test scores were interpreted as indicative that cancer patients suffered from denial and repression of emotions, with “poorly developed outlets for emotional discharge.” Kissen concluded that the more repressed the individual, the fewer cigarettes it took to induce cancer.

Other experiments have attempted to identify what particular emotions are repressed. One which has been repeatedly identified is aggression. In order to understand how inhibition of aggression can lead to the somatic state of cancer, one must understand the notion of discharge. For Freud, the normal functioning of the mind is governed by a “control apparatus that organizes, leads, and inhibits deep...