Psychodynamic Psychotherapy for Cancer Patients

Abstract

Psychodynamic psychotherapy is effective as an approach to understanding the psychological conflicts and the psychiatric symptoms of cancer patients as well as to planning useful psychological interventions. The author recommends that the psychotherapist who treats cancer patients be familiar with the following: 1) the natural course and treatment of the illness, 2) a flexible approach in accord with the medical status of the patient, 3) a common sense approach to defenses, 4) a concern with quality-of-life issues, and 5) counter- transference issues as they relate to the treatment of very sick patients. Case reports illustrate the unique problems facing psychotherapists who are treating cancer patients. Further, these cases show the effective use of psychodynamic principles to inform the therapist of successful psychotherapeutic interventions.

The model of psychodynamic psychotherapy is particularly useful for understanding the emotional reactions of patients with cancer. It provides a point of view for clarifying the onset of psychiatric symptoms in response to the stresses of having a cancer diagnosis. It also offers a perspective on the doctor–patient relationship that is useful for understanding and resolving conflicts. Compliance and noncompliance with treatment recommendations for cancer can be understood in terms of transferences and resistances as in a psychoanalytic psychotherapy.

Current psychoanalytic theoretical models add to an understanding of the emotional symptomatology of the cancer patient as well as provide a point of view for intervention. The ego psychological model offers a look at defenses and coping mechanisms. The object relations model is helpful in terms of understanding the threat of object loss and the relationship between patient and caregiver. The model of self psychology is pertinent to the threat to the integrity of the self and the need for an empathic approach.

This article briefly reviews findings on the effects of psychosocial factors and psychotherapy on medical outcome, recurrence, and length of survival. The article also highlights certain unique issues that I feel are important in any psychotherapy with cancer patients. Phases of the cancer illness and psychological problems of each phase, including case reports, are presented. Each case is examined from a psychodynamic point of view in terms of how the patient was understood and how the psychotherapy unfolded.

Background

Psychosocial factors, as well as psychosocial interventions, have now become issues for study in relationship to cancer onset, quality of life, and length of survival. It is now documented that emotional expression,¹ social supports,² lower levels of emotional distress,^{3, 4} and a fighting spirit^5–7 tend to be associated with improved survival time in cancer patients. It would therefore be reasonable to expect that psychotherapeutic interventions that address these issues might improve quality of life, decrease level of stress, and improve survival time for cancer patients.⁸ Hill et al.⁹ in a recent review showed that in 12 of 17 controlled studies, the psychotherapeutic interventions were efficacious in reducing psychological stress; only 2 studies showed no benefit.

Some studies have indicated a direct beneficial effect of social support on survival time. The first and most publicized study of Spiegel et al.¹⁰ showed that at 10-year follow-up there was a statistically significant survival advantage for women with breast cancer who had participated in group therapy treatment. They lived an average of 18 months longer than control subjects. Richardson et al.¹¹ reported the effects of home visits and educational interventions on leukemia and lymphoma patients. The intervention group lived significantly longer, even when differences in medical treatment were controlled for. The conclusion was that the psychosocial intervention was the significant variable. Finally, Fawzy et al.,¹² working with melanoma patients, documented a survival advantage and lower rates of recurrence for 40 patients randomly assigned to 6 weeks of extensive group psychotherapy. There are as yet no controlled studies of the impact of individual psychotherapy on recurrence or survival time; however, clinical experience is suggestive.

A very brief review of the psychodynamic psychotherapies is helpful before we examine typical psychological problems of patients with cancer who present for consultation. Briefly, the spectrum includes psychoanalysis and the psychoanalytic psychotherapies such as the exploratory, ego supportive, and crisis intervention therapies.¹³ The insight-oriented psychotherapies are most closely related to psychoanalysis. The common elements include a focus on core conflicts as they present in the patient's present life situation, in past family history, and in the transference. These conflicts are analyzed and worked through actively, with the therapist in a position of neutrality. The crisis intervention model^14,15 attempts to relieve symptoms and stabilize the crisis by reviewing recent events, allowing a catharsis, and manipulating the environment. Ego supportive therapy includes support, reassurance, and encouragement. The goal is symptom suppression while promoting a positive transference.

Approaches to the Cancer Patient

Anyone contemplating conducting a dynamic psychotherapy with a cancer patient must have some familiarity with the phases of the cancer illness and the challenges presented to the patient and doctor.¹⁶ Patients who present for psychotherapy in any stage of the cancer illness require a very flexible approach. They need to be evaluated initially on the basis of their presenting symptoms as well as their physical health and the stage of the disease. They also need to have a psychiatric and psychodynamic evaluation. The shifting nature of the disease, with diagnosis, therapy, remissions, recurrences, and terminal illness phases, requires that the person conducting psychotherapy be flexible in his or her approach. Psychoanalysis and/or insight-oriented psychotherapy may have to give way to crisis intervention and supportive therapy (temporarily or permanently, depending on the medical condition of the patient), whereas patients who might first present for crisis intervention or supportive therapy may later require a more intensive psychotherapy. Furthermore, the psychotherapist must be flexible in regard to the need for medication or for a referral for behavior therapy for conditioned nausea.

I also suggest a common sense approach to defenses¹⁷ as they relate to coping with the cancer illness and treatment. Defenses should be evaluated in terms of whether they are adaptive and promote optional coping and compliance, or whether they are maladaptive. Preconceived notions such as “denial is good” or “denial is bad” do not make sense in the clinical situation. Denial will serve the patient well if it wards off anxiety or depression without interfering with compliance or the patient's life goals; the affect associated with the prognosis is frequently denied. Others, however, might use denial of their state of health to avoid necessary medical appointments. In such instances, denial must be confronted to allow for maximum quality of life. Similarly, regression must be evaluated in terms of its clinical consequences. Regression in terminally ill patients is clinically helpful and can be encouraged, whereas regression in patients in remission needs to be confronted and challenged. These principles are well illustrated in the clinical examples that follow.

Psychotherapists also need to keep quality-of-life issues in focus.¹⁸ The expected life span, the patient's relationship to the oncologist, and issues related to the patient's symptoms should never be far from the psychotherapist's attention. One must be an advocate for the patient in this regard and not remain passive. I would also recommend a focus on continuity of care, so that patients whose psychotherapy terminates are encouraged to return should their disease progress.

Finally, special attention is required in dealing with one's countertransference (N. Straker, unpublished). A failure in this regard will lead to self-protective mechanisms that keep the therapist from engaging with the patient in an empathic, helpful manner. In fact, it might result in premature therapeutic termination or in abandonment of the patient. Other reactions include hopelessness, depression, anxiety, and low self-esteem. I have been impressed each year with the emotional reactions of each new group of psycho-oncology fellows who feel overwhelmed and wonder if psychotherapy has much to offer these people who face pain, terror, death, and despair. They have yet to recognize the power of an empathic relationship and the transference, especially in terminally ill patients. Supervision and support groups with case discussions are very helpful in preventing these reactions and forestalling burnout.¹⁹

Phases of Cancer

First Phase: Diagnosis

The first phase is the diagnostic and initial treatment phase. This phase is usually handled surprisingly well by most patients.²⁰ Shock, disbelief, anxiety, some depression, guilt, and bitterness usually are buttressed by the hope that the initial treatment will be successful. A positive transference to the healing physician is very important and most common. However, some patients require psychotherapeutic intervention at this stage. For some patients who have devoted themselves to trying to avoid illness through diet, exercise, and a healthy lifestyle, a cancer diagnosis can be a major affront. Many patients feel they have caused their cancer by not handling their life stresses well enough and thus producing a failure of their immune system. Others who might also seek psychotherapy are overwhelmed by the fear of death; the fear of dependency; the threat of loss of power, attractiveness, and income; or existential anxiety about the meaning of life. Some patients, referred by oncologists, cannot comply with treatment recommendations because of denial, obsessive paralysis, or depression.

In general, the psychotherapeutic efforts during this period are primarily directed toward adapting to the crisis and choosing the appropriate treatment. The ego supportive and crisis intervention models are usually effective on a short-term basis with most patients. Symptom suppression can usually be accomplished by both methods. Occasionally, the addition of psychopharmacological intervention will assist in this process. For others who have long-standing character disorders, the stress of illness may require an insight-oriented psychotherapy to enable them to deal with potential compliance issues and arrive at some acceptance of this new reality.

Clinical Examples

1. A middle-aged woman with breast cancer and a knowledge of the effects of stress on the immune system was referred for brief psychotherapy. She was depressed, pessimistic about her prognosis, and filled with guilt, feeling that she had caused her disease. She was sure her marital infidelities were responsible for causing her cancer—a fitting punishment, she thought. The early phase of psychotherapy allowed her to deal with the fact of being a cancer patient. She was also helped to relate her guilt feelings to her marital infidelities. Her own theory of causality, with cancer as a punishment, was contrasted with scientific knowledge.

This patient was depressed in response to the narcissistic injury of losing her good health. Her character was highly narcissistic with obsessive features. She had always prided herself on being in control and being fit. To become ill was a devastating blow. She reestablished some sense of control by blaming herself for the cancer and feeling guilty.

The psychotherapy evolved into several phases. A positive transference was encouraged while the patient was helped to mourn the loss of her good health. She was also encouraged to take control of understanding her disease and the reasons for her marital infidelities. She worked to improve her marriage, as well as to understand why she was unfaithful. She also became committed to fighting her cancer and became an advocate for more research funding for cancer. She was discharged from psychotherapy after a year and a half of twice-a-week psychotherapy feeling more in control and optimistic. Long-term follow-up of 5 years showed her to be well and still involved in fundraising for cancer research.

2. The next case did not go as well. Despite a dynamic understanding of the case, the resident therapist in supervision experienced the same hostile and aggressive feelings as the referring oncologist. A middle-aged woman with ovarian cancer who had difficulty keeping her scheduled chemotherapy appointments was referred for psychotherapy because of noncompliance. She had a history of long-standing authority problems and marital conflict. Within a few psychotherapy interviews, she developed a negative transference, repeating the problems she had with the oncologist. The psychiatric resident pointed out her core conflicts as they reappeared in the psychotherapeutic relationship. The psychotherapy was stormy, with many arguments that repeated the problems the patient had had with her husband and her father. The patient eventually quit her therapy and was lost to follow-up.

3. In a more successful intervention, a psychiatric resident in supervision was able to intervene and preserve the cancer therapy through interpretive dynamic psychotherapy. A young woman with a history of childhood sexual abuse was referred to psychiatry because of difficulty cooperating in vaginal exams and a refusal of vaginal implants, the treatment required for her advanced cervical cancer. The patient's difficulty in complying with the treatment was understood to be the result of a resonance with earlier childhood traumatic experiences. Insight-oriented psychotherapy was recommended. As the female resident continued working with her, the patient recognized her feelings of being invaded by the psychotherapist, and she expressed the desire to discontinue her psychotherapy. Skillful interpretive work by her psychiatrist allowed for a working through of her core conflict of experiencing the repetition of sexual abuse in the psychotherapy, the vaginal exams, and the radiation implants. The therapy allowed for compliance and a good outcome. This intervention was brief, one time per week, until the cancer therapy was complete.

Second Phase: Follow-Up

The follow-up phase after the first cancer treatment (surgery, chemotherapy, and/or radiotherapy) is usually greeted with mixed emotions. The patient is pleased to be done with the rigors of treatment and side effects, but now has to face the future with less certainty of good health. This new vulnerability may be denied by some or become overwhelming to others. The threat of recurrence or of an early death may lead some patients who have achieved a somewhat fragile adaptation to regress and become dysfunctional. Others, who had previously never faced their own mortality, will have to come to terms with unaccomplished life goals and the pressing need to immediately address them.

Patients referred for consultation during this phase of their illness tend for the most part to be in remission and physically well. This is the phase in which referrals for dissatisfaction with relationships and/or careers will be most prevalent, the result of character pathology. I recommend that assessment of these patients for psychotherapy be based primarily on their psychological needs and psychiatric diagnosis. In this group, there will be some who require insight-oriented psychotherapy or psychoanalysis. Such patients will be those who have strong motivation, psychological mindedness, tolerance for anxiety, and enough intelligence to engage in a process that could offer significant psychological change.

Clinical Examples

1. A middle-aged man with lymphoma was described as the ideal patient during his arduous chemotherapy treatment. When the treatment was over, the oncologist expressed surprise that with an excellent result and a good prognosis the patient was depressed and panicky. The patient, an overachiever, had always taken control of his life, beginning at age 8 when he first began delivering newspapers. He never received financial help of any kind from his family. His hard work and take-charge attitude resulted in great success in the corporate world and the belief that he alone could totally control his destiny. He emotionally confronted the reality of his cancer only after he had finished his chemotherapy. He felt totally vulnerable, panicky, and unable to depend on anyone. Dependency was to be avoided at all costs, as it had only led to rejection and disappointment during his childhood.

The early phase of psychotherapy focused on the importance of establishing a relationship with the therapist. His childhood and the coping mechanisms he used were reviewed and discussed in relationship to his reluctance to count on anyone. At the same time, he was encouraged to accept his need to depend on his wife and children, as well as his therapist. He was also helped to experience the feelings he had dissociated and suppressed during his chemotherapy. His need for control was redirected to healthier pursuits. He began to learn about his cancer and to focus on how he might cope with it. He became interested in the importance of diet and exercise, as well as modifying his lifestyle in an effort to “control his destiny.” He became partners with his therapist in his exploration of how to have a healthier lifestyle. He felt more optimistic and less vulnerable 6 months after his remission, and he claimed he looked and felt younger and stronger than before he became ill. An understanding of the character and defenses of the patient allowed for this psychodynamic intervention, which addressed the suppression of affects and the need for dependency and redirected the patient to once again take control of his life by encouraging him to adopt a healthier lifestyle.

2. Two female patients in their twenties presented severely regressive symptomatology after arduous treatments for cancer. One patient had extensive chemotherapy for bone cancer; the other patient had two bone marrow transplants for lymphoma. They both achieved a marginal adult adjustment after a stormy adolescence and difficulty separating from home to go to college. The mothers of both patients were reported to have very disturbed personalities. The fathers were both highly successful and had the closest attachment to their daughters with cancer. During the cancer treatments the patients returned to their parents' homes and became enmeshed in old family dynamics. The marriages of the parents in both situations underwent serious strain. At the end of the cancer treatments, both patients were totally dysfunctional and regressed, unable to separate from their parents (especially their fathers) and resume independent living. As a transition to independence, both patients required an intensive supportive psychotherapy three to four times per week. In both cases, the treatments were successful in dealing with the cancer experience and working through conflicts from the past. This allowed the patients to resume their independent lives: a legal career in one case, postgraduate school in the other. One of the patients had psychoanalysis for 5 years and, at follow-up, was well and married with two children.

3. In several cases, workaholic males with very successful careers have presented for psychotherapy following remission of cancer. They are narcissistic characters with shallow relationships whose main interest in life is becoming very wealthy. The confrontation with their own mortality has left them with a life-crisis unparalleled. When they present for psychiatric consultation, their lives feel meaningless and without a legacy. These patients have generally been best suited to an intensive psychotherapy or psychoanalysis. Improved relationships as well as active involvement in charitable organizations have led to a more satisfactory adjustment.

In the above cases from the treatment and remission stages, the patients have all done very well both psychologically and in terms of avoiding a recurrence. The female patient with the negative transference who quit was the one exception. It is tempting to postulate a causal relationship, but clearly without controlled studies such a conclusion would be fallacious.

Third Phase: Recurrence

The recurrence and re-treatment phase tends to repeat the diagnostic and first-treatment phase, with the following major differences. The meaning of recurrence makes the patient less hopeful for cure. Patients may blame themselves or their doctors for what is usually considered a failure. Anger, depression, anxiety, and distrust will be more prominent. Alternative treatments are more likely to be sought out. Compliance with medical recommendations may be lower than before. Problems erupt in the doctor–patient relationship, especially hostility toward the doctor.

Psychotherapeutic issues more closely resemble those in the diagnostic and initial treatment phase. Crisis intervention and ego supportive therapy, with or without medication, will often be sufficient to reestablish medical compliance. However, patients with character problems will be in need of a more intensive insight-oriented psychotherapy that will highlight the problem of compliance as it reappears in the psychotherapeutic relationship in the form of resistance. Others, whose compliance problems are related to maladaptive defenses such as denial, require confrontation so that they can have an opportunity to mourn their hopes for continual remission and begin to accept the need to choose a new therapy.

Patients referred following recurrence of cancer have often suffered the consequences of relying too heavily on the psychological defense of denial in relationship to their illness, prognosis, or state of health. Following are several examples, with psychotherapeutic strategies appropriate to the psychiatric diagnoses and medical conditions of the patients.

Clinical Examples

1. A 70-year-old man with no history of manic-depressive disease was referred for consultation when he became manic on learning of his recurrence. He had all the symptoms of mania and was unable to comply with recommendations to discuss the need for more cancer or psychiatric treatment. History revealed a successful businessman with a life dedicated to physical fitness and weightlifting even at age 70. He was sure he had beat the cancer. It was quite difficult to enlist the cooperation of the patient in treating the manic episode. The psychiatric resident invoked family pressure after the patient engaged in wild spending sprees. Finally, the patient accepted lithium. The task in the psychotherapy was to confront the patient's denial with the utmost sensitivity and tact so that he would not flee the treatment. He did become depressed, as was expected, and was continued in a supportive psychotherapy with antidepressants and lithium. The intervention allowed for more chemotherapy and a successful remission.

2. A young man in his thirties who prided himself on his independence could not accept his deteriorating health from a recurrent lymphoma. In fact, his denial was so great that he applied for a work position that was in a distant city and required physical vigor. His oncologist, recognizing his flight from reality, referred the patient for psychotherapy. This psychotherapeutic treatment required sensitivity, but, after a supportive relationship had been established, it also required direct confrontation of his denial. After several sessions, the resident therapist, with encouragement from his supervisor, did confront the patient. The resident pointed out the patient's need—because of his fear of being dependent— to try to flee his weakness and failing health by pretending he had the vigor of a man without cancer. This interpretation, repeated several times, allowed the patient to begin to talk about his fears of being feminine and weak when growing up. The patient became very emotional and temporarily very dependent on the resident therapist for frequent psychotherapeutic sessions. The resident therapist felt quite guilty about disturbing the patient's psychological defenses, and worried about whether the patient's upset mental state might lead to his becoming less able to fight his cancer. The supervisor supported the resident, reminding him of the need to confront the patient's maladaptive denial and fears of dependency and accept the patient's temporary upset and need for dependency. The patient continued in a long-term supportive therapy while complying with the chemotherapeutic regimen.

Fourth Phase: Terminal Stage

The terminal palliative phase is the most difficult, especially for physicians. Only recently have medical students and physicians been better taught to deal with the terminal phase of illness. Palliative techniques can reduce pain, anxiety, depression, insomnia, and other discomforts to tolerable levels if physicians have been taught well and can face the death of their patients. Psychiatric consultation in the hospital during this phase is quite common. Aside from the management of delirium, anxiety, or depressive symptoms, some patients and their families request psychiatric intervention to discuss when to terminate active treatment and how to live knowing your time is limited. More recently, some patients have wanted to discuss assisted suicide. Occasionally patients are more realistic than their physicians regarding their prognosis and need assistance in asserting their desire to end heroic treatments. Others need affirmation about the life they have led and may need to address unfinished business in relation to family members or friends. Still others need comfort and empathic supportive relationships because they fear abandonment. Treatment based on an understanding of Kohut's idealized and omnipotent transferences²¹ and an encouragement of regression in the terminal phase is of great comfort to some patients. Norton²² recommends helping the patient to defend against object loss by facilitating a regressive relationship. Deutsch²³ writes about the importance of settling differences. Eissler²⁴ recommends that the psychiatrist share the patient's belief in immortality and indestructibility, as well as sharing the patient's defenses and developing an admiration for the patient's inner strength. Finally, Cassem²⁵ emphasizes a common sense approach and regards listening to the patient tell his or her own story in a supportive relationship as most therapeutic. Tact and support are essential.

Clinical Examples

The following case examples illustrate the value of a psychodynamic approach to the terminally ill patient who is undergoing palliative care. The first case illustrates the importance of recognizing that some cases of depression in patients who have led active, controlling lives are due to feelings that they have lost all control and power as they get physically weaker. The psychotherapeutic intervention that allows the person to take some control and exercise his or her power even while bedridden can relieve the sense of passivity and hopelessness. The second case focuses on the importance of providing affirmation and selfobject relatedness to a patient who was experiencing excessive isolation and feelings of abandonment. The third case, with similar dynamics to the second, required the addition of heavy doses of anxiolytic medications to permit sufficient regression to enable the patient to experience the staff as idealized, omnipotent parent images so that her panic feelings of helplessness would be dissolved.

1. A 68-year-old man in the terminal phase of his disease refused to make a will or help his family make plans to manage his large and successful business. All his life the patient had been a very active man who took great pleasure in being “in charge.” His failing health had resulted in an uncharacteristic passivity and severe depression. Discussion with the patient centered on reviewing his former life pursuits, his pleasure in having taken care of his family over the years, and his need to feel that he was still in control. He was helped to become aware that he still had the power to affect the future of his family and business. The patient was again able to assume an in-charge position. He subsequently made out a will and began teaching members of his family how to run the business. His new sense of purpose resulted in significant alleviation of depression, even in the final weeks of life.

2. A 71-year-old married father of two, terminally ill with colon cancer, felt the need to talk about his life and resolve some family matters. This was his first request for psychotherapy. He had led a very active, successful professional life and was accomplished in the community and socially. He had not been able to successfully communicate intimately with his family. He had some guilt in this regard. The therapy focused on mirroring his life accomplishments, providing the intimacy he felt he had lacked, and encouraging him to broach the subjects he felt he had neglected with his family. The psychotherapy continued until the patient died. The treating resident felt the satisfaction of helping this patient improve his final days by encouraging him to communicate more intimately with his family while affirming his life accomplishments.

3. A 52-year-old divorced mother of two children became progressively panicky as her breast carcinoma showed symptoms of spreading to the brain. She lost a quadrant of her visual fields, and this was followed by weakness in her legs and arms. This nightmare promoted a severe helpless panic. The patient, whose level of consciousness varied, was quite panicky when conscious. Her psychiatrist's use of a combination of benzodiazepines and major tranquilizers and his twice-daily visits, however brief, were an attempt to tranquilize her without undue sedation and regress her to the state in which he and other staff members functioned as omnipotent selfobjects. The family was grateful for the extra time the patient could be conscious, as a result of minimal sedation without panic, until she slipped into a coma.

Comment

The cases reported in this article demonstrate several of the important principles that are unique to the psychotherapeutic work with cancer patients. These principles include a focus on the medical illness, an adaptive, common sense approach to defenses such as denial, a focus on quality-of-life issues, and a special sensitivity to countertransference issues as they relate to patients with cancer. The fear of disrupting patients' defenses can often result in therapeutic passivity. Also, common countertransference issues such as hopelessness or depression, especially when a therapist is confronting very sick or terminally ill patients, often lead to premature withdrawal from patients. Psychiatric residents often feel nihilistic about what they can offer patients, particularly in the terminal or palliative phase of treatment. Supervision and case conferences should emphasize the value of the transferential relationship along with practical therapeutic approaches that can enhance the quality of life for patients in the final phases of life. This emphasis in training will counter the “what can I do?” attitude of those with little experience treating terminally ill cancer patients.

Dynamic psychotherapy with cancer patients is emotionally challenging, intellectually stimulating, and highly rewarding. Time pressures will often enhance the motivation for psychological change and allow the patient and therapist to work productively and rapidly toward resolving long-standing conflicts. Work of this kind requires therapists to believe in the value of dynamic psychotherapy in the face of pain, suffering, and death, and to be able to cope with intimacy and separation without undue disruption to themselves.

Acknowledgments

The author thanks the Fellows in Psycho-Oncology at Memorial Sloan-Kettering Cancer Center for permission to use some of their cases in this presentation.