The Crisis of Illness

Transcription

1 IV The Crisis of Illness Cancer among Adults Most adults envision cancer as a uniquely frightening illness. Cancer is associated with progressive physical debilitation, passive submission to protracted treatment that may involve pain and mutilation, and a capricious course that creates a pervasive sense of uncertainty.6 Adults who develop cancer must accept the diagnosis and their altered status, deal with the discomfort of physical symptoms and treatment procedures, and cope with the increased dependency and loss of personal dignity that are often entailed in becoming a patient. Patients' personal accounts highlight the value of active coping strategies in managing the stress of cancer. Ann O'Connell read as much as she could about her disease and obtained a sense of control over it by learning its pathophysiology.5 The knowledge she acquired countered some of her hopelessness in that she became more optimistic when she discovered that she had a slowgrowing tumor. Ann also dealt with her illness actively by using mental imagery to try to strengthen her body's immune system. Another patient, Neil Fiore, systematically acquired information about the precise prognostic indicators of his disease and about the particular treatment recommended by his physician.2 He also found that mental imagery provided some sense of mastery over the illness and enabled him to fight the cancer actively rather than relying solely on the therapy his doctor advocated. More generally, positive adaptation depends on the characteristics of the disease (such as the extent of spread and need for surgery and adju- 101

2 102 PART IV vant therapy), the psychological resources of the patient, and the supportiveness of the social context.3,s In the first article, Avery D. Weisman outlines four psychosocial phases that cancer patients may experience during the course of their illness. His aim is to identify high-risk periods and promote appropriate interventions by making typical problems more expectable. The first phase, existential plight, begins with diagnosis and may continue for up to four months. Patients are unusually vulnerable during this phase, and their major concern is whether they will live or die. They may respond to the threat posed by their illness with anxiety, sadness, and temporary denial. But this is also a time of optimism, as patients seek information, share their concerns, and hope for an eventual cure. Part of the uncertainty patients experience in this phase is due to their worry about the potency of treatment. David Nerenz and his associates suggest that staff can decrease patients' distress by providing them with the information and skills necessary to appraise the state of their health accurately and track the effectiveness of treatment.4 For example, they recommend that patients be taught to monitor symptoms, such as feelings of pressure or pain from tumors or decreases in the size of lymph nodes. Patients can also be shown their x-rays or lymphangiograms to enable them to see the extent of the cancer and note improvements as treatment progresses. Moreover, graphic presentations of specific cancer sites might dispel patients' visions of wildly growing cancer cells invading their entire body. In the second phase, patients cope by trying to accommodate to the illness and to mitigate their distress. They return to customary activities and resume the business of normal living. At this time patients must come to grips with the residual effects of the cancer and its treatment, such as decreased energy and morale and loss of body function or disfigurement. Patients adopt a "wait-and-see" attitude to deal with the fact that resurgence of the cancer may necessitate more treatment. Phase three, which begins when there is a recurrence or relapse, marks the end of optimism and the formation of a grimmer outlook. Patients and their families may shy away from additional treatment because they are disenchanted with the physician or are afraid of the agony of another course of therapy. Eventually, when a cure or reprieve is no longer possible, the

3 CANCER AMONG ADULTS 103 patient enters the fourth and final phase, deterioration and decline. At this point, the patient has fewer options and limited time. Acceptance of the inevitable may promote some disengagement and therby mitigate distress. In general, patients cope better with the vicissitudes of cancer when they seek information and confront problems directly, redefine salient issues in solvable terms, flexibly alter their behavior as circumstances permit, and are cooperative but not overly compliant. Patients who are able to communicate their distress and express their anger openly may survive longer than those who cannot.1 Remission is one of the few bright spots in the cancer experience. Hope abounds. But remission has its own special problems. One problem is the underlying dread that the cancer has not been totally eliminated and may reappear. In the second article, Judith B. Sanders and Carl G. Kardinal describe some adaptive coping patterns of leukemia patients in remission. Denial proved effective for patients receiving outpatient therapy. These patients had no physical symptoms and thus could try to forget about being ill, maintain their self-image, and resume normal activities. Because the hospital vividly reminded patients of their precarious physical state, returning to the clinic for chemotherapy was hard. One patient avoided facing the reality of his illness by not showing up on scheduled days for treatment. When patients reentered the hospital for maintenance therapy, they identified with other patients and the camarader.ie of the "hospital family." Patients compared treatments, discussed recent cancer research, and speculated about their chances for survival based on the number and length of remissions experienced by their peers. These exchanges helped patients to cope by enabling them to predict their likelihood of recovery, though anxiety about the future surfaced when fellow patients died. In the ensuing process of mourning for their peers, patients were able to grieve for themselves. Mutual support and psychotherapy groups can facilitate anticipatory grieving and provide a "desensitizing experience" in which patients share their fears about death and acquire some mastery of them (see Chapter 28). Such groups also contribute to patients' well-being by teaching them active ways of managing stress and reducing their reliance on indirect and less adaptive coping styles. 7 The cancer patient must try to maintain a satisfying life while

4 104 PART IV confronting a potential untimely death. The final article is an eloquent personal statement about living with the threat of death. Alice S. Trillin, a victim of lung cancer, reflects on the fear of dying, the way we try to deny our mortality, and most importantly, how she and other cancer patients come to live with the shadow of death that has been cast over them. Trillin describes the talismans (coping mechanisms) cancer patients use to gain a sense of control over their fear and ennui. Some patients are sustained by faith in the physician's power to keep them well. Others are calmed and derive a sense of mastery from their physician's explanations about the disease process. The talisman of will plays an important part in helping cancer patients to cope. The author's own will to live was strong. She found having cancer unacceptable and delighted in hearing about people who refused to succumb to their illness. Trillin also notes how cancer patients put on a "brave act" to convince themselves and people around them that they are well. Cheerfulness, optimism, and tales of successful cures help patients face the uncertain future. Another way to cope with the threat of death is by being involved in everyday life-people and work. Following a course of chemotherapy, the author relished her ability to concentrate on such mundane activities as the care of her garden peas instead of having to worry about symptoms and how her body was functioning. Like other cancer patients (see Chapter 28), Trillin speaks of living a richer life because she has confronted death and not been destroyed by it. References 1. Derogatis, L., Abeloff, M., & Melisaratos, N. Psychological coping mechanisms and survival time in metastatic breast cancer. Journal of the American Medical Association, 1979, 242, Fiore, N. Fighting cancer-one patient's perspective. The New EnglandJournal of Medicine, 1979, 300, Holland, J. C., & Mastrovito, R. Psychologic adaptation to breast cancer. Cancer, 1980, 46, Nerenz, D. R., Leventhal, H., & Love, R. R. Factors contributing to emotional distress during cancer chemotherapy. Cancer, 1982,50, O'Connell, A. L. Death sentence: An invitation to life. American Journal of Nursing, 1980, 80,

5 CANCER AMONG ADULTS Silberfarb. P., & Greer, S. Psychological concomitants of cancer: Clinical aspects. American Journal of Psychotherapy, 1982,36, Spiegel, D., Bloom,]., & Yalom, 1. Group support for patients with metastatic cancer: A randomized prospective outcome study. Archives of General Psychiatry, 1981,38, Weisman, A. D. Coping with cancer. New York: McGraw-Hill, 1979.