Take Home Final Exam Question #4: Identify psychotherapeutic issues particular to the care of cancer patients. Compare and contrast psychotherapy in oncology to psychotherapy generally with respect to both similarities and differences. Kristy Brosz ID# 229954 MDSC 635 (S01) Fall 2011 University of Calgary 1 P a g e
Comparison of Psychotherapy in Oncology with General Psychotherapy 1: Introduction Literature suggests that 35-45% of North American cancer patients can expect to experience significant distress during their cancer journey (Bultz & Carlson, 2006; Carlson & Bultz, 2004; Carlson et al., 2004; Zabora, et al., 2001). Given this large prevalence of distressed cancer patients, the need for psychotherapy within oncology is clear. This paper will examine the psychotherapy issues unique to oncology and provides a comparison between general and oncology psychotherapy. 2: Psychotherapeutic Issues Unique to Oncology Sources of distress for cancer patients are multifaceted and can include: Biological Sources: may include impacts from surgical procedures Dollinger, et al, 2002), sleep disturbance and fatigue (Hearson & Sawatzky, 2009; Waller & Garland, 2011), impacts from tumour locations and treatment side effects (Dollinger et al., 2002). Systemic Sources: may include interactions with biomedical systems (Bultz, 2002; Carlson et al., 2004) medical disability systems (Bultz, 2002; Canadian Strategy for Cancer Control, 2001)., drug coverage and instrumental needs systems(national Comprehensive Cancer Network, 2002), and existing systems within the family unit (Bultz, 2002). Existential Sources: may include facing mortality (Angen et al., 2002; Hallenbeck, 2003), meaningmaking (Hallenbeck, 2003; White, 2004), spirituality (Hallenbeck, 2003; Vachon, 2008), and identity (Hallenbeck, 2003; Reynolds & Prior, 2005). Given these multifaceted sources of distress, psychotherapeutic issues for oncology patients often include a variety of specific issues depending on points along the disease trajectory that can include: 1. Pre-Diagnosis and/or Prevention: Dealing with impacts of family history of cancer, increased risk for developing cancer, and decision making for genetic testing for some cancers. Psychotherapeutic goals generally focus on information mobilization and education (Dollinger et al, 2002; Sourkes, Massie & Holland, 1998). 2 P a g e
2. Diagnosis: Facing impacts of diagnosis that includes: day-to-day considerations; financial and drug coverage considerations; biomedical considerations and treatment; and existential concerns over having a life-threatening illness. Psychotherapeutic goals general focus on education, addressing practical concerns, coping in the moment, and providing specific emotional support (Briebart, 2002; Mages et al., 1981; Schroever, Kraaiji & Garnesfki, 2011; Sourkes, Massie & Holland, 1998). 3. Treatment: Generally includes dealing with concerns as treatment progresses. Includes disruptions to usual routines, impacts of the disease, and treatment side effects. Psychotherapeutic goals continue from those identified in the diagnosis phase as the reality of the illness and isolation set in (Schroever, Kraaiji, & Garnesfski, 2011; Sourkes, Massie & Holland, 1998). 4. Post-Treatment: Facing impacts of treatment such as changes in body image from surgery, cognitive effects from chemotherapy, or fatigue effects from chemotherapy and/or radiation. Psychotherapeutic goals focus on active coping and continuing to think about integrating the role of cancer survivor into life (Boehmer, Luszcynska, & Schwarzer, 2007; Reynolds & Prior, 2005). 5. Survivorship: Begin to re-establish routines, relationships, and roles within employment/school and family systems. Psychotherapeutic goals focus on dynamics in re-establishing these identities and roles while examining life values, beliefs, and priorities as a cancer survivor. Also focuses on developing a healthy life style and existential considerations such as fear of recurrence and mortality (LeShan, 1990; Magee & Scalzo, 2006; Vachon, 2008; Zebrak, 2000). 6. Recurrence: Focus on similar considerations as initial diagnosis to develop a treatment plan as and concerns related to progression of a life-threatening illness. Psychotherapeutic goals focus on active coping, living fully in the moment, ensuring a meaningful life, dealing with treatment side effects, support systems, and existential concerns (Reynolds & Prior, 2005; Schroever, Kraaiji, & Garnesfski, 2011; Sourkes, Massie & Holland, 1998). 7. Advanced Stage Disease/End-of-Life: Focus on comfort, dignity, and end-of-life decision making and planning. Psychotherapeutic goals include those identified by the patient for dying well and may include: decision making in shifts from curative to palliative treatment options; existential issues; spiritual concerns; meaning making; and expectations of the dying process (Briebart, 2002; Chochinov, 2002; Hallenbeck, 2003;. Schroever, Kraaiji, & Garnesfski, 2011; Sourkes, Massie & Holland, 1998) In addition to the issues identified above, psychotherapeutic issues also are experienced by the cancer patient and the families and/or support system throughout the disease trajectory. These may include 3 P a g e
similar themes as identified above, but also may include specific relationships and interactions within the family unit, work, school, community, and additional pertinent social netweorks. In addition, various levels of grief and loss are also psychotherapeutic issues that span over the disease trajectory as often the losses experienced by the cancer highlight additional losses. The family may also experiencebereavement concerns such as planning for the future without their loved ones while at the same time managing their distress and attempting to live more in the moment. 3: Comparison of Psychotherapy in Oncology with General Psychotherapy While oncology related therapy does have unique attributes, psychotherapeutic oncology shares many traits with general psychotherapy: 1. Psychotherapeutic approaches and frameworks utilized by the therapist should be targeted to client s needs (Turner, 2011). 2. Importance of the developing, maintaining, and evaluating the therapeutic relationship (Truscott, 2010). 3. General phases of individual counseling or group session (Shebib, 2007). 4. General types of questions asked within sessions (Trustcott, 2010). 5. Importance of the creation of hope and presence of healing ritual/structure within the psychotherapy process (Truscott, 2010). 6. Deductive therapeutic styles can be used to provide informational knowledge and coping skills 7. Interactive therapeutic styles can be used to provide coping skills, informational knowledge, or social/emotional support 8. Inductive therapeutic styles can be used to provide social/emotional support and coping skills 9. Need for continual research to evaluate evidence bases for psychotherapeutic approaches (Turner, 2011). 10. Utilizes basic assumptions about human nature, change, and the impacts of distress (Turner, 2011). 11. May carry a mental health stigma (Turner, 2011). Despite these many similarities, there also exist many differences between general psychotherapy and oncology given the complex disease trajectory patients face with this life-threatening illness. Table 3.1 4 P a g e
highlights the differences noted within the literature that exist in oncology-related psychotherapy. Table 3.1: Similarities and Differences Between General Psychotherapy and Oncology. Category Oncology Psychotherapy General Psychotherapy Commonly used types of interventions Educational, behavioural training, group interventions, and individual psychotherapy (Sourkes, Massie & Holland, 1998). Varies depending on presenting issues (Sourkes, Massie & Holland, 1998) Prevalence of evidence bases for psychotherapeutic interventions Most evidence bases are still developing as it is difficult to obtain solid RCT studies given the specific health challenges of oncology patients. Often evidence bases are reported based on specific tumor groups that may be difficult to generalize to all tumour groups and additional disease populations Many contain some very strong historical evidences bases as there are often larger available base for samples and therefore ability to conduct larger RCT trials is more likely (Sourkes, Massie & Holland, 1998) Therapeutic Content and Process Specific considerations include: acknowledgement of defense coping mechanisms to deal with the present; maintain an awareness of the relationship between prognosis and time; focus on present issues of a life threatening diagnosis (Sourkes, Massie & Holland, 1998). Often follows a more unstructured flow of content and process where past, present, and future are interwoven among themes (Sourkes, Massie,& Holland, 1998). Definition of the client While the client may be the patient undergoing oncological treatment, the definition of who the client is widely variable and may change over the course of the treatment to include family members, couples, or the entire family unit or specific support individuals Likely well defined from start of psychotherapy as either the individual, couple, or family unit. While additional members may be added/removed for particular sessions, the client is more solidly defined Identification of Psychiatric disorders such as anxiety or depression Criteria may differ from DSM criteria given the biophysical effects from both tumours and treatments (e.g. fatigue may be from treatment side effects rather than diagnostic of depression) (Edicott, 1984; Guo et al., 2006; Kathol et al., 1990). Typically follows DSM criteria for diagnosis of psychiatric disorders (Edicott, 1984; Guo et al., 2006; Kathol et al, 1990). Primary focus of psychotherapy Timing of psychotherapy sessions Impacts of distress due to the cancer diagnosis Timing often depends on patient s point within the disease trajectory and is dependent on the patient s biomedical abilities to engage in session. In addition, given the potential for interruption or termination of therapy given disease progression, each session should be complete within itself. (Sourkes, Massie & Holland, 1998). Broad range of general interpersonal sources of distress of the client (Sourkes, Massie & Holland, 1998) Timing is typically more rigid (eg: 50 minute session) to assist in creating a consistent structure and is critical to the containment of the process. The potential for unexpected interruption or termination is likely less than in oncology (Sourkes, Massie & Holland, 1998). 5 P a g e
Table 3.1 CONTINUED: Similarities and Differences Between General Psychotherapy and Oncology Category Oncology Psychotherapy General Psychotherapy Location/Space for psychotherapy Therapist knowledge base and consultations with additional professionals Group Interventions Setting is generally consistent and often different depending on outpatient/inpatient status and may include the hospital, clinic, or patient s home (Mehnert & Koch, 2005; Sourkes, Massie & Holland, 1998). Therapist is required to be familiar in general terms with oncology diagnosis, prognosis and treatment and consults with other biomedical oncology professionals Group members are encouraged to interact and provide support to each other outside of the group (Sourkes, Massie & Holland, 1998) Generally able to provide a consistent setting of the therapists office for psychotherapy (Sourkes, Massie & Holland, 1998). Consultation with additional professionals may be less frequent and dependent on specific client circumstances Group members often are not encouraged to interact outside of the group (Sourkes, Massie & Holland, 1998) In addition to those highlighted within Table 3.1, I have observed additional facets that make psychotherapy in oncology. These center around facing a life threatening illness that requires deep human connectedness when facing the possibility of death in multifaceted ways. Examples of additional differences could include: 1. A diagnosis of cancer often comes with many losses which may have the potential to compound other life losses for the patient. 2. The diagnosis may present and sense of urgency which prepares the client for therapy differently. This may also lead the exploration of family coping strategies to look differently than in general psychotherapy. 3. Given a strong sense of isolation and many forms of distress cancer patients face, there may be an increased use of self within reflecting teams in an attempt to normalize the cancer experience. 4. Non-traditional psychotherapy interventions such as residential retreat programs and mindfulness programs are a stronger fit with this population as they provide an opportunity to go deeper with others in similar situations. 4: Concluding Thoughts Given the complexity of an oncology diagnosis, psychotherapy for cancer patients seeks to address many unique issues specific to a life threatening cancer diagnosis, the patient themselves, and the systems they interact with. This paper highlights that despite these differences that there still exists some key similarities to general populations based on core principles of psychotherapy. 6 P a g e
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