Psychotherapy and the Treatment of Cancer Patients

Bearing Cancer in Mind

Lawrence Goldie, Jane Desmarais

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135446475
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Psychotherapy and the Treatment of Cancer Patients addresses the need for a more integrated care of cancer patients within hospitals which pays attention to the mental anguish as well as physical distress caused by the disease. This book is based on Lawrence Goldie's own research with cancer patients, which has shown that psychoanalytic psychotherapy together with general medical care can significantly help dying patients cope with the pain and suffering associated with the disease.

Drawing on this research, the book advocates a more holistic approach to the cancer patient and suggests ways in which more expert attention might be provided through awareness, training and resources. The book describes the innovative approach of applying the psychoanalytic psychotherapeutic approach within the hospital context to help individuals cope with cancer. As well as an overview of cancer and the therapeutic approach, topics covered include:

* the impact of cancer on hospital relationships

* cancer in different areas of the body and mind

* 'mind-bending pain'

* dread and trauma- on being told the truth

* psychoanalytic psychotherapy in the NHS 'general' hospital

* examining group processes in hospital.

Psychotherapy and the Treatment of Cancer Patients challenges the existing orthodoxies about palliative care and points to ways in which the principles and methods of psychoanalysis can be applied successfully to cancer care within the hospital context.

Chapter 1

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In the front line with cancer

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The discovery of cancer plunges the normal individual into the abnormal world of the hospital. It can be a dehumanising process: individuality is lost. Dresses and suits are replaced by simple night attire, dressing gowns are nondescript; individuals become ‘patients’ with a number more important than their name. They are disempowered and beholden to all ‘non-patients’. In becoming ill, they enter hospital, a world apart, where no one really listens to anything but answers to stylised questions. What cancer patients suffer from first of all is a kind of shell shock brought about by the diagnosis and the dislocation from ordinary life. Cancer engenders considerable trauma.

In this chapter, I compare working with cancer patients to being in the line of action in a war situation, and having cancer to having the symptoms of shell shock. In the same way that soldiers during the First World War suffered from psychological trauma that went unheeded, I argue that the mental states of cancer patients have been ignored. Psychoanalytic psychotherapy is an important intervention for patients within the hospital context, and in the clinical cases selected in the second part of this chapter there is a transformation in the suffering individual as they begin to talk and to be listened to. Some patients experience a release of creativity whereas others are able to change their way of thinking and show concern for others at the most painful part of their life.

An attrition of the self

The first observations of psychological reactions to trauma were made during the First World War, most notably by W.H.R. Rivers.¹ The conditions that men endured at that time were unprecedented. Rivers found that what he saw in his patients confirmed much of what he had read in Freud, the only person to have made a systematic study of mental processes. In his observations of war trauma, Rivers found that there were confusing moral issues to be considered. What did it mean to get one of these men ‘better’? Medically, it was to help them recover their pre-trauma state, but militarily it was to return them to the very conditions that had produced their breakdown. These two aims were in conflict in his mind.

Carl May (1998) quoting from Lord Moran’s 1945 ‘Memoir’, describes the soldiers of the 1914–18 war as men who were unafraid of death if it came swiftly and decently, but who were unable to cope when they were hit by random shelling on a huge scale. It was too much for them. They were too passive. May comments:

Courage, of course remained the normative expectation of the fighting man. However, the way in which courage itself was conceptualised changed: it shifted from episodic physical heroism to stoical endurance and adjustment to powerlessness. The individual soldier on the Western Front often appeared to have little effect on the outcome of anything; his actions only became meaningful in relation to membership of a group that suffered annihilation in the most random way. Individuals faced the prospect of weeks and months of physical and psychological hardship followed by a random, meaningless and repulsive death.²

It was Elliot Smith, however, Professor of Anatomy and Dean of Medicine at Manchester University, who argued in the Lancet in 1916 that the real trauma of war was ‘psychical not physical’. He called it ‘war strain’ not ‘shell shock’ and he argued that ‘it was due to “an attrition of the self”, suffered by exposure to terrible anxiety and reminders of their own peril by the deaths of those around them’.³ He realised that individuals in war were exposed to unprecedented conditions, and that the war precipitated great numbers of people from their everyday lives into another world; a world of obscene mutilations and death. This could apply to a ward of cancer patients, particularly the ‘terminal ward’. Cancer patients also feel themselves to be helpless victims of a random process ending in death, and when I began working in the hospital and my colleagues referred patients who were very distressed, I wondered, like Rivers, what was expected of me. Was Ito make patients ‘better’? What was ‘better’? If they became cheerful and happy despite their physical state, was this successful treatment? How was 1, as both a physician and psychotherapist, to help? How was Ito bring the two approaches together to good effect?

Cancer treatment by chemotherapy (ironically one of the first chemotherapy agents was mustard gas used in the First World War) and surgery has changed the course of the disease and lengthened the survival time of patients. This treatment produces its own stresses and strains and the individual has no guarantee of cure. Descriptions of ‘shell shock’ resonate here; they could apply to the young men with cancer, who, in profound despair, become mute and unresponsive. In his ‘Memoir’, Lord Moran described a soldier who became mute and apathetic and later shot himself. Moran admits that initially he gave it little attention. This soldier was clearly not afraid of death, but he could not face the trenches, and worse, the accusations of cowardice and the reproaches of his fellow sufferers in the trenches. Moran describes his own reaction to this man’s suicide in a way that is uncomprehending (to put it mildly) of the soldier’s state of mind .⁴ He thought it was a condition of the poorer, inferior classes and therefore not a condition of officers! Later, when he experiences a close bombardment, he becomes more sympathetic to the suffering of the soldiers. Experiencing the ‘corrosion’ of the battlefield at first hand, he suffers all the symptoms of ‘shell shock’!

The ‘shell shock’ of cancer

The questions that beset Rivers concerning ‘treatment’ of shell shock are applicable to the treatment of cancer patients. Many that I saw were in pain that was distressing and could not be relieved. In many cases, the patient’s condition was deteriorating and treatment had ceased; sometimes a token course of treatment was initiated with no real hope of its effectiveness. I was in a different position to Rivers in that I was with the patients in the ‘front line’ and there was no way of avoiding the pounding, from the disease, the treatment and the disability, which the patient suffered.

Ubiquitous phantasies about death and dying inform many of the attitudes in hospitals towards the dying patient. Isolation is a universally feared option; and yet the practice is to isolate dying patients and then hide them from view using single side-rooms and screened-off beds. Our own attitudes towards death affect the way in which others are cared for. In 1915, Freud wrote about the difficulty of imagining our own death in ‘Thoughts for the Times on War and Death’. He described war as being:

… far from straightforward. To any one who listened to us we were of course prepared to maintain that death was the necessary outcome of life, that everyone owes nature a death and must expect to pay the debt — in short that death was natural, undeniable and unavoidable.In reality, we are accustomed to behave as if it were otherwise. We show an unmistakable tendency to put death on one side, to eliminate it from life. It is indeed impossible to imagine our own death; and whenever we attempt to do so we can perceive that we are in fact still present as spectators. Hence the psychoanalytic school could venture on the assertion that at bottom no one believes in his own death, or, to put the same thing in another way, that in the unconscious every one of us is convinced of his own immortality.⁵

Eighty years after the First World War a review took place of all instances in that war when soldiers were shot for cowardice. They were perceived as being brave men paralysed by the inner conflict between group obligations and an uncontrollable aversion to war conditions. Through his work with victims of shell shock, Rivers challenged the prevailing view of soldiers with mutism, which saw them as individuals consciously refusing to speak. Instead, he took a more compassionate stance, maintaining that that they were victims of an inner conflict produced by the terrible conditions.

Attention to psychological trauma in the general hospital

The influence of psychological forces on physical processes in a general hospital is generally unacknowledged because no one understands them or how to use them in the treatment of the whole patient. There is also an aversion to considering ‘mind processes’. People specialised in their knowledge of physical processes stay with what they know: which is also what they can control. My armamentarium of ‘just words’ was unimpressive in comparison to the resources of a physician or anaesthetist for treating pain and the high-tech world of a modern hospital with its ‘scans’, magnetic resonance imaging, computer tomography, and other equipment (mainly for diagnosis and X-ray machines for radiotherapy). But this leaves out of the account the healing properties of talking and listening, and the untapped power of the mind for denying, or modifying, the effects of sensory input to the body. The diagnosis of cancer itself produces physiological and psychological pain, it produces pain and shock, sometimes experienced simultaneously.

In the case of trauma caused by cancer, the relationship between patient and doctor in psychoanalytic psychotherapy occurs immediately and is from a very early and primitive relationship, that is, it is a relationship stripped of defences and pretences, and resembles very early relationships between, say a parent and a child. It is important to realise that it comes into being because of the traumatic situation and not because of any special features in the doctor or nurse. After the patient has been told that they have cancer their doctors become empowered and have a responsibility to act with care. Both patient and doctor are vulnerable; the doctor from feelings of omnipotence and the patient from extreme passivity. The significance of pain for the patient, how it is perceived, is rarely discussed. The patient might ask is this pain going to be for the rest of my life? What is pain relief going to do to my sense of the world? The answers to these questions can directly influence vital functions, but in many cases, the patient does not get to ask questions.

The task of trying to understand and help the patient understand unconscious thought processes is the province of the psychoanalyst and it is that form of enquiry and procedure, this book aims to show, which is most appropriate for the alleviation of deep mental pain and suffering.

The following accounts are a selection from the hundreds of patients I saw when I was a psychiatric consultant working mainly at the Royal Marsden Hospital and also, but much less frequently, at the Royal National Ear, Nose and Throat Hospital and the Institute of Obstetrics and Gynaecology at the Hammersmith Hospital in London.

The psychotherapy ‘process’

The psychotherapy ‘process’ is with each patient a ‘pure’ research project. Neither the patient nor the therapist knows what we will discover following the truth. It is not ‘invention’ in the sense of having an objective; which in these circumstances could be to relieve anxiety, reduce fear, produce an ‘acceptance’ of death. There are no prior formulations of aims and no promises. The psychological situation is entirely different when surgery and other measures have eliminated cancer. These patients have difficulties, not because of pain and imminent death, but because life now has many things missing from it that make it enjoyable. Patients feeling quite well can discover they have cancer and then feel unwell after treatment. The treatment produces changes that can devastate their life. For example, some men with cancer of the testicle feel castrated, and women made infertile by treatment for cancer of the genitalia may feel ‘de-feminised’. The surgical removal of cancer in the head and neck region may result in the loss of the larynx, oesophagus or tongue, removing the normal means of communication. All these constitute, in effect, a subversion of the order of things for the patient, whose world is turned upside down.

Without a voice

Passing the ward office on my round one day, the nurse on duty said ‘Could you see the patient, a nice lady, in the second bed before she goes?’ There was no suggestion that she was ‘difficult’, ‘neurotic’ or depressed. By the bed stood a fit, smartly dressed woman with her case closed ready to go … She was in striking contrast to all the other patients on this large ward who looked unwell, as they lay quiet and pale in their beds. Mouthing the words she responded to my greeting, and I knew why I was there and what had happened to her. The cancer had gone and so had her larynx. I later realised that the cancer had been in the oesophagus and both larynx and oesophagus had had to be removed. Her life and the capacity to enjoy life had gone with them.

She spoke with the faintest of whispers shaping exhaled breath into words. She had no voice, and unlike the laryngectomy patients who use oesophageal speech, she could not swallow air. Eliminating cancer in the sites of the oesophagus and larynx involves the removal of the structure that contains it. Life without these structures is unimaginable and the experience traumatic. She had not fully appreciated the consequences of the operation. When she had learned she had cancer, her prime concern was the preservation of her life, not how she would live that life.

When she was working, she spent her time talking to her clients on the telephone. Without audible speech she was ruined. Instead of her oesophagus, she now had a piece of large bowel running under the skin of her chest. Loud gurgling noises issued from her misshapen chest, and she would awaken to find bile stains on her pillow. She felt she could not share her bed with anyone. She could not socialise and she could not make love. She had suffered a loss of life, her way of life. She felt she could not engage in psychotherapy until she found a way of speaking with greater facility. I thought that psychotherapy using writing to communicate would be valuable; it could be a way of ‘brain storming’ to find ways of living, with fulfilment. Nothing in her life had prepared her for this eventuality. She felt too hopeless at this point, however, to consider that anything could help her.

Learning to take charge

One young woman when she first developed breast cancer had no doubt that she could control and cope with it as she had with everything else in her life. She felt that she could cope with any eventuality in her life; up until she was diagnosed with cancer, nothing had shaken this belief. She had a mastectomy and without drawing breath, as it were, she continued her very busy professional and domestic life. After two years the cancer recurred and it was then that her fantasy that she could cope with anything was exposed. She was the lynchpin of the family, looking after her husband, two young children and two elderly relatives at the same time as working full time in her profession. She was devastated when the cancer recurred because she believed that she had ‘defeated’ it. She said ‘It has come back. I have failed! I am going to die!’ She felt that there was no point in speaking. She was the last person her ‘dependants’ would have expected to collapse; previously able to conquer any difficulty, she was now completely powerless. I suggested psychotherapy as a way of exploring her situation. She could not conceive of how anyone could help her situation, nevertheless she accepted my offer. She left hospital and came weekly to see me for several months for psychotherapy. She quickly realised that she was the victim of her own thinking. She had to believe again that she could cope with and control everything in her life. The work we did was constructive and engaging. She acquired insight rapidly and she knew we would carry on for as long as possible. There was no anxiety or fear and during one of our last meetings she said, referring to her own experience of psychotherapy ‘I would not have missed this for anything!’ She had changed her views of all her relationships and she felt liberated from her burdens placed upon her by internal demands. Something good and positive had resulted from her illness. She valued the release from the internal straight jacket. She was in charge of herself, integrated and independent.

This woman’s response was mirrored in the interviews I had with old soldiers from the 1914–18 war about their experiences. Grim though they were, they would say: ‘I would not have missed it for anything!’ They had endured unimaginable conditions and found that ...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• The art of living well and dying well are one
• Contents
• Preface
• Acknowledgements
• Introduction
• 1 In the front line with cancer
• 2 Cancer and the psychotherapeutic endeavour
• 3 The impact of cancer on hospital relationships
• 4 Cancer in different areas of the body and mind
• 5 Mind-bending pain
• 6 Dread and trauma - on being told the truth
• 7 Psychoanalytic psychotherapy in the NHS 'general' hospital
• 8 Examining group processes in hospital
• Bibliography
• Index