An Introduction to Psycho-Oncology

Patrice Guex, Heather Goodare

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781134922147
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Cancer is extremely common and in many situations a truly frightening disease, but for too long the psychological aspects and effects have been ignored. An Introduction to Psycho-Oncology deals in a clear and simple manner with the reactions of cancer patients to their illness, and the ways in which they can be helped. In the context of a multidisciplinary approach that takes account of medical treatments as well as psychological interventions, Guex offers suggestions for better ways of communicating so as to provide a therapeutic partnership between carer and client.

Chapter 1
Psychosomatics and cancer

PSYCHOSOMATICS

Psychosomatic research in the study of cancer has existed for a long time. Many authors have tried to establish links between psychological problems and the onset of cancer. They have primarily engaged in retrospective studies, starting with isolated cases where there was a striking correlation between emotional traumas and the appearance of tumours after a certain delay (Abse 1964; Abse et al.1973; Bahnson and Bahnson 1964; Bahnson 1969, 1975; Baltrusch 1956, 1975; Booth 1969). Longitudinal prospective studies, with more elaborate methodology, are rare; in broad outline, they share the conclusions of the former studies (Thomas and Greenstreet 1973; Thomas and Duszynski 1974; Greer and Morris 1975; Fox 1978; Greer et al. 1979). In his work of synthesis, Bammer (1981) has reviewed about two hundred works.

A central observation seems to run unanimously through all these publications: the experience, in the course of patients’ lives, of separation, emotional upheavals (for example, divorce), or very painful bereavements, often cumulative, and without the possibility of working through them in a favourable environment (LeShan 1963).

Galen, in the second century AD, thought that melancholic women were predisposed to breast cancer. This theme was taken up again in the eighteenth century by Gendron (1701), who found that his patients who suffered from depression and anxiety were more subject to cancer. Guy (1759) added a little more detail by observing that nervous and hysterical women developed cancer after existential traumas and bereavements.

In the nineteenth century, it was asserted that reverses of fortune, bad socio-economic conditions and ‘mental misery’ are at the source of carcinomas (Walshe 1846). In 1900, there was renewed insistence on the influence of emotional losses, bereavement, and melancholy. Evans, in 1926, was the first to formulate the basis for oncological psychodynamics, after having studied the material obtained in the course of a hundred psychotherapeutic treatments.

The losses in question can go back to early childhood and be reactivated by the events of adult life, sometimes several years before the appearance of the first symptoms of the disease (Wirsching et al.1982). ‘Loss’ and ‘lack’ seem to underlie the predisposition to cancer; to surmount this loss, the patient appears to have denied suffering so as to hyperadapt to reality, to the detriment of his emotional life. This would allow one to consider it as a psychosomatic construct, characterized by a rigid mental attitude, difficulty in expressing emotions, and a restricted capacity for forming relationships (Marty and M’Uzan 1963; Fain 1966). The doctor, in fact, is often faced with patients who present a virgin and uneventful psychological case history, a rather disquieting lack of capacity for depression, and with whom a dialogue, apart from small talk, is very difficult to engage in because of problems in making contact. These difficulties are not immediately noticeable, for everything seems to be working out for the best, but they appear as soon as one can test the possibility of a genuine encounter (Schneider 1969b). Certain authors have observed that their patients have oral fixations, which lead to their forming asymmetrical relationships of dependence on others, where altruism and the search for harmony are pursued to the detriment of their own interests. Attachment to others is a way of reassuring oneself and of fighting depression. Any failure in this system, appearing in adult life, inevitably gives rise to the reopening of early wounds. The consequence of this is a kind of psychosomatic regression, with emotional isolation, which seems to provide fertile soil for the growth of cancer (Rusch 1944; Fisher 1967; Vaillant 1977; Greenberg and Dattore 1981).

Thomas and Duszynski (1974) attempted to validate such observations by putting in hand a prospective study of a group of students at an American university. Those who were to develop cancer later were characterized by inability to express feelings, and they described their parents as cold and distant: for them, the repression and denial of affects seem to be bad prognostic factors. For Reznikoff (1955; Reznikoff and Martin 1957), women attacked by breast cancer are maladapted psychosexually and have been dominated by their mothers. LeShan (LeShan and Worthington 1956a; LeShan 1966), who studied 500 cancer patients over twelve years, discovered that three-quarters of them had had a traumatic experience, symbolic or actual, in childhood. Studying a group of breast cancer patients, Schmale and Iker (1964, 1966) noted that the longer the ‘lagtime’ before consultation, the more patients had recourse to denial, felt powerless to modify the course of their lives, and were socially isolated. They found a significant correlation between difficulty in communication and the development of tumours.

In taking as a base the psychological characteristics of cancer patients, Abse (1964) was able to determine, before any histological result, that 31 patients probably had lung cancer of the 59 who had to undergo a thoracotomy. Greer and Morris (1975) did the same, successfully predicting the result of breast lump biopsies on the basis of a psychological questionnaire. They described how the rate of malignancy was inversely proportional to the capacity to express aggression. Schonfield (1975), for his part, was less successful, in that he only managed to predict 27 cancerous lesions out of 112 biopsies, and he reckons that there is no correlation between malignancy and recent stressful event.

More generally, it has been noted that many behavioural factors have been associated with the onset of cancer. These factors seem to operate by way of several routes (Levy 1985), and we refer later to various cancer-related immunological processes. A large number of studies implicate several quite different types of psychosocial variables as predictors of cancer outcome (see Fox 1978 for a critical review). In the next section we see how a constellation of traits and coping styles may contribute to the ‘cancer-prone personality’.

THE PSYCHODYNAMIC APPROACH

The ‘cancer personality’ has been graphically described by several authors, including Bahnson (1980).

Some patients have bad memories of their childhood, with the impression of having lacked affection, and above all of never having been able to express needs and feelings in the face of cold and distant parents. In such a context, to express one’s resentments exposes one (in reality, or at least in one’s imagination) to the threat of desertion and break-up. Apparently, the only way of keeping a protective framework is to compel affection, by exercising a strict control over oneself (so being precociously reasonable), and by subjecting oneself rigidly to social norms (that is to say, to begin with, to the supposed rules of one’s parents).

Such a child can only maintain a harmonious relationship with his parents at the cost of great effort, in prematurely taking on too-heavy tasks, which goes together with a considerable feeling of inadequacy. This is one of the basic mechanisms of dependency. In adolescence, liberation is perceived as a too-painful deprivation, which one later tries to overcome by establishing bonds with an idealized object or by engaging with all one’s energy in an intense activity (producing conflict between the ideal of the ego and reality). A new affective trauma in adulthood, if it is superimposed on such a history, can only be devastating. The individual, having learnt to be wary of his parents and to control his hostility towards them, transfers these feelings to his partner. When there is a break-up, the despair of infancy, up till now well camouflaged, springs up, reactivating all the old wounds.

Table 1.1 The at-risk personality (after Bammer 1981)

Bereavement or divorce may precede the onset of cancer by several years. The patient, who has already more or less survived severe psychological difficulties since adolescence, is not equipped to cope with this new attack. He turns in on himself and becomes isolated from other people. This break-up involves a psychological regression to old ways of coping. Instead of expressing his suffering, his helplessness, his sadness, or his tragedy, the patient represses his emotions, as he learnt to do when younger. He tries to overcome everything stoically, head held high, and relying henceforth on his own strength alone. Thus pathological relationships are exacerbated, and the individual expects no help from others. He will put people off the track by appearing pleasant and adaptable. The cancer would thus appear as a sort of solution, a response to all expectations. Psychosomatic regression makes the body sick, but at the same time it gives one permission to have the right to say at last ‘I suffer’, to ask for help, perfectly justified this time, and at the same time to set limits. In fact, being ill also means not being able to respond to what one imagines to be the excessive expectations of others. It is also a way of saying: ‘I am incapable of telling you what I want, but since you can’t guess my needs, I will destroy myself.’

This psychodynamic model establishes a link between repeated emotional stress and cancer. One could say that we are dealing with people who have developed a double life, or a double self, or else a fundamental ambivalence, with on the one hand a definition of self well adapted to reality and to others, and on the other, deeply buried, a ‘phantom ego’, which feels isolated, unloved, hurt, and often empty (Table 1.1).

THE SYSTEMIC APPROACH

We have seen that impassivity, rigidity of behaviour, struggle against depressive tendencies, and loneliness may result from affects that were inhibited during childhood; these are the mechanisms which are called ‘repression’ or denial and which may be secondary to the threats (supposed or actual) hanging over the unity of the family of origin (Kissen 1963; Bahnson and Bahnson 1964; Henderson 1966; Derogatis et al. 1979a). In this type of family, where mutual isolation and distancing are the rule, a certain precocious individuation is necessary, for the child can neither say who he is nor share his experiences with his relatives. It is in such conditions that, often, the repression of these negative feelings (sadness, anger, or jealousy) and the inhibition of desires appear in order to ‘protect the family equilibrium’: one has the impression that in such systems the emphasis is not on social opening-out, adaptation, and blossoming, but rather on self-mastery and control. Thus the future patient has made a habit of relying only on his own strength, and he expects no extra help from his family circle. It is precisely when he finally realizes that he is alone that he will fall ill. Certain studies (Greene 1966, Schmale and Iker 1966) seem to indicate that the passage of the family through an important stage of the life cycle—the emancipation of the children, for example—may also engender illness: breast cancer in the mother, or else leukaemia, Hodgkin’s disease, or testicular cancer in the young (according to Minuchin’s 1974 model of families with psychosomatic transactions). This would seem to be a decisive moment for activating a latent biological process. One could nevertheless doubt whether this scenario is specific to cancer and wonder if one has here enough elements to speak rather of a general tendency to illness than of a particular type of ailment. Indeed, according to certain authors (Hinkle et al. 1958; Greenberg and Dattore 1981), the patients who have the most risk factors do not inevitably develop cancers rather than other types of illness (cardiovascular for example), nor do they develop one type of cancer rather than another.

In conclusion, and with reference to the contextual theories of Boszormenyi-Nagy and Spark (1973), one could say that this type of cancer patient has had a career as a ‘parentified child’, preferring family stability to his own processes of individuation, in the face of unreceptive parents who offer few rewards. If the balance of ‘debits and credits’ is too unfavourable to the person who has followed such an itinerary, he will perhaps ‘gain’ this ‘right to destroy’, which is the source of many behavioural disorders and psychiatric problems. Further, depending on the degree of inability of the family to change, one could imagine that the patient turns this ‘right to destroy’ against himself, and that then the cancerous illness would correspond well with that ‘narcissistic’ regression described by other authors (Bahnson 1980).

BIOPSYCHOSOCIAL PERSPECTIVES

Some research suggests that behaviour, life-style, social environment, and stress play a part in the onset of cancer. It is in all probability the endocrine and immunological mechanisms which make the link between the context, the individual, and his organic carcinogenic determinants. The biopsychosocial model (Engel 1977) and general systems theory (von Bertalanffy 1964) offer a way of integrating psycho-oncological data. In fact, if we limit ourselves to the biomedical model we can hardly achieve an integrated understanding of cancer, which has a multidimensional aetiology (Baltrusch and Waltz 1985).

Stressful life events require increased efforts of adaptation on the part of the individual, and generally lead to painful states of tension; depending on the gravity of the situation, this may bring about the exhaustion of the capacity to fight, and to ‘giving up’. For a physical illness to ensue, a synergy seems to be necessary between stress, the patient’s personality structure and an unfavourable sociofamilial situation. Certain authors posit that external factors contribute to the direct induction of tumours and to the proliferation of cancerous cells, after exposure to a certain number of carcinogens (Sklar and Anisman 1980). Epidemiological studies have demonstrated, for example, that compared with the average for the population of the same age, widows or divorcées suffer more from depressive illness, cardio-vascular diseases and cancers (Weisman and Worden 1975, 1976–7). Some people have exhibited anomalies in the immune function after bereavement, with a significant diminution in the number of lymphocytes (Ader 1975; Dutz et al. 1976).

The richness of social relations plays a considerable part in the maintenance of the mental and physical health of the adult. It is clear that good-quality affective bonds are an essential factor in helping one to cope with difficult existential situations. Conversely, poor relationships, notably an undermined marital or family background, constitute a very unfavourable milieu. This is an argument which must be taken into account when caring for cancer patients, where a certain kind of pathology in relationships makes for difficulty. It is necessary to observe how the patient interacts with the therapeutic team, because that will be evidence of his early experiences of socialization. It is thus that the same factors that have hampered emotional development have played a not inconsiderable role in the pathogenesis of the disease and have influenced the cognitive and affective processes of response to stress and to cancer. All these aspects add up to the fact that in therapeutic practice one may well have to deal, without really being aware of it, with a natural selection of ‘good’ and ‘bad’ patients. In fact the most common tendency is to deal most and best with those who are at the least psychosocial risk. We have seen that the personal life-style of the patient, the manner in which he has led his life and been able to flourish, already give him effective adaptive resources and influence his prognosis. People who are inhibited, hyper-adapted, conformist, norm-fixated, and rejecting depression will create a corresponding attitude among the carers and render them inadequate or insufficient. It is for these people that a systematic programme of support must be developed.

THE PSYCHOBIOLOGICAL MODEL OF CANCER

The preceding pages show that we still have no fundamental understanding of the aetiology of neoplastic diseases at all levels of organization of the human being. The only certainty is that somatic mutation is an important factor, but is not a sufficient explanation for cancers (Greer and Watson 1985). More simply, one could say that there are mechanisms which control tumour growth and cellular dissemination, where the psyche certainly plays a protective role. Conversely, with certain individuals, psychological conflicts contribute to the emergence of cancers in synergy with biological disturbances. The role of stress has been mentioned (Greer and Morris 1975) but also contested (Schonfield 1975). One explanation of this contradiction is that often, in replying to questionnaires, patients are reluctant to admit that they have been through painful existential episodes. Moreover, retrospective studies introduce other uncertainties, because stories are reinterpreted. Enquiries often have recourse to psychometric tests which were originally established for psychiatric patients (the MMPI) and not tested on the very different population of cancer patients (Shekelle et al. 1981). Depressive antecedents, which often figure in the literature, may also be unreliable as a predictor (Greene 1966; LeShan 1966). Since the start of a cancer cannot be dated with accuracy, it is quite possible that depressive episodes were provoked by cancers already evolving but still undetected (Kerr et al. 1969) rather than by traumatic events. The only point of agreement is that there is some correlation between the diagnosis of cancer and a certain kind of behaviour characterized by abnormal control of aggression and affects (Bahnson and Bahnson 1966). The work of Greer demonstrates, for example, that women of under age 50 affected by cancer express less anger than members of a healthy control group of the same age (Greer and Morris 1975). According to another study, women who have had a mastectomy show their anxiety less, are apparently more optimistic and have a tendency to avoid conflicts (Jansen and Muenz 1984). Studies of melanoma have come to the same conclusions, with a discrepancy between the anxiety which is acknowledged, that is to say none, and that registered by electrodermal activity (Kneier and Temoshok 1984). But all is not yet clear. For certain people, emotional inhibition and the capacity to develop a cancer may both result from genetic factors and need not be in a causal relationship.

As with the personality of the coronary patient, there have been attempts to define a type ‘C’ behaviour typical of the cancer patient (Morris 1980). This is characterized principally, as seen above, by the inhibition of emotions and of aggressive reactions, as well as by conformism, exemplary submission, relationships without conflict, and patience. The importance of this profile is useful for indicating a prognosis. For melanoma, for example, this corresponds to the more invasive tumours (Temoshok 1985). A crucial element for behavioural research is that one would be dealing with suppression of behavioural responses rather than with repression of feelings (Greer and Watson 1985). In fact, in that study the subjects admitted ...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• TABLES
• FORWORD
• PREFACE TO THE REVISED EDITION
• TRANSLATOR’S NOTE
• INTRODUCTION
• CHAPTER 1: PSYCHOSOMATICS AND CANCER
• CHAPTER 2: LIFE TURNED UPSIDE DOWN
• CHAPTER 3: THE CONCEPT OF ‘QUALITY OF LIFE’
• CHAPTER 4: THE PAIN OF THE CANCER PATIENT
• CHAPTER 5: PSYCHOPHARMACOLOGY AND CANCER
• CHAPTER 6: THE DIAGNOSIS
• CHAPTER 7: THE DOCTOR
• CHAPTER 8: NURSING CARE A SPECIAL RELATIONSHIP
• CHAPTER 9: CONTINUITY OF CARE
• CHAPTER 10: TREATMENTS
• CHAPTER 11: COMPLEMENTARY MEDICINE
• CHAPTER 12: THE PSHCHOSOCIAL APPROCH
• CHAPTER 13: TERMINAL ILLNESS
• BIBLIOGRAPHY
• APPENDIX 1 SOME USEFUL ORGANIZATIONS
• APPENDIX 2 DECLARATION OF RIGHTS OF PEOPLE WITH CANCER