Lecture
«Every suffering and illness introduces into a person's spiritual world such changes, bringing forward some of its aspects, obscuring others, sometimes altering the entire harmony of the personality, as well as the character of one's relationship to oneself and to everything around, that there is reason to conclude that in his practice a physician has to reckon not with an ordinary person, but with a suffering person as a special psychological variety» [11].
G.I. Rossolimo (1860–1928) – Russian physician
Information about a cancer diagnosis disrupts a person's habitual and secure existence and fills their life with painful experiences, at the core of which lies the fear of death. Psychological studies conducted both abroad and in our country indicate that cancer patients need psychological help [12, 14]. For adequate psychological help, it is important to define the situation in which the patient and their family find themselves. The situation of cancer is usually described as stressful. At present, the Department of Psychology of Crisis and Extreme Situations of the Faculty of Psychology at Saint Petersburg State University has developed a conceptual approach from the standpoint of which the situation of cancer is defined as extreme and crisis-related. A person in an extreme situation experiences ultra-intense stress, while in a crisis situation they experience prolonged macrostress.
The situation of cancer possesses all the features characteristic of crisis and extreme situations: the suddenness of the situation's onset, the presence of a vital threat, the destruction of one's worldview, the absence of control over what is happening, the uncertainty of the future, and the staged progression of reactions to the illness. The situation of
cancer is also characterized by specific features that supplement the general ones: the polyetiological nature of the disease, the mutilating character of surgical intervention, prolonged and difficult treatment, the absence of guarantees of recovery, and changes in social status and financial situation.
The features that distinguish these situations from other life situations create entirely unique experiences for a person. It is impossible to understand the full range and meaning of a cancer patient's experiences without taking into account the «predetermined» nature of these experiences by the very situation of the illness [15].
What is common to extreme and crisis situations is that they are accompanied by experiences that are extreme in their intensity. In this connection, there is always a danger of psychological trauma within them. In trauma, information from outside – and in the situation of cancer this is the diagnosis of cancer – is appraised by the personality as intolerable for existence. External trauma is transformed into an internal «self-traumatizing» force [10]. As a result, the person's psychic life is reduced.
There are differences between extreme and crisis situations. If an extreme situation is an excessive pressure of external circumstances on a person, which exceeds their internal adaptive capacities, then a crisis situation is a turning point in the development of the personality, at which there occurs a loss of the subjective meaning of life, of the most important reference points and values, whose restoration is impossible without a fundamental reconstruction of the personality.
The adequate resolution of extreme and crisis situations is the gradual restoration of psychological balance. In doing so, a person not only restores emotional balance but, by integrating new experience, has a chance for an expansion of identity and personal growth. Moreover, with an adequate resolution of the crisis there occurs a reappraisal and rethinking of life values, priorities, goals, and life
meaning. The impossibility of an adequate way out of these situations leads to the most diverse forms of maladjustment.
Such a division of the experiences of a person in an extremely difficult life situation into extreme and crisis states is quite conditional. In reality, when describing a person's experience of such situations, elements of both extreme and crisis states may be present.
Cancer lays bare the very essence of life and inevitably confronts the patient, their family, and their immediate circle with existential problems that in ordinary life may be hidden.
First of all, as noted above, the patient is confronted with a threat to life, their own life. In addition, the illness leaves the person alone with their problems: after all, loved ones, however much they may wish to, cannot experience the pain and suffering on behalf of another person. These experiences, agonizing for the patient, evoke a profound sense of loneliness. In patients, the illusion of a just world order is destroyed. The person loses the meaning of existence. There is not a single cancer patient who has not asked themselves the question «Why did I get sick?», which is reformulated into other questions: «What for?», «For what sins?», «How am I to live now?», «Is it worth living if all of life is chemotherapy?» The patient is faced with questions of responsibility for their way of life, for their contribution to treatment; they are confronted with the need to reflect on the significance of the illness, its meaning, and the meaning of their own life, in order to live accordingly in the conditions of the illness. Spiritual problems are not always consciously recognized by a person, but they lend their experiences a particularly agonizing shade.
Everything described above is accompanied by negative experiences: fear, anxiety, shame, resentment, worry, and guilt, which are manifestations of suffering.
Against the background of intense negative emotions, patients exhibit a change in cognitive processes: difficulties in concentrating attention, a reduction in the scope of attention, and impairment of memory. There occurs a decline in the assimilation and a distortion of information necessary for the correct appraisal of one's own capabilities, as a result of which the ability to make constructive decisions is impaired.
At the somatic level, there appear a sensation of physical weakness, physical exhaustion, a feeling of tightness in the throat, shortness of breath with a sensation of lack of air, and intermittent breathing with sighs.
Thus, the illness manifests itself at all levels of a person's existence:
somatic – through disruption of the functioning of organs and systems;
emotional – through the manifestation of negative emotions: fear, anxiety, anger, resentment, rage, and others;
psychological – through disruption of one's relationship to oneself and to those around;
social – through changes in social status and social ties;
spiritual – through experiencing the finitude of life, loneliness, responsibility, and the meaning of life.
The illness seizes the person as a whole, and the identified levels penetrate one another (the patient complains of pain, and this is not only physical pain, since in total pain, alongside physical pain, there is also emotional and spiritual pain).
The psychological rehabilitation of cancer patients and the psychological help provided to them must be aimed at helping patients cope with the psychological consequences caused by cancer and adapt to the situation of the illness.
A patient's psychological adaptation to the illness consists in the ability to live in the conditions of the illness and to accept all those changes that it introduces or may introduce into their life. In the situation of cancer
a person comes into contact with the finitude of their own life, and this evokes in them ultra-intense agonizing experiences: the worldview of the ill person is destroyed, their whole being refuses to believe that life as it was will no longer exist [16]. And they defend themselves as best they can against this destructive, catastrophic information, using unconscious mechanisms of psychological defense.
Psychological defense is a manifestation of unconscious psychic activity that has formed in the process of the personality's development. Psychological defense arises immediately, as soon as the danger of illness appears; it exists both during the process of treatment and after it, preventing the development of psychological and physiological disturbances. Thanks to psychological defense, information about the illness is not admitted into the consciousness of the ill person at all (for example, the repression of information about the illness from the conscious sphere into the unconscious; denial of the malignant nature of the disease; regression – a return to earlier, infantile personal reactions manifested in a display of helplessness and dependence), and if traumatizing information is admitted, then it is interpreted in a manner that is as «painless» as possible for the person (rationalization – explaining information about the illness in such a way that it becomes acceptable: «The illness is severe, but it was detected in time»; intellectualization – control over emotions through the predominance of reasoning about them instead of directly experiencing them). Psychological defense acts as a buffer to weaken emotional tension and to reduce anxiety and fear in the patient, but, once entrenched, it hinders the assimilation of new information and, consequently, the processing of the traumatizing situation of the illness.
Adaptation to illness in general, and to cancer in particular, is determined by one's attitude toward the illness. The attitude toward the illness is an integrative personal characteristic of a person in the situation of illness, which
is formed in the process of the illness and its treatment and consists of various elements.
One such element of the attitude toward the illness is the internal picture of the illness. The internal picture of the illness is defined as «everything that the patient feels and experiences, the entire mass of their sensations, not only local painful ones but also their general well-being, self-observation, their conceptions of their illness, of its causes – everything that for the patient is connected with the visit to the physician, – that entire enormous inner world of the patient, which consists of very complex combinations of perception and sensation, emotions, affects, conflicts, psychic experiences, and traumas».
Thus, the internal picture of the illness represents the diverse facets of the subjective side of the disease and, in cancer patients, consists of the following components [15]:
The sensory (bodily) component is represented in the form of sensations of physical discomfort and ill-being, painful sensations, and their intensity. The illness compels a person to focus on symptoms of ill-being emanating from the body, and in doing so resentment toward one's own body may arise («My body betrayed me» – patient S.). Thus, patients with breast cancer in 80% of cases admit that before the illness they did not care for their bodies: they paid no attention to those «signals» of fatigue and discomfort that «came» from their bodies. It should be noted that concern about the state of one's body in the situation of illness (especially at the onset of the illness) is for a person a «discovery» of their corporeality and is a natural reaction. In the absence of information accessible to the patient about the illness and the predictability of the disease's course, the patient's concern about the state of their body may become entrenched and turn into hypochondriacal reactions, when any physical symptomatology, and all the more so painful sensations, are perceived as life-threatening.
The cognitive component includes conceptions of and knowledge about the illness, the patient's reflections, and their understanding of the illness. On the basis of
information obtained from various sources, including the media, the internet, and communication with other people, the patient makes an intellectual appraisal of their disease as either dangerous or not dangerous. Cancer, for a person, is one of the most complex, incomprehensible, mysterious, and uncertain of illnesses. This fear not infrequently leads to people not wanting to know anything about this disease and unconsciously defending themselves against it with the help of «denial» and «repression». The distorted conception of cancer that can be observed in contemporary society contributes to this. However, most cancer patients want to know information about the disease in order to control their lives. A certain contradiction is observed between the «desire to know» the truth about the disease and the «fear of knowing» the truth about it, which is resolved in such a way that the patient «desires to know» only information that is «favorable» to them. The cognitive component is connected with the information the patient receives about the disease from the physician. The absence of adequate information for the patient and the impossibility of discussing questions concerning their condition and treatment increase the patient's anxiety, up to an intensification of the symptoms of the illness, and contribute to an unfavorable prognosis.
The emotional component includes the patient's emotional reactions, which can be evoked by both individual symptoms and the disease as a whole, as well as its consequences, including possible changes in family and social status. The characteristics and intensity of emotional experiences conditioned by the illness depend on the degree of significance of those relationships that the illness affects. The emotional component of the internal picture of the illness in a cancer patient includes, first of all, the fear of death and pain, as well as other negative emotions: worry, anxiety, resentment, anger, guilt and shame, and emotional states of aggression and depression. These emotions and emotional states arise in response to the intellectual appraisal of the disease. The physician, in informing the patient of the diagnosis, addresses their
cognitive appraisal of the event and directly affects the patient's emotional reactions.
The emotional component of the attitude toward the illness is closely connected with the somatic condition. Thus, emotions are one of the factors in the holistic process of the disease's pathogenesis. The patient's anxiety and depression, which often accompany cancer, are indicators of emotional pain and always intensify physical pain.
The motivational component is manifested through the person's unconscious and in their conscious behavior directed at recovery, deliverance from suffering, and the restoration of physical and emotional health, or behavior not conducive to it. It is expressed in the form of the patient's hope and patience while awaiting both a positive result of treatment and, in the case of a negative manifestation of the illness and treatment. Not infrequently the verbal motives of recovery and overcoming the illness do not correspond to the patient's actual attitudes. The motivational component plays a leading role in the whole internal picture of the illness, since it is on this component that it depends how the patient will build their life in the context of their disease.
Thus, the internal picture of the illness is an instrument for creating and mastering the space of the illness in which the ill person exists. The space of the illness is that part of the patient's life that influences the course of their life in other spheres and not infrequently determines the quality of their life. The internal picture of the illness has a certain stability and, at the same time, a variability that refines and expands the patient's own conception of the illness. Why does the patient need to master the space of the illness? First, the uncertainty that arises from the moment the disease is discovered evokes anxiety, which may intensify. The patient tries to reduce the uncertainty by explaining their illness in one way or another, which leads, correspondingly, to a reduction of anxiety. Second, being informed about the illness, which consists not only of information about the disease but also about treatment and about possible
complications, and about what the patient themselves can do for their own treatment, to a certain extent creates a sense of control over the situation. Finally, mastering the space of the illness makes it possible to accept it and to reshape one's conception of the world and of oneself, which corresponds to successful adaptation.
The totality of the components of the internal picture of the illness forms a broad spectrum of a cancer patient's psychological reactions to the disease and determines the leading conscious strategies for coping with stressful situations – coping strategies. Let us give several examples of different variants of coping strategies:
Cognitive coping strategies:
«Problem analysis» of the illness, its consequences, the search for relevant information, questioning physicians, and deliberation. The indicated coping strategy
–is adaptive, since it corresponds to behavior directed at analyzing the difficulties that have arisen and possible ways out of them. A patient using such a coping strategy turns again and again to their illness: to its symptoms, to their experiences, tries to understand it, thereby gradually processing the traumatizing situation of the illness. At the same time, this patient evokes incomprehension in those around them; it seems to them that the patient has become «fixated», that the patient is difficult: they may ask questions to which there is not always an answer.
«Ignoring», switching one's thoughts to other topics. This coping strategy is maladaptive, since it represents a deliberate underestimation of troubles and corresponds to passive behavior on the part of the patient. In doing so, those around often support precisely this strategy: «Don't think about the illness»; it seems to them that with their advice they are shielding the patient from suffering.
Emotional coping strategies:
«Protest» – is adaptive, since the patient actively expresses protest in relation to the difficulties.
«Suppression of emotions» – a maladaptive coping strategy, characterized by a suppressed emotional state.
Behavioral coping strategies:
«Turning to others» – an adaptive coping strategy, characteristic of which is the search for support in one's immediate social circle.
«Active avoidance» – a maladaptive coping strategy, since it corresponds to behavior involving the avoidance of thoughts about troubles.
It should be noted that a person's psychological adaptation (including in the situation of a serious illness) is a complex internal process that develops not in a linear progression. Various options are possible for returning to former forms of adaptation with a subsequent turning to new experience. Proceeding from this, the constructiveness of psychological adaptation cannot be appraised unambiguously.
Psychological adaptation is also influenced by the context of the situation in which the ill person finds themselves:
Coping strategies that are constructive from the point of view of the possibilities of psychological adaptation are not always supported by one's social circle: loved ones tend to expect of themselves and of the patient behavior that conforms to the rigid framework of socio-cultural stereotypes.
Even if, from the point of view of psychological adaptation, a certain strategy is adaptive, its rigidity (persistence) may indicate the presence of psychological problems in the person. For example, the predominance in a patient, at all stages of the disease's course, of the behavioral strategy of «turning to others» may indicate that the patient is oriented exclusively toward an external resource, which aggravates their lack of confidence in their own strength.
The constructiveness of any strategy is determined by a person's congruence
with themselves. Thus, the emotional coping strategy of «optimism» testifies to the presence in a person of hope for a
favorable outcome. At the same time, very often in cancer patients optimism has a protective function. Some patients with a pronounced anosognosic component of reacting to the illness deny the malignant nature of their disease and therefore avoid actual knowledge of the illness and live in an «unreal» world. Others use the assertion that «everything will be fine» as an incantation, trying in this way to cope with the anxiety and fear evoked by the illness. By not allowing these feelings to manifest, they only intensify their internal psychic tension. Such patients ask little about the illness, since they are afraid of hearing something bad, and therefore their world too is unreal. Real optimism is possible on the basis of adequate information about the disease and its treatment. A real optimist can be a person who realistically appraises the situation and at the same time finds the strength and courage to live and to set concrete life goals for themselves. Confidence in the existence of a way out of a difficult situation is built on the basis of a holistic perception of the situation, whereby the person deepens into the semantic level of experiencing what is happening. The patient's finding of a resource in their experiences is possible when there is a profound trust in and contact with themselves.
In the situation of cancer, one of the key moments of the attitude toward the illness and a criterion of the patient's successful psychological adaptation is their acceptance of the malignant nature of the pathological process. The process of accepting the malignant nature of the disease requires inner emotional work on the part of the patient, as a result of which a new inner position of the person is formed, reflecting the content and dynamics of the principal semantic changes in the structure of the personality. Emotional experiences are characteristic of all cancer patients, but each experiences them in their own way. Often it is precisely experiences that are extreme in their intensity that motivate a person to seek the meaning of the events taking place in their life.
The acceptance of the malignant nature of the disease is manifested in the dynamics of the patient's psychic state. This dynamic may represent three phases, which do not coincide with the stages of the course of the cancer and the patient's treatment. They reflect the individual adaptation of a specific person to the disease [17].
The first phase of the dynamics of the patient's psychic state – from denial of the illness to acceptance. The patient's psychological task is the acceptance of the illness. This is the longest and most agonizing stage. The American psychologist E. Kübler-Ross described the stages of cancer patients' awareness and acceptance of their death. In a modified form, the description of these stages can be extended to the awareness and acceptance of any serious, distressing event associated with an emotionally significant loss.
Psychological shock. Caused by receiving information about the presence of cancer. There occurs a loss of the sense of security. The patient is in a state of confusion, despair, and panic. A sensation of hopelessness, of a dead end, arises. Suicidal thoughts appear. The predominant feeling is fear.
The stage of denial. Unconscious psychological defense mechanisms are triggered, reducing the traumatization from the information received about the presence of the disease, in the form of denial of the malignant nature of the disease or the repression of thoughts about the disease. The deeply suppressed and unrecognized feeling is fear. The outwardly manifested feeling is calmness, slight agitation. At this stage patients are characterized by an anosognosic type of attitude toward the illness.
The stage of aggression. The unconscious psychological defense mechanisms cease to function. The patient acknowledges the seriousness of the situation. They search for the causes of the illness. They blame those around them and life circumstances for the onset of the illness. The predominant, often unrecognized feeling is
fear. The manifested feelings are anger, rage, and resentment. The stage of aggression is characterized by a dysphoric, accusatory type of reacting.
The stage of depression. The unconscious psychological defense mechanisms cease to function. The patient begins to recognize the seriousness of the situation. They search for the causes of the illness. They engage in self-blame and self-flagellation. The predominant, often unrecognized feeling is fear. The manifested feelings are depression, anxiety, guilt, and shame. Suicidal thoughts appear (a suicide attempt is possible). The stage of depression is characterized by a depressive type of reacting.
Aggression and depression are stages of suffering. They are accompanied by intense negative feelings and experiences. There occurs a repeated alternation of the stage of aggression and the stage of depression. The possibility of manifesting feelings at these stages is a condition for the reduction of emotional tension and the transition to the next stage.
The stage of an attempt at «bargaining with fate». There occurs a reduction of emotional tension and the patient develops a motivation to be cured. Attempts arise to «bargain with fate», to «haggle for» health. There occurs a search for ways and means of deliverance from the illness (both conventional and unconventional). The predominant feelings are fear and hope.
The stage of acceptance of the illness. There occurs the acceptance of oneself as an ill person. A new identity, «I am ill», is formed, which testifies to an intellectual acceptance of the illness, which occurs earlier, and to an emotional acceptance, which comes later. It is precisely the acceptance of the illness that allows the patient to be treated actively and responsibly and to live in the conditions of the illness. Psychological balance is restored.
The predominant feelings are fear, hope, and acquiescence.
The acceptance of the illness is accompanied by ultra-intense and agonizing experiences. Experiences are a special kind of emotional work, thanks to which the processing of psychic trauma occurs, there arises
the possibility of psychological recovery, a meaning to live appears, and new life experience is acquired.
The second phase of the dynamics of the patient's psychic state. The patient's psychological task is adaptation to the disease, that is, learning to live in the conditions of the illness. The patient develops a desire to be treated, to control the situation of the illness and life to the extent that this is possible and as they understand it. The patient intuitively senses that they have an inner potential that is not being used in the process of medication treatment. During this period the patient turns both to external resources (family, friends, physicians, colleagues) and to internal ones (hope, the desire to live), and willingly learns new techniques of self-regulation.
At this phase of the dynamics of the psychic state, patients who live through the cancer as an extreme situation psychologically adapt to the situation of the illness. As a result of becoming aware of their feelings and experiences, the patient's emotional tension decreases, the situation is transformed from an intolerable one into a more tolerable one, and the patient becomes capable of controlling their condition and the situation to the extent that this is possible. In the patient there occurs the acceptance of the illness and of themselves in the role of a patient, thanks to which their range of adaptive reactions in the given life situation expands, and experience of behavior in illness is acquired. Thus, an adequate resolution of the extreme situation occurs.
The third phase of the dynamics of the patient's psychic state is characteristic of patients who experience the disease as a crisis. The patient's psychological task is the transformation and reconstruction of the personality. Through turning to authenticity, the patient arrives at a new personal integration. In doing so, patients understand that they «can no longer live as before». Suffering, undergoing agonizing experiences, they try not to avoid or reduce the acuteness of these experiences, but to «pass through them». With an adequate resolution of the crisis there occurs a reappraisal and rethinking of life
values, priorities, goals, and life meaning. The situation of the illness, associated with a vital threat, promotes a person's coming into contact with themselves, with their own authenticity. The person turns to existential questions: «What is my life?», «What is the meaning of life?», «What is death for a person?» The experience of meaning is related to the understanding of oneself, to the awareness of one's own identity, and to the acceptance of the continuity of the life process. The patient develops the ability to experience and overcome life's difficulties, and this creates the preconditions for personal growth.
The success of a cancer patient's adaptation is influenced by different factors, but, first of all, by the patient's attitude toward the illness, which necessarily includes the semantic content of the disease, as well as the ways by which the ill person copes with a difficult-to-endure life situation.
It should be taken into account that in the normally proceeding process of adaptation to the situation of cancer there arise, and are natural, such states of the patient that include elements of psychopathology. This can be explained by the fact that the patient's former conceptions of their health, of themselves, and of the world – everything that pertains to a person's worldview – are destroyed under the influence of the traumatizing information, accompanied by agonizing emotional suffering, and only as a result of the destruction of one thing is something else, something new, created; strictly speaking, this is precisely what adaptation consists of. For example, an acute stress reaction to information about the malignant nature of the disease is inherent in most patients and corresponds rather to a normal manifestation of the human psyche than to a psychopathological one. Another example is anxiety and a depressive state accompanying the process of accepting the illness, which are also necessary components in the structure of the patient's experiences and may be expressed to a considerable degree. Yet another example, concerning the patient's hypochondria, who
through the presentation of hypochondriacal complaints objectifies bodily sensations and thereby reflects their views on the illness, their expectations and fears, while the absence of adequate information about the disease and its treatment makes the patient's hypochondriacal experiences persistent – the indicated hypochondriacal symptomatology is a natural and necessary component in the situation of the illness.
The boundary that separates the normal state of the patient's psyche in the process of adaptation from psychopathological complications caused by the psychotraumatizing character of the illness is quite thin, and the perspective of a medical psychologist is needed in order to determine what is still the norm for the patient and what is already pathology that disrupts the process of adaptation.
Examples of this are:
Fixation on one of the stages. For example, patients with a pronounced anosognosic component of reacting to the illness deny the malignant nature of their disease and therefore avoid actual knowledge of the illness and live in an «unreal» world «without cancer».
Neurotic manifestations. Even in a state of stable remission, among patients' complaints the symptomatology of the neurotic register predominates: affective lability in the form of impressionability, vulnerability, and poor tolerance of stressful situations; disturbances of social contacts in the form of discomfort in situations of broad interaction; hypochondriacal complaints; recollections of the illness endured and its treatment evoke reflexive nausea, a feeling of profound fatigue, and asthenization.
The emergence of other somatic diseases of a psychogenic nature.
Physicians not infrequently identify cardiovascular complications arising in cancer patients as a result of polychemoradiation therapy, which is reflected both in the quality of their life and in its duration. At the same time, in the opinion of some authors, in the
development of cardiac complications no less a role than the direct action of chemo- and radiation therapy is played by the autonomic and central nervous systems: the stressful situation of the illness and treatment, separation from the family, often disruption of family relationships, and difficulties of social rehabilitation [18, 19].
Suicide. The patient exhibits suicidal thoughts and actions.
At present, life-threatening illnesses have been included in the list of traumatic stressors capable of causing post-traumatic stress disorder (PTSD), which manifests itself not immediately after the trauma but, as a rule, a month or more later.
Two principal differences are noted between the traumatizing impact of illnesses with a vital threat and other types of stressors:
1. the impossibility of separating the traumatizing event from the individual themselves, since the threat that the illness carries within itself proceeds not from the external environment but is located inside the organism;
2. a life-threatening disease threatens a person's future life, in contrast to other types of trauma, which, as a rule, are
events of the past, imprinted in memory and influencing the present.
The experiences accompanying the situation of cancer meet the criteria for diagnosing PTSD (DSM – IV; since 2013 DSM – V has been in effect):
the situation includes a threat to life, a threat of serious injury, and a threat to physical integrity;
the patient's reaction includes intense fear, horror, and a sense of helplessness [13].
The clinical picture of PTSD in cancer patients includes such signs as:
intrusive, recurring dreams about events associated with the illness; any pain or other physical sensations incomprehensible to the patient
evoke in them neurotic and psychosomatic symptoms, which for the patient symbolize a recurrence of the disease, a manifestation of metastases;
the patient cannot speak about their illness; an encounter with the specialists who treated them evokes tears; the patient expresses a desire to «forget everything», and in doing so tends to isolate themselves from other people and sees no life prospects;
difficulties falling asleep, irritability, and outbursts of anger;
difficulties in concentrating attention and a heightened level of vigilance.
The totality of the indicated symptoms testifies to psychic traumatization of the patient leading to maladjustment, but individually, to one degree or another, these symptoms may be present in the experiences of a cancer patient even in the process of adaptation to the illness.
In our view, practically every cancer patient is traumatized by the information about the presence of a malignant neoplasm. However, the degree of adaptation disturbances in patients varies. Thus, a small proportion of patients are able, in a cumulative manner, to gather and organize the psychological help they need; these patients independently process the traumatizing information, they are able to perform inner emotional work and adapt to the situation of the illness. In other patients, on the contrary, psychopathological and pathopsychological complications develop in the form of neurotic and psychosomatic disturbances, an acute stress reaction, and PTSD, which testify to a disturbance of adaptation and may require medication treatment. But in doing so it must be taken into account that psychopharmacological help is directed only at the patient's current emotional state. As a result, the patient does not undergo the experiencing of the traumatizing situation of the illness, which is necessary for its acceptance, and there is no awareness of the illness on the psychological and spiritual levels. The larger part of cancer patients are in a state of emotional tension and psychic instability. It is precisely this group of patients that should to a greater extent be in the focus of medical psychologists' attention, since professional psychological help provided in a timely and adequate manner to patients of this group can promote their successful adaptation to the situation of the illness, which meets the aim of psychological rehabilitation.
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