Edith Kitchmann Postdoctoral Research Fellow in Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, Toronto, Ontario
Overcoming Adversity: are positive changes possible after an advanced cancer diagnosis?

Authors: Emily C. Freeman, PhD; Christopher Lo, PhD; Sarah Hales, MD; Gary Rodin, MD

Affiliations: Princess Margaret Hospital, Toronto, Ontario
 
Advanced cancer patients and their caregivers often experience a range of emotional reactions, triggered by the burden of disease and the losses that have occurred and that are anticipated.  A current psychotherapeutic intervention developed at Princess Margaret Hospital by psychiatrists, Sarah Hales and Gary Rodin, and psychologist, Christopher Lo is designed to help patients cope with the distress associated with advanced cancer. The impact of a novel psychotherapeutic intervention in this population is described briefly here:


Background

Cancer patients and their loved ones are at risk to develop feelings of depression, isolation, and demoralization as a result of the multiple losses and burdens associated with advanced or metastatic disease (Kissane et. al., in press). The dramatic alterations in life circumstances and the threat of mortality faced by these individuals can be highly distressing, but may lead to a constructive process of reflection about the meaning and purpose of life and about priorities and goals (Rodin, 2009). This process of self-reflection can be difficult and sometimes painful, but has the potential to lead to positive change (Hefferon et. al., 2009).

Some researchers have described the positive psychological changes that may occur following a life crisis, using such words as benefit-finding, post-traumatic growth, and resiliency (Hefferon et. al., 2009). 

These changes include:
•    an increased appreciation of life,
•    greater feelings of compassion and empathy for others,
•    closer relationships with family members,
•    stronger spiritual beliefs,
•    and a greater sense of life meaning.

Factors that may affect the likelihood that these positive psychological changes will occur include:
•    severity of physical suffering,
•    life stage of the patient,
•    opportunity to reflect,
•    availability of friends, family, health care professionals and other social supports.

It remains unclear to what extent such positive changes may spontaneously arise in patients coping with advanced cancer and the threat of impending death.

Managing Cancer and Living Meaningfully (CALM) therapy

The idea that there may be a “silver lining” or a “positive experience” to the tragedy of cancer has increasingly entered the popular media, and while it might be appealing, it is a complicated issue that warrants further research.  However, it remains unclear to what extent such positive changes may spontaneously arise in patients coping with advanced cancer and the threat of impending death.  Research on outcomes following other forms of trauma suggests that the nature of environmental support following the trauma may be a critical determining factor. Whether this occurs may depend upon the individual and upon the support provided by the environment. A psychotherapeutic relationship with a heath care provider in some cases may increase the likelihood that emotional distress does not become prolonged and that post-traumatic growth will occur. In support of this goal, our team has developed a structured individualized psychotherapy treatment to relieve distress and to promote psychological growth in patients with advanced cancer.  This intervention, called Managing Cancer and Living Meaningfully (CALM ) therapy (Kissane et al., in press) is a brief 3-8 session intervention designed for patients with metastatic cancer and delivered by specially trained mental health professionals. 

CALM is a semi-structured intervention that includes modules on symptom control and relationships with health care providers, self concept and personal relationships, spiritual well-being and issues related to the end of life. All of these were identified as common areas of concern in advanced cancer populations by our research into the determinants of depression and distress near the end of life (Rodin et al., 2009).  CALM is primarily an individual intervention but also allows for the inclusion of a spouse, partner or other primary caregiver in therapy and works on the principle that in order to relieve distress, patients are in need of an empathic and reflexive space to process the traumatic events that have occurred and that continue to occur,  and to help prepare for the future.

Effects of CALM therapy: Preliminary Qualitative Results

Patients with advanced cancer who completed CALM therapy participated in subsequent qualitative interviews conducted by postdoctoral researcher Dr. Emily Freeman.  These patients reported appreciating the opportunity for self-reflection, without the pressure they otherwise felt to have only positive thoughts and feelings. They felt that such pressure otherwise inhibited them from openly expressing their fears and concerns about the future.

Some patients reported benefit from being able to restore estranged relationships with family members or from not taking loved ones for granted. Others reported a greater appreciation of the events of daily life and a lesser tendency to see, “the ugliness of everyday life.” For another patient, CALM allowed her to “unload” her feelings onto someone (the therapist) who cared about her but who could also provide her with unbiased advice. At the end of her therapy, she was able to say, “I no longer take each day for granted”.  Another patient found it useful to have a focused therapy, in which he and his wife could discuss one or two items per session such that they didn’t feel “overwhelmed with the cancer experience”. This patient felt the therapy sessions created “problem-solving time” for him and his wife to work through relationship issues with his family. The time and space provided by CALM allowed this patient to develop a stronger relationship with members of his family and to consider multiple solutions and approaches that would otherwise have not occurred to him.

Perhaps one of the most striking testaments that we have received about the benefits of the CALM intervention came from a patient who described his experience as one of finally being “seen as a person within the medical system”.  He had previously felt “lost” in navigating the health care system, and the focus on his medical condition and treatment had left little time for consideration of him “as a whole” person. 

Next steps

A randomized control trial of CALM therapy is now underway in depressed patients with metastatic cancer to determine to what extent it is associated with a significantly greater reduction in depression and improvement in spiritual well-being and posttraumatic growth, compared to usual care. Findings from this study will then inform the allocation of psychosocial resources available to the treatment of this population and how such an intervention how can be routinely integrated into cancer care.



References:

Hefferon K, Grealy M, Mutrie N. Post-traumatic growth and life threatening physical illness: a systematic review of the qualitative literature. Br J Health Psychol. 2009 May;14(Pt 2):343-78.

Kissane DW, Levin T, Hales S, Lo C, & Rodin G. (In press). Psychotherapy for depression in cancer and palliative care.  In: Kissane DW, Maj M, Sartorius N. (eds.) Depression and Cancer. World Psychiatric Association.

Rodin G. Individual psychotherapy for the patient with advanced disease. In: Chochinov H, Breitbart W (eds). Handbook of Psychiatry in Palliative Medicine. London: Oxford University Press, 2009:443-453.

Rodin G, Lo C, Mikulincer M, Donner A, Gagliese L, Zimmermann C. Pathways to distress: the multiple determinants of depression, hopelessness, and desire for hastened death in metastatic cancer patients. Social Science and Medicine 2009;68:562-9.